Women’s sexual health is one of the most misunderstood areas in medicine — and this podcast of Peter Attia highlights exactly why. It breaks down the biology, hormones, psychology, anatomy, and cultural misconceptions that shape a woman’s sexual experience across her entire lifespan according to Dr. Sally Greenwald, MD, MPH, a board-certified Obstetrician and Gynecologist with specialized certification in Menopause Medicine and a Master's in Public Health.

1. 🌺 Hormones Drive Far More Than We Realize

One core theme: female hormones fluctuate constantly, especially in perimenopause — and these shifts deeply influence sex drive, mood, energy, memory, and athletic performance.

The expert begins with a simple but powerful first question for patients:
“Do you like ovulating?”

Why? Because women who enjoy the natural rise in libido and wellbeing that occurs mid-cycle may want to preserve ovulation with their treatment plan. Others who feel worse during certain phases may want to suppress fluctuations.

🌟 Ovulation = Peak Performance

Right before ovulation:

• estrogen is at its highest

• testosterone is elevated

• progesterone is low

This hormonal combination boosts:
💥 memory
💥 strength
💥 energy
💥 libido

Olympic-level athletes even time competitions around ovulation to lift heavier and run faster.

🧘 Progesterone = Calm, Rest, Recovery

Natural progesterone creates a “rest and digest” state — helpful for sleep, emotional regulation, and pregnancy preparation, but not ideal for peak physical output.

2. ❤️ Sexual Desire: Men vs. Women (They’re Not the Same)

One of the biggest clarifications:
Only 15% of women experience spontaneous desire.

That means most women do not simply “feel in the mood” out of nowhere — even when they love their partner.

🔥 Two types of desire:

• Spontaneous desire (common in men): arousal triggered internally or visually.
  

• Responsive desire (common in women): arousal that builds after sexual or emotional engagement.

This explains why a partner rubbing your shoulders, offering support, or doing the dishes (“chore-play”) can effectively trigger desire.

Key Insight:
Women often need arousal before desire kicks in — and there’s nothing “wrong” with that.

3. 💧 Lubrication: Why It Varies & Why Most Women Need Help

Many assume lubrication problems only appear after menopause. Not true.

Lubrication fluctuates throughout the month and is influenced by:

• hydration

• stress

• medication

• hormonal shifts

The natural lube sources include:

• Skene’s glands

• Bartholins glands

• cervical mucus

• the vaginal channel itself (which “sweats” lubrication)

Dr. Greenwald emphasizes:
“Most women need lubrication — and should use it.”

💡 The 30-Minute Lube Trick

Dr. Greenwald recommends applying silicone-based lube inside the vagina ~30 minutes before intimacy to support responsive desire.

This gives tissues time to soften and enhances arousal — especially helpful for women who struggle to “switch gears” mentally.

4. 🌈 Anatomy 101: What Women Were Never Taught

Most women (and men) don’t know basic female anatomy — especially related to pleasure.

⭐ Key anatomical points:

• The clitoris has 8,000+ nerve fibers

• Much of it is internal, shaped like a wishbone

• Pleasure sensitivity differs from side to side

Only 41% of Gen Z men can locate the clitoris on a diagram.

Understanding anatomy empowers women to advocate for their pleasure — and helps partners avoid guesswork.

5. 🌿 Tools to Improve Arousal & Orgasm

The expert outlines several evidence-based strategies for enhancing pleasure.

💠 Pelvic Floor Physical Therapy

A pelvic floor PT can help with:

• pain

• orgasm quality

• muscle tone

• trauma recovery

Strong pelvic floor = stronger orgasms.
Hypertonic muscles = pain and low desire.

💠 Mindfulness-Based Sex Therapy

Mindfulness helps by anchoring awareness into sensations:
“Describe what’s happening to yourself in your head.”

This is especially effective for anxiety, distraction, and post-trauma situations.

💠 Vibrators, Erotica & Sensory Support

Apps like Dipsea or Meet Rosie offer erotic stories tailored to women’s brains — which prefer narrative arousal over purely visual stimulation.

Vibrators and lube are encouraged as everyday wellness tools, not “last resort” options.

6. 🌿 Hormone Therapies: Estrogen, Progesterone & Testosterone

Managing hormones in perimenopause is complex because levels fluctuate dramatically.

Testosterone

Although off-label for many age groups, testosterone can improve:

• libido

• energy

• arousal

• sense of wellbeing

Clinicians aim for a total testosterone level “above 20” but adjust based on symptoms, not numbers alone.

7. 💊 Medications for Desire: What Actually Works?

Only two FDA-approved medications exist for women’s sexual desire:

• Addyi (flibanserin) — daily pill

• Vyleesi (bremelanotide) — injection

✨ Addyi

• increases satisfying sexual encounters by one per month

• interacts with alcohol and some antidepressants

• takes 6 weeks for effect
  

  ✨ Vyleesi

• injected before sex

• can cause 40% nausea rate

• works on the melanocortin pathway (also known as the “Barbie drug”)

Both offer modest benefit. Dr. Greenwald still prefers testosterone for many patients.

8. 🧠 Sex Education Is Failing Women

The transcript ends with a powerful message:
Sex education is outdated, fear-based, and anatomically inaccurate.

Girls aren’t taught about pleasure.
Boys aren’t taught how female bodies work.
And porn is filling the gap — inaccurately.

Her proposed vision for sex ed:

• accurate anatomy

• pleasure literacy

• safe exploration

• masturbation destigmatization

• partner communication

• trauma-informed discussions

This isn’t “extra.”
This is sexual health.

✨ Key Takeaways

• Women’s sexual desire is complex, cyclical, and heavily influenced by hormones.

• Responsive desire is normal in women and not a dysfunction.

• Lubrication varies — most women benefit from added lube.

• Clitoral anatomy is intricate and mostly internal.

• Pelvic floor therapy, mindfulness, vibrators & erotica are powerful wellness tools.

• Testosterone therapy can be effective in select patients.

• Sex education needs a revolutionary overhaul.

Want more on women’s health? Check out Dr. Andrew Huberman’s interview with Dr. Aliabadi on PCOS, endometriosis, hormone testing, fertility, breast cancer risk, pregnancy, and menopause!

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