My Personal HRT Protocol with Dr. Rachel Rubin, Urologist and Sexual Medicine Expert
about the episode
Why Do Women Feel “Not Like Themselves” in Midlife? Dr. Rachel Rubin on HRT, Menopause & Hormones
Why do so many women reach midlife feeling dismissed, exhausted, and “not like themselves” and why are so many still struggling to find evidence-based care?
In this episode of Innovate & Elevate, Sharon Kedar speaks with Rachel Rubin, board-certified urologist and sexual medicine specialist, about the menopause care crisis and why better hormone education may change women's health for generations.
Together they discuss hormone replacement therapy, testosterone, vaginal estrogen, progesterone, systemic estrogen, and Dr. Rubin’s framework for helping clinicians better understand midlife health. The conversation explores why menopause care is about more than symptom relief and why dignity, education, and access matter.
What You’ll Learn from this Episode:
The Midlife Care Crisis: Understand why women are often left to navigate menopause symptoms like brain fog, joint pain, and sleep issues on their own, and how the medical community's siloed approach to care has failed them. Dr. Rubin explains why this is a systemic problem, not a failure of individual doctors.
The "NFLM" Diagnosis: Learn about the "Not Feeling Like Myself" diagnosis that Dr. Rubin uses to describe the common, but often dismissed, symptoms of perimenopause and menopause.
The Five Pillars of HRT: Get a detailed look at the five key areas of hormone replacement therapy that Dr. Rubin covers in her course for clinicians: systemic estrogen, progesterone, testosterone, vaginal hormones, and vulvar vestibule cream.
A Call for Dignity: Hear why Dr. Rubin and Sharon believe that access to proper menopause care is about more than just managing symptoms—it's about a woman's fundamental dignity. Dr. Rubin shares a poignant story about a patient who was at risk of dying from a UTI due to lack of treatment
About dr. rachel rubin
Dr. Rachel Rubin is a board-certified urologist and a fellowship-trained specialist in sexual medicine. An assistant clinical professor at Georgetown University, she is dedicated to providing comprehensive care for people of all genders. Dr. Rubin is a passionate advocate for human health, working to advance the fields of research, education, and advocacy in sexual medicine. She is a prolific educator, teaching doctors how to prescribe hormone therapy through her online courses.
Connect with Dr. Kelly Casperson on LinkedIn, Instagram, or her website. Take the Hormone Therapy for Early Adopters course.
Episode Outline
(0:00) Introduction and The Menopause Care Crisis
(1:50) What Midlife Care Looks Like with Dr. Rubin
(6:08) Why The Medical System Got It Wrong
(11:00) Fixing the Marketing Problem
(15:15) The Fear of Breast Cancer
(18:25) The Dignity of Aging
(20:01) The Care Crisis and Dr. Rubin’s Course
(25:40) Unpacking the HRT Prescriptions
(26:10) Systemic Estrogen (the "Workhorse")
(30:22) Progesterone
(35:50) Testosterone
(39:40) Vaginal Estrogen: A Life-Saving Treatment
(44:40) Vulvar Vestibule Cream
(46:25) Dr. Rubin's Wish for the Future
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Sharon Kedar, CFA: Welcome back to Innovate and Elevate. I'm Sharon Kedar, your host.
Welcome, my good friend and my personal doctor, Dr. Rachel Rubin, to the podcast. We've been working together for a couple of years now. I'm 51 and I take five different medicines, which we will unpack in today's episode. Let's talk about how we got here and how we're really going to fix this menopause care crisis.
Speaker 3: First, just a quick background on Dr. Rachel Rubin. She is a board certified urologist and a fellowship trained expert in sexual medicine. She's an assistant clinical professor at Georgetown University, and she's dedicated her career to providing comprehensive care for people of all genders.
So let's dive into this conversation.
Sharon Kedar, CFA: I have my good friend and my personal doctor, Rachel Rubin, on the podcast today. Hi Rachel.
Dr. Rachel Rubin: Hi. I am so glad we finally got around to doing this.
Sharon Kedar, CFA: I like your necklace.
Dr. Rachel Rubin: Thank you.
Sharon Kedar, CFA: Do you think people actually knew what you were wearing? Your necklace on Peter Attia?
Dr. Rachel Rubin: I think some of the women did. I think probably 5% of the women who saw it knew what it was, and 95% of all humans had no clue.
Sharon Kedar, CFA: Wait, that's what's so awesome about you is you are blazing the freaking trail. Like you are redefining, in my opinion, what it means - not just like women midlife, but dare I say, to be a woman.
Dr. Rachel Rubin: That's very nice of you to say. I think the reality is, I try to talk about sex like it's high blood pressure and diabetes and really bring it back to biology and physiology and how the body works.
Sharon Kedar, CFA: I wanna take the listener and viewer into the doctor's appointment with you. So you've been my doctor for a couple years. I'm 51, and I just think most people don't get to have this appointment with you. I brought my husband, Greg, who I've been with for 30 years to see you last month, to see you at the first appointment.
I think it is so much more than sex. And I'm just gonna go on record. You are redefining what it is to be a woman, 'cause I think women are basically like discarded at midlife almost, and it's like we birth the whole population. So can we talk about midlife and can we talk about what a midlife appointment looks like with you? I think you're just so natural at it that you just think it's normal. But before we do, do you think it's more than sex?
Dr. Rachel Rubin: It's a lot more than sex. It's funny as a urologist, right? I was raised being a urologist, so I take care of men, I take care of men's quality of life, all sorts of things. I never thought I would treat so much joint pain, so much brain fog, so many sleep problems.
Yes, so many bladder and sexual health issues, which I was trained to do. But because when we look at the whole picture and the whole person, you find that there are so many areas screaming at this time period about when there is a change in hormones. And so you have hormone receptors throughout your whole body, and they don't teach us in medicine,
we're very siloed. The gynecologist focuses on your reproductive organs, the cardiologist focuses on your heart, right? Like, very few people are looking at the whole picture. And there's many reasons why they've ignored HRT for so long as you can see from Sharon's button there...
Sharon Kedar, CFA: With HRT being Hormone Replacement Therapy, for anyone who's new to this, which is basically something that all women's hormones, as Tamsen [Fadal] said at her party for Vonda [Wright], run out the door at a certain age. They don't walk, they run, but...
Dr. Rachel Rubin: Yeah, no, I think right there is, in your 30s and 40s, the best way to describe it, I think it's so beautiful is NFLM, Not Feeling Like Myself. And so really when people come to see me, I really let them tell me their story.
Sharon Kedar, CFA: That's what's so amazing. So I know that you can't just sign up for an appointment with you, practically, for a lot of reasons. By the time I got to you, I had seen five doctors. Nobody had told me that, basically, I would have a baby at 40 who was my third, and then in that same third C-section, basically have my tubes tied, which was my choice, but effectively, enter into perimenopause.
Nobody explained the concept. You'd think I'd know 'cause both my siblings are doctors. I'm the only non-doctor. But I think you hear this story all the time. But I think the biggest part of the care crisis, and then we'll walk into your office, is that no one tells us. So how do we even know that this is happening?
Has anyone ever walked into your office actually ahead of this yet? Maybe our daughters will, but is everyone like a hot mess like when I walked in? And I don't wanna minimize myself and describe that way, but I wasn't sleeping,
I had brain fog. It was, like, Help me, Rachel. At that point it was Dr. Rubin, and then we quickly became friends.
Dr. Rachel Rubin: Can I tell you I am hopeful, actually. I had a neighbor who texted me last week and said, I started having bad sleep and I had my first hot flash, and I am quickly patched. I just got my first patch. And I never would've done this so quickly if it hadn't been for your social media and me following what you're doing.
She's not my patient, she found a different clinician to help her, but I'm really hopeful 'cause she didn't suffer. Whereas I saw someone else, who was a family friend who I see at family functions, who basically didn't come see me till she was 53. AndI'm not quiet or shy about what I do.
She knew who I was and what I did for years and years. She finally said, What the hell have I been doing for 10 years? And basically told her family members who are younger than her, don't wait. You don't have to feel this way. So I think, what you're doing is so important and revolutionary and I don't wanna minimize the importance of people who are bringing awareness to this topic. The more you realize that NFLM, Not Feeling Like Myself, is a diagnosis in and of itself, of: Is your sleep different? Is your mood different? Is your sexual health different? Are you feeling hot? Is your temperature different?
Are you getting hot flashes, night sweats, heart palpitations, aches and pains? The joint pain is a huge one that we have dismissed. So we are not making this up. It's not new, it's just that we didn't have language around it. And I think what's beautiful is now there's a lot more awareness and language that we're putting towards a problem that has been around for our mothers and their mothers before them.
Sharon Kedar, CFA: I have chills 'cause I'm just going to go on record saying that I think you're a women's Dignity Doctor. I think about women like my mom, who you know. Because of you... She's 77 and she was pulled off of her estrogen 20 years ago and she hasn't slept in 20 years.
I literally have chills. But these conversations don't even come up. Someone just today offered her an estrogen ring. She's got some additional issues, but I asked her like why? And I guess it's like, why did you settle for where you were? And I guess that's like a big question I have. If I'm defining you as a women's Dignity Doctor... which, by the way, I think is super pro families. I think that any partner, any husband is so much happier when you know their midlife woman is on the right treatment. But why did we get it so wrong? And I know that Peter [Attia] called it the greatest medical indignity of our time.
I didn't tell you I was showing up at the FDA, but I wanted to support you that July day. You will forever be in my head about that. But why did we get it so wrong and how do we fix it? And then I'd love to save time to just go through like a doctor's appointment with you.
Dr. Rachel Rubin: Yeah, I think there's a lot of reasons and we could write books and books about how... all the different ways we've gotten it wrong and why it's so wrong. And I think we often lack a humility in medicine to say, hey, we got it wrong and we need to do better. Sometimes we do the best that we can with the background that we have and the information that we have.
In the field of OBGYN, we expect those brilliant, amazing, wonderful humans who have no resources, who are expected to take care of half the population. I'm a urologist, right? I'm a men's health doctor. No man comes to me for his heart, for his lungs, for his brain, for his breast exam.
No man comes to me for everything. And we expect the idea that a 10 minute visit with your legs up in stirrups once a year as adequate healthcare for a woman. We ask OBGYNs to be emergency room doctors, to be surgeons, to be baby doctors, to be pregnant people doctors. We ask them to do primary care. We ask them to do too much with no resources, with higher malpractice costs, with no extra training, with no support. And the rest of the medical community saying, women, that's an OBGYN issue, go to your GYN. It is unconscionable what we're doing.
Sharon Kedar, CFA: Every doctor should know how to take care of women, actually.
Dr. Rachel Rubin: We should do a better job of training all the doctors to understand women's health and not just through the lens of this was studied in men. And the problem is it just takes time. We need more women in high research positions and high places of power and with funding.
It is changing 'cause of people like you and your friends and people who are saying, Hey, we need more research in this and awareness.
Sharon Kedar, CFA: But there's just so much to unpack there. So when you said, this was studied in men, basically this idea that medicine, I just think it's helpful for people to know, doctors mean well. But the history is that the system was trained on a 75 kilogram man. And so we can look back at all of the history. Going forward, I think that the reason I'm involved is, I just want people to know it's like, I went to five different doctors, was prescribed the wrong medicines. I just want women and their families to know that they're gonna have to advocate for their care.
How do we fix this care crisis? I can imagine that we enhance medical school curriculums. You're doing amazing work with your class, which I'd love to unpack, but how do we get women like my 77-year-old mom to know to ask. She was, like, I didn't even know I needed to ask. And it's like suddenly she's got an estrogen ring which she only has to replace every three months. I know that the whole vaginal estrogen conversation is gonna take 17 years to go from the new protocol to doctor's offices.
So what do we do?
Dr. Rachel Rubin: I actually think you are uniquely able to put your brain on this and help us because I think actually a little bit we have a marketing problem. Like we actually have a marketing problem that is fixable. I always talk about how we're at a battle on many fronts. We are battling the status quo in that we are not using the tools that we have and have had for decades.
We're not using them appropriately. You weren't offered the tools that we do have. We have the unknown, right? The things that need to still be figured out, the research that has to happen. We have the battle against the snake oil; the people who are trying to take advantage of women and families that spend money on things that don't actually work and have no evidence or science behind them.
That's why we went to the FDA, because when your mom gets her estrogen ring, there is a label, a big box label on it that says it's gonna cause a stroke, heart attack, blood clots, probable dementia, none of that is true.
Sharon Kedar, CFA: I don't even think people realize the 20 years of misinformation that happened from the false information from the 2002 government funded Women's Health Initiative until the Menopause Society in 2022 updated guidelines, which is like 20 years.
But you're saying that now the misinformation has been updated, but...
Dr. Rachel Rubin: But there's still a marketing problem because it's not getting to the people who need to hear it. And so we do, we have a marketing problem of getting people to know why it's important, how to do it, how to change it. And then really for me it's how to write the prescriptions. 'Cause the challenge is, and who is responsible for writing these prescriptions?
Because it should be primary care doctors. It should be cardiologist or orthopedic surgeons.
Like people dying of fractures, they have horrible osteoporosis, they get urinary tract infections after their joint replacements, they can't exercise 'cause their muscles have atrophied. So they are the most important doctors to talk about estrogen and testosterone...
Sharon Kedar, CFA: That's why I think it's women's dignity. Like I think we're literally talking about dignity. I did a post last year for season one that talked about how breast cancer doesn't care about your political party.
This just has to do with, no matter who you are, your own personal dignity. But when you say that there's a marketing problem. And it's funny 'cause someone asked me to be on a marketing podcast for the health of women. I was like, I'm not a marketer. Like I'm a venture capitalist, I'm an investor, I'm an innovator, but I'm like marketing?
Dr. Rachel Rubin: I didn't mean it from the venture capital, but from the Harvard Business School approach, right? This idea of, from a business perspective, how do you sell a product? How do you get popularity? How do you sell an idea to someone? You are uniquely qualified to help us get out of our own way 'cause I think right now we're not getting out of our own way. And we need big thinkers like you and others who can, and this is why, right? When the Melinda Gates comes out and says she's gonna fund hundreds of millions of dollars worth of research. The challenge is that it doesn't get us anywhere because these researchers and scientists and doctors don't know how to message and market and really get to the important issues.
Sharon Kedar, CFA: To your point, there is a cycle that needs to be broken and that was talked about a bit last season and some things surprised me last season with the health of women. I didn't think it should be too surprising to the world that mice don't menstruate and when that was said to me by Don Ingber, it surprised the world 'cause mice are the bedrock of research today. Basically that effectively means women are human lab experiments. But the part that I think is the marketing problem right now, and I haven't unpacked this enough to understand it. The part that I think is the biggest marketing problem is one in eight women will get breast cancer.
And the fears from 2002 about breast cancer, I don't know enough to talk about that, but when I really have private conversations with people, to me, and I don't know if that's what you hear, to me, that's the thing that scares people the most.
Dr. Rachel Rubin: I think the reality is, not every breast cancer is the same thing and not every patient has the same risk factors. And actually this blanket,
like, you can't have this, we have to move past that, because it's dignity. Everyone's gonna die. You and I are both gonna die. And the question is, how are we gonna live and with what dignity?
Because my grandma, God bless her soul, had dementia and osteoporosis and lived a floor apart from my grandfather, who broke her ribs just giving her a hug, and she didn't know who he was. I don't wanna live to 93 and be that way, right? If I'm gonna live till 72 but be able to live a life of purpose and strength. That's what I choose. But...
Sharon Kedar, CFA: Wait Rachel, I'm covered. I'm covered in chills because like the train has left the station on the call for dignity. Like my mom said, I could say this and my sister laughs when I say this, but when you think about women's dignity, my mom is finally getting the treatment she needs, but she has an issue that she didn't even tell me.
It's like women just suffer and it's a condition called Lichen sclerosus in her vagina. Where's the dignity to level up? I wanna go through, 'cause it was actually really hard for me to get on my own HRT, reclaim my dignity, learn that I do deserve to sleep again.
As I turned 50 and it was like the lights went out when I suddenly wasn't sleeping. But before we go there, can we just talk a little bit about... so what you're saying is you think it's effectively all doctors. And I do agree 'cause I think menopause can and should be, whatever you wanna call it, women's midlife, a specialty. But that will take years. I was trying to think of the last time a specialty emerged. I think family medicine emerged in the 60s. Neuroscience emerged in a field around the same time.
That's not a medical specialty, but there is precedent for... but it takes a long time for medicine to emerge, and for new specialties to emerge. But like, until then, we need GPs, general practitioners, we need OBGYNs, which, okay, maybe it's 20 different fields, but it's at least the child birthing years and the following years are separate where women deserve a conversation.
And I think my big message to people right now is, I do love doctors. I wanna get another pin that says, I love doctors. They weren't trained on this. For whatever the reason, keep going to doctors till you get to the right one. But can you just talk about your course and how you came up with it and like how you think that'll fill things.
But also, where should someone go? I do think it's a care crisis. So I asked you a lot, answer it however you want, and just thank you for being part of the answer.
Dr. Rachel Rubin: The care crisis is so overwhelming and so all consuming that my way out of it is through action; is how can we take as much action as we can to move steps forward? So what I've chosen to do is focus on research, advocacy, education, and mentorship. I really try to live my life with those goals in mind.
And so one of the things is I try to take action wherever I can. So I see the patient one-on-one in the exam room. We're gonna talk loudly about your case publicly, which will help so many people be - and I love this idea of being able to do that. But then it really came to me as how, I do a lot of courses,
I teach for Harvard, I teach for all these people where I go and I try to teach. And one of the ways that I try to teach is, I put prescription pads on the big slides and I say, this is how I write the prescription. It's the way I've learned to teach. And everybody kept saying, oh, your lectures, they're so funny, they're so interesting, they're so helpful. And so I actually had a friend who said, okay, where's the course? Where's the course? We put together a very short course with continuing medical education that teaches doctors how to write the five common types of prescriptions in menopause care.
It's about a five-hour course. It's not that long. There are modules that we've made that are 20ish minutes so that you can do it on a commute and you can just listen to me, and I'm hilarious. But it's a really very basic question, why did we get to where we are? How do we talk about the Women's Health Initiative?
I teach through the concept of what are you afraid of? And so when a doctor says, can I do this to a 52-year-old woman with a history of high blood pressure, my answer back is, What are you afraid of? If they say stroke? There's no increased risk of stroke when we use transdermal hormones in this patient population.
And I show the data. And so we teach them what they think they're afraid of and then we match it with data to say, you shouldn't be afraid of this for these reasons. And at the end of it, it's for basic prescribing of hormone therapy. Again, the very complex cases, the complex pelvic pain cases, the complex sexual medicine patients, send 'em to a specialist like me or one of my colleagues where you can find them through ISSWSH.org is a way to find sexual medicine providers. But the reality is basic menopause care should be - anybody can and should be doing it. So this course, we go over the five common things that we have to care about, and that's what we can talk about your prescriptions and what you chose out of the toolbox. So the five modules of this course are whole body estrogen or what we call systemic estrogen.
And that could be a patch, a gel, a ring, or a pill, right? There is a whole body progesterone, which means if you have a uterus, you have to protect it with progesterone, but it also helps you with sleep and anxiety reduction in most people, not everybody. So estrogen, progesterone, testosterone, which is, helps with libido.
And all of my patients say it helps with so much more than just libido, but we go over the evidence-based reasons of how and why to prescribe testosterone, which is lifesaving and wonderful for many people. Vaginal hormones, which is the most important thing for your 98-year-old grandmother in the nursing home, or your perimenopausal patient, because it will prevent urinary tract infections, will make sex not painful, will help with lubrication, arousal, orgasm will also help with frequency and urgency in getting up in the middle of the night to pee.
And the fifth one, and that's the most, I would say, nuanced and expert level thing that we sometimes talk about is the area at the opening of the vulva called the vulvar vestibule, which requires some hormones, both estrogen and testosterone, to help with pain with intercourse. And so that's an extra bonus module.
We do have a module on libido where we talk about some libido drugs, non-hormonal options and things like that. We teach people in this course how to do exams, how to talk to patients. We go over the data and we give the papers of why this is so important. And we've had hundreds and hundreds of doctors now take this course.
And clinicians, we've got nurse practitioners and PAs. But for me it's the start of like, how can we make sure the prescriptions are getting written? So that's a big overview, but let's talk about what you've chosen to do.
Sharon Kedar, CFA: Let's talk about it, for anyone who's listening who is a doctor, 'cause I do have a lot of doctor friends, where can they take the course?
Dr. Rachel Rubin: Yeah, so it's on our website, rachelrubinmd.com under the education page. You can find it on all my social media. It's online, so it's just a course platform that we've used and you can get some continuing medical education credits. The nice thing about it is you don't have to show up.
You do it at your own pace. So it was really beautiful. And my birthday actually was last weekend. And someone posted on Instagram that they were sitting there with coffee on a Sunday morning, taking my course. And I was like, that is the best birthday present in the world knowing that I was not teaching and, on my birthday, thank goodness my husband would've killed me. I was not teaching on my birthday but that someone was learning how to do this. It just gives me chills to think about. Again, people are talking about it 'cause people, as you said earlier, which I think is so important: doctors care. They wanna do the right thing, they wanna help you. And they really are good people that are suffering right now. Also, doctors are really suffering right now. And, the reality is, no one taught them how to do this. They truly don't know how to do this. And so I'm trying to help them say, I get it.
I get you don't know how to do this. Let me help you. And really, if I as a urologist can do this, you as a brilliant primary care doc, OBGYN, endocrinologist. You can do this. And the way I know that I'm onto something is that I spoke this last year at the American College of Physicians, which is the largest internal medicine conference in the country.
There are 20,000 doctors, and I was asked to give a course on female sexual medicine, and I put a lot of menopause content in the course. And doctors, and I am one of them, never fill out evaluations. We do not do it. We do not fill out a commentary. And there were 275 people in the room, and I got 275 thank yous with comments about how it was like the best lecture they ever
I heard how they learned so much, and the comments were just so incredible.
I got a standing ovation at the end of my talk, which we don't do at medical conferences.
Sharon Kedar, CFA: As you should though. As you should.
Dr. Rachel Rubin: But it, they're hungry.
Sharon Kedar, CFA: And the reality is no other content at the meeting was about menopause or women's health.
Yeah.
It's almost like your point, permission to dig deeper just given some of the history and some of the fear and just... so we'll talk through actually those exact five areas.
Dr. Rachel Rubin: You meet people where they are and you give them what they need. The first time we gave you things wasn't like, oh, everything's perfect and now everything's perfect.
I think sometimes there are challenges. It is not a one size fits all. Not everyone needs the same thing and not everyone needs all the things. The more you can learn about it, the more you can tinker and say, okay, now I'm really not sleeping, so now I really need to try this.
Sharon Kedar, CFA: So I'll just start with where I am now. But I'll just say and Rachel knows this, it was a two-year journey, and this is a little bit embarrassing, but I was so overwhelmed and this is where it can't be a 10 minute appointment, 'cause as Dr. Rubin says there's five areas, and that takes iteration. Every human body is different. Mice don't menstruate, so we don't have that history and that information. So we have to iterate through a patient. I iterated this protocol with Dr. Rubin and my holistic doctor together. I would not be here without this brilliant woman who never gave up on me. I actually initially got so overwhelmed that I just didn't do anything after spending all this time, I just felt overwhelmed. So I know this can be overwhelming,
Dr. Rachel Rubin: Which is actually, just pause for a second. I want you to know how normal that is and actually doesn't scare me. It really is sometimes this wave of, you dip a toe, you jump out, you dip a toe, you jump out. And I've had patients who try and then they stop everything and they'll come back a few months or even a year later and say, oh, I thought that was perimenopause?
Now I'm really in it and I'm ready to try again. And we're here. I always say, my mission is to meet you where you are and give you what you need. Some patients need to take those breaks. You can't upset me. This is not about me and my ego. This is about you and what you need.
And so some patients need a little tough love or a little bit of, Hey let's get through this together. Some patients need some handholding, some patients need time. It's really your doctor and you have to create this team of, what actually do you need? I will tell you, some of my happiest patients are the ones who came to me and said, Rubin, I will not take hormone therapy.
I'll never do this. It's dangerous. And through really talking about the data and talking about it, meeting them where they were, they dipped a toe, decided to try it, and now they are evangelists. And almost religious about telling everyone about hormone therapy. And they could be poster children on a billboard about hormone therapy. It's very funny. So education and meeting people where they are and going at their pace 'cause it's not a race. You gotta run your own race here.
Sharon Kedar, CFA: You do. And it's a personal story. First, so estrogen this could be a title that estrogen is not a four-letter word. Obviously talk to your doctor. This is my medicine from Dr. Rubin. But this estrogen patch, it's a branded patch. It's the 0.075.
It took me a while to work up to it. When we first talked about estrogen, this idea that you put, it looks like a bandaid, but it's something you put every three and a half days on, either, I guess like where the fatty part in the front or the back, I put it in the back, near my hip.
I don't know. Everyone on Instagram has it in the front, I'm not sure why.
Dr. Rachel Rubin: So the interesting thing... so we love estradiol, which is the natural form of estrogen as opposed to a birth control pill style, more synthetic hormone. But that's okay too. That's actually a lot safer than we thought it was also; so there's no right or wrong answer, but many of us like transdermal non pill versions of estradiol, but it comes in many forms.
So it's the same medicine, but it may come in a gel, it may come in a patch, it may come in a ring that goes in the vagina. There are pill versions of it as well. You could even inject it if you really wanted to, there's an FDA injection. So there are ways to give it to you, but it's the same stuff.
It just is a different sort of way to give it to yourself. And there's no right or wrong answer. It's what works for you.
Sharon Kedar, CFA: Okay. And just like the concept I'll just show everyone what it looks like, but the idea of getting on the right dose... this is what it looks like and then it just goes on the front or the back. Actually, Rachel and I posted my patch a couple months ago with some...
Dr. Rachel Rubin: Dirty, grimy stuff that... It's the tiger stripes that everybody gets. So it's a... it has some buildup around it, which can get annoying. And some people don't like patches for that reason and they go to a gel or they switch to something else. And the dose, right? So I actually think a lot of my colleagues who are nervous about hormone therapy...
Sharon Kedar, CFA: Totally.
Dr. Rachel Rubin: ...They go too low.
Sharon Kedar, CFA: Yes.
Dr. Rachel Rubin: Now I like starting medium or low with people 'cause you can get breast tenderness. And so I'm okay with starting low. I like this 0.05 dose at least to get to people 'cause I think it's enough to really get your hot flashes gone; to really help with the temperature issues.
I'm a little bit more aggressive than many, but I think that's part of the issue 'cause I think sometimes we go too low and you don't notice the benefits, so you think, oh, this doesn't work for me.
Sharon Kedar, CFA: Also some of the emerging data on the bone benefits, bone health and estrogen, going too low is not helpful in that sense. So folks need to talk with their individual doctors, but I think this is tricky in the sense that, to me, it's like the foundation of the house estrogen.
When you're in perimenopause/menopause and when you think about all the symptoms: brain fog, not sleeping frozen shoulder, just all the things. To me this is like the foundation. It can take a couple weeks.
Is there anything else you wanna say about estradiol before we get to the second?
Dr. Rachel Rubin: If you go to a clinician and they have one option, one dose, one thing that they know how to do, they may not have the whole toolbox for you. If they say pellets are your only option, then they don't have the whole toolbox for you. And they may not really know the data and know what's going on.
So as we teach people how to do this and people are learning, you want to see that ability to say, yeah, there's lots of options: you could do a patch, you could do a ring, you could do a gel. They know the pharmacies to send it to, they know the costs of it, they know how insurance covers it. So that's the goal is to get your clinicians to have this language a little bit better.
But yeah, I agree with you, estrogen is the workhorse, I call it. It's good for your bones, it's good for your blood vessels, right? It gets your hot flashes gone. So it's often what we start with. Again, in perimenopause it gets confusing because your ovaries go really high still, but they can drop really low so that estrogen could be 900 one day and 20 the next day.
And that hurts, that fluctuation can really hurt. So people work with that in different ways. And then if you have a uterus, it's really important that you balance your estrogen with what's called progesterone or progestin. And we love natural progesterone, which I think is what Sharon's gonna talk about next.
Sharon Kedar, CFA: Yeah, and just on this too, like one thing that I love that Rachel and I did because she knows me well enough now is, I am one of those hypersensitive patients unfortunately - or fortunately - it's probably why I'm doing the podcast. But when we went from 0.05 to 0.075, we cut... This is when you know you have a world class doctor. We cut a 0.025 in half to help get me up because of some of my, and I don't like to identify as hypersensitive, but it's just the reality that I do better with gradual changes.
So that was amazing and I think we innovated that and it's not that easy to cut a patch in half, but then the progesterone that I take is... there's the one that helps make everyone sleep; that one hurts my stomach. It's important to follow your doctor's orders. But I ended up doing compounded progesterone through talking to Rachel and my integrative doctor, and it was just like a game-changer for me.
It doesn't help me sleep. I don't know why it doesn't have the same sleep benefits as the over-the-counter one. But Rachel, let's not forget for a while, as you and I were innovating, the advice was to stick it up there in my vagina. But that was a hot mess, literally 'cause every morning I would wake up to a clump in my underwear. I cannot believe we're talking about this, but...
Dr. Rachel Rubin: You're doing great. You can put pills in the vagina that sometimes it can work and absorb in that way. And sometimes it works for people and sometimes it doesn't. So progesterone, basically if we think of the estrogen grows things, your hair, skin and nails, it can also grow the lining of your uterus.
A progesterone's kinda like a lawnmower, it keeps the lining thin of the uterus so that you don't thicken up the uterine lining, which after many years could lead to uterine cancer. We don't want you to get uterine cancer. So the progesterone is good if you have a uterus. Now I have patients without a uterus who sometimes take it for sleep benefits.
And the FDA-approved version of progesterone for about, I don't know, 80% of my patients, they do very well with it. It gives them good sleep, they're fine. But about 20% are extra sensitive. And it's okay, we come up with other workarounds. So some of the workarounds are using it vaginally: IUDs, like a Mirena IUD, could be a workaround.
Some people use compounded products, though you don't wanna use... I'm not a fan of topical products, so you don't really wanna use a progesterone cream because we really don't have safety data on absorption from that. So you do wanna be careful. And again, if you're bleeding like crazy or something's not right, you really do need a workup and you need to see someone who knows what they're doing to make sure that everything is absorbing well and no overgrowth is happening.
Sharon Kedar, CFA: And 100 is the starter dose. I know you can take 200, you can take 300...
Dr. Rachel Rubin: This is an area where we wonky experts like to debate and talk about and where we need more data. I think 100 is a great place. Sometimes I'll try to get patients up to 200, which can be helpful, especially if they're going higher on their estrogen dose.
It's not very clear. But again, if you bleed like crazy or something's happening, it's a tell that either you need more progesterone or you need less estrogen, or that maybe you've grown a polyp or something like that.
Sharon Kedar, CFA: Yeah. And this speaks to why it's not a 10 minute doctor's appointment. But if someone's on 100 of progesterone; that's like the baseline, right?
Dr. Rachel Rubin: Yep. Yeah, I wouldn't go lower. We don't really agree with lower than that as a long term plan.
Sharon Kedar, CFA: I have so many just like stories of my journey, but when this was getting compounded, I got it through my alternative doctor, and they gave me sustained release, so when I was at the White House in December for that women's health event, I was on 300 of sustained release.
Why am I so tired? And I was drinking so much coffee, but getting the compounded progesterone is not that easy. And then it's I think you actually have to say, so this is like when people ask my why, you have to actually have a sensitivity to the prescription one to be able to get it
and then you gotta make sure it's immediate release.
Dr. Rachel Rubin: The FDA-approved option has peanut oil in it. So if you have a peanut allergy, you also wanna get a compounded product.
Sharon Kedar, CFA: Yeah. And for most people it helps them sleep and doesn't hurt their stomach. Of course, for me, I was that like 1%. And then this is the testosterone from you.
Dr. Rachel Rubin: Ooh.
Sharon Kedar, CFA: So what do you wanna say about
Dr. Rachel Rubin: testosterone?
So testosterone is not a feeling. It's also not a man thing; it's an everybody thing. We all have testosterone. We actually make a lot more testosterone in our body than we do estrogen. And testosterone actually starts to drop in your 30s. We find, actually, it's not menopause, but as you're in your 30s, you start to have hm... my libido's a little lower.
My arousal, my orgasm are changing a little bit, I have more dryness. Maybe I got a urinary tract infection or a yeast infection a couple times in my late 30s. It's because the microbiome is changing. And if you put that on top of, oh, I just had babies, you know; where Sharon and I are in Washington, DC, where everyone's having babies in your late 30s and your 40s, you're going straight into perimenopause and this androgen or testosterone drop. We have no FDA-approved testosterone for women. We have approved testosterone in Australia, New Zealand, and Britain.
And it doesn't make sense why there is not a product in the United States, so we have to use either male-dosed generic testosterone, which Sharon will tell you sometimes has a musty smell to it. Versus sometimes you can get it compounded. So I use the FDA-approved version in my tubes, but Sharon likes this compounded.
So we have options. We have tools of, if one doesn't work for you, we switch to something else.
Sharon Kedar, CFA: Okay. So there's so much to say about that. One is Kelly Casperson, we recorded an episode in her book, which talks about testosterone as "The Forgotten Quarterback". I think testosterone, to your point as you said, is just so much more than libido.
It's about brain fog, it's about feeling strong. It's just so many different things, and that's why HRT, or PET, whatever we're calling it, is estrogen, progesterone, and testosterone. A lot of the doctors who prescribe forget about testosterone, or aren't trained on it.
Dr. Rachel Rubin: You had a good response to testosterone. Tell people what you felt when you said, because I, you had an immediate response.
Sharon Kedar, CFA: So don't forget, I came to you - I didn't share with you all of the five doctors - but the first perimenopause appointment that I had was a really prestigious doctor in town who we won't name. And the doctor was like, I'm gonna inject you with a testosterone pellet.
Talk about why I wanna do this podcast. And she was like, it's gonna change your life 'cause I'm like, I'm tired. I'm like, yeah, I'm tired. Like I run a venture capital firm. I have three kids. We had a puppy at the time. And so I called Greg and I'm like, Greg, I'm gonna get a testosterone pellet. Okay, I'll see you soon. And I'm a pretty bold person. But he was like, Do not do that. Basically for anyone who's listening, the testosterone pellet; Kelly [Casperson] talks about earning your pellet. I am a hyper absorber of testosterone. So Dr. Rubin, this is like half of what she normally prescribes, and I probably use about half of what's on the prescription.
Dr. Rachel Rubin: which is probably 1/1 millionth of what your pellet was.
Sharon Kedar, CFA: All right, so I'm gonna go through the other two pieces and then just ask you a couple final questions and we'll wrap. But this one is so important. And Dr. Rubin actually had the guidelines changed. I know how important the following medicine is for, like, UTIs. 'Cause I literally gave up - I had an appointment at One Medical, I think I told you - and like I gave it up because it was this little old lady in a wheelchair. Her husband was pushing her around a couple months ago and they wouldn't give her an appointment because it was like four o'clock on a Friday, she had a cup of urine and like they didn't have any more appointments and they couldn't see her.
It was so clear she had a UTI, and I gave her my appointment and I think it's like the most love I've received in a look like maybe in the past several years, but this vaginal estrogen is so important and people have made comments about - I talk about on my Instagram - but it's like, you stick it in your vagina twice a week. And it's so helpful and Dr. Rubin can talk about it for UTIs, for sexual health. But the part that sort of gets me, when you pick it up, it's three of these boxes. It does take a little getting used to, walking out of the pharmacy with a massive box and being like, I'm here for my vaginal estrogen.
Dr. Rachel Rubin: And yet it is the most important thing. There's two bad words on that box. The word vagina and the word estrogen, right? People have feelings about both of those things and you put them together and people have a lot of feelings and they don't know how to write the prescription.
But you're talking about a medicine here that is safe, is like one of the safest medicines I could even think of, okay? There's very little harm to a vaginal hormone product. Occasionally when you first start it, you get a yeast infection; just treat the yeast infection and keep going. But other than that, there is no harm that comes from this product.
And yet it will prevent urinary tract infections. It will help urinary frequency, urinary urgency, irritation, burning, and itching of the vulva and vagina. It will help with pain with sex, dryness, arousal, and orgasm. So the reality is vaginal, estrogen is Viagra. It is Viagra in every way, shape and form.
Viagra helps with sex and it helps with urination, and yet it also prevents UTIs which could save our healthcare system; not only would it save lives, but it would save our healthcare system billions of dollars. It's actually not even expensive anymore. It's well covered by insurance. A tube of vaginal estrogen cream is $13 on Mark Cuban's Cost Plus Drugs website, where you have your doctor send a prescription.
So it's not expensive. It's easy to use. It's completely safe. It doesn't matter how much money you have or how educated you are or anything, if you're not using this, you can die of a urinary tract infection. I had a woman in my office just this week who's in her eighties. Whose name is on buildings that you and I see every single day who comes from lots and lots of money, who was dressed to the nines and looked beautiful, but she was gorked out of her mind from a urinary tract infection, and her vaginal pH was 7.5. And she was growing a very aggressive and terrible proteus in her bladder as well as other bacteria. And we had to give her a big shot of an antibiotic as well as other antibiotics. And I had to shake this woman and say to her, I don't care how rich you are, you are going to die if you don't use a vaginal hormone product. We got her, just like what your mom was just prescribed, a ring that sort of looks like my hair tie that goes in for three months at a time so she can go to her granddaughter's wedding, so that she can go on her bike trip, so that she can go and do the things she wants to do.
She will die quickly of a urinary tract infection. it is...
Sharon Kedar, CFA: This is probably like the most important part of this episode 'cause there's nothing controversial about it. You talked about this at the FDA, the Urological Society, which if you could name it in a moment, changed guidelines in the past six months to talk about this.
The alternative, even before death, is just taking macrobid, or these antibiotics that are just a bad road to repeatedly go down.
This is why we have a free prescribers guide on our website. We've got free training on YouTube and on our website about how to treat genital urinary syndrome of menopause. The guidelines lay it out for you from the American Urologic Association. This is why I go to conferences.
Dr. Rachel Rubin: This is why I do courses. This is why, if you ever see me on social media, I'm like a broken record. Even my brother and my dad and my husband can tell you how to prescribe vaginal estrogen.
But this is what saves lives, right? This is what I spoke about at the FDA. My mother in the ICU, we couldn't get it because of all of these roadblocks that we had. And yet it is something that could have saved her life. It's really important that we talk about these vaginal hormones.
That's a very simple tool that we use. And yours is a tablet insert, which is great. It's a generic product that's well covered by insurance. There are vaginal DHEA suppositories, there are rings, there are creams, there are different options that you can use. And it's not a one size fits all, so you gotta find what works for you.
I always say the one that you can use for the rest of your life is the one that you should use.
Sharon Kedar, CFA: Yeah 'cause I remember when we first met, we talked about Intrarosa as an option. Okay, last one. This is the... someone asked about this actually after I saw you; I posted that Greg and I went with the pin. And so this is the vulvar....
Dr. Rachel Rubin: Vulvar vestibule.
Sharon Kedar, CFA: Okay. Cream. I can't even say that. But the thing that I think has made you so well known is you give women a mirror when they first come in.
What was so eye opening is you use this Q-tip to point out like where people's sensitivities are. But a lot of women can relate to it, it's like suddenly... I had three babies that were each over eight pounds. So I'm like, I just assumed that was why maybe I had to step out of meetings more often to go to the bathroom. But this is like a game-changer. I don't know if I really believed it when you first said it, but it's like, what do you wanna say about this?
Dr. Rachel Rubin: Okay, so if I could tell you that the outside of your cheek... if I gave you a jalapeno pepper and you rubbed it on the outside of your cheek, would feel different than if you rubbed it on the inside of your cheek. Do you agree with me? That the inside of your cheek and your mouth is very sensitive, delicate tissue compared to the skin on the outside of your cheek.
The reason I say that is that they're close together, but they're different kinds of tissue. If you open up your labia minora right inside your labia minora, surrounding the urethra right before you go inside the vagina is a very delicate piece of tissue called the vulvar vestibule; it's not the skin and it's not the vagina.
It's actually a piece of bladder. And this piece of bladder is very sensitive to estrogen and testosterone. And this piece of bladder is called the vulvar vestibule. It is very sensitive to hormonal changes. So if you are lactating or breastfeeding, if you're on birth control pills, if you are a menopausal or perimenopausal, you may have sensitivity or discomfort.
Maybe tampons are painful, maybe you can't do speculum exams, maybe penetration is painful. And it's often due to a hormonal problem of a lack of little estrogen or a little testosterone. So all we do is liquefy a very minuscule low dose, low concentration amount of estrogen and testosterone. And it's actually the only place I compound.
Otherwise I use FDA-approved products. And the reason I compound here is 'cause I don't have an FDA-approved product. The closest thing we have is intrarosa or vaginal DHEA, which helps a little bit with this problem, but you can't rub it directly on the tissue. So a liquid version would be lovely.
But that's it. Those are the five treatments. And there's lots of options within those treatments. And again, we go on a long bit about all of these on that Peter Attia podcast that we did. And also the course, if you're a clinician who wants to prescribe, or a clinician who wants to prescribe, we go into full detail on the course, which is really just wonderful.
Sharon Kedar, CFA: Okay. Wait, Rachel, so what is, just the last question. What is your wish over the next five years when it comes to women in midlife and you being someone who's fighting for our dignity, basically.
Dr. Rachel Rubin: Yeah. For me, I want to train myself out of being interested in this space. I wanna advance the field of sexual medicine. I have no interest in being the face or the voice of anything. I wanna advance the seriousness, the research, the education, the advocacy, and the mentorship within the field. That is my dream.
Sharon Kedar, CFA: There's a whole history and it almost doesn't matter how we got here, but there is a dark history here.
So if you care about the women in your life, share this episode, listen. And to me, Dr. Rubin is so much more than a sexual medicine doctor, which is important, but I think it's so much more than that. And I just gotta show you, she came to my surprise - I've never had a surprise party - and Rachel came, and that morning I had done a post about how I wish that we knew more for women at midlife. And she wrote me this card. I won't share what it is, but it basically said here's something for someone with amazing vibes.
And I just thought, I just think you're cool because you just say it like it is. You are out there making changes and I am your biggest fan. So if you ever need anything, let me know and just thank you for taking care of me.
Dr. Rachel Rubin: Thank you for you and you're just awesome and thank you for having me on.
Speaker 3: All right, that's a wrap on another incredible episode of Innovate and Elevate. Dr. Rachel Rubin, thank you so much for joining me and our viewers and listeners today. Your work is a gift to women and their families everywhere, and I am so grateful for your passion, your humility, and your brilliance. What I hope you take away from our conversation today is this, your symptoms are not in your head.
Your symptoms are real, and there is hope. There are doctors like Dr. Rachel Rubin and other well-meaning doctors. Doctors are well-meaning, and we are rewriting the script together of what it means to be in midlife as a woman. And as Dr. Rachel Rubin said, we deserve to age with dignity and power. Thank you for tuning in.
If you know a woman, or are someone in a woman's life who can help her hear this information, please share it. When women are healthier, families thrive. Here's to a better second half and to better health for everybody.
Additional Resources
Find a sexual medicine provider at ISSWSH.org
The 2002 Women's Health Initiative
American Urologic Association guidelines on genital urinary syndrome of menopause
Free trainings on genital urinary syndrome of menopause on Dr. Rubin's YouTube
Mark Cuban's Cost Plus Drugs website
About Your Host
Sharon Kedar, CFA, is Co-Founder of Northpond Ventures. Northpond is a multi-billion-dollar science-driven venture capital firm with a portfolio of 60+ companies, along with key academic partnerships at Harvard’s Wyss Institute, MIT’s School of Engineering, and Stanford School of Medicine. Prior to Northpond, Sharon spent 15 years at Sands Capital, where she became their first Chief Financial Officer. Assets under management grew from $1.5 billion to $50 billion over her tenure, achieving more than 30x growth. Sharon is the co-author of two personal finance books for women. Sharon has an MBA from Harvard Business School, a B.A. in Economics from Rice University, and is a CFA charterholder. She lives in the Washington, DC area with her husband, Greg, and their three kids.
Connect with Sharon
Connect with Sharon on LinkedIn: Sharon Kedar
Follow with Sharon on Instagram: @sharonkedarcfa
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FAQs
Why do women say they do not feel like themselves during menopause?
On Innovate & Elevate, Dr. Rachel Rubin discusses the experience many women describe as “not feeling like myself” during perimenopause and menopause. Symptoms can include brain fog, joint pain, sleep disruption, mood changes, and shifts in overall wellbeing that are often dismissed or treated separately rather than viewed as part of a broader hormonal transition.
Why are doctors often not trained in menopause care?
On Innovate & Elevate, Dr. Rachel Rubin explains that many physicians received little formal education in menopause and midlife health. The conversation explores how gaps in medical training contributed to ongoing challenges in hormone education and patient care.
What hormones are commonly included in hormone replacement therapy?
In this Innovate & Elevate conversation, Dr. Rachel Rubin discusses five major areas often considered in hormone therapy conversations: systemic estrogen, progesterone, testosterone, vaginal hormones, and vulvar vestibule treatments. Treatment plans vary depending on symptoms, goals, and medical history.
What does estrogen do in menopause treatment?
On Innovate & Elevate, Dr. Rachel Rubin describes systemic estrogen as a foundational component of hormone treatment and explains its role in supporting symptoms and overall health during menopause.
Is testosterone used in women's hormone therapy?
On Innovate & Elevate, Dr. Rachel Rubin discusses testosterone as one component that may be considered in women’s hormone treatment depending on symptoms and individual goals. The conversation explores why testosterone conversations are becoming more common in menopause care.
Is vaginal estrogen safe?
In this Innovate & Elevate discussion, Dr. Rachel Rubin describes vaginal estrogen as an important treatment option for symptoms related to genitourinary syndrome of menopause and discusses why education around its use remains important.
What is genitourinary syndrome of menopause?
On Innovate & Elevate, Dr. Rachel Rubin discusses genitourinary syndrome of menopause, often called GSM, and explains how hormonal changes can affect urinary health, vaginal tissues, sexual health, and quality of life.
Why does Dr. Rachel Rubin describe menopause care as a dignity issue?
On Innovate & Elevate, Dr. Rachel Rubin explains that menopause care is not only about symptom management. She argues that access to effective care influences comfort, function, quality of life, and dignity as women age.
Why are women advocating for better menopause care?
On Innovate & Elevate, Dr. Rachel Rubin and Sharon Kedar discuss why more women are seeking evidence-based information, demanding improved education, and pushing for better conversations around menopause and hormone therapy.