unPAUSED with Dr. Mary Claire Haver
Menopause, Hormones and Women’s Sexual Health with Dr. Rachel Rubin
27 Jan 2026
Chapter 1: What is the role of OBGYNs in women's health?
And let me just say, as a urologist, nobody expects me to take care of all of a man's health needs. No man comes to see me for all of his medical care, and he shouldn't. He should have several different doctors that take care of him.
So the mere fact that we have OBGYNs and they are expected to take care of a woman once a year for 15 minutes with your legs up in stirrups and that's medical care for the rest of your life is unconscionable. And so women have to stop expecting their OBGYNs to know everything about their bodies because they simply don't. Why does an OBGYN know about your heart?
I don't know about a man's heart as a urologist to the level that an OBGYN is expected to know about breast cancer and heart disease and bone health. It makes no sense. The views and opinions expressed on Unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only.
No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. Today's guest is not only one of the most influential voices in sexual medicine, but someone I'm lucky enough to call a friend. Dr. Rachel Rubin is a board certified urologist and a nationally recognized expert in sexual medicine.
She is one of the few physicians fellowship trained in both female and male sexual health. And she serves as an assistant clinical professor of urology at Georgetown University. She has shaped the field through her leadership as the former education chair and current director at large for the International Society for the Study of Women's Sexual Health.
She also serves on the editorial boards of the Journal of Sexual Medicine and the Video Journal of Sexual Medicine. And she is a contributor and vocal advocate for the 2025 American Urological Association Guidelines on the Genital Urinary Syndrome of Menopause. Her work extends far beyond the clinic.
Rachel founded the Sexual Medicine Research Team, a collaborative initiative advancing clinical research in sexual health. Their work has pioneered our understanding around advocacy and around clitoral adhesions, genitourinary syndrome of lactation, and many other rarely discussed sexual health conditions. But before I ever knew the full depth of her credentials, I knew her fire.
I knew her honesty. I knew her relentlessness. Rachel and I have shared stages, compared notes from clinic, and cheered each other on through the exhausting work of changing healthcare for women.
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Chapter 2: Why is there a disparity in training for sexual health between genders?
I trust her not just as a clinician, but as an ally and truth teller. Advocacy has been amplified through her deeply personal experiences. During the July FDA panel on women's health and hormone therapy, Rachel spoke openly about her mother's challenging prolonged ICU stay and her difficulty accessing local vaginal estrogen to prevent urinary tract infections and sepsis.
She used this story to show the deep harm the outdated and incorrect FDA warning labels placed on patient care and physician knowledge. That experience lit a fire in Rachel that has fueled her entire career. It is the reason she fights outdated regulations. It is the reason she pushes for better training.
It is the reason she is tireless in making sure no woman is ever left in the dark about her own anatomy, her hormones, or her sexual health. Rachel is one of the rare physicians who combines rigorous scientific expertise with compassion, clarity, and courage.
She works, teaches, researches, publishes, advocates, and educates with a singular mission to bring women the evidence-based care they have deserved for generations. I love her fire. I love her honesty. I love her commitment to doing the hard, necessary work of rewriting women's healthcare.
I'm Dr. Mary Claire Haver, a board-certified obstetrician and gynecologist and certified menopause practitioner. I'm also an adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch. Welcome to Unpaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life.
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Chapter 3: What are the key issues surrounding women's sexual health education?
Welcome to Unpaused. Oh, my gosh. How cool that we're finally doing this. Oh, my God. You are like people don't know that we actually know each other. So when we're like, who should we have on the podcast? Your name was like at the top. Oh, my gosh. Like they want to talk about sex. They want to talk about sexual health. And I'm like, I am. And here we are doing it.
Let's let our audience get to know you a tiny bit. Where are you from? So I'm a little bit from all over. I was born in Ohio, moved to Connecticut, and grew up mostly in the Washington, D.C. area, which is where I am now. Medical training was in Boston, and my residency urology training was also in Washington, D.C. I did one year of fellowship, sexual medicine fellowship, in San Diego.
So I got to live in San Diego for a year, which is not a terrible place to have your first baby. And I'm practicing in the Washington, D.C. area. Okay. Why urology? For our listeners, most women do not choose urology as a profession. Yeah, every little girl dreams of being a penis doctor, actually. It's part of, you know, a life's dream. It is kind of strange how I got here.
Sometimes I wake up, I say, how did I end up here? You know, about 10% of practicing urologists are women. So we are a small but mighty group. We are very funny. We're very silly. And we can say as many bad words as we want. It's actually something you, we all like each other very much. But, you know, urology is a fascinating field, right? where you can take care of women. Nobody realizes this.
You can take care of women. You can take care of men. Because women actually have kidneys and ureters. Shocking. Women have kidneys and bladders and genitals. And urologists are sex doctors. We care about quality of life. We care about sexual health. And people assume that their gynecologists know everything about sex. And it turns out they don't.
And so it was a really fun field where I didn't have to deliver babies and be up all night. And I could do women's health without being an obstetrician. You did a sexual medicine...
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Chapter 4: How does the anatomy of the clitoris impact sexual health?
fellowship, which is rare as well. Yeah. What was that like? Yeah, I'm probably one of only a handful of people who can say that they're a sexual medicine doctor. Now, there are many people who practice sexual medicine, but these fellowships are rare and we're hoping to build more. That's one of my dreams is to have a fellowship. If I speak it now, I can put it into the world.
But this, you know, my mentor is a guru. Amazing. You should totally have him on the podcast. This guy, Erwin Goldstein, who really pioneered men's sexual health and then realized, well, wait a minute, there's nothing for women. And so he pioneered this amazing organization called ISWISH, the International Society for the Study of Women's Sexual Health, ISSWSH.
And he pioneered that over 20 years ago, around the time Viagra had come out. And it really has advanced the field of women's sexual health. His training is what I did. I trained with him. And you learn sexual medicine for men and women. You learn sexual medicine for everybody.
And it really was the only fellowship up until a year or two ago, it was the only fellowship that even acknowledged women's sexual health. There are a handful of us. We're the fellowship family. We call each other brother and sister. Now there are two programs that have come out, OBGYN programs for women's sexual health. But that's it.
You're talking about three programs in the last three years that even acknowledge women's sexual health. We have more than 27 for men's sexual health. And so the reason your doctor doesn't know how to talk to you about libido, arousal, orgasm, or pain is no one ever taught them. I learned nothing. Like, literally nothing. Nothing.
And say it louder for the people in the back because it's not your fault. Right. I just graduated from my training program. I could deliver the shit out of a baby upside down, backwards, all in the middle of the night, one hand tie behind my back surgery. Like I was trained so well how to take care of pregnant people and that's important.
I knew how to do a hysterectomy and basic gynecologic surgeries. I could do vaginal procedure, you know, remove a cyst or drain a, you know, infected area or whatever. But like, so I graduate and I go into my clinical practice and I'm super excited. I hang up my shingle and I open the door and the women come in.
And if they're not pregnant, they're coming for gynecology or they're well woman in their checkups. And I cannot tell you how many times I would blank stare at a patient and feel horrified that I didn't know how to help her. that she was complaining of some type of sexual dysfunction that was affecting her life.
And let me just say, as a urologist, nobody expects me to take care of all of a man's health needs. No man comes to see me for all of his medical care, and he shouldn't. He should have several different doctors that take care of him. So the mere fact that we... have OBGYNs and they are expected to take care of a woman once a year for 15 minutes with your legs up in stirrups.
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Chapter 5: What are the common sexual health issues women face during menopause?
And then there's also arousal and orgasm issues. So let's break those down because the listeners are like, whoa. Yeah, no. And there are some that really don't get talked about. So there's so again, sometimes low libido can be seen. Sometimes change in orgasm can happen. Sometimes change in arousal can happen so that either the erections or clitoral arousal.
And we see we see these different conditions, you know, genital what we call dysesthesia or when your genitals just don't feel like they used to. So patients report it's really it's wild because patients will say, I feel. feel like I feel nothing when my genitals get touched. Like I feel the sensation like you're touching me, but it's no different than if you touched my elbow.
There is no longer that sexual sensation. And you have to be very careful when you're listening to patients talk about sexual function because because sex education is really bad in this country that we often don't have the same language. So I have a guy who comes to see me, says, Dr. Rubin, I'm so mad and distressed and angry because my libido is gone.
And when you really talk to him at length and you ask more questions, it's not just his desire or his interest in sex. It's sort of his arousal. It's his connection to arousal. It's his, you know, erections and things like that. And so you have to talk to patients. And that's with men. It's hard with women.
It's damn near impossible because women are not taught anything about, you know, sort of language. They don't have the language. That's always the first thing I ask. A partnerectomy, I always say, can be sometimes a really good cure for your sexual health. I love I don't prescribe it often. I want to prescribe it often, but just to kind of cut your partner out of out of the situation.
But it is biopsychosocial. And I think too often we jump to that. It's all in your head sort of because it's easy. It's easy to tell people that and say, well, it's not my problem. Go see go see a mental health specialist. Why is sexual side effect counseling, why do you think this is? Routine in men. I think because you get fired as a clinician. And almost non-existent in women.
It's a great question. So again, let's go back to this. Your OBGYN, who's responsible for delivering babies all night long, emergency surgeries, massive blood transfusions, women dying in childbirth, dead babies. All the things. Like they are responsible for the most horrific and insane things that you've ever seen in your life. And then every 10 minutes, they're having to see someone else.
So think about going to a room being like, you have a dead baby. Let's talk about it.
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Chapter 6: How do hormonal contraceptives affect women's sexual health?
And then the next room being like, oh, your libido is low. Let's talk about it. Like that is not an easy life or job. There is a whole field of medicine devoted to the male penis, right? I am a urologist. I was taught, you know, the male penis is important. Erections are important. Arousal is important. Viagra is a billion-dollar industry.
If you haven't watched the series on Viagra, it's fascinating because it's all about the marketing. It's the biggest marketing campaign in the history of the universe. So you have a whole field of medicine devoted to the male penis. Yes, we do prostates and bladders and kidneys, but that's kind of, you know, that's sidebar. And the clitoris isn't even discussed in OBGYN sort of training.
So you all. And we know that there's one. So, yeah. We kind of know that top part. But if you look at CREOG, which is sort of your check marks of what I must know to graduate as a resident. I was a former program director. I was in charge of the CREOG guidelines to make sure that we were covering all the lectures to hit all of the points. And the clitoris was not a part of it.
And what I understand and what I've heard is the word clitoris does not appear on any of those, you know, sort of segments. And so you have to understand. So it just isn't in the routine discussions of, you know, what women have with their doctors.
And yet with because of Viagra, because of sexual medicine in men, because of the pioneering research and work that people have done in this space, it has become just bread and butter urology. Right. But it doesn't just happen. It happens because people made it happen, because researchers made it happen, because money made it happen, because Pfizer made it happen. Right.
They saw an economic opportunity. That's why it happened. And so when we dismiss women, when we say it is all, you know, again, we have incredible, incredible psychosocial research for women about sex therapy, about mindfulness, about cognitive behavioral therapy, because there are strong, powerful women in those fields that do the research. So then we think it's all psychosocial, but it's not.
It's just that the people being the loudest and doing the work are the psychosocial researchers. And so we don't mentor and fund and support women doing sexual medicine research. Because if you want to be taken seriously as a woman, you study prostate cancer, you study breast cancer, you study bone health. You don't study the clitoris, right? We are the laughingstock of the medical community.
And yet when your orgasm breaks down, who do you go see?
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Chapter 7: What options are available for improving women's sexual health?
Who takes care of you? Who can you even talk to about it? So one other drug I want to cover as far as sexual side effects and this week, you know, I feel like we have to tread lightly because this is like a hot topic political.
Anytime we mention birth control and we talk about proper counseling and shared decision making and side effects, a lot of people get really upset because there seems to be a certain political group that wants to remove all access to contraception. That is not what we're talking about here. So I just want to be clear. These are medications that have side effects.
Walk me through, because this has happened to patients and I didn't know how to help her, that of some of the sexual side effects of being on oral hormonal contraception where we're suppressing ovulation. Yeah, so the data is... mixed here, I would say. And I would love to see more data on it. But let's think of how birth control works, okay? Birth control, different kinds of birth control.
But if you take an oral contraceptive that is a combined estrogen progestin, the goal of it is to turn off your ovaries, which is elegant, right? So you don't ovulate, you don't have a baby. You don't have a baby. Well, you're winning. And there's no fluctuations of your hormones. So in many ways, it's very elegant and quite lovely.
The challenge becomes when you are giving back this large dose of a final estradiol and a progestin, that comes with side effects for some people, weight changes, mood changes, potentially other changes. Like any drug, there can be side effects, which is totally, again, reasonable for any drug to have side effects, pros and cons. Right.
But what it doesn't do, like the ovary, the way I was taught, does estrogen, progesterone, and testosterone. And so there's no conversation about testosterone.
And so if we believe as a society that testosterone, that women have testosterone and make testosterone, and we know that testosterone helps with libido, well, then if women take birth control and are complaining about low libido, which I know a lot of you listening are complaining about, is the logical answer that it may be a testosterone problem. It makes logical sense. Right.
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Chapter 8: What steps can women take to reclaim their sexual health?
Do we have all the funding in the world and all the research to prove it? No. But for all the people listening, we would love to fund some research on this. But it may be a testosterone story. Now, again, I said that vulvar vestibule where people have pain with sex at that opening around the urethra has testosterone receptors. So researchers have seen that.
That when women take birth control pills, that tissue can get red. It can get irritated. It can get painful. And when you examine it, you find a source of pain. And so women have pain with tampons. They have pain with sex. Said, oh, I was fine until I started my birth control pill. And then everything went south.
And so for those patients, we get their story, we talk to them, we examine them, and we say, huh, could this be your birth control pill? Could we switch to something like a Mirena IUD, a hormonal IUD, which actually is not a combined, doesn't shut ovulation off, so you still can make your own hormones. And we find that is a lot better for contraception for these patients who are prone.
And not every patient that takes birth control has these side effects, but those who do, they may have improvement. Now, we also add back some local hormones, whether it's vaginal DHEA or topical estrogen or a topical estrogen testosterone that gets compounded, right? Those are treatments that we have seen work for these patients.
And pelvic floor physical therapy, which all of those combined can be life-changing. Not to say that also sex therapy also is wonderful because if something hurts you all the time, why would you ever want to do it? And you got to work on those aspects as well. So birth control, it has side effects like any other medication. And we should not dismiss those patients who say they have side effects.
And we should be counseling women just like before they have surgery. We should find out, do they have pleasure in certain areas? We should be asking patients about sexual health when it comes to their birth control choices. Because informed consent and shared decision making is the right way to do things, right?
And so what I find patients get most upset about is, well, no one told me that was gonna happen to me. I didn't know what to expect. This could be a possibility. I didn't even know that my birth control was the reason why I had pain with sex. And when you give them that information, some of them stay on birth control. Some of them switch to an IUD.
Some of them have like they have options, but they feel in control of those options. And again, that is medicine. When a patient knows what's going to happen and they can say, you know what, I heard all the options. I've weighed my pros and cons. This is what I would like to do. Right.
And again, if you're thinking medical legally, like I think those patients sue less because they feel like they were informed and a part of the decision making process. Right. Oh, spironolactone. Let's go back for a second. Another medication with surprising, very commonly given for acne, for hair loss, you know, how does it work and why would it change?
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