Side Project Podcast 16: Marriage and “Intimacy” with Nicole Cirino

Julie Liegl (00:09.25)

Hello everyone and welcome to Side Project, our journey through some of today’s middle-aged health and wellness issues. I’m Julie Liegl.

Ruthie Miller (00:17.385)

And I’m Ruthie Miller. As always, we are here to talk about the things that keep coming up in conversations with our friends. And today’s episode is a little different for us. We are talking about marriage and really more specifically, we’re talking about sex. We love it when listeners request a topic that they want to hear more about. And this topic, sex in marriage, is one that has been requested so many times. So we’re happy to kind of get in there, get in the weeds and talk about it.

Julie Liegl (00:46.464)

And it’s really fun, Ruthie, because we’ve been friends for 23 years-ish, 22. We’ve never talked about sex. So it’s really ironic that you and I are co-hosting today. But we’ve both been married for a long time. Many of us have at this age and we’ve been through a lot in our relationships. They’ve evolved, they’ve changed. And it’s a good topic to dive into.

Ruthie Miller (01:16.471)

It’s true, Julie and I got married the same year. So we’ve both been married for 15 years now. And I think it’s important for couples to kind of check under the hood, if you will, about their marriages. And 15 years felt like a big milestone. But it’s also important to kind of reset and make sure you’re going to make it not just the next 15 years, but the next one or two. It’s very important to kind of examine your relationships from a different lens.

Julie Liegl (01:46.23)

And we’ve talked so much about perimenopause and all the ways it affects our health, our fitness, know, medications we might take, things like that. And there is a connection here too, because as our bodies change, our, you know, emotions change, our sexual health changes, there’s all these other changes. You sent me that article about how fast our ovaries age.

Ruthie Miller (02:07.06)

Yes, absolutely. I read an article this week about USA Today, I mean, and USA Today. I’ll throw in a link. But it talks about how the ovaries age twice as fast as other organs because they’re working so hard at the beginning of our lives. So maybe that has something to do. We’re always trying to get to the bottom of what’s going on in our bodies and maybe that has something to do with it. I don’t know.

Julie Liegl (02:27.736)

That’s good. I thought my skin was aging the fastest, but it’s nice to know there’s stuff on the inside that’s aging even faster. Yeah. So Ruthie, who do we have today?

Ruthie Miller (02:34.568)

Yeah, great. We have with us today psychiatrist Dr. Nicole Cirino. Dr. Cirino has worked in the field of reproductive psychiatry for the past 20 years and she’s been laser focused on women’s mental health. So some of what she does is perinatal, yes, but really what she focuses most on is supporting women through menopause and perimenopause. I was lucky enough to hear her speak on a panel recently, a fantastic panel full of doctors who support women kind of throughout this transition. And she mentions that her main focus is on sex and libido. And so I thought, you know, bells going off in my head, this is the perfect person to join us to talk about this long requested topic, marriage maintenance and sex, that kind of stuff. So welcome Dr. Cirino, and thanks for joining us.

Nicole (03:29.035)

It’s so great to be here. I love talking about this stuff with women, which I usually do at my girls’ weekends as well.

Julie Liegl (03:35.714)

Awesome. Think of this as your girls weekend on camera. No pressure. Let’s start off talking about reproductive psychiatry. You’ve been doing this for 20 years. I’ve never heard of reproductive psychiatry. So I’m assuming you’re part of a pioneer for this specialty. Tell us about yourself and what is reproductive psychiatry and how you got into it.

Nicole (03:58.7)

Oh yeah, thank you for asking. It’s a great field and we’re really advocating at the national level and I think we’re almost there to make it an official psychiatry specialty. So basically, as a general psychiatrist, you start with your general psychiatry training and then we have specialization of reproductive psychiatry. So it’s strictly really the intersect between, would say, in some ways I can say between OBGYN and psychiatry, but it’s the impact of our hormones and behavior and on our brains. It’s like the study of the female brain and how that influences us throughout the major kind of reproductive stages of our life. So we say perimenstrual, what’s happening around our period, perinatal pre-post pregnancy postpartum and perimenopausal, what’s happening during the main reproductive events in our lives.

Ruthie Miller (04:53.591)

That’s so interesting. And more specifically, you really focus on female sexual function. So what are some of the concerns and complaints that your patients come to you with? And really I’m asking like, what do we need to be looking at?

Nicole (05:10.367)

Right, so besides reproductive psychiatry, then I got an additional certification in what’s called sex therapy, which is really rare for a psychiatrist to get. So I’m considered to be a sex therapist, but I got that certification in order to work in the medical setting and help my patients with sexual function conditions. So I’m in a medical set model, and the psychiatry clinic is within an OB-GYN clinic. So we look at the sexual complaints in the medical model, is really four different separate sexual pain, sexual conditions. So let’s start with the first problems with libido. What does our brain think about? Does the brain want sex? The second is problems with arousal. Is our body responding to sexual stimuli, increased breathing, heart racing, kind of blood flow to the vagina, that type of thing. The third is orgasm. Are we able to have an orgasm? That’s the third phase. And then the last are sexual pain conditions. So whenever I see somebody with any sort of sexual complaint, and I only see women, we go over each of those categories and try to understand how each of those categories work and how they’re affecting each other.

Ruthie Miller (06:17.067)

And they’re not, it’s not like you have one, but not the others, right? You can like, you can suffer from, you can not be able to do any of those four or multiple, you know? It’s not, sorry, I don’t even know what I’m trying to ask here, but it’s not like they’re separate, you know? It’s like they are combined.

Nicole (06:35.135)

Well, sometimes they’re separate. Like for instance, if I have a woman that comes in who is unable to orgasm because that’s a side effect of an SSRI, she may have no pain, good libido and arousal, but she cannot reach orgasm. So that’s a common thing that we do see something like that. Or someone could have a sexual pain condition and that of course ruined her arousal, her libido, and she doesn’t even want to have sex so she wouldn’t want to orgasm. So you’re right. They can be intertwined.

Ruthie Miller (07:04.119)

Thank you for understanding what I was trying to say there because I’m not even sure how I was trying to phrase that question.

Julie Liegl (07:11.042)

All right, we’ve talked so much about hormones on this podcast and many of us are on hormones, but can you just talk about how hormones play into, I’m guessing especially like libido and arousal, but sort of all these stages are changing hormones and perimenopause and menopause.

Nicole (07:27.701)

Right, libido arousal, orgasm and pain. So remember, let’s even start with pain for a minute. one of the most popular pain conditions that occurs during perimenopause, common, the word I wanna use, not popular, yeah, right, genitor urinary syndrome of menopause. It’s directly in effect from us having decreased estrogen. So it is a kind of progressive pain condition because the estrogen kind of helps our vagina to basically maintain elasticity. So that is where we get thin skin and the pain condition and lack of lubrication from a decline in estrogen. So that could be directly related and is treatable. Other estrogen really supports our sexual activity in a reproductive function. So as estrogen declines, it also can impact our libido because it impacts our brain.

And like we said, our vaginal ability to like have penetrative sexual activity. Now the other important hormone for women like men is testosterone. We have one-tenth the testosterone of men. We are very sensitive to testosterone changes. Our testosterone starts to go down at about age 35 to 40, and it goes to about 70 to 80 % of our highest level. And we are so sensitive to testosterone that for a lot of women, that kind of drives libido and that decrease in testosterone can decrease our libido. And we start to notice that during the perimenopausal period.

Julie Liegl (09:04.424)

I’ve been hearing so much about testosterone and I was just telling Ruthie before there was a big New York Times magazine article about it and I’m hearing so much about women getting pellets and I mean what’s the wisdom on that because I’m hearing in some circles it’s totally untested, unproven and then I’m also watching The Real Housewives of Orange County where they’re like it’s completely changed my life. So where are you on the testosterone debate?

Nicole (09:28.019)

Yeah, no, that’s a great question. So pretty universally in the medical community, including like the menopause society and ACOG, we do feel that physiologic levels or lower dose of testosterone replacement in perimenopause or postmenopausal women is a safe alternative, a safe thing to use for hormone replacement therapy, particularly for women with the complaints of low libido. So, but what that is different than that means like a three to five milligram dose a day. That is really different from the pellets that are something 60 times that dose and they are unstudied and unregulated. So those pellets that go into your body, you can’t take them out because they start to disseminate into the tissue. So we are not fans of the pellets because we think that that is much too high a dose testosterone. It can cause changes in behavior. Changes in, of course, facial hair growth and is not steady in terms of heart risk. 

Julie Liegl (10:28.418)

Why… or how did the pellets come about? Why is that a thing people are doing?

Nicole (10:33.163)

Right, right. Well, why do all these things coming about? I think the thought is a little bit helps. So why don’t we try something with a lot? And so technically they didn’t even try to go through the FDA to get it approved because we couldn’t kind of evaluate safety. And remember testosterone is technically a controlled substance. It does provide kind of increased energy, elevated mood and increased muscle mass and increased libido. So sometimes it is abused as well.

Ruthie Miller (11:01.931)

That feels very American. Like a little is good. Why not try just a shit ton? 

Julie Liegl (11:07.65)

Supersize it.

Nicole (11:08.139)

Right, right, yeah, now it’s crazy. And you know, I think there are women that are probably on the pellets. So I do not think that they are purposely like aware of the studies. And I think that the kind of sold is something that is kind of enhancing our longevity, right? But now that we’re starting to really be able to study this stuff in the FDA and FDA approved the estrogen and took the black box warning off of estrogen recently. I think we’re gonna get women really understanding the science better and clearer messages to consumers.

Ruthie Miller (11:48.408)

Well, let’s actually, let’s talk about that. That was big news this week about the FDA is removing the black box label from estrogen. And that we’ve talked about that on this podcast before, just how important estrogen is and the problems with the initial study. What are your thoughts on that, removing the label and what are your thoughts on just hormone therapy in general?

Nicole (12:10.569)

I think most of us in this field are big proponents of the safe use of hormone therapy. So we are in favor of the removal of that black box warning. was really kind of, it was really for like even vaginal estrogen, which is what we used to treat by, talked about that sexual pain condition that had a black box warning, even though no data supported that the vaginal estrogen actually was enough to increase the risk of the cancer and other risks.

I’m in support of that. I’m in support of women having all the information. I’m supportive of being able to study the medication and improve the science behind it. And I do think that as you see as well, more women are using estrogen and safe doses transdermally. And we see that the all kind of cause mortality decreases with estrogen use, not increases. So I think, I do think that we really are thinking, especially sexual function and mood, that estrogen is really positive for many women.

Ruthie Miller (13:13.655)

I struggle with this a little myself. I was on an estrogen patch for several months and it was, I mean, I was living my best life. It was great. I had no more hot flashes. I felt very clear-headed and it was great. But then one week my boobs like really started to hurt. They were very, very tender. And I do have a little bit, I am at a little bit higher risk of breast cancer. And so I kind of freaked out a little bit and I stopped taking it.

I did actually make an appointment with a menopause doctor here in Houston. And they’re so popular now. made the appointment in October and I couldn’t get into her until April. So I’m gonna talk to her. I’d really like to get back on it, but it just sort of made me really nervous in that moment. And I don’t know if that’s a common side effect or if it was, in my crazy head, I was like, my boobs hurt. I must be getting cancer. It was a little, maybe a rush to judgment, but that’s, it’s a scary conundrum kind of.

Nicole (14:20.051)

I think that’s what we’ve been told, that estrogen causes cancer and that it’s kind of selfish for us to use estrogen, even though it makes us feel a lot better because it can increase these risks. And I think what we’re trying to say is like, we really need to look at the science. That is kind of popular, but incorrect. And of course there are women that shouldn’t be on estrogen, right?

Julie Liegl (14:39.639)

Yeah.

Julie Liegl (14:43.286)

Yeah, I mean, I told this story in another podcast that right after I went on hormones, I went for a wellness visit and the doctor was like, you’re on hormones. Well, you need a mammogram. And I was like, well, I do need a mammogram because I’m due and I’m the age that I am, but not because of the hor, like it was just, it was, it’s so intrinsic based on, again, we know that totally outdated study. I think we do have this fear because it’s been whispered about our whole lives.

Nicole (15:07.967)

Yeah, absolutely.

Julie Liegl (15:10.434)

So we are talking a lot about hormones, but we know there’s other things going on that are affecting our romantic and sexual connections and our relationships. We’ve talked about, have aging parents. Many of us still have children at home. We are stressing about our jobs. We’re stressing about our own health and the million different things that are going on. Daily stresses and emotional things are affecting this as well. I guess, how do we think about what’s hormonal versus what’s emotional or other and how can we address it when it’s more on the emotional mind side of things.

Nicole (15:47.094)

Right, great question. I mean, for women, you probably as opposed to men, our kind of brain is our biggest sex organ. We really have to be in a space to be receptive to sexual stimuli and receptive, you know, to kind of approach men and connection. And that can be hard when we are stressed, tired, you know, angry at our partner.

You know, when we’re, there’s laundry on the floor that we see needs to get cleaned. So we really have to get our mind in a spot to be receptive to sexual activity. And that’s really the biggest challenge. So before I grab medicine or anything else, or even testosterone, we talk about this kind of stress management. So we do know kind of over evolution that when a species, women are stressed, that we should, you know, they actually, cut off the reproductive response. So we stop having periods when we’re stressed, but long before we stop having periods, we stop wanting sex. I think it’s a way to preserve our species so that we’re not having babies during famines or during war, right? So stress does cut off our libido and is probably the most significant thing that cuts off our libido. So I think stress management is really, really key in setting yourself up for success, that you are kind of planning at time to be intimate.

in that you do not have the kids about to walk in or you are in a spot where you’re not tiredness at the end of the night. You really kind of plan a time that you’re going to be the most receptive, responsive, that you feel well, and the most relaxed. And that’s a lot of things that we do when we talk to women about libido.

Ruthie Miller (17:30.017)

So I’m hearing it’s okay to not be as spontaneous as we once were. I feel like spontaneity was once a key part and like it’s hard. I mean, when you’re middle-aged and you’ve got kids running around, it is hard to be spontaneous sometimes.

Nicole (17:46.142)

Absolutely. And we actually do think that in long-term monogamous relationships, particularly for women, this kind of spontaneous desire, wow, in middle of the day, I want to have sex, is usually very low or gone. We think it’s kind of normal for us to not be walking around and saying, gosh, I want to have sex. But what we have found for women, that when we do engage in positive sexual activity, that we feel this kind of responsive desire during the encounter that kind of like, why don’t I do this more? This feels good, I feel connected, there’s some stress relief. So I think that’s what we are kind of telling women, not to wait for the spontaneous desire to think, I want to have sex, but to instead be receptive to it.

Ruthie Miller (18:31.479)

That’s great. So sex, obviously, it’s a very important part of any relationship, but I think a lot of women just get overwhelmed. And again, I think that’s playing off the stress. It’s playing off, you know, we see in movies and TV shows what life is supposed to be like, and some of our lives are not like that. What advice do you have for women who are looking to improve intimacy and sex in their own relationship?

Nicole (19:00.511)

I mean, I think it is to take care of your health, your emotional and physical health. We’re going to feel sexier when we’re feeling better. One of the things I like about perimenopause in the stage of our life sometimes is that we finally, our kids are, some of our kids are older. They don’t need us quite as much. We can start focusing on the multiple medical appointments and the Pilates class I went to at 6 a.m. So like we start focusing on our health again.

And we have some often have more resources and time to focus on our health again. So staying healthy and well, I think is important. And then you have to set aside time, like anything that you want to do, have to set aside time for connection with your partner. Doesn’t have to be time for, quote, sex, but time to be relaxed. Even touching each other, just like holding hands increases oxytocin, can increase libido, can help with testosterone.

So there’s a lot of ways I think we really just have to kind of carve it out and be intentional as we age. And so, you know, those things kind of also build up on each other. The more positive sexual experiences we have, we have a little boost in testosterone, kind of the more our desire increases. getting back into these kinds of positive sexual experiences will really can help be helpful.

Julie Liegl (20:18.786)

That’s so interesting. And it’s funny is I’m just sort of thinking about, I think we have a tendency, those of us who are married sort of around this age is you spend a lot of time with your partner, but it’s a lot of time, you know, housekeeping and, you know, kid discussing and logistical and sort of setting aside time that isn’t about that, because then it’s easy to say, we’re spending all this time together, but I don’t have these feelings. So maybe you don’t have these feelings because you’re talking about, you know, errands and pick up and doctor’s appointments and that’s not exactly going to boost your mood.

Nicole (20:51.699)

Yeah, and we do know the other thing that turns on the sexual brain a bit is novelty or newness. So that can be really something really small, like a new candle, a new scent, like just, you know, a new bedspread. So little things like novelty or newness or surprise turns our brain on in different way. So that’s the other thing that I’d

Ruthie Miller (21:12.373)

I do need a new bedspread. So hey, maybe I can use that as a reason that we need a new bedspread.

Julie Liegl (21:25.902)

So we’ve talked about testosterone and estrogen. Are there other sort of treatments or things that you suggest for females who are looking to improve their sex lives? And or are there supplements? Are there other things that we could be doing? And I do want to mention, I just want to make sure I understood you talked about handholding can actually boost our testosterone. So are there other things we can do?

Nicole (21:48.236)

Well, so there are other things we can do. So let’s start with like behavioral. So what can we do without adding a chemical? Even though I consider the hormones chemicals, so we have ways to boost our oxytocin, ways to boost our testosterone, right? So something called an old kind of technique actually discovered by Masters and Johnson like 50 years ago is just sensate focus where we just lay with our partner, even with clothes on, and just take turns massaging your partner and just taking turns. One person’s touching, the other person’s not. And you know we do is we stop talking. So what we’re trying to do is get out of our brains a little bit and just be in a mindful experience of just feeling touch and feeling your partner. And so I think sometimes we’re doing a lot of talking or in our head and we want to let our bodies take over again.

And so things that can get you back in your body can be helpful. So that’s kind of one behavioral technique. The other thing I talked about is scheduled sex. That can be helpful for both mismatched libido and low libido. The lower libido partner is setting up the time and the place and the setting and preparing to be receptive to sexual stimuli. Then there are medicines, two FDA approved medicines and testosterone, which we talked about.

So the two FDA approved medicines are flavanserin or Addi, it’s for low libido in women. The other is bremelanotide or Vilece. They are kind of interesting that they’re recently FDA approved. They’re kind of moderately effective and often behavioral interventions are as effective and there’s a really big placebo response, but there are some options there.

Ruthie Miller (23:39.564)

That’s interesting. And I don’t know if you know the answer to this, but are they covered by insurance? Because a lot is made about how things like Viagra, they’re like, you know, handing it out on street corners like candy for free. Whereas anything having to do with women’s health, they, you know, jack up the prices and make it, you know, really difficult to attain.

Nicole (23:59.712)

Yeah, no, that’s a great point. So I would say with about half of the commercial insurances, if I prescribe it, it’s covered. And other times women have to pay out of pocket for it. You have to be diagnosed with a condition of HSDD, which is basically hyperactive sexual desire disorder. But it can be covered. And in fact, what’s interesting about the Bremenal Antide is it’s actually, this is why a lot of women don’t like it. But it’s an injection that you take like 30 minutes prior to sexual activity, a little kind of, we’re getting, actually a lot of women are getting more used to the injections now, and they’re like, I lost medication. It used to be like a no, but now it’s like, um.

Ruthie Miller (24:34.711)

Yes ma’am.

Julie Liegl (24:35.288)

We’re all getting Botox. you know, just one more needle.

Ruthie Miller (24:40.626)

But is it like one of those pens? Like I had gestational diabetes and I had to use an insulin pen and it was really no big deal. I always think that when you think about doing an injection, I’m thinking of like, you know, the syringe on the cover of that album, whatever album that is, you know, where it’s like a six inch long needle. It’s like, I’m not doing that, but you know, the little insulin needle was really no big deal at all. So if it’s more like that, then I think women will be fine with it.

Nicole (25:03.871)

Yeah. Yeah. And then, you know, we also did a study that looked at we collectively, not me, but the community, exercise 30 minutes a day, the day of, and 30 minutes prior to sexual activity actually boosts our, our, dopamine and can reverse like SSRI, anorgasmia. So exercise actually does something to our brain as well. What a, what a surprise, right?

Julie Liegl (25:30.828)

Yeah. I love the 30 minutes before, because that dovetails so well with your schedule stuff. So it’s like, look, taking this injection at 2.30, three o’clock is go time. Like it’s all, it’s like connected. I am, and I don’t know if you can answer this, but you you’re obviously a wonderful doctor to talk to about this stuff. Most of us don’t have you for a doctor. So for women who are either uncomfortable bringing this up or feel like their doctors are like, you know, let’s talk about your cholesterol, let’s talk about your pap smear next. How can we advocate for ourselves or what questions should we be asking or how do we find a doctor who can take this seriously and will be open to prescribing or discussing these things with us?

Nicole (26:17.961)

Yeah, no, good question. Well, I do think there’s some good podcasts that are that where physicians are kind of leading the voice and teaching about this. I’m going to have to like them up because they’re on top of my head. But I think most menopause clinics do have they’ve studied sexual medicine. the Menopause Society and is one organization where you can look up, a provider in my neighborhood or in my area. And then ASECT is an organization of certified sex therapists. That could be helpful, but there’s a more sex therapist, not necessarily like sexual medicine. And we’re starting to teach more people about this so that we have more doctors to talk to. Then there’s some good books. Maybe what I can do is give you some resources that you can share. I have list of resources that I think are really excellent, both books and podcasts that people could go into more.

Julie Liegl (27:21.816)

Amazing and we could put that up.

Ruthie Miller (27:21.867)

Absolutely. I mean, it does feel like an under resourced area. As I mentioned earlier, I tried to make an appointment with someone and it’s going to take me six months to get in because her patient load is so full. So clearly this is a need that’s out there. And kudos to you for being a pioneer in this field. It’s a wonderful service, especially now as it becomes more of a public conversation. And speaking of public conversations, we actually hear that we have a lot of our male friends who listen to this podcast because they tell us it helps them understand their wives better, which, we love this. We’re so happy to do that. For any of our male listeners here, how can they support their wives and their partners on this journey? What are some tips you have for them?

Nicole (28:11.391)

You know, studies have shown that when a partner is involved in menopause care, even sometimes, which I don’t typically see, but attending the appointments, but, you know, reading up, talking about it, and that actually really supports the woman and the couple. So I would, you know, be curious about your wife’s perimenopausal or menopausal transition and what she’s experiencing and what she’s noticing, because it is pretty unique, right? And then I would encourage, you know, take time so that she can access the health that she needs. So if that’s working out, healthcare, that can be really important as well, because I think we’re finally at a stage where some of our kids are older and we need to address some of the medical conditions, mental health conditions, possibly learning mindfulness strategies and new techniques that can take some time to get us really comfortably through this area. And then also kind of recognizing that the female brain is the biggest kind of sex organ for women. So, you know, that does mean things like, you know, kindness and helping out and supportive statements and saying positive things and all those things really matter. They really matter to women. What do you guys think? Does that make sense?

Ruthie Miller (29:23.703)

Absolutely. Yeah, absolutely. I mean, I Julie and I are both lucky that we both have very supportive husbands who are very involved and stuff, but you you hear about the ones who aren’t and it’s little things that can really make a big difference.

Nicole (29:42.667)

Yeah, I’m interested to hear what you guys think. What do you think the husbands should know? You’ve done this a couple times. What do you think?

Ruthie Miller (29:49.952)

That is funny because I have a group of friends here and one of my friends actually suggested that we do an entire episode for men that’s like things that your wives want you to know. And one of them said the number one thing she wants her husband to know is she wants him to chew quieter. And I was like, okay, there we go. There’s our whole episode. So we’ve addressed that here. So now we can cross that right off our list.

Julie Liegl (30:18.114)

I do think though, that whole the mind-body connection and that it is more about, like, I do think it’s so important and I’m so glad we’re talking about all this hormone stuff. And I think, you know, having a partner who’s willing to talk to you and ask questions and maybe encourage you to get that help. But at the same time, like so many of these things are about, you know, staying connected. Again, like I talked about not just on logistics, but emotionally helping each other, supporting each other. And if you have a partnership where one person is taking on more of the household stuff just because of the nature of it, is that what’s getting in the way of having the time or the desire to have more intimacy?

Nicole (30:55.883)

Absolutely. Yeah, that makes a lot of sense.

Julie Liegl (31:03.17)

How do I know, or how does one know if it’s just like, I’m tired, I’m almost 50, like this is what it is versus like, no, it’s time to see a doctor. Is it just like, I want more or is there a point where I know it’s actually into dysfunction? Like how do I define if it’s dysfunction?

Nicole (31:23.947)

Well, would, okay, just a couple things. So if you’re having any pain, then you need to see your doctor, because that can kill a libido. So any pain condition, go see your menopause specialist. If you have lost your ability to orgasm, that’s quote abnormal and reversible. So that’s another piece that’s important. The libido piece is more tricky. So I would say that if you should, you’re not normally gonna have like kind of spontaneous libido, but you should be enjoying sexual activity that’s pleasurable. And that should then lead, you should feel, be feeling more connected. That should lead you then to feel like some sort of regular sexual activity generally is something that you want in your life. I’d say is what most people would describe kind of as normal. If you don’t want to have sex, then that is also fine. But usually if you are wanting to have a sexual relationship with your partner, which is healthy for the relationship, then being able to maintain that consistently at some sort of cadence that you got you to agree on is probably the healthy sexual lifestyle that you would have, I would say, in the menopausal period, if you want to kind of say on average. Did I answer your

Julie Liegl (32:37.806)

You just said, yeah, I was going to say you said, I’m not going to press quickly. You’ve now mentioned orgasms twice and just now you said if that’s the problem, that’s reversible. Talk to us about orgasms. Like what can be done if that’s the challenge?

Nicole (32:53.227)

So sometimes it’s a matter of just as our bodies age, we need different or more stimuli, just basic stimulus. So that sometimes the medical treatment for an orgasmia may be using a vibrator to increase stimuli as we age. And then sometimes there are medications that could reverse.

the adverse effects of some medications. So several medications can cause delayed orgasm or anorgasmia. So we can reverse them with medications like an anas needed medicine. For instance, Viagra in females, not very well studied, but it’s something that can reverse some of the sexual side effects of the anorgasmia side effects. then like, well, butrin is another antidepressant that can reverse sexual side effects of SSRIs and antidepressants. So it kind of depends on the reason for it. But it’s something that to see a doctor about

And there are several strategies that we can use. There’s also a really good website that’s a little bit explicit, but it’s just to help women who are struggling to figure out how to have an orgasm. And so it goes over just techniques. It’s called OMGS, but it’s quite interesting. But it is basically talking about teaching women how to have an orgasm. Because women and kids, as you probably know, don’t just know that it actually requires clitoral stimulation to have an orgasm. It’s not just penis and vagina sex that gives most women orgasms. And so I think we don’t teach women that. So I see a lot of women in their 20s and 30s and 40s that have never had an orgasm. They didn’t know that. They didn’t know what it takes to have an orgasm. So sometimes it’s really simple, just education, sex education around it.

Julie Liegl (34:38.626)

And is there something as we age, can it become more difficult to orgasm? Like are there hormonal changes there or you’re nodding, so I’m guessing I’m onto something.

Nicole (34:47.943)

Yeah, I mean, think that depends on a lot of medical conditions can impact it. But I think just just general aging is it takes more stimuli and different stimuli. So both brain stimuli and also just like vibratory stimulation, external stimuli. So I think we do notice a change in our orgasm as we age. And so rather than feel, gosh, what are we missing out on? This is so difficult. I just give up. I think that’s the time to communicate with your partner.

and kind of figure out what do you need? What is now going to be the stimulus needed to achieve orgasm? And now I’m like reflecting on the fact that my parents might watch this also. We’re talking about orgasm.

Julie Liegl (35:31.31)

But at least this is your job. I mean, think about our parents.

Ruthie Miller (35:34.165)

Yeah, they have to know what you do, so.

Julie Liegl (35:36.812)

You have a medical degree.

I’m just gonna tell my parents not to listen.

Nicole (35:45.259)

My husband’s used to me because I’m lecturing in front of hundreds of people and he stays far away.

Ruthie Miller (35:53.985)

That is funny. Well, so as we kind of draw things to a close, what are a couple of things that you want women to walk away with today? So maybe some tips for sex-cess as we like to say.

Nicole (36:08.043)

I think that thinking about novelty, when I say novelty, newness in the sexual relationship really can turn your brain on in different ways. It doesn’t have to be super fancy. So I would be thinking about that. Think about your five senses. You can use any of them, like taste, your skin, sound, is it different music?

So those are like really kind of easy wins that sometimes can help you get your brain engaged and off the idea of what your to-do list is. So engage your brain with those five senses. think, as you guys have said this, see a doctor that specializes in these conditions, especially perimenopausal, and you’ve had to change your sexual function during perimenopause, I think would be really important. And then you kind of have to prioritize it and set outside time for you and your partner so that you’re not rushed because it might take longer to have the sexual response that you had in your 20s. So give yourself more time. Grace, yeah.

Ruthie Miller (37:12.043)

and grace a little bit maybe. I’m in grace. Well, that was fabulous. I learned so much. Thank you so much for joining us. That was a really interesting conversation. was motivational and practical.