← unPAUSED with Dr. Mary Claire Haver
unPAUSED with Dr. Mary Claire Haver
Where Did My Orgasm Go? Menopause, SSRIs, and the Science of Pleasure with Dr. Lauren Streicher
00:56:50
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Let me be straight with you. I have put my hair through a lot. Color, heat, chemicals, you name it. And for years I just accepted that dry brittle. Well, I did this to myself. Hair was the price I had to pay. It wasn't. The product that finally shifted things for me was K18's leave in molecular Repair hair mask. I first tried it because a friend who's way more disciplined about her hair than I am told me it was the only thing that kept her hair strong through constant color appointments. And she wasn't exaggerating. Here's the truth. Most of us don't think about everyday styling, environmental stress, and all the little things we do without realizing it can actually damage the inner structure of your hair. That's why it ends up weak and fragile. K18's biomimetic K18 peptide works differently. It mimics the keratin in your hair and repairs damage at the deepest molecular level so your hair comes back stronger and more resilient no matter what you put it through. And once you understand the science behind it, it completely changes how you think about caring for your hair and honestly, your body. And that's what sold me. You can find K18's Molecular Repair Hair Mask at Sephora or get 10% off your first purchase with code unpaused@k18hair.com that's code unpaused18hair.com 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.
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Hollywood has set the tone that women should expect expect to have a mind blowing orgasm within 10 second of penis and vagina sex. And this is a huge problem because women think there is something because that.
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A
Is, I think, what their partners are expecting.
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B
Well, and their partners are expecting that too. And because of that, there's this script that women have that you're supposed to have penis and vagina sex and you're gonna have this incredible, incredible orgasm. And because that doesn't happen with me, then I'm broken.
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A
The views and opinions express 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. Today I'm joined by Dr. Lauren Stryker, professor of Obstetrics and Gynecology at Northwestern University Feinberg School of Medicine. She's the host of Dr. Stryker's Inside Information podcast and the creator of Come Again, a new 30 episode audio series that explores sexuality, orgasm, and the science of sexual function. Dr. Stryker is also the author of several best selling books on menopause and sexual health. To say she's an icon in the field is an understatement. Dr. Stryker is one of the true OGs of sexual medicine. She helped define and legitimize a specialty that for decades simply didn't exist. Her research, her patient advocacy, and her willingness to talk openly about topics that most people still shy away from have changed how women and their clinicians approach sexual health. I met Lauren in Austin at south by Southwest and her candor, her humor, and the sheer depth of her knowledge was striking. She has spent her career educating both physicians and women about what's really happening to our bodies, and she's never been afraid to push the conversation forward. I'm thrilled to have her here today to talk about postmenopause orgasm, sexual function, and what women need to know about the impact of SSRIs and other medications to desire and pleasure. I hi, I'm Dr. Mary Claire Haver, a board certified obstetrician and gynecologist and certified medical practitioner. I'm also an adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch. Welcome to Unpaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life. Thank you so much for being here today.
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B
I am so thrilled to be here with you talking about one of my favorite things, Taboo topics. Orgasm.
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A
So where did you grow up? Tell me your background. Give me your origin story. Our listeners love to hear this about it.
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B
Well, it's actually not that exciting. I had a pretty unremarkable childhood, which is good. You don't want it to be remarkable necessarily. I grew up in a suburb of Chicago and I've been a Chicagoan my entire life. And in fact, I went to medical school at the University of Illinois and then did my residency in Chicago.
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A
Why obgyn?
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B
Well, I actually started out in internal medicine. Really? My father was an internist. I kind of fell into medical school. I wasn't planning on, you know, some people. For me it was not. My parents wanted me to be a concert pianist. I didn't have the talent. I wanted to be a ballerina. I didn't have the talent. I was an undergrad. I was majoring in English. I was thinking about journalism. I wasn't really sure what I wanted to do. And then my big brother had just started medical school, and he made some offhand comment about, well, I don't think you could cut it in medical school. And that's all it took for me to say, right, I'm going to medical school. So I applied to medical school, got in, never expected to be there. And then I ended up not really knowing what I wanted to do. Cause I liked it all. It was all interesting. So I started off in internal medicine because my father was an internist. And then I discovered that that really didn't fit my personality. I'm one of these. I want a solution. I want to make it happen quickly. And internal medicine is all about, let's face it, chronic disease. Chronic disease. It's like psychiatry. You know, I don't have 30 years to solve your problem. I want to solve your problem in the next hour. And OB GYN is really perfect for that because, you know, you deliver the baby, you stop the bleeding, you take out the tumor. Everything is very quick, relatively speaking, in the medical world. And I love the variety. I love the variety. And I did love working with women. I had been involved in women's reproductive rights for a long time. I loved the people I was working with. So that's how I ended up in OB gyn.
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A
Did you do any postgraduate training, like fellowship or. There's no fellowship, right?
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There is no fellowship. No. I started just as a generalist and probably like you, you know, delivering babies, wiping out chronic vaginitis, saving the world from endometriosis, all of that. And then over time, I pivoted. I pivoted because I found what I really loved was doing surgery. And specifically, minimally invasive surgery. I was the first to bring laparoscopic hysterectomy to Chicago. And I was doing a lot of surgery, which I loved. But I also found that part of taking out someone's uterus and specifically their ovaries puts them into a surgical menopause. And I felt ill equipped to help these women navigate menopause. So that's what brought me to the whole menno world.
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Yeah.
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Now the sexual medicine world. That came later.
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That came later.
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And really, it was because I was writing along the way. I was always writing. In fact, my first book, the Essential Guide to Hysterectomy, I have two editions. I really need a third one. It was my first book in my true love, because that's what got me out there and realized what an impact you can make by writing high level good information for women so that they can make good decisions for themselves. And so after that, my next book was gonna be about menopause and particularly about post menopause sexuality. And my publisher, HarperCollins said, well, we'd really like this to be for all ages, not just postmenopause. So SexRx morphed into a book about sexual medicine throughout the lifespan, starting in the 20s until your 90s. And because of that, and you know this, when you write something is when you're forced to really learn about it, right? You have to read everything. I don't have anyone else do my writing. If it has my name on it, I wrote it. And that meant I had to do all the research and write and write and write. And that's what brought me into the world of sexual medicine, which I knew very little about, like most gynecologists. And I remember going to my first conference and I'm like, oh my God, there's a whole world out there of people who really know this stuff. The science, the biology, what's going on in the brain, what's going on in the clitoris, all this stuff that we never had any exposure to. And so that was definitely part of my learning path. And then I expanded out to a lot of other areas. And then of course, we have Kinsey. And I'm the board of the Kinsey Institute and I'm a senior researcher at Kinsey, which has been wonderful because it exposes me to a whole nother.
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Tell our listeners what the Kinsey Institute is. Cause most of them, I know what it is, but most of them may not know.
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B
The Kinsey Institute is at Indiana University and it, it is the foremost academic research arm in the United States. It is absolutely, maybe even the word medicine.
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For sexual medicine.
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For sexual medicine. Specifically for sexual medicine. It was started by Alfred Kinsey, who is a biologist. He was just asked to teach sex education and really didn't know much about sexuality. So he did this enormous survey of both men and women about what their sexual habits were. He was not a physician. He did. Masterson Johnson examined people, they were looking in the laboratory. What happens when someone has an orgasm? That was not Kinsey. Kinsey talked to people for hours and hours and hours. And in fact, the statue of Kinsey at Indiana University is him sitting in a chair, leaning forward, and there's an empty chair right in front of him. And the idea is you go and you sit in the empty chair, and you tell him all of your sexual issues. So that's what he did. And he started publishing his findings. And then that morphed into this incredible research arm which is still alive today. And I love being involved with them because that really is where a lot of the cutting edge research happens.
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A
So I want to give our listeners a chance to understand how really groundbreaking this is and how unusual it is. Because in my four years of residency, so I was a resident from 98 to 2002, and then I took over teaching duties and then became a program director in the 2010s ish. I learned how to define where the clitoris was. I still actually could not have anatomically drawn it correctly until the last five years, probably. And I knew what an orgasm was. I knew a little bit about Masters and Johnson, nothing about Kinsey. We had zero clinical application of any of that knowledge. There was no discussion of libido or desire or anything. And if there was, I can just remember being kind of a taint of, well, it's psychological. This is a purely psychological issue.
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B
Exactly. And especially when it comes to orgasm, I think a lot of women and doctors are pretty comfortable talking about the fact that, you know what? I just don't have the desire for sex anymore. But how many doctors say to patients, are you able to have an orgasm? I can tell you how many.
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Yeah.
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If they're not a sexual medicine doctor, it's almost zero.
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Almost zero.
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It's almost zero. And the reason they don't is because if a woman says, I'm so glad you asked. I'm having great difficulty. They have nothing to say, but I'm so sorry, so sorry. I'm so sorry. And then change the train. Well, they're not trained because they don't know what to tell people.
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So let's back up. Let's educate our audience. What is an orgasm?
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B
You know, describing an orgasm to someone who's never had one is kind of like describing how chocolate tastes to someone who's never had chocolate. It's not so easy. But here goes. Basically, what an orgasm is, is it is the physical things that occur, or hopefully occur following sexual arousal. So what's going on? You're getting a rush of blood to the vulva, the vagina and the clitoris. You're also getting a rush of blood to the pelvic floor muscles, which give women this feeling of satisfaction and pleasure and fullness. And then usually physical stimulation of the clitoris is required. Those nerve endings send messages directly to the pleasure center. In the brain explodes with pleasure and then in turn sends another message down to the pelvic floor, which causes those muscles which also are congested with blood. And all the vulva and vaginal congestion all gets released. That's when the orgasm is over. So that a woman is left feeling very satisfied. This kind of overwhelming sense of, oh, that was really lovely. And of course being grateful to the partner who helped her do that or her vibrator or whatever. But it's really kind of this sense of incredible. That's the cliffnote version. Yeah. You know, we'll get into some of the nuances of this, but that's basically what it is. It is a physical phenomenon that follows sexual arousal.
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A
When we watch a lot of Hollywood movies, when we. So, you know, a lot of pornography that's floating around out there, it's very different than what you describe.
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Oh, yeah. Hollywood has set the tone that women should expect. Expect to have a mind blowing orgasm within 10 seconds of penis and vagina sex. And this is a huge. Because women think there is some.
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A
Because that is, I think, what their partners are expecting.
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B
Well, and their partners are expecting that too. And because of that, there's this script that women have that you're supposed to have penis and vagina sex and you're gonna have this incredible, incredible orgasm. And because that doesn't happen with me, then I'm broken.
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A
There is penis and vagina sex. Can that stimulate an orgasm?
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It can, but those are the rare ones. Which is why the medical term for women who do not have an orgasm in penis and vagina sex is normal. It's the medical terminology. You are normal if you do not have.
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It's the most common thing.
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Correct. So we're talking about 10% now. So let's talk about what a vaginal orgasm actually is.
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Okay.
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A vaginal orgasm is when you have an orgasm without clitoral stimulation. That's key. We'll get to that in a second from just having. And when I say penis, let's include toys in that too. Because everybody has a penis in their life. So whether it's a vibrator or a dildo or a penis, when you have an object in your vagina for the purpose of sexual stimulation, will an orgasm occur? So there's really three ways that that might happen. Number one, we know that many women, if they are aroused enough, will not need physical stimulation to have an orgasm. There are women that can fantasize their way to orgasm.
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A
Lucky girls.
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Lucky girls. It's in the single digits, but yes, it can Happen. So then we have number two. Number two is a cervical orgasm. Now, cervical orgasms are fascinating because when we talk about the neurology of orgasm, and when I just talked about what is an orgasm, I talked about clitoral stimulation and how those clitoral nerves go straight down the highway to the brain. Right. It's not the only road to nirvana. We also know that the cervix can stimulate an orgasm. And the reason we know this is because of research done in spinal cord patients that that path from the clitoris to the brain no longer is functional. It doesn't exist. They have to go on the side route, which is cervical stimulation.
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Cervical.
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Why does that work? It works because you are stimulating the vagus nerve. The vagus nerve has a different pathway. It doesn't go through the pelvis. It happens much higher in the spinal cord. So even spinal cord patients can use that road. And this is the fascinating part. If you do an MRI of a woman having an orgasm, and yes, there are people that do that. I've seen.
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I've seen the MRI stuff.
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So interesting. But a different area of the brain lights up. So if you have a cervical orgasm, a different area of the brain lights up than if you have a clitoral orgasm. And in fact, women that have both, some women do have both, they will tell you that they are both pleasurable, but they're different. But they're different. So many women that have a vaginal orgasm, it is from stimulation of the cervix. Size sometimes does matter. I'm just saying we say size doesn't matter, but in that case it does.
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A
You know, I was taught, and I know this is absolutely incorrect, but. But when I was coming through the ranks, certain cervical procedures, we didn't give any anesthesia because we were taught there's no cervical nerve endings. So why would we anesthetize something that doesn't have nerves? Just go ahead and do the biopsy or do the, you know.
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Correct.
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And we've learned so much. And that some of that data comes from that of showing the electric. The stimulation of the nerves when you touch the cervix.
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Exactly. There's very sensitive nerves in the cervix. So then we get to the third pathway to orgasm from vaginal penetration, and that would be what is commonly called the G spot.
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Now, popular culture would make you think everyone has a G spot.
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Popular culture would be wrong. So.
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Because I've looked for it.
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Oh, no. I know. You could go on a search, you know, with the headlights on and all. The different wands and things. No, everyone does not have a G spot. And in fact, a lot of people don't think of this as a spot, which implies there's this very, very specific little anatomical spot. It's better referred to as a G spot plexus, meaning a little bundle of nerves in the roof of the vagina that's a few inches back from the opening, which is quite frankly an extension of the clitoris. Keep in mind that when we're looking at the clitoris, which I hope everyone will look at, and we'll get to that.
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So on YouTube, I think we'll pop up a picture of the actual anatomic drawing of a clitoris which looks a little bit like Gumby the Gumby doll.
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Totally, totally. So keep in mind that the clitoris, when you're looking at the tip of the iceberg for what you can actually see when you look with the mirror, and that it actually dives into the pubic bone and go to the roof of the vagina. So that's where this plexus is. Some women, not all women, if that area is stimulated, can have an orgasm. So those are the three ways that people can have a vaginal orgasm. Most women that have an orgasm during penetrative sex, and they think that it's from vaginal stimulation other than being aroused. It is not. It is from simultaneously clitoral stimulation.
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A
Kind of a cross contamination.
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Exactly. We call this pairing, meaning that someone has a fingers or vibrator or something else down there. So the clitoris is being stimulated at the same time. So one of the questions that comes up is, well, what's the likelihood of that happening? Well, we know the answer to that question. It's about, you know, depending on some different factors, maybe 20, 30% of just plain if two people are having intercourse, allowing that clitoral stimulation.
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A
So on the flip side, still totally more normal. So that's abnormal, you know, outside of the normal curve is women don't have orgasm that way. Most women need more stimulation.
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B
Most women are not able to have orgasm without some kind of clitoral stimulation. So this brings me to who the person is who's most likely to have clitoral stimulation without the help of a vibrator and fingers, just during plain penis and vagina sex. So let me tell you the fascinating story of Princess Maria Bonaparte. Oh, my gosh, as in great niece of, you know, Napoleon. Napoleon. So she was actually a student of Sigmund Freud, and she was personally very frustrated that she was not able to have an Orgasm during intercourse. And she really tried. She had multiple lovers, so it wasn't, you know, we can't blame it on the guy. And it just didn't happen. And then it occurred to her as a scientist that her clitoris was actually a little bit far away from her vagina. And maybe that was the problem. So she measured and she found that her, her clitoris was indeed a little bit far away from the vagina. Then she gathers up 240 women, I have no idea how, and she pulls them and she says, are you able to have an orgasm during intercourse? And then she measured the distance between their clitoris and their vaginal opening in all of these women. And what she determined is that the magic number is about 2.5 centimeters, which translates to about one inch.
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One inch.
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Now, I know everyone is putting this on pause right now. Pause. So they can go find the tape measure and measure. So go do that. That's fine. Come back. I did not know this.
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This is so fascinating.
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But so you say, okay, why is this? Well, it's because it's anatomical, right? It's anatomical that his pubic bone. Pubic bone, very important. Is likely to be pounding against the clitoris if there's that distance. So Maria Bonaparte, being a problem solver, she decided that she is going to brace herself, wait for it, surgically move her clitoris, and she found a surgeon to do it. But it didn't work. So she did it two more times. Oh, my gosh. It never worked. But the point is, is she onto something? And in fact, all of those records in French are at the Kinsey Institute. Her research has since been reproduced by two other researchers. And the fact of the matter is, is that if your clitoris. Now we use the urethra. Cause it's easier to measure urethra, clitoris. If your clitoris is within about 1 inch of the urethra, you are one of the lucky women who is very likely to be able to have an orgasm during intercourse without any help from fingers or vibrator. There's also something called coital alignment. And I can give you a picture of this one where the man is. We're talking missionary position here where the man is basically riding high on the woman so that he's positioning his pelvis, his pubic bone, right over her clitoris.
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Those who are motivated as well, like I've had my girlfriends talk about, you know, in some positions, it's easier for them with PIV penis and vagina sex, especially if she's on top that she's able to kind of manipulate to get that stimulation correct.
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B
Exactly. But then we also looked talking about position. This is why a lot of women like positions that are not on top necessarily, so that they have access to their clitoris to stimulate it during intercourse. Foreign.
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A
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B
Yes. And now we're seeing.
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A
And now we're seeing one at the gop.
- [26:52]
B
So I think we have a study that we need to do, Right? Yeah. Cause this is important. This is important because women already don't have an education as far as. And their own anatomy and how to make orgasm happen. And then this gets thrown at them, and they're like, are you kidding? Are you kidding? It's kind of like women after hysterectomy, which is another area of research for me, that they are told that your sex life will not change after hysterectomy. And for most women, that's true. But not for the women who have cervical orgasms. If their cervix is removed, guess what? It's gonna change. Yeah, that's one of my episodes. And come again is sex after hysterectomy. And there's a lot of information that I can promise you your surgeon never told you. Well.
- [27:32]
A
Cause they didn't know.
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B
They didn't know. They didn't know.
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A
So what is anorgasmia?
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B
Anorgasmia is the Latin of no orgasm, does not happen at all.
- [27:42]
A
And how common is it?
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B
Well, we divide it into two groups. There's what we call primary anorgasmia, meaning people who've never had an orgasm. Some people call that preorgas. I like that. And then we have acquired anorgasmia. So when we look at how common it is, when we look at anorgasmia, it's not common. And when we're usually finding out about it is in young women. Young women who have nothing biologically or hormonally wrong with them. It's usually a matter of education, cultural problems, past trauma. And in most of those women, if we get them in the hands of a good doctor, who with a mirror, shows them where their clitoris is and what to do with it, and in the hands of a good sex therapist, they do very, very well. And, you know, you say guys don't have that problem. Well, guys have the obvious advantage of their penis is really easy to locate, and they figure out what to do with it real fast. Women don't know where their clitoris is, and a lot of young women don't, and there's no discussion about that. So when we look at primary anorgasmia in young women, the numbers are pretty low. And this is almost 100% curable unless they're on an SSRI. We see a lot of primary anorgasmia in women who were on an SSRI from an early age and then just never had an orgasm. Acquired anorgasmia is someone who used to have orgasms just fine, and then something happened that all their tried and true methods were no longer working. And that's my area of interest in research, because that's what we are primarily seeing in peri and post menopause women. The women who just figured it out at some point in their life, and then they are blindsided because no one tells them about that. When mom sits down and maybe tells you about a hot flash or two, she doesn't tell you that you're also gonna lose your ability to have an orgasm. And they are just devastated that suddenly they are no longer able to have an orgasm. Now, keep in mind, there is a spectrum when you say anorgasmia. We also have hypoorgasmia, which means someone who has an orgasm, but it takes so long that it's like, are you kidding? It's not worth the effort? Or it doesn't have the same feeling. It's not as satisfying. So there's a lot of different permutations of that.
- [29:47]
A
I'll tell you a story. I am 57, have been postmenopausal for nine years now, and started struggling with the time it was taking. Like, frustrating, you know, like, why is this taking so long? So I casually mention it to Corinne Men, one of our mutual friends, and she says, this was a couple of years ago. And she says, well, how much vaginal estrogen are you on? And I was like. I had a big smile on my face, like, I'm not. And she says, mary Claire, what? And I said, I kind of transitioned, you know, and I didn't have any obvious symptoms of what I was thinking. Gsm. And I was like, when I get there, I'll use it. I had a tube in my drawer. I did. I just never used it. It was magical. Like, I just wasn't thinking, like. And I thought it was medication. It was stress. It was whatever else.
- [30:39]
B
Of course, you blamed it on yourself and said, it's stress.
- [30:42]
A
So it was that me, who's menopause certified, who talks about this all day long. I don't have a great. You know, that's why I love having you on, because I have so much to learn about sexual function, and I couldn't even diagnose myself. You know, it was my, well, you are not alone girlfriend.
- [30:58]
B
You are not alone.
- [30:59]
A
Who had to tell me?
- [31:01]
B
We just spent a few days together. I adore her. But it's not just vaginal estrogen. When you put the estrogen in the vagina, and of course, in the opening of the vagina and the vestibule. Cause it doesn't matter how nice the room is if you can't get through the door. And then you take that cream and you go north.
- [31:16]
A
I do. I've learned. I tell all my patients, you know, true north, down both labia and inside.
- [31:21]
B
And also, a lot of people think that this is something they're supposed to do just before sex. No, you do this on a regular basis. Because we are all about increasing healthy blood flow to the clitoris so it will wake up those nerve endings.
- [31:35]
A
Walk me through the physiology of what happens post menopause and why our orgasms could change.
- [31:41]
B
To do that. I'm gonna start with talking about just what needs to happen to have an orgasm.
- [31:47]
A
Perfect.
- [31:47]
B
So what needs to happen to have an orgasm is, number one, there needs to be arousal. The difference between libido and arousal. Cause it's a little confusing. Libido is, I want to have sex. I hope I have sex. Please can I have sex? It's all in the brain.
- [32:01]
A
Brain.
- [32:01]
B
It's on the brain. Arousal are the physical manifestations of being sexually excited. Blood flow to the pelvis, lubrication. It's your body getting ready for sex. So that has to be there. That's a requirement. We also then have to have intact neurology, nerve endings that are gonna respond and send mail to the brain to say, hey, pleasure center, something's happening here. There also needs to be blood flow. You have to have adequate blood flow to make all this happening. You need to have some physical stimulation in most cases. And then, of course, there's everything that's going on in the brain in terms of the neurotransmitters and all of that. Notice what's not on the list of requirements?
- [32:42]
A
A penis.
- [32:43]
B
Estrogen.
- [32:44]
A
Oh, no.
- [32:45]
B
Penis is obviously not on the list. That's like really low. But. But you do not need estrogen. You do not need testosterone. You do not need emotion. You don't have to be emotionally invested in your vibrator to have an orgasm. Right. So this is a huge relief to the post menopause women of America who have no estrogen, who maybe don't have an emotional relationship that they can still have orgasms. Now, does estrogen help? You bet. And we're gonna talk about how it helps. But it is not a. A biologic requirement. And think about it. I mean, how many people are taking estrogen at this point? We know it's in single digits, yet most women are able to have orgasms at least early on in menopause until things start to change with that. All right, so let's talk about what happens with all of those things post menopause. Okay, so starting with arousal. Well, this gets tricky.
- [33:39]
A
So arousal, meaning the physiology of the physical things that are happening in the pelvis.
- [33:43]
B
And arousal is. Is dependent on good blood flow. We know that estrogen is a vasodilator. It helps blood flow. So if you don't have estrogen, you are not going to get the same levels of arousal, which is also one of the reasons why there is vaginal dryness and pain. There is no orgasm killer like pain, any kind of pain, but certainly pain during activity. So that's one reason that arousal is just not happening for a lot of women post menopause, because it hurts. It hurts. And we also know very, very good data that women who have other menopause symptoms like hot flashes, insomnia, aches and pains in their joints, they do not become aroused. So that's, number one that's happening. Number two is, let's talk about what's happening to clitoral blood flow and nerve endings. Now, keep in mind that. And the clitoris is kind of a small space there, right? What that means is that the blood vessels are teeny, teeny tiny capillaries, the smallest blood vessels, and the nerve endings are also really, really tiny. And what that means is that they're more vulnerable to damage. The other thing that's going on, in addition to menopause, in most cases, unless someone has very early menopause. But we're looking at the consequences of aging. We're also looking at the consequences of other medical conditions like diabetes and cardiovascular disease. By age 50, 51, the average age of menopause, 50% of women have at least. At least one other medical problem, such as cardiovascular disease or diabetes. And of course, the older they get, the more likely they are to have multiple conditions. So all of these things are going to impact on blood flow and on nerve health. And then we put on top of that, the fact that they no longer have estrogen on board to be that nice vasodilator that's gonna increase blood flow. So there's a lot going on. It's not as simple as, oh, let's just give you some estrogen, and everything's gonna be Fine. Because there's so many other factors. The nerve issues are huge because there's a lot of diabetes in this country. Let's just start with that. And most people are familiar with neuropathy, meaning that they have numbness in their feet. Well, you can get a clitoral neuropathy. And this has been biopsy proven. We don't normally biopsy the clitoris, which I know sounds terrifying, but in studies we have in diabetics, that shows that we have nerve degeneration. So if you have diabetes and you are unable to have an orgasm. Yes. Part of that may be because of the loss of estrogen, but a lot of that may also be because of your diabetes and cardiovascular disease and all that. So we see that going on. The other thing that happens post menopause is medications. The number one medication that women are getting, imperium. Postmenopause are SSRIs. Yes. I mean, how often have you talked about that? And we're not talking about women who are given SSRIs for depression or anxiety, which may have been a lifelong thing. We are talking about women who are given SSRIs to treat menopause symptoms like hot flashes, because their doctors are not comfortable prescribing estrogen. And those same doctors are not warning. Oh, and by the way, you may have difficulty with not only libido, but the ability to have an orgasm. So we have that going on. So when you say, what's going on with postmenopausal orgasm? There's a lot.
- [37:09]
A
There's a menu.
- [37:10]
B
There's a lot of things that are there to sabotage the ability to have the kind of sex that women are looking to have. But I just. I have to stop right now and just say, before we get any further, we have solutions for all of this.
- [37:20]
A
I mean, when I'm sitting here thinking.
- [37:21]
B
I am so bummed out. Please.
- [37:23]
A
I'm like, is there hope?
- [37:24]
B
Is there hope? I just. I can't even even stand this anymore. We're gonna get to the solutions. I just have to throw that in so that people don't get, you know, really upset. But. Yeah, but. So. So there are a lot of reasons that almost 50% of women at the menopause transition are having difficulty. And then, of course, the older they get, the more likely it is to happen.
- [37:45]
A
And we're not even talking about desire.
- [37:47]
B
Oh, no, no. We're just talking about orgasm.
- [37:49]
A
Straight up, the ability.
- [37:50]
B
Straight up, the ability to have an orgasm.
- [37:51]
A
I think a lot of women are sitting in their cars listening right now feeling very validated, like, this is me.
- [37:56]
B
This is me, and I'm not alone. And that there is a biologic reason why this is happening. The other thing that should make all these women feel better, this is mirroring exactly what's going on with the men, their husbands, because a penis is just a big clitoris, less sensitive, of course. And if you look at the rates of erectile dysfunction, they mirror it. They mirror it. So, you know, and it's easy. The algorithm, you know, it, you know, 50% of men at 50 have some difficulty maintaining an erection. By 60, it's 60%. By 70, it's 70%. So the same guys that are having problems with an uncooperative penis are the ones who have women who are saying, my clitoris is dead. Nothing's happening. And just like we have solutions for the guys, we have solutions for the women.
- [38:41]
A
Are they the same?
- [38:42]
B
Sometimes.
- [38:43]
A
Sometimes.
- [38:43]
B
Sometimes we don't give men estrogen, although they have a little, by the way. I mean, you know that people forget that women will say, well, if I use my vaginal estrogen, if it gets on his penis, is that a problem? And I'm like, no, he's got his own supply.
- [38:55]
A
I'm like, what women don't realize is that once you go through menopause, your husband's estradiol level is higher than yours.
- [39:02]
B
In some cases, that is absolutely true. And testosterone, of course, is metabolized to estrogen. So don't get too worried about getting a little estrogen in his penis. But that's off the topic.
- [39:10]
A
They think he'll grow breast or something will happen.
- [39:12]
B
Not gonna happen. Not even close.
- [39:14]
A
Well, before we get into treatments, let's talk about the pelvic floor. Let's touch on that.
- [39:18]
B
I'm so glad you brought that up, because the poor, forgotten pelvic floor.
- [39:22]
A
Oh, my gosh. The poor pelvic floor therapist out there on the Internet trying so hard to educ. What did I learn about the pelvic floor? How to sew it back together or ignore it altogether?
- [39:31]
B
Yeah, I mean, we just. We didn't even talk about the pelvic floor. The only problem with those pelvic floor physical therapists is we don't have enough of them because it is so critically important. A lot of people are aware that these pelvic floor muscles, which, of course, are the group of.
- [39:44]
A
What is the pelvic floor?
- [39:45]
B
The pelvic floor is a group of muscles that line the pelvis, but beyond that, these muscles surround the vagina, the rectum, the bladder. And a healthy pelvic floor is what keeps your urine in your bladder when it's. Doesn't let it out until it's supposed to come out. Make sure that you do not have stool incontinence. 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, as opposed to tightening up, saying, oh, my God, are you kidding? This is just gonna hurt. Stay out. And the other thing that a pelvic floor is important for is orgasm. People don't think about that because think about what I said earlier in terms of what happens during an orgasm. The final step of an orgasm is those pelvic floor muscles contract and release. We always think about a strong pelvic floor. It's not just about being strong and contracting. You also need to let those muscles relax. It's a coordination of the pelvic floor muscles. And with orgasm, that's part of the pleasure, is feeling that contraction, but it's also the release. All that blood that's gotten congested, there's. Gets released, and that leaves you with this feeling of satisfaction. So, okay, what happens to your pelvic floor post menopause? Well, generally, it's not good. I'll start with that. You know, we know that there's an extremely high correlation of women who have urinary incontinence and problems with orgasm. And the reason is. Is because these are both controlled by the pelvic floor.
- [41:11]
A
And let's go over what incontinence is.
- [41:12]
B
Incontinence is the involuntary loss of urine or stool. When we talk about taboo topics, people are somewhat comfortable talking about urinary incontinence. But they're.
- [41:21]
A
It's funny.
- [41:22]
B
It's funny. Yeah. Ha ha. You know, diapers. You've normalized diapers in America. Don't get me started. Goldberg was not doing us a favor when she went on and told the world she was wearing diapers, because that made it seem like this was something everyone should do, as opposed to actually working on your pelvic floor and getting pelvic floor physical therapy to eliminate the incontinence. But be that as it may, we know that the pelvic floor is critically important in the ability to have an orgasm. So what happens if you have a weak pelvic floor is you're not gonna get this. You're not going to get that satisfaction. So what happens to the pelvic floor? Well, there are a number of things. Number one is you can get pain in the pelvic floor. I talked about how important it was for the pelvic floor to be able to relax. Some people have what we call pelvic floor tension, meaning they get tight knots, they get contracted muscle. It's kind of like if you do a thousand sit ups, the next day your belly is going to be so sore you can barely move. Well, think about happening to your pelvic floor all the time, that they are constantly, constantly having these tight, tight, painful muscles. The other thing that happens, and I know you've talked about this in other episodes, is muscles in general. We have estrogen receptors in our muscle, and those estrogen receptors and testosterone receptors are very important in terms of muscle health. So we have that going on. We have a problem with women having obesity in this country, which is also going to impact on the pelvic floor. And we have a lot of other pelvic floor disruptors, if you will. So the pelvic floor health is critically important in terms of having an orgasm, which is why having access to a pelvic floor physical therapist, I call them my vagicians, is so important because we can do what we're gonna do and we can give all these recommendations. But at the end of the day, particularly if someone is having pain, it's the work of the pelvic floor therapist that is going to, to cut that pain pathway, which is absolutely critical in order to become aroused and have an orgasm.
- [43:20]
A
Taking care of your mental health can feel isolating. There are days when scrolling through advice online just doesn't give you what you need. And let's be honest, reaching out for support can be overwhelming. It can be hard to know where to start, but that's where Alma comes in. With a nationwide network of over 20,000 diverse licensed therapists, 99% of whom accept insurance, ALMA makes finding the right care simple and affordable. You can search without creating an account, then filter by what matters most, like gender, race or therapeutic approach, and even see the session costs upfront with their free insurance estimator. On average, people using Alma save 80% on their sessions. What stands out most about Alma is that this isn't about quick fixes or generic advice advice. It's about real human connection. Which means you can schedule free 15 minute consultations with as many therapists as needed to find one who truly fits your goals. Building a meaningful relationship over time leads to better mental health outcomes. And ALMA makes that easier than ever. Better with people, better with Alma. Visit helloalma.com unpaused to get started. And schedule a free consultation today. That's helloama.com unpaused hormones affect more than how you feel.
- [44:42]
B
They affect your skin too. As estrogen drops in midlife, your skin can lose collagen, hydration and elasticity. That's where Alloy Health comes in. Alloy makes evidence based menopause care accessible, connecting women with menopause experts. And now they're redefining skin care with M4, their prescription line made with Microsoft Estriol, a form of estrogen that only works on the skin. It started with the M4 Face Cream RX and now Alloy's added two game changers, the M4 Face Serum RX and the M4 Eye Cream RX. Getting started is easy. Head to myalloy.com that's my a L-L-O-Y.com answer a few quick questions and a licensed physician will review your info. Use code MCH20. That's MCH20. For 20 bucks off your first order, your personalized skincare ships right to your door. No appointments, no pharmacy lines because your skin's changing and your routine should too. Visit myalloy.com and use code MCH20. That's MCH20.
- [45:41]
A
In midlife, so many women struggle with fatigue, brain fog, weight changes, hot flashes, and they're still being told these symptoms are just a part of getting older. I hear about it every day from women who are searching for real answers and not getting the care they deserve. That gap in menopause care is exactly what Midi Health is here to close. Midihealth is a telehealth clinic serving women in midlife with expert evidence based care. Their clinicians and medical leaders are professionals I trust committed to treating the whole person. And as the only national women's telehealth clinic clinic covered by major insurance, they make high quality care accessible and affordable. When you work with Mitti, you'll get a personalized plan built around your unique needs. This might include hormone therapy, nutrition, lifestyle guidance or support for weight management. Everything is designed to help you feel better now and protect your long term health. We're seeing the difference MIDI is making with patients everywhere and women are getting the answers, relief and care that truly makes an impact on their daily lives. It's such an encouraging moment for women's health. We're finally seeing menopause care evolve into what it should be thoughtful, informed and centered on women's real experiences. I'm so thrilled by what Midi Health is doing to help women feel supported and empowered. You deserve care that supports you now and protects Your long term health. Visit joinmitti.com to meet with a midi clinician and start feeling your best for the years ahead. So you talked about pain and the pelvic floor. We talked a little bit about general urinary syndrome of menopause. So, like, walk me through how GSM can derail an orgasm.
- [47:37]
B
Genital urinary syndrome. Menopause is actually a huge culprit when it comes to postmenopause problems with orgasm. Number one, if you don't have vaginal lubrication, if you have vaginal dryness, and if you have pain, you're not gonna have an orgasm. The anticipation of that alone is going to sabotage your ability to become aroused. The other piece of this is a phrase a lot of women have not heard, and that's clitoral atrophy. We talk about vaginal atrophy. What is vaginal atrophy? We don't like to use that word because it has such negative connotations. Who wants to have an atrophic vagina? You know, it sounds awful. I mean, it sounds like it's, you know, aging and wilted. And the problem, though is atrophy is an actual description of what's happening biologically, meaning that there's decreased blood flow so that there's thinning of the tissue. And as a result of this, those nerve endings rely on blood to be healthy. We get less responsive nerve endings. So what happens when there's clitoral atrophy? 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. They start to fail. So, in fact, when you are treating genital urinary syndrome of menopause, either using a vaginal estrogen or DHEA or oral Aspenipine or whatever you choose to do, you also need to treat the clitoris to wake up those nerve endings to say, hello, we're here.
- [49:08]
A
And you may apply the medication to the clitoris.
- [49:10]
B
Exactly. So let's say, and this comes up a lot because you might have someone who chooses to use a vaginal estrogen in the form of an insert or a pill or the ring estring. And what are they gonna do? They're gonna get an additional tube of estrogen cream, and they're gonna put some on their finger and they're gonna apply it to their clitoris at least twice a week. Take your time rubbing it in.
- [49:33]
A
I'm just saying five minutes.
- [49:35]
B
At least five minutes, if not more. And what that's gonna do is that's going to directly treat your clitoral atrophy. Does every woman need to know this? No. If you're having orgasms, just fine, don't bother, don't bother. But if you are having trouble, you need to look. Let's talk about looking for a minute, okay?
- [49:51]
A
Okay.
- [49:51]
B
Because guys have the obvious advantage that it takes absolutely no effort on their part to inspect their penis obsessively, with which they do. They do. Right? Women, not so easy. It's hidden. Their mothers don't tell them where it is, and even if they look, they can't always see it. It's actually one of the side things that's happened as a result of pubic hairstyles.
- [50:08]
A
Well, I've practiced for long enough. I've seen the evolution of pubic hairstyles.
- [50:14]
B
One of the things that has happened with women removing their pubic hair is they are able to see their vulvas more. I actually have a YouTube video on how to get a hands free, amazing view of your vulva and your clitoris. And it's important that it's hands free because you want to be able to pull back the hood. You want to see what's under the hood and potentially apply either medication or estrogen or whatever you're doing. But women need to look. They need to look at their vulvas, they need to look at their clitoris. In the sexual medicine clinic that I started at Northwestern University, every single woman was given a mirror. And during the examination, we would talk about each part as we went through it. And women do not have that education. I cannot tell you how many women would tell us. And we're talking women in their 50s, 60s, 70s, who would tell us, I've never seen my vulva, I've never seen my clitoris. I mean, how sad is that? Can you imagine if you said to a 60 year old guy, can you imagine never having seen your penis? They would look at you like, what? What? Yet women have never seen it. And again, to circle back, when we talk about women who've never had an orgasm, they need a mirror and they need a man. And all women would benefit from that.
- [51:21]
A
And I think the younger you start, the better. So you know what your normal looks like.
- [51:25]
B
My three year old granddaughter knows that it's a vulva.
- [51:28]
A
Proper anatomical terms, yes.
- [51:30]
B
We were in the bathroom the other day and she said, grandma, I need to wipe my vulva. And this woman in the stall next to you woke up silent. He looks at us like, whoa. But it's important. And yes, she Has a book that, of course, my other daughter, the sex therapist gave her that says, you know, I have a vulva and a clitoris and it shows pictures. We're very progressive in my family.
- [51:50]
A
No, I think it's.
- [51:51]
B
It's a discussion that needs to happen in a very matter of fact way. Because quite frankly, if that matter of fact discussion was happening in homes across America, we would not be having a lot of the issues that we're having later in life in terms of sexual problems.
- [52:03]
A
Let's move on to treatments.
- [52:06]
B
Yes.
- [52:08]
A
So it depends on what the problem is. Does a woman need to go and see a doctor and who does she go see? So she's self identified. I'm struggling with orgasm and I want.
- [52:17]
B
Yeah, I think this is one of those situations. It's not a do it yourself project because this is so multifactorial. We've talked about a number of things that can sabotage someone's ability to have an orgasm. There are others, many other things that we've not touched on. So it takes someone to really do the deep dive into your medical history to do an exam to really figure out what's going on. I talk all the time about how doctors don't know much about menopause. They know a whole lot less about, of course, not only sexual function, but specifically orgasm. Which is why in my Come Again series, I have additional material specifically for healthcare professionals. I have videos on how to do an exam, how to do a neurologic exam on a woman who can't have an orgasm, how to take a proper history so that you can maybe uncover something that you weren't even thinking about. You know, because we're not trained in that. So it is a bit frustrating because women are not necessarily gonna be able to find someone to help, which is quite frankly why I did Come again because it is educating both women at a high level. It's 30 episodes. So I go through all the things that can cause problems. About the first 10 episodes is all the things that can happen. The rest of it is all about solutions and also for, of course, healthcare professionals to give them a roadmap to be able to help these patients. So yes, in most cases you need to see someone who knows what they're doing with this. But it's not necessarily going to be complicated to fix because some people, people, it is as simple as they're having pain with intercourse and someone needs to be able to give them the appropriate vocal vaginal estrogen product, connect them with the pelvic floor physical therapist, and that Alone. That alone is gonna solve the problem. We know. We know that if a woman is having severe hot flashes and insomnia, first of all, when she sees that pillow, all she wants to do is get a decent night's sleep. She's not thinking about sex. But we also know because of all those neurotransmitters in the brain that are sending the messages down to the pelvis and so the clitoris, you gotta take care of all those other symptoms if you're gonna be able to have an orgasm. Most doctors are able to do that. We hope we're getting there. We're getting there. You know, we're educating them, so that's more likely. And then we get to the whole SSRI thing.
- [54:30]
A
Well, let's cover it.
- [54:31]
B
Let's cover it.
- [54:32]
A
Women on SSRIs are quite common. So I read the data. The latest I could find was premenopausal. It's about 10% of the female population is on an SSRI. We double that to 20% across the menopause transition. And then by the time we're 65, it goes up to one in four.
- [54:52]
B
One out of four. One out of four.
- [54:53]
A
25% of women are on an SSRI.
- [54:55]
B
That's correct.
- [54:56]
A
How is that going to affect her orgasm?
- [54:58]
B
Well, first of all, it doesn't affect everybody's orgasm. Let's be clear about that. And so, and there's many classes, right? And there's different SSRIs. We know that it's a big culprit. So how do you know if that's what's causing the problem? Well, the first thing we look at is tone. If someone has been on an SSRI since they're 30, and then when they're in their 50s, they're no longer able to have an orgasm, the SSRI is not their problem. If it's going to happen, it happens from the get go. Either someone is vulnerable to it or they're not. On the other hand, if someone starts an SSRI and then two, three weeks later they realize that 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. If you're looking at a woman who's midlife or older, chances are it's not the only culprit. You know, there's a big difference between the 20 year old or 25 year old who's putting an SSRI on there. She's going, oh my God, I can't have an orgasm anymore. That's really pretty straightforward, right? That it's your SSRI. Honey, we know it's nothing else. But when you're 50 or 60 and you're put on an SSRI and you're also having hot flashes, which is why you were put on the ssri. And you also have genital urinary syndrome of menopause, so you have clitoral atrophy. And at the same time, your arthritis is suddenly just so bad that you can't even get into bed and get into a comfortable position. And now your husband has a non cooperative penis. And it's the whole thing, right? So I don't want to simplify and say it's just your ssri, but it is important to look at the timing because very often that's the thing that tips the pendulum so that they just can't have an orgasm. So the first question is, okay, what do I do? Do I take my SSRIs and throw them in the garbage can? No, you do not. This is not a do it yourself process project. You need to talk to the person who is prescribing the ssri. Let me start by saying, for a lot of women, this will go away on its own at least 30% of the time. Give it some time. We're talking months. That your brain will figure it out. Because it's the brain where this is all happening. It's the neurotransmitters that are triggering orgasm, that are put on hiatus because of your ssri. So sometimes the brain is an amazing organ. It has what we call brain plasticity, meaning it adapts. That's why brain fog goes away. That's why hot flashes eventually go away, because your brain figures it out. Same thing if you're on an ssri. Sometimes your brain will figure it out and your orgasm will come back. So part of it is just be a little patient. The other thing is, is that sometimes it's dosage. So you can look at dosage, sometimes it's the ssri. You might find that a different SSRI is going to be better in terms of sexual function, which is why you have to have this conversation with your prescriber. We also know that sometimes you can take a little SSRI holiday again under the direction of your prescriber.
- [57:28]
A
What does that mean?
- [57:29]
B
Meaning that you take your SSRI Monday through Thursday, and then you take a little break on Friday and Saturday. And for a lot of women, that will help in terms of libido and orgasm. So I can help everybody. And it Also depends on which SSRI you're on. I have an episode and come again about SSRIs. And I go through the ones that have a short half life. So this might be a good strategy versus one that has a long half life. And you could take a vacation for weeks and it's not gonna happen.
- [57:55]
A
Yeah, it sticks around yourself.
- [57:56]
B
So that's one thing that may help, which is very interesting. It also speaks to the fact when you say, well, if you do go off your ssri, how long is it going to take to get your orgasm back? And if the SSRI is the issue, it's going to be pretty quick. Once it's out of your system, you're going to be good to go. But this brings me to Viagra.
- [58:15]
A
Okay.
- [58:16]
B
You asked earlier, you said, are some of the treatments for orgasmic problems the same as for erectile dysfunction? And the answer is yes. It appears that sildenafil, which is the name, the chemical name for Viagra, has been useful in women who are having SSRI induced problems with orgasm. And I want to start by saying that Viagra is not FDA approved for women. So this is an off label use, which doesn't mean it's illegal, it just means that you. That's different than what the FDA intended it to be used for. Do we have a lot of studies? No, we do not. It's pathetic. We have very, very few studies. However, one of the things I learned.
- [58:54]
A
I learned when we scraped together the evidence for women.
- [58:56]
B
Well, the other thing also is, as you know me, Mary Claire, you know, I am very data driven and I think it's really important to stick to the data. But I've also had decades of experience in this stuff. I ran a sexual medicine clinic and these women would come in and they say, I started, started my SSRI and it was like the lights went out and I would give them Viagra and they'd say, huzzah. So anecdotally, in my experience, and especially in young women, if that's the only thing going on, if someone has SSRI induced anorgasmia, then very often oral sildenafil pill will kick it back into action. We, you know, again, have to be careful with the dosage a little lower. We worry about cardiovascular risks in older women. So. So again, you don't wanna just borrow your husband's Viagra. You wanna talk to your doctor and make sure. But we do know that it does seem to be very beneficial in some subsets of women, and SSRIs is on that list. So what about topical siltiful?
- [59:50]
A
I was gonna say yeah, yeah, I've seen it compounded.
- [59:53]
B
Correct. So compounded meaning again, not FDA approved, but you get someone, a pharmacist, who will mix it together in a creamer, an ointment. And the idea that you put sildenafil on your clitoris, is that gonna help? Help? Let's look at the data. We're done looking at the data. There's no data. There's no data. We have anecdotal reports biologically. So when there's no data, what I like to look at is. Okay, biologically, what does sildenfil do? Well, sildenafil is actually an antihypertensive for high blood pressure, meaning that it is a vasodilator, increases blood flow. So when you put sildenafil on the clitoris, it increases blood flow to the clitoris, which obviously is going to help help if you have clitoral atrophy. So does topical sildenafil work? Anecdotally? It does seem to work in a lot of women, and not just women with SSRI induced anorgasmia, but women who just have clitoral atrophy. So is there going to be an FDA approved topical sildenafil? Yes, there is one in phase three trials, which we expect it hopefully to be available sometimes in 20, 26, maybe 27. You know how slowly these things move. But all of the clinical trials for this particular FDA approved product were done in wait for it caused women. And listen, I have talked to the people in the company. The company's called dare. I don't work with them, but I've just talked to them. About what? Are you kidding?
- [61:22]
A
Really?
- [61:23]
B
Really? 30 year olds don't have problems having an orgasm once they find where their clitoris is and they know what to do with it. It's the 50, 60, 70 year olds. But of course they're looking for FDA approval. That's the shortest path to FDA approval. And you can always use it off label, which is fine, except it's not going to get covered by insurance. So that's the state of the art right now. But the point is, is sildenafil is interesting and for some women may be the answer.
- [61:46]
A
Okay, as a reminder to our audience, you can follow Dr. Stryker on Instagram @doctor strike on substack and on her website@doctorstriker.com. 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 Mary Claire and get honest, accurate information on health, family and navigating midlife@thepauselife.com 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 Pod 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.