Optimizing Vaginal Health During Menopause With Urologist Dr. Rachel Rubin

For our first webinar of 2024, we went BIG. We were so excited to have Dr. Rachel Rubin with us! 

Dr. Rubin is a board-certified urologist and sexual medicine specialist. She’s an assistant clinical professor of urology at Georgetown University and owns a private practice in the Washington D.C. region. One of only a handful of physicians fellowship-trained in male and female sexual medicine, Dr. Rubin is a clinician, researcher and vocal educator in the field of sexual medicine. In addition to being education chair for the International Society for the Study of Women's Sexual Health, she also serves as an associate editor for the Journal of Sexual Medicine Reviews. Her work has been featured in the New York Times, PBS, and NPR, among others.

Dr. Rubin talked with Alloy’s community manager, Rachel Hughes, about all things vaginal health. Be sure to check out the whole webinar on our YouTube, and read some highlights from the interview (which have been edited for brevity and clarity) below!

Rachel Hughes: Welcome, Dr. Rubin, to the Alloy community. Thank you so much for being here.

Let's start with what urologists treat. I think many people don't realize that your specialty encompasses all of what it does and why you may be the right person to see, for a variety of reasons, in perimenopause and menopause, and I would argue even earlier, but that's perhaps a different conversation.

Dr. Rachel Rubin: Thank you, I am thrilled to be here. 

So, it's confusing, right? Urologists are penis doctors, right? I'm a penis doctor, but what people don't realize is that urologists are board-certified to take care of all genders and all genitalia. Everyone's got kidneys and a bladder and a urethra and sexual organs. I deal with issues of libido, arousal, orgasm and pain. These are really important issues and they're very bio-psychosocial issues. 

I strongly believe that treating menopause is not one size fits all. It's not just a “here's your package and go.” If we can get to know you and get to know what you care about, we can customize treatments that make sense for you and your life and your life stage. And so I know we're going to talk a lot about bladder health because bladder health and sexual health are very intricately linked.

Rachel Hughes: You perfectly illustrated why this matters so much to health overall. I don't think people realize, certainly I never did before, how intertwined bladder health is, for example, with health in general and longevity. 

Dr. Rachel Rubin: A lot of people don't associate bladder issues with menopause, but the bladder is a very hormonally sensitive structure. The opening to the vulva is actually bladder tissue. When you lose hormones, it increases your risk of urinary tract infections. And you can die from a urinary tract infection. It might not kill you at 30, but it might kill you at 80 or 90. So it's really important that we understand the hormonal relationship. And while hot flashes might go away eventually, bladder issues often get worse and worse over time. And there are safe and effective treatments. 

Rachel Hughes: So let's hover there for a little bit and sort of illustrate for us, if you will, what happens in perimenopause and menopause hormonally and why this impacts this whole region that you treat.

Dr. Rachel Rubin: Absolutely. So the genitals-- the vagina, the vulva, the clitoris, the urethra, the bladder-- that tissue is very hormone-sensitive, and has both estrogen receptors and testosterone receptors. The hormones in your body are important for that tissue to stay strong, healthy, and to prevent and fight infection. And when your hormones are fluctuating, you may see your symptoms fluctuate as well. And symptoms like frequent UTIs, dryness, urgency, and frequency, can start way before your periods end.

Rachel Hughes: Can we talk about bladder prolapse?

Dr. Rachel Rubin: Think of the vagina as a house. Sometimes, the ceiling can fall down, sometimes the floors can come up, and sometimes the walls can crash in. Prolapse is when things are dropping. Your uterus may drop down, your bladder may drop down. If you feel a bulge, if you feel anything falling out of your vagina, that might be prolapse. It isn’t usually painful, but it can feel heavy, and it can come with all sorts of bladder symptoms and things like that. And you should be treated for that. There are urologists who can treat you, there are urogynecologists who can treat you, and there are a lot of people who specialize in prolapse issues. And there are treatments that are minimally invasive, maximally invasive, and everything in between. 

Rachel Hughes: Yesterday was lichen sclerosis day. Can you tell us what that's all about?

Rachel Rubin: Lichen sclerosis is an autoimmune inflammatory condition that can create a lot of scarring at the vulva. It's a condition that attacks the skin. It can happen in other places, but we see it commonly in the vulva. It's not rare. And so if you have any sort of white looking, almost thin, papery itching and scarring, or you're losing your labia minora even, that might be lichen sclerosis. And you need to see a doctor who specializes in it. Some dermatologists do it. Some of our specialists do it as well. And there are two really important strategies when you're treating lichens sclerosis. First of all, it is imperative that you get a biopsy and a diagnosis because that inflammation can turn into vulvar cancer. It's also important that you are treated with maintenance therapy for life because you have to keep that inflammation away. Sometimes, people are given topical steroids to fix the lichen, which is helpful, but you also need to treat the hormonal changes, because what happens is that hormone depletion causes inflammation to go into overdrive. A local topical hormone and a steroid used one or two times a week as maintenance therapy can work together to help keep it from coming back.

Rachel Hughes: Thank you. I also want to segue into people who are suffering from thinning vaginal skin, dryness, irritation, and painful sex, but who do not have sclerosis. Can you speak to that? 

Dr. Rachel Rubin: It’s important to treat the genitourinary syndrome of menopause. Let’s talk about vaginal hormones. It’s not enough to go into your bloodstream, so it’s not whole body menopause care; it’s local. It’s safe for everyone, and we can use it to keep vaginal tissue strong, healthy, and lubricated, which is so important. The pH of your vagina is supposed to be four and a half. It’s supposed to be acidic so you can fight infections. And it’s important for your vaginal skin to be thick and lubricated so you don’t experience pain and dryness and so that you can enjoy sex. Vaginal hormones are very, very safe, and extremely effective. And if you’re using them, you need to be using enough of them that they’re actually working. 

Vaginal symptoms don’t get better without treatment. And vaginal hormones have been proven over and over and over again to prevent urinary tract infections by way more than half. I mean, there's data going back to the 1990s. The fact that we are not using more vaginal estrogen is a marketing issue. That’s why I’m on social media. It’s not safety, it’s not efficacy, it’s not cost. It’s marketing. People don’t know they need this.

Rachel Hughes: When do you suggest someone start?

Dr. Rachel Rubin: So, I'm very aggressive. There's no right answer here. Certainly if you have any urinary symptoms, frequency, urgency, leakage, getting up at night to pee, any UTI symptoms, any pain with sex, any dryness, yes, you should be on vaginal hormones. But I believe strongly in prevention. I never want you having symptoms, and there is no danger to vaginal hormones. So, we’ll use them in people in their twenties and thirties because you’re not adding any risk. You can’t overdo it.

Rachel Hughes: What if you’re taking oral estrogen or using a patch?

Dr. Rachel Rubin: Topical estrogen is still almost always necessary. We don’t have a perfect number for this, but for some reason the pills and patches do not fully fix local symptoms. So if you’re on a patch or pill and still have any symptoms, adding a vaginal hormone is a must. 

Rachel Hughes: Thank you. Let’s take some questions from our audience. “Will vaginal estrogen trigger yeast infections if you’re prone to them?” 

Dr. Rachel Rubin: So, if you start vaginal hormones, in that window before you get your maximal acidity to fight infection, occasionally a yeast infection can pop up. But we can treat that. And it’s not super common.

Rachel Hughes: Great. Somebody asks, “I have bladder prolapse and at times I feel it coming out of my vagina. I saw a specialist, but she said to do nothing yet as I am stage two. Any suggestions? I had a hysterectomy years ago.”

Dr. Rachel Rubin: Pelvic floor physical therapists and vaginal hormones are your key to happiness. And so again, the actual prolapse itself probably isn't bothering you as much as the lack of hormones in the tissue. If you’re feeling bulgy, it might be because of vaginal dryness and irritation that can come from not having hormones. So add those back in and do some exercises to strengthen your pelvic floor.

Rachel Hughes: “Asking for my 84-year-old mom, who gets UTIs almost monthly and was refused estradiol cream because she had breast cancer 20 years ago. What can you recommend?”

Dr. Rachel Rubin: Good question. You got to show mom, every video I've ever done, every tweet I've ever done, and get her to fall in love with me on the internet. You’ve got to find a way because it is the UTI I that's going to kill her. She will not die of breast cancer. She's going to die of a urinary tract infection. So, find a knowledgeable urologist or gynecologist.  And don’t give up.

Rachel Hughes: Thank you so much for everything today. Where can people find you? 

Dr. Rachel Rubin: So, on Instagram , Twitter, and Facebook it’s @drrachelrubin. We also have a website, rachelrubinmd.com. We have a newsletter, and we also have a clinic. Our practice is growing, and we’d love for you to follow along! Thank you for having me. It’s been such a pleasure. 

Rachel Hughes: Always a pleasure. I also just want to let everyone know (shameless plug!), that we have access to doctors who know how to get to the root of what is troubling us. That's who we are at Alloy. We are a telehealth platform. We have menopause-trained physicians who are aware of what your needs are and how to get them to you. Thank you so much for being here, Dr. Rubin.

Watch the whole webinar (there’s a lot more!) on our YouTube. And, follow us everywhere @myalloy to learn about upcoming webinars!