Where Did My Orgasm Go? Menopause, SSRIs, and the Science of Pleasure with Dr. Lauren Streicher

What happens to your orgasm after menopause? It's something nearly half of women experience changes with in midlife, but so few are talking about it. In this episode of unPAUSED, Dr. Mary Claire Haver sits down with Dr. Lauren Streicher to discuss exactly what changes to orgasm, libido, and sex, why it happens, and what you need to know if you're struggling. Dr. Streicher is a professor of Obstetrics and Gynecology at Northwestern University Feinberg School of Medicine, the host of Dr. Streicher's Inside Information Podcast, and the creator of Come Again, a 30 episode audio series on sexuality and sexual function. She's a senior researcher at the Kinsey Institute and one of the true pioneers of sexual medicine, helping to define and legitimize a specialty that for decades simply didn't exist. Dr. Haver and Dr. Streicher start with the basics: what an orgasm actually is, the anatomy of the clitoris, and why most women cannot have an orgasm from penetrative sex alone. Dr. Streicher explains vaginal orgasms, cervical orgasms, the G spot, and the historical research of Princess Marie Bonaparte, who measured the distance between the clitoris and vaginal opening in 240 women in an effort to understand why she couldn't orgasm during intercourse. They discuss what happens to orgasm and sex post menopause, including the role of blood flow, nerve health, clitoral atrophy, cardiovascular disease, diabetes, and medications, especially SSRIs that can affect both libido and orgasm. Dr. Streicher walks through how genitourinary syndrome of menopause affects the clitoris, why the pelvic floor matters for orgasm, and why so many women have never even seen their own anatomy. They also talk about anorgasmia, the inability to have an orgasm, both primary and acquired, and why this is almost never discussed in medical training. Guest links: Dr. Streicher https://www.drstreicher.com/ Dr. Streicher https://www.instagram.com/drstreich/?hl=en (Instagram) Dr. Streicher: Menopause: The Inside Info https://drstreicher.substack.com/ (Substack) Dr. Streicher’s Inside Information: Menopause, Midlife, and More https://podcasts.apple.com/us/podcast/dr-streichers-inside-information-menopause-midlife/id1615785832 (Apple Podcasts) COME AGAIN https://%E2%81%A0DrStreicher.com/comeagain Lauren Streicher - Faculty Profile https://www.feinberg.northwestern.edu/faculty-profiles/az/profile.html?xid=13740 (Northwestern Medicine) Dr. Streicher https://www.youtube.com/c/drstreichertv (YouTube) Subscribe to COME AGAIN: Sexuality and Orgasm DrStreicher.com/comeagain https://www.drstreicher.com/comeagain Use code UNPAUSED20 for 20% off (This code expires Dec 23) Dr. Streicher's Podcast Dr. Streicher’s Inside Information: Menopause, Midlife and More http://ow.ly/74TI50IvXK6 DrStreicher’s Substack https://drstreicher.substack.com/ Gyne Hacks! https://drstreicher.substack.com/p/dr-streichers-gyne-hacks (Including how to How to Get a Hands-free Free Vulvar View) Books: “Slip Sliding Away: Turning Back the Clock on Your Vagina,” https://www.amazon.com/Slip-Sliding-Away-gynecologists-post-menopause/dp/B092H87LHQ/ by Dr. Lauren Streicher <a href="https://www.amazon.com/Gynecologists-Turning-Streichers-Inside-Information/dp/B09FC8C8CT/ref=sr_1_3?dib=eyJ2IjoiMSJ9.ygMOA9RRO8TIXDMld8zeG ...

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Speaker 00

  Hollywood has set the tone that women should expect, expect to have a mind-blowing orgasm within 10 seconds of penis and vagina sex. And this is a huge problem because women think there is something wrong with them.

• 0:13Dr. Mary Claire Haver?

  Because that is, I think, what their partners are expecting.

• 0:14Speaker 00

  Well, and their partners are expecting that, too. And because of that, there's this script that women have, that you're supposed to have penis and vagina sex, and you're going to have this incredible, incredible orgasm. And because that doesn't happen with me, then I'm broken.

• 0:38Dr. Mary Claire Haver?

  The views and opinions expressed on UnPaused are those of the talent and guests alone, and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. Today, I'm joined by Dr. Lauren Streicher, professor of obstetrics and gynecology at Northwestern University-Feinberg School of Medicine. She's the host of Dr. Streicher's Inside Information podcast and the creator of Come Again, a new 30-episode audio series that explores sexuality, orgasm, and the science of sexual function. Dr. Striker is also the author of several bestselling books on menopause and sexual health. To say she's an icon in the field is an understatement. Dr.

• 1:22Dr. Mary Claire Haver?

  Striker is one of the true OGs of sexual medicine. She helped define and legitimize especially that for decades simply didn't exist. Her research, her patient advocacy, and her willingness to talk openly about topics that most people still shy away from have changed how women and their clinicians approach sexual health. I met Lauren in Austin at South by Southwest, and her candor, her humor, and the sheer depth of her knowledge was striking. She has spent her career educating both physicians and women about what's really happening to our bodies, and she's never been afraid to push the conversation forward. I'm thrilled to have her here today to talk about post-menopause orgasm, sexual function,

• 2:02Dr. Mary Claire Haver?

  and what women need to know about the impact of SSRIs and other medications to desire and pleasure. I'm Dr. Mary Claire Haver, a board-certified obstetrician and gynecologist and certified medical practitioner. I'm also an adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch. Welcome to UnPaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life.

• 2:29Dr. Mary Claire Haver?

  Thank you so much for being here today.

• 2:31Speaker 00

  I am so thrilled to be here with you, talking about one of my favorite taboo topics, orgasm.

• 2:37Dr. Mary Claire Haver?

  So, where did you grow up? Tell me your background, give me your origin story. Our listeners love to hear this about.

• 2:43Speaker 00

  Well, it's actually not that exciting. I had a pretty unremarkable childhood, which is good. You don't want it to be remarkable necessarily. I grew up in a suburb of Chicago, and I've been a Chicagoan my entire life. And in fact, I went to medical school at the University of Illinois and then did my residency in Chicago.

• 2:58Dr. Mary Claire Haver?

  Why OB-GYN?

• 3:00Speaker 00

  Well, I actually started out in internal medicine. My father was an internist. I kind of fell into medical school. I wasn't planning on, you know, some people it's a passion. For me, it was not. My parents wanted me to be a concert pianist. I didn't have the talent. I wanted to be a ballerina. I didn't have the talent. I was an undergrad. I was majoring in English. I was thinking about journalism. I wasn't really sure what I wanted to do. And then, my big brother had just started medical school, and he made some offhand comments about, well, I don't think you could cut it in medical school. And that's all, took for me to say, right, I'm going to medical school. So, I applied to medical school, got in, never expected to be there. And then, I ended up not really knowing what I wanted to do, because I liked it all. It was all interesting. So, I started off in internal medicine, because my father was an internist.

• 3:43Speaker 00

  And then, I discovered that that really didn't fit my personality. I'm one of these, I want a solution. I want to make it happen quickly. And internal medicine is all about, let's face it, chronic disease. It's like psychiatry, you know, I don't have 30 years to solve your problem. I want to solve your problem in the next hour. And OB-GYN is really perfect for that, because, you know, you deliver the baby, you stop the bleeding, you take out the tumor. Everything is very quick, relatively speaking, in the medical world. And I love the variety. I love the variety. And I did love working with women. I had been involved in women's reproductive rights for a long time. I loved the people I was working with. So, that's how I ended up in OB-GYN.

• 4:21Dr. Mary Claire Haver?

  Did you do any postgraduate training, like fellowship? Or, there was, there's no fellowship, right?

• 4:26Speaker 00

  There is no fellowship. No, I started just as a generalist, and probably like you, you know, delivering babies, wiping out chronic vaginitis, you know, saving the world from endometriosis, all of that. And then, over time, I pivoted. I pivoted because I found what I really loved was doing surgery, and specifically minimally invasive surgery. I was the first to bring laparoscopic hysterectomy to Chicago, and I was doing a lot of surgery, which I loved. But I also found that part of taking out someone's uterus, and specifically their ovaries, puts them into a surgical menopause. Okay. And I felt ill-equipped to help these women navigate menopause. So that's what

• 5:09Speaker 00

  brought me to the whole meno world. Yeah. Now, the sexual medicine world, that came later. That came later. And, and really, it was because I was writing. Along the way, I was always writing. In fact, my first book, The Essential Guide to Hysterectomy, I have two editions. I really need a third one. It was my first book and my true love, because that's what got me out there and realized what an impact you can make by writing high-level, good information for women so that they can make good decisions. For themselves. And so after that, uh, my next book was going to be about menopause, and particularly about post-menopause sexuality. And my publisher, Harper Collins, said, "Well, we'd really

• 5:48Speaker 00

  like this to be for all ages, not just post-menopause." So SexRx morphed into a book about sexual medicine throughout the lifespan, starting in the twenties until your nineties. Yeah. And because of that, and, and you know this, when you write something is when you're forced to really learn about it. Right. You have to read everything. I don't have anyone else do my writing. If it has my name on it, I wrote it. And that meant I had to do all the research, and write, and write, and write. And that's what brought me into the world of sexual medicine, which I knew very little about, like most gynecologists. And I remember going to my first conference, and I'm like, "Oh, my God, there's a whole world out there of people who really know this stuff. The science, the biology, what's going on in the brain, what's going on in

• 6:32Speaker 00

  the glitoris, all this stuff that we never had any exposure to." No. And so that was definitely part of my learning path. And then I expanded out to, to a lot of other areas. Right. And then, of course, we have Kinsey. And I, um, I'm the board of the Kinsey Institute, and I'm a senior researcher. Director at Kinsey, which has been wonderful because it exposes me to a whole nother.

• 6:53Dr. Mary Claire Haver?

  Tell our listeners what the Kinsey Institute is because most of them, I know what it is, but most of them may not know.

• 6:58Speaker 00

  The Kinsey Institute is at Indiana University and it is the foremost academic research arm in the United States. It is eps, and maybe even the world.

• 7:11Dr. Mary Claire Haver?

  For sexual medicine.

• 7:12Speaker 00

  For sexual medicine, specifically for sexual medicine. It was started by Alfred Kinsey, who was a biologist. He was just asked to teach sex education and really didn't know much about sexuality. So he did this enormous survey of both men and women about what their sexual habits were. He was not a physician. He did Masters and Johnson examined people. They were looking in the laboratory, what happens when someone has an orgasm. That was not Kinsey. Kinsey talked to people for hours and hours and hours. And in fact, the statue of Kinsey at Indiana University is him sitting in a chair leaning forward and there's an empty chair right in front of him. And the idea is you go and you sit in the empty chair and you tell him all of your sexual issues. So that's what he did. And he started publishing his findings. And then that morphed into this incredible research arm, which is still

• 7:57Speaker 00

  alive today. And I love being involved with them because that really is where a lot of the cutting edge research happens.

• 8:03Dr. Mary Claire Haver?

  So I want to give our listeners a chance to understand how really groundbreaking this is and how unusual it is. Because in my four years of residency, so I was a resident from 98 to 2002, and then I took over teaching duties and then became a program director in the 2010s-ish. I learned how to define where the clitoris was. I still actually could not have anatomically drawn it correctly until the last five years, probably. And I knew what an orgasm was. I knew a little bit about Masters and Johnson, nothing about Kinsey. We had zero clinical application of any of that knowledge. There was no discussion

• 8:44Dr. Mary Claire Haver?

  of libido or desire or anything. And if there was, I can just remember being kind of a taint of, well, it's psychological. This is a purely psychological issue.

• 8:54Speaker 00

  Exactly. And especially when it comes to orgasm. I think a lot of women and doctors are pretty comfortable talking about the fact that, you know, I just don't have the desire for sex anymore. But how many doctors say to patients, are you able to have an orgasm? I can tell you how many. They're not a sexual medicine doctor. It's almost zero.

• 9:13Dr. Mary Claire Haver?

  Almost zero.

• 9:14Speaker 00

  It's almost zero. And the reason they don't is because if a woman says, I'm so glad you asked, I'm having great difficulty, they have nothing to say but, I'm so sorry.

• 9:20Dr. Mary Claire Haver?

  So sorry.

• 9:21Speaker 00

  I'm so sorry. And then change the subject.

• 9:22Dr. Mary Claire Haver?

  Well, they're not trying.

• 9:23Speaker 00

  Because they don't know what to tell people.

• 9:25Dr. Mary Claire Haver?

  So, so let's back up. Let's, let's educate our audience. What is an orgasm?

• 9:28Speaker 00

  You know, describing an orgasm to someone who's never had one is kind of like describing how chocolate tastes to someone who's never had chocolate. It's not so easy, but here goes. Basically, what an orgasm is, is it is the physical things that occur, or hopefully occur, following sexual arousal. So what's going on? You're getting a rush of blood to the vulva, the vagina, and the clitoris. You're also getting a rush of blood to the pelvic floor muscles, which give women this feeling of satisfaction and pleasure and fullness. And then, usually physical stimulation of the clitoris is required.

• 10:12Speaker 00

  Those nerve endings send messages directly to the pleasure center in the brain, explodes with pleasure, and then in turn sends another message down to the pelvic floor, which causes those muscles, which also are congested with blood, and all the vulvar and vaginal congestion all gets released. That's when the orgasm is over, so that a woman is left feeling very satisfied. This kind of overwhelming sense of, oh, that was really lovely. And of course, being grateful to the partner who helped her do that, or her vibrator, or whatever.

• 10:46Dr. Mary Claire Haver?

  Whatever.

• 10:46Speaker 00

  But it's really kind of a sense of incredible release. That's the Cliff Note version.

• 10:51Dr. Mary Claire Haver?

  Yeah.

• 10:51Speaker 00

  Yeah, we'll get into some of the nuances of this, but that's basically what it is. It is a physical phenomenon that follows sexual arousal.

• 10:59Dr. Mary Claire Haver?

  When we watch a lot of Hollywood movies, when we, so, you know, a lot of pornography that's floating around out there, it's very different than what you described.

• 11:10Speaker 00

  Oh, yeah. Hollywood has set the tone that women should expect, expect to have a mind-blowing orgasm within 10 seconds of penis and vagina sex. And this is a huge problem. Because women think there is something wrong with them.

• 11:22Dr. Mary Claire Haver?

  Because that is, I think, what their partners are expecting.

• 11:25Speaker 00

  Well, and their partners are expecting that too. And, and because of that, there's this script that women have, that you're supposed to have penis and vagina sex, and you're going to have this incredible, incredible orgasm. And because that doesn't happen with me, then I'm, I'm broken.

• 11:39Dr. Mary Claire Haver?

  There is penis and vagina sex. Can that stimulate an orgasm?

• 11:43Speaker 00

  It can, but those are the rare ones, which is why the medical term for women who do not have an orgasm in penis and vagina sex is normal. It's the medical terminology. You are normal if you do not have a penis.

• 11:56Dr. Mary Claire Haver?

  It's the most common thing.

• 11:58Speaker 00

  Correct. So we're talking about 10%. Now, so let's talk about what a vaginal orgasm actually is.

• 12:04Dr. Mary Claire Haver?

  Okay.

• 12:05Speaker 00

  A vaginal orgasm is when you have an orgasm without clitoral stimulation. That's key. We'll get to that in a second. From just having, and when I say penis, let's include toys in that too, because not everybody has a penis in their life. So whether it's a vibrator or a dildo or penis, when you have an object in your vagina for the purpose of sexual stimulation, will an orgasm occur? So there's really three ways that that might happen. Number one, we know that many women, if they are roused enough, will not need physical stimulation to have an orgasm. There are women that can fantasize their way to orgasm.

• 12:40Dr. Mary Claire Haver?

  Lucky girls.

• 12:41Speaker 00

  Lucky girls. It's in the single digits, but yes, it can happen. So then we have number two. Number two is a cervical orgasm. Now cervical orgasms are fascinating, because when we talk about the neurology of orgasm, and when I just talked about what is an orgasm, I talked about clitoral stimulation and how those clitoral nerves go straight down the highway to the brain, right? It's not the only road to nirvana. We also know that the cervix can stimulate an orgasm. And the reason we know this is because of research done in spinal cord patients, that that path from the clitoris to the brain no longer is functional. It doesn't exist. They have to go on the side route, which is cervical stimulation.

• 13:25Dr. Mary Claire Haver?

  Cervical.

• 13:25Speaker 00

  Why does that work? It works because you are stimulating the vagus nerve. Vagus nerve has a different pathway. It doesn't go through the pelvis. It happens much higher in the spinal cord, so even spinal cord patients can use that road. And this is the fascinating part. If you do an MRI of a woman having an orgasm, and yes, there are people that do that.

• 13:45Dr. Mary Claire Haver?

  I've seen, I've seen the MRI.

• 13:46Speaker 00

  So interesting, but a different area of the brain lights up. So if you have a cervical orgasm, a different area of the brain lights up than if you have a clitoral orgasm. And in fact, women that have both, some women do have both, they will tell you that they are both pleasurable, but they're different, but they're different. So many women that have a vaginal orgasm, it is from stimulation of the cervix. Size sometimes does matter. I'm just saying. We say size doesn't matter, but in that case it does.

• 14:14Dr. Mary Claire Haver?

  You know, I, I was taught, and I know this is absolutely incorrect, but when I was coming through the ranks, certain cervical procedures, we didn't give any anesthesia because we were taught there's no cervical nerve endings. So why would we anesthetize something that doesn't have nerves? Just go ahead and do the biopsy or do the, you know,

• 14:30Speaker 00

  correct.

• 14:31Dr. Mary Claire Haver?

  And we've learned so much. And that, some of that data comes from that of showing the electric, the stimulation of the nerves when you touch the cervix.

• 14:39Speaker 00

  Exactly. There's very sensitive nerves in the cervix. So then we get to the third pathway to orgasm from vaginal penetration, and that would be what is commonly called the G-spot.

• 14:50Dr. Mary Claire Haver?

  Now, popular culture would make you think everyone has a G-spot.

• 14:53Speaker 00

  Popular culture would be wrong.

• 14:55Dr. Mary Claire Haver?

  So, so this is. Because I've looked for it.

• 14:57Speaker 00

  Oh, no, I know. You could go on a search, you know, with the headlights on and all the different wines and things. No, everyone does not have a G-spot. And in fact, a lot of people don't think of this as a spot, which implies there's this very, very specific anatomical spot. It's better referred to as a G-spot plexus, meaning a little bundle of nerves in the roof of the vagina that's a few inches back from the opening, which is quite frankly, an extension of the clitoris. Keep in mind that when we're looking at the clitoris, which I hope everyone will look at and we'll get to that.

• 15:30Dr. Mary Claire Haver?

  So on YouTube, I think we'll pop up a picture of the actual anatomic drawing of the clitoris, which looks a little bit like Gumby, the Gumby doll.

• 15:36Speaker 00

  Totally, totally. So keep in mind that the clitoris, when you're, you're looking at the tip of the ice. For what you can actually see when you look with a mirror. And that it actually dives into the pubic bone and goes to the roof of the vagina. So that's where this plexus is. Some women, not all women, if that area is stimulated, can have an orgasm. So those are the three ways that people can have a vaginal orgasm. Most women that have an orgasm during penetrative sex, and they think that it's from vaginal stimulation, other than being aroused, it is not. It is from simultaneous clitoral stimulation.

• 16:12Dr. Mary Claire Haver?

  Kind of a cross contamination.

• 16:13Speaker 00

  Exactly. We call this pairing. Meaning that someone has a fingers or vibrator or something else down there. So the clitoris is being stimulated at the same time. So one of the questions that comes up is, well, what's the likelihood of that happening? Well, we know the answer to that question. It's about, you know, depending on some different factors, maybe 20, 30% of just plain, if two people are having intercourse, allowing that clitoral stimulation.

• 16:39Dr. Mary Claire Haver?

  So on the flip side, still totally more normal, so that's abnormal. You know, outside of the normal curve is women don't have orgasm that way. They need more stimulation.

• 16:50Speaker 00

  Most women are not able to have orgasm without some kind of clitoral stimulation. So this brings me to who the person is who's most likely to have clitoral stimulation without the help of a vibrator and fingers, just during plain penis and vagina sex. So let me tell you the fascinating story of Princess Maria Bonaparte.

• 17:11Dr. Mary Claire Haver?

  Oh, my gosh.

• 17:12Speaker 00

  As in, great niece of, you know.

• 17:15Dr. Mary Claire Haver?

  Napoleon.

• 17:15Speaker 00

  Napoleon. So she was actually a student of Sigmund Freud. And she was personally very frustrated that she was not able to have an orgasm during intercourse. And she really tried. She had multiple lovers, so it wasn't, you know, we can't blame it on the guy. And it just didn't happen. And then it occurred to her as a scientist that her clitoris was actually a little bit far away from her vagina, and maybe that was the problem. So she measured and she found that her clitoris was indeed a little bit far away from the vagina. Then she gathers up 240 women, I have no idea how, and she polls them. And she says, are you able to have an orgasm? During intercourse. And then she measured the distance between their clitoris and their vaginal opening in all of these women.

• 18:00Speaker 00

  And what she determined is that the magic number is about 2.5 centimeters, which translates to about one inch. Now, I know everyone is putting this on pause right now, pause, so they can go find the tape measure and measure. So, so go do that. That's fine.

• 18:16Dr. Mary Claire Haver?

  I did not know this. This is so fascinating.

• 18:18Speaker 00

  But, so you say, okay, why is this? Well, it's because

• 18:21Dr. Mary Claire Haver?

  It's anatomical, right.

• 18:22Speaker 00

  It's anatomical that his pubic bone, pubic bone, very important, is likely to be pounding against the clitoris if there's that distance. So Maria Bonaparte, being a problem solver, she decided that she is going to brace herself, wait for it, surgically move her clitoris. And she found a surgeon to do it. But it didn't work. So she did it two more times.

• 18:47Dr. Mary Claire Haver?

  Oh, my gosh.

• 18:47Speaker 00

  It never worked. But the point is, is it, she was onto something. And in fact, all of those records in French are at the Kinsey Institute. Her research has since been reproduced by two other researchers. And the fact of the matter is, is that if your clitoris, and now we use the urethra because it's easier to measure urethra to clitoris, if your clitoris is within about one inch of the urethra, you are one of the lucky women who is very likely to be able to have an orgasm during intercourse without any help from fingers or vibrator. There's also something called coito alignment. And we can, I can give you a picture of this one where the man is, we're talking missionary position here, where the man is basically riding high on the woman so that he's positioning

• 19:29Speaker 00

  his pelvic bone, his pubic bone, right over her clitoris. So for those who are motivated, it can be done.

• 19:35Dr. Mary Claire Haver?

  Positional as well. Like I've had, my girlfriends talk about, you know, in some positions, it's easier for them with PIV, penis and vagina sex, especially if she's on top, that she's able to kind of manipulate to get that stimulation.

• 19:48Speaker 00

  Correct. Exactly. But then we also looked, talking about position, this is why a lot of women like positions that are not on top necessarily, so that they have access to their clitoris to stimulate it during intercourse.

• 20:04Dr. Mary Claire Haver?

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• 21:14Dr. Mary Claire Haver?

  So I've had a couple of patients through the years. It's been a while, but back when, when a lot of patients were getting gastric bypass surgery and they were having rapid weight loss. And then they'd have all this X X skin and they were having abdominoplasties too. And what we figured out was pulling the skin up because they make the big incision at the abdomen. They were actually pulling up the location of their clitoris a bit and it was changing their sexual response. That's correct. And not in a way that made them happy. And I had, I couldn't find any data. This was also very new because you know, the surgeries kind of all started happening at once, massive weight loss and then this, then the second surgery, which changed. And I was like, wondering, did you ever hear or see anything similar?

• 21:57Speaker 00

  Yes, and now we're seeing

• 21:58Dr. Mary Claire Haver?

  And now we're seeing it with the GOP ones.

• 21:59Speaker 00

  So I think we have a study that we need to do, right?

• 22:01Dr. Mary Claire Haver?

  Yeah.

• 22:02Speaker 00

  This is, because this is, this is important, this is important because women already don't have an education as far as in their own anatomy and how to make orgasm happen. And then this gets thrown at them and they're like, are you kidding? Are you kidding? It's kind of like women after hysterectomy, which is another area of research for me, that they are told that your sex life will not change after hysterectomy. And for most women, that's true, but not for the women who have cervical orgasms. If their cervix is removed, guess what? It's gonna change. That's one of my episodes and come again is sex after hysterectomy. And there's a lot of information that I can promise you, your surgeon never told you.

• 22:39Dr. Mary Claire Haver?

  Well, because they didn't know.

• 22:40Speaker 00

  They didn't know. They didn't know.

• 22:41Dr. Mary Claire Haver?

  So what is anorgasmia?

• 22:43Speaker 00

  Anorgasmia is the Latin of no orgasm, does not happen at all.

• 22:49Dr. Mary Claire Haver?

  And how common is it?

• 22:50Speaker 00

  Well, we divide it into two groups. There's what we call primary anorgasmia, meaning people who've never had an orgasm. Some people call that pre-orgasmic. I like that. And then we have acquired anorgasmia. So when we look at how common it is, when we look at anorgasmia, it's not common. And when we're usually finding out about it is in young women, young women who have nothing biologically or hormonally wrong with them. It's usually a matter of education, cultural problems, past trauma. And in most of those women, if we get them in the hands of a good doctor who with a mirror shows them where their clitoris is and what to do with it, and in the hands of a good sex therapist, they do very, very

• 23:33Speaker 00

  well. And you know, you say guys don't have their problem. Well, guys have the obvious advantage of their penis is really easy to locate and they figure out what to do with it real fast. Women don't know where their clitoris is, and a lot of young women don't. And there's no discussion about that. So when we look at primary anorgasmia

• 23:47Dr. Mary Claire Haver?

  Okay.

• 23:48Speaker 00

  in young women, the numbers are pretty low, and this is almost 100% curable, unless they're on an SSRI. We see a lot of primary anorgasmia in women who were on an SSRI from an early age

• 23:59Dr. Mary Claire Haver?

  Mm-hmm.

• 24:00Speaker 00

  and then just never had an orgasm. Acquired anorgasmia is someone who used to have orgasms just fine, and then Then something happened that all their tried and true methods were no longer working. And that's my area of interest in research because that's what we are primarily seeing in perimenopause menopause women. The women who just, you know, figured it out at some point in their life. And then they are blindsided because no one tells them about that. You know, when mom sits down and maybe tells you about a hot flash or two. She doesn't tell you that you're also going to lose your ability to have an orgasm. And, and they are just devastated that suddenly they are no longer have, able to have an orgasm. Now, keep in mind, there is a spectrum. When you say anorgasmia, we also have hypoorgasmia, which means someone who has an orgasm,

• 24:44Speaker 00

  but it's, takes so long that it's like, are you kidding? It's not worth the effort? Or it doesn't have the same feeling? It's not as satisfying? So there's a lot of different permutations of that.

• 24:55Dr. Mary Claire Haver?

  I'll tell you a story. I am 57, have been postmenopausal for nine years now. And started struggling with the time it was taking, like frustrating, you know? Why is this taking so long? So I casually mentioned it to Corinne Mann, one of our mutual friends. And she says, this was a couple of years ago. And she says, well, how much vaginal estrogen are you on? And I was like, I had a big smile on my face, like, I'm not. And she says, Mary Claire, what? And I said, I, I kind of transitioned, you know, and I didn't have any obvious symptoms of what I was thinking GSM. And I was like, when I get there, I'll use it. I had a tube in my drawer, I just never used it.

• 25:40Dr. Mary Claire Haver?

  It was magical. Like, I just wasn't thinking, like, and, and I thought it was medication, it was stress, it was whatever else.

• 25:46Speaker 00

  Of course, you blamed it on yourself.

• 25:48Dr. Mary Claire Haver?

  Yeah.

• 25:49Speaker 00

  It's stress.

• 25:49Dr. Mary Claire Haver?

  So it was that me, who's menopause certified, who talks about this all day long. I don't have a great, you know, that's why I love having you on because I have so much to learn about sexual function. And I couldn't even diagnose myself, you know, it was my.

• 26:04Speaker 00

  Well, you are not alone.

• 26:05Dr. Mary Claire Haver?

  Girlfriend.

• 26:05Speaker 00

  You are not alone.

• 26:06Dr. Mary Claire Haver?

  Who has had to tell me.

• 26:08Speaker 00

  We just spent a few days together, I adore her. But it's not just vaginal estrogen. When you put the estrogen in the vagina and of course, in the opening of the vagina and the vestibule. Because it doesn't matter how nice the room is if he can't get through the door. And then you take that cream and you go north.

• 26:23Dr. Mary Claire Haver?

  I did. I've learned. I tell all my patients, you know, true north, down both labia and inside.

• 26:29Speaker 00

  And also, a lot of people think that this is something they're supposed to do just before sex. No, you do this on a regular basis because we are all about increasing healthy blood flow to the clitoris. So it will wake up those nerve endings.

• 26:42Dr. Mary Claire Haver?

  Walk me through the physiology of what happens post-menopause and why our orgasms could change.

• 26:49Speaker 00

  To do that, I'm going to start with talking about just what needs to happen to have an orgasm.

• 26:54Dr. Mary Claire Haver?

  Perfect.

• 26:55Speaker 00

  So what needs to happen to have an orgasm is number one, there needs to be arousal. The difference between libido and arousal, because it's a little confusing. Libido is, I want to have sex. I hope I have sex. Please, can I have sex? It's all in the brain.

• 27:08Dr. Mary Claire Haver?

  Brain.

• 27:09Speaker 00

  It's on the brain. Arousal are the physical manifestations of being sexually excited. Blood flow to the pelvis, lubrication, it's your body getting ready for sex. So that has to be there. That's a requirement. We also then have to have intact neurology, nerve endings that are going to respond and send mail to the brain to say, hey, pleasure center, something's happening here. There also needs to be blood flow. You have to have adequate blood flow to make all this happening. You need to have some physical stimulation in most cases. And then, of course, there's everything that's going on in the brain in terms of the neurotransmitters and all of that. Notice what's not on the list of requirements.

• 27:50Dr. Mary Claire Haver?

  A penis.

• 27:51Speaker 00

  Estrogen.

• 27:52Dr. Mary Claire Haver?

  Oh.

• 27:52Speaker 00

  No, penis is obviously not on the list. It's like, it's really low. But you do not need estrogen. You do not need testosterone. You do not need emotion. You don't have to be emotionally invested in your vibrator to have an orgasm, right? So this is a huge relief to the post-menopause women of America who have no estrogen.

• 28:15Dr. Mary Claire Haver?

  Yeah.

• 28:15Speaker 00

  Who maybe don't have an emotional relationship, that they can still have orgasms. Now, does estrogen help? You bet. And we're going to talk about how it helps. But it is not a biologic requirement. And and think about it. I mean, how many people are taking estrogen at this point? We know it's in single digits, yet most women are able to have orgasms, at least early on in menopause until things start to to to change with that. All right. So let's talk about what happens with all of those things post menopause.

• 28:43Dr. Mary Claire Haver?

  Yeah.

• 28:43Speaker 00

  Okay, so starting with arousal. Well, this gets tricky.

• 28:47Dr. Mary Claire Haver?

  So arousal, meaning the physiological, the physical things that are happening in the pelvis.

• 28:51Speaker 00

  And arousal is dependent on good blood flow.

• 28:53Dr. Mary Claire Haver?

  Okay.

• 28:54Speaker 00

  We know that estrogen is a vasodilator. It helps blood flow. So if you don't have estrogen, you are not going to get the same levels of arousal, which is also one of the reasons why there is vaginal dryness and pain. There is no orgasm killer like pain, any kind of pain, but certainly during pain during activities. So that's one reason that arousal is just not happening for a lot of women post menopause. Because

• 29:20Dr. Mary Claire Haver?

  It hurts.

• 29:20Speaker 00

  It hurts. And we also know very, very good data that women who have other menopause symptoms, like hot flashes, insomnia, aches and pains in their joints, they do not become aroused. So that's number one that's happening. Number two is let's talk about what's happening to clitoral blood flow and nerve endings. Now, keep in mind, the clitoris is kind of a small space there, right? What that means is that the blood vessels are teeny, teeny, tiny capillaries, the smallest blood vessels, and the nerve endings are also really, really tiny. And what that means is that they're more vulnerable to damage.

• 30:01Speaker 00

  The other thing that's going on, in addition to menopause, in most cases, unless someone has very early menopause, but we're looking at the consequences of aging. We're also looking at the consequences of other medical conditions like diabetes and cardiovascular disease. By age 50, 51, the average age of menopause, 50% of women have at least, at least one other medical problem, such as cardiovascular disease, diabetes, and of course, the older they get, the more likely they are to have multiple conditions. So all of these things are going to impact on Blood flow and on nerve health. And then we put on top of that, the fact that they no longer have estrogen on board to be that nice vasodilator that's going to increase blood flow.

• 30:45Speaker 00

  So there's a lot going on. It's not as simple as, oh, let's just give you some estrogen and everything's going to be fine because there's so many other factors. The nerve issues are are huge because there's a lot of diabetes in this country. Let's just start with that. And most people are familiar with neuropathy, meaning that they have numbness in their feet. Well, you can get a clitoral neuropathy. And this has been biopsy proven. We don't normally biopsy the clitoris, which I know sounds terrifying, but but in studies we have in diabetics that shows that we have nerve degeneration. So if you have diabetes and you are unable to have an orgasm, yes, part of that may be because of the loss of estrogen, but a lot of that may also be because of your diabetes

• 31:29Speaker 00

  and cardiovascular disease and all that. So so we see that going on. The other thing that happens post menopause is medications. The number one medication that women are getting in perineum post menopause are SSRIs. Yes. I mean, how often have you talked about that? And we're not talking about women who are given SSRIs for depression or anxiety, which may have been a lifelong thing. We are talking about women who are given SSRIs to treat menopause symptoms like hot flashes because their doctors are not comfortable prescribing estrogen. And those same doctors are not warning, oh, and by the way, you may have difficulty with not only libido, but the ability to have an orgasm. So we have that going on.

• 32:13Speaker 00

  So when you say what's going on with post menopausal orgasm, there's there's a lot. There's a menu. There's a lot of things that are there to sabotage the ability to have the kind of sex that women are looking to have. But I just I have to stop right now and just say before we get any further, we have solutions for all of this. Yeah, okay. I mean, women are sitting here thinking, I am so bummed out. Please, I'm like, I want my. Yeah, I'm like, is there hope? Is there hope? This sounds like. I just, I can't even stand this anymore. We're going to get to the solutions. I just have to throw that in so that people don't get, you know, really upset. But yeah, but so so there are a lot of reasons that almost 50% of women. At the menopause transition are having difficulty. And then, of course, the older they get, the more likely it is to happen.

• 32:52Dr. Mary Claire Haver?

  And we're not even talking about desire.

• 32:54Speaker 00

  Oh, no, no, we're just talking about this is orgasm.

• 32:56Dr. Mary Claire Haver?

  Straight up the ability to.

• 32:57Speaker 00

  This is straight up the ability to have an orgasm.

• 32:58Dr. Mary Claire Haver?

  I think a lot of women are sitting in their cars, listening right now, feeling very validated. Like, this is me.

• 33:03Speaker 00

  This is me, and I'm not alone.

• 33:05Dr. Mary Claire Haver?

  Yeah.

• 33:05Speaker 00

  And that there is a biologic reason why this is happening. The other thing that should make all these women feel better, this is mirroring exactly what's going on with the men.

• 33:16Dr. Mary Claire Haver?

  Their husbands.

• 33:16Speaker 00

  Because a penis is just a big clitoris, less sensitive, of course. And if you look at the rates of erectile dysfunction.

• 33:25Dr. Mary Claire Haver?

  They mirror.

• 33:26Speaker 00

  So, you know, and it's easy, the algorithm, you know it, you know, 50% of men at 50 have some difficulty maintaining an erection. By 60, it's 60%. By 70, it's 70%. So, the same guys who are having problems with an uncooperative penis are the ones who have women who are saying, my clitoris is dead. Nothing's happening. And just like we have solutions for the guys, we have solutions for the men.

• 33:48Dr. Mary Claire Haver?

  Are they the same?

• 33:49Speaker 00

  Sometimes.

• 33:50Dr. Mary Claire Haver?

  Sometimes.

• 33:51Speaker 00

  Sometimes. We don't give men estrogen. They have a little, by the way. I mean, you know that. People forget that. The women will say, well, if I use my vaginal estrogen and forget on his penis, is that a problem? And I'm like, no, he's got his own supply.

• 34:03Dr. Mary Claire Haver?

  I'm like, what, what women don't realize is that, once you go through menopause, your husband's estradiol level is higher than yours.

• 34:09Speaker 00

  In some cases, that is absolutely true. And testosterone, of course, is metabolized to estrogen. So, don't get too worried about getting a little estrogen on his penis, but that's off the topic.

• 34:18Dr. Mary Claire Haver?

  They think he'll grow breasts or something will happen.

• 34:20Speaker 00

  Not gonna happen, no.

• 34:21Dr. Mary Claire Haver?

  Not even close. Well, before we get into treatments, let's talk about the pelvic floor a little bit. Let's touch on pelvic floor.

• 34:26Speaker 00

  I'm so glad you brought that up, because the poor, forgotten pelvic floor.

• 34:29Dr. Mary Claire Haver?

  Oh, my gosh, the poor pelvic floor therapist out there on the internet, trying so hard to educate, I, what did I learn about the pelvic floor? How to sew it back together?

• 34:38Speaker 00

  Or ignore it altogether.

• 34:39Dr. Mary Claire Haver?

  Yeah.

• 34:39Speaker 00

  I mean, we just, we, we didn't even talk about the pelvic floor. The only problem with those pelvic floor physical therapists is we don't have enough of them.

• 34:46Dr. Mary Claire Haver?

  Yeah.

• 34:46Speaker 00

  Because it is so critically important. A lot of people are aware that these pelvic floor muscles, which of course are the group of muscles.

• 34:52Dr. Mary Claire Haver?

  So, what is the pelvic floor?

• 34:53Speaker 00

  The pelvic floor is a group of muscles that line the pelvis. But beyond that, these muscles surround the vagina, the rectum, the bladder. And a healthy pelvic floor is what keeps your urine in your bladder when it doesn't let it out until it's supposed to come out. Make sure that you do not have stool incontinence. And when it comes to sex, we need those muscles around the vagina to relax to say to the penis, "I'm ready, come on in," as opposed to tightening up saying, "Oh, my God, are you kidding? This is just gonna hurt, stay out." And the other thing that a pelvic floor is important for is orgasm. People don't think about that because think about what I said earlier in terms of what happens during an orgasm.

• 35:33Speaker 00

  The final step of an orgasm is those pelvic floor muscles contract and release. We always think about a strong pelvic floor. It's not just about being strong and contracting. You also need to let those muscles relax. It's a coordination of the pelvic floor muscles. And with orgasm, that's part of the pleasure, is feeling that contraction. But it's also the release. All that blood that's gotten congested there gets released and that leaves you with this feeling of satisfaction. So, okay, what happens to your pelvic floor post-menopause? Well, generally, it's not good. I'll start with that. You know, we know that there's an extremely high correlation of women who have urinary incontinence and problems with orgasm. And the reason is, is because these are both controlled by the pelvic floor.

• 36:18Dr. Mary Claire Haver?

  And let's go over what incontinence is.

• 36:20Speaker 00

  Incontinence is the involuntary loss of urine or stool. When we talk about taboo topics, people are somewhat comfortable talking about urinary incontinence.

• 36:29Dr. Mary Claire Haver?

  It's funny.

• 36:29Speaker 00

  It's funny, yeah. Ha ha. You know, diapers, you've normalized diapers in America. Don't get me started. We go, but was not doing us a favor when she went on and told the world she was wearing diapers because that made it seem like this was something everyone should do as opposed to actually working on your pelvic floor and getting pelvic floor physical therapy to eliminate the incontinence. But be that as it may, we know that the pelvic floor is critically important in the ability to have an orgasm. So what happens if you have a weak pelvic floor is you're not gonna get those contractions, you're not gonna get that satisfaction. So what happens to the pelvic floor? Well, there are a number of things. Number one is you can get pain in the pelvic floor. I talked about how important it was for the pelvic floor to be able to relax. Some people have what we call pelvic floor tension, meaning they get tight knots, they get contracted muscle.

• 37:12Speaker 00

  It's kind of like if you do 1,000 sit-ups, the next day, your belly is gonna be so sore. You can barely move. Well, think about happening to your pelvic floor all the time, that they are constantly, constantly having these tight, painful muscles. The other thing that happens, and I know you've talked about this in other episodes, is muscles in general. We have estrogen receptors in our muscle. Mm-hmm. And those estrogen receptors and testosterone receptors are very important in terms of muscle health. So we have that going on. We have a problem with women having obesity in this country, which is also going to impact on the pelvic floor. And we have a lot of other pelvic floor disruptors, if you will.

• 37:53Speaker 00

  So the pelvic floor health is critically important in terms of having an orgasm, which is why having access to a pelvic floor physical therapist, I call them my "vagicians," is so important because we can do what we're gonna do, and we can give all these recommendations, but at the end of the day, particularly if someone is having pain, it's the work of the pelvic floor therapist that is going to cut that pain pathway, which is absolutely critical in order to become aroused and have an orgasm.

• 38:31Dr. Mary Claire Haver?

  So you talked about pain and the pelvic floor. We talked a little bit about genital urinary syndrome of menopause. So like, walk me through how GSM can derail an orgasm.

• 38:42Speaker 00

  Genital urinary syndrome of menopause is actually a huge culprit when it comes to post-menopause problems with orgasm. Number one, if you don't have vaginal lubrication, if you have vaginal dryness, and if you have pain, you're not gonna have an orgasm. The anticipation of that alone is going to sabotage your ability to become aroused. The other piece of this is a phrase a lot of women have not heard, and that's clitoral atrophy. We talk about vaginal atrophy. What is vaginal atrophy? We don't like to use that word because it has such negative connotations. Who wants to have an atrophic vagina? You know, it's, it sounds awful. I mean, it sounds like it's, you know, aging and wilted. And, and the problem, though, is atrophy is an actual description

• 39:27Speaker 00

  of what's happening biologically, meaning that there's decreased blood flow, so that there's a thinning of the tissue. And as a result of this, those nerve endings rely on blood to be healthy. You get less responsive nerve endings. So what happens when there's clitoral atrophy? The clitoris actually shrinks? It becomes pale, there is decreased blood flow, which means it does not become aroused. And the nerve endings start to fail. They start to fail. So in fact, when you are treating genital urinary syndrome of menopause, either using a vaginal estrogen or DHEA or oral spimaphine, or whatever you choose to do, you also need to treat the clitoris to wake up those nerve endings,

• 40:12Speaker 00

  to say hello, we're here.

• 40:13Dr. Mary Claire Haver?

  And you mean apply the medication to the clitoris as well?

• 40:16Speaker 00

  Exactly. So let's say, and this comes up a lot, because you might have someone who chooses to use a vaginal estrogen in the form of an insert or a pill or the ring, S- string. And what are they gonna do? They're gonna get an additional tube of estrogen cream. And they're gonna put some on their finger and they're gonna apply it to their clitoris at least twice a week. Take your time rubbing it in, I'm just saying.

• 40:39Dr. Mary Claire Haver?

  Five minutes.

• 40:40Speaker 00

  At least five minutes, if not more. And what that's gonna do is that's going to directly treat your clitoral atrophy. Does every woman need to do this? No, if you're having orgasms, just fine, don't bother. Don't bother. But if you are having trouble, you need to look. Let's talk about looking for a minute, okay?

• 40:56Dr. Mary Claire Haver?

  Okay.

• 40:56Speaker 00

  Because guys have the obvious advantage that it takes absolutely no effort on their part to inspect their penis obsessively, which...

• 41:02Dr. Mary Claire Haver?

  They do.

• 41:02Speaker 00

  They do, right. Women, not so easy. It's hidden. Their mothers don't tell them where it is. And even if they look, they can't always see it. It's actually one of the side things that's happened as a result of pubic hairstyles.

• 41:13Dr. Mary Claire Haver?

  Well, I've practiced for long enough. I've seen the evolution of pubic hair styles.

• 41:19Speaker 00

  One of the things that has happened with women removing their pubic hairs, they are able to see their vulvas more. I actually have a YouTube video on how to get a hands-free, amazing view of your vulva and your clitoris. And it's important that it's hands-free because you wanna be able to pull back the hood.

• 41:38Dr. Mary Claire Haver?

  Uh huh.

• 41:38Speaker 00

  You wanna see what's under the hood and potentially apply either medication or estrogen or whatever you're doing. But women need to look. They need to look at their vulvas. They need to look at their clitoris. In the sexual medicine clinic that I started at Northwestern University, every single woman was given a mirror. And during the... The exam, we would talk about each part as we went through it. And women do not have that education. I cannot tell you how many women would tell us. And we're talking women in their 50s, 60s, 70s, who would tell us, "I've never seen my vulva. I've never seen my clitoris." I mean, how sad is that? Can you imagine if you said to a 60-year-old guy, "Can you imagine never having seen your penis?" They would look at you like, "What? What?" Yet, women have never seen it. And again, to circle back, when we talk about women who've never had an orgasm,

• 42:23Speaker 00

  they need a mirror and they need a map. And all women would benefit from that.

• 42:26Dr. Mary Claire Haver?

  And I think the younger you start, the better. So you know what your normal looks like.

• 42:30Speaker 00

  My three-year-old granddaughter knows that it's a vulva.

• 42:33Dr. Mary Claire Haver?

  Proper anatomical terms.

• 42:35Speaker 00

  Yes. We were in the bathroom the other day, and she said, "Grandma, I need to wipe my vulva." And this woman in the stall next to you woke up, and she looks at us like, "Whoa." But it's important. And, and yes, she has a book that, of course, my other daughter, the sex therapist, gave her that says, "I have a vulva and a clitoris," and it shows pictures. We're very progressive in my family.

• 42:55Dr. Mary Claire Haver?

  No, I think it's great.

• 42:56Speaker 00

  It's a discussion that needs to happen in a very matter-of-fact way. Because quite frankly, if that matter-of-fact discussion was happening in homes across America, we would not be having a lot of the issues that we're having later in life in terms of sexual problems.

• 43:08Dr. Mary Claire Haver?

  Let's move on to treatments. Yeah. So it depends on what the problem is. Does a woman need to go and see a doctor? And who does she go see? So she's self-identified, I'm struggling with orgasm, and I want one.

• 43:22Speaker 00

  Yeah, I think this is one of those situations. It's not a do-it-yourself project. Because this is so multifactorial. We've talked about a number of things that can sabotage someone's ability to have an orgasm. There are others, many other things that we've not touched on. So it takes someone to really do the deep dive into your medical history, to do an exam, to really figure out what's going on. I talk all the time about how doctors don't know much about menopause. They know a whole lot less about, of course, not only sexual function, but specifically orgasm. Which is why in my Come Again series, I have additional material specifically for healthcare professionals. I have videos on how to do an exam, how to do a neurologic exam in a woman who can't have an orgasm.

• 44:04Speaker 00

  How to take a proper history so that you can maybe uncover something that you weren't even thinking about, you know, because we're not trained in that. So it is a bit frustrating because women are not necessarily going to be able to find someone to help them, which is, quite frankly, why I did come again, because it is educating both women at a high level. It's 30 episodes. So I go through all the things that can cause problems. But the first 10 episodes is all the things that can happen. The rest of it is all about solutions. And also, for, of course, healthcare professionals to give them a roadmap to be able to help these patients. So, yes, in most cases, you need to see someone who knows what they're doing with this. But it's not necessarily going to be complicated to fix, because some people,

• 44:49Speaker 00

  it is as simple as they're having pain with intercourse, and someone needs to be able to give them the appropriate local vaginal estrogen product, connect them with a pelvic physical therapist, and that alone, that alone is going to solve the problem. We know, we know that if a woman is having severe hot flashes and insomnia, first of all, when she sees that pillow, all she wants to do is get a decent night's sleep. She's not thinking about sex. But we also know because of all those neurotransmitters in the brain that are sending the messages down to the pelvis and to the clitoris, you got to take care of all those other symptoms, if you're going to be able to have an orgasm. Most doctors are able to do that, we hope. We're getting there. We're getting there. We're educating them. So that's, that's, you know,

• 45:31Speaker 00

  that's more likely. And then we get to the whole SSR, I think.

• 45:35Dr. Mary Claire Haver?

  Well, let's cover it.

• 45:36Speaker 00

  Let's cover it.

• 45:37Dr. Mary Claire Haver?

  Women on SSRIs are quite common. So I read, I read the data. The latest I could find was pre-menopausal, it's about 10% of the female population is on an SSRI. We double that to 20% across the menopause transition. And then by the time we're 65, it goes up to 1 in 4.

• 45:57Speaker 00

  1 out of 4.

• 45:57Dr. Mary Claire Haver?

  25% of women are on an SSRI.

• 46:00Speaker 00

  That's correct.

• 46:00Dr. Mary Claire Haver?

  How is that going to affect her orgasm?

• 46:03Speaker 00

  Well, first of all, it doesn't affect everybody's orgasm. Let's be clear about that.

• 46:06Dr. Mary Claire Haver?

  And there's many classes.

• 46:07Speaker 00

  And, and, right, and there's different SSRIs. We know that it's a big culprit. So how do you know if that's what's causing the problem? Well, the first thing we look at is timing. If someone has been on an SSRI since they're 30, and then when they're in their 50s, they're no longer able to have an orgasm, the SSRI is not their problem. If it's going to happen, it happens from the get-go. Either someone is vulnerable to it, or they're not. Okay. On the other hand, if someone starts an SSRI, and then two, three weeks later, they realize that not only do they have no libido, but they can't have an orgasm, there's a very good chance that the SSRI is the culprit. If you're looking at a woman who's midlife or older, chances are it's not the only culprit. You know, there's a big difference between the 20-year-old or 25-year-old who's put an SSRI on there,

• 46:50Speaker 00

  and she's going, "Oh, my God, I can't have an orgasm anymore." That's really pretty straightforward. Right. That it's your SSRI, honey. We know. It's nothing else. But when you're 50 or 60 and you're put on an SSRI, and you're also having hot flashes, which is why you were put on the SSRI, and you also have genital urinary syndrome of menopause. Right. So you have clitoral atrophy. And at the same time, your arthritis is suddenly just so bad that you can't even get into bed and get into a comfortable position. And now your husband has an uncooperative penis. And it's the whole thing, right? So I don't want to simplify and say, "It's just your SSRI." But it is important to look at the timing, because very often, that's the thing that tips the pendulum so that they just can't have an orgasm. So the first question is, okay, what do I do? Do I take my SSRIs and throw them in the garbage can? No, you do not.

• 47:34Speaker 00

  This is not a do-it-yourself project. You need to talk to the person who is prescribing the SSRI. Let me start by saying, for a lot of women, this'll go away on its own. At least 30% of the time, give it some time. We're talking once, that your brain will figure it out, because it's the brain where this is all happening. It's the neurotransmitters that are triggering orgasm that are put on hiatus because of your SSRIs. So sometimes, the brain is an amazing organ. It has what we call brain plasticity, being it adapts. That's why brain fog goes away. That's why hot flashes eventually go away, because your brain figures it out. Same thing. If you're on an SSRI, sometimes your brain will figure it out, and your orgasm will come back. So part of it is just be a little patient. The other thing is, is that sometimes, it's dosage. So you can look at dosage. Sometimes, it's the SSRI.

• 48:18Speaker 00

  You might find that a different SSRI is going to be better in terms of sexual function, which is why you have to have this conversation with your prescriber. We also know that sometimes you can take a little SSRI holiday, again, under the direction of your prescriber. What does that mean? Meaning... That you take your SSRI Monday through Thursday, and then you take a little break on Friday and Saturday. And for a lot of women, that will help in terms of libido and orgasm. It's not going to help everybody. And it also depends on which SSRI you're on. I have an episode in Come Again about SSRIs, and I go through the ones that have a short half-life. So this might be a good strategy versus the one that has a long half-life, and you could take a vacation for weeks. And it's not gonna, it's not gonna help.

• 49:00Dr. Mary Claire Haver?

  Yeah, it sticks around your system longer.

• 49:01Speaker 00

  So that's one thing that may help, which is very interesting. It also speaks to the fact when you say, well, if you do go off your SSRI, how long is it going to take to get your orgasm back? And if the SSRI is the issue, it's going to be pretty, pretty quick. Once it's out of your system, you're going to be good to go. But this brings me to Viagra.

• 49:20Dr. Mary Claire Haver?

  Okay.

• 49:21Speaker 00

  You asked earlier, you said, are some of the treatments for orgasmic problems the same as for erectile dysfunction? And the answer is yes. It appears that sildenafil, which is the name, the chemical name for Viagra, has been useful in women who are having SSRI-induced problems with orgasm. And I want to start by saying that Viagra is not FDA-approved for women. So this is an off-label use, which doesn't mean it's illegal. It just means a use that's different than what the FDA intended it to be used for. Do we have a lot of studies? No, we do not. It's pathetic. We have very, very few studies. However, one of the things I learned.

• 49:59Dr. Mary Claire Haver?

  When we scrape together the evidence for women.

• 50:01Speaker 00

  Well, the other thing also is, is you know me, Mary Claire. You know, I am very data-driven, and I think it's really important to stick to the data. But I've also had decades of experience in this stuff. I ran a sexual medicine clinic. And these women would come in and they'd say, I started my SSRI, and it was like the lights went out. And I would give them Viagra, and they'd say, huzzah. So anecdotally, in my experience, and especially in young women, if that's the only thing going on, if someone has SSRI-induced anorgasmia, then very often oral sildenafil pill will kick it back into action. We, you know, again, had to be careful with the dosage, a little lower. We worry about cardiovascular risks in older women. So again, you don't want to just borrow your husband's Viagra. You want to talk to your doctor.

• 50:44Speaker 00

  Make sure, but we do know that it does seem to be very beneficial in some subsets of women. And SSRIs is on that list. So what about topical?

• 50:55Dr. Mary Claire Haver?

  I was gonna say, yeah.

• 50:56Speaker 00

  Yeah.

• 50:57Dr. Mary Claire Haver?

  I've seen it compounded.

• 50:58Speaker 00

  Correct. So compounded meaning, again, not FDA approved, but you get someone, a pharmacist, who will mix it together in a cream or an ointment. And the idea that you put sildenafil on your clitoris, is that gonna help? Let's look at the data. We're done looking at the data.

• 51:16Speaker 00

  There's no data. There's no data. We have anecdotal reports. Biologically, so when there's no data, what I like to look at is, okay, biologically, what does sildenafil do? Well, sildenafil is actually an antihypertensive for high blood pressure, meaning that it is a vasodilator, increases blood flow. So when you put sildenafil on the clitoris, it increases blood flow to the clitoris, which obviously is gonna help if you have clitoral atrophy. So does topical sildenafil work? Anecdotally, it does seem to work in a lot of women. And not just women with SSRI-induced anorgasmia, but women who just have clitoral atrophy. So is there going to be an FDA-approved topical sildenafil?

• 51:57Speaker 00

  Yes, there is one in phase three trials, which we expect it hopefully to be available sometime in 2026, maybe 27, you know how slowly these things move. But all of the clinical trials for this particular FDA-approved product were done in, wait for it?

• 52:15Dr. Mary Claire Haver?

  Pre-menopausal women.

• 52:19Speaker 00

  Pre-menopausal. And listen, I have talked to the people in the company, the company's called Dare, I don't work with them, but I've just talked to them, about, what? Are you kidding? Really? Really? Thirty-year-olds don't have problems having an orgasm once they find where their clitoris is and they know what to do with it. It's the 50, 60, 70-year-olds. But of course, they're looking for FDA approval. That's the shortest path to FDA approval. And you can always use it off-label, which is fine, except it's not gonna get covered by insurance. So that's the state of the art right now. But the point is, is sildenafil is interesting, and for some women, maybe the answer.

• 52:51Dr. Mary Claire Haver?

  Okay.

• 52:53Dr. Mary Claire Haver?

  As a reminder to our audience, you can follow Dr. Stryker on Instagram at DrStryke, on Substack at DrStryker.substack.com, and on her website at DrStryker.com. She is also the host of Dr. Stryker's Inside Information podcast, and she has released a 30-episode audio series on sexual function called Come Again that is available for purchase through her website. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at DrMaryClaire and get honest, accurate information on health, fitness, and navigating midlife at thepauselife.com. My new upcoming book, The New Perimenopause, is available for preorder on Amazon. If you're loving this podcast,

• 53:36Dr. Mary Claire Haver?

  be sure to click Follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review and be sure to share the show with the women you love. We would be so grateful. You can also find full episodes on YouTube at Dr. Mary Claire. UnPaused is presented by Odyssey in conjunction with Podpeople. I'm your host, Dr. Mary Claire Haver. The views and opinions expressed on UnPaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment.