Podcast Summary

Podcast: unPAUSED with Dr. Mary Claire Haver
Episode: Where Did My Orgasm Go? Menopause, SSRIs, and the Science of Pleasure with Dr. Lauren Streicher
Release Date: December 16, 2025
Host: Dr. Mary Claire Haver
Guest: Dr. Lauren Streicher, Professor of Obstetrics and Gynecology at Northwestern University, sexual medicine expert, author, and host of Come Again and Dr. Streicher’s Inside Information podcasts

Episode Overview

In this bold and unfiltered conversation, Dr. Mary Claire Haver welcomes Dr. Lauren Streicher—an icon in the field of sexual medicine—to discuss the science of pleasure, postmenopausal sexuality, the effects of SSRIs on sexual function, cultural myths about orgasm, and practical solutions for women struggling with orgasm in midlife and beyond. The episode emphasizes de-stigmatizing female sexual pleasure, debunking myths, and offering evidence-based approaches to reclaiming sexual satisfaction during and after the menopause transition.

Key Discussion Points & Insights

1. Challenging Sexual Myths and Cultural Scripts

• Cultural Narratives:
  Hollywood perpetuates the myth that women should experience “mind-blowing orgasms within 10 seconds of penis-in-vagina sex,” setting up unrealistic expectations for both women and their partners. (01:44–02:22, 12:44–13:24)

  “Hollywood has set the tone that women should expect to have a mind-blowing orgasm within 10 seconds of penis and vagina sex. And because that doesn’t happen with me, then I’m broken.” —Dr. Streicher (13:09)

• Normal Sexual Response:
  The reality is only ~10–20% of women can orgasm from penetrative intercourse alone; the medical term for not orgasming from penetration is "normal." Most require clitoral stimulation. (13:28–14:25)

  “The medical terminology: you are normal if you do not have orgasm during penis and vagina sex.” —Dr. Streicher (13:41)

• The Anatomy of Orgasm:
  Orgasms typically require arousal (blood flow to genitalia), clitoral (sometimes cervical or G-spot) stimulation, and intact nerve pathways. Dr. Streicher recounts historical misconceptions and the lack of proper sexual education, even for OB/GYNs. (11:13–12:44)

2. Pathways and Physiology of Female Orgasm

• Three Pathways to Orgasm:

  1. Clitoral stimulation: Most common and necessary for the majority.
  2. Cervical stimulation: Possible due to the vagus nerve; supported by research on women with spinal cord injuries. (15:09–15:31)
  3. G-spot (plexus) stimulation: Only some women have the nerve plexus enabling this; it’s an extension of the internal clitoris. (16:24–17:14)

• Anatomic Variation:
  The placement of the clitoris relative to the vaginal opening (within 2.5 cm or ~1 inch) facilitates orgasm from intercourse for some; this is a minority, not the norm. The story of Princess Marie Bonaparte illustrates this point. (18:35–21:18)

3. How Menopause and Aging Affect Orgasm

• Blood Flow and Nerve Health:
  Estrogen loss reduces blood flow and vaginal/ clitoral lubrication and can impair nerve function—aggravated by diabetes, cardiovascular disease, and aging. (33:43–37:09)

• Genitourinary Syndrome of Menopause (GSM):
  Pain, dryness, and tissue atrophy directly diminish sexual pleasure and the ability to orgasm. Clitoral atrophy can result in a less sensitive or smaller clitoris. (47:36–49:10)

  “The clitoris actually shrinks. It becomes pale, there is decreased blood flow, which means it does not become aroused. And the nerve endings start to fail.” —Dr. Streicher (48:44)

• Menopause vs. Libido:
  Estrogen is not strictly required for orgasm, but it is helpful since it promotes vascular health and lubrication. Desire (libido) is different from arousal (physical response). (32:01–32:44)

• Other Medical Factors:
  Common peri- and postmenopausal medications, particularly SSRIs, are major contributors to acquired difficulties with orgasm. (36:50–37:44)

4. Understanding Anorgasmia

• Primary vs. Acquired Anorgasmia:

  • Primary: Never able to orgasm (often related to lack of sex education or past trauma in young women; rarely biological except when SSRIs are started very young).
  • Acquired: Loss of ability after previous normal function, most frequently seen in perimenopausal and postmenopausal women due to hormonal, vascular, neurologic, or pharmacologic changes. (27:33–29:47)

• Hypoorgasmia:
  When orgasm is possible but takes much longer or is less satisfying.

5. The Role of the Pelvic Floor

• Importance:
  Healthy pelvic floor muscles are crucial for sexual function, enabling both strength (contraction during orgasm) and relaxation (to allow pleasurable penetration). (39:14–41:10)

  “A healthy pelvic floor is what keeps your urine in your bladder … and when it comes to sex, we need those muscles around the vagina to relax, to say to the penis, I’m ready—come on in … and the other thing that a pelvic floor is important for is orgasm.” —Dr. Streicher (39:45)

• Common Problems:
  Pelvic floor tension or weakness can seriously impact sexual response and pleasure.

6. SSRIs and Medications: The Double-Edged Sword

• Prevalence:
  By age 65, 25% of women are on SSRIs (antidepressants), which can significantly delay or prevent orgasm—sometimes acutely upon starting, sometimes in combination with other midlife changes. (54:51–54:54)

• Mechanism & Management:
  SSRIs can inhibit neurotransmitter pathways necessary for orgasm. Brain plasticity may allow symptoms to improve for some with time. Other management strategies include dose modification, switching medications, or implementing “SSRI holidays” under medical guidance. (54:57–57:54)

  “If someone starts an SSRI and then two, three weeks later they realize not only do they have no libido but they can’t have an orgasm, there’s a very good chance that the SSRI is the culprit.” —Dr. Streicher (54:57)

7. Treatments and Solutions

• Review the Full Picture:
  Orgasmic difficulties are multifactorial—addressing pain (GSM), pelvic floor issues, hormone status, medication side effects, and relationship dynamics is crucial. (52:07–52:16)

• Topical and Vaginal Estrogens:
  Using estrogen creams not just in the vagina but also around the vulva and clitoris helps restore tissue health and nurture nerve endings. (31:00–31:21, 49:10–49:34)

  “In fact, when you are treating genital urinary syndrome of menopause … you also need to treat the clitoris to wake up those nerve endings to say, hello, we’re here.” —Dr. Streicher (49:07)

• Pelvic Floor Physical Therapy:
  Accessing a pelvic floor therapist—“my vagicians”—may be critical, particularly where pain is a barrier. (41:10–43:20)

• Use of Sildenafil (Viagra):
  Off-label use of sildenafil can restore orgasmic function in some women, particularly those with SSRI-induced anorgasmia—though evidence is limited. Topical sildenafil is being studied and may become available soon. (58:15–61:46)

  “It appears that sildenafil … has been useful in women who are having SSRI-induced problems with orgasm … anecdotally, in my experience … very often oral sildenafil will kick it back into action.” —Dr. Streicher (58:15–58:54)

• Self-Education and Body Awareness:
  Women are encouraged to look at and understand their vulvas and clitoris using a mirror, fostering both sexual self-awareness and the ability to advocate for their pleasure. (49:50–51:20)

• Seeking Specialist Help:
  Not a DIY project—seeing clinicians with expertise in sexual medicine, like those trained in Dr. Streicher's protocols or using her Come Again resources, is advised for persistent issues. (52:07–54:29)

Notable Quotes & Memorable Moments

• On Culture and Orgasm Myths:
  “Popular culture would make you think everyone has a G spot … Popular culture would be wrong.” —Dr. Streicher (16:38)

• On Female Anatomy Education:
  “I have practiced for long enough. I have seen the evolution of pubic hairstyles … One of the things that has happened with women removing their pubic hair is they are able to see their vulvas more.” —Dr. Streicher (50:13)

• On Post-Menopausal Reality:
  “There is no orgasm killer like pain, any kind of pain, but certainly pain during activity.” —Dr. Streicher (33:43)

• On SSRIs and Orgasm:
  “For a lot of women, this [orgasm problem] will go away on its own—at least 30% of the time. Give it some time. We’re talking months. Your brain will figure it out.” —Dr. Streicher (56:13)

Timestamps for Critical Segments

• Debunking Orgasm Myths: 01:44, 12:44–14:25
• Definitions and Mechanisms of Orgasm: 11:13–12:44
• Anatomy & Measurement, Princess Bonaparte Story: 18:35–21:18
• Impact of Menopause on Orgasm: 33:43–37:09
• Definition and Types of Anorgasmia: 27:33–29:47
• GSM & Clitoral Atrophy: 47:36–49:34
• Pelvic Floor’s Role: 39:14–43:20
• SSRIs in Midlife: 54:51–57:54
• Viagra/Sildenafil Use: 58:15–61:46
• Encouraging Self-Looking and Education: 49:50–51:29
• Treatment and Seeking Help: 52:06–54:29

Tone

Candid, humorous, warm, and empowering—both doctors use humor and real stories to encourage women to get informed, advocate for themselves, and demand better education and care around sexuality and menopause.

For Further Resources

• Dr. Streicher’s 30-episode audio series, Come Again (available via her website)
• Inside Information podcast (Dr. Streicher)
• Dr. Haver’s Instagram: @DoctorMaryClaire
• Dr. Streicher’s Instagram: @doctorstrike
• Book: The New Perimenopause by Dr. Mary Claire Haver

In sum:
This episode delivers an honest, science-based roadmap for understanding and troubleshooting orgasmic challenges in menopause, demystifying women’s anatomy, and offering tangible hope and resources for pleasure in the second half of life.