The Complexities of Desire: Understanding Libido in Women Part I

Summary

In this episode of the Hot Flash Diaries, Jessica Caceres interviews Dr. Maureen Slattery, a board-certified OBGYN and menopause practitioner, about the complexities of libido and sexual health in women. They discuss the multifaceted nature of libido, emphasizing the biopsychosocial model that includes biological, psychological, and social factors. The conversation highlights the impact of stress, mental health, and relationship dynamics on sexual desire, as well as the importance of education and individualized care in addressing these issues. In this conversation, Jessica Caceres and Dr. Maureen Slattery delve into the complexities of sexual health, intimacy, and the misconceptions surrounding them. They discuss the importance of understanding individual desires, the evolution of sexual norms, and the impact of hormonal changes on intimacy. The conversation emphasizes the need for open dialogue about sexual health, the significance of vaginal health, and the role of education in dispelling myths about sex. They also highlight the importance of knowing one's body and the dynamics of relationships in addressing libido issues.

Takeaways

Dr. Slattery emphasizes the importance of understanding libido as a complex interplay of various factors.

Sexual health is not just about hormones; it involves psychological and relational components.

Stress and mental load significantly impact sexual desire and overall well-being.

Women often feel pressured to conform to societal expectations regarding sexual activity.

Education and open conversations about sexual health are crucial for empowerment.

Hormone therapy is not a one-size-fits-all solution; individual needs must be considered.

Relationship dynamics play a critical role in sexual desire and intimacy.

Many women experience changes in libido during perimenopause and menopause due to hormonal fluctuations.

It's essential to address mental health concerns when discussing sexual health.

Women should feel validated in their experiences and understand that fluctuations in desire are normal.  

It's okay to honor where you're at in your sexual journey.

Misconceptions about sex can hinder healthy intimacy.

Understanding your own pleasure is crucial for intimacy.

Normal sexual frequency varies for each individual.

Pain during intimacy can lead to a disinterest in sex.

Using lubrication is essential for comfort during sex.

Hormonal changes can significantly affect sexual health.

Open communication with partners is vital for intimacy.

Education about sexual health is often lacking.

Therapy can be beneficial for addressing libido issues.

Interested in connecting with Dr. Slattery?

https://www.drmaureenslattery.com/

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Transcript

Jessica Caceres (00:01.806)
Okay. Well, Welcome back to the Hot Flash Diaries. This is officially episode two, followed by episode three. We are actually dividing up this long episode into two because there is so much information and I hope that you can all just enjoy and learn a little something from this wonderful human being who has agreed to come onto the Hot Flash Diaries podcast. I am so excited to introduce you to Dr. Maureen Slattery from Rochester, New York.

She is a board certified OBGYN with over 20 years of clinical experience. And she is also a certified menopause practitioner, certified sex educator, and a certified sexuality counselor. That is a mouthful. That's a lot. So she literally understands, you know, what it's like to be a woman and going through so many different things. But here's what makes her different. She's not just a

Maureen Slattery, MD (00:44.108)
It's a lot. It is.

Jessica Caceres (00:56.648)
to collect sort of or has collected credentials. She is the kind of provider who doesn't just hand you a prescription and sort of sends you on your way. Instead, she actually sits down with you, listens to the whole story and helps you understand what is really going on, not just with your hormones, but also with your life, your stress and your relationships. Maureen has built her entire practice around breaking the stigma around sex through education and empowerment. She is not afraid of saying words like vagina and sex. I love it.

Maureen Slattery, MD (01:25.76)
Not at all.

Jessica Caceres (01:26.386)
She treats women like intelligent humans who deserve real answers, not just quick fixes. She's having the conversations that most providers avoid, the messy, the complicated, the real stuff that affects how we feel in our bodies and in our relationships. And we couldn't be happier to have you here today to talk about libido and all things desire. Thank you so much for being here.

Maureen Slattery, MD (01:48.332)
You're welcome. That was such an amazing introduction. I appreciate it. It also, it makes me feel old too. Cause when I get to tell people that it's been like, I've been in practice for like 20 years, it's just, it's a little insane.

Jessica Caceres (01:53.198)
my

Jessica Caceres (02:03.68)
I know I was actually thinking back to how long I've been in this industry and I mean, was a nurse practitioner or I've been a nurse practitioner for almost 15 years, then eight years as an RN. And I think, how did that go by so quickly? And so it really just you blink and here we are. But I'm so grateful. And as I'm sure all of your patients are grateful and all of your colleagues that you do the work that you do. I had the pleasure of seeing you at the pleasure principle that Kristen Parisi put on in Hamilton last spring.

Maureen Slattery, MD (02:15.671)
Yeah.

Jessica Caceres (02:33.288)
And it was just a remarkable conversation. really enjoyed it. So I thought for sure she needs to come on the podcast as soon as possible. today we're chatting. my gosh. Thank you. Today we're going to really dive deeply into a topic that comes up with almost every single woman that I see in, in my practice. And that is that of libido and sex drive. It is a tough one because it's multifaceted so many different things that are part of.

Maureen Slattery, MD (02:39.213)
Thanks for having me.

Jessica Caceres (03:02.606)
aspects that are part of why our libido starts to sort of tank or decrease as time goes on. And it's complicated because it's really so individualized. And I really want to chat with you a bit more about, you know, your experience with libido specifically, as this is really your area of expertise. So one of the things I wanted to start off with is to chat about how

What I find in my practice is women come in and say, Hey, can you check my testosterone? Cause I'm sure that that's what's causing my low libido and my low sex drive to which I say, well, it's only a small, small bit of it. Right. So let's talk about that.

Maureen Slattery, MD (03:40.695)
Mm-hmm.

I get that too quite frequently and just all hormones in general, I think as a menopause practitioner, but specifically with libido. I mean, I do a little bit of specialized kind of counseling, which is kind of awesome. I get a little bit longer with patients certain days and then otherwise I'm just seeing patients like in a regular gynecology practice. And I feel like every other patient either has an issue with their libido or they have an issue with their libido and they want me to check something. And it's such a can of worms.

because in a 15 minute office visit, it is, if I go down that can of worms in a great amount of detail to kind of help them and educate them and show them how multifactorial it is, like I get way behind for the rest of my schedule, yeah. So a lot of times I'll give them a little bit of information that I've saved that I can kind of give as a handout and have them schedule another appointment to talk about that specifically, especially if they came in for something else.

Jessica Caceres (04:27.467)
Absolutely.

Maureen Slattery, MD (04:42.677)
like an annual visit or like abnormal bleeding because it's just so hard and it actually takes longer I think to talk about than abnormal bleeding really yeah

Jessica Caceres (04:53.134)
for sure. Yeah, it deserves its own visit. And luckily when I do my consultations, I actually reserve an hour for each patient, which I know in your case is not possible. But in that case, we're actually able to dive into it, not as deeply as I'd like to in some cases, because there are in some cases, lots of other things happening. But you're right, it really does deserve its own conversation. And there's no way that you can get there in 15 minutes coupled with other concerns.

That's great that you bring them back.

Maureen Slattery, MD (05:24.629)
Yeah, I have to. I have because I want people to know about this. It was actually the reason that I kind of came to doing this in my practice is because I was telling people stuff and I wasn't sure I was telling them the right thing because we don't really get educated about it in medical school, residency and nurse practitioner school, PA school. It just doesn't happen to any near the degree it should. So there's a lot of misconceptions floating around. So I try very hard to like start the conversation and keep them engaged.

engaged and then bring them back. But I also try to send them with something so that they have some something they can do or look into or some context before we get a chance to talk again. I do get some like one hour time slots, but they are they're few and far between and I do save them for my sexual health patients. Yeah.

Jessica Caceres (06:14.894)
Amazing. So in that, then you would agree that, you know, if somebody came to you and said, Hey, I just want my testosterone check because I'm sure that that's the sole cause of my low libido. What, what, how do you respond to that?

Maureen Slattery, MD (06:27.693)
you

Yeah, I mean, you might hear me say this multiple times over the two episodes, but you know, sex is a biopsychosocial activity. So there is no way to just have it be biology without psychology or sociology or your actually your relational component, right? Like if unless it's solo sex, it's involving a partner or multiple partners. And so none of those things are operate independently and none of them are the only

reason why you might be having a problem with your sexual health, right? The biology is a lot of it, but it's not even just hormones. mean, there's neurotransmitters and all sorts of other, you know, blood flow. There's all sorts of other things that are involved in the biological side. So I, yeah, so I do, I do get that a lot, but I try to kind of break that down as quickly as I can so that people are aware that like, you know, everybody wants to be 22 again and have a carefree, like,

exciting sex life and if I could do that, it would take us all out of menopause, would take us all out of like, you know, 20 years of sleeping with the same person, kind of like contextual stuff and make it fun again, but I can also teach them all the things that they can potentially do and all the things that are involved and trying to make it like good and fun and, you know, worthwhile again. Yeah, yeah, yeah.

Jessica Caceres (07:33.55)
Exactly.

Jessica Caceres (07:50.978)
Exciting again. Yeah, absolutely. Yeah, because that is possible. I always try to really, you know, get that message across that, you know, you're not broken. There is so much hope here that things are going to get a lot better if you want them to get better. Because again, there's some people that are not very sexual, and they've never been very sexual. And it doesn't bother them that they're, they don't really care. And that's okay. I find

in those particular patients, it's, I was out for dinner with some girlfriends and all they really talked about was sex. And then I thought, well, maybe I should be having more sex. It's like, but no, that's just who you are, right? That's okay. But if you wanted things to change and you want to have a more desire and enjoy the actual act of intimacy and intercourse, then there are so many things that can be done. But it's not simply just checking your testosterone level.

replacing testosterone because inevitably it's going to be low. mean, have yet, unless the patient has PCOS and they're either in perimenopause or very early menopause, I mean, the likelihood of seeing a testosterone that is anywhere close to normal is unlikely. So as I'm sure you would agree.

Maureen Slattery, MD (08:51.872)
Yeah.

Maureen Slattery, MD (09:02.507)
Yeah.

It's true. And when people ask me to just check their hormones in general, because they're feeling perimenopausal, those are always normal too, with the exception of occasionally an FSH, right? So it's hard for me to even explain to people that we don't need those hormones, at least to manage what's going on. know, everything but testosterone. Like we don't need it if we're managing those symptoms. it's a hard kind of like, I feel like I tell the residents this when I teach them all the time, I spend so much time educating

If I had known when I went into, you medicine that I was going to spend so much time teaching. But I literally every visit all day long, even in annuals, I feel like I'm teaching this stuff to people. Yeah, it's... yeah.

Jessica Caceres (09:47.886)
It's true. Yeah. mean, even with non-midlife topics, that's really such a big job. You're a big role of our, or a big part of our role is what I'm trying to say. It's just educate, educate, educate. And I find those of us that really focus on that and do it well, our patients do better because they actually are empowered and have the tools that they need to be able to make changes if they want to make those changes. So I'm so glad that you spend that time doing that. I feel like

Maureen Slattery, MD (09:52.972)
Sure.

Maureen Slattery, MD (10:12.342)
Yeah.

Jessica Caceres (10:16.767)
you know, overall, the idea of getting hormones checked is sort of because as you know, there's a ton of sort of hormone influencers now on social media. And so I find that there while there's a lot of good messaging there that's empowering a lot of it as well as misinformation. And I find that hard to deal with in practice sometimes. But it's also an opportunity to educate. Right. So I do really love

Maureen Slattery, MD (10:24.555)
Mm-hmm.

Jessica Caceres (10:44.586)
hormone replacement therapy when when there's a need for it. Not everybody is a candidate. But even things like progesterone, I find as a replacement in perimenopause for women who are not sleeping well, mood changes, terrible PMS. And when it comes to linking it back to libido, nobody's gonna want to have sex if they're angry and they can't stand the sound of their partner breathing. mean, yeah, I don't think you want to have sex with that or chewing. my gosh. Right?

Maureen Slattery, MD (10:47.905)
Mm-hmm.

Maureen Slattery, MD (11:07.373)
Or chewing. That's a big one for me.

Jessica Caceres (11:12.982)
and you're not sleeping, so any little thing just drives you crazy when normally you would have been able to function just fine, right? Because you were rested and you weren't deprived of progesterone. So, you know, there's a role for sure, but I agree with you, not everyone's a candidate and it's just, there's so much unneeded testing that's being done. And then it's being used as like the tool to determine if you need.

Maureen Slattery, MD (11:16.937)
Yes.

Maureen Slattery, MD (11:24.268)
Right.

Maureen Slattery, MD (11:35.435)
Yeah.

Jessica Caceres (11:40.142)
treatment versus really the tool is the symptoms, right?

Maureen Slattery, MD (11:44.94)
Yes, absolutely. Yeah, and improving quality of life. And sometimes that does involve testosterone, but not always. And honestly, no amount of testosterone is gonna make your sex life better if you are chronically, like you said, sleep deprived, or if you're the only one carrying the mental load running the household with all the schedules. And the older or the more complicated your schedules get, the harder it is to have like five seconds to yourself.

Jessica Caceres (11:49.24)
totally.

Maureen Slattery, MD (12:14.863)
any kind of, you don't have any space for it a lot of the time. Like our modern society has us like running like crazy. And if some of the day to day stuff is not shared very equally across partners or even with kids having some responsibility for their own stuff, like it's exhausting day in and day out. So no amount of testosterone is gonna help that.

Jessica Caceres (12:34.774)
It is.

Exactly. so with that, you know, tell us more about how stress and sort of that mental load really does physiologically affect desire. Because I think it's important for people to understand that.

Maureen Slattery, MD (12:49.685)
Yeah, no, it totally does. I mean, first of all, not getting a good night's sleep increases your cortisol levels, which not only make it harder for you to maintain or lose weight, but it decreases your capacity to deal with stuff that's outside the mundane and the norm. You just don't have the mental wherewithal to deal with stuff that comes along that you weren't anticipating or just getting every

done because you are fatigued with these higher levels of cortisol and stress hormones. When you are stressed and there is nothing else to relieve that in your sexual relationship, you don't... it's almost like not being seen in some ways, but it's like if you're carrying all this stuff around and you barely have time to go to the bathroom or eat lunch or like you never get help with anything, it just drains you to have the free time and the

Jessica Caceres (13:25.646)
Absolutely, yeah.

Maureen Slattery, MD (13:49.562)
focus and the energy to put it towards something that I don't want to say sex is frivolous, but it is not hunger, thirst, or sleep, right? As far as drives go, like it is not like a basic necessity. We all don't need to procreate and we don't all need to do it indefinitely through our entire lives between, you know, puberty and menopause. So if we need to have space for that, like we need to almost create space. And if we are running around like a chicken with our head cut off, there is absolutely most of the time

no space. If there's also no space for you, would argue, because I find a lot of people have... Anne Hedonia, my friend Nan Wise, talks about this all the time, but like if you can't find joy in your life because you are just scheduled to the max and just doing the things that you need to do, but you don't have time for yourself, you've given up all the things in your life that might give you joy, even if that includes sex, like you don't paint anymore or you don't read anymore or you don't run anymore, then you don't really have the space to enjoy things in your

life either. So it kind of goes back and forth. You gotta make space for these things.

Jessica Caceres (14:51.372)
Sure. Yeah.

It's so interesting that you say that because again, personally, I have found over the last year, at least if not the last three years, I have really done absolutely nothing for myself, you know, really great at looking after everybody around me. But when it comes to looking after myself, I've really put myself on the back burner and the whole premise of sort of season two of the hot flash diaries for me is really about stopping that, know, putting myself

first and really looking at as a woman, are the things that we need to do to feel better looking at prevention, looking at really trying to feel better in my shell, in my body. And so then I can show up and be the best person that I can be. But you're right. When you start to pull away things that are not do things that you enjoy, like I used to like doing pottery and all kinds of stuff. I stopped doing all of that. And then all you can think of is all of this crazy scheduling and things that you have to do and get this done and this done and get the kids here and the other kid there.

and grocery shop and all this adulting that is exhausting and we all have to do it. mean, but then what's worse yet is if you have a partner who doesn't help. Fortunately, John's great and has been very helpful, but at the same time, you know, there needs to be balance and that is really tough. And so of course, sex is not on the, you know, the list of priorities when you're just feeling exhausted, you're feeling, you know, overworked, and then you're not sleeping well.

Maureen Slattery, MD (15:58.135)
exhausting.

Maureen Slattery, MD (16:04.225)
Mm-hmm.

Jessica Caceres (16:19.79)
And so for me personally, progesterone has been a game changer because I've actually been able to sleep well and my mental load feels better. And in some of my patients, I've been cycling progesterone a little higher doses in their luteal phase, so the week before their period, and that has been a game changer for them as well. But I wanted to ask you specifically, with women who are suffering with anxiety, depression, or other mental health concerns, how much...

Maureen Slattery, MD (16:33.613)
Mm-hmm.

Maureen Slattery, MD (16:40.321)
Mm-hmm.

Jessica Caceres (16:48.946)
Or how much more difficult or challenging is libido in women who already have perhaps some of this serotonin and norepinephrine, all of these neurochemicals that really affect our mood when we head into midlife?

Maureen Slattery, MD (17:07.441)
man, mean, the women that come to see me, it's specifically for in midlife, if it's specifically for sex or if it's for kind of like hormonal, you know, considering the menopausal therapy or both, I do find that almost all of them have like a change in their anxiety, their, you know, you know, frustration tolerance, their, you know, their, their overall mood. It's in the background and sometimes it's prominently by

bothering them, but then when I'll ask the question, it's there. So it is hard, especially in people who have been stabilized for a long time, and then all of a sudden they're like, wait a minute, I've been on this antidepressant for 10 years. Like all of a sudden it doesn't work anymore. It's complicated because, I mean, you know as well, the antidepressants, like it's almost like a flip of a coin if they're going to produce some form of sexual dysfunction, whether you're 20 or 70. So there's already that in the background that people have learned to work around. But then now there's this like background.

piece that makes them almost think they're crazy, where all of a sudden they're like, you know, come to think of it, like I am way more anxious and I don't understand it, or I feel like have ADHD when I didn't before. And then you start asking them questions about how they did things and you're like, well, maybe you did have ADHD, but like it was tolerable and controllable until, you know, your hormone chaos has like unearthed the inability to come to like to deal with it, right? I, it's hard when people have this at baseline because

I swear and I think right now I sometimes question myself like is the state of the world also making everything worse or not and I'm 49 and a half so I'm kind of in the middle of it with everybody else too and I keep going like actually I know this but also like what's going on in the world is like making everyone crazy but then again like it's not always affecting everyone the same way I mean I just feel like there's so many different influences but the mood piece is hard because

Sometimes in order to control that or help that alleviate some of those symptoms and make things more of a steady state You can sometimes even make you know sex does that sexual desire worse? So it's a fine line That's why everybody needs kind of an individualized focus and plan for what's going on and they need to not just get a like a like a prescription Because if you don't take the time to find out that like yeah the anxiety it has flared up and I have a frozen shoulder or yes I don't have an interest in sex but

Jessica Caceres (19:26.03)
thing.

Maureen Slattery, MD (19:36.911)
but also like I can't get out of bed in the mornings, like that plays a role both medically, physically, socially, interpersonally with our partner. And so if you don't address all of it, like you're not really gonna fix it, so.

Jessica Caceres (19:47.265)
sure.

Jessica Caceres (19:51.722)
for sure. That's doing a mental health screen as part of any women's wellness assessment is so important. It's so important. And you're right. The thing is, is that, you know, somebody comes in anxious or depressed, they may need an antidepressant or anti-anxiety medication, but maybe instead of

increasing it, you know, when they're in their late 40s, early 50s, perhaps it's because of the hormones that that's why there's that sudden, you know, spike or fluctuation, not so much that they need more of a of an anti anxiety or antidepressant in there, right. And I do see a lot of that in I do cover for a couple of family doctors. So I see people that, know, for one time that I've never met them before, they come in and we're talking about things and I look and it's

Maureen Slattery, MD (20:24.64)
Absolutely.

Jessica Caceres (20:35.714)
you see these incremental increases of anxiety medications and they're not getting better. They're not feeling better. Plus they have a whole plethora of other symptoms that just scream perimenopause or menopause. And unfortunately it's been missed. And again, I can't blame my colleagues because it's something that they're not trained in per se, but when you see it, it's actually really liberating and exciting as a clinician. And then when you explain it to the

Maureen Slattery, MD (20:57.451)
Yeah.

Jessica Caceres (21:03.854)
the patient, they're like, oh, oh, maybe is that why this is happening and that's happening? And of course, inevitably libido is in there. But then what we've done is by increasing these medications, one of the biggest side effects of these medications, right, is low libido for men, erectile dysfunction, right? These are common, which is unfortunate because in people who need to be taking them because there's truly an imbalance.

Maureen Slattery, MD (21:19.189)
Yeah, low libido.

Jessica Caceres (21:31.448)
they may stop taking it because of the sexual side effects and they want to preserve their libido. So it's really a double edged sword. But it's such an interesting concept when it comes to libido, right? Like there's such a psychological component. It's not just strictly one hormone that or two hormones or three hormones that are out of whack. It's really just, there is a huge psychological component there.

Maureen Slattery, MD (21:35.059)
yeah.

Maureen Slattery, MD (21:38.561)
Yeah.

Maureen Slattery, MD (21:47.604)
Ugh.

Maureen Slattery, MD (21:54.412)
Yeah.

And along those lines, like a lot of clinicians who don't have any background in, I mean, I think the menopause training and specialization does give us some, know, it gives us a window into sex. It's not the whole picture. But what I do find is a lot of times when women end up seeing me for either or both, they have actually seen sometimes a rheumatologist, sometimes they've seen an orthopedic, sometimes they've seen a mental health provider or been urged to do that. They've usually

Jessica Caceres (22:08.942)
for sure.

Maureen Slattery, MD (22:25.045)
been like referred out or seen other specialists when nobody actually goes, hey, you know, all of these things fall on a list of common symptoms of like a menopausal transition, especially in perimenopause. Like it rings a bell for people when someone hasn't had a period in 12 months. But the rest of it, it's just so funny to me how like I would say the overwhelming majority of people that come to me and I don't know about you, they've seen at least one other specialist that their primary doctor, their family doctor, their internist has sent them to because no

Jessica Caceres (22:41.432)
Totally.

Maureen Slattery, MD (22:54.895)
Nobody put the light bulb on and said, my god, this is your 48 and you have skipped a couple periods. Maybe all of this is partially triggered by your hormones right now.

Jessica Caceres (23:09.142)
for sure. that's again, that's one of the biggest issues I think with women understanding where they're at with their bodies is that there are the known symptoms of perimenopause and menopause. And then there are about a million unknown or not unknown, but less known, I should say, symptoms, right? So, and there's a reason why I called the podcast, the hot flash diaries, because people will read that and say, I know what that means. You know, I know what that is. I understand who the target audience is.

Maureen Slattery, MD (23:24.319)
Yeah, absolutely. Yep.

Maureen Slattery, MD (23:34.188)
Yes.

Jessica Caceres (23:37.824)
If I would have called it like frozen shoulder diaries, they would have thought it was an orthopedic podcast, right? But yet, yeah, exactly. so they would, they would totally. It should be, I should have actually called it something like, you know, cause all these women that I see now with these rashes and these histamine intolerances and all of this, I'm sort of like,

Maureen Slattery, MD (23:43.271)
Absolutely, right? Or an itchy ear diary or a yeah, they ban you if it was dry vagina. The diet, the dry vagina. Yeah.

Jessica Caceres (24:05.058)
The rash diaries, that sounds really gross in dermatology, but anyway, something like that, it makes you itchy. But all that said, there are so many symptoms that people don't know are associated. And it's so funny that you say itchy ears, because I've actually seen about four or five of them in practice recently that I'm like, that's what it is? And it's amazing what a little estrogen cream will do for you, not just in your vagina or externally. But that all said,

Maureen Slattery, MD (24:06.425)
Yeah, it does. Yeah.

Maureen Slattery, MD (24:30.198)
Right.

Jessica Caceres (24:31.948)
You sort of alluded to another large component of the libido phenomenon, if you will, as being that of your relationship dynamics, right? With your partner, your household, like your children, if you're a single parent. But that is so huge. I hear women that come in and they're like, you know, we don't really get along that great, or there's been some sort of major

event like the death of somebody in the family or, you know, a recent diagnosis of some sort that's life changing for a family. And I think that people forget just how traumatic a lot of that can be for us, especially as women being very cerebral human beings, and how that absolutely is directly impacting their desire.

Maureen Slattery, MD (25:03.745)
Yes.

Maureen Slattery, MD (25:18.774)
Yeah.

Maureen Slattery, MD (25:25.621)
Yeah, I mean that again, I tell people like, you know, there's always the context in which you live and we all are aging even like men who don't go through menopause. Things are changing. I wish we could live in the bubble of like our carefree, you know, most likely child free 20 something self or you know, when we had so little things that we and the adulting you could kind of handle.

It's so different when like and we can't stop it right like life is gonna happen to us The dog is gonna get sick our parents might die, know Your child might have a diagnosis your partner might have a diagnosis You might have a diagnosis of something like cancer or diabetes that affects everything and we can't live in a bubble where none of that is happening to us or the people around us as much as we want to Right. So that has to play into whether or not you're in the mood or whether or not you have

the mental, emotional bandwidth to actually engage. if you don't, sex when you're unengaged and you're just doing it to appease a partner, the number of women who do that but can't put themselves into the moment, it makes them dislike it even more. Because if you can't focus on all the good stuff that happens when someone is trying to please you and when you're trying to have that kind of

Jessica Caceres (26:40.718)
you

Maureen Slattery, MD (26:48.107)
you know, pleasureful connection with someone else or multiple people if that's how you roll, if your brain is elsewhere, like, it is not going to be good, right? If you are sad or grieving, it's not necessarily going to be good. And there are definitely times when, you know, it needs to be a back burner thing. But we don't want the entirety of life as an adult or a mid-aged adult to also make that a, like a

backstage kind of piece you know it does it deserves absolutely

Jessica Caceres (27:16.908)
No, for sure. But I think it helps to bring awareness, right? So that women can, it's really validating, right? I am not feeling like being intimate or have that sexual desire today, this week, this month, because our pet died, you know? And it's really sad. And maybe you can identify that that's why, that you feel that bit of, you know, sadness, anxiety, perhaps depression around that. It's situational.

Maureen Slattery, MD (27:23.99)
Yeah.

Maureen Slattery, MD (27:32.107)
Yeah.

Jessica Caceres (27:43.715)
But there's a reason that you're feeling that way and it's okay, you know, you'll come out of that eventually, but it's also honoring where you're at in the moment and knowing that you are not a robot and you can simply just flip a switch to say, I want to have sex now and then, you know, be lubricated and ready to rock. Like that's not how it works. Yeah.

Maureen Slattery, MD (27:46.69)
Yeah.

Maureen Slattery, MD (28:00.586)
Right. Yeah. No, I know. I mean, and a lot of people do. think we're going to touch on this at some point. But there's just so much inaccurate education about sex in the world to begin with. And there's just so many like, you know.

narratives that roll from like one perspective that just makes sex out to be something so narrow that if we take the time to understand, you know, all that it can be and all of its dimensions that also like helps, right? Like it doesn't need to be, you know, simultaneous orgasms from penetration. Like there are so many other ways in which you can engage sexually with someone that is still sex that counts, right? But we discount it a lot because we don't know or don't teach

Jessica Caceres (28:43.246)
100%. Yes.

Maureen Slattery, MD (28:47.407)
that, you know?

Jessica Caceres (28:49.142)
Or maybe because it was different than it was five, 10 years ago, right? It's still, it's just, looks different now, but it really is under the same umbrella. But for sure, there are so many misconceptions around what sex is and what healthy sex is. I had somebody ask me the other day, how many times a week should they be having sex? And I said, well, that's not for me to answer. That's really for you to determine how often do you have the desire and want and it's a...

Maureen Slattery, MD (28:52.522)
Exactly.

Maureen Slattery, MD (29:12.012)
Right.

Jessica Caceres (29:18.668)
relationship with yourself and with your partner. That was one thing I really appreciated from my conversation with Dr. Nan Wise, who's your dear friend. You know, really talking about that exploration of yourself too, like how on earth could you possibly have good quality intimacy if you don't even know how to pleasure yourself, right? And to really know where your pleasure centers are for you because they're different for everybody. And you know, maybe it's

Maureen Slattery, MD (29:21.815)
Right.

Maureen Slattery, MD (29:25.42)
Yeah.

Maureen Slattery, MD (29:38.076)
yeah.

Maureen Slattery, MD (29:43.403)
They are.

Jessica Caceres (29:45.825)
seeing your partner cleaning the house that does it for you versus, you know, wearing a sexy outfit or what have you, right? Like there's a million and one things and nobody knows, you know, there's one meme that's floating around Instagram right now that just makes me laugh and it's the husband that's disciplining the children. And you can clearly see that the spouse is turned on by the fact that the husband is disciplining the children, right? Just to say like, you need to clean up your toys. And then she's like,

all hot and bothered. mean, whatever turns your crank, like that's like very individualized and that's all good. But you, you need to know for you, you know what, that's not for somebody else to answer or for your partner to say, we need to have sex four times a week. And if we're not, then that means our relationship is not healthy.

Maureen Slattery, MD (30:18.209)
Yeah.

Maureen Slattery, MD (30:23.987)
Mm-hmm. Yeah.

Maureen Slattery, MD (30:33.227)
Yeah, that's definitely a dynamic thing too. think, you know, when I was 20, there were things that would work that absolutely do not work now. But you know, that question about normal, I get it all the time. I actually got it more than once from the AARP, because I do a lot of work with them talking about like sex over age 50. And people always want to know what's normal. And they don't like the answer. But I have to reiterate all the time, like normal is what's normal for you. And that normal may evolve.

Jessica Caceres (31:01.816)
Totally.

Maureen Slattery, MD (31:03.241)
as well. It may evolve into more sex, it may evolve into less sex, but that's going to change with you as you know like from day to day, week to week, year to year, all of those things you know can evolve as well.

Jessica Caceres (31:18.926)
Absolutely. Well, that's exactly it. And I think just reassuring people, I know it's, it's, it's a sort of open ended response. And some people who are structured, they just want a number. But again, it's impossible. It's impossible to say that. So I think, again, just trying to hear hear where the person's coming from. But I always like those questions, because I feel like it's a good intro into, you know, how the person is feeling and trying to identify if there's more to it, you know.

Maureen Slattery, MD (31:47.594)
Absolutely.

Jessica Caceres (31:49.463)
So with that, I've chatted in a few of my other episodes about vaginal dryness and physical changes that come with of course, hormonal changes. pain and discomfort while having intimacy is a pretty fast way to tell your brain, to rewire your brain into thinking that sex is not comfortable, right? And so therefore you do not wanna have sex and everything gets shut down.

Maureen Slattery, MD (32:14.156)
Yeah.

Jessica Caceres (32:18.072)
Can you chat a little bit more about that? Because again, my mission is really to educate women around the safety of vaginal products, whether it's a lubricant and moisturizer or a hormonal product, so that they can have a more enjoyable, intimate life.

Maureen Slattery, MD (32:34.891)
Yeah, well 100 % some of the women and I don't know if I had to guess I might say it's like 20 % 20 to 30 % will come in under the guise of like I don't I've lost interest in sex. But if you ask the right questions, it is not that they have lost interest. It's that it hurts and they don't want to do it. I mean, I've had women describe it as like a wire bottle brush, 1000 shards of glass, like they got sand in there from being at the beach like horrible things, right? And so I

always tell them, and I think it's worth repeating what you just said, but you can't want to want something that hurts you. Yes, there's sadism and masochism, and that's a whole nother picture, and that pain brings them pleasure, and it is not every time there's penetration, I have this unbearable new unexpected discomfort. That is a completely different box of fun. But what we're talking about here is anatomic changes, hormonal changes that come with a menopausal transition.

some earlier with women than others. Usually by three years post menopause, think it's like 75 % of women have dryness and irritation that makes it very difficult to have sex. So I do, I think the one thing I do jump up and down about, even if I don't bring people back right away, is that you need to do something. One, lube, always lube. Lube is not a failure just because you're not dripping wet like the romance novels say you should be. does not mean that you are not

Your brain is your biggest sex organ and I'm gonna say that again at some point, but it is it's your biggest sex organ Your body doesn't always respond and in menopause it doesn't have the the same capacity to respond So yes use lube when you are sexually active If you don't want to use hormones, which there's really almost no reason not to use a topical estrogen product Really at all, but if you don't want to use any kind of topical hormones The least you can do is use a vaginal moisturizer

Jessica Caceres (34:11.022)
Absolutely.

Maureen Slattery, MD (34:34.551)
that will stay in the vagina. So you want to make sure that it's like, you know, the osmolality is appropriate for it not getting like sucked up and absorbed, but that it will like coat and protect to the surface layer. So at the very least when the lack of estrogen prevents the elasticity and the moisture, you will have like a slippy, protective, healthy base so that you don't end up with as much like, I mean, people sometimes have like little spotty bleeding every time they attempt to have sex with that.

Jessica Caceres (34:59.784)
sure that they have terrors and all kinds of fissures and things that happen.

Maureen Slattery, MD (35:01.259)
tears, yeah, micro tears in the vagina all over. Yeah, and that's not pleasant. And those get harder to heal also without the estrogen. So I have some patients that have some chronic fissures that are really, we're struggling to fix. But the last piece of this is that like literally there's almost virtually no one who would not benefit from using topical estrogen product. I have a dog who, I don't know if you can hear him, unfortunately.

Jessica Caceres (35:25.198)
It's okay.

Jessica Caceres (35:30.06)
He agrees with the conversation. I love it.

Maureen Slattery, MD (35:31.368)
He totally does, but I'm about ready to strangle him because it's literally just someone walking down the street, but I didn't really have another place to...

Jessica Caceres (35:37.688)
Well, how dare they walk down the street?

Maureen Slattery, MD (35:39.694)
I didn't really have another place to do this, but if we don't replete some of the estrogen loss at the vestibule, so 360 degrees around the vaginal opening of the urethra, the urethra and the bladder, there's just a huge pile of side effects that nobody needs or wants. Nobody wants a higher risk of getting a UTI. Nobody wants more of an overactive bladder than is, and it's never necessary, but it's definitely gonna happen with the estrogen loss. And then nobody wants that soreness, lack of elasticity,

Nobody wants any of that and nobody should have to deal with that. I think I give it away. know in Canada, healthcare is a little different. We have some issues with insurance covering it, which I think is crazy. So I do...

Jessica Caceres (36:15.502)
Agreed, yep.

Jessica Caceres (36:28.118)
I know, it's crazy.

Maureen Slattery, MD (36:29.357)
Yeah, and so, it's been, you know, generic for eons. Like, I went to go pick mine up at a grocery store and they told me it was at our pharmacy at a grocery store. Told me it was gonna be $250. I was like, you gotta be kidding me. So when I...

Jessica Caceres (36:41.378)
for how many weeks or months supply that's crazy.

Maureen Slattery, MD (36:43.255)
for like one 42, whatever it is, 42.5 gram tube, which is basically two to three months if you're using it internally only. I tell people to use it externally all the time too because it helps so much more. But I have a handout that'll give people about where to use it and also about where you can get it cheaper because there are, I am so sorry. There are...

Jessica Caceres (36:48.81)
Ugh. Right.

Jessica Caceres (36:56.054)
Yes, for sure.

Jessica Caceres (37:05.782)
No, don't worry. It's okay.

Maureen Slattery, MD (37:06.475)
There are pharmacies, usually mail order pharmacies, where they will give it to a generic cost. So my costs personally went from $250 all the way down to $17, like for two to three months. It's ridiculous. It is. So that for a long time, and even still recently has been something that's been prohibitive here, at least in the States.

Jessica Caceres (37:13.005)
Yes.

Jessica Caceres (37:20.468)
my goodness. That's robbery. That's terrible.

Maureen Slattery, MD (37:32.322)
But I try to help people in all ways get around it. And I've literally gotten to the point where I'm flat out rejecting there. It's gonna give me breast cancer. I'm like, nope, how many studies do want me to give you? It's not gonna do that. It's not even gonna increase your systemic estrogen levels. Like, it's just gonna make you feel better. It's gonna make sex better. It's gonna give you less infections. So I'm up, I preach it all the time. It is one of the things that I'm giving to people left and right. And it's safe. I really hope, at least in the US, they take that warning off.

Jessica Caceres (37:42.05)
great.

Jessica Caceres (37:45.943)
Nope.

Jessica Caceres (38:00.879)
So safe.

Maureen Slattery, MD (38:02.255)
because I still today on my desk I had a paper thing that was telling me that I couldn't give someone an estradiol patch and their vaginal estrogen cream and I was like I don't have the time to call and educate every person who works at an insurance company and a pharmacy and like it's frustrating because I'm gonna educate my patients I am NOT gonna give them the time of day so

Jessica Caceres (38:16.75)
So frustrating. Yes. Yes. Yes.

It is so frustrating. I have had quite a few pharmacists that I've had to chat with for the very same reason, you know, denying them their progesterone or their prometrium because, you know, they're not exhibiting hot flashes. Well, newsflash, it's not just for, I mean, first of all, helps minimally for hot flashes. It's for about 400 other reasons that I'm prescribing it and you're not the prescriber. But when it comes to vaginal products, it's actually interesting in terms of cost because I went down the rabbit hole of

Maureen Slattery, MD (38:33.996)
Yeah.

Maureen Slattery, MD (38:44.523)
Yeah. Yes.

Jessica Caceres (38:53.366)
of looking at the cost for patients who don't have third party insurance. And the brand name, Ivexie, was actually cheaper than good old Vagifem from, you know, that's been around for a bazillion years. And I tend to prescribe the tablet as opposed to the cream just because I find most people don't like the messiness of the cream, but I will prescribe the cream for the external if they need that too. Yeah.

Maureen Slattery, MD (38:57.493)
Mm-hmm.

Maureen Slattery, MD (39:06.541)
forever.

Maureen Slattery, MD (39:16.973)
Eternal, yep. Yeah.

Jessica Caceres (39:20.418)
But we also have, I don't know if you have this in the US, I think you do, Interrosa, which is the DHEA, which is just fabulous too. And it's actually less expensive than even the least expensive estrogen. So when people are open to a product that they'll use nightly, which most are because once you get into a routine and then you feel how great your vagina feels, it's like, why would you say no to that? But fantastic product. And then it also is replacing some of the testosterone at

Maureen Slattery, MD (39:25.483)
Yep. Yep. It's fabulous. Yep.

Maureen Slattery, MD (39:42.837)
Right.

Jessica Caceres (39:49.9)
the level of the vulva vestibule as you mentioned and all of that. So it's really fantastic. Yeah.

Maureen Slattery, MD (39:52.462)
right because of its metabolites. Yeah. Yeah, no, it is. I do tend to make sure that everybody has vaginal estrogen and I like it, but it is messy and I will do the absolutely the same thing. If it's easier to use some kind of like, you know, like the Vagifem or in a Rosa or anything, fine. But I still think we need to treat the vestibule, especially for sexually active women, because like that six o'clock spot, which is if you're looking at it, right, the bottom most part of the vagina, the

Jessica Caceres (40:14.126)
Yes.

Maureen Slattery, MD (40:22.555)
opening that's closest to your bottom. I say this a lot to people but I'm like doesn't matter if you're in missionary reverse cowgirl or doggy style that area is gonna get the most friction and pressure and and you need to treat it nicely and help it allow it to be like stretchy and tolerant otherwise it's it's not gonna be fun.

Jessica Caceres (40:33.218)
Yes.

Jessica Caceres (40:43.342)
Well, and it's no coincidence that that's one of the most common areas to see fissures too, as we get older as well. We have in our clinic, we have the B-Pulse chair, which is the Canadian version of the M. Sala chair. I don't know if you're familiar with that, but it's that the EMS, the magnetic energy basically that does your Kegels for you. And above and beyond the pelvic floor strengthening component. One of the things that I absolutely love about it is that it's also stimulating blood flow, right? Because

Maureen Slattery, MD (40:57.375)
Yeah, there I am.

Maureen Slattery, MD (41:04.151)
Yeah.

Maureen Slattery, MD (41:12.961)
Mm-hmm.

Jessica Caceres (41:13.378)
blood flow to the pelvic floor into the vaginal area, it really starts to become, you know, a little more challenged as time goes on, just like it does to our fingertips and our toes and our nose and our ears and all the things in between. and for men, their penis, right? And so without good blood flow, then you start to lose some sensation and also your healing time is impaired. So I really like to sort of, mix things up and, and use that for the purpose of blood flow as well.

Maureen Slattery, MD (41:28.949)
Mm-hmm.

Jessica Caceres (41:42.317)
Although I'm careful in the context of a tight pelvic floor, because we don't want to make things tighter. But that's where we get our friend Kristen in to see our patients and say, yep, yes, no, you know, so we can safely treat them. it's just, it's again, multifactorial and a huge part of libido, a huge part. I mean, if you're having pain with intimacy, you are going to tell your brain, absolutely not. And your brain is your biggest sex organ period. So.

Maureen Slattery, MD (41:46.701)
Worse, yeah.

Maureen Slattery, MD (42:06.423)
Mm-hmm, that's right.

Jessica Caceres (42:08.492)
Yeah. So now tell me how you help women sort of determine where, which part of the million and one things that could be affecting their libido that it could be, how do you help them pinpoint? Perhaps it's a combination of three, four different things. Like how do you help them come up with, you know, figuring out what is most significant in their particular individual situation?

Maureen Slattery, MD (42:33.505)
Yeah, mean, definitely I fought to have more time to have these discussions. And then I always, I say this too, it's like lube always lube and your brain is your biggest sex organ. I feel like my superpower is talking about sex. Even with partners in the room, even with like angry or irritable partners in the room, like even with postpartum patients, like I can tell them like, if you're not ready, you're not ready. Sorry, buddy, but like she needs more time. I feel like I'll let them start

telling me what's going on and I'll ask follow-up questions and we'll keep talking and I think that I'm down to earth enough, again another superpower, that people feel comfortable and I do think that gynecologists a lot of the time miss the mark. Yes, we need to be professional but if you are stuffy and you don't listen and you're not understanding or you're not hearing what they're telling you then you are not really going to make them comfortable enough to talk about sex and most providers don't bring it up to begin with. So if they're opening

up to you. Like I ask follow-up questions. When we go down the, you know, the talking about things. And I know some of the classic things we've already talked about that can affect how things are going. But I mean, I get into partner dynamics. Like is your partner helping you with the household? Do you live alone? Do you have, you know, does college kid move back in? Do you have any time alone? Wait a minute, your schedules are that you only have Saturday nights in the house together and otherwise you travel on different schedules. Like you have to peel the onion. So I will ask relationship

I will ask about, you know, masturbation and those kinds of things. I will ask about if things have been this way for a long time. I will ask about previous relationships. Usually it comes out and in the small cases where it hasn't, do get people have like blurted it out to me when I've got like five minutes left. They'll be like, by the way, we lost a 16 year old daughter two years ago. And I'm like, and she goes, I didn't want you to think that was the only reason. I'm like, clearly that's never the only, it's never the only reason, but like,

If you don't think that's still a reason and she goes, no, I think it is and I said well Then I'm glad that you brought it up so we can talk about it But you know validating all this stuff, but it's it's it's an onion You got to peel layers and some things people are hesitant to talk about but you have to look at the whole picture, right? The relationship and how that works what's happened in the past with that partner or with other partners? You have to look at what's going on medically. Is it perimenopause? Does someone have cancer diagnosis? You know, you've got to peel all these layers who else is in the household. Do you have any time to yourself?

Maureen Slattery, MD (45:03.135)
Like what is your stress level all of these things? Like how did you learn about sex? How did how was it growing up? Are you terrified to have sex because it was always a sin and naughty and they're gonna kick you out of the house if you got pregnant like There's so many pieces that you just have to I try to make it as a natural of a conversation as possible But I just peel the onion until we find things and then I ask the patient. Do you how much do you think this is? Affecting what's going on and usually they'll say a decent amount right like the other day I found

Jessica Caceres (45:14.858)
Exactly. Yeah.

Maureen Slattery, MD (45:32.998)
a woman who had been with someone for like six years and like faked an orgasm for six years and I was like okay so you know we can do one of two things if you want to fix this or work on this right so we kind of like started talking about it but yeah whole relationship partners supposedly never knew that she was just faking it and she's like how do I undo that like

Jessica Caceres (45:39.687)
goodness.

Maureen Slattery, MD (45:55.692)
Well, so we go through it. it's complicated and it does take a little bit of time because it's so multifactorial. But I think just by listening and asking questions and having an honest conversation, which I wish there was more time in the regular office to do, but I also wish people who are providers like us who know this stuff, but there are people, there's so many who don't, and they will tell people like, go have a glass of wine or use more lube or you're too young for those symptoms. Like those are some of my

Jessica Caceres (45:55.896)
Right.

Maureen Slattery, MD (46:25.665)
as pet peeves from like the general population of providers because none of those things are ever the answer. Like honestly, like not even under any circumstance. mean unless you're... yeah, not even. It doesn't help anything and it just it what it shows to me is is their discomfort with the topic and probably their lack of knowledge on the topic almost definitely. But it's hard for patients. It's hard so we've got to do better, you know?

Jessica Caceres (46:34.082)
No. They're not even a band aid. No. No.

Jessica Caceres (46:51.918)
And it also puts blame in the, you know, towards the woman. Well, it's you, you're not relaxed enough, go and have a glass of wine. Like, on what planet does that make sense? You know, no, and a glass of wine is actually gonna dry your vagina more, for the record.

Maureen Slattery, MD (46:54.657)
Yes. Yes.

Maureen Slattery, MD (47:07.725)
Yeah, and what perimenopausal woman doesn't complain that like they can't drink wine like they used to? All of a sudden they're like, I used to have a glass of wine here and there and now I just, can't, I wake up with a headache. And I'm like, yeah, we get it at all angles. We don't.

Jessica Caceres (47:13.742)
Exactly.

Jessica Caceres (47:19.81)
You just don't metabolize it the same. Yeah. Well, it's true. And then you get somebody who's uninformed and uneducated and just adds complexity to an already complex matter. But that's, it's so, it's so important, like you said, to just, love your analogy of the onion, like peel back the onion, right? It's so true. There's a million and one different things that are involved in, you know, in, in determining what is affecting your libido. And truly my default is we, we will

peel back the onion for sure, but I am not a psychotherapist and I encourage my patients big time. Listen, you need to go and see a therapist if you're willing by yourself at least, if not with your partner. And I think that that is so important so that you can have some, you know, open, honest dialogue and then determine from there, how do you get past this and move forward so that you have the type of sex life and intimacy that you both desire because it takes two.

Maureen Slattery, MD (47:51.051)
Yeah, me too.

Maureen Slattery, MD (47:58.754)
Mm-hmm.

Jessica Caceres (48:18.112)
Also, I love how you said you ask about masturbation and so forth. It's so important. You need to know your own body, right? Again. And if you know, and that's the thing.

Maureen Slattery, MD (48:23.425)
You need to know your body. You do. You need to know what works for you. And if you're a good partner, you should also want to know what works for your partner and ask them. I mean, it goes both ways.

Jessica Caceres (48:34.474)
Exactly. Exactly. And to that point, I think that there is such a huge gap, not only with women, but with men, understanding the hormonal changes. And it's interesting because, again, in family medicine, having both the husband and the wife as patients and having seen them for different things, when a woman comes in and expresses

Maureen Slattery, MD (48:43.475)
Ugh. They don't understand it at all.

Jessica Caceres (49:02.894)
you know, what's happening and then knowing the partner, albeit on a superficial level because they're in, know, for a handful of times, you think it's just that he doesn't know and he just needs to know. So let's educate him on this. And that in and of itself is super empowering to say, oh, wait a minute. And the number of women, even just with the addition of some vaginal estrogen, how it's life changing for them. Not only are they not getting UTIs anymore, they're actually lubricating somewhat. And then

Maureen Slattery, MD (49:12.651)
Yeah.

Maureen Slattery, MD (49:16.279)
Mm-hmm.

Jessica Caceres (49:31.442)
not feeling like it's a failure having to use lubrication. know, it's just amazing how it can be so effective for people. But yeah, it's a huge topic. Yeah.

Maureen Slattery, MD (49:43.369)
It is. Yep, lots of education, even for people who might not be in the room.

Jessica Caceres (49:49.046)
Yes, exactly. Exactly. So with that, I'm going to conclude this episode and we're going to move over to our episode three of the hot flash diaries momentarily where we're going to talk about all things of how to solutions and action plan towards how can we sort of improve all of these different aspects of our libido. Of course, it's going to be very, very individualized, but we're going to go through some of the things that you can do to improve things if you want to improve things that is.

Maureen Slattery, MD (50:17.13)
Right.

Jessica Caceres (50:17.551)
So we'll see you over in episode three. Thanks so much for listening and we appreciate your time. Have a good day. Okay, I'm gonna stop it and I'm gonna re-record the

Maureen Slattery, MD (50:25.995)
Alright.