Dr. Rachel Rubin is a urologist and sex medicine specialist who is frustrated that women’s sexual health is widely neglected by medicine, leaving women without access to basic information and treatments that could dramatically improve their quality of life, relationships, and even save their lives. The conversation covers hormones, pain with sex, orgasm gaps, pelvic floor health, and the power of communication as the foundation for better sex and relationships.
The Systemic Neglect of Women’s Sexual Health
Even wealthy, well-connected women like Melinda Gates, Oprah, and Halle Berry have been failed by doctors who lack training in menopause, hormone therapy, and sexual health.
The word “clitoris” does not appear on the checklist of what an OB/GYN is required to learn in training in 2026, meaning most gynecologists have never been taught about the clitoris, vulva, sexual pain, libido, arousal, or orgasm.
Doctors often dismiss women’s hormonal concerns rather than saying “I don’t know,” partly because medical appointments are too short (around 10 minutes) for nuanced care, and partly because they were never trained in this area.
Only 1.7% of women who should be offered hormone therapy prescriptions are actually getting them, and more than 75% of people in large databases are not getting prescriptions for vaginal hormones that could prevent serious problems.
Hormones Across a Woman’s Lifespan
Testosterone is not just a “male hormone.” Women make it too, and it starts dropping precipitously in their 30s, leading to lower libido, longer time to orgasm, reduced arousal, and less engorgement of the clitoris.
Birth control pills work by shutting down the ovaries, which stops production of estrogen, progesterone, and testosterone. Coming off the pill can restore libido as the ovaries “wake back up.”
GLP-1 weight loss drugs (like Ozempic and Mounjaro) and antidepressants both have under-researched sexual side effects, with surveys suggesting around 25% of women on GLP-1s report sexual side effects.
Perimenopause can start as early as age 35 and lasts roughly 10 years before menopause (average age 52). Symptoms include sleep disruption, anxiety, brain fog, joint pain, dry eyes, burning mouth, pain with sex, UTIs, and irregular periods.
Menopause is essentially a “castration event” where estrogen drops to near zero, affecting bone health, brain, heart, and sexual health.
The Four Buckets of Hormone Therapy
Whole-body estrogen: Helps with hot flashes, night sweats, bone loss, sleep. Must be paired with progesterone if the woman has a uterus, because estrogen alone can cause the uterine lining to thicken and potentially lead to endometrial cancer.
Progesterone: Protects the uterus, helps with sleep and anxiety.
Testosterone: Helps with libido, arousal, orgasm, satisfaction, and body image. There is global consensus that it helps with libido in postmenopausal women, and data supports benefit in perimenopausal women too.
Vaginal hormones (estrogen or DHEA): Microdoses applied locally that support the vagina and bladder. They prevent UTIs by more than half, help with pain during sex, dryness, arousal, orgasm, urinary frequency, urgency, and leakage. They are safe at any age, including for women who have had cancer, blood clots, or stroke.
Vaginal Hormones in Practice
Available as a cream (as low as $14 on Mark Cuban’s pharmacy, lasting about 2.5 months), a tablet insert, a ring that stays in for 3 months, or DHEA (Intrarosa) which converts to both estrogen and testosterone locally.
Used twice a week, rubbed into the walls of the vagina like sunscreen on skin.
Research since the 1990s has shown these prevent UTIs by more than half, yet most women and doctors do not know about them.
Cranberry juice and “pee after sex” advice are largely folklore; vaginal hormones are the data-driven solution.
Pain During Sex
Up to 75% of women will experience painful sex at some point; 10-20% of US women have persistent chronic pain during sex; in menopause, estimates climb to nearly half of women.
Sex is not supposed to be painful. Causes can include hormonal changes (tissue becomes thin and fragile like a sunburn), skin conditions, pelvic floor muscle tightness, nerve problems (such as sciatica causing pelvic pain), scar tissue from endometriosis, or other structural issues.
Women should see a specialized gynecologist or urologist with an active interest in pelvic pain and may need multiple opinions.
The Orgasm Gap and the Clitoris
Women orgasm significantly less than men. The majority of the problem is education: most women think orgasm comes from penetration, but the clitoris is how most women orgasm.
The clitoris is a large internal structure (the visible tip is just the “tip of the iceberg”) made of the same tissue as the penis. It extends all the way to the buttocks bones.
About 23% of women have a clitoral adhesion, where the hood sticks to the head of the clitoris, preventing full stimulation. A simple in-office procedure to remove adhesions improved orgasm, arousal, and satisfaction by up to 60-70%.
No doctor has ever examined the clitoris of most women, and no one asks about orgasm or satisfaction during routine visits.
If a woman orgasms “like clockwork” within 5.5 minutes of penetration every time, there is a high chance it is not real, since most women need well over 13-15 minutes and clitoral stimulation to orgasm.
Spontaneous vs. Responsive Desire
About 70% of men have spontaneous arousal (they can think themselves into being aroused), while only 10-15% of women do.
About 40-50% of women have responsive desire, meaning they become aroused once foreplay or sexual activity has already started, compared to 10-15% of men.
This mismatch is a major source of misunderstanding in heterosexual relationships.
Pelvic Floor Health
The pelvic floor is a group of thick muscles that support the organs and genitals. Healthy muscles are required for engorgement, penetration, and orgasm (which is a series of muscle contractions).
If the muscles are too tight, sex can be painful, orgasm can be weak or impossible, and arousal and lubrication can be diminished.
Pelvic floor physical therapists can help with coordination and treatment. Kegel exercises are one tool, but many women actually need to learn to relax rather than strengthen.
Pornography and Its Effects
Roughly 65% of Pornhub traffic is men, meaning porn is largely designed for male arousal, not female pleasure.
This shapes young men’s expectations about what sex looks like and what women enjoy, often creating a false template that makes real partners feel broken.
Porn itself is not inherently bad, but heavy solo use, deception about use, and desensitization of the brain’s reward system can damage relationship satisfaction and create performance anxiety.
Women who watch porn together with partners or consume content like “Heated Rivalry” (an HBO show popular with heterosexual women) can find it enhances arousal and connection.
Communication as the Foundation
The host shares a personal story: a former partner told him she did not enjoy sex, and he assumed it was his fault. It turned out to be a physiological issue that could have been treated. Neither of them had the education or communication skills to address it at the time.
Many women hide pain from their partners; many men hide insecurities and erectile dysfunction. Both are driven by shame and lack of education.
Key questions couples should ask each other: What does great sex mean to you? What do you want? What do you enjoy about sex? What arouses you?
Scheduling sex (like quarterly date days) can be a practical tool for busy couples, countering the myth that sex must always be spontaneous.
Understanding that “there is no bad guy” in most sexual conflicts, reframing problems as “us against the problem” rather than “me against you,” removes shame and blame and opens the door to resolution.
Bringing partners into medical appointments can be transformative: when a partner sees that touching the vulva with a Q-tip causes pain “like a sunburn,” it reframes the issue from “my partner doesn’t want me” to “my partner needs medical help.”
Practical Takeaways
Women should be taught their anatomy (labia majora, labia minora, clitoris, urethra) and how their hormones work so they can advocate for themselves.
Vaginal hormones are a safe, cheap, underused tool for preventing UTIs, reducing pain with sex, and improving arousal and orgasm at any age.
Hormone therapy decisions should be individualized based on symptoms, not a one-size-fits-all rule about when to start.
The most important factor in great sex is communication: curiosity about your partner, vulnerability in sharing your own needs, and the willingness to have uncomfortable conversations outside the bedroom.
