#371 – Women's sexual health: desire, arousal, and orgasms, navigating perimenopause, and enhancing satisfaction | Sally Greenwald, M.D., M.P.H.
Timestamps are as accurate as they can be but may be slightly off. We encourage you to listen to the full context.
Podcast Summary
Dr. Sally Greenwald, an OB-GYN specializing in women's sexual health, explores how sexual health is a vital component of overall well-being and longevity. The episode covers the physiology of female arousal and orgasm, the significant "orgasm gap" between men and women (95% of men vs 30% of women achieving orgasm with partners), and evidence-based strategies for improving sexual satisfaction. (05:15)
• Key focus areas include desire vs. arousal, the role of hormones in sexual health, practical approaches to vaginal care, and how sexual function changes throughout life stages from perimenopause through menopause.
Speakers
Dr. Sally Greenwald
Dr. Sally Greenwald is an OB-GYN who specializes in women's sexual health from a hormonal and physiologic perspective. Her clinical focus spans desire, arousal, pelvic floor function, contraception, and menopause care with a commitment to evidence-based strategies for improving sexual well-being. She brings a unique approach that combines traditional gynecology with specialized expertise in sexual medicine, helping women understand and optimize their sexual health throughout all life stages.
Dr. Peter Attia
Dr. Peter Attia is a physician focused on the science of longevity, with expertise in nutritional interventions, exercise physiology, sleep optimization, and preventive medicine. He hosts The Drive podcast and is known for translating complex medical research into actionable insights for health optimization and extending both lifespan and healthspan.
Key Takeaways
Understanding Responsive vs. Spontaneous Desire
Only 15% of women experience spontaneous desire (wanting sex in anticipation), while most women have responsive desire - becoming aroused in response to stimulation and the right environment. (19:00) This fundamental difference means women benefit from "showing up at the party" - using lubricant 30 minutes beforehand, engaging in mindfulness, reading erotic literature, or using vibrators to cultivate arousal. The key insight is that responsive desire is completely normal and doesn't reflect lack of interest in one's partner.
The Importance of Foreplay for Anatomical Changes
Adequate foreplay (ideally over 21 minutes) allows the vagina to lengthen, widen, and change angle, which is crucial for comfortable intercourse. (15:14) Without sufficient arousal time, 30% of women experience pain with intercourse due to inadequate anatomical preparation. This anatomical education helps explain why certain positions may be uncomfortable and how proper preparation can expand a couple's repertoire while reducing pain.
The Clitoral Complex and External Stimulation
The clitoris has over 8,000 nerve endings and includes both external and internal components (the "wishbone" structures extending down each side). (31:15) Less than 10% of women can achieve orgasm from penetrative intercourse alone - the other 90% require external clitoral stimulation. Understanding this anatomy normalizes the need for external stimulation and helps both partners focus on what actually works physiologically rather than what's portrayed in media.
Vaginal Care as Preventive Medicine
Dr. Greenwald advocates treating vaginal health like facial skincare: use lubricant as "sunscreen" (silicone-based with osmolality around 300), vaginal moisturizers as daily "moisturizer" (like Reverie or Replenz), and consider topical hormones for long-term tissue health. (1:19:15) This preventive approach helps avoid pain cycles and maintains sexual function throughout aging, with evidence showing it reduces micro-abrasions and supports tissue integrity.
Hormone Optimization Requires Individual Assessment
The key question for perimenopausal women is "Do you like ovulating or not?" which determines whether to use ovulation-suppressing contraceptives or menopause hormone therapy. (50:11) About 70-80% prefer not to ovulate due to worsening PMS and perimenopausal symptoms. For sexual desire specifically, testosterone therapy (cream preferred, targeting levels above 20 ng/dL) shows the strongest evidence, though it's officially only recommended for postmenopausal women.
Statistics & Facts
- 95% of men report having an orgasm almost every time during partnered sex, while only 30% of women achieve the same consistency. For one-night stands, this drops to 12% for women while men maintain 90%. (16:57)
- About 20% of couples (ages 30-60) have sex twice a week or more, 10% are essentially sexless (no sex in the past year), and 70% fall somewhere in between. The key risk factor for divorce is sexual desire discordance, not frequency. (19:08)
- Sexual activity burns approximately 60-70 calories for women (6-7 metabolic units), roughly equivalent to walking slowly on a treadmill, though participants reported much greater enjoyment from sex than treadmill walking. (08:27)
