Peter Attia MD259 - Women's sexual health: Why it matters, what can go wrong, and how to fix it
At a glance
WHAT IT’S REALLY ABOUT
Women's Sexual Health: Underrecognized Problems, Real Treatments, and Closing the Gaps
- Sharon Parish argues that the distress and loss of quality of life from sexual dysfunction are usually underestimated, and that women need permission to seek help for it.
- Through hypothetical case studies, Parish separates desire from arousal and orgasm, and she walks through the history she takes, the medications and birth control that can contribute, and the lifestyle and relationship factors she reviews before prescribing.
- The conversation covers testosterone for women, where trials show benefit for low desire but no FDA-approved product exists, so clinicians must use off-label male products at about one tenth of the male dose or compounded formulations.
- Two FDA-approved drugs for low desire in premenopausal women, flibanserin (Addyi) and bremelanotide (Vyleesi), are described as little known and underprescribed.
- For menopause, Parish and Attia say hormone therapy is the best treatment for vasomotor symptoms and that fears from the Women's Health Initiative are overblown, and Parish lays out a stepwise approach for genitourinary syndrome of menopause.
IDEAS WORTH REMEMBERING
5 ideasSexual dysfunction is a real quality-of-life issue that clinicians underestimate.
Parish says studies show clinicians rate the distress as lower than patients do, and that women often feel it is indulgent to seek treatment, so she emphasizes giving explicit permission to seek help.
Desire and arousal should be kept as separate concepts.
Parish says some women get aroused and reach orgasm but still lack desire, and that treatments and risk factors differ for each. She cautions that models normalizing responsive desire should not be taken to normalize low desire that distresses someone.
Combined hormonal contraception can affect sexual function in several ways.
Parish describes possible vestibular pain with very low-dose pills, mood and neurotransmitter effects, and a rise in SHBG that may lower free testosterone and persist after stopping. She notes most women have no problem, and that the free-testosterone mechanism is a theory.
Testosterone helps women with low desire, but the lack of an approved product makes prescribing awkward.
Parish cites a large body of trial data supporting efficacy and safety at physiologic doses. The FDA declined to approve a patch over long-term safety data, so clinicians use male products at about one tenth the dose, with monitoring of total testosterone.
Two FDA-approved drugs for premenopausal low desire exist but are rarely used.
Flibanserin is a nightly pill and bremelanotide is an on-demand injection. Parish says many people, including Attia, had not heard of them, and that they work by different central mechanisms.
WORDS WORTH SAVING
5 quotesUsually it's way underestimated how distressing or, um, impairing it is to quality of life.
— Sharon Parish
women who are perimenopausal, menopausal, and postmenopausal aren't sick, right?
— Sharon Parish
a woman has much more testosterone in her body than she has estrogen. This is a staggering thing that surprises most women and most men alike.
— Peter Attia
It's okay to want to want.
— Sharon Parish
you don't treat a testosterone, you treat a syndrome.
— Sharon Parish
High quality AI-generated summary created from speaker-labeled transcript.
