#259 - Women's sexual health: Why it matters, what can go wrong, and how to fix it | Sharon Parish, M.D.
Dr. Sharon Parish, a sexual medicine specialist at Weill Cornell Medicine, discusses women's sexual health, covering physiology, conditions like low desire and anorgasmia, and the impact of factors like childbirth, metabolic health, and menopause. She explores treatment options, including hormones and FDA-approved drugs.
Deep Dive Analysis
21 Topic Outline
Introduction to Sexual Medicine and Dr. Parish's Background
The Biopsychosocial Model of Sexual Response in Women
Hormonal Changes and Life Stages Affecting Female Sexuality
Impact of Childbirth and Pelvic Floor Health on Sexual Function
Metabolic and Vascular Health's Role in Female Sexual Function
The Importance of Sexual Health for Overall Well-being
Case Study 1: Pre-menopausal Woman with Low Sexual Desire
Distinguishing Between Sexual Desire and Arousal in Women
Medications That Can Reduce Female Sexual Desire
Testosterone's Role in Women and FDA Approval Challenges
Practicalities and Challenges of Off-Label Testosterone Use
The Role of DHEA in Female Sexual Health
Case Study 2: Young Woman with Primary Anorgasmia
Understanding Female Orgasm and Stimulation Techniques
Resources for Enhancing Female Sexual Pleasure and Overcoming Anxiety
FDA-Approved Drugs for Low Desire in Pre-menopausal Women
Underutilization of Treatments for Female Sexual Dysfunction
Case Study 3: Post-menopausal Woman with Symptoms and Hormone Fears
Debunking Misconceptions About Hormone Replacement Therapy and Cancer
Treatment Options for Genitourinary Syndrome of Menopause
Addressing Ageism in Sexual Health and Finding Qualified Providers
8 Key Concepts
Biopsychosocial Model
This model integrates biological (neurotransmitters, hormones, vascular system), psychological (conditioning, reward, disappointment), and social/contextual factors (relationships, culture, life stage) to understand and address sexual health and response. It emphasizes the complex interplay of these elements in an individual's sexual experience.
Pelvic Floor
A basket of muscles and soft tissues that attach to the inner pelvis, supporting organs like the uterus, urethra, and anus. These muscles are crucial for urination, defecation, childbirth, and play an active role in sexual activity, contracting and releasing during arousal and orgasm.
Desire vs. Arousal (in women)
Desire refers to the mental willingness, interest, or 'sex hunger' to engage in sexual activity, while arousal is the physical and subjective excitement that occurs in response to sexual stimuli. Clinically, it's important to differentiate them as treatments often target distinct aspects of these experiences, despite some models combining them.
Circular Incentive Model
An alternative model for female sexual response, suggesting that women may not always experience spontaneous desire first. Instead, motivation for intimacy, connection, or the anticipated benefits of sex can drive engagement, leading to arousal, satisfaction, and then a desire to re-engage, forming a circular rather than linear process.
Genital Urinary Syndrome of Menopause (GSM)
This is the updated terminology for vulvovaginal atrophy, describing a collection of symptoms like vaginal dryness, pain during sex (dyspareunia), and other genitourinary issues that arise due to declining estrogen levels during and after menopause. The term aims to de-medicalize the condition, focusing on it as a syndrome rather than a disease.
Primary Anorgasmia
A condition in which an individual has never experienced an orgasm, either alone through self-stimulation or with a partner. It is distinct from secondary anorgasmia, where the ability to orgasm is lost after having previously experienced it.
Spectatoring and Performance Anxiety
Psychological phenomena where an individual becomes overly self-aware and critically observes their own sexual performance or body during sexual activity. This self-monitoring can create significant anxiety, distract from pleasure, and ultimately worsen sexual dysfunction, making it harder to achieve arousal or orgasm.
Sensate Focus
A therapeutic technique used in sex therapy to reduce performance anxiety and improve intimacy. It involves a structured series of exercises where partners engage in non-demanding physical touch, gradually increasing in intimacy, with the explicit goal of focusing on sensations and pleasure rather than performance or orgasm.
14 Questions Answered
Women are most likely to seek help for sexual dysfunction during their perimenopausal, late reproductive, and early postmenopausal years, often due to changes they weren't expecting or a desire to improve their sexuality.
While some women experience transient difficulties postpartum, most recover. Vaginal deliveries are generally safer for women's sexual health than C-sections, which can lead to other difficulties. Breastfeeding can cause temporary postmenopausal-like symptoms (dryness, irritation, low sex drive) due to low hormone levels.
Research is emerging, but there's a growing understanding that metabolic syndrome, obesity, hypertriglyceridemia, and cardiovascular disease risk factors may correlate with female sexual dysfunction, similar to how they impact erectile dysfunction in men.
Distressing low sexual desire is strongly correlated with impaired overall quality of life, leading to feelings of despair, sadness, and disconnection. Validating the importance of sexual function can motivate women to seek help, as it contributes significantly to happiness and relationship health.
Evolution did not prioritize female sexual function post-childbearing, leading to significant hormonal and physiological changes (like vulvovaginal atrophy) that can impact sexual health. However, modern medicine offers tools to safely manage and reverse these changes.
Desire is the mental willingness, interest, or 'sex hunger,' while arousal is the physical and subjective excitement that occurs in response to sexual stimuli. It's crucial to distinguish them clinically because treatments target different aspects, even though some models suggest they can be intertwined for women.
Antidepressants (especially SSRIs and SNRIs) are well-known offenders, causing multi-phase dysfunction in 30-40% of users. Combined hormonal contraceptives can also reduce desire by increasing SHBG, which binds testosterone, and by affecting local vulvar tissue.
Despite numerous randomized controlled trials showing efficacy and safety for low sexual desire in women, the FDA has not approved a testosterone product due to a perceived lack of long-term safety data, creating a regulatory conundrum.
Without an FDA-approved product, clinicians must rely on imprecise methods like using one-tenth of male topical doses or compounded creams, making it difficult to achieve consistent physiological levels and ensure safety.
Oral DHEA has not shown convincing efficacy for low sexual desire in women, and its safety is not well-studied. However, intravaginal DHEA (Intrarosa) is FDA-approved for genitourinary syndrome of menopause, effectively treating dryness and pain with minimal systemic absorption.
Strategies include learning about one's own body and effective stimulation techniques (e.g., clitoral flanks, vibrators), improving communication with partners, and addressing psychological factors like performance anxiety through sex therapy or mindfulness.
Yes, Flibanserin (Addyi) and Bremelanotide (Vyleesi) are two FDA-approved drugs for distressing low sexual desire in pre-menopausal women. Flibanserin is a daily oral pill, and Bremelanotide is an on-demand self-injectable.
There is a lack of awareness among women and healthcare providers about available treatments, persistent taboos around female sexuality, and a perception that seeking treatment for desire is an 'indulgence' rather than a legitimate health concern.
Systemic estrogen (with progesterone if she has a uterus) is the most effective treatment for vasomotor symptoms and can protect bone density. Local vaginal hormones or DHEA can address dryness and discomfort. Misconceptions about HRT risks (especially breast cancer) from past studies (like WHI) are often overblown and don't apply to modern, bioidentical, lower-dose therapies.
28 Actionable Insights
1. Prioritize Sexual Health for Wellbeing
Validate the importance of sexual function for overall quality of life, as this legitimizes seeking treatment and making lifestyle changes to improve happiness and well-being.
2. Manage Metabolic Health for Sex
Actively manage lifestyle and chronic conditions like diabetes and cardiovascular issues, as poor metabolic and vascular health are strongly linked to sexual dysfunction in both men and women.
3. Consider Menopausal Hormone Therapy
For post-menopausal women with disruptive hot flashes and night sweats, consider combined estrogen-progesterone therapy (or estrogen alone if no uterus) as it is the most effective treatment for symptom relief and is safe at low doses for short-term use.
4. Debunk HRT Breast Cancer Fears
Understand that modern bioidentical, lower-dose, transdermal hormone replacement therapy (HRT) has a much safer breast cancer profile than previously thought, with re-analysis of older studies showing minimal absolute risk and no increase in mortality.
5. HRT for Bone Health
Prioritize hormone replacement therapy for bone health and fracture prevention, as the risk of death from fractures later in life significantly outweighs the risk of death from breast cancer due to hormones.
6. Treat Vaginal Dryness Promptly
Seek treatment for vaginal dryness and discomfort, as it is one of the most treatable and manageable sexual health conditions with clear therapeutic options available.
7. Multi-Tool Approach for Vaginal Dryness
For vaginal dryness, pain with sexual activity, or genitourinary symptoms, use a multi-pronged approach including lubricants during sex, regular vaginal moisturizers, dilators for tightness, vibrators for enhanced stimulation, and consistent sexual activity.
8. Seek Postpartum Sexual Health Help
If breastfeeding and experiencing vaginal dryness, difficulty, pain, or low sexual function for six months or more without menses, consult a doctor as these symptoms are treatable and similar to post-menopausal changes.
9. Evaluate Contraception for Sexual Health
Be aware that combined hormonal contraception, especially ultra-low dose estrogen pills, can cause pain, mood issues, and lower free testosterone, impacting sexual desire and function. Discuss these potential effects with your doctor.
10. Demand Informed Contraception Choice
Seek informed consent about all contraception options and their potential impact on sexual health from your doctor, rather than just accepting a prescription, to make choices that align with your overall well-being.
11. Treat Depression for Sexual Function
Prioritize treating depression, as improving mental health often leads to better sexual function; if sexual dysfunction persists, discuss switching antidepressant medications with your doctor.
12. Explore Orgasm Stimulation Techniques
For anorgasmia, explore various stimulation techniques (clitoral, vaginal, vibrators, nipple stimulation) and learn what works best for your body, then communicate these preferences effectively to your partner.
13. Use Orgasm Education Resources
Utilize recommended books (e.g., ‘For Yourself,’ ‘Becoming Orgasmic,’ ‘The Joy of Sex’) and websites like OMGSYES.com to learn about female sexual anatomy and effective stimulation techniques for achieving orgasm.
14. Address Sexual Performance Anxiety
If experiencing performance anxiety or spectatoring during sex, consider sensate focus therapy, which gradually reintroduces sexual and partner communication in a non-threatening way.
15. Address Psychological Barriers to Sex
Seek psychological therapy if deep-seated issues like sexual trauma, genital aversion, PTSD, or strong religious/cultural prohibitions are interfering with sexual quality of life.
16. Testosterone for Female Low Desire
For post-menopausal women with distressing low desire, testosterone can be prescribed off-label using one-tenth of the male transdermal dose, prioritizing transdermal products and monitoring levels to stay within the physiologic range.
17. Safe Topical Testosterone Application
Apply topical testosterone to a relatively hairless area like the buttock, outer thigh, or back of the calf, avoiding washing for a couple of hours and ensuring no transfer to children or partners.
18. Reliable Contraception with Testosterone
Women of reproductive age using testosterone therapy must be on reliable contraception to prevent pregnancy, as testosterone use during pregnancy is not recommended.
19. Consider Flibanserin for Low Desire
For pre-menopausal women with distressing low desire, after addressing other factors, consider Flibanserin (Addyi), a daily 100mg bedtime pill that is FDA-approved and can improve desire and sexual events in 4-12 weeks.
20. Consider Bremelanotide for Low Desire
For pre-menopausal women with distressing low desire, consider Bremelanotide (Vyleesi), a self-injected on-demand treatment taken 45 minutes before sexual activity, which stimulates dopaminergic pathways to increase desire and arousal. Limit use to four times a month to reduce hyperpigmentation risk.
21. Vaginal DHEA for Atrophy
Consider intravaginal DHEA (Intrarosa) as an option for vulvovaginal atrophy and associated pain, especially post-menopause, as it has good efficacy and safety data with minimal systemic absorption.
22. Choose Transdermal HRT for VTE
For women considering hormone replacement therapy, opt for transdermal estrogen products (patches or gels) over oral formulations to potentially lower the risk of venous thromboembolism.
23. IUD for HRT Endometrial Protection
When using systemic estrogen with an intact uterus, a progesterone-coated IUD (like Mirena) can be considered as an off-label but clinically supported alternative for endometrial protection.
24. Manage Lifestyle for Menopause
Assess and manage lifestyle factors such as body weight, exercise, sleep, and relationship stress, as they can significantly influence the experience and distress of menopausal symptoms and overall sexual health.
25. Avoid Irritating Vaginal Products
Avoid warming liquids and scented products for vaginal care, as the sensitive tissue can be irritated by chemicals in these products.
26. Avoid Oral DHEA for Low Desire
Do not use oral DHEA for low sexual desire, as studies have not convincingly demonstrated its efficacy or safety for this indication.
27. Seek Sexual Medicine Specialists
To find specialized care for sexual health concerns, look for ‘sexual medicine specialist,’ ‘menopause specialist,’ ‘pelvic floor physical therapist,’ or ‘sex therapist’ using ‘find a provider’ websites from relevant professional societies.
28. Men: Get Cardiovascular Assessment for ED
Men experiencing erectile dysfunction should undergo a cardiovascular assessment, as ED can be a mirror to small vessel cardiovascular or cerebrovascular disease.
8 Key Quotes
Evolution has not been kind to women in a whole collection of ways. And although women aren't sick, our position in the field, and certainly mine, is that we have the skills, the tools, and the sophistication to manage it and to reverse it and to have a very different outcome than evolution would command.
Sharon Parish
I never want the forgotten, we'll call her sister, the forgotten sister to desire is arousal.
Sharon Parish
The data suggests, and my experience with this field suggests, that the time when women are most interested in looking into it is in those perimenopausal, late reproductive perimenopausal and early postmenopausal years.
Sharon Parish
I mean, women who are perimenopausal, menopausal, and postmenopausal aren't sick. And so sometimes people talk about it, and when you have postmenopausal, vulvovaginal atrophy, right? Like, that's a horrible term.
Sharon Parish
The goal, and this is like my mantra... is to fine tune that just the right amount of giving exogenous testosterone safely to turn the brain back on to where she was when she was satisfied, meaning like premenopausal satisfied, but not invoking lethality and keeping her safe.
Sharon Parish
It's not all that unusual for women to just have like a transient difficulty for four to six weeks and things improve. But having surgery, an abdominal surgery, you know, you're opening your abdominal wall, there are muscles, there's scarring. It sometimes leads to other kinds of later difficulties that people don't anticipate. And it's also safer for the mother and the baby not to have surgery.
Sharon Parish
The brain is a really active organ, as I'm sure you can imagine. We have thinking and feeling, and that probably on a biologic or neurophysiological level translates into neurotransmitters and the interaction with hormones and pathways, brain neural pathways, neural networks.
Sharon Parish
I couldn't agree with you more that there's a lot of misconceptions about the importance of preventing bone loss. And probably we're also treating osteoporosis when it becomes established and that the other options, although there are good ones, have limitations and you don't get the added benefit of some of the things that combined hormone therapy has.
Sharon Parish
3 Protocols
Hypothetical Treatment Plan for Pre-menopausal Woman with Low Desire (Case Study 1)
Sharon Parish- Conduct a comprehensive biopsychosocial assessment to identify all contributing factors (lifestyle, relationship, psychological, medical, medications).
- Address modifiable factors, such as changing contraception if combined hormonal contraceptives are suspected to be contributing to low desire.
- Consider FDA-approved medications for distressing low desire (Flibanserin or Bremelanotide) if other factors are managed and the problem persists.
- Monitor patient response to treatment, including efficacy and side effects, and adjust as needed based on individual preferences and clinical outcomes.
Management of Anorgasmia (Case Study 2)
Sharon Parish- Determine if the anorgasmia is primary (never experienced orgasm) or secondary (lost the ability to orgasm).
- Explore the context and reasons for seeking help now, ruling out psychological issues like trauma, relationship struggles, or external pressure.
- Assess the woman's knowledge of her own anatomy and various stimulation techniques.
- Provide education on different types of stimulation (e.g., clitoral flanks, vibrators) and recommend resources like books (e.g., 'For Yourself', 'Becoming Orgasmic', 'The Joy of Sex') or websites (e.g., OMGYES.com).
- Encourage exploration of different stimulation patterns to discover what works best for her.
- Facilitate communication with partners to teach them effective stimulation techniques if in a partnered relationship.
- Consider referral to a sex therapist for more explicit techniques like directed masturbation, sensate focus, or to address performance anxiety.
- If deep-seated psychological issues (e.g., sexual trauma, strong religious/cultural prohibitions) are identified, refer to a psychological professional for specialized therapy.
Treatment for Genitourinary Syndrome of Menopause (GSM) / Vulvovaginal Atrophy
Sharon Parish- For comfort during sexual activity, use lubricants (silicone-based are often recommended; avoid warming or scented products).
- For regular moisture and tissue health, use vaginal re-moisturizing agents (gels, suppositories, lotions) multiple times a week.
- If tissue tightness is present, particularly after a period of sexual inactivity, consider the use of dilators.
- To enhance response and maintain tissue health, promote regular sexual activity, including self-stimulation, and consider vibratory stimulation.
- If non-pharmacological methods are insufficient for dryness and pain, add a low-dose local vaginal hormone product (e.g., estrogen creams, rings, tablets, or DHEA/Intrarosa) to resurface the mucosal tissue.