The Curbsiders Internal Medicine Podcast · The Curbsiders Internal Medicine Podcast

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

·1 hr 35 min·5 clips

The boxed warning still tells women vaginal estrogen could mean “probable dementia,” despite no study showing that at those doses.

1. The Curbsiders Internal Medicine Podcast #507 focuses on menopause hormone therapy with Dr. Rachel Rubin. 2. Hosts Dr. Matthew Frank Watto, Dr. Paul Nelson-Williams, and Dr. Mollie Hoiblein frame Rubin as a board-certified urologist and Georgetown assistant clinical professor who works on women’s sexual health and menopause care. 3. The episode asks how primary care clinicians should prescribe vaginal estrogen, systemic estrogen, progesterone, and testosterone now that menopause treatment is getting more public attention. 4. Rubin says the field has moved from “lowest dose, shortest amount of time possible” to shared decision-making in the 2022 menopause society guidelines. 5. She links the shift to social media, where patients can compare “multiple TV shows” of medical advice and arrive asking for hormone therapy. 6. The case features a 60-year-old woman, 10 years past menopause, with night sweats, poor sleep, joint stiffness, low libido, hypertension, and prediabetes. 7. Rubin explains that the Women’s Health Initiative studied oral synthetic hormone therapy, including PremPro and conjugated equine estrogen, in an average-age-62 population that mostly did not have menopausal symptoms. 8. She says the WHI did not show the blanket harm many clinicians associate with hormone therapy and instead found reassuring signals such as reduced fracture risk and diabetes risk. 9. Rubin distinguishes estrogen, progesterone, testosterone, vaginal hormones, oral hormones, and transdermal hormones as different products with different risk profiles. 10. She emphasizes that transdermal estrogen avoids first-pass liver effects and does not increase clotting factors the way oral therapy can. 11. She says micronized progesterone is different from medroxyprogesterone acetate, the progestin used in the WHI, and argues that the evidence is more nuanced than a simple yes-or-no warning. 12. Rubin reads the boxed warning language on estrogen products and says it includes endometrial cancer, cardiovascular disorders, probable dementia, and breast cancer even for vaginal products. 13. She calls vaginal estrogen “micro dosing” and says there is no study showing those doses cause probable dementia. 14. Rubin compares the seriousness of estrogen warnings with sildenafil labeling, noting that Viagra also has risks such as blindness and dangerous interactions with nitrates. 15. She argues that the bigger problem is not only labels but also clinician training, because residents and fellows are often not taught how to prescribe these medications. 16. Rubin says she sees women in their 50s and 60s regain sleep, libido, relationships, and work function after treatment, and she describes a neighbor who told her “the testosterone finally kicked in” after five months. 17. The conversation stays practical and case-based, with Paul and Mollie asking specific questions about cardiovascular risk, breast-cancer family history, and what actually makes prescribers uneasy. 18. Rubin’s style is direct and advocacy-driven, but she keeps returning to shared decision-making, guideline language, and specific pharmacology. 19. Listeners who manage menopausal symptoms, sexual health, or primary care prescribing will get the most from this episode. 20. People looking for a broad lifestyle discussion without medication details may skip it.

As heard by us

A practical clinician guide to menopause care, with clear focus on goals, risk discussion, and when harder cases need specialist input.

This episode treats menopause care as ordinary primary care, and that is where it feels most grounded. It draws a clean line between routine cases and the ones that belong with specialists, then keeps coming back to the same practical questions: what the patient wants to change,…

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A practical reset for menopause care in primary care.

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