#507 Swinging the Pendulum on Menopause Care With Dr Rachel Rubin

December 8, 2025 | By Molly Heublein

Audio

Video

Transform your approach to menopause care with the latest evidence and expert insights you can use tomorrow. Learn how to move beyond outdated WHI-era fears and confidently prescribe individualized, effective hormonal therapies. We’re joined by urologist and sexual medicine specialist Dr Rachel Rubin (@DrRachelRubin), who brings clarity, practicality, and a fresh perspective to this rapidly evolving field.

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Show Segments

• Intro
• Case
• Shifting care for menopause
• WHI/black box warning labels
• What makes you nervous?
• Local vaginal treatments
• Progesterone therapy
• Estrogen therapy
• Testosterone therapy
• Perimenopause
• Outro

Disclosures

Dr. Rachel Rubin reports financial support from Sprout Pharmaceuticals . The Curbsiders report no relevant financial disclosures. 

Menopause Pearls

1. Modern menopause care has moved far beyond “lowest dose, shortest duration,” emphasizing shared decision making around evidence-based hormone therapy.
2. Transdermal estrogen and micronized progesterone are safer than the synthetic preparations used in the WHI and do not carry the same clotting or breast cancer risks.
3. Vaginal estrogen and DHEA are highly effective for GSM, and are safe in basically all patients.
4. Ask yourself “what are you afraid of around prescribing HT?” to help uncover misconceptions and explore current guidelines.  If you are new to this, start with younger healthy patients to get comfortable, refer complicated cases to menopause specialists.
5. Testosterone can be prescribed off-label for low libido in postmenopausal women using very low doses, despite lack of FDA-approved female formulations.
6. It is safe to treat perimenopausal women who are having menopausal symptoms with hormones- consider if they need contraception or just symptom relief when choosing.

Menopause Show Notes

Menopause Care is Changing 

Menopause care is evolving, moving away from the old mantra of “lowest dose, shortest duration possible” rooted in fear from messaging after the Women’s Health Initiative (WHI) (JAMA 2002). Clinicians often avoid hormones due to perceived risks, but modern guidelines emphasize shared decision-making, individualized therapy, and patient-centered care (Menopause 2022). Research now clarifies that not all hormones are the same: transdermal estrogen bypasses first-pass liver metabolism and does not increase clotting risk (ACOG 2013), micronized progesterone does not raise breast cancer risk (Abenhaim 2022), and vaginal hormones are extremely safe (Biehl 2019). Even re-analyses of Women’s Health Initiative (WHI) data in symptomatic women under 70 show no increased cardiovascular risk and highlight benefits such as reduced fracture risk, lower diabetes risk, and decreased mortality (Rossouw, JAMA 2025).  By embracing updated evidence, dispelling outdated fears, and focusing on individualized patient needs, clinicians can provide safe, effective, and empowering care that meaningfully improves quality of life during this transformative stage.

Black Box Warnings on Hormones

On November 10, 2025 the FDA announced plans to remove the black box warnings from menopausal estrogen products.  Prior to this all estrogen hormone therapy products for menopause (including vaginal estrogen) carried a black box warning that these increase risk of endometrial cancer, cardiovascular disorders, dementia, and breast cancer.  Hormone therapy carries risks, but there is nuance based on the type of product and this fear of negative effects has discouraged clinicians from prescribing these effective medications and made patients hesitant to take them.  This removal of the black box represents an alignment with current research data around menopausal estrogen therapies.

Hormone Therapy Improves Symptoms of Menopause

Dr Rubin highlights that she sees patients who after starting hormone therapy “feel like themselves again”.  She has seen menopausal patients have improved joint pain, energy, sleep, and libido, in addition to reduction to the vasomotor symptoms of menopause (Wright 2024, Pan 2022, Nappi 2006).   Hormone therapy reduces diabetes and fracture risk (Menopause 2022).  FDA approval for estrogen for menopause hormone therapy are specifically for treatment of moderate to severe vasomotor symptoms, moderate to severe symptoms of vulvar and vaginal atrophy, treatment of premature menopause, and prevention of postmenopausal osteoporosis. Dr Rubin expert opinion: quality of life is important!

What are you Afraid of around Prescribing Hormone Therapy?

Dr Rubin likes to frame questions around hesitancy to prescribe hormone therapy by asking, “what are you afraid of?” 

Considering the latest data around the risks of modern HT:

Cardiovascular disease (CVD): In women below age 70 with menopausal symptoms, the WHI did not show an increased risk of cardiovascular disease (Rossouw, JAMA 2025).  Current hormone therapy preparations (transdermal estrogen, micronized progesterone) are likely much safer  than the synthetic hormones used in the WHI (Levy 2024).  

Liver disease: with decompensated cirrhosis, avoiding systemic hormones is recommended.

Blood Clots: Generally patients with a history of blood clots are considered higher risk to take systemic HT, though Dr Rubin anecdotally has treated some of these patients with transdermal therapy and they have done well (ACOG 2013). 

Breast cancer:  Patients with a history of breast cancer (especially hormone sensitive breast cancer) are contraindicated to take systemic HT due to risk of recurrence, but this is an area of growing research (Glynne 2025).  We know there is an increased risk of CVD in treating premenopausal women with ovarian suppression/aromatase inhibitors for breast cancer, so some researchers worry we are putting these patients at risk by not offering them treatment (Polter 2024).  Micronized progesterone seems much safer than synthetic progesterone in terms of primary breast cancer development while on HT(Abenhaim 2022).

Used shared decision making with patients- explain what we know about the risks and benefits.  Start with the more simple cases, and get comfortable with prescribing these.  Refer more complex patients to specialists.

Prescribing Hormone Therapy:

Dr Rubin’s General Pro Tips

Take a good history and figure out what the patient’s goals and fears are?  Is she most concerned about pain with sex or vaginal dryness?  Hot flashes and night sweats?

Share resources with patients- Dr Rubin highlights the importance of education, be it books, podcasts, youtube- before starting hormone therapy to make sure patients are well informed.  

Don’t give information overload at the first visit!  For most patients starting with 1-2 prescriptions is the right approach (see below), and then reassessing/adding more treatment at future visits.

Don’t tell your patient to come back for their annual next year, schedule a follow up in 1-3 months to get feedback on how the HT is going and help adjust.

Vaginal Hormones:

These are extremely safe and effective management of genitourinary syndrome of menopause (GSM).  They can improve symptoms of vaginal dryness, urinary frequency/incontinence, and recurrent UTI (Christmas 2023).  It takes about 2 months of regular use to see benefits.  Performing a vaginal exam can be very helpful to rule out other causes of pelvic symptoms, but topical vaginal treatments should not be withheld without an exam.  

• Estradiol 0.01% vaginal cream is the cheapest, but some women find it to be messy.
  •  Comes with a reusable vaginal insert device, which can be inconvenient.  Patients can purchase disposable inserters over the counter if they prefer.  
  • Dr Rubin’s recs on how to apply: You don’t put sunscreen on your face, glop it on and walk out the door. You rub it in so that you don’t see it. So you tell patients if you don’t want it to be messy, you put a gram on your finger and twice a week rub it into the walls of the vagina completely so that it absorbs into the tissue.
  • Cost: about $30 on GoodRx or $13 at CostPlusDrugs
• Conjugated Equine Estrogen 0.625mg/gm vaginal cream is more expensive and contains alcohol, so Dr Rubin discourages using it.
• 10mcg vaginal estrogen suppositories twice weekly: convenient and easy to use.  Generic often covered by insurance. Cash price may be a little more expensive than estradiol cream.
• Estradiol 7.5mcg daily vaginal ring: very convenient as it is placed and left in for 3 months, but often quite expensive. Be aware this is different from the systemic estrogen ring dosing (estradiol acetate ring 0.05mg or 0.1mg)- the systemic level dosing requires progesterone for uterine protection while local/vaginal microdosing does not.
• Prasterone 6.5mg vaginal insert daily (DHEA), often requires prior authorization.  DHEA is the precursor to estrogen and testosterone, so may give some of the benefits of topical androgens (see more below re: vulvar vestibule).  

In patients with GSM who are on systemic estrogen therapy, clinicians should offer the option of local low-dose vaginal estrogen or vaginal dehydroepiandrosterone (DHEA) (Kaufman 2025)

Vulvar Vestibule

The vulvar vestibule is the area that surrounds the urethra at the introital opening, and it is very hormone sensitive. Dr Rubin uses vaginal DHEA or compounded low dose estrogen and testosterone on this tissue to help these patients with pain with sex (Raghunandan 2010, Simon 2018).  

Systemic Hormone Therapy

Progesterone

In patients with a uterus, progesterone is needed to prevent endometrial cancer when a patient is on systemic estrogen.  Progesterones can help improve sleep in some patients, but sometimes can cause bloating or fatigue.

• Progesterone 100mg nightly most commonly prescribed, or 200mg 12 days of the month in women who are still cycling.  
• Synthetic progesterones, bazedoxifene (20 mg) a SERM or off label levonorgestrel IUDs are also options for select patients who can not tolerate micronized progesterone (Menopause 2022).
• Levonorgestrel 52mg IUD – can act as contraception and bleeding control especially in perimenopause, current evidence suggests this should be replaced at 5 years (Voedisch 2025).

Estrogen

Estrogen is the primary HT for most menopausal symptoms. Estradiol 0.05- 0.1 mg patches are a good easy starting option.  Dr Rubin counsels us to not under-dose, as using the lowest dose may not improve symptoms adequately.   Check out our prior episode for more information on dosing options: #409 Hormonal and Nonhormonal Therapy for Vasomotor Symptoms of Menopause with Dr Monica Christmas.

In Dr Rubin’s expert opinion there are cases where she might find checking hormone levels helpful to give more information, understanding that guidelines generally discourage checking labs and lab results only offer a partial picture.  A menstruating woman typically has an estrogen level between 50-150pg/mL.  In pregnant patients, estrogen levels can reach 3000pg/mL.  The Estradiol 0.1mg patch typically brings blood estrogen levels to 70-100pg/mL; an estradiol 0.05mg patch might bring estrogen levels to 40pg/mL.  There are variations in absorption and metabolism of these medications (Glynne 2025). Dr Rubin does not recommend salivary, urine, or expensive hormonal panels, but checking a blood estradiol level and a free total testosterone have sometimes been helpful in her expert opinion.

Testosterone

Dr Rubin’s expert opinion is that low dose testosterone for MHT is not that serious, we make a bigger deal about it than it should be.  Testosterone is a controlled prescription in the US which makes it harder to prescribe, and currently there are no FDA approved testosterone prescriptions for women (though they are approved in a few other countries). She tends to prescribe testosterone primarily for libido, but finds some women see additional benefits.  

Dr Rubin uses FDA approved male testosterone 1% cream.  This can come in 50mg/5g tubes, and she recommends applying 0.5 gram daily to the skin of the leg, so a tube should last 7-10 days.  A male supply is 50mg daily, so is usually dispensed in thirty  tubes (a 30 day supply for men) which will last 10 months for a postmenopausal woman (Plinik 2025).

Bleeding after starting HT

Systemic hormone therapy can trigger some uterine bleeding.  The Menopause Society recommends evaluating this as you would other post-menopausal bleeding if it is occurring more than 6 months after adjusting hormone therapy.  Evaluations for this would include a pelvic ultrasound and if that is not reassuring, an endometrial biopsy (Menopause 2022).

Perimenopausal HT Treatment

This is an under studied area, but it is safe and reasonable to start hormone therapy when women are in perimenopause if they are having classic symptoms.

Dr Rubin suggests several treatment options:

• Birth control/oral contraceptive pills (OCPS).  This prevents pregnancy and evens out hormone levels so can reduce symptoms. 
• Levonorgestrel IUD + transdermal MHT estrogen.  This prevents pregnancy and regulates bleeding while providing a more natural estrogen replacement and with lower doses than OCPs.
• Regular MHT dosing- be aware this does not prevent pregnancy.  

When to stop HT

Use shared decision making.  If a patient is on oral synthetic HT, it may be safer to transition to transdermal.  A recent, observational study showed long term use of HT after age 65 was safe in a very large Medicare database set (Baik 2024).  

Links

Menopause Society (formerly North American Menopause Society (NAMS)) 2022 Hormone Therapy Position Statement

ISSWSH – International Society for the Study of Women’s Sexual Health

The AUA/SUFU/AUGS Guideline on Genitourinary Syndrome of Menopause

Levy B, Simon JA. A Contemporary View of Menopausal Hormone Therapy. Obstet Gynecol. 2024 Jul 1;144(1):12-23. 

Rachel Rubin, MD’s website and social media Insta: @DrRachelRubin X: @DrRachelRubin 

Goal

Listeners will challenge the convention that menopausal hormonal therapy is unsafe and should only be offered to a limited group of perimenopausal/newly postmenopausal patients.

Learning objectives

After listening to this episode listeners will…

1. Differentiate the current evidence regarding the safety and risks of menopausal hormone therapy (MHT) from outdated beliefs rooted in earlier studies and media interpretations.
2. Apply principles from the 2022 North American Menopause Society (NAMS) statement and other contemporary guidelines to counsel patients considering initiation or continuation of MHT beyond the early postmenopausal period.
3. Formulate an individualized, evidence-based approach to menopause care that integrates patient preferences, comorbidities, and symptom burden to optimize quality of life and minimize risk.

Citation

Heublein M, Rubin R, Williams PN, Watto MF. “#507 Swinging the Pendulum on Menopause Care”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast.  December 8, 2025.