Welcome to the huberman Lab podcast, where we discuss science and science based tools for everyday life. I'm Andrew huberman and I'm a professor of neurobiology and Ophthalmology at Stanford school of medicine. Today. My guest is dr. Rena Malik dr. Rena. Malik is a board-certified urologist and pelvic surgeon. She is an expert in both male and female Urological pelvic floor, and sexual health during today's episode, dr. Malik answers.
The most commonly asked questions about urinary pelvic and sexual health. For instance, how to avoid getting UTIs urinary tract infections. We also discussed pelvic floor, anatomy and function, as it relates to overcoming an overly tight or an overly. Relax pelvic floor. This is a key distinction that most people aren't aware of many. People hear about the need to so-called strengthen their pelvic floor. But in fact, many people need to do the exact opposite. They need to learn to relax their pelvic floor.
Order to achieve proper Urologic and sexual function. So today, you'll learn about that. You will also learn about sexual health, as it relates to erectile function as it relates to things like vaginal lubrication as it relates to orgasm, we separate out very carefully. The difference between psychological desire and arousal that occurs within the genitals themselves and dr. Malik highlights some important misconceptions about sexual dysfunction. For instance, that
many people believe that hormones are responsible for sexual dysfunction. But in reality hormone dysregulation is responsible for only a very small percentage of sexual dysfunction and yet pelvic floor and blood flow. Related issues can account for a large number of cases of sexual dysfunction in both males and females. So I assure you that today's discussion is going to illuminate, many new areas of information, many new tools and protocols that I'm
Most people have not heard of, we talk about the neural vascular that is blood flow related and muscular aspects of bladder function, prostate function schemes glands. We talked about vaginal Health as well as penile Health. We talk about these things as it relates to different stages across the lifespan. It is a far-reaching and in-depth and practical conversation that, I'm certain everyone will glean important. Takeaways, from now, before we go any further, I do want to highlight that the content of
today's episode is sexual in nature. We talk very directly about different types of sexual behavior and we talked about it from the standpoint of the clinician and biologist so it is a medical / scientific discussion that said we can't be aware of where this podcast is being played and who is listening and I assert that there are certain themes within today's discussion that would not be suitable for young children, how young well that is certainly not for us to
CERN. We realize that different parents and different households should be the Arbiters of what sorts of information their children are exposed to or not. So my suggestion would be that if you have any concern whatsoever that the content of today's episode would not be appropriate to be heard by some member of your family that you please listen to the podcast first or at least check the timestamps where we've detailed what specific topics are covered and then to make your decision accordingly. I should mention that. Not only is dr. Malik
Still an active clinician. She sees patients daily out of her clinic in Southern California, and we provided a link to that clinic in the show. No captions. She's also authored dozens of high quality peer reviewed Publications in the fields of Urology, public health, and sexual health, and we've also provide a link to that bibliography in the show. No captions, and she is also a spectacular public educator. She provides zero cost content, about sexual health, pelvic floor, health and Urology, as it relates to both men and women on her YouTube channel, and there to, we
A link to dr. Malik YouTube channel, in the show notes, captions to this episode. Before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is however, part of my desire and effort to bring zero cost to Consumer information about science and science related tools to the general public in keeping with that theme. I'd like to thank the sponsors of today's podcast. Our first sponsor is rokka rokka makes eyeglasses and sunglasses that are the absolute highest quality. I've spent a lifetime working on the bye.
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Mom. So if you would be so kind as to take a few minutes to fill out the survey and help us continue with bringing you the best possible content here at The huberman Lab podcast. And as always, thank you for your interest in science and now for my discussion with dr. Rena Malik. Dr. Rena. Malik welcome. Thank you. Thank you so much. It's an honor to be here. 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 here 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 over hearing 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 STIs fear of unwanted pregnancy, all of which, of course, is extremely important for people to learn about, but far less about sort of that healthy versions of sexual health, right? Yeah, absolutely. So this is an, especially important conversation. 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, let's just say,
Say influences out there that relate to them, 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 you can clarify things for us and we're going to stay out of those trenches and the last thing I'd like to say is that because a number of terms will certainly come up and I think for some people 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 going to 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 we can reduce the shock the shock response. I love it. We got to talk
about all of it. Great.
So just 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
Kitchens. 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 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 ameliorate and
Healthy pelvic
floor. Absolutely. So pelvic floor, very simply is basically a bowl of mussels 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 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
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 so important in so many different aspects and we deal with it a lot as urologist 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 and women men also suffer from pelvic floor, dysfunction or problems with the pelvic floor.
So busy public photos. Function 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, or overuse, or posture problems. Things of that nature.
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 five minutes later you have.
Urinate again,
exactly something of that. So 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 can present a number of different ways and then with 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
These different things going on. And it's really just pelvic floor, dysfunction with with GI function, you can definitely have constipation and then often, you can also have back pain. 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 childbirth delivering children. With some people who have neurologic disorders, they can have weak pelvic floors or connective tissue.
Orders like, ehlers-danlos 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, 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 over contraction or chronic contraction of the muscles there versus two week? And one of the challenges in having this conversation is that if we were talking
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. Is there a way to describe pelvic floor, muscular, shortening, in a way that everyone can understand with this. Be like, like I said, we're going to be direct today with this, like, be like tensing up ones.
Danis and bout the opposite of the movement. That one would do before, initiating a bowel movement and relaxation is sort of the pattern of pelvic floor, muscular 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 gradual and so it can go over time become noticeable with these symptoms but otherwise it's very difficult.
It's not a muscle that we were ever trained to recognize, right? Like you hear about Kegel 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, 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 from
When 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 digital palpation where that's a medical technology for fingers are called digits. So, you know, I'm old enough to to recognize what a digital prostate exam is right. The physician inserts their fingers through it into the anus and feels the prostate to see whether or not it's swollen or not. And as I'm saying this, I'm
You know, sometimes we think of medicine quote-unquote. Modern medicine is so evolved. This is 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 folks, for those of you that think that medicine has evolved much up, it clearly has in many ways but in any event. So a prostate exam goes, as I just described, what would, what would a pelvic floor exam for a male and a pelvic floor exam? Four
Female involve at a kind of granular level.
Yeah. So for women you can feel the pelvic floor muscles through the vagina so you can feel the Elio, coccidia the pubococcygeus elevator and I those are all names of different muscles in this bowl.
This is the physician who can feel them. Correct
fingers. Correct. And, you know, you could to 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 week 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 general physical examination. And then also, you can observe. So, I can say, contract, your book, squeeze your pelvic floor up, and I can look and see, are they squeezing, or are they pushing that? Are they coordinated or not? Right? Because that's a function of normal, use of the pelvic floor, and sometimes you'll see that they're just coordinated. You can also assess for sensation in the area and things like that, that could be consequences of
dysfunction to their Beach.
Is functioning laterality. Like the pelvic floor is pulling up into the right or up into 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 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, therapist will just align your bones and and 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, there's obviously difficulty in putting fingers into the urethra, one would hope to small and 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 its through the anus, you can feel the muscles through the anus and then you can feel the paranoia.
Neal area and feel the muscles there as well sensation. So so perineal area, so from the outside of the body, okay? The region between the scrotum in the anus. Yes. 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 into on their own necessarily. It would be difficult. I mean, so there are things you can buy online like probes that you
Insert in the vagina that will teach you how to do kegel exercises and give you some read, you know, some readings, but they're not really meant to diagnose. They 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. So there's nothing that's going to give you like a baseline reading. Is this normal or
abnormal? Let's talk about kegels. First of all who's Kegel.
So he is a gynecologist, I don't remember all the specifics to be quite honest, but basically he came up
With kegels, which are strengthening exercise for the pelvic floor. And so what it is, what we described it to for patients. As 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 the one 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 to speak. And so you'll do the other way. People describe it is pulling up and in in the like the video
Enough or for men's. And as you'll see, 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 using describe it. Yeah. So those are kind of the ways that you can describe those muscles and so you can squeeze 45 seconds and relax for five seconds and do them in repetitions and they're just like any sort of exercise you do. You don't want to start doing 100 of them. Right? You want to do them? I tell that people I tell patients through them lying down so that you're only focusing on those muscles. You're not working on your posture. You
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
17 or 19. Repetitions so yellow socks. That's enough.
So yeah. 10 to 15 repetitions in the morning, 10 to 15 repetitions at night. 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 kegels, 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 kegels, 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 kegels for those that need them? Yes. So they are typically prescribed for urinary incontinence
Specifically stress urinary incontinence. So leakage that occurs when you have an increase in your intra-abdominal pressure like a valsalva or coughing, sneezing lifting heavy things jumping on a trampoline. So for those purposes, we use kegels 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 prescribed them for people who have had a prostatectomy
Who then subsequently develop leakage after the prostatectomy that is again, stress urinary incontinence. Now, a lot of people use, kegels 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 because then you can lead to a more tense pelvic floor, which is not where we want to end up. Yes, I will underscore that cautionary.
Note years ago, I heard about kegels. It's like, okay, try it sounds all good, right? I only heard good things about kegels and what it quickly resulted in was painful urination. And I thought this is weird, everyone's saying, kegels are so great and the best thing I could do for my pelvic floor. It seemed was to avoid kegels. Yes. And a little bit later. I'll when we're talking about prostate, I'll explain at least what my
It was as it relates to the prostate, 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 over treat anything else. And so you just have to if you really want to do kegels, 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 of stop and go see a urologist so that they can kind of assess your pelvic floor.
What is the anti Kegel? 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 women, you can do massage of the
Are you can use vaginal dilators to help relax the muscles. You can take suppositories that have medications like valium or baclofen which are muscle relaxants and 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 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 down train the pelvic floor. For example, one of the ones I tell my patients is
Like happy baby pose. It actually you know, stretches and elongate 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 and 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 and one point in my life and I made 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 kegels. Yeah, so again for me, seeing the kegels is 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. That tell me if you agree or not that if you hear about something online or on this podcast or anywhere else and
You tried, 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 are 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, is it possible? That's creating a symmetry?
In the pelvic floor. And now, I'm sure I'm angering yoga teachers and crunch crunch in East has everywhere. But, you know, hey, if it's a question of your pelvic floor, or a few extra delineations in your abs, you know, where my votes 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 the chest in your mouth and throat.
Wrote. 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 intra-abdominal pressure, you're you're causing to increase from the exercise, whether it's a squad, or as crunch or whatever, you're increasing your abdominal pressure, your pelvic floor,
Then Contracting to help stabilize that. And so 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 pudendal nerve and the pudendal artery that runs 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.
Auction 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, any time 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, and so on. So we won't be overly systematic in our parsing of all this. But 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.
Will cut off blood flow. In fact, one of the more common questions I got and I consulted with a couple of 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 experience things, like, erectile dysfunction, that they experience 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 also talked about the role of testosterone 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 in the male sexual response and the female sexual response, of course, but they are impeding their erections. So you can start to see how 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 sending themselves backward in some cases. So the question is, how does one know whether or not something like, let's say low lubrication or pain during vaginal intercourse or 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,
It or neural related and if it's neuro related, how does one know of its issue of lack of appropriate signals from the brain over suppression or lack of arousal from the brain or whether or not. It's some peripheral neural thing of innervation 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?
There's all these questions that will help us go down the
route. Sorry to interrupt when you say aroused for sake of this discussion, I just want to make sure that we distinguish between psychological arousal, the desire to do, I guess here. We also have to be precise arousal to engage in Intercourse and arousal to desire. Essentially, I think people learn to recognise or we talking about arousal as the response of the genitals correct. So, so desire and arousal.
Well, this is a very important concept doesn't always go in One Direction. Sometimes you can feel arousal, meaning you have The Tell-Tale signs of arousal, your nipples, get erect. You have more lubrication. If you're a female, you're both male and female nipples. Get erect during around slowly fell think so. Yes though, you know, you maybe get the sex flush, right? You get some some redness or warm feeling that's your body's response right to arousal and sometimes that can be an hour,
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 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 it? Is that 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
limit 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. 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 psychogenic components, right? You can really get in your head about erections when you have a problem in the
Dream with performance, it becomes a vicious cycle, right? So 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, I'm 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 important first to identify those issues and then also for blood flow a lot.
Of times we can, we can assess based on well, what other comorbidities 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 the exit - Lee - Lee. So so that will point us to a more vascular issue. Hormonal issues are very important for desire and and you know as far as sexual function in terms of erection
There's only three percent of erectile dysfunction is related to hormones so it's
actually a erect erectile function. Correct as opposed to desire Christian fire is 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 and they actually have estrogen. So testosterone is very important for both men and women for a variety of reasons. And so, you know, using that discussion
With the patient will help you kind of identify where you're headed in terms of 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 venous outflow and so that can assess those
Since 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.
As you did, when you were younger and so that kind of overlays all of this. 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 and what's going on, like, really thinking about each of those aspects, and also, what's going on your relationship and what's going on in, you know, your life stress anxiety. Like, how are those playing a role? As many of you know, I've been taking a G1 daily since 2012. So I'm delighted that they're sponsoring the podcast. A G1 is a
Mineral probiotic drink, that's designed to me all of your foundation on nutrition needs. Of course, I try to get enough servings of vitamins and minerals through whole food sources that include vegetables and fruits every day. But often times, I simply can't get enough servings but with a G1 I'm sure to get enough vitamins and minerals and the probiotics that I need. And it also contains adaptogens to help buffer, stress. Simply put, I always feel better when I take a G1, I have more focus and energy and I sleep better and it also happens to taste great for all these reasons, whenever,
Sir, I'm asked if you could take Just One supplement, what would it be? I answer a G1. If you'd like to try a G1. Go to drink. AG one.com huberman to claim a special offer. They'll give you five free travel packs. Plus a year supply of vitamin D3 K to again. That's drink. AG, one.com huberman. Gosh. Lots there to unpack and I'm glad you mentioned the relationship itself because there are all sorts of things that can impact the arousal response novelty.
I'm not everyone's in a committed relationship whether or not people are engaging in a lot of masturbation to the point of ejaculation or climax or not pornography Etc, we will get into that. It's a vast space to explore before we go any further, I want to make sure, however, that week you people to wear, and how they could find a really good. Let's say pelvic floor therapist 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, 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 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 some of the
Ones ones area. Can it be done over telemedicine? Yeah. Well 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 in urology, you'll look for people who are board certified in female pelvic medicine and reconstructive surgery. If you're a woman,
Woman if you're a man, maybe sexual medicine someone who specializes in sexual medicine, would be a good place to look for gynecologist. 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, Physical Medicine Rehabilitation, at least when I was in training. There was about 20 p.m. and our doctors around the country who are 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
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 therapist 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 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
shame or at least lack of clarity as to how one gets help for issues that relate to the genitals, right? Because if you have a headache or you having an eye issue I mean it's or nowhere to go. Yeah. Hopefully your headache doesn't warrant going to a neurologist but it might you know, I stuff tends to be opthamologist optometrists right? Yeah. 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 round 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 painful intercourse mean, is there a
Is it even possible to have a parallel conversation about these two
things? So, it's different in some circumstances. There are homologs, right? So, the penis is the homologue 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, is actually quite long. And so, you can in men, you can have erectile dysfunction, because you,
See it. But in women, you may have difficulty with orgasm and it's not exactly a parallel, but difficulty orgasming and women is multifactorial, and we can get into that. But I think there are 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
Of reasons that you might not have an erection that we sort of touched on your vascular problems. Hormonal problems, neurologic problems, psychogenic, issues and other medications you're taking. So there are issues that can affect erectile function and, and so that can be a 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,
Those are kind of the ways you can look at
it. Thank you for flushing 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 people still generally agree that if one looks at the embryological origins of the penis and the clitoris they are essentially analogous structures. And that a lot of male genital development involves literally the regression The Disappearance of the female sexual.
Italian Associated, organs, mullerian 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, 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 that we can knock down a few of these pins in a little less time because there's a lot to tackle here. First off, I'd like to address the hormonal issues, you mentioned that only
Three percent of erectile dysfunction. And by extension can we say also female issues with sexual arousal are hormonal and origin. Is that right?
So with desire? Yes. Okay. Are hormonal in general, and arousal is in terms of lubrication if you're using that as a barometer. Yes. You can see less vaginal lubrication due to hormones and I guess I'd say three to six percent more, you know, up to 6%. We see of erectile dysfunction is hormonal, it's a small percentage.
Age 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 mindset, we've all come to believe that testosterone is prohibido. Its Pro desire in men and women think now people are showing you appreciate that, spro desire and women as well, certainly in men and that dopamine is also associated with desire. And the general public tends to have this view of estrogen is being sort of
Anti libido or anti-male which is, frankly, false in fact, and I've covered this on the podcast with dr. Carl Gillette, and with dr. Peter Atiya and another fellow YouTuber Derek for more plates. More dates, has talked a lot about the fact that if people if men excuse me, take drugs like Anastrozole to suppress their estrogen.
Thinking that oh, it's all about having high testosterone, low estrogen, oftentimes, they Crush their libido. Just abolish it. Yeah, which has led to a slowly growing. But I think positive shift in, how people are thinking about estrogen, estrogen is great for brain function estrogens, great for libido, and men and women. And that is a revision of, 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 oestrogen in the female sexual response that
At that makes sense. But what we're trying to do here is clarify some of the misconceptions. Now, the reason I mentioned dopamine is that my understanding is that dopamine is involved in the route, 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 direction can't occur another. Perhaps orgasm can't occur in females Etc, but my understanding is that's also not
not that simple. And we need to take a step back, perhaps, and just talk about the physiological underpinnings of the desire 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
Direction 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 psychogenic 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 edginess or excitement adrenaline. In other words can stimulate erection or vaginal lubrication. So it gets tricky. You. I would, 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
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 catecholamines, dopamine norepinephrine and epinephrine also called adrenaline and noradrenaline are released and that the climax responsive which may or may not include ejaculation. We have to separate that out is one. That is really of the stress system.
The body and then in the post-coital or post ejaculatory or post climax phase, then there's a shift back to the parasympathetic nervous system. That's where the pillow talk and the, the exchange of odors and tastes and other molecules is known to enhance, pair bonding through things like, oxytocin vasopressin and so on. And at what I just described is exceedingly over. Simplified, I realize. But is that more or less? How the physiology
Elegy works. Yeah so the way we're taught in medical schools point and shoot. So point is the parasympathetic nervous system all your all the male audience will like that on 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 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
Oxide from the parasympathetic nervous system and that could be for some people aggression, or, you know, some form of that, right?
That's all people about nitric oxide because we'll get into this. When we talk about drugs, that increase, blood flow, Cialis Viagra, and also non prescription drugs, things like l-citrulline Arginine and watermelon for that matter, right outside. So I read on the internet. Yeah,
so yeah, so nitric oxide is essentially the ignition for what we say for erections. The
And for our actions that we if you thought 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 2000 about the
clitoris. Okay. We have to this was actually a major section of the comments. Yeah. On when I asked for for questions on Instagram in comments on comments and yeah how come why not Etc.
Is that because the Urology and sexual health field was dominated by men, that's going to be the presumption. Or is it? Because it's easier to study somehow. I mean, what's going on here? Yeah, I think there's been a lot of you can go back to like, Freud where he thought that the female sexual response was less valuable. And so there are some really valuable. I guess, I don't know if that's the right term but oh no, I'm not catching.
You know, 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 stay 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? We do this for people who have erectile dysfunction, they'll take medications that increased blood flow, like trimix fuel injected into the penis, and you'll see in Iraq,
So you can actually try mixed traffic, so there's it's
injured. All the entire male audience just went away. What do you check
in there are there are three basically brand names of intra cavernosa, injections that we use for erectile dysfunction. I hear injection and Venus and I think I'd say I like to think that it reflects a natural male response, I sort of taken aback. I don't know. Maybe there's a pelvic floor, contractions in there someplace, 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 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 as the most effective non-surgical treatment. We have, for erectile dysfunction, and it's usually either one medication to medications are three. So you can have, you know, a prostitute papaverine and
Third one, that's a good. We can look at someone will put in the comments. Surely they will, what, what is it designed to do? Is it, is it a vasodilator sword? So they work in different mechanisms. But similar to the medications that we have pde5 Inhibitors, pde5 Inhibitors work in the erection Cascade. Basically, what happens, let's actually let's take it back to the nitric oxide thing. We'll get there. So nitric oxide essentially is released by the endothelium in response to a
All tactile stimulus stimulating Q, 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 phosphodiesterase and so medications that inhibit phosphodiesterase like Viagra and Cialis tend to prevent the breakdown of that cgmp. So you have longer lasting erections. And so similarly, these medications work sort of similar to that some of them, we don't know. Exactly.
Chloe, how they work, but they work by increasing increasing cgmp RCMP that are involved in those
Cascades. And what about l-citrulline, I hear about l-citrulline used. It's an over-the-counter supplement and it's in the Arginine pathway. And my understanding is that it works similarly to things like Cialis Viagra but is perhaps not as potent. I also just cautionary note out there l-citrulline can give people vicious cold sores and canker sores vicious
So, you heard about this on the Internet, it's been verified by grotesque images that you do not want to Google for and not everyone, tolerates it well.
So these actually work by increasing nitric oxide. So they're not in the, 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 l-citrulline converts, tell Arginine, but it is last much longer in the bloodstream, which is why people tend to use l-citrulline. Now, you know, in in
Medicine these supplements while there has 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 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 four hundred percent times more. And so that's kind of the struggle that we as medical doctors have. And I know we get a lot of flack 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 relationship to accept that. I mentioned them all the time is examine.com, which has references to human studies and where there's a lot of efficacy shown and we got into some side effect issues. Does can't address brick, you know, quality by brand issues but thanks for mentioning that what percentage of males who take Cialis.
AKA to dial fill or Viagra for erectile dysfunction. Get relief from that because you mentioned only 3% of erectile issues in males, are hormone only in origin 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 vascular in nature, right? That's the number one cause in
In as men age. So we know that about 50 percent of fifty, two percent of men over the age of 40 will have erectile dysfunction and that continues to increase as you age. So 50% of 50 year old 60 percent of 60 year old and so on and so forth. So it's very very common and the success rate in the studies is about sixty to seventy percent. So when you give someone a medication, they will have sustained directions that are sufficient for penetrative intercourse which is the way we kind of discuss erectile dysfunction.
He's an in with patients is about sixty to seventy percent. So not everyone will have success but not all of that is because the medication doesn't work. Sometimes people are not taking them correctly, sort of people need to try different Doses and then there's still this issue of your brain is still active and so if you're having anxiety or 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 but generally speaking, they are effective and they do work quite well.
And they're tolerated pretty well. So she to 70% is not a small number. That's, that's a significant number. That's the majority. Yeah. But by a significant margin, is there a basis for the use of Cialis to Dallas? Fill Viagra l-citrulline 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 and certainly something you can try off, leave.
And certainly people do try, 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 controlled 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 make a note here that nowadays there's increasing use of low dosage, Cialis / tadalafil. So rather than
Than what I found online was that the erectile dysfunction treatment? Dosage of Cialis Adele feels somewhere in the, you know, 15 to 20 mg range. What we're talking about here is daily use of 2.5, 25 milligrams of see all stood a, a feel for prostate health. And I learned in researching for this episode that tadalafil Cialis was actually developed as a drug for the treatment of prostate health to essentially
Blood flow to the prostate to increase prostate health, not for the treatment of erectile dysfunction. So I found that to be somewhat interesting and a lot of people are now starting to use that. I also learned that if you dive into the guts of the internet, one can find that. Now there's a growing use of combined low dosage, see, Alice and April morphine, which is a pro dopaminergic agent and we'll get back to dopamine a little bit later. But is there any basis for low dosage? Say 2.5.
25, mg daily use of Cialis, tadalafil in females.
Yes. Oh well let's talk about it in for males and females, I think low-dose daily Cialis is excellent for erectile function in men. Even that true even
a 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 promote as far as for women. There's, you know, again, it can help with blood flow. So, if you're having issues, if you have a female's having sexual dysfunction and she's got signs of vascular problems, like she's got
Got diabetes, high blood pressure, she smokes and yes it's certainly reasonable to try and see how they do. You 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. 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, vaping and smoking badge for erectile function, in prep, sexual health and males. And females generally because nicotine is a vasoconstrictor. Nicotine does have certain benefits and I covered this in an episode on nicotine, neurocognitive benefits and the elderly in particular, but it is a vasoconstrictor. So it runs against all of the sexual arousal stuff that we're talking about. But okay, let's assume that mail 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. You know, they're not doing legs cross kegels, while doing crunches or something, while inhaling on the crunch, that was a quiz. By the way. Thanks for earlier topics covered. Let's assume they're you know eating pretty well majority their foods are coming from non-processed or minimally processed foods.
They're doing a little meditation each day, they're engaging in, hopefully healthy relationships. They're not masturbating like crazy to porn. And, you know, let's assume that they are, you know, not on SSRI, why are all these 20 30 year, olds on the internet asking, mainly you, this is they can run to you 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
They very often have pelvic floor dysfunction. So the, even though they're doing all the right things, 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 lot of us are sitting long periods of time, especially during covid. I mean, people sat for months, right years, like, just sitting at their home computer. And so, 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's probably the more common cause
so walk more. Yeah
I've actually heard standing desk.
Yeah yeah walk more standing desk. Okay. So and then my guess is that there's some psychogenic feedback loop. Absolutely it's just nerd speak for things aren't working as well as they would like them. They're stressing about it and the stress is making things worse. Absolutely. And you know you mentioned that people are not masturbating or using porn but a lot of people learn about sex through porn.
And 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 by last name but yeah, the kid down the street, you know, had porno magazines. Yeah, or magazines. And then there was actually a library of these goodness. I shouldn't say where they were in the town. I grew up in where kids would stash them in specific locations.
In parking lots. And then, you know, boys would bike or skateboard over. We're walk over and then they would like take terms. Look, take turns use me looking at them. But that, that actually is to raise a, perhaps, a more important point, 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 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 masturbating to pornography, to the point of ejaculation is creating a deficit of seeking out and cultivating healthy real-world. Sexual interactions. Yeah, so I want to I want to start this before I get into that is to say that if you're masturbating to porn and you have normal healthy relationships and your
Going to work and you're have a great, you know, partner and you everything's great in your life. It's okay. Like shame is a real problem and it may be there 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 poor problematic. Pornography use and it's only describing about 4% of people in these studies. So it's a small subset of people. I think it's becoming more common because pornography is so accessible and it activates
It's the dopamine Pathways just like any other sort of addiction, right? 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. And also, I would say sorry at Jin truck, but that the dopamine response as a hardwired biological mechanism for adaptive behaviors including and let's just Define,
Healthy sexual behavior. Because I feel like there's such a range on that depending on one's background religious beliefs, Etc. Any time 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. That I'm getting 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 and Jacqueline to pornography, and have a normal life and so that's fine. I think that, you know, if we shame those people were creating problems, right? We say like, oh, you do that? That's horrible. And then they're in their head, right? And then they're causing,
Oblems in their life, because they're because of Shame. And so there's I think there's a little bit of 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. Cause 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 their religion, or their between relationships. Yeah. And they're relying on masturbation specifically, right? Um, are there any data that distinguish between?
Pure Imagination Fantasy Versus visual fantasy 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. So I think one intended.
So I think that the beat the thing about young, people want to get back to that and 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.
Out what sex is, right? No one has a conversation with their kids. Like, hey guys, this is what happens when you have sex, has how long it should take, this is what foreplay is. And this is, like, not normal. This is the production. This is a produced product, that's meant to arouse you write and to give you ideally an ejaculation orgasm, right? So no one has that discussion, so then go to relationships. Like, why did my partner not react like that woman did on the porno? Right. Or why did I not?
Act like that woman did
on the porno. Right. Why didn't he react? Yeah. When you know, like they would in porn because again, I think females are watching porn as well. Yeah, you know, I think I so I think that you raised a really critical point which is that this shame can extend both
ways mmm-hmm. And so I think to that and that's a problem and because it's so accessible. I think we need to have conversations. I think it needs to be open, we have to talk about sex and that's what kind of why I do what I do. We have to have these conversations. So
I know what normal is, thank you for that. I do think that 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'd like to take a quick break and acknowledge our sponsor inside tracker inside trackers a personalized nutrition platform that analyzes data from your blood and DNA to help you better understand your body and help you meet your health goals. I'm a big believer in getting regular
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And for some people, the sounds of people having sex is extremely arousing. If you ever lived in a major city like New York, which I spent summers in New York, you hear a lot. You hear more often than you do in areas where people are living further apart. You hear people having sex? Yeah, it's part. It's part of the art of the auditory
landscape. Yep. You're very close together. So but yeah. So there's not exactly at least to my knowledge. I don't know how the data that looks at Fan.
Tennessee versus visual versus auditory. But I will see 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, 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 might not be able to replicate that during penetrative intercourse. 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-exploration again with the caveat that as long as you're not masturbating to excess and avoiding your obligations, or your family or Partners or your friends, right? Like you are just masturbating for the benefits of maybe sleep Improvement, mood boosting reduction in anxiety. Those
Those things are great. And so I think with that being said, you just want to be thoughtful about, varying it up
one of the issues with masturbation that talks about when I was a guest on other podcasts, mainly in the context of male masturbation and perhaps with pornography, perhaps not is that it's pretty clear based on the data surrounding addiction, that anytime they're 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
D 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 any more funding to
make. I mean I was weaned in the era when you know no smartphones or anything and
no, my point is I think that we've become very 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 pre male friends always have where a lot of what we learned about. Sex came from older. My case guys. Mmm my sister probably learned a lot about sex from her female friends and there was always that one guy who would just say stuff that years later I realized was incredibly misleading. 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. They might be that guy. Yeah. Right. Absolutely. And and if you look at the, if I look at the long Arc of those people that guy's life, it didn't speak to tremendous success in the domain for which they were asserting such confidence. Let me put it that way. Okay, 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 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. Mmm, some cases is not true. The Stereotype is that,
Women are more intimacy and relationship based on their sexual response.
That can't be true. I have female friends and have known women who also are just really interested in having sex for
sex sake. Hmm at times. Yep.
Or maybe all the time. I think. I like to think that we are past the stage of human development where the stereotypes around this are are fixed, right? And 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've just going to earmark now that any time we say something like arousal or orgasm, there are multiple forms of that, right? 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
Axe and this was I guess. Okay, back female sex workers, yeah, with men. So they watched and they took note of the, the site, 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 your breathing, a little heavier, there's the sex flush, you can see redness and areas like, you know, in the vulva, in the breast, I mean, the nipples and then you go to sort and that can last a variety of different times.
I'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 point eight 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.
And 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 four 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'd need something more novel and exciting to then again resumed that cycle
again, Coolidge effect. Yeah, we'll talk. I've talked about the glitch effect before on this podcast. I'll just Q people to it.
Timestamp Link in the show notes option, so we don't go the down the path. But one thing that's really important to understand is that the Coolidge effect is present in both males and females, meaning, if a male Jackal eights and 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 a novel sexual partner, female or male depending on their their proclivities can override.
Refractory period, and they can have another erection. And ejaculation. Similarly female will have a post orgasmic refractory period. If they are given an adequate stimulus, the write something arousing enough, they can experience arousal and orgasm again. And we know based on really good pharmacology that this is a dopamine driven thing. The prolactin is essentially establishing the refractory period in the dopamine is essentially
Overriding the refractory period, fascinating neurochemistry there, and it speaks to the incredible extent to which the brain is controlling the genitals.
Yeah, well, I mean, 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 their FDA approved for premenopausal women with low libido.
But maybe just throw those out because
One that I'm aware of is in that's often used in let's say Niche cultures is melanocytes stimulating hormone and Men which gives people a tan makes them erect. Melanocytes stimulating hormone at msh comes from the medial pituitary. If I'm not mistaken one of those weird regions, know everyone talks about and everybody. I'm but and people are now injecting this as a peptide. It can cause priapism. I have not had that experience. I've never tried this. MSA.
Eh, but I'm told that it people are getting Cavalier with it. They can have issues, priapism, being enduring, and perhaps, even final erection, is that true that through priapism priapism? I mean, it's actually from priapus, the Greek god, who is often photographed with a really big erection. Well, I didn't hear enough about that. Greek, god in school. But is it Roman? Roman or Greek. But anyways, so either way it's an erection that lasts longer than four hours and it is actually a
Jackal or it's not a surgical, but it's actually an emergency. If you have an erection that lasts longer than four 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. So it's really important to actually go to the emergency room. Don't wait because you're embarrassed, really get there and get treated. However, if I'm not mistaken earlier, you mentioned that it is exceedingly rare that people who take
Take Cialis / to Dow, fill, or Viagra for erections are getting true priapism, correct. And it's mostly from those injectables we talked about earlier. Those inter cavernosa injections people can get priapism from those a little bit more commonly. And so that's something we always Council on and also certain medications like trazodone or if you have sickle cell anemia those are the most common reasons that we see. People coming in with private rooms ago, I'm really okay, I'm going to refrain from my
Figure out that one. So I don't take us down a rabbit hole here.
So I wanted to get back to the msh. There's actually an FDA-approved medication called bream. Alana tide is the brand name. Vile EC is the sorry Bree monetize the generic name by Lisi 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 but it is basically the same peptide, right? So it is
Milano courtin 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 said about an hour 45 minutes before we 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 may be up to 48.
Has it been? I mean, I know of men using linas a stimulating hormone peptides. I also really want to
Some people about obtaining gray Market peptides, sorry for this insertion here but 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 and animals in the laboratory and it is amazing to me how many websites are selling this stuff and it arrives to you easily. You just buy it on the internet, says not for human or
Or animal, use some people are injecting it. And the LPS issue is something I think is potentially going to shut down that whole Market at some point. But if you are interested in using a peptide, you should be obtaining, it by a prescription from a quality physician, exactly. And because we have Bri mallanna tide, 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. And so you know this is available for premenopausal women. The other
Medication that's available for low. Libido is called flibanserin. Also known as ADI, is the brand name and that also works on Saratoga. It's got kind of a mixed response serotonin and dopamine energetic 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 six forty-five to sixty percent of patients. And you need to take it for some time. Now, both of these are brand-new
Name medications. So they are a little bit costly and sometimes insurance doesn't cover them, but they are available. 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. Therefore, yes. There there 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 vaginal lubrication arousal and female orgasm, but as long as we're talking about arousal and
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 tool either, but there's no chart. It's not like a thermometer that says your 98.6 plus or minus two degrees. You're good. If it's too high, much higher than that, you have a fever if much lower than that your hypothermic. So my understanding, my
I don't was a naive understanding, but 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 accrue enough of a sample size, they did 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 compared to how they felt in earlier years or at different times of the year under different psychological conditions and stress conditions, that kind of thing, but we really don't have a benchmark.
That's right. I mean we can't say that for instance, that if 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 yes, those are think about 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
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 FSF I, you can actually see that about 40% of people qualify for having sexual dysfunction, but really bother is only seen in about twelve percent and you can be bothered because you're bothered, you can be bothered cause your partner's 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, but 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 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
Asian Ali, you have a physical interaction with someone where sometimes, it's not even physical interaction. And they are just so unbelievably arousing to you or somewhere in between, or sometimes it just sort of ain't there. 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 a not just put on males, this is put on females. I hope she doesn't kill me for saying this. I know somebody who is
Family member, who once said, sometimes you have to realize you never want to sleep with somebody again because by Sleeping with them and here we're not talking about traumatic experience, right? So, you know, again that discussion around libido. As you, so aptly, pointed out and gauging, 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. Let's get back to female sexual arousal response an 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 to be more specific. So it what it does is the cervix moves up and out of the way the the inner 1/3 2/3 of the vagina lengthens and elongates to allow for penetration and it can actually
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 Painful intercourse. It's because they haven't had adequate time for arousal. And so they're the penis 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
need a longer period of time of what as you described for plate 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 be-all end-all. Some people just make a lot of lubrication and some people don't and certainly that changes with age and hormones. So if 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 we know from it's not a pleasant topic from
Reports following sexual assault that, you know, oftentimes the victim is demonized for having been 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. Okay. So, let's set that aside and unpleasant topic, but one that's important to to flag or
Their forms of non libido type arousal.
Lubrication that allow for non-painful or even pleasureful penetration, that are important to distinguish from the arousal based lubrication. In other words, I have to imagine 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 mainly in the context of a real.
Özil you know postmenopausal reductions in lubrication but are there also postmenopausal reductions in Baseline. Lubrication are some people's vaginas just more lubricated at once a at rest. Its like the scientist in me when they're asleep. For instance, I mean men are having erections in their sleep. Are women getting vaginal lubrication and their sleep? Periodically, my guess is. Yes, well, they're definitely getting clitoral and Gorge mint right there. Getting little engagement. There's been some studies on that that they are also getting nocturnal tumescence, right? Just like men do as far
Lubrication, you know, that the data at least, from what I understand is like there is 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. There's also Baseline vaginal discharge, that's completely normal. Women will make physiologic discharge, in fact, in our examinations, when we examine will say normal physiologic discharge, because we see it,
There's always discharge and it is it can be up to like five milliliters and so it's not a small amount, it can happen, it can be quite a lot.
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. You don't need to smell a certain way or or reduce that discharge. This is like completely
Healthy and you talked about chemistry and I know there's like not a ton of data on this but they're like pheromones right there sense that are coming from you which are actually attractive to a partner potentially and in whatever, physiologic you know, I don't know, there's not a lot of time data on this but like there is that part of it. So you know, there's a lot of marketing towards women that your dirty you should be smelling like peaches or whatever. And there's a lot of marketing I maybe this is generational thing, but I learned early on me I think probably
Behavioral Neuroscience courses that vaginal lubrication is were part of the arousal response from both. These were always framed in the context of heterosexual relationships, but both Partners, let's just say both partners because this could be a homosexual, female relationship to write. We want to make the conversation as broad as possible. And that the odor, let's be frank here. The odor, and The Taste played a role in both arousal, but also the
Are bonding response that would establish future arousal and anyone that's ever been in a relationship that let's say you had healthy sexual relations relations. I like to think his experience, I'm remembering somebody smell or think about somebody smell and that itself can be very arousing. Yes Partners. Even I'm smelling different articles of each other's clothing. Not being arousing. Yeah, so I mean this is the stuff of real physiology. We're not we're not making this stuff up, right? But there is, there is a lot of marketing towards
In 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 microbiomes of their pH is changing and that can affect, you know, their risk for UTIs or bacterial vaginosis. And, 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 doctors think. Oh I'm you know, I think I have an STD but it's like normal physiologic discharge. And so I think it's important to say that this is
All 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. What about other infections? Like yeast infections or bacterial infections of the number of questions about mycoplasma infections which we don't hear that often about? But yeah. So you can see if your discharge has
Has changed and become more like cottage cheese, like, or there's, you know, it other symptoms like itching or discomfort then, you know, those are signs to go get evaluated. Mycoplasma 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 mycoplasma. That could be causing symptoms in the
Self. We've had a couple episodes about the gut microbiome. My colleague, Justin Sonnenberg at Stanford as Laboratories directly above for, my is expert in the gut microbiome. Done a couple episodes about this and he reminded me and I like to remind people that every mucosal lining of your body has a robust microbiomes. That means intranasal and true vaginal entry urethral in males and females, there's an anal microbiome. There's a microbiome on your skin, on your eyes.
Eyes, and you mentioned douching and other in other ways of 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 a bad thing, in many cases because it's wiping out the microbiome. What are some of the things that females can do in order to promote the health of their vaginal microbiome? So it's it's really our bodies are amazing, the vagina is a self-cleaning oven. You don't have to do anything. You just walk.
Vagina is a self-cleaning oven. I'm not going to, I'm not going to repeat that too often and too many different contexts, but I'm going to remember it
forever. You will you what the fuck? And so all you need to do is wash the hair bearing areas because those are the ones that create sweat and and should be cleaned. But other than that, lets soapy water run down. You don't need to do anything, your body will take care of itself. When I was five 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 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 Argentina. 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, yeah, 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, he's like, yeah, amazing. Well, I went out into the world and anyway, he figured it out.
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 to parse this, I think that the simplest way to parse it is going to be from the anatomical standpoint clitoral, orgasm versus so-called G-spot
Poor penetration based orgasm, but of course, penetration based orgasm is also a bit of a misnomer because there can be clitoral stimulation by pelvic pressure or by digit. We're gonna talk about fingers, its digits, because we're both in the medical / science profession. But we try my fingers here or something else, right? Vibrator toy, whatever. I'm told for a depends on how flexible you are, I don't know. But the point being that I think the simplest way to go about this is going to be to talk about
the distinction between clitoral orgasm and G-spot orgasm. However, those are achieved and to also talk about this idea of graded versus absolute. Okay? So, this has actual parallels to Neuroscience where we talk about communication between neurons being graded. Meaning, it's kind of, you know, one level than a higher level, than a lower level where all or none, right? How shall I say this? It is clear in my life experience and observation that there are multiple kinds
A 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. 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 period of time in which they
Become hypersensitive to touch. So, lots of different things going on there, psychologically physiologically. 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 clitoral stimulation in order to climax. So very few actually climax through just vaginal penetration alone and so this is you know a real problem we're seeing on the media that you know you you have sex and you penetrate a melee 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 homologue of the penis, or the pieces of homologue of the clitoris. However, you want to say it on you. Forgetting it, both directions. Yeah, I probably would have screwed that one up. So, so clitoral stimulation is just like penile 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 percent of men are having an orgasm. We look at first time, sexual encounters for women with, in heterosexual,
Relationships, it's about 45 to 50 percent are having an orgasm. And when you look at homosexual relationships of women, it's again, 90 percent. So, there's clearly some lacking in ninety percent of 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 busy ology in Psychology. Yeah, that's you. That's you.
You know, there's a huge gap there, and so I think to bring it home as a clitoral 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 crew ra 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 clip. The clitoral shaft which goes deep into the pelvis. The G-Spot is is an area as an erogenous Zone.
Where it's kind of in the anterior wall of the vagina about 2 to 3 cm. Then that's the location of these pair urethral glands called the skenes gland 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 huge variety of ways you can stimulate with stimulate anyone, it can be man or woman, some people will have orgasms to just nipple stimulation alone. Some will just hear something or see something and be able to achieve an orgasm and it's so varied from person to person and I think the big take home 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. 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 I think the the take homes for this and also the vaginal penetration is actually usually from cervical stimulation not necessarily vaginal because the large density of innervation, the vagina isn't the first outer third of the vagina, the the deeper.
Upper two-thirds of the vagina has, as much less Innovation and yet there is such a thing as cervical orgasm. Hmm. So and the cervix being further up, the vaginal Canal is cervical orgasm. Specifically the one of the stimulation and act the foci 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 years ago, when I worked on hormone base sexual differentiation, which, by the way, we've done it, episode of the podcast on previously. You know, I learned that the
Leavitt or any muscle is the muscle that controls erection and males and presumably clitoral tumescence and and engorgement in females. Is there an equivalent muscle responsible for the orgasm response or is the contraction of the pelvic floor part of a more General theme of muscular contraction and a bunch of different nerve Roots Contracting? The reason I ask this is that eventually in this conversation we're going to migrate up toward the brain but because this
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, in other people and descriptions Etc. But are we talking about a response that originates at a Foci? Kind of like, in a in the brain. We talked about a seizure, you know, starting at a focus of Foci and then spreading out, or 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. Yeah. Or as a whole body response and the here, we're not talking about the flood of neuro chemicals into the body. I'm talking about during those moments of orgasm. What is happening Neroli? I mean it does have certain parallels to
seizure, right? It does, it does. So, let me go back to your first part of the question, which was about orgasm and sorry, erection, and to mesons being a little elevator. A nice. So actually, what
Happens. During the reason you get an erection and presumably clitoral stimulation the same way as blood flows into the erectile tissue and the Tunica which is the outer layers of the of the shit of the erectile tissue, which are to basically cylindrical shaped structures in the penis. And in the clitoris, they will fill with blood and then that Tunica 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 with we wanted to study erection?
Behavior in rodents, we would give them injections of testosterone, females or males and observe changes in sexual behavior, accordingly, erection and clitoral tumescence. Although it's harder harder to measure in rodents. There's a way of indirectly measuring that and then we would measure the size and weight of the Levitt or any muscles as a readout of how Androgen eyes that whole system was, you know, in other words, what is the role of the mentor?
Any in the sexual
response, the levator and I are, well, I think Olivia, you would know I still. So those muscles are part of the pelvic floor, right? And so those contract when you, when you climax, right? So whether it's orgasm for male or female, they're Contracting and they're exercising right there. Get. So, that's how they would increase their, their strength, or their density. If you're measuring that through the actual climax of what you can't see in rodents, right? So like you're kind of using it as a surrogate in that.
Way. So that's what happened. 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 way you described it as like a ripple effect, it's more of like it's the way your body responds to that particular stimuli and it's actually like the ultimate
I'm 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 were very present in that moment. And so people will feel different simulations depending on, you know, how they're how they kind of how their sensor, you know, their nerves are their Sensations, are and things like
that. It's perhaps a good time to mention dopamine. We talked about a few times earlier when talking about the arousal Arc, that starts with parasympathetic sort of
Of calm. And then move typically starts as calm and then moves to the orgasm response. We know that the orgasm response is associated with release of dopamine and then prolactin which sets up the relative or absolute refractory period. The, the interesting thing, and I got some questions about this is that there's literature as I understand about the elevation and dopamine caused by
Say antidepressants like Wellbutrin grouper iron which increases dopamine and norepinephrine people who recreationally use drugs like cocaine or other stimulants people who take Adderall Vyvanse or other drugs that increase levels of dopamine. Because I did whole episode about those drugs and they are different forms of n feta mean, unless we're talking about Ritalin, which is a little bit different and I got a lot of questions about people.
Who experience feeling a lot of Desire, sort of arousal but not being able to achieve the physical arousal, erection or vaginal lubrication. So it's almost as if they're sitting further along that arousal art. Hence the importance I think of people learning to have calm states of mind. When going into sexual interactions. Now, I realized that in saying that it might be confusing because a lot of people think that's anything but calm, right. Sexual arousal is anything.
Calm but maintaining enough calm that they can ride that Arc for whatever duration is appropriate, for that interaction and them, right? Because again and we should probably get back to this, you know, you know, some people will have sex for a long periods of time. Some for shorter periods of time in here, people don't really know what other people are doing, except by way of pornography and self-report and discussion. So 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 combined, April morphine, which is a dopaminergic drug with tadalafil, which is a pde5 inhibitor. So, it's going to increase blood flow, and I'm hearing about men and women, but mainly men doing this. So rampant up their dopamine. Ramping up their blood flow to their genitals in order to have, presumably more arousal in sex.
Does that make sense? Yeah. So as a mechanism
yes. So in terms of April morphine 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 but you know it's a very complex responsible like I mentioned that flibanserin which is essentially acting medication, it actually has not only inhibitory and not only stimulatory but also inhibitory effects on dopamine. So the way it's 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 antidepressant and what they found was that women were actually having let you know better 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, 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
What's going on here and it was because they were having better
erection. Is it true that at some Urology meeting that the first description of Viagra as a treatment for 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 very good. I think it was an intricate ever nosal injection, though, I think he came out, 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 trouble, see it.
But I'll read the article. 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 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, I suppose at the Urology meeting or OBGYN meeting where a woman comes out and reveals her enhance vaginal lubrication, then we will have, we will have gender and sex.
Balance at the meetings on Urology, will be interesting to attend one of those someday.
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 fertility, experts on the podcast, but clearly, there are differences in hormones across the menstrual cycle. We know that for sure. Yeah, clearly there can be psychological variation according to those hormones,
only 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 correlation between desire and stage of the menstrual cycle? There are some obvious assumptions that one might make, you know, prior to ovulation etcetera around the time of ovulation. But what about the other direction to is there? A category of women that are very interested in sex at certain stages of their menstrual?
Go and then not at all interested in sex at other stages, dimensional
cycle, you know, all that I data that I've heard and maybe a gynecologist could speak more on this because they study 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 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 lack of Interest. I don't believe there's a to 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, people are careful to point out that many women don't have penetration based orgasm, and then they separate out clitoral stimulation as more calm, more common route to orgasm. But of course, there can
Clitoral stimulation with penetration, absolutely right. And depending on the physical arrangement there can be clitoral stimulation purely by way of penetration through pelvic contact, you know fingers Etc. So yeah. So 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 there's like the rocking stimulation. So that
Can also stimulate so meaning that the your penetrating, but there's like a rocking motion that can also penetrate the clitoris. There's stimulation of just the outer part of the vagina. Which again, as I mentioned, the G-Spot is, there. It's more highly integrated 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 simulation, either by yourself or by the partner. And so there are multiple different ways to do.
That right? And so there, I think that it's important to really kind of expect. 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'd like to actually tell the other partner. Right. There's a huge part of communication that I think 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, such important conversations for so many reasons. As you point out, 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 key for things, we talked about earlier which is that you know, consent and age appropriate, context appropriate, these kinds of things and and obviously substances like Alcohol and Other Drugs can strongly confound those issues. And so that's, we'll just
That as a kind of an obvious one. As long as we're talking about communication and sexual interactions, perhaps it would be useful to people to cultivate a language or a nomenclature there to to facilitate that some of the language that I've heard that is quite useful as things. Like, you know, people have different arousal templates, right? Some people certain ideas are stimulating to them and other ideas are aversive to them. And then there's this category in between where
sometimes people sort of either don't know because 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. 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,
The 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, at least for that particular moment. And
we have folks listening and some challenging conversations on his podcast challenge previously challenging because they, you know, you're trying to get things clear and as clear as possible. This one is challenging because there's so many caveats, everything, right? We do.
On it. Of course, people have sex in cars, right? Or they did when I was growing up and sometimes they still do okay. Please
continue. Yes, so that's one and then to like when you're discussing it, I mean this is kind of goes for any difficult. Conversation is like you make, I 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 it 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 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 a sec ta sect dot-org where you can look for a sex therapist near you and you can even do those things virtually. And so that can be really helpful when you're having difficulty having a conversation.
Yeah, I think again such important conversations. And then when people differ in terms of their level of experience, it gets potentially problematic. But also it can be potentially educational. And then of course there 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 reverse it right back and 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 that. It's understandable, why those conversations are challenging and it also is understanding why pornography isn't going to involve those conversations, right? Right. Only conversations there between your brain, your hands and your eyes, and your ears. Some not going to highlight any particular order there.
I want to switch gears slightly and talk about UTIs. 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? As it relates to the acidity or alkalinity? How
One prevent getting UTIs, get them from swimming, should you urinate after sex? Tell us about UTIs and how not to get them and how to get rid of them? Happy too. So UTIs are very common in women probably up to 50 percent of women. Get at least one, UTI in their lifetime. And up to a third of them, get recurrent UTIs. 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
It's not as until you're having recurrent UTIs, so you just have one a year, or you have one every few years. It's not a huge issue in men. However, UTIs are much less common and that's because the urethra is longer. So, there's less entry from the outside world into the bladder, which causes infections. And so 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
Anatomic abnormalities or functional abnormality with a bladder that's causing the UTIs. In terms of prevention, there are kind of major things they're higher than the guidelines that we all we all talk about. So one is hydration so making sure you're drinking about two to three liters of fluid. Ideally water a day 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
Nothing in women who have Altered States of estrogen. Whether it's postmenopausal, surgical menopause, or maybe have reduced estrogen for postpartum or other reasons
for about during the second half of the menstrual cycle.
We're not necessarily for those specific people, but for those specific times, but because it's pretty short-lived, I guess you could use it. But is vaginal estrogen. So vaginal estrogen, meaning estrogen, that's applied in the vagina, either through a cream, a superb.
The Tory or a ring is is highly effective in reducing the occurrence of recurrent UTIs. 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 UTIs. 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
our clinics will 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 on the perimenopause because it's hard to tell just by looking, if they are really heading into a lower estrogen strip steak sometimes. And so that's very, very effective and very, very safe. So when you look at estrogen, you know, they're the, the Women's Health Initiative way back when sort of made a big stink about how estrogen is related to cancer.
Ever vaginal estrogen has never ever been, a reported breast cancer, uterine cancer, or any other blood clot any other adverse event associate with vaginal estrogen. You can get some breast, tenderness some discharge, those things can occur, but the absorbed amount vaginally is so little that your estrogen level barely goes up. It doesn't even reach premenopausal level. So it just goes up, very slightly in the bloodstream, not enough to create any sort of abnormality. So a 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, 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 have to be consistent, you apply it about twice a week at night sometimes three times a week and it's very effective the ring you put in once and it lasts for three 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 toilets. 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 you're in a sitting in the bladder for long periods of time, it's basically food for bacteria to grow.
Ow, and so bacteria grows and then you get recurrent UTIs. 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 because sometimes standing you're not able to empty completely. Whoa, a lot of men are going to because they're these, what, you know, it was fun to research for this episode because there are entire discussions on Reddit about what what percentage of males sit while urinating my understanding
Based on having visited many male bathrooms in my lifetime and just being in the world that that, I assumed that men stood up in order to urinate. But there are decent percentage of men that sit down to urinate there are. And in fact it's very well by country. And probably the reason it's become more interesting lately as I'm eating tree. So a certain country was recently surveyed. Think it was Germany 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 was 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 prostate enlargement that can sometimes allow you to develop a little bit more intra-abdominal pressure because you're sitting and you can lean forward to overcome sort of a blockage. And and so there are some
Sweet. Some indications were sitting is better, but if you're peeing fine on your 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 spermicides or condoms or both increase the frequency of UTIs 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 UTIs.
Other things I want to touch on. You did ask about cranberry. So cranberries actually in the American Urologic Association guidelines, for prevention of recurrent, UTIs and 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 proanthocyanidins or pacas and in. Or they've actually looked at the amount of PA sees you need and what formulation. So you need 36 mg of PA sees in a soluble form. So a lot of the supplements on the market.
It will say that they're 36 mg of pacas, but they're like the whole Berry so they're using 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 using is a soluble form of the cranberry, and it's actually very very effective at reducing the risk of
UTIs. So do you mean capsules like a gel cap? Yeah. It's a capsule 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
A post-coital UTIs that you can take to on the day of sex and to 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. 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 d-mannose is one of them you take you know about 2 grams a day of d-mannose and you drink it and that actually helps reduce UTI risk. It's been
Even small randomized, controlled trial to be effective and 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 in the Flora there. So those are kind of the big things and there is actually a lot of microbiome study and UTIs going on actually at UCLA where they're looking at the microbiome of people who are more at risk for UTIs or even overactive bladder
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. In terms of wiping from front to back and swimming and peeing after sex. There's no good data on any of those things 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 it's less of an issue.
What we're talking about is you're referring to any contamination from anal, any bacteria, around the
anus. Yeah. Right. And a lot of women who have recurrent UTIs like tend to come and feel very dirty, like there's something wrong with them. Like oh I wash all the time and really clean and 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 that could mean it's
Like very infrequent. I would say, like I've never seen a patient who's dirty and that's the reason I couldn't UTIs. Perhaps even the opposite is true. They're cleaning too much based on what you told us earlier. And they're eliminating the gut microbiome, excuse me, just rolls off the tongue. Yeah, no pun intended. Perhaps it's there 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 when Sonnenberg was a guest on
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. Yeah but we have to imagine how we evolved as a species was not with antibacterial soaps and alcohol, swabs everywhere and obviously we don't want infections but over cleaning.
Disrupt the microbiome, which presumably can lead to UTIs. 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 over cleaning and so that's one of the things we like I definitely have a UTI. Definitely have one will know 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 his pelvic floor dysfunction. So, very often pelvic floor.
I can 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 at the pain, just triggered, the pilot photo tense up, it didn't relax. Because again we're not taught how to relax our pelvic floor and and then they've developed pelvic floor. Dysfunction likewise UTI, not going away. Why does it keep coming back? And so, that's another common thing that we see in people who have quote-unquote recurrent UTIs but don't really have them.
Them to be clear, I experienced the pain in urination, as a consequence of trying, those damn kegels that everyone's talking about stopping. That was informative in two directions. One it relieves the pain very quickly. So that was good. The other was, I realized that it is possible to have a pelvic floor. That's neither hyper contracted nor over relaxed, and in some cases just not doing anything for it as the best circumstance, right? So, and they're only reason I mentioned that is because obviously this
It is not about my pelvic floor. This discussion is about fact that some people, perhaps need
To clean less, some people may be more, but probably not based on what you said, some people might need to strengthen their pelvic floor. Some people might need to relax their pelvic floor. In some people's pelvic floor is probably a okay, you know, I think any discussion about anything medical or, you know, especially hormone stuff. This happens a lot in the discussions around that, get into, it seems with, with males there, 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.
And as you point out earlier at least in terms of sexual function that's unlikely to be the case may be less desire. But but in terms of 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, 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 will get back to UTIs and I want to talk about kidney stones but 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 desire and arousal effect.
Or perhaps just one or the
other. So I've the way that we discussed testosterone using there are like consensus statements and there's actually an abundance of data on testosterone, use particular in postmenopausal women for low libido or low sexual desire and it's all been very positive and because there's been increased 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.
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 but, you know, relationship, other issues that can affect little medications. There's a lot of things, obviously, that go into that. But if we set and we've checked their testosterone, it appears to be low for physiologic levels for women, which again, is one-tenth of the mail level, then we can actually prescribed off-label.
Will testosterone and the guidelines are the consensus statements are 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 calves, or the upper outer buttock, hairless area for absorption. That can improve desire overall. And then the other place we use testosterone is in women who have what we call vestibule edenia. So, the vestibule is the
Outside the vagina which is very hormonal e active. There's lots of Energon 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, to Sasson receptors or Androgen receptors all over the body, very much in the genitals, very much in the brain, and they're very useful.
Awful to 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. How do you avoid getting them and how do you get rid of them? So, kidney stones, very often are they, 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, dehydration combined with
Be a slight metabolic abnormality where you're creating more calcium or oxalate in your urine can result in in kidney stones. And so, how can you prevent them? I mean, I, 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
Kris your fluid intake, two to three liters. Again, the same number, I told you before you want to decrease your oxalate intake. Now, if you Google oxly, you're going to find a million things that you eat that have oxide in them. But the big ones are spinach and rhubarb, we're seeing a lot of nuts to that aren't, 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 having like a spinach salad every day, well switch it to a different green, right? Don't eat spinach every day. Also, you want to increase your
Citrate intake, that's an inhibitor of kidney stone formation. So increasing fruits and things like that to increase citrate vegetables as well. They actually won easily accessible thing is Crystal Light. It has a high citrate composition so you can drink crystallite with that two to three liters and that can be helpful. You want to decrease your protein intake. So high levels of purines are pure organic Meats like red meats and things can also put you at higher risk. So these are kind of the general
Art of preventive measures we talked about for kidney stones, if you have a kidney stone. So a lot of times people can have kidney stones and 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 ureters or the tubes that drain the kidney, oftentimes, they're their company with pain, quite a bit of pain and it can be very uncomfortable in those cases we can, if they're not
Beginning infection symptoms being there's no signs of a urinary tract infection. There's no fevers no chills, we can treat it conservatively with pain medication and also there are medications like Flomax as you use for enlarged prostate, as well. That actually relaxes the ureteral smooth muscle to allow the stone to pass a little bit better. If you're having an infection you gotta get treated right away. It could you can get very sick very quickly. In fact I've seen young healthy patients like there, pal,
Easier than me walk in the, in the ER, with a kidney stone and within 24 hours there in the ICU because they're really sick because of a
kidney stone. But I'm still good urinating tea colored urine. So the meaning blood in the urine. Yeah, 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 hydronephrosis or pressure behind the kidney and your
You know, you have these signs of infection. We don't want to wait because you can get sick pretty quickly and then, you know, once to treat the kidney stones, there's three major options. One is shock waves. Another is ureteroscopy where we go in with a camera and we have a small laser. We break it up into small pieces and dangerously camera inserted through the urethra. Correct, you're asleep under anesthesia so you don't have to stop. You saw that. Yeah, I saw the winds and then percutaneous now for lithotomy, 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. So we're extremely helpful. Bits of information are not even B. These are this is enormous amount of useful information. I'd like to Pivot again for sake of bread. We can't go into extreme depth on
Anything, but appreciate your willingness to follow this. Carousel with me. Oral contraception. Previously, on this podcast, I hosted a female physician guest who offered both sides of female. Oral contraception discuss some of the benefits discuss 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 intrigued by how polarized the discussion is around, female oral contraception and female contraception in general. So NuvaRing norplant the
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 seemed to come mainly from women were of the, this stuff is terrible. It ruined my life, it ruins lives, it destroys you. It has immense risk. And then the other half seem to say no, there's reduced risk of certain forms of cervical, cancer.
This has allowed me the sexual choices and lifestyle that I prefer without risk of pregnancy that. I mean, it was astonishing to the point where I thought, wow, if only I could post both clip simultaneously so obviously I don't know what the answer is but I do know that this is among the more polarizing topics available for discussion. 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, bonded. In fact, we even did a study. And again, this is not like high quality evidence, but we looked at Reddit threads and we looked at sexual dysfunction specific low libido. Did orgasm like difficulties and we like read hundreds of threads and we did like a qualitative analysis to be in females to see like what are people talking about and problems.
with oral contraceptives and antidepressants leading to low libido and and being very like as you described very like this is ruined, my life was very common and so the theory is that you know taking oral contraceptives increases the amount of sex hormone-binding globulin 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 there up and that even after they stopped the oral contraceptives, you'll see elevated shbg levels from Baseline. Well, you know, for like at least four months afterwards.
Still see elevated shbg level. So we don't
know, but not infinite. I mean, we don't know and yeah, the endocrine system is weird because it it 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 we do see this and I think that the other side of this. Yeah, absolutely oral contraceptives are amazing right there. They're helpful for sexual Freedom sort for for preventing pregnancy for
You know, for a lot of things and particularly other conditions to like PCOS and another problems oral contraceptives are amazing and they've changed, you know, Gynecology and management of these women for, you know, in a very positive way. And so I think, you know yes I do think that there is oral contraceptive related, sexual dysfunction usually low dose estrogen sort of contraceptives are the culprit but you know, I think that it's it's again the data.
Most actually spent the 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 or just kind of a Adonia and apathy, not just lowered libido. I can imagine how that would be the case through the elevated sex hormone-binding globulin, which is, you know, preventing testosterone estrogen from being free, right? 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, well, it sounds to me like oral contraception for women. 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 in seem to mind it. I've had some that hated it and like like no way. Tried that never will.
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, you know, what are the other options as you know, is the ring copper IUD. So any sort of long-acting hormonal contraceptive, we've seen we that's what
We consultations 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 engine the effect of on the Androgen receptors or estrogen receptors is affecting you know the lubrication 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 ID and our IUD is our IUD safe and here we should probably say Okay copper IUD is one form you want to mention a few of the other form. So I don't prescribe iuds
Generally speaking, they're very safe. Of course, there's risk with any sort of, you know, it's a procedure, you're inserting an IUD, so there's obviously some small risks associated with it, but it is safe and effective form of contraception. If people are wondering why the copper IUD is an effective form of contraception copper, is like the third rail for sperm as I understand it so much. So that I was able to find some evidence for this, in the medical textbooks that in the old days as they say.
Prostitutes who wanted to avoid pregnancy, would put copper pennies in their vagina, really? Oh. Now I don't recommend that to anyone and please and I don't think it's a foolproof form of contraception, but there is evidence that, that it happened, 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 did you strum that of behavior? Yeah, that's it. Cena's cringe.
I am not suggesting people do that. I think it's just an interesting medical factoid. Yeah, I can tell you want to move on from this topic. So we will 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 antidepressants.
It's that have disrupted their sexual function, or their sexual desire. Seems in particular, do you see a lot of this in your clinic to hear about it? What can people do about it? You know, oftentimes, these sexual arousal or dysfunction issues associated with ssris and other medications, make those medications prohibitive people. So, you know, serotonin is kind of the anti to orgasm.
And so, in fact, we will use ssris 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 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 another antidepressant. For example, Wellbutrin, that does not have such severe effects on.
A function. And so, you can also use like Cialis and Viagra. Like you've taught what we've talked about for erectile dysfunction as an addition, if we can't change their medication management because, you know, and it is 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 it
Everywhere are shouting. Yes,
no I think you know I think that there's a lot of discussion 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. But yes, there it is. Definitely a known thing. We use it to our advantage when needed and and it can be helpful to switch medications or reduce the dose
you mentioned earlier that trazodone can cause sustained Direction.
And is trazodone in the category of touchings of the serotonin transmission system.
You know, I don't remember the mechanism, but interestingly, trazodone is also used for off-label like as a third, or fourth line for premature ejaculation, as well. So, so I don't remember the mechanism of
hand. Let's talk about prostate and prostate health earlier. I queued up that there's a growing Trend toward. I would say more Progressive
Male Physicians or Physicians who treat males, excuse me, thanks. Yeah, prescribing low dose 2.5. 25 mg Cialis, which is tadalafil, which may assist with directions but it the rationale for this low dose daily low dose is not centered around erections per se. It's really about prostate health. Improving blood flow to the prostate reducing prostatitis, maybe even reducing the probability.
D of prostate cancer. What other sorts of things, are you encouraging men to think about when thinking about their prostate? Yes. Oh, before I forget, I want to mention that low-dose. Tadalafil is actually a treatment for erectile dysfunction. In fact, it works quite well. Particularly men who are having a lot of psychogenic issues, one, because they 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 half-life
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 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
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 pee 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 so 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 grandfather had a large prostate, you're probably more likely to have an enlarged prostate. Do we know exactly 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 over activity. So you'll see your bladder is responding to having to push hard against that narrow urethra.
He threatened to push urine out, so it's having more urgency like the sudden desire to go to the bathroom that you can't delay. Your may be 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 a stops and starts and so those you know or you're just like I can't empty like it's not because just drips or very weak stream and so those are kind of the things
Can happen over a lifetime. Now what, what are some things that you can do to help, you know, Cialis helps, relax those those the fibers smooth muscle, the prostate so that allows urine to pass more easily. There's also other medications that you can treat very often Flomax or other alpha. Blockers are helpful in that area 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 I'm not everyone's affected the same
Way. So I don't want people to be like, oh, I gotta 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 everyday and you find yourself writing the bathroom a lot. If you limit your caffeine intake, you might see that you're not going the bathroom quiz 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 and his people forget they have caffeine in them and so limiting that
Improve your symptoms alcohol also is a bladder irritant and these have actually been studying animal models and you'll see that the bladder contracts more often when they're given these sorts of substances 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 in someone who drinks it. Every once in a while, other things can be 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 years ago. There was a discussion about bicycle seats causing damage to the prostate, maybe even sexual dysfunction. Is that still a thing? I thought they put grooves into the seats, but I've also in reading on the internet, I can do a deep dive on Reddit, but it seems that
Women are reporting some Bladder incontinence from excessive bicycle CEUs maybe even exercise bike. 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 perineum 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 in 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,
Who are really high volume cyclers. Now, the studies have looked at like maybe they did a 350 km race or they there, 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 decrease lubrication, maybe G.
East arousal as well and 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 Herrero riding you're putting pressure on 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 ischial tuberosities and posture is a huge part of your pelvic floor. I know we didn't talk about that earlier but sitting you know with good posture
And not kind of slouching or leaning forward, can actually really do wonders for your pelvic floor. So focusing on posture is helpful but also when biking postures helpful. So they've actually looked at this data and they found that people who are 0 ride, meaning Lean Forward are people who use narrow bike seats are more likely to have issues. And so you want to get kind of a noseless feet and a wider seat. The the cutouts actually, when they looked at kind of mechanics of the cutouts, they'll see higher pressure around
Opening. So it's actually not good to have a bike with a cutout 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. I don't cycle. I don't like the exercise bike. I'll sometimes read The Assault bike for which has the big seat there for a few minutes, but
I just want to add one one thing because I think that I don't want to make people not cycle. I think it's really valuable. Cycling is a
Aerobic exercise has lots of benefit for cardiovascular health, but there was actually another study that looked at people who were parts of sports club. So they were like swimmers Runners 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 cycler. So maybe you know, because those other sites were just looking at cyclers that maybe it's just the general rate of erectile dysfunction in that population at that point in time. So,
I don't with the numbness is definitely an issue. The erectile dysfunction, maybe, maybe
not. So I just have a couple more questions for you and by the way, you've been incredibly generous with your time and information here, thank you. 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, it's very interesting post. Very interesting
D. Ya covered. Yeah. And you explained it very clearly, I'm guessing there are relatively few but perhaps some other studies as well about this. Let's talk about anal sex and maybe if you could just offer some of the key bullet points that you learn from the literature and from your clinical practice, you know how frequent is it with protection without protection? How safe is it?
Um, you know, what are the different reasons people do it? That might seem like a kind of a silly question, but it turns out when it comes to this topic, it's their interesting data. Yeah, educate us.
So anal, sex. Let's talk about it. Well, when you, when you talk about anal sex, the reason people, it's become more and more common. Let's say it's more and more, heterosexual couples are doing it. We know that 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 it 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 field but in general 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 and they are with vaginal penetrative intercourse because the anal tissue is very
A thin and friable. So when you penetrate the anus, particularly, if you have any trauma, you can have, you know, you can have blood loss and that blood loss can then easily more easily transmitted 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
use specific lubricants that are aiso osmolar to anal pH so you can actually look up anal. Lubricant and we could talk about lubricants. But generally there's water based silicone-based, oil-based lubricants. Water-based are the most easily accessible silicone-based are a little more slippery and last a little longer and oil-based also last longer, but are not good for use with condoms. So, definitely using lubricants and always kind of making sure to be in the context. Of course have been consensual
It also like never fourth, always take your time 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. So I think it's really important one to prevent from a sexually, transmitted infections to to be thoughtful and cautious and sometimes it requires some preparation if you're going to
Penetrate anus. It's going to you know, you're not going to start with a large girth item. You're going to start with something smaller and kind of work your way up and then I think ultimately why people have anal sex. So as I mentioned earlier, the prostate is, you know, highly innervated 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 Innovation around there, the pelvic floor and you know so that's certainly a
Well 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 you menstruation or other reasons. 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
Have to, and this particular study that 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 talking about why they specifically recruit 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 and safety purposes. And so those were kind of the common reasons.
What about infection not related to sexually? Transmitted infection, my presumption is there is a higher risk with anal sex. Then there is with other other forever, you know, vaginal intercourse, oral sex, Etc. But is there evidence for that? Not necessarily, it's more about sexually transmitted infections more than anything else, it's rare to you can sometimes, I mean, the rare things that people have kind of comment on like anal and continents, temporarily, or things like that. Very rare.
Mostly, it's just sexually transmitted infections because, you know, you can't 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. 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. But
Generally speaking, you know, there's, there's lots of things you can look up to make it safe and healthy,
and I'm sure some people are listening to this and there. Maybe they've turned it off already, but and I think we can expect a varied response to this discussion, but it's happening out there apparently with increasing
frequency. Yeah, and I don't know if that's because of the increasing availability of pornography where it's visualized more or if I don't really know why. But we do know that there's more
Going on in heterosexual. Couples and
prior as a final category of question, 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. On this podcast, I always say always always we emphasize behavioral tools first do's and don'ts right? Because those are the foundation of mental health, physical health and performance. You know in all contexts
There is, of course, a role for prescription drugs. Sometimes often times, people can't do the things and avoid the certain things they want to because of depressive States. Anxious dates, Etc. And prescription drugs can serve a role, but I do believe the goal is always behaviors 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 because they represent, I think,
Important category of over-the-counter compounds that can play a role. And I've talked before about Tom golly, this Indonesian herb, I think it can be Malaysian as well, but this Indonesian herb is typically the one that I am aware works best for mild, libido enhancement sometimes, especially in the case of people taking ssris, it can enhance libido to override some of the challenges with SSRI induce.
In in libido and generally even if people aren't on our accessorize, I hear from people who take tone golly and get 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 Tom golly, maybe some cortisol suppression as well. Maybe some estrogen receptor modulation with maca root, maybe some dopaminergic tone changes. I'm Sheila G this ayurvedic herb which
There is at least one study that I think is done. Well, that shows increases in FSH follicle stimulating hormone with Sheila G use what are your thoughts on things like Tonga? Ali maca root, Sheila. Gee how do you talk to your patients about this
stuff? Yeah, so I think that, you know, I see these my patient population is still in the Behavioral Management place, right? At the biggest cause of sexual dysfunction, whether it's low testosterone.
Roster. Own erectile dysfunction sexual dysfunction is often comorbidities 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 know, both cardiovascular aerobic exercise. But also doing resistance training, particularly like a large, muscle groups. And, and then, you know, really working on reducing blood pressure.
And, and preventing diabetes, and those things I think are really key. And I know we taught you talk about the Milan 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 they may have diabetes as a cause of it. 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 erection, for sake of erections. So I think that really if I can say one thing before you do supplements, but I don't have a problem with. I think that it's reasonable to try them. 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 pde5 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 what boost testosterone and even you know you mentioned this all the time. But getting early morning light, but it's beneficial for testosterone as well because you're really helping release testosterone with the Circadian biology. So I think that those things like I can't stress enough like how valuable they are and if you're smoking, quit smoking, it will kill your erection vaping and vaping. Yeah. And then lastly, if you are
Developing true organic impotence. Being that. There's a biologic problem that's causing your sexual dysfunction. Then it's really important to get your cardiovascular health assess because about 15 percent of men who develop erectile dysfunction seven years later, we'll 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,
Probably the same for women, we just don't have the data
yet.
I know a good number of women that take Tonga Ali 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 get assess with Consulting, your physician, of course, and they to some of them have reported improvements and libido and desires. Well so yeah. And I that Sheila G is less known about the distinguishing quality versus low.
Low quality sources of Sheila, G is harder, dosing is hard. It comes as this tar, typically typically maybe more science on Sheila. G will come out in the next few years. We could get it behind it a bit more right now. I'm sort of on the yeah. Maybe if you are an adventurer, you might try it. But I'm not. It's not one that I'd normally throw to the top of the
list. I think that like l-citrulline is is pretty good ashwagandha for stress reduction, which also has implications for sexual function. Tongkat Ali has reasonable data. I think there.
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. And you know, as like I said, I think it's reasonable. They're smaller studies. They're not, you know, there is bias in many studies but there, you know, there is effort done in this area and there's never going to be really high quality science. No one's going to really fund that, I think so. I think our expectations need to be able to tempered when it comes to that stuff. Well Rina, dr. Malik, I want to thank you ever. So.
So much for this discussion today you provide us so much useful information 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, prostate urethra UTIs. All these topics that many people are just afraid to raise and to confront directly and you've, you've taught us so much about how to promote the health of this incredibly important system. Honestly, one thing we know for sure,
You're either in Vivo or in a dish. We're all here because a sperm and an egg. And, and of course, there are other reasons why people engage in sexual activity, they have nothing to do with reproduction but surely it is quarter, 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 will provide links to your clinic. 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. 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.
Thank you for joining me for today's discussion with dr. Rena moloch, all about Urology, pelvic floor and Sexual Health. If you're learning from, and, or enjoying this podcast, please subscribe to our YouTube channel. That's a terrific, zero cost way to support us. In addition. Please subscribe to the podcast on Spotify and apple and on both Spotify and apple. You can leave us up to a five star review if you have questions for me or comments about the podcast or guessed that you'd like me to consider hosting on the huberman Lab podcast. Please put those in the comment section on YouTube.
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