Dr. Rena Malik: Improving Sexual & Urological Health in Males and Females

00:00:00.000 | Welcome to the Huberman Lab Podcast, where we discuss science and science-based tools for everyday life.

00:00:05.540 | I'm Andrew Huberman, and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine.

00:00:14.260 | Today, my guest is Dr. Rina Malik.

00:00:17.300 | Dr. Rina Malik is a board-certified urologist and pelvic surgeon.

00:00:21.740 | She is an expert in both male and female urological, pelvic floor, and sexual health. During today's episode, Dr.

00:00:28.940 | Malik answers the most commonly asked questions about urinary pelvic and sexual health.

00:00:33.940 | For instance, how to avoid getting UTI's, urinary tract infections.

00:00:38.340 | We also discuss pelvic floor anatomy and function as it relates to

00:00:43.000 | overcoming an overly tight or an overly relaxed pelvic floor.

00:00:47.720 | 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,

00:00:54.560 | but in fact, many people need to do the exact opposite. They need to learn to relax their pelvic floor in order to achieve proper

00:01:01.000 | urologic and sexual function. So today you'll learn about that. You will also learn about sexual health as it relates to

00:01:08.760 | erectile function, as it relates to things like vaginal lubrication, as it relates to orgasm. We separate out very carefully the difference between

00:01:17.720 | psychological desire and

00:01:21.120 | arousal that occurs within the genitals themselves. And Dr. Malik highlights some important misconceptions about sexual dysfunction.

00:01:28.100 | For instance, that many people believe that hormones are responsible for sexual dysfunction, but in reality,

00:01:34.880 | hormone dysregulation is responsible for only a very small percentage of sexual dysfunction and yet

00:01:42.600 | pelvic floor and blood flow related issues can account for a large number of cases of

00:01:49.640 | sexual dysfunction in both males and females.

00:01:51.640 | So I assure you that today's discussion is going to illuminate many new areas of information,

00:01:56.840 | many new tools and protocols that I'm guessing most people have not heard of. We talk about the neural

00:02:03.160 | vascular, that is blood flow related, and

00:02:06.120 | muscular aspects of bladder function, prostate function, skeins, glands.

00:02:11.120 | We talk about vaginal health as well as penile health.

00:02:14.380 | We talk about these things as it relates to different stages across the lifespan.

00:02:18.280 | It is a far-reaching and in-depth and practical conversation that I'm certain everyone will glean

00:02:24.200 | important takeaways from. Now before we go any further, I do want to highlight that the content of today's episode is

00:02:30.920 | sexual in nature.

00:02:33.040 | We talk very directly about

00:02:35.160 | different types of sexual behavior and we talk about it from the standpoint of the clinician and biologist.

00:02:41.520 | 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

00:02:49.400 | I assert that there are certain themes within today's discussion that would not be suitable for young children.

00:02:56.600 | How young? Well, that is certainly not for us to discern. We realize that different parents and different households

00:03:02.660 | should be the arbiters of what sorts of information their children are exposed to or not.

00:03:08.980 | So my suggestion would be that if you have any concern whatsoever

00:03:11.900 | that the content of today's episode would not be appropriate to be heard by some member of your family,

00:03:18.180 | that you please listen to the podcast first or at least check the time stamps where we've detailed what specific topics are covered and

00:03:24.740 | then to make your decision accordingly. I should mention that not only is Dr. Malik still an active clinician,

00:03:31.100 | she sees patients daily out of her clinic in Southern California, and we provided a link to that clinic in the show note captions.

00:03:37.660 | She's also authored dozens of high-quality peer-reviewed publications in the fields of urology, pelvic health, and sexual health.

00:03:43.600 | And we've also provided a link to that bibliography in the show note captions. And she is also a spectacular public educator.

00:03:50.020 | She provides zero-cost content

00:03:52.280 | about sexual health, pelvic floor health, and urology as it relates to both men and women on her YouTube channel. And there, too,

00:03:59.560 | we provided a link to Dr. Malik's YouTube channel in the show note captions to this episode.

00:04:04.920 | Before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford.

00:04:09.980 | 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.

00:04:17.320 | In keeping with that theme, I'd like to thank the sponsors of today's podcast.

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00:07:39.120 | And as always, thank you for your interest in science.

00:07:42.620 | And now for my discussion with Dr. Rina Malik. Dr. Rina Malik, welcome.

00:07:47.120 | Thank you. Thank you so much. It's an honor to be here.

00:07:49.620 | I'm delighted to have you here. I'm a huge fan of your content.

00:07:53.620 | 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,

00:08:05.620 | but that ordinarily people don't really know where to get the high quality information.

00:08:11.120 | And coming to you for that information means they are going to get the highest quality information.

00:08:16.120 | I truly believe that because as everyone will soon hear today, we're going to have a very frank discussion,

00:08:22.620 | but one that's really grounded in science and medicine around sexual health and related topics.

00:08:30.120 | These are topics that typically people learn about, perhaps a little bit in school,

00:08:36.120 | maybe at home, from friends, usually overhearing things as opposed to direct exploratory conversation,

00:08:44.120 | online, pornography, and at least in my experience growing up, you know,

00:08:51.120 | there was education around sexual health, reproductive health, et cetera,

00:08:56.120 | that was more oriented toward the fear of things like STIs, fear of unwanted pregnancy.

00:09:02.120 | All of which, of course, is extremely important for people to learn about.

00:09:05.120 | But far less about sort of the healthy versions of sexual health, right?

00:09:11.120 | - Yeah, absolutely.

00:09:12.120 | - So this is an especially important conversation.

00:09:15.120 | It's also one that I think has a backdrop that we should just acknowledge right off the bat,

00:09:22.120 | that because the information is gleaned from multiple sources

00:09:26.120 | and because there are, let's just say influences out there that relate to the morality of different practices,

00:09:35.120 | that there can be shame, there can be misunderstanding, there can be secrecy,

00:09:40.120 | and that further leads to misinformation.

00:09:42.120 | So I'm confident that today you can clarify things for us and we're going to stay out of those trenches.

00:09:49.120 | And the last thing I'd like to say is that because a number of terms will certainly come up

00:09:54.120 | and I think for some people they're not used to hearing and general discourse,

00:09:58.120 | I'm just going to get them out of the way now.

00:10:00.120 | Penis, vagina, anus, prostate, you know, what else is there?

00:10:06.120 | We're going to talk about libido.

00:10:08.120 | We're going to talk about intercourse, oral sex, anal sex.

00:10:11.120 | We're going to talk about all of that.

00:10:13.120 | So I just want to get that out there so that we can reduce the shock response.

00:10:19.120 | - I love it.

00:10:20.120 | We're going to talk about all of it.

00:10:21.120 | - Great.

00:10:22.120 | So to start off in anticipation of this episode, I solicited for questions on social media

00:10:26.120 | and I got thousands of questions, but there was a lot of overlap in the questions.

00:10:30.120 | So to start off, I'd like to talk about pelvic floor, okay?

00:10:35.120 | Because both males and females have a pelvic floor.

00:10:39.120 | And my understanding is that there's a muscular component, there's a neuromuscular component,

00:10:43.120 | there's a blood flow component.

00:10:46.120 | What is a healthy pelvic floor?

00:10:48.120 | What does a healthy pelvic floor do?

00:10:51.120 | And then we can talk about some of the health issues that an unhealthy pelvic floor creates

00:10:57.120 | and some of the ways to ameliorate an unhealthy pelvic floor.

00:11:00.120 | - Absolutely.

00:11:01.120 | So a pelvic floor very simply is basically a bowl of muscles that's connected to bones

00:11:07.120 | that hold up all your organs.

00:11:09.120 | So basically in your pelvis, there's all these muscles there.

00:11:12.120 | And their function is essentially many.

00:11:14.120 | It helps with urination, defecation, sexual function.

00:11:19.120 | It helps with posture.

00:11:20.120 | And so having a strong, healthy pelvic floor can mean that you're having normal urination,

00:11:25.120 | you're having normal defecation, you're having great sex,

00:11:28.120 | and that you are also not having ailments like back pain or issues related to those functions

00:11:36.120 | and those organs.

00:11:37.120 | And so, you know, pelvic floor is so important in so many different aspects

00:11:42.120 | and we deal with it a lot as urologists because it's so integral to these functions

00:11:47.120 | that we take care of.

00:11:48.120 | And so when you have an unhealthy pelvic floor, it can vary from person to person.

00:11:53.120 | And while you hear about it a lot in women, men also suffer from pelvic floor dysfunction

00:11:57.120 | or problems with the pelvic floor.

00:11:59.120 | So basically pelvic floor dysfunction happens a lot when you're doing things like

00:12:04.120 | if you were to go to the gym and do repetitions of any sort of exercise and you didn't rest,

00:12:10.120 | then that muscle would become contracted and short.

00:12:13.120 | Very similarly, if your pelvic floor is overstrained, it can become contracted and short

00:12:19.120 | and tight all the time.

00:12:20.120 | And you may not know it.

00:12:21.120 | It may just be a function of stress, anxiety, or overuse, or posture problems,

00:12:28.120 | things of that nature that can affect your pelvic floor.

00:12:31.120 | And so this can lead to issues.

00:12:34.120 | Let's start with urination.

00:12:35.120 | You can have symptoms of urgency, frequency, meaning you have to go a lot to the bathroom

00:12:41.120 | or you have to go and have a sudden desire that you can't delay, sometimes even have leakage.

00:12:46.120 | In some cases, it can make it difficult to urinate because the pelvic floor is so tense.

00:12:51.120 | Or perhaps to incompletely vacate the bladder.

00:12:54.120 | Correct.

00:12:55.120 | Like you go to urinate and then you go back to your desk

00:12:58.120 | and then five minutes later you have to urinate again.

00:13:00.120 | Exactly.

00:13:01.120 | Well, it can be either that you're not emptying completely

00:13:03.120 | or that the pelvic floor muscles are so tense that they're stimulating the bladder

00:13:07.120 | so it feels like there's more to go.

00:13:09.120 | So it's not always that you're not evacuating.

00:13:11.120 | It can present in a number of different ways.

00:13:13.120 | And then with sexual function, if it's very tense, you can have pain.

00:13:19.120 | So you can have pain with sex.

00:13:21.120 | You can have pain with erections.

00:13:23.120 | You can have pain with ejaculation.

00:13:25.120 | Sometimes it can be a lot of different kind of pain syndromes

00:13:27.120 | and you're like I have all these different things going on

00:13:30.120 | and it's really just pelvic floor dysfunction.

00:13:33.120 | With GI function, you can definitely have constipation

00:13:38.120 | and then often you can also have back pain.

00:13:41.120 | And so all of these things can happen when your pelvic floor is too tense.

00:13:45.120 | Sometimes your pelvic floor can be too weak

00:13:48.120 | and that can be often because of -- we see this in women a lot --

00:13:51.120 | because of childbirth, delivering children.

00:13:54.120 | With some people who have neurologic disorders,

00:13:56.120 | they can have weak pelvic floors or connective tissue disorders

00:13:59.120 | like Ehlers-Danlos syndrome, for example.

00:14:02.120 | These sorts of things can cause weakness to the pelvic floor

00:14:05.120 | which can then cause very often what I see

00:14:07.120 | is like urinary incontinence or leakage

00:14:09.120 | which can then create problems for people down the line.

00:14:13.120 | Thank you for that.

00:14:15.120 | So first question, how does somebody know if their pelvic floor is too tight

00:14:19.120 | from an over-contraction or chronic contraction of the muscles there

00:14:23.120 | versus too weak?

00:14:25.120 | And one of the challenges in having this conversation

00:14:28.120 | is that if we were talking about contraction of the calf muscle or the bicep,

00:14:31.120 | I think everyone intuitively knows

00:14:33.120 | because they've seen the shortening of the muscles

00:14:35.120 | when the muscle is "flexed"

00:14:37.120 | and the lengthening of the muscles when it is relaxed.

00:14:41.120 | Is there a way to describe pelvic floor muscular shortening

00:14:46.120 | in a way that everyone can understand?

00:14:48.120 | Would this be like -- like I said, we're going to be direct today --

00:14:51.120 | would this be like tensing up one's anus

00:14:57.120 | and the opposite of the movement that one would do

00:15:01.120 | before initiating a bowel movement

00:15:03.120 | and relaxation is sort of the pattern of pelvic floor muscular relaxation

00:15:09.120 | just prior to initiating bowel movement?

00:15:12.120 | So I will say most people can't recognize it

00:15:15.120 | because it's very difficult to notice.

00:15:17.120 | It's sort of gradual.

00:15:19.120 | And so it can over time become noticeable with these symptoms.

00:15:24.120 | But otherwise it's very difficult

00:15:26.120 | because it's not a muscle that we were ever trained to recognize, right?

00:15:29.120 | Like you hear about Kegel exercises, for example,

00:15:32.120 | and people talk about how to do them,

00:15:34.120 | but that's all you ever hear about the pelvic floor.

00:15:37.120 | And so you don't really know how to kind of do things in a way

00:15:40.120 | that protects your pelvic floor

00:15:42.120 | or kind of what -- how to even tell when it's too tight or not relaxing.

00:15:47.120 | And so that takes sort of a training.

00:15:49.120 | And so usually when people come --

00:15:51.120 | first you get an examination to see if your pelvic floor is tight.

00:15:54.120 | So for women it's a pelvic exam and for men it's usually a rectal exam.

00:15:57.120 | How does that exam go?

00:16:00.120 | So it's essentially palpating the muscles and also looking at the function.

00:16:04.120 | So we'll say --

00:16:05.120 | So digital palpation, that's a medical technology for fingers,

00:16:08.120 | they're called digits.

00:16:10.120 | So I'm old enough to recognize what a digital prostate exam is, right?

00:16:18.120 | The physician inserts their fingers into the anus

00:16:21.120 | and feels the prostate to see whether or not it's swollen or not.

00:16:25.120 | And as I'm saying this I'm realizing sometimes we think of medicine,

00:16:28.120 | "modern medicine" is so evolved.

00:16:30.120 | This has basically been the practice for what, 50 years, 60 years,

00:16:34.120 | maybe 100 years in the same way that the old school practice for glaucoma,

00:16:38.120 | excessive eye pressure, was for the physician to just touch the eyeball.

00:16:42.120 | So folks, for those of you that think that medicine has evolved much,

00:16:45.120 | it clearly has in many ways.

00:16:47.120 | But in any event, so a prostate exam goes as I just described.

00:16:51.120 | What would a pelvic floor exam for a male

00:16:54.120 | and a pelvic floor exam for a female involve at a kind of granular level?

00:17:00.120 | Yeah, so for women you can feel the pelvic floor muscles through the vagina.

00:17:05.120 | So you can feel the iliococcygeus, the pubococcygeus, the levator, ani,

00:17:09.120 | those are all names of different muscles in this bowl.

00:17:12.120 | This is the physician who can feel them with their fingers.

00:17:14.120 | Correct, and you could too, you could put your finger in,

00:17:17.120 | but you don't have a reference of normal, right?

00:17:19.120 | So you wouldn't know what a normal pelvic floor feels like

00:17:21.120 | versus a tight one versus a weak one.

00:17:24.120 | And so you can assess the tenseness based on palpation,

00:17:28.120 | you can also see if there's tenderness,

00:17:31.120 | and so you can assess that based on just a general physical examination.

00:17:35.120 | And then also you can observe.

00:17:36.120 | So I can say contract your, squeeze your pelvic floor up and in,

00:17:39.120 | I can look and see are they squeezing or are they pushing,

00:17:42.120 | like are they coordinated or not, right?

00:17:44.120 | Because that's a function of normal use of the pelvic floor

00:17:47.120 | and sometimes you'll see that they're just coordinated.

00:17:50.120 | You can also assess for sensation in the area and things like that

00:17:53.120 | that could be consequences of dysfunction.

00:17:55.120 | Could there be dysfunction in laterality,

00:17:57.120 | like the pelvic floor is pulling up and to the right or up and to the left?

00:18:00.120 | Absolutely.

00:18:01.120 | So what typically when you see a pelvic floor therapist,

00:18:04.120 | now I'm not a pelvic floor therapist,

00:18:05.120 | but these are the people who do the work, right?

00:18:08.120 | They work with you on a prolonged basis

00:18:10.120 | to help you normalize the function of your pelvic floor.

00:18:13.120 | It's like going to the gym with a trainer, right?

00:18:15.120 | They really work with you to get your pelvic floor functioning correctly.

00:18:18.120 | And the first step to that, a lot of pelvic floor therapists

00:18:21.120 | will just align your bones and your kind of the way you sit and walk

00:18:27.120 | to make sure that you're not straining those muscles

00:18:30.120 | by pulling in different directions.

00:18:32.120 | And if a male goes to the physician to get a pelvic floor exam,

00:18:39.120 | there's obviously difficulty in putting fingers into the urethra,

00:18:44.120 | one would hope, too small an opening.

00:18:46.120 | So how are they doing the pelvic floor exam?

00:18:48.120 | Is it external to the body or is it through the anus?

00:18:51.120 | So some of it's through the anus.

00:18:52.120 | You could feel the muscles through the anus

00:18:54.120 | and then you can feel the perineal area

00:18:56.120 | and feel the muscles there as well as sensations.

00:18:59.120 | So perineal area, so from the outside of the body?

00:19:01.120 | Correct.

00:19:02.120 | The region between the scrotum and the anus?

00:19:04.120 | Yes.

00:19:05.120 | Okay.

00:19:06.120 | So it sounds to me like if people want to get a high quality assessment

00:19:11.120 | of whether or not their pelvic floor is healthy or not,

00:19:13.120 | they need to see a pelvic floor specialist,

00:19:16.120 | that it's not the sort of thing that they could into on their own necessarily.

00:19:21.120 | It would be difficult.

00:19:22.120 | I mean, so there are things you can buy online,

00:19:25.120 | like probes that you can insert in the vagina

00:19:27.120 | that will teach you how to do Kegel exercises and give you some readings,

00:19:32.120 | but they're not really meant to diagnose.

00:19:34.120 | They're usually something people use if they say have a weak pelvic floor

00:19:37.120 | and they want to try to do it at home on their own.

00:19:39.120 | So there's nothing that's going to give you like a baseline reading,

00:19:42.120 | is this normal or abnormal?

00:19:44.120 | Let's talk about Kegels.

00:19:46.120 | First of all, who's Kegel?

00:19:48.120 | So he is a gynecologist.

00:19:52.120 | I don't remember all the specifics to be quite honest,

00:19:55.120 | but basically he came up with Kegels,

00:19:57.120 | which are a strengthening exercise for the pelvic floor.

00:20:00.120 | And so what it is, what we describe it to for patients is we say,

00:20:03.120 | there's a few different ways to describe it.

00:20:06.120 | You're going to use the muscles that you use when you urinate,

00:20:09.120 | but try to stop the flow.

00:20:10.120 | But you don't want to do them when you're urinating

00:20:12.120 | because that can create dysfunction.

00:20:14.120 | You want to learn what the muscles are and then you squeeze those muscles

00:20:17.120 | and relax in between sets, so to speak.

00:20:21.120 | And so the other way people describe it is pulling up and in in the vagina,

00:20:26.120 | or for men, sometimes you'll say it's like the feeling

00:20:29.120 | that you're trying to lift your penis off the floor without touching it.

00:20:32.120 | So those are kind of using--

00:20:34.120 | That's a good way to describe it.

00:20:35.120 | So those are kind of the ways that you can describe those muscles

00:20:38.120 | and so you can squeeze for five seconds and relax for five seconds

00:20:42.120 | and do them in repetitions.

00:20:43.120 | And they're just like any sort of exercise you do.

00:20:45.120 | You don't want to start doing 100 of them, right?

00:20:47.120 | You want to do them--

00:20:48.120 | I tell patients, do them lying down

00:20:52.120 | so that you're only focusing on those muscles.

00:20:54.120 | You're not working on your posture, you're not doing anything else.

00:20:57.120 | And as you get better with them lying down, you then sit up and do them

00:21:01.120 | and then once you're good with them sitting up, you can do them standing

00:21:04.120 | and start with, you know, 10 to 15 at a time.

00:21:07.120 | Like once in the morning.

00:21:08.120 | 10 to 15 repetitions.

00:21:09.120 | So yeah, let's talk sets and reps.

00:21:11.120 | So yeah, 10 to 15 repetitions in the morning,

00:21:14.120 | 10 to 15 repetitions at night,

00:21:16.120 | maybe one more during the middle of the day.

00:21:18.120 | But don't overdo it because just like anything,

00:21:21.120 | especially when you're starting out, you can.

00:21:23.120 | And if you're doing tons and tons of Kegels,

00:21:25.120 | then you will get a tight, short pelvic floor muscles

00:21:28.120 | and you will then develop pelvic floor dysfunction.

00:21:31.120 | So it's really important to kind of understand those mechanics,

00:21:35.120 | which is why a lot of people think they know how to do Kegels,

00:21:38.120 | but they really don't.

00:21:39.120 | And so I always encourage people if you have the time

00:21:41.120 | and the resources to go to a pelvic floor physical therapist

00:21:44.120 | so they can really work with you and make sure you're doing them correctly.

00:21:47.120 | What are some of the benefits of Kegels for those that need them?

00:21:51.120 | Yes, so they are typically prescribed for urinary incontinence,

00:21:56.120 | specifically stress urinary incontinence.

00:21:58.120 | So leakage that occurs when you have an increase in your intraabdominal pressure

00:22:02.120 | like a Valsalva or coughing, sneezing, lifting heavy things,

00:22:06.120 | jumping on a trampoline.

00:22:08.120 | So for those purposes, we use Kegels to strengthen the pelvic floor

00:22:12.120 | and also in women, pelvic organ prolapse.

00:22:14.120 | So when you have weakness of the pelvic floor that leads to a bulge

00:22:18.120 | that you can visibly see or feel in the vagina.

00:22:21.120 | For men, we often prescribe them for people who have had a prostatectomy

00:22:26.120 | who then subsequently develop leakage after the prostatectomy

00:22:29.120 | that is, again, stress urinary incontinence.

00:22:32.120 | Now a lot of people use Kegels recreationally

00:22:34.120 | because improving the pelvic floor musculature

00:22:37.120 | can lead to more intense pelvic floor contractions during orgasm

00:22:41.120 | which can be more pleasurable.

00:22:43.120 | And so some people do it for those purposes,

00:22:45.120 | but again I caution people not to overdo it

00:22:48.120 | because then you can lead to a more tense pelvic floor

00:22:51.120 | which is not where we want to end up.

00:22:53.120 | Yes, I will underscore that cautionary note.

00:22:57.120 | Years ago, I heard about Kegels.

00:22:59.120 | I was like, okay, I'll try it.

00:23:00.120 | It sounds all good, right?

00:23:02.120 | I only heard good things about Kegels

00:23:04.120 | and what it quickly resulted in was painful urination.

00:23:09.120 | And I thought, this is weird.

00:23:12.120 | Everyone's saying Kegels are so great.

00:23:14.120 | And the best thing I could do for my pelvic floor, it seemed,

00:23:17.120 | was to avoid Kegels.

00:23:19.120 | Yes.

00:23:20.120 | And a little bit later, when we're talking about prostate,

00:23:23.120 | I'll explain at least what my experience was as it relates to the prostate.

00:23:29.120 | But I guess the take-home message that I'm gathering from what you're telling us

00:23:32.120 | is that strengthening the pelvic floor is great if you have a weak pelvic floor.

00:23:38.120 | Strengthening your pelvic floor further

00:23:40.120 | if you have a strong pelvic floor can be detrimental.

00:23:43.120 | It can be. It can be if you overtrain it,

00:23:46.120 | just like if you overtrain anything else.

00:23:48.120 | And so you just have to, if you really want to do Kegels,

00:23:52.120 | if you have any symptoms at all,

00:23:54.120 | like you described, painful urination or the things I've described,

00:23:57.120 | like pain with erections, pain with ejaculation, pain difficulty emptying,

00:24:02.120 | any of those symptoms, stop and go see a urologist

00:24:05.120 | so that they can kind of assess your pelvic floor.

00:24:08.120 | What is the anti-Kegel?

00:24:10.120 | In other words, if somebody decides that they have a tight pelvic floor,

00:24:15.120 | how can they learn to relax their pelvic floor?

00:24:18.120 | So there's a lot of different sort of things that you can do.

00:24:22.120 | So for women, you can do massage of the area.

00:24:26.120 | You can use vaginal dilators to help relax the muscles.

00:24:30.120 | You can take suppositories that have medications like Valium or Baclofen,

00:24:35.120 | which are muscle relaxants, and that can help as well.

00:24:39.120 | Although they're not treatments, they're more of a Band-Aid,

00:24:41.120 | but they can help with the symptoms that you're having.

00:24:44.120 | And then you can also--I think the best thing is to work with a physical therapist

00:24:48.120 | because they can teach you certain exercises that will help down train the pelvic floor.

00:24:53.120 | For example, one of the ones I tell my patients is like happy baby pose.

00:24:57.120 | It actually, you know, stretches and elongates the pelvic floor muscles.

00:25:01.120 | So doing these exercises regularly will help you lengthen the pelvic floor muscles.

00:25:06.120 | One thing that I've experienced extreme pain from

00:25:11.120 | and that stopping was one of the best things that ever happened for my pelvic floor

00:25:17.120 | was to not do any kind of crunching movement with my legs crossed.

00:25:21.120 | I would go to these yoga classes at one point in my life,

00:25:24.120 | and they'd have everybody do these crunches,

00:25:27.120 | and I've always done some abdominal work here and there during the week if I'm being diligent,

00:25:31.120 | but they would have us cross our feet,

00:25:33.120 | and that seemed to lead to some pelvic floor discomfort

00:25:36.120 | that was similar to what I had experienced when I did the Kegels.

00:25:40.120 | So again, for me, ceasing the Kegels was one of the best decisions I ever made.

00:25:44.120 | I only did them for a short while. I was like, "Okay, this is clearly not for me."

00:25:47.120 | And I guess that's another point that tell me if you agree or not

00:25:51.120 | that if you hear about something online or on this podcast or anywhere else

00:25:55.120 | and you try it and it seems to be sending things in the wrong direction,

00:25:58.120 | either you're doing it wrong or it might not be the right thing for you.

00:26:02.120 | I think all too often we hear, "This thing is great,"

00:26:05.120 | and people jump on that bandwagon and then they end up worsening their problems

00:26:08.120 | or developing problems where they didn't have them previously.

00:26:11.120 | But is there anything about the anatomy of the neuromuscular connections

00:26:15.120 | or vasculature of the pelvic floor that would provide support for my experience there?

00:26:21.120 | That doing crunches with legs crossed is essentially--

00:26:24.120 | is it possible that it's creating asymmetries in the pelvic floor?

00:26:28.120 | And now I'm sure I'm angering yoga teachers and crunchanistas everywhere,

00:26:33.120 | but hey, if it's a question of your pelvic floor or a few extra delineations in your abs,

00:26:39.120 | you know where my vote's going.

00:26:41.120 | So there's a couple things here that we should dive into.

00:26:43.120 | One is that people don't often breathe correctly during exercise, right?

00:26:47.120 | And so diaphragmatic breathing is really important,

00:26:50.120 | which is like a deep breath that expands the diaphragm,

00:26:53.120 | not kind of shallow breathing, but just in your mouth and throat.

00:26:56.120 | And that is actually when you do any sort of exercise,

00:27:01.120 | your trainer will tell you exhale on the effort, right?

00:27:04.120 | And there's a reason for that because when you inhale, your pelvic floor relaxes.

00:27:09.120 | When you exhale, your pelvic floor contracts.

00:27:12.120 | And so actually that contraction stabilizes the pelvic floor.

00:27:16.120 | So whatever intraabdominal pressure you're causing to increase from the exercise,

00:27:20.120 | whether it's a squat or a crunch or whatever,

00:27:23.120 | you're increasing your abdominal pressure,

00:27:25.120 | your pelvic floor is then contracting to help stabilize that.

00:27:29.120 | And so part of the reason people tend to hold their breath during crunches, right?

00:27:33.120 | They don't do the appropriate breathing and so that can be part of it.

00:27:37.120 | The other thing that can happen with certain things is that there are nerves and arteries,

00:27:42.120 | particularly the pudendal nerve and the pudendal artery that run through the pelvic floor.

00:27:46.120 | So when you get pelvic floor dysfunction,

00:27:49.120 | you can cause decreased blood flow to the pelvic floor muscles,

00:27:54.120 | which can affect sexual function,

00:27:56.120 | and you can get nerve inflammation as well that can also cause pain.

00:28:00.120 | And so this is kind of how it all comes together.

00:28:03.120 | I'm so glad that you mentioned blood flow.

00:28:05.120 | I think our entire discussion today should be framed up,

00:28:09.120 | at least in the back of our minds and the minds of our listeners and viewers,

00:28:13.120 | as involving at least three things.

00:28:15.120 | You know, anytime we're talking about erectile function or dysfunction

00:28:18.120 | or pelvic floor function or dysfunction or vaginal lubrication or lack thereof,

00:28:23.120 | we need to think about the hormonal influences,

00:28:26.120 | the blood flow related influences and the neural influences,

00:28:32.120 | including the neural influences that come from the brain,

00:28:35.120 | the signals of arousal, for instance, or lack of arousal and so on.

00:28:39.120 | So we won't be overly systematic in our parsing of all this,

00:28:44.120 | but I think what you just mentioned raises a really important point

00:28:47.120 | that sometimes in an effort to do something that's good for the muscles,

00:28:51.120 | like strengthen the muscles, one will cut off blood flow.

00:28:55.120 | In fact, one of the more common questions I got,

00:28:57.120 | and I consulted with a couple of exercise physiologists about this,

00:29:00.120 | and they confirmed that a lot of people who squat and deadlift heavy in the gym

00:29:06.120 | or even who just tense their pelvic floor

00:29:09.120 | when they're doing things like dumbbell curls or other exercises,

00:29:13.120 | and especially people who seem to do a lot of abdominal work,

00:29:18.120 | reported to me in the questions that they experienced things like erectile dysfunction,

00:29:24.120 | that they experienced things like pain during vaginal intercourse,

00:29:29.120 | that essentially they had created some sort of what sounds to me

00:29:33.120 | like a hyper contraction of the muscles in that area

00:29:35.120 | that were impeding all the things that they wanted

00:29:39.120 | as either side effects or direct effects of exercise

00:29:41.120 | because many people are exercising for aesthetic reasons and health reasons,

00:29:45.120 | but nowadays it seems especially on the male side,

00:29:49.120 | but we will also talk about the role of testosterone on the female side,

00:29:52.120 | a lot of males lift weights in order to increase their testosterone

00:29:56.120 | and for reasons that are obvious also want to have healthy sexual function,

00:30:00.120 | and here they are doing this thing that's very good for increasing testosterone

00:30:03.120 | if they're doing it correctly,

00:30:05.120 | and testosterone is involved in libido and the male sexual response

00:30:08.120 | and the female sexual response, of course,

00:30:11.120 | but they are impeding their erections.

00:30:14.120 | So you can start to see how there are probably a lot of confused

00:30:19.120 | and maybe even distraught people out there.

00:30:21.120 | They're trying to do all the right things and they're setting up roadblocks

00:30:24.120 | and even sending themselves backward in some cases.

00:30:27.120 | So the question is how does one know whether or not something like,

00:30:33.120 | let's say, low lubrication or pain during vaginal intercourse

00:30:36.120 | or loss of erectile strength or some sort of erectile dysfunction,

00:30:42.120 | or maybe because it can take on different forms as we'll talk about,

00:30:45.120 | how does one know if it's blood flow related, hormone related,

00:30:48.120 | or neural related?

00:30:50.120 | And if it's neural related, how does one know if it's an issue

00:30:53.120 | of lack of appropriate signals from the brain,

00:30:56.120 | oversuppression or lack of arousal from the brain,

00:30:59.120 | or whether or not it's some peripheral neural thing of innervation

00:31:02.120 | of the penis or vagina?

00:31:04.120 | So I think there's a lot that we can go into here,

00:31:07.120 | but essentially first you want to find out like very specifically

00:31:10.120 | what is going on.

00:31:12.120 | Are you getting aroused?

00:31:14.120 | Are you having erections?

00:31:16.120 | Are you masturbating?

00:31:18.120 | Like there's all these questions that will help us go down the route.

00:31:21.120 | - Sorry to interrupt.

00:31:22.120 | When you say aroused, for sake of this discussion,

00:31:24.120 | I just want to make sure that we distinguish between psychological arousal,

00:31:28.120 | the desire to, I guess here we also have to be precise,

00:31:32.120 | arousal to engage in intercourse and arousal to desire, essentially,

00:31:39.120 | that I think people would learn to recognize.

00:31:41.120 | Or are we talking about arousal as the response of the genitals?

00:31:45.120 | - Correct.

00:31:46.120 | So desire and arousal, this is a very important concept,

00:31:50.120 | doesn't always go in one direction.

00:31:54.120 | Sometimes you can feel arousal,

00:31:56.120 | meaning you have the telltale signs of arousal.

00:31:59.120 | Your nipples get erect.

00:32:00.120 | You have more lubrication if you're a female.

00:32:03.120 | - Do both male and female nipples get erect during arousal?

00:32:05.120 | - I believe so.

00:32:06.120 | - I think so, yeah.

00:32:07.120 | You know, you maybe get the sex flush, right?

00:32:10.120 | You get some redness or warmth feeling.

00:32:13.120 | That's your body's response, right, to arousal,

00:32:16.120 | and sometimes that can be an erection and sometimes that's not.

00:32:19.120 | Not having an erection does not mean you're not aroused.

00:32:21.120 | It may mean other things, but certainly that's part of it.

00:32:24.120 | And then desire, do you want to have sex?

00:32:27.120 | Do you have, like when you think about your partner

00:32:30.120 | or whoever you want to engage with,

00:32:33.120 | is there a desire to actually do that, right?

00:32:36.120 | Or is it just more of obligation or other things?

00:32:38.120 | And it doesn't matter if the desire comes after arousal.

00:32:41.120 | For some women in particular,

00:32:43.120 | we see that they may not have the desire right away,

00:32:46.120 | but they want to be intimate or close with their partner,

00:32:49.120 | and so they'll start just being close with them

00:32:52.120 | and then arousal will come, and then, "Oh, yeah, I like this."

00:32:55.120 | So then the desire comes after, and that's normal.

00:32:58.120 | That's totally fine.

00:32:59.120 | So you want to kind of parse that out,

00:33:02.120 | and then for men you can ask,

00:33:04.120 | "Are you getting erections at night?"

00:33:06.120 | Because that will tell us the function of your organ at night

00:33:09.120 | versus during the day where you have also psychogenic components, right?

00:33:13.120 | You can really get in your head about erections.

00:33:16.120 | When you have a problem in the bedroom with performance,

00:33:19.120 | it becomes a vicious cycle, right?

00:33:21.120 | So you have a problem.

00:33:23.120 | The next time you're really stressed, you're not present.

00:33:25.120 | You're not mindful in the moment with sex,

00:33:28.120 | and you're thinking about, "Oh, my God, am I going to perform okay?

00:33:30.120 | Am I going to perform okay?"

00:33:32.120 | And then it doesn't perform again, and it's getting worse and worse,

00:33:35.120 | and the anxiety is through the roof,

00:33:37.120 | and that's actually causing your sexual dysfunction.

00:33:40.120 | So I think it's important first to identify those issues,

00:33:45.120 | and then also for blood flow, a lot of times we can assess based on,

00:33:50.120 | well, what other comorbidities do you have?

00:33:52.120 | Do you have other issues ongoing that may be affecting your blood flow?

00:33:56.120 | Most common, high blood pressure, diabetes, heart disease, and if you smoke.

00:34:01.120 | All of those things will affect blood flow to the genitals,

00:34:04.120 | and so that will point us...

00:34:05.120 | -Negatively. -Negatively.

00:34:07.120 | So that will point us to a more vascular issue.

00:34:11.120 | Hormonal issues are very important for desire,

00:34:14.120 | and as far as sexual function in terms of erections,

00:34:18.120 | there's only 3% of erectile dysfunction that's related to hormones.

00:34:22.120 | -So it's actually more... -But that's pure erectile function...

00:34:25.120 | -Correct. -...as opposed to desire.

00:34:27.120 | Desire is predominantly modulated by the hormone testosterone

00:34:33.120 | for both men and women.

00:34:34.120 | In fact, a lot of people don't know this,

00:34:37.120 | but women have more testosterone in their bodies than they actually have estrogen.

00:34:41.120 | So testosterone is very important for both men and women for a variety of reasons.

00:34:45.120 | And so using that discussion with the patient

00:34:48.120 | will help you kind of identify where you're headed

00:34:52.120 | in terms of what you need to focus on for treatment.

00:34:56.120 | There are certain things you can use to assess blood flow.

00:34:59.120 | You can do Doppler ultrasounds of the penis as well as the clitoris

00:35:04.120 | to see if there is good blood flow.

00:35:06.120 | You can assess the peak systolic velocity,

00:35:08.120 | which will tell you if there's a problem with arterial inflow,

00:35:11.120 | versus the end diastolic velocity,

00:35:13.120 | which will tell you if there's a problem with venous outflow.

00:35:16.120 | And so that can assess those things.

00:35:18.120 | There are some tests you can do for nerve function,

00:35:21.120 | although they're very uncommonly done

00:35:23.120 | because mostly we can kind of get that through a clinical report.

00:35:26.120 | And unfortunately, if you're having nerve problems,

00:35:28.120 | sometimes it depends on what's causing them,

00:35:30.120 | but sometimes they can be very difficult to reverse,

00:35:32.120 | and that's kind of a problem.

00:35:34.120 | We know that as people age, their sensation becomes less.

00:35:38.120 | So just through aging, the nerves, the receptors become less sensitive,

00:35:42.120 | and so you will generally have less responsiveness

00:35:46.120 | to the same sensations you did when you were younger.

00:35:49.120 | And so that kind of overlays all of this.

00:35:52.120 | So it's complex, but really, you know,

00:35:54.120 | a lot of it comes from the discussion you have with your patient,

00:35:57.120 | or you know, you kind of really doing a deep dive in what's going on,

00:36:00.120 | like really thinking about each of those aspects,

00:36:03.120 | and also what's going on in your relationship,

00:36:05.120 | and what's going on in, you know, your life, stress, anxiety,

00:36:08.120 | like how are those playing a role?

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00:37:07.120 | - Gosh, lots there to unpack,

00:37:09.120 | and I'm glad you mentioned the relationship itself

00:37:12.120 | because there are all sorts of things that can impact the arousal response.

00:37:16.120 | Novelty, not everyone's in a committed relationship.

00:37:20.120 | Whether or not people are engaging in a lot of masturbation

00:37:23.120 | to the point of ejaculation or climax or not,

00:37:26.120 | pornography, et cetera, we will get into that.

00:37:29.120 | It's a vast space to explore.

00:37:31.120 | Before we go any further, I want to make sure, however,

00:37:35.120 | that we cue people to where and how they could find

00:37:39.120 | a really good, let's say pelvic floor therapist

00:37:44.120 | and where they could find a really great urologist

00:37:49.120 | to do the sorts of exams

00:37:51.120 | and perhaps the sorts of treatments that we've talked about,

00:37:53.120 | because at least as far as I understand,

00:37:55.120 | much of what people want to learn on this podcast

00:37:57.120 | is how things work and what happens when things break down,

00:38:00.120 | but also how to resolve those issues.

00:38:02.120 | So let's say somebody wants to check out their pelvic floor,

00:38:07.120 | figure out what's going on there.

00:38:09.120 | Maybe they're having issues, maybe they're not.

00:38:11.120 | If they are male or female, where do they go?

00:38:15.120 | Is there a place online that has a great list

00:38:17.120 | of some of the best ones in one's area?

00:38:19.120 | Can it be done over telemedicine?

00:38:21.120 | How does one go about that?

00:38:24.120 | - Yeah, so in terms of your pelvic floor,

00:38:26.120 | it's good to get assessed by a physician

00:38:30.120 | who specializes in pelvic floor.

00:38:31.120 | Now, that could be a urologist,

00:38:33.120 | that could be a gynecologist or even a physical medicine rehabilitation doctor

00:38:37.120 | that specializes in pelvic floor health.

00:38:40.120 | So typically you'll see in urology,

00:38:42.120 | you'll look for people who are board certified

00:38:44.120 | in female pelvic medicine and reconstructive surgery.

00:38:47.120 | If you're a woman, if you're a man, maybe sexual medicine,

00:38:50.120 | someone who specializes in sexual medicine

00:38:52.120 | would be a good place to look.

00:38:54.120 | For a gynecologist, again, you want to look at someone

00:38:56.120 | who has interest in this area, who does manage pelvic floor.

00:39:00.120 | And then in terms of pelvic floor physical medicine rehabilitation,

00:39:04.120 | at least when I was in training, there was about 20 PM&R doctors

00:39:07.120 | around the country who really focused on this.

00:39:09.120 | So it's not a lot of people.

00:39:11.120 | If you can go to a pelvic floor physical therapist

00:39:14.120 | and you have one near you, that's great as well.

00:39:16.120 | You do want to make sure that one,

00:39:19.120 | they do are certified in pelvic floor physical therapy

00:39:22.120 | and that they have taken care of your gender.

00:39:25.120 | So if you have male anatomy,

00:39:27.120 | then you want to go to someone who's actually seen men

00:39:29.120 | because a lot of the pelvic floor physical therapists

00:39:31.120 | tend to treat a lot of women.

00:39:33.120 | And so that's kind of what I tell my patients,

00:39:35.120 | generally speaking, there's no, at least to my knowledge,

00:39:37.120 | no great resource and maybe we'll look that up

00:39:39.120 | and see if we can find one.

00:39:40.120 | - That's very helpful, thank you.

00:39:42.120 | Because again, going back to what I said

00:39:44.120 | at the beginning of our conversation,

00:39:46.120 | I think there's a lot of shame or at least a lack of clarity

00:39:50.120 | as to how one gets help for issues

00:39:52.120 | that relate to the genitals, right?

00:39:54.120 | Because if you have a headache or you're having an eye issue,

00:39:57.120 | I mean, you sort of know where to go.

00:39:59.120 | Hopefully your headache

00:40:00.120 | doesn't warrant going to a neurologist, but it might.

00:40:03.120 | Eye stuff tends to be ophthalmologist optometrists, right?

00:40:07.120 | So I don't think we hear often enough

00:40:10.120 | about where to access the best quality care for these things.

00:40:13.120 | So thank you for that.

00:40:15.120 | In thinking about sexual dysfunction,

00:40:18.120 | I'd like to have that conversation

00:40:19.120 | more or less in parallel if we can

00:40:21.120 | around male sexual dysfunction and female sexual dysfunction.

00:40:24.120 | And I want to make sure that before we do that,

00:40:26.120 | that I'm creating the correct parallel construction,

00:40:29.120 | as they say.

00:40:30.120 | Erectile dysfunction in males

00:40:32.120 | is clearly a form of sexual dysfunction.

00:40:35.120 | What is the parallel to erectile dysfunction in females?

00:40:39.120 | Is it lack of vaginal lubrication

00:40:41.120 | and lack of relaxation of the vagina

00:40:43.120 | to have non-painful intercourse?

00:40:46.120 | I mean, is it even possible

00:40:48.120 | to have a parallel conversation about these two things?

00:40:50.120 | - So it's different.

00:40:52.120 | In some circumstances, there are homologs, right?

00:40:55.120 | So the penis is the homologue of the clitoris.

00:40:58.120 | So the clitoris is essentially

00:41:00.120 | the same sort of spongy erectile tissue

00:41:02.120 | that you see in the penis.

00:41:03.120 | It gets erect with arousal

00:41:06.120 | and it actually extends very deep into the pelvis,

00:41:10.120 | so it's not just a small little organ.

00:41:12.120 | It's actually quite long.

00:41:13.120 | And so you can, in men, you can have erectile dysfunction

00:41:17.120 | 'cause you can see it,

00:41:18.120 | but in women, you may have difficulty with orgasm.

00:41:21.120 | And it's not exactly a parallel,

00:41:23.120 | but difficulty orgasming in women is multifactorial

00:41:26.120 | and we can get into that.

00:41:28.120 | But I think they're different

00:41:30.120 | and I think also sexual dysfunction

00:41:31.120 | presents differently in both genders.

00:41:33.120 | So when you talk about men,

00:41:36.120 | the one visual they see of arousal is erections.

00:41:40.120 | And so it becomes very ingrained in your psyche

00:41:43.120 | that if I don't have an erection, I'm not aroused, right?

00:41:46.120 | But there's a lot of reasons

00:41:47.120 | that you might not have an erection

00:41:49.120 | that we've sort of touched on,

00:41:50.120 | vascular problems, hormonal problems, neurologic problems,

00:41:54.120 | psychogenic issues, and other medications you're taking.

00:41:57.120 | So there are issues that can affect erectile function

00:42:00.120 | and so that can be part of it

00:42:03.120 | where you might feel like you have low desire

00:42:06.120 | because your arousal's not there

00:42:08.120 | and that becomes a little bit confusing.

00:42:09.120 | For women, what they can assess

00:42:12.120 | is their level of lubrication if sex hurts

00:42:15.120 | and if they get an orgasm.

00:42:17.120 | And so those are kind of the ways you can look at it.

00:42:19.120 | - Thank you for fleshing all of that out.

00:42:22.120 | Years ago, I worked on sexual differentiation

00:42:25.120 | and in particular the role of hormones

00:42:27.120 | in sexual differentiation.

00:42:28.120 | And indeed, as you described,

00:42:30.120 | we learned because we were taught

00:42:31.120 | and I think people still generally agree

00:42:33.120 | that if one looks at the embryological origins

00:42:36.120 | of the penis and the clitoris,

00:42:37.120 | they are essentially analogous structures

00:42:40.120 | and that a lot of male genital development

00:42:43.120 | involves literally the regression,

00:42:45.120 | the disappearance of the female sexual genitalia

00:42:48.120 | and associated organs,

00:42:49.120 | malaria and ducts and things like that,

00:42:50.120 | and what would become the ovaries,

00:42:52.120 | become the testes, et cetera, et cetera.

00:42:54.120 | Those are anatomical parallels,

00:42:56.120 | but what you just described for us very beautifully

00:42:59.120 | is the sort of functional parallels

00:43:01.120 | as it relates to sexual function and dysfunction.

00:43:04.120 | So I'm hoping with that framing

00:43:05.120 | that we can knock down a few of these pins

00:43:09.120 | in a little less time

00:43:11.120 | because there's a lot to tackle here.

00:43:13.120 | First off, I'd like to address the hormonal issues.

00:43:16.120 | You mentioned that only 3% of erectile dysfunction

00:43:20.120 | and by extension, can we say also female issues

00:43:25.120 | with sexual arousal are hormonal in origin.

00:43:28.120 | Is that right?

00:43:29.120 | - So with desire, yes.

00:43:31.120 | They are hormonal in general

00:43:33.120 | and arousal in terms of lubrication,

00:43:36.120 | if you're using that as a barometer,

00:43:38.120 | yes, you can see less vaginal lubrication due to hormones.

00:43:41.120 | And I guess I would say three to 6% more,

00:43:43.120 | up to 6% we see of erectile dysfunction is hormonal.

00:43:46.120 | It's a small percentage

00:43:47.120 | of the entirety of erectile dysfunction.

00:43:51.120 | - Okay, so I think in looking in the landscape

00:43:53.120 | of social media and podcasts

00:43:55.120 | and just in the common mindset,

00:43:59.120 | we've all come to believe

00:44:01.120 | that testosterone is pro libido.

00:44:04.120 | It's pro desire in men and women.

00:44:06.120 | I think now people are starting to appreciate

00:44:07.120 | that it's pro desire in women as well,

00:44:10.120 | but certainly in men.

00:44:11.120 | And that dopamine is also associated with desire.

00:44:14.120 | And the general public tends to have this view

00:44:16.120 | of estrogen as being sort of anti libido

00:44:18.120 | or anti male, which is frankly false.

00:44:21.120 | In fact, and I've covered this on the podcast

00:44:23.120 | with Dr. Kyle Gillette and with Dr. Peter Attia

00:44:26.120 | and another fellow YouTuber Derek

00:44:29.120 | from More Plates More Dates has talked a lot

00:44:31.120 | about the fact that if people,

00:44:33.120 | if men, excuse me, take drugs

00:44:36.120 | like an astrozole to suppress their estrogen,

00:44:40.120 | thinking that, oh, it's all about having high testosterone,

00:44:43.120 | low estrogen, oftentimes they crush their libido,

00:44:46.120 | just abolish it, which has led to a slowly growing,

00:44:51.120 | but I think positive shift

00:44:53.120 | in how people are thinking about estrogen.

00:44:55.120 | Estrogen is great for brain function.

00:44:56.120 | Estrogen is great for libido in men and women.

00:44:59.120 | And that is a revision of,

00:45:02.120 | I think how most people think of the male sexual response.

00:45:05.120 | It's more in keeping with how people think

00:45:07.120 | about the female sexual response.

00:45:08.120 | Oh, estrogen and the female sexual response.

00:45:10.120 | That makes sense.

00:45:11.120 | But what we're trying to do here

00:45:12.120 | is clarify some of the misconceptions.

00:45:14.120 | Now, the reason I mentioned dopamine

00:45:16.120 | is that my understanding is that dopamine

00:45:18.120 | is involved in the, excuse me, the desire response.

00:45:21.120 | We will distinguish desire, the psychological arousal

00:45:24.120 | from genital arousal, physical arousal.

00:45:27.120 | And that prolactin is associated with the refractory period

00:45:32.120 | during which erection can't occur.

00:45:33.120 | Another perhaps orgasm can't occur in females, et cetera.

00:45:37.120 | But my understanding is that's also not that simple.

00:45:41.120 | And we need to take a step back perhaps

00:45:43.120 | and just talk about the physiological underpinnings

00:45:46.120 | of the desire and arousal response.

00:45:49.120 | So I'll tell you what I was taught

00:45:50.120 | and then you can tell me where it's wrong.

00:45:52.120 | - Sure.

00:45:53.120 | - I hope.

00:45:54.120 | I was taught that the erection response

00:45:57.120 | and the vaginal lubrication response

00:45:59.120 | is generated by the parasympathetic nervous system,

00:46:03.120 | the relaxed, the rest and digest aspect of the nervous system

00:46:07.120 | hence why some people can get psychogenic sexual issues

00:46:10.120 | of lack of erection or lack of vaginal lubrication.

00:46:14.120 | But that there are individuals out there

00:46:17.120 | for whom a lot of alertness maybe even,

00:46:20.120 | and this is a controversial thing,

00:46:22.120 | but for some people even some sense of aggression

00:46:24.120 | or kind of edginess or excitement,

00:46:26.120 | adrenaline in other words,

00:46:28.120 | can stimulate erection or vaginal lubrication.

00:46:31.120 | So it gets tricky.

00:46:32.120 | It's not like the textbooks,

00:46:33.120 | it's not like they taught us in high school

00:46:35.120 | as far as I know.

00:46:36.120 | I was taught that the arousal response

00:46:38.120 | in males and females

00:46:39.120 | is initiated by a parasympathetic sort of relaxed tone.

00:46:43.120 | And that as sexual desire and arousal

00:46:49.120 | and sex or masturbation progresses,

00:46:52.120 | that it shifts more towards the sympathetic nervous system,

00:46:55.120 | which has nothing to do with emotional sympathy

00:46:56.120 | and has everything to do with arousal,

00:46:58.120 | the catecholamines, dopamine, norepinephrine and epinephrine,

00:47:02.120 | also called adrenaline and noradrenaline are released.

00:47:05.120 | And that the climax response,

00:47:07.120 | which may or may not include ejaculation,

00:47:10.120 | we have to separate that out,

00:47:11.120 | is one that is really of the stress system of the body.

00:47:15.120 | And then in the post-coital or post ejaculatory

00:47:18.120 | or post climax phase,

00:47:20.120 | then there's a shift back

00:47:22.120 | to the parasympathetic nervous system.

00:47:24.120 | That's where the pillow talk

00:47:28.120 | and the exchange of odors and tastes and other molecules

00:47:33.120 | is known to enhance pair bonding

00:47:34.120 | through things like oxytocin, vasopressin, and so on.

00:47:37.120 | And what I just described

00:47:38.120 | is exceedingly oversimplified, I realize,

00:47:41.120 | but is that more or less how the physiology works?

00:47:45.120 | - Yeah, so the way we're taught in medical school

00:47:47.120 | is point and shoot.

00:47:49.120 | So point is the parasympathetic nervous system.

00:47:52.120 | - All the male audience will like that one.

00:47:54.120 | - And then you go on to the sympathetic nervous system,

00:47:56.120 | but it makes sense.

00:47:58.120 | And the reason that I think you're hearing

00:47:59.120 | about this aggression

00:48:00.120 | or these things that are leading to arousal

00:48:04.120 | is because there needs to be a stimulus, right?

00:48:07.120 | A visual stimulus, a tactile stimulus,

00:48:10.120 | some sort of stimulus that you're getting

00:48:12.120 | that is then causing the release of nitric oxide

00:48:15.120 | from the parasympathetic nervous system.

00:48:16.120 | And that could be for some people,

00:48:18.120 | aggression or some form of that, right?

00:48:20.120 | - Can you tell people about nitric oxide?

00:48:22.120 | Because we'll get into this

00:48:23.120 | when we talk about drugs that increase blood flow,

00:48:27.120 | Cialis, Viagra, and also non-prescription drugs,

00:48:31.120 | things like L-citrulline, arginine,

00:48:33.120 | and watermelon for that matter, right?

00:48:36.120 | So I read on the internet.

00:48:38.120 | - So yeah, so nitric oxide is essentially the ignition

00:48:42.120 | for what we say for erections, the ignition for erections.

00:48:45.120 | The reason I talk about erections more often

00:48:48.120 | is when you look at the data,

00:48:49.120 | in fact, there was a paper on this

00:48:51.120 | where they looked at the number of articles

00:48:53.120 | that came up when you put in the word penis

00:48:55.120 | and the number of articles

00:48:56.120 | that came up when you put in the word clitoris,

00:48:58.120 | and it was 50,000 about penis and 2000 about the clitoris.

00:49:02.120 | - Okay, this was actually a major section of the comments

00:49:05.120 | on when I asked for questions on Instagram

00:49:09.120 | and comments on comments and yeah,

00:49:11.120 | how come, why not, et cetera?

00:49:15.120 | Is that because the urology and sexual health field

00:49:20.120 | was dominated by men?

00:49:21.120 | That's going to be the presumption.

00:49:23.120 | Or is it because it's easier to study somehow?

00:49:27.120 | I mean, what's going on here?

00:49:29.120 | - Yeah, I think there's been a lot of,

00:49:31.120 | I mean, you can go back to like Freud

00:49:34.120 | where he thought that the female sexual response

00:49:36.120 | was less valuable.

00:49:38.120 | And so there are some reasons-

00:49:39.120 | - Less valuable?

00:49:40.120 | - I guess, I don't know if that's the right term, but-

00:49:42.120 | - Oh, no, no, I'm not challenging your term.

00:49:44.120 | I just meant-

00:49:45.120 | - You know, it was sort of dismissed.

00:49:46.120 | - He seemed to be obsessed with it, right?

00:49:48.120 | - But it was more about the male sexual response

00:49:50.120 | than the female sexual response.

00:49:52.120 | And so in general, yes, there is, you know,

00:49:54.120 | there were more men in medicine.

00:49:55.120 | There was more, and it is easier to study, right?

00:49:58.120 | You can't say the clitoris quite as easy

00:50:00.120 | as you can study the male penis response

00:50:02.120 | because you can see it visually.

00:50:04.120 | You can inject it and see an erection response, right?

00:50:06.120 | We do this for people who have erectile dysfunction.

00:50:08.120 | They'll take medications that increase blood flow,

00:50:11.120 | like Trimix, and you'll inject it into the penis

00:50:13.120 | and you'll see an erection.

00:50:14.120 | So you can actually-

00:50:15.120 | - Trimix?

00:50:16.120 | - Trimix, so there's, it's-

00:50:17.120 | - The entire male audience just went,

00:50:19.120 | "Wait, what are you injecting into the penis?"

00:50:21.120 | - So there are three basically brand names

00:50:24.120 | of intracavranosal injections

00:50:26.120 | that we use for erectile dysfunction.

00:50:28.120 | - I hear injection in penis, and I think I'd say,

00:50:31.120 | I like to think that it reflects a natural male response.

00:50:34.120 | I sort of, taken aback.

00:50:37.120 | I don't know, maybe there's a pelvic floor contraction

00:50:39.120 | in there someplace.

00:50:41.120 | - So it is scary to hear about.

00:50:44.120 | It's a very small needle.

00:50:45.120 | It is very well tolerated.

00:50:47.120 | I've done it to patients in the office

00:50:49.120 | and they look at me and say, "You're done?"

00:50:50.120 | Like they don't even, you know,

00:50:51.120 | it's not as painful as it seems.

00:50:53.120 | And when you are not having erections

00:50:55.120 | and you've tried multiple things,

00:50:57.120 | people get to the point where they're willing to try that.

00:50:59.120 | You know, and so it is very effective.

00:51:02.120 | It is the most effective non-surgical treatment

00:51:04.120 | we have for erectile dysfunction.

00:51:06.120 | And it's usually either one medication,

00:51:09.120 | two medications or three.

00:51:10.120 | So you can have, you know, alprostedil, papaverine,

00:51:13.120 | and the third one.

00:51:15.120 | - That's a good, we can look at,

00:51:16.120 | someone will put it in the comments.

00:51:18.120 | - Sure, sure.

00:51:19.120 | - Surely they will.

00:51:20.120 | What is it designed to do?

00:51:22.120 | Is it a vasodilator of sorts?

00:51:24.120 | - So they work in different mechanisms,

00:51:26.120 | but similar to the medications that we have,

00:51:29.120 | PDE-5 inhibitors.

00:51:31.120 | PDE-5 inhibitors work in the erection cascade.

00:51:34.120 | Basically what happens, let's actually,

00:51:35.120 | let's take it back to the nitric oxide thing

00:51:37.120 | and we'll get there.

00:51:38.120 | So nitric oxide essentially is released

00:51:41.120 | by the endothelium in response

00:51:43.120 | to a visual tactile stimulating cue, right?

00:51:46.120 | And so your body releases nitric oxide,

00:51:49.120 | which then sets off the cascade for the erection.

00:51:52.120 | And so that releases CGMP,

00:51:55.120 | which causes the erection

00:51:57.120 | and it's degraded by phosphodiesterase.

00:52:00.120 | And so medications that inhibit phosphodiesterase,

00:52:03.120 | like Viagra and Cialis,

00:52:05.120 | tend to prevent the breakdown of that CGMP

00:52:08.120 | so you have longer lasting erections.

00:52:10.120 | And so similarly,

00:52:11.120 | these medications work sort of similar to that.

00:52:13.120 | Some of them, we don't know exactly how they work,

00:52:15.120 | but they work by increasing CGMP or CAMP

00:52:18.120 | that are involved in those cascades.

00:52:20.120 | - And what about L-citrulline?

00:52:21.120 | I hear about L-citrulline use.

00:52:23.120 | It's an over-the-counter supplement

00:52:25.120 | and it's in the arginine pathway.

00:52:28.120 | And my understanding is that it works similarly

00:52:31.120 | to things like Cialis, Viagra,

00:52:34.120 | but is perhaps not as potent.

00:52:36.120 | I also just, a cautionary note out there,

00:52:39.120 | L-citrulline can give people vicious cold sores

00:52:42.120 | and canker sores, vicious.

00:52:44.120 | You hear about this on the internet.

00:52:45.120 | It's been verified by grotesque images

00:52:48.120 | that you do not want to Google for

00:52:50.120 | and not everyone tolerates it well.

00:52:53.120 | - So these actually work by increasing nitric oxide.

00:52:55.120 | So they're not later down the pathway.

00:52:57.120 | They're actually increasing the availability

00:52:59.120 | of nitric oxide.

00:53:00.120 | So L-arginine is the more direct pathway,

00:53:03.120 | but it's very low bioavailability.

00:53:05.120 | L-citrulline converts to L-arginine,

00:53:07.120 | but it lasts much longer in the bloodstream,

00:53:09.120 | which is why people tend to use L-citrulline.

00:53:12.120 | Now, in sexual medicine, these supplements,

00:53:16.120 | while there's been some studies on them

00:53:18.120 | and they are effective,

00:53:20.120 | there's no regulation on the supplement industry.

00:53:22.120 | So we can recommend them,

00:53:24.120 | but we just can't say that for sure

00:53:25.120 | that the supplement is exactly what's said on the bottle.

00:53:28.120 | We see lots of studies where they'll say,

00:53:30.120 | I read one about melatonin

00:53:31.120 | and there's a variation of melatonin

00:53:34.120 | from like what's on the bottle to 400% times more.

00:53:37.120 | And so that's kind of the struggle

00:53:38.120 | that we as medical doctors have.

00:53:40.120 | And I know we get a lot of slack for it

00:53:41.120 | that we don't talk about supplements,

00:53:43.120 | but it's really the challenge there

00:53:45.120 | is like finding the quality supplement.

00:53:47.120 | - A great site is, which I have no relationship to,

00:53:51.120 | except that I mention them all the time,

00:53:54.120 | is examine.com, which has references to human studies

00:53:59.120 | and where there's a lot of efficacy shown.

00:54:01.120 | And we'll get into some side effect issues.

00:54:03.120 | Can't address quality by brand issues,

00:54:07.120 | but thanks for mentioning that.

00:54:08.120 | What percentage of males who take Cialis,

00:54:13.120 | AKA to dalafil, or Viagra for erectile dysfunction

00:54:18.120 | get relief from that?

00:54:21.120 | Because you mentioned only 3% of erectile issues in males

00:54:24.120 | are hormonal in origin,

00:54:27.120 | but what percentage are likely to be blood flow

00:54:31.120 | related in origin?

00:54:32.120 | - So a large percentage are blood flow related.

00:54:35.120 | That doesn't mean that the medication

00:54:36.120 | will be effective for everyone.

00:54:38.120 | If you look at the large percentage

00:54:40.120 | are vascular in nature, right?

00:54:42.120 | That's the number one cause as men age.

00:54:45.120 | So we know that about 52% of men over the age of 40

00:54:49.120 | will have erectile dysfunction,

00:54:51.120 | and that continues to increase as you age.

00:54:53.120 | So 50% of 50 year olds, 60% of 60 year olds,

00:54:57.120 | and so on and so forth.

00:54:58.120 | So it's very, very common.

00:55:00.120 | And the success rate in the studies is about 60 to 70%.

00:55:03.120 | So when you give someone a medication,

00:55:06.120 | they will have sustained erections

00:55:08.120 | that are sufficient for penetrative intercourse,

00:55:10.120 | which is the way we kind of discuss

00:55:12.120 | erectile dysfunction in studies

00:55:14.120 | and with patients is about 60 to 70%.

00:55:18.120 | So not everyone will have success,

00:55:20.120 | but not all of that is because the medication doesn't work.

00:55:22.120 | Sometimes people are not taking them correctly.

00:55:25.120 | Sometimes people need to try different doses.

00:55:27.120 | And then there's still this issue of,

00:55:30.120 | you know, your brain is still active.

00:55:31.120 | And so if you're having anxiety

00:55:32.120 | or having other issues or stress in your life,

00:55:34.120 | that can have an effect on your ability

00:55:36.120 | to create an erection.

00:55:37.120 | So there's lots of factors that go into it.

00:55:39.120 | But generally speaking, they are effective

00:55:42.120 | and they do work quite well and they're tolerated pretty well.

00:55:45.120 | And 60 to 70% is not a small number.

00:55:48.120 | That's a significant number.

00:55:50.120 | That's the majority, but by a significant margin.

00:55:53.120 | Is there a basis for the use of Cialis to Dallafil, Viagra,

00:55:58.120 | L-citrulline in females?

00:56:02.120 | - So yeah, there's not a lot of data on this,

00:56:05.120 | but certainly, you know,

00:56:07.120 | if you have surmised that there is a blood flow issue

00:56:10.120 | and they're having difficulties with orgasm,

00:56:12.120 | it's certainly something you can try off label.

00:56:14.120 | And certainly people do try these medications off label

00:56:18.120 | to see if they improve sexual function for women,

00:56:20.120 | but there's not a whole bunch of robust, you know,

00:56:23.120 | randomized controlled trial studies on women

00:56:26.120 | with these medications.

00:56:28.120 | - A little bit later,

00:56:29.120 | we will talk about prostate health specifically,

00:56:32.120 | but I'm just going to make a note here

00:56:34.120 | that nowadays there's increasing use

00:56:38.120 | of low dosage Cialis/Todalafil.

00:56:43.120 | So rather than what I found online

00:56:46.120 | was that the erectile dysfunction treatment dosage

00:56:49.120 | of Cialis/Todalafil is somewhere

00:56:51.120 | in the 15 to 20 milligram range.

00:56:53.120 | What we're talking about here is daily use

00:56:57.120 | of 2.5 to 5 milligrams of Cialis/Todalafil

00:57:01.120 | for prostate health.

00:57:02.120 | And I learned in researching for this episode

00:57:05.120 | that Todalafil Cialis was actually developed

00:57:08.120 | as a drug for the treatment of prostate health

00:57:12.120 | to essentially increase blood flow of the prostate

00:57:15.120 | to increase prostate health,

00:57:16.120 | not for the treatment of erectile dysfunction.

00:57:19.120 | So I found that to be somewhat interesting.

00:57:21.120 | And a lot of people are now starting to use that.

00:57:24.120 | I also learned that if you dive

00:57:26.120 | into the guts of the internet,

00:57:28.120 | one can find that now there's a growing use

00:57:31.120 | of combined low dosage Cialis and Apomorphine,

00:57:35.120 | which is a pro dopaminergic agent.

00:57:37.120 | And we'll get back to dopamine a little bit later,

00:57:39.120 | but is there any basis for low dosage,

00:57:43.120 | say 2.5 to 5 milligram daily use

00:57:46.120 | of Cialis/Todalafil in females?

00:57:49.120 | - Yes, so, well, let's talk about it for males and females.

00:57:51.120 | I think low dose daily Cialis is excellent

00:57:54.120 | for erectile function in men.

00:57:57.120 | - Is that true even, sorry to interrupt,

00:57:59.120 | but is that true even for men

00:58:00.120 | that are not experiencing erectile dysfunction?

00:58:03.120 | - It's not indicated for that purpose,

00:58:05.120 | but there's a thought that, you know,

00:58:07.120 | it's increasing blood flow to the area.

00:58:08.120 | So people, I've personally used it for men

00:58:11.120 | who have pelvic pain to help with increasing blood flow.

00:58:14.120 | You can also use it potentially as a preventative.

00:58:17.120 | So some people have, you know, kind of thought,

00:58:19.120 | okay, it's increasing blood flow,

00:58:20.120 | it's preventing fibrosis of that erectile tissue

00:58:23.120 | that can happen with age or other vascular problems.

00:58:26.120 | So it may be beneficial for that as well.

00:58:28.120 | Although, again, that's off label

00:58:30.120 | and not something that we generally promote.

00:58:33.120 | As far as for women, there's, you know, again,

00:58:35.120 | it can help with blood flow.

00:58:37.120 | So if you're having issues,

00:58:38.120 | so if you have a female who's having sexual dysfunction

00:58:40.120 | and she's got signs of vascular problems,

00:58:43.120 | like she's got diabetes, high blood pressure, she smokes,

00:58:47.120 | then yes, it's certainly reasonable to try

00:58:49.120 | and see how they do.

00:58:50.120 | Usually you want to give at least a four-week trial

00:58:52.120 | to see if there's any benefit with those medications.

00:58:55.120 | - Great, thank you for that.

00:58:56.120 | Why is it that I get so many questions

00:59:01.120 | about erectile dysfunction

00:59:03.120 | from males who are in their 20s and 30s?

00:59:06.120 | Because everything you said up until now

00:59:08.120 | was mainly focused on men 40 years and older.

00:59:12.120 | Is it from lack of physical activity, overuse of nicotine,

00:59:15.120 | by the way, vaping as far as we know,

00:59:18.120 | vaping and smoking bad for erectile function

00:59:20.120 | and perhaps sexual health in males and females generally

00:59:23.120 | because nicotine is a vasoconstrictor.

00:59:25.120 | Nicotine does have certain benefits,

00:59:27.120 | and I covered this in an episode on nicotine,

00:59:29.120 | neurocognitive benefits in the elderly in particular,

00:59:32.120 | but it is a vasoconstrictor.

00:59:34.120 | So it runs against all of the sexual arousal stuff

00:59:37.120 | that we're talking about.

00:59:38.120 | But okay, let's assume that a male in their 20s or 30s

00:59:44.120 | is sleeping enough, you know, six to eight hours a night,

00:59:49.120 | is exercising, isn't doing anything

00:59:50.120 | to punish their pelvic floor in the gym.

00:59:53.120 | You know, they're not doing legs cross kegels

00:59:55.120 | while doing crunches or something

00:59:57.120 | while inhaling on the crunch.

00:59:58.120 | [laughing]

01:00:01.120 | That was a quiz by the way, folks,

01:00:04.120 | for earlier topics covered.

01:00:07.120 | Let's assume they're, you know, eating pretty well.

01:00:10.120 | Majority of their foods are coming from non-processed

01:00:13.120 | or minimally processed foods.

01:00:15.120 | They're doing a little meditation each day.

01:00:17.120 | They're engaging in hopefully healthy relationships.

01:00:21.120 | They're not masturbating like crazy to porn.

01:00:23.120 | And, you know, let's assume that they are, you know,

01:00:27.120 | not on any SSRI.

01:00:29.120 | Why are all these 20 and 30 year olds

01:00:31.120 | on the internet asking mainly you?

01:00:34.120 | 'Cause they mainly run to you.

01:00:37.120 | But also to my direct messages about their erectile issues.

01:00:40.120 | - So I will say, I have seen a lot of young men in my clinic

01:00:44.120 | and I will say that they very often

01:00:46.120 | have pelvic floor dysfunction.

01:00:48.120 | So that even though they're doing all the right things,

01:00:51.120 | they do have, I mean, we're in a stressful society

01:00:53.120 | so you can try all the things to decrease your stress,

01:00:57.120 | but a lot of us are sitting long periods of time,

01:00:59.120 | especially during COVID.

01:01:00.120 | I mean, people sat for months, right?

01:01:03.120 | Years, like just sitting at their home computer.

01:01:05.120 | And so, you know, exercising one hour

01:01:08.120 | is not gonna offset the day full of sitting.

01:01:11.120 | And so all of those things can affect pelvic floor function.

01:01:14.120 | So my theory is that that's probably the more common cause.

01:01:17.120 | - So walk more.

01:01:18.120 | - Yeah.

01:01:19.120 | - I've actually heard that.

01:01:20.120 | - Or use a standing desk.

01:01:21.120 | - Yep, yeah, walk more standing desk.

01:01:24.120 | Okay, so, and then my guess

01:01:27.120 | is that there's some psychogenic feedback loop.

01:01:30.120 | - Absolutely.

01:01:31.120 | - There's just nerd speak for things aren't working

01:01:34.120 | as well as they would like, then they're stressing about it

01:01:35.120 | and the stress is making things worse.

01:01:37.120 | - Absolutely, and you know, you mentioned

01:01:39.120 | that people are not masturbating or using porn,

01:01:42.120 | but a lot of people learn about sex through porn.

01:01:45.120 | Whether it's good or bad, we can't, you know,

01:01:47.120 | it's not a great thing, but like that's accessible now.

01:01:50.120 | When we were growing up, you had to find a VCR,

01:01:52.120 | you had to find a quiet room that no one was gonna walk in.

01:01:55.120 | - I'm old enough to remember when the kid down the street,

01:01:57.120 | I won't mention him, by last name,

01:02:00.120 | but yeah, the kid down the street, you know,

01:02:02.120 | had porno magazines.

01:02:04.120 | - Yeah, or magazines.

01:02:05.120 | - And then there was actually a library of these,

01:02:08.120 | goodness, I shouldn't say where they were,

01:02:10.120 | in the town I grew up in where kids would stash them

01:02:12.120 | in specific locations in parking lots.

01:02:16.120 | And then, you know, boys would bike or skateboard over

01:02:19.120 | or walk over and then they would like take turns,

01:02:22.120 | take turns, excuse me, looking at them.

01:02:24.120 | But that actually is to raise

01:02:26.120 | perhaps a more important point,

01:02:28.120 | which is that looking at pornography

01:02:31.120 | is different than masturbating to pornography,

01:02:34.120 | which is also different than masturbating to pornography

01:02:36.120 | to the point of ejaculation, right?

01:02:38.120 | Because I also get a lot of questions

01:02:42.120 | from people about their porn addiction issues.

01:02:45.120 | And there's a growing theory out there that overuse

01:02:49.120 | that meaning, not just looking at,

01:02:52.120 | but masturbating to pornography to the point of ejaculation

01:02:56.120 | is creating a deficit of seeking out

01:03:00.120 | and cultivating healthy, real world sexual interactions.

01:03:05.120 | - Yeah, so I want to start this before I get into that

01:03:09.120 | is to say that if you're masturbating to porn

01:03:11.120 | and you have normal, healthy relationships

01:03:14.120 | and you're going to work and you have a great partner

01:03:18.120 | and everything's great in your life, it's okay.

01:03:20.120 | Like shame is a real problem.

01:03:22.120 | - And maybe they're watching pornography together.

01:03:24.120 | - Yeah, so I think it's important though

01:03:26.120 | that at least in the literature,

01:03:28.120 | they don't describe porn addiction.

01:03:30.120 | They call it problematic pornography use.

01:03:33.120 | And it's only described in about 4% of people

01:03:36.120 | in these studies.

01:03:37.120 | So it's a small subset of people.

01:03:39.120 | I think it's becoming more common

01:03:41.120 | because pornography is so accessible

01:03:43.120 | and it activates the dopamine pathways

01:03:46.120 | just like any other sort of addiction, right?

01:03:48.120 | You watch pornography, you get a dopamine response.

01:03:51.120 | Your brain then says, "Oh, I want that again."

01:03:54.120 | And you keep seeking more novel, more aggressive,

01:03:57.120 | different types of pornography to get that same response,

01:04:00.120 | but it doesn't happen to everybody.

01:04:02.120 | - But also I would say, sorry to interrupt,

01:04:05.120 | but that the dopamine response

01:04:08.120 | as a hardwired biological mechanism

01:04:10.120 | for adaptive behaviors, including,

01:04:14.120 | and let's just define healthy sexual behavior

01:04:16.120 | because I feel like there's such a range on that

01:04:19.120 | depending on one's background, religious beliefs, et cetera.

01:04:22.120 | Anytime we talk about sex on this podcast,

01:04:24.120 | I like to say that involves at least four things,

01:04:27.120 | obviously consensual, age appropriate,

01:04:32.120 | context appropriate, species appropriate.

01:04:36.120 | - Yes, absolutely, absolutely.

01:04:38.120 | I'm really glad you brought that up.

01:04:40.120 | So I've heard you say that before,

01:04:41.120 | but it's very important.

01:04:42.120 | And so I think there is a spectrum,

01:04:45.120 | a large spectrum of people who watch pornography,

01:04:48.120 | ejaculate to pornography and have a normal life.

01:04:50.120 | And so that's fine.

01:04:51.120 | I think that if we shame those people,

01:04:54.120 | we're creating problems, right?

01:04:55.120 | We say like, "Oh, you do that, that's horrible."

01:04:57.120 | And then they're in their head, right?

01:04:59.120 | And then they're causing problems in their life

01:05:01.120 | because of shame.

01:05:02.120 | And so I think there's a little bit of cultural shame

01:05:06.120 | that comes of this discussion.

01:05:08.120 | And so it's a problem in the longterm

01:05:10.120 | if we say that, "Oh, this is gonna create problems,"

01:05:12.120 | 'cause not everyone has.

01:05:13.120 | There's so many people who watch pornography

01:05:15.120 | and have no problems, who have normal healthy relationships,

01:05:18.120 | great sex with their partner, and it's fine.

01:05:21.120 | - Or they're between relationships.

01:05:23.120 | - Yeah.

01:05:24.120 | - And they're relying on masturbation specifically.

01:05:25.120 | - Right.

01:05:26.120 | - Are there any data that distinguish

01:05:28.120 | between just pure imagination fantasy

01:05:32.120 | versus visual fantasy as it relates to developing

01:05:36.120 | or inhibiting sexual health?

01:05:38.120 | And here we're talking about the desire aspect.

01:05:40.120 | Let's assume physical arousal is handled.

01:05:44.120 | - No pun intended.

01:05:45.120 | - So I think that the thing about young people,

01:05:50.120 | I wanna get back to that, then I'll answer your question.

01:05:53.120 | But the thing about young people who are watching pornography,

01:05:55.120 | that's what they think sex is supposed to be like.

01:05:57.120 | They don't get an education about what sex is, right?

01:06:01.120 | No one has a conversation with their kids like,

01:06:03.120 | "Hey guys, this is what happens when you have sex.

01:06:06.120 | "This is how long it should take.

01:06:07.120 | "This is what foreplay is.

01:06:09.120 | "And this is like not normal.

01:06:11.120 | "This is a production.

01:06:12.120 | "This is a produced product that's meant to arouse you, right?

01:06:16.120 | "And to give you ideally an ejaculation or an orgasm, right?"

01:06:20.120 | So no one has that discussion.

01:06:22.120 | So then go to relationships like,

01:06:24.120 | "Why did my partner not react like that woman did

01:06:27.120 | "on the porno, right?

01:06:28.120 | "Or why did I not react like that woman did

01:06:30.120 | "on the porno, right?"

01:06:31.120 | - Or why didn't he react when, you know,

01:06:34.120 | like they would in porn?

01:06:36.120 | Because again, I think females are watching porn as well.

01:06:38.120 | - Exactly, yeah.

01:06:39.120 | - So I think that you raise a really critical point,

01:06:42.120 | which is that the shame can extend both ways.

01:06:44.120 | - And so I think to that end, that's a problem.

01:06:48.120 | And because it's so accessible,

01:06:50.120 | I think we need to have conversations.

01:06:52.120 | I think it needs to be open.

01:06:54.120 | We have to talk about sex.

01:06:55.120 | And that's kind of why I do what I do.

01:06:57.120 | We have to have these conversations

01:06:59.120 | so people know what normal is.

01:07:00.120 | - Thank you for that.

01:07:01.120 | I do think that people need to know what normal is

01:07:03.120 | and what the range on normal is.

01:07:04.120 | Keeping the constraints that we talked about place earlier,

01:07:07.120 | because I do think those are universal healthy constraints.

01:07:11.120 | Consensual, age appropriate, context appropriate,

01:07:13.120 | species appropriate.

01:07:14.120 | - Absolutely.

01:07:15.120 | - I'd like to take a quick break

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01:08:21.120 | I asked whether or not imagined

01:08:24.120 | the pure imagination-based arousal versus visual arousal.

01:08:30.120 | And for some people, the sounds of people having sex

01:08:33.120 | is extremely arousing.

01:08:35.120 | If you've ever lived in a major city like New York,

01:08:37.120 | which I've spent summers in New York,

01:08:39.120 | you hear more often than you do in areas

01:08:44.120 | where people are living further apart,

01:08:46.120 | you hear people having sex.

01:08:48.120 | It's part of the auditory landscape.

01:08:52.120 | - Yep, you're very close together.

01:08:54.120 | But yeah, so there's not exactly,

01:08:56.120 | at least to my knowledge,

01:08:57.120 | I don't know of the data that looks at fantasy

01:09:00.120 | versus visual versus auditory,

01:09:01.120 | but I will say that you can get habituated

01:09:04.120 | to certain things.

01:09:05.120 | And there is that data that maybe you can get habituated

01:09:08.120 | to watching a certain type of thing to get aroused

01:09:10.120 | and then normal things do not get you aroused, right?

01:09:13.120 | Like you may watch pornography

01:09:15.120 | and then you may have difficulty getting aroused

01:09:17.120 | or turned on when you see your partner.

01:09:20.120 | You may get used to masturbating a certain way, right?

01:09:23.120 | So if you use certain vibratory stimulation

01:09:26.120 | or certain pressure sensation every single time

01:09:28.120 | you masturbate, you can get habituated to that

01:09:31.120 | and you may not be able to replicate that

01:09:33.120 | during penetrative intercourse.

01:09:35.120 | And so I think that's really important

01:09:37.120 | and I think the take home is to try

01:09:39.120 | and vary what you're doing.

01:09:40.120 | Masturbation is find healthy way of self exploration.

01:09:43.120 | Again, with the caveat that as long as you're not

01:09:46.120 | masturbating to excess and avoiding your obligations

01:09:50.120 | or your family or your partners or your friends, right?

01:09:52.120 | Like you are just masturbating for the benefits

01:09:54.120 | of maybe sleep improvement, mood boosting,

01:09:57.120 | reduction in anxiety, those things are great.

01:10:01.120 | And so I think with that being said,

01:10:04.120 | you just want to be thoughtful about varying it up.

01:10:07.120 | - One of the issues with masturbation

01:10:08.120 | that I've talked about when I was a guest on other podcasts,

01:10:10.120 | mainly in the context of male masturbation

01:10:13.120 | and perhaps with pornography, perhaps not,

01:10:17.120 | is that it's pretty clear based on the data

01:10:21.120 | surrounding addiction that anytime there are big increases

01:10:26.120 | in dopamine without a lot of effort required

01:10:30.320 | to generate that dopamine, like turning on pornography

01:10:33.780 | on the internet versus asking someone out on a date,

01:10:37.680 | going out on a date.

01:10:39.120 | Again, we're talking about going through the conversations

01:10:41.640 | and the mating ritual that is the human mating ritual

01:10:44.200 | that of course in the context of healthy interactions

01:10:46.920 | involves getting mutual consent

01:10:49.100 | and these kinds of things, right?

01:10:50.800 | That you could imagine how,

01:10:54.160 | without placing any moral judgment on it,

01:10:57.000 | without shaming anybody, you could imagine

01:10:59.000 | that if somebody exclusively masturbated

01:11:02.680 | and didn't develop the skills of courtship

01:11:06.160 | and building healthy sexual relationships,

01:11:08.580 | that pornography and or masturbation

01:11:12.240 | could start to create quote unquote problems, right?

01:11:15.280 | Whereby somebody only felt comfortable in those domains.

01:11:18.680 | And I think that's what I'm hearing more and more about

01:11:22.420 | when it seems to be young men reach out.

01:11:25.200 | - Absolutely and I think you're,

01:11:27.240 | it's definitely the ease of access, right?

01:11:29.500 | But I think that's pervasive in the young society now.

01:11:33.240 | You don't have to actually go and find a mate.

01:11:36.040 | You can just go on an app and look for somebody, right?

01:11:38.440 | Like there's many- - Well, that's a form

01:11:39.800 | of finding a mate.

01:11:40.640 | I mean, I was weaned in the era

01:11:42.520 | when no smartphones or anything and-

01:11:46.000 | - No, my point is I think that we've become

01:11:48.760 | very connected to technology in our world,

01:11:52.300 | which also means that we're having less conversations.

01:11:55.080 | The younger generation is having less conversations

01:11:57.600 | and more online conversations.

01:11:59.520 | And I think that's a skill

01:12:00.440 | that needs to be developed as well.

01:12:01.760 | And I think part of that is contributing

01:12:03.620 | to all this as well.

01:12:05.000 | - Well, one thing that I can attest to is that,

01:12:06.820 | I grew up in a community of mostly male friends.

01:12:10.200 | I have, female friends always have,

01:12:12.460 | where a lot of what we learned about sex

01:12:14.100 | came from older, in my case, guys.

01:12:16.800 | My sister probably learned a lot about sex

01:12:18.320 | from her female friends.

01:12:19.720 | And there was always that one guy who would just say stuff

01:12:25.540 | that years later I realized was incredibly misleading, right?

01:12:29.200 | Maybe even just detrimental.

01:12:31.400 | And I just want to remind people that when you are on Reddit

01:12:34.240 | or anywhere on the internet

01:12:35.400 | and there's people saying things with certainty,

01:12:39.120 | they might be that guy, right?

01:12:42.400 | And if I look at the long arc of those people's,

01:12:47.400 | that guy's life, it didn't speak to tremendous success

01:12:52.640 | in the domain for which they were asserting such confidence.

01:12:55.780 | Let me put it that way.

01:12:57.060 | Okay, I'd like to slightly pivot

01:13:00.260 | to a different aspect of this conversation

01:13:02.660 | because it's just really critical,

01:13:04.180 | which is the female sexual response.

01:13:08.480 | This is something that does not get enough discussion.

01:13:13.240 | - Absolutely.

01:13:14.120 | - And there's a lot of stereotypes, right?

01:13:17.420 | The stereotype that we hear about is,

01:13:20.240 | oh, they need more foreplay, which can be true.

01:13:24.720 | Some cases is not true.

01:13:26.880 | The stereotype is that women are more intimacy

01:13:31.680 | and relationship based in their sexual response.

01:13:34.880 | That can be true.

01:13:36.760 | I have female friends and have known women

01:13:39.080 | who also are just really interested

01:13:41.160 | in having sex for sex sake at times, or maybe all the time.

01:13:45.340 | I like to think that we are past the stage

01:13:49.880 | of human development where the stereotypes

01:13:53.160 | around this are fixed, right?

01:13:57.360 | And we hear more about this and we see more about this now,

01:14:00.400 | but what is the real deal

01:14:03.000 | around the female arousal response?

01:14:06.200 | And then we will talk about female orgasm response.

01:14:09.620 | And there, I'm just going to earmark now

01:14:12.240 | that anytime we say something like arousal or orgasm,

01:14:17.040 | there are multiple forms of that, right?

01:14:20.660 | And we will talk about the multiple forms of female orgasm.

01:14:23.240 | - Yeah, so if you talk about the response cycle,

01:14:26.700 | you can go back to the research of Masters and Johnson.

01:14:29.240 | And so what they did, this was way back when,

01:14:31.160 | and they actually watched sex workers have sex.

01:14:34.480 | And this was, I guess, okay back then.

01:14:36.240 | - Female sex workers.

01:14:37.340 | - Yeah, with men, yeah.

01:14:38.360 | So they watched and they took note

01:14:40.840 | of the steps of the female arousal or sexual response.

01:14:45.320 | And so the first phase is excitement, right?

01:14:48.400 | And during that phase, your heart rate goes up,

01:14:51.460 | you're breathing a little heavier, there's the sex flush.

01:14:54.560 | You can see redness in areas like in the vulva,

01:14:57.800 | in the breast, I mean, in the nipples.

01:15:00.040 | And then you go to sort of,

01:15:01.480 | and that can last a variety of different times.

01:15:03.920 | You'll also start seeing some lubrication vaginally, right?

01:15:06.240 | And then the plateau response is when, you know,

01:15:09.800 | that is kind of at its peak and it kind of stays steady.

01:15:12.760 | And then you reach orgasm.

01:15:14.360 | And so orgasm essentially is a response of the body

01:15:18.520 | where you will have, again, increased sympathetic response,

01:15:21.560 | and you will have pelvic floor muscle contractions,

01:15:24.320 | which are rhythmic, about 0.8 seconds or so,

01:15:27.240 | you're having a rhythmic pelvic floor contraction,

01:15:30.080 | along with the sensation of orgasm.

01:15:32.540 | And then you'll have your recovery period,

01:15:34.500 | which you talked about briefly earlier,

01:15:35.960 | which can have, you know, sort of a refractory time period,

01:15:39.380 | at which point you can no longer, you know, orgasm again,

01:15:42.560 | if you'd like to, or for men to obtain another erection,

01:15:45.960 | again, for a short period of time.

01:15:47.440 | And that can be kind of an absolute refractory period,

01:15:49.840 | so where it's definitely not happening,

01:15:51.560 | and then a relative refractory period

01:15:53.320 | where you'd need something more novel and exciting

01:15:55.880 | to then, again, resume that cycle again.

01:15:58.360 | - The Coolidge Effect. - Yeah.

01:16:00.180 | - I've talked about the Coolidge Effect

01:16:01.400 | before on this podcast.

01:16:02.300 | I'll just cue people to a timestamp link

01:16:04.880 | in the show note caption so we don't go down the path.

01:16:06.960 | But one thing that's really important to understand

01:16:08.880 | is that the Coolidge Effect is present

01:16:10.400 | in both males and females,

01:16:11.920 | meaning if a male ejaculates and is of the feeling

01:16:16.920 | that they can't have another erection

01:16:19.320 | for some period of time,

01:16:20.280 | the presentation of a novel,

01:16:22.680 | I guess we should say partner,

01:16:23.840 | because we could be talking

01:16:24.680 | about homosexual relationship here, not just heterosexual,

01:16:27.040 | but a novel sexual partner, female or male,

01:16:29.780 | depending on their proclivities,

01:16:32.600 | can override the refractory period,

01:16:35.760 | and they can have another erection and ejaculation.

01:16:39.160 | Similarly, a female will have

01:16:41.360 | a post-orgasmic refractory period.

01:16:43.380 | If they're given an adequate stimulus, right,

01:16:47.240 | something arousing enough,

01:16:49.140 | they can experience arousal and orgasm again.

01:16:53.280 | And we know, based on really good pharmacology,

01:16:56.400 | that this is a dopamine-driven thing,

01:16:59.700 | the prolactin is essentially establishing

01:17:01.680 | the refractory period,

01:17:02.520 | and the dopamine is essentially overriding

01:17:04.960 | the refractory period.

01:17:05.940 | Fascinating neurochemistry there,

01:17:08.240 | and speaks to the incredible extent

01:17:10.560 | to which the brain is controlling the genitals.

01:17:14.000 | - Yeah, I mean, we always say in sexual medicine

01:17:16.320 | that the brain is the most powerful organ for sex.

01:17:18.520 | Not your genitals, but the brain,

01:17:20.360 | because it is so powerful.

01:17:22.040 | And I'm not sure if we're going to touch on this later,

01:17:23.440 | but I'll bring it up now.

01:17:24.320 | There are some centrally acting medications now available

01:17:28.080 | for, they're FDA-approved for premenopausal women

01:17:31.540 | with low libido.

01:17:32.540 | - Oh, well, maybe just throw those out,

01:17:33.860 | because the one that I'm aware of is in,

01:17:36.680 | that's often used in, let's say niche cultures,

01:17:40.700 | is melanocyte-stimulating hormone in men,

01:17:43.300 | which gives people a tan, makes them erect.

01:17:46.100 | The melanocyte-stimulating hormone at MSH

01:17:48.100 | comes from the medial pituitary, if I'm not mistaken,

01:17:51.980 | one of those weird regions.

01:17:53.680 | No, everyone talks about anterior posterior,

01:17:56.200 | but, and people are now injecting this

01:17:58.000 | as a peptide, it can cause priapism.

01:18:00.960 | I have not had that experience.

01:18:02.080 | I've never tried this MSH,

01:18:04.160 | but I've been told that people are getting cavalier with it.

01:18:07.840 | They can have issues.

01:18:09.480 | Priapism being enduring and perhaps even final erection.

01:18:14.160 | Is that true?

01:18:15.000 | - So a priapism, a priapism, I mean,

01:18:17.280 | it's actually from Priapis, the Greek god

01:18:19.660 | who's often photographed with a really big erection.

01:18:23.200 | - Oh, wow, we didn't hear enough

01:18:24.240 | about that Greek god in school.

01:18:26.240 | - But, or is it Roman, Roman or Greek?

01:18:28.560 | But anyway, so-- - Either way.

01:18:30.280 | - It's an erection that lasts longer than four hours,

01:18:32.560 | and it is actually a surgical, or it's not a surgical,

01:18:35.500 | but it's actually an emergency.

01:18:36.860 | If you have an erection that lasts longer than four hours

01:18:39.360 | in the absence of, you know, sexual arousal,

01:18:42.140 | then it is important to get to an emergency room

01:18:44.780 | because at that point, you can start developing

01:18:47.220 | decreased blood flow and ultimately changes

01:18:50.520 | to the actual tissues, scarring, fibrosis.

01:18:53.920 | So it's really important to actually go

01:18:55.240 | to the emergency room, don't wait 'cause you're embarrassed.

01:18:57.720 | Really get there and get treated.

01:18:59.240 | - However, if I'm not mistaken, earlier you mentioned

01:19:01.520 | that it is exceedingly rare that people who take Cialis

01:19:04.720 | slash Tadalafil or Viagra for erections

01:19:08.940 | are getting true priapism.

01:19:11.140 | - Correct, and it's mostly from those injectables

01:19:14.680 | we talked about earlier, those intracavranosal injections.

01:19:17.340 | People can get priapism from those

01:19:19.480 | a little bit more commonly,

01:19:20.720 | and so that's something we always counsel on.

01:19:22.360 | And also certain medications like Trazadone

01:19:25.860 | or if you have sickle cell anemia,

01:19:27.680 | those are the most common reasons

01:19:29.320 | that we see people coming in with priapism.

01:19:31.480 | - Trazadone, really.

01:19:32.320 | Okay, I'm gonna refrain from my desire to figure out that one

01:19:34.760 | so I don't take us down a rabbit hole here.

01:19:36.740 | - Sorry, I wanted to get back to the MSH.

01:19:38.800 | There is actually an FDA approved medication

01:19:41.000 | called bremelanotide is the brand name.

01:19:43.440 | Vilecy is the, sorry, bremelanotide is the generic name.

01:19:48.240 | Vilecy is the brand name, which is FDA approved

01:19:51.320 | for women with low desire,

01:19:54.640 | hypoactive sexual desire disorder, premenopausal women,

01:19:57.860 | premenopausal because that's what they studied,

01:20:00.120 | but it is basically the same peptide, right?

01:20:02.740 | So it is a melanocortin receptor agonist,

01:20:05.880 | and it works on the brain pathways to increase desire.

01:20:10.800 | It's taken as an injectable, again, just like you said,

01:20:14.220 | about an hour, 45 minutes before when you want to want,

01:20:17.540 | you take it 45 minutes before,

01:20:19.280 | and it works quite effectively in increasing desire.

01:20:22.600 | - How long does it last?

01:20:23.920 | - About 24 hours, some people maybe up to 48.

01:20:27.840 | - Has it been, I mean, I know of men

01:20:30.060 | using melanocyte stimulating hormone peptides.

01:20:33.080 | I also really want to caution people

01:20:35.480 | about obtaining gray market peptides.

01:20:37.240 | Sorry for this insertion here,

01:20:40.040 | but there are a lot of peptides available

01:20:42.380 | without a prescription on the internet.

01:20:43.880 | They are almost all contaminated

01:20:46.440 | with something called LPS, lipopolysaccharide,

01:20:48.760 | which is not something

01:20:49.600 | you want to be injecting a lot over time.

01:20:51.240 | That's actually how we induce an immune response

01:20:53.880 | in animals in the laboratory,

01:20:55.800 | and it is amazing to me how many websites

01:20:58.280 | are selling this stuff, and it arrives to you easily.

01:21:01.720 | You just buy it on the internet.

01:21:02.680 | It says not for human or animal use,

01:21:04.520 | some people are injecting it,

01:21:05.920 | and the LPS issue is something that I think

01:21:08.040 | is potentially going to shut down that whole market

01:21:10.480 | at some point, but if you're interested in using a peptide,

01:21:13.920 | you should be obtaining it by a prescription

01:21:15.460 | from a quality physician.

01:21:17.320 | - Exactly, and because we have bremelanotide,

01:21:19.760 | we can prescribe that for men as well.

01:21:22.180 | So sometimes we'll do it off-label

01:21:23.680 | for men who are having delayed ejaculation

01:21:25.960 | 'cause it will help them achieve orgasm

01:21:28.040 | a little bit better.

01:21:29.760 | And so this is available for premenopausal women.

01:21:33.060 | The other medication that's available for low libido

01:21:36.640 | is called Flibanserin, also known as Addy is the brand name,

01:21:39.900 | and that also works on serotonergic,

01:21:42.240 | it's got kind of a mixed response,

01:21:43.840 | serotonin and dopaminergic areas of the brain,

01:21:47.040 | and essentially works as a daily medication

01:21:50.000 | taken before bedtime, 100 milligrams a day,

01:21:53.480 | that actually helps with decreasing

01:21:55.880 | hypoactive sexual desire disorder.

01:21:57.680 | Works in about 45 to 60% of patients,

01:22:01.000 | and you need to take it for some time.

01:22:02.760 | Now, both of these are brand name medications,

01:22:05.280 | so they are a little bit costly,

01:22:07.000 | and sometimes insurance doesn't cover them,

01:22:08.840 | but they are available,

01:22:10.000 | and I think very few people know about them,

01:22:12.080 | and I think they're really great

01:22:13.160 | and useful tools in the toolbox.

01:22:14.880 | - And these are for desire.

01:22:16.520 | - They're for, yes, they're FDA approved

01:22:18.280 | for what we call hypoactive sexual desire disorder,

01:22:20.840 | which is essentially low libido

01:22:22.520 | that causes distress and bother.

01:22:25.040 | - I don't want to take us off course

01:22:26.560 | about vaginal lubrication, arousal, and female orgasm,

01:22:31.360 | but as long as we're talking about arousal

01:22:33.760 | and reduced arousal that requires treatment,

01:22:38.760 | I have to ask this now.

01:22:40.540 | Anytime we talk about arousal and libido, there's no BMI,

01:22:45.900 | which by the way, the body mass index

01:22:48.100 | is probably not the best tool either, but there's no chart.

01:22:52.200 | It's not like a thermometer that says you're 98.6

01:22:54.640 | plus or minus two degrees, you're good.

01:22:56.120 | If it's too high, much higher than that, you have a fever.

01:22:59.160 | If much lower than that, you're hypothermic.

01:23:01.400 | So my understanding, I don't want to say naive understanding,

01:23:06.000 | but my understanding is that one determines

01:23:11.040 | whether or not their libido is normal, high, or low,

01:23:16.040 | largely based on some intuitive understanding

01:23:20.040 | of what their partner or partner's desire,

01:23:23.060 | whether or not they can meet those desires.

01:23:25.260 | And if they sort of accrue enough of a sample size,

01:23:29.460 | they date enough people where they have sexual interactions,

01:23:31.580 | they figure out over time whether or not

01:23:34.620 | they have a low, medium, or high sex drive.

01:23:37.160 | And people tend to compare to how they felt

01:23:39.580 | in earlier years or at different times of the year

01:23:41.760 | or under different psychological conditions

01:23:43.340 | and stress conditions, that kind of thing.

01:23:45.160 | But we really don't have a benchmark for this, right?

01:23:47.180 | I mean, we can't say that, for instance,

01:23:49.480 | that if people are not desiring sex or thinking about sex

01:23:54.480 | with blank frequency, that they have low libido, right?

01:23:58.620 | It's sort of what is working or not working for you

01:24:02.100 | in the context of your life, right?

01:24:04.060 | Is that a reasonable way to think about it?

01:24:06.180 | - There's no right or wrong.

01:24:07.540 | Basically what you're saying,

01:24:08.400 | there's no right or wrong amount of libido.

01:24:10.380 | There's many people who identify as asexual

01:24:13.080 | and they are happy with that.

01:24:14.720 | There are people who like to have sex once a month

01:24:17.780 | and they're happy with that.

01:24:18.860 | It really is a matter of distress.

01:24:21.220 | Are you bothered by it?

01:24:22.680 | So when we look at studies for female sexual dysfunction,

01:24:25.300 | you can, using validated questionnaires like the FSFI,

01:24:29.360 | you can actually see that about 40% of people qualify

01:24:33.300 | for having sexual dysfunction,

01:24:35.420 | but really bother is only seen at about 12%.

01:24:38.720 | And you can be bothered because you're bothered,

01:24:41.740 | you can be bothered 'cause your partner is bothered,

01:24:43.660 | but it's really up to you, right?

01:24:45.200 | Like if you feel like there's something

01:24:47.400 | that you wanna improve on,

01:24:48.740 | then that's when you go see your doctor.

01:24:50.520 | But there's no right or wrong answer, right?

01:24:52.340 | This is very subjective and a lot of times we'll see couples

01:24:55.380 | who have mismatched libidos.

01:24:56.800 | Now, does that mean one person's right

01:24:58.220 | and one person is wrong?

01:24:59.360 | No, it's just a matter of like, well, how do you,

01:25:01.660 | if you wanna come to a point where you agree,

01:25:04.760 | how do we get there, you know?

01:25:06.160 | And what is your end goal?

01:25:08.100 | - Yeah, later we'll talk a little bit more about chemistry,

01:25:10.620 | which I find infinitely fascinating

01:25:12.220 | because in my life experience,

01:25:13.740 | I've just been struck by the fact that occasionally

01:25:17.380 | you have a physical interaction with someone

01:25:19.740 | or sometimes it's not even physical interaction

01:25:21.820 | and they are just so unbelievably arousing to you

01:25:25.640 | or somewhere in between or sometimes

01:25:27.860 | it just sort of ain't there

01:25:30.260 | or it's just not there that much

01:25:31.580 | or nobody likes to talk about this

01:25:33.560 | or it's there until you sleep together

01:25:36.060 | and then it's not there.

01:25:37.420 | And this is not just put on males, this is put on females.

01:25:41.120 | I hope she doesn't kill me for saying this.

01:25:44.580 | I know somebody who is a family member who once said,

01:25:48.700 | sometimes you have to realize you never wanna sleep

01:25:50.500 | with somebody again by sleeping with them.

01:25:52.560 | And here we're not talking about traumatic experience, right?

01:25:54.940 | So, you know, again, the discussion around libido,

01:25:58.260 | as you so aptly pointed out,

01:26:00.940 | engaging what is healthy levels of libido

01:26:02.940 | has a lot to do with what one's self desires

01:26:05.720 | as well as the hopes and expectations

01:26:08.280 | of the people that we are sexually involved with.

01:26:10.420 | So we'll get back to that a little bit later

01:26:11.760 | in the context of chemistry

01:26:12.720 | 'cause I find it so fascinating

01:26:14.160 | and it's something that isn't talked about enough.

01:26:16.800 | But thank you for that.

01:26:17.900 | Let's get back to female sexual arousal response and orgasm.

01:26:23.140 | - So physiologically, what happens to the body

01:26:26.480 | is it prepares for penetration.

01:26:28.980 | Now that could be a penis, that could be a sex toy,

01:26:31.240 | that could be a digit finger, to be more specific.

01:26:35.080 | So what it does is the cervix moves up and out of the way,

01:26:39.520 | the inner 1/3, 2/3 of the vagina lengthens and elongates

01:26:43.840 | to allow for penetration.

01:26:45.440 | And it can actually nearly double in size

01:26:47.680 | of the baseline vaginal length.

01:26:50.120 | And so it is preparing for that.

01:26:52.060 | So if you, and so that's part of it.

01:26:54.360 | In some people who have painful intercourse,

01:26:57.720 | it's because they haven't had adequate time for arousal.

01:27:00.400 | And so the penis is penetrating

01:27:02.700 | before they've had those adaptations to occur.

01:27:05.600 | And also the labia open up to allow for that penetration.

01:27:08.640 | So these things actually happen physiologically

01:27:10.760 | to allow for preparation.

01:27:11.960 | So while some people may be aroused

01:27:14.240 | and get to that point quicker,

01:27:15.320 | some people do need a longer period of time

01:27:18.440 | of, as you described, foreplay.

01:27:19.920 | And not everyone is the same,

01:27:21.300 | but I think it's important to have that discussion

01:27:23.480 | with your partner.

01:27:24.500 | And lubrication is one of the ways

01:27:27.140 | that people assess arousal,

01:27:28.900 | but that's not the be all end all.

01:27:30.540 | Some people just make a lot of lubrication

01:27:32.500 | and some people don't.

01:27:33.880 | And certainly that changes with age and hormones.

01:27:36.680 | So if, certainly we know that after menopause

01:27:39.720 | with a drop in estrogen and testosterone,

01:27:42.040 | you will see a decrease in lubrication.

01:27:45.320 | And sometimes if people are on medications

01:27:47.240 | that can alter their hormonal access,

01:27:49.160 | they may also see changes in lubrication

01:27:51.240 | after, during breastfeeding,

01:27:52.660 | you can see changes in lubrication.

01:27:54.180 | And again, this is not a, they're not aroused necessarily.

01:27:57.120 | This is like a physiologic problem that they're having.

01:27:59.460 | - Can we distinguish between arousal based lubrication,

01:28:02.900 | let's say sexual arousal based lubrication.

01:28:05.780 | And again, folks,

01:28:06.620 | forgive me for being so hyper specific in language,

01:28:08.620 | but there are other forms of arousal

01:28:10.340 | besides sexual arousal that we know from,

01:28:13.960 | it's not a pleasant topic from reports

01:28:16.960 | of following sexual assault,

01:28:18.760 | that oftentimes the victim is demonized

01:28:21.900 | for having been lubricated and they will say,

01:28:25.120 | well then people will presume that somehow

01:28:27.480 | they wanted that interaction.

01:28:28.840 | And that's not true in those cases.

01:28:31.280 | It's clear that those, that the lubrication occurred

01:28:35.320 | independent of libido type arousal.

01:28:37.980 | - Exactly. - Right, okay.

01:28:38.820 | So let's set that aside, again, unpleasant topic,

01:28:41.380 | but one that's important to flag.

01:28:44.880 | Are there forms of non libido type arousal lubrication

01:28:53.240 | that allow for non painful or even pleasureful penetration

01:28:58.240 | that are important to distinguish

01:29:02.320 | from the arousal based lubrication.

01:29:04.720 | In other words, I have to imagine that women will have sex

01:29:09.720 | and it can be pleasureful or at least not painful.

01:29:14.380 | And that might relate in some way

01:29:16.800 | to baseline levels of lubrication.

01:29:18.760 | And here we've been talking about lubrication

01:29:20.860 | mainly in the context of arousal.

01:29:22.680 | You know, post-menopausal reductions in lubrication,

01:29:24.840 | but are there also post-menopausal reductions

01:29:27.240 | in baseline lubrication?

01:29:28.600 | Are some people's vaginas just more lubricated at,

01:29:32.440 | I won't say at rest, it's like a scientist in me,

01:29:35.360 | when they're asleep, for instance.

01:29:37.400 | I mean, men are having erections in their sleep.

01:29:39.080 | Are women getting vaginal lubrications

01:29:40.600 | in their sleep periodically?

01:29:41.620 | My guess is yes.

01:29:42.580 | - Well, they're definitely getting clitoral engorgement,

01:29:45.580 | right, they're getting clitoral engorgement.

01:29:46.840 | There's been some studies on that,

01:29:47.940 | that they are also getting nocturnal tumescence, right,

01:29:50.560 | just like men do.

01:29:51.780 | As far as lubrication, you know,

01:29:53.920 | the data, at least from what I understand,

01:29:55.700 | is like there is a protective mechanism whereby women,

01:29:59.540 | when there's any sense that there may be penetration,

01:30:03.540 | that their body will immediately start creating lubrication.

01:30:06.300 | And that is protective to avoid trauma and injury.

01:30:10.880 | There's also baseline vaginal discharge.

01:30:13.100 | That's completely normal.

01:30:14.600 | Women will make physiologic discharge.

01:30:16.760 | In fact, in our examinations,

01:30:18.560 | when we examine women, we'll say normal physiologic discharge

01:30:21.160 | because we see it, there's always discharge.

01:30:23.860 | And it can be up to like five milliliters.

01:30:26.860 | And so it's not a small amount.

01:30:28.400 | It can happen, it can be quite a lot.

01:30:30.240 | - And it's menstrual cycle dependent

01:30:31.920 | in terms of the viscosity and the--

01:30:33.800 | - Yes, it changes over the cycle

01:30:35.720 | and it can be different in color and different in thickness.

01:30:38.320 | And that's completely normal.

01:30:39.720 | And I think that's a real problem

01:30:41.600 | in the feminine hygiene industry.

01:30:44.840 | You don't need to smell a certain way

01:30:47.680 | or reduce that discharge.

01:30:50.920 | This is like completely normal, healthy.

01:30:52.760 | And you talked about chemistry

01:30:54.120 | and I know there's like not a ton of data on this,

01:30:56.080 | but there's like pheromones, right?

01:30:57.080 | There's scents that are coming from you,

01:30:59.500 | which are actually attractive to a partner potentially.

01:31:02.800 | And in whatever physiologic,

01:31:05.200 | I don't know there's not a lot of data on this,

01:31:06.680 | but like there is that part of it.

01:31:08.560 | So there's a lot of marketing towards women

01:31:11.880 | that you're dirty, you should be smelling like peaches

01:31:15.080 | or whatever. - Really?

01:31:16.760 | - There's a lot of marketing.

01:31:18.160 | - Maybe this is a generational thing,

01:31:19.460 | but I learned early on,

01:31:20.960 | I think by behavioral neuroscience courses

01:31:23.280 | that vaginal lubrications were part of the arousal response

01:31:28.280 | for both, these were always framed in the context

01:31:32.400 | of heterosexual relationships, but both partners,

01:31:34.640 | let's just say both partners,

01:31:36.080 | because this could be a homosexual female relationship too.

01:31:38.720 | We want to make the conversation as broad as possible.

01:31:42.120 | And that the odor, let's just be frank here,

01:31:46.240 | the odor and the taste played a role in both arousal,

01:31:51.240 | but also the pair bonding response

01:31:53.140 | that would establish future arousal.

01:31:55.440 | And anyone that's ever been in a relationship

01:31:58.660 | that let's say had healthy sexual relations,

01:32:02.500 | I like to think his experience remembering somebody's smell

01:32:05.700 | or thinking about somebody's smell

01:32:06.800 | and that itself can be very arousing.

01:32:09.020 | Partners even, I'm smelling different articles

01:32:11.280 | of each other's clothing and that being arousing.

01:32:13.860 | So, I mean, this is the stuff of real physiology.

01:32:17.260 | We're not making this stuff up.

01:32:19.080 | - But there is, there is a lot of marketing towards women

01:32:22.160 | that they should use douching or other things

01:32:24.760 | to clean themselves and it's damaging, right?

01:32:28.120 | It's actually, one, it can affect the vaginal microbiome

01:32:31.380 | so their pH is changing and that can affect their risk

01:32:35.120 | for UTIs or bacterial vaginosis.

01:32:37.920 | And so they're buying these, spending their money

01:32:41.540 | on these things because they're being told

01:32:42.780 | that they're not clean and they come to the doctor saying,

01:32:44.880 | "Oh, I'm, you know, I think I have an STD,"

01:32:46.940 | but it's like normal physiologic discharge.

01:32:49.620 | And so I think it's important to say that this is normal

01:32:52.380 | and it's normal to have an odor that is distinct to you

01:32:55.880 | and that there's, you know, of course,

01:32:57.320 | if you have like a fishy odor, that may be a sign of,

01:32:59.740 | like a very strong new novel odor that wasn't there before,

01:33:03.580 | that may be a sign of a sexually transmitted infection,

01:33:05.940 | but if it's your general odor that you've always had,

01:33:08.500 | that's normal.

01:33:09.340 | - And what about other infections like yeast infections

01:33:11.580 | or bacterial infections of the,

01:33:13.620 | I got a number of questions about mycoplasma infections,

01:33:17.100 | which, you know, we don't hear that often about, but-

01:33:19.860 | - Yeah, so you can see if your discharge has changed

01:33:22.440 | and become more like cottage cheese-like

01:33:24.540 | or there's, you know, other symptoms like itching

01:33:29.180 | or discomfort, then, you know,

01:33:30.860 | those are signs to go get evaluated.

01:33:33.340 | Mycoplasma is another infection that we see in the vagina,

01:33:36.860 | but we also actually sometimes see in the urine.

01:33:39.580 | And while it's not something we routinely test for

01:33:42.260 | when we have people who have symptoms

01:33:43.980 | of urinary tract infection and they're not improving,

01:33:47.140 | sometimes we will check for mycoplasma

01:33:50.300 | that could be causing symptoms in the urethra itself.

01:33:53.620 | - We've had a couple episodes about the gut microbiome.

01:33:56.620 | My colleague, Justin Sonnenberg at Stanford,

01:33:59.020 | whose laboratory is directly above for mine,

01:34:00.540 | is expert in the gut microbiome,

01:34:02.220 | done a couple episodes about this.

01:34:03.580 | And he reminded me, and I like to remind people,

01:34:06.980 | that every mucosal lining of your body

01:34:10.100 | has a robust microbiome.

01:34:11.540 | So that means intranasal, intravaginal,

01:34:14.340 | intraurethral in males and females.

01:34:17.200 | There's an anal microbiome.

01:34:19.420 | There's a microbiome on your skin, on your eyes.

01:34:22.080 | And you mentioned douching and other ways of,

01:34:27.720 | I'm gonna say quote unquote cleaning it

01:34:29.040 | because that language falls in line

01:34:30.380 | with the idea that it's a good thing.

01:34:31.460 | You're telling me it's a bad thing in many cases

01:34:34.220 | because it's wiping out the microbiome.

01:34:36.820 | What are some of the things that females can do

01:34:39.720 | in order to promote the health of their vaginal microbiome?

01:34:43.760 | - So it's really, our bodies are amazing.

01:34:47.220 | The vagina is a self-cleaning oven.

01:34:49.380 | You don't have to do anything.

01:34:51.220 | You just wash- - I love that.

01:34:52.060 | The vagina is a self-cleaning oven.

01:34:54.440 | I'm not gonna repeat that too often

01:34:56.540 | in too many different contexts,

01:34:57.460 | but I'm gonna remember it forever.

01:34:58.700 | - You will, you will.

01:34:59.820 | And so all you need to do is wash the hair-bearing areas

01:35:03.700 | because those are the ones that create sweat

01:35:05.620 | and should be cleaned.

01:35:07.420 | But other than that, let soapy water run down.

01:35:09.580 | You don't need to do anything.

01:35:10.780 | Your body will take care of it itself.

01:35:12.980 | - When I was five years old,

01:35:13.900 | I pulled my parents in the bathroom and I said,

01:35:16.060 | they still talk about this.

01:35:16.900 | I said, "I wanna know everything about sex.

01:35:18.900 | I wanna know everything."

01:35:19.980 | And they were like, "Oh my God, what are we dealing with?"

01:35:21.940 | And I'll never forget, my dad just looked at me.

01:35:23.540 | He's Argentine and he said,

01:35:24.760 | "Just remember, kids are the one thing in life

01:35:27.020 | you can't give back."

01:35:28.940 | That's all he said.

01:35:29.900 | That was it. - That's it.

01:35:31.180 | - That was it. - Oh gosh.

01:35:32.980 | - Well, I will tell you my discussions with my sons are my son,

01:35:35.660 | my older son has been much more graphic than that.

01:35:38.340 | I tell him- - Amazing.

01:35:39.180 | - Yeah. - Amazing.

01:35:40.000 | Well, I went out into the world and anyway.

01:35:42.600 | - You figured it out. - Okay.

01:35:44.860 | Let's spend a few minutes or more

01:35:46.080 | talking about female orgasm.

01:35:47.740 | One of the more cryptic topics on the internet,

01:35:51.760 | not because it isn't discussed,

01:35:55.340 | but because I think that the nuance of it

01:35:58.020 | isn't discussed often enough or in full depth.

01:36:00.980 | So let's take the time we need to parse this.

01:36:03.520 | I think that the simplest way to parse it

01:36:07.040 | is going to be from the anatomical standpoint,

01:36:10.140 | clitoral orgasm versus so-called G-spot

01:36:13.420 | or penetration-based orgasm.

01:36:15.680 | But of course, penetration-based orgasm

01:36:17.660 | is also a bit of a misnomer

01:36:19.100 | because there can be a clitoral stimulation

01:36:23.520 | by pelvic pressure or by digit.

01:36:26.360 | We're talking about fingers as digits

01:36:27.700 | because we're both in the medical/science profession,

01:36:30.420 | but we're talking about fingers here

01:36:31.440 | or something else, right?

01:36:33.020 | Vibrator, toy, whatever.

01:36:34.300 | I'm toe for, it depends on how flexible you are.

01:36:36.280 | I don't know.

01:36:37.120 | But the point being that I think the simplest way

01:36:39.520 | to go about this is going to be to talk about

01:36:43.080 | the distinction between clitoral orgasm

01:36:45.460 | and G-spot orgasm, however those are achieved.

01:36:49.040 | And to also talk about this idea of graded versus absolute.

01:36:55.900 | Okay, so this has actual parallels to neuroscience

01:36:58.940 | where we talk about communication between neurons

01:37:00.780 | being graded, meaning it's kind of one level,

01:37:03.600 | then a higher level, then a lower level,

01:37:05.220 | or all or none, right?

01:37:08.020 | How should I say this?

01:37:09.540 | It is clear in my life experience and observation

01:37:12.020 | that there are multiple kinds of female orgasm.

01:37:14.640 | Those that are graded and in some cases cumulative,

01:37:18.500 | they sort of build towards a larger and larger orgasm.

01:37:22.180 | And then there are what some people have described

01:37:24.500 | as cliff-type orgasms where there's a refractory period.

01:37:27.940 | I think that's a fair way to frame this.

01:37:29.980 | And clearly there are different responses

01:37:32.060 | to the orgasm response.

01:37:33.560 | Some people get sleepy, some people get energized,

01:37:35.780 | some people, it heightens their desire for more.

01:37:38.680 | Some people, they need a period of time

01:37:41.960 | in which they become hypersensitive to touch.

01:37:45.700 | So lots of different things going on there,

01:37:49.660 | psychologically, physiologically.

01:37:51.580 | Yeah, tell us all of it.

01:37:54.660 | - So in terms of orgasm, right,

01:37:57.180 | I think it's important to distinguish

01:37:58.540 | that there is orgasm and then there's different areas

01:38:01.080 | that you stimulate to achieve orgasm.

01:38:03.340 | So some people will stimulate,

01:38:05.220 | the clitoris is probably the most reliable form

01:38:08.340 | of stimulation that will achieve orgasm.

01:38:10.940 | And when you look at the data,

01:38:12.180 | and again, female sexual dysfunction data

01:38:14.180 | is not super robust,

01:38:15.780 | but what we find is that about 85% of women

01:38:19.860 | require clitoral stimulation in order to climax.

01:38:23.220 | So very few actually climax through just

01:38:27.060 | vaginal penetration alone.

01:38:29.340 | And so this is a real problem we're seeing on the media

01:38:34.340 | that you have sex and you penetrate,

01:38:37.660 | and immediately women are having orgasms.

01:38:39.260 | That's not the reality for a lot of women.

01:38:41.740 | And in terms of stimulation,

01:38:43.980 | so like we've talked about throughout this podcast,

01:38:46.000 | the clitoris is the homolog of the penis

01:38:47.700 | or the penis is the homolog of the clitoris,

01:38:49.120 | however you wanna say it.

01:38:50.820 | - Good on you for getting it both directions.

01:38:52.780 | I probably would have screwed that one up.

01:38:55.120 | - So clitoral stimulation is just like

01:38:57.460 | female stimulation for women.

01:38:58.760 | That is very reliable.

01:38:59.980 | And there's a huge orgasm gap.

01:39:01.940 | For men, it's pretty consistent

01:39:03.660 | that when they have a first-time sexual encounter,

01:39:06.180 | 95% of men are having an orgasm.

01:39:08.620 | When you look at first-time sexual encounters

01:39:10.520 | for women in heterosexual relationships,

01:39:13.780 | it's about 45 to 50% are having an orgasm.

01:39:17.540 | And when you look at homosexual relationships of women,

01:39:20.700 | it's again, 90%.

01:39:22.300 | So there's clearly some lacking in-

01:39:25.600 | - 90% of female homosexual interactions

01:39:30.480 | that are first-time interactions,

01:39:31.700 | 90% are having orgasm.

01:39:33.420 | - Correct.

01:39:34.260 | - Presumably because they understand the anatomy of other

01:39:36.660 | by way of understanding the anatomy of self.

01:39:38.740 | - So there's a huge gap.

01:39:39.580 | - And physiology and psychology of-

01:39:41.180 | - Yeah, that too, that too.

01:39:42.820 | But you know, there's a huge gap there.

01:39:44.580 | And so I think to bring it home

01:39:47.220 | is that clitoral stimulation is the most reliable way.

01:39:49.440 | And as you mentioned, when you're stimulating vaginally,

01:39:51.980 | you're often, the clitoris is like a wishbone

01:39:54.420 | and it goes around the vagina.

01:39:56.060 | And so you're often stimulating those,

01:39:58.140 | the crura is what we call the legs, I guess,

01:40:00.740 | for lack of a better term, of the clitoris.

01:40:02.660 | And so you're stimulating that.

01:40:03.660 | You're also stimulating the clitoral shaft,

01:40:06.680 | which goes deep into the pelvis.

01:40:08.620 | The G-spot is an area, is an erogenous zone

01:40:13.060 | where it's kind of in the anterior wall of the vagina,

01:40:15.960 | about two to three centimeters in.

01:40:18.060 | That's the location of these periorhythral glands

01:40:20.700 | called the Skeen's glands.

01:40:22.340 | And they are analogous or homologous to the male prostate.

01:40:26.420 | So just like some men have prostate play

01:40:30.200 | and enjoy pleasure from prostate stimulation,

01:40:32.740 | some women enjoy G-spot stimulation.

01:40:36.100 | Now that's not universal, right?

01:40:37.340 | Not all men enjoy prostate play

01:40:39.060 | and not all women are gonna be aroused

01:40:40.780 | by G-spot stimulation.

01:40:42.860 | And so I think there's a huge variety of ways

01:40:47.560 | you can stimulate anyone.

01:40:49.500 | It can be man or woman.

01:40:50.860 | Some people will have orgasms

01:40:52.220 | through just nipple stimulation alone.

01:40:54.060 | Some will just hear something or see something

01:40:56.380 | and be able to achieve an orgasm.

01:40:58.060 | And it's so varied from person to person.

01:41:01.380 | And I think that the big take home from this

01:41:03.740 | for people listening is like,

01:41:04.900 | you have to talk to your partner.

01:41:06.700 | And this is the hardest thing.

01:41:07.540 | We never learned how to talk about sex.

01:41:09.900 | Like, what do you like?

01:41:11.220 | What do you not like?

01:41:12.460 | And don't take it personally, right?

01:41:14.780 | Like, I think a lot of times people feel like

01:41:17.340 | you have to orgasm to have pleasure,

01:41:19.500 | which may not be the case for everybody.

01:41:21.980 | And if it is, how do you prioritize that

01:41:24.780 | for your relationship?

01:41:25.740 | So I don't know if I got off track there,

01:41:27.260 | but that's kind of, I think, the take homes for this.

01:41:31.060 | And also the vaginal penetration,

01:41:32.980 | it's actually usually from cervical stimulation,

01:41:35.620 | not necessarily vaginal,

01:41:36.980 | because the large density of innervation of the vagina

01:41:39.660 | is in the first outer third of the vagina.

01:41:42.460 | The deeper two thirds of the vagina

01:41:44.100 | has much less innervation.

01:41:46.140 | And yet there is such a thing as cervical orgasm.

01:41:49.940 | So, and the cervix being further up the vaginal canal,

01:41:54.020 | is cervical orgasm specifically the stimulation,

01:41:59.020 | the foci of an orgasm that starts in the back of the vagina?

01:42:03.120 | Is that-

01:42:03.960 | - Yeah, so it's from stimulation of the cervix

01:42:06.300 | through whatever means, right?

01:42:07.900 | And that can be pleasurable and lead to orgasm.

01:42:11.180 | And again, orgasm is defined differently, right?

01:42:15.100 | But the one thing we know

01:42:16.220 | is that there are pelvic floor contractions,

01:42:18.420 | which are measurable.

01:42:19.260 | So you can kind of tell that your partner

01:42:21.220 | is having an orgasm if you have a female partner,

01:42:23.780 | because you can actually feel those contractions, right?

01:42:26.820 | Whether it's on your digit or your organ or a sex toy.

01:42:30.860 | - Okay, super nerdy question here.

01:42:33.260 | Years ago when I worked

01:42:34.160 | on hormone-based sexual differentiation,

01:42:36.020 | which by the way,

01:42:36.860 | we've done a episode of the podcast on previously,

01:42:41.860 | I learned that the levator ani muscle

01:42:45.140 | is the muscle that controls erection in males

01:42:49.020 | and presumably clitoral tumescence

01:42:51.540 | and an engorgement in females.

01:42:54.060 | Is there an equivalent muscle

01:42:55.280 | responsible for the orgasm response

01:42:57.940 | or is the contraction of the pelvic floor

01:43:01.060 | part of a more general theme of muscular contraction

01:43:04.120 | and a bunch of different nerve roots contracting?

01:43:06.980 | The reason I asked this

01:43:08.020 | is that eventually in this conversation,

01:43:09.380 | we're going to migrate up toward the brain,

01:43:11.620 | but because this is a science and health podcast,

01:43:14.780 | when we talk about orgasm,

01:43:16.620 | of course, many people recognize that

01:43:18.040 | as their experience of it

01:43:19.060 | and their recognition of it in other people

01:43:21.340 | and descriptions, et cetera.

01:43:23.940 | But are we talking about a response

01:43:27.140 | that originates at a foci,

01:43:30.460 | kind of like in the brain,

01:43:31.560 | we talk about a seizure,

01:43:33.360 | starting at a focus of foci and then spreading out,

01:43:36.120 | or are we talking about a bunch of different nerve roots

01:43:40.220 | and brain centers firing in synchrony

01:43:42.660 | and that's why some people experience it

01:43:44.620 | as behind their forehead and in their genitals

01:43:47.820 | or as a whole body response.

01:43:49.740 | And here, we're not talking about the flood

01:43:51.420 | of neurochemicals into the body,

01:43:53.180 | I'm talking about during those moments of orgasm,

01:43:56.900 | what is happening neurally?

01:43:58.580 | I mean, it does have certain parallels to seizure, right?

01:44:01.780 | - It does, it does.

01:44:02.660 | So let me go back to your first part of the question,

01:44:05.180 | which was about orgasm and, sorry,

01:44:08.980 | erection and tumescence being related to levator ani.

01:44:11.740 | So actually, what happens during,

01:44:14.500 | the reason you get an erection

01:44:15.700 | and presumably clitoral stimulation the same way

01:44:18.000 | is blood flows into the erectile tissue

01:44:21.060 | and the tunica, which is the outer layers

01:44:23.980 | of the erectile tissue,

01:44:26.580 | which are two basically cylindrical-shaped structures

01:44:29.300 | in the penis and in the clitoris,

01:44:31.280 | they will fill with blood

01:44:32.300 | and then that tunica will compress veins on the outside

01:44:35.220 | to prevent blood flow from leaving.

01:44:36.900 | So it's not a muscular event,

01:44:38.560 | it's an actual blood flow event.

01:44:40.380 | - Then how come when we wanted to study

01:44:42.340 | erection behavior in rodents?

01:44:44.900 | We would give them injections of testosterone,

01:44:49.460 | females or males,

01:44:50.900 | and observe changes in sexual behavior accordingly,

01:44:54.500 | erection and clitoral tumescence,

01:44:57.060 | although it's harder to measure in rodents,

01:44:59.260 | there's a way of indirectly measuring that,

01:45:01.220 | and then we would measure the size and weight

01:45:03.700 | of the levator ani muscles as a readout

01:45:07.160 | of how androgenized that whole system was.

01:45:10.340 | In other words, what is the role of the levator ani

01:45:13.460 | in the sexual response?

01:45:14.300 | - So the levator ani, well, I say levator ani--

01:45:16.740 | - Well, you would know, I think.

01:45:18.660 | - So those muscles are part of the pelvic floor, right?

01:45:21.780 | And so those contract when you climax, right?

01:45:26.520 | So whether it's orgasm for male or female,

01:45:28.500 | they're contracting and they're exercising, right?

01:45:30.900 | So that's how they would increase their strength

01:45:34.060 | or their density, if you're measuring that,

01:45:36.860 | through the actual climax of,

01:45:39.040 | which you can't see in rodents, right?

01:45:40.660 | So you're kind of using it as a surrogate in that way.

01:45:43.660 | So that's what happens.

01:45:44.500 | Those muscles contract as a response,

01:45:46.900 | and climax is a brain-initiated event.

01:45:49.240 | Orgasm is a brain-initiated event.

01:45:50.760 | So that's why, to answer your second part,

01:45:53.140 | you obviously feel focal response,

01:45:56.060 | but you also can feel a variety of responses

01:45:59.380 | 'cause it's all coming from the brain.

01:46:00.700 | It's not kind of the way you described it

01:46:04.300 | as like a ripple effect.

01:46:06.300 | It's more of like a,

01:46:07.840 | it's the way your body responds to that particular stimuli.

01:46:10.860 | And it's actually like the ultimate form of mindfulness.

01:46:13.960 | You can't think of anything else

01:46:15.540 | when you're orgasming, right?

01:46:16.800 | So it's like, you have this moment of clarity

01:46:18.700 | and everything, you were very present in that moment.

01:46:22.700 | And so people will feel different simulations

01:46:25.060 | depending on how their,

01:46:27.220 | how they kind of, how their nerves are,

01:46:29.900 | their sensations are, and things like that.

01:46:32.740 | - It's perhaps a good time to mention dopamine.

01:46:35.780 | We've talked about it a few times earlier

01:46:38.800 | when talking about the arousal arc

01:46:41.020 | that starts with parasympathetic, sort of calm,

01:46:43.380 | and then move, typically starts as calm,

01:46:46.320 | and then moves to the orgasm response.

01:46:51.320 | We know that the orgasm response

01:46:53.500 | is associated with release of dopamine and then prolactin,

01:46:57.860 | which sets up the relative or absolute refractory period.

01:47:01.900 | The interesting thing, and I got some questions about this,

01:47:06.460 | is that there's literature, as I understand,

01:47:09.740 | about the elevation in dopamine caused by say,

01:47:13.340 | antidepressants like wellbutrin, bupren,

01:47:15.580 | which increases dopamine and norepinephrine.

01:47:18.480 | People who recreationally use drugs like cocaine

01:47:23.100 | or other stimulants.

01:47:24.320 | People who take Adderall, Vyvanse,

01:47:28.660 | or other drugs that increase levels of dopamine,

01:47:32.180 | because I did a whole episode about those drugs

01:47:34.660 | and they are different forms of amphetamine,

01:47:36.460 | unless we're talking about Ritalin,

01:47:37.380 | which is a little bit different.

01:47:38.940 | And I got a lot of questions about people

01:47:42.820 | who experience feeling a lot of desire, sort of arousal,

01:47:47.120 | but not being able to achieve the physical arousal,

01:47:51.500 | erection or vaginal lubrication.

01:47:53.340 | So it's almost as if they're sitting further

01:47:55.340 | along that arousal arc.

01:47:57.140 | Hence the importance, I think, of people learning

01:48:00.020 | to have calm states of mind

01:48:04.720 | when going into sexual interactions.

01:48:06.880 | Now, I realize that in saying that it might be confusing

01:48:09.580 | because a lot of people think,

01:48:10.420 | well, that's anything but calm, right?

01:48:11.700 | Sexual arousal is anything but calm,

01:48:13.500 | but maintaining enough calm that they can ride that arc

01:48:17.300 | for whatever duration is appropriate

01:48:20.180 | for that interaction in them, right?

01:48:21.620 | 'Cause again, and we should probably get back to this,

01:48:25.920 | some people will have sex for long periods of time,

01:48:28.100 | some for shorter periods of time.

01:48:29.220 | And here, people don't really know

01:48:31.320 | what other people are doing,

01:48:32.220 | except by way of pornography and self-report and discussion.

01:48:35.680 | So is it the case that drugs that increase dopamine

01:48:40.680 | can inhibit the sexual response?

01:48:43.620 | Do they tend to promote the sexual response?

01:48:45.340 | Because I also mentioned earlier,

01:48:46.860 | there's this growing trend of people taking,

01:48:49.540 | by way of prescription, of course, from a physician,

01:48:52.260 | combined apomorphine, which is a dopaminergic drug

01:48:56.380 | with Tadalafil, which is a PD-5 inhibitor,

01:49:00.140 | so it's going to increase blood flow.

01:49:01.820 | And I'm hearing about men and women,

01:49:03.480 | but mainly men doing this.

01:49:04.800 | So ramping up their dopamine,

01:49:06.380 | ramping up their blood flow to their genitals

01:49:10.040 | in order to have presumably more arousal and sex.

01:49:12.840 | Does that make sense as a mechanism?

01:49:16.560 | - Yes, so in terms of apomorphine,

01:49:18.680 | that has been studied,

01:49:21.020 | and it's mostly been approved outside of the United States,

01:49:24.140 | so we don't use it very often here in the United States

01:49:26.420 | 'cause it hasn't been FDA-approved.

01:49:28.660 | But it's a very complex response.

01:49:30.660 | So like I mentioned that flibanserin,

01:49:33.300 | which is a centrally acting medication,

01:49:34.860 | it actually has not only inhibitory,

01:49:37.460 | and not only stimulatory,

01:49:38.740 | but also inhibitory effects on dopamine.

01:49:40.700 | So the way it sort of works to enhance interest, or libido,

01:49:45.700 | is sort of complex and kind of confusing.

01:49:48.500 | When it was actually approved,

01:49:50.180 | it was being studied for an antidepressant.

01:49:52.700 | And what they found was that women

01:49:54.420 | were actually having better interest in sex,

01:49:57.860 | or more interest in sex.

01:49:58.760 | And so that's kind of how it was discovered.

01:50:00.620 | Similarly, Viagra was actually studied

01:50:02.540 | for high blood pressure.

01:50:03.920 | And when they went to,

01:50:05.620 | it was horrible blood pressure medication,

01:50:08.300 | but then the men who took it

01:50:10.060 | actually didn't return the samples for the study.

01:50:12.260 | So they realized like, "Oh, what's going on here?"

01:50:13.900 | And it was because they were having better erections.

01:50:15.740 | - Is it true that at some urology meeting

01:50:19.660 | that the first description of Viagra

01:50:23.900 | as a treatment for erectile dysfunction

01:50:26.220 | involved the speaker actually coming out

01:50:27.860 | from behind the podium and revealing his erection?

01:50:30.380 | Is that a true story?

01:50:31.580 | - Yes, I don't think it was Viagra.

01:50:32.900 | I think it was an intracavrenosal injection though.

01:50:35.420 | I think he came out.

01:50:37.560 | It is a true story.

01:50:38.400 | There's actually a published article.

01:50:39.620 | I'll send it to you so you can share it if you'd like.

01:50:41.540 | There's a published- - I'm not sure I want to see it,

01:50:42.620 | but I'll read the article.

01:50:44.420 | - There's a published article about people

01:50:46.580 | who were attending at the meeting.

01:50:48.060 | And yes, he came out.

01:50:49.020 | And at the time, like it was mostly men in urology,

01:50:51.820 | but there were like spouses, I guess, in the audience,

01:50:54.040 | which is not typical now.

01:50:55.540 | But so there were women in the audience

01:50:57.820 | and he came out with a full-on erection

01:50:59.600 | to show that it worked.

01:51:01.980 | - Well, I suppose at the urology meeting

01:51:04.460 | or OBGYN meeting where a woman comes out

01:51:07.140 | and reveals her enhanced vaginal lubrication,

01:51:09.500 | then we will have gender and sex balance

01:51:13.060 | at the meetings on urology.

01:51:14.500 | It'll be interesting to attend one of those someday.

01:51:17.700 | So differences in arousal

01:51:21.460 | as a function of stage of the menstrual cycle.

01:51:24.380 | Really interested in this.

01:51:25.360 | I did a long episode on fertility

01:51:27.040 | and we're going to have a few other IVF experts,

01:51:30.100 | fertility experts on the podcast.

01:51:32.340 | But clearly there are differences in hormones

01:51:38.640 | across the menstrual cycle.

01:51:40.900 | We know that for sure.

01:51:42.000 | Clearly there can be psychological variation

01:51:47.020 | according to those hormones,

01:51:48.300 | but probably other things across the menstrual cycle.

01:51:50.100 | And it's always an imperfect experiment

01:51:51.700 | because we aren't laboratory rats

01:51:54.800 | and people are having different interactions

01:51:56.620 | across the menstrual cycle.

01:51:57.980 | Is there any known correlation between desire

01:52:02.980 | and stage of the menstrual cycle?

01:52:05.400 | There are some obvious assumptions that one might make,

01:52:08.060 | prior to ovulation, et cetera,

01:52:09.400 | around the time of ovulation.

01:52:10.860 | But what about the other direction too?

01:52:14.100 | Is there a category of women that are very interested

01:52:17.060 | in sex at certain stages of their menstrual cycle

01:52:18.860 | and then not at all interested in sex

01:52:20.660 | at other stages of the menstrual cycle?

01:52:22.580 | - All the data that I've heard,

01:52:24.860 | and maybe a gynecologist could speak more on this

01:52:27.220 | 'cause they studied those variations a little better,

01:52:29.200 | but there is data to suggest that libido does increase

01:52:32.740 | prior to ovulation and during ovulation.

01:52:35.860 | I think it's like a couple of days prior

01:52:37.820 | because that's the optimal time for fertility.

01:52:40.020 | So yes, there is data to suggest that

01:52:41.860 | in terms of like completely lack of interest,

01:52:46.380 | I don't believe there's data, but I'm not sure.

01:52:49.380 | - Is there evidence that females

01:52:50.420 | who perhaps have not experienced so-called G-spot orgasm

01:52:54.860 | or cervical orgasm can learn to do that?

01:52:57.700 | And I always find it interesting

01:52:59.860 | that whenever there's a discussion

01:53:01.800 | about different forms of female orgasm,

01:53:04.380 | people are careful to point out

01:53:06.540 | that many women don't have penetration-based orgasm

01:53:10.620 | and then they separate out clitoral stimulation

01:53:13.660 | as a more common route to orgasm.

01:53:17.520 | But of course, there can be clitoral stimulation

01:53:19.900 | with penetration. - Absolutely.

01:53:21.700 | - Right, and depending on the physical arrangement,

01:53:24.980 | there can be clitoral stimulation

01:53:26.360 | purely by way of penetration through pelvic contact,

01:53:30.420 | fingers, et cetera.

01:53:33.180 | So yeah, so how should we think about this?

01:53:35.900 | How should we talk about it?

01:53:36.940 | - So there was an interesting study

01:53:38.340 | that I just read recently

01:53:39.780 | where they gave women words for these things, right?

01:53:43.540 | So there's like the rocking stimulation,

01:53:47.320 | so that can also stimulate,

01:53:49.560 | so meaning that you're penetrating,

01:53:51.620 | but there's like a rocking motion

01:53:53.740 | that can also penetrate the clitoris.

01:53:55.400 | There's stimulation of just the outer part of the vagina,

01:53:59.200 | which again, as I mentioned, the G-spot is there.

01:54:01.180 | It's more highly innervated,

01:54:02.440 | so that can be more stimulating.

01:54:04.020 | There's also ways to align yourself

01:54:06.180 | so that when you're penetrating,

01:54:07.360 | you're putting pressure on the clitoris.

01:54:09.300 | And then there's stimulation with,

01:54:11.820 | like actual stimulation of the clitoris,

01:54:13.620 | like intentional stimulation

01:54:14.900 | either by yourself or by the partner.

01:54:16.380 | And so there are multiple different ways to do that, right?

01:54:19.460 | And so I think that it's important to really kind of,

01:54:24.180 | it's okay to explore and not always be a home run.

01:54:26.780 | And I think that's like when you get into a relationship

01:54:28.660 | where you're maybe second, third, fourth time

01:54:31.140 | having intercourse with someone

01:54:32.640 | that you can try and explore these different things,

01:54:35.080 | or if the partner themselves knows what they like

01:54:37.240 | to actually tell the other partner, right?

01:54:39.020 | There's a huge part of communication

01:54:40.620 | that I think plays a huge role in this

01:54:42.640 | because we know ourselves better than anyone else.

01:54:44.920 | So you can tell your partner what you like.

01:54:47.380 | And I think that we have never been taught how to do that.

01:54:50.280 | - Yeah, such important conversations for so many reasons.

01:54:55.020 | As you point out,

01:54:56.220 | definitely not something they teach people in school,

01:54:58.300 | except they might say something about,

01:55:00.860 | communication is important.

01:55:02.240 | And that almost always circles back

01:55:04.140 | to the key four things we talked about earlier,

01:55:06.740 | which is that consent and age appropriate,

01:55:09.700 | context appropriate, these kinds of things.

01:55:11.820 | And obviously substances like alcohol and other drugs

01:55:16.820 | can strongly confound those issues.

01:55:20.080 | And so we'll just leave that as a kind of an obvious one.

01:55:23.440 | As long as we're talking about communication

01:55:26.100 | around sexual interactions,

01:55:27.420 | perhaps it would be useful to people

01:55:29.940 | to cultivate a language or a nomenclature there too,

01:55:34.280 | to facilitate that.

01:55:36.020 | Some of the language that I've heard that is quite useful

01:55:40.420 | is things like, people have different arousal templates.

01:55:44.500 | Some people, certain ideas are stimulating to them

01:55:46.660 | and other ideas are aversive to them.

01:55:49.000 | And then there's this category in between

01:55:50.860 | where sometimes people sort of either don't know

01:55:53.020 | 'cause they haven't tried it or haven't thought about it,

01:55:55.340 | or they're sort of curious, but kind of unsure,

01:55:58.100 | or it might work in the right context,

01:55:59.860 | but maybe not all the time.

01:56:01.260 | So is there any kind of structure

01:56:04.740 | that's been put out there as a way to improve communication

01:56:09.700 | around sexual interactions?

01:56:11.380 | - Yeah, I mean, there's no like script,

01:56:13.180 | but I think in general,

01:56:14.620 | you wanna have the conversation outside of the bedroom.

01:56:16.760 | So not like right before sex or right after sex,

01:56:19.020 | because that leads to like a sense of insecurity

01:56:22.200 | for the other person, right?

01:56:23.100 | Did I do something wrong?

01:56:23.980 | Did something go wrong here?

01:56:25.340 | So you wanna kind of move those to a neutral location.

01:56:28.000 | So like kitchen table, in the car, whatever,

01:56:30.100 | somewhere where sex is not gonna happen,

01:56:33.100 | at least for that particular moment.

01:56:34.980 | And--

01:56:36.340 | - We have folks listening,

01:56:37.980 | some challenging conversations on this podcast,

01:56:41.620 | previously challenging because you're trying

01:56:43.820 | to get things clear and as clear as possible.

01:56:47.420 | This one's challenging because there's so many caveats

01:56:49.940 | to everything, right?

01:56:50.900 | We don't, of course, we love sex in cars, right?

01:56:54.360 | Or they did when I was growing up,

01:56:56.340 | and sometimes they still do.

01:56:57.740 | Okay, please continue.

01:56:59.620 | - Yes, so that's one.

01:57:01.340 | And then two, like when you're discussing it,

01:57:03.900 | I mean, this is kind of goes for any difficult conversation

01:57:06.500 | is like you make I statements, right?

01:57:08.400 | You say, I like it when this, I don't like it with this.

01:57:11.540 | It's not something you did, right?

01:57:12.860 | It's not you didn't do this, you didn't do that.

01:57:14.740 | It makes kind of an animosity sort of situation.

01:57:16.860 | And then, you know, I think also part of it

01:57:19.380 | is like being open about those things.

01:57:21.620 | And it may, it's not gonna happen in one conversation.

01:57:23.940 | I think that's the hard part.

01:57:24.820 | Like you think you're gonna have a conversation,

01:57:26.420 | it's gonna go great and things are gonna be better.

01:57:28.440 | It's gonna be like multiple conversations.

01:57:30.440 | And some of them are not gonna go well, right?

01:57:32.440 | So like, that's another place

01:57:34.520 | where you can actually get the help of a sex therapist.

01:57:36.740 | And there is a website for that.

01:57:38.180 | It's A-A-S-E-C-T, asex.org,

01:57:41.500 | where you can look for a sex therapist near you,

01:57:43.520 | and you can even do those things virtually.

01:57:45.900 | And so that can be really helpful

01:57:47.780 | when you're having difficulty having a conversation.

01:57:51.140 | - Yeah, I think, again, such important conversations.

01:57:54.440 | And then when people differ

01:57:56.700 | in terms of their level of experience,

01:57:58.420 | it gets potentially problematic,

01:58:00.980 | but also it can be potentially educational.

01:58:04.100 | And then of course, there are the twists and turns

01:58:07.580 | that occur with when one is asking

01:58:09.760 | about somebody else's arousal template,

01:58:11.900 | oftentimes you'll learn things about people's sexual past.

01:58:14.740 | And that can be either neutral, stimulating, or aversive,

01:58:18.740 | right, that can open up all sorts of other issues

01:58:20.680 | related to the psychological interplay.

01:58:22.540 | So there's no way we can parse all of those now.

01:58:24.820 | I just think it's worth highlighting

01:58:27.020 | that it's understandable

01:58:28.620 | why those conversations are challenging.

01:58:30.660 | And it also is understanding

01:58:33.500 | why pornography isn't going to involve those conversations.

01:58:37.060 | The only conversations there are between your brain,

01:58:38.820 | your hands, and your eyes, and your ears.

01:58:40.820 | Not going to highlight any particular order there.

01:58:44.700 | I want to switch gears slightly and talk about UTIs.

01:58:50.420 | I got a lot of questions about urinary tract infections.

01:58:53.460 | Let's make it related to both females and males,

01:58:57.180 | because yes, males get urinary tract infections,

01:58:59.540 | females get them.

01:59:00.540 | More females asked about urinary tract infections,

01:59:03.380 | how common are they?

01:59:04.560 | Should they always be treated with antibiotics?

01:59:06.700 | Is cranberry really a good treatment?

01:59:08.820 | If so, why are there other things that are better?

01:59:10.920 | Is it related to the acidity or alkalinity?

01:59:13.480 | How does one prevent getting UTIs?

01:59:17.940 | Can you get them from swimming?

01:59:19.460 | Should you urinate after sex?

01:59:22.580 | Tell us about UTIs and how not to get them

01:59:24.220 | and how to get rid of them.

01:59:25.380 | - Happy to.

01:59:26.220 | So UTIs are very common in women.

01:59:29.500 | Probably up to 50% of women get at least one UTI

01:59:32.720 | in their lifetime.

01:59:34.060 | And up to a third of them get recurrent UTIs.

01:59:37.300 | And what that means is they have two or more in six months

01:59:39.980 | or three or more in a year.

01:59:42.300 | Now, this is common, and so we'll see a lot of it.

01:59:45.500 | And it's not as, until you're having recurrent UTIs,

01:59:48.700 | say you just have one a year

01:59:49.900 | or you have one every few years, it's not a huge issue.

01:59:52.700 | In men, however, UTIs are much less common.

01:59:56.300 | And that's because the urethra is longer.

01:59:58.460 | So there's less entry from the outside world

02:00:01.540 | into the bladder, which causes infections.

02:00:03.820 | And so when men get a UTI, it's concerning.

02:00:07.900 | Like, why is a man getting a UTI?

02:00:10.220 | You know, there's multiple reasons that it could happen,

02:00:12.580 | but it should be investigated

02:00:14.600 | so that you can make sure there's no anatomic abnormality

02:00:17.540 | or functional abnormality

02:00:18.780 | with a bladder that's causing the UTIs.

02:00:21.660 | In terms of prevention, there are kind of major things

02:00:26.260 | that are highlighted in the guidelines

02:00:27.460 | that we all talk about.

02:00:29.380 | So one is hydration.

02:00:30.740 | So making sure you're drinking

02:00:32.100 | about two to three liters of fluid, ideally water a day,

02:00:35.500 | 'cause dilution is the solution to the pollution, right?

02:00:37.900 | So drinking more fluids is gonna get that bacteria

02:00:40.940 | and you're gonna pee it out.

02:00:41.860 | It's gonna help keep,

02:00:42.700 | not let it sit around in the bladder very often.

02:00:45.360 | Another thing in women who have altered states of estrogen,

02:00:49.680 | whether it's post-menopausal, surgical menopause,

02:00:53.380 | or maybe have reduced estrogen for postpartum

02:00:56.960 | or other reasons.

02:00:58.040 | - What about during the second half of the menstrual cycle?

02:01:00.480 | - Well, not necessarily for those specific people,

02:01:02.980 | but for those specific times,

02:01:04.440 | but 'cause it's pretty short-lived.

02:01:06.960 | I guess you could use it, but is vaginal estrogen.

02:01:10.440 | So vaginal estrogen,

02:01:12.020 | meaning estrogen that's applied in the vagina

02:01:14.000 | either through a cream, a suppository, or a ring

02:01:17.540 | is highly effective in reducing the occurrence

02:01:21.220 | of recurrent UTIs.

02:01:22.700 | And this is because when you have low estrogen,

02:01:26.980 | the pH in the vagina goes up.

02:01:29.060 | And the pH in the vagina goes up

02:01:30.480 | because there's less conversion of glycogen to lactobacilli.

02:01:34.260 | And then those lactobacilli are preventative for UTIs.

02:01:37.620 | So essentially you wanna reduce the pH

02:01:40.300 | back to its normal acidic pH.

02:01:42.500 | And vaginal estrogen is very effective at doing that.

02:01:45.100 | In fact, in our clinics,

02:01:46.140 | we'll actually check a vaginal pH

02:01:49.100 | to see if there is an indication

02:01:51.180 | that their pH is too high,

02:01:52.200 | that maybe they do need vaginal estrogen,

02:01:53.820 | particularly around the perimenopause,

02:01:55.300 | 'cause it's hard to tell just by looking

02:01:57.240 | if they are really heading

02:01:59.560 | into a lower estrogen state sometimes.

02:02:02.440 | And so that's very, very effective and very, very safe.

02:02:05.440 | So when you look at estrogen,

02:02:08.600 | the Women's Health Initiative way back when

02:02:10.980 | sort of made a big stink

02:02:12.820 | about how estrogen is related to cancer.

02:02:15.540 | However, vaginal estrogen

02:02:17.860 | has never ever been a reported breast cancer,

02:02:20.580 | uterine cancer, or any other blood clot,

02:02:23.380 | any other adverse event associated with vaginal estrogen.

02:02:26.100 | You can get some breast tenderness, some discharge.

02:02:28.900 | Those things can occur.

02:02:30.740 | But the absorbed amount vaginally is so little

02:02:34.460 | that your estrogen level barely goes up.

02:02:37.300 | It doesn't even reach premenopausal level.

02:02:39.780 | So it just goes up very slightly in the bloodstream,

02:02:42.340 | not enough to create any sort of abnormality.

02:02:44.920 | So vaginal estrogen is extremely safe,

02:02:47.500 | and it's pretty affordable.

02:02:48.840 | You could actually use coupons

02:02:50.200 | if your insurance doesn't cover it

02:02:52.020 | through GoodRx or Mark Cuban's pharmacy

02:02:54.900 | and get it very, very affordably.

02:02:56.380 | And it's very effective.

02:02:58.040 | It does take about three months to work.

02:03:00.340 | So you have to be consistent.

02:03:02.020 | You apply it about twice a week at night,

02:03:03.820 | sometimes three times a week.

02:03:05.820 | And it's very effective.

02:03:07.020 | The ring you put in once and it lasts for three months.

02:03:08.940 | But so generally speaking,

02:03:10.620 | that's the most effective option for low estrogen states.

02:03:14.820 | Other kind of simple things are trying to make sure

02:03:17.040 | you're completely emptying your bladder.

02:03:19.200 | So over a lifetime,

02:03:20.520 | people can develop some mild pelvic floor dysfunction.

02:03:23.220 | Not enough to create pain or discomfort,

02:03:25.120 | but maybe they're not emptying completely, right?

02:03:27.380 | Because maybe they used to hold their urine

02:03:29.200 | for long periods of time when they were a kid,

02:03:31.020 | or maybe they're always hovering over the toilet

02:03:32.820 | 'cause they don't wanna sit on it at work.

02:03:34.300 | And over time,

02:03:35.140 | that can create a little bit of mild dysfunction,

02:03:37.400 | which can make it more difficult to completely empty

02:03:39.820 | the bladder.

02:03:40.660 | And when urine is sitting in the bladder

02:03:42.380 | for long periods of time,

02:03:43.700 | it's basically food for bacteria to grow.

02:03:45.820 | And so bacteria grows and then you get recurrent UTI.

02:03:48.420 | So making sure you've completely empty by sitting,

02:03:50.860 | relaxing on the toilet, sometimes leaning forward,

02:03:53.740 | and then maybe going a second time.

02:03:55.320 | So standing up, sitting back down, going again.

02:03:57.260 | And even for men sometimes trying to sit

02:03:59.420 | and see if you completely empty,

02:04:00.900 | 'cause sometimes standing,

02:04:01.820 | you're not able to empty completely.

02:04:03.300 | - Whoa, a lot of men are gonna,

02:04:04.980 | because they're these,

02:04:06.740 | it was fun to research for this episode

02:04:08.380 | because there are entire discussions on Reddit

02:04:11.240 | about like what percentage of males sit while urinating.

02:04:14.460 | I mean, my understanding,

02:04:15.760 | based on having visited many male bathrooms in my lifetime

02:04:18.580 | and just being in the world that I assumed

02:04:23.420 | that men stood up in order to urinate,

02:04:25.420 | but there are a decent percentage of men

02:04:27.820 | that sit down to urinate.

02:04:28.800 | - There are.

02:04:29.640 | And in fact, it's variable by country.

02:04:31.320 | And probably the reason it's become more interesting lately

02:04:33.920 | is immediate. - By country.

02:04:35.060 | - So a certain country was recently surveyed.

02:04:38.060 | I think it was Germany,

02:04:39.820 | but essentially this recent, like picked up by the media,

02:04:42.420 | that Germans sit more often to pee.

02:04:44.740 | And so then people are like,

02:04:46.260 | "Oh, is this better for me to sit to pee or stand to pee?"

02:04:49.020 | And there's this whole big discussion on the media.

02:04:50.800 | But the reason being is when you're sitting,

02:04:53.300 | your pelvic floor is most relaxed.

02:04:55.140 | And so if you're having any issues emptying your bladder,

02:04:57.580 | you're gonna pee better.

02:04:59.460 | Also, if you have an enlarged prostate,

02:05:00.980 | which I'm sure we're gonna talk about prostate enlargement,

02:05:04.320 | that can sometimes allow you to develop

02:05:06.860 | a little bit more intra-abdominal pressure

02:05:08.760 | 'cause you're sitting and you can lean forward

02:05:10.580 | to overcome sort of a blockage.

02:05:13.380 | And so there are some indications where sitting is better,

02:05:18.380 | but if you're peeing fine and you're standing,

02:05:20.260 | that's fine too.

02:05:21.300 | I don't think you have to.

02:05:22.420 | I think it's just something that in other countries,

02:05:24.620 | they do more and here we don't.

02:05:26.160 | And I don't think it's right or wrong.

02:05:27.220 | It just depends on your individual circumstance.

02:05:30.040 | - Can spermicides or condoms or both increase

02:05:34.500 | the frequency of UTIs for females?

02:05:37.540 | - So spermicides, absolutely.

02:05:38.980 | So spermicides, if your condom has spermicide on it

02:05:41.240 | or you're using spermicides,

02:05:42.440 | that is a known risk factor for UTIs.

02:05:45.780 | Other things I wanna touch on,

02:05:46.940 | you did ask about cranberry.

02:05:48.200 | So cranberry is actually

02:05:49.200 | in the American Urological Association guidelines

02:05:51.940 | for prevention of recurrent UTIs in women.

02:05:54.880 | Now, how does cranberry work, right?

02:05:56.620 | Like, do I just drink juice?

02:05:58.180 | It's actually a specific active ingredient in the cranberry,

02:06:01.700 | which is called proanthocyanidins or PACs.

02:06:05.260 | And they've actually looked at the amount of PACs you need

02:06:08.680 | and what formulation.

02:06:09.820 | So you need 36 milligrams of PACs in a soluble form.

02:06:14.100 | So a lot of the supplements on the market

02:06:15.900 | will say that they're 36 milligrams of PACs,

02:06:18.380 | but they're like the whole berry.

02:06:19.760 | So they're using the skin of the berry

02:06:22.180 | and the stem of the berry, and that's not gonna help you.

02:06:24.340 | So you need to make sure that the supplement you're using

02:06:26.940 | is a soluble form of the cranberry.

02:06:28.980 | And it's actually very, very effective

02:06:31.140 | at reducing the risk of UTIs.

02:06:33.340 | - So do you mean capsules, like a gel cap?

02:06:37.060 | - Yeah, it's a capsule that you take once a day.

02:06:40.040 | And there is some, although not as much data

02:06:42.140 | that if you're having them around sex,

02:06:43.740 | which some women do always have post-coital UTIs,

02:06:47.860 | that you can take two on the day of sex

02:06:49.820 | and two on the day after, and that may be helpful.

02:06:52.220 | But there's not a lot of data there,

02:06:53.820 | but certainly an option that you can try

02:06:55.460 | that's pretty low risk.

02:06:57.840 | So that's kind of the guidelines.

02:06:59.900 | Now there's a ton of other things that you can do

02:07:02.540 | to help prevent that are kind of available

02:07:05.140 | and have some data behind them.

02:07:06.660 | So D-Manos is one of them, where you take, you know,

02:07:09.740 | about two grams a day of D-Manos and you drink it,

02:07:12.460 | and that actually helps reduce UTI risk.

02:07:15.240 | It's been studied in a small, randomized,

02:07:16.980 | controlled trial to be effective.

02:07:18.940 | And so those are kind of the bigger ones.

02:07:21.500 | There's other things that people use, like probiotics,

02:07:24.020 | but there's a lot of heterogeneity, as you know,

02:07:26.500 | in probiotics and what to take,

02:07:28.220 | and are they really effective vaginally

02:07:30.740 | in the flora there.

02:07:32.260 | So those are kind of the big things.

02:07:33.940 | And there is actually a lot of microbiome study

02:07:36.980 | and UTIs going on, actually, at UCLA,

02:07:39.260 | where they're looking at the microbiome

02:07:41.860 | of people who are more at risk for UTIs

02:07:44.420 | or even overactive bladder, other conditions like that,

02:07:46.660 | and they're trying to figure out, like,

02:07:47.800 | is there something here that we can target

02:07:49.940 | or that we can figure out is causing problems?

02:07:52.300 | Because sometimes we just can't figure out

02:07:54.020 | why it's happening.

02:07:55.800 | In terms of wiping from front to back

02:07:58.500 | and swimming and peeing after sex,

02:08:01.420 | there's no good data on any of those things.

02:08:04.100 | Wiping from front to back,

02:08:05.280 | I think it does create a little bit of, like, shame.

02:08:07.620 | Like, it's not a big deal if you wipe back to front,

02:08:10.200 | as long as you're not, like, you know,

02:08:11.460 | as long as you've, like, cleaned yourself, so to speak.

02:08:13.520 | So I think it's less of an issue.

02:08:15.820 | - But what we're talking about is you're referring

02:08:17.480 | to any contamination from any bacteria around the anus.

02:08:20.980 | - Correct, yes.

02:08:21.820 | And a lot of women who have recurrent UTIs,

02:08:24.500 | like, tend to come and feel very dirty.

02:08:26.440 | Like, there's something wrong with them.

02:08:27.280 | They're like, oh, I wash all the time.

02:08:29.040 | I'm really clean.

02:08:29.880 | I'm really this.

02:08:30.700 | And, you know, it's not something they're doing.

02:08:32.380 | It's probably a microbiome effect or a hormonal effect,

02:08:35.900 | or, you know, there's something going on

02:08:37.520 | that we need to investigate further.

02:08:38.900 | It could also be an anatomical or functional problem

02:08:41.380 | where you're not emptying the bladder correctly.

02:08:42.860 | So there's lots of different factors it could be,

02:08:45.220 | and it's, like, very infrequent.

02:08:47.940 | I would say, like, I've never seen a patient who's dirty,

02:08:50.780 | and that's the reason they're getting UTIs.

02:08:53.500 | - Perhaps even the opposite is true.

02:08:55.220 | They're cleaning too much,

02:08:56.180 | based on what you told us earlier,

02:08:57.700 | and they're eliminating the gut micro, excuse me,

02:09:00.780 | just rolls off the tongue.

02:09:02.340 | Again, no pun intended.

02:09:03.540 | Perhaps it's, they are abolishing the local microbiome

02:09:08.220 | on the skin.

02:09:09.040 | Too much cleaning eliminates the microbiome on the skin.

02:09:11.840 | Not that we don't want to wash,

02:09:13.140 | but when Sonnenberg was a guest on this podcast,

02:09:16.100 | he said actually kids can develop a very healthy gut

02:09:18.780 | microbiome and general microbiome oftentimes by,

02:09:22.700 | sorry, parents, not washing their hands before eating

02:09:25.260 | if they've been playing with soil outside or dirt.

02:09:27.780 | A little bit of that is actually healthy.

02:09:29.220 | Pets actually offer microbiome support.

02:09:31.860 | This is so weird.

02:09:32.680 | I know it sounds kind of dirty,

02:09:34.540 | but we have to imagine how we evolved as a species

02:09:36.860 | was not with antibacterial soaps

02:09:38.760 | and alcohol swabs everywhere.

02:09:41.740 | And obviously we don't want infections,

02:09:44.020 | but over cleaning can disrupt the microbiome,

02:09:46.580 | which presumably can lead to UTIs.

02:09:48.660 | So perhaps someone who's cleaning excessively

02:09:51.460 | is more at risk than somebody who's cleaning a little less.

02:09:54.260 | - Absolutely.

02:09:55.100 | And actually the cleaning can irritate the dermis, right?

02:09:58.420 | So you can actually get contact dermatitis type symptoms

02:10:01.100 | from over cleaning.

02:10:02.000 | And so that's one of the things we're like,

02:10:03.780 | I definitely have a UTI, I definitely have one.

02:10:05.900 | Well, no, you don't,

02:10:06.780 | but there's a host of other things that it could be.

02:10:09.280 | One of them could be that.

02:10:10.620 | Another very common one that we already touched on

02:10:12.660 | is pelvic floor dysfunction.

02:10:13.980 | So very often pelvic floor dysfunction,

02:10:15.820 | just like you had pain with urination,

02:10:17.780 | women can also develop pain with urination

02:10:20.000 | that doesn't go away.

02:10:20.900 | And it can start where they had a UTI

02:10:23.320 | that triggered the pelvic floor

02:10:25.140 | and then the pelvic floor just didn't relax,

02:10:26.900 | where the pain just triggered the pelvic floor to tense up.

02:10:29.340 | It didn't relax because again,

02:10:30.780 | we're not taught how to relax our pelvic floor.

02:10:33.240 | And then they've developed pelvic floor dysfunction.

02:10:35.620 | Like why is the UTI not going away?

02:10:37.080 | Or why does it keep coming back?

02:10:38.660 | And so that's another common thing that we see

02:10:41.960 | in people who have quote unquote recurrent UTIs,

02:10:44.460 | but don't really have them.

02:10:45.780 | To be clear, I experienced the pain and urination

02:10:47.900 | as a consequence of trying those damn kegels

02:10:49.900 | that everyone was talking about.

02:10:50.980 | Stopping that was informative in two directions.

02:10:55.300 | One, it relieved the pain very quickly.

02:10:57.280 | So that was good.

02:10:58.180 | The other was, I realized that it is possible

02:11:01.820 | to have a pelvic floor that's neither hyper contracted

02:11:05.020 | nor over relaxed, and in some cases,

02:11:07.220 | just not doing anything for it is the best circumstance.

02:11:10.720 | Right, so, and the only reason I mentioned that

02:11:13.140 | is because obviously this discussion

02:11:15.740 | is not about my pelvic floor.

02:11:17.240 | This discussion is about the fact that

02:11:19.340 | some people perhaps need to clean less.

02:11:22.660 | Some people may be more,

02:11:24.260 | but probably not based on what you said.

02:11:25.880 | Some people might need to strengthen their pelvic floor.

02:11:27.720 | Some people might need to relax their pelvic floor.

02:11:30.380 | And some people's pelvic floor is probably A-okay.

02:11:33.020 | You know, I think any discussion about anything medical

02:11:36.420 | or, you know, especially hormone stuff,

02:11:38.160 | this happens a lot in the discussions around

02:11:41.420 | that I get into, it seems, with males.

02:11:44.220 | They're like, every male now seems to wonder

02:11:46.220 | if their testosterone is too low,

02:11:48.300 | except the ones that are blasting testosterone

02:11:50.060 | 'cause they know it's excessively high.

02:11:52.460 | And as you pointed out earlier,

02:11:54.580 | at least in terms of sexual function,

02:11:55.860 | that's unlikely to be the case.

02:11:58.100 | Maybe less desire, but in terms of

02:12:02.220 | genital-based arousal function, probably to do.

02:12:04.780 | - Yeah, and I mean, you've talked about testosterone

02:12:06.300 | a lot on the podcast, so I'm sure your audience

02:12:08.240 | knows very well the multitude of benefits for testosterone.

02:12:11.280 | So I think there is value in assessing hormone panels

02:12:15.600 | and assessing your level of free testosterone and testosterone

02:12:18.020 | and, you know, assessing if you're having symptoms

02:12:20.280 | that are not always sexual, right?

02:12:21.760 | It can be depression, it can be weight gain,

02:12:23.780 | that you're not gaining muscle mass,

02:12:26.420 | you can have cognitive changes.

02:12:28.100 | So those things can still be a sign of low testosterone

02:12:31.100 | and very valuable and important to assess.

02:12:33.420 | - That reminds me of another thing,

02:12:34.680 | and then we'll get back to UTIs

02:12:36.680 | and I want to talk about kidney stones.

02:12:37.980 | But I've heard of women using a small amount

02:12:41.920 | of testosterone cream directly on the clitoris

02:12:45.320 | as a way to amplify the,

02:12:48.320 | maybe it's the desire and arousal effect,

02:12:51.320 | or perhaps just one or the other.

02:12:53.480 | - So the way that we discuss testosterone use,

02:12:57.000 | and there are like consensus statements,

02:12:58.720 | and there's actually an abundance of data on testosterone use

02:13:02.240 | particularly in post-menopausal women for low libido

02:13:04.640 | or low sexual desire, and it's all been very positive.

02:13:07.860 | And since there's been increased sexual desire

02:13:10.560 | based on validated questionnaires,

02:13:12.240 | increased number of sexually satisfying events

02:13:14.940 | with testosterone use.

02:13:16.320 | Now the range of testosterone in women

02:13:18.400 | is about a 10th of the amount of testosterone a man needs.

02:13:22.720 | So testosterone cream is systemically absorbed

02:13:26.080 | wherever you apply it.

02:13:27.280 | And so the way we generally recommend women to try this,

02:13:30.640 | if they are having low libido

02:13:32.120 | and we've ruled out other issues

02:13:33.920 | that may be psychologic, you know, relationship,

02:13:36.760 | other issues that can affect libido medications,

02:13:38.980 | there's a lot of things obviously that go into that.

02:13:41.400 | But if we say, and we've checked their testosterone,

02:13:43.520 | it appears to be low for physiologic levels for women,

02:13:46.880 | which again is 1/10 of the male level,

02:13:49.360 | then we can actually prescribe off-label testosterone.

02:13:53.020 | And the guidelines, or the consensus statements,

02:13:55.200 | they're not like true guidelines,

02:13:56.180 | but they recommend using transdermal testosterone.

02:13:59.720 | So getting, you know, androgel tubes from the pharmacy

02:14:03.160 | and putting a 10th of one tube on the back of the calf

02:14:07.240 | or the upper outer buttock, a hairless area for absorption

02:14:11.700 | that can improve desire overall.

02:14:14.040 | And then the other place we use testosterone

02:14:16.560 | is in women who have what we call vestibulodynia.

02:14:19.520 | So the vestibule is the area outside the vagina,

02:14:23.140 | which is very hormonally active.

02:14:24.800 | There's lots of androgen receptors there.

02:14:27.100 | And it can actually, when you have hormonal issues,

02:14:30.320 | meaning lower testosterone and estrogen in that area,

02:14:33.560 | it can cause pain.

02:14:34.840 | And so actually applying a combined

02:14:37.200 | or compounded estrogen testosterone cream to that area

02:14:40.560 | over time can reduce that pain and discomfort.

02:14:44.280 | So as you know, testosterone receptors

02:14:46.240 | or androgen receptors all over the body,

02:14:48.400 | very much in the genitals, very much in the brain,

02:14:50.320 | and they're a very useful place

02:14:53.300 | to treat women for those issues.

02:14:55.740 | - Thank you.

02:14:57.600 | - Kidney stones, I hope to never have one.

02:15:00.560 | - I hope you don't either.

02:15:01.400 | - But people get them.

02:15:02.320 | How do you avoid getting them

02:15:04.480 | and how do you get rid of them?

02:15:06.200 | - So kidney stones very often are,

02:15:10.960 | they can be for a variety

02:15:12.920 | of different metabolic disorders, right?

02:15:14.920 | So it can be, one, dehydration is a very common cause of it.

02:15:18.660 | So dehydration combined

02:15:21.120 | with maybe a slight metabolic abnormality

02:15:23.200 | where you're creating more calcium or oxalate in your urine

02:15:26.880 | can result in kidney stones.

02:15:30.020 | And so how can you prevent them?

02:15:31.940 | I mean, each person is individual.

02:15:33.720 | If you get a kidney stone,

02:15:34.920 | typically we do what's called a 24-hour urine analysis

02:15:38.080 | plus some blood work to assess

02:15:39.960 | what is the metabolic abnormality

02:15:41.760 | so we can target that either with diet or with medication.

02:15:45.920 | And so the kind of general recommendations

02:15:49.000 | for people who have kidney stones,

02:15:50.680 | one is increase your fluid intake to two to three liters.

02:15:53.660 | Again, the same number I told you before.

02:15:56.160 | You wanna decrease your oxalate intake.

02:15:58.320 | Now, if you Google oxalate,

02:15:59.440 | you're gonna find a million things that you eat

02:16:02.000 | that have oxalate in them,

02:16:03.140 | but the big ones are spinach and rhubarb.

02:16:05.880 | We're seeing a lot of nuts too

02:16:07.220 | that are people eating a lot more nuts to get more protein.

02:16:10.160 | So cutting back,

02:16:11.600 | it's impossible to get rid of all of that in your diet,

02:16:14.000 | but if you're having like a spinach salad every day,

02:16:15.920 | well, switch it to a different green, right?

02:16:17.840 | Don't eat spinach every day.

02:16:19.840 | Also, you wanna increase your citrate intake.

02:16:22.200 | That's an inhibitor of kidney stone formation.

02:16:24.680 | So increasing fruits and things like that

02:16:27.400 | to increase citrate vegetables as well.

02:16:29.520 | Actually, one easily accessible thing is crystal light.

02:16:32.880 | It has a high citrate composition,

02:16:35.520 | so you can drink crystal light with that two to three liters

02:16:37.700 | and that can be helpful.

02:16:39.820 | You wanna decrease your protein intake.

02:16:42.220 | So high levels of purines or purigenic meats

02:16:46.360 | like red meats and things can also put you at higher risk.

02:16:49.440 | So these are kind of the general sort of

02:16:52.000 | preventative measures we talk about for kidney stones

02:16:55.640 | if you have a kidney stone.

02:16:57.600 | So a lot of times people can have kidney stones

02:16:59.720 | in their kidneys, they're not creating any problems,

02:17:01.540 | they're tiny, we can observe them over time.

02:17:04.720 | If they start coming, if they start getting very large

02:17:07.520 | or they are starting to move into the ureters

02:17:10.440 | or the tubes that drain the kidney,

02:17:12.280 | oftentimes they're accompanied with pain,

02:17:14.840 | quite a bit of pain and it can be very uncomfortable.

02:17:18.800 | In those cases, if they're not having any infection symptoms

02:17:22.880 | and there's no signs of a urinary tract infection,

02:17:25.920 | there's no fevers, no chills,

02:17:27.600 | we can treat it conservatively with pain medication

02:17:30.920 | and also there are medications like Flomax

02:17:33.760 | which we use for enlarged prostate as well

02:17:36.040 | that actually relaxes the ureteral smooth muscle

02:17:38.720 | to allow the stone to pass a little bit better.

02:17:42.220 | If you're having an infection,

02:17:43.600 | you gotta get it treated right away.

02:17:45.040 | You can get very sick very quickly.

02:17:47.480 | In fact, I've seen young, healthy patients,

02:17:50.400 | like they're healthier than me,

02:17:51.860 | walk in the ER with a kidney stone

02:17:53.660 | and within 24 hours they're in the ICU

02:17:56.160 | 'cause they're really sick because of a kidney stone.

02:17:58.320 | - So fever, urinating, tea-colored urine,

02:18:01.860 | so meaning blood in the urine,

02:18:03.680 | all of those are important warning signs

02:18:05.420 | that you ideally don't get to.

02:18:06.960 | - Yeah, blood in the urine,

02:18:07.920 | I mean, it doesn't always mean infection,

02:18:09.160 | it could just be irritation from the stone,

02:18:10.840 | but certainly fevers, chills,

02:18:12.800 | or you have a sign of an infection

02:18:14.400 | and the stone looks like it's blocking,

02:18:16.000 | so if you get imaging and you see what's called

02:18:17.640 | hydro nephrosis or pressure behind the kidney

02:18:20.540 | and you have these signs of infection,

02:18:22.720 | we don't wanna wait

02:18:23.540 | because you can get sick pretty quickly.

02:18:25.540 | And then to treat the kidney stones,

02:18:28.640 | there's three major options.

02:18:30.160 | One is shock waves, another is ureteroscopy

02:18:33.320 | where we go in with a camera and we have a small laser,

02:18:35.520 | we break it up into small pieces and take it out.

02:18:37.800 | - Where is the camera inserted?

02:18:39.160 | Through the urethra?

02:18:40.000 | - Correct, you're asleep under anesthesia

02:18:41.960 | so you don't have to--

02:18:43.000 | - You saw that, you saw the wince.

02:18:46.320 | - And then percutaneous nephrolithotomy,

02:18:49.120 | which is done if you have a large kidney stone

02:18:51.920 | or a very hard kidney stone that's up in the kidney,

02:18:54.360 | you can go in through the back with a small,

02:18:56.920 | like a small incision and with a specialized camera

02:19:00.440 | that goes in and uses ultrasonic lithotripsy

02:19:03.160 | to break up that stone and kind of suck it out that way.

02:19:06.360 | - These are extremely helpful bits of information,

02:19:10.480 | or not even bits, this is an enormous amount

02:19:13.160 | of useful information.

02:19:15.080 | I'd like to pivot again for sake of breadth.

02:19:19.000 | We can't go into extreme depth on everything,

02:19:21.640 | but appreciate your willingness

02:19:23.720 | to follow this carousel with me.

02:19:25.780 | Oral contraception.

02:19:28.960 | Previously on this podcast,

02:19:30.320 | I hosted a female physician guest

02:19:33.800 | who offered both sides of female oral contraception,

02:19:38.880 | discussed some of the benefits, discussed some of the risks.

02:19:42.560 | I made the decision to post clips about both

02:19:45.660 | on the internet and wow, wow, wow,

02:19:49.760 | was I surprised, but also frankly a bit shocked

02:19:54.760 | and then finally intrigued by how polarized

02:20:01.560 | the discussion is around female oral contraception

02:20:05.840 | and female contraception in general.

02:20:08.160 | So NuvaRing, Norplant, The Pill,

02:20:13.160 | broad category of things there,

02:20:14.760 | but for sake of discussion, The Pill, et cetera.

02:20:18.260 | I mean, it seemed that approximately 50% of responses,

02:20:21.720 | which seemed to come mainly from women,

02:20:24.360 | were of the, this stuff is terrible.

02:20:27.760 | It ruined my life.

02:20:29.040 | It ruins lives.

02:20:30.440 | It destroys you.

02:20:31.880 | It has immense risk.

02:20:34.780 | And then the other half seemed to say, no,

02:20:38.300 | there's reduced risk of certain forms of cervical cancer.

02:20:41.840 | This has allowed me the sexual choices and lifestyle

02:20:47.020 | that I prefer without risk of pregnancy.

02:20:49.400 | I mean, it was astonishing to the point where I thought,

02:20:53.480 | wow, if only I could post both clips simultaneously.

02:20:56.120 | So obviously I don't know what the answer is,

02:21:00.720 | but I do know that this is among the more polarizing topics

02:21:04.620 | available for discussion.

02:21:06.080 | So what is the story?

02:21:09.420 | Meaning, what are the data about oral contraception?

02:21:12.160 | Why so much controversy and what's the real deal here?

02:21:16.200 | - Yes, so it is a very polarizing topic

02:21:19.120 | and there is abundance data, abundant data.

02:21:22.280 | In fact, we even did a study, and again,

02:21:23.940 | this is not like high quality evidence,

02:21:27.120 | but we looked at Reddit threads

02:21:28.860 | and we looked at sexual dysfunction,

02:21:30.380 | specifically low libido, orgasmic difficulties.

02:21:33.360 | And we read hundreds of threads

02:21:35.400 | and we did a qualitative analysis to see, in females,

02:21:38.540 | to see what are people talking about.

02:21:41.280 | And problems with oral contraceptives

02:21:44.120 | and antidepressants leading to low libido

02:21:47.760 | and being very, as you described,

02:21:50.000 | very like this has ruined my life, was very common.

02:21:53.600 | And so the theory is that taking oral contraceptives

02:21:57.620 | increases the amount of sex hormone binding globulin,

02:22:01.480 | which binds testosterone and estrogen.

02:22:04.480 | And that actually makes testosterone less available,

02:22:07.160 | which is, as we've talked about,

02:22:08.520 | a very important hormone for desire.

02:22:10.840 | And so in some subset of people,

02:22:13.760 | they're seeing very significant consequences

02:22:17.480 | of taking oral contraceptives.

02:22:19.340 | Now, I think that there is, you know,

02:22:22.160 | we don't know which women are gonna have this problem

02:22:24.560 | and we don't know how.

02:22:25.400 | It's probably a very small subset of people,

02:22:27.700 | but we do know that this does happen

02:22:30.080 | in that when you measure SHBG levels, they're up,

02:22:32.840 | and that even after they stop the oral contraceptives,

02:22:35.720 | you'll see elevated SHBG levels from baseline.

02:22:38.920 | - For how long?

02:22:40.120 | - You know, for like at least four months afterwards,

02:22:42.240 | you'll still see elevated SHBG levels.

02:22:44.120 | So we don't know. - But not infinite.

02:22:46.360 | - We don't know.

02:22:47.520 | - Yeah, the endocrine system is weird

02:22:49.000 | because we assume everything has a short-term effect,

02:22:52.760 | but there's some plasticity in the system,

02:22:54.960 | especially 'cause it's a neuroendocrine system.

02:22:56.600 | - Exactly, yeah. - So, yeah, okay.

02:22:58.040 | - So I think, yeah, there's some neuroplasticity there

02:22:59.920 | that occurs as well, and so we do see this,

02:23:02.920 | and I think that the other side of it is,

02:23:05.000 | yeah, absolutely, oral contraceptives are amazing, right?

02:23:07.320 | They're helpful for sexual freedom,

02:23:09.400 | for preventing pregnancy, for a lot of things,

02:23:13.780 | and particularly other conditions too, like PCOS,

02:23:16.280 | and other problems, oral contraceptives are amazing,

02:23:18.880 | and they've changed gynecology and management

02:23:22.240 | of these women in a very positive way.

02:23:25.880 | And so I think, you know, yes,

02:23:27.440 | I do think that there is oral contraceptive-related

02:23:31.560 | sexual dysfunction, usually low-dose estrogen

02:23:35.560 | sort of contraceptives are the culprit,

02:23:38.280 | but, you know, I think that it's, again,

02:23:41.480 | the data, female sexual dysfunction literature

02:23:43.400 | is just not as robust as male sexual dysfunction literature.

02:23:46.920 | - I saw a lot of comments about how oral contraception

02:23:49.280 | had led to depressive-like symptoms,

02:23:52.760 | or just kind of ahedonia and apathy,

02:23:56.360 | not just lower libido.

02:23:58.120 | I can imagine how that would be the case

02:23:59.680 | through the elevated sex hormone binding globulin,

02:24:02.800 | which is, you know, preventing testosterone and estrogen

02:24:05.880 | from being free, literally, and exerting their effects

02:24:10.880 | on not just the body, but the brain.

02:24:13.080 | But is there any evidence that oral contraception

02:24:15.440 | can disrupt, you know, transmitters?

02:24:17.320 | I'm not aware of any.

02:24:18.400 | - I don't think so, not to my knowledge.

02:24:20.240 | - Okay, well, it sounds to me like oral contraception

02:24:26.160 | for women, 'cause that's where we normally hear about it,

02:24:29.320 | it sounds like there's a varied response

02:24:31.640 | and it's highly individual.

02:24:33.040 | I certainly had partners that loved the pill,

02:24:35.320 | or at least didn't seem to mind it.

02:24:36.460 | I've had some that hated it and like,

02:24:39.240 | it's like, no way, tried that, never will.

02:24:41.940 | Or, you know, just went with other forms of contraception,

02:24:45.180 | or for whatever reason, we're not using contraception.

02:24:47.400 | So it seems to me that there's a lot of variation out there.

02:24:51.820 | How does one explore that without risk of permanent damage?

02:24:55.680 | It sounds like truly permanent damage is unlikely.

02:24:58.560 | You know, what are the other options?

02:25:01.540 | You know, is the ring copper IUD?

02:25:05.420 | - So any sort of long acting hormonal contraceptive,

02:25:09.860 | we've seen, that's what we counsel patients on,

02:25:12.940 | is if they're having issues with oral contraceptives,

02:25:15.400 | even if they come in with pelvic pain

02:25:16.780 | and they're on oral contraceptives,

02:25:18.040 | I'll tell them, you know what, just stop,

02:25:19.420 | because maybe the effect on the androgen receptors

02:25:23.380 | or estrogen receptors is affecting, you know,

02:25:25.360 | the lubrication or other things, we're not sure,

02:25:27.880 | but you know, why don't you stop

02:25:28.960 | and go get a long acting contraceptive method?

02:25:31.560 | - Like an IUD? - Like an IUD.

02:25:33.060 | - And are IUDs safe?

02:25:35.700 | And here we should probably say,

02:25:36.920 | okay, copper IUD is one form.

02:25:38.980 | You want to mention a few of the other forms of IUDs?

02:25:40.300 | - So I don't prescribe IUDs,

02:25:42.100 | but generally speaking, they're very safe.

02:25:44.100 | Of course there's risk with any sort of, you know,

02:25:46.380 | it's a procedure, you're inserting an IUD.

02:25:48.700 | So there's obviously some small risks associated with it,

02:25:51.180 | but it is safe and effective form of contraception.

02:25:54.660 | - If people are wondering why the copper IUD

02:25:56.960 | is an effective form of contraception,

02:25:59.540 | copper is like the third rail for sperm, as I understand it.

02:26:04.540 | So much so that I was able to find some evidence

02:26:07.460 | for this in the medical textbooks that in the old days,

02:26:11.500 | as I say, prostitutes who wanted to avoid pregnancy

02:26:15.860 | would put copper pennies in their vagina.

02:26:18.900 | Now I don't recommend that to anyone, and please,

02:26:23.020 | and I don't think it's a foolproof form of contraception,

02:26:28.020 | but there is evidence that that did happen.

02:26:30.860 | So, which is amazing.

02:26:31.860 | That means that people somehow figured out

02:26:34.300 | the copper sperm relationship,

02:26:36.440 | which isn't a good one for the sperm,

02:26:38.000 | and deduced from that a behavior.

02:26:40.220 | - Yeah, that's- - I mean, that's cringing.

02:26:42.460 | I am not suggesting people do that.

02:26:44.820 | I think it's just an interesting medical factoid.

02:26:47.220 | I can tell you want to move on from this topic.

02:26:51.100 | So we will.

02:26:52.740 | Before discussing prostate and anal sex,

02:26:57.380 | not stated next to one another for any particular reason,

02:27:01.580 | I want to talk about SSRIs.

02:27:04.300 | A lot of people over the last 20, 30 years

02:27:06.780 | have been prescribed selective serotonin reuptake inhibitors

02:27:10.540 | and other antidepressants that have disrupted

02:27:15.180 | their sexual function or their sexual desire,

02:27:18.540 | it seems in particular.

02:27:19.640 | Do you see a lot of this in your clinic?

02:27:22.860 | Do you hear about it?

02:27:24.060 | What can people do about it?

02:27:25.680 | Oftentimes these sexual arousal or dysfunction issues

02:27:31.600 | associated with SSRIs and other medications

02:27:34.480 | make those medications prohibitive for people.

02:27:37.700 | So serotonin is kind of the anti to orgasm.

02:27:42.420 | And so in fact, we will use SSRIs off-label

02:27:45.800 | for people who are having premature ejaculation.

02:27:48.380 | So it delays ejaculation.

02:27:50.220 | And then there's also other sexual dysfunctions

02:27:52.100 | we see with it.

02:27:53.300 | And it does happen, absolutely.

02:27:54.340 | It's dose dependent.

02:27:55.420 | So in some cases,

02:27:57.500 | when someone comes in with SSRI related dysfunction,

02:28:00.540 | if they're doing well,

02:28:02.040 | you can either try to reduce the dose

02:28:04.340 | or switch them to another antidepressant,

02:28:07.700 | for example, Wellbutrin,

02:28:08.920 | that does not have such severe effects on sexual function.

02:28:12.740 | And so you can also use like Cialis and Viagra,

02:28:17.460 | what we've talked about for erectile dysfunction

02:28:18.900 | as an addition,

02:28:19.740 | if we can't change their medication management,

02:28:22.140 | because, you know,

02:28:23.100 | and this gets a little bit complicated

02:28:25.020 | because we know erectile dysfunction and depression

02:28:27.460 | are very interrelated.

02:28:28.860 | Now what's causing what and where do we,

02:28:32.220 | like maybe somebody went to see their doctor for depression,

02:28:35.860 | but was also having issues with erections.

02:28:37.540 | And now what do you, if you fix the erections,

02:28:39.440 | do you help with the depression?

02:28:40.780 | Like what, you know what I mean?

02:28:41.780 | So I think- - Males everywhere

02:28:42.660 | are shouting yes. (laughs)

02:28:44.420 | - So I think, you know,

02:28:45.380 | I think that there's a lot of discussion

02:28:46.980 | that has to be had there.

02:28:47.820 | It's a lot easier to talk to your primary care doctor

02:28:50.780 | about depression than it is about your erections.

02:28:53.060 | And so I think it's important to like really dig into that

02:28:55.580 | a little bit, but yes,

02:28:57.380 | it is definitely a known thing.

02:28:59.180 | We use it to our advantage when needed.

02:29:01.540 | And it can be helpful to switch medications

02:29:05.580 | or reduce the dose.

02:29:07.180 | - You mentioned earlier that trazodone

02:29:09.020 | can cause sustained erection.

02:29:11.940 | And is trazodone in the category

02:29:14.460 | of touching the serotonin transmission system?

02:29:17.620 | - You know, I don't remember the mechanism,

02:29:19.860 | but interestingly, trazodone is also used for off-label,

02:29:23.200 | like as a third or fourth line

02:29:24.660 | for premature ejaculation as well.

02:29:26.900 | So I don't remember the mechanism off-hand.

02:29:31.220 | - Let's talk about prostate and prostate health.

02:29:35.380 | Earlier, I queued up that there's a growing trend toward,

02:29:40.380 | I would say more progressive male physicians

02:29:44.920 | or physicians who treat males, excuse me.

02:29:47.020 | - Thanks for that.

02:29:48.900 | - Yeah. (laughs)

02:29:51.020 | Prescribing low dose, 2.5 to five milligram Cialis,

02:29:54.380 | which is to dalafil, which may assist with erections,

02:29:57.240 | but the rationale for this low dose, daily low dose,

02:30:01.760 | is not centered around erections per se.

02:30:03.880 | It's really about prostate health,

02:30:06.580 | improving blood flow to the prostate, reducing prostitis,

02:30:10.100 | maybe even reducing the probability of prostate cancer.

02:30:13.460 | What other sorts of things are you encouraging men

02:30:18.140 | to think about when thinking about their prostate?

02:30:21.160 | - Yeah, so before I forget,

02:30:23.880 | I want to mention that low dose to dalafil

02:30:26.060 | is actually a treatment for erectile dysfunction.

02:30:28.100 | In fact, it works quite well,

02:30:30.200 | particularly in men who are having

02:30:31.280 | a lot of psychogenic issues.

02:30:32.800 | One, because they don't have to remember

02:30:34.080 | to take a pill before sex.

02:30:35.840 | It's always on board.

02:30:37.420 | And you're taking five milligrams every day,

02:30:39.980 | and it has a 36 hour half-life,

02:30:42.140 | so you're kind of increasing those,

02:30:43.980 | so it can actually work quite well,

02:30:45.980 | and is a great option for erectile dysfunction.

02:30:48.220 | So I do want to make that caveat.

02:30:50.420 | In terms of prostate health,

02:30:52.260 | it has been shown to be effective for BPH,

02:30:54.820 | or enlarged prostate.

02:30:56.100 | And this is a very common condition.

02:30:57.980 | In fact, if you look at autopsy studies,

02:31:00.420 | 80% of men at 80 have an enlarged prostate.

02:31:03.380 | Like, it's very, very common.

02:31:04.940 | Now, does everyone get symptoms,

02:31:06.660 | and what's the long-term concerns of it,

02:31:08.620 | and what can you do about it?

02:31:10.340 | So typically, as the prostate enlarges,

02:31:13.340 | it's right around the urethra.

02:31:14.500 | It's a walnut-shaped gland,

02:31:15.700 | sits underneath the bladder around the urethra,

02:31:18.020 | and it can narrow the urethra, or the P-tube.

02:31:20.780 | And so, over time, you can imagine,

02:31:23.060 | like if you're, I always give this example,

02:31:25.220 | if you're sucking from a straw, right,

02:31:26.580 | you're drinking from a straw,

02:31:27.740 | if you have a wide-diameter straw,

02:31:29.820 | it's really easy to drink.

02:31:30.980 | If your straw gets really narrow,

02:31:32.340 | like say you take a coffee straw,

02:31:33.700 | and you drink out of that,

02:31:34.740 | it's very difficult to drink.

02:31:36.500 | Very similarly, it can become very difficult to urinate

02:31:40.260 | if you have an enlarged prostate.

02:31:42.360 | Now, what causes an enlarged prostate?

02:31:44.440 | There's a whole host of factors.

02:31:46.060 | A lot of them are genetic,

02:31:47.140 | so if your father or your grandfather had a large prostate,

02:31:50.220 | you're probably more likely to have an enlarged prostate.

02:31:53.700 | Do we know exactly how to prevent that?

02:31:57.180 | Not exactly, but we know how to mediate

02:31:59.420 | the symptoms a little bit.

02:32:00.540 | So, the other symptoms you'll see

02:32:02.340 | before you have difficulty urinating

02:32:04.260 | is sometimes you'll see overactivity.

02:32:06.700 | So, you'll see your bladder's responding

02:32:09.520 | to having to push hard against that narrow urethra

02:32:12.300 | to push urine out.

02:32:13.260 | So, it's having more urgency,

02:32:14.920 | like the sudden desire to go to the bathroom

02:32:16.740 | that you can't delay.

02:32:18.020 | You're maybe going more frequently,

02:32:19.780 | and very often, you're going more often at night.

02:32:22.700 | And so, those are kind of the first signs people will see.

02:32:25.260 | And then over time, it may become more and more difficult

02:32:27.940 | to empty the bladder.

02:32:28.860 | You might see some hesitancy,

02:32:30.480 | like you're waiting for your stream to start,

02:32:32.620 | or it stops and starts.

02:32:34.900 | And so, those, you know, or you're just like,

02:32:36.700 | I can't empty, like it's not,

02:32:38.060 | 'cause it drips or a very weak stream.

02:32:40.220 | And so, those are kind of the things

02:32:42.060 | that can happen over a lifetime.

02:32:43.760 | Now, what are some things that you can do to help?

02:32:47.180 | You know, Cialis helps relax the fiber,

02:32:50.380 | the smooth muscle of the prostate,

02:32:51.540 | so that it allows urine to pass more easily.

02:32:54.260 | There's also other medications

02:32:55.620 | that you can treat very often.

02:32:56.920 | Flomax or other alpha blockers are helpful in that area.

02:33:01.820 | In terms of like things that you can do in general

02:33:04.100 | for bladder health, prostate health,

02:33:05.920 | there are certain things that are irritants to that area.

02:33:08.660 | And so, what I tell people,

02:33:10.100 | not everyone's affected the same way.

02:33:12.180 | So, I don't want people to be like,

02:33:13.380 | oh, I gotta stop all these delicious things I eat and drink,

02:33:16.820 | but certainly it can be useful to just pay attention.

02:33:19.380 | So like, if you say you drink coffee every day

02:33:22.980 | and you find yourself running to the bathroom a lot,

02:33:24.940 | if you limit your caffeine intake,

02:33:27.340 | you might see that you're not going to the bathroom

02:33:28.860 | quite as often because caffeine is a bladder irritant.

02:33:31.740 | So, that can be coffee, tea, chocolate, you know,

02:33:34.420 | things of that nature that have caffeine in them,

02:33:37.140 | energy drinks, sometimes people forget

02:33:38.420 | they have caffeine in them.

02:33:39.760 | And so, limiting that may improve your symptoms.

02:33:43.860 | Alcohol also is a bladder irritant.

02:33:46.020 | And these have actually been studied in animal models

02:33:48.260 | and you'll see that the bladder contracts more often

02:33:51.480 | when they're given these sorts of substances.

02:33:54.320 | And it's dose dependent.

02:33:55.540 | And some people can actually habituate

02:33:57.260 | or get used to a certain dose of caffeine.

02:33:59.900 | So, if you're drinking coffee every day,

02:34:01.460 | you may have less symptoms than someone who drinks it

02:34:03.620 | every once in a while.

02:34:05.620 | Other things can be sometimes carbonated beverages,

02:34:09.540 | spicy foods or acidic foods,

02:34:11.940 | those sorts of things can also irritate the bladder lining.

02:34:14.100 | So, sometimes limiting those things may be helpful

02:34:17.180 | in those situations.

02:34:18.960 | - Thank you so much.

02:34:19.980 | That's very informative.

02:34:22.040 | Years ago, there was a discussion about bicycle seats

02:34:26.060 | causing damage to the prostate,

02:34:27.660 | maybe even sexual dysfunction.

02:34:29.260 | Is that still a thing?

02:34:32.140 | I thought they put grooves into the seats,

02:34:35.420 | but I've also in reading on the internet,

02:34:38.820 | I didn't do a deep dive on Reddit,

02:34:40.500 | but seems that women are reporting some bladder incontinence

02:34:45.300 | from excessive bicycle seat use,

02:34:47.440 | maybe even exercise bike, doesn't have to be road bike.

02:34:50.940 | - Yeah, so this is a great point.

02:34:52.540 | So cycling, if you think about it,

02:34:54.460 | you're sitting on your perineum,

02:34:55.900 | which is that space for men

02:34:57.500 | between the scrotum and the anus,

02:34:59.000 | for women between the vagina and the anus.

02:35:00.660 | And right there runs your pudendal artery

02:35:03.220 | and your pudendal nerve,

02:35:04.340 | which are again responsible for blood flow

02:35:06.800 | and nerve function to the area.

02:35:08.700 | So the most common things we see in people

02:35:10.860 | who are really high volume cyclers now,

02:35:15.420 | the studies have looked at like,

02:35:17.400 | maybe they did a 350 kilometer race

02:35:19.860 | or they're biking three times a week for 60 minutes,

02:35:22.920 | but there's no like consistency,

02:35:24.600 | but they're seeing pretty high rates of genital numbness.

02:35:28.220 | So like up to 50% and also in men erectile dysfunction.

02:35:33.220 | In women, you'll also see numbness,

02:35:35.380 | but because sensation is a big part of arousal,

02:35:39.020 | you'll also see kind of decreased lubrication,

02:35:41.540 | maybe decreased arousal as well in women.

02:35:44.100 | And so how can you prevent that?

02:35:46.700 | The reason is because when you're sitting,

02:35:48.540 | particularly if you're leaning forward,

02:35:50.100 | like competitive bikers do or aero riding,

02:35:52.420 | you're putting pressure on the beak of the bicycle seat.

02:35:55.700 | And that's where most of the,

02:35:57.620 | it's not your weight, it's not distributed evenly.

02:35:59.820 | So the goal is to take a bike seat

02:36:01.940 | that allows you to sit comfortably

02:36:04.220 | on your ischial tuberosities.

02:36:05.940 | And posture is a huge part of your pelvic floor.

02:36:07.900 | I know we didn't talk about that earlier,

02:36:09.340 | but sitting with good posture

02:36:12.340 | and not kind of slouching or leaning forward

02:36:16.000 | can actually really do wonders for your pelvic floor.

02:36:18.400 | So focusing on posture is helpful,

02:36:20.240 | but also when biking posture is helpful.

02:36:21.900 | So they've actually looked at this data

02:36:23.700 | and they found that people who aero ride,

02:36:25.980 | meaning lean forward,

02:36:27.140 | or people who use narrow bike seats

02:36:30.000 | are more likely to have issues.

02:36:31.700 | And so you wanna get kind of a noseless seat

02:36:34.140 | and a wider seat.

02:36:35.540 | The cutouts actually,

02:36:37.420 | when they've looked at kind of mechanics of the cutouts,

02:36:39.780 | they'll see higher pressure around the opening.

02:36:42.660 | So it's actually not good to have a bike with a cutout,

02:36:46.060 | a bike seat with a cutout because they've seen,

02:36:48.060 | at least with some of the cutouts,

02:36:49.500 | the pressure actually becomes higher on the area

02:36:51.340 | that's right around it.

02:36:53.600 | - Very important point.

02:36:55.700 | I don't cycle, I don't like the exercise bike.

02:36:58.260 | I'll sometimes ride the assault bike for,

02:37:00.620 | which has the big seat for a few minutes, but.

02:37:03.780 | - I just wanna add one thing

02:37:05.960 | because I think that I don't wanna make people not cycle.

02:37:09.880 | I think it's really valuable.

02:37:11.080 | Cycling is a great aerobic exercise,

02:37:13.360 | has lots of benefit for cardiovascular health.

02:37:16.140 | But there was actually another study

02:37:18.180 | that looked at people who were parts of sports clubs.

02:37:21.140 | So they were like swimmers, runners, and cyclists.

02:37:24.060 | And they looked at rates of dysfunction

02:37:26.760 | and they found that actually

02:37:28.020 | the rate of erectile dysfunction was not different

02:37:30.660 | between runners, swimmers, and cyclists.

02:37:33.500 | So maybe, because those other sites

02:37:35.620 | were just looking at cyclists,

02:37:36.940 | that maybe it's just the general rate of erectile dysfunction

02:37:39.700 | in that population at that point in time.

02:37:41.580 | So the numbness is definitely an issue.

02:37:44.680 | The erectile dysfunction, maybe, maybe not.

02:37:47.940 | - So I just have a couple of more questions for you.

02:37:50.500 | And by the way, you've been incredibly generous

02:37:52.260 | with your time and information here.

02:37:54.700 | - Oh, thank you, thank you.

02:37:55.540 | - So I really appreciate it,

02:37:57.500 | as I'm sure our listeners do as well.

02:38:00.340 | Anal sex, you recently did a post describing

02:38:04.740 | the multiple reasons why women do or do not have anal sex.

02:38:09.740 | Very interesting post, very interesting study

02:38:12.340 | that you covered.

02:38:13.180 | And you explained it very clearly.

02:38:15.300 | I'm guessing there are relatively few,

02:38:19.480 | but perhaps some other studies as well about this.

02:38:21.980 | Let's talk about anal sex.

02:38:25.460 | And maybe if you could just offer some of the,

02:38:30.020 | the key bullet points that you've learned

02:38:32.420 | from the literature and from your clinical practice.

02:38:35.540 | How frequent is it with protection, without protection?

02:38:40.540 | How safe is it?

02:38:42.340 | What are the different reasons people do it?

02:38:47.180 | That might seem like a kind of a silly question,

02:38:48.860 | but it turns out when it comes to this topic,

02:38:50.500 | it's, they're interesting data.

02:38:52.660 | Yeah, educate us.

02:38:54.700 | So anal sex, let's talk about it.

02:38:57.660 | Well, when you talk about anal sex,

02:39:00.700 | the reason people, it's become more and more common.

02:39:03.100 | Let's say it's more and more heterosexual couples

02:39:05.820 | are doing it.

02:39:06.660 | We know that male homosexual couples are having anal sex.

02:39:09.940 | And I think the one thing is that it's safe

02:39:12.300 | in terms of pregnancy, right?

02:39:13.380 | You're not gonna get pregnant from anal sex,

02:39:15.500 | which is one of the reasons people do engage in anal sex.

02:39:18.460 | - Do you think that's the reason people

02:39:19.460 | are doing it more frequently?

02:39:20.700 | - No, I think that's one of the reasons that people,

02:39:23.060 | one of the reasons people do it.

02:39:24.580 | But in general, the issue with anal sex

02:39:28.260 | is that people forget to use protection,

02:39:31.220 | like a condom, for example,

02:39:32.540 | because sexually transmitted infections

02:39:34.300 | are actually more likely with anal sex

02:39:36.820 | than they are with vaginal penetrative intercourse,

02:39:39.620 | because the anal tissue is very thin and friable.

02:39:43.980 | So when you penetrate the anus,

02:39:45.380 | particularly if you have any trauma,

02:39:48.700 | you can have, you know, you can have blood loss

02:39:51.380 | and that blood loss can then easily,

02:39:52.780 | more easily transmit sexually transmitted infection.

02:39:54.820 | So it's really important to use a condom

02:39:57.300 | and use adequate lubrication.

02:39:59.460 | The anus does not make any of its endogenous lubrication.

02:40:03.460 | You have to use lubricant.

02:40:05.420 | The other interesting thing about anal sex

02:40:07.580 | is that the anus pH is different from the vaginal pH.

02:40:11.260 | So you wanna use specific lubricants

02:40:13.500 | that are isoosmolar to anal pH.

02:40:16.060 | So you can actually look up anal lubricants.

02:40:19.020 | And we could talk about lubricants,

02:40:20.300 | but generally there's water-based, silicone-based,

02:40:23.420 | oil-based lubricants.

02:40:24.820 | Water-based are the most easily accessible.

02:40:27.780 | Silicone-based are a little more slippery

02:40:29.580 | and last a little longer.

02:40:30.780 | And oil-based also last longer

02:40:32.540 | but are not good for use with condoms.

02:40:34.220 | So definitely using lubricants

02:40:36.420 | and always kind of making sure to be,

02:40:39.860 | in the context, of course, of being consensual,

02:40:42.100 | but also like never force, always take your time.

02:40:45.740 | And those things are really important to avoid trauma

02:40:48.220 | because trauma can happen.

02:40:50.180 | And usually it's not severe trauma, right?

02:40:52.460 | It's not gonna create long-lasting problems,

02:40:54.380 | but it is inconvenient, uncomfortable,

02:40:57.260 | and probably we're not seeing as much of it

02:40:59.060 | because they're not coming to the emergency room

02:41:00.460 | if they're having issues unless it's really serious.

02:41:03.460 | So I think it's really important,

02:41:04.780 | one, to prevent from sexually transmitted infections,

02:41:07.020 | two, to be thoughtful and cautious.

02:41:09.700 | And sometimes it requires some preparation

02:41:11.540 | if you're gonna penetrate an anus.

02:41:13.020 | It's gonna, you're not gonna start with a large girth item.

02:41:17.420 | You're gonna start with something smaller

02:41:18.660 | and kind of work your way up.

02:41:20.100 | And then I think ultimately why people have anal sex.

02:41:24.100 | So as I mentioned earlier,

02:41:25.500 | the prostate is highly innervated

02:41:28.020 | and can be a source of pleasure.

02:41:29.620 | So some people enjoy that,

02:41:30.980 | particularly men may enjoy anal penetration.

02:41:33.500 | Women as well may enjoy anal penetration

02:41:36.140 | because of the innervation around there, the pelvic floor.

02:41:39.740 | And so that's certainly reasonable to do so.

02:41:43.300 | As far as why people engage in anal sex,

02:41:46.620 | so sometimes it's because, as I mentioned,

02:41:48.980 | they're trying to avoid vaginal penetration,

02:41:51.220 | either to avoid pregnancy or maybe menstruation

02:41:54.980 | or other reasons.

02:41:56.740 | Sometimes it's because people wanna do something special

02:42:00.200 | with their partner.

02:42:01.040 | Like they feel like this is my special thing

02:42:02.980 | with this partner that I do with them.

02:42:04.660 | And so it may be something kind of like a gift

02:42:06.980 | or something like that.

02:42:08.060 | Sometimes it's almost like they feel like they have to.

02:42:12.500 | And this particular study that I looked at,

02:42:14.100 | there's actually not a lot of studies

02:42:15.460 | on why people engage in anal sex.

02:42:17.300 | And this particular study that I had talked about

02:42:19.620 | on my channel or on my Instagram

02:42:21.100 | was talking about why they specifically recruited drug users.

02:42:25.740 | And so a lot of people had used drugs

02:42:28.760 | prior to engaging in anal sex.

02:42:30.980 | And I think that that's not ideal.

02:42:32.600 | You always wanna be kind of in the right state of mind

02:42:34.940 | for consent and safety purposes.

02:42:38.320 | And so those were kind of the common reasons.

02:42:41.400 | - What about infection

02:42:43.060 | not related to sexually transmitted infection?

02:42:45.420 | My presumption is there is a higher risk with anal sex

02:42:50.220 | than there is with other vaginal intercourse,

02:42:54.940 | oral sex, et cetera.

02:42:56.200 | But is there evidence for that?

02:42:59.460 | - Not necessarily.

02:43:00.640 | It's more about sexually transmitted infections

02:43:02.620 | more than anything else.

02:43:03.460 | It's rare.

02:43:04.300 | You can sometimes, I mean, the rare things

02:43:05.620 | that people have kind of commented on

02:43:07.220 | like anal incontinence temporarily

02:43:09.220 | or things like that, very rare.

02:43:11.340 | Mostly it's just sexually transmitted infections

02:43:14.160 | because you can't have more,

02:43:16.060 | it's more easy to create bleeding through anal sex

02:43:18.940 | if you're not careful.

02:43:20.140 | - And are people doing enemas before anal sex

02:43:22.000 | to prevent bacterial infection?

02:43:23.540 | Or is that just like it's a kind of-

02:43:25.740 | - Some people are, some people are not.

02:43:27.440 | I think it's, people are making sure

02:43:29.180 | they're evacuated fully.

02:43:31.100 | There's some media articles

02:43:33.180 | about like what you should eat before

02:43:35.000 | to kind of keep your gut healthy

02:43:37.740 | and avoid kind of loose stools and things like that.

02:43:40.740 | But generally speaking, you know,

02:43:42.300 | there's lots of things you can look up

02:43:44.220 | to make it safe and healthy.

02:43:45.840 | - Yeah, and I'm sure some people are listening to this

02:43:48.660 | and they're, maybe they've turned it off already.

02:43:50.740 | But, and I think we can expect a varied response

02:43:54.420 | to this discussion, but it's happening out there.

02:43:58.060 | - It's happening.

02:43:58.900 | - Apparently with an increasing frequency.

02:44:00.940 | - Yes.

02:44:01.780 | And I don't know if that's because

02:44:02.820 | of the increasing availability of pornography

02:44:04.940 | where it's visualized more or if,

02:44:07.480 | I don't really know why,

02:44:09.580 | but we do know that there's more going on

02:44:11.860 | in heterosexual couples than prior.

02:44:14.140 | - As a final category of question,

02:44:15.860 | I was really interested in some of the posts you've done

02:44:19.940 | about herbs and supplements

02:44:23.140 | in the context of sexual desire and sexual function.

02:44:25.960 | On this podcast, I always say, always, always,

02:44:31.100 | we emphasize behavioral tools first, do's and don'ts.

02:44:34.020 | Because those are the foundation of mental health,

02:44:35.580 | physical health and performance in all contexts.

02:44:39.420 | There is of course a role for prescription drugs sometimes.

02:44:44.860 | Oftentimes people can't do the things

02:44:46.980 | and avoid the certain things they want to

02:44:48.560 | because of depressive states, anxious states, et cetera.

02:44:51.060 | And prescription drugs can serve a role.

02:44:52.720 | But I do believe the goal is always behaviors first.

02:44:56.500 | Then of course, things like adequate sleep, nutrition,

02:45:01.140 | healthy social interaction, all of that stuff, exercise.

02:45:06.040 | But we do often talk about supplements

02:45:08.760 | because they represent, I think, an important category

02:45:11.920 | of over-the-counter compounds that can play a role.

02:45:15.960 | And I've talked before about tonga ali, this Indonesian herb.

02:45:20.480 | I think it can be Malaysian as well,

02:45:22.000 | but this Indonesian herb is typically the one

02:45:24.420 | that I am aware works best for mild libido enhancement.

02:45:29.420 | Sometimes, especially in the case of people taking SSRIs,

02:45:35.380 | it can enhance libido to override some of the challenges

02:45:39.420 | with SSRI induced reduction in libido.

02:45:41.880 | And generally, even if people aren't on SSRIs,

02:45:44.480 | I hear from people who take tonga ali

02:45:46.100 | and get libido increases.

02:45:48.140 | Also things like maca root,

02:45:50.140 | which we don't really know how these things work exactly.

02:45:53.900 | Probably some freeing up of testosterone with tonga ali,

02:45:56.980 | maybe some cortisol suppression as well,

02:45:59.740 | maybe some estrogen receptor modulation with maca root,

02:46:02.700 | maybe some dopaminergic tone changes.

02:46:05.600 | Shila G, this Ayurvedic herb,

02:46:10.720 | which there is at least one study

02:46:13.380 | that I think has done well that shows increases in FSH,

02:46:18.940 | follicle stimulating hormone, with Shila G use.

02:46:22.820 | What are your thoughts on things like tonga ali,

02:46:25.180 | maca root, Shila G?

02:46:27.220 | How do you talk to your patients about this stuff?

02:46:29.900 | - Yeah, so I think that I see at least my patient population

02:46:34.600 | is still in the behavioral management place, right?

02:46:38.020 | The biggest cause of sexual dysfunction,

02:46:40.240 | whether it's low testosterone, erectile dysfunction,

02:46:43.580 | sexual dysfunction is often comorbidities, right?

02:46:46.980 | So managing high blood pressure,

02:46:48.580 | managing diabetes with diet, which you talk about a lot,

02:46:51.700 | but the best studied diet is the Mediterranean diet,

02:46:54.460 | at least in the sexual dysfunction literature.

02:46:57.460 | Exercise, like doing both cardiovascular aerobic exercise,

02:47:01.940 | but also doing resistance training,

02:47:03.580 | particularly of large muscle groups.

02:47:06.700 | And then really working on reducing blood pressure

02:47:11.260 | and preventing diabetes.

02:47:13.180 | And those things I think are really key.

02:47:14.860 | And I know you talk about them all on this podcast,

02:47:17.220 | but I will tell you that when people are getting ready for,

02:47:21.060 | for example, we do a surgery for erectile dysfunction

02:47:23.820 | called penile prosthesis.

02:47:25.020 | So this is like end of the line, nothing's working,

02:47:27.460 | they can't get an erection at all.

02:47:29.520 | And it can be, and they may have diabetes as a cause of it.

02:47:33.340 | And when we say you have to get your hemoglobin A1c

02:47:35.900 | below a certain level to do surgery,

02:47:38.500 | I cannot tell you how quickly

02:47:40.300 | these men change their behaviors.

02:47:42.660 | - For sake of erections.

02:47:43.620 | - For sake of erections.

02:47:44.940 | So I think that really, if I can say one thing

02:47:47.580 | before you do supplements, which I don't have a problem with,

02:47:50.680 | I think that it's reasonable to try them.

02:47:53.680 | I would try one at a time to see what's working.

02:47:56.260 | So you're not taking a bunch of things

02:47:57.560 | and not knowing what exactly is working

02:47:59.040 | and realizing that they're not gonna work immediately.

02:48:01.140 | If you take something that works immediately,

02:48:03.360 | it's probably got a PDE-5 inhibitor mixed in there.

02:48:06.440 | And so it's gonna kind of build over time

02:48:08.820 | and you're gonna see changes over time.

02:48:10.860 | But I would say that the number one thing

02:48:13.180 | that I recommend for people is improving their diet,

02:48:16.480 | exercising, getting good sleep.

02:48:18.400 | As you know, it boosts testosterone.

02:48:20.120 | And even, you mentioned this all the time,

02:48:22.420 | like getting early morning light,

02:48:23.900 | but it's beneficial for testosterone as well

02:48:26.120 | because you're really helping release testosterone

02:48:28.180 | with a circadian biology.

02:48:29.560 | So I think that those things, I can't stress enough,

02:48:32.680 | like how valuable they are.

02:48:34.260 | And if you're smoking, quit smoking.

02:48:36.260 | It will kill your erections.

02:48:37.860 | - And vaping.

02:48:38.700 | - Yeah, and vaping.

02:48:39.540 | - Yeah.

02:48:40.360 | - And then lastly,

02:48:41.200 | if you are developing true organic impotence,

02:48:43.240 | meaning that there's a biologic problem

02:48:45.300 | that's causing your sexual dysfunction,

02:48:47.580 | then it's really important

02:48:48.820 | to get your cardiovascular health assessed

02:48:51.100 | because about 15% of men who develop erectile dysfunction

02:48:55.420 | seven years later will have a cardiovascular event.

02:48:58.100 | It is the canary in the coal mine,

02:49:00.140 | meaning that it's a sign

02:49:01.580 | that you may be developing cardiovascular problems

02:49:04.380 | or like endothelial dysfunction

02:49:06.420 | that's first presenting in the penis

02:49:08.860 | or in their sexual organs.

02:49:10.260 | And this probably is the same for women.

02:49:12.760 | We just don't have the data yet.

02:49:14.420 | - I know a good number of women that take Tonga Ali.

02:49:18.340 | In part, I think on the recommendation,

02:49:20.460 | although I want to be clear,

02:49:21.420 | I never recommended it.

02:49:22.260 | It was an offer of something that people could try

02:49:24.620 | if they're doing everything else correctly

02:49:26.040 | and could assess with consulting your physician, of course.

02:49:30.060 | And they too, some of them have reported improvements

02:49:35.860 | in libido and desire as well.

02:49:37.940 | - That makes sense, yeah.

02:49:39.040 | - Yeah, and the Shilaji is less known

02:49:41.620 | about the distinguishing quality

02:49:44.380 | versus low quality sources of Shilaji is harder.

02:49:46.980 | Dosing is harder.

02:49:47.820 | It comes as this tar typically.

02:49:50.620 | Maybe more science on Shilaji will come out

02:49:53.040 | in the next few years.

02:49:53.880 | We could get behind it a bit more.

02:49:56.200 | Right now, I'm sort of on the, yeah, maybe,

02:49:58.020 | if you are in an adventure, you might try it,

02:50:00.140 | but it's not one that I'd normally throw

02:50:03.180 | to the top of the list.

02:50:04.020 | - Yeah, I think that like L-citrulline is pretty good.

02:50:07.460 | Ashwagandha for stress reduction,

02:50:09.140 | which also has implications for sexual function.

02:50:11.860 | Tonga Ali has reasonable data.

02:50:14.400 | I think there is reasonable data on these things.

02:50:16.880 | I think the website you talk about all the time,

02:50:18.380 | examine.com is a great place to look at that.

02:50:21.560 | And like I said, I think it's reasonable.

02:50:24.020 | They're smaller studies.

02:50:25.120 | They're not, there is bias in many studies,

02:50:28.100 | but there is effort done in this area

02:50:31.140 | and there's never going to be a really high quality science.

02:50:34.100 | No one's going to really fund that, I think.

02:50:36.280 | So I think our expectations need to be a little tempered

02:50:38.420 | when it comes to that stuff.

02:50:40.300 | - Well, Rina, Dr. Malik, I want to thank you ever so much

02:50:46.100 | for this discussion today.

02:50:47.260 | You provide us so much useful information

02:50:50.220 | and really have transcended the divide between, you know,

02:50:53.900 | the mysterious thing that everyone wants to know about sex

02:50:56.780 | and sexual health, genitals and genital health,

02:50:59.900 | prostate urethra, UTIs, all these topics

02:51:02.940 | that many people are just afraid to raise

02:51:07.260 | and to confront directly.

02:51:09.080 | And you've taught us so much about how to promote the health

02:51:12.040 | of this incredibly important system.

02:51:14.180 | One thing we know for sure, either in vivo or in a dish,

02:51:17.140 | we're all here because of sperm and an egg.

02:51:19.180 | And of course there are other reasons

02:51:22.100 | why people engage in sexual activity

02:51:23.660 | that have nothing to do with reproduction,

02:51:25.660 | but surely it is core to our biology

02:51:28.780 | and our psychology and wellbeing.

02:51:31.120 | So thank you so much.

02:51:32.500 | And also thank you for the work you do day in and day out,

02:51:35.660 | week in and week out in your clinic.

02:51:38.560 | We will provide links to your clinic.

02:51:41.000 | People are interested in working with you directly

02:51:43.140 | as well as online.

02:51:44.660 | That's how I initially found you.

02:51:46.020 | And when I did, I was just absolutely delighted.

02:51:48.700 | I thought, finally, there's somebody who's providing

02:51:50.960 | the kind of information that everybody wants

02:51:53.380 | in a thoughtful, logical, clear and respectful way.

02:51:58.380 | So on behalf of all the listeners and viewers

02:52:01.540 | and on behalf of myself, I just want to say,

02:52:04.400 | thank you, thank you, thank you for what you do

02:52:06.160 | and please keep going and please come back.

02:52:08.700 | - Thank you so much.

02:52:09.580 | And honestly, the work you do is phenomenal.

02:52:11.900 | It's an honor to be here.

02:52:12.860 | Thank you so much.

02:52:14.580 | - Thank you for joining me for today's discussion

02:52:16.320 | with Dr. Rina Malik, all about urology,

02:52:19.580 | pelvic floor and sexual health.

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02:52:52.780 | Not on today's podcast, but on many previous episodes

02:52:55.500 | of the Huberman Lab Podcast, we discuss supplements.

02:52:58.040 | While supplements aren't necessary for everybody,

02:53:00.180 | many people derive tremendous benefit from them

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02:53:05.760 | The Huberman Lab Podcast has partnered

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02:54:17.020 | Thank you once again for joining me for today's discussion

02:54:19.420 | with Dr. Rino Malek.

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Dr. Rena Malik: Improving Sexual & Urological Health in Males and Females | Huberman Lab Podcast

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