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

Episode Date: August 14, 2023

In this episode, my guest is Dr. Rena Malik, M.D., a board-certified urologist and pelvic surgeon, male and female pelvic medicine expert, and public health educator. We discuss the major causes of and treatments for sexual and urologic dysfunction, including how to restore, maintain and enhance pelvic floor function and proper neural and vascular (blood) supply to the genitals. We also discuss what controls and can enhance desire and arousal, how to assess and treat erectile dysfunction, and challenges with vaginal lubrication and/or orgasm. We also discuss vaginal and penile health, including preventing urinary tract infections (UTIs) and which common prescription drugs can cause sexual dysfunction in males and females. This episode covers a range of topics: oral contraception, masturbation, pornography, prostate health, and male and female hormone health.  Note: This episode covers topics related to sexual and reproductive health. Some content might not be suitable for all audiences and ages. For the full show notes, including articles, books, and other resources, visit hubermanlab.com. Take our survey and get 2 months of Huberman Lab Premium Thank you to our sponsors AG1: https://drinkag1.com/huberman ROKA: https://roka.com/huberman Helix Sleep: https://helixsleep.com/huberman InsideTracker: https://insidetracker.com/huberman Supplements from Momentous https://www.livemomentous.com/huberman Timestamps (00:00:00) Rena Malik (00:04:04) Sponsors: ROKA & Helix Sleep; HLP Survey (00:07:45) Pelvic Floor: Urination & Sexual Function (00:14:13) What is a Healthy Pelvic Floor? (00:19:44) Kegels, Benefits & Risks, Urinary Incontinence (00:24:08) Pelvic Floor Relaxation; Exercise & Pelvic Floor (00:28:03) Desire vs. Arousal, Erections: Psychology, Hormones, Blood Flow & Nerves (00:36:10) Sponsor: AG1 (00:37:07) Pelvic Floor: Medical Professionals & Physical Therapy (00:40:15) Sexual Dysfunction, Erectile Dysfunction, Orgasm Difficulty (00:43:13) Desire & Arousal Issues; Erectile Dysfunction, Viagra, Cialis (Tadalafil)  (00:52:20) L-Citrulline, Supplements (00:54:09) Erectile Dysfunction & Cialis; Prostate Health; Females  (00:58:58) Erectile Dysfunction in Young Men (01:01:37) Pornography, Masturbation & Ejaculation; Healthy Sexual Behavior  (01:07:16) Sponsor: InsideTracker (01:08:22) Arousal Habituation, Masturbation, Addiction (01:12:57) Female Arousal Response, Orgasm, Coolidge Effect (01:17:22) Priapism, Melanocyte Stimulating Hormone; Women & Low Libido Medications (01:22:25) Libido & Individuality (01:26:18) Female Arousal, Vaginal Lubrication; Discharge, Odors & Douching (01:33:09) Vaginal Infections, Discharge; Vaginal Microbiome (01:35:45) Female Orgasm, Vaginal Penetration, Stimulation, Clitoris, G-Spot (01:42:31) Erection & Orgasm, Pelvic Floor Muscles (01:46:32) Dopamine-Enhancing Medication & Arousal Arc (01:51:18) Menstrual Cycle & Libido (01:52:49) Vaginal Penetration, Variation & Communication  (01:55:24) Sexual Interaction Communication, Sex Therapists (01:58:45) Urinary Tract Infections (UTIs) in Male & Females; Prevention, Vaginal Estrogen (02:04:04) Male Urination Sitting; Spermicide, Cranberry, D-Mannose & UTIs (02:11:33) Testosterone, Post-Menopausal Women & Libido (02:14:56) Kidney Stones: Prevention & Treatment (02:19:14) Oral Contraception, Libido, Individuality, Intrauterine Device (IUDs) (02:26:52) Anti-Depressants, SSRIs & Low Libido (02:29:32) Prostate Health, Cialis, Urination Difficulty (02:34:22) Bicycling, Genital Numbness, Erectile Dysfunction (02:37:48) Anal Sex, Females, Sexually Transmitted Infections (STIs), Lubricants (02:44:14) Libido, Behavioral Interventions, Supplements (02:49:15) Supplements for Libido (02:52:14) Zero-Cost Support, YouTube Feedback, Spotify & Apple Reviews, Sponsors, Momentous, Social Media, Neural Network Newsletter Title Card Photo Credit: Mike Blabac Disclaimer

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 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's glands. We talk about vaginal health as well as penile health. We talk about these things as it relates to different stages across the lifespan. It is a far reaching and in-depth and practical conversation that I'm certain everyone

will glean important takeaways from. Now before we go any further, I do want to highlight that the content of today's episode is sexual in nature. We talk very directly about different types of sexual behavior. And we talk about it from the standpoint of the clinician and biologist. So it is a medical slash scientific discussion that said, we can't be aware of where this podcast is being played and who is listening.

And I assert that there are certain themes within today's discussion that would not be suitable for young children. How young? Well, that is certainly not for us to discern. We realize that different parents and different households should be the arbiters of what sorts of information their children are exposed to or not. So my suggestion would be that if you have any concern whatsoever that the content of today's episode would not be appropriate to be heard by some member of your family that you please listen to the podcast first or at least check the time stamps where we've detailed what specific topics are covered and then to make your decision accordingly.

I should mention that not only is Dr. Malik still an active clinician, she sees patients daily, out of her clinic in Southern California and we've provided a link to that clinic in the show note captions. She's also authored dozens of high quality peer reviewed publications in the fields of urology, public health, and sexual health. And we've also provided a link to that bibliography in the show note captions. And she is also a spectacular public educator. She provides zero-cost content about sexual health, pelvic floor health, and urology, as it relates to both men and women on her YouTube channel.

And there too, we've provided a link to Dr. Malik's YouTube channel in the show note captions to this episode. Before we begin, I'd like to emphasize that link to Dr. Malik's YouTube channel in the show noteworthy 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.

Roka makes eyeglasses and sunglasses that are the absolute highest quality. I've spent a lifetime working on the biology of the visual system and I can tell you that your visual system has to contend with an enormous number of challenges in order for you to be able to see clearly. Roka understands this and has developed their eyeglasses and sunglasses so that you always see with perfect clarity. In addition, they are extremely light weight and they won't slip off your face if you get sweaty. Indeed, Roka eyeglasses and sunglasses were initially designed for performance in sports, but now they include aesthetics and styles that are really designed to be worn anytime. I, for instance, wear readers

at night, I'll sometimes wear sunglasses during the day when I drive, and of course I do not wear sunglasses when I do my morning sunlight viewing, which I highly recommend everyone do their morning sunlight viewing. If you'd like to try Roka eyeglasses or sunglasses, you can go to roka. That's roka.com and enter the code huberman to save 20% off your first order. Again, that's roka roka.com and enter the code huberman at checkout. Today's episode is also brought to us by helix sleep. Helix sleep makes mattresses and pillows that are customized to your unique sleep needs in order to allow you to get the best possible night's sleep.

Now sleep is the foundation of mental health, physical health, and performance. When we are sleeping well and enough, mental health, physical health, and performance all stand to be at their best. One of the key things to getting a great night's sleep is to make sure that your mattress is tailored to your unique sleep needs. Helix Sleep has a brief two-minute quiz that if you go to their website, you take that quiz and answer questions

such as do you tend to sleep on your back, your side of your stomach, do you tend to run hot or cold in the middle of the night, maybe you don't know the answers to those questions and that's fine. At the end of that two-minute quiz, they will match you to a mattress that's ideal for your sleep needs.

I sleep on the dusk at the USK mattress, and when I started sleeping on a dusk mattress about two years ago, my sleep immediately improved. So if you're interested in upgrading your mattress, go to helixleap.com slash huberman, take their two-minute sleep quiz, and they'll match you to a customized mattress for you, and you'll get up to $350 off any mattress order and two free pillows. Again, if interested, go to helixleap.com slash huberman for up to $350 off and two free pillows. We are always striving to make the huberman lab podcast better, and to that end, we need

your help. Over the next month, we are going to be carrying out a survey. The purpose of the survey is to improve the Hubertman Lab podcast according to your feedback. We put together a brief survey to understand what you love about the podcast. Hopefully you love a few things at least, or maybe just one thing, as well as what you think could be improved, or perhaps the many things that you think could be improved about the Hubertman Lab podcast. Basically, what we are asking is to get your feedback so that we can improve

any and all things about the Hubertman Lab podcast. The survey does not take long and every single response will be reviewed. As a thank you for completing the survey, we are offering two months free of the Hubertman Lab Premium Channel. If you're already a member of the Hubertman Lab Premium Channel, do not worry, 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.

So 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 HubermanLab podcast. And as always, thank you for your interest in science. And now for my discussion with Dr. Rina Malik. Dr. Rina Malik, welcome. Thank you. Thank you so much. It's an honor to be here.

I'm delighted to have you here. I'm a huge fan of your content. I find that you are able to deliver critical information about sexual health, urology, pelvic floor, libido, and so many other things that are of immense interest to people, but that ordinarily people don't really know where to get the high quality information. And coming to you for that information means they are going to get the highest quality

information. I truly believe that because as everyone will soon hear, today we're going to have a very frank discussion, but one that's really grounded in science and medicine around sexual health and related topics. These are topics that typically people learn about, perhaps a little bit in school, maybe at home, from friends, usually overhearing things as opposed to direct exploratory conversation, online, pornography, and at least in my experience growing up, you know, there was education around sexual health, reproductive health, etc. That was more oriented toward the fear of things like STI, fear of unwanted pregnancy, all of which of course is extremely important for people to learn about.

But far less about sort of the healthy versions of sexual health, right? Yeah, absolutely. So this is an especially important conversation. 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 gonna get them out of the way now. Penis, vagina, anus, prostate. You know, what else is there? We're going to talk about libido. We're going to talk about intercourse, oral sex, anal sex.

We're going to talk about all of that. So I just want to get that out there so that 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 it. Great. So to start things off in anticipation of this episode, I solicited for questions on social media and I got thousands of questions, but there was a lot of overlap in the questions. So to start off, I'd like to talk about pelvic floor, okay, because both males and females have a pelvic floor. And my understanding is that there's a muscular component, there's a 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 a 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, and 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 and short. Very similarly, if your pelvic floor is overstrained, it can become contracted and short and tight all the time. And you may not know it. It may just be a function of stress, anxiety, or overuse,

or posture problems, things of that nature that can affect your pelvic floor. And so, this can lead to issues. Let's start with urination. You can have symptoms of urgency, frequency, meaning you have to go a lot to the bathroom, or you have to go and have a sudden desire that you can't delay. Sometimes 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. Like you go to urinate and then you go back to your desk or then five minutes later, you

have to urinate again. Exactly. Something of that sort. 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 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 two tens. Sometimes your pelvic floor can be two 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 earlier'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 two week. 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? Would this be like, like I said, we're going to be direct today. Would this 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 keygal exercises, for example, and people talk about how to do them, but that's all you ever hear about the pelvic floor. And so you don't really know how to kind of do things in a way that protects your pelvic floor or kind of what, how to even tell when it's too tight or not relaxing?

And so that takes a sort of a training. And so usually when people come to first, you get an examination to see if your pelvic floor is tight. So for women, it's a pelvic exam and for men, it's usually a rectal exam. How does that exam go? So it's essentially palpating the muscles and also looking at the function.

So we'll say for... So digital palpation the muscles and also looking at the function. So we'll say for- So digital palpation, 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 it into the anus and feels the prostate to see whether they're not at 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 been the practice for, what, 50 or 60 years, maybe 100 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 pelvic floor exam for a male and a pelvic floor exam for a female involved at a granular level here? Yeah. So for women, you can feel the pelvic floor muscles

through the vagina. So you can feel the pelvic floor muscles through the vagina. So you can feel the Iliocoxidius, the pubocoxidius, the levator, anion. Those are all names of different muscles in this bowl. This is the physician who can feel their fingers. Correct. 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

weak one. And so you can assess the tenseness based on, you know, palpation. You can also see if there's tenderness. And so you can assess that based on just a general physical examination. And then also, you can observe. So I can say, contract your, squeeze your pelvic floor up and in. 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 discordinated. You can also assess for sensation in the area and things like that that could be consequences of dysfunction.

To there be dysfunction in 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 work with you on a prolonged basis

to help you normalize the function of your pelvic floor. It's like going to the gym with a trainer, right? They really work with you to get your pelvic floor functioning correctly. And the first step to that, a lot of pelvic floor therapists will just align your bones and 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 in 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 perineal area and feel the muscles there as well, sensation. Okay, so perineal area, so from the outside of the okay, the region between the scrotum and the anus. Yes.

Okay. So it sounds to me like if people want to get a high quality assessment of whether or not their pelvic floor is healthy or not, they need to see a pelvic floor specialist. That it's not the sort of thing that they could in-two 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. Kegel exercises and give you some read, you know, some readings, but they're not really meant to diagnose. They're usually something people use if they 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 is we say, you're going to, there's a few different ways to describe it. You're going to use the muscles that you use when you urinate, but try to stop the flow. But you don't want to do 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 people describe it is pulling up and in, in 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... That's good when you 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 people, I tell patients, do them lying down so that you're only focusing on those muscles. You're not working on your posture. You're not doing anything else. And as you get better with them lying down, you then sit up and do them. And then once you're good with them sitting up, you can do them standing and start with, you know, 10 to 15 at a time, like once or more. 10 to 15 repetitions. So yeah, let's talk sets and wrap. Yeah.

So yeah, 10 to 15 repetitions in the morning, 10 to 15 repetitions at night, maybe one more during the middle of the day, but don't overdo it because just like anything, especially when you're starting out, you can. And if you're doing tons and tons of kegels, then you will get a tight, short pelvic floor muscles, and you will then develop pelvic floor dysfunction. So it's really important to kind of understand those mechanics, which is why a lot of people think they know how to do kegels, but they really don't. And so I always encourage people, if you have the time and the resources to go to a pelvic

floor physical therapist, so they can really work with you and make sure you're doing them correctly. What are some of the benefits of kegels for those that need them? Yes, so they are typically prescribed for urinary incontinence, specifically stress urinary incontinence. So leakage that occurs when you have an increase in your intra-abdominal pressure like a Valsalva or coughing, sneezing, lifting heavy things, jumping on a trampoline. So for those purposes, we use kegels to strengthen the pelvic floor and also in women pelvic organ prolapse. So when you have weakness of the

pelvic floor that leads to a bulge that you can visibly see or feel in the vagina. For men, we often prescribe them for people who have had a prostitectomy, who then subsequently develop leakage after the prostitectomy that is against stress-earning condens. Now a lot of people use teagles recreationally because improving the pelvic floor musculature can lead to more intense pelvic floor contractions during orgasm, which can be more pleasurable. And so some people do it for those purposes, but again, I caution people not to overdo it because then you can lead to a more tense pelvic floor,

which is not where we want to end up. Yes, I will underscore that cautionary note. Years ago, I heard about kegels. I was like, okay, I'll try it. 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 prostate, 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 describe pain for your nation or the things I've described, like pain with erections, pain with ejaculation, 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 antichegal? In other words, if somebody decides that they have a tight pelvic floor, how can they learn to relax their pelvic floor? So there's a lot of different sort of things that you can do. So for women, you can do massage of the area. You can use vaginal dilators to help relax the muscles.

You can take suppositories that have medications like Valium or baccalafin, 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. And then 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 stretches and elongates the pelvic floor muscles. So doing these exercises regularly will help you lengthen 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, pointing my life and they'd have everybody to 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, seeing the kegels was one of the best decisions I ever made. I only did them for a short while as I could get this as 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 vascular

sure of the pelvic floor that would provide support for my experience there? That doing crunches with legs crossed is essentially, is it possible that's creating asymmetries in the pelvic floor? And now I'm sure I'm angering yoga teachers and crunch crunch, crunch anista is everywhere, but you know, hey, if it's a question of your pelvic floor or a few extra delineations in your abs, you know where my vote's 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's just in your mouth and throat.

And that is actually when you do any sort of exercise, 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 contraction 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 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 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 pelvic floor muscles, which can affect sexual function, and you can get nerve inflammation as well that can also cause pain. And so this is kind of how it all comes together. I'm so glad that you mentioned blood flow. I think our entire discussion today should be framed up, at least in the back of our minds, and the minds of our listeners and viewers,

as involving at least three things. Anytime we're talking about erectile function or dysfunction or pelvic floor function or dysfunction or vaginal lubrication or lack thereof, we need to think about the hormonal influences, the blood flow related influences, and the neural influences, including the neural influences that come from the brain, the signals of arousal, for instance, or lack of arousal, 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 strength in the muscles, one will cut off blood flow. In fact, one of the more common questions I got, and I consulted with a couple of exercise physiologists about this, and they confirmed that a lot of people who squat and deadlift heavy in the gym, or even who just tense their pelvic floor when they're doing things like dumbbell curls or other exercises, and especially people who seem to do a lot of abdominal work reported to me in the questions that they experienced things like erectile dysfunction, that they 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'll also talk about the role of testosterone on the female side. A lot of males lift weights in order to increase their testosterone and for reasons that are

obvious, also want to have healthy sexual function. And here they are doing this thing that's very good for increasing testosterone if they're doing it correctly. And testosterone is involved in libido and the male sexual response and the female sexual response, of course, but they are impeding their erections. So you can start to see how 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 innervation of the penis or vagina? So I think 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 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 erecturing arousal. I believe so. I think so, yeah. Yeah. You know, you maybe get the sex flush, right? You get 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 having an erection does not mean you're not aroused. It may mean other things. But certainly that's part of it. And then desire, do you want to have sex? Do you have, like, when you think about your partner or whoever you want to engage with,

is there a desire to actually do that, right? Or is it just more of obligation or other things? And 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 a rousal 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 have a problem.

The next time you're really stressed, you're not present, you're not mindful in the moment with sex and you're thinking about, oh my God, am I gonna perform okay? Am I gonna 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 important first to identify those issues and then also for blood flow, a lot of times 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. Yeah. Yeah. So that will point us to a more vascular issue. Hormonal issues are very important for desire and 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 more. But that's pure erectile function as opposed to desire. Correct. Psychological isl. Desire is predominantly modulated by the hormone testosterone for both men and women. In fact, 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 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 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 stolic 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 uncommonly done, because mostly we can kind of get that through a clinical report. And unfortunately, if you're for nerve function, although they're very uncommonly done because mostly we can kind of get that through a clinical report.

And unfortunately, if you're having nerve problems, sometimes it depends on what's causing them, but sometimes they can be very difficult to reverse. And that's kind of a problem. We know that as people age, their sensation becomes less. So just through aging, the nerves, the receptors become less sensitive. And so you will generally have less responsiveness to the same sensations you did when you were younger. And so that kind of overlays all of this.

So it's complex, but really, you know, a lot of it comes from the discussion you have with your patient, or, you know, you kind of really doing a deep dive in what's going on, like really thinking about each of those aspects, and also what's going on in your relationship, and what's going on in like really thinking about each of those aspects, and also what's going on in your relationship and what's going on in your life, stress, anxiety, like how are those playing a role? As many of you know, I've been taking AG1 daily since 2012, so I'm delighted that they're

sponsoring the podcast. AG1 is a vitamin mineral probiotic drink that's designed to meet all of your foundational nutrition needs. Now, of course, I try to get enough servings of vitamins and minerals through whole food sources that include vegetables and fruits every day, but oftentimes I simply can't get enough servings. But with AG1, I'm sure to get enough vitamins and minerals and the probiotics that I need, and it also contains adaptogens to help buffer stress. Simply put, I always feel better when I take AG1. I have more focus and energy and I sleep better, and

it also happens to taste great. For all these reasons, whenever I'm asked, if you could take just one supplement, what would it be? I answer AG1. If you'd like to try AG1, go to drinkag1.com slash huberman to claim a special offer. They'll give you five free travel packs plus a year supply of vitamin D3K2. Again, that's drinkag1.com slash Hubertman. Gosh, lots there to unpack. And I'm glad you mentioned the relationship itself because there are all sorts of things that can impact the arousal response, novelty. I'm 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, et cetera, we will get into that. It's a vast space to explore. Before we go any further, I want to make sure, however, that we cue people to where and how they could find a really good, let's say, pelvic floor therapist, 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 at least as far as I understand much of what people want to learn on this

podcast is how things work and what happens when things break down, but also how to resolve those issues. So, let's say somebody wants to check out their pelvic floor, figure out what's going on there. Maybe they're having issues, maybe they're not. If they are male or female, where do they go? Is there a place online that has a great list of some of the best ones in one's area? Can it be done over telemedicine? Yeah, how does one go about that? Yeah, so in terms of your pelvic floor,

it's good to get assessed by a physician who specializes in pelvic floor. Now, that could be a urologist, that could be a gynecologist or even a physical medicine rehabilitation doctor that specializes in pelvic floor health. So typically you'll see in urology, you'll look for people who are board certified

in female pelvic medicine and reconstructive surgery if you're a woman, if you're a man, maybe sexual medicine, someone who specializes in sexual medicine would be a good place to look. For a gynecologist again, you want to look at someone who has interest in this area, who does manage pelvic floor. And then in terms of pelvic floor physical medicine rehabilitation, at least at least when I was in training, there was about 20 PM and our doctors around the country who were 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 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 wanna go to someone who's actually seen men because a lot of the pelvic floor physical therapists tend to treat a lot of women. And so that's kind of what I tell my patients,

generally speaking, there's no, at least to my knowledge, no great resource, and maybe we'll 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 nowhere to go. Yeah, hopefully your headache doesn't warrant going to a neurologist, but it might. You know, eye stuff tends to be ophthalmologist optometrist, right? So I don't think we hear often enough about where to access the best quality care for these things. So thank you for that.

In thinking about sexual dysfunction, I'd like to have that conversation more or less in parallel if we can, around male sexual dysfunction and female sexual dysfunction. And I want to make sure that before we do that, that I'm creating the correct parallel construction, as they say, erectile dysfunction in males is clearly a form of sexual dysfunction. What is the parallel to erectile dysfunction in females? Is it lack of vaginal lubrication

and lack of relaxation of the vagina to have non-pinful intercourse. I mean, is it even possible to have a parallel conversation about these two things? So, it's different. In some circumstances, there are homologs, right? So the penis is the homologue of the clitoris. Right. So the clitoris is essentially the same sort of spongy erectile tissue that you see in the

penis. It gets erect with arousal and 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 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 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.

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 of male genital development involves literally the regression, the disappearance of the female sexual genitalia and associated organ malarion, ducks and things like that, and what would become the ovaries, become the testes, et cetera, et cetera.

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 and by extension, can we say also female issues

with sexual rousal are hormonal in origin? Is that right? So with desire, yes. They're hormonal in general, and arousal in terms of lubrication, if you're using that as a barometer, yes, you can see less vaginal lubrication due to hormones. And I guess I would say three to six percent, more, you know, up to six percent,

we see of erectile dysfunction is hormonal. It's a small percentage of the entire entirety of erectile dysfunction. Okay, so I think in looking in the landscape of social media and podcasts, 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 showing you appreciate that it's pro-desire in women as well. It's certainly in men. And that dopamine is also associated with desire. And the general public tends to have this view of estrogen as being sort of anti-libido or anti-male, which is frankly false. In fact, and I've covered this on the podcast

with Dr. Kyle Gillette and with Dr. Peter Atia and another fellow YouTuber, Derek, for more plates and more dates has talked a lot about the fact that if men take drugs like an astrozole to suppress the estrogen, thinking that, oh, it's all about having high testosterone low estrogen, oftentimes they crush their libido, just abolish it. Which has led to a slowly growing, but I think positive shift in how people are thinking about estrogen, estrogen is great for brain function, estrogen is great for libido in men and women. And that is a revision of, I think how most people think of the male sexual response. It's more in keeping how most people think of the male sexual response.

It's more in keeping with how people think about the female sexual response. Oh, estrogen and the female sexual response. That 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, 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, et cetera. 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 a rousal response.

So I'll tell you what I was taught, and then you can tell me where it's wrong. Sure. I hope. I was taught that the erection response and the vaginal lubrication response is generated by the parasympathetic nervous system, the relaxed, the rest and digest aspect of the nervous system.

Hence, why some people can get psychogenic sexual issues of lack of erection or lack of vaginal lubrication. But, that there are individuals out there for whom a lot of alertness may be 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. It's not like the textbooks, it's not like they taught us in high school, as far as I know. I was taught that the arousal response in males and females is initiated by a parasympathetic, sort of relaxed tone and that as sexual desire and arousal and sex or masturbation

progresses, that it shifts more towards the sympathetic nervous system, which has nothing to do with the emotional sympathy, and has everything to do with arousal. The catacoleum, means dopamine, norepinephrine, and epinephrine, also called adrenaline, and noradrenaline are released and that the climax response, which may or may not include ejaculation, we have to separate that out, is one that is really of the stress system of the body. And then in the post-coidal or post-adjaculatory or post-climax phase, then there's a shift back

to the parasympathetic nervous system. That's where the pillotalk and 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 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 these things that are leading to a rousal is because there needs to be a stimulus, right? A visual stimulus, a tactile stimulus, some sort of stimulus that you're getting that is then causing the release of nitric oxide from the parasympathetic nervous system. And that could be for some people aggression or, you know, some form of that, right? And you tell people about

nitric oxide because we'll get into this when we talk about drugs that increase blood flow, sea Alice Viagra, and also non-prescription drugs, things like El citrulline, arginine, and watermelon for that matter, right? So I read on the internet. So, yeah, so nitric oxide is essentially the ignition for what we say for erections, the ignition for erections.

The reason I talk about erections more often is when you look at the data, in fact there was a paper on this, where they looked at the number of articles that came up when you put in the word penis, and the number of articles that came up when you put in the word clitoris. And it was 50,000 about penis and 2,000 about the clitoris.

Okay, we have to, this was actually a major section of the comments on when I asked for questions on Instagram and 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? I mean, 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 the female sexual response was less valuable. And so there are some, some, some valuable, I guess, I don't, that's the right term, but yeah. Oh, no, no, I'm not, I'm not trying to return my just man. I just, you know, he was supposed to be obsessed with it. He was, but it was more about the male sexual response than the female sexual response. And so in general, yes, there is, you know,

there were more men in medicine. There was more, and it is easier to study, right? You can't 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. We do this for people who have a rectal dysfunction. They'll take medications that increase blood flow,

like trimics, and you'll inject it into the penis and you'll see an erection. So you can actually try mix. So there's, it's, it's, you're the entire male audience just went, wait, what are you injecting in the penis? So there are, there are three basically brand names of intra-cavernosal injections that we use

for a reptile dysfunction. I hear injection in this and I think I'd say, I like to think that it reflects a natural male response. I sort of, I take it a back. I don't know, maybe there's a pelvic floor contractions in there someplace. So 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. They don't even, 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.

And so it is very effective. It 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 a prostadil, papavrine, and third one. That's okay, we can look at someone we'll put in the comments. Sure. Surely they will. What is it designed to do? Is it a vasodilator of sorts? So they work in different mechanisms, but similar to the medications that we have, PDE5 inhibitors, PDE5 inhibitors work in the erection cascade,

basically what happens, let's actually, let's take it back to the nitric oxide thing and we'll get there. So nitric oxide essentially is released by the endothelium in response to a visual tactile stimulating cue, right? And so your body releases nitric oxide, which then sets off the cascade for the erection. And so that releases CGMP, which is, which is causes the erection and it's degraded by phosphodiesterase. And so medications that inhibit phosphodiesterase, like Viagra and Cialis,

tend to prevent the breakdown of that CGMP so you have longer lasting erections. And so similarly, these medications work sort of similar to that. Some of them, we don't know exactly how they work, but they work by increasing CGMP or CAMP that are involved in those cascades. And what about El Citrillin?

I hear about El Citrillin used it to over-the-counter supplement. And it's in therilline? I hear about El Citrilline 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 Cialis via agro, but is perhaps not as potent. I also just cautionary note out there, El Citrilline can give people vicious cold sores

and canker sores. Vicious. So 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, but it's very low bioavailability.

L-Citrilene converts to L-Argenine, but it is last much longer in the bloodstream, which is why people tend to use L-Citrilene. Now, 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 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, I read one about melatonin, and there's a variation of melatonin from what's on the bottle to 400% times more. That's the struggle that we as medical doctors have, and 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 examine.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 quality by brand issues, but thanks for mentioning that. What percentage of males who take Cialis, aka Tidalfil, or Viagra for rectile dysfunction get relief from that? Because you mentioned only 3% of erectile issues and males are hormonal in origin, but what percentage are likely to be blood flow related

in origin? So a large percentage or a blood flow related that doesn't mean that the medication will be effective for everyone. If you look at the large percentage are our 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 erectile 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 intercourse, which is the way we kind of discuss erectile 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 delative. And so if you're having anxiety, you're 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 so, the 70% is not a small number. That's a significant number. That's the majority by a significant margin. Is there a basis for the use of siallis, to dallophil, viagra, el citrilline, and females?

So yeah, there's not a lot of data on this, but certainly, you know, if you have surmised that there is a blood flow issue and they're having difficulties with orgasm, it's certainly something you can try off-label, and certainly people do try these medications off-label to see if they improve sexual function for women, but there's not a whole bunch of robust, you know, randomized controlled trial studies on women with 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, Cialis slash Tidalophil. So, rather than what I found online was that the erectile dysfunction treatment dosage of Cialis Tidalophil 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 Cialis Tidalophil for prostate health. And I learned in researching for this episode that Tidalfil, Cialis, was actually developed as a drug for the treatment of prostate health to essentially increase blood flow of the prostate to increase prostate health, not for the treatment of erectile dysfunction. So I found that to be somewhat interesting. And a lot of people are now starting to use that. I also learned that if you dive into the guts of the internet, one can find that now there's a growing use

of combined low-dose-age, sea-alice, and apomorphine, which is a pro-dopamin uretric agent. And we'll get back to dopamine a little bit later. But is there any basis for low-dose-age, say 2.5 to 5 milligram daily use of sealas to dallophil in females? Yes. So, let's talk about it for males and females.

I think low dose daily sealas 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 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, 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, I 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 in males and females generally because nicotine is a vasoconstrictor,

nicotine does have certain benefits, and I covered this in an episode on nicotine, neurocognitive 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, six's assume that a 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, and 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 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 an SSRI. Why are all these 20 and 30-year-olds on the internet asking, mainly you? This is, they may run to you, but also to my direct messages about their erectile issues. So I will say, I have seen a lot of young men in my clinic and I will say that they very often have pelvic floor dysfunction. So 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 exercising one hour is not gonna 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. You have a standing desk. Yeah. Walk more standing desk. Okay, so, and then my guess is that there's some psychogenic feedback loop, 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 are 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 gonna 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, good in the session, say where they were, in the town they 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 turns, take turns, use me looking at them. But 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 wanna start this before I get into that is to say that if you're mastering de porn and you have normal healthy relationships and you're going to work and you 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, Jindra, 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. 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, ejected pornography, and have a normal life. That's fine. I think that if we shame those people, we're creating problems. We say, you do that, that's horrible.

Then they're in their head, and then they're causing problems in their life because of shame. I think there's a little bit of cultural shame that comes of this discussion. And so 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 have normal healthy relationships,

great sex with their partner, and it's fine. Or they're both foreign. Or they're between relationships. And they're relying on masturbation specifically. 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 handled.

So I think... No pun intended. air aspect. Let's assume physical arousal is, you know, handled. So I think. Yeah. So I think that the, 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 four play is,

and this is like not normal, this is a 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 we've then go to relationships like, why did my partner not react like that woman did on the porno, right? So no one has that discussion. So we've 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? Well, why didn't he react when, you know, like they would in porn because, again, I think females are watching porn as well.

Exactly. Yeah. Yeah. I think so I think that you raise a really critical point, which is that the shame can extend both ways. Mm-hmm. 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 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, right? Yeah. Consential age appropriate, context appropriate, species appropriate. Absolutely. I'd like to take a quick break and acknowledge our sponsor

inside tracker. Inside tracker is a personalized nutrition platform that analyzes data from your blood and DNA to help you better understand your body and help you meet your health goals. I'm a big believer in getting regular blood work done. For the simple reason that many of the factors that impact your immediate and long-term health can only be analyzed from a quality blood test. However, with a lot of blood tests out there, you get information back about blood lipids about hormones and so on, but you don't know what to do with that information. Within side tracker, they have a personalized platform that makes it very easy to understand your data,

that is to understand what those lipids, what those hormone levels, etc. mean, and behavioral supplement, nutrition, and other protocols to adjust those numbers to bring them into the ranges that are ideal for your immediate and long-term health. Insight Tracker's ultimate plan now includes measures of both APOB and of insulin, which are key indicators of cardiovascular health and energy regulation. If you'd like to try Inside Tracker, you can visit insidetracker.com slash Huberman to get 20% off any of Inside Tracker's plans. Again, that's insidetracker.com slash Huberman to get 20% off. I asked whether or not you imagined the pure imagination based arousal versus visual arousal.

And for some people, the sounds of people having sex is extremely arousing. If you've ever lived in a major city like New York, which I spent summers in New York, you hear a lot, you hear more often than you do in areas where people are living further bright. You hear people having sex. Yeah. 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 laboratory 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. Mastervation is find healthy way of self-exploration. Again, with the caveat that as long as you're doing. Masterbation 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 against another podcast, 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 anytime there are big increases in dopamine, without a lot of effort required to generate that dopamine,

like turning on pornography on the internet versus asking someone out on a date, going out on a date. 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, there's a lot of. Well, that's a form of finding a mate. I mean, I was weaned in the era when, you know, no smartphones or anything. And, um, no, my point is I think that we've become very connected to technology in our world, which also means that we're having less conversations. The younger generation is having less conversations and more online conversations. And I think that's a skill that needs to be developed as well. And I think part of that is contributing to all this as well.

Well, one thing that I can attest to is that you know I grew up in a community of mostly male friends, I have 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 wanna 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 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. 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, 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, sake at times, 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 oralzo 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, cycle, you can go back to the research of masters in 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, with men. Yeah.

So they watched and they took note of the kind of the steps of the female arousal or sexual response. 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 of, 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 sort of a refractory time period at which point you can no longer 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 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 cue people to a timestamp link in the show no cap, and 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 proclivities, can override the refractory period and they can have another erection and ejaculation. Similarly, a female will have a post-organic 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 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, well, 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 premenopausal women with low libido. Oh, but maybe just 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. The melanocyte simulating hormone at MSH

comes from the medial pituitary, if I'm not mistaken, one of those weird regions, no, everyone's talking about anti-interior 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 people are getting cavalier with it.

They can have issues. Pripyzm being enduring and perhaps even final erection, is that true? Pripyzm. Pripyzm, I mean, it's actually from Pripyz, the Greek God who is often photographed with a really big erection. Oh, wow. I'm reading here enough about that Greek God in school. But is it Roman?

Roman, but anyway, so 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 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, slashed to dallophil, or viagra for erections are getting true

preopism. Correct. And it's mostly from those injectables we talked about earlier, those intercavernosal injections, people can get prior 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 prejudice. Trasidone 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, sorry, Bremelanitide is a generic name.

Valisi is the brand name, which is FDA approved for women with low, hyperactive 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 on the brain pathways to increase desire. It's taken as an injectable, again, just like you said, about an hour or 45 minutes before when you want to want,

you take it 45 minutes before, and it works quite effectively in increasing desire. How long does it last? About 24 hours. Some people may be up to 48. I mean, I know men using melanocyte 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, Lippie-Polly Sackaride, 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. Arrives to you easily. You just buy it on the internet. It says not for human or animal use, and people are injecting it. And the LPS issue is something that 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 a prescription from a quality physician. Exactly. And because we have brimilanetide, we can prescribe that for men as well. So sometimes we'll do it off label for men

who are having delayed ejaculation, because it will help them achieve orgasm a little bit better. And so 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 45 to 60% of patients, and you need to take it for some time. Now, both of these are brand name medications. So they are are a little bit costly and sometimes insurance doesn't cover them, but they are available, and I think very few people know about them, and I think they're really great and useful tools in the toolbox. And these are for desire. They're for yes, they're 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 or rousal and fimoorgasm, but as long as we're talking about a rousal and reduced a rousal that requires treatment, I have to ask this now. Anytime we talk about a rousal in 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 two degrees, you're good. If it's too high, much higher than that, you have a fever. If much lower than that, you're hypothermic. So my understanding, my, 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 partner's desire, whether or not they can meet those desires. And if they sort of accrue enough of a sample size, they date enough people where they have sexual interactions, they figure out over time whether or not they have a low, medium

or high sex drive. And people tend to compare to how they felt in earlier years or at different times of the year or under different psychological conditions and stress conditions, that kind of thing. But we really don't have a benchmark for this, right? I mean, we can't say that, for instance, that if 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, there's no way to think about it? 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 asexual 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 questionnaires like the FSFI, you can actually see that about 40% of people qualify for having sexual dysfunction, but really bother is only seen in about 12%. And you can be bothered because you're bothered, you can be bothered because your partner is bothered, but it's really up to you, right? Like, if you feel like there's something that you want to improve on, then that's when you go see your doctor. But there's no right or wrong answer, right? This is very subjective. And a lot of times we'll see couples who have mismatched libidos. Now, does that mean one person's right and one person is wrong? No, it's just a matter of like, well,

how do you, if you want to come to a point where you agree, how do we get there, you know? And what is, what is your end goal? Yeah, I later will 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 who's, sometimes it's not even physical interaction and they are just so unbelievably arousing to you. Or somewhere in between, or sometimes it just sort of ain't there.

Or it's just not there that much, or nobody likes to talk about this, or it's there until you sleep together, and then it's not there. And this is 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? 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 oneself desires, as well as the hopes and expectations of the people that we are sexually involved with. So we'll get back to that a little bit later in the context of chemistry because I find it so fascinating and it's something that isn't talked about enough. But thank you for that. 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 what it does is the cervix moves up and out of the way. 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 baseline vaginal length. And so it is preparing for that.

So if you, and so that's part of it, in some people who have painful intercourse, it's because they haven't had adequate time for arousal. And so there, 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 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 end all. Some people just make a lot of lubrication and some people don't, and certainly that changes with age and hormones. So if, 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 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 a rousal besides sexual rousal that we know from, it's not a pleasant topic, from reports following sexual assault that 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 the lubrication occurred independent of libido type arousal. Exactly. Okay, so let's set that aside, again, unpleasant topping, but one that's important to flag, and unpleasant topping, but one that's important to flag, are there forms of non-lebedo 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. Post-menopausal reductions in lubrication, but are there also post-menopausal reductions in lubrication, but are there also postmenopausal reductions in baseline lubrication? Are some people's vaginas just more lubricated at, I wanna 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 engorgement, right? They're getting literal engorgement. 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 there's any sense that there may be 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, we'll say, normal physiologic discharge because we see it. There's always discharge and 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 then it's menstrual cycle dependent in terms of the viscosity and the changes over the cycle and it can be different in color and different in thickness. And that's completely normal. And I think that's a real problem in the feminine hygiene industry. You don't need to smell a certain way or reduce that discharge. This is completely normal, healthy, and you talked about chemistry. I know there's not a ton of data on this, but there's like pheromones, right?

There's sense that are coming from you, which are actually attractive to a partner potentially. And in whatever physiologic, I don't know there's not a lot of time to date on this, but like there is that part of it. So, you know, there's a lot of marketing towards women that you're dirty, you should be smelling like peaches or whatever. Really? There's a lot of marketing.

I may be this is a generational thing, but I learned early on, and I think about 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 too,

right? We wanna make the conversation as broad as possible, and that the odor, let's just be 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 relationship that, let's say, had healthy sexual relations,

I like to think his experience, remembering somebody's smell, or thinking about somebody's smell, and that itself could be very arousing. Yes. Partners even, I'm smelling different articles of each other's clothing, and that being arousing. So, I mean, this is the stuff of real physiology.

We're not making this stuff up. Right. But there is, there is a lot of marketing towards women that they should use douching, or other things to clean themselves. And it is, it's damaging, right? It's actually one, it can affect the vaginal microbiome, so their pH is changing and that

can affect, you know, their risk for UTIs or bacterial vaginosis. And, 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,, oh, 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 it's normal to have an odor that is distinct to you, and that there's, of course, if you have a fishy odor, that may be a sign of 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'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? I got a number of questions about microplasma infections, which we don't hear that often about, but...

Yeah, so 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 a microplasma that could be causing symptoms in the urethra itself.

We've had a couple episodes about the gut microbiome. My colleague Justin Sonnenberg at Stanford is laboratory's directly above from I as expert in the gut microbiome. I've 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, intru vaginal, intru urethral, and males and females.

There's an anal microbiome, there's a microbiome on your skin, on your eyes. And you mentioned douching and other ways of, I want to say quote unquote, cleaning it because that language falls in line with the idea that it's a good thing. You're telling me it's 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. 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 our Argentina. 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 or my son, my older son, has been much more graphic than that. Amazing. Yeah.

Amazing. Well, I went out into the world and anyway. He figured it out. Let's spend a few minutes or more talking about female orgasm. One of the more cryptic topics on the internet, not because it isn't discussed, but because I think that the nuance of it isn't discussed often enough or in full depth. So let's take the time we need, um, to parse this. I think that the simplest way to parse it is going to be from the anatomical standpoint.

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 a literal stimulation by pelvic pressure or by digit. We're going to talk about fingers as digits because we're both in the medical slash science profession, but we're talking about fingers here or something else, right? Bibrator toy, whatever. I'm tow for depends on how flexible you are. I don't know.

But the point being that I think the simplest way to go about this is going to be to talk about the distinction between literal orgasm and chief 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 a lower level, or all or none. Right? How shall I say this? It is clear in my life experience in 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 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 clitorial stimulation or to climax. So very few actually climax through just vaginal penetration alone. And so this is a real problem. We're seeing on the media that 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've 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 clitorial stimulation is just like penile stimulation for women that is very reliable. And there's a huge orgasm gap for men. It's pretty consistent that when they have a first time sexual encounter, 95% of men are having an orgasm. When you look at first time sexual encounters for women with 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. Presumably because they understand the anatomy of other

by a way of understanding the anatomy of self. So there's a huge gap. And physiology and psychology. Yeah, that too. That too. But there's a huge gap there. And so I think to bring it home is the clitorial 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 crura is what we call the legs, I guess, for lack of a better term of the clitoris. And so you're stimulating that. You're also stimulating the clitorial shaft, which goes deep into the pelvis. The G spot is an area, is an erogenous zone, where it's kind of in the anterior wall of the vagina

about two to three centimeters in. That's the location of these periorethal glands called the skeens glands. And they are analogous or homologous to the male prostate. So just like some men have prostate play and enjoy pleasure from prostate stimulation, some women enjoy G-spot stimulation. Now that's not universal, right?

Not all men enjoy prostate play and not all women are gonna be aroused by G-spot stimulation. And so I think 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 so varied from person to person. And I think 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 take-homes for this. And also, the vaginal penetration, it's actually usually from cervical stimulation, not necessarily vaginal, because the large density of innervation, the vagina, isn't the first outer third of the vagina. The deeper two thirds of the vagina 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 stimulation and 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 is defined differently, right? But the one thing we know is that there are pelvic floor contractions, which are measurable. So you can kind of tell that your partner is having an orgasm if you have a female partner, because you can actually feel those contractions, right, whether it's on your digit or your organ or a sex

toy. Okay, super nerdy question here. Years ago when I worked on hormone-based sexual differentiation, which by the way we've done an episode of the podcast on previously, I learned that the levatory any muscle is the muscle that controls erection and males and presumably a literal tumestense and 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 like 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 and their recognition of it and other people and descriptions, et cetera. But are we talking about a response that originates at a fosai, kind of like in the brain, we talk about a seizure, you know, starting at a focus of fosai 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, you know, behind their forehead and in their genitals. Or as a whole body response. And here, we're not talking about the flood of neurochemicals into the body. I'm talking about during those moments of orgasm, what is happening, gnarly? 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 erection and two medicines being lived, levator A and I. So actually what happens during the reason you get an erection and presumably clitoral stimulation the same way is blood flows into the erectile tissue and the tunica, which is the outer layers of the, of the erectile tissue, which are two basically cylindrical shaped structures in the penis and in the clitoris, they will fill with blood and then that tunica will compress veins on the outside to prevent blood flow from leaving. So it's not a muscular event, it's an actual blood flow event.

Then how come 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 literal to-messence, although it's harder to measure in rodents, there's a way of indirectly measuring that. Then we would measure the size and weight of the levator antimussels as a readout of how androgenized that whole system was. In other words, what is the role of the levator antian in the sexual response? So the levator antian, I say the levator antian, you know, I think it. So those muscles are part of the pelvic floor, right?

And so those contract when you, when you climax, right? So whether it's orgasm for male or female, they're contracting and they're exercising, right? They're, so that's how they would increase their, their strength or their density. If you're measuring that through the actual climax of which you can't see in rodents, right? So like you're kind of using it as a surrogate in that way. So that's what 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 everything. You are very present in that moment. and so people will feel different simulations depending on how they kind of, how their nerves or their sensations are and things like that. It's perhaps a good time to mention dopamine.

We talked about it 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 interesting thing, and I got some questions about this, is that there's literature as I understand

about the elevation in dopamine caused by, say, antidepressants like wild butren, reprieron, which increases dopamine and norepinephrine. People who recreationally use drugs like cocaine or other stimulants. People who take adorol, vivants, who recreationally use drugs like cocaine or other stimulants. People who take Adderall, vivants or other drugs that increase levels of dopamine because I did a whole episode about those drugs

and they are different forms of anphetamine. Unless we're talking about Ritalin, which is a little bit different. And I got a lot of questions about people who experience feeling a lot of desire, sort of a rousal, but not being able to achieve the physical rousal 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, some people will have sex for long periods of time, some for shorter periods of time, and here people don't really know what other people are doing, except by way of pornography and self-report and discussion.

So, 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 Tidalafil, which is a PDE5 inhibitor, so it's going to increase blood flow. And I'm hearing about men and women, but mainly men doing this. So ramping up their dopamine, ramping up their blood flow to their genitals in order to have presumably more rousal insects. Does it make sense as a mechanism? Yes. So in terms of apomorphine, 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 it's a very complex response. So like I mentioned that flabancerin, which is essentially acting medication, it actually has not only in the 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. When it was actually approved, it was being studied for an antidepressant. And what they found was that women were actually having 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 realized, 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 Artile 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 Biagra. I think it was an intracurneusal 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 published article, but I'll read the article. There's a published article about people who were attending at the meeting and yes, he came out.

And at the time, it was mostly men in urology, but there were spouses, I guess, in the audience, which is not typical now. So there were women in the audience and he came out with a full on erection to show that it, you know, it worked. All right. Well, I suppose that the urology meeting, or OBGYN meeting where a woman comes out and reveals her enhanced vaginal lubrication, then we will have gender and sex balance at the meetings on urology.

It will be interesting to attend one of those someday. Differences in arousal as a function of stage of the menstrual cycle. I'm really interested in this. I did a long episode on fertility and we're going to have a few other IVF experts, fertility experts on the podcast. 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 things across the menstrual cycle. And it's always an imperfect experiment because 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, et cetera, around the time of ovulation. But what about the other direction, too? Is there a category of women that are very interested in sex at certain stages of their menstrual cycle and then not at all interested in sex at other stages of the menstrual 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 studied those variations a little better,

but there is data to suggest that libido does increase prior to ovulation and during ovulation. I think it's like a couple days prior because that's the optimal time for fertility. So yes, there is data to suggest that in terms of like completely lack of interest. I don't believe there's data, but I'm not sure. Is there evidence that females who perhaps have not experienced so-called G-spot,

orgasm or cervical orgasm can learn to do that? And I always find it interesting that whenever there's a discussion about different forms of female orgasm, people are careful to point out that many women don't have penetration-based orgasm. And then they separate out literal stimulation as a more common route to orgasm. But of course, there can be literal stimulation with penetration. Absolutely. Right. And depending on the physical arrangement,

there can be literal stimulation purely by way of penetration through pelvic contact, fingers, et cetera. So 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. So there's the the rocking stimulation,

so that can also stimulate, so meaning that the, you're penetrating, but there's like a rocking motion that can also penetrate the clitoris. There's 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 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 explore, 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 consent in age-appropriate, context-appropriate, these kinds of things. And obviously, substances like alcohol and other drugs can strongly confound those issues. And so that's, we'll just leave that as a kind of an obvious one. As long as we're talking about communication around sexual interactions,

perhaps it would be useful to people to cultivate a language or a nomenclature there too 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, right? 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 script, but I think in general, you want to have the conversation outside of the bedroom. So not like right before sex or right after sex, because that leads to like a, you know, a sense of insecurity for the other person, right? Did I do something wrong? Did something go wrong here? So you want to kind of move those to a neutral location. So like kitchen table in the car, whatever. Somewhere where, you know, sex is not going to happen, at least for that particular moment. And we have some challenging conversations on this podcast,

challenging previously challenging because they, you know, you're trying to get things clear and as clear as possible. This one is challenging because 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 two, 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. It makes kind of an animosity sort of situation. And then, I think also part of it is like being open about those things, and it may, it's not gonna happen in one conversation. I think that's the hard part. Like you think you're gonna have a conversation, 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-A-S-E-C-T-A-S-E-S-E-C-T-S-E-S-E-C-T. org, where you can look for a sex therapist near you.

And you can even do those things virtually. And so that can be really helpful when you're having difficulty having a conversation. Yeah, I think 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 there are the twists and turns that occur with when one is asking about somebody else's arousal template, oftentimes you'll learn things about people's sexual past.

And that can be either neutral, stimulating or aversive, right? That can open up all sorts of other issues related to the psychological interplay. So there's no way we can parse all of those. Now, I just think it's worth highlighting that it's understandable why the most conversations are challenging. And it also is understanding why pornography isn't gonna involve those conversations.

Right, right. Building conversations there are between your brain, your hands, and your eyes, and your ears. Not gonna highlight any particular order there. I wanna switch gears slightly and talk about UTIs. I got a lot of questions about urinary tract infections. Let's make it related to both females and males because yes, males get urinary tract infections,

females get them, more females asked about urinary tract infections. How common are they? Should they always be treated with antibiotics? Is cranberry really a good treatment? If so, why are there other things that are better? Is it 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 UTI, so you just have one a year, or you have one every few years, it's not a huge issue. In men, however, UTIs are much less common, and that's because the urethra is longer. So there's less entry from the outside world into the bladder, which causes infections.

And so 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 that are highlighted in the guidelines that we all talk about. So one is hydration.

So making sure you're drinking about two to three liters of fluid, ideally water a day, because dilution is the solution to the pollution, right? So drinking more fluids is going to get that bacteria and you're going to pee it out. It's going to help keep not let it sit around in the bladder very often. Another thing in women who have altered states of estrogen, whether it's postmenopausal, surgical menopause, or maybe have reduced estrogen for postpartum or other reasons.

What about you in the second half of the menstrual cycle? Not necessarily for those specific people, but for those specific times, but because it's pretty short-lived. I guess you could use it, but is vaginal estrogen. So vaginal estrogen, meaning estrogen that's applied in the vagina, either through a cream, a suppository, or a ring, 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 at doing that. In fact, in our clinics, we'll actually check a vaginal pH to see if there is an indication that their pH is too high that maybe they do need vaginal estrogen, particularly on the perimenopause, because it's hard to tell just by looking if they are really heading into a lower estrogen state sometimes. And so that's very, very effective and very, very safe.

So when you look at estrogen, the Women's Health Initiative way back when sort of made a big stink about how estrogen is related to cancer. However, vaginal estrogen has never, ever been a reported breast cancer, uterine cancer, or any other blood clot, any other adverse event associated with vaginal estrogen. You can get some breast tenderness, some discharge, those things can occur, but the absorbed

amount vaginally is so little that your estrogen level barely goes up. It doesn't even reach premenopausal level. So it just goes up very slightly in the bloodstream, not enough to create any sort of abnormality. So vaginal estrogen is extremely safe, and it's pretty affordable. You could actually use coupons if your insurance doesn't cover it through, you know, good RX or Mark Cuban's pharmacy and get it very, very affordably. And it's very effective. It does take about three months to work.

So you have to be consistent and you apply it about twice a week at night, sometimes three times a week. And it's very effective. The ring you put in once and it lasts for three months. But so generally speaking, that's the most effective option for low estrogen states. Other kind of simple things are trying to make sure you're completely emptying your bladder. So over a lifetime, people can develop some mild pelvic floor dysfunction, right? Not enough to create pain or discomfort, but maybe they're not emptying completely, right?

Because maybe they used to hold their urine for long periods of time when they were a kid, or maybe they're always hovering over the toilet because they don't want to sit on it at work. And over time, that can create a little bit of mild dysfunction, which can make it more difficult to completely empty the bladder. And when urine is sitting in the bladder for long periods of time, it's basically food for bacteria to grow. And so bacteria grows, and then you get current UTI. So making sure you've completely empty by sitting, relaxing on the toilet, sometimes leaning forward,

and then maybe going a second time. So standing up, sitting back down, going again, and even for men, sometimes trying to sit and see if you completely empty, because sometimes standing, you're not able to empty completely. Whoa, a lot of men are gonna, because there are these, you know, it was fun to research for this episode because there are entire discussions on Reddit about what percentage of males sit while urinating. I mean, minor-sharing 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 yearnate, but there are decent percentage of men that sit down to yearnate. There are. And in fact, it's very little like country. And probably the reason it's become interesting lately is media. My country. So a certain country was recently surveyed. I think it was Germany. But essentially, there's recent, like, picked up by the media, that Germans sit more often to pee. And so, you know, then people like, oh, is this better for me to sit to pee or stand to pee? And there's this whole big discussion on the media. But the reason being is when you're sitting,

your pelvic floor is most relaxed. And so if you're having any issues emptying your bladder, you're 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 intra-abdominal pressure, because you're sitting and you can lean forward to overcome sort of a blockage. And so there are 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 on it or you're using spermicides, that is a known risk factor for UTIs. Other things I wanted 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-anthosianidins,

or PACs. And they've actually looked at the amount of PACs you need in 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 skin of the berry and the stem of the berry, and that's not going to help you. So you need to make sure that the supplement you're using

is a soluble form of the cranberry, and it's actually very, very 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-coital UTIs,

that you can take two on the day of sex and two on the day after, and that may be helpful. But there's not a lot of data there, but certainly an option that you can try that's pretty low risk. So that's kind of the 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 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 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 at UCLA where they're looking at the microbiome of people who are more at risk for UTIs or even overactive blood or other conditions like that and they're trying to figure out like is there something here that we can target or that we can figure out is causing problems because sometimes we just can't figure out why it's happening. In terms of wiping from front to back and swimming and peeing after sex, there's no good data on any of those things. Wiping from front to back I think it does create a little bit of like shame.

Like it's not a big deal if you wipe back to front as long as you're not like, you know, as long as you've like cleaned yourself, so to speak. So I think it's less of an issue. But what we're talking about, is that you're referring to any contamination from any bacteria around the age. Correct. And a lot of women who have recurrent UTIs tend to come and feel very dirty. There's something wrong with them.

They're like, oh, I wash all the time. I'm really clean. I'm really this. And it's not something they're doing. It's probably a microbiome of fact or a hormonal of fact. Or 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. Um, perhaps even the opposite is true. They're cleaning too much based on what you told us earlier. Yeah. And they're eliminating the gut microbe, excuse me.

Just rolls off the tongue. Got you. Um, again, no pun intended. Um, perhaps it's, they're, they are abolishing the local microbiome on the skin. Too much cleaning eliminates the microbiome on the skin. Not that we don't want to wash, but when Sonnenberg was a guest on this podcast, he said, actually, kids can develop a very healthy microbiome and general microbiome. Oftentimes, by, sorry, parents, not washing their hands before eating

if they've been playing with soil outside or dirt, a little bit of that is actually healthy. Pets actually offer microbiome support. This is so weird, I know it sounds like dirty. No, I'm not that good, 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 overcleaning 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 overcleaning. And so that's one of the, you know, things for, I definitely have a UTI, I definitely have one. Well, no, you don't, but there's a host of other things that it could be. One of them could be that. Another very common one that we already

touched on is pelvic floor dysfunction. So very often pelvic floor dysfunction, just like you had pain with the urination, women can also develop pain with the urination that doesn't go away. And it can start where they had a UTI that triggered the pelvic floor. And then the pelvic floor just didn where they had a UTI that triggered the pelvic floor. And then the pelvic floor just didn't relax. But the pain just triggered the pelvic floor to tense up.

It didn't relax because again, we're not taught how to relax our pelvic floor. And then they've developed pelvic floor to sponge like, why is the UTI not going away? Why does it keep coming back? And so that's another common thing that we see in people who have quote unquote recurrent UTIs, but don't really have them. To be clear, I experienced the pain in urination as a consequence of trying those damn key goals that everyone's talking about.

Stopping that 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 hypercontracted nor over relaxed. In some cases, just not doing anything for it is the best circumstance. Right.

And the only reason I mentioned that is because obviously this discussion is not about my pelvic floor. This discussion is about the fact that some people perhaps need to clean less. Some people may be 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-OK.

Any discussion about anything medical, or especially hormone stuff, this happens a lot in the discussions around that get into, it seems, with males, 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 genital-based arousal function. Probably to you. And I mean, you've talked about testosterone a lot on the podcast, so I'm sure your audience knows very well. but in terms of a general-based arousal function. Probably too. Yeah, and I mean, you've talked about testosterone a lot on the podcast, so I'm sure your audience knows very well the multitude of benefits for testosterone. So I think there is value in assessing hormones, panels, and assessing your level of free testosterone

testosterone, and you know, assessing if you're having symptoms that are not always sexual, right? It can be depression, it can be weight gain, that you're not gaining muscle mass. You can have cognitive changes. So those things can still be a sign of low testosterone and very valuable and important to assess. That reminds me of another thing,

and then we'll get back to 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 deralsal 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 postmenopausal 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, you know, relationship, other issues that can affect libido medications, there's a lot of things, obviously, that go into that.

But if we said, 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 awfully bull testosterone. And the guidelines are the consensus statements are not a true guidelines, but they recommend using transdermal testosterone. So getting, you know, Androgelle tubes from the pharmacy and putting a tenth of one tube on the back of the calf or the upper outer buttock, a hairless area for absorption that can improve desire overall. And then the other place we use testosterone is in women who have what we call vestibulodinia.

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 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 the kind of general recommendations for people who have kidney stones, one is increase your fluid intake to two to three layers, again, the same number I told you before. You want to decrease your oxalate intake. Now, if you Google oxalate,

you're gonna 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 people eating a lot more nuts to get more protein. So cutting back, it's impossible to get rid of all of that in your diet, but if you're having 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 things like that to increase citrate vegetables as well. Actually, one easily accessible thing is crystal light. It has a little high citrate composition so you can drink crystal light with that two to three liters

and that can be helpful. You want to decrease your protein intake. So high levels of purines or pergenic meats, like red meats and things can also push you at higher risk. So these are kind of the general sort of preventative measures we talk about for kidney stones. If you have a kidney stone, so a lot of times people

can have kidney stones and their kidneys, they're not creating any problems, they're tiny, we can observe them over time. If they start coming, if they start getting very large or they are starting to move into the uritors 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, I think there's no signs of a urinary tract infection, there's no fever, 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 enlarged prostate as well, that actually relaxes the ureteral smooth muscle

to allow the stone to pass a little bit better. If you're having an infection, you gotta get treated right away, 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, walking 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 started. So, to be very urinating, T colored urine, so the meaning blood in the urine, all of those

are important warning signs that you ideally don't get to. Yeah, blood in the urine, all of those are important warning signs that you ideally don't get to. Yeah, blood in the urine doesn't always mean infection. It could just be irritation from the stone, but certainly fever, it'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

hydrinifrosis, they're pressure behind the kidney, and you have these signs of infection, we don't want to wait because you can get sick pretty quickly. And then, you know, once, to treat the kidney stones, there's three major options. One is shock waves. Another is ureteroscopy where we go in with a camera and we have a small laser.

We break it up into small pieces and... Where is the camera inserted through the urethra? Correct, you're asleep under anesthesia, so you don't have to... You saw the... Yeah, I saw the... You saw the winds. And You saw the wince. 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 incision and with a specialized camera that goes in and uses ultrasonic lithotripsy to break up that stone and kind of suck it out that way. These are extremely helpful bits of information, or 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. Let's 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 nuva ring, nor plant, the pill brought category of things there, but for sake of discussion of the pill, et cetera.

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 seem 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 clip 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? Yeah, 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, specifically low libido, to orgasm, like 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 described very like this 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 subset of people, they're seeing very significant consequences of taking oral contraceptives. Now, I think that there is, we don't know which women are gonna have this problem and we don't know how it's probably a very small subset of people, but we do know that this does

happen and that when you measure SHBG levels, they're up. And that even after they stop the oral contraceptives, you'll see elevated SHBG levels from baseline. For how long? You know, for like at least four months afterwards, you'll still see elevated SHBG levels. We're not, but not infinite. levels. So we don't know. But not infinite. I mean, we don't know. And yeah, the endocrine system is weird because it, it, um, we assume everything is a short-term effect, but there's some plasticity in the system, especially because it's a neuroendocrine system. So yeah, okay.

So I think yeah, there's some neuroplasticity there that occurs as well. And so, uh, we do see this. And I think that the other side of it is, yeah, absolutely, oral contraceptives are amazing, right? They're helpful for sexual freedom, for preventing pregnancy, for a lot of things, and particularly other conditions, too, like PCOS, and other problems. Oral contraceptives are amazing, and they've changed 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, 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 elevated sex hormone binding globuline, which is 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.

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. What are the other options? Is the ring copper IUD? So any sort of long acting hormonal contraceptive, we've seen, that's what we counsel patients on is if they're having issues with oral contraceptives, even if they come in with pelvic pain and they're on oral contraceptives, I'll tell them, you know what, just stop because maybe the effect of, on the energy receptors or estrogen receptors is affecting the lubrication or other things. We're not sure, but why don't you stop and go get a long acting

contraceptive method? Like an IUD. Like an IUD. And our IUDs are 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 IUDs. 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. Tempted. 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.

You know. I am not suggesting people do that. I think it's just an interesting medical factoid. 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? Oftentimes these sexual arousal or dysfunction issues associated with SSRIs and other medications, make those medications prohibitive for people. So serotonin is kind of the anti-toorgasm. 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 Cialis and Viagra, like you've talked about for a rectilis function as an addition if we can't change their medication management because you know, and it gets a little bit complicated because we know a reptile dysfunction and depression

are very interrelated. Now what's causing what? And where do we, maybe somebody went to see their doctor for depression, was also having issue with directions. And now, if you fix the erections, do you help with the depression? What, you know what I mean? So I think-

Males everywhere are shouting yes. So 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 it can be helpful to switch medications or reduce the dose.

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 I don't remember the mechanism off hand. Let's talk about prostate and prostate health. Earlier, I queued 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. Yeah. Prescribing low dose, 2.5 to 5 milligram sea allis, which is to Dalifilm, which may assist with erections, but the rationale for this daily low dose is not centered around erections per se. It's really about prostate health, improving blood flow to the prostate, reducing prostate as 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 Tidalafil 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 though, so it can actually work quite well and is a great option for a reptile dysfunction. So I do wanna make that caveat.

In terms of prostate health, it has been shown to be effective for BPH or enlarged 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, it's 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 genetic. 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 overactivity. So you'll see your bladder is responding to having to push hard against that narrow urethroid to push urine out. So it's having more urgency

like the sudden desire to go to the bathroom that you can't delay. You're maybe going more frequently and very often you're going more often at night. And so those are kind of the first signs people will see. And then over time, it may become more and more difficult to empty the bladder. You might see some hesitancy, like you're waiting for your stream to start, or it stops and starts. And so those, or you're just like, I can't empty.

It's not because it's drips or a very weak stream. And so those are kind of the things that can happen over a lifetime. Now, what are some things that you can do to help? You know, Cialis helps relax those, those, the fibres smooth muscle of the prostate so that it allows urine to pass more easily. There's also other medications that you can treat very often flow max or other alpha blockers are helpful in that area.

In terms of like things that you can do in general for bladder health, prostate health, there's certain things that are irritants to that area. And so what I tell people, not everyone's affected the same way. So I don't want people to be like, oh, I 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 see that you're not going to the bathroom quite as often because caffeine is a bladder irritant. So that can be coffee, tea, chocolate,

things of that nature that have caffeine in them, energy drinks, sometimes people forget they have caffeine in them. And so limiting that may improve your symptoms. Alcohol also is a bladder irritant. And these have actually been studied in animal models and you'll see that the bladder contracts more often when they're given these sorts of substances. And it's dose dependent.

And some people can actually habituate or get used to a certain dose of caffeine. So if you're drinking coffee every day, you may have less symptoms than someone who drinks it every once in a while. Other things can be sometimes carbonated beverages, spicy foods or acidic foods. Those sorts of things can also irritate the bladder lining. So sometimes limiting those things may be helpful in those situations.

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 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 CEUs, maybe even exercise bike, it 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 really high volume cyclers now, the studies have looked at like maybe they did a 350 kilometer race or they're biking three times a week for 60 minutes, but there's no consistency. But they're seeing pretty high rates of genital numbness, so 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 decreased lubrication, maybe decreased arousal as well in women. How can you prevent that? The reason is because when you're sitting, particularly if you're leaning forward, like competitive bikers do, are arrow riding, you're putting pressure on the beak of the bicycle

seat. And that's where, you know, most of the, it's not your weight, it's not distributed evenly. So the goal is to take a bike seat that allows you to sit comfortably on your ishield to arosities. And posture is to sit comfortably on your ishield to velocities. And posture is a huge part of your pelvic floor. I know we didn't talk about that earlier, but sitting with good posture and not slouching or leading 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 wanna get kind of a nozzless seat and a wider seat. The cutouts, actually when they've looked at kind of mechanics of the cutouts, they'll see higher pressure around the opening.

So it's actually not good to have a bike with a cutout. Bikes eat 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. I don't cycle. I don't like the exercise bike. I'll sometimes ride the assault bike which has the big seat. I made it for a few minutes, but I just want to add one which has the big seat, maybe for a few minutes, but. I just want to add one thing because I think that, I don't want to make people not cycle. I think it's really valuable.

Cycling is a great aerobic exercise, has lots of benefit for cardiovascular health. But there was actually another study that looked at people who were parts of sports club. So they were like swimmers, runners, and 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

sides 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 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. Oh, thank you. Thank you.

So I really appreciate it, as I'm sure our listeners do as well. Anal sex. You recently did a post describing the multiple reasons why women do or do not have anal sex. You recently did a post describing the multiple reasons why women do or do not have anal sex. It's a very interesting post, a very interesting study that you covered. And you explained it very clearly. I'm guessing there are relatively few, but perhaps some other studies as well about this. Let's talk about anal sex and maybe if you could just offer some of the the key bullet points that you've learned from the literature and from your clinical practice. How frequent is it with protection without protection, how safe is it?

What are the different reasons people do it? That might seem like a kind of a silly question, but it turns out when it comes to this topic, it's their interesting data. Yeah. Educators. So anal sex, let's talk about it. Well, when you talk about anal sex, the reason people, it's become more and more common, let's say it's more and more heterosexual couples are doing it.

We know that male homosexual couples are having anal sex. And I think 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 won of the reasons. But in general, 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, you can have blood loss and that blood loss can then easily, more easily transmit sex reaches and the infection. So it's really important to use a condom and use adequate lubrication. The anus does not make any of its endogenous lubrication. You have to use lubricant. The other interesting thing about anal sex is that the anus pH is different from the vaginal pH. You want to use specific lubricants that are isoosmolar to anal pH.

You can actually look up anal lubricants. We could talk about lubricants, but generally there is water-based, silicone-based, oil-based lubricants. Water-based are the most easily accessible, silicone-based are a little more slippery and last a little longer, and oil-based also lasts longer, but are not good for use with condoms. So definitely using lubricants and always kind of making sure

to be in the context, of course, of being consensual, but also, like, never force, always take your time. And those things are really important to avoid trauma because trauma can happen. And usually it's not severe trauma, right? It's not going to create long-lasting problems, but it is, you know, inconvenient, uncomfortable, and probably we're not seeing as much of it because they're not coming to the emergency room if they're having issues unless it's really serious. So I think it's really important, to prevent from sexually transmitted infections to be

thoughtful and cautious. And sometimes it requires some preparation. If you're going to penetrate an anus, 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. And then I think ultimately why people have anal sex. So as I mentioned earlier, the prostate is 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 there, the pelvic floor. And so that's certainly reasonable to do so. As far as why people engage in anal sex. So sometimes it's because, as I mentioned, they're trying to avoid vaginal penetration, either to avoid pregnancy or maybe menstruation or other reasons. Sometimes it's because people want to do something special with their partner.

Like they feel like this is my special thing with this partner that I do with them. And so it may be something kind of like a gift or something like that. Sometimes it's almost like they feel like they have to. And this particular study 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, on my Instagram was talking about why they specifically recruited drug users. And so a lot of people had used drugs prior 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 safety purposes.

And so those were kind of the common reasons. What about infection not related to sexually transmitted infection? My presumption is there is a higher risk with anal sex than there is with other, you know, vaginal and recourse, oral sex, et cetera. What is their evidence for that? 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 and 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 are things like that very rare.

Mostly, 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 animals 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. 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 lose stools and things like that. But generally speaking, you know, 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 maybe they've turned it off already. But, and I think we can expect a varied response to this discussion, but it's happening out there. It's happening. Apparently with increasing frequency. Yes, and I don't know if that's because

of the increasing availability of pornography where where it's visualize more or if they don't really know why, but we do know that there's more going on in heterosexual couples than prior. As a final category of question, 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. On this podcast, I always say, always, always, we emphasize behavioral tools first. Do's and don'ts, because those are the foundation of mental health, physical health, and performance in all contexts.

There is of course a role for prescription drugs sometimes. Oftentimes people can't do the things and avoid the certain things they want to because of depressive states, anxious states, etc. and prescription drugs can serve a role. But I do believe the goal is always behaviors first. Then, of course, things like adequate sleep, nutrition, healthy social interaction, all of that stuff, exercise. But we do often talk about supplements because they represent, I think, an important category

of over-the-counter compounds that can play a role. And 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, it can enhance libido to override some of the challenges with SSRI induced reduction in libido. And generally, even if people aren't on our SS rise, I hear from people who take Tonga Ali

and get 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, maybe some estrogen receptor modulation with maka root, maybe some dopaminergic tone changes. Sheligy, this Ayurvedic herb, which there is at least one study that I think has done

well that shows increases in FSH, follicle stimulating hormone with Sheligy use. What are your thoughts on things like Tonga Ali, Maka root, cheligy? How do you talk to your patients about this stuff? Yeah, so I think that, you know, I see at least my patient population is 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 a sexual dysfunction literature, exercise like doing both cardiovascular, aerobic exercise, but also doing resistance training, particularly of like large muscle groups. And then, you know, really working on reducing blood pressure and preventing diabetes. And those things, I think, are really key. And I know we talk about them a lot on this podcast, but I will tell you that when people

are getting ready for, for example, we do a surgery for erectile dysfunction called penile prosthesis. So this is like, end of the line, nothing's working, they can't get an erection at all. And it can be a, and they may have diabetes as a cause of it. 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 supplementary, I don't have a problem with.

I think that it's reasonable to try them. 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. 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, at 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, I can't stress enough, like how valuable they are.

And if you're smoking, quit smoking, it will kill your erections. And vaping. And vaping. Yeah. And then lastly, if you are developing true organic impotence, meaning 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 it's the sign that you may be developing cardiovascular problems or endothelial dysfunction that's first presenting in the penis or in their sexual organs. And, you know, this probably is the same for women. We just don't have the data yet.

I know a good number of women that take Tonga Ali. In part, I think, on the recommendation, although I want to be clear, I never recommended it. It was an offer of something that people could try if they're doing everything else correctly and could assess with consulting your physician of course and They too some of them have reported improvements in libido and desires Yeah, yeah, and I that she-leggy is less known about the distinguishing quality versus low quality sources of Shilogy.

It's harder, dosing is harder. It comes as this tar typically, maybe more science on Shilogy will come out in the next few years. We could 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, L. Citroen is pretty good.

Ashwagandha for stress reduction, which also has implications for sexual function. Tunkadali has reasonable data. I think there is reasonable data on these things. I think the website you talk about all the time, examin.com is a great place to look at that. And as I said, I think it's reasonable. They're smaller studies.

They're not, you know, there is bias in many studies, but there, you know, there is effort done in this area and there's never gonna be really high quality science. No one's gonna really fund that, I think. So I think our expectations need to be a little tempered when it comes to that stuff. Well, Rina, Dr. Malik, 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

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 raise and to confront directly. And you've taught us so much about how to promote the health of this incredibly important system. Absolutely. One thing we know for sure, either in vivo or in a dish, we're all here because of sperm at an egg.

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. 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 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. Reno Malik, all about urology, pelvic floor, and sexual health. If you're learning from Endor and join this podcast, please subscribe to our YouTube channel. That's a terrific zero-cost way to support us.

In addition, please subscribe to the podcast on Spotify and Apple. And on both Spotify and Apple, you can leave us up to a five-star review. If you have questions for me or comments about the podcast or guests that you'd like me to consider hosting on the Hubertman Lab podcast, please put those in the comment section on YouTube. I do read all the comments. Please also check out the sponsors mentioned at the beginning and throughout today's episode. That's the best way to support this podcast. Not on today's podcast, but on many previous episodes of the Hubertman

Lab podcast, we discuss supplements. While supplements aren't necessary for everybody, many people derive tremendous benefit from them for things like improving sleep, hormone support, and focus. The Hubertman Lab podcast has partnered with Momentus Supplements. If you'd like to access the supplements discussed on the Hubertman Lab podcast, you can go to LiveMomentus spelled OUS, so it's livemomentus.com slash Hubertman, and you can also receive 20% off. Again, that's LiveMomentus spelled OUS.com slash Hubertman. If you haven't already subscribed to our neural network newsletter, our neural network newsletter

is a completely zero cost monthly newsletter that includes summaries of podcast episodes as well as protocols. That is short PDFs describing, for instance, tools to improve sleep, tools to improve neuroplasticity. We talk about deliberate cold exposure, fitness, various aspects of mental health, again, all completely zero cost. And to sign up, you simply go to HubermanLab.com, go over to the menu in the corner, scroll down to newsletter, and provide your email. We do not share your email with anybody.

If you're not already following me on social media, I am HubermanLab on all platforms. So that's Instagram, Twitter, Threads, LinkedIn, and Facebook. And at all of those places, I talk about science and science-related tools, some of which overlaps with the content of the Hubertman Lab podcast, but much of which is distinct from the content of the Hubertman Lab podcast. Again, it's Hubertman Lab on all social media platforms. Thank you once again for joining me for today's discussion with Dr. Reno Malik. And last but certainly not least, thank you for your interest in science.

You know, Mollek, and last, but certainly not least, thank you for your interest in science.