#371 – Women's sexual health: desire, arousal, and orgasms, navigating perimenopause, and enhancing satisfaction | Sally Greenwald, M.D., M.P.H.
Dr. Sally Greenwald, an OB-GYN specializing in women's sexual health, discusses why sexual health is vital for overall well-being. She covers drivers of desire, anatomy, orgasm myths, hormonal roles in perimenopause/menopause, and practical strategies for enhancing sexual satisfaction and intimacy.
Deep Dive Analysis
15 Topic Outline
The Importance of Sexual Health for Longevity and Well-being
Understanding Female Orgasm and the Orgasm Gap
Foreplay, Responsive Desire, and the Role of Lubrication
Anatomy of the Clitoris and Pathways to Female Pleasure
The Accelerator and Brake Model of Female Sexual Desire
Testosterone Therapy for Hypoactive Sexual Desire Disorder in Women
Personalizing Perimenopause Care: Ovulation Preference and Hormonal Choices
Contraception Options and Their Impact on Hormones and Desire
Factors Affecting Female Libido Across Life Stages
Addressing Sexual Trauma and Pain in Sexual Health
A Comprehensive Vaginal Care Routine
Tips for Enhancing Sexual Satisfaction for Female Partners
Pharmacological Treatments for Low Sexual Desire in Women
Sexual Health Considerations During and After Pregnancy
Redesigning Sex Education for Comprehensive Understanding
6 Key Concepts
Accelerator and Brake Model (Sexual Desire)
This framework describes factors that increase (accelerators) or decrease (brakes) sexual desire. Accelerators include neurotransmitters like estrogen, testosterone, nitric oxide, dopamine, and oxytocin, which promote arousal and interest. Brakes include serotonin and prolactin, which can inhibit desire and arousal.
Spontaneous vs. Responsive Desire
Spontaneous desire is when arousal arises without direct stimulation, often in anticipation of intimacy, and is more common in men. Responsive desire is when arousal builds in response to physical or emotional stimulation, and is more common in women, often requiring an environment conducive to arousal.
Orgasm Gap
Refers to the significant disparity in orgasm frequency between men and women during heterosexual encounters. While 95% of men report almost always having an orgasm with a woman, only 30% of women report the same with a male partner, highlighting a health disparity in sexual pleasure.
Hyperosmolar Lubricants
These are lubricants with a high osmolality, meaning they have a higher concentration of solutes than vaginal tissues. Over time, hyperosmolar lubricants can draw water out of the vaginal cells due to osmosis, leading to dryness and micro-abrasions rather than effective lubrication.
Women's Dual Sexuality
A theoretical concept suggesting that women's motivations for participating in intercourse differ at various points in their menstrual cycle. During fertile windows, women may prioritize partners with features indicating genetic dominance, while at other times, they may seek partnership, companionship, and protection.
Genitourinary Syndrome of Lactation
This condition describes the hypoestrogenic (low estrogen) state of the vagina during lactation, which mimics the symptoms and pathophysiology of menopause. It can lead to vaginal dryness, pain with sex, and other discomforts, often requiring local estrogen treatment.
8 Questions Answered
Female orgasm is typically defined by rhythmic contractions of the pelvic floor muscles, occurring in four stages: excitement, plateau, orgasm, and resolution. It involves increased blood flow, neurotransmitter release, and muscle contractions.
When women are on their own, the average time to orgasm is less than four minutes. With a partner, it can be upwards of 21 to 25 minutes, though this is highly variable depending on the type of intimacy.
Appropriate foreplay allows for physiological changes in the vagina, such as lengthening, widening, and a change in angle, which can prevent pain during intercourse. It also helps build arousal, especially for women with responsive desire.
The 'G-spot' is a branch of the clitoris located along the anterior (front) wall of the vagina, about a third of the way in. It can be found by a 'come hither' motion with a finger and is easier to locate when aroused, though only about 10% of women orgasm from its stimulation alone.
This is largely a myth; while some data suggests acclimating to specific practices might make partnered orgasms harder if those practices aren't integrated, there's also data that orgasms beget orgasms, meaning more orgasms (regardless of method) can make it easier to achieve them in various contexts.
The impact is highly variable: meta-analyses show 20% of women experience an increase in sex drive, 65% no change, and 15% a decrease when suppressing ovulation with contraception. The sense of safety from pregnancy can also be a positive contributor to sexual desire.
Yes, in a healthy pregnancy without specific contraindications (like a low-lying placenta, low-lying blood vessel, or cervical insufficiency), sex is completely safe and can be quite pleasurable due to increased blood flow and higher levels of estrogen and oxytocin.
Key advice includes using lubrication, understanding female anatomy (clitoral complex, G-spot), engaging in sufficient foreplay, and recognizing the 'approach' phase (moments before orgasm) where consistency in stimulation is often preferred.
44 Actionable Insights
1. Prioritize Sexual Health
Consider sexual health a core part of overall health, life quality, and a ’longevity lever’ to include in your centenarian decathlon goals, as it impacts sleep, cardiovascular health, and relationships.
2. Address Desire Discordance
Recognize that sexual desire discordance (one partner wanting more, the other less) is a significant risk factor for divorce, and actively work to align on sexual frequency and satisfaction with your partner.
3. Achieve High VO2 Max
To enable sexual activity in your 80s or 90s, aim for a VO2 max north of 45-50 ml/kg/min in your younger years, as sex requires about 7 METs (VO2 of 25) and you need to be below your maximum.
4. Embrace Responsive Desire
Understand that women often experience ‘responsive desire’ (arousal leading to desire) rather than spontaneous desire, and actively curate arousal through environment, lubrication, vibrators, and mindfulness.
5. Extend Foreplay Duration
For women, foreplay lasting greater than 21 minutes significantly increases the likelihood of orgasm (over 90%), and appropriate foreplay reduces pain by allowing the vagina to change angle, width, and length.
6. Pre-Intercourse Lubrication Protocol
For women, use a silicone-based lubricant with a lube shooter 30 minutes prior to intercourse, placing it higher in the vaginal canal, then relax (e.g., read, drink tea, wash face) to cultivate arousal.
7. Choose Silicone-Based Lubricant
Opt for silicone-based lubricants over water-based ones, as many water-based products are hyperosmolar due to additives and can paradoxically dry out the vagina long-term by drawing out water molecules.
8. Check Lube Osmolality
Select lubricants with an osmolality close to 300 mOsm/kg (e.g., Uber Lube ~600, Good Clean Love Almost Naked ~280-300), and avoid high osmolality products like Astroglide (~8000) or KY (~4000-6000).
9. Eliminate Friction for Women
Recognize that friction is not necessary for female orgasm and is strongly associated with micro-tearing and pain during intercourse; women need no friction for pleasure.
10. Integrate Vibrators for Orgasm
Introduce vibrators into your sex life, especially as type A nerve fibers (responding to vibration/deep pressure) age better due to myelin, to help maintain the ability to achieve orgasm.
11. Explore Clitoral Anatomy
Understand the full clitoral anatomy, including the tip, vestibule, crura (wishbone structures), and the G-spot (anterior vaginal wall), to discover varied pleasure points and communicate effectively with partners.
12. Identify Pleasure Asymmetry
Recognize that the clitoral crura can be asymmetric, leading to greater pleasure on one side; explore and identify if you or your partner are a ‘righty’ or ’lefty’ for targeted stimulation.
13. Stimulate the G-Spot
For women, find the G-spot (anterior vaginal wall, about a third in, using a ‘come hither’ motion) when aroused, and relax through the urge to urinate to potentially achieve orgasm.
14. Normalize Non-Penetrative Orgasm
Understand that it is normal for 90% of women not to orgasm from penetrative intercourse alone; external clitoral stimulation is often necessary and valid for achieving orgasm.
15. Communicate Pleasure Preferences
Women should actively communicate their individual anatomical preferences and desired stimulation techniques to their partners to enhance pleasure and increase the likelihood of orgasm.
16. Pursue More Orgasms
Recognize that ‘orgasms beget orgasms,’ meaning the more you have, the easier it becomes to achieve them, training your body’s response to stimuli.
17. Implement Scheduled Sex
Schedule sex to proactively work on desire, treating it as a prioritized activity, as ‘sex begets sex’ and can increase overall desire.
18. Try ‘Fuck It February’
Engage in a ‘Fuck It February’ protocol by scheduling sex 2-3 times a week for the month to reduce pressure on the initiator and help the less interested partner cultivate responsive desire.
19. Consider Testosterone for HSDD
If experiencing hypoactive sexual desire disorder (low sex drive for over six months where you care), discuss testosterone therapy with your doctor, as it is well-studied for this condition in post-menopausal women.
20. Administer Testosterone Cream
For women, administer testosterone via cream (e.g., compounded or Testim oil in a syringe) on the inner thigh, aiming for a total testosterone level above 20 ng/dL and adjusting based on symptomatic response.
21. Assess Ovulation Preference
As a perimenopausal woman, determine if you prefer to continue ovulating or not, as this fundamental preference guides the most appropriate hormone therapy decisions for managing symptoms and contraception.
22. Track Cycle Symptoms
Maintain detailed symptom tracking, including timelines and relation to menstrual bleeds, to provide your doctor with crucial information for personalized hormone therapy decisions.
23. Consider 17-beta Estradiol Contraceptives
For perimenopausal women seeking contraception without ovulation, explore newer birth control pills containing 17-beta estradiol (e.g., Natasia) for potential bone and overall health benefits.
24. Use Slynd for Estrogen Contraindications
If estrogen is contraindicated, consider the drospirinone-only pill (Slynd) to suppress ovulation (98% efficacy), which can also help mitigate water retention and PMS symptoms due to its diuretic component.
25. Combine Slynd with Estradiol Patch
To achieve both contraception (via ovulation suppression with Slynd) and menopause hormone therapy benefits (like bone protection), consider combining the drospirinone-only pill with a 17-beta estradiol patch.
26. Natasia for Heavy Bleeding
For perimenopausal women experiencing heavy menstrual bleeding and needing contraception, Natasia (progestin with estradiol valerate) is an FDA-approved option that also provides hot flash and bone benefits.
27. Local Estrogen for Postpartum/Lactation
For breastfeeding women experiencing vaginal dryness or pain due to low estrogen, use local estrogen cream to maintain vaginal health and moisture, mimicking menopause treatment.
28. Local Estrogen for Cancer Survivors
Cancer survivors experiencing vaginal dryness or pain should feel comfortable using local estrogen treatment, as it is considered safe and encouraged for almost all patients in this population.
29. Consult Pelvic Floor Physical Therapist
Consider seeing a pelvic floor physical therapist to improve pelvic floor tone (leading to better quality orgasms) or to address hypertonicity caused by stress, trauma, or pain.
30. Implement Vaginal Moisturizer Routine
Incorporate vaginal moisturizers (e.g., Reverie, Replens suppositories nightly) into your self-care routine to recruit water molecules, lower pH, and maintain long-term vaginal tissue health.
31. Add Topical Estrogen (If Needed)
If systemic hormone therapy does not resolve vaginal pain or dryness within 6-8 weeks, add local intravaginal estrogen as a targeted long-term strategy to improve collagen and overall vaginal tone.
32. Utilize Oral Sex for Orgasm
Recognize that oral sex is one of the most effective ways for women to achieve orgasm with a partner, and explore techniques to maximize this pleasure.
33. Master ‘The Approach’ Technique
During stimulation, when a woman is just prior to orgasm, maintain the exact same pressure, speed, and depth without change, as two-thirds of women report this consistency is key for achieving orgasm.
34. Practice ‘Edging’ for Intensity
To achieve a more intense orgasm, use the ’edging’ technique by bringing your partner close to orgasm, stopping, and then repeating the process.
35. Consider Low-Dose THC
If legal, explore 1-2 milligrams of THC (preferably via standardized edibles) to enhance sexual experience and desire, noting that higher doses may be sedating and counterproductive.
36. Maintain Sex During Pregnancy
In a healthy pregnancy without contraindications (e.g., low placenta), continue sexual activity as it is completely safe and can be more pleasurable due to increased hormones and blood flow.
37. Resume Sex Postpartum at 6 Weeks
Plan to resume sexual activity at six weeks postpartum, regardless of vaginal or C-section birth, after receiving a medical check-up to ensure proper healing.
38. Use Correct Anatomical Verbiage
When educating children, use correct anatomical terms (e.g., penis, vulva) and normalize these as healthy parts of the body to foster accurate understanding and reduce shame.
39. Normalize Healthy Masturbation
Teach children that masturbation is a normal, healthy part of exploring their body and sexuality, emphasizing it should be done in a private setting to avoid shame.
40. Teach Specific, Enthusiastic Consent
Educate young people on consent as specific, enthusiastic, and persistent, emphasizing that it can change as the activity changes and should be continuously affirmed.
41. Address Pornography’s Unrealistic Expectations
Discuss the unrealistic expectations set by pornography with young people, and introduce healthy, accurate resources (e.g., omgyes.com) to provide a more realistic view of sexuality and pleasure.
42. Prioritize Safer Oral Sex Practices
Educate that penetrative intercourse with a condom is often safer for STI prevention than unprotected oral sex, challenging cultural perceptions and promoting informed choices.
43. Embrace Lifelong Sex Education
Advocate for and engage in sex education as an evolving, lifelong process, recognizing that bodies, physiology, and sexual needs change throughout different life stages.
44. Utilize omgyes.com Resource
Women and their partners can use omgyes.com to learn about female anatomy and various pleasure techniques, such as hard, round, gentle, or internal touches, to enhance sexual satisfaction.
5 Key Quotes
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.
Sally Greenwald
The divorce risk factor is what we call sexual desire discordance, or one partner wants more and one partner wants less.
Sally Greenwald
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.
Sally Greenwald
Orgasm is healthy, but 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.
Sally Greenwald
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. There's a lot more that goes into women's sexuality that I want you to be aware of.
Sally Greenwald
3 Protocols
Sensate Focus Exercise (for re-establishing intimacy after trauma or a break)
Sally Greenwald (referencing Dr. Leah Milhauser)- Step 1: Spend 20 minutes a couple of times a week being intimate with your partner, with no touching of the breasts or genitals.
- Step 2: Allow touching of breasts and genitals, but orgasm is off the table.
- Step 3: Orgasm is allowed, but no penetrative sex.
- Step 4: Penetrative intercourse is allowed.
Vaginal Care Routine (Analogous to Facial Care)
Sally Greenwald- Use a silicone-based lubricant (e.g., Uber Lube, Good Clean Love Almost Naked) during sexual activity to reduce micro-abrasions and pain.
- Use a vaginal moisturizer (e.g., Reverie, Replens suppositories) nightly to recruit water molecules and maintain tissue hydration.
- Consider topical/local estrogen (intravaginal hormones) if systemic hormone therapy is insufficient for vaginal health, acting as a 'long game' for collagen and tissue tone.
Fuck It February (Scheduled Sex for Increasing Desire)
Sally Greenwald- Schedule sex 2-3 times a week for the month of February (or any chosen month).
- The goal is to 'show up' and participate, without the pressure of immediate desire or guaranteed orgasm.
- This helps cultivate responsive desire and can lead to a sustained increase in libido over time.