We recently held our fifth Instagram Live session of Bonafide Talks with special guest Lyndsey Harper – MD, FACOG, IF and founder/CEO of Rosy, an award-winning women’s health technology company that connects women who have sexual health concerns with hope, community, and research-backed solutions.
During the conversation, Bonafide Chief Medical Officer, Dr. Alyssa Dweck and Dr. Harper cover a variety of topics ranging from the sexual side effects that may accompany some antidepressants, to hypoactive sexual desire disorder (HSDD), and sexual satisfaction changes encountered during menopause and beyond. They also discuss solutions that may help to combat some of these sexual symptoms.
In case you missed it, we’ve included a recording of this fifth session here, along with a full transcript of the video.
Stay tuned for more Instagram Live sessions in the future!
The Connection Between Antidepressants and Sexual Side Effects
Dr. Lyndsey Harper: I'm so excited to be back with you all and to chat with Dr. Dweck here in a minute. We're going to talk all about sexual health, and we got asked a lot of questions beforehand. So, there's going to be a lot of great discussion here about desire, about antidepressant medicines, all kinds of good stuff.
So, we're going to get Dr. Dweck in here in a minute, and we're going to get started. I'll give a little intro about myself. I'm Dr. Lindsay Harper. I'm the founder and CEO of Rosy, and Rosy is a women's sexual health platform where this is all we do all day long – talk about sex! All right, I'm going to get Dr. Dweck in here with us.
Hello, hello. Hi there, how are you?
Dr. Alyssa Dweck: I'm doing great. How are you doing?
Dr. Lyndsey Harper: We haven't connected in a while and it's so good to see you.
Dr. Alyssa Dweck Great to see you as well. And I'm so happy to be doing this. I think this is such an amazingly complex, but well sought after conversation that we're going to have.
Dr. Lyndsey Harper: We were just talking about how everyone wants to talk about sex, and no one really talks about it. So, that's what we're here to do today! We’re so excited to have you, and this will be a great discussion. I was just giving a little bit of background on who I am. Do you want to introduce yourself and share with everybody what you do?
Dr. Alyssa Dweck: Of course. So, as you so kindly introduced me, my name is Dr. Alyssa Dweck. I am also an OBGYN here in the New York area. And recently, or not that recently, I have taken on a new role other than my clinical practice – as the Chief Medical Officer at Bonafide Health. We are a company that really strives to provide hormone-free and non-drug options for those in the menopause space and who are suffering with symptoms.
Dr. Lyndsey Harper: I love that. Well, I’m so glad you're here today. And I often talk about supplements in the sexual health space. And there are so few companies, in fact, I can only think of two, Bonafide being one, that have any data to support their interventions. And so, I'm always happy to do things with your company, because you know, that's so needed. And it's a drum, I will never stop beating, that these companies need to be doing research. And I'm so thankful that you all focus on that.
Dr. Alyssa Dweck: Me too. Yes.
Dr. Lyndsey Harper: We'll get the conversation kicked off by chatting, maybe a little bit about antidepressants and sexual health, because this is so common. I learned in my training that sexual health problems and depression are the number one comorbidities of one another, right? So, we often see patients who have sexual problems with depression and patients who have depression who then develop sexual health problems. So, this is a really, really common issue. I'd love to know how you think that medications for depression, which we call antidepressants, or SSRIs, impact sexual function. What does the data show, in terms of how patients respond?
Dr. Alyssa Dweck: Any medication is going to potentially come with side effects. But one of the well-known side effects of some of the SSRIs, like those you're speaking of – even some of the older antidepressants types, called tricyclic antidepressants; and some of the newer ones, called SNRIs, may have side effects, including a drop in libido or sexual drive or arousal, and they also may influence, in a negative way, the orgasmic experience and make it more difficult to achieve orgasm, make it weaker, or just make it different and not as satisfying.
These are well known side effects of many of these medications. But the thing that we always have to think about, which I know you're touching upon is – is it the medication? Or is it what we're treating with the medication; meaning worsening depression, which can contribute to changes to sexual function. So, it's always a really fine line to help to tease those things out.
Dr. Lyndsey Harper: And how do you help patients think about that, like if they if they have a sexual problem while on a depression medication, how do you decide what to do?
Dr. Alyssa Dweck: So, you know, first and foremost, I really rely so heavily on my mental health colleagues to help get my patients through these difficult times. Many, many times these are the providers who are actually giving the prescriptions for these medications, and I surely don't want to interfere with their treatment plan.
Certain things that we do consider and talk about? One would be altering the medication, altering the timing of taking the medication, or maybe altering the dosage. Sometimes we will lessen the dosage of one antidepressant and add another one in, so that the depression is being well managed, or maybe so the side effects are not as uncomfortable or notable. So that's one thing that we can do.
Surely we recommend other options to help enhance libido, whether it happens to be, you know, planning sex, and I know you are super familiar with all of these options! Whether it's getting involved with some sort of erotic reading or erotic videos, or romance, whatever might get some sexual thoughts on the brain. And, you know, we try to tease out other issues; I mean, are you having relationship issues? Because that's not really going to be part of altering medications, but might really fall on a counselor to help with an emotional [or relationship] issue that needs to be addressed.
One last thing I always like to bring up, because it's such an issue for people and they don't like to talk about it, is sexual self-esteem, usually in the form of not feeling comfortable because of maybe a couple of pounds of weight gain or not having the tone that you might prefer. And these are things that we work on with diet, exercise, and stress reduction.
Dr. Lyndsey Harper: Absolutely, yeah. And I think it's so important for physicians like you and I to talk about this, and also for patients to know that if you have a new onset of sexual side effects after you’ve started depression medicine, that's a reason to go back and talk to your doctor. And I think so many of us, whenever we're starting patients on medicine for depression, we don't adequately describe what the sexual side effects could be. And that if you experience side effects, you can go back and say, “Hey, I can't have an orgasm anymore. This isn't for me.”
We don't want you to stop your medicine without the guidance of your mental health provider or the prescriber that wrote that medicine, but it is important to know that there are other options that could potentially have less sexual side effects – or we can add another medicine to the prior medicine you're taking to decrease those negative effects. So, don't feel like it's hopeless. And it might be the medicine, and there are things we can do. Right, Dr. Dweck?
Dr. Alyssa Dweck: Absolutely. You know, one thing that always comes to mind, and I want to make sure I get this in because it really makes people feel better, is that a lot of sexual function is about blood flow to the genital area. And you know, with menopause, blood flow is diminished a little bit, and with certain medical issues, blood flow is diminished. So, sometimes, I do get people crawling under the table when I mentioned this, but you could explore using your vibrator or purchase one for the first time and really work to enhance blood flow to the genital area. And this works almost like a medical massage, if you will, to help with blood flow.
We also have done some studies on a supplement that we provide, called Ristela®, which I know you're familiar with. And Ristela is something that really helps to enhance blood flow through this pathway called nitric oxide. Nitric oxide, when it's produced, helps blood vessels to dilate and then become more engorged, so that there'll be more blood flow to the genitals. Almost similar to the way Viagra can work for men or some of the other medications in that field.
Understanding “Responsive Desire” and Hypoactive Sexual Desire Disorder
Dr. Lyndsey Harper: I love that. And I think it hits on something that I talk about all day, every day, which is something called responsive desire. So, many people I know come to both of us and they're like, “Oh, I just I don't want to have sex anymore. I don't know what's wrong with me.” “I used to want to have sex and now I don't…what can I do?” And one of the most powerful things to learn about is something called responsive desire, which means that, there's a sexual cue, for like you were saying earlier; it could be erotica, or it could be a vibrator; something that makes your body aroused, which happens in the genitals. And just like men, women experience erections in the clitoris. The clitoral tissue, which is the head of the clitoris, which we can all see, but then also the body of the clitoris that extends down into the labia, becomes engorged with blood, just like Dr. Dweck was saying. That's that nitric oxide pathway that we were just talking about, and the clitoris becomes erect, and that's called arousal.
And so, when women experience arousal, oftentimes then it sends a message to their brain: “Oh, hey, sex! Sex sounds good. I'd like to have sex!” And that's actually a very normal way to experience libido or sex drive, as well. And it doesn't mean there's a diagnosis; doesn't mean you need medication. It just means you need to be aware that that's how your systems work together. And then that way, you can intervene appropriately with whichever tool makes the most sense for you.
I love always to talk about responsive desire with my patients. And I also think that it's a good time to talk about the difference between low desire and HSDD, which is another thing that we focus on a lot, which stands for hypoactive sexual desire disorder. And there's a subset of women – 38% of women – who report that they have low desire. And 10% of women would qualify for a diagnosis of HSDD, which means they don't have desire that starts in the brain, also known as spontaneous desire, but they also don't have responsive desire – the desire that starts as arousal, and then goes to the brain.
So, the way that I talk to patients about that is, you can be on a desert island with the partner or partners of your dreams. There are no kids, there's no nagging job, you have all the things and inducements in the world...and still, you could not care less about sex. And so that is when we might think about a diagnosis of HSDD and the different interventions that could come along with that, so I definitely wanted to talk about that.
Dr. Alyssa Dweck: Absolutely. So, I just want to confirm and help you to reassure everybody out there; sex drive does naturally wax and wane throughout the lifecycle. Would you agree with that? Because I think some people expect that they're going to be a sexual dynamo, 365, seven days a week, and that is just not the case. Correct?
Dr. Lyndsey Harper: Totally. Absolutely. And it's just like anything, you know, our commitment and our interest in things throughout our life changes. And that's totally normal and doesn't mean that there's anything wrong with us. That's why I like to think of sexual health as a journey. You never get to check all the sexual health boxes and wash your hands and be like, “I'm the queen of sexual health. I've achieved the ultimate, satisfaction and wellness status!” It's a journey and it changes as we go; when we're in puberty, and we're learning about our bodies, learning about sex, when we first start to explore our bodies and explore what sex means to us, when we are in a longer term sexual relationship, when we have any sort of reproductive life event; whether we decide not to have kids or we experience infertility, or we actually have children. I mean, these are all times when sex and sexual health needs to be renegotiated.
In addition to sex and aging, the changes in hormones that you mentioned, the changes in our bodies, the changes in ourselves as sexual beings, we oftentimes think of older people not being sexually active and like, we're just going to ride off into the sunset, never to touch one another again. And that makes me really sad. That's not the future I want. And so, I think we have to change that narrative. But that doesn't mean that sex looks the same when we’re 80 as when compared to when we’re 25…and that's all okay! It's all beautiful. It's all part of the process. But it requires that we keep an open dialogue and keep our brains open to new ideas and possibilities as we're on that journey. What do you think?
Treatment Options to Consider for HSDD
Dr. Alyssa Dweck: I completely agree. So, to your question about HSDD, I think the thing that comes to my mind is, you know, this is something that's manageable. I applaud the FDA for finally addressing this in a serious manner and approving now two pharmacologic options for HSDD.
Again, individuals with HSDD are people who never think about sex and who are distressed about it.
There is one that is an oral medication called Flibanserin, which is to be used every single day and it has been shown to increase satisfaction during sexual encounters, significantly. And then the second is more of an on-demand product, called Vyleesi, which is given as a little self-injection. Also helpful, and it may be right for certain people in our practices so, it's great to know that these things are available.
Dr. Lyndsey Harper: Absolutely. And I think also, you know, understanding the symptoms we’re experiencing like, “Okay, I have low desire, what are the things I can do?”
First, we talked about learning about responsive desire. Educating yourself is another evidence-based way to improve desire, whether that's learning about responsive desire, whether that's learning that 87% of women have orgasms through clitoral stimulation. If there's this huge orgasm gap, and women are never having orgasms, we're definitely not going to be wanting to have partnered sex a lot either. So, that's so important, that educational piece.
The communication between your partner and your healthcare provider about sexual experiences and sexual health, learning about supplements that have an evidence base, like the one that Bonafide makes, and then learning about those FDA approved options, as well as others. So, it's about identifying the problems, starting the conversation, and then getting access to those evidence-based tools, for sure.
Dr. Alyssa Dweck: You know, we did do a study on Ristela. This is the blood flow enhancing supplement we referenced earlier, on women on antidepressants, and to your point, it did show that there was an improvement in sexual satisfaction overall and in some of the individual aspects of sexual function [as well], like arousal, like orgasmic response – when taking Ristela along with antidepressants. So, I think that gave my patients a lot of hope and also gives us a lot of pride in the fact that we do a lot of research on our products.
I think you're speaking to such an important point, bringing all these things up about how complex libido is for women, you know, this is just not a matter of a mechanical thing not working. We have relationship status, medical status, hormonal status, so many things to consider. And I think that's just a really important notation to make.
The Complexities of Female Sexual Desire and Sexual Satisfaction
Dr. Lyndsey Harper: Totally. And so, on one hand, it's like, yes, you know, sexual health and desire is like an onion, right? There are lots of layers. And then on the other hand, I spend a lot of my time educating physicians, and the title of my lecture is “Women's Sexual Health. It's Not That Complicated.” Because let me tell you, we've created this narrative in our minds as a medical community that like, whoa, Pandora's box, like we can't possibly go there because we're not counselors, we're not therapists. We don't have time for this. And it's like, “Well, is that how we treat men with sexual health problems?” I don't think so. You know, we understand, for men that there is a medical component, just like there is a mental health component and a relational component. But we take our responsibility to the medical piece of things. And this is a whole soapbox for me, Dr. Dweck. So, I'll try not to bore all of Instagram with it.
The point is, it is complicated, it is nuanced. That's what makes it so interesting, and fun and beautiful. But also, there are ways we can get to the point and understand what's going on with ourselves and with our patients in a way that we can make real progress, pretty quickly. And the thing is, we don't ever talk about this stuff. So, half of it is just, you know, starting the conversation and that can go a really, really long way.
Dr. Alyssa Dweck: I couldn't agree more. And you know, you bring up such a good point, because your gynecologist is really the natural healthcare provider to come to with issues of concern [regarding sexual health]. I mean, after all, we have brought, hopefully, our patients through the decade – through their first menstrual cycles, through contraception, through having children, through the perimenopausal journey, and of course, sexual health is really important and something that, you know, I think a trusted provider who's been taking care of you for years and years is really very well armed to handle these issues. So, definitely the best first stop, in my opinion.
Dr. Lyndsey Harper: I agree. And that's why with Rosy, when we went to market, we went to OBGYNs – so, I know Bonafide has done the same thing because I used to have your samples in my office. And so that's what I tell physicians when I'm educating, it’s like, “Hey, if you have a patient who comes in with low desire, the first thing that I want you to do is have them do an educational or behavioral intervention, like read a book,” like my friend, Laurie Mintz wrote A Tired Woman's Guide to Passionate Sex, “or download Rosy, either way,” and then start with a supplement, an over the counter, evidence-based supplement, like Ristela. And that's like the perfect way to get people started on their sexual health journey. Then, come back, follow up in a month and see where we are, see what progress has been made. And that way, we can really dig into this specific issue. So, I think there are ways to get to the bottom of things while also still making significant progress, even though it might feel a little overwhelming to everyone involved.
Dr. Alyssa Dweck: Well, look, I think providers are also pressed for time and sexual health requires time and compassion. So, when I feel limited, I often invite somebody back, quickly, so that we can dig in and keep the conversation going.
I would love to pick your brain on sexual pain, specifically due to vaginal dryness, because I feel like not a day goes by in my practice where this isn’t a real, distressing topic of conversation. And there are so many things we can do about it.
So, why don't you start out and you know, give me your vaginal dryness 101 chat?
What Role Does Vaginal Dryness Play in Sexual Satisfaction and Drive?
Dr. Lyndsey Harper: I love it. Yeah, vaginal dryness is so common, and it often happens as a result of a decrease in estrogen, right? So, the times when we experience that are when we're making milk, when we're lactating. Also, during the pre-menopausal time, you can start to experience that decrease in estrogen right before your [menstrual] cycle. So, you can kind of start to feel a little uncomfortable and maybe dry, and then lastly, is during and after menopause.
So, menopause, as I know and most people know, is defined as a year without a period. So, that's for people who are regularly having periods, but that's how we define, sort of arbitrarily as gynecologists, when you're technically in menopause. And many women, the majority of women, will have vaginal symptoms, because of the lack of estrogen during and after menopause, and that results in changes to the skin of the vagina and the vulva. And the vulva is the external genitalia, right? And so, this skin gets thin, it gets dry, it tears more easily, it becomes more prone to infection, because the bacteria in the vagina that keeps our vaginas healthy and balanced, starts to change. And so, all kinds of things are happening down there. Meanwhile, we're just trying to live our lives and get some sleep and get relief from hot flashes and our vagina is having its own problems. And so, that can result over time, and sometimes, sort of insidiously – like it's kind of there, and then it's there a little more, and then it's really there – pain with sex. This is because of a lack of lubrication due to no estrogen.
How to Treat Vaginal Dryness and Painful Sex
And so, there's lots of different ways to address it. There's over-the-counter options, lubricants that come in all shapes and formulations. There are suppositories, moisturizers, there's vaginal estrogen, which, you know, there's so many in the sexual health community who are strong proponents of vaginal estrogen. And then there's also vaginal DHEA, for which there's an FDA approved option that gets converted into estrogen and testosterone, because it’s important to remember that there are testosterone receptors down there, too.
So, there are lots of options and more women need to know about them because they're suffering in pain and silence. It’s like, well, men, also as an age-related issue, develop more erectile dysfunction. We're throwing the 26 FDA approved medications for erectile dysfunction at our partners. And women, meanwhile, are over here experiencing painful sex. And as a result, lack of desire, because it hurts. And we're not really spreading the message as we should be from that perspective. So, I'd love to hear how you approach that with your patients and that population.
Dr. Alyssa Dweck: I agree with everything you've said, and this is again, it's something that I address in practice day in and day out. I like to start sort of conservatively and then move to more aggressive treatments. So typically, we'll start out with an over-the-counter moisturizer. I'm a big fan of hyaluronic acid as an ingredient, of course, Bonafide makes an insert called Revaree® with hyaluronic acid.
But the main point I want to get across is that the vaginal dryness and the symptoms of atrophy, which is sort of the older term for this, they will not get better by themselves, over time, like hot flashes, which are eventually going to dissipate. But vaginal dryness, if unaddressed, will chronically and progressively continue throughout our lives. So, I think it's something to address either proactively or regularly so that we're not back behind the eight ball again.
Lubricants? Absolutely. I tend to favor silicone-based lubricants because they're long lasting and my patients really love them. That is just a little secret out of my practice, when we give out goodie bags, they usually contain a silicone lubricant, a little sample. And, you know, absolutely vaginal estrogen is a wonderful option. However, a lot of my patients get the prescription, take it home, pick up the label and throw it away because they're afraid of the labeling – it makes it sound a little scary. Education is really important around the fact that these are usually minimally absorbed and really not problematic.
For sure I like to mention, and we talked about using vibrators a little to enhance blood flow, but dilators; vaginal dilators really can help with vaginal pain, particularly because the vagina does shrink in width and length and opening, making it smaller and much more delicate, as you described. And so instead of avoiding relations, it's reasonable to practice with dilators slowly and regularly to help to mechanically stretch the vagina, but also to train the brain that something does not have to hurt, and the muscles won't naturally tighten up so much, with practice. So, that's a big mainstay in my practice as well. Those are two of the sort of easier things to initiate. And then of course, a lot of the medications we spoke about earlier that have been shown to be helpful.
Dr. Lyndsey Harper: Yeah, and I think, to your point regarding things with the vagina, whenever the estrogen goes away, things kind of get progressively worse. It's not something that's going to pass, like hot flashes – that's such a good point. And I think whenever it's been a long time, and I think we've all taken care of patients who, you know, stopped having sex 10 years ago, maybe because their partner died or there was a separation or whatever, and then all of a sudden they're excited to be sexually active again, but it's been 10 years they haven't had any penis and vagina sex, no penetrative sex and they've been having vaginal dryness that hasn't really been an issue, because they haven't been active. But over that time, to your point, [the vagina] shortens, it thins, it becomes narrower. And so, then that's when dilators are necessary.
So, I think there's a way, just like you said, to be proactive and not be in that position. But also, it's not uncommon. And it doesn't mean that if you are in that position, that we can't help with some of these interventions that we're talking about. So, we definitely want patients throughout their life, at whatever time they want to, to feel sexually intimate and expressive – to be able to achieve those goals with all of these tools. And that's what women need more of; we need more conversation, we need more research and development, we need more people to care about our sexual health. Because we need as much help as we can get! We've been centuries without any so we need everything we can get, for sure!
Dr. Alyssa Dweck: Do you ever speak to your patients about outercourse? Because I sometimes feel like I have 10 heads when I bring this up in my office; but there are some people where intercourse is going to be off the table for them because of dryness and discomfort. So, we talk about outercourse, which is everything else. And I think this is a very, very good conversation to have and kind of normalizes it and, you know, gets the pressure off some people.
Dr. Lyndsey Harper: 100%. And that's what I was, you know, kind of meaning in my head earlier, when I said, opening your mind to other ways to experience pleasure, because spoiler alert, it's not all about the penis in the vagina. Like, there's a lot of other ways to get where you want to be, whether that includes orgasm, or not, totally up to you as well.
And so, it's really about understanding what do you want from a sexual experience? Is it an orgasmic sort of release? Is it increased intimacy with yourself? Is it appreciation for your body? Is it something to do with your relationship and sort of putting, you know, effort and touch into that? And once you kind of know what you're wanting from this, then you can create a million scenarios on how to get there, one of which is penis and vagina sex. But there's so many other ways. And I think, you know, we have so much mind expansion to do about defining pleasure for ourselves – to talking about that with our partners, and really helping the world to understand that if something's going on with a partner, and to your point, penis and vagina sex isn't anatomically going to happen, or if that's not what we want to happen. That's okay. And that doesn't mean that anything has gone wrong, for sure.
What’s Considered “Normal” When It Comes to How Often You’re Having Sex?
Dr. Alyssa Dweck: I'm going to leave you with a question that I get asked all the time, which I would imagine you get asked all the time too, which is, how much is normal? What is normal, normal sexual life or sexual drive? And I find that to be an extremely difficult question to answer.
Dr. Lyndsey Harper: I always lead with, “you're not going to like my answer.” Because nobody does; they want some quantitative data. But the point is, [what’s normal is] whatever is normal for: number one, you, that's the number one answer, whatever fills your needs. And then if you have a partner or partners, there's a discussion about what are their needs. And just like everything in life, if you were raised in a different financial sort of mindset, right, we have to kind of negotiate that with our partners and negotiate, not in the sense of, “I'll give you five nights of penis and vagina sex for a new Chanel bag,” right? It's not that kind of negotiation. Come to a place where everyone's relatively happy and feels like they're getting what they need from the relationship. So, just like we do with parenting, just like we do with money, just like we do with so many things in life, oftentimes, we have to do that with sex. And that's okay, there's nothing wrong with that!
If there's a higher desire partner, they can be responsible for their own pleasure on days when you're not really interested and haven't, you know, decided to come to the table for that. And, you know, the lower desire partner should feel free to express their concerns as well.
So, there is no number, sorry. And we don't really want to promote a number because it's really about what's right for you and your relationship and in that specific context. How do you answer it?
Dr. Alyssa Dweck: Well, first of all, thank you for validating my answer. There is no normal, it's what's normal for you. And yes, I would say that is my answer and it’s often met with a little bit of disappointment.
Dr. Lyndsey Harper: I know people want a number! Sorry, guys, sorry to disappoint.
Well, this was great fun, Dr. Dweck. Thank you so much for joining me today. I hope you have a great rest of your week.
Dr. Alyssa Dweck: It's been my pleasure. Thank you and rock on. We love your site.
Dr. Lyndsey Harper: Oh, same. Same. Well, great. Have a great rest of your night. Thanks, everyone!