#348 ‒ Women's sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.

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Previously titled “#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.” — renamed by the publisher on Aug 3, 2026

The Peter Attia Drive 2h 13m 2 speakers 10 chapters transcribed

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Who are the hosts and guest of this episode?

Dr. Peter Attia 0:11

Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen. It is extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members, and in return, we offer exclusive member-only content and benefits above and beyond what is available for free. If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peteratiamd.com forward slash subscribe. My guest this week is Dr. Rachel Rubin.

Dr. Peter Attia 1:07

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.

Dr. Peter Attia 2:15

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.

Dr. Peter Attia 3:08

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.

What is Dr. Rubin's background and how did she specialize in women's sexual health?

Dr. Rachel Rubin 3:21

I am so thrilled to be here. I have been nervous for quite a long time, but I'm super happy to be here.

Dr. Peter Attia 3:26

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.

Dr. Rachel Rubin 3:52

Yes, but what you forget, Peter, is that urologists are ultimately the quality of life doctors. We deal with urination problems and we deal with sexual medicine, right? No one cares about erections and orgasm and libido quite the way that a urologist cares about. And when we're board certified, actually, it's not a gender thing. We're not penis doctors only.

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Chapters

10 chapters

1 Who are the hosts and guest of this episode? 0:11–3:21 2 What is Dr. Rubin's background and how did she specialize in women's sexual health? 3:21–8:56 3 What hormonal changes occur during perimenopause and menopause? 8:56–19:44 4 Why do women experience variable symptoms with progesterone fluctuations? 19:44–29:17 5 What are the health risks for postmenopausal women not on hormone therapy? 29:17–38:18 6 How did the Women’s Health Initiative (WHI) study impact hormone replacement therapy use? 38:18–51:49 7 Why is there a lack of training and knowledge among doctors about menopause care? 51:49–58:33 8 What role does testosterone play in women's sexual health and hormone therapy? 58:33–1:16:12 9 What are the biases and barriers affecting hormone replacement therapy adoption? 1:16:12–1:25:48 10 What are the safe and effective hormone therapy options for women? 1:25:48–2:13:22

Speakers

2 identified

Dr. Rachel Rubin 86 min Dr. Peter Attia 44 min

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Topics in this episode

FDA 2 NIH 2 perimenopause 2 menopause 2 testosterone 2 Breast Cancer 2 dementia 2 Estrogen 2 progesterone 2 Peter Attia 1 cardiovascular disease 1 osteoporosis 2

Source

Recorded12 May 2025

Publisherpeterattiadrive.libsyn.com ↗

CollectionAudioscrape Public Library

Transcriptspeaker-named · 100+ languages

Handlerec:260917

Show notes

View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter Rachel Rubin is a board-certified urologist and one of the nation's foremost experts in sexual health. In this episode, she shares her deep expertise on the often-overlooked topic of women’s sexual health, exploring why this area remains so neglected in traditional medicine and highlighting the critical differences in how men and women experience hormonal decline with age. Rachel explains the physiology of the menstrual cycle, the complex hormonal shifts of perimenopause, and the wide-reaching health risks associated with menopause, including osteoporosis, cardiovascular disease, dementia, and recurrent urinary tract infections. She also breaks down the controversy surrounding hormone replacement therapy (HRT), particularly the damaging legacy of the Women’s Health Initiative study, and provides guidance on the safe and personalized use of estrogen, progesterone, and testosterone in women. With particular emphasis on local vaginal hormone therapy—a safe, effective, and underused treatment—Rachel offers insights that have the potential to transform quality of life for countless women. We discuss: Rachel’s training in urology and passion for sexual medicine and women’s health [3:00]; Hormonal changes during ovulation, perimenopause, and menopause: why they occur and how they impact women’s health and quality of life [5:30]; Why women have such varied responses to the sharp drop in progesterone during the luteal phase and after menopause, and the differing responses to progesterone supplementation [14:45]; The physical and cognitive health risks for postmenopausal women who are not on hormone therapy [17:45]; The history of hormone replacement therapy (HRT), and how misinterpretation of the Women’s Health Initiative study led to abandonment of HRT [20:15]; The medical system’s failure to train doctors in hormone therapy after the WHI study and its lasting impact on menopause care [29:30]; The underappreciated role of testosterone in women’s sexual health, and the systemic and regulatory barriers preventing its broader use in female healthcare [35:00]; The bias against HRT—how institutional resistance is preventing meaningful progress in women’s health [46:30]; How the medical system’s neglect of menopause care has opened the door for unregulated and potentially harmful hormone clinics to take advantage of underserved women [53:30]; The HRT playbook for women part 1: progesterone [57:15]; The HRT playbook for women part 2: estradiol [1:05:00]; Oral formulated estrogen for systemic administration: risks and benefits [1:13:15]; Topical and vaginal estrogen delivery options: benefits and limitations, and how to personalize treatment for each patient [1:17:15]; How to navigate hormone lab testing without getting misled [1:24:15]; The wide-ranging symptoms of menopause—joint pain, brain fog, mood issues, and more [1:31:45]; The evolution of medical terminology and the underrecognized importance of local estrogen therapy for urinary and vaginal health in menopausal women [1:37:45]; The benefits of vaginal estrogen (or DHEA) for preventing UTIs, improving sexual health, and more [1:41:00]; The use of DHEA and testosterone in treating hormone-sensitive genital tissues, and an explanation of what often causes women pain [1:50:15]; Is it too late to start HRT after menopause? [1:56:15]; Should women stop hormone therapy after 10 years? [1:58:15]; How to manage hormone therapy in women with BRCA mutations, DCIS (ductal carcinoma in situ), or a history of breast cancer [2:00:00]; How women can identify good menopause care providers and avoid harmful hormone therapy practices, and why menopause medicine is critical for both women and men [2:06:00]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

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