Sexual Health, Libido, and Orgasm: What Medicine Missed with Dr. Kelly Casperson

18:02Dr. Kelly Casperson:I remember early in my social media life, there was a group of physicians and you were talking about, do you take out the cervix or the hysterectomy? And me kind of going to Ishwish and learning about Dr. Goldstein's data of like the cervix, for some people, is an important sexual structure. Not everybody, but some people probably should ask about that before you talk about cervix sparing or not hysterectomy. And they're like, there's no data. And then I published, I said, these are the papers looking at the innervation of the cervix and the effect on sexual health. And then the response is, but there's not a lot of data.

18:36Dr. Kelly Casperson:So it's like dismissed every, like, there's no data, then there's not enough data. And it's like, when are you going to realize that these people have sexual health issues in their pelvis? And so do these people. We all started from the same thing. We just care about these people's quality of life better. So, you know, to me, again, it's gender equality until the end of like, that's my why. Of like, I just want the same thing for women that men get. And the other thing I see a lot is you're medicalizing women. You're medicalizing them if you're trying to give them Addy or you're trying to give them hormones.

19:11Dr. Kelly Casperson:And I'm like, did anybody say we were medicalizing the men in 1998 when we came out with Viagra? Did anybody say Pfizer? You shouldn't make billions of dollars from solving their problems. From a non-erect penis. Yeah. So we're only medicalizing. Again, we're keeping women from having what men already have.

19:29Dr. Mary Claire Haver:Let's do some sex med 101 for our listeners, because none of us learned anything in our sex education. If you got any, it was basically sex education was how to not get pregnant.

19:40Dr. Kelly Casperson:Don't get a disease and don't get pregnant.

19:42Dr. Mary Claire Haver:You know, and those are important things.

19:44Dr. Kelly Casperson:Take a test. but they're important things but for the average let's say midlife person who might you know they've got birth control they're in a long-term committed relationship that has nothing to do with their sex life at all and we've just left them hanging in my residency so i did ob-gyn we had full blocks

20:03Dr. Mary Claire Haver:about 60-ish percent of my training maybe 55 was obstetrics important stuff right how to get someone pregnant keep them pregnant and you know healthy and get the baby delivered and then all the postpartum care. Okay, fine. Then it's a four-year residency. Then we had gynecology where everything else was lumped in and that was pediatric gynecology, gen oncology, all the cancer stuff. So ovarian cancer, vulvar cancer, vaginal cancer, all those, you know, we had full blocks on that. We had reproductive endocrinology, which is ended up being a catch-all for helping people get pregnant who were struggling to get pregnant.

20:37Dr. Mary Claire Haver:In the REI block, which we had two rotations and four years of residency. So two six-week blocks, one lecture per week on menopause. That was it. And nothing on sex med. Absolutely nothing. I didn't know that there was any treatments available. So I get out of my residency and I think I am a well-prepared OBGYN. And granted, what we focused on in the residency program was not sex med. No one came in complaining of much, or we were thought that they were a little bit crazy because that's also what we were taught. women somaticize psychological issues. But I'm getting out and I have my gynecology patients.

21:14Dr. Mary Claire Haver:And as I'm walking out the door after they're well woman, they're like one more thing. They would gather the courage and take a deep breath to admit in their little paper gowns, you know, with their butts on the paper, start talking about sexual dysfunction. And I was a deer in the headlights. I had no idea how to help them. And so many were, I was shocked by the percentage of patients, well-educated, resourced women who were complaining with tears in their eyes. And I had no idea what to do. Nothing.

21:47Dr. Kelly Casperson:It's not life-threatening, right? And in our training, I'm not excusing our training. I'm just being like, you know, it's hard to argue that getting a baby out safely in cancer isn't more important when you're like, we've got 80 topics and two minutes to teach everything. But as far as quality of life goes, sexual health is huge. It's absolutely huge. And so, like, disproportionately of, like, uterine cancer is awful, but it's thankfully pretty rare. Sex is everybody, right? So, like, as a percentage of, like, maybe we should learn things in percentage to how much it affects people, sex med affects everybody.

22:24Dr. Kelly Casperson:And so when you think of it like that, you're like, well, we are really underserved in our education for it. And I think about that because I didn't learn it in med school. I operated around the clitoris and didn't know that the clitoris had, you know, these... No, look like Gumby. Yeah. It looks like a penis that's kind of been widened and because they're the same structures. And I'm like, you're telling me I've been putting mid-urethral slings around the clitoris bodies for a decade and I didn't know that yes yeah that's that's what we're telling you and so i come to this very humbly of like if i didn't know i don't assume anybody else knows no i had no idea i'm the surgeon in the pelvis

23:02Dr. Mary Claire Haver:it's been amazing i think of all of the laceration repairs from obstetrics that we did and we were literally just throwing sutures to stop bleeding and repair anatomy without any thought of where

23:14Dr. Kelly Casperson:yeah scars hurt right and scars especially episiotomy scars it's a thin of tissue that's what a scar is. And then when perimenopause and postmenopause hits and we lose our protection from our hormones down there, those episiotomy scars get really tender and painful. And often they're around that six o 'clock part of the vulva. And so I always call it the six o 'clock spot, but that gets really thinned and irritated. And so I'll do an exam and I'll be like, did you have an episiotomy? And they're like, oh yeah, right there. It's like, that's what hurts.

23:43Dr. Mary Claire Haver:So it'll come back years and years after delivery, especially as the hormones change.

24:18Dr. Kelly Casperson:We'll see you next time. by state law.

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26:19Dr. Mary Claire Haver:Walk me through the female sexual response cycle.

26:22Dr. Kelly Casperson:You got to go way back to the 1950s, and we had Masters and Johnson and the Kinseys and the researchers, which was very groundbreaking because nobody had really documented the sexual health cycle. And so, stereotypically, it's kind of a rise up a hill and then a drop off. What do I mean? Desire, arousal, and then orgasm, and then resolution, right? Now, desire was assumed because if you're somebody in the 1950s traveling to the Midwest to have Kinsey and Johnson tie electrodes up to you and watch you have sex, desire is kind of implied, right? So they actually didn't have desire on there in the beginning.

26:58Dr. Kelly Casperson:It was just like arousal, orgasm, resolution. They put desire at the beginning. Well, if you put desire at the beginning, you're kind of broken if you don't have desire because it's at the beginning, right? Even though these people had no desire issues, they were like a little voyeuristic. They're like, I volunteer as a tribute to understand human sexuality. Yeah, yeah, yeah. They were willing to go. Rosemary Bassan comes along well after and she says, but women's desire doesn't always happen before they have sex. It could happen during sex. A desire for sex can happen after sex. And the example I give of that is like, you have amazing sex and then you look at your beloved and you're like, that was so good.

27:36Dr. Kelly Casperson:That was awesome. I forgot how good that is. Remind me how good that is again. We should do that again. That's me desiring sex right after I had sex, right? And so what we do is we think sex is this very linear, again, male model, very linear way of having sex, and women feel ultimately broken because they're not sitting around desiring sex all the time. And I'm like, of course you're not sitting around desiring sex all the time. You've got a job, you've got kids, you've got a household to manage, you're busy, and you're not in a sexual context, right? Like, this is very unsexual to me right now.

28:09Dr. Kelly Casperson:And I'm not interested in having sex. A lot of women will respond to being in a sexual context. I feel safe right now. I feel safe enough to have sex. I feel like I'm connected to you. That allows me to want to have sex, right? And so our society, and what does Hollywood get wrong about sex, is like everybody thinks desire has to happen first, and then no sex, because you don't have any desire. Instead of how the female sexual response cycle happens, thanks to Rosemary Besson and others, is, put yourself in a nice place, prioritize sex if you want it in your life. the desire will come. That's called responsive desire, right?

28:48Dr. Kelly Casperson:But Hollywood tells us about spontaneous desire, where desire comes first, go find somebody to have sex with. Instead of like, I want sex in my life. Let's prioritize it. Am I safe? Are we connected right now? Are we doing things that are arousing? Oh, yeah, yeah, sex is good. Let's have sex now, right? And so instead of waiting for the breeze of desire to blow in, we got to create the sexual circumstances that we want to be part of. What's the difference between desire and arousal? Good question. So I think of arousal as blood flow, right? And nobody thinks of the female pelvis as blood flow.

29:21Dr. Kelly Casperson:But when you think of a penis... Just like a man. Yeah. When you think of a penis and an erection, how does it get big and hard? Blood flow. And so the clitoris is the same. The clitoris will engorge with blood and that's surrounding the vulva. The whole pelvis fills with blood. And to me, I'm like, that's why you can't just put something in the vagina without being aroused. Number one, it can be traumatic and painful, right? Blood flow helps the tissues be resilient and help tolerate what's going to happen. Because I always joke, I'm like, the pelvis is like, is this a tampon? Like, what's your plan with this right now?

29:52Dr. Kelly Casperson:Like, you've got to let your pelvis know, like, what the plan is. So blood flow is helpful. New, exciting research looking at the role of vibration. And a lot of people will think a vibrator means putting something inside your pelvis, inside your vagina. That's not what these researchers did. They took vibrators, they put them on the outside of the vulva with no pretense of like, this is how you need to do it or that you have to have an orgasm. Just put it on the outside of the vulva. Increase blood flow, improve sexual function, help desire. And the prelim data says this might actually help with signs of atrophy and lichen sclerosis.

30:29Dr. Kelly Casperson:Yes, we need more data on that. But it's not the vibrator and it's not the sex. It's the blood flow that's helping that. And then you think, well, yeah, blood flow is good for our brain. It's good for our heart. It's good for our muscles. It's kind of a no-brainer that blood flow is good for your pelvis. Right? So when I think about arousal, I really think about blood flow. Now, where we're really lacking in research, we know tons about erectile dysfunction, right? Impaired blood flow as men get older affects the rigidity or the firmness or the time span of which the penis can be and stay hard.

31:01Dr. Kelly Casperson:We know that. Heart disease affects it. Diabetes affects it. Smoking affects it. Drugs. Drugs affect it. Well studied. Same anatomy in females. Not studied at all. We know that women with diabetes have more sexual dysfunction. Same with women with other medical issues. But it is not studied like the erection is studied. But same, same. Clitoris, penis. Same, same.

31:25Dr. Mary Claire Haver:Wow. And let's talk about the brain. What are the role of the neurotransmitters? Dopamine, serotonin. And what is the reward pathway?

31:33Dr. Kelly Casperson:Yeah. The brain is the biggest sex organ. and it plays a huge role. And I was like, you know, that's kind of when I got into like coaching and understanding the brain because I can give you vaginal estrogen. I can send you to a pelvic floor physical therapist. I can give you a really good pelvis. We can fix prolapse. We can help with leakage. But if you're not thinking about sex in a way that is pro-sex, that impairs your sexual health too. So biggest sex organ is the brain. Dopamine pathway is super interesting because dopamine is released on pursuing something bound to be rewarding. Why is that important with sex?

32:08Dr. Kelly Casperson:You can't take me out to dinner and feed me cold chicken and mushy broccoli and then say, well, why don't you like food, Kelly? Well, I don't like mushy broccoli. I can't desire something that's not rewarding to me. And so, so many women, and this was very interesting. So a male researcher, I was interviewing him for my podcast about women's sexual health and desire, and he knows a lot about this. And I'm like, wait, hold on. You're assuming women are having sex worth desiring. And he's like, well, yeah. And at that moment, I was like, whoa, that's such a male-centric way to think about sex because you're having desirable sex, right?

32:48Dr. Kelly Casperson:These women are having mushy broccoli sex and feeling beat up about it because they don't desire sex.

32:55Dr. Mary Claire Haver:Do we have percentages here? Do we know?

32:57Dr. Kelly Casperson:you can use orgasm as a proxy for quote-unquote good sex right where the experts will be like you can have good sex and not have an orgasm like we can get new or vice versa yeah but let's use orgasm as a proxy you can have an orgasm and think it's shitty you can have an orgasm and think it's shitty sex absolutely so let's look at the orgasm gap most pronounced in heterosexual couples so what they did and it's interesting because they did a recent study and an old study and the orgasm gap has not gotten better. Decades have gone by, not getting better, right? So the group with the largest disparity in chance of orgasm with having sex is the heterosexual man clocking in at around 97 % orgasm with intimacy with the heterosexual woman who clocks in around 60 % of the time.

33:45Dr. Kelly Casperson:Same-sex lesbians, same-sex gay men, they're all pretty matched up much higher. I think the Lesbians are like high 80s, gay men are up high 90s. The heterosexual female has the least amount of orgasm of any of those people. And 60 % is if she's in a long-term, loving, committed relationship.

34:05Dr. Mary Claire Haver:I think they only studied women in long-term, loving, committed relationships.

34:08Dr. Kelly Casperson:Yes, but then they studied hookup sex in college. And this is what you need to tell your daughters. So if it's hookup sex in college, he still has an orgasm, high 90s. she has an orgasm 7 % of the time. So to me, I'm like, honey, what are you participating in this game for? Risk of disease, risk of pregnancy, risk of societal shame, 7 % chance of orgasm? Don't play at that table in Vegas. Like, it doesn't make sense. That was a big aha for me is like, oh, the male researcher of female sexual desire thinks she's having sex worth desiring and that she's just not desiring it. And that's where sex education comes in, you think?

34:47Dr. Kelly Casperson:Yeah, well, you know, a woman will come in and she'll be like, I have a... Like, he's happy. He's getting off. He is having an orgasm. And usually he has no idea that it could be a different way. Right? Like, because we didn't get taught about sex, let alone how to talk about communicating about sex.

35:04Dr. Mary Claire Haver:Oh, God, no.

35:05Dr. Kelly Casperson:Let alone talking about communicating about bad sex. Right? So it's like, oh, we got some work to do. So I always say, talk about sex when it's good. like just normalize talking about good sex that was so great i love it when we do that tuesday tuesday morning seemed to be a good time for us to do that right just talk about having good sex because inevitably the sex might get not good i'm stressed i've got a deadline at work my mom's sick the kids need me more i just had a baby now we got rocky road sex right if we can talk about it when it's good we're all the more prepared to be like i love it when it's good and we already got that bond about talking about it.

35:43Dr. Kelly Casperson:Let's talk about it when it's rocky. So a lot of women will come in and they'll be like, I don't desire sex. I use a party metaphor. When you're at the party, is the party good? Do you like being at the party? And they'll be like, oh yeah, I love the party. Love it. Always great. Happy to be taken to the party. Don't always want to go to a party, but happy that I'm at the party. I'm like, great. Just prioritize partying. Go have great parties, versus, no, I don't even like going to the party. The party's kind of gray. Or party's kind of blah. And I think that's going back to the dopamine pathway.

36:16Dr. Kelly Casperson:When we talk about hypoactive sexual desire disorder and when we should do a medication for it, it's like, sex is gray. It's gray. But it used to be amazing. And it's not a relationship problem. Our relationship's great. But it used to be awesome. And it's just not bad anymore. Maybe it's a neurotransmitter issue. Maybe it is the brain. And that's where these medications come in. They are safe. They're effective. They've been completely derided by the media. Because again, the men get the Viagra and the women, what do you need that for?

36:49Dr. Mary Claire Haver:So let's go there. So what are the drugs you're talking about? There's two FDA approved medications you're talking about right now. And they work in the level of the brain.

36:57Dr. Kelly Casperson:Yep, they both work, theorized to work in the dopamine pathway or to influence the dopamine pathway. to help you want to desire something worth desiring. That's the stereotype. Are you just going to make a bunch of horny women who are going to go off and do crazy things? No, no, no, no. That's not what we're trying to do here. She had a great sexual relationship. Just the lights got dimmed. Let's help her out. Maybe it's a neurotransmitter issue. Incredibly safe. The Addy, which is full of banserin is the generic, been around for quite a while, just got FDA approved for 65 and under. We should definitely talk about that.

37:32Dr. Kelly Casperson:It's one pill a day. You take it at night. And it's not an on-demand drug. So you have to have it in your, kind of like an antidepressant or a high blood pressure medication. Like you have to just keep taking the medication in order for it to work. Take it for a couple of months to see if it helps or not. And if it doesn't help, you then can stop. The problem is many people's insurance in America has sexual health riders. A lot of people don't know this. So you're not going to get your Viagra covered.

37:57Dr. Mary Claire Haver:Wait, for women or for men?

37:59Dr. Kelly Casperson:All people. All people. But the good news is Viagra is generic and cheap.

38:02Dr. Mary Claire Haver:It's 13 cents. Yeah.

38:04Dr. Kelly Casperson:And Addy is not. It is still on brand. Just for people who are looking for it, then PhilRx, P-H-I-L-R-X, is the pharmacy. And you can go to Addy.com because you can't just go to Walgreens and get this medication. Yeah. Especially pharmacy if you want to get it. The other one is called Vilisi or Bremelanatide. That is an injectable, more of an on-demand desire medication. It just doesn't have as much use. I would say I don't know in America how much people are actually prescribing one versus the other. It has more nausea than Addy does, so that's bothersome to some people. They'll take an anti-nausea medication.

38:43Dr. Kelly Casperson:Being nauseous isn't very sexy, so it's not a great side effect if you're trying to have sex. What's super interesting about Addy, though, is it's FDA approved for women. It's in a pink box. What percentage of those prescriptions are taken by men? 10%.

39:00Dr. Mary Claire Haver:Really?

39:01Dr. Kelly Casperson:Pink box, FDA approved for women, 10 % of the prescriptions are taken by men. Why? Because it's a brain drug. We all have brains. It works the same. So there's actually published literature of men with trouble with orgasm. And it helps. It helps men with desire. So it's not that it only works in female brains. It was just designed and FDA approved for that.

39:22Dr. Mary Claire Haver:How much of women's sexual dysfunction is biology? And how much is culture? how much is stress?

39:30Dr. Kelly Casperson:I don't know if I've ever seen a breakdown. And my argument would be like, I don't think everything affects everything. And that's what the sex therapist would say. That's what the testosterone researchers would say is like, society affects our biology and our biology affects how you are in the world. And it's like so intertwined. But we certainly see distress with desire go up with age. So that might be more of a biology thing. But stereotypically, women are not thought of as biologic in the way that men are, right? Like where men are like, maybe this is a hormone problem. Like, you know, how many women have doctors who are like, your sexual health issue?

40:12Dr. Kelly Casperson:Maybe it's a blood flow problem. Maybe it's a neurotransmitter problem. Maybe it's a hormone problem. Yeah. The fact is we're blaming everything on society for women. And we're biologic beings also.

40:25Dr. Mary Claire Haver:What do you think is the most important scientific fact about women's sexual health that is just not being taught?

40:32Dr. Kelly Casperson:Women can have orgasms as easily as men. I mean, I see this perpetuated a lot. People will be like, women take longer. Well, there's a very awesome bisexual study. So they took bisexual women and they said, when you're partnered with a man and you're partnered with a woman, number one, how frequent do you have orgasms and how long does it take? You literally put a penis in the bedroom and her chance of orgasm goes down. Same biology. Yeah. Different partner. Which tells you a lot again about society. Who's, who gets the privilege of having an orgasm and then sex ends? The man, right? Stereotypically.

41:07Dr. Kelly Casperson:And so I just, I think that bisexual study is like such a glamorous way of being like, women are not difficult. Women do not take longer. Women sometimes need to take time to have arousal. Great, but that doesn't mean we're difficult.

41:20Dr. Mary Claire Haver:Why do so many women confuse libido with arousal? What is libido?

41:24Dr. Kelly Casperson:Well, nobody got any sex ed, so that's my answer to everything. So libido is thought of as the desire to pursue something. It actually comes from Freud. So Freud is such a good word. It's like libidinous. It's like the pursuit of something. So like the pursuit of food, the pursuit of water, the pursuit of sleep. And the less you have it, the more you pursue it because it's like life-saving, right? So it's these innate drives. And so Freud said libido or desire for sex is an innate drive. And so especially with the responsive desire folk, they're like, I must be broken because I don't desire this.

42:04Dr. Kelly Casperson:Like if I'm thirsty, I desire water, right? And the joke is like some men will be like, but I feel like I will die if I don't have sex. And like, I know, but you won't die like food and water, right? So it goes all the way back to Freud, and he messed up a lot of things for us. Famously, he said that the vagina orgasm is the adult orgasm. The clitoris orgasm is the infantile orgasm. So to be an adult woman, have you not heard that? No. So to be an adult woman, you must have an orgasm vaginally, aka your husband must provide it by putting something in your vagina. Okay, well, if that's the truth.

42:40Dr. Kelly Casperson:Oh, I've never even heard of a vaginal orgasm. Wait, there's more. So if Freud says it's the truth and that's the truth, you as a woman who wants to be an adult woman but can't, what would you do then? You can have a surgery that can move your clitoris closer to your vagina. Yes. In an age without antibiotics, these women were trying to surgically take their clitoris and put it closer to the vagina because Freud said that's the adult orgasm. It's fixed. Mm-hmm. And very famous women of the time had these surgeries. you can only imagine no anesthesia no antibiotics like so for if anybody's wondering uh Freud was wrong all you know you'll get into like the tantric people not to I'm not downplaying them but they'll be like I had a woman come and she's like I want to tell women about the 17 different ways to have an orgasm and I'm like they're they struggle to have one can we work on one like like don't give them you know like here's 17 different ways of like they're gonna be like They're happy with one.

43:39Dr. Kelly Casperson:Let's learn one first, right? I was like, oh my God, I thought I was broken. Now I'm really broken because there's 16 other ones I haven't done yet. To me, I'm like, most people think that stimulating the clitoris, however you're going to do that, is the orgasm. But there is research that people can stimulate their ear and have an orgasm and you can dream and have an orgasm. And right, so like our bodies are wonderfully complex and intertwined, but the clitoris is the organ of pleasure. The vagina is close, but we don't rub a scrotum and wonder why a man doesn't have an orgasm. It's close, but it's not his organ of pleasure.

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47:47Dr. Mary Claire Haver:Why are women still being gaslit about sexual function today?

47:50Dr. Kelly Casperson:Because nobody knows anything about sex. Like, doctors got no sex ed. No. But they're the authority on her having access to solutions that can help her sex life. Right? So it's like, if you don't know what you're talking about, A, learn, like, you know, I did. or B, keep your mouth shut, refer out, refer out. And Ishwish will say that. Ishwish will say, International Society for the Study of Women's Sexual Health, they'll say, you don't have to be an expert on everything, but refer out, refer out as needed. And I think, you know, why I wrote my first book, You Are Not Broken, is so much help can happen from a little bit of sex ed.

48:29Yeah.

48:29Dr. Kelly Casperson:A little bit of sex ed. Just validation. Just validation of like, oh, you need to incorporate the clitoris in pleasure. I didn't know that. I thought I was broken. Right. So it's like so much refer out books, podcasts, classes, sex therapists when needed. Like doctors don't have to know it all, but don't tell people wrong things.

48:51Dr. Mary Claire Haver:Yeah. What is an orgasm from a medical standpoint?

48:54Dr. Kelly Casperson:An orgasm, it's, you know, there there's an old saying of like, you know, porn when you see it, like define porn. Well, you know when you see it. So orgasm, that's what the experts will be like. You know it when you see it. It is a rhythmic contraction of the pelvic floor in 0.6 second intervals. What is the pelvic floor? Pelvic floor is a whole bunch of muscles that sit. You can't see them. You can't flex them like a bicep. But they sit in the base of the pelvis and they hold in your bladder. I'm flexing them right now. Flexing them right now. They hold in your pelvic organs, right? And they hold in your pee and they can get weakened with childbirth and they contract.

49:29Dr. Kelly Casperson:With coughing, with smoking, with, yeah. Yeah. Orgasm usually happens after stimulation, arousal, and then it's a release basically of a buildup. And that release is 0.6 second rhythmic contractions lasting for a couple of seconds to many, many, many minutes. For most people, incredibly pleasing. For some people, it can be people can get profound headaches afterwards or pelvic pain afterwards. But what's happening in the brain? I have a really awesome sex therapist friend and he's like, in the brain, you're dumb and happy with an orgasm. And what he means by that is the frontal lobe, which is our cognitive center, it is our planning, thinking, worry center, literally has to be shut off.

50:11Dr. Kelly Casperson:You can't have a frontal lobe activation and have an orgasm at the same time. I know it's so cool. So they put people in MRIs to actually prove it. They're like, and that went dark. And you had an orgasm. And you can't engage both at the same time. And that's why some people, you know, sex is different, means different things for different people. But where it comes close to, you know, Valhalla and spiritual and the present moment and just this release of all your worry from the world is because your frontal lobe goes dark in order to experience pleasure. It's very cool.

50:45Dr. Mary Claire Haver:So I advise patients who are struggling with like middle of the night awakenings and having racing thoughts. You know, usually if they can't self-soothe to go back to bed or do box breathing or meditation, I'm like, have an orgasm. And that will stop those thoughts right in their tracks and see if that will help sleep. Is that crazy of me to prescribe that?

51:04Dr. Kelly Casperson:I don't think it's crazy. To me, I'm like, make sure she's comfortable with sex. You have a decent role. Again, it's like the, you know, if you say, just say, how do you feel about orgasm?

51:12Dr. Mary Claire Haver:Do you masturbate?

51:13Dr. Kelly Casperson:you know there's some recently published data saying that orgasm helps decrease menopausal symptoms wonderful i i believe it we're we're cutting off kind of the paying attention to anything else part of the brain with an orgasm it's that's neuroscience and i worry that the you know the popular press takes that research and they're like solve your hot flashes with

51:35Dr. Mary Claire Haver:i've seen articles like that and i'm like you just need to come more yeah and when you feel like crap

51:40Dr. Kelly Casperson:telling somebody go have an orgasm, like with no sex ed, with no sub, maybe they've had mushy broccoli their whole life. You know, it can come across kind of obtuse.

51:49Dr. Mary Claire Haver:I've had patients say, well, that sounds nice, but I, my partner will get mad at me.

51:55Dr. Kelly Casperson:Yeah. Yeah. Some people think that there's only so many orgasms that you're allowed to have in a week and that they all must be paired with your partner. Like, did you sign that marriage contract? Right. And did you ever ask your partner, am I only allowed to have orgasms with you? right nobody's ever asked their partner that but we don't get taught how to communicate about sex so we assume things about our partner a big thing that women assume is when a man has erectile dysfunction that she's unattractive she's unlovable and he's having an affair it's a blood flow problem it usually doesn't mean all of those things but if you can't communicate we assume

52:30Dr. Mary Claire Haver:right and sometimes we assume worst case scenario what is the most persistent orgasm myth that you would love to retire.

52:39Dr. Kelly Casperson:That it's difficult for women to have an orgasm or that it always takes longer. Like it's a burden for us or we're less gifted. It kind of has this undertone of like, it's just not going to be easy for you.

52:52Dr. Mary Claire Haver:What happens to the orgasm with normal aging?

52:55Dr. Kelly Casperson:Orgasm can diminish for several reasons. Number one, it's a pelvic floor contraction. It's a muscle contraction. We lose muscle as we age, right? So if we don't have as strong of pelvic floor, the experience of orgasm might be less. In addition, we need hormones to help blood flow. The big hormones for blood flow in our pelvis, estrogen, testosterone, DHEA. They did this awesome study where they gave women testosterone and they took an ultrasound probe and they put it on their clitoral artery and just watched the blood flow of the clitoral artery go up after they gave them testosterone. I'm like, has anybody ever told you testosterone helps orgasm?

53:30So as our

53:31Dr. Kelly Casperson:hormones go down, the orgasm can kind of feel blunted, not as strong, a little more challenging to get over the hill, right? Like, I like it. I got arousal. I think, no, not going to happen today, right? So there are challenges that can happen. Most people, hormones going down, pelvic floor going down, atrophy. Specifically, yeah. So atrophy, what's happening to the nerves?

53:54Dr. Mary Claire Haver:What's happening?

53:56Dr. Kelly Casperson:Do you have diabetes going on? Do you have high blood pressure going on? Do we We have other comorbidities along with aging, right? And then as hormones go down, we lose our lubrication. We lose our blood flow. We might lose our architecture. Like, so the thing that always breaks the internet, right? Yeah.

54:11Dr. Mary Claire Haver:And my biggest substack, like hundreds of thousands of views, is the one I wrote about how the anatomy of the vulva can change with aging. Yeah.

54:18Dr. Kelly Casperson:Yeah, yeah. And menopause. It went to, like, these things go to the top of the people on social media. They're like, you can't see that. You brought a clitoris, right? I brought a clitoris. But yeah, people are like, does the vagina go away? and I'm like, you don't know what a vagina and a vulva is.

54:30Dr. Mary Claire Haver:Please pull out the clitoris.

54:31Dr. Kelly Casperson:Vagina's different.

54:32Dr. Mary Claire Haver:Oh, it's tiny.

54:33Dr. Kelly Casperson:I've got a tiny clitoris.

54:34Dr. Mary Claire Haver:Oh, it looks like Gumby. For those of you watching on YouTube.

54:38Dr. Kelly Casperson:So all we see in the female pelvis is the head of the clitoris. The gland. It looks like a penis. It looks like a penis. Yeah, it's shocking, right? Look at that. It looks like a penis. So same, same. So head of the clitoris is head of the penis. Okay. Shaft of the clitoris, shaft of penis. And these are the crura or the bulbs of the clitoris, which wrap around the vulva. So the vulva. Where is the vagina in all of this? Right here, my finger. There. So you can see that the crura in the bodies and the clitoris wraps around the vulva. Now, again, your skin's going to be here, right?

55:08Dr. Mary Claire Haver:So where's the issue of cavernosis in the vulvo? In the male equivalent? Yeah.

55:13Dr. Kelly Casperson:Yeah, here. These things. Okay. The body and the crura.

55:16Dr. Mary Claire Haver:Because that is what we were taught to look for when we were reconstructing the pelvic anatomy after laceration from obstetrics. Impressive. and um but i didn't realize i was throwing big giant sutures of chromic into the clitoris well

55:30Dr. Kelly Casperson:when people are hemorrhaging you need to do what you need to do but then it would be kind to ask afterwards like how's sexual function the other big myth we should get rid of is that women should be good to go sexually active six weeks after childbirth no there's no data in that no data i like asked how many you were probably on a text read i'm like where's the data that says why six Six weeks. Six weeks, good to go. Is the good to go.

55:51Dr. Mary Claire Haver:I can't tell you how many patients came back in horrific pain. What we know now is that she had GSM. It wasn't full menopause, but she had general urinary syndrome because her estrogen was so low because she was nursing her baby and we suppress our estrogen. Yeah. We suppress ovulation when we nurse. It is nature's way of spacing out children biologically. And so no estrogen, the vulva takes a hit. I know. And so all her architecture changes, her lubrication changes, or pain changes, and she's having horrifically painful sex.

56:22Dr. Kelly Casperson:And then she likely has a male partner who doesn't know any of this is happening, is having his own like, wait, there's a baby now, and what's my role, and am I still loved? And oftentimes, sex is a connection for him, right? So the connection's broken now. And they don't know how to communicate about this. So big, big, big relationship issues because nobody got a decent sex ed or an understanding of what happens.

56:45Dr. Mary Claire Haver:What are the earliest sexual changes that we can see in perimenopause that women often miss or internalize as failure?

56:52Dr. Kelly Casperson:Well, desire is a big one. So as hormones go down, and the stereotype is testosterone is the desire hormone, but estrogen is too. I mean, I know you've seen this. Like, you get a woman on an estrogen patch and she's like, I'm good. Having fun again. It's all I needed. Right. And there's older literature on it. Nothing's being studied in the world of hormones much right now in sexual health with women. But there are older studies saying estrogen's role in sexual health certainly involve our health. So when hormones change, desire can go down, but also just moisture, lubrication. Everybody was so happy when we got genital urinary syndrome of menopause.

57:28Dr. Kelly Casperson:And now we have genital urinary syndrome of menopause guidelines. The only people that aren't happy with that are the people who are like, but genital urinary syndrome of menopause happens before menopause and during breastfeeding and with cancer treatments. And like, so now - Anytime you have a low estrogen state. Whenever you have a low hormone state, right? And so, again, the stereotype - On with like control pills. You don't get any treatment because you're still having periods, which is super stupid because we don't tell a man he can't have testosterone or Viagra because he has a little bit of, you get a little bit of a boner, dude, so you don't get any of that.

58:00Dr. Kelly Casperson:That's what we're telling women. You have a little bit of a period still. You don't get any of this. But as you know, the amount of hormones needed to produce a period, not even ovulating, just produce periods, is actually very low, right? Very, very low amount. But we're using that as a marker of if you're allowed to have help or not. I mean, what we've learned

58:19Dr. Mary Claire Haver:or what I've learned in the last, you know, three or four years, and especially getting ready for the new perimenopause and writing the book is the period, the menstrual cycle changes are the last things. You know, like stuff's happening in the brain, in your bones, you know, palpitations, skin changes well before your hormones get low enough to affect your periods.

58:41Dr. Kelly Casperson:And if you look at the data on who's affected most by hypoactive sexual desire disorder. So low desire and - What is hypoactive sexual desire disorder? So low desire for sex and bothered by it with no other known cause, meaning relationship issues, other health issues, stuff like that.

59:00Dr. Mary Claire Haver:Now it's time for the MidiPause. I'm Dr. Mary Claire Haver, host of the podcast Unpaused, bringing you a word from MidiHealth. Today, we're talking about perimenopause. Perimenopause is driven by fluctuating hormone levels and can trigger dozens of symptoms, including irregular periods, breast soreness, hot flashes, moodiness, insomnia, and weight gain. But here's the good news. MidiHealth is dedicated to changing how perimenopause is treated with a personalized approach tailored to each woman's specific needs. Women come to MidiHealth to address the symptoms of perimenopause and menopause they see and feel every day.

59:40Dr. Mary Claire Haver:What you may not know is that perimenopause is often diagnosed by symptoms alone. There is no perfect blood test to determine if a woman is in perimenopause due to the wildly fluctuating hormone levels. A discussion with your doctor about your symptoms can lead to answers and possible treatment, including changes to your eating and nutrition, possible over-the-counter supplements, and potential hormone therapy. With the right treatment, you can ease uncomfortable symptoms. Let me add, perimenopause is a natural expected phase of life that a woman will experience if she's fortunate to live long enough.

1:00:18Dr. Mary Claire Haver:And the more we talk about it, the less mysterious and isolating it becomes. Progress starts with a personal plan. That's why the MIDI approach centers on a holistic combination of solutions, from medications to lifestyle changes, in a care plan that works for your body and needs. As the nation's fastest-growing women's telehealth company, MIDI provides accessible, insurance-covered services. Building on its leadership in perimenopause and menopause, MIDI fills the critical health gaps women face at every age and life stage. If you want a clinician in your corner who understands what your body and brain need right now, that's exactly what midi is built for go to join midi.com join midi.com and connect with one of their clinicians today what do you tell the woman so let me let me take a caveat for a second who says i don't want to have sex and i don't care thank you for bringing this up i don't care i can't tell you there's a war on the internet every time i post about female sexual desire about half of the comments are women who are like, I don't give a fuck if I ever, you know, like.

1:01:31Dr. Kelly Casperson:That needs to be talked about because I'm like, we need to talk about, because right now we're just talking about HSDD. I have low desire and I care. Who's talking about I don't have desire and I don't care? Because I would argue with no data or research to back me up that that effect on relationships is as big, if not more big than, And honey, I want to. I just don't feel like it, but I want to. And I'm bothered by it versus honey, I don't care.

1:02:00Dr. Mary Claire Haver:I don't want it to be part of my life anymore.

1:02:01Dr. Kelly Casperson:Right. And nobody's talking about that. But it's very common.

1:02:07Dr. Mary Claire Haver:And at least on the internet.

1:02:08Dr. Kelly Casperson:It's on the internet. And nobody's complaining to your doctor about it. You only complain if you want to do it again. Right. Yes, exactly. Right. And so there's a lot to unpack. A lot to unpack. Let's unpack it. Like women are taking notes. Were you having mushy broccoli in the first place? Were you having 7 % orgasm in the first place? Was sex all about his gratification and not yours? You might not ever want bad sex again, and you're finally at a point in your life where you're like, I'm willing to actually say that. Thank you very much. And we must realize we probably got into this relationship because it was sexual.

1:02:43Dr. Kelly Casperson:Let's honor that and respect that and say just because one, and we're kind of gendering here, but it could be any gender in any part of the relationship where they were like, we got into this because of sex. This was a sexual relationship. One of us has decided I'm fine without it. That's significant. That's a fracture in that relationship. And we don't want to dismiss either partner's important point in this. What do you do? How do you counsel? Is divorce the only answer? I don't think so. But just talking about it. What is it? Most people don't know. They're in a long-term relationship. Most people don't know.

1:03:18Dr. Kelly Casperson:What does sex mean to you? What does this mean to you? Why do we do this? When you have sex with me, what do you get out of it? Like, these are like the things we'd never learn to talk about. And I, you know, I learned this from my sex therapist friends. and I go home to my husband and I'm like, what's sex mean to you? We've been married for like over 15 years before I asked him this question. I'm like well into my social media sex ed career, right? And I'm like, what's sex mean to you? And he's like, well, sex means X, Y, and Z. And I'm like, no shit. Didn't know that. Right? And so you're like, if I'm like, hey, I could take or leave sex, but maybe your partner wants to have sex.

1:03:56Dr. Kelly Casperson:We need to talk about that. What's sex mean to you? Like just starting to communicate of why don't you want it without shame, out of curiosity, judgment-free zone. Maybe we need a therapist to help us communicate. Maybe the communication is already so bad, right? Maybe we have a lot of blame and shame and assumptions going on. Maybe we need support. But again, going back to like, what if we taught people how to talk about sex when it was good so that we can talk about sex when it's bad?

1:04:22Dr. Mary Claire Haver:I've had patients and lots of people in my comment or in my DMs, they won't say this in public who say, I'm totally fine taking care of myself. I orgasm on demand. I'm happy to masturbate. I don't care if I have a partner.

1:04:37Dr. Kelly Casperson:Awesome. I mean, I always say like, I'm not here. But it's affecting their relationship. Oh, so you're partnered. Yeah. You just don't want to be with your partner. Yeah. Separate. You're in a partnership. We need to communicate with that. Right. What's going on? Why are we not bonded? Why are we not close? Right. Why can't we talk to you? Why are we texting a stranger in a DM instead of talking to the person in your house? Right? It's like, we're so uncomfortable talking about sex, but like, I can tell a stranger all about my sex life. It's like, oh, that's really interesting, isn't it?

1:05:09Dr. Mary Claire Haver:Well, it's so wrapped up in the emotional part of it and upsetting someone and how they don't feel loved or, you know, it just, there's so much more to it, you know, of what we assign to this physical relationship. Yeah.

1:05:24Dr. Kelly Casperson:And maybe you don't want sex because you have untreated depression or you have low hormones or you have a health condition, but we're making it be a personality flaw. Right. Again, women get blamed as being it's all psychological. Like, no, maybe you have a health condition. Maybe your thyroid's like crazy out of whack. And that's why you don't want to have sex. Right. So that's what the sex med doctor is like. Let's look into some things. What are you doing? You know, the other thing going back to like desire and pleasure and stuff is like, how much pleasure do you have in your life in the first place?

1:05:53Dr. Mary Claire Haver:Talk to me about the word natural and how it's being weaponized against women.

1:05:59Dr. Kelly Casperson:Well, dying in childbirth is natural. Wearing socks is not natural, right? So natural tends to mean something that is within nature. And what humans have done to that is we've assumed superiority to that natural world. Likely because we live so far out of the natural world right now, we forgot how deadly it is, right? Because it's like, it's very easy to live in a climate-controlled, beautiful condo with a steady food supply and clean water and be like, nature's nice. Like, no, we created this because nature wasn't nice and we died in childbirth and you had a femur fracture and you died because of blunt force trauma, right?

1:06:39Dr. Kelly Casperson:And so I was researching it for my second book and it's called The Naturalistic Fallacy. And it is a thought error that because something is from nature, it is therefore superior or better. so I see I see it a lot on social media and wellness culture what is it it plays into and it's just another tool in a toolbox to control women like don't you know you need to be perfect and natural and 25 forever you need to be young forever yeah don't age by the way like the most the most natural thing on the planet is things are born and then age and then die that's the most natural thing and we're like yeah but don't do that but do everything else naturally Like once you can step back and actually see the like social construct on all of this, like it's just an immense level of bullshit.

1:07:28Dr. Mary Claire Haver:And then I see a lot of people who want to fight, you know, why would you treat menopause or the things that are happening because of your menopause? This is natural. You are meant to do this. Yeah. What is your comment for that?

1:07:42Dr. Kelly Casperson:Well, flossing isn't natural, but it makes it extend the lifespan of our gums and our teeth. I mean, I first have to break down the natural myth, right? And then I also break down the like, we treat everything else in medicine to help quality of life. Like thyroid, replace that. Pancreas, replace that. Heart valve, replace that. Hip, replace that. Teeth, replace that. Hearing aids, check. Glasses, check. Hair, check. Like everything. Because then once you have to point that out to people because they can't see the sea they're swimming in, right? So you're like, wait, we take care of that's medicine.

1:08:19Dr. Kelly Casperson:We take care of everything. Dry eyes, check. Pimples, check. Right. Everything except for the ovary. Not that one. Everything else, but not that one. And so once you kind of point that out to people, they can see their thought of like, oh, that is kind of weird, isn't it? It's kind of weird that one organ is the organ we've decided not to help out. To ignore. To ignore or to say, you know, that's the natural. I never like, well, sorry, you know, got gum disease. that's natural. Like, we don't do it with anything else. And I always say, like, I'm not here to make you have sex. I'm not here to make you have hormones.

1:08:53Dr. Kelly Casperson:I don't care. It's your life. But I care profoundly that you have the education that you need to make your own decision and that you know how to advocate to help you in making that decision. That's my jam. But if you take hormones or not, I don't care. I'm not going to live in your body. But I know enough to be like, hormones are basic building blocks. And if you choose to outlive them, that's what we're doing. We're choosing to outlive them. Antibiotics alone increased human life expectancy by 26 years. Really? We are choosing to outlive our hormones. We have climate controlled buildings. We're choosing to not freeze, right?

1:09:30Dr. Kelly Casperson:Like we're choosing to live very long. If you choose to not replace the building blocks, tissues can suffer and they will change. Whether you feel that suffering or not, things change. That's just facts. I just, I want people to have the information because I feel like we're jumping to a conclusion about what should be done with no education about it.

1:09:53Dr. Mary Claire Haver:You can find Kelly through her website at kellycaspersonmd.com, where you can listen to her podcast, You Are Not Broken, and find links to all her books, as well as to more information on her clinic, the Casperson Clinic. You can find full episodes of Unpaused on YouTube at Dr. Mary Claire. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire and get honest, accurate information on health, fitness, and navigating midlife at thepawselife.com. My new book, The New Perimenopause, is available everywhere you buy books. If you're loving this podcast, I have an important request.

1:10:33Dr. Mary Claire Haver:Please take a moment to follow Unpaused on your favorite podcast app. Following and listening is what pushes this information to more women who need it. So if this podcast has helped you feel seen, understood, or supported, hit follow right now so you never miss an episode. Thank you for being here with me. Let's keep going Unpaused. Unpaused is presented by Odyssey in conjunction with Pod People. I'm your host, Dr. Mary Claire Haver. The views and opinions expressed on Unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment.