We Can Do Hard Things with Glennon Doyle - Finally, Menopause Relief: How Did We Not Know This? with Dr. Rachel Rubin

Episode Date: October 13, 2026

If you don’t feel like yourself lately, it might not be stress, aging, or “all in your head.” Dr. Rachel Rubin tells us what every woman deserves to know about perimenopause, menopause, and the hormones that can affect everything from our sleep and mood to our brains, bodies, relationships, and sex lives. - The surprising signs of perimenopause—and how early they can start - Why a “normal” hormone test doesn’t mean you’re not in perimenopause - What doctors were never taught about menopause - The truth about HRT—and why generations of women were taught to fear hormones - Estrogen, progesterone & testosterone: what each actually does - How to advocate for the care you need to feel like yourself again Find more information at https://www.rachelrubinmd.com/ and sign up for Dr. Rubin’s newsletter here.  About Dr. Rubin:  Dr. Rachel Rubin is a board-certified urologist and sexual medicine specialist who is changing the way we talk about menopause, hormones, and sexual health — especially the things women have historically been told to accept, endure, or simply stop talking about. She practices in the Washington, D.C., area as well as Los Angeles and is an Assistant Professor of Urology at Georgetown University. A nationally recognized educator, researcher, and advocate, Dr. Rubin has become a leading voice for greater awareness and access to treatments like vaginal estrogen and testosterone use in menopausal women. She is known for making complicated science understandable — and beloved for telling the truth about women’s health, which medicine has too often failed to say. Follow We Can Do Hard Things on:  Instagram — ⁠https://www.instagram.com/wecandohardthings⁠

This episode is brought to you by MIDI Health, a sponsor of We Can Do Hard Things. If you are listeners, you know we and probably many of you have been experiencing symptoms of paramenopause and menopause and are looking for answers and help. Sometimes we don't even know what questions to ask, so we're excited to have a conversation today with a very special guest who does know. Hi, welcome to We Can Do Hard Things. we are going to jump in quickly today. Because today we have Dr. Rachel Rubin.

You may have seen Dr. Rubin everywhere. You may have seen her saving women's lives through all of her incredible wisdom all over Instagram. You may have seen her lobbying Congress recently to get us our damn patches. She is going to teach us exactly what paramenopause is, exactly what we need to do to advocate for our own health during this time of our lives. And she's with us today. She is not affiliated with Middy. She is a board certified urologist and sexual medicine specialists who is changing the way we talk about menopause, hormones, and sexual health, especially the things women have historically been told to. accept. She practices in D.C., L.A., and she's an assistant professor of urology at Georgetown.

Dr. Rubin has become a leading voice for greater awareness and access to treatments like vaginal estrogen and testosterone use in menopausal women. All right, let's hear from the superhero Dr. Rachel Rubin. Oh, my God. Hi, friends. I can't with this. Like, can I, I know you have a lot to say to me, But can I just say for a second, back in the day when I was just starting all of this, I've never pitched a podcast in my life. And back in the day when I would think about like the dream podcast to be on,

yours was number one, two, and three. It was before Amy Polar had a podcast. Fair or not. To be fair. To be fair. But my thing is like, how do I get this information out to the people who need to hear it? You have the people. You have the exact demographic that needs this information that can change not only their lives,

but their mothers, their grandmothers, their children, the community that you guys have together, it's incredible and like so many people are going to be helped, I mean, are already helped by just being in your world, but with this information. We agree, which is why we're very happy you're here. Old me would have, like, panicked and stressed about this. New me is like just off a full day at clinic,

and I'm like, hey, guys, what's that? Like, let's see this. Same. Same. At the very top. I am worried about the people who are like, I love listening to the podcast, but I'm not in pari menopause. I'm not in menopause. And I want to make sure, are you sure, y'all?

Because the theme of it can be, you're not too young, right? And I sort of did that to Abby when she came on. I was like, hey, girl, you're not too young. And I think that is really interesting, right? because we have this mindset, especially like our generation as this mindset of that's like golden girls. Like I've got time. And we're in D.C., as you all know. And so I saw a woman today who is on the news and has a one-year-old and a four-year-old and is in it. Like is in it and is like, it sucks because her postpartum experience is her perimenopause experience. It's all in this like big nightmare.

And like her husband wants sex all the time. And you're like, are you fucking? kidding me. You're empty. It's not even on the top 200 of her radar of something that she wants to deal with right now. Yes. And I just feel like for me personally, there are so many things that I was not attributing to perimenopause. I was just thinking, oh, my anxiety has gotten inexplicably out of control. Why am I so lethargic? And all of these things that I wasn't connecting. My kind of like personal olive branch is if you don't know. know this is for you this episode. That's all the more reason to please listen to it. There is a lot of mourning that comes the psychosocial piece of this, as Glennon has learned

biosyncocial as a good word, is it's almost like that realizing the age is happening and that confrontation of you're still hot and you're still amazing and you're still full of life, but things are changing whether you like it or not. And again, I love the perimenopause analogy here. is like, my little girl is nine years old. And no matter what she does, her body's going to change, right? Everything's going to change. And she's going to have new smells and new hairs and new body and new clothes and new attitude, which she has very raging right now.

All of it's going to happen no matter how much she breathes or does yoga or has fun with her friends. It's not going to change the inevitability of her puberty experience. We hold so much space for her, right? but we don't hold space for ourselves. We gaslight ourselves into just eat better, just be more clean, just do more mindfulness, which those are wonderful things. I'm not discounting that.

But the biology is the biology here. When people come to you, it's already just like such a subsection of people who clearly have been suffering a lot and are kind of like, please, please help me. What are the things that you see most often in folks that they haven't, I identified as belonging to this universe of perimenopause, but that has been causing suffering and lack of quality of life in their lives. The best way I can describe it is when we're trained as doctors, the model is not built for human beings, let's just say.

I don't even think this is a woman. I don't think is built for human beings, but the model is we have time for one problem. We call them problem visits. And with those problem visits, we get to talk about your blood pressure or we get to talk about your eyesight or your joint pain, like you get one problem and hormonal shifts, there are hormonal receptors in all of your body, right? Your whole body. And so nobody has one problem. That's insane, right? You have many problems and they are all tied together. But if we don't look at the whole thing, then we're missing what is the one problem, which is the fluctuations of the

ovaries and the lack of gonadal stability or ovarian stability, right? Your ovaries are not stable in the way that you're used to them. And so it causes everything and it's different in everybody and everyone feels alone in this moment. And it's that curiosity of, again, my favorite term is NFLM, which is not feeling like myself. NFLM. That should be a diagnosis in and of itself. If you come to me and you say, I don't feel like me, 10 alarm fire, what the fuck is going on? Right. And what's happening is we just, I have a lot of theories about why this is. But like, we. We just go towards you're stressed. You know, life is crazy.

Of course life is crazy. You're in your mid-40s, early 50s. The kids are nuts because they're going through stuff. The world is on fire. I don't know if you've read the news recently. Your parents are aging and having their own health crises. Your marriage is on the right. You know, like everything is happening as much.

So of course you have so many reasons to believe in the psychosocial. And it's happening at a time when your biology is just going nuts. So of course there's going to be a higher. incidents of mental health crises in this moment. There's an increase in all of the inflammation and the autoimmune disorders. And so again, you can't ignore what is happening in people's lives, but you must understand the biology, which they forgot to teach us in school. So again, I think the surprise for me has been actually how curious I've become. I'm a urologist. Okay, so I am trained as a penis doctor. I am trained in genitals. I am trained in urinary issues. What has been so

surprising for me is the curiosity of realizing I'm helping with so many things beyond what I was trained to do. And leaning into that and following it and realizing how much of a blessing it is, because if I can get women sleeping, if I can get people not having joint pain, if I can get people feeling like themselves again, I save marriages, I save jobs. And those are the wild ones for me when I didn't mean to. My intention was to be a urologist who dealt with sexual health issues, but what I've realized is I have given people so much dignity back to be able to live the lives that they want to live. And I don't know that I was expecting that part of it. Besides the overview of that, what are the specific things that you might want a listener to perk up and say, wait a minute,

that could be paramenopause? We have all been taught the Golden Girls had hot flashes. So if I'm not having hot flashes. Like that's the one symptom of menopause that we all were taught. Give us a list of other things. Yeah, absolutely. So I think you can kind of go from head to toe and think of where in the body do you have hormone receptors. And that's kind of an interesting way to look at it. And I think this idea, again, I'm too young. You know, I'm not ready for that yet. The average age of menopause is 45 to 55. Okay, that's average. So if you're in menopause at 45, which means you've had no period for over a year, you're normal. Congratulations, you're in the spectrum of normal. If you're 55 still getting periods, you're in the spectrum of normal. But average age is 45 to 55. Right in the

average is about 51, 52, right? So again, you're normal. Perimenopause, you don't just turn it all off one day. Unless you're surgically remove your ovaries, you don't have an immediate abrupt menopause. There's a long journey before that. And that could be 10 years. And so if we're not gaslighting ourselves and we talk about 10 years. What is 45 minus 10? I know that. That's 35. You got it. I'm terrible at math, right? You nailed that one. So 35, right? 35-year-old women are starting to not feel like themselves. And that's valid and legitimate and needs to be look at. Do we have all the data of research in the world? No. But if we just look at facts, like that's factual. Now we know testosterone, testosterone, which is this hormone, nobody even told women that they have,

starts to drop in your 30s, okay? Percipitously drop. Every year it's dropping, and this is a universal thing that it is dropping. Men start to get lower, not all of them, but some of them start to dip a little low. All women, like their ovaries turn off, and testosterone is really starting to drop before that in your 30s. And so that matters. Some people are more sensitive to testosterone than others. Some people like testosterone in their body more than others.

There's a lot of research that we don't have on testosterone for women that we need and we're asking for. So for the bodies, what do you feel? You may have your sleep start to change. You may start to get more migraines than you ever got before. You may start to feel brain fog or what is this thing called? If anyone, I'm holding up a pen, if you're listening to the audio, you know, what is this? Oh, yeah, it's a pen. It was on the tip of my tongue.

I swear I knew that word before. I called them brain zaps. You may be irritable. I had a patient today. Again, the woman I saw today, she said, early in my cycle, I want to rip my partner's face off. and I knew a week before that he would do the same shit, and it just didn't bother me the same level that it did in that moment in my cycle.

And even she knew what he did was super annoying and she didn't like it, but she flipped her lid in a way that was unusual for her, right? Your ability to tolerate hard stuff, I mean, where you can do hard things, you can all do hard things, but sometimes it's harder than it used to be. And you're like, this is something I used to be able to navigate, and it just feels harder. That's real. And there's a biology to that.

There's a biology that I'm seeing these patterns. For some people, again, we're still in the head, but it could be itchy ears. I've had patients with burning mouth. I had this law firm partner where she had a burning mouth and she talks for a living. She's a litigator. And she had this horrible burning mouth. You gave her a little estrogen and all went away. Like it wasn't that challenging, right?

She just needed hormones. For some people, their allergies start to get worse. They're like, I never had allergies before. There you go. There you go. Hi, friend. Me too, right? My allergies started to get a lot worse. For some people, heart palpitations. Like, this is what got Oprah, right? Oprah saw five doctors and she had these horrible heart palpitations.

And she said it recently on a podcast, she did one little bit of estrogen and like, boom, they were gone. Like it was just that simple for her. But it took five doctors. Again, bone density changes. And the problem with bone density, the book says, don't start checking till 65. Your bones start to decay in your 40s. No one's paying attention to you. I think of hormones is fluid, like fluid for the body. So vaginal lubrication, eye lubrication, ear lubrication. How about joint lubrication, right? Your joints are swimming in fluid. That's what makes them work. So we see frozen shoulder. We see planter fasciitis. We see all these knee pain. Again, all this joint pain. So that now they're calling the musculoskeletal syndrome of menopause. I had an orthopedic surgeon's

day at my house last night. She was the one to first define that muscular skeletal syndrome of menopause, and we have this beautiful table full of people asking her questions, and she says, listen, only 6% of orthopedic surgeons are women. The men have been seeing this idiopathic shit that happens in your 40s, and they don't question it, they don't research it, they don't care about it, because none of them have ever lived it. They've never had that happen, and it's not a coincidence now that the women in the space are researching on it, publishing on it, and saying, hey, actually, hormones might be the answer here, and not when it happens, but preventatively. But it's never been looked at before. So again, we could go on and now I didn't even get to the sexual problems.

Your arousal starts to change so that things that made you lubricated and engorge don't work as well anymore. Your orgasm takes longer to have. Like you got to go deep into that fantasy in order to have the orgasm, let alone the second orgasm. Even your interest in having an orgasm changes drastically because your libido often goes in the toilet and you assume that it's life. You assume that you're busy. You assume that you're stressed. Like you assume that you assume all these things and it's not just life and there's hormones involved in that too. So there are so many things and the people who hate us and we do have our haters out there, they love, oh, it's just aging. This is just aging. And it's wild how much we want to chalk up to aging, getting older. But what's

the difference? This happens in 100% of bodies that are lucky to live long enough. And we have solutions. That's what's so cool about it is we have a toolbox full of solutions. Now, I'm not suggesting that everyone needs all the tools. But what I'm suggesting is if we pay attention to this early enough, maybe at the first twinge of not feeling like myself, you can start to know what you want to try, what you want to put into your body, what you want to help you. Does that make sense? It totally does.

It totally does. So good. You are talking about all the biology. Can you pretend like we're 12? And when it comes to science, we are. What is actually happening? We have three hormones, right? Progesterone, estrogen, testosterone.

All men and women have all three of those, right? Yes, at different levels. At different levels. Give us a two-minute, 12-year-old, what is happening. And let me be clear, everybody doesn't know this. Even doctors don't know this. You think, like, oh, I don't know anything. You know more.

The fact that you just named what you named means you're smarter than 99% of all humans out there. Like, nobody knows this. But it's actually cool because when I teach the basics and what I know, then you put it to your body and how you're feeling and you're like, oh, that makes perfect sense, right? Oh, this is how this is working. And when you know how your body works, you can advocate for it appropriately. And when things are going wrong, or when you start talking about it to your friends and you hear that their experiences are very different, then you can say, well, what's different about your body? Why is your body behaving this way? what is the underlying issue? And I think of myself as a sex detective. What can I learn about people?

Because I'm a sex doctor, but like, you know, what can I learn about people to put these things together to make it make sense? So let's, again, talk about some of the basics of what we sort of know. And again, science is very evolving thing. And we forgot to study women. So it's, we're doing our best here with the limited information that we have. So if we take someone who has a period, let's take your average 25-year-old on no birth control pills who is living their best life, high libido, they're single in New York City right now, dating, having a great, great old time. Let's all go back to that moment in life where we didn't know what was ahead. So this 25-year-old, right, say it gets a cycle every 28 days will bleed, okay? When she bleeds, like the day she starts bleeding, that is like the start of the cycle. Let's just say that's moment zero.

your hormones are the lowest in that moment. Your estrogen is low. Your progesterone is low. Everything's kind of low, which is why people will feel great when they have their period. They're still fine, but they're like not, you know, they may notice and different people notice different things, right? Some people have raging symptoms and some people are fine. Take one Advil, they go on with their day. You should be mostly fine. If you are not mostly fine during your period, 10 alarm fire, you need to see someone who can help you because you probably have a endometriosis. or adenomyosis or something that deserves medical attention. Let's be very clear on that. But say you're at your, you know, you're, have your period, your hormones that are low. They're not zero, though. Your estrogen might be, let's just give it a number 30, 50.

It's low. Like say that's low on the gas tank, but it's not zero. Menopause, you're zero, right? So then you're ovulating. So you're just going along your time and half, like maybe 10, 14 days later, you're making an egg that's getting ready to pop out and you're starting to get horny because The world wants you to make a baby, so your testosterone starts to go up. So your libido goes a little up. You're now receptive to exciting things. And boom, you pop out an egg, and the shell of the egg makes progesterone. So it's like the candied shell makes progesterone.

And first half of your cycle, you have no progesterone in your body. Egg pops out. You make all this progesterone, which makes you gain a little bit away. You get a little sleepier. You get a little more relaxed. We call it the ludial phase. The candy shell makes all this. is progesterone. And then if there is no fertilization of that egg, the progesterone shell kind of

decomposes, and it is that decrease in progesterone that causes you to bleed all over again. And so you live in this space between estrogen at 50, then it goes up to like 150, then down to 50, then back up to 150. And I think of it like a quarter tank to three quarters tank, a quarter tank to three quarters tank, you're driving wherever you want to go. Maybe you don't feel as good at a quarter tank, but you can drive. then you have three quarters tank. When you're pregnant, your estrogen, remember 50 to 150 is like 10,000. It's so high. For like nine months, it's so high. Some people do great with that. Some people don't do great with that, right? So it's super, super high. Then when you give birth, it immediately goes to zero.

When you go into menopause, it goes to zero. So you go from being used to 50 to 150, then you are sustained at zero. But you don't just go to zero. You go on a. crazy road rage journey to zero. So it's not just like a slow decline. Instead of going from 50 to 150 down to 50 to 150, you go from zero to 900 back to 50 up to 800 and your body is in chaos mode. So your receptors are full, then they're empty, then they're full, then they're empty. And you start getting glitchy, right? And you just, your body's not recognizing itself. Your body's double checking. it's thinking, it's trying to figure it out. And for some people, they feel horrible, but for other people, they're okay. Or if you get your ovaries just removed and you just like immediately go from, you know, gas in your tank to zero, that also doesn't feel good. And everyone has such an individualized experience with it. And they don't have the language or the words or the biology to show themselves. And so they just do what they can control, which means they make their world smaller, which means that they get a little more insular. They're, figure out what works for them. So they get their, oh, I can sleep fine, but I have to have everything

on dark out shades and I have to wear the ear things and I have to be in this position and I have to do it this way, but then I'm okay, right? Or like, as long as my partner doesn't speak to me from 8 p.m. to 10.30 p.m. like, I'm great, right? And so I get a lot of people who come to me after we get them feeling better again. And they sort of say, holy shit, I didn't realize how bad it was. Yes. Right? My whole world changed.

We have to go on an apology tour afterwards, just like a worldwide tour saying, sorry for how I behaved during paramedopause. It's a lot. I feel the opposite. I feel like I could cry for compassion and grief for all of us that are not equipped for any of this who are just kidnapped by this thing. And no one told us or gave us any tools. and we're just trying to get through our days and keep take care of our people and all of the suffering that's happening within that.

And then all the compensating, as you're saying, like just trying to figure out, oh, well, I guess I'm just a bitch now. Okay. I should try to keep that to myself. Oh, I guess I'm, you know, all of this navigating that we do because we're in what is a biological mind fuck. I take care of veterans on Wednesdays. I call it my pro boner work. That's a good lawyer joke. There you go. That's my good lawyer line. I take care of veterans, and I had a veteran last week.

We've been really good at getting menopause care into the VA. I've been really advocating loudly. We got it approved for testosterone approved for veteran women nationwide, which is like my biggest achievement. But I saw talk to this woman and she said, Dr. Rubin, I had a meeting with my bosses and I explained to them, you know, how much better I felt like going on this therapy. And they really said to me, they said, wow, like you went through a really rough patch where we weren't able to give you. feedback. We were like afraid to talk to you. Like you weren't answering the things like the way you used to. And she was like, I completely see that now. And there was such a biology there. And I think it's happening everywhere and a lot. This isn't rare. This is 100% of people between 45 and 55 that we are ignoring, not validating, not holding that space for. And what's so wild from my standpoint is people feel so

alone and yet it's this universal thing that is happening to people. And the fact that there aren't this isn't even a field of medicine. This isn't even a place where we, I just, this afternoon, I talked to medical students from Iowa. I just randomly zoomed into one of their conferences. And I was like, what did you learn about this in med school so far? And I just got a lot of like nothing, right? Nothing. So I think compassion. I like Amanda's version of the compassion for yourself and your friends and your people. And I'll be honest, when the men see it, they actually can't unsee it. And they develop some compassion sometimes, too, that like they just didn't know.

No, like, because we didn't know. How are we going to help explain something to our partners that we didn't fully understand ourselves, right? Right. So paramedopause, it's the time before the tank goes to zero estrogen. And it is a time of wild fluctuation of hormones that we cannot predict up and down, up and down, up and down all around. And that affects our mental health and our bodies and our relationships and everything. That's sort of the description of it, right? That's exactly perfect.

And then there's one moment. How do you define how long do you need to have not had a period to call it menopause? To be honest, friends, menopause is a stupid-ass term. Okay. It's just stupid because it doesn't mean anything, right? Menopause by research definition is you haven't had a period in a year, right? And so there is a whole year. that you have been at zero, right, before we say officially you're in menopause and then you're forever postmenopause. You're never not in menopause. You're always in menopause. This is for science and researchers, it doesn't really help your average person who's trying to understand their body because people think, oh, I already went through menopause. No, no, 70-year-old woman,

your osteoporosis, your UTIs, your pain with sex, your low libido is still all because of menopause. It's just you're 20 years into menopause at this point. And there are So many things that you could do to help yourself, it's not too late. This is actually a marketing problem. And you guys are excellent at marketing and messaging and information. We have so much knowledge and research and data and products that we can use in perimenopause and menopause and postmenopause. But nobody knows.

And nobody has access to the people giving it. Like we saw with Oprah and even Melinda Gage just said she had to see three doctors before she got help in her prescriptions. and so we're in the early stages of getting people this information. Women are incredibly good at adapting, which sounds like a compliment, and it is, but it can also get us into trouble. Because it means that when something changes in our bodies, we probably think, okay, I guess this is just my life now. We stop sleeping through the night, so we learn how to function tired. We start getting headaches, so we start keeping painkillers in our bags.

We're exhausted in a way that sleep doesn't seem. to fix, so we drink more coffee and just decide that this must be what getting older feels like. What we are perhaps less good at is stopping and saying, wait, why am I working this hard just to feel okay? And that's something I appreciate about Midi health. Midi is virtual care exclusively for women's hormonal health, and it was built by women who have been through this themselves. So when you visit Midi, you're talking to clinicians who understand paramenopause and menopause and are actually looking at what's happening to you as a whole person. Because the headaches, the mood swings, the fatigue that won't quit, they may not be separate

problems. You can spend so much time trying to solve each individual thing without realizing that during paramenopause and menopause, they can all be part of the same hormonal story. And there is something incredibly validating about finally having somebody connecting these dots with you. Yeah, that's right. You do not have to become your own hormone. health detective. For me, that's what I want for my health care. I want to be able to say,

here is what's happening, here is what feels different, here's what is making my life harder. And then I want somebody knowledgeable to help me understand what those things might mean together. That's why I recommend midi health to so many women who haven't been able to find the health care that they need. You don't have to have the perfect vocabulary for what's happening. You don't have to walk in already knowing whether something is related to paramedopause or menopause. Their clinicians are so, so knowledgeable. And best of all, Mitty is covered by most major insurance plans. So if you've noticed that you don't quite feel like yourself lately, maybe your sleep has changed,

maybe you're dealing with headaches, maybe your mood is a little unpredictable, or maybe you just have this collection of things happening in your body that you cannot quite make sense of. I really encourage you to stop assuming you just have to push through it. Your symptoms have answers. Visit join midi.com right now to book your first visit today. That's join midI.com to book your first visit. Join midi.com. Insurance covers varies.

Check with your plan for coverage. So if a lot of people, and then I know this happened to me, but if you go to your doctor and you say I'm having these mental health issues, I'm having these bodily issues, I can't sleep. For me, I had these crazy, itchy arms so that I, just random symptoms, irritability. I made my life very small to control my environment so that I wouldn't be irritated because I was so irritated by everything. Went to the doctor. I have an excellent doctor who I love and said, I took a test and he said, your hormones are fine. You're not in paramedipause. And this happens to everyone I know. It happened to me three times. Right. So what's happening there?

Because we don't teach this. Again, remember, your hormones were fine because they're fluctuating rapidly. So by definition, you weren't zero because you were still getting periods. And so depending on where in that cycle, we checked it, right? Like, this is why doctors hate when women go to them and say, can you check my hormones? If you're still cycling, you still have hormones in your body. And they're going to change from day to day from week to week. And it's one test is not going to tell you what your body is doing.

But your symptoms are loudly telling us what you're doing. And the problem is, is we minimize that. We don't teach anything about menopause to people in medical school. Are you kidding me? Like perimenopause? There is no guidance. There's no guidelines. There's no medical teaching on it. Like, I can't get your 52-year-old woman who hasn't had a period in a year. I can't get doctors to write her an estrogen patch and a progesterone pill and some topical testosterone. It is the most easy, classic, text. case you could ever imagine, and we can't get doctors to know how to write this prescription. So what are we going to do for the 47-year-old or the 44-year-old who feels like crap and is being told her only option is birth control pills? It's an option. It's not a terrible option, but there are more options than just a birth control pill. And so we have a long way to go of training. There's only like, and I'm going to get this number wrong, but there is, I want to say, 20,000 gynecologists, some like ridiculously low number in this country, and for 85 million women, right? And those gynaecologists are delivering babies. They're doing emergency surgeries.

Most of them are not trained on menopause. It's not enough. It goes very deep into a systems issue. We've created a world where women are accepting this idea that a gynecologist is the only person that delivers their health care. And oh, by the way, we forgot to teach gynaecologists anything about perimenopause and menopause. The loudest voices in this space are actually the gynecologists who are standing up saying, I didn't learn any of this in my training, right? This is not me. This is very well-researched information. So they just, he didn't know. Like, actually bless your doctor for even trying. And if I remember correctly, I think you told me before that they tried something. And in their minds, they gave you the treatment, but they didn't know enough about it

to know, was it dosed correctly? Were you absorbing it properly? Was it the right thing that you needed? And so people in perimenopause shouldn't have to travel across state lines to see an expert in this to help them. But unfortunately, in 2026, that's the way that it goes. I'm curious about this perimenopause stage versus the menopause stage. Is the menopause stage going to be much more easy to control and to manage? So much easier. It's so much easier. It's so easy because you're flatlined. Yeah. Right. You are, and you're not fluctuating. So actually, so people will say the brain fog gets better in menopause, right, which I believe because your, your, your brain is just in stable mode. Even though it's stable mode at zero, it's in stable mode. So your brain

finally gets to relax and it feels better. So actually people are like, yeah, no worries. The brain fog, it gets better. That's because you are completely like zero and you have nothing. And so yes, in many ways menopause is so easy, right? Because you're just adding back some hormones that your body once had and liked. The problem with perimenopause is, are you having symptoms because you're high? Are you having symptoms because you're low? Or are you having symptoms because you're crashing from high to low? And that's where it's not that hard either, but there's a few ways to approach it. And I think that's really the key is this is not cookie cutter. Everyone gets the same thing. This is sort of let me get to know you, and figure out what makes sense here. And then if you have any medical problem on top of that,

well, then it's even more. I have no research. Diet of patient today with a congenital defect in the way her body responds to testosterone, right? And she's having all your classic perimenopause symptoms, and yet she has this known defect in her enzymes that is very well known about. But there's no research in how I should manage her perimenopause. But what's so fun about working with her, she knows that I don't know how to do this because no one knows how to do this. We're like, here's your three options. Let's pick one of them that makes sense. We try it. And then if we need to go down a different path, we go down a different path. And so I think it's actually frustrating, but it requires everybody out there listening to learn about your body, to learn how your body works, to learn how hormones

work in your body, to be curious and to find people who want to partner with you to try the thing that's going to work for you because the thing you hear on Instagram may work perfectly for one person, but it may not be the thing that you need. And so I learn all the time from my colleagues, from my friends in the space. We're obsessed with this, right? So we're always learning and adjusting and tweaking. And so if someone tells me something that makes logical sense and it like makes sense to everything that I know, I'm like Plato. I changed my practice that day of like, okay, now we're doing it this way. And I fluctuated how I give progesterone has fluctuated, how I I think about giving hormones and I'm a lot less scared of oral estrogen than I was, you know, five years ago.

And I'm learning constantly. Doctors don't always do a great job of evolving their practices. Is there any test that you do with your patients that gives you any kind of insight or that we could ask for? Or is it or do I hear you saying it's entirely symptom driven? I always say there's the book answer, the Instagram answer and my answer somewhere in the middle, right? So the book says never check labs. Labs are never helpful. They never tell us any information. If you feel like crap, then you have symptoms. The problem is doctors aren't doing that level. They're just saying, oh, it's all in your

head. It's all stress. There is fluctuations. It's real. There are many expensive testing things that are happening right now that I think are taking advantage of people, saliva tests, certain urine tests that give us almost too much information where it's actually probably fine information. It's just what do I do with all of your estrogen metabolites? There's no actual data to to tell me what's good or bad. Like, the science hasn't evolved for any of us to know how to make sense of those very expensive tests. So you getting them, there's no shade.

Like, I think there's some information in them. But again, your hormones are fluctuating throughout the month wildly. There are some companies right now being curious about continuous hormone monitors, like a continuous glucose monitor. I think that's the future. But I don't know if the technology is there yet. And some of these companies are coming out with things. Where is it's like, are you Elizabeth?

Holmes or are you real? Is this legit? Not like I'm not smart enough to be able to discern if it actually means the same thing. I don't know, right? I don't know. There's a lot of unintended consequences if we have that technology. It's sort of like, is it going to be used for good? Is it going to be used for bad? Is it going to be helpful? Is it going to be a mess of data? I don't know the answer to that. I use labs in my practice and I use blood tests that you would get at Lab Corps or I use what's called liquid chromatography mass spec. Don't worry about it. It's just a more sensitive measurement of the hormone.

And so, and I check strategically. So if I want to know how low do you go, I'm going to check your estrogen levels on day one or two or three of your cycle because that's where I expect you to be between, you know, 50-ish, right? If you're zero in that moment, well, shit, you're too, you're pretty low, right? That's helpful information. And then maybe I'll want to check around ovulation or when we think ovulation is, and I want to see how high you go. Are you like out of this stratosphere high? Because that's helpful information.

Or are you still super low? Well, that's good information too. But the truth is, just because we do a spot check at certain times, the next month might be totally different. And it's being Plato in understanding that this is complicated and evolving. I like using analogies with my patients a lot. And one of my favorites right now is this is leeches and bloodletting era of women's health. Yes. Right? That's it. Like, so we're frustrated.

So think about it. If you were Belinda Gates or Oprah level in the 1800s in New York City, no matter how much money you had, no matter how many railroads you built or whatever the heck they did, they had leeches and bloodletting, right? The fancy doctors came with their fancy doctor bags and all they did was they were well-published. They did lectures. They were well-researched. They were the fanciest.

doctors we had to give. And you get a lead. And you get a leash. I was just thinking that. That's all they got, right? And at some point, it started to change. And they found antibiotics. And they found all this other stuff. And the question is, what happened? Did everyone just jump on the new bandwagon? No. Those doctors had to die. Or some of them started to change. Some of them were like, hey, what's happening over there with the septic technique? What is that sterilization thing? What is soap? But like, what is this gloves thing that you want me to wear? Or what are these antibiotics? What is Louie Pester doing with this mold? That's so interesting, right? And it's so uncomfortable. And we all hate each other while it's happening and it's so messy. That is how

life has always evolved. If you look at the suffragist movement, which I'm obsessed with right now, because I just saw the musical suffs, it was the same thing. You had the old guard. You had the new guard. Young people didn't, like, they wanted to blow shit up and just put everything on, and the old people are like, no, that's not how we do things. And then they work together to have the right to vote. Like, everything is always messy and ugly and mad. And I think of that all the time when I'm like, I have this patch. I think it's going to help you. I know in the future, we will have precision medicine. Like, does Glenn and Doyle need the same hormones that Abby freaking Wombeck needs? Like, I don't think so. I don't know. Like, I want to know. I am so

interested in that. I want to know what Abby Wambach's testosterone levels is naturally when she's at the height of soccer amazement. Like that's the stuff I want to know. What are her receptors like? How does she maintain that level of athleticism? There's clearly a biology that has to do and work ethic and also you're amazing. But like there's clearly a biology there, right, that we don't understand. And we all knew the kids in high school, right? They're the kids who just love sex. They're interested in sex. They have these high drives, and then you have the kids who couldn't care less. Like, it's just not even on their radar. The biology is different there. It's not all upbringing and religion and all of this stuff. And so we don't know all this information. Sorry, that was a very long-winded way of saying

there's stuff ahead that's so exciting, but we have the toolbox that we have right now, and it's not always the best. So with the lab testing, it sucks. It doesn't make us feel good, and we feel like we're missing things. We are. We absolutely are. It doesn't mean we never check labs, but it also doesn't mean labs actually fix this problem. Does that make sense? It makes total sense. But it's so important because if you are hearing that labs close the door to further questions, then you are hearing incorrectly. If someone says, I read your labs and therefore there is no more to see here, that person is wrong. They just are under-informed. Right. And you have options to advocate for yourself. And so the question is, is the person giving you that information

of friendly, I like to call them friendlies, like a person who is worth working with, a person who is also curious, who is also paying attention to the Instagram algorithm, who can hear things and see things and say, oh, let's try to figure this out together. Those are the best clinicians to work with, and they're amazing. Or do you invest in a telehealth company that actually is obsessed with this too, and they're doing the best that they can sort of with the tools that they have. Maybe that's your best option if you're in the middle of nowhere with an undereducated sort of clinician. Or do you fly in to see someone who, you know, is just the top of their game? That doesn't mean you'll get perfect results.

That just means you'll have someone who is smart enough and takes the time with you to think through the pros, the cons, the risks, the benefits. And again, if you hear something or see something that makes sense to you, go to you. go down that path. And I think sometimes it's the right path and sometimes it's not. But if it makes logical sense to you, it's always worth looking into. And I think women have this deep intuition that something is not right. And I have never seen it be wrong. When they have this thought of there's something that you're not picking up on, there's something you're not hearing, there's some other explanation here. Sometimes science can answer it and sometimes we're not there yet with science answering it, but it's always real. I think we tend as women, if one person tells us it's nothing, we just dig it, like put it down even further and we're just like, oh, it's nothing. Like, like we are taught to gaslight ourselves. What does a person do if they have an unfriendly? I mean, this could happen at a gynaecologist. It could happen at your primary care doctor. I'm a woman somewhere out there listening. I am losing my mind on many levels. I went to my doctor. They said your estrogen level is this.

I didn't even understand what that meant. I get the feeling this person is an unfriendly. Where should they go? And then can you talk to us about what HRT actually is? What does it consist of? The data is very clear that less than 6% of doctors, primary care, family practice, gynecology, get any training whatsoever about menopause, right? The data is very clear.

So it is more likely than not that you're going to run into an unfriendly. And so actually, before you bring it even up, like you could preface it with saying, man, the world is blowing up about paramedopause and menopause. Is that something you're following? Are you interested in that at all? Have you been to any conferences? I see now that Harvard has two separate conferences about menopause. It's, you know, the government's talking about it. There's guidelines now. It's all over the news. Melinda Gates talking about it. She just gave, you know, millions of dollars to women's health. Are you following this news? Is that interesting to you? And you'll get your answer right there, right? You sure will. If they're a friendly or not. You can't ignore it. This isn't a fad.

This isn't even an Instagram fad anymore. This is Melinda Gates. This is a Senate hearing on menopause. This is meetings about pat shortages with RFK. This is an entire day at the FDA about testosterone. Like, you can't ignore that this is legitimate and in the news. It's on the New York Times. It's everywhere.

And so if your doctor has their head, the sand and they just don't want to hear it, well, is that someone you want your health to be in the hands of? And that's really a question too, because the world is shifting, right? GLP-1s didn't exist a few years ago and now they're everywhere. So can they learn GLP-1s but not hormone therapy? That to me is a red flag. And so there are courses now. There's lots of them. They can go on my website and take one of my courses. They can take one of my friends' courses. I teach two different courses at Harvard, you know, that they can come to. There's a lot of teaching happening. So if they're unfriendly and they're not willing to learn and they dismiss it as a fad, as something that's not real, as something that doesn't matter or is not safe, then they're not reading the news and they're not updating themselves on continuing medical education. And so it may be a good time to either find a new doctor or just separate out your care. Maybe they're still good for getting your pap smear, giving you your mammogram slip. Maybe they're great for telling you to get a colonoscopy. But they're not going to be your doctor for your hormonal

journey. And I think it's actually a good time for us to tell women that you need more than one doctor. I am not a man's only doctor. I am a man's urologist. I'm not even a man's full urologist. I send them somewhere else to check their prostate and their kidneys. If you get a kidney stone, you don't want to come to me, but I'm going to help you with erectile function. I'm going to help you with your pelvic floor issues. I'm going to help you with your libido and your whole body testosterone. But men have cardiologists. They have primary care doctors. They have neurologists. like men have all these different doctors. If you only have one doctor as a woman, you're doing it wrong, right? And that's really the key is that you need multiple doctors, you need a pit crew, and you need a

team of people who care about you. It includes mental health professionals. It includes physical therapists. Everybody needs a pit crew to help you. And you, as a human being on earth, deserve that. And you deserve smart ones that take the time that get to know you. But our medical system is set up to give you 10 minutes with your legs up and stir up once a year. And that's unconscionable. I mean, it's insane. I just want to take a moment to just there's the individual grief and compassion of, you know, living years of our lives feeling like trash and then berating ourselves for feeling like trash. And there is also just the life grief of the reality of having to go to a doctor and pose the question of, are you interested in the quality of life of half of your patients

for half of their lives? Is that of interest to you? The horse shittery that is that we have to tiptoe around medical professionals and ask if they're interested in our lives to see if we can get something out of them that they should have been bringing to us from the beginning. It is a disgrace and it is a shame. It is the reality. So like we'll get there. Let's just get there. But let's have a moment of acknowledgement that the gynecologists, the ones in charge of

the ovaries and the uterus and all of the things, six out of 100 of them were told anything about menopause in their years and years and years of becoming a medical doctor. And it's half of our lifetime. The bigger issue is so enormous. It's so large that it feels out of control and it disregulates us because the rage and the frustration is so large. And I think that's what's happening. Your gynecologist actually isn't the bad guy here, although it feels that way. And it's easy to throw. The system has taught the gynecologist that what gives her money or him money is surgeries, is deliveries, is not spending time with you,

is they have to get that pap smear, they have to get the mammogram. They were taught that it's all about problems, not about prevention or about lifestyle or quality of life. That's the system. The system that even created gynecology as a small field of medicine to take care of 50% of the population is insanity in and of itself. And the gynecologists don't want to be bad at this. It's just that the system never taught them to be good at it. They never taught them to examine vulva. They never taught them about the word clitoris is nowhere in their training of like what they need to know to graduate. And so the system is broken. The individual gynecologist is a person who's trying really hard to help the patient in front of her. They get

paid way worse. Literally, if I do a surgery on a man that is equivalent to a surgery a gynaecologist does on a woman, I get paid much more money than the gynaecologist get pays. My malpractice insurance is less than what a gynecologist has to pay. And so the fact that anyone goes into gynaecology and devotes their life to women, they should be supported. And they still don't know how to do this. They don't know how to write testosterone. They don't know how to manage your perimenopause symptoms fully. And some do. Some have become obsessed with it and our leading national figures in the field. But we have to hold space for how big of a problem this is. The bad guy is the fact that we are treated as a rare disease. Women are treated as a rare disease in 2026 and we are half the population.

So the real problem is why aren't we voting people in? Why are we forcing the research dollars to go towards it? Why are we supporting people who give good information? Yes, to everyone doing the best they can. And there is, you know, all of us are inside these weird systems where we suddenly get a wake-up call and then we have a choice about whether we're going to dig in with the new information and even step away from the machine a little bit and push and push and push and do what is needed. So there are gynecologists, there are people like you who are doing what needs to be done and there are people who are choosing not to. I left a gynecologist who all over the walls were posters for Botox in GLPs.

Wouldn't help me with menopause, but was advertising Botox. I also feel like there is a underlying punishing women vibe to all of this. Like it's not just, oh, we don't have the information. There is a punishing vibe to it. It is, we are a culture that thinks that women are good for procreation and that's it. So it is not a coincidence that the second we start. to become not able to be in the window of baby making, everyone says you're on your own. That is not a coincidence.

And you know, Dr. Rubin, that recently will talk about this, but I went to the pharmacy, my local pharmacy in Los Angeles in California, to pick up my prescription for testosterone. I'm now on an estrogen patch, and I have an IUD which secretes. You taught me this, Dr. Revan. It's not progesterone. It's progestin. So I don't take progesterone pills. I also recently was put on testosterone.

This just happened two weeks ago. When I went to the little window at my local CVS to pick up my testosterone that was prescribed to me by a doctor, the pharmacist first would not give it to me. When I kept pushing and pushing, the pharmacist who was a man, looked at me and said, testosterone is for men. And I looked back at him and said, since you are wearing that fancy white coat, I know that at some point someone taught you that women have testosterone to, yes? And he said, kind of mumbled through. And what I can't stop thinking about is he does know that. I did not teach him anything. He does know that. He wanted to punish me for some reason. reason for requesting, for demanding testosterone. What is that about? He does know that.

This is all I think about. And I think this goes very deep into the origins of all of it. And who started medicine and how we got from bloodletting and leeches to today and who was in charge and who taught who, right? I learned from my mentors, who learned from their mentors and what breaks these cycles. And I think we live in this society where we do things because that's the way it's always been done, right? One of the things I'm famous for is learning that the clitoris can get what's called adhesions where the hood of the clitoris is stuck to the head of the clitoris.

Penis has a foreskin. It can get stuck to the head of the penis well understood in men, well understood for penises, very boring. And yet I'm world famous for what happens to clitoris is because no one had ever looked at it before. We don't talk about clitorial hygiene for women and girls, and the question is, it's because we haven't or because we shouldn't. Is it because we haven't or because we shouldn't? Because I guarantee you, the three of you have never had a doctor, ask you about your clitoris, your orgasm, your arousal, or ever examine it in a million years, because going near that would be inappropriate and would make you uncomfortable.

Can you imagine me, a penis doctor, if I was told, don't touch the penis when you examine the man because you will make him uncomfortable. It is a body part like any other body part. Things can go wrong with all the parts of your body. Every single part of your body, something can go wrong with it. But if we never look at what it is to be normal, how are we ever going to know what it means to be a little off of typical, right? And then what does that mean for your arousal, for your orgasm, for your pleasure? So while I love telemedicine companies, nothing sort of like that's going to be, if it all goes to telemedicine and no one is examining genitalia, which changed drastically with hormonal changes, we're going to lose the art of how to examine people. I did a training. I went to some place called Pelvicon last this weekend. So fun. Pelvicon.

1,500 of the greatest pelvic floor physical therapist in the world that you ever meet. And we did a training for them about how to examine genitals properly from sort of the medical way. And we were able to show them live exams. We were about to teach them sort of how to examine genitalia. It's not taught to anyone. And so again, I think it goes back to who taught you this, that these people aren't bad for, it's just no one taught them or gave them the permission to ask the question or to look. There's a lot of fear around even talking about these issues, let alone examining certain parts of the body and giving people safe spaces to feel comfortable, right, is the other piece. Women don't always come in. They won't see a male doctor. They don't want to talk about it or they don't want to be

examined. They don't want the vulnerability that comes with it. But they lose out on education and knowledge if they're with the right clinician. Does that make sense? I never thought about that. The trauma can keep people from medicine. Trauma keeps people from the ability to learn about their own bodies. And so we see that a lot. And you have to build, I always joke, my visits are so long with people because I have to take on all the medical trauma that happened before me. I have to absorb it. Your neurologist is not going to ask you about your UTIs. Your primary care doc is not going to examine your genitals to find that. cancer or that skin condition because they don't feel safe examining a part of your body because

they were told that's not for them. And so there's an underlying issue also of when we call them private parts, when they come with all sorts of trauma and emotion and feeling, which I'm not diminishing that. That's real. But then we lose access to a part of the body that no one knows how to examine and it gets lost in mystery when really you had a clitoral adhesion the whole time or you had a hormonal change or you had a skin condition that nobody picked up on that developed into a cancer that nobody found, right? And that's what's happening now to women because we don't teach doctors to be comfortable talking about sex, talking about orgasm, looking at the genitals. It's not simple. And there's the bad guy is deeper than what we want the bad guy to be.

At this point, you probably know how much we love Middy Health at this show. They stand for everything we do, supporting women, believing women when they tell us what they're experiencing, and making sure we have the information and care we need to make decisions about our own bodies. I'll just share this about my own paramedopause story. For me, there wasn't one day where I just woke up and thought, oh, this is perimenopause. It was first, just not sleeping well, which I've definitely struggled with off and on throughout my life.

But then these random symptoms like headaches and brain fog and increasing. anxiety, all of it just started appearing with not a huge thunderbolt to make it obvious. It was just like one layer upon another layer and I just didn't feel like myself. So what I really want to stress is the relief I felt joining my MIDI call for the first time and talking to someone who didn't downplay or wave off anything I was experiencing. Visit join midi.com right now to book your first visit today. That's join M-I-D-I-D-com to book your first visit. Join midi.com. Insurance coverage varies. Check with your plan for coverage. Let's circle the ragons around what we can control. We've found our self-compassion.

We've found a doctor who maybe doesn't have the means or knowledge to help us, but also has compassion for us. And we want to learn about. HRT. Hormone replacement therapy. That is a term we're using. HART is what you'll hear it commonly referred to as. Before we get into the nuts and bolts of that, because I know we really need to do that for the people, if you could start from scratch about HART and take away the, you know, decades of confusion and shame and problems with marketing, what would you want us to know? I would want you to know that the ovary, as we understand it in 2026, naturally makes estrogen, progesterone, and testosterone at fluctuating amounts. Okay? But never zero, but fluctuating amounts. When you feel your best,

when you feel the most like you, there is some element, there's some amount of estrogen, progesterone, testosterone that is swirling through your body and feeding your body in ways that make you feel like yourself. And then if you're lucky enough to be old enough, it goes to zero and you no longer make those things and your body has to adjust. And that comes with consequences and symptoms. And so when we talk about hormone therapy, it's really just giving you back some amount of those hormones to try to get them to levels that make you feel like you as safely as possible and minimizing the risk and the risks that we know. And I think changing that conversation of what are the risks of doing something like hormone therapy compared to what are the risks of not doing something

like hormone therapy? There are very, very significant risks of you not using any hormones after menopause. And one of them that I speak the most strongly about is urinary tract infections. And so when you don't have hormones in your body, your bladder, your urethra, the vagina, it changes the microbiome. It changes the health and acidity of those body parts. And so infections start to happen. It may also be pain with sex, maybe dryness, and maybe urinary urgency, but UTIs will kill you. And we have known for decades that microdosing vaginal estrogen or vaginal DHA, which is another precursor hormone, prevents UTIs massively, like more than half. So if you love someone or know someone that has ever had a urinary tract infection, and they haven't been offered vaginal hormones,

whether they're 99 or 49 or 39 or any age, actually, their doctor is practicing against medical guidelines. And so we've worked really hard to write those guidelines and to publish those guidelines. And so this is a product that is safe and useful, even if you've had cancer, if you've had a history of blood clots, it's safe for everyone, microdose. hormones for your bladder. I call it sepsis prevention cream. And it might look like a cream that you use twice a week. So when we start, we're going to start talking about the toolbox a little bit. This is a tool for everybody. Your grandma in the nursing home, your sister who's breastfeeding, your perimenopausal aunt and your menopausal mother, all of you could potentially be using

vaginal hormones. If you have any urinary symptoms, any pain, dryness, and if you've ever had a UTI and you don't want one, this will prevent them. And so the cheapest option is a cream. This is an estradiol vaginal cream that you use twice a week. You kind of can rub it on your finger, like up to your knuckle, and then you can rub it into the walls of the vagina, like you rub sunscreen on your face. You don't glop on sunscreen and walk out the door, right? You rub it in, you know, for a second. So you can rub it into the walls of the vagina. Not everybody loves creams. they make a tablet that you can just plug into the vagina twice a week. So it's a little pill.

And it comes with this applicator and you press a button and it pops this micro-dosed amount of pill of estrogen in the vagina. You do it at bedtime. You go to sleep, it absorbs. It cannot hurt a partner. It can't hurt a partner's mouth. It can't hurt a partner's genitals. You cannot hurt someone with estrogen on their body in these very low doses.

Does that make sense? Yes. The other product that some people like is, this is a lovely product. It's DHEA. So it is a suppository that looks like this little bullet here. And it's made of DHEA and palm oil, very natural, very lubricating, moisturizing. And this is every night in the vagina. All three of those products prevent urinary tract infections. They make your orgasm come back. They help your arousal, the lubrication that has gone. And they fix urinary frequency, urgency, and pain. You can do it while breastfeeding. You can do it if you're on birth control. Pills, getting UTIs, you can do it really at any age, very safe, very effective. This is the thing I care about most in the world because people are dying of urinary tract infections. And so a recent publication came out. It was just written about in the USA Today that age 20 to 100 people who were given these

prescriptions, 2 million. It looked at 2 million people with urinary tract infections. If they had been given this prescription, there was a more than 50 percent, decrease in hospitalizations, sepsis admissions, and death for age 20 to 100. Okay? It's everyone that you love needs these products to save their lives. And the data is very clear that less than 5% of people have access to these medications. And this is because when you have a UTI and you go to urgent care, the doctors there or the nice

clinicians there are like, here's your antibiotics. This is for your gynecologist to prescribe. Nah, this is for everybody to prescribe. So we've created handouts, guidelines. My website has a whole page just about this problem that has all the information on it. If your doctor won't give you this prescription, they are practicing against medical guidelines. And that's very clear. So that's for local vaginal hormones to prevent UTIs. The problem is called genitone urinary syndrome of menopause. That's the name of it, GSM, genitoneurinary, because it affects your genitals in your urinary tract. And it's called syndrome of menopause, but it affects perimenopause.

It affects breastfeeding people, birth control people. And so the guidelines do include those people, but the name hasn't updated fully yet, if that makes sense. And that thing is like $13. It's literally, this is literally $14 a tube. They used to call this problem senile vagina in the 1960s. God damn it. They've always got a way to insult every body part. We've got incompetent cervix. Incompetent cervix. Advanced maternal and geriatric pregnancy. Hysteria, right? A hysterectomy because you're hysterical.

But this is senile vagina. And so I just put on my Instagram yesterday of we're calling it senile penis until further notice. Until we can get this right. So the toolbox has really four things in it. Vaginal hormones, that's for everyone. And that's what we just described. Vaginal hormones are for everyone, for life, always amazing. They are safe.

They are for everybody. The other three tools that you can play with, both in perimenopause and menopause, are going to be your whole body estrogen, your whole body progesterone, and your whole body testosterone. And those are different pros and cons and risks and benefit. And there's different ways to do those. Birth control pills have very different side effects than an IUD or a condom, right? We understand them. Like birth control, we know can cause blood clots, can have side effects to them.

birth control is not perfect for everybody. A condom doesn't have the same side effects as a birth control pill. But if we lump them all together and say contraception is all the same thing, then condoms should have warning labels that say cause blood clots, right? We should have warning labels on condoms that say cause blood clots because all contraception can cause blood clots because birth control can cause blood clots. And that's how we treat. That's crazy, right? Condoms don't cause blood clots. Hopefully your listeners know that not what's going to be. She's saying if you put a too big umbrella and you decide arbitrarily to put things together. Right. My brain goes in crazy.

Yeah, I was tracking with you, Dr. Roe. I got you. I've been worried about condoms for a while, so I didn't know if maybe they'd gone wrong. She's like, thank God one thing. Condoms do not cause blood clots, but this idea that we oversimplify things. So if we say all hormones cause cancer, all hormones cause blood clots, all hormones are dangerous, that's insanity, right? Because all hormones are different. The way you take estrogen matters. The dose that you take matters. And so that's where some of this nuance comes. It says not one dose, one product

for one person. So if you go to your doctor and all they have is one dose, one product, one way to do it, red flag, right? They don't know the whole menu, the whole toolbox. They can take one of our courses. They can learn this. It's actually not, I'm a urologist. If I can learn this, anybody can learn this. It's not that challenging. So the way that for whole body estrogen, right, that tends to be the thing that helps the most for a lot of people because your hot flashes, your night sweats, you're for many people, their brain fog, your bone density, all of that is improved with estrogen. It can also help your libido. It can help your vaginal dryness, you know, some of your sexual issues as well. I think mood too. For many people, yeah, yep, for many people, it is on label for hot flashes

and bone protection. That's kind of what it's intended for, but patients have way more joint pain. So many of my patients will say, oh, my God, I can, like, move my joints. Like, I don't feel like an old person. So we do see it help with the musculoskeletal symptoms as well. Sometimes people underdose it, so they're too low in their dosing, or people don't absorb it very well through their skin. So we'll give estrogen in a bunch of different ways. This is all natural estradiol that I typically use. There's some more synthetic birth control pill style things that I don't use a lot of, but there are patches that you change twice a week, sometimes once a week, but I don't love those products as much. They're bigger and bulkier. Sometimes it's a gel you put

on your leg every day. Sometimes it's a gel you put on your arm every single day. Sometimes it's aerosol spray that you put on your arm. And then they make a ring. This one's fun. They make a ring that you put in for three months at a time that gives you both vaginal hormones and whole body hormones. so it's great for your busy person who, you know, wants to set it and forget it. There's also injections. There's pills that you can take. There are many forms. There are some people who do off-label pellets and things like that.

Now, those aren't regulated by the FDA. There are some people who compound products that come in these little clicky things. Now, the clicky is not bad. It's not regulated by the FDA, and it's just not studied very well. But if we can't find other things, sometimes you go to the clicky option. So that's whole body estrogen. I want to see that helping with your hot flashes, your night sweats, I want it to, you know, getting you sleeping a little bit better. Like that's the goal of estrogen.

And sometimes the challenge with perimenopause, if your estrogen is too high and that's what's causing your craziness, sometimes just adding estrogen isn't helpful. But sometimes it is. And so it's learning of like what's going on with your chaos. Sometimes just adding some estrogen can help raise your floor so that it's not super low. Sometimes that's not enough. Now, if you take whole body estrogen, there are consequences. It can grow the lining of your uterus, and that can over many years lead to something like uterine cancer. So we take progesterone, which is a pill that for many people take at bedtime that many people like is a great option to protect your uterus to keep the lining thin. But some people don't tolerate it. And like just Glennon said, she uses an IUD, which is a tiny little T-shaped thing. that locally coats the tissue in that hormone to keep the lining thin. The progesterone counteracts the negative long-term consequences that are possible with the estrogen. Absolutely. So if you have a uterus, progesterone protects that uterus.

If you don't have a uterus, some people still like progesterone because some people get mood and sleep benefits from it, but not everybody. I would say about 80% of people really love it for sleep. Some people feel too sleepy or they feel off, but they just don't do great with it. So there are some other options for progestins and progesterones, but this micronized progesterone is extremely safe. Like, we give it to pregnant women. We don't give anything to pregnant women. It's pretty well-study. There's no risks of cancer with the micronized progesterone. It is a very safe option and useful for many people for sleep. I will often start with estrogen and progesterone. Now, neither of those is birth control. So if you're in your 40s, not feeling like yourself, you still may any contraception, which could be common. condoms. It could be non-hormonal contraception. It could be an IUD. It could be a birth control pill. There may be reasons why you individually need a different tailored approach. And there's ways to be

creative in perimenopause. There are progestin-only birth control pills where then you can still have an estrogen patch or you can still add testosterone to it. And so there's approaches that you could take from that. So the toolbox, again, there's four things, whole body estrogen. That's going to help with your hot flashes, your night sweats, your osteopenia, so it's going to protect your bones. I think estrogen probably is the thing that feels really, it's the heavy lifter, I think. Progesterone is there to protect your uterus from cancer. It might help you sleep. It may help your mood. You definitely need some kind of a progesterone if you have a uterus or progestin. If you don't have a uterus, you can still take it. It's not going to hurt you.

And then the third piece of this is testosterone. And we just spent a whole day at the FDA. talking about testosterone, which is revolutionary of itself that the FDA gave us that amount of time. And the reason is there's no FDA-approved testosterone for women. Okay. We've known that women have made testosterone since the 1940s. We've known that testosterone was useful in women since the 1940s. And yet, it took 10 years to get a product FDA-approved. It took 10 years for the first FDA-male testosterone product to get approved.

So you're looking at the 1940s or 50s when you had the first male testosterone product approved. And I think we've had like 27 products since then approved for men. And there are zero products approved for women, even though there's global consensus that it works for libido. And it's approved in Australia, New Zealand, South Africa, and England. Okay. So it's approved in those countries. And so it's insane. Okay.

So but we need a company to come and actually like, like go to the FDA with a product. 20 years ago was the last time a company went to the FDA with a product and it was safe. It was effective. And they were rejected because it was around the time that big study told women hormones were dangerous. And so it was because of the marketing of that. And the FDA admits that that's why they were just too scared. And so they said no.

Can we stop there for one second? Yeah, please. Just tell people a little bit about that because I want people to know. Yeah. This is actually wild. I was telling the medical students this today. And it was so fun, you should have seen their faces of like, holy crap, it can't really be this bad. Okay, so you're afraid of, here's why you're afraid of hormones.

Here's why you think hormones cause cancer. Because in the late 90s, a billion dollars went into the NIH to study hormones in women. And they did this study where they took a birth control pill style hormone therapy and they gave it to women age 50 to 79. Okay? They gave the 79-year-old grandma birth control pill, essentially. And they followed them. Now, none of those people had hot flashes or night sweats or not feeling like themselves because they would know if they had a placebo or not. So they actually took relatively well-feeling women, and they gave them all a birth control pill, age 50 to 79, and they watched it for a few years. And the head of the study was an epidemiologist and not a clinician, this person who's never prescribed hormone therapy before.

and they got an alert from their data people, and they said, oh, my God, there's a signal that this is really dangerous and this is a problem. And so they held a press conference live on TV in 2002 where this epidemiologist, he gets basically up there and he says, oh, my God, hormones cause cancer and heart disease, stop the presses, everybody throw their hormones in the garbage. This is a 10 alarm fire. The paper hadn't been published in the journal yet. Doctors didn't have social media. They just saw. the press conference and Matt Lauer got on TV, you know, Brokaw got on TV, Peter Jennings got on TV. It was the top of the fold of the New York Times. It was the front page of Time magazine.

And it said, hormones are dangerous. They're going to kill you. No one had seen the paper yet. When the paper came out and the doctors looked at the paper and doctors aren't that great at looking at research either, they also just saw the headlines. And they all said, well, crap, this is going to kill you. What did the data actually show? It showed decrease in fractures. decrease in diabetes, decrease in all-cause mortality, decrease in cancer-specific mortality, decrease in colon cancer. If you were just on the estrogen, so you weren't on the fake progestin part because you didn't have a uterus, decrease risk of getting and dying from breast cancer. I'm going to repeat that. There was a decreased risk of getting and dying

from breast cancer. And just last year, that same epidemiologist who did that press conference published saying that below age 70, even that hormone therapy pill that we don't give anymore because it can't increase blood clot risk, it said no increased risk of blood clots or strokes or heart disease below age 70. So this study actually showed hormones were safe. And yet the marketing said hormones are dangerous. Hormones cause cancer. Hormones cause heart disease. None of that was true. Immediately after that press conference, the FDA put a blanket warning on all hormone products that said, warning, stroke blood clots, heart attacks, probable dementia. None of that was true. So the progestins, there was some worry that the fake progestin

may be slight increased risk of breast cancer. We don't give those anymore. That's why we use the micronized progesterone. We use safer forms of progesterone. We know that if you use a patch or a gel or through your skin, there's no increased risk of blood clots, none. And so we have safer formulations of hormones. But look at the good, decreased fracture. decreased diabetes, all cause mortality, decreasing cancer, and yet no one got the memo because they didn't do a press conference to say how good hormones were. And there was a warning label that said they were dangerous for 20 years because the epidemiologist decided to do a press conference and misinterpreted how he spoke about data. The man has never prescribed a hormone in his life.

So when we were invited in July to speak to the FDA to beg them to remove the label, which they did, you know, the head of the FDA at the time, to put us all together in a room, that epidemiologist was in the audience and he heckled us. Hecled us. So the politics here are fascinating. He heckled us. What a dick. It's crazy that this continues.

So the labeling has been removed as of November. They announced that the warning labels because they were never true. That doesn't mean hormones don't have risk. That doesn't mean everybody should take hormones and hormones don't have risk. But the warning labels of these things are going to kill you immediately if you do them, it was never true. For 20 years. For 20 years, women would deny that. They don't even know that these products exist, let alone what dose and how to titrate them and how to give them to you.

If I give you the lowest dose of this patch, you know what? You're not going to have improvements in. Your hot flashes. You're not going to feel better. and you're going to say, oh, hormones didn't work for me. No, they just gave you too low of a dose. Or your body didn't absorb them and you needed a different type of estrogen for you to feel better.

But my colleagues do not know the details because they never learned because that epidemiologist said they were dangerous 20 years ago. This is the nightmare that we live in. And so we're changing it, right? We're all getting loud. This is why we come on these platforms to tell the women, it's not your gynaecologist's fault, but she still or he still may not know the right dose for you. So you, like bloodletting and leeches, you got to fight to get your next level of this.

And that means you have to help educate your clinicians. Maybe it's showing them this podcast. Maybe it's showing them the guidelines for GSM. Maybe it's showing them Melinda Gates' stuff to say that she's, you know, out there giving money to this problem. And so you have to fight like hell like your life depended on it. Because guess what, friends? your life depends on it. And so it's your job. It's not your doctor's job to have all the answers. It's not your doctor's job to know everything. It's your job to fight for your life. And you have to advocate for

yourself. And the person who delivered your beautiful babies or your doctor who checks your blood pressure once a year may not be the person who knows the difference between these products, right? But they can learn. And if they're friendly, then they're going to want to learn and they're going to want to be your partner in this. And we've seen, we've had thousands of doctors take our courses over the past couple of years. I have a lecture next week. I'm going to teach 4,000 primary care clinicians at a keynote. See, that's my audience. Those are the people I want, you know, I want to talk to because when you give them permission and say, hey, you got it wrong. It's okay. Let's learn new things. They actually perk up their ears. They say, oh, huh, that's interesting. Like every little bit will help change their

mind, but it's a marketing problem. It's not a data problem. It's not a science. doesn't know yet or we need more research. It's actually not that at all. Yes, we need more research, but we're not using the data that we have, which is awesome. It's a travesty. What's this quote-unquote marketing problem that us women have gone through. And I'm just excited because I have frozen shoulder, got my blood tested last week, I'm going to the doctor. And I think I'm definitely going to start my HRT now. Good. Good. The last thing we need is two of us and one untreated and one house. This is a lesbian. This is a lesbian emergency, Dr. Rubin. And I love, right, but I love that too, because, like, you can see how it affects both of you. And, like, I do think the frozen shoulder

stuff is so interesting because we don't know the exact regimen that is going to help, you know, and the question is, should we have been on it before to prevent frozen shoulder? Would that have worked? We actually don't know. But it'll be so interesting for you to get some estrogen, to get some testosterone potentially. It's crazy. I had neck pain, horrible neck pain. I couldn't move my neck. I took one progesterone pill and boom, it all went away. It was craziest thing I've ever experienced. And like, so it's, we don't always have explanations for it, but this is where we try things and we see what on the menu may help us, you know, with our different symptoms. Yeah. I mean, I've just been watching Glenn and go through it. And after

talking to you two or three weeks ago, you're a different person. So. Thanks be to God. I'm thinking of people listening to this right now. One of the ideas I just had that take it or leave it, but it's so much, it's so much information, and there's also so much about testosterone that I think you probably have on your website. Is that right? Dr. Berman can people go? We have lots of information. And our newsletter is awesome.

We don't spam and we just try to give information, courses, data, new articles that are coming out. So just on my website, if you Google my name, you'll find our website. But our newsletter is very popular as well. Okay. I just wonder, it's so much information and it's so hard to figure out on your own. And it reminds me a little bit of when my sister was diagnosed with breast cancer and had to learn an entire language and system while she was traumatized by this information and how cruel that felt.

And I think that menopause feels a little bit like that. It feels like you have to learn an entire new language while you have brain frog, while you're at your kind of lowest capacity. And so one of the ideas I had as you were speaking is if you have a group of friends who gets together, who talks to each other, send this to them. Get together with your group of friends. Sit down in a living room or a coffee shop or wherever the heck you go and talk. Talk about what symptoms you're having. Talk about what doctors you're going to that are positive and negative.

start journaling your experiences, start gathering information, do it together because this is too hard of a thing to figure out by yourself. And I think a group together might be able to tackle this. I love that. And I think of it like the pit crew model is that you might need, like again, you might need a mental health person, you might need a physical therapist, you might need a hormone doctor, you might need a sex doctor, you might need, and you always need friends along the way. And so I actually ask very, very intentionally in my intake on people, sort of what's your support system look like? Because you need your ride or dies. You need your people that can also hold you accountable and help you.

Because a lot of times, again, does women sometimes feel that they should suffer? That they're like, well, that's nice that you can do this. And I actually want to speak for just one second to the women listening to this saying, well, that's nice, but I feel left out because I can't take hormone therapy. I can't use hormones and I feel very left out. And I think my answer to that would be we have lots of non-hormonal options to help you, but there are actually a lot of hormones you can take, even if you have thought, like, there are people with breast cancer and there's data that shows if you use vaginal hormones, you die less, okay?

So this idea that you can do nothing and there are breast cancer patients who are using testosterone and we are having a lot more conversations about the data that says you can't have hormones in breast cancers, not great. data. It's controversial data, actually. And so we're starting to push back on anybody who tells you no, may not be know what they're talking about. And I think my energy here comes from the urology world. We never tell men no. We tell them shared decision making. It's not recommended. Here are your choices. We never say you can't do this. Hard no. It's language we only use for women, actually. And so often women are told, you can't have that. Because of your history of blood clots or because of your genetic history,

you can't do this. And the answer then needs to roll off your tongue. Show me the data. Show me the data that actually says, I can't have this. And this is where it's changing. A beautiful paper came out yesterday. International guidance of cardiologists and gynecologists. And they said if you have high cholesterol, history of heart disease, all of these things, use through the skin estrogen and micronized progester. And it's safer than a birth control pill or an oral pill, but you can still do it, right? Here's what you can do. And so the guidance is changing and it actually in real time, we're watching science shift. So if you're a doctor told you no, no, I don't actually believe them and I actually think that you have some pushback there. So I

hope this conversation, listen to it again, take it in chunks, there's books, there's all sorts of resources now because something's going to click for you and you're going to say, huh, I do deserve more. I do deserve to feel like myself. I do deserve to sleep. I deserve to not have frozen shoulder. I deserve to have a great libido. And I would love my orgasm back. That would be lovely.

And you deserve those things. But in 2026, you got to fight for them. I love that. This is the leeches. It's unfortunate that this is where we are. And it's not our fault that we are here. But it's our responsibility if we want to have a life that feels good to live in to fight for it ourselves. And I'm very, very thankful to doctors like you

who are out there. You were humble about that, but I know how much of yourself you gave to get those labels taken off those false lie, preventing women from getting the care that helps them labels off of the hormones. And that was there for 20 years. Through a lot of different administrations, let's remind ourselves. And I think that's an important piece is that this is actually a bipartisan issue, both it's been horrible bipartisan. Right. And we all, all, everybody wants it to get better. And I think that's also where it's been fun being in D.C. is I don't get to choose who's in power and I don't get to choose who's in charge, but I am fighting like hell to make sure we have access to patches, that the manufacturers are making more, that we have FDA-proof products,

that companies are paying attention. Honestly, the companies think that this is just a fad. We met with RFK and all of the patch companies. Like literally, I was one of two clinicians, my friend Kelly Casperst and I were the only two clinicians in the room. And CVS, Amazon was there, Walgreens was there, all the patch companies were there. They were all there. And the pharmacies said, we're just giving them out as quickly as we're getting them. It's not our fault. And the manufacturers literally looked at us and said, well, how long of a blip do you think this will be? How long of a fad do you think this is going to be? Like what market share? Do you think that this is going to be?

Business people listening, this is not going away. This is only going to get more and more and louder. So invest in the companies, invest in the products. The women need products. They need their estrogen and like do more. Whatever it is, do more of it. Like we are not going away. I mean, there's no greater love than this.

And Dr. Rubin has sat with RFK on our behalf. Sincerely. And had to have a serious conversation with that man about women. You know what my favorite squirrely little move that she did is because, you know, Keg's Breath, when he wanted to do that whole give all the men testosterone because we're the manliest man, whoever man. And so when he did. Yeah. Yeah, I like to call him Kegsbrass. Got it.

But Peter Heggsap, he, Pete Hicketts, sorry. When he did his write up, the Department of War, they were like testosterone for all warriors. And Dr. Rubin saw that and was like, all warriors, huh? And so made them give it to the women, too, because he said all warriors. Well, so it's a really good point, right? So that was my end of like, what are we doing for perimenopause and menopause management for all of our war fighters and our military people? Because the women in the military are their highest and best institutional knowledge for us when they're between, you know, 35 and 55. And so we need to, more clinicians in the military who pay attention to perimenopause and menopause.

So even though that was like a ridiculous thing that they came out with that sounded ridiculous, it actually might end up being this incredible thing that can help so many feel like themselves again. And actually, so again, my God complex is if I can keep all of you feeling amazing, then you can keep fighting for us and doing all of the things that you can do better than all of us. Like we need everybody at the tape. We need everybody fighting. There are fights here. My fight happens to be this one tiny thing. This is my fight.

But I believe if we do it right, then it's going to keep so many more people in the game fighting. And that's kind of what drives me. That's right. Thank you, Dr. Rubin. We're going to put in the show notes your website and sign up for Dr. Rubin's email. One of the really amazing things on your website is, and if you have a friendly, go look at this, is Dr. Rubin has like a whole page.

that if you have a doctor and they are compassionate and trying to help you, but they literally don't know how to prescribe this stuff, there's a whole page on her website that is like, print this out, bring it to your doctor, it explains to your doctor how to prescribe for you. And so it's such a service. We're trying and we've got a lot of work to do. And I think we're just getting started here. And just thank you for the platform. Thank you for the people listening here.

they have mothers dying of sepsis from UTIs. They have daughters who are struggling. They themselves are struggling. And this little bit of information can save a family. And so I take this very seriously. And I'm just so grateful that you have such a large following of amazing humans that are trying so hard to live their best lives. And I think a little bit of education can really help them maximize their quality of life.

And also just feel a little less alone because there is. biology that explains so much of this. And it feels so much less personal or that it's like somehow some kind of flaw that you didn't try hard enough. You tried so hard and you did a great job with a very empty tank. And there's a lot of options to help you. And I just want to personally thank you from my family to you. Like you've changed our family's life. It means a lot to us. So thank you for what you've done for us personally too. Thanks, Dr. Rubin. You're the best. All right, Pod Squad. Bye Pod Squad. See you next time.

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