#371 ‒ Women’s sexual health: understanding desire, arousal, and orgasms, navigating perimenopause with contraceptives and hormone therapy, enhancing sexual comfort and satisfaction, and more | Sally Greenwald, M.D., M.P.H.

How sexual health influences physical health, emotional well-being, and relationships [A: 3:15, V: 0:11]

• This is a topic that on the surface might seem somewhat directed towards 50% of the population, but it’s safe to say it’s probably going to be directed towards a 100% of the population

Sally is an OB-GYN, but her focus is not just on the standard OB-GYN things, but really around women’s sexual health 

Is that a fair assessment? 

• From a hormonal and physiologic perspective, yes
• Peter was introduced to Sally through a mutual friend/patient who had listened to the Rachel Rubin podcast, and was super impressed by it and said, “You have got to speak with Sally.”

Why would a podcast that focuses on health, longevity, all of these things that pertain to living longer and better? 

Why would sex be an important part of that discussion? 

• Sally is having a hard time understanding how sex couldn’t be a part of that conversation
• First of all, this is a performance driven podcast, and so for the 50% of listeners who are male, if you want to improve your performance, Sally is going to give you facts and anatomical descriptions and describe some pathophysiology so that you can improve your performance
• Clearly sexual health is health, and when you look at your longevity levers and you think about your centenarian decathlon and what you want to do when you’re a hundred, for many people, this is on the list
  • Sally wants to talk about how to structure your life and get you ready to do that
• She also thinks that there’s probably a small group of listeners similar to herself who always thought that The Drive was supposed to be about sex drive and that you just had a branding era when you named it the drive
  • For those people as well, we’re finally going to talk about the drive that you actually care about, which is sex drive 

Peter wants to talk a little bit about the actual health component of this 

• If you look at this through the lens of evolution, everybody clearly understands why sex is important and it’s the single most important thing in the propagation of our species
• Peter doesn’t just mean emotional and mental health where he thinks we could easily make that connection

Is there any evidence whatsoever that a healthy sex life plays a direct role in health as it pertains to disease? 

Sally begins with 2 caveats

• 1 – This is an understudied, under-investigated area of our health
  • Many of the studies that she will reference are not going to be robust in volume
• 2 – This is an incredibly heteronormative conversation
  • For that reason, this is a data-driven podcast and Sally doesn’t have a lot of data on non-heteronormative
  • Meaning [she will focus on] men who identify as men, having sex with women who identify as women
  • So that should alarm you as well that we don’t have that data
  • But that’s the space in which we have a data-rich zone, and that’s where we have to stay

⇒ The discrepancy when you look at sexual health is greatest among those 2 participants [men and women] 

• When we look at sexual health and we try to make the argument that sexual health is a part of health, we can use Peter’s 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
• Post-orgasm, you have a great activation of the parasympathetic nervous system
  • You release neurotransmitters, dopamine, oxytocin ‒ these are relaxing neurotransmitters

When we study it either via diary or via 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) sleep subjectively and objectively improve with intercourse 

• 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 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

There is limited data on cardiovascular health 

• We know that sex can mimic a lot of the pathophysiology that we experienced during exercise
  • There’s been arguments over the decades about is it low intensity, is it moderate intensity? (it depends on the couple)
  • Studies have tried to measure the MET (or the metabolic equivalents) or essentially the energy output: for women, on average it’s around 6-7 metabolic units for every sexual encounter
  • It’s about 60-70 calories used during sexual activity
• There’s a great study that compared this to walking slowly on a treadmill for the same amount of time
  • 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, and that’s something to consider
• We know sex is tapping into the body’s natural pharmacology, and that’s really interesting to think about from a relationship perspective
  • Thinking about neurotransmitters and positive impact on mood and relationships

Sally adds, “What I don’t want to say, what I don’t believe is that everyone has to have lots of sex and that there’s a number that we’re trying to target.”

• Is there a number needed to treat [NNT]? 
• Is there a dose that we’re trying to go for? 
• No, there’s no studies on that
• Realize that every person, every couple is different

When you look at couples, Sally likes to look at who is having sex and by what frequency 

• About 20% of couples ages 30-60, 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
• About 70% of couples are having sex between those, meaning once a month, twice a month, 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: where one partner wants more and one partner wants less
  • Identifying that as the risk factor, Sally hopes it gives people affirmation or interest in the fact that if you want to work on it, she will help you, but not everyone has to

This is not a podcast about everyone needs to go work on their sex drive, but if you do, she’ll go through the normal path of physiology and some additional tips and tricks to help you have a healthier sex life 

Peter’s takeaways  

• 1 – The discordance of desire is a much bigger risk factor than anywhere you lie on the distribution of [sex frequency]
  • 10% of people are basically asexual, 20% of couples are at twice a week or greater, and basically 2/3 of couples are somewhere in between
• 2 – Peter can’t resist coming back to the Centenarian Decathlon, and he’s glad Sally brought it up because it is one of the items on our list on the framework that 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, and about ⅔ 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 tempting
• To go back to the point about METs, if 7 METs is what is required energetically to have sex, we can convert that into VO₂, and that translates to about a VO₂ of 25 mL/kg/min
  • 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 mL/kg/min 
  • Why? Because it would be pretty tough to have sex if you were doing it right at your maximum VO₂ ‒ that would be like asking you to do the fastest 800 meter run you’ve ever done and bring that level of exertion to sex
  • You got to be a little bit below your limit
  • While most adults can easily muster a VO₂ max of 30 mL/kg/min, if you want to be able to achieve that in your 80s or 90s, when your 50, you need to be probably north of 45 or 50

“If I could just make one more shameless plug for having a high VO₂ max, it’s going to allow you to be sexually active in the last decade of your life.”‒ Peter Attia

Understanding the physiology of the female orgasm, sexual comfort and satisfaction, and the disparity between men and women [A: 12:45, V: 10:21]

• 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 exemplary use of medication and he can still have an orgasm, but you’re not actually witnessing an ejaculation

With women, how is an orgasm actually defined?  

Is it a biochemical response in the brain? Is it a muscular contraction in the body? 

• We are going to talk about “normal” things, and there are a lot of pathophysiology and deviations from what’s normal

What’s normal in most women is a rhythmic contraction of the pelvic floor muscles 

There’s 4 stages to an orgasm

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