[@PeterAttiaMD] 371 – Women’s sexual health: desire, arousal, and orgasms, navigating perimenopause, and more

Link: https://youtu.be/_SZUHFA8KyM

Short Summary

This podcast episode of The Drive explores the crucial, yet often overlooked, role of sexual health in overall health and longevity for both men and women. OBGYN Sally, emphasizes that sexual health directly impacts sleep, cardiovascular function, and mental well-being, while debunking common myths and highlighting the importance of personalized approaches to sexual wellness, including hormonal considerations, open communication, and addressing the orgasm gap.

Key Quotes

Here are 5 direct quotes from the provided transcript that represent valuable insights or interesting data points:

1. "This is clearly sexual health is health. And when you look at your longevity levers and you think about your centinarian decathlon and what you want to do when you're 100, for many people, this is on the list and I want to talk about how to structure your life and get you ready to do that." This quote emphasizes the connection between sexual health and overall well-being, framing it as a significant factor in longevity.

2. "About 20% of couples, and this is ages 30 to 60, about 20% of couples are having sex twice a week or more. About 10% of couples are what we call never having sex. And that means in the last year and about 70% of couples are having sex between those, meaning once a month, twice a month, sort of around that number." This provides a statistical overview of sexual frequency in couples, setting the stage for discussions on desire discordance.

3. "When you look at risk factor for divorce, it's the same across all numbers in the sense that it doesn't matter how much sex you're having. You could never have sex or you could have lots of sex. The divorce risk factor is what we call sexual desire discordance or one partner wants more and one partner wants less." This highlights a critical factor in relationship stability, suggesting that mismatched desires are more impactful than the sheer frequency of sexual activity.

4. "Foreplay lasting greater than 21 minutes over 90% of women orgasm." This quote reveals a correlation that can be applied directly, time really does matter and allowing the physiology to happen will allow for better intercourse and positions.

5. "95% and what about women? 30%. And what about for a one night stand? What percent of women are having orgasms on one night stands with men?... Yeah, it's around 12%." This exposes a stark disparity in orgasm rates between men and women, particularly in casual encounters, underscoring a broader issue of pleasure equity.

Detailed Summary

Okay, here is a detailed summary of the YouTube video transcript in bullet points, highlighting key topics, arguments, and information:

Introduction & Framing

• Podcast: The Drive, hosted by Peter Attia, featuring OBGYN Sally (last name omitted for privacy), focusing on women's sexual health.
• Topic Relevance: While seemingly focused on women, the discussion aims to benefit everyone interested in overall health and longevity.
• Connection: Sally was recommended by a mutual contact who was impressed by a previous podcast on a similar topic.
• Sex as a Health Component: Peter questions, "Why would sex be an important part of a longevity discussion?" Sally argues it's integral to overall health and performance.

Arguments for Sexual Health as Health

• Performance Enhancement: Sex drive can be improved with facts and anatomical descriptions.
• Longevity Lever: Sexual health is part of a fulfilling life, even at age 100.
• Evolutionary Importance: Sex is essential for species propagation, but it also has direct health benefits.
• Data Limitations: Studies in this area are often underfunded and lack robust data, especially in non-heteronormative relationships.

Direct Health Benefits Discussed

• Sleep:
  • Sexual activity (with or without orgasm) shifts the nervous system to parasympathetic, releasing relaxing neurotransmitters (dopamine, oxytocin).
  • Sleep quality (latency, resting heart rate) improves subjectively and objectively after intercourse.
  • Orgasm with a partner synergistically improves sleep more than solo or partner-less orgasms due to connection and intimacy.
• Cardiovascular Health:
  • Sex can mimic exercise physiology; though intensity varies by couple.
  • Women use approximately 6-7 METs (60-70 calories) during sex, comparable to slow treadmill walking.
  • Sex is more enjoyable for many than traditional exercise.
• Relationship Health:
  • No set number of sexual encounters is necessary for relationship health.
  • Sexual desire discordance (one partner wanting more than the other) is the biggest risk factor for divorce, regardless of frequency.
• Centenarian Decathlon Connection: Having a sex life is a popular choice for those selecting 10 activities they want to be able to perform in their last decade of life. A minimal V02 max is needed to be sexually active in your 80s or 90s.

Defining Orgasm in Women

• Normal (Most Common) Definition: Rhythmic contractions of the pelvic floor muscles.
• Four Phases:
  • Excitement: Engorgement of tissues, increased blood flow, lubrication.
  • Plateau: Neurotransmitter and hormone release phase (duration varies).
  • Orgasm: Rhythmic contractions
  • Resolution: Post orgasmic recovery
• Time to Orgasm:
  • Self-stimulation: Average <4 minutes.
  • With a Partner: 21-25 minutes.
  • Foreplay lasting longer than 21 minutes results in over 90% of women having orgasms.
• Foreplay Importance: Facilitates blood flow, vaginal widening/lengthening, and angle change, potentially reducing pain during deeper penetration.

The Orgasm Gap and Female Pleasure Disparity

• Men's Orgasm Rate: 95% report nearly always having an orgasm with a female partner.
• Women's Orgasm Rate:
  • 30% report always having an orgasm with a male partner.
  • ~12% report orgasms in one-night stands with men.
• Health Disparity: Women experiencing less pleasure is a health disparity.
• Orgasm's Correlation to Health: Linked to pelvic floor strength and vascular blood supply.

Foreplay Defined and Responsive Desire

• Social Definition: Anything outside of penetrative intercourse.
• Medical Definition: Physiological changes (increased blood flow, clitoral nerve stimulation, brain signals).
• Spontaneous vs. Responsive Desire:
  • Spontaneous: Desire arises without external stimulus (more common in men, ~15% in women).
  • Responsive: Desire arises in response to arousal (more common in women).

Strategies for Cultivating Arousal/Responsive Desire

• Lubrication: Use silicone-based lube 30 minutes prior.
• Erotic Literature/Auditory Porn: Dipsia, Meet Rosie
• Mindfulness: Breathing techniques, staying present (Lori Brotto's book).
• Vibrator: Using a vibrator, use of different positions.

Lubrication Details

• Myth Dispelled: Lube is not just for older women; most women benefit from it.
• Natural Lubrication Sources: Skins glands, Bartholins glands, sweating of cells in the vaginal canal, cervical mucus
• WHO Guidelines: Important for HIV prevention (decreasing microabrasions).
• Friction vs. Lubrication: Less friction required for women.

Clitoral Anatomy and Nerve Stimulation

• Importance of Clitoral Knowledge: Many women, and especially men, lack detailed knowledge of clitoral anatomy. A recent study show that only 41% of Gen Z men could accurately identify the clitoris.
• Clitoral Structure: Composed of the clitoris, a vestibule of the clitoris, the crew of the clitoris and labia. There is also the labia minora and majora, all the way down to the clitoral nerve.
• Clitoral Nerve Fibers:
  • Type A: Vibration and deep pressure; myelin sheath protects against degradation.
  • Type C: Heat and light touching.
• Vibrator Use: Recommended for women who find certain positions are no longer working or to help with aging and degradation of nerves.
• Clitoral Model: It is important to understand that sexual organs can and should look different. There is a great website called the labia library that normalizes the variety in size and shape.
• Female Ejaculation: Fluid is not directly lubricating the vaginal walls, it is external.
• G-spot: A branch of the clitoris that runs along the anterior part of the vagina. You can find this branch by taking your middle finger and stick it as far in as you can and sort of do a a come hither movement. You'll know you are there if you feel a sensation to urinate.
• Penetrative Intercourse and Orgasm: Most women need clitoral stimulation alongside penetration to achieve orgasm.

Consults with Female Patients & Improving Communication

• Surprising Lack of Knowledge: Many women lack basic anatomical knowledge, appropriate verbiage, or how the clitoris works.
• Male Partner Education: Give men a roadmap to explore and find the anterior branch of the vagina.
• Biopsychosocial Model: Sexual dysfunction involves biological, psychological, and social components.

Pelvic Positioning & Orgasm

• Pelvic Floor Physical Therapy is helpful for both increasing tone of the pelvic floor and also for hypertonicity.
• Understanding anatomy helps women and partners understand how to stimulate properly.

Myths and Desires

• Vibrator Use & Partnered Sex: Myth that vibrator use makes orgasm with a partner harder is false.
• Sex Begets Sex: More sex leads to increased desire.
• Scheduled Sex: Can help with desire, reduce initiation pressure.
• Discordance of Desire (Male vs Female): Commonly male has a higher desire than female but I can go either way based on stressors such as partners health, work etc.
• Desire, Throttles & Break:
  • Accelerators are estrogen, testosterone, nitric oxide, dopamine, and oxytocin.
  • Breaks are serotonin and prolactin.

Hormone Replacement Therapy: Menopause and Peri-menopause

• Hormones (Estrogen and Testosterone): It is well understood to have a benefit in sex drive, more so for testosterone.
• Hormone method for administration: Cream is most effective and there is no preference in efficacy between oil and cream.
• Target Testosterone: To get the patients testosterone levels above 20.
• Initiation of Estrogen, Progesterone, and Testosterone Use in Peri-menopausal Women: Ask "Do you like ovulating or not?" This will guide how you approach therapy.
  • 1st 70% of the patients prefer not to ovulate. *Oral contraceptives work well to suppress the gonadropen pathway.
• Synthetic Progestins v. Natural Progesterone: Synthetic Progesterins can come with very different side effects.
• Hormone Therapy Types (Pros and Cons):
  • Drosperinone Only: This helps to have a great mood benefit for women who cannot take estrogen.
  • Hormone Suppression/Natural Hormone Combination: An example is adding a slind drosperione for hormone suppression, with estrogen from menopause.

Sexual Assault and Trauma

• Address It: Sexual Trauma plays a big part in the a woman's ability to have a healthy sexual life and this needs to be addressed.
• Seek Support: Therapists play an important role in the patient's life and ability to curate arousal.
• Sensate Focus Exercise: Sensate Focus Exercises which are evidence based for trauma survivors have four steps and allows one to create a safe space.
• Physical Therapy: Physical therapy can help to reduce hypertonicity and encourage pelvic floor relaxation.
• Treat Vagina like Face: Give the same treatment and care to the vagina, as you would to you face with these three important keys. Sunscreen, moisturizer and collagen enhancement/hormones. *It is understood to use silicone based lube instead of water based lube.
• There are some recommended silicone based lubes such as uber lube and good clean love. *Hyaluronic acid suppositories like Reie are also used for hydration.

Other Recommendations

• Oral Sex: Book Recommendation, She Comes First.
• Pharmacology for Sexual Health: *There are to major prescriptions of interest and both affect serotonin, dopamine, and norepinephrine (MAOI pathways). Addie & Vile. *Addie (pill) - 1 month before it can be seen to have an affect. *Vile (injection)- is more commonly known as the Barbie drug and can cause nausea. *Cannabis- there is strong correlation for cannabis, more specifically thc at about 1 to 2 mg can improve sexual performance.

Pregnancy & Sexual Health

• Sex During Pregnancy: Is completely fine and has a lot of relationship and psychosocial benefits.
• Sexual Activity Post Partum: Both for vaginal and C Section the recommendation is at 6 weeks you are clear to resume sexual activity.
• Genital Urinary Syndrome of Lactation Local estrogen prescription is recommended to keep vaginal healthy.
• It is not recommended to have a routine episiotomy.

Sex Education & Pornography

• It is recommended to move from a don't list of the fears and reasons why you shouldn't do it, to actual education.
• Education should include both genders so there is understanding from each parties.
• Masturbation should be normalized as part of education and sexual health.
• Porn sets unrealistic expectations for sexual encounters.
• Sex Ed needs to be evolved and is not just that one conversation you had in 8th grade.
• A healthy way to deal with pornography is to introduce and encourage healthy sexuality.

Conclusion: Sally's Concerns & Excitements

• Excited about: new information on hormones, menopause/perimenopause treatment, estrogen and progesterone optimization.
• Passion: Encouraging couples to consider sexual health as a key part of health and well being.

I hope this is a helpful summary!