216 Enriching Sexual Function, Part Two with Dr. Kris Christiansen

*DISCLAIMER* This episode includes adult content and is not intended for young ears.

 

216. Enriching Sexual Function, Part Two with Dr. Kris Christiansen

 

**Transcription Below**

 

1 Corinthians 6:12 (NIV) “I have the right to do anything,” you say—but not everything is beneficial. “I have the right to do anything”—but I will not be mastered by anything.

 

Questions and Topics We Discuss:

1. What are a few benefits of orgasm?
2. What is the treatment plan for clients who have never experienced an orgasm?
3. What is Perimenopause?

 

Dr. Kris Christiansen is a board-certified family physician who specializes in sexual medicine. She attended medical school and completed her residency in family medicine at the University of Minnesota. She practiced full spectrum family medicine for 10 years and then pursued additional training to specialize in sexual medicine. She works as a sexual medicine specialist at two different clinics in the twin cities.  Her clinical interests include both male and female sexual dysfunction, and she loves working with individuals and couples to restore an important part of life. 

 

Dr. Christiansen is involved with teaching medical students and residents at the University of Minnesota Medical School, and she has presented at multiple local, national, and international medical conferences. She is involved with the International Society for the Study of Women’s Sexual Health (ISSWSH) and serves on committees, collaborates with other experts to publish articles for medical journals, and edits informational articles for the society’s new patient facing website. She is passionate about teaching patients, students, and colleagues about the importance of sexual health and well-being.    

 

In her free time, she started her own business called Intimate Focus which provides information and quality products to enhance and restore sexual health and wellness. She also enjoys shopping, hiking, and spending time with her family.

 

Dr. Kris Christiansen's Website

North American Menopause Society

Women's Sexual Health Information

ISSWSH Website

 

Thank You to Our Sponsor: Midwest Food Bank

 

Connect with The Savvy Sauce on Facebook or Instagram or Our Website

 

Gospel Scripture: (all NIV)

 

Romans 3:23 “for all have sinned and fall short of the glory of God,”

 

Romans 3:24 “and are justified freely by his grace through the redemption that came by Christ Jesus.”

 

Romans 3:25 (a) “God presented him as a sacrifice of atonement, through faith in his blood.” 

 

Hebrews 9:22 (b) “without the shedding of blood there is no forgiveness.” 

 

Romans 5:8 “But God demonstrates his own love for us in this: While we were still sinners, Christ died for us.” 

 

Romans 5:11 “Not only is this so, but we also rejoice in God through our Lord Jesus Christ, through whom we have now received reconciliation.” 

 

John 3:16 “For God so loved the world that he gave his one and only Son, that whoever believes in him shall not perish but have eternal life.”

 

Romans 10:9 “That if you confess with your mouth, “Jesus is Lord,” and believe in your heart that God raised him from the dead, you will be saved.” 

 

Luke 15:10 says “In the same way, I tell you, there is rejoicing in the presence of the angels of God over one sinner who repents.”

 

Romans 8:1 “Therefore, there is now no condemnation for those who are in Christ Jesus”

 

Ephesians 1:13–14 “And you also were included in Christ when you heard the word of truth, the gospel of your salvation. Having believed, you were marked in him with a seal, the promised Holy Spirit, who is a deposit guaranteeing our inheritance until the redemption of those who are God’s possession- to the praise of his glory.”

 

Ephesians 1:15–23 “For this reason, ever since I heard about your faith in the Lord Jesus and your love for all the saints, I have not stopped giving thanks for you, remembering you in my prayers. I keep asking that the God of our Lord Jesus Christ, the glorious Father, may give you the spirit of wisdom and revelation, so that you may know him better. I pray also that the eyes of your heart may be enlightened in order that you may know the hope to which he has called you, the riches of his glorious inheritance in the saints, and his incomparably great power for us who believe. That power is like the working of his mighty strength, which he exerted in Christ when he raised him from the dead and seated him at his right hand in the heavenly realms, far above all rule and authority, power and dominion, and every title that can be given, not only in the present age but also in the one to come. And God placed all things under his feet and appointed him to be head over everything for the church, which is his body, the fullness of him who fills everything in every way.”

 

Ephesians 2:8–10 “For it is by grace you have been saved, through faith – and this not from yourselves, it is the gift of God – not by works, so that no one can boast. For we are God‘s workmanship, created in Christ Jesus to do good works, which God prepared in advance for us to do.“

 

Ephesians 2:13 “But now in Christ Jesus you who once were far away have been brought near through the blood of Christ.“

 

Philippians 1:6 “being confident of this, that he who began a good work in you will carry it on to completion until the day of Christ Jesus.”

 

**Transcription**

[00:00:00] <music>

Laura Dugger: Welcome to The Savvy Sauce, where we have practical chats for intentional living. I'm your host Laura Dugger, and I'm so glad you're here. 

[00:00:17] <music>

Laura Dugger: Today's message is not intended for little ears. We'll be discussing some adult themes, and I want you to be aware before you listen to this message. 

Thank you to an anonymous donor to Midwest Food Bank who paid the sponsorship fee in hopes of spreading awareness. Learn more about this amazing nonprofit organization at MidwestFoodBank.org. 

This week we are continuing part two of an interview with a sexual medicine expert, Dr. Kris Christiansen. Don't miss last week's conversation about hormones and the real story behind hormone therapy. And now today, we're going to discuss common dysfunctions that motivate people to seek treatment. She's going to teach us what to expect and how to work with our bodies to make the most of perimenopause and menopause. [00:01:20] 

Here's our chat. 

Welcome back to The Savvy Sauce, Dr. Christiansen. 

Dr. Kris Christiansen: Well, thank you, Laura. It's great to be back. We had so much fun last week and looking forward to our conversation this week. 

Laura Dugger: We really did have a great time. I hope anyone listening today makes sure that they go back and listen to last week's episode first because you laid so much groundwork and we covered a lot of topics. 

But let's just continue the conversation today. You've worked with men who have low testosterone and women who have low sexual desire. So what have you learned about these specific topics over the years? 

Dr. Kris Christiansen: Well, as we mentioned last week, men with low testosterone often have several symptoms like fatigue, low sex drive, trouble with erections and orgasm, irritability, and depressed mood. [00:02:20] It can affect cognition, too. So sometimes they're just not thinking quite as clearly. 

They may even have hot flashes, night sweats, and sleep problems just like women in menopause. You may have heard the term andropause, pausing with those androgens, and it's very similar to what women experience. 

Along with feeling crummy, many studies indicate that men with low testosterone have an increased risk of heart disease, strokes, diabetes, and osteoporosis. And treating men who have low testosterone often makes them feel better, but it doesn't work for everyone. So it's not the fountain of youth like people hope for, and it's definitely not without risks. 

There are side effects such as oily skin, acne, hair loss on the top of their head, which they don't like, and hair gain elsewhere. It can also cause increased breast size or man boobs because indirectly it increases their estrogen levels. [00:03:24] 

Testosterone treatment can decrease testicle size, decrease sperm count, and increases the risk of infertility. So young men who want to have children should not use testosterone. There are other treatments, just not testosterone itself because of the risk of infertility. There's also a risk of potentially blood clots and cardiovascular events in older men. 

Testosterone doesn't cause prostate cancer, just like estrogen doesn't cause breast cancer. But it often increases the PSA, that's the prostate cancer blood screening test. Unfortunately, prostate cancer is relatively common, like 1 in 8 men. So we have to monitor men more closely for prostate cancer when they take it. Not because the testosterone causes it, but we just need to watch it because potentially the cancer could grow faster if it's there and if they're using testosterone. [00:04:25] 

Besides, feeling crabby and fatigued and having sexual problems may not be due to low testosterone. These are fairly common issues and they can certainly be attributed to other problems, like pressures of work, work stress, pressures of life, and relationship issues. So just because they may be having some of these general symptoms doesn't automatically mean that they're a candidate for testosterone treatment. 

As for women, I see women all the time in my clinic who come in with low desire. I kind of have to play detective to see what could be the underlying problem to their low libido. We talk about a biopsychosocial model when it comes to sexual function and dysfunction. So we have to ask about all these different aspects of the biopsychosocial model. 

For example, the bio aspect refers to the biological and physical components, like hormones, pain, medications, side effects, and chronic medical problems. [00:05:28] Pain is often a common factor in low desire. And it's not uncommon for my patients to have always had pain with sexual activity, intercourse, or penetration, so she thinks this is normal for her. But pain is not normal. It's never normal. And who would want to have sex if it hurts? 

So we have to figure out what's causing the pain and fix that before we can help the libido. And sometimes that's all we have to do. 

Fatigue is also a very common factor. So if you're working and you're working 40 hours a week, you come home, you have to make dinner, you clean up and put the kids to bed, then you just don't have any energy left over for sex. 

And for stay-at-home moms who have the most important job in the world, they don't get lunch breaks, days off, or break from the daily routine, so it's ongoing. Sometimes they just need a little help or a little break and reserve a little time and energy for sex because it's often not there. [00:06:32] 

Women usually don't have sex at the forefront of their brains, our brains. Our brains are not bathed in testosterone like men's are. So we're not thinking about sex all the time like guys often are. Not always because sometimes women have higher libido than their husbands. 

But we divide desire into two different kinds. There's spontaneous desire and responsive desire. Spontaneous desire is when we're thinking about sex, want to engage in intimate time with our partner and initiate the encounter. 

However, more often, women are not the initiators. A common scenario is for desire to happen after sexual intimacy has begun. And we refer to this as responsive desire. So once you're engaged in that intimate time and you can relax and it feels good and say, "Oh, I wish we would do this more often." But then that more often doesn't happen. [00:07:34] 

So when we're young and the relationship is new and exciting and sex is exciting, we look forward to it and we initiate it. As the relationship matures, sex is still a wonderful way to connect with our spouse. But we're not thinking about it all the time like we did when things were new and fresh. So as that relationship matures and as we mature, that's when responsive desire comes into play. And it is a completely normal response. 

For example, when dinner's done, dishes are put away, kids are in bed, and your husband starts to rub your back, and then you think, "Okay, this is nice." And the back rub turns to more intimate activity. And that's when your desire kicks in. And that is a totally normal response. 

So even if you don't have desire at the get-go, if it comes along, then it's okay. So it's also important to know that all back rubs don't have to lead to sex. Some women, they're afraid to hug or they're afraid to be touched because they think that touch is going to lead to sex. So we need to know that non-sexual touch is very nice. And it's okay to stop there. Just because you get a back rub doesn't mean that it has to proceed to that next step. [00:08:52] You can just enjoy that touch for what it is. 

Laura Dugger: That's really helpful because if you say that many women do experience low sexual desire, you're not saying that if you don't have spontaneous desire that would be low sexual desire. That would more so be diagnosed if you are even into the act of sexual intimacy and into those arousing touches, but you're still not experiencing desire. Is that right? 

Dr. Kris Christiansen: That's right. There's a diagnosis called hypoactive sexual desire disorder. It's common in women for sure, and it also happens in men too. But hypoactive sexual desire is low desire that causes personal distress, and that distress can be exhibited as frustration, grief, loss, sadness, sorrow, and has a negative impact on the relationship. [00:09:56] 

So if we have low desire but it's not causing any problems, it's not an issue. Not everything has to be treated. It's when the low desire is actually causing problems within that person, the personal distress or within the relationship, that's something that we need to address. 

So if we don't have the spontaneous desire where it's at the forefront of our brain, yet the responsive desire is happening and both parties know that and it's okay, it's not an issue. But if it's causing an issue, then we can look into it, see what's contributing to it, and try to help. 

Laura Dugger: And if this is the most common sexual dysfunction in women, then how can women identify if they are experiencing this? 

Dr. Kris Christiansen: Well, you may have hypoactive sexual desire disorder if you just don't think about sex, don't desire it, and don't enjoy it once engaged in sexual activity. [00:11:02] There was a big study published years ago, 2009. They looked at 31,000 women. So big study. They found that 44% of women have some sort of sexual problem in their lives. 44%, it's almost half of us. But we only call it a disorder or a problem if it causes distress. So if we take distress into account, then the prevalence is more like 12%. 

When it comes to low desire, depending on the study that you read, anywhere from 30% to 50% of women will experience low desire at some point in their life. But it's only an issue if it's causing distress, and that happens in about 10%. 

Sexual desire decreases as we get older. Not for everybody. Like I said, I got women in their 80s coming in. And we know that sexual problems are most common in the middle years, like 45 to 64. So if you have low desire, it's causing problems, and you want help, know that there is help out there for you. [00:12:12] 

There are subtypes of HSDD. We talk about situational versus generalized. With situational HSDD, this implies that certain factors are affecting the low libido, such as relationship issues, stress or fatigue, medications, pregnancy, recent childbirth, menopausal symptoms, or other sexual issues like pain, decreased arousal or orgasm problems. 

Sometimes it's a matter of our partner's sexual problems, which then spill over and affect us. So if we can improve these contributing factors, then libido often improves. Sexual pain, decreased lubrication, and arousal problems often go along with the low libido. So if a woman simply just does not experience pleasure with sexual intimacy, meaning she's not experiencing arousal or those pleasurable feelings, she's probably not going to participate in sexual intimacy in the future. [00:13:22] 

We know that many women engage in sexual activity just to feel close to their husband. But if she's not getting any pleasure from it, why does she want to do it? We also know that foreplay is an absolute must. It takes time to warm up, time to get aroused, and it takes longer as we get older. 

I heard of one podcaster referred to sex without pleasure like mushy steamed broccoli. So if sex is like mushy steamed broccoli and you really don't like mushy steamed broccoli, then you're probably going to avoid it. So we've got to fix the mushy steamed broccoli. 

Other things that can affect libido, chronic medical conditions such as diabetes, metabolic syndrome, thyroid problems, urinary incontinence, MS, multiple sclerosis, Parkinson's, and cancer, especially breast cancer and other gynecologic cancers. [00:14:24] 

So treating those underlying medical conditions can be helpful, and the better that we can manage them, like with our blood pressure and cholesterol and diabetes, the better our bodies work, both men and women. 

Medications can affect sexual function like blood pressure meds. We talked about hormonal contraceptives last week. Spironolactone. Spironolactone is a water pill, but sometimes women take it to treat acne or to treat facial hair, especially in women who have PCOS, polycystic ovarian syndrome.

The reason spironolactone works for those issues is because it's an antiandrogen. Androgens have to do with testosterone. So if this spironolactone is treating our acne and treating the facial hair, which is great, but it's antiandrogenic, meaning decreasing our testosterone levels, it's going to affect sexual function. [00:15:25] 

Other medications, antidepressants, other mental health medications, and most definitely breast cancer treatments. 

Other factors. Depression and anxiety have a huge impact on sexual function and libido. And we know that the medications that we take to treat the depression and anxiety, they cause sexual side effects.

However, the anxiety and depression often have bigger effects than the medications themselves. We also know that having depression increases the risk of sexual dysfunction by 50% to 70%. So if you have depression, you have a 50% to 70% increased risk of sexual problems.

The reverse is true. Having sexual dysfunction, whether that be low libido, orgasm issues, or guys with erectile problems, having sexual dysfunction increases the risk of depression by 130% to 210%. [00:16:26] And stress and fatigue are really common problems.

So, if you go on vacation, you get adequate rest, and you escape the stressors of life, and you find that your libido is much improved, well, then I guess you need a permanent vacation. So send me an email, I'll give you a doctor's note, and let's make sex better. 

That's situational HSDD, low libido that's due to specific situations. 

There's also generalized HSDD. This is where there are no other contributing factors like pain or medications or whatever, but libido is still low. This means it also occurs in all settings, so whether you're home or whether you're on vacation, and with all partners, but hopefully you just have the one lifetime partner.

HSDD that is not caused by contributing factors is thought to be attributed to an imbalance of brain chemicals, like depression. [00:17:26] Sexual desire is regulated by key regions in the brain through the action of various neurotransmitters. So there's a balance of excitation and inhibition, and the balance of the excitatory and inhibitory neurotransmitters impacts sexual function.

Sexual excitation is mediated by the chemicals dopamine, melanocortin, oxytocin, vasopressin, norepinephrine. So these are all good positive sex steroids or sex hormones that help with sexual function. The inhibitory ones are opioids, so pain meds, so people who are on chronic pain meds has a negative impact.

Serotonin, which comes in many antidepressants. Serotonin can have a negative impact. Endocannabinoids, so cannabinoids, meaning THC, negative impact. And prolactin, these are all associated with sexual inhibition. [00:18:27] 

So prolactin is a big factor in breastfeeding women, because when you're breastfeeding, that prolactin level increases because it causes milk letdown. But prolactin decreases dopamine and libido. So, again, it's a natural function, and I think it's God's way of making sure that women don't get pregnant right away. 

You know, we don't understand all the biological causes of HSDD, but we think that the generalized acquired HSDD involves either this predisposition towards inhibitory processes, which shuts everything down and results in decreased excitation, or there are some women with increased inhibition where those other neurochemicals have too much of an inhibitory effect, or it could be a mixture of both. 

The other breakdown of the HSDD is acquired versus lifelong. So acquired means previously libido was normal, it was good, it was not a problem, and then something changed. [00:19:30] Lifelong HSDD is when libido has always been low, it's never been high, and there can be many different factors contributing to this. 

We do have several treatments available. And the treatment really depends on what type of HSDD the patient has. So if it's situational HSDD, meaning attributed to a specific underlying factor or factors, then we've got to try to fix those, whether it's addressing relationship issues, trust, pain, medications, or other sexual problems. 

Sex therapy is very helpful, regardless of the type of HSDD. Sex therapy is talk therapy, trying to peel back the layers of the onion and figuring out what's contributing to it and dealing with some of these problems. 

When it comes to generalized acquired HSDD, we have a number of ways that we can treat it. [00:20:33] That's really good news. Part of it is just education, talking about normal sexual functioning and understanding the difference between spontaneous and responsive desire. So if you don't have spontaneous, it doesn't mean that you're broken or something's not working. As long as that responsive desire happens, that's totally normal. 

The role of motivation in sexual desire, making sure that he or she is well-rested and the experience is good and pleasurable and other things that contribute to the positive aspect. 

We have to talk about the importance of adequate stimulation. This is where foreplay is really important. Stimulating the clitoris, starting with non-sexual touch or whatever is important and arousing for the person, and it's different for everybody. And what's arousing one day may not be arousing the next, so it's really important to keep those lines of communication open. [00:21:34] 

We also need to address any modifiable factors, such as depression or anxiety or self-esteem or body image problems. So if a woman feels really self-conscious and just can't be comfortable, is uncomfortable being without clothes in front of her partner, that can be a big impact. Addressing stress or distractions.

You want to make sure that you have that privacy and can be comfortable in this situation. A history of abuse can have a lifelong impact. Substance abuse, self-imposed pressure for sex. So if we're imposing this pressure that we have to have sex or if our partner is imposing that pressure on us, that's not going to lead to a very positive experience.

Lifestyle factors, relationship factors, and even beliefs about sexuality. God talks about sex and intimacy throughout the Bible. It's a gift that He created for us, and He wants us to be able to enjoy that with our spouse. And that's the way it's meant to be. [00:22:43] 

But if we kind of forget that factor and still think of it as being dirty or off-limits and, you know, you shouldn't engage in that and you shouldn't enjoy it, that's going to have a definite impact on sexual function. Other factors, making sure we've got adequate lubrication and addressing arousal problems if they happen. 

Sex therapy, like I mentioned above, is really effective. Sounds weird, people are reluctant, but talking through these issues with a trained therapist is really helpful. 

The other good news is that we have two medications approved by the FDA for the treatment of HSDD in premenopausal women. These have been approved just in the last few years, and they work on the brain chemistry.

We talked about the excitatory versus the inhibitory aspects of these neurotransmitters, and that's exactly what these medications are addressing. [00:23:43] They're approved for use in premenopausal women, but they've also been studied in postmenopausal women, and they are safe and effective. It's just that they don't carry the indication because it would take another billion dollars for all the studies to get them approved by the FDA for postmenopausal women.

I still use them off-label in my postmenopausal women. I probably use them more often in my older patients than my younger ones because they work. They work by either activating those stimulatory pathways or reducing the inhibitory pathways that regulate desire.

And when they're effective, which honestly they work in about 45% of women, not 100%, women say that the medication gives them that want-to-want back. And that's what so many of them are missing. It's like somebody turned off a switch in their brain, and as much as they want to, and they really want to be close to their husband, they just can't bring themselves to do it. [00:24:44] This is when the medication can be helpful.

Medication doesn't help relationship problems. It doesn't help other medication side effects and such, but it just restores the brain chemistry. 

One of the medications, the first one approved, is a pill. It's called Addyi, A-D-D-Y-I. Flibanserin is the generic name. It's a pill that has to be taken every day, taken at night, and it takes about six to eight weeks before we see the full effect. Kind of like an antidepressant. It takes time to restore the brain chemistry. 

The other medication is called Vyleesi, with a V as in victory. The generic name is bremelanotide. This is an injection. It comes in a pen, a single-use pen, much like an insulin pen, so you never see the needle, and the needle's teeny tiny, and it really doesn't hurt. So you give yourself this injection in your abdomen about 45 minutes prior to sexual activity, and it's going to be effective for 10 to 12 hours, so it's not like you have 45 minutes. Clock is ticking. It does give you some time. [00:25:49] 

For our late perimenopausal, postmenopausal patients, testosterone can be helpful. So actually giving women testosterone. It is off-label. Unfortunately, we don't have an FDA-approved treatment for testosterone in women, but again, we use it quite often, and it can be an effective treatment.

There's no approved product, testosterone product, for women, so we have to use male products in female doses. Again, we have about 10% of the amount of testosterone that men do, so we use 10% of the amount of the testosterone gel or whatever. These improvements are gradual, and sometimes it takes a few months before they take full effect. 

So please know that HSDD is treatable. There are treatments, there are options, and bottom line, there is hope.

Laura Dugger: And now a brief message from our sponsor. [00:26:49] 

Sponsor: Midwest Food Bank exists to provide industry-leading food relief to those in need while feeding them spiritually. They are a food charity with a desire to demonstrate God's love by providing help to those in need.

Unlike other parts of the world where there's not enough food, in America, the resources actually do exist. That's why food pantries and food banks like Midwest Food Bank are so important. The goods that they deliver to their agency partners help to supplement the food supply for families and individuals across our country, aiding those whose resources are beyond stretched.

Midwest Food Bank also supports people globally through their locations in Haiti and East Africa, which are some of the areas hardest hit by hunger arising from poverty. This ministry reaches millions of people every year, and thanks to the Lord's provision, 99% of every donation goes directly toward providing food to people in need. The remaining 1% of income is used for fundraising, cost of leadership, oversight, and other administrative expenses. [00:27:56] 

Donations, volunteers, and prayers are always appreciated from Midwest Food Bank. To learn more, visit MidwestFoodBank.org or listen to Episode 83 of The Savvy Sauce, where the founder, David Kieser, shares miracles of God that he's witnessed through this nonprofit organization. I hope you check them out today.

Laura Dugger: Well, I love learning more about the intricate and brilliant way God designed our physical bodies. So with that in mind, what are a few benefits of orgasm?

Dr. Kris Christiansen: There actually are several benefits to orgasm. One of them is that it can boost mood. So with orgasms, we get the release of neurochemicals or hormones that make us feel better.

Those hormones can be oxytocin, dopamine, and endorphins. [00:28:56] So oxytocin is also known as the love hormone and the bonding hormone. It's released 500 times the normal amount with orgasm and plays a role in sexual arousal and ejaculation for men. It also increases when you're hugging someone or breastfeeding your baby. 

It has other non-sexual roles. It causes uterine contractions in labor and childbirth. And like I said, it's involved with breastfeeding and allows the milk to be released. 

It also impacts human behaviors and social interactions like recognition and trust and that romantic attachment. So that's why that snuggle time as part of sexual intimacy is just so valuable. It connects us. 

Dopamine is our feel-good hormone. It allows you to feel pleasure and satisfaction and motivation. [00:29:58] And it plays a role as the reward center. So when you do something pleasurable, your brain releases a large amount of dopamine. So you feel good and seek more of that feeling, whether it's sex or junk food. Dopamine is also that hormone that gets released as part of that runner's high that just makes you feel good and makes the pain go away. 

Other benefits. Orgasm can strengthen relationships, improve sleep, increase body confidence. And it helps to reduce stress by releasing that dopamine and strengthening our pelvic muscles. It helps relieve pain with those endorphins.

Laura Dugger: Wow, that is incredible to kind of hear it summarized in all of the science behind it. But then it also makes me consider people who have never experienced this. So what is the treatment plan for your clients who have never experienced an orgasm? [00:31:00] 

Dr. Kris Christiansen: The first intervention is usually education because orgasm often comes from the clitoris. There are a lot of women who just really don't know what it is and where it is. But God gave us a clitoris, and it only has one function, which is sexual pleasure.

So we think of it as being just that little pea-shaped structure that you can see and touch. But it's actually much larger and much more involved than just the little pea-sized glands clitoris that we think of. 

It's a deep structure. It's made up of mostly erectile tissues and nerves, just like the penis. And it reaches deeper into the pelvis. It encircles the vagina, and it goes all the way around. It has kind of like legs that extend on either side. 

Boys and girls start with the same genital structure as the developing embryo, and then we differentiate into the different male and female genitalia. [00:32:07] So our clitoris really started looking like a penis, or vice versa. And it's a glans clitoris, or what we think of as the whole clitoris, but it's just that small glans, which is the same structure as the glans penis, the head of the penis. So our clitoris is really like the head of a penis. 

The female equivalent of the penile shaft is the cruse, or the legs, and the vestibular glands that extend down and around the vagina, just inside the labia majora. So it's much larger than what we anticipate. And stimulating just the labia majora can be quite pleasurable, because it's part of the clitoris. 

There was an article published in the New York Times just last October, and it was entitled, Half the World Has a Clitoris. Why Don't Doctors Study It? We really don't know that much about the clitoris, because nobody's really looked into it. [00:33:07] So this article talks about how little we know about it. 

Shortly after that article came out, there was a study published in one of the medical journals that noted that the clitoris actually has more than 10,000 nerve fibers. Actually, 10,281 to be exact. 

Previously, they were basing the knowledge, we thought it was only 8,000, based on a study that looked at bovine or cow clitorises. Anyway, most women, up to 70% or 75%, are not able to reach orgasm with just vaginal penetration. 

Most women need direct stimulation to the clitoris in order to be able to experience orgasm. And a lot of women don't know that. A lot of men don't know that. So we think that just penile-vaginal intercourse should lead to orgasm, and it doesn't. [00:34:07] 

It also doesn't happen spontaneously. That only happens in the movies. Unfortunately, movies and media just do us all a big disservice. So there's a reason that God tells us to guard our hearts and our eyes. But intimacy is all about intimate connection with giving and receiving pleasure.

So if we keep that in mind, that it's giving and receiving pleasure and connection, and not about the goal of reaching orgasm. Because if that's the reason you engage in sexual intimacy is just to reach orgasm, it's not going to happen. Your brain's not going to let you go there. You have to be able to relax and let go, feel vulnerable, and be in the moment.

There are a lot of issues that can contribute to difficulty with orgasm. One of the biggest ones is anxiety. So if we're anxious about not being able to reach orgasm or if we're placing pressure on ourselves, that's one of the biggest deterrents. [00:35:11]

Other factors are medications. Antidepressants, especially those SSRIs, like Prozac and Zoloft, and Paxil, can cause sexual problems, especially orgasm issues. In men, if they have premature ejaculation, we often prescribe those medications for that reason because that helps delay ejaculation at least a few minutes.

Other meds which we may not know about is the birth control pills. I think we talked about that previously and the negative impact that birth control pills can have in some women.

Other issues: hormonal issues, especially when our testosterone levels decrease, that can be an issue. 

Medical problems and physical trauma like injury or surgery or radiation to the pelvic area. Emotional trauma and relationship issues. [00:36:10] So, again, if we don't feel safe and can make ourselves feel vulnerable, orgasm probably is not going to happen. 

Hypertonic or really tight pelvic floor muscles also play a role. 

Age is a factor. So there are normal age-related changes, and women often have decreased lubrication and need increased time for stimulation and lots and lots of foreplay.

Nerves just become less sensitive, and then when you also are dealing with medications and circulation issues and the decreasing hormone levels, unfortunately, that plays a role. However, it doesn't mean sex isn't pleasurable. 

In men with orgasm, they experience, you may have heard, andropause, because their testosterone levels decrease with age too. And so just like women, men often need more time and directed stimulation in order to maintain the erection and be able to reach orgasm as they get older. [00:37:15] So if things change, it doesn't mean that we have to give up on sex. It just may look a little differently as we age.

It's also important to use a really good lubricant. Using a good lubricant can actually increase your ability to reach orgasm by 70% or 80%. As far as treatment options, besides education and learning about our bodies, sex therapy is really helpful.

It combines a cognitive behavioral therapy and often sensitive focus exercises. And sometimes it's just plain communication between spouses and expectations. Experimenting with non-coital, non-vaginal intercourse type of activities, such as massage or oil or manual stimulation, and using a vibrator.

So a vibrator provides additional stimulation and helps overcome the problem of decreased sensation because those nerves aren't as sensitive as we get older, especially with medications and problems like diabetes, which affects the nerves. [00:38:24] So using a vibrator with partnered play can be really fun. 

Again, keeping in mind this is giving and receiving pleasure, and our spouse often gets a lot of pleasure about giving us pleasure. So changing things up, changing your routine, say the location or time of day, changing positions. 

So if we usually wait until bedtime to engage in sexual intimacy, we're tired and our bodies don't work as well when we're tired. So trying to carve out some time earlier in the day or reserving some energy for that fun time can make a big difference.

There are no FDA-approved medications for orgasmic disorder, but we often use off-label treatments, which is a lot of what I do in my specialty, to help different things like with arousal and orgasm. [00:39:26] One of the things we may try is Viagra or Cialis in women. So yes, this is off-label, and insurance usually doesn't cover it for men, and it most definitely does not cover it for women, but there are ways to get it really, really cheaply.

Anyway, so Viagra and Cialis, they don't help with desire. For men, it doesn't really help with desire either, except that it gives them the confidence that they may get a better erection. So the way these medications work, they increase blood flow to the erectile tissues, which is our clitoris.

So by increasing blood flow, it may work a little bit better and help with arousal and orgasm. There actually have been a few small studies that show that it is helpful, especially in women with diabetes or taking antidepressants. 

Other treatments may include an arousal cream, which is compounded. [00:40:25] It does require a prescription, and you have to get it from a special pharmacy. But this arousal cream often has something like Viagra and testosterone and a few other things in it to help increase blood flow. 

There are over-the-counter options. One of them is called Zestra, Z-E-S-T-R-A. It's a mixture of some botanical or herbal supplements that are meant to increase blood flow. Another one is Arouse Serum by Rosebud Woman, which can be helpful. 

Like I said, a vibrator or there's such a thing as a clitoral stimulator that acts directly on the clitoris that can be helpful. You know how men have a vacuum erection device to help with erections? Well, there's a similar device for women. It's called Eros, E-R-O-S. It acts like a little mini vacuum device that goes over the glans clitoris and it pulls blood into the clitoris to help with the arousal and orgasm. [00:41:30] It basically works like the erection device for a penis. 

Sometimes orgasm just comes down to learning your own body and discovering what feels good. So like we mentioned, you've got to be completely relaxed, uninhibited, and be able to let yourself go.

The more you try to reach orgasm just for the sake of reaching orgasm, the less likely it's going to happen and your brain really just won't let you go there. So I want to try to not engage in goal-oriented sex. The goal is to reach orgasm and once you reach orgasm, you're done. You don't want to do that because we have to be able to relax and enjoy the journey. So remember sexual intimacy is about intimate connection and giving and receiving pleasure.

Laura Dugger: Thank you. That was a very holistic response, which I appreciate looking at various angles to help with this. [00:42:32] Even I think I've shared on the podcast before, one woman shared with me that when she and her husband are engaging in sexual intimacy, if she is having difficulty, like you said, just getting there, relaxing enough, spiritually, she will just pray silently and ask God to help her. She said the results... I can't remember the exact quote, but are miraculous or supernatural. So I love the holistic approach. 

And then also it just made me think when you were talking about different physicalities that I would recommend if anyone's listening and they are struggling with this right now, there are so many reasons to seek out a professional like Dr. Christiansen, who we're talking to today. Because even things that we wouldn't think of like back injuries, where something has happened and... I don't know all the science behind it. You wouldn't know this better than me, but where the brain can't interpret what is going on in the genitals. And I'm not sure if it's spinal cord severing, but sometimes people with back injuries have said they have more difficulty experiencing orgasm. [00:43:43] So there's just so many things to unpack. And that's why you're such a brilliant resource.

Dr. Kris Christiansen: Well, and that's so true. And it really is the spinal cord because those same nerves that come from your clitoris track all the way up your spinal cord to your brain. Even just, you know, say a herniated disc or a small tear in the disc or some injuries can impact sexual function. And if you tell that to a neurosurgeon or an orthopedist, they're going to say, No, that doesn't impact it. But it really does.

Laura Dugger: How did you find out about The Savvy Sauce? Did someone share this podcast with you? Hopefully you've been blessed through the content. And now we would love to invite each of you to share these episodes with friends and help us spread the word about the Savvy Sauce. You can share today's episode or go back and choose any one of your other previous favorites to share. Thanks for helping us out. [00:44:42] 

Well, kind of on a different topic, we have over 50 Savvy Sauce episodes that are related to sex, but we have not yet covered perimenopause and menopause in depth. So let's just begin with a definition. First, what is perimenopause?

Dr. Kris Christiansen: Perimenopause is the transition phase from our reproductive life where we're experiencing regular periods to the point where those periods stop. And it may begin 8 to 10 years prior to menopause. In some women, it can last up to 14 years.

So it often starts in the early to mid-40s. Menstrual cycles become irregular and unpredictable. The only predictable part is to expect it to be unpredictable. [00:45:43] 

Our periods can become heavier, lighter, closer together, or farther apart. You know, so we just really don't know what to expect. They can be heavy and frequent and lead to excessive blood loss, and sometimes women become anemic. So if that's the case, if, you know, heavy frequent periods, please see your provider because there are lots of things we can do for this. 

Other symptoms can also include the psychological and other physical symptoms. Psychological symptoms may include anger, irritability, mood swings, depression, anxiety, difficulty concentrating, brain fog, mild memory problems, and some trouble with word finding.

So, you know, we may think we're going crazy or whatever, but it's just really... It's perimenopause and our fluctuating estrogen levels that just don't let our brain work as well as it used to. [00:46:44] 

Other physical symptoms may include hot flashes, night sweats, decreased libido, weight gain, urinary problems such as urgency, frequency, and incontinence, and vaginal dryness and painful intercourse can often happen. We often think of this as menopause, but these symptoms may start happening as early as our early to mid-40s.

The reason behind all of this, it's due to fluctuating and decreasing levels of estrogen. So some days our ovaries may be working great, giving us plenty of estrogen, we feel pretty good. The next day they're taking a break and we're not feeling like ourselves. 

So even in perimenopause, estrogen, systemic estrogen can be helpful. So as long as we don't have any contraindications like breast cancer or history of blood clots, a little bit of estrogen can make us feel normal again. [00:47:43] 

Laura Dugger: Wow. Is that something you would recommend? Do you begin going to your OBGYN if you're experiencing difficulty sleeping and brain fog and these different things that you've talked about to check if you are anemic or if you're in perimenopause or need some estrogen? What would be the next step?

Dr. Kris Christiansen: Yes, absolutely. Starting either with your primary doctor or your OBGYN, if you're still seeing one, that would be your next step. But I would recommend going on the menopause.org website. That's a national organization for menopause. 

There's a list of providers on there who have a special interest or even certified in menopause treatments. So menopause.org, click on Find a Provider, and you put in your location to find someone in your area who would be a little probably more well-versed in menopause and perimenopause treatments. [00:48:45] 

Laura Dugger: Wonderful. Now, what all can you teach us about menopause?

Dr. Kris Christiansen: Menopause is defined as 12 months after the last period. So it's just like 12 months one day... it's a mark in time. It's a normal, natural event in a woman's life, and it can occur naturally or due to surgery, like removal of the ovaries.

Sometimes we just don't know when menopause occurs because a woman may not be getting her period in her 40s because of birth control pills and IUD or a gynecologic procedure such as an endometrial ablation or hysterectomy. So if she's not getting her period in her 40s and 50s, we don't know exactly when it happens. We do know the average age is 51, and it usually occurs somewhere between the ages of 45 and 55. [00:49:45] And it's all due to the reduced functioning of ovaries and decreased levels of estrogen and progesterone. So it marks the permanent end of fertility. 

Like with perimenopause, a lot of women experience symptoms and physical changes, and they may include hot flashes, night sweats, sleep problems, mood changes, weight gain, slowed metabolism, hair becomes thinner, skin may become a little drier, and loss of skin elasticity where wrinkles are a little more prevalent, loss of breastfulness, and even some mild memory problems.

Not to mention, though, hot flashes and night sweats can be really disruptive, especially if the night sweats don't allow us to get a good night's sleep. They tend to be worse in perimenopause and early menopause. They affect like 50 to 80 percent of women and more common in Black and Latino women. [00:50:46] 

Cigarette smoking increases frequency and severity. So one more reason to stop smoking. Hot flashes resolve in 85% of women within about five years. But 10% to 15% of women may have persistent flashes throughout their lifetime. They usually last about seven years, and up to 30% of women can have them for 10 or more years. So they can last a while, but in most people, they do get better and go away.

A very common problem is also what we call the genitourinary syndrome of menopause. We call it GSM. It's very common. It affects up to 85% of women in menopause. And unfortunately, that issue gets worse with time. 

So GSM is a collection of symptoms caused by the lack of estrogen and affects the vulva, the vagina, and the urinary system. [00:51:46] We used to call it vaginal atrophy, but because we know it also affects the urinary system, they broadened the term. 

So the vulvovaginal symptoms may include vaginal dryness, loss of elasticity, painful intercourse, vaginal atrophy, tight nips, shortening of the vagina, vaginal itching, and thinning of the vaginal tissues, which can make it prone to tearing.

It affects sexual function with decreased arousal, decreased sensation, trouble with orgasms, and tearing of the tissues, which causes pain and bleeding. So those urinary symptoms may be urinary urgency, frequency, painful urination, urinary incontinence or leaking, and even UTIs.

Laura, I can't tell you the number of women I see with these problems. And most of them say, no one ever told me this was going to happen to me. [00:52:44] And these problems get worse with time, unfortunately. Like those hot flashes, they get better and go away. But our GSM symptoms, they don't get better, they get worse. The good news, though, is that we have great treatment options for GSM, so it doesn't have to happen.

Vaginal estrogen is highly effective and it's extremely safe. The vaginal estrogen acts locally just on the vulva and the vagina and the bladder, so it doesn't get absorbed and affect the whole body. More importantly, we have studies to show that it does not cause breast cancer, heart attacks, strokes, or blood clots.

If you get a prescription and you read the package insert, unfortunately it does say it has these risks, but the drug companies have taken these risks associated with systemic estrogen, like pills and patches that increase our blood levels, and they apply that same risk to the vaginal treatments as a class effect, but this is totally not the case. [00:53:53] Unfortunately, it scares women away from a very safe, very effective treatment. And you can use it until you die. There's no reason that you have to stop it at any point. 

And it's not necessarily just about sex. It's about vaginal health because urinary urgency and frequency incontinence is really bothersome. There are several over-the-counter vaginal moisturizers that can be effective, especially if you start using it when your symptoms are mild. 

You've got to use these vaginal moisturizers regularly and consistently, like every few days in order for them to work, and it may take a month or two before you see the full effect. So they don't work if you're just using them right before intercourse. Vaginal estrogen doesn't work that way either. Both of these, they have to be used regularly and consistently if you want to see the benefits. 

With the over-the-counter moisturizers, though, you have to be careful. There's a common one called Replens that you can buy in just about any grocery store or drugstore. [00:54:55] But that Replens has propylene glycol in it, which can actually be irritating. So you don't want to use anything that's going to make the problem worse.

Three ingredients that I recommend avoiding in lubricants and moisturizers are glycerin, parabens, and propylene glycol because they can cause irritation.

Back to menopause, I think it's important that we look at this time and embrace it and enjoy it because it's a change in life. It's a new chapter. Some women may feel a sense of loss or grief as we no longer have our menstrual cycle or reproductive ability, and our experience changes with aging, of course. 

Society, as we know, places a lot of pressure on women to stay youthful and vivacious, and using our youth makes us feel less desirable or less valuable. [00:55:55] Obviously, this is a harmful and false narrative, so we must look at aging as a gift and embrace it as a gift from God.

A lot of women feel a renewed zest and look at this season as an opportunity to try something new, new hobbies, interests, ministries, or goals that had previously been elusive because we were too busy. It's a great time to seek the Lord and learn what He has in store for us.

Laura Dugger: I love that positive perspective. It's always helpful to hear the good news. One of the most common questions that couples ask related to their sex lives, and I would say especially Christian couples, will ask, is this okay? I realize this is a sensitive and controversial topic, but from your vantage point, Dr. Kris, as a Christian and as a clinician, what is your opinion on sex toys? [00:56:58] 

Dr. Kris Christiansen: That's a great question. I get that also: Is it okay? You know, it really is, I think, a condition of the heart. If we're looking at sex toys as a way to just experience great orgasms or to pleasure ourselves and not using them in the context of the sexual intimacy that God has intended for us, that's probably not the most ideal setting.

But if we look at sex toys as a tool to help us enjoy our sexual intimacy with our spouse, I look at it as a tool and as an aid, because as we get older, our sexual function changes, our bodies change, and using, especially like a vibrator, increases that sensation, it increases the arousal, and it allows us to be able to continue to connect in various ways. [00:58:08] So as long as we're not looking at it as a way to replace our partner and it's a way to enhance our intimate time together, I think it's okay. But again, it's a condition of the heart.

Like Paul says in 1 Corinthians, I have the right to do anything you say, but not everything is beneficial. I have the right to do anything, but I will not be mastered by anything. You say, food for the stomach and the stomach for food, and God will destroy them both. The body, however, is not meant for sexual immorality, but for the Lord and the Lord for the body. 

I think as long as we're using them in the context of our loving, intimate relationship with our spouse and they're there to help enrich the experience, I think it's okay. But again, it comes down to the condition of the heart. [00:59:08]

Laura Dugger: Thank you for sharing your perspective on that. I know there have been previous episodes with authors who have even given questions as filters and kind of used this same scripture. Is this beneficial to your marriage? Is this something that in your heart you feel is God-honoring? So I love that recommendation that everybody takes it to the Lord themselves and see where He convicts them. If it is something He says, yes, enjoy freely, or provides a word of caution, and maybe it's different for different couples.

Well, Dr. Kris, where can we go after this chat to learn more from you?

Dr. Kris Christiansen: I have a business that I started. It's called Intimate Focus. The website is www.intimate-focus.com. I started this company because I wanted to provide a place where women and couples can learn more about sexual health, sexual wellness, and purchase quality products to enhance their sex lives. [01:00:19] 

In my medical practice, I often recommend getting a good lubricant or a vibrator which can help with stimulation, but obviously many women are reluctant to go to an adult store or order something like this from Amazon if other people are looking at their purchase history. Like with lubricants and moisturizers, you can buy them at Target or the grocery store, but they often contain ingredients that can be irritating and contribute to pain, so you have to be really careful.

So I wanted to provide a safe, comfortable space where people can get good information about sexual health and wellness and be able to purchase quality products. From that website, products will arrive in an unmarked box from IGH Focus, not even Intimate Focus, so nobody will suspect anything crazy. 

But God planted the idea of this business in my heart, and I consider my business and my medical specialty as my ministry, because God designed sexual intimacy, and we need to be able to provide a platform where it's safe, it's not shameful, and it's okay to talk about it. [01:01:34] 

So I want to help educate and empower women to take away the shame associated with sexual intimacy and pleasure. I believe that sexual health and function and pleasure are God-given gifts, and we should be able to enjoy sexual intimacy throughout our lives.

However, as we've discussed, there are a lot of factors that can negatively impact sexual function, and people need to know that there is help available. So if you go to the website, intimate-focus.com, and you click on Contact, right now it's just me, so that email would come directly to me, and that's a way to reach out. 

On sexual health concerns in general, especially if you need a sexual medicine provider, please go to the ISSWSH website, stands for the International Society for the Study of Women's Sexual Health, isswsh.org. [01:02:35] And on that website there is a "Find a provider", so you can type in your location and see if there is a provider near you.

Laura Dugger: Wonderful. We will provide all of these links in the show notes for today's episode. Dr. Christiansen, I have one final question for you. We are called The Savvy Sauce because savvy is synonymous with practical knowledge, and so as my final question for you today, what is your savvy sauce?

Dr. Kris Christiansen: One verse that comes to mind is James 1:19 and 20. "My dear brothers and sisters, take note of this. Everyone should be quick to listen, slow to speak, and slow to become angry, because human anger does not produce a righteousness that God desires." 

So, if we could all take James' advice, be quick to listen, slow to speak, and definitely slow to become angry, we would do a better job of understanding others, have empathy, love, and compassion. [01:03:49] I try to do that. Can't say I'm always really good at it. That's one of my savvy sauces.

Laura Dugger: Oh, I love that. Dr. Christiansen, I just want to again say thank you for educating us on these sensitive subjects and doing so with kindness and gentleness. I am so grateful for you and I just want to, again, say thank you for being my returning guest.

Dr. Kris Christiansen: Well, thank you, Laura. I have enjoyed this and I really, really appreciate the opportunity because God created sexual intimacy, He wants us to enjoy it. Sometimes it doesn't always work as planned, so we have to provide a place where people can go for help.

Laura Dugger: Well said. 

One more thing before you go. Have you heard the term "gospel" before? It simply means good news. And I want to share the best news with you. But it starts with the bad news. Every single one of us were born sinners and God is perfect and holy, so He cannot be in the presence of sin. [01:04:52] Therefore, we're separated from Him.

This means there's absolutely no chance we can make it to heaven on our own. So for you and for me, it means we deserve death and we can never pay back the sacrifice we owe to be saved. We need a savior. But God loved us so much, He made a way for His only Son to willingly die in our place as the perfect substitute.

This gives us hope of life forever in right relationship with Him. That is good news. Jesus lived the perfect life we could never live and died in our place for our sin. This was God's plan to make a way to reconcile with us so that God can look at us and see Jesus. 

We can be covered and justified through the work Jesus finished if we choose to receive what He has done for us. Romans 10:9 says that if you confess with your mouth Jesus is Lord and believe in your heart that God raised Him from the dead, you will be saved. [01:05:57] 

So would you pray with me now? Heavenly, Father, thank You for sending Jesus to take our place. I pray someone today right now is touched and chooses to turn their life over to You. Will You clearly guide them and help them take their next step in faith to declare You as Lord of their life? We trust You to work and change their lives now for eternity. In Jesus name, we pray, amen. 

If you prayed that prayer, you are declaring Him for me, so me for Him, you get the opportunity to live your life for Him. 

At this podcast, we are called Savvy for a reason. We want to give you practical tools to implement the knowledge you have learned. So you're ready to get started?

First, tell someone. Say it out loud. Get a Bible. The first day I made this decision my parents took me to Barnes and Noble to get the Quest NIV Bible and I love it. Start by reading the book of John. [01:06:56] 

Get connected locally, which basically means just tell someone who is part of the church in your community that you made a decision to follow Christ. I'm assuming they will be thrilled to talk with you about further steps such as going to church and getting connected to other believers to encourage you. 

We want to celebrate with you too. So feel free to leave a comment for us if you made a decision for Christ. We also have show notes included where you can read Scripture that describes this process.