Dr. Peter Attia
speaker
5,258 appearances
36 recordings
6 series
first heard Jan 2024
last heard Jun 2025
Dr. Peter Attia’s voice in public audio — every appearance, attributed to the second.
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Rachel is a board-certified urologist and one of the nation's leading experts in sexual health. She is among a select group of physicians with fellowship training in sexual health for both men and women, bringing a rare and deeply informed perspective to her clinical work. In our conversation today, we focus on women's sexual health.
We discuss why sexual medicine, particularly for women, remains so neglected in traditional healthcare. The critical difference in how men and women experience hormone decline with age, the physiology of the menstrual cycle, including the role of estrogen, progesterone, FSH, and LH and Y perimenopause is characterized by extreme hormone fluctuations.
the risks of menopause beyond just symptoms like hot flashes, including the risk of osteoporosis, cardiovascular disease, dementia, and recurrent UTIs, the long-standing controversy around HRT, and how a single study, the Women's Health Initiative study, led to decades of fear-based medicine and an entire generation of women, by my calculation more than 20 million, deprived of the benefits of HRT.
How to use estrogen, progesterone, and testosterone therapy for women, including dosing, delivery method, such as oral transdermal vaginal, and why personalized care is essential. The overlooked role of testosterone in women's health, both before and after menopause.
The benefits of local vaginal hormonal therapy, a safe, inexpensive, and underutilized treatment that prevents urinary tract infections, improves sexual function, and dramatically enhances quality of life in postmenopausal women.
This is a podcast in which I learned a lot, even though I like to think I know quite a bit about this already, but Rachel's expertise here is second to none, and I was feverishly taking notes throughout and obviously can't wait to implement many of the things I learned into my own clinical practice. So without further delay, please enjoy my conversation with Dr. Rachel Rubin.
Rachel, thank you so much for making the trip out to Austin. I have been looking forward to this episode for a while, and I'm willing to go on record predicting that this will be a very popular episode given the nature of our discussion.
I almost don't know where to begin, but it might not be a bad idea to just give people a little bit of a sense of your background. You are a urologist by training, and maybe help us understand how your training in urology led you to what you're doing today, because most urologists wouldn't be doing exactly what you're doing.
When we think of urology, we think about prostates, we think about kidneys, we think about bladders.
Yeah, and I really mostly want to talk about it from a female standpoint today, truthfully, because I think this is where there's just a dearth of great information out there, where I think there's an abundance of garbage information out there.
So while I appreciate that your breadth of knowledge will cover both sexes, you'll probably notice kind of a bias in what I want to talk about vis-a-vis women specifically. So let's start with perhaps the biggest and most obvious difference between men and women.
And that is from an endocrine perspective, women go through this period called menopause, which is a rather sudden and abrupt loss of their sex hormones. And that's to be contrasted with the way men's sex hormones decline over time a little more slowly.
So again, the listeners of this podcast are highly erudite and they won't need the lengthy dissertation, but just give us a quick overview of what the heck is happening in menopause. Why is it happening? And then we can get into maybe what some of the symptoms are before women might really notice them.
I love that analogy. I've never heard it before, but it absolutely replicates what, of course, we see clinically, which is in perimenopause, why do we sometimes, when we're measuring a woman's labs, say every three months, see periods where estradiol is through the roof, FSH and LH are low, and three months later it's completely flipped, and of course with it go symptoms.
So can you explain why there's this, if we have hormones running like this during pre-menopause, They're like this during menopause, but this transition is nothing linear.
And what I'd like to do now is make sure that anybody listening who wants a more nuanced overview of this, we're going to link to a video that I made a couple of years ago where I walk through the ovulatory cycle and I draw the graph of estrogen. progesterone, FSH, and LH, according to the nomenclature you're using by days.
But let's also have you do an explanation now of the role of FSH and LH on the brain, because you've already referred to that, and what the feedback cycle looks like with estrogen. I just want to make sure people are following the physiology you're describing.
And again, just to make the obvious statement, it's because most of the time when a woman ovulates, she does not get pregnant.
Yeah, a lot of my patients don't read the book about what their physiology is supposed to do. It's very disappointing.
So let's talk about why. So why is it that in perimenopause, the fluctuations in estradiol level are so dramatic?
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