How to Take Care of your Clitoris....The Right Way! Ft. Dr. Rachel Rubin

How to Take Care of your Clitoris....The Right Way! Ft. Dr. Rachel Rubin

Author Name:Rena Malik, M.D.

Youtube Channel Url:https://www.youtube.com/@RenaMalikMD

Youtube Video URL:https://www.youtube.com/watch?v=ZSVqBCIUJ4I



Transcript:
(00:00) Every woman over the age of 50 goes to an empty tank. It's fact. It's castration. It is no longer hormones. All I can guarantee you ahead is shit's about to get weird, right? And I think there's this whole timeline of people in their late 30s, 40s, and 50s where you really start to NLM not feeling like myself.
(00:21) I remember being told, "Don't go near the clitoris cuz you don't want to make your patient uncomfortable." Reena, you and I are urologists. Can you imagine us being told don't touch the penis? Sex is supposed to be fun. It's supposed to be joyful. It's supposed to be adult playtime and and playful. And so if you're not talking about it, trying new things, it's going to get a little stale and a little bit, you know, maybe lonely.
(00:43) Did you know there's a part of female anatomy that's only job is to provide pleasure? And most doctors never even examine it. In fact, most women have never even seen their own anatomy with a mirror. I'm Dr. Reina Malik, urologist and pelvic surgeon, and welcome back to the Reena Malik MD podcast.
(01:01) Your trusted source for leveling up your health, relationships, and sex lives with evidence-based tools. Today, I'm joined by my dear friend and colleague, Dr. Rachel Rubin, the urologist and sexual medicine specialist who is redefining the standards of women's healthcare. She challenges outdated textbooks and has created global education platforms.
(01:18) She is the leading voice for hormonal and sexual health and is literally changing the future of medicine. In this conversation, we are covering so many things. We're talking about the clitoris and why even anatomy textbooks don't show the full structure of the clitoris, clitoreral adhesions that affect up to one in five women, the ulvar vestibial, which is a hidden cause of sexual pain, how birth control pills affect sexual function, and what's actually happening to your genitals during menopause.
(01:48) and we talk about vaginal hormones and why only 9% of patients receive this treatment even though it can be lifechanging. This is a conversation about bodies pleasure and medical education that should have happened decades ago. Before we get into the conversation, I have to tell you guys about the Better Sex app.
(02:04) This is an app that I designed so that I could reach more of you and help guide you to become better in bed, whatever that means to you. This app personalizes to your goals. If it's just to be better in bed or you're struggling with erectile dysfunction or low sexual desire, it doesn't matter. This app guides you. It has a 247 AI support chatbot.
(02:24) It also has daily modules and tasks that you can do to help improve your life and improve your sex life. Check it out today at studio.com/rena for less than a dollar a day. Dr. Rachel Rubin, I'm so happy to have you here. >> I'm so glad we finally got to do this. You have been a wonderful friend and even though we're contemporaries, I found you to be like a mentor at times and someone I can come to when I have questions and it's just been such a great pleasure knowing you.
(02:52) It's such a joy to be contemporaries because what I learned about mentorship is that I have so many mentors now that are way younger than me that show me how to do the buttons and help me with so many things and then obviously so many people older than me. But it's really this wonderful community where we can learn from each other. Yeah.
(03:09) And you know, before this, we were talking about how we need to be looking at the couple instead of just the individual man or woman. And I think it's so interesting because a lot of my audience is men, but they do genuinely care about their female partners and making them happy and giving them pleasure.
(03:26) Tell us about your experience in taking care of couples. >> Yeah, I think it's so important. And we were talking at breakfast this morning about how because we're actually friends in real life. Um, but we were talking about how challenging this is because the way medicine is set up right now is the boys go to the boy doctor and the girls go to the girl doctor and they never talk to each other or even understand what's happening with the other one.
(03:51) And we minimize biology here and there is so much biology here that can happen to everybody and it evolves over your lifespan and we don't talk about it. And so, um, then there's the whole psychosocial aspect, which is huge, and how you approach this, how you talk about it, how you evolve this intimacy. And there really aren't a lot of doctors to have those conversations.
(04:11) And so, we talked about that there's like 27 fellowships for men's sexual health. There are now two fellowships um focused on women's sexual health, but they don't do both. Actually, my fellowship that I did with Irwin Goldstein, who you had on the show, it's the only fellowship in the country that even acknowledges sort of the couple, right? And I can't tell you how much easier my job is when I can really work with both sides of the couple.
(04:38) >> Yeah. And the issues are similar but different, right? like the the the self-conscious, the thoughts, the the stressors are similar, but they're often dealing with very different physiology and very different issues physiologically that they don't even know what's going on. They just feel like something's wrong with them.
(04:56) And I find I can use things from my toolbox for each one to actually help with the other one. And when you give people sort of a language about their bodies, their anatomy, how their anatomy works, and you can like share it with them, it it kind of opens their eyes of, "Oh my gosh.
(05:14) " And what I find is it's easier to talk about sex when you talk about like it's high blood pressure, diabetes, or like, "Hey honey, I'm having a surgery." You know, it's so much easier to talk about the biology than it is the feelings and the intimacy. And so sometimes we use the biology as a way to get to the feelings and the intimacy. >> Absolutely.
(05:32) Yeah. Absolutely. So, let's talk about some of the the anatomy. Let's talk about the clitoris. As you've mentioned many times, and I have, it is the only organ in the body that's solely there for pleasure, but it's largely ignored. So, what do you wish people knew about the clitoris? Oh, I wish so much. Right.
(05:49) So, when we trained, um, our anatomy textbooks don't show the full entire clitoris. Right. It is what we think of as if you follow the labia manora up those inner wings then you get to the hood of the clitoris you pull that back you'll see the head of the clitoris just like the head of the penis that is the tip of the iceberg and so there is a shaft of the clitoris and there are these giant legs of a clitoris that go all the way down to your butt bones just like a penis sort of splits into two and goes all the way down to your butt bones and most people don't
(06:17) know this most doctors don't know this because our anatomy textbooks really didn't go into this and no one taught us the clitoreral exam was not a part of a routine exam when you're taught in med school. In fact, I remember being told, "Don't go near the clitoris because you don't want to make your patient uncomfortable.
(06:32) " Reena, you and I are urologists. Can you imagine us being told, "Don't touch the penis. You may make your patient uncomfortable." It's wild, right? And so, people don't understand the anatomy. And then there's this thought that pleasure comes from vaginal penetration, which for most people is not the case. And so it's when you understand that you realize that you're you're quite normal in the way that you experience pleasure.
(06:57) >> Absolutely. And you were the person who taught me about clitoreral adhesions. So just like men have foreskin and you pull it back and it can get infected, inflamed, stuck, you can get smegma, women can have the same thing happen. Yeah. So let's tell talk about this. It's so wild. Okay.
(07:17) So um about we did research in 2017 where we looked at thousands of pictures of clitorises and about 22% of them had some degree of adhesions. Now this isn't cancer, this isn't heart disease. Uh it's literally the hood of the clitoris gets stuck to the head of the clitoris. I sort of think of it like if you wake up in the morning and your eye is crusted close.
(07:37) You know, you're like you don't go to the emergency room, you just pick out the eye crusties and open your eye. But if you think you can't see, that's a horrible thing. But it's not that serious. It's not. And that's what happens to the clitoris. It gets stuck together. And then we found we actually asked people what happens when you unstick it together.
(07:53) We do a very a simple procedure in the office where we separate the hood from the head. It's not cutting. We're not we're not doing surgery. And 60 to 70% of people said their orgasms improved, their arousal improved, their satisfaction improved. Six women who had never had an orgasm before were able to after this procedure, which was incredible.
(08:11) And my colleagues have since published even more on it and and replicating that data which is always very cool when that happens. And so the challenge is is that no one's ever examined your clitoris. >> Absolutely. >> Ever. >> Yeah. >> And so we became very famous from this fact that we just give people a mirror in the exam room and we're say this is your labia majora.
(08:32) This is your labia minora. This is your clitoris. This is your cleral hood. A and and it got a it got so much press because that's apparently novel medicine in 2026. >> You know, it's so funny. I wrote about that in my book. I said, you know, my dear friend Dr. Rachel Rubin got famous from talking about giving women a mirror in the exam room.
(08:49) And I was like, if I did that for men, I'd be told I was crazy. Like literally, if I was like, "Here's your penis. Here's a mirror to look at it." People would literally think I'm I've gone nuts, right? And it's it's insane to me that that is like really I mean it's it's it's a speaks to how far society is from like making women's anatomy be normalized.
(09:09) >> Yeah. And it's so hidden from us, right? Like men, they pull their pants down, they see everything. You they see every wrinkle, every vein, and if it changes, they're going to call us, right? They see everything. They're used to looking at their scrotum and their testicles and all of this thing.
(09:24) It's all out in the open. And women there is this gymnastics that has to be done. You can't really see down there unless you're looking and you get a mirror and you're you're sort of so you don't always know what's happening. And this is a dynamic part of the body. It changes it. A baby's genitals don't look like a grown-up's genitals.
(09:41) And then when you go through hormonal changes or shifts like in menopause, they change again. But we've been hiding that from women. Not on purpose. It's just that we forgot to tell them which is a little bit frustrating. You know the when I I actually did a cleral adhesionis which is the name of that procedure that we do for women with cleral adhesions on a a young woman with persistent genital arousal syndrome.
(10:04) So she had for those who are listening basically condition where she always felt like she was aroused and would and it would be uncomfortable. So it's not actually like a lovely thing. It's actually very very uncomfortable very distressing and pe patients get so distressed that some become suicidal. It's like a very serious condition.
(10:22) So she came to me, we did an exam, we saw clitoral adhesions, I lice the clitoral adhesions and she got better. >> It's amazing. >> It's amazing. So it's a really important evaluation. So any woman who's listening, please look at your genitalia. >> We're actually presenting a case at the conference that I'm here for, which is why I'm in California, of a young child uh from another country who had horrible, horrible pain and irritation in that area of her body.
(10:46) And she went to every doctor they could find in their country. and no one could sort of figure out. I don't even know if anyone examined her. The notes just kept saying she needed cognitive behavioral therapy. This was a young child and uh the parents because they had seen our research brought her to our clinic and she had clitorol uh adhesions.
(11:05) We brought her to the operating room because we didn't want to do anything while she was awake. We usually do it in the office and it was gone. Like it literally she's she's better like and this was to the point of tears every night at bedtime. she was missing school. She was always, you know, like grabbing at that area when a simple exam and a simple procedure sort of cured it.
(11:25) And so, and that she was already being told at such a young age that she needed cognitive behavioral therapy. Like, you just can't make this stuff up. >> Terrible. My husband's idea of skincare is using a bar of soap and whatever free lotion sample we have lying around. I finally convinced him to try something new after finding the cleanest option possible, Based Body Works.
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(12:26) com and get a free toiletry bag when you buy a set because confidence shouldn't come at the cost of your health. You also said the organs change during menopause and the genital organs. And you actually also went viral for talking about what happened to the labia during menopause. I this was a funny one.
(12:45) Um so it is scientific fact that labia minora these little inner wings people call them lips. I actually don't like that term. It gives me the heebie-jebies. So I like wings. I always thought wings was a cool ter term. So these these wings like babies they're very small. They're very thin. They're very very minimal in size.
(13:04) And then puberty happens and they grow. They get fuller. In fact, many times they'll go all the way down to the sort of bottom of the opening of like a full uh you know, they fully look like wings. Now, different people have different shapes and sizes. And we really haven't done a good job characterizing why they change size and shape.
(13:24) Uh they are clearly hormone sensitive, but we really don't have much research out there about what hormones are driving these changes, but we know that with menopause, they start to shrink or resorb or disappear. Now, they don't always disappear completely, though they can. And I I just like made a video about this and the internet broke.
(13:45) I went so viral on Tik Tok, they made all these like joke videos about it. I'm not on Tik Tok. I was getting all of these things like you have millions of views. I was in clinic and um within like one day my elementary school had commented on the post and Kim Kardashian had texted someone to ask me about it.
(14:05) Like was like, "Is that true?" And the person was like, "If Rachel says it's true, it's true." So, it just went so viral and to the point where other people started talking about it and then they went viral sort of talking about it, which is so great. I also had people telling me they that I should lose my medical license because I'm clearly spreading fake news.
(14:22) And it was like, "No, no, like this is like an anatomical medical fact that this happens and you're just there's so much anger about it because it's so no one told you that this could happen and we don't talk to women about it." And I think the women are very upset about that. >> Yeah, absolutely. And it's it's crazy, right? Because people spend money on genital uh surgeries to change the shape of their labia to look more like they're not there.
(14:47) And that's what's so challenging is that again, so much pornography depicts very small labia. And part of that is probably because a lot of these uh uh actresses, a lot of these uh a lot of these performers are on birth control pills which probably changes the size of their labia. Uh also people do have surgery and things like that.
(15:10) But like big labia the big are hormonally healthy probably. And so we don't do enough of teaching young people that actually this is a sign of good hormones and good hormonal status. There's a lot of nerve endings. There's a lot of arousal tissue underneath. And so rushing to a surgery, we've seen a lot of unhappy people because surgeries can sort of hurt nerve endings which can affect sexual health for some people.
(15:30) >> Absolutely. And and I will say that I think that performers self- select, right? Because the performers that do well, you can visualize things better, right? They act better when the laby are not in the way. And so probably one they get more attention and two they self- select because if you want to be in that field of of work then you need to be able to see what's happening for the audience right so I think that's probably part of it it's really crazy the things that we're not taught about our own bodies and and I talk about this
(15:58) a lot but I really think sex ed in this school and you actually go back to your high school is it and talk about sex at every year and there's just so many things that we were not taught and and we just like are expected to learn somehow. >> Well, I think it's so interesting, right? Because we're not when are we supposed to learn and how are we supposed to learn? Because you don't really want to hear about this from your mom and your teachers don't really, you know, they can tell you some basic stuff, but like where do we get this
(16:27) education? Where did you get this? Like we don't get in medical school. And so this is where doctors become really fumbly and not that good because they weren't taught how to talk about sex. They didn't learn it themselves. They spent most of their 20s in school. So they weren't having fun. most of us uh and you know and and so it's so challenging.
(16:47) Every year I go back to my high school and every year I expected not to be invited back because I I they do not give me any guardrails or any rules and I went to a small private school and every year I put up a big slide uh with my cell phone number on it. Actually, I've been doing WhatsApp recently and all the students can start texting me questions and it's so fun because they they get really um they try to gross me out and they try to like say ridiculous things and then they realize that I'm actually going to answer their questions and that I they can't make me
(17:17) blush and I don't skip a beat. And it was it's and then I teach them about anatomy. I teach them how the body works and then I'll stop every once in a while and I'll answer their questions. And it's such a fascinating thing because there are kids who are doing stuff like a lot of it's usually the seniors that we're talking and then there's ones who are just, you know, like sort of like can't believe that we're having these conversations and it's wild.
(17:40) And every year my actually the same principal who was my principal, she'll be in the back of the room and she'll come up. She'll be like, I learned a few things this year. It's like mortifying. It's hilarious. >> What is What is one of the most surprising things that you got asked? They ask a lot about anal sex.
(17:55) They have tons of anal sex questions. Interesting. Um tons of questions about um how to get, you know, a lot of pregnancy questions, a lot of safety questions, you know, they they have a lot of curiosity about their each other's bodies. And I think that's really interesting of like, well, you know, how can I get my girl how can I get my boyfriend to know how I orgasm? Well, you need to learn how to orgasm to teach your boyfriend how to orgasm, you know, and I bring in a lot of models.
(18:23) I bring in a lot of, you know, showand tell of like here's what it looks like. Um, you know, I think it's we don't we don't talk about basics. Like we don't teach boys how to masturbate or like what they should be doing and and there's a lot of injuries that can happen and and every year the question I always think I should write a whole book about all the questions that I get asked cuz and every once in a while I'll get texts from these kids you know many months or years later of like hey you taught me sex ed I got into this situation what should I do
(18:50) and and you know one year I remember three different women came up to me and said I have pain with tampons I thought I was normal but you're telling me that it's not normal. normal. And that was really cool because we got to get them, you know, potentially to help sooner uh than they normally would have gotten help cuz it's you should, you know, things shouldn't hurt.
(19:09) There shouldn't be pain. >> That's so amazing. I wonder if you actually like studied this in a empirical way and looked at like their outcomes of pleasure and sat relationship satisfaction like years down the line, I bet you they'd be higher. >> And it's interesting because it's it's sort of like you give them the per like they sort of get shocked of like, oh, like it's okay to talk about this.
(19:29) And I think, you know, they've already had sex. This is more just like ask the sex doctor anything. And so I don't go into all of the doom and gloom and scare tactics. I'm there to talk about pleasure and fun and joy and con, you know, they they've done lots with consent. They've done all this stuff, but really talking to them about like, but like you deserve pleasure and here's how it happens and know your body and if you know your body, then you can advocate for it and you can talk about it. And it's just wild, right? you see
(19:54) these kids that are they can't even talk to each other and yet they are touching each other's bodies in ways that are so intimate so so personal um but they don't have the language and so when you can work and I love that we do it all together so the boys and the girls everyone's together because then they have that shared language of like we should be able to talk about periods we should be able to talk about masturbation we should be able to talk about orgasm and you should use the words of like what it is you like and if
(20:17) you don't know what you like you should probably find out because how are you going to tell a partner you know and expect them to know what you like >> yeah they can't read your mind. >> It's this fascinating thing, right? And it's wild. Like I find with maybe you think this too, like with my patients, the young ones who have sex problems, by the way, everyone will have a sex problem at some point in their life.
(20:36) Like that's inevitable. And so I actually feel really bad for my older patients who start developing problems in their 70s and they have no language around it. Like I and my younger patients, even though it's terrible that they have problems, they learn language. They they actually fig they they learn how to communicate.
(20:57) And I think they're better at sex ultimately than these other people who are just kind of winging it in this silent dance for a while. >> Yeah. Yeah. Okay. I have to be honest with you. When I first heard Honey Love made a wireless bra, I was skeptical. I thought there is no way a bra without an underwire is going to do anything for me. I was wrong.
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(22:36) And I think that really sets them up for a huge problem, right? They're they are learning how to masturbate on their own, which could be good or bad, whatever, but usually they're rushing through it. They're hiding it from their their parents. They're doing it in the shower, people, you know, and and they feel shame around it, right? And they they're learning to rush through this act of pleasure, right? And I think that sets them up for a whole host of issues down the line.
(22:59) Well, and also again, who do you talk to if you have questions or problems or issues, right? The pediatrician doesn't really get taught how to counsel about this. The primary care doc, it's not their expertise. Like my dream, I have so many dreams, but one of my dreams is to have a clinic where you go every couple of years for like just like you go to a wellchild visit, you go for like an age appropriate sexual health visit where maybe you start just with anatomy.
(23:27) Then maybe it gets to questions about consent and masturbation. Like it you just form this relationship where you realize there is a place to go when I have questions. So if something goes wrong, it's not, oh, I have to search on the internet secretly late at night and no one knows and then you end up on some shady, you know, thing.
(23:46) It's, hey mom, can I go see the, you know, can I go to this clinic? or you know how to kind of I just think it would be gosh this world would be such a different place right if we had access to like good information. >> Absolutely. 100%. I mean, I think that I I know that you probably do this, too, but I talk to my kids about sex and about masturbation and about pornography and, you know, try to leave the door open so they can ask me questions all the time.
(24:11) And um my son is starting to read, you know, older books and he'll be like, "Mom, what's the clitoris?" or like, you know, and and we talk about it, right? Because I think it's so important. And I do feel like even if we don't have that yet, right? We don't have that sort of like come to this clinic and learn about sex. The parents can learn and start learning how to talk to their kids because guess what? You're with them all the time.
(24:30) And if they feel comfortable talking to you, that's amazing. >> You should have my friend Carrie Le on the show. She is this amazing doctor in Detroit who does a lot of um sexed for, you know, she has these programs where they do sexed and there's a whole curriculum. And she's taught me a couple things that I love.
(24:46) You know, one is don't call them private parts. She's like call them personal parts. And I just think that's beautiful, right? this idea they're not private, they're personal to you. And when you have something that's personal, you share it with the people you want to share it with, but they're, you know, and the other thing that she said which I think is so beautiful is she says, you know, talking to your kids about sex should not be one 30 minute conversation.
(25:07) It should be 31 minute conversations. It should be something that is just talked about all of the time. You can start at the zoo and talk about how elephants procreate. who can, you know, watch TV shows and have these little moments of like, you know, explaining interactions. Cars are great places because you're not looking at each other and you can have these conversations.
(25:25) And I just think again, the more we aren't afraid of it cuz they the kids are like dogs. They smell fear, right? They smell awkward. They smell fear. They know when you're uncomfortable with something. And if we shut it down and we show, you know, I think one of the things that makes us good urologists is we show up confident and competent in these topics.
(25:44) And so we talk about these things again like it's, you know, I don't know, somebody else's high blood pressure, high blood pressure, right? Like we talk about it very easily and I find that's what makes these patients so comfortable talking to us about it, right? Because we don't flinch. If we flinched, >> they probably it would probably be a different story.
(25:59) >> Well, maybe you and I don't flinch, but I'm certain there are people who do flinch, which is unfortunate, but hopefully we're changing that a little bit. Let's talk about sex. What are the top five things you think people need to know to have good sex? Top five things people need to know to have great sex.
(26:16) I mean, I think education is the obvious number one. If you know your body specifically and you know how to like education number one, communication number two is every sexual experience you have is a new sexual experience. I mean, even with the same partner and so this idea, you know, from uh encounter to encounter is going to change.
(26:37) There are numerous different ways that people can experience pleasure. There's so many different ways that you can, you know, learn about each other's bodies and areas of pleasure. There's always more learning to do. And then if you have a different sexual encounter with somebody else, whole new ball game, right? And so the more you understand your body and then you can talk about it with the person, you know, obviously the more fun you're going to have and you get to decide how much fun you have.
(26:59) So I would say education, communication, you know, again great sex is biocschosocial and I think we minimize I think on the male side we minimize psychosocial and on the female side we minimize biology. >> Yeah. >> And I think we need to do a lot better about understanding that everybody is biology with feelings and you know sort of an upbringing and baggage like we all have that.
(27:25) And I think that's important is is that, you know, I think there's a whole lot more biology than we give it credit for. Everybody's too serious these days. Everything's so serious and terrible and awful >> and um it's really hard to we've been through a lot. I think pandemic wrecked us and we did nothing to heal from the collective trauma of pandemic and we are in this giant sex recession where people are not connecting.
(27:50) They're not communicating. They are in their little insular bubbles, you know, surrounded by people who are saying all the same things that they are and they're really struggling. And sex is supposed to be fun and joyful and pleasurable. And again, people, there's a lot of bad stuff out there. And so, we have to find ways to bring the fun back.
(28:14) I think um because people deserve pleasure. You deserve pleasure. You deserve fun. But on the flip side, like no one's ever died because they didn't have an orgasm, right? Like this is the other challenge. >> Well, you could argue that maybe they have died. We just can't attribute it exactly to the orgasms. >> Not enough orgasms.
(28:28) I mean, you know, because there is a mortality benefit to more sex, right? So, there's actually data that supports that people who have sex 52 times a year, like once a week, live longer than people who don't. >> I think there's cardiovascular benefit. I think it's connection. I think it's movement.
(28:44) I think being able to have sex, right? Sex is a high contact sport. And so, um, and and what I find is there are no age limits to when people like you don't ever have to stop having sex. You can at any point stop having sex. But if it's important to you and your partner, then it's important. It should be important to your doctors and there should be ways to sort of have pleasure.
(29:04) And then also knowing that penetration is not the only pathway to great sex. >> Absolutely. And you know, we've talked about it here on this channel, but like on this podcast about like how you need a certain V2 max to have sex, right? And so if you don't take care of your health in a multitude of ways, specifically resistance training and cardiovascular training in some shape or form, like at some point it may become physically difficult for you to have sex.
(29:28) And so if that's important to you, that needs to be a part of your lifestyle. >> And it's really important that if you have a vagina and you are in menopause age that things do change. It is a very hormonally sensitive structure. And so without hormones, the tissue gets thin, it gets raw, it gets irritated. And not only is there vaginal dryness, but significant pain with sex.
(29:49) And as so many of your listeners know, it also comes with a lot of urinary problems, frequency, urgency, leakage, and then you can be very high risk of urinary tract infections. And so using vaginal hormones can be lifesaving uh for anybody of any age, of any history, um to really help uh so sex isn't painful and that you don't get urinary tract infections.
(30:10) >> Yeah. And we've said it before, we'll say it again. There is no risk of cancer, blood clots, stroke, really anything untoward with vaginal hormones. >> Yeah. So these local lowd dose vaginal hormones is essentially micro doing. It's super small uh dose and it absolutely heals the tissue. It improves lubrication.
(30:31) Uh it changes the pH in the microbiome and so all the good bacteria can grow and the bad bacteria get suppressed. Um and it it truly is better than Viagra, right? So it female Viagra truly exists because it helps with arousal, it helps with orgasm. So this is vaginal estrogen or vaginal DHEA. There's a cream you could do twice a week.
(30:50) There's a suppository you could do twice a week. Vaginal DHEA is every night. So you could choose any of those options. There's even a ring you could set it and forget it for 3 months. And so um this is why we we actually helped publish guidelines last year by the American Urologic Association on this issue which is called genital urinary syndrome of menopause or GSM.
(31:09) And we have developed all these free trainings um on YouTube. We have a whole YouTube channel about it on our website. We have a whole pocket guide of like bring a piece of paper to your doctor say hey I want this prescription which links to all the information because uh actually one of our colleagues just published on this is like Medicare patients with a diagnosis of this problem 9% get a prescription nine >> nine you know that's wild to me because you I know you you know this but we prescribe this like candy like every
(31:38) woman who is permenopausal or menopausal and has symptoms or even doesn't have symptoms but may be worried about gang symptoms gets offered this in in my clinic. >> 9%. You are a unicorn. You're a magician unicorn. We appreciate you greatly. >> Um that's wild. That's wild to me. 9%. >> So sad. >> It really is.
(32:00) It's it's as if look if if a man came in with erectile dysfunction n everyone is getting offered viagis >> but not every woman is getting offered >> like this is these 9% with a diagnosis. Like that's what's so depressing because it's so much so many people have this problem that is are not getting a diagnosis code and so e those with a diagnosis 9% get a prescription.
(32:21) So we have so much work to do. This is why we just do not stop yelling. >> Yeah. It's so important. So we've talked about exercise and we've talked about hormones. What other like lifestyle diet changes do you think people need to make to have great sexual desire, arousal, and just sexual function? I mean truly if it's good for your heart, it's good for your genitals.
(32:44) And so anything, you know, there's a the data is a little bit anytime you have nutrition data, exercise data, it's a little murky. Um there's been some data on Mediterranean diet. Um you want to fix sleep apnea. You need to be sleeping. You want to check hormones, testosterone. If you're a woman, you want to consider menopause hormone therapy.
(33:02) Um we know dopamine is very important. So a lot of medications like anti-depressants can hurt sexual health either lower libido or delay orgasm. And so there are medications that could boost libido. We have two FDA approved medication. One is Atti, one is Vilei that help with low libido, but also work with other sexual problems.
(33:19) So it's they help with arousal and orgasm and satisfaction as well, which are great to have in our toolbox. And so and the other thing that we've published on recently is really devices and erotica. And and we as clinicians must get comfortable talking to our patients about devices and erotica because uh they work. They're fabulous.
(33:38) They're great education tools and it gives your patients permission and getting them to understand. I think we need to do a better job of bringing in devices into the bedroom and getting everyone on board with it because we wear eyelasses. We uh you know we get all sorts of other aids that we need or or things that I get in my car to drive like I need my phone to check my email like >> we have like weighted blankets and weighted eye masks and you know fancy mattress pads and all sorts of stuff.
(34:06) We use technology for so many things, right? We are. And so getting comfortable and and again devices, the device industry is so deliciously beautiful now compared to, you know, sort of when we were growing up. And so it's you can go on Amazon. You can, you know, you can really find it at CVS today.
(34:27) And again, understanding that vibration can be extremely helpful to access the clitoris and uh the internal sort of parts of the clitoris. And so it doesn't make you a bad partner. It actually makes you a good partner if you bring in devices into the bedroom. And so we really want to encourage um sort of that we know uh erotica is very helpful whether it's reading erotica, listening to erotica, watching erotica.
(34:47) Again, the brain likes fantasy. It likes new things. It likes danger. It likes it likes excitement. It likes to think about things that you maybe would never do. Um that doesn't mean you want to do them. and it means that that you like watching or listening or hearing about those types of things.
(35:05) And so just giving that permission, it's it's funny. I I um I was taking care of a patient the other day. We go to a similar uh clinic uh with veterans and I had this this veteran with me and I was talking her with her about this show on HBO that's gone crazy viral called Heated Rivalry. And I say Heated like HRT is not hormone replacement therapy anymore.
(35:26) It's heated rivalry therapy. And it's this is a show um that went totally crazy viral. Um it was a Canadian streaming show that got picked up by HBO and is now one of the most watched ever TV shows right now. And it's six episodes. It's based off from a book and it's about these uh gay hockey players, like these two very macho rival hockey players that fall in love and have a lot of erotic moments and then also this very kind Have you watched it? It's it's incredible.
(35:54) How many times have you watched it? Just once. Okay, so you're you know you're I'm still a newbie. Apparently 15% of people have watched it more than five times. So people are really into this show. And what has it's causing all of these heterosexual people to be like, "Wow, I find watching two men have sex extremely pleasurable, erotic.
(36:16) What does that say about me?" Or what does that mean for me? And is this good? Is this bad? Why do I like this so much? And it's not just the act of sex, but it's watching their emotions, their feelings, and their relationship. And so I was talking to this patient about it and she goes, "Wait, I like really like that type of pornography and I I've never said that out loud before and I thought there was something wrong with me.
(36:37) " And I was like, "No, no, there's nothing wrong with you. like this is what lots of people like and this is and you could see like her like she just like light like everything kind of like relaxed a little bit and she was so excited to talk to me about it and I taught her about the so it was just again the more we normalize and can talk about these things people feel a lot less sort of alone in this >> absolutely I mean look it's it's it's fantasy it doesn't mean that you necessarily want to participate you just want to watch it or you just enjoy it
(37:04) like who cares right but yeah absolutely I mean there's just there's there's so much importance in in giving people permission, right? Especially like we you and I see older patients, particularly veterans, right? And I will talk to them about toys and sometimes they're like, "Oh, no." Like they they're so shut off to it.
(37:21) But I've also had patients like, "Well, I've never tried. Which one should I get? What should I do?" And I think it's really important like I'll I'll tell my male patients, I'll be, you know, you can get like vibrating cock rings, right? And that can be great to help you maintain an erection, also be pleasurable for your partner and you.
(37:38) um or if you're having trouble getting to if you're having delayed ejaculation, sometimes these toys can really help. And so I think just realizing like yes, it's okay. You're allowed to experiment and try different things. Absolutely. The clitoris likes vibration. The penis also likes vibration. The paranium likes vibration.
(37:56) Uh and so getting devices for couples and playing with devices and different devices. Again, sex is supposed to be fun. It's supposed to be joyful. It's supposed to be adult playtime and and playful. And so if you're not talking about it, trying new things, doing, you know, it's going to get a little stale and a little bit, you know, maybe lonely.
(38:16) And so this is where I think people tend to go into their own heads or their own spaces and live their own sex lives sort of by themselves because they're afraid of sort of communicating and having these conversations with their partners. >> Absolutely. You talked about Viagra. Uh there was we recently published a paper on looking at Viagra for cardiovascular risk mitigation or basically reducing cardiovascular risk in post-menopausal women.
(38:40) What did you find? >> Well, this was just a wonderful paper that was just recently published in the journal of sexual medicine where it's more in theory of like here we know that men who take Viagrais have decreased risk of cardiovascular problems, strokes, heart attacks, actually at least less dementia. uh which is so fascinating because these are um sort of increase blood flow you know more than to just your penis but they increase blood flow and they help with all of these things.
(39:05) Now, we know when you give women Viagra seialis, it increases blood flow to their clitoris. They have better arousal. It's just that nobody prescribes this to women because women aren't complaining of arousal problems. Typically, they've got dryness, they've got pain, they have low libido. And so, we use a lot of these drugs sort of as an adjunct to these other things that we do.
(39:25) But we, this paper really looked at, well, why aren't we looking at this for cardiovascular benefit in women? And it's so frustrating because in order to pull off a trial, you need money and these are generic drugs that you know there's not a lot of money in this. And so and you also have to get your cardio cardiology people to care which is very hard to do right because as a urologist it's hard to look at cardiovascular markers.
(39:48) Um so there's a lot of interest in this and we would love to pull off a study. Um but we just got to figure out how. >> Yeah. I think it's interesting you know I've heard this before that women don't complain of arousal issues but I don't think they have the language to complain about arousal issues. is like they don't really know what that means outside of like oh maybe my lubrication is inadequate which is not all of arousal right I think there's more to it and they can't see their arousal like they can't see an erection of their clitoris
(40:11) necessarily and so I think they don't really know >> it's a huge problem in sex research because as we say shit in shit out right if you're if you have bad data that you're working with you're going to get a bad like you're not going to have anything that makes sense and the way we ask the questions are so bad.
(40:30) And women have like with men it's okay but your erection is different than your orgasm which is different than your ejaculate which is different than your libido and we tend to lump like do you have female sexual dysfunction right like it's sort of like like when I go to conferences like this is listen I just went to a conf big conference Mayo Clinic and you have a like a whole panel about different aspects of erectile dysfunction and then it's like okay you get 15 minutes to talk about all of female sexual dysfunction you know and
(40:57) you're just you can never get into the weeds because you're still staying so broad, which I'm glad I'm grateful that I had the opportunity to speak on this, but again, it's so challenging because we do we've got libido problems, arousal problems, orgasm problems, and then pain, and then there's hormones that play a role in all of it as well.
(41:15) >> Absolutely. And I think it is it is so important to think about all those different things for women listening or for partners who care about their female partners. Like figure out what is really try to figure out what you're feeling. Try to articulate it. Don't be afraid to like really go in the weeds.
(41:32) Whatever you can say about what you're feeling because it gives us more information, right? You not your doctor may not have the tools, but they they certainly can find out. They can look into it and they can ask. And I think the other thing is like if a doctor says, "Oh, go drink a glass of wine or you're okay.
(41:48) " The right answer would be, "I don't know what to do for you, but I can find someone who to refer to." >> I give you a perfect example. Uh I had a a DM just uh a couple days ago from a patient of mine who uh is a fellow physician and her husband went to the doctor and he's got some low testosterone and the primary care doctor says, "Oh, we got to give you testosterone.
(42:11) " and they gave him testosterone at not the dose I would give but they gave him testosterone and she says well you know I'm on testosterone and he scoffs at her and says there's no data for women on testosterone and there's no possible reason why you should need that and so he's he literally doesn't know the data there's global consensus by the way that testosterone works for women for libido global consensus and he's confidently telling this woman who is a doctor who knows the data who is benefit benefiting from testosterone has been life-changing
(42:41) for her and she he's telling her that there's no data and she shouldn't be taking testosterone while he is prescribing her husband testosterone. I mean, you cannot make this stuff up. So, why can't why when it comes to women's health can you just like just say like this is not my specialty. This is not my area of expertise.
(43:00) Like, how hard is it to say those words? >> Yeah. I I really don't understand like if you just don't know like you are misinformed, right? That doctor is misinformed. Maybe there wasn't data when he was training, right? But there is now and he's misinformed. It's frustrating. It really, really is. Let's talk about um the ulvar vestibule.
(43:20) So, I think this is a part of ulvar anatomy that every woman and partners should know about because it's it's really valuable and important and a cause of pain for a lot of people. so important and it is so wild how basic anatomy is completely missed on the doctor and the patient and it gets completely hidden. So we talked about those inner wings, those labia minora.
(43:45) Well, if you spread them to the side like a book, you open them up like a book. Then right in front of your face is an ovalshaped strip of tissue that surrounds the urethra, the tube that you pee through, and it surrounds the opening of the vagina, which is the inside part. And that tissue is called the ulvar vestibule. Now, it's very sensitive hormonally mediated tissue.
(44:08) And so if you think of like the outside of your cheek and the inside of your cheek, they're very close together, but they're very different, right? One is very skin and thick and tough, and the inside of your cheek is very delicate, very sensitive, and you know, would react, so you know, would react differently to different, you know, sort of things.
(44:27) And so the skin of the labia majora and the labia minora are are skin. They're tougher. And then this strip of tissue right at the opening is like the inside of your cheek. It's like this very delicate mucosal surface that is essentially the same as the the bladder, right? So the bladder turns into the urethra and then the same tissue surrounds the opening of the vulva and vagina.
(44:50) It's called the vestibule because it's sort of the entrance like as you then go inside to the vaginal canal. This area is often the reason why people have pain with sex, pain with tampons, uh UTI, interstitial cyitis, um you know, uh post-ex pain, you know, things like that. It is often in this tissue. And because this tissue is so sensitive to hormones, as I always say, when you play with hormones, there are consequences, sometimes good, sometimes bad.
(45:20) Things like birth control pills can affect this tissue, breastfeeding, um menopause, gender affirming hormone therapy, um you know, surgical menopause, um uh breast cancer therapies that affect hormones. There are so many medicines uh and things people do, acne medications that can affect testosterone levels because this tissue is very sensitive to both estrogen and testosterone.
(45:43) And also a lot of inflammation can happen on this tissue. And so we see increase in mass cell issues come up uh in this tissue as well. And so the problem your doctor often was not taught that this exists nor were they ever taught how to examine it. It's very easy to examine by the way. You spread the labia minor open.
(46:00) You take a Q-tip and you poke at the tissue and if it hurts you have a problem. It shouldn't hurt. But what do the doctors do is they take a speculum and they put it into the vagina and then they open the speculum and it completely bypasses so you can't see it. So your doctor will say, "Oh, everything looks normal. Put the speculum in.
(46:17) Oh, everything looks normal. You're normal. This is all in your head." And that has been going on for decades and decades. Women are told their bodies are normal. It's all in their head. to the point where patients come to see me and they're like, "I've been to 10 doctors and no one's been able to figure out why I have pain and I don't think you're going to be able to find it either and you get that Q-tip out and you find their pain because they don't have pain everywhere.
(46:40) They just have pain in this part of their body and and their eye they just go like they they're in disbelief, right, that you can find their pain. >> It is it is so important and and you mentioned many things that affect it. Another thing that sometimes we see right is when women get recurrent yeast infections or recurrent um STI this can also affect the vestibule.
(46:59) Yeah, absolutely. It's very sensitive tissue. So any kind of infection can bring inflammation and then again sex we said is a high contact sport. So if you have something scraping against this tissue creating like an inflammatory response. It's kind of like people will describe it like sandpaper like shards of glass like cutting, burning, stinging, cracking, uh tearing.
(47:20) These are sort of the words that we get from people. And for some people they can't have penetrative activities. For some people they can but they are going to pay for it later. Um and for some people it affects their uh urinary health. So they got more frequency urgency. Um they've get constipation. This one's wild. I get patients who don't can't have sex but their pelvic floor muscles are so tight they have horrible constipation and that's sort of their only sort of symptom.
(47:46) This tissue again is so hormonally sensitive and so we want to make sure it has optimi optimal hormone hormones whether it's a vaginal DHEA topical estrogen a topical estrogen testosterone you want to keep it hormonally healthy if a patient's on birth control pills we often try to get them to have a hormonal IUD which doesn't affect hormones as much and then uh you also want to look at their pelvic floors so so the muscles underneath can cause pain here so working with pelvic floor physical therapists Sometimes we'll put Botox in pelvic floor muscles
(48:16) which can be sort of life-changing for patients. Um and then you know sometimes there's an inflammatory thing uh that's happening that you have to navigate as well and very rarely we'll need to do surgery on this part of the body. >> Yeah. Yeah. And you've mentioned birth control a few times. So one you mentioned it earlier when you talked about the labia shrinking and another when we just talked about the vestibial.
(48:37) So let's talk a little bit how that works and why does it change the hormones. >> Yeah. So uh uh I love birth control as a concept, right? I love the idea for women having control over their bodies and when they reproduce and pregnancy is extremely dangerous with high complication rates and people die in childirth.
(48:54) So I I love the idea of contraception. I love vasectomies too. They're they're a great form of contraception. Um but again as I said when you play with hormones there are consequences. Sometimes those are very good consequences like not getting pregnant and sometimes they're you know sort of negative consequences. everyone who takes oral birth control pills that stop the the way they work is they stop the ovary from making its own estrogen, progesterone, and testosterone.
(49:19) And so, anyone who takes a birth control pill turns off their ovaries production of testosterone. And if we believe testosterone is important for the pelvis, the vulva, the clitoris, uh the libido, which we know, we know the penis is a testosterone driven organ. We know male libido is affected, male muscle, male bone is affected by testosterone.
(49:41) And so if we think like it it just makes logical sense and we have data too, but like it makes logical sense that it's important for women. And so um that's how birth control works. So what you see and the data is mixed here because again many people on birth control feel very confident in their sexuality.
(49:57) They feel more in control. So they have better sex life, better sex outcomes. But there is a growing uh area of research where you see people with lower libido, it's pain with sex, you know, vulvar complaints, things like that. And I think it's important that we explain these possible side effects to our patients.
(50:14) Now, IUDs don't usually turn off the ovary and so they can pre like prevent. We like IUDs because they are you set it and forget it, but then also they your body is still making its own hormones. >> Absolutely. Um so important. I think so important for I I I mean I talked about this with Irwin too, but I think it's so important that we're not actually counseling women on this.
(50:35) Like I wasn't counsled on it when I got put on birth control when I was younger. I don't think that women are getting the appropriate counseling about how this could affect their hormones. I think that's where so much of the anger is right now is people are just like, "Could you just tell me?" Right? You're not You didn't tell me about pmenopause.
(50:50) You didn't tell me about menopause. You didn't tell me about my clitoris and the full anatomy. Every time I've gone viral, it is for that exact reason where people are like, "Shit, why didn't I know that like I am a smart, educated, went to C like and I didn't know that, right?" Like, and so it's it's kind of giving those moments of like, "Hey, I bet you didn't know this about your body.
(51:14) " And I think women are just pissed. I think the men are pissed, too, cuz like they want to know what's going on, too. Like I can't tell you how cool it is to have a a male partner stand behind me and see a vulvar vestibule exam and realize that he's like like it's not him like that she has essentially a sunburn on her vulva that hurts.
(51:34) And so it's there's this empathy that comes with actually seeing the problem and understanding the problem. And so again, birth control is not good or bad, right or wrong, but like any medicine or anything you do or do not do to your body, there are potential risks and benefits and side effects. >> Absolutely. And the thing is I think that I don't know if it's taught in OBGYn residency, but I don't remember learning this in medical school about oral contraceptives.
(51:56) >> So I once got into a screaming match uh with a eurog gynecologist in my area when I was a resident because I was following the data and actually knew what was going on. And uh and he and I yelled. We're yelling at each other and he was saying birth control doesn't have side effects. It doesn't have side effect.
(52:13) And I and I was just like yell he doesn't like me very much, but that's okay. Well, you're right and he's wrong. So, it is what it is. In the vein of hormones, let's talk a little bit about menopause. You learned how to treat menopause as did I after leaving residency, after sort of being trained as urology, realizing that there was just not many people.
(52:33) In fact, we had this conversation. I don't know if you remember it actually when we were in your clinic and I said well who's treat teach who's treating menopause and you said I said aren't the gynecologists treating it and you said no no one's treating it and that was actually what prompted me to learn about it but why do you think that one people are not learning it what prompted you to learn about it medicine is a dumpster fire of brokenness right now and probably for a long time we have decided as a society that there is one type of doctor that is
(53:03) responsible for everything that has to do with women. And I'll tell you, the gynecologists are a little busy right now, right? They get these 10-minute visits. They put your legs up in stirrups. They make sure you get your mammogram. They they're responsible for your breast health, your bone health, your brain health, your heart health.
(53:18) They're responsible for you being safe and like, you know, and like they are on call every few nights, up all night delivering babies, dealing with emergency surgeries, like emergency life and death. You and I have never had a call as bad as what a weekly call is like for an OB/GYN. And and no one cares.
(53:40) Okay? So, when you have a room where you deliver a dead baby and then you go to the next room and it's the best moment of that person's life, right, cuz they're having their first baby, let's just say, and then you have to go to clinic the next day to talk about someone's libido or hot flashes, and you get 10 minutes to do it. So, the idea that the gynecologist can do this or and they're not taught any of this, by the way, none of this in residency.
(54:03) In fact, I was just at a conference and I was sitting at the bar and there was a gynecologist sitting uh sitting there and she didn't know who I was and and I said, "Oh, I'm a urologist. I do sexual health." And she says, "Oh, I like I I've never written a testosterone prescription. Everyone's coming in asking me for testosterone.
(54:20) " I said, "Oh, it's really easy. I'm happy to tell you." And I explained it to her and I taught her the dosing. And she looks at me and she goes, "Well, maybe it's not because I'm afraid to write testosterone. I just don't want to see these patients." She said, "They take too long. They fill up your clinic. I don't want to be known as the person who does this because I do a whole lot of other things.
(54:41) " And that's the truth bomb, right? Like, and she does do a lot of other things and she does important things. And so, the question is whose responsibility? This is half the population. And so, primary care is swamped, right? Gynecology is swamped. everyone else wants to be a surgeon. Like, who takes care of these people? It cannot be niche medicine.
(55:01) And so, I we're struggling. So, it's kind of all hands- on deck, which is why I created a course to teach doctors how to prescribe hormone therapy because no one else is stepping up to the plate, right? Right now, how many ways can you learn how to prescribe a GLP-1? Probably 572. Like, if you go online, there's probably a million courses.
(55:19) We have very few courses and and uh continuing medical education to teach people how to write prescriptions for hormone therapy, why you need to do why you should consider it, how to counsel patients, but even just what dose and what pharmacy do you use? So, it really doesn't exist and that's crazy in 2026 that it really doesn't exist.
(55:37) So, our friend Heather Hirs has a great course. I started a course, right? There are few now. There's uh like Harvard's putting out an ICME uh that's happening in March uh that people can go to, but there really aren't that many opportunities to learn how to do this. And it really is all hands- on deck. Anyone who wants to learn how to do this, like join us.
(55:55) We need you. And we need evidence-based practitioners out there who are like really able to meet patients where they are and give them customized advice. >> Absolutely. Because there are some serious consequences to prescribing this the incorrect way, right? And you can't just play with hormones, right? >> Yeah.
(56:14) You want, listen, you want knowledgeable clinicians and that unfortunately it's getting it's very hard to find in the menopause space right now. Um I think there are a lot of people doing things in ways that maybe I wouldn't do them. But patients are hungry for answers. They just want to feel like themselves. They want to feel like they're doing everything that they can do to stay as strong and as healthy and as hot as possible.
(56:40) And like patients deserve shared decision-m and they deserve to work with someone who's going to like fight with them for them, right? And fight alongside them. >> Yeah. Yeah. Absolutely. And I think that um you you sort of describe menopause as a total body castration event, which um I think it's it's really interesting way to put it because I think you and I also see men with low testosterone and they feel horrible. They feel miserable.
(57:06) They don't feel like themselves. They are not productive members of society like they used to be. Um they're unhappy. But this is what happens to every woman. >> It's wild cuz I there is nothing more joyful than taking a man who's got a testosterone in the 200s getting them to like the five or 600s and with a weekly injection.
(57:28) And I can't tell you they're like three minute visits where they're like, "Ruben, I feel great. I have so much energy. I'm back at the gym. My my partner is happy. My libido is back up. My pills are working fine for erections. I'm so happy. Please give me refills. Blood counts look good. Testosterone levels look good. See you in 6 months.
(57:46) Right? Like the the joy like I have all these men male patients out there who think I am the greatest human on earth for a three minute visit, you know, after we counseledled and all those things and they're feeling so good. And and it's so funny because um you know some of our other like our endocrinology colleagues, our primary care colleagues, they are not as sort of cavalier about male testosterone as the urologists are.
(58:09) Like we really because we really love quality of life and we love talking to patients about stuff like that. And then these patients go back to those doctors and they're like okay like you're you know like what do they say? Like these patients are so happy. Um and so >> well they just tell them their heart is gonna explode or something >> which it's not.
(58:27) It's not and that data is not. So that's when men, you know, again, if you think of it like a gas tank, their gas tank is like, you know, a little bit low. It's like a quarter tank. Every woman over the age of 50 goes to an empty tank. It's it's fact. It's castration. It is no longer hormones.
(58:44) And I'm sorry people don't like that word, but that's what's happening. And we do not castrate men willy-nilly, nor should we castrate women the same, you know, and sort of not fight back. And we have tech like I would not be able to see without my contact lenses like not at all. Since first grade I would not I can't see anything. Okay.
(59:05) And so I use technology so that I can be a surgeon and like live in this world and like do things. So we have incredible bioididentical hormone therapy that can help prevent osteoporosis, help with hot flashes and night sweats, help get you feeling like yourself again, you know, help the genital and urinary symptoms. I'm not going to apologize for wanting my patients to optimize their sexual health, their quality of life, and live their best life because I will tell you, my grandmother was 90 in the nursing home with dementia and cracked ribs. And
(59:38) that is not the life that I want, right? Like that's not good aging to me, nor and if that's what I'm fighting against. Like the data is so clear to me that it's about strength and prevention and doing everything you can while your body is functioning, right? And so that includes >> eating well and exercising and lifting, but it also includes discussions about hormone therapy. Correct. Absolutely.
(1:00:02) So, let's talk about what actually happens to your entire body when your estrogen drops during parmenopause and menopause. >> It's super interesting. So, actually in your 30s, your testosterone starts to drop. And no one talks about this and I do think it's important. It's actually not a menopause problem.
(1:00:20) It's sort of as you age, I guess you could call it pmenopause. Um, but but your testosterone start, so you still might be having your periods normally, but you still kind of don't feel like yourself. Maybe your stress incontinence gets a little worse. Maybe your libido goes a little bit down. Maybe you're getting urinary tract infections or BV infections or yeast infections every once in a while after sex, but you just don't quite feel like you.
(1:00:43) And menopause, the average age of menopause, which is the full castration event where your estrogen is zero, you know, that's kind of 45 to 55. So all you 40year-olds out there, you're not too young, right? Like 45 to 55 is a reasonable normal age to be fully menopausal. Yeah, you recognized Ricky Martin at the Super Bowl, you should be listening.
(1:01:04) >> Exactly. And he's aging in reverse and I don't understand that at all. It was literally amazing. Um, but so, so if Perry menopause, if we say things start getting weird about 10 years before that, you're talking 35 to 45. So for you 30-year-olds, like this is you're you're not too young.
(1:01:21) I had a reporter just talk to me this morning about how the algorithm, she's 39 and the algorithm is feeding her constant things about pmenopause and it's creating a lot of anxiety. I'm like kind of conflicted there because I was like, you actually do need to learn about this. You need to know what's happening because all I can guarantee you ahead is shit's about to get weird, right? And I think there's this whole timeline of people in their late 30s, 40s, and 50s where you really start to NLM not feeling like myself.
(1:01:48) And it's kind of different for everyone. And people fight back. They're like, "Well, this is just aging." And like what's the difference, right? Like I I don't know. And like again, eyeglasses like I choose to wear contact lenses. So why wouldn't you add hormones to help with some of these symptoms if it helps you and if it works? And really what are you afraid of? So when I teach people, it's like sort of what are you scared of? We give birth control pills all the time to people this age which is very high dose you know sort of very very
(1:02:15) highdosese synthetic hormone therapy is is essentially so people are prescribing hormone therapy they're just doing it it as the birth control form and so we try to teach like there are other ways to potentially do it to try to alleviate some of your patient symptoms. It's so important to to have these conversations.
(1:02:33) And yes, everyone's experience is going to be different, right? Not everyone is going to have this crazy chaotic hormonal fluctuations just like everyone doesn't have crazy um periods, right? Everyone is a little bit different and and you shouldn't have really really painful periods, but some people have more, some people have less, right? There is a variation of normal.
(1:02:50) Um and I think the similarly like your experience may be different, but there is going to be a change. And this is where I really like the education piece because when I can educate my patients on the toolbox, the different forms of hormone therapy, right? We're talking estrogen, progesterone, testosterone for the whole body.
(1:03:06) We're talking about vaginal hormones. Um, when we talk about that toolbox that they all have different products that you can use in different doses, in different forms, the more my patients understand the toolbox, the more they can play with the toolbox, right? And they will find throughout their 40s and 50s, they may play in different ways.
(1:03:24) And it's not a one-sizefits-all, but the magic words for me is when the patient comes back and says, "Ah, I'm back. I feel like myself again, right? We got it. We we hit it right." And the challenge with pmenopause is there's a lot of wild fluctuations. And that is sort of a challenge, which is why birth control for some people is a good idea because it it flattens out the fluctuations.
(1:03:44) But there are other ways to consider doing it, too. >> Yeah. When do you determine like for someone who's on birth control, should they just stay on it if they're doing okay versus should they try to switch to menopausal therapy? >> It's a completely individualized discussion. I have many patients who choose to stay on it.
(1:04:00) I have some who will add testosterone because remember birth control shuts down your ovary. It adds back fake estrogen and fake progesterine. It doesn't do anything to testosterone. I'm like, why don't they put testosterone in the birth control pill, right? Like that would be great. So, so we do have patients who add testosterone and vaginal hormones to their birth control pill.
(1:04:19) We have patients who choose to maybe get an IUD and then use menopause hormone therapy with estrogen, progesterone, testosterone, um you know, sort of different variations of it and vaginal hormones of course because actually even if you're on whole body hormone therapy, vaginal hormones are still very much needed and and should be prescribed.
(1:04:37) >> Absolutely. The the one big thing that I talk about a lot is how it causes recurrent UTI. And so I'll have women who are already on systemic hormone therapy, but they're getting UTI and tell them you need to start vaginal estrogen and they get confused because they're like, I'm already on estrogen. I said, well, no, it doesn't actually affect the local tissue.
(1:04:53) So if you want the local benefits, meaning more lubrication, no pain with sex, prevention of UTI, you need the vaginal. And for anyone who's nerdy and listening, we this is a guideline statement number 11 in the American Neurologic Association that says, it's my favorite guideline statement that patients who are on systemic hormone therapy should still be screened and offered treatment for the genital urinary symptoms.
(1:05:14) So we've got guidelines to pro, you know, to really say this is something we should be offering. >> Do you think, and this is obviously I don't think we have clear data on this yet, do you think that DHEA is better than regular estrogen? I think if I h if I was in charge, which nobody ever wants that to happen, um I would if vaginal DHEA were available, it would be my first line because again, we know that the genital tissue and the bladder tissue is androgen sensitive.
(1:05:42) So, both estrogen and testosterone. And DHEA is the only FDA approved product that we have that does both. And so, I love it. I think it's great. um it's just often difficult for our patients to access and and not always well covered. But I think it's a fabulous product >> and it's not the same as oral DHA supplements.
(1:06:02) So vaginal DHEA that's prescribed by your doctor. >> Correct. >> Absolutely. Um let's talk about I think the thing that patients struggle with when they're starting menopausal therapy is that they it's finding the right dose for them, right? Because sometimes the estrogen is too high and they have bleeding or discomfort.
(1:06:18) What is your approach to that? How should patients approach that? Yeah. So again, it depends a little bit if they are per menopausal, right? So you're normally a reproductive age, your estrogen probably shifts between like 50 to 150 down to 50. When you're pregnant, your estrogen is 3,000. And when you're in menopause, it's zero.
(1:06:39) And so we're looking at between zero and 3,000 as our range. We don't want you to be up to 3,000 like pregnancy. But if you're talking between zero and 150, you know, that's kind of the range with which we often play. Um, and it depends because in perry menopause, your ovaries can do some wild things.
(1:06:58) I've seen patients have estrogen like 900, a thousand, you know, these wild high fluctuations. And no one's trying to get those down. Let's remind ourselves like no one's castrating those women. No one's running around with those women telling them their estrogen has to be lower. no one's checking their estrogen levels.
(1:07:15) And so, um, if you're in pmenopause, there are patients who will start getting breast tenderness a lot because the fluctuating hormones of their own ovaries doing, um, they'll get hot flashes, they'll get night sweats, and a lot of it is that fluctuation from 900 to zero and back back up. >> And so, we try, at least with those patients, I tend to either to try to like make their estrogen not zero.
(1:07:36) So, I give them a little bit of gas in their tank, but they may not need a a high dose because their ovaries are still producing estrogen. Now, if you've been fully menopausal for, you know, haven't bled in over a year and you haven't had estrogen around, then you may want to start with kind of a medium or low dose just to prevent, you know, the side effects, which can be breast tenderness, bleeding, things like that.
(1:07:56) So, you go a little bit slower sometimes with those patients. So, it really depends. Again, it's not like a one-sizefits-all. I often tell patients, start with 005, you know, and you know, cut it in half, go up or down and kind of use a medium dose to kind of play with that. >> Well, I think the other important thing what I tell my patients is like look, it it is going to be variable.
(1:08:14) Everyone is individual. There's not more is not better and less is not like inferior. It really depends on how your body responds to it. And you know, it's interesting to me that we just started talking about checking estrogen levels on people getting transermal estrogen, meaning gels or patches, because we've been doing that for testosterone for years because we know that 20% of guys don't absorb their testosterone.
(1:08:37) >> You're such a logical urologist. I just I love your brain because it just uses logic and unfortunately that doesn't exist in the real world. Yeah, it's a challenge because we know men don't absorb testosterone topically very well. So why would women be all that different? And and I think we struggle with this.
(1:08:55) We do I do we do have patients that do not absorb the topical estrogens. And so we play, you know, again, there are role there's a role for oral estrogen, there's a role for injectable estrogen. And again, if you know the toolbox and you have some understanding of the toolbox, you can play within the toolbox. But um it is not not every patient who gets the same dose of a patch absorbs it the same way.
(1:09:16) >> Absolutely. And and I think that it's so important that like Yeah. It's okay to check the hormones. Like I actually had a friend of mine, a mutual friend of ours, call me like, "My gynecologist refuses to check my estrogen, but I'm on trans dermal estrogen and I don't feel great and I think I might not be absorbing it.
(1:09:32) " And I was like, "Yeah, it's very reasonable in that circumstance." What are other circumstances where you think it's reasonable to check levels? I mean, if you're on a good dose of hormones and you're having symptoms still, right? If you're still in hot flashes, night sweats, you know, you're just not feeling good.
(1:09:47) I'll tell my patients all the time, if you have like a really bad day, you know, certainly you it doesn't mean it's going to be the answer, but like I had a patient um she wore a fem ring and that's a ring, an estrogen ring, highdose estrogen ring that goes in the vagina for 3 months. She's a marathon runner, like super super elite athlete.
(1:10:07) Um and she had been doing great and she calls me one day and she's like, "I feel awful. All my symptoms are back. You know, I feel terrible." I said, "Oh my gosh, like how old is your ring? You know, sometimes it runs out. Let's check." So, she goes to the lab, she gets her lab, and her estrogen is three, right? And I was like, "This doesn't make sense.
(1:10:22) You need to take your ring out and change it." And so, she goes to the bathroom, she tries to take her ring out, and she can't find it. >> So, what probably happened is she had a big bowel movement. Something happened, she beared down, the ring fell out, and she didn't notice. And so, she wasn't getting any estrogen.
(1:10:35) And so, again, did we need the lab to tell us that? No. We probably could have started with the estrogen check for the ring, but it's just a good story of like her symptoms, you know, were telling us something was wrong, >> right? What about before getting any therapy? So, like I think there's a lot of confusion, right? There's a lot of people getting blood tests and as you mentioned, pmenopause is like a roller coaster and so getting a random blood test is not useful.
(1:10:58) But when is it useful for patients to check and how should they know that they're getting a blood test that's actually going to give them some information? Uh it's a huge challenge cuz again I think when patients come in and say I want you to check my hormones. >> That's the language they're using to say I don't feel good and I want something to help me and I want validation here and I want numbers to help explain the way that I feel because I think you're going to just tell me to do more yoga and deep breathing and there has to be
(1:11:25) another reason. >> Right? And I think in moments like that, we need to take a second and instead of putting our, well, let me tell you how hormones work and let me tell you why you're wrong and and you're stupid for even asking me that question. It it doesn't help. Um, I think there are a lot of labs out there right now that are pushing a lot of hormone testing and a lot of expensive hormone testing, which I don't agree with.
(1:11:48) >> But I think if we understand the roller coaster of the hormone fluctuations, then there are certain points where you could check. The guidelines are clear that you should check a you can check a total testosterone at any point and that is very guideline driven. So if your doctor says we that hormones are not helpful, you could show them the testosterone guidelines and say hey a total testosterone is helpful.
(1:12:08) Um, and then I find again, and this is just one of the ways that I was taught, is that when you check if you have your period, um, that's kind of you're at your low. And so if you check around the time where you have your period, so maybe day 1, 2, or three, you know, check that estrogen level, how low do you go, right? If I have a patient who's 38 and her day two estrogen is seven, I don't love that for her bones, right? I don't love it.
(1:12:35) And do I have all the data in the world to say that she should be? But it tells a story. It helps me tell a story. Now the next day her estrogen could go to 200, right? And that's a challenge, right? Vis and and the more your patients understand the roller coaster and they understand that. And I think again um the way technology is advancing so quickly, I think this is going to be a very interesting space to watch because I think we've got continuous glucose monitors.
(1:12:58) I think we'll have continuous hormone monitors not so far in the future. I agree. And I think the book is going to have to be rewritten because I bet you most people do not follow the book that we were all taught. And so we have to be for any doctors listening or clinicians listening, we have to be Plato. Everything is different now.
(1:13:17) There are so many things in medicine that did not exist when we were in training. And we have to be willing to be humble and and and have some humility and this ability to say like, "Wow, we're going to learn new things and we're going to get it wrong sometimes and we're going to get we got this wrong and we're going to get more things wrong.
(1:13:33) " But like we have to be Plato a little bit. >> Yeah, absolutely. And I think it's it's just so important and yeah, I do think continuous hormone monitoring is coming and I think it's going to be very useful, but also it's going to be very prayed upon. It's going to have a lot of unintended consequences and there's going to and like with all things there's going to be right there are people who are and we've seen it with the continuous glucose monitors right the amount of anxiety that it builds the amount of you know there's a lot of bad
(1:13:59) you see all the people who talk about it non-stop and then you stop hearing from them for a while right and they put it away they're obsessed with it and then they put it away and and so I think like all things like it's it's like I mean look at operating with a robot right you and I didn't train you know fully on the robot started to come in when we kind of towards the end of our training and now they use a robot for everything, right? And it becomes the technology is there.
(1:14:22) So, you're like, "Okay, we're going to use it." And then like, "Do you need it?" Well, now we don't know how to do open surgery, you know, like there's there's pros and cons. Let's talk about women with IUDs or anything that's suppressing Well, IUDs I think are more specific because you can't really stop an IUD.
(1:14:39) Um, how do they know when they are going to be in pmenopause or when hormone therapy might be useful for them? So, IDs are great because they make you not bleed, but they're also a little bit challenging because then you don't know um sort of what's going on with your periods. Are you skipping periods? Where are you? And I think this again is where education is so important of Nflm not feeling like myself.
(1:14:58) So, I have a friend who wasn't feeling like herself and just kind of was feeling awful and she had an IUD in place and we um we spot checked, you know, her hormone levels. Uh but you didn't even need to do that. We started her on an estrogen patch because her uterus is protected and she started an estrogen patch.
(1:15:16) U she was on vaginal estrogen and she decided to use testosterone and when I tell you she's a completely like transformed human being and she's in her early 40s and it is just like night and day and she has an energy and a you know she's at the gym way more and her libido is up and she's feeling like herself. Um, which is great because she's got a big seauite position now and she's, you know, working harder than ever, but she feels like she can do it.
(1:15:42) And it's so fun to watch. Um, but again, is that what everybody should do? No. But like you have to have these conversations of like what do you want to, you know, what makes sense for you and how are you feeling? >> Absolutely. The other thing there's been a lot of discussion about brain health and heart health benefits with hormone therapy, which is sort of controversial in the data.
(1:16:03) What how do you consult patients on that? I am not a uh neurology researcher nor a cardiovascular researcher. I always say like I'm a boner doctor, not a bone doctor. And I I I really it to me it's such a ridiculous conversation that is happening in this fake place called the internet where people are fighting over nonreality things that are happening.
(1:16:24) Everyone's saying is like, "Oh, the influencers are telling women to take hormone therapy to prevent dementia and they're evil influencers." None of the influencers are saying that. Influencers are saying, "Hey, look at Lisa Muscone's data. Hey, look at all this interesting data out there.
(1:16:40) You know, libido helps with your testosterone helps with libido. Libido is a mood. Like, could it affect, you know, we see some some studies show benefits for brain? You know, we have data showing decreased cardiovascular disease." So, so people are talking about data. No one is seeing a patient in their clinic who says the only reason I want hormone therapy is to prevent heart attacks.
(1:17:01) like that patient doesn't exist. And to say that patient exists like come find me because that patient has low libido, urinary tract infections, osteopenia, she has hot flashes, night sweats, and she's not sleeping and she's not feeling like herself. That is like many indications where hormone therapy is absolutely beneficial for that patient and should be discussed.
(1:17:21) So the idea that patients are coming to you saying, "Well, I need to take this to prevent dementia." That's not true. Patients are coming in saying, "I don't feel like myself. I have all these symptoms and I'm interested in the brain data out there. Hey, so am I. I'm also interested in the brain data out there. So, I think it's a ridiculous conversation that's happening and it's distracting from the point, the real problem, which is nobody knows how to write goddamn hormone prescriptions, right? Like, like I don't care that they're fighting about this on the
(1:17:47) internet when you are giving the primary care doctors an excuse of saying I don't need to learn how to do this. You do need to learn how to do this. In fact, you absolutely should know how to write an estrogen prescription, a progesterone prescription, a vaginal hormone prescription, and yes, you can learn how to write a testosterone prescription.
(1:18:03) And so, every doctor, honestly, I think orthopedic surgeons should learn how to write hormone therapy prescriptions because people die of fractures. Like, it's wild to me. I think neurologists should learn how to write hormone prescriptions. I think rheumatologists absolutely should learn how to write hormone therapy prescriptions.
(1:18:20) Literally, endocrinologists don't know how to write hormone therapy prescriptions. I go and speak at academic centers at endocrinology departments and I was like how embarrassing that a urologist is teaching a bunch of endocrinologists how to write estrogen patches right like this is basic stuff but we are fighting about the minutiae on the internet it boggles my mind how dumb that conversation is yeah and I think the way I tell people is like yes there may be benefit is not 100% proven if you ask me based on what I see in men's health
(1:18:48) because there's an abundance of data on testosterone benefits that probably there is But I can't say for sure, right? Like I can't say with a 100% certainty that it's going to cause any prevention of dementia or it's going to do be cardioprotective. But um you know to some degree but cardio protection there is some good data on that.
(1:19:06) But I think in general like it doesn't Yeah, you're right. They're not there for that purpose. There was an interesting paper that you were involved in that looked at treating menopause might actually impact patients who are considering plastic surgery. Oh, I we wrote a paper with a plastic surgery resident about why the plastic surgeon needs to learn about hormone therapy.
(1:19:27) Just like we were talking like we need plastic surgeons to learn about hormone therapy because listen, you have hormone receptors in all of your body. Your skin, your hair, your nails, like your bowels, your your your wound healing is so important. Like hormones are so important for wound healing.
(1:19:44) And so plastic surgeons are doing laboplastes, they're doing clitoreral surgeries, they're doing aesthetic things, they're doing skin care, they are doing so many things that are around and and breast tummy tucks and breast reconstruction. They are always working with permenopausal and menopausal patients. And for them to say like, oh, hormone therapy is not my lane.
(1:20:06) We can't do this is ridiculous. So, it was really just a paper going through sort of why the plastic surgeons should care about this. I really I want a paper in every journal. You know, this is why the geriatrician should care about this and this is why the ID doctor should care about this because truly there is no field of medicine that shouldn't care about this topic.
(1:20:25) >> You know, it's so interesting. I that there's so much fear around hormones and this is true because I saw you know there was obviously you were on the FDA panel for women and estrogen and removing that blackbox warning for estrogen. Uh but there's also a panel that was on testosterone and it was mostly about male testosterone.
(1:20:44) There was some discussion about female testosterone but it was very interesting. I was part of this group. I don't remember which one it was, but it was this group on online and there was a lot of doctors complaining about how how this panel was so biased and how testosterone is so bad for you. And I was literally sitting there and shocked because I was like, one, they don't know the data.
(1:21:06) Like, they're literally sitting there based on some education they got years ago that's inaccurate. Again, it's this group think mentality and sort of this idea of once you believe something, it is really hard to change people's minds. And I think this is where we're struggling because no one everyone's excited about GLPs. Everyone's excited about GLPs, right? You don't have the pitchforks of the people a little bit, but like most people are learning about them, learning how to prescribe them.
(1:21:36) They're taking courses. They're getting mentored on it. And they're all about the GLP ones, right? It's new and new things people can get like keep an open mind. Oh, this is new. Let me learn about it. Well, they already have a an emotional attachment to the term estrogen and testosterone. And there's emotions behind it.
(1:21:57) And it has to do with these really annoying patients who come asking for, you know, things that that you think they don't need. These really annoying patients that take too much time and they're asking for things that you don't know how to do. And so, you're uncomfortable with it. So, you shut them down.
(1:22:10) And instead of just telling them you don't know, you know, and then they go to the meta-pas and they get it from, you know, somebody who took a weekend course and that so they must be all be snake oil, so it must all be snake oil. And it's simply not true, right? But again, these clinicians are trying in their minds to deal with life and death medicine.
(1:22:29) They're preventing they're screening for cancer. They're dealing with high blood pressure and diabetes. they don't have time to worry about people's libidos or erections or um you know muscle mass and things like that. And you're seeing patients more and more care about prevention and care about sort of health and it's new and the doctors aren't keeping up so much.
(1:22:50) There's so much bias. There's so much group think and even we see it um we see a lot of the emotion like the way an endocrinologist is taught to do male testosterone is very different than the way a urologist is taught. Um, and it's way worse on the female side. >> What is one thing that you changed your mind on about sexual medicine or menopause therapy since you started uh specializing in the space? >> Oo, uh, great question.
(1:23:17) I I'm constantly changing my mind. I'm constantly learning new things, um, which I love. I'm always trying to listen and learn from colleagues. I would say libido is a really perfect example. When I came out of my fellowship in 2016, uh we had one drug approved for low libido and um the other one was approved I think in 2018 and in my mind I was sort of a surgeon and I you know you you do surgical things and like libido that's all the psychosocial stuff and it really was I think a lecture by Irwin who you interviewed you know where it it
(1:23:51) showed sort of the neurobiology of libido and we see patients all the time with uh SSRI or anti-depressant induced sexual problems, low libido, delayed orgasm, cognitive, like just challenges with sexual health. And there was like this moment I like remember this like light bulb moment like holy crap, if medicine can bot your sexual health, can medicine improve your sexual health? And I got really sort of like, oh, and whose job is it to have these conversations with patients? Because why aren't the psychiatrists prescribing these
(1:24:24) medicines? You know, why aren't the gynecologist? why aren't the primary care? And like no one taught them how to do it. And so I got really loud about it because if not me, then who, right? If I'm not out there prescribing these things and looking like no one else thinks this is their lane because no one else cares enough about sexual health to like actually, you know, prescribe.
(1:24:43) So I use So I've been a big prescriber and sort of interested in these medicines for low libido and hormone therapy for low libido. And we've seen just the magic. I mean, we've seen do they work in everybody? No. But when they work, it's just so you're a hero. I mean, you're just a hero when you can help raise dopamine in someone's body and they get this surge of sort of dopamine, sexual health, libido, and it's so fun.
(1:25:09) So, I think that was a big um a big aha moment for me. Yeah. And you know, I think that the even bigger thing that we haven't touched on too much is that sexual health is a biomarker of your health, right? It is not just this thing you do for fun, right? Yeah, of course it's fun and it's pleasurable, but moreover, it's it's interconnected into your entire being, right? It's interconnected into your heart health, your brain health, and like it should be everybody's lane. It should be.
(1:25:36) And as you mentioned, I think that it's just so important that anyone who's listening, if you're struggling with sex, it is not something to be ashamed of or something that we just talk about with certain doctors. Like, it is a part of your life and we should make it normal to talk about. Yeah. it.
(1:25:50) You know, I've been told over and over in my career, even with people you used to work with, right, of like what you do is weird. What you do is weird. You're not going to make enough money. This is not medicine doesn't value this. This is not real medicine. Um, and you know, we were just talking about how everybody always minimizes us and what we do and what we're capable of.
(1:26:11) And yet when we pull it out, like people are so interested in this. Everyone is affected by this. And that's why it's funny because I lecture a lot um and I teach a lot about this stuff and and I don't really speak differently when I'm talking to a group of of clinicians versus patients because everyone knows nothing and nobody knows anything.
(1:26:32) And so I talk to and I know that they're all patients. Everyone in that audience is a patient. And I know because they send me they come to see me or they send me their their partners and and it is wild how no one was taught how to do this. It never ceases to amaze me like how is it that I have been able to get on the the the platforms and the stages that I've gotten on like I you know the smart the more I learn the more I feel like I don't know anything.
(1:26:58) Um and yet you know that's how bad it is. It's like there really aren't enough people out there talking about this, teaching about this, and there certainly aren't enough people writing the prescriptions. And that's the challenge is cuz everyone deserves access to sexual health, quality of life, sleep, libido, orgasms, you know, feeling like yourself. Like, everybody deserves that.
(1:27:19) Uh, and and we should be fighting for that a whole lot more. >> Yeah. And and I think the bigger issue is not that people don't care, it's that medicine doesn't care. is that the insurance companies don't reimburse the care for these issues, right? They don't reimburse you for the time you spend talking to patients about this.
(1:27:36) And some of the codes aren't even reimbursed, right? Many of the female sexual codes are not reimbursed by insurance. And so you for for so a regular physician who needs to put food on the table doesn't have is not able to see these patients because they literally cannot like cannot make ends meet by seeing patients like this.
(1:27:56) And so it's it's really comes down to what medicine values or not medicine but what insurance companies value >> which yeah it's and uh it's a huge problem. >> So where should people find you? Where can they find out practice your research your course everything you're working on? >> Uh yeah so uh our website's a great place to go rachelrubenmd.com.
(1:28:15) Um we have amazing newsletter that you should sign up for. Uh our courses can be found on there. Our free um education can be found on there. Uh we have a research team that meets once a month. So if you're a student listening or you want to get involved in research, please join us.
(1:28:32) Um and we are always coming up with new ideas and new ways to reach people. So uh follow me on Instagram, Dr. Rachel Rubin. So Dr. Rachel Rubin, and uh we'd love for you to join along. >> Awesome. So we end our podcast with four questions that we ask everyone. It doesn't have to be about sexual medicine. It can be about anything you want.
(1:28:50) So what is something you know now in life that you wish you knew earlier? I should have been kinder to myself and that progress over perfection. >> Absolutely. Absolutely. What's a non-negotiable? Something you have to do every day. >> I sleep I sleep like eight hours a night. >> Really? >> Yeah. >> Oh, I love that. >> I'm neither an early bird or a night owl.
(1:29:10) It's actually wild how productive I am because I cannot stay up late or get up early. >> But that's good. What's a life hack or health hack you'd share with people? >> It's all mindset work. The whole story. Everything is about your mindset work. And the more you invest in constant mindset work, the better your life truly is.
(1:29:30) Um because your brain is sort of like uh the default of your brain is weeds. And if you don't cultivate and actually work on it all the time, the weeds will continue to grow. And uh that has been absolutely life-changing. >> If you couldn't be a physician, a urologist, an entrepreneur as you are now, what would you be? I always joke that I would name nail polish colors because they always have really witty fun names, but I don't actually ever get my nails painted. So, I don't know.
(1:29:56) >> With the plight of a surgeon, we never get our nails done. >> I know. I know. Uh that's the best answer I can come up with. >> What have you thought of a nail polish color that you like like a red or like a I don't know. >> It would probably be clearly the best or something like that. Yeah. >> Yeah. I love that.
(1:30:11) >> All right. Thank you. >> Did you guys love that conversation? Because I know I did. And if you are enjoying this conversation and you've been a longtime listener, I need one favor from you guys. Hit the subscribe button or the follow button on the podcast platform you're listening on right now.
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