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

Sally Greenwald, an OB-GYN specializing in women's sexual health, delves into the intricacies of female sexual anatomy and how understanding this can improve sexual wellbeing for both men and women.

Female Genitalia Anatomy: Clitoral Complex, Vaginal Tissue, Erogenous Zones

The discussion explores female genitalia, particularly the clitoral complex, vaginal tissue, and erogenous zones, highlighting why this knowledge is vital for sexual function.

Clitoris Has a Larger Internal Structure, With Nerve Fibers That Can Be Stimulated For Orgasm

Greenwald discusses the anatomy of the clitoris, which is comprised of more than just the small, visible part; it's akin to an iceberg's tip, with a larger structure beneath. The internal part includes the vestibule and the "crura," forming a wishbone shape with nerve structures on either side of the labia minora. This part of the clitoris has a larger internal structure with over 8,000 nerve endings that receive increased blood flow during arousal, leading to the potential for orgasm. The clitoral nerve is home to two types of nerve fibers: type A and C. Type A fibers respond to vibration and deep pressure, while type C fibers to heat and light touching. Both of these nerve types can be stimulated for orgasm, and it's worth noting that type A fibers have a myelin sheath that protects them over time.

Vaginal Tissue Changes During Arousal to Facilitate Intercourse

Throughout arousal, vaginal tissues undergo transformation, preparing the body for intercourse. The excitement phase of orgasm involves engorgement of pelvic tissues and an increased blood flow, which makes the vagina longer, wider, and changes its angle to reduce potential discomfort during penetration. The vagina lubricates internally in a process that Greenwald compares to sweating, with the cells of the vaginal canal releasing water molecules for lubrication, aided by cervical mucus.

Targeting Sensitive Vaginal Areas Like the G-Spot Enhances Pleasure

Greenwald goes on to cover sensitive vaginal areas, such as the "G-spot," a part of the clitoral structure that runs along the anterior part of the vagina. She explains that when aroused, engagement of this area with a “come hither” movement can escalate sexual pleasure. While only about 10% of women initially orgasm from stimulation of this internal clitoral branch, this figure may increase with education. Greenwald advises partners to explore thi ...

Sexual desire and arousal patterns differ significantly between sexes, with nuances that can affect satisfaction in sexual relationships. Sally Greenwald provides insights into these differences, particularly focusing on women's sexual response and the discrepancies known as the orgasm gap.

Women Experience Responsive, Not Spontaneous, Sexual Desire

Women More Aroused by Situational Cues Than Visual Stimuli

Spontaneous desire, common in men, is only present in about 15% of women, as women tend to have what is known as responsive desire. This form of desire often requires environmental or situational cues, rather than spontaneous arousal. Partners can stimulate arousal by making emotional investments, such as helping with chores, offering physical touch, or creating contextually stimulating situations.

Greenwald notes that visual stimuli, often effective for men, are not as influential for women, pointing out that women tend to be more responsive to situational cues for sexual desire. For example, women may find greater arousal through reading erotic literature or using auditory or literature-based erotica apps. To cultivate arousal patterns, it's key for women to engage in regular sexual activity, which can help them understand their body's response to various stimuli and learn to develop responsive desire over time. Greenwald advises using lubricants and other methods of curation, including scheduled sex, which can train the system.

Communication and exploration with a partner are also vital for women in order to create an environment for arousal. Greenwald emphasizes the importance of staying present in the moment with techniques such as breathing and mindfulness, as well as self-descriptive engagement with one's physiological responses.

The Orgasm Gap Between Men and Women

Men Orgasm More Often Than Women During Sex

A substantial orgasm gap exists between men and women. Approximately 95% of men report that they almost always have an orgasm when having sex with a woman. In contrast, only about 30% of women report the same with a male partner. This disparity is even more pronounced in one-night stands, where around 90% of men, compared to a meager 12% of women, report having orgasms. This gap suggests that the frequency of orgasms could affect one's ease in achieving orgasm, potentially contributing to the differences observed between men an ...

Sally Greenwald, a specialist in women's sexual health, provides insights into how hormones influence sexual function and the benefits of hormone therapy for libido and arousal in perimenopausal and menopausal women.

Hormones Impacting Sexual Function

Greenwald and Peter Attia discuss the complexities involved in sexual desire, conceptualizing it in terms of "accelerators" and "brakes."

Estrogen and [restricted term] "Accelerate" Sexual Desire; Progesterone "Brakes" It

Greenwald describes how neurotransmitters like estrogen and [restricted term] serve as accelerators to sexual desire, while other hormones can act as brakes. Estrogen, she notes, works through alpha receptors to stimulate the sex drive and beta receptors to decrease anxiety and inhibition. [restricted term] has a more direct relationship with the sex drive, and its replacement therapy can improve libido indirectly by enhancing sleep and reducing hot flashes. Additionally, natural spikes in these hormones around ovulation can boost a woman's sex drive. Conversely, Peter Attia adds that progesterone may act as a "brake" on performance, including sexual function, as it is low before ovulation when sexual desire seems to be heightened.

Hormone Therapy For Libido and Arousal in Perimenopausal and Menopausal Women

Greenwald emphasizes the use of hormone therapy to manage sexual health issues in perimenopausal and menopausal women. She discusses the use of DHEA intravaginal application to alleviate vaginal pain and [restricted term], often in cream form, to boost sex drive and desire. Her aim is to achieve a total [restricted term] level above 20, using patient symptoms as a guide for adjustments. [restricted term], which increases sex hormone-binding globulin, impacts free [restricted term] levels in the body.

For women who can't take estrogen—such as those with a family history of blood clots or who experience migraines—Greenwald suggests using [restricted term], a progestin derived from [restricted term], as it has a high ovulation suppression rate and a diuretic component that improves tolerance.

Yet for women who do want estrogen, they can opt between synthetic estrogen, which is more readily available and covered by insurance, and a natural form of estrogen. The natural form boasts additional benefits like bone health but is ...

In a discussion covering vaginal health, Sally Greenwald and Dr. Tammy Rowan emphasize the importance of understanding the role of lubricants, moisturizers, and local estrogen therapy, especially for postmenopausal women.

Lubricants Reduce Friction; Silicone-Based Options Are More Effective and Last Longer

Greenwald underscores the importance of lubricants in maintaining sexual health, regardless of age or natural lubrication levels. Lubricants reduce friction during intercourse, which can prevent the micro abrasions and tearing that contribute to pain and potential conditions like vaginismus. She particularly recommends using a silicone-based lubricant 30 minutes before intercourse, with application higher up in the vaginal canal using a lube shooter, due to their longer-lasting effects compared to water-based options. Medications, life stages, and other factors affecting natural lubrication support the need for lubricants, although some glands like the Bartholin's can sometimes get clogged and cause pain.

The World Health Organization provides guidelines focused on reducing HIV transmission, but Greenwald notes that these guidelines are equally applicable to sexual pleasure and health—recommended for almost everyone to protect against pain and injury. She advises against lubricants with high osmolality, such as Astroglide and KY, due to their dehydrating effects. Instead, she endorses products like Uberlube, with an osmolality of 600, and Good Clean Love Almost Naked, with an osmolality of 280 to 300.

Vaginal Moisturizers Maintain Health and Comfort Outside Sex

Greenwald also speaks to the significance of vaginal moisturizers for ongoing health, which lower the pH and hydrate the tissue. Products like Reverie, comprised of hyalur ...

Peter Attia and Sally Greenwald discuss the significant impact of adverse sexual experiences on women's ability to have a fulfilling sexual life, highlighting the spectrum of trauma and the ways in which individuals can reclaim intimacy.

Negative Sexual Experiences Can Impact a Woman's Sense of Safety and Sexual Enjoyment

Attia notes that negative sexual experiences ranging from egregious cases like sexual assault and rape to less severe but still impactful events, such as a poorly conditioned and unpleasant first consensual encounter, can severely affect a woman's sense of safety and enjoyment in sexual activities later in life. He points out that such experiences are not uncommon and can lead to lasting and profound effects on sexual function.

Trauma-Informed Methods, Such as Sensate Focus, Help Women Reclaim Intimacy and Sexuality

Sally Greenwald mentions that many of her patients have had sexual traumas that influence their current sexual experiences. She talks about the importance of a trauma-informed approach to sexual encounters, especially when a patient may not feel ready to engage sexually. The use of trauma-informed methods, such as sensate focus exercises, can as ...

Pharmaceutical advances see the development of substances aimed at enhancing sexual desire and arousal, particularly among women. The FDA has approved two medications, Addyi and Vyleesi, for these purposes, but their efficacy is limited and they come with significant side effects.

FDA's Addyi, Vyleesi Aim to Boost Desire, but Have Limited Efficacy, Significant Side Effects

Addyi, a pill, and Vyleesi, an injection, are the only two FDA-approved medications targeting arousal in women. They operate by adjusting neurotransmitters—increasing [restricted term] and [restricted term] and reducing serotonin.

Neither medication was studied in postmenopausal women and can take up to six weeks for benefits to be realized. Addyi trial data revealed only about one extra satisfying sexual encounter per month, and use of the medication requires abstaining from alcohol due to the risk of nausea and potential interactions with antidepressants and mood stabilizers.

The societal context surrounding Addyi's approval reflects the complexities of women's sexual drive and the hurdles in pharmacological interventions. The pill showed a significant placebo effect in clinical trials. Vyleesi, related to PT 141 and sometimes called the 'Barbie drug,' can lead to tanning and affects mood and sexual desire.

[restricted term] Therapy and Cannabis May Enhance Sexual Function

Dr. Sally Greenwald discusses using [restricted term] treatment, aiming for hormone levels that alleviate symptoms, which may vary significantly among patients. She also addresses the balancing act of prescribing estrogen and progestins, the latter can offset an increase in sex hormone binding globulin caused by estrogen.

It’s noted, though not in the given transcript, that [restricted term] is advised only for postmenopausal women as per the guidelines. In addition, Greenwald sheds light on data showing that legal ...

As women navigate the stages of their reproductive lives, sexual health issues vary. During pregnancy, postpartum, and menopause, women encounter different physiological and hormonal changes that impact their sexual desire, function, and comfort.

Pregnancy Boosts Desire, but Pelvic Changes and Pain Pose Challenges

Sally Greenwald and her fellow discussants note that sex during a healthy pregnancy is safe and beneficial, assuming there are no contraindications like a low-lying placenta or cervical insufficiency. Due to high levels of estrogen and [restricted term], as well as increased blood flow to the genital area, sex can become quite intense and pleasurable.

Postpartum Healing Requires Patience; Local Estrogen Aids Vaginal Dryness and Pain

Postpartum sexual health is particularly delicate, with a standard recommendation of waiting six weeks before resuming sexual activity after both vaginal birth and C-section. Greenwald explains that high prolactin levels postpartum reduce sexual interest, which is nature's way of spacing pregnancies. American College of Obstetrics and Gynecology also recommends 18 months between pregnancies for the health of the mother and subsequent baby.

Especially for breastfeeding women who may experience vaginal dryness and pain due to low estrogen levels, similar to menopausal symptoms, local estrogen is noted to be beneficial for postpartum healing. To maintain vaginal health, Greenwald prescribes estrogen cream to postpartum women, as she does with postmenopausal women.

Hormonal Shifts in Menopause Impact Sexual Function, Requiring a Multifaceted Approach

Discussing hormonal changes in menopause, it is mentioned that the decline in estrogen and potential degradation of the nerve fiber in the clitoral complex can affect sexual function. However, teaching women how to achieve orgasms from parts of the clitoral nerve with a better blood supply can help maintain sexual pleasure and interest during menopause.

For perimenopausal patients, after determining their preferences regarding ovulation and contraception, hormone therapy options like 17 beta [restricted term], the main estrogen during reproductive years with various health benefits, can be considered. New birth control pills containing 17 beta [restricted term] or [restricted term] valerate offer health benefits while also providing contraception.

Perim ...