Males & females have similar anatomy + physiology when it comes to libido, arousal, and orgasm—but they can differ in likes and experiences. To improve sexual health, couples should communicate about these. Learn also how hormonal, medication, education, and technological methods can help both younger and older people.
Rachel Rubin, M.D. Practicing Clinical Urologist and Sexual Medicine Specialist in the Washington DC area; Assistant Clinical Professor of Urology at Georgetown University. Clinician, researcher, and educator.
During This Episode We Discuss:
- Information on female sexual health that is useful for both males found in the episode description and females to know.
- Conversation and communication about sex in couples, of any gender or orientation, helps each partner to have rewarding sex.
- We don’t learn much about how to talk about or have sex in our educational system, despite sex being a key part of our anatomy, physiology and adult lives.
- Libido, arousal, orgasm and pain are the main sexual health issues for males, females & all genders. There are many causes (including antidepressants or other medications for example), but the good news is that there are ways to help each of these issues.
- The orgasm gender gap: Heterosexual men are orgasming at higher frequencies than heterosexual females. The average time for a male orgasm is five and a half minutes. The average time for a female orgasm is 13 minutes with a partner, or 5.5 minutes solo.
- Solutions to improve sexual function and experience for individuals and couples include biological (hormone), medication, educational, therapy and technological methods, with many new and some game changing (e.g.vaginal creams).
- Loss of estrogen with menopause can change the sexual experience for females, but “There is no age at which sexual health stops being important,” says Dr. Rubin. There are approved meds for boosting libido in women (dopamine based), and safe vaginal creams that restore estrogen and other hormones to reduce dryness and pain. The creams also reduce urinary tract issues such as urgency, frequency, infections.
- The focus in this episode is on heterosexual sexual health. Many issues will be the same for LGBTQIA sexual health.
— “We’re talking about what happens when two people are not meeting at the same level of sexual desire, or health or accomplishment, and what can we do.”
— “Sexual health is just health. Genitals are just anatomy and physiology.”
— “There is no age at which sexual health stops being important.”
- To find sexual health information or a sexual medicine doctor:
- International Society for the Study of Women’s Sexual Health (ISSWSH)
- The North American Menopause Society (NAMS)
- Listen to other podcast episodes on sexual health:
- The Original Guide to Men’s Health— see podcast episodes on sexual health:
- Health by Heather Hirsch — see podcast episodes on sexual health
Dr. Pelman (00:00):
Good news. “ The Original Guide to Men’s Health” has just finished a brand new website. And you can find it online at theoriginalguidetomenshealth.com, also theoriginalguidetomenshealth.org. Our website has podcast episodes, resources links to our brand new social media accounts, which can also be found in the episode description. Whatever you do, whatever you enjoy, you need your health. Welcome to The Original Guide to Men’s Health,” a podcast designed for men of all ages to learn about and access good health. This guide shares knowledge on how to be and stay healthy; maintenance and prevention strategies; along with reviews of conditions and issues affecting wellness are explored. Please join me, your host, Dr. Richard Pelman, as I interview renowned experts who will provide you with timely, relevant, and vital information so that you can embark on a journey towards better health.
Dr. Pelman (01:18):
On this episode of “The Original Guide to Men’s Health,” we will be exploring female sexual health, what men should know, with Dr. Rachel Rubin. Dr. Rachel Rubin is a board-certified urologist and sexual medicine specialist. She’s an assistant clinical professor of urology at Georgetown University and works in private practice in the Washington DC region. She is one of only a handful of physicians fellowship-trained in male and female sexual medicine. Dr. Rubin is a clinician, researcher, and vocal educator in the field of sexual medicine. She completed her medical and undergraduate training at Tufts University; her urology training at Georgetown University, and her fellowship training under Dr. Irwin Goldstein in San Diego. In addition to being education chair for the International Society for the Study of Women’s Sexual Health, ISSWSH*, she also serves as an associate editor for the Journal of Sexual Medicine Reviews. Dr. Rachel Rubin. Welcome, Dr. Rubin.
** Journal of Sexual Medicine Reviews: https://www.journals.elsevier.com/sexual-medicine-reviews
Dr. Rubin (02:27):
Thank you so much for having me. It is just how fun and my absolute honor to be here.
Dr. Pelman (02:33):
We’re so happy that you have a moment. I understand you’ve just opened a new practice and you’re busy, but thank you for joining us. So to initiate, we’ve done some prior episodes on sexual health. We have episode 20*, which is on sexual health, particularly about erectile and ejaculatory problems. And then we do a couple of more explorations of sexual health, particularly with episodes 39 and 38. We have a website at www.theoriginalguidetomenshealth.com, where you can find all episodes to date. And in particular, you can find the episodes related to sexual health that we’re referring to. In episode 38, we covered dating, sex, and relationships in young adults. And in episode 39, we covered sexual desire and function in human sexuality part two, with Irwin and Sue Goldstein. So why are we covering this particular subject now? I really wanted to be more specific about female sexual health in particular.
Speaker 1 (03:50):
Dr. Rubin, I had listened to you present in a recent University of California-Irvine review on sexual medicine, and I really found it fascinating. I was wondering why we were exploring female sexual health in a male sexual health course. And of course, it fits perfectly. So I think I’m going to just add one more comment, and then we’ll delve into this subject. The comment was from a PBS interview on fresh air with Ari Shapiro and Dan Savage. And one of the things I was struck with, he says a lot of readers get, and what a lot of straight people sort of intuitively get is that your gay friends know a little bit more about sex than you do, and maybe are a little better at it than you are. And that’s not because we’re magic. Although we are magic, it’s something else. Gay people have to communicate about sex; straight people get to consent and stop talking about what happens next or what they want.
Dr. Pelman (04:48):
And when two people of the same sex go to bed, they get to, yes, they get to consent. And then they have to have a whole conversation about what’s going to happen. So, I think a lot of what we’re gonna be talking about here is how to have a conversation with your partner. And the last thing I’ll say is, there are many people who are very comfortable being asexual or in relationships that are asexual. And that’s perfectly fine, but we’re going to be exploring what happens when two people are not meeting at the same level of sexual desire or health or accomplishment and what we can do. So, Dr. Rubin, I’ve talked a lot. I’m going to let you start with perhaps a review of female sexual health and some data for what men should know about female sexual response and sexual health. Dr. Rubin.
Dr. Rubin (05:38):
Well, what a wonderful introduction. And it is my absolute honor to be talking with you today as such an expert, and as someone who is sort of newer in this field, right? I’ve only been out of my training for about four years, how exciting and wide-open of a field it is, sexual medicine. We have so much research that needs to be done that is not yet perfect. And how exciting that we get to watch it evolve in front of us. So I do feel like I’m a part of something much bigger than myself. And my big thing is that sexual health is just health. Sexual medicine is no different than any other type of medicine. Genitals are just anatomy and physiology. And it’s really how they drive, and how do we get them to drive with more pleasure or with more consistency. And sometimes they need an oil change every now and then, and how do we get plumbing to work together?
Dr. Rubin (06:31):
How do we get genitals to match up in a way that is satisfactory and pleasurable to all people who are engaging in these activities? And it’s not always so simple. And so I don’t know about you, but a 10 to 15-minute doctor’s visit is not really a great space to have these conversations. And sometimes it can get really lost and you are left believing that your sexual health does not matter to a medical doctor. And I really, really try to fight against that. And so these issues do take time and they do take some expertise, but there are a handful of us out there who do love talking about these types of issues. So I am very blessed in my practice. And you had Irwin and Sue Goldstein on your podcast, who are my mentors and have taught me so very much. And in my practice, I take care of all genders.
Dr. Rubin (07:16):
And it’s really an incredible opportunity to be able to help everyone, as well as to maximize everyone’s quality of life. And so when I talk about sexual health problems, they’re no different in either gender. We deal with libido issues, arousal issues, orgasm issues, and pain issues. It’s really those four buckets, and they all overlap. And they’re super messy because all sorts of medical conditions and medications and surgeries and cancer can all affect each one of those buckets. And so whether you are a man or a woman or any gender that you identify with, those are issues that can come up. And so, my job as a sexual medicine doctor is to really talk to you and listen to your story because I’ll tell you, your story is not like anybody else’s. And how can I take your story and really figure out what are the biological solutions? What are the psychosocial interventions? What is the education that I can give you that will get you to just have as much fun as humanly possible when you are alone, or with a partner or partners?
Dr. Pelman (08:20):
So let’s explore that a little bit. We’ve explored some of the male sexual responses in episode 20 on erections and ejaculatory dysfunction* and erectile dysfunction**. But I think for a lot of listeners, they’re sort of not that educated about female sexual arousal and sexual response. So, go a little bit through that area so we can then move into what happens when couples and heterosexual couples get together, or same-sex couples that aren’t satisfying each other.
*Ejaculatory dysfunction: https://denverurology.com/male-urology/sexual-health/ejaculatory-dysfunction/
Dr. Rubin (08:52):
Yes. We love to talk about how men and women are so different, right? Men love and need sex and think about it all the time, and women never do. And it’s just not true. We all live on a spectrum, and I can’t tell you how many male patients I have in heterosexual relationships who come to me because their libidos are not as high as their female partner’s, and just the opposite, right? I see it all. And so I think sexual response, in my opinion, is probably pretty similar. Again, the libido, there’s a lot of discussion about libido in women and how some women have responsive desire, where a partner initiates and then they get interested in sex, as opposed to innate desire, where they just come up with it on their own. And what the data really shows is that some women have an innate desire, and some women have responsive desire.
Dr. Rubin (09:40):
And most women have both at different times and even, you know, within different relationships. And that’s all sort of a spectrum of normal. And so if you’re bothered by it, is it a medical problem? And my answer is if I’m bothered by the wrinkles in my forehead, I can go get lots of Botox* treatments to fix that. So, if you are bothered by your sexual functioning, yes, it’s a medical problem. And yes, there are medical solutions. So, libido is definitely something we see, and sometimes you have an innate desire and sometimes you have responsive desire. And arousal for a female is really essentially erectile function. So as a penis relaxes, it grows big and gets hard, and can penetrate. And as a clitoris**, which is exactly the same as a penis, is made up of all the same tissue and embryologically comes from the same place, when it relaxes it fills with blood and it expands and engorges
Dr. Rubin (10:31):
And so the clitoris is mostly an internal organ that lives underneath the vulvar*, the labia major. And so as that tissue swells, when a woman has arousal, they feel engorgement. They feel swelling; they feel an increase in blood flow and sometimes good sensations, and that arousal can come with a good brain sensation. And so, when women experience orgasm, it is overwhelmingly due to clitoral stimulation, either from manual stimulation, oral stimulation, or vibratory, vibration, stimulation of the clitoris, which as I said, lives in the labia majora sort of area. So, it’s not typically vaginal penetration that allows the majority of women to orgasm. And I think that is a big societal misnomer out there in that most people think, “Oh, my partner should be able to orgasm from penetration.” Or, I see women coming to see me and say, “Dr. Rubin, I’m broken. I can’t orgasm from penetration.”
Dr. Rubin (11:31):
You’re not broken, more than 80% of women cannot orgasm from penetration. You are normal. And I sort of explain it to my male patients like this, “If you rub the inside of your thigh over and over again, are you gonna have an orgasm?” Probably not, right? If you really rub the inside of your thigh really hard for like 10 minutes, are you gonna orgasm? Probably not. And I say why? And they say, “Well, Dr. Rubin, it’s not my penis.” I said, “But it’s close to your penis.” And they say, “Yeah, but it’s not my actual penis.” And that’s my exact point when it comes to women. The vagina is close to the clitoris, but it is not the actual clitoris. And so most women cannot orgasm from vaginal penetration. That doesn’t mean that women don’t enjoy it and like it and want it, and it certainly helps with reproduction. But it’s really important just to understand how the plumbing works. Because when we understand how it works, we can navigate it a little bit better and make it work better.
Dr. Pelman (12:24):
So I’ll go back to my lead-in from Dan Savage. We have couples that meet each other. They’re a younger spectrum; they may not have much sexual experience. How does the female partner in that scenario tell a male partner that’s not doing it for her?
Dr. Rubin (12:42):
It’s so challenging. And I will tell you, you know, I show a slide often when I give lectures. And I think I showed it at the lecture that you saw me speak at of a male gym teacher from a movie called Mean Girls that says you, it’s basically, he’s teaching sex ed and says, “Don’t get pregnant cuz you will die,” or “Don’t have sex because you will die and get pregnant.” And again, that’s where most people get their sex education from. If they’re lucky enough to get sex education, it’s from like a male gym teacher or something. And so we don’t get the lesson of how to talk to our partners, and no one teaches us how to say, “Honey, that move you’ve been doing for 30 years, it’s not working anymore,” or, “It doesn’t feel as good,” or, “I’ve been saying I like it, but I actually don’t like that move you’ve been doing.” How do you have those conversations? And I find couples can talk about almost anything. They can talk about children’s diarrhea and constipation, and all sorts of bodily fluids. But when it comes to genitals and masturbation and orgasm, it’s not so easy. I couldn’t agree with you more that communication is really, really important, but actually one of these great universal things that most people are terrible at.
Dr. Pelman (13:48):
Yeah. I think his quote was so right that a lot of people can engage if they’re heterosexual. Whereas the same-sex couple has to have a conversation. And so the heterosexual couple just initiates intercourse. There may never be a conversation. And that’s so important for people to talk about, you know? What’s good? What do you like?
Dr. Rubin (14:09):
And it’s hard because a lot of people start having the conversation when things go wrong, right? A man’s erection starts to get weaker, or a woman starts to have pain. And they’ve never talked about it when it was going well. And so now that things are not going well, or somebody comes up with a medical condition, it becomes that much harder to talk about. And so, we don’t do a very good job of leading people through those conversations.
Dr. Pulman (14:32):
So, what do you do when say a female patient comes into you and says is anorgasmic or is delayed and it’s really disturbing the relationship. What things are looked into and what? We heard a little background that it’s not so different. Men and women, you know, we have the peripheral nerves* and stimulation and hormones involved in the central nervous system. But go through that a little bit.
Central and peripheral nerves: https://courses.lumenlearning.com/wm-biology2/chapter/the-central-and-peripheral-nervous-systems/
Dr. Rubin (14:55):
So orgasm is just a reflex, right? It’s a very good feeling reflex. Almost like a seizure, even when you have it, you know, your brain kind of stops working a little bit in a good pleasurable way, not for everybody. And there is a subset of humans who can’t orgasm or have delayed orgasm, muted orgasm, or too many orgasms. It can, all sorts of things can go haywire and go wrong. And so, my job as a urologist and sexual medicine specialist is a little bit like a sex detective, right? I put on my detective hat, and I really have to listen to the story and listen, listen, listen. Did you have an orgasm, and you lost it? Have you never had an orgasm? How do you try having orgasms? Is it just through penetration? Are there other devices at play? Is there other visual stimulation, right?
Dr. Rubin (15:41):
Really asking detailed questions and then understanding, well, what is your education around orgasm? And then really, again, a medical history. Have you had back surgery? Have you had pelvic surgery? Are you on medications that can affect your hormones? A physical exam is so important. We do not train doctors how to examine clitorises. It’s a nightmare. And so, a lot of my work is in clitoral anatomy and getting other doctors to examine the vulva systematically so that we can pick up pathology. We have a whole, Dr. Pelman, you and I have spent our entire careers in the field of male sexual organs. We are penis doctors, right? And yet the penis and the clitoris are exactly the same things. And we have no understanding of anything that can go wrong with the clitoris. Whereas we have a whole medical specialty devoted to the male penis. It’s so interesting, the barriers that we have. And so many things can go wrong with the clitoris. And so we’re doing some research on that right now because we are finding that there are some anatomical things that can happen that can delay, mute, or impair the ability to orgasm. But since nobody’s looking or asking, nobody’s finding it.
Dr. Pelman (16:55):
In our episode with the Goldsteins, we did touch on the fact that blunted sexual responses for females and males can change because of medications. And one of the common issues is antidepressants. And there are females who were probably orgasmic and didn’t have difficulties who, when they go on antidepressants, find things change. And there are some other medications as well. You wanna just touch on that?
Dr. Rubin (17:16):
Many medications can affect sexual function, whether its blood pressure medications, antidepressants, anything that affects hormones like birth control pills or acne medications, or even sometimes hair loss medications. All of them can have sexual consequences. And sometimes they’re worth the risk, and sometimes they’re not worth the risk. And that’s a big problem because if doctors who are prescribing these things don’t know the risk, they don’t even know to warn you about the risk. They’re not talking about sexual function. They’re not gonna warn you about the risk. And so, we often see people after the fact, unfortunately. And so yes, those are very common things that can happen.
Dr. Pelman (17:53):
And then we do have some newer medications on the market that can help. So, if somebody needs the antidepressant, just a little enlightenment, as far as what they should be going to the doctor about.
Dr. Rubin (18:03):
Yeah. There are some great things that are out there right now. I have really a lot of hope for the future, but I’m usually a very pessimistic person. So, we all know that antidepressants can cause sexual problems. And so can there be medications that can boost sexual function and kind of promote dopamine in your brain and get you more interested? And there are two FDA-approved medications that do just that. These are two medications that are approved for low libido in premenopausal* women. Though we do have data that they work great in postmenopausal women, and even there’s some research being done that they work in men. And the way these medicines work, they work on your brain similar to how medicine for depression might work on the brain, but it works in that opposite way to boost dopamine** and to get it to improve sexual response.
Dr. Rubin (18:47):
And like any medicine on your brain, you know, not everyone responds to Prozac* the same way. They work in about 50 to 60% of people who take them. And when they work, what’s so cool about it is that it boosts libido, but it also shows improvements in orgasm, arousal, lubrication, and satisfaction. And so, the first one to the market was called Addyi**, A-D-D-Y-I, Addyi. And it’s a pill you take every night at bedtime. And the cool side effect of this drug is it’s a nice sleep aid. And so my patients get a really good night’s sleep and wake up well-rested. So I can often get patients off melatonin or Ambien,*** or, you know, whatever they’re taking for sleep. And when it works, again in that 50 to 60%, it is really, really beneficial. It’s called Addyi, A-D-D-Y-I, the doctor’s name is flibanserin. And so, it can be a really great medication to sort of counteracting some of those side effects of antidepressants.
*Prozac (Fluoxetine): https://medlineplus.gov/druginfo/meds/a689006.html
**Addyi (Flibanserin): https://addyi.com/
***Ambien (Zolpidem): https://medlineplus.gov/druginfo/meds/a693025.html
Dr. Rubin (19:42):
The other FDA-approved option is called Vyleesi*, or bremelanotide, and that is a subcu** auto-injector. So it’s a little injection that you give yourself sort of an hour before you wanna hit dopamine. An hour before you want to want and get excited about sex. And so, it’s a little more on-demand, as opposed to the Addyi, which is kind of always in your system and kind of more brings you back to that baseline of sexual thoughts. And so both are great options. Not each one works for every person. So, it’s very cool that I have more tools in my toolbox now as a sexual medicine specialist for all genders.
**Subcu (Subcutaneous): https://medlineplus.gov/ency/article/002297.htm
Dr. Pelman (20:18):
And the second medicine again is?
Dr. Rubin (20:22):
Vyleesi. The other name is bremelanotide.
Dr. Pelman (20:24):
So it’s a V, as in victory?
Dr. Rubin (20:26):
V. V as in victory.
Dr. Pelman (20:28):
Great. So these options occur. What happens when, you know, there’s a differential. The average time for male orgasm is?
Dr. Rubin (20:37):
Five and a half minutes.
Dr. Pelman (20:39):
And the average time for female orgasm?
Dr. Rubin (20:42):
Well, remember I said most don’t orgasm from penetration ever. Ever. But most with a partner, the data seems to show that it’s around 13 minutes. This is interesting data. I’ve seen data to show that a woman by herself, also five and a half minutes, just like a man. She can do it pretty quickly. Soon as you get a partner in there, it bumps up to like 13 minutes because you got, you’re all distracting. And it’s hard to concentrate on your orgasm when there’s a partner around. And so we do have an orgasm gap in the country that heterosexual men are orgasming with a much higher frequency than heterosexual women.
Dr. Pelman (21:14):
So, one of the most important things in a visit would be to bring the partner?
Dr. Rubin (21:19):
It can be incredibly helpful. I mean, education on just the basics of how your body functions is so important. I had a patient recently; this was so magical. I had a patient recently who I see for sexual pain. And her partner, I’ve been working with her for several years. And finally, her partner came in and watched me do an exam. And he saw how it wasn’t painful everywhere. That there was just one piece of her body that had pain, and why it has pain. And we talked about it, and he looked at, he sat, sort of stood behind me as was doing the exam. And I was talking through the exam and he said, “Holy shit Dr. Ruben. Why didn’t I come three years ago? I mean, I just learned so much.” You know, it’s not about me and our relationship. The tissue, it hurt, it hurts to the touch. And I can see with my eyeballs where this problem is, and it was so transformative for their relationship to be able to talk about the issues.
Dr. Pelman (22:09):
So, flashing on a one-man show that I saw years ago called Defending the Caveman*. It was, I think, Becker was the author and initial actor. I remember him talking about the fact that women have multiple erogenous zones and pleasure zones, and that his wife was approaching by rubbing his back and saying, “Isn’t that great?” And he was thinking, “Well, yeah, but you’re still two feet away.” So there are different approaches here, and it was very comical. But there’s some truth. And so both people in the relationship really do need to communicate about what is good, what’s useful. What other options do you give besides medication for males who may be climatic in a more rapid sense than the female partner? Besides trying to extend orgasm for the male, there are some solutions. So, you can talk a little about that.
*Defending the Caveman: https://en.wikipedia.org/wiki/Defending_the_Caveman
Dr. Rubin (23:03):
We do have solutions to try to make men “last longer.” Nothing wrong with wanting to prolong sexual pleasure, right? There’s nothing wrong with that. I think it’s really understanding what gives each of you pleasure and is their pleasure. I think the word foreplay should be stricken from vernacular. We should no longer use the word foreplay. It should all be sex, right? This idea that you can have great sex without penetration should be talked about. If you can both orgasm and roll around in the sheets and you know, and have a good time, you should see that as a positive sexual experience, as opposed to, oh my gosh, I didn’t penetrate my partner. I’m an absolute failure. So some of it is just getting our minds around what is sex, right? Why is sex solely based on a man’s penetrative experience? It shouldn’t be.
Dr. Rubin (23:49):
And so, I think the idea that a female partner might orgasm before her male partner, and I know we’re speaking very heterosexually. And so the answer is it can look so many kinds of ways. Sex can be long. It can be short. It can be multiple times. It can be one time. It can be once a month. It could be once a year. But if it is pleasurable to you and it’s enough for you, then it’s a success. It’s a win. And I think this idea that it has to look a certain way for society to be okay with it makes no sense because nobody’s in the bedroom with you, except your partner. Your clergy is not in the bedroom with you, God willing, unless you are clergy, and then it’s your own bedroom. Your middle school gym teacher who taught you sex ed isn’t in the bedroom with you. The porn stars are not in the bedroom with you unless you’re choosing to watch them, right? Like this idea that we think we’re supposed to behave a certain way. Nobody’s watching. Just enjoy yourself.
Dr. Pelman (24:41):
You know, introducing toys and simulators. I mean, how do you make suggestions sometimes that that’s useful?
Dr. Rubin (24:48):
I love that question because I love devices and sex technology. All of our lives are so much better because of tech, and worse because of technology. But how cool you are on the west coast right now, and I’m on the east coast right now. And we’re able to provide education to people because of technology. I can order my groceries with a click of a button on my phone if I want to. There are so many things that make our lives better due to technology. Sex is no different. And so, if you need a prosthetic leg, you’re gonna, or a motorized wheelchair to get around to improve your quality of life, you’re gonna do those things. And it’s wonderful, right? Similar, if you have delayed orgasm, and if we add vibration to make your orgasm happen more powerfully and more enjoyably, let’s use some vibration. And the technology out there, and even what’s coming out in the future, is so exciting. And there are so many wonderful devices out there for couples; for men who have sex with men who; for women who have sex with women; for women alone; for men alone; prostate stimulation; vaginal stimulation; clitoral stimulation; nipple stimulation. I think why not add more fun tools to your sexual toolbox.
Dr. Pelman (25:59):
As you say, technology is improving. So, for males who have some difficulty maintaining erections, there are congestion rings. But some of the congestion rings actually come with some vibratory sense that buts the clitoris that can help satisfy both partners’ needs. And I also looked at the consumer electronics show. I think it was 2019 when they gave an award to a female stimulation device, and then realized what it was, took it back, and then gave it back when they finally awoke to the fact that we’re modern and that this is part of life. And I think that company was Osé, O-S-E, and there’s a newer group out there, satisfyer.com. I think that’s where now incorporating smartphone technology into female stimulation. So you can dial up what you need. So there are all kinds of solutions. People shouldn’t just give up.
Dr. Rubin (26:50):
People should not give up. And most importantly, your sexual health matters. Whether you have extra weight on you; whether you don’t like the way you look; whether you’re in a wheelchair; whether you have had cancer; your sexual health matters. And if it is important to you, let’s figure out how to maximize the pleasure and the quality.
Dr. Pelman (27:12):
So, you know, we spoke about a younger couple. How does the young guy who visions that, you know, everything he does is all she needs and she approaches him with, “Well, actually.”? How do you advise them to go about that discussion?
Dr. Rubin (27:28):
Very interestingly, I have an anecdote. I went back to my old high school last week and I got to teach, give a booster sex-ed class to the seniors who were about to graduate. They graduate early where I used to go to high school. And I gave them all my cell phone numbers at the beginning of the talk. And I said, text me questions. A girl texted me anonymously and said, “Can you please teach the boys where the clitoris is, but like, actually teach them. Why are they so bad at giving oral sex?” And I read this out loud to the whole group. And I said, “Well, that’s a very good question. Did you get that class in middle school about how to do oral sex and how to properly give oral sex?” No, none of us got that class, right? How is this senior in high school boy supposed to know how to properly give oral sex to his senior girl partner when no one ever taught him how? Good for him for attempting to give her pleasure, but we have to learn and find ways, you know, to be able to navigate and talk to each other and find out. If you don’t know your own buttons, how are they supposed to know what buttons to push?
Dr. Rubin (28:27):
And so it really becomes education and self-exploration and the ability to use words, use real adult words, and talk about it.
Dr. Pelman (28:35):
Yeah, especially when your high school did have a class. Many high schools don’t anymore, and resources seem to be disappearing from certain library shelves so.
Dr. Rubin (28:45):
So where do people learn? They learn from pornography, which is it’s like learning how to exercise watching the WWF, right? Like it’s all fake.
Dr. Pelman (28:54):
Yeah. You know, we did cover a bit about pornography with episode 39 from a professor at the U who teaches sexual education class. It’s been going on for years. And she’s the third generation of a professor who has a wonderful episode. And, you know, she feels porn is okay as long as people realize that they’re well-paid actors. So, if we go back to kind of looking at than a couple, you kind of mentioned that they’ve been together, everything was okay, and now things change. So we moved from the spectrum of youth to age, and things change in the female body with age. So, talk a little bit about the effects for listeners on menopause and its effect on sex.
*The U: University of Washington
Dr. Rubin (29:40):
Yeah. You know, as you age, you know, the day you stop looking is the day you die. But some people, there’s their brains and their sexual interest does not wane, right? I saw a patient this week that I see both partners in the relationships. He’s in his late eighties and his partner, and she’s in her late seventies. And I see them every year or so, or every six months. And every time he is getting older, he keeps telling me, he says, “Geez, doc,” every time he says to me, “Dr. Rubin, I love my wife more than ever before. I am so attracted to her. I love being with her. I love caressing her. I love holding her. And I love having sex with her.” His erections are not perfect. They can’t do penetration. And he is okay with that. And he thinks of the sex that they do have as phenomenal and wonderful.
Dr. Rubin (30:23):
And he loves his sex life. And for her, right, she has changed from menopause and may have some dryness and delayed orgasm and things like that. And so they’ve added some devices, and they’ve added some vaginal hormones to help with lubrication and orgasm. And so we tinker, and we kind of work with each of them to say, “What can we do to maximize, you know, the quality of your sexual health together?” And it’s been really fun to watch because there’s no age with which sexual health for some people stops being important. If you’re not bothered, if you’re not having sex and you’re not bothered by it, you don’t have a problem. It’s okay. No one ever died because they didn’t have an orgasm. But if it bothers you and then it’s an important part of your life then yeah, come see someone who really cares about this stuff.
Dr. Pelman (31:06):
So, you know, part of menopause* is the change in tissue is a loss of estrogen**. So that is a physical change. But there’s also a change in libido as estrogen dissipates because some of that estrogen changes to some testosterone, and that’s what drove libido. So, what happens when a guy’s still interested, but his menopausal wife, who decides not to go on estrogen is not getting the systemic total body benefit of estrogen, libido starts going? What do you advise?
Dr. Rubin (31:39):
Yeah. We have lots of biopsychosocial options. So, sex therapy is always a good option. Nobody doesn’t benefit from sex therapy, right? Everyone can get better talking about sex. And we do have medical options. So, they range from hormonal and non-hormonal. So, you can use testosterone in women. So maybe if she’s not on estrogen therapy, you could use estrogen therapy. It works great. And is typically very safe to do. If you’re before age 60, within 10 years of menopause on a case-by-case basis, we’ll do it after that fact and would typically use more, not pills, but typically more like patches and transdermal* or through the skin products. So there are some patients who benefit from that. Testosterone is an option. You can use testosterone therapy for your whole body. And that has lots of data to show benefit in women’s sexual health, especially libido. But we don’t have an FDA-approved testosterone option for women in the United States.
*Transdermal estrogen patch: https://medlineplus.gov/druginfo/meds/a605042.html
Dr. Rubin (32:31):
It’s approved in Australia. So it’s good enough for the Australians, but there’s a lot of politics that do not allow us to have it in America. So we typically, at least in my practice, use male-approved testosterone in female doses, which is about 1/10th of the dose. And then there are non-hormonal options. Like the ones we talked about earlier that are typically approved for pre-menopausal women, but they work great in postmenopausal women. So, ways to that Addyi and Vyleesi to boost dopamine in people’s brains. I don’t know of a single antidepressant that is approved for premenopausal women, but not postmenopausal women. So there’s really no reason that these medications don’t work great, and they do clinically. They do work great.
Dr. Pelman (33:10):
And some of the changes also come, as I said, physically in females. Milu in the vagina, there is a change without estrogen. So if somebody elects not to go on systemic estrogen or is not safe for them, there’s still local estrogen that can help revive the tissue.
Dr. Rubin (33:27):
Local hormones, either vaginal estrogen or vaginal DHEA*, which is also available in America, are universally beneficial for every human over 45 and should be used until death do they part. If you are 98 and not sexually active, vaginal hormones are so beneficial for urinary frequency, urinary urgency, and to prevent urinary tract infections, which can kill you right? And that’s really important. And so, we actually, I spend a lot of time teaching and talking about the importance of local vaginal hormones for this condition not as a sexual medicine doctor, but as a urologist who wants to decrease urinary tract infections in this world.
Dr. Pelman (34:06):
Yeah. There’s a lot of benefit to maintaining that Milu that comes from local estrogen. And so of course, a lot of patients who have experienced breast cancer are concerned about any estrogen. Can you speak to that a little?
Dr. Rubin (34:21):
Yeah. Thank you for asking. There is no data. There is not a single piece of data to show any harm of vaginal estrogen. In fact, we have data that shows no breast cancer progression, no breast cancer recurrence, no increased risk of blood clots. There’s no data to show harm or risk. It’s just that the word estrogen scares people. And I can’t make it not scare people other than to present them with the data that shows it’s not scary. And that all hormones are not the same. So, an oral medication that you take by mouth, that’s like a birth control pill, goes through your whole body is going to have very, very different side effects and risks than a very small tablet or cream that you put locally in your vagina that doesn’t go your bloodstream. And so, I spend a lot of time and it really does take time, just counseling women on what is the true data? What do we know? What don’t we know? Let’s talk with your oncologist and let’s look and show, you know. And we need more studies, which hopefully one day will be done, and some are being done. But again, it’s really hard to undo the fear that media has built up over something that has no data to show harm.
Dr. Pelman (35:26):
You know, there is so much news out there. Say a woman has a BRCA gene,* and she’s done some genetic testing and says, “Oh, I’m at risk for breast cancer. I don’t wanna hear the word estrogen.” A local vaginal estrogen does not promote breast cancer. Correct?
Dr. Rubin (35:41):
So the very interesting thing about this is how wrong they got the data in the first place. There’s an amazing podcast called Women’s Health* by Heather Hirsch. And one of her most recent episodes has the physician who wrote the oncologist who wrote the book, Estrogen Matters.** It’s a must-read book and his podcast with her, Avrum Bluming I believe his name is. And it was incredible, again, to show what a cancer doctor has to say about estrogen. The study that Women’s Health Initiative that made all the headlines, that study that came out that said estrogen was dangerous, when women in that study were on estrogen alone, they had a decreased risk of getting breast cancer and a decreased risk of dying from breast cancer. Estrogen was always protective against breast cancer. And yet the media somehow made that data look to say estrogen causes cancer, which was never what the data said. And so we got it wrong. And I don’t know about you, but look at what of the messes of getting the messaging wrong. You know, COVID has everyone doing every which way? Every which thing, because the messaging is not unified and is not correct. And we have a really hard time. Once people get it in their brain of yes or no good or bad to change their minds. And so it’s a nightmare. It’s such a mess right now and it’s been decades and it is N mess.
* Women’s Health by Heather Hirsch podcast
Dr. Pelman (37:00):
So, what was the name of that podcast that you were just referred to?
Dr. Rubin (37:04):
It’s called Women’s Health by Heather Hirsch. It’s a brilliant podcast all about menopause. She’s Harvard’s menopause doctor and a very good friend. And her recent episode with Avrum Bluming, he wrote the book, Estrogen Matters.
Dr. Pelman (37:19):
If you looked at actual estrogen, locally. We’re not talking about taking it orally or injections or patches. We’re talking about it just vaginally placed. That is very, very, very, very safe,
Dr. Rubin (37:33):
Very, very, very, very safe. I’ll add an extra very.
Dr. Pelman (37:36):
And how do you compare that to some quasi estrogen or synthetic estrogen patches like Vagifem,* that other estrogen substitutes, I guess?
Dr. Rubin (37:48):
Vagifem is a bio-identical estradiol tablet. So Vagifem is fabulous. Estradiol creams are fabulous. DHEA inserts are wonderful. There is a synthetic form called Premarin*, which works great. It works fine. Again is safe, but has some, you know, the way they make it with horse urine and there’s some politics behind if you agree with that or not. And creams are not always my favorite because patients don’t always like them. But of all the FDA-approved options, the local options work. And we just have to find one that is affordable and that you will actually use because if it sits in your bathroom drawer, unopened, it will not work. It actually definitely won’t work. And like wearing a seatbelt or brushing your teeth, you don’t get to say, “Well, I’ve done this for a month. I can stop now.” Right? You have to keep doing it forever and ever because your body’s never gonna make estrogen again. And that tissue and your bladder, your urethra, your vagina, your vulva need hormones in order to function well.
Dr. Pelman (38:45):
You mentioned the economics of local vaginal replacement, and it can be costly. And do you have any solutions for patients?
Dr. Rubin (38:54):
Have a huge solution and it just happened about two weeks ago. This big entrepreneur down in Texas, Mark Cuban, you might have heard of him, started his own online pharmacy* and he’s trying to take very expensive drugs and make them affordable. And you can have your doctor type in Mark Cuban into their pharmacy list, and it will pop up a vaginal androgen, estradiol, 10 microgram tablets. You use one every day for two weeks, and then twice a week till death do you part is about $10 a month. I’m talking game-changing. If you like vaginal creams, a tube is only $50, whereas before it was $450. And that tube will last you about two months or more. And so holy macro it’s been the best two weeks of my life because it used to be that women could not always afford these products and that insurance would not always cover these products, which we got a lot of work to do. But now there has been a game-changing situation just in the last couple of weeks.
*Mark Cuban Cost Plus Drugs Company: https://costplusdrugs.com/
Dr. Pelman (39:53):
Well, we always like to ask, is there anything else you’d like to contribute and then look towards some resources that you would recommend for listeners? So any other things that we didn’t cover that you would like to add in?
Dr. Rubin (40:05):
I think you did a really fabulous job, and it’s been such a wonderful opportunity to get to speak with you. And I think even more important that partners talk to each other, and really listen to each other’s type of medicine. Because you know, it used to be the girls in one room and the boys in another room, and girls got to hear about periods. Boys need to hear about periods, and boys need to hear about dry vaginas and menopause. And because it matters to them, their pleasure depends on it too sometimes. And so it’s really important that we all know about each other and advocate for each other, which is really, really important. So in terms of resources, if you wanna find a doctor who understands women’s sexual health, I strongly recommend for the menopause age group go to the North American Menopause Society, or NAMS*. They have a find a provider on their website. And for all ages, the Women’s Sexual Health Society or ISSWSH.org, ISSWSH.org. That again is I-S-S-W-S-H, isswish.org, also has a wonderful find a provider resource where you can find a doctor who gives a crap about all this stuff because it’s really, really, really important. And just thank you so much for having me on.
Dr. Pelman (41:19):
This is terrific, and it’s so enlightening and so important. And unfortunately, it’s getting swept under the table in certain areas, and youth aren’t getting exposed. And so I think there’s still like you said, a lot of work to do. But it’s nice to know that there are people that people can go to. Appreciate your time, thank you.
Dr. Pelman (41:38):
My pleasure. Thank you for having me.
Dr. Pelman (41:41):
This completes another episode of The Original Guide to Men’s Health podcast. We wish to thank all guests who volunteered their time and knowledge. The information presented is the opinion of the speakers. The show’s recordings are engineered and edited by Sean Fox. Episode titles and descriptions as well as editing assistance, are provided by Dr. Kathleen O’Connor, Ph.D. Music for our show is San Juan Bells written and performed by Dr. David Whiting. The podcast is sponsored and published by the Washington State Urology Society. The Original Guide to Men’s Health is an original publication of the Washington State Urology Society. Reproduction and use without the expressed or written consent of the Society are prohibited. For more information about men’s health and previous episodes, as well as additional recommended resources, visit us online at theoriginalguidetomenshealth.com. This is Dr. Richard Pelman, Thank you for listening and reminding me to take care of yourself.