#371 – Women's sexual health: desire, arousal, and orgasms, navigating perimenopause, and enhancing satisfaction | Sally Greenwald, M.D., M.P.H.

Hey everyone.

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My guest this.

Week is Dr. Sally Greenwald. Sally is an OB GYN who specializes in women's sexual health from a hormonal and physiologic perspective with a clinical focus that spans desire, arousal, pelvic floor function.

Contraception, menopause and perimenopause care and evidence.

Based strategies to improve sexual well being. In this episode we discuss why sexual health is a core part of overall health and life quality for both men and women a practical framework for desire.

The accelerator and brake model and how.

Patterns change across life anatomy for sexual function, the clitoral complex and vaginal anatomy and why understanding it matters both for.

Men and women orgasm realities and myths.

And varied pathways to orgasm beyond penetrative sex vaginal tissue health lubrication, moisturizers and when local estrogen is helpful pain with sex, the common causes evaluation and a multidisciplinary approach to treating it perimenopause and menopause symptom patterns and the roles of estradiol, progesterone, progestins and testosterone contraception across the reproductive years and how different methods interact with hormones and sexual function Medications and adjuncts for low desire or arousal, including the FDA approved options and the realistic expectations around them the use of vibrators and other devices as therapeutic tools both solo and with partners when medications and substances help or hinder arousal and.

Orgasm, such as cannabis, THC, SSRIs and.

Practical strategies for use, pregnancy and postpartum sexual health considerations and safer sex practices and STI screening plus communication and sexual.

Health education around how to talk to your kids about sexual this podcast will have an immediate and obvious application and.

Interest to women, but I can tell you guys if you're listening. This is something you will want to understand greatly. I learned an enormous amount during this interview with Sally. And if you want to understand your partners better, this is definitely the podcast for you. So without further delay, please enjoy my conversation with Dr. Sally Greenwald.

Sally, thank you so much for coming out to Austin.

Thank you for having me.

This is a topic that on the surface might seem somewhat directed towards 50% of the population, but I think it's safe to say it's probably going to be directed towards 100% of the population. So you have a practice, you're an ob gyn, but your focus is not just on maybe the standard OBGYN things, but really around women's sexual health. Is that a fair assessment?

That would be a fair assessment, yes. From a hormonal and physiologic perspective, yes.

Awesome. Well, by way of background, we were introduced through a mutual friend patient who had listened to the Rachel Rubin podcast that I did recently, was super impressed by it and said, you have got to speak with Sally. And one thing led to another and we are now speaking. So let's start by helping people understand. Why would a podcast that focuses on health, longevity, all of these things that pertain to living longer and better, why would sex be an important part of that discussion?

Well, I'm having a hard time understanding how sex couldn't be a part of that conversation. First of all, this is a performance driven podcast. And so for the 50% of your listeners who are male, if you want to improve your performance, I'm going to give you facts and anatomical descriptions and describe some pathophysiology so that you can improve your performance. Clearly, sexual health is health. And when you look at your longevity levers and you think about your centenarian decathlon and what you want to do when you're a hundred, for many people, this is on the list. And I want to talk about how to structure your life and get you ready to do that. I also think that there's probably a small group of listeners similar to myself, who always thought that the drive was supposed to be about sex drive and that you just had a branding error when you named it the drive. So for those people as well, we're finally going to talk about the drive that you actually care about, which is sex drive.

So there's a lot to sort of unpack there. But I think I want to kind of go back and talk a little bit about something you said vis a vis the actual health component of this. If you looked at this through the lens of just evolution. Everybody clearly understands why sex is important and it's the single most important, important thing in the propagation of our species. But can you say a little bit more about how it actually factors into health? And I don't just mean emotional and mental health, where I think we could easily make that connection. Is there any evidence whatsoever that a healthy sex life plays a direct role in health as it pertains to disease?

Definitely. I'll start out with my two caveats though, which is one, this is an understudied, under investigated area of our health. That's part of my messaging today. So many of the studies that I'll reference are not going to be robust in volume. And second, this is a incredibly heteronormative conversation for that reason. This is a data driven podcast and I don't have a lot of data on non heteronormative, meaning men who identify as men having sex with women who identify as women. So that should alarm you as well that we don't have that data. But that's the space in which if we're going to stay in a data rich zone, that's where we have to stay. And also the discrepancy when you look at sexual health is greatest among those two participants. When we look at sexual health and we try to make the argument that sexual health is a part of health, we can sort of use your longevity framework. If we start with sleep, there is great data. We know that when you are sexually active, with or without orgasm, just participation in a sexual activity, you switch from sympathetic to parasympathetic. So post orgasm, you have a great activation of the parasympathetic nervous system. You release neurotransmitters, dopamine, oxytocin, These are relaxing neurotransmitters. And when we study it, either via diary or via great studies that look at resting heart rate, sleep latency, many of the measurements that we look to in terms of looking at sleep efficiency and quality subjectively and objectively improve with intercourse. What's really interesting and why I wanna pull in all listeners, not just 50%, is there was a great trial that looked at how women slept after an orgasm with themselves and they slept better. And then it looked at women being intimate with a man and they slept better. But women being intimate with a man and having an orgasm with that man synergistically improved their sleep. You're getting sort of a dual benefit of that neuropharmacology that you're releasing from your brain, improving your biometrics, but also There's a connection and intimacy, a partnership that we know fosters better sleep. Cardiovascular health. This is also limited. We don't have tons, but we know that sex can mimic a lot of the pathophysiology that we experience during exercise. There's been arguments over the decades about is it low intensity, is it moderate intensity? I think it depends on the couple. But we have studies that have tried to measure the mets or the metabolic equivalence, or essentially the energy output for women. On average, it's around six to seven metabolic units for every sexual encounter. It's about 60 to 70 calories used during sexual activity. And there's a great study that compared this to walking slowly on a treadmill for the same amount of time. And they said that although sex was slightly lower in your energy export than walking on the treadmill, many of the participants reported that they had a much better time having sex than they did walking on the treadmill. And so it's still something to consider. We know the net sort of tapping into the body's natural pharmacology, thinking about neurotransmitters and positive impact on mood and relationships. It's really interesting to think about from a relationship perspective. What I don't want to say, what I don't believe is that everyone has to have lots of sexual and that there's a number that we're trying to target. Is there a number needed to treat? Is there a dose that we're trying to go for? No, there's no studies on that. But I also don't believe that every person, every couple is different. When you look at couples, I like to look at who's having sex and by what frequency. And so about 20% of couples, and this is ages 30 to 60, about 20% of couples are having sex twice a week more. About 10% of couples are what we call never having sex. And that means in the last year, and about 70% of couples are having sex between those, meaning once a month, twice a month, sort of around that number. When you look at risk factor for divorce, it's the same across all numbers in the sense that it doesn't matter how much sex you're having, you could never have sex or you could have lots of sex. The divorce risk factor is what we call sexual desire discordance, or one partner wants more and one partner wants less. And so identifying that as the risk factor, I hope gives people sort of affirmation or interest in the fact that if you want to work on it, I will help you. But not everyone has to this is not a podcast about Everyone needs to go work on their sex drive. But if you do, I'll sort of go through the normal pathophysiology and some additional tips and tricks to help you have a healthier sex life.

All right, so two things I just want to reiterate that you've said that are both important and at least interesting to me. One is discordance of desire is a much bigger risk factor than anywhere you lie on the distribution of if I recall, 10% of people are basically asexual, 20% of couples are at twice a week or Greater, and basically 2/3 of couples are somewhere in between. So that's very interesting. Second thing you said, I can't resist coming back to the centenarian decathlon. I'm glad you brought it up because it is one of the items on our list on the framework that we hand to patients when we ask patients to pick the 10 most important things that they want to be able to do in their marginal decade in the last decade of their life. And I would say about 2/3 of our patients select having sex as one of those 10 activities. That says something, given that we're giving people a list of about 150 things to choose from, all of which are quite tempting. And to go back to your point about Mets, if 7 Mets is what is required energetically to have sex, we can convert that into VO2. So 7 Mets translates to about a VO2 of 25 milliliters per kilogram per minute. Which means if you want to be able to have sex in your marginal decade, you need to have a VO2 max of probably about 30 milliliters per kilogram per minute. Why? Because it would be pretty tough to have sex if you were doing it right at your maximum VO2. That would be like me asking you to do the fastest 800 meter run you've ever done and bring that level of exertion to sex, you gotta be a little bit below your limit. While most adults can easily muster a VO2 max of 30 milliliters per kilogram per minute, if you want to be able to achieve that in your 80s or 90s when you're my age or your age, you're a lot younger than me, you need to be probably north.

Of 45 or 50.

So if I could just make one more shameless plug for having a high VO2 max, it's going to allow you to be sexually active in the last decade of your life.

And I think in addition to that, it would be great if at the end of this, we had a list of a few sort of action items in addition to a minimal VO2 max that we could consider a toolkit in order to get this action as something that's actually attainable on your centenarian list.

Let's talk a little bit about. Let me ask a very silly question. When it comes to understanding what an orgasm means for a man, it seems relatively straightforward in that it's tied to ejaculation. And while there are examples where a man can have a retrograde ejaculation due to, example, the use of medication, and he can still have an orgasm, but you're not actually witnessing an ejaculation with women, how is an orgasm actually defined? Is it a biochemical response in the brain? Is it a muscular contraction in the body? Help me and help us understand that.

I think it's important to say that we're going to talk about normal things. Yes, there's a lot of pathophysiology and deviations to what's normal. And you should see a doctor and we can talk to you about it. But similar to sort of your focus on what's normal in men to describe what's most normal in women is a rhythmic contraction of the pelvic floor muscles. There's four stages to an orgasm. It starts with the excitement phase, which is an engorgement of the pelvic tissues. There's increased blood flow. There's lubrication released by the Skenes glands and other glands of the vaginal canal. Then there's a plateau phase that is predominantly a neurotransmitter phase and a hormone release phase. You can stay in that for a variety of time periods. It's person and partnership dependent. There's the orgasm, then there's the resolution phase. And these four stages. Understanding how they work and where you are in that stage can allow for the introduction of interventions that can improve your sexual life or help you foster a healthier life in general.

What is the period of time in which a woman will go from those first to fourth phases? Again, I realize there's gonna be a lot of variation, but what would be sort of considered interquartile range of that transit.

So it really depends when women are on their own. The average time to orgasm is less than four minutes. And when women are with a partner, it's upwards of like 21 to 25 minutes.

Question there. With a partner, you could still have it manual. It could be oral, it can be intercourse.

So how much does that really skews the data, I don't have the numbers on that. I don't think we have that. And women are actually individually so different as well. An interesting takeaway from your interest in looking at those numbers is to think about a statistic we do know, which is that foreplay lasting greater than 21 minutes over 90% of women orgasm. It's really interesting and enlightening to think about, oh, gosh, so time actually does matter in that stage. And why do we care about foreplay? What's happening during that time? That's when you're in the excitement phase, building up towards orgasm. So blood is flowing to the area. So we think about your anatomy changes. So the vagina that's usually like three and a half by nine, so three and a half inches wide by nine inches deep will actually get longer and wider. And why do we care? 30% of women will experience pain with intercourse. So actually appropriate foreplay, where the vagina not only gets wider and longer, but actually the angle of the vagina changes. And I think this is something that I love talking to couples about because I have many women who will say, you know, my partner loves this position and often it's a deep penetration position, but it really hurts me. And I say, well, how much foreplay is going on? And so if there's not enough foreplay, you don't actually change the angle of the vagina or change the angle of the canal. And so you will experience more pain. You'll have the tightness of the pelvic floor muscles. And pain fosters pain. You can get into a pain cycle. And so actually appropriate amount of foreplay, allowing the angle of the vagina to change can allow women to participate in positions most commonly we call doggy style or sort of deeper penetration positions, which can then be sort of a part of your repertoire, if you're interested in that.

So what about just the differences in ability to achieve orgasm, the so called orgasm gap? What can you tell us about that?

I hope I've proven to you that sexual health, pleasure, orgasms are a part of health. And so I think when we then look at the disparities in how different parties will participate or receive enjoyment out of these activities, I hope it highlights to you how important it is that we work on this. And so I'm gonna quiz you now, which is what percent of men, when they're having sex with a woman, report that they almost every time have an orgasm?

95%.

It's 95%. And what about women?

What percentage of women would report always Being able to have an orgasm with a male Partner.

Correct.

50%, 30%.

And what about for a one night stand? What percent of women are having orgasms on one night stand stands with men?

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

Yes, around 12%.

What about men at one night stands? Still 95%.

Correct. 90. Actually, I should say it's 90%. And so when we think about the orgasm. So if I've proven to you that sexual health is health and if we understand that orgasm is one metric that we can use, it's not the end all, be all, there's other satisfaction, intimacy, connection, pleasure benefits that women get out of intercourse. But this is one numeric finding that we can track. This disparity or this discrepancy is a big deal. And this, this disparity in how women experience pleasure becomes a health disparity. Because if sexual health is health and women are not experiencing it with the same amount of pleasure that men are.

This is a health disparity, by the way, within women. Does orgasm at all correlate with underlying health?

Yes, we know that orgasm is related to strength of the pelvic floor, vascular blood supply. So there are issues. So there's a lot of sort of bidirectional. If you're healthy enough to be able to have an orgasm, then you can have an orgasm. And if you're having orgasms, you're likely healthier. So there's a lot to that. And we know that bidirectionality. But I think still looking at the numbers, I'm hoping that you're thinking, my gosh, this matters. This is a big deal. We should, we classically think about sexual health as sort of an afterthought. When we think about longevity, we think about cancer screening and prevention and chronic diseases, and now sleep and exercise. And once we've sort of addressed all of those, we now have the luxury of addressing sexual health. And I just think we should put it a little higher on the list.

Okay, so let's talk a little bit more about foreplay. When most people hear foreplay, they assume what Anything that is sexual shy of intercourse. How do we define foreplay?

There's medical definitions of foreplay in social. So social definitions tend to say anything outside of penetrative intercourse. Medical definitions rely more on the physiologic changes that are happening in your body. Increased blood flow, recruitment of swelling of the clitoral nerve, physiologic signals from your brain that sort of prepare you emotionally to participate in this interaction. What's most interesting to me about this is when we think about, let's start with desire, we think about socially men's desire. So men's desire is what we call spontaneous desire. And I use men. This is sort of, I should say, less sweeping statements. I should say when we think about desire, we think of more of the spontaneous desire. Spontaneous desire is more common in men. Spontaneous desire is only present in about 15% of women. Women have what we call responsive desire. So spontaneous desire is you've been married for 20 years, you see your partner get out of the shower for the 8,845th time and you think to yourself, gosh, I would love to be intimate with this person. That's spontaneous desire. That's sort of desire in anticipation of intimacy. Responsive desire is you see your partner get outta the shower for the 8,645th time and you think, did I sign up for the right treadmill tomorrow morning at 6am and that's because your brain's just not there. It's not in the same place as your partner. But if your partner comes over and starts to rub your shoulders and rub your feet or maybe has made dinner. We call chore play, which is where sort of emotional investments in the relationship can sometimes lead to responsive desire using lubrication. And we'll talk about how to use lube using a vibrator, sort of creating an environment in which you are capable of being aroused. That's responsive desire. And thinking about what's happening in that circumstance can be really helpful and validating for women. And it can help their partners get them there too, with the ultimate goal of sort of being aligned in your sexual desire from a frequency perspective.

So you're saying it's more typical that men experience spontaneous desire where arousal comes on in a moment, in anticipation, in anticipation. And often based on perhaps a visual cue.

Correct.

For women, that is less common. But not implausible.

Correct. And so acknowledging that there's a few sort of lessons that we can take from that. The first is if you're listening to this podcast and you want to work on your desire, if you're waiting for your husband to get a new shirt or a new Selby or anything, the visual stimulus is not evidence based on stop waiting for that.

What about getting a new car?

I'd love one, but. No, but just to be clear, I would love one. I want you to think about how you get responsive desire in response to arousal. And how we do that is lubrication. So we know how to use lube? Most of us do. You're in the act, you take some lubricant, you put it on the penis, you put it on the vagina, you have intercourse. I want to sort of encourage you to think about lube, potentially using it 30 minutes prior to intercourse. So I want you to take a silicone based lube and I'll tell you why in a moment. And I want you to think about using a lube shooter, which is a little droplet, to take some of the lube and put it higher up in the vaginal canal. And then I want you to read a book, drink a cup of tea, wash your face. Women, as you sort of alluded to, are less visually stimulated into desire. There's great data that women like to read erotic literature and there's great apps for that. Meet Rosie. Dipsia are great companies that have auditory or literature porn for women. There's great data that mindfulness can work for women. Lori Broado wrote a book called Better Sex Through Mindfulness, Thinking about breathing techniques, staying present in the moment. My favorite strategy for this is to describe to yourself in your head, not aloud, what's happening. Breathing is relaxing. My vagina feels wet. Sort of talking yourself through what's happening from a pathophysiologic perspective to bring yourself into the moment. But when we think about how to curate that arousal, essentially what you're doing is showing up at the party and then seeing what happens. And there's no expectations what happens at the party. But Emily Nagowski, who wrote Come as yous Are, talks about it's Friday night and you really want to put on your bathrobe and watch Love island, but instead you're going to go to a party with your friends because you said you would. And you get there and it's actually kind of fun. So you stay, you have a good time, you have a drink, you actually like it when you're there. That's the sort of idea behind curating your own desire through arousal, which is use a vibrator, use some lubricant, relax, get in the moment, start to participate. And if you don't want to, obviously consent is of utmost importance and stop. But if you sort of start participating and decide that you're happy that you're there and you like it, please stay and have a good time.

Okay, a lot of questions come up when you said all those things. Let's start with the need for lubrication. I very naively have assumed that women who are young enough so not even approaching estrogen withdrawal are not having an issue with lubrication. That clearly must be incorrect or you wouldn't be stating this. What can you say about perhaps the differences in the amount of lubricant and maybe even just talk a little bit physiologically about what is the lube that is naturally made, where is it coming from, and what drives variability both across women and within a given woman's life. Let's not even talk about it within her life within a given month or something like that.

You're correct with that line of questioning to sort of assume that throughout the month women will have different levels of lubrication. Medications can impact lubrication, life age, life cycle. There's so many factors that go into your ability to have the amount of lubrication that you need in order to have a comfortable sexual encounter. This idea that we just use lube, need lube as we age, I want to completely dispel. I think the majority of women need lubrication and should use it. The way that we sort of naturally get lube in our vagina is from a variety of different glands that work better or worse. There's the Skene's glands that sort of support the vagina, which are where they're right on either side of the urethra. And fun fact about this, many people will have more prolific Skene's glands in the sense that they can shoot the lubrication a little bit stronger. So when we sort of talk about women who what we call squirt, it's actually the Skene's glands releasing lubrication in a more aggressive form. There's Bartholin's glands that produce lubrication that are commonly known for their likelihood to sometimes get clogged and to cause pain. But there's so much that goes into lubrication, and it's so important throughout the life stages that the who, the World Health Organization, actually has guidelines in terms of how to pick out your lube. And if you're wondering right now, wow, I never knew that the WHO cares so much about my sexual life. That's wonderful. They don't. They care about HIV transmission. And picking the appropriate lube decreases microabrasions, less friction, less tearing, less HIV transmission. But we can sort of take this data into the pleasure world and think about sexual health. So what types of lube should we use, I think is the next part of that question.

Well, actually, I want to go back and ask a different question, which is, isn't there sort of a min max optimization problem around lube. Because friction is also part of what is necessary, at least for the male to have an orgasm. How much does it matter for the female?

Less so. Friction matters. Less so to women. And let's talk about the clitoral nerve anatomy. To answer that question, I'm going to leave this for you as a gift.

I'll keep it on my desk.

It's pure gold, so you may want to put it in your safe. But this is sort of the anatomy of the clitoris. And what you're looking at is what we tend to discuss in terms of clitoral anatomy. Typically, we talk about is the tip of the iceberg or the clitoris. There's the crew of the clitoris and there's the vestibule, which is an engorgement structure. When blood comes to the area, your labia minora would be here and your labia majora would be here. This would make up the vulva. When we think about the clitoral nerve, it actually has two types of nerve fibers in it. One is a type A nerve fiber, and one is type C. Type A responds to vibration and it responds to deep pressure. And type C responds to heat and light touching. So A is vibration and deep pressure, and C is heat and light touching. What's really interesting about using this to answer your question is that friction is not a requirement to hit any of those four metrics and actually is so significantly associated with micro tearing and pain. With the 30% of women experiencing pain with intercourse, I would argue that women need no friction.

No friction.

But to think about how that nerve changes over time is really fascinating. Because type A fibers, the vibration and the deep pressure, they have a myelin sheath around them, and so they age better. Nerves protected by a myelin sheath are more resistant to degradation.

And that's the A fiber, and that's the A fiber.

And so I have women come in to my clinic and they say, I've been with my partner for 35 years. We do this position for six minutes. It always works. It's not working. And I say, have you considered using a vibrator or introducing a vibrator into your sex life? And there's a, oh, I don't know if my partner would feel good about that. And I sort of say, this is an evidence based intervention. Understanding the science of myelin sheaths and nerve degradation. This has nothing to do with your husband and nothing to do with your relationship.

How would you do that? So if a woman comes in and says, in this position, it's exactly as you just said when you're saying introduce a vibrator, do you mean use it after or before or during?

I see.

So put the vibrator externally.

Externally, got it. And there's different types of vibrators. Some are internal. But if you're trying to pick a vibrator that you want to use when you are with a partner, buying something like a wand is long enough that you can reach the structure in a variety of positions. Jimmy Jane makes a nice wand goop. The wand makes a great product as well.

Did you bring any of these long.

Discussion with your staff about what you wanted laid out on the table and that net was. No.

That might have been a strategic error. I think people at least I'm kind of curious as to what these products are. We'll link to them in show notes.

That sounds great. There are air pulse vibrators that you can put on the clitoris. These are sort of all external vibrators that you can sort of bring into a partnered encounter to have an evidence based way to continue to achieve orgasm. Because that is one of your greatest ways in which you can continue to mean a healthy sex life.

Again, not to get too graphic, but just because if I'm asking this question, I'm sure someone watching this is if you're talking about a sexual position where the man is on top of the woman and she's using an external vibrator, does the man also receive some pleasure from that?

He might. And there are more strategic ways that you can try to do that if the man likes that. But there's ways that the man can angle his pelvis that he doesn't have to.

He doesn't feel it.

He doesn't have to.

Okay, I want to go back to something about the female ejaculation. All of that ejaculatory material seems external.

Some is, some isn't.

Yeah. So how is the vagina being lubricated inside?

So they've actually studied this. The Kinsey Institute has great studies where they put cameras inside the vagina and they actually watched the vagina essentially sweats. The cells of the vaginal canal release water molecules. There's cervical mucus that also serves as a lubricant as well. Again, all of these things very dependent upon hydration and medications and things like that. So you can understand the importance of sort of making sure it is appropriately lubricated through the use of external lubricants. But yeah, there's many different ways. So the vagina sweats the cervical mucus and then the glands that secrete mucus into the canal.

And for women who do experience that ejaculation, that's perfectly normal, do they have control over that?

Most people think that they do not. Most people think they do not. In terms of like how much you're more hydrated, if you're more relaxed. But no, in general, people do not believe that it's a normal physiologic response.

That you cannot control and it doesn't imply a better orgasm?

No.

And what was the frequency again of women who achieved that squirting?

I actually. I don't have statistics on that. I don't know.

Okay, maybe a helpful thing to do right now would actually be to go over a little bit of the anatomy. And I see that you brought a model that I think will make it easier for everyone to kind of understand. So I want to start by asking, when you deal with your female patients, who presumably are much more familiar with this anatomy than men are, what surprises you the most? When a woman comes into your clinic and you're taking care of her, what are you most surprised by in terms of her lack of knowledge about her.

Own body, Anatomical lack of education, just literacy. From a. Where was the sex education? Did we have it? Did we go. I mean, from a verbiage perspective, referring to the vagina as the vaginal. That's the vaginal canal is the vagina. The vulva is the outside of the vagina. There's labia majora and minora all the way down to the clitoral nerve and sort of the fact that it has different nerve roots. And so if we think about looking at this model, this is sort of if a female is lying down on her back, that's the angle that you're looking at. There was a great study that was done recently that said that only 41% of Gen Z men could accurately identify the clitoris on a pictorial.

What would that be for Gen X? Like how much of that is a representation of declining intimacy as younger generations? Or is that a general statement of men, period?

I take from that sex education needs to get better. I mean, I sort of take from that the need for better sex education that's actually anatomical and not fear based. And so women as well, I mean, most women, not all do know about the clitoral hood, which is the clitoris or the bulb. That's what we sort of think about in terms of the tip of the iceberg. But what women often don't know is that they have sort of what we call the vestibule. Of the clitoris, which are these bulb like structures that can receive engorgement or when there's an increase in blood flow. And then there's the crew of the clitoris, which is these nerve structures that go on either side of the labia minora. It's a wishbone like structure. And what's really fascinating is to sort of normalize that anatomy can and should look different. There's a great website called the Labia Library that normalizes all different types and sizes of labia minora and majora. But the wishbone structures are often asymmetric as well. And so it is quite common for a woman to experience greater pleasure on one side of the vagina versus the other. Meaning that this nerve root of the clitoris may be thicker or more sensitive. There's over 8,000 nerve roots as a part of the clitoris and there can be more focused on one side versus the next. And so I hope that half of your listeners are thinking, I always wondered why I was a righty or I always, yeah, I'm a lefty. I also Hope the other 50% are wondering if you've been with your partner for a long enough time. I hope you know if your partner is a righty or a lefty, because there's asymmetry in how we experience pleasure. And then very interestingly is that there is, if you're sort of looking at the tip of the clitoris, There's a nerve root, there's a part that goes sort of inside the vagina. And that's what we talk about in terms of social terms. We talk about the G spot. What that is, is it's a branch of the clitoris that runs along the anterior or the front part of the vagina. It's about a third into the vagina. The best way to find it is if a woman is trying to find it on herself, is to take her dominant hand, middle finger, stick it as far in as you can, and sort of do a come hither movement or sort of movement of the finger towards the top part of the vaginal wall. It's easier to find when you're aroused because there's engorgement of the tissues. It feels a little more rugated. And you'll know that you're there if you feel a sensation to urinate. But if you relax into that, you won't. And so only about 10% of women now are able to orgasm from stimulation of that internal branch of the clitoral nerve. There's some data that shows that with education that can go up. And so talking to women about how they can find the anterior branch of their clitoral nerve not only allows them different ways to orgasm, but also gives them a sense of empowerment and sort of ownership to sort of talk their partner through how to maintain pleasure. But for those people who can't have orgasms from the inner part of their vagina, the other 90% are having orgasms from external stimulation of the clitoral nerve. And so Dr. Lauren Stryker says, for the 10% of women who can orgasm via the G spot or the anterior branch, that's great. And she diagnoses the other 90% who can't orgasm from stimulation of the internal nerve as normal. So it's totally normal if you can't have an orgasm from that part of the clitoral nerve. But many women, after hearing this podcast, I hope try partners should try it has better blood supply than the tip of the iceberg. And so as we age, this is one of my favorite techniques for women in the perimenopause and menopausal period, as their hormones change and the nerve fiber degrades a little bit, Teaching women how to have orgasms from the part of the nerve that has better blood supply can help maintain pleasure and help maintain interest in sexual activity as we age.

All right, so when a woman is having intercourse, and maybe for the percentage of guys who might not be familiar, can you point out where the entry to the vagina is on this model?

Yeah. So here's entry to the vagina. There are some statistics that talk about what percentage of women can orgasm simply by having penetrative intercourse. So penis here. And what's interesting is that the distance of the clitoris to the vaginal opening is variable. They tend to say less than 1 inch. The shorter the distance of the clitoris to the vaginal opening, the more likely you are to be able to orgasm during penetrative intercourse. And that's because the distance is so short that the angle of the man's body is sort of able to stimulate that area. If that distance is greater, you're less likely to be able to orgasm simply from penetrative intercourse. Cue introducing a vibrator, manual stimulation, et cetera.

So what percentage of women are able to intercourse without any stimulatory vibrator or anything like that from intercourse?

Less than 10%.

Wow. So it's the same number that you have from the G spot.

Correct.

So if a woman is listening to this and she's never had an orgasm through intercourse, she is in the 90%, there's nothing wrong with her.

We would diagnose her as normal.

And for those women out there who are regularly achieving an orgasm through intercourse, you're in the minority. And.

Or they're doing external. More likely they're doing external stimulation of the clitoris. Those grave statistics are without any external manipulation of the clitoris. So for women who are achieving orgasm with a partner, it's because they've identified positions with their partners. They're using manual stimulation, they're introducing vibrators. They've figured out, regardless of distance of clitoris to vaginal opening, how to stimulate the clitoris, the external part of the clitoris. And I like to talk about anatomy so that patients can sort of think about their own individual anatomy, talk to their partners about it, and think about if there's someone who needs to sort of introduce that external stimulation, or shall they, as a couple, just try to find the anterior branch of the clitoral nerve. There's lots you can do as a part of that.

How often do you have men in your practice who are there with their female partners who you're trying to educate.

For a sexual health consult? 20% of the time.

And what is the most common. I don't want to use the word ignorance, but what is the most common thing that you appreciate about men when you're helping them in terms of their lack of understanding about their partner's anatomy?

Giving men a roadmap, being very descriptive. Most partners want their partners to be happy. It's not. There's the selfish aspect of performance and there's the sexual empathy component where they care about their partner and they want their partner to feel well. Giving them a roadmap to sort of explore around and find the anterior branch and think about the wishbone structures is really exciting to them. Spontaneous desire. Thinking through that is really exciting for them. How they tap into that, how they can curate that with their partner. Thinking about their partner's arousal and then sort of supporting. There's a communication component. I think when we think about sexual dysfunction, we tend to break it down into a biopsychosocial model. I like to talk mostly about bio. I'm a clinical physician, I'm a gynecologist. So I think a lot about anatomy and pathophysiology and neurotransmitters and hormones. But there's a lot of other people in this field that are helping with the psychosocial sex therapists. Communication. There's a great book called Sex Talks by Vanessa Marin, which talks about how to communicate with your partner. Clitorit is a great book to think through. Different ways that you can sort of improve your communication about what pleasures you and how to investigate that. There's really good websites now. OMGYes.com is a website that talks about your anatomy and how to find it and how to find your pleasure spots. So there's a lot out there. I'm not alone in this space by any means, but I like to think about it from a very biologic physiologic perspective.

Talk to me about. You mentioned a moment ago, for example, that a number of women are able to have an orgasm during intercourse, but it requires them using their own hand. For example, how much does a woman control her ability to have an orgasm by the way she positions her pelvis?

Female dependent and dependent upon your own anatomy. So in thinking about how far your clitoral hood is from your vaginal opening, thinking about if you're a lefty or a righty, understanding your anatomy, exploring your anatomy can help you sort of figure this out and talk to your partner about it. So yes, there is a good amount of control that women can have over this, but the first step is understanding their own anatomy.

Is it a myth that if a woman uses a vibrator regularly on her own, it makes it harder for her to have an orgasm with her male partner unless she becomes dependent on using it as well?

It is a myth in the sense that there is data on either side. And so there is some data that talks about if you sort of acclimate to sexual practices that you cannot bring into a partnered model, then it may be harder to have orgasms in a partnered situation. But if you are comfortable using whatever technique you find upon your own time, and you can bring that into your relationship, then you're more likely to have orgasms. And so thinking about whatever it is that you're doing, and however it is that you're doing it, if you can inject that into your life with your partner, you are more likely to have orgasms. There is really good data that orgasms beget orgasms. Meaning, like, the more orgasms you have, the easier it is to have an orgasm. In terms of training the system, sort of learning, your body's response to stimuli can be trained, your body's response to things can be trained. And I think from a going back to sort of how we could use this from a desire perspective, there is good data that sex begets sex, meaning the more sex that you have, the more sex that you want. And so I talk to my Patients about scheduled sex as a way to sort of work on your desire. And most of my patients, when I bring up scheduled sex, are like, oh, my God, another thing I have to do, like, ugh, what a hassle. I point out the fact that you've always scheduled sex when you met your partner, and your partner said, what are you doing Friday? He was scheduling sex with you. And when you said, sushi sounds good, and you shaved your armpits and put on a nice T shirt, you were planning for sex. So you were prioritizing your sex life in a way. And so scheduling sex is a great technique that we use. How that sort of rolls out depends on the patient and what frequency they're going for. But I have my patients do what I call fuck it, February, where I essentially have my patients having sex, scheduling sex two to three times a week for the month of February. It's a romantic month. It's the shortest month of the year. And this takes pressure off of patients. Wondering, the person who's been the initiator sort of gets to relax and not have to worry about rejection. And the person who has been less interested knows that they're sort of working through an arousal pathway. They're working on responsive desire. And scheduling just means that you'll show up. You don't have to have sex, but you just show up and you try it. And there's great data that sort of, after a month, women will sort of have that maintenance of their increased desire, and they can sort of ride on that for a couple of months.

You mentioned earlier discordance as an issue. Discordance of desire. How often is the discordance in one direction versus the other? So how often is the discordance that the male wants more than the female and vice versa?

I wish I had a specific number for you. We can probably look that up and put that in the notes. But anecdotally, I'll say it is most often the male has a higher desire than the female.

Does it say anything about the couple.

If it's the reverse, I, anecdotally, as well, have the reverse as well. And there's so much that goes into this in terms of the partner's health status and chronic diseases and stressors at work. So there's a lot to sort of think through, and it can go both ways. But by far and large, it is predominantly the male with the stronger sexual desire.

And so, on the topic of sexual desire, because this podcast is called the Drive and we're talking about cars, what's the Throttle. And what's the brake pedal on sexual desire for men and for women? And I assume it's different.

I would assume it's different, too. I never talk about men because I'm not an expert in men's sex lifespan. I'll recuse that to the next guest. But when we think about women, we think about accelerators and brakes. It's a common framework that we use from a social, behavioral perspective, like what helps you feel relaxed and what turns you off. But from a pathophysiologic perspective, we think about neurotransmitters. And so accelerators from a neurotransmitter perspective would be things like estrogen and testosterone, nitric oxide, dopamine and oxytocin. And those five neurotransmitters are in a complex interplay to sort of tell our brain and our body through a variety of different pathways, I'd like to participate in intercourse. Estrogen is very interesting because although we know, you know, there's different types of estrogen receptors throughout the body, but when it comes to sex drive, we think about alpha receptors, which stimulates sex drive, and beta receptors, which decreases anxiety and inhibition. But it's not as clear cut when we replace estrogen. It's not a slam dunk that, you know, you cannot make the connection then that, oh, so if I replace estrogen as it's dropping, I fixed my sex drive all as well. Testosterone has a little bit more of a direct link to that. So when we think about, for example, the postmenopausal female, and I'll use the term menopause hormone therapy over hormone replacement therapy, and I would be so excited if you switched your nomenclature as well. But I think when we think about postmenopausal women, we think about menopause hormone therapy replacing estrogen. We sometimes do see an improvement in sex drive, but that's usually through an indirect pathway. You're sleeping better, you have more energy, like you're not having as many hot flashes. So we'll see sort of an indirect improvement in sex drive. Testosterone is well studied for hypoactive sexual desire disorder or a decrease in your sex drive. To meet that diagnosis, you have to have a low sex drive for more than six months and you have to care. Not your partner cares, but you have to care. And if you meet that diagnosis, testosterone is very well studied in terms of its benefits on your sex drive.

What is your preferred method for administering testosterone to women?

I prefer a cream. So I do also prescribe Testim, which is an oil and that's where I will sort of get resealable packets. I'll put it into a empty syringe, the kind that we give our children Tylenol with, not an actual needle syringe. And then you can administer 0.5cc and rub it on the inner thigh is my favorite place to do it. I do a lot of compounding cream. I use Koshland Pharmacy. They have a pretty standard like well mixed formula. And I'll sort of use. I'll prescribe a testosterone cream where the patient will use a pump a day. When they get out of the shower, they'll let it dry for 20 minutes and then they can put on there and get dressed.

Do you think the oil is more efficacious and consistent in its absorption than the cream?

I don't. I do follow labs when prescribing testosterone. So anecdotally and from a lab perspective, I don't find a difference. I'm interested in what you say. I sort of go mace to UP based more on patient preference. If they want an FDA approved product, although it's not FDA approved for women, then we'll go ahead and use the Testim. If they don't, I much prefer to just compound it. It's cleaner, it's less messy, it's easier to dose. There's so many dosing issues with the oil in terms of how we dispense it when it's not supposed to be dispensed. For women that I much prefer the cream. How about you?

We use a cream more typically.

Yeah, I don't use intranasal. I do use intravaginal, but sort of in the form of dhea. I use a lot of intrarosa. Intrarosa or prosterone is sort of a metabolite that can ultimately come down the testosterone estrogen pathway. I will use that. That's for pain of the vagina. But when it comes to sex drive and desire to administer testosterone, mostly cream.

Do you target a specific level for total testosterone or free testosterone, or are you just basically saying I want to get it above a certain floor and then symptoms determine where we end up.

I want to get it above 20 in terms of total testosterone.

Wow, that's a low floor.

It's very, very low. And then I use symptoms. So for example, 20 to 80 would be the range at which I'm interested. I predominantly use symptoms. The guidelines in terms of how to titrate it are not clear. Anecdotally, I'll have patients at 80 who have no benefit to their sex drive, I have 20 who see a great benefit. So I want to see like some sort of modest improve, improvement in their testosterone and then interview see how they're doing.

Given how much variability there is in men with androgen receptor density, I think we have a pretty clear sense that in men levels don't tell you much unless you're below 350, 400. If you're below that level, you're really going to be hypogonadal. But men can be replete at 600 and other men might not be replete till they're at a thousand. And again, it just comes down to AR density. Do you have any sense of how.

That works in women other than it's incredibly complicated, as you alluded to, but more so in women because most women who are on testosterone are also on estrogen. And we know that estrogen increases your sex hormone binding globulin quite significantly. Sex hormone binding globulin being that protein that sort of runs around and gobbles up free androgens or testosterone. And so because I'm prescribing estrogen and progestins actually have the ability to blunt or mitigate that increase in the sex hormone binding globulin. The more androgenic the progestin, the more mitigating effect on that increase in sex hormone binding globulin. This is my true passion in sort of thinking about hormones and contraceptive and menopause hormone therapy and sort of tinkering with hormones, because some of what you do will help the sex drive, some of what you do will hurt. But the addition of the two variables of estrogen and progestin make this incredibly more challenging.

As you know, we talked about this at length with Rachel Rubin, but I think it's always worth rehashing. How do you like to initiate estrogen, progesterone and testosterone use in a perimenopausal woman who is obviously one of the most difficult to treat because she still has waxing and waning natural levels of all of those hormones, but during her nadirs is typically pretty debilitated by the symptoms. What is your playbook on that? Which is obviously pretty challenging.

I love this topic because it's so different. It's so different for each woman in terms of how she responds. The first question that I try to answer in my interview with my perimenopausal patients is, do you like ovulating or not? And that's the sort of first branch point at which I sort of decide how I'm going to approach this patient.

Let's just stop on that question for a second. I've never really thought of that question, obviously being someone who's never ovulated. But tell me why that question matters and why would a woman know the answer to that question? At the risk of sounding naive.

So I'm going to answer this from first a sexual health perspective and then a general health perspective. Some people, when their sex drive is higher around ovulation, they love it. They like the benefit that ovulation gives to their sex drive. There are times in the month when they have a great sex drive, they ovulate and they feel good. Similarly, the first half of your cycle, when estrogen is climbing right before ovulation is a high performance part of your cycle. So these women who like to cycle feel good the first part of their cycle, they feel great. Right before ovulation. There are a lot of biometrics that are peak right before ovulation. Your memory is stronger, your energy is stronger. I have a few Olympic athletes in my practice and we will figure out when their events are and we will try to figure out their ovulation so that they are competing in the first arounds, day 9, 10, 11, 12 to 15 of their cycle. Because right before ovulation is where they can lift the heaviest, they can run the fastest. I'd love for you to do a study on VO2 max throughout the cycle. Super interesting. It's really interesting. When you look at the metrics that we care about, many of them are peak.

Sorry, just to be clear, at that moment in time, her estrogen is pretty much at her highest. Progesterone is very low. Low testosterone is high.

Correct.

So does that mean progesterone is a performance inhibiting hormone or does it mean that estrogen, because obviously testosterone is a performance enhancing hormone, does it really mean estrogen is performance enhancing? Progesterone is performance inhibiting because in the luteal phase you would also see high estrogen, but you now have high progesterone.

Not as high estrogen, but you're correct. At the risk of boring anyone listening to get a little more academic about it, you're really talking about a progestogen is there's estrogen and there's progestogen within progestogen, there's progestins and there's progesterone. Now, natural progesterone, we know which is what's in your body is progesterone. Yes, it is a sort of rest and digest a low energy Phase A preparation in case helps with sleep. But in terms of the progestin, prepares.

For implantation, prepares for pregnancy.

Exactly. In terms of the progestins, which are a synthetic class of progestogens, we then think about what is the family that this was derived from and the side effects can be very, very, very different. And I think about that in terms of what pills I will prescribe my patients. But to bring it back to the question, I essentially through interview, and this is where the patient can really advocate for herself. For patients who are listening. We care doctors. We've worked our butts off to get here. We deeply care about helping you, all doctors do. But you coming in with great symptom tracking and timelines and relations to bleeds and things like that can really help us understand through interview whether you're someone who feels great because of ovulating or whether you're someone who really suffers from pms. Premenstrual syndrome, has it turned into premenstrual dysphoric disorder where it's pms, but now it's impacting your life. There's so many reasons by which you would say I actually feel terrible cycling. I would prefer not to. But that's the first branch point when I have a perimenopausal woman.

And just gimme the divide there, Sally. What percentage of women who are, let's just call it 44 years old, 45 years old, will respond to that first question as, yep, I really enjoy ovulating. Let's keep it up versus let's make this go away.

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

Okay.

This is the 45 year old who's like, I used to be really short tempered with my kids the day before my periods and now I'm just the whole week before I'm really short tempered. All of the symptoms of low estrogen, hot flashes, vaginal dryness. I have all of these hypoestrogenic symptoms. Perimenopause is your brain is yelling at your ovaries to please do one last ovulation. Listen up. So you have this sort of hyper stimulation of signaling, a hyper responsive FSH follicle stimulating hormone. So much so that you can get a loop event which is a luteal out of phase event where essentially you ovulate twice. Your FSH is so high, it's so busy yelling at your ovaries that your ovaries are like, I heard you and I heard you again. And they Essentially double ovulate. And that's that story where you'll have long cycle and then a short cycle and then a long cycle. So these are all clues that you don't like to ovulate. And so if you do like to ovulate, let's go down that lesser travel.

By the way, you're the first person besides me who I've heard use the yelling analogy. I'll never forget 10 years ago, I was sitting down with a male patient. He came in and he had a pretty high testosterone. It was not very high, but it was probably like 7 or 800, which for his age was actually pretty high. And his FSH and his LH were 2x normal and he wasn't taking anything. And I was like, this is really interesting. And he's like, why? And I sort of drew him a picture and I said, basically, your pituitary gland is yelling, it's screaming at your nuts and they're really responding. I forgot about the statement. Six months later, a year later, two years later, he keep coming back with that. At some point I started taking care of one of his friends. His friends told me about it. They're like, he's really been bragging about this. I'm sure women do not go and brag to their other friends that their pituitary glands are screaming at their ovaries. But that's a guy thing. A guy would brag about that.

I would agree with that. What women do do is they're walking around the block with their protein sh, they're doing their thing. And you have one 46 year old, average age of perimenopause being 46. You have one 46 year old saying, gosh, I feel so great. I'm on a birth control pill and I just feel so great. And the other 46 year old's like, me too, I'm on menopause hormone therapy. I just feel so great. And then they look at each other like, why are you on that? And the heart of this for me is who likes to ovulate and who doesn't. And from a sexual health perspective, understanding is your sex drive and all the other things that make you happy and feel good, which ultimately go into your sex drive. Do you want to ovulate? And if you do want to ovulate, then we can think about, do you need contraception?

And sorry, just go down that branch point again because you just made a distinction that I don't know that every listener will understand. You just talked about oral contraceptives, which are hormones and then menopausal therapy, which is hormones. Can you explain why that branch point is different? In response to your question, menopause hormone.

Therapy, the dosages do not suppress the gonadropin pathway. And so when you are on menopause hormone therapy, you still ovulate. If you're gonna ovulate, you still to.

Still ovulate through it.

Yeah. Whereas contraception, many forms of contraception suppress ovulation, but not all forms. To be clear, when talking about contraception and how it affects your sex drive, we talk about ovulation and how women's sex drive can be ovulation dependent. Remember though that we've looked at how suppressing ovulation impacts your sex drive and the data shows they've great meta analysis of 32 trials and it looked at over 14,000 women and it said that 20% of women who suppressed ovulation still had an increase in their sex drive, 65% had no change in their sex drive, and 15% had a decrease in their sex drive. So I don't want you to think that by choosing some form of contraception that suppresses ovulation, you know, will absolutely have an impact on your sex drive. It's so multifactorial and safety from pregnancy can be so reassuring for patients that that's definitely not the case. And when we think about how hormone pills can impact your sex drive, we think about sort of the twofold suppression of the hypothalamic pituitary access in terms of suppressing your hormones downstream and you're therefore ovulation, but also going to your ovaries and shutting them down, which then decreases their production of testosterone. So even though, yes, we have biologic plausibility for how contraception impacts your sex drive, there's so much going into this from a biopsychosocial perspective that we don't see the equal number of changes in terms of how it actually impacts your sex drive. And so once we sort of identify, okay, you do not want to ovulate, then we can sort of march down, okay, do you need contraception? Do we need to do contraception? But that continues to allow you to ovulate things like a paragard, iud, spermicides, there's a vaginal ph modifiers, there's many ways that we can provide contraception without impacting your ovulation. Or if contraception is not an issue and you like to ovulate, then we go down the menopause hormone therapy route.

So if you said that 70% of women would be fine without ovulating anymore. Does that imply that 70% of perimenopausal women would be better off on oral contraceptives than on estradiol and progesterone?

Yes. My patient panel, they are happier on that. What's really interesting is I want to talk about. So when we think about menopause hormone therapy, we're thinking about 17 beta estradiol, which is this estrogen. It's an E2, and it's the predominant estrogen when we're in our reproductive years. And there's so many benefits to this estrogen. There are some new birth control pills on the market that have this 17 beta estradiol. So it's an fascinating mix where you're suppressing ovulation, you have contraception, but you're potentially still getting the health benefits of being on a 17 beta estradiol or an estradiol valerate, which is metabolized into 17 beta estradiol. And so for my perimenopausal patients, once we establish, okay, do you wanna ovulate, yes or no, do you need contraception, yes or no? Then we can sort of think through how we pick a pill.

Cause that would be my concern with an oral contraceptive as a bridge through menopause, which is they're missing out on real estrogen and progesterone. And I think we have pretty good evidence that the benefits you accrue later in life, especially with respect to bone density, but probably with respect to other metrics of health, are heavily dependent on getting real 17 beta estradiol and real progesterone right away, never having an interruption in those hormones.

I agree with you.

If what we believe on that front is correct, then it means any woman who's gonna go down the oral contraceptive route would be best receiving that oral contraception in the form of what you just described, which is a real 17 beta. And I guess my next question. I'm worried. I know the answer to this question, but I'm gonna ask it anyway. What is the cost of that type of oral contraceptive? And how often are insurance companies covering that?

Rarely covering it out of pocket.

Monthly cost on that pill would be how much?

100 ish. 100 ish a month.

So it's a huge expensive.

It's incredibly prohibitive, if you were to think about, okay, so now I'm perimenopausal and I don't want to ovulate. I want to be on a birth control pill. The first question is, do I want to be on estrogen. You and I are sort of alluding to the fact, yes, I want to be on estrogen, but a certain kind of estrogen. Remember, some people are not candidates for estrogen. Migraines with aura, blood clot, family history, so. But we still want to suppress ovulation. The newest progesterone on the market is something called drospirenone. Trospirenone, the pill is called slind. It suppresses ovulation in about 98% of women, whereas previous progesterone only pills suppressed ovulation 50 to 70% of the time. So you're getting a huge mood benefit for these women who cannot take estrogen but really don't want to feel the ups and downs of perimenopause cycling, which can be wild. Drospirenone being a derivative of spironolactone, there's a diuretic component to it and so it's a ratio really well tolerated. Really exciting. I hope I can convey how excited I am about this progestin, because having drospirenone means that we can mitigate some of the other side effects such as water retention. Water retention. Okay, so now we've decided. All right, if I don't want estrogen, I'll use slins, this drospirenone only, but ovulation suppressant, medication. What if I do want estrogen? Then the branch point is, do I want something synthetic said very few people ever. Or do I want something more natural said? Both of us, the people who do end up on a synthetic estrogen. Your insurance covers it. It's available at all pharmacies. So there's sort of an access issue here that we would be sort of remiss to ignore. Within that category, I still have pills that I like. Historically, if you interview patients, they may be able to tell you, oh, I did well on this synthetic estrogen. So as we sort of get into the later 40s, I care more in terms of getting them back on a more natural estrogen for the reasons you mentioned in terms of bone prevention and things like that.

When you're Talking to a 28 year old woman who just needs birth control, you don't have a concern with putting her on a synthetic estrogen.

I don't. I still have favorites. Low lowestrin.

I was just about to say that's my favorite.

Yeah, so I use low low estrine a lot. Lowestrin is norothindrone progestin. The reason why I like norothindrone is it's a little bit More androgenic, the more androgenic the progestin, it has the ability to blunt or mitigate the increase in sex hormone binding globulin. Again, I'm talking about pills from a sexual health perspective. There's lots of other ways you could view this, but today this is my angle. And so when you think about super low dose ethanol estradiol, low side effects, plus a slightly more androgenic progestin, you then can have a blunting of the increase in sex hormone binding globulin. It's less likely to gobble up all those extra androgens and patients tolerate it really well. Side effects are there's more bleeding because of the low ethanol estradiol. So sometimes I'll go up to a less which is a 20 microgram ethanol estradiol. And this has a levonorgestrel progestin to it. And this progestin is similarly a little bit more androgenic, less likely to impact your sex hormone binding globulin. And then my last two very popular Yaz and Yasmin, the reason why those are so popular is the progestin in them is drospirenone. And so it has that ability to morbid diuretic. Exactly, it acts as a diuretic when we think about ethanol estradiol. And if I could just step out of professionalism for a moment and ask my father in law to tune in because he's a nephrologist and he would be so excited to hear that I'm going to talk about angiotensinogen, which is ethanol estradiol goes to the kidneys and some 17 beta estradiol goes to the kidneys and causes sodium retention, water retention. So when we think about estrogen and how it impacts our bodies, our pms, our breasts feeling heavy and painful, bloating, slight weight gain, this is estrogen effects. And drospirenone being a derivative of spironolactone, can have a mitigating or a diuretic blunting effect on that water retention. Dave, if you could tune out now because I might say orgasm soon. But anyways, using this counteracting principle in these newer medications can help me pick a really good synthetic form of contraception. Now if we're gonna go to the natural form, there's a few combinations that I'm using now that my patients are tolerating really well. The first is to go back to that progesterone progestin only pill, which is sling drospirenone and adding a 17 beta estradiol patch to it. So you're essentially taking an ovulation suppressive component of contraception, but adding in menopause, hormone therapy, estrogen, and that's where the benefits are. You get the bone protection. So for my patients who are on contraceptive pills.

Sorry to interrupt you. The progestin alone will help with suppression.

Of ovulation, which equals contraception that you can use.

Physiologic 17 beta estradiol.

Correct.

That's super interesting. I'm ashamed to admit I didn't know that.

So it's a great in between step, because you can provide contraception, you can provide drospirenone, which is a diuretic, which 17 beta estradiol does have some sort of water retention components to it. The downsides to it, although these work very well throughout the body, at the level of the endometrium or the lining inside the uterus, you have a little bit more breakthrough bleeding because the 17 beta estradiol does not stabilize the endometrium as much. So one of the side effects in limiting reasons for which my patients won't be happy on this is if they're having breakthrough bleeding. There's other options that are better at that. That's two medications that I want to make sure you know about, and I have no disclosures, but I'd love to have some. Is the next medication that we think about is Nextellis, and Nextellis is Drospirenone, which is the spironolactone derivative, the diuretic with Estetrol or E4. It's a natural estrogen. It's typically produced by the fetal liver, but this has a longer half life than 17 beta estradiol. So you get less breakthrough bleeding, less spotting. We don't know. We think natural estrogens, you must get bone protection and bone benefit. We don't know yet. It's currently being studied.

It's only made by the fetal liver. Correct. So that you have none of this in your body right now?

Hopefully not.

Yeah. Unless you're taking this.

Yeah.

We might have to cut this out of the podcast because it is so freaking nerdy at this point. What do we understand about. We understand how E1, E2 and E3, estrone, estradiol, estriol. We understand, if we want to, we can understand exactly how they move between each other. And do we understand how E4 fits into that pathway? Does E4 have any conversion back to E2 or is it acting as an independent agent?

We don't totally know we think it's independent. Something we do know about E4 is that it does not activate the angiotensinogen pathway.

So you don't get these.

So you don't get the water retracted, you don't get the bloating. So you have that plus drospirenone and patients feel really good. Remember, drospirenone is so good for bloating and pms.

Until we know if this is going to be protective of bones and all these other things, wouldn't there be a risk that we're solving one problem without addressing the jugular problem?

Yes. Currently being studied, the benefits of drospirenone, less spotting or breakthrough bleeding than the drospirenone plus menopause hormone therapy level estrogen. But I think by you asking that question and sort of the dedication to making sure that we're on a steadied 17 beta ethanol estradiol. The newest medication on the market is called Natasia. And Natasia is a progestin with estradiol valerate, which essentially is 17 beta ethanol estradiol. And this is a hugely important contraceptive option for a few reasons. The first is it's the only contraceptive pill that's been approved by the FDA to treat heavy menstrual bleeding. And this is a huge issue in perimenopause and contributes greatly to sex drive and desire.

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

This is sort of like I said, that I wanted to stay in sort of the normal pathology part for this podcast, a luteal out of phase event when you're double ovulating and having heavy bleeding of perimenopause, that still to me falls in the realm of normal. So Natasia is great because it's great for heavy menstrual bleeding. But the estradiol valerate or the 17 beta estradiol, you get the hot flash benefit, the bone benefit, you get the benefits of menopause hormone therapy with something that can also help bleeding and prevent pregnancy.

And just to close the loop on progesterone, if you're using micronized progesterone, even at 200 milligrams, which would probably be the upper limit of what we would use, that's not enough to suppress ovulation.

Obviously 3,300ish, 300 plus is what you would need to predictably reliably.

But of course at three, most women can't tolerate that.

Too sedating. And additionally, not to be left out, is menopause hormone therapy plus an iud or menopause hormone therapy plus a salpingectomy, removal of the tubes. There's other ways to get at this, but I think that's why I really start at the branch point. Those points do not block ovulation. So that's why to me, I really care how you feel in relation to ovulation. That's the branch point in how I decide how to treat my patients.

A lot of what we just talked about probably went over the heads of a lot of people, which is understandable. It is pretty complicated stuff. I want to kind of bring this back to a listener. To me, the takeaway is if you're a woman, you've got to show up with a point of view on what you're trying to optimize around. Just up with a point of view around preferences. And this one around do I like ovulating or not is important. So that's something that regardless of how young a woman is listening to this, and truth be told, I don't think our audience skews very young, but I'm sure There is a 25 year old out there listening. This is something she could be paying attention to right now. She's 20 years away from having to deal with what we're talking about, but she can still be pretty receptive to the idea of how do I feel during my cycle?

That would be my greatest takeaway. And to make you aware that that changes, the way in which we feel in the second part of our cycle, as our estrogen declines as we age, can become more and more dramatic. So it's a very important question to me for everyone and a very, very important question for me for my perimenopausal patients.

And how much does that change based on children and the number of children a woman has or any other factor like that?

I would feel a little theoretical going into that. I don't think we have great data. There's some studies talking about the later you have your last child, the earlier you'll go into perimenopause. The way that I think about hormones and what happens, I think one thing I want to go back to from a neurotransmitter perspective is you asked me about the accelerators and we launched into a discussion about hormones, but we didn't talk about the brakes. And the breaks are serotonin. So we know about how SSRIs can impact our sex drive and can think about what to do about that. But prolactin is a break and it's really interesting because when in our lives is prolactin high? Breastfeeding postpartum women can find this very validating. But from a biologic perspective, we know that pregnancies spaced 18 months apart. That's the ACOG, or American College of Obstetrics and Gynecology. They recommend 18 months between pregnancies because that second pregnancy will be healthier, the baby will be bigger, it's more likely to make it to term. So we know that spacing pregnancies is healthy. And so having a high prolactin postpartum and keeping you from being interested in sexual intercourse is your body's natural way of spacing out pregnancies for the better.

While we're on the topic of evolution, there's something I've always wondered that seems a bit at odds with a pure natural selection. And this is gonna expose how naive my thinking might be. So. So it's not a surprise that men would have a high sex drive for as long as they are capable of reproducing, which is seemingly indefinitely. But you could make an argument, maybe theoretically that women's sex drive should decline after a certain age, call it 30ish, when evolutionarily their probability of producing healthy offspring goes down. But I don't think we believe that to be true at all. I don't think we see that women's sex drive goes down as they age, which sort of flies in the face of maybe at least one naive interpretation of what natural selection might interpret. So is there a smarter explanation for why a woman's sex drive goes up or it doesn't go down? Maybe.

To phrase it more accurately, there are many explanations. This is hard to study. Potentially the most popular one, which the European Society of Sexual Medicine gives like a grade 2 level B rating. So not super high rating, meaning like case control studies.

No, no, this is like theoretical.

Theoretical. If we can sort of tangent on the theory for a little bit. There' something called women's dual sexuality. And it basically talks about women's motivation to participate in intercourse being different at different parts of the cycle, meaning mid cycle, when you are able to get pregnant, you are fertile, you are more likely to participate or to want to participate in intercourse for purposes of reproduction. And the mates that you are more likely to select during that time will have features of genetic dominance, such as a very symmetric face, more masculine features. We talk about the histocompatibility complex. And there's dissimilarity that we look for at this time because we know that mixing of genes is better than not. And then there's other times of the cycle when you are interested in participating in intercourse and you're seeking out things such as partnership, shelter, companionship, protection, and.

You'Re not optimizing around, you end up.

With less attractive or less symmetric or less masculine partner. But your partner may have better communication skills, the ability to provide better shelter protection. It's very interesting. People take this and run with it online and they talk about, you know, in your 20s, what form of contraception should you be on when choosing a mate? This goes back to that question of do you want to ovulate or not? Because there's so much. This is not an anti ovulation, anti contraception discussion. Your sex drive is so multifactorial and being protected from pregnancy is for many can be such a positive contributor to their sex life. But if you believe in this evolutionary hypothesis, and if you believe that you would rather pick your future mate when you're still ovulating versus being on something like a contraceptive pill that blocks ovulation, there is some data to show that you may pick a different partnership. The discussion section is you may want to pick a partner that has a less symmetric face but is more likely to have a partnership and communication skills. But. But I'll sort of excuse myself from that and you can decide for yourself.

That is super fascinating. And honestly, there's more to explore there than the simple and obvious stuff I proposed. I want to go now back to some of the other stuff that we talked about around desire. We didn't touch on this, but this must be a very important topic that you deal with, which is how much do adverse sexual experiences during the early part of a woman's life negatively impact her ability to have a healthy sexual life later on? I think we could talk about this across the entire spectrum. So we could take the most egregious example, which would be sexual assault, rape, things of that nature. But then we can also, I think, fan this out into things which is just no. You know, the first time I had sex, it was awful. It was in a car in the backseat with a guy that I didn't really know that well. And we were both drunk and yeah, I was consenting, but it was awful. So it's hard to imagine that that many women can't relate to that type of experience. How does that play forward?

I see it incredibly often in my patient panel. It is, unfortunately, if you're listening to this and you have a history of sexual trauma, you are unfortunately not at all alone and there are things we can do about it. So yes, it plays a part and yes, we should do things about it. So there are lots of different approaches. I hope that patients are in therapy and that they have sort of the right support team around them. I want to bring up. Sex therapists are a great sort of contributor in this area and sort of thinking about how your experiences are brought into the bedroom and how do we sort of use a trauma informed approach when talking about how to curate arousal and bringing yourself to the encounter when you're not quite ready. There's a sensate focus exercise that is really evidence based for survivors of trauma, but can also be very applicable to patients who, for example, are listening to this podcast and it's been a year or it's been six months and they want to think about how to become intimate again. And it's a four step program that can be done over a month, over four months. You can sort of pick how long each stage you want it to last. Dr. Leah Millhouser, who's done a ton of work in sexual health from a gynecologic perspective, talks about this. And it's essentially step one is to, let's say, spend 20 minutes a couple of times a week if you want it to. The stage to last a week is to sort of be intimate with your partner. No touching of the breasts, no touching of the genitals. Step two would be okay to touch breasts and genitals, but orgasm off the table. Step three would be orgasms on the table, but no penetrative sex. And step four is penetrative intercourse is allowed. And this is a evidence based way in which you can create a safe space to sort of start to find yourself back in your body. There is a book called the Body Keeps Score which talks about how to bring your sort of mindfulness back into your when you are a trauma survivor. And Emily Nagowski talks a lot about it in her book as well. And then there's a sort of potentially less traumatic but still pain that can present itself in sexual encounters. It just hurt. I see this a lot in my cancer survivors.

I was just about to ask you about cancer, by the way.

Yeah, so I see this a lot. Cancer. I often see sort of a twofold hit. There is the psychosocial of I'm mad at my body and there's all those complex feelings. And there's this physiologic aspect of chemotherapy, radiation and how that impacts pain and lubrication of the vagina and comfort of Hormone use. Although we really feel quite confident that local estrogen treatment of the vagina is completely safe for almost all cancer survivors. Dr. Tammy Rowan talks a lot about this with ISSWISH and Menopause Society, sort of encouraging not only patients but also doctors to feel comfortable prescribing local estrogen in this patient population. Physical therapists. Pelvic floor physical therapists can be incredibly helpful. I think every woman. If you're making a centenarian plan and you're seeing a physical therapist to keep your posture and your muscles healthy, I think you should see a pelvic floor physical therapist. They're great in terms of increasing the tone of the pelvic floor. We know that strength of contraction can lead to better quality orgasms. I often get emails like, oh, I just had the best sex. Thanks for sending me to the pelvic floor with physical therapist. But it also is good for hypertonicity, where your pelvic floor is too tight, where you carry stress and trauma and pain. In terms of thinking about how we take care of the vagina, I would like to encourage you to think about taking care of the vagina like you take care of your face.

You listened to my recent podcast?

I did. And I would like to say you are going to go out in the sun and you put on sunscreen. You put sunscreen on your face. So if you're gonna have intercourse, you should use lube.

Even if a woman says, I've never had any difficulty with lubrication, I don't have any discomfort with sex, you still think a woman should be using lubricant?

I do. The data shows less microabrasions.

If you're not concerned with sexually transmitted diseases, which is what the WHO is concerned with. If you're with one partner and only one partner, are microabrasions a problem?

They lead to pain. And once we get into a pain signaling process, you can get this is a common cause of what we call vaginismus, or a tightening of the pelvic floor, which then leads to more pain. It is very possible and you should absolutely work at it. But breaking a vaginismus cycle takes a lot of work. Part of this recommendation that almost everyone should use lube is this idea that we're trying to avoid pain.

Even young women.

Yes. This is one of my favorite things to talk to young teens about when we think about sexual education and we there's a great study looking at 1200 high school students and asked them about what we call sexual debut or their first sexual encounter.

Not intercourse.

First sexual encounter.

That includes kissing.

No sexual encounter.

What defines that?

I'm in a guest. Penetrative intercourse. 70% of boys gave responses related to pleasure, and 70% of girls gave responses related to pain. That's a big deal. And so talking about foreplay and lubrication, even for young women who have an adequately lubricated vagina and decreasing the likelihood that they'll get into pain, that they'll clench up the pelvic floor, it will then hurt more. Breaking out of that cycle is incredibly important to me. So, yes, lube. If you're going to have sex going back to the face, you likely are putting moisturizer on your face.

Only recently.

Only recently. There's vaginal moisturizers. So if you want to use your vagina when you're older using a vaginal moisturizer, there's good ones on the market. There's Reverie, which is a hyaluronic acid suppository. It lowers the pH of the vagina and brings water molecules with it. There's Replenze, which is a polycarbophil suppository that also recruits water molecules. You're moisturizing your vagina.

Sorry, just explain to me how this is used. This is like part of your nightly routine.

Yeah, yeah. Put on your eye cream, moisturize your vagina.

Or morning.

Most people like evening.

Then what? If you're having sex after, whether you're.

Using a vaginal moisturizer or whether you're using a hormone, which will be the third part of this facial analogy recommendation. If you put it in and you decide you want to have intercourse, please do. I wouldn't use it for the purpose of it. It's sort of. You're playing the long game. So if you think about step three with your face, you're using a vitamin C serum or a DNA repair enzyme or an exosome or whatever, that's sort of the long game in terms of collagen and overall sort of tone of the face. So hormones would be this counterpart from a vaginal perspective.

Topical.

Yeah, intravaginal. Topical. Local estrogen. Of my patients who are on menopause hormone therapy, about 30 to 40% of them, and that's consistent with the data, are also on local estrogen therapy. So just to be so clear, we treat local vaginal conditions with local treatment for women who don't respond from a vaginal health perspective to systemic hormones.

All right, so let's recap that. So the equivalent of sunscreen was lubrication, silicone Based, silicone based.

It lasts longer. So water based lubricant doesn't last as long. And so in order to make a water based lubricant work, they have to add a lot of additives. You add additives, you get hyperosmolar lubricants, which then, if you go back to high school chemistry, means that you're actually long game is water molecules are going from the vagina into lubricant because of the osmolality.

So it's drying you out.

So it's drying you out in the long tame. So I like a silicone based lube.

Give us a couple brands.

I like Uber Lube, the Osmolal. Uber. Like you're getting what I took here? Yeah, like I took an Uber here. So I like Uber lube. Osmolality is 600. I like good clean love. Almost naked. Osmolality is about 280 to 300. The osmolality of the vagina is 300. It's really quite shocking to me when you go to a drugstore and you pick up, let's say, Astroglide. So the osmolally of astroglide is 8000. They have a gentler one that's lower. Most people don't know about that, don't buy it. If you look at KY, it's around 4 to 6,000.

Wow.

I mean, it's crazy.

These things shouldn't be sold.

They should not be sold, but they are. And they smell good and they taste good.

Why are they the most ubiquitous lubes out there?

They taste good or they smell good or they have a cool package.

Do these lubes say the osmolarity on the package?

If you look on the back, they should say it right.

So you want to be basically in the 280 to 300, 300.

As close to 300 as you can.

Okay, that's great to know. So uber lube, what was the other one?

Good clean love. Almost naked.

That's a long name. They might want to shorten it.

Good clean love.

Good clean love. All right, so if that's your sunscreen, your moisturizer is a reverie or a replens.

And these are suppositories that you can put in the vagina nightly.

And the suppository is providing what it.

Is recruiting water molecules into the cells. And the reverie is also slightly lowering the PH of the vagina. The lower the ph of the vagina or as close is a natural desirable outcome.

And how does a woman know if her systemic Hormone therapy is insufficient and therefore she requires topical as the third part of this playbook.

If you are going to respond to systemic hormone therapy in terms of improvement of pain, dyspareunia, we call it, feels like sandpaper canal. There's a sort of a rubbing, raw feeling to the vagina. You'll respond by about six to eight weeks.

So give it a start. See if things get better. If there's no change, if you weren't having pain and nothing gets better, you were probably fine. This strikes me as a great example of something that a male who's listening to this podcast, who's female partner is not, could actually bring home and talk about over dinner. Look, I mean, half our audience is men, half our audience is women. So there's a guy who's listening to this episode whose partner is not. If I'm in his shoes, I'm thinking, what am I bringing back to the table? And this would be one of those things which is, hey, let's have a discussion about these three things. So anyway, hopefully we'll link to examples of all of these in the show notes. What percentage of women are regularly receiving oral sex?

I don't have that statistic. We'll have to find that and look it up. I will say that when you look at orgasm frequency with any sort of intimate encounter, it is one of the highest likelihood to be able to achieve orgasm acts that a man and a woman can participate in together. There's a great book called she Comes first by Ian Kerner that has diagrams and tips and tricks and talks about essentially how to do that. One of the best ways, if you sort of from a performance perspective, is to go back to the stages of orgasm that we talked about. The excitation plateau, orgasm and resolution. When you think about the plateau phase, that's sort of the hormone cascade that's happening in the woman. There's two different ideas that are relevant here. The first is something called the approach. And the approach is the seconds or moments just prior to orgasm. When surveyed, 2/3 of women report that whatever's happening when the approach starts, that it should just keep happening exactly as it is. So no increase in pressure, no increase. Whatever you're doing, just. Just keep doing it. No change in temperature, pressure, speed, depth, nothing. So understanding that as sort of like a key component for most women, but not all can be something that can sort of help you from a performance.

Perspective, the onus is on both the woman and the man. The woman needs to recognize she's there and have a cue to her partner that says don't change a thing.

Yeah.

The guy needs to not try to be a hero and needs to know when she taps my head or whatever it is is don't change a thing.

Yeah. And that's a strategy to help women have more of a guaranteed orgasm. And then the contrary is something called edging, which is where you do stop what you're doing and you're sort of like bring your partner close to orgasm and then you stop what you're doing and then you can bring your partner close again and then you stop. And this is for women to be able to achieve more of an intense orgasm, this edging technique.

So if you were to give a guy a few pieces of advice on how to be more successful at helping his partner achieve orgasm using oral sex and penetration, what would be your advice?

Lube. Get over it. It's evidence based. It's for friction. It has nothing to do with how interested your partner is in you. Anatomical awareness. So understanding that there's these two wishbone nerve pieces. Enjoy being massaged. Try to explore with your finger two thirds of the way into the vagina on the anterior or the front wall where the G spot is. Find that rougated area lead up to the event. So foreplay, what does that look like for you as a couple? What does it look like outside of the bedroom? Is it you made dinner or you put the kids down? What is your chore play? What chores did you do as a part of foreplay? What nice text messages. There's so much contextual going on. There's. There's really funny research pieces that talk about people who are in the military who are traveling around and there's bombs everywhere and it's really dangerous and men are still like ready to have sex and women are feared for their lives. A lot more that goes into women's sexuality that I want you to be aware of. There's no need to take this personal, but I hope today sort of understanding arousal versus desire, responsive desire, anatomically thinking about not just the tip of the clitoris, although, though many men haven't even thought of that. But in addition to the tip of the clitoris, the wishbone structures that go down the anterior wall of the vagina, thinking about what phase of orgasm your partner's in, is she in the excitement phase? Is she in the plateau phase or is she sort of in the orgasm phase? And what does that look like?

What about little details like, for example, if you're stimulating the clitoris, is it just very individual variation up and down side to side around individual variation. And is this something where a guy should ask a woman and say, hey, how do you like this done? Or is a woman put off by a guy asking that?

In my dream world, these conversations would take place. There's books that walk you through how to have these conversations. The sex talks book that I mentioned by Vanessa Marin, she writes it with her husband, so you get sort of both perspectives. But I think that website, OMG yes.com actually teaches women how to find the different techniques. So they go over a hard stroke, a round stroke, a gentle touch, an internal touch. They actually teach women. And yeah, I have a dream that women would go to this website and learn for themselves how to do it and talk to their partners about it. Men can also go to the website. It's a one time flat fee website. And then you have access to all of their content and it walks you through different techniques so you can actually learn and talk about with your partner what she likes.

All right, let's pivot a little bit and talk about pharmacology of arousal. We've talked a little bit about it through a hormone perspective, and we've obviously talked about how testosterone in particular, but also estrogen and progesterone play a role in the arousal of a woman. But there are also drugs that are specifically used to target this. What can you tell us about them? There are a couple in particular that I know have come up on this.

Podcast previously using that sort of accelerator and break analogy. Many of the medications will work on one or both of those pathways. The two most common medications and the only two that are FDA approved for women are Addi, which is a pill, and Vylisi, which is an injection. They work along the MAOI pathway on increasing norepinephrine and dopamine and decreasing serotonin. So if you go back to those neurotransmitters thinking about serotonin as a break, so they decrease that norepinephrine and dopamine to the reward center of the brain and they increase those, I don't use them a ton in practice. They are not studied. For postmenopausal women. ADDI is a nightly pill. You take it for six weeks. Well, you take it forever. But after it takes about six weeks before you can see benefit to it. In the trial for which it was FDA approved, it increased your number of satisfying sexual encounters by one. So you went from having like 2ish satisfying sexual encounters a month to 3ish satisfying sexual encounters. You can't drink Alcohol on it, it can cause nausea for some people. It can interact with antidepressants and mood stabilizing drugs. It's not a contraindication but can change the way in which they work. I just don't use it very much.

How much does this drug cost?

I don't know the answer to that.

Why do you think this drug was approved with such limited efficacy?

It's statistically significant to go from let's say 2 ish to 3 ish satisfying sexual encounters. But there was a social movement at the time. There was frustration about how easy it was for Viagra to be approved. The data for Viagra and men is much more clear and easy to see. This is women's sex drive is very complex and this potentially one angle at improving it.

But it's a bit of a bad analogy. Viagra is not really a drive drug, it's a performance drug.

It's a performance drive that ultimately can impact drive as well.

Are there any data that show that Viagra or Cialis or any phosphodiesterase inhibitor improve orgasm quality in women?

They've looked at Viagra a great deal. The studies do not show for women across the population level when study that it impacts drive or orgasm quality except when looking at a specific patient population. So when you look at Viagra, the patients who had an improvement in their quality of sex, be it dry or orgasm quality, et cetera, were women, diabetics, MS, multiple sclerosis, spinal cord patients and SSRIs. These are women who we think that the vasodilation of the nitric oxide and the physiologic response that they have to Viagra dosed at 25 to 51 to two hours prior to anticipated intercourse can be helpful. Let's go back to Addie the Pill. When I talk about one satisfying sexual encounter, you know, improved per month, remember that that's compared to placebo. So there is still a great placebo benefit here and for many that's exciting and fine to introduce into their life. Bileesi is an injection. You may get questions about it from your patient panel because it's similar to the peptide PT141 melanotan. This sort of has the the street name as the Barbie drug because it works through the MCR4 or the melanocorticine pathway. So you get tan and pretty happy and horny is what they say. So they call it the Barbie drug for that reason. There's a significant amount of nausea. You inject yourself for the first two hours. 40% of women will have nausea. I often prescribe Zofran, an anti nausea medicine. When I Prescribe this drug, after 2 ish 3 ish hours, the nausea can go away and then the drug lasts for up to six hours. You can't use it more than twice a week. But this had slightly similar efficacy to ADDI in terms of improving your sex drive.

When I hear that a drug causes that much nausea and you can only use it twice a week, I worry that it's doing something unhelpful as a side effect beyond what you just said. Do you have a concern with long term use of this drug?

It's been out since 2019. We don't have particularly long term data on it. I have the same questions. People anecdotally do like it, but I do think there's a great placebo effect going on here.

Do you think one is better than the other?

It's really hard for me to convince patients to inject themself with a shot, you know, an hour or so prior to intercourse. It doesn't really feel. So it's a preload of psychosocially. Yeah, sexy.

I guess it speaks to obviously the magnitude of the problem. I don't suppose these drugs have been compared head to head to testosterone.

I don't believe that they have. No.

I assume that it would be prudent to make sure a woman's testosterone has been pushed to the physiologic limits before you would engage with any of those drugs.

I just prefer testosterone, which to be clear, testosterone is sort of from a guideline perspective recommended only in the post menopausal woman. So if we're going to stay in the. Where is most of the data? When do I ever use these drugs? So this is in the pre menopause.

From an FDA perspective.

Exactly. So if you're looking like why even use these. This is studied for premenopausal. Testosterone is postmenopausal. But there's a lot of sort of behavioral interventions which I've already mentioned. And then more off label would be cannabis. There is some pretty good data now that we have in some states legal thc that opens up for researchers to study and investigate. And there's really good trials talking about cannabis and your ability to have more satisfying sexual encounters. But it is dose dependent. So when we think about cannabis, I'm probably an inverted.

You should.

It's inverted. Yeah. So it's specifically THC. Around 1 to 2 milligrams is the recommended dose. Anything higher for some can be sedating to speak to your sort of inverse relationship which adversely affects your sexual experience and desire to participate. But around 1-2mg patients report that they have more satisfying orgasms or have a hyper awareness of their senses. Sex drive is higher. It's quite significant in the data. Much more significant than the medications they've already talked about.

And 1 to 2 milligrams. So is that through any form edible inhaled? I don't know enough about how do you dose inhaled?

If this is an illegal substance where you live, it is not a recommendation. If it is legal. There are safer ways to ingest thc. Smoking, vaping obviously have a great impact on the lung. We're, you know, incredibly worried about that. One of the best ways to sort of dose adjust is to get name brand thc. So there are brands out there that have unregulated but arguably quite standardized dosing of gummies. And you can get a 1 milligram or a 2 milligram or a 5 milligram.

And is 1 milligram altering of senses at all? Seems pretty low.

Yeah, it's pretty low for most people. It's sort of a heightened sense response in terms of physical sense ability to appreciate orgasm, stay in the moment, but not enough to cause paranoia or things like that.

Munchies.

Munchies.

True for men and women or just women?

Both.

Let's talk about pregnancy for a minute. What is happening to a woman's arousal during pregnancy? Again, if you go back to my naive evolutionary view now I can modify my view by the way. So my view would have been a pregnant woman should not want to have sex at all because any amount of penetration puts the fetus at risk. However, based on what you taught me a few minutes ago, there's another reason for her to have sex during pregnancy, which is to keep her male partner around to protect her and hopefully their child. So I assume it's a balancing act of those things. So how does that shake out in the real world? What do we actually observe about a woman's sexual desire during pregnancy? And what are the do's and don'ts?

Complex, as you can imagine. And yes, that would be the evolutionary approach to it from a medical perspective because I think it might scare some women to say, oh, it puts the fetus at risk. To be clear, in a healthy pregnancy, in the absence of a contraindication, a low lying placenta, a low lying blood vessel or a cervical insufficiency, which we would pick up on in routine ultrasound, sexual health sex during pregnancy is Completely safe, totally fine, and has a lot of relationship and psychosocial benefits.

Is there a point late enough in the pregnancy where you would recommend a woman not have intercourse in the absence of a. Absence of any of those things?

Pathology? Absolutely not.

Wow. Okay.

We know that for many women, sex during pregnancy can be quite intense. In the pleasurable category, the reasons for this are the neurotransmitters. Right? You have super high levels of estrogen and oxytocin, so that can make for a more pleasurable experience. There's more blood flow to the genital area, so the contractions of the muscles are sort of more intense. The blood vessels are sort of bringing more heat to the area. And then for some women, I wish this for all women to feel safe and supported and bonding with a partner in pregnancy, but. But that's not the case for all post pregnancy.

What do you advise your women? Let's start with vaginal versus C section. So if a woman has had a C section, what do you think is the right time for her to go back to sexual activity? Pending her desire, we don't change the.

Recommendation for when to resume sexual activity post vaginal birth or C section. It's six weeks across the board. That's the time when you go see your doctor. They check you out, they make sure everything is well healed. It sits uneasy for a lot of people to say, well, gosh, why is it the same recovery time for both? A C section is so much bigger. The thought process is that by six weeks you should have complete healing from the C section in the absence of complications. And we're more sort of from a hormonal physiologic perspective, making sure that the uterus has shrunk down a significant amount, that you're not at increased risk of infection by having things in the vagina. You're a good candidate to have contraception at that time, so we can provide you with protection from future pregnancies. But I think from a postpartum perspective, reason number 15, why I loved your podcast and why I love Rachel Rubin. She recently published on the genitourinary syndrome of lactation, which basically talks about the hypoestrogenic or the low estrogen state of the vagina postpartum and how that mimics the pathophysiology of women in menopause. And so for a lot of my patients who are breastfeeding, who have high prolactin, who have low estrogen, I'm prescribing them the estrogen cream that I'm prescribing my postmenopausal women to sort of keep the vagina as healthy and moisturized as possible.

Does an episiotomy affect the ability to resume intercourse after pregnancy or is that usually healed by six weeks as well?

The hope is that it's healed, but unfortunately pain from tearing in general or episiotomies, which are, to be clear, out of fashion in the absence of an emergency. We don't do routine episiotomies. The data is clear against those. But we do see that any sort of tearing or cutting that happens the vagina can lead to pain, which can lead to dyspareunia, pain with sex, and therefore we have drive issues and sexual health issues as well. Another thing to think about from a postpartum perspective is how these insults of pain can sort of manifest into something bigger than they are. Participating in sex before you're ready and having a painful sexual experience can cause tightening of the pelvic floor, rigidity in the muscles, and can set into motion a pain cycle that then takes future pelvic floor physical therapy to break that pain cycle.

You alluded to sexual education a number of times. I have to be honest, I'm a little naive. I don't really know what's being taught in sex ed. I don't even really remember what I learned in sex ed, Although I remember watching these really embarrassing movies on a vcr. That's about the extent of it. But if you were sex ed czar appointed from atop the mountain, how would you design the curriculum? How would it Differ for boys vs girls? When would you initiate it?

If I were queen of sex ed, I would get away from the fear based, don't get pregnant, don't get an std, you're going to get HIV sort of fear based counseling.

Aren't those things important though?

They are important, but there has to be some actual education in terms of pleasure and anatomy and pathophysiology. This is not a podcast talking about the plight of women. As a mom to four boys, I am equally committed that boys are as educated as girls are. And I care that my boys care about the experience that their potential future partners might have with them. Women's sexuality is complex. It's the anatomy you cannot see as well as you can see with men. Just sort of the nature of the fact that when a bunch of boys are in a locker room, they can see other boys anatomy. They see the differences, they understand that that's healthy. Girls don't often see other girls vaginas as clearly as boys. See other penises. And so normalizing through the labia library and realizing what's normal and understanding the clitoral nerve for both boys and girls thinking about safe ways to sort of explore intimacy. If you don't provide them with informational content such as omg, yes. And teaching them about how to explore their anatomy, they will turn to porn. And we have great data that almost all of the porn is not healthy for teens in terms of setting expectations that are unrealistic, both anatomical and describing penetrative penis and vagina sex as the way that women have screaming orgasms. That's just not accurate.

It.

And so it sets expectations for encounters that are just not obtainable and leads to disappointment and self confidence issues. So I'd love to for sexual education to be informative from an anatomical, physiologic, accurate, pleasure based perspective and talk them through how to have safer encounters.

You said you have four boys, so this is obviously near and dear to your heart. What is the way in which you're going to communicate with your boys about this in an environment where they're growing up in a world that you, me, your husband, we just can't relate to. Made this point before, I think with Rachel on the podcast. When I was growing up, porn was a black and white playboy or something. It's a totally different thing. So what are you going to do and what is your advice for other parents out there who have growing boys and girls for that matter?

Yeah, I mean, I think I don't distinguish the genders as much. I think education about all bodies should be provided to all people. So first is using the correct verbiage and anatomical nomenclature, calling a penis a penis and calling a vulva a vulva and normalizing this as a part of your health. Masturbation is incredibly healthy. It should be done in a private setting and it's healthy. And there's a lot about shaming, masturbation and how that can put your child at higher risk for issues in the future if you sort of shame their exploration of their body. It's normal, it's healthy, it's a part of your health. Orgasm is healthy, but it should be done in a private place and sort of how you interact. Like what is consent? What are the components to consent? What does that look like? Is it specific? Is it enthusiastic? Is it persist as the activity changes? Is there a timeline on it? Thinking about all the different ways that we think about consent and then sort of changing the way that society allows its perceptions to trickle into what we think of in terms of safety. So, for example, as a culture, we tend to say penetrative sex, penis and vagina is the end, all top of the pyramid, most intimate act you can do with someone. But condoms are quite effective at preventing sexually transmitted diseases when used in a penetrative sexual encounter. People don't really use protection when performing oral sex, either women on men or men on women. And so as we see the rise of herpes across college campuses, this is an intervention that we really need to talk about. If you're at a party and you're with someone and you want to be intimate with them, having penetrative intercourse with a condom on is safer and less likely to transmit a sexually transmitted disease than if you're going to perform oral sex on each other. And so thinking about it from a safety perspective and not a cultural perspective would be another sort of key foundational change that I think needs to happen. And also sex education needs to change. Like what we talk about in, did you have sex education in college? What about grad school? What about perimenopause and menopause? There sort of needs to be an evolving door in terms of different providers coming in and talking and educating, because our bodies change, our physiology changes, and our needs change. And this is not a, like, eighth grade, one hour split, the boys and girls talk about it kind of a thing.

Coming back to this specific issue, how much of an issue is pornography for young boys and what is the solution like? It's not going to get regulated away. Although there are some states where at least age verification is required. I don't know how effective that is. I mean, that's a step in the right direction.

My strategy in general when thinking about don't do this, is always to do it, don't do this, do this. So it is sort of like, introduce what you should do instead of what you shouldn't. It's, let's introduce something healthy. So what does a healthy sexual life look like? The porn industry, there are parts of it that have evolved. There is healthier informational videos that you can watch if you're looking for arousal. There are healthy ways to have an orgasm and to interact with another human being. And talking about how you bring someone into your life that's healthy, what frequency is healthy for both of you? And if you're not getting that, to what ends do we go to get it elsewhere? And what are you searching for? Is it a dopamine release? What can we add and replace that? That neurotransmitter release that you're looking for.

Is there a crisis of intimacy in young people? I've heard this a lot, but again, I just don't know the data. But I keep hearing that people in their 20s today are becoming less and less intimate over time relative to a decade ago, two decades ago. So first of all, I don't know if that's something, you know, I don't.

I sort of have the same anecdotal experience in my clinical practice where I have very lonely, less intimate 20 year old women in my practice. Sort of ask when I take a sexual health history, which I always do, there is a lot lacking there. And it would be a whole nother podcast to talk about AI and how that's going to sort of, you know, replace intimacy and how we can use that for arousal and things like that. That it's something to think about.

So I guess final thoughts. What are you most concerned with right now as you think about your professional world and what are you most excited about?

I'm most excited about the new information that we have coming in about hormone options in terms of how we provide menopause hormone therapy and how we treat perimenopause and the new top types of estrogen and progestin and how we tinker with those and moderate those to optimize women and how they feel. This is super personalized, super individualized medicine and we want to do this as physicians. We love doing this. But I think the more research that's coming out and the more drugs available make it really fun to be a part of. So that's definitely my area of passion right now in terms of concerns. Do I have to have a concern or. I guess I just have another passion, which is that I think the world is changing and I think people are ready for it. I'm ready to push it there. You're pushing it there. I think it's really exciting to think about sexual health as a part of your health and talking about it in a very sort of like generic safe place from a physiologic perspective. Think about all the people you can get on your team to help you. Sex therapists and pelvic floor physical therapists and. And how to tinker with your hormones and behavioral interventions. And I love thinking about couples listening to this podcast together and trying different things and seeing this as potentially orgasm, as another biometric or, you know, sexual satisfaction as another sort of longevity lever that we pull when improving the happiness and health of our lives.

I think that's an awesome way to close this discussion and I definitely appreciate the optimism and lack of pessimism around it. So so thanks again for all of this insight. I learned a lot, as is often the case with podcasts. So thank you.

Thank you for having me.

Thank you for listening to this week's episode of the Drive. Head over to Peteratti md.com shownotes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram and Twitter, all with the handle PeterAttiaMD. You can also leave us review on Apple Podcast or whatever podcast player you use. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional healthcare services, including the giving of medical advice. No doctor patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously. For all of my disclosures and the companies I invest in or Advise, please visit PeterAttiamD.com about where I keep an up to date and active list of all disclosures.