#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.

Rachel Rubin is a board-certified urologist and one of the nation’s foremost experts in sexual health. In this episode, she shares her deep expertise on the often-overlooked topic of women’s sexual health, exploring why this area remains so neglected in traditional medicine and highlighting the critical differences in how men and women experience hormonal decline with age. Rachel explains the physiology of the menstrual cycle, the complex hormonal shifts of perimenopause, and the wide-reaching health risks associated with menopause, including osteoporosis, cardiovascular disease, dementia, and recurrent urinary tract infections. She also breaks down the controversy surrounding hormone replacement therapy (HRT), particularly the damaging legacy of the Women’s Health Initiative study, and provides guidance on the safe and personalized use of estrogen, progesterone, and testosterone in women. With particular emphasis on local vaginal hormone therapy—a safe, effective, and underused treatment—Rachel offers insights that have the potential to transform quality of life for countless women.

How Stress Affects Women’s Bodies Differently & (What to Do)

Stress is an unavoidable part of life but the way it affects us can differ greatly between men and women. For women, stress doesn’t just impact mood or sleep; it weaves its way into hormonal balance, digestion, reproductive health, and even chronic disease risk. Understanding these gender-specific differences can help women navigate stress more effectively and support their health holistically. In this article, we’ll explore how stress uniquely affects women’s bodies and outline practical, evidence-based strategies to help women manage it. Let’s dive into how the female body responds to stress and what you can do to protect your well-being.

1. The Female Stress Response: What Makes It Different?

Women tend to experience a “tend and befriend” stress response, compared to the male “fight or flight” response. This is largely influenced by the female hormone oxytocin, which promotes bonding and nurturing behaviors. Estrogen enhances oxytocin’s effects, making women more likely to seek social support during stressful times. Cortisol, the body’s primary stress hormone, also behaves differently in women, often staying elevated longer than in men. This prolonged exposure can increase vulnerability to anxiety, depression, and hormonal imbalances. Additionally, stress affects the hypothalamic-pituitary-adrenal (HPA) axis differently in women, potentially exacerbating emotional reactivity. These variations mean women are not just emotionally but biologically wired to experience stress differently. Recognizing these differences is essential for developing targeted self-care and medical approaches. By understanding how stress manifests in women, we can adopt strategies that support emotional resilience, hormonal health, and long-term well-being.

2. Hormonal Havoc: Stress and the Female Endocrine System

Stress significantly disrupts the endocrine system, particularly in women. The HPA axis, which controls cortisol release, is closely linked to the reproductive hormonal axis. When stress is chronic, the body may prioritize cortisol production over sex hormone synthesis. This shift can suppress ovulation, reduce progesterone levels, and cause irregular or missed periods. For women of reproductive age, this can affect fertility and menstrual regularity. For those in perimenopause or menopause, stress may worsen symptoms like hot flashes, mood swings, and sleep disturbances. Moreover, cortisol can interfere with the thyroid. Another critical gland for regulating metabolism and energy. Hypothyroidism and adrenal fatigue often show up together in women under chronic stress. Understanding the hormonal consequences of stress is key to regaining balance. Lifestyle interventions like reducing caffeine, prioritizing sleep, and adding adaptogens can be helpful. Hormonal testing may also reveal patterns that require personalized support through nutrition or integrative medicine.

3. Stress and Gut Health: Why Women Are More Vulnerable

The brain-gut axis, how your mind communicates with your digestive system, is particularly sensitive in women. This means that emotional stress often leads to physical gut symptoms like bloating, cramping, constipation, or diarrhea. Women are more likely than men to be diagnosed with irritable bowel syndrome (IBS), which is strongly influenced by psychological stress. Hormonal fluctuations throughout the menstrual cycle also affect gastrointestinal function, making symptoms worse during PMS or ovulation. Stress can alter gut motility, reduce beneficial bacteria, and increase intestinal permeability (aka “leaky gut”), contributing to inflammation and food sensitivities. Managing stress is critical for restoring gut function. Techniques like diaphragmatic breathing, mindfulness, and regular movement help activate the parasympathetic nervous system. The body’s rest-and-digest mode. Certain supplements, such as probiotics and herbal blends like gi revive, can help repair and soothe the gut lining. Addressing both emotional and digestive health together is key for long-term relief.

4. Emotional Burnout: Anxiety, Depression, and Women

Women are statistically more likely than men to suffer from anxiety and depression, and stress is a key contributing factor. This isn’t just due to social roles and expectations; biological factors play a big part. Fluctuations in estrogen and progesterone throughout a woman’s life influence neurotransmitters like serotonin and dopamine, which regulate mood. Chronic stress reduces serotonin levels and shrinks the hippocampus, the part of the brain responsible for memory and emotional regulation. This can make it harder for women to bounce back from stressful events. Emotional burnout also arises when the demands of work, caregiving, and daily life overwhelm coping capacity. Symptoms may include fatigue, irritability, brain fog, and loss of motivation. Therapy, especially cognitive-behavioral therapy (CBT), is effective for addressing underlying thought patterns. Mindfulness meditation, journaling, and social support are also powerful tools. Treating stress-related mood disorders in women requires both emotional validation and physiological support.

5. Reproductive Health: Fertility, PMS, and Menopause

Stress has profound effects on female reproductive health. In women of childbearing age, stress can disrupt ovulation, reduce libido, and contribute to conditions like polycystic ovary syndrome (PCOS) and endometriosis. Chronic cortisol elevation lowers progesterone and increases androgens leading to irregular periods and fertility issues. Women with PMS often report worsened mood and physical symptoms when under stress, including heightened cramps, bloating, and fatigue. During menopause, stress amplifies hot flashes, insomnia, and mood swings due to declining estrogen and reduced adrenal reserve. The reproductive system is highly sensitive to perceived safety, so when the body is under chronic threat, it may “turn off” fertility mechanisms. This is why stress management is crucial when trying to conceive or managing hormonal transitions. Strategies like acupuncture, magnesium supplementation, restorative yoga, and herbal support (like chaste tree berry or black cohosh) can make a significant difference. A holistic approach helps balance hormones naturally and supports reproductive vitality.

6. Weight Gain and Metabolism: Stress’s Silent Influence

When stress hormones like cortisol remain elevated, it can alter metabolism and encourage fat storage. Especially around the abdomen. This central weight gain is not just a cosmetic concern; it increases the risk for insulin resistance, type 2 diabetes, and cardiovascular disease. Women may also experience more intense sugar or carb cravings when under stress, leading to emotional eating or binge cycles. Stress impairs the body's ability to regulate blood glucose effectively, which can further contribute to energy crashes, irritability, and fatigue. Additionally, cortisol breaks down muscle tissue for fuel, slowing metabolism over time. Even if calorie intake remains the same, weight may increase due to this hormonal shift. Managing stress through consistent meals, strength training, and mindfulness-based eating can prevent metabolic slowdowns. Sleep hygiene is equally important. Sleep deprivation alone raises cortisol and ghrelin (your hunger hormone). Empowering women with metabolic education and stress-relief practices can support sustainable weight and energy balance.

7. Skin, Hair, and Inflammation: Beauty from the Inside Out

Stress shows up in the mirror. From adult acne and eczema to hair thinning and dullness, women’s skin and hair are particularly responsive to internal imbalances. Cortisol increases inflammation in the body, aggravating skin conditions like psoriasis, rosacea, and hives. It also disrupts the skin barrier, causing dryness and premature aging. Hair loss is a common but under-discussed response to chronic stress, often triggered by a condition called telogen effluvium. This occurs when hair follicles enter a resting phase prematurely, leading to shedding weeks or months later. Hormonal changes, nutrient depletion, and poor sleep compound these effects. Supporting skin and hair health under stress requires a whole-body approach. Anti-inflammatory foods like berries, omega-3 fats, and leafy greens nourish from within. Topical treatments help, but true healing begins with calming the nervous system and restoring balance internally. Adaptogens like ashwagandha and nutritional support with B vitamins can promote radiance and resilience.

8. Immune System Impact: Getting Sick More Often?

Women often juggle multiple roles, leaving their immune systems overtaxed. Chronic stress suppresses immune function, making it harder for the body to fight off viruses and infections. Cortisol initially acts as an anti-inflammatory, but over time, chronic exposure impairs immune cell communication and increases susceptibility to illness. Women under stress may notice more frequent colds, longer recovery times, or autoimmune flare-ups. The immune system also plays a role in regulating inflammation, which underlies many chronic conditions. Stress-induced inflammation may worsen asthma, rheumatoid arthritis, or skin conditions like lupus. All more prevalent in women. Supporting immunity involves both physical and emotional care. Prioritizing sleep, staying hydrated, and using immune-supportive herbs like elderberry and echinacea can help. Meditation and time in nature have been shown to lower cortisol and boost natural killer cell activity. Taking a proactive approach to stress and immunity ensures that women stay resilient and protected long-term.

9. What You Can Do: Everyday Stress-Busting Strategies

Managing stress doesn’t have to be complicated. It just needs to be consistent. Building a toolkit of stress-relief practices that suit your lifestyle and preferences is key. Start by identifying what triggers your stress and how your body responds. Then, create daily routines that include physical movement (like walking, yoga, or strength training), mindful breathing, and downtime. Prioritize sleep by getting 7–9 hours nightly allows your brain and body to reset. Nutrition plays a huge role; eat whole, unprocessed foods and avoid skipping meals to keep blood sugar stable. Supplements like magnesium, L-theanine, and adaptogenic herbs can support nervous system regulation. Don’t underestimate the power of connection. Talking with friends, therapists, or support groups can provide emotional relief. Digital detoxes, journaling, and creative hobbies also help you stay grounded. Remember: stress relief isn’t indulgent; it’s a form of self-preservation. The more you prioritize your own care, the more resilient and empowered you become.

10. When to Seek Help: Knowing the Signs

Sometimes, stress goes beyond what you can manage on your own. If you're experiencing persistent anxiety, chronic fatigue, sleep disturbances, or digestive problems, it may be time to seek professional help. Women often wait too long to address stress-related symptoms, chalking them up to “just life.” But ignoring these signs can lead to burnout or more serious health issues. A mental health professional can help identify the root causes of your stress and provide strategies tailored to your personality and situation. Functional medicine doctors and dietitians can also assess hormonal imbalances, gut health, and nutrient deficiencies that might be contributing to your symptoms. Don’t hesitate to ask for support. It's a strength, not a weakness. Addressing chronic stress with a multidisciplinary approach ensures that your mental, emotional, and physical health are all considered. Healing begins when you take your well-being seriously and when you recognize you don’t have to do it alone.

A Comprehensive List of Every Single Menopause Symptom—and What to Do About Each

Here’s everything you can expect, with advice straight from OB/GYNs on how to cope. By Emily Laurence

With the exception of childbirth, menopause is the biggest physical change a woman will experience after puberty. Menopause is the permanent end of menses, which is completely natural and caused by a decrease in estrogen. Women spend roughly 40% of their life in the postmenopausal years.

The onset of perimenopause typically begins around 45, with the average age of being in full-blown menopause between 50 and 52. If you're around this age, you may be wondering what exactly to expect. Sure, you've heard of hot flashes, but what about the less talked about symptoms? Or perhaps you are all too familiar with menopause symptoms and you just want to know how to make them more bearable. 

With renewed research around hormone replacement therapy, many women are wondering if HRT might be a possible solution. "Hormone replacement therapy is traditionally used when a patient is experiencing menopausal changes that are distracting, distressing or making life complicated," says Dr. Brian Tesler, MD, FACOG, the System Chief Medical Director for Women's Health and Perinatal Services at McLaran Health Care. He explains that hormone replacement therapy is when the body is supplemented with hormones the ovaries decrease or stop producing to help the body better adjust to the changes happening during menopause. "It's important to know there are different types of hormone replacement therapy and the ways you take them," he says.

Dr. Tesler says it's important to talk to your doctor about your particular symptoms, medical history and get a comprehensive lab panel to know if HRT is necessary. "Each patient's journey through perimenopause and menopause is different. Some patients can manage concerns by changing their lifestyle and environment, such as sleeping in lighter clothing to help with night sweats or using fans during the day for hot flush feelings. Other patients can take non-hormonal medications or supplements and see reasonable control of symptoms," he says. Most experts recommend starting hormone replacement therapy before the age of 60 and sticking with it for a maximum of 10 years, he says.

Included here is a comprehensive list of every single menopause symptom as well as how to make all of them easier to endure.

Hot flashes

You’ve probably heard of hot flashes, but what exactly are they? They happen spontaneously and suddenly, a feeling of warmth that is felt on the chest, neck and face. Often, hot flashes make you sweat.

“Hot flashes can be uncomfortable, but there are several strategies you can try to make them more manageable through lifestyle change,” says Dr. Anna Cabeca, DO, OBGYN, FACOG. Dr. Cabeca recommends dressing in layers, which makes it easier to adjust when a hot flash strikes. She adds that certain foods and drinks can trigger hot flashes, including spicy foods, caffeine and alcohol, so it can help to minimize consumption of them.

“Stress can contribute to hot flashes. Practice relaxation techniques like yoga, meditation or deep breathing,” Dr. Cabeca added, noting that getting enough sleep also helps minimize hot flashes. If you try all of this and hot flashes are still making you miserable, Dr. Cabeca says it may be beneficial to consider hormone therapy, which can be discussed with your doctor. “There are also medications specifically approved for hot flashes that don't contain hormones,” she adds.

Dr. Tesler says that breast tenderness often happens during perimenopause and goes away when menopause sets in. "Breast tenderness is related most to the fluctuation or changes of hormones like progesterone and estrogen. Often during perimenopause, or the period around menopause when the ovaries start to shut off gradually, is when most people experience breast tenderness," he says. Dr. Tesler says that, for some people, caffeine can make breast tenderness worse, so it may be beneficial to minimize how much you're consuming. He says that making sure your bras fit correctly can help too, as well as hormone therapy if it's really inhibiting you from enjoying life.

Dry mouth

Something else that can happen due to a drop in estrogen, Dr. Tesler says, is your mouth feeling extra dry. "There have been studies that show the amount and consistency of saliva change in menopausal patients. This can be as severe as what is known as 'burning mouth syndrome,' where some experience a feeling that their tongue and mouth are on fire," he says, adding that if it's something you are experiencing, you should tell your doctor and dentist because it can impact the teeth and gums. To manage dry mouth, Dr. Tesler suggests using sugar-free, natural lozenges such as ginger, known to stimulate saliva production, or special mouthwashes.

Vaginal dryness

If you are experiencing vaginal dryness, don’t be afraid to talk to your doctor about it! Dr. Cabeca says this is an extremely common menopause symptom.

“Vaginal dryness during menopause can be such a frustrating experience, but there are definitely ways to manage it and feel more comfortable. You want to keep it moisturized, using gentle, natural moisturizers like coconut oil, shea butter, aloe vera gel, hyaluronic acid or vitamin E. These can help soothe and hydrate the skin down there without any harsh chemicals,” she says. (Be sure to speak with your OB/GYN before using anything topical inside your vagina, or you may risk irritation and infections, not to mention wrecking latex condoms if you're sexually active, putting you at risk of STIs.) Dr. Cabeca adds that eating a nutritious diet can help as well. If those don't help, you can consider prescription medications, according to Cleveland Clinic, so be sure to speak to your OB/GYN.

Sleep disturbances

Trouble sleeping is one of the primary symptoms of menopause and can mean trouble falling asleep or waking up in the middle of the night. “Sleep disturbances are common during menopause due to hormonal fluctuations. Estrogen levels decline, which can disrupt the body's natural sleep-wake cycle. Additionally, hot flashes and night sweats can wake women up throughout the night,” Dr. Cabeca says.

Dr. Cabeca recommends making your bedroom as conducive to a good sleep environment as possible. That means making sure it’s cool and dark and having bedding that feels good to you. She also says it’s important to stick to a regular sleep schedule, which helps support circadian rhythms.

Mood swings

It’s not your imagination if you find yourself moodier than usual. This is yet another common symptom of menopause. “Hormonal fluctuations, specifically the decline of estrogen and progesterone levels, can lead to significant emotional symptoms such as irritability, anxiety, depression and feeling overwhelmed,” Dr. Cabeca explains. The fix here? Dr. Cabeca says to prioritize self-care and do what you can to support balance in the body by eating a nutritious diet, which is less likely to spike blood sugar levels than one that primarily consists of sugary, ultra-processed foods, which can make mood swings more likely.

And don’t be afraid to see a therapist if you are really struggling. “You can always look for help. Talk to someone that can help you as you’re processing these changes in life and within your body,” Dr. Cabeca says This may also be an area where hormone therapy can be useful, so if nothing else is helping, definitely talk to your OB/GYN or a psychiatrist, who will be able to prescribe hormonal replacements or medications to help you feel like your best self again..

Weight gain

It’s natural to gain weight during menopause, especially around the abdomen. “The hormonal changes we experience during menopause, especially the drop in estrogen, has a direct impact on our metabolism which in turn, will impact your weight,” Dr. Cabeca told us. While she says that maintaining a healthy diet and regular exercise can help, she says it can be especially beneficial to maintain a low-carb diet and eat lots of leafy greens. “This approach not only helps with weight loss, but also supports overall hormone balance,” she says. Dr. Cabeca added that doing what you can to minimize stress can be helpful too, because it keeps cortisol levels from rising. This is key since high cortisol makes weight gain easier.

Itchy skin

Dr. Tesler explains that as estrogen decreases, skin loses collagen (a connecting tissue that gives it elasticity) and natural oils that keep it hydrated. This can make the skin feel dry and itchy. "Other than hormone replacement, successful remedies include decreasing hot shower temperature, moisturizer, avoiding skin irritants and wearing looser non-synthetic clothing," he says.

Dry eyes

Dr. Abby Flannagan, DO, an OB/GYN at UnityPoint Health, says it isn't unusual to experience dry eyes during menopause. To manage it, she suggests using lubricating eye drops, which provide moisture. Dr. Flannagan says that taking an omega-3 fatty acid supplement may help too because it helps balance hormones. She adds that it's also a good idea to stay on top of your yearly eye exams to make sure nothing else is contributing to the dryness. 

Brain fog

“Another symptom that often flies under the radar is brain fog,” Dr. Cabeca says, describing brain fog as a feeling of forgetfulness or trouble concentrating. Some ways to minimize brain fog include taking regular breaks from activities that require a lot of focus, getting consistent, good quality sleep, minimizing stress, exercising regularly and eating a balanced diet. Brain fog can also be a symptom of long COVID, so if you're concerned, definitely talk to your doctor to determine the root cause of the problem.

Ringing in the ears

While Dr. Flannagan says that menopause can cause ringing in the ears, she says this symptom could also stem from a change in hearing due to age. For this reason, she suggests seeing an audiologist to make sure there are no underlying health issues and for treatment. "Estrogen is believed to play a role in the connections between the hearing mechanisms of the ear and the brain that processes the sounds. Research states both progesterone and estrogen are to blame when it comes to hearing and ringing problems during menopause," Dr. Tesler says, adding that aspirin, ibuprofen, caffeine and alcohol can all exacerbate symptoms. "Some studies have shown success with distraction techniques such as yoga and deep breathing to 'block out' the ringing," he adds. 

Heart palpitations

Heart palpitations is another symptom Dr. Cabeca says many people don’t realize is connected to menopause, but it’s something more than half of menopausal women experience. Scientific research shows that hormone replacement therapy may help with heart palpitations, so if it’s something you are experiencing regularly and it’s impacting your ability to function or enjoy life, it may be beneficial to talk to your doctor about it.

Frozen shoulder

Dr. Cabeca says that another symptom of menopause many people don’t know is frozen shoulder, which is experiencing pain or stiffness in one or both shoulders. While hormone replacement therapy can help decrease this, it can also be treated by taking an over-the-counter painkiller or applying a heating pad.

Restless legs

Ever experience an uncomfortable feeling in your legs that feels like the urge to move them? This restless leg symptom can be due to menopause, Dr. Cabeca says. Medications like gabapentin and pregabalin can help decrease symptoms, so if it’s something you’re experiencing regularly, talk to your doctor.

Alcohol intolerance

You may find that alcohol affects you more during menopause. "Alcohol causes a lot of changes in the menopausal person. People may notice it makes them have to use the restroom more often, hangovers are worse and the amount they can drink is significantly less," Dr. Tesler says. 

Dr. Tesler explains that this is likely due to the liver losing the ability to process alcohol as well, so alcohol stays concentrated for longer. "It is also known that the body loses water more quickly during menopause, and this is thought to reduce the ability to dilute alcohol and its effects," he adds. He recommends minimizing intake—especially before bed as it can disrupt sleep. “It's important to remember that menopause is a unique experience for every woman,” Dr. Cabeca says. “Some might sail through with minimal symptoms, while others might face a mix of these challenges. If you're noticing any changes that feel ‘off,’ it's always a good idea to chat with your healthcare provider.”

Remember, if any symptom is getting in the way of your daily functioning or is making you feel depressed, talk to your doctor. Together, you can find a way to decrease your symptoms so you can go back to feeling like yourself again.