Dr Rachel Rubin: Women’s Sexual Health, Menopause, Hormone Replacement Therapy (HRT), and Orgasms!
In this episode of The Diary Of A CEO, Dr. Rachel Rubin discusses the state of women's sexual and hormonal health, highlighting significant gaps in medical education and patient care. Rubin explains how hormones like testosterone, estrogen, and progesterone affect women throughout their lives—from menstrual cycles to perimenopause and beyond—and addresses the widespread misinformation surrounding hormone replacement therapy that keeps most eligible women from accessing beneficial treatments.
The conversation covers fundamental aspects of female sexual anatomy, particularly the clitoris and its role in pleasure, as well as common issues like painful sex, difficulty reaching orgasm, and clitoral adhesions that often go undiagnosed. Rubin and Bartlett also explore how communication, lifestyle factors, body image, and understanding different arousal patterns impact intimacy and satisfaction. Throughout, Rubin emphasizes the importance of patient self-advocacy and education in navigating a healthcare system that often fails to adequately address women's sexual and hormonal health needs.
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1-Page Summary
Women's Hormones Across Life Stages and Hormone Therapy
Hormones profoundly influence women's health across all life stages, yet clinical attention and public awareness remain limited due to historical stigma and educational gaps. Rachel Rubin explains that women's [restricted term] levels decline significantly starting in the mid-to-late thirties, well before menopause, leading to decreased libido, reduced clitoral engorgement and lubrication, and slower orgasms. Despite these effects, medical training focuses primarily on estrogen and progesterone, leaving [restricted term] largely overlooked. Birth control pills can further suppress [restricted term], causing painful sex and low libido in some users, prompting Rubin to urge women to discuss alternatives with healthcare providers.
Understanding the menstrual cycle's hormonal patterns is fundamental to women's health. The cycle begins with low estrogen and progesterone during menstruation, followed by rising estrogen in the follicular phase to prepare for ovulation. After ovulation, progesterone dominates the luteal phase, affecting mood, sleep, and sexual interest. [restricted term] peaks during ovulation, coinciding with heightened fertility and increased sexual desire.
Perimenopause typically begins around age 45 but can start as early as 35, bringing hormonal fluctuations that cause hot flashes, sleep disruption, anxiety, cognitive changes, joint pain, and more frequent UTIs. Rubin emphasizes that declining progesterone commonly disrupts sleep and increases anxiety, yet symptoms are frequently misattributed or dismissed due to low awareness of perimenopause's early onset.
Many women avoid hormone therapy due to outdated fears stemming from a misinterpreted early-2000s study, the Women's Health Initiative. Researchers prematurely warned that hormone therapy caused cardiovascular disease and breast cancer, leading to widespread withdrawal from hormone prescriptions. However, a 2025 reanalysis confirmed that hormone therapy under age 70 does not increase cardiovascular or stroke risk. Despite this, only about 1.7% of eligible women receive hormone prescriptions—a public health failure Rubin attributes to physician undertraining.
Rubin defines four categories of hormone therapy that can be individualized to symptoms: whole-body estrogen (for hot flashes, night sweats, and bone loss), whole-body progesterone (for uterine protection, sleep, and anxiety), [restricted term] (for libido, arousal, and orgasm), and vaginal hormones (for urinary issues, recurrent UTIs, painful intercourse, and dryness). Vaginal hormones, delivered as low-dose creams, tablets, or rings, are proven safe for all ages—including postpartum women—and dramatically improve quality of life while preventing UTIs. Rubin stresses that therapy choice should be driven by symptoms, not age, and that initiation should occur when symptoms impact quality of life. Empowering women with accurate information and compassionate, knowledgeable physicians enables informed decisions about hormone health at every stage.
Sexual Health, Dysfunction, and Anatomy
The clitoris is central to women's sexual pleasure, yet it remains poorly understood and barely featured in gynecology training. Rubin explains that the visible head is just the tip of a large internal structure extending to the pelvic bones, with approximately 10,000 nerve endings. Most women do not orgasm from penetration alone; the clitoris is the main event for sexual pleasure. Despite this, medical education largely ignores the clitoris—no specialty actively teaches how to examine it, and future ob-gyn training requirements continue to omit meaningful coverage of clitoral anatomy and function. The practice of using sheets during exams further keeps women unfamiliar with their own anatomy, reducing opportunities for education and advocacy.
Approximately 23% of women experience clitoral adhesions, where the clitoral hood sticks to the head, limiting pleasure and function. Because clitoral exams are not standard practice, most women remain undiagnosed. Simple in-office procedures to release these adhesions can dramatically improve orgasm, arousal, and sexual satisfaction by 60-70%.
About 20% of women experience difficulty achieving orgasm, but Rubin emphasizes that the primary reason is lack of education rather than biology. Most women incorrectly believe penetrative sex alone should result in orgasm, yet the clitoris—not penetration—is how most women reach orgasm. Men reach orgasm after five and a half minutes of penetration, while women require significantly more time and, crucially, clitoral stimulation. Rubin notes that penetration without clitoral stimulation is like rubbing a thigh and expecting orgasm. Unlike men, women can potentially achieve multiple orgasms, as their period of sensitivity after climax is shorter. More awareness of clitoral physiology could help change dynamics, offering greater pleasure and satisfaction.
Up to 75% of women report having experienced painful sex, with causes including hormonally-sensitive skin diseases, scar tissue from endometriosis, nerve entrapments, and pelvic floor muscle dysfunction. Despite high prevalence, pain is frequently dismissed, and women rarely receive proper examination or diagnosis. Declining hormone levels, particularly estrogen and [restricted term], can cause dryness and loss of elasticity, increasing pain. Proper management—including vaginal hormone therapy—can restore healthy tissue, lubrication, and sexual function.
The pelvic floor consists of muscles that must contract and relax for healthy sexual response. Tight muscles can create burning, soreness, difficulty with penetration, impaired orgasms, and diminished arousal by restricting blood flow. Surgery, childbirth, and general muscle changes can lead to dysfunction. Specialist physical therapy can restore proper brain-genital connection and sexual function.
Genitourinary syndrome of menopause describes hormonal changes leading to vaginal and bladder symptoms, including dryness, decreased acidity, and imbalanced microbiome. Vaginal application of micro-doses of hormones effectively restores acidity, alleviates pain and dryness, and prevents UTIs. These therapies are safe for all ages—even for those with cancer, blood clot, or stroke histories. Despite these benefits, less than 25% of women are prescribed these vital treatments. Sexual activity introduces non-acidic semen and foreign bacteria, raising infection risk, making hormone therapy's maintenance of vaginal acidity especially protective.
Medical Education Gaps and Doctor-Patient Advocacy
Medical education's neglect of women's sexual health and hormonal care leaves doctors unprepared to meet women's needs. Rubin emphasizes that obstetrician-gynecologists still receive no formal training on the clitoris, vulva, sexual pain, libido, arousal, or orgasm. She notes that "the word clitoris today in 2026 does not exist in the checklist for what an OBGYN has to learn in their training." Despite this lack of education, physicians frequently express authoritative opinions on women's sexual health or hormone therapy, often denying treatments because it is easier than acknowledging knowledge gaps. Rubin, who comes from a men's health background, describes how "in men's health, we talk about risks, we talk about benefits, we talk about shared decision-making," while women are far more likely to hear "no, you can't have this" from gynecologists.
Rubin highlights that failures in women's healthcare cross socio-economic boundaries. Melinda Gates needed three doctors before anyone could properly prescribe hormone therapy, Oprah Winfrey saw five doctors before anyone recognized her menopause-related heart palpitations, and Halle Berry was misdiagnosed with genital herpes when she was actually experiencing genitourinary syndrome of menopause. Rubin underscores that "if the rich people are not getting good information about their bodies, about their hormonal health, about their sexual health, what are the rest of us doing?"
The long-lasting effects of fear and misinformation about hormone therapy have turned hormone prescribing into a "lost art" among physicians. Doctors are rarely taught how to write hormone prescriptions or discuss their risks and benefits. The lag between emerging research and its re-interpretation leads many physicians to default to unnecessary denial of care. Rubin argues it is far better for clinicians to admit their limitations and refer patients to specialists than to dismiss requests out of ignorance or fear.
Faced with systemic gaps, Rubin encourages women to actively advocate for themselves by seeking providers who are curious, up-to-date, and respectful, and leaving doctors who do not engage meaningfully or who restrict care without evidence. Crucially, Rubin emphasizes the power of education: "You can learn about your body parts, you can learn how hormones work in your body, and you can learn basic medicine for you that becomes important for how you advocate for what you want, what you care about, and who you bring into your medical life." Through self-advocacy and education, women can press for quality care, even in the face of persistent system-wide training gaps.
Communication, Relationships, and Lifestyle Factors in Sexual Health
Steven Bartlett and Dr. Rachel Rubin explore how communication, lifestyle, media, and psychology all intersect to shape intimacy and satisfaction. Most couples rarely ask fundamental questions about what sexual satisfaction means for their partners, how they experience arousal, or what interests them. Bartlett admits that even in close relationships, he and others have bypassed these conversations, letting awkwardness prevent deeper dialogue. Rubin encourages explicit check-ins about physiology and pleasure, suggesting questions like "What does great sex mean for you?" She frequently brings both partners into clinical conversations and physical exams, allowing them to jointly discover physical sources of issues, replacing blame with understanding. These conversations work best outside moments of intimacy, when stakes are lower and thoughtful discussion is possible. A particularly charged area is the faked orgasm—Rubin asserts that many women fake orgasms to protect their partner's feelings, which ultimately prevents genuine intimacy and deprives both partners of true pleasure.
Rubin dismantles common male anxieties about penis size, rigidity, or duration, stating that women's satisfaction overwhelmingly depends on clitoral stimulation, emotional connection, and individualized understanding—not male anatomy. To truly enhance satisfaction, men should invest in learning their partner's unique anatomy and preferences. Many women require precise or indirect clitoral stimulation to orgasm, and disproportionate focus on penetration leaves many feeling broken when the real issue is lack of education and misplaced priorities.
Bartlett and Rubin recognize pornography's nuanced effects on sexual expectations. Mainstream content caters largely to male desires, instilling unrealistic ideas about women's pleasure. Heavy solo pornography use can desensitize the reward system, leading to performance anxiety and unrealistic standards. However, occasional partnered viewing, especially of female-oriented content, can enhance arousal and broaden understanding of desires. The emphasis is on honesty and intentionality—open discussion about porn is far more important than blanket moral judgments.
Modern life's stressors—overwork, sleep deprivation, continuous digital engagement, and mental burnout—drain [restricted term] and sap sexual desire. Rubin confirms these lifestyle challenges are common factors in patients presenting with low libido. Optimizing sleep, reducing screen time, and scheduling time for intimacy are practical interventions. Scheduling intimacy, often disparaged as unspontaneous, is reframed as anticipation and preparation that can reignite eroticism, just as date nights built anticipation during early courtship.
Body image insecurity is a profound barrier to sexual fulfillment. Rubin notes that women often fixate on thinness rather than building strength and self-acceptance, which are far more correlated with sexual pleasure. There is a marked cognitive distortion: while women believe their friends of any body type deserve pleasure, they do not extend the same compassion to themselves. Education on pleasure, biology, self-worth, and the diversity of desirability is vital for shifting these deeply embedded beliefs.
A crucial insight is the distinction between spontaneous and responsive arousal. Around 70% of men experience spontaneous arousal, while only 10–15% of women do. In contrast, 40–50% of women feel aroused responsively—meaning their desire emerges during engagement or foreplay, not in anticipation. Understanding responsive arousal helps debunk the myth that all sex should begin with overwhelming, instantaneous passion. What appears to be "low libido" or "lack of attraction" is often simply a normal arousal style responding to the right conditions and connection.
1-Page Summary
Additional Materials
Clarifications
- Estrogen primarily regulates the development of female reproductive organs and secondary sexual characteristics, and it supports bone health and cardiovascular function. Progesterone prepares the uterus for pregnancy and helps regulate the menstrual cycle, also influencing mood and sleep. [restricted term], though lower in women than men, contributes to libido, sexual arousal, muscle strength, and overall energy. These hormones interact dynamically, with fluctuating levels affecting various physical and emotional aspects of women's health.
- The menstrual cycle is divided into phases based on ovarian activity and hormone levels. The follicular phase starts after menstruation, with follicles in the ovary maturing under follicle-stimulating hormone (FSH) influence. Ovulation occurs mid-cycle when a mature egg is released, triggered by a surge in luteinizing hormone (LH). The luteal phase follows ovulation, with the corpus luteum producing progesterone to prepare the uterus for possible pregnancy.
- Perimenopause is the transitional phase before menopause when hormone levels fluctuate irregularly, causing symptoms but menstruation continues. Menopause is defined as the point when a woman has not had a menstrual period for 12 consecutive months, marking the end of reproductive ability. Perimenopause can last several years, while menopause is a single event. Symptoms often begin during perimenopause and may continue or change after menopause.
- The Women's Health Initiative (WHI) was a large clinical trial launched in the 1990s to study hormone therapy's effects on postmenopausal women. Early results published in 2002 suggested increased risks of breast cancer, heart disease, and stroke, causing widespread fear and a sharp decline in hormone therapy use. Later analyses revealed these risks were overstated, especially for younger women starting therapy near menopause. This misinterpretation led to lasting stigma and underuse of hormone therapy despite its benefits.
- Hormone therapy categories target different symptoms by replacing or supplementing specific hormones. Whole-body estrogen helps regulate temperature and bone density by compensating for estrogen loss. Whole-body progesterone supports uterine health and calms the nervous system, improving sleep and reducing anxiety. [restricted term] therapy addresses sexual function by enhancing libido and arousal, while vaginal hormones focus locally on urinary and vaginal tissue health.
- Clitoral adhesions occur when the clitoral hood, a fold of skin covering the clitoris, sticks to the clitoral glans, restricting its movement and exposure. This can reduce sensitivity and make stimulation less effective or uncomfortable. Adhesions often result from inflammation, irritation, or lack of hygiene. Treatment involves a simple, painless procedure to gently separate the hood from the glans, restoring normal function.
- The clitoris extends internally with two long, curved structures called crura that reach along the pelvic bones. These internal parts are made of erectile tissue that fills with blood during arousal, similar to the penis. The clitoris also includes bulbs on either side of the vaginal opening, contributing to sexual sensation. This extensive internal anatomy explains why stimulation beyond the visible glans can enhance pleasure.
- The refractory period is the recovery time after orgasm during which a person cannot achieve another orgasm. In men, this period typically lasts minutes to hours, preventing multiple orgasms in quick succession. Women generally have a much shorter or absent refractory period, allowing some to experience multiple orgasms without needing a recovery break. This difference is due to variations in physiological and neurological responses after climax.
- Genitourinary syndrome of menopause (GSM) results from decreased estrogen causing thinning, drying, and inflammation of vaginal and urethral tissues. This leads to symptoms like vaginal dryness, irritation, urinary urgency, and recurrent infections. GSM can impair sexual function and quality of life if untreated. Local estrogen therapy restores tissue health and reduces symptoms effectively.
- The pelvic floor muscles support pelvic organs and control bladder and bowel function. They contract to increase blood flow and sensation during arousal, enhancing sexual response. Relaxation of these muscles is necessary for comfortable penetration and orgasm. Dysfunction, such as tightness or weakness, can cause pain, reduced sensation, and difficulty with sexual activity.
- Vaginal acidity, measured by pH, is typically low (acidic) to inhibit harmful bacteria and support beneficial ones. This acidic environment helps maintain a balanced vaginal microbiome, primarily dominated by Lactobacillus species that protect against infections. Disruption of this balance can lead to overgrowth of harmful bacteria, causing infections like bacterial vaginosis or increasing UTI risk. Hormones, especially estrogen, promote vaginal acidity by supporting healthy tissue and beneficial bacteria growth.
- Medical education has historically prioritized male anatomy and reproductive health, leading to minimal coverage of female sexual anatomy like the clitoris. This gap stems from longstanding cultural taboos and gender biases in medicine. As a result, many healthcare providers lack detailed knowledge about female sexual function and anatomy. This deficiency contributes to inadequate diagnosis and treatment of female sexual health issues.
- Spontaneous sexual arousal occurs without any external triggers, often arising suddenly and involuntarily. Responsive sexual arousal happens as a reaction to specific stimuli, such as touch, emotional connection, or sexual context. Men more commonly experience spontaneous arousal, while women more often experience responsive arousal. Recognizing this helps normalize different patterns of desire and reduces misunderstandings about sexual interest.
- Pornography often portrays exaggerated or unrealistic sexual scenarios that can shape viewers' expectations about sex and pleasure. Frequent exposure to such content may alter brain reward pathways, potentially reducing sensitivity to real-life sexual stimuli. This can lead to difficulties in arousal or performance anxiety when actual sexual experiences do not match these expectations. However, mindful and shared consumption of diverse, realistic content can foster better understanding and communication about desires.
- [restricted term] is a brain chemical that drives motivation, reward, and pleasure, including sexual desire. Chronic stress depletes [restricted term] levels, reducing motivation and interest in sex. High stress also increases cortisol, which can inhibit [restricted term] production and sexual function. Restoring [restricted term] through stress management and healthy lifestyle habits can improve libido.
- Cognitive distortion refers to irrational or biased ways of thinking that negatively affect self-perception. In body image and sexual self-worth, it causes individuals to undervalue their own attractiveness and pleasure despite recognizing these qualities in others. This distortion often leads to harsh self-criticism and diminished confidence in sexual situations. Overcoming it involves challenging these false beliefs and fostering self-compassion.
- Scheduling intimacy helps couples prioritize connection amid busy lives, reducing stress and distractions. It creates anticipation, which can heighten desire and emotional readiness. Planning also allows partners to prepare mentally and physically, improving the quality of the experience. This approach normalizes intimacy as a shared activity rather than spontaneous pressure.
- Male orgasms typically occur faster during penetrative sex, often within minutes, while female orgasms usually require longer stimulation and are less likely from penetration alone. Women often need direct or indirect clitoral stimulation to reach orgasm, as the clitoris is the primary source of sexual pleasure. Unlike men, women can experience multiple orgasms because their refractory period—the recovery time after orgasm—is shorter or absent. Female sexual response is more variable and influenced by emotional and contextual factors, making timing and stimulation needs more individualized.
Counterarguments
- While hormone therapy can be beneficial for many women, some studies and guidelines still urge caution, especially for women with certain risk factors (e.g., history of hormone-sensitive cancers, blood clots), and recommend individualized risk assessment rather than broad reassurance.
- The assertion that [restricted term] decline is a major cause of sexual dysfunction in women is debated; some research suggests that psychological, relational, and contextual factors often play a larger role than hormonal levels alone.
- The prevalence and clinical significance of clitoral adhesions are not universally agreed upon in the medical community, and some experts question whether routine screening or intervention is warranted for asymptomatic women.
- The claim that vaginal hormone therapy is safe for all women, including those with a history of cancer, is not universally accepted; some oncologists and guidelines recommend caution or avoidance in certain cancer survivors.
- While medical education on women's sexual health is limited, some programs and continuing education efforts are working to address these gaps, and the situation may be improving in some regions or institutions.
- The focus on hormonal explanations for sexual dysfunction may risk underemphasizing the importance of psychological, relational, and sociocultural contributors, which are often primary drivers of sexual satisfaction and distress.
- The idea that scheduling intimacy is universally beneficial may not resonate with all couples; for some, it may feel artificial or increase pressure, potentially reducing desire.
- While pornography can have negative effects, some research suggests it can also have neutral or positive impacts on sexual satisfaction and communication for certain individuals and couples.
- The emphasis on clitoral stimulation as the primary route to orgasm may not reflect the diversity of women's sexual experiences; some women do report orgasm from penetration alone or from other forms of stimulation.
- The assertion that only 1.7% of eligible women receive hormone prescriptions may not account for women who choose not to pursue therapy for personal, cultural, or health reasons unrelated to physician undertraining.
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Women's Hormones Across Life Stages and Hormone Therapy
Hormones influence nearly every stage of a woman’s life, affecting sexual health, mood, sleep, and wider aspects of well-being. Yet, essential hormonal changes and available therapies often receive little clinical focus and are hindered by historical stigma and lack of public awareness.
[restricted term] Declines Affect Women's Sexual Function and Arousal
Contrary to common belief, [restricted term] is not exclusive to men; women also produce this hormone. Rachel Rubin explains that women’s [restricted term] levels start to decline precipitously in the mid-to-late thirties, well before menopause. This drop can result in decreased libido, diminished clitoral engorgement and lubrication, slower or less intense orgasms, and reduced arousal. Clitoral erection, like penile erection, depends on blood flow driven by [restricted term].
Despite these significant effects, this decline garners little attention from clinicians, as medical education remains largely focused on estrogen and progesterone. Birth control pills can further lower [restricted term], leading to lower libido and sometimes painful sex in a subset of users. Rubin urges women who experience these side effects to discuss alternatives with their healthcare providers to find options that don’t impact [restricted term] as strongly. Personal anecdotes affirm that libido changes linked to birth control can resolve after discontinuation, though individual causes may vary.
The Menstrual Cycle Involves Complex Hormonal Fluctuations: Estrogen Peaks Before Ovulation, Progesterone Rises After, and Both Drop Before Menstruation, Forming the Foundation For Understanding Women's Hormonal Health
Understanding the menstrual cycle’s hormonal changes is key to women’s health. The cycle starts with low estrogen and progesterone as menstruation begins. Estrogen rises in the early follicular phase to prepare an egg for release, while progesterone remains absent. During ovulation, estrogen peaks as an egg is released. The leftover egg shell then produces progesterone in the luteal phase, dominating the second half of the cycle and impacting mood, sleep, and sexual interest. If fertilization doesn’t occur, both hormones decrease, triggering menstruation.
[restricted term] typically remains stable throughout the menstrual cycle but peaks during ovulation. This coincides with heightened fertility and functions to increase sexual desire, which aids reproductive success. Estrogen measurements rise from roughly 50 at their lowest to 150–300 around ovulation, reaching 3000+ in pregnancy.
Perimenopause, Typically Starting Around Age 45 (Range 35–55), Causes Hormonal Fluctuations With Symptoms Like Hot Flashes, Sleep Disruption, Anxiety, Cognitive Changes, Joint Pain, and More UTIs
Perimenopause may begin as early as age 35 and is characterized by significant hormonal fluctuation. Rubin identifies a vast array of symptoms—temperature changes, fatigue, cognitive difficulties, joint pain, low libido, painful sex, frequent or recurrent UTIs, dry eyes, and irregular periods—that can all arise in this transitional period. Hormonal factors for bladder health and UTI prevention are especially overlooked.
Progesterone decline during perimenopause commonly disrupts sleep and increases anxiety. If a woman in her early forties reports poor sleep, low progesterone is often implicated. Since awareness of perimenopause’s early onset is low, symptoms are frequently misattributed or dismissed, leading to delayed diagnoses and interventions. Rubin emphasizes evolving awareness around offering hormone support as soon as perimenopausal symptoms appear.
HRT Stigma From Misinterpreted Study Leads To Rejection Despite Safety in Women Under 70
Many women avoid hormone therapy due to outdated fears or misinformation, often passed down from relatives. This reluctance stems from a misinterpreted early-2000s study, the Women's Health Initiative. The researchers prematurely halted the study and warned—incorrectly—that hormone therapy caused cardiovascular disease and breast cancer. This led to an abrupt, industry-wide withdrawal from hormone prescriptions.
However, deeper examination revealed the study's actual data didn’t support these conclusions. In 2025, the same researchers published a reanalysis confirming that hormone therapy under age 70 does not increase cardiovascular or stroke risk. Despite this, a generation of physicians remain undertrained in hormone therapy, and only about 1.7% of eligible women are prescribed hormones—a public health failure as organ failure in any other system would never be so widely tolerated.
Hormone Replacement Therapy Includes Four Categories: Whole-Body Estrogen, Whole-Body Progesterone, [restricted term], and Vaginal Hormones—Each Addressing Different Symptoms and Requiring Individualized Treatment Planning
Rubin defines four categories of hormone therapy that can be combined or selected individually, tailored to symptoms and medical history:
- Whole-Body Estrogen Therapy: Alleviates hot flashes, night sweats, and bone loss (osteopenia/osteoporosis), and improves hair, skin, and nails. It also benefits sleep. In women with a uterus, estrogen must be combined with progesterone to prevent overgrowth of the uterine lining and reduce cancer risk.
- Whole-Body Progesterone Therapy: Protects the uterus and is particularly helpful for sleep and reducing anxiety; typically taken at night.
- [restricted term] Therapy: Demonstrated to boost libido, arousal, orgasm, satisfaction, and potentially even body image ...
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Women's Hormones Across Life Stages and Hormone Therapy
Additional Materials
Clarifications
- [restricted term] in women supports sexual desire by enhancing nerve sensitivity and blood flow to genital tissues. It also influences mood, energy, and muscle strength, contributing to overall well-being. Unlike in men, women produce much lower [restricted term] levels, primarily from ovaries and adrenal glands. Deficiency can impair sexual function and reduce physical vitality.
- Clitoral engorgement occurs when blood vessels in the clitoris dilate, allowing increased blood flow that causes swelling and heightened sensitivity. [restricted term] helps regulate this process by promoting nitric oxide production, which relaxes blood vessel walls. Without sufficient [restricted term], blood flow to the clitoris can decrease, reducing engorgement and sexual arousal. This mechanism is similar to how [restricted term] influences penile erection in men.
- The follicular phase begins with menstruation and involves the growth of ovarian follicles stimulated by follicle-stimulating hormone (FSH). Ovulation occurs mid-cycle when a surge in luteinizing hormone (LH) triggers the release of a mature egg. The luteal phase follows ovulation, during which the corpus luteum forms and secretes progesterone to prepare the uterus for possible pregnancy. If fertilization does not occur, the corpus luteum degenerates, leading to a drop in progesterone and the start of menstruation.
- Estrogen rises gradually in the follicular phase to stimulate the growth of the uterine lining and peaks just before ovulation to trigger egg release. Progesterone remains low during the follicular phase but surges after ovulation to prepare the uterus for potential pregnancy. If fertilization does not occur, both estrogen and progesterone levels fall sharply, causing menstruation. [restricted term] peaks briefly around ovulation, enhancing sexual desire and fertility-related behaviors.
- The "uterine lining overgrowth" refers to excessive thickening of the endometrium, the tissue lining the inside of the uterus. This condition, called endometrial hyperplasia, can occur when estrogen is unopposed by progesterone. If untreated, it may increase the risk of developing endometrial cancer. Progesterone therapy helps prevent this by balancing estrogen’s effects on the uterine lining.
- Whole-body hormone therapy delivers hormones systemically, affecting the entire body through pills, patches, or injections. Vaginal hormone therapy applies hormones locally, targeting tissues in the vagina and urinary tract without significant absorption into the bloodstream. This local delivery minimizes systemic side effects and specifically treats symptoms like vaginal dryness, pain, and urinary issues. Whole-body therapy addresses broader symptoms such as hot flashes, bone loss, and mood changes.
- Progesterone has calming effects on the brain by enhancing the activity of GABA, a neurotransmitter that promotes relaxation and reduces anxiety. It also helps regulate the sleep-wake cycle by increasing slow-wave (deep) sleep. Low progesterone levels can lead to insomnia and heightened anxiety symptoms. This hormone’s influence on mood and sleep is why its decline during perimenopause often causes sleep disturbances and anxiety.
- The Women's Health Initiative (WHI) was a large, government-funded study launched in the 1990s to assess the risks and benefits of hormone therapy in postmenopausal women. Early results, published in 2002, suggested increased risks of breast cancer, heart disease, and stroke, causing widespread fear and a sharp decline in hormone therapy use. Later analyses revealed these risks were overstated, especially for women under 60 or within 10 years of menopause. This misinterpretation led to persistent stigma and underuse of hormone therapy despite its benefits for many women.
- [restricted term] dosing in women is much lower than in men because women naturally have significantly lower [restricted term] levels. Using about one-tenth of a male dose helps avoid masculinizing side effects like deepening voice or excessive hair growth. The dose is carefully adjusted to restore normal female [restricted term] levels, improving symptoms without causing harm. Monitoring by a healthcare provider ensures safe and effective treatment.
- Vaginal hormones are localized treatments that deliver small amounts of hormones directly to vaginal tissues, minimizing systemic absorption and reducing side effects. DHEA (IntraRosa) is a vaginal insert that converts into estrogen and androgen locally, improving vaginal tissue health and function. These treatments restore the vaginal lining, increase lubrication, and reduce inflammation, which helps alleviate urinary symptoms like urgency and recurrent infections. Their targeted action makes them safe for long-term use, including in breastfeeding and postpartum women.
- Declining estrogen levels thin and dry the vaginal and urethral tissues, reducing natural lubrication and elasticity. This makes the vaginal area more prone to irritation, pain during sex, and easier entry for bacteria causing UTIs. Estrogen also supports the growth of healthy vaginal flora that protect against ...
Counterarguments
- The long-term safety of hormone therapy, especially [restricted term] therapy in women, remains under-researched, and regulatory agencies in many countries have not approved [restricted term] products specifically for women due to insufficient large-scale, long-term data.
- Some studies suggest that hormone therapy may carry risks, such as increased risk of certain cancers, blood clots, or stroke, particularly in women with specific risk factors, and these risks should be weighed carefully against benefits.
- The reanalysis of the Women's Health Initiative data is not universally accepted as definitive, and some clinicians and researchers maintain a cautious approach to hormone therapy, especially in women with a history of hormone-sensitive cancers or cardiovascular disease.
- Not all women experience significant symptoms during perimenopause or menopause, and many manage symptoms effectively with non-hormonal interventions such as lifestyle changes, cognitive behavioral therapy, or non-hormonal medications.
- The assertion that only 1.7% of eligible women receive hormone therapy may not account for women who choose to avoid hormones for personal, cultural, or medical reasons, and low uptake is not solely due to stigma or misinformation.
- The benefits of hormone therapy for is ...
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Sexual Health, Dysfunction, and Anatomy
Clitoris: A Complex Organ With 10,000 Nerve Endings Largely Unstudied in Gynecology Training
Beyond the Visible Head: The Clitoris's Complex Anatomy and Its Role in Women's Sexual Pleasure
The clitoris is central to women's sexual pleasure and orgasm, yet remains poorly understood and barely featured in gynecology training. Its visible part—the head—is just the tip; the clitoris is a large internal structure extending to the pelvic bones and is made of the same tissue as the penis, functioning similarly. With approximately 10,000 nerve endings, its sensitivity varies from person to person. While some find direct stimulation pleasurable, others may find it overwhelming and prefer indirect or external stimulation. Most women do not orgasm from penetration alone; rather, the clitoris is the main event for sexual pleasure and climax.
Despite this, medical education and gynecology largely ignore the clitoris. No specialty actively teaches how to examine or locate it, and during standard pelvic exams—when women are draped and unable to see their own anatomy—doctors rarely discuss the clitoris or invite patients to learn about their bodies. This lack of knowledge undermines women’s sexual health, pleasure, and ability to advocate for themselves.
Clitoris Excluded From 2026 Ob-gyn Training Checklist, Leaving Gap in Clitoral Sexual Dysfunction Education
Future ob-gyn training requirements continue to omit meaningful coverage of clitoral anatomy and function, resulting in clinicians who are unprepared to address clitoral sexual dysfunction or ask about a woman’s sexual satisfaction, even during pain or libido consultations.
Speculums and Sheets Obscure Women's View During Pelvic Exams, Limiting Body Familiarity and Health Advocacy
The practice of using sheets to cover women during exams, though intended for modesty, also tends to keep women unfamiliar with their own genitalia, reducing opportunities for education and advocacy.
Clitoral Adhesions Affect 23% of Women; Surgical Correction Can Improve Orgasm, Arousal, and Sexual Satisfaction By 60-70%
Clitoral Adhesions Limit Access and Impair Pleasure and Function
Approximately 23% of women experience clitoral adhesions, where the clitoral hood sticks to the head, often obscuring the full extent of the clitoris and limiting pleasure. Ideally, the clitoris has a mushroom shape similar to a penis, but adhesions hinder stimulation and function.
High Clitoral Adhesions Prevalence; Most Women Unexamined by Clinicians
Because clitoral exams are not standard practice, most women remain undiagnosed for this manageable condition. However, simple in-office procedures to release these adhesions can yield dramatic improvements—boosting orgasm, arousal, and overall sexual satisfaction by 60-70%.
Educational Deficits Drive Orgasm Gap: Most Women Incorrectly Believe Penetration Alone Produces Orgasm Instead Of Clitoral Stimulation
Orgasm Difficulties Affect 20% of Women and Men, Highlighting Education Gaps, Not Biology
About 20% of women and men experience difficulty achieving orgasm, but for women, the primary reason is a lack of education rather than biology.
Misunderstanding Female Anatomy: Most Women Need Clitoral Stimulation For Orgasm
Despite clear evidence, most women believe penetrative sex alone should result in orgasm, largely because anatomical education is poor. The clitoris, not penetration, is how most women reach orgasm—yet many women don’t even know where their clitoris is or how to stimulate it. If sexual encounters focus solely on penetration, similar to continuously rubbing the thigh near a penis, orgasm is unlikely.
Penetrating Without Clitoral Stimulation Is Like Rubbing a Thigh Expecting Orgasm; Penetration Alone Rarely Leads to Orgasm In Most Women
Normally, men reach orgasm after five and a half minutes of penetration, while women require significantly more time and, crucially, clitoral stimulation. Penetration without such stimulation yields little pleasure for most women, although some enjoy penetration due to additional nerve endings or individual preferences. The prevailing myth that penetration equals orgasm perpetuates the orgasm gap.
Women May Experience Multiple Orgasms Post-Climax, With Brief Sensitivity Decline and Recovery, Allowing For Additional Orgasms and Greater Pleasure, Often Under-Discussed In Partnerships
Unlike men, women can potentially achieve multiple orgasms, as their period of sensitivity and arousal after climax is shorter. Despite this, women often have no orgasms while men have one, due to focus on penile pleasure and the misconception that the male experience is standard. More awareness of clitoral physiology could help change this dynamic, offering greater pleasure and satisfaction.
Intercourse Pain Affects 75% of Women; 10-20% Experience Chronic Pain, 20-50% During Menopause, yet It Gets Inadequate Medical Attention and Training
Causes of Painful Intercourse: Skin Conditions, Pelvic Floor Dysfunction, Nerve Impingement, Endometriosis Scar Tissue, Hormonal Insufficiency
Up to 75% of women report having experienced painful sex. Causes include hormonally-sensitive skin diseases (like eczema or autoimmune conditions), scar tissue from endometriosis, nerve entrapments, and, commonly, pelvic floor muscle dysfunction.
Women Deserve Proper Evaluation For Pain Causes, Not Dismissal, Needing Pelvic Pain Management Specialists
Despite high prevalence, pain is frequently dismissed, and women rarely receive the examination or diagnosis they deserve. Specialized pelvic pain management, including attention to anatomical, muscular, and hormonal factors, is rarely offered.
Hormonal Factors in Painful Intercourse Can Be Addressed With Hormone Therapy to Restore Tissue Elasticity, Lubrication, and Health
Declining hormone levels, particularly estrogen and [restricted term], can cause dryness and loss of elasticity, increasing pain. Proper management—including vaginal hormone therapy—can restore healthy tissue, lubrication, comfort, and sexual function.
The Pelvic Floor Consists Of Muscles That Need to Contract and Relax For Healthy Sexual Function, yet Dysfunction Often Goes Undiagnosed and Untreated
Tight Pelvic Floor Muscles Cause Pain, Hinder Penetration, Impair Orgasm-Contractions, and Restrict Blood Flow For Arousal
The pelvic floor is a set of thick muscles supporting the pelvic organs and genitals. For healthy sexual response—including arousal, engorgement, penetration, and orgasm—these muscles must contract and relax in coordination. Tight muscles can create burn ...
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Sexual Health, Dysfunction, and Anatomy
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Counterarguments
- While the clitoris is indeed central to sexual pleasure for many women, some women do report orgasm from penetration alone, indicating that sexual response is highly individual and not universally dependent on clitoral stimulation.
- The assertion that medical education "largely ignores" the clitoris may not fully reflect recent improvements in some medical curricula, where there has been increased attention to female sexual anatomy and function.
- The prevalence of clitoral adhesions (23%) and the claim that surgical correction improves sexual satisfaction by 60-70% may be based on limited or preliminary studies; more large-scale, peer-reviewed research is needed to confirm these figures and outcomes.
- The statement that hormone therapies are safe for all women, including those with cancer, blood clot, or stroke histories, may not align with all clinical guidelines, as some medical organizations recommend caution or individualized assessment in these populations.
- The comparison of penetration without clitoral stimulation to "rubbing a thigh expecting orgasm" may oversimplify the diversity of women's sexual experiences and preferences.
- While pelvic floor physical therapy can be beneficial, not all cases of painful intercourse or pelvic floor dysfunction require or respond to this intervention; other medical or psychological factors may also need to be addressed.
- The claim that educational deficits are the primary reason for orgasm difficulties in women may overlook biological, psychological, relational, and cultural fac ...
Actionables
- you can use a hand mirror during your next self-exam or after a shower to visually explore your vulva and clitoris, noting any changes or areas that feel different, which helps build body familiarity and confidence in discussing your anatomy with healthcare providers
- This hands-on approach lets you observe your own anatomy, recognize what’s normal for you, and notice any adhesions, discomfort, or changes over time. For example, you might gently retract the clitoral hood to check for mobility or sensitivity, or compare both sides of your vulva for symmetry. This practice can make it easier to communicate specific concerns during medical appointments.
- a practical way to advocate for your sexual health is to prepare a written list of questions or requests about clitoral and pelvic floor evaluation before your next gynecological visit
- For instance, you could ask your clinician to assess for clitoral adhesions, explain the pelvic floor’s role in sexual function, or discuss options for managing pain or dryness. Bringing a list ensures you don’t forget important topics and signals to your provider that these issues matter to you.
- you can track your sexual comfort, pleasu ...
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Medical Education Gaps and Doctor-Patient Advocacy
Medical education’s longstanding neglect of women’s sexual health and hormonal care leaves even the most experienced doctors unprepared to meet women’s needs. Dr. Rachel Rubin describes in detail how systemic failures impact care and patients’ ability to advocate for themselves.
Insufficient Training in Women's Sexual Health and Hormones Leaves Doctors Unprepared
Obstetrician-Gynecologists Lack Formal Training in Clitoris, Vulva, Sexual Pain, Arousal, Orgasm, and Libido, Despite Their Female Sexual Health Focus
Rachel Rubin emphasizes that the current medical education for obstetrician-gynecologists still fails to formally include essential aspects of female sexual anatomy and function. She notes that “the word clitoris today in 2026 does not exist in the checklist for what an OBGYN has to learn in their training.” In practice, most doctors specializing in obstetrics and gynecology never receive training on the clitoris, vulva, sexual pain, libido, arousal, or orgasm, despite their centrality to female sexual health. Only a small minority of gynecologists seek additional instruction on these topics. As a result, patients routinely enter appointments expecting expertise their doctors do not possess about hormones, sexual function, and pleasure.
Physicians Often Form Strong Opinions on Women's Hormone Therapy or Sexual Health Without Formal Education, Defaulting To Denial Rather Than Admitting Knowledge Gaps
Rubin points out that despite this lack of education, physicians frequently express authoritative opinions on women's sexual health or hormone therapy, often denying treatments because it is easier than acknowledging their knowledge gaps or discussing nuanced risks and benefits in short visits. She contrasts this with men’s health care, where shared decision-making about risks and benefits is standard. Rubin suggests this difference is not because doctors are malicious, but because they lack training and try to save face in brief consultations. She explains that many are taught to view hormones as inherently dangerous in older women—a misconception born from decades-old misinterpretation of science and lack of continuing education.
Men's Health and Women's Health Differ: Urologists Use Shared Decision-Making For Men, While Gynecologists Impose Outdated Restrictions on Women
Rubin, who comes from a men’s health background, describes how “in men's health, we talk about risks, we talk about benefits, we talk about shared decision-making.” In contrast, women are far more likely to hear “no, you can’t have this” from gynecologists planning hormone therapies, a reflection of ingrained double standards and inadequate clinical education.
Affluent Women Struggle With Hormonal and Sexual Health Care Due to Systemic Medical Education Failures
Melinda Gates, Oprah, and Halle Berry's Menopause-Related Medical Consultations
Undertreatment of Women's Hormonal and Sexual Health Stems From Research Gaps and Physician Training Deficiencies
Rubin highlights that failures in women’s healthcare cross socio-economic boundaries. Melinda Gates publicly shared that she needed to see three doctors before anyone could properly prescribe hormone therapy. Oprah Winfrey saw five doctors before anyone recognized her menopause-related heart palpitations. Halle Berry, despite her resources, was misdiagnosed with genital herpes when she was actually experiencing genitourinary syndrome of menopause. These cases expose a system where even wealthy and well-connected women are not getting proper information, much less effective treatment. Rubin underscores that “if the rich people are not getting good information about their bodies, about their hormonal health, about their sexual health, what are the rest of us doing?” The core of the problem is inadequate education: doctors aren’t taught about these issues in medical school or residency, so many cannot effectively care for women experiencing menopause or sexual health concerns.
Training Doctors in Hormone Therapy, Clitoral Exams, and Sexual Health Discussions
Physicians Need Instruction Before Prescribing
The Gap Between Concerning Hormone Therapy Data Publication and Reinterpretation Showed Doctors Needed Current Education On Evidence Over Media Headlines Misrepresenting Research
Physicians Protect By Denying Hormonal Treatments Over Time and Liability; Better to Admit Limits and Refer Specialists
Rubin points to the long-lasting effects of fear and misinformation about hormone therapy that originated decades ago, turning hormone prescribing into a “lost art” among physicians. Doctors are rarely taught how to write hormone prescriptions, understand their differences, or discuss their risks and benefits with patients. Even large philanthropic contributions, like Melinda ...
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Medical Education Gaps and Doctor-Patient Advocacy
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Counterarguments
- While gaps in women’s sexual health education exist, medical curricula are continually evolving, and some programs have begun to address these deficiencies in recent years.
- Not all gynecologists lack knowledge of female sexual anatomy and function; some pursue additional training or continuing education in these areas.
- The complexity and variability of hormone therapy risks may make some physicians cautious, prioritizing patient safety in the absence of clear, universally accepted guidelines.
- Shared decision-making is increasingly emphasized in both men’s and women’s health care, though implementation may vary by provider and institution.
- Some misdiagnoses or delays in care can occur in any area of medicine, not exclusively in women’s hormonal or sexual health.
- The challenges described are not unique to the United States; similar issues exist internationally, reflecting broader systemic and cultural factors in medicine.
- Large-scale changes in medical education and practice often require time, resources, and consensus among ...
Actionables
- You can create a personal health timeline that tracks your hormonal and sexual health symptoms, questions, and any treatments or advice you receive, then bring this document to every medical appointment to prompt more informed and specific conversations with your provider. This helps you notice patterns, clarify your needs, and ensure your concerns are addressed, even if your doctor isn’t proactively asking.
- A practical way to ensure you get balanced information is to prepare a list of specific questions about hormone therapy, sexual health, and anatomy before appointments, and request that your provider answer each one directly or provide written resources for any they can’t answer. This approach encourages transparency and helps you identify when a second opinion or specialist referral is n ...
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Communication, Relationships, and Lifestyle Factors in Sexual Health
Steven Bartlett and Dr. Rachel Rubin explore the multiple dimensions of sexual health, examining how communication, anatomy, lifestyle, media, and psychology all intersect to shape intimacy and satisfaction.
Essential Conversations: Discussing Sex, Satisfaction, and Desires
Most couples rarely ask their partners fundamental questions about what true sexual satisfaction means for them, how they experience arousal, or what types of sexual exploration interest them. Rubin observes that the default is to assume compatibility or avoid these vulnerable—yet potentially transformative—conversations. Bartlett candidly admits that even in close relationships, he and others have bypassed conversations about sexual satisfaction, letting awkwardness or discomfort prevent deeper dialogue. It is often assumed that if nothing is said, everything is fine, but as Bartlett points out, silence can mask unmet needs and dissatisfaction.
Rubin encourages explicit check-ins about physiology and pleasure, suggesting questions such as “What does great sex mean for you?” or “Where and how do you experience pleasure?” Partners should be curious about each other’s individual bodies and preferences, not just rely on generalizations. She also frequently brings both partners into her clinical conversations and physical exams, allowing them to jointly discover physical sources of issues—such as the pain at the vulva’s entrance—dismantling the notion that lack of desire is always about attraction or performance. Seeing the biology together replaces blame with understanding.
Importantly, Rubin and Bartlett agree these conversations work best outside moments of intimacy—when people are not naked or in the midst of foreplay—so that the stakes are lower, thoughtful discussion is possible, and neither partner feels pressured to perform or defend themselves.
Communication’s impact reverberates through all relationship health. Bartlett relates how conflict resolution—built on safe, honest, and caring communication—determines whether relationships become stronger or weaker after challenges. Open, vulnerable dialogue aids conflict healing, prevents misunderstandings from festering, and fosters enduring connection.
A particularly charged area is the faked orgasm. Rubin asserts that many women fake orgasms to protect their partner’s feelings, avoid uncomfortable discussions, or uphold an illusion of satisfaction, which ultimately prevents them from experiencing and communicating true pleasure. This pattern deprives both partners of genuine intimacy. Education, curiosity, and the courage to be honest are the foundations Rubin seeks to instill in her patients.
Penis Characteristics Minimally Impact Women's Sexual Satisfaction
Rubin dismantles common male anxieties about penis size, rigidity, or duration. She states unequivocally that women’s satisfaction overwhelmingly depends on clitoral stimulation, emotional connection, mental engagement, and individualized understanding—not male anatomy. Obsessing over penile attributes diverts attention from what women actually need to feel pleasure.
To truly enhance sexual satisfaction, men should invest in learning their partner’s unique anatomy and preferences, asking about levels of arousal, sensitivity, and desired types of touch. A universal solution or formula does not exist. Recognizing and exploring the vast variability among women’s sexual responses—especially the prominence of clitoral stimulation—redirects the focus from penetration to the tangible sources of pleasure.
Rubin further stresses that many women require precise or indirect clitoral stimulation to orgasm, and this is both normal and healthy. Disproportionate focus on penetration leaves many women feeling broken or abnormal, when in fact the real issue is lack of education and misplaced priorities in sexual scripts.
Pornography's Impact on Sexual Expectations and Satisfaction Depends On Consumption
Bartlett and Rubin recognize the nuanced effects of pornography on sexual expectations and satisfaction. Pornography—especially mainstream content—caters largely to male desires, instilling unrealistic ideas about women’s pleasure, body types, and sexual scripts. Many men learn about sex from porn and assume women enjoy the same acts, leading to misunderstandings and mutual dissatisfaction.
Heavy solo pornography use can desensitize the reward system, leading to performance anxiety, erectile issues in partnered sex, and unrealistic standards that diminish fulfillment in real-life intimacy. Deception about porn use, rather than the use itself, is particularly corrosive, breeding betrayal and insecurity between partners.
However, Rubin points out that not all porn consumption is negative. Occasional partnered viewing, especially of female-oriented or romantic erotic content, can enhance arousal, foster connection, and broaden understanding of desires. Some couples intentionally use pornography to manage mismatched libidos or bring novelty into their relationship with clear boundaries. The emphasis, once again, is on honesty and intentionality: open discussion about porn is far more important than blanket moral judgments.
Stress, Burnout, and Lifestyle Factors Diminish Sexual Desire By Depleting [restricted term] and Arousal Resources
Modern life’s stressors—overwork, sleep deprivation, continuous digital engagement, and mental burnout—drain [restricted term] and sap sexual desire for both men and women. Rubin confirms that these lifestyle challenges are common factors in patients presenting with low libido, often overshadowing biological causes.
Optimizing sleep, reducing screen time, engaging in regular exercise, and scheduling time for intimacy are practical interventions. Rubin admits even she finds it difficult to consistently prioritize well-being amid life’s demands, highlighting how pervasively lifestyle factors undermine sexual health. Creating intentional “white space” in a packed schedule ...
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Communication, Relationships, and Lifestyle Factors in Sexual Health
Additional Materials
Counterarguments
- While open communication about sexual needs is ideal, some couples may find that nonverbal understanding or implicit compatibility works well for them, and explicit conversations are not always necessary for satisfaction.
- The emphasis on clitoral stimulation as the primary source of female pleasure may overlook the diversity of women’s sexual preferences, as some women do report satisfaction from penetration or other forms of stimulation.
- Scheduling intimacy may not work for all couples; for some, it can feel forced or reduce spontaneity, potentially diminishing desire rather than enhancing it.
- The negative effects of pornography are not universal; some individuals and couples report no adverse impact on their sexual satisfaction or expectations, and some research suggests that moderate, mindful consumption can be neutral or even positive.
- The assertion that lifestyle factors overshadow biological causes in low libido may not apply to everyone, as hormonal or medical issues can be primary for some individuals.
- Not all women experience significant body image insecurity, and s ...
Actionables
- you can set up a monthly “sexual curiosity night” with your partner where you each anonymously write down one new question or desire about intimacy, physiology, or pleasure, then take turns drawing and discussing them together in a relaxed, non-intimate setting to foster honest conversation and reduce pressure.
- a practical way to address body image and self-worth is to create a private “body appreciation journal” where you and your partner each write three things you value about your own and each other’s bodies after intimate moments, then share and discuss these lists to reinforce positive self-perception and mutual acceptance.
- you can experiment with a “responsive a ...
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