The EngagED Midwife
The EngagED Midwife
Your Libido Is Not Broken
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Sex can change fast after birth, and it can change again in perimenopause and menopause, but that doesn’t mean you’re broken. We dig into why libido, arousal, and comfort often shift when estrogen drops postpartum and later in life, and how that hormone reality shows up as vaginal dryness, painful sex (dyspareunia), and the sense that your body isn’t responding the way it used to. We also talk about the common brain-body mismatch many women experience and how mental load can shut desire down even when the relationship is solid.
We walk through the postpartum hormone landscape, including the steep fall in estrogen and progesterone after placenta delivery and how breastfeeding keeps estrogen low through prolactin and oxytocin. Then we get practical about what helps: pelvic floor physical therapy (and what to expect so it’s not a surprise), using plenty of lubricant, considering vaginal estrogen for atrophy, and expanding intimacy beyond penetration while healing happens.
From there, we transition into perimenopause and menopause, including genitourinary syndrome of menopause, irritability and sleep disruption, and why libido issues are often tied to androgens like testosterone. We cover options clinicians may consider for hypoactive sexual desire disorder, plus the overlooked impact of medications like antidepressants and blood pressure meds. We wrap with the PLISSIT model so midwives and clinicians have a clear framework to open these conversations with permission, simple education, specific suggestions, and referrals when needed.
If this helps you feel more informed or less alone, subscribe, share the episode with a friend, and leave a review so more people can find honest, evidence-informed sexual health support.
#LetsTalkAboutSexBaby #SexualHealth #SexAcrossTheLifespan #PostpartumWellness #HormonalHealth #PelvicHealth #IntimacyAfterBirth #MenopauseSupport #SexualWellness
#EmpoweredAging
Rainy Beach Banter And Welcome
SPEAKER_00Welcome to the Engage Midwife podcast. This is Missy.
SPEAKER_01And this is Kara. There's rain at the beach. It's, you know, as I just posted on Facebook, rain at the beach is still rain. At the beach. It just makes it better. I mean, I guess. It is beautiful. It's kind of chilly. We were covered up with blankets, listening to the rain. It's been a nice day. A nice leisurely day.
SPEAKER_00You actually said you were cold.
SPEAKER_01I know. That's saying something too.
SPEAKER_00But Betsy and I decided that we were gonna go to the beach before the rain started, and we went to the beach and there were dolphins. And I said, you know what? They just recognized that we were mermaids and they wanted to come say hello.
Why Talk About Sexuality Now
SPEAKER_01We did also eat at the same sushi place twice in one week. I don't see the problem with that. If you're ever in or near Navarre, Florida, we're gonna call out the slippery mermaid. It is delightful. Yes. Delightful. I think some of the best sushi around anywhere ever. So good. So good. All right. Well, you know, since you hinted at my warmth with menopause, let's talk about having a little segue here into our topic for today. Um, we've had a lot of interest and people reaching out saying they wanted to hear about sexuality in the postpartum and sexuality in later years. And so we just decided to combine that together and talk about sexuality across the lifespan. Let's do it. Yeah. And there's a lot of similarity. So I think it makes sense to talk about this together. But sometimes um conversations around sexuality can be kind of challenging for people, especially newer midwives, people that just, you know, we need to normalize the conversations and normalize talking about libido and talking about pleasure and talking about body changes and transitions and all of those different things. So we're hopeful that this will help you all.
SPEAKER_00We did a podcast episode though, once where we talked a lot about toys and we did, like uh orgasm and all of that. So if that's the thing you want to listen to, yeah, go back and listen to that episode and we talk about all of the things. Yeah. Good giving game. Yes, GGG. Yeah, was the name of that podcast episode. So go find that because there's a lot of self-disclosure.
SPEAKER_01Yeah, but I think what we want to talk and focus about this time is a little bit more of a focus on some of the hormonal changes that people experience across the lifespan and why that might impact libido, might impact um the, you know, health of your vagina, that sort of thing. And then also talking a little bit about how people sometimes think that sexuality things are all in their head or that, you know, it's a psychiatric issue when really it might be a hormonal change.
Brain Versus Body Desire Mismatch
SPEAKER_00I want to say something as we start. Okay. Because I think this is just a really big thing that I think across the board that women need to understand about their bodies, because I think it's um um it's different with different genders, right? So men, their brains and their genitals are very much connected. And because of that, if they're thinking about sex, their brain is causing them to have a genital response, right? It doesn't take a lot for men to have an erection. Generally, yes. It does not take a lot in general terms. Women, however, have very much a disconnect between their brain and their genitals. And there is really good research about this where it says that, like we can be really turned on in our brains, and our genitals are like, yeah, no, thank you.
SPEAKER_01Or there's just so many committee competing demands. Correct. Yeah.
SPEAKER_00The other thing is that our genitals can be saying something where they're like, oh yeah, I want to do this thing. And our brains are like, no way. So the disconnect, I think, for women, it comes with competing things, right? But also like our bodies do not work the same way as male bodies do. And so we have to figure out a way to put our brains and our reproductive organs on the same path. And that's sometimes really hard.
SPEAKER_01Yeah, I think the idea that we're not broken if um things aren't always matching up is also really helpful. That can be times of recalibration, it can be finding out what's normal for you in that time. And then, as I say often to students and also say to my patients, if you're not having, if you're not feeling like it is a dysfunction to you, it's you're not having sexual dysfunction. Right. Your partner may think that you are, but if you are happy and pleased with your sexual life, then it's more about relationship dynamics and less about is there sexual dysfunction.
SPEAKER_00Yes. And I, I mean, even like in my own relationship, like I'm pretty sure that my husband would want to have sex with me three times as much as I do. Like he would just every day if he wanted to. Yeah. If I would. Yeah. Um so I think that's really interesting too. Like they would be game to do as many times as yeah.
SPEAKER_01And I think it varies amongst so many different people, right? Like there's people that have sex twice a year, whether they need it or not, like on their anniversary and birthday.
SPEAKER_00We call that obligatory, right? Or celebratory. Obligatory is when you have to do it because it's like your anniversary. Yeah. Celebratory is like, oh, I had some drinks, maybe we're celebrating something and we have sex. Is it obligatory or celebratory?
Postpartum And Menopause Share Low Estrogen
Breastfeeding Hormones Dryness And Pain
SPEAKER_01Yeah, and for some people, that's a couple of times a year. Or not. Birthdays, yeah, anniversaries. Yeah. And other people are much more active. And but it doesn't mean the one's right or wrong. Correct. Okay. So let's talk about kind of the tie between, especially postpartum, which we've had people ask us about, and menopause and understanding that in both situations, estrogen is declining or is low, and that can lead to vaginal atrophy. And when the vagina is atrophic, doesn't feel good, isn't as responsive, then it can be hard to want to have sex. And that can impact libido. Absolutely. All right. So let's talk a little bit. Should we talk a little bit specifically about the postpartum landscape and how breastfeeding can impact that as well and get a little deeper understanding about postpartum? Pick me. Pick you.
SPEAKER_00Okay. Uh, Missy, did you have something you wanted to say? I do, because I just finished teaching this, so I feel really good about like off the cuff talking about postpartum. Okay. So, um, as you know, if you've been listening the last few weeks, Karen and I have been at the beach teaching, and so I've been doing a lot of postpartum things. And so I talk in my postpartum lecture about the hormonal changes that happen during the postpartum period. The thing that happens as soon as the placenta is delivered is you get a drop in estrogen and progesterone. And those two hormones are usually at like your low, like beginning of the menstrual cycle phase, that level, um, within about a week postpartum. But there's a huge drop immediately postpartum, because that drop in estrogen and progesterone is what then stimulates prolactin and oxytocin to come from the anterior pituitary gland. And so just like with anything else, we see that estrogen or lack of estrogen can cause all kinds of physical symptoms. And so when moms breastfeed specifically, you are getting that suppression of estrogen and progesterone because you've got so much prolactin and oxytocin like floating around the body. So a normal breastfeeding postpartum woman is gonna have a low estrogen level. And that can lead to vaginal dryness, dysparenia, like all kinds of things that affect your sexual health. How they do.
SPEAKER_01Yeah, no, that's great. It's really great. It's, you know, the other thing is that, you know, we're not there yet, but also when you're breastfeeding in those first few days and you're breastfeeding so frequently and you're baby wearing and you're so close, you can also feel really touched out, and you're getting the oxytocin response that you would sometimes get from sexual activity from your baby and from breastfeeding. Yep. And not in a sexual way, but you're not having that drive. Correct.
SPEAKER_00Also, the postpartum period is like the worst time to be thinking about your sex life. I mean, I think I was thinking about keeping myself and my kids alive. Yeah. Postpartum.
SPEAKER_01Yeah. And even if people do have desire, sometimes they're fearful, they're, you know, there's pain, there's all kinds of other things that go along with it. But let's keep talking a little bit about that idea in the postpartum, and that, you know, with those estrogen and progestin levels so low and the vaginal atrophy, you're not ovulating. And ovulation is kind of its own built-in sex drive. We were just talking about this with students the other day. Like, mother nature's constantly trying to get us pregnant. When people ovulate, things look so much better. It's true. So if you're not ovulating, you're not having that built-in drive as well. Correct. Yeah. So you mentioned atrophy. We know that people that have repairs, epesiotomies, that sort of stuff, oftentimes have a lot of anxiety, but dysperunia is very, very common. Anywhere from like 85 to 95% of women will report that they have some dysperonia or painful intercourse after childbirth. And it really can, I mean, it can last for a long time. There's something like 20 to 25% of women that are still reporting pain a year to 18 months after delivery.
SPEAKER_00So I was also talking to students about this thing with dyspronia and like pain with intercourse. And because we were talking about repairs. And so there's some dyspronia that can come after you've had like a perineal repair, any kind of repair after delivery. And there's really good research that says, like with first and second degree repairs, if we don't close the skin and we let those heal by secondary intent, that women have higher satisfaction because they have less pain afterwards, which I think is fascinating research. But I also think that like this is where pelvic floor PT really can be beneficial in the postpartum period.
SPEAKER_01Yeah, absolutely. And the fact that someone doesn't have a vaginal birth, they may have a C-section, that doesn't mean they also won't have dysprunia because a fair amount of women have dysprunia even with a C-section. It's so wild. It is. So we talked a little bit about the mental load, and you mentioned that, you know, like you're just trying to keep yourself alive and keep your babies alive at that time. There's a big mental load, and a fair amount of people that go through postpartum blues, a fair amount that have postpartum depression and anxiety, and that can certainly have an impact on libido as well.
SPEAKER_00Yeah. We talked the other day about how I used to cry over Rory, like when he was a little bitty baby, for a multitude of reasons. And the last thing I was thinking was about having sex as I'm like sobbing over top of my baby. Yeah.
What Helps Lube PT Estrogen Communication
SPEAKER_01So I think we've talked about the reasons that someone could have decreased libido, why they might have sexual pain disorders, why there is, you know, this feeling of not necessarily um feeling like themselves. So let's talk about some of the things that can help. You mentioned pelvic floor physical therapy, and I think that's a great idea.
SPEAKER_00Yeah, I mean, they can help desensitize scar tissue and really teach your brain that penetration doesn't have to be painful. I also want to put a caveat on this because I don't think I realized how invasive pelvic floor PT was until I experienced it myself.
SPEAKER_01I think you've mentioned it in another episode, but yes, tell us like what that experience was like.
SPEAKER_00I think a lot of people think like you're gonna go to physical therapy and they're gonna tell you exercises to do, and that feels like not super invasive. But with pelvic floor PT, sometimes they want to insert things in your vagina. Sometimes they want to put their hands in places that may they want to feel where there's tight muscles. Correct. Yeah. Um, my very first visit, they put a bunch of sensors down near my perineum and were like doing a lot of testing in terms of like what was happening with my muscle fibers, and like, you know, as like a trauma survivor, it really was very triggering to me. And I think most of it was because I didn't know what to expect when I walked in. And so, for those of you listening, if you don't learn anything else when I when you talk about pelvic floor PT, I think it's really important for you to understand so you can prepare people for what that is like when you go into a setting like that. Yeah. And I I even say I like lost all my modesty after I had a baby. Like everybody's seen my vagina. All the nurses that I work with have seen my vagina. Everybody's seen my boobs after breastfeeding for an extended amount of time. It was not a comfortable like situation to be in with somebody that I'd just met. Yeah. And so pelvic floor PT, I think, is super valuable. So helpful, yes. So helpful. But I also think you have to prepare people for what they're getting themselves into.
SPEAKER_01Yeah. And I've I, you know, I have several colleagues and friends that are pelvic floor physical therapists, and they will talk about how like getting patients postpartum sooner rather than later, getting patients that are having urinary incontinence sooner rather than later. Because these are things that they can oftentimes have a really big impact on and can really help improve people's quality of life. But that's not to say that it's not invasive and that it can be a difficult experience.
SPEAKER_00It can be triggering. Yeah. I actually only went once. Yeah. Because I was not in a mental state that I could like put myself there. Yeah.
SPEAKER_01So anyone that knows me knows that I will say if a little lube is good, a lot is better. So certainly a huge fan of lube and helping people that are postpartum to understand that it is not because things aren't working right. It's not because there's a problem with their body or anything like that. But lube can be really, really helpful generally. You know, if you're talking about someone that's using condoms, we want to use water-based, but there are a lot of really great um lubricants out there that you can get that don't feel gummy, don't feel sticky. Um, and then if we're talking about someone that's really having vaginal atrophy, even the use of estrogen cream, which is not a lube, but it also makes up tissue locally feel healthier, more plump, more stretchy, more elastic, and that can feel better as well.
SPEAKER_00Yeah, vaginal estrogen is amazing. Yeah, can really do a good job. A little primer and cream goes a long way. It does.
SPEAKER_01It does, absolutely. Yeah. And so then there's our other types of therapy that we can recommend for people like psychotherapy, sex therapy, um, some of those different things, helping them think about um are there more comfortable positions, especially if they're having pelvic pain, are there activities that they could do that aren't penetrative? You know, helping them to really understand all of the various ways that we can express love and affection and physical touch and those sorts of things without causing pain and distress.
SPEAKER_00Yeah. I I do think that there is a lot of this too that goes into like it being an opportunity to communicate with your partner. And you and I talk a lot, we have talked a lot about toys and about other things that we can use to like stimulate those like kinds of situations. And I just think if you're open and honest about the conversations that you're having about why you don't want to have sex or what does or doesn't feel good, or what you need in that situation, like that will also help with you know, just gradually starting more activity.
Perimenopause Libido Testosterone And HSDD
SPEAKER_01Yeah. I mean, even good, good people in good, solid relationships that are mature can sometimes get into passive aggressive, like I'm gonna avoid him and I'm gonna get avoid going to bed at the same time because I don't want to have the same conversation and you know, all of those different things, or he's, you know, feeling like he's being rejected all the time. And really just good open, honest communication with each other can be really helpful. Yeah. Okay, so that is a good transition into our perimenopausal period. And some of the exact same things can be happening in that perimenopausal transition because our estrogen levels are decreasing. The estrogen that we do have is a weaker estrogen as estradiol changes to estrone. And so I think pain, as well as just all the psychiatric, like the short fuse, the irritability, the feeling hot all the time, the confusion. I mean, there's so many different things that people are going through in the perimenopausal transition. Um, and even if they're having a pretty easy transition, the changes to your body and the changes um that can feel really sudden um can be a little disconcerting and make you not feel like yourself. I mean, yeah.
SPEAKER_00Like the I I mean, everything that you just said, there's a million reasons why you don't feel like yourself. I will always continue to go back to mental load. Yes. And whether it doesn't matter what what part of life you're in, whether that's like postpartum, whether that's menopause or perimenopause, like I always go back to mental load. Like I think sometimes, like if I could just take five things off of my mental load, then maybe I'd want to fall in bed with my husband more often.
SPEAKER_01Yeah. Yeah. Um, it's just, you know, that to-do list is so crazy long. And, you know, I've often said in my life, if I can sleep or have sex, I'm gonna probably choose sleep.
SPEAKER_00I really, really, really like sleep. Yeah. I think the issue too, the biggest issue that I see in perimenopausal and menopausal women is libido issue. Yes. And um the libido issue is almost always related to androgens, and that would be testosterone, right? Yes. So if you're the midwife and your patient's complaining of decreased libido, I would always check their testosterone level because testosterone supplementation is something that absolutely can improve your quality of life if the problem that you're having is libido. If the problem that you're having is arousal disorder, there are even some things that we can do for arousal disorder.
SPEAKER_01There are, yeah. So can we talk about a couple of those? Yes. Yeah. So especially in pre-menopausal, so perimenopausal, but pre-menopausal women, there's a medication called Adii or Adi, I think is it philbanthrin or something like that, that can really be helpful for hypoactive sexual desire disorder. And you can't, it's only intended for people that don't also have comorbid depression, but it can be really helpful for um libido, for desire. And um, one other thing to know about it is that you want to avoid taking it um and having any alcohol, but that's something that could be helpful.
SPEAKER_00Sometimes the alcohol is what's helpful.
SPEAKER_01Decreases some inhibitions a little bit. I mean, I'm just saying. Yeah. Um, the other thing is that you could recommend therapies to people, um, communication. Um, we've talked before kind of about use it or lose it. If you're in a habit of having sexual activity, you may want to feel more like it's natural, that it's not something you have to overcome to become active, if that makes sense. So making it a habit can be um a good thing.
SPEAKER_00Yeah. So the real the actual name for those like desire and arousal disorders are HSDD, which is hypoactive sexual desire disorder. Yep. And so um the level of interest, etc. But we didn't really talk about um GU syndrome of menopause, right? Right. So we could go there next. Okay.
GSM Atrophy Relief And Changing The Game
SPEAKER_01So really common because of decreasing estrogen and that people can have I I always say that you're just constantly aware that you have a vagina. Like when you move, when you go to the bathroom, anything can cause discomfort, it's kind of itchy, it's kind of dry. But also then obviously any sexual activity could feel more uncomfortable and you could have dysprunia.
SPEAKER_00Yeah. And what do you always say about lubricants if they taste good, smell good, taste good, or tingle?
SPEAKER_01But they're probably not good for your vagina. Right. Yeah, but and so lubricants and moisturizers can be helpful, but sometimes that's just gonna mask the symptoms of atrophy, where estrogen topically could be really helpful. Also, if someone's needing to take medications for other symptoms like vasomotor symptoms or something like that, then systemic hormones are probably gonna be really helpful for their vagina as well. Yeah.
SPEAKER_00I also like the idea when you get to perimenopause or menopause of like changing the game. Yeah. And that for me, that means like, you know, it doesn't have to be missionary in the dark. It can be why are you lying?
SPEAKER_01No, I also am just thinking, like, you keep saying, like, I can't believe you're gonna sell your house and that. And I'm like, my children are leaving. That sounds kind of nice. Missionary in the dark. No, I'm just saying it changes up the game. Oh, changing the game, yeah. You're not stuck in the bedroom necessarily. It can be decent. What did we have a conversation the other day about? Like, you know, sex it can be like ice cream. It may be vanilla ice cream, but it could be a hot thug Sunday with a cherry on top. I mean, plain ice cream isn't bad. I can't keep a straight face. Plain ice cream is not bad.
SPEAKER_00Okay. Well, I also live in a house where my children are only home 50% of the time. So I can do whatever I want, whenever I want, wherever I want. You're getting freak on. Sometimes when the kids come home, I think, oh, you won't want to know what we did there.
SPEAKER_01Well, what was it? I said also the other day. We were talking about um sex during pregnancy. And someone said, like, oh God, I didn't want to do it while I was pregnant. I'm like, what? Like, that's the only time you can't get pregnant.
SPEAKER_00Because your only desire to in life is to not be pregnant. No, to not have an unplanned pregnancy. That's right, an unplanned funding. So when I say change the game, I mean it doesn't have to be all the things that you used to do. Right. It could be different places, different positions. It could involve toys, it can be just different. And sometimes you need a different level of arousal than your partner needs. Yes. And vice versa. And so, you know, a little more work for you know mutual pleasure, but just don't be afraid to change it up. If what you are doing when you are pre-menopausal isn't working now that you're menopausal, then figure out what works.
SPEAKER_01Well, I mean, and we certainly know that men as they age sometimes need some assistance and just watch any sporting event and you will know that there is a wide amount of variation in medications that are available. And so the fact that you might need a toy or the fact that you might need a little more stimulation is not the fact that something's broken, it's just that something's changed. Correct. Yeah. That's right. We, you know, yeah. We should mention here that the use though of seldinophil or viagra, any of the erectile dysfunction meds, would be completely off label for use in women in anything outside of um a you know, study, uh clinical trial. So it's not really recommended, although I've certainly heard of people trying some of the different products to see if it would help.
unknownYeah.
SPEAKER_00Why do men get all the good drugs? Liam. That's a story for another day. Yes, that is a story for another day.
SPEAKER_01Okay. So I think you know, we've talked about some of the different things that are available, some of the different um the problems that we can experience. It would be worth us also mentioning that as we age, we oftentimes will have chronic health conditions and maybe some decreased mobility. So thinking about assistive devices or different positions or, you know, different things of ways that you can show and be intimate is not something that we should shy away from in talking with our patients. And I think our patients would welcome conversation around that. That they they may be embarrassed to bring it up, but if we bring it up and normalize those types of conversations, I think they would welcome them.
Meds Chronic Illness And The PLISSIT Model
SPEAKER_00Yeah. And then also understanding that medications can often also interfere and cause like low desire or difficulty with arousals. So that can be one of those big things is antidepressants. Specifically, Lexapro can cause anorgasmia, which is an unfortunate side effect of Lexapro. Um, blood pressure meds, too, like beta blockers and diuretics, can also impair blood flow to the clitoris or to the vagina. Also, it can be the same in men in terms of erectile dysfunction. And then other things like um opioids and chronic pain meds can lower testosterone and lead to like decrease in desire. So I think, you know, what medications are you on and are those affecting like your drive and your arousal and those kinds of things?
SPEAKER_01Yeah. And then we've talked a little bit and will again in the future about the changes that can happen after, you know, cancer diagnosis and surgery and body dysmorphia. So also helping people to understand that it may not just be medications, but surgeries and other things that can change um, you know, the way they feel about their body and the about their sexuality and helping just have open, honest conversations around that as well. Yeah. Yeah. I want to mention because we haven't said it explicitly, and I want to, but when we talk about um psych sexual health and having these open, honest conversations with people, there is a model called the Plicit model, and it stands for permission, limited information, specific suggestions, and intensive therapy. And that model is how we should operate and really giving that permission to have conversation around it, the limited information and the specific suggestions. And then if we need to make referrals for intensive therapy, we can definitely do that.
SPEAKER_00I love that. Okay. So I don't want to like be remiss in missing any of like the sort of chronic things that may be affecting sexual desire, especially menopause and perimenopause. We talked some about chronic pain, depression, heart disease, but like and medications, but like things like dementia, chronic pain, arthritis, um, obesity, stroke, all of those things can have ill, unward effects on our sex lives. Yeah. And so those are things too that I think you need to like, as you're doing sexual history, especially if your patients come in with a complaint, like considering what's on their problem list.
SPEAKER_01Yeah. And just because people are aging, we shouldn't assume that they are no longer having a desire or wanting to be um, you know, active sexually and that sexual health is part of our health. Yeah.
SPEAKER_00Yeah.
Key Takeaways And Closing
SPEAKER_01Well, this has been really helpful, I think, especially as we think about how these two different time periods that we've talked about, how perimenopause as well as the postpartum period can have such an impact um on people's lives, but also just, you know, there are different varieties of times and situations that happen throughout the life and really helping to open up the lines of communication with our patients can be really helpful.
SPEAKER_00And, you know, you and I are saying to students all the time and to new midwives, like, if you understand the physiology of what's happening in a female body at any given time, you will be able to accurately understand why women have complaints. Yes. So understanding the physiology of the postpartum period, what's happening with hormones, understanding the physiology of perimenopause and menopause so that you can understand the hormones. If you understand the hormones that happen throughout the life cycle of a woman, you will be able to adequately put your finger on why people are having d pain, discomfort, low libido, low desire, low arousal, sexual dysfunction as a blanket term. Yes. Right. And so, you know, I we will always tell you to go back to the physiology.
SPEAKER_01Yeah. And helping patients to understand their bodies, I think that's the other thing is that while some of the physiology is hard for us, we can certainly understand that patients aren't gonna get that and understand it completely. So if we can break it down for them and help them to understand, again, that they're not broken and that sometimes we're just redefining new normals and redefining ways that we can show intimacy.
SPEAKER_00Yeah, this is so great. Yeah. And we got some laughs out. Well, every once in a while we talk about fun things. So we do. Well, thanks for joining us for the Engaged Midwife podcast. We can't wait to talk to you again. Take care.