Say Goodbye to UTIs + Painful Sex. Plus, the 411 on Testosterone Therapy with Dr. Rachel Rubin
Show Snapshot:
We are ending 2023 with a bang! Close out the year by saying goodbye to things that no longer serve you—maddening UTIs, painful sex, itching, burning, urinary urgency and more. Top urologist and sexual wellness expert Dr. Rachel Rubin walks us through the life-changing magic of vaginal estrogen and gives us the 411 on testosterone therapy. We talk pellets, creams, and the impact on libido. Plus, the link between antidepressants and sexual dysfunction.
Show Links:
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More Resources:
ISSWSH: International Society for the Study of Women's Sexual Health
Quotable:
When [testosterone therapy] kicks in and patients are like, “Oh my god, Dr. Rubin, my libido is so much better. Oh my god, I thought about sex.” Or “Wow, my energy is better.” So, we see more than just libido...As reproductive women, you have more testosterone in your body than you have estrogen. Adding some testosterone back, is like adding gas into your tank.
Transcript:
Katie Fogarty 0:03
Welcome to A Certain Age, a show for women who are unafraid to age out loud. I'm your host, Katie Fogarty. Beauties, we have a special show today. You can think of it as the last show of 2023 or the first show you've tuned into that takes your fear of sneeze peeing and of drinking water while being stuck in the middle row of an airplane seriously. Or, you can think of it as one of the many A Certain Age pod shows to feature a super smart, savvy, supportive doctor you wish you had on speed dial. Okay, fine, fine. You can think of this show as all of the above because this episode is all that and a bag of chips. I am joined today by board certified urologist and sexual medicine specialist, Dr. Rachel Rubin. She is one of only a handful of physicians with fellowship training in sexual medicine for all genders. She is a clinician, researcher, and passionate educator. She serves on the board of the International Society for the Study of Women's Sexual Health and as Associate Editor for the Journal of Sexual Medicine Reviews. If you have questions about urinary incontinence, sexual wellness, testosterone therapy, and more, and I know you do, stick around, this show is for you. Welcome, Dr. Rubin.
Dr. Rachel Rubin 1:20
Thank you so much for having me, what an honor.
Katie Fogarty 1:22
I'm excited. I have had the pleasure of having urologist, Dr. Kelly Casperson, on the show, I had Dr. Angelish Kumar in my first season. And I know from having both of those conversations that people are in need of what it is that you bring to the table, your expertise. I was inundated with DMs and messages, I had former guests reach out to me after Dr. Kumar was on the show to have, you know, to share that they were reaching out to her for appointments because women are suffering.
Well, I know them both very well and Dr. Casperson just texted me about three minutes ago. So yeah, it's a it's a great group, we're a very funny, smart and very loud group of people, these lady urologists.
Well, I love it. And you need to be loud, because I learned from talking to Dr. Kumar, when I said, how long do your patients wait before they come in, you know, to sort of seek help, and she said that many of her patients walk through the door after they've been suffering for 10 years, which is pretty astonishing. And, you know, you got to be loud and change that, that, calculus. People need to get the help that they deserve sooner. And I know from prepping for this show that over 50% of women experience some degree of urinary incontinence during menopause. This is an insane number. What are some reasons why that is happening? What are some steps that we can take to fix this?
Dr. Rachel Rubin 2:54
So I think the reason Dr. Kumar, Casperson, and I are so loud about this is we grew up taking care of men, and we take care of everybody, and men don't wait around when they have something wrong with their genitals, they pretty quickly go see their doctors. And there's a different conversation that happens when it comes to quality of life issues for men. It's very normal to have shared decision making with your doctor when you're a man about what your sexual health is, what treatments are for different things, and the risks and benefits. It turns out, though, that there aren't a lot of those conversations happening on the women's health side of things. A lot of times, we only go to risk. And we also really don't talk to women about quality of life and all of the things that we do, that actually can help them live better lives, not just not die from cancer, but actually enjoy their life a little bit better. And a lot of it comes down to understanding your anatomy and understanding your quote unquote, private parts and how they function. And when you learn how your body works, turns out you will make really excellent health care decisions for yourself, right. Things that make sense for you. And we have a lot of different treatment options, ranging from do nothing, to do certain exercises, to local hormone therapy, to surgeries and other things that can help with leakage. So there's actually quite a large toolbox that women aren't even being offered a lot of times.
Katie Fogarty 4:18
Yeah, it's truly amazing. You know, I myself, I've had some, you know, I joke about the middle row of the airplane, but I, you know, for many years didn't want to sit in it. You know, I was always the person on the aisle seat because I had to run, you know, to the bathroom a lot and I work with a pelvic floor therapist, and that helped. And I've been using vaginal estrogen, which I believe helps and I've, you know, I've taken some other steps to try to improve this. I know that women suffer. Dr. Rubin, I know that you were quoted in the sort of blockbuster New York Times article that came out several months ago, written by Susan Dominus called Women Have Been Misled About Menopause. In that article, somebody mentioned the fact, I don't think it was you I think it might have been another doctor, that we have a high tolerance, a high cultural tolerance, for women's suffering. And I think part of the problem is, is that women, you know, have been led to believe that urinary incontinence is just an inevitable part of aging. You know, can you bust that myth for our listeners? Do we have to suffer, is this inevitable?
Dr. Rachel Rubin 5:26
Yeah, I think it goes back to pregnancy and sort of us thinking that natural pregnancies, first of all us doing no research on pregnant people so we say, oh, you can't even take Tylenol, you don't want to hurt the baby, or you can't do this, you can't eat cheese, you can't do all these things. And so I think we just are raised to think that quote, unquote, natural or less actually makes you somehow more badass, if you want. I don't know if I can say that on your podcast.
Katie Fogarty 5:52
You can say whatever you want. First of all, we are, we are grownups.
Dr. Rachel Rubin 5:55
Right, or like, we're like, I didn't do an epidural so I'm somehow tougher than you are. And like, we women think that, oh, if we just do more clean eating and yoga and breathing, and we kind of make each other feel like, you know, somehow that makes you better than another woman. And we gotta get, we gotta move past that, you know, if I didn't wear contact lenses, I would not be able to see or do anything, right. So like, if we just said, oh, my age, I'm just aging, I can't see anything, I would have not been productive after the first grade, right? Because I use technology so that I can see what I'm doing. And so this idea that natural is somehow better, is kind of a crock of crap, if you will. So if you are leaking all the time, and you can't go hang out with your friends and you can't get through a movie and you can't have intimacy with your partner without feeling terrible about yourself, the idea that you just have to suffer or that you have to spend lots of money on pads, or incontinence underwear, is just not true. And if your doctor tells you that, then it's really important that you see a specialist who actually can give you a good, good information about the toolbox. Because not everyone needs surgery, of course not. But there is quite a large toolbox and you want someone to customize it for your story and your exam, which is really important.
Katie Fogarty 7:17
We're gonna get into this toolbox in just a minute, but I want to ask you about something that you just said, that you need to work with a specialist who gets it. How would you and where would you direct our listeners to find doctors, because just like my DMs lit up with people saying, hey, I've made appointments with Dr. Angelish Kumar, I mean she's in New York City. So people listen to the show across the country. Where can they find a doctor who gets it and who can help them?
Dr. Rachel Rubin 7:43
Yeah, I mean, I think educating yourself is really important and knowing that not all doctors learn the same things and know the same things. So it also really depends on what specific topic you want help with. If it's hormones and menopause, you want to see someone who's specialized in menopause. And so that would be going to menopause.org and find a provider. If it's for sexual health issues, orgasm, arousal, libido, or sexual pain, then you want to see someone from the International Society for the Study of Women's Sexual Health or ISSWSH, isswsh.org. There's a find-a-provider. If you want help with incontinence, then you're really going to want to see either someone trained in female urology or in urogynecology and there are websites, SUFU, sufuorg.com, I believe it is. And the other one is the American Urogynecology Association and right now I'm not remembering their acronym, but I can give it to you for your show notes. And all of those will have find-a-provider and sometimes you got to get second opinions too. If someone's recommending surgery and you're not comfortable with that answer, you're always welcome to get a second or even third opinion and any of your doctors who don't like you getting other opinions, I strongly recommend you find another doctor.
I love that piece of advice. That is, that is such, you know, such smart advice, find a doctor that makes you feel seen and supported. It works, you know, beyond simply, you know, for your pelvic floor health, it applies to everything in your life. Dr. Rubin, we're heading into a quick break. When we come back, I want to pick up something you said about how it's important to use technology for things like our eyes and I want to ask you about something specific for urinary incontinence. We'll be back in a minute.
Katie Fogarty 9:29
[AD BREAK]
Dr. Rubin, we're back from the break. I love what you shared about how you use technology, eyeglasses, right, super high tech, to make your eyes work better. And I know from doing my research for this that, I read the article that you were quoted in an Oprah Magazine, where you said that every person born with a uterus should be getting three prescriptions at their annual physical once they turn 45. A colonoscopy, a mammogram, and a third for local vaginal estrogen. Local vaginal estrogen is not technology but it is a, it is an amazing product that we can use to improve the health of our vaginal walls. You know, so how how does this work in terms of urinary incontinence, and it's sort of knock on effect of also helping prevent UTIs?
Dr. Rachel Rubin 10:14
It is really the most important thing that we have in our toolbox to prevent urinary tract infections, to make sex not painful, and to fix urinary frequency and urgency. And what's so crazy Katie, is this technology, quote, unquote, has been around since the 1970s. I would argue this is female Viagra because it helps with sex and it helps with urinary symptoms, two things that Viagra does as well. But Viagra doesn't prevent urinary tract infections. So it's even better than Viagra. And it was around before Viagra. So we actually have a marketing problem, because women don't realize that they have access now to gold, if you will, this is actually the only essential oil that exists. It's the only probiotic that actually works and actually exists. So here's how it works. The genitals and the bladder and the urethra are very hormone sensitive structures. When you're a baby, you don't have hormones and pee your diaper all the time, then in puberty, you get you know, you get all these hormones, and the tissue changes, it morphs, baby genitals don't look like grown up genitals. And so, it becomes pink, it becomes lubricating, you know, sex, tampons, those kinds of things can happen. And so what happens is, the tissue needs hormones to be healthy. And then as you get into your late 30s, early 40s, your hormones start to change, your testosterone starts to drop, and then eventually your estrogen goes to essentially zero. And the tissue, which is rich in hormone receptors, loses all of that healthy nourishing hormones that it's used to. So it gets thin, it gets raw, it gets dry, it gets irritated, the bladder starts to squeeze too much. So you get urinary frequency and urgency, you lose the acidity of the tissue to fight infection. So bacteria starts to grow that shouldn't grow, the microbiome starts to change for the worse. And so if that is still a sexual place, all this bacteria gets introduced, and you can't fight it off like you could in your reproductive years. And so you get urinary tract infections, and those can kill you. And so these therapies, either local vaginal estrogen, or vaginal DHEA. And it comes in different forms. It can be a cream, a suppository, a ring, or a tablet insert, there's lots of options, there's even a pill that is an option as well. And these prevent all of those problems. So we call this problem genital urinary syndrome of menopause, or GSM for short. And vaginal hormones are safe for everybody. They're safe for your 98 year old great grandmother in the nursing home, they're safe for your aunt who had a history of breast cancer, they're safe for your friend who had a blood clot one time. And so it's really important, but like sunscreen and seatbelts, it only works if you actually keep using them. So Katie, it sounds like you're on vaginal hormones. And you're going to be on that for the rest of your life if you want to prevent urinary tract infections.
Katie Fogarty 13:21
Which I 100% do because I am somebody who has played with them when I was younger, actually, ironically, during my reproductive years, I had UTIs all, you know, constantly and I know how irritating they can be. They're disruptive in terms of just the quality of your life. I've gotten much better about always urinating after sex, and that has helped really kind of prevent them. And I am taking vaginal estrogen because I'm a podcaster. And I've learned from doing the show that I need to be doing it. I did not hear about that from my own doctor until I wound up switching and I now work with a wonderful integrative physician, OBGYN, who has, you know, encouraged me and I'm assuming a lot of her other patients to make use of vaginal estrogen. So I am here for that because UTIs are annoying and you raise the point too, that they can be deadly. I don't think that people recognize that that's one of, a big cause of hospitalization as women age and then they struggle with UTIs. For anyone who's, you know, hasn't gotten that message, you know, when you said it's deadly, like share with us a little bit more about that.
Dr. Rachel Rubin 14:28
Well, urinary tract infections, you know, when you're young, usually you take antibiotics, they go away. But as you get older, a lot of things can happen. So if you keep getting them, well you start to grow what's called antibiotic resistant bacteria, which is very dangerous because if you run out of the antibiotics to use, well then you end up needing IV antibiotics or even more scarily, there are no antibiotics that will work for you. And if an infection is left untreated, it can go to your kidneys and it can go through your bloodstream and cause sepsis which, can, is very dangerous and can lead to multi system organ failure and death. And not only can it, it does on a regular basis. And this is something that plagues nursing homes, our elderly, we know that our nursing home patients can get mental status changes, and that sometimes is the only sign of a urinary tract infection. So you know, you can get worsening dementia. And really it can, it's just horrible and we can prevent it. But nobody's offering it to these women, because vaginal hormones are thought to treat a little vaginal dryness and no one is thinking that these urinary tract infections can be prevented with the use of these very safe and effective products.
Katie Fogarty 15:40
You've sold, you've sold the listeners I'm sure. I've already been sold because I've had this conversation a number of times on the podcast and I know how important it is to be using vaginal estrogen, which as you pointed out is extremely safe. So you mentioned there it comes in different formats. So there's, you know, there's a buffet of choices for people, you can use a cream, a suppository, a ring, a tablet. Walk us through if we are using cream, which I think is, you know, a very popular option, what's the cadence that we're using it? Are we, how often?
Dr. Rachel Rubin 16:08
The cream, a vaginal estrogen cream, and I like the Estradiol or Estrace brand name better than I love the synthetic Premarin. I'll be honest, I'm very biased. And the reason I don't love the synthetic Premarin is sometimes there's like alcohol in it that can be irritating. So if the creams irritate you choose a different product, because there are other products out there. Don't say I tried it, it didn't work for me. The product didn't work for you, but not the hormone itself. So you got to find a different delivery system. Now we love the creams because they are the cheapest option. So without insurance, you can get a tube of estrogen cream for $20 using what's called either a GoodRX coupon at your local pharmacy, you go to goodrx.com or costplusdrugs.com, which is Mark Cuban that guy from Shark Tank, it's his pharmacy online.
Katie Fogarty 16:58
Wow.
Dr. Rachel Rubin 16:58
Which is, that guy knows more about vaginal hormones than your doctor. And he is an absolute wonderful human for getting affordable options. When I got out of my training seven years ago, a tube of estrogen was $500. And now it's $20. So you're talking so much access. Now your doctor has to write a prescription to your local pharmacy that takes a GoodRx coupon or the costplusdrugs.com. And it should be $20 for a tube, which should last you about two to three months. Now, you use at least one gram every day for two weeks and then you can go down to one gram twice a week till death do you part. So one gram is usually about a finger length full, or you can use the applicator that it comes with. Now one trick I learned from a very wonderful friend of mine is a lot of women don't like creams because they're goopy and messy. And so one trick is to take one gram and put it on your finger and then rub it on the inside walls of the vagina until it's completely rubbed in like you would do sunscreen or moisturizer. You don't just glob it on and go on with your day. And so by rubbing it into the walls, it won't leak, it won't drip, it won't feel yucky for you. And this is a really wonderful workaround for patients who don't love creams.
Katie Fogarty 17:01
That's such a smart piece of advice because, you know, the, I use the applicator and this notion of using your fingers so that you don't have the sort of discharge and the dripping is super smart and it makes it so manageable. I actually had another doctor on the show who also recommended using a little bit around, you know, not just within your vaginal walls, but a little bit externally. Where do you land on that?
Dr. Rachel Rubin 18:36
Yeah, so I am a big fan of adding a little bit externally on the urethra and the lining of the inside of the labia minora, that tissue can be very irritated as well. What I don't like is when my colleagues tell people to just do that, because I think it's not enough. And so one thing that we have in our office is pH papers, we want to make sure the vaginal pH is four and a half. So we want an acidic pH. So if you think that you're using enough, one quick test is to check the pH of your vaginal walls and see if it's enough. So just putting a little on the urethra in my opinion is not enough. But if you do at least a gram twice a week in the vagina and some on the urethra, you're good to go and I love it.
Katie Fogarty 19:18
Okay, and so why do people then opt to use things like rings and tablets versus the cream which is pretty user friendly and as you pointed out, cost effective now that the price has been lowered?
Dr. Rachel Rubin 19:29
Yeah, so it's, sometimes creams irritate people so the chemicals within the creams and a lot of people have sensitive tissue. And so if you have really sensitive tissue and you add the cream, some people feel burning, irritation, and they are just so annoyed with you. They also don't love the goopiness, the messiness, and a lot of people don't love plunging creams into their vagina. And so the ring, okay so perfect example, the ring, there's a vaginal estrogen ring that excretes local small doses of estrogen into the vagina, which heals the bladder, and it lasts for three months at a time. This is fabulous for anyone who wants to set it and forget it. But really nice for a patient who might be in a nursing home with poor dexterity of their fingers or somebody who may have dementia who can't remember to put a cream or an insert in. They can make, you know, an appointment with their doctor every three months or their aide can put it in every three months. It's such a lovely option for someone who can't remember to do something and, or if someone is just way too busy and doesn't want to do something. And there is a pill. The pill is called ospemifene, which is a pill that you take, you know, there are women who refuse to put things in their vaginas. And so if you have no other options, then you do have an oral option to take.
Katie Fogarty 20:46
Okay, there's so many good choices. Really a buffet of choices to fit with your lifestyle, your preferences and, and your timing.
Dr. Rachel Rubin 20:54
Now, I should add one caveat here is that there is a magical product called Intrarosa, which is vaginal DHEA. Now, I, testosterone is a very hot topic. And it turns out your urethra and bladder like testosterone as much as it likes estrogen and actually probably needs both. And so Intrarosa, DHEA is the precursor to estrogen and testosterone and the only FDA approved option that adds both. And so we love it, especially those people who try estrogen and it's just not quite enough, they're still having pain, or urinary tract infections, we may be able to save the day with something like Intrarosa. So we're a big fan of that product. Now if it's covered by insurance, it's fabulous. Sometimes it's max cash price is $85 a month at places like Costco, so you got to know the deals and where to get it. So it's a little bit more challenging than just that tube of cream.
Gotcha. And Dr. Rubin, how are we spelling that so our listeners can look it up and I can add it to the show notes.
Intrarosa is I-n-t-r a-r o-s-a.
Katie Fogarty 21:55
Phenomenal. So this is a great time to segue maybe into testosterone therapy and the role that it can play with sexual dysfunction. You said it's very buzzy, testosterone's, you know, as important and maybe sometimes more important than estrogen. What is testosterone therapy? How does it work?
Dr. Rachel Rubin 22:19
So when we talk about, so what I was just talking about was the genital and urinary symptoms of menopause. And those can be treated with very local low dose hormones that really don't help your whole body but really help the vagina and the bladder. And those things are safe for just about everyone and I'll fight anyone who says otherwise, I will just put me on a stage and I'll fight them to the death. And then when we're talking about testosterone for your whole body or hormone replacement therapy, then you start getting into more detailed controversial issues, if you will. Now menopause, that Susan Dominus article in The New York Times, I hope you link to it because it really was a fabulous, she's a brilliant woman and it's a fabulous article, that goes through the controversy of why everyone thinks hormones are so dangerous, and what actually is the data, you know, in 2023. And so, um, so I don't know that we're gonna get into all the details on this podcast, but I think the idea that hormones are dangerous is much more nuanced, and they're actually a lot safer and a lot, there should be a lot more women being offered hormone replacement therapy in menopause than are currently being offered it. And in that Susan Dominus article, I was quoted as saying that menopause has the worst PR campaign in the history of the universe because everyone thinks it's just hot flashes and night sweats. But it's so much more than that. It's brain fog, it's a depression, anxiety, it's heart palpitation, it's your skin drying out, it's your eyeballs drying out, it can be frozen shoulder, right? There's so many symptoms of perimenopause that nobody picks up on and so you start to feel crazy, you start to feel like you're dying, you start to feel like no one in the world understands. You can't sleep anymore, you can't remember what a pen is called anymore, you think you have dementia? And so the idea that you just -
Katie Fogarty 24:13
Dr. Rubin, it sounds like you've been, like you've like moved into my bedroom because -
Dr. Rachel Rubin 24:17
Right?
Katie Fogarty 24:17
- that was a lot of what I was experiencing when I was in the early stages. I would like point at the kitchen timer and be like that thing that like counts the time, like I couldn't remember words. It's weird.
Dr. Rachel Rubin 24:30
And the idea that you just have to suck it up buttercup is -
Katie Fogarty 24:33
Yes, no bueno. No bueno. We're not here for that.
Dr. Rachel Rubin 24:36
- it's insane. And so hormone therapy is you, right, indicated for hot flashes and night sweats, for osteoporosis prevention, and for the genital urinary syndrome of menopause. But it does a lot more than that. And women should be offered a treatment for their very debilitating symptoms. And so a hormone therapy often looks like whole body estrogen. If you have a uterus we give you progesterone to protect it from uterine cancer, and testosterone, which the most data we have is for low libido. That doesn't mean it only treats low libido, but that's essentially the majority of the data that we have. Now, testosterone is, there's global consensus that testosterone is safe for menopausal women, that it works well and it's safe. Global consensus. Right now in 2023, I don't think we have global consensus on anything.
Katie Fogarty 25:28
On anything, exactly.
Dr. Rachel Rubin 25:29
And yet we have global consensus that testosterone is safe, and it works for low libido. But we have a big problem. We don't have an FDA approved version of testosterone that is dosed correctly for women.
Katie Fogarty 25:40
Why not?
Dr. Rachel Rubin 25:41
It's very simple. The FDA hates women, there's like no other explanation. So there was a company that studied it, and a billion dollars went into it. And it was five years of data, and it was safe. And the FDA said, well...this is women we're talking about, so we're gonna need five more years of data. To get a male testosterone product approved is six months of data and about $10 million. So you're talking about another billion dollars that would have to go into a study for low libido, which no company can afford or is going to do. That's a big problem. It's approved in Australia, so it really doesn't make any sense. Because if it's good enough for the Australian Government and the Australian people, it makes no sense why the FDA wouldn't have, the benchmarks are different for men and women. And it's really just unfair, like it's really discrimination. So, um, so we don't, you can tell I'm opinionated about this.
Katie Fogarty 26:38
Yes, no, well we like strong opinions.
Dr. Rachel Rubin 26:40
So we don't have a product that is approved for women. So we have to use off label, which we do off label things all the time. If you've ever had a birth control pill for acne, that's off label, right? So so what we do is we actually use male testosterone, and we just use it at female doses, which is about 1/10 the amount. So it's actually very inexpensive. You don't have to get fancy compounding, you don't have to get pellets, you literally can get through a GoodRx coupon, you can get it for about $6 a month to use topical male generic testosterone. It's very easy to do. And so, but you need a doctor who actually knows how to do it, who knows the tricks, and I find urologists are more comfortable in the testosterone space, because we give it to people all the time. Whereas gynecologist don't often give testosterone therapy to people. So we really have to get the gynecologists who really care about this and take extra courses. Does that, does that make sense?
Katie Fogarty 27:35
Yeah, no, it totally makes sense. I want to explore this a little bit further. So my gynecologist actually did prescribe to me, testosterone cream. And I used it and I will tell you, it was like I used it for maybe a week and I felt like my engine had turned over. I was like, oh, hello. Like it really does like rev up your libido and your energy. And I, it was noticeable. And I use it as a topical cream. So I'd love to hear about, and you use the word pellets and I know there's some, you know, from spending time online and doing some research, there's controversy around pellets. Walk us through what that controversy is, do you prefer a topical cream to that option? Is testosterone ever delivered orally, or is it only a pellet or a cream?
Dr. Rachel Rubin 28:19
Oh, I love all these questions. So right now, as I said, we have no FDA approved option for women. While we use male testosterone, and right now I use mostly topical testosterone that I would use for my male patients. Interestingly, there is a new oral testosterone out there that we're very interested in and would love the companies to study it in women. But we have no data at this point. So there's no pill option at this point that is safe for women to take. Now pellets was very controversial and interesting. There is an FDA approved pellet for men. It's called Testopel. They did the studies, they went through the FDA, and they got approval. Now, there are many companies out there marketing pellets for women, and there are many women getting pellets. But that's not FDA regulated, which means nobody is going under the hood at those pharmacies to even confirm that that's what's in the pellet. And sometimes you can't confirm the dosing. So if you put a pellet, which is like basically putting a tic tac under your butt, in your butt fat, and it gives you a high dose of testosterone. Now if you've never had testosterone in your body before, you may have too high of a dose which can lead to side effects like oily skin or acne. In very, very severe cases, you could get a clitoral growth or deepening of your voice. It's rare, but it's possible. Now pellets could be safe and could be effective for women, but my problem is if the pellet companies loved women as much as they claim to, why aren't they doing the work? Why aren't they doing the studies? Why aren't they going through the FDA to get regulated? I'll tell you Katie, my kid's applesauce pouches have been recalled because there's dangerous things in my kid's applesauce pouches. So at least the FDA is looking inside my kid's applesauce pouches. But nobody's looking inside these pellet companies.
Katie Fogarty 30:07
Is it because of the expense, do you think?
Dr. Rachel Rubin 30:09
Probably. It's because they don't have to. Because they can make billions of dollars, because they're, because these people are saying, well, we're safe. We're a good company, we're safe. But like, really? Like, if they cared about women, do the work. Like the FDA is not perfect. I've got plenty, I just said that the FDA hates women. So I've got my beef with the FDA. But the, but they're still, they're still regulating things. They're looking under the hood, they're seeing what's going on, and they don't get it right every time. But this is totally unregulated. So that's my issue. I actually believe pellets could be a really good thing for women, because who wouldn't want to do something just every four to six months? But why wouldn't they do the work, right?
Katie Fogarty 30:50
Yeah, they have to put the research in I guess, in order to have women to feel that level of comfort.
Dr. Rachel Rubin 30:55
We should care about women enough to do the research.
Katie Fogarty 30:57
Absolutely. And so, you know, I know that there are, you know, that's in the works, hopefully. So how, you know, I'm going to do an entire separate show on what listeners should be doing as consumers and voters in order to encourage the different, you know, arms of our government to, you know, research and more effectively advocate and steward women's health. So I love that you've put that on, you know, the listener's radar, and I'm definitely picking up a show in 2024 on that very topic. So if you're feeling as riled up as Dr. Rubin, and you should be listeners, were gonna have some ideas for what you can put into action to help. But moving on a little bit more to testosterone before we switch gears, so that the creams, though. So do you believe this is still a great option for women today, since it's, what, the only thing that's readily available, is that correct?
Dr. Rachel Rubin 31:46
I think creams are a great option. We, I like the FDA approved creams for men and I use them, you know, in just female doses. There are people who use compounded products because either they don't have access to this or they don't know how to do it well, but again, you can check your hormone level, your testosterone levels, and kind of see what they are, make sure you're absorbing the cream. And in your, you know, what patients are reporting to us is that, I think it takes more than a week, like you said, you noticed in about a week, I tend to see more that like three, four months, like that's when it kind of kicks in. And patients are like oh my god, Dr. Rubin, my libido is so much better. Oh my god, I thought about sex, I had a sex dream for the first time so long, or wow, my energy is better I'm getting, my workouts are, actually I feel like I'm getting credit for them finally, did you see this muscle that I grew. So we see more than just libido, but the most data that we have is for libido. So, so I think that's, and I think the really important message to the listeners is it's not that scary. Testosterone's not that serious. As reproductive women, you have more testosterone in your body than you have estrogen, it's just that nobody told you. And so adding some testosterone back, I think of it like adding some gas into your tank, right, you've got an empty tank, and we're just trying to put some gas into it. And so we do that with hormones, we do that with sex therapy, we do that with education, we do that with antidepressants, if sometimes, right? There's so many different things that we do to try to just fill your bucket. And so it's really just finding a doctor who's going to really learn about you to figure out what makes sense, like what is your gas tank and what do we need to add to it?
Katie Fogarty 33:24
Yeah, we definitely need to fill up our tanks. I love that. Let's switch gears for a minute because I want to talk about something that I saw on your website. It was an article that you had been quoted in and it was about, the premise of the article was the focus on sexual dysfunction that can be caused by antidepressants. And you know, I've learned from recording this show that women over 60 are the largest demographic of antidepressant users in the US. But across genders here, you know, people over 40 represent one of the largest blocks of antidepressant users in general. So what should we know about SSRIs, and am I saying that correctly, and sexual dysfunction? I feel like I might have thrown an extra S in there, but you know.
Dr. Rachel Rubin 34:10
No, no you were perfect, you're perfect. So, so medications have side effects. All medications have side effects and any doctor who says take this, except vaginal estrogen that's the perfect medication with no side effects. Just kidding, occasionally with vaginal estrogen people get yeast infections, but other than that, there's like no side effects. So most medications have side effects. And so you have to understand what the side effects are. And antidepressants are no exception. They can be wonderfully life saving for some people and life alteringly ruinous for other people. Same as birth control pills, same as any surgery that you get, right. There's so many risks and benefits to different things. And so we've known over the years that many antidepressants can have sexual side effects, and it has to do with how serotonin works on the brain, we think, and how dopamine is, you know, how much dopamine that you have. And so, if you, you know, so if a medication can have sexual side effects, then other medications can boost sexual function. And we have medicines that work on the brain that can boost sexual health. And so again, back to the gas tank, sort of analogy, if you are depressed and anxious and you can't get out of bed, then sometimes adding an antidepressant will fill the tank. However, if you're adding an antidepressant and you notice a decrease in your libido, or a delay in your orgasm, we're actually taking gas out of the tank with that antidepressant. And so it really becomes having a team that you can talk to, and that can help understand what your goals are, because it really only matters what you care about, not what anybody else cares about. And so we have antidepressants that maybe have less or fewer sexual side effects, we have ones that could boost sexual health, like there's all sorts of things that we can do. But if your doctor doesn't know that these are your side effects, or that sexual health is a priority for you, they won't know how to alter that medication cocktail that they're going to recommend.
Katie Fogarty 36:06
Yeah, absolutely. And so if somebody is working with a clinician who is prescribing antidepressants, and that person could be, I guess, maybe a psychiatrist, or your medical doctor, and they are not sexual wellness experts, you know, where do you recommend that a patient who is experiencing sexual dysfunction, turn to? You know, I mean, it sounds tricky, right to find the right person.
Dr. Rachel Rubin 36:30
The key is advocating for yourself. And if your doctor looks at you, or talks to you, like it's not a priority, or it's not important, then asking for another recommendation or seeing somebody else. Again, things like the Sexual Medicine Society of North America, or seeing sex therapy specific providers. And AASECT is the sex therapy website, which is mostly sex therapists, not psychiatrists who are prescribing, but they will know who the sex friendly psychiatrists in town are. And so it's okay to ask your doctors, do they, do they know a lot about this? Or have they seen this before? And it's also okay to get some different opinions.
Katie Fogarty 36:31
Yeah, it's, uh, you know, the very first guest I had on this podcast is a doctor named Dr. Anita Sadaty. And she shared that when she is doing her, you know, well-checks with people and she's about to walk out the door, and she literally has her hand on the doorknob, the patient will say to her, you know, oh, there is one more thing. And she always knows that that's, you know, it's that they're having painful sex, even though she's asked them questions, they haven't shared it, and then, that this is an issue. And so you really have to, some of the, we want our doctors to be our advocates and to be educated and to be menopause, you know, trained and sort of cognizant of what's going on in the latest science, but we also have to be our own advocates. And you know, doctors aren't mind readers, we have to really let them know what's going on with our bodies in order to get the treatment and care that we deserve.
Dr. Rachel Rubin 38:02
And it's not only okay to care about your sexual health, but if it's important to you, it should absolutely be important to your clinician, right? Like, this is the thing, like don't minimize it. Men don't minimize it, and women shouldn't minimize it either. If it's important to you, then you deserve to be given a toolbox of, you know, that can help you. And it exists. I think the problem is we sort of make women think that the only toolbox that exists are, you know, aesthetic creams and gels and supplements that are on the internet.
Katie Fogarty 38:31
I, yes, I so agree. And by the way, you just, when you said the word toolbox, it just jogged a memory. We're gonna be heading into our speed round in just a minute because our time is wrapping up. But I did find this phenomenal quote when I was researching you in the New York Times, and it said, 'I think doctors should be prescribing vibrators, which are health aids, just like eyeglasses or hearing aids, the more we normalize them and educate patients in our exam rooms about them, the better.' And I love that. So, you know, this, you mentioned the word tool. Before we head into the speed round, why is a vibrator something that we should all have in our sexual wellness, or just overall wellness, toolkit?
Dr. Rachel Rubin 39:08
Well, so we know that the clitoris is mostly an internal organ. The clitoris and the penis are exactly the same thing. They're made up of exactly the same tissue and they work exactly the same way. It's just that women don't often penetrate with and they definitely don't pee through their clitoris. And so scientists ignore that completely. But to access a clitoris often requires vibration, because it's very difficult to get to it because it's mostly an internal organ. So we know from data that more than 50% of women use vibration to help them achieve orgasm. So why wouldn't you want to bring tools into the bedroom to make for more maximal sexual pleasure? And I'll tell you, penises love vibration as well, it's just many haven't tried. So we love devices for men, we love devices for anybody, for women, and there's a lot of couples devices out there. And so the more we normalize this as just medical devices or just, uh, you know, quality of life devices, the better life will be. Because at the end of the day, most sex is just about fun and pleasure. The whole, you know, the reproductive, baby making part of sex is a very short period of time for most people. And so if the goal is fun and joy and pleasure, why wouldn't you add toys? You don't go to the same restaurant every single time you want to go to a nice restaurant, you don't go on the same vacations, why are you having sex the same way every time? Why aren't you adding more tools to your toolbox?
Katie Fogarty 40:35
We could all use more fun. So I think that everyone should think about putting one of these fun sex tools, a vibrator, in your, you know, Christmas stocking or as a Hanukkah gift, you know. Or gift it to yourself in January if it hasn't shown up, as a present for yourself. So think about that, ladies. All right, we are moving into our speed round. Are you ready? This is just one to two word answers to end.
Dr. Rachel Rubin 40:59
Oh, I've never been good at one to do word answers but let's try it. I'm game.
Katie Fogarty 41:03
You're good, we can do hard things and you're good at lots of stuff. I bet you can be good at this. Let's do it.
Dr. Rachel Rubin 41:08
Let's try it.
Katie Fogarty 41:08
Okay, I could talk about this menopause topic again and again:
Dr. Rachel Rubin 41:12
Was that a question?
Katie Fogarty 41:13
Yeah, it's like a fill in the blank.
Dr. Rachel Rubin 41:16
Oh, this topic? Oh, GSM.
Katie Fogarty 41:19
Nice. Okay, what is the number one issue that brings female patients to you?
Dr. Rachel Rubin 41:25
Sexual pain.
Katie Fogarty 41:26
You are an incredible resource to women dealing with menopause symptoms. What's another resource, either a book, a person, a podcast, that women should have on their radar?
Dr. Rachel Rubin 41:36
Kelly Casperson's podcast and Heather Hirsch's podcast.
Katie Fogarty 41:39
Nice. You say every woman should have a vibrator. What is another product or tool for our sexual wellness toolkit?
Dr. Rachel Rubin 41:47
Pelvic floor physical therapist.
Katie Fogarty 41:49
Nice. I thought you were gonna say lube, but that works too. Okay, even doctors need to work on their well being, this lifestyle choice or hack fuels well being in your own life:
Dr. Rachel Rubin 42:00
Sleep.
Katie Fogarty 42:01
Nice. Finally, your one word answer to complete this sentence, as I age I feel:
Dr. Rachel Rubin 42:08
Empowered.
Katie Fogarty 42:09
Love it. Love it, love it, love it. Dr. Rubin, this has been phenomenal. I have learned so much from you. I so appreciate your time and I'm, I feel like we're ending the year with a bang with this show. Before we say goodbye, how can our listeners keep following you and your work?
Dr. Rachel Rubin 42:25
I would love for you all to sign up for my newsletter at rachelrubinmd.com. And follow us on social media. It's @drrachelrubin, Dr. Rachel Rubin on all of the channels. Except Tik Tok, I'm not on that one yet.
Katie Fogarty 42:38
I love it. Thank you so much. This wraps A Certain Age, a show for women who are aging without apology. And this wraps our 2023 shows. Thank you for listening all year and supporting the show. We are taking the next two weeks off for the holidays. But we will be back the second week of January with shows to jumpstart your 2024. From fitness to finances to reinvention and more. Now before I say goodbye a quick favor. I would love it if you could take five minutes to write an end of the year Apple podcast review. Did you learn something on our 2023 shows? Does tuning in every Monday make you feel seen and supported? If so, please take five minutes to rate or review the show over on Apple podcasts. Special thanks to Michael Mancini who composed and produced our theme music. See you next year and until then, age boldly beauties!