The Peter Attia Drive, Episode #371

Guest: Dr. Sally Greenwald, MD, MPH (OB/GYN, women's sexual health specialist)
Host: Dr. Peter Attia, MD
Date: November 3, 2025
Title: Women’s sexual health: desire, arousal, and orgasms, navigating perimenopause, and enhancing satisfaction

Episode Overview

This episode explores women's sexual health from physiological, hormonal, and practical perspectives, with Dr. Sally Greenwald offering clinical insight into desire, arousal, orgasm, the realities of perimenopause, and tools for enhancing satisfaction. Peter and Dr. Greenwald discuss why sexual health should be considered a core domain of health and longevity; break down anatomy, biology, and evidence-based interventions; challenge common myths; and provide actionable guidance for both women and their partners.

Key Discussion Points & Insights

1. Why Sexual Health is Foundational to Health and Longevity

• Sexual health is integral to quality of life across all ages.

  “Sexual health is health... When you look at your longevity levers and think about your centenarian decathlon, for many people, this is on the list.” (Dr. Greenwald, 04:33)

• Regular sex provides measurable benefits: improved sleep quality, cardiovascular health (similar METs as light-to-moderate exercise), and positive relationship impact.
• Sexual desire discordance (partners mismatched in how much sex they want) is a strong risk factor for relationship dissatisfaction—more so than frequency of sex:

  “The divorce risk factor is what we call sexual desire discordance, or one partner wants more and one partner wants less.” (Dr. Greenwald, 09:44)

2. The Four Phases of Female Orgasm and Their Implications

• Four phases: Excitement (engorgement, lubrication), Plateau (neurotransmitter/hormone release), Orgasm (pelvic floor contractions), Resolution (return to baseline).
• Foreplay is critical:
  • Extended foreplay (>21 min) leads to >90% of women reaching orgasm.
  • Insufficient foreplay increases pain due to unprepared vaginal anatomy.

  “Foreplay lasting greater than 21 minutes, over 90% of women orgasm.” (Dr. Greenwald, 14:47)

3. The Orgasm Gap & Its Health Implications

• Orgasm frequency is starkly different by gender:
  • Men: ~95% report orgasm during partnered sex.
  • Women: ~30% report consistent orgasm with male partners (drops to 12% during one-night stands).
• This disparity is a “health gap,” not just a bedroom issue:

  “This disparity in how women experience pleasure becomes a health disparity. If sexual health is health and women aren’t experiencing it with the same amount of pleasure that men are...” (Dr. Greenwald, 18:06)

4. Models of Desire: Spontaneous vs. Responsive

• Men tend to have spontaneous desire (arousal from anticipation/visual cues); only ~15% of women do.
• Women generally have responsive desire (arousal from context, emotional connection, “getting started”).
• Techniques to foster responsive desire include:
  • Using lube proactively (ex: 30 minutes before sex, with “lube shooter” for internal application).
  • Mindfulness, erotic literature, chore play (“emotional investments in the relationship can lead to desire”).

  “If you want to work on your desire... stop waiting for that visual stimulus... Think about how you get responsive desire in response to arousal.” (Dr. Greenwald, 21:22)

5. Lubrication: Essentials for All Ages

• Most women need and benefit from lube, regardless of age or hormonal status.
• Correct lube selection is critical for minimizing pain and optimizing safety (see Product Recommendations below).
• Natural lubrication is produced by Skene’s glands, Bartholin’s glands, vaginal wall “sweating,” and cervical mucus.

  “The majority of women need lubrication and should use it.” (Dr. Greenwald, 24:32)

6. Vulvar and Clitoral Anatomy—What Most People Don’t Know

• The clitoris is a complex wishbone structure with 8,000+ nerve endings, mostly internal.
• Key point: Only ~10% of women can orgasm from penetration alone; most require direct clitoral stimulation.

  “For women who are achieving orgasm with a partner, it’s because they’ve identified positions, manual stimulation, introducing vibrators.” (Dr. Greenwald, 37:23)

• Many women and men lack anatomical literacy about the vulva and clitoris, contributing to the orgasm gap.
• Individual anatomy varies (e.g., “lefty/righty” sensitivity), reinforcing the need for personalized exploration.

7. Practical Tools: Vibrators, Positioning, and Communication

• Vibrators are evidence-based interventions—external vibration supports aging nerve fibers.
• Scheduling sex, self-exploration, and tailored positioning all enhance orgasmic potential.

  “Orgasms beget orgasms... The more orgasms you have, the easier it is to have an orgasm.” (Dr. Greenwald, 40:39)

8. Hormonal Interventions During Perimenopause—Individualized, Nuanced

• Main branch point: Does the patient like ovulating or not—guides whether to preserve or suppress cycles.
  • Menopause hormone therapy (MHT) uses 17β-estradiol (E2); does not suppress ovulation.
  • Oral contraceptives can suppress ovulation; newer forms use more “natural” estradiol or spironolactone derivatives (drospirenone).
  • Dosage, estrogen/progestin formulations, and delivery routes (patch, cream, etc.) are highly personalized.
• Dr. Greenwald favors comprehensive symptom tracking and patient involvement in decision-making.

9. Additional Topics

• Local estrogen is safe (even for many cancer survivors) for vaginal atrophy/dryness.
• Pelvic floor physical therapy is recommended both for pain and for enhancing orgasmic quality.
• Practical care: Using lubricant is compared to using sunscreen—“even if you never get sunburnt, it’s wise preventive care” (79:39).

Notable Quotes & Memorable Moments

• On why sexual health belongs in longevity discussions:

  “I'm having a hard time understanding how sex couldn't be a part of that conversation… It’s about quality of life for as long as possible.” (Dr. Greenwald, 04:33)

• On the impact of sexual education:

  “Only 41% of Gen Z men could accurately identify the clitoris on a pictorial... Sex education needs to get better.” (Dr. Greenwald, 32:20)

• On lubrication as a universal need:

  “I think the majority of women need lubrication and should use it… This idea that we just use lube as we age, I want to completely dispel.” (Dr. Greenwald, 24:32)

• On pleasure inequality:

  “If sexual health is health... this disparity in how women experience pleasure becomes a health disparity.” (Dr. Greenwald, 18:06)

• On actionable tips for men:

  “Lube. Get over it. It’s evidence-based. Anatomical awareness… understanding your partner’s pleasure zones... Foreplay starts outside the bedroom.” (Dr. Greenwald, 88:08)

• On how to teach kids about sexual health:

  “I would get away from the fear-based, ‘don’t get pregnant, don’t get an STD’... There has to be some education in terms of pleasure and anatomy and pathophysiology.” (Dr. Greenwald, 102:43)

Product Recommendations & Practical Strategies

• Preferred Lubricants:
  • UberLube (osmolality ~600, close to vaginal norm at 300)
  • Good Clean Love, Almost Naked (osmolality ~280–300)
  • Avoid high-osmolality lubes (e.g., KY, Astroglide) due to risk of dryness and tissue damage (83:19)
• Moisturizers:
  • Reverie (hyaluronic acid-based, pH balancing)
  • Replens (polycarbophil-based) (81:25)
• Vibrators:
  • Wand-type (e.g., Jimmy Jane, Goop Wand)
  • Air Pulse (for external stimulation)
• Scheduled Sex:
  • “F*ck It February”: Try 2–3 scheduled sessions/week to “reset” desire and increase frequency. (41:04)
• Mindfulness and Resources:
  • Erotic literature & audio apps (e.g., Dipsia, Meet Rosie)
  • OMGYes.com for anatomical education and pleasure strategies

Timestamps for Landmark Segments

• The Centrality of Sexual Health to Longevity: 04:33–10:25
• Orgasm Physiology and Foreplay: 13:25–16:17
• Orgasm Gap & Health Disparity: 16:24–19:00
• Desire: Spontaneous vs. Responsive, Practical Strategies: 19:11–23:49
• Lubrication: Physiology, Timing, Best Practices: 24:32–27:43
• Clitoral Anatomy & Implications for Orgasm: 31:11–38:05
• Positioning, Vibrators, and Myths: 39:49–43:01
• Menopause & Perimenopause Hormone Navigating: 49:32–70:54
• Education Gaps, Sex Ed Reforms, How to Talk to Kids: 102:43–109:07
• Pharmacologic & Nonpharmacologic Hacks for Low Desire: 90:35–97:46

Actionable Takeaways & Toolkit

• For Women:
  • Advocate for your sexual health as part of whole health.
  • Use lube—proactively, with intention, and select it with care.
  • Self-exploration is foundational: Know your anatomy, learn what you enjoy, and communicate it.
  • Track your cycle and preference regarding ovulation for better hormonal discussions.
  • Consider pelvic floor PT for pain or to enhance pleasure.
• For Partners (of Any Gender):
  • Learn about the clitoral complex and responsive desire.
  • Understand that more friction is not always better—listen, ask, and adapt.
  • Foreplay matters; timing and emotional context influence arousal.
  • Open communication about preferences is vital.
• For Clinicians:
  • Take detailed histories, including sexual function, pain, desire, trauma.
  • Individualize hormonal discussions (contraceptives vs. MHT; ovulation preferences).
  • Educate about, not just screen for, sexual health concerns.

Further Reading and Resources Cited

• Come As You Are (Emily Nagowski)
• Better Sex Through Mindfulness (Lori Brotto)
• Sex Talks (Vanessa Marin)
• She Comes First (Ian Kerner)
• OMGYes.com (for sexual education)
• Labia Library (normalizing vulvar variation)

Final Thoughts

Both Peter and Dr. Greenwald emphasize that sexual health isn’t just a “perk”—it’s a vital sign, a pillar of well-being, and an actionable longevity lever. The episode delivers practical, evidence-based advice with warmth, humor, and a no-shame philosophy, making it essential listening for women and their partners at every stage of life.