#259 - Women's sexual health: Why it matters, what can go wrong, and how to fix it | Sharon Parish, M.D.

Episode Summary

Executive Summary: Peter Atiyah and Dr. Sharon Parrish explore women’s sexual health across the lifespan, emphasizing that desire, arousal, orgasm, and pain are distinct and often treatable. They cover childbirth, menopause, metabolic health, antidepressants, contraception, testosterone, DHEA, and FDA-approved options for low desire, while arguing that sexual dysfunction is a real quality-of-life issue deserving proactive care and better education.

Main Topics: Framework for women’s sexual health (Priority: 5/5): Parrish explains sexual function through a biopsychosocial lens: brain, hormones, genital anatomy, vascular health, psychology, relationships, and culture all interact. Desire vs arousal vs orgasm (Priority: 5/5): A major theme is separating low desire from arousal problems and orgasmic difficulty, because they are not the same clinically and may require different treatments. Menopause, postpartum, and pelvic floor changes (Priority: 5/5): The discussion covers hormonal shifts in menopause, breastfeeding-related hypoestrogenism, and how childbirth and pelvic floor anatomy can affect comfort and sexual function. Metabolic and cardiovascular health (Priority: 4/5): The episode explores whether women’s sexual dysfunction may mirror systemic vascular/metabolic disease, similar to erectile dysfunction in men, though evidence is still emerging. Hormonal and medication treatments (Priority: 5/5): They review vaginal estrogen, DHEA, systemic hormone therapy, testosterone, and the impact of SSRIs/SNRIs, birth control, and other drugs on sexual function. FDA-approved treatments for low desire (Priority: 4/5): Parrish details flibanserin (Addyi) and bremelanotide (Vyleesi) as the two approved drugs for premenopausal hypoactive sexual desire disorder. Education, stigma, and access to care (Priority: 4/5): The conversation closes on the need for better sexual-health education, less ageism, and more referral pathways to sexual medicine, menopause care, pelvic floor PT, and sex therapy.

Key Arguments: Women’s sexual dysfunction is common, distressing, and often under-recognized; it should be treated as a legitimate quality-of-life issue rather than an afterthought. Desire and arousal should be separated clinically because women may want sex without arousal problems, or have arousal/orgasm issues without low desire; lumping them together obscures diagnosis and treatment. Menopause and breastfeeding can create a low-estrogen state that causes dryness, pain, and reduced sexual function, but these symptoms are highly treatable. Childbirth usually does not permanently damage sexual function, and vaginal delivery is generally not worse than C-section for sexual health; postpartum issues are often transient unless there is trauma. Metabolic syndrome, diabetes, obesity, and dyslipidemia likely matter for women’s sexual health too, but the evidence is less mature than in men. Antidepressants, especially SSRIs/SNRIs and other psychotropics, can impair desire, arousal, and orgasm; treating depression well often improves sexual function, but medication choice matters. Combined hormonal contraception can reduce free testosterone via increased SHBG and may contribute to low desire or vestibular pain in a subset of women. Testosterone is important in women and may be underappreciated; physiologic replacement can improve low desire in selected postmenopausal or late-reproductive-age women, but dosing and regulation are problematic in the U.S. Vaginal estrogen, vaginal DHEA, lubricants, moisturizers, and vibratory stimulation are practical, effective tools for genitourinary syndrome of menopause and dyspareunia. Sex therapy, mindfulness, bibliotherapy, and communication coaching can be essential when the issue is learning, anxiety, trauma, or relationship dynamics rather than biology alone.

Data Points: ISSWSH annual meeting attendance: 600 attendees - Parrish uses this to illustrate how small the women’s sexual medicine field is. Breast cancer absolute risk increase in WHI: 0.1% - Atiyah cites the Women’s Health Initiative as showing only a very small absolute increase with the studied hormone regimen. Hot flash reduction with systemic estrogen/progestogen: 75% to 80% reduction - Parrish says combined hormone therapy is the most effective treatment for disruptive vasomotor symptoms. Duration of menopausal symptoms: 3 to 5 years on average; up to 5 to 7 years - She notes vasomotor and related menopausal symptoms often persist for years around the transition. Breast cancer incidence in WHI estrogen-only arm: No increase; near-significant reduction (p≈0.2) - Parrish says reanalysis suggests the negative signal was driven by MPA rather than estrogen alone. Women in testosterone trials: ~8,500 women across 46 studies - She cites a large meta-analysis supporting efficacy/safety of testosterone for HSDD in selected women. Testosterone patch dose studied: 300 micrograms - The Intrinsa patch was described as approximating physiologic female testosterone levels. Hirsutism in testosterone patch trials: ~18% - Reported as mild hair growth, not virilization, in short-term studies. Combined hormonal contraception and sexual pain: ~10% of users - Parrish says a subset of women develop vestibulodynia/dryness/pain on systemic combined contraception. FSH threshold for postmenopausal-like state during breastfeeding: FSH >35 - She says fully breastfeeding, anovulatory women can look biochemically postmenopausal. Estradiol during breastfeeding: As low as 20–30 - Used to illustrate that lactation can create a low-estrogen state similar to menopause. Treatment-emergent sexual dysfunction with SSRIs: ~35% to 40% - Parrish gives this as a rough estimate for SSRI-associated sexual side effects. Flibanserin dose: 100 mg nightly - Addyi is taken at bedtime for premenopausal HSDD. Bremelanotide dose: 1.57 mg subcutaneous (0.3 mL) - Vyleesi is an on-demand self-injection used before anticipated sexual activity. Bremelanotide nausea rate: ~45% initially, falling to ~8% - She notes nausea is common at first but often diminishes with repeated use. Bremelanotide blood pressure effect: ~8 to 10 mmHg increase - This is why uncontrolled hypertension and cardiovascular disease are contraindications. Oral DHEA evidence: Not convincingly positive - Parrish says oral DHEA has not shown strong efficacy for HSDD. Vaginal DHEA indication: Dyspareunia/GSM - Intrarosa is described as effective for vulvovaginal atrophy with minimal systemic absorption. Population study size: 31,000 women - She references the PRESIDE study as a large survey of distressing sexual problems. Orgasmic problems in population study: 3% to 6% - Reported prevalence of orgasmic dysfunction in the PRESIDE study. Overall sexual dysfunction/desire problems in population study: 10% to 15% - Reported prevalence of distressing sexual problems in the PRESIDE study.

Pivotal Quotes: "“It’s okay to want to want.”" — Dr. Sharon Parrish: She uses this to validate treatment for low desire even when arousal and orgasm are intact. "“The single best treatment for disruptive vasomotor and collection of symptoms is combined estrogen progesterone therapy.”" — Dr. Sharon Parrish: Her summary recommendation for menopausal hot flashes and related symptoms. "“We need to have these categories be separate.”" — Dr. Sharon Parrish: She argues desire and arousal should not be merged into one diagnosis because treatment differs.

Implications: Listeners should know that many sexual-health problems in women are diagnosable and treatable, not inevitable. The field needs better education, more nuanced prescribing, and easier referral to specialists; future research should catch up on women’s vascular, hormonal, and medication-related sexual dysfunction.