The Peter Attia Drive - #371 – Women's sexual health： desire, arousal, and orgasms, navigating perimenopause, and enhancing satisfaction

00:00:00.000 Hey, everyone. Welcome to The Drive Podcast. I'm your host, Peter Atiyah. This podcast,

00:00:16.540 my website, and my weekly newsletter all focus on the goal of translating the science of longevity

00:00:21.520 into something accessible for everyone. Our goal is to provide the best content in health and

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00:00:53.200 of the subscription. If you want to learn more about the benefits of our premium membership,

00:00:58.020 head over to peteratiyahmd.com forward slash subscribe. My guest this week is Dr. Sally

00:01:06.380 Greenwalt. Sally is an OBGYN who specializes in women's sexual health from a hormonal and

00:01:12.700 physiologic perspective, with a clinical focus that spans desire, arousal, pelvic floor function,

00:01:18.800 contraception, menopause, and perimenopause care, and evidence-based strategies to improve sexual

00:01:25.680 well-being. In this episode, we discuss why sexual health is a core part of overall health

00:01:32.120 and life quality for both men and women, a practical framework for desire, the accelerator

00:01:38.080 and brake model, and how patterns change across life, anatomy for sexual function, the clitoral complex

00:01:44.860 and vaginal anatomy, and why understanding it matters, both for men and women, orgasm realities

00:01:50.860 and myths, and varied pathways to orgasm beyond penetrative sex, vaginal tissue health, lubrication,

00:01:58.140 moisturizers, and when local estrogen is helpful, pain with sex, the common causes, evaluation,

00:02:04.000 and a multidisciplinary approach to treating it, perimenopause and menopause, symptom patterns

00:02:09.240 and the roles of estradiol, progesterone, progestins, and testosterone, contraception across the reproductive

00:02:16.080 years and how different methods interact with hormones and sexual function, medications and

00:02:21.360 adjuncts for low desire or arousal, including the FDA-approved options and the realistic expectations

00:02:27.940 around them, the use of vibrators and other devices as therapeutic tools, both solo and with partners,

00:02:34.180 when medications and substances help or hinder arousal and orgasm, such as cannabis, THC, SSRIs,

00:02:42.300 and practical strategies for use, pregnancy and postpartum sexual health considerations, and safer

00:02:48.400 sex practices and STI screening, plus communication and sexual health education around how to talk to

00:02:54.460 your kids about sex. This podcast will have an immediate and obvious application and interest to

00:03:00.180 women, but I can tell you guys, if you're listening, this is something you will want to understand

00:03:05.420 greatly. I learned an enormous amount during this interview with Sally, and if you want to understand

00:03:12.280 your partners better, this is definitely the podcast for you. So without further delay,

00:03:17.180 please enjoy my conversation with Dr. Sally Greenwald.

00:03:25.220 Sally, thank you so much for coming out to Austin.

00:03:27.820 Thank you for having me. This is a topic that on the surface might seem somewhat directed towards

00:03:34.280 50% of the population, but I think it's safe to say it's probably going to be directed towards 100%

00:03:39.200 of the population. So you have a practice, you're an OBGYN, but your focus is not just on maybe the

00:03:47.140 standard OBGYN things, but really around women's sexual health. Is that a fair assessment?

00:03:52.680 That would be a fair assessment, yes. From a hormonal and physiologic perspective, yes.

00:03:56.720 Awesome. Well, by way of background, we were introduced through a mutual friend slash patient

00:04:04.500 who had listened to the Rachel Rubin podcast that I did recently, was super impressed by it and said,

00:04:11.580 you have got to speak with Sally and one thing led to another and we are now speaking. So let's start by

00:04:18.560 helping people understand why would a podcast that focuses on health, longevity, all of these things

00:04:27.420 that pertain to living longer and better. Why would sex be an important part of that discussion?

00:04:33.700 Well, I'm having a hard time understanding how sex couldn't be a part of that conversation.

00:04:38.340 First of all, this is a performance driven podcast. And so for the 50% of your listeners who

00:04:44.560 are male, if you want to improve your performance, I'm going to give you facts and anatomical

00:04:50.040 descriptions and describe some pathophysiology so that you can improve your performance.

00:04:55.480 Clearly, sexual health is health. And when you look at your longevity levers and you think about

00:05:01.420 your centenarian decathlon and what you want to do when you're 100, for many people, this is on the list.

00:05:07.480 And I want to talk about how to structure your life and get you ready to do that.

00:05:10.520 I also think that there's probably a small group of listeners similar to myself who always thought

00:05:17.460 that the drive was supposed to be about sex drive and that you just had a branding error when you

00:05:22.260 named it the drive. So for those people as well, we're finally going to talk about the drive that

00:05:26.720 you actually care about, which is sex drive. So there's a lot to sort of unpack there, but I think

00:05:33.560 I want to kind of go back and talk a little bit about something you said vis-a-vis the actual health

00:05:39.540 component of this. If you looked at this through the lens of just evolution, everybody clearly

00:05:44.820 understands why sex is important and it's the single most important thing in the propagation of

00:05:50.840 our species. But can you say a little bit more about how it actually factors into health? And I don't

00:05:56.440 just mean emotional and mental health, where I think we could easily make that connection.

00:06:00.480 Is there any evidence whatsoever that a healthy sex life plays a direct role in health as it

00:06:07.380 pertains to disease? Definitely. I'll start out with my two caveats, though, which is one, this is an

00:06:13.020 understudied, underinvestigated area of our health. That's part of my messaging today. So many of the

00:06:18.860 studies that I'll reference are not going to be robust in volume. And second, this is a incredibly

00:06:23.700 heteronormative conversation for that reason. This is a data-driven podcast, and I don't have a lot of

00:06:28.860 data on non-heteronormative, meaning men who identify as men, having sex with women who identify as

00:06:34.140 women. So that should alarm you as well that we don't have that data, but that's the space in which

00:06:38.180 if we're going to stay in a data-rich zone, that's where we have to stay. And also the discrepancy when

00:06:43.240 you look at sexual health is greatest among those two participants. When we look at sexual health and

00:06:48.240 we try to make the argument that sexual health is a part of health, we can sort of use your longevity

00:06:53.680 framework. If we start with sleep, there is great data. We know that when you are sexually active

00:06:59.440 with or without orgasm, just participation in a sexual activity, you switch from sympathetic to

00:07:06.220 parasympathetic. So post-orgasm, you have a great activation of the parasympathetic nervous system.

00:07:11.880 You release neurotransmitters, dopamine, oxytocin. These are relaxing neurotransmitters.

00:07:17.840 And when we study it either via diary or via great studies that look at resting heart rate, sleep latency,

00:07:24.860 many of the measurements that we look to in terms of looking at sleep efficiency and quality

00:07:28.840 subjectively and objectively improve with intercourse. What's really interesting and why I want to pull

00:07:34.180 in all listeners, not just 50%, is there was a great trial that looked at how women slept after

00:07:39.260 an orgasm with themselves and they slept better. And then it looked at women being intimate with a man

00:07:45.160 and they slept better. But women being intimate with a man and having an orgasm with that man

00:07:51.380 synergistically improved their sleep. You're getting sort of a dual benefit of that neuropharmacology that

00:07:57.560 you're releasing from your brain, improving your biometrics, but also there's a connection and

00:08:00.960 intimacy, a partnership that we know fosters better sleep. Cardiovascular health, this is also

00:08:06.240 limited. We don't have tons, but we know that sex can mimic a lot of the pathophysiology that we

00:08:11.440 experience during exercise. There's been arguments over the decades about, is it low intensity? Is it

00:08:17.800 moderate intensity? I think it depends on the couple. But we have studies that have tried to measure the

00:08:22.460 METs or the metabolic equivalents or essentially the energy output. For women, on average, it's around

00:08:27.980 six to seven metabolic units for every sexual encounter. It's about 60 to 70 calories used during

00:08:35.620 sexual activity. And there's a great study that compared this to walking slowly on a treadmill for

00:08:41.160 the same amount of time. And they said that although sex was slightly lower in your energy export than

00:08:47.120 walking on the treadmill, many of the participants reported that they had a much better time having

00:08:52.000 sex than they did walking on the treadmill. And so it's still something to consider. We know the

00:08:57.280 net sort of tapping into the body's natural pharmacology, thinking about neurotransmitters

00:09:01.000 and positive impact on mood and relationships. It's really interesting to think about from a

00:09:05.780 relationship perspective. What I don't want to say, what I don't believe is that everyone has to have

00:09:10.760 lots of sex and that there's a number that we're trying to target. Is there a number needed to

00:09:15.640 treat? Is there a dose that we're trying to go for? No, there's no studies on that. But I also don't

00:09:20.040 believe that every person, every couple is different. When you look at couples, I like to look at who's

00:09:25.340 having sex and by what frequency. And so about 20% of couples, and this is ages 30 to 60, about 20% of

00:09:34.360 couples are having sex twice a week or more. About 10% of couples are what we call never having sex. And that

00:09:40.820 means in the last year. And about 70% of couples are having sex between those, meaning once a month, twice a

00:09:47.080 month, sort of around that number. When you look at risk factor for divorce, it's the same across all numbers in

00:09:53.520 the sense that it doesn't matter how much sex you're having. You could never have sex, you could have lots of

00:09:56.780 sex. The divorce risk factor is what we call sexual desire discordance, or one partner wants more, and one

00:10:03.820 partner wants less. And so identifying that as the risk factor, I hope, gives people sort of affirmation

00:10:10.360 or interest in the fact that if you want to work on it, I will help you. But not everyone has to. This

00:10:15.900 is not a podcast about everyone needs to go work on their sex life. But if you do, I'll sort of go through

00:10:20.460 the normal pathophysiology and some additional tips and tricks to help you have a healthier sex life.

00:10:26.200 All right. So two things I just want to reiterate that you've said that are both important and at least

00:10:30.480 interesting to me. One is, discordance of desire is a much bigger risk factor than anywhere you lie

00:10:37.100 on the distribution of, if I recall, 10% of people are basically asexual, 20% of couples are at twice

00:10:44.620 a week or greater, and basically two-thirds of couples are somewhere in between. So that's very

00:10:50.360 interesting. Second thing you said, I can't resist coming back to the centenary and decathlon. I'm glad

00:10:55.480 you brought it up because it is one of the items on our list, on the framework that we hand to

00:11:00.740 patients when we ask patients to pick the 10 most important things that they want to be able to do

00:11:05.840 in their marginal decade, in the last decade of their life. And I would say about two-thirds of our

00:11:12.620 patients select having sex as one of those 10 activities. That says something, given that we're

00:11:19.220 giving people a list of about 150 things to choose from, all of which are quite tempting. And to go

00:11:26.020 back to your point about METs, if seven METs is what is required energetically to have sex, we can

00:11:33.660 convert that into VO2. So seven METs translates to about a VO2 of 25 milliliters per kilogram per minute,

00:11:42.740 which means if you want to be able to have sex in your marginal decade, you need to have a VO2 max

00:11:50.440 of probably about 30 milliliters per kilogram per minute. Why? Because it would be pretty tough to

00:11:57.260 have sex if you were doing it right at your maximum VO2. That would be like me asking you to do the

00:12:03.480 fastest 800 meter run you've ever done and bring that level of exertion to sex. You got to be a little

00:12:10.260 bit below your limit. While most adults can easily muster a VO2 max of 30 milliliters per kilogram per

00:12:17.360 minute, if you want to be able to achieve that in your eighties or nineties, when you're my age or

00:12:23.560 your age, you're a lot younger than me, you need to be probably north of 45 or 50. So if I could just

00:12:30.340 make one more shameless plug for having a high VO2 max, it's going to allow you to be sexually active in

00:12:35.960 the last decade of your life. And I think in addition to that, it would be great if at the end of

00:12:40.180 this, we had a list of a few sort of action items in addition to a minimal VO2 max that we could

00:12:46.240 consider a toolkit in order to get this action as something that's actually attainable on your

00:12:51.300 centenarian list. Let's talk a little bit about, let me ask a very silly question. When it comes to

00:12:57.280 understanding what an orgasm means for a man, it seems relatively straightforward in that it's tied

00:13:02.680 to ejaculation. And while there are examples where a man can have a retrograde ejaculation due to,

00:13:09.120 example, the use of medication and he can still have an orgasm, but you're not actually witnessing

00:13:13.620 an ejaculation. With women, how is an orgasm actually defined? Is it a biochemical response

00:13:20.040 in the brain? Is it a muscular contraction in the body? Help me and help us understand that.

00:13:25.680 I think it's important to say that we're going to talk about normal things. Yes, there's a lot of

00:13:29.480 pathophysiology and deviations to what's normal and you should see a doctor and we can talk to you

00:13:34.000 about it, but similar to sort of your focus on what's normal in men. To describe what's most

00:13:38.220 normal in women is a rhythmic contraction of the pelvic floor muscles. There's four stages to an

00:13:44.380 orgasm. It starts with the excitement phase, which is an engorgement of the pelvic tissues. There's

00:13:50.140 increased blood flow. There's lubrication released by the skeins, glands, and other glands of the

00:13:54.340 vaginal canal. Then there's a plateau phase that is predominantly a neurotransmitter phase and a

00:13:59.780 hormone release phase. You can stay in that for a variety of time periods. It's person and

00:14:03.900 partnership dependent. There's the orgasm, then there's the resolution phase. And these four

00:14:08.200 stages, understanding how they work and where you are in that stage, can allow for the introduction

00:14:13.440 of interventions that can improve your sexual life or help you foster a healthier life in general.

00:14:18.300 What is the period of time in which a woman will go from those first to fourth phases? Again,

00:14:25.320 I realize there's going to be a lot of variation, but what would be sort of considered

00:14:28.840 interquartile range of that transit? So it really depends. When women are on

00:14:33.580 their own, it's the average time to orgasm is less than four minutes. And when women are with

00:14:37.720 a partner, it's upwards of like 21 to 25 minutes. Question there. With a partner, you could still

00:14:43.580 have it manual to be oral. It can be intercourse. So how much does that really skews the data?

00:14:49.900 I don't have the numbers on that. I don't think we have that. And women are actually individually so

00:14:53.420 different as well. An interesting takeaway from your interest in looking at those numbers is to think

00:14:57.900 about a statistic we do know, which is that foreplay lasting greater than 21 minutes,

00:15:03.480 over 90% of women orgasm. It's really interesting and enlightening to think about, oh gosh, so time

00:15:08.940 actually does matter in that stage. And why do we care about foreplay? What's happening during that

00:15:13.160 time? That's when you're in the excitement phase, building up towards orgasm. So blood is flowing to

00:15:16.800 the area. So we think about your anatomy changes. So the vagina that's usually like three and a half by

00:15:22.000 nine, so three and a half inches wide by nine inches deep, will actually get longer and

00:15:26.640 wider. And why do we care? 30% of women will experience pain with intercourse. So actually

00:15:31.580 appropriate foreplay where the vagina not only gets wider and longer, but actually the angle of

00:15:37.180 the vagina changes. And I think this is something that I love talking to couples about because I have

00:15:42.780 many women who will say, you know, my partner loves this position and often it's a deep penetration

00:15:47.260 position, but it really hurts me. And I say, well, how much foreplay is going on? And so if there's not

00:15:51.760 enough foreplay, you don't actually change the angle of the vagina or change the angle of the

00:15:55.720 canal. And so you will experience more pain. You'll have the tightness of the pelvic floor muscles and

00:15:59.940 pain fosters pain. You can get into a pain cycle. And so actually appropriate amount of foreplay,

00:16:05.920 allowing the angle of the vagina to change can allow women to participate in positions.

00:16:10.760 Most commonly we call doggy style or sort of deeper penetration positions, which can then be sort of a part

00:16:15.540 of your repertoire if you're interested in that.

00:16:17.260 So what about just the differences in ability to achieve orgasm, the so-called orgasm gap?

00:16:23.600 What can you tell us about that?

00:16:25.220 I hope I've proven to you that sexual health, pleasure, orgasms are a part of health. And so

00:16:31.140 I think when we then look at the disparities and how different parties will participate or receive

00:16:37.620 enjoyment out of these activities, I hope it highlights to you how important it is that we

00:16:42.240 work on this. And so I'm going to quiz you now, which is what percent of men, when they're having

00:16:49.780 sex with a woman, report that they almost every time have an orgasm?

00:16:55.480 95%?

00:16:56.140 It's 95%. And what about women?

00:16:59.300 What percentage of women would report always being able to have an orgasm with a male partner?

00:17:04.120 Correct.

00:17:04.420 50%?

00:17:08.100 30%. And what about for a one-night stand? What percent of women are having orgasms on one-night

00:17:14.880 stands with men?

00:17:16.820 Well, if it's 30% on a regular basis, I would say 10 to 20%.

00:17:23.080 Yes, around 12%.

00:17:24.760 What about men at one-night stands? Still 95%?

00:17:28.280 Correct. 90. Actually, I should say it's 90%.

00:17:31.540 And so when we think about the orgasm, so if I've proven to you that sexual health is health,

00:17:37.680 and if we understand that orgasm is one metric that we can use, it's not the end-all, be-all.

00:17:44.320 There's other satisfaction, intimacy, connection, pleasure benefits that women get out of intercourse,

00:17:49.560 but this is one numeric finding that we can track. This disparity or this discrepancy is a big deal.

00:17:55.320 And this disparity in how women experience pleasure becomes a health disparity because if sexual health is health

00:18:02.880 and women are not experiencing it with the same amount of pleasure that men are, this is a health disparity.

00:18:08.460 By the way, within women, does orgasm at all correlate with underlying health?

00:18:13.240 Yes. We know that orgasm is related to strength of the pelvic floor, vascular blood supply.

00:18:21.060 So there are issues. So there's a lot of sort of bi-directional.

00:18:24.860 If you're healthy enough to be able to have an orgasm, then you can have an orgasm.

00:18:28.080 And if you're having orgasms, you're likely healthier.

00:18:30.220 So there's a lot to that. And we know that bi-directionality, but I think still looking at the numbers,

00:18:35.640 I'm hoping that you're thinking, my gosh, this matters. This is a big deal.

00:18:39.400 We classically think about sexual health as sort of an afterthought. When we think about longevity,

00:18:44.620 we think about cancer screening and prevention and chronic diseases and now sleep and exercise.

00:18:52.320 And once we've sort of addressed all of those, we now have the luxury of addressing sexual health.

00:18:57.980 And I just think we should put it a little higher on the list.

00:19:00.660 Okay. So let's talk a little bit more about foreplay. When most people hear foreplay,

00:19:05.520 they assume, what, anything that is sexual shy of intercourse? How do we define foreplay?

00:19:11.440 There's medical definitions of foreplay and social. So social definitions tend to say anything

00:19:16.040 outside of penetrative intercourse. Medical definitions rely more on the physiologic changes

00:19:20.380 that are happening in your body. Increased blood flow, recruitment of swelling of the clitoral nerve,

00:19:26.160 physiologic signals from your brain that sort of prepare you emotionally to participate in this

00:19:31.300 interaction. What's most interesting to me about this is when we think about, let's start with desire,

00:19:37.840 we think about socially men's desire. So men's desire is what we call spontaneous desire. And I use men,

00:19:42.940 this is sort of, I should say, less sweeping statements, I should say. When we think about desire,

00:19:47.460 we think of more of the spontaneous desire. Spontaneous desire is more common in men. Spontaneous desire is

00:19:54.720 only present in about 15% of women. Women have what we call responsive desire. So spontaneous desire is

00:20:01.900 you've been married for 20 years, you see your partner get out of the shower for the 8,845th time,

00:20:09.380 and you think to yourself, gosh, I would love to be intimate with this person. That's spontaneous desire,

00:20:15.060 that sort of desire in anticipation of intimacy. Responsive desire is you see your partner get out

00:20:22.760 of the shower for the 8,645th time, and you think, did I sign up for the right treadmill tomorrow

00:20:27.940 morning at 6 a.m.? And that's because your brain's just not there. It's not in the same place as your

00:20:32.540 partner. But if your partner comes over and starts to rub your shoulders and rub your feet or maybe

00:20:37.880 has made dinner, we call chore play, which is where sort of emotional investments in the relationship can

00:20:43.260 sometimes lead to responsive desire. Using lubrication, I mean, we'll talk about how to use lube,

00:20:48.140 using a vibrator, sort of creating an environment in which you are capable of being aroused. That's responsive

00:20:54.960 desire. And thinking about what's happening in that circumstance can be really helpful in validating for

00:21:01.260 women and it can help their partners get them there too with the ultimate goal of sort of being aligned in your

00:21:05.560 sexual desire from a frequency perspective.

00:21:09.080 So you're saying it's more typical that men experience spontaneous desire where arousal comes on in a moment.

00:21:17.420 In anticipation.

00:21:18.580 In anticipation. And often based on perhaps a visual cue.

00:21:21.920 Correct.

00:21:22.760 For women, that is less common, but not implausible.

00:21:26.320 Correct. And so acknowledging that, there's a few sort of lessons that we can take from that.

00:21:31.400 The first is if you're listening to this podcast and you want to work on your desire,

00:21:34.820 if you're waiting for your husband to get a new shirt or a new Selby or anything,

00:21:40.700 the visual stimulus is not evidence-based. Stop waiting for that.

00:21:43.960 What about getting a new car?

00:21:45.000 I'd love one, but no. But just to be clear, I would love one. I want you to think about how

00:21:49.880 you get responsive desire in response to arousal. And how we do that is lubrication. So we know how

00:21:57.440 to use lube. Most of us do. You're in the act. You take some lubricant, you put it on the penis,

00:22:02.700 you put it on the vagina, you have intercourse. I want to sort of encourage you to think about lube

00:22:06.320 potentially using it 30 minutes prior to intercourse. So I want you to take a silicone-based

00:22:11.020 lube and I'll tell you why in a moment. And I want you to think about using a lube shooter,

00:22:15.320 which is a little droplet to take some of the lube and put it higher up in the vaginal canal.

00:22:19.660 And then I want you to read a book, drink a cup of tea, wash your face. Women, as you sort of alluded

00:22:26.020 to, are less visually stimulated into desire. There's great data that women like to read erotic

00:22:31.600 literature and there's great apps for that. Meet Rosie, Dipsia are great companies that have

00:22:36.420 auditory or literature porn for women. There's great data that mindfulness can work for women.

00:22:42.840 Lori Brado wrote a book called Better Sex Through Mindfulness. Thinking about breathing techniques,

00:22:47.600 staying present in the moment. My favorite strategy for this is to describe to yourself in your head,

00:22:52.580 not aloud, what's happening. Breathing is relaxing. My vagina feels wet. Sort of talking yourself through

00:22:58.120 what's happening from a pathophysiologic perspective to bring yourself into the moment.

00:23:02.360 But when we think about how to curate that arousal, essentially what you're doing

00:23:05.300 is showing up at the party and then seeing what happens. And there's no expectations what happens

00:23:10.540 at the party. But Emily Nagowski, who wrote Come As You Are, talks about it's Friday night and you

00:23:16.260 really want to put on your bathrobe and watch Love Island. But instead, you're going to go to a party

00:23:21.880 with your friends because you said you would. And you get there and it's actually kind of fun.

00:23:26.020 So you stay, you have a good time, you have a drink. You actually like it when you're there.

00:23:30.180 That's the sort of idea behind curating your own desire through arousal, which is

00:23:35.700 use a vibrator, use some lubricant, relax, get in the moment, start to participate. And if you

00:23:41.060 don't want to, obviously consent is of utmost importance and stop. But if you sort of start

00:23:45.440 participating and decide that you're happy that you're there and you like it, please stay and have

00:23:48.840 a good time. Okay. A lot of questions come up when you said all those things. Let's start with the

00:23:53.940 need for lubrication. I very naively have assumed that women who are young enough, so not even

00:24:01.520 approaching estrogen withdrawal, are not having an issue with lubrication. That clearly must be

00:24:07.760 incorrect or you wouldn't be stating this. So what can you say about perhaps the differences in the

00:24:12.960 amount of lubricant and maybe even just talk a little bit physiologically about what is the lube

00:24:18.180 that is naturally made? Where is it coming from? And what drives variability both across women

00:24:24.260 and within a given woman's life? Let's not even talk about it within her life, within a given month

00:24:30.920 or something like that. You're correct with that line of questioning to sort of assume that throughout

00:24:35.540 the month, women will have different levels of lubrication. Medications can impact lubrication,

00:24:40.260 life, age, life cycle. There's so many factors that go into your ability to have the amount of

00:24:45.180 lubrication that you need in order to have a comfortable sexual encounter. This idea that we

00:24:49.240 just use lube, need lube as we age, I want to completely dispel. I think the majority of women

00:24:54.600 need lubrication and should use it. The way that we sort of naturally get lube in our vagina is from a

00:24:59.880 variety of different glands that work better or worse. There's the skeins glands that sort of support

00:25:04.480 the vagina. Which are where? They're right on either side of the urethra. And fun fact about this,

00:25:10.420 many people will have more prolific skeins glands in the sense that they can shoot the lubrication a

00:25:14.960 little bit stronger. So when we sort of talk about women who, what we call squirt, it's actually the

00:25:19.480 skeins glands releasing lubrication in a more aggressive form. There's Bartholin's glands that

00:25:24.700 produce lubrication that are commonly known for their likelihood to sometimes get clogged and to

00:25:30.880 cause pain. But there's so much that goes into lubrication. And it's so important throughout the

00:25:36.020 life stages that the WHO, the World Health Organization, actually has guidelines in terms of how to pick out

00:25:42.240 your lube. And if you're wondering right now, wow, I never knew that the WHO cares so much about my

00:25:50.380 sexual life. That's wonderful. They don't. They care about HIV transmission. And picking the appropriate

00:25:56.100 lube decreases micro abrasions, less friction, less tearing, less HIV transmission. But we can sort of

00:26:02.180 take this data into the pleasure world and think about sexual health. So what types of lube should we

00:26:07.600 use, I think, is the next part of that question? Well, actually, I want to go back and ask a

00:26:10.980 different question, which is, isn't there sort of a min-max optimization problem around lube? Because

00:26:17.020 friction is also part of what is necessary, at least for the male to have an orgasm. How much does it

00:26:24.420 matter for the female? Less so. Friction matters less so to women. And let's talk about the clitoral nerve

00:26:31.360 anatomy to answer that question. I'm going to leave this for you as a gift. I'll keep it on my

00:26:38.220 desk. It's pure gold. So you may want to put it in your safe. But this is sort of the anatomy of the

00:26:44.160 clitoris. And what you're looking at is what we tend to discuss in terms of clitoral anatomy. Typically,

00:26:49.820 we talk about is the tip of the iceberg or the clitoris. There's the crew of the clitoris and there's

00:26:54.520 the vestibule, which is an engorgement structure when blood comes to the area. Your labia minora would be

00:26:59.920 here and your labia majora would be here. This would make up the vulva. When we think about the

00:27:04.660 clitoral nerve, it actually has two types of nerve fibers in it. One is a type A nerve fiber and one

00:27:11.000 is type C. Type A responds to vibration and it responds to deep pressure. And type C responds to

00:27:17.600 heat and light touching. So A is vibration and deep pressure and C is heat and light touching.

00:27:26.140 What's really interesting about using this to answer your question is that

00:27:29.540 friction is not a requirement to hit any of those four metrics and actually is so significantly

00:27:36.800 associated with micro tearing and pain with the 30% of women experiencing pain with intercourse.

00:27:41.840 I would argue that women need no friction. But to think about how that nerve changes over time is

00:27:47.840 really fascinating because type A fibers, the vibration and the deep pressure, they have a myelin

00:27:53.720 sheath around them. And so they age better. Nerves protected by a myelin sheath are more resistant to

00:27:59.720 degradation. And that's the A fiber? And that's the A fiber. And so I have women come in to my clinic

00:28:05.300 and they say, I've been with my partner for 35 years. We do this position for six minutes. It always

00:28:10.780 works. It's not working. And I say, have you considered using a vibrator or introducing a vibrator into

00:28:16.060 your sex life? And there's a lot. I don't know if my partner would feel good about that. And I sort of

00:28:20.920 say this is an evidence-based intervention, understanding the science of myelin sheaths

00:28:26.380 and nerve degradation. This has nothing to do with your husband and nothing to do with

00:28:30.260 your relationship. How would you do that? So if a woman comes in and says,

00:28:34.660 in this position, it's exactly as you just said, when you're saying introduce a vibrator,

00:28:40.080 do you mean use it after or before? Or during. I see. So put the vibrator externally.

00:28:47.500 Externally. Got it. And there's different types of vibrators. Some are internal.

00:28:50.920 But if you're trying to pick a vibrator that you want to use when you're with a partner,

00:28:55.640 buying something like a wand is long enough that you can reach the structure in a variety of

00:29:00.160 positions. Jimmy Jane makes a nice wand. Goop the wand makes a great product as well.

00:29:05.820 Did you bring any of these?

00:29:07.000 Long discussion with your staff about what you wanted laid out on the table. And that net was no.

00:29:11.260 That might've been a strategic error. I think people, at least I'm kind of curious as to what

00:29:15.780 these products are. We'll link to them in show notes.

00:29:17.920 That sounds great. There are air pulse vibrators that you can put on the clitoris. These are sort

00:29:22.800 of all external vibrators that you can sort of bring into a partnered encounter to have an

00:29:28.000 evidence-based way to continue to achieve orgasm because that is one of your greatest ways in

00:29:32.360 which you can continue to make a healthy sex life.

00:29:35.120 Again, not to get too graphic, but just because if I'm asking this question, I'm sure someone watching

00:29:40.240 this is. If you're talking about a sexual position where the man is on top of the woman and she's using an

00:29:46.180 external vibrator, does the man also receive some pleasure from that?

00:29:50.240 He might. And there are more strategic ways that you can try to do that if the man likes that,

00:29:55.180 but there's ways that the man can angle his pelvis that he doesn't have to.

00:29:58.480 He doesn't feel it.

00:29:58.980 He doesn't have to.

00:29:59.760 Okay. I want to go back to something about the female ejaculation. All of that ejaculatory

00:30:04.840 material seems external.

00:30:06.820 Some is, some isn't.

00:30:07.940 Yeah. So how is the vagina being lubricated inside?

00:30:10.340 So they've actually studied this. The Kinsey Institute has great studies where they put

00:30:14.460 cameras inside the vagina and they actually watched the vagina essentially sweats. The

00:30:19.740 cells of the vaginal canal release water molecules. There's cervical mucus that also

00:30:24.300 serves as a lubricant as well. Again, all of these things very dependent upon hydration and

00:30:28.940 medications and things like that. So you can understand the importance of sort of making

00:30:32.160 sure it is appropriately lubricated through the use of external lubricant. But yeah, there's many

00:30:37.360 different ways. So the vagina sweats, the cervical mucus, and then the glands that secrete mucus into

00:30:42.360 the canal.

00:30:43.760 And for women who do experience that ejaculation, that's perfectly normal. Do they have control over

00:30:50.500 that?

00:30:51.080 Most people think that they do not. Most people think they do not in terms of like how much,

00:30:54.940 if you're more hydrated, if you're more relaxed. But no, in general, people do not believe that it's

00:30:58.780 a normal physiologic response that you cannot control.

00:31:01.940 And it doesn't imply a better orgasm?

00:31:05.020 No.

00:31:05.220 And what was the frequency again of women who achieved that?

00:31:08.860 Squirting. I actually, I don't have statistics on that. I don't know.

00:31:11.360 Okay. Maybe a helpful thing to do right now would actually be to go over a little bit of the

00:31:15.640 anatomy. And I see that you brought a model that I think will make it easier for everyone to kind

00:31:20.340 of understand. So I want to start by asking, when you deal with your female patients who presumably

00:31:27.340 are much more familiar with this anatomy than men are, what surprises you the most? When a woman comes

00:31:32.600 into your clinic and you're taking care of her, what are you most surprised by in terms of her

00:31:37.700 lack of knowledge about her own body?

00:31:40.400 Anatomical lack of education.

00:31:43.100 Just literacy?

00:31:44.260 From a, where was the sex education? Did we have it? Did we go, I mean, from a verbiage perspective,

00:31:51.180 referring to the vagina as the vaginal, that's the vaginal canal is the vagina. The vulva is the

00:31:56.360 outside of the vagina. There's labia majora and menorah, all the way down to the clitoral nerve and sort of the

00:32:01.600 fact that it has different nerve roots. And so if we think about looking at this model, this is sort

00:32:06.700 of if a female is lying down on her back, that's the angle that you're looking at. There was a great

00:32:11.520 study that was done recently that said that only 41% of Gen Z men couldn't accurately identify the

00:32:17.660 clitoris on a pictorial.

00:32:20.880 What would that be for Gen X? Like how much of that is a representation of declining intimacy as

00:32:27.660 younger generations? Or is that a general statement of men, period?

00:32:31.860 I take from that sex education needs to get better. I mean, I sort of take from that the

00:32:35.840 need for better sex education that's actually anatomical and not fear-based. And so women

00:32:40.580 as well, I mean, most women, not all, do know about the clitoral hood, which is the clitoris or the

00:32:46.420 bulb. That's what we sort of think about in terms of the tip of the iceberg. But what women often don't

00:32:51.360 know is that they have sort of what we call the vestibule of the clitoris, which are these

00:32:55.300 bulb-like structures that can receive engorgement or when there's an increase in

00:32:59.660 blood flow. And then there's the crew of the clitoris, which is these nerve structures that

00:33:04.260 go on either side of the labia minora. It's a wishbone-like structure. And what's really

00:33:09.880 fascinating is to sort of normalize that anatomy can and should look different. There's a great

00:33:16.120 website called the Labia Library that normalizes all different types and sizes of labia minora and

00:33:21.680 majora. But the wishbone structures are often asymmetric as well. And so it is quite common for

00:33:27.920 a woman to experience greater pleasure on one side of the vagina versus the other, meaning that this

00:33:35.120 nerve root of the clitoris may be thicker or more sensitive. There's over 8,000 nerve roots as a part

00:33:40.540 of the clitoris. And there can be more focused on one side versus the next. And so I hope that half of

00:33:47.160 your listeners are thinking, I always wondered why I was a righty or I always, yeah, I'm a lefty.

00:33:52.380 I also hope the other 50% are wondering if you've been with your partner for a long enough time.

00:33:57.100 I hope you know if your partner is a righty or a lefty because there's asymmetry in how we experience

00:34:01.560 pleasure. And then very interestingly is that there is, if you're sort of looking at the tip of the

00:34:07.380 clitoris, there's a nerve root. There's a part that goes sort of inside the vagina. And that's what we

00:34:11.960 talk about in terms of social terms. We talk about the G spot. What that is, is it's a branch

00:34:17.420 of the clitoris that runs along the anterior or the front part of the vagina. It's about a third

00:34:23.720 into the vagina. The best way to find it is if a woman is trying to find it on herself is to take

00:34:28.580 her dominant hand, middle finger, stick it as far in as you can and sort of do a come hither movement

00:34:33.840 or sort of movement of the finger towards the top part of the vaginal wall. It's easier to find when

00:34:38.320 you're aroused because there's engorgement of the tissues. It feels a little more rugated and you'll

00:34:42.960 know that you're there if you feel a sensation to urinate, but if you relax into that, you won't.

00:34:48.020 And so only about 10% of women now are able to orgasm from stimulation of that internal branch of

00:34:54.140 the clitoral nerve. There's some data that shows that with education that can go up. And so talking

00:35:00.040 to women about how they can find the anterior branch of their clitoral nerve not only allows them different

00:35:04.740 ways to orgasm, but also gives them a sense of empowerment and sort of ownership to sort of talk

00:35:09.260 their partner through how to maintain pleasure. But for those people who can't have orgasms from

00:35:14.820 the inner part of their vagina, the other 90% are having orgasms from external stimulation of the

00:35:19.560 clitoral nerve. And so Dr. Lauren Stryker says for the 10% of women who can orgasm via the G-spot or

00:35:27.180 the anterior branch, that's great. And she diagnoses the other 90% who can't orgasm from stimulation of the

00:35:34.100 internal nerve as normal. So it's totally normal if you can't have an orgasm from that part of the

00:35:39.660 clitoral nerve. But many women, after hearing this podcast, I hope try, partners should try. It has

00:35:45.140 better blood supply than the tip of the iceberg. And so as we age, this is one of my favorite techniques

00:35:50.160 for women in the perimenopause and menopausal period as their hormones change and the nerve fiber

00:35:54.800 degrades a little bit. Teaching women how to have orgasms from the part of the nerve that is better blood

00:35:59.840 supply can help maintain pleasure and help maintain interest in sexual activity as we age.

00:36:05.380 All right. So when a woman is having intercourse, and maybe for the percentage of guys who might not

00:36:10.820 be familiar, can you point out where the entry to the vagina is on this model?

00:36:14.960 Yeah. So here's entry to the vagina. There are some statistics that talk about what percentage of

00:36:20.000 women can orgasm simply by having penetrative intercourse, so penis here. And what's interesting

00:36:26.040 is that the distance of the clitoris to the vaginal opening is variable. They tend to say less than

00:36:31.400 one inch. The shorter the distance of the clitoris to the vaginal opening, the more likely you are to

00:36:37.040 be able to orgasm during penetrative intercourse. And that's because the distance is so short that the

00:36:42.240 angle of the man's body is sort of able to stimulate that area. If that distance is greater,

00:36:47.000 you're less likely to be able to orgasm simply from penetrative intercourse. Q, introducing a vibrator,

00:36:52.380 manual stimulation, et cetera. So what percentage of women are able to intercourse without any

00:36:58.900 stimulatory vibrator or anything like that from intercourse?

00:37:02.560 Less than 10%.

00:37:03.440 Wow. So it's the same number that you have from the G-spot.

00:37:06.840 Correct.

00:37:07.520 So if a woman is listening to this and she's never had an orgasm through intercourse,

00:37:12.160 she is in the 90%. There's nothing wrong with her.

00:37:15.520 We would diagnose her as normal.

00:37:17.260 And for those women out there who are regularly achieving an orgasm through intercourse,

00:37:21.920 you're in the minority and...

00:37:23.800 Or they're doing external. More likely, they're doing external stimulation of the clitoris. Those

00:37:28.900 grave statistics are without any external manipulation of the clitoris. So for women

00:37:33.520 who are achieving orgasm with a partner, it's because they've identified positions with their

00:37:37.760 partners. They're using manual stimulation. They're introducing vibrators. They've figured out,

00:37:43.300 regardless of distance of clitoris to vaginal opening, how to stimulate the clitoris,

00:37:47.320 the external part of the clitoris. And I like to talk about anatomy so that patients can sort of

00:37:51.900 think about their own individual anatomy, talk to their partners about it, and think about if

00:37:55.820 there's someone who needs to sort of introduce that external stimulation. Or shall they, as a

00:38:00.480 couple, just try to find the anterior branch of the clitoral nerve? There's lots you can do as a

00:38:04.120 part of that.

00:38:05.320 How often do you have men in your practice who are there with their female partners who you're

00:38:10.460 trying to educate?

00:38:11.720 For a sexual health consult, 20% of the time.

00:38:14.420 And what is the most common, I don't want to use the word ignorance, but what is the most common

00:38:20.240 thing that you appreciate about men when you're helping them in terms of their lack of understanding

00:38:24.960 about their partner's anatomy?

00:38:26.840 Giving men a roadmap, being very descriptive. Most partners want their partners to be happy. It's not,

00:38:33.440 there's the selfish aspect of performance, and there's the sexual empathy component where they

00:38:39.260 care about their partner and they want their partner to feel well. Giving them a roadmap to

00:38:43.700 sort of explore around and find the anterior branch and think about the wishbone structures

00:38:48.540 is really exciting to them. Spontaneous desire, thinking through that is really exciting for them,

00:38:53.620 how they tap into that, how they can curate that with their partner, thinking about their partner's

00:38:57.300 arousal. And then sort of supporting, there's a communication component, I think, when we think

00:39:01.900 about sexual dysfunction, we tend to break it down into a biopsychosocial model.

00:39:06.220 I like to talk mostly about bio. I'm a clinical physician, I'm a gynecologist, so I think a lot

00:39:11.720 about anatomy and pathophysiology and neurotransmitters and hormones. But there's a lot of other people

00:39:17.260 in this field that are helping with the psychosocial. Sex therapists, communication, there's a great

00:39:22.480 book called Sex Talks by Vanessa Marin, which talks about how to communicate with your partner.

00:39:26.880 Clitorate is a great book to think through different ways that you can sort of improve your

00:39:30.380 communication about what pleasures you and how to investigate that. There's really good websites now,

00:39:35.460 omgyes.com, is a website that talks about your anatomy and how to find it and how to find your

00:39:41.420 pleasure spots. So there's a lot out there. I'm not alone in this space by any means, but I like to

00:39:46.360 think about it from a very biologic, physiologic perspective. Talk to me about, you mentioned a

00:39:51.620 moment ago, for example, that a number of women are able to have an orgasm during intercourse, but it

00:39:58.560 requires them using their own hand, for example. How much does a woman control her ability to have an

00:40:03.960 orgasm by the way she positions her pelvis? Female dependent and dependent upon your own anatomy.

00:40:09.140 So in thinking about how far your clitoral hood is from your vaginal opening, thinking about if

00:40:14.760 you're a lefty or a righty, understanding your anatomy, exploring your anatomy can help you sort

00:40:19.940 of figure this out and talk to your partner about it. So yes, there is a good amount of control that

00:40:23.960 women can have over this, but the first step is understanding their own anatomy.

00:40:26.980 Is it a myth that if a woman uses a vibrator regularly on her own, it makes it harder for

00:40:34.740 her to have an orgasm with her male partner, unless she becomes dependent on using it as well?

00:40:39.600 It is a myth in the sense that there is data on either side. And so there is some data that talks

00:40:44.940 about if you sort of acclimate to sexual practices that you cannot bring into a partnered model,

00:40:50.920 then it may be harder to have orgasms in a partnered situation. But if you are comfortable using

00:40:56.720 whatever technique you find upon your own time, and you can bring that into your relationship,

00:41:01.740 then you're more likely to have orgasms. And so thinking about whatever it is that you're doing

00:41:06.000 and however it is that you're doing it, if you can inject that into your life with your partner,

00:41:10.080 you are more likely to have orgasms. There is really good data that orgasms beget orgasms,

00:41:14.840 meaning like the more orgasms you have, the easier it is to have an orgasm in terms of

00:41:18.860 training the system, sort of learning your body's response to stimuli can be trained,

00:41:23.640 your body's response to things can be trained. And I think from a going back to sort of how we

00:41:28.740 could use this from a desire perspective, there is good data that sex begets sex, meaning the more

00:41:34.620 sex that you have, the more sex that you want. And so I talked to my patients about scheduled sex

00:41:42.020 as a way to sort of work on your desire. And most of my patients when I bring up scheduled sex are like,

00:41:48.660 oh my God, another thing I have to do, like, oh, what a hassle. I point out the fact that

00:41:54.780 you've always scheduled sex. When you met your partner and your partner said, what are you doing

00:41:59.860 Friday? He was scheduling sex with you. And when you said sushi sounds good and you shaved your

00:42:05.600 armpits and put on a nice t-shirt, you were planning for sex. So you were prioritizing your sex life in a

00:42:11.140 way. And so scheduling sex is a great technique that we use. How that sort of rolls out depends on the

00:42:17.720 patient and what frequency they're going for. But I have my patients do what I call fuck it February,

00:42:22.800 where I essentially have my patients having sex, scheduling sex two to three times a week for the

00:42:28.260 month of February. It's a romantic month. It's the shortest month of the year. And this takes

00:42:34.340 pressure off of patients wondering the person who's been the initiator sort of gets to relax and not have

00:42:39.700 to worry about rejection. And the person who has been less interested knows that they're sort of

00:42:44.380 working through an arousal pathway. They're working on responsive desire and scheduling just means that

00:42:49.880 you'll show up. You don't have to have sex, but you just show up and you try it. And there's great

00:42:53.140 data that sort of after a month, women will sort of have that maintenance of their increased desire

00:42:58.720 and they can sort of ride on that for a couple of months. You mentioned earlier discordance as an

00:43:03.760 issue, discordance of desire. How often is the discordance in one direction versus the other?

00:43:08.920 So how often is the discordance that the male wants more than the female and vice versa?

00:43:14.620 I wish I had a specific number for you. We can probably look that up and put that in the notes,

00:43:19.500 but anecdotally, I'll say it is most often the male has a higher desire than the female.

00:43:25.960 Does it say anything about the couple if it's the reverse?

00:43:28.880 I anecdotally as well have the reverse as well. And there's so much that goes into this in terms of

00:43:33.380 the partner's health status and chronic diseases and stressors at work. So there's a lot to sort of

00:43:38.840 think through and it can go both ways, but by far and large, it is predominantly the male with the

00:43:44.280 stronger sexual desire. And so on the topic of sexual desire, because this podcast is called

00:43:49.280 The Drive and we're talking about cars, what's the throttle and what's the brake pedal on sexual

00:43:54.420 desire for men and for women? And I assume it's different. I would assume it's different too.

00:43:58.980 I never talk about men because I'm not an expert in men's sex lives. I'll recuse that to the next guest.

00:44:04.160 But when we think about women, we think about accelerators and brakes. It's a common framework

00:44:09.500 that we use from a social behavioral perspective, like what helps you feel relaxed and what turns

00:44:14.920 you off. But from a pathophysiologic perspective, we think about neurotransmitters. And so accelerators

00:44:20.660 from a neurotransmitter perspective would be things like estrogen and testosterone, nitric oxide,

00:44:26.240 dopamine, and oxytocin. And those five neurotransmitters are in a complex interplay to sort of tell our

00:44:33.480 brain and our body through a variety of different pathways. I'd like to participate in intercourse.

00:44:39.100 Estrogen is very interesting because although we know, you know, there's different types of

00:44:43.300 estrogen receptors throughout the body, but when it comes to sex drive, we think about alpha receptors,

00:44:47.480 which stimulates sex drive and beta receptors, which decreases anxiety and inhibition.

00:44:53.600 But it's not as clear cut when we replace estrogen. It's not a slam dunk that, you know,

00:44:57.700 you cannot make the connection then that, oh, so if I replace estrogen as it's dropping,

00:45:02.360 I fixed my sex drive all as well. Testosterone has a little bit more of a direct link to that.

00:45:07.780 So when we think about, for example, the postmenopausal female, and I'll use the term

00:45:12.420 menopause hormone therapy over hormone replacement therapy. And I would be so excited if you switched

00:45:18.560 your nomenclature as well. But I think when we think about postmenopausal women, we think about

00:45:24.060 menopause hormone therapy replacing estrogen. We sometimes do see an improvement in sex drive,

00:45:29.800 but that's usually through an indirect pathway. You're sleeping better. You have more energy,

00:45:33.860 like you're not having as many hot flashes. So we'll see sort of an indirect improvement in sex

00:45:37.740 drive. Testosterone is well studied for hypoactive sexual desire disorder or a decrease in your sex

00:45:44.520 drive. To meet that diagnosis, you have to have a low sex drive for more than six months. And you have

00:45:51.100 to care. Not your partner cares, but you have to care. And if you meet that diagnosis,

00:45:55.840 testosterone is very well studied in terms of its benefits on your sex drive.

00:46:00.220 What is your preferred method for administering testosterone to women?

00:46:03.860 I prefer a cream. So I do also prescribe Testim, which is an oil. And that's where I will sort of get

00:46:10.060 resealable packets. I'll put it into a empty syringe, the kind that we give our children Tylenol with,

00:46:15.320 if not an actual needle syringe. Then you can administer 0.5 cc's and rub it on the inner thigh

00:46:21.140 is my favorite place to do it. I do a lot of compounding cream. I use Koshlin Pharmacy. They

00:46:25.980 have a pretty standard, like well-mixed formula. And I'll sort of use, I'll prescribe a testosterone

00:46:30.800 cream where the patient will use a pump a day. When they get out of the shower, they'll let it dry for

00:46:34.640 20 minutes and then they can put on there and get dressed. Do you think the oil is more efficacious

00:46:38.800 and consistent in its absorption than the cream? I don't. I do follow labs when prescribing

00:46:45.040 testosterone. So anecdotally and from a lab perspective, I don't find a difference. I'm

00:46:50.020 interested in what you say. I sort of go based more on patient preference. If they want an FDA

00:46:55.940 approved product, although it's not FDA approved for women, then we'll go ahead and use the Testim.

00:47:01.820 If they don't, I much prefer to just compound it. It's cleaner. It's less messy. It's easier

00:47:06.200 to dose. There's so many dosing issues with the oil in terms of how we dispense it when

00:47:11.040 it's not supposed to be dispensed for women that I much prefer the cream. How about you?

00:47:16.200 We use a cream more typically.

00:47:19.020 Yeah. I don't use intranasal. I do use intravaginal, but sort of in the form of DHEA, I use a lot

00:47:25.620 of intrarosa. Intrarosa or prasterone is sort of a metabolite that can ultimately come down

00:47:31.480 the testosterone-estrogen pathway. I will use that. That's for pain of the vagina,

00:47:35.680 but when it comes to sex drive and desire to administer testosterone, mostly cream.

00:47:40.140 Do you target a specific level for total testosterone or free testosterone,

00:47:44.400 or are you just basically saying, I want to get it above a certain floor and then symptoms

00:47:48.340 determine where we end up?

00:47:49.840 I want to get it above 20 in terms of total testosterone.

00:47:52.580 Wow, that's a low floor.

00:47:53.480 It's very, very low. And then I use symptoms. So for example, 20 to 80 would be the range at

00:47:59.460 which I'm interested. I predominantly use symptoms. The guidelines in terms of how to titrate it are

00:48:04.560 not clear. Anecdotally, I'll have patients at 80 who have no benefit to their sex drive. I have 20

00:48:10.040 who see a great benefit. So I want to see like some sort of modest improvement in their testosterone

00:48:14.540 and then interview, see how they're doing.

00:48:17.180 Given how much variability there is in men with androgen receptor density, I think we have a pretty

00:48:22.340 clear sense that in men, levels don't tell you much unless you're below 350, 400. If you're below

00:48:29.560 that level, you're really going to be hypogonadal. But men can be replete at 600 and other men might

00:48:35.420 not be replete till they're at 1000. And again, it just comes down to AR density. Do you have any

00:48:40.120 sense of how that works in women?

00:48:42.100 Other than it's incredibly complicated, as you alluded to, but more so in women, because most women who are

00:48:47.500 on testosterone are also on estrogen. And we know that estrogen increases your sex hormone binding

00:48:52.940 globulin quite significantly. Sex hormone binding globulin being that protein that sort of runs around

00:48:58.040 and gobbles up free androgens or testosterone. And so because I'm prescribing estrogen and progestins

00:49:04.120 actually have the ability to blunt or mitigate that increase in the sex hormone binding globulin,

00:49:09.300 the more androgenic the progestin, the more mitigating effect on that increase in sex hormone

00:49:14.620 binding globulin. This is my true passion in sort of thinking about hormones and contraceptive and

00:49:19.840 menopause hormone therapy and sort of tinkering with hormones, because some of what you do will

00:49:24.340 help the sex drive, some of what you do will hurt. But the addition of the two variables of estrogen

00:49:29.280 and progestin make this incredibly more challenging.

00:49:32.620 As you know, we talked about this at length with Rachel Rubin, but I think it's always worth rehashing.

00:49:36.620 How do you like to initiate estrogen, progesterone, and testosterone use in a perimenopausal woman

00:49:43.960 who is obviously one of the most difficult to treat because she still has waxing and waning

00:49:49.500 natural levels of all of those hormones, but during her naders is typically pretty debilitated by

00:49:56.260 the symptoms. What is your playbook on that, which is obviously pretty challenging?

00:50:00.460 I love this topic because it's so different. It's so different for each woman in terms of how

00:50:05.040 she responds. The first question that I try to answer in my interview with my perimenopausal

00:50:09.760 patients is, do you like ovulating or not? And that's the sort of first branch point at which

00:50:15.640 I sort of decide how I'm going to approach this patient.

00:50:19.020 Let's just stop on that question for a second. I've never really thought of that question,

00:50:22.800 obviously being someone who's never ovulated, but tell me why that question matters and why

00:50:28.160 would a woman know the answer to that question at the risk of sounding naive?

00:50:31.540 So I'm going to answer this from first a sexual health perspective and then a general health

00:50:36.300 perspective. Some people, when their sex drive is higher around ovulation, they love it. They

00:50:40.460 like the benefit that ovulation gives to their sex drive. There are times in the month when they

00:50:45.260 have a great sex drive, they ovulate and they feel good. Similarly, the first half of your cycle

00:50:50.780 when estrogen is climbing right before ovulation is a high performance part of your cycle. So these

00:50:56.180 women who like to cycle feel good the first part of their cycle. They feel great right before

00:51:01.440 ovulation. There are a lot of biometrics that are peak right before ovulation. Your memory is

00:51:07.780 stronger. Your energy is stronger. I have a few Olympic athletes in my practice and we will figure

00:51:13.180 out when their events are and we will try to figure out their ovulation so that they are competing in

00:51:18.480 the first around day 9, 10, 11, 12 to 15 of their cycle because right before ovulation is where they

00:51:24.860 can lift the heaviest, they can run the fastest. I'd love for you to do a study on VO2 max throughout the

00:51:30.080 cycle. That's super interesting. It's really interesting when you look at the metrics that

00:51:33.540 we care about. Many of them are peak. Sorry, just to be clear, at that moment in time, her estrogen is

00:51:39.240 pretty much at her highest. Progesterone is very low. Low. Testosterone is high. Correct. So does that

00:51:45.440 mean progesterone is a performance inhibiting hormone or does it mean that estrogen, because

00:51:52.780 obviously testosterone is a performance enhancing hormone, does it really mean estrogen is performance

00:51:57.340 enhancing progesterone is performance inhibiting? Because in the luteal phase, you would also see

00:52:02.500 high estrogen, but you now have high progesterone. Not as high estrogen, but you're correct. At the

00:52:07.400 risk of boring anyone listening to get a little more academic about it, you're really talking about

00:52:11.500 a progestogen. There's estrogen and there's progestogen. Within progestogen, there's progestins

00:52:17.040 and there's progesterone. Now, natural progesterone, we know, which is what's in your body is progesterone.

00:52:22.680 Yes, it is a sort of rest and digest, a low energy phase, a preparation in case-

00:52:28.440 Helps with sleep.

00:52:29.040 Helps with sleep. But in terms of the progestin-

00:52:32.740 Prepares for implantation, prepares for pregnancy.

00:52:35.260 Exactly. In terms of the progestins, which are a synthetic class of progestogens, we then think about

00:52:40.980 what is the family that this was derived from and the side effects can be very, very, very different.

00:52:46.480 And I think about that in terms of what pills I will prescribe my patients. But to bring it back

00:52:52.120 to the question, I essentially, through interview, and this is where the patient can really advocate

00:52:56.880 for herself, for patients who are listening. We care. Doctors, we've worked our butts off to get

00:53:02.540 here. We deeply care about helping you. All doctors do. But you coming in with great symptom

00:53:08.780 tracking and timelines and relations to bleeds and things like that can really help us understand

00:53:14.000 through interview, whether you're someone who feels great because of ovulating, or whether

00:53:19.080 you're someone who really suffers from PMS, premenstrual syndrome. Has it turned into premenstrual

00:53:24.720 dysphoric disorder where it's PMS, but now it's impacting your life? There's so many reasons by

00:53:29.700 which you would say, I actually feel terrible cycling. I would prefer not to. But that's the

00:53:34.680 first branch point when I have a perimenopausal woman.

00:53:37.660 And just give me the divide there, Sally. What percentage of women who are, let's just call it 44 years

00:53:43.620 old, 45 years old, will respond to that first question as, yep, I really enjoy ovulating, let's

00:53:50.160 keep it up, versus let's make this go away?

00:53:52.620 I would say about 70% of my patients, 70 to 80% of my patients, prefer not to ovulate.

00:53:57.440 Okay.

00:53:57.800 This is the 45-year-old who's like, I used to be really short-tempered with my kids the day before

00:54:02.940 my periods, and now I'm just, the whole week before, I'm really short-tempered. All of the symptoms of

00:54:08.200 low estrogen, hot flashes, vaginal dryness, I have all these hypoestrogenic symptoms.

00:54:11.940 And perimenopause is, your brain is yelling at your ovaries to please do one last ovulation,

00:54:18.380 listen up, so you have this sort of hyper-stimulation of signaling, a hyper-responsive

00:54:23.040 FSH, follicle-stimulating hormone, so much so that you can get a loop event, which is a luteal

00:54:28.320 out-of-phase event, where essentially you ovulate twice. Your FSH is so high, it's so busy yelling at

00:54:33.620 your ovaries, that your ovaries are like, I heard you, and I heard you again. And they essentially

00:54:38.560 double ovulate, and that's that story where you'll have long cycle, and then a short cycle,

00:54:42.920 and then a long cycle. So these are all clues that you don't like to ovulate. And so if you

00:54:48.980 do like to ovulate, let's go down that lesser travel.

00:54:52.020 By the way, you're the first person besides me who I've heard use the yelling analogy. I'll never

00:54:57.240 forget 10 years ago, I was sitting down with a male patient. He came in, and he had a pretty high

00:55:02.920 testosterone. It was not very high, but it was probably like 700 or 800, which for his age was

00:55:07.960 actually pretty high. And his FSH and his LH were 2x normal, and he wasn't taking anything.

00:55:14.940 I was like, this is really interesting. And he's like, why? And I sort of drew him a picture,

00:55:18.280 and I said, basically, your pituitary gland is yelling. It's screaming at your nuts,

00:55:24.560 and they're really responding. I forgot about the statement. Six months later, a year later,

00:55:29.120 two years later, he keep coming back with that. At some point, I started taking care of one of his

00:55:33.000 friends. His friends told me about it. They're like, he's really been bragging about this.

00:55:37.960 I'm sure women do not go and brag to their other friends that their pituitary glands are screaming

00:55:43.280 at their ovaries. But that's a guy thing. A guy would brag about that.

00:55:46.120 I would agree with that. What women do do is they're walking around the block with their protein shakes.

00:55:50.920 They're doing their thing. You have one 46-year-old average age of perimenopause being 46. You have

00:55:55.520 one 46-year-old saying, gosh, I feel so great. I'm on a birth control pill.

00:55:59.120 And I just feel so great. And the other 46-year-old is like, me too. I'm on menopause

00:56:03.440 hormone therapy. I just feel so great. And then they look at each other like,

00:56:06.860 why are you on that? And the heart of this for me is who likes to ovulate and who doesn't?

00:56:12.000 And from a sexual health perspective, understanding is your sex drive and all the other things that

00:56:15.920 make you happy and feel good, which ultimately go into your sex drive. Do you want to ovulate?

00:56:20.440 And if you do want to ovulate, then we can think about, do you need contraception?

00:56:24.980 And sorry, just go down that branch point again, because you just made a distinction that I

00:56:27.860 don't know that every listener will understand. You just talked about oral contraceptives,

00:56:32.440 which are hormones, and then menopausal therapy, which is hormones. Can you explain why

00:56:37.240 that branch point is different in response to your question?

00:56:40.700 Menopause hormone therapy, the dosages do not suppress the gonadotropin pathway. And so when

00:56:46.940 you are on menopause hormone therapy, you still ovulate. If you're going to ovulate,

00:56:50.260 you still ovulate.

00:56:50.740 You're going to still ovulate through it.

00:56:51.560 Yeah. Whereas contraception, many forms of contraception suppress ovulation, but not

00:56:58.240 all forms. To be clear when talking about contraception and how it affects your sex drive,

00:57:03.660 we talk about ovulation and how women's sex drive can be ovulation dependent. Remember,

00:57:08.440 though, that we've looked at how suppressing ovulation impacts your sex drive. And the data

00:57:14.740 shows the great meta-analysis of 32 trials, and it looked at over 14,000 women. And it said that

00:57:21.940 20% of women who suppressed ovulation still had an increase in their sex drive, 65% had no change in

00:57:30.000 their sex drive, and 15% had a decrease in their sex drive. So I don't want you to think that by

00:57:35.420 choosing some form of contraception that suppresses ovulation, you know, will absolutely have an impact

00:57:40.300 on your sex drive. It's so multifactorial, and safety from pregnancy can be so reassuring for

00:57:46.800 patients that that's definitely not the case. And when we think about how hormone pills can impact

00:57:52.920 your sex drive, we think about sort of the twofold suppression of the hypothalamic pituitary access

00:57:58.300 in terms of suppressing your hormones downstream and your therefore ovulation, but also going to

00:58:03.080 ovaries and shutting them down, which then decreases their production of testosterone. So even though,

00:58:08.280 yes, we have biologic plausibility for how contraception impacts your sex drive, there's so much going into

00:58:14.360 this from a biopsychosocial perspective that we don't see the equal number of changes in terms of

00:58:19.600 how it actually impacts your sex drive. And so once we sort of identify, okay, you do not want to

00:58:26.800 ovulate, then we can sort of march down, okay, do you need contraception? Do we need to do contraception?

00:58:31.820 But that continues to allow you to ovulate. Things like a Perigard IUD, spermicides, there's a vaginal

00:58:39.840 pH modifiers, there's many ways that we can provide contraception without impacting your ovulation. Or if

00:58:45.700 contraception is not an issue, and you like to ovulate, then we go down the menopause hormone

00:58:50.560 therapy route.

00:58:51.200 So if you said that 70% of women would be fine without ovulating anymore, does that imply that

00:58:58.980 70% of perimenopausal women would be better off on oral contraceptives than on estradiol and

00:59:05.300 progesterone?

00:59:06.440 Yes. In my patient panel, they are happier on that. What's really interesting is I want to talk about,

00:59:12.180 so when we think about menopause hormone therapy, we're thinking about 17-beta estradiol, which is this

00:59:17.580 estrogen, it's an E2, and it's the predominant estrogen when we're in our reproductive years,

00:59:23.400 and there's so many benefits to this estrogen. There are some new birth control pills on the

00:59:28.380 market that have this 17-beta estradiol. So it's a fascinating mix where you're suppressing ovulation,

00:59:35.000 you have contraception, but you're potentially still getting the health benefits of being on a

00:59:38.840 17-beta estradiol, or an estradiol valerate, which is metabolized into 17-beta estradiol.

00:59:43.920 And so for my perimenopausal patients, once we establish, okay, do you want to ovulate? Yes or

00:59:49.140 no. Do you need contraception? Yes or no. Then we can sort of think through how we pick a pill.

00:59:54.440 Because that would be my concern with an oral contraceptive as a bridge through menopause,

01:00:01.220 which is they're missing out on real estrogen and progesterone. And I think we have pretty good

01:00:06.240 evidence that the benefits you accrue later in life, especially with respect to bone density,

01:00:12.740 but probably with respect to other metrics of health, are heavily dependent on getting real

01:00:18.540 17-beta estradiol and real progesterone right away, never having an interruption in those hormones.

01:00:25.140 I agree with you.

01:00:26.340 If what we believe on that front is correct, then it means any woman who's going to go down the oral

01:00:32.200 contraceptive route would be best receiving that oral contraception in the form of what you just

01:00:37.860 described, which is a real 17-beta. And I guess my next question, I'm worried I know the answer to

01:00:43.700 this question, but I'm going to ask it anyway. What is the cost of that type of oral contraceptive

01:00:49.200 and how often are insurance companies covering that?

01:00:52.060 Rarely covering it.

01:00:53.300 Out-of-pocket monthly cost on that pill would be how much?

01:00:56.200 A hundred-ish. A hundred-ish a month.

01:00:57.560 So it's a hugely expensive.

01:00:59.260 Yeah. It's incredibly prohibitive.

01:01:00.980 If you were to think about, okay, so now I'm perimenopausal and I don't want to ovulate.

01:01:06.100 I want to be on a birth control pill. The first question is, do I want to be on estrogen?

01:01:10.040 You and I are sort of alluding to the fact, yes, I want to be on estrogen, but a certain kind of

01:01:14.040 estrogen. Remember, some people are not candidates for estrogen. Migraines with aura, blood clot,

01:01:19.120 family history. But we still want to suppress ovulation. The newest progesterone on the market

01:01:23.380 is something called drospirinone. Drospirinone, the pill is called SLIND. It suppresses ovulation in

01:01:29.000 about 98% of women, whereas previous progesterone only pills suppressed ovulation 50 to 70% of the

01:01:34.940 time. So you're getting a huge mood benefit for these women who cannot take estrogen, but really

01:01:40.800 don't want to feel the ups and downs of perimenopause cycling, which can be wild. Drospirinone being a

01:01:46.500 derivative of spironolactone, there's a diuretic component to it. And so it's a really well-tolerated,

01:01:52.040 really exciting. I hope I can convey how excited I am about this progestin because having drospirinone

01:01:58.420 means that we can mitigate some of the other side effects. Such as water retention? Water

01:02:02.680 retention. Okay, so now we've decided, all right, if I don't want estrogen, I'll use SLIND, this

01:02:07.500 drospirinone only, but ovulation suppressant medication. What if I do want estrogen? Then

01:02:12.860 the branch point is, do I want something synthetic, said very few people ever, or do I want something

01:02:18.260 more natural, said both of us? The people who do end up on a synthetic estrogen, your insurance

01:02:23.860 covers it. It's available at all pharmacies. So there's sort of an access issue here that we would

01:02:28.900 be sort of remiss to ignore. Within that category, I still have pills that I like. Historically, if you

01:02:35.640 interview patients, they may be able to tell you, oh, I did well on this synthetic estrogen. So as we

01:02:40.620 sort of get into the later 40s, I care more in terms of getting them back on a more natural estrogen

01:02:45.820 for the reasons you mentioned in terms of bone prevention and things like that.

01:02:49.480 When you're talking to a 28-year-old woman who just needs birth control, you don't have a concern

01:02:54.700 with putting her on a synthetic estrogen? I don't. I still have favorites. Loloestrin.

01:02:59.560 I was just about to say, that's my favorite. Yeah. So I use Loloestrin a lot. Loloestrin is

01:03:05.240 norethindrone progestin. The reason why I like norethindrone is it's a little bit more androgenic.

01:03:11.180 The more androgenic the progestin, it has the ability to blunt or mitigate the increase in sex

01:03:16.380 hormone-binding globulin. Again, I'm talking about pills from a sexual health perspective.

01:03:20.260 There's lots of other ways you could view this, but today this is my angle. And so when you think

01:03:24.600 about super low-dose ethanol estradiol, low side effects, plus a slightly more androgenic

01:03:30.500 progestin, you then can have a blunting of the increase in sex hormone-binding globulin. It's

01:03:35.600 less likely to gobble up all those extra androgens, and patients tolerate it really well. Side effects

01:03:40.540 are there's more bleeding because of the low ethanol estradiol. So sometimes I'll go up to a less,

01:03:44.500 less, which is a 20-microgram ethanol estradiol. And this has a levonogestral progestin to it.

01:03:50.780 And this progestin is similarly a little bit more androgenic, less likely to impact your sex

01:03:55.740 hormone-binding globulin. And then my last two very popular, Yaz and Yasmin, the reason why those are

01:04:00.960 so popular is the progestin in them is drospirinone. And so it has that ability to not only improve...

01:04:05.940 A little more of a diuretic.

01:04:07.220 Exactly. It acts as a diuretic.

01:04:08.680 When we think about ethanol estradiol, and if I could just step out of professionalism for a

01:04:14.040 moment and ask my father-in-law to tune in because he's a nephrologist, and he would be so excited to

01:04:19.620 hear that I'm going to talk about angiotensinogen, which is ethanol estradiol, goes to the kidneys,

01:04:24.680 and some 17-beta estradiol goes to the kidneys and causes sodium retention, water retention.

01:04:29.880 So when we think about estrogen and how it impacts our bodies, our PMS, our breasts feeling heavy and

01:04:35.060 painful, bloating, slight weight gain, this is estrogen effects. And drospirinone being a

01:04:41.160 derivative of spironolactone can have a mitigating or a diuretic blunting effect on that water

01:04:46.960 retention. Dave, if you could tune out now because I might say orgasm soon. But anyways, using this

01:04:53.120 counteracting principle in these newer medications can help me pick a really good synthetic form of

01:04:58.960 contraception. Now, if we're going to go to the natural form, there's a few combinations that I'm

01:05:03.680 using now that my patients are tolerating really well. The first is to go back to that progesterone,

01:05:09.100 progestin-only pill, which is Slynd, drospirinone, and adding a 17-beta estradiol patch to it. So you're

01:05:15.600 essentially taking an ovulation suppressive component of contraception, but adding in menopause

01:05:20.960 hormone therapy estrogen. And that's where the benefits are. You get the bone protection.

01:05:25.500 So for my patients who are on contraceptive pills...

01:05:28.540 Sorry to interrupt you. The progestin alone will help with suppression?

01:05:32.860 Of ovulation, which equals contraception.

01:05:35.720 Which that you can use physiologic 17-beta estradiol.

01:05:39.900 Correct.

01:05:40.820 That's super interesting. I'm ashamed to admit I didn't know that.

01:05:44.040 So it's a great in-between step because you can provide contraception, you can provide

01:05:48.920 drospirinone, which is a diuretic, which 17-beta estradiol does have some sort of water retention

01:05:54.720 components to it. The downsides to it, although these work very well throughout the body, at the level of

01:06:00.420 the endometrium or the lining inside the uterus, you have a little bit more breakthrough bleeding

01:06:05.060 because the 17-beta estradiol does not stabilize the endometrium as much. So one of the side effects

01:06:11.180 in limiting reasons for which my patients won't be happy on this is if they're having breakthrough

01:06:15.480 bleeding. There's other options that are better at that. That's two medications that I want to make

01:06:20.480 sure you know about. And I have no disclosures, but I'd love to have some.

01:06:23.900 The next medication that we think about is Nextelis. And Nextelis is drospirinone,

01:06:30.240 which is the spironolactone derivative, the diuretic, with estetrol or E4. It's a natural

01:06:36.240 estrogen. It's typically produced by the fetal liver, but this has a longer half-life than 17-beta

01:06:43.900 estradiol. So you get less breakthrough bleeding, less spotting. We don't know. We think natural

01:06:49.960 estrogens, you must get bone protection and bone benefit. We don't know yet. It's currently

01:06:53.740 being studied. It's only made by the fetal liver so that you have none of this in your body right

01:06:59.540 now. Hopefully not. Yeah. Unless you're taking this. Yeah. We might have to cut this out of the

01:07:04.160 podcast because it is so freaking nerdy at this point. What do we understand about, we understand

01:07:09.420 how E1, E2, and E3, estrone, estradiol, estriol, we understand if we want to, we can understand exactly

01:07:14.960 how they move between each other. And do we understand how E4 fits into that pathway? Does E4 have any

01:07:20.100 conversion back to E2 or is it acting as an independent agent? We don't totally know.

01:07:24.320 We think it's independent. Something we do know about E4 is that it does not activate the

01:07:30.120 angiotensinogen pathway. So you don't get these. So you don't get the water retention. You don't

01:07:34.620 get the bloating. So you have that plus drospirinone and patients feel really good. Remember, drospirinone

01:07:40.000 is so good for bloating and PMS. Until we know if this is going to be protective of bones and all

01:07:45.740 these other things, wouldn't there be a risk that we're solving one problem without addressing the

01:07:51.660 jugular problem?

01:07:52.960 Yes. Currently being studied, the benefits of drospirinone, less spotting or breakthrough

01:07:57.400 bleeding than the drospirinone plus menopause hormone therapy level estrogen. But I think by

01:08:03.620 you asking that question and sort of the dedication to making sure that we're on a studied 17 beta

01:08:08.480 ethanol estradiol, the newest medication on the market is called Natazia. And Natazia is a progestin

01:08:17.660 with estradiol valerate, which essentially is 17 beta ethanol estradiol. And this is a hugely

01:08:25.480 important contraceptive option for a few reasons. The first is it's the only contraceptive pill that's

01:08:31.720 been approved by the FDA to treat heavy menstrual bleeding. And this is a huge issue in perimenopause

01:08:37.160 and contributes greatly to sex drive and desire.

01:08:40.740 But this is once you've ruled out fibroids and things that otherwise can't.

01:08:44.840 This is sort of like I said that I wanted to stay in sort of the normal pathology part for this

01:08:49.420 podcast. A luteal out of phase event when you're double ovulating and having heavy bleeding of

01:08:54.220 perimenopause that still to me falls in the realm of normal. So Natazia is great because it's great for

01:09:00.060 heavy menstrual bleeding, but the estradiol valerate or the 17 beta estradiol, you get the hot flash benefit,

01:09:05.880 the bone benefit. You get the benefits of menopause hormone therapy with something that

01:09:09.880 can also help bleeding and prevent pregnancy.

01:09:12.260 And just to close the loop on progesterone, if you're using micronized progesterone,

01:09:18.060 even at 200 milligrams, which would probably be the upper limit of what we would use,

01:09:21.940 that's not enough to suppress ovulation, obviously.

01:09:24.500 Three.

01:09:24.840 300 is?

01:09:25.740 300 plus is what you would need to predictably, reliably.

01:09:29.220 But of course, most women can't tolerate that.

01:09:31.260 To sedating. And additionally, not to be left out is menopause hormone therapy plus an IUD

01:09:36.360 or menopause hormone therapy plus a salpinegectomy, removal of the tubes. There's other ways to get

01:09:41.840 at this, but I think that's why I really start at the branch point. Those points do not block

01:09:46.900 ovulation. So that's why to me, I really care how you feel in relation to ovulation. And that's

01:09:52.920 the branch point in how I decide how to treat my patients.

01:09:55.560 A lot of what we just talked about probably went over the heads of a lot of people,

01:09:58.040 which is understandable. It is pretty complicated stuff. I want to kind of bring this back to a

01:10:02.360 listener. To me, the takeaway is if you're a woman, you've got to show up with a point of view

01:10:07.800 on what you're trying to optimize around. Just show up with a point of view around preferences.

01:10:12.340 And this one around, do I like ovulating or not is important. So that's something that

01:10:16.740 regardless of how young a woman is listening to this, and truth be told, I don't think our audience

01:10:21.360 skews very young, but I'm sure there is a 25-year-old out there listening. This is something

01:10:25.700 she could be paying attention to right now. She's 20 years away from having to deal with

01:10:30.340 what we're talking about, but she can still be pretty receptive to the idea of how do I feel

01:10:35.540 during my cycle? That would be my greatest takeaway. And to make you aware that that changes

01:10:40.420 the way in which we feel in the second part of our cycle as our estrogen declines as we age can

01:10:46.540 become more and more dramatic. So it's a very important question to me for everyone and a

01:10:51.700 very, very important question for me for my perimenopausal patients.

01:10:54.920 And how much does that change based on children and the number of children a woman has or any

01:11:00.060 other factor like that?

01:11:01.400 I would feel a little theoretical going into that. I don't think we have great data. There's

01:11:05.080 some studies talking about the later you have your last child, the earlier you'll go into

01:11:09.280 perimenopause. The way that I think about hormones and what happens, I think one thing I want to go

01:11:15.020 back to from a neurotransmitter perspective is you asked me about the accelerators and we launched

01:11:19.520 into a discussion about hormones, but we didn't talk about the breaks. And the breaks are serotonin.

01:11:25.220 So we know about how SSRIs can impact our sex drive and can think about what to do about that. But

01:11:30.840 prolactin is a break. And it's really interesting because when in our lives is prolactin high,

01:11:36.940 breastfeeding, postpartum. Women can find this very validating, but from a biologic perspective,

01:11:41.580 we know that pregnancies spaced 18 months apart, that's the ACOG or American College of Obstetrics

01:11:47.920 and Gynecology, they recommend 18 months between pregnancies because that second pregnancy will be

01:11:53.320 healthier, the baby will be bigger, it's more likely to make it to term. So we know that spacing

01:11:58.160 pregnancies is healthy. And so having a high prolactin postpartum and keeping you from being

01:12:03.660 interested in sexual intercourse is your body's natural way of spacing out pregnancies for the better.

01:12:08.340 While we're on the topic of evolution, there's something I've always wondered that seems a bit

01:12:13.880 at odds with a pure natural selection. And this is going to expose how naive my thinking might be.

01:12:18.740 So it's not a surprise that men would have a high sex drive for as long as they are capable of

01:12:24.320 reproducing, which is seemingly indefinitely. But you could make an argument, maybe theoretically,

01:12:30.560 that women's sex drive should decline after a certain age, call it 30-ish, when evolutionarily

01:12:38.140 their probability of producing healthy offspring goes down. But I don't think we believe that to

01:12:43.680 be true at all. I don't think we see that women's sex drive goes down as they age, which sort of flies

01:12:48.940 in the face of maybe at least one naive interpretation of what natural selection might interpret. So is there

01:12:54.600 a smarter explanation for why a woman's sex drive goes up or it doesn't go down, maybe to phrase it more

01:12:59.920 accurately?

01:13:00.720 There are many explanations. This is hard to study. Potentially the most popular one,

01:13:06.860 which the European Society of Sexual Medicine gives like a grade two level B rating. So not

01:13:11.780 super high rating, meaning like case control studies.

01:13:14.800 No, no, this is like theoretical.

01:13:16.120 But theoretical, if we can sort of tangent on the theory for a little bit, there's something called

01:13:20.000 women's dual sexuality. And it basically talks about women's motivation to participate in intercourse

01:13:26.540 being different at different parts of the cycle, meaning mid-cycle, when you are able to get

01:13:31.660 pregnant, you are fertile. You are more likely to participate or to want to participate in intercourse

01:13:37.540 for purposes of reproduction. And the mates that you are more likely to select during that time

01:13:44.000 will have features of genetic dominance, such as a very symmetric face, more masculine features.

01:13:51.200 We talk about the histocompatibility complex, and there's dissimilarity that we look for at this

01:13:56.420 time because we know that mixing of genes is better than not. And then there's other times

01:14:01.420 of the cycle when you're interested in participating in intercourse and you're seeking out things such

01:14:06.340 as partnership, shelter, companionship, protection.

01:14:11.120 And you're not optimizing around genetic features.

01:14:14.120 Attractive or less symmetric or less masculine partner. But your partner may have better

01:14:19.040 communication skills, the ability to provide better shelter, protection. It's very interesting.

01:14:23.840 People take this and run with it online. And they talk about, you know, in your 20s,

01:14:27.960 what form of contraception should you be on when choosing a mate? This goes back to that question

01:14:33.260 of do you want to ovulate or not? Because there's so much, this is not an anti-ovulation,

01:14:39.500 anti-contraception discussion. Your sex drive is so multifactorial and being protected from pregnancy

01:14:45.580 is, for many, can be such a positive contributor to their sex life. But if you believe in this

01:14:51.200 evolutionary hypothesis and if you believe that you would rather pick your future mate when you're

01:14:56.940 still ovulating versus being on something like a contraceptive pill that blocks ovulation,

01:15:02.360 there is some data to show that you may pick a different partnership.

01:15:05.420 The discussion section is you may want to pick a partner that has a less symmetric face but is

01:15:10.960 more likely to have a partnership and communication skills. But I'll sort of excuse myself from that

01:15:16.020 and you can decide for yourself. That is super fascinating. And honestly,

01:15:21.020 there's more to explore there than the simple and obvious stuff I proposed. I want to go now back to

01:15:25.580 some of the other stuff that we talked about around desire. We didn't touch on this, but this must be

01:15:31.280 a very important topic that you deal with, which is how much do adverse sexual experiences during

01:15:37.220 the early part of a woman's life negatively impact her ability to have a healthy sexual life

01:15:43.700 later on? I think we could talk about this across the entire spectrum. So we could take the most

01:15:47.800 egregious example, which would be sexual assault, rape, things of that nature. But then we can also,

01:15:53.240 I think, fan this out into things which is just, no, you know, the first time I had sex,

01:15:57.260 it was awful. It was in a car in the back seat with a guy that I didn't really know that well.

01:16:02.100 And we were both drunk and yeah, I was consenting, but it was awful. So it's hard to imagine that

01:16:07.020 many women can't relate to that type of experience. How does that play forward?

01:16:12.120 I see it incredibly often in my patient panel. It is unfortunately, if you're listening to this and

01:16:18.440 you have a history of sexual trauma, you are unfortunately not at all alone. And there are

01:16:23.600 things we can do about it. So yes, it plays a part and yes, we should do things about it. So there

01:16:28.060 are lots of different approaches. I hope that patients are in therapy and that they have sort

01:16:32.740 of the right support team around them. I want to bring up sex therapists are a great sort of

01:16:36.920 contributor in this area and sort of thinking about how your experiences are brought into the bedroom and

01:16:41.940 how do we sort of use a trauma-informed approach when talking about how to curate arousal and bringing

01:16:47.420 yourself to the encounter when you're not quite ready. There's a sensate focus exercise that is

01:16:53.220 really evidence-based for survivors of trauma, but can also be very applicable to patients who,

01:17:00.300 for example, are listening to this podcast and it's been a year or it's been six months and they want

01:17:04.700 to think about how to become intimate again. And it's a four-step program that can be done over a

01:17:10.600 month, over four months. You can sort of pick how long each stage you want it to last. Dr. Leah

01:17:16.300 Melhauser, who's done a ton of work in sexual health from a gynecologic perspective,

01:17:20.640 talks about this. And it's essentially step one is to, let's say, spend 20 minutes a couple of times

01:17:27.900 a week if you want it. The stage to last a week is to sort of be intimate with your partner. No

01:17:32.720 touching of the breasts, no touching of the genitals. Step two would be okay to touch breasts

01:17:37.200 and genitals, but orgasm off the table. Step three would be orgasms on the table, but no penetrative

01:17:42.160 sex. And step four is penetrative intercourse is allowed. And this is a evidence-based way in which

01:17:47.820 you can create a safe space to sort of start to find yourself back in your body. There is a book

01:17:54.200 called The Body Keeps Score, which talks about how to bring your sort of mindfulness back into your body

01:18:00.480 when you are a trauma survivor. And Emily Nagowski talks a lot about it in her book as well. And then

01:18:07.060 there's a sort of potentially less traumatic, but still pain that can present itself in sexual

01:18:11.780 encounters. It just hurt. I see this a lot in my cancer survivors.

01:18:15.300 I was just about to ask you about cancer, by the way.

01:18:17.720 Yeah. So I see this a lot. Cancer, I often see sort of a twofold hit. There is the psychosocial

01:18:22.500 of I'm mad at my body and there's all those complex feelings. And there's this physiologic

01:18:27.620 aspect of chemotherapy, radiation, and how that impacts pain and lubrication of the vagina and

01:18:33.360 comfort of hormone use. Although we really feel quite confident that local estrogen treatment of

01:18:40.680 the vagina is completely safe for almost all cancer survivors. Dr. Tammy Rowan talks a lot about this

01:18:47.100 with a swish and menopause society, sort of encouraging not only patients, but also doctors

01:18:51.540 to feel comfortable prescribing local estrogen in this patient population. Physical therapists,

01:18:56.440 pelvic floor physical therapists can be incredibly helpful. I think every woman, if you're making a

01:19:01.620 centenarian plan and you're seeing a physical therapist to keep your posture and your muscles

01:19:05.500 healthy, I think you should see a pelvic floor physical therapist. They're great in terms of

01:19:10.300 increasing the tone of the pelvic floor. We know that strength of contraction can lead to

01:19:14.540 better quality orgasms. I often get emails like, oh, I just had the best sex. Thanks for sending me

01:19:19.980 to the pelvic floor physical therapist. But it also is good for hypertonicity where your pelvic floor

01:19:25.300 is too tight, where you carry stress and trauma and pain. In terms of thinking about how we take care of

01:19:30.740 the vagina, I would like to encourage you to think about taking care of the vagina like you take care

01:19:36.160 of your face. You listened to my recent podcast. I did. And I would like to say you're going to go

01:19:43.160 out in the sun and you put on sunscreen, you put sunscreen on your face. So if you're going to have

01:19:48.160 intercourse, you should use lube. Even if a woman says, I've never had any difficulty with lubrication,

01:19:54.540 I don't have any discomfort with sex, you still think a woman should be using lubricant?

01:19:58.340 I do. The data shows less microabrasions.

01:20:01.540 If you're not concerned with sexually transmitted diseases, which is what the WHO is concerned with,

01:20:06.600 if you're with one partner and only one partner, are microabrasions a problem?

01:20:11.140 They lead to pain. And once we get into a pain signaling process, you can get,

01:20:16.520 this is a common cause of what we call vaginismus or a tightening of the pelvic floor, which then leads

01:20:21.240 to more pain. It is very possible and you should absolutely work at it. But breaking a vaginismus

01:20:27.260 cycle takes a lot of work. Part of this recommendation that almost everyone should

01:20:31.920 use lube is this idea that we're trying to avoid pain.

01:20:35.520 Even young women?

01:20:36.340 Yes. This is one of my favorite things to talk to young teens about. When we think about sexual

01:20:41.600 education and we, there's a great study looking at 1,200 high school students and it asks them

01:20:46.800 about what we call sexual debut or their first sexual encounter.

01:20:49.680 Not intercourse.

01:20:50.760 First sexual encounter.

01:20:51.740 That includes kissing?

01:20:52.840 No, sexual encounter.

01:20:53.920 What defines that?

01:20:54.660 I'm going to guess penetrative intercourse. 70% of boys gave responses related to pleasure and 70%

01:21:01.740 of girls gave responses related to pain. That's a big deal. And so talking about foreplay and

01:21:07.220 lubrication, even for young women who have an adequately lubricated vagina and decreasing the

01:21:12.220 likelihood that they'll get into pain, that they'll clench up the pelvic floor, it will then hurt more.

01:21:16.840 Breaking out of that cycle is incredibly important to me. So yes, lube if you're going to have sex.

01:21:21.700 Going back to the face, you likely are putting moisturizer on your face.

01:21:25.800 Only recently.

01:21:26.480 Only recently. There's vaginal moisturizers. So if you want to use your vagina when you're older,

01:21:30.980 using a vaginal moisturizer, there's good ones on the market. There's Reverie,

01:21:34.820 which is a hyaluronic acid suppository. It lowers the pH of the vagina and brings water molecules with

01:21:40.020 it. There's Replens, which is a polycarbophil suppository that also recruits water molecules.

01:21:46.440 You're moisturizing your vagina.

01:21:47.900 Sorry, just explain to me how this is used. This is like part of your nightly routine.

01:21:52.380 Yeah. Yeah. Put on your eye cream, moisturize your vagina.

01:21:54.500 Or morning.

01:21:55.240 Most people like evening.

01:21:56.540 Then what if you're having sex after?

01:21:58.320 Whether you're using a vaginal moisturizer or whether you're using a hormone, which will be

01:22:02.220 the third part of this facial analogy recommendation. If you put it in and you decide you want to have

01:22:07.840 intercourse, please do. I wouldn't use it for the purpose of it. It's sort of, you're playing the

01:22:11.900 long game. So if you think about step three with your face, you're using a vitamin C serum or a

01:22:17.020 DNA repair enzyme or an exosome or whatever. That's sort of the long game in terms of collagen and

01:22:22.300 overall sort of tone of the face. So hormones would be this counterpart from a vaginal perspective.

01:22:27.780 Topical.

01:22:28.020 Yeah. Intravaginal, topical, local estrogen. Of my patients who are on menopause hormone therapy,

01:22:35.380 about 30 to 40% of them, and that's consistent with the data, are also on local estrogen therapy.

01:22:41.980 So just to be so clear, we treat local vaginal conditions with local treatment for women who

01:22:48.240 don't respond from a vaginal health perspective to systemic hormones.

01:22:51.820 All right. So let's recap that. So the equivalent of sunscreen was lubrication.

01:22:58.520 Silicone-based?

01:22:59.960 Silicone-based, it lasts longer. So water-based lubricant doesn't last as long.

01:23:04.780 And so in order to make a water-based lubricant work, they have to add a lot of additives. You

01:23:08.660 add additives, you get hyperosmolar lubricants, which then if you go back to high school chemistry

01:23:14.300 means that you're actually, long game is water molecules are going from the vagina into the

01:23:18.500 lubricant because of the osmolality.

01:23:19.940 So it's drying you out.

01:23:20.640 So it's drying you out in the long time. So I like a silicone-based lube.

01:23:23.520 Give us a couple brands you like.

01:23:24.740 I like Uber lube, the osmolality, Uber.

01:23:26.640 Literally spelt like the car.

01:23:27.880 Like what I took here. Yeah. Like I took an Uber here. So I like Uber lube. Osmolality

01:23:31.620 is 600. I like good, clean love, almost naked. Osmolality is about 280 to 300. The osmolality

01:23:38.860 of the vagina is 300. It's really quite shocking to me when you go to a drugstore and you pick

01:23:46.060 up, let's say Astroglide. So the osmolality of Astroglide is 8,000. They have a gentler

01:23:52.380 one that's lower. Most people don't know about that. Don't buy it. If you look at KY, it's

01:23:56.880 around 4,000 to 6,000.

01:23:58.500 Wow.

01:23:58.880 I mean, it's crazy.

01:23:59.880 These things shouldn't be sold.

01:24:00.980 They should not be sold, but they are. And they smell good and they taste good.

01:24:04.980 Why are they the most ubiquitous lubes out there?

01:24:07.720 They taste good or they smell good or they have a cool package.

01:24:10.940 Do these lubes say the osmolality on the package?

01:24:14.360 If you look on the back, they should say it.

01:24:16.240 All right. So you want to be basically in the 280 to 300 range?

01:24:19.300 300, as close to 300 as you can.

01:24:21.520 Okay. That's great to know. So Uber Lube, what was the other one?

01:24:24.440 Good, clean love, almost naked.

01:24:26.820 That's a long name. They might want to shorten that.

01:24:28.540 Good, clean love.

01:24:29.520 Good, clean love. All right. So if that's your sunscreen, your moisturizer is?

01:24:34.540 A Reverie or a Replens. And these are suppositories that you can put in the vagina nightly.

01:24:40.220 And the suppository is providing what?

01:24:41.860 It is recruiting water molecules into the cells. And the Reverie is also slightly lowering the pH

01:24:48.820 of the vagina. The lower the pH of the vagina or as close is a natural desirable outcome.

01:24:55.680 And how does a woman know if her systemic hormone therapy is insufficient and therefore

01:25:03.060 she requires topical as the third part of this playbook?

01:25:06.340 If you are going to respond to systemic hormone therapy in terms of improvement of pain,

01:25:13.060 dyspareunia, we call it, feels like sandpaper canal. There's a sort of a rubbing raw feeling

01:25:18.400 to the vagina. You'll respond by about six to eight weeks.

01:25:22.000 So give it a start. See if things get better. If there's no change, if you weren't having pain and

01:25:25.980 nothing gets better, you are probably fine. This strikes me as a great example of something that

01:25:31.180 a male who's listening to this podcast, whose female partner is not, could actually bring home

01:25:37.340 and talk about over dinner. Look, I mean, half our audience is men, half our audience is women.

01:25:42.600 So there's a guy who's listening to this episode whose partner is not. If I'm in his shoes, I'm

01:25:47.440 thinking, what am I bringing back to the table? And this would be one of those things, which is,

01:25:51.880 hey, let's have a discussion about these three things. So anyway, hopefully we'll link to

01:25:56.080 examples of all of these in the show notes. What percentage of women are regularly receiving oral

01:26:01.380 sex? I don't have that statistic. We'll have to find that and look it up. I will say that when you

01:26:06.040 look at orgasm frequency with any sort of intimate encounter, it is one of the highest likelihood to

01:26:12.620 be able to achieve orgasm acts that a man and a woman can participate in together. There's a great

01:26:18.360 book called She Comes First by Ian Kerner that has diagrams and tips and tricks and talks about

01:26:25.120 essentially how to do that. One of the best ways, if you sort of from a performance perspective,

01:26:29.680 is to go back to the stages of orgasm that we talked about, the excitation, plateau, orgasm,

01:26:35.280 and resolution. When you think about the plateau phase, that's sort of the hormone cascade that's

01:26:40.180 happening in the woman. There's two different ideas that are relevant here. The first is something

01:26:44.500 called the approach. And the approach is the seconds or moments just prior to orgasm.

01:26:49.220 When surveyed, two-thirds of women report that whatever's happening when the approach starts,

01:26:54.480 that it should just keep happening exactly as it is. So no increase in pressure, whatever you're

01:27:00.720 doing, just keep doing it. No change in temperature, pressure, speed, depth, nothing. So understanding

01:27:06.440 that as sort of like a key component for most women, but not all, can be something that can sort of help

01:27:11.000 you from a performance perspective. The onus is on both the woman and the man. The woman needs to

01:27:16.220 recognize she's there and have a cue to her partner that says, don't change a thing. The guy needs to

01:27:23.100 not try to be a hero and needs to know, when she taps my head or whatever it is, don't change a

01:27:29.120 thing. Yeah. And that's a strategy to help women have more of a guaranteed orgasm. And then the

01:27:35.060 contrary is something called edging, which is where you do stop what you're doing. And you sort of like

01:27:41.100 bring your partner close to orgasm and then you stop what you're doing. And then you can bring your

01:27:46.140 partner close again and then you stop. And this is for women to be able to achieve more of an intense

01:27:52.100 orgasm, this edging technique. So if you were to give a guy a few pieces of advice on how to be

01:28:00.740 more successful at helping his partner achieve orgasm using oral sex and penetration, what would

01:28:07.480 be your advice? Lube, get over it. It's evidence-based. It's for friction. It has nothing to do with how

01:28:12.760 interested your partner is in you. Anatomical awareness. So understanding that there's these

01:28:18.100 two wishbone nerve pieces. Enjoy being massaged. Try to explore with your finger two-thirds of the

01:28:24.820 way into the vagina on the anterior or the front wall where the G-spot is. Find that rugated area.

01:28:30.860 Lead up to the event. So foreplay, what does that look like for you as a couple? What does it look

01:28:35.200 like outside of the bedroom? Is it you made dinner or you put the kids down? What is your chore play?

01:28:40.240 What chores did you do as a part of foreplay? What nice text messages? There's so much contextual

01:28:45.940 going on. There's really funny research pieces that talk about people who are in the military who

01:28:52.000 are traveling around and there's bombs everywhere and it's really dangerous and men are still like

01:28:57.720 ready to have sex and women are feared for their lives. A lot more that goes into women's sexuality

01:29:03.400 that I want you to be aware of. There's no need to take this personal.

01:29:06.380 But I hope today sort of understanding arousal versus desire, responsive desire, anatomically

01:29:12.980 thinking about not just the tip of the clitoris, although many men haven't even thought of that.

01:29:18.020 But in addition to the tip of the clitoris, the wishbone structures that go down, the anterior

01:29:22.440 wall of the vagina, thinking about what phase of orgasm your partner's in. Is she in the excitement

01:29:29.300 phase? Is she in the plateau phase? Or is she sort of in the orgasm phase? And what does that look

01:29:34.140 like? What about little details like, for example, if you're stimulating the clitoris,

01:29:38.980 is it just very individual variation, up and down, side to side, around?

01:29:43.320 Individual variation.

01:29:44.620 And is this something where a guy should just ask a woman and say, hey,

01:29:48.560 how do you like this done? Or is a woman put off by a guy asking that?

01:29:52.680 In my dream world, these conversations would take place. There's books that walk you through

01:29:57.360 how to have these conversations. The sex talks book that I mentioned by Vanessa Marin,

01:30:02.200 and she writes it with her husband. So you get sort of both perspectives. But I think that website,

01:30:07.040 omgyes.com, actually teaches women how to find the different techniques. So they go over

01:30:12.140 a hard stroke, a round stroke, a gentle touch, an internal touch. They actually teach women.

01:30:18.140 And yeah, I have a dream that women would go to this website and learn for themselves how to do it

01:30:22.980 and talk to their partners about it. Men can also go to the website. It's a one-time flat fee website,

01:30:28.040 and then you have access to all of their content. And it walks you through different techniques.

01:30:32.160 So you can actually learn and talk about with your partner what she likes.

01:30:35.680 All right. Let's pivot a little bit and talk about pharmacology of arousal. We've talked a

01:30:42.720 little bit about it through a hormone perspective. And we've obviously talked about how testosterone in

01:30:47.740 particular, but also estrogen and progesterone play a role in the arousal of a woman. But there are

01:30:53.020 also drugs that are specifically used to target this. What can you tell us about them? There are a

01:30:57.200 couple in particular that I know have come up on this podcast previously.

01:31:00.920 Using that sort of accelerator and brake analogy, many of the medications will work on one or both

01:31:07.580 of those pathways. The two most common medications and the only two that are FDA approved for women

01:31:13.100 are ADDI, which is a pill, and Vilesi, which is an injection. They work along the MAOI pathway on

01:31:20.660 increasing norepinephrine and dopamine and decreasing serotonin. So if you go back to those neurotransmitters,

01:31:26.820 thinking about serotonin as a break, so they decrease that norepinephrine and dopamine to

01:31:32.060 the reward center of the brain, and they increase those. I don't use them a ton in practice.

01:31:38.020 They are not studied for postmenopausal women. ADDI is a nightly pill. You take it for six weeks.

01:31:44.100 Well, you take it forever, but after, it takes about six weeks before you can see benefit to it.

01:31:49.500 In the trial for which it was FDA approved, it increased your number of satisfying sexual

01:31:56.720 encounters by one. So you went from having like two-ish satisfying sexual encounters a month to

01:32:03.460 three-ish satisfying sexual encounters. You can't drink alcohol on it. It can cause nausea for some

01:32:09.960 people. It can interact with antidepressants and mood-stabilizing drugs. It's not a contraindication,

01:32:15.080 but it can change the way in which they work. I just don't use it very much.

01:32:19.300 How much does this drug cost?

01:32:20.620 I don't know the answer to that.

01:32:21.960 Why do you think this drug was approved with such limited efficacy?

01:32:25.140 It's statistically significant to go from, let's say, two-ish to three-ish satisfying sexual

01:32:29.980 encounters. But there was a social movement at the time. There was frustration about how easy it was

01:32:34.940 for Viagra to be approved. The data for Viagra in men is much more clear and easy to see.

01:32:42.100 This is women's sex drive is very complex and there's potentially one angle at improving it.

01:32:47.420 But it's a bit of a bad analogy. Viagra is not really a drive drug. It's a performance drug.

01:32:52.560 It's a performance drug that ultimately can impact drive as well.

01:32:56.940 Are there any data that show that Viagra or Cialis or any phosphodiesterase inhibitor improve

01:33:01.760 orgasm quality in women?

01:33:03.940 They've looked at Viagra a great deal. The studies do not show for women across the population level

01:33:09.820 and study that it impacts drive or orgasm quality, except when looking at a specific

01:33:15.400 patient population. So when you look at Viagra, the patients who had an improvement in their

01:33:20.140 quality of sex, be it drive or orgasm quality, et cetera, were women, diabetics, MS, multiple

01:33:26.200 sclerosis, spinal cord patients, and SSRIs. These are women who we think that the vasodilation of

01:33:31.520 the nitric oxide and the physiologic response that they have to Viagra dosed at 25 to 50,

01:33:38.040 one to two hours prior to anticipated intercourse can be helpful.

01:33:41.720 Let's go back to Addy, the pill. When I talk about one satisfying sexual encounter, you know,

01:33:47.480 improved per month, remember that that's compared to placebo. So there is still a great placebo

01:33:52.100 benefit here. And for many, that's exciting and fine to introduce into their life.

01:33:57.100 If Viagra is an injection, you may get questions about it from your patient panel because it's

01:34:02.400 similar to the peptide PT-141, melanotan. This sort of has the street name as the Barbie drug

01:34:10.200 because it works through the MCR4 or the melanocortican pathway. So you get tan and pretty

01:34:15.540 happy and horny is what they say. So they call it the Barbie drug for that reason. There's a

01:34:20.060 significant amount of nausea. You inject yourself. For the first two hours, 40% of women will have

01:34:25.960 nausea. I often prescribe Zofran, an anti-nausea medicine when I prescribe this drug. After two-ish,

01:34:31.540 three-ish hours, the nausea can go away and then the drug lasts for up to six hours. You can't use

01:34:36.540 it more than twice a week. But this had slightly similar efficacy to Addy in terms of improving

01:34:41.920 your sex drive. When I hear that a drug causes that much nausea and you can only use it twice a week,

01:34:48.200 I worry that it's doing something unhelpful as a side effect beyond what you just said. Do you have

01:34:55.280 a concern with long-term use of this drug? It's been out since 2019. We don't have

01:35:00.280 particularly long-term data on it. I have the same questions. People anecdotally do like it,

01:35:06.360 but I do think there's a great placebo effect going on here. Do you think one is better than

01:35:10.480 the other? It's really hard for me to convince patients to inject themselves with a shot, you

01:35:14.680 know, an hour or so prior to intercourse. It doesn't really feel so... It's a preloaded pen?

01:35:18.860 Psychosocially, yeah, sexy. I guess it speaks to obviously the magnitude of the problem.

01:35:24.440 I don't suppose these drugs have been compared head-to-head to testosterone?

01:35:27.500 I don't believe that they have, no. I assume that it would be prudent to make sure a woman's

01:35:31.840 testosterone has been pushed to the physiologic limits before you would engage with any of those

01:35:37.120 drugs? I just prefer testosterone, which to be clear, testosterone is sort of from a guideline

01:35:42.020 perspective recommended only in the post-menopausal woman. So if we're going to stay in the,

01:35:48.860 when do I ever use these drugs? So this is in the pre-menopausal.

01:35:51.580 This is pre-menopausal.

01:35:52.280 This is pre-menopausal.

01:35:53.120 From an FDA perspective.

01:35:54.320 Exactly. So if you're like, why even use these? This is studied for pre-menopausal. Testosterone

01:35:59.160 is post-menopausal. But there's a lot of sort of behavioral interventions, which I've already

01:36:03.060 mentioned. And then more off-label would be cannabis. There is some pretty good data now that we have

01:36:09.600 in some states legal THC that opens up for researchers to study and investigate. And there's really

01:36:16.620 good trials talking about cannabis and your ability to have more satisfying sexual encounters,

01:36:22.100 but it is dose dependent. So when we think about cannabis, I'm probably an inverted U-shape.

01:36:27.060 It's inverted. Yeah. So it's specifically THC around one to two milligrams is the recommended

01:36:32.180 dose. Anything higher for some can be sedating to speak to your sort of inverse relationship,

01:36:36.840 which adversely affects your sexual experience and desire to participate. But around one to two

01:36:42.180 milligrams, patients report that they have more satisfying orgasms or have a hyper-awareness of

01:36:47.880 their senses. Sex drive is higher. It's quite significant in the data, much more significant

01:36:52.300 than the medications I've already talked about. And one to two milligrams. So is that through any

01:36:58.260 form? Edible? Inhaled? I don't know enough about. How do you dose inhaled? If this is an illegal

01:37:03.940 substance where you live, it is not a recommendation. If it is legal, there are safer ways to ingest THC.

01:37:09.960 Smoking, vaping obviously have a great impact on the lung or is, you know, incredibly worried about

01:37:14.500 that. One of the best ways to sort of dose adjust is to get name brand THC. So there are brands out

01:37:21.340 there that have unregulated, but arguably quite standardized dosing of gummies. And you can get

01:37:27.820 a one milligram or a two milligram or a five milligram. And is one milligram altering of senses at

01:37:33.620 all? Seems pretty low. Yeah, it's pretty low. For most people, it's sort of a heightened

01:37:37.660 sense response in terms of physical sensibility to appreciate orgasm, stay in the moment,

01:37:42.860 but not enough to cause paranoia or things like that. Munchies. Munchies. True for men and women

01:37:48.520 or just women? Both. Let's talk about pregnancy for a minute. What is happening to a woman's arousal

01:37:54.100 during pregnancy? Again, if you go back to my naive evolutionary view, now I can modify my view,

01:38:00.340 by the way. So my view would have been a pregnant woman should not want to have sex at all because

01:38:05.180 any amount of penetration puts the fetus at risk. However, based on what you taught me a few minutes

01:38:10.220 ago, there's another reason for her to have sex during pregnancy, which is to keep her male partner

01:38:15.180 around to protect her and hopefully their child. So I assume it's a balancing act of those things.

01:38:21.920 So how does that shake out in the real world? What do we actually observe about a woman's

01:38:25.900 sexual desire during pregnancy? And what are the do's and don'ts?

01:38:30.040 Complex, as you can imagine. And yes, that would be the evolutionary approach to it.

01:38:33.680 From a medical perspective, because I think it might scare some women to say,

01:38:38.240 oh, it puts the fetus at risk. To be clear, in a healthy pregnancy, in the absence of a

01:38:43.460 contraindication, a low-lying placenta, a low-lying blood vessel, or a cervical insufficiency,

01:38:48.880 which we would pick up on in routine ultrasound, sexual health, sex during pregnancy is completely

01:38:55.020 safe, totally fine, and has a lot of relationship and psychosocial benefits.

01:38:59.300 Is there a point late enough in the pregnancy where you would recommend a woman not have intercourse?

01:39:04.160 In the absence of a pathology, absolutely not.

01:39:08.120 Wow. Okay.

01:39:08.960 We know that for many women, sex during pregnancy can be quite intense in the pleasurable category.

01:39:17.100 The reasons for this are the neurotransmitters, right? You have super high levels of estrogen and

01:39:21.980 oxytocin, so that can make for a more pleasurable experience. There's more blood flow to the genital

01:39:26.840 area, so the contractions of the muscles are sort of more intense. The blood vessels are sort of

01:39:32.500 bringing more heat to the area. And then for some women, I wish this for all women to feel safe and

01:39:37.600 supported and bonding with a partner in pregnancy, but that's not the case for all.

01:39:42.620 Post-pregnancy, what do you advise your women? Let's start with vaginal versus C-section. So if a

01:39:47.840 woman has had a C-section, what do you think is the right time for her to go back to sexual activity

01:39:54.920 pending her desire?

01:39:56.800 We don't change the recommendation for when to resume sexual activity post-vaginal birth or

01:40:02.900 C-section. It's six weeks across the board. That's the time when you go see your doctor,

01:40:06.960 they check you out, they make sure everything is well-healed. It's uneasy for a lot of people to

01:40:11.960 say, well, gosh, why is it the same recovery time for both? A C-section is so much bigger.

01:40:16.840 The thought process is that by six weeks, you should have complete healing from the C-section

01:40:21.580 in the absence of complications. And we're more sort of from a hormonal physiologic perspective,

01:40:27.980 making sure that the uterus has shrunk down a significant amount, that you're not at increased

01:40:33.380 risk of infection by having things in the vagina. You're a good candidate to have contraception at

01:40:38.200 that time so we can provide you with protection from future pregnancies. But I think from a postpartum

01:40:43.580 perspective, reason number 15 why I loved your podcast and why I love Rachel Rubin, she recently

01:40:50.660 published on the genitourinary syndrome of lactation, which basically talks about the hypoestrogenic

01:40:57.260 or the low estrogen state of the vagina postpartum and how that mimics the pathophysiology of women

01:41:03.180 in menopause. And so for a lot of my patients who are breastfeeding, who have high prolactin,

01:41:09.400 who have low estrogen, I'm prescribing them the estrogen cream that I'm prescribing my

01:41:13.800 postmenopausal women to sort of keep the vagina as healthy and moisturized as possible.

01:41:19.040 Does an episiotomy affect the ability to resume intercourse after pregnancy or is that usually

01:41:24.980 healed by six weeks as well?

01:41:26.640 The hope is that it's healed, but unfortunately, pain from tearing in general or episiotomies,

01:41:32.120 which are, to be clear, out of fashion in the absence of an emergency, we don't do routine

01:41:36.860 episiotomies. The data is clear against those. But we do see that any sort of tearing or cutting

01:41:42.680 that happens, the vagina can lead to pain, which can lead to dyspareunia, pain with sex, and therefore

01:41:48.780 we have drive issues and sexual health issues as well. Another thing to think about from a

01:41:53.900 postpartum perspective is how these insults of pain can sort of manifest into something bigger than

01:42:00.260 they are. Participating in sex before you're ready and having a painful sexual experience can cause

01:42:06.260 tightening of the pelvic floor, rigidity in the muscles, and can set into motion a pain cycle that then

01:42:11.640 takes future pelvic floor physical therapy to break that pain cycle.

01:42:15.880 You alluded to sexual education a number of times. I have to be honest, I'm a little naive. I don't

01:42:20.500 really know what's being taught in sex ed. I don't even really remember what I learned in sex ed,

01:42:25.700 although I remember watching these really embarrassing movies on a VCR. That's about the extent of it.

01:42:30.660 But if you were sex ed czar appointed from atop the mountain, how would you design the curriculum?

01:42:38.980 How would it differ for boys versus girls? When would you initiate it?

01:42:43.760 If I were queen of sex ed, I would get away from the fear-based, don't get pregnant, don't get an

01:42:51.640 STD, you're going to get HIV, sort of fear-based counseling.

01:42:55.420 Aren't those things important though?

01:42:56.940 They are important, but there has to be some actual education in terms of pleasure and anatomy

01:43:02.940 and pathophysiology. This is not a podcast talking about the plight of women. As a mom

01:43:10.380 to four boys, I am equally committed that boys are as educated as girls are, and I care that my boys

01:43:18.480 care about the experience that their potential future partners might have with them. Women's

01:43:23.620 sexuality is complex. It's the anatomy you cannot see as well as you can see with men. Just sort of the

01:43:30.860 nature of the fact that when a bunch of boys are in a locker room, they can see other boys' anatomy,

01:43:35.620 they see the differences, they understand that that's healthy. Girls don't often see other girls'

01:43:40.080 vaginas as clearly as boys see other penises. And so normalizing through the labia library and

01:43:46.540 realizing what's normal and understanding the clitoral nerve for both boys and girls,

01:43:51.420 thinking about safe ways to sort of explore intimacy. If you don't provide them with informational

01:43:57.460 content such as OMG, yes, and teaching them about how to explore their anatomy, they will turn to

01:44:03.340 porn. And we have great data that almost all of the porn is not healthy for teens in terms of setting

01:44:11.140 expectations that are unrealistic, both anatomical and describing penetrative penis and vagina sex as

01:44:17.680 the way that women have screaming orgasms. That's just not accurate. And so it sets expectations for

01:44:23.240 encounters that are just not obtainable and leads to disappointment and self-confidence issues. So

01:44:29.360 I'd love for sexual education to be informative from an anatomical, physiologic, accurate,

01:44:35.640 pleasure-based perspective and talk them through how to have safer encounters.

01:44:40.540 You said you have four boys. So this is obviously near and dear to your heart.

01:44:44.120 What is the way in which you're going to communicate with your boys about this in an environment where

01:44:49.460 they're growing up in a world that you, me, your husband, we just can't relate to?

01:44:54.740 Made this point before, I think, with Rachel on the podcast. When I was growing up, porn was a

01:44:59.240 black and white playboy or something. It's a totally different thing. So what are you going to do? And

01:45:04.600 what is your advice for other parents out there who have growing boys and girls for that matter?

01:45:09.620 I think I don't distinguish the genders as much. I think education about all bodies should be

01:45:16.300 provided to all people. So first is using the correct verbiage and anatomical nomenclature,

01:45:22.360 calling a penis a penis and calling a vulva a vulva and normalizing this as a part of your health.

01:45:28.400 Masturbation is incredibly healthy. It should be done in a private setting and it's healthy. And

01:45:33.360 there's a lot about shaming masturbation and how that can put your child at higher risk

01:45:37.780 for issues in the future if you sort of shame their exploration of their body. It's normal. It's

01:45:42.680 healthy. It's a part of your health. Orgasm is healthy, but it should be done in a private place.

01:45:47.220 And sort of how you interact. What is consent? What are the components to consent? What does that

01:45:51.020 look like? Is it specific? Is it enthusiastic? Is it persist as the activity changes? Is there a

01:45:58.000 timeline on it? Thinking about all the different ways that we think about consent and then sort of

01:46:02.720 changing the way that society allows its perceptions to trickle into what we think of

01:46:08.480 in terms of safety? So for example, as a culture, we tend to say penetrative sex, penis and vagina is

01:46:14.400 the end all, top of the pyramid, most intimate act you can do with someone. But condoms are quite

01:46:20.800 effective at preventing sexually transmitted diseases when used in a penetrative sexual encounter.

01:46:26.080 People don't really use protection when performing oral sex, either women on men or men on women.

01:46:31.600 And so as we see the rise of herpes across college campuses, this is an intervention that we really

01:46:37.000 need to talk about. If you're at a party and you're with someone and you want to be intimate with them,

01:46:41.540 having penetrative intercourse with a condom on is safer and less likely to transmit a sexually

01:46:46.620 transmitted disease than if you're going to perform oral sex on each other. And so thinking about it

01:46:50.940 from a safety perspective and not a cultural perspective would be another sort of key foundational

01:46:55.740 change that I think needs to happen. And also sex education needs to change. Like what we talk about in

01:47:01.220 did you have sex education in college? What about grad school? What about perimenopause and menopause?

01:47:06.440 There sort of needs to be an evolving door in terms of different providers coming in and talking and

01:47:11.260 educating because our bodies change, our physiology changes, and our needs change. And this is not a

01:47:16.400 like eighth grade, one hour, split the boys and girls, talk about it kind of a thing.

01:47:21.500 Coming back to this specific issue, how much of an issue is pornography for young boys? And what is the

01:47:29.200 solution? Like it's not going to get regulated away. Although there are some states where at least age

01:47:35.440 verification is required. I don't know how effective that is. I mean, that's a step in the right

01:47:39.220 direction.

01:47:39.660 My strategy in general, when thinking about don't do this is always to do it. Don't do this,

01:47:44.880 do this. So it is sort of like introduce what you should do instead of what you shouldn't.

01:47:49.620 It's let's introduce something healthy. So what does a healthy sexual life look like?

01:47:53.800 The porn industry, there are parts of it that have evolved. There is healthier informational

01:47:59.320 videos that you can watch if you're looking for arousal. There are healthy ways to have an orgasm

01:48:05.140 to interact with another human being and talking about how you bring someone into your life that's

01:48:10.620 healthy and what frequency is healthy for both of you. And if you're not getting that, to what ends

01:48:15.620 do we go to get it elsewhere? And what are you searching for? Is it a dopamine release? What can

01:48:20.580 we add and replace of that neurotransmitter release that you're looking for?

01:48:24.800 Is there a crisis of intimacy in young people? I've heard this a lot, but again, I just don't know the

01:48:30.820 data, but I keep hearing that people in their twenties today are becoming less and less intimate

01:48:36.940 over time relative to a decade ago, two decades ago. So first of all, I don't know if that's

01:48:42.420 something you know. I don't. I sort of have the same anecdotal experience in my clinical practice

01:48:47.140 where I have very lonely, less intimate 20 year old women in my practice would have asked when I take

01:48:52.640 a sexual health history, which I always do, there is a lot lacking there. And it would be a whole

01:48:57.700 another podcast to talk about AI and how that's going to sort of, you know, replace intimacy and

01:49:02.960 how we can use that for arousal and things like that. It's something to think about.

01:49:07.740 So I guess final thoughts, what are you most concerned with right now as you think about

01:49:14.960 your professional world and what are you most excited about?

01:49:19.580 I'm most excited about the new information that we have coming in about hormone options in terms of

01:49:26.800 how we provide menopause hormone therapy and how we treat perimenopause and the new types of

01:49:33.220 estrogen and progestin and how we tinker with those and moderate those to optimize women and how they

01:49:39.820 feel. This is super personalized, super individualized medicine. And we want to do this as physicians.

01:49:46.000 We love doing this, but I think the more research that's coming out and the more drugs available

01:49:51.980 make it really fun to be a part of. So that's definitely my area of passion right now.

01:49:56.800 In terms of concerns, do I have to have a concern? I guess I just have another passion,

01:50:01.480 which is that I think the world is changing and I think people are ready for it. I'm ready to push

01:50:06.260 it there. You're pushing it there. I think it's really exciting to think about sexual health as a

01:50:11.820 part of your health and talking about it in a very sort of like generic safe place from a physiologic

01:50:17.560 perspective. Think about all the people you can get on your team to help you, sex therapists and

01:50:23.420 pelvic floor physical therapists and how to tinker with your hormones and behavioral interventions.

01:50:28.020 And I love thinking about couples listening to this podcast together and trying different things and

01:50:33.540 seeing this as potentially orgasm as another biometric or, you know, sexual satisfaction as

01:50:39.020 another sort of longevity lever that we pull when improving the happiness and health of our lives.

01:50:44.560 I think that's an awesome way to close this discussion. And I definitely appreciate the

01:50:49.700 optimism and lack of pessimism around it. So thanks again for all of this insight. I learned a lot

01:50:55.320 as is often the case with podcasts. So thank you.

01:50:58.440 Thank you for having me.

01:51:00.200 Thank you for listening to this week's episode of The Drive. Head over to peteratiyamd.com

01:51:06.540 forward slash show notes. If you want to dig deeper into this episode, you can also find me on

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The Peter Attia Drive - November 03, 2025

#371 – Women's sexual health： desire, arousal, and orgasms, navigating perimenopause, and enhancing satisfaction ｜ Sally Greenwald, M.D., M.P.H.

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