Orgasm After Menopause: Vibrators, Testosterone & Solutions with Dr. Lauren Streicher (Pt. 2)

Summary

unPAUSED with Dr. Mary Claire Haver

Episode: Orgasm After Menopause: Vibrators, Testosterone & Solutions with Dr. Lauren Streicher (Pt. 2)

Date: December 18, 2025
Host: Dr. Mary Claire Haver
Guest: Dr. Lauren Streicher

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Overview

In this candid and information-packed episode of unPAUSED, Dr. Mary Claire Haver continues her conversation with Dr. Lauren Streicher, Professor of OB/GYN at Northwestern and author of the audio series Come Again. They delve deep into orgasm after menopause—why orgasms can become elusive, the science behind vibrators (and which ones work best), the role of testosterone and other treatments, closing the orgasm gap, how to find a sexual medicine expert, and what gives Dr. Streicher hope for women’s sexual health moving forward. The tone is frank, empowering, and focused on practical solutions for midlife and beyond.

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Key Discussion Points & Insights

1. The Orgasm Gap and Why It Narrows with Age

• Orgasm gap definition: Men are statistically more likely than women to have orgasms during sex, particularly in younger age groups, but the gap narrows as both age ([23:51]).
• Why the gap narrows:
  • Men’s sexual function declines, while women grow more confident in advocating for their own pleasure and learn what works for them.
  • “Most women, hopefully by the time they hit 50, do know where their clitoris is and do know what to do with it.” — Dr. Streicher ([24:18]).
• Changing expectations: The cultural script is shifting—older women are less willing to compromise on their own pleasure ([25:11]).

2. Vibrators: Tools, Not Toys

• Vibration as a solution: Dr. Streicher reframes vibrators as “tools,” not toys, because they make orgasm possible for many women after menopause ([04:44]).
  • “Vibration will often work when nothing else does… the nerve endings that respond to vibration are not only bigger, but they have a thick myelin coat… and are going to last and last and last.” ([05:25])
• Vibrator science:
  • Different types respond to specific nerve endings—vibration-sensitive nerves are more durable with age.
  • Pulsatile modes may help with arousal; steady vibrations can be better for triggering orgasm ([07:25]).
• Including partners: It’s important for women to be able to discuss vibrators openly with partners. Dr. Streicher’s daughter, a sex therapist, provides scripts for these conversations on their podcast ([06:43]).
• Travel “hacks”: Some women use Sonicare toothbrushes as stand-ins for vibrators while traveling, though Dr. Streicher warns against using the brush head directly for safety reasons ([08:29]).

3. Gyne Hacks: Hands-Free Vulvar Viewing & More

• Hands-free mirror setup: Dr. Streicher describes a clever way for women to view their vulva using a magnifying mirror and the toilet seat—practical “Gyne hacks” also shared on her YouTube ([10:03]).
• Removing devices: For those with long nails, using dental floss as a retrieval string for vaginal rings is another tip ([11:05]).

4. Non-Hormonal Arousal Solutions

• Arousal creams: Most are vasodilators aimed at increasing blood flow; evidence is largely anecdotal ([11:37]).
  • “A lot of them are compounded products… do they work? Anecdotally, for a lot of women they do seem to make a difference.” ([12:07])
• CBD creams: Could help by increasing nerve sensitivity and blood flow—anecdotal reports of enhanced orgasm, with no known risks if used topically ([13:09]).
• Placebo effect: Acknowledged, but “at a minimum, it’s not going to be harmful” ([13:09]).

5. Neurotransmitters, Libido Drugs, and Testosterone

• Brain’s role: Orgasm relies on healthy neurotransmitter function, which is influenced by estrogen and testosterone levels ([14:14]).
• FDA-approved drugs:
  • Flibanserin (Addyi): Daily oral medication, originally approved for premenopausal women with hypoactive sexual desire disorder (HSDD), but also used off-label in older women ([16:32]).
    • “It works in about 50% of women, at best.” — Dr. Streicher ([17:20])
  • Bremelanotide (Vyleesi): Injectable, used on-demand, also about 50% effective. Main drawback is possible nausea ([17:21]).
• Testosterone: Often preferred by women because it feels “more natural”; efficacy is similar (about 50% see benefits), but careful monitoring is needed ([18:43]).
  • “There’s a comfort level with testosterone… just like estrogen, this is something that is in their body naturally.” ([18:43])

6. The Problem with Testosterone Pellets

• Pellet risks: Pellets deliver unregulated, super-physiologic doses of testosterone with higher risk of side effects—hair loss/growth, irreversible voice changes, potential for uterine pathology ([19:13]).
  • “Women should not use pellets because… increased risks of uterine pre-cancer and even cancer... and they’re very expensive.” ([21:19])
  • Voices of caution: Especially for professionals who use their voice (e.g., singers/actors), even normal doses can affect vocal cords ([23:18]).
• Ethical concerns: The business model is often cash-based with unnecessary testing and profit-driven practices ([21:33]).

7. Clinical Approach to Orgasm Difficulties

• Step-by-step approach:
  1. Take a detailed history—medical issues, medications, menopause symptoms, relationship factors ([28:08]).
  2. Address pain first: Pain with sex must be resolved before working on arousal/orgasm ([29:21]).
  3. Manage menopause symptoms, medications, sleep, show “the map to their clitoris.”
  4. Realistic outcomes:
     • “Is everyone going to be successful? I’d like to say yes, but that would not be honest. The answer is no. But that’s okay.” — Dr. Streicher ([30:57])
     • Emphasize pleasure, not orgasm as the only “goal” ([31:23]).
  5. Shift the sexual script: Sex can be defined by intimacy, affection, and touching—not just intercourse or orgasm.

8. Finding a Sexual Medicine Expert

• Expertise scarcity: Few formal sexual medicine fellowships exist; resources can be regional or incomplete ([32:27]).
  • Where to start: Menopause experts are often a good first step for midlife sexual concerns ([33:01]).
  • Oncology clinics: Sometimes have sexual health specialists, especially post-cancer ([33:49]).
  • Directory: International Society for the Study of Women’s Sexual Health maintains a directory, albeit incomplete ([32:31]).

9. Hope for the Future: Sex-Ed and Medical Training

• Grassroots change: Medical student interest is high—Dr. Streicher mentors a nationwide student consortium focused on sex education ([34:23]).
• Bringing specialties together: Multiple paths to become a sexual medicine expert (OBGYN, psychiatry, internal medicine, urology, etc.) ([35:51]).
• Cultural shift:
  • “Menopause is not just having a moment. I’ve been talking about menopause for 20, 30 years, but no one wanted to talk about it… now that’s all they want to talk about.” — Dr. Streicher ([37:51])
  • Goal: Normalize these conversations between all generations ([38:56]).

10. Empowering Women with Resources

• Dr. Streicher’s series:
  • Come Again: 30-episode audio series for clinicians and consumers, with actionable insights and historical context ([36:29]).
• Practical advice: Women without access to specialists can use scripts to advocate for themselves in general clinical settings ([41:35]).
  • “Not only do we have solutions, but… I’m going to give you the roadmap. I’m going to give you the script…” ([41:35])

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Notable Quotes

“Vibrators are tools, not toys… because a tool is something that makes having an orgasm possible.”
— Dr. Lauren Streicher ([04:44])

“The nerve endings that respond to vibration are not only bigger, but they have a thick myelin coat… and are going to last and last and last.”
— Dr. Lauren Streicher ([05:25])

“Pulsatile is better for arousal, but steady is better to actually trigger the orgasm.”
— Dr. Lauren Streicher ([07:25])

“I think it’s important to rewrite the script. There’s this idea that sex is not successful unless you have an orgasm… Sex is over when you’re ready for it to be over because you’ve been having pleasure.”
— Dr. Lauren Streicher ([31:23])

“If someone is pushing pellets, don’t walk, run.”
— Dr. Lauren Streicher ([21:33])

“We want to make a difference… Some days it gets overwhelming, [but] someone will say something I wrote… made them find a doctor, change their life… that’s why I’m doing this.”
— Dr. Mary Claire Haver ([41:12])

“If you don’t have a doctor, it’s okay. I’m going to give you the roadmap… and you can go to that doctor and you can say, ‘Dr. Haver told me…’ They will not say no.”
— Dr. Lauren Streicher ([41:35])

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Important Timestamps

• Orgasm gap and its evolution: [23:51] – [25:11]
• Why vibrators work post-menopause: [04:44] – [06:42]
• Travel hacks for vibrators: [08:29]
• Non-hormonal arousal creams and CBD: [11:37] – [14:08]
• Neurotransmitters, medications, and testosterone: [14:14] – [18:43]
• Dangers of testosterone pellets: [19:13] – [23:18]
• Doctor’s clinical approach to orgasm issues: [28:08] – [31:23]
• How to find a sexual medicine expert: [32:27] – [34:17]
• Medical student sex-ed consortium: [34:23]
• Empowering women with self-advocacy: [41:35]

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Resources & How to Connect

• Dr. Lauren Streicher:
  • Instagram: @doctorstriker
  • Website: drstriker.com
  • Podcast: Dr. Streicher’s Inside Information
  • Audio Series: Come Again (available via her website)
• Dr. Mary Claire Haver:
  • Instagram: @doctormaryclair
  • Website: thepauselife.com
  • Book: The New Perimenopause (pre-order on Amazon)

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Final Thoughts

Dr. Streicher and Dr. Haver’s open, solution-oriented discussion demolishes taboos around women’s pleasure in midlife, providing science-backed advice, practical hacks, and hope for better, more accessible sexual health care. Women don’t need to settle—they have options, tools, and the right to advocate for their own pleasure at every stage of life.

Transcript

[A]

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[B]

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[B]

Hi, I'm Dr. Mary Claire Haver. If you're loving these bold, unfiltered conversations about what it takes to thrive in midlife, make sure you never miss an episode. Follow unpaused with Dr. Mary Claire Haver on Amazon Music. It's free and easy. Just tap follow in the Amazon Music app so every new episode is ready when you are.

[C]

You know, sex ed, we know, is all about how not to get pregnant or get an sti. It has nothing to do with pleasure. But the guys are not taught that. The guys are taught you should have pleasure. So that's part of the problem is that there isn't the expectation. So are they upset? I think the ones that expect pleasure are the ones who know how to have pleasure. So older women, different story.

[B]

So we have an older patient who comes into your clinic and she says, I am struggling with orgasm. I used to have them. They're great and I still want them. What's your first step? Walk me through.

[C]

The first step is, unless you're running a sexual medicine clinic, the likelihood of that happening is about zero. Let's be honest. How many of patients when you were doing General Obgyn walked in your door and said, hey, Dr. Haver, I can't have an orgasm. Will you help me?

[B]

The views and opinions expressed on Unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis or treatment. Welcome back to unpaused. I'm Dr. Mary Claire Haver. In our last episode, Dr. Lauren Stryker and I started an in depth conversation about orgasm, sexual function and why these topics are still so difficult to talk about even in doctor's offices. There was so much ground to cover on this topic that we decided to split this conversation into a two part episode. So today we're picking up right where we left off. If you're just joining us, let me tell you about Dr. Stryker. She's a professor of obstetrics and gynecology at Northwestern University Feinberg School of Medicine, the host of Dr. Stryker's Inside Information podcast, and the creator of come again, a 30 episode audio series on sexuality and sexual function. For decades, she's been leading the conversations that most clinicians still won't have. Today we're talking about vibrators and what the research shows, non hormonal arousal creams and whether they work, the role of neurotransmitters and FDA approved libido drugs like Addi and Vylice, and why testosterone is often the preferred option for women. Dr. Stryker breaks down the problem with pellets, explains the orgasm gap between men and women and why it narrows with age, and walks us through her actual clinical approach when a patient comes in struggling with orgasm. We also talk about how to find a sexual medicine expert, why pain must be addressed first, and what gives her hope for the future of this field. If you missed part one, I encourage you to go back and listen. But if you're ready to learn what actually is possible when it comes to sexual function in midlife and beyond, let's continue the conversation. Talk to me about vibrators devices. You touched on them earlier, but why does vibration work so well?

[C]

I call vibrators tools, not toys, because toys implies that it's gonna give you additional pleasure and it's gonna make pleasure possible. A tool is something that makes having an orgasm possible. So let's call them tools because I think that also really is kind of just empowering to women to say, you know, if I can't swim and I'm gonna go on a life raft to get me to have fun in the water. Well, if I can't have an orgasm, then I'm gonna use this tool to facilitate my ability to have an orgasm. Why did vibration work when nothing else does? Let me back up. Because so often a woman will come to the clinic and say, I can't have an orgasm anymore. And I'll say, well, how about when you use your vibrator? And she'll say, well, of course if I use my vibrator I can. But I didn't used to have to use my vibrator. Got it. So what's changed? Well, before I talked about those little nerve endings in the clitoris. It turns out we have different types of nerve endings and different sizes of nerve endings. Some of them respond to soft touch, licking, stroking. Some of them respond to vibration. It turns out that the little nerve endings in the clitoris that respond to stroking and licking and touch are the ones that tend to deteriorate with age the most quickly. So even if you have the best liquor and stroker in town, those nerve endings are just dead. They're just not functional. But there is a God or goddess. The nerve endings that respond to vibration are not only bigger, but they have a thick myelin coat which is good to go. Chin around them, they are good to go. And they are going to last and last and last. So what that means is that vibration will often work when nothing else does. And I think if people are gonna listen to come again if they're only gonna listen to one episode, the vibrator one.

[B]

Yes, yes.

[C]

And then my daughter, who also joins in in that episode, she's a sex therapist. She talks about how to get the partner in your life on board with a vibrator. Because a lot of times women are embarrassed to bring it up. They think that the guy's gonna feel like a failure, partner's gonna feel like a failure. If you need to bring the vibrator in the bedroom. So she gives the script, the language, how to approach that, because that's just as important as. No, I mean, it's fine when you're on your own, but if you're looking to have an orgasm with partnered sex, you need to get your partner to, to be in on it.

[B]

So has anyone done a head to head comparison of different vibrators? Cause there's, you know, I guess I lump them into only on the outside or optional, you know, penetration. And so people feel very strongly about what kind of vibrator they should have. And now there's the ones with the little suction.

[C]

The suction which is a whole different thing. The suction is different. Cause what the suction is doing. Well, it's a lot. It's pretty intense, and not necessarily in a good way, but. But what the suction is doing is it's drawing blood flow, it's increasing blood flow. So that's not working with vibration. Have people done this study? Oh, you bet. There's a lot of vibrator companies out there who are really on a mission to find out what is the pulsation speed, what is the level of vibration. And there's data. There's data. I don't think I put that in. Come again? Cause it just got too sciency. But when I do have a lecture, I have a lecture that I give to doctors on vibration, and I talk about how you get different levels of vibration and what seems to work better. For example, pulsatile is better for arousal, but steady is better to actually trigger the orgasm.

[B]

Because I have these conversations with my girlfriends, and it's all very different. They. Most of them feel like the least complicated the better. Like all these extra buttons and whistles and heat.

[C]

Exactly.

[B]

And then you have to go back through the cycles. Well, not to mention you've got to.

[C]

Turn the lights on to see.

[B]

Your glasses on to see.

[C]

Exactly. Do you know what is one of the strongest vibrators out there? Your Sonicare toothbrush.

[B]

I'm Jesus God Almighty. We just shot the stock of Sonicare. Up, up.

[C]

Okay, I want to be clear. Do not use your brush.

[B]

How would you do that?

[C]

No, you get, like, abrasions of your clitoris. That would be a disaster.

[B]

Okay, so I have a Sonicare. How would I use it as a vibrator?

[C]

This is a big travel thing, of course, because people are worried about the TSA finding their vibrator in their suitcase, which, trust me, it won't be the first vibrator they found. As a matter of fact, it's really funny because when I come home from conferen and people are just throwing vibrators at me right and left, you know, this is great to be my friend, because this is a gift that I give to all my friends because I have more vibrators than any human being would know what to do. So I go through tsa and they're, like, holding them up one after another, saying, wow, what does she do for a living?

[B]

Pink, purple, blue.

[C]

And then they find, of course, my podcast microphone, and they think that's some kind of really super duper special vibrator. But I digress. So. But travel. Travel Vibrator. A lot of people do rely on their toothbrush. You need to put something over it, like a gym sock. At a minimum. At a minimum. And be really, really careful. I don't, I'm just to be clear, I'm not recommending a toothbrush. I'm just saying this is what a.

[B]

Lot of people do. I'm gonna check the stock of Sonicare right now. We're gonna invest today.

[C]

Okay. So someone I. I have a YouTube right next to my. I have, it's called Gyne hacks and I have seven or eight YouTube videos on interesting hacks to solve problems. Which is why I have the hands free vulva Vue. How to get your s string out. If you have language.

[B]

Walk me through this. I'm so fascinated. Can you explain to our listeners how hands free view of their vulva? Is it possible?

[C]

Oh, yeah. And with things you have at home. Okay, this is, you know, but I will say it's kind of hard to describe without a video. But I'll tell you what it is.

[B]

And then I'm imagining a mirror.

[C]

I'll give you the link. No, no, it's actually much more innovative than that. What you do is you take one of those magnifying makeup, fold up round mirrors, check on a hinge, ideally with a light. Okay. You lift up the toilet seat, you put the unmirrored part under the toilet seat and you put it down. Now you're going to sit on the toilet seat because now it's holding it in place. Can you picture this?

[B]

Yeah.

[C]

So the mirror is now coming out from the toilet seat and you can adjust the mirror to get the perfect view. If you don't have a mirror with a light, you know, you can use a ring light or you can use your phone, you can use your cell phone, whatever. And suddenly you are sitting on it, holding it into place and you've got a hands free view.

[B]

That's amazing.

[C]

So this is right after my Gyne hack on how to get your fem ring or your s string out. If you have long nails, dental floss. You tie a long ring of unmented dental floss. Just like a tampon string, push it up and then when it's time to take out your ring.

[B]

Oh, and then you'd like a tampon. You made a string.

[C]

You just pull it down. It comes down to the opening of the vagina and you just grab it out. So I have, so I have about 15 gyne hacks. I haven't put all of them on YouTube.

[B]

People are going to be running to your YouTube. This is hilarious. Let's go through non hormonal arousal creams. Do we have any evidence this is.

[C]

Also a data free zone? However, there are a lot of them out there. These are also compounded products.

[B]

I've seen Scream cream.

[C]

Yeah, we try not to call it scream cream because we think that's kind of offensive.

[B]

Yeah.

[C]

You know, women having pleasure shouldn't be labeled as we want you screaming, we want them. Anyway, I call it just arousal cream.

[B]

Smile cream.

[C]

Arousal cream. Arousal cream, Orgasm cream. What are these? Well, there's different combinations of products that are all basically vasodilators.

[B]

Okay.

[C]

They all increase blood flow. And do they work anecdotally? For a lot of women, they do seem to make a difference. Again, the instructions usually say use it just prior to sexual activity. I think you're better off using it on a regular basis to increase the health of the clitoris. It can be irritating to some women. And in that episode, of course, I go through all the ingredients to look for all the things that might help the other arousal cream that is out there that a lot of women are using. CBD really? Well, think about this. Okay, again, data free zone. Although I've done some research on that which I had not published yet. But the use of CBD on the clitoris, CBD cannabidiol is number one, a vasodilator. Number two, it's anti inflammatory. Number three. This is where it gets interesting. In diabetics who have peripheral neuropathy, CBD cream has been shown to increase nerve sensitivity.

[B]

Wow.

[C]

Now, clitoral nerves are not foot nerves. However, nerves are nerves. And I will tell you anecdotally that women who use CBD oil on their clitoris appear to have enhancement of their ability to have an orgasm. Again, rubbing it in for a long time helps. A lot of this might be placebo. We don't know. This is a data free zone. But whenever I recommend something that we don't have, data, at a minimum, I want to recommend something that is not going to be harmful. And we know that this is not going to be harmful with the information that we do have. Because CBD is used in large amounts all over the body. Not the same as using systemic cannabis. That's a whole nother discussion. A lot of women will use that for orgasm too. And without getting into the biology and the science, a lot of that is about disinhibition. It's working more in the brain in terms of maybe helping with general aches and Pains, maybe just waking up your neurotransmitters. We don't know. We don't know. But that's not getting the same local application.

[B]

Talk to me about neurotransmitters and kind of brain forward strategies to help with orgasm.

[C]

All right, so we know. We know that those neurotransmitters are critically important in terms of not only arousal, but in sending messages down to the pelvis. It's kind of, you know, that's the brain, like everything else is in charge of what's happening all over your body. We also know, and I know you've talked about this, Mary Claire, again and again and again, that we have estrogen receptors and testosterone receptors throughout our brain. What do they do? They prime the pump, they make those neurotransmitters work better, and they enhance the release of those neurotransmitters. So if you have something that's gonna get in the way of that, you are going to lose the benefit of the brain talking to your pelvis. What's gonna get in the way of that? Well, we've already talked about if you don't have estrogen, right, not only are you gonna have problems in terms of what's happening right down at the level of your vulva, vagina and clitoris, but you're also going to have some problems in terms of the function of your neurotransmitters. They're not gonna be primed as much. Which is also why when people take systemic estrogen, even if they're not putting it directly on their clitoris, for a lot of women, in addition to getting rid of their menopause symptoms, that can in some cases also enhance sexual function. So there's that. We've already talked about the SSRIs and the impact that they have when we talk about how else can we enhance the function of these neurotransmitters. Well, there are two libido drugs that are FDA approved. One is flibanserin, the other is Brimulanatide. And these are FDA approved for use in young women, of course. But we do have data in older women. And it's important to keep in mind that while we don't think of those drugs as being orgasm drugs, they really are because they are working on those transmitters, specifically dopamine. Dopamine is the one we really want. You know, when you're dopey with love, that's how I always remember it's dopamine. When I teach the medical students, I always say dopamine is Dopey with love. Serotonin is stop, stop, stop. We gotta go work and do laundry. So we know that those drugs enhance the release of dop, so in turn is going to help with arousal, which in turn is going to help with our guests.

[B]

So we have a terrible PR campaign around these drugs. And I don't think most women even know what they are, that they're available and what they could do. So I think just let's take two minutes to go over them again.

[C]

Flo Bancerin has been FDA approved now for, I think it's, boy, is it 10 years, almost 10 years. The trade name is Addie, Addy, Addie. And this is a pill that you take not on, on demand. You have to take it on a regular basis.

[B]

It's like a vitamin.

[C]

I come on. My patients take it at night because it might make you a little sleepy, which is a good thing for most women. But other than that, it really has very few side effects. There was a concern initially about alcohol, which didn't really pan out. But for most women it is a safe drug and it does help with libido, is. It is FDA approved specifically for hypoactive sexual desire disorder, which is decreased libido in women who want to do something about it. Not everybody does. And we know that decreased libido is actually the number one sexual problem that postmenopausal women have. And so. But of course, this is not FDA approved in postmenopause women, but we have studies that show that it is in our clinic.

[B]

We use it offline, that it is.

[C]

You have to pay for it. That's the problem. So how well does it work? It works in about 50% of women, at best. At best. And when people say, well, why is it so few? It's because desire is so multifactorial. You know, this is not the only thing happening here. The, the other drug, brimalanotide, the trade name is Vylisi. And this is an on demand drug. And the way Vilici works is that this is a pen like little EpiPen kind of thing, and you plunge it into your thigh about 30, 40 minutes before you would like to have sex. And again, it's gonna modify those all important neurotransmitters, kick them into action so that you are suddenly in the mood. It also works in about 50% of women. The number one side effect, which is a problem, it's not the fact that you've got to auto inject, it's the nausea, you know, something about vomiting on Your partner is a real libido killer. But most women, that doesn't happen. And actually, sometimes it happens initially and then it gets better. Do a lot of women use these drugs? No, they do not. Do they use them postmenopausally? No, they do not. Aside from the fact that a lot of people, especially with addi, they don't like the idea of taking something every day. I tell them about the nausea. That kind of scares them off. And when I talk to women who want something pharmacologic and I offer them these two, and then I also mentioned testosterone. And when I go through the options of flibanserin, brimalanatide and testosterone, most women opt to give testosterone a try. And I. And I think the reason why that.

[B]

We have the same clinical experience and.

[C]

The reason why is I. There's a comfort level with testosterone. When I explain to women that just like estrogen, this is something that is in their body naturally, that we are giving them a little boost of their testosterone to help with their libido. And that just sits better. It sits better. There is more of a comfort level with that. But when we look at how well testosterone works for libido specifically, it's about the same. Yeah, it's about 50% at best. Again, because it's so multifactorial.

[B]

Lot of talk about pellets.

[C]

Don't get me started on pellets. I have an entire episode called the problem with pellets. Pellets.

[B]

So the problem is not the pellets, it's the pellets.

[C]

It's the pellet pushers.

[B]

I'm like, I don't want to demonize a method of delivery to the human body. We have FDA approved pellets for certain medications. Like, it's just a way to get medicine in your system. But the way it's marketed, the way that they teach. I even went and signed up to do a pellet. You're brave to get. No, just because I wanted to see what are they teaching these clinicians.

[C]

As you said, it's not the method of delivery, it's what's in the pellets. And they are these super physiologic, meaning much higher doses than every woman has ever met.

[B]

Patient come to me, we check everyone's levels who was ever in a physiologic range.

[C]

Sky high, sky high. And, you know, we could go on and we could spend hours just talking about pellets. So let's cut to the chase and say that women should not use pellets because not only are they getting unnecessarily high levels of testosterone, but when we look at the side effects, aside from the cosmetic side effects, like losing your hair where you want it, getting hair where you don't want it, like all over your face, getting an enlargement of the clitoris, getting oily skin, getting pimples. We look at more serious side effects long term, such as a buildup in the lining of the uterus, increasing risks of uterine pre cancer and even cancer. And we have very good data, which I talk about in my episode and come again about the increased number of hysterectomies in women on pellets because the levels are so high. Now one of the things that's confusing for women is that the biggest sellers of pellets, of course, are women who have them, who tell all their friends how incredible they feel. And there's no question that a big bolus of testosterone is gonna make you feel amazing. Huge, huge amounts of energy, feeling sexy, feeling alive, feeling productive. The problem is that's the initial, that's the initial feeling. Over time, people require higher and higher doses. The side effects get to be a huge problem. And it's not like you can just say stop taking it. They sit there under the skin for months. You cannot take them out. You have to wait for them to dissolve. And there have been some very serious problems. Women think they're FDA approved. There was a study that they were shocked to find out that they're very expensive doctor.

[B]

And a lot of women, it's all they're offered. They're not given the cornucopia of options.

[C]

Correct. And why is that? There are a lot of doctors that are making a lot of money off of pellets because they're not FDA approved. It's a cash business. And along with the pellets, they're not only selling pellets, they're doing unnecessary blood work. They're doing these panels, the Dutch panel, a lot of things that are not only extremely, extremely expensive, cash only, but are not helpful in any way, not necessary in any way. I love when they tell you this is custom compounded just for you. They're giving everyone the same friggin palate, you know, but they're drawing your blood every 10 minutes and charging you for it to make you feel like you're special. And this is just for you. So what I say to people is if someone is pushing pellets, don't walk, run, go to someone who is going to prescribe testosterone in a responsible way. In appropriate dosages. Do we watch levels? We do when we prescribe estrogen. We don't, because we generally don't need to. There are exceptions, but in general, we're not getting levels. Testosterone, you need to start with a baseline level, because if your level's already high, I can tell you taking testosterone is not going to help. And in fact, you are more likely to get side effects. And then because they're compounded, that means that the levels of testosterone that you're getting may not be consistent. So it is always a good idea, at least in the beginning, until you're on a steady, stable dose, to watch those levels to make sure that you're getting the right amount. And also, I just have to throw out there for people that rely on their voice professionally. We're talking actors, voiceover artists, singers. You need to know that if you take testosterone, even in the normal physiologic low doses, that for some people, and we can't predict who that's gonna be, there will be a change in your voice. It is not reversible. It's not reversible. And already, and that's a whole other topic, is the impact of menopause on the voice, because you have estrogen receptors, of course, in your voice box, which is why opera singers very often will use estrogen and why there is a change as women go through menopause.

[B]

Lots of questions from our audience. One is, and this is also very curious to me, is the orgasm gap between males and females and between heterosexual couples and same sex couples for women.

[C]

All right, orgasm gap. This is the realization that men are far more likely to have orgasms than women because of course they know how they're able to have orgasms. And we see this orgasm gap starting very, very young, 20s, 30s, 40s. Well, I have good news for all the peri and postmenopausal women out there. The orgasm gap narrows as people get older because the guys are losing their ability to have.

[B]

Now that we get better, they get worse.

[C]

Exactly. We're not getting better, they get worse. But actually, in some ways. Let's just talk about the woman who's not having difficulty with orgasm. If you look at a 20 or 30 year old who has no clue where her clitoris is or what to do with it. Most women, hopefully by the time they hit 50, do know where their clitoris is and do know what to do with it and are well aware that if they stimulate the clitoris either manually or orally or with a vibrator and they're not relying on a partner anymore, or a partner because they know better. They're actually able to have an orgasm. So I know this sounds crazy, and you don't expect me to say this necessarily, and no one's really studied this, but the orgasm gap in my mind absolutely narrows for two reasons. One, women are better at knowing how to elicit orgasm, whether with a partner or on their own. And men are losing their ability to orgasm. So it's a level playing field.

[B]

Well, and I feel that women are not willing to sacrifice their own pleasure anymore. You know, they're not just gonna do it to do it. They're like, if I'm in, I'm in. You know, and we're gonna. We're gonna do this until I also have an orgasm. Rather than. Than just putting themselves second, they're really putting themselves first, I think, for their pleasure.

[C]

One of my favorite books, and it's an old book, is Ian Kerner's book called she Comes First. And this is a book that's intended for men because men need this education to say, okay, dude, she comes first. Take care of her orgasm first, and then you can have your orgasm. And this is very, very important for people who are totally knowledgeable. I'm talking. Can we talk about the men for a second? Well, I'll tell you a funding story.

[B]

And I. When the first divorce happened in our friend group, I think that book went around. The guys freaked in our big giant friend group. And I think the guy's kind of like. And I think that book went around because I noticed a definite more attention to making sure that I was gonna be okay. And there's Sometimes I'm just like, it's fine. I'm sick, or I'm just not it. You know, whatever. But. And I think it was born of that fear of that first divorce that happened. And, like, what can I do to hang onto this relationship? So we were very appreciative of that book in my friend group. I think when I read the data, it's like 70 to 80% of men will have an orgasm with intercourse. And women, it's like more like 40 or 50% each time. When you look at the raw numbers, like, that's how big the gap is. But then we see narrow.

[C]

You're talking about young women.

[B]

Young women.

[C]

Correct, Correct. But then again, we do not have data on the orgasm gap. That's one of the studies I want to do with Kinsey. I've been talking to them about that. But we do not have data on the orgasm gap. As you get into older folks, do.

[B]

You think it bothers women that there's an orgasm gap? Because I see these, like, very, you know, politically slanted articles written about it of like, you know, it's not fair and da, da, da. And most of my patients are okay.

[C]

Are you talking about younger women or older women?

[B]

Younger. Yeah. Really younger. When they're coming to me older, they're coming with a problem they need to fix.

[C]

Yeah. You know, if you. They say that it's okay, it's because culturally there's this expectation that men expect pleasure when they have sex and women do not. Another wonderful book that addresses this is Girls and Sex. And it really talks about how young girls are not really educated in pleasure. Sex ed, we know, is all about how not to get pregnant or get an sti. It has nothing to do with pleasure. But the guys are not taught that. The guys are taught you should have pleasure. So that's part of the problem, is that there isn't the expectation. So are they upset? I think the ones that expect pleasure are the ones who know how to have pleasure. So older women, different story.

[B]

So we have an older patient who comes into your clinic and she says, I am struggling with orgasm. I used to have them. They're great, and I still want them. What's your first step? Walk me through.

[C]

The first step is unless you're running a sexual medicine clinic, the likelihood of that happening is about zero. Let's be honest. How many of patients, when you were doing General OBGYN, walked in your door and said, hey, Dr. Haver, I can't have an orgasm. Will you help me?

[B]

Maybe one in 20 years. Thank God they didn't. Because more common for them to complain about desire. Desire.

[C]

Well, first of all, that's easier to spit out. And second of all, it is more common. It is more common. So when you talk about across the board, if you look at women between the ages of 18 and 100, most of them are not gonna bring that up. Even though 40% of women across the board have these issues with sexual problems, doctors are not gonna ask because they're not gonna be able to help them. The only time that we have a flip in that script, of course, is if you're running a sexual medicine clinic, because that's why they're there. So if a woman comes to a sexual medicine clinic and comes to see an expert and says, I'm not able to have an orgasm, what are we gonna do? Well, number one, we are going to take a very detailed history. We need to Know it all. And in fact, I have the history form income again, that I use for clinicians, so they don't even have to make it up. They can just use my history form because it goes through all of the things that might impact on the ability to have an orgasm. We're talking, you know, menopause symptoms, we're talking medications, we're talking diabetes, medical problems, surgery, radiation, chemotherapy. I mean, there's a very long list of things that we need to go through. And then depending on what their issue is, and it's never one thing, it's always multiple things, then we're going to set up a treatment plan. But the number one thing that we generally have to get rid of in almost every woman is pain. Pain, pain, pain. If someone says, I have no desire for sex, and if I do have sex, I don't have an orgasm, my next question is, well, when was the last time you had sex? Oh, it was a couple months ago. How'd it go? Well, it hurt like hell. Well, your vagina's not stupid. And if sex hurts like hell, it's gonna take your. Tell your brain, don't go there. You're not gonna get aroused. And if you don't get aroused, you. You're not going to have an orgasm. So until we fix painful sex, we've got nothing to talk about. So you've got to do that. You've got to look at the medications, you have to get rid of the menopause symptoms. If someone is flashing all day and all night, they're not going to be aroused. Keep in mind, and I keep circling back to this, in order to have an orgasm, you must have arousal. You must. That's your clitoris, that's your pelvis. That's your brain getting primed to trigger those nerve endings to do their job. Right?

[B]

Right.

[C]

So almost every treatment I have is going to help arousal get rid of the symptoms, get a decent night's sleep, eliminate pain, look at your drugs, show someone the map to their clitoris.

[B]

So is everyone going to be successful with having an orgasm?

[C]

I would like to say yes, but that would not be honest. The answer is no. But that's okay. What's important is we need to rewrite the script. There's this idea that sex is not successful unless you have an orgasm, which is why, quite frankly, so many women fake it, because they want them to stop trying already. Oh, my God, please, I just want to go to sleep. And part of that script is that sex isn't over until you have an orgasm. Sex is over when you're ready for it to be over because you've been having pleasure. Stop having orgasm. As the end game, there is a new normal. Very often for women to say, I don't need to have penis and vagina sex. I don't need to have an orgasm if I am in a relationship. I need to have someone who is loving, who is kind, and who touches me in a way that's pleasurable. I was once on a. I think it was a Today show or something. And I was on with a sex therapist. And we were asked the question, how often should people have sex? What's the right number? How many times a week? And the other person who was on this episode with me, I thought gave such a beautiful answer. He said, the number of how often you have sex is unimportant. What's important is how often you are sexual. Meaning that you touch someone, you kiss them, you speak to them in a way which is kind and loving and lets them know that you are attracted to them. That's great sex.

[B]

What is a sexual medicine clinic and how would you find one?

[C]

That's a really hard question.

[B]

Who's a sexual medicine expert?

[C]

It's not something that. There is a fellowship in the International Society of the Study of Women's Sexual Health. They do maintain a directory. I don't even know if I'm on that directory or not, or if my clinic is. It's not complete.

[B]

It's a starting point.

[C]

I will tell you that.

[B]

We'll put it in the show notes. Because people are gonna be looking up.

[C]

Stuff for a peri and postmenopause woman. For a lot of them, their starting place is going to be with the menopause expert. Because while all menopause experts are not experts in sexual medicine, we've already established that. You've gotta get rid of the hot flashes. You've gotta get rid of the menopause symptoms. You gotta treat your genital urinary syndrome.

[B]

It's a decent place to start.

[C]

Absolutely. And for a lot of women, that is going to be not only the best place to start, it may be all that they need. They may not need to go to that next level. But once they go see their menopause expert and get rid of all of those things, if they are still having trouble, then you may need to find a sex med expert. And some of the major medical centers have them. Most do not. I will say that I'm at Northwestern. We have a sexual medicine center there that I founded. I'm no longer there. But I have excellent, excellent clinicians who are using all the protocols that I put into place when we open the center. And there are a number of places that do that. Interestingly, where you'll see it more than anyplace else is sometimes in oncology departments, because we haven't talked about that. But certainly when we look at people who are having a great deal of difficulty with sexual function, it is young women, all women of all ages, who are dealing with not just a cancer diagnosis, but chemotherapy, radiation, surgery. So that's a whole different world and very well recognized by a lot of the top oncology centers. University of Chicago has a wonderful, wonderful center for sexual function post cancer. So that's another place to look.

[B]

What is in the future for you? Where do you see this going? Do you feel like access to this kind of care is getting better?

[C]

I do have hope. One of the reasons I have hope is I am the mentor for a medical student organization that is all about sex education. There's a wonderful, wonderful. Now she's a resident. When she came to me when she was a first or second year medical student, Jennifer Ramonello, I don't know if you've come across her.

[B]

I think you brought her to a conference somewhere in Chicago.

[C]

I brought her to a conference, yes. And this is a young woman who said, wait a minute, wait a minute. How come we're not getting this education? And she is one of those people that puts words into action. And she put together a medical student consortium, which started in Chicago. But I encouraged her because it was during COVID I said, you might as well get medical students from all over the country. So now we have medical students, hundreds and hundreds of medical students from all over the country that are part of this medical student consortium for education. We'll put the link in, because if there are any students out there listening, they have to get involved. And we have events and we have lectures and we do all kinds of things. They're doing research. They're working with Rachel Rubin. She's another faculty mentor. And because it was Covid, one of the few advantages of COVID is that I said, hey, this is all virtual. Let's get the best of the best of the best. And we got like the top 15 sexual medicine doctors to get on board for their board of advisors. And these medical students are loving it. They are all over it. We bring them to conferences, we get them involved in research, and it gives me great hope in terms of what kind of fields are they going into, because this is a discussion they're medical students. Well, if I want to do this, what field should I pursue? And there are many routes to being a sexual medicine expert. You could be an obgyn. You have to like doing surgery and other things. If you do that. A lot of them go into psychiatry, the talkers, the ones that want to keep their clothes on and don't really want to do those exams of the clitoris. Internal medicine, internal medicine, family medicine. There's urology. There's a lot of ways for people to become sexual medicine experts if they're interested. So yes, I do have hope because we have this very large group of students who are very excited about this.

[B]

Wrap it up with Come Again. What it is, how to find it, who it's for.

[C]

Come Again is for everyone. It is for healthcare clinicians, meaning doctors, advanced practice nurses, anyone who's taking care of patients. Not just gynecology, but in all aspects of medicine, there's not one single medical specialty that doesn't need to know about this. Come Again is for women who at a high level want to understand what's going on, what's changing, and most important, what they can do about it. Come Again is for men who want to understand what's going on with the women in their lives. 30 episodes sounds like a lot, but I promise you it's entertaining. Some of them are short, some of them are 10, 15 minutes, some of them are longer. It started out as 50 or 60 episodes, so could it be. And you do it in little bites, you little bites. And I throw in there a lot of history of this stuff, like we talked earlier about Princess Maria Bonaparte. I love that stuff.

[B]

I would love to write a book, the history of.

[C]

The history of all this. So I throw a lot of fun stuff. It really is for everyone who has a curiosity about this. And even though it's skewed towards women who are appearing post menopause, because, let's face it, those are the women that are having the biggest challenge. It is really for all age groups because these are problems that can happen at any time in life. And the most important is I'm solution driven. It's not enough to talk about the problem. Let's talk solutions.

[B]

Well, it feels like, you know, menopause is having this renaissance and that it's this new topic. But you've been doing this work for 30 years, a long time.

[C]

You know, whenever we talk about how menopause is having a moment, and that makes me a little crazy. Cause I'm thinking it's not having a moment. I'VE been talking about menopause for 20, 30 years, but no one wanted to talk about it. And I used to do a ton of media, you know, Good Morning America and Today's show, and on and on and all these shows. And I would always pitch to the producers, let's talk about menopause. And they'd be like, no, no, we're not. No, no, give me another topic. And now, of course, that's all they want to talk about. And. And I would like to think it's because you laid the groundwork right. Well, there's. There's that. But I would like to think that there's this interest in menopause because people are acknowledging that it is important. And there is some of that. A lot of it is. We. We know there's a lot of money to be made in menopause, which is why people have to be careful with where they're getting their information. But I am glad that this somewhat taboo topic is now being talked about, not just in the doctor's office, but with your manicurist, with your friends, with your brother, you know, the watercolor. That's as it should be. That's as it should be. When women talk to their daughters about their first period, they should also be talking about their first hot flash.

[B]

Yeah. And their last period.

[C]

And their last period. Yeah.

[B]

I'm guessing you could retire if you wanted to.

[C]

Well, officially, I have. Cause I'm not seeing patients anymore.

[B]

But you're always working, Lauren, somehow. Why? What keeps you going?

[C]

My husband keeps saying to this. He said, wait, you've retired, but you're working harder than ever. What keeps me going?

[B]

Why aren't you paused?

[C]

Oh, gosh, I don't think I'm.

[B]

Are you on pause?

[C]

Well, no, I'm not on pause. When people say, are you retired? And I'm like, no, I'm rewired. I'm now going on to the next thing, to the next chapter. Because my passion has always been education. I mean, let's face it. I started off thinking I was going to be a journalist. I started off writing. I have five books. I have another one in the works. I've created this Come Again series. I have my podcast. Nothing gives me pleasure like getting out there and talking to people and making a difference. Because whenever someone says, why this? Why not something else? And I've always been driven to go towards what is no one else doing? What's the unmet need? No one else is talking about alternatives to hysterectomy. I'm going to be that person. No one's talking about menopause. I'm going to be that person. No one's talking about the inability to have an orgasm. I'm gonna be that person. That's what keeps me going. To be the one who's out there talking about these things that are gonna make a difference, that are really gonna make a difference in someone's life. And what I also realized is I've always been in both worlds, the very academic worlds. I'm lecturing to doctors and medical students, and I still do that. And then also in the consumer world, and they're equally important to me. And I would like to see those two worlds come together more because this is a conversation that needs to happen. And whenever I'm thinking, I just. I. I can't do this anymore. I'm overwhelmed. I have to stop. And then something will happen. A stranger will come up to me on the street. I had a stranger. I work on a treadmill desk. And my treadmill desk broke. And I called the company. They tried to troubleshoot over the phone, and they couldn't do it. And they said, let's talk to the owner of the company. The owner of the company gets on, and he said, are you Lawrence Stryker that wrote Sex Rx? And I said, yes, I am. He said, your book saved my marriage. I'm sending you a new treadmill desk. And you just go, stop it.

[B]

You're like, okay.

[C]

And you're that okay. This is why I do what I do. Because it makes a difference. Yeah, we want to make a difference.

[B]

I feel the same.

[C]

We want to make a difference.

[B]

Some days make a difference. It gets overwhelming.

[C]

That's what drives you. That's what drives you.

[B]

Take a breath, and then someone will say, something I wrote or said or did made them find a doctor, you know, change their life, whatever. And I'm like, that's why I'm doing this. Like I told you at the beginning, this is for the ladies on the couches in Ohio, in middle America, who don't have a sex med doctor, who don't have access, who don't know where to go or what to do, and are feeling so alone.

[C]

And for those women, what I want to tell them is that not only do we have solutions, but if you don't have a doctor, it's okay. Because I'm going to give you the roadmap. I'm going to give you the script of to go to the doctor that you do have. You may not have a choice, but you can go to the script. You can go to that doctor and you can say, Dr. Haver told me that it might help me to use a local vaginal estrogen. Will you prescribe one for me? Dr. Stryker said that if I use that estrogen on my clitoris, it might help with my orgasm. Will you prescribe it for me? They will.

[B]

They will.

[C]

They're not going to say no. They will not say no.

[B]

Well, thank you so much for coming on the podcast. It was an honor having you on today.

[C]

Thank you for having me. It's been great fun.

[B]

As a reminder to our audience, you can follow Dr. Stryker on Instagram @doctorstrike, on substacker, and on her [e-mail] she is also the host of Dr. Stryker's Inside Information podcast and she has released a 30 episode audio series on sexual function called Come Again that is available for purchase through her website. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram @Doctor Maryclair and get honest, accurate information on health, fitness and navigating [e-mail] My new upcoming book, the New Perimenopause is available for pre order on Amazon. If you're loving this podcast, be sure to click Follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review and be sure to share the show with the women you love. We would be so grateful. You can also find full episodes on YouTube at Dr. Maryclaire. Unpaused is presented by Odyssey in conjunction with PodPage People. I'm your host, Dr. Mary Claire Haver. The views and opinions expressed on Unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis or treatment.