Hormones, Desire & Midlife Sex w/ Dr. Gillian Goddard | Szn. 3 Ep. 18

Hi, it's Dr. Jen Kennedy. I'm a sexologist and couples therapist. The Pleasure Project podcast is about sex and relationships. So this includes discussions on desire, dysfunction, dissatisfaction, exploration of all things sex related. So sometimes I'll do toy reviews and we'll look at trends. And sometimes I'll also enlist other experts. We'll increase your insight and enhance your pleasure. So tune in. Are you ready to learn more about perimenopause and what is happening with your sex life? Because in this episode, I sit down with an endocrinologist, Dr. Jillian Goddard, and we talk all about it. Specifically, what is going on with blood flow? How does it get to your genitals? And why does it matter? We talk about hormones. We talk about specifically testosterone, both for men and for women. We talk about the value of estrogen. What is it doing in your body and how does it help? How does it inform your sex life? Sex drive, all of it. What is your, like, what is your pelvis doing? What is your, you know, are you having atrophy? We cover all of it. Tune in. It's a really good conversation. I learned a lot. I think you will too. So if you're anywhere near met, metapause, metapause, it's really worth listening to. So I hope you'll enjoy it. Tune in. I am so excited to welcome today's guest, Dr. Jillian Goddard. She's an endocrinologist with over 15 years of clinical experience and a deep expertise in hormone health, especially changes that affect women during the reproductive years. So basically pregnancy through perimenopause. Jillian teaches at the NYU Grossman School of Medicine. She is also the author of Hot Flash. I love that name. A newsletter about women's hormone health. I also am living that name. And the forthcoming book, The Hormone Loop, she has a degree in journalism, which I found interesting, which means that she brings together the rare and powerful mix of communication and clinical insight. So welcome to the pleasure project. I'm so glad you're here. Thank you so much for having me. I'm excited to be here. Yeah. So I am curious, journalism, as well as medicine. Why did you, what was that path about? It was about being 18 and not really knowing what I wanted to do with my life. So I was kind of an artsy kid. I was always, I was like a theater kid. I danced very seriously, like for most of my childhood. And then I got to high school and I always was, you know, got positive feedback about my writing. And it was, I mean, it was the 90s. I wasn't, you know, I wasn't too sure. A career in science was a thing that, you know, that girls did. And so I got a journalism degree. And I actually worked in public relations for several years. And I happened to fall into pharmaceutical public relations. And then it was through that that I realized that I really wanted to go to med school. That's so funny. Okay, so my degree, bachelor's in public relations, and I worked in PR for a couple years before going back and getting a degree in photography before getting a degree in psychology. So I was like, because I caught that. I was like, oh, because we, yeah, I saw some similarities there. And I was, yeah, absolutely. Do you think it makes, I do think the fact that I have a journalism degree does make me better at communicating with patients, with readers. It's a great skill to have, no matter, no matter what you end up doing. Understanding how to communicate, position, right, just some of that basic stuff is really helpful, actually. And that's probably also why you're willing to do this kind of work and be public facing, because you understand how to do messaging. Yeah. And I, and I really enjoy it. I really, it's, it adds a different aspect. You know, I love seeing patients in the office. But this is like, you know, bringing things full circle feels like kind of a new and interesting challenge. I've been writing regularly for the last two years. And I've just really been enjoying it. Yeah, it's part of, part of the larger satisfying mix of like rate, there's your primary job. And then there's also like, spreading the message and as you'll, you know, we're going to unpack, knowing what you know. And then also like, how do you communicate it out to not just one on one patient care, but also write through the newsletter, through your writing, all of it. How do you help more people? Well, and I think it's so important because one of the things that a lot of people don't realize is endocrinology is an incredibly small specialty. There are 9,000 practicing endocrinologists in the United States. And there's 168 million women in the United States. And not all those endocrinologists are experts in women's health either. Being able to communicate at scale, I think is really important when you're in a, in a specialty where it's not possible to see everyone. Yeah. Wow. Only 9,000. That is so few. And you can see the population altogether. Yeah. Okay. Great. So, and also to that, to that point, if you like what you hear today, please subscribe to Jillian's newsletter, Hot Flash. That's also a bar in LA, if you're interested. Which I found funny. They encourage women, older women to come to this lesbian bar specifically. But yes, so it's time I'm there. I love to check that out. They have Hot Flash and Hotter Flash. The Hotter Flash is for the older women still. It's so funny. But also if you want to know more about general sex and relationships, you can subscribe to my newsletter, which you can find at pleasureproject.com. And also if you enjoy what you hear today, then please like and leave us a review. So that's always really helpful to spread the word. So let's jump in. So first of all, I'm not sure that everybody knows what you do. You know, you said it's a very specific, it's a specialty that not a lot of people understand. So tell us a little bit about endocrinology. Absolutely. So endocrinology is an area of medicine that is part of sort of general medicine. So we learn general medicine and then we do a fellowship where we specialize in all things, glands and hormones. And that includes things like thyroid disease and diabetes, but it also includes things like perimenopause and osteoporosis. Yeah, which we care more and more about as women, as we age. And so when you when you reach out to me, I was like, Oh gosh, I am squarely in all of the all of the things you suggested. I was like, I care about this for me. And so I'm sure most of my listeners are kind of in the 50 to 75 range. And so I think this conversation is very relevant. And I'm excited that we're going to unpack it. Let's talk about perimenopause specifically first. What you know, kind of what is that? And when does it start? Yeah, typically. So perimenopause is the stage of our reproductive lives, where not to sound too dire, but the eggs that we have in our ovaries are starting to dwindle. There's not so many left. And women are born with all the eggs that they will ever have. And over the course of our reproductive lives, we use them up. As we approach, as the eggs dwindle, the ones that are left in our ovaries are not such great quality either. And that affects how our body drives the process of ovulation. So ovulation is driven from our brain and from our pituitary gland. And those older, lower quality eggs need more stimulation from our pituitary gland to mature and be and be ready for ovulation. The hormone that drives that follicle stimulating hormone or FSH also drives estrogen production. And so when you have, when you're getting these big FSH signals, you can be getting big rises in your estrogen, and then estrogen levels can just plummet. And so what we see in perimenopause is women start to have irregular periods. They're further apart, they're closer together. But they also have hormone levels that are incredibly volatile. They're rising super high, they're dropping super low. And that hormonal process is what actually drives a lot of the symptoms of perimenopause, things that people think of all the time like hot flushes and night sweats and sleep disruption, but also things like changes in libido and arousal, changes in vaginal lubrication. Mood. Bonkinas. Illy. So the typical age of menopause, so the typical age that you are when you have your very last period is between the ages of 45 and 60. Women can start having... It's a big range. It's a huge range. It's a huge range. The average age is 52. Most women start having symptoms in their mid to late 40s, but obviously some women will have symptoms earlier. And if you're not going to have your last period until you're 59, you might get well into your 50s before you have any symptoms. There's no way to game this, right? There's no way to change it. Like it just happens. You can't... Yeah, I mean it's... It's inevitable. Savings or you can't know, right? So they're doing research on that. There are people looking at prolonging ovarian function, and so that'll be something we'll have to talk about in the future because the jury is still out on whether it works. Well, that's the thing, right? Like at a certain point, how long should... How long... I mean, the process of the transition is not great, but women do tend to come out the other side feeling good and not dealing with a lot of the things that go along with being an ovulating, menstruating woman. Yeah. There are some upsides. Yes. Well, and I see a lot of women that are also... There's lifestyle components as well that are hitting women at that period of time. So I'm mostly a couple's therapist, and so they're coming in with the stressors of kids are leaving, the relationship has been under pressure, they're in mid to high career, and they're getting all these... All this symptomology. And so it's hard to know... It's hard to... With the full context to know what the heck is going on and what's what. And so they're like, is my marriage over? Is my body closed for business? What's affecting what? Yeah. Well, and one of the things that can happen for some women... So as you know, we have big gaps in our knowledge around the physiologic drivers of libido and arousal in women. We think testosterone plays a role, but we don't really understand exactly how the neurotransmitters and hormones are all sort of working together to have women want to have sex and have sex feel good when they do. But we think testosterone is a key piece. And one of the things that happens for some women during perimenopause is that their testosterone levels can drop. So in perimenopause, testosterone can do almost anything. Some women get higher testosterone in perimenopause. Some women's testosterone doesn't change much at all, but lots of women see a big dive in their testosterone levels. And so between low estrogen, leaving us with vaginal dryness and discomfort and lower testosterone, potentially leading to lower, you know, hormonal drive for sex, you can imagine why so many women are like, I kind of just like to like to have sex again. Okay, with the vaginal dryness, is that because I haven't actually necessarily had that experience, is that more like just can't lubricate or can't like just cross the board? Like it's just not. So yeah, so a couple things are happening there. So estrogen actually acts on the tissues of the vagina, both the mucosa that lines the vagina and the smooth muscle that sits just underneath that mucosa. And so when estrogen levels drop around perimenopause, you see a couple of different things happen. The tissue becomes dry, there's less lubrication. That's the first thing that can happen. And that can happen across the board, not just during sex. The tissue thins, it can become atrophied and the muscles, the smooth muscles that line the vagina can also thin out. That your vagina kind of is important as it sits between your rectum and your bladder for kind of keeping along with your pelvic floor, kind of keeping your uterus and your rectum in your bladder all up in your pelvis where they belong. And so when if you start to get that kind of atrophy, the vagina can kind of slump down, pulls, yeah, doesn't that sound lovely? Then the uterus pushes on the bladder or on the rectum, you can feel like you have to go to the bathroom all the time. The urethra gets pulled closer to the anus. And so it's easier to get urinary tract infections because you get bacteria from the anus and rectum into the urethra. In addition to a sagging face, you get a sagging vagina? You can. You can. But the good news is we have really effective treatment for vaginal dryness and vaginal atrophy, which by the way is the worst. I mean, it's up there with elderly gravata as the absolute worst medical term ever. So but we have really effective treatment, vaginal estrogen. So either as a cream or a pill is super effective. And that's topical, right? Not the systemic estrogen. Yeah, we're talking about putting estrogen directly on your vagina and you don't have to do it as a cream. You can do it as a tablet that you put in your vagina so it doesn't have to get all gloppy and messy. It's super effective and it's safe for virtually all women, women who maybe can't take systemic estrogen because of systemic meaning a pill you would take or a patch or a patch. Yeah, yeah, yeah, yeah, exactly. So a patch or a pill, women for whom that's not a good option because of their heart risk or because of their breast cancer risk can absolutely safely use vaginal estrogen. And in some cases, even women with a history of breast cancer can safely use vaginal estrogen. The vast, vast majority of women have this available to them as a treatment option. So there's absolutely, if you have vaginal dryness, you should bring it up immediately because there's really no reason to head down that path toward vaginal atrophy and all the and you would know you're having vaginal dryness if you're having pain. You might have pain with sex, but sometimes women just feel like it's uncomfortable, like they sit down or they move around. One of my patients described it as feeling like the walls of her vagina were two pieces of velcro and she would move it would feel like they were like ripping apart or shifting. I was like, that is, that is, does not sound pleasant. Let's do something about that. Right. Okay. Yeah, so I can just feel like things are kind of like stuck together in an uncomfortable way. So if you're, yeah, so if you're dry or uncomfortable, it's time to intervene. So let's talk about testosterone for a minute because that has been all over the news. I spoke to Kelly Casperson a couple months back. She was on the podcast and she has been talking to Congress and I know she's a big advocate. And I just started testosterone on Monday, three of taking testosterone. They said put it on a part that doesn't have hair. I was like, where's that? I just love my foot. I want more hair on my head. So I put it there. So I'm putting it on my inner wrist and I'm waiting to see what happens. I'm sort of like, you know, because I talk about all this stuff with my clients and I'm trying to also understand it. And so I'm, you know, I'm trying most of this stuff out, but I'm waiting to sort of see what happens. My testosterone was barely out of range. I just had a full panel of blood work. I did like 900 vials. My doctor looked at everything and she said, everything looks perfect. Your testosterone is a smidge low. And I was like, okay, I want to try it, you know, because I want to see what it's like. And I'm, you know, I'm trying to decide like, well, first I'm like waiting. Like, is it placebo? Because like day two, I was like, I think I feel a little more, you know, arousal. But then I was like, I might be making that up. I'm not sure. What is likely to be expected to occur? Like what is a listener if they start testosterone as a woman? Like what can they expect? Yeah. So I think there's a lot of misinformation about that out there about testosterone for women. It is touted is sort of this like, it's going to put a spring in your step and a smile on your face. It's going to, you're going to, it's going to be fix what ails you. And, and some of my patients have felt like they've gotten those types of benefits. But I would say that's more, more anecdotal. What the data says about testosterone is that women who use testosterone for, they start to see benefit at the four week mark. And most of the studies are only 12 to 16 weeks long. So if the studies are short, what they see is that women report more satisfying sexual experiences. So what that is is really two different things. They're having, they're either having more sex or they're having better sex or they're having more better sex, right? He doesn't typically qualify as better sex. Not, well, in my mind it doesn't, but that is how they, that is how it does. Men want more, women want better quality. Right. But that is actually, that's the metric that they use. It is the number of satisfactory sexual encounters. So satisfactory, I think being the key. The tricky thing about all this data, so there's a bunch of studies, they look at, they look at all different ways. Basically the difference between the studies is the amount of testosterone and the vehicle for getting it into you. It's always transdermal. So you're always using a gel, a patch, a cream. In some cases they use sprays that are not available on the market. And they all saw kind of the same thing, which is if you think about like a graph and they, you know, you enter it, you enroll in the study and you get randomized to get the testosterone or you get randomized to get a gel that doesn't, is just a gel with nothing in it. Right. Yeah. And what they saw is everybody's low when they start and then everybody, including the placebo group, sees a significant improvement in their sexual satisfaction. So even the placebo group gets a significant improvement. The difference between the testosterone group and the placebo group is big enough that the testosterone group gets a benefit too. That's so funny. But even the placebo group gets a huge bump. And I think, I mean, this gets more into your area than mine, but I think a lot of it is about relief that someone's trying to do something to help them. And then that, that that just giving attention to the problem in some ways can provide some relief. So my day two, my day two experience was completely placebo. Absolutely. You really don't see, you really don't see a benefit so far. I went to Belize and I was like, ooh, ooh, it's kind of attractive. And I was like, it's working, it's working. But remember, I mean, not that we want to treat everyone with placebo, we want treatments that really work. But remember, the placebo effect is very real. It is not an all in your head kind of thing. Yeah. Yeah. It is a very real, it is a very real effect. So it has benefit too, even though we'd like more benefit than just that. Yeah. One of the tricky things though about testosterone for women, and you may have talked about this before, is there is, at least in the US, there is not a formulation of testosterone that is formulated in a strength that's appropriate for women. So we are always doing one of two things. We are fiddling around with the testosterone gel that's made for men and trying to take a smaller portion of it. Or we're using compounded testosterone cream from a compounding pharmacy. And the issue there is really that compounding pharmacies are not well regulated. They're regulated by the state. They're not regulated by the FDA. And there's no good way to know if your compounding pharmacy is a good compounding pharmacy or not a good compounding pharmacy. I mean, I have tried to figure out, you know, they all say they're good. They're all going to say they're good. They want your business. There's not a good way to figure out if that's really true. I mean, short of being a pharmacist in the back and looking at their procedures. So then it's up to the physician to sort of be the screening. Like the gatekeeper. And that's tough because it's hard to do. And so having a product that was FDA approved for women would really go a long way. I think toward... Exactly. Yeah, because mine came from a compounding pharmacy, APIG. Yeah. I mean, the other issue is that if it's not approved by the FDA, your insurance is not going to pay for it. And so there are even the testosterone gels that are for men. Some of my patients will use like measure out little amounts of the gel, like of the typical testosterone gel menus. That doesn't get paid for it either because it's only covered for men. And so we have some gaps here between what the research tells us about effective treatments and what's really available to women and easily available. Well, and I know that's why Kelly is going so hard at them, right? Is to say, come on, parody. Yes, we need to have this be available because it makes a difference for women's quality of life. And what you really need, and this is the real challenge, what you really need is a pharmaceutical company who wants to go through the... Who wants to manufacture it and go through the process. And that's expensive for them to do. And so that's... She's fighting the good fight and I'm appreciative, but I think it's going to take some hard work. Yeah. Well, and also it's interesting when I saw some of the stats around the amount of women who are taking estrogen. And I can't believe how low it is, right? Because of the studies that came out and how many women got afraid of that. So as I came in, I have a physician here in town, a gynecologist who's definitely very knowledgeable about women's health and menopausal health. And she's part of that whole world. And so she started me early on estrogen and progesterone. But as I started talking to all my friends, I'm turning 52 this month. And I started it when I was 47 or 48. Yeah. I realized none of my friends were on it. And even still, they're just starting to. There's been a lot. And all of my friends who are 55 and up, none of them took it. And there was a lot of fear about it. Yeah. Because they're of that generation that was like, no, their doctors weren't even knowledgeable and were definitely hesitant. Yeah. I mean, I think this is... I love that we're talking about perimenopause more than ever before. And I love that we're raising awareness. We are hitting a point. And I love that we're talking about estrogen because it is the most effective treatment for perimenopausal symptoms. I think... Some of these friends, in fact, are now postmenopausal and they're circling back and getting on estrogen. You know, and they're all like running around their weighted vests and they're freaking out trying to like, they're not like, no, I missed out on the, you know, the help. And so they're still returning to the estrogen and trying to get some, some of the benefits. Which luckily you can do until you're 10 years postmenopause or 60 on average, or whichever is older, typically. But it is true. There was a ton of fear. I was in medical school when the studies came out about the Women's Health Initiative. And I mean, women were throwing their hormone replacement therapy and the garbage, like, en masse. It was, it was really... And it wasn't... It really wasn't the data. It was the reporting on the data that had women that really got women really fearful. But the other thing that then happens is, you know, now you have a generation of doctors who have really gotten no... I mean, so one of the benefits for me is that as a guy, as an endocrinologist, we get training on hormone therapy because we get training on premature ovarian insufficiency, which is what we used to call a premature menopause. But gynecologists get virtually no training on menopause and hormone therapy. And so you have this whole generation of gynecologists who've never prescribed hormone therapy. And so between 2005 and 2020, only about four per four to five percent, depending on the study you look at, four to five percent of women took hormone therapy. Even if we're just so... That's like, that's like so many women suffering. So many women are hot at night. So this is my thing. So, you know, people are like, oh, people should be taking it for cardiovascular prevention and dementia prevention. The data there is not as great. But my point is, is 80 percent of women have hot flashes and night sweats. And so there's 75 percent of the women out there going through menopause have symptoms that could be treated by estrogen, whether it's helping their cardiovascular health down the road or they're reducing their dementia risk. They could at least be treating their symptoms now. And we do know that it reduces your risk for osteoporosis too. Quality. Absolutely. Taking the toll. And brain fog. And, you know, they did... There was a study that came out recently that showed that women who went to a doctor for a diagnosis of like a menopausal symptom made 10 percent less after they were diagnosed. It was called the menopause penalty. And what the authors of that study found is that the women were actually cutting back on their... It wasn't that people were getting paid less for the same job necessarily. It was that they were cutting back on their work hours or leaving the workforce altogether. And they found that women who started on treatment for their menopausal symptoms did not see that dip in their income. And so, I mean, there's so many reasons to close the gap between the number of women who were taking hormone therapy and the number of women who are having symptoms. A ton of work to do. Yeah. Just to get the symptomatic people taken care of. Right. To understand what's going on rather than just attributing it to, you know, bad attitudes and, you know, mom's just cranky. Right. Is there like a menopause version of this? So, Matt, that's a great question. So, one of the things that I think is confusing to everyone is that, you know, there's hormones that we think of as male hormones. And there's hormones that we think of as female hormones. So, we think of estrogen and progesterone as female hormones. We think of testosterone as male. But really, women have testosterone and need testosterone. And men have estrogen and need estrogen. So, there are more similarities than there are differences. What I would say about men is that their testosterone levels are highest in their teens and twenties. And they see a gradual falling off of testosterone levels over the course, usually if there's 40s, 50s and 60s. So, they are not experiencing this like cliff in their testosterone levels that women experience. And they're not experiencing the hormonal volatility of perimenopause and menopause. But they do see a very gradual decline in testosterone over midlife among men. And it can be quite important, not just because it certainly affects testosterone loss, certainly affects libido and sense of well-being and mood. In men, it also affects their ability to build muscle mass. But it's also important for their bones because men get estrogen from their testosterone. They use an enzyme that converts testosterone into estrogen. And so, if their estrogen levels they may also have low estrogen levels and that puts them at risk for osteoporosis. So, it's not as dramatic and it's not as chaotic. But they do see a general some decrease in their sex hormones over time. Okay. Because I do hear some echoes of that and I feel like when they, you know, when I start seeing any sort of reduction, when they report out reduction in desire, reduction in libido, they have a little bit of an internal crisis because typically they're thinking about they're having access to desire so easily up until late 50s, early 60s. Yeah. Yeah. And then they start sometimes having, and also of course, if they're having any sort of blood pressure issues or and they're starting to any sort of medication. Yeah. Or anything like that can really. But then they're like, what's happening? Yeah. Yeah. Yeah. And so, you can imagine if you're a couple in midlife and everybody's experiencing these changes that can have real significant effects on your relationship. Yep. Okay. So, let's take a quick break. A quick pause here to share something that I've been working on that I think you will really appreciate, especially if you've ever felt confused or disconnected from your sexual desire. It's a self paced course that I created for women who want a better understanding of their sexual desire, especially if it's felt confusing, inconsistent or hard to access. A lot of us are taught that desires should just be there, effortless, spontaneous, always on, but that is not the reality for most people. And when it's not, it can leave you feeling frustrated or like something is wrong with you. 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Now back to the episode. All right, so let's jump in and talk specifically about the vulva and the vagina and some pleasure. So specifically, blood flow, thinning, tissue, kind of loss of elasticity. We talked about that a little bit, but let's go into that some more because pain with sex is a big kind of desire killer that comes up for women. 100%. I feel like it's supposed to be fun. And so if it's painful, why would you want to do it? And it's like lube is historically one of those things like you shouldn't need is sort of the and I feel like everybody should have lube in their bedside table. It's a helpful thing and it doesn't, especially if you're having a longer lovemaking session anyway, even if you're younger and you're lubing, you're generating your own lubrication fine. It's helpful, but as we age and the tissue is thinning, etc. It's just helpful to have. The decreased blood flow sounds like it's happening even for men as they age, but it's certainly happening for women because it's just part of the process. Yeah, yeah, I mean estrogen, estrogen also has a lot of effects on the vasculature around our pelvic organs. So this is this stems from not just sex, but the need to circulate blood to a developing fetus during pregnancy. So as we evolve as humans, there's, you know, estrogen has huge effects on how how blood gets directed in and around our pelvic organs, our uterus, our ovaries, our vulva and vagina. And so without that, you know, without that estrogen, you get this, you get thinning of tissues, you get the dryness is also the chronic dryness. So not just dryness during sex, chronic dryness also means, you know, we're talking about, we were talking about the, you know, feeling like the two walls of your vagina are velcro getting ripped apart. You can imagine on top of everything else that's creating trauma and inflammation, you can be getting little, you know, small micro tears abrasions, micro tears, and all of those things are really going to affect how sex feels to mine. Yeah, kind of a loop expectation. Well, the other thing that occurs to me too is the value of foreplay, because right for women, if you've created some foreplay time and you've got some blood flow going, right, if you're if you're going in cold, it's not you're not going to have enough blood flow, it's not going to feel as good. But if you've given yourself some warm up time between you, you've got more blood flow, and you're likely to have a better experience too. And I do think that that's why sometimes if people can get over the hump of just engaging in some foreplay, a lot of times then they find that they have more desire, it becomes like a feed forward, right? Like it's a, well, what happens like physically when blood flow hap, when blood, when blood arrives at the genital organs for women? Yeah, all kinds of amazing things happen, actually. And, and I think it explains a lot about why when you're not feeling aroused, sex can be so so much less pleasurable. So the first thing is, is it engorges the clitoris? And when the clitoris is engorged, it is more sensitive. And you get, you know, it's sending many more pleasurable signals back to your brain. It the blood flow engorges the vaginal walls and the tissues of the vulva. And so again, touch and stimulation are, are much more pleasurable. That, that blood flow is also what goes into the cells and actually helps create the lubrication. But on top of that, as we become, as women become aroused, the vagina, which is really just a flattened out tube most of the time, actually tense up and opens up. And so instead of having the walls of the vagina be, you know, pressed together, you actually go from a potential space to an actual space where someone could insert a finger, enter penis or whatever, you know, whatever it creates more space to accommodate. It does, it does, it accommodates, it accommodates some internal stimulation as well. Again, whatever, whatever you use for that internal stimulation. And then there is, you know, the clitoris extends back along the sides and front of the vagina. And so then you get clitoral stimuli, some people get clitoral stimulation internally as well. And so when you create the space, you create this lubrication, it just allows the whole feedback loop to work so much better. And so then you have the worst stimulation. I've never actually heard it. Okay, I love that I asked that because I've never heard it explained that way, that the whole tenting and the whole expansion and the sensory internally, that makes so much more sense. So yeah, spend the time to do some foreplay because it's going to be 100% better experience overall. Yeah, yeah, that makes sense. So the benefits, I guess, part of this too is the lifestyle, the sleep, the stress, all the benefits of that we just want to look at the whole system. You would sort of mentioned that that's part of it. But like, I guess if we want to touch on any of that, that feels like it's relevant in your domain. Sure, I mean, I guess what I would say is nobody feels good when they're uncomfortable and poorly slept. And they're stressed and they have a lot of demands. Nobody feels good and no one feels like they want to have sex and no one necessarily, it's much harder in that situation to be emotionally available and generous to others too. And that is such a big part of people's sex lives as well. We did a survey of hot flash readers a few months ago asking them about their sex lives. And it was so interesting to see the difference between women in their 40s and women in their 60s and how they responded to these questions. Because I feel like women in their 40s and early 50s, they really are in that space where they're feeling really tugged in every direction. And that is where we got a ton of responses that we're like, I just want to want to have sex again. I don't even care if I have sex again, I just want to want to have sex again, which to me is like, that's that's what I don't know. You're getting to the bottom of the barrel, but they're like, I don't actually want to want to want it. Yeah. Yeah. Then you saw by the time people got to their 60s, a lot of people had figured it out, but other things had happened too. They had, I mean, one respondent was like, my husband retired and I work from home and our kids are grown and out of the house. And if the mood strikes us, we can have sex whenever we want, which I think is a lot of it, right? When you're in your 40s and 50s, you may also have a teen knocking at your door, your jogging, so many things. So many things. So many things. And so I was heartened to see that the older respondents to the survey were really experiencing sort of a sexual renaissance once they had kind of come through these more challenging times. And I really was like, Oh, well, I can't, I'm looking forward to that. It's like, Peggy Kleinclaps wrote this book on, it's called Magnificent Sex. And she's all couples in older, they've been together like 30 plus years or something. And it's, you know, it's not that they've got this like magic thing, but it's more like acceptance and allowance as an older couple being together and having this, like you're not trying to do it all. You're actually just allowing and embracing whatever's feasible in the here and now. Yeah. Yeah. Yeah. I think there's, in some ways, there's less pressure for both partners at that point, right? Like it's, um, hopefully, one would hope. I think that, I think that in our, you know, everybody's feeling pulled in sort of the throes of your 40s and, but also it's like, well, you're still supposed to be young and sexy. And, you know, that's a lot of pressure. That's a lot of pressure to put on yourself. Yeah. And I think sometimes the body changes of perimenopause have some women feeling less, less confident to, I mean, well, cause you're on that cusp of like, yeah, like you're still trying to, trying to have it all together and trying to be everything. And it's like, by 60, you're sort of like, okay, this is, this is who I am, right? There's hopefully been this transition into like, you get, you get what you see and I'm confident and I'm comfortable in who I am. And I'm not gonna, I'm not gonna try to be somebody. And I'm not gonna change it for you. And yeah, exactly. Exactly. You were anybody else. Yeah. So I was, I was really happy to see that, that people were coming out of that and were circling back to that and finding fulfilling sex lives after menopause. So that was exciting. Yeah. So I like the message that sex doesn't have to fade in midlife. Like I definitely want to communicate that. The other piece, I guess, that I always try to get it instilled, I guess, in my couples is there's there's sex and then there's intimacy. And that's kind of what we're talking about now, right? It's like, yeah, intimacy can deepen and sex can transform, right? It doesn't have to look like it used to look to be satisfying because the pursuit of the orgasm might not be the best goal. Right. So, so, because I find that sometimes women don't have as much access to orgasm as they used to. Do you have any thoughts about that? Specifically? I mean, I feel like getting, getting to orgasm has been difficult. It's been different since I've probably been over 45. Yeah. And, and I think there's a lot of reasons, a lot of those. I think that there's, that the physiology that we talked about is related, right? Because if you aren't getting the same level of circulation and blood flow to the clitoris, the vulva, the vagina, the, you know, it can be difficult to get that, that feed forward stimulation. It may feel really nice and really good. And that's great. But you may not get enough of the excitation to reach sexual climax. I think that there's some things that are important to do. If that, if it's important to you to kind of pursue that, I think people a lot of times, by the time they get to their mid f-ies, especially if they've been in a relationship for a long time, right? It can be like, well, this is how we have sex. This is the foreplay we have. This is how we do this. There's not always a lot of, yes, exactly. There's not always a lot of exploration. I'd agree. It's like, oh gosh, we've got like this window and then, you know, we've both got these other demands on our time or we want to go to sleep or, and so it does, I feel like, especially if you've been in a relationship for a long time, it definitely can get a little like, this is how we do it. And I think that one of the things that has to happen in midlife is that you have to be open to a little bit more exploration. I mean, this gets to your like, have some lube in the bedside table, you know, explore different types of touch, different types of stimulation and what feels good to you because it might take more stimulation to get that cycle moving forward. Yeah. Well, and there's also, there's some toys that are really nice. Like there's, they have some warming wands, that kind of thing that can be used internally that can help with blood flow. Taboo has a really nice one that I like to recommend. Sex toys have come a long way in the last decade or so, which is fantastic because they can be so useful for exploring these types of need for different types of stimulation. Yeah. So how do you suggest people talk, women, talk to their health providers? Like, say their health providers aren't that savvy about, you know, menopause or perimenopause. You know, I like the idea of advocating, but also I want to be careful because you don't, you know, sometimes doctors aren't that big of fans of being told what they don't know. Like, how do we walk this line? Yeah, I think there's a few different ways to do this. I think the first thing is to remember that your doctor typically for a follow-up appointment has 15 minutes. So if there are, I recommend having a goal for every doctor's visit you go into. So before you show up, know exactly what you're hoping to get out of the visit. And I don't mean I want a prescription for estrogen. I mean, I want to talk about my perimenopause symptoms and how they're affecting my sex life. That would be your goal and to come to and create a plan for how to move forward with that. So you have your goal, make sure you know what your questions are. It is 100% okay to do your research before you go in. Although I caution people against googling or Reddit boards as their research, I recommend going to the menopause society, the urologic society, like the actual the endocrine society. All of those studies have patient information and that's all vetted and evidence based. And you know, if your doctor seems like they are out of their depth, I think you can do one of two things. I think it's always helpful to approach someone who's out of their depth with questions and with a little generosity. So I never mind when a patient comes in and says, Have you seen this article? For example, you're not telling them anything about you're just saying, Have you seen this? I read it and I was interested. And sometimes when patients do that, I have seen the article. I mean, there's so much information out there. It's not unusual for them to come in and I haven't seen the article unless it's like, you know, some huge earth shattering thing. But then I always seek it out. I always tell them, Well, I haven't read it, but I will and I'll get back to you. And so that is the kind of response that you're looking for from your doctor, someone who is open and willing and interested in your curiosity. Yeah, yeah, they're shutting you down. They could be having a bad day. But if you're getting shut down, we're we're human. We have bad days. You don't know who was why I was seeing right before you necessarily and what that interaction was like or maybe my kid's school called between patients and now somebody's got to go pick the kids sick kid up. You don't know what's going on. So if it's one, I would say be a little generous, especially if it's a doctor, doctor that you've had a long relationship with. But if you're routinely getting shut down, it's time to it's time to maybe consider finding a new provider who is one. I feel like especially on this topic, we know that a lot of doctors weren't trained. And so if you know, do your own research and say, Hey, these are my symptoms. And if you're ready to, you know, then say, I would like to try this, try it and see what see how it goes for you and be in conversation. And you might have to lead that conversation and, you know, see how it works. And you might have to try it with a different position if that doctor's not interested in getting up to speed. But I think, I think doctors are, I mean, if you're seeing a gynecologist, I would think they're probably in the loop these days. I think they're coming along. I think that one of the things that's hard is you're asking a group of people who what they were really trained to do was deliver babies and deal with the structures of the female reproductive system, do things like hysterectomies and deal with cysts and, and you're asking them to kind of develop a whole separate skill set. I think a curious doctor will do that. I think a thoughtful clinician will do that and recognize the demand. And there are lots of doctors doing that. But, but it's not going to be all of them. I totally assumed my doctor was not an OBE. She's like really a GYN. And so I associated her with this work. But I guess what you're saying is really it's not in her zone. Interesting. Okay. So yeah, I guess it's more in the. So most people go to their primary care doctor or their gynecologist when they're having symptoms of menopause. But it has not historically been a thing that either of those groups of people have been taught to manage. So they have to seek out training and education. That training as a separate thing. Okay. Yeah, that's, that's, that makes sense. There's lots of ways to do that. We're all required to do continuing medical education all the time. And there's all kinds of ways in which you can do that. But I think if you are specifically, if you find yourself in need of a new doctor, and you're looking for someone who is well versed in treating menopausal, some perimenopausal symptoms, you can look for a practitioner that is NAMS certified, which is a certification that the menopause society provides. And it basically says that you've received, that you've sought out, completed this extra education regarding treating perimenopausal and menopausal symptoms with all the different modalities out there. Great. Okay. That's good to know. Okay. And then where, let's see, we can find you Instagram at Jillian Goddard. And I'm on Instagram. I'm Jillian M. Goddard. Jillian M. Goddard. Sorry. And then what's the best website for you? So I am hot flashes at the savvy, the savvypatient.substack.com. Okay, great. And we'll put that in the show notes as well. Great. Thank you so much. This has been a really fun conversation. I've enjoyed it so much. Yeah. My pleasure. Thank you again for joining me. And if you've liked today, please subscribe and please give us a like. Hey, it's Dr. Jen. Thanks so much for tuning in. Please leave us a review and leave a comment if something struck you. We'd love to get the feedback. It really helps the podcast. And if you want to reach me, go ahead and direct message me on Instagram or you can reach me at Jen at revieratherapy.com. Thanks.