The Anatomy of Women’s Health
Rubin’s core argument is blunt: women are denied basic hormonal and sexual health care not because the science is missing, but because doctors were never taught it — and neither were the women themselves. Her aim is to put both the language and the toolbox back in reach.
Women don’t know either
The quiet assumption underneath most of this is that the women in a man’s life already understand their own bodies — periods, pregnancy, menopause, hormones. Men assume women know. They don’t — and no one taught them. Women are rarely given the language for their own anatomy, and the medical encounter often reinforces the gap rather than closing it.
Rubin points to the pelvic exam itself: a drape is placed for modesty, but it also hides a woman’s own genitalia from her while the clinician works “under the hood,” and nobody narrates what they’re looking at. Her fix is deliberately low-tech — she hands the patient a mirror and names each structure as she goes: labia majora and minora, the clitoris, the urethra. Naming is the first act of self-advocacy; you cannot ask for what you cannot name.
The training gap is just as stark. As of 2026, she says, the word clitoris does not appear on the checklist an OBGYN must learn — meaning the doctor most women see for sexual health was never taught about the clitoris, vulva, sexual pain, libido, arousal or orgasm. And this isn’t a problem money solves: Melinda Gates reportedly saw three doctors before getting appropriate hormone therapy, Oprah five before anyone connected her heart palpitations to perimenopause, and Halle Berry was told she had genital herpes when the real issue was the genitourinary syndrome of menopause.
Men assume the women in their lives already know. They don’t — and the medical system that should have taught them was never taught either.
Hormone therapy in four buckets
Rubin frames hormone therapy as a toolbox with four distinct components. The first three act on the whole body; the fourth is applied locally. Her position is that every woman should have access to the toolbox — treatment is driven by symptoms and by what the woman wants, not dictated by her age.
Systemic estrogen
Treats hot flushes, night sweats and bone loss, and supports hair, skin, nails and sleep. Because estrogen thickens the uterine lining, it is paired with progesterone in anyone who still has a uterus.
Systemic progesterone
The counterpart to estrogen — it protects the endometrium against the thickening unopposed estrogen can drive. Rubin also finds it aids sleep and reduces anxiety in many patients, which is why some begin here in perimenopause.
Testosterone
Strongest evidence is for libido, with added benefit reported for arousal, orgasm, satisfaction and body image. Prescribed off-label at roughly one-tenth of the male dose; effect expected at three to six months.
Vaginal & local hormones
Microdosed estradiol or vaginal DHEA. Supports the bladder and vagina, eases painful sex and dryness, calms urinary urgency and leakage, and cuts UTIs by more than half. The bucket she is most emphatic about.
When to start
Not age-based. Rubin’s rule is that treatment begins when symptoms begin, matched to the woman’s own goals. She rejects the idea that a woman must reach full menopause — twelve consecutive months without a period — before anyone acts, comparing it to letting an organ fail completely before treating it. She also flags the postpartum and breastfeeding window as a menopause-like hormone crash she calls the genitourinary syndrome of lactation, safely treated with local hormones.
Hormones across the menstrual cycle
Understanding the natural cycle is what makes hormone therapy legible: replacement aims to restore early-cycle levels (roughly 50–70), not the thousands seen in pregnancy. Estrogen peaks at ovulation; progesterone rises only in the second half, made by the shell of the released egg. Rubin’s key point is what the standard teaching graph leaves out entirely — testosterone.
The missing line. Textbooks graph estrogen and progesterone. Testosterone — relatively steady across the cycle, with a small ovulation rise — is often left off the diagram entirely, which is part of why its decline goes unnoticed.
The testosterone story
Rubin stresses that testosterone loss is not a menopausal event. It begins to fall in a woman’s 30s — well ahead of the estrogen decline of menopause. Clinically this can show up as lower libido, slower or weaker orgasm, reduced arousal and less engorgement, often in women who are told they are “too young” for anything hormonal to be wrong.
Illustrative, not to scale. The shape is the point: the meaningful drop happens decades before menopause, which is why symptoms in the 30s and 40s are so often dismissed.
What quietly lowers desire
Rubin’s informed-consent framing: every medication has common, less-common and disastrous side effects, and the disastrous ones make the adverts while the sexual ones often go unstudied. Several everyday prescriptions move hormones or blunt desire — not a reason to stop them, but a reason to know, so the effect isn’t misread as lost attraction.
Combined birth control
Works by quieting the ovaries so they stop ovulating — and stop making their own testosterone, which the pill doesn’t add back. Up to 27% of users report lower libido; for some, desire returns once they stop.
GLP-1s (Ozempic, Mounjaro)
Barely studied for sexual effects in women. In Rubin’s own (unpublished) survey of 1,000 users, about 25% reported sexual side effects — roughly half of those worse, a quarter better.
Antidepressants (SSRIs)
Genuinely help many people, but commonly bring low libido and delayed orgasm. Worth naming up front so a couple can read it as biology, not a verdict on the relationship.
Hair-loss & acne meds
Several work by acting on testosterone pathways, which can lower testosterone and, with it, desire — in women and men alike.
The bucket she’s loudest about
Local vaginal hormones treat the cluster Rubin calls genitourinary syndrome of menopause: dryness, painful sex, urinary frequency, urgency, leakage and recurrent UTIs. Hormones keep the vaginal environment acidic and its microbiome healthy; when they fall, bad bacteria grow and infection risk climbs. In older women, she notes, UTIs are not trivial — they can escalate to urosepsis and become fatal. Because the dose is tiny and stays local, she describes it as safe at essentially any age and with essentially any history — a claim worth reading alongside the caveat below.
She’s dismissive of the folk advice — peeing after sex, wiping front to back, cranberry — as, at best, small. The evidence-backed prevention, she argues, is local estrogen or DHEA, which has been shown since the 1990s to cut UTIs by more than half. It comes in four everyday formats.
Cream
Estradiol, rubbed in twice weekly
Tablet
Small insert, less mess
Ring
Diffuses estradiol for ~3 months
DHEA
Precursor insert (Intrarosa)
Pain with sex is common — and diagnosable
Up to 75% of women report painful sex at some point; 10–20% live with it chronically, and the figure climbs through menopause. Rubin’s line is firm: sex is not supposed to hurt, and pain is not something to endure — you deserve a diagnosis. The cause usually sits in one of four systems, and finding which one is the whole task.
Skin
The vulva is hormonally sensitive skin — it can dry and thin, or carry eczema and autoimmune conditions.
Pelvic floor
The vulva sits inside large muscles that can go tight and sore, like a chronically knotted shoulder.
Spine-referred
A back problem can send pain down into the pelvis — the genital equivalent of sciatica.
Endometriosis
Internal scar tissue can pull and tether, producing pain with penetration.
On the muscles specifically: everyone with a pelvis has a pelvic floor, and it has to relax for comfortable penetration and contract for orgasm. When it’s too tight, penetration burns and orgasm can be weak or blocked; when blood flow is poor, arousal and lubrication suffer. The fix isn’t always strengthening — a pelvic-floor physiotherapist may work on coordination and release rather than Kegels.
The orgasm gap
About 20% of women say they can’t orgasm — a rate far higher than men’s. Rubin calls it an orgasm “pay gap,” and argues the biggest driver is simply education. Most women don’t orgasm from penetration because the organ of orgasm is the clitoris: under the microscope it’s the same tissue as the penis, carries around 10,000 nerve endings, and is mostly an internal structure. Penetration often doesn’t reach it — so women who orgasm easily by other means, but not through intercourse, are entirely typical, not broken.
Timing tells the same story. Average intercourse runs about 5.5 minutes; women who reach orgasm through clitoral focus usually need well over 13–15 minutes. So a partner who appears to orgasm like clockwork inside that short window is often, she suspects, performing rather than climaxing — usually to protect the other person’s feelings. Her practical takeaways: consider letting the woman orgasm first (pelvic-floor release makes penetration more comfortable), treat penetration as one item on the menu rather than the main event, and use external vibration, which recruits blood flow to the clitoris.
Two kinds of desire
Much partnered friction comes from assuming everyone works the same way. Spontaneous desire arrives before any contact — a thought is enough. Responsive desire shows up only once things are already underway. Rubin’s analogy is exercise: some people want to go to the gym; others never want to start but feel good once they do. Neither is dysfunction — but they skew differently by sex, and mismatches get misread as rejection.
Figures as cited in the interview. Men skew heavily spontaneous; women skew responsive — arousal that follows engagement rather than preceding it. Knowing which pattern each partner has reframes “low libido” as a matter of sequence, not absence.
Desire drains, and the scheduling fix
Rubin situates a lot of “low libido” in the ordinary conditions of an overloaded life — stress, burnout, no white space, small children, and endless scrolling at bedtime. She frames it as a dopamine drain: if there’s nothing left in the tank, desire has nowhere to come from. It’s part of a broader “sex recession” — people connecting less, and increasingly turning to screens and chatbots instead of each other.
Against this she pushes back on the spontaneity myth — the film-scene idea that real desire must be unplanned. Dating, she points out, was scheduled sex all along: you booked Saturday night and anticipated it all week. Her prescription is to plan for connection deliberately — even a single blocked-out partner day once a quarter (a walk, a bath, a massage, time to remember you like each other) — timed when you actually have energy, not as an 8pm performance slot.
On body image, she reframes the double standard people hold: your best friend deserves great sex at any weight without question — so why exempt yourself? She wishes the energy women spend on wanting to be thin went instead toward wanting to be strong.
Communication is the treatment
Rubin borrows a financial-literacy frame for what good sex actually requires — because, she notes, people are equally bad at talking about money and about sex, and want to be great at both.
Sleep, nutrition, movement, safety and — above all — communication. The non-negotiables everyone needs before anything else is worth adding.
Hormones, pelvic-floor health, mental health and sex therapy, and toys or devices. Not everyone will use all of it, but everyone should be able to talk about it.
The Instagram injections, procedures and supplements promising to “fix” sex. Not forbidden — but never the starting point, and never the whole portfolio.
Underneath the frame is her real thesis: biology matters, and women’s biology is the part everyone skips. When a couple assumes a sexual problem is emotional or a verdict on attraction, they miss the physical cause sitting in plain sight. Bringing a partner into the room to see it — the vulvar tissue that’s inflamed “like a sunburn,” or the antidepressant lowering his own libido — converts blame into understanding. Two things can be true at once: she isn’t rejecting you, and there’s a biological reason sex hurts.
Her view on pornography follows the same non-dogmatic logic. It isn’t inherently harmful — she points to the enormous female audience for romantic, sexual storytelling as evidence that “porn for women” simply looks different. The harm comes from deception and concealment, from relying on it instead of a partner, and from conditioning arousal so narrowly that real, messy, human sex can’t compete. The through-line of the whole conversation: education plus communication, ideally with a skilled third party holding the space, is the actual intervention.
Every woman should have access to the toolbox — not because everyone needs everything in it, but because no one should be told no without the data.
The history behind the hesitation
Rubin traces today’s under-prescribing to the 2002 Women’s Health Initiative press conference, which she argues badly misrepresented the study and collapsed hormone prescribing overnight. Clinicians who were seeing benefit couldn’t square the alarm with their own patients — and when the data was re-examined, it didn’t say what the headlines claimed. She notes the original researchers have since walked the alarm back for younger women, a reversal now reflected in the wider literature.
Clinical note
These are Dr Rubin’s positions as stated in the interview, not consensus guidance. Several figures are from her own unpublished or self-cited work (the GLP-1 survey; the clitoral-adhesion outcomes), and the penetration/premature-ejaculation parallel she offers elsewhere is explicitly a theory. Her aside that PCOS is “now called PMOS” refers to a proposed renaming — polycystic ovary syndrome to polycystic metabolic syndrome — that simply hasn’t circulated widely enough yet to be established terminology, which is likely why it lands as unfamiliar rather than wrong. The under-70 cardiovascular reassurance is cleanest for women starting therapy in their 50s; initiating in the late 60s carries more nuance. On her boldest claim — that local vaginal hormones are safe for essentially everyone, including cancer survivors — current research largely supports her; the detail is set out below.
Evidence check · Vaginal estrogen after cancer
The research broadly backs Rubin’s confidence. Because low-dose vaginal estrogen acts locally, systemic absorption is minimal, and studies show it does not increase breast or endometrial cancer recurrence or mortality.1,2,3 Safety still varies with treatment and history.
Breast cancer survivors. Observational studies — including a large American Society of Clinical Oncology (ASCO) review — show local vaginal estrogen does not diminish survival, and it is particularly well-supported for women taking tamoxifen. For survivors using aromatase inhibitors the profile is more complex, and the decision should be made collaboratively with the oncology team.4,5,6
Endometrial cancer survivors. A study reported by The Menopause Society found short-term vaginal estrogen therapy safe for younger survivors, with no elevated risk of recurrence.7
In practice. Non-hormonal lubricants and moisturisers are typically tried first; where hormones are used, low-dose options such as vaginal tablets, estriol or prasterone (DHEA) are often preferred. Because untreated vaginal atrophy causes real harm — severe discomfort and recurrent infection — and the risk profile is low, experts stress that symptoms should not be ignored. Local hormone options should be weighed with an oncologist or gynaecologist against the specific cancer subtype.8
References
- PubMed — Local vaginal estrogen and cancer recurrence/mortality
- ScienceDirect — Vaginal estrogen safety in survivors
- AJOG — Local estrogen therapy outcomes
- ASCO Daily News — Local estrogen does not diminish survival (breast cancer)
- Menopause & Cancer — Navigating vaginal oestrogen after breast cancer
- Breastcancer.org — HRT and aromatase inhibitors
- The Menopause Society — Vaginal estrogen not linked to endometrial cancer recurrence
- ScienceDirect — First-line management and low-dose options
