Taking Charge of Your Sexual Health

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things reproductive health. I'm your host, Dr. Erica Newlin. This podcast is intended to help you better understand your health, leaving you feeling empowered to live your best. On each episode, you'll hear from our experts on topics such as pregnancy, fertility, menopause, and everything in between.

On today's episode, we're having an honest and important conversation about sexual health from changes in desire to questions about pleasure, age, and treatment options. Many women experience concerns at some point, but often don't feel comfortable talking about them. Today, I'm joined by OB/GYN, Dr. Jacqueline Zuponcic, to help normalize these experiences and provide clear, supportive guidance. Thank you so much for joining me on the podcast, Dr. Zuponcic.

Jacqueline Zuponcic, DO:

It's so good to be here. Thank you for having me.

Erica Newlin, MD:

Before we start, can you tell our listeners a little bit about your role in Cleveland Clinic and your background?

Jacqueline Zuponcic, DO:

Sure. So I am a generalist OB/GYN down at Akron General. I went through residency there as well and graduated in 2018. And as a generalist OB/GYN and for any OB/GYN that goes through training, you learn a lot about GYN care and a little bit about menopause care and OB care, but you don't get a lot in education surrounding sexual health. And so when I came out in practice in 2018, I had a lot of patients kind of back to back to back in practice who had questions about sexual health and just felt kind of woefully unprepared to handle those questions, which is too bad because you'd think of any field of medicine, OB/GYN is the place that you would go to ask those questions as a woman. So over the last eight years or so, I've picked up various conferences and kind of made it my own little special focus to pick up and take care of patients and their sexual concerns or complaints.

Erica Newlin, MD:

Let's start by talking about what sexual health really means and why many women experience changes over time. How do you define sexual health for women across different life stages?

Jacqueline Zuponcic, DO:

That's a very broad question and I think you'll find that as we answer these questions, not one answer is perfect or straightforward. This topic is very multifactorial. I hate to sound like the Webster's dictionary, but the World Health Organization does have a very specific definition of sexual health and it's a state of physical, emotional, mental, and social wellbeing in relation to sexuality, not just doing well in the absence of disease or dysfunction or infirmity. But I would say this, for women across different life stages, it can look the same. It's whatever you want it to be or whatever you want it to look like. And I would say there is no typical normal for what's considered normal for sexual function. If you're happy in your relationship and you're happy with where you are sexually in your relationship, that is good enough. And even wanting to feel sexy for yourself is okay and not be partnered.

Jacqueline Zuponcic, DO:

So there is a very broad definition of sexual health and I think it can look very similar across life stages and very different across life stages just depending on what diagnoses you have or how your body ages through those things.

Erica Newlin, MD:

What are some of the most common sexual health concerns women bring up in clinical practice?

Jacqueline Zuponcic, DO:

So I think the most common thing that I hear about, and it's a very broad topic, is decreased sexual desire. I see that even in my younger patients who are in their 20s, but the most common age range I see that in is like 45 to 65. The other large complaint that I hear or concern, the word complaint's a little much, but the large concern is vaginal dryness. And we see a lot of that as well within that same age range as we see changes in our hormones as our estrogen and testosterone levels tend to drop closer and closer to menopause. But the other two common concerns or concerns that we see as it relates to sexuality are orgasm concerns or even pain with sex. So while those are less common, certainly we see those as well within the office setting.

Erica Newlin, MD:

And as you mentioned, so many of these concerns are connected to changes in desire and enjoyment. Let's take a closer look at what can affect those experiences. What are some of the most common reasons why women may not enjoy intimacy as much as they expect or as they used to?

Jacqueline Zuponcic, DO:

Sure. So this gets into the complicated discussion of this. There are a lot of very interesting models looking at sexual arousal. There is one model that's very broad looking at sexual desire called the biopsychosocial models. So it really takes into account from a broad perspective what's going on with any of us biologically, psychologically and socially. For a lot of us who are in our perimenopausal transition, kind of this early to mid-40s to early to mid-50s, which is where the majority of these concerns arise, but not all, we do see changes in our hormonal levels with drops in our estrogens and our testosterones as our ovaries tend to age and get closer to not functioning after menopause. So that's where a lot of this change in desire and vaginal dryness comes from. But keep in mind, there are so many different aspects to sexual desire overall. This can fluctuate based off of what medications you're on, what diagnoses you have.

Jacqueline Zuponcic, DO:

If you have a history of treated or untreated anxiety or depression or untreated depression or anxiety in terms of psychological history, we've kind of hit that, but also how we were raised, what our cultural and religious beliefs are. If we're having issues such as pain during sex, how our relationship is going. Do you feel supported? Do you feel respected? Do you feel like you communicate well with your partner? Do you find your partner attractive? Do you find anyone attractive? Or for a lot of my moms out there, are the socks off of the floor? Are the dishes done? Are my kids sleeping in my bed? Where is the dog? So there's a lot of sub context to the idea of decreased sexual desire. And so often when we approach the conversation surrounding that, it may not just be this or that. It is a very global discussion and the treatment options kind of hinge on whether or not those other factors in your life may also be impacting this.

Jacqueline Zuponcic, DO:

In terms of vaginal dryness, I will say the approach for that tends to be a little bit more straightforward. We usually start with first line things like lubricants or moisturizers for the vagina and the vulva. But if those aren't quite cutting it and that isn't unusual, we know that the vaginal tissue gets very thin. It doesn't stretch well. It tears easily with that loss of estrogen in some testosterones. And so you can have those hormones replaced vaginally and that's relatively low risk and can kind of give you back that stretchy, lubricated, thick, tough vaginal tissue that you had prior to perimenopause.

Erica Newlin, MD:

And like you mentioned, these can be complicated and complex issues. And as we were kind of talking about before we started recording, I think it's really important to talk about these with your physician, but because they take so much time and consideration, it's helpful to have a specific visit dedicated to these issues because it's sometimes not able to be addressed at an annual visit.

Jacqueline Zuponcic, DO:

I would agree. And while I find that to be disappointing for patients, it is something that if we slammed it into 15 minutes or less, it would be doing you a disservice to throw something like a medication at you, but not actually sort out where is this coming from?

Erica Newlin, MD:

I love talking about these things in the office. I do. But I hate when we have such a short amount of time to do so.

Jacqueline Zuponcic, DO:

Yeah. Agreed.

Erica Newlin, MD:

Some women worry that they've never experienced an orgasm. How common is that and what should those people know?

Jacqueline Zuponcic, DO:

Sure. So what I'd say is true anorgasmia, the inability to have an orgasm and what's called primary anorgasmia, you've never had an orgasm, can be as common as four to 10%. The secondary anorgasmia, which means you could do it at one point, but now you can't, is a lot more common. It's around like 20 to 30% and can often depend on medication use that we have. And then just some other interesting facts that I would like to normalize. Only 30% of women orgasm from vaginal penetration. And I have so many women that come into the office and think that their air quotes broken. And there's some education that goes with that. So that's some education that I just want to put as a PSA out there for everybody. Okay. Only 30% of us can do that vaginally. The rest of us are external gals.

Jacqueline Zuponcic, DO:

But as far as what to do with primary anorgasmia, that can be a little bit more difficult. Often it involves a review of your personal past medical history, surgical history, medications that you're on, an exam. There are some dermatologic or skin conditions of the vulva that can impact the way that the clitoris functions. And then sitting down with potentially like a sex therapist to work through different options that we have to improve the sensation in that area. And actually we're very lucky at Cleveland Clinic because we just got a sex therapist within the last year or so, Dr. Theresa Callard-Moore, and she is very helpful with that type of diagnostic workup and therapeutic discussion. So in terms of primary anorgasmia, often with a sex therapist, but also just making sure there's nothing else medically going on. With secondary anorgasmia, meaning you could and now you can't.

Jacqueline Zuponcic, DO:

Usually it's looking at what has changed in your medical history. Did you start on a new antidepressant? Because that's really common. Did you have a recent fall where you might have injured the nerve that feeds that area? If you have any type of pelvic floor dysfunction, you can pull a vagina muscle and that can impact and put pressure on the pudendal nerve. There's a lot of things to consider for secondary anorgasmia that does take a good workup as well.

Erica Newlin, MD:

Should people expect their orgasms to weaken as they get older?

Jacqueline Zuponcic, DO:

That doesn't happen for everybody, although it certainly can. We know that the way our nerves carry the signals to our brain tends to get worse as we age. So that is not unusual. We also know that while we lose estrogen body wide and that vaginal tissue starts to get thin, that the clitoris is also impacted by that as well and can get smaller so it gets less blood flow. So for some reasons we can see some decreased intensity of orgasm or what's called muted orgasm. That's not terribly unusual, but it's not necessarily the same for everybody. There are various things that we can do to improve that. Sometimes topical estrogen in that area can work, but you'd always want an exam first to make sure there's nothing else going on with your nerves or your anatomy that would be impacting that for you.

Erica Newlin, MD:

Beyond physical factors, sexual health is also closely linked to life stage, hormones and aging. Let's explore how that plays a role. How does aging affect general sexual health and desire in women?

Jacqueline Zuponcic, DO:

So for a lot of us, there's no change at all and that's not unusual. But for a lot of us, there is a change. We know that as those hormones change as we get older or go through that menopausal transition, a drop in that estrogen and that testosterone level can negatively impact sexual desire and sexual function. Overall, as that pertains to mental and physical health, there are a lot of excellent studies that show that while you're living your life and you're doing well, the quality of your physical and psychological health is greatly improved with your level of sexual function.

Erica Newlin, MD:

There's increasing interest in medications and treatments specifically for low desire or low libido. Can women use medications? Is there a version of Viagra for women?

Jacqueline Zuponcic, DO:

That's a great question. So let's pull back a little bit. If we think about desire overall, studies show time and again that the desire for men is almost always more than the desire for women. Maybe we approximate each other in our late teens and early 20s when our hormones are just kicking off, but then there tends to be a little bit of drop in that desire around 35 and then around 50. Men overall, their desire is higher. And so when we give a man Viagra, we're allowing them to have an erection for desire they already have. Now, if I gave a woman a Viagra and the studies for the record are very limited on Viagra for women and their efficacy, it doesn't really do a whole lot. It might make your clitoris a little bit engorged, but if you don't have the initial desire to have sex, it may not do very much for you.

Jacqueline Zuponcic, DO:

So when we look at the biology of sexual desire, we can break it down into two categories. So for a lot of us, it's hormonal, which for the record, we don't recommend hormonal replacement for decreased sexual desire until after menopause. And that's often in the form of testosterone replacement, which is low dose for this purpose. And we can talk about that later if we'd like. And then the other aspect of decreased sexual desire, at least the biological aspect is the neurotransmitter. So the little chemicals that we have floating in our brain. And there are a bunch that make us feel sexy and there are some that make us feel not so sexy. And a lot of the medications that are out there now that focus on improved sexual desire prior to menopause work on that brain neurochemistry. So for example, norepinephrine and dopamine are very energizing.

Jacqueline Zuponcic, DO:

They give us a little pep in our step. They can make us feel real sexy. Serotonin, which is often what the number one neurotransmitter is that's modulated by antidepressants. Serotonin makes us feel very calm, very satiated. We're good. We don't need it. Cortisol stress, as you can imagine, also negatively impacts sexual desire as well as prolactin, which can be elevated during breastfeeding. When we look at medications that are otherwise out there for decreased sexual desire, they all change this brain neurochemistry. That's their overall goal. There are two FDA approved medications for decreased sexual desire prior to menopause. One is called flibanserin and it's an oral medication that is taken nightly over six weeks to get to maximum benefit. And over six weeks you would see changes in your sexual desire. Little things at first, but then potentially greater things later. For example, my partner looks really good when he or she bent over in their jeans today.

Jacqueline Zuponcic, DO:

I had a sexy dream last night. Maybe I'm more receptive to sex. The other medication that's FDA approved for decreased sexual desire, and it's really the only on-demand decreased sexual desire medication that we have. And in that capacity, maybe like Viagra because Viagra's on-demand, but works in a different way. It's called bremelanotide. And bremelanotide looks like an EpiPen and you truly inject it into your leg about 45 minutes before sex and it rapidly changes your brain neurochemistry for about 18 hours to be more receptive or pursue sex more frequently or more often. It's a great medication. You have to get over the needle aspect of it, certainly.

Jacqueline Zuponcic, DO:

There are some side effects to be aware of and your doctor would counsel you on these as well, but it can raise your blood pressure so we don't recommend it for hypertensives. Anytime you change your brain neurochemistry really fast, it can make you very nauseated. So often we give ondansetron for nausea concurrently with that medication. And then the other thing is that it's actually related to melanin. If you get patchy at all in the sun like your skin gets patchy or darker, it can make those little patches worse. But it is really the only on-demand medication we have for decreased sexual desire. So not Viagra, but maybe the closest thing we'd have to it. There are two antidepressants that are out there as well, which have been shown to have some positive impact on sexual desire as well because they change that norepinephrine and dopamine level by elevating it or they lower the serotonin level.

Jacqueline Zuponcic, DO:

So there is an antidepressant called bupropion, which elevates norepinephrine and dopamine, and that can be a really nice antidote for the sexual side effects that come with antidepressants. And so we see that often used for that capacity with that antidepressant to help with sexual desire. There's also an antidepressant called BuSpar, which can turn down serotonin. And concurrently, if you're turning down that neurotransmitter that makes us feel less sexy, you get the opposite effect, which can improve sexual desire. Not all of these are perfect. Everyone is different. The nice thing is they can all be used overlapping, which is nice, but everybody responds differently to these medications and not any one of them is 100%.

Erica Newlin, MD:

There is a lot in media and you've touched on this about testosterone.

Jacqueline Zuponcic, DO:

Yes. So when you look at testosterone replacement therapy in women, it is not FDA approved for this purpose in this country for the purpose of decreased sexual desire. But there are a lot of really wonderful women's health organizations like ACOG, ISSWSH and NAMS that all support the use of low dose transdermal through your skin. Testosterone replacement for decreased sexual desire and decreased sexual desire only. There hasn't been a lot of data or enough studies at this point in time to suggest that testosterone is really going to be impactful or positive for anything else like your bones, your muscles, your cognitive capabilities, your strength, things like that. It truly is studied only in this fashion. The goal with transdermal testosterone is to get your testosterone levels in menopause back to premenopausal values. You might have a little bit of acne, you might have a little extra hair growth, but nothing truly impactful.

Jacqueline Zuponcic, DO:

You shouldn't have other symptoms like voice deepening or enlarging clitoris or loss of hair. But over six weeks to six months, a lot of women have improvement in decreased sexual desire and also report improved sexual function. It does require some monitoring. So if you pursue that with your physician, just expect to get lab pokes first around the six-week mark, the six-month mark, and the year mark, and then yearly thereafter.

Erica Newlin, MD:

We've talked about causes and treatment, but one of the most important steps is feeling comfortable seeking help. Let's talk about how women can take that step. When should someone consider talking to a healthcare provider about sexual health concerns?

Jacqueline Zuponcic, DO:

That's a great, great question. So at the end of the day, what you consider concerning is what we consider concerning. If you are not a highly sexual person or a moderately sexual person and you never have been and you're not bothered by it, I'm not bothered by it either. But if it's bothering you or if it's creating what we call interpersonal distress, like it's impacting your relationship and that is impacting your quality of life, that is very common. You should come and see us for that. Overall, we see that female sexual dysfunction, whether that's decreased sexual desire, pain with sex, changes in orgasm, changes in arousal like lubrication, that can be possible for 40 to 50% of us at any point in time. About 12% of us experience distress with it, meaning it bothers us or it's impacting our quality of life with our partner.

Jacqueline Zuponcic, DO:

And so at that point in time, you should absolutely consider pursuing looking into that further. You should find a provider that you are comfortable addressing it with. And then we do have those resources within Cleveland Clinic certainly and locally as well.

Erica Newlin, MD:

What advice do you have for women who feel embarrassed or unsure how to start the conversation?

Jacqueline Zuponcic, DO:

I would say first that it's a topic I understand that we haven't talked about for a long time. And in truth, we really didn't start talking about women's sexual health in modern medicine until the '70s. And so I think a lot of us were raised in households where that topic was taboo. And now there's not a lot of awesome things that I can say about social media, but with the advent of social media, what I do appreciate is that we're all beginning to talk about these things as a population together. And I love that. If you're embarrassed, I can completely understand where you're coming from, but there are so many more treatment options for these concerns than there were even 10 or 15 years ago. And we know from the studies that about half of us go through this. So you're not alone. And finding someone who can address that conversation with you would be so amazing for your quality of life.

Jacqueline Zuponcic, DO:

Nobody ever comes to my office and says, "Thank you for my pap. I can't wait for my mammogram. Please schedule my colonoscopy." But they are excited if we can get you back to the level of function that you were in the past and that is truly correlated to your quality of life.

Erica Newlin, MD:

And you highlighted this in the beginning. I think this is something that's been overlooked in our training. I think if you do go to an OB/GYN provider and it doesn't seem like they're as comfortable addressing this, it doesn't mean that you as the patient are in the wrong bringing this up. This is something that you should feel comfortable bringing up with your gynecologist. And if you're not able to get those answers, then seek care with someone who is more comfortable talking about that with you. They should be able to provide referrals for you.

Jacqueline Zuponcic, DO:

That's correct. And there are a lot of wonderful websites even through ISSWSH that have a list of local providers who have this skillset and you can pursue those as well.

Erica Newlin, MD:

This has been such an important and helpful conversation. Before we wrap up, let's leave our listeners with one final takeaway. What is the most important message you want women to remember about their sexual health?

Jacqueline Zuponcic, DO:

That nothing is considered not normal, but if you're bothered by it, come in and talk to us.

Erica Newlin, MD:

Dr. Zuponcic, thank you so much for joining me on the podcast today. For more information and helpful resources on sexual health, visit clevelandclinic.org/sexualhealth. That's clevelandclinic.org/sexualhealth. If you found this episode helpful, subscribe and share it with a friend. Remember, understanding your sexual health is an important part of feeling confident, supported and well at every stage of life.

Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.