Sexual health is integral to overall health and longevity, impacting sleep, cardiovascular health, and mood, and should be prioritized alongside other health metrics.
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The 'orgasm gap' between men and women is significant, with only 30% of women consistently achieving orgasm with a male partner, highlighting a health disparity.
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Foreplay, lubrication (silicone-based, osmolality 280-300), and external clitoral stimulation are crucial for women's sexual pleasure, regardless of age or natural lubrication.
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Perimenopausal women often benefit from hormone therapy, with a key decision point being whether they prefer to suppress ovulation, and newer contraceptive pills offer natural estrogen options.
Protocols
Concrete recipes — what, when, how much, and why
6 items
Using Lubrication for All Sexual Activity
WhatApply silicone-based lubricant with an osmolality close to 300 mOsm/kg, even if natural lubrication is adequate, to prevent micro-abrasions and pain.
WhenBefore and/or during intercourse, with a suggestion to apply 30 minutes prior for responsive desire.
For whomAll women, regardless of age or perceived natural lubrication adequacy.
WhyReduces friction, prevents micro-abrasions and pain, which can lead to vaginismus and long-term sexual dysfunction. It also supports responsive desire by creating an environment conducive to arousal.
CaveatsAvoid hyperosmolar water-based lubricants (e.g., Astroglide, KY Jelly) as they can draw water out of vaginal tissues, causing dryness in the long term.
The expert strongly advocates for universal lubricant use, comparing it to applying sunscreen to the face. She explains that even in young women with seemingly adequate natural lubrication, friction can cause micro-abrasions. These tiny tears, while not immediately obvious, can lead to pain, which in turn can cause the pelvic floor muscles to clench (vaginismus), creating a vicious cycle of pain and discomfort during sex. Breaking this cycle is difficult, so prevention through lubrication is key. She specifically recommends silicone-based lubricants because they last longer and are less likely to contain additives that make water-based lubes hyperosmolar, which can paradoxically dry out the vagina over time by drawing water from the cells. The ideal osmolality is around 300 mOsm/kg, matching the vagina's natural state.
Mechanism
Silicone-based lubricants with appropriate osmolality (around 300 mOsm/kg) mimic the natural vaginal environment, reducing friction without dehydrating tissues. This protects delicate vaginal tissues from micro-tears and prevents the initiation of pain cycles.
I do. The data shows less microabbrasions. And also, what I really... if you're not concerned with sexually transmitted diseases... if you're with one partner and only one partner, are microabbrasions a problem? They lead to pain.
Testosterone Cream for Hypoactive Sexual Desire Disorder (HSDD)
WhatAdminister testosterone via a cream or oil to improve sex drive.
WhenDaily, typically after showering.
DoseTarget total testosterone above 20 ng/dL, with a range of 20-80 ng/dL, adjusting based on symptoms.
For whomPost-menopausal women diagnosed with HSDD who care about their low sex drive.
WhyTestosterone has a direct link to sex drive and is well-studied for HSDD, which is defined as low sex drive for over six months where the woman cares about the decrease.
CaveatsNot FDA-approved for women, but commonly prescribed off-label. Labs are followed, but symptom improvement is the primary guide. Estrogen can increase Sex Hormone Binding Globulin (SHBG), which binds free testosterone, complicating dosing.
The expert prefers testosterone cream, often compounded by pharmacies like Koshlin, applied as a pump daily to the inner thigh after showering. She also uses Testim (an oil) by dispensing it into a syringe for precise dosing. While she monitors labs, her primary guide for titration is symptom improvement, aiming for total testosterone levels between 20-80 ng/dL. She notes that there's significant individual variability in response, with some women seeing benefits at 20 ng/dL and others at 80 ng/dL. The complexity is further compounded by the interplay with estrogen and progesterone, as estrogen can significantly increase SHBG, which binds free testosterone, making it less available. More androgenic progesterones can help blunt this SHBG increase.
Mechanism
Testosterone directly influences sexual desire. While estrogen also plays a role (via alpha receptors for drive and beta receptors for anxiety), its impact on sex drive when replaced is often indirect (e.g., better sleep, more energy). Testosterone's effect is more direct. The challenge in women is that estrogen therapy can increase SHBG, which reduces the amount of free, active testosterone. Progesterones, especially more androgenic ones, can mitigate this SHBG increase.
Testosterone is, you know, wellstudied for hypoactive sexual desire disorder or a problem with, you know, I wouldn't say, a decrease in your sex drive... testosterone is very well studied um in terms of its benefits on your sex drive.
Scheduled Sex
WhatPlan specific times for sexual activity, even if desire isn't initially present.
WhenRegularly, e.g., 2-3 times a week for a month (like 'F*** it February').
Dose2-3 times a week for a month, then assess.
For whomCouples experiencing desire discordance or a general decrease in sexual frequency.
WhySex begets sex; the more sex you have, the more you desire it. It helps cultivate responsive desire and reduces pressure on the initiator.
CaveatsThe goal is to 'show up' and participate, with no expectation of intercourse or orgasm. Consent is paramount, and activity can be stopped at any time.
The expert suggests that just as people schedule other important activities, they should schedule sex. She uses the example of 'F*** it February' where patients aim for sex 2-3 times a week during the shortest, romantic month. This strategy addresses responsive desire in women, where arousal often precedes desire. By scheduling, the pressure is removed from the partner who typically initiates, and the less interested partner knows they are working on an arousal pathway. The idea is that showing up and engaging in intimacy can lead to unexpected pleasure, much like going to a party you initially didn't want to attend but then enjoying it. After a month, many women report a sustained increase in desire.
There is really good data that sort of uh orgasms beget orgasms. Meaning like the more orgasms you have, the easier it is to have an orgasm in terms of training the system... And so I talk to my patients about scheduled sex as a way to sort of work on your desire.
Sensate Focus Exercise for Trauma Survivors
WhatA four-step program to gradually reintroduce intimacy and pleasure after sexual trauma, focusing on non-genital touch before progressing.
WhenOver weeks or months, depending on individual comfort.
DoseEach step can last a week or longer, with 20-minute sessions a couple of times a week.
For whomSurvivors of sexual trauma, or anyone seeking to re-establish intimacy after a period of disconnect or pain.
WhyCreates a safe, structured environment to reconnect with one's body and partner, rebuilding trust and pleasure without pressure for orgasm or penetration.
CaveatsRequires open communication and mutual consent between partners. Progress should be at the pace of the trauma survivor.
This evidence-based program, championed by experts like Dr. Leia Melhouser, is designed to help individuals, particularly trauma survivors, re-engage with intimacy. It involves a progressive series of steps: 1) Intimate touch with no touching of breasts or genitals. 2) Touching of breasts and genitals allowed, but orgasm is off the table. 3) Orgasm is allowed, but no penetrative sex. 4) Penetrative intercourse is allowed. The gradual nature of this exercise allows individuals to regain a sense of safety and control, focusing on pleasure and connection without the pressure of performance or specific outcomes. It helps to 'find yourself back in your body' and can be adapted to individual needs and timelines.
It's a it's a four-step program that can be done over a month, over four months. You can sort of pick how long each stage you want it to last... step one is to you know let's say spend 20 minutes a couple of times a week if you want it the stage to last a week is to sort of be intimate with your partner. No touching of the breasts, no touching of the genitals.
Vaginal Moisturizers
WhatUse suppositories containing hyaluronic acid or polycarbophil to moisturize vaginal tissues.
WhenNightly, as part of a routine.
DoseOne suppository nightly.
For whomWomen who want to maintain vaginal health and comfort, particularly as they age or experience dryness.
WhyMaintains vaginal health, elasticity, and comfort, especially as women age, preventing dryness and discomfort during sex.
CaveatsThese are for long-term maintenance, not immediate lubrication for sex. If sex occurs after use, it's fine, but that's not their primary purpose.
The expert likens vaginal moisturizing to moisturizing one's face, emphasizing it as a long-term strategy for maintaining vaginal health. Products like Reie (hyaluronic acid suppository) and Replen (polycarbophil suppository) work by drawing water molecules into the vaginal cells, improving hydration and elasticity. This is crucial for preventing dryness and discomfort, which can otherwise lead to pain during intercourse. While not a substitute for immediate lubrication during sex, regular use of vaginal moisturizers contributes to overall vaginal tissue health, making sexual activity more comfortable and enjoyable over time.
Mechanism
Hyaluronic acid and polycarbophil are humectants that recruit water molecules into the vaginal cells, keeping the tissues hydrated. Hyaluronic acid also helps lower the vaginal pH, which is a natural and desirable outcome for vaginal health.
If you want to use your vagina when you're older, using a vaginal moisturizer, there's, um, good ones on the market. There's Reie, um, which is a hyaluronic acid suppository. It lowers the pH of the vagina and brings water molecules with it.
Local Estrogen Therapy for Vaginal Health
WhatApply topical estrogen directly to the vagina.
WhenAs needed, often in conjunction with systemic hormone therapy.
For whomWomen experiencing vaginal dryness, pain (dyspareunia), or other local symptoms, particularly post-menopausal women or cancer survivors, even if on systemic hormone therapy.
WhyTreats local vaginal conditions (dryness, pain) that may not fully respond to systemic hormone therapy, especially in post-menopausal women or cancer survivors.
CaveatsConsidered safe for almost all cancer survivors, a point emphasized by major medical societies.
The expert explains that local estrogen therapy is the 'vitamin C serum' or 'DNA repair enzyme' of vaginal care, focusing on long-term tissue health. About 30-40% of women on systemic menopause hormone therapy still require local estrogen for vaginal symptoms because systemic hormones may not fully address local tissue changes. This is particularly relevant for cancer survivors, where local estrogen is considered safe and effective for mitigating chemotherapy/radiation-induced vaginal dryness and pain. It directly improves the health of the vaginal lining, making it more resilient and comfortable.
Mechanism
Local estrogen directly targets estrogen receptors in the vaginal tissues, improving blood flow, elasticity, and natural lubrication, without significant systemic absorption. This addresses symptoms like dryness and pain more effectively than systemic hormones alone in some cases.
We treat local vaginal conditions with local treatment for women who don't respond from a vaginal health perspective to systemic hormones.
What's new
Personal practice updates, fresh positions, predictions
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Sexual Health as a Longevity Lever
The expert argues that sexual health is a critical component of overall health and longevity, not just an afterthought, impacting physical and mental well-being.
Why this matters: This reframes sexual health from a niche topic to a core element of a longevity-focused lifestyle, aligning it with other health pillars like sleep and exercise.
Background
Traditionally, sexual health is often considered secondary to other health concerns like cancer screening or chronic disease management. The expert challenges this hierarchy.
The expert emphasizes that sexual health directly contributes to a longer, healthier life. She connects it to the 'centenarian decathlon' concept, suggesting that maintaining sexual activity is a goal for many in their later years. Beyond emotional and mental well-being, there are physiological benefits. For instance, sexual activity, especially with orgasm, shifts the nervous system from sympathetic to parasympathetic, releasing relaxing neurotransmitters like dopamine and oxytocin, which improve sleep quality. Studies show that both subjective and objective measures of sleep (resting heart rate, sleep latency) improve with intercourse. Furthermore, sex can provide cardiovascular benefits, mimicking moderate-intensity exercise, burning 60-70 calories per encounter, and is often preferred over activities like walking on a treadmill for the same energy output.
This is clearly sexual health is health. And when you look at your longevity levers and you think about your centinarian decathlon and what you want to do when you're 100, for many people, this is on the list and I want to talk about how to structure your life and get you ready to do that.
Discordance of Sexual Desire as a Divorce Risk Factor
The expert highlights that the primary risk factor for divorce related to sex is not the frequency of sex, but rather the discordance in desire between partners (one wants more, the other less).
Why this matters: This challenges the common assumption that a specific frequency of sex is necessary for relationship health, shifting focus to mutual satisfaction and communication.
The expert presents statistics on sexual frequency among couples aged 30-60: about 20% have sex twice a week or more, 10% are 'never having sex' (meaning not in the last year), and 70% fall in between. Crucially, she states that the risk factor for divorce is not tied to these numbers, but to 'sexual desire discordance' – when one partner consistently desires more sex than the other. This insight suggests that open communication and alignment of expectations are more vital for relationship stability than adhering to a perceived 'normal' frequency.
When you look at risk factor for divorce, it's the same across all numbers in the sense that it doesn't matter how much sex you're having. You could never have sex or you could have lots of sex. The divorce risk factor is what we call sexual desire discordance or one partner wants more and one partner wants less.
Responsive vs. Spontaneous Desire in Women
Women predominantly experience 'responsive desire,' meaning arousal often precedes desire, unlike men who more commonly experience 'spontaneous desire' where desire arises in anticipation of intimacy.
Why this matters: This distinction is crucial for understanding female sexuality and provides actionable strategies for women and their partners to cultivate desire and arousal.
Background
Many women may feel abnormal if they don't experience spontaneous desire, leading to frustration or a sense of inadequacy. This explanation normalizes their experience.
Spontaneous desire, more common in men, is characterized by an immediate urge for intimacy, often triggered by visual cues. For women, responsive desire means that the desire for sex often emerges *after* arousal has begun, perhaps through physical touch, emotional connection, or a conducive environment. The expert suggests that women should not wait for spontaneous desire but actively 'curate' arousal through practices like using lubrication, vibrators, engaging in 'chore play' (emotional investments like making dinner), or reading erotic literature. This reframing empowers women to take an active role in their sexual experience and helps partners understand how to support their arousal.
Spontaneous desire is more common in men. Spontaneous desire is only present in about 15% of women. Women have what we call is responsive uh desire.
The 'Orgasm Gap' and its Health Implications
There's a significant disparity in orgasm frequency between men and women during partnered sex, with 95% of men reporting orgasm almost every time compared to only 30% of women with a male partner (and 12% in one-night stands). This 'orgasm gap' is framed as a health disparity.
Why this matters: This highlights a major inequality in sexual pleasure that impacts women's overall health and well-being, urging a re-evaluation of sexual health priorities.
The expert presents stark statistics: 95% of men consistently orgasm with a female partner, while only 30% of women do. This drops to 12% for women in one-night stands, compared to 90% for men. She argues that if sexual health is indeed health, then this significant disparity in pleasure constitutes a health disparity for women. This gap underscores the need for greater understanding of female anatomy, responsive desire, and effective stimulation techniques to ensure women experience comparable pleasure and health benefits from sexual activity.
If I've proven to you that sexual health is health, and if we understand that orgasm is one metric that we can use... this disparity or this discrepancy is a big deal. And this this disparity in how women experience pleasure becomes a health disparity because if sexual health is health and women are not experiencing it with the same amount of pleasure that men are, this is a health disparity.
Anatomical Ignorance and the Clitoris
Many women, and especially men, lack fundamental knowledge about female sexual anatomy, particularly the full extent and function of the clitoris beyond its visible tip.
Why this matters: This lack of anatomical literacy contributes to the orgasm gap and pain during intercourse, emphasizing the need for better, pleasure-focused sex education.
Background
Traditional sex education is often fear-based and lacks detailed anatomical and pleasure-focused information, leading to widespread ignorance.
The expert points out that only 41% of Gen Z men can accurately identify the clitoris on a diagram, and many women are unaware of its full structure. She explains that the clitoris is much larger than its visible tip, extending internally with 'crura' (wishbone-like structures) and a 'vestibule' that engorges with blood. It contains two types of nerve fibers: Type A (vibration, deep pressure) which are myelinated and age better, and Type C (heat, light touch). Understanding this anatomy is crucial for effective stimulation. For example, the G-spot is an internal branch of the clitoral nerve, and only about 10% of women can orgasm from its stimulation alone, with the majority requiring external clitoral stimulation. This anatomical knowledge empowers individuals and couples to explore and optimize pleasure.
What women often don't know is that they have sort of what we call is the vestibule of the clitoris, which are these sort of bulblike structures that can receive engorgment or when there's an increase in blood flow. And then there's the crew of the clitoris, which is these nerve structures that go on either side of the labia minora.
Perimenopause Management: Ovulation Preference
A critical first step in managing perimenopausal symptoms and hormone therapy is determining whether a woman prefers to continue ovulating or suppress it, as this dictates the treatment pathway.
Why this matters: This offers a personalized approach to perimenopause, moving beyond a one-size-fits-all model and empowering women to make informed choices based on their symptoms and preferences.
Background
Perimenopause is characterized by fluctuating hormones and often debilitating symptoms, making treatment complex. Traditional approaches may not fully address individual needs.
The expert explains that perimenopause involves the brain 'yelling' at the ovaries to ovulate, leading to erratic hormone fluctuations and symptoms like PMS, mood swings, and irregular bleeding. For women who enjoy the benefits of ovulation (e.g., higher sex drive, peak performance in the first half of their cycle), the approach might involve hormone therapy that doesn't suppress ovulation. However, for the majority (70-80% in her practice) who suffer from PMS or PMDD and prefer not to ovulate, contraceptive pills (even newer ones with natural estrogens) become a viable option. This initial 'branch point' decision is crucial for tailoring effective and satisfying hormone management.
The first question that I try to answer in my interview with my permenopausal patients is do you like ovulating or not? And that's the sort of first branch point at which I sort of decide how I'm going to approach this patient.
Recommendations
Products, supplements, and tools mentioned in the episode
11 items
Uber Lube
Product
Recommended as a silicone-based lubricant with an ideal osmolality for vaginal health.
Uber Lube is highlighted for its osmolality of 600 mOsm/kg, which is closer to the physiological osmolality of the vagina (300 mOsm/kg) compared to many common drugstore brands (e.g., Astroglide at 8000, KY at 4000-6000). The expert prefers silicone-based lubricants because they last longer and avoid the hyperosmolar additives found in many water-based lubricants that can paradoxically dry out the vagina over time.
I like Uber lube. The osmol Uber like you're getting like what I took here. Yeah. Like I took an Uber here. So I like Uber lube. Um the osmolality is 600.
Recommended as a silicone-based lubricant with an ideal osmolality for vaginal health.
This lubricant is praised for its osmolality of 280-300 mOsm/kg, which is almost perfectly matched to the natural osmolality of the vagina (300 mOsm/kg). This ensures that the lubricant supports vaginal hydration rather than drawing water out of the tissues, a common problem with hyperosmolar lubricants. It's presented as a superior choice for maintaining vaginal health and comfort during sexual activity.
I like good, clean, love, almost naked. Osmolality is about 280 to 300. The osmality of the vagina is 300.
A vaginal moisturizer for long-term vaginal health.
Reie is a hyaluronic acid suppository designed to be used as a vaginal moisturizer. Hyaluronic acid is a humectant, meaning it draws water into the tissues, helping to keep the vaginal lining hydrated and healthy. It also contributes to lowering the vaginal pH, which is beneficial for the vaginal microbiome. This product is recommended as part of a regular routine, similar to facial moisturizer, to maintain vaginal elasticity and comfort over time, rather than for immediate lubrication during sex.
There's Reie, um, which is a hyaluronic acid suppository. It lowers the pH of the vagina and brings water molecules with it.
A vaginal moisturizer for long-term vaginal health.
Replen is a polycarbophil suppository that, like hyaluronic acid, works by recruiting water molecules to moisturize the vaginal tissues. It serves the same purpose as Reie: to maintain the health, hydration, and comfort of the vagina as part of a regular, long-term care routine. This helps prevent dryness and discomfort that can arise from aging or other factors, contributing to more comfortable sexual experiences.
There's Replen, which is a, um, polycarbophil, um, suppository that also recruits water molecules.
A book by Emily Nagowski that discusses female sexuality, particularly responsive desire.
Emily Nagowski, who wrote Come As You Are, talks about, you know, it's Friday night and you really want to put on your bathrobe and watch Love Island, but instead you're going to go to a party with your friends because you said you would and you get there and it's actually kind of fun.
A book that helps women understand their anatomy and pleasure.
Clitorate is a great book to think through different ways that you can sort of improve your communication about what pleasures you and how to investigate that.
A website that educates women (and men) on female anatomy and various techniques for pleasure and orgasm.
OMGyes.com is described as a valuable resource for learning about female anatomy and pleasure techniques. It offers content that teaches women how to explore their own bodies and understand what works for them, covering different types of strokes (hard, round, gentle, internal). The expert encourages both women and men to use this platform to enhance their sexual literacy and improve communication with partners about pleasure. It's presented as a healthier alternative to pornography for sexual education.
There's really good websites now. OMG yes.com is a website that sort of talks about your anatomy and how to find it and how to find your pleasure spots.
Recommended for all women to maintain pelvic health, improve orgasm quality, and address pain or hypertonicity.
The expert suggests that pelvic floor physical therapy should be as routine as seeing a general physical therapist for overall musculoskeletal health. It can significantly improve the strength and tone of pelvic floor muscles, which is directly linked to better quality orgasms. Conversely, it's also crucial for addressing hypertonicity (overly tight pelvic floor muscles) that can result from stress, trauma, or pain, leading to conditions like vaginismus. By addressing both strength and relaxation, pelvic floor PT plays a vital role in preventing and treating sexual pain and enhancing pleasure.
I think every woman you know if you're sort of making a centinarian plan and you're seeing a physical therapist to keep your posture and your muscles healthy health healthy I think you should see a pelvic floor physical therapist. They're, you know, great in terms of increasing the tone of the pelvic floor. We know that strength of contraction can lead to better quality orgasms.
Lines worth pulling out — contrarian, specific, or perfectly phrased
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If you want to be able to have sex in your marginal decade, you need to have a V2 max of probably about 30 milliliters per kilogram per minute. Why? Because it would be pretty tough to have sex if you were doing it right at your maximum V2.
This quote humorously and concretely links a specific physiological metric (VO2 max) to the ability to maintain sexual activity into old age, reinforcing the idea of sexual health as a longevity lever.
I would argue that women need no friction.
This is a strong, contrarian statement that challenges the common perception that friction is a necessary component of sexual pleasure for women, instead emphasizing its role in causing pain and micro-tears.
This has nothing to do with your husband and nothing to do with your relationship.
This quote addresses the common misconception that a woman's changing sexual needs (e.g., needing a vibrator) are a reflection of her partner or relationship, instead framing it as an evidence-based physiological change due to aging nerves.
We would diagnose her as normal.
This statement normalizes the experience of the vast majority of women (90%) who cannot orgasm from penetrative intercourse alone, countering societal pressures and potential feelings of inadequacy.
I think that education about all bodies should be provided to all people.
This encapsulates the expert's philosophy on sex education, advocating for comprehensive, inclusive, and anatomically accurate information for everyone, regardless of gender.
Smoking vaping obviously have a great impact on the lung was you know incredibly worried about that. Um, one of the best ways to to sort of dose adjust is to to get uh name brand THC.
This provides practical, harm-reduction advice for those considering cannabis for sexual enhancement, emphasizing safer consumption methods and precise dosing.
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Educational summary of the cited expert source — not medical advice. Open the source recording linked above and consult a qualified physician before acting on any protocol.
