Where Did My Orgasm Go? Menopause, SSRIs, and the Science of Pleasure with Dr. Lauren Streicher

Dr. Streicher emphasizes that many women are prescribed vaginal estrogen but only told to insert it vaginally, missing the clitoris. She explains that the clitoris is an extension of the same tissue and needs direct contact with the cream. Even if a woman is using a vaginal estrogen insert (like Vagifem) or ring (Estring), she should ask her doctor for a separate estradiol cream to apply to the clitoris. The application should be slow and deliberate: “Take your time rubbing it in. … At least five minutes if not more.” This is not about sexual stimulation but about allowing the medication to absorb into the microcapillaries. She notes that this practice is based on her clinical experience in a dedicated sexual medicine clinic, where it transformed outcomes for women who thought they had permanently lost their orgasm.

Streicher points out that pelvic floor health is rarely addressed in medical training. OB/GYNs are taught to sew the pelvic floor back together after childbirth but not to assess its function in sexual pleasure. She observes an epidemic of pelvic floor tension in midlife women, often from years of stress, which makes sex painful and blocks arousal. She cites the high correlation between urinary incontinence and orgasm problems — both controlled by the same muscles — and stresses that solving incontinence often unlocks orgasm. In her clinic, referral to a pelvic floor therapist was a standard first step. She also warns that even women with “strong” pelvic floors from Kegels may have dysfunctional muscle patterns if they never learn to relax.

Streicher notes that the highest SSRI usage occurs in women over 65, many of whom were put on the drug for menopause‑related hot flashes when doctors were afraid to prescribe estrogen. She stresses that if the SSRI is the cause, orgasm returns quickly once the drug clears — a sharp contrast to GSM‑related problems, which take weeks to reverse. She also warns that for midlife women, it is rarely only the SSRI; they usually also have GSM, joint pain, partner issues, and vascular changes, so an SSRI holiday alone may not suffice. Still, she considers this a low‑risk, high‑reward maneuver when appropriately timed.

Streicher acknowledges the evidence base is “pathetic” but emphasizes the clinical track record from her Northwestern sexual medicine clinic: women who felt the “lights went out” after starting an SSRI would return after a single dose of sildenafil and describe restored orgasm. She is careful to separate this from the broader population of women with postmenopause anorgasmia; she views sildenafil as specifically useful for the SSRI subgroup. She is optimistic about the upcoming topical sildenafil cream from DARE but notes its trials excluded postmenopausal women, so oral sildenafil remains the only immediate off‑label option.

Streicher created a sexual medicine clinic at Northwestern where every patient was handed a mirror during the exam. She says many women in their 50s, 60s, and 70s confessed they had never viewed their own vulva. She contrasts this with men, who inspect their penis obsessively from a young age. The lack of visual literacy perpetuates orgasm difficulties because women don’t know that the clitoris is the primary pleasure organ. She also notes that pubic hair removal has inadvertently given some women a better view, but the cultural taboo remains. She urges women to look under the hood, apply medications precisely, and take ownership of their sexual anatomy.

Streicher describes this as “cross‑contamination” — many women who think they are having a vaginal orgasm are actually receiving simultaneous clitoral stimulation without realizing it. She references the anatomical research of Maria Bonaparte and the concept of coital alignment technique, where the man shifts his pelvis to ride higher against her mons pubis. She also emphasizes that partners should be educated that using a vibrator during intercourse is not a sign of failure but an enhancement, and that women on top often have better control of clitoral contact.

Dr. Streicher details three ways a vaginal orgasm can occur: (1) pure arousal leading to orgasm without touch (rare), (2) cervical stimulation activating the vagus nerve, which enters the spinal cord higher and thus remains functional even when clitoral pathways are severed, and (3) G‑spot (clitoral plexus) stimulation. She notes that MRI shows different brain areas light up for cervical vs. clitoral orgasms, and women who can have both describe them as distinctly pleasurable but different. The implication is that removing the cervix during hysterectomy can eliminate this orgasmic route, contrary to assurances that hysterectomy never affects sex.

Streicher explains that the clitoris is supplied by the tiniest capillaries and nerve endings; both are highly vulnerable to the loss of estrogen’s vasodilatory effect, aging, and comorbidities like diabetes. Clitoral atrophy leads to a pale, shrunken organ with unresponsive nerves, which she says can be directly treated by rubbing a small amount of estrogen cream onto the clitoris at least twice a week. She emphasizes that this is on top of any vaginal estrogen insert, ring, or pill a woman might already be using. The goal is to increase healthy blood flow and “wake up those nerve endings.” She underscores that this is not necessary for women who are orgasming fine, only for those who have lost sensitivity.

Streicher describes two distinct uses of sildenafil. First, oral sildenafil (Viagra) given to women with SSRI-induced anorgasmia: in her Northwestern sexual medicine clinic, she says they would present saying “I started my SSRI and it was like the lights went out,” and after a lower-than-male dose pill they would exclaim “Huzzah.” She concedes the data are scarce but argues biology and anecdote align. Second, topical sildenafil applied to the clitoris: there are zero published trials, but because sildenafil is a vasodilator (originally developed as an antihypertensive), it can increase clitoral blood flow, which would theoretically help with clitoral atrophy. An FDA-reviewed topical sildenafil cream from the company DARE is in phase 3 trials exclusively in premenopausal women; Streicher expects it might be available in 2026-27, but she laments that the trials excluded postmenopausal women, the very population that most needs it. Caveats include cardiovascular risk and the necessity of medical guidance — she explicitly warns against borrowing a husband’s Viagra.

Dr. Streicher recounts that Princess Maria Bonaparte, frustrated by her own inability to orgasm during intercourse, hypothesized her clitoris was too far from her vagina. She gathered 240 women, asked about their orgasm experience, and measured the distance. The magic number was about 2.5 cm (one inch). Two subsequent researchers replicated the finding. The mechanism: when the clitoris is close to the vaginal opening, the man’s pubic bone (during missionary) or the partner’s body can apply enough rhythmic pressure to stimulate the clitoris. Streicher also notes the possibility of coital alignment technique, where the man rides high to position his pubic bone directly over the clitoris. She further references women who, after massive weight loss and tummy tucks, found their sexual response changed because the skin pull altered clitoral position — a modern confirmation of the principle.

Streicher points out that the clitoris is essentially the same tissue as the penis, less sensitive but supplied by the same kind of microvasculature and nerves. At menopause, estrogen loss, cardiovascular disease, and diabetes all conspire to damage these tiny vessels and nerves — exactly the same mechanism that produces ED in men. Therefore, the prevalence curves match. She notes that when a 60-year-old man has an uncooperative penis, his same-age wife is likely dealing with a clitoris that “is dead.” The solutions are partially shared: PDE5 inhibitors like sildenafil work for some women, and pelvic floor therapy can help both sexes. This parallel, she argues, should finally destigmatize female orgasm loss and spur the same medical innovation that men have enjoyed.