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

1. 0:00 – 0:11

   Intro

   1. PAPeter Attia0:00

      [upbeat music] Hey everyone, welcome to the Drive podcast. I'm your host, Peter Attia. [upbeat music]

2. 0:11 – 10:21

   How sexual health influences physical health, emotional well-being, and relationships

   1. PAPeter Attia0:11

      Sally, thank you so much for coming out to Austin.

   2. SGSally Greenwald0:13

      Thank you for having me.

   3. PAPeter Attia0:14

      This is a topic that on the surface might seem somewhat directed towards 50% of the population, but I, I think it's safe to say it's probably gonna be directed towards 100% of the population. Um, so you have a practice, you're an OB-GYN, but your focus is not just on maybe the standard OB-GYN things, but really around women's sexual health. Is that a fair assessment?

   4. SGSally Greenwald0:39

      That would be a fair assessment, yes. From a hormonal and physiologic perspective, yes.

   5. PAPeter Attia0:43

      Awesome. Well, by way of background, we were introduced through, uh, a mutual, uh, friend/patient, um, who had listened to the Rachel Reuben podcast that I did, uh, recently, was super impressed by it and said, "You have got to speak with Sally." And one thing led to another, and we are now speaking. So, um, let's start by helping people understand why would a podcast that focuses on health, longevity, all of these things that pertain to living longer and, and better, why would sex be an important part of that discussion?

   6. SGSally Greenwald1:22

      Well, I'm having a hard time understanding how sex couldn't be a part of that conversation. Um, I think, you know, first of all, this is a performance driven podcast, and so for the 50% of your listeners who are male, if you want to improve your performance, I'm going to give you facts and anatomical descriptions, um, and describe some pathophysiology so that you can improve your performance. Um, this is clearly sexual health is health. And when you look at your longevity levers and you think about your centenarian decathlon and what you wanna do when you're 100, for many people, this is on the list, and I wanna talk about how to structure your life and get you ready to do that. Um, I also think that there's probably a small group of listeners similar to myself who th- always thought that the Drive was supposed to be about sex drive and that you just had a branding, uh, error when you named it the Drive. So for those people as well, I-- we're finally gonna talk about the drive that you actually care about.

   7. PAPeter Attia2:22

      [laughs]

   8. SGSally Greenwald2:23

      Um, which is sex drive.

   9. PAPeter Attia2:25

      So, um, th- there's, there's a lot to sort of unpack there, but I think I want to kind of go back and talk a little bit about something you said vis-a-vis, um, the actual health component of this, right? So if you, if you, if you, if you looked at this through the lens of just evolution, everybody clearly understands why sex is important, and it's the single most important thing in the propagation of our species. But can you say a little bit more about how it actually factors into health? Um, and I don't just mean emotional and mental health, where I think we could easily make that connection. Is there any evidence whatsoever that a healthy sex life d- plays a direct role in, in health as it pertains to disease?

   10. SGSally Greenwald3:11

       Definitely. I'll start out with my two caveats though, which is, one, this is an understudied, under investigated area of our health. That's part of my messaging today. So many of the studies that I'll reference are not going to be robust in, in volume. Um, and second, this is a incredibly heteronormative conversation for that reason. This is a data driven podcast, and I don't have a lot of data on non-heteronormative, meaning men who identify as men having sex with women who identify as women. Um, so that should alarm you as well that we don't have that data, but that's sort of the space in which if we're gonna stay in a data rich zone, that's where we have to stay. Um, and also the discrepancy when you look at sexual health is greatest among those two participants. Um, when we look at sexual health and we try to make the argument that sexual hearth is-- health is a part of health, um, you know, we can sort of use your longevity framework if we start with sleep. There is great data. We know that when you are sexually active with or without orgasm, just participation in a sexual activity, you switch from sympathetic to parasympathetic. So post orgasm you have a great activation of the parasympathetic nervous system. You release neurotransmitters, dopamine, oxytocin. These are relaxing neurotransmitters. And when we study it either via diary or via-- there's great studies that look at resting heart rate, sleep latency. Many of the measurements that we look to in terms of looking at sleep efficiency and quality subjectively and objectively improve with intercourse. What's really interesting and why I wanna pull in all listeners, not just 50%, is there was a great trial that looked at how women slept after an orgasm with themselves, and they slept better. And then it looked at women being intimate with a man, and they slept better. But women being intimate with a man and having an orgasm with that man synergistically improved their sleep. You're getting sort of a dual benefit of that neuropharmacology that you're releasing from your brain, improving your biometrics, but also there's a connection and intimacy, a partnership that we know fosters better sleep. Cardiovascular health, this is also, you know, limited. We don't have tons. But we know that sex can mimic a lot of the pathophysiology that we experience during exercise. There's been arguments over the decades about is it low intensity?

   11. PAPeter Attia5:27

       [laughs]

   12. SGSally Greenwald5:27

       Is it moderate intensity? I think it depends on the couple. Um, but we have studies that have tried to measure the Mets or the metabolic equivalents or essentially the, the energy output. For women, on average, it's around f- uh, six to seven metabolic, um, units for every sexual encounter. It's about 60 to 70 calories used during sexual activity. And there's a great study that compared this to walking slowly on a treadmill for the same amount of time. And they said that although sex was slightly lower in your energy export than walking on the treadmill, many of the participants reported that they had a much better time having sex than they did walking on the treadmill.

   13. PAPeter Attia6:06

       [laughs]

   14. SGSally Greenwald6:06

       And so it's still something to consider. We know the n- sort of tapping into the body's natural pharmacology, thinking about neurotransmitters and the sort of positive impact on mood and relationships, um- It's really interesting to think about from a relationship perspective. I think what I don't want to say, what I don't believe is that everyone has to have lots of sex, and that's, you know, sort of, uh, and that there's a number that we're trying to target. Is there a number needed to treat? Is there a dose that we're trying to go for? No, there's no studies on that, but I also don't believe that. Every person, every couple is different. When you look at couples, um, I like to look at sort of who's having sex and by what frequency. Um, and so 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. 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, 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. And so identifying that as the risk factor I hope gives people sort of affirmation or interest in the fact that if you want to work on it, I will help you. But not everyone has to. This is not a podcast about everyone needs to go work on their sex life. But if you do, I'll sort of go through the normal pathophysiology and some additional tips and tricks to help you have a se- a healthier sex life.

   15. PAPeter Attia7:45

       All right. So two things I just want to reiterate that you've said that, that are both important and at least interesting to me. One is, um, discordance of desire is a much bigger risk factor than anywhere you lie on the distribution of, if I recall, 10% of people are basically asexual, 20% of couples... Uh, or is it 10% of couples? 20% of couples are at twice a week or greater, and basically two-thirds of couples are somewhere in between. So that's very interesting. Second thing you said, I can't resist coming back to the centenarian decathlon. I've, I'm glad you brought it up because it is one of the items on our list on the framework that we, we hand to patients when we ask patients to pick the 10 most important things that they want to be able to do in their marginal decade, in the last decade of their life. Um, and I would say about two-thirds of our patients select having sex as one of those 10 activities. That says something, given that we're giving people a list of about 150 things to choose from, all of which are quite, uh, tempting. Um, and to go back to your point about Mets, if seven Mets is what is required energetically to have sex, we can convert that into VO2. So seven Mets translates to about a VO2 of 25 milliliters per kilogram per minute, which means if you want to be able to have sex in your marginal decade, you need to have a VO2 max of probably about 30 milliliters per kilogram per minute. Why? Because it would be pretty tough to have sex if you were doing it right at your maximum VO2. That would be like me asking you to do the fastest 800 meter run you've ever done and bring that level of exertion to sex. You gotta be a little bit below your limit. And while most adults can easily muster a VO2 max of 30 milliliters per kilogram per minute, if you want to be able to achieve that in your 80s or 90s, when you're my age or your age, you're a lot younger than me, you need to be probably north of 45 or 50. So if I could just make one more shameless plug for having a high VO2 max, it's gonna allow you to be sexually active in the last decade of your life.

   16. SGSally Greenwald10:06

       And I think in addition to that, it would be great if at the end of this we had a list of a few sort of action items in addition to a minimal VO2 max that we could consider a toolkit in order to get this action as something that's actually attainable on your centenarian list.

3. 10:21 – 16:57

   Understanding the physiology of the female orgasm, sexual comfort and satisfaction, and the disparity between men and women

   1. PAPeter Attia10:21

      Let's talk a little bit about... Well, I, let me ask a very silly question. Um, when it comes to understanding what an orgasm means for a man, it seems relatively straightforward in that it's tied to ejaculation. And while there are examples where a man can have a retrograde ejaculation due to, example, the use of medication, and he can still have an orgasm, but you're not actually witnessing an ejaculation. Um, with, with women, how is an orgasm actually defined? Is it a biochemical response in the brain? Is it a muscular contraction in the body? He- help, help me and help us understand that.

   2. SGSally Greenwald10:57

      I think it's important to say that we're gonna talk about normal things. Um, yes, there's a lot of pathophysiology and deviations to what's normal, and you should see a doctor and we can talk to you about it. But similar to sort of your focus on what's normal in men, to describe what's most normal in women is a rhythmic contraction of the pelvic floor muscles. Um, it is, there's four stages, um, to an orgasm. It starts with the excitement phase, which is an engorgement of the pelvic tissues. There's increased blood flow. There's lubrication released by the Skene's glands and other glands of the vaginal canal. Then there's a plateau phase that is predominantly a neurotransmitter phase and a hormone release phase. You can stay in that for a variety of time periods. It's person and partnership dependent. There's the orgasm, then there's the resolution phase, and these four stages, understanding how they work and where you are in that stage can allow for the introduction of interventions that can improve your sexual life or help you foster a healthier life in general.

   3. PAPeter Attia11:51

      What is the period of time in which a woman will go from those first to fourth phases? A- again, I realize there's gonna be a lot of variation, but what would be sort of considered interquartile range of that transit?

   4. SGSally Greenwald12:05

      So it really depends. Um, when women are on their own, it's the average time to orgasm is less than four minutes, and when women are with a partner, it's upwards of like 21 to 25 minutes.

   5. PAPeter Attia12:14

      Question there. Um, with a partner, you could still have it manual, you could st- it could be oral, it could be intercourse.

   6. SGSally Greenwald12:21

      And that really skews-

   7. PAPeter Attia12:22

      So how much does that-

   8. SGSally Greenwald12:23

      Really skews the data. Um, I don't have the numbers on that. I don't think we have that, and women are actually individually so different as well. An interesting takeaway from, from your interest in looking at those numbers is to think about a statistic we do know, which is that foreplay lasting greater than 21 minutes, over 90% of women orgasm. So it's, it's really sort of interesting and enlightening to think about, oh, gosh, so, so time actually does matter in that stage, and, and, and why do we care about foreplay? What's happening during that time? That's, you know, sort of when you're in the excitement phase building up towards orgasm, so blood is flowing to the area. So we think about your anatomy changes. So the vagina that's usually like three and a half by nine, so three and a half inches wide by nine inches deep, um, will actually get longer and wider. And why do we care? 30% of women will experience pain with intercourse, so actually appropriate foreplay where the vagina not only gets wider and longer, um, but actually the angle of the vagina changes. And I think this is something that I love talking to couples about because I have many women who will say, "You know, my partner loves this position," and often it's a deep penetration position, um, "but it really hurts me." And I say, "Well, how much foreplay is going on?" And so if there's not enough foreplay, you don't actually change the angle of the vagina or change the angle of the canal, um, and so you will experience more pain. You'll have the tightness of the pelvic floor muscles, and pain fosters pain. You can get into a pain cycle. And so actually appropriate amount of foreplay, allowing the angle of the vagina to c- to change, can allow women to participate in positions most commonly we call doggy style or sort of deeper penetration positions, which can then be sort of a part of your repertoire if you're interested in that.

   9. PAPeter Attia14:00

      So what about just kind of the differences in ability to achieve orgasm, the, the so-called orgasm gap? What, what can you tell us about that?

   10. SGSally Greenwald14:08

       I hope I've proven to you that sexual health, pleasure, orgasms are a part of health. And so I think when we then look at the disparities in how different parties will participate or receive enjoyment out of these activities, I hope it highlights to you how important it is that we work on this. And so I'm gonna quiz you now, which is what percent of men do you think report when they're having sex with a woman, report that they almost every time have an orgasm?

   11. PAPeter Attia14:41

       95%.

   12. SGSally Greenwald14:42

       It's 95%. And what about women?

   13. PAPeter Attia14:45

       Uh, what percentage of women would report always-

   14. SGSally Greenwald14:47

       Always

   15. PAPeter Attia14:47

       ... being able to have an orgasm with a male partner?

   16. SGSally Greenwald14:50

       Correct.

   17. PAPeter Attia14:53

       50%?

   18. SGSally Greenwald14:54

       30%. And what about for a one-night stand? What percent of women are having orgasms on one-night stands with men?

   19. PAPeter Attia15:03

       Well, if it's 30% on a regular basis, I would say 10 to 20%.

   20. SGSally Greenwald15:10

       Yeah, it's around 12%. And so-

   21. PAPeter Attia15:13

       What about men at one-night stands? Still 95%?

   22. SGSally Greenwald15:16

       Correct. 90, actually, I should say. It's 90%. Um, and so when we think about the orgasm, so if I've proven to you that sexual health is health, and if we understand that orgasm is one metric that we can use, it's not the end all, be all, um, there's other sort of satisfaction, intimacy, connection, pleasure benefits that women get out of intercourse, but this is one numeric finding that we can track, um, this disparity or this discrepancy is a big deal, and this, this disparity in how women experience pleasure becomes a health disparity. Because if sexual health is health and women are not experiencing it with the same amount of pleasure that men are, this is a health disparity.

   23. PAPeter Attia16:01

       By the way, within women, do, does orgasm at all correlate with underlying health?

   24. SGSally Greenwald16:08

       Yes. Um, we do. We see that. We know that orgasm is related to strength of the pelvic floor, vascular blood supply, so there are issues, so there's a lot of sort of bidirectional, you know, if you're healthy enough to be able to have an orgasm, then you can have an orgasm, and if you're having orgasms, you're likely healthier. So there's a lot to that.

   25. PAPeter Attia16:27

       Mm-hmm.

   26. SGSally Greenwald16:28

       And we know that bidirectionality, but I think still looking at the numbers, I'm hoping that you're thinking, "My gosh, this is, this matters. This is a big deal." We should, you know, we classically think about sexual health as sort of an afterthought. When we think about longevity, we think about cancer screening and prevention and chronic diseases, and now sleep and exercise. And once we've sort of addressed all of those, we now have the luxury of addressing sexual health, and I just think we should put it a little higher

4. 16:57 – 22:10

   Foreplay, the science of desire, and methods to help women cultivate arousal and connection

   1. SGSally Greenwald16:57

      on the list.

   2. PAPeter Attia16:57

      Okay. So let's talk a little bit more about foreplay. I, I, w- when I think, when most people hear foreplay, they assume what? Anything that is sexual shy of intercourse? How, how do we define foreplay?

   3. SGSally Greenwald17:09

      Great question. Um, there's medical, uh, definitions of foreplay and social. So social definitions tend to say anything outside of penetrative intercourse. Um, medical definitions rely more on the physiologic changes that are happening in your body, um, increased blood flow, um, recruitment of, uh, swelling of the clitoral nerve, um, physiologic signals from your brain that sort of prepare you emotionally to participate in this interaction. Um, what's most interesting to me about this is when we think about sort of, let's start with desire. When we think about desire, we think of more of the spontaneous desire. Spontaneous desire is more common in men. Spontaneous desire is only present in about 15% of women. Women have what we call is responsive, uh, desire. Spontaneous-

   4. PAPeter Attia17:57

      So sorry, just help me understand that. Oh, you were just about to-

   5. SGSally Greenwald17:59

      Yeah

   6. PAPeter Attia17:59

      ... explain spontaneous.

   7. SGSally Greenwald18:00

      Yeah, so spontaneous desire is, um, you've been married for 20 years, you see your partner get out of the shower for the 8,845th time, and you think to yourself, "Gosh, I would love to be intimate with this person." That's spontaneous desire. That's sort of desire in anticipation of intimacy.

   8. PAPeter Attia18:19

      Mm-hmm.

   9. SGSally Greenwald18:20

      Responsive desire is you see your partner get out of the shower for the 8,645th time, and you think, "Did I sign up for the right treadmill tomorrow morning at 6:00 AM?" And that's because your brain's just not there. It's not in the same place as your partner. But if your partner comes over and starts to rub your shoulders and rub your feet or maybe has made dinner, um- We call chore play, which is where sort of emotional, uh, investments in the relationship can sometimes lead to, to responsive desire. Um, using lubrication, um, and we'll talk about how to use lube. Using a vibrator, sort of creating an environment in which you are capable of being aroused, that's responsive desire. And thinking about what's happening in that circumstance can be really helpful and validating for women, and it can help their partners get them there, too, with the ultimate goal of sort of being aligned in your sexual desire, um, from a frequency perspective.

   10. PAPeter Attia19:13

       And so you're saying it's more typical that men experience spontaneous desire where arousal comes on in a moment.

   11. SGSally Greenwald19:22

       In anticipation.

   12. PAPeter Attia19:23

       In anticipation, and often based on perhaps a visual cue?

   13. SGSally Greenwald19:26

       Correct.

   14. PAPeter Attia19:27

       For women, that is less common-

   15. SGSally Greenwald19:29

       Correct

   16. PAPeter Attia19:30

       ... but not implausible.

   17. SGSally Greenwald19:32

       Correct. And so acknowledging that, there's a few sort of lessons that we can take from that. Um, the first is if you're listening to this podcast and you want to work on your desire, if you're waiting for your husband to get a new shirt or a new Selby or anything, it... The visual stimulus is not evidence-based. Stop waiting for that. I want you to think about-

   18. PAPeter Attia19:52

       What about getting a new car? Does that-

   19. SGSally Greenwald19:54

       I'd love one, but no. Um, but just to be clear, I would love one.

   20. PAPeter Attia19:58

       [laughs]

   21. SGSally Greenwald19:58

       Um, I want you to think about how you get s- responsive desire in response to arousal. And how we do that is lubrication. So we know how to use lube. Most of us do. You're in the act, you take some lubricant, you put it on the penis, you put it on the vagina, you have intercourse. Um, I want to sort of encourage you to think about lube, potentially using it 30 minutes prior to intercourse. So I want you to take a silicone-based lube, and I'll tell you why in a moment, um, and I want you to think about using a lube shooter, which is a little droplet, um, to take some of the lube and put it higher up in the vaginal canal. And then I want you to read a book, drink a cup of tea, wash your face. Um, women, as you sort of alluded to, are less visually stimulated into d- into desire. Um, there's great data that women like to read erotic literature, and there's great apps for that. Meet Rosie, Dypsia are great companies that have auditory or literature porn for women. Um, there's great dad that's-- there's great data that mindfulness can work for women. Um, Laurie Brato wrote a book called Mind-- Better Sex Through Mindfulness, thinking about breathing techniques, staying present in the moment. My favorite strategy for this is to describe to yourself in your head, not aloud, what's happening. "My breathing is relaxing, my vagina feels wet," sort of talking yourself through what's happening from a pathophysiologic perspective to bring yourself into the moment. Um, but when we think about how to curate that arousal, essentially what you're doing is showing up at the party and then seeing what happens. And there's no expectations what happens at the party. But Emily Nagoski, who wrote Come as You Are, talks about, you know, it's Friday night, and you really want to put on your bathrobe and watch Love Island, but instead, you're going to go to a party with your friends because you said you would. And you get there, and it's actually kind of fun, so you stay and, and you have a good, you have a good time. You have a drink. You actually like your-- like it when you're there. Um, that's the sort of idea behind curating your own arouse-- desire through arousal, which is use a vibrator, use some lubricant, relax, get in the moment, start to participate, and if you don't want to, obviously consent is of utmost importance, and stop. But if you sort of start participating and decide that you're happy that you're there and you like it,

5. 22:10 – 30:19

   The physiology and sources of female lubrication, the role of clitoral nerve anatomy in pleasure, and the use of lubricants and vibrators to enhance comfort and sexual health

   1. SGSally Greenwald22:10

      please stay and have a good time.

   2. PAPeter Attia22:11

      Okay. A lot of questions come up when you said all those things. Let's start with the need for lubrication. So I very naively have assumed that women who are young enough, right, so not even ap- approaching estrogen withdrawal, are not having an issue with lubrication. Um, that clearly must be incorrect or you wouldn't be stating this. So c- what can you say about, um, perhaps the differences in the amount of lubricant, and maybe even just talk a little bit physiologically about w- where is this-- what, what is, what is the lube that is naturally made, where is it coming from, uh, and what drives variability both across women and within a given woman's life? Or not, let's not even talk about it within her life. Within a given month or something like that.

   3. SGSally Greenwald23:00

      You know, you're correct with that line of questioning to sort of assume that throughout the month women will have different levels of lubrication. Um, medications can impact lubrication, life, age, life cycle. There's so many factors that go into your ability to have the amount of lubrication that you need in order to have a comfortable sexual encounter. This idea that we just use lube, need lube as we age, I want to completely dispel. I think the majority of women need lubrication and should use it. Um, the reason, the way that we sort of naturally get lube in our vagina is from a variety of different glands that work, you know, better or worse. There's the Skene's glands that sort of support the vagina.

   4. PAPeter Attia23:36

      Which are where?

   5. SGSally Greenwald23:37

      They're right on either side of the urethra. And fun fact about this, many people will have more prolific Skene's glands in the sense that they can sh- sort of shoot the lubrication a little bit stronger. So when we sort of talk about women who what we call squirt, it's actually the Skene's glands releasing lubrication in a more aggressive form. Um, there's Bartholin's glands that produce lubrication that are commonly known, uh, for their likelihood to sometimes get clogged and to cause pain. Um, but there's so much that goes into lubrication, and it's so important throughout the life stages that the WHO, the World Health Organization, actually has guidelines in terms of how to pick out your lube. And if you're wondering right now, "Wow, I never knew that the WHO cares so much about my sexual life. That's, that's wonderful," um, they don't. They care about HIV transmission, and picking the appropriate lube decreases-

   6. PAPeter Attia24:31

      Less friction

   7. SGSally Greenwald24:31

      ... microabrasions, less friction, less tearing, less HIV trans- transmission. But we can sort of take this data into the pleasure world and think about sexual health and sort of what-- so what types of lube should we use, I think, is the next part of that question.

   8. PAPeter Attia24:45

      Well, actually, I want to go back and ask a different question, which is Isn't there sort of a min-max optimization problem around lube? Because friction is also part of what is necessary, at least for the male to have an orgasm. How much does it matter for the female?

   9. SGSally Greenwald25:01

      Less so. Um, friction is fr- friction matters less so to women, and let's talk about the clitoral nerve anatomy to answer that question. Um, I, I'm gonna leave this for you as a gift, but I've, I-

   10. PAPeter Attia25:15

       I'll, I'll keep it on my desk

   11. SGSally Greenwald25:16

       ... it's pure, pure gold. Um, so you may wanna put it, um, in your safe, but, um, this is sort of the anatomy of the clitoris, and what you're looking at is sort of what we tend to discuss in terms of clitoral anatomy. Typically, we talk about is the tip of the iceberg or the, the clitoris. But there's, um, there's the crew of the clitoris, and there's the vestibule, which, which is an engorgement structure when blood comes to the area. Your labia minora would be here, and your labia majora would be here. This would make up the vulva. When we think about the clitoral nerve, it actually has two types of nerve fibers in it. One is a type A nerve fiber, and one is type C. Type A responds to vibration, and it responds to deep pressure, and type C responds to heat and light touching. So A is vibration and deep pressure, and C is heat and light touching. What's really interesting about using this to answer your question is that there's, you don't, friction is not a requirement to hit any of those four metrics, and actually is so significantly associated with microtearing and pain, with the 30% of women experiencing pain with intercourse. I would argue that women need no friction.

   12. PAPeter Attia26:27

       No friction.

   13. SGSally Greenwald26:28

       Um, but to think about how that nerve changes over time is really fascinating because type A fibers, the vibration and the deep pressure, they have a myelin sheath around them, and so they age better. Nerves protected by a myelin sheath are more resistant to degradation.

   14. PAPeter Attia26:47

       And that's the A fiber?

   15. SGSally Greenwald26:48

       And that's the A fiber. And so I have women come into my clinic, and they say, "I've been with my partner for 35 years. We do this position for six minutes. It always works. It's not working." And I say, "Have you considered using a vibrator or introducing a vibrator into your sex life?" And there's a, "Oh, I don't know if my partner would feel good about that. I don't want him to make him f- " And I sort of say, "This is an evidence-based intervention understanding the science of myelin sheaths and nerve degradation. This has nothing to do with your husband and nothing to do with your relationship."

   16. PAPeter Attia27:20

       How would you do that? So if a, if a, if a woman comes in and says, "In this position," it's exactly as you just said. When you're saying introduce a vibrator, do you mean use it-

   17. SGSally Greenwald27:31

       During it

   18. PAPeter Attia27:31

       ... after or before?

   19. SGSally Greenwald27:33

       Or during.

   20. PAPeter Attia27:34

       I see. So put the vibrator externally.

   21. SGSally Greenwald27:36

       Externally.

   22. PAPeter Attia27:37

       Got it.

   23. SGSally Greenwald27:38

       And there's different types of vibrators. Some are internal. Um, but if you're trying to pick a vibrator that you wanna use when you're with a partner, buying something like a wand, so something that sort of has a, uh, it ha- it is long enough that you can reach the structure in a variety of positions.

   24. PAPeter Attia27:52

       Mm-hmm.

   25. SGSally Greenwald27:53

       Um, something, Jimmy Jane makes a nice wand. Um, GOOP, the wand, makes a, makes a great, great product as well. Um-

   26. PAPeter Attia27:59

       Did you bring any of these?

   27. SGSally Greenwald28:00

       I, you know, I, a long discussion with your staff about what you wanted laid out on the table and, and the net-net was no.

   28. PAPeter Attia28:06

       Oh, we, I-

   29. SGSally Greenwald28:06

       Um

   30. PAPeter Attia28:06

       ... I, that might have been a strategic error.
6. 30:19 – 41:40

   Understanding female anatomy and what is needed for orgasm

   1. PAPeter Attia30:19

      an, an, a helpful thing to do right now would actually be to go over a little bit of the, um, anatomy, and I, I see that you've brought a model that I think will make it easier, um, for, for everyone to kind of understand. So, um, I wanna start by asking, when you deal with your female patients who presumably are much more familiar with this anatomy than, than men are, what surprises you the most? When a woman comes into your clinic, um, and you're taking care of her, what are you most surprised by in terms of her lack of knowledge about her own body?

   2. SGSally Greenwald30:51

      Anatomical lack of education. Um, from a-

   3. PAPeter Attia30:56

      Just literacy?

   4. SGSally Greenwald30:57

      Liter- f- from a, from a, um, where was the sex education? W- w- did, did we have it? Did we go... I mean, from a, a verbiage perspective, referring to the vagina as the vaginal, that's the vaginal canal is the vagina. The vulva is the outside of the vagina. There's labia majora and minora. And, um, all the way down to the, to the clitoral nerve and sort of the fact that it has different, different nerve roots. Um, and so if we think about, you know, looking at this model, uh, this is sort of if a female is lying down on her back, that's the angle that you're looking at. Um, there was a great study that was done recently that said that only 41% of Gen Z men could accurately identify the clitoris on a pictorial. Um, women surprisingly-

   5. PAPeter Attia31:44

      I'm sorry. W- w- what would that be for Gen X? Like, how much of that is a representation of declining intimacy as, as, as people are, i- in younger generations, or is that j- a general statement of men, period?

   6. SGSally Greenwald31:58

      Uh, I take from that sex education needs to get better. I, I mean, I sort of take from that the, the need for better sex education that's actually anatomical and not fear-based. And so women as well, I mean, most women, not all, do know about the clitoral hood or the, which is the clitoris or the, the bulb. Um, that's what we sort of think about in terms-

   7. PAPeter Attia32:18

      Mm-hmm

   8. SGSally Greenwald32:18

      ... of the tip of the iceberg. But what women often don't know is that they have sort of what we call is the vestibule of the clitoris, which are these sort of bulb-like structures that can receive engorgement or when there's an increase in blood flow. And then there's the crura of the clitoris, which is these nerve structures that go on either side of the labia minora. It's a wishbone-like structure, and what's really fascinating is to sort of normalize that anatomy can and should look different. Um, there's a great website called The Labia Library that normalizes all different types and sizes of labia minora and majora. Um, but the wishbone structures are often asymmetric as well, and so it is quite common for a woman to experience greater, greater pleasure on one side of the vagina versus the other, meaning that this nerve root of the clitoris may be thicker or more sensitive. There's over 8,000 nerve roots as a part of the clitoris, and there can be more focus on one side versus the next. And so I, I hope that half of your listeners are thinking, "I always wondered why I was a righty," or, "I always... I- I'm a lefty." But I, I also hope the other 50% are wondering, if you've been with your partner for a long enough time, I hope you know if your partner is a righty or a lefty-

   9. PAPeter Attia33:33

      Sure

   10. SGSally Greenwald33:33

       ... um, because there's asymmetry in how we experience pleasure. Um, and then very interestingly is that there is, you know, if you're sort of looking at the, uh, tip of the clitoris, there's a nerve root. There's a part that goes sort of inside the vagina, and that's what we talk about in terms of, um, social terms, we talk about the G-spot. And what that is is it's a branch of the clitoris that runs along the anterior or the front part of the vagina. It's, um, about a third into the vagina. The best way to find it is to, if you're sort of, if a woman is trying to find it on herself, is to take her dominant hand, middle finger, stick it as far in as you can and sort of do a, a come hither movement or a sort of movement of the finger towards the top part of the vaginal wall. It's easier to find when you're aroused because there's engorgement of the t- the tissues. Um, it feels a little more rugated, and you'll know that you're there if you feel a sensation to, to urinate. But if you relax into that, you, you won't. Um, and so only about 10% of women now are able to orgasm from stimulation of that internal branch of the clitoral nerve. There's some data that shows that with education, that can go up. And so talking to women about how they can find the anterior branch of their clitoral nerve not only allows them different ways to orgasm, um, but also gives them a sense of empowerment and sort of ownership to sort of talk their partner through how to sort of maintain pleasure. Um, but for those people who can't have orgasms from the inner part of their vagina, the other 90% are having orgasms from external stimulation of the clitoral nerve. And so Dr. Lauren Streicher says, you know, for the 10% of women who can orgasm via the G-spot or the anterior branch, that's great, and she diagnoses the other 90% who can't orgasm from stimulation of the internal nerve as normal. Um, so it's totally normal if you can't have an orgasm from that part of the clitoral nerve. But many women, after hearing this podcast, I hope try. Um, partners should try. It has a little bit, it has better blood supply than the tip of the iceberg, and so as we age, this is one of my favorite techniques, um, for women in the perimenopause and menopausal period as their hormones change and the nerve fiber degrades a little bit. Teaching women how to have orgasms from the part of the nerve that is better innerv- better, has a better b- blood supply can help maintain pleasure and help maintain interest in sexual activity as we age.

   11. PAPeter Attia35:53

       All right. So when a woman is having intercourse, and maybe for the percentage of guys might, who might not be familiar, can you point out where the entry to the vagina is on this model?

   12. SGSally Greenwald36:03

       Yeah. So here's entry to the vagina. Um, of those, um, there is, um, there are some statistics that talk about what women can, what percentage of women can orgasm simply by having penetrative intercourse, so, um-

   13. PAPeter Attia36:17

       Yeah

   14. SGSally Greenwald36:17

       ... penis here. And what's interesting is that the distance of the clitoris to the vaginal opening is variable. And the shorter the distance, we, they tend to say less than one inch. The shorter the distance of the clitoris to the vaginal opening, the more likely you are to be able to orgasm, um, during penetrative intercourse, and that's because the distance is so short that the angle of the man's b- body is sort of able to stimulate that area. If that distance is greater, you're less likely to be able to orgasm simply from penetrative intercourse. Cue introducing a vibrator, manual stimulation, et cetera.

   15. PAPeter Attia36:50

       So what percentage of women are able to intercourse without any stimulatory vibrator or anything like that from intercourse?

   16. SGSally Greenwald36:58

       Less than 10%.

   17. PAPeter Attia36:59

       Wow. So it's the same number that you have from the G spot?

   18. SGSally Greenwald37:02

       Correct.

   19. PAPeter Attia37:03

       So if a woman is listening to this and she's never had an orgasm through intercourse, she is in the 90%. There's nothing wrong with her.

   20. SGSally Greenwald37:11

       We would diagnose her as normal.

   21. PAPeter Attia37:13

       And for those women out there who are regularly achieving an orgasm through intercourse, you're in the minority and-

   22. SGSally Greenwald37:20

       Or they're doing external, more, more likely they're doing external stimulation of the clitoris. Those, those grave statistics are without any external manipulation of the clitoris.

   23. PAPeter Attia37:29

       I see. Got it.

   24. SGSally Greenwald37:30

       So for women who are achieving orgasm with a partner, it's because they've identified positions with their partners, they're using manual stimulation, they're introducing vibrators. They've figured out, regardless of distance of clitoris to vaginal opening, how to stimulate the clitoris, the external part of the clitoris. And I like to talk about anatomy so that patients can sort of think about their own individual anatomy, talk to their partners about it, and think about if they're someone who needs to sort of introduce that external stimulation or shall they, as a couple, just try to find the anterior branch of the clitoral nerve. There's lots you can, you can do as a part of that.

   25. PAPeter Attia38:02

       How often do you have men in your practice who are there with their female partners who you're trying to educate?

   26. SGSally Greenwald38:09

       For a sexual health consult, 20% of the time.

   27. PAPeter Attia38:12

       And what is the most common, um, I don't want to use the word ignorance, but what is the most common thing that you appreciate about men when you're helping them in terms of their lack of understanding about the, their partner's anatomy?

   28. SGSally Greenwald38:26

       Giving men a roadmap, being very descriptive. You know, men, m- most partners want their partners to be happy. It's not, you know, there's the selfish aspect of performance, and there's the sexual empathy component where they care about their partner and they want their partner to feel well. Giving them a roadmap to sort of explore around and find the anterior branch and think about the wishbone structures, um, is really exciting to them. Um, desire, spontaneous desire, thinking through that is really exciting for them, how they tap into that, how they can curate that with your, their partner, thinking about their partner's arousal. Um, and then sort of supporting, uh, i- there's a communication component. I think when we think about sexual dysfunction, we tend to break it down into a biopsychosocial model. Um, I like to talk mostly about bio. I'm a clinical physician. I'm a gynecologist, so I think a lot about anatomy and pathophysiology and neurotransmitters and hormones. But there's a lot of other people in this field that are helping with the psychosocial, sex therapists, communication. There's a great book called Sex Talks by Vanessa Marin, which talks about how to communicate with your partner. Um, Cliterate is a great book to think through different ways that you can sort of improve your communication about what pleasures you and how to investigate that. There's really good websites now. Omgyes.com is a website that sort of talks about your anatomy and how to find it and how to find your pleasure spots. So there's a lot out there. I'm not alone in this space by any means, but I like to think about it from a very sort of biologic, physiologic perspective.

   29. PAPeter Attia39:56

       Y- you mentioned a moment ago, for example, that a number of women are able to have an orgasm during intercourse, but it requires them using their own hand, for example.

   30. SGSally Greenwald40:06

       Mm-hmm.
7. 41:40 – 50:48

   Understanding sexual desire, how to cultivate it, the role of hormones, and testosterone therapy in women

   1. SGSally Greenwald41:40

      Um, and I think from a, um, going back to sort of how we, how we could use this from a desire perspective, there is good data that sex begets sex, meaning the more sex that you have, um, the more sex that you want. And so I talk to my patients about scheduled sex as a way to sort of work on your desire, and most of my patients, when I bring up scheduled sex, are like, "Oh my God, another thing I have to do. Like, ugh, what a hassle." And I sort of, I, I point out, um, the fact that you, you've always scheduled sex, right? Like when you met your partner and your partner said, "What are you doing Friday?" He, he was scheduling sex with you. And when you said, "Sushi sounds good," and you shaved your armpits and put on a nice T-shirt, you, you were planning for sex. So you were prioritizing your sex life in a way. And so, uh, scheduling sex is a great technique that we use. Um, how that sort of rolls out is, depends on the patient and what frequency they're going for, but I have my patients do, uh, what I call a fuck it February, where I essentially have my patients having sex, scheduling sex two to three times a week for the month of February. It's a romantic month. It's the shortest month of the year. Um, and this sort of takes pressure off of patients wondering, you know, the person who's been the initiator sort of gets to relax and not have to worry about rejection, and the person who has been less interested knows that they're sort of working through an arousal pathway. They're working on sp- responsive desire. Um- And scheduling just means that you'll show up. You don't have to have sex, but you just show up and you try it. Um, and there's great data that sort of after a month women will sort of have that maintenance of, uh, you know, their increased desire and they can sort of ride on that for a couple of months.

   2. PAPeter Attia43:27

      You mentioned earlier discordance as an issue, discordance of desire. Um, how often is the discordance, um, in one direction versus the other? So how often is the discordance that the male wants more than the female and vice versa?

   3. SGSally Greenwald43:41

      I wish I had a specific number for you. Um, we can probably look that up and put that in the notes. But anecdotally I'll say it is most often, um, the male has a higher desire, uh, than the female.

   4. PAPeter Attia43:53

      Does it say anything about the couple if it's the reverse, or is it simply-

   5. SGSally Greenwald43:57

      I anecdotally as well have ... I, I have the reverse as well, and there's so much that goes into this in terms of like, you know, the partner's health status and chronic diseases and, and, you know, stressors at work. So there's a lot to sort of think through, and it can happen both... It, it can go both ways, but f- by far and large it is predominantly the male with the stronger sexual desire.

   6. PAPeter Attia44:17

      And so on the topic of sexual desire, what are the, you know, because this podcast is called The Drive and we're talking about cars, uh, what are the, what's the throttle and what's the brake pedal on sexual desire for men and for women, and I assume it's different?

   7. SGSally Greenwald44:33

      I would assume it's different too. I never talk about men because I'm not an expert in men's, uh-

   8. PAPeter Attia44:37

      Got it

   9. SGSally Greenwald44:37

      ... sex life, so I'm gonna... I'll, I'll recuse that to, to the next guest. Um, but when we think about women and we think about accelerators and brakes, it's a common framework that we use, um, from a social behavioral perspective like, you know, what helps you feel relaxed and what turns you off. Um, but from a pathophysiologic perspective we think about neurotransmitters. And so accelerators from a neurotransmitter perspective would be things like estrogen and testosterone, nitric oxide, dopamine, and oxytocin. And those sort of five neurotransmitters are in a complex interplay to sort of tell our brain and our body through a variety of different pathways, "I'd like to participate in intercourse." Estrogen is very interesting, um, because although we know, you know, there's different types of estrogen receptors throughout the body. But when it comes to sort of sex drive we think about alpha receptors, um, which stimulates sex drive, and beta receptors which decreases anxiety and inhibition. But it's not as clear cut when we replace estrogen. It's not a slam dunk that, you know, you cannot make the connection then that, oh, so if I replace estrogen as it's dropping, I fixed my sex drive, all is well. Testosterone has a little bit more of a direct link to that. So when we think about, for example, the post-menopausal female, and I'll use the term menopause hormone therapy over hormone replacement therapy, um, and I would be so excited if you switched your nomenclature as well. Um, but I think when we think about post-menopausal women, we think about menopause hormone therapy replacing estrogen. Um, we sometimes do see an improvement in sex drive, um, but that's usually through an indirect pathway. You're sleeping better. You have more energy. Like you're not having as many hot flashes. So we'll see sort of an indirect improvement in sex drive. Testosterone is, you know, well-studied for hypoactive sexual desire disorder or a, a problem with, you know, I shouldn't say pro- a decrease in your sex drive. Um, to, to meet that diagnosis you have to have a low sex drive for more than six months and you have to care. Not your partner cares, but you have to care. And if you meet that diagnosis, testosterone is very well-studied, um, in terms of its benefits on your sex drive.

   10. PAPeter Attia46:44

       What is your preferred method for administering testosterone to women?

   11. SGSally Greenwald46:48

       I prefer a cream. Um, I, you know, I think prescribing test- I, so I do also prescribe Testim, um, which is an oil. Um, and that's where I will sort of like get resealable packets. I'll put it into a empty syringe and that syringe, um, uh, the kind that we give our children Tylenol with, not an actual, uh, n- needle syringe.

   12. PAPeter Attia47:08

       Yeah. Yeah.

   13. SGSally Greenwald47:08

       But, um, and so and then you can administer .5 cc and rub it on the inner thigh is my favorite place to do it. I do a lot of, um, compounding cream. I use Koshland Pharmacy. They have a pretty standard like well-mixed formula, and I'll sort of use, um, I'll prescribe a testosterone cream where the patient will use a pump a day. When they get out of the shower they'll let it dry for 20 minutes, and then they can put on their, get, sort of get dressed.

   14. PAPeter Attia47:29

       Do you think the oil is more efficacious and consistent in its absorption than the cream?

   15. SGSally Greenwald47:34

       I don't. Um, I find sort of when... And, and I do try, I do follow labs, um, when prescribing testosterone. So anecdotally and from a lab perspective, I don't find a difference. I'm interested in what you say. I sort of go mas- based more on patient preference. If they want an FDA-approved product, although it's not FDA-approved for women-

   16. PAPeter Attia47:56

       For that, yeah

   17. SGSally Greenwald47:56

       ... then we'll go ahead and use the Testim. If they don't, I much prefer to just compound it. It's, it's cleaner. It's less messy. It's easier to dose. Um, there's so many, um, dosing issues with the oil in terms of how we dispense it when it's not dispense- you know, supposed to be dispensed for women, that I much prefer the cream. Wha- how about you?

   18. PAPeter Attia48:14

       Uh, we use a cream more typically.

   19. SGSally Greenwald48:18

       Yeah. I don't use intranasal. Um, I do use intravaginal. So I will use, um, but sort of in the form of DHEA. Um, I use-

   20. PAPeter Attia48:26

       Yeah

   21. SGSally Greenwald48:26

       ... a lot of Intrarosa. Um, Intrarosa or prasterone is sort of a metabolite that can ultimately, you know, come down the testosterone estrogen pathway. I will use that. Um, but, uh, f- in terms of s- that's for pain of the vagina, but when it comes to sort of sex drive and desire to administer testosterone, mostly cream.

   22. PAPeter Attia48:44

       Do you target a, um, a level for total testosterone or free testosterone, or are you just basically saying, "I want to get it above a certain floor," and then symptoms determine where we end up?

   23. SGSally Greenwald48:53

       I want to get it above 20 in terms of total testosterone. Um-

   24. PAPeter Attia48:56

       Wow, that's a low floor

   25. SGSally Greenwald48:57

       ... it's very, very low. Um, and then I use symptoms. Um, and so then I use... So, so for example, um, so 20 to 80 would be, you know, the range at which I'm interested. Um, but I'm, I predominantly use symptoms. Um, there, the guidelines in terms of how to titrate it are not clear, and I, you know, anecdotally I'll have patients at 80 who have no benefit to their sex drive. I have 20 who see a great benefit. So I want to see like, you know, some sort of moderate, modest improvement in their testosterone and then interview, see how they're doing.

   26. PAPeter Attia49:25

       And given how much variability there is in men with androgen receptor density, we I th- I think we have a pretty clear sense that in men, levels don't tell you much unless you're below, you know, 350, 400. You know, if you're below that level, you're really gonna be hypogonadal. Um, but men can be replete at 600, and other men might not be replete till they're at 1,000. And again, it just comes down to AR density. Do, do you have any sense of how that works in women?

   27. SGSally Greenwald49:54

       Other than it's incredibly complicated, as you alluded to, but more so in women, because most women who are on testosterone are also on estrogen. And we know that estrogen increases your sex hormone binding globulin quite significantly. Sex hormone binding globulin being that protein that sort of runs around and gobbles up free androgens or testosterone. And so, y- you know, because I'm prescribing estrogen and, um, then we know progestins actually have the ability to, to blunt or mitigate that increase in the sex hormone binding globulin, the more androgenic the progestin, the more mitigating effect on that increase in sex hormone binding globulin. And so this is where this is my true passion in sort of thinking about hormones and contraceptive and menopause hormone therapy and sort of tinkering with hormones, because some of what you do will help the sex drive, some of what you do will hurt. But the addition of the two variables of estrogen and progestin make this incredibly more challenging.

8. 50:48 – 1:02:13

   Personalizing perimenopause care: how desire for ovulation guides the choice between contraception and menopausal hormone therapy

   1. PAPeter Attia50:48

      As you know, we talked about this at length with, with Rachel Rubin, but I think it's always worth rehashing. How, how do you like to initiate, um, estrogen, progesterone, and testosterone use in a perimenopausal woman who is, um, obviously one of the most difficult to treat because she still has waxing and waning natural levels of all of those hormones, but during her nadirs is, is typically pretty, um, debilitated by the symptoms. So how... What, what is your, what is your playbook on that, which is obviously pretty challenging?

   2. SGSally Greenwald51:20

      This is when you'll see me get very animated. I l- I love this topic because it's c- so different. It's so different for each woman in terms of how she responds. The first question that I try to answer in my interview with my perimenopausal patients is, "Do you like ovulating or not?" And that's the sort of first branch point at which I sort of decide how I'm going to approach this patient. Um, the heart of this-

   3. PAPeter Attia51:43

      So let's, let's just stop on that question-

   4. SGSally Greenwald51:44

      Yeah

   5. PAPeter Attia51:44

      ... for a second. I've never really thought of that question, obviously being someone who's never ovulated. But tell me why that question matters and why would a woman know the answer to that question, at the risk of sounding naive?

   6. SGSally Greenwald51:56

      So I'm gonna answer this from first a sexual health perspective and then a general health perspective. Some people, when their sex drive is higher around ovulation, they love it. They like the benefit that ovulation gives to their sex drive. There are times in the month when they have a great sex drive, they ovulate, and they feel good. Similarly, um, the first half of your cycle when estrogen is climbing right before ovulation is a perf- is a high performance part of your cycle. And so these women who like to cycle feel good the per- the first part of their cycle. They feel great right before ovulation. Um, there are a lot of biometrics that are peak right before ovulation. Um, your memory is stronger, your energy is stronger. Um, I have a few Olympic athletes in my practice, and we will figure out when their events are, and we will try to figure out their ovulation so that they are competing in the first 10 to f- around day nine, 10, 11, 12, um, to 15 of their cycle because right before ovulation is where they can lift the heaviest, they can run the fastest. I'd love for you to just do a study on VO2 max throughout the cycle, but I, I, I-

   7. PAPeter Attia53:01

      That's super interesting

   8. SGSally Greenwald53:01

      ... it's really interesting when you look at the, the metrics that we care about, many of them are peak. So-

   9. PAPeter Attia53:06

      But sorry, just to be clear, at that moment in time, her estrogen is pretty much at her highest, progesterone is very low-

   10. SGSally Greenwald53:13

       Low

   11. PAPeter Attia53:13

       ... testosterone is high.

   12. SGSally Greenwald53:15

       Correct.

   13. PAPeter Attia53:16

       So does that mean progesterone is a performance inhibiting hormone, or does it mean that estrogen... 'Cause obviously testosterone is a performance enhancing hormone. Does it really mean estrogen is performance enhancing, progesterone is performance inhibiting? Because in the, in the luteal phase, you would also see high estrogen, but you now have high progesterone.

   14. SGSally Greenwald53:37

       And not as high estrogen, but you're cor- correct. Um, I think to, to make this, at the risk of boring, um, a- anyone listening, to get a little more academic about it, you're really talking about a pro- progestogen is, sort of which is a, there's estrogen and there's progestogen. Within progestogen, there's progestins and there's progesterone. Now, natural progesterone we know, which is, that's what's in your body is progesterone. Yes, it is a sort of rest and digest, a low energy phase, a preparation in case any of-

   15. PAPeter Attia54:05

       Helps with sleep

   16. SGSally Greenwald54:06

       Helps with sleep. Um, but in terms of the progestin- progestins-

   17. PAPeter Attia54:11

       Prepares for implantation, prepares for pregnancy, yeah

   18. SGSally Greenwald54:13

       Exactly. In terms of the progestins, which are a synthetic class of progestogens, we then think about what is the family that this was derived from, and the side effects can be very, very, very different. And I think about that in terms of what pills I will prescribe my patients. But to bring it back to the question, um, I essentially, through interview, and this is where the patient can really advocate for herself, you know, so for patients who are listening, we, you're, we care, right? Doctors, we, we've worked our butts off to get here. We deeply care about helping you. All doctors do. Um, but you sort of coming in with great symptom tracking and timelines and relations to bleeds and things like that can really help us understand through interview whether you're someone who feels great because of ovulating or whether you're someone who, you know, really suffers from PMS, premenstrual syndrome. Has it turned into premenstrual dysphoric disorder, where it's PMS, but now it's impacting your life? There's so many reasons by which you would say, "I actually feel terrible cycling. I would prefer not to." But that's the first branch point when I have a perimenopausal woman.

   19. PAPeter Attia55:19

       And, and just give me the divide there, Sally. What percentage of women, uh, who are, let's just call it 44 years old, 45 years old, will respond to that first question as, "Yep-" "I really enjoy ovulating, let's keep it up," versus, "Let's make this go away"?

   20. SGSally Greenwald55:35

       I would say about 70% of my patients, 70 to 80% of my patients prefer not to ovulate.

   21. PAPeter Attia55:40

       Okay.

   22. SGSally Greenwald55:40

       This is the 45-year-old who's like, "You know, I used to be really short-tempered with my kids the day before my periods, and now I'm just, you know, it's the whole week before I'm really short-tempered. Um, so, you know, I have all of the symptoms of low estrogen, hot flashes, vaginal dryness. I have all these hypoestrogenic symptoms, but I also have..." You know, perimenopause is, you know, your brain is yelling at your ovaries to please do one last ovulation. Listen up. So you have this sort of hyperstimulation of signaling, um, a hyperresponsive FSH, follicle-stimulating hormone, um, so much so that you can get, you know, a LOOP event, which is a luteal out of phase event, where essentially you ovulate twice. Your FSH is so high, it's so busy yelling at your ovaries that your ovaries are like, "I heard you. Oh, and I heard you again." And they essentially double ovulate, and that's that story where you'll have, you know, a long cycle and then a short cycle and then a long cycle. So these are all clues that you don't like to ovulate. And so if you do like to ovulate, let's go down that sort of l- less- lesser traveled.

   23. PAPeter Attia56:41

       By the way, you're the first person besides me who I've heard use the yelling analogy. I, I'll never forget, 10 years ago, I was sitting down with a male patient, and he came in, and he had a pretty high testosterone. It was, I mean, not very high, but it was probably like seven or 800, um, which for his age was actually pretty high. And his FSH and his LH were 2X normal, and he wasn't taking, you know, anything. And I was like, "This is really interesting." And he's like, "Why?" And I sort of drew him a picture, and I said, "Basically, your pituitary gland is yelling. It's screaming at your nuts, and they're really responding." And, like, I forgot about the statement, right? And, like, a y- six months later, a year later, two years later, he keep coming back with that. At some point, I started taking care of one of his friends. His friends told me about it. They're like, "He's really been bragging about this."

   24. SGSally Greenwald57:32

       [laughs]

   25. PAPeter Attia57:32

       [laughs] And so anyway, I just thought, you know. I'm sure women do not go and brag to their other friends that their pituitary glands are screaming at their ovaries, but that's a guy thing. A guy would brag about that.

   26. SGSally Greenwald57:42

       I would agree with that. What, what women do do is, you know, they're, they're walking around the block with their protein shakes. They're, you know, doing their thing, and you have one 46-year-old, average age of perimenopause being 46. You have one 46-year-old saying, "Gosh, I, I feel so great. I'm on a birth control pill, and I just feel so great." And the other 46-year-old's like, "Me too. I'm on menopause hormone therapy. I just feel so great." And then they look at each other like, "Wait, why are you on that? Wait, why did you, why are you on that?" And the heart of this, for me, is who likes to ovulate and who doesn't? And from a sexual health perspective, understanding is your sex drive and all the other things that make you happy and feel good, which ultimately go into your sex drive, do you want to ovulate? And if you do want to ovulate, then we can think about, you know, do you need contraception, right? So how can we sort of... Yeah.

   27. PAPeter Attia58:25

       And sorry, just go down that branch point again.

   28. SGSally Greenwald58:27

       Yeah.

   29. PAPeter Attia58:27

       Because you just, you just made a distinction that I, I don't know that every listener will understand. You just talked about oral contraceptives, which are hormones, and then menopausal therapy, which is hormones. Can you explain why that branch point is different for, in response to your question?

   30. SGSally Greenwald58:41

       Yeah. So, um, menopause hormone therapy, the dosages do not suppress the gonadotropin pathway. And so when you are on menopause hormone therapy, you still ovulate. If you're going to ovulate, you still ovulate.
9. 1:02:13 – 1:15:11

   Considerations for choosing contraceptives and hormonal therapies during perimenopause

   1. PAPeter Attia1:02:13

      that would be my concern with an oral contraceptive as a bridge through menopause, which is they're missing out on real estrogen and progesterone, and I think we have pretty good evidence that the benefits you accrue later in life, especially with respect to bone density, but probably with respect to other metrics of health, are heavily dependent on getting real 17-beta estradiol and real progesterone right away, never having an interruption in those hormones. So if, if, if that is correct-

   2. SGSally Greenwald1:02:46

      I agree with you

   3. PAPeter Attia1:02:46

      ... yeah, if that, if, if what we believe on that front is correct, then it means any woman who's gonna go down the oral contraceptive route would be best receiving that oral contraception in the form of what you just described, which is a real, uh, 17-beta. And I guess my next question, I, I'm worried I know the answer to this question, but I'm gonna ask it anyway. Um, what is the cost of that type of oral contraceptive, and how often are insurance companies covering that?

   4. SGSally Greenwald1:03:14

      Rarely covering it. So, so to sort of-

   5. PAPeter Attia1:03:16

      And the out-of-pocket monthly cost on that pill would be how much?

   6. SGSally Greenwald1:03:19

      Hundred-ish. Hundred-ish a month.

   7. PAPeter Attia1:03:21

      So it's a hugely expensive-

   8. SGSally Greenwald1:03:22

      Incredibly cost- yeah. It's incredibly, uh, prohibitive. So when you, you know, if you were to think about, okay, so now I'm perimenopausal and I don't want to ovulate. Um, I want to be on a birth control pill. The first question is, do I want to be on estrogen? You and I are sort of alluding to the fact like, yes, I want to be on estrogen, but a certain kind of estrogen. Remember, some people are not candidates for estrogen, right? Migraines with aura, blood clot, family history. So, um, then, but we still want to suppress ovulation. The newest progesterone on the market is something called drospirenone. Drospirenone, the pill is called Slynd. It suppresses ovulation in about 98% of women, whereas previous progesterone-only pills suppressed ovulation 50 to 70% of the time. So you're getting a huge mood benefit, um, for these women who cannot take estrogen but really don't want to feel the ups and downs of perimenopause cycling, which can be wild. Um, drospirenone being a derivative of spironolactone, there's a diuretic component to it, and so it's a really well-tolerated, really exciting... I hope I can convey how excited I am about this progestin because having drospirenone means that we can mitigate some of the other side effects. And so-

   9. PAPeter Attia1:04:30

      Such as water retention

   10. SGSally Greenwald1:04:31

       ... water retention. And so then, okay, so now we've decided, all right, I, if I don't want estrogen, I'll use Slynd, this drospirenone only, but ovulation suppressant medication. What if I do want estrogen? Um, then the branch point is do I want something synthetic, said very few people ever, or do I want something more natural, said both of us. Um, the people who do end up on a synthetic estrogen are, it's, um, it costs, it's che- your insurance covers it. Um, uh, it's available at all pharmacies, so there's sort of an access issue here that, uh, we would be sort of remiss to ignore. Um, I still have favorite pills, and, uh, within that category, I still, um, have pills that I like. And historically, if you interview patients, they may be able to tell you, "Oh, I did well on this, you know, synthetic estrogen." So a- as we sort of get into the later 40s, I care more in terms of getting them back on a more natural estrogen for the reasons you mentioned in term of, terms of bone prevention and things like that.

   11. PAPeter Attia1:05:29

       But when, when you're talking to a 28-year-old woman who just needs birth control, you don't have a concern with putting her on a synthetic estrogen.

   12. SGSally Greenwald1:05:35

       I, I don't, and I still have favorites, so I still, you know, low Loestrin-

   13. PAPeter Attia1:05:39

       I was just about to say that's my favorite.

   14. SGSally Greenwald1:05:41

       Yeah. So I use low Loestrin a lot. Um, low Loestrin is a norethindrone progestin. The reason why I like norethindrone is it's a little bit more androgenic. The more androgenic the progestin, the wa- the, it has the ability to m- blunt or mitigate the increase in sex hormone binding globulin. Again, I'm talking about pills from a sexual health perspective. There's lots of other ways you could view this.

   15. PAPeter Attia1:06:02

       Yeah.

   16. SGSally Greenwald1:06:02

       But today this is my angle. And so when you think about a super low dose ethinyl estradiol, low side effects, um, plus a, you know, slightly more androgenic progestin, you then can have a, you know, blunting of the increase in sex hormone binding globulin. It's less likely to gobble up all those extra androgens, and patients tolerate it really well. Side effects are there's more bleeding because of the low ethinyl estradiol, so sometimes I'll go up to a less, um, which is a 20 microgram ethinyl estradiol, and this has a levonorgestrel progestin to it, and this progestin is similarly a little bit more androgenic, less likely to impact your sex hormone binding globulin. And then my last two very popular, Yaz and Yasmin, the reason why those are so popular is the progestin in them is drospirenone. And so it has that ability to, to, to not only improve-

   17. PAPeter Attia1:06:49

       A little more of a diuretic

   18. SGSally Greenwald1:06:50

       ... exactly. It acts as a diuretic. Um, when we think about ethinyl estradiol, and I, if I could just sort of step out of professionalism for a moment and ask my father-in-law to tune in because he's a nephrologist, and he would be so excited to hear that I'm gonna talk about angiotensinogen, which is, um, in the kidneys. Estrogen goes, ethinyl estradiol goes to the kidneys. Um, and some 17-beta estradiol goes to the kidneys and causes sodium retention, water retention. So when we think about estrogen and how it impacts our bodies, our PMS, our breasts feeling heavy and painful, bloating, slight weight gain, this is from, this is estrogen effects. And drospirenone being a derivative of spironolactone can have a mitigating or a diuretic, a m- blunting effect on that water retention. Um, Dave, if you could t- tune out now 'cause I might say orgasm soon. Um, but anyways, th- uh, using this sort of counteracting principle in these newer medications can help me pick a really good synthetic form. of contraception. Now, if we're gonna go to the natural form, um, one of the... There's a few combinations that I'm using now that my patients are tolerating really well. Um, the first is to go back to that progesterone, progestin only pill, progestin only pill, which is Slynd, drospirenone, and adding a 17-beta estradiol patch to it. So you're essentially taking an ovulation suppressive component of contraception, but adding in menopause hormone therapy estrogen, and that's where the benefits are.

   19. PAPeter Attia1:08:17

       Mm.

   20. SGSally Greenwald1:08:17

       You get the bone protection, you get the... So for my patients who are on contraceptive pills-

   21. PAPeter Attia1:08:22

       But you're saying the pr- sorry to interrupt you, the progestin alone will help with suppression of ovulation-

   22. SGSally Greenwald1:08:28

       Of ovulation, which equals contraception

   23. PAPeter Attia1:08:30

       ... such that you can u- such that you can use physiologic 17-beta estradiol?

   24. SGSally Greenwald1:08:34

       Correct.

   25. PAPeter Attia1:08:35

       That's super interesting. I, I'm ashamed to admit I didn't know that.

   26. SGSally Greenwald1:08:39

       So it's a great, it, this is a great, um, sort of, uh, in between step because you can-

   27. PAPeter Attia1:08:44

       It, it's a cool hack

   28. SGSally Greenwald1:08:44

       ... provide contraception, you can provide drospirenone, which is a diuretic, which 17-beta estradiol does have, you know, some sort of, uh, water retention components to it. But it, the downsides to it, as the, although these sort of work very well throughout the body, they, at the level of the endometrium-

   29. PAPeter Attia1:09:00

       Mm

   30. SGSally Greenwald1:09:00

       ... or the lining inside the uterus is, um, you have a little bit more breakthrough bleeding because the 17-beta estradiol does not stabilize the endometrium as much. So one of the side effects and limiting reasons for which I won't, my patients won't be happy on this is if they're having breakthrough bleeding. Um, s- so when there's other options that are better at that. So an, a newer, the sort of two medications that I, I wanna make sure you know about, and I have no disclosures, but I'd love to have some, um, is, is that the next medication that we think about is Nexstelis. And Nexstelis is drospirenone, um, which is the spironolactone derivative, the la- the diuretic, um, with estetrol or E4. It's a natural estrogen. It's typically produced by the fetal liver. Um, but this has a longer half-life than 17-beta estradiol, so you get less breakthrough bleeding, less spotting. Um, we don't know, we think natural estrogens, you must get bone protection and bone benefit. We don't know yet. It's currently being studied.
10. 1:15:11 – 1:19:48

    Factors negatively affecting desire, and why female libido persists with age and fluctuates across the menstrual cycle

    1. SGSally Greenwald1:15:11

       I think one thing I wanna go back to from a neurotransmitter perspective is you asked me about the accelerators, and we launched into a discussion about hormones, but we didn't talk about the brakes. Um, and the brakes are, uh, serotonin. Um, so we know about how SSRIs, um, can impact our sex drive and what to, you know, we can think about what to do about that. But prolactin, um, is a brake. And it's really interesting because when in our lives is prolactin high?

    2. PAPeter Attia1:15:36

       Breastfeeding.

    3. SGSally Greenwald1:15:36

       Breastfeeding, postpartum. And so women can find this very validating, but from a biologic perspective, we know that pregnancies spaced 18 months apart, that's the ACOG, or American College of Obstetrics and Gynecology, they recommend 18 months between pregnancies because that second pregnancy will be healthier. The baby will be bigger. It- it's more likely to make it to term. So we know that spacing pregnancies is healthy. And so having a high prolactin postpartum and keeping you from being interested in sexual intercourse is your body's natural way of spacing out pregnancies for the better.

    4. PAPeter Attia1:16:09

       While we're on the topic of evolution, there's a- there's something I've, I've always wondered, um, that seems a bit at odds with pure, a pure natural selection, and this is gonna expose how naive my thinking might be. So it's not a surprise that men would have a high sex drive for as long as they are capable of reproducing, which is seemingly indefinitely, right? Um, but you, you could make an argument maybe theoretically that women's sex drive should decline after a certain age, call it 30 or ish, when, when evolutionarily their probability of producing healthy offspring goes down. But I don't think we believe that to be true at all. I don't think we see that women's sex drive goes down as they age, which sort of flies in the face of maybe at least one naive interpretation of what natural selection might interpret. So are there, is there a smarter explanation for why a woman's sex drive goes up, or, or it doesn't go down, maybe to phrase it more accurately?

    5. SGSally Greenwald1:17:09

       There are many es- explanations. Um, uh, you know, this is hard to study. Um, potentially the most popular one, um, which the European Society of Sexual Medicine gives like a grade two, level B rating, so not super high rating, meaning like case control studies-

    6. PAPeter Attia1:17:26

       No, no

    7. SGSally Greenwald1:17:26

       ... low quality

    8. PAPeter Attia1:17:26

       This is like theoretical.

    9. SGSally Greenwald1:17:27

       But theoretical. If you, if we can sort of tangent on the theory for a little bit, there's something called women's dual sexuality, and it basically talks about women's motivation to participate in intercourse being different at different parts of the cycle. Meaning mid-cycle, when you are able to get pregnant, you are fertile. You are more likely to participate or to want to participate in intercourse for purposes of reproduction, and the mates that you are more likely to select during that time will have features of genetic dominance, such as a very symmetric face, more masculine features. We talk about the histocompatibility complex, and there's dissimilarity that we look for at this time 'cause we know that mixing of genes-

    10. PAPeter Attia1:18:09

        Super interesting, yeah

    11. SGSally Greenwald1:18:11

        ... is, is better than not. And then there's other times of the cycle when you're interested in participating in intercourse, and you're seeking out things such as partnership, shelter, companionship, protection. And so talking about this-

    12. PAPeter Attia1:18:25

        And you're not optimizing around-

    13. SGSally Greenwald1:18:27

        And you're not, and, and the, and you there, you end up with like a-

    14. PAPeter Attia1:18:28

        ... genetic features

    15. SGSally Greenwald1:18:29

        ... less attractive or less symmetric or less masculine partner. Um, but your partner may have, like, better communication skills, the ability to provide better shelter or protection. Um, it's very interesting. People take this and run with it online, and they talk about, you know, in your 20s, what form of contraception should you be on when choosing a mate.

    16. PAPeter Attia1:18:48

        Hmm.

    17. SGSally Greenwald1:18:48

        This goes back to that question of do you want to ovulate or not because, um, you know, there's so much. This is not an, uh, an anti, you know, ovulation, anti-contraception discussion. Um, the, s- your sex drive is so multifactorial, and being protected from s- from pregnancy is, you know, for many can be such a positive contributor to their sex life. But if you believe in this evolutionary hypothesis, and if you believe that you would rather pick your future mate when you're still ovulating versus being on something like a contraceptive pill that blocks ovulation, um, there is some data to show that you may pick a different partnership. The, the discussion section is, um, y- you may wanna pick a partner that's, has a less symmetric face but is more likely to have a partnership and communication skills, but that's, that's, I'll sort of excuse myself from, from that. And you can decide for yourself on that one.

    18. PAPeter Attia1:19:40

        That is super fascinating. And, and honestly But there's more to explore there than, than the, than the simple and obvious stuff I

11. 1:19:48 – 1:24:29

    How sexual trauma and physical pain can affect sexual health, and evidence-based strategies for recovery

    1. PAPeter Attia1:19:48

       proposed. I want to go now back to some of the other stuff that we talked about th- um, around desire. W- we didn't touch on this, but this must be a very important topic that you deal with, which is how much do adverse sexual experiences during, um, during the early part of a woman's life negatively impact her ability to have a healthy sexual life later on? And again, we can-- I think we could talk about this across the entire spectrum, right? So we could take the most egregious example, which would be sexual assault, uh, rape, things of that nature. But then we can also, I think, uh, fan this out into things which is just like, "No, you know, the first time I had sex, it was awful. It was in a car in the back seat with a g- guy that I didn't really know that well, and we were both drunk, and yeah, I was consenting, but it was awful." So i- it's hard to imagine that m- many women can't relate to that type of experience. How does that play forward?

    2. SGSally Greenwald1:20:42

       I see it incredibly often, um, in my patient panel. It is unfortunately, um, you know, if you're listening to this and you have a history of sexual trauma, you are unfortunately not at all alone. Um, and there are things we can do about it. So yes, it plays a part, and yes, we should do things about it. So there are lots of different approaches. Um, you know, I hope that patients are in therapy and that they have sort of the right support team around them. I want to bring up sex therapists are a great sort of, uh, contributor in this area and sort of thinking about, um, how you br- how your experiences are brought into the bedroom and sort of, um, you know, how do we sort of use a trauma-informed approach, um, when sort of talking about how to curate arousal and bringing yourself to the encounter when you're not quite ready. Um, there are-- there's a, there's a, a sensate focus exercise that is really evidence-based for survivors of trauma, but can also be very applicable to patients who, for example, are listening to this podcast, and it's been a year or it's been six months, and they want to sort of think about how to become intimate again.

    3. PAPeter Attia1:21:46

       Mm.

    4. SGSally Greenwald1:21:46

       And it's a, it's a four-step program that can be done over a month, over four months. You can sort of pick how long each stage you want it to last. Um, Dr. Leah Millhauser, who's done a ton of work, um, in sexual health from a gynecologic perspective, um, talks about this, and it's essentially, um, you know, step one is to, you know, let's say spend twenty minutes a couple of times a week if you want it, the stage to last a week, is to sort of be intimate with your partner. No touching of the breasts, no touching of the genitals. Um, step two would be okay to touch breasts and genitals, but orgasm off the table. Um, step three would be orgasms on the table, but no penetrative sex. And step four is, um, penetrative intercourse is allowed. And this is sort of, this is a evidence-based way in which you can create a safe space to sort of start to, you know, find yourself back in your body. Um, there is, um, a book called, uh, The Body Keeps the Score, which talks about how to bring your sort of mindfulness back into your body when you are a, you know, trauma survivor. Um, and Emily Nagoski talks a lot about it in her book as well. Um, and then there's a sort of potentially less traumatic but still pain that can, you know, sort of present itself in sexual encounters like it just hurt. Like, you know, um, I see this a lot in my cancer survivors.

    5. PAPeter Attia1:23:05

       I was just about to ask you about cancer, by the way, so yeah.

    6. SGSally Greenwald1:23:07

       Yeah. So I see this a lot. Cancer, I often see sort of a twofold hit. There is this sort of a psychosocial of I'm mad at my body, and I, you know, there's all those sort of complex feelings, and there's this sort of like physiologic aspect of, you know, chemotherapy, radiation, and how that impacts pain and lubrication of the vagina and, you know, comfort of hormone use. Although, you know, we really feel, you know, quite, quite confident that, you know, local estrogen, uh, treatment of the vagina, um, is completely safe, um, for almost all, um, cancer survivors. Um, Dr. Tammy Rohan talks a lot about this, um, with, um, the, you know, ISSWSH and Menopause Society sort of re-- you know, encouraging not only patients, but also doctors to feel comfortable prescribing local estrogen in this patient population. Um, physical therapists, pelvic floor physical therapists can be incredibly helpful. Um, I think every woman, you know, if you're sort of making a centenarian plan and you're seeing a physical therapist to keep your posture and your muscles healthy, healthy, I think you should see a pelvic floor physical therapist. They're, you know, great in terms of increasing the tone of the pelvic floor. We know that strength of contraction can lead to better quality orgasms. I often get emails like, "Oh, I just had the best sex. Thanks for sending me to the pelvic floor thys- physical therapist." Um, but it also is good for hypertonicity, where your pelvic floor is too tight, where you carry stress and trauma and pain.

12. 1:24:29 – 1:32:05

    Vaginal care routine: lubricants, moisturizers, topical hormones, and other approaches for vaginal health

    1. SGSally Greenwald1:24:29

       Um, you know, in terms of thinking about how we take care of the vagina, I would like to encourage you to think about taking care of the vagina like you take care of your face.

    2. PAPeter Attia1:24:40

       You, you listened to my recent podcast.

    3. SGSally Greenwald1:24:41

       [chuckles] I did. Um, and I would like to say, so, you know, you're going to go out in the sun, um, and you put on sunscreen. You put sunscreen on your face. So I-- if you're gonna have intercourse, you should use lube. Um, that's just what we do.

    4. PAPeter Attia1:24:56

       Even if a woman says, "I've never had any difficulty with lubrication. I'm-- uh, I, I don't have any discomfort with sex," you still think a woman should be using lubricant?

    5. SGSally Greenwald1:25:05

       I do. The data shows less microabrasions. And also, what I really-

    6. PAPeter Attia1:25:08

       And, and sorry, if you're not concerned with sexually transmitted diseases, which is what the WHO is concerned with, if you're with one partner and only one partner, are microabrasions a problem?

    7. SGSally Greenwald1:25:19

       They lead to pain, and once we get into a pain signaling process, you can get-- this is a common cause of what we s- call vaginismus or a tightening of the pelvic floor, which then leads to more pain. Um, it is very possible and y- and, and, and you should absolutely work at it. But breaking a vaginismus cycle takes a lot of work. And so part of this recommendation that almost everyone should use lube is this idea that we're trying to avoid pain, and we're trying to avoid-

    8. PAPeter Attia1:25:47

       Even young women?

    9. SGSally Greenwald1:25:47

       Yes. Um, this is one of my favorite things to talk to young teens about. Um, you know- You know, when we think about, uh, sexual education and we-- there's a great study looking at 1,200, you know, high school students, and it asked them about what we call sexual debut or their first sexual encounter. And, um, then it sort of-

    10. PAPeter Attia1:26:04

        Not intercourse, just first-

    11. SGSally Greenwald1:26:06

        First sexual encounter

    12. PAPeter Attia1:26:07

        ... that includes kissing?

    13. SGSally Greenwald1:26:08

        Cor-- uh, no. Uh, no, sexual encounter. Um, uh, that-

    14. PAPeter Attia1:26:10

        What defines that?

    15. SGSally Greenwald1:26:12

        I'm gonna guess penetrative intercourse based off of-

    16. PAPeter Attia1:26:14

        Oh, okay. Yeah

    17. SGSally Greenwald1:26:14

        ... yeah.

    18. PAPeter Attia1:26:14

        Yeah. Okay

    19. SGSally Greenwald1:26:15

        ... yeah. And, um, 70% of boys gave responses related to pleasure, and 70% of girls gave responses related to pain.

    20. PAPeter Attia1:26:23

        Hmm.

    21. SGSally Greenwald1:26:24

        And that's a big deal. And so talking about foreplay and lubrication, even for young women who have an adequately lubricated vagina, and decreasing the likelihood that they'll get into pain, that they'll clench up the pelvic floor, it will then hurt more. Breaking out of that cycle is incredibly important to me. So yes, lube if you're going to have sex. Um, going back to the face, um, you likely are putting moisturizer on your face.

    22. PAPeter Attia1:26:46

        Only recently.

    23. SGSally Greenwald1:26:47

        Only recently. Um, so there's vaginal moisturizers. So if you wanna use your vagina when you're older, using a vaginal moisturizer, there's, um, good ones on the market. There's Reverie, um, which is a hyaluronic acid suppository. It lowers the pH of the vagina and brings water molecules with it. Um, there's Replens, which is a, um, polycarbophil, um, suppository that re- also recruits water molecules. You're moisturizing your vagina. Um, and then you-

    24. PAPeter Attia1:27:13

        And so just explain to me how this is used. This is, like, part of your nightly routine?

    25. SGSally Greenwald1:27:17

        Yeah, yeah, put on your eye cream-

    26. PAPeter Attia1:27:18

        Or morning? Would you-

    27. SGSally Greenwald1:27:19

        ... moisturize your vagina

    28. PAPeter Attia1:27:19

        ... mor- morning or night?

    29. SGSally Greenwald1:27:20

        Most people like evening because a moisturizer-

    30. PAPeter Attia1:27:22

        But then what if you're having sex after?
13. 1:32:05 – 1:37:15

    Tips for sexually satisfying your female partner

    1. PAPeter Attia1:32:05

       what percentage of women are regularly receiving oral sex?

    2. SGSally Greenwald1:32:09

       I don't have that statistic. We'll have to find that and look it up. I will say that when you look at orgasm, uh, frequency with any sort of intimate encounter, it is one of the, um, highest likelihood to be able to achieve orgasm acts that a man and a woman can participate in together. Um, there's a great book called She Comes First by Ian Kerner that has diagrams and tips and tricks and, um, talks about essentially how, how to do that. One of the best way if you sort of from a performance perspective is to go back to the sort of stages of orgasm that we talked about, the excitation, plateau, orgasm, and resolution. Um, when you think about the, um, plateau phase, that's sort of the hormone cascade that's happening in the woman. There's two different ideas and sort of, that, that are relevant here. The first is, um, something called the approach, and the approach is the seconds or moments just prior to orgasm. When surveyed, two-thirds of women report that whatever's happening when the approach starts, that it should just keep happening exactly as it is. So no increase in pressure, no increase... Whatever you're doing, just keep doing it. No change in temperature, pressure, speed, depth, nothing. So understanding that as sort of like a key component for most women, but not all, can be something that can sort of help you from a performance perspective.

    3. PAPeter Attia1:33:23

       So, so there's, the, the onus is on both the woman and the man. The woman needs to recognize she's there and have a cue to her partner-

    4. SGSally Greenwald1:33:30

       Yeah

    5. PAPeter Attia1:33:30

       ... that says, "Don't change a thing."

    6. SGSally Greenwald1:33:32

       Yeah.

    7. PAPeter Attia1:33:33

       The guy needs to not try to be a hero and needs to know when the, when she taps my head or whatever it is, don't change a thing.

    8. SGSally Greenwald1:33:40

       Yeah.

    9. PAPeter Attia1:33:41

       Okay.

    10. SGSally Greenwald1:33:41

        And that's a strategy to help women, you know, sort of have more of a guaranteed orgasm, and then the contrary is something called edging, which is where you do stop what you're doing, and you sort of like bring your partner close to orgasm, and then you stop what you're doing. And then you can bring your partner close again, and then you stop. And this is for women to be able to achieve more of an intense orgasm, this edging technique.

    11. PAPeter Attia1:34:07

        So if, if you were to give a guy a few pieces of advice on how to be more successful at helping his partner achieve orgasm using oral sex and penetration, what, what, what would be your advice?

    12. SGSally Greenwald1:34:22

        Lube, get over it. It's evidence-based. It's for friction. It has nothing to do with how interested your partner is in you. Um, anatomical awareness, so understanding that there's two, these two wishbone nerve pieces, um, enjoy being massaged. Um, try to explore with your finger two-thirds of the way into the vagina on the anterior or the front wall where the G-spot is. Find that rugated area. Um, lead up to the event. So, you know, foreplay, what does that look like for you as a couple? What does it look like outside of the bedroom? Is it, is it you made dinner, or you put the kids down? What is your chore play? What chores did you did as, do as a part of foreplay? Um, what nice text messages. There's so much, um, contextual going on. There's really funny, um, research pieces that talk about, you know, um, uh, people who are in the military who are traveling around, and there's bombs everywhere, and it's really dangerous, and men are still like ready to have sex, and women are w- feared for their lives. So there's, you know, there's women, there's a lot goes into, a lot, little bit more that, or a lot more that goes into women's, uh, sexuality that I want you to be aware of. There's no need to take this personal. But, um, I hope today sort of understanding, you know, arousal versus desire, responsive desire, anatomically thinking about not just the tip of the clitoris, although many men haven't even thought of that. But in addition to the tip of the clitoris, the wishbone structures that go down the anterior wall of the vagina. Thinking about, you know, what phase of, um, orgasm your partner's in. Is she in the excitement phase? Is she in the plateau phase? Um, or is she sort of in, in the orgasm phase, and what does that look like?

    13. PAPeter Attia1:36:02

        What about little details like, for example, um, if you're stimulating the clitoris, is it just very individual variation, up and down, side to side, around, like?

    14. SGSally Greenwald1:36:12

        Individual variation.

    15. PAPeter Attia1:36:14

        And is this something where a guy should just ask a woman and say, "Hey, how do you like this done?" Or is a woman put off by a guy asking that?

    16. SGSally Greenwald1:36:22

        In my dream world, these conversations would take place. There's books that walk you through how to have these conversations, the Sex Talks book that I mentioned by Vanessa Marin. She writes it with her husband, so you get sort of both perspectives. Um, but I think, you know, that website omgyes.com actually teaches women how to find the different techniques. So they go over, you know, a hard stroke, a round stroke, a gentle touch, an internal touch. They actually teach women, and yeah, I have a dream that women would, you know, go to this website and learn for themselves how to do it and talk to their partners about it. Men can also go to the website. It's a, like a one-time flat fee website. Then you have access to all of their content, and it walks you through different techniques, um, so you can actually learn and talk about with your partner what she likes.

    17. PAPeter Attia1:37:07

        All right. Let's pivot a little bit and talk about, um, sort of the pharmacology of arousal.

14. 1:37:15 – 1:45:31

    The pharmacology of arousal: various treatments for low sexual desire in women

    1. PAPeter Attia1:37:15

       We've talked a little bit about it through a hormone perspective, and we've obviously talked about how testosterone in particular, but also estrogen and progesterone play a role in, um, in the arousal of a woman. But there are also drugs that are specifically used to target this. What, what can you tell us about them? There are a couple in particular that, uh, that I know have come up on this podcast previously.

    2. SGSally Greenwald1:37:36

       So, um, using that sort of accelerator and brake analogy, many of the medications will work on one or both of those pathways. Um, the two most common medications and the only two that are FDA approved for women are Addyi, which is a pill, and Vyleesi, which is an injection. They work along the MAOI pathway on increasing norepinephrine and dopamine and decreasing serotonin. So if you go back to those neurotransmitters, thinking about serotonin as a brake, so they decrease that. Um, norepinephrine and dopamine, um, to the reward center of the brain, and they increase those. Um- I don't use them a ton in practice. Um, they are studied for, um, they are not studied for post-menopausal women. Um, Addyi is a nightly pill. You take it for six weeks, or you take it forever, but after it takes about six weeks before you can see benefit to it. Um, in the trial for which it was FDA approved, it increased your number of satisfying sexual encounters by one. So you went from having, like, two to two-ish satisfying sexual encounters a month to three-ish satisfying sexual encounters. You can't drink alcohol on it. Um, it can cause, um, nausea for some people. Um, it can interact with, um, antidepressants and mood stabilizing drugs. It, it's not a contraindication, but it can change the way in which they work. I just don't use it very much.

    3. PAPeter Attia1:39:06

       Why, why, how much does this drug cost?

    4. SGSally Greenwald1:39:09

       I don't know the answer to that.

    5. PAPeter Attia1:39:10

       Why do you think this drug was approved with such limited efficacy?

    6. SGSally Greenwald1:39:14

       It's statistically significant to go from, let's say, two-ish to three-ish satisfying sexual encounters, but there was a social movement at the time. There was frustration about how easy it was for Viagra to be approved. The data for Viagra in men is much more clear and easy to see. This is, you know, women's sex drive is very complex and this, you know, is potentially one angle at improving it. But from a-

    7. PAPeter Attia1:39:38

       But it's a bit of a bad analogy. Viagra's not really a drive drug. It's a performance drug, right?

    8. SGSally Greenwald1:39:44

       It's a performance dru- drug that ultimately can impact drive as well. I think, um-

    9. PAPeter Attia1:39:50

       But it also impacts... Are there any data that show that Viagra or Cialis or any phosphodiesterase inhibitor improve orgasm quality in women?

    10. SGSally Greenwald1:39:59

        They've looked at Viagra a, a, a great deal. Um, the studies do not show for women across the population level when studied that it impacts drive or orgasm quality-

    11. PAPeter Attia1:40:10

        Just select women

    12. SGSally Greenwald1:40:11

        ... except when looking at a specific patient population. So when you look at Viagra, um, the patients who had an improvement in their quality of sex, be it drive or orgasm quality, et cetera, were women, um, diabetics, MS, uh, multiple sclerosis, spinal cord patients, and SSRIs. These are women who we think that the vasodilation of the nitric oxide and the physiologic response that they have to Viagra dosed at 25 to 50-

    13. PAPeter Attia1:40:36

        Mm-hmm

    14. SGSally Greenwald1:40:36

        ... you know, one to two hours prior to anticipated intercourse can be helpful. Let's go back to Addyi, uh, the pill. Um, when I talk about, um, one satisfying sexual encounter, you know, improved per month, like, remember that that's compared to placebo, so there is still a great placebo benefit here, and for many that's, you know, exciting and, and fine to introduce, uh, into their life. Um, Vyleesi is an injection. Um, I'll, you may, you may get questions about it from your patient panel because it's similar to the peptide PT-141, um, melanotan. This sort of has the, the, um, the o- the, the street, uh, name as the Barbie drug because it works through the MC4 or the melanocortin pathway. So you, you get tan and pretty happy and, and horny is what they say. So they, they call it the Barbie drug for that reason. There's a significant amount of nausea. You inject yourself. Um, for the first two hours, there's about 40% of women will have nausea. I often prescribe Zofran, an anti-nausea medicine, when I prescribe this drug. After two-ish, three-ish hours, the nausea can go away, and then the drug lasts for up to six hours. You can't use it more than twice a week. Um, but this had slightly sort of similar efficacy, uh, to Addyi in terms of improving your sex drive.

    15. PAPeter Attia1:41:52

        When, when I hear that a drug causes that much nausea and you can only use it twice a week, I worry that it's doing something unhelpful as a side effect beyond what you just said. W- do you have a concern with long-term use of this drug?

    16. SGSally Greenwald1:42:07

        We, it has not been... It's been out since 2019. We don't have particularly long-term data on it. I have the same, you know, questions. Um, people anecdotally do like it, but I do think there's a great placebo effect going on here. Um-

    17. PAPeter Attia1:42:21

        Do you think one is better than the other?

    18. SGSally Greenwald1:42:23

        It's really hard for me to convince patients to inject themself with a shot prior to, to, you know, an hour or so prior to intercourse. It doesn't really feel so-

    19. PAPeter Attia1:42:31

        It's a preloaded pen

    20. SGSally Greenwald1:42:31

        ... psychosocially, yeah, sexy.

    21. PAPeter Attia1:42:34

        Yeah. Um, well, yeah, I guess it speaks to, um, obviously the magnitude of the problem. Ha- have, uh, I don't suppose these drugs have been compared head-to-head to testosterone?

    22. SGSally Greenwald1:42:44

        I don't believe that they have, no.

    23. PAPeter Attia1:42:46

        I assume that it would be prudent to make sure a woman's testosterone has been pushed to the physiologic limits before you would engage with any of those drugs.

    24. SGSally Greenwald1:42:55

        I just prefer testosterone, which to, to be clear, testosterone is, is, is sort of from a guideline perspective recommended only in the post-menopausal woman. So if we're going to sort of stay in the, the, you know, where is most of the data, why, you know, when do I ever use these drugs, so this is in the premenopausal.

    25. PAPeter Attia1:43:12

        This is premenopausal.

    26. SGSally Greenwald1:43:12

        This is premenopausal.

    27. PAPeter Attia1:43:13

        From an FDA perspective.

    28. SGSally Greenwald1:43:14

        Exactly. So if you're like, "You know, well, why even use these?" This is studied for premenopausal. Testosterone is postmenopausal. Um, but there's a lot of sort of behavioral interventions, which I've already mentioned. Um, and then, you know, sort of more off-label would be cannabis. Um, there is some pretty good data now that we have in some states, um, you know, legal THC, um, that opens up for researchers to study and investigate, and there's really good trials talking about cannabis and your ability to have more satisfying sexual encounters. Um, uh, but it is dose dependent, so when we think about T, when we think about cannabis, I'm speaking-

    29. PAPeter Attia1:43:51

        It's probably an inverted U shape.

    30. SGSally Greenwald1:43:52

        It's inverted, yeah. So it's specifically THC. Um, we, around one to two milligrams is the recommended dose. Anything higher for some can be sedating, to speak to your sort of inverse relationship, which adversely affects your, your sex, sexual experience and desire to participate. But around one to two milligrams, patients report that they, um, have more satisfying orgasms or, you know, have a hyper-awareness of their senses. Sex drive is higher. It's quite significant in the data, much more significant than the medications I've already talked about.
15. 1:45:31 – 1:50:24

    Sex during and after pregnancy: impact on arousal, safety of sex, and how to manage postpartum recovery and pain

    1. PAPeter Attia1:45:31

       Um, let's talk about pregnancy for a minute. Um, what is happening to a woman's arousal during pregnancy? Again, if you go back to my naive evolutionary view, now I can modify my view, by the way. So my view would have been a pregnant woman should not want to have sex at all because any amount of penetration puts the fetus at risk. However, based on what you taught me a few minutes ago, there's another reason for her to have sex during pregnancy, which is to keep her male partner around to protect her and hopefully their child. So I assume it's a balancing act of those things. So how does that shake out in the real world? What do we actually observe about a woman's sexual desire during pregnancy, and what are the dos and don'ts?

    2. SGSally Greenwald1:46:12

       So complex as you can imagine, and yes, that would be the evolutionary approach to it. Um, from a medical perspective, um, because I think it might scare some women to say, you know, "Oh, it puts the fetus at risk," to, to be clear, um, in a healthy pregnancy in the absence of a contraindication, a low-lying placenta, a low-lying blood vessel, or a sh- cervical insufficiency, um, which we would pick up on in routine ultrasound, um, sexual health, sex during pregnancy is completely safe, totally fine, and has a lot of relationship and psychosocial benefits.

    3. PAPeter Attia1:46:45

       Is there a point at which the... at, at, late enough in the pregnancy where you would recommend a woman not have intercourse?

    4. SGSally Greenwald1:46:50

       In the absence of a, you know-

    5. PAPeter Attia1:46:52

       Absence of any of those things

    6. SGSally Greenwald1:46:52

       ... pathology, absolutely not.

    7. PAPeter Attia1:46:54

       Wow, okay.

    8. SGSally Greenwald1:46:56

       Um, we know that, um, for many women, uh, sex during pregnancy can be quite intense, um, in the pleasurable, uh, category. The reasons for this are the neurotransmitters, right? You have super high levels, um, of estrogen and oxytocin, so that can make for a more pleasurable experience. Um, there's more blood flow to the genital area, so the contractions, um, of the muscles are sort of more s- or more intense. The blood vessels are-

    9. PAPeter Attia1:47:22

       Hmm. Yeah

    10. SGSally Greenwald1:47:22

        ... sort of bringing more heat to the area. Um, and then for some women, I, I wish this for all women to feel sort of safe and supported and bonding with a partner in pregnancy, but that's the not the case for all.

    11. PAPeter Attia1:47:33

        Post-pregnancy, what do you advise your women, assuming they've had a normal... Uh, well, let's start with, uh, vaginal versus C-section. So if a woman has had a C-section, what do you think is the right time for her to go back to sexual activity pending her desire?

    12. SGSally Greenwald1:47:49

        We don't change the recommendation, uh, for, uh, when to resume sexual activity post-vaginal birth or C-section. It's six weeks across the board. Um, that's the time when you go see your doctor. They check you out. They make sure everything is well-healed. It sort of sits uneasy for a lot of people to say, "Well, gosh, like, why would... Why is it the same recovery time for both? A C-section is, is so much bigger." Um, the thought process is that by six weeks you should have, uh, complete healing from the C-section in the absence of complications. Um, and we're more sort of from a hormonal physiologic perspective making sure that the uterus has shrunk, you know, down a significant amount, that you're not at increased risk of infection by having things in the vagina. Um, you're a good candidate to have contraception at that time, so we can provide you with, you know, protection from future pregnancies. Um, but I think from a postpartum perspective, you know, maybe reason number 15 why I loved your podcast and why I love Rachel Rubin is, um, she recently published on the genitourinary, uh, syndrome of lactation, which basically talks about the hypestrogenic or the low estrogen state of the vagina postpartum and how that mimics the pathophysiology of women in menopause. And so for a lot of my patients who are breastfeeding, who have high prolactin, um, who have low estrogen, I'm prescribing them the estrogen cream that I'm prescribing my post-menopausal women, um, to sort of keep the vagina as, as healthy and sort of, uh, moisturized as possible.

    13. PAPeter Attia1:49:22

        Does an episiotomy affect the ability to resume intercourse after pregnancy, or is that usually healed by six weeks as well?

    14. SGSally Greenwald1:49:29

        The hope is that it's healed, but unfortunately, um, pain from tearing in general or episiotomies, which are, um, to be clear, out of fashion in the absence of an emergency. Um, we don't do routine episiotomies. The data is clear against those. Um, but we, um, we do see that any sort of tearing or cutting that happens, um, at the vagina can lead to pain, which can lead to dyspareunia, pain with sex, and therefore we have, you know, drive issues and sexual health issues as well. And another thing to think about from a postpartum perspective is how these, you know, s- these insults of pain can sort of manifest into something bigger than they are. So initiating, you know, or sort of participating in sex before you're ready and having a painful sexual experience can cause tightening of the pelvic floor, rigidity in the, in the muscles, um, and can set into motion a pain cycle that then takes, you know, future pelvic floor physical therapy to break that pain cycle.

16. 1:50:24 – 1:58:22

    How Sally would redesign sex education

    1. PAPeter Attia1:50:24

       You alluded to sexual education a number of times. I have to be honest, I'm a little naive. I don't really know what's being taught in sex ed. Um- I don't even really remember what I learned in sex ed, although I remember watching these really embarrassing movies that's on, on a VCR. That's about the extent of it. Um, but if you were sex ed czar, uh, appointed from the, atop the mountain, um, how, how would you design the curriculum? How would it differ for boys versus girls? When would you initiate it?

    2. SGSally Greenwald1:50:57

       So if, if I were, uh, queen of sex ed, um, I would get away from the fear-based, "Don't get pregnant," "Don't get an STD," you know, "Don't, don't, d- you're gonna get HIV," sort of fear-based counseling, and really provide the, the ed part.

    3. PAPeter Attia1:51:14

       Isn't it, aren't those things important, though?

    4. SGSally Greenwald1:51:15

       They are important, but there has to be some actual education in terms of pleasure and anatomy and pathophysiology. Um, this is not a podcast talking about, you know, the plight of women. I have, as a mom to four boys, I'm equally committed that boys are as educated as girls are, and I care that my boys care about the experience that their potential fut- future partners might have with them. Um, women's sexuality is complex. It's the anatomy you cannot see as well as you can see with men. Just sort of the nature of the fact that, you know, when a bunch of boys are in a locker room, they can see other boys' anatomy. They see the differences. They understand that that's healthy. Women don't often see other... You know, girls don't often see other girls' vaginas, um, as clearly as, as, you know, boys see other penises. And so normalizing through, you know, the, the labia, you know, library and, and realizing what's normal and understanding the clitoral nerve for, for both boys and girls, thinking about safe ways to sort of explore intimacy. If you don't provide them with informational content such as, you know, OMG Yes, and, and teaching them about how to explore their anatomy, they will turn to porn. Um, and we have great data that almost all of the porn is not healthy, um, for, uh, teens in terms of setting expectations that are unrealistic, um, both anatomical and sort of describing, you know, penetrative penis and vagina sex as the way that women have, like, screaming orgasms. That's just not accurate. And so it set expect- sets expectations for encounters that are just not obtainable and leads to, you know, disappointment and, um, self-confidence issues. So, um, I'd love to, for, for, for the, you know, sexual education to be informative from an anatomical, physiologic, accurate, pleasure-based perspective and talk them through how to have safer encounters.

    5. PAPeter Attia1:53:11

       You said you have four boys, so this is obviously near and dear to your heart. What is, um, what is the way in which you're going to communicate with your boys about this in an environment where they're, they're growing up in a world that w- you, me, your husband, like, we just can't relate to, right? Like, I've made this point before, I think with, with Rachel on the podcast. Like, when I was growing up, porn was a black and white Playboy or something, right? [laughs] Like, it's a totally different thing. So what, what are, what, what are you going to do, and what is your advice for other parents out there who have growing boys?

    6. SGSally Greenwald1:53:46

       So-

    7. PAPeter Attia1:53:46

       And girls for that matter who are-

    8. SGSally Greenwald1:53:47

       Yeah, and I, I think I don't distinguish the genders, you know, as, as much. I think that, you know, pe- I think that education about all bodies should be provided to all people. Um, and, you know, so first is sort of, like, you know, using the correct verbiage and anatomical nomenclature. Um, calling a penis a penis and, you know, calling a vulva a vulva and sort of normalizing this as a part of your health. Um, masturbation is incredibly healthy. Um, it should be done in a private setting, and this, these are sort of ex- ex- it's healthy. And there's a lot about shaming masturbation and how that can result, be, put your child at higher risk, um, for issues in the future if you sort of shame their exploration of their body. It's normal. It's healthy. It's a part of your health. Orgasm is healthy, but it should be done in a private place. Um, and sort of how you interact. Like, what is consent? What are the components to consent? What does that look like? You know, is it specific? Is it enthusiastic? Um, is it, um, persist as the activity changes? Um, is there a timeline on it? Like thinking, thinking about all the different ways that we think about consent and then sort of changing the way that sort of society allows its perceptions to, to trickle in to what we think of, of in terms of safety. So for example, you know, as a s- as a culture, we tend to say that, you know, penetrative sex, penis in vagina, is sort of the end all, you know, top of the pyramid, most, um, intimate act you can do with someone. Um, but condoms are relatively, are quite effective at preventing sexually transmitted diseases when used, uh, you know, in a, in a penetrative sexual encounter. Um, people don't really use protection when, when performing oral sex, either, you know, women on men or men on women. And so as we see the rise of the, you know, herpes across college campuses, this is an intervention that we really need to talk about. If you're at a party and you're with someone and you want to be intimate with them, having penetrative intercourse with a condom on is safer and less likely to transmit an, a sexually transmitted disease than if you're going to perform oral sex on each other. And so thinking about it from a safety perspective and not a cultural perspective, um, would be another sort of key f- foundational change that I think needs to happen. Um, and also sex education needs to change. Like what we talk about in... Like, did you have sex education in college? What about grad school? Um, what about perimenopause and menopause? There sort of needs to be an evolving door in terms of, um, you know, different providers coming in and talking and educating because our bodies change, our physiology changes, and our needs change. And this is not a, like, eighth grade, one-hour, you know, split the boys and girls, talk about it kind of a thing.

    9. PAPeter Attia1:56:18

       Um, but coming back to this specific issue, how much of an issue is pornography for young boys, and what, what is the solution? Like, it's not going to get regulated away, right? Although there are some states where Yeah, at, at least age verification is required. I don't know how effective that is, but I assume it's, I mean, that's a step in the right direction

    10. SGSally Greenwald1:56:41

        So my strategy in general when thinking about don't do this is always to do a don't do this, do this. So to sort of like introduce what you should do instead-

    11. PAPeter Attia1:56:49

        Mm-hmm

    12. SGSally Greenwald1:56:49

        ... of what you shouldn't. It's let's introduce something healthy. So what does a healthy sexual life look like? Um, there are, you know, the porn industry is, is, you know, there are parts of it that have evolved. There is, you know, healthier informational videos that you can watch if you're looking for arousal. Um, there are healthy ways to have an orgasm and to interact with another human being. And talking about how you, you know, bring someone into your life that's healthy and how you have, what, you know, what frequency is healthy for both of you. And if you're not getting that, like to what ends do we go to get it elsewhere? And, um, you know, what are you searching for? Is it a dopamine release? Is it, you know, what can we add and replace of that neurotransmitter release that you're looking for?

    13. PAPeter Attia1:57:31

        Is there a crisis of intimacy in young people? I've heard this a lot, but again, I just don't know the data. But I keep hearing that people in their 20s today are becoming less and less intimate over time relative to a decade ago, two decades ago. And, uh, so first of all, I don't know if that's something you know, but is that d- is there-

    14. SGSally Greenwald1:57:52

        I don't. I, I sort of have the same anecdotal experience in my clinical practice where I have very lonely, less intimate 20-year-old, you know, uh, women in my practice sort of ask, you know, and, and when I, when I take a sexual health history, which, which I always do, you know, I, there is, there is a lot lacking there. And, uh, we could, you know, it would be a whole nother, uh, podcast to talk about AI and how that's gonna sort of, you know, replace intimacy and how we can use that for arousal and things like that. But I think, um, it's something to think about.

17. 1:58:22 – 2:00:41

    Sally’s optimism about a new era in women’s sexual health

    1. PAPeter Attia1:58:22

       So I guess maybe final, final thoughts. Um, what are you most concerned with right now as you think about your, your, your professional world, and what are you most excited about?

    2. SGSally Greenwald1:58:36

       I'm most excited about the new information that we have coming in about hormone options in terms of how we provide menopause hormone therapy and how we treat perimenopause and the new types of estrogen and progestin, and how we tinker with those and moderate those to optimize women and how they feel. Um, this is super personalized, super individualized medicine, and we want to do this as physicians. We love doing this. But I think the more research that's coming out and the more, you know, drugs available make it really fun to be a part of. So that's definitely my area of passion right now. Um, in terms of concerns, um, do I have to have a concern or I, I guess I just have another passion, which is that I, I, um, I, I think we're, I think the world is changing and I think we're, I think people are ready for it. Um, I'm ready to, to push it there. You're pushing it there. I think it's really exciting to think about, um, sexual health as a part of your health and talking about it in a very sort of like generic safe place from a physiologic perspective. Think about all the people you can get on your team to, to help you, you know, sex therapists and pelvic floor physical therapists, and how to tinker with your hormones and behavioral interventions. And I love thinking about couples listening to this podcast together and trying different things and, and, um, you know, seeing this as, uh, an, you know, potentially orgasm as another biometric or, you know, sexual satisfaction as another sort of longevity lever that we pull when improving, you know, the happiness and health of our lives.

    3. PAPeter Attia2:00:13

       I think that's an awesome way to, to close this discussion, and I definitely appreciate the optimism, um, and lack of pessimism around it. So thanks again for all of this, um, this insight. I learned a lot, um, as is, uh, often the case with podcasts. So thank you.

    4. SGSally Greenwald2:00:30

       Thank you for having me. [upbeat music]

Episode duration: 2:00:41