Dr Louise Newson: So Rachel Rubin, I want you in my studio. You're nearly here, you're remote, you're in US, and you are just brilliant because you understand probably as much, more than me about how hard it is for women to be listened to, to be treated properly, the safety and the efficacy of hormones, especially when it comes to even just vaginal hormones, right? They're really very safe and people can't access them.

Dr Rachel Rubin: Yeah, I mean, holy, holy, holy mother of God. And I'm a urologist. I know you're married to a urologist. We curse a lot. So I'm gonna try to be appropriate here because I know on the other side of the pond, you guys are are much more proper than we are. But I have a lot of bad words to say about this. And I think it really comes from my frustration on the men's health side because we do not do...what we do to women, we don't do to men. We don't have the same level of you can't do this. You can't have this. I saw a woman this week in my busy clinic. I have one day a week of a busy clinic, and she was a picture perfect candidate for hormone therapy. Picture perfect. She had all the symptoms, she was very healthy, she had no medical problems, no family history. I mean, it was a homerun as if I were to give a lecture on the the perfect patient to easy, give easy hormone therapy to. And she said to me, she said, But Dr Rubin, my my doctor said I wasn't a good candidate for hormones. And I said, What are you talking about? You're a perfect candidate for hormones. And this poor patient is now stuck between a doctor who truly doesn't know the data and doesn't know what she's talking about, but confidently told her no, you know, and me who is like, yeah, no, this is a no brainer. You should go on, you know, this is what I would recommend for you. And our patients are really stuck in this Well, who should I believe? And so actually I'm grateful for you because I give your information and all these other people's information. Don't just trust me, listen to others.

Dr Louise Newson: Yeah, and it's really hard. In fact, while I was waiting for you to just join, I was just looking at my Instagram and I got a DM from a lovely, well sounds lovely lady. She's just had her ovaries removed and went to ask her GP for some HRT. Not unreasonable because as you know, the ovaries produce progesterone, estradiol, testosterone. So she just asked for some hormones. And her GP, I kid you not, said You are just jumping on the HRT bandwagon because menopause is talked about everywhere. Like it's like a fashion drug. It's just madness.

Dr Rachel Rubin: But I, in my email, this... I was just getting my hair done, which is why I was late to come do this. And I was looking at my email and a new article came out in the Menopause Journal that says people who have a hysterectomy and have their ovaries removed are at a higher risk of stroke. And yet people think hormones cause strokes, which we know is not true. And more data is coming out showing that that's not true. And yet people's brains are flipped. Like this is no longer a cool thing to do, people. This is called life saving you know, lifestyle.

Dr Louise Newson: Absolutely. And I think this is the whole thing, is the risks of not having hormones are more than any risks of having hormones, especially when we talk about the natural body identical hormones. And I can't think of any other area of medicine where there's just so much debate and fear, and fear among our colleagues as well. And you know, the risks that women are exposed to are huge. And as a urologist, obviously you see lots of people with urinary tract symptoms, but generally genitourinary syndrome of menopause, which is such a long mouthful, but it basically means vaginal symptoms, symptoms affecting the vulva, the perineum, and urine symptoms. And they're so common, aren't they?

Dr Rachel Rubin: I think it's a nightmare, actually, because these are so common. And the problem is is we we have a marketing problem, as you know, right? Menopause is actually a marketing problem. It is we are not...yes, there is information we don't have and data that we need. And I'm so grateful actually, your team is always publishing amazing work to help us learn more. But the reality is is we're not using the data that we do have, and we're ignoring all of the data that we do have. And we need to market that data better. And part of this marketing problem is this idea that menopause is a moment in time. Oh, I had it, I went through it, I'm okay on the other side, or this is happening. But when you are 80 years old, you have horrible menopause symptoms. You have osteoporosis, you have ugenitourinary syndrome of menopause, which means you have urinary frequency, urinary urgency, leakage. And if you're sexually active or not, you have an increased risk of getting urinary tract infections. And that's all from menopause. That's all from a lack of estrogen and testosterone in your body. And yet our doctors, our clinicians do not know this. And our patients definitely don't know this. So they just give out antibiotics like they're candy, which has a whole host of very big problems when you're doing that. And there's no discussion of prevention or the reason why you have these. And so we were instrumental in advocating for new guidelines to say, hey. We should be screening, diagnosing, examining, and offering vaginal hormones to every human on earth who has a hormone issue. But again, a marketing problem. It doesn't matter that we wrote the guidelines. If nobody reads them or changes their practice pattern, it does nothing. So I'm so grateful. Honestly, I do so much of my yelling and screaming because I've watched you and how much progress you've made. Truly, I I know I'm I'm playing cool right now, but I am, you know, one of your biggest fans in the sense of like, I watch how you've changed the conversation and it hasn't been easy and it hasn't been straightforward, but it has made real impact in in people's lives. Because as we know, if you can say, if you can help women feel better, that actually helps their partners and it actually keeps men alive longer. So you're helping everybody, or we're helping everybody. So the genital and urinary symptoms will kill you. The UTIs will kill you. You will wake up in the middle of the night to go pee and fall and break your hip and you will die, right? Like this is not a little vaginal dryness or just a little bit of a lifestyle medication. This is life-saving therapy.

Dr Louise Newson: And that's really really important because my my daughter, my middle daughter had sepsis when she was 12, and it was horrendous to watch her so poorly. And that was from an infection in her bones. But about 30% of sepsis is due to urinary tract infections. And the majority of that is in women. And I agree with you, Rachel. The majority of those could be prevented by vaginal hormones. And when we talk about vaginal hormones, that's just something that is inserted in the vagina. It could be a cream, it could be a gel, it could be a pessary, there's even a little silicone ring. And it doesn't even go into the system. So it's really, really low dose. So anybody can use them, but not just menopausal women, women who are perimenopausal, women who are on contraceptives, women who are young. It doesn't there's no...

Dr Rachel Rubin: Breastfeeding. Breastfeeding.

Dr Louise Newson: Breastfeeding. Really important. And and I wish I'd known that. I feel so embarrassed because I didn't think about it when I was a GP. And I on a Monday morning I'd get to work and there'd be literally six or seven women lining outside to come in with their little urine pots. And the the receptionists would dip them to see if they had a dipstick and they'd go, Oh no, this one the dipstick's negative. This one we're gonna send off for a, to the labs. And I never ever thought about what what do they need vaginal hormones. And and we've got data from the 80s,from 1980s showing us that incidence of recurrent urinary tract infections reduces with vaginal hormones, haven't we?

Dr Rachel Rubin: It's so true, right? We have had data for decades. It's been in the New England Journal of Medicine. There have been guidelines since 2019. The recurrent urinary tract infection guidelines clearly state we should be giving vaginal hormones. 2025,we've published the guidelines on genitourinary syndrome of menopause. So it's actually not a research question or a research problem. This isn't a, oh, we need more data to see that it's safe. In fact, there was a study came out recently that said if you have a urinary tract infection, you are at much higher risk of stroke and heart attack. And there is a paper from a few years ago, I think it was 2018, that showed people who use vaginal estrogen have a decreased risk of stroke and heart attack compared to those who don't. So we have so much data to show that these are life-saving, safe and zero papers to show harm. Zero papers show any problems with vaginal hormones. You may get a yeast infection initially, but just keep going and treat the yeast infection. You'll get, you'll be okay. But the benefits outweigh the risk more than any other thing that I can think of in this world, like truly more than any other thing I can think of. And we published that we would save our Medicare system, our government healthcare system between six and twenty two billion dollars a year if women were given vaginal hormones. So can you imagine how much money the NHS would save if every woman over 40, I would say 35, was literally just handed vaginal hormones and explained why they must take it for life. It's a lifelong therapy. Can you imagine how much money they would save as a system?

Dr Louise Newson: It's just a no brainer. But I've also changed my practice the last probably three or four years in that I don't actually prescribe vaginal estrogen first line anymore. I prescribe something called prasterone, which is DHEA. So it converts to estradiol and testosterone. And you've got some really key papers and research on that because you've had it in the US longer than we've had it in the UK. We've had it in the UK for a few years now. But can you just summarise your data, especially the ones with people with diabetes?

Dr Rachel Rubin: Yeah, is it easy for you to get for your patients in the UK? 'Cause we have some trouble.

Dr Louise Newson: Well, it's a postcode lottery. And and in fact, yes, it's available on the NHS, it's got MHRA approval, but a lot of doctors refuse to prescribe it. And one of my patients I spoke to on Monday actually has been trying to get it, and she went to a an a specialist clinic, and I read the letter, I I normally, nearly cried with her because it said that you cannot have this prasterone. You need to try four different preparations of vaginal estrogen for at least six months each. So she has to try the the vaginal gel, the vaginal cream, the vaginal pessary, and the vaginal ring for six months each, and then and only then if she's still having symptoms, she can come back and talk. So that's two years of inappropriate treatment.

Dr Rachel Rubin: It's wild. So, so when it comes to hormone therapy, right? We have for the approved options, we have estradiol in the United States and we have DHEA. And both are fabulous, all are fabulous products that are going to acidify the tissue. We want your pH to be four and a half so that it can have a healthy microbiome and fight infections like urinary tract infections. And so we know that both vaginal estrogen and vaginal DHEA do this. Now, just like we said, we've had data going back to the 90s and before that vaginal estrogen prevents urinary tract infection. Well, we hypothesise that vaginal DHEA does the same thing. And we published on this a couple of years ago, actually last year, that vaginal DHEA also decreases urinary tract infections by more than half. And it doesn't matter if you have a history of diabetes, which we know infections are worse, and it doesn't matter sort of any medical problems, that it really is effective at decreasing your risk of urinary tract infections. We have it is it is we hypothesise that it is a fabulous mechanism of action because it's not just estrogen, but it is the precursor to both estrogen and androgens or testosterone, which the tissue is rich with. And so what is actually quite revolutionary about these new guidelines in the genitourinary syndrome of menopause, which have been endorsed by the urologists, by the urogynecologists, by the menopause society, is and the women's sexual health societies is that the word androgen is all over these paper, this guideline, and that it really does say that this is not just an estrogen problem, but this is an androgen problem as well. And so again, I hope that this gets, you know, you you all just had even more testosterone approvals in your system. You know, we're very far behind. And so I hope that companies are starting to look at more preparations for GSM therapies, therapies for genitourinary syndrome of menopause that have androgens in them. Because we see, right? If I'll give you an example of why this is so important, it's important in menopause, but in the women on birth control pills. Birth control basically shuts down your ovaries and it adds back fake estrogen and fake progestin, but it doesn't add back testosterone. And so we actually see a significant genital and urinary syndrome in these women that they have increased UTIs, pain with sex, dryness, irritation, low libido, because of the lack of androgens, we think, right, on this tissue. So it is what an incredible thing to think about. First, we should be thinking about birth control that adds back testosterone. We should be thinking about more bioidentical types of birth control if they exist, or ones that don't shut your ovaries off. But we should be, what if we added testosterone to birth control? No one is anyone studying this, right? This, these are the things that that I need people's brains on. And you know, everyone in the United States, everyone kicks and screams and says, Oh, we need more research, oh, we need more research. Nobody's gonna be doing research. There's no money for research. And to do research requires, as you know, because you do research, requires funding and planning and and brains and participants and people. And so it it we have so much work to do, right, to advance women's health.

Dr Louise Newson: But in the meantime, we need to use common sense, don't we, Rachel? Because you know, we've got androgen receptors around our vulva, our vagina, our perineum, and our urinary tract. So why would we not give replacement when we know that it's low? You know, it's so simplistic.

Dr Rachel Rubin: So logical, right? And I think that's, you know, one of the things I do a lot of teaching. I have like you, I have a course where I try to teach clinicians how to prescribe hormone therapy. And my big push is what are you afraid of? Right. What are you afraid of here? Because you know, when I think the problem is so many people have these fears that actually aren't based in any data or logic. And so when you have something you're afraid of, the question becomes, are you afraid because there's data that says you should be afraid? Are you afraid because there's no data, or are you afraid because that like they're there, like you don't know the data? And so my whole thing is like when you're talking about genital hormones, vaginal and genital hormones, like like there's I'm not afraid of anything, right? I I am afraid of nothing, no stroke, no blood clots, no heart attacks. Why would dementia happen? It doesn't make any logical sense. So I love your, your point is that you have to use logic. You have to use data and logic and compassion and education, right? That is our pathway to helping get women the information so that they can make decisions about what's right with for them.

Dr Louise Newson: Absolutely. And, you know, I have had so many urinary tract infections, despite being married to lovely Paul, the urologist, he's watched me squirm, he's watched me in pain, he's watched me, you know, have haematuria, blood in my urine, he's he's watched me with loin pain, he's and I've had numerous antibiotics and then after I had a hysterectomy a few years ago, it, they became a lot worse. And I,no-one really spoke to me about vaginal hormones. And then I thought, actually, I'm already on HRT. Do I need vaginal hormones? And of course I do. And my life has been transformed with prasterone. But every day I use prasterone whenever I open the box of my prasterone, there's a lovely patient information leaflet. And I'm a very good patient. And I open it and I read it. And it tells me that prasterone is has an increased risk of heart attack, strokes, plot, breast cancer. I'm a migraine sufferer, so if I am a migraine sufferer, I shouldn't really take it. And and and that, you know, the list is as long as the box sort of prasterone that your patients will be receiving as well. So I know your FDA have been looking at this, and you did the most amazing presentation, which I was so proud and tingly when I watched it. I thought it was amazing. It was a panel discussion and and everybody was listening and it's part of starting a conversation because when they inaccurately labelled all hormones as carcinogens in the 1980s,because they realised there was an association with ethanylestradiol, which is a synthetic estrogen, the synthetic progestins and also they conjugated equine estrogen the pregnant horse's urine. They just made every single hormone a carcinogen, which is so wrong because how can our natural hormones cause cancer? Like, you know, our bodies are really clever. They're not going to come against us and turn against us and cause cancer. We know that, but it's unpicking the evidence. Because I was reading a paper recently and it was looking at people's, like you say, healthcare professionals are often very scared of prescribing hormones. And it was looking at urologists, and they were saying one of the big factors for not prescribing vaginal hormones isn't because they don't know the evidence, is because of the perceived risks and this insert. Because our computer system, I don't know what it's like for yours, islinked with those inserts. So the inserts, the warnings are exactly the same that's what what's on our computer screens. So you have to be quite confident to click override to actually prescribe it.

Dr Rachel Rubin: Totally. And so it's we have, I sort of think of this as we are at war and the enemy is on multiple fronts, right? Like this is a battle and we have a lot of enemies. One of our enemies is the system, right? The system, the labelling that is harming us that is telling us this is dangerous when it's actually not. It's false. It's lies. How they can have such a strong warning label with not a single paper on earth to back it up. So it's it's actually killing women by trying to protect them, but there's no data. We think, there's no data. There's no data to support it. So there's that enemy. There's the enemy of the status quo of the people who are just doing the same thing over and over again and women are dying. So it is your clinician who was never taught this, who has no even doesn't know how to write the prescription, doesn't know why they have to write the prescription, doesn't know how to educate the patient about it. And then we have the enemy of the patient, the uninformed patient, the patient who doesn't know that her urinary tract infections can kill her, that can be prevented, that can easily be fixed, not just treated, but fixed and prevented. And so we have this enemy on all fronts. And which is why I always joke, you know, people in this space, what I love about this space is how collaborative it's become and how we all really like each other because anyone who wants to do this work and wants to get loud about it. I don't need to agree with a hundred per cent of what they think. I don't even agree with a hundred per cent of what my husband thinks or what my children think. But the idea is that when you're in this fight and you see those enemies, those are the true enemies. You, you know, I need you on my team and we need to work together to get loud. And that's kind of what we've, this this group that we've created and these, these, this sort of army that we're building. And I just honestly, I've watched what you've all done in Britain and the army and the collaboration and what you've done. And I've been saying for years, how do we copy that? How do we do that in America? And it's, we're a few years behind, but you feel it, you feel a sea change, you feel a little bit of more power than we had before in getting the word out. But we're also in this echo chamber. The way my algorithm works is I only see what I want to see. And so sometimes you forget how this is half the population. This is not niche boutique, a super specialised medicine. So we have to teach everybody how to do this.

Dr Louise Newson: Yeah, it's so important and it's great because we're part of a group with lots of really inspirational doctors and we're whatsapping and at different hours because we're in different time zones, but we're all supporting each other because at the end of the day, we went into medicine to help people. And sometimes this is forgotten with politics and medicine. And I think, you know, there is still a hierarchy with medicine and you know, certain people will look at different specialties in different lights. Whereas I don't think we need to do this because hormonal changes affect every single specialty, whether you're a urologist, whether you're a family physician, whether you're a brain surgeon, whether you're a psychiatrist. It doesn't matter. The hormones get everywhere. And it's about time that we all had joined up thinking and we all thought about how to improve our patients' day to day living and their future health as well, isn't it?

Dr Rachel Rubin: I mean, I I know of no other field where people who are not in the field adamantly tell women they can't have something so confidently. I was at dinner a few like last year, and it was a big dinner with really nice people. And I was sitting next to a neurosurgeon, and he finds out what I do for a living, and he said, Oh, hormone therapy, that's so dangerous. I tell all my patients not to take it because or get off it immediately because it causes meningiomas. And I looked at him and I said, what's the data? Is it all hormones? Is it certain types of hormones? And he looked at me and he said, I don't know. And I was like, I was like, well, well, that doesn't make any sense because hormones are all different. And like, there's estrogen, there's progesterone, there's testosterone, there's synthetic ones, there's bioavailable ones. Like, what are you talking about? And he had no idea. And he said, Oh, but I tell every woman I know never to take it because of this rare, benign brain thing that can happen to you. And I looked at the data and it was on Depot-Provera. Okay. And there's a slight increase of brain meningiomas when you take a high-dose synthetic progestin birth control for young people. And that has absolutely nothing to do with hormone therapy and menopause. And so he's looking at this one thing. He's not looking at your bones. He's not looking at your urinary tract infections. He's not looking at your heart. He's not looking at your muscles. He's not looking at your mental health. He is looking at this very rare brain meningioma that has like a very low risk of ever happening to you. And yet he confidently, with the most confidence you've ever seen, scares women into thinking that what they're doing is dangerous. I I just I don't like it's it's one of those moments of like what, like it's so it again, that's the enemy. That's the art, that's the that is part of the enemy.

Dr Louise Newson: Yeah, I was at a conference recently and I was telling someone about the difference between synthetic hormones, which are chemicals in contraception, the difference between that and the natural body identical hormones that we prescribe. And he looked at me and he's really clever. I've worked with him for many years in the past. And he said, Louise, I'm sorry, you've lost me. I don't understand what you're talking about. I said, But hang on, it's not difficult. It's really not difficult. But there's this willful blindness that has occurred and it carries on. And I I know people are threatened of change. They don't like change. But I think what we're doing differently to previous generations of doctors who have been silenced, is that we can reach people, not just our patients. We can reach bigger populations and we can allow them to decide whether they want antibiotics or vaginal hormones and they can ask. And some people don't like it, but I'm sure you're the same as me, Rachel. There's that, I love it when patients come and ask and have a discussion about treatment choices in the consultation room.

Dr Rachel Rubin: I'm with you. I, an educated patient, an informed patient, a passionate patient, I absolutely adore. I mean, I think it's the, with today, with AI, with Google, with what we have available to us, patients are smarter than we are. They are better researched than we are some of the time. When you have rare conditions and we're seeing more and more sort of these rare things pop up, I believe that it is patient advocates who change medicine because they are not messing around. So I work a lot in the pelvic pain space. And nobody is smarter than women who are trying to navigate pelvic pain and navigate the challenges of of being told it's all in your head when they very clearly have a medical problem. And so I love when patients come in asking questions. And I actually love when they say, Hey, I'm, you know, all the time I'll tell them. If you see a paper, if you see something that scares you, if you see something that seems wrong about what I've said, listen, we're always learning, we're always pivoting, we're always evolving. Science changes. Come to me, teach me. So I actually, like you probably, learn about new articles, new things that come out because patients are very they're interested and they're teaching me as much as I'm teaching them sometimes. And so that's part of the army that we're building. Educated patients. So when we dismiss patients and say, you know, I I'm an, you'll actually find if you listen to me carefully, and I have lots of people who listen to me carefully, I never call myself an expert. I hate, I actually hate that word very much because I I feel dumber than ever. I feel completely clueless in that, like there is so much we don't know. And I'm up to date on a lot of the data, you know. And and so because we are so far behind and we have so much work to do, I can't, you know, I'm always humble in realising like we, you know, be curious, be interested, be curious, and then balance people's quality of life, what their goals are, what they care about with risk benefit, known risk, known benefit, and have like good conversations with people and show them you care. Could people get cancer in in life? Of course. Are my patients gonna die? Every single one of them, every single one of my patients is going to die. But how are my patients going to live? What do they want to do with their life? How do they want to age? Because I've seen a lot of ways I don't want to age, right? And you have too. And so it becomes what decisions am I going to make for my body that I want to try, knowing that I might get some of them right and I might get some of them wrong. But like I'm going to do the best that I can with the information that I have.

Dr Louise Newson: Yeah, such good advice. So I could listen to you forever and I I'm going to have to get you to come back again, Rachel. But before we end, obviously I want to ask you three take-home tips. Three things that people should be asking about vaginal hormones. So what are the three biggest reasons why we should all, I think, be considering vaginal hormones as women?

Dr Rachel Rubin: Everyone should be on vaginal hormones because they prevent urinary tract infections, which are going to kill you. Okay. They help all your urinary symptoms, frequency, urgency, and leakage, and they make sex possible. So they can help with lubrication, arousal, orgasm, and make sex not painful. So actually, you know, I'm gonna put my finish with my urology hat. Vaginal hormones, estrogen or DHEA is better than Viagra or Cialis. Okay. It's better than Viagra. Why? Viagra helps with erections, arousal. It helps get a penis hard and helps men have sex. But it can also, if you take a low dose of Cialis daily, it can help with urinary symptoms. So Viagrins, like those kinds of meds help with arousal and urination. Vaginal hormones help with arousal for women, urination, and they prevent urinary tract infections. So vaginal hormones is female Viagra times a million because they will, it will save your life. And so this is so important because it's a marketing problem. We've had vaginal hormones long before we had Viagra, and yet Viagra had great marketing. And so everyone wants to use it. Vaginal hormones need the same excitement and marketing as Viagra did for men. And it's it will actually not only save lives, it will save our governments billions of dollars.

Dr Louise Newson: Great way to end. Thank you ever so much. So we all need to be thinking about vaginal hormones. So thanks for a great conversation, Rachel.

Dr Rachel Rubin: Thank you for having me.

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