The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Mon, 12 May 2025
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
Chapter 1: Who are the hosts and guest of this episode?
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.
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.
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Chapter 2: What is Dr. Rubin's background and how did she specialize in women's sexual health?
I am so thrilled to be here. I have been nervous for quite a long time, but I'm super happy to be here.
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.
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.
We're board certified to take care of everybody's genital and urinary tracts. Unfortunately, society has led us to know a lot more about the men's sexual health and men's genitals than female genitals. And so my background, I trained in urology really because I was interested in women's health, but I also was interested in sexual health, sexual medicine. And I didn't like delivering babies.
I didn't like OBGYN. It just didn't fit well with my personality. And what I love about urology is that we can see everybody and we can really dive deep on quality of life issues. And the magic of urology is also that you really get to know your patients. It's not like when you did surgery, you take out someone's appendix and you never see them again. Maybe you do one post-op visit.
Urologists have deep relationships. We're both surgeons, but we actually care about the medical side of these quality of life issues. And so as I was going through medical school, I really realized that talking about sexual health, quality of life issues, that was fun for me. I was good at that. And in medicine, you gravitate towards what is easy, not what is hard. And so it's just been a joy.
And really, I've been working to further the field of urology to make us better at taking care of women. And so really, I do a lot of educating and teaching to my colleagues about how we really need to care about the whole, like everybody.
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.
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Chapter 3: What hormonal changes occur during perimenopause and menopause?
But I'd be very interested because the book says are low. So if you have your period that you're bleeding, that's day one. your low is not zero. In fact, it's probably somewhere 40, 50 is probably what the low should be of estradiol. And that's picograms per milliliter, as opposed to testosterone, which we do nanograms per deciliter, as you know. So let's say 50 is your low.
Then you go at ovulate and that's in your mid cycle. And usually it's about 150. Let's say ish. Maybe it's 200, 300, whatever it is. Pregnancy, your level is 3000 or higher, right? It's very high. And so if you're in your normal reproductive cycle, you go from 50 to 150. So let's use the gas tank analogy.
You're at a quarter tank at 50, and you go to three quarters tank at 150, then down to a quarter tank. You can drive wherever you want to go during that time. What happens in perimenopause, and it is this chaos and erratic fluctuation where your body is just wanting more hormone than it has. Your brain, your FSH is telling your eggs to do more than they can. Sometimes they overshoot.
So now you are overflowing gas. I had a lady come in, her day one, her estrogen was 200, and her day 10, her estrogen was 900. So this is this wild fluctuation in perimenopause.
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 that video is so fantastic. We actually were talking about it before doing this podcast about that video. And I said, you know, if you asked most OBGYNs to draw the menstrual cycle, many of them wouldn't be able to do so. It's incredibly complicated. And it's so confusing. And we think our doctors know everything. And unfortunately, they don't.
And so what happens is estrogen, you have your period, your lining of your uterus is shedding, your estrogen is kind of at its all time low.
And again, just to make the obvious statement, it's because most of the time when a woman ovulates, she does not get pregnant.
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Chapter 4: Why do women experience variable symptoms with progesterone fluctuations?
I think there's no question that we see worsening. Now, I will say perimenopause, from what I understand of the data, is actually worse on mental health and can actually level out a little bit once there's less erratic hormones. But again, an empty gas tank is still an empty gas tank. And so we see a lot of challenges in this time period.
We talked about obviously the risk of dementia. We talked about the risk of osteoporosis, cardiovascular disease, colon cancer. All of these are risks that are pretty clearly going up in the absence of hormones. So do you want to talk about the history of HRT? I mean, it was a largely normal practice in the 1960s. They certainly had some fits and starts.
They initially were just replacing estrogen. figured out pretty quickly, i.e. within a few years, that if you only gave a woman estrogen, you were going to run the risk of endometrial cancer going up because the endometrial lining just continued to get bigger and bigger and bigger, and you eventually developed hyperplasia, which presumably became metaplasia and ultimately cancer.
We figured out pretty quickly how to combat that. If you just oppose the estrogen with progesterone, keep the endometrial lining in check, And this largely became the standard of care through the 1980s and into the 1990s. And this was largely validated by epidemiologic observations, which showed that women who took hormones did significantly better.
Now, people who listen to this podcast are well aware of how critical I am of epidemiology, and it's certainly very easy to make the case that in the 1980s, women who were taking hormones had a healthy user bias.
These are women that probably had better access to healthcare, they were probably more health conscious, and as a result, they were probably doing many more things to improve the quality of their health. The NIH did something that I think made a lot of sense. It was the right thing to do, which was they said, look, we can't rely on this epidemiology. We need to do a randomized control trial.
And they did it through something called the Women's Health Initiative, which had two components, a nutritional component that was asking a question about low-fat diets, and then a component that was looking at the HRT.
Would you like to pick up the story as to how the study was designed, maybe talk about some of the potential pitfalls of it, and ultimately how the results of that have been misunderstood and misinterpreted for so long?
The fact that this story hasn't been made into a Hollywood biopic mega drama, I don't know. This is a big deal. A billion dollars of our resources went into doing this study. And there are many things that we learned that were helpful and useful and this huge set of data that we're still using today to extrapolate information from. And there was a lot of good that came from it.
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Chapter 5: What are the health risks for postmenopausal women not on hormone therapy?
got breast cancer, though she didn't die from it at any increased rate to the women who didn't get the hormone. This to me, and I'd like you to push back on this, although I'm worried you won't be able to because you share my bias. This is the greatest injustice imposed by the modern medical system in our lifetime.
You are not going to get pushback from me on that. This is a disaster. I just got back yesterday from teaching at the largest internal medicine conference, ACP, the American College of Physicians, and you're talking more than 20,000 internal medicine physicians. What a wonderful thing. I was asked to give a course on female sexual dysfunction, and it was wonderful. I talked a lot about menopause.
There was no other menopause content at this course. There was no courses, how to prescribe, given everything you've done, my colleagues and myself have done to bring it into just popularity. Patients are coming in asking questions, and there wasn't even a course to learn about I can't say that's true for GLP-1s or any of these lipid-lowering agents or all of the things that you've been pushing.
The problem is you now have a brain drain, I think, because the doctors who prescribed hormone therapy either retired or died, and there was no one they taught ahead of them. Now, I was very lucky. I had very good mentorship and incredible experience, but we are now trying to make up for lost time to train people how how to write prescriptions.
So it's not enough to say, hey, the WHI was misinterpreted and we've done a bad thing for women. People don't know how to do this. It's a huge problem. And the reality is this is half the population. This is not niche medicine. The fact that menopause medicine is the tiniest little room of subset of gynecology, which it should not be under gynecology. This is whole body medicine.
And yet nobody seems to care.
Yeah, it's really interesting to hear you say that because you're highlighting something that's as dramatic and potentially more dramatic than the thing I've tended to focus on. I've focused more so, maybe I just take for granted that I got lucky and I had amazing mentors and they taught me how to do this stuff, but it's also the nature of my personality to just
be endlessly curious and show up in somebody's clinic for two weeks and do this. I've tended to focus on the lost generation of women. So I had my analysts do this analysis two years ago, and I don't remember the exact numbers, but the analysis was
Calculate for me or estimate for me the number of women who were deprived of HRT because of the WHI and calculate the excess mortality that was achieved through that injustice, through hip fractures, cardiovascular disease. We just went through the entire list.
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Chapter 6: How did the Women’s Health Initiative (WHI) study impact hormone replacement therapy use?
So birth control turns off your ovaries, and it adds back a final estradiol and a synthetic progestin. It doesn't add back testosterone. So we are botching testosterone for women along the life cycle, to be honest. But if you take someone who's never been on birth control, their testosterone starts to drop in their 30s. So what are they complaining about? It's not just a libido thing.
We know there are testosterone receptors all throughout the genitals and the urinary tract. So we see women have an increased risk of UTIs. We see an increased risk of pain with intercourse or pelvic pain conditions. We see there are some studies that indicate potentially depression and anxiety can increase because we do think there's a testosterone effects on the brain.
But we have global consensus. And I don't know if you've read the news lately, Peter, but we don't agree on too much as a globe. But there is global consensus that testosterone in women works for low libido. And so specifically, the data is on postmenopausal women. That's where the global consensus is. But there is data in perimenopause and much smaller studies before that.
The consensus is it works. But everyone has emotions about testosterone. I didn't think testosterone was a feeling, but apparently it is a feeling for people because people hate talking about it. And again, nobody taught you how to prescribe it. And there's no FDA approved product for women, except in Australia, it's approved by their governing body.
And so you have a lost art of knowing how to give people back testosterone when they are symptomatic.
I think this is an area where women sometimes are also a bit concerned about what happens if I take testosterone because testosterone, understandably, conjures up images of all sorts of things from large muscles, big mustaches, lots of other things. So how do you talk to women about this? We enjoy having these discussions and also acknowledging side effects from
The most common side effect we see in women is acne. I don't think I've ever gotten to the point where I've seen any of the really dramatic side effects, but I do tell women, I say, look, there's a decent chance if you were shaving your legs every five days, you're going to be shaving them every three days. That's a chance.
If you were kind of susceptible to acne growing up, you might get a little bit more of it and we'll have to back off. How do you talk about the risks of testosterone therapy?
I love talking about this and I'm actually grateful for celebrities because just in the news in the past few weeks, Halle Berry says she's on testosterone. Kate Winslet says she's on testosterone therapy. They look pretty amazing to me and they don't look androgenized at all. And so I actually want to do this study.
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Chapter 7: Why is there a lack of training and knowledge among doctors about menopause care?
But it does give me hope that a new generation of women will come along and take ownership over their health. And look, I've seen a change in 10 years. 10 years ago, when I was prescribing hormones to women, you cannot believe the fights I would have with their other doctors. And I don't mean like we weren't fist fighting, but they were scolding me like, how dare you?
But it came with an arrogance, a lack of willingness to even look at the data. which I found ironic. If you want to scold me, you better know as much as me and hopefully more. But this arrogance of I'm going to scold you, but I know nothing.
And I'm not actually willing to have a discussion with you because I'd be like, great, turn to figure two in the JAMA paper and let's look at this and look at the appendix and look at the supplemental data. Like, are you seeing the same thing I'm seeing? Can we at least agree on the fact?
No, we can't. And it's so fascinating because I would never, I do sexual medicine, so I look at the whole patient, I look at everything, and I would never say to them, hey, you have to stop this beta blocker right now because it's causing your erectile dysfunction.
I would never tell a patient that, though the beta blocker may be worsening his erectile dysfunction, but I would never say, stop this medicine. It's hurting you. I would talk to their doctor. I would have a conversation. But there's something about hormones that doctors who know nothing feel very confident in saying, you can't be on this.
You must stop this without even having that curiosity of, huh, I wonder if the person who prescribed it actually knew what they were talking about. And it is everywhere. We see this all the time.
Now, let's talk about the flip side, because the unfortunate nature of everything we've just described is you create a fringe movement. And unfortunately, I've seen a lot of dock on a box hormone practices that are, I believe, putting women at risk and I believe are doing bad things to women in the name of doing good. And I don't believe that these are inherently bad individuals.
I think they're ill-informed. I think they're just not that bright. And maybe some of them are just actually charlatans and they're seeing an enormous opportunity here. As a general rule, I tell patients be very, very suspicious of a doctor that is selling you hormones. Be incredibly suspicious of any physician
who has their own compounding pharmacy within the practice and is giving you compounded formulations and also making money on it. Talk a little bit about, I don't want to call it the dark side, but just the fringe side of this world.
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Chapter 8: What role does testosterone play in women's sexual health and hormone therapy?
I typically start orally.
You're going to start at 100 milligrams, 50 milligrams.
Depending on your dose of estrogen. I typically start with 100 milligrams. Some people say if you're going higher with your estrogen, you may need to do 200 milligrams of progesterone. That data is not very clear. And there's really two ways to give progesterone. You could do it every single day, so typically 100 milligrams every day.
And then some people in a lot of data shows if you do it cyclically, like 200 milligrams 12 to 14 days out of the month is another way to do it. Both are fine. When we see many patients, they feel better doing it 100 every day because it can help with sleep and anxiety reduction.
Do we believe that 100 systemically is sufficient to oppose estrogen?
I think there is not enough data there and we need more. I think if patients bleed, it's a nice tell that maybe they need more progesterone.
I think there's some interesting that I've learned that some people say if you take it with fat or you take it with something to eat, it absorbs better because progesterone is not absorbed very well, which is why we always had synthetic progestins in the first place. And so we're still learning the capabilities of micronized progesterone.
But according to most menopause specialists out there, they typically will use 100 milligrams every day or 200 milligrams 12 to 14 days of the month.
So the only thing that we do I would say different there is while we start women at 50 to 100, we will generally take them to 200 if tolerated, and if not, keep them where they are at 100. But we find women who are in that one-third to one-half group who are very positively selected towards progesterone, they feel fantastic at 200. The most notable improvement is sleep.
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Chapter 9: What are the biases and barriers affecting hormone replacement therapy adoption?
And it doesn't drive up SHBG, presumably?
Presumably, because it doesn't go through the liver, which actually, if you think about it logically, I love logic here because we don't have a lot of data, so we love logic. I said, well, if you take an estrogen ring, a high-dose estrogen ring, and you put it in the vagina, same thing. You absorb estrogen vaginally. What's the difference there, right? A sublingual estradiol.
So I think it's fascinating. I don't have many patients on it, but I would love to see data look in that direction because it's cheap. Oral estrogen is cheap. You get lots of doses. You can dose it
Does that mean you can get away with a lower dose?
You can get away with a lower dose. Absolutely.
You must, right?
Yeah.
Because of that first pass effect. So how do you dose it?
Again, I don't have patients on this and I haven't seen any studies on this.
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Chapter 10: What are the safe and effective hormone therapy options for women?
So we're going to get a lot of hate. There's a lot of disagreements when it comes to hormone therapy, how to properly do hormone therapy, how to check for hormone therapy. And one of the places, and it's funny because I truly believe, and for anyone who's going to say mean things about me on the internet from this podcast, I truly believe that actually most of us agree on like 98% of this.
Truly, we want women feeling better. Most of us believe the data that hormones, the benefits outweigh the risk. And so I think 98% we agree. There's the 2% where there is disagreement, and part of it is also in the what we don't know yet, the unknown and the curiosity and sort of things. And lab testing is one of those issues. The book says never check labs.
If your doctor checks labs, they are really doing something wrong. You should only care about symptoms. And then you have sort of the fringe that are doing all saliva based testing every minute, check labs, do all these expensive labs, which I do not agree with. Again, the Instagram answer, the book answer, the Dr. Rubin answer of sort of there are reasons to check labs. And I do find labs.
Similar to you, my curiosity with labs is so fascinating. When you can capture this perimenopausal fluctuations and show the patient the reason you feel so terrible is because your estrogen was 1,000 and now it's zero and that hurts. Now, do I need numbers to know that that's what's happening? It actually helps patients quite a lot for them to look at this and see the data.
What is your take on that?
I'm actually surprised, but you have to understand, I don't spend any time paying attention to the buffoons in the periphery on this topic. I don't like the whole terminology around functional medicine. I don't buy into the idea that you need to be spending an inordinate amount of money on esoteric, non-validated labs.
You can go to LabCorp, you can go to Quest, you can go like any CLIA approved lab that knows how to do an assay correctly is all you need. Our view and what we tell patients is the symptoms are the most important things, but the numbers help direct my thinking. This is how we manage thyroid. This is how we manage sex hormones.
And to be clear, there's a caricature of the Dunning-Kruger curve that I just find so helpful. So for the folks who aren't familiar, on the x-axis, you have experience. And on the y-axis, you have confidence. In the sort of character version of the representation of this curve, you initially have a huge spike, which then falls into a valley and then a slow rise.
And of course, the huge spike is referred to as the peak of Mount Stupid, followed by the Valley of Despair and the Slope of Enlightenment. It's just important for people to understand that when you are on Instagram and YouTube, disproportionately, you are seeing people at the peak of Mount Stupid, which is to say they have very low experience, insanely high confidence.
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