Pelvic floor dysfunction, which can manifest as either tightness or weakness, significantly impacts urinary, bowel, and sexual function in both men and women; proper diagnosis requires specialized examination by a pelvic floor specialist, and treatment ranges from Kegel exercises for weak pelvic floors to relaxation techniques for tight ones, while sexual health involves understanding the interplay between hormonal, vascular, and neural factors that influence arousal, desire, and function.
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A Complete Guide to Sexual & Urological Health in Men and Women | Dr. Rena MalikHinzugefügt:
Dr. Reno Malik, welcome.
>> Thank you. Thank you so much. It's an honor to be here. Oh, >> I'm delighted to have you here. I'm a huge fan of your content. I find that you are able to deliver critical information about sexual health, urology, pelvic floor, libido, and so many other things that are of immense interest to people, but that ordinarily people don't really know where to get the high quality information. and coming to you for that information means they are going to get the highest quality information. I truly believe that because as everyone will soon hear today we're going to have a very frank discussion but one that's really grounded in science and medicine around sexual health and related topics. These are topics that typically people learn about perhaps a little bit in school, maybe at home, from friends, usually overhearing things as opposed to direct exploratory conversation online, pornography.
And at least in my experience growing up, you know, there was education around sexual health, reproductive health, etc. that was more oriented toward the fear of things like STI, fear of unwanted pregnancy, all of which of course is extremely important for people to learn about, but far less about um sort of the healthy versions of sexual health, right?
>> Yeah, absolutely.
>> So, this is an especially important conversation. Uh it's also one that I think has a backdrop that we should just acknowledge right off the bat that because the information is gleaned from multiple sources and because there are um let's just say uh influences out there that relate to the morality of different practices that there can be shame, there can be misunderstanding, there can be secrecy and that further leads to misinformation. So, I'm confident that today uh you can clarify things for us and we're going to stay out of those um trenches. And the last thing I'd like to say is that because a number of terms will certainly come up that I think for some people um they're not used to hearing and general discourse. I'm just going to get them out of the way now. Penis, vagina, anus, prostate.
You know what else is there? We're we're going to talk about libido. We're going to talk about intercourse, oral sex, anal sex. We're going to talk about all of that. So, I just want to get that out there so that um we can reduce the uh shock uh the shock response.
>> I love it. We got to talk about all of it.
>> Great. So, to start things off, in anticipation of this episode, I solicited for questions on social media and I got thousands of questions, but there was a lot of overlap in the questions. So, to start off, I'd like to talk about pelvic floor. Okay? Because both males and females have a pelvic floor and my understanding is that there's a muscular component, there's a neuromuscular component, there's a blood flow component.
What is a healthy pelvic floor? What does a healthy pelvic floor do? And then we can talk about some of the health issues that an unhealthy pelvic floor creates and some of the ways to ameliate an unhealthy pelvic floor.
>> Absolutely. So a pelvic floor very simply is basically a bowl of muscles that's connected to bones that hold up all your organs. So basically in your pelvis there's all these muscles there and their function is essentially many.
It it helps with urination, defecation, sexual function. It helps with posture.
And so having a strong healthy pelvic floor can mean that you're having normal urination, you're having normal defecation, you're having great sex, and that you are also not having ailments like back pain or issues related to those those functions and those organs.
And so, you know, pelvic floor is is so important in so many different aspects.
And we deal with it a lot as urologists because it's so integral to these functions that we take care of. And so when you have an unhealthy pelvic floor, it can vary from person to person. And while you hear about it a lot in women, men also suffer from pelvic floor dysfunction or problems with the pelvic floor. So basically, pelvic floor dysfunction happens a lot when you're doing things like if you were to go to the gym and do repetitions of of any sort of exercise and you didn't rest, then that muscle would become contracted and short. Very similarly, if your pelvic floor is overstrained, it can become contracted and short and tight all the time. And you may not know it.
It may just be a function of stress, anxiety, um, or overuse or posture problems, things of that nature that can affect your pelvic floor. And so this can lead to issues. Let's start with urination. You can have symptoms of urgency, frequency, meaning you have to go a lot to the bathroom or you have to go and have a sudden desire that you can't delay. Sometimes even have leakage. In some cases, it can make it difficult to urinate because the pelvic floor is so tense >> or perhaps to incompletely vacate the bladder. Correct.
>> Like you go to urinate and then you go back to your desk or then 5 minutes later you have to urinate again.
>> Exactly.
>> Something of that sort. Well, it can be either that you're not emptying completely or that the pelvic floor muscles are so tense that they're stimulating the bladder, so it feels like there's more to go. So, it's not always that you're not evacuating it. It can present in a number of different ways. And then with uh with sexual function, it if it's very tense, you can have pain. So, you can have pain with sex, you can have pain with erections, you can have pain with ejaculation.
Sometimes it can be a lot of different kind of pain syndromes and you're like, I have all these different things going on and it's really just pelvic floor dysfunction. Um, with with GI function, you can definitely have constipation and then often you can also have back pain.
Um, and so all of these things can happen when your pelvic floor is too tense. Sometimes your pelvic floor can be too weak and that can be often because of we see this in women a lot because of child birth delivering children. Um with some people who have neurologic disorders they can have weak pelvic floors or connective tissue disorders like Eller's Dlo syndrome for example these sorts of things can cause weakness to the pelvic floor which can then cause very often what I see is like urinary incontinence or leakage um which can then you know create problems for people down the line.
>> Thank you for that. So, first question, how does somebody know if their pelvic floor is too tight from a uh overcontraction or chronic contraction of the muscles there versus too weak?
Um, and one of the challenges in having this conversation is that if we were talking about contraction of the calf muscle or the bicep, I think everyone intuitively knows because they've seen the shortening of the muscle is when the muscle is quote unquote flexed and the lengthening of the muscles when it is relaxed. Um, is there a way to describe pelvic floor muscular shortening in a way that everyone can understand? Would this be like um, like I said, we're going to be direct today. Would this like be like tensing up one's um, uh, anus and b the opposite of of the movement that one would do before initiating a bowel movement. and relaxation is sort of the pattern of pelvic floor muscular um relaxation just prior to initiating a bowel movement.
>> So I will say most people can't recognize it because it's very difficult to notice. It's sort of uh gradual and so it can over time become noticeable with these symptoms but otherwise it's very difficult because it's not a muscle that we were ever trained to recognize.
Right? Like you hear about Keele exercises for example and people talk about how to do them, but that's all you ever hear about the pelvic floor. And so you don't really know how to kind of do things in a way that protects your pelvic floor or um or kind of what how to even tell when it's too tight or not relaxing. And so that takes a sort of a training. And so usually when people come to first you get an examination to see if your pelvic floor is tight. So for women it's a pelvic exam and for men it's usually a rectal exam. How does how does that exam go?
>> So, you know, it's essentially palpating the muscles and also looking at the function. So, we'll say for >> so digital palpation where that's a medical technology for fingers are called digits. Uh so, um you know, I'm old enough to uh to recognize what a digital prostate exam is, right? The physician inserts their fingers through it into the anus and and and feels the prostate to see whether or not it's swollen or not. And and as I'm saying this, I'm realizing, you know, sometimes we think of medicine, quote unquote modern medicine as so evolved. This has basically basically been the practice for what 50 years, 60 years, maybe a hundred years. In the same way that the the old school practice for glaucoma, excessive eye pressure, was for the physician to just touch the eyeball.
>> So, uh, folks, for those of you that think that medicine has evolved much, uh, it clearly it has in many ways. But, um, in any event, so a prostate exam goes as I just described. What would a what would a pelvic floor exam for a male and a pelvic floor exam for a female um involve at a kind of granular level here?
>> Yeah. So for for women, you can feel the pelvic floor muscles through the vagina.
So you can feel the ilioigious, the pubo coxigious, the levator ani. Those are all names of different muscles in this bowl.
>> This is the physician who can feel them with their fingers.
>> Correct. And you know you could too. You could put your finger in but you don't have a reference of normal, right? So you wouldn't know what a normal pelvic floor feels like versus a tight one versus a weak one. And so you can assess the tenseness based on, you know, palpation. You can also see if there's tenderness. And so you can assess that based on just a a general physical examination. And then also you can observe. So I can say contract your squeeze your pelvic floor up and in. I can look and see are they squeezing or are they pushing? Like are they coordinated or not? Right? Because that's a a function of normal use of the pelvic floor. And sometimes you'll see that they're discoordinated. Um, you can also assess for sensation in the area and things like that that could be consequences of dysfunction.
>> Can there be dysfunction in laterality?
Like the pelvic floor is pulling up into the right or up and to the left.
>> Absolutely. So, what typically when you see a pelvic floor therapist, now I'm not a pelvic floor therapist, but these are the people who do the work, right?
They they work with you on a prolonged basis to help you normalize the function of your pelvic floor. It's like going to the gym with a trainer, right? They really work with you to get your pelvic floor functioning correctly. And the first step to that, a lot of pelvic floor therapists will just align your bones and and your your kind of the way you sit and walk to make sure that you're not straining those muscles by pulling in different in different directions. And if a male goes to the physician to get a pelvic floor exam, um there's obviously um uh difficulty in putting fingers into the urethra, one would hope. Uh too small an opening. So how are they doing the pelvic floor exam? Is it external to the body or is it through the anus?
>> So some of it's through the anus. You can feel the muscles through the anus and then you can feel the paranal area and feel the muscles there as well as sensation. So >> okay. So paranal area. So from the outside of the body. Okay.
>> Um the region between the scrotum and the anus. Okay.
>> So it sounds to me like if people want to get a high quality assessment of whether or not their pelvic floor is healthy or not, they need to see a pelvic floor specialist.
>> That it's not the sort of thing that they could intu on their own necessarily.
>> It would be difficult. I mean, so there are things you can buy online like probes that you can insert in the vagina that will teach you how to do Keele exercises and give you some read, you know, some readings, but they're not really meant to diagnose. They're usually something people use if they say have a weak pelvic floor and they want to try to do it at home on their own.
Um, so there's nothing that's going to give you like a baseline reading. Is this normal or abnormal?
>> Let's talk about Keeles. Um, first of all, who's Keele?
So he is a uh gynecologist.
I don't remember all the specifics to be quite honest, but basically he came up with keigull which are a strengthening exercise for the pelvic floor. And so what it is, what we describe it to for patients is we say you're going to there's a few different ways to describe it. You're going to use the muscles that you use when you urinate, but try to stop the flow. But you don't want to do them when you're urinating because that can create dysfunction. You want to learn what the muscles are and then you squeeze those muscles and relax, you know, in between sets so so to speak.
And so you'll do the other way people describe it is pulling up and in in the like the vagina or for men sometimes you'll say it's like the feeling that you're trying to lift your penis off the floor without touching it. Right? So those are kind of used.
>> That's a good way to describe it.
>> Yeah. So those are kind of the ways that you can describe those muscles. And so you can squeeze for 5 seconds and relax for 5 seconds and do them in repetitions. And they're just like any sort of exercise you do. You don't want to start doing a hundred of them, right?
You want to do them, I tell them people, I tell patients, do them lying down so that you're only focusing on those muscles. You're not working on your posture. You're not doing anything else.
And as you get better with them lying down, you then sit up and do them. And then once you're good with them sitting up, you can do them standing. And start with, you know, 10 to 15 at a time. like once in a while >> 10 to 15 repetitions.
>> So yeah, let's talk sets and reps.
>> So yeah, 10 to 15 repetitions in the morning, 10 to 15 repetitions at night, uh maybe one more during the middle of the day, but don't overdo it because just like anything, especially when you're starting out, you can. And if you're doing tons and tons of keigull, then you will get a tight short pelvic floor muscles and you will then develop pelvic floor dysfunction. So, it's really important to kind of understand those mechanics, which is why a lot of people think they know how to do keigull, but they really don't. And so, I always encourage people if you have the time and the resources to go to a pelvic floor physical therapist so they can really work with you and make sure you're doing them correctly.
>> What are some of the benefits of KeeL for those that need them?
>> Yes. So, they are typically prescribed for urinary incontinence, specifically stress urinary incontinence. the leakage that occurs when you have an increase in your intraabdominal pressure like a valva or coughing, sneezing, lifting heavy things, jumping on a trampoline.
Um so for those purposes we use keigull to strengthen the pelvic floor and also in women pelvic organ prolapse. So when you have weakness of the pelvic floor that leads to a bulge that you can visibly see or feel in the vagina. For men, we often prescribe them for people who have had a prostatctomy who then subsequently develop leakage after the prostatctomy. That is again stress, urinary incontinence. Now, a lot of people use keigull recreationally because improving the pelvic floor musculature can lead to more intense pelvic floor contractions during orgasm, which can be more pleasurable. And so some people do it for those purposes, but again, I caution people not to overdo it uh because then you can lead to a more tense pelvic floor, which is not where we want to end up.
>> Yes, I will underscore uh that cautionary note. Years ago, I heard about Keeles. I was like, okay, I'll try it. Sounds all good, right? I only heard good things about Keull. Um and what it quickly resulted in was painful urination.
And I thought, this is weird. Everyone saying keigull are so great.
>> Um and the best thing I could do for my pelvic floor it seemed was to avoid keigull.
>> Yes.
>> Um and a little bit later I'll when we're talking about prostate I'll I'll explain um at least what my experience was as it relates to the prostate. Um but I guess the take-home message that I'm gathering from what you're telling us is that strengthening the pelvic floor is great if you have a weak pelvic floor. strengthening your pelvic floor further if you have a strong pelvic floor can be detrimental.
>> It can be. It can be if you overtrain it just like if you overtrain anything else. And so, um, you just have to, if you really want to do keigull, if you have any symptoms at all, like you described, painful urination or the things I've described, like pain with erections, pain with ejaculation, pain, difficulty emptying, any of those symptoms, stop and go see a urologist so that they can kind of assess your pelvic floor.
>> What is the anti-agal?
In other words, if somebody decides that they have a tight pelvic floor, how can they learn to relax their pelvic floor?
>> So, there's a lot of different sort of things that you can do. So, for uh women, you can do massage of the area.
You can use vaginal dilators to help relax the muscles. You can take suppositories that have medications like Valium or Blephin, which are muscle relaxants, and um that can help as well.
Although they're not treatments, they're more of a band-aid, but they can help with the symptoms that you're having.
And then um you can also I think the best thing is to work with the physical therapist because they can teach you certain exercises that will help downrain the pelvic floor. For example, one of the ones I tell my patients is like happy baby pose. It actually, you know, stretches and elongates the pelvic floor muscles. So, doing these exercises regularly will help you lengthen the pelvic floor muscles.
>> One thing that I've experienced extreme pain from that stopping was one of the best things that ever happened for my pelvic floor was to not do any kind of crunching movement with my legs crossed. I would go to these yoga classes at one point in my life and I they'd have everybody do these crunches and I've always done some abdominal work here and there during the week if I'm being diligent, but they would have us cross our feet and that seemed to lead to some pelvic floor discomfort that was similar to what I had experienced when I did the Keeles.
>> Yeah.
>> So again, for me, ceasing the Keull was one of the best decisions I ever made. I only did them for a short while. I was like, "Okay, this is clearly not for me." And I guess that's another point um that Tell me if you agree. uh or not that if you hear about something online or on this podcast or anywhere else and you tried it and it seems to be sending things in the wrong direction either you're doing it wrong or it might not be the right thing for you.
>> Exactly.
>> You know, I think all too often we hear this thing is great and people jump on that bandwagon and then they end up worsening their problems or developing problems where they didn't have them previously. But is there anything about the anatomy of the neuromuscular connections or or vasculature of the pelvic floor that would provide support for my experience there? Yeah. That doing crunches with legs cross is essentially um is it possible that's creating asymmetries in the pelvic floor?
>> Um and now I'm sure I'm angering yoga teachers and um crunch crunchinistas everywhere. But you know, hey um if it's a question of your pelvic floor or a few extra um delineations in your abs, you know where my vote's going. So there's a couple things here that we should dive into. One is that people don't often breathe correctly during exercise, right? And so diaphragmatic breathing is is really important, which is like a deep breath that expands the diaphragm, not kind of shallow breathing that's just in your mouth and throat. And that is actually when you you know when you do any sort of exercise, the your trainer will tell you exhale on the effort, right? And there's a reason for that because when you inhale, your pelvic floor relaxes. When you exhale, your pelvic floor contracts. And so it actually that contraction stabilizes the pelvic floor. So whatever intraabdominal pressure you're you're causing to increase from the exercise, whether it's a squat or a crunch or whatever, you're increasing your abdominal pressure, your pelvic floor is then contracting to help stabilize that. And so part part of the reason people tend to hold their breath during crunches, right? they don't do the appropriate breathing and so that can be part of it. The other thing that can happen with certain things is that there are you know nerves and arteries particularly the predendal nerve and the predendal artery that run through the pelvic floor. So when you get pelvic floor dysfunction you can cause decreased blood flow to the to the pelvic floor muscles which can affect sexual function and you can get nerve inflammation as well that can also cause pain. And so this is kind of how it all comes together.
>> I'm so glad that you mentioned blood flow. I think our entire discussion today should be framed up at least in the back of our minds and the minds of our listeners and viewers as involving at least three things. You know, anytime we're talking about erectile function or dysfunction or pelvic floor function or dysfunction or vaginal lubrication or lack thereof, we need to think about the hormonal influences, the blood flow related influences and the neural influences, including the neural influences that come from the brain, the signals of arousal, for instance, or lack of arousal um and so on. So, um, we won't be overly systematic in in our, uh, parsing of all this, but I I think what you just mentioned raises a really important point that sometimes in an effort to do something that's good for the muscles, like strengthen the muscles, one will cut off blood flow. In fact, one of the more common questions I got and I consulted with a couple of um exercise physiologists about this and they confirmed that a lot of people who squat and deadlift heavy in the gym or even who just tense their pelvic floor when they're doing things like dumbbell curls >> or other exercises and especially people who seem to do a lot of abdominal work reported to me in the questions that they experienced things like erectile dysfunction >> that They experienced things like pain during vaginal intercourse that essentially they had created some sort of what sounds to me like a hyper contraction of the muscles in that area that were impeding all the things that they wanted as either side effects or direct effects of exercise because many people are exercising for aesthetic reasons and health reasons. But nowadays it seems especially on the male side, but we'll also talk about the role of testosterone on the female side. A lot of males lift weights in order to increase their testosterone and for reasons that are obvious also want to have healthy sexual function. And here they are doing this thing that's very good for increasing testosterone if they're doing it correctly. And testosterone is involved in libido and the male sexual response and the female sexual response of course, but they are impeding their erections. So you can start to see how um there are probably a lot of confused and maybe even distraught people out there. They're trying to do all the right things and they're setting up roadblocks and even um sending themselves backward in some cases. So the question is how does one know whether or not something like um let's say low lubrication or pain during vaginal intercourse or um loss of erectile strength or some sort of erectile dysfunction whatever it may be because it can take on different forms as we'll talk about. How does one know if it's blood flow related, hormone related or neurall? And if it's neurore related, how does one know if it's a issue of lack of appropriate signals from the brain, over suppression or lack of of arousal from the brain or whether or not it's some peripheral neural thing of intervation of the penis or vagina?
>> So I think there's there's a lot that we can go into here, but essentially first you want to find out like very specifically what is going on. Are you getting aroused? Are you having erections? Are you masturbating? like there's all these questions that will help us go down the route.
>> Sorry to interrupt. When you say aroused, um, for sake of this discussion, I just want to make sure that we distinguish between psychological arousal, the desire to to um, I guess here we also have to be precise. Um, arousal to engage in intercourse, arousal to um, desire essentially that I think people learn to recognize or are we talking about arousal as the response of the genitals?
>> Correct. So, so desire and arousal, this is a very important concept, doesn't always go in one direction. Sometimes you can feel arousal, meaning you have the telltale signs of arousal. Your nipples get erect. You have more lubrication if you're a female.
>> Do both male and female nipples get erect during arousal? I believe so. I think so. I believe so. Um, you know, you maybe get the sex flush, right? You get some some redness or or warmth feeling. That's your body's response, right, to arousal. And sometimes that can be an erection and sometimes that's not. Not having an erection does not mean you're not aroused. It may mean other things, but certainly that's part of it. And then desire. Do you want to have sex? Do you have the like when you think about your partner or who whoever you want to engage with, does is there a desire to actually do that, right? Or is it just more of obligation or other things? And does the desire it doesn't matter if the desire comes after arousal? For some women in particular, we see that they may not have the desire right away, but they want to be intimate or close with their partner. And so they'll start just being close with them and then arousal will come and then oh yeah, you know, I like this. So then the desire comes after and that's normal.
That's totally fine. Um so you want to kind of parse that out. And then for men you can ask, are you getting erections at night? because that will tell us the function of your organ at night versus during the day where you have also psychoggenic components, right? You can really get in your head about erections.
When you have a problem in the bedroom with performance, it becomes a vicious cycle, right? So you you have a problem the next time you're really stressed.
You're not present. You're not mindful in the moment with sex and you're thinking about, "Oh my god, am I going to perform okay? Am I going to perform okay?" and then it doesn't perform again and you're just it's getting worse and worse and the anxiety is through the roof and that's actually causing your sexual dysfunction. So I think it's it's important first to identify those issues and then also for uh blood flow a lot of times we can we can assess based on well what other coorbidities do you have? Do you have other issues ongoing that may be affecting your blood flow? most common high blood pressure, diabetes, heart disease, and if you smoke, all of those things will affect blood flow to the genitals. And so that will point us negatively >> negatively negatively. So So that will point us to a more vascular issue.
Hormonal issues are are very important for desire and and you know, as far as sexual function in terms of erections, there's only 3% of erectile dysfunction that's related to hormones. So it's actually >> pure ere erectile function, >> correct? as opposed to desire. Correct.
Psychological arousal. Desire is predominantly modulated by the hormone testosterone for both men and women. In fact, if you a lot of people don't know this, but women have more testosterone in their bodies than they actually have estrogen. So testosterone is very important for both men and women for a variety of reasons. And so you you know using that discussion with the patient will help you kind of identify where you're headed in terms of um what you need to focus on for treatment. There are you know certain things you can use to assess blood flow. You can do Doppler ultrasounds of the penis as well as the clitoris to see if there is good blood flow. You can assess the peak systolic velocity which will tell you if there's a problem with arterial inflow versus the end diastolic velocity which will tell you if there's a problem with venus outflow. And so that can assess those things. There are some tests you can do for nerve function although they're very uncommonly done because mostly we can kind of get that through clinical report. And unfortunately if you're having nerve problems sometimes it depends on what's causing them but sometimes they can be very difficult to reverse and that's kind of a problem. We know that as people age their sensation becomes less. So just through aging the nerves the receptors become less sensitive and so you will generally have less responsiveness to the same sensations you did when you were younger. And so that kind of overlays all of this. Uh so it's complex but really you know a lot of it comes from the discussion you have with your patient or you know you kind of really doing a deep dive in what's going on like really thinking about each of those aspects and also what's going on in your relationship and what's going on in you know your life stress anxiety like how are those playing a role.
>> Gosh lots there to unpack um and I'm glad you mentioned the relationship itself because um there are all sorts of things that can impact the arousal response. um novelty. Not everyone's in a committed relationship. Um whether or not people are engaging in a lot of masturbation to the point of ejaculation or climax or not, um pornography, etc. We we will get into that. It's a it's a vast space to explore. Before we go any further, I want to make sure, however, that we cue people to where and how they could find a really good, let's say, pelvic floor uh therapist.
um and where they could find a really great urologist to do the sorts of exams and perhaps the sorts of treatments that we've talked about because um at least as far as I understand much of what people want to learn on this podcast is how things work and what happens when things break down but also how to resolve those issues. So let's say somebody wants to um check out their pelvic floor, figure out what's going on there. Maybe they're having issues, maybe they're not. If they are male or female, where do they go? What is there a place online that has a great list of of some of the best ones in one's area?
Can it be done over tele medicine? Um yeah, how how does one go about that?
>> Yeah. So, in terms of your pelvic floor, it's good to get assessed by a physician who specializes in pelvic floor. Now, that could be a urologist, that could be a gynecologist, or even a physical medicine rehabilitation doctor that specializes in pelvic floor health. So typically you'll see um in urology you'll look for people who are board certified in female pelvic medicine and reconstructive surgery if you're a woman. If you're a man maybe sexual medicine uh someone who specializes in sexual medicine would be a good place to look for gynecologists. Again you want to look at someone who has interest in this area who you know does manage pelvic floor. And then in terms of pelvic floor uh physical medicine rehabilitation at least when I was in training there was about 20 PMR doctors around the country who really focused on this. So, it's not a lot of people. If you can go to a pelvic floor physical therapist and you have one near you, that's great as well. You um you do want to make sure that one they do are certified in pelvic floor physical therapy and that they have taken care of your gender. So, if you have male anatomy, then you want to go to someone who's actually seen men because a lot of the pelvic floor physical therapists tend to treat a lot of women. And so, that's kind of what I tell my patients.
Generally speaking, there's no, at least to my knowledge, no great resource. and maybe we'll we'll look that up and see if we can find one.
>> That's very helpful. Thank you. Because again, going back to what I said at the beginning of our conversation, I think there's a lot of know shame or at least a lack of clarity as to how one gets help for issues that uh relate to the genitals, right? Because if you have a headache or you're having an eye issue, I mean, you sort of know where to go.
Yeah. Hopefully your headache doesn't warrant going to a neurologist, but it might. Um, you know, eye stuff tends to be opthalmologist, optometrists, right?
Yeah. Um, so I don't think we hear often enough about where to access the best quality care for these things. So thank you for that. In thinking about sexual dysfunction, I'd like to have that conversation more or less in parallel if we can around male sexual dysfunction and female sexual dysfunction. And I want to make sure that before we do that that I'm creating the correct parallel construction as they say. Erectile dysfunction in males is clearly a form of sexual dysfunction.
What is the parallel to erectile dysfunction in females? Is it lack of vaginal lubrication and lack of relaxation of the vagina to have non-p painful intercourse? I mean, is there is it even possible to have a parallel conversation about these two things?
>> So, it's different in in some circumstances. There there are homologues, right? So, the penis is the homalue of the clitoris, right? So, the clitoris is the you know, essentially the same sort of spongy erectile tissue that you see in the penis. It gets erect with arousal and it is it actually extends very deep into the pelvis. So it's not just a small little organ. It's actually quite long and so you can in men you can have erectile dysfunction because you can see it. But in women you may have difficulty with orgasm and it's not exactly a parallel but difficulty orgasming in women is multiffactorial.
And we we can get into that but I think they're they're they're different. And I think also sexual dysfunction presents differently in both genders. So when you talk about men, they're very the one visual they see of arousal is erections.
And so it becomes very ingrained in your psyche that if I don't have an erection, I'm not aroused, right? But there's a lot of reasons that you might not have an erection that we've sort of touched on. Vascular problems, hormonal problems, neurologic problems, um psychoggenic issues, and other medications you're taking. So there are issues that can affect erectile function. Um and and so that can be part of it where you know you might feel like you have low desire because your arousal is not there and that becomes a little bit confusing for women. What they can assess is their level of lubrication if sex hurts and if they get an orgasm. And so those are kind of the ways you can look at it.
>> Thank you for fleshing all of that out.
You know, years ago, I worked on sexual differentiation and in particular the role of hormones in sexual differentiation. And indeed, as you described, we learned because we were taught and I think um people still generally agree that if one looks at the embryological origins of the penis and the clitoris, they are essentially analogous structures.
>> Um and that a lot of male genital development involves literally the regression, the disappearance of the female sexual genitalia and associated organs, malarian ducks and things like that. and what would become the ovaries become the testes etc etc those are anatomical parallels but what you just described for us uh very beautifully is the sort of functional parallels as it relates to sexual function and dysfunction so I'm hoping with that framing that we can uh that we can uh knock down a few of these pins uh in a little less time um because there's a lot to tackle here first off I'd like to address the hormonal issues you mentioned that only 3% of erectile dysfunction And by extension can we say also um female uh issues with sexual arousal are hormonal in origin. Is that right?
>> So with desire yes they are hormonal in in general and arousal in terms of lubrication. If you're using that as a as a barometer yes you can see less vaginal lubrication due to hormones. And I guess I'd say 3 to 6% more you know up to 6% we see of erectile dysfunction is hormonal. It's a small percentage of the entire entirety of erectile dysfunction.
>> Okay. So, I think in looking on the landscape of social media, podcast and and just in the common um mindset, we've all come to believe that testosterone is pro libido. It's pro- desire in men and women. I think now people are starting to appreciate that it's pro- desire in women as well. Um but certainly in men.
And that dopamine is also associated with desire. And the general public tends to have this view of estrogen as being sort of anti- libido or anti-male, which is frankly false. In fact, and I've covered this on the podcast with Dr. Kyle Gillette and with Dr. Peter Aia and um another fellow uh YouTuber uh Derek from More Plates More Dates has talked a lot about the fact that if people if men excuse me take drugs like an astrol to suppress their estrogen thinking that oh it's all about having high testosterone low estrogen oftentimes they crush their libido just abolish it which um has led to a slowly growing but um I think positive shift in how people are thinking about estrogen Estrogen is great for brain function.
Estrogen is great for libido in men and women.
>> Correct.
>> Um, and that is a revision of I I think how most people think of the male sexual response. It's more in keeping with how people think about the female sexual response. Oh, estrogen and the female sexual response. That that makes sense.
But what we're trying to do here is clarify some of the um misconceptions.
Now, the reason I mentioned dopamine is that my understanding is that dopamine is involved in the ar excuse me, the desire response. We will distinguish desire the psychological arousal from genital arousal physical arousal and that prolactin is associated with the refractory period during which erection can't occur another perhaps orgasm can't occur in females etc. But my understanding is that's also not that simple and we need to take a step back perhaps and just talk about the physiological underpinnings of the desire and and arousal response. So, I'll tell you what I was taught and then you can tell me where it's wrong.
>> Sure.
>> I hope I was taught that the erection response and the vaginal lubrication response is generated by the parasympathetic nervous system, the relaxed, the rest and digest aspect of the nervous system. Hence why some people can get psychoggenic sexual issues of lack of erection or lack of vaginal lubrication.
But that there are individuals out there for whom a lot of alertness maybe even and this is a controversial thing but for some people even some sense of aggression or kind of edgginess or excitement adrenaline in other words can stimulate erection or vaginal lubrication. So it gets tricky like it's not like the textbooks. It's not like they taught us in high school as far as I know. I was taught that the arousal response in males and females is initiated by a parasympathetic sort of relaxed tone and that as sexual desire and arousal and sex or masturbation progresses that it shifts more towards the sympathetic nervous system which has nothing to do with emotional sympathy and has everything to do with arousal. the catakolamines, dopamine, norepinephrine and epinephrine also called adrenaline and noradrenaline are released and that the climax response which may or may not include ejaculation. We have to separate that out is one that is really of the stress system of the body and then in the postcoidal or post ejaculatory or postclimax phase then there's a shift back to the parasympathetic nervous system. Um that's where um the uh pillow talk and the uh the exchange of uh odors and tastes and other molecules is known to enhance pair bonding through things like oxytocin, vasopressin and so on.
And what I just described is exceedingly oversimplified I realize. But is that more or less how the physiology works?
>> Yeah. So the way we're taught in medical school is point and shoot. So point is the parasympathetic nervous system. all your all the male audience will like that one. Yeah.
>> And then, you know, you go on to the sympathetic nervous system. But it makes sense. And the reason that I think you're hearing about this aggression or or these things that are leading to arousal is because there needs to be a stimulus, right? A visual stimulus, a tactile stimulus, some sort of stimulus that you're getting that is then causing the release of nitric oxide from the parasympathetic nervous system. And that could be for some people aggression or or you know, some form of that, right?
Can you tell people about nitric oxide because we'll get into this when we talk about um drugs that increase blood flow sealis Viagra and also um non-prescription drugs things like uh elcitrine arginine and um watermelon for that matter right so I read on the internet >> so yeah so nitric oxide is essentially the ignition for what we say for erections the ignition for erections that we if you the reason I talk about erections more often is when you look at the data in fact there was a paper on this where they looked at the number of articles that came up when you put in the word penis and the number of articles that came up when you put in the word clitoris and it was 50,000 about penis and 2,000 about the clitoris.
>> Okay, we have to we this was actually a major section of the comments. Yeah. On when I asked for for questions on Instagram um and comments on comments and yeah, how come um why not um etc. Is that because the urology and um sexual health field was dominated by men?
That's going to be the presumption. Or is it because it's easier to study somehow >> or I mean what's going on here?
>> Yeah, I think there's been a lot of um I mean you can go back to like Freud where he thought that that the female sexual response was less valuable and and so there are some some reason >> valuable >> I guess I not I don't that's the right term but >> Oh no no no I'm not challenging your term. I just ran I just >> you know it was >> you seem to be obsessed with it right but it was more about the male sexual response than the female sexual response and so in general yes there is you know there were more men in medicine there was more and it is easier to study right you can't study the clitoris quite as easy as you can study the male penis response because you can see it visually you can inject it and see an erection response right you we do this for people who have erectile dysfunction they'll take medications that increase blood flow like tryix and you'll inject it into the penis and you'll see an erection. So you can actually >> try mix >> try mix. So there's it's >> you're the entire male audience just went wait what are you injecting into?
>> So there there are there are three basically brand names of intracinosal injections that we use for erectile dysfunction.
>> I hear injection in penis and I I think it's a I like to think that it reflects a a natural male response. I sort of uh um I I taken a back. I don't know maybe there's a pelvic floor contractions in there someplace. So, so it is it is scary to hear about. It's a very small needle. It is very well tolerated. I've done it to patients in the office and they look at me and say, "You're done."
Like, they don't even, you know, it's it's not as painful as it seems. And when you are not having erections and you've tried multiple things, people get to the point where they're willing to try that. I, you know, and and so it is very effective. It is the most effective non-surgical treatment we have for erectile dysfunction. And it's usually either one medication, two medications, or three. So you can have uh you know alproadil paparene and what's the third one?
>> That's okay. We can um look someone will put it in the comments. Um uh surely they will. Um what what is it designed to do? Is it is it um a vasod diilator of sorts?
>> So they they they work in different mechanisms but similar to the medications that we have PD5 inhibitors.
PD5 inhibitors work in the erection cascade. Basically what happens let's actually let's take it back to the nitric oxide thing and we'll get there.
So nitric oxide essentially is released by the endothelium in response to a visual tactile stimula stimulating cue, right? And so your body releases nitric oxide which then sets off the cascade for the erection. And so that releases cgmp which is which is causes the erection and it's degraded by phosphodieststerase. And so medications that inhibit phosphodieststerase like Viagra and Cialis tend to prevent the breakdown of that cgmp so you have longerlasting erections. And so similarly these medications work sort of similar to that. Some of them we don't know exactly how they work but they work by increas increasing cgmp or c that are involved in those cascades.
>> And what about elcitrine? I hear about elcitrine use. It's an over-the-counter supplement um and it's in the arginine pathway >> and my understanding is that it works similarly to things like uh seialis Viagra but is perhaps not as potent. I also just a cautionary note out there elcitrine can give people vicious cold sores and canker sores vicious. You hear about this on the internet it's been verified by grotesque images that you do not want to Google for. um and not everyone tolerates it well.
>> So these actually work by increasing nitric oxide. So they're not in this they're not later down the pathway.
They're actually increasing the availability of nitric oxide. So L arginine is the more direct pathway but it's very low bioavailability.
Lcitrilline converts to larginine but it is lasts much longer in the bloodstream which is why people tend to use lcitrilline. Now, you know, in in sexual medicine, these supplements, while there's been some studies on them and they are effective, there's no regulation on the supplement industry.
So, you know, we can recommend them, but we just can't say that for sure that the supplement is exactly what's said on the bottle. We see lots of studies where they'll say, you know, I read one about melatonin and there's, you know, a variation of melatonin from like what's on the bottle to 400% times more. And so that's kind of the struggle that we as medical doctors have and I know we get a lot of slack for it that we don't talk about supplements. But it's really the challenge there is like finding the quality supplement. A great site is which I have no uh relationship to except that I mention them all the time um is examine.com >> um which uh has references to human studies and where there's a lot of efficacy shown and we'll get into some side effect issues does can't address um you know quality by brand issues but um thanks for mentioning that what percentage of males who take seialis um aka tadalapil or viagra for erectile dysfunction get um relief from that? Um because you mentioned only 3% of erectile issues in males are hormonal in origin. Um but what percentage are likely to be blood flow related in origin?
>> So a large percentage are blood flow related. That doesn't mean that the medication will be effective for everyone. If you look at the large percentage are are vascular in nature, right? That's the number one cause in in as men age. So we know that about 50% of 52% of men over the age of 40 will have erectile dysfunction and that continues to increase as you age. So um 50% of 50y old, 60% of 60-y old and so on and so forth. So it's very very common and the success rate in the studies is about 60 to 70%. So when you give someone a medication they will have sustained erections that are sufficient for penetrative intercourse which is the way we kind of discuss erectile dysfunction in studies and in you know with patients is is about 60 to 70%. So not everyone will have success but not all of that is because the medication doesn't work. Um sometimes people are not taking them correctly. Sometimes people need to try different doses and then there's still this issue of, you know, your brain is still active and so if you're having anxiety or you're having other issues or stress in your life, that can have an effect on your ability to create an erection. So there's lots of factors that go into it. Um, but generally speaking, they are effective and they do work quite well and they're tolerated pretty well.
>> And 60 to 70% is not a small number.
That's that's a significant number.
That's the majority by a significant margin. Is there a basis for the use of um seialis uh tadalapil viagra um elcitrine um in females? So yeah, there there's not a lot of data on this, but certainly, you know, if you have surmised that there is a blood flow issue and they're having difficulties with orgasm, it's certainly something you can try off label. And certainly people do try uh try these medications off label to see if they improve sexual function for women, but there's not a whole bunch of robust, you know, randomized control trial studies on women with with these medications.
A little bit later we will talk about prostate health specifically but I'm just going to um make a note here that um nowadays there's um increasing use of low dosage um seialisadal um so rather than uh what I found online was that the erectile dysfunction treatment dosage of seialis dalopil is somewhere in the you know 15 to 20 milligram range what we're talking about here is um daily use of um 2.5 to 5 milligrams of seialis tadalapil for prostate health and I learned in researching for this episode that um tadalapil seialis was actually developed as a drug for the treatment of prostate health to um essentially increase blood flow of the prostate to increase prostate health not for the treatment of erectile dysfunction. So I found that to be somewhat interesting um and a lot of people are now starting to use that. I also learned that um if you dive into the uh the guts of the internet um one can find that now there's a growing use of combined lowd dosage seialis and apomorphine which is a pro-dopamineergic agent and we'll get back to dopamine a little bit later but um is there any basis for low dosage say 2.5 to 5 milligram daily use of seialist in females >> yes so well let's talk about it in for males and females I think lowd dose daily is excellent for erectile function in men even >> is that true even sorry to interrupt but is that true even for men that are not experiencing erectile dysfunction >> it's not indicated for that purpose but there's a thought that you know it's increasing blood flow to the area so people I I've personally used it for men who have pelvic pain to help with increasing blood flow you can also use it potentially as a preventative so some people have you know kind of thought okay it's increasing blood flow it's preventing fibrosis of that erectile tissue that can happen with age or other vascular problems. So, it may be beneficial for that as well, although again that's off label and not something that we generally um promote. Uh as far as for women, there's, you know, again, it can help with blood flow. So, if you're having issues, so if you have a female who's having sexual dysfunction and she's got signs of vascular problems, like she's got uh diabetes, high blood pressure, she smokes, and yes, it's certainly reasonable to try and see how they do. We usually want to give at least a four-week trial to see if there's any benefit with those medications.
>> Great. Thank you for that. Um, why is it that I get so many questions about erectile dysfunction from males who are in their 20s and 30s? Because everything you said up until now was mainly focused on men 40 years and older. Is it from lack of physical activity, overuse of nicotine? By the way, vaping, as far as we know, um, vaping and smoking bad for erectile function and perhaps sexual health in males and females generally because nicotine is a vasoc constrictor.
>> Nicotine does have certain benefits and I covered this in an episode on nicotine um, neurokcognitive benefits in uh, the elderly in particular, but it is a vasoc constrictor. So, it runs against all of the uh, sexual arousal stuff that we're talking about. Um but okay, let's assume that um a male in their 20s or 30s is sleeping enough, you know, six to eight hours a night, is exercising, isn't doing anything to punish their pelvic floor in the gym. Um you know, they're not doing legs cross keull while doing crunches or something while inhaling on the crunch. Um uh that was a quiz, by the way, folks. um for earlier uh topics covered. Um let's assume they're, you know, eating pretty well. Majority of their foods are coming from nonprocessed or minimally processed foods. Um they're doing a little meditation each day.
They're engaging in hopefully healthy relationships. They're not masturbating like crazy to porn. And um uh you know, let's assume that they are, you know, not on any SSRI. Why are all these 20 and 30 year olds on the internet asking mainly you this is they mainly run to you um but also to my direct messages about their erectile issues.
>> So I will say I have seen a lot of young men in my clinic and I will say that they very often have pelvic floor dysfunction. So that even though they're doing all the right things, they're they do have I mean we're in a stressful society. So you can try all the things to be to decrease your stress but a lot of us are sitting long periods of time especially during co I mean people sat for months right years like just sitting at their home computer and so um you know exercising one hour is not going to offset the day full of sitting and so all of those things can affect pelvic floor function. So my theory is that that's probably the more common cause.
So, walk more.
>> Yeah, >> I've actually heard that.
>> Standing desk. Yeah.
>> Yep. Yeah. Walk more. Standing desk. Um, okay. So, um, and then my guess is that there's some psychoggenic feedback loop.
>> Absolutely.
>> Which is just nerd speak for things aren't working as well as they would like, then they're stressing about it and the stress is making things worse.
>> Absolutely. And, you know, you mentioned that people are not masturbating or or using porn, but a lot of people learn about sex through porn. whether it's good or bad, we can't, you know, it's not a great thing, but like that's accessible now. When we were growing up, you had to find a VCR. You had to find a quiet room that no one was going to walk in.
>> I'm old enough to remember when the kid down the street, I won't mention him um uh by last name, but yeah, the kid down the street, you know, had um porno magazines.
>> Yeah. Or magazines. And then there was actually a library of these goodness, I shouldn't say where they were where um in the town I grew up in where kids would stash them in um in specific locations in parking lots and then you know boys would bike or skateboard over or walk over and then they would like take turns look take turns excuse me looking at them. But that that actually is to raise uh perhaps a more important point um which is that looking at pornography is different than masturbating to pornography which is also different than masturbating to pornography to the point of ejaculation right because um I also get a lot of questions from people about their porn addiction issues >> and there's a growing theory out there that overuse that meaning not just looking at but um masturbating to pornography to the point of ejaculation is creating a deficit of seeking out and um cultivating healthy realworld sexual interactions.
>> Yeah. So I want to I want to start this before I get into that is is to say that if you're masturbating to porn and you have normal healthy relationships and you're going to work and you're have a great you know partner and everything's great in your life it's okay. like shame is a real problem and >> and maybe they're watching pornography together.
>> Yeah. So I think you know I think it's important though that at least in the literature they describe they don't describe porn addiction. They call it p problematic pornography use and it's only described in about 4% of people in these studies. So it's it's a small subset of people. I think it's becoming more common because pornography is so accessible and it it activates the dopamine pathways just like any other sort of addiction. Right? You you watch pornography, you get a dopamine response. Your brain then says, "Oh, I want to I want that again." And you keep seeking more novel, more aggressive, different types of pornography to get that same response. But it doesn't happen to everybody. But also I would say um sorry to interrupt but um that the dopamine response as as a hardwired biological mechanism um for adaptive behaviors including and let's just define healthy sexual behavior because I feel like um there's such a range on that depending on one's background, religious beliefs, etc. Um anytime we talk about sex on this podcast, I like to say that involves at least four things.
obviously consensual, age appropriate, context appropriate, species appropriate.
>> Yes, absolutely. Absolutely. I'm really glad you brought that up. So, I've heard you say that before, but it's very important. And so, I think, you know, there is a spectrum, a large spectrum of people who watch pornography, ejaculate to pornography, and have a normal life.
And so, that's fine. I think that, you know, if we shame those people, we're creating problems, right? We say like, "Oh, you you do that. that's horrible.
And then they're in their head, right?
And then they're causing problems in their life because they're because of shame. And so there's I think there's a little bit of um cultural shame that comes of this discussion. And so, you know, it's a problem in the long term if we if we say that, oh, this is going to create problems because not everyone has there's so many people who watch pornography and have no problems who, you know, have normal healthy relationships, great sex with their partner and it's fine or they >> or they're between or they're between relationships. Yeah. And they're relying on masturbation specifically, right? Um, are there any data that distinguish between um just pure imagination fantasy versus visual fantasy um as it relates to developing or inhibiting sexual health? And here we're talking about the desire aspect. Let's assume physical arousal is you know handled, >> no pun intended.
>> So I think that um the the the thing about young people I wanted to get back to that then I'll answer your question.
But the thing about young people who are watching pornography, that's what they think sex is supposed to be like. They don't get an education about what sex is, right? No one has a conversation with their kids like, "Hey guys, this is what happens when you have sex. This is how long it should take. This is what foreplay is. And this is like not normal. This is a production. This is a produced product that's meant to arouse you, right? And and to give you ideally an ejaculation or an orgasm, right? So, um, no one has that discussion. So, we then go to relationships and like, why did my partner not react like that woman did on the porno, right? Or why did I not react like that woman did on the porno, right?
>> Or why didn't he react?
>> Yeah.
>> When, you know, like they would in porn because again, I think females are watching porn as well.
>> Exactly. Yeah.
>> You know, I think so I think that you raise a really critical point which is that the shame can extend both ways.
Mhm. Mhm. And so I think to that end that's a problem and and because it's so accessible I I think we need to have conversations. I think it needs to be open. We have to talk about sex and that's kind of why I do what I do. We have to have these conversations so people know what normal is.
>> Thank you for that. I do think that um people need to know what normal is and what the range on normal is. Keeping the constraints that we talked about place earlier because I do think those are universal healthy constraints, right?
consensual, age appropriate, context appropriate, species appropriate.
>> Absolutely.
>> I asked whether or not imagined you pure imagination based arousal versus um visual arousal. Um and for some people the sounds of of people having sex is extremely arousing. If you ever lived in a major city um like New York, which I've spent summers in New York, you hear a lot you hear more more often than you do in um areas where people are living further apart, you hear people having sex. Yeah, >> it's part it's part of the um part of the auditory landscape.
>> Yep. You're very close together. So, um but yes, so there's not exactly, at least to my knowledge, I don't know of the data that looks at fantasy versus visual versus auditory, but I will say that you can get habituated to certain things. And there is that data that maybe you can get habituated to watching a certain type of thing to get aroused and then normal things do not get you aroused, right? Like you may watch pornography and then you may have difficulty getting aroused or turned on when you see your partner. Uh you may get used to masturbating a certain way, right? So if you use certain vibratory stimulation or certain pressure sensation every single time you masturbate, you can get habituated to that and you may not be able to replicate that during penetrative intercourse. Um and so I think that's really important and I think the take-home is to try and vary what you're doing. Masturbation is fine, healthy way of self-exloration. Again, with the caveat that as long as you're not masturbating to excess and avoiding your obligations or your family or your partners or your friends, right? Like you are just masturbating for the the benefits of maybe sleep improvement, mood boosting, reduction in anxiety.
Those those those things are great. And so I think um with that being said, you just want to be thoughtful about varying it up. One of the issues with masturbation that I've talked about when I was a guest on other podcasts um mainly in the context of male masturbation and um perhaps with pornography perhaps not is that it's pretty clear based on the data surrounding addiction that anytime there are big increases in dopamine without a lot of effort required to generate that dopamine like turning on pornography on the internet versus you know asking someone out on a date, going out on a date, you know, again, we're talking about going through the conversations and the mating ritual that is the human mating ritual that of course in the context of healthy interactions involves getting mutual consent and these kinds of things, right? that you could imagine how without placing any moral judgment on it, without shaming anybody, you could imagine that if somebody exclusively masturbated and didn't develop the skills of courtship and building healthy sexual relationships that pornography and or masturbation could start to create quote unquote problems, right, whereby somebody only felt comfortable in those domains. Yeah.
And I think that's what I'm hearing more and more about when it seems to be young men reach out.
>> Absolutely. And I think you're, you know, it's definitely the ease of access, right? But I think that's pervasive in the young society now. Like you don't have to actually go and find a mate. You can just go on an app and look for somebody, right? Like there's there's >> Well, that's a form of finding a mate. I mean, I I was weaned in the era when uh you know, no smartphones or anything.
And um >> no, my my point is I think that we've become very um connected to technology in our world, which also means that we're having less conversations. The younger generation is having less conversations and more online conversations. And I think that's a skill that needs to be developed as well. And I think part of that is is contributing to all this as well.
>> Well, one thing that I can attest to is that, you know, I grew up in a community of mostly male friends. I have female friends, always have. um where a lot of what we learned about sex came from older, in my case, guys.
>> Mhm.
>> My sister probably learned a lot about sex from her female friends. Um and there was always that one guy who would just say stuff that years later I realized was incredibly misleading, right? Maybe even just detrimental.
>> And I just want to remind people that when you are on Reddit or anywhere on the internet and there's people saying things with certainty, um they might be that guy. Yeah.
>> Right. And um and if you look at the if I look at the long arc of those people's that guy's life, it it didn't speak to um tremendous success in the domain for which they were asserting such confidence. Let me put it that way.
Okay. Um I'd like to slightly pivot to a different aspect of this conversation because it's just really critical, which is the female sexual response. You know, this is something that um does not get enough discussion.
>> Absolutely.
>> And there's a lot of stereotypes, right?
The stereotype that we hear about is oh, you know, they need more foreplay, which can be true.
>> Some cases is not true. Um the stereotype is that women are more um intimacy and relationship based in their sexual response.
That can be true. I have female friends and have known women who also are just really interested in having sex for sex sake >> at times.
>> Yep.
>> Or maybe all the time. Um I think I like to think that we are past the stage of human development where the stereotypes around this are um are fixed, right? And I and and we hear more about this and we see more about this now, but what is the real deal around the female arousal response? And then we will talk about female orgasm response. And there I'm just going to earmark now that um anytime we say something like arousal or orgasm, there are multiple forms of that, right?
Um and we will talk about the multiple forms of female orgasm.
>> Yeah. So if you talk about the response cycle, you can go back to the research of Masters and Johnson. And so what they did, this was way back when, and they actually watched sex workers have sex.
And this was, I guess, okay. Back then, >> female sex workers.
>> Yeah. With men. Yeah. So they they watched and they took note of the the kind of the steps of the female arousal or sexual response. And so the first phase is excitement, right? And during that phase, your heart rate goes up, you're breathing a little heavier, there's this sex flush, you can see redness in areas like, you know, in the vulva, in the breast, I mean, in the nipples. And then you go to sort and that can last a variety of different times. You'll also start seeing some lubrication vaginally, right? And then the plateau response is when you know that is kind of at its peak and it kind of stays steady and then you reach orgasm. And so orgasm essentially is a response of the body where you will have again increased sympathetic response and you will have pelvic floor muscle contractions which are rhythmic about 08 seconds or so you're having a rhythmic pelvic floor contraction along with the sensation of orgasm and then you'll have your recovery period which you talked about briefly earlier which can have you know sort of a refractory time period at which point you can no longer you know orgasm again if you'd like to or for men obtain another erection again for a short period of time and that can be kind of an absolute refractory period so where it's definitely not happening and then a relative refractory period where you need something more novel and exciting to then again resume that cycle again >> the coolage effect >> we'll talk I've talked about the coolage effect before on this podcast I'll just cue people to a a timestamp link in the show not caption so we don't go the down the path but one thing that's really important to understand is that the coolage effect is present in both males and females meaning if a male ejaculates and um is of the feeling that they can't have another erection for some period of time. The presentation of a novel I guess we should say partner because we could be talking about homosexual relationship here not just heterosexual but um a novel sexual partner female or male depending on their um their proclivities um can override the refractory period um and they can have another erection and ejaculation. Um similarly, a female will have a post-orggasmic refractory period if they're um given an adequate stimulus, right? Something arousing enough, they can um experience arousal and orgasm again. And we know based on really good pharmarmacology that this is a dopamine driven um thing. The prolactin is essentially establishing the refractory period and the dopamine is essentially overriding the refractory period.
Fascinating neurochemistry there. Um, and speaks to the incredible extent to which the brain is controlling the genitals.
>> Yeah. I mean, we we always say in sexual medicine that the brain is the most powerful organ for sex. Not not your genitals, but the brain because it is so powerful. And I'm not sure if we're going to touch on this later, but I'll bring it up now. There are some centrally acting medications now available for they're FDA approved for premenopausal women with low libido. Oh, but maybe just throw those out because the one that I'm aware of um is uh in that's often used in let's say niche cultures um is melanocy stimulating hormone in men >> um which gives people a tan makes them erect. Um that melanocy stimulating hormone at MSH comes from the medial >> pituitary if I'm not mistaken. Um one of those weird regions. No, everyone talks about anterior posterior. Um uh but and people are now injecting this as a peptide. It can cause priism. I have not had that experience. I've never tried this um MSH, but I've been told that it it people are getting cavalier with it.
They can um have issues. Prepism being enduring and perhaps even final erection. Is that true? That >> Priapism or Priapism? I mean, it's actually from Priapus, the Greek god who is often photographed with a really big erection.
>> Oh, wow. We didn't hear enough about that Greek god in school, >> but um or is it Roman? Roman to Greek.
But anyway, so either way, um, it's an erection that lasts longer than 4 hours and it is actually a surgical or it's not a surgical, but it's an actually an emergency. If you have an erection that lasts longer than 4 hours in the absence of, you know, sexual arousal, then it is important to get to an emergency room because at that point, you can start developing decreased blood flow and ultimately changes to the actual tissues, scarring, fibrosis. Uh, so it's really important to actually go to the emergency room. Don't wait because you're embarrassed. um really get there and get treated.
>> However, if I'm not mistaken, earlier you mentioned that it is exceedingly rare that people who take Seialis Dadalapil or Viagra for erections are getting true priism.
>> Correct. And it's mostly from uh those injectables we talked about earlier, those intercronosal injections. People can get priapism from those a little bit more commonly. And so that's something we always counsel on. also certain medications like trazadone um or if you have cickle cell anemia those are the most common reasons that we see people coming in with private >> transone really okay I'm going to refrain from my um desire to figure out that one so I don't take us down a rabbit hole here >> sorry I wanted to get back to the MSH there's actually an FDA approved medication called brimalanotide is the brand name vile is the uh the sorry brimanide is a generic name is the brand name which is FDA approved for women with with low desire hypoactive sexual desire disorder, premenopausal women, premenopausal because that's what they studied. Um, but it is basically the same peptide, right? So, it is a melanoorton receptor agonist and it works dope, you know, on the the brain pathways to increase desire. It's taken as an injectable again just like you you said about an hour 45 minutes before want when you want to want you take it 45 minutes before and it works quite effectively in increasing desire.
>> How long does it last?
>> About 24 hours some people maybe up to 48. Um >> has it been I mean I know of men using melanocy stimulating hormone peptides. I also really want to caution people um about obtaining gray market peptides.
Sorry for this um uh insertion here, but um there are a lot of peptides available without a prescription on the internet.
They are almost all contaminated with something called LPS, lippy polysaccharide, which is not something you want to be injecting a lot over time. That's actually how we induce an immune response in animals in the laboratory. Um and it is amazing to me how many uh websites are selling this stuff and it um arrives to you easily.
You just buy it on the internet. that says not for human or animal use and people are injecting it and uh the LPS issue is something I think is um potentially going to shut down that whole market at some point but if you're interested in using a peptide you should be obtaining it by a prescription from a quality physician.
>> Exactly. And because we have brelanitide we can prescribe that for men as well.
So sometimes we'll do it off label for men who are having delayed ejaculation because it will help them achieve orgasm a little bit better. Um and so you know this is available for premenopausal women. The other uh medication that's available for low libido is called flabanserin also known as atti is the brand name and that also works on serot.
It's got kind of a mixed response serotonin and dopamineergic areas of the brain and essentially works as a daily medication taken before bedtime 100 milligrams a day that actually helps with decreasing hypoactive sexual desire disorder. works in about 45 to 60% of patients and you need to take it for some time. Now, both of these are brandame medications, so they are a little bit costly and sometimes insurance doesn't cover them, but they are available and I think very few people know about them and I think they're really great and useful tools in the toolbox.
>> And these are for desire.
>> They're for Yes, they're they're FDA approved for what we call hypoactive sexual desire disorder, which is essentially low libido that causes distress and bother.
I don't want to take us off course about uh vaginal um lubrication, arousal, and female orgasm, but as long as we're talking about arousal and um reduced arousal that requires treatment, I have to ask this now. Anytime we talk about arousal and libido, there's no BMI, which by the way, the body mass index is probably not the best uh tool either. Um but there's no chart. It's not like a thermometer that says you're 98.6 plus or minus two degrees, you're good. If it's too high, much higher than that, you have a fever. If it's much lower than that, you're hypothermic. So my understanding, my uh I don't want to say naive understanding but um my understanding is that one determines whether or not their libido is normal, high or low largely based on some intuitive understanding of what their partner or partners desire, whether or not they can meet those desires. And if they sort of uh acrew enough of a sample size, they date enough people where they have sexual interactions, they can they figure out over time whether or not they have a low, medium or high sex drive.
And people tend to compare to how they felt in earlier years or at different times of the year or under different psychological conditions and stress conditions, that kind of thing. But we really don't have a benchmark for this, right? I mean we can't say that um for instance that if uh people are not desiring sex or thinking about sex with blank frequency that they have low libido right it's sort of what is working or not working for you in the context of your life right is that is that reasonable way to think about it >> there's no right or wrong basically what you're saying there's no right or wrong amount of libido there's many people who identify as asexual and they are happy with that there are people who uh like to have sex once a month and they're happy with that. It really is a matter of distress. Are you bothered by it? So, when we look at studies for female sexual dysfunction, you can using like validated questionnaires like the FSFI, you can actually see that about 40% of people qualify for having sexual dysfunction. But really, bother is only seen at about 12%. And you can be bothered because you're bothered, you can be bothered because your partner is bothered, but it's really up to you, right? Like if you feel like there's something that you want to improve on, then that's when you go see your doctor.
But there's no right or wrong answer, right? This is very subjective. And a lot of times we'll see couples who have mismatched libidos. Now, does that mean one person's right and one person is wrong? No. It's just a matter of like, well, how do you if you want to come to a point where you agree, how do we get there, you know, and what is what is your end goal?
>> Yeah. I later we'll talk a little bit more about chemistry which I find infinitely fascinating because in my life experience I've just been struck by the fact that occasionally you have a physical interaction with someone or sometimes it's not even physical interaction and they are just so unbelievably arousing to you >> or somewhere in between or sometimes it it just sort of ain't there.
>> Yeah.
>> Or it's just not there that much or nobody likes to talk about this or it's there until you sleep together and then it's not there. And this is all not just put on males. This is put on females. I I uh I hope she doesn't kill me for saying this.
>> I know somebody who is a family member uh who once said sometimes you have to realize you never want to sleep with somebody again be by sleeping with them.
And here we're not talking about traumatic experience. Right. So you know again that the discussion around libido as you um so aptly pointed out engaging what is healthy levels of libido has a lot to do with what oneself desires as well as the hopes and expectations of the people that we are sexually involved with. So we'll get back to that a little bit later in the context of chemistry because I find it so fascinating and it's something that isn't talked about enough but thank you for that. Um let's get back to female sexual arousal response and orgasm. So physiologically what happens to the body is it prepares for penetration. Now that could be a penis, that could be a sex toy, that could be a digit finger um to be more specific. So it what it does is the cervix moves up and out of the way. The the inner one/3 2/3 of the vagina lengthens and elongates to allow for penetration and it can actually d nearly double in size of the of the baseline vaginal length. And so it is preparing for that. So if you and so that's part of it in some people who have um painful intercourse it's because they haven't had adequate time for arousal and so they're the penis is penetrating before they've had those adaptations to occur and also the labia open up to allow for that penetration. So these things actually happen physiologically to allow for preparation. So while some people may be aroused and get to that point quicker, some people do need a longer period of time of what as you described foreplay and not everyone is the same.
But I think it's important to have that discussion with your partner and you know lubrication is one of the ways that people assess arousal but that's not the beall endall. Some people just make a lot of lubrication and some people don't and certainly that changes with age and hormones. So if um certainly we know that after menopause with a drop in estrogen and testosterone you will see a decrease in lubrication and sometimes if people are on medications that can alter their hormonal axis they may also see changes in lubrication after during breastfeeding you can see changes in lubrication and again this is not a they're not aroused necessarily this is like a physiologic problem that they're having. Can we distinguish between arousal-based lubrication, let's say sexual arousal based lubrication, >> and again folks, forgive me for being so hyper specific in language, but there are other forms of arousal besides sexual arousal that um we know from it's not a pleasant topic from um reports uh following sexual assault that you know often times the victim is demonized for having been um lubricated and they will say well then people will presume that somehow they wanted that interaction and That's not true in those cases. It's clear that those that the lubrication occurred independent of libido type arousal.
>> Exactly.
>> Right. Okay. So, let's set that aside.
Again, unpleasant topic, but one that's important to to um to to flag.
Are there forms of non- libido type arousal lubrication that allow for non-p painful or even pleasureful penetration?
that are important to distinguish from the arousal-based lubrication. In other words, I have to imagine um that women will have sex and it can be pleasureful or at least not painful. And that might relate in some way to baseline levels of lubrication. And here we've been talking about lubrication um mainly in the context of arousal, you know, post-menopausal reductions in lubrication. But are there also post-menopausal reductions in baseline lubrication? Are some people's vaginas just more lubricated at um I want to say at rest. It's like the scientist in me.
Um when um they're asleep for instance, I mean men are having erections in their sleep. Are women getting vaginal lubrications in their sleep periodically? My guess is yes.
>> Well, they're definitely getting clitorol engorgment, right? They're getting clitoreral engorgment. There's been some studies on that that they are also getting nocturnal tumes, right?
Just like men do. As far as lubrication, you know, the the data, at least from what I understand, is like there is a a protective mechanism whereby women when when there's any sense that there may be penetration that their body will immediately start creating lubrication and that is protective to avoid you know trauma and injury. Uh there's also baseline vaginal discharge that's completely normal. Women will make physiologic discharge. In fact, in our examinations, when we examine women, we'll say normal physiologic discharge because we see it. There's always discharge and it is um it can be up to like 5 milliliters. And so, it's not a small amount. It can happen. It can be quite a lot.
>> And it's menstrual cycle dependent in terms of the viscosity and the >> Yes, it changes over the cycle. And it can be different in color and different in thickness and that's completely normal. And I think that's a real problem in the feminine hygiene industry. um you don't need to smell a certain way or or reduce that discharge.
This is like completely normal, healthy.
And you talked about chemistry and I know there's like not a ton of data on this, but there's like pherommones, right? There's scents that are coming from you which are actually attractive to a partner potentially and and in whatever physiologic, you know, I don't know there's not a lot of ton of data on this, but like there is that part of it.
So um you know there's a lot of marketing towards women that you're dirty, you should be smelling like peaches or whatever and there's a lot of marketing. I I maybe this is a generational thing, but I learned early on I think my behavioral neuroscience courses that vaginal lubrications were um part of the arousal response for both >> um these were always framed in the context of heterosexual relationships, but both partners, let's just say both partners. Um because this could be a homosexual female relationship too, right? We want to make the conversation as broad as possible. Um and that the uh odor, let's just be frank here. um the odor and the taste um played a role in both arousal but also the pair bonding response that would establish future arousal. And anyone that's ever been in a um in a relationship that uh let's say had healthy sexual rel uh relations I like to think has experienced um remembering somebody's smell or thinking about somebody's smell and that itself can be very arousing.
>> Yes.
>> Partners even I'm smelling different articles of each other's clothing and that being arousing. So I mean this is the stuff of of real physiology. We're not we're not making this stuff up, >> right? But there is there is a lot of marketing towards women that they should use douching or other things to clean themselves. And it is it's damaging, right? It's actually one it can affect the vaginal microbiome. So, their pH is changing and that can affect, you know, their risk for UTI or bacterial vaginosis and um and and so they're they're buying these spending their money on these things because they're being told that they're not clean and they come to the doctor saying, "Oh, I'm you know, I think I have a STD, but it's like normal physiologic discharge." Um, and so I think it's important to say that this is normal and and it's normal to have an odor that is distinct to you and that there's, you know, of course if you have like a fishy odor that may be a sign of like a very strong new novel odor that wasn't there before, that may be a sign of a sexually transmitted infection. But if it's your general odor that you've always had, that's normal.
And what about other infections like yeast infections or bacterial infections of the um I got a number of questions about myopplasma um infections which you know we don't hear that often about but um >> yeah so you you can see if your discharge has changed and become more like cottage cheese like or there's um you know other symptoms like itching um or discomfort then you know those are signs to go get evaluated.
Myopplasma is another infection that we see in the vagina, but we also actually sometimes see in the urine. And while it's not something we routinely test for, when we have people who have symptoms of urinary tract infection and they're not improving, sometimes we will check for myopplasma that could be causing symptoms in the urethra itself.
>> Um, we've had a couple episodes about the gut microbiome. My colleague Justin Saunenberg at Stanford whose laboratory is directly above from expert in the gut microbiome. I've done a couple episodes about this and um he reminded me and I like to remind people that um every mucosal lining of your body has a robust microbiome. So that means intraasal, intra vaginal, intraurethal in um males and females. Um there's an anal microbiome. There's a microbiome on your skin, on your eyes. Um and you mentioned douching and other uh and other ways of I want to say quote unquote cleaning it because that language falls in line with the idea that it's a good thing. you're telling me it's it's a it's it's a bad thing in many cases um because it's wiping out the microbiome. What are some of the things that females can do in order to u promote the health of their vaginal microbiome?
>> So, it's it's really um our bodies are amazing. The vagina is a self-cleaning oven. You don't have to do anything. You just >> I love that the vagina is a self-cleing oven. I'm not going to I'm not going to repeat that too often in too many different contexts, but I'm going to remember it forever.
>> You will. You will. And so all you need to do is wash the hairbearing areas because those are the ones that create sweat and and and should be cleaned. But other than that, let soapy water run down. You don't need to do anything.
Your body will take care of it itself.
>> When I was 5 years old, I pulled my parents in the bathroom and I said, >> they still talk about this. I said, I want to know everything about sex. I want to know everything. And they were like, "Oh my god, what are we dealing with?" And I'll never forget, my dad just looked at me. He's Argentine. He said, "Just remember, kids are the one thing in life you can't give back."
That's all he said. That was it.
>> That's it.
>> That was it.
>> Oh gosh.
>> Well, I will tell you my discussions with my sons are my son, my older son has been much more graphic than that. I tell him >> amazing. Well, I went out into the world and uh Anyway, um >> you figured it out.
>> Okay, >> let's spend a few minutes or more talking about female orgasm.
One of the more cryptic topics on the internet.
not because it isn't discussed, but because I think that the nuance of it isn't discussed often enough or in full depth. So, let's take the time we need um to parse this.
I think that the simplest way to parse it is going to be from the anatomical standpoint. Clitorol orgasm versus so-called G-spot or penetrationbased orgasm. But of course, penetration based orgasm is also a bit of a misnomer because um there can be uh clitoreral stimulation by pelvic pressure or by digit. We're talking about fingers as digits because we're both um in the medical/science profession, but we're talking about fingers here or something else, right? Vibrator, toy, whatever toe for it depends on how flexible you are.
I don't know. But the point being um that I think the simplest way to go about this is going to be to talk about the distinction between clitoreral orgasm and G-spot orgasm. However those are achieved. Um and to also talk about this idea of graded versus absolute.
Okay. So um this has actual parallels to neuroscience where we talk about communication between neurons being graded meaning it's kind of you know one level then a higher level then a lower level or all or none right um how shall I say this um it is clear in my life experience and observation that there are multiple kinds of female orgasm those that are graded and in some cases cumulative they sort of build towards a larger and larger orgasm and then there are what some people have described as cliff type orgasms where there's a refractory period.
>> Mhm.
>> I think that's a fair way to frame this.
And clearly there are different responses to the orgasm response. Some people get sleepy, some people get energized, some people it heightens their desire for more, some people they need a a a period of time in which um they become hyper sensitive to touch.
>> Um so uh lots of different things going on there. Um psychologically, physiologically um yeah tell us all of it. So in terms of orgasm, right, I think it's important to distinguish that there is orgasm and then there's different areas that you stimulate to achieve orgasm. So some people will stimulate the clitoris is probably the most reliable form of stimulation that will achieve orgasm.
And when you look at the data and again, you know, female sexual dysfunction data is not super robust, but what we find is that about 85% of women require clitoreral stimulation in order to climax. So very few actually climax through just vaginal penetration alone.
And so this is, you know, a a real problem. We're seeing on the media that, you know, you you have sex and you penetrate and immediately women are having orgasms. That's not the reality for a lot of women. And in terms of stimulation, so like we've talked about throughout this podcast, the clitoris is the homalogue of the penis or the penis is the homalogue of the clitoris, however you want to say it. Um, >> good on you for getting it both directions. I probably would have screwed that one up.
>> Yeah.
>> So, um, so clitoreral stimulation is just like penal stimulation. For women, that is very reliable. And there's a huge orgasm gap. For men, it's pretty consistent that when they have a first time sexual encounter, 95% of men are having an orgasm. When you look at firsttime sexual encounters for women with in heterosexual relationships, it's about 45 to 50% are having an orgasm.
And when you look at homosexual relationships of women, it's again 90%.
So there's clearly some lacking in >> 90% of um female homosexual interactions that are first-time interactions, 90% are having orgasm.
>> Correct.
>> Presumably because they understand the anatomy of other by way of understanding the anatomy of self.
>> So there's a huge >> and physiology and psychology of of >> that too. That too. But you know there's a huge gap there. And so I think to to bring it home is that clitoreral stimulation is the most reliable way.
And as you mentioned when you're stimulating vaginally, you're often the clitoris is like a wishbone and it goes around the vagina. And so you're often stimulating those the cura is what we call the legs I guess for lack of a better term of the clitoris. And so you're stimulating that. You're also stimulating the cli the clitorol shaft which goes deep into the pelvis. The G-spot is um is an area is a neurogynous zone where it's kind of in the anterior wall of the vagina about 2 to 3 cm in.
That's the location of these parurethal glands called the skins glands and they are analogous or homologous to the male prostate. So just like some men have prostate play and enjoy pleasure from prostate stimulation, some women enjoy G-spot stimulation. Now that's not universal, right? Not all men enjoy prostate play and not all women are going to be aroused by G-spot stimulation. And so I think there's a huge uh huge variety of ways you can stimulate w stimulate anyone. It can be man or woman. Some people will have orgasms through just nipple stimulation alone. Some will just hear something or see something and be able to achieve an orgasm. And it's it's so varied from person to person. And I think that the big takehome from this for people listening is like you have to talk to your partner. And this is the hardest thing. We never learned how to talk about sex. Like what do you like? What do you not like? And and don't take it personally, right? Like I think a lot of times people feel like you have to orgasm to have pleasure, which may not be the case for everybody. Um and if it is, you know, how do you prioritize that for your relationship? So, I don't know if I got off track there, but that's kind of um I think the the takehomes for this. And also the vaginal penetration, it's actually usually from cervical stimulation, not necessarily vaginal because the large density of intervation of the vagina is in the first outer third of the vagina. The the deeper two/irds of the vagina has has much less intervation.
>> And yet there is such a thing as cervical orgasm. Mhm.
>> So, and the cervix being further up the the vaginal canal. Um, is cervical orgasm specifically the what the stimulation and uh the fosai of an orgasm that starts in the back of the vagina? Is that >> Yeah. So, it's from stimulation of the cervix through whatever means, right?
And that can be pleasurable and lead to orgasm. And again, orgasm, you know, is is defined differently, right? But the one thing we know is that there are pelvic floor contractions which are measurable. So you can kind of tell that your partner is having an orgasm if you have a female partner because you can actually feel those contractions, right?
Whether it's on your digit or your organ or a sex toy.
>> Okay, super nerdy question here. um years ago when I worked on hormone-based sexual differentiation of which by the way we've done a episode of the podcast on previously um uh you know I learned that the levator any muscle um is the muscle that controls erection in males and presumably uh clitoreral tumes and an engorgment in females. Is there an equivalent muscle responsible for the orgasm response or is the contraction of the pelvic floor um part of a more general theme of of muscular contraction and a bunch of different um nerve roots contracting? The reason I asked this is that eventually in this conversation we're going to migrate up toward the brain. But because this is a science and health podcast, when we talk about orgasm, of course, many people recognize that as their experience of it and their recognition of it and other people um and descriptions, etc. But, um are we talking about a response that originates at a fosi? Um kind of like in a in the brain we talk about a seizure, you know, starting at a focus, a fosi, and then spreading out. um or are we talking about a bunch of different nerve roots and brain centers firing in synchrony and that's why some people experience it as you know behind their forehead and in their genitals or as a whole body response and here we're not talking about the flood of of neurochemicals into the body I'm talking about during those moments of orgasm um what is happening neurally I mean it does have certain parallels to seizure right in >> it does it does so let me go back to your first part of the question which was um about orgasm and sorry erection and tumes being related to levator ani.
Actually what happens during um the reason you get an erection and presumably clitoral stimulation the same way is blood flows into the erectile tissue and the tunica which is the outer layers of the of the sh of the erectile tissue which are two basically cylindrical shaped structures in the penis and in the clitoris they will fill with blood and then that tuna will compress veins on the outside to prevent blood flow from leaving. So it's not a muscular event it's an actual blood flow event. Then how come when we wanted to study erection behavior in rodents, we would um give them injections of testosterone, females or males, >> and observe changes in sexual behavior accordingly, erection and clitoreral tumes. Um although that's hard harder to measure in rodents, there's a way of indirectly measuring that. And then we would measure the the size and weight of the levator annie muscles as a readout of how androgenized that whole system was. You know, in other words, what is the role of the levator ani in in the sexual response?
>> So the levator ani or I say levator.
>> Well, you would know I I think it so those muscles are part of the pelvic floor, right? And so those contract when you e when you climax, right? So whether it's orgasm for male or female, they're contracting and they're exercising, right? they're get. So that's how they would increase their their strength or their density um if you're measuring that through the actual climax of which you can't see in rodents, right? So like you're kind of using it as a surrogate in that way. Um so that's what happens.
Those muscles contract as a response and climax is a brain initiated event.
Orgasm is a brain initiated event. So that's why to answer your second part, you obviously feel focal response, but you also can feel a variety of responses because it's all coming from the brain.
It's not kind of the the way you described it as like a ripple effect. Um it's more of like a it's the way your body responds to that particular stimuli. And it's actually like the ultimate form of mindfulness. You can't think of anything else when you're orgasming, right? So it's like you have this moment of clarity and and every and and everything you present in that moment and so people will feel different stimulations depending on you know how their how they kind of how their sensor you know their nerves are their sensations are and things like that.
>> Um this is perhaps a good time to um mention dopamine. We talked about it a few times um earlier when talking about the arousal arc that starts with parasympathetic sort of calm and then um move typically starts as calm and then moves to um the orgasm response. We know that the orgasm response is associated with release of dopamine uh and then prolactin which sets up the relative or absolute refractory period. the uh the interesting thing and I got some questions about this is that um there's literature as I understand about the elevation in dopamine caused by say anti-depressants like wellbutrin prior which increases dopamine and norepinephrine um people who recreationally use drugs like cocaine or other stimulants um people who take um aderall vivance or other drugs that increase um levels of dopamine because I did a whole episode about those drugs and they are different forms of amphetamine unless we're talking about rolin which is a little bit different.
>> Um and I got a lot of questions about people who experience feeling a lot of um desire sort of arousal but not being able to achieve the um physical arousal erection or vaginal lubrication. So it's almost as if they're sitting further along that arousal arc. Hence the importance I think of um people learning to have um calm um states of mind when going into sexual interactions. Now I realize that in saying that it might be confusing because a lot of people think well that's anything but calm, right?
Sexual arousal is anything but calm. But maintaining enough calm that they can um ride that arc >> um for whatever duration is appropriate for that interaction in them, right?
Because again, and we should probably get back to this, you know, um, you know, some people will have sex for long periods of time, some for shorter periods of time, and here people don't really know what other people are doing except by way of pornography and and self-report and discussion. So, um, is it the case that drugs that increase dopamine can inhibit the sexual response? Do they tend to promote the sexual response? Because I also mentioned earlier there's this growing trend of people taking by way of prescription of course from a physician um combined apomorphine which is a dopamineergic drug um with tadalapil which is a um PD5 inhibitor so it's going to increase blood flow and I'm hearing about men and women but mainly men doing this so ramping up their dopamine uh ramping up their blood flow to their genitals in order to have presumably more arousal and sex. Does that make sense? um as a as a mechanism.
>> Yes. So in terms of apomorphine um the that has been studied and it's mostly been approved outside of the United States. So we don't use it very often here in the United States because it hasn't been FDA approved. Um but you know it's a very complex response. So like I mentioned that um flancerin which is a centrally acting medication it actually has not only um inhibitory and not only stimulatory but also inhibitory effects on dopamine. So the way it sort of works to enhance interest or libido is sort of complex and kind of confusing. The when it was actually approved, it was it was being studied for an anti-depressant. And what they found was that women were actually having le you know better um interest in sex or more interest in sex. And so that's kind of how it was discovered.
Similarly, Viagra was actually studied for high blood pressure. And when they went to um it was horrible blood pressure medication, but then the people the men who took it actually didn't return the samples for the study. So they realized like what's going on here?
And it was because they were having better erections.
>> Is it true that um at some urology meeting that the first um description of Viagra as a treatment for um erectile dysfunction involved the speaker actually coming out from behind the podium and revealing his erection. Is that a true story?
>> Yes. I don't think it was Viagra. think it was an intricate heavosal injection though. I think he came out um it is a true story. There's actually a published article. I'll send it to you so you can share it if you'd like. There's >> I'm not sure I want to see it, but I I'll read the article.
>> There's a there's a published article about people who were attending at the meeting and yes, he came out and at the time like it was mostly men in urology, but there were like spouses, I guess, in the audience, which is not typical now, but um so there were women in the audience and he came out with a full-on erection to show that it, you know, it worked >> well. Well, I suppose at the urology meeting um or OBGYn meeting where a woman comes out and reveals her um enhanced vaginal lubrication, then we will have um we will have uh gender and sex balance at the meetings on urology.
Um it'll be interesting to attend one of those someday. Um differences in arousal as a function of stage of the menstrual cycle. Really interested in this. I did a long episode on fertility and we're going to have a few other IVF experts um fertility experts on the podcast. Um but clearly um there are differences in hormones across the menstrual cycle. We know that for sure. Yeah.
>> Um >> clearly there can be psychological variation according to those hormones but probably other things across the menstrual cycle. And it's always an imperfect experiment because you know we aren't laboratory rats and people are having different interactions across the menstrual cycle. Is there any known um correlation between uh desire and stage of the menstrual cycle? There are some obvious um assumptions that one might make you know prior to ovulation etc around the time of ovulation. Um but what about the other direction too? Um, is there a category of women that are very interested in sex at certain stages of their menstrual cycle and then not at all interested in sex at other stages of the menstrual cycle?
>> You know, all that I the data that I've heard and maybe a gynecologist could speak more on this because they studied those variations a little better, but there is data to suggest that libido does increase prior to ovulation and during ovulation. I think it's like a couple days prior because that's the optimal time for fertility. So yes, there is data to suggest that in terms of like completely uh lack of interest, I don't believe there's data, but I'm not not sure.
>> Is there evidence that females who perhaps have not experienced so-called G-spot orgasm or cervical orgasm can learn to do that? And I always find it interesting that whenever there's a discussion about different forms of female orgasm, um, people are careful to point out that many women don't have penetrationbased orgasm. And then they separate out clitorol stimulation as more a more common route to orgasm. But of course, there can be clitoreral stimulation with penetration.
>> Absolutely.
>> Right. And uh depending on the physical arrangement um there can be clitoreral stimulation purely by way of penetration through pelvic contact um you know fingers etc. >> So yeah so how how do we how should we think about this? How should we talk about it?
>> So there was an interesting study that I just read recently where they gave women words for these things, right? So um they there's like the rocking stimulation so that can also stimulate so meaning that the you're penetrating but there's like a rocking motion that can also penetrate the clitoris. There's um stimulation of just the outer part of the vagina which again as I mentioned the G-spot is there. It's more highly innervated so that can be more stimulating. There's also ways to align yourself so that when you're penetrating, you're putting pressure on the clitoris. And then there's, you know, stimulation with like actual stimulation of the clitoris, like intentional stimulation either by yourself or by the partner. And so there are multiple different ways to do that, right? Um, and so there I think that it's important to really um kind of it's okay to explore and not always be a home run. And I think that's like when you get into a relationship where you're maybe second, third, fourth time having intercourse with someone that you can try and explore these different things or if the partner themselves knows what they like to actually tell the other partner, right? There's a huge part of communication that I think is is plays a huge role in this because we know ourselves better than anyone else. So you can tell your partner what you like and I think that that we have never been taught how to do that.
>> Yeah. um such important conversations for so many reasons. And as you point out, um definitely not something they teach people in school except, you know, they might say something about, you know, communication is important. And that almost always circles back to the the key four things we talked about earlier, which is, you know, consent and age appropriate, context appropriate, these kinds of things. And um and obviously substances like alcohol and other drugs can strongly confound those issues. And so that's we'll just leave that as a as a kind of an obvious one.
Um as long as we're talking about communication around sexual interactions, um perhaps it would be useful to people to cultivate a a language or an omenclature there too to facilitate that. Um some of the language that uh I've heard that is um quite useful is things like um you know people have different arousal templates, right?
Some people certain ideas are stimulating to them and other ideas are aversive to them. Mhm.
>> And then there's this category in between where sometimes people sort of either don't know cuz they haven't tried it or haven't thought about it or they're sort of curious but kind of unsure or it might work in the right context but maybe not all the time.
>> Yeah.
>> Um so is there any kind of structure that's been put out there as a way to improve communication around sexual interactions?
>> Yeah. I mean there's no like script, but I think in general you want to have the conversation outside of the bedroom. So not like right before sex or right after sex because that leads to like a you know a sense of insecurity for the other person, right? Did I do something wrong?
Did something go wrong here? So you want to kind of move those to a neutral location. So like kitchen table, in the car, whatever, somewhere where you know sex is not going to happen um at least for that particular moment. And um >> we have for folks listening um some challenging conversations on this podcast. challenging previously challenging because that you know you're trying to get things clear and uh as clear as possible. Um this one is challenging because there's so many caveats to everything, right? We don't of course people have sex in cars, right? Um or they did when I was growing up. Um and sometimes they still do. Um okay, please continue.
>> Yes. So that's one. And then two, like when you're discussing it, I mean this is kind of goes for any difficult conversation is like you make eye statements, right? you say, "I like it when this. I don't like it with this.
It's not something you did, right? It's not you didn't do this, you didn't do that." It makes kind of an animosity sort of situation. And then, you know, I think also part of it is like being open about those things. And it may it's not going to happen in one conversation. I think that's the hard part. Like you think you're going to have a conversation, it's going to go great and things are going to be better. It's going to be like multiple conversations and some of them are not going to go well, right? So like um that's another place where you can actually get the help of a sex therapist and there is a website for that. It's a sct asex.org where you can look for a sex therapist near you and you can even do those things virtually. Um and so that can be really helpful when you're having difficulty having a conversation. Yeah, I think um again such important conversations and then when people um differ in terms of their level of experience, it gets um potentially problematic, but also it can be potentially um educational. Um and then of course there are the twists and turns that occur with when one is asking about somebody else's arousal template.
Oftentimes you'll learn things about people's sexual past and that can be either neutral, stimulating or aversive, right? that can open up all sorts of other issues related to the psychological interplay. So, there's no way we can parse all of those. Now, I just think it's worth highlighting um that it's understandable why those conversations are challenging. Um and it also is understanding why pornography isn't going to involve those conversations, right? Right. The only conversations there are between uh your brain, your hands, and your eyes, and your ears. Um uh not going to highlight any particular order there. Um, I want to switch gears slightly, um, and talk about UTI. I got a lot of questions about urinary tract infections. Let's make it related to both females and males because yes, males get urinary tract infections. Females get them. More females asked about urinary tract infections. How common are they? Should they always be treated with antibiotics?
Is cranberry really a good treatment? If so, why? Are there other things that are better? Is it related to the acidity or alkalinity? Um, how does one prevent getting UTI? Can you get them from swimming? Should you urinate after sex?
Tell us about UTI and how not to get them and how to get rid of them.
>> Happy to. So, UTI are very common in women. U probably up to 50% of women get at least one UTI in their lifetime and up to a third of them get recurrent UTI.
And what that means is they have two or more in six months or three or more in a year. Now, this is common and so we'll see a lot of it and it's not as um until you're having recurrent UTI, say you just have one a year or you have one every few years, it's not a huge issue.
In men, however, UTI are much less common and that's because the urethra is longer. So, there's less um entry from the outside world into the bladder which causes infections. And so, um the when men get a UTI, it's concerning like why is a man getting a UTI? You know, there's multiple reasons that it could happen, but it should be investigated like so that you can make sure there's no anatomic abnormality or functional abnormality with a bladder that's causing the UTI. In terms of prevention, uh there are kind of major things that are highlighted in the guidelines that we all we all talk about. So, one is hydration. So, making sure you're drinking about 2 to three liters of fluid, ideally water a day. Um because dilution is the solution to the pollution, right? So drinking more fluids is going to get that bacteria and you're going to pee it out. It's going to help keep not let it sit around in the bladder very often. Another thing in women who have altered states of estrogen, whether it's post-menopausal, surgical u menopause or maybe have uh reduced estrogen for postpartum or other reasons. What about during the second half of the menstrual cycle when >> not necessarily for those specific people, but for those specific times, but because it's pretty short-lived. Um, I guess you could use it, but um, is is vaginal estrogen. So, vaginal estrogen, meaning estrogen that's applied in the vagina either through a cream, a suppository, or a ring, is is highly effective in reducing the occurrence of recurrent UTI. And this is because when you have low estrogen, the pH in the vagina goes up. And the pH in the vagina goes up because there's less conversion of glycogen to lactobacilli. And then those lactobacilli are preventative for UTI. So essentially, you want to reduce the pH back to its normal acidic pH. And vaginal estrogen is very effective at doing that. In fact, in our clinics, we'll actually check a vaginal pH, you know, to see if there is an indication that their pH is too high, that maybe they do need vaginal estrogen, particularly around like perry menopause, because it's hard to tell just by looking if they are really um heading into a lower estrogen state sometimes. And so that's very very effective and very very safe. So when you look at estrogen, you know, there the w the the women's health initiative way back when sort of made a big stink about how estrogen is related to cancer.
However, um vaginal estrogen has never ever been a reported breast cancer, uterine cancer or any other blood clot, any other adverse event associated with vaginal estrogen. You can get some breast tenderness, some discharge, those things can occur. Uh but the absorbed amount vaginally is so little that your estrogen level barely goes up. It doesn't even reach premenopausal levels.
So it just goes up very slightly in the bloodstream. Not enough to create any sort of abnormality. So vaginal estrogen is extremely safe and it's pretty affordable. You could actually use coupons if your insurance doesn't cover it through, you know, um Good RX or Mark Cuban's pharmacy and get it very very affordably and it's very effective. It does take about 3 months to work. So, you know, you have to be consistent. You apply it about twice a week at night, sometimes three times a week. Um, and it's it's very effective. The ring you put in once and it lasts for 3 months.
But, so, generally speaking, that's the most effective option for low estrogen states. Other kind of simple things are trying to make sure you're completely emptying your bladder. So, over a lifetime, people can develop some mild pelvic floor dysfunction, right? Not enough to create pain or discomfort, but maybe they're not emptying completely, right? because maybe they used to hold their urine for long periods of time when they were a kid or maybe they're always hovering over the toilet because they don't want to sit on it at work.
And over time, that can create a little bit of mild dysfunction which can make it more difficult to completely empty the bladder. And when urine is sitting in the bladder for long periods of time, it's basically food for bacteria to grow. And so bacteria grows and then you get recurrent UTI. So making sure you've completely empty by sitting, relaxing on the toilet, sometimes leaning forward, and then maybe going a second time. So standing up, sitting back down, going again. And even for men sometimes trying to sit and see if you completely empty cuz sometimes standing you're not able to empty completely.
>> Whoa. A lot of men are going to because there are these, you know, it was fun to research for this episode because um there are entire discussions on Reddit about like what percentage of males sit while urinating. I mean, my understanding based on having visited many male bathrooms in my lifetime and um just being in the world um that that I assumed that men stood up in order to to urinate, but there are a decent percentage of men that sit down to urinate.
>> There are and in fact it's variable by country and probably the reason it's become more interesting lately is the media >> country. So a certain country was recently surveyed, I think it was Germany, um but essentially this recent like picked up by the media that Germans sit more often to pee. And so you know then people like oh is this better for me to sit to pee or stand to pee? And there's this whole big discussion on the media. But the reason being is when you're sitting your pelvic floor is most relaxed. And so if you're having any issues emptying your bladder, you're going to pee better. Also, if you have an enlarged prostate, which I'm sure we're going to talk about pro prostate enlargement, um that can sometimes allow you to develop a little bit more intraabdominal pressure because you're sitting and you can lean forward to overcome sort of a blockage. And and so there are some some indications where sitting is better, but if you're being fine and you're standing, that's fine, too. I don't think you have to. I think it's just something that, you know, in other countries they do more and here we don't. And I don't think it's right or wrong. It just depends on your individual circumstance.
>> Can uh spermicides or condoms or both um increase the frequency of UTI for females?
>> So spermicides absolutely. So spermicides, if your condom has spermicide on it or you're using spermicides, that is a known risk factor for UTI. Um other things I want to touch on, you did ask about cranberry. So cranberry is actually in the American Urological Association guidelines for prevention of recurrent UTI in women.
Now how does cranberry work, right? like do I just drink juice? It's actually a specific active ingredient in the cranberry which is called pro-anthocyanidins or PAC's and in order they've actually looked at the amount of PACs you need and what formulation. So you need 36 milligrams of PAC's in a soluble form.
So a lot of the supplements on the market will say that they're 36 milligrams of PAC's but they're like the whole berry. So they're using the the skin of the berry and the stem of the berry and that's not going to help you.
So, you need to make sure that the supplement you're using is a soluble form of the cranberry and it's actually very very effective at reducing the risk of UTI.
>> So, do you mean um capsules like a gel cap? Uh yeah, it's a capsule um that you take once a day and there is some although not as much data that if you're having them around sex, which some women do always have postcoidal UTI um that you can take two on the day of sex and two on the day after and that may be helpful. But there's not a lot of data there, but certainly an option that you can try that's pretty low risk. Um so that's kind of the the guidelines. Now, there's a ton of other things that you can do to help prevent that are kind of available and have some data behind them. So, de Manos is one of them where you take um you know about two grams a day of de Manos and you drink it and that actually helps uh reduce UTI risk.
It's been studied in a small randomized control trial to be effective and um and so those are kind of the bigger ones.
There's other things that people use like probiotics, but there's a lot of heterogeneity as you know in probiotics and what to take and are they really effective vaginally uh in the flora there. So those are kind of the big things and there is actually a lot of microbiome study and UTI going on actually at UCLA um where they're looking at the microbiome of people who are more at risk for UTI or even overactive bladder or other conditions like that and they're trying to figure out like is there something here that we can target or that we can figure out is is causing problems because sometimes we just can't figure out why it's happening. Um, in terms of wiping from front to back and swimming and peeing after sex, uh, there's no good data on any of those things. Um, wiping from front to back, I think it does create a little bit of like shame. Like it's not a big deal if you wipe back to front as long as you're not like, you know, as long as you've like cleaned yourself, so to speak. So, I think um, it's less of an issue.
>> But what we're talking about is you're referring to any contamination from anal u any bacteria around the anus.
>> Correct. Yes. And a lot of women who have recurrent UTI like tend to come and feel very dirty, like there's something wrong with them. They're like, "Oh, I wash all the time. I'm really clean. I'm really this." And you know, it's not something they're doing. It's probably a microbiome effect or a hormonal effect or, you know, there's something going on that we need to investigate further. It could also be an anatomical or functional problem where you're not emptying the bladder correctly. So, there's lots of different factors. It could be and it's like very infrequent.
And I would say like I've never seen a patient who's dirty and that's the reason they're getting UTI. Um >> perhaps even the opposite is true.
They're cleaning too much based on what you told us earlier and they're eliminating the gut micro excuse me >> just rolls off the tongue. Um again, no pun intended. Um perhaps it's they're they are abolishing the local microbiome on the skin. Too much cleaning eliminates the microbiome on the skin.
Not that we don't want to wash, but um when Sonnenberg was a guest on this podcast, he said actually kids can develop a very healthy gut microbiome and general microbiome oftentimes by >> sorry parents not washing their hands before eating if they've been playing with soil outside or dirt. A little bit of that is actually healthy. Pets actually offer microbiome support. This is so weird. I know it sounds kind of dirty, but we have to imagine how we evolved as a species was not with antibacterial soaps and um >> alcohol swabs everywhere and um obviously we don't want infections, but over cleaning can disrupt the microbiome which presumably can lead to UTI. So perhaps someone who's cleaning excessively >> is more at risk than somebody who's cleaning a little less.
>> Absolutely. And actually the cleaning can irritate the dermis, right? So you can actually get contact dermatitis type symptoms from overcleaning. And so that's one of the, you know, things we're like, I I definitely have a UTI. I definitely have one. Well, no, you don't. But there's a host of other things that it could be. One of them could be that. Another very common one that we already touched on is pelvic floor dysfunction. So, very often, pelvic floor dysfunction, just like you had pain with urination. Women can also develop pain with urination that doesn't go away. And it can start where they had a UTI that triggered the pelvic floor and then the pelvic floor just didn't relax, right? The pain just triggered the pelvic floor to tense up. it didn't relax because again we're not taught how to relax our pelvic floor and um and then they've developed pelvic floor dysfunction like why is the UTI not going away or why does it keep coming back and so that's another common thing that we see um in people who have quote unquote recurrent UTI but don't really have them >> to be clear I experienced the pain in urination as a consequence of trying those damn keulls that everyone's talking about stopping that um was informative in two directions one it relieved the pain very quickly so that was good the other was um I realized that it is possible to have a pelvic floor that's neither um hyper contracted nor over relaxed and in some cases just not doing anything for it is is the best circumstance. Right? So um and the only reason I mention that is because >> um obviously this discussion is not about my pelvic floor. This discussion is about the fact that some people perhaps need to clean less, some people maybe more but probably not based on what you said. Some people might need to strengthen their pelvic floor. Some people might need to um relax their pelvic floor and some people's pelvic floor is probably a-ok. Okay. You know, I think any discussion about um anything medical or you know, especially hormone stuff, this happens a lot in the discussions around um that get into it seems with with males. They're like every male now seems to wonder if their testosterone is too low except the ones that are blasting testosterone because they know it's excessively high. Um, and as you point out earlier, >> at least in terms of sexual function, that's unlikely to be the case, maybe less desire, but um, but in terms of uh, genital-based arousal function, probably.
>> Yeah. And I mean, you've talked about testosterone a lot on the podcast, so I'm sure your audience knows very well the multitude of benefits for testosterone. So I think there is value in assessing hormones panels and assessing your level of free testosterone, testosterone and you know assessing if you're having symptoms are not always sexual, right? It can be depression, it can be weight gain that you're not gaining muscle mass, um you can have cognitive changes. So those things can still be a sign of low testosterone and very valuable and important to assess. That reminds me of another thing and then I'll we'll get back to uh UTI and I want to talk about kidney stones. But um I've heard of women using a small amount of testosterone cream directly on the clitoris as a way to amplify the maybe it's the uh desire and arousal effect or perhaps just one or the other. So I've uh the way that we discuss testosterone use and there are like consensus statements and there's actually an abundance of data on testosterone use particularly in postmenopausal women for low libido or low sexual desire and it's all been very positive and it says there's been increased uh sexual desire based on validated questionnaires increased number of sexually satisfying events with testosterone use. Now the range of testosterone in women is about a tenth of the the amount of testosterone a man needs. Right? So testosterone cream is systemically absorbed wherever you apply it. And so the way we generally recommend women to try this if they are having low libido and we've ruled out other issues that may be psychologic, you know, relationship, other issues that can affect libido medications. There's a lot of things obviously that go into that.
But if we said and we've checked their testosterone and it appears to be low for physiologic levels for women, which again is onetenth of the male level, then we can actually prescribe offlabel testosterone. And the guidelines or the consensus statements, they're not like true guidelines, but they recommend using transdermal testosterone. So getting, you know, androgel tubes from the pharmacy and putting a tenth of one tube on the back of the calf or the upper outer buttock, a hairless area um for absorption that can improve desire overall. And then the other place we use testosterone is in women who have uh what we call vestibularia. So the vestibule is the area outside the vagina which is very hormonally active. there's lots of androgen receptors there and it can actually when you have hormonal issues meaning lower testosterone and estrogen in that area it can cause pain and so actually applying a combined or compounded estrogen testosterone cream to that area over time can reduce that pain and discomfort. So, as you know, testosterone receptors or androgen receptors all over the body, very much in the genitals, very much in the brain, and they're very useful to a very useful place to treat women for those issues.
>> Thank you.
Kidney stones, I hope to never have one.
>> I hope you don't either.
>> People get them. Um, how do you avoid getting them and how do you get rid of them? So kidney stones um very often are they um they can be for a variety of different metabolic disorders, right? So it can be one dehydration is a very common cause of it. So uh dehydration combined with maybe a slight metabolic abnormality where you're creating more calcium or oxalate in your urine can result in um in kidney stones. And so how can you prevent them? I mean I you know each person is individual. If you get a kidney stone, typically we do what's called a 24-hour urine analysis plus some blood work to assess what is the metabolic abnormality. So we can target that either with diet or with medication. And so the kind of general recommendations for people who have kidney stones, one is increase your fluid intake to two to three liters.
Again, the same number I told you before. You want to decrease your oxalate intake. Now, if you Google oxalate, you're going to find a million things that you eat that have oxalate in them. But the big ones are spinach and rhubarb. We're seeing a lot of nuts too that are, you know, people eating a lot more nuts to get more protein. So, you know, cutting back. It's impossible to get rid of all of that in your diet, but if you're having like a spinach salad every day, well, switch it to a different green, right? Don't eat spinach every day. Um, also, you want to increase your citrate intake. That's an inhibitor of kidney stone formation. So, increasing fruits and um and things like that to increase citrate vegetables as well. Actually, one easily accessible thing is Crystal Light. It has a high citrate composition. So, you can drink Crystal Light with that two to three liters and that can be helpful. Um, you want to decrease your protein intake.
So, high levels of uh purines or purogenic meats like red meats and things can also put you at higher risk.
So, these are kind of the general sort of preventative measures we talk about for kidney stones. Um, if you have a kidney stone, so a lot of times people can have kidney stones in their kidneys, they're not creating any problems.
They're tiny. We can observe them over time. If they start coming if they start getting very large or they are starting to move into the urers or the tubes that drain the kidney, often times they're they're accompanied with pain, quite a bit of pain. Um, and it can be very uncomfortable. In those cases, uh we can if they're not having any infection symptoms, meaning there's no signs of a urinary tract infection, uh there's no fevers, no chills, we can treat it conservatively with pain medication and also um there are medications like PHMAX which we use for uh enlarged prostate as well that actually relaxes the uriteral smooth muscle to allow the stone to pass a little bit better. Um if you're having an infection, you got to get it treated right away. It can you can get very sick very quickly. In fact, um I've seen young healthy patients like they're healthier than me walk in the in the ER with a kidney stone and within 24 hours they're in the ICU cuz they're really sick because of a kidney stone obstructed >> urinating uh tea colored urine. So meaning blood in the urine. All of those are important warning signs that you ideally don't get to.
>> Yeah. Blood in the urine, I mean doesn't always mean infection. It could just be irritation from the stone, but certainly fevers, chills, or you have a sign of an infection and the stone looks like it's blocking. So if you get imaging and you see what's called hydronosis or pressure behind the kidney and you're you know you have these signs of infection we don't want to wait because you can get sick pretty quickly. Um and then you know once uh to treat the kidney stones there's three major options. One is shock waves. Another is ureeroscopy where we go in with a camera and we have a small laser. We break it up into small pieces and take >> Where is the camera inserted? Through the urethra.
>> Correct. You're asleep under anesthesia.
So you don't have to >> You saw You saw that? I saw >> you saw the ws >> and then um perccutaneous nephilostomy which is done if you have a large kidney stone or a very hard kidney stone that's up in the kidney you can go in through the back with a small like a small incision and with a specialized camera that goes in and uses ultrasonic lithotripsy to break up that stone and kind of suck it out that way. These are extremely helpful um bits of information or not even bits. These are uh this is enormous amount of useful information.
I'd like to pivot again um for sake of breadth. We can't go into extreme depth on everything, but um appreciate your willingness to to follow this carousel with me. Um oral contraception.
Previously on this podcast, I hosted a a female physician guest um who offered both sides of female oral contraception, discussed some of the benefits, discussed some of the risks.
I made the decision to post clips about both on the internet and wow wow wow was I surprised but also frankly a bit shocked. And then finally um intrigued by how polarized the discussion is around female oral contraception um and female contraception in general. So nuvar ring um nor plant um the pill broad category of things there but for sake of discussion the pill etc. I mean it seemed that approximately 50% of responses which seem to come mainly from women were of the this stuff is terrible. It ruined my life. It ruins lives. It um destroys you. It has immense um risk. And then the other half um seem to say no there's reduced risk of certain forms of cervical cancer. um this has allowed me uh the you know sexual choices and lifestyle that I prefer without risk of pregnancy. I mean it was astonishing to the point where I thought wow if only I could post both clips simultaneously. So um obviously I don't know what the answer is um but I do know that this is among the more polarizing topics available for discussion. Um so what is the story meaning what are the data about oral contraception why so much controversy and what's the real deal here >> yes so it is a very polarizing topic and there is abundance data abundant data in fact we even did a study and again this is um not like high quality evidence but we looked at Reddit threads and we looked at sexual dysfunction specifically low libido orgasmic difficulties and we like read hundreds of threads and we did like a qualitative analysis to see in females to see like what are people talking about and problems with oral contraceptives and anti-depressants leading to low libido and and being very like as you described very like this has ruined my life was very common. And so the the theory is that, you know, taking oral contraceptives increases the amount of sex hormone binding globbulin which binds testosterone and estrogen and that actually makes testosterone less available which is as we've talked about a very important hormone for desire. And so in some subset of people they're seeing very significant consequences of taking oral contraceptives. Now, I think that there is, you know, we don't know which women are going to have this problem and we don't know how it's probably a very small subset of people, but we do know that this does happen and that when you measure SHBG levels, they're up and that even after they stop the oral contraceptives, you'll see elevated SHBG levels from baseline.
>> For how long?
>> You know, for like at least four months afterwards, you'll still see elevated SHBG levels. So, we don't know.
>> Not but not infinite. I mean, >> we don't know. Yeah, the endocrine system is weird because it >> it um we assume everything is a short-term effect, but there's some plasticity in the system, especially because it's a neuroendocrine system.
So, yeah. Okay.
>> So, I think yeah, there's some neuroplasticity there that occurs as well. And so, uh we do see this and I think that the other side of it is yeah, absolutely oral contraceptives are amazing, right? They're they're helpful for sexual freedom for for preventing pregnancy for you know for a lot of things and particularly other conditions too like PCOS and and other problems.
Oral contraceptives are amazing and they've changed uh you know gynecology and management of these women for you know in in a very positive way. And so I think you know yes I do think that there is oral contraceptive related sexual dysfunction. Usually lowd dose estrogen um sort of contraceptives are the culprit. Uh but you know I think that it's it's again the data female sexual dysfunction literature is just not as robust as male sexual dysfunction literature. I saw a lot of comments about how oral contraception had led to depressive like symptoms um or just kind of ahidonia and um apathy not just low lowered libido. I can imagine how that would be the case through the elevated sex hormone binding globulin which is you know um preventing testosterone estrogen from um being free literally and exerting their effects on not just the body but the brain. But is there any evidence that oral contraception can disrupt neurotransmitters? I'm not aware of any.
>> I don't think so. Not to my knowledge.
>> Okay. Uh well, it sounds to me like oral contraception for women because that's where we normally hear about it. It sounds like there's a varied response and it's highly individual. I certainly had partners that love the pill or at least didn't seem to mind it. I've had some that hated it and like it's like no way tried that, never will. um or you know just went with other forms of contraception or for whatever reason we're not using contraception. So it seems to me that there's a lot of variation out there. How does one explore that without risk of permanent damage? It sounds like truly permanent damage is unlikely. Um you know what are the other options? you know, is the ring um uh copper IUD. Um >> so any sort of long acting hormonal contraceptive we've seen we we that's what we consult patients on is if they're having issues with oral contraceptives. Even if they come in with pelvic pain and they're on oral contraceptives, I'll tell them, you know what, just stop because maybe the androgen the effect of on the androgen receptors or estrogen receptors is affecting you know the lubrication or other things. We're not sure, but you know, why don't you stop it and go get a long acting contraceptive method >> like an IUD?
>> Like an IUD.
>> And are IUDs? Are IUDs safe? And here we should probably say, okay, copper IUD is one form. You want to mention a few of the other forms?
>> So, I don't prescribe IUDs, but generally speaking, they're very safe.
Of course, there's risk with any sort of, you know, it's a it's a procedure.
You're inserting an IUD, so there's obviously some small risks associated with it, but uh it is safe and effective form of contraception. If people are wondering why the copper IUD is an effective form of contraception, uh copper is um it's like the third rail for sperm as I understand it. So much so that um I was able to find some evidence for this in the medical textbooks that um in the old days as they say um prostitutes who wanted to avoid um pregnancy would put copper pennies in their vagina.
>> Really? Uh now I don't recommend that to anyone and uh please and um I don't think it's a foolproof form of of uh contraception uh but there is evidence that that um did happen. So which is amazing. That means that people somehow figured out the copper sperm relationship which isn't a good one for the sperm and uh deduced from that a behavior.
>> Yeah, that's cringing.
>> I am not suggesting people do that. I think it's just an interesting medical factoid. Yeah. Um, I can tell you want to move on from this topic. So, we will.
Um, before discussing prostate and anal sex, not stated next to one another for any particular reason, I want to talk about SSRIs. A lot of people over the last 20, 30 years have been prescribed selective serotonin reuptake inhibitors and other anti-depressants um that have disrupted their sexual function or their sexual desire seems in particular. Um >> do you see a lot of this in your clinic?
Do you hear about it? Um what can people do about it? um you know often times these sexual uh arousal or dysfunction issues associated with SSRIs and other medications make those medications prohibitive for people.
>> So you know serotonin is kind of the anti to orgasm and so in fact we will use SSRI off label for people who are having premature ejaculation. So it delays ejaculation and then there's also other sexual dysfunctions we see with it and it does happen absolutely it's dose dependent. So um in some cases when someone comes in with SSRI related dysfunction if they're doing well you can either try to reduce the dose or switch them to um another anti-depressant for example wellrin that does not have such severe effects on sexual function. Um, and so you can also use like Seialis and Viagra like you've t we've talked about for erectile dysfunction as an addition if we can't change their medication management because you know and this gets a little bit complicated because we know erectile dysfunction and depression are very interrelated. Now what's causing what and what you know where do we like maybe somebody went to see their doctor for depression but was also having issues with erections and now what do you if you fix the erections do you help with the depression like what you know what I mean? So males everywhere are shouting yes.
>> So I think you know I think that there's a lot of discussion that has to be had there. It's a lot easier to talk to your primary care doctor about depression than it is about your erections. And so I think it's important to like really dig into that a little bit. Um but yes there it is definitely a known thing. We use it to our advantage when needed. And um and it can be helpful to to switch medications or reduce the dose. Nick, you mentioned earlier that trazadone can cause um sustained erection. Um and is trazadone in the category of of touching the serotonin transmission system?
>> You know, I don't remember the mechanism, but interestingly, trazadone is also used for off label like as a third or fourth line for premature ejaculation as well. So, um so I I don't remember the the mechanism offhand.
>> Let's talk about prostate and prostate health. Earlier I queued up that um there's a growing um trend toward I I would say more progressive um male physicians um or physicians who treat males, excuse me. Um >> thanks for that.
>> Yeah. Um prescribing lowd dose 2.5 to 5 milligram seialis which is toalifil which may assist with erections but it the the rationale for this low dose daily low dose is not centered around erections per se. It's really about um prostate health, improving blood flow to the prostate, reducing prostitis, um maybe even reducing the probability of prostate cancer. Um what other sorts of things are you encouraging men to think about when thinking about their prostate?
>> Yes. So uh before I forget, I want to mention that lowdose tadalapil is actually a treatment for erectile dysfunction. In fact, it works quite well particularly in men who are having a lot of psychoggenic issues. one because I don't have to remember to take a pill before sex. It's always on board and you know you're taking five milligrams every day and it has a 36-hour halflife so over you know you're kind of increasing those so it can actually work quite well and is a great option for erectile dysfunction. So I do want to make that caveat. Um in terms of prostate health it has been shown to be effective for BPH or enlarged prostate and this is a very common condition. In fact, if you look at autopsy studies, 80% of men at 80 have an enlarged prostate. Like, it's very, very common.
Now, does everyone get symptoms and what's the long-term concerns of it?
And, you know, what can you do about it?
So, typically, as the prostate enlarges, it's right around the urethra. It's a walnut-shaped gland. Sits underneath the bladder around the urethra, and it can narrow the urethra or the P tube. And so, over time, you can imagine like if you're I always give this example, if you're sucking from a straw, right?
you're drinking from a straw. If you have a wide diameter straw, it's really easy to drink. If your straw gets really narrow, like say you take a coffee straw and you drink out of that, it's very difficult to drink. Very similarly, it can become very difficult to urinate if you have an enlarged prostate. Now, what causes an enlarged prostate? There's a whole host of factors. A lot of them are genetic. So, if your father or your grandfather had a large prostate, you're probably more likely to have an enlarged prostate. um do we know exactly um how to prevent that? Not exactly, but we know how to mediate the symptoms a little bit. So, the other symptoms you'll see before you have difficulty urinating is sometimes you'll see overactivity. So, you'll see um your bladder is responding to having to push hard against that narrow urethra to push urine out. So, it's having more urgency like the sudden desire to go to the bathroom that you can't delay. You're maybe going more frequently and very often you're going more often at night.
And so those are kind of the first signs people will see. And then over time it may become more and more difficult to empty the bladder. You might see some hesitancy like you're waiting for your stream to start or it stops and starts.
Um and so those you know or you're just like I can't empty like it's not it just drips or a very weak stream. And so those are kind of the things that can happen over a lifetime. Now what what are some things that you can do to help?
um you know, seialis helps relax those those the fiber the smooth muscle of the prostate so it allows urine to pass more easily. There's also other medications that you can treat very often. PHMax um or other alpha blockers are helpful in that area. Um in terms of like things that you can do in general for bladder health, prostate health, there are certain things that are irritants to that area. And so what I tell people, not everyone's affected the same way.
Okay. So, I don't want people to be like, "Oh, I got to stop all these delicious things I eat and drink." But certainly, it can be useful to just pay attention. So, like if you say you drink coffee every day and you find yourself running to the bathroom a lot, if you limit your caffeine intake, you might see that you're not going to the bathroom quite as often because caffeine is a bladder irritant. So, that can be coffee, tea, chocolate, you know, things of that nature that have caffeine in them. Energy drinks, sometimes people forget they have caffeine in them. Um, and so limiting that may improve your symptoms. Um, alcohol also is a bladder irritant. And these have actually been studied in animal models and you'll see that the bladder contracts more often when they're given these sorts of substances. Um, and it's dose dependent.
And some people can actually habituate or get used to a certain dose of caffeine. So if you're drinking coffee every day, you may have less symptoms than someone who drinks it every once in a while. Um other things can be uh sometimes carbonated beverages, spicy foods or acidic foods, those sorts of things can also irritate the bladder lining. So sometimes limiting those things may be helpful in those situations.
>> Thank you so much. That's very informative. Um years ago there was a discussion about um bicycle seats causing damage to the prostate, maybe even sexual dysfunction.
>> Um is that still a thing? I thought they put grooves into the the seats. Um, but I've also in reading on the internet. I didn't do a deep dive on Reddit, but um seems that women are reporting some bladder incontinents from excessive bicycle seat use, maybe even um exercise bike. It doesn't have to be road bike.
>> Yeah. So, this is a great point. So, cycling, if you think about it, right, you're sitting on your paranneeium, which is that space for men between the scrotum and the anus. for women between the vagina and the anus and right there runs your pudendal artery and your pudendal nerve which are again responsible for blood flow and nerve function to the area. So the most common things we see in people who are you know um who are really high volume cyclers now the studies have looked at like uh maybe they did a 350 kilometer race or they they're you know biking three times a week for 60 minutes but there's no like consistency but they're seeing pretty high rates of genital numbness.
So like up to 50% and also in men erectile dysfunction. In women you'll also see numbness but because sensation is a big part of arousal you'll also see kind of decreased lubrication maybe decreased arousal as well in women. And so how can you prevent that? The reason is because when you're sitting, particularly if you're leaning forward like competitive bikers do or arrow riding, you're putting pressure on the the beak of the bicycle seat and that's where you know most of the it's not your weight is not distributed evenly. So the goal is to take a bike seat that allows you to sit comfortably on your isial tuberosities and posture is a huge part of your pelvic floor. So, I know we didn't talk about that earlier, but sitting, you know, with good posture and not um kind of slouching or leaning forward uh can actually really do wonders for your pelvic floor. So, focusing on posture is helpful, but also when biking, posture is helpful. So, they've actually looked at this data and they found that people who arride, meaning lean forward, um or people who use narrow bike seats, are more likely to have issues. And so, you want to get kind of a noseless seat and a wider seat. the the cutouts actually when they've looked at kind of mechanics of the cutouts, they'll see higher pressure around the opening. So, it's actually not good to have a a bike with a cutout uh bike seat with a cutout because they've seen at least with some of the cutouts that the pressure actually becomes higher on the area that's right around it.
>> Very important point. Um I don't cycle.
I don't like the exercise bike. I'll sometimes ride the assault bike for which has the big seat and maybe for a few minutes. But um >> I I just want to add one um one thing because I think that I don't want to uh make people not cycle. I think it's really valuable. Cycling is a great aerobic exercise. Has lots of benefit for cardiovascular health. But um there was actually another study that looked at people who were parts of sports club.
So they were like swimmers, runners and and and cyclists. and they looked at rates of dysfunction and they found that actually the rate of erectile dysfunction was not different between runners, swimmers and cyclers. So maybe you know because those other studies were just looking at cyclingers that maybe it's just the general rate of erectile dysfunction in that population at that point in time. So I don't the numbness is definitely an issue the erectile dysfunction maybe maybe not.
So, I just have a couple of more questions for you. And by the way, you've been incredibly generous with your uh time and information here. So, I really appreciate it, >> as I'm sure our listeners do as well.
Anal sex. You recently did a post describing the multiple reasons why women do or do not have anal sex. Yes.
Very interesting post, very interesting study that you covered and you um explained it very clearly. Um, I'm guessing there are relatively few, but perhaps some other studies as well about this. Um, let's talk about anal sex and, uh, maybe if you could just, uh, offer some of the the key bullet points that you've learned from the literature and from your clinical practice. Um, you know, how frequent is it? Um, uh, with protection, without protection, how safe is it? Mh.
>> Um, you know, what are the different reasons people do it? Um, that might seem like a kind of a silly question, but it turns out when it comes to this topic, it's they're interesting data.
>> Yeah. Um, educate us.
>> So, anal sex, let's talk about it. Um, well, when you when you talk about anal sex, the reason people it's become more and more common. Let's say it it's more and more heterosexual couples are doing it. We know that um male homosexual couples are having anal sex. And I think the one thing is that it's safe in terms of pregnancy, right? You're not going to get pregnant from anal sex, which is one of the reasons people do engage in anal sex.
>> Do you think that's the reason people are doing it more frequently?
>> No, I think that's one of the reasons that people one of the reasons people do. But um in general, uh the issue with anal sex is that people forget to use protection like a condom for example because sexually transmitted infections are actually more likely with anal sex than they are with vaginal penetrative intercourse. because the anal tissue is very thin and fryable. So when you penetrate the anus particularly if you have any trauma um you can have you know uh you can have blood loss and that blood loss can then easily more easily transmit sexually transmitted infection.
So it's really important to use a condom and use adequate lubrication. The the anus does not make any of its endogenous lubrication. You have to use lubricant.
The other interesting thing about anal sex is that the anus pH is different from the vaginal pH. So you want to use specific lubricants that are isoosolar to anal pH. So you can actually look up anal lubricants. And we could talk about lubricants, but generally there's water-based, siliconebased, oil-based lubricants. Water-based are the most easily accessible. Um siliconebased are a little more slippery and last a little longer. And oilbased also last longer, but are not good for use with condoms.
So definitely using lubricants and always kind of making sure to um be in the context of course of being consensual, but also like never force, always take your time and and those things are really important to avoid trauma because trauma can happen. And usually it's not severe trauma, right?
It's not going to create long-lasting problems, but it is, you know, inconvenient, uncomfortable, and probably we're not seeing as much of it because they're not coming to the emergency room if they're having issues unless it's really serious. Um, so I think it's really important one to prevent from sexually transmitted infections. Two, to be thoughtful and cautious and sometimes it requires some preparation. If you're going to penetrate an anus, it's going to, you know, you're not going to start with a a large girth item. You're going to start with something smaller and kind of work your way up. Um, and then I think ultimately why people have anal sex. So, as I mentioned earlier, the prostate is, you know, highly inervated and can be a source of pleasure. So, some people enjoy that. particularly men may enjoy anal penetration. Women as well may enjoy anal penetration because of the intervation around there the pelvic floor. Um and and you know so that's certainly reasonable to do so as far as why people engage in anal sex. So sometimes it's because as I mentioned they're trying to avoid vaginal penetration either to avoid pregnancy or maybe um menstruation or other reasons.
Um, sometimes it's because people want to do something special with their partner, like they feel like this is my special thing with this partner that I do with them. And so it may be something kind of like a gift or something like that. Sometimes it's almost like they feel like they um they have to. And this particular study that I looked at, there's actually not a lot of studies on why people engage in anal sex. And this particular study that I had talked about on my channel or on my Instagram was um talking about why they they specifically recruited drug users. And so a lot of people had used drugs prior to using to engaging in anal sex. And I think that that's not ideal. You always want to be kind of in the right state of mind for consent and um and safety purposes. And so um those were kind of the common reasons.
>> What about infection not related to sexually transmitted infection? Um my presumption is there is a higher risk with anal sex um than there is with other um other for you know vaginal intercourse, oral sex etc. Um but is there evidence for that?
>> Um not necessarily. It's more about sexually transmitted infections more than anything else. It's rare. You can sometimes I mean the rare things that people have kind of commented on like anal incontinence temporarily or things like that very rare. Um, mostly it's it's just sexually transmitted infections because, you know, you can have more it's more easy to create bleeding through anal sex if you're not careful.
>> And are people doing enemas before anal sex to prevent bacterial infection or is that just like it's a kind of >> Some people are, some people are not. I think it's, you know, people are making sure they're evacuated fully. Um, there's some, you know, media articles about like what you should eat before to kind of keep your gut, you know, healthy and avoid kind of loose stools and things like that. Um, but generally speaking, you know, there's there's lots of things you can look up to make it safe and healthy.
>> Again, I'm sure some people are listening to this and they're maybe they've turned it off already, but um and I think we can expect a varied response to this discussion, but >> it's happening out there.
>> It's happening >> apparently with increasing frequency.
>> Yes. And I don't know if that's because of the increasing availability of pornography where it's visualized more or if um yeah I don't really know why but we do know that there's more going on in heterosexual couples than prior.
>> As a final category of question um I was really interested in some of the posts you've done about herbs and supplements in the context of sexual desire and sexual function. Um on this podcast I always say always always um we emphasize behavioral tools first dos and don'ts right because those are the foundation of mental health physical health and performance you know um in all contexts um there is of course a role for prescription drugs sometimes oftenimes people can't do the things and avoid the certain things they want to because of depressive states anxious states etc and prescription drugs can serve a role but I do believe the goal is always um behavior aviors first, then of course things like adequate sleep, nutrition, healthy social interaction, all of that stuff, >> right?
>> Exercise, but we do often talk about supplements um because they represent um I think an important category of, you know, over-the-counter compounds that can play a role. And um I've talked before about Tonga Ali, >> this Indonesian herb. I think it can be Malaysian as well, but this Indonesian um herb is typically the one that um I am aware works best for mild libido enhancement. Um sometimes um especially in the case of people taking SSRIs >> um it can enhance libido to override some of the uh challenges with SSRI induced reduction in libido. And generally even if people aren't on SSRIs, I hear from people who take Tonga Ali and get um libido increases. Also things like maca root which we >> don't really know how these things work exactly. Probably some freeing up of testosterone with tongad ali. Maybe some cortisol suppression as well. Um maybe some estrogen receptor modulation with macaroot. Maybe some dopamineergic tone changes. um Sheila >> um this Ayurvedic herb um which there is at least one study um that uh I think has done well that um shows increases in FSH follical stimulating hormone with um Sheila use. What are your thoughts on things like tonga ali maca root Sheila?
Um how do you talk to your patients about this stuff? Yeah. So I think that um you know I see at least my patient population is is still in the behavioral management place right the biggest cause of sexual dysfunction whether it's low testosterone erectile dysfunction sexual dysfunction is often coorbidities right so managing high blood pressure managing diabetes with diet which you talk about a lot but the best studied diet is the Mediterranean diet at least in in the sexual dysfunction literature exercise like doing you you know, both cardiovascular, aerobic exercise, but also doing resistance training, particularly of like large muscle groups. Um, and and then, uh, you know, really working on reducing blood pressure and and preventing diabetes.
And those things I think are really key.
And I know we t you talk about them a lot on this podcast, but I will tell you that when people are getting ready for, for example, we do a surgery for erectile dysfunction called penile prosthesis. So this is like end of the line, nothing's working, they can't get an erection at all. And it can be a and and they may have diabetes as a cause of it. And when we say, you know, you have to get your hemoglobin A1C below a certain level to do surgery, I cannot tell you how quickly these men change their behaviors >> for sake of erections >> for sake of erections. So I think that really if I can say one thing before you do uh supplements, which I don't have a problem with, I think that it's reasonable to try them. Um, I would try one at a time to see what's working and so you're not taking a bunch of things and not knowing what exactly is working and realizing that they're not going to work immediately. If you take something that works immediately, it's probably got a PD5 inhibitor mixed in there. And so, it's going to kind of build over time and you're going to see changes over time. But I would say that the number one thing that I recommend for people is improving their diet, exercising, getting good sleep. as you know, it boosts testosterone and even, you know, you mention this all the time, but getting early morning light, but it's it's beneficial for testosterone as well because you're really helping release testosterone with the circadian biology. So, I think that those things I I can't stress enough like how valuable they are. And if you're smoking, quit smoking. It will kill your erections >> and vaping.
>> And vaping.
>> Yeah. And then lastly, if you are developing true organic impetence, meaning that there's a biologic problem that's causing your sexual dysfunction, then it's really important to get your cardiovascular health assessed because about 15% of men who develop erectile dysfunction 7 years later will have a cardiovascular event. It is the canary in the coal mine. meaning that you know it's the sign that you may be developing cardiovascular problems or like endothelial dysfunction that's first presenting in the penis or in their sexual organs and you know this probably is the same for women we just don't have the data yet >> I know a good number of women that take Tonga Ali um in part I think on the recommendation although I want to be clear I never recommended it was an offer of something that people could try if they're doing everything else correctly and could assess um >> with consulting your physician of Um and they too some of them have uh reported improvements in libido and and desire as well. So um yeah and I the shilogy is less known about the um distinguishing quality versus lowquality sources of shilogy is harder. Dosing is harder. It comes as this tar typ typically um maybe more science on chilogy will come out in the next few years. We could um get get behind it a bit more. Right now I'm sort of on the yeah maybe if you are an adventure you might try it but I'm not um it's not one that I'd normally throw to the top of the list.
>> Yeah I think that like elcitrine is is pretty good. Ashwagandha for stress reduction which also has implications for sexual function. Tonad Ali has reasonable data. Um I think there you know there is reasonable data on these things. I think the website you talk about all the time examine.com is a great place to look at that. Um and you know I like I said I think it's reasonable. They're smaller studies.
They're not um you know there is bias in many studies but there there you know there is effort done in this area and there's never going to be uh really high quality science. No one's going to really fund that I think. Um, so I think our expectations need to be a little tempered when it comes to that stuff.
>> Well, Reena, Dr. Malik, I want to thank you ever so much um for this discussion today. you provide us so much useful information um and really have transcended the divide between you know the mysterious thing that everyone wants to know about sex and sexual health genitals and genital health uh prostate urethra UTI all these topics that um many people are just afraid to to raise and and to confront directly and you've um you've taught us so much about how to promote the health of this incredibly important system one thing we know for sure either in vivo or in a dish We're all here because a sperm and an egg and uh and um and of course there are other reasons why people engage in sexual activity that have nothing to do with reproduction but um surely it is core to our biology and our psychology and well-being. So thank you so much and also thank you for the work you do day in and day out week in and week out in your clinic. We will provide links to your uh clinic um people are interested in working with you directly as well as online. That's how I initially found you. And when I did, I was just absolutely delighted. I thought finally there's somebody who's providing the kind of information that everybody wants in a in a thoughtful, logical, clear, and respectful way. Um, so on behalf of all the listeners and viewers and on behalf of myself, I just want to say thank you. Thank you. Thank you for what you do and please keep going and please come back.
>> Thank you so much. And honestly, the work you do is phenomenal. It's an honor to be here. Thank you so much.
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