Peter Attia MD259 - Women's sexual health: Why it matters, what can go wrong, and how to fix it
CHAPTERS
- 0:00 – 7:18
Sharon Parish's path into sexual medicine and the state of the field
Peter Attia introduces why women's sexual health matters and asks about Sharon Parish's background. She describes her path from internal medicine to sexual medicine and explains that women's sexual medicine is a small, less clearly defined field compared with men's.
- •Parish trained in internal medicine and primary care and was pulled between internal medicine, psychiatry and gynecology
- •Women's sexual medicine spans several disciplines and is hard to define
- •About 500-600 people attended the international women's sexual health meeting, versus roughly 20,000 at the urology meeting
- •Attia says the topic also affects the partners of women
- 7:18 – 10:28
The biopsychosocial model and hormonal changes across a woman's life
Parish explains the biopsychosocial framework for sexual response, covering brain, hormones, vasculature and genital tissue. She then describes how puberty and menopause are peak hormonal transitions and why midlife women most often seek help.
- •Sexual response integrates brain, hormones, the vascular and nervous systems, and local genital tissue
- •Menopause lowers estrogen, which affects vaginal comfort, while declining androgens affect desire
- •Perimenopausal and early postmenopausal women are most likely to look into sexual health
- •It is hard to separate relationship, menopausal and sexual function causes in midlife
- 10:28 – 21:43
Defining the problems, childbirth, the pelvic floor and breastfeeding hormones
Attia lists low desire, anorgasmia and pain as key problems, and Parish adds arousal as the forgotten sibling of desire. They then discuss the pelvic floor, vaginal versus C-section delivery, and postpartum hormone states resembling menopause.
- •Arousal is a distinct complaint from desire and from orgasm
- •The pelvic floor is described as a basket of muscles that supports organs and takes part in sexual activity
- •Parish says routine C-sections to preserve sexual function are probably a myth, and vaginal delivery is generally better
- •Breastfeeding women can have very low estradiol and symptoms like dryness, irritation and reduced drive
- •Attia says no woman should have to struggle with vaginal dryness
- 21:43 – 28:46
Metabolic and vascular health as a mirror for sexual function
Attia asks whether the metabolic and vascular links seen in men's erectile dysfunction apply to women. Parish describes emerging research such as clitoral Doppler ultrasound and the 'motivator and mirror' idea.
- •In men, erectile dysfunction can mirror small-vessel cardiovascular disease
- •Clitoral color Doppler is still research-only and no clinical correlates like coronary calcium scoring are established in women
- •Parish describes sexual function as both a motivator and a mirror for health
- •Prevention and lifestyle should be taught as important for sexual health
- 28:46 – 38:37
Conditions linked to sexual dysfunction and why sexual health matters for well-being
Parish reviews the associations between lifestyle, medical conditions and sexual function, and the evidence that low desire impairs quality of life. She stresses the importance of legitimizing the concern.
- •Most research is associational; resilience, partnership, social connection, normal BMI and a Mediterranean diet are linked to better function
- •Metabolic syndrome, hypertriglyceridemia, cancers, genitourinary and menopausal symptoms, and depression and anxiety are associated with dysfunction
- •In women with heart disease or diabetes, psychological adaptation seems to matter more than disease severity
- •Clinicians tend to underestimate how distressing low desire is
- •Attia notes quality of life matters even apart from longevity
- 38:37 – 43:27
Evolution, menopause terminology and the goal of treating safely
Attia asks whether evolution disadvantages women's sexual function after childbearing years. Parish explains the shift to the term genitourinary syndrome of menopause and the balance between optimizing function and avoiding harm.
- •Parish stresses that menopausal women aren't sick
- •Vulvovaginal atrophy was renamed genitourinary syndrome of menopause to neutralize the term
- •Declining ovarian hormones and androgens reduce sexual function and cause pain
- •The field aims to safely counter these changes without causing cancer or cardiac problems
- 43:27 – 56:17
Case study 1: Desire versus arousal and the sexual response models
Attia presents a 39-41-year-old premenopausal mother of two who has no desire. Parish walks through the linear Masters and Johnson cycle, Kaplan's addition of desire, and Basson's circular model.
- •Desire and arousal should be kept separate because treatments and risk factors differ
- •The DSM combines them while sexual medicine societies and the upcoming ICD keep them separate
- •The circular incentive model describes receptive, motivated desire in long-term relationships
- •The model does not normalize distressing low desire that can't be made to work
- •Workup covers arousal, orgasm, pain, menstrual history and medications
- 56:17 – 1:02:09
Medications that reduce desire: SSRIs, SNRIs and alternatives
Attia and Parish discuss which psychotropic drugs affect sexual function. They cover differences between SSRIs, SNRIs and newer agents, and new thinking that treating depression often improves function.
- •SSRIs and SNRIs are associated with treatment-emergent sexual dysfunction in roughly 35-40%
- •Individual drugs differ within the class, so switching can help
- •Bupropion, mirtazapine, desvenlafaxine, vortioxetine and vilazodone appear to have fewer sexual side effects
- •A colleague's view: if treating depression doesn't improve function, the drug is likely responsible
- •Other drug categories can also be involved
- 1:02:09 – 1:18:56
Combined hormonal contraception, SHBG and testosterone
Parish explains how combined contraceptives can affect desire through vestibular tissue changes, mood effects and raised SHBG that lowers free testosterone. Attia and Parish discuss testosterone assays and androgen receptor saturation.
- •About 10% of users may develop vestibulodynia, especially on ultra-low-dose estrogen pills
- •All users of high-dose pills have higher SHBG, which may reduce free testosterone
- •SHBG may stay elevated after stopping, though evidence is limited
- •Free testosterone is calculated, and it is unclear it's the bioactive fraction
- •Attia raises androgen receptor saturation as an unmeasured factor
- 1:18:56 – 1:52:39
Testosterone for women: the FDA gap, dosing challenges and DHEA
Attia notes that women have more testosterone than estrogen, and the two discuss why no testosterone product is approved for women despite substantial trial data. Parish explains one-tenth male dosing, monitoring, and the role of DHEA.
- •No testosterone product is approved for women in the US, and only Australia has a government-approved product
- •Parish cites a large meta-analysis supporting efficacy and safety at physiologic doses
- •Clinicians must use a tenth of a male dose, via transdermal products, compounding or cutting patches
- •Total testosterone is monitored, and Parish advises against combining testosterone with continued birth control in premenopausal women
- •Oral DHEA has not shown convincing efficacy, while vaginal prasterone is effective for pain after menopause
- 1:52:39 – 2:02:35
Case study 2: Primary anorgasmia and how orgasm works
Attia presents a 30-year-old woman who has never had an orgasm. Parish explains the physiology of orgasm, the variability of experience, and how she approaches the history.
- •Parish first distinguishes primary from secondary anorgasmia and asks why the patient is seeking help now
- •Orgasm involves parasympathetic then sympathetic activation, pelvic floor contraction and vasodilation
- •Squirting is controversial and not the main concern for most patients
- •Primary anorgasmia is more common in younger women and tends to improve with age
- •Parish explores knowledge of anatomy, stimulation and communication with partners
- 2:02:35 – 2:15:11
Resources and therapy for orgasm, anxiety and desire
Parish recommends books, a video education website and sex therapy, and explains techniques like sensate focus. She also notes that trauma or cultural factors may call for psychological referral.
- •Books include Becoming Orgasmic, The Joy of Sex, and work by Lori Brotto
- •OMGYES is described as an educational site for women and partners
- •Sex therapists use directed techniques, homework and sensate focus for anxiety
- •Mindfulness and cognitive therapy have data for several sexual disorders
- •Deep-seated trauma or prohibitions warrant referral to a psychological specialist
- 2:15:11 – 2:39:37
Two FDA-approved drugs for low desire in premenopausal women
Parish describes flibanserin (Addyi) and bremelanotide (Vyleesi), including mechanisms, dosing, side effects, contraindications and costs. They discuss why these are not widely used.
- •Addyi is a daily bedtime pill acting centrally on serotonin and dopamine, with effect judged over 8-12 weeks
- •Vyleesi is an on-demand subcutaneous injection taken about 45 minutes beforehand, with transient nausea
- •Selection depends on preference, CYP3A4 interactions, liver disease and blood pressure
- •Both were approved only for premenopausal women because of FDA requirements, with limited postmenopausal data
- •Parish says the drugs are under-recognized and that women need validation that it's okay to want to want
- 2:39:37 – 2:57:28
Case study 3: Menopausal symptoms and the fears around hormone therapy
Attia presents a postmenopausal woman with hot flashes, vaginal dryness, osteopenia and fear of hormones due to family breast cancer history. Parish breaks down the symptoms and defends systemic hormone therapy, with Attia discussing the WHI and bone health.
- •Combined estrogen and progestogen is the most effective treatment for vasomotor symptoms
- •Short-term lowest-dose therapy is unlikely to cause breast cancer, though no one can promise
- •The WHI used oral synthetic hormones in older, largely asymptomatic women; Attia says its risk signals were small
- •Transdermal products and a progestin IUD can be used for endometrial protection
- •Attia argues that more women die from fractures than breast cancer from hormones, and alcohol and insulin resistance carry breast cancer risk
- 2:57:28 – 3:10:53
Treating genitourinary syndrome of menopause, aging and finding a provider
Parish lays out the stepwise treatment of dryness and pain, from lubricants and moisturizers to local hormones, and explains that tissue changes progress over time. The episode closes with takeaways, ageism and how to find a sexual medicine provider.
- •Stepwise care includes lubricants, moisturizers, dilators, vibrators, regular sexual activity, then local estrogen, prasterone or oral ospemifene
- •Atrophy affects everyone but severity varies, and needs often increase years after menopause
- •Parish calls for education across the life cycle and notes ageism in older women's sexual health
- •Providers can be found via sexual medicine societies, the menopause society, sex therapist and pelvic floor PT directories
