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The Menopause Hour with Winona
Welcome to The Menopause Hour, the podcast where you’ll find the answers to your most pressing menopause questions—the ones you won't get from your OB/GYN. Hosted by Winona’s Chief Medical Officer, Dr. Michael Green, and Medical Director, Dr. Cat Brown, The Menopause Hour is here to empower you with expert insights, tips, and real talk on navigating menopause with confidence and clarity.Brought to you by Winona – menopause care made easy. Join us each episode as we explore the symptoms, solutions, and science of menopause, all while breaking down the stigmas and misconceptions along the way.
The Menopause Hour with Winona
Episode #46: Addressing Sex Stress: Practical Strategies to Increase Desire
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Is it possible to restore intimacy and sexual desire during perimenopause and menopause?
In this episode, Dr. Cat Brown and Dr. Betsy Greenleaf explore how stress, shifting hormone levels, and gut health directly impact women's libido and overall sexual wellness. They share practical lifestyle strategies, from prioritizing restorative sleep and fiber intake to incorporating vaginal estrogen into their routine, to help support and restore sexual wellness during this stage of life.
Welcome to the Menopause Hour, your go-to source for answers to your burning menopause questions. The ones you won't get from your OBGYN. Brought to you by Winona, where menopause care is made easy. Download our free Winona community app where thousands of women connect and access exclusive content, expert-led courses, exciting events, and more. It's time to take the guesswork out of your hormonal journey.
SPEAKER_03Hello, hello everyone, and welcome to our Dr. Dialogue. As you can see, I have some really amazing guests with me here today. In just a minute, I'll have them introduce themselves. But I just wanted to say that we're so glad that you are here and that you are taking the time out of your schedule to make time for this conversation. We're going to be talking about all things sex stress and then practical strategies to increase desire. So I think these are the two women that are going to be amazing at walking us through this topic. And I know it's one that we talk a lot about in our communities and that there's lots of questions a lot of times around this topic. So I think without further ado, we can kind of get into it. But we have Dr. Kat and Dr. Betsy here tonight with us. And then so maybe Dr. Kat, you can start with an introduction of who you are, and then we can jump to Dr. Betsy. I'd love to hear a little bit about you and what you're bringing to the conversation.
SPEAKER_01Sounds great. Absolutely. So those of you who don't know me, I'm Dr. Kat Brown. I'm the medical director here at Winona. I'm a board-certified OBGYN, an Army veteran, mom of three, avid gardener when I'm not seeing patients who are doing menopause care. I'm trying to do as much as I can outside. But I've dedicated my career to women's health, and this is a topic that's near and dear to my heart because I'm also in the thick of it with you as well, dealing with my own perimenopause issues and you know, on HRT myself. So women's health is has been an undervalued, understudied, under-researched, underfunded topic in the medical community. And Dr. Greenleaf and I are both people that are trying to change that. And you know, having a dialogue like this tonight, we just want to get education out there, help women learn more about their bodies. And that's what I really, really love to do is education and helping patients everywhere and helping women everywhere. So that's a little bit about me. And Dr. Betsy, tell us about you more.
SPEAKER_04Yeah. So thank you guys for having me. I'm so excited. I'm always love working with you all and Dr. Kat. It's been a while since I've seen you, but um, I'm Dr. Betsy Greenleaf. I am a quadruple board certified physician, and I'm laughing because I'm actually in the process of getting my fifth board certification. They always Are you really? Yeah. So officially it's uh my official training um started with obstetrics and gynecology, and I'm the first board-certified female urogynecologist in the United States. But my additional uh board certifications are in aesthetics, functional medicine, and I'm wrapping up two weeks. I'll be finishing up my fellowship in integrative medicine. So I'm a lifelong learner. I love learning. So, and very, very passionate about women's health and especially sexual medicine. And actually, another thing I'm doing, I'm very excited, is next week I'm actually going away for a book writing retreat, and I'm gonna be writing a book on passion and libido. So um, this is this is a perfect, this is a perfect topic and perfect timing. So you guys will get me like go getting my brain going to figure out what to be putting into this book. So um, but I I'm located in New Jersey. I have a uh practice called the International Pause Institute, and uh so our tagline is we help people busy people over the age of 40 look great, feel great, and perform great in and out of the bedroom. So, and um, I just am very excited to be here with you all today and having this conversation. And just a little also background with me and Dr. Kat. Dr. Kat and I met on in in Costa Rica on this set of a menopause documentary. So that was incredibly fun. We had such a great time filming that.
SPEAKER_01Yes, yes, dealing with the humidity was was not so fun, but all the conversations we had and then tarantulus. Well, that and then I had monkeys on my roof at our resort at the nighttime. Like I would hear this thumping on the roof. It was kind of crazy, but but yeah, no, it was great to meet you, and then we found out we were not that far from each other. You know, I'm in the Philadelphia area, she's in New Jersey, so we're not we're not that far from each other, which is great too.
SPEAKER_03I love that. Well, thank you both so much for giving that like quick little overview kind of of who you guys are, because I know that some of our uh attendees tonight probably know Dr. Kat, Dr. Betsy, you might be a new face. You might also be an old face because I know that we uh you've had us or you were with us at our um our social um Indianapolis. So I know that you've been around for a while. Um, but kind of just to jump into the topic tonight, I would love to maybe hear from both of you as a starting point. You know, when when you're talking about this topic of uh of sex um and stress, and maybe a patient comes to you and tells you, oh, I just like I don't really want to have sex anymore, what is like that first thing that you're kind of listening for or thinking about that comes up in that topic?
SPEAKER_01I think the hard part is, you know, for most patients, they're really ashamed and afraid to bring it up. I can tell you, like when I was still in the office and seeing patients in person, this would not be something patients would come to me and forthright like talk about. It was always like I did their entire annual exam, done their path, like we've talked about their birth control, whatever, um, or HRT. And then it's when their hand is on the doorknob and they're literally about to end the visit that they'll bring it up. So I think the most important thing is to kind of bring the dialogue up. But if the patient brings it up, we need to have tools as providers to kind of help figure out and fine-tune what is it, you know, because a woman's libido and sex drive and you know, it has so many different dimensions to it. And it's not just a physical thing, it's not just a hormonal thing. And so part of what we have to do as the doctor is to try to figure out and get to the bottom of where the real issue is. And so it really, it really needs its own visit, it really needs its own like in-depth history. We need to talk to patients a little bit more detailed to find out what's going on. Um, but it was almost it was almost like an afterthought. And I would I would say most of my time in practice, patients would not bring this up. And I think that that's why it's important for the doctors to ask, you know, and for us to to have that open dialogue and to be comfortable talking to our patients about this.
SPEAKER_04I agree. I'm laughing over here because uh the same thing. We always called it the doorknob conversation because it was it was like you're right, it even if you bring it up, they would be like, okay, but then like at the end, it was when they were like, Oh, you know what? Actually, I do have a problem. And the best thing was is in in the office, patients will say, like, I'm the only person that you probably have heard of that has this problem. And I'm like, man, if I had you know a dollar for every person that said that, we'd be I'd be really rich. And but I think that's the problem, is that it's not talked about very often. Um, unfortunately, I think sex in general is something that still kind of gets like it's a little taboo, and I don't know why. I mean, one of my passions in life is for us to reach a point where we could just talk about like sex and vaginas and penises and whatever body parts and not even blink an eye and it just be like normal conversation. And so, um, but I think like the more we talk about it, the more people realize that like this is normal, and like you're not the only person that's struggling with this, and more importantly, that there's things that can be done. So I think that that's really important. And I think, you know, I think unfortunately, many people present to the doctor with questions about sex drive and potentially like low libido, and they're there asking for hormones, and I definitely think hormones are a tool in our toolbox, but it's much deeper than that because the other thing people need to understand is that hormones are not a panacea, and they're gonna be really disappointed if there's other things that haven't been looked into, which we're gonna be going deeper into in the next couple minutes. But if you get the hormone and you're not getting the results you want, it's not a hormone failure, it's that the hormone hasn't been optimized to be used in the body, so we need to go look at well, what are the other issues? So, but I think a lot of times it's the hormones that bring people into the office, which is a good starting point, but there's a lot of things that people can be doing uh at home on their own, and we'll we'll get into all that.
SPEAKER_01So absolutely, yeah. So true.
SPEAKER_03So, yeah, Dr. Betsy, and maybe kind of talking a little bit about that is you know, you I believe you've talked a little bit about like a an intimacy an intimacy like stress loop, kind of that a lot of women kind of go through. Can you walk us through a little bit about kind of what's happening there? Like when you know, stress really starts, you know, stealing that desire.
SPEAKER_04Yeah, so you know, it it sex and stress cannot coexist. And from a chemical standpoint, like Dr. Kat and I will probably geek out on this, and you might not be actually as interested in the like physiology and chemical process, but I'll, you know, just for your education purposes, they that our sex hormones are made in a pathway that are derived from cholesterol. A lot of times we vilify cholesterol, we make cholesterol in a bad as a bad guy, but cholesterol is our parent hormone, and we only make our sex hormones in a nice relaxed, relaxed state. So the parasympathetic state, which is our nice relaxed state, there are things that are supposed to be happening in the body when we're relaxed, and that is digestion, healing, and sex. So, and when I say sex, that means your sex hormones, that means reproduction, that's fertility, that means libido, like all that, you have to be in a nice relaxed state for that to be happening. So if there's any stressors in your body, whether it is things like, and we'll go into these deeper, but it's like lack of sleep or um inflammatory foods or mental stress or illness, or there's a there's a giant laundry list of things that can count in the body as stress, the body doesn't prioritize at that point in time the healing, the digestion, fertility. At that point in time, when you're under any kind of stress, the body goes, Oh my gosh, I need to go prioritize survival. And so, actually, from a chemical standpoint, your hormones will actually even shift and you'll make cortisol, which is one of your stress hormones. So that's how we also know as scientists that we can see like this is not, you know, these things are are happening and you're shifting, you know, you're gonna shift, you're either in relaxed state or you're in a stress state. And when we're relaxed, that's when sex can happen. But if there's any stress or inflammation, then you're gonna be in a stress state, and that's when the body's gonna prioritize survival. Because you think about like as cave people when we evolve, you know, if you're like walking across the savannah, you know, holding hands with your honey and you're about to go get romantic and a lion jumps out. You don't want to be like, excuse me, lion, while I go like have some sex because you'd be dead, right? So your body's like, oh my god, like sex, fertility, digestion, healing, like all that goes to the side because I need to either all of a sudden become so strong to fight that lion or so fast to run away from that lion. And those that stress state is technically supposed to be a very small spurt and we need it to for survival, but then you're supposed to go back to being nice and relaxed. Uh, but in today's modern age, like our lions present as so many different things, so we get kind of almost stuck in that stress state, and then we sit there and want and then you sit there and you wait, you wait for the sex drive, but it's just not gonna happen if you're stressed. So we need to like focus on okay, how do we decrease stress and increase libido and decrease inflammation?
SPEAKER_03So yeah, yeah, absolutely. And Dr. Kat, kind of like touching on, you know, kind of how it seems like you know, we really lowering kind of that stress can be a really important factor as well. Just like we're kind of you know exploring that a little bit more. Um, so you know that like elevated cortisol can like suppressed testosterone, um, which is a big um aspect you know that drives desire in women and not just men. Um, can you kind of like walk us through a little bit about what is kind of going on and shifting hormonally during perimenopause and menopause, like whether that's estrogen, like whether that's testosterone, kind of what is all happening in that side of things with the the hormones as well?
SPEAKER_01Yeah, I mean, even before perimenopause hits, our testosterone levels are dropping over time as women. And I think not a lot of women realize that they have testosterone in their body until they start doing a deep dive and learning more about what's happening in their body during midlife. But our testosterone levels in our 30s are lower than they are in their 20s, and then in our 40s, they drop even further. But then as we start to get into perimenopods, our estrogen levels are decreasing as well. And so those two hormones are really what's driving a lot of the health of a lot of the tissues in our body, but also the way our brain functions, our normal circadian rhythms, like our sleep cycles, but even like your physical response to sexual stimuli at all. So, like your genitalia are not going to respond and get aroused as well when they are devoid of estrogen and they're you don't have testosterone circulating. So the that hormonal connection is a big part of it too. Um, and I think not a lot of women realize that the testosterone piece starts way before midlife even occurs, um, that those levels are decreasing rapidly. And so, you know, part of you know, treating yourself and and helping yourself kind of get through this time, like you have to do the supportive things in your day-to-day life, like trying to optimize your sleep, trying to, you know, optimize your nutrition and do everything you can to support your body and being its best it can be. But also taking hormones can also help, you know, to try to balance things, you know, bringing levels back. And you're never gonna get them back to where they were when you were 25 or 21. Um, but it's a it's about giving your body enough so that your body's tissues can function the best that they can during this transition. And so, and and also for a lot of women, it's a new normal, right? So, you know, this isn't about returning us back into youth and like reversing the aging process, but it's more about making our lives and our bodies function the best they can in the in the body that we're in at the age that we're in, um, you know, and maintaining that vitality and wellness the best we can. And, you know, in addition to our physical health, but also our sexual wellness too, you know, and I think that's uh the key thing to remember as well.
SPEAKER_03Absolutely. Then Dr. Betsy, you you mentioned a little uh just a bit earlier, kind of about how you know, when we're not as much in a state of stress, that's a great time for like digestion as well. Can you talk a little bit about, I think we've spoken before about like kind of what that um connection between like the gut, hormones, pelvic floor kind of looks like. Can you kind of walk us through a little bit of this thought as well?
SPEAKER_04Yeah, how many hours do you have?
SPEAKER_02This is my favorite topic.
SPEAKER_04So the you know, some people have heard of this gut-brain connection. So I'm gonna start there, and you're like, wait a minute, how is something that's all the way up here connected to your gut? But it is through the microbiome, which is the bacteria that's found, like my microbiome just refers to the different types of bacteria and organisms that are found in different areas of the body. So our skin bacteria is different than our mouth bacteria that's different than our gut bacteria. But they found that um the gut bacteria makes like 90% of it makes our happy hormone. So serotonin, which is our happy hormone. And so um what ends up happening is if the now I'm not saying that there isn't a role for like antidepression medication. There is definitely a role, but there in some people anxiety and depression may be a gut issue rather than a deficiency of let's let's say a medication. So um, so we know that there's this connection between the gut and the brain. If we if our gut is good, we tend to be in a better mood. But they also have found in studies that for both men and women, that if the gut is healthy, we are more likely to have a healthier sex drive because the body's pretty darn smart. And it so if the gut is off, there can be things that the body senses as inflammation and it goes, well, now's not the right time to be reproducing because something's not balanced, and the body doesn't know the difference between like you want to actually make a baby versus like you want to have fun with a partner. So there's this interesting connection between how our mood, our sex drive, and things that are going on in the gut, and then taking that even further, there is a connection between the vaginal microbiome, so the bacteria that's in the vagina, and now our libido. So there's a feedback loop, let's say things are off in the vagina, there's a feedback loop to the brain that says, you know what, not time to be reproducing. So all those processes get dampened, such as libido. Um, and unfortunately, as we're meant entering menopause or in menopause, one of the problems that starts to happen is the estrogen levels are starting to go a little bit lower. And as they go lower, the vaginal tissue tends to get a little bit thinner. As the tissue gets thinner, what's happening is the healthy bacteria actually loses its food source because the healthy bacteria is there when we're younger because we're making new tissue all the time, new cells. Those cells are kind of sloughing off and they contain a chemical called glycogen, which then feeds them. In return, the healthy bacteria actually will make peroxide, which keeps the vagina very acidic, and that decreases our risk of getting recurrent urinary tract infections, recurrent vaginal infections, and can help support the libido. I mean, some women will even notice, like if they're wearing dark underwear, they'll notice that their discharge may actually bleach their underwear. And that isn't because there's something weird going on with their discharge, it's that the healthy bacteria is making peroxide and it'll actually like bleach darker fabric. So we lose that healthy bacteria as we go through menopause. So not only do you end up getting a little bit of vaginal dryness from that thinning, and you can end up getting issues with pain with inner pores because of lack of elasticity, but now we actually get this kind of shift in the healthy bacteria that has this crazy, you know, feedback loop that's gonna actually support um is gonna support the sex drive. So it's another reason, and then that's something that interestingly enough, that um sometimes, for example, with hot flashes, in some people they get better as time goes on without hormones. But without hormones, if we ignore the vagina, it doesn't get better, it doesn't go away, it actually will get worse. So something that they've renamed genital urinary syndrome and menopause gets worse if we don't consider using something to rejuvenate the vagina, and this is why women who are in this stage of life, not only libido can get affected, but the discomfort with sex, also much higher risk of urinary tract infections and recurrent vaginal infections, odor, itching, burning. So there's definitely something that there's a giant role for using hormones or any kind of regenerative therapies in that area.
SPEAKER_03Absolutely. Um Dr. Kat, could you maybe get kind of playing off of that a little bit as well? Could you kind of just walk us through kind of some of the roles that maybe like daily nutrients also can play in stress resilience? Um, and then I think you know, since we're talking about desire, by extension, desire as well, and how that all is all connected at the end of the day.
SPEAKER_01Did you say nutrients? That's what you wanted to nutrients, yes, sorry.
SPEAKER_03Or if you have another angle that you think would fit with the other.
SPEAKER_01Well, I mean, I think that um, you know, that's part of our nutrition is is is part of it, but actually vaginal estrogen is such an important, important thing. I think that even women that are too high risk to take systemic hormone therapy in midlife would benefit from topical vaginal estrogen therapy. And I think that's by far the most benefit. Thing for vaginal health and for sexual wellness, I think. And I I mean, many of us believe it should be over the counter. You know, it's it's such a safe treatment and should be available to everyone, really. Um, and that's probably the single most popular thing I would recommend to patients who are having issues when it comes to discomfort with sex, um, changes in the response of the tissue, you know, and the in the vulva, and the clitoris, and the vagina, and not being responsive to sexual contact. I think vaginal estrogen would go such a long way. Um, you know, and a lot of women are out there trying to find supplements, and and you know, there are plenty of companies out there that'll try to promise women the moon when it comes to like a supplement for sexual wellness, but really it's about finding your own happiness and peace in your body, finding that, you know, self-love, you know, and really making sure that you're comfortable in your own skin and that you're loving the body you're in and treating it well. You know, you are what you eat, and so you know, feeding your body with the fuel that's going to make it feel good and give you energy, um, making sure you stay hydrated, probably one of the best nutrients is water, you know, just simple, simple water. I think most of us in America are chronically dehydrated, myself included, sometimes. I mean, it's it's one of those things that, you know, all the tissues in our body would optimally function better if we were better hydrated. And so I think that's an important thing too. And then along that, you know, the same guidelines with the talking about the microbiome and their gut and that that connection, you know, getting fiber in our diet is another huge thing. So, you know, we have a huge problem with colorectal cancer in the United States, but also chronic constipation. And I don't know about you ladies, the ones who are listening, but if you're really, really constipated and you haven't pooped for days, do you want to have sex? Absolutely not. There's just, you know, our I don't think that a lot of people think about it, but the vagina and the rectum are, you know, parallel hallways basically in our lower pelvis. And if the one compartment is completely filled up with stool and we can't pass it, then the vagina is not going to be receptive to having any kind of sexual contact, especially penetrative contact, you know, with a toy or a penis, or, you know, and so I think that that's an important thing to think about too is the fiber intake that we get in our diet. That's such an important nutrient to make us, you know, that regularity helps with our microbiome, but also helps with our overall feeling of health in the lower pelvis and the musculature and our pelvic floor, you know, everything functions better when we're having regular evacuation of our waste. Um, so that's important too. You know, other than that, I don't think that there's other many other important nutrients that I would focus on. What were we gonna say, Betsy?
SPEAKER_04You know what is I saw recently that the average American only eats about nine grams of fiber a day. And we really need like 30 to 40 plus.
SPEAKER_01Yes.
SPEAKER_04And you and definitely you need it to be able to feed that healthy back because all the probiotics in the world aren't gonna do anything unless you have the fiber to feed the healthy bacteria. So, and then you don't even need the necessary probiotics, you could be adding fermented foods into the diet. So, um, but yeah, but it's and I I've counted my own fiber too. Like, I'm guilty of this. I tell people all day long like more fiber. And then one day, you know, you get busy and you're running around, and you know, you're grabbing things to eat, and I counted and I was like, oh my god, I only ate nine grams of fiber today. I'm like, I need to, you know, get that up. So I've been making a conscious effort to do it.
SPEAKER_01So yeah, I think it's so important to think about tracking your macros, you know, in your diet. Like many of us were trained to count calories and calories in, calories out, but it's more about the fiber you're getting, the protein you're getting, and eating whole foods and you know, really making sure you're getting that. I I've done the same thing. Like, we're just on a typical day try to track what I'm eating and thinking about, you know, looking at the fiber content. And then luckily I keep a bottle of um like a container of fiber supplement so that if I'm not getting enough in the natural foods that I'm eating, then I could add that into the daily regimen too.
SPEAKER_04I like uh beta fiber or um or uh sun fiber, those are the different, and I put it in my coffee because it doesn't get like gritty, so you don't even know it's there, so you can like sneak it and put it in drinks and like not even know.
SPEAKER_01Right. Exactly. It's not like our grandmother's fiber, like that old metamusil drink.
SPEAKER_02Yeah, that just like would sit at the bottom of like a chunk.
SPEAKER_01Yeah, no, no. No.
SPEAKER_03Well, and kind of talking about all that we've just been chatting about, I'd love to hear from both of you if you know, if someone, if one of the women listening to this this this conversation tonight could only change one lifestyle habit this month to kind of work on that stress, work on that desire. Um, what would you tell them to prioritize?
SPEAKER_01I think mine if I had to choose one thing, it's something I still struggle with myself as an OBGYN physician, it's sleep.
SPEAKER_02One of the ones I was gonna say about it.
SPEAKER_01Yeah. So I think that so many of us are trying to multitask and fit so much into our day. And often it's like, you know, where are you gonna fit in the exercise? Where are you gonna fit in this? Where are you gonna fit in that? And then we sacrifice our sleep unnecessarily. And when you do get optimal sleep and you're getting eight to nine hours a night, uh, it's amazing how much better all the aspects of your life fall into place when your sleep is the best it can be. And so I think that that's probably my biggest advice. And you know, I struggle with this because I'm still working overnight shifts in a hospital several times a month, and you know, but I wear a Fitbit and I track my sleep and then I try to make up for it when I can. But I think that that's probably my biggest advice is really to optimize your sleep because I think that would go a long way with helping our biggest sexual organ as women, which is our brain. You know, we need that that downtime, that restorative sleep to reset everything, but also to lower our stress levels, you know, lower that fight or flight response. Um, to really optimize our digestion and every function in our body, we need that restorative sleep. And so I think that would go such a long way.
SPEAKER_04I second that. And but I have I have two. So sleep was my number one. And but I also think about sometimes I think remind myself with the sleep too, as I'm running around doing things and I'm like, I just want to get one more thing done. I want to get one more thing done. But guess what? Those things will be there tomorrow. And statistically, I came across a study. This one kind of freaked me out. Um, you know, many of us, me included, struggle with weight, especially in that menopausal period, which doesn't, which doesn't add to feeling very sexy. Um, and that actually, if you get six or less, or if you get six hours of sleep a night, that incon increases your risk of obesity by like 23%. If you get five hours of sleep, now all of a sudden that jumps to like something like 75%. So I was like, oh no, I'm working on the sleep.
SPEAKER_01So I read that too, and and the number of hours was like really shocking to me that that was such a strong correlation with difficulty with weight management, but it makes sense. It really does.
SPEAKER_04Yeah, so that would be the one thing. The other thing from um, and it's not so much like a lifestyle when we talk about like diet or or because all those any lifestyle thing work, but you know what? Um, something I talk to patients about, and a lot of times on their first visit, I tell them about the rosemary basan model of sexual response, um, which sounds very scientific. But in, I'm just gonna tell you, a lot of us, and I've been there too, you know, want our sex drive and desire to be like it was when we were like 18 or 20. But what happens is when we're now 40, 50, and beyond, our life is a lot more complicated than it was when we were like 18 or 20, and you know, going back to stress. So a lot of women, and I like I said, I have been in this boat too before I understood this. We wait to like we're in the mood to like have sex, but if you're running around trying to juggle everything all at once, and you wait to be in the mood, you're gonna be waiting a very long time. And that's what um Rose Marie Basson was a sex researcher. She unfortunately just passed away this past year at the age of like 90 something. And what she said is you can still have spontaneous desire that exists, but there's also if you have the willingness to actually engage into something that is pleasurable, and so this is something that I just tell everybody is setting me time, like setting time that's either for you, meaning you by yourself or you with a partner, and having a conversation with the partner that, hey, this doesn't actually have to lead to intercourse because you don't want that pressure that this is gonna lead to something, but just setting like intimate time by themselves, and that sometimes having the willingness to kind of go ahead and maybe you know, cuddle or do something together, that that sometimes starts the whole process and you know, with you know, mark it on the calendar. I have people like put it on the calendar and don't let anything else like sneak into the calendar, and sometimes just you know, doing something with your partner, whether it's sexual or not, or with yourself, sexual or not, just having some mean relaxation time, sometimes that leads into things, and so sometimes you then all of a sudden, all of a sudden now have like a desire or arousal coming before, you know, like you were like sitting around waiting, like, oh, I wish I was in the mood. You know, sometimes it's just you gotta create the situation that now would bring up more of the mood than actually wait waiting for it. So yeah. So on that lifestyle was setting me time.
SPEAKER_03Absolutely. Well, and I'd love to hear, I think Dr. Betsy, you were just talking talked about it a little bit, but I'd love to hear from both of you as well. Is kind of like what role does a partner's understanding or lack of it kind of play into this sex stress, to looking for desire.
SPEAKER_01I think just having a partner who is willing to have the conversation about, you know, what you're going through. Because I think another big piece of this in midlife and women is when you're going through all the symptoms of perimenopause and menopause, and you're dealing with hot flashes and night sweats, and you're gaining weight and you're not knowing why, like all of a sudden you feel like a, you know, like your body is not your own. And it's it's a very strange situation and feeling for a lot of women, but like they need to be open to their partners, like you know, because partners can take offense. Like when they try to initiate and they're trying to do something romantic or trying to like give you a kiss or cuddle, and you know, you think like, oh God, they're kissing me, they're gonna want sex. Um, and it's like automatically you want your your guards go up because you're not there, but you know, you've been left to talk to your partner about, well, it's not you, it has nothing to do. I just am not comfortable. Let me tell you how I'm feeling, and having that dialogue, I think, is so very important because then the partner will understand and be a little bit more supportive, and then there'll be more willingness to do some of that, you know, you know, intimate talk and trying to talk about things and trying to work on things together. I think that's that's really important. Um, so teaching our partners and not like trying to keep it hidden. I think a lot of women are ashamed about what's going on and what they're feeling, and they're afraid that talking about these things openly with their partner is going to turn them off, too. I think that that's part of the fear. Um, but when someone truly loves you, they love all of you. And so the good, the bad, the ugly, you know, and so it's totally it's it's important to let them know and let them in to what you're experiencing and what's going on so that you know they can kind of help you through it too.
SPEAKER_04I totally agree with you. I can even add to that because you covered, you must be reading my mind.
SPEAKER_02You said exactly everything I would have said. Awesome.
SPEAKER_01No, I think we're just we're we're in tune, Betsy.
SPEAKER_04Yeah, because you know, I I just heard it this week. Like, I actually had a lesbian couple in my office, and uh the one wife was saying that she's like, I just want my wife back. She's like, I don't know what I'm doing wrong. And the the the woman that was having the low libido was just like, I just, you know, she's in the middle of perimenopause. She's like, I just don't feel great. She's like, and so it was it was nice that I had them both in the office and we were, you know, able to have a conversation that doesn't always happen, but it is having an open conversation with the partner because the partner's wondering, like, what am I doing wrong? Like, am I not attractive anymore? Like, why don't you want to be with me? Like, when it's usually it's just like you just feel like not yourself anymore, and it really isn't, you know, that of an issue. So having that open conversation, then you get to work more together, you know, towards the goal.
SPEAKER_03So absolutely. And kind of as we're starting to wrap up our conversation, I'd love to kind of just open the floor to both of you as well. And is there something specific that like comes to mind that you're like, wow, like this is really important that we should let the women on this call know, or this is something that we definitely don't want to like miss talking about tonight?
unknownYeah.
SPEAKER_01I think the other thing too is that I'm sorry. No, go ahead. The other thing that I think is a huge stressor for women is the pressure to orgasm. Or also women really think that they're supposed to be able to orgasm with penetrative sex, especially if they're in a heterosexual couple. And most women will not. I mean, it's like less than 30% of women will have an orgasm from sex alone. And so I think it's the other important thing I recommend to patients is to explore their own body and to explore masturbation and explore clitoral stimulation. And because your partner can't help you and learn your body better and kind of help your, you know, help you achieve more pleasure if you don't also know how to help yourself receive pleasure. And I think that's something that we don't talk about enough. Um, you know, certainly in the confines of like a traditional medical appointment, like there's there's just not enough time to get into all of that. But you know, the the experts out there in sexual wellness really, you know, recommend this too. That it's you know, self-exploration is so important. And I think that there's so much stigma around that, and there's so much stigma about women's sexuality in general, that it's like, you know, a lot of people in society feel like we exist to reproduce, and that you know our sexuality and our sexual satisfaction is not as important as a man's. Um, I'll tell you a funny story, really quick. August 8th was International Female Orgasm Day. And we did like some little posts on my account and everything, but I was on call that day. And I went to the hospital and I'm on labor and delivery, and now it was every nurse that was signing off, every nurse that was coming on, doctors going off coming on, and we were doing like our day-to-day sign out, and they said, Anybody have any announcements? And I said, Yes, today is International Female Orgasm Day. I want everyone to know it. And if you never knew what that meant and you haven't ever explored it, like take the day to learn more, to talk to friends. And let me tell you, every male in the room turned all kinds of shades of red, including my OBGYN colleagues. It was hilarious. I love that. And of course, my boss was there, and he's like, oh, I can't. Like, you know, embarrassed that I even brought it up. And I'm like, and the reason why everyone's embarrassed and turning red is the very reason we need to talk about this more, you know? So important. Like it should not be this taboo thing. It should not be something that we hide in the closets. Like if we talk about it regularly, sex would be better for everybody, you know? Um, so yeah, that was just a little funny story, a little anecdote, because even even in a professional workplace where our job is delivering babies through the vagina, it should not be a taboo topic to talk about. It was still something that made a lot of people uncomfortable for me to say those words out loud. Female orgasm. Everyone's like, oh gosh, it's crazy.
SPEAKER_04I I have two things, but I'm gonna kind of jump off of like that. That is May is international masturbation month. Oh, you get a whole month. So um, and it's funny from that standpoint, um, you know, I I realize there's a lot of different beliefs and personal beliefs and religious beliefs surviving um, you know, surrounding self-pleasure, but from a purely medical standpoint, self-pleasure is pelvic physical therapy. Yeah, because if you don't use it, you will lose it. So one of the things about actually stimulating, you know, stimulating the clitoris, the vulva, the vagina, um, anywhere that feels pleasurable, especially in the pelvic floor, is that we're bringing blood flow into that area. And the more blood flow we bring into the tissue, the healthier that tissue is going to be. So here's the thing: the more you use it, the better it's gonna be. So if you're waiting, you know, to have like sometimes too, you know, even with a partner who's willing, sometimes schedules are just like all over the place and it's not happening. So this is why, like, you know, learning to do things on your own is really good because in this way it works better than when you are with a partner because you've kept that tissue nice and healthy and functional. So, um, from a purely medical standpoint, it is actually very good for you and keeps that tissue you know super, super responsive and super healthy. Um, because it like they've actually shown those blood vessels. If you're not getting blood flow into the palp, it's going to shrink. Those blood vessels are gonna shrink, the vulva can shrink, like we we gotta make sure we're using it. Um, the other thing that comes up often is I get a lot of people, a lot of my female patients complain and they're like, it's not fair, men have Viagra, like we don't have anything, and it kind of connects back to what I just talked about is Viagra is not a horny pill. And so um that you know, people are like, you know, waiting for this pill that's gonna put them in the mood. Well, number one, Viagra is just a blood flow pill, it's a blood that's all it does, but you have to be sexually stimulated mentally for it to trigger blood flow below. So, like a man can take it, and it's not just gonna necessarily give him an erection just from taking a Viagra. There has to be a brain process that happens first. And so here's the thing I tell everybody is your brain is your most important sex organ. And this is why we're not gonna necessarily there's medications that are out there to help with libido that are indicated for pre-menopausal women, and that that's you know where they're working on developing these drugs. But do I ever expect a perfect medication to happen? I'm not you know, this is not a bad thing. I'm not expecting a perfect medication to be coming out because everybody's brain is different. And so finding what stimulates your brain and having that honest conversation with yourself that hey, this really turns me on, that's where you're gonna like, you know, that's where things are gonna be working really well. And then once you figure out what turns your brain on, then you can actually say to a partner, hey, this is something I like, this is something I want to do, this is something I want to talk about, this is something I want to fantasize about, you know. And that there's so many different options when it comes to, you know, what can be done next. So giving like a prescription, you know, some people you know like toys, and I'm like, all right, great. If that works for you, then go go there, but it doesn't work for everybody. So yeah, figuring out what you know gets your brain going is really important.
SPEAKER_03Absolutely. Well, thank you so much, Dr. Kat, and thank you so much, Dr. Betsy, for being here tonight and really just like diving into this topic. I think we talked about a lot of really interesting things and spanned quite quite a um quite an expanse on it as well. So really appreciate your all's time and being willing to dive into these topics. I think it's so important to have events like this where we really get to have these conversations. Um I think that's so great.
SPEAKER_01It is. Now I know we have a few women on the call, like listening in. Do we want to open the floor for any sexual health related questions or see if anybody has anything they'd like us to answer?
SPEAKER_03Yeah, if anyone has any questions, we can we can definitely do a couple questions and give them a minute or two to get those in. Um absolutely give people a second if they do have them for sure.
SPEAKER_01I definitely think when we've when we've had other talks about anything sexual health and wellness related, we don't get as many questions. Because I think people are embarrassed. You know, it's definitely it's definitely a topic that not everyone is very open to talking about. And like if we had the ability for someone to put an anonymous question, we might be more likely to get questions. But oh, it looks like some people are typing.
SPEAKER_03We'll give them a second just in case.
SPEAKER_04Yeah. Trying to figure out where you guys are seeing this because I see question and answers are disabled. So I'm trying. Oh, is it oh in the chat? It's the chat. Yeah. So um and then somebody I saw somebody raise their hand. I know it's not as familiar with this.
SPEAKER_01This is a safe space. So for any women watching, if you really have a a deep burning question, Dr. Greenleaf and I are gonna any no question is off limits. You know, you can you can ask us anything related to the topic, you know. So now's your chance. Maybe if you've been to America to bring it up to your in-person doctor.
SPEAKER_04You know, it's funny is I sometimes will tell people if they're uncomfortable talking about sex, like actually just, you know, especially there was a study, there was a uh study out of the UK that said that 65% of women are uncomfortable saying the word vagina. And so, but I'm like 80% of us will have something wrong with our vagina at some point in our lives. So if we can't talk about it and can't get help. So sometimes I'll tell people like when they're alone in the bathroom and nobody can hear, like, just say the word vagina. And so like I mean, I definitely like it. I laugh that I'm a psychologist. I mean, like an um like OBGOM because I remember when I was in my sexual medicine class, like in college, I was so embarrassed I would sit in the back. I was like, I'm not talking. And now I talk about sex and vaginas, like it's no big deal because I'm so desensitized to it by now.
SPEAKER_03Yeah.
SPEAKER_04Oh, we got some questions there. I see them.
SPEAKER_03We do have a couple. Yeah. So our first question from Liz, she says, um, I'm 59 without vaginal pain or dryness, but physically it doesn't feel uh does not feel pleasurable. Can you do you have any thoughts on this?
SPEAKER_01Yeah, that can still be related to the loss of estrogen from those tissues, and you could still benefit from vaginal estrogen to help get those tissues, tissues more supple, you know, more responsive. Really, the the skin of the vulva and the vagina thins when we lose estrogen. And so the nerve endings may not respond the same as when they were at their best, and you know, the tissue is more moisturized and supple and thick. So I think that that's something that could definitely help. And it is about the blood flow going to that area and the tissue being responsive. Um, so not every woman is going to experience necessarily pain or dryness, um, but it's very common for women to get dryness or like loss of lubrication. Um, and and also like you're describing that the tissues just don't respond the way they used to. Um, and so that's something that vaginal estrogen could help, I think.
SPEAKER_04Yeah, in addition, um, strengthening the pelvic floor, because we start to lose about eight to 10% of our muscle mass after the age of 30 for every decade that we live. And so one of the problems is we think about exercising our arms and legs, and we don't think about exercising our pelvic floor. And so sometimes what happens is as those muscles get weak, not only can we see problems with incontinence leaking urine, but sometimes orgasm like having an orgasm or holding on to an orgasm or orgasms could be weaker. So strengthening those muscles will actually help to strengthen orgasmic response and even sexual response. So um, so I would think about that too.
SPEAKER_03Yeah, for sure. And we then have another question or next question is from Heather. Um, and she has two parts. She says, Do you have anything to share about sex after a TBI? And then she also asks, what do you think about is it rejuva-type vaginal bones?
SPEAKER_01I mean, there's a lot of different products out there that are, you know, um people are you know saying are will help with um discomfort in the vulva or the genitourinary syndrome of menopause. I don't know about rejuva specifically. I I've seen a lot of ads on my own social media for a variety of different things. There's uh like a VIP stick that's out there, there's all kinds of other stuff. Ultimately, as a gynecologist, I always encourage patients to scrutinize ingredients, um, especially when it comes to midlife and after. Are you looking it up, Betsy? That's yeah, yeah. Okay, cool.
SPEAKER_04I'm trying to figure out if um if it's one of the ones that is just hyaluronic acid.
SPEAKER_01Um yeah, you just want to make sure that it doesn't have perfumes, dyes, that it's a relatively pH balanced, you know, vaginal appropriate base to whatever it is that you're gonna be using. Um, and so that's something that's important. I don't know about that particular brand.
SPEAKER_02Um, I'm having actually a hard time because I'm it's get I'm getting other things um are showing up.
SPEAKER_01So um but TBI, we can talk about that other part of her question too. So for those that don't know, TBI is a traumatic brain injury. So when it comes to how our body functions in many senses, um, you know, there can be a lot of after-effects after a traumatic brain injury. Um, and it can affect, you know, women in multiple ways. It can affect your response to intimate contact, it can respond, you know, affect your body's ability to respond to things positively. Um, and this is where, you know, seeing someone who specializes in sex therapy could definitely help. They could do like some cognitive behavioral therapy, you know, it and really specifically addressing your specific issues. Um, and so I think that that's something, you know, to consider. But it has to be kind of a multimodal approach. And most TBI centers of excellence will kind of attack things from multiple ways. But when it comes to your female health and sexual wellness, you know, I think that that's something that could you could benefit from both physical treatment, you know, helping the tissues to respond better, but also like a sex therapist to help with the brain piece and and how you respond to things.
SPEAKER_04Oh, I see what I see what we're we're talking about with well, actually, there's a couple rejuvis. There's um and really quick with the TBI, anything affecting the brain can potentially you know affect sexual function. So um try uh the TBIs, the Parkinson's, Alzheimer's, they all can potentially, you know, affect um they can all affect sexual function. Actually, you said rejuva bomb. Yeah, I didn't find I'm finding like there's tons of things called rejuva, but I'm like, um, I didn't see rejuva bomb.
SPEAKER_01Yeah, but when when it comes to these over-the-counter products, if you're looking into things like that, if it sounds too good to be true, it probably is, you know. Um, so that's something that you know, you want to look at the claims that any product is making and what it actually the ingredients are and take that into account. You know, not everything that these companies promise will actually happen. And so as the consumer, as the patient, you have to really think about risks and benefits and you know, pros and cons before you decide to try something. Um, and if you have a GYN or if you're one of our Winona patients and you're finding something over the counter you want to try, don't be afraid to ask your doctor. Show them the ingredients list and say, hey, is this safe? Is this something that I could try? Um, and we're happy to give you an opinion on that. You can always ask your Winona doctor in the portal if you want.
unknownYeah.
SPEAKER_03And we have another next question is from Lisa. Um Lisa's wondering, she says, if I use a toy, will it call cause reduction in libido? Like sometimes taking like taking some meds reduce effectiveness.
SPEAKER_01Well, so it depends. There's a lot of different toys out there, and that could be a whole nother, you know, episode, really. But there there is something to be said for getting like desensitized from like vibrating toys, um, suction toys, things like that. But there are ones out there that are specific, specifically meant for like clitoral stimulation. Um, and it's all about learning your body and learning what feels good to you and not like overdoing it. Um, you know, I do think that there's a there's a good role for toys if that's something that helps spice up your psych sex life or it helps with your self-play and self-pleasure, but you have to be careful about not over-stimulating the tissue so that when you're with your partner and their hands or their genitalia or their mouth doesn't stimulate you because you've kind of gotten desensitized from something that's a battery-operated friend or a rechargeable friend. Um, so that's something just to take into account. But for most women with average use, it's not an issue, it's not going to cause a reduction in libido. Actually, those stimulating toys can help with that blood flow going to the tissues in the vulva and the clitoris to help with your experience and your arousal during sexual activity.
SPEAKER_04I I agree exactly with Dr. Kat. And then, you know, even from a standpoint, the body doesn't like things that are too stimulating for too long. So, like anything in the body that is at a steady state for too long, whether it's like hormones or like a vibrator or people who have exposed their brain to pornography, like those little things, all like you know, in spurts can can help. So, you know, we see sometimes I have patients who um will use the toys and then they just become desensitized to them. And a lot of toys will actually now have multi-functions so that they do different patterns of the vibration to try to like break up the stimulation. But I even seen this with people with pornography where they say that they and that's a whole nother, I know there's an ethical conversation with all that too, but um, but some people who are very visually stimulated might find it exciting at first and then they watch it, and if they're watching it too much, they're like they don't get anything out of it. And the pornography industry kind of knows this and they make more and more and more extreme things because people have to watch more and more extreme things to kind of get the brain going. So, with any of those things, I will tell them like take a break. Like, if the you know the vibrations become like don't seem to be working anymore, just take a break from it. Take a break from watching the pornography, give you time for your brain to kind of reset, for the nerves to reset. So, um, and that's another reason, like when talking about hormones. Um, even though I am a doctor that will do pellets on people, I'm not a big fan of pellets because the pellet hormones stay at a steady state for a very long time. Your body's more likely to tune out those hormones than a topical hormone or injectable hormone or you know, whatever kind of hormone that's like a daily dose or a shorter acting one than a longer acting thing, because it's it's all the same process that's happening.
SPEAKER_03So absolutely. And for our, I would say our last question tonight, there's two, but I'm gonna kind of wrap them into one. Um, Lisa is wondering, she says, how long will people need to take the estrogen cream to help with pain and dryness? And then on in that same realm, Heather says that she was interested in the Winona estrogen cream, but that she didn't see a list of ingredients and she's a little bit worried because she has sensitive skin. So, kind of both of those two topics around the estrogen cream.
SPEAKER_01Well, just you know, with regarding any vaginal estrogen product, you know, I typically recommend vaginal estradiol. Like years ago, we had, you know, topical premarin, which is the conjugated estrogens, which is a cream, and I don't like that because it's not bioidentical to our bodies. But estradiol cream, whether you're getting it from Winona or you're getting it from your in-person doctor in a prescription or wherever, if it is a prescription strength estradiol and it's made for the vagina, that means it's in a base that's pH balance and that's you know appropriate biochemically for that vaginal tissue. That doesn't mean that when you first start using it, you might not experience you might not experience some irritation. If you really have genital urinary syndrome of menopause, sometimes applying anything can be a little irritating because that skin is already kind of devoid of its nutrients, it's already lost its moisture barrier, and it's all already lost that glycogen barrier that you were talking about earlier, Betsy. Um, and so what we typically recommend whenever we're starting someone on vaginal estrogen initially is that we want them to use it every day for like the first two weeks to kind of help build up that tissue, and then after that, we can kind of space it out to more of a maintenance mode. Um, and these vaginal estrogen products come with an applicator that kind of looks like a tampon, but for many patients, it can be irritating to insert the applicator initially. So you can also put just some cream on the finger and apply it to the outer vulva and vaginal opening initially to try to help get that tissue healthier and more responsive to be able to receive the applicator later. Um, but I have some women that never use the applicator, you know, that just use their, you know, wash your hands and put some on your finger and rub it directly into the tissue where you need it. Um, and most women when they're starting vaginal estrogen, usually start to notice some improvement within a month or so, especially with regular use. And that's the hardest part is remembering the regular use. We usually recommend taking it or using it at night because the less moving around, rubbing on your clothes, your underwear, um, and especially if you're inserting vaginal estrogen into the vagina, you know, gravity plays a role. So what goes up must come down. So we do not want to put the cream inside when you're still vertical and walking around all the day. We want you to put it in and then lay down so that you're horizontal and the cream has plenty of time to be in direct contact with the vaginal tissue where it's going to absorb those hormones from the cream. Um, and so usually I tell women to keep it on their bedside table, you know, and put it in right before they're gonna go to sleep because then it's the most beneficial and has the most chance of having long, prolonged contact with the vaginal tissues that it's meant to treat and the vulvar tissues that you're meant to treat. So, but most women will notice improvement pretty quickly when they start vaginal estrogen. And it's a cumulative effect. I think that, you know, with that maintenance, like women will notice continued improvement as well.
SPEAKER_04You know, it's funny because I do a lot of aesthetics also. And um, in my office, we do things like vaginal lasering and and platelet-rich plasma and all these other things. And it's funny because I always tell patients it's easier to do prevention than it is to reverse. So, not that we can't reverse the vagina, but the longer you've been in menopause and the longer that tissue has gotten thin and irritated, it's just gonna take a little bit longer. And from there are so many different ways to rejuvenate a vagina. And some people think like, oh, laser must be better because it's like laser and it's fancy. And here's the honest truth whether I'm using vaginal cream, like estrogen cream or laser, on average, it's still gonna take about the same time to rejuvenate the tissue, and so um, you know, like like Dr. Kat said, it can be anywhere from like a month before people feel better. But I'm gonna say, like at average, it like looking at average across all women, whether they start in their 40s versus like their 90s, I'm gonna say just average, it takes about three months to get it back to the way you're the best, yeah. Yeah, and so and it doesn't make a difference whether it's like it's not any faster to do a laser than it is to do the estrogen cream, but there's obviously you know some individual variation with that. So yeah.
SPEAKER_05Absolutely.
SPEAKER_04But I that's I think something we should we should think be like talking to women about is actually starting this some of this stuff like in perimenopause when maybe you're not actually having that vaginal dryness, like maybe when you're starting to start seeing, you know, issues, because like I said, it's easier to prevent and maintain tissue than it is to reverse things later on.
unknownYeah.
SPEAKER_03Well, thank you so much, Dr. Kat and Dr. Betsy. It looks like it is time for our event, but thank you guys so much for giving your time tonight. Also for answering some questions that I know the women that are on the call had tonight. I think that's also a very special aspect of getting to have these calls. Um, but thank you also to all the women who were able to jump in tonight. We're so glad that you were able to spend part of your evening with us. Um, and I think this is gonna be a great, I think a great conversation to have and to continue to have um with the people in our communities, our families, our friends. Um, so yes, I also thank you again, Dr. Betsy and Dr. Kat, for just giving a little bit of your time to have this conversation.
SPEAKER_04Thank you so much. I really appreciate the time and being here, and I love having this conversation. So um, yeah, and I don't know, Maddie, if we're allowed to like give the sneak peek that there's a course coming out on the Winona app about this.
SPEAKER_03Absolutely, yeah. I bet not, I just spilled the beans. We can, yeah. I think in the coming months, Dr. Betsy will be having an exciting course that we're gonna be talking about. So definitely keep an eye out for that. I think it's gonna be really amazing for sure.
SPEAKER_04And I was gonna say, if you're on any socials, come find me and say hi and say you were here because I love interacting with people.
SPEAKER_01So yeah, thank you so much for coming on tonight, Betsy. It's been really good to see you again. I always love having conversations with you. And thanks to all the women who came out tonight and for taking that step to learn more about their sexual wellness and tell your friends, don't gatekeep the information. Um, and if you wanted to listen to this episode again, you know, we have these also posted on our Winona pages. You can you'll hear this again as part of our menopause hour podcast as well. Um, so there's there's lots of opportunity to share this with friends as well so that they can hear the good stuff you heard tonight as well.
SPEAKER_03That's awesome. Absolutely. All right. Well, everyone, I hope you have a great rest of your night. And hopefully, we will see you at our next Dr. Dialogue.
unknownAll right.
SPEAKER_00Good night, everyone. Good night, all. Thanks for spending time with us. We hope today's conversation helped you feel more informed, more supported, and a lot less alone. If you're ready to go deeper, download the Winona app. It's free, it's for you, and it's filled with resources, real stories, expert insights, and a vibrant space to connect with women navigating the same season. Have questions? Join our next live QA. Until next time, take care of yourself. We'll be here when you're ready for more.