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

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 general public in keeping with that theme I'd like to thank the sponsors of today's podcast our first sponsor is Roca Roca makes eyeglasses and sunglasses that are the absolute highest quality I've spent a lifetime working on the biology of the visual system and I can tell you that your visual system has to contend with an enormous number of challenges in order for you to be able to see clearly Roca understands this and has developed their eyeglasses and sunglasses so that you always see with perfect clarity in addition they are extremely lightweight and they won't slip off your face if you get sweaty indeed Roca eyeglasses and sunglasses were initially designed for performance in sports but now they include Aesthetics and 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would be so kind as to take a few minutes to fill out the survey and help us continue with bringing you the best possible content here at The huberman Lab podcast and as always thank you for your interest in science and now for my discussion with Dr 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 as many of you know I've been taking ag1 daily since 2012. so I'm delighted that they're sponsoring the podcast ag1 is a vitamin mineral probiotic drink that's designed to meet all of your foundational nutrition needs now of course I try to get enough servings of vitamins and minerals through whole food sources that include vegetables and fruits every day but oftentimes I simply can't get enough servings but with ag1 I'm sure to get enough vitamins and minerals and the probiotics that I need and it also contains adaptogens to help buffer stress simply put I always feel better when I take ag1 I have more focus and energy and I sleep better and it also happens to taste great for all these reasons whenever I'm asked if you could take Just One supplement what would it be I answer ag1 if you'd like to try ag1 go to drinkag1.com huberman to claim a special offer they'll give you five free travel packs plus a year supply of vitamin D3 K2 again that's drink ag1.com huberman gosh Lots there to unpack and I'm glad you mentioned the relationship itself because there are all sorts of things that can impact the arousal response novelty 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 I'd like to take a quick break and acknowledge our sponsor inside tracker inside tracker is a personalized nutrition platform that analyzes data from your blood and DNA to help you better understand your body and help you meet your health goals I'm a big believer in getting regular blood work done for the simple reason that many of the factors that impact your immediate and long-term Health can only be analyzed from a quality blood test however with a lot of blood tests out there you get information back about blood lipids about hormones and so on but you don't know what to do with that information with inside tracker they have a personalized platform that makes it very easy to understand your data that is to understand what those lipids what those hormone levels etc mean and behavioral supplement nutrition and other protocols to adjust those numbers to bring them into the ranges that are ideal for your immediate and long-term Health inside tracker's ultimate plan now includes measures of both APO B and of insulin which are key indicators of cardiovascular health and energy regulation if you'd like to try inside tracker you can visit insidetracker.com huberman to get 20 off any of inside trackers plans again that's inside tracker.com huberman to get 20 off I 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 I think that the simplest way to parse it is going to be from the anatomical standpoint clitoral orgasm versus so-called G-spot or penetration-based orgasm but of course penetration-based orgasm is also a bit of a misnomer because there can be clitoral stimulation by pelvic pressure or by digit we're talking about fingers it's digits because we're both in the Medical Science profession but we're talking about fingers here or something else right vibrator toy whatever I'm toe for it depends on how flexible you are I don't know but the point being um that I think the simplest way to go about this is going to be to talk about the distinction between clitoral orgasm and G-spot orgasm however those are achieved um and to also talk about this idea of graded versus absolute okay so this has actual parallels to Neuroscience where we talk about communication between neurons being graded meaning it's kind of you know one level then a higher level than a lower level or all or none right um how should I say this um it is clear in my life experience and observation that there are multiple kinds of female orgasm those that are graded and in some cases cumulative they sort of build towards a larger and larger orgasm and then there are what some people have described as Cliff type orgasms where there's a refractory period I think that's a fair way to frame this and clearly there are different responses to the orgasm response some people get sleepy some people get energized some people it heightens their desire for more some people they need a a period of time in which um they become hypersensitive to touch um so uh lots of different things going on there psychologically physiologically um yeah tell us all of it so in terms of orgasm right I think it's important to distinguish that there is orgasm and then there's different areas that you stimulate to achieve orgasm so some people will stimulate the clitoris is probably the most reliable form of stimulation that will achieve orgasm and when you look at the data and again you know female sexual dysfunction data is not super robust but what we find is that about 85 percent of women require clitoral stimulation in order to climax so very few actually climax through just vaginal penetration alone and so this is you know a real problem we're seeing on the media that you know you you have sex and you penetrate and immediately women are having orgasms that's not the reality for a lot of women and in terms of stimulation so like we've talked about throughout this podcast the clitoris is the homologue of the penis or the penises the homologous the clitoris however you want to say it good on you for getting it both directions yeah I probably would have screwed that one up yeah so um so clitoral stimulation is just like penile stimulation for women that is very reliable and there's a huge orgasm gap for men it's pretty consistent that when they have a first time sexual encounter 95 of men are having an orgasm when you look at first-time sexual encounters for women with in heterosexual relationships it's about 45 to 50 percent are having an orgasm and when you look at homosexual relationships of women it's again 90 so there's clearly some lacking in ninety percent of um female homosexual interactions that are first-time interactions 90 percent are having orgasm correct presumably because they understand the anatomy of other by way of understanding the anatomy of self so there's a huge but you know there's a huge gap and so I think to to bring it home is the clitoral stimulation is the most reliable way and as you mentioned when you're stimulating vaginally you're often the clitoris is like a wishbone and it goes around the vagina and so you're often stimulating those the Kura is what we call the legs I guess for lack of a better term of the clitoris and so you're stimulating that you're also stimulating the clip the clitoral shaft which goes deep into the pelvis the G-Spot is um is an area as a neurogenous Zone where it's kind of in the anterior wall of the vagina about two to three centimeters in that's the location of these periathral glands called the skene's glands and they are analogous or homologous to the male prostate so just like some men have prostate play and enjoy pleasure from prostate stimulation some women enjoy G-spot stimulation now that's not Universal right not all men enjoy prostate play and not all women are going to be aroused by G-spot stimulation and so I think there's a huge huge uh huge variety of ways you can stimulate what stimulate anyone it can be man or woman some people will have orgasms through just nipple stimulation alone some will just hear something or see something and be able to achieve an orgasm and it's it's so varied from person to person and I think that the big take home from this for people listening is like you have to talk to your partner and this is the hardest thing we never learned how to talk about sex like what do you like what do you not like and and don't take it personally right like I think a lot of times people feel like you have to orgasm to have pleasure which may not be the case for everybody and if it is you know how do you prioritize that for your relationship so I don't know if I got off track there but that's kind of um I think the the take-homes for this and also the vaginal penetration it's actually usually from cervical stimulation not necessarily vaginal because the large density of innervation of the vagina is in the first outer third of the vagina the the deeper two-thirds of the vagina has has much less Innovation and yet there is such a thing as cervical orgasm so and the cervix being further up the vaginal Canal um is cervical orgasms specifically the what if the stimulation and act uh the foci of an orgasm that starts in the back of the vagina is that yeah so stimulation of the through whatever means right and that can be pleasurable and lead to orgasm and again orgasm you know is is defined differently right but the one thing we know is that there are pelvic floor contractions which are measurable so you can kind of tell that your partner is having an orgasm if you have a female partner because you can actually feel those contractions right whether it's on your digit or your organ or a sex toy okay super nerdy question here um years ago when I worked on hormone-based sexual differentiation which by the way we've done a episode of the podcast on previously um uh you know I learned that the levatory any muscle um is the muscle that controls erection in males and presumably uh clitoral tumescence and an engorgement in females is there an equivalent muscle responsible for the orgasm response or is the contraction of the pelvic floor um part of a more General theme of of muscular contraction and a bunch of different nerve Roots Contracting the reason I asked this is that eventually in this conversation we're going to migrate up toward the brain but because this is a science and health podcast when we talk about orgasm of course many people recognize that as their experience of it and their recognition of it in other people um and descriptions Etc but um are we talking about a response that originates at a Foci um kind of like in a in the brain we talk about a seizure you know starting at a focus a Foci and then spreading out um or are we talking about a bunch of different nerve roots and brain centers firing in synchrony and that's why some people experience it as you know behind their forehead and in their genitals or as a whole body response and here we're not talking about the flood of of neurochemicals into the body I'm talking about during those moments of orgasm um what is happening neurally I mean it does have certain parallels to seizure right it does it does so let me go back to your first part of the question which was um about orgasm and sorry erection and tumescence being related to levator A9 so actually what happens during the reason you get an erection and presumably clear stimulation the same way is blood flows into the erectile tissue and the Tunica which is the outer layers of the of the of the erectile tissue which are two basically cylindrical shape structures in the penis and in the clitoris they will fill with blood and then that Tunica will compress veins on the outside to prevent blood flow from leaving so it's not a muscular event it's an actual blood flow event then how come when we wanted to study erection behavior in rodents we would um give them injections of testosterone females or males and observe changes in sexual behavior accordingly erection and clitoral tumescence although it's harder harder to measure in rodents there's a way of indirectly measuring that and then we would measure the the size and weight of the levator Annie muscles as a readout of how androgenized that whole system was you know in other words what is the role of the laboratory Annie in in the sexual response so the levator Ani well you would know I I still think so those muscles are part of the pelvic floor right and so those contract when you when you climax right so whether it's orgasm for male or female they're Contracting and they're exercising right they're get so that's how they would increase their their strength or their density if you're measuring that through the actual climax of which you can't see in rodents right so like you're kind of using it as a surrogate in that way so that's what happens those muscles contract as a response and climax is a brain initiated event orgasm is a brain initiated event so that's why to answer your second part you obviously feel focal response but you also can feel a variety of responses because it's all coming from the brain it's not a kind of the the way you described it as like a ripple effect um it's more of like uh it it's the way your body responds to that particular stimuli and it's actually like the ultimate form of mindfulness you can't think of anything else when you're orgasming right so it's like you have this Moment of clarity and and every and and everything you were very present in that moment and so people will feel different stimulations depending on you know how they're how they kind of how they're censored you know their nerves are their Sensations are and things like that um it's perhaps a good time to um mention dopamine we talked about it a few times um earlier when talking about the arousal Arc that starts with parasympathetic sort of calm and then um move typically starts as calm and then moves to um the orgasm response we know that the orgasm response is associated with release of dopamine and then prolactin which sets up the relative or absolute refractory period the uh the interesting thing and I got some questions about this is that um there's literature as I understand about the elevation and dopamine caused by say antidepressants like Wellbutrin buprin which increases dopamine and norepinephrine um people who recreationally use drugs like cocaine or other stimulants people who take Adderall Vyvanse or other drugs that increase levels of dopamine because I did a whole episode about those drugs and they are different forms of amphetamine unless we're talking about Ritalin which is a little bit different and I got a lot of questions about people who experience feeling a lot of Desire sort of arousal but not being able to achieve the physical arousal erection or vaginal lubrication so it's almost as if they're sitting further along that arousal Arc hence the importance I think of people learning to have calm states of mind when going into sexual interactions now I realize that in saying that it might be confusing because a lot of people think well that's anything but calm right sexual arousal is anything but calm but maintaining enough calm that they can ride that Arc um for whatever duration is appropriate for that interaction in them right because again and we should probably get back to this you know um you know some people will have sex for long periods of time some for shorter periods of time and here people don't really know what other people are doing except by way of pornography and self-report and discussion so um is it the case that drugs that increase dopamine can inhibit the sexual response do they tend to promote the sexual response because I also mentioned earlier there's this growing trend of people taking by way of prescription of course from a physician combined apomorphine which is a dopaminergic drug um with tidalophil which is a pde5 inhibitor so it's going to increase blood flow and I'm hearing about men and women but mainly men doing this so ramping up their dopamine ramping up their blood flow to their genitals in order to have presumably more arousal in sex does that make sense uh um yes as a mechanism yes so in terms of apromorphine the that has been studied and it's mostly been approved outside of the United States so we don't use it very often here in the United States because it hasn't been FDA approved but you know it's a very complex responsible like I mentioned that um phlebanserin which is essentially acting medication it actually has not only um inhibitory and not only stimulatory but also inhibitory effects on dopamine so the way it sort of works to enhance interest or libido is sort of complex and kind of confusing the when it was actually approved it was it was being studied for an antidepressant and what they found was that women were actually having you know better interest in sex or more interest in sex and so that's kind of how it was discovered similarly Viagra was actually studied for high blood pressure and when they went to um it was horrible blood pressure medication but then the people the men who took it actually didn't return the samples for the study so they realized like what's going on here and it was because they were having better erections is it true that um at some Urology meeting that the first description of Viagra as a treatment for erectile dysfunction involved the speaker actually coming out from behind the podium and revealing his erection is that a true story yes I don't think it was Viagra I think it was an intricate cavernosal injection though I think he came out um it is the true story there's actually a published article I'll send it to you so you can share it if you'd like to see it but I'll read the article there's a there's a published article about people who were attending at the meeting and yes he came out and at the time like it was mostly men in urology but there were like spouses I guess in the audience which is not typical now but um so there were women in the audience and he came out with a full-on erection to show that it you know it worked well I suppose that the Urology meeting um or OB GYN meeting where a woman comes out and reveals her enhanced vaginal lubrication then we will have um we will have a gender and sex balance at the meetings on Urology um it'll be interesting to attend one of those someday um differences in arousal as a function of stage of the menstrual cycle really interested in this I did a long episode on fertility and we're going to have a few other IVF experts fertility experts on the podcast um but clearly um there are differences in hormones across the menstrual cycle we know that for sure yeah um clearly there can be psychological variation according to those hormones but probably other things across the menstrual cycle and it's always an imperfect experiment because you know we aren't laboratory rats and people are having different interactions across the menstrual cycle is there any known correlation between desire and stage of the menstrual cycle there are some obvious um assumptions that one might make you know prior to ovulation Etc around the time of obligation um but what about the other direction too um is there a category of women that are very interested in sex at certain stages of the menstrual cycle and then not at all interested in sex at other stages the menstrual cycle you know all that other and maybe a gynecologist could speak and study those variations a little better but there is data to suggest that libido does increase prior to ovulation and during ovulation I think it's like a couple days prior because that's the optimal time for fertility so yes there is data to suggest that in terms of like completely lack of Interest I don't believe there's data but I'm not not sure is there evidence that females who perhaps have not experienced so-called G-spot orgasm or cervical orgasm can learn to do that and I always find it interesting that whenever there's a discussion about different forms of female orgasm people are careful to point out that many women don't have penetration-based orgasm and then they separate out clitoral stimulation as more a more common route to orgasm but of course there can be clitoral stimulation with penetration absolutely right and depending on the your physical arrangement there can be clitoral stimulation purely by way of penetration through pelvic contact um you know fingers Etc so yeah so how do we how should we think about this how should we talk about it so there was an interesting study that I just read recently where they they gave women words for these things right so um they there's like the rocking stimulation so that can also stimulate so meaning that the you're penetrating but there's like a rocking motion that can also penetrate the clitoris there's um stimulation of just the outer part of the vagina which again as I mentioned the G-Spot is there it's more highly innervated so that can be more stimulating there's also ways to align yourself so that when you're penetrating you're putting pressure on the clitoris and then there's you know stimulation with like actual stimulation of the clitoris like intentional stimulation either by yourself or by the partner and so there are multiple different ways to do that right um and so there I think that it's important to really um kind of it's okay to explore and not always be a home run and I think that's like when you get into a relationship where you're maybe second third fourth time having intercourse with someone that you can try and explore these different things or if the partner themselves knows what they like to actually tell the other partner right there's a huge part of communication that I think is is plays a huge role in this because we know ourselves better than anyone else so you can tell your partner what you like and I think that that we have never been taught how to do that yeah um such important conversations for so many reasons as you point out um definitely not something they teach people in school except you know they might say something about you know communication is important and that almost always circles back to the the key four things we talked about earlier which is you know consent and age-appropriate context appropriate these kinds of things and um and obviously substances like Alcohol and Other Drugs can strongly confound those issues and so that's we'll just leave that as a as a kind of an obvious one um as long as we're talking about communication around sexual interactions um perhaps it would be useful to people to cultivate a language or a nomenclature there too to facilitate that um some of the language that I've heard that is quite useful is things like um you know people have different arousal templates right some people certain ideas are stimulating to them and other ideas are reversive to them and then there's this category in between where sometimes people sort of either don't know because they haven't tried it or haven't thought about it or they're sort of curious but kind of unsure or it might work in the right context but maybe not all the time yeah um so is there any kind of structure that's been put out there as a way to improve communication around sexual interactions yeah I mean there's no like script but I think in general you want to have the conversation outside of the bedroom so not like right before sex or right after sex because that leads to like a you know a sense of insecurity for the other person right did I do something wrong did something go wrong here so you want to kind of move those to a neutral location so like kitchen table in the car whatever somewhere where you know sex is not going to happen um at least for that particular moment and um listening um we've been some challenging conversations on this podcast challenge uh previously challenging because they you know you're trying to get things clear and uh as clear as possible um this one is challenging because there's so many caveats to everything right we don't of course people have sex in cars right yeah um or they did when I was growing up um and sometimes they still do um okay please continue yes so that's one and then two like when you're discussing it I mean this is kind of goes for any difficult conversation is like you make I statements right you say I I like it when this I don't like it with this it's not something you did right it's not you didn't do this you didn't do that it makes kind of an animosity sort of situation and then you know I think also part of it is like being open about those things and it may it's not going to happen in one conversation I think that's the hard part like you think you're going to have a conversation it's going to go great and things are going to be better it's going to be like multiple conversations and some of them are not going to go well right so like um that's another place where you can actually get the help of a sex therapist and there is a website for that it's a-a-s-e-c-t-asect.org where you can look for a sex therapist near you and you can even do those things virtually and so that can be really helpful when you're having difficulty having a conversation yeah I think um again such important conversations and then when people differ in terms of their level of experience it gets um potentially problematic but also it can be potentially educational and then of course they're the twists and turns that occur with when one is asking about somebody else's arousal template oftentimes you'll learn things about people's sexual past and that can be either neutral stimulating or aversive right that can open up all sorts of other issues related to the psychological interplay so there's no way we can parse all of those now I just think it's worth highlighting um that it's understandable why those conversations are challenging um and it also is understanding why pornography isn't going to involve those conversations right right the only conversations there are between your brain your hands and your eyes and your ears um uh not going to highlight any particular order there um I want to switch gears slightly and talk about UTIs I got a lot of questions about urinary tract infections let's make it related to both females and males because yes males get urinary tract infections females get them more females asked about urinary tract infections how common are they should they always be treated with antibiotics is cranberry really a good treatment if so why are there other things that are better is it relates to the acidity or alkalinity um how does one prevent getting UTIs can you get them from swimming should you urinate after sex tell us about UTIs and how not to get them and how to get rid of them happy to so UTIs are very common in women probably up to 50 of women get at least one UTI in their lifetime and up to a third of them get recurrent UTIs and what that means is they have two or more in six months or three or more in a year now this is common and so we'll see a lot of it and it's not as until you're having recurrent utsc you just have one a year or you have one every few years it's not a huge issue in men however UTIs are much less common and that's because the urethra is longer so there's less entry from the outside world into the bladder which causes infections and so um the when men go to UTI it's concerning like why is a man getting a UTI you know there's multiple reasons that it could happen but it should be investigated like so that you can make sure there's no anatomic abnormality or functional abnormality with a bladder that's causing the UTIs in terms of prevention there are kind of major things that are had in the guidelines that we all we all talk about so one is hydration so making sure you're drinking about two to three liters of fluid ideally water a day because dilution is the solution to the pollution right so drinking more fluids is going to get that bacteria and you're going to pee it out it's going to help keep not let it sit around in the bladder very often another thing in women who have Altered States of estrogen whether it's post-menopausal surgical menopause or maybe have a reduced estrogen for postpartum or other reasons but what about you in the second half of the menstrual cycle not necessarily for those specific people but for those specific times but because it's pretty short-lived I guess you could use it but um is vaginal estrogen so vaginal estrogen meaning estrogen that's applied in the vagina either through a cream a suppository or a ring is is highly effective in reducing the occurrence of recurrent UTIs and this is because when you have low estrogen the pH in the vagina goes up and the pH in the vagina goes up because there's less conversion of glycogen to lactobacilli and then those lactobacilla are preventative for UTIs so essentially you want to reduce the pH back to its normal acidic pH and vaginal estrogen is very effective at doing that fact in our clinics will actually check a vaginal pH you know to see if there is an indication that their pH is too high that maybe they do need vaginal estrogen particularly around like perimenopause because it's hard to tell just by looking if they are really um heading into a lower estrogen State sometimes and so that's very very effective and very very safe so when you look at estrogen you know the the Women's Health Initiative way back when sort of made a big stink about how estrogen is related to cancer however vaginal estrogen has never ever been a reported breast cancer uterine cancer or any other blood clot any other adverse event associated with vaginal estrogen you can get some breast tenderness some discharge those things can occur but the absorbed amount vaginally is so little that your estrogen level barely goes up it doesn't even reach pre-menopausal levels so it just goes up very slightly in the bloodstream not enough to create any sort of abnormality so a vaginal astronaut is extremely safe and it's pretty affordable you could actually use coupons if your insurance doesn't cover it through you know GoodRx or Mark Cuban's pharmacy and get it very very affordably and it's very effective it does take about three months to work so you know you have to be consistent you apply it about twice a week at night sometimes three times a week and it's very effective the ring you put in once and it lasts for three months but so generally speaking that's the most effective option for low estrogen States other kind of simple things are trying to make sure you're completely emptying your bladder so over a lifetime people can develop some mild pelvic floor dysfunction right not enough to create pain or discomfort but maybe they're not emptying completely right because maybe they used to hold their urine for long periods of time when they were a kid or maybe they're always hovering over the toilet because they don't want to sit on it at work and over time that can create a little bit of mild dysfunction which can make it more difficult to completely empty the bladder and when urine is sitting in the bladder for long periods of time it's basically food for bacteria to grow and so bacteria grows and then you get recurrent UTI so making sure you're completely empty by sitting relaxing on the toilet sometimes leaning forward and then maybe going a second time so standing up sitting back down going again and even for men sometimes trying to sit and see if you completely empty because sometimes standing you're not able to empty completely whoa a lot of men are gonna because they're these you know it was fun to research for this episode because um there are entire discussions on Reddit about like what percentage of males sit while urinating I mean my understanding based on having visited many male bathrooms in my lifetime and um just being in the world um that that I assumed that men stood up in order to to urinate but there are a decent percentage of men that sit down to urinate there are and in fact it's variable like country and probably the reason it's become more interesting lately so a certain country was recently surveyed I think it was Germany um but essentially this recent like picked up by the media that Germans sit more often to pee and so you know then people like oh is this better for me to sit to pee or stand to pee and there's this whole big discussion on the media but the reason being is when you're sitting your pelvic floor is most relaxed and so if you're having any issues emptying your bladder you're gonna pee better also if you have an enlarged prostate which I'm sure we're going to talk about prostate enlargement that can sometimes allow you to develop a little bit more abdominal pressure because you're sitting and you can lean forward to overcome sort of a blockage and and so there are some some indications were sitting is better but if you're peeing fine and you're standing that's fine too I don't think you have to I think it's just something that you know in other countries they do more and here we don't and I don't think it's right or wrong it just depends on your individual circumstance can spermicides or condoms or both increase the frequency of UTIs for females so spermicides absolutely so spermicides if your condom has spermicide on it or you're using spermicides that is a known risk factor for UTIs other things I want to touch on you did ask about cranberry so cranberry is actually in the American Urological Association guidelines for prevention of recurrent UTIs in women now how does cranberry work right like do I just bring juice it's actually a specific active ingredient in the Cranberry which is called proanthocyanidins or Pacs and in order they've actually looked at the amount of Pacs you need and what formulation so you need 36 milligrams of Pacs in a soluble form so a lot of the supplements on the market will say that they're 36 milligrams of Pacs but they're like the whole Berry so they're using the the skin of the berry and the stem of the berry and that's not going to help you so you need to make sure that the supplement you're using is a soluble form of the cranberry and it's actually very very very effective at reducing the risk of UTIs so do you mean um capsules like a gel cap yeah it's a capsule that you take once a day and there is some although not as much data that if you're having them around sex which some women do always have post-coital UTIs that you can take two on the day of sex and two on the day after and that may be helpful but there's not a lot of data there but certainly an option that you can try that's pretty low risk so that's kind of the the guidelines now there's a ton of other things that you can do to help prevent that are kind of available and have some data behind them so d-mannose is one of them where you take you know about two grams a day of d-mannose and you drink it and that actually helps reduce UTI risk it's been studying a small randomized controlled trial to be effective and um and so those are kind of the bigger ones there's other things that people use like probiotics but there's a lot of heterogeneity as you know in probiotics and what to take and are they really effective vaginally in the Flora there so those are kind of the big things and there is is actually a lot of microbiome study and UTIs going on actually at UCLA where they're looking at the microbiome of people who are more at risk for UTIs or even overactive blood or other conditions like that and they're trying to figure out like is there something here that we can Target or that we can figure out is is causing problems because sometimes we just can't figure out why it's happening in terms of wiping from front to back and swimming and peeing after sex there's no good data on any of those things wiping from front to back I think it does create a little bit of like shame like it's not a big deal if you wipe back to front as long as you're not like you know as long as you've like cleaned yourself so to speak so I think it's less of an issue what we're talking about is you're referring to any contamination from anal any bacteria around the ants right yeah right and a lot of women who have recurrent UTIs like tend to come and feel very dirty like there's something wrong with them they're like oh I wash all the time I'm really clean I'm really this and you know it's not something they're doing it's probably a microbiome effect or a hormonal effect or you know there's something going on that we need to investigate further it could also be an anatomical or functional problem where you're not emptying the bladder correctly so there's lots of different factors it could mean it's like very infrequent I would say like I've never seen a patient who's dirty and that's the reason they're getting UTIs um perhaps even the opposite is true they're cleaning too much based on what you told us earlier yeah and they're eliminating the gut micro excuse me just rolls off the tongue um again no pun intended um perhaps it's there they are abolishing the local microbiome on the skin too much cleaning eliminates the microbiome on the skin not that we don't want to wash but when Sonnenberg was a guest on this podcast he said actually kids can develop a very healthy microbiome and general microbiome oftentimes by sorry parents not washing their hands before eating if they've been playing with soil outside or dirt a little bit of that is actually healthy pets actually offer microbiome support this is so weird I know it sounds yeah but we have to imagine how we evolved as a species was not with antibacterial soaps and um alcohol swabs everywhere and obviously we don't want infections but over cleaning can disrupt the microbiome which presumably can lead to UTI so perhaps someone who's cleaning excessively is more at risk than somebody who's cleaning a little less absolutely and actually the cleaning can irritate the dermis right so you can actually get contact dermatitis type symptoms from over cleaning and so that's one of the you know things like I definitely have a UTI I definitely have one well no you don't but there's a host of other things that it could be one of them could be that another very common one that we already touched on is pelvic floor dysfunction so very often pelvic floor dysfunction just like you had pain with urination women can also develop pain with urination that doesn't go away and it can start where they had a UTI that triggered the pelvic floor and then the pelvic floor just didn't relax but the pain just triggered the pelvic floor to tense up and it didn't relax because again we're not taught how to relax our pelvic floor and and then they've done about pelvic floor dysfunction like why is UTI not going away why does it keep coming back and so that's another common thing that we see in people who have quote unquote recurrent UTIs but don't really have them to be clear I experienced the pain in urination as a consequence of trying those damn key goals that everyone's talking about stopping that um was informative in two directions one it relieved the pain very quickly so that was good the other was I realized that it is possible to have a pelvic floor that's neither hyper contracted nor over relaxed and in some cases just not doing anything for it is the best circumstance right so um and the only reason I mention that is because um obviously this discussion is not about my pelvic floor this discussion is about the fact that some people perhaps need to clean less some people maybe more but probably not based on what you said some people might need to strengthen their pelvic floor some people might need to relax their pelvic floor and some people's pelvic floor is probably A-Okay you know any discussion about um anything medical or you know especially hormone stuff this happens a lot in the discussions around um that I get into it seems with with males they're like every male now seems to wonder if their testosterone is too low except the ones that are blasting testosterone because they know it's excessively High um and as you pointed out earlier at least in terms of sexual function that's unlikely to be the case maybe less desire but um but in terms of uh genital based arousal function yeah and I mean you've talked about testosterone a lot on the podcast so I'm sure your audience knows very well the multitude of benefits for testosterone so I think there is value in assessing hormones panels and assessing your level of free testosterone testosterone and you know assessing if you're having symptoms that are not always sexual right it can be depression it can be weight gain that you're not gaining muscle mass you can have cognitive changes so those things can still be a sign of low testosterone and very valuable and important to assess that reminds me of another thing and then we'll get back to UTIs and I want to talk about kidney stones but um I've heard of women using a small amount of testosterone cream directly on the clitoris as a way to amplify the maybe it's the desire and arousal effect or perhaps just one or the other so I've uh the way that we discuss testosterone use and there are like consensus statements and there's actually an abundance of data on testosterone use particularly in post-menopausal women for low libido or low sexual desire and it's all been very positive and since there's been increased uh sexual desire based on validated questionnaires increased number of sexually satisfying events with testosterone use now the range of testosterone in women is about a tenth of the the amount of testosterone a man needs right so testosterone cream is systemically absorbed wherever you apply it and so the way we generally recommend women to try this if they are having low libido and we've ruled out other issues that may be psychologic but you know relationship other issues that can affect libido medications there's a lot of things obviously that go into that but if we set and we've checked their testosterone it appears to be low for physiologic levels for women which again is one tenth of the male level then we can actually prescribe off-label testosterone and the guy guidelines or the consensus statements they're not like true guidelines but they recommend using transdermal testosterone so getting you know AndroGel tubes from the pharmacy and putting a tenth of one tube on the back of the calf or the upper outer buttock a hairless area for absorption that can improve desire overall and then the other place we use testosterone is in women who have what we call vestibulodynia so the vestibule is the area outside the vagina which is very hormonally active there's lots of Androgen receptors there and it can actually when you have hormonal issues meaning lower testosterone and estrogen in that area it can cause pain and so actually applying a combined or compounded estrogen testosterone cream to that area over time can reduce that pain and discomfort so as you know testosterone receptors or Androgen receptors all over the body very much in the genitals very much in the brain and they're very useful to a very useful place to treat women for those issues kidney stones I hope to never have one I hope you don't either people get them um how do you avoid getting them and how do you get rid of them so kidney stones very often are they they can be for a variety of different metabolic disorders right so it can be one dehydration is a very common cause of it so dehydration combined with maybe a slight metabolic abnormality where you're creating more calcium or oxalate in your urine can result in um in kidney stones and so how can you prevent them I mean like you know each person is individual if you get a kidney stone typically we do what's called a 24-hour urine analysis plus some blood work to assess what is the metabolic abnormality so we can Target that either with diet or with medication and so the kind of General recommendations for people who have kidney stones one is increase your fluid intake to two to three liters again the same number I told you before you want to decrease your oxalate intake now if you Google oxalate you're going to find a million things that you eat that have oxalate in them but the big ones are spinach and rhubarb we think a lot of nuts too that are you know people eating a lot more nuts to get more protein so you know cutting back it's impossible to get rid of all of that in your diet but if you're having like a spinach salad every day well switch it to a different green right don't eat spinach every day um also you want to increase your citrate intake that's an inhibitor of kidney stone formation so increasing fruits and um and things like that to increase citrate vegetables as well actually one easily accessible thing is Crystal Light it has a high citrate composition so you can drink Crystal Light with that two to three liters and that can be helpful you want to decrease your protein intake so high levels of uh purines or perogenic Meats like red meats and things can also put you at higher risk so these are kind of the general sort of preventative measures we talk about for kidney stones if you have a kidney stone so a lot of times people can have kidney stones in their kidneys they're not creating any problems they're tiny we can observe them over time if they start coming if they start getting very large or they are starting to move into the ureters or the tubes that drain the kidney oftentimes they're they're accompanied with pain quite a bit of pain um and it can be very uncomfortable in those cases uh we can if they're not having any infection symptoms I mean there's no signs of a urinary tract infection there's no fevers no chills we can treat it conservatively with pain medication and also there are medications like Flomax which you use for enlarged prostate as well that actually relaxes the urethral smooth muscle to allow the stone to pass a little bit better if you're having an infection you got to get treated right away it you can get very sick very quickly in fact I've seen young healthy patients like they're healthier than me walk in the in the ER with a kidney stone and within 24 hours they're in the ICU because they're really sick because of a kidney stone urinating uh tea colored urine so the meaning blood in the urine yeah all of those are important warning signs that you ideally don't get to yeah blood in the urine I mean doesn't always mean infection it could just be from the stone but certainly fevers chills or you have a sign of an infection and the stone looks like it's blocking so if you get Imaging and you see what's called hydronephrosis or pressure behind the kidney and you're you know you have these signs of infection we don't want to wait because you can get sick pretty quickly and then you know once to treat the kidney stones there's three major options one is shock waves another is ureteroscopy where we go in with a camera and we have a small laser we break it up into small pieces and there's the camera inserted through the urethra correct your sleep under anesthesia so you don't have to you saw that yeah I saw you saw the winds and then perky utifer lozotomy which is done if you have a large kidney stone or a very hard kidney stone that's up in the kidney you can go in through the back with a small like a small incision and with a specialized camera that goes in and uses ultrasonic lithotripsy to break up that stone and kind of suck it out that way these are extremely helpful um bits of information are not even bits these are this enormous amount of useful information I like to Pivot again um for sake of bread we can't go into extreme depth on everything but um appreciate your willingness to to follow this Carousel with me um oral contraception previously on this podcast I hosted a female physician guest who offered both sides of female oral contraception discussed some of the benefits discuss some of the risks I made the decision to post clips about both on the internet and wow wow wow was I surprised but also frankly a bit shocked and then finally um intrigued by how polarized the discussion is around female oral contraception and female contraception in general so NuvaRing nor plant the pill broad category of things there but for sake of discussion the pill Etc I mean it seemed that approximately 50 percent of responses which seem to come mainly from women were of the this stuff is terrible it ruined my life it ruins lives it um destroys you it has immense um risk and then the other half seemed to say no there's reduced risk of certain forms of cervical cancer um this has allowed me uh the you know sexual choices and lifestyle that I prefer without risk of pregnancy I mean it was astonishing to the point where I thought wow if only I could post both Clips simultaneously so um obviously I don't know what the answer is um but I do know that this is among the more polarizing topics available for discussion um so what is the story meaning what are the data about oral contraception why so much controversy and what's the real deal here yes so it is a very polarizing topic and there is abundance data abundant data in fact we even did a study and again this is um not like high quality evidence but we looked at Reddit threads and we looked at sexual dysfunction specifically low libido orgasmic difficulties and we like read hundreds of threads and we did like a qualitative analysis in females to see like what are people talking about and problems with oral contraceptives and antidepressants leading to low libido and and being very like as you describe very like this has ruined my life was very common and so the theory is that you know taking oral contraceptives increases the amount of sex hormone binding globulin which binds testosterone and estrogen and that actually makes testosterone less available which is as we've talked about a very important hormone for desire and so in some subset of people they're seeing very significant consequences of taking oral contraceptives now I think that there is you know we don't know which women are going to have this problem and we don't know how it's probably a very small subset of people but we do know that this does happen and that when you measure shpg levels they're up and that even after they stop the oral contraceptives you'll see elevated shbg levels from Baseline for how long you know for like at least four months afterwards you'll still see elevated shpg levels so we don't know but not infinite we don't know we don't know yeah the endocrine system is weird because it it um we assume everything is a short-term effect but there's some plasticity in the system especially because it's a neuroendocrine system so yeah okay so I think yeah there's some neuroplasticity there that occurs as well and so uh we do see this and I think that the other side of it is yeah absolutely oral contraceptives are amazing right they're they're helpful for sexual Freedom so for for preventing pregnancy for you know for a lot of things and particularly other conditions too like PCOS and and other problems oral contraceptives are amazing and they've changed uh you know Gynecology and management of these women for you know in in a very positive way and so I think you know yes I do think that there is oral contraceptive related sexual dysfunction usually low-dose estrogen sort of contraceptives are the culprit uh but you know I think that it's it's again the data female sexual respect literature is just not as robust as male sexual dysfunction literature I saw a lot of comments about how oral contraception had led to depressive-like symptoms um or just kind of a hedonia and apathy not just lower libido I can imagine how that would be the case through the elevated sex hormone binding globulin which is you know preventing testosterone estrogen from um being free right literally and exerting their effects on not just the body but the brain but is there any evidence that oral contraception can disrupt no transmitters I'm not aware of any I don't think knowledge uh well it sounds to me like oral contraception for women because that's where we normally hear about it it sounds like there's a varied response and it's highly individual I certainly had partners that love the pill or at least didn't seem to mind it I've had some that hated it and like it's like no way tried that never will um or you know just went with other forms of contraception or for whatever reason we're not using contraception so it seems to me that there's a lot of variation out there how does one explore that without risk of permanent damage it sounds like truly permanent damage is unlikely um you know what are the other options you know is the ring um uh copper IUD um so any sort of long-acting hormonal contraceptive we've seen we've we that's what we counsel patients on is if they're having issues with oral contraceptives even if they come in with pelvic pain and they're on oral contraceptives I'll tell them you know what just stop because maybe the engine the effect of on the Androgen receptors or estrogen receptors is affecting you know the lubrication or other things we're not sure but you know why don't you stop it and go get a long-acting contraceptive method like an IUD like an IUD and our IUD is our IUD safe and here we should probably say Okay copper IUD is one form you want to mention a few of the other forms so I don't prescribe iuds but generally speaking they're very safe of course there's risk with any sort of you know it's a procedure you're inserting an IUD so there's obviously some small risks associated with it but it is safe and effective form of contraception people are wondering why the copper IUD is an effective form of contraception copper is like the third rail for sperm as I understand it so much so that um I was able to find some evidence for this in the medical textbooks that um in the old days as I say um prostitutes who wanted to avoid pregnancy would put copper pennies in their vagina really oh now I don't recommend that to anyone and uh please and um I don't think it's a foolproof form of of uh contraception but there is evidence that that um did happen so which is amazing that means that people somehow figured out the copper sperm relationship which isn't a good one for the sperm and deduced from that of behavior yeah that's I think it's just an interesting medical factoid yeah I can tell you want to move on from this topic so we will um before discussing prostate and anal sex not stated next to one another for any particular reason I want to talk about ssris a lot of people over the last 20 30 years have been prescribed selective serotonin reuptake Inhibitors and other antidepressants that have disrupted their sexual function or their sexual desire it seems in particular um do you see a lot of this in your clinic do you hear about it what can people do about it um you know oftentimes these sexual uh arousal or dysfunction issues associated with ssris and other medications make those medications prohibitive for people so you know serotonin is kind of the anti-2 orgasm and so in fact we will use ssris off label for people who are having premature ejaculation so it delays ejaculation and then there's also other sexual dysfunctions we see with it and it does happen absolutely it's dose dependent so in some cases when someone comes in with SSRI related dysfunction if they're doing well you can either try to reduce the dose or switch them to another antidepressant for example Wellbutrin that does not have such severe effects on sexual function um and so you can also use like Cialis and Viagra like you've taught well we've talked about for erectile dysfunction as an addition if we can't change their medication management because you know and it gets a little bit complicated because we know erectile dysfunction and depression are very interrelated now what's causing what and what you know where do we like maybe somebody went to see their doctor for depression was also having issue with erections and now what do you if you fix the erections do you help with the depression like what you know what I mean so it goes everywhere are shouting yes so I think you know I think that there's a lot of discussion has to be had there it's a lot easier to talk to your primary care doctor about depression than it is about your erections and so I think it's important to like really dig into that a little bit but yes there it is definitely a known thing we use it to our advantage when needed and um and it can be helpful to to switch medications or reduce the dose you mentioned earlier that trazodone can cause um sustained erection um and is trazodone in the category of of touching the serotonin transmission system you know I don't remember the mechanism but interestingly trazodone is also used for off label like as a third or fourth line for premature ejaculation as well so um so I I don't remember the the mechanism offhand let's talk about prostate and prostate health earlier I queued up that um there's a growing Trend toward I would say more Progressive male Physicians or Physicians who treat males excuse me um thanks for that yeah um prescribing low dose 2.5 to 5 milligram Cialis which is to Dallas which may assist with erections but it the the rationale for this low-dose daily low dose is not centered around erections per se it's really about um prostate health improving blood flow to the prostate reducing prostatitis um maybe even reducing the probability of prostate cancer um what other sorts of things are you encouraging men to think about when thinking about their prostate yes so before I forget I want to mention that low dose tadalafel is actually a treatment for erectile dysfunction in fact it works quite well particularly men who are having a lot of psychogenic issues one because they don't have to remember to take a pill before sex it's always on board and you know you're taking five milligrams every day and it has a 36 hour Half-Life so over you know you're kind of increasing those so it can actually work quite well and is a great option for erectile dysfunction so I do want to make that caveat in terms of prostate health it has been shown to be effective for BPH or enlarged prostate this is a very common condition in fact if you look at autopsy studies eighty percent of men at 80 have an enlarged prostate like it's very very common now does everyone get symptoms and what's the long-term concerns of it and you know what can you do about it so typically as the prostate enlarges it's right around the urethra it's a walnut-shaped gland sits underneath the bladder around the urethra and it can narrow the urethra or the P tube and so over time you can imagine like if you're I always give this example if you're sucking from a straw right you're drinking from a straw if you have a wide diameter straw it's really easy to drink if your straw gets really narrow like say you take a coffee straw and you drink out of that it's very difficult to drink very similarly it can become very difficult to urinate if you have an enlarged prostate now what causes an enlarged prostate there's a whole host of factors a lot of them are genetic so if your father or grandfather had a large prostate you're probably more likely to have an enlarged prostate do we know exactly how to prevent that not exactly but we know how to mediate the symptoms a little bit so the other symptoms you'll see before you have difficulty urinating is sometimes you'll see overactivity so you'll see your bladder is responding to having to push hard against that narrow your re-thread to push urine out so it's having more urgency like the sudden desire to go to the bathroom that you can't delay you're maybe going more frequently and very often you're going more often at night and so those are kind of the first signs people will see and then over time it may become more and more difficult to empty the bladder you might see some hesitancy like you're waiting for your stream to start or it stops and starts um and so those you know or you're just like I can't empty like it's not because just drips or a very weak stream and so those are kind of the things that can happen over a lifetime now what what are some things that you can do to help um you know Cialis helps relax those those the fiber the smooth muscle of the prostate so that it allows urine to pass more easily there's also other medications that you can treat very often Flomax or other alpha blockers are helpful in that area in terms of like things that you can do in general for bladder health prostate health there's certain things that are irritants to that area and so what I tell people not everyone's affected the same way so I don't want people to be like oh I gotta stop all these delicious things I eat and drink but certainly it can be useful to just pay attention so like if you say you drink coffee every day and you find yourself right in the bathroom a lot if you limit your caffeine intake you might see that you're not going to the bathroom quite as often because caffeine is a bladder irritant so that can be coffee tea chocolate you know things of that nature that have caffeine in them energy drinks sometimes people forget they have caffeine in them and so limiting that may improve your symptoms alcohol also is a bladder irritant and these have actually been studied in animal models and you'll see that the bladder contracts more often when they're given these sorts of substances and it's dose dependent and some people can actually habituate or get used to a certain dose of caffeine so if you're drinking coffee every day you may have less symptoms than someone who drinks it every once in a while other things can be sometimes carbonated beverages spicy foods or acidic Foods those sorts of things can also irritate the bladder lining so sometimes limiting those things may be helpful in those situations very informative um years ago there was a discussion about um bicycle seats causing damage to the prostate maybe even sexual dysfunction um is that still a thing I thought they put grooves into the the seats um but I've also in reading on the internet I didn't do a deep dive on Reddit but um seems that women are reporting some Bladder incontinence from excessive bicycle seat use maybe even um exercise bike doesn't have to be road bike yeah so this is a great point so cycling if you think about it right you're sitting on your perineum which is that space for men between the scrotum and the anus for women between the vagina and the anus and right there runs your pudendal artery and your pudendal nerve which are again responsible for blood flow and nerve function to the area so the most common things we see in people who are you know who are really high volume cyclers now the studies have looked at like maybe they did a 350 kilometer race or they they're you know biking three times a week for 60 minutes but there's no like consistency but there's seeing pretty high rates of genital numbness so like up to 50 percent and also in men erectile dysfunction in women you'll also see numbness but because sensation is a big part of arousal you'll also see kind of decreased lubrication maybe decreased arousal as well in women and so how can you prevent that the reason is because when you're sitting particularly if you're leaning forward like competitive bikers who are Arrow riding you're putting pressure on the the beak of the bicycle seat and that's where you know most of the it's not your weight it's not distributed evenly so the goal is to take a bike seat that allows you to sit comfortably on your ischial tuberosities and posture is a huge part of your pelvic floor I know we didn't talk about that earlier but sitting you know with good posture and not kind of slouching or leaning forward can actually really do wonders for your pelvic floor so focusing on posture is helpful but also when biking posture is helpful so they've actually looked at this data and they found that people who Arrow ride meaning Lean Forward are people who use narrow bike seats are more likely to have issues and so you want to get kind of a noseless seat and a wider seat the the cutouts actually when they've looked at kind of mechanics of the cutouts they'll see higher pressure around the opening so it's actually not good to have a a bike with a cutout a bike seat with a cutout because they've seen at least with some of the cutouts the pressure actually becomes higher on the area that's right around it very important Point um I don't cycle I don't like the exercise bike I'll sometimes Ride The Assault bike for which has the big seat maybe for a few minutes but um I just want to add one one thing because I think that I don't want to uh make people not cycle I think it's really valuable cycling is a great aerobic exercise has lots of benefit for cardiovascular health but there was actually another study that looked at people who were parts of sports club so they were like swimmers Runners and and cyclists and they looked at rates of dysfunction and they found that actually the rate of erectile dysfunction was not different between Runners swimmers and cyclers so maybe you know because those other sites were just looking at cyclers that maybe it's just the general rate of erectile dysfunction in that population at that point in time so I don't the numbness is definitely an issue the erectile dysfunction maybe maybe not so I just have a couple of more questions for you and by the way you've been incredibly generous with your time and information here thank you so I really appreciate it as I'm sure our listeners do as well anal sex you recently did a post describing the multiple reasons why women do or do not have anal sex yes very interesting post very interesting study that you covered yeah and you um explained it very clearly um I'm guessing there are relatively few but perhaps some other studies as well about this um let's talk about anal sex and uh maybe if you could just offer some of the the key bullet points that you've learned from the literature and from your clinical practice um you know how frequent is it um uh with protection without protection how safe is it um you know what are the different reasons people do it that might seem like a kind of a silly question but it turns out when it comes to this topic it's there are interesting data yeah yeah um educate us so anal sex let's talk about it um well when you when you talk about anal sex the reason people it's become more and more common let's say it's more and more heterosexual couples are doing it we know that male homosexual couples are having anal sex and I think the one thing is that it's safe in terms of pregnancy right you're not going to get pregnant from anal sex which is one of the reasons people do engage in anal sex do you think that's the reason people are doing it more frequently no I think that's one of the reasons that people one of the reasons but in general the issue with anal sex is that people forget to use protection like a condom for example because sexually transmitted infections are actually more likely with anal sex than they are with vaginal penetrative intercourse because the anal tissue is very thin and friable so when you penetrate the anus particularly if you have any trauma you can have you know you can have blood loss and that blood loss can then easily more easily transmit sexually to the infection so it's really important to use a condom and use adequate lubrication the anus does not make any of its endogenous lubrication you have to use lubricant the other interesting thing about anal sex is that the anus pH is different from the vaginal pH so you want to use specific lubricants that are ISO osmolar to anal pH so you can actually look up anal lubricants and we could talk about lubricants but generally there is water-based silicone-based oil-based lubricants water-based are the most easily accessible silicone based are a little more slippery and lasts a little longer and oil based also last longer but are not good freeze with condoms so definitely using lubricants and always kind of making sure to be in the context of course of being consensual but also like never for course always take your time and those things are really important to avoid trauma because trauma can happen and usually it's not severe trauma right it's not going to create long lasting problems but it is you know inconvenient uncomfortable and probably we're not seeing as much of it because they're not coming to the emergency room if they're having issues unless it's really serious so I think it's really important one to prevent from a sexually transmitted infections to to be thoughtful and cautious and sometimes it requires some preparation if you're going to penetrate an anus it's gonna you know you're not gonna start with a a large girth item you're going to start with something smaller and kind of work your way up um and then I think ultimately why people have anal sex so as I mentioned earlier the prostate is you know highly innervated and can be a source of pleasure so some people enjoy that particularly men may enjoy anal penetration women as well may enjoy anal penetration because of the innervation around there the pelvic floor um and and you know so that's certainly reasonable to do so as far as why people engage in anal sex so sometimes it's because as I mentioned they're trying to avoid vaginal penetration either to avoid pregnancy or maybe menstruation or other reasons sometimes it's because people want to do something special with their partner like they feel like this is my special thing with this partner that I do with them and so it may be something kind of like a gift or something like that sometimes it's almost like they feel like they um they have to and this particular story that I looked at there's actually not a lot of studies on why people engage in anal sex and this particular study that I had talked about on my channel or my Instagram was talking about why they've specifically recruit drug users and so a lot of people had used drugs prior to using to engaging in anal sex and I think that that's not ideal you always want to be kind of in the right State of Mind for consent and um and safety purposes and so um those were kind of the common reasons what about infection not related to sexually transmitted infection um my presumption is there is a higher risk with anal sex than there is with other um other you know vaginal intercourse oral sex Etc um but is there evidence for that um not necessarily it's more about sexually transmitted infections it's rare you can sometimes I mean the rare things that people have kind of commented on like anal incontinence temporarily or things like that very rare um mostly it's it's just sexually transmitted infections because you know you can't have more it's more easy to create bleeding through anal sex if you're not careful and are people doing enemas before anal sex to prevent bacterial infection or is that just like it's a kind of some people are I think it's you know you know for their evacuated fully there's some you know media articles about like what you should eat before to kind of keep your gut you know healthy and avoid kind of loose stools and things like that but generally speaking you know there's there's lots of things you can look up to make it safe and healthy again I'm sure some people are listening to this and they're maybe they've turned it off already but um and I think we can expect a varied response to this discussion but it's happening out there apparently with an increasing frequency yes and I don't know if that's because of the increasing availability of pornography where it's visualized more or if um I don't really know why but we do know that there's more going on in heterosexual couples than prior as a final category of question um I was really interested in some of the posts you've done about herbs and supplements in the context of sexual desire and sexual function um on this podcast I always say always always we emphasize behavioral tools first do's and don'ts right because those are the foundation of mental health physical health and performance you know in all contexts um there is of course a role for prescription drugs sometimes oftentimes people can't do the things and avoid the certain things they want to because of depressive States anxious States Etc and prescription drugs can serve a role but I do believe the goal is always um behaviors first then of course things like adequate sleep nutrition healthy social interaction all of that stuff right exercise but we do often talk about supplements um because they represent um I think an important category of you know over-the-counter compounds that can play a role and um I've talked before about Tonga Ali this Indonesian herb I think it can be Malaysian as well but this Indonesian um herb is typically the one that um I'm aware works best for mild libido enhancement sometimes especially in the case of people taking ssris um it can enhance libido to override some of the uh challenges with SSRI induced reduction in libido and generally even if people aren't under ssris I hear from people who take Tonga Ali and get libido increases also things like maca root which we don't really know how these things work exactly probably some freeing up of testosterone with Tongan Ali maybe some cortisol suppression as well maybe some estrogen receptor modulation with maca root maybe some dopaminergic tone changes um Sheila G um this ayurvedic herb um which there is at least one study um that uh I think has done well that shows increases in FSH follicle stimulating hormone with um Sheila G use what are your thoughts on things like Tonga Ali maca root shilaji um how do you talk to your patients about this stuff yeah so I think that you know I see at least my patient population is is still in the Behavioral Management place right the biggest cause of sexual dysfunction whether it's low testosterone erectile dysfunction sexual dysfunction is often comorbidities right so managing high blood pressure managing diabetes with diet which you talk about a lot but the best studied diet is the Mediterranean diet at least in in a sexual dysfunction literature exercise like doing you know both cardiovascular aerobic exercise but also doing resistance training particularly like large muscle groups um and and then uh you know really working on reducing blood pressure and and preventing diabetes and those things I think are really key and I know we talk you talk about them a lot on this podcast but I will tell you that when people are getting ready for for example we do a surgery for erectile dysfunction called penile prosthesis so this is like end of the line nothing's working they can't get an erection at all and it can be a and they may have diabetes as a cause of it when we say you know you have to get your hemoglobin A1c below a certain level to do surgery I cannot tell you how quickly these men change their behaviors for sake of erection for sake of erections so I think that really if I can say one thing before you do uh supplements which I don't have a problem with I think that it's reasonable to try them um I would try one at a time to see what's working and so you're not taking a bunch of things and not knowing what exactly is working and realizing that they're not going to work immediately if you take something that works immediately it's probably got a pde5 inhibitor mixed in there and so it's going to kind of build over time and you're going to see changes over time but I would say that the number one thing that I recommend for people is improving their diet exercising getting good sleep as you know it boosts testosterone and even you know you mention this all the time but getting early morning light but it's it's beneficial for testosterone as well because you're really helping release testosterone with a circadian biology G so I think that those things like I can't stress enough like how valuable they are and if you're smoking quit smoking it will kill your erection and vaping and vaping yeah and then lastly if you are developing true organic impotence meaning that there's a biologic problem that's causing your sexual dysfunction then it's really important to get your cardiovascular health assessed because about 15 of men who develop erectile dysfunction seven years later will have a cardiovascular event it is the canary in the coal mine meaning that you know it's a sign that you may be developing cardiovascular problems or like endothelial dysfunction that's first presenting in the penis or in their sexual organs and you know this probably is the same for women we just don't have the data yet I know a good number of women that take Tonga Ali in part I think on the recommendation although I want to be clear I never recommended it it was an offer of something that people could try if they're doing everything else correctly and could assess um with Consulting your physician of course um and they too some of them have uh reported improvements in libido and desires as well so yeah um yeah and I the Sheila G is less known about the um distinguishing quality versus low quality sources of shilaji is harder dosing is harder it comes as this tar typically typically um maybe more science on Trilogy will come out in the next few years we could um get get behind it a bit more right now I'm sort of on the yeah maybe if you are an adventurer you might try it but I'm not um it's not one that I'd normally throw to the top of the list yeah I think that like l-citrulline is is pretty good ashwagandha for stress reduction which also has implications for sexual function tongue cataly has reasonable data um I think there you know there is reasonable data on these things I think the webs that you talk about all the time examine.com is a great place to look at that um and you know like I said I think it's reasonable they're smaller studies they're not um you know there is bias in many studies but they're they're you know there is effort done in this area and there's never going to be really high quality science no one's going to really fund that I think um so I think our expectations need to be a little tempered when it comes to that stuff Rena Dr Malik I want to thank you ever so much for this discussion today you provide us so much useful information um and really have transcended the Divide between you know the mysterious thing that everyone wants to know about sex and Sexual Health genitals and genital Health uh prostate urethra UTIs all these topics that um many people are just afraid to to raise and and to confront directly and you've um you've taught us so much about how to promote the health of this incredibly important system absolutely one thing we know for sure either in Vivo or in a dish we're all here because a sperm had an egg and uh and um and of course there are other reasons why people engage in sexual activity that have nothing to do with reproduction but um surely it is our biology and our psychology and well-being so thank you so much and also thank you for the work you do day in and day out week in and week out in your clinic we'll provide links to your clinic people are interested in working with you directly as well as online that's how I initially found you and when I did I was just absolutely delighted I thought finally there's somebody who's providing the kind of information that everybody wants in a in a thoughtful logical clear and respectful way so on behalf of all the listeners and viewers and on behalf of myself I just want to say thank you thank you thank you for what you do and please keep going and please come back thank you so much and honestly the work you do is phenomenal it's an honor to be here thank you so much thank you for joining me for today's discussion with Dr Rena Malik all about Urology pelvic floor and Sexual Health if you're learning from and or enjoying this podcast please subscribe to our YouTube channel that's a terrific zero cost way to support us in addition please subscribe 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lab on all social media platforms thank you once again for joining me for today's discussion with Dr Rena Malik and last but certainly not least thank you for your interest in science [Music]