Women's Sexual Health
Low desire, dryness, pain or trouble reaching orgasm are common, especially after 40, and they are rarely just “in your head.” Hormones, thyroid, nutrition, medications and stress all play a part. We test, find the cause, and build a plan that fits you.
Less interest in intimacy? Dryness or pain? Harder to reach orgasm? Feeling disconnected?
Length
6-month program, 3 phases
Approach
Hormones, peptides, botanicals and the O-Shot®
Pricing
Discussed at your consultation
Why it matters
Sexual health is part of your overall health. It is tied to your mood, energy, confidence, sleep and relationships. Yet it is one of the least discussed parts of women’s care. Many women feel uncomfortable raising it, short appointments leave little time for it, and good information is hard to find. So many women quietly assume that losing desire is just part of getting older.
It often is not. When desire fades and no one knows why, it can lead to hurt feelings and misunderstanding between partners, when the real cause may be physical. Naming it is the first step. We make time for this conversation, privately and without judgment.
What changes after 40
Testosterone levels decline gradually with age, and by the 40s many women have noticeably less than they did in their 20s. Often a woman does not connect this to her fading desire. But testosterone rarely acts alone. Desire, arousal and comfort depend on a balance of several hormones and on your overall health.
Supports desire, arousal, orgasm, energy and confidence. A drop may show up as low libido and low motivation.
A building block your body uses to make testosterone and estrogen. It also declines with age.
Keeps vaginal tissue thick, moist and well supplied with blood. Low levels may cause dryness and painful sex.
Supports calm and sleep. Too little or too much, relative to estrogen, may affect mood and desire.
Low thyroid can cause low libido, fatigue, weight gain and dryness, and is common in midlife women.
Low B12, vitamin D, iron or zinc can sap energy and desire. These are simple to test and correct.
Long work hours. Growing kids. A partner. Aging parents. Most women are busy taking care of everyone else, and they put themselves last. Stress hormones like cortisol rise, sleep suffers, and desire is often the first thing to go. Many women let these symptoms slide for years.
Hot flashes, irritability, anxiety and poor sleep may come from changing hormones. These symptoms are sometimes treated as anxiety or depression alone, with an antidepressant. Antidepressants help many people and are sometimes the right choice. But some, especially SSRIs, can lower desire and make orgasm harder. That is why we start with a symptom questionnaire and blood tests, so your treatment matches the cause.
Never stop an antidepressant on your own. We work with you and your prescribing doctor.
What may be causing it
Most women have more than one factor. Open a section to learn more.
AntidepressantsSSRIs, such as sertraline, fluoxetine, paroxetine and escitalopramSNRIs, such as venlafaxine and duloxetineHormonal birth controlPills, patches and rings can raise SHBG, a protein that binds testosterone, leaving less free testosteroneAnti-androgen medicinesSpironolactoneFinasterideBlood pressure medicinesBeta-blockers, such as metoprolol and atenololSome water pills (diuretics)Mental health and sleep medicinesAnti-anxiety medicines and sedatives, such as alprazolam and clonazepamSome antipsychotics, which can raise prolactinPain medicinesOpioids, especially long-termAllergy and cold medicinesAntihistamines and decongestants, which can dry vaginal tissueCancer treatmentsTamoxifen and aromatase inhibitors for breast cancerChemotherapy and pelvic radiationOther medicinesSome anti-seizure medicinesMedicines that suppress the ovaries, such as leuprolideDo not stop or change any medication on your own. Many of these medicines are important for your health. Bring a list of everything you take, and we will work with you and your other doctors on the safest plan.
Perimenopause and menopauseSurgical menopause (ovaries removed)Thyroid diseaseDiabetes and insulin resistancePMOS (formerly PCOS)High prolactinDepression and anxietyVaginal and urinary changes of menopause (GSM)Recurrent urinary or yeast infectionsBladder leakagePelvic floor problemsEndometriosisChronic pain or fibromyalgiaHeart disease and high blood pressureSleep apneaObesityCancer and its treatmentAfter childbirth and while breastfeeding
Caring for young childrenCaring for aging parentsLong work hoursRelationship strain or poor communicationBody image concernsGrief or major life changesFinancial stressExhaustionPast painful or difficult experiencesWhen emotional or relationship factors play a big part, a counselor or sex therapist can be a valuable part of your care, and we are happy to refer you.
LifestyleToo little sleepOngoing stress and high cortisolAlcohol, which may dull arousal and orgasmSmoking, which reduces blood flowToo little movementSugar and processed food, which disrupt blood sugar and hormonesSocietySex is still a hard topic for many families and culturesWomen are often taught to put everyone else firstLittle education about how the female body worksThe myth that low desire is simply part of agingFew trusted places to get informationWomen’s sexual health has historically received less research attention than men’s
Self-check
15 questions about desire, arousal, lubrication, orgasm, satisfaction, comfort and well-being. Think about the past 4 weeks.
1. In the past 4 weeks, how often have you felt sexual desire or interest?
2. How often have you had sexual thoughts or daydreams?
3. During sexual activity, how often have you felt aroused or "turned on"?
4. How often have you felt confident that you would become aroused?
5. How often have you had enough natural wetness (lubrication)?
6. How often did that wetness last until the end of sexual activity?
7. How often have you been able to reach orgasm when you wanted to?
8. How often have you felt satisfied with your ability to reach orgasm?
9. How often have you felt emotionally close to your partner during intimacy?
10. How often have you felt satisfied with your sex life overall?
11. How often have you had pain or discomfort during or after intercourse?
12. How often have you avoided intimacy because of pain or dryness?
13. How often has your level of interest in sex caused you worry or distress?
14. How often has sex or intimacy caused tension or misunderstanding with your partner?
15. How often have you felt anxious, down or uninterested in things you used to enjoy?
This questionnaire is for information only. It is not a diagnosis. It covers the same areas as validated female sexual function questionnaires, but it is not one of them. If you have not been sexually active recently, answer based on how you feel about intimacy. Your answers stay on your device. They are not saved or sent to us.
Testing
It starts with a detailed health and sexual history questionnaire, followed by comprehensive lab testing through LabCorp or Quest.
CBC, CMP, vitamin B12 and folate
LH and FSH
Estradiol, estrone and estriol, progesterone, total and free testosterone, SHBG, DHEA and DHEA-S
TSH, free T3, free T4, TPO antibodies, thyroglobulin antibodies and thyroid-binding globulin
Vitamins A, D and K, and zinc
Your provider may add tests based on your history and symptoms
If needed, we refer you for a gynecological examination.
How it works
1
Book a private consultation by phone or online.
2
Complete your health and sexual history questionnaire.
3
We give you a lab order. Get your blood drawn at LabCorp or Quest.
4
We review your results and discuss the likely causes of your symptoms.
5
We build a step-by-step plan to address the cause, not just the symptom.
Treatment
First we look at what we can remove from your life that may be holding you back, and what we can add to help your body without medication. Then we optimize your hormones. Other treatments come after.
1
Review medications that may be affecting desire, especially some mental health medicines, with your prescribing doctor. Cut back on alcohol and other things that work against you.
2
Sleep, stress, nutrition, blood sugar and movement. Correct nutrient gaps with B12 injections and vitamin D. Help your body make and balance its own hormones.
3
Hormone therapy, peptides, vaginal care, botanicals or the O-Shot®, based on your labs and your goals.
TestosteroneA low, female-range dose may help low desire, which has the strongest evidence. Given as a cream or gel, sometimes as an injection, or as pellets. There is no FDA-approved testosterone product for women in the U.S.; use is off-label and products are compounded.DHEAMay support energy, mood and the body’s own production of testosterone and estrogen.Estradiol and progesteroneBioidentical hormones to restore balance in perimenopause and menopause.ThyroidIf your thyroid is underactive, treating it may improve energy and desire.Learn more on our Women’s Hormone Health page.
Local treatments work right where they are needed, with very little absorbed into the bloodstream.Vaginal estradiol creamMay restore thickness, moisture and comfort, ease painful sex and help reduce urinary symptoms and infections. Many women use it alongside oral or vaginal probiotics to support healthy Lactobacillus flora.Vaginal DHEA (prasterone)An insert used at bedtime. FDA-approved (as Intrarosa®) for moderate to severe pain with intercourse caused by menopause. Inside the vaginal cells, DHEA is converted into small amounts of estrogen and testosterone.ProbioticsLactobacillus strains may help keep the vaginal pH healthy and lower the risk of infections.
What is HSDD?Hypoactive sexual desire disorder (HSDD) means a lasting or recurring lack of sexual desire that causes you distress, and that is not fully explained by another medical condition, a medication or relationship problems. It is one of the most common sexual health concerns in women.FDA-approved formPT-141 (bremelanotide)Works in the brain on pathways linked to desire and arousal. FDA-approved as Vyleesi® for acquired, generalized HSDD in premenopausal women. It is injected under the skin as needed, at least 45 minutes before sexual activity. Compounded versions are also available but are not FDA-approved. Use outside the approved group is off-label. Common side effects include nausea, flushing and headache; it can briefly raise blood pressure.CompoundedOxytocinOften called the “bonding hormone.” It may support emotional closeness, arousal and orgasm. Given as a compounded nasal spray or dissolving tablet. Research in women is limited, and use for sexual health is off-label.Other FDA-approved options. Flibanserin (Addyi®) is a daily pill FDA-approved for HSDD in premenopausal women; alcohol must be limited around doses. Ospemifene (Osphena®) is a pill FDA-approved for painful intercourse caused by menopause. Your provider can discuss whether either fits your situation.About peptides. Peptides are prescribed only after a consultation, when your provider decides they are appropriate for you. Compounded peptides are not FDA-approved, and the FDA does not review them for safety, effectiveness or quality. Availability of some peptides may change as FDA rules change. Possible side effects include nausea, flushing, headache and injection-site reactions. Individual results vary.
Some herbs have been studied for female sexual function. Most studies are small, and quality varies between brands.Maca rootMay support desire and energy, including in women whose desire is affected by antidepressants. Not estrogenic.AshwagandhaAn adaptogen that may lower stress and cortisol and support arousal and satisfaction.Discuss with us if you have thyroid disease.Tribulus terrestrisStudied for low desire in women before and after menopause.Avoid in pregnancy.Korean red ginsengMay support arousal and energy in menopausal women.Caution with blood thinners and stimulants.SaffronStudied for antidepressant-related sexual side effects in women.Use only standard supplement doses.Ginkgo bilobaMay support blood flow. Results for sexual function are mixed.Caution with blood thinners.ShatavariA traditional Ayurvedic tonic for women’s vitality.Limited research.FenugreekA small study suggested benefits for desire and arousal.May lower blood sugar.DamianaA traditional herb for libido, often used in blends.Limited research.L-arginineAn amino acid that supports blood flow, often combined with ginseng and ginkgo.Avoid after a heart attack or with low blood pressure.We also optimize nutrients that support energy and desire, such as B12 injections and vitamin D.Supplement disclaimer. These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease. Supplements can interact with medications and are not right for everyone. Talk with your provider before starting any supplement. Individual results vary.
Treatment
The O-Shot® (Orgasm Shot®) uses platelet-rich plasma (PRP) from your own blood. Platelets carry growth factors that play a role in the body’s natural repair. In the O-Shot, PRP is placed near the clitoris and in the upper vaginal wall to support healthy tissue, sensitivity and blood flow. It has been offered for more than a decade.
Dr. Sagar Verma, MD trained with Dr. Charles Runels, who developed the O-Shot®, and is a licensed O-Shot® provider.
1
A small amount of your blood is drawn, like a routine lab test.
2
Your blood is spun in a centrifuge to concentrate the platelet-rich plasma.
3
A numbing cream is applied so you stay comfortable.
4
The PRP is placed with a very fine needle. The visit takes about an hour.
Laser (CO2 or erbium) and radiofrequency devices are offered elsewhere for dryness, laxity and mild bladder leakage. These devices are not FDA-approved for vaginal “rejuvenation” or sexual function, and the FDA has warned about marketing them for those uses. We do not offer these devices, but we are happy to discuss them with you.
If there is a structural problem, such as pelvic organ prolapse, significant bladder leakage or ongoing pelvic pain, you may benefit from a urogynecologist or a pelvic floor physical therapist. We will refer you to the right specialist.
Your program
It takes about six months to find and fine-tune what works for you. You are followed monthly. At each visit we review your labs, your hormones and how you are responding, and adjust your plan.
1
Questionnaires, a detailed history, lab testing and a review of your medications. Together we find what is driving your symptoms.
2
We start your plan: lifestyle changes, nutrient support and the treatments chosen for you.
3
Monthly visits to review labs and your response, and fine-tune your plan.
Bioidentical testosterone, DHEA, estradiol, progesterone and thyroid support, based on your labs.
PT-141, oxytocin and other peptides when appropriate.
Herbs and nutrients chosen for your symptoms.
The O-Shot® and vaginal treatments may be added when right for you. Pricing is discussed with your provider during your consultation.
It is common, but it is not something you simply have to accept. Hormones, thyroid, nutrients, medications, stress and sleep can all play a part, and many of these can be addressed.
Yes. Never stop your medication on your own. We can look at other factors, and work with your prescribing doctor if a change may help.
In low, female-range doses with regular monitoring, testosterone is widely used for low desire after menopause. It is not FDA-approved for women in the U.S., and it has possible side effects, which we review with you.
We apply numbing cream first. Most women feel only mild pressure or brief discomfort.
It depends on the cause and the treatment. Some women notice changes within weeks, while hormone balancing can take a few months. Results vary.
No, but partners are welcome if you would like them to join a visit.
The program is self-pay. Standard lab tests may be billed to insurance. Pricing is discussed at your consultation.
Yes. Your health information is protected by law, and all visits are handled discreetly.
About these treatments. O-Shot® and Orgasm Shot® are registered trademarks of Dr. Charles Runels, used under license. Vyleesi®, Addyi®, Intrarosa® and Osphena® are trademarks of their respective owners; we are not affiliated with them. The O-Shot® is not FDA-approved for sexual dysfunction or incontinence. Compounded hormones and peptides are not FDA-approved. Testosterone, oxytocin and some other treatments described here are used off-label in women. All treatments are given only after a medical evaluation, have benefits and risks, and are not right for everyone. Results vary and are not guaranteed. This page is for education and is not medical advice. Medical disclaimer.
