Activating Your Sexual Health During Perimenopause

Anna Cabeca, DO, OBGYN, FACOG

Oh, my gosh. Betsy, as always, I love to have our conversations.

Betsy Greenleaf, DO, FACOOG (Distinguished)

I know I could go on forever with this with you. And so but this is something, you know, sexual dysfunction is a topic that I know you’ve seen tons of this complaint in your practice and in what you do on a day-to-day basis.

Anna Cabeca, DO, OBGYN, FACOG

Yeah, absolutely. And I just reflect back on where we met. So that’s if you remember, I met we met at the American College of Obstetricians and Gynecologists conference, the osteopathic in, somewhere in Arizona, we were there many, many, many years ago. And you were on stage speaking about sexual pain, and pelvic pain, and I was on stage speaking about libido. And like after we were both done our session, we’re like, oh my gosh, let’s have dinner, let’s, you know, talk. I mean, just to find a kindred spirit. And believe it or not, like in, you know, as far as OB-GYNs go, it is very few that have expertise in this area of sexual dysfunction. And gosh, I hate that word dysfunction.

Betsy Greenleaf, DO, FACOOG (Distinguished)

Yeah, I do, too. Yeah. And then it’s a shame because, you know, for women, when they do have problems, first of all, this is not something that a lot of people talk about. And I know anytime I’m in the supermarket, you look over at like a Cosmo magazine or glamor or whatever it is, and it’s like not having sex ten times a day. What’s wrong with you? Like all these, like, crazy sex headlines and you start, like, questioning yourself and you’re like, wait a minute. Like, what’s normal? Like, what’s not normal? Like, I don’t know, because we’re not having this conversation.

Anna Cabeca, DO, OBGYN, FACOG

You know, I think it’s really important to say first and foremost, like, if you think of life as a Schwarzenegger movie, it is not right. And if you think of sex as if it’s porn, it is not right. Like that is just fantasy and it is not the common experience. And so it’s you know, a lot of this is really important. It’s part of shedding the, you know, what you’ve seen, what you’ve heard and go within yourself to say what’s true for you. What are you experiencing? How can you activate your senses? How can you be present? How can you have mindblowing orgasms? And it’s not by thinking of other things, it is by going within and being very, very present in what’s real for you. The softest of touch, the changes where, the foreplay, what leads up to it, right? And then when it, you know, like this whole concept of dysfunction, like when we talk about sexual health, like having getting your sexy back, like what makes you feel sexy and attractive and not just from the outside in, but from the inside out. That’s even more important because that’s where the openness, the receptivity to beautiful intimacy, that’s where it starts. It’s hard to get there sometimes and get that.

Betsy Greenleaf, DO, FACOOG (Distinguished)

And, you know, I hear a lot of times, like women are like especially who ones who’ve been in long-term relationships, they’ll always bring up like, oh, it was like fireworks when we first met. And now, you know, a year, five years, 10 years, 20 years, whatever down the road, they’re like, let’s the last thing that is on their mind. What do you say to those types of patients that bring that up who are like, I just want to I want it to be the way it was when we first met.

Anna Cabeca, DO, OBGYN, FACOG

Well, I’ll give you an example, because, you know, I have a program called sexual CPR. You know, sexual CPR. You guys in medicine, we talk about CPR, you know, cardiopulmonary resuscitation like it brings you back to life. There’s the same thing for sexual CPR. So it’s a very holistic program. Now, in this course, I mean, there are many reasons you’ve got and you’re addressing all of these in your summit. But the medical, the hormonal, the physical, the psychological, the relational. I mean, there are many factors here that come into play with our sexual health. And so I had it and I like to teach every aspect so that we can reconnect with our own sexy, as I like to call it. So I have this couple, her name is Lauren and she was 45 years old. And she and her husband, she says were like roommates. They were roommates for the last 10 years. They really didn’t have sex very rarely. And she never initiated it. And so she had to join sexual CPR as a last ditch to figure out what was wrong with her is how she put it, what was wrong with her versus what was wrong with her marriage. And as she went through like my first class sexual CPR is called Help Doctor. My sex drive has no pulse. So help the doctor, call 911. My sex drive has no pulse. So we need CPR. Right. And let me see if I can and I have a list of questions that I bring that I have women ask. And it starts with like what’s physical, what makes you feel good? And start to go through these questions, hormonal issues, what’s going on? Are there certain times of the month when you tap into your sexuality more than others? You know, do you allow yourself to experience pleasure inside and outside the bedroom? And then psychological factors like, did you grow up with ideas that sex was bad or, you know, don’t talk about your vaginal area, your clitoris. I mean, these are don’t touch, don’t talk. And, you know, what were some of those old things that made you think, oh, my gosh, now I have long put that past me. Bring it up again. Just, you know, tap into how you feel around it. And then was there any problem with pregnancy like physical reasons, any problems with pregnancy or childbirth that could have caused pain? And then, of course, relationship what are and it gets a three-page questionnaire that I just gave you in 2 seconds. But you know, relational. Are you able to communicate your desires? Are you able to communicate what makes you happy? How do you feel? Do you feel safe with your partner? Do you feel safe in your environment? When was the last time you felt love for them? When was the last time you felt turned on for them and by them? And let’s talk about these things. And I remember like, you know, that process. And very quickly, she said, you know, it was eye-opening. She realized she had been holding resentment for something that happened a decade ago and that really shut her off sexually. And so she started just talking to her about it. I learned from Dr. Diana Kirschner, who wrote Love in 90 Days. I interviewed her and she says back-to-back communication, safe communication. You don’t have to look at each other in your eyes when you’re talking about an uncomfortable topic. She said that my patient, Lauren, she just started she said we had back-to-back conversations. And I talked about this. I voiced what was coming up in me and that the situation and he literally got down on his knees and said, I am so sorry. I never meant to hurt you. What I was going through during that time was this. And they had a heart-reconnecting moment. And she goes, We literally went from roommates to boyfriend-girlfriend again. You never know. You never know. Right? What is causing the disconnect?

Betsy Greenleaf, DO, FACOOG (Distinguished)

I mean, I just listening to that story, it even made me a little teary because I’m like, wow, you know, you don’t realize it in life kind of gets in the way sometimes and it really comes down to we’re just not necessarily communicating with our partners like they’re there and we just sometimes take them for granted and don’t realize that, you know, we need any relationship, whether it’s a friendship or, you know, a love relationship takes work. So.

Anna Cabeca, DO, OBGYN, FACOG

Yeah, it’s so true. And that’s like when it goes back to like the ABCs of sexual CPR and that is, you know, a bird CPR, it’s airway, breathing, circulation. And I think those are still the ABCs. And for sexual CPR, it’s for accepting where you are right now, accept what you like about yourself, accept the roles or whatever. Because you sometimes are repositioning yourself because you’re like, Oh, I don’t want them to see the side of me or whatever or feel these roles and the mirror neurons are a turnoff. Like when you’re turned on and you’re on fire. They are even more so because we have mirror neurons. They feel what we’re feeling. And so remember that accept where you are right now because I guarantee you that 10 years from now you’ll look back at that moment with compassion or that that self, that picture of yourself with compassion accept where you are right now and is present, be present. That’s the whole sensate focus. Now, you know, be present and get into your body, out of your head. Get completely into your body. Your body is designed for pleasure. What feels good, what feels good, and see, communicate that. Communicate what feels good. Communicate what turns you on, communicate go faster, go slower, communicate be harder, go softer. And wherever it is, you know, like just explore your erogenous zone from the nonpelvic region. Where do you have erogenous zones around your body and start communicating that? And so the ABCs of sexual CPR, what makes you happy, what feels good, and know it for yourself. And so you’re able to communicate it and use that time for fun and for play to explore that. And you know, and that’s like that’s non-medical treatment for our sexual dysfunction.

Betsy Greenleaf, DO, FACOOG (Distinguished)

You know, it’s funny because I remember growing up myself and being like, you know, early in my marriage and be like, Oh, that’ll never happen to me. Like, weird. Like, this is so much fun. And then all of a sudden kids came and it was like this light switch went off and like, my focus went on the kids and I kind of forgot my husband even existed and I felt guilty. But, you know, sometimes I wonder, like, how much of that is there like a biologic-like trigger that’s happening or is it something that as women that were just kind of, you know, doing to ourselves where we just kind of either hyper-focus on one thing too much or we tend to do 10 billion different things all at once and, you know, can’t relax and have, you know, enjoy our sex lives.

Anna Cabeca, DO, OBGYN, FACOG

Yeah. No, that’s so true. I mean, because that is part of the evolutionary design that when we are, you know, child-rearing, that our attention is on them. So the modern life intervention is self-care, right? Because resentment is a lack of self-care. So you’ve got to do that self-care and then date nights, you know, having date nights, having time away and having like trusted support around you and so that you can feel safe, able to get into the play mode and making it a priority, making that time as a couple a priority because, you know, in 20 years or so they’re going to be out of the house. For me, it’s like I’m still raising. I’ve been raising kids for 30 years now, so my youngest has three more years. And so but you know, what does that you know what does that look like for you when you want to spend the rest of your life with some? I mean, that’s the commitment. But is it is it fun? Is it playful? Can you re-energize, reconnect, and bring that back? Let me tell you, I’ve heard from so many couples that when they do that, their relationship is better, stronger, and happier than they ever imagined. And I just love that and I honor that. So and I know that there’s times, you know, like heck no, there’s no way I can do this. But don’t let, like, let it not be the, you know, let it not be something preventable that we can fix, that can reconnect you like sexual intimacy and how important that is. And the ability to communicate. And if you can’t communicate outside the bedroom, you certainly can’t communicate inside the bedroom. So practice practicing that both ways. And then, of course, there are the hormonal causes of sexual dysfunction. Now we get into just the changes as we age, the physical changes of the changes to the vagina and the perineum and the clitoris and the loss of sensation potentially, unless you’re using unless you’re continuing to exercise, have it like if you don’t use it, you lose that that exercise of the vaginal walls, whether it’s from sex pelvic floor exercises using kegal balls, is going to keep the muscles strong and then adding back hormone as needed for sure.

Betsy Greenleaf, DO, FACOOG (Distinguished)

You know, and that’s one thing I wanted to bring up because I didn’t realize I just found out this year that May is international masturbation month which I had, 

Anna Cabeca, DO, OBGYN, FACOG

I heard the word masturbation, you didn’t call it self-pleasure.

Betsy Greenleaf, DO, FACOOG (Distinguished)

I know. I know.

Anna Cabeca, DO, OBGYN, FACOG

I like to call it self-pleasuring.

Betsy Greenleaf, DO, FACOOG (Distinguished)

I like that better too. But there are actual physical therapy benefits to that, to keeping things working well. So you don’t necessarily always have to have a partner to keep your intimate life kind of healthy.

Anna Cabeca, DO, OBGYN, FACOG

Yeah, with or without a partner for sure. And then self-pleasuring to use that word.

Betsy Greenleaf, DO, FACOOG (Distinguished)

Yes.

Anna Cabeca, DO, OBGYN, FACOG

It’s so much better. And I think that’s again, understanding our body. We want to keep our we want to keep our all our muscles in our body healthy and our pelvic floor muscles are so important because bladder control, vigal control, vaginal support, I mean, it’s so important to do to keep that area healthy. Pelvic floor exercises, self-pleasuring, and orgasm that increase oxytocin, which is the most healing hormone that we have in our body, is the most powerful hormone in our body. And we get that through pleasure, through laughter, through orgasm, through climax, through massage, through kissing, through playing, through, you know, just what brings a smile to your face. You’re dripping oxytocin at that point.

Betsy Greenleaf, DO, FACOOG (Distinguished)

You know, I get a lot of patients who ask, you know, when are they going to make a pill for women? And referring to things like Viagra. But I know that you probably have a lot to say about that idea.

Anna Cabeca, DO, OBGYN, FACOG

I am you know, again, I have created products and I’ve created programs. And I always say it’s not and it’s not solely in a product, a pill, a program for sure. And I think what we’ve done, we have trained people to think, well, I need something else because I can’t do it myself or I need something out. I mean, sometimes we do, sometimes we do, and sometimes we do for a short time. That’s the goal, right? We want to, but we want to create the goal that we want to create within ourselves. And I had a client this last week, a patient of mine came to see me and she said she didn’t have an orgasm until she was 41. And then she had a beautiful orgasm. She says she’s been with her husband for, gosh, how many years now? She’s 35 years old. She’s been with her husband and she had an orgasm at 41. So she goes like, I felt like I was in that perimenopause transition and I had an orgasm for five, six years, but I haven’t had one since. And I really want to have one. Am I broken? You know, am I broken. Is there something wrong with me? And so that’s the point. Like, what are your physical activities? Are you a cyclist or, you know, an equestrian? Is there are you having a loss of sensation? Is there an alignment issue?

Both you and I are osteopathic, so we think of alignment. Sacral floor, Pudendal nerve, S2, S3, S4. Is there a problem with your lower? Is there a nerve damage issue? And this is a quick, easy like thing that I tell my patients, can you spread your toes? You know, like the yoga toes? Spread your toes. Well, that means you’ve got good as two, three, and four. And if you are not able to, then there’s probably an alignment issue, a weakness in the sacral nerves. And so we can improve that through physical exercise training. Sometimes there’s a pelvic floor release we need to do or acupuncture can come in very, very handy to do that. And again, pelvic recognizing what we need to do to improve that area to keep that healthy along with sensation, you know, is there atrophy to the clitoris? What’s going on in the Vulvovaginal area and how can we improve sensitivity there instead of taking away from it? And so, you know, an interesting question I get is, is the vibrator trauma issue, you know?

Betsy Greenleaf, DO, FACOOG (Distinguished)

Yes.

Anna Cabeca, DO, OBGYN, FACOG

And it’s real and yes, especially I mean, for the clitoris, specifically the vagina. You mean that vibration is good for the vagina, for blood flow. But you know, Betsy, this is, let’s let’s talk about that because that’s so something that comes up very, very often.

Betsy Greenleaf, DO, FACOOG (Distinguished)

Yeah. And in fact, actually, you know, well, I think, you know, anything that with the body that becomes overstimulated, the body starts to ignore. So if we’re putting too much stimulation with a vibrator or, you know, or sometimes even stem with hormones, if people are taking too many hormones, then they stop working. The body goes, oh, it’s too much stimulation, I’m just going to ignore it. So I did have one patient in an extreme, like a very, very extreme in a fellowship where she self-pleasured so much to the point where she developed calluses on her clitoris and she got to the point where she could not orgasm and we had to say like, all right, this is a little bit too much stimulation. The nerves are just tuning it out, back off and you can get those nerves to become sensitive again.

Anna Cabeca, DO, OBGYN, FACOG

So I think that’s the practice too. And so to teach, you know, teach clients that the lightest touch to reactivate that lightest touch so the clitoris and all of a sudden you get awakening of these sleeping nerves and so it can feel like a pincer needle type of experience initially. And I take that as a very good sign you’re reawakening that nerve supply. So instead of the firm go, light, go, the lights go in clockwise, go counterclockwise, light, touch, experience, it’s that going to train your partner to do that for you where, you know, there’s, you know, just able to experience that touch. You don’t have to take it any further. Just create this reawakening of the clitoral nerves that there are over 8000 of them. So they, you know, from cycling, from horseback riding, from, you know, all these things that I do, all of the above. Right. And so to really be conscious of taking those breaks to reawakening, to stay in tune with the lightest touch. So during intercourse with contact with the clitoris, there is that ability to increase the orgasm.

Betsy Greenleaf, DO, FACOOG (Distinguished)

So and that’s actually something that’s been really nice is there’s been a lot more awareness about the anatomy of the clitoris and you know, I know that, you know, they’re starting to depict it better, and in anatomy books, whereas not just that little tip that’s sticking out, but it actually extends back into the pelvis.

Anna Cabeca, DO, OBGYN, FACOG

Absolutely right. I mean, it’s quite long. Right. Quite long. And you have just the bulb and then the clitoral bulbs that go longitudinally. And so the vulvovaginal area, I mean, the vulva, the lips, the labia are beautiful, sensitive, pleasure, pleasurable organs. You have to take time to experience that. And again, that part of the erogenous zone that experiences our exploration is to experience all areas. What brings you pleasure? And to identify them and to be able to communicate. And it’s a fun exercise and something that I want women to hear is that your turn on is your partner’s turn on, you know, like, you know, for guys we know this that we can ask the most chauvinistic guys out there like, okay, what’s, what’s your biggest turn on during sex? And they won’t say when they ejaculate when they come in blah, blah, blah. They’ll say when she’s turned on, like when she climaxes, when can see she enjoyed it. And so being able to express that is pretty powerful.

Betsy Greenleaf, DO, FACOOG (Distinguished)

You know, going back to I think it’s such a good point that there’s so many different factors that support sexual wellness and intimate health and in general, just in general health and wellness. And then when we rely on pills to be the answer to things, it’s not the answer. I mean, even Viagra gets misconstrued. It’s not a libido drug. It’s a blood flow drop. So we don’t have a pill that’s going to put you in the mood. That’s, you know, your brain is going to be your most important sex organ when it comes to that.

Anna Cabeca, DO, OBGYN, FACOG

Yeah. And I think, you know, with all these medications and I often lecture about this, the different medications, the side effect profiles, are they really worth it? And what do you have to do when it’s within us, I mean, we can learn to have an orgasm or climax without anyone, right? Without anyone else present, without a vibrator, without anything, with breathing, with the way we conduct our breathing, the way we like fire, breath, or orgasm. That Barbara Corrales teaches us. And, you know, so there’s different things that that we can do to remember don’t give your power away. As a woman, we’ve done way too much about it. Don’t give your power away. Go inside. Let’s see what we need to do. What can we, you know, where can we enhance her experience and certainly like G-spot injections that with biller can be great using I created a product jojoba to help with the conditioning and you’re not your body’s natural moisture so, you know there are things that can help there’s you know, compounding formulas with that we can use to increase blood flow to the area. So there are some things that we can do to get you back in touch with your body and keep everything healthy. So that is that’s for sure. But many of these medications don’t have favorable side effect profiles and, you know, may be fun. Hey, play with whatever, you know, periodically, but don’t rely on it. Don’t rely on it. I think that’s an important lesson.

Betsy Greenleaf, DO, FACOOG (Distinguished)

You know, it’s funny, I was actually just having this conversation yesterday about there’s a product. I don’t know if it’s still on the market. I’d have to look, but I remember it was out in the market when I was a resident, and it was this oil that had a bunch of different essential oils in it. And they claim that these essential oils put you in the mood. But if you actually read the instructions, the instructions were to put this oil on your clitoris and to rub it in the clitoris for 10 minutes, and then that would work. And I said, Wait a minute. Oh, my goodness. Was it the essential oils versus the actual stimulation and the mental willingness to get it to work so.

Anna Cabeca, DO, OBGYN, FACOG

Now so true. So true. You know, and I think that’s it. And then recognizing that secondary desire is very normal, especially after you’ve been with someone for two years. I learned this from my patients when I would ask them and they’d say, Oh, now my libido is an issue. And then they would say, Oh, I’m great when we get started, you know? And in that secondary desire. So that’s normal. So creating that space and, and that time can make a big difference in your life. So.

Betsy Greenleaf, DO, FACOOG (Distinguished)

Well, this has been great. Is there anything that I haven’t asked you that you want people to know about?

Anna Cabeca, DO, OBGYN, FACOG

I think it’s just that we’re not broken sexual dysfunction is a terrible term. Yes, you know, it is it is a terrible term. But it’s it’s this opportunity to explore what is your turn on. What makes you happy? Where’s your sexy? How can you tap into that? What makes you feel good? And maybe it does help to go back and say, when did I stop feeling this playfulness, this joy, this happy? When did I stop feeling this energy like that, that sexy, that play, that joyfulness? What stopped us? What stopped? What created the barrier to where I’m at now and then being able to eliminate that? But the right key is to be present, to be willing, and to know that there’s always one next. Right, stop.

Betsy Greenleaf, DO, FACOOG (Distinguished)

So now this is great. Where can people find out more information about you?

Anna Cabeca, DO, OBGYN, FACOG

So definitely come find me at drannacabeca.com and follow me on social media at thegirlfrienddoctor.

Betsy Greenleaf, DO, FACOOG (Distinguished)

All right, everybody, go make sure you check out Dr. Anna Cabeca. And don’t forget, stick around for some amazing sessions coming up. Thank you so much, Dr. Anna, for being with us.

Anna Cabeca, DO, OBGYN, FACOG

Thank you.