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

Welcome to the Huberman Lab podcast where we discuss science and science-based tools for everyday life. I'm Andrew Huberman and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. Today my guest is Dr. Reno Malik. Dr. Reno 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 here 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 and arousal that occurs within the genitals themselves.

And Dr. Malik highlights some important misconceptions about sexual dysfunction. For instance, that many people believe that hormones are responsible for sexual dysfunction. But in reality, hormone dysregulation is responsible for only a very small percentage of sexual dysfunction. And yet, pelvic floor and blood flow related issues can account for a large number of cases of sexual dysfunction in both males and females.

So I assure you that today's discussion is going to illuminate many new areas of information, many new tools and protocols that I'm 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 function, skin sclans. 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. 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 timestamps where we've detailed what specific topics are covered and then to make your decision accordingly. I should mention that not only is Dr. Malik still an active clinician. She sees patients daily out of her clinic in Southern California.

And we provided a link to that clinic in the show not captions. She's also authored dozens of high quality peer reviewed publications in the fields of urology, public health and sexual health. And we've also provided a link to that bibliography in the show not captions. And she is also a spectacular public educator. She provides zero cost content about sexual health, public floor health and urology as it relates to both men and women on her YouTube channel.

And there too we provided a link to Dr. Malik's YouTube channel in the show not 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 Roka.

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You will get an additional two free months for carrying out this survey. You can find the link to the survey in the show notes for this podcast episode and on our website, HubermanLab.com. If you would be so kind as to take a few minutes to fill out the survey and help us continue with bringing you the best possible content here at the Huberman Lab podcast. As always, thank you for your interest in science. Now for my discussion with Dr. Reno Malik. Dr. Reno 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, 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 the healthy versions of sexual health. Yeah, absolutely. So this is an especially important conversation. It's also one that I think has a backdrop that we should just acknowledge right off the bat.

That because the information is gleaned from multiple sources and because there are, let's just say, 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 in 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, intercourse, oral sex, anal sex. We're going to talk about all of that. So I just want to get that out there so that we can reduce the shock response. I love it. We're going to talk about all of it.

Great. So just start things off in anticipation of this episode. I solicited for questions on social media and I got thousands of questions. There was a lot of overlap in the questions. So to start off, I'd like to talk about pelvic floor. Because both males and females have a pelvic floor. And my understanding is that there's a muscular component, there's a neuromuscular component, there's a blood flow component. What is a healthy pelvic floor? What does a healthy pelvic floor do?

And then we can talk about some of the health issues that an unhealthy pelvic floor creates. And some of the ways to 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 functions and those organs. And so, you know, pelvic floor is so important in so many different aspects. And we deal with it a lot as 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 any sort of exercise and you didn't rest, then that muscle would become contracted in short.

Very similarly, if your pelvic floor is overstrained, it can become contracted in 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 you 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. And then you go back to your desk or five minutes later, you have to urinate again. Exactly. Well, it can be either that you're not emptying completely or that the pelvic floor muscles are so tense that they're stimulating the bladder so it feels like there's more to go.

So it's not always that you're not evacuating it. It can present in a number of different ways. And then with sexual function, 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. It's really just pelvic floor dysfunction.

With with GI function, you can definitely have constipation. And then often you can also have back pain. And so all of these things can happen when your pelvic floor is too tense. Sometimes your pelvic floor can be too weak. And that can be often because of we see this in women a lot because of childbirth, delivering children. With some people who have neurologic disorders, they can have weak pelvic floors or connective tissue 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 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.

Is there a way to describe pelvic floor muscular shortening in a way that everyone can understand with this be like, like I said, we're going to be direct today with this like be like tensing up. One's anus and the opposite of the movement that one would do before initiating a bowel movement and relaxation is sort of the pattern of pelvic floor muscular relaxation just prior to initiating a bowel movement.

So I will say most people can't recognize it because it's very difficult to notice it's sort of gradual and so it can 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 keg Alexa sizes for example and people talk about how to do them, but that's all you ever hear about the pelvic floor.

And so you don't really know how to kind of do things in a way that protects your pelvic floor or or kind of what how to even tell when it's too tight or not relaxing and so that takes a sort of 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 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 with that's a medical technology for fingers are called digits. So you know I'm old enough to recognize what a digital prostate exam is right the physician inserts their fingers through into the anus and and feels the prostate to see whether or not it swollen or not.

And as I'm saying this I'm realizing you know sometimes we think of medicine quote unquote modern medicine is so evolved. This has basically basically been the practice for what 50 years 60 years maybe a hundred years in the same way that the old school practice for glaucoma excessive eye pressure was for the physician to just touch the eyeball.

So folks for those of you that think that medicine has evolved much it clearly has in many ways, but 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. Involve at a kind of granular level. Yeah so for women you can feel the pelvic floor muscles through the vagina so you can feel the Iliocoxidius the pubocoxidius the levator a now those are all names of different muscles in this bowl.

This is the physician who can feel them with their fingers. And you know you could too you could put your finger but you don't have a reference of normal right so you wouldn't know what a normal pelvic floor feels like versus a tight one versus a week one. And so you can assess the tenseness based on you know palpation you can also see if there's tenderness.

And so you can assess that based on just a general physical examination and then also you can observe so I can say contract your your pelvic floor up and 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 to there be dysfunction and laterality like the pelvic floor is pulling up into the right or up into the left absolutely so what typically when you see a pelvic floor therapist now I'm not a pelvic floor therapist but these are the people who do the work right they they work with you on a prolonged basis to help you normalize the function of your pelvic floor it's like going to gym with a

trainer right they really work with you to get your pelvic floor functioning correctly and the first step to that a lot of pelvic floor therapist will just align your bones and and your your kind of the way you sit and walk to make sure that you're not straining those muscles by pulling in different in different directions and if a male goes to the physician to get a pelvic floor exam there's obviously

difficulty in putting fingers into the urethra one would hope too small and opening so how are they doing the pelvic floor exam is it external to the body or is it through the anus. So some of it's through the anus you can feel the muscles through the anus and then you can feel the perennial area and feel the muscles there as well sensation so perennial area so from the outside of the body the region between the scrotum and the anus.

Okay so it sounds to me like if people want to get a high quality assessment of whether or not their pelvic floor is healthy or not they need to see a pelvic floor specialist that it's not the sort of thing that they could 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

what to do kegile exercises and give you some read you know some readings but they're not really meant to diagnose they're usually something people use if they say have a week pelvic floor and they want to try to do it at home on their own so there's nothing that's going to give you like a baseline reading is this normal or abnormal. Let's talk about kegels first of all who's kegel.

So he is a gynecologist I don't remember all the specifics to be quite honest but basically he came up with kegels which are strengthening exercise for the pelvic floor and so what it is what we describe it to for patients as we say you're going to there's a few different ways to describe it you're going to use the muscles that you use when you urinate but try to stop the flow but you don't want to do the one you're

urinating because that can create dysfunction you want to learn what the muscles are and then you squeeze those muscles and relax you know in between sets so to speak and so you'll do the other way you're going to be able to 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 using

good way to describe it yeah so those are kind of the ways that you can describe those muscles and so you can squeeze for 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

patients do them lying down so that you're only focusing on those muscles you're not working on your posture you're not doing anything else and as you get better with them lying down you then sit up and do them and then once you're good with them sitting up you can do them standing and start with you know 10 to 15 at a time like once more to

you know you're not doing any more repetitions so yeah let's talk sets and wrap up 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 over do 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

think so 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 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

prostratectomy who then subsequently develop leakage after the prostratectomy that is against 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

intense 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 will try it sounds all good right I only heard good things about kegels and what it quickly resulted in was painful urination and I thought this is weird everyone saying kegels are so great

and the best thing I could do for my pelvic floor it seemed was to avoid kegels. Yes. And a little bit later when we're talking about prostrate I'll explain 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 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 kegel in other words if somebody decides that they have a tight pelvic floor how can they learn to relax their pelvic floor.

So there's a lot of different sort of things that you can do so for women you can do massage of the area you can use vaginal dilators to help relax the muscles you can take supositories that have medications like valium or backlefin which are muscle relaxants and that can help as well although they're not treatments they're more of a bandaid but they can help with the symptoms that you're having.

You can also I think the best thing is to work with the physical therapist because they can teach you certain exercises that will help down train the pelvic floor for example one of the ones I tell my patients is like happy baby pose it actually you know stretches and elongate the pelvic floor muscles so doing these exercises regularly will help you lengthen the pelvic floor muscles.

One thing that I've experienced extreme pain from and that stopping was one of the best things that ever happened for my pelvic floor was to not do any kind of crunching movement with my legs crossed. I would go with these yoga classes and pointing 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.

So again for me ceasing the kegels was one of the best decisions I ever made I only did them for a short while as I could get this is clearly not for me and I guess that's another point that tell me if you agree or not that if you hear about something online or on this podcast or anywhere else and you tried and it seems to be sending things in the wrong direction either you're doing it wrong or it might not be the right thing for you.

Exactly. 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 vascular sure of the pelvic floor that would provide support for my experience there that doing crunches with legs crossed as essentially is it possible that's creating a symmetries in the pelvic floor.

And now I'm sure I'm angering yoga teachers and crunch crunch and east does everywhere but you know hey if it's a question of your pelvic floor a few extra delineations in your abs you know where my votes going.

So there's a couple things here that we should dive into one is that people don't often breathe correctly during exercise right and so diaphragmatic breathing is really important which is like a deep breath that expands the diaphragm not kind of shallow breathing that just in your mouth and throat.

And that is actually when you when you do any sort of exercise the your trainer will tell you exhale on the effort right and there's a reason for that because when you inhale your pelvic floor relaxes when you exhale your pelvic floor contracts and so it actually that contractions stabilizes the pelvic floor so whatever

intra abdominal pressure 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 pedendal nerve and the pedendal 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.

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.

The neural influences that come from the brain the signals of a rousal for instance or lack of a rousal and so on so we won't be overly systematic in our parsing of all this but I think what you just mentioned raises a really important point that sometimes in an effort to do something that's good for the muscles like strengthen the muscles 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.

A lot of people who squat and deadlift heavy in the gym or even who just tense their pelvic floor when they're doing things like dumbbell curls or other exercises and especially people who seem to do a lot of abdominal work reported to me in the questions that they experienced things like erectile dysfunction that they experienced things like pain during vaginal intercourse

that essentially they had created some sort of what sounds to me like a hyper contraction of the muscles in that area that were impeding all the things that they wanted as either side effects or direct effects of exercise because many people are exercising for aesthetic reasons and health reasons but nowadays it seems especially on the male side but we also talk about the role testosterone the female side a lot of males lift weights in order to increase their testosterone and for reasons that are obvious.

Also want to have healthy sexual function and here they are doing this thing that's very good for increasing testosterone if they're doing it correctly and testosterone is involved in libido 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 there are probably a lot of confused and maybe even distraught people out there they're trying to do all the right things and they're setting up roadblocks and even sending themselves backward in some cases.

So the question is how does one know whether or not something like let's say low lubrication or pain during vaginal intercourse or loss of erectile strength or some sort of erectile dysfunction whatever it may be because it can take on different forms as we'll talk about how does one know if it's blood flow related hormone related 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 innovation of the penis or vagina. So I think there's there's a lot that we can go into here but essentially first you want to find out like very specifically what is going on are you getting aroused are you having erections are you masturbating like there's all these questions that will help us go down the route.

Sorry to interrupt when you say aroused for sake of this discussion I just want to make sure that we distinguish between psychological arousal the desire to do I guess here we also have to be precise arousal to engage in intercourse and arousal to desire essentially that I think people learn to recognize or are we talking about arousal as the response of the genitals correct.

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 arousal I think so.

You know you maybe get the sex flush right you get some some redness or warm feeling that's your body's response right to arousal and sometimes that can be an 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 that 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 just a little bit more.

Of 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 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 I'm going to perform okay I'm 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 3% of erectile dysfunction that's related to hormones so it's actually correct to the right to a function as opposed to desire.

Desire is predominately 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 peaks of the systolic velocity which will tell you if there's a problem with arterial inflow versus the end diastolic velocity which will tell you if there's a problem with venous outflow and so that can assess those things there are some tests you can do for

nerve function although they're very uncommily done because mostly we can kind of get that through clinical report and unfortunately if you're having nerve problems sometimes it depends on what's causing them but sometimes they can be very difficult to reverse and that's kind of a problem we know that as people age their patient becomes less so just through aging the nerves the receptors become less sensitive and so you will generally have less response of this 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

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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 drink AG1 dot com slash 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 dot com slash 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

social 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 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

get a good floor therapist and where they could find a really great urologist to do the sorts of exams and perhaps the sorts of treatments that we've talked about because least as far as I understand much of what people want to learn on this podcast is how things work and what happens when things break down but also how to resolve those

issues so let's say somebody wants to check out their pelvic floor figure out what's going on there maybe they're having issues maybe they're not if they are male or female where do they go what is there a place online that has a great list of some of the best ones in one's area can

it be done over telemedicine how does one go about that yeah so in terms of your pelvic floor it's good to get assessed by a physician who specializes in pelvic floor now that could be a urologist that could be a gynecologist or even a physical medicine rehabilitation doctor that specializes in

pelvic floor health so typically you'll see in urology you'll look for people who are board certified in female pelvic medicine and reconstructive surgery if you're a woman if you're a man maybe sexual medicine someone who specializes in sexual medicine would be a good place to look for gynecologist again you want to look at someone who has interest in this area who

who has 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 PM and our 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 you do want to make sure that one they do are certified in pelvic floor physical therapy and that they have taken care of your gender so if you have male anatomy then you want to go to someone who's actually seen men because a lot of the pelvic floor physical

therapist tend to treat a lot of women and so that's kind of what I tell my patients generally speaking there's no at least to my knowledge no great resource and maybe we'll 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 shame or at least a lack of clarity as to how one gets help for issues that

relate to the genitals right because if you have a headache or you're having an eye issue I mean sort of know where to go yeah hopefully your headache doesn't warrant going to a neurologist but it might you know I stuff tends to be of the malgis optometrist 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

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-plainful intercourse is there

is it even possible to have a parallel conversation about these two things so it's different in in some circumstances there are homologs right so the penis is the homologue of the clitoris right so the clitoris is the you know essentially the same sort of spongy erectile tissue that you see in the penis it gets erect with arousal and it is it actually extends very deep

into the pelvis so it's not just a small little organ 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 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 new vascular problems hormonal problems neurologic problems psychogenic issues and other medications you're taking so there are issues that can affect erectile function

and so that can be part of it where you know you might feel like you have low desire because your arousal is not there and that becomes a little bit confusing for women what they can assess is their level of lubrication if sex hurts and if they get an orgasm and so those are kind of the ways you can look at it

thank you for fleshing all of that out you know years ago I worked on sexual differentiation and in particular the role of hormones in sexual differentiation and indeed as you described we learned because we were taught and I think 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 genitalian associated organ malary and docks 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 knock down a few of these pins in a little less time because there's a lot to tackle here first off I'd like to address the hormonal issues you mentioned that only 3% 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 there 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 3 to 6% more you know up to 6% we see of erectile dysfunction is hormonal it's a small percentage of the entire entirety of erectile dysfunction

okay so I think in looking in the landscape of social media podcasts and and just in the common mindset we've all come to believe that testosterone is pro libido it's pro desire in men and women I think now people are starting to appreciate that it's pro desire in women as well it's really in men and that dopamine is also associated with desire

and the general public tends to have this view of estrogen is being sort of anti libido or anti male which is frankly false in fact and I've covered this on the podcast with Dr. College of Latin with Dr. Peter atia and another fellow YouTuber Derek for more plates more dates has talked a lot about the fact that if people if men

excuse me take drugs like an astrozone to suppress the restrogen thinking that oh it's all about having high testosterone low estrogen oftentimes they crush their libido just abolish it yeah which has led to a slowly growing but I think positive shift in how people are thinking about estrogen estrogens great for brain function estrogens great for libido in men and women

and that is a revision of I think how most people think of the male sexual response it's more in keeping without 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 misconceptions

now the reason I mentioned dopamine is that my understanding is that dopamine is involved in the around 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

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 constimulate erection or vaginal lubrication so it gets tricky I would it's not like the textbooks it's not like they taught us in high school as far as I know I was taught that the arousal response in males and females is initiated by a parasympathetic sort of relaxed tone and that as sexual desire and arousal and

sexual and sex or masturbation progresses that it shifts more towards the sympathetic nervous system which has nothing to do with the emotional sympathy and has everything to do with arousal the catacolamines dopamine nor epinephrine and epinephrine also called adrenaline and nor adrenaline 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 coidal or post ejaculatory or post climax phase then there's a shift back to the parasympathetic nervous system that's where the pillow talk and the the exchange of odors and tastes and other molecules is known to enhance parabonding 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 all your all the male audience will like that on and then 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 they're leading to arousal is because there needs to be a stimulus

right a visual stimulus 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 see Alice by agro and also non prescription drugs things like a ill citrulline arginine and watermelon for that matter right so I read on the internet yeah so yeah so nitric oxide is essentially the

mission for what we say for erections the ignition for erections that we if you thought the reason I talk about erections more often is when you look at the data in fact there was a paper on this where they looked at the number of articles that came up when you put in the word penis and the number of

articles that came up when you put in the word clitoris and it was 50,000 about penis and 2000 about the clitoris okay we have to we this was actually a major section of the comments yeah on when I asked for for questions on Instagram comments on comments and yeah how come why not et cetera is that because the urology and sexual health field was dominated by men that's going to be the

presumption or is it because it's easier to study somehow or I mean what's going on here yeah I think there's been a lot of 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 valuable I guess I don't that's the right term but yeah oh no no I'm not

not your term I just ran you know it was you know it was more about the male sexual response than the female sexual response and so in general yes there is you know there were more men in medicine there was more and it is easier to study right you can't stay the clitoris quite as easy as you can study the male penis response because you can see it visually you can inject it and see an erection response right you we do this for people

who have a reptile dysfunction they'll take medications that increase blood flow like try mix and you'll inject it into the penis and you'll see an erection so you can actually try mix try so there's it's you're all the entire male audience just went wait what do you do there are there are three basically brand names of intracavernosal injections that we use for a reptile dysfunction I hear injection and this and I think I'd say I like to

think that it reflects a natural male response I sort of I I taken a back I don't know maybe there's a public floor contractions in there someplace so it is it is scary to hear about it's a very small needle it is very well tolerated I've done it to patients in the office and they look at me and say you're done like they don't even you know it's 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 is the most effective non surgical treatment we have for a reptile dysfunction and it's usually either one medication two medications or three so you can have you know I'll prostitute the pavrine and that's okay we can look at someone will put it in the comments surely they will what what is it designed to do is it is it a vasodilator of sorts so they they work in different

mechanisms but similar to the medications that we have PDE 5 inhibitors PDE 5 inhibitors work in the erection cascade basically what happens let's actually let's take it back to the nitric oxide thing and we'll get there so nitric oxide essentially is released by the end of helium in response to a visual tactile stimulant stimulating Q right and so your body releases nitric oxide which then sets off the cascade for the erection

and so that releases CGM P which is which is causes the erection and it's degraded by phosphodiesterase and so medications that inhibit phosphodiesterase like Viagra and CLS tend to prevent the breakdown of that CGM P so you have longer lasting erections and so similarly as medications work sort of similar to that some of them we don't know exactly how they work but they work by increase increasing CGM P or CMP that are involved in those cascades

and what about el citralline I hear about el citralline use it's an over the counter supplement and it's in the arginine pathway and my understanding is that it works similarly to things like CLS Viagra but is perhaps not as potent I also just cautionary note out there

and so that is actually what I'm going to talk about is that the el citralline can give people vicious cold sores and canker sores vicious that you hear about this on the internet it's been verified by grotesque images that you do not want to the Google for and not everyone tolerates it well.

So these actually work by increasing nitric oxide so they're not in this they're not later down the pathway they're actually increasing the availability of nitric oxide so L arginine is the more direct pathway very low bio availability L citralline converts tell arginine but it is last much longer in the bloodstream which is why people tend to use el citralline Now you know in in sexual medicine these supplements while there has been some studies on them and they are effective

there's no regulation on the supplement industry so you know we can recommend them but we just can't say that for sure that the supplement is exactly what'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 relationship to except that I mentioned them all the time is examin.com which has references to human studies and where there's a lot of efficacy shown and we'll get into some side effect issues

does can't address you know quality by brand issues but thanks for mentioning that what percentage of males who take siallis to ak to dalfil or viagra for rectile dysfunction get relief from that because you mentioned only 3% of erectile issues and males are formal in origin But what percentage are likely to be blood flow related in origin?

Large percentage are blood flow related that doesn't mean that the medication will be effective for everyone if you look at the large percentage are vascular in nature right that's the number one cause in as men age So we know that about 50% of 52% of men over the age of 40 will have a rectile dysfunction and that continues to increase as you age So 50% of 50 year old 60% of 60 year old and so on and so forth so it's very very common and the success rate in the studies is about 60 to 70%

So when you give someone a medication they will have sustained erections that are sufficient for penetrating in a course which is the way we kind of discuss the rectile dysfunction in studies and in you know with patients is about 60 to 70% So not everyone will have success but not all of that is because the medication doesn't work sometimes people are not taking them correctly

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 a significant number that's the majority but by a significant margin Is there a basis for the use of siallis, to dallophil, viagra, el citrilline, and females?

There's not a lot of data on this but certainly if you have surmised that there is a blood flow issue and they're having difficulties with orgasm and certainly something you can try off label and certainly people do try try these medications off label to see if they improve sexual function for women

But there's not a whole bunch of robust randomized controlled trial studies on women with these medications A little bit later we will talk about prostate health specifically but I'm just going to make a note here that nowadays there's increasing use of low dosage

Siallis slash to dallophil so rather than what I found online was that the erectile dysfunction treatment dosage of siallis to dallophil is 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 siallis to dallophil for prostate health

And I learned in researching for this episode that to dallophil, siallis 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 if you dive into the guts of the internet One can find that now there's a growing use of combined low dosage siallis and apomorphine which is a pro dopaminergic agent

And we'll get back to dopamine a little bit later but is there any basis for low dosage say 2.5 to 5 milligram daily use of siallis to dallophil in females Yes, so let's talk about it for males and females I think low dose daily siallis is excellent for erectile function in men

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'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 want to give at least a four week trial to see if there's any benefit with those medications Great thank you for that why is it that I get so many questions about erectile dysfunction from males who are in their 20s and 30s Because everything you said up until now was mainly focused on men 40 years and older Is it from lack of physical activity over use of nicotine by the way vaping as far as we know

Vaping and smoking bad for erectile function and perhaps sexual health and males and females generally because nicotine is a vasoconstrictor Nicotine does have certain benefits and I covered this in an episode on nicotine norcognitive benefits and the elderly in particular But it is a vasoconstrictor so it runs against all of the sexual rousal stuff that we're talking about But okay let's assume that 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 That was a quiz by the way folks for earlier topics covered

Let's assume they're you know eating pretty well majority of their foods are coming from non-processed or minimally processed foods They're doing a little meditation each day they're engaging in hopefully healthy relationships they're not masturbating like crazy to porn and You know let's assume that they are you know not on any SSRI why are all these 20 and 30 year olds on the internet asking mainly you

But also to my direct messages about their erectile of shoes 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 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 covid I mean people sat for months right years just sitting at their home computer And so you know exercising one hour is not going to offset the day full of sitting and so all of those things can affect pelvic floor function

So my theory is that that's probably the more common cause so walk more yeah I've actually heard that Yeah, yeah walk more standing desk, okay, so 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 by last name but yeah the kid down the street you know had porn or magazines Yeah or magazines

And then there was actually a library of these goodness I shouldn't say where they were in the town that grew up in where kids would stash them 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 use me looking at them But that that actually is to raise perhaps a more important point which is that looking at pornography is different than masturbating to pornography

Which is also different than masturbating to pornography to the point of ejaculation right because I also get a lot of questions from people about their porn addiction issues And there's a growing theory out there that overuse that meaning not just looking at but masturbating to pornography to the point of ejaculation is creating a deficit of seeking out and cultivating healthy real world sexual interactions

Yeah so I want to start this before I get into that 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 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 described in about 4% of people in these studies so it's a small subset of people I think it's becoming more common because pornography is so accessible And it activates the dopamine pathways just like any other sort of addiction right you watch pornography you get a dopamine response Your brain then says oh I want 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 sorry to interrupt but that the dopamine response as a hardwired biological mechanism for adaptive behaviors Including and let's just define healthy sexual behavior because I feel like there's such a range on that depending on one's background religious beliefs etc. 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 do that that's horrible and then they're in their head right and then they're causing problems in their life because they're because of shame And so there's I think there's a little bit of cultural shame that comes of this discussion and so you know it's a problem in the long term 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 both fine Or they're between or they're between relationships yeah and they're relying on masturbation specifically right

Are there any data that distinguish between 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 I think So I think that 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 for play is and this is like not normal This is the production this is a produced product that's meant to arouse you right and to give you ideally an ejaculation or an orgasm right

So no one has that discussion so then go to relationships like why did my partner not react like that woman did on the porno right or why did I not react like that woman did on the porno Why didn't he react when you know like they would in porn because I think females are watching porn as well

Exactly yeah yeah 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 because it's so accessible I think we need to have conversations I think it needs to be open

We have to talk about sex and that's what kind of why I do what I do we have to have these conversations so 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 place earlier Because I do think those are universal healthy constraints yeah, consensual age appropriate context appropriate species appropriate

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That's inside tracker.com slash Huberman to get 20% off I asked whether or not imagined the pure imagination based arousal versus visual arousal And for some people the sounds of people having sex is extremely arousing if you ever lived in a major city like New York which I spent summers in New York You're more often than you do in areas where people are living further bright you hear people having sex It's part of the auditory landscape Yep, you're very close together

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

You may get used to masturbating a certain way right so if you use certain biobatory 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

And 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 with that being said you just want to be thoughtful about varying it up

One of the issues with masturbation that I've talked about when I was a guest on other podcasts mainly in the context of male masturbation and perhaps with pornography perhaps not is that it's pretty clear based on the data surrounding addiction that Any time there are big increases in dopamine without a lot of effort required to generate that dopamine like turning on pornography on the internet versus asking someone out on a date going out on a date

And 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 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 a form of finding make I mean I was weaned in the era when you know no smartphones or anything and No my point is I think that we've become very connected to technology in our world which also means that we're having less conversations

The younger generation is having less conversations and more online conversations and I think that's a skill that needs to be developed as well and I think part of that is contributing to all this as well One thing that I can attest to is that you know I grew up in a community of mostly male friends I have female friends always have 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

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

They might be that guy yeah absolutely and and if you look at the look if I look at the long arc of those people's that guy's life It didn't speak to tremendous success in the domain for which they were asserting such confidence let me put it that way Okay I'd like to slightly pivot to a different aspect of this conversation because it's just really critical which is the female sexual response You know this is something that does not get enough discussion Absolutely

And there's a lot of stereotypes right the stereotype that we hear about is oh you know they need more for play which can be true Some cases is not true the stereotype is that women are more 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 Or maybe all the time I think I like to think that we are past the stage of human development where the stereotypes around this are fixed

And we hear more about this and we see more about this now but what is the real deal around the female oral response And then we will talk about female orgasm response and there I'm just going to earmark now that 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 like well you can go back to their research of masters and Johnson

And so what they did this was way back when and they actually watched sex workers have sex and this was I guess okay back then Female sex workers Yeah so they watched and they took note of 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 need something more novel and exciting to then again resume that cycle again The Coolidge effect yeah I've talked about the Coolidge effect before on this podcast I'll just queue people to it at a time stamp link in the show no captions so we don't go 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 is of the feeling that they can't have another erection for some period of time the presentation of a novel I guess we should say partner because we could be talking about homosexual relationship here not just heterosexual but a novel sexual partner female or male depending on their their proclivities can override the refractory period

And they can have another erection and ejaculation 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 thing the prolactin is essentially establishing the refractory period and the dopamine is essentially overriding

the refractory period fascinating neurochemistry there and speaks to the incredible extent to which the brain is controlling the genitals Yeah, I mean we always say in sexual medicine that the brain is the most powerful organ for sex not not your genitals but the brain because it is so powerful and I'm not sure if we're going to touch on this later but I'll bring it up now there are some centrally acting medications now available for their FDA proof for pre menopausal women with low libido

Oh, but maybe throw those out because the one that I'm aware of is in that's often used in let's say niche cultures is melanocyte simulating hormone in men which gives people a tan makes them erect that melanocyte simulating hormone at MSH comes from the medial pituitary if I'm not mistaken one of those weird regions no everyone talks about the anterior position

but and people are now injecting this as a peptide it can cause pre-pism I have not had that experience I've never tried this MSH but I've been told that it people are getting cavalier with it they can have issues pre-pism being enduring and perhaps even final erection is that true? I mean it's actually from Priapis the Greek God who is often photographed with a really big erection. Oh wow, I wouldn't hear enough about that Greek God in school.

But is it Roman Roman a Greek but anyway so either way 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 an actually an emergency if you have an erection that lasts longer than four hours in the absence of sexual arousal

then it is important to get to an emergency room because at that point you can start developing decreased blood flow and ultimately not 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 siallus slash to dallophil or viagra for erections are getting true pre-pism.

Correct and it's mostly from those injectables we talked about earlier those intercavernosal injections people can get pride pizzerum from those a little bit more commonly and so that's something we always counsel on and also certain medications like trasodone or if you have sickle selenemia those are the most common reasons that we see people coming in with pride. Trasodone really okay I'm going to refrain from my 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 Bremelanatide is the brand name. Valisi is the the sorry Bremelanatide is a generic name. Valisi is the brand name which is FDA approved for women with low design hypoactive sexual desire disorder premenopausal women premenopausal because that's what they study.

But it is basically the same peptide right so it is a melanocortin receptor agonist and it works dope on the the brain pathways to increase desire it's taken as an injectable again just like you said about an hour forty five minutes before want when you want to want you take it forty five minutes before and it works quite effectively in increasing desire how long does it last about twenty four hours some people maybe up to forty eight.

I mean I know men using melanocytes stimulating hormone peptides I also really want to caution people about obtaining gray market peptides sorry for this insertion here but there are a lot of peptides available without a prescription on the internet they are almost all contaminated with something called LPS lipopoly saccharide which is not something you want to be injecting a lot over time that's actually how we induce an immune response and animals in the laboratory.

And it is amazing to me how many websites are selling this stuff and it arrives to you easily 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 potentially going to shut down that whole market at some point but if you are interested in using a peptide you should be obtaining it by prescription from a quality physician.

Exactly and because we have bream melanatide we can prescribe that for men as well. So sometimes we're off label for men who are having delayed ejaculation because it will help them achieve orgasm a little bit better. And so you know this is available for premenopausal women the other medication that's available for low libido is called flabansaran also known as Adi is the brand name and that also works on 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 hyperactive sexual desire disorder works in about 65 to 60% of patients and you need to take it for some time now both these are brand name medications. So they are a little bit costly and sometimes insurance doesn't cover them but they are available I think very few people know about them and I think they're really great and useful tools in the toolbox.

And these are for desire. 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 lubrication arousal and femoral orgasm but as long as we're talking about arousal and reduced arousal that requires treatment I have to ask this now.

Anytime we talk about arousal and libido there's no BMI which by the way the body mass index is probably not the best tool either but there's no chart it's not like a thermometer that says you're 98.6 plus or minus 2 degrees you're good if it's too high much higher than that you have a fever much lower than that your hypothermic so my understanding my I don't want to say naive understanding but my understanding is that. One determines whether or not their libido is normal high or low.

Largely based on some intuitive understanding of what their partner or partners desire whether or not they can meet those desires and if they sort of a crew enough of a sample size they gave 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 different times of the year 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

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 yeah so there's no right or wrong basically what you're saying there's no right or wrong amount of libido there's many people who identify as sexual and they are happy with that there are people who

like to have sex once a month and they're happy with that it really is a matter of distress are you bothered by it so when we look at studies for female sexual dysfunction you can using like validated question is like the FSFI you can actually see that about 40% of people qualify for having sexual dysfunction but really bother is only seen about 12%

and you can be bothered because your 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 libido 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 later we'll talk a little bit more about chemistry which I find infinitely fascinating because in my life experience I've just been struck by the fact that occasionally you have a physical interaction with someone or sometimes it's not even physical interaction and they are just so unbelievably arousing to you or somewhere in between or sometimes it it just sort of ain't there 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 then it's not there and this is not just put on males this is put on females I hope she doesn't kill me for saying this I know somebody who is 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 about libido as you so aptly pointed out engaging what is healthy levels of libido has a lot to do with what one self desires as well as you know

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's so fascinating and it's something that isn't talked about enough but thank you for that let's get back to female sexual rousal response and orgasms 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 because they haven't had adequate time for arousal and so they're the penis penetrating before they've had those adaptations to occur and also the labia open up to allow for that penetration so these things actually happen physiologically to allow for preparation so while some people may be aroused and get to that point quicker some people do need a longer period of time of what as you described before play and you know

that's not as you described before play and not everyone is the same but I think it's important to have that discussion with your partner and you know lubrication is one of the ways that people assess arousal but that's not the be all and all some people just make a lot of lubrication and some people

and certainly that changes with age and hormones so if certainly we know that after menopause with a drop in estrogen and testosterone you will see a decrease in lubrication and sometimes if people are on medications that can alter their hormonal 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 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 and unpleasant topic but one that's important to to to to flag are their forms of non libido type arousal lubrication that allow for non-painful or even pleasurable 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 pleasurable 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 postmenopausal reductions in lubrication but are there also postmenopausal reductions in baseline lubrication are some people's vagina is just more lubricated at I want to say at rest it's like a scientist in me when

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 literal engagement right they're getting literal engagement there's been some studies on that that they are also getting nocturnal

to messants right just like men do as far as lubrication you know the data at least from what I understand is like there is a protective mechanism whereby women when when there's any sense that maybe penetration that their body will immediately start creating lubrication and that is protective to avoid trauma and injury there's also baseline vaginal discharge that's completely normal women will make

physiologic discharge in fact in our examinations when we examine will say normal physiologic discharge because we see it there's always discharge and it is it can be up to like five milliliters and so it's not a small amount it can happen it can be quite a lot and it's menstrual cycle dependent in terms of the viscosity and yes it changes over the

cycle and it can be differently in color and different in thickness and that's completely normal and I think that's a real problem in the feminine hygiene industry you don't need to smell a certain way or or reduce that discharge this is like completely 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 sense 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 ton of data on this but like there is that part of it so you know there's a lot of marketing towards women that your dirty you should be smelling like peaches or whatever and there's a lot of marketing maybe this is a generational thing but I learned early on I think by behavioral neuroscience courses that vaginal lubrications were part of the arousal response for both

these were always framed in the context of heterosexual relationships but both partners let's just say both partners because this could be a homosexual female relationship to right we want to make the conversation as broad as possible and that the odor let's just frank here the odor and the taste 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 in a relationship that let's say

had healthy sexual relations I like to think is experienced remembering somebody smell or think about somebody smell and that itself can be very arousing yes partners even I'm smelling different articles of each others 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

dosing 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 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

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 I got a number of questions about microplasma infections which you know we don't hear that often about but yeah so you you can see if your discharge has changed and become more like cottage cheese like or there's you know other symptoms like itching or discomfort

then you know those are signs to go get evaluated a microplasma is another infection that we see in the vagina but we also actually sometimes see in the urine and while it's not something we routinely test for when we have people who have symptoms of urinary tract infection and they're not improving sometimes we will check for microplasma that could be causing symptoms in the urethra itself.

We've had a couple episodes about the gut microbiome my colleague Justin Saunenberg at Stanford his laboratory is directly above from eyes expert in the gut microbiome done a couple episodes about this and he reminded me and I like to remind people that every mucosal lining of your body has a robust microbiome so that means intranasal through vaginal intranuorethral 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 in 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 a bad thing in many cases because it's wiping out the microbiome. What are some of the things that females can do in order to promote the health of their vaginal microbiome? So it's really our bodies are amazing the vagina is a self cleaning of it you don't have to do anything you just wash it.

I love that the vagina is a self cleaning of it. I'm not going to repeat that too often in two main 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 should be cleaned but other than that let's 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 Argentine and he said just remember kids are the one thing in life you can't give back. That's all he said that was it that's it that was it oh gosh well I will tell you my discussions with my sons are my son my old son.

My son my older son has been much more graphic than that I tell him yeah amazing well I went out into the world and anyway 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 to parse this.

I think that the simplest way to parse it is going to be from the anatomical standpoint.

Literal 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 literal stimulation by pelvic pressure or by digit we're talking about fingers is digits because we're both in the medical slash science profession but which I'm at fingers here or something else right vibrator toy whatever I'm told for depends on how flexible you are I don't know but the point being that I think the simplest way to go about that.

This is going to be to talk about the distinction between literal orgasm and g spot orgasm however those are achieved.

And to also talk about this idea of graded versus absolute okay so this has actual parallels to neuroscience where we talk about communication between neurons being graded meaning it's kind of you know one level then a higher level then lower level or all or none right how shall I say this 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 period of time in which they become hypersensitive to touch.

So lots of different things going on there psychologically physiologically yeah tell us all of it so in terms of orgasm right I think it's important to distinguish that there is orgasm and then there's different areas that you stimulate to achieve orgasm so some people will stimulate the clitoris is probably the most reliable form of stimulation that will achieve orgasm and when you look at the data and again you know female sexual dysfunction data is not super robust.

But what we find is that about 85% of women require literal stimulation or to climax so very few actually climax through just vaginal penetration alone and so this is you know a real problem we're seeing on the media that you know you you have sex and you penetrate a melee women are having orgasms that's not the reality for a lot of women.

And in terms of stimulation so like we talked about throughout this podcast the clitoris is the homolog of the penis or the penis is the homolog of the clitoris however you want to say it good on you for getting it both directions I probably want to screw that one up.

So so clitoral stimulation is just like penal stimulation for women that is very reliable and there's a huge orgasm gap for men it's pretty consistent that when they have a first time sexual encounter 95% of men are having an orgasm.

We look at first time sexual encounters for women with a heterosexual relationships it's about 45 to 50% are having an orgasm and when you look at homosexual relationships of women it's again 90% so there's clearly some lacking in 90% of female homosexual interactions that are first time interactions 90% are having orgasm. Correct. Because they understand the anatomy of other by way of understanding the anatomy of self.

So there's a huge gap. And physiology and psychology. Yeah that's true that's true but you know there's a huge gap there and so I think 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 trying to do that.

So you're stimulating that you're also stimulating the clitoral shaft which goes deep into the pelvis the G spot is is an area is an erogenous zone where it's kind of in the anterior wall the vagina about two to three centimeters in that's the location of these periorethal glands called the skeens glands and they are analogous or homologous to the male prostate.

And so I think 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.

There's a huge huge variety of ways you can stimulate with stimulate anyone it can be man or woman some people will have orgasms who 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 don't take it personally right like I think a lot of times people feel like you have to orgasm to have pleasure which may not be the case for everybody.

And if it is you know how do you prioritize that for your relationship so I don't know if I got off track there but that's kind of I think the the take comes for this and also the vaginal penetration it's actually usually from cervical stimulation not necessarily vaginal because the large density of innervation the vagina is the first outer third of the vagina there the deeper two thirds of the vagina has has much less innervation.

And yet there is such a thing as cervical orgasm so and the cervix being further up the vaginal canal is cervical orgasm specifically the one of the stimulation in the the foci of an orgasm that starts in the back of the vagina is that yeah so it's from stimulation of the cervix through whatever means right and that can be pleasurable and lead to orgasm and again orgasm you know is is defined differently right but the one thing we know.

Is that there are pelvic floor contractions which are measurable so you can kind of tell that your partner is having an orgasm if you have a female partner because you can actually feel those contractions right whether it's on your digit or your organ or sex toy. So I think it's a super nerdy question here years ago when I worked on hormone-based sexual differentiation which by the way we've done an episode of the podcast on previously.

You know I learned that the levator any muscle is the muscle that controls erection and males and presumably a literal to mess and send an engorgement in females is there an equivalent muscle responsible for the orgasm response or is the contraction of the pelvic floor.

Part of a more general theme of muscular contraction and a bunch of different nerve roots contracting the reason I 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 in their recognition of it and other people and descriptions etc but are we talking about a response that originates at a foci.

Like in the brain we talk about a seizure starting at a focus of foci and then spreading out 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 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 what is happening nearly I mean it does have certain parallels to seizure right. It does it does so let me go back to your first part of the question which was about orgasm and sorry erection and two mess and being literally levator a night so actually what happens during the reason you get an erection and presumably clitostomulation the same way is blood flows.

In to 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 is an actual blood flow event.

Then how come we want to study erection behavior in rodents we would give them injections of testosterone females or males and observe changes in sexual behavior accordingly erection and clitoral to messence although it's harder to measure in rodents there's a way of indirectly measuring that and then we would measure the size and weight of the levator any muscles as a read out of how androgenized that whole system was.

In other words what is the role of the laboratory any in the sexual response. So the levator a night or what I say levator a night.

Well you know I 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 there so that's how they would increase their their strength or their density if you're measuring that through the actual climax of the 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 happened those muscles contract as a response and climax is a brain initiated event orgasm is a brain initiated event so that's why to answer your second part you obviously feel focal response but you also can feel a variety of responses because it's all coming from the brain it's not kind of the way you described it as like a ripple effect.

It's more of like a it's the way your body responds to that particular stimuli and it's actually like the ultimate form of mindfulness you can't think of anything else when you're orgasming right so it's like you have this moment of clarity and and everything and everything you were very present in that moment and so people will feel different simulations depending on you know how they're how they kind of how their sensor you know their nerves are their sensations are things like that.

And this perhaps a good time to mention dopamine we talked about a few times earlier when talking about the arousal arc that starts with parasympathetic sort of calm and then move typically starts as calm and then moves to the orgasm response we know that the orgasm response is associated with release of dopamine.

And then prolactin which sets up the relative or absolute refractory period the the interesting thing and I got some questions about this is that there's literature as I understand about the elevation and dopamine caused by say antidepressants like well butrin reprieron which increases dopamine and or epinephrine people who recreationally use drugs like cocaine or other stimulants.

And people who take at all by dance or other drugs that increase levels of dopamine because I did whole episode about those drugs and they are different forms of an fetamine unless we're talking about riddle in which is a little bit different. And I got a lot of questions about people who experience feeling a lot of desire sort of a rousal 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 whether that's anything but calm right sexual arousal is anything but calm but maintaining enough calm that they can ride that arc.

For whatever duration is appropriate for that interaction in them right because again when we should probably get back to this you know you know some people will have sex for long periods of time some for shorter periods of time and here.

So I don't really know what other people are doing except by way of pornography and self report and discussion so is it the case that drugs that increase dopamine can inhibit the sexual response do they tend to promote the sexual response because I also mentioned earlier there's this growing trend of people taking by way of prescription of course from a physician combined apomorphine which is a dopaminergic drug with to Dalafil which is a PD 5 inhibitor so it's going to increase blood.

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 and sex does it make sense as a mechanism yes so in terms of apomorphine 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 response so like I mentioned that flabancerin which is essentially acting medication it actually has not only inhibitory and not only stimulatory but also inhibitory effects on dopamine so the way it 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 insects or more interest insects and so that's kind of how it was discovered similarly Viagra was actually studied for high blood pressure and when they went to. It was horrible blood pressure medication but then the people the men who took it actually didn't return the samples for the study so they realize like what's going on here and it was because they were having better erections is it true that at some urology meeting that the first.

Description of Viagra as a treatment for our tal 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 have a no slow injection though I think he came out. It is a true story there's actually a published article I'll send it to you so you can share it if you'd like there's a public see but I'll read the article.

There's a published article about people who were attending at the meeting in the s he came out and at the time like it was mostly men in urology but there were like spouses I guess in the audience which is not typical now but. So there were women in the audience and he came out with the full on erection to show that it you know correct well I suppose that the urology meeting or.

We have a bg y in meeting where a woman comes out and reveals her enhance vaginal lubrication then we will have we will have a gender and sex balance at the meetings on urology. It will be interesting to attend one of those someday. Differences in a ralzel as a function of stage of the menstrual cycle really interested in this I did a long episode on fertility we're going to have a few other IVF experts fertility experts on the podcast but.

Clearly there are differences in hormones across the menstrual cycle we know that for sure yeah clearly there can be psychological variation according to those hormones were probably other than. Across the menstrual cycle and it's always an imperfect experiment because. You know we aren't laboratory rats and people are having different interactions across the menstrual cycle is there any known correlation between.

Desire and stage of the menstrual cycle there are some obvious assumptions that one might make you know prior to ovulation etc around the time of ovulation.

But what about the other direction to is there a category of women that are very interested in sex at certain stages of the menstrual cycle and then not at all interest in sex at other stages the mental cycle you know all that I the data that I've heard and maybe a guy in college could speak more on this because they study those variations a little better but there is data to suggest that libido does increase prior to ovulation and during ovulation i think it's a couple days prior because that's the optimal time for fertility so yes there is data.

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 or.

And then they separate out literal stimulation as more common route to orgasm but of course there can be literal stimulation with penetration and depending on the physical arrangement there can be literal stimulation purely by way of penetration through pelvic contact fingers etc so how do we how should we think about this how should we talk about it so there was an interesting study that I just read.

Recently where they gave women words for these things right so there's like the rocking stimulation so that can also stimulate so meaning that the your penetrating but there's like a rocking motion that can also penetrate the clitoris there's.

Stimulation of just the outer part of the vagina which again as I mentioned the g spot is there it's more highly integrated so that can be more stimulating there's also ways to align yourself so that when you're penetrating you're putting pressure on the clitoris and then there's you know stimulation with like actual stimulation of the clitoris like intentional stimulation either by yourself or by the partner and so there are multiple different ways to do that right.

And so there I think that it's important to really kind of it's okay to explore and not always be a home run and I think that's like when you get into 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 we have never been taught how to do that.

Yeah, such important conversations for so many reasons as you point out definitely not something they teach people in school except you know they might say something about you know communication is important and that almost always circles back to the key four things we talked about earlier which is you know consent and age appropriate context appropriate these kinds of things and and obviously substances like alcohol and other drugs can strongly confine the people and the people that you know they can't do that.

And so that's we'll just leave that as a kind of an obvious one. As long as we're talking about communication on sexual interactions perhaps it would be useful to people to cultivate a language or a nomenclature there to to facilitate that some of the language that I've heard that is quite useful is things like you know people have different arousal templates.

Some people certain ideas are stimulating to them and other ideas are aversive to them and then there's this category in between where sometimes people sort of either don't know because they haven't tried it or haven't thought about it or they're sort of curious but kind of unsure or it might work in the right context but maybe not all the time. 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 sense of insecurity for the other person right did I do something wrong did something go wrong here. So you want to kind of move those to a neutral location so like kitchen table in the car whatever somewhere where you know sex is not going to happen at least for that particular moment.

And we have some challenging conversations on this podcast challenge previously challenging because they you know you're trying to get things clear and as clear as possible this one is challenging because there's so many caveats to everything right we don't of course be a lot of sexing cars right yeah or they did when I was growing up and sometimes they still do.

Okay, please continue yes so that's one and then to like when you're discussing it I mean this is kind of goes for any difficult conversation is like you make eye statements right you say I like it when this I don't like it with this it's not something you did right it's not you didn't do this you didn't do that 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 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 sec a sect or where you can look for a sex therapist near you and you can even do those things virtually.

And so that can be really helpful when you're having difficulty having a conversation. Yeah I think again such important conversations and then when people differ in terms of their level of experience it gets potentially problematic but also it can be potentially educational and then of course they're the twists and turns that occur with when one is asking about somebody else's arousal template oftentimes you learn things about people sexual past and you can actually get a conversation.

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 that it's understandable why the most conversations are challenging.

And it also is understanding why pornography isn't going to involve those conversations right really conversations there between your brain your hands and your eyes and your ears some not going to highlight any particular order there. I want to switch gears slightly and talk about UTIs I got a lot of questions about urinary tract infections let's make it related to both females and males because yes males get urinary tract infections females get them more female.

Asked about urinary tract infections how common are they should they always be treated with antibiotics is cranberry really a good treatment if so why are there other things that are better is it related to the acidity or alkalinity. 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 UTIs you just have one a year or you have won 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.

When men get a UTI it's concerning like why is a man getting a UTI you know there's multiple reasons that it could happen but it should be investigated like so that you can make sure there's no anatomic abnormality or functional abnormality with the bladder that's causing the UTIs in terms of prevention.

There are kind of major things are higher than the guidelines that we all we all talk about so one is hydration so making sure you're drinking about two to three liters of fluid ideally water a day because dilution is the solution to the pollution right so drinking more fluids is going to get that bacteria and you're going to pee it out it's going to help keep not let it sit around the bladder very often.

Another thing in women who have altered states of estrogen whether it's postmenopausal surgical menopause or maybe have reduced estrogen for postpartum or other reasons about you in the second half of the menstrual cycle when not necessarily for those specific people but for those specific times but because it's pretty short lived I guess you could use it but is is vaginal estrogen so vaginal estrogen meaning estrogen that's applied in the vagina either through a cream.

A suppository or a ring is is highly effective in reducing the occurrence of recurrent UTIs and this is because when you have low estrogen the pH in the vagina goes up and the pH in the vagina goes up because there's less conversion of glycogen to lactobacilli and then those lactobacilli are preventative for UTIs so essentially you want to reduce the pH back to its normal acidic pH and vaginal estrogen is very effective.

And so that's very effective and very safe so when you look at estrogen you know the women's health initiative way back when sort of made a big stink about the vagina and the

estrogen is related to cancer. However vaginal estrogen has never ever been a reported breast cancer uterine or a breast cancer uterine cancer or any other blood clot any other adverse event associated with the vaginal estrogen you can get some breast tenderness some discharge those things can occur but the absorbed amount vaginally is so little that your estrogen level barely goes up it doesn't even reach premenopausal level so it just goes up very slightly in the blood

stream not enough to create any sort of abnormality so vaginal estrogen is extremely safe and it's pretty affordable you can actually use coupons if your insurance doesn't cover it through you know good Rx or Mark Cubans pharmacy and get it very very affordably and it's very effective it does take about three months to work so you have to be consistent you

apply it about twice a week at night sometimes three times a week and it's it's very effective the ring you put in one step last 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 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 you're in a 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 completely empty you by sitting relaxing on the toilet sometimes leading 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

a lot of men are going to because there these you know it was fun to research for this episode because there are entire discussions on Reddit about like what percentage of males sit while urinating I mean minor shunning based on having visited many male bathrooms in my lifetime and just being in the world that I assumed that men stood up in order to urinate but there are a decent percentage of men that sit down to urinate

there are and in fact it's very little like country and probably the reason it's become more interesting lately is the media so a certain country was recently surveyed I think it was Germany but essentially this recent like picked up by the media that Germans sit more often to pee and so you know then people

like always is better for me to sit to pee your 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 you're not acting you're glad you're going to pee better also if you have an enlarged prostate which I'm sure we're going to talk about prostate enlargement that can sometimes allow you to develop a little bit more

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 where sitting is better but if you're being fine and you're standing that's fine too I don't think you have to I think it's just something that you know in other countries they do more and here we don't and I don't think it's right or

wrong it just depends on your individual circumstance can spermicides or condoms or both increase the frequency of UTIs for females so spermicides absolutely so spermicides if your condom has spermicide 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

and women now how does cranberry work right like do I just bring shoes it's actually a specific active ingredient in the cranberry which is called pro anthocyanidens 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 using is a soluble form of the cranberry and it's actually very very effective at reducing the risk of UTIs so do you mean capsules like a gel cap

yeah it's a capsule that you take once a day and there is some although not as much data that if you're having them around sex which some women do always have post-coidal 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 manos is one of them where you take you know about two grams a day of D manos and you drink it and that actually helps reduce UTI risk it's been studying a small randomized controlled trial to be effective and and so those are kind of the bigger ones

there's other things that people use like probiotics but there's a lot of heterogeneity as you know in probiotics and what to take and are they really effective vaginally in the flora there so those are kind of the big things and there is actually a lot of microbiome study in UTIs going on actually 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 going to figure out like is there something here that we can target or that we can figure out 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

you know as long as you've like cleaned yourself so to speak so I think it's less of an issue. Well we're talking about is it you're referring to any contamination from any

bacteria around the years. And a lot of women who have recurrent UTIs like tend to come and feel very dirty like there's something wrong with them like oh I wash all the time I'm really clean I'm really this and you know it's not something they're doing it's probably a microbiome of fact or a hormonal effect or you know there's something going on that we need to investigate further it could also be an anatomical or functional problem where you're not

emptying the bladder correctly so there's lots of different factors it could be 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. 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 again no pun intended. Perhaps

it's there they are abolishing the local microbiome on the skin too much cleaning. Limit the microbiome on the skin not that we don't want to wash but when Saunenberg was a guest on this podcast he said actually kids can develop a very healthy gut microbiome and general microbiome oftentimes by sorry parents not washing their hands before eating if they've been playing with soil outside or dirt a little bit of that is actually healthy pets actually offer microbiome

support this is so weird I know it sounds like. Yeah but we have to imagine how we evolved as a species was not with antibacterial soaps and alcohol swabs everywhere and obviously we don't want infections but over cleaning 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 I definitely have a UTI 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 the urination women can also develop pain with the urination that doesn't go away they can start where they had a UTI that triggered the pelvic floor and then the pelvic floor just didn't relax with the pain just triggered the pelvic floor to tense up it didn't relax because again we're not taught how to relax our pelvic floor and and then they've developed pelvic floor dysfunction like why is

UTI not going away or 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 kegels that everyone's talking about stopping that 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 and the only reason I mentioned that is because obviously this discussion is not about my pelvic floor

this discussion is about 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 I think any discussion about anything medical or you know especially hormone stuff this happens a lot in the discussions around that get into it seems with males like every male now seems to wonder if their testosterone is too low except the ones that are blasting testosterone because they know it's excessively high and as you point out earlier at least in terms of sexual function that's unlikely to be the case maybe less desire but in terms of a general 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 are not always sexual right it can be depression it can be weight gain that you're not gaining muscle mass you can have cognitive changes so those things can still be a sign of low testosterone and very valuable and important to assess

that reminds me of another thing and then I'll we'll get back to UTI's and I want to talk about kidney stones but I've heard of women using a small amount of testosterone cream directly on the clitoris as a way to amplify the maybe it's the desire and arousal effect or perhaps just one or the other

so I've the way that we discussed testosterone use and there are like consensus statements and there's actually an abundance of data on testosterone use particularly in postmen appausal women for low libido or low sexual desire and it's all been very positive

and since there's been increased sexual desire based on validated questionnaires increased number of sexually satisfying events with testosterone use now the range of testosterone women is about a tenth of the amount of testosterone on 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 psychological 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 guidelines or the consensus statements are not a true guidelines but they recommend using transdermal testosterone so getting you know androgylle tubes from the pharmacy

and putting a tenth of one tube on the back of the calf or the upper outer buttock a heralist area for absorption that can improve desire overall and then the other place we use testosterone is in women who have what we call vestibule

what we call vestibule odinia so the vestibule is the area outside the vagina which is very hormonally active there's lots of energy and receptors there and it can actually when you have hormonal issues meaning lower testosterone and estrogen in that area it can cause pain and so actually applying a combined or compounded estrogen testosterone cream to that area over time can reduce that pain and discomfort so as you know testosterone receptors or androgen receptors all over the body

very much in the genitals very much in the brain and they're very useful to a very useful place to treat women for those issues thank you kidney stones I hope to never have one I hope you don't either people get them 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 in kidney stones and so how can you prevent them I mean I you know each person is individual if you get a kidney stone typically we do what's called a 24 hour urine analysis

plus some blood work to assess what is the metabolic abnormality so we can target that either with diet or with medication and so that's kind of general recommendations for people who have kidney stones one is increase your fluid intake to two to three liars again the same number I told you before

you want to decrease your oxalate intake now if you google oxalate you're going to find a million things that you eat that have oxalate in them but the big ones are spinach and rhubarb we're seeing a lot of nuts too that are you know people eating a lot more nuts to get more protein

so you know cutting back it's impossible to get rid of all of that in your diet but if you're having like a spinach salad every day well switch it to a different green right don't eat spinach every day also you want to increase your citrate intake

that's an inhibitor of kidney stone formation so increasing fruits and 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 liars

and that can be helpful you want to decrease your protein intake so high levels of purines or purginec 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 people can have kidney stones and their kidneys they're not creating any problems they're tiny we can observe them over time if they start coming if they're starting very large or they are starting to move into the yearters

or the tubes that drain the kidney oftentimes they're accompanied with pain quite a bit of pain and it can be very uncomfortable in those cases we can if they're not having any infection symptoms there's no signs of a urinary tract infection there's no fever there's no chills

we can treat it conservatively with pain medication and also there are medications like flomex which are used for in large prostate as well that actually relaxes the urethal smooth muscle to allow the stone to pass a little bit better

if you're having an infection you got to treat it right away you can get very sick very quickly in fact I've seen young healthy patients like they're healthier than me walk 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

but I've stalked a teacolored urine so meaning blood in the urine all of those are important warning signs that you ideally don't get to yeah blood in the urine I mean it doesn't always mean infection it could just be irritation from the stone but certainly fever's 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 hydronophrosis their 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 urethoroscopy where we go in with a camera and we have a small laser we break it up into small pieces and where is the camera inserted through the urethra?

correct your sleep under anesthesia so you don't have to you saw the wins and then percutaneous nephilisotomy 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 lithotrypsy to break up that stone and kind of suck it out that way these are extremely helpful bits of information are not even bits these are this is an enormous amount of useful information

I like to pivot again for sake of bread we can't go into extreme depth on everything but appreciate your willingness to follow this carousel with me oral contraception previously on this podcast I hosted a female physician guest who offered both sides of

female oral contraception discuss some of the benefits discuss some of the risks I made the decision to post clips about both on the internet and wow wow wow was I surprised but also frankly a bit shocked and then finally intrigued by how polarized the discussion is around female oral contraception

and female contraception in general so new verin nor plant the pill brought category of things there but for sake of discussion the pill etc I mean it seemed that approximately 50% of responses which seem to come mainly from women were of the this stuff is terrible it ruined my life it ruins lives

it destroys you it has immense risk and then the other half seemed to say no there's reduced risk of certain forms of cervical cancer this has allowed me the sexual choices in 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 obviously I don't know what the answer is but I do know that this is among the more polarizing topics available for discussion so what is the story meaning what are the data about oral contraception

why so much controversy and what's the real deal here yes so it is a very polarizing topic and there is abundance data abundant data in fact we even did a study and again this is not like high quality evidence but we looked at reddit threads and we looked at sexual dysfunction specific low libido

orgasmic difficulties and we read hundreds of threads and we did like a qualitative analysis to see in females to see like what are people talking about and problems with oral contraceptives and antidepressants leading to low libido and being very like as you describe very like this is ruined my life was very common and so the theory is that you know taking oral contraceptives increases the amount of sex hormone binding glomulin 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 sub-sets 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 sub-sets of people but we do know that this does happen and that when you measure SHBG levels they're up and that even after they stop the oral contraceptives

you'll see elevated SHBG levels from baseline for at least four months afterwards you'll still see elevated SHBG levels we don't know but not infinite I mean you we don't know we don't know yeah the endocrine system is weird because it we assume everything is a short-term effect but there's some

plasticity in the system especially because it's a neuro endocrine system so yeah so I think yeah there's some neuro plasticity there that occurs as well and so we do see this and I think that the other side of it is yeah absolutely oral contraceptives are amazing right there they're helpful for sexual freedom for preventing pregnancy for you know for a lot of things particularly other conditions too like PCOS and other problems oral contraceptives are amazing and they've changed you know

gynecology and management of these women for you know in a very positive way and so I think you know yes I do think that there is oral contraceptive related sexual dysfunction usually low dose estrogen sort of contraceptives are the culprit but you know I think that it's again the data

female sexual dysfunction literature is just not as robust as male sexual dysfunction literature I saw a lot of comments about how oral contraception had led to depressive like symptoms or just kind of a hedonia and apathy not just lower libido I can imagine how that would be the case through the

elevates sexual hormone binding globuline which is you know preventing testosterone estrogen from being free literally and exerting their effects on not just the body but the brain but is there any evidence that oral contraception can disrupt no transmitters I'm not aware of any I don't think so not to my knowledge okay well it sounds to me like oral contraception for women 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 something that hated it and like no way tried that never will 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 you know what are the other options you know is the ring copper IUD so any sort of long acting

hormonal contraceptive we've seen we that's what we consult patients on is if they're having issues with oral contraceptives even if they come in with pelvic pain and they're on oral contraceptives I'll tell them you know what just stop because

maybe the energy the effect of on the energy 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 and go get a long acting contraceptive method 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 of IUD 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 if people are wondering why the copper IUD is an effective form of contraception copper is like the third rail for sperm as I understand it so much so that I was able to find some evidence for this in the medical textbooks that

in the old days as I say prostitutes who wanted to avoid pregnancy would put copper pennies in their vagina really now I don't recommend that to anyone and please and I don't think it's a foolproof form of contraception but there is evidence that that 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 it that's crazy I am not suggesting people do that I think it's just an interesting medical factoid yeah I can tell you want to move on from this topic so we will before discussing prostate and anal sex not stated next to one another for any particular reason I want to talk about SSRIs a lot of people over the last 20-30 years have been prescribed

selective serotonin reuptake inhibitors and other antidepressants that have disrupted their sexual function or their sexual desire seems in particular do you see a lot of this in your clinic do you hear about it what can people do about it you know oftentimes

these sexual arousal or dysfunction issues associated with SSRIs and other medications make those medications prohibitive for people you know serotonin is kind of the anti-to orgasm and so in fact we will use SSRIs off label for people who are having premature ejaculation so it delays

ejaculation and then there's also other sexual dysfunctions we see with it and it does happen absolutely it's dose dependent so in some cases when someone comes in with SSRI related dysfunction if they're doing well you can either try to reduce the dose or switch them to another antidepressant for example well butrin that does not have such severe effects on sexual function and so you can also use like CLS and Viagra like you've talked about

for rectilis function as an addition if we can't change their medication management because you know it gets a little bit complicated because we know rectilis function 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 I think

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 and it can be helpful to switch medications or reduce the dose and you mentioned earlier that trasidone can cause sustained

erection and is trasidone in the category of touching the serotonin transmission system? you know I don't remember the mechanism but interestingly trasidone is also used for off label like as a third or fourth line for premature ejaculation as well so so I don't remember the mechanism off hand. let's talk about prostate and prostate health earlier I cued up that there's a growing trend toward I would say more progressive male physicians or physicians who treat males excuse me. thanks for that.

prescribing low dose 2.5 to 5 milligram sea allis which is to dallefil which may assist with erections but the rationale for this low dose daily low dose is not centered around erections per se it's really about prostate health improving blood flow to the prostate reducing prostitis maybe even reducing the probability of prostate cancer. what other sorts of things are you encouraging men to think about when thinking about their prostate?

yeah so before I forget I want to mention that low dose 2dallefil is actually a treatment for erectile dysfunction in fact it works quite well particularly in 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 5 milligrams every day and it has a 36 hour half life so over you know you're kind of increasing 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 in large prostate and this is a very common condition in fact if you look at autopsy studies 80% of men at 80 have an enlarged prostate like it's very, very common.

now does everyone get symptoms and what's the long term concerns of it and you know what can you do about it so typically as the prostate enlarges it's right around the urethra it's a walnut shaped gland sits underneath the bladder around the urethra and it can narrow the urethra or the p-tube and so over time you can imagine like if you're I always give this example if you're sucking from a straw right you're drinking from a straw if you have a wide

diameter straw it's really easy to drink if your straw gets really narrow like so you take a coffee straw and you drink out of that it's very difficult to drink very similarly it can become very difficult to urinate if you have an enlarged prostate. now what causes an enlarged prostate there's a whole host of factors a lot of them are genetics so if your father your grandfather had a large prostate you're probably more likely to have an enlarged prostate.

do we know exactly how to prevent that not exactly but we know how to mediate the symptoms a little bit so the other symptoms you'll see before you have difficulty urinating is sometimes you'll see over activity so you'll see your bladder is responding to having to push hard against that narrow

urethra 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 getting for your stream to start or it stops and starts and so those you know or you're just like I can't empty like it's not because it 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 you know see Alice helps relax those those the fibres smooth muscle of the prostate so that allows urine to pass more easily there's also other

medications that you can treat very often flow max or other alpha blockers that 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 ear tends 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 got to stop all these delicious things I eat and drink but certainly it can be useful to just pay attention so like if you say you drink coffee every day and you find yourself running the bathroom a lot if you limit your caffeine intake you might

not go into 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 unless you'll 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 thank you so much that's very informative years ago there was a discussion about bicycle seats causing damage to the prostate maybe even sexual dysfunction

is that still a thing I thought they put grooves into the the seats but I've also in reading on the internet I didn't do a deep dive on Reddit but seems that women are reporting some bladder incontinence from excessive bicycle seat use maybe even exercise bike doesn't have to be road bike

yeah so this is a great point so cycling if you think about it right you're sitting on your perineum which is that space for men between the scrotum and the anus for women between the vagina and the anus and right there runs

your pedendal artery and your pedendal 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're

you know biking three times a week for 60 minutes but there's no like consistency but they're seeing pretty high rates of genital numbness so like up to 50% and also in men erectile dysfunction in women you'll also see numbness but because

sensation is a big part of arousal you'll also see kind of decreased lubrication maybe decreased arousal as well in women and so how can you prevent that the reason is because when you're sitting particularly if you're leaning forward like competitive bikers do or arrow riding

you're putting pressure on the the beak of the bicycle seat and that's where you know most of the it's not your weight is not distributed evenly so the goal is to take a bike seat that allows you to sit comfortably on your ishield to arosities 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 nozzles seat and a wider seat the cutouts actually when they've looked at kind of mechanics of the cutouts

the higher pressure around the opening so it's actually not good to have 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 yeah i don't want to uh make people not cycle i think it's really valuable cycling is a great aerobic exercise has lots of benefit for cardiovascular health but um there was actually another study that looked at people who were parts of sports club so they

were like swimmers runners and and cyclists and they looked at rates of dysfunction and they found that actually the rate of erectile dysfunction was not different between runners swimmers and cyclers so maybe you know because those other studies were just looking at 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 more questions for you and by the way you've been incredibly generous with your time and information here so i really appreciate it as i'm sure our listeners do as well anal sex you recently did a post describing the multiple reasons why women do or do not have

anal sex yes very interesting post very interesting study that you covered and you explained it very clearly um i'm guessing there are relatively few but perhaps some other studies as well about this um let's talk about anal sex and uh maybe if you could just uh offer some of the the key bullet points that you've learned from the literature and from your clinical practice um you know how frequent is it with protection without protection how safe is it um you know what are the different

reasons people do it um that might seem like a kind of a silly question but it turns out when it comes to this topic it's uh they're interesting data yeah um educate us so anal sex let's talk about it um well when you when you talk about anal sex the reason people it's become more and more

common let's say it's more and more heterosexual couples are doing it we know that um male homosexual couples are having anal sex and i think that one thing is that it's safe in terms of pregnancy right you're not going to get pregnant from anal sex which is one of the reasons people do engage

in anal sex do you think that's the reason people are doing it more frequently no i think that's one of the reasons that people one of the reasons people do but um in general uh the issue with anal sex is that people forget to use protection like a condom for example because sexual 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 um you can have you know uh you can have blood loss and that blood loss can then

easily more easily transmit sexual intercourse so it's really important to use a condom and use adequate lubrication the the anus does not make any of its endogenous lubrication you have to use lubricant the other interesting thing about anal sex is that the anus pH is different from the

vaginal pH so you want to use specific lubricants that are iso-osmolar to anal pH so you can actually look up anal lubricants and we could talk about lubricants but generally there's water-based silicone-based oil-based lubricants water-based are the most easily accessible um silicone-based

are a little more slippery and last a little longer and oil-based also last longer but are not good for use with condoms so definitely using lubricants and always kind of making sure to um be in the context of course it being consensual but also like never force always take your time and

and those things are really important to avoid trauma because trauma can happen and usually it's not severe trauma right it's not going to create long-lasting problems but it is you know inconvenient uncomfortable and probably we're not seeing as much of it because they're not coming

to the emergency room if they're having issues unless it's really serious um so I think it's really important one to prevent from that 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 going

to you know you're not going to start with a large girth item you're going to start with something smaller and kind of work your way up um and then I think ultimately why people have anal sex so as I mentioned earlier the prostate is you know highly innovative 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 their the pelvic floor um 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 um sometimes it's because people want to do something special with their partner like they feel like this is my special thing with this partner that I do with

them and so it may be something kind of like a gift or something like that sometimes it's almost like they feel like they um they have to and this particular state that I looked at there's actually not a lot of studies on why people engage in anal sex and this particular study that I had talked

about on my channel or on my Instagram was um talking about why they they specifically recruited drug users and so a lot of people had used drugs prior to using to engaging in anal sex and I think that that's not ideal you always want to be kind of in the right state of mind for consent and um and

safety purposes and so um those were kind of the common reasons what about infection not related to sexually transmitted infection um my presumption is there is a higher risk with anal sex um then there is with other um other for you know vaginal intercourse oral sex etc um what is their evidence for that um not necessarily it's more about sexually transmitted infections more than anything else it's rare to you can sometimes I mean the rare things that people have kind of 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 some people are not I think it's you know people are making sure they're evacuated fully um there's some you know media articles about like what you should eat before to kind of keep your gut you know healthy and avoid kind of

loose tools and things like that um but generally speaking you know there's there's lots of things you can look up to make it safe and healthy yeah and 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 it 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 they don't really know why but we do know that there's more going on in heterosexual

couples then prior as a final category of question um I was really interested in some of the posts you've done about herbs and supplements in the context of sexual desire and sexual function um on this podcast I always say always always um we emphasize behavioral tools first 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 that 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 behaviors first then of course things like adequate sleep nutrition healthy social interaction all of that stuff right exercise but we do often talk about supplements because they represent

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 herb is typically the one that 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 are known on SSRIs I hear from people who take Tonga Ali and get um libido increases also things like maka

root which we don't really know how these things work exactly probably some freeing up of testosterone with Tonga Ali maybe some cortisol suppression as well um maybe some estrogen receptor modulation with maka root maybe some dopaminergic tone changes um sheelogy um this irovedic herb um which

there is at least one study um that uh I think has done well that um shows increases in FSH follicle stimulating hormone with um sheelogy use what are your thoughts on things like Tonga Ali maka root sheelogy um how do you talk to your patients about this stuff yeah so I think that um you

know I see at least my patient population is still in the behavioral management place right the biggest cause of sexual dysfunction whether it's low testosterone rectile 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 study diet is the metatranian diet at least in in a sexual dysfunction literature exercise like doing you know both cardiovascular aerobic exercise but also doing resistance training particularly of like large muscle groups um and and then uh you

know really working on reducing blood pressure and and preventing diabetes and those things I think are really key and I know we talk you talk about them along 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 and when we say you know you have to get your hemoglobin a1c below a certain level to do surgery I cannot tell you how

quickly these men change their behaviors for sake of 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 boost testosterone and even you know you mentioned this all the time but getting early morning light but it's beneficial

for testosterone as well because you're really helping release testosterone with the circadian biology so I think that those things like I can't stress enough like how valuable they are and if you're smoking quit smoking it will kill your erections and vaping yeah and vaping yeah and then last if you are developing true organic impotence being that there's a biological 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 the sign that you may be developing

cardiovascular problems are 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 was an offer of something that people could try if they're doing everything else correctly and could assess with consulting your physician of course and they too some of them have reported improvements in libido and desires

but that makes sense yeah yeah and that chilegie is less known about the distinguishing quality versus low quality sources of chilegie is harder dosing as hard it comes as this tar typically maybe more science on chilegie will come out in the next few years we could get get behind it a

bit more right now I'm sort of on that yeah maybe if you are in an adventure you might try it but I'm not it's not one that I normally throw to the top of the list yeah I think that like el citralline is is pretty good ashwagandha for stress reduction which also has implications for

sexual function tongue cattali has reasonable data I think there you know there is reasonable data on these things I think the website you talk about all the time examine dot com is a great place to look at that and you know as like I said I think it's reasonable their smaller studies

they're not you know there is bias in many studies but they're they're you know there there is effort done in this area and there's never going to be really high quality science no one's going to really fund that I think so I think our expectations need to be a little tempered when it comes

to that stuff well reena dr. mullick I want to thank you ever so much for this discussion today you provide us so much useful information and really have transcended the divide between you know the mysterious thing that everyone wants to know about sex and sexual health genitals and genital

health prostate urethra uti's all these topics that many people are just afraid to to raise and to confront directly and you've you've taught us so much about how to promote the health of this incredibly important system one thing we know for sure either in vivo or in a dish we're

all here because a sperm at an egg and and of course there are other reasons why people engage in sexual activity that have nothing to do with reproduction but surely it is core to our biology and our psychology and well-being so thank you so much and also thank you for the work you do

day in and day out weekend and week out in your clinic we will provide links to your clinic people are interested in working with you directly as well as online that's how I initially found you and when I did I was just absolutely delighted I thought finally there's somebody who's

providing the kind of information that everybody wants in a in a thoughtful logical clear and respectful way so on behalf of all the listeners and viewers and on behalf of myself I just want to say thank you thank you thank you for what you do and please keep going and please come back thank you so much and honestly the work you do is phenomenal it's an honor to be here thank

you so much thank you for joining me for today's discussion with dr. rena mullick 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

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