The Most Important Conversation You’ll Ever Hear About Women’s Health

This episode is a MUST listen. Mel calls it one of the most important conversations she has ever had on The Mel Robbins Podcast.

Most women don’t know this, and this information could save the life of a woman you love.

If you are thinking you’re “fine,” while quietly suffering through symptoms that are treatable, you probably don’t know this life-saving medical fact either.

Today, Mel is joined by Dr. Rachel Rubin, MD, a leading urologist and sexual health expert, to talk about hormones, menopause, libido, pelvic health, UTIs, and what’s happening in your body.

In fact, since recording this episode, the majority of women on the team have spoken to their doctors about what Dr. Rubin shared.

You’re about to hear what she wishes every woman knew sooner: Almost every issue that you're dealing with “down there” is likely related to changing hormones.

If you’ve ever dealt with a UTI, leaking, urgency, dryness, painful sex, or that feeling that something is “off” down there, and you’ve been told it’s normal, it’s aging, or it’s just something you have to live with, this episode could change your life and have you asking, Why have I not heard this before?

Do not learn this too late.

By the time most women get the right information, they have already lost years to pain, discomfort, anxiety, and unnecessary treatments.

No matter how old you are, all women need to understand this information.

This is the conversation that will make you understand your body differently, and realize you have been tolerating things you do not have to tolerate.

If you’re a woman in your 20s, 30s, 40s, 50s, 60s and beyond, this is information you deserve to have now.

Your health should not be a mystery.

You should not have to suffer.

This conversation will give you the truth about your health and may even save your life or the lives of a woman you love.

In this episode:

0:00 Meet the Guest
3:35 Why Women’s Sexual Health Falls Through The Cracks
5:45 The Most Common (And Harmful) Advice Women Hear About Pain
6:23 The Symptoms Women Are Told To “Just Live With”: Dryness, Painful Sex, UTIs, Night Peeing, Anxiety, Mood Shifts
8:17 Hormones Across The Female Lifespan: Puberty, Ovulation, Pregnancy, Postpartum, Breastfeeding, Perimenopause, Menopause
14:36 Recurrent UTIs In Women
6:17 Genitourinary Syndrome of Menopause (GSM Explained)
19:20 Vaginal Estrogen Box Warnings
21:16 GSM, Explained Simply: pH, Thinning Tissue, Burning, “UTI-Like” Symptoms, And Why GSM Gets Misdiagnosed
30:11 Why Systemic HRT Often Isn’t Enough
33:19 Vaginal Estrogen Delivery Options: Cream, Tablet, Ring—Benefits, Dosing, Cost, And How To Choose
41:00 Dr. Rubin’s Mother’s ICU Story
47:38 Who Should Consider Vaginal Estrogen Or Vaginal DHEA
49:54 Genitourinary Syndrome Of Lactation (GSL): Why Breastfeeding Can Mimic Menopause
55:39 Spironolactone And Birth Control
57:15 The Benefits Of Vaginal Estrogen Beyond UTIs And Why Dr. Rubin Calls It “Women’s Viagra”
1:01:21 How Hormones Trigger UTIs
1:05:39 The Story Behind The FDA’s Blackbox Warning on HRT
1:17:40 The 4 Buckets Framework For Hormone Care
1:19:10 Testosterone In Women’s Health
1:23:21 Vaginal DHEA Vs. Vaginal Estrogen Vs. Systemic Testosterone
01:36:36 Clitoral Adhesions: The Condition Affecting 1 In 4 Women
1:55:29 The 2 Most Common Causes of Painful Sex
1:58:30 How To Advocate For Yourself At The Doctors


Women's Hormone Health: What Every Man on TRT Should Know to Help Women in Their Lives
GSM, Vaginal Estrogen, Testosterone for Women, and the FDA's Historic Label Change

Curated By Nelson Vergel | ExcelMale.com | Updated April 2026

Key Takeaways ✓ Genitourinary Syndrome of Menopause (GSM) affects roughly half of postmenopausal women, causing UTIs, painful sex, urgency, and dryness - and it's dramatically undertreated. ✓ Low-dose vaginal estrogen reduces recurrent UTIs by more than 50%, costs as little as $7/month, and carries negligible systemic absorption. The FDA removed its black box warning in November 2025. ✓ Testosterone therapy in women improves libido, arousal, and orgasm at about one-tenth the male dose. A 2019 Global Consensus endorsed by 11 medical societies confirmed its safety and efficacy. ✓ The 2002 Women's Health Initiative press conference led to two decades of hormone fear based on misinterpreted data. Modern evidence shows that HRT initiated within 10 years of menopause lowers all-cause mortality and fractures. ✓ Men on TRT are uniquely positioned to understand hormone optimization. Use that knowledge to support your partner, mother, or sister in getting the care she deserves.

Why Should Men on TRT Care About Women's Hormones?​

If you're on testosterone replacement therapy, you already know what it feels like when hormones are out of balance - the fatigue, the brain fog, the loss of drive. You also know how much better life gets once those levels are optimized. Now imagine your partner, your mother, or your sister going through something similar, except nobody tells them there's a fix. That's the reality for millions of women right now.
Women produce estrogen, progesterone, and testosterone - and all three decline with age. When estrogen drops during menopause, the consequences go far beyond hot flashes. The vaginal and urinary tract tissues lose their integrity, leading to chronic infections, painful sex, and bladder problems that can last decades. Meanwhile, testosterone levels start falling in a woman's 30s, long before menopause, quietly eroding libido, energy, and sense of self.
Here's the good news: the science on treating these hormone deficiencies has never been stronger. In November 2025, the FDA removed the black box warning from all estrogen-containing hormone therapy products - a move decades in the making. The 2025 AUA/SUFU/AUGS guidelines now provide the first comprehensive, evidence-based framework for treating Genitourinary Syndrome of Menopause (GSM). And a global consensus from 11 medical societies confirms that testosterone therapy is safe and effective for women with low libido.
This article breaks down what every man should know about women's hormone health - not just so you can understand the science, but so you can be an informed advocate for the women in your life.

Genitourinary Syndrome of Menopause: The Condition You've Never Heard Of​

Genitourinary Syndrome of Menopause (GSM) is the medical term for what happens to the vagina, vulva, urethra, and bladder when estrogen and androgen levels decline. Think of it as the urogenital equivalent of sarcopenia - a progressive tissue deterioration driven by hormone loss. The term was adopted in 2014 to replace older labels like "vaginal atrophy" and "atrophic vaginitis," which failed to capture the full scope of the condition.
GSM isn't a minor inconvenience. It's a progressive condition that doesn't resolve on its own and typically worsens over time without treatment. The vaginal and urethral tissues are densely packed with estrogen and testosterone receptors. When those receptors go unfed, the tissue thins, the pH rises, the protective acidic microbiome collapses, and pathogenic bacteria move in. The result is a cascade of symptoms that can dominate a woman's daily life.

Symptoms of GSM​

GSM affects three overlapping systems - genital, urinary, and sexual:
• Genital: Vaginal dryness, burning, irritation, discharge changes, loss of labial tissue, and vulvar discomfort that makes wearing pants uncomfortable
• Urinary: Increased frequency, urgency, incontinence, recurring UTIs, and a chronic sensation of bladder irritation
• Sexual: Pain during intercourse (dyspareunia), reduced arousal, difficulty reaching orgasm, decreased lubrication, and postcoital bleeding
As Dr. Rachel Rubin, a board-certified urologist and sexual medicine specialist, puts it: this isn't just "a little dryness." It's a condition where women stop having sex, stop leaving the house, and plan their entire lives around bathrooms and UTI episodes. And here's the kicker - studies show that roughly half of postmenopausal women experience GSM, but only about 9% of Medicare beneficiaries with a GSM diagnosis ever fill a prescription for vaginal estrogen.

Vaginal Estrogen: The Most Undertreated Therapy in Medicine​

Low-dose vaginal estrogen is a micro-dosed, locally applied hormone that stays in the vaginal and urethral tissues. It doesn't meaningfully enter the bloodstream. A woman using vaginal estrogen cream or suppositories might see her serum estradiol blip up to around 20 pg/mL for a couple of hours before returning to baseline - for reference, the average man's estradiol level runs around 20-35 pg/mL. That's how safe we're talking about.

What It Does​

Vaginal estrogen restores the tissue environment from the inside out. It thickens the vaginal and urethral lining, drops the pH back into the acidic range that fights infection, rebuilds the protective lactobacillus-dominant microbiome, and restores blood flow to the genital tissues. In practical terms, it stops the burning, eliminates the dryness, makes sex comfortable again, and - critically - prevents UTIs.
The evidence for UTI prevention is particularly compelling. The landmark 1993 Raz trial published in the New England Journal of Medicine showed that women on vaginal estrogen cream had a median UTI incidence of 0.5 per patient-year compared to 5.9 in the placebo group. That's a reduction of more than 90%. Subsequent systematic reviews of 44 studies confirmed that vaginal estrogen significantly lowers UTI frequency across all commercially available formulations - creams, rings, tablets, and suppositories.

Available Products and Costs​

The four main delivery options for vaginal estrogen are:
• Estradiol cream (generic): Applied 1 gram vaginally twice per week. A tube costs about $13 cash price and lasts roughly 2.5 months - roughly $7/month.
• Estradiol vaginal tablet/suppository (Vagifem/Yuvafem): A 10-microgram tablet inserted twice per week. Convenient and less messy than cream.
• Estradiol vaginal ring (Estring): A flexible ring placed in the vagina and changed every 3 months. Best for women who want a set-it-and-forget-it option.
• Vaginal DHEA (prasterone/Intrarosa): Converts locally to both estrogen and testosterone. Some experts consider it the ideal option because it addresses both receptor types, though it tends to cost more.
The 2025 AUA/SUFU/AUGS guideline - the first comprehensive GSM guideline from a major urology organization - issued a strong recommendation for offering vaginal estrogen to patients with GSM symptoms. The guideline also notes that vaginal DHEA is a moderate-strength recommendation. Both treatments are considered safe for long-term use, including in women with a history of breast cancer.

The FDA Black Box Removal: Two Decades of Fear, Corrected​

On November 10, 2025, the FDA announced it was removing the black box warning from all estrogen-containing hormone therapy products. This was the strongest type of safety alert the agency can place on a drug label - the bold-bordered text warning of stroke, blood clots, heart attacks, and "probable dementia" that had appeared on every estrogen product since 2003.
To understand why this matters, you have to go back to 2002 and the Women's Health Initiative (WHI). The WHI was a massive NIH-funded study that tested a specific combination - conjugated equine estrogens (horse-derived estrogen) plus medroxyprogesterone acetate - in women whose average age was 63. Before the paper was even published, NIH officials held a press conference declaring that hormones cause breast cancer and heart disease. The media amplified the message. Doctors stopped prescribing virtually overnight. Hormone therapy use among postmenopausal women plummeted from 27% in 1999 to roughly 5% by 2020.
The problem? The data didn't actually say what the headlines claimed. When researchers later analyzed women who started hormones closer to menopause onset (under age 60 or within 10 years), the results looked very different: no significant increase in coronary heart disease, reduced all-cause mortality, and - in the estrogen-only arm - a lower risk of breast cancer. The study's formulations were also outdated. Modern hormone therapy typically uses bioidentical estradiol delivered through patches or gels, which carry a different risk profile than oral horse estrogen.
For vaginal estrogen specifically, the black box warning was always scientifically indefensible. A Cochrane meta-analysis of 30 randomized controlled trials found negligible systemic absorption and no increased risk of endometrial or breast cancer. Yet the label persisted for over 20 years, scaring patients and doctors alike. Studies showed that nearly one in three women who received a vaginal estrogen prescription never filled it because of the warning label.
The label change went into effect in February 2026. New labels will include age-specific guidance indicating that women who begin hormone therapy within 10 years of menopause onset may experience long-term health benefits, including reduced fracture risk and lower all-cause mortality.

Testosterone for Women: The Global Consensus​

This is where ExcelMale readers will feel right at home. Testosterone isn't a "male hormone" - it's a human hormone. Women's ovaries and adrenal glands produce it throughout their reproductive years, and it plays a critical role in libido, arousal, orgasm, energy, mood, and musculoskeletal health. Women actually produce more testosterone than estrogen on a daily basis.
Here's the timeline that matters for women: testosterone levels begin declining in the early 30s, independent of menopause. By the time a woman reaches perimenopause, she may have lost 50% or more of her peak testosterone. Add in oral contraceptives or spironolactone - both of which suppress testosterone - and you can see women in their 20s and 30s with significantly depleted androgen levels.

What the Evidence Shows​

In 2019, a Global Consensus Position Statement endorsed by 11 international medical societies - including the Endocrine Society, the International Menopause Society, and the European Menopause and Andropause Society - confirmed that testosterone therapy is effective for treating hypoactive sexual desire disorder (HSDD) in postmenopausal women. The benefits include improved sexual desire, arousal, orgasm frequency, pleasure, and reduced sexual distress.
The ISSWSH Clinical Practice Guideline expanded on this in 2021, providing a practical framework for prescribing. The key points:
• Dosing: About one-tenth the male dose. Typically 0.5 mL of generic testosterone gel (the same product prescribed to men) applied daily to the leg.
• Timeline: Effects typically take 4-6 months to fully develop. Patience is required - this isn't like starting TRT in men where many notice changes within weeks.
• Monitoring: Total testosterone is checked at baseline and monitored to keep levels within the physiologic premenopausal range. The goal is restoration, not supraphysiologic dosing.
• Safety: At physiologic doses, serious adverse events are not observed. Minor side effects like oily skin or mild acne are possible but uncommon at these low doses.
• Cost: About $8/month using generic male testosterone gel at female dosing.
The frustrating reality? No testosterone product is FDA-approved for women in the United States, despite being approved in Australia, New Zealand, South Africa, and England. The FDA rejected a testosterone patch for women in the mid-2000s not because of safety concerns, but because the agency wanted five more years of data - a second billion-dollar study that no pharmaceutical company was willing to fund. So clinicians prescribe male testosterone products off-label at adjusted doses.

Women's Hormone Therapy at a Glance​

The four main categories of hormone therapy for women:

Therapy​	What It Treats​	Forms​	Key Notes​
Systemic Estrogen	Hot flashes, night sweats, osteoporosis prevention	Patch, pill, gel, pellet	Best started within 10 years of menopause
Systemic Progesterone	Uterine protection, sleep, mood support	Oral capsule (micronized)	Required if uterus is intact and taking systemic estrogen
Vaginal Hormones	GSM, UTI prevention, painful sex, dryness, urinary symptoms	Cream, tablet, ring, DHEA insert	Local only - negligible systemic absorption. Safe for all ages
Systemic Testosterone	Low libido (HSDD), arousal, orgasm, energy, mood	Gel (male product at 1/10 dose)	Not FDA-approved for women in U.S. - prescribed off-label

Practical Steps: How to Help the Women in Your Life​

You understand hormones better than 95% of the general population. You've navigated dosing protocols, lab monitoring, and the frustration of finding a competent provider. That experience makes you an invaluable resource for the women around you. Here's what to do with it.

Start the Conversation​

Many women don't know that their UTIs, painful sex, bladder urgency, or vanished libido have a hormonal cause. They've been told it's "just aging" or "all in your head." If your partner mentions any of these symptoms, you can say: "You know, there's actually a well-studied hormonal treatment for that. It's safe, inexpensive, and your doctor can prescribe it." Sometimes the most powerful thing you can do is validate that the problem is real and treatable.

Know the Red Flags for Undertreated GSM​

• Frequent UTIs (3+ per year), especially if they started around menopause
• Avoiding sex due to pain or dryness
• Constantly needing to find a bathroom
• Recurrent antibiotic use without anyone addressing the root cause
• A doctor who says "this is just part of getting older"

Advocate at the Doctor's Office​

If your partner's doctor isn't familiar with vaginal estrogen or dismisses hormone therapy based on outdated WHI fears, that's a sign they need updated information - or a second opinion. The 2025 AUA/SUFU/AUGS GSM guideline, the ISSWSH testosterone guideline, and the FDA's label removal are all powerful reference points. Dr. Rachel Rubin's website (rachelrubinmd.com) offers a free downloadable guide that teaches clinicians how to write the prescription.

Understand the Parallel to Men's TRT​

The parallels are striking. Men's testosterone therapy faced decades of stigma and regulatory resistance - remember the FDA's 2015 label warning about cardiovascular risk? Women's hormone therapy has faced even worse. The WHI debacle was to women's HRT what the flawed 2010 testosterone meta-analyses were to men's TRT - bad science amplified by bad journalism, creating fear that took decades to undo. Your experience navigating the TRT landscape gives you the context to understand what women are up against.

The Bigger Picture: Why This Matters for Couples​

Sexual health doesn't exist in a vacuum. When a woman on no hormone therapy experiences pain with sex, loses her libido, or gets her fifth UTI of the year, it affects the entire relationship. Men on TRT often report improved libido and sexual function - but if their partner is struggling with untreated GSM or testosterone deficiency, the mismatch creates frustration on both sides.
Optimizing both partners' hormone health creates a positive feedback loop. She's comfortable, aroused, and interested. He's performing well and feeling connected. It sounds simple, but the number of couples suffering silently because nobody connected the dots is staggering. The ExcelMale community is in a unique position to bridge this gap - to take the evidence-first, patient-advocacy mindset that drives men's health optimization and extend it to the women who matter most in their lives.

Related ExcelMale Forum Discussions​

Explore these community discussions for additional insights:
Testosterone & HRT in Women: Master Index - Comprehensive resource hub with links to all women's HRT-related threads on ExcelMale
FDA Removes Black Box Warning: What the New HRT Guidelines Mean - In-depth breakdown of the November 2025 FDA decision and what it means for families
Genitourinary Syndrome of Menopause (GSM) - Dr. Rachel Rubin's presentation on GSM diagnosis and treatment strategies
Hormone Replacement Therapy HRT for Women Guide - ExcelMale's cornerstone guide to women's HRT, covering estrogen, progesterone, and testosterone
The Use of Testosterone in Women - Is It Worth It and Safe? - Long-running community thread (24K views) on the evidence for testosterone therapy in women
Treatments That May Increase Sex Drive in Women - Practical discussion of treatment options for female sexual dysfunction (30K views)
Practical Clinical Summary on Testosterone Therapy in Women - Concise clinical overview for quick reference on dosing, monitoring, and safety
Sexual Dysfunction in Women: A Practical Approach - Evidence-based approach to evaluating and treating female sexual dysfunction
Comparison of U.S. Clinical Guidelines on HRT in Women - Side-by-side comparison of NAMS, Endocrine Society, AUA, and ACOG recommendations
Vaginal Syndrome of Menopause: Treatments - Detailed discussion of vaginal estrogen, DHEA, moisturizers, and non-hormonal options

Key References​

1. Kaufman MR, Ackerman LA, Amin KA, et al. The AUA/SUFU/AUGS Guideline on Genitourinary Syndrome of Menopause. J Urol. 2025;214(3):242-250. doi:10.1097/JU.0000000000004589
2. Makary MA, Nguyen CP, Hoeg TB, Tidmarsh GF. Updated Labeling for Menopausal Hormone Therapy. JAMA. 2025;335(2):117-118. doi:10.1001/jama.2025.22259
3. Davis SR, Baber R, Panay N, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Clin Endocrinol Metab. 2019;104(10):4660-4666. doi:10.1210/jc.2019-01603
4. Parish SJ, Simon JA, Davis SR, et al. ISSWSH Clinical Practice Guideline for the Use of Systemic Testosterone for HSDD in Women. J Sex Med. 2021;18(5):849-867. doi:10.1016/j.jsxm.2020.10.009
5. Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N Engl J Med. 1993;329(11):753-756. doi:10.1056/NEJM199309093291102
6. Gallo K, Zhang C, Burton C, Kamdar N, Enemchukwu E. Vaginal Estrogen Utilization Among Medicare Beneficiaries With GSM. JAMA Netw Open. 2025;8(12):e2549822. doi:10.1001/jamanetworkopen.2025.49822
7. Islam RM, Bell RJ, Green S, Page MJ, Davis SR. Safety and efficacy of testosterone for women: a systematic review and meta-analysis of randomised controlled trial data. Lancet Diabetes Endocrinol. 2019;7(10):754-766. doi:10.1016/S2213-8587(19)30189-5
8. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative. JAMA. 2002;288(3):321-333. doi:10.1001/jama.288.3.321
9. Manson JE, Chlebowski RT, Stefanick ML, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the WHI randomized trials. JAMA. 2013;310(13):1353-1368. doi:10.1001/jama.2013.278040
10. Kling JM. Testosterone for the Treatment of Hypoactive Sexual Desire Disorder in Perimenopausal and Postmenopausal Women. Obstet Gynecol. 2025;146(3):341-349. doi:10.1097/AOG.0000000000006015

Medical Disclaimer​

This article is for informational and educational purposes only. It does not constitute medical advice, diagnosis, or treatment. Hormone therapy decisions should be made in consultation with a qualified healthcare provider who can evaluate individual risks, benefits, and medical history. The information presented here reflects the best available evidence as of April 2026 but should not replace professional medical guidance. If you or a loved one is experiencing symptoms discussed in this article, please consult a healthcare professional.

About ExcelMale​

ExcelMale.com is the internet's leading expert-moderated men's health forum, with over 24,000 members and more than 20 years of community-driven health discussions. Founded by Nelson Vergel - author of Testosterone: A Man's Guide and Beyond Testosterone - ExcelMale provides evidence-based information on testosterone replacement therapy, hormone optimization, sexual health, and general wellness. The ExcelFemale section extends this mission to women's hormone health, reflecting our community's understanding that optimizing health is a family affair. Visit us at ExcelMale.com to join the conversation.