You have 4 summaries left

The Peter Attia Drive

Women's sexual health: Why it matters, what can go wrong, and how to fix it | Sharon Parish, M.D.

Mon Jun 19 2023
Women's Sexual HealthMenopauseSexual DysfunctionHormone Replacement TherapyTestosteronePsychological Factors


The podcast explores women's sexual health, covering topics such as physiology, potential problems, and available treatments. It discusses the impact of the brain, pelvic floor, childbirth, menopause, psychological factors, medications, testosterone, and hormone replacement therapy on sexual function. The episodes emphasize the importance of understanding and managing women's sexual health for improved quality of life and relationships.


Understanding Women's Sexual Health

Women's sexual health is complex and influenced by various factors including physiology, hormones, relationships, and psychological factors. It is important for healthcare professionals to have a comprehensive understanding of these factors to provide effective treatment and support.

The Role of Testosterone in Women's Sexual Function

Testosterone plays a significant role in women's sexual desire and function. It is important to consider testosterone levels and potential treatments when addressing sexual dysfunction in women.

Challenges in Managing Menopausal Symptoms

Menopause can cause a range of symptoms that impact sexual health. Hormone replacement therapy and other pharmaceutical options can be effective in managing these symptoms and improving overall quality of life.

Psychological Factors and Sexual Dysfunction

Psychological factors can significantly impact sexual function in women. Addressing these factors through therapy and counseling can be an important part of treatment for sexual dysfunction.

Treatment Options for Sexual Dysfunction

There are various treatment options available for sexual dysfunction in women, including medications, hormonal therapies, and psychological interventions. It is important to consider individual preferences and needs when choosing a treatment approach.

Understanding Female Sexual Desire and Arousal

Female sexual desire and arousal are complex concepts that should be considered separately in the evaluation and treatment of sexual dysfunction. Understanding the distinctions between desire and arousal can help target appropriate treatments.

Managing Vulvovaginal Atrophy

Vulvovaginal atrophy is a common symptom of menopause that can cause discomfort and impact sexual function. There are various treatment options available, including lubricants, moisturizers, and hormonal therapies.

The Impact of Medications on Sexual Function

Certain medications, such as SSRIs and SNRIs, can have side effects that impact sexual function. It is important to consider these effects when prescribing medications and explore alternative options if necessary.

The Importance of Hormone Replacement Therapy

Hormone replacement therapy can be an effective treatment for menopausal symptoms and sexual dysfunction in women. It is important to weigh the potential risks and benefits when considering this treatment option.

Addressing Orgasmic Disorders

Orgasmic disorders can significantly impact sexual satisfaction and quality of life. Treatment options include psychological therapies, education about sexual stimulation techniques, and medication interventions.


  1. Introduction
  2. The Brain and Sexual Health
  3. Pelvic Floor and Postpartum Issues
  4. Understanding Women's Sexual Health
  5. Psychological Factors and Sexual Dysfunction
  6. Understanding Female Sexual Desire and Arousal
  7. Debate on Female Sexual Desire and Arousal
  8. Medications and Sexual Dysfunction
  9. Testosterone and Women's Sexual Function
  10. Testosterone Treatment in Women
  11. Methods of Testosterone Treatment
  12. Applying Testosterone and Monitoring Levels
  13. Measuring Testosterone Levels and DHEA
  14. Testosterone Replacement Therapy
  15. Orgasmic Disorders and Treatment
  16. Treatment Options for Orgasmic Disorders
  17. Psychological Therapies for Sexual Disorders
  18. Pharmaceutical Options for Sexual Dysfunction
  19. Treatment Options for Sexual Dysfunction
  20. Managing Sexual Dysfunction
  21. Menopause and Sexual Health
  22. Hormone Replacement Therapy for Menopause
  23. Managing Menopausal Symptoms
  24. Treatment Options for Vulvovaginal Atrophy


00:11 - 07:25

  • The podcast focuses on translating the science of longevity into accessible content in health and wellness.
  • Dr. Sharon Parrish, a sexual medicine specialist, is the guest for this episode.
  • The conversation revolves around women's sexual health, covering topics such as physiology, potential problems, and available treatments.
  • Three case studies are used to explore issues women may face throughout their lives, including desire, arousal, birth control, achieving orgasm, and hormone replacement.
  • The host expresses that he learned a lot from this episode and believes it will improve the quality of life for both men and women.

The Brain and Sexual Health

06:56 - 13:30

  • The brain plays a significant role in sexual health, involving neurotransmitters, hormones, neural pathways, conditioning, and learning.
  • Various factors impact sexual health including the general medical state, vascular system, nervous system, systemic medical issues, hormones, local genital milieu (vascular system, nervous system, mucosa), muscles and soft tissue.
  • Puberty and menopause are important milestones in a woman's life that can significantly affect sexual health due to hormonal changes and cognitive development.
  • Midlife women often face complex challenges in sexual medicine due to various factors such as relationships, menopausal changes, sexual function issues.
  • Anatomy changes post childbirth can impact sexual function. Common problems include low or hyperactive sexual desire, inability to have an orgasm, and discomfort or pain.
  • Desire as arousal is an important aspect of sexual health that should not be overlooked. It involves mental excitement and the response of genitals.
  • Childbirth involves hormone swings with estrogen and progesterone coming off quickly while testosterone declines more gradually. Vaginal delivery may have different impacts on the pelvic floor compared to C-sections.

Pelvic Floor and Postpartum Issues

13:14 - 19:42

  • Vaginal delivery and C-section have different impacts on the pelvic floor.
  • The pelvic floor is a basket of muscles that hold things up and help with movement.
  • Issues with the pelvic floor can lead to difficulty with urination, incontinence, pain during sexual activity, and changes in orgasmic function.
  • During pregnancy, the pelvic floor muscles stretch out, but improvements in sexual function may occur if there were previously tight muscles causing issues.
  • Deliveries can cause stretching, irritation, tearing, or trauma to the pelvic floor muscles.
  • C-sections are not necessarily better for women's sexual health compared to vaginal deliveries.
  • Postpartum issues like breastfeeding can lead to vaginal dryness, irritation, changes in sex drive, and vulva-vaginal symptoms.
  • Breastfeeding can result in hormonal changes similar to postmenopausal women.
  • If experiencing dryness and low sexual function while breastfeeding, it's important to talk to a doctor for possible solutions.
  • There are effective treatments available for managing vaginal dryness regardless of age or menopause status.

Understanding Women's Sexual Health

19:26 - 25:50

  • Understanding the complexity of women's sexual health is a major challenge for healthcare professionals.
  • The role of metabolic health and systemic vascular health in women's sexual health is still being studied.
  • In men, there is a clear relationship between cardiovascular disease and erectile dysfunction.
  • There is emerging discussion about whether similar measures exist in women.
  • Assessing genital sensation and blood flow in women is not as clear cut as it is in men.
  • Research on clitoral doppler testing and its correlation with risk factors in women is ongoing.
  • There is a need to define the role of clitoral doppler testing and its use as a predictor of other vascular issues for women.
  • Currently, there are limited options available for understanding and managing women's sexual health compared to men.
  • Improving metabolic health may have positive effects on sexual function in both men and women.

Psychological Factors and Sexual Dysfunction

31:29 - 38:08

  • Psychological factors, past sexual function or trauma, religious upbringing, and cultural influences can contribute to sexual dysfunction.
  • Sexual dysfunction can cause extreme distress and impair quality of life.
  • Loss of sexual desire, feelings of despair, hopelessness, feeling old or ugly, lack of connection, sadness, and hurt are common emotions associated with sexual dysfunction.
  • The level of distress experienced by individuals with sexual dysfunction is often underestimated by others.
  • Seeking assistance or treatment for sexual dysfunction is important for improving quality of life and relationships.
  • There is research suggesting that addressing sexual dysfunction may also improve overall health.
  • Evolution did not prioritize women's sexual function post childbearing years, which may contribute to challenges in women's sexual health.
  • Women who are perimenopausal, menopausal, and postmenopausal are not sick but experience physiological changes that can affect their sexual function.
  • Genital urinary syndrome of menopause is a more neutral term used to describe the symptoms experienced during and after menopause.
  • Despite evolutionary limitations, there are tools and strategies available to manage and reverse the effects of aging on women's sexual function.

Understanding Female Sexual Desire and Arousal

37:40 - 43:51

  • Evolution has not been kind to women in various ways, but women have the skills and tools to manage and reverse it.
  • The challenge is to balance therapy without causing additional problems like breast cancer or cardiac disease.
  • The field focuses on optimizing sexual function, quality of life, and longevity.
  • Desire and arousal are separate concepts in sexual dysfunction.
  • Masters and Johnson's response cycle model includes arousal leading to orgasm.
  • Helen Singer Kaplan added the concept of desire as distinct from arousal.
  • Separating desire and arousal helps understand different problems in patients.
  • Available treatments target different aspects of sexual dysfunction.

Debate on Female Sexual Desire and Arousal

43:27 - 49:50

  • There is a debate about whether female sexual desire and arousal should be separate or combined.
  • Clinical experience suggests that separating them is necessary to understand the problem and target different treatments.
  • The psychiatric compendium combines desire and arousal into one category, while sexual medicine societies advocate for separate categories.
  • The DSM-5 combines desire and arousal, but the upcoming ICD will maintain separate coding for both men and women.
  • A circular incentive model suggests that sexual response in women is not linear but driven by motivation, intimacy, stimuli, arousal, and satisfaction.
  • This model normalizes motivations other than spontaneous sexual desire.
  • However, it does not apply to individuals with low sexual desire who cannot make it work.
  • Factors like pain, medication use, menstrual history, and gynecologic health should also be considered when evaluating sexual function.

Medications and Sexual Dysfunction

49:26 - 55:24

  • Medications can affect different phases of sexual dysfunction.
  • SSRIs and SNRIs are known to cause multi-phase dysfunction.
  • Not all drugs within the same class have the same effects on sexual function.
  • Finding the right combination of efficacy and side effects with SSRIs or SNRIs may require switching drugs.
  • SNRIs have more variability in their effects on sexual dysfunction compared to SSRIs.
  • Venylyl vaccine functions as both an SSRI and an SNRI depending on the dosage.
  • Newer drugs like Velazidone and Vortioxetine work with multiple receptors, making them potentially better for sexual dysfunction.
  • Metazepine has low sexual dysfunction but comes with other side effects like sedation and weight gain.
  • Treating depression is important for improving sexual function in depressed individuals.

Testosterone and Women's Sexual Function

55:04 - 1:01:22

  • Testosterone acts in the brain and interacts with neurotransmitters to regulate desire.
  • The goal of testosterone treatment is to fine-tune the levels to where a woman was satisfied before menopause without causing harm.
  • There is uncertainty about what cells testosterone acts on in a woman's body.
  • Testosterone is more abundant in a woman's body than estrogen.
  • Changes in testosterone can be just as important for women's sexual desire as they are for men.
  • Many people underestimate the importance of testosterone for women's sexual functioning.
  • There is a lack of scientific rigor and double standards when it comes to evaluating testosterone replacement therapy for women.
  • A transdermal testosterone patch called Intrinsia showed positive improvements in sexual function but was not approved by the FDA.

Testosterone Treatment in Women

1:00:53 - 1:07:13

  • It showed positive improvements in hyperbiotics, sexual desire disorder, sex driver libido.
  • No adverse effects were observed in the short run.
  • The main side effects were hercitism (hair growth) and acne, which were relatively mild and easily managed.
  • The lack of long-term safety data was the main concern for FDA approval.
  • There is a double standard in approving testosterone products for men compared to women.
  • The libigel drug did not have efficacy but showed no increased rates of cardiovascular disease or breast cancer.
  • The FDA does not consider expert consensus and history when evaluating testosterone products for women.
  • A government-approved testosterone product called androfam is available in Australia but not widely used elsewhere.
  • Prescribing off-label testosterone for women is imprecise due to lack of regulation.

Methods of Testosterone Treatment

1:06:54 - 1:13:18

  • There are three methods to rely on for testosterone treatment in women, none of which are FDA approved.
  • The options include compounded cream, compounded injection, and compounded pellets.
  • Testosterone treatment aims to reach the physiologic range for mid to late reproductive age women.
  • Studies have shown that a dose of one-tenth of the male dose is safe and efficacious.
  • Long-term use data exists for up to four to five years with FDA-approved products for men.
  • Treating HSTD involves treating a syndrome rather than just testosterone levels.
  • Using male products at female doses is recommended due to difficulties in consistent concentrations with compounding.
  • Transdermal application is preferred over pellets or injections to avoid super physiologic levels.
  • Getting one-tenth of a male dose is challenging and requires creative solutions like dividing tubes into smaller piles or using specific measurements.
  • There is no standardized instruction for applying testosterone in women.

Applying Testosterone and Monitoring Levels

1:25:14 - 1:31:17

  • Testosterone can be applied to relatively hairless areas like the outer thigh or back of the calf for maximum absorption.
  • Avoid washing the area within a couple of hours after application.
  • Testosterone can transfer through skin-to-skin contact, so be cautious if you have children or a female partner.
  • If there is a potential for getting pregnant, good contraception is necessary to avoid using testosterone during pregnancy.
  • Correcting hormonal imbalances is preferred over leaving a patient on birth control pills and adding testosterone.
  • Patches and rings are effective forms of contraception and should be considered before making any changes.
  • The decision on which form of contraception to use should be discussed with a doctor based on individual factors.
  • Monitoring blood levels is important to ensure safe and effective doses of testosterone in women.
  • Total testosterone levels are used as a measure, but it's not clear if it's the best marker for determining effectiveness in cells and brain function.

Measuring Testosterone Levels and DHEA

1:30:49 - 1:37:17

  • Testosterone has complex effects on cells and can be measured using direct assays or mass spectrometry testing.
  • Supplements can impact testosterone readings, leading to inaccurate results.
  • DHEA is a precursor to testosterone and is available over the counter in the United States.
  • Oral DHEA has not shown positive outcomes for low sexual desire in trials, and safety data is limited.
  • Vaginal DHEA (introsa) has good efficacy and safety data for vulvovaginal atrophy resulting from menopause.
  • There is no significant difference in efficacy between estrogen suppositories and DHEA for this condition.
  • Some practitioners prefer DHEA due to its lack of a black box warning, which is associated with systemic estrogen therapy and breast cancer risk.

Testosterone Replacement Therapy

1:43:05 - 1:49:36

  • Some patients prefer not having a black box.
  • There is no proof that it's any more or less likely to cause any cancer at all.
  • In cancer survivors, it doesn't have a black box.
  • There are some people who might be quite androgen deficient and it might be a better choice to start with.
  • When you take someone's ovaries out at a young age, you're lapping off the younger, worse part of what they have.
  • There are two FDA-approved drugs for low sexual desire in women.
  • Primary anorgasmia means they've never had an orgasm, while secondary means they had one and now suddenly it's gone.
  • The most common reason women seek help for orgasm issues is being in a new relationship.
  • An orgasm is a peaking sensation of maximal pleasure and overall escalation throughout the body.
  • During sexual activity, there is sensory input that triggers the autonomic nervous system and causes vasodilation and muscle relaxation.
  • Eventually, the sympathetic nervous system gets triggered and leads to pelvic floor muscle contraction, blood vessel dilation, local hormone release, secretions, and the feeling of orgasm.

Orgasmic Disorders and Treatment

1:43:27 - 1:55:22

  • There is variability in the experience of orgasm, with some people feeling intense pleasure and pelvic floor contractions while others may only feel a warm sensation in their genitals.
  • The proportion of women who have an ejaculatory response is uncertain, with estimates ranging from every woman having it but not perceiving it to about 20% being aware of it.
  • The controversy surrounding female ejaculation centers around whether women have a prostate function that results in fluid squirting.
  • More commonly, lubrication from the mucosal surface becomes robust during arousal and orgasm due to vasodilation, nervous system activity, and local hormones like VIP and nitric oxide.
  • The location of the female prostate and where fluid squirting occurs is still debated.
  • The biggest issue for many women is not the lubrication or squirting, but rather the overall sensory experience, intensity, and muscle contractions associated with orgasm.
  • When addressing a woman's lack of orgasmic response, it is important to determine if this is a primary or secondary issue. Primary means she has never experienced orgasm while secondary means she used to have orgasms but no longer does.
  • For primary anorgasmia, factors such as psychological impact or physiological conditions should be explored. Medications or neurological conditions could be potential causes.

Treatment Options for Orgasmic Disorders

1:54:52 - 2:01:17

  • In large population-based studies, orgasmic problems are reported by 3 to 6% of women.
  • Orgasmic disorders tend to be most commonly reported in younger women.
  • Women who learn about their orgasmic response usually don't lose it unless there is an organic or psychological factor involved.
  • The workup for a woman with orgasmic problems involves taking a sexual function history and checking other phases of sexual function.
  • Communication between partners is important for addressing orgasmic problems in partner sex.
  • Many women need more stimulation with age, even without any pathology. Vibratory stimulation can help normalize this.
  • Education about vaginal, vulvar, and clitoral stimulation techniques can be helpful. Books like 'Becoming Orgasmic' and 'The Joy of Sex' provide useful information.
  • 'OMG Yes' is a website that offers education and videos on female stimulation and becoming orgasmic. It can also be helpful for partners to learn about female pleasure.
  • Psychological therapies like mindfulness-based therapy and cognitive therapy can be used for treating orgasmic disorders.

Psychological Therapies for Sexual Disorders

2:01:01 - 2:06:46

  • Sex therapists can be helpful for patients with sexual disorders, using techniques like directed masturbation and sensate focus.
  • Psychological therapies such as mindfulness-based therapy and cognitive therapy can also be used for sexual disorders.
  • Anxiety and performance anxiety can worsen sexual problems, but gradual introduction of sexual and partner communication can help alleviate these issues.
  • Deep-seated psychological issues, such as past trauma or religious prohibition, may require referral to a psychological professional.
  • Before considering pharmaceutical options, a biopsychosocial assessment should be conducted to identify modifiable factors and explore counseling or therapy options.
  • Testosterone is an option for postmenopausal women with distressing low desire, while pre-menopausal women have FDA-approved drugs like Flabanserin (Addyi) available.

Pharmaceutical Options for Sexual Dysfunction

2:06:26 - 2:12:47

  • The first drug discussed is an FDA-approved centrally acting drug for low libido in women.
  • It is taken daily at bedtime and has a single dose of 100 milligrams.
  • The drug has been around since 2019 and is similar in class to SSRIs.
  • Side effects include dizziness, tiredness, and dry mouth, but they are manageable if taken at night.
  • The drug is as safe as any central acting drug routinely prescribed.
  • There are contraindications with CIP-3A4 inhibitors that can worsen side effects of esolcerizal.
  • The second drug discussed is bremalanitide, which acts on dopaminergic pathways to stimulate desire.
  • It is self-injected on demand and lasts in the body for about 24 hours.
  • Women report feeling more interested and turned on after taking the drug.

Treatment Options for Sexual Dysfunction

2:12:21 - 2:18:24

  • Women experience increased interest and arousal when engaging in sexual activity.
  • Full Bancer and Bremen Lanotite are two available options for women.
  • Both medications have guaranteed maximum costs between $40 and $90 per month.
  • Nausea is a common side effect of these medications, but it usually subsides after the first couple of doses.
  • Using the medication without attempting sexual activity initially can help alleviate nausea.
  • The effects of the medication can last for at least 12 to 15 hours, possibly up to 24 hours.
  • Prescribing an anti-nausea pill along with the medication can help manage nausea symptoms.
  • Patient preference is an important factor in choosing between Full Bancer and Bremen Lanotite.
  • Focal hyperpigmentation is a rare occurrence associated with using Full Bancer more than eight times a month.
  • The medication is not approved for postmenopausal women due to FDA requirements, but there is no significant difference in outcomes or risks compared to premenopausal women.
  • Addie and Testosterone can be prescribed off-label for postmenopausal women without contraindication.
  • Testosterone is a controlled substance that requires a DEA number to prescribe monthly doses.

Managing Sexual Dysfunction

2:18:08 - 2:24:48

  • The choice of medication for sexual dysfunction depends on patient preference and any contraindications, such as CYP3A4 inhibitors or liver disease.
  • Some patients may be hesitant to inject themselves with medication, while others find it to be no big deal.
  • There is a lack of prescriptions being written for these drugs, possibly due to underutilization or lack of awareness.
  • Many women may not know about the available tools and treatments for sexual dysfunction, leading to misunderstandings and confusion.
  • Some women may feel invalidated in their desire for sexual pleasure and may benefit from medications that increase desire.
  • Treatment options for vulvovaginal atrophy causing GSM include lubricants, moisturizers, and topical hormones.
  • There is low recognition and uptake of treatment options for GSM, leading many women to suffer in silence.
  • Younger women may delay seeking help for sexual issues, focusing more on STD prevention rather than quality of sex or relationships.

Menopause and Sexual Health

2:24:24 - 2:30:47

  • Observations suggest that young adults in their 20s are not engaging in meaningful discovery about sexuality, which may impact future relationships.
  • A hypothetical patient is described as being post-menopausal with vasomotor symptoms, vaginal dryness, discomfort, and decreased sexual desire.
  • Menopausal transitional symptoms include hot flashes, night sweats, fatigue, difficulty sleeping, cognitive fogginess, and mood instability.
  • Mislabeling mental health issues during menopause should be avoided as it is a vulnerable time and hormonal changes can affect neurotransmitters.
  • The duration of menopausal symptoms can last three to five years or longer.
  • Menopause can also affect bone density and cause vulvovaginal tissue changes and discomfort during sexual activity.
  • Factors such as weight, exercise habits, relationship stress, and overall health status influence the experience of menopausal symptoms.
  • Combined estrogen progesterone therapy is an effective treatment for disruptive vasomotor symptoms but should be considered based on individual risk factors.

Hormone Replacement Therapy for Menopause

2:30:36 - 2:37:03

  • I can't promise that using hormones for a short-term period at the lowest effective dose won't give you breast cancer, but the risk is very low.
  • The Women's Health Initiative (WHI) study showed only a 0.1% increase in breast cancer risk with conjugated equine estrogen and MPA, which are not commonly used today.
  • Re-analyses of the WHI data have debunked many of the perceived risks associated with hormone therapy.
  • There are alternative oral and transdermal therapies available with lower doses and potentially better outcomes.
  • Progesterone therapy is important to protect against endometrial hyperplasia, even if used for a short term.
  • Transdermal estrogen may be safer than oral estrogen in terms of venothromboembolism risk.
  • A progesterone-coated IUD can be used for endometrial protection, although it's not a labeled indication.
  • The IUD strategy is considered safe and effective by many clinicians.
  • Hormone therapy can also be beneficial for osteoporosis prevention and bone protection.

Managing Menopausal Symptoms

2:36:42 - 2:43:03

  • Hormone replacement therapy (HRT) can prevent fractures in women and is more effective than breast cancer prevention.
  • Misconceptions about the importance of preventing bone loss have led to many women being deprived of HRT for the past 20 years.
  • Other factors like drinking alcohol, insulin resistance, and being overweight are riskier for breast cancer than small doses of transdermal hormones.
  • HRT is the best treatment for menopause symptoms and should be used at the lowest dose necessary.
  • There are other pharmaceutical options for managing symptoms, but they have limitations and may not work as well as HRT.
  • Vaginal dryness and discomfort can be addressed with lubricants, moisturizers, dilators, and increased stimulation.
  • Regular sexual activity can help maintain lubrication in the vagina.
  • Various estrogen products are available for vaginal atrophy, including rings, tablets, creams, inserts, and oral pills.

Treatment Options for Vulvovaginal Atrophy

2:42:34 - 2:48:28

  • Asfina, an oral pill called asfemipine, is indicated for vulva vaginal atrophy and may have benefits for breast protection in people at risk.
  • Esfenate, an oral serum, is indicated for vulva vaginal atrophy causing dysperunia. It may be theoretically useful for people who need breast protection or positive effects on bone, but it's not commonly prescribed.
  • The severity of tissue changes in women with hormone deficiency varies. Catching someone earlier can delay the need for additional treatments beyond lubricants and moisturizers.
  • Over time, the tissue changes progress and hormonal treatment may become necessary to prevent or manage symptoms.
  • There are barriers to managing vulva and vagina health, such as reluctance to use products or engage in self-care activities.
  • Education about sexual health and function across the life cycle is important to ensure proactive management of symptoms.