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

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• Sexual health is a vital component of overall health and longevity, impacting sleep quality (via parasympathetic activation) and cardiovascular health (mimicking moderate exercise).  Copied to clipboard!
• Female sexual desire is typically responsive (arousal follows stimulation) rather than spontaneous (common in men), suggesting that creating an environment for arousal via methods like lubrication or mindfulness is key to cultivating desire.  Copied to clipboard!
• The 'orgasm gap' is a significant health disparity, with only about 30% of women reporting orgasm almost every time during sex with a male partner, compared to 95% of men, highlighting the importance of clitoral stimulation, as less than 10% of women orgasm from penetrative intercourse alone.  Copied to clipboard!
• Contraception choices that suppress ovulation have variable effects on sex drive, with data showing 20% of women experience an increase, 65% no change, and 15% a decrease, highlighting the biopsychosocial complexity.  Copied to clipboard!
• For vaginal health, lubrication (ideally silicone-based with low osmolality, near 300) and nightly moisturizers (like Reverie or Replense suppositories) are recommended as preventative measures, similar to using sunscreen on the face.  Copied to clipboard!
• Effective sexual education should shift from fear-based counseling to accurate, pleasure-based information covering anatomy, physiology, and consent, as unrealistic expectations from pornography can lead to disappointment.  Copied to clipboard!

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Sexual Health as Longevity

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(00:04:16)

• Key Takeaway: Sexual activity, including orgasm, positively impacts sleep quality by activating the parasympathetic nervous system and releasing relaxing neurotransmitters.
• Summary: Sexual activity shifts the nervous system from sympathetic to parasympathetic, especially post-orgasm, improving sleep latency and efficiency. For women, intimacy with a partner synergistically improves sleep more than solo orgasm. Sex also provides a moderate energy expenditure, equivalent to about six to seven metabolic units (METs) for women.

Defining Female Orgasm

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(00:12:52)

• Key Takeaway: The normal female orgasm is defined by rhythmic contractions of the pelvic floor muscles, progressing through excitement, plateau, orgasm, and resolution phases.
• Summary: The average time to orgasm is less than four minutes when a woman is alone, but upwards of 21 to 25 minutes with a partner. Foreplay lasting over 21 minutes results in orgasm for over 90% of women, as this time allows for necessary physiological changes like vaginal lengthening and angle adjustment.

The Orgasm Gap Disparity

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(00:16:23)

• Key Takeaway: The significant disparity where 95% of men report orgasm during sex with a woman, compared to only 30% of women, constitutes a measurable health disparity.
• Summary: This discrepancy highlights that sexual health is health, and the lower rate of female pleasure is a metric that needs addressing. Orgasm frequency correlates with underlying health factors like pelvic floor strength and vascular blood supply. Addressing this gap is crucial for overall well-being.

Understanding Arousal and Desire

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(00:19:01)

• Key Takeaway: Most women experience responsive desire, meaning arousal follows stimulation, contrasting with the more common spontaneous desire seen in men.
• Summary: Responsive desire means women often need external cues, like physical touch or emotional investment (‘chore play’), to become aroused, rather than initiating desire spontaneously. To cultivate responsive desire, applying silicone-based lubricant 30 minutes prior to intercourse and engaging in mindfulness or erotic literature can be effective strategies.

Lubrication and Clitoral Anatomy

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(00:23:53)

• Key Takeaway: Lubrication is necessary for most women regardless of age, and the clitoral nerve contains Type A fibers (vibration/deep pressure) and Type C fibers (heat/light touch), with Type A fibers aging better due to myelin sheaths.
• Summary: Natural lubrication comes from sweating vaginal cells, cervical mucus, and specialized glands like the Skene’s glands. Friction is less critical for female pleasure than for male orgasm, and avoiding friction minimizes micro-tearing and pain. Introducing external vibrators can compensate for age-related degradation of Type A nerve fibers.

Female Genital Anatomy Education

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(00:31:16)

• Key Takeaway: The clitoris is a wishbone-like structure with over 8,000 nerve endings, including an internal branch often referred to as the G-spot, which is stimulated by only about 10% of women during intercourse.
• Summary: The vestibule and crura (wishbone structures) of the clitoris engorge with blood flow, and asymmetry in these structures can lead to greater pleasure on one side. Since less than 10% of women orgasm from penetration alone, external clitoral stimulation or stimulating the anterior branch of the clitoris is necessary for the majority.

Managing Desire and Vibrator Use

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(00:40:27)

• Key Takeaway: The myth that using a vibrator solo creates dependency that hinders partnered orgasm is false; whatever technique leads to orgasm can often be integrated into partnered sex, and ‘orgasms beget orgasms.’
• Summary: Scheduling sex, such as a ‘fuck it February’ of 2-3 times a week, can help maintain desire, as sex tends to beget more sex. Discordance in desire (one partner wanting more than the other) is a greater risk factor for divorce than the absolute frequency of sex.

Hormones and Perimenopause Strategy

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(00:43:55)

• Key Takeaway: Accelerators for female sexual desire include estrogen, testosterone, nitric oxide, dopamine, and oxytocin, while the primary decision point in perimenopause is whether the patient prefers to continue ovulating.
• Summary: Testosterone is more directly linked to sex drive than estrogen, and for hypoactive sexual desire disorder, testosterone cream is a preferred administration method, aiming for total testosterone levels above 20 ng/dL based on symptom response. Menopause Hormone Therapy (MHT) allows ovulation, whereas many contraceptives suppress it, creating different pathways for managing perimenopausal symptoms and sexual function.

Contraception and Ovulation Impact

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(00:57:21)

• Key Takeaway: Suppression of ovulation via contraception has a highly variable impact on female sex drive, with a majority experiencing no change.
• Summary: A meta-analysis of 32 trials involving over 14,000 women showed that 20% had increased sex drive, 65% had no change, and 15% had a decrease when ovulation was suppressed. Hormonal pills suppress sex drive by suppressing the hypothalamic-pituitary axis and decreasing ovarian testosterone production. Patients who do not wish to ovulate can opt for non-ovulation-suppressing contraception like the ParaGard IUD.

Hormone Pill Selection Nuances

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(00:59:06)

• Key Takeaway: For perimenopausal women needing contraception, choosing pills containing 17-beta-estradiol and progesterone is preferred over synthetic options for long-term health benefits like bone density.
• Summary: Oral contraceptives containing 17-beta-estradiol offer potential health benefits often missed by synthetic estrogen pills, which is a concern when using them as a bridge through menopause. The newer progesterone-only pill, Slinda (drosperinone), reliably suppresses ovulation (98% efficacy) and offers mood benefits due to its diuretic component, making it suitable for those who cannot take estrogen. Synthetic estrogen pills like Low-Ogestrel are often covered by insurance, unlike the more natural 17-beta-estradiol options which can cost around $100 monthly.

Natural Estrogen Contraceptive Options

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(01:05:06)

• Key Takeaway: A combination of the progesterone-only pill (Slinda) and a 17-beta-estradiol patch offers contraception while providing systemic estrogen benefits for bone health.
• Summary: Nextellis, combining drosperinone (diuretic) with estetrol (E4, a natural estrogen), is being studied for bone protection benefits while avoiding the angiotensinogen pathway activation that causes water retention. Natasia, containing estradiol valerate (17-beta-estradiol), is the only FDA-approved contraceptive pill for heavy menstrual bleeding, offering both contraception and potential hot flash/bone benefits.

Sexual Trauma and Pain Recovery

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(01:15:29)

• Key Takeaway: The sensate focus exercise is an evidence-based, four-step program that can help survivors of sexual trauma or those recovering intimacy safely.
• Summary: Sexual trauma significantly impacts sexual health, and trauma-informed approaches, often involving sex therapists, are necessary for recovery. The sensate focus exercise involves gradually reintroducing touch, first without touching breasts/genitals, then allowing touch without orgasm, then allowing orgasm without penetration, and finally allowing intercourse. Local estrogen treatment is considered safe for almost all cancer survivors experiencing vaginal pain and dryness post-treatment.

Vaginal Care and Lubrication Science

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(01:19:28)

• Key Takeaway: Lubricants should be chosen based on osmolality, aiming for a value close to the vagina’s natural osmolality (around 300) to avoid drying out tissue.
• Summary: Lubricant use is recommended for almost all sexual encounters to prevent microabrasions that can lead to pain and vaginismus cycles, even in young women whose first sexual encounters often involve pain rather than pleasure. Water-based lubricants with high osmolality (like Astroglide at 8,000 or KY at 4,000-6,000) are actively drying because they pull water out of the vaginal cells. Silicone-based lubes like Uberlube (osmolality 600) or Good Clean Love Almost Naked (osmolality 280-300) are preferred.

Tips for Partner Orgasm Success

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(01:25:58)

• Key Takeaway: For men assisting a partner to orgasm, understanding the ‘approach’ phase—where the partner desires no change in stimulation just before orgasm—is crucial.
• Summary: Oral sex is one of the highest likelihood acts for women to achieve orgasm when partnered with a man, and men should ‘get over’ the need for friction, as it relates to anatomy, not interest. During the plateau phase, two-thirds of women report that stimulation should remain exactly the same (no change in pressure, speed, or depth) when they reach the ‘approach’ to orgasm. Success requires anatomical awareness, including exploring the anterior wall of the vagina (G-spot area), and considering contextual foreplay like chore completion.

Pharmacology for Low Sexual Desire

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(01:30:36)

• Key Takeaway: FDA-approved drugs for female low desire (Addyi and Vyleesi) target the norepinephrine/dopamine pathways, but cannabis (1-2mg THC) shows significantly higher efficacy in reported satisfying encounters.
• Summary: Addyi (flibanserin) is a nightly pill that increases arousal neurotransmitters (dopamine/norepinephrine) while decreasing serotonin (a ‘break’), but its efficacy is modest (one extra satisfying encounter per month). Viagra/PDE5 inhibitors only show benefit in specific populations like diabetics or those on SSRIs, not generally for female drive or orgasm quality. Low doses of THC (1-2mg) are associated with significantly more satisfying orgasms and heightened senses, though this is an off-label intervention.

Sex During and Post-Pregnancy

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(01:37:52)

• Key Takeaway: In healthy pregnancies without contraindications, sexual activity is safe throughout gestation, often intensified by high estrogen and oxytocin levels.
• Summary: In a healthy pregnancy, sexual intercourse is safe up to term unless contraindications like a low-lying placenta exist, offering psychosocial benefits to the relationship. Postpartum, the recommendation to resume sexual activity is six weeks for both vaginal birth and C-section to allow for uterine involution and healing. Breastfeeding postpartum women experience a hypoestrogenic state mimicking menopause, often requiring local estrogen cream to maintain vaginal health.

Redesigning Sex Education

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(01:42:15)

• Key Takeaway: Sex education must evolve beyond fear-based warnings to include accurate anatomy, physiology, pleasure-based learning, and a safety hierarchy that prioritizes barrier use during oral sex over intercourse.
• Summary: Education should normalize anatomy (using correct nomenclature like vulva) and masturbation as healthy behaviors, counteracting unrealistic expectations set by pornography, which often inaccurately portrays female orgasm via penetration. Parents should teach consent as enthusiastic and specific, changing as activity changes. From a safety standpoint, penetrative sex with a condom is statistically safer regarding STI transmission than unprotected oral sex, a critical point often missed in traditional curricula.

Future of Women’s Sexual Health

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(01:49:17)

• Key Takeaway: The future of women’s sexual health lies in highly personalized medicine, utilizing new hormone options and integrating a team approach including physical therapists and sex therapists.
• Summary: The speaker is most excited about the increasing availability of personalized hormone options for perimenopause and menopause, allowing for individualized treatment plans. Sexual health should be viewed as a vital biometric lever for overall happiness and longevity, requiring a team approach involving medical providers, pelvic floor physical therapists, and sex therapists. Couples are encouraged to view sexual satisfaction as an area for proactive optimization and tinkering.