Dhru Purohit Show - Struggling with Low Libido? Your Blood Sugar Could Be to Blame. Top Tips for Boosting Libido with Sex and Metabolic Experts

Episode Date: April 14, 2025

This episode is brought to you by Levels and Maui Nui. When most people think about metabolic health, they think of weight management and steady energy. But here’s what often gets overlooked: metabolic health also plays a major role in sexual function and fertility. Our hormones depend on a delicate balance—and when blood sugar spikes and crashes, that balance gets thrown off. The result? Not just weight gain, mood swings, and fatigue, but also a higher risk of erectile dysfunction, infertility, reduced sexual pleasure, and more. Today on The Dhru Purohit Show, we’re bringing you a special compilation episode featuring Dhru’s conversations with experts on how sexual health can reflect your overall metabolic health. Dr. Casey Means explains that blood flow, hormones, and psychology are the three pillars of good sexual function. She shares how diet impacts all three through a hormonal cascade, along with effects on nitric oxide and neurotransmitter production. Dr. Rena Malik dives into the importance of a healthy sex life and the common challenges men and women face—from low libido and hormone imbalances to lifestyle factors that get in the way. She breaks down the science behind sexual health, including the roles of diet, exercise, and orgasms, and unpacks the key roadblocks that can prevent us from experiencing a truly fulfilling sex life. Dr. Casey Means is a Stanford-trained physician, Co-founder of the metabolic health company Levels, and author of Good Energy. Her mission is to maximize human potential and reverse the epidemic of preventable chronic disease by empowering individuals with tools that foster a deep understanding of their bodies and support personalized, sustainable dietary and lifestyle choices. Dr. Rena Malik is a board-certified urologist with a talent for dispelling medical misinformation, discussing intimate topics, and evidence-based discussions of taboo topics. Dr. Malik is also a  prominent reconstructive urologist treating bladder conditions, sexual dysfunction, pelvic pain, and hormone management. In this episode, Dhru and his guests dive into: Paying attention to your sexual and overall health (1:37) The link between sex drive and metabolic function (5:49) Three key ways metabolic and sexual health are connected (8:41) Habits that restrict blood flow and negatively impact sex drive (14:21) The alarming rate of fertility decline (18:50) How metabolic health affects egg quality, sperm quality, and hormone balance (22:11) The connection between sex, longevity, and a healthy lifespan (33:09) How exercise boosts internal motivation and physical desire for sex (36:14) The effects of a sedentary lifestyle on libido and sexual health (33:11) Top factors interfering with a pleasurable sex life (37:39) Hormonal and menopause-related challenges—and potential solutions (44:14) Hormone therapy and its benefits for women’s libido (49:25) Physical factors that can prevent enjoyment of sex (51:23) Final thoughts (55:14) Also mentioned: Full episode with Dr. Casey Means Full episode with Dr. Rena Malik 3 Ways metabolic health affects sexual function This episode is brought to you by Levels and Maui Nui.  Right now, Levels is offering my listeners an additional 2 FREE months of the Levels annual Membership when you use my link: levels.link/DHRU. Make moves on your metabolic health with Levels today. Right now Maui Nui Venison is offering my listeners a limited collection of my favorite cuts and products. Just go to mauinuivenison.com/dhru to secure your access now —but hurry, supply is limited! Learn more about your ad choices. Visit megaphone.fm/adchoices

Hi everyone, Drew Brode here. Today, we're diving into the fascinating science on an often overlooked topic, how your sexual health can serve as an indicator of your metabolic and hormonal health. You might not immediately think that these things are connected, but the truth is your sexual function, fertility, and even your desire for intimacy can all provide insights into many other areas of your overall health. So in today's compilation episode, I'm sharing portions of,

of my conversations with Dr. Casey Means, all about the ways that metabolic health can impact your sexual health and sexual function. Dr. Means is a Stanford-trained physician, one of the founders of the metabolic health company levels, and of course the author of one of my favorite books, Good Energy. She's also an associate editor of the International Journal of Disease Reversal and Prevention

and a lecture at Stanford University. And in addition to Dr. Means, we also speak with board-certified urologist and prominent reconstructive urologist, Dr. Rina Malick, all about the role that hormone imbalances play in sexual desire, function, and much more. But first, let's listen into my conversation with Dr. Casey Means. You had shared that if you care about your long-term health, if you care about being in your optimal health,

you want to pay attention to your sexual health. Let's talk about that. I think we got a lot of people who perked up all of a sudden. They're very interested in this topic. What do you mean by paying attention to our sexual health? sexual health and how that's connected to our optimal health. This is a fascinating link that I've been discovering as I've dived deep into the metabolic health world.

And what we've really come to realize is that if you care about sexual function, fertility, and even sexual pleasure, then you really need to be thinking about metabolic health and metabolic optimization. The link now is extremely clear and we don't really talk about it. And it makes sense because metabolism is fundamentally how we produce energy in every cell of our body. And sexual function and fertility are incredibly complex, very well-orchestrated events in the body that involve so many things. They involve neurologic factors, vascular factors, psychological factors, and hormonal factories, just to get things right when you're thinking about sex or fertility.

And all of those elements of the body, all of those cell types that are involved, they all require the cells to make energy properly, which is metabolism. As you know, we are dealing with a metabolic disease epidemic in this country. You've talked about it so many times on your podcast, but 88% of American adults are metabolically dysfunctional. This is unbelievable. This means that 88% of American bodies are not producing energy properly in their cells. and we cannot have any health without having ourselves, having their basic functions met with energy.

And so this really is paralleling issues that we're seeing with sexual dysfunction in this country, which are actually becoming quite rampant. The statistics are harrowing and sobering. So if you look at women, about 40% of all women have issues with sexual dysfunction. And this means arousing. or interest or orgasm. When you get to menopausal age, that number goes up to 85%. Wow. The vast majority of women having issues with sexual function and sexual pleasure, which is an incredibly important part of life and well-being. So those numbers are way too high, in my opinion.

When you look at men, you see that about 50% of men are dealing with. issues with sexual function and this largely manifest in erectile dysfunction. And even under the age of 40, a quarter of men are dealing with erectile dysfunction. This number should probably be closer to zero. And again, when we think about erectile dysfunction, we're thinking about a complex orchestra of physiological events, all of which require good metabolism to work. So that's kind of the landscape of what we're talking about. And we need to think about the relationship between metabolic health and sexual function and happy to dive into all of that more. I think it's a super important topic to go into. And I think it's also part of how we make

metabolic health be sexy is to actually talk about the direct link that it has to our sex drive in our life. That's actually one of the openings that you had in one of the articles that you wrote on this topic, which we have a link to in the show notes over here. And because sometimes, you know, if you're trying to talk to young people especially in the rates of diabetes and metabolic health for young people are also crazy. Every year younger and younger, you're seeing kids with diabetes and other indicators of poor metabolic health. And I think if we're going to reach the younger audience, we have to also help them understand

that, number one, first and foremost, it's crazy to have to say this in this day and age, but actually the drive for sex is a good thing, right? Of course, we want to have good and proper sexual education for people that's available to them. And we shouldn't be ashamed the fact that people have a sex drive. men and women who historically, you know, women got the short end of the stick saying that we shouldn't, you know, women shouldn't have a sex drive. So I think all those things are important to talk about, but if we're going to get them excited, it's like, hey, actually eating healthier, living healthier is important to how you not only perform, but your interest in wanting sex in the first place. That's exactly right.

And I really think we need to reorient to realize that our sexual function and even something like our libido and our in. interest in sex is actually a barometer for our underlying fundamental health. I mean, that is such a key thing that we need to focus on. If you're having issues in those domain, which, as we just talked about those statistics, many or most Americans are, it may be a big red warning sign. There are things happening under the hood in terms of our metabolic health and metabolic dysfunction that will lead to very serious issues down the road, like all the diseases we, I'm understand or related to metabolic dysfunction. And we know this by looking at certain statistics like in men with erectile dysfunction, they have a 1.5 to 2.6 times higher chance of developing

cardiovascular disease. There are these direct epidemiologic links between this non-lethal pain point in our life and the risk of future metabolic issues. Because when we look from that root cause perspective of what is the actual physiology that's going wrong when we have some of these issues, we see that there are clear, clear links between these diseases. And I think you're absolutely right. I mean, metabolic health is sexy. And I think the reason it's sexy to me and endlessly fascinating is that, as we've talked about on other podcasts, metabolic health is this core link that's connecting so many of the diseases and symptoms that we're facing today in the American Western industrialized world. These metabolic associated diseases and symptoms are

making up 90% of our $4 trillion health care costs. And the beauty is, and why it's sexy, is because we can do something about it. This is something where we can lean into dietary and lifestyle behaviors in our own lives to actually have a positive impact on these factors and have multifarious benefits in terms of our health and things like our sexual function and pleasure and interest. So it's exciting. Let's talk a little bit about how you were maybe taught to look at the problem in your training as a physician from a conventional standpoint, right? How are you taught to look at what are the drivers for,

let's talk about specifically sexual health, interest, or even just, you know, again, it's so complicated and there's a lot of different layers here, like therapy can play a role in couples, there's a lot of different factors, but we're specifically talking about the sort of physiological side, which actually also, I think this is gonna be a big insight for people as they listen today,

it actually influences the mental side too. That actually might be worth touching on for a second because there's some people that are paying attention today and saying that, hey, listen, like, what does metabolism have to do with some of the mental aspects of the pursuit or the enjoyment of sexual health? Yeah. So to answer your first question, which is how are you conventionally trained to think about these things? I can sum it up in about one sentence. What are your symptoms? Oh, I have low sex drive and I have trouble having an erection. Cool. Here's some Viagra. It's, its symptom and then diagnosis and then medication. It's just so algorithmic and it's so unfortunate

because when you give that medication, something like Viagra or Cialis or whatever it is, you are missing an incredible opportunity to help this person understand their fundamental health so much better and make the choices that are ultimately going to positively impact that specific issue, but so many other areas of their life. And that leads into the question of what's really going on here with some of the physiology, including the psychological component. So there are really three main ways that metabolic health and sexual function are linked. The first is blood flow, the second is hormones, and the third is psychology and mood. So when we think about blood flow, this gets at the Viagra conversation. So what does Viagra do? It allows you to produce more of a chemical in the blood

called nitric oxide, which is a vasodilator. It allows blood vessels to dilate. And when you do that, you can get engorgement of erectile tissues, and that's part of arousal and sexual function. Interestingly, in both men and women, really for any sexual function, you need dilation of blood flows and blood flow to go to the erectile tissue. In the women, this is going to be all the areas of the clitoris and around the clitoris, and in men, of course, it's going to be the penis. And Dr. Sarah Gottfried, who's written extensively on hormones and sexual function, she says that erectile dysfunction in a man under 40 is atherosclerosis of the penile artery until proven otherwise.

It is blockage of this artery to the penis unless proven otherwise. And so we really have to focus on blood flow. And of course, metabolic health is one of the biggest determining factors in how our blood vessels are working. So insulin resistance actually affects all aspects of nitric oxide production. So it actually, insulin resistance in the brain can block some of the central factors and central mechanisms that set off the cascade of events that leads to nitric oxide stimulation. This may be cut, maybe because of the pro-inflammatory cytokines that are upregulated in the brain in the setting of insulin resistance. it's not totally clear what the reason is, but we know that with insulin resistance, it affects the central aspects that ultimately set off the cascade of releasing this chemical nitric oxide

that dilates blood vessels. So that's a problem. It's also a problem not just for the engorgement of erectile tissues in men and women, but also for things like lubrication and vaginal wall dilation and sort of relaxation. And so there's so many aspects of this whole process that are ultimately related to nitric oxide and blood flow. But bottom line, if you want good sexual function, performance, and pleasure, you need blood flow to these organs. And that is very much dictated by metabolic health and nitric oxide. Now, before we get to the other couple ones, let's just start off a little bit

with what are some of the things that restrict that blood flow in the body? Like, what are some of the things that the lifestyle factors? So we know that it's through the mechanism of poor metabolic health, But what are some of the things that people are doing every day that are contributors to having plaque build up and restricting the blood flow, which ends up negatively impacting your sexual drive? Yeah. So the big lifestyle factors that we think about is really anything that causes blood sugar spikes and anything that leads to insulin resistance.

So there's a lot of different things that contribute to insulin resistance in the body. But of course, a key one is going to be, are we eating diets that are spiking our glucose over and over and over throughout the day and causing this glycemic variability, this roller coaster of ups and downswings in glucose. One of the reasons that's problematic is that not only does it contribute to insulin resistance and makes the body essentially numb to this insulin signal, but it also induces oxidative stress. So the production of advanced glycation end products and excess reactive oxygen species.

So these are metabolic byproducts that can cause damage to our cells and bodies. And what we know that reactive oxygen species and in excess of them being oxidative stress can do is lead to narrowing of blood vessels. It can cause thickening of the capillarian arterial walls and cause that narrowing constriction. Another thing that happens when you have those big blood sugar spikes over and over, and ultimately when this leads towards things like pre-diabetes and diabetes, is it affects the nerves that actually impact the elasticity and dilation of arteries, and then of course also the nerves of things like the penis and clitoris and whatnot.

So it's really, it's multifactorial. It's nitric oxide. It's reactive oxygen species. It's impact on nerves. But one of the key things you can do is keep the blood sugar down. So eating in a way that allows your blood sugar to be more balanced, which we've talked about on many of our podcasts together, things like eating a whole foods, unrefined diet. where you're really avoiding the refined sugars, refined carbohydrates,

you know, making sure that you're pairing your carbohydrate sources with fat, protein, and fiber, not just eating naked carbohydrates that are going to get into the bloodstream quickly and spike the glucose. That's all really important. But there are several other factors, of course, for eating a metabolically healthy diet as well. We want to make sure that we're eating probiotic and prebiotic rich foods, which are going to support our microbiome, which directly feeds into our metabolic health. we want to be eating lots of antioxidants and micronutrients to support the metabolic machinery

in the body that lets us make energy properly in ourselves. And we want to be focusing on clean organic food because we know that some of the pesticides that are covering so much of our food today are actually toxins that hurt our metabolic machinery. And they even have a new class of names for these types of chemicals called obesity because they directly lead to obesity. So a really micronutrient antioxidant, probiotic, prebiotic, rich, dieting, rich diet that's ideally cleanly and sustainably sourced and doesn't spike glucose is the name of the game when it comes to having a more metabolically healthy diet. So I know that sounds pretty

complex, but it's basically like eat real whole foods as much as you can. Yeah, a lot of things sound complex when you're getting started, but the more that you listen to people who are good at breaking them down and you are great at breaking it down. And also, I love your newsletter, which also has like great recipes inside of there. We'll link that up. If anybody wants like fantastic recipes on a weekly basis, your newsletter is Dr. Casey's Kitchen is what it's called, right? Yeah. Is a fantastic one. You know, I was really blown away to see one stat that you had referenced in your article. It said twice as many women would type two diabetes experience sexual dysfunction compared to women without. That's mind-blowing. Yeah. It's mind-blowing. And then

another one that is on the side of the statistics with men. You talked about ED a little bit. We often think about ED as erectile dysfunction as being something that affects, you know, older men. But one thing that I pulled from yours was ED also affects up to a quarter of gentlemen under the age of 40. When you hear those statistics and you look at this world and you also see, you know, like population decline and all this other stuff, like, does this Is that any of this like, were you, when do you see statistics like this? Absolutely, because we are dealing with somewhat of a fertility crisis right now. 20% of women of childbearing age who have not had a prior pregnancy are not able to conceive after one year of trying.

That's a lot. That's one fifth of women. And there's evidence that this rate is going up. One study that's a global study looks at that this might be increasing by about 0.37% per year. And when you step back and think about what's really happening, it's quite shocking. You know, what is more evolutionarily vital than our ability to reproduce? And right now, it seems that that is partially under siege by this fundamental issue we're having with our metabolism, which of course is also leading to nine of the ten leading causes of death in the U.S.

So it's a metabolic crisis that we're dealing with, and one of the offshoot of that is a fertility and sexual function crisis. And unfortunately, the way the conventional medical system approaches this is very, very simplistic and very unenpowering. And I think when you are dealing with issues as sensitive as this, and issues where we have very poor education in our upbringing and our school, the system, unfortunately, people are very desperate to get on top of these things and we'll kind of do whatever, you know.

And so we have all of this push towards simplistic pharmaceutical interventions and virtually no push towards thinking about this network of diseases, this system of diseases that's happening and how fertility and sexual function fit into it. So it's really, unfortunately, kind of up to us right now to learn about these things and to take control of them in our own lives. But yeah, you know, and I think there's, it's just interesting. You know, I think sexuality, it's such a complex and nuanced thing. It's not something I'll be able to sum up simply, of course, in a podcast. But I think it's, you know, aside from being evolutionarily vital for us to, like, propagate our species, it's also very much.

link to, I think, drive and creativity and sort of our ability to feel like we're truly deeply engaged in sort of like the core, you know, generative aspects of our lives. And I think when you when you pull that away and when lifestyle factors are subtly undermining that that really just sort of, you know, primal creative force within us, it's very problematic for society. And you are seeing issues with, you know, rates of desire, libido, et cetera, that I think are worth having a bigger conversation about. Yeah, I think one thing that's interesting on the fertility side, as people wait to have children at a later age, I think one argument that's there is that great, there might be a lot

of different factors, and it's a multifactoral thing. We've got to focus on the economy and jobs and child care. There's a lot of different things that play into it. But if your metabolic health is better, that also means that you're egg. quality is going to be better, and in the case of men, your sperm quality is going to be better. Can you chime in on that? Definitely. So fascinating statistics about sperm recently. So research suggests that sperm count is down about 50% over the last 40 years. This should make every man's ears perk up. I mean, this is pretty astounding. And there are several proposed reasons why this might be

happening, many of which are related to things we've already talked about. But metabolism seems to be a core link. And one of the pieces of research that really gets at this was a study out of Harvard that looked at, as you go from normal weight to overweight to obesity, sperm count goes down. So if you are an obese man, you have about an 80% higher likelihood of having no sperm in your semen compared to a man of normal weight. And overweight men, it's in between there around 40%. And so that's pretty astounding that these metabolic issues are leading to downstream

physiology that's essentially stopping our body from making sperm. I mean, that's incredible to me. And one of the reasons this might be is because, tissue actually has this fascinating hormonal effect of converting testosterone to estrogen. And so many people don't think of fat as an endocrine organ, but it absolutely is. It's, as Ben Bickman often says, fat tissue acts like an ovary in men. And so we're seeing lower levels of testosterone in men as their weight goes up. And we know that weight loss can be very effective in getting testosterone levels back up.

There's actually, you know, four great things that men can do very simply to get their testosterone levels in a better place. Aerobic exercise, resistance training, stress management, sleep, and slightly more defined. one is weight loss, but you do those things, testosterone will generally go up. And so this is a big part of why I think we're seeing decline in sperm count. Sperm quality as well. Some of those research that I'm citing, the conclusions of the paper is actually that sperm count and quality should be considered a barometer for overall health of the man. And this, of course, makes sense. This is a a type of cell that is being produced constitutively, you know, week after week throughout a man's entire lifetime. So if there's problems with foundational health, you're going to see problems

in this cell type. And so that's definitely very real. In terms of egg quality, that's an area that I don't actually know if there's been as much research about, like how insulin resistance and foundational health affects the quality of the egg. The eggs and sperm are a bit different in the sense that the eggs are all in the woman's body when she's born in her ovaries. And we, of course, release them each month during our reproductive age, whereas sperm is just being created all the time throughout a man's lifetime. And so that's one I don't know exactly.

I have to assume if the body in which these eggs are living is being exposed to more oxidative, stress, you know, dysfunctional levels or unbalanced levels of sex hormones, higher inflammation, that it's going to have an impact. But one thing that we do know is that in pregnancy, even if a woman is able to get pregnant, people with metabolic dysfunction, pre-diabetes, type 2 diabetes, have higher rates of miscarriage. And so, we know that blood sugar and insulin resistance both have an impact on placental function. And so even if we get through all the steps required to actually have, you know, proper ovulation, sperm production, fertilization, implantation, then we get to actual caring of the

baby. And even at that level, having issues with blood sugar and insulin resistance can create a higher risk environment for the placenta and for carrying the baby to term. You mentioned those three areas that are related to the sexual health. We covered blood flow, which had a few different components to it. The other one that you mentioned was hormones. Let's dive into hormones a little bit and how key hormones are to this whole topic. Yeah. So hormones are such a complex topic, but one thing that I think is key to understand is that there's this sequence in the body called the HPG axis.

hypothalamic, pituitary gonatal access. You can think sort of like brain down to sex organs. And this this is a cascade of events that happens that ultimately stimulates us to have the right balance of of sex hormones. And insulin resistance and metabolic dysfunction can hurt the HPZ access at basically every level. If we have insulin resistance in the brain where the hypothalamus is, it's going to cause problems for this central top level aspect of this coordination that can ultimately result in issues with testosterone and estradiol production. And so HPGXS, basically, if there's issues with metabolism, you're going to have issues with that. You know, moving into sort of the specific hormones themselves, testosterone, like I mentioned, is we're having issues with testosterone, given the fact

that many men are overweight or obese, have excess fat tissue, and are therefore going to be converting their testosterone to estrogen and disrupting that very delicate balance of hormones that's required for sexual function and optimal fertility in sperm production. So that's really the key things, I think, to know about the hormone aspect is that insulin resistance is going to affect the brain. It's going to affect testosterone production and conversion to estrogen. and it's going to also impact our ovaries. Our ovaries are what make a lot of our female sex hormones.

And one thing that's quite interesting is that when women have higher levels of insulin in the setting of insulin resistance, that insulin actually can stimulate the ovaries to make more testosterone. And so this is actually the root of the leading cause of infertility in the U.S. for women, which is called polycystic ovarian syndrome. And essentially, when insulin levels are high, in the setting of insulin resistance, the fecal cells of the ovary, which have insulin receptors, are stimulated in excess, and they produce more male hormones or androgens like testosterone. And when a woman has too much testosterone circulating in her body, that's going to cause things like menstrual regularity, potentially lack of ovulation, excess hair growth, acne, or hercetism, and issues with excess. weight storage. And so these are all symptoms that we see in polycystic ovarian syndrome,

which are related to the fact that high insulin levels can drive the ovaries to make excess testosterone. And in women, throw off that, again, delicate balance between testosterone and estrogen. So that's kind of the landscape of hormones. And I think, long story short, we really want to keep our insulin levels down because it's going to protect our ovaries in women from producing too much testosterone. In men, of course, high insulin levels are going to be associated with excess fat storage, and that's going to be a problem for our testosterone and estrogen levels in men. I further discussed this fascinating link between hormonal imbalances and sexual health in my

conversation with Dr. Rina Malik. She shares more about how testosterone and estrogen can directly affect libido, sexual function, and overall well-being. Let's listen in. I want to start off big picture. What do we know about the connection between? sex, longevity, and a healthy lifespan? This is a great question.

I'm surprised no one's asked me that before. But we know that having a sex is a barometer of health. Sexual health is health. So when you're having issues with sex, it's often a sign of other issues. So because there's blood flow, the arteries to, for example, the penis are much smaller than the arteries to the heart. So very often when men develop sexual dysfunction or erectile dysfunction, it's because they're having vascular dysfunction and they have not yet developed problems that are

dramatic enough to affect their heart. And so having good sexual function is basically showing you that you have a good healthy vascular system, a good healthy neurologic system, good healthy hormones. Your brain is functioning well, right? That your mindset is able to focus and not be distractible by other things. So having a good sex life and having to have good continued function is actually a barometer of good health. And so in terms of the things you need to do to maintain your sexual health, it's the same things that you need to do to maintain good heart, right? You need to eat, right? You need to exercise. You need to continue to monitor how you improve with those things and get outside, get sunlight. Those sorts of things are all going to help you have

good sexual function because they're going to help with good hormone health, good blood flow, good nerve function. And so generally speaking, And then there's also the benefits of orgasm, right? So having orgasms regularly has multitude of benefits, better sleep, better focus, better mood, and even some benefits with cardiovascular effects, like better heart rate, better blood pressure. And so those things, just incorporating them in your life, right? Having good sexual function throughout life, having regular intimate moments, whether it's with yourself or with someone else, and having orgasm are really positive. What percentage do you find?

And of course, it's going to vary per people. But if you look at the sort of national landscape, and that's why you put stress at the top, how much of there being a gap in terms of an individual of where they are and where they want to be in terms of the fulfillment in their sex life, which might play into frequency, how much of that is mental

and how much of that is physical? You know, it depends. and obviously I'm biased because I see a lot of the physical issues, right? And so unfortunately, things like erectile dysfunction and menopause for women can have really detrimental effects to people's sex life, right? And so those things do play a big role, particularly as we age. So as you age, the physical side starts to take over. When you're a little bit younger, it's very more often the stress, the mental anxiety,

the other sort of mental roadblocks that come into play. On the physical side, just as a little bit of a teaser, because you talk about it so frequency, is exercise one of the top things that people can do to improve their internal motivation and desire for sex from a physical level? Yeah, so desire is complex. And a lot of people combine desire with testosterone, and a lot of part of it is testosterone. And so in terms of boosting testosterone for both men and women, women have a lot of testosterone. In fact, they have more testosterone in their bodies than estrogen,

and it's also very linked to desire. And so in both cases, to boost your natural testosterone, exercise is a very excellent way to do that. And so it can absolutely improve your desire and your interest in sex. So having sort of regular exercise, combining both aerobic activities and anaerobic activities, being resistance and cardiovascular training, and doing that consistently has shown to not.

not only improve testosterone, but it will improve other parameters. It will improve your vascular flow, so you'll have more blood flow to your genitals, which will then allow you to have for men better erections, for women, better arousal. And so all those things can be easily improved by exercise. And so being consistent is the hardest thing. I think people will exercise for short periods of time, but doing it consistently will help overall improve many facets of your sexual function, including desire.

So let's flip to the opposite of exercise, which is the sedentary lifestyle that most people are living. They're not getting even the most minimum amount of exercise that's there. What impact does a sanitary lifestyle have on our libido and our sexual health? Yeah, I mean, being sedentary in general is so bad for so many different reasons. One is that obviously you're not getting exercise, but being sedentary, if you're sitting a lot, you're actually sitting on the nerves that give innervation to your genitals, right? you're sitting on the pedendal nerve, one of the nerves that gives a lot of innervation to your

genitals. So you can start developing numbness in that area. You can start getting dysfunction from sitting all the time. And so that's not great. And then in general, you know, when you're sitting and you're eating and drinking, you're just gaining more fat. So there's so much data on having people who have greater amounts of obesity, metabolic syndrome, which you get from sitting all the time and not exercising like diabetes, high blood pressure, high cholesterol, all those things. are going to have negative impacts on your health, which is ultimately going to affect your libido, your ability to function sexually. So overall, there's really, if you're going to have, if you have a job that makes you sit, it really is up to you to make that time, like, throughout the day to get

little activity, right? Like, go up and down the stairs, go get up, walk around throughout the day, put a timer on your phone and just do it. Like, it doesn't have to be a huge workout every day, but actually making sure you have consistent movement throughout the day is going to go a long way. It's almost like our sexual health is really that barometer to come back to the beginning of the podcast, is that if, and there's many many different reasons why people may not be having sex as frequently, they could not be in a relationship, in between a relationship, et cetera. But if that desire is not there, you had a level that was maybe a benchmark, even though we know that when you're a teenager, that desires skyrocketed, right?

Hormones and everything like that. That general desire is not there as an adult. been a big shift that's there. Sure, there could be things that we want to pay attention to that are specifically for our sexual health, but that sometimes can be an indication of, hey, let's check in on our physical health as well. Absolutely. And I think, you know, desire is very complex.

Like I said, a lot of stress, anxiety, mental, psychological disorders, they can all affect desire. Medications you're on can affect desire. So sort of figuring out like, okay, which areas of my life do I need to improve? and if they have fixed all those other things, then maybe there's a medical issue going on that those are important things to assess because like I said,

if certain medications, like a lot of people are antidepressants, they can affect desire quite significantly. Even things that people use for hair growth, like finasteride or propitia can affect desire. So things like that can affect desire. You may not even realize it. So just sort of looking at the things you're putting in your body can affect your desire.

And so it's important always to sort of assess am I getting enough sleep? Am I exercising enough? Am I eating right? Those things need to be good. What am I putting in my body? And then, okay, is there a medical issue? Is my hormone health okay?

Is my vascular health okay? Are all those things working together that can help me get normal desire and normal function? Let's start with women and then we'll come back to men. But on the physical side, what are the top list of reasons that you see that would be interfering with a patient's unique expression of wanting a more healthy and pleasurable sex life. In women, there's so many reasons.

So one, very often we see in midlife women's desire plummets. And that's often because they're taking care of children. They're working. They're cooking. They're cleaning. They're doing a large burden of household chores. right? So they're they're taking care of the majority of the household duties and that can very much weigh into desire. So that's a very common indicator, right? And then other things can occur as well.

So one is they can have issues with particularly when you're in a longer term relationship, we see less of this, but sometimes women are having less sensation or less ability to orgasm. And that can change because as we age, sensation can decrease a bit. So that can play a role in desire. If you're not having climax during sex, what people may feel like, well, I'm not getting the same result from intercourse as I was before or whatever. And so why my desire goes down, right? Because there's that too. Obviously, there's hormone changes that occur during perimenopause and menopause. And perimenopause can start around the age of 40. So it's not that old. In fact, you can have symptoms as early as your 40s. And so people can start having changes in their hormones

that can cause changes in desire, particularly your testosterone can decrease. And testosterone can decrease, and that can really affect desire overall. So, and also in women who are taking some subset of women who are taking oral contraceptives can also develop a low testosterone because a lot of that testosterone gets bound up by something called sex hormone binding glubulin, which goes up. And that can then affect desire. So certainly, like I said, medications you're taking can affect you. And then lifestyle.

and then, of course, physiologic issues. So difficulty orgasming, probably the number one reason we see is that women are not getting sufficient clitoral stimulation. So when people see sex on TV or wherever, it's always vaginal penetration. But some women don't climax. In fact, 15% of women, 15% to 20% probably don't climax through vaginal penetration. Only 15% to 20% of women climax through vaginal penetration alone. The remainder needs some sort of clitoral stimulation in order.

to penetrate or to climax. And that's basically because the clitoris is the homologue of the penis. And so a lot of people don't know that. It's very simple, but they just don't know that that is the area that needs to be stimulated for women, just like the penis needs to be stimulated for men. Continue on the topic of women. You mentioned hormones. And that beginning at perimenopause, which also a lot of people don't know, men don't know,

men don't know, a lot of women don't know. It could be a 10-year period, at least, right? Absolutely. Before you're entering officially into menopause. And for women that find themselves in this category where their hormones are starting to change, what are the topics of discussion that you have with him? Do you talk about, well, let me give it over to you. What topics do you talk about and how do you assess if somebody's hormones are in range

that are supporting their overall health but also their sexual health? And what are the key hormones that you're looking at and bringing up with your patient about them being out of range and them needing to be addressed. So this is a long answer. But generally speaking, when we talk about hormones for women, you think about systemic hormones, so things that will affect the levels of hormones in your blood versus vaginal hormones.

And so we'll start with vaginal hormones. It's a little bit of a more concise discussion. But vaginal hormones, so when women go through menopause, a lot of changes happen. Their labia actually shrink. their clitoris can get smaller, they can get atrophy, and they can get thinning of their vaginal epithelium. And so that I can see on exam, but women may come saying it feels dry down there. I'm not getting as much lubrication during sex, or I'm getting recurrent urinary tract infections.

So those are sort of the very common things that people will complain of, and that can be very easily addressed with hormones. Vaginal estrogen is very, very safe. There's a lot of misinformation, but vaginal estrogen is not absorbed systemically, not a lot of it. Very, very minimal amounts could absorb systemically. Most of it is just local for the tissues. And so if you're having those symptoms, vaginal estrogen either in a cream, a pill, or a ring, can actually, a ring that goes in the vagina can all help support the normal vaginal epithelium and the tissues to keep them healthy.

And so one, it's really great for recurrent urinary tract infections. A lot of people don't know this and are, you know, getting antibiotics. after antibiotic after antibiotic, and all they really need is vaginal estrogen to help prevent UTIs. It's actually one of the highest levels of evidence we have for preventing UTIs is with vaginal estrogen. And so there's that. And then we're talking about systemic hormones.

Now systemic hormones, at least by the book, are used for vasomotor symptoms, which are hot flashes, feeling palpitations, those sorts of symptoms that occur very commonly that people hear about and bone health. So those are kind of the most common things. we know that bone health deteriorates and estrogen can prevent bone loss. So it's very helpful for that. It's very helpful for vaso motor symptoms. But there's more and more data on, I mean, estrogen receptors are everywhere in the body.

So we have estrogen receptors in the brain. We have estrogen receptors so that can help with cognition and prevent dementia. There's some data that shows that it actually prevents dementia. There was some studies recently that talked about how it actually was linked with dementia, it was because these women were started on hormones for vasomotor symptoms, which are also linked with dementia. And so there's sort of a correlation with the other things that people were starting hormones for and not the hormones themselves.

So there's a sufficient amount of data that it helps with cognition, helps with bone health, helps with, you know, somewhat of modulating weight, right? Because it helps with metabolic syndrome. So people who have hyperglycemia from insulin resistance, they actually see an improvement. in their glycemia when they're on estrogen. Now, these are not reasons to, in terms of like what the society say, but this is the data, right? So it does show improvements in hyperglycemia, shows improvements in metabolic syndrome, shows improvements to small degrees in weight, better sleep.

Because one, if you're having vasomotor symptoms are hot flashes and you're waking up at night, your sleep is poor. And sleep has a huge association with dementia and other issues. So your sleep is better. And so there's a lot of benefits to having hormones. therapy systemically when you're having, if you're having symptoms or when you're going through menopause because it supports so many factors. It even improves skin health. So it improves collagen content in your skin. It improves, it reduces the fine lines and wrinkles on your

skin. It helps prevent like your skin from getting hollowed in because it supports, there's estrogen receptors in the epithel layer of the skin. So there's so many benefits to getting hormones. And if you are, don't have a uterus, then estrogen, if you have a uterus and you need progesterone to prevent endometrial cancer, both of those can be used systemically. So you can take them in pill form, in patch form, injectable form, topical like gels. There's lots of different formulations and you can talk about those with your doctor to see what is best for you. But ultimately, there's lots of options available. And so deciding, you know, are you a candidate? Interestingly, we don't always.

always look at hormones, at least as a whole, people don't say that it's required. It's more of a clinical diagnosis. But I often look at hormones because I want to see, are we seeing an improvement? What are the levels when we start? And are we seeing improvements? Because that's sort of how we measure men. When we give testosterone for men, we check their hormones and we follow them to see how they're doing.

And as it correlate with their symptoms, but bottom line is we're treating the person and not the numbers. And there's a lot of reasons why a woman might want to have hormone therapy. in relationship to, and you listed many of them that are there, generally speaking, for somebody who feels like their libido is very low, is hormone therapy enough of, does it, how often does it work for a woman who feels like their libido is low? So in terms of libido, usually hormone therapy can help a little bit if it's going to help

with lubrication so that can help with a sensation of arousal. A lot of times our brain like connects arousal with libido, right, even though they're two separate things. So feeling aroused, meaning having lubrication and having that response can make you like, oh, that kind of your brain makes a link with that as desire. So that can help with that part of it. But generally speaking, when you're thinking about libido in postmenopausal women or perimenopausal women, there's a few things that we assess. One is how's their testosterone level? So the testosterone for women should be about one-tenth of a male amount of testosterone. And so we check the testosterone level.

And if it's low, then we can supplement it with topical testosterone, a very small amount of topical testosterone. You put on the back of the calf every day and see if they improve. There's also some medications that we have available. Those are technically FDA approved for premenopausal women, but they're also available to use off-label for women post-menopausal for low libido that are, uh, called phlebancerin and brimelanatide, which are medications that work centrally on different receptors in the brain to help with desire. Because I said, desire is very complex. It's that you

have some receptors that are upregulated, some are down regulated, and, you know, so there's inhibitors and there's promoters of desire. And so we're trying to kind of balance, make the promoters higher and the inhibitors lower with these types of medications. We were talking about some of the things that interfere with having healthy sex desire. libido, et cetera. What are some of other physical things that women in particular go through that you see in your clinic that prevent them from enjoying sex? For example, I know one topic that's come on this podcast a few times is some women. I don't know what percentage you probably know, experience painful sex. So 12% of women experience pain with sex. At least that's, and it can vary,

but that's sort of the average number we say. That's not a small number. Consistent pain with sex. Now, people can have pain with sex for a variety of different reasons, but, and sometimes some studies will say is as high as 40%. But it's very common. Now, pain with sex is never normal. So people say, oh, you know, it's okay. Drink a glass of wine. You'll be fine.

No, no, it's not okay. Like, you should never experience pain with sex. So it's about determining where that pain is and what's causing that pain. Is it pain on initial penetration, deep penetration after sex? And then kind of parsing out where, what's, what's, what's, causing that. So I'll go through some of the things that cause pain with sex. One is inadequate lubrication. So I don't know why, but in society in general, we feel like we shouldn't be using lubrication. But lubrication is great. It makes things slippery. It makes things fun. And it's relatively affordable. And it helps. So a lot of times what

happens is women need a significant amount of time to develop adequate lubrications. They need a significant amount of foreplay to get the adequate amount of lubrication to be ready, to be penetrated. Our bodies actually change when we're getting aroused. So women will actually, the length and width of their vagina will increase, almost double. Their cervix will move up and out of the way. They will develop adequate lubrication. If they don't have enough time for that, it'll be painful, right? So that's one of the most common things.

One is that. And two, is having low lubrication doesn't always mean that they're not interested or they're not into it, right? We, there could be medication issues. There could be just natural genetic differences. And so using lubrication is not a, like a bad thing. It's a great thing. It makes sex better, right?

So those are a couple of the common things we see, particularly in younger people, where they're, they're just not ready to be penetrated. And they are. And then it hurts. You can also see pelvic floor dysfunction, which is, which I see a lot of. So I'm biased because I see a lot of it. But basically, it's when you have tension in your pelvic floor. So when your, your pelvic floor.

essentially this bowl of muscles that sits in your pelvis that holds up all your organs. So your bladder, your rectum and women, the uterus. And these muscles, just like any other muscle, usually relax and contract when needed. But when some people develop a lot of stress, anxiety, or they may even just have like hip pathology or other kind of factors that can affect function of the pelvic floor, their pelvic floor can become tense and it doesn't relax normally. And so that can create a lot of pain with sex because you don't normally, normally you need a relaxed pelvic floor to allow something to penetrate it.

And so that can be very uncomfortable. And the good news is that can be treated through pelvic floor physical therapy. And if that doesn't work, we have other options like Botox and the pelvic floor and things that can help relax it. But essentially learning how to relax that pelvic floor is actually very beneficial. And sometimes people overdo kegles, right? They'll do too many kegels and they'll develop high tone pelvic floor because they don't really know how to do them.

And they're just clenching, clenching, clenching, clenching, clenching. and they're not relaxing. It's just like going to the gym. You need to have rest. You need to relax the muscle in between sets. Very similar for doing kegels. You need to actually relax the muscle. And so it's important to sort of do those with caution

if you're going to do them. And then, you know, there's also a whole host of other things. But since we've been talking about hormones, the vestibule, which is this area right outside the vagina, is very hormone sensitive. So that can become exquisitely tight. during perimenopause and menopause, and that, or if you're taking certain medications in your younger, like oral contraceptives, that can become exquisitely tender, and then that can

cause problems and pain with sex. So there's a whole host of things, but those are just kind of a few of the more common ones. A fulfilling sex life is an essential part of our overall well-being. Not only can it enhance our vitality and strengthen the bond we share with our partner, but can also serve as a powerful reflection of our overall health. When our metabolic health is suffering, or our hormones are out of balance, it can often show up in our sexual health and function. So if you're dealing with low energy, changes in your libido, even things like erectile dysfunction, which my cardiologist says that ED, erectile dysfunction, stands for ED endothelial dysfunction, which I've always appreciated. It might be time to take a closer look at what's happening with

your metabolic and hormonal health. For deeper insights into these topics, be sure to check out my full-length conversations with Dr. Casey Means and Dr. Rina Malick. And if you like this episode, do me a favor. Please consider sharing it with a friend. Until next time, thanks for tuning in.