Women's Sexual Health and Pelvic Wellness: Common Issues and Treatments
TL;DR
- Viewing pornography can habituate individuals to specific, high-intensity stimulation, potentially making partnered sex less satisfying and requiring conscious effort to re-sensitize to real-life intimacy.
- The "orgasm gap" between heterosexual men and women stems from a lack of education on female anatomy and pleasure, highlighting the need for open communication and clitoral stimulation.
- Pelvic organ prolapse, a weakening of pelvic floor muscles causing organs to descend, is a common quality-of-life issue that can be addressed through physical therapy and other interventions.
- Genitourinary syndrome of menopause, characterized by vaginal dryness and recurrent UTIs due to estrogen depletion, is highly treatable with vaginal estrogen, significantly improving quality of life.
- Low sexual desire in women is multifactorial, influenced by stress, sleep, relationship dynamics, and hormonal changes, with treatment options including lifestyle adjustments, medications, and testosterone therapy.
- Orgasms offer significant health benefits, including reduced heart rate, lower blood pressure, improved sleep, and pain reduction, underscoring their value as a "medical tool."
- Addressing pelvic floor dysfunction, whether weakness or tightness, is crucial for maintaining continence, sexual function, and overall pelvic health, often requiring specialized physical therapy.
Deep Dive
Dr. Rena Malik, a urogynecologist, argues that sexual health and pelvic wellness are critical, yet often stigmatized, aspects of women's health, particularly during perimenopause and menopause. This episode debunks common myths and provides actionable insights into pelvic floor function, incontinence, sexual health, and the genitourinary syndrome of menopause, emphasizing that these issues are common, treatable, and deserve open discussion.
The conversation highlights that pelvic floor dysfunction, including stress and urge incontinence, affects one in three women and is often exacerbated by childbirth, obesity, and lifestyle factors. Dr. Malik clarifies that while not life-threatening, these conditions significantly impact quality of life and can worsen if left unaddressed. She stresses the importance of seeking specialist care, such as from a urogynecologist or pelvic floor physical therapist, who can diagnose and treat issues related to both weakened and overly tight pelvic floors. The genitourinary syndrome of menopause, characterized by vaginal dryness, discomfort, and recurrent UTIs, is also a significant concern, which can be effectively managed with vaginal estrogen therapy.
Beyond pelvic floor health, the discussion delves into sexual function, emphasizing that the clitoris, with its 10,000 nerve endings, is the primary source of pleasure and the most reliable route to orgasm for most women. Dr. Malik explains that changes in hormones, particularly estrogen and testosterone decline, coupled with potential decreases in blood flow, can lead to diminished clitoral size, reduced sensation, and weaker orgasms. She addresses the "orgasm gap," noting that women in heterosexual relationships experience fewer orgasms than men, a disparity that disappears in same-sex relationships, suggesting that a lack of education about female anatomy and clitoral stimulation contributes to this. The episode also tackles the complexities of desire, differentiating between arousal (blood flow-related) and desire (brain-related), and outlines treatment options for low desire, including medications like flibanserin and vyleesi, and off-label testosterone therapy. Finally, the conversation addresses the prevalence of UTIs in midlife women, linking them to hormonal changes and offering preventative strategies like increased hydration and proper bladder emptying, while also debunking myths around cranberry juice and advocating for open communication about sexual health with partners and children.
Action Items
- Audit pelvic floor function: Assess for weakness, tightness, or prolapse using a standardized checklist across 5 key movement patterns.
- Implement vaginal estrogen therapy: For women experiencing genitourinary syndrome of menopause, initiate daily or twice-weekly vaginal estrogen to restore vaginal health and reduce UTI risk.
- Track sexual activity frequency: Aim for weekly intimate encounters, focusing on connection and pleasure, to support cardiovascular health and mood.
- Explore clitoral stimulation techniques: For women experiencing orgasm difficulties, dedicate 15-30 minutes to focused clitoral stimulation to achieve climax.
- Discuss sexual health openly: Initiate conversations with partners and children about anatomy, pleasure, and safe sex practices to destigmatize and educate.
Key Quotes
"orgasm are great they have huge health benefits they decrease heart rate decrease blood pressure they help you with sleep for some people they help with focus because they get this like post orgasmic clarity but like really they are so beneficial in fact like we know they decrease pain right so some people who are having pain with orgasm and pain goes down and so with there's not a lot of studies looking at this because you know there's obviously like irb issues but like i think if people looked at orgasms as a medical tool sometimes like we'd probably see a lot more benefits than we do and there are 10 000 nerves that you are not using ladies"
Dr. Malik highlights the significant health benefits of orgasms, framing them as a potential medical tool. She emphasizes their positive impact on physiological markers like heart rate and blood pressure, as well as their role in pain reduction and improved focus. The interpretation points to the underutilization of orgasms in medical practice due to a lack of research.
"absolutely so to start incontinence is very very common right one in three women experience incontinence so the fact that no one's commenting there's this is not uncommon if you look at my instagram for example you will see no comments like i put tons of content out but no one's commenting on sexual dysfunction urinary problems on anything because they're embarrassed right and that's a real problem we know that like i said one in three women are suffering from leakage now a lot of it is due to childbirth because it weakens the pelvic floor"
Dr. Malik addresses the prevalence of incontinence, stating that one in three women experience it, and attributes much of this to childbirth weakening the pelvic floor. She notes the common embarrassment surrounding these issues, which leads to a lack of open discussion and comments on related content. This quote underscores the widespread nature of incontinence and the societal stigma that prevents women from seeking help or sharing their experiences.
"basically what happens is that the pelvic floor muscles tense up and they don't relax and this can be due to a lot of different things it can be due to trauma it can be due to prior like stress anxiety you know community being a type a personality it's basically like everyone knows about tmj dysfunction right people clench up their jaw at night and they wake up with headaches or they have their grinding their teeth it's the same type of thing the muscles are clenching up involuntarily you're not telling them like oh i'm stressed like clench up they just do it right and when they're tight and you can't relax them then they can't function normally which means they can create issues like your your bladder is sitting right on top of those pelvic floor muscles so when it's tense it's like oh hey you got to go got to go you got to go more often"
Dr. Malik explains the concept of a tight pelvic floor, describing it as muscles that tense up and fail to relax, often due to trauma, stress, or anxiety. She uses the analogy of TMJ dysfunction to illustrate how these muscles can involuntarily clench. The interpretation highlights that this chronic tension can lead to various issues, including increased urinary urgency because the tense pelvic floor irritates the bladder.
"so pelvic organ prolapse is essentially a weakness in the pelvic floor that causes a essentially essentially a hernia right so you see the vaginal wall coming down into the vaginal canal and this causes sort of a a feeling of pressure like something's falling out like you have a tampon falling out of the vagina sort of that kind of feeling and so again not dangerous for the large majority of people when it gets really severe sometimes that can cause more problems but for the large majority of people this is a quality of life issue because they feel this pressure"
Dr. Malik defines pelvic organ prolapse as a weakness in the pelvic floor leading to a hernia-like condition where the vaginal wall descends. She describes the common sensation as feeling like something is falling out or a tampon is dislodged. The interpretation emphasizes that while generally not dangerous, prolapse significantly impacts quality of life due to the persistent feeling of pressure and discomfort.
"yes absolutely so the clitoris is identical to the penis so if you were to look anatomically and you were to do a dissection the tissues would just be a little smaller but they're literally identical there's a shaft a clitoral shaft that goes deep into the pelvis and then it forks around the vagina and it has these clitoral bulbs and so it's basically like a wishbone so it goes deep into the pelvis it goes around the vagina and it is extremely sensitive in fact it has more nerve endings than the head of the penis so the clitoris has 10 000 nerve endings it is the only structure in the female body and in any human body that is there solely for pleasure right there's no urethral thread going through it there's it is solely for pleasure and it is the most reliable route to orgasm"
Dr. Malik asserts that the clitoris is anatomically identical to the penis, extending deep into the pelvis with bulbs that surround the vagina. She emphasizes its high concentration of nerve endings, stating it has 10,000 nerve endings and is the sole structure in the human body dedicated to pleasure. This quote underscores the clitoris's primary role in female sexual response and its reliability as a pathway to orgasm.
"so i think the one thing to take if you're watching it yourself is like this is a produced product they use lubricants they use all sorts of things to make it look like the camera angles to make it look a certain way and they're actors they're acting like they are literally screaming and they know how to fake an orgasm and they fake squirting and they do all these sorts of things that that and they also chose this profession for a reason right maybe they are hypersexual maybe they do enjoy maybe they are very responsive and they're easy to orgasm but that is not the norm right the norm for women is that it takes 15 to 30 minutes for full arousal for their vagina to lengthen and widen to accommodate and to naturally lubricate to accommodate a phallus right and so they take time and again 85 of women need clitoral stimulation to climax and so they're not going to climax through just vaginal penetration alone that's what normal is right"
Dr. Malik clarifies that pornography is a produced product featuring actors and specific techniques that do not represent typical sexual experiences. She states that the norm for women involves a longer arousal period (15-30 minutes) and that 85% require clitoral stimulation to climax, often not achieved through vaginal penetration alone. This interpretation highlights the discrepancy between media portrayals and realistic female sexual response.
Resources
External Resources
Books
- "Yes, Your Kid" by Dr. Debbie Herbnik - Mentioned as a resource for understanding how children interact with pornography and sexual content.
Articles & Papers
- Study on testosterone levels and abstinence (Unpublished) - Mentioned as a study that found a tiny increase in testosterone and more intense orgasms in men who abstained for 21 days, though the intensity may be due to anticipation.
People
- Dr. Rena Malik - Guest urologist and sexual medicine specialist, assistant professor at the University of Maryland School of Medicine, known for educational content on YouTube and Instagram.
- Dr. Stephanie Estima - Host of the podcast "BETTER! Muscle, Mobility, Metabolism & (Peri)Menopause."
- Esther Perel - Mentioned in relation to the concept of "maintenance sex" in long-term couples.
- Vanessa and Xander - Sex therapists and hosts of the podcast "Pillowtalks," recommended for their practice of daily kissing as a ritual to reconnect.
- Dr. Nicole Prousy - Mentioned in relation to a study on multiple orgasms in women.
- Dr. Debbie Herbnik - Author of "Yes, Your Kid," discussed for her research on children's interaction with pornography.
- Sue Johanson - Canadian sex educator, mentioned as a predecessor to Dr. Rena Malik in frank discussions about sex.
Organizations & Institutions
- University of Maryland School of Medicine - Affiliation of Dr. Rena Malik.
- American Urological Association - Awarded Dr. Rena Malik "Young Urologist of the Year" in 2023.
Websites & Online Resources
- YouTube - Platform where Dr. Rena Malik shares educational content.
- Instagram - Platform where Dr. Rena Malik shares educational content.
- Rina Malik MD Podcast - Podcast hosted by Dr. Rena Malik.
- Pornhub - Mentioned as a source of pornography accessible to children.
- Netflix - Platform where the show "Sex Life" was mentioned as featuring clitoral stimulation.
- HBO - Platform mentioned as a possible host for the show "Sex Life."
Other Resources
- Flibanserin (Addy) - Medication taken daily at night to help with desire in premenopausal and postmenopausal women.
- Vyleesi - Injection medication taken on demand to increase desire, with potential side effects like nausea.
- Vaginal estrogen - Treatment for genitourinary syndrome of menopause, shown to reduce recurrent UTIs.
- Pelvic floor physical therapy - Recommended for improving pelvic floor strength and addressing dysfunction.
- Pelvic floor wands - Devices used for people with pelvic floor tension to relax or stretch muscles.
- Dilators - Devices used for people with pelvic floor tension.
- Pelvic floor trainers - Devices that provide feedback on pelvic floor muscle squeezing.
- Pessary - A device inserted into the vagina to support pelvic organs in cases of prolapse.
- Vaginal hormones - Treatment for genitourinary syndrome of menopause.
- AG1 - Nutritional supplement used by the podcast host to cover nutrient gaps and support gut health.
- Bondcharge Massage Gun - Mentioned as a tool for muscle relief with heat and cold therapy options.
- OS1 Hair Peptide Scalp Serum - Product from OneSkin designed to target cellular senescence for age-related hair loss.
- Cranberry supplements - Recommended for UTI prevention, specifically those with 36mg of soluble proanthocyanidins.
- 100% Cranberry Juice - Recommended for UTI prevention, though noted as unpalatable.
- Vaginal pH testing - Used to assess hormonal changes.
- Testosterone replacement therapy - Considered for women with low desire and low testosterone levels.
- Compounded testosterone cream - A form of testosterone therapy for women.
- Testosterone pellets - A form of testosterone therapy, with potential side effects if levels become too high.
- Viagra and Cialis - Medications for erectile dysfunction in men.
- Scream creams - Topical creams for arousal difficulties in women.
- Oral medications for arousal difficulties in women - Mentioned as having mixed results in small studies.
- Choking - Mentioned as a sexual practice increasingly seen in pornography that can be dangerous.
- Masturbation - Discussed in relation to pornography use and pleasure.
- Orgasm - Discussed as having health benefits including decreased heart rate, blood pressure, and improved sleep and focus.
- Genitourinary syndrome of menopause (GSM) - A collection of symptoms related to hormonal changes during menopause.
- Responsive desire - A type of desire that arises after intimacy has begun, common in women.
- Maintenance sex - The practice of regular intimacy in long-term relationships to maintain connection.
- "The Orgasm Gap" - The difference in orgasm rates between men and women, particularly in heterosexual encounters.
- Clitoral stimulation - Identified as crucial for most women to achieve orgasm.
- G-spot stimulation - Mentioned as a potential source of orgasm for some women.
- Cervical stimulation - Mentioned as a potential source of orgasm for some women.
- Semen retention - A practice discussed in relation to potential benefits for men, though scientific evidence is limited.
- "No Nut November" - A challenge related to semen retention.
- Edging - The practice of bringing oneself close to orgasm and then stopping, potentially leading to more intense orgasms.
- Pelvic organ prolapse (POP) - Weakness in the pelvic floor causing organs to descend into the vaginal canal.
- Urinary incontinence - Leakage of urine, including stress incontinence and urge incontinence.
- Tight pelvic floor - A condition where pelvic floor muscles are tense and do not relax properly.
- Pelvic floor muscles - Muscles that support the pelvic organs.
- Kegel exercises - Pelvic floor muscle exercises.
- Smegma - A natural secretion that can accumulate under the clitoral hood.
- Adhesions - Scar tissue that can cause tissues to stick together.
- Clitoral hood - The fold of skin covering the clitoris.
- Clitoral atrophy - Shrinking of the clitoris, potentially due to hormonal changes and reduced blood flow.
- Erectile dysfunction (ED) - Difficulty achieving or maintaining an erection in men.
- Cardiovascular disease - Mentioned as a potential parallel concern for women experiencing arousal difficulties.
- Lactation - A state that can involve low estrogen levels.
- Lactobacilli - Beneficial bacteria in the vagina that help maintain a healthy pH.
- Proanthocyanidins - Compounds found in cranberries that may help prevent UTIs.
- Soluble proanthocyanidins - The specific form of proanthocyanidins that is effective in cranberry supplements.
- Kidney stones - Mentioned as a potential cause of recurrent UTIs.