Podcast Summary: Orgasms as Medicine – De-Stigmatizing Sex & Pelvic Wellness in Perimenopause

Podcast: BETTER! Muscle, Mobility, Metabolism & (Peri)Menopause with Dr. Stephanie
Host: Dr. Stephanie Estima
Guest: Dr. Rena Malik (Board-certified Urologist)
Episode Date: December 15, 2025

Overview

This episode takes a bold, comprehensive dive into women’s pelvic health and sexuality through perimenopause and menopause, focusing on destigmatizing sex, the medical importance of orgasms, pelvic floor function, and practical approaches for better pelvic and sexual wellness. Dr. Stephanie Estima and Dr. Rena Malik break down science, clinical experience, and actionable tips – with plenty of myth-busting along the way. The conversation blends humor, frankness, and deep expertise, explicitly aiming to empower women to understand, discuss, and own their health and pleasure.

Key Topics and Insights

1. Orgasms as Medicine & Their Health Benefits

• Opening remark (00:00):
  Dr. Rena Malik:

  “I would say for the majority of people, orgasms are great. They have huge health benefits, they decrease heart rate, they decrease blood pressure, they help you with sleep. For some people, they help with focus because they get this like post orgasmic clarity...they decrease pain, right? So some people who are having pain orgasm and pain goes down...if people looked at orgasms as a medical tool sometimes, like we'd probably see a lot more benefits than we do.”

• Orgasm health impacts:

  • Reduces blood pressure and heart rate
  • Improves sleep and focus
  • Decreases pain
  • Potentially improves mood, longevity, and cardiovascular outcomes

• Notable quote (71:13):
  Dr. Stephanie:

  “There are 10,000 nerves that you are not using, ladies.” Dr. Malik:
  “Yes, absolutely.”

2. Pelvic Floor Anatomy, Health, and Dysfunction

• Definition and Function (05:56):
  Dr. Malik:

  • Pelvic floor = “a bowl of muscles that sits underneath the pelvis...”
  • Key roles: stability, continence, support for organs, sexual function

• What Hurts Pelvic Floor Health:

  • Childbirth (vaginal or C-section)
  • Sedentary lifestyle
  • Stress, anxiety (esp. “type A” personalities)
  • Constant bladder/bowel holding
  • Hovering to urinate

• Signs of Pelvic Floor Dysfunction:

  • Incontinence, bowel issues, sex-related pain
  • Hip/back pain
  • Urinary urgency or frequency

3. Incontinence Types & Pelvic Prolapse

• Types of Incontinence (09:46):

  • Stress Incontinence: Leakage when sneezing/laughing/jumping – often due to pelvic floor weakness
  • Urgency Incontinence: Sudden, uncontrollable urge – more related to the bladder and may be hormonal
  • Both can coexist; quality of life impacts are huge, though rarely dangerous

• Progression & Treatment:

  • Without intervention, symptoms can worsen with time/age
  • Delaying care common due to shame or busy lifestyles
  • Treatment is available, including pelvic floor therapy (14:48)

• Tight Pelvic Floor Issues (15:53):

  • May result from stress, trauma, or “clenching” behavior
  • Symptoms: pain with urination, constipation, pain during sex
  • Confused with weakness; professional evaluation is key

4. Pelvic Floor Solutions & Exercises

• Kegels (“Puss Ups”) (18:48):

  • Most popular exercise, helpful for many but often done incorrectly
  • Visualization: “pulling a blueberry up into the vagina”
  • In-person or online pelvic floor physiotherapy is ideal

• Tools/Devices:

  • Vaginal weights and trainers: Mixed opinions
  • Dr. Malik advises caution; personal assessment needed (23:24)

• Pelvic Organ Prolapse (21:31):

  • Feels like “something’s falling out”
  • Quality of life issue; treatable with exercises, pessary devices, or surgery

5. Pelvic Floor Exams: What to Expect (25:40)

• Stepwise, respectful approach
• Use of mirrors for education
• Partial speculum for greater comfort
• Functional assessments: bear down, cough
• Internal exam: test for both tension and strength
• Frequency: Not needed unless symptoms change

6. Genitourinary Syndrome of Menopause & Hormonal Changes

• Vaginal atrophy, tissue thinning, “lightning crotch”
• Common symptoms: dryness, UTIs, reduced sensation
• Vaginal hormones (esp. estrogen) are safe, easy, and underused:

  “It should be just available for everybody.” (34:07)

• Clitoral changes: atrophy, hood adhesions, reduced sensation

7. Clitoral Anatomy, Orgasms, and Blood Flow

• The clitoris is the direct homologue to the penis
• 10,000 nerve endings; much of structure internal (“wishbone” shape) (37:05)
• Blood flow, nerve function, and hormonal status all impact orgasm quality
• Arousal and erection happens in women, but is less externally visible

8. Responsive Desire & The “Orgasm Gap”

• Responsive desire: For most women, arousal often follows the start of intimacy, not the other way around (41:42)

  “It's like going to the gym: you don’t ever really want to go, but once you’re there, you’re happy you did.”

• Scheduling sex, “maintenance sex,” and prioritizing connection are important

• The “orgasm gap”:

  • First time heterosexual encounters – 95% of men orgasm, 65% of women
  • Lesbian couples, the rate for women is 95% – “it’s not that women are more complicated, it’s that we know our anatomy” (48:42)
  • Clitoral stimulation is key; communication and self-knowledge essential

• Pornography vs. Reality:

  • Porn sets unrealistic expectations; clitoral stimulation, arousal time, and real-life responses differ
  • Open conversation about sex and pleasure with kids is crucial; porn exposure starts early and can create misconceptions (54:07–56:02)

9. Low Desire in Perimenopause & Menopause

• Causes:

  • Multifactorial: hormonal (mainly testosterone/estrogen), blood flow, psychological, relationship dynamic, life stress

• Treatments:

  • Hormonal: Topical vaginal estrogen, off-label testosterone (compounded), but review with an experienced provider due to side effect potential
  • Meds: Flibanserin (Addyi), Vyleesi – limited to U.S., off-label for postmenopausal
  • Non-pharma: therapy, scheduling intimacy, improving communication
  • Emphasis on non-judgement and self-advocacy

10. UTIs and Bladder Health (84:19)

• Why women in midlife get recurrent UTIs
  • Hormonal changes, more basic vaginal pH, less lactobacilli
  • Prevention:
    • Hydration: +1.5L/day = 46% risk reduction
    • Vaginal estrogen
    • Cranberry (100% juice or 36mg soluble proanthocyanidins supplement)
  • Behavioral: don’t hover, empty bladder fully, urinate after sex
  • Shame is misplaced: “You are not dirty!”

Notable Quotes & Memorable Moments

• “I would say for the majority of people, orgasms are great. They have huge health benefits...”
  — Dr. Rena Malik (00:00)
• “The clitoris has 10,000 nerve endings. It is the only structure in the human body that is there solely for pleasure.”
  — Dr. Rena Malik (37:05)
• “If people looked at orgasms as a medical tool sometimes, like we'd probably see a lot more benefits than we do.”
  — Dr. Rena Malik (00:00, repeated at 70:02)
• “There are 10,000 nerves that you are not using, ladies.”
  — Dr. Stephanie Estima (71:13)

Actionable Takeaways

• Get familiar with your pelvic floor and genitalia; self-exploration is healthy and empowering
• Seek professional evaluation for any pelvic pain, incontinence, or sexual dysfunction – don’t let shame delay care
• Kegels and pelvic floor exercises are great but best done with professional pre-assessment; not everyone needs “strengthening”
• For midlife UTIs: prioritize vaginal estrogen, stay hydrated, and review supplements with a professional
• Communicate openly with partners about sex, pleasure, and preferences – the “orgasm gap” can (and should) be closed
• Talk to kids about sex, anatomy, and porn proactively; open dialogue is protective
• For low desire, explore biological, relational, and lifestyle roots before jumping to pharmaceuticals

Segment Timestamps

• 00:00 – Orgasms as medicine/introduction
• 05:36 – Pelvic floor: anatomy and basics
• 09:46 – Incontinence: types and impact
• 13:27 – Why symptoms worsen over time
• 15:53 – Tight pelvic floor and pain
• 18:48 – Kegels, cues, and therapy
• 21:31 – Pelvic organ prolapse explained
• 25:40 – What a pelvic floor exam is like
• 32:12 – Menopausal/vulvovaginal changes, vaginal estrogen
• 34:07 – Clitoral changes, atrophy, sensation
• 37:05 – Clitoral anatomy, women’s erections, responsive desire
• 44:38 – Maintenance sex, scheduling intimacy, media myths
• 48:42 – Orgasm gap, pleasure education, closing gap
• 54:07 – Porn vs. reality, sex ed for kids
• 58:22 – Does porn use affect real-life sex?
• 62:39 – Diversifying stimulation; types of orgasms
• 66:35 – Semen retention myths and science
• 70:02 – Orgasms: frequency, medical benefits
• 73:30 – Low desire: causes, treatments, testosterone
• 84:19 – UTIs, bladder health, prevention strategies
• 87:22 – Where to find Dr. Rena Malik online

Final Thoughts

This episode is an essential listen (and share!) for women moving into or through midlife, anyone partnered with a woman, and anyone interested in truly understanding pelvic health, sex, and destigmatizing conversations about both. Dr. Malik brings clarity, compassion, and expertise – reminding us that health and pleasure are not only compatible, they are fundamentally intertwined.

“We have 10,000 nerves there for a reason. What a shame not to put them to good use!”
— Dr. Stephanie Estima (Closing remarks)