Dr. Rachel Rubin on Perimenopause, Menopause, and Sexual Health

Perimenopause and menopause can take their toll on your sex life. Between your hormones, your busy life, and stress, it can be hard to even *think* about sex. But, you deserve a healthy and satisfying sex life.

Dr. Rachel Rubin is a board-certified urologist and sexual medicine specialist. She’s an assistant clinical professor of urology at Georgetown University and owns her own private practice in the Washington, D.C. area. She’s trained in both male and female sexual medicine (and is one of only a handful of physicians fellowship-trained in both).

She’s the education chair for the International Society for the Study of Women’s Sexual Health (ISSWSH) and is an associate editor for the Journal of Sexual Medicine Reviews. Her work has been featured in the New York Times and on PBS and NPR.

We were thrilled to have Dr. Rubin back for another webinar! She and our community manager, Rachel Hughes, had an amazing conversation about sex, perimenopause, and menopause. We highly recommend you watch the whole thing on YouTube.

We’re sharing highlights from their conversation below, which has been edited for brevity and clarity. As always, this content is for educational purposes only, and should not be used as personal medical advice.  

Rachel Hughes: Welcome. To set the stage for our conversation today, could you share why it’s so important for women to prioritize their sexual health?

Dr. Rachel Rubin:

Thank you. Yes, that’s a great question. I think I’ll start by saying that doctors are not trained to give a crap about your sexual health, and that’s a problem. I’ve never been asked in a doctor’s visit about my libido, about my orgasm, about my goals, or what I care about from a pleasure standpoint. Have you ever been asked? 

Rachel Hughes:

Never. 

Dr. Rachel Rubin:

There has never been space in a doctor’s office. Patients don’t ask because they’re uncomfortable and they don’t know how to ask sometimes. And doctors aren’t trained to ask. But your sexual health is health. It is your wellbeing. It is joy, it is pleasure, and it is really, really important. And if it’s not important to you, that’s okay, but if it’s not important to you, you’re probably not on this webinar. But if it is, it’s important that you have a medical team that’s there to support you and help you and give you education and evidence-based resources to help you thrive. Rachel Hughes:

Thank you. 

What’s the one thing you hear most from your patients about sexual health in perimenopause or menopause? 

Dr. Rachel Rubin:

I think the thing I hear most is, “I don’t feel like myself.” And there’s this beautiful term that’s being thrown out there called NFLM, which stands for not feeling like myself. And what I try to do is get people feeling like themselves again. And many people come in seeking help in preventing osteoporosis, or to make their hot flashes go away. But many people also come through our doors and see our clinicians and say, “I really care deeply about my libido. I really don’t want to have pain with sex. My orgasm is muted.” And we take those things seriously. 

Rachel Hughes: What are some common misperceptions that people in this phase of life have about their sexual health? 

Dr. Rachel Rubin: That it’s just aging. That it’s supposed to be this way. That it’s just a way of life. Women love to suffer. It drives me nuts! They wear it as a badge of honor. “I didn’t use any pain medication, I didn’t take anything during pregnancy, I didn’t use an epidural. I haven’t slept in years.” We have got to stop making suffering a badge of honor. 

But the idea that losing your sexual health or your sexual identity, the idea that it has to be the case is BS, in my opinion. 

Rachel Hughes: Thank you. You are a part of a community of face-forward, vocal advocates for education and taboo-smashing in all areas related to sexual health. But for many, those taboos remain. Women feel embarrassed or unsure about seeking help. What advice might you have for people who are hesitant to talk to their healthcare providers?

Dr. Rachel Rubin: To educate yourself, and to start early. I love talking to my 35 year old patients about perimenopause. You have to educate yourself and invest in yourself. Practice good nutrition, start lifting weights. This phase of life may be half your life! People who are educated on the topic of menopause have better outcomes. And when you give women education, they make amazing decisions for themselves.

And also, lean in to your superpower. Perimenopause and menopause comes with a lot of bad things. We know that. But there’s also a superpower that comes with perimenopause. You have no more Fs left to give. You get an energy, and a confidence.

Rachel Hughes: Can you take us through perimenopause as it relates to your health below the belt? Can you take us through the anatomy and tell us what starts happening?

Dr. Rachel Rubin: I like to think of it like a gas tank. So, there’s an empty gas tank, a full gas tank, a quarter tank, etc. Perimenopause is like, you’re trying to drive a hundred miles an hour down a highway and you overflow your gas tank and then seconds later it goes to zero. Then it gets full again. Then it goes to zero again. That’s not good for a car. You’ll break your car if that happens. Perimenopause is like that. You have receptors throughout your whole body. They’re getting full, and then they’re getting empty. It’s a really crazy time of really high hormones and really low hormones, and that’s where our symptoms come from. You get hot flashes and night sweats and increased inflammation, and bad sleep and irritability and anxiety and depression. And your testosterone also starts to drop in your thirties, and testosterone is really important for libido. And everyone just gets told they’re not doing enough yoga. 

I’m a urologist, and I care deeply about sex because that’s what my training is in. And, urinary tract infections are killing women. 

So, that’s the biology. In menopause, everything stables out, but it stables out at zero. So your gas tank stays at zero and it doesn’t go anywhere. So when I treat patients, I’m talking about putting gas in the tank. And sometimes it involves more than one thing. You may have estrogen and progesterone, and possibly some testosterone. And you may have vaginal estrogen which is safe to use and prevents urinary tract infections. You’re just filling your gas tank.

And, yes, there are health benefits to taking hormones. But we don’t talk enough about the risks of not considering hormone therapy. There are risks, like UTIs and osteoporosis. It’s not just the risk of taking MHT that we need to consider. There are also risks associated with not taking it.

Rachel Hughes: You sort of mentioned hormones broadly, vaginal, estrogen. I would love to let you riff on the wonders of vaginal estrogen. As you said, UTIs can kill women. Dr. Rachel Rubin: So, let’s paint a picture here. Your genitals are hormone sensitive. When there are hormones, they thrive, they are thick, they lubricate, they are healthy, they are acidic. Healthy lactobacillus are growing, and the microbiome is on point. You can fight infection, you can have sex, you can wear pants without thinking about your genitals, and you can sleep through the night without urinating. When hormones are robust, you feel great most of the time. When your hormone levels start to drop, you start getting urinary frequency or urgency, you start to get itching, burning, and dryness, and you may start to have pain with sex. Your orgasm may be muted, and no one is explaining anything to you.

And then, you may want to avoid sex, which can cause issues. And the craziest thing is that the Genitourinary Syndrome of Menopause was only coined in 2014. We used to call this vulvovaginal atrophy, like somehow you're atrophic and everything is shriveling up and disappearing, which sounds bad. And, we minimize it. We say, this is just a little vaginal dryness, just a little vaginal dryness. Suck it up. You'll be fine. This is not just a little vaginal dryness. This problem causes urinary tract infections, which, again, are killing people.

And the solution is hormones. Low-dose, vaginal hormones have been around since the 1970s, and yet no one is being offered them. No one is told about them, no one is using them. They’re generic, they’re inexpensive, and there are lots of different options. And they work. Now, the dose is so low that your bloodstream levels don't increase. So on the bad side, it doesn't help with your hot flashes or your bones or your skin, but on the good side, there's no risk when it doesn't go through to your bloodstream. There is zero data on the planet that shows problems with it. 

Rachel Hughes: Great! Thank you. Are there any lifestyle changes like diet or exercise that can impact sexual health during perimenopause and menopause? Dr. Rachel Rubin: Of course! So, we always say, if it’s good for your heart, it’s good for your genitals. And genitals are vascular structures. So, when you exercise and eat well and sleep well and your brain is fueled and you feel great and sexy and you have adrenaline and endorphins, you’re going to have great sex. So, diet and exercise are helpful. That said, they’re not the whole story. You also need to prioritize yourself and your partnership.

Rachel Hughes: Can you talk about the pelvic floor and pelvic floor exercises? Dr. Rachel Rubin:

So, if you have a pelvis, you have a pelvic floor. Your pelvis is lined, and if it’s lined with thick muscles, they’re working to contract and relax and hold things like urine in, and they’re trying to relax for sex and trying to have orgasms, and trying to hold all your organs in. And we don’t do enough for them. We think about our biceps and quads, but no one is teaching us about our pelvic floors. And then we go ahead and do crazy things like putting watermelons through them, either through the vagina or through the abdominal wall muscles, and still nobody talks to us about the importance of it. That’s the insanity of 2024. You give birth and nobody talks to you about rehab. My dear mother-in-law, during the height of the pandemic, on lockdown, got a knee replacement, and Medicare paid for a physical therapist to come to her house three times a week during lockdown to rehab her knee. And yet you give birth to a watermelon and you leak and you have no control of your bowels and your vagina's falling out a little bit. And all of these things are happening, and no one talks to you about rehab.

So, we have pelvic floor physical therapists. They’re personal trainers for your genitals and your pelvis. And it's going to help with things like urination, and it’s going to help with your sex life. I think there is no one on earth who couldn’t benefit from a consultation with a pelvic floor physical therapist. 

Rachel Hughes: Thank you. Someone asks, what are some anatomical reasons for anorgasmia? Dr. Rachel Rubin: Those are two very good reasons for anorgasmia. And not being able to have an orgasm is one of the most challenging problems that we face as sexual medicine clinicians. It could be a clitoral adhesion, where there’s no access to your full clitoris. It could be a tight pelvic floor muscle. It could be a bulge in your spine, which is the same thing that causes sciatica. It could be your antidepressant. It could be the way you were raised thinking about sex. It could even be that you haven’t found the right vibrator. And you deserve to figure out what it is, because everyone deserves access to orgasm and pleasure and joy. Rachel Hughes: If there is one piece of advice, Dr. Rubin, that you could give to women struggling with low libido, in particular around perimenopause and menopause, what might you say?

Dr. Rachel Rubin: You’ve got to educate yourself, because there is a toolbox. Do you have space in your life for joy and pleasure and sex right now? Are you just so busy with just surviving? Because when you're just surviving, pleasure and joy and orgasm is not on your list of things that are a priority. Are your basic life needs being met? And if not, what are we doing? How are we going to get there? So education is really important. And then the biology piece of if your gas tank is empty, how are you going to feel joy and pleasure and libido? And so my job is to fill your gas tank with biology, but also to force you to work on the psychosocial stuff. Your relationship, the fun. Are you having lazy sex? If you're having lazy sex, why would you want it? My friend Kelly Casperson just wrote a book that everybody should get called You Are Not Broken. I love this book. She always says, if you're having mushy broccoli sex, why would you want it? No one wants mushy broccoli. No one will choose mushy broccoli. Put some effort into roasting 'em a little bit and making 'em a little crispy and adding some glaze or whatever. So put some effort in. It’s like everything in your life. Your pleasure and your orgasm should be a priority. And if it’s not, take ownership of that.  Rachel Hughes:

Thank you so much. That was fantastic.

For more of their conversation, watch the whole webinar on YouTube. And, follow us everywhere @myalloy to stay updated on future events!