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

welcome to the huberman Lab podcast

where we discuss science and

science-based tools for everyday life

I'm Andrew huberman and I'm a professor

of neurobiology and Ophthalmology at

Stanford School of Medicine

today my guest is Dr Rina Malik Dr Rina

Malik is a board-certified urologist and

pelvic surgeon she is an expert in both

male and female Urological pelvic floor

and sexual health during today's episode

Dr Malik answers the most commonly asked

questions about urinary pelvic and

sexual health for instance how to avoid

getting UTI's urinary tract infections

we also discuss pelvic floor anatomy and

function as it relates to overcoming an

overly tight or an overly relaxed pelvic

floor this is a key distinction that

most people aren't aware of many people

hear about the need to so-called

strengthen their pelvic floor but in

fact many people need to do the exact

opposite they need to learn to relax

their pelvic floor in order to achieve

proper Urologic and sexual function

so today you'll learn about that you

will also learn about sexual health as

it relates to erectile function as it

relates to things like vaginal

lubrication as it relates to orgasm we

separate out very carefully the

difference between psychological desire

an arousal that occurs within the

genitals themselves and Dr Malik

highlights some important misconceptions

about sexual dysfunction for instance

that many people believe that hormones

are responsible for sexual dysfunction

but in reality

hormone dysregulation is responsible for

only a very small percentage of sexual

dysfunction and yet

pelvic floor and blood flow related

issues can account for a large number of

cases of sexual dysfunction in both

males and females so I assure you that

today's discussion is going to

illuminate many new areas of information

many new tools and protocols that I'm

guessing most people have not heard of

we talk about the neural vascular that

is blood flow related and muscular

aspects of bladder function prostate

functions schemes glands we talk about

vaginal Health as well as penile Health

we talk about these things as it relates

to different stages across the lifespan

it is a far-reaching and in-depth and

practical conversation that I'm certain

everyone will glean important takeaways

from now before we go any further I do

want to highlight that the content of

today's episode is sexual in nature we

talk very directly about different types

of sexual behavior and we talk about it

from the standpoint of the clinician and

biologist so it is a medical slash

scientific discussion that said we can't

be aware of where this podcast is being

played and who is listening and I assert

that there are certain themes within

today's discussion that would not be

suitable for young children how young

well that is certainly not for us to

discern we realize that different

parents and different households should

be the Arbiters of what sorts of

information their children are exposed

to or not so my suggestion would be that

if you have any concern whatsoever that

the content of today's episode would not

be appropriate to be heard by some

member of your family that you please

listen to the podcast first or at least

check the time stamps where we've

detailed what specific topics are

covered and then to make your decision

accordingly I should mention that not

only is Dr Malik still an active

clinician she sees patients daily out of

her clinic in Southern California and we

provided a link to that clinic in the

show note captions she's also authored

dozens of high quality peer-reviewed

Publications in the fields of Urology

pelvic health and sexual will health and

we've also provided a link to that

bibliography in the show note captions

and she is also a spectacular public

educator she provides zero cost content

about sexual health pelvic floor health

and Urology as it relates to both men

and women on her YouTube channel and

there too we've provided a link to Dr

Malik's YouTube channel in the show note

captions to this episode before we begin

I'd like to emphasize that this podcast

is separate from my teaching and

research roles at Stanford it is however

part of my desire and effort to bring

zero cost to Consumer information about

science and science related tools to the

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science and now for my discussion with

Dr Rina Malik Dr Rina Malik welcome

thank you thank you so much it's an

honor to be here I'm delighted to have

you here I'm a huge fan of your content

I find that you are able to deliver

critical information about sexual health

Urology pelvic floor

libido and so many other things that are

of immense interest to people but that

ordinarily people don't really know

where to get the high quality

information and coming to you for that

information means they are going to get

the highest quality information I truly

believe that because

as everyone will soon hear today we're

going to have a very Frank discussion

but one that's really grounded in

science and medicine

around sexual health and related topics

these are topics that typically people

learn about

perhaps a little bit in school maybe at

home

from Friends

usually overhearing things as opposed to

direct exploratory conversation

online

pornography

and at least in my experience growing up

you know there was education around

Sexual Health reproductive Health Etc

that was more oriented toward the fear

of

things like STIs fear of unwanted

pregnancy all of which of course is

extremely important for people to learn

about but far less about sort of the

healthy versions of sexual health right

yeah absolutely so this is an especially

important conversation

uh it's also one that I think

has a backdrop that we should just

acknowledge right off the bat that

because the information is gleaned from

multiple sources and because there are

um let's just say uh influences out

there that relate to the morality of

different practices that there can be

shame

there can be misunderstanding there can

be secrecy and that further leads to

misinformation so I'm confident that

today you can clarify things for us and

we're going to stay out of those

trenches and the last thing I'd like to

say is that because a number of terms

will certainly come up and I think for

some people they're not used to hearing

and general discourse I'm just going to

get them out of the way now penis vagina

anus prostate you know what else is

there we're going to talk about libido

we're going to talk about intercourse

oral sex anal sex we're going to talk

about all of that so I just want to get

that out there so that um we can reduce

the shock uh the shock response I love

it we got to talk about all of it great

so to start things off in anticipation

of this episode I solicited for

questions on social media and I got

thousands of questions but there was a

lot of overlap in the questions

so

to start off I'd like to talk about

pelvic floor okay because both males and

females have a pelvic floor

and my understanding is that there's a

muscular component there's a neural

muscular component there's a blood flow

component

what is a healthy pelvic floor what does

a healthy pelvic floor do and then we

can talk about some of the health issues

that an unhealthy pelvic floor creates

and some of the ways to ameliorate an

unhealthy pelvic floor absolutely so

pelvic floor very simply is basically a

bowl of muscles that's connected to

bones that hold up all your organs so

basically in your pelvis there's all

these muscles there and their function

is essentially many it helps with

urination defecation sexual function it

helps with posture and so having a

strong healthy pelvic floor can mean

that you're having normal urination

you're having normal defecation you're

having great sex and that you are also

not having ailments like back pain or

issues related to those those functions

and those organs

and so you know pelvic floor is is so

important in so many different aspects

and we deal with it a lot as urologists

because it's so integral to these

functions that we take care of and so

when you have an unhealthy pelvic floor

it can vary from person to person and

while you hear about it a lot in women

men also suffer from pelvic floor

dysfunction or problems with the pelvic

floor so basically pelvic floor

dysfunction happens a lot when you're

doing things like if you were to go to

the gym and do repetitions of of any

sort of exercise and you didn't rest

then that muscle would become contracted

and short very similarly if your pelvic

floor is over strained it can become

contracted and short and tight all the

time and you may not know it it may just

be a function of stress anxiety or

overuse or posture problems things of

that nature that can affect your pelvic

floor and so this can lead to issues

let's start with urination you can have

symptoms of urgency frequency meaning

you have to go a lot to the bathroom or

you have to go and have a sudden desire

that you can't delay sometimes even have

leakage in some cases it can make it

difficult to urinate because the pelvic

floor is so tense or perhaps to

incompletely vacate the bladder correct

like you go to urinate and then you go

back to your desk or then five minutes

later you have to urinate again exactly

something of that well it can be either

that you're not emptying completely or

that the pelvic floor muscles are so

tense that they're stimulating the

bladder so it feels like there's more to

go so it's not always that you're not

evacuating it can present in a number of

different ways

and then with uh with sexual function it

if it's very tense you can have pain so

you can have pain with sex you can have

pain with erections you can have pain

with ejaculation sometimes it can be a

lot of different kind of pain syndromes

and you're like I have all these

different things going on and it's

really just pelvic floor dysfunction

um with with GI function you can

definitely have constipation and then

often you can also have back pain and so

all of these things can happen when your

pelvic floor is too tense sometimes your

pelvic floor can be too weak and that

can be often because of we see this in

women a lot because of childbirth

delivering children with some people who

have neurologic disorders they can have

weak pelvic floors or connective tissue

disorders like there's download syndrome

for example these sorts of things can

cause weakness to the pelvic floor which

can then cause very often what I see is

like urinary incontinence or leakage

which can then you know create problems

for people down the line

thank you for that so first question how

does somebody know if their pelvic floor

is too tight from a over contraction or

chronic contraction of the muscles there

versus too weak and one of the

challenges in having this conversation

is that if we were talking about

contraction of the calf muscle or the

bicep I think everyone intuitively knows

because they've seen the shortening of

the muscles when the muscle is quote

unquote flexed and the lengthening of

the muscles when it is relaxed

um is there a way to describe pelvic

floor muscular shortening in a way that

everyone can understand would this be

like

um like I said we're going to be direct

today would this like be like tensing up

one's um uh

anus and the opposite of of the movement

that one would do before initiating a

bowel movement and relaxation is sort of

the pattern of pelvic floor muscular

relaxation just prior

to initiating a bowel movement so I will

say most people can't recognize it

because it's very difficult to notice

it's sort of uh gradual and so it can

over time become noticeable with these

symptoms but otherwise it's very

difficult because it's not a muscle that

we were ever trained to recognize right

like you hear about Kegel exercises for

example and people talk about how to do

them but that's all you ever hear about

the pelvic floor and so you don't really

know how to kind of do things in a way

that protects your pelvic floor or um or

kind of what how to even tell when it's

too tight or not relaxing and so that

takes a sort of a training and so

usually when people come to First you

get an examination to see if your pelvic

floor is tight so for women it's a

pelvic exam and for men it's usually a

rectal exam how does how does that exam

go so you know it's essentially

palpating the muscles and also looking

at the function so we'll say for digital

palpation where that's a medical

technology for fingers they're called

digits uh so

um you know I'm old enough to uh to

recognize what a digital prostate exam

is right the physician inserts their

fingers through it into the anus and and

and feels the prostate to see whether or

not it's swollen or not and and as I'm

saying this I'm realizing you know

sometimes we think of medicine quote

unquote modern medicine is so evolved

this is basically basically been the

practice for what 50 years 60 years

maybe 100 years in the same way that the

the old school practice for glaucoma

excessive eye pressure was for the

physician to just touch the eyeball so

uh folks for those of you that think

that medicine has evolved much uh it

clearly has in many ways but

um in any event so a prostate exam goes

as I just described what would a what

would a pelvic floor exam for a male and

a pelvic floor exam for a female

um involved at a kind of granular level

yeah so for for women you can feel the

pelvic floor muscles through the vagina

so you can feel the iliococcygeus the

pubic oxygous the levator Ani those are

all names of different muscles in this

bowl this is the physician who can feel

them with their fingers correct and you

know you could too you could put your

finger in but you don't have a reference

of normal right so you wouldn't know

what a normal pelvic floor feels like

versus a tight one versus a weak one and

so you can assess the tenseness based on

you know palpation you can also see if

there's tenderness and so you can assess

that based on just a general physical

examination and then also you can

observe so I can say contract your

squeeze your pelvic floor up and then I

can look and see are they squeezing or

are they pushing like are they

coordinated or not right because that's

a function of normal use of the pelvic

floor and sometimes you'll see that

they're just coordinated you can also

assess for sensation in the area and

things like that that could be

consequences of dysfunction can there be

dysfunction in laterality like the

pelvic floor is pulling up and to the

right or up and to the left absolutely

so what typically when you see a pelvic

floor therapist now I'm not a pelvic

floor therapist but these are the people

who will do the work right they they

work with you on a prolonged basis to

help you normalize the function of your

pelvic floor it's like going to the gym

with a trainer right they really work

with you to get your pelvic floor

functioning correctly and the first step

to that a lot of pelvic floor therapists

will just align your bones and and your

your kind of the way you sit and walk to

make sure that you're not straining

those muscles by pulling in different in

different directions and if a male goes

to the physician to get a pelvic floor

exam

um there's obviously

difficulty in putting fingers into the

urethra one would hope too small an

opening so how are they doing the pelvic

floor exam is it external to the body or

is it through the anus so some of it's

through the anus you can feel the

muscles through the at least and then

you can feel the perineal area and feel

the muscles there as well as Sensations

so okay so perineal area so from the

outside of the body okay

um the region between the scrotum and

the anus yes okay so it sounds to me

like if people want to get

a high quality assessment of whether or

not their pelvic floor is healthy or not

they need to see a pelvic floor

specialist that it's not the sort of

thing that they could into on their own

necessarily it would be difficult I mean

so there are things you can buy online

like probes that you can insert in the

vagina that will teach you how to do

kegel exercises and give you some read

you know some readings but they're not

really meant to diagnose they're usually

something people use if they they have a

weak pelvic floor and they want to try

to do it at home on their own so there's

nothing that's going to give you like a

baseline reading is this normal or

abnormal let's talk about kegels

um first of all who's Kegel

so he is a a gynecologist I don't

remember all the specifics to be quite

honest but basically he came up with

kegels which are a strengthening

exercise for the pelvic floor and so

what it is what we describe it to for

patients is we say you're going to

there's a few different ways to describe

it you're going to use the muscles that

you use when you urinate but try to stop

the flow but you don't want to do them

when you're urinating because that can

create dysfunction you want to learn

what the muscles are and then you

squeeze those muscles and relax you know

in between sets so to speak and so

you'll do the other way people describe

it is pulling up and in in the like the

vagina or for men sometimes you'll say

it's like the feeling that you're trying

to lift your penis off the floor without

touching it right so those are kind of

used the way you describe it yeah yeah

so those are kind of the ways that you

can describe those muscles and so you

can squeeze for five seconds and relax

for five seconds and do them in

repetitions and they're just like any

sort of exercise you do you don't want

to start doing a hundred of them right

you want to do them I tell them people I

tell patients do them lying down so that

you're only focusing on those muscles

you're not working on your posture

you're not doing anything else and as

you get better with them lying down you

then sit up and do them and then once

you're good with them sitting up you can

do them standing and start with you know

10 to 15 at a time like 15 repetitions

yeah

so yeah 10 to 15 repetitions in the

morning 10 to 15 repetitions at night

maybe one more during the middle of the

day but don't overdo it because just

like anything especially when you're

starting out you can and if you're doing

tons and tons of kegels then you will

get a tight short pelvic floor muscles

and you will then develop pelvic floor

dysfunction so it's really important to

kind of understand those mechanics which

is why a lot of people think they know

how to do kegels but they really don't

and so I always encourage people if you

have the time and the resources to go to

a pelvic floor physical therapist so

they can really work with you and make

sure you're doing them correctly

what are some of the benefits of kegels

for those that need them yes so they are

typically prescribed for urinary

incontinence specifically stress urinary

incontinence so leakage that occurs when

you have an increase in your

intra-abdominal pressure like a valsalva

or coughing sneezing lifting heavy

things jumping on a trampoline so for

those purposes we use kegels to

strengthen the pelvic floor and also in

women pelvic organ prolapse so when you

have weakness of the pelvic floor that

leads to a bulge that you can visibly

see or feel in the vagina for men we

often prescribe them for people who have

had a prostatectomy who then

subsequently develop leakage after the

prostatectomy that is again stress

urinary incontinence now a lot of people

use kegels recreationally because

improving the pelvic floor musculature

can lead to more intense pelvic floor

contractions during orgasm which can be

more pleasurable and so some people do

it for those purposes but again I

caution people not to overdo it because

then you can lead to a more tense pelvic

floor which is not where we want to end

up yes I will underscore that cautionary

note

years ago I heard about kegels I was

like okay I'll try it sounds all good

right I only heard good things about

kegels

um and what it quickly resulted in was

painful urination

and I thought this is weird everyone's

saying kegels are so great

um and the best thing I could do for my

pelvic floor it seemed was to avoid

kegels yes

um and a little bit later when we're

talking about prostate I'll I'll explain

um at least what my experience was as it

relates to the prostate but I guess the

take-home message that I'm gathering

from what you're telling us is that

strengthening the pelvic floor is great

if you have a weak pelvic floor

strengthening your pelvic floor further

if you have a strong pelvic floor can be

detrimental it can be it can be if you

over train it just like if you over

train anything else and so

um you just have to if you really want

to do kegels if you have any symptoms at

all like you described painful urination

or the things I've described like pain

with erections pain with ejaculation

pain difficulty emptying any of those

symptoms stop and go see a urologist so

that they can kind of assess your pelvic

floor

what is the anti-kegal in other words if

somebody decides that they have a tight

pelvic floor how can they learn to relax

their pelvic floor so there's a lot of

different sort of things that you can do

so for women you can do massage of the

area you can use vaginal dilators to

help relax the muscles you can take

suppositories that have medications like

valium or baclofen which are muscle

relaxants and that can help as well

although they're not treatments they're

more of a Band-Aid but they can help

with the symptoms that you're having and

then you can also I think the best thing

is to work with a physical therapist

because they can teach you certain

exercises that will help down train the

pelvic floor for example one of the ones

I tell my patients is like happy baby

pose it actually you know stretches and

elongates the pelvic floor muscles so

doing these exercises regularly will

help you lengthen the pelvic floor

muscles

one thing that I've experienced extreme

pain from

and that stopping was one of the best

things that ever happened for my pelvic

floor was to not do any kind of

crunching movement with my legs crossed

I would go with these yoga classes at

one point in my life and I they'd have

everybody do these crunches and I've

always done some abdominal work here and

there during the week if I'm being

diligent but they would have us cross

our feet and that seemed to lead to some

pelvic floor discomfort that was similar

to what I had experienced when I did the

kegels yeah so again for me ceasing the

kegels was one of the best decisions I

ever made I only did them for a short

while I was like okay this is clearly

not for me and I guess that's another

point that tell me if you agree uh or

not that if you hear about something

online or on this podcast or anywhere

else and you try it and it seems to be

sending things in the wrong direction

either you're doing it wrong or it might

not be the right thing for you exactly

you know I think all too often we hear

this thing is great and people jump on

that bandwagon and then they end up

worsening their problems or developing

problems where they didn't have them

previously but

is there anything about the anatomy of

the neuromuscular connections or or

vasculature of the pelvic floor that

would provide support for my experience

there yeah that doing crunches with legs

crossed is essentially

um is it possible that's creating

asymmetries in the pelvic floor

um and now I'm sure I'm angering yoga

teachers and um crunch crunchinistas

everywhere but you know hey

um if it's a question of your pelvic

floor or a few extra delineations in

your abs you know where my vote's going

yeah so there's a couple things here

that we should dive into one is that

people don't often breathe correctly

during exercise right and so

diaphragmatic breathing is is really

important which is like a deep breath

that expands the diaphragm not kind of

shallow breathing that's just in your

mouth and throat and that is actually

when you you know when you do any sort

of exercise the your trainer will tell

you exhale on the effort right and

there's a reason for that because when

you inhale your pelvic floor relaxes

when you exhale your pelvic floor

contracts and and so it actually that

contraction stabilizes the pelvic floor

so whatever intra-abdominal pressure

you're you're causing to increase from

the exercise whether it's a squat or a

crunch or whatever you're increasing

your abdominal pressure your pelvic

floor is then Contracting to help

stabilize that and so part part of the

reason people tend to hold their breath

during crunches right they don't do the

appropriate breathing and so that can be

part of it

the other thing that can happen with

certain things is that there are you

know nerves and arteries particularly

the pudendal nerve and the pudential

artery that run through the pelvic floor

so when you get pelvic floor dysfunction

you can cause decreased blood flow to

the to the pelvic floor muscles which

can affect sexual function and you can

get nerve inflammation as well that can

also cause pain and so this is kind of

how it all comes together I'm so glad

that you mentioned blood flow I think

our entire discussion today should be

framed up at least in the back of our

minds and the minds of our listeners and

viewers as involving at least three

things you know anytime we're talking

about erectile function or dysfunction

or pelvic floor function or dysfunction

or vaginal lubrication or lack thereof

we need to think about the hormonal

influences

the blood flow related influences and

the neural influences including the

neural influences that come from the

brain the signals of arousal for

instance or lack of arousal um and so on

so we won't be overly systematic in in

our parsing of all this but I I think

what you just mentioned raises a really

important point that sometimes in an

effort to do something that's good for

the muscles like strengthen the muscles

one will cut off blood flow in fact one

of the more common questions I got and I

consulted with a couple of exercise

physiologists about this and they

confirmed that a lot of people who Squat

and deadlift heavy in the gym

or even who just tense their pelvic

floor when they're doing things like

dumbbell curls or other exercises

and especially people who seem to do a

lot of abdominal work

reported to me in the questions that

they experienced things like erectile

dysfunction

that they experience things like pain

during vaginal intercourse

that essentially they had created some

sort of what sounds to me like a hyper

contraction of the muscles in that area

that were impeding all the things that

they wanted as either side effects or

Direct effects of exercise because many

people are exercising for aesthetic

reasons and health reasons but nowadays

it seems especially on the male side but

we'll also talk about the role of

testosterone on the female side a lot of

males lift weights in order to increase

their testosterone and for reasons that

are obvious also want to have healthy

sexual function and here they are doing

this thing that's very good for

increasing testosterone if they're doing

it correctly and testosterone is

involved in libido and the male sexual

response and the female sexual response

of course

but they are impeding their erections so

you can start to see how um there are

probably a lot of confused and maybe

even distraught people out there they're

trying to do all the right things and

they're setting up roadblocks and even

um sending themselves backward in some

cases so the question is

how does one know whether or not

something like

um let's say low lubrication or pain

during vaginal intercourse or loss of

erectile strength or some sort of

erectile dysfunction whatever it may be

because it can take on different forms

as we'll talk about how does one know if

it's blood flow related hormone related

or neural related and if it's neural

related how does one know if it's an

issue of lack of appropriate signals

from the brain over suppression or lack

of arousal from the brain or whether or

not it's some peripheral neural thing of

innervation of the penis or vagina so I

think there's there's a lot that we can

go into here but essentially first you

want to find out like very specifically

what is going on are you getting aroused

are you having erections are you

masturbating like there's all these

questions that will help us go down the

road sorry to interrupt when you say

aroused um for sake of this discussion I

just want to make sure that we

distinguish between psychological

arousal the desire to to

um I guess here we also have to be

precise

um arousal to engage in Intercourse and

arousal to

um desire essentially I think people

learn to recognize or are we talking

about arousal as the response of the

genitals correct so so desire and

arousal this is a very important concept

doesn't always go in One Direction

sometimes you can feel arousal meaning

you have the telltale signs of arousal

your nipples get erect you have more

lubrication if you're a female you're

both male and female nipples get erect

during around I believe so I think so

um you know you maybe get the second

flush right you get some some redness or

warmth feeling that's your body's

response right to arousal and sometimes

that can be an erection and sometimes

that's not not having an erection does

not mean you're not aroused it may mean

other things but certainly that's part

of it and then desire do you want to

have sex do you have like when you think

about your partner or you whoever you

want to engage with does is there a

desire to actually do that right or is

it just more of obligation or other

things and does it is that it doesn't

matter if the desire comes after arousal

for some women in particular we see that

they may not have the desire right away

but they want to be intimate or close

with their partner and so they'll start

just being close with them and then

arousal will come and then oh yeah you

know I like this so then the desire

comes after and that's normal that's

totally fine so you want to kind of

parse that out and then for men you can

ask are you getting erections at night

because that will tell us the function

of your organ at night very versus

during the day where you have also

psychogenic components right you can

really get in your head about erections

when you have a problem in the bedroom

with performance it becomes a vicious

cycle right so you you have a problem

the next time you're really stressed

you're not present you're not mindful in

the moment with sex and you're thinking

about oh my God am I going to perform

okay am I going to perform okay and then

it doesn't perform again and you're just

it's getting worse and worse and the

anxiety is through the roof and that's

actually causing your sexual dysfunction

so I think it's it's important first to

identify those issues and then also for

blood flow a lot of times we can we can

assess based on well what other

comorbidities do you have do you have

other issues ongoing that may be

affecting your blood flow most common

high blood pressure diabetes heart

disease and if you smoke all of those

things will affect blood flow to the

genitals and so that will Point

negatively negatively negatively so so

that will point us to a more vascular

issue hormonal issues are very important

for desire and and you know as far as

sexual function in terms of erections

there's only three percent of erectile

dysfunction that's related to hormones

so it's actually pure erectile function

correct as opposed to desire correct the

desire is desire is predominantly

modulated by the hormone testosterone

for both men and women in fact if you a

lot of people don't know this but women

have more testosterone in their bodies

and they actually have estrogen so

testosterone is very important for both

men and women for a variety of reasons

and so you you know using that

discussion with the patient will help

you kind of identify where you're headed

in terms of what you need to focus on

for treatment there are you know certain

things you can use to assess blood flow

you can do Doppler ultrasounds of the

penis as well as the clitoris to see if

there is good blood flow you can assess

the peak systolic velocity which will

tell you if the there's a problem with

arterial inflow versus the end diastolic

velocity which will tell you if there's

a problem with venous outflow and so

that can assess those things there are

some tests you can do for nerve

functionality they're very uncommonly

done because mostly we can kind of get

that through a clinical report and

unfortunately if you're having nerve

problems sometimes it depends on what's

causing them but sometimes they can be

very difficult to reverse and that's

kind of a problem we know that as people

age their sensation becomes less so just

through aging the nerves The receptors

become less sensitive and so you will

generally have less

responsiveness to the same Sensations

you did when you were younger and so

that kind of overlays all of this so

it's complex but really you know a lot

of it comes from the discussion you have

with your patient or you know you kind

of really doing a deep dive in what's

going on like really thinking about each

of those aspects and also what's going

on in your relationship and what's going

on in you know your life stress anxiety

like how are those playing around

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to unpack and I'm glad you mentioned the

relationship itself because there are

all sorts of things that can impact the

arousal response novelty not everyone's

in a committed relationship whether or

not people are engaging in a lot of

masturbation to the point of ejaculation

or climax or not pornography

Etc we will get into that it's a vast

space to explore before we go any

further I want to make sure however

that we cue people to where and how they

could find a really good let's say

pelvic floor

therapist

um and where they could find a really

great urologist to do the sorts of exams

and perhaps the sorts of treatments that

we've talked about because

um at least as far as I understand much

of what people want to learn on this

podcast is how things work and what

happens when things break down but also

how to resolve those issues so let's say

somebody wants to

um check out their pelvic floor figure

out what's going on there maybe they're

having issues maybe they're not if they

are male or female where do they go is

there a place online that has a great

list of some of the best ones in one's

area can it be done over telemedicine

um yeah how does one go about that yeah

so in terms of your pelvic floor it's

good to get assessed by a physician who

specializes in pelvic floor now if that

could be a urologist that could be a

gynecologist or even a Physical Medicine

Rehabilitation doctor that specializes

in pelvic floor health so typically

you'll see in urology you'll look for

people who are board certified in female

pelvic medicine and reconstructive

surgery if you're a woman if you're a

man maybe sexual medicine someone who

specializes in sexual medicine would be

a good place to look for a gynecologist

again you want to look at someone who

has interest in this area who you know

does manage pelvic floor and then in

terms of pelvic floor Physical Medicine

Rehabilitation at least when I was in

training there was about 20 PMR doctors

around the country who really focused on

this so it's not a lot of people if you

can go to a pelvic floor physical

therapist and you have one near you

that's great as well you um you do want

to make sure that when they do are

certified in pelvic floor physical

therapy and that they have taken care of

your gender so if you have male anatomy

then you want to go to someone who's

actually seen men because a lot of the

pelvic floor physical therapists tend to

treat a lot of women and so that's kind

of what I tell my patients generally

speaking there's no at least to my

knowledge no great resource and maybe

we'll we'll look that up and see if we

can find one that's very helpful thank

you and because again going back to what

I said at the beginning of our

conversation I think there's a lot of

you know shame or at least a lack of

clarity as to how one gets help for

issues that uh relate to the genitals

right because if you have a headache or

you're having an eye issue I mean you

sort of know where to go yeah hopefully

your headache doesn't weren't going to a

neurologist but it might

um you know eye stuff tends to be

ophthalmologist optometrists right yeah

um so I don't think we hear often enough

about where to access the best quality

care for these things so thank you for

that in thinking about sexual

dysfunction I'd like to have that

conversation more or less in parallel if

we can around male sexual dysfunction

and female sexual dysfunction and I want

to make sure that before we do that that

I'm creating the correct parallel

construction as they say

erectile dysfunction in males is clearly

a form of sexual dysfunction

what is the parallel to erectile

dysfunction in females is it lack of

vaginal lubrication and lack of

relaxation of the vagina to have

non-painful intercourse I mean is there

is it even possible to have a parallel

conversation about these two things so

it's different

different in in some circum

homologue of the clitoris right so the

clitoris is the I you know essentially

the same sort of spongy erectile tissue

that you see in the penis it gets erect

with arousal and it is it actually

extends very deep into the pelvis so

it's not just a small little organ it's

actually quite long and so you can in

men you can have erectile dysfunction

because you can see it but in women you

may have difficulty with orgasm and it's

not exactly a parallel but difficulty

orgasming in women is multifactorial and

we can get into that but I think they're

they're they're different and I think

also sexual dysfunction presents

differently in both genders so when you

talk about men they're very the one

visual they see of arousal is erections

and so it becomes very ingrained in your

psyche that if I don't have an erection

I'm not aroused right but there's a lot

of reasons that you might not have an

erection that we've sort of touched on

vascular problems hormonal problems

neurologic problems psychogenic issues

and other medications you're taking so

there are issues that can affect

erectile function and and so that can be

part of it where you know you might feel

like you have low desire because your

arousal is not there and that becomes a

little bit confusing for women what they

can assess is their level of lubrication

if sex hurts and if they get an orgasm

and so those are kind of the ways you

can look at it thank you for flushing

all of that out

you know years ago I worked on sexual

differentiation and in particular the

role of hormones in sexual

differentiation and indeed as you

described we learned because we were

taught and I think people still

generally agree that if one looks at the

embryological origins of the penis and

the clitoris they are essentially

analogous structures and that a lot of

male genital development involves

literally the regression The

Disappearance of the female sexual

genitalia and Associated or it's

mullerian ducts and things like that and

what would become the ovaries become the

testes etc etc

those are anatomical parallels but what

you just described for us very

beautifully is the sort of functional

parallels as it relates to sexual

function and dysfunction so I'm hoping

with that framing that we can

that we can knock down a few of these

pins uh in a little less time because

there's a lot to tackle here first off

I'd like to address the hormonal issues

you mentioned that only three percent of

erectile dysfunction and

by extension can we say also female

issues with sexual arousal are hormonal

in origin is that right

so with desire yes okay they are

hormonal in in general and arousal in

terms of lubrication if you're using

that as a as a barometer yes you can see

less vaginal lubrication due to hormones

and I guess I would say three to six

percent more you know up to six percent

we see of erectile dysfunction is

hormonal it's a small percentage of the

entire entirety of erectile dysfunction

okay so I think in looking on the

landscape of social media podcasts and

and just in the common

um mindset we've all come to believe

that testosterone is pro libido it's Pro

desire in men and women I think now

people are starting to appreciate that

it's Pro desire and women as well

um but certainly in men and that

dopamine is also associated with desire

and the general public tends to have

this view of estrogen as being sort of

anti-libido or anti-male which is

frankly false in fact and I've covered

this on the podcast with Dr Kyle

Gillette and with Dr Peter attia and um

another fellow YouTuber uh Derek from

more plates more dates has talked a lot

about the fact that if people if men

excuse me take drugs like an astrozole

to suppress their estrogen

thinking that oh it's all about having

high testosterone low estrogen

oftentimes they Crush their libido just

abolish it yeah which um has led to a

slowly growing but I think positive

shift in how people are thinking about

estrogen estrogen is great for brain

function estrogen is great for libido in

men and women correct um and

that is a revision of I I think how most

people think of the male sexual response

it's more in keeping with how people

think about the female sexual response

oh estrogen and the female sexual

response that that makes sense but what

we're trying to do here is clarify some

of the um misconceptions now the reason

I mentioned dopamine is that my

understanding is that dopamine is

involved in the Ural excuse me the

desire response we will distinguish

desire the psychological arousal from

genital arousal physical arousal

and that prolactin is associated with

the refractory period during which

erection can't occur another perhaps

orgasm can't occur in females Etc but

my understanding is that's also not that

simple and we need to take a step back

perhaps and just talk about the

physiological underpinnings of the

desire and arousal response so I'll tell

you what I was taught and then you can

tell me where it's wrong sure I hope I

was taught that

the erection response and the vaginal

lubrication response is generated by the

parasympathetic nervous system the

relaxed the rest and digest aspect of

the nervous system

hence why some people can get

psychogenic sexual issues of lack of

erection or lack of vaginal lubrication

but

that there are individuals out there for

whom

a lot of alertness maybe even and this

is a controversial thing but for some

people even some sense of aggression or

kind of edginess or excitement

adrenaline in other words can stimulate

erection or vaginal lubrication so it

gets tricky like it's not like the

textbooks it's not like they taught us

in high school as far as I know I was

taught that the arousal response in

males and females is initiated by a

parasympathetic sort of relaxed tone

and that as sexual desire and arousal

and sex or masturbation progresses that

it shifts more towards the sympathetic

nervous system which has nothing to do

with emotional sympathy and has

everything to do with arousal the

catecholamines dopamine norepinephrine

and epinephrine also called adrenaline

and noradrenaline are released and that

the climax response which may or may not

include ejaculation we have to separate

that out is one that is really of the

stress system of the body and then in

the post-coital or post-ejaculatory or

post climax phase

then there's a shift back to the

parasympathetic nervous system

um that's where

um the pillow talk and the uh the

exchange of uh odors and tastes and

other molecules is known to enhance pair

bonding through things like oxytocin

vasopressin and so on and what I just

described is exceedingly oversimplified

I realize but is that more or less how

the physiology works yeah so the way

we're taught in medical schools point

and shoot so point is the

parasympathetic nervous system oh you're

all the male audience will like that one

yeah and then you know you go on to the

sympathetic nervous system but it makes

sense and the reason that I think you're

hearing about this aggression or or

these things that are leading to arousal

is because there needs to be a stimulus

right a visual stimulus a tactile

stimulus some sort of stimulus that

you're getting that is then causing the

release of nitric oxide from the

parasympathetic nervous system and that

could be for some people aggression or

or you know some form of that right

people about nitric oxide because we'll

get into this when we talk about

drugs that increase blood flow Cialis

Viagra and also

um non-prescription drugs things like

l-citrulline Arginine and um watermelon

for that matter right um so I read on

the internet yeah

so yeah so nitric oxide is essentially

the ignition for what we say for

erections the ignition for erections

that we if you the reason I talk about

erections more often is when you look at

the data in fact there was a paper on

this where they looked at the number of

articles that came up when you put in

the word penis and the number of

articles that came up when you put in

the word clitoris and it was 50 000

about penis and 2 000 about the clitoris

okay we have to we this was actually a

major section of the comments yeah on

when I asked for for questions on

Instagram

um and comments on comments and yeah how

come

um why not Etc is that because the

Urology and um sexual health field was

dominated by men that's going to be the

presumption or is it because it's easier

to study somehow or I mean what's going

on here yeah I think there's been a lot

of

um I mean you can go back to like Freud

where he thought that that the female

sexual response was less valuable and

and so there are some some reasons

valuable I guess that's the right term

but no no I'm not challenging your term

I just ran uh you know he seemed to be

obsessed with it right but it was more

about the male sexual response than the

female sexual response and so in general

yes there is you know there were more

men in medicine there was more and it is

easier to study right you can't study

the clitoris quite as easy as you can

study the male penis response because

you can see it visually you can inject

it and see an erection response right we

do this for people who have erectile

dysfunction they'll take medications

that increase blood flow like trimix and

you'll inject it into the penis and

you'll see an erection so you can

actually try mix try mix so there's it's

in here the entire male audience just

went away so there there are there are

three basically brand names of

intracavernosal injections that we use

for erectile dysfunction I hear

injection and sickness and I I think

it's a I like to think that it reflects

a natural male response I sort of uh

um I taken aback I don't know maybe

there's a pelvic floor contractions in

there someplace so so it is it is scary

to hear about it's a very small needle

it is very well tolerated I've done it

to patients in the office and they look

at me and say you're done like they

don't even you know it's it's not as

painful as it seems and when you are not

having erections and you've tried

multiple things people get to the point

where they're willing to try that I you

know and and so it is very effective

it's the most effective non-surgical

treatment we have for erectile

dysfunction and it's usually either one

medication two medications or three so

you can have uh you know alprostadel

pavering and the third one that's a good

we can um look at someone will put it in

the comments

um uh surely they will

um what what is it designed to do is it

is it um a vasodilator of sorts so they

they work in different mechanisms but

similar to the medications that we have

pde5 Inhibitors pde5 Inhibitors work in

the erection Cascade basically what

happens let's actually let's take it

back to the nitric oxide thing we'll get

there so nitric oxide essentially is

released by the endothelium in response

to a visual tactile stimuli stimulating

cue right and so your body releases

nitric oxide which then sets off the

Cascade for the erection and so that

releases cgmp which is which is causes

the erection and it's degraded by

phosphodiesterase and so medications

that inhibit phosphodiesterase like

Viagra and Cialis tend to prevent the

breakdown of that cgmp so you have

longer lasting erections and so

similarly these medications work sort of

similar to that some of them we don't

know exactly how they work but they work

by increasing increasing cgmp or camp

that are involved in those Cascades and

what about l-citrulline I hear about

l-citrulline use it's an

over-the-counter supplement

um and it's in the Arginine pathway and

my understanding is that it works

similarly to things like uh Cialis

Viagra but is perhaps not as potent I

also just a cautionary note out there

l-citrulline can give people vicious

cold sores and canker sores vicious you

hear about this on the Internet it's

been verified by grotesque images that

you do not want to Google for

um and not everyone tolerates it well so

these actually work by increasing

nitrate side so they're not in this

they're not later down the pathway

they're actually increasingly

availability of nitric oxide so

L-Arginine is the more direct pathway

but it's very low bioavailability

l-citrulline converts L-Arginine but it

lasts much longer in the bloodstream

which is why people tend to use

l-citrulline now you know in in sexual

medicine these supplements while there's

been some studies on them and they are

effective there's no regulation on the

supplement industry so you know we can

recommend them but we just can't say

that for sure that the supplement is

exactly what's said on the bottle we see

lots of studies where they'll say you

know I read one about melatonin and

there's you know A variation of

melatonin from like what's on the bottle

to 400 times more and so that's kind of

the struggle that we as medical doctors

have and I know we get a lot of slack

for it that we don't talk about

supplements but it's really the

challenge there is like finding the

quality supplement a great site is which

I have no uh relationship to except that

I mention them all the time

um is examine.com which has references

to to human studies and where there's a

lot of efficacy shown and we'll get into

some side effect issues does can't

address you know quality by brand issues

but um thanks for mentioning that what

percentage of males who

take Cialis

um AKA tadalafel or Viagra for erectile

dysfunction get relief from that because

you mentioned only three percent of

erectile issues in males are hormonally

in origin but what percentage are likely

to be blood flow related in origin so a

large percentage of our blood flow

related that doesn't mean that the

medication will be effective for

everyone if you look at the large

percentage are are vascular in nature

right that's the number one cause in in

as men age so we know that about 50 of

52 percent of men over the age of 40

will have erectile dysfunction and that

continues to increase as you age so 50

of 50 year olds 60 of 60 year olds and

so on and so forth so it's very very

common and the success rate in the

studies is about 60 to 70 percent so

when you give someone a medication they

will have sustained erections that are

sufficient for penetrative intercourse

which is the way we kind of just discuss

erectile dysfunction in studies and in

you know with patients is is about 60 to

70 so not everyone will have success but

not all of that is because the

medication doesn't work

um sometimes people are not taking them

correctly sometimes people need to try

different Doses and then there's still

this issue of you know your brain is

still active and so if you're having

anxiety or having other issues or stress

in your life that can have an effect on

your ability to create an erection so

there's lots of factors that go into it

but generally speaking they are

effective and they do work quite well

and they're tolerated pretty well and 60

to 70 is not a small number that's

that's a significant number that's the

majority by a significant margin is

there a basis for the use of um Cialis

uh to delophyll Viagra

l-citrulline in females

yeah there there's not a lot of data on

this but certainly you know if you have

surmised that there is a blood flow

issue and they're having difficulties

with orgasm it's certainly something you

can try off label and certainly people

do try uh try these medications off

label to see if they improve sexual

function for women but there's not a

whole bunch of robust you know

randomized controlled trial studies on

women with with these medications

a little bit later we will talk about

prostate health specifically but I'm

just going to make a note here that

um nowadays there's increasing use of

low dosage

Cialis slash tadalafel so rather than

what I found online was that the

erectile dysfunction treatment dosage of

cialisa Delphos somewhere in the you

know 15 to 20 milligram range what we're

talking about here is daily use of 2.5

to 5 milligrams of sea Austin for

prostate health and I learned in

researching for this episode that

tidalophil Cialis was actually developed

as a drug for the treatment of prostate

health to

essentially increase blood flow of the

prostate to increase prostate health not

for the treatment of erectile

dysfunction so I found that to be

somewhat interesting and a lot of people

are now starting to use that I also

learned that um if you dive into the uh

the guts of the internet one can find

that now there's a growing use of

combined low dosage Cialis and April

morphine which is a pro-dopaminergic

agent and we'll get back to dopamine a

little bit later but

um is there any basis for low dosage say

2.5 to 5 milligram daily use of Cialis

to delophyll in females yes so

land females I think low-dose daily

Cialis is excellent for erectile

function in men even is that true even a

sorry to interrupt but is that true even

for men that are not experiencing

erectile dysfunction it's not indicated

for that purpose but there's a thought

that you know it's increasing blood flow

to the area so people I I've personally

used it for men who have pelvic pain to

help with increasing blood flow you can

also use it potentially as a

preventative so some people have you

know kind of thought okay it's

increasing blood flow it's preventing

fibrosis of that erectile tissue that

can happen with age or other vascular

problems so it may be beneficial for

that as well although again that's off

label and not something that we

generally promote as far as for women

there's you know again it can help with

blood flow so if you're having issues so

if you have a female who's having sexual

dysfunction and she's got signs of

vascular problems like she's got

diabetes high blood pressure she smokes

and yes it's certainly reasonable to try

and see how they do usually you want to

give at least a four-week trial to see

if there's any benefit with those

medications great thank you for that

um

why is it that I get so many questions

about erectile dysfunction from males

who are in their 20s and 30s because

everything you said up until now was

mainly focused on men 40 years and older

is it from lack of physical activity

overuse of nicotine by the way vaping as

far as we know vaping and smoking bad

for erectile function and perhaps Sexual

Health in males and females generally

because nicotine is a vasoconstrictor

nicotine does have certain benefits and

I covered this in an episode on nicotine

um neurocognitive benefits in the

elderly in particular but it is a

vasoconstrictor so it runs against all

of the sexual arousal stuff that we're

talking about

um but okay let's assume that

um uh male in their 20s or 30s is

sleeping enough

you know six to eight hours a night is

exercising isn't doing anything to

punish their pelvic floor in the gym you

know they're not doing legs cross kegels

while doing crunches or something while

inhaling on the crunch

um

that was a quiz by the way folks

um for earlier topics covered

um let's assume they're you know eating

pretty well majority of their foods are

coming from non-processed or minimally

processed foods

um they're doing a little meditation

each day they're

engaging in hopefully healthy

relationships they're not masturbating

like crazy to porn and um uh you know

let's assume that they are you know not

on any SSRI why are all these 20 and 30

year olds on the internet asking mainly

you this is they mainly run to you

um but also to my direct messages about

their erectile issues so I will say I

have seen a lot of young men in my

clinic and I will say that they very

often have pelvic floor dysfunction so

they even though they're doing all the

right things they're they do have I mean

we're in a stressful Society so you can

try all the things to be to decrease

your stress but a lot of us are sitting

long periods of time especially during

covet I mean people sat for months right

years like just sitting at their home

computer and so

um you know exercising one hour is not

going to offset the day full of sitting

and so all of those things can affect

pelvic floor function so my theory is

that that's probably the more common

cause so walk more yeah I've actually

use a standing desk yeah yep yeah walk

more standing desk

um

okay so

um and then my guess is that there's

some psychogenic feedback loop

absolutely which is just nerd speak for

things aren't working as well as they

would like then they're stressing about

it and the stress is making things worse

absolutely and you know you mentioned

that people are not masturbating or

using porn but a lot of people learn

about sex through porn whether it's good

or bad we can't you know it's not a

great thing but like that's accessible

now when we were growing up you had to

find a VCR you had to find a quiet room

that no one was going to walk in I'm old

enough to remember when the kid down the

street I won't mention them

um uh by last name but yeah the kid down

the street you know had

um porno magazines yeah or magazines and

then there was actually a library of

these goodness I shouldn't say where

they were in the town I grew up in where

kids would stash them in um in specific

locations in parking lots and then you

know boys would bike or skateboard over

or walk over and then they would like

take terms look take turns excuse me

looking at them but that that actually

is to raise uh perhaps a more important

Point

um which is that looking at pornography

is different than masturbating to

pornography which is also different than

masturbating to pornography to the point

of ejaculation right because

um I also get a lot of questions from

people about their porn addiction issues

and there's a growing Theory out there

that overuse that meaning not just

looking at but

um masturbating to pornography to the

point of ejaculation is creating a

deficit of seeking out and

um cultivating healthy real world sexual

interactions yeah so I want to I want to

start this before I get into that is is

to say that if you're masturbating to

porn and you have normal healthy

relationships and you're going to work

and you're have a great you know a

partner and everything's great in your

life it's okay like shame is a real

problem and maybe they're watching

pornography together yeah so I think you

know I think it's important though that

at least in the literature they describe

they don't describe porn addiction they

call it problematic pornography use and

it's only describing about four percent

of people in these studies so it's it's

a small subset of people I think it's

becoming more common because pornography

is so accessible and it activates the

dopamine Pathways just like any other

sort of addiction right you you watch

pornography you get a dopamine response

your brain then says Oh I wanna I want

that again and you keep seeking more

novel more aggressive different types of

pornography to get that same response

but it doesn't happen to everybody but

also I would say um sorry to interrupt

but um that the dopamine response as a

hardwired biological mechanism

for adaptive behaviors including and

let's just Define healthy sexual

behavior because I feel like

um there's such a range on that

depending on one's background religious

beliefs Etc

um anytime we talk about sex on this

podcast I like to say that involves at

least four things

obviously consensual

age-appropriate

context appropriate

species appropriate yes absolutely

absolutely that I'm really glad you

brought that up so I've heard you say

that before but it's very important and

so I think you know there is a spectrum

a large spectrum of people who watch

pornography ejaculate to pornography and

have a normal life and so that's fine I

think that you know if we shame those

people we're creating problems right we

say like oh you you do that that's

horrible and then they're in their head

right and then they're causing problems

in their life because they're because of

Shame and so there's I I think there's a

little bit of

um cultural shame that comes of this

discussion and so you know it's a

problem in the long term if we if we say

that oh this is going to create problems

because not everyone has there's so many

people who watch pornography and have no

problems who you know have normal

healthy relationships great sex with

their partner and it's fine or they're

between relationships yeah and they're

relying on masturbation specifically

right

um are there any data that distinguish

between

um Just Pure Imagination Fantasy Versus

visual fantasy as it relates to

developing or inhibiting sexual health

and here we're talking about the desire

aspect let's assume physical arousal is

you know handled so no pun intended so I

think that

um the the thing about young people I

want to get back to that then I'll

answer your question but the thing about

young people who are watching

pornography that's what they think sex

is supposed to be like they don't get an

education about what sex is right no one

has a conversation with their kids like

hey guys this is what happens when you

have sex this is how long it should take

this is what foreplay is and this is

like not normal this is the production

this is a produced product that's meant

to arouse you right and and to give you

ideally an ejaculation or an orgasm

right so

um no one has that discussion so if men

go to relationships like why did my

partner not react like that woman did on

the porno right or why did I not react

like that woman did on the porno why

didn't he reaction yeah when you know

like they would in porn because again I

think females are watching porn as well

exactly yeah you know I think so I think

that you raise a really critical point

which is that the shame can extend both

ways

and so I think to that end that's a

problem and and because it's so

accessible I think we need to have

conversations I think it needs to be

open we have to talk about sex and

that's kind of why I do what I do we

have to have these conversations so

people know what normal is thank you for

that I do think that people need to know

what normal is and what the range on

normal is keeping the constraints that

we talked about placed earlier because I

do think those are Universal healthy

constraints right consensual

age-appropriate context appropriate

species appropriate absolutely

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asked whether or not

imagined the pure imagination-based

arousal versus

um visual arousal

um and for some people the sounds of of

people having sex is extremely arousing

have you ever lived in a major city

um like New York which I spent summers

in New York you hear a lot you hear more

more often than you do in

um areas where people are living further

apart you hear people having sex yeah

it's part it's part of the um part of

the auditory landscape yep you're very

close together so um but yeah so there's

not exactly at least to my knowledge I

don't know of the data that looks at

Fantasy Versus visual versus auditory

but I will say that you can get

habituated to certain things and there

is that data that maybe you can get

habituated to watching a certain type of

thing to get aroused and then normal

things do not get you aroused right like

you may watch pornography and then you

may have difficulty getting aroused or

turned on when you see your partner uh

you may get used to masturbating a

certain way right so if you use certain

vibratory stimulation or certain

pressure sensation every single time you

masturbate you can get habituated to

that and you may not be able to

replicate that during penetrative

intercourse and so I think that's really

important and I think the take home is

to try and Vary what you're doing

masturbation is find healthy way of

self-exploration again with the caveat

that as long as you're not masturbating

to excess and avoiding your obligations

or your family or your partners or your

friends right like you are just

masturbating for the benefits of maybe

sleep Improvement mood boosting

reduction in anxiety those those things

are great and so I think

um with that being said you just want to

be thoughtful about bearing it up one of

the issues with masturbation that I've

talked about when I was a guest on other

podcasts mainly in the context of male

masturbation and um perhaps with

pornography perhaps not is that it's

pretty clear based on the data

surrounding addiction

that

anytime there are big increases in

dopamine without a lot of effort

required to generate that dopamine like

turning on pornography on the internet

versus you know asking someone out on a

date going out on a date you know again

we're talking about going through the

conversations and the mating ritual that

is the human mating ritual that of

course in the context of healthy

interactions involves getting Mutual

consent and these kinds of things right

that you could imagine how without

placing any moral judgment on it without

shaming anybody you could imagine that

if somebody exclusively masturbated

and didn't develop the skills of

courtship and building healthy sexual

relationships that pornography and or

masturbation

could start to create quote unquote

problems right whereby somebody only

felt comfortable in those domains yeah

and I think that's what I'm hearing more

and more about

when it seems to be young men Reach Out

absolutely and I think you're you know

it's definitely the ease of access right

but I think that's pervasive in the

young Society now like you don't have to

actually go and find a mate you can just

go on an app and look for somebody right

like there's there's no form of finding

to make I mean I I was weaned in the era

when uh you know no smartphones or

anything and um no my point is I think

that we've become very connected to

technology in our world which also means

that we're having less conversations the

younger generation is having less

conversations and more online

conversations and I think that's a skill

that needs to be developed as well and I

think part of that is is contributing to

all this as well well one thing that I

can attest to is that you know I grew up

in a community of mostly male friends I

have free male friends always have

um where a lot of what we learned about

sex came from older my case guys

my sister probably learned a lot about

sex from her female friends

um and there was always that one guy who

would just say stuff that years later I

realized was incredibly misleading right

maybe even just detrimental

and I just want to remind people that

when you are on Reddit or anywhere on

the internet and there's

people saying things with certainty

um they might be that guy yeah right

absolutely and um and if you look at the

Lo if I look at the long Arc of those

people that guy's life it it didn't

speak to um tremendous success in the

domain for which they were asserting

such confidence let me put it that way

okay

um I'd like to slightly pivot to a

different aspect of this conversation

because it's just really critical which

is the female sexual response

you know this is something that

um does not get enough discussion

absolutely and there's a lot of

stereotypes right The Stereotype that we

hear about is oh you know they need more

foreplay which can be true some cases

is not true

um The Stereotype is that women are more

um intimacy and relationship based in

their sexual response

that can be true

I have female friends and have known

women who also are just really

interested in having sex for sex sake

at times yep or maybe all the time

um I think I like to think that we are

past the stage of human development

where the stereotypes around this are

um are fixed right and and we hear more

about this and we see more about this

now but what is the real deal around the

female arousal response and then we will

talk about female orgasm response and

there I'm just going to earmark now that

um anytime we say something like arousal

or orgasm

there are multiple forms of that right

and we will talk about the multiple

forms of female orgasm yeah so if you

talk about the response cycle you can go

back to the research of Masters and

Johnson and so what they did this was

way back when and they actually watched

sex workers have sex and this was I

guess okay female sex workers yeah with

men yeah so they watched and they took

note of the the site the kind of the

steps of the female arousal or sexual

response and so the first phase is

excitement right and during that phase

your heart rate goes up you're breathing

a little heavier there's the sex flush

you can see redness in areas like you

know in the vulva in the breast I mean

in the nipples and then you go to sort

and that can last a variety of different

times you'll also start seeing some

lubrication vaginally right and then the

plateau response is when you know that

is kind of at its peak and it kind of

stays steady and then you reach orgasm

and so orgasm essentially is a response

of the body where you will have again

increased sympathetic response and you

will have pelvic floor muscle

contractions which are rhythmic about

0.8 seconds or so you're having a

rhythmic pelvic floor contraction along

with the sensation of orgasm and then

you'll have your recovery period which

you talked about briefly earlier which

can have you know sort of a refractory

time period at which point you can no

longer you know orgasm again if you'd

like to or for men to obtain another

erection again for a short period of

time and that can be kind of an absolute

refractory period so where it's

definitely not happening and then a

relative refractory period where you'd

need something more novel and exciting

to then again resume that cycle again

the Coolidge effect yeah and we'll talk

I've talked about the Coolidge effect

before on this podcast I'll just cue

people to a a timestamp link in the show

note caption so we don't go the down the

path but one thing that's really

important to understand is that the

Coolidge effect is present in both males

and females meaning

if a male ejaculates and

um is of the feeling that they can't

have another erection for some period of

time the presentation of a novel I guess

we should say partner because we could

be talking about homosexual relationship

here not just heterosexual but

um a novel sexual partner female or male

depending on their um their proclivities

um can override the refractory period

um and they can have another erection

and ejaculation

um similarly a female will have a

post-orgasmic refractory period if

they're given an adequate stimulus right

something arousing enough

they can experience arousal and orgasm

again and we know based on really good

pharmacology that this is a dopamine

driven

um thing the prolactin is essentially

establishing the refractory period and

the dopamine is essentially overriding

the refractory period fascinating

neurochemistry there

um and it speaks to the incredible

extent to which the brain is controlling

the genitals yeah I mean we we always

say in sexual medicine that the brain is

the most powerful organ for sex not not

your genitals but the brain because it

is so powerful and I'm not sure if we're

going to touch on this later but I'll

bring it up now there are some centrally

acting medications now available for

their FDA approved for premenopausal

women with low libido oh maybe just

throw those out because the one that I'm

aware of um is uh in that's often used

in let's say Niche cultures

um is melanocyte stimulating hormone in

men which gives people a tan makes them

erect um the melanocyte stimulating

hormone and msh comes from the media

deal pituitary if I'm not mistaken one

of those weird regions no everyone talks

about anterior poster but and people are

now injecting this as a peptide it can

cause pre-opism I have not had that

experience I've never tried this um msh

but I've been told that it it people are

getting Cavalier with it they can have

issues uh pre-pism being enduring and

perhaps even final

erection is that true yeah

I mean it's actually from priapists the

Greek god who is often photographed with

a really big erection oh well we didn't

hear enough about that Greek god in

school but um or is it Roman Roman or

Greek but anyways so either way um it's

an erection that lasts longer than four

hours and it is actually a surgical or

it's not a surgical but it's actually an

emergency if you have an erection that

lasts longer than four hours in the

absence of you know sexual arousal then

it is important to get to an emergency

room because at that point you can start

developing decreased blood flow and

ultimate really no changes to the actual

tissues scarring fibrosis so it's really

important to actually go to the

emergency room don't wait because you're

embarrassed really get there and get

treated however if I'm not mistaken

earlier you mentioned that it is

exceedingly rare that people who take

Cialis slash to Dallas or Viagra for

erections are getting true priapism

correct and it's mostly from uh those

injectables we talked about earlier

those intracavernosal injections people

can get priapism from those a little bit

more commonly and so that's something we

always Counsel on and also certain

medications like trazodone or if you

have sickle cell anemia those are the

most common reasons that we see people

coming in with priorities okay I'm going

to refrain from my um desire to figure

out that one so I don't take us down a

rabbit hole here sorry I wanted to get

back to the msh there's actually an FDA

approved medication called brie

melanotide is the brand name vilisi is

the uh the sorry brie melaton is a

generic name vilisi is the brand name

which is FDA approved for women with

with low design hypoactive sexual

desired disorder premenopausal women

pre-menopausal because that's what they

studied but it is basically the same

peptide right so it is a melanocortin

receptor Agonist and it works dope you

know on the the brain Pathways to

increase desire it's taken as an

injectable again just like you said

about an hour 45 minutes before one when

you want to want you take it 45 minutes

before and it works quite effectively in

increasing desire how long does it last

about 24 hours some people may be up to

48. um has it been I mean I know of men

using melanocyte stimulating hormone

peptides I also really want to caution

people

um about obtaining gray Market peptides

sorry for this um uh insertion here but

um there are a lot of peptides available

without a prescription on the internet

they are almost all contaminated with

something called LPS Lippy

polysaccharide which is not something

you want to be injecting a lot over time

that's actually how we induce an immune

response in animals in the laboratory

and it is amazing to me how many

websites are selling this stuff and it

um arrives to you easily you just buy it

on the internet says not for human or

animal use and people are injecting it

and the LPS issue is something I think

is um potentially going to shut down

that whole Market at some point but if

you're interested in using a peptide you

should be obtaining it by a prescription

from a quality physician exactly and

because we have Brie melanotide we can

prescribe that for men as well so

sometimes we'll do it off label from men

who are having delayed ejaculation

because it will help them achieve orgasm

a little bit better and so you know this

is available for pre-menopausal women

the other uh medication that's available

for low libido is called phlebanserin

also known as Addie is the brand name

and that also works on Sarah's it's got

kind of a mixed response serotonin and

dopaminergic areas of the brain and

essentially works as a daily medication

taken before bedtime 100 milligrams a

day that actually helps with decreasing

hypoactive sexual desire disorder Works

in about 6 45 to 60 percent of patients

and you need to take it for some time

now both of these are brand name

medications so they are a little bit

costly and sometimes insurance doesn't

cover them but they are available and I

think very few people know about them

and I think they're really great and

useful tools in the toolbox and these

are for desire they're for yes they're

they're FDA approved for what we call

hypoactive sexual desire disorder which

is essentially low libido that causes

distress and bother

I don't want to take us off course about

vaginal

um lubrication arousal and female orgasm

but as long as we're talking about

arousal and

um

reduced arousal that requires treatment

I have to ask this now

anytime we talk about arousal and libido

there's no BMI which by the way the body

mass index is probably not the best tool

either but there's no chart it's not

like a thermometer that says your 98.6

plus or minus two degrees you're good if

it's too high much higher than that you

have a fever if much lower than that

you're hypothermic so my understanding

my uh I don't want to say naive

understanding but um my understanding is

that

one determines whether or not their

libido is normal high or low

largely based on some intuitive

understanding of what their partner or

partner's desire whether or not they can

meet those desires and if they sort of

uh accrue enough of a sample size they

date enough people where they have

sexual interactions they can they figure

out over time whether or not they have a

low medium or high sex drive and people

tend to compare to how they felt in

earlier years or at different times of

the year or under different

psychological conditions and stress

conditions that kind of thing but we

really don't have a benchmark for this

right I mean we can't say that for

instance that if uh people are not

Desiring sex or thinking about sex with

blank frequency that they have low

libido right it's sort of what is

working or not working for you in the

context of your life right is that is

that yes there's no right or wrong

basically what you're saying there's no

right or wrong amount of libido there's

many people who identify asexual and

they are happy with that there are

people who like to to have sex once a

month and they're happy with that it

really is a matter of distress are you

bothered by it so when we look at

studies for female sexual dysfunction

you can using like validated

questionnaires like the fsfi you can

actually see that about 40 percent of

people qualify for having sexual

dysfunction but really bother is only

seen in about 12 percent and you can be

bothered because you're bothered you can

be bothered because your partner is

bothered but it's really up to you right

like if you feel like there's something

that you want to improve on then that's

when you go see your doctor but there's

no right or wrong answer right this is

very subjective and a lot of times we'll

see couples who have mismatched libidos

now does that mean one person's right

and one person is wrong no it's just a

matter of like well how do you if you

want to come to a point where you agree

how do we get there you know and what is

what is your end goal yeah I later we'll

talk a little bit more about chemistry

which I find infinitely fascinating

because in my life experience I've just

been struck by the fact that occasion

only you have a physical interaction

with someone or sometimes it's not even

physical interaction and they are just

so unbelievably arousing to you or

somewhere in between or sometimes it it

just sort of ain't there or it's just

not there that much or nobody likes to

talk about this or it's there until you

sleep together and then it's not there

and this is all not just put on males

this is put on females i i

she doesn't kill me for saying this

I know somebody who is a family member

who once said sometimes you have to

realize you never want to sleep with

somebody Again by Sleeping with them and

here we're not talking about traumatic

experience right right so you know again

the discussion around libido as you um

so aptly pointed out engaging what is

healthy levels of libido has a lot to do

with what one's self-desires as well as

the hopes and expectations of the people

that we are sexually involved with so

we'll get back to that a little bit

later in the context of chemistry

because I find it so fascinating and

it's something that isn't talked about

enough

but thank you for that

um let's get back to

female sexual arousal response and

orgasm so physiologically what happens

to the body is It prepares for

penetration now that could be a penis

that could be a sex toy that could be a

digit finger to be more specific so it

what it does is the cervix moves up and

out of the way the the inner one-third

two-thirds of the vagina lengthens and

elongates to allow for penetration and

it can actually double nearly double in

size of the of the Baseline vaginal

length and so it is preparing for that

so if you and so that's part of it in

some people who have Painful intercourse

it's because they haven't had adequate

time for arousal and so they're the

penis is penetrating before they've had

those adaptations to occur and also the

labia open up to allow for that

penetration so these things actually

happen physiologically to allow for

Preparation so while some people may be

aroused and get to that point quicker

some people do need a longer period of

time of what as you described before

play and not everyone is is the same but

I think it's important to have that

discussion with your partner and you

know lubrication is one of the ways that

people assess arousal but that's not the

be-all end-all some people just make a

lot of lubrication and some people don't

and certainly that changes with age and

hormones so if um certainly we know that

after menopause with a drop in estrogen

and testosterone you will see a decrease

in lubrication and sometimes if people

are on medications that can alter their

hormonal access they may also see

changes in lubrication after during

breastfeeding you can see changes in

lubrication and again this is not a

they're not aroused necessarily this is

like a physiologic problem that they're

having can we distinguish between

arousal-based lubrication let's say

sexual arousal based lubrication and

again folks forgive me for being so

hyper-specific in language but there are

other forms of arousal besides sexual

arousal that we know from it's not a

pleasant topic from reports uh following

sexual assault that you know oftentimes

the victim is demonized for having been

lubricated and they will say well then

people will presume that somehow they

wanted that interaction and that's not

true in those cases it's clear that

those that the lubrication occurred

independent of libido type arousal

exactly right okay so let's set that

aside again unpleasant topic but one

that's important to to um to flag

are there forms of non-libido

type arousal

lubrication that allow for non-painful

or even pleasureful

penetration

that

are important to distinguish from the

arousal based lubrication in other words

I have to imagine

that women will

have sex and it can be pleasureful or at

least not painful and that might relate

in some way to Baseline levels of

lubrication and here we've been talking

about lubrication mainly in the context

of arousal you know post-menopausal

reductions in lubrication but are there

also postmenopausal reductions in

Baseline lubrication are some people's

vaginas just more lubricated at

um I won't say at rest it's like a

scientist in me um when um they're

asleep for instance I mean men are

having erections in their sleep are

women getting vaginal lubrications in

their sleep periodically my guess is yes

well they're definitely getting clitoral

in engorgement right they're getting

clear engorgement there's been some

studies on that that they are also

getting nocturnal tumescence right just

like men do as far as lubrication you

know the the data at least from what I

understand is like there is a protective

mechanism whereby women when when

there's any sense that there may be

penetration that their body will

immediately start creating lubrication

and that is productive to avoid you know

trauma and injury there's also Baseline

vaginal discharge that's completely

normal women will make physiologic

discharge in fact in our examinations

when we examine we'll say normal

physiologic discharge because we see it

there's always discharge and it is um it

can be up to like five milliliters and

so it's not a small amount it can happen

it can be quite a lot it needs menstrual

cycle dependent in terms of the

viscosity and the yes it changes over

the cycle and it can be different in

color and different in thickness and

that's completely normal and I think

that's a real problem in the feminine

hygiene industry

um you don't need to smell a certain way

or or reduce that discharge this is like

completely normal healthy and you talked

about chemistry and I know there's like

not a ton of data on this but there's

like pheromones right there's scents

that are coming from you which are

actually attractive to a partner

potentially and and in whatever

physiologic you know I don't know

there's not a lot of data on this but

like there is that part of it so

um you know there's a lot of marketing

towards women that you're dirty you

should be smelling like peaches or

whatever and there's a lot of marketing

maybe this is generational thing but I I

learned early on I think about

behavioral Neuroscience courses that

vaginal lubrications were

um part of the arousal response for both

um these were always framed in the

context of heterosexual relationships

but both Partners let's just say both

Partners um because this could be a

homosexual female relationship too right

we want to make the conversation as

broad as possible

um and that the odor let's just be frank

here um the odor and The Taste

um played a role in both arousal but

also the pair bonding response that

would establish future arousal and

anyone that's ever been in a um in a

relationship that uh let's say you had

healthy sexual relations I like to think

his experience I'm remembering

somebody's smell or thinking about

somebody's smell and that itself can be

very arousing yes Partners even I'm

smelling uh different articles of each

other's clothing and that being arousing

so I mean this is the stuff of of real

physiology we're not we're not making

this stuff up right but there is there

is a lot of marketing towards women that

they should use douching or other things

to clean themselves and it is it's

damaging right it's actually one it can

affect the vaginal microbiome so their

pH is changing and that can affect you

know their risk for UTIs or bacterial

vaginosis and um and and so they're

they're buying these spending their

money on these things because they're

being told that they're not clean and

they come to the doctor saying oh I'm

you know I think I have a STD but it's

like normal physiologic discharge

um and so I think it's important to say

that this is normal and and it's normal

to have an odor that is distinct to you

and that there's you know of course if

you have like a fishy odor that may be a

sign of like a very strong new novel

odor that wasn't there before that may

be a sign of a sexually transmitted

infection but if it's your general odor

that you've always had that's normal

what about other infections like yeast

infections or bacterial infections of

the um I got a number of questions about

mycoplasma infections which you know we

don't hear that often about but um yeah

so you you can see if your discharge has

changed and become more like Cottage

cheese-like or there's um you know other

symptoms like itching

um or discomfort then you know those are

signs to go get evaluated a mycoplasma

is another infection that we see in the

vagina but we also actually sometimes

see in the urine and while it's not

something we routinely test for when we

have people who have symptoms of urinary

tract infection and they're not

improving sometimes they will check for

you mycoplasma that could be causing

symptoms in the urethra itself we've had

a couple episodes about the gut

microbiome my colleague Justin

Sonnenberg at Stanford whose laboratory

is directly above for my his expert in

the gut microbiome I've done a couple

episodes about this and um he reminded

me and I like to remind people that

every mucosal lining of your body has a

robust microbiome so that means

intranasal and true vaginal intra

urethral in males and females there's an

anal microbiome there's a microbiome on

your skin on your eyes

and you mentioned douching and other uh

and other ways of I want to say quote

unquote cleaning it because that

language Falls in line with the idea

that it's a good thing you're telling me

it's it's a bad thing in many cases

um because it's wiping out the

microbiome what are some of the things

that females can do in order to promote

the health of their vaginal microbiome

so it's it's really our bodies are

amazing the vagina is a self-cleaning of

it you don't have to do anything you

just watch that the vagina is a

self-cleaning oven I'm not gonna I'm not

going to repeat that too often in too

many different contexts but I'm going to

remember it forever you will you will

and so all you need to do is wash the

hair bearing areas because those are the

ones that create sweat and and and

should be cleaned but other than that

let soapy water run down you don't need

to do anything your body will take care

of it itself when I was five years old I

pulled my parents in the bathroom and I

said they still talk about this I said I

want to know everything about sex I want

to know everything and they were like oh

my God what are we dealing with and I'll

never forget my dad just looked at me

he's Argentina he said Just remember

kids are the one thing in life you can't

give back that's all he said that was it

that's it that was it oh gosh yeah well

I will tell you my discussions with my

sons are my son my older son has been

much more graphic than that I tell him

amazing yeah amazing well I went out

into the world and uh anyway

um you figured it out

let's spend a few minutes or more

talking about female orgasm

one of the more cryptic topics on the

internet

not because it isn't discussed but

because I think that the Nuance of it

isn't discussed often enough or in full

depth so let's take the time we need um

to parse this