#371 – Women's sexual health: desire, arousal, and orgasms, navigating perimenopause, and enhancing satisfaction | Sally Greenwald, M.D., M.P.H.

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Nov 3, 2025

Dr. Sally Greenwald, an OB-GYN specializing in women's sexual health, delves into the intricate world of female sexual wellness. She discusses the importance of sexual health for overall well-being, exploring the physiology behind desire and arousal. Highlights include navigating the orgasm gap, practical strategies to enhance intimacy, and the impact of hormones during perimenopause. Sally also addresses common misconceptions, effective communication with partners, and the latest in contraceptive and hormone therapy options, providing vital insights for women and their partners.

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ADVICE

Schedule Sex To Rebuild Responsive Desire

Try scheduled sex (e.g., twice weekly) as a behavioral tool; 'fuck it February' uses scheduled encounters to retrain desire.
Showing up without pressure often restores responsive desire and can increase long-term frequency.

INSIGHT

'Do You Like Ovulating?' Is A Key Branch Point

Ask perimenopausal women whether they 'like ovulating' as a key branch point for treatment.
That preference guides whether to use contraception that suppresses ovulation or menopause hormone therapy that may preserve ovulation.

ADVICE

Combine Progestin Contraception With Estradiol Patch

If you don't want to ovulate but want bone/menopausal benefits, consider combining a progestin-only ovulation suppressor with a 17‑β estradiol patch.
This gives contraception and physiologic estrogen while suppressing ovulation to control perimenopausal symptoms.

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Sally Greenwald is an OB-GYN who specializes in women's sexual health from a hormonal and physiologic perspective, with expertise spanning desire, arousal, pelvic floor function, contraception, and menopause care. In this episode, she explains why sexual health is a vital component of overall well-being, exploring topics such as the drivers of desire, the anatomy of sexual function, myths and realities around orgasm, and the role of hormones in perimenopause and menopause. She also covers vaginal and pelvic health, pain with sex, evidence-based therapies for low desire and arousal, how contraception and medications can affect sexual function, and practical strategies for enhancing sexual satisfaction and maintaining intimacy across life stages. This episode offers a comprehensive, evidence-based discussion with immediate real-world relevance for women as well as for men who want to better understand their partners.

We discuss:

How sexual health influences physical health, emotional well-being, and relationships [3:15];
Understanding the physiology of the female orgasm, sexual comfort and satisfaction, and the disparity between men and women [12:45];
Foreplay, the science of desire, and methods to help women cultivate arousal and connection [19:00];
The physiology and sources of female lubrication, the role of clitoral nerve anatomy in pleasure, and the use of lubricants and vibrators to enhance comfort and sexual health [23:45];
Understanding female anatomy and what is needed for orgasm [31:15];
Understanding sexual desire, how to cultivate it, the role of hormones, and testosterone therapy in women [41:15];
Personalizing perimenopause care: how desire for ovulation guides the choice between contraception and menopausal hormone therapy [49:30];
Considerations for choosing contraceptives and hormonal therapies during perimenopause [59:45];
Factors negatively affecting desire, and why female libido persists with age and fluctuates across the menstrual cycle [1:11:00];
How sexual trauma and physical pain can affect sexual health, and evidence-based strategies for recovery [1:15:15];
Vaginal care routine: lubricants, moisturizers, topical hormones, and other approaches for vaginal health [1:19:15];
Tips for sexually satisfying your female partner [1:25:45];
The pharmacology of arousal: various treatments for low sexual desire in women [1:30:30];
Sex during and after pregnancy: impact on arousal, safety of sex, and how to manage postpartum recovery and pain [1:37:45];
How Sally would redesign sex education [1:42:15];
Sally's optimism about a new era in women's sexual health [1:49:00]; and
More.

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