The Sidelining of Women’s Pleasure, Especially Into Menopause—And How Viagra May Help

“Half the World Has a Clitoris. Why Don’t Doctors Study It?” That was the attention-grabbing headline of a story published by The New York Times last October that quickly made its way across many women’s group-chat threads. “This!” one friend texted me with a link. Indeed the story cracked open a topic that has been woefully overlooked, not just culturally but also medically. That the clitoris is connected to women’s pleasure is at the heart of the issue. “The full anatomy of the clitoris wasn’t published until 2005 by Dr. Helen O’Connell, if you can believe that,” says Amy Killen, MD, a regenerative- and sexual-medicine practitioner. “If we’ve only understood the shape of the clitoris for 18 years, it’s not a surprise that we’re behind in understanding female sexual pleasure compared to male pleasure.”

Look at a diagram comparing the anatomy of the clitoris to that of the penis (women’s health start-up Alloy Health handily offers one on their website) and you’ll be struck by the similarities. “When doctors showed us that chart, I was like, Oh, my God, I had no idea how large the clitoris was—it really shouldn’t be that hard to find,” quips Anne Fulenwider, cofounder, along with Monica Molenaar, of Alloy Health. Medical textbooks are often missing anatomical drawings of this clitoral anatomy and aroused vaginas, leading to a major knowledge gap, says Carolyn Wheeler, cofounder of sexual-wellness brand Vella. “The Western medical establishment—specifically how medicine is taught and practiced—is still broadly illiterate when it comes to female sexual anatomy and physiology, as conceptually distinct from our ability to reproduce,” says Wheeler.

That physiology can change dramatically with age and the menopause transition and have a ripple effect on sex drive, libido, and arousal. First there are diminishing hormones, particularly estrogen and testosterone. “Testosterone is the main hormone responsible for a healthy sex drive and libido,” says Monica Grover, MD, an ob-gyn and chief medical officer for sexual-health spa VSPOT, adding that a decrease means less signaling to the genital system to increase sensitivity and response. Estrogen also plays a role. “The decline in estrogen impacts sexual behavior in women due to its connection to genital arousal,” says Leah Millheiser, MD, an ob-gyn and chief medical officer for menopause telemedicine company Evernow. Less blood flow means less vaginal lubrication, difficulty with or an inability to achieve orgasm, and decreased sensation in the vulva during sexual activity. Grover points to vaginal atrophy, which can cause pain and dryness during intercourse, as another significant physical roadblock for libido. She says low libido can be a side effect of necessary medications like antidepressants, anxiolytics, antipsychotics, antacids, and even ones for blood pressure, not to mention a result of anxiety and stress, concerns about body image, and discord in your relationship. Statistics show that about 40% of women report some degree of sexual dysfunction, though it’s important to note the word report there, as it’s something that most women aren’t regularly doing with their doctors. “Most doctors don’t ask you about how pleasurable or good your sex life is because they don’t want to have the conversation, and also patients don’t want to bring it up,” says Molenaar. Killen points to a 2012 study of ob-gyns that found that while 65% of doctors ask patients if they’re having sex, only around 14% follow up with whether it’s pleasurable.

And for those women with a healthy libido, while they have desire, they may still struggle with actual arousal or an arousal strong enough to reach orgasm. “The female sexual-response cycle generally starts at desire, which is psychological. Desire leads to arousal, which is physiological, and arousal leads to orgasm,” says Wheeler. Just as arousal presents itself as an erection for men, the same is true for women; it’s just more difficult to see and feel an erection in the clitoris. Oral Viagra (known generically as sildenafil), which has been approved for use in men since 1998, is a vasodilator that increases blood flow to the penis leading to an erection. “There is data showing that Viagra can increase blood flow to the genitalia in women, which can increase sensitivity and arousal,” says Millheiser, adding that it has been prescribed for years off-label, not for low libido but for the treatment of genital-arousal disorder or orgasmic disorder. It’s a solution for women that has been hiding in plain sight, says Molenaar. “The only reason it hasn’t been available for women is that nobody cared or prioritized our sexual pleasure,” she says.

What Alloy Health has started offering its customers is a topical version of sildenafil, which it has branded as Oh-mazing Cream. Containing a percentage that is a fraction of the dose men take, the topical sildenafil, says Molenaar, functions the same way but, unlike its oral predecessor, has no contraindications. Apply 15 to 30 minutes before a sexual experience solo or with a partner, and its effects will kick in. While sildenafil handles arousal, Alloy encourages customers to first use vaginal estrogen to address common issues like dryness and irritation that happen when the vaginal walls naturally weaken. “Once you have re-estrogenized the vagina, sildenafil is a great tool to improve sexual pleasure,” says Fulenwider. Vella’s signature Pleasure Serum works similarly but with cannabinoids and liposomes. “It facilitates increased blood flow and clitoral engorgement, which, even for women who do not have any problems with reaching climax, can mean a stronger and longer lasting orgasm and an easier and quicker time toward multiple orgasms,” says Wheeler. If your barrier to intercourse has to do with dryness, Millheiser recommends personal lubricants (silicone or oil-based versions as they last longer) to reduce friction or nonhormonal vaginal moisturizers (used consistently two to three times a week) to increase moisture content. When lower libido is related to menopausal hormone shifts, she sometimes turns to off-label testosterone therapy. Sexual mindfulness, or what Millheiser calls “beforeplay,” is something she discusses with all her patients. “Many women during and after the menopause transition experience a decline in spontaneous desire and tend to rely more on responsive desire, meaning they need something to get them in the mood,” she explains. Beforeplay is a way of building arousal (whether it be by masturbating or watching or reading something stimulating) before your partner is even in the room. There are still only a few medications approved by the FDA for female sexual dysfunction (Addyi, Vyleesi, vaginal estrogen therapy, Intrarosa), and, Millheiser adds, there are none approved for low libido, the most common sexual disorder in postmenopausal women.

While there have been advancements and there is more discussion about female sexual health, not to mention havens for treatment like New York’s Vspot, there is still a ways to go. Right now, we are witnessing, says Wheeler, a soft launch of women’s sexual pleasure. “There is still an enormous amount of work to be done, including medical research and public education, but it’s finally regarded as a true subset of women’s sexual health and, in turn, our overall health,” says Wheeler. As it should be because sexual health is, adds Fulenwider, about quality of life. Besides a wider cultural reckoning and reeducation about female sexual pleasure—“It’s still very challenging to say the word vagina on TV during daytime hours without getting censored,” says Millheiser—the medical establishment needs to be brought up to speed as well. “Education around female sexual disorders is not a requirement in medical school and residency curricula, and as a result clinicians are not being trained on these common conditions,” says Millheiser. “When a clinician does not know how to address or treat a medical disorder, they usually will not ask their patients about it.” Oftentimes, experts agree, when women find a solution for their issues of libido or arousal that works, it can be transformative. Says Fulenwider: “Once you have a nice experience, you’re going to want to do it again more.”