One in Four Women Has Clitoral Adhesions — and No Doctor Is Checking

Source: Diary of a CEO | Published: 2026-06-22T07:00:39Z

Studies show 23% of women have clitoral adhesions, a condition that can be resolved with a simple in-office procedure and improve orgasm quality by 60–70%. Yet it's almost never screened for in routine exams.

This isn't about individual health choices. Melinda Gates saw three doctors before she got a hormone prescription. Oprah saw five, and not one of them connected her heart palpitations to perimenopause. Halle Berry can afford any doctor on the planet — and was diagnosed with genital herpes. She actually had a hormone deficiency called genitourinary syndrome of menopause.

If that's what happens to women with every advantage, where does that leave everyone else?

Doctors Were Never Taught This — Not Because It Doesn't Matter

In 2026, the word "clitoris" appears nowhere in the training curriculum for OB-GYN practitioners in the United States.

Not reduced. Not renamed. Absent. Which means the doctor who examines your body once a year has received zero systematic training on the clitoris, orgasm, libido, or painful sex.

Rubin is a urologist specializing in sexual health. She lectures, publishes, and flies across the country training clinicians on how to prescribe hormones — something that should have been covered in medical school. But an entire generation of doctors missed that training. The gap was created by a scientific PR disaster that happened twenty years ago.

The Press Conference That Destroyed an Entire Field

In the 1990s, hormone replacement therapy was widely used in menopausal women, and observational studies suggested multiple benefits including cardiovascular protection. The NIH invested a billion dollars in a large randomized controlled trial called the Women's Health Initiative (WHI), tracking thousands of women between ages 50 and 79.

In 2002, the study was terminated early. At the press conference, researchers announced that hormone therapy causes cardiovascular disease and breast cancer. Stop immediately. Overnight, a multi-billion-dollar prescription market collapsed. Women were told to throw their medication away. It was dangerous.

Clinicians who had been prescribing hormones knew something was wrong. Their patients weren't dying of heart disease in higher numbers. No extra breast cancer cases appeared. When researchers eventually dug into the data, they found the paper had never said what the press conference claimed — it had been badly misread.

In 2025, the same authors published a new analysis and stated explicitly: women under 70 using that class of hormone therapy showed no increased risk of cardiovascular disease or stroke.

But an entire generation of doctors had already been frightened off. They didn't know how to prescribe it anymore — because nobody had taught them in the first place, and the panic persisted for twenty years. Today, only 1.7% of women who should be offered hormone prescriptions are actually receiving them.

Women's Testosterone Starts Dropping in Their Thirties

When most people think about menopause, they think estrogen collapse — something that happens after fifty. But Rubin points to a hormone chart almost no one has seen and says the problem starts in your mid-thirties.

Estrogen does mainly drop during menopause. But testosterone — widely misclassified as a "male hormone" — begins a steep decline in women in their mid-to-late thirties. The ovaries produce three hormones: estrogen, progesterone, and testosterone. The menstrual cycle diagrams in medical textbooks show estrogen and progesterone. The testosterone line is typically absent.

Clinically, this presents as: women in their mid-thirties to early forties noticing their libido isn't what it was, orgasms take longer, sensation feels duller, lubrication decreases. They go to a doctor. The doctor says they're tired, or that this is normal aging, or says nothing at all.

The physiology is actually well understood: testosterone helps the clitoris engorge, supports arousal, and sustains libido. Its decline doesn't happen at menopause — it happens during perimenopause, roughly ages 35 to 45, a full decade before periods stop.

The Pill Shuts Down the Ovaries — And Testosterone Doesn't Come Back

Oral contraceptives work by creating artificial hormone levels high enough to convince the body it doesn't need to ovulate — so the ovaries temporarily go quiet and stop producing hormones on their own. For estrogen and progesterone, that's largely fine, because the pill contains synthetic replacements. But the pill doesn't replace testosterone.

When the ovaries go quiet, testosterone disappears with them.

Research Rubin cites shows that in some studies, up to 27% of people on oral contraceptives experience decreased libido. For those people, different contraceptive approaches — ones with less impact on testosterone — may be worth discussing.

This isn't an argument against the pill. Every drug has side effects, and informed consent requires that doctors explain those side effects clearly — including the sexual ones. But sexual health side effects in women tend to be the last thing studied, or not studied at all.

GLP-1 weight-loss drugs are a case in point: not a single published paper examines their effects on women's sexual health. Rubin's team conducted their own survey of a thousand women on these medications (unpublished, presented at medical conferences), finding that roughly 25% reported changes in sexual function — about half reporting a decline, about a quarter reporting improvement.

Four Buckets of Hormone Therapy, Each With Its Own Use Case

Rubin organizes hormone therapy into four buckets:

Systemic estrogen — the classic version, addressing hot flashes, night sweats, bone density, and sleep. Because estrogen promotes uterine lining growth, anyone with a uterus needs progesterone alongside it, or the thickening tissue becomes a risk.

Systemic progesterone — protects the uterine lining while also delivering secondary benefits for sleep and anxiety. Worsening sleep and rising anxiety can sometimes be early signals that progesterone is declining during perimenopause.

Testosterone — the best-evidenced indication is low libido. In her clinic, Rubin uses FDA-approved male testosterone formulations at one-tenth the male dose. Effects typically take three to six months to appear. She's treated a woman in her sixties who, after starting testosterone, not only recovered her libido but decided to apply to law school — and graduated first in her class.

Vaginal local hormones — the fourth bucket, and the one Rubin pushes hardest.

A Twice-Weekly Estrogen Cream That Costs Fourteen Dollars and Saves Lives

Vaginal local hormone therapy is not systemic. It's a micro-dose of estrogen or DHEA applied directly to the vaginal wall — local tissue only, with minimal absorption into the bloodstream.

In the UK, this product requires no prescription. In the US, it does. Mark Cuban's online pharmacy sells it for $14, good for two and a half months.

What it does: reduces urinary tract infections by more than 50%, relieves urinary urgency and leakage, addresses painful sex, improves lubrication and arousal, and improves orgasm quality.

Why does estrogen prevent UTIs? The vagina's defense mechanism depends on an acidic environment, which is maintained by healthy bacteria, which in turn depend on estrogen and testosterone. When hormones decline, beneficial bacteria diminish, harmful bacteria proliferate, and infection risk rises. Sex itself introduces external microorganisms internally, and semen is alkaline — which is why sexually active women face higher UTI risk. The biology is straightforward.

This has been established since the 1990s. It has been known for over thirty years. Yet fewer than 9% of Medicare patients receive vaginal hormone prescriptions. In large database studies, more than 75% of women who should have been offered a prescription never were.

Elderly women are dying from UTIs — because infections can enter the bloodstream, cause sepsis, and land them in the ICU. This is not trivial. And the preventive tool is cheap, safe, and appropriate for women of any age and any medical history — including cancer survivors and breastfeeding mothers.

In the episode, Rubin holds up the cream on camera to demonstrate: 1 gram, applied with a finger to the inside of the vaginal wall, rubbed in like sunscreen. Twice a week.

23% of Women Have Clitoral Adhesions — and No One Has Ever Checked

The clitoris and the penis are homologous organs — same embryonic tissue, same dependence on blood flow for engorgement, except that most of the clitoris is internal. What's visible externally is the tip of the iceberg. The clitoris has a prepuce — a foreskin — that under normal circumstances can be gently retracted to expose the head beneath.

In about 23% of cases, the prepuce adheres to the head and cannot be retracted. This is called clitoral adhesion.

Research Rubin has published shows that after a simple in-office procedure to release the adhesion, patients report 60% to 70% improvements in orgasm quality, arousal, and sexual satisfaction.

Nearly one in four women. Improvements of up to seventy percent. And yet no doctor checks for this during routine exams, no gynecologist asks about the clitoris during consultations, no guidelines require it.

When Rubin's clinic first opened, they bought two mirrors from Amazon and began handing them to patients during exams — narrating as they went: this is the labia majora, this is the labia minora, this is the clitoris, this is the urethra. Because most women have never had someone point to their own anatomy and tell them what it's called.

The Orgasm Gap Isn't a Biology Problem — It's an Education Problem

About 20% of women say they cannot reach orgasm. In men, the figure is close to zero.

Rubin's position is that most of this is a knowledge problem: most women, and their partners, believe orgasm comes from penetration. But penetration stimulates a site that is anatomically separate from the clitoris. "It's like rubbing someone's thigh. Rub it all day, no orgasm — because it's near the penis, but it's not the penis."

Women require an average of more than 13 to 14 minutes of focused stimulation to reach orgasm. The average duration of penetrative sex is 5.5 minutes.

Put those numbers together: most sexual encounters end before a woman is anywhere close. When women "always orgasm anyway" under those conditions, Rubin is direct about what that means.

Her structural suggestion: let the woman orgasm first, then begin penetration. The pelvic floor muscles relax afterward, making penetration more comfortable; a woman's capacity for multiple orgasms also becomes more accessible. Her underlying question: why are zero female orgasms and one male orgasm considered a normal outcome?

75% of Women Have Experienced Painful Sex — and the Cause Can Be Found

Painful sex is extraordinarily common. Studies report that up to 75% of women experience it at some point in their lives; 10% to 20% of American women live with persistent, chronic pain during sex; after menopause, some estimates put the figure at nearly half.

But pain is not normal. Pain means there is something to find. The cause could be tissue-related (hormonal atrophy and dryness), dermatological (vulvar eczema, autoimmune skin conditions), muscular (hypertonic pelvic floor), neurological (spinal issues generating pelvic pain), or internal adhesions from endometriosis.

Every one of these is diagnosable. Every one has a treatment pathway.

The problem is that OB-GYNs receive almost no training in any of it. Not out of negligence — because it was never built into the training system.

Two Arousal Patterns, One Very Common Misunderstanding

Human sexual arousal comes in two types: spontaneous and responsive. Spontaneous arousal is desire that arises without any trigger. Responsive arousal means desire emerges only after stimulation has begun — like people who don't feel like going to the gym until they're already there.

Rubin's numbers: roughly 70% of men have highly spontaneous arousal; for women, that figure is 10% to 15%. Responsive arousal appears in only 10% to 15% of men — and 40% to 50% of women. Mixed patterns account for about 35% of women.

This means women statistically require more of a "startup process" than men. Without that understanding, a partner reads a woman's lack of spontaneous desire as rejection. The woman, meanwhile, doesn't understand why she feels no unprompted interest. Both conclude something is wrong. Neither is right.

The host shared something in the episode: years ago, a former partner told him she didn't enjoy sex. He was in his twenties and interpreted it as his failure — he wasn't good enough, or the relationship wasn't working. He later learned she had an undiagnosed physical condition. He eventually told a close friend. The friend said: "My partner is the same way. We haven't had sex in three months."

Two men in their thirties, each arriving at the same wrong conclusion, suffering through it in isolation — because no one had ever offered them a different explanation.

The Orgasm Gap Comes with a Communication Debt

Rubin draws a direct comparison: America has a well-known gender pay gap. Running alongside it, equally measurable and nearly undiscussed, is an orgasm gap.

"We don't talk about money. We don't talk about sex."

Why not? The host's answer: both are too entangled with self-worth. If a partner expresses dissatisfaction, the first reaction isn't "here's a solvable problem" — it's "am I inadequate?" Then comes shame, self-doubt, and erosion.

The assumptions persist largely because both people choose silence. Women don't mention pain because they don't want to embarrass their partners. Men don't ask because no complaints means no problems. So what starts as a physiological issue — often one with a low-cost solution — quietly becomes an unsolvable relationship problem.

One of Rubin's recommendations: move conversations about sex out of the bedroom. Don't discuss sex while having sex — the same way you wouldn't debate a podcast's editorial strategy while recording it. She also suggests couples schedule one full uninterrupted day together per quarter — not dedicated to sex, but to rebuilding curiosity about each other outside the gravitational pull of children, work, and schedules.

Some patients come to her after years of concealing pain, or years of faking. She doesn't rush to prescribe. Instead, she brings both partners to the exam table, points to the anatomy together, and lets the partner understand what "it's not that I don't feel anything for you" actually looks like in a body. When you can point to a specific structure and say "this is what it feels like every time — like being burned" — the problem stops being someone's fault and becomes something two people can address together.