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

Peter Attia

Nov 3, 2025

Episode description

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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, moist

Episode description

View the Show Notes Page for This Episode

Become a Member to Receive Exclusive Content

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, moist

Mindsip insights from this episode:

Implement three-step vaginal health routine for optimal care

Adopt a three-step vaginal health routine analogous to facial care: use lubricant like sunscreen, a vaginal moisturizer like face cream, and local hormones as a long-term health serum.

#skin

#vagina

Choose silicone-based lubricants with optimal osmolality for vaginal health

Use silicone-based lubricants with an osmolality near 300, like Good Clean Love, as popular brands like KY or Astroglide can have an osmolality of 4,000-8,000, which dehydrates vaginal tissue.

#vagina

Utilize vibrators to maintain orgasm as nerve fibers age

As women age, the nerve fibers responsive to light touch degrade, while myelinated fibers responsive to vibration and deep pressure remain, making vibrators an evidence-based tool for maintaining orgasm.

#aging

#device

Recognize responsive desire in women to enhance intimacy

Unlike men who often have spontaneous desire, about 85% of women experience "responsive desire," meaning desire is triggered in response to arousal, not in anticipation of it.

#sex

#women

Acknowledge need for external clitoral stimulation in 90% of women

It is completely normal for the 90% of women who cannot orgasm from penetrative intercourse alone to require external clitoral stimulation.

#orgasm

#women

Utilize low-dose THC to enhance orgasm satisfaction and sex drive

A low dose of 1-2 milligrams of THC can significantly increase orgasm satisfaction and sex drive, whereas higher doses may be sedating and have an adverse effect.

#sex

Address sexual desire discordance to reduce divorce risk

The biggest risk factor for divorce is not the frequency of sex, but "sexual desire discordance," where one partner wants more sex than the other.

#relationships

#risk

Determine ovulation preference to guide perimenopause hormone strategy

For perimenopausal women, the first question to determine hormone strategy is "do you like ovulating or not," which guides the choice between ovulation-suppressing contraception or non-suppressing MHT.

#hormones

#perimenopause

Peter Attia

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