Clitoral Adhesions & Testosterone: Dr. Rachel Rubin on What Doctors Overlook

Dr Sameena Rahman (0:0.742)

Okay. Hey y'all, it's me, Dr. Sameena Rahman, Gyno Girl. Welcome back to another episode of Gyno Girl Presents, Sex, Drugs and Hormones. I am super excited. You guys heard the intro. You my dear friend and colleague is here today and I'm gonna introduce her like Oprah would. It's Dr. Rachel Rubin. Oh, I wish. But you get a vibrator though, baby. Not that you need another one. Not that you need another.

Rachel Rubin, MD (0:20.206)

Do I get a car?

Rachel Rubin, MD (0:26.208)

I have many behind me right now.

Dr Sameena Rahman (0:31.515)

Well, thanks Rachel for coming today and bringing out your knowledge to the rest of the world as you do so well. So I appreciate you being on today.

Rachel Rubin, MD (0:42.104)

I am so happy to be here and I cannot believe we haven't done this before.

Dr Sameena Rahman (0:45.490)

I know, were just talking before that our lines got crossed many times. Listen, I want to talk about the funny story of how when I first met Rachel actually, because this will evolve into her clitoral information story, but I met her I think when she was a fellow with Dr. Erwin Goldstein and she was presenting the clitoral lysis of adhesions that they were just learning, were just learning how to do or like presenting the data on it basically.

Rachel Rubin, MD (0:52.546)

Thank you for all the work you're doing.

Dr Sameena Rahman (1:15.766)

And I remember like after that I went home and tried to, you know, had my first patient with one and I called Rachel and she was very helpful. Maybe that was a year after, but still it was like, you in that time period.

Rachel Rubin, MD (1:27.820)

I remember talking to you. You were some gynecologist in Chicago and you were asking for help. actually remember I was in front of a pool. I was at some conference and I remember being on the phone with you. It's incredible how many years later and how we're still doing this.

Dr Sameena Rahman (1:39.012)

Yeah, I was like, I know. I know. I know. It's great. We all love what we do. I think this is a good time to talk about like how you guys did this whole like, okay, why we all know that

New York Times paper like half the world has a clitoris and nobody's talking about it. And I think that we can credit you and Ishwish and the Goldsteins and everything for really bringing the clitoris to the forefront of our attention because nobody was talking about it and nobody was learning how to evaluate it. And I think that's a big problem when it comes to really female pleasure and sexual function as we all know. But can you tell us the story about how that kind of evolved and why the research was done?

Rachel Rubin, MD (2:21.898)

Yes, no, I love this story and let's talk about it because it's a really fun story. So the clitoris is and the penis are exactly the same thing, right? When we are in the uterus, we all have the exact same anatomy and then depending on chromosomes and hormones, you develop a penis or you develop a clitoris, but they're made of the same tissue. They look the same, they act the same. It's just that women don't penetrate with or pee through their clitoris and so science has completely ignored it forever.

Dr Sameena Rahman (2:49.746)

Yes, yeah.

Rachel Rubin, MD (2:51.368)

And the challenge is most of the clitoris is internal, is inside the body. And it's not really in our anatomy textbooks. We're not really taught it in med school. And when we are taught in med school to do a physical exam, a pelvic exam on a person, I'd to hear your experience if you remember it from med school, but when I did it, you had one standardized patient. Now, the one I had looked like my mom, which was super weird.

and she had a big Rosie the Riveter tattoo on her breast. And it was like so crazy, because I was in a room with five of my friends and I was about to do a pelvic exam on someone that looked like my mother. It's kind of weird. But anyway, so you get one shot at doing a breast and pelvic exam, because there's five people in the room and you don't want to do too many on this lovely volunteer that is doing this. And so what do you learn at that exam? Well, you learn to put the speculum in, you learn to find the cervix, and you get one shot and that's it.

Now, if you're lucky and you do an OB-GYN rotation, maybe you'll get to do more. But really, for many people, it's not until residency that they get to do a lot more exams. During that exam, you are taught, don't touch the clitoris as not to make this lovely patient volunteer uncomfortable. And now, if you think of it, right, like have I ever been told, don't

touch the penis. I'm a urologist, right? I'm a penis doctor. You're a gynecologist. I'm a urologist. Can you imagine if I was taught, don't touch the penis because you don't want to make the patient uncomfortable. It's not a thing, right? You learn how to examine a penis. So here we are. No one teaches you how to examine a clitoris. No one teaches you how to talk about the clitoris or ask about orgasm to all your listeners. Your doctor's never asked you, how's your orgasm? How's your libido? It's not something doctors routinely talk about. And so it's kind of this completely missed

o when I was in fellowship in: 2016

Rachel Rubin, MD (4:59.470)

you actually can't see the full head of the clitoris, which should look like the head of a penis with the little rim. know, the penis has a little mushroom head, the little rim around, it looks kind of like a mushroom. That rim is called a corona. And so 23 % of people, when you tried to pull back the hood, you couldn't see the corona. Now, some were mild, where it was like you could see, almost see the corona. Some were moderate, where it was pretty significant. And then some were so severe, you couldn't see any piece of that little gland, the little head of the clitoris. And then you oh, that's interesting.

udy was. We published that in: 2016

Dr Sameena Rahman (5:55.975)

Hahaha.

Rachel Rubin, MD (5:56.642)

And that's it. And so we would do routinely and the fellow before me actually developed this office-based procedure. Her name is Sharita King and she's an incredible doctor in Georgia. And she created this office-based procedure where actually we just spread apart those adhesions and we get rid of the adhesions. And so we had been performing that procedure quite often, but we didn't have any data. We didn't know who it was helping. We had anecdotes of like, wow, this patient really had benefit. This patient didn't have benefit. We had no data.

And so I started a research team around this time with medical students. And we meet once a month on Zoom. We call ourselves the Sexual Medicine Research Team or SMRT. And we have this growing group of medical students. And these three medical students said, Ruben, we need data. I was like, yeah, we need data, but I'm too busy to get the data. So they said, we'll take care of it. They wrote up the IRB. They got approval. They created a whole questionnaire. And they spent a lot of time going through all the patients who I had done this procedure on and said, how did we do? And the data.

was unbelievable. It was about 60 to 70 % improvement, whether it was for decrease in pain, improvement in orgasm, improvement in arousal, improvement in satisfaction. People were happy. Like 80 % of people would recommend it to a friend. People said it wasn't painful. People are saying, game changer, more sensitivity, gave me a better understanding of my body. Now, so we published that and it went, you know, the craziest part is the editor of the journal that published it has

called me out in public and said, I'm not academic enough. Like what you do is not important and you're not academic enough. And then that paper was the most read article in his journal for like six months, which was really fun. So that's it. That's the story. And since other, my colleague, Joe Kraft has published a paper which has said very similar data that it really improves people's lives. And as you know, I would love to hear your experience, know, from that patient, you've now taken care of many patients with these issues and you were not taught to do this in med school. So what has been your experience?

Dr Sameena Rahman (7:34.492)

Yeah.

Dr Sameena Rahman (7:53.714)

mean, mean, you know, as we know, it can be a source of a persistent general arousal for some patients. So when we look at that first region, you know, some people have been curative by removing those keratinized pearls. But every single one of my patients that I've done this procedure on, it's been transformative. They've always said to me like, first of all, like, wow, my orgasms are so much better. And then if they were the ones that came in with clitoral pain, because I think we always describe it as like, you know, saying in your eyes is the same thing that they might feel if they have these little keratinized pearls.

under their hood, you know, it's the same thing. Like they're just like this, now I finally don't have pain or now I can actually reach orgasm without pain. So I think it's a really important and it's been a pivotal procedure in my practice that, you know, like I've had so many people just, you know, especially after the New York Times article, they were just like, can you come look at my clitoris? When I looked at it, it doesn't look the same as it should. So that's really been transformative. And you're totally right. When I was a medical student, I was directly told, do not touch a woman's clitoris. Like do not do that.

it's going to make her feel weird. And so that was nothing that we ever did. Yeah. I'll start in minutes. Great.

Rachel Rubin, MD (8:59.894)

And it's true, your doctor should not touch your clitoris unless they are telling you that they are going to touch your clitoris and asking permission to do so. And I think that's an important piece of this is they have to be able to read the room. But if you have a clitoral problem, there should be doctors who you could go see to actually help you. But if no one teaches them how to do the exam, then what are we doing?

Dr Sameena Rahman (9:19.966)

then what are we doing exactly? And it's true, I think it's important when you do an exam on patients, like I always like, especially if it's their first time having a pelvic exam, explain to them that we're gonna look at your vulva, which no one really taught you to do either, you're right, they just go in straight for the speculum. We're gonna look at your vulva, we're gonna do your clitoris and lift up the hood and see if it comes down. And so think those are things that should be verbalized to prevent medical trauma that we see gets experienced by all our patients.

Rachel Rubin, MD (9:45.966)

And what we do, and again, why the New York Times wrote about it was when I started my practice three years ago is I didn't buy fancy lasers or fancy ultra, I bought mirrors and I got these big mirrors on Amazon. And so every patient that comes in, we give them a tour. We say, we're gonna give you a tour of what's going on down there. And they're watching us and we, this is your labia majora, this is your labia minora, this is your clitoris, this is your clitoral hood, this is your vulvar vestibule, this is your pelvic floor, and this is the urethra, the tube you pee through. And patients don't have to do it.

Dr Sameena Rahman (9:55.036)

Yes.

Rachel Rubin, MD (: 10:15

But every patient who does it, which is the majority of patients, it is empowering. It is incredible. It is just, changes their understanding of their own body. And now they have language when something feels good or hurts or is abnormal. It's not, ooh, that hurts down there. They actually have words. Because if your face hurts, it's really important to know where your face hurts. Because you wouldn't go to the eye doctor if you had tooth pain, right? You wouldn't. They're all part of your face, but there's 12 doctors.

to see if you have face problems.

Dr Sameena Rahman (: 10:46

Yeah, absolutely. And so yeah, I've also incorporated that in my practice over the last, you know, whatever, eight years or seven years that we're looking with mirrors now too. So it's been transformative for sure. And I think sometimes it's just that education that's really a key component to really improving a patient's sexual life and pelvic health and all that.

And so, you know, we do these procedures, clitoral lysis of adhesions should help with, you know, orgasm function for some, may help reduce pain for others. And I think that's really imperative. And so feel like you've really, really moved the needle on that, Rachel. That's an amazing thing that I think you've done across the world, really, because I mean, you know, I go to all the world sexual medicine conferences and people are always talking about, you know, that article or, you know, tell us more about this region one and Oregon, how do you approach it? So.

I want to applaud you and everyone else's effort for that because it's really been transformative for a patient's life.

Rachel Rubin, MD (: 11:45

Now, what's so cool is this article that never would have gotten written without these brilliant medical students is all three of them are now in their residency trainings. And one of them is an internal medicine resident. One of them is an OB-GYN resident. And one is a neurosurgery resident. And I just love that story because they are going to go into all different fields. And then yet they change the world, in my opinion, on what we know about the clitoris and what we know about clitoral adhesions. And so it's really this collaborative effort.

But as I train my medical students is you can't just write the papers, you gotta get loud. Because if we had not gotten loud, no one's gonna read an article in the Journal of Sexual Medicine if they're not you or me and sexual medicine people. And so by getting loud about it, we bring awareness and we've done that as well with our research on vaginal estrogen costs and how much we could save Medicare and things like that is it's translating the research into the public domain and getting people fired up about it. And that's what we're seeing.

Dr Sameena Rahman (: 12:19

Yeah.

Yeah. Yeah.

Rachel Rubin, MD (: 12:43

makes the changes happen.

Dr Sameena Rahman (: 12:45

Yeah, and let's talk about something else you get a lot about a lot and that's vaginal estrogen. And I want to talk about, you know, what the dangers of this box warning that we've been trying to get off of everything, off of the actual product. So let's talk about that initiative a little bit because you've been spearheading that in many ways.

Rachel Rubin, MD (13:4.716)

Yeah, so it gets confusing for the general listener. And everyone hears about hormones and menopause, and it gets very confusing. And so there's hormones that you take for your whole body. When we talk about hormone replacement therapy or menopause hormone therapy, you'll hear people talk about estrogen, progesterone. You may hear people talk about testosterone. And that's whole body hormones. And that's really beneficial for hot flashes, night sweats, prevent osteoporosis and fractures. And those things are really good for your whole body symptoms.

There is another problem though that is not talked about enough, and that's the genitourinary syndrome of menopause or GSM. And what happens when you don't have hormones in your body, the genitals and the bladder system is really affected. And so without hormones, things are dry, things are irritated, things are itchy, things are uncomfortable. So you may have urinary frequency and urgency, you may have more leakage, you may get up at night to pee, you may have dryness, pain with sex, change in your orgasm, change in your arousal.

And most importantly, you may get recurrent urinary tract infections which can and do kill you and kill our patients. And so if you keep getting urinary tract infections, which happens when you don't have the proper microbiome and the lack of hormones, is...

is you get resistant infections and then you need bigger and bigger antibiotics and sometimes you need IV antibiotics, sometimes you need to be hospitalized, very scary stuff that really you don't want to mess with and it actually costs our government dollars like a lot of money every single year. And so the data is actually pretty crazy. And so the genitourinary syndrome of menopause

And we've had data since the: 1970

Rachel Rubin, MD (15:7.352)

re pregnant, your estrogen is: 3000

Dr Sameena Rahman (15:9.778)

Thank you.

Rachel Rubin, MD (: 15:35

for some people becomes a really scary topic. It shouldn't be. And so the problem is there is a big difference between taking a high dose birth control pill and using a microdosed amount of vaginal hormones, which can prevent urinary tract infections. And so every type of estrogen that exists, and there are many, there is the same labeling that the FDA puts on it that said that was in 2003 that they have not yet reversed, that it says that estrogen products cause stroke, blood clots, heart attacks,

probable dementia, you'll get breast cancer and you have to take it with a progestin. None of that is true by the way about vaginal estrogen. Zero, zero percent of it is true. And so the problem is when you label everything as the same thing, you're actually killing people.

because there are women out there not taking vaginal estrogen for fear and they're gonna die of a urinary tract infection. They're gonna get up in the middle of the night to pee and break their hip and die. They're going to, you know, they're gonna suffer in the nursing home with leakage and just being absolutely miserable from a quality. And the more I talk about this, the more patients and people on Instagram and my scrub tech and the person who's cutting my hair, everyone has a story. My grandma.

Dr Sameena Rahman (: 16:44

Yeah.

Rachel Rubin, MD (: 16:46

My mom, my aunt, my friend's mom suffered deeply. And if they had gotten this information, and no matter how many times we talk about it, it's very simple. It's cheap, it's easy to do. You can do this for less than $7 a month. Your insurance should cover it. And yet people are dying because they don't have access to this information.

Dr Sameena Rahman (17:7.100)

Yeah, absolutely. I think, and so there's a now a push with trying to get the FDA to remove that box warning off of bachelor estrogen, which we'll put a link in our support.

Rachel Rubin, MD (: 17:19

Please, so if you can go to this campaign and write to your Congress people and write letters, I mean, we make it very easy for you to do so. Nobody's paying for this. This is just, we are all sitting around saying, what can we do? What can we do to make change? And here's something very easy that you can do to put your voice behind.

Dr Sameena Rahman (: 17:31

Yeah.

Dr Sameena Rahman (: 17:38

Absolutely, because it's true. Like no matter how many times I might tell a patient, do not read that warning label inside of that box, they will read it. And sometimes it really does prevent them from wanting to use it, even though you sit and you educate them about it. And so sometimes it's just, it's scary writing, you know? anyway, I think that the vaginal estrogen component has been really transformative for most patients as well, improving their sexual life. And, you know, we always talk about, you know, we have to treat it.

it's a chronic progressive condition. It's not, you know, the only thing that we use to treat these problems. We have to also, you know, be cognizant of the pelvic floor muscles. Can we talk a little bit about the pelvic floor and, you know, the importance in sexual function and what you do for that additionally? I mean, we always use our therapists. We love our therapists, their own speed dial, but...

Rachel Rubin, MD (: 18:29

Yeah, so everybody has a pelvic floor, right? If you have a pelvis, you have a pelvic floor. And the pelvic floor is just the muscles that surround the pelvic bones that hold everything up, right? This is your skeleton that holds up all your organs. And the problem is, is no one teaches us that your pelvic floor needs exercise. Your pelvic floor needs attention. And we do a lot of things to mess up our pelvic floors. Like you have a watermelon come out of your vagina or out of your abdomen, also called babies.

Dr Sameena Rahman (: 18:58

Yeah.

Rachel Rubin, MD (: 18:58

Men have significant pelvic floor problems and they can have constipation or pelvic pain or penis pain or perineal pain or orgasm pain. Women can get all the same things. They can get pelvic pain. They can get orgasm issues. They can get arousal issues, all sorts of things from a musculoskeletal perspective. Now, if you get a knee replacement, you get rehab, you do physical therapy three times a week. Yet when you have a baby or if you have a fall or you have something going on with your pelvis,

you have a hysterectomy or you have surgery, no one talks to you about rehab. And that's a mistake. Because if you have a pelvis, it needs rehab, it needs care, it needs attention. And while you can learn how to lift like weights and work on your bicep, very few people invest in learning about how to exercise their pelvic floor. And it's not all about strengthening and tightening, right? Kegel's got a good PR campaign early on. But you know, Kegel's is so just the like one

one side of a coin and really like there's so much more like most of our patients need to do reverse kegels to learn actually how to relax their pelvic floors because we've got a lot of, I see, can I say tight asses on your podcast? I'm in Washington DC. We got a lot of tight asses in this area. So you can, yeah, we got a lot of clenching going on. And so there's a lot that needs to be done actually to relax those muscles.

Dr Sameena Rahman (20:5.788)

Yeah.

Dr Sameena Rahman (: 20:10

Everyone's punching, we know that.

Dr Sameena Rahman (: 20:18

Yeah, absolutely. And so we all you know, I've had a number of therapists on my podcast as well who talk about all the work that they do. So you guys can listen to that. But it's an important part. And, you know, as sexual medicine clinicians, we kind of guide

all the other, we always talk about it being a biopsychosocial approach and we have to approach it as a multidisciplinary thing. And I think that's what we love about Ishwish so much is because it brings together so many different people from different walks of life. And so I think it's really important to coordinate all of your care with one person. And that's what think the majority of us try to do.

Okay, and then let's also talk about your other favorite topic, testosterone. So there's a lot of controversies around testosterone. I you're giving a talk at Ishwish. We're doing a whole thing on controversies and testosterone, and you're gonna be talking a lot about from a woman's health perspective. But you're lucky enough that you're treating both sexes. So can we talk a little bit about testosterone replacement and why there's so much controversy around it?

Rachel Rubin, MD (: 21:24

You know, there's controversy for testosterone for both men and women and transgender. There's, testosterone is controversial all the way around. And what's so funny is it's truly, deeply not that serious. Everyone wants testosterone to be so much more serious than it is. And there is so much fear that around this hormone that everybody makes, everybody makes testosterone from your adrenal glands to your gonads, meaning your eggs or your testicles, everybody makes testosterone. And in fact,

Women make a lot more testosterone than they make estrogen and that's the truth. And so we just have chosen not to study it fully in women and as aggressively, which doesn't make it not important. And so when we talk about testosterone, I think about men, I just got back from a Harvard Continuing Medical Education course, which is fabulous, all about testosterone therapy for everybody. I teach the female side, but I learn a lot from my colleagues, because I take care of men as well and transgender patients.

And so it's so interesting because during this course, it really goes into all the research of like, hey, this thing's not that scary. It helps with people's mood. It helps with people's energy. It helps with muscles and weak muscles, especially as people are getting older and have sarcopenia and muscle atrophy. It helps with people's pelvic floor muscles. It can help with incontinence and urethral strength in men and stress incontinence for women. It can help with libido. can help with, know, and yet,

There's so much fear around it. And what's funny is I'll tell a quick story is the day before I left for this conference, which is the third year I'm helping to teach it, I had a patient in my office. She's 47, I think, in her 40s, and she's on testosterone and she's doing great. She's got no complaints. She's really happy. And she said, Dr. Rubin, my gynecologist said that I must stop testosterone because it's dangerous for my heart, Dr. Rubin.

And he said, my gynecologist said, it's dangerous for the heart. And we know that in men, that it's dangerous for their heart. And I said, huh, that's really interesting. And as I pull up Google on my computer and I type in New England Journal of Medicine Traverse Trial, and the study pulls up from this past year that says, we gave thousands of men with cardiovascular risk factors testosterone for five years and we followed them. And guess what?

Rachel Rubin, MD (: 23:42

There was no impact on their cardiovascular events. In fact, it was a little better. But this craziness of it, this gynecologist was speaking with such certainty, you can't do this because it's dangerous in men. And I was like, but wait a minute, he doesn't actually know the data for men. Why would he? He's a gynecologist. He's not up to date on male testosterone. I don't blame him. But you're scaring my patient who actually is totally safe to take testosterone. And so our friend Kelly Casperson always said, what other drug

Do we give to people in 10 times the super physiologic dose and follow them for decades? And that's your transgender men. I don't forget politics aside, I don't care how you believe, you have a population of people that are born with ovaries and vulvas that you give super physiologic testosterone to for years and years and decades and decades. And no, the sky is not falling. There may be challenges and issues and we can get into that, but the sky, people are not dropping dead.

Dr Sameena Rahman (: 24:35

Yes.

Rachel Rubin, MD (: 24:41

like in droves, it's not happening, right? And so it's so fascinating because testosterone is just not that serious and we make it so much more of a big deal than it needs to be.

Dr Sameena Rahman (: 24:50

Yeah, I think people just get scared of hormones and so let's just like...

know, contributes to that estrogen testosterone fear is out there. And we're talking about both of those hormones at Ishwish. If any of you guys are clinicians, we're gonna do a whole thing on both estrogen and testosterone issue in Atlanta. And that's gonna be, actually, I don't know when this is gonna air, it might air right at the same time. Anyway, well, Rachel, tell us what's coming up for you in terms of what you're doing or where do think some of the research is going for sexual medicine these days?

Rachel Rubin, MD (: 25:24

Yeah, we're really excited about a lot of different projects. I have a whole notebook here where all I do is write down more projects, more things I want to study, more things that we have to look at. So I'm hoping for just more. We are advancing our research we just put out, and thank you for your help. We just put out a big survey on GLP-1 medications and sexual dysfunction or sexual help. We don't know. We're asking because we have so many patients now on these medicines, and we're trying to, usually sex is the last thing to get studied.

Dr Sameena Rahman (: 25:34

Yes.

Rachel Rubin, MD (: 25:52

So we're trying to get ahead of it a little bit and figure out there's some reports. Yeah, there's some reports that people have erectile dysfunction with them or low libido. I have people who have better sexual function because they have more confidence and they feel better in their bodies. We just need the data. So we're excited about that. We're expanding our research on a new topic that we coined this term, genitourinary syndrome of lactation.

Dr Sameena Rahman (: 25:55

period.

Dr Sameena Rahman (26:2.366)

Yes.

Rachel Rubin, MD (: 26:14

So this idea that breastfeeding or lactating, pumping people are really suffering from bladder and genital symptoms and no one's paying attention. So we're trying to get more research on that topic, which we're very excited about. And so we're constantly trying to learn more. I think for me, I wanna keep educating. I wanna keep teaching doctors how to prescribe hormone therapy, how to be confident in just, it's one thing to read the articles and to follow people on Instagram and say, wow, hormones are having a comeback.

It's a whole other thing to know how to write the prescription. And so we're really trying to expand our education to clinicians on how to write the prescriptions, how to feel confident, and how to know what prescriptions to write. so, yeah, so always good to keep track of me. We have a great newsletter, which you can find at my website, RachelRubinMD.com. And so we're always posting about.

courses and speaking engagements and just events and things like that. And so people love our newsletter, which is rare. I delete a lot of newsletters, but people read ours, which is good. I hope it keeps going.

Dr Sameena Rahman (: 27:18

Yeah, I read yours too when I have a chance. It's good. All right, well, that's great. I'm glad to hear it. I'm glad that we've connected in life and that we can move the pencil or pen forward when it comes to sexual medicine for women and for men as well, and all people.

Rachel Rubin, MD (: 27:39

Well, thank you. I can't thank you enough. You know, it is so much more fun to do this with friends and to have a community around this and to have people really working together collaboratively. so just and just thank you for your platform, for getting the word out. mean, it is just so, so important what you do. And I'm so glad to be on.

Dr Sameena Rahman (: 27:56

Yeah, absolutely. All right, guys, well, you know, catch me again next week. Thank you, Rachel, for your visit here today for Gyno Girl Presents Sex, Drugs, and Hormones. I'm Dr. Samina Raman. As you know, I'm here to educate so you could advocate for yourself. Please join me on another episode next week. Yay.