Key Moments
259 - Women's sexual health: Why it matters, what can go wrong, and how to fix it
Peter Attia MDKey Moments
Unpacking women's sexual health: from desire to menopause, understanding challenges and treatment paths.
Key Insights
Women's sexual health is often underestimated in its impact on quality of life and is frequently overlooked or normalized as “part of aging.”
A comprehensive approach to female sexual dysfunction requires a biosociopsychosocial model, considering biological (hormonal, vascular, anatomical), psychological, and social/relationship factors.
Perimenopause and postmenopause represent a pivotal time when women are most likely to seek help for sexual health issues due to significant hormonal and life changes.
Testosterone plays a crucial, often underestimated, role in women's sexual health, particularly in desire, yet FDA-approved female-specific testosterone products are unavailable.
Vaginal dryness and discomfort due to genitourinary syndrome of menopause (GSM) are highly treatable conditions with local hormonal and non-hormonal options, though often under-addressed.
Two FDA-approved medications (flibanserin and bremelanotide) exist for hypoactive sexual desire disorder (HSDD) in premenopausal women, but they remain largely unknown and underutilized.
THE UNDERESTIMATED IMPORTANCE OF WOMEN'S SEXUAL HEALTH
Sexual health is a critical, yet often undervalued, component of a woman's overall well-being and quality of life. Many women experience distress and impairment due to sexual dysfunction, but this is frequently underestimated by medical professionals and normalized within society. Legitimizing these concerns is the first step toward effective diagnosis and treatment. Women need permission to acknowledge that these issues are real, impact their lives significantly, and that it's acceptable to seek help for them.
A HOLISTIC APPROACH: THE BIOPSYCHOSOCIAL MODEL
Understanding female sexual function and dysfunction requires a holistic, biopsychosocial approach. Biologically, the brain (neurotransmitters, hormones, neural networks), general medical state (vascular, nervous system), and local genital milieu (vascular, nerves, mucosa, muscles) all play a role. Psychologically, conditioning, learning, unlearning, and emotional responses are key. Socially, relational issues, cultural norms, and individual experiences over time intricately integrate to influence sexual health throughout a woman's life cycle.
LIFE STAGE TRANSITIONS AND SEXUAL HEALTH
Significant life stages profoundly impact women's sexual health. Puberty marks the onset of sexual development, while menopause, with its dramatic endocrine shifts, is often the most defining moment. Perimenopausal, late reproductive, and early postmenopausal years are when women are most likely to seek care due to unexpected changes in desire and function. This period is complex, involving body changes, career peaks, aging parents, and evolving partner dynamics, making midlife sexual medicine both challenging and rewarding.
CHILDBIRTH'S IMPACT ON PELVIC FLOOR AND SEXUAL FUNCTION
Childbirth can temporarily affect sexual function. The pelvic floor, a 'basket of muscles' supporting organs and aiding movement, stretches significantly during pregnancy and delivery. While problems are often transient postpartum, severe birth trauma, lacerations, or scarring can lead to persistent issues like pain or altered orgasmic function. Vaginal deliveries are generally recommended over C-sections, as the latter can lead to abdominal scarring and other unforeseen difficulties, contrary to popular myths about preserving sexual health.
POSTPARTUM HORMONAL SHIFTS AND THE FORGOTTEN SYNDROME
Breastfeeding women often experience hormonally induced vaginal dryness, irritation, and decreased sex drive, akin to postmenopausal symptoms. This is due to suppressed ovulation and significantly low estrogen levels. Many women are unaware of this phenomenon and needlessly suffer. Simple interventions, similar to those for menopausal vaginal symptoms, are available and highly effective. Prompt recognition and treatment can alleviate discomfort and improve sexual quality of life during this vulnerable period.
METABOLIC AND SYSTEMIC HEALTH LINK TO FEMALE SEXUAL FUNCTION
The link between metabolic health and female sexual function is an emerging and crucial area of study. In men, erectile dysfunction often mirrors cardiovascular disease, but a clear correlation in women is less established. Research using clitoral Doppler ultrasound aims to objectively measure arousal and assess systemic vascular risk in women. While not yet clinical standard, it's hypothesized that conditions like metabolic syndrome and diabetes contribute to female sexual dysfunction, necessitating preventive lifestyle interventions to preserve sexual health.
SEXUAL HEALTH AND OVERALL WELL-BEING: THE 'MIRROR AND MOTIVATOR'
Strong associations exist between good sexual function and overall well-being. Resilience, positive attitude, social connection, and a healthy lifestyle (e.g., normal BMI, Mediterranean diet) correlate with better sexual function. Conversely, distressing low desire significantly impairs quality of life, leading to feelings of despair, hopelessness, and disconnection. Sexual health can serve as both a 'motivator' for healthier choices and a 'mirror' reflecting underlying physical and psychological conditions, validating its importance beyond mere indulgence.
COMMON CAUSES OF FEMALE SEXUAL DYSFUNCTION
Several conditions are 'heavy hitters' in causing female sexual dysfunction. Metabolic syndrome, obesity, hypertriglyceridemia, coronary artery disease, and diabetes are associated with lower function, though psychological adaptation to chronic illness in women often plays a more prominent role than disease severity itself. Genitourinary symptoms of menopause, various cancers (breast, gynecologic), and psychological disorders like depression and anxiety—along with their treatments—also significantly contribute to sexual health challenges in women.
DEFINING AND DISTINGUISHING SEXUAL DYSFUNCTIONS: DESIRE VS. AROUSAL
Accurately diagnosing female sexual dysfunction requires distinguishing between desire, arousal, orgasm, and pain. While some integrate desire and arousal into 'female sexual interest/arousal disorder,' clinical experience and treatment efficacy argue for their separation. Desire involves the 'wanting' or willingness, while arousal encompasses the mental and physical excitement. The 'circular incentive model' suggests that for many women, desire follows arousability and satisfaction, not preceding it, further highlighting the nuanced interplay of these phases.
MEDICATIONS AFFECTING FEMALE SEXUAL FUNCTION
Many medications can impact female sexual function. Psychotropics, especially SSRIs and SNRIs, are known offenders, often causing multi-phase dysfunction, though effects can be drug-specific. While treating depression can improve sexual function, treatment-emergent sexual dysfunction may necessitate switching medications. High-dose combined hormonal contraception can lead to local vulvovaginal pain (vestibulodynia), mood issues, and most notably, increase sex hormone binding globulin (SHBG), which binds testosterone and potentially lowers free testosterone, especially in older reproductive-aged women.
THE CRITICAL ROLE OF TESTOSTERONE IN WOMEN
Testosterone, often mistakenly considered a 'male hormone,' is the most abundant sex hormone in women, both pre- and postmenopause. Its decline can significantly impact desire and genital sensitivity. Despite robust scientific evidence of efficacy and safety for treating hypoactive sexual desire disorder (HSDD) in postmenopausal women, there are no FDA-approved testosterone products for women. This leads to challenging off-label prescribing, using imprecise male formulations or unregulated compounded products, hindering optimal patient care and consistent dosing.
ANORGASMIA: DIAGNOSIS, EDUCATION, AND INTERVENTION
Anorgasmia, the inability to achieve orgasm, can be primary (never experienced) or secondary (lost capacity). A thorough history helps understand its context, ruling out medical factors, psychological trauma, or relationship distress. Counseling focuses on education about female anatomy and diverse orgasmic responses (clitoral, vaginal, mixed). Techniques like directed masturbation, vibrator use, and improved partner communication are key. Resources like books and websites (e.g., OMG Yes) offer explicit guidance, and sex therapy can provide tailored support.
PHARMACEUTICAL INTERVENTIONS FOR LOW DESIRE
Beyond testosterone, two FDA-approved medications currently exist for hypoactive sexual desire disorder (HSDD) in premenopausal women. Flibanserin (Addyi), a daily oral medication, acts on serotinergic and dopaminergic receptors, improving desire with moderate efficacy. Bremelanotide (Vyleesi) is an on-demand, self-injected treatment targeting melanocortin receptors, stimulating dopaminergic pathways to increase arousability. Both have specific side effect profiles and contraindications, and while effective for responders, they remain largely underutilized and underrecognized by many clinicians and patients.
MANAGING MENOPAUSAL SYMPTOMS AND BEYOND
For postmenopausal women, systemic hormone replacement therapy (HRT) with estrogen (and progesterone if uterus is present) is the most effective treatment for disruptive vasomotor symptoms (hot flashes, night sweats) and helps prevent bone loss. Misconceptions about HRT risks, often stemming from the Women's Health Initiative, have led to underutilization. Reanalysis of data shows HRT is safe, especially when initiated around menopause for symptom management with bioidentical, lower-dose, transdermal options. Local vaginal hormones (estrogen or DHEA) are highly effective for genitourinary syndrome of menopause (GSM), addressing dryness, painful intercourse, and urinary symptoms, often in conjunction with systemic HRT or as standalone treatments when systemic HRT is contraindi.
ADVOCACY AND ACCESS TO CARE
Despite advancements, significant barriers exist in women's sexual health, including lack of education, societal taboos, and limited specialized care. There's a critical need for comprehensive sexual health education across all life stages, from adolescence through older age. Clinicians must validate patients' concerns, offer informed consent for contraception, and actively screen for sexual dysfunction. Increased awareness of available resources, including sexual medicine specialists, menopause societies, and specialized therapists, is crucial to ensure women receive optimal care and improve their quality of life, challenging ageist assumptions about female sexuality.
Mentioned in This Episode
●Supplements
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●Organizations
●Books
●Drugs & Medications
●Studies Cited
●Concepts
●People Referenced
Common Questions
Female sexual health is frequently underestimated in its impact on quality of life. Many women feel impaired by sexual dysfunction but don't feel permission or validation to seek help, often experiencing despair, hopelessness, and disconnect.
Topics
Mentioned in this video
A urological society whose 20,000 members are often perceived to handle erectile dysfunction, highlighting the asymmetry in expertise between male and female sexual health.
One of the sexual medicine societies offering 'find a provider' websites for patients seeking specialists.
A medical journal that published a 2019 meta-analysis on testosterone trials in women.
An organization that publishes guidelines and provides 'find a provider' resources for menopause specialists.
Where Dr. Sharon Parish completed a fellowship in psychosocial and behavioral medicine.
An organization focused on women's sexual health, for which Dr. Parish was president. Its annual meeting attracts several hundred attendees.
An organization that has a 'find a provider' website for sex therapists.
Pioneering researchers who developed the initial linear model of the sexual response cycle.
A psychologist who, in the 1970s, added the concept of 'desire' as a distinct phase to the sexual response cycle.
Mother of the circular incentive model of female sexual response, suggesting motivation for intimacy or relationship benefits drives sexual engagement rather than spontaneous desire.
Researcher involved in creating normal testosterone ranges for women.
Researcher involved in creating normal testosterone ranges for women.
Conducted the only good study analyzing what happens to SHBG levels after discontinuing birth control pills.
Original Principal Investigator on the Women's Health Initiative, who has carefully reanalyzed subgroups and follow-up data to clarify the study's findings.
Researcher whose work focuses on mindfulness and its role in sexual function, mentioned in context of lay press books on the circular incentive model.
A leading researcher in female testosterone, particularly in Australia, and first author on important consensus papers.
A sex therapist who wrote several books on desire and sexuality.
Host of The Drive podcast, interviewing Dr. Sharon Parish on women's sexual health.
The Diagnostic and Statistical Manual of Mental Disorders, which controversially combines desire and arousal into a single diagnosis 'Female Sexual Interest/Arousal Disorder'.
A framework for understanding sexual response by integrating biological, psychological, social, and contextual factors.
A class of antidepressants that also has a class effect on sexual dysfunction, though with more variability in data.
A newer antidepressant with unique mechanisms (mixed serotonergic agonist/antagonist and D4 dopamine receptor activity) that seems to have fewer sexual side effects.
A male topical testosterone product, considered suboptimal and difficult to dose precisely for women due to high concentration.
An FDA-approved, centrally acting drug for hypoactive sexual desire disorder (HSDD) in premenopausal women, taken daily at bedtime. Works on serotinergic and dopaminergic receptors.
A medication that can be used for hot flashes but has low rates of success and many side effects.
A prior drug for female sexual dysfunction that underwent long-term safety trials, showing no adverse effects on cardiovascular, cancer, or metabolic outcomes, but failed to meet efficacy endpoints, thus was not submitted to the FDA.
An SSRI commonly associated with reduced sexual desire.
An SNRI that can cause sexual dysfunction.
A newer antidepressant with unique and complex mechanisms that also seems to have fewer sexual side effects.
A medication that can be used for hot flashes but has low rates of success and many side effects.
An SSRI commonly associated with reduced sexual desire and orgasmic difficulties.
An SSRI likely to cause sexual dysfunction.
A bioidentical progesterone therapy available for managing menopausal symptoms, often used with estrogen.
An antidepressant that is more dopaminergic and can be a different choice, potentially with fewer sexual side effects compared to SSRIs and SNRIs.
An SSRI commonly associated with reduced sexual desire and orgasmic difficulties.
A commonly used SNRI. At low doses, it acts like an SSRI, and at higher doses, it functions as an SNRI, making dose-dependent sexual dysfunction tricky to tease out.
An ultra-low dose oral contraceptive implicated in causing vulvovaginal symptoms more frequently than standard doses.
A class of antidepressants known to cause multiphase sexual dysfunction, including reduced desire and difficulty with orgasm in many women.
An SSRI likely to cause sexual dysfunction.
An SNRI that may be less likely to cause sexual dysfunction compared to venlafaxine.
An FDA-approved, self-injected drug for HSDD in premenopausal women, taken on demand 45 minutes before sexual activity. It's a melanocortin receptor agonist stimulating dopaminergic pathways.
An oral SERM (Selective Estrogen Receptor Modulator) indicated for vulvovaginal atrophy causing dyspareunia, a less common but approved treatment option.
A combined hormonal contraceptive patch that can have similar effects on sexual function as oral contraceptive pills.
An intrauterine device that can be used off-label for endometrial protection in women on systemic estrogen therapy, offering an alternative to oral progestins.
A 5mg testosterone cream available and government-approved in Australia to treat low sexual desire in women, offering precise dosing not available in other countries.
A combined hormonal contraceptive ring that can have similar effects on sexual function as oral contraceptive pills.
A 300-microgram testosterone patch by Johnson & Johnson, which showed efficacy for low desire in premenopausal women but was not FDA approved due to lack of long-term safety data, then later removed from global markets.
A vaginal DHEA suppository approved for vulvovaginal atrophy resulting in genitourinary symptoms of menopause, with good efficacy and safety and minimal systemic absorption.
A transdermal estrogen product in gel form, used for managing menopausal symptoms.
A precursor to testosterone. Oral DHEA has not shown convincing efficacy or safety for low sexual desire, but a vaginal DHEA product (prasterone/Intrarosa) is effective for vulvovaginal atrophy due to local metabolism into both estrogens and androgens.
A bioidentical estrogen therapy available for managing menopausal symptoms, used at different and lower doses than those in the WHI.
An atypical antidepressant with very low sexual dysfunction rates, but can cause sedation and weight gain.
Clinical modification that maintains separate coding for desire and arousal, contrasting with the DSM-5.
A lay press book by Emily Nagoski that discusses the circular incentive model of female sexual response.
A classic lay press book on sexuality, recommended as a resource for learning about sexual stimulation and response.
A book recommended for women to learn more about their orgasmic response and techniques for stimulation.
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