Sex Isn’t Supposed to Hurt and Other Facts About Women’s Sexual Health

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What happens when a woman’s body changes as a result of aging or pregnancy and childbirth? What’s the impact on her sex life and what options exist for treatment? Jean Marino, CNP, a female sexual health expert, explores these and other questions and others to break down the myths and share the latest science. There are a variety of treatments for arousal, desire and continuing a healthy sex life after menopause.


Pete Kenworthy
When we talk about living a healthy, fulfilled life, there are essentials to making that happen, right? And, and we’ve talked about lots of them on this podcast. Things like healthy diet, good sleep, doing things that make us happy, having lots of sex.

Macie Jepson
Of course, you would say having lots of sex. Oh, that makes perfect sense. You know, my husband often jokes that it’s a great way to burn calories. You know, that’s his point, constantly. But really a healthy sex life, Pete, is part of overall well-being, right? I mean, studies actually back that up. It’s good for your heart. Sex decreases anxiety. It improves sleep. And it also should be fun. By the way, in case you’re wondering, sex burns about 230 calories on average for about 30 minutes. But it also evolves over time. And today we’re going to tackle some parts of the female sex life that can be kind of tricky. And yes, men, this one’s for you, too. Hi everybody. I’m Macie Jepson.

Pete Kenworthy
And I’m Pete Kenworthy. And this is The Science of Health. So much of what’s happening in our sex life is connected to what’s happening in our just life, right? Stress at work, a crying baby, your hormones are out of whack.

Macie Jepson
On the flip side, there’s vacation. The kids are asleep. Maybe you’re empty nesters. That can be a game changer in a good way. Joining us today to talk about the female sex drive is Jean Marino, Senior Women’s Health Nurse Practitioner at University Hospitals in Cleveland. Thanks for being with us.

Jean Marino, CNP
I am happy to be here.

Pete Kenworthy
So, let’s start with the elephant in the room here, right? This idea that men and women are built differently when it comes to sex. So, first of all, is that true when it comes to arousal, desire?

Jean Marino, CNP
I’m going to say no. I’m going to say there’s a bias that is assumed that women don’t like sex as much. They don’t have as high of a desire as men do. But I would say that that is not accurate. I meet equal amounts of women who want to have more desire and equal amounts of women who are frustrated that their partners can’t match their desire. In fact, I just had a phone call from a patient yesterday who’s 80 years old and was shopping for lubricants and wanted my opinion on a good one. So, I would say that women can absolutely have high desire.

Macie Jepson
That is what this whole conversation is going to be about.

Jean Marino, CNP
Wonderful.

Macie Jepson
So, the desire is there. They just don’t know how to get there. So, we’re going to talk about all of that. So, we all expect that sex will change over time. But do we accept that it has to? I mean, I know couples who say sex is better now 20 years into marriage than it ever was. So, before we actually get to the sexual hiccups of life, let’s talk about those people. I want to know their secret.

Jean Marino, CNP
Yeah. I meet lots of those women. So again, I think that’s where this bias comes in. And if we all took time to kind of really talk about this, you would see that there are plenty of women having great sex well into retirement age and beyond. So, those women I find have really great communication with their partners. They have really great self-esteem, positive body image. They are committed, and their partner’s committed. So, that’s the other part. And they want this great sex life. And they can have it.

Pete Kenworthy
I’m glad you talked about communication. We’re going to get to that a little bit later. But there is actual science. We love to talk about the science behind medicine, right? And there and there is science behind the physical and emotional factors that change sex for women, right? Entire books are written about it, right? About sex life after having a baby.

Macie Jepson
How about sex life while you are having a baby? I just always tell this story among my close friends. What To Expect When You’re Expecting. I asked my husband to read it, and he dogeared the parts about, yes, it’s okay to have sex when you’re pregnant. I’m like, seriously? Is that all you got out of this? Anything else that you’re interested in my nine month journey here?

Jean Marino, CNP
Right. Like about the back rubs and stuff.

Macie Jepson
Exactly. But anyway, I digress. Pete.

Pete Kenworthy
No. That makes sense. I get that. But then, you know, you talk about after the baby comes, right? And then there’s a lot going on in your life. You have a brand new baby. Is low desire normal after having a baby for women?

Jean Marino, CNP
I would say it’s common. It does not have to be the new norm, for sure. You know, so you add in talk about body image and changing body image in postpartum. Perhaps there is soreness. There might be stitches. So, then it’s just recovery as part of it. Then you add in just fatigue and a whole new family structure at home with a new baby. And then if a woman decides to breastfeed her baby, she’s got lower amounts of estrogen, and vaginal dryness can be an issue, which is so easy to treat. But I don’t think everyone knows that that can happen with breastfeeding and that we can do something about it.

Macie Jepson
I want to ask something else about low desire. It makes sense when you’ve had a baby and all those things are happening in your life and in in your body. But what about other reasons for low desire? Because you said it’s common.

Jean Marino, CNP
It is common. So, out of all the female sexual dysfunctions, that one is the most common. And low desire for women is so multi-factoral. So, it could be due to problems in the relationship. It could be due to pain with intercourse. It could be due to difficulty reaching orgasm, cause I always tell women, of course you have low desire; you’re smart. Why would you do something that hurts, so you’re not getting much out of it? And sometimes it’s due to how we’re raised. So, if you have this negative perception towards sex, whether or not it’s because of trauma; it’s because of a family or a cultural teaching. So, there’s so much that can play into desire in women. And then sometimes it’s just straight up low desire. Everything else is working, but still that desire is just not there. And when it’s distressing to women, then that’s an official diagnosis of low desire.

Macie Jepson
And what do you do with that diagnosis?

Jean Marino, CNP
So, if it’s not related to these other things, we actually have medications for it, which is wonderful in women’s sexual health. We’re finally gaining some ground, which is wonderful news. So, the very first medication that was FDA approved is Addyi. It’s a medication that a woman takes that bedtime every night, takes about eight to 12 weeks to work, but helps improve desire in the brain. It has the most amazing side effects. It helps women sleep. It helps improve moods, and it helps them lose weight. So, why aren’t we talking about this medication more?

Macie Jepson
What’s the catch then? Why is every woman not on this? Is there a downside?

Jean Marino, CNP
No. I mean about 60% of women respond to it. So, it’s not a hundred percent. So, I would say that would be the potential downside. But I mean, exactly. Why aren’t we all talking about this? It’s fabulous, right?

Pete Kenworthy
And what’s it called again?

Jean Marino, CNP
Addyi.

Pete Kenworthy
Okay.

Jean Marino, CNP
Yeah. So, FDA approved for women. There’s also Vyleesi. So, they wanted something kind of like a Viagra for women, so an on-demand medication. So, it’s an injection a woman gives to herself. Very user friendly. Not a big needle. So, nothing to be intimidated by. Works within 45 minutes; lasts for about 16 hours. You’ve got a pretty big window of opportunity. This is something that women are advised to use once or twice a week. So, nothing that you’re doing every morning over breakfast. But what it also does is improve desire in the brain, but then improves the physical kind of feeling turned on. So, better arousal, lubrication, better orgasm. Just this feeling like I got to act on this. And then we have testosterone, which is not FDA approved for women, but studied, safe. There’s guidelines specifically more so for menopausal women. And that improves desire in the brain and helps improve that physical kind of turning on arousal, lubrication, orgasm, too.

Macie Jepson
Good news. We’re getting there.

Jean Marino, CNP
We are getting there.

Pete Kenworthy
Before we move on, you mentioned a couple times already about body image and the role that that plays. And this is probably a huge part of female sexual health. And I wonder as I’m asking you to comment about it, what women go through with that? And what maybe they shouldn’t be going through because their partners aren’t seeing what they’re seeing? Does that make sense?

Jean Marino, CNP
Exactly. No, it makes perfect sense. So many women, they’re just embarrassed. So, it’s either after a baby. Or it’s they’re older and they’ve gained some weight. Or we could talk about menopause and how the body shifts weight into the abdomen. And women are just really self-conscious and worried. They quite frankly don’t want to be naked in front of a partner. And oftentimes they’ll say, well, what does your partner say? And then she’ll say, he still wants to have sex with me. He thinks I look great. And so the big question is, why aren’t you believing him?

Pete Kenworthy
What’s the answer to that? So, how do we get through that?

Jean Marino, CNP
Right. So, that’s where I think some of our brilliant psychologists, sex therapists can really kind of help that. I mean, I try as much as I can to it. Let’s rethink this. Let’s listen. Let’s believe your partner. Let’s do some self positive talks to ourselves and those kinds of things. And then if that’s not enough, then therapy to kind of, you know, look through that a little bit more deeper is always great. Mindfulness, those kinds of things.

Macie Jepson
You know what surprised me? We’re talking about menopause, is that it is seems to be getting younger and younger. In my mind, menopause was a 55, 60 year old thing. Not the case?

Jean Marino, CNP
So, the average age in North America is 52, but can be anywhere from 40 to 60; 40 to 45 is considered early. However, I was just at a menopause conference and they had a big presentation talking about African American women do have earlier menopause, and they think it’s related to this lifelong stress of racism and feminist sexism, those kinds of things. And so, they have, you know, their ovaries stop working faster because of that.

Pete Kenworthy
And what’s the impact on sex of menopause? And is there anything men can do to support their wives during it?

Jean Marino, CNP
Oh yeah. There’s lots of stuff. I’m glad you asked. So again, when we’re talking about sex and everything that goes into it, so a lot of times women are having struggles with hot flashes. And so, they tell me I’m already really sweaty and hot. I don’t want to be that close to my partner and be hotter still. Or it’s the body image issues. Or it’s the not sleeping. And so, they’re just tired. But then the vaginal symptoms are gigantic. So, with that significant drop off of estrogen, which is about 90%, the vulva, the vagina takes a huge hit. So, that tissue’s not as stretchy or resilient. It can’t withstand friction. You also have a decrease in blood flow. So, arousal, lubrication, getting to orgasm is harder. And again, that’s where that negative feedback loop goes to the brain, cause I always tell women again, you’re smart. Why would you want to do something that hurts or you’re not getting much out of? But even though that is very common…so at least 50% some studies saying 80% of women…there are tons of treatment options that are safe and effective. And this is another thing every single person should be talking about and know about. It’s so easy to treat.

Macie Jepson
I like, Pete, that you said what can we guys do…

Jean Marino, CNP
Yes. I got off on a tangent.

Macie Jepson
…to support, too? I’d love to hear more of that.

Jean Marino, CNP
Yeah. Thank you. So, men can go ahead and start and give that positive feedback. So, with that body image, no, I still think you look fantastic. No, I still want to be with you. Being supportive. I understand this is a hard time you’re going through. Or perhaps a woman just needs longer for arousal and whatnot. And so having that communication with your partner. This is what I need you to do. And I think that would all be wonderful.

Macie Jepson
We’ve got some quick questions here that I just want to fire off. Some issues that women have that are pretty common and I’d love to get your feedback on them. Pain during sex. What can we do about that?

Jean Marino, CNP
Tons of things. So, that’s the quick answer. So, in menopause, when you have that drop off of estrogen…it’s called the genital urinary syndrome of menopause…you don’t have to start with lubricants and moisturizers. They’re totally fine. They just address the symptoms. But vaginal estrogen, vaginal, DHEA, safe, effective, actually addresses the problem that’s going on. It will not cause cancer. It will not cause blood clots, heart disease, stroke, dementia, nothing. Super safe. You don’t need progesterone with it. It is a fantastic therapy. Sometimes women also have painful sex because of their pelvic floor. So, those are the muscles within the pelvis, and we have amazing pelvic floor therapists that can help with that. Also, you can have something called vulvadynia, where you have these extra nerves around the opening of the vagina called the vestibule. And we can do treatment for that. Sometimes there’s chronic vulvar skin conditions that can be addressed. I mean, everything can be addressed. Sex should never be painful.

Macie Jepson
And you talked a little bit about vaginal dryness with the pain and sex. But is there anything else we need to know about that?

Jean Marino, CNP
So, don’t put up with it. And you can do a lubricant at the time of intercourse, but really vaginal estrogen is fantastic. It will fix that dryness. It’ll help with arousal, lubrication, orgasm, all of those things. One of my biggest pet peeves is the lack of treatment for that vaginal dryness or officially called the genital urinary syndrome of menopause, just because it’s so common and just so easy to treat. So, all of the vaginal estrogens work equally well. They’re all really safe. Sometimes people are a little turned off by price. But I can always find a good price on GoodRX. There’s always options. There’s the vaginal DHEA as another option. There’s actually even an oral pill that works like an estrogen in the vaginal tissue. And I just can’t emphasize enough how safe they are, how effective they are. And really no reason to not be using these products.

Macie Jepson
There’s a bad rap out there with some of these products. Women are afraid of cancers and so forth.

Jean Marino, CNP
So, what I should also warn people is that there is a black box warning on all of those products. And that warning is based off of the WHI, that big infamous 2002 study that looked at systemic hormone therapy in older women. So, that black box warning on the vaginal products has nothing to do with the studies of vaginal estrogen. It’s based on that systemic hormone therapy in women in their 60s. And they asked at several organizations, asked the FDA to remove it because it does a huge disservice to women. It scares women. It scares providers. It scares pharmacists. And it’s not valid. And unfortunately, FDA would not remove it. So, part of this not treating effectively is people not realizing how safe it is.

Macie Jepson
I think with women it’s a different thing when we’re talking about arousal, and you touched on this already a little bit, but arousal versus desire.

Jean Marino, CNP
Right. And so it can happen to both men and women, but a little bit more common in women where instead of spontaneous desire. So, that meaning throughout the day you’re just thinking about sex. Someone turns your eye when you are walking down the street, that sort of thing. Instead, women, and like you said, some men can have more of like a reactive desire. So, they enter into a sexual encounter for whatever reason. They want to burn those calories you talked about. They want to be close to their partner, et cetera. And then once they kind of get going, and lubrication gets up and their blood flow gets up, and then there’s kind of like this, oh, I forgot. Yeah, I do like this. This was worth it. And so then sometimes the desire follows the arousal. And that’s completely normal.

Pete Kenworthy
And you touched on this a little bit earlier when we were talking about body image, and we talked about how maybe men don’t see you the way you think that you look, right? Like you still look great to him, right? So, communication has to be a huge part of this healthy relationship and sex life. What’s the best way…not everybody’s good at this, right, talking about sex and hey, do you want to have sex…it’s hard sometimes to communicate about having sex.

Jean Marino, CNP
I think it’s sometimes just hard to be vulnerable even with something, even with someone that you’re in a close relationship with. So, that can be tricky. One thing, and perhaps this isn’t quite answering your question, but what I would say is that women aren’t always taught to explore pleasure in their own bodies. And so sometimes women that I work with are kind of waiting for their partner to kind of bestow an orgasm upon them, et cetera. And I think women really need to figure out what works for them, what turns them on, what helps with arousal, orgasm, and they need to kind of figure that out first and then teach that to a partner. So, that could be part of the communication is giving permission to the woman: you deserve this. You can seek this pleasure in your own body, too, and then ex explore that with your partner.

Pete Kenworthy
That’s not always a comfortable conversation though, right?

Jean Marino, CNP
Exactly. Yeah. And that can be tricky. And again, I think it has a lot to do with culture and how we’re raised and the messages that we’re heard, that we hear. So, that is hard. That is a hard conversation to have.

Pete Kenworthy
And then, is there a point where one or both people are frustrated? Is there a point where you seek help for something like that?

Jean Marino, CNP
Yeah. I would say to not wait and to seek help as soon as you guys just can’t quite communicate. It’s hard. I think it’s rare to find a couple that both people are on the exact same page as far as desire and frequency and whatnot. So, that’s where the help with a sex therapist, a psychologist, someone like that can just kind of help navigate that a little bit better for the couple. But, you know, couples can, it’s a vulnerable topic and whatnot. And the other partner can take things pretty personally if one doesn’t have the same level of desire.

Macie Jepson
I think the message at the end of the day is that great sex is a journey.

Jean Marino, CNP
Yeah.

Macie Jepson
It’s not just going to miraculously happen.

Jean Marino, CNP
Correct. And it’s just like all good things in life. We all have to kind of plan for it and work for it. And it doesn’t mean it’s less sexy. It just means it’s valuable.

Macie Jepson
Jean Marino, Senior Women’s Health Nurse Practitioner at University Hospitals in Cleveland, thanks so much for being here today.

Jean Marino, CNP
Thank you for having me.

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