Rachel Rubin’s crusade to help women

At eight thirty each morning Dr Rachel Rubin arrives at her Bethesda clinic. A fresh stack of charts waits on her desk. Most describe women in their late forties to mid-sixties who feel tired, restless at night, and unsure why their own bodies seem unfamiliar. Only six percent of American women over fifty receive hormone therapy, mostly because of misunderstandings, bad reporting, and an undeserved reputation for causing cancer. Rubin calls that avoidable harm and has built her practice to close the gap. She tries to help as many women as possible, but there are more than she can handle.

In the entire United States, only about 1,300 clinicians have earned formal Menopause Society certification, a tiny fraction of the roughly fifty thousand obstetrician-gynecologists and nearly half a million primary-care doctors who could, in theory, prescribe hormone therapy. Against that limited pool stand more than sixty million women already past age fifty, plus another twenty-three million now entering the transition, the vast majority of whom could benefit from properly managed estrogen, progesterone, and (for some) testosterone. Yet fewer than one in twenty office visits by mid-life women results in a hormone prescription, a gap that forces many patients to drive hours or even fly across state lines to find competent care.

The three core hormones

Estrogen: This hormone steadies body temperature, supports memory, keeps skin elastic, maintains flexible artery walls, and is a critical component of building muscle and bone. Rubin prefers a skin patch or clear gel because those forms avoid the small clot risk linked to older tablets.

Progesterone: It protects the uterine lining whenever estrogen is present and, when taken at bedtime, improves deep sleep. Rubin starts with a micronized capsule if a woman still has a uterus. A progesterone-releasing IUD steps in when capsules cause daytime grogginess or mood change.

Testosterone: In women, testosterone is far less prevalent than in men, but it's also about 100 times more prevalent than estrogen. Testosterone allows exercise to increase muscle and bone mass, supports motivation, and restores sexual interest. Rubin prescribes a metered cream measured in tenths of a milliliter. Doses stay low and levels are reviewed until symptoms improve without skin or mood side-effects.

Strategy by life stage

Perimenopause: Cycles continue but hormone levels swing. Rubin eases symptoms with a low estrogen patch. She adds a small progesterone pill only when heavy periods or poor sleep persist. Testosterone is rarely used during this stage.

Menopause: Twelve months have passed without a period and estrogen production has dropped sharply. Most patients move to a moderate patch for joint comfort, mood stability, and bone support. Progesterone becomes mandatory for women with a uterus, delivered nightly or through an IUD. A daily micro-dose of testosterone joins the plan for muscle maintenance and libido.

Post-menopause: Needs depend on bone scans, lipid panels, and day-to-day function. Estrogen stays in place for bone and cardiovascular support, sometimes at a lower dose than before. Progesterone continues when a uterus is present and may be kept for sleep even after hysterectomy. Testosterone is trimmed or raised in small steps as weight, exercise, or skin response changes.

Patient stories

Carla, 57, improved sleep and mood on a standard estrogen patch plus a quarter millilitre of testosterone cream. Four months later chin acne appeared and impatience grew. Blood work showed testosterone high and estrogen low. Rubin halved the cream, increased the patch, and limited testosterone use to three days a week. Acne cleared and temperament steadied within six weeks.

Sandra, 52, reached menopause with disturbed sleep as her only complaint. A one-hundred-milligram progesterone capsule deepened her sleep but left her slow at breakfast. Dropping to fifty milligrams caused spotting. Rubin replaced the capsule with a progesterone IUD and restored the original estrogen patch. Sleep and daytime alertness both improved.

Ellen, 60, arrived with a testosterone pellet implanted by a wellness spa. Her gym results were strong, but hair thinned and mood swings were constant. Pellets cannot be adjusted after insertion. Rubin added a low estrogen patch and nightly progesterone, waited six months for the pellet level to fall, then switched Ellen to a measured cream. Hair loss slowed and mood stabilised while muscle strength held steady.

Carrie, 54, thought she couldn't take estrogen because she had had a blood clot in her 40s. Rachel explained that today's patches and creams are extremely safe and don't cause blood clots.

Patty, 73, said she couldn't have estrogen because she had breast cancer. Rachel told her she has many cancer survivors on estrogen patches and this was just another myth promoted by social media.

Maria, 63, seems to be playing a high-stakes game of hormone roulette. High estrogen eases her joints but triggers headaches. Lower estrogen calms her head yet stiffens her knees. Progesterone deepens sleep but slows recall. Testosterone brightens focus one month and feels emotionally flat the next. Rubin reviews the data every quarter and alters doses in small steps. The goal is the best balance available at the moment, not perfection.

Laurie, 74, kept having urinary-tract infections. Rubin explains that if women would use a cheap tube of vaginal estrogen cream every night, the US would save up to $22 billion just in treating urinary-tract infections alone, and save hundreds of lives. She even brought the cream to her own mother in the ICU and had to educate the doctors on why they should let her apply it.

Recently, Katie, 67, found me and asked if I would train her to build bone in the gym. The first question I asked was "How much estrogen do you have?" She looked up her number and said it was 12. I said "How are you going to build muscle and bone with no estrogen?" She agreed to go meet with Rachel and get started, because she doesn't want to break a hip when she's 80.

Persistent bleeding, fibroids, or a thick uterine lining can block safe estrogen use. For some women, no amount of progesterone seems right. In those cases, Rubin will recommend hysterectomy to reduce cancer risk.

Proven benefits

Balanced hormone therapy started within ten years of the last period lowers hot-flash frequency, slows bone loss, reduces hip-fracture risk, improves cholesterol balance, supports muscle maintenance when paired with resistance exercise, and improves sexual function. Early studies also suggest benefits for coronary health and cognition.

Rubin schedules forty-minute reviews because hormones seldom resolve in ten. Lab numbers and patient diaries guide each change. Two-thirds of women settle into a steady routine within a year. The rest need ongoing fine-tuning as their bodies adapt to the new reality.

Rachel Rubin wants every primary-care visit for a woman over forty to include clear explanations of hormone options, risks, and gains. Most new patients arrive believing they must tolerate their symptoms. Rubin prefers they leave knowing the tools exist, they are safe when used correctly, and adjustments will continue until daily life feels right again. She wants women to spread the word – hormone therapy saves lives, relationships, and provides a higher quality of life after menopause. She hopes young people will want to go to med school and help fill the need for more doctors to help more women. Listen to this entire conversation with Peter Attia, you’ll be glad you did …