Dr. Rachel Rubin: You rub it inside the walls of the vagina, like that. rub it in like you would rub sunscreen on your face. And if you do that twice a week, it makes sex not painful and dry. It helps with arousal and orgasm. It's literally better than Viagra. And it's cheap. And I'm telling you all this as a urologist that this cream can also help prevent death from urinary tract infections. But more than 75% of people in large database collections are not getting prescriptions for this. And so women are not getting access to generic medications that could save their lives and also really improve quality of life. And so I am filled with rage because people are limiting their ability to have great sex, great health because they aren't having access to all the information that they could. For example, women are not orgasming as much as men. The data is very clear there. And women come to see me all the time as I'm a sex doctor. And they say, "I'm broken and you have to fix me. I'm not orgasming during sex." And I think the majority of problem is education. Women think that orgasm comes from penetration. But the clitoris is how most women orgasm. And yet most women do not know where their clitoris is. And in fact, the word clitoris today in 2026 does not exist in the checklist for what an OBGYN has to learn in their training.

Host: And as men, what are we getting wrong in heterosexual relationships when we're trying to arouse our partners?

Dr. Rachel Rubin: Well, men are constantly asking about they want their penises bigger, harder, straighter, girthier, lasting longer. But none of that has anything to do with how women experience pleasure [music] and satisfaction in the bedroom. So that's why I'm so loud about these things because no one is getting good sex ed. Because the basic information is not being shared. And we fundamentally don't give a crap about women's sexual health, about their menstrual cycles, pregnancy, menopause, hormones, pain with sex, libido. [music] But we actually do have a lot of information that we are not using because everyone forgot to teach your doctor.

Host: And I want to focus today's conversation on women's health cuz I have so many questions and curiosities.

Dr. Rachel Rubin: Right.

Host: So let's start with the subject of hormones.

Dr. Rachel Rubin: This is going to be so [ __ ] good.

Host: This is super interesting to me. My team gave me this report to show me how many of you that watch this show subscribe, and some of you have told us, according to this, that you are unsubscribed from the channel randomly. So, favor to ask all of you, please could you check right now if you've hit the subscribe button if you are regular viewer of the show and you like what we do here. We're approaching quite a significant landmark on this show in terms of a subscriber number. So, if there was one simple, free thing that you could do to help us, my team, everyone here, to keep this show free, to keep it improving year over year and week over week, it is just to hit that subscribe button and to double-check if you've hit it. Only thing I'll ever ask of you. Do we have a deal? If you do it, I'll tell you what I'll do. I'll make sure every single week, every single month, we fight harder and harder and harder to bring you the guests and conversations that you want to hear. I stayed true to that promise since the very beginning of The Diary of a CEO, and I will not let you down. Please help us. Really appreciate it. Let's get on with the show.

[music]

Dr. Rachel Rubin. Before we started recording, you said a line to me, which I found to be very interesting. You said, "I'm filled with rage." Why are you filled with rage?

Dr. Rachel Rubin: I am filled with rage because I do think that people are limiting their ability to have great sex, great relationships, and great health because they aren't having access to all the information that they could, and they're going to see doctors who actually don't know how to help them with these problems.

Host: And on the subject of women's health, sexual health, hormones, etc., can you give me the background context of the disservice that's been done? I remember you you were talking previously about how even the most affluent women in the world are being let down.

Dr. Rachel Rubin: Yeah, I think this is the great equalizer in the fact that no one is getting good medical care here when it comes to hormone therapy, menopause, and sexual health. Melinda Gates just came out and said she had to see three doctors before she got proper hormone therapy prescriptions. Oprah had to see five doctors and still they didn't understand that her heart palpitations was from perimenopause and menopause. How about Halle Berry, right, who has access to all the doctors in the world and she publicly came out and said she was diagnosed with genital herpes when she really just had the genitourinary syndrome of menopause. The rich people are not getting good information about their bodies, about their hormonal health, about their sexual health. So, what are the rest of us doing? We don't teach it in medical schools, we don't teach it in residencies. I didn't learn anything about it and so we are actually getting worse at this, not better at this. And so I'm full of rage because we actually do have a lot of data and we do have a lot of information that we are not using because everyone forgot to teach your doctor.

Host: It's staggering to me that, you know, those very affluent women that you've mentioned still are being let down by a medical system. Um, it also sort of begs the question that if men were in that situation, this probably wouldn't be the case. And that's says something about the research and the investment that's gone into understanding women's health relative to men's health.

Dr. Rachel Rubin: It's a huge problem. We don't have enough specialties of medicine that focus on women's health and we don't have enough like manpower behind us. We can throw money at the situation, but you need physical human beings to roll up their sleeves and do this work. Like doing research is challenging and you need people to actually disseminate the research and talk about the research and you need the training to happen so it has to trickle down. So, just because someone wrote a paper doesn't mean it automatically gets downloaded into every doctor's brains. So, someone has to teach someone how to do something. So, I I lecture all the time. I do a lot of trying to teach clinicians how to do this. I travel all over to say, "Here's how to write prescriptions." because that's what it's going to take. There was so much fear and misinformation 20 years ago about hormone therapy that it is a lost art. Doctors don't know how to write the prescriptions. Nobody taught them how. So, even if they see headlines and Melinda Gates giving $10 million to the Menopause Society, that's wonderful, but it doesn't translate into them knowing how to actually write the prescription, knowing the difference between the type of hormones, knowing the safety, the risk, the benefits, because they never had the class. For example, I'm a urologist. If someone comes in to me asking about their blood pressure, I'm not going to pretend like I know everything about their blood pressure. I'm going to be very honest that I have the limitations in my training. But, for some reason with hormone therapy and women's health, every doctor you go see has strong opinions and will tell women what they can and cannot have with their bodies even when they don't know the data. I come from the men's health world. We don't tell men you can't have this. You can't do this. We we talk about shared decision-making. We talk about risks. We talk about benefits. For some reason we don't do that enough in women's health.

Host: Why?

Dr. Rachel Rubin: I think part of it I don't think your doctor is evil. I actually have a thought about this. So, I think your doctor wasn't trained. I think they're trying to save face. And I think 10 minutes is impossible to give good medical care. I could never get to know you fully in 10 minutes and really give you great advice on your life that's customized for you. It's almost like the difference between a viral clip that you're going to try to do from this episode and the long-form nuanced conversation that you're going to have. You love the nuanced conversation. You love spending those those 2 hours. And I

Doctor: I think patients want that, too. But, when they go to the doctor, they're getting the 10-minute version. And instead of doctors saying I don't know, they're sort of saying no no you can't have this cuz it's easier than sort of going into that nuance, which can take time. I also think that people are going to their doctor, say you want to talk about your orgasm or your libido. Okay? You go to your gynecologist. Of course, my gynecologist should know everything there is to know about the clitoris, about orgasm, about hormones, about That's what they do. And the truth is it's not what they do. And it's they were never taught that. The word clitoris today in 2026 does not exist in the checklist for what an OB/GYN has to learn in their training. The word doesn't exist.

Host: What is an OB/GYN for anyone that doesn't know?

Doctor: An OB/GYN is a doctor who specializes in obstetrics, so delivering babies, and gynecology. So, your gynecologist has never been taught about the clitoris, about the vulva, about sexual health, about sexual pain, about libido, arousal, and orgasm. And so, the ones who have taken it on their themselves to get extra training, they're very few and far between. And so, every day women, and men too, are going to a doctor expecting answers on a topic that their doctor probably has never gotten training on.

Host: And I do want to focus today's conversation on women's health. And I want to preface all of this by saying that I'm going to be as dumb as I am on this subject. If you say something about the vagina and I don't know what it means, I'm not going to pretend to know. I'm going to ask you what it means. And I say that because I sometimes think with these conversations the host often is too shy to admit their ignorance. And I have lots of ignorance on this. But I also have lots of curiosity, and I want to fill those gaps. And that's going to require me to be very, very dumb. And also, my second reason why is because I have so many women in my life. If you just look at my company, my entire executive team in my company are all women. And also, I've got my fiance, my mom, my sister. And understanding the women in my life, one element of understanding them is understanding their health. Women's health isn't something that I was ever taught in school. It's not like a lesson I had. So, I also think this conversation is for men. Every man has four important women in their lives. So, my question to you is if a woman has clicked on this conversation right now, what are they going to get from it? Let's start with that first question.

Doctor: So, I think it's really important because as men, we expect the women to know. Surely the woman knows about their menstrual cycle, about pregnancy, about postpartum, about menopause, about hormones. Surely my partner knows, you know, or the woman in my life, my mom, my sister, my daughter, they know all of that, so I don't have to. And the truth is, they don't know. When the women in your life go to their doctor and they're getting a pelvic exam, say they're getting a Pap smear, a doctor is looking at their genitalia, putting a speculum in, going inside the canal and looking around. We put a sheet over you like we are mechanics looking under the hood. So, we put a sheet to keep you comfortable, to keep you modest, but we hide your genitalia from you and we don't teach as we go. So, I became famous again because when I started my practice, I didn't buy any fancy equipment, I bought two mirrors on Amazon and I give women a mirror and as I'm examining them, I say to them, "This is your labia majora. This is your labia minora. This is your clitoris. This is your urethra, the tube that you pee through." Because women can't see it. You've got skin, you've got bones, you've got muscles, you've got nerves, you've got, you know, all the organs that are on the inside and women don't have access to this language. Certainly men don't have access to this language. And so, it's that basic ability to give women language, 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. You may have a physical therapist, you may have a mental health person, you may have a primary care, a gynecologist, you may go on Instagram and get great information from people on Instagram. And so, that doctor that makes you feel like crap because they tell you something that you don't agree with, find a different one, right? You have to advocate for yourself and I find we are starting to empower women to do that, which is very challenging.

Host: What is the most popular question you get asked now that you've been on these podcasts and you know you're out there and you've done millions and millions of views all over the place and on clips and so forth. What is the number one most popular question you get asked?

Doctor: I'm asked a lot about hormones. Like people want to know about hormones. People want to know about pain with sex. And I think people want to know about libido. I think those are the three I would say most common things that we talk about.

Host: Let's go in that order then. So let's start with the subject of hormones. What is it about hormones that people are so desperate to understand?

Doctor: So hormones are fascinating because we forgot to teach doctors anything about hormones. And what we have taught about them, they think it's dangerous, they think they're harmful, they think that you know it's almost like this thing that is natural in your body is somehow dangerous once you get over a certain age. And that is all politics and bad interpretation of science.

Host: I've got this graph here which shows female testosterone levels by age. And again, as someone that has started to understand more about female hormones, I was quite surprised because you think of testosterone as a male hormone.

Doctor: Yeah, so that's the biggest misconception is that women don't make testosterone. Testosterone is just a hormone. It's not a male hormone, a female, it's just a hormone. It's also not a menopausal hormone. We think of menopause as estrogen starts to drop, right? So menopause is a castration event. If I cut your testicles off right now, you would have hot flashes, night sweats, osteoporosis, depression, low libido, erectile dysfunction, metabolic syndrome, your weight would go up and you would be generally pretty unhappy. It's a big deal when we castrate people. And yet, we don't do it for men regularly unless there's a very significant medical reason to do so. And yet, every woman over the age of 50, her estrogen goes to essentially zero. And that affects bone health, it affects the brain, it affects the heart, it affects sexual health, it affects UTIs start to go up. And so it's a whole body event that happens. Now, testosterone's really interesting cuz it actually isn't at menopause that you lose testosterone. It happens in your 30s. So, if you look at this graph, right? You can see testosterone starts to precipitously drop in your 30s. So, what do we see clinically? Sometimes nothing, but we have a lot of people who will start in their 30s, mid-30s, late 30s start to say, "Ooh, my libido's not as high as it used to be. Huh, my orgasm takes a little bit longer. I don't feel as aroused. My engorgement is not the same. My lubrication..."

Host: Engorgement.

Doctor: Engorgement of the clitoris. It's the same as an erection, right? So, the clitoris and the penis are the same. They get hard with blood flow. And so, this happens in your 30s and no one's paying attention because if you look at the graphs that we are taught in med school, they look more like this. So, the books all talk about estrogen and progesterone. They don't talk about testosterone very often. And there's also a lot of things we do to worsen this problem. When you play with hormones, there are consequences, sometimes good and sometimes bad because we do so much to mess with our hormone levels. Again, birth control pills, the way that they work is changing hormone levels. Medications for acne, medications for hair loss that...

Doctor: People using can affect your testosterone levels. So, birth control is wonderful, but there are side effects to birth control just like there's side effects to any medication. And so, one of the side effects is it lowers testosterone. And so, that can cause low libido, pain with sex in a small subset of people who take it. So, if you're someone who does have side effects, then it's worth having conversations of different forms of birth control which may not lower your testosterone as much. Does that make sense?

Stephen: It does make sense and it's interesting. My partner's talked about this before. My fiance, she was on birth control for a long time and she also had concurrently libido problems. Now, we don't know whether it was the birth control, whether it was something else, but when she came off the birth control pills, her libido challenges also evaporated.

Doctor: So, can explain cuz I think again, knowing the basics and the fundamentals give women and men access to the information so they can make choices with what they want to do with it. Okay, so how do birth control pills work? Um when you take a combined birth control pill, it has a fake amount of estrogen and a fake amount of progestin in it so high that it tricks your body into not ovulating. So, when you have so much hormone around, your body says, "Oh, I don't need to make my own cuz there's plenty around." And so, the ovaries shut down. So, your ovaries are no longer making their own hormones because this happens to men, too. When you take high doses of testosterone, you become infertile because your testicles say, "Oh, I don't need to produce sperm right now cuz there's plenty of testosterone around." And so, birth control causes your ovaries to just stay quiet. They shut down for a bit. But, your ovary does three things. It does estrogen, progesterone, and testosterone. It doesn't add back testosterone. So, her experience possibly was because she wasn't making her own testosterone. And when she went off that birth control, her ovaries woke back up and make estrogen, progesterone, and testosterone, which to you equaled more pleasure. Now, because we focus on the psychosocial, I'll have a lot of people saying, "No, no, no, it's all communication." And all of that is important. Don't get me wrong. But, the biology matters too. And we know there is a biological basis to sexual health for everybody.

Stephen: I was just looking at some data and it said that in some studies, up to 27% of people on birth control report a decrease in their libido/sex drive.

Doctor: Yeah.

Stephen: Which is shocking cuz, you know, it varies in these studies from one to seven people to one to that's almost like one one in three people are experiencing it. How does one navigate that, you know, cuz birth control has tremendous um upsides? So, how do you navigate that?

Doctor: I think that everything that we do, there's the risk of doing something and the risk of not doing something. No drug is going to be without possible side effects and so that's where becomes important to know what are the non-negotiables. Antidepressants is a perfect example. We know that they can help people, right? A lot of people, but we know there are sexual side effects like low libido, delayed orgasm. And so it has to do with informed consent, which means, Stephen, if I'm going to give you a medicine, I want you to know that there is the common side effects, the less common side effects, and then the disastrous side effects. That's why on the commercials they talk about all the disastrous side effects. But often they don't even research the sexual side effects. So for example, GLP-1s, okay?

Stephen: What's a GLP-1?

Doctor: Yep, the GLP-1s are the weight loss drugs that everybody's talking about. Ozempic, Mounjaro, all the all the celebrities are on these injections that are making them lose tons of weight. We are starting to look at these drugs in women, but they're not nobody's looking at it for sexual health. Everyone's looking at it for can you get pregnant? Reproductive health. There is not a single published paper on sexual health side effects for women. So we did a survey, it's not published yet, but we presented it at a conference at a medical conference. We surveyed a thousand women online who have taken these medications and about 25% report sexual side effects from these medications. Again, that's not to say the medicines are good or bad, right or wrong, but there are side effects. Now of those 25% about 50% of those people said it lowered their sexual function whether it's libido, arousal, and orgasm. And about 25% said it made it better.

Stephen: So carrying on in this track about women's hormone levels through time and through age and through life phases, what else do I need to know or understand about how important testosterone is?

Doctor: So we know we have global consensus actually that testosterone helps for libido in postmenopausal women, okay? Now there is also data in perimenopausal women as well and that is clear data. It helps with libido, but it also helps with arousal, it helps with orgasm, and satisfaction. It can also help with body image, which is like a cool a really cool thing. In my clinic, I use FDA approved testosterone for men, and I give it to them in doses appropriate like 1/10 the dose for a man, I give it to my female patients. And I see that over the 3 to 6 months of taking it, they get this it clicks. Now, does that mean every woman on Earth needs it? No, we're not there yet, but if you want it and you want to try it and you're curious about it, then you should have access to physicians who understand how this works and they know how to write the damn prescription.

Stephen: There's five life stages on here. We have puberty, your fertile years, perimenopause, menopause, and then post menopause. When you think about a woman's hormonal journey through these different life stages, what is the sort of advice you would give them to make sure they're hormonally healthy across every life stage? What are like the basics? What are the tactics, strategies, medications that they should be thinking about? And I say this because I've got women women in my life for every stage in this life phase at the moment. I've got you know, I've got my nieces in the sort of puberty era. I've got my my fiance in the fertile years. I've got my mom and grandparents etc. in the peri- and post-menopause years as well.

Doctor: Yeah. So, if you look at your nieces for example, when they were babies compared to now, there are changes happening. Their bodies are transforming because they're getting a surge of hormones in their body and that's estrogen, progesterone, and testosterone. They're cycling, which means they're getting periods. So, let's talk about the menstrual cycle for a second. I think it's helpful.

Stephen: Okay.

Doctor: So, [clears throat] when women have their period, they bleed for a few days, right? And that's when their hormones, their estrogen and their progesterone is at its lowest, okay? So, hormones are at their lowest. And then the hormones start to increase. Your estrogen starts to go up. You don't make progesterone yet in the beginning. Your estrogen starts to go up and it make there's a a follicle in your ovary which has an egg, right? It's going to pop out an egg. Ovulation is when the egg pops out. So, you get this big surge of estrogen and then when the egg pops out of the ovary, right? That's what's going to make a baby if it gets fertilized, there is a shell of the egg, right? The egg has a shell which makes progesterone. So, the second half of the cycle there's progesterone around, okay? First half of the cycle no progesterone.

Stephen: Mhm.

Doctor: And so, that [clears throat] second half of the cycle the shell has making progesterone and then when you don't have fertilization, the shell starts to break down.

Stephen: Okay.

Doctor: And that natural breakdown is a drop in progesterone which causes the lining of the uterus to shed and you get a period again. And so, it's estrogen goes high in the beginning and then pops out an egg, progesterone gets high in the second half and then they both fall and you have a period. And so, the hormones being low in the beginning, estrogen is not zero. It's about 50, okay? So, when we talk about numbers, if you get your hormones checked, if they're at their...

Speaker A: low it's like 50, but when you ovulate, your estrogen may be 150, 200, 300. And then when you're pregnant, your estrogen may be as high as 3,000 or higher, right? It's very many thousands. And so, these hormones have actions in our bodies. And so, the reason it's important is cuz when we give back hormone therapy, well, are we giving back 10,000 like pregnancy? No, we're giving back to be like 50, 60, 70, the way that you are early in your cycle kind of a thing. Now, testosterone's not even on this graph that everybody gets taught of estrogen then progesterone, but we do know testosterone is pretty stable through the cycle, although we do believe it peaks during ovulation which makes sense cuz you want to have a baby, right? So, evolution says, "Okay, you need to be horny around the time that you are going to ovulate." And so, your testosterone starts to go up. Now, it's really important cuz you're probably not having a conversation with your nieces about their menstrual cycles, but it's a problem because no one's talking about it if they're painful, if they're abnormal, if they're um uh uh uh we don't have a lot of conversations around what is a normal amount of bleeding. We have so many people who have problems, whether it's PCOS, which is now called PMOS, which is a metabolic issue that causes you to have irregular periods. There's endometriosis where you have painful periods. There are so many medications we give to people that can alter their hormonal health and and sexual health for that matter. And then it all starts to get even more chaotic in perimenopause, which is again age 35 to 45. If menopause we say is 45 to 55, right, is normal menopausal age. Average age is 52, and we think perimenopause is when things start to change for people about 10 and it can be about 10 years. That means 35 to 45. So, how old are you? I don't remember.

Speaker B: 33.

Speaker B: 33. And my partner's 33.

Speaker A: All right, so 33. So, this idea that I'm too young or it's too early or I'm not there yet, the truth is things do start to change.

Speaker B: What changes for a woman?

Speaker A: So, there are so many symptoms to hormonal fluctuations. So, for some people it's temperature changes, for some people it's fatigue, for some people it's remembering things, for some people it's low libido. Some people get dry eyes, itchy ears, burning mouth, joint pain. Some people get irregular periods. Some people get pain with sex. Some people get UTIs. I would love to talk about what why hormones are so important for the bladder and UTI prevention. And so, there are so many symptoms and everyone says, "Oh, we're blaming everything on hormones." And the truth is, we haven't talked about hormones enough to actually start looking at this to figure out what is important and what is hormonally important.

Speaker B: So, when you start to lose progesterone, when you arrive at perimenopause, what are the symptoms you feel? Are they different symptoms to decline in estrogen?

Speaker A: So, it's hard to know for sure, but some people think that as the progesterone, so your sleep starts to get a little crazy, anxiety starts to go up. And so, some people will start with progesterone as a support for you know sort of perimenopausal hormone therapy but estrogen can also help with many of those symptoms. So it's not a one size fits all of whether we give people everybody gets progesterone or everybody gets estrogen. Sometimes people just get testosterone because remember that falls in your 30s you know so there's sometimes where we do all three and there's sometimes where we do just one or two. Now it's a very evolving conversation because most of the book answers most of the guidelines really talk about menopause and how we treat people in this menopause when you're flatlined. Remember that castration event where everything's zero and then we add back hormones. So now we're starting to talk about perimenopause as a place to to start giving women hormones and that's a a very important and evolving conversation that is happening.

Speaker B: And so this conversation that's sort of raging on about HRT about safety about what age you should take it who should take it what form you should take it in. What's your perspective on that and what do women need to know about that?

Speaker A: Yeah so so it's important because

Speaker B: is HRT?

Speaker A: Yeah it's a great question. So hormone replacement therapy which is a term that we used to use for hormones in menopause. It has a bunch of different names and everyone tries to change the marketing around it but hormone therapy in general is this idea of giving back hormones when you have hot flashes night sweats osteoporosis you know sort of this over 50 crowd that has this declining estrogen and progesterone levels. And so typically classic hormone therapy is estrogen and progesterone. Now again taking just estrogen estrogen grows things it helps your bone health it helps your hair skin and nails it helps you not have hot flashes it helps you sleep. It can also grow the lining of the uterus and so if it gets thicker thicker thicker there is worry over years that leads to endometrial or uterine cancer. So endometrium is the lining of the uterus so here I can okay so this is a this is a vagina and then at the the vagina's like a socket. The very end of the socket is a tiny hole and that hole is the the pinpoint opening of the cervix and that hole if you go through that tiny tiny hole, it gets to the uterus and the uterus is a cavity where we hold babies where the lining comes out. That's what period blood is is the lining of the uterus here which we'll call the endometrial lining. So progesterone is very important for this lining here. If the the lining of the uterus gets too thick with just estrogen, that can lead to problems, but if you match it with progesterone, those problems go away.

Speaker B: Right. So so if you just gave someone estrogen, then the linings of the uterus would get so thick that that would cause a problem, but if you give it to both hormones together, it sort of balances itself.

Speaker A: them out and so that's why you'll hear hormone therapy talked about estrogen and progesterone just like the birth control pill your partner was on was an estrogen and a progestin. There was a combination.

Speaker B: Okay, got you.

Speaker A: And also the history is kind of important here of why your mothers and grandmothers weren't given access to this medication and the stigma behind it. In the late 90s, a lot of people were on hormone replacement therapies and they were seeing benefits. They actually were all these observational studies that showed wow, the heart disease is less and like

Speaker B: During menopause.

Speaker A: during menopause and a billion dollars went into the NIH to study this in women and they did they that was called the Women's Health Initiative. It was thousands and thousands of people age 50 to 79. They gave a hormone pill like a birth control pill almost to all of these women and they followed them and they stopped the study early in the early 2000s and they did a press conference and at this press conference they said we're shutting down the the study early. Hormone therapy causes cardiovascular disease and breast cancer. And overnight, a multi-billion dollar industry went to nothing. Everyone was told throw your hormones in the garbage. This is dangerous. What was crazy is those people who were prescribing hormone therapy were looking around saying, "I don't understand. My patients aren't dying of heart disease. They're not getting extra breast cancers. Like, this doesn't make any sense." And when people actually looked at the study, it didn't say any of those things. It was wild how misinterpreted this study was. In fact, the same authors of this study back in the early 2000s published this year, in 2025 actually, that below age 70 that type of hormone therapy, which we don't really use anymore, has no increased risk of cardiovascular disease or stroke. And yet now you have a generation of doctors who weren't taught how to do this. Only 1.7% of women have are getting prescriptions for hormone therapy who who should be offered prescriptions. So, it is a disaster.

Speaker B: Only 1.7%?

Speaker A: Only 1.7%.

Speaker B: Oh, really? Hmm. Wow.

Speaker A: And so, hormone therapy is not something that I'm saying every woman must have, but every woman should have access to the toolbox. I like to think about hormone therapy

Speaker A: is really four buckets that we talk about. Hormone therapy is whole body estrogen, which helps with hot flashes, night sweats, uh bone loss, progesterone, whole body progesterone therapy, which protects the uterus and is this yin yang, especially if you have a uterus, but it helps with sleep, and it can help with anxiety reduction in many of our patients, not everybody, but a lot of them. The third thing is testosterone, which we talked about, which can help with libido. Um that's what we have the most evidence for. And then the fourth thing is vaginal hormones. Now, vaginal hormones are microdoses of estrogen or what we call DHEA vaginally, that supports the bladder and the vagina. So, it helps with pain with sex, dryness, urinary frequency, urinary urgency, leakage, and it prevents urinary tract infections massively. It is safe for your great grandmother in the nursing home. It is safe for your wife who's breastfeeding. So, if you know anyone in your life who is a woman, who's having urinary frequency, urgency, leakage, urinary tract infections, pain with sex, dryness, there is a magical solution that is safe for everybody on Earth um that is microdosing these hormones vaginally.

Speaker B: At any age?

Speaker A: At any age at all. In fact, even more important for people who are older because they are dying of urinary tract infections. So, it's it's it's one thing when a young person gets a urinary tract infection and they go to the urgent care and they get an antibiotic. Even they deserve prevention and this is prevents uh those problems in those people, too.

Speaker B: Again, what is this?

Speaker A: So, vaginal hormones. So, this is a really important topic. It's called genitourinary syndrome of menopause or GSM. Say GSM loudly for your listeners.

Speaker B: GSM.

Speaker A: GSM, genitourinary syndrome of menopause. Genital, urinary, syndrome of menopause. But, really, it's kind of a dumb name because it's any hormonal changes in your body can affect the bladder and the genitals.

Speaker B: So, UTI. What is a UTI? And what's what's causing a UTI? U- urinary tract infection.

Speaker A: Yeah, very good. So, urinary tract infections are when there is bacteria in the bladder and it can be a lot of uh of bad bacteria that can grow and create uh inflammation. It causes bladder pain, pain with urination. It feels like razor blades. Um but, it can also go into your bloodstream and cause fevers and chills and cause kidney infections. It can cause something called urosepsis where you have to go to the intensive care unit and need uh antibiotics through an IV and it can kill you if you have an infection go through your whole body. And this gets worse and worse as you get older.

Speaker B: Why is there a link between hormones and UTIs?

Speaker A: Yeah, because what happens is the vagina is supposed to be acidic and healthy and hormones help keep it. It is the hormones, the estrogen and the testosterone, that keep healthy bacteria growing in the vagina and suppress or lower the bad bacteria.

Speaker B: So, there really is a vagina microbiome.

Speaker A: There is and There's There's no probiotic on Earth that is proven to do what the vagina needs quite like hormones. Hormones make the tissue go from uh not acidic to quite acidic, and it is that acidic environment that protects it from infection. And so, perimenopause and menopause or other situations happen, and it changes that microbiome, so the good bacteria are are lower and the bad bacteria start to grow, which can increase your risk of infections. And sex Right, sex is a contact sport. So, uh you're bringing the outside environment into the inside environment. Uh ejaculate is also not acidic, and that can change the microbiome as well. And so, we know women who are sexually active also have an increased risk of urinary tract infections. So again, like a plant needing water, vaginal hormones help support the vagina and the bladder to maintain that acidic environment. And research has been clear since the 1990s that using vaginal hormones prevent UTIs, urinary tract infections, by more than half.

Speaker B: So, what have we got here in front of me?

Speaker A: All right. So, there's a bunch of different ways you can give yourself vaginal hormones. The most common way is a cream. Now, this cream is uh $14 on Mark Cuban's pharmacy, and it lasts about 2 and 1/2 months. Now, this cream that comes with an applicator, which you don't ever have to use if you don't want to, but what you can do is you want to use 1 g of this cream. So, this amount is 1 g of this cream. We'll put it on this paper here to show you. 1 g of this cream rubbed into the vagina. So, you take it You can take it on your fingers and rub it into the walls like you If you put sunscreen on your face, you don't glob it on and walk out the door. You rub it in, so it doesn't look all white and filmy. So, you put it in You take it with your finger and you put it in the vagina and you rub it into the walls of the vagina you can rub it on the outer this area as well at the opening.

Speaker B: Let me try it. I don't have a vagina but So you take the this what what is this cream called?

Speaker A: It's estradiol cream.

Speaker B: Estradiol take it on your finger you rub it inside the walls of the vagina like this.

Speaker A: rub it in like you would rub sunscreen on your face and if you do that twice a week you can prevent death from urinary tract infections. You can help with urinary frequency, urinary urgency, leakage, you make sex not painful and dry, it helps with arousal and orgasm. It's literally better than Viagra and this is over the counter in the UK. In the United States you need a prescription um but it's as little as $14 if you use Mark Cuban's online website it should be covered by your insurance. Now some women hate creams and so we have things that are not as messy as what you're showing right there and we have little tablet inserts. So here is a it comes with an applicator and so what a woman does is put this in her vagina and press a button and this little tablet so instead of a cream you could just put this little tablet in twice a week and that does the same thing as the cream.

Speaker B: Ah okay.

Speaker A: Okay so it's a little less messy so people tend to like the creams better. Now if you really don't want to do anything twice a week this is a ring that goes in the vagina and it can stay in there for 3 months. Now this it's sort of like a tampon you can kind of put it in the vagina and the vagina does not feel it. By the way the vagina is not very sensitive in terms of nerve endings and so when women put tampons in they don't feel them. When you put this ring in that you wouldn't feel it either and it would stay in for 3 months at a time.

Speaker B: It's quite it's quite quite a big ring.

Speaker A: Vagina can hold like a bowling ball of a baby can come out of a vagina so it can actually withstand quite a lot of volume.

Speaker B: And there's a chemical inside this ring that's going to diffuse

Speaker A: Estradiol that slowly diffuses estrogen for the ring. So that's nice for women who have dementia, who have very bad dexterity with their fingers, they're in a nursing home, uh for someone who's on the go and they can't remember something twice a week. So, our ADHD patients like things like that. And so, there's just different It's all the same stuff. It's just in different formulations. Now, the one different one, this is something called DHEA. Now, DHEA is the precursor hormone to estrogen and testosterone. And remember I said the vulva, the vagina, the bladder need testosterone, too. It So, this is a a chemical that converts into estrogen and testosterone. And so, DHEA is a supplement you can buy, you know, sort of in the in the supplement aisle, but if you put it locally in the vagina, this is an FDA-approved product. It's called Intrarosa. And if you just put this in the vagina, uh uh it's meant for every night, but you can do it twice a week. Um it it melts at bedtime. When you wake up, and it prevents UTIs. It helps with pain with sex.

Speaker B: And just to be clear again, so you think a lot of people should be taking these these things?

Speaker A: believe it's preventative. So, I think And we wrote guidelines by the American Urological Association uh why this is so important, how to do it. So many women have symptoms of urinary frequency, urgency, leakage, uh urinary tract infections, pain

Dr. Rubin: ...with sex, dryness. And this is a safe option for all of those women. Does that make sense?

Steven: It does make sense. And one of the things that doctors sometimes tell their patients to take to help with the UTI situation is that?

Dr. Rubin: Okay, this is a disaster. So, women get urinary tract infections a lot. And so, what do we tell women? Pee after sex. Wipe from front to back. Like, that's not data-driven, by the way. That's all a folk tale. Like, that's folklore. There is some data that cranberry pills can help with preventing UTIs, but the amount that you'd have to drink is very sugary and diabetes-inducing and won't taste that good. And so, there they do make pills, but it's a small... These things are small things that help. Drinking lots of water can help, but vaginal hormones, vaginal estrogen or vaginal DHEA, which we just showed a bunch of, prevent UTIs by more than half. They don't just prevent UTIs, they help with urinary frequency, urgency, leakage, pain with sex. They help your arousal, they help your orgasm, and they're safe for every age with every medical problem. If you've had cancer, blood clot, stroke, any problems at all, vaginal hormones are safe and could save your life. And so this is such an important topic.

Steven: There should be a button just down below here. And if it says subscribe, you're already subscribed. If it says subscribe-ah, that means you're not yet. And if you're not subscribed, please could you do us a favor and hit that button. It helps to show more than you know. And according to the algorithm, you're someone that watches our show, but you haven't yet hit that button. Thank you so much. My partner's 33 years old now. She's not yet in the perimenopause stage. At what point does someone start taking HRT? Is it when they're in the menopause stage, which is defined as 12 consecutive months without your period? Is it when they're postmenopausal? Is it in perimenopause?

Dr. Rubin: Yeah, this is a very important question cuz it's not a one-size-fits-all. At this age, start this medicine. It's really when people start having symptoms. And so I'll give you an example. So say your partner gets pregnant, okay? You decide to have a baby. Her estrogen is going to go to 10,000 for 9 months. It's going to be super super high. And the day she gives birth, it's going to crash to zero. So you go from super high hormones down to zero. And if she chooses to breastfeed or pump or do any of that, they stay extremely low in the menopausal range for the entire time you're breastfeeding. So when you are breastfeeding or pumping or doing anything and your periods don't come back, you're basically menopausal.

Steven: And what are the symptoms then? So if you just had a baby, you're breastfeeding.

Dr. Rubin: ...have hot flashes, she may have night sweats, she may, you have urinary frequency, urgency, leakage. There's all sorts of symptoms that come with that.

Steven: Libido changes as well.

Dr. Rubin: Libido definitely changes, pain with sex goes up. And so we call this the genitourinary syndrome of lactation. And so there's all sorts of hormonal changes that can happen at that time. So we see a big need for vaginal hormones in this patient population. It's safe for the breast milk, it's safe for the baby, it doesn't cause any problems, but it can really help with all of those symptoms.

Now say she is done having babies and now she's 38, 39, 40 and she is doing fine and she has regular periods and she has no symptoms and no problem. She may not need anything at all. But what if she starts getting a lot of urinary tract infections or having dry scratchy painful sex or her libido just doesn't feel it sort of feels like back it when it did on birth control pills. That may be an indication where she may benefit from whether it's testosterone or vaginal hormones or some kind of combination. What if she's 43 and her sleep starts to get really bad and that may be an indication for progesterone.

I have a patient who was having hot flashes and night sweats and brain fog and fatigue. I see her and she says I will not take hormone therapy. It's not safe. My mother told me it causes cancer. At no point am I going to do this. I said, okay. We had a long conversation. I shared data and papers and we did a shared we just worked with each other and I wasn't pushing anything on her, but ultimately she started with vaginal hormones. Her orgasms come back. Her arousal gets back and she comes back to see me and says, "Rubin, what are you doing here? I'm feeling much better. Like this is you've given me my life again. I'm not peeing in the middle of the night so I'm sleeping better. I don't have as much dryness. Sex is no longer painful. I haven't had a UTI in months. What else do you got?"

Well, she was still suffering with hot flashes and night sweats. She had a bone density scan which showed osteopenia and she was worried about osteoporosis cuz her mother died of osteoporosis fractures. Well, if she did whole body estrogen, she would prevent her risk of a of a fracture. She would make her hot flashes and night sweats go away, which would have benefit on how she sleeps, and ultimately probably benefit on her whole vascular system. And so, she started estrogen, and cuz she had a uterus, she took progesterone at night, and she said, "Well, my libido is still a bit low." We looked at her testosterone. We said, "Testosterone will likely help with your libido, but it's going to take 4 to 6 months."

So, 4 to 6 months, she comes back to see me. Not only is her libido so much better, but she feels that she has the cognitive ability to enroll in law school. Like, this woman literally decides that she wants to change the trajectory of her career and enrolls in law school, and her brain is working in like ways she hasn't seen it in so long, and she is competing against 22-year-olds in law school. And when I tell you she finished at the top of her class, she finished at the top of her class, whereas she said, "I would have never even considered this opportunity if I hadn't been doing all of these things." So, in...

Steven: And what age is she?

Dr. Rubin: She's in... Now, she's in her 60s. And so, that's why I'm so loud about these things, because what other organ in medicine do we let fail completely before we like do something about it. We don't make you go blind completely before we give you eyeglasses. We don't let your kidneys run out completely before we give you dialysis or medications to help your kidneys along. We don't let you go into full liver failure before you get the transplant. Like, this idea of your ovaries have to fail, and you have to suffer for 12 months before someone intervenes is insanity.

Steven: But for some women, they do start HRT during the perimenopausal phase.

Dr. Rubin: Yeah.

Steven: And for some, they start it during menopausal postmenopausal stage.

Dr. Rubin: Correct.

Steven: And it's all depending on you how you're feeling.

Dr. Rubin: It's all depending on how you're feeling and what you want, what your objectives are.

Steven: Okay. But it's never too early to start necessarily.

Dr. Rubin: Not necessarily. Like, so again, we give birth control all the time to people in their reproductive years. Birth control is just high-dose fake hormone therapy, right? So, we're giving women hormone therapy as young as in their teens, right? To help with different things in birth control. But, so if you think of it as all of it is some form of hormone therapy, it just depends are we using the natural form of hormone therapy or we using the synthetic hormone therapy? We have to get comfortable with hormones at all ages.

And the thing that we see most commonly, Steven, is sort of what we call NFLM, not feeling like myself. I love that statement because women are coming to the doctor every day saying NFLM, I'm not feeling like myself, and they're getting dismissed. And the truth is there are often hormonal reasons why you may not be feeling like yourself. So, for some people it might be musculoskeletal pain, so we see plantar fasciitis and frozen shoulder, and we think of as those having underlying hormonal causes as well. So, there's published data that less than 9% of Medicare patients are getting prescriptions for this. More than 75% of people in large database collections are not getting prescriptions for this. And so...

Guest: Women are not getting access to generic medications that could save their lives and also really improve quality of life. I don't know about you, but dryness People are not having sex anymore because of the pain, the dryness, the irritation when it's fixable.

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You said um earlier that one of the questions people come to you about is pain during sex. Why are are women experiencing pain during sex? What is What is What is going on there physiologically?

Guest: Yeah, pain with sex is actually not rare at all. There are some published reports that up to 75% of women will say at some point in their life sex is painful.

Host (Steven): So, a really dumb question here. Sex is not supposed to be painful.

Guest: Sex is not supposed to be painful. If sex is painful, you need to figure out why it's You deserve a diagnosis. You deserve an answer. You deserve to understand exactly why sex is painful. You could have a problem with the tissue. So, you could have a skin problem, which as we know the tissue of the vulva is very hormonally sensitive. So, that tissue could be impacted by hormones. It's skin. So, people can get eczema. They can get autoimmune skin conditions. So, you may have a skin condition. You may have problem with your muscles. So, remember the vagina and the vulva are surrounded by these big pelvic floor muscles. And just like you can get tight muscles in your neck and in your back, you can get tight muscles in your pelvis. We also know there's nerves that are involved in this area. So, if you have a back problem and you feel it running down your leg, right? That's called sciatica or sciatic pain, you can have a back problem that actually causes you to have pelvic pain. So, we see people with penis pain or vulva pain because of problems in their spines. If you have scar tissue inside your body from endometriosis, that's pushing and scarring this tissue from the inside, you may have pain with sex. And so, there are many different things that can cause pain with sex. But remember I said your OBGYN got almost no training in this.

Host (Steven): So, if if I'm currently experiencing pain during sex as a woman, what advice would you give them? What should they do?

Guest: Yeah, so I would really try to see someone who has an active interest in this. See a specialized gynecologist or a specialized urologist who has an interest in pelvic pain. And you may need a couple of opinions. Just like if you go to the first plumber, you want to get a couple quotes on well, who's going to do the best job? It's okay to see a few different people for this problem.

Host (Steven): And in terms of prevalence, up to 75% of women as you say will experience painful intercourse at some point in their lives. Between 10 and 20% of US women suffer from persistent chronic pain during sex. And during menopause, it climbs drastically with estimates ranging to 20 to almost half of women having pain during sex.

Guest: And that probably doesn't even add to the people who stopped having sex because either they don't have a partner or because they it's too painful to even consider it. And I think it's important to know that hormones play a fundamental role here. Not a like a not it's not the whole story, but it's a huge part of it.

Host (Steven): In different seasons of life, if if a woman wanted to have the best sex of her life, what are the fundamental things you'd aim at to make sure she can have the best sex of her life?

Guest: Yeah, so as you know, this is Diary of a CEO. So I love how you you love the health topics, but obviously financial literacy is really important to for you to help people because for some reason people stink about talking about money and talking about sex, and yet we all want to be really great at both, right? We all want a lot of money and we all want to have great sex, and yet people stink at talking about it. They they don't know the fundamentals, they don't know the basics. And so I actually use financial literacy sort of as a as a framework in how we talk about good sex. And so you've got your savings account and your you know, your your checking account. Those are the those are the basics. Everyone needs money in their checking and savings account, right? That's what everybody needs. So that's going to be your education, your nutrition, your exercise, your sleep, your your your communication, uh safety. Like are you safe in your relationship? Like the basics. Are you doing the basic things you need to have great sex? You know, communication is probably the most important thing. Can you talk about it? Can you use words? Um can you explore? Can you ask questions? So so that's really important for great sex. Then there's the 401k, right? The 401k is something that we all want and should have access to, right? It's important for compounding growth and long-term support of your financial life. Think about hormones. Think about going to a doctor who's going to make sure that everything is optimized the way that it should be. Your your pelvic muscles are in good condition. Your mental health is in good Do you know do you have Do you need a sex therapist? Do you want to bring toys into the bedroom and devices to have even more fun? That's kind of like the really important. Not everybody has access to it. Not everyone's going to do it, but I think it's really, really important for everyone to talk about. Then there's like crypto. Okay, so crypto, that's not to say don't do crypto. Like don't put all your money in crypto. Don't do everything and don't start with crypto. So that's going to be when you're watching, you're scrolling Instagram and you see these ads for do this injection, do this, you know, cosmetic procedure, do this supplement that's going to make sex great again. Uh the truth is if it looks too good to be true on TV and in the ads like it probably isn't going to fix what if if other things are are are struggling. So I think great sex is within everybody's reach, but I think your great sex is different than other people's great sex.

Host (Steven): So let's go through these slowly and one one at a time. I kind of broke it down into three categories, which is there's biological and physical blockers to great sex, which are

Host: So some of the things we talked about, um hormone crashes, etc. You mentioned the pelvic floor. How is an issue with your pelvic floor going to impact your sex? And what is the pelvic floor? Why would you have an issue with it? What do you see in patients?

Expert: Yeah, so everyone has a pelvis has a pelvic floor. So men have a pelvic floor, women have a pelvic floor. It just means the bones of your pelvis, so your hips, right? And your pelvis bone, your butt bones, all of this is this big bony structure that holds all of your organs in place. And your genitals are attached to this pelvic floor. And the pelvic floor is surrounded by thick big muscles. So if we look at the inside of the pelvic floor, it's these big thick muscles. And muscles are just like your biceps, right? Like muscles are something that contract and relax and there can be problems with muscles, right? just like if you work out too much and you've got a sore trap and you got to go get it massaged and and or you got to do physical therapy cuz your shoulder is hurting. A lot can go wrong with the pelvic floor. And so, sex is a contact sport. So, if you're going to get erections, if you're going to have an orgasm, if you're going to allow for penetration to happen, you have to have healthy muscles because you're asking your muscles to contract and relax in a sexual way. And so, as blood is flowing through the area, blood is going to engorge the clitoris and it's going to get bigger and erect, it's going to engorge the penis, it's going to get bigger and erect. These muscles are going to have to relax so that you can have penetration cuz if they're too tight, tight muscles are painful, they're sore, they're they're they burn. And so, penetration can happen if you're relaxed, but then orgasm is a series of muscle contractions which equates to pleasure and release, which is all has to do with the nerves and the muscles. Does Does that make sense?

Host: I'm trying to understand how the pelvic floor would would give me bad sex and how I would know if the pelvic floor is the reason I'm currently having bad sex.

Expert: Yeah, so if if sex hurts, so if the muscles are too tight and you can't have penetration but you want it, yeah, that can be bad sex. If orgasm is painful, weak, or impossible, it could have to do with the muscles. It's not always the muscles, but it could have to do with the muscles of the pelvic floor. If arousal, your ability to engorge and lubricate are diminished or less, that could be due to pelvic floor cuz you're not getting enough blood flow to the area. And so, there are multiple different ways and if you're not feeling your genitals, you watch something sexy on TV and then you feel it in your genitals or you see someone attractive walking down the street and you feel it in your genitals, there's this brain genital connection. And sometimes that you So, you have to have perfect wiring and of your nerves, your hormones, and your muscles, and so that could have be affected by your pelvic floor. Now, we do a lot to mess up our pelvic floor, by the way. People do surgery, people have babies, uh people um muscle uh health changes for many reasons, and so when you have problems, there may be biological reasons to these problems.

Host: Should we be going to the gym and like doing pelvic floor exercises to improve our sex lives?

Expert: You typically don't do them at the gym. There are typically trained physical therapists who help you know what's going on with your pelvic floor. So for some people it's to strengthen it and to do like almost contractions, we call them Kegel exercises, but for many people it's just learn the coordination.

Host: And you can go and get an exam.

Expert: You can go get an exam and work with a pelvic floor physical therapist.

Host: So some women, uh cuz we sometimes have them writing with questions, talk about the fact that they're they're not having orgasms. Is that normal or is that not normal as it relates to um sexual contact?

Expert: So about 20% of women will say that they can't have an orgasm. And the real question, I'm I'm fascinated by this data because not 20 20% of men do not have orgasm problems. And so again, if we go back to the financial literacy equation, we have a pay gap in this country, right? Women are not paid as much as men. Well, women are not orgasming as much as men. And so the data's very clear there. And I think the majority of problem is education. Women think that orgasm comes from penetration. Surely if the in and out penetration is happening, I should be able to have an orgasm. And the truth is that's not how most women orgasm. Some can, but the reason why women don't orgasm from penetration is cuz the clitoris is up here. So the clitoris is how women orgasm, right? Penetration is not how most women orgasm. Just like if you rub your thigh over and over again, you're not going to have an orgasm. Now you could keep rubbing your thigh for the whole duration of this podcast, you still won't have an orgasm cuz it's close to your penis, but it's not actually your penis, which is where men have orgasms from. And so the clitoris, if you follow those labia minora, those inner wings, you get to the hood of the clitoris or a foreskin, we call it a prepuce, and that, if you pull it back, you see what is the tip of the head of the clitoris, but that's just the tip of the iceberg. The clitoris is this huge structure. My necklace is, of course, like a gold clitoris. Um the this a huge structure that goes all the way down to your butt bones. It's a penis. Under the microscope, it looks like a penis. It is made up of the same tissue as a penis. It works exactly the way a penis does. It's just that we have a whole field of medicine devoted to the male penis. I'm a urologist. And no one is even taught how to examine a clitoris or where it is. So, if the penis is going in here or a toy or a finger or a device, that is not activating the the clitoris, which is a mostly internal structure.

Host: There's something called a clitoral adhesion, which people don't know about as well, which I've heard you talk about before.

Expert: Yeah.

Host: What is that? And how many people suffer with that?

Expert: Yeah, so the clitoris has this hood to it, okay? And about 23% of the time, the hood can get stuck to the head. So, for example, I'm wearing a sleeve here. So, you should be able to pull back the hood of the clitoris to see the whole head. It looks like a mushroom. You know how penises have like that almost like a mushroom rim rim around it. So, the clitoris should have that, too. But about 23% of the time it gets stuck. So, you actually cannot see the full head of the clitoris. It's called a clitoral adhesion. And so, you should be able to pull it back, but in about a quarter of the time you cannot. And we published data that if you remove these adhesions in an office-based very simple procedure, we saw improvements in orgasm, arousal, and satisfaction up to 60 to 70%.

Host: Wait. So, so one five women

Expert: Yeah.

Host: have a clitoral adhesion. And when solved, it improves their sexual satisfaction by up to 60%.

Expert: Yes, but no one's examined any woman in your life. No one has ever examined their clitoris, ever. In any exam, in any doctor's visit, and nobody's asking women about their orgasm, about their satisfaction. Where like they come in with pain or they come in with libido issues, but no one is examining this part of the body. And so, it's this question of is it cuz we haven't or cuz we shouldn't? It's cuz we haven't. We haven't We have never done this before.

Host: You pulled up the sex toys though. I think we were talking about orgasm gaps.

Expert: So, again, when you were talking about orgasm and how women experience pleasure, it's all buried inside the body. So, if your penis was entirely inside your body, say you gained 500 lb, okay? And your your belly was so big you couldn't hold on to your penis to to do what it takes to have an How would you orgasm?

Host: Uh probably I don't know.

Expert: The vibrator industry would be a gazillion dollar industry instead of just a billion dollar industry because vibration can help activate this blood flow. And so, for women, vibration on the outside can be extremely helpful cuz remember the clitoris is kind of

Expert: ...around this area. And so, by putting vibrators on the outside. Now, inside, you can also have pleasure, but not everyone experiences pleasure the same way. And so, understanding devices and trying different things is really really important.

Interviewer: I don't know. Oh, here we go. Okay, so this is vibrating now.

Expert: So, this one. This kind of device is interesting because it is a wand that can help just like with trigger points. So, if you have pain in in these muscles, this can go inside, vibrate to help with engorgement, but can also get rid of some of the tension in some of those muscles.

Interviewer: As men, what are we getting wrong in heterosexual relationships when we're trying to arouse our partners um both of the context of using sex toys, but also without sex toys? What is it that we just don't understand?

Expert: I think that men are constantly asking about they want their penises bigger, harder, straighter, girthier, uh lasting longer, and none of that has anything to do with how women experience pleasure and and satisfaction in the bedroom. And so, the question needs to be how do women experience pleasure? What is their anatomy like? How can we activate the clitoris, the arousal response? What are the brain things that we need to do to make women interested, right? What what gets women excited cuz it's different than what gets men excited. And your part every partner's different in terms of what gets them excited. And I would love to see more curiosity. I wish everyone was were as curious as you about what do we need to learn about women and how they behave and how they act and what they want.

Interviewer: Yeah, so you need

Interviewer: I'd like to implement it tonight.

Expert: Communication, right? It's that question and also understanding that your partner never got told any of these things. And so this is where watching this podcast together could be really helpful to say, "Did you know that? Was it What do you like? Do you know? Like can we look at your clitoris together? Like do you know what these body parts are called? Where is it that you experience pleasure?" Cuz some people find direct stimulation of their clitoris is too sensitive. Cuz we know the clitoris has like 10,000 nerve endings. So going directly over the clitoris can sometimes be too much. Some partners love it. Some partners want more stimulation on just the outside here. Some people need vibration. So that's another big problem.

Interviewer: I can So she's going to orgasm at some point if this is sufficiently stimulated.

Expert: there's sort of a build-up and release of pleasure, right? That's orgasm. And again, that is often not happening during penetration.

Interviewer: And once she experiences that, what happens immediately after for her? Cuz I know from a man's perspective, if I orgasm, there's some kind of like decline in arousal and I don't want you to touch it again.

Expert: That's very similar in women.

Interviewer: Okay, so it's the same thing.

Expert: Except women can bounce back faster. Not all of them, but but but women can have multiple orgasms.

Interviewer: So she orgasms, it's very very sensitive, she doesn't want me to touch it for a while.

Expert: Yeah.

Interviewer: And then she could she potentially could bounce back faster.

Expert: She could potentially. Some people do, some people don't, but that's the conversation of is this something that is pleasurable? Is this something to try again? Is multiple orgasms something that you want to have or try to have? When does penetration happen during the dance? Because often times men orgasm and then they're done, they all over, go to sleep, whatever it is. Is the orgasm happening after your orgasm, before your orgasm? Is it happening before and after your orgasm? Like are there cuz that could be a nice way to sandwich it of like there is, you know, giving the the sensitive tissue some time to rest, then your orgasm happens and then you potentially go for round two.

Interviewer: So, if the sensitive pleasurable part is on the outside here on the clitoris, then what do they get from penetrative sex if the this one of main event is here in the clitoris?

Expert: Many times nothing. Many times [clears throat] connection. Many times uh sort of this need for closeness and pleasure. Many times there are women who have extra nerve endings sort of inside the vagina on the top of the vagina and the cervix. So, there are women who love penetration, but many women get the main event from the clitoris and so it's part of the whole menu as opposed to penetration is the whole story. And I think every woman's body is different and so kind of making these broad statements of every partner likes this, but many women are asking for penetration mainly because they're like, "Okay, that's when you have your orgasm it's done and then I can go to bed, I can read my book, I can do all these other things." But the pleasure often comes from that clitoral stimulation. Now, some women can orgasm from penetra- I have a theory. It's a really interesting theory that maybe your listeners can prove with science or help me prove with science. So, you know how there's men who prematurely ejaculate? Like who ejaculate very quickly?

Interviewer: Yeah.

Expert: There are men who orgasm in a minute or less. That's probably [clears throat] 8% of men, okay? So, if we think men and women's bodies are very similar, could we argue that 8% of women will orgasm within a minute or less? Theoretically, it makes sense, right? I think those are the women who orgasm with penetration. They're so sensitive, their nerves are so sensitive that penetration's very pleasurable and then they have this magical orgasm and they do it very quickly. So, it's good in a way, it's often seen as like great in a woman and not great in men. And so, I just have this theory that like there are women who have extra sensitive body parts.

Interviewer: So, I mean, one of the things I've learned from everything you've said is just like how much porn has messed up our perception of sex.

Expert: I mean, WWF has messed up our perception of I don't know. Like what people's bodies are like exercise fighting like like it's all manufactured. And it's all manufactured because that's the algorithm that has been working to get men excited. And it doesn't like again, it's that question of that curiosity of who's watching porn, what do people want from porn, what are they getting from porn because it's not what women want typically. And it has really messed up people's perceptions of what is actually fun and pleasurable for the partner. So, seeing that curiosity of like what does my partner actually want? You know, you can have great sex without penetration. And so, the question is is what does great sex look like?

Interviewer: For you and your partner. When I look at a website, got some data here on a website like Pornhub, which is one of the leading porn websites, it says that roughly 65% of their traffic is men. Independent surveys tracking any regular pornography use find a similar gap, but note that women's consumption is highly age dependent. Men between the age of 18 and 35, 75 to 95% of them report viewing porn regularly, whereas women age 18 to 35, only 34% roughly, report viewing porn regularly. And if we think about these systems as catering to demand, it means that porn websites are catering to predominantly male demand. And that explains why for most young men, we learn about sex from porn websites.

Expert: Right.

Interviewer: And then we assume that's the the woman looked like she was having fun, and the man was doing this particular thing, and then And take that into our relationships, and I think this is where the misunderstanding begins.

Expert: And the women think they're broken because they're not having magical orgasms from penetration. They come to see me all the time and say, "I'm broken. You have to fix me. I'm not orgasming during sex." They have wildly good orgasms with a vibrator, with a hand, with a shower head, with whatever it is from on their clitoris, and that's totally normal, right? And then you show them the body parts. You say, "This is right, the clitoris and the penis are the same thing. You activate a penis for a man to orgasm. You activate a clitoris for a woman to orgasm." And once you teach them that, it makes perfect sense to them. Like they were normal the whole time.

Interviewer: What do you think of pornography?

Expert: I actually think pornography is great.

Interviewer: For relationships? For

Guest: connection? the right porn. Like look at Okay, let's look at something like Heated Rivalry. Have you heard of it?

Host: No.

Guest: Okay, Heated Rivalry is an HBO show that came out this year that is about two gay male hockey players. Okay, it's based on a romance novel book in came from Canada, and HBO put it out there, and it went viral in levels that the world has never seen before. And it is about two young men who fall in love, but there's a very sexual relationship between them. And heterosexual women have watched this 10 times over. Like they are addicted to this show. It's all over social media. It's this huge thing. It's essentially porn for women, right? It is women who are watching these pornographic episodes, and it's really important. They love it. It's supported. Everyone's talking about it. So, I don't think porn in and of itself is bad. I think porn, we, you know, watching people have sex, watching people fall in love, watching people with in romance. People like that. It gets them excited. It gets them aroused. But I think too much, if you are watching porn because and not interacting with humans, if you are watching porn all the time, if you need to if you can only watch porn to have good sex, like then that may not be the best, you know, and healthiest thing to do.

Host: I guess the question I was asking is, if you're in a relationship and one partner is using a lot of porn, won't that kill the sexual desire to be intimate with your partner?

Guest: It depends. It depends on the relationship and it depends on what each person needs in order to feel supported and connected, right? I don't think we can say blanketly it's good or bad, right or wrong. I think if it is good or bad, right or wrong for that couple, then it's a problem. Cuz there are couples who like to watch porn together. There are couples where oh, that maybe someone has a much higher libido than the other person. So they said, "Okay, the high libido person can use porn and then once a week we'll circle together and we'll have a great experience together." Because it's not everyone's job to meet each other on the libido.

Host: The study that I was looking at was a couple dozen studies including a major meta-analysis show a consistent link between solo porn consumption and lower relationship and sexual satisfaction. The erosion of intimacy is usually driven by deception. Finding a partner is hiding porn use is usually triggers intense feelings of betrayal, rejection, and insecurity. And heavy solo use can desensitize the brain's reward system leading to performance anxiety and erectile issues during real-life partner sex. It can also create highly unrealistic expectations regarding body types, stamina, and performance making real sex feel less stimulating.

Guest: Again, it was that deception. It's the hiding. If your that that ex of yours didn't tell you what was really going on and so you felt disconnected from that person because you didn't get that honest truth of what was going on.

Host: But also the desensitization of it. Like it's never going to you know I guess it depends on how you're using pornography.

Guest: It depends on how you use it. So again, that's the truth.

Host: Like you can like train your brain to get pleasure in a certain way. And then when you're with your partner, one could argue that it's going to be quite difficult for them to replicate that particular way that you've pleasure you've learned to pleasure yourself.

Guest: Right. And that's a that's a problem, right? If you're only able to do something in one way, in one position, with one watching one specific thing, that may not translate into great intimate sex with a partner.

Host: For the last couple years I've been working on something that I realized every podcaster listening to this, but actually probably every creator listening to this might just need. Podcasting is difficult for many reasons, and one of them is that these hosting platforms don't give you much information, and also because they're so fragmented, you kind of have to go through every single platform uploading it to YouTube and then taking the same big old video file and uploading it to Spotify's platform. It takes huge amounts of time, and that friction means most of us don't do it. That is the problem we set out to solve, and so we built something called Flight School, which you can find at flightcast.com. And today Flight School is also one of our show sponsors, and some of the world's biggest podcasters are now using our platform to run their shows because it gives you an edge. It saves you time. It gives you analytics most people won't typically get. It allows you to use AI to be more informed on your show, and it has growth tools that other hosting platforms don't have. So, podcasters that are using Flight School have this unfair advantage. So, go to flightcast.com/doac now. I've done almost 700 interviews with some of the most interesting people in the world, and one of the things you learn, which is unexpected, is that vulnerability is the doorway to connection. And after sitting here for 2 3 hours with a guest, I feel a deep sense of connection to them. And as they leave, what I get them to do is to write a question in the Diary of a CEO. We've taken all of the questions from the Diary of a CEO. We have put the question here on this card with the name of the person that wrote it. So, you can sit at home, as I do with my fiance, and my colleagues at work, and other people in my life, whenever we get a minute, we play the Diary of a CEO conversation cards, and it is incredible what happens. These are great if you're in a romantic relationship and you want to connect your partner more. These are also great if you're in a team and you want to bond your team together. And I have to say they're also great for families that want to learn more about each other and that need a good excuse to spend some time in a digital world in the analog environment connecting human to human. It is remarkable what the right question at the right time can do. Go to the diary.com and you can get these conversation cards right now.

Host: And there's different types of arousal, right? I was I heard from a sex expert I spoke to that men and women often have different types of arousal, spontaneous and like reactive. Is it?

Guest: Yep. Yep. So there again, this idea of like I want to have sex, I'm ready to go versus I want to have sex because we've started having sex and we've started that process and now I can get into it. Sort of like exercise. Some people are like ready to go to the gym and exercise and other people like I don't want to I never want to exercise, but once they start getting going, oh I know this is good for me, I should do this. This feels really good and that's sex for a lot of people. But again, it's also a question of what kind of sex are you having? If you have sex the same way every single time and it's not that fun and it's not that interesting to your partner, are they going to look forward to it? Are they going to Are they going to want it? Are they going to seek it out? And is that really low libido at all or is that sort of the product of like we just aren't talking about it improving. If you had the same podcast guest on every single week and it was the same conversation every single week, it's not going to last you very long, right? You do different things. You try different things. Oh, what worked? What didn't work? How could we do this better? What does the algorithm want us to do now? No one's doing that in their sex lives. Like Like no one's even talking about it. Like honey, what's working? What do we like? What's going on? I saw this thing like

Host: Why? Why don't we talk about it?

Guest: Because we don't talk about money either. We don't talk about sex. Because we're trying to be a pro I don't know. What do you think?

Host: I think that's a little bit of it, but I think the subjects are like deeply personal, emasculating and so intrinsically linked to like self-esteem.

Guest: It's vulnerable.

Host: Yeah, it's like super vulnerable. So And if someone I remember I had a partner turn around to me who interestingly was going through some of the issues that were undiagnosed, turn around once upon a time and expressed that she didn't like having

Speaker A: sex and I didn't understand that at like a 20 as a 23 22-year-old guy.

Speaker B: Yeah.

Speaker A: And so you kind of look yourself in the mirror and go, "Oh shit." Like it's super emasculating. It turned out that there was actually a physiological challenge she'd had.

Speaker B: Yeah.

Speaker A: But we'd been in a relationship for a long time and she wasn't enjoying sex for because there was a physiological issue.

Speaker B: Mhm.

Speaker A: She didn't say anything to me.

Speaker B: Yeah.

Speaker A: I didn't know. And then the day she said something to me, my I didn't know anything about sex. So I just interpreted it as like, "Damn, I'm not good in the you know I might I must not be good in the bedroom or something." Um which is super like hurtful. Yeah. And then that kind of breaks the relationship down and it's all predicated on this like highly emotional, highly self-esteem linked, poorly educated subject which destroys relationships.

Speaker B: Destroys it. I And that's such an important story, right? Because if you had had access to the information, she thought she was protecting you by not telling you that information.

Speaker A: interesting? I went to one of my friends and one of my best friends and said, like, "My partner's just said this to me. Like what does that mean?" And he went to me, he goes, "Mine too." I was like, "What?" I was like, "So youre not having sex with your partner?" He goes, "No." And we And by the way, I'm talking about 30 year olds. He was like, "No, we haven't had sex in 3 months." And I was like, "What What's the reason?" And he said to me, "She said she just doesn't like having sex." And I'm like, "Oh, okay. So that's that's the same in my relationship. My my former ex-girlfriend said she just doesn't like having sex." And I can't tell you how ignorant and poor and insufficient the conclusions in such a situation we arrive at are. We're like, "Well, maybe maybe there's something wrong with me. Maybe it's a sexuality challenge. Maybe it's a genetic thing. Maybe they were just but they were born in didn't want to have sex like we don't we just don't know what it is." From doing this podcast and speaking to people like you, I like, "Oh my god. I just wish like 5 10 years ago when I had these conversations with my guy friends and also with my the ex-partner that I'm referencing, I just wish I knew that it wasn't any of those things.

Speaker B: Mhm.

Speaker A: It was something that um could have been helped.

Speaker B: Yeah. What's so important is that you were able to learn and see and grow in this, right? A little bit of information gave you empathy for this partner where you took it on as a you problem, it became a you problem cuz it was both of you together, but it started with biology. And so, if we actually taught people the biology or to think about biology or to like be able to talk about sex, to talk about sexual health, to talk about genitals, to make them not private parts, how much better would your sexual upbringing really have been? How much less hurt and shame and guilt would you have felt because it actually wasn't you at all, right?

Speaker A: It's the horrible conclusions you arrive at and the the conclusions you arrive at are often seen as both unchangeable and therefore, in my situation back then, the conclusion was, well, this relationship's never going to work. Because the false conclusion we'd arrived at was not something we could we could change.

Speaker B: Mhm.

Speaker A: Uh whereas, when I hear about all of these different things we've talked about today, I go, "Oh my god, there's so many other conclusions I could have arrived at or my friends could have arrived at that would have been fixable and therefore, the relationship, which is a perfectly great relationship with a person, was therefore savable." One of them is the thing we just talked about, which is this idea that men and women have different types of arousal, spontaneous and responsive. And I was looking at some of the data on the variance, which I think is very important for people to know. And it says that men are highly spontaneous in their arousal, which kind of means, from my interpretation, and please correct me if I'm wrong, that as a man, I can literally be I can literally think about something and get aroused. And it's not to say that women can't, but it the data suggests that men are more that way inclined. The data here says that their spontaneous rate in a man is about 70%, whereas in women, it's about 10 to 15%. It says the responsive rate, which I guess is like I get aroused once the ship starts moving, once we start foreplay, once contact starts, is 10 to 15% in men, and in women in this particular report is 40 to 50%.

Speaker B: Mhm.

Speaker A: So, that would suggest to me that women are much more likely to be aroused once, you know, foreplay or contact or the sexual actions have taken place, I'm guessing.

Speaker B: Mhm.

Speaker A: And then the mixed style is 15 to 20% in men and 35% in women. Um is that all accurate?

Speaker B: It's accurate, and I think it really comes to this idea of your path to having a better understanding of that prior relationship was actually education and communication.

Speaker A: Yes.

Speaker B: Right?

Speaker A: If you had a better understanding of the biology, if she had a better understanding of the biology, if she were vulnerable enough to be real with you and honest with you up front as opposed to kind of a bombshell that happened too late, um all of that pain, all of that hurt probably would have looked different.

Speaker B: Right? It would have looked like the world would have looked very different. Now, that's what I'm fighting against because I think that to your point, I think men are suffering. They're feeling disconnected from their partners. They're feeling a difficulty of even finding a partner, and part of that is cuz they lack that curiosity of like, what like, what do they want? What do they need? What kind of communication helps me get to where I want to go with this person? And a lot of that is vulnerability and curiosity and interest, and I think that's what women often are looking for in partners. Is they're looking for someone who's going to give a crap about them enough to care what they specifically need and want, not what gen What do women want, and what is it like like, what specifically about this person in front of me? What does she need to feel that erotic love, support, connection, lust? And for the man, too. Like, what do you need to feel all of those things? And what a good relationship is is when people work together to try to optimize that for everybody.

Speaker A: are the questions that you would ask your patients to ask their partner to start to tease out some of these things? Couples will come up to me when I'm in a restaurant or something, and they'll come up together, and they'll always they'll often say to me that the episode they watched together was about sex. So, I I literally have this image of this particular couple that came up to me when I was abroad, and they said, "We were just listening on the plane about your sex episode." So, I'm like they're listening now.

Speaker B: Like again, I think it's that basic thing of like what does great sex mean for you?

Speaker A: Okay.

Speaker B: [clears throat]

Speaker A: What what do you want? Like what what is a great time? What's it something fun? Like what is it about sex that you enjoy? When you ask people what do they get out of sex, it's like 200 different reasons. Everyone wants something different, and everyone doesn't always know what they want. And then having that ability, if you don't know what you want, is having that curiosity to explore together.

Speaker B: So, with that said, 200 different opinions on what good sex is. And this is kind of what I think you find in couples. And when I've sat with my partner before and said like what do you what arouses you during sex? What do you like? The two things can often be different.

Speaker A: Totally.

Speaker B: And so, is this not a problem that one partner might say, "I really want you to tie me up and da da da da da." And then the other partner might say, "I really want you to not tie me up and be really soft and gentle." And there's a bit of a dichotomy between sorts of sex preferences,

Speaker A: Mhm.

Speaker B: which means no one's really ever getting what they want. Like how do you navigate that?

Speaker A: When you go to buy a house, you don't always

Doctor: Like there are compromises in life, and and there is no all good or all bad. You're never going to find

Doctor: this is actually the problem with pornography is you figure out the exact porn in the exact situation

Doctor: or even worse with AI. Like you're going to have a sex robot who's going to be able to do exactly what you want in the way that you want to do it

Doctor: and people are afraid about what that means for intimacy and relationships and great sex going forward

Doctor: because the truth is sex is messy, it's awkward, it's smelly, there's fluids, there's funny noises, there's like it's it's vulnerable,

Doctor: it's like really uncomfortable sometimes for to like have these deep conversations, but isn't that why life exists?

Doctor: Like isn't that like the most fun part is when you can kind of have that with somebody else where they know all of you and they want to explore that with you.

Doctor: Now, if it's not the right relationship, it's not the right relationship, right? Like and and figuring out if that is an important part of your life and it's a non-negotiable,

Doctor: then find the rooms where there are other people who do that those things too. I mean, what you will find is that people have all sorts of agreements and relationship setups

Doctor: and as a sex doctor, like the things I hear in a room like would, you know, are quite wild and you you wouldn't even believe.

Doctor: Like people are doing Well, I think people have multiple like there are there are people who have open relationships. So, they have multiple partners or they have certain kinks, right?

Doctor: So, there are things that they really enjoy that maybe somebody would look at that and be like, oh, that's very strange, but there are other consenting people who also are comfortable and want to do those things.

Doctor: There are websites that deal with different erotica and different kinks and things like that. And there's also this idea of fantasy.

Doctor: It's also okay to have things that you think about but that you don't actually want to partake in and and that you use.

Interviewer: On this point of fantasy, what if you have a you probably have experience where someone's come to you and they have a fantasy

Interviewer: but they don't want to tell or a kink and they don't want to tell their partner because they're worried about the reaction.

Doctor: Yeah, this is where things like sex therapy become really helpful of how do you have a third party?

Doctor: Cuz again, when your doctor's telling you to do something or bringing something out, it's it's so much less scary than if you're doing it on your own.

Doctor: There are also different like apps and things like that where you can sort of dip a toe where you you you have There's one called Spicer, I believe,

Doctor: where you can sext each other in ways and they'll push questions. If you both agree, it'll tell each other that you both agree with things.

Doctor: So, there's ways to dip a toe here and sort of be curious about it, but again, that's where watching things together or asking the questions.

Doctor: This should happen not when you're naked in the bedroom actively having sex. Like it's okay to have conversations about sex when you're not having sex, right?

Doctor: Like you plan these podcasts before you actually sit down to record. Afterwards, you talk with your team,

Doctor: "Hey, this is what I liked about it. Here's what I didn't like. Let's change this in the future. Let's never have Dr. Ruth Westheimer on again, right?"

Doctor: Like these are the conversations you're going to have with your team. People don't do that about sex very often, right?

Doctor: They don't actually do after action. What went well? What didn't go well? Do you ever want to try this? Like what would be fun here? Like there there is often a a lack of curiosity.

Interviewer: And to be you are sex doctor, but people come to you and sort of offload their sex lives to you.

Doctor: My job is so fun. I love my job. It's so fun because people will talk to me about their most

Doctor: Like we do 2 hours and we talk about their lives in the context of their sexual health for 2 hours and people never have those types of conversations even with their partners.

Doctor: And it is incredibly vulnerable. It's incredibly important for people to see that and see, "Oh, that was actually really nice to talk about. I didn't know this, that, and the other thing about my body."

Interviewer: And what you find that men and women typically are hiding from their partners when they do confide in you?

Doctor: I think they don't tell their partners just about anything. Like they don't There's a lot they don't tell their partners, right?

Interviewer: Is there a difference between men and women what they are not saying?

Doctor: That's a great question. I would say that no one is talking about sex at all. Women are hiding their pain from their partners.

Doctor: Men are hiding their um insecurities and their frustrations and there's a lot of shame around erectile dysfunction and sexual problems in men

Doctor: and so they a lot of people just either stop having sex or stop talking about it or sort of have a mediocre sex because they are not that great at talking about these things.

Interviewer: And I imagine your I mean my first reaction would be like, "Oh, you should tell them." But I imagine that doesn't necessarily work.

Doctor: I think it's a challenge. Like if you have had if you have been faking an orgasm for your entire relationship

Interviewer: And women have been.

Doctor: Yeah, many. The statistics are quite clear. Like if you're only having penetration and your partner orgasms every time and it's a perfect orgasm every time,

Doctor: I would say there's a high percentage that that's not real. Because the truth is is orgasm often takes a lot of arousal and a like like again, stopwatch.

Doctor: Every header if a penis enters a vagina and they orgasm about 5 and 1/2 minutes is on average how long men last, right? Like that's science. It's about 5 and 1/2 minutes.

Doctor: Now, if you're longer, great job. If it's shorter, it's okay. It's all within the range of normal. Women, if penetration is happening,

Doctor: almost nobody orgasms in 5 and 1/2 minutes. It's usually well over 13, 14, 15 minutes and penetration is usually not how that happens.

Doctor: Cuz again, if you're distracted while you're trying to stimulate your penis, it's going to take longer. Women need focus on the clitoris.

Doctor: So again, if your partner is orgasming every time within that 5 and 1/2 minutes and it's like clockwork, I would call [ __ ] on a high percentage of it.

Doctor: So but but a partner doesn't want to tell you, right? Like they're afraid to tell you cuz they're they want to make you happy, right?

Doctor: It's not that they're having bad sex. They just know that that's not what's going to get them to orgasm and they want you to be happy and to feel supported.

Interviewer: So that presents a pretty good case that the woman should orgasm first.

Doctor: I think so because I think orgasm first will allow for pelvic floor release and relaxation, which will make penetration more pleasurable, enjoyable.

Doctor: I think women can have multiple orgasms, so there's a case to be made for before and after.

Doctor: Why are women having zero orgasms, men having one orgasm when women could be having three orgasms and men have one orgasm?

Doctor: So I think we should be actively trying to change the orgasm gap and focus on the pleasure and I think making penetration the main event is where the challenge

Doctor: I think penetration can be part of the whole story but doesn't necessarily always need to be the main event.

Interviewer: On the physical blockers you talked about some of them like anxiety. One of them that I think isn't talked about enough especially in the modern world

Interviewer: is what they call like the dopamine drain where you've got mental burnout or chronic stress or we talked a little bit about depression but I did notice that through my life when I'm very very overworked shall I say my libido is not the same.

Doctor: Yeah.

Interviewer: And this is also the case for for women as well. Do you have a lot of women come to you or couples come to you where this is quite clearly the problem this sort of like dopamine drain

Interviewer: it's actually their stress and lifestyle it could be the kids it could be

Doctor: Oh it's a huge problem right? It makes logical sense again if we go back to the fundamentals of

Doctor: if you're not sleeping if you're overworked if you're burned out if you have no white space for yourself why are why are you going

Guest: to have all this excitement for your partner and all of these things like if we're scrolling all the time at bedtime or if we're watching porn all the time or we're watching reading romance novels all the time but we're not talking to the partner with that we're with or we're not creating that time and space I think there's a big opportunity for people in our modern society which is over scheduled to schedule sex. I mean they do this quite well. So when you were dating right and you would ask your your date you know let's go out Saturday night you were literally scheduling potential sex. You're like I could get lucky I'm going to plan for it all week I'm going to get excited I'm taking this person out I'm like it's going to be really fun and I'm going to do whatever it takes to sort of cross that finish line. So we were always scheduling sex and it was very erotic and fun when you're in your dating life and now you live with a person and you sort of they see you at your best they see you at your worst they see you at your crankiest and your most tired and so it's really hard to get that level of excitement when you're dealing with those, you know, sort of life circumstances.

Host: People will say that, you know, there's a spontaneity myth around sex that it should be spontaneous and that's kind of how we see it in films. Like they grab you in the hallway and you start kissing and whatever else.

Guest: not real. It's just the same as WWF. Like it's not real. And so that's the truth is like you If you see your partner every day and you see your partner your high and your low and the crankiest and all of these things and you're all working like crazy, where is the space for that? Like that's not how humans work. So creating That's why vacation sex is always fun for people or they find time, you know, so again, if you've got kids and your kids are staying up later than you are and you don't have a lock on your door and you're worried about making noises and you don't want to be too loud. Like how are you going to have great sex in that situation?

Host: One of the I guess the challenges people might also bring up is that if you're scheduling sex, it puts a lot of performance pressure on you. If I know tonight at 8:00 p.m. I have to have sex because that's the time we scheduled this week, then like, gosh, I'm going to be finishing my work at 5:00, 6:00, 7:00. I don't know. I need to get home. [snorts] I need to have I need to have sex as well. Gosh.

Guest: So So this is where you schedule it around a time that you know is going to work for you. So I do I tell people to do things like quarterly dates. So I get I Listen, I'm working in DC. Everyone is very high-powered with very busy jobs. I say one Friday a quarter, you and your spouse can literally block your calendars. One a quarter cuz quarter. Okay, that means you might have sex every week. You might have your your your eight late night sex whenever. You could might have sex whenever you have sex. But once a quarter, have a day where you just block it out and you have a spouse day or a partner day or whatever it looks like and maybe do an act It doesn't necessarily have to be a sex day, but you actually take time of your little mini Maybe you go on a walk. Maybe you go on a hike. Maybe take a bath. Maybe get a massage. You kind of create space for you to actually say, "Oh, wait, we like each other. Oh, we like talking to each other. We don't have to just talk about the kids all the time." So again, the more you invest in each other and in a joyful way, the better sex you're going to have.

Host: What about self-esteem issues? You mentioned that as well. Body image issues. How often do you see that being the blocker to great sex?

Guest: It's a huge problem. Again, I wish that the energy that my female patients put into wanting to be skinny is is enormous and I wish that energy was put into wanting to be strong, but it's kind of funny because what people think about themselves versus what they think for their friends are very different. Your best friend, say they're overweight. Do they deserve great sex?

Host: Of course.

Guest: Of course they do, right? Your best friend deserves great orgasms, great sex, no matter what they look like, no matter what they weigh. Everybody deserves intimacy, pleasure, and connection with someone that they can have intimacy, pleasure, and connection with. But for some reason when we think of ourselves, "Oh, I can't be naked with this person. Oh, I can't be happy until I lose this much weight. I don't deserve an orgasm unless I am, you know, skinny." And that's a huge problem.

Host: So, what do we do about it?

Guest: I think it's empowerment, it's communication, it's explaining to people. I think that all of the mindset stuff that you do and you talk about is so important cuz look, you changed your mind around your own situation with this ex of yours because you got education, right? You were able to see that it was more complicated than that. And I do think by educating people on bodies, on pleasure, on joy, on connection, on intimacy, I actually think it changes the narrative. I think people we're in a sex recession, okay? People are having less sex than ever. People are not connecting, people are scrolling and they're on their AI chatbots instead of like human connection. We're getting worse at this, not better. I I I just think that like we have to reach humans and we have to be able to talk about it to change the narrative.

Host: What is the the most important thing we haven't talked about that we should have talked about as it relates to all the work that you do?

Guest: I think the most important thing is that biology matters in women and we often spend so much time talking about psychosocial issues, about emotions, and all of that is true. That is important to sexual health, but we minimize biology when it comes to women, and we have to let women advocate for themselves about the biology, and we need to train doctors to care about the biology. I would love to find out from all the women in your life and the women on your team, like what experience Like I would love for you to ask them their experiences with medical providers, cuz I don't think we have that curiosity of like what are you experiencing that's different.

Host: Yeah, I think that I Yeah, I think that's probably going to have to If for me to have like a healthy relationship with my partner, I think that's going to have to be uh practice or like part of our You know, we check in on our relationship, etc. But we don't really check in on the physiology.

Guest: So, super interesting. So, I spend 2 hours with people, and there are times when the partner comes to that talk. And so, they get to hear sort of what their partner is describing. They even get to see the exam, and they get sort of a tour of their own partner's body parts. And so, it is helpful sometimes to bring partners into those conversations, the biology conversations, of like she doesn't want to have sex with you not because you're bad at sex. Look how painful it is right here at the opening of her vulva. It's like a sunburn. I touch it with a Q-tip, and she's on fire. Like, what do you think your penis is doing? And it gives that ability to say, "Oh, it's not a me problem. How do I support her best knowing that this is the issue?" So, getting partners to understand the biology is extremely helpful. Or, say you have a man who's taking an antidepressant or a hair loss medication that can cause sexual dysfunction as well. Um say you have a man who takes an antidepressant and it lowers his libido. Is it, "Oh, honey, you're not attracted to me anymore. You must not love me." Or, is it, "I actually understand the biology that your libido is lower because of this antidepressant." And two things can be true. So, so I think understanding your partner's biology and your own biology is quite important.

Host: Yeah, I guess that's the the crux of the conclusion really is that both education and communication are where it all begins.

Guest: Which is the fundamentals, right?

Host: Yeah. And I think here gosh, if I had better education on these subjects got at the start of my adult life and also I had like figured out how to

Stephen: communicate with my partner and maybe even also with yourself. And like to be a bit honest with yourself about how you're feeling, not to gaslight yourself, not to gaslight your partner. Just It just goes to show how better relationships would have been, not just with your romantic partner, but really with all the people in your lives. And this is easier said than done. Like especially the communication part. Because these are very, very sensitive subjects. And so we we'd rather just shut up about them and keep them as these sort of like secrets among that we whisper about with the closest people in our lives, maybe our best friend. And I just think generally one of the things I've come to learn from doing this podcast as well is that you know, there was this quote I read. It said you can predict the long-term health of a relationship by whether each challenge heals to 101% or 99%. Does your conflict make you stronger? And what it's essentially saying is like conflict is guaranteed in life, but the thing that's going to turn your conflict into a strengthened relationship or a weakened one is your how you deal with it. Like and that's all predicated on communication. And so if we can just teach people how to communicate, if we can become better communicators, which is both function of speaking and listening and I guess curiosity then all of these downstream challenges and misunderstandings would have a chance of being solved for. And I think about this all often. I think often think, okay, how I'm communicating with my partner currently is really going to determine whether we have an argument in two years time or a year's time or six months time. Our strategy of communication. Does she feel safe expressing a problem? How do I receive the problem even when it feels like I'm being blamed? And vice versa. And then are we open-minded about solutions or do we come with a bias around this is the solution, this is what I think the correct answer will be. I've spent a lot of time, you know, I'm like 7 years into my relationship now, almost. So, I spend a lot of time thinking, okay, like how do people go how do they build a relationship like 50 years? And the crux of it seems to be conflict resolution / communication. That seems to be the crux of it. And actually with finance issues that we talk about with finance experts, always sex issues, the crux of it seems to be conflict resolution / communication. And I also know, cuz I know lots of couples, that we're all living on a different spectrum here. Some couples are like they come home at 6:00 p.m. and all they want to do is talk about the most sensitive subjects. And then you've got this other group of couples who almost don't talk about anything. They're kind of like strangers that are like burying everything in the cupboard. And they think burying it in the cupboard means that it's out of sight, out of mind, and it's not impacting anything. But again, you come to learn that any problem buried raise its head in unexpected ways. And you know, I'm thinking of one particular friend of mine who was in a relationship for 14 years, had a baby, they kind of stopped having sex, didn't really talk about it. They become like parallel lines that are drifting apart. And they get, you know, several years later go, "What happened? What happened to our relationship?" Well, they never spoke about it. So,

Guest: >> I think you understand this perfectly, and for you to see it in this you can help so many people because I think these are the fundamentals. How do we teach young people and old people that conflict resolution is important and intimacy and vulnerability are important and biology is important, science is important, and we can do this. I I just taught you a few things that I know today, and you Not only did you understand it, but you were curious about it to ask further questions, and you can now figure out how it works in your own relationship, in your own life. You're even caring enough about thinking about your friends' lives. And so, if you've shown that this matters and this is important, I just think how many people are going to benefit by your vulnerability and your curiosity and saying, "Oh, I could do that, too."

Stephen: >> Yeah, it's crazy, isn't it? That like if you love this person so much, yet you don't often love them enough just to communicate about some of these like sensitive, tricky subjects, which is like craziness when you articulate it like that. Like I've been in relationships where I just absolutely love this person, but no, I wouldn't I wouldn't raise X, Y, and Z subject. It's just it's just too uncomfortable.

Guest: >> And the few times, I guess I will ask that you have been vulnerable, has it gone well or not well?

Stephen: >> gosh, it's like the most important thing. I just I always think, "Why didn't I do this sooner?"

Guest: >> Mhm.

Stephen: >> I I Yeah, okay. So, to be even more honest, I like didn't have conversations with my partner about sex at all. Like I just I assumed she liked it. I think she assumed I liked it. And it wasn't until like a year further into the relationship that you start going like, "Wait, I don't think this is how this person wants to have sex." Or I don't know. I actually have to give her the credit cuz she's the one that started like pushing on the communication. I think sometimes as men we just You know, that that old slightly toxic phrase, "Happy wife, happy life." I think sometimes as men we just kind of assume that if no one's saying anything, then everything's great. But it takes two to tango.

Guest: >> And I think expecting your partner to have all the words and to know everything is the wrong answer. So, that's where again, that third party, whether people come to see me together as a medical person or a sex therapist or or a third party to help you have that conversation, cuz I think we assume our partners know everything about their own bodies and can communicate about their own bodies, and that's just not true. Even showing that curiosity makes you quite evolved, right? And I think that that's the energy that we need in 2026 is breaking down those barriers because it will lead to stronger relationships, it will lead to stronger partnerships, and it's those hard moments that you grow the most from.

Stephen: >> You need the words though as you say.

Guest: >> Yeah.

Stephen: >> When you say you need the words, what what what specifically do you mean by that? You need to know how to start the conversation, how to handle the conversation, how to receive a subject that might be a little bit offensive, that might hurt your ego a little bit. Is this what you mean by like have the words?

Guest: >> hard to do that on your own because people don't want to hurt other people's feelings. And so just saying it as it is may not be the right approach either. That's where again couples therapists are very good at holding space for those different conversations. And I think one of the other problems here Stephen is many times there's no bad guy. Of course when it's obvious someone cheats on someone, someone breaks trust, yes there's a bad guy. But so often, you know, say someone has a higher libido than someone else. There's no bad guy. That person has a high libido and that person has a low libido. There's no evil bad guy, but there is still conflict. And so how do you deal with conflict when it's not a good guy bad guy situation, but you and how do you love someone and evolve with them, right? Like I think it's not easy.

Stephen: >> I think your point there though is actually where it starts often which is this point of empathy. The minute you realize that there is no bad guy. Just as you said it, I thought oh my gosh, yeah. Back when I had those intimacy challenges in that relationship, it was a case of trying to figure out who the bad guy was. I was like, is it me? Is that me problem? Is it a you problem? That's kind of like what the brain jumps to. But actually now that had time passed and we figured out what it was, turns out that it was neither of us. It was really the whole time not me against her or her against me. It was me and her against the problem.

Guest: >> Mhm.

Stephen: >> And that refrain, I think removes the like shame, the blame, and all that stuff that gets in the way and focuses you

Host: ...as a team on resolution and conflict resolution. Thank you. You've you know, you said that I will help people, but actually you're the one that's helping people. I'm just asking questions and uh

Dr. Rachel: I disagree. I think it's the simple is the vulnerability of watching others. It's the simple stuff that makes the biggest change.

Host: Why does this matter so much, Jack? I can see it in your face.

Dr. Rachel: Because so many people are hurting. Relationships are hurting. People's health is hurting. People aren't having as much pleasure and joy and quality of life that they could be having using what we already know to be true. Simple things, communication, connection, education, basic medical care. These things can bring so much joy, health, great relationships, great living. I see it every day in my clinical practice and I want that. I want that for every person out there and I want them to fight for it and I want them to advocate for it and I want doctors to show up in a big way to help them and I think we can do it. But I I I am so passionate about this because I see all the like I see how much it's not being done.

Host: Dr. Rachel, we have a closing tradition where the last guest leaves a question for the next not knowing who they're leaving it for. The question left for you is, what would be one thing you would like to do or improve in your life tomorrow?

Dr. Rachel: I would like to get better about practicing what I preach because we always say the shoemakers kids don't wear shoes. I am addicted and obsessed with what I do. I love my work so much, but I don't necessarily spend as much time lifting weights that I should or not scrolling on my phone and paying attention to my children that I should. I don't spend as much time, you know, scheduling those quarterly spouse dates that I tell other people to do. And so I think practicing what I preach is a huge opportunity for me.

Host: Well, that's refreshing to hear cuz none of us are perfect in that regard. So, it's good to know that just having all the information doesn't necessarily mean um it's easy to execute upon.

Dr. Rachel: Easy to do, easy not to do.

Host: Amen. Um where do people go to find more from you? Do they go to your Instagram, your website, your YouTube channel? Where should you Where should they go?

Dr. Rachel: Yeah, our website is really fabulous. We are very big into research, education, advocacy, and mentorship. So, rachelrubinmd.com that would lead you to sign up for our newsletter which is really an incredible source of education. We are extending you the the latest and greatest in studies, research that you can be a part of, job opportunities, um and advocacy for clinicians. We have courses in teaching you how to do this both free and uh ones that come with continuing medical education. I would say Instagram is um the most popular for me right now. Uh although we're trying to get louder. If only I had your skills, I I would love to be louder on YouTube and other places. Uh we do have a clinical practice both in Washington D.C. and Los Angeles. And so, if we can help in any way on the sexual health side, please reach out to us because sexual health is just health and your quality of life absolutely matters.

Host: I'll link all of that below. And I hope people sign up for your newsletter as well. That sounds really interesting.

Dr. Rachel: Thank you.

Host: Dr. Rachel Rubin, thank you so much for all of this. Um I think it's it's so so telling that your conversations are often the most shared on the podcast and in generally in podcasting because the subjects are so um so important to so many people's lives and they can relate to feeling not themselves as you say, but there's very few people out there that have the credibility, the experience with patients, but also the the ability to articulate it in a way that's highly accessible like you have. So, I know that you you know, we talked beforehand, you don't necessarily love doing this, but um it's a very very important worthy cause cuz there's very few people that can speak to these subjects with the in the way that you can. So, please keep doing it.

Dr. Rachel: So kind.

Host: Anybody who's listening now, I highly recommend if there's somebody in your life that might want to listen to this conversation, I think there's a reason why Dr. Rachel's conversations are always the most shared. Um please do share it with them. Dr. Rachel, thank you so much for your time.

Dr. Rachel: Thank you.

Host: YouTube have this new crazy algorithm where they know exactly what video you would like to watch next based on AI and all of your viewing behavior. And the algorithm says that this video is the perfect video for you. It's different for everybody looking right now. Check this video out and I bet you you might love it.