unPAUSED with Dr. Mary Claire Haver - Where Did My Orgasm Go? Menopause, SSRIs, and the Science of Pleasure with Dr. Lauren Streicher

Episode Date: December 16, 2025

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 Dr. Streicher (Instagram) Dr. Streicher: Menopause: The Inside Info (Substack) Dr. Streicher’s Inside Information: Menopause, Midlife, and More (Apple Podcasts) COME AGAIN Lauren Streicher - Faculty Profile (Northwestern Medicine) Dr. Streicher (YouTube) Subscribe to COME AGAIN: Sexuality and Orgasm 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 DrStreicher’s Substack https://drstreicher.substack.com/ 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,” by Dr. Lauren Streicher “Hot Flash Hell-A Gynecologist's Guide to Turning Down the Heat (Dr. Streicher's Inside Information),” by Dr. Lauren Streicher “The Essential Guide to Hysterectomy: Advice from a Gynecologist on Your Choices Before, During, and After Surgery,” by Dr. Lauren Streicher “Sex Rx: Hormones, Health, and Your Best Sex Ever,” by Dr. Lauren Streicher “She Comes First: The Thinking Man's Guide to Pleasuring a Woman,” by Dr. Ian Kerner “The New Perimenopause,” by Dr. Mary Claire Haver ⁠"The New Menopause"⁠ by Dr. Mary Claire Haver To learn more about listener data and our privacy practices visit: https://www.audacyinc.com/privacy-policy Learn more about your ad choices. Visit https://podcastchoices.com/adchoices

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. Because that is what their partners are expecting. 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. 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 Stryker, professor of obstetrics and gynecology at Northwestern University, Feinberg School of Medicine. She's the host of Dr. Stryker'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. Stryker is also the author of several best-selling books on menopause and sexual health. To say she's an icon in the field is an understatement. Dr. Stryker 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 and 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 postmenopause orgasm, sexual function 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 in 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. Thank you so much for being here today. I am. I am so thrilled to be here with you talking about one of my favorite taboo topics, orgasm. So where did you grow up? Tell me your background. Give me your origin story. Our listeners love to hear this about it. 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 in Chicago in my entire life. And in fact, I went to medical school at the University of Illinois and then did my residency in Chicago. Why OBGYN? Well, I actually started out an internal. medicine. My father was an internist. I kind of fell into medical school. I wasn't planning on, you know, some

people was 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 comment about, well, I don't think you could cut it in medical school. And that's all it took for me to say, right, I'm going to medical school. 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. 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 OBGYN 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 love the people I was working with. So that's how I ended up in OBGYN. Did you do any postgraduate training like fellowship or there was no fellowship, right?

There is no fellowship. No, I started it. just as a generalist and probably like you, you know, delivering babies, you know, 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 uter, and specifically their ovaries, puts them into a surgical menopause. And I felt ill-equipped to help these women navigate menopause.

So that's what brought me to the whole meno world. Yeah. Now, the sexual medicine world, that came later. That came later. And really, it was because I was writing. Along the way, I was always writing. In fact, my first book, The Essential Guide to Historic Me, I have two editions that 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 do. make by writing high-level good information for women so that they can make good decisions. And so after that, 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 like this to be for all ages, not just post-menopause. So sex r-X morphed into a book about sexual medicine throughout the lifespan. starting in the 20s until your 90s. And because of that, and you know this,

when you write something is when you're forced to really learn about it. 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 The science, the biology, what's going on in the brain, what's going on in the clitoris, all this stuff that we never had any exposure to. And so that was definitely part of my learning path. And then I expanded out to a lot of other areas. Right.

And then, of course, we have Kinsey. And I'm the board of the Kinsey Institute. I'm a senior researcher at Kinsey, which has been wonderful because it exposes me to a whole other approach. Tell our listeners what the Kinsey Institute is because most of them, I know what it is, but most of them may not know. 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. For sexual medicine. 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 ideas

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 alive today. And I love being involved with them because that really is where a lot of cutting edge research happens. 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 clinic. I learned how to define where the 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 Kenzie. We had zero clinical application of any of that knowledge. There was no discussion 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. 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. Yeah. If they're not a sexual medicine doctor, it's almost zero. 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. I'm so sorry. I'm so sorry. And then changed the subject because they don't know what to tell people. So, so let's back up. Let's educate our audience. What is an orgasm? 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. 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 vulva 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. But it's really kind of a sense of

incredible release. That's the Cliff Note version. 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. When we watch a lot of Hollywood movies, when we, you know, a lot of pornography that's floating around out there,

it's very different than what you describe. 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. Because that is, I think, what their partners are expecting. 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. There is penis and vagina sex. Can that stimulate an orgasm? 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 It's the most common thing. Correct. So we're talking about 10%. Now, so let's talk about what a

vaginal orgasm actually is. Okay. A vaginal orgasm is when you have an orgasm without clitor 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 a vibrator or a dildo or a 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. It's just a thing. 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 on 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. Serbical. Why does that work? It works because you are stimulating the vagus nerve. The 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. Yes, there are people that do that. I've seen the MRI. 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 collateral 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.

You know, 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. Correct. And we've learned so much. And some of that data comes from that of showing the stimulation of the nerves when you touch the cervix. 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. Now, popular culture would make you think everyone has a G spot.

Popular culture would be wrong. Because I've looked for it. Oh, no, I know. You could go on a search, you know, with the headlights on and all the different ones 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 very, very specifically an 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. 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. Totally, totally. So keep in mind that the clitoris, when you're looking at the tip of the iceberg for what you can actually see when you look with the mirror, and that it actually dives under 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 simulated, 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. Exactly. We call this pairing, meaning that someone has a fingers or a vibrator or something else down there so that 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 percent of just plain if two people are having intercourse allowing that clitoral stimulation. 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. 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. Oh my gosh. As in great niece of, you know, Napoleon.

Napoleon. So she was actually a student of Sigmid Freud. And she was personally very frustrated that she was not able to have an orgasm during a. 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 pulls 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. 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 go do that. That's fine. Come back. I did not know this. This is so fascinating. So you say, okay, why is this? Well, it's because it's anatomical. 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 yourselves, 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. Oh my gosh. It never worked. But the point is, is, it's a she shoes on to something. And in fact, all 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 you're clitoris, and now we use the urethra because it's easier to measure urethra to clitor, 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 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 his pelvic bone, his pubic bone, right over her clitoris. So, again, those who are motivated, it can be done. It's 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 cells, especially if she's on top, that she's able to kind of manipulate to get that stimulation. Correct. Exactly. But then we also look at 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 simulate it during intercourse.

Hi, my name is Lloyd Lockridge, and I'm the host of a new podcast from Odyssey called Family Lore. In this podcast, I'm going to have people on to tell unusual and sometimes far-fetched stories about their families. I've heard my whole life that she invented the margarita. And then we're going to investigate those stories and find out how much of it is true. He gets a patent one month before the Wright brothers. Oh my God. Please follow and listen to Family Lore, an Odyssey podcast, available now on Apple Podcasts, Spotify, or wherever you get your shows. So I've had a couple of patients through the years.

It's been a while, but back when a lot of patients were getting gastric bypass surgery and they were having rapid weight loss, and then they'd have all this sexx skin, and they were having abdominal plasies 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 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 the second

surgery, which changed. And I was like wondering, did you ever hear or see anything similar? Yes. And now we're seeing with the GLP ones. So I think we have a study that we need to do, right? Yeah. This is, because this is important. This is important because women already don't have an education as far as 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 going to change. That's one of my episodes and come again is Sex After Historectomy.

And there's a lot of information that I can promise you your surgeon never told you. Well, because they didn't know. They didn't know. They didn't know. So what is an orgasmia? Anorgasmia is the Latin of no orgasm. Does not happen at all. And how common is it?

Well, we divided into two groups. There's what we call primary an orgasm, meaning people who've never had an orgasm. Some people call that pre-orgasmic. I like that. And then we have acquired an orgasmia. So when we look at how common it is, when we look at an orgasmia, it's not common. And when we're usually finding out about it is in young women, young women who have nothing biologically or homonally 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 the 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 well. And 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 an orgasmia 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

an orgasmia in women who were on an SSRI from an early age and then just never had an Acquired an orgasmia is someone who used to have orgasms just fine, and then something happened, and all their tried and true methods were no longer working. And that's my area of interest in research, because that's that we are primarily seeing in parium postmenopause 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 flasker to, she doesn't tell you that you're also going to lose your ability to have an orgasm.

And they are just devastated that suddenly they are no longer able to have an orgasm. Now, keep in mind, there is a spectrum. When you say an orgasm, we also have hypoorgasmia, which means someone who has an orgasm, but it 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.

I'll tell you a story. I am 57. I've been postmenopausal for nine years now and started struggling with the time it was taking, like, frustrating. You know, like, why is this taking so long? So I casually mention it to Corinna, 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. I'm not.

And she says, Mary Claire, what? And I said, 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. It was magical. Like, I just wasn't thinking. Like, and I thought it was medication.

It was stress. It was whatever else. Of course. You blamed it on yourself and said it's stress. So it was at me who's metapause 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... Well, you are not alone. Girlfriend. You are not alone. I love her. You 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. Go north. I've learned. I tell all my patients, you know, true north, down both labia and inside. 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. Walk me through the physiology of what happens post menopause and why our orgasms could change. To do that, I'm going to start with talking about just what needs to happen to have an orgasm.

Perfect. 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. It's on the brain. 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 intense. hacked 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.

A penis. Estrogen. Oh. No, penis is obviously not on the list. It's like there'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 postmenopause women of America who have no estrogen. Yeah. 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 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 change with that. All right, so let's talk about what happens with all of those things postmetapause. Okay. So starting with arousal. Well, this gets tricky. So arousal meaning the physiological with the physical things that are happening in the pelvis.

And arousal is dependent on good blood flow. Okay. 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 pain during activity. So that's one reason that arousal is just not happening for a lot of women postmenopause.

Because it hurts. 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. 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 or 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. 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 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 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 and cardiovascular disease and all that. So we see that going on. The other thing that happens postmenopause is medications. The number one medication that women are getting, Imperium postmenopause, 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 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. So when you say, what's going on with postmenopause orgasm, there's a lot. There's a many. 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. I mean, women are sitting here. I am so bummed out. Please. I'm like, I'm like, is there a hope? Is there a hope? 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, 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. And we're not even talking about desire. Oh, no, no. This is just talking about this is orgasm. This is straight up the ability to have an orgasm. I think a lot of women are sitting in their cars listening right now feeling very validated. Like, this is me. This is me.

And I'm not alone. Yeah. 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. Their husbands. Because a penis is just a big clitoris, less sensitive, of course. And if you look at the rates of erectile dysfunction, they mirror it.

So, you know, and it's easy. The algorithm, you know, 50% of men at 50 have some difficulty maintaining an erection. By 60%, it's 60%. By 70% is 70%. So the same guys that 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 women.

Are they the same? Sometimes. Sometimes. Sometimes. Sometimes. We don't get men estrogen. Although, they have a little, by the way. Yeah.

You know that. People forget that. The women will say, well, if I use my vaginal estrogen and if it gets on his penis, is that a problem? I'm like, no, he's got his own supply. I'm like, what women don't realize is that once you go through menopause, your husband's estrogen level is higher than yours. In some cases, that is absolutely true. And testosterone, of course, is metabolized to estrogen.

And so don't get too worried about getting a little estrogen's penis, but that's off the topic. They think he'll grow breast or something will happen. Not going to happen. I'm not even close. Well, before we get into treatments, let's talk about the pelvic floor. Yeah. Oh, I'm so glad you brought that up because the poor forgotten pelvic floor. Oh, my gosh.

The poor pelvic floor therapist out there on the internet trying so hard to educate, what did I learn about the pelvic floor, how to sew it back together? Or ignore it altogether. Yeah. I mean, 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. Yeah. 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. So what is the pelvic floor? 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 going to 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. 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 postmenopause? 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. And let's go over what incontinence is. Incontinence is the involuntary loss of urine or stool. When we talk about taboo topics, people are somewhat comfortable talking about urinary incontinence. It's funny. It's funny. Yeah, ha-ha. You know, diapers.

You've normalized diapers in America. Don't get me start with the goal, but it was not doing us a favor. When she went on and told the world she was wearing diapers because that made it seem like. 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 going to get those contractions. You're not going to 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. It's kind of like if you do a thousand sit-ups the next day, your belly is going to 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. 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. 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 vodicians, is so important because we can do what we're going to 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. So you talked about pain and the pelvic floor. We talked a little bit about general urinary syndrome of menopause. So like walk me through how GSM can derail an orgasm. Genital urinary syndrome of menopause is actually a huge culprit when it comes to postmenopause 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 going to have an orgasm. The anticipation of

that alone is going to sabotage your ability to become aroused. The other piece of this, 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 vaginas? You know, it sounds awful. I mean, it sounds like it's, you know, aging and wilted. And the problem, though, is astrophy is an actual description of what's happening biologically, meaning that there's decreased blood flow, so that there's thinning of the tissue. And as a result of this, those nerve endings, rely on blood to be healthy, if you get less responsive nerve endings. So what happens when there's

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 DHA or oral themafina, whatever you choose to do, you also need to treat the clitoris to wake up those nerve endings to say, hello, we're here. And you mean to apply the medication to the clitoris as well. 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 estring. And what are they going to do? They're going to get an additional tube of estrogen cream. And they're going to put some on their finger,

and they're going to apply to their clitoris, at least twice a week. Take your time rubbing it in, I'm just saying. Five minutes. At least five minutes, if not more. And what that's going to do is that's going to directly treat your clitorial atrophy. Does every woman need to know 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? Okay. Because guys have the obvious advantage that it takes absolutely no effort on their park to inspect their penis obsessively, which they do. 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 hair styles. Well, I've practiced for long enough. I've seen the evolution of pubic hair styles.

One of the things that has happened with women removing their pubic hair is 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 want to be able to pull back the hood, want to 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 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. We're talking women in their 50s, 60, 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, you know, 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, they need a mirror and they need a map. And all women would benefit from that.

And I think the younger you start, the better so you know what your normal looks like. My three-year-old granddaughter knows that it's a vulva. Proper anatomical terms. 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, you woke up and he looks at us like, whoa. But it's important. And yes, she has a book that, of course, my other daughter, the sex therapist, gave her that says, you know, I have a vulva and a clitoris and it shows pictures.

We're very progressive in my family. No, I think it's great. 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. Let's move on to treatments. Yes. 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. 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 materials specifically for health care professionals. I have videos on how to do an exam, how to do a neurologic exam, and a woman who can't have an orgasm,

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, you know, I go through all the things. that can cause problems. About the first 10 episodes, there's all the things that can happen and the rest of it is all about solutions. And also for, of course, health care professionals

to give them a road map 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, 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 the pelvic floor physical therapists. 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 educating them. So that's, you know, that's more likely. And then we get to the whole SSRI, I think. Well, let's cover it.

Let's cover it. Women on SSRIs are quite common. So I read the data. The latest I could find was premenopausal. 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 one and four. One out of four.

25% of women are on an SSRI. That's correct. How is that going to affect her orgasm? Well, first of all, it doesn't affect everybody's orgasm. Let's be clear about that. And there's many classes. 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 in 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 SSR on there. She's going, oh, my God, I can't. to 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 half-fleshers, which is why you were put on the SSRI, and you also have genital urinary syndrome of menopause.

So you have clitorial 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.

This is not a do-it-yourself project. You need to talk to the person who is prescribing the SSR-Rite. Let me start by saying for a lot of women, this will go way on its own. At least 30 percent 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 is the neurotransmitters that are triggering orgas. that are put on hiatus because of your SSRI. So sometimes the brain is an amazing organ. He has what we call brain plasticity, meaning 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 that sometimes it's dosage, so you can look at dosage. Sometimes it's the SSRI. 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. So I can help everybody. And it also depends on which SSRI you're on. I have an episode and 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 going to help. Yeah, it sticks around your system longer. 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 quick. Once it's out of your system,

you're going to be good to go. But this brings me to Viagra. 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 slynephil, 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 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...

When we scrape together the evidence for women. 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 say, I started my SSRI, and it was like the lights went out, and I would give them Viagra, and they'd say, has a 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 slytrophil pill will kick it back into action we you know again have to be careful with the dosage a little lower we worry about cardiovascular risks and older women so again you don't want to just borrow your husband's viagra

you want to talk to a doctor and 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? I was going to say, yeah. Yeah. I've seen it compounded. Correct.

So compounded meaning, again, not FDA-approved, but you get someone to pharmacists who will mix it together in a cream or anointment, and the idea that you put sylidophil on your quiteris, is that going to help? Let's look at the data. We're done looking at the data. There's no data. There's no data. reports. Biologically, so when there's no data, what I like to look at is, okay, biologically,

what does seldenafil do? Well, slyphil is actually an anti-hypertensive 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 going to help if you have clitoral atrophy. So does topical slyylenophil work? Adidotally, it does seem to work in a lot of women, and not just women with SSRI-induced an an orgasmia, but women who just have clitoral atrophy. So is there going to be an FDA-approved topical slytylenophil? Yes. There is one in phase three trials, which we expect it, hopefully, to be available sometime in 20, 26, 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. Pre-menopause women. And listen, I have talked to the people in the company. The company is called Dare. I don't work with them, but I've just talked to them about what? Are you kidding? Really? Really?

30-year-olds don't have problems having an orgasm once they find where they're 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 going to get covered by insurance. So that's the state of the art right now.

But the point is, is seldenafil. is interesting, and for some women, maybe the answer. Okay. As a reminder to our audience, you can follow Dr. Stryker on Instagram at Dr. Stryke, on Substack at Dr.Striker.com, and on her website at Dr. Striker.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. anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire and get honest, accurate information on health, fitness, and navigating midlife at thepawslife.com. My new upcoming book, The New Peri Menopause, is available for pre-order on Amazon. If you're loving this podcast, 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 pod people.

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.