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

Starting point is 00:00:00 Welcome to the Huberman Lab podcast, where we discuss science and science-based tools for everyday life. I'm Andrew Huberman and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. Today my guest is Dr. Rina Malik. Dr. Rina Malik is a board-certified urologist and pelvic surgeon. She is an expert in both male and female urological, pelvic floor, and sexual health. During today's episode, Dr. Malik answers the most commonly asked questions of, about urinary pelvic and sexual health. For instance, how to avoid getting UTIs,

Starting point is 00:00:37 urinary tract infections. We also discuss pelvic floor anatomy and function as it relates to overcoming an overly tight or an overly relaxed pelvic floor. This is a key distinction that most people aren't aware of. Many people hear about the need to so-called strengthen their pelvic floor, but in fact many people need to do the exact opposite.

Starting point is 00:00:57 They need to learn to relax their pelvic floor in order to achieve proper urinary floor 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,

Starting point is 00:01:17 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

Starting point is 00:01:41 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

Starting point is 00:02:07 of bladder function, prostate function, skeins, 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

Starting point is 00:02:54 not be suitable for young children. How young? Well, that is certainly not for us to discern. We realize that different parents and different households should be the arbiters of what sorts of information their children are exposed to or not. So my suggestion would be that if you have any concern whatsoever, that the content of today's episode would not be appropriate to be heard by some member of your family, that you please listen to the podcast first or at least check the timestamps where we've detailed what specific topics are covered and then to make your decision accordingly. As she mentioned 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, pelvic 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.

Starting point is 00:03:50 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 provided a link to Dr. Malik's YouTube channel in the show note captions to this episode. Before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is, however, part of my desire and effort

Starting point is 00:04:12 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. And now for my discussion with Dr. Rina Malik. Dr. Rina Malik, welcome. Thank you.

Starting point is 00:04:27 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

Starting point is 00:05:04 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, et cetera, that was more oriented toward the fear of things like STIs,

Starting point is 00:05:39 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,

Starting point is 00:06:14 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 that I think for some people, they're not used to hearing in general discourse.

Starting point is 00:06:37 I'm just going to get them out of the way now. Penis, vagina, anus, prostate, you know, what else is there? We're going to talk about libido, we're going to talk about intercourse, oral sex, anal sex, 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 got to talk about all of it. Great. So to start things off in anticipation of this episode, I solicited for questions on social media and I got thousands of questions. But there was a lot of overlap in the questions. So to start off,

Starting point is 00:07:11 I'd like to talk about pelvic floor, okay, because both males and females have a pelvic floor. and my understanding is that there's a muscular component, there's a neural muscular component, there's a blood flow component. What is a healthy pelvic floor? What does a healthy pelvic floor do? And then we can talk about some of the health issues that an unhealthy pelvic floor creates and some of the ways to ameliorate an unhealthy pelvic floor. Absolutely.

Starting point is 00:07:40 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.

Starting point is 00:08:32 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, 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,

Starting point is 00:09:06 or posture problems, things of that nature, that can affect your pelvic floor. And so this can lead to issues. Let's start with urination. you can have symptoms of urgency, frequency, meaning you have to go a lot to the bathroom or you have to go and have a sudden desire that you can't delay, sometimes even have leakage. In some cases, it can make it difficult to urinate because the pelvic floor is so tense. Or perhaps to incompletely vacate the bladder.

Starting point is 00:09:33 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 of. 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,

Starting point is 00:09:54 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, and it's really just pelvic floor dysfunction. With, with, GI function, you can definitely have constipation, and then often you can also have back pain. And so all of these things can happen when your pelvic floor is too tense. Sometimes your pelvic floor can be too weak. And that can be often because of, we see this in women a lot, because of childbirth, delivering children with some people who have neurologic disorders,

Starting point is 00:10:36 they can have weak pelvic floors or connective tissue disorders, like Ellers-Danloaf syndrome, for example. These sorts of things can cause weakness to the pelvic floor. which can then cause very often what I see is like urinary incontinence or leakage, which can then, you know, create problems for people down the line. Thank you for that. So first question, how does somebody know if their pelvic floor is too tight from a over-contraction or chronic contraction of the muscles there versus too weak? And one of the challenges in having this conversation is that if we were talking about

Starting point is 00:11:08 contraction of the calf muscle or the bicep, I think everyone intuitively knows because as 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 gonna be direct today, would this be like tensing up

Starting point is 00:11:32 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.

Starting point is 00:12:08 Like you hear about Kegel exercises, for example, and people talk. about how to do them, but that's all you ever hear about the pelvic floor. And so you don't really know how to kind of do things in a way that protects your pelvic floor or kind of what, how to even tell when it's too tight or not relaxing. And so that takes a sort of training. And so usually when people come to first, you get an examination to see if your pelvic floor is tight. So for women, it's a pelvic exam. And for men, it's usually a rectal exam. How does that exam go? So, you know, it's essentially palpating the muscles and also looking at the function. So we'll say for...

Starting point is 00:12:44 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 or not it's 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 years, 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,

Starting point is 00:13:30 what would a pelvic floor exam for a male and a pelvic floor exam for a female involve at a kind of granular level. Yeah. So for for women, you can feel the pelvic floor muscles through the vagina. So you can feel the ilio coxidius, the pubic oxygias, the levator, ani, those are all names of different muscles in this bowl. This is the physician who can feel them with their fingers. Correct. And you know, you could too, you could put your finger in, but you don't have a reference of normal, right? So you wouldn't know what a normal pelvic floor feels like versus a tight one versus a weak one. And so you can assess the tenseness based on, you know, palpation. You can also see if there's tenderness. And so you can assess that based on just a general physical

Starting point is 00:14:13 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? Because that's a function of normal use of the pelvic floor. And sometimes you'll see that they're discoordinated. You can also assess for sensation in the area and things like that. That could be consequences of dysfunction. Can there be dysfunction in laterality? Like the pelvic floor is pulling up 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

Starting point is 00:14:49 prolonged basis to help you normalize the function of your pelvic floor. It's like going to the gym with a trainer, right? They really work with you to get your pelvic floor functioning correctly. And the first step to that, a lot of pelvic floor therapists will just align your bones and and you're kind of the way you sit and walk to make sure that you're not straining those muscles by pulling 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 an opening. So how are they doing the pelvic floor exam?

Starting point is 00:15:28 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 as sensation. Okay, so perineal area, so from the outside of the body? Correct, correct. The region between the scrotum and the anus.

Starting point is 00:15:44 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 is not the sort of thing that they could into on their own necessarily. It would be difficult.

Starting point is 00:16:01 I mean, so there are, things you can buy online like probes that you can insert in the vagina that will teach you how to do kegel exercises and give you some read you know some readings but they're not really meant to diagnose they're usually something people use if they say have a weak pelvic floor and they want to try to do it at home on their own so there's nothing that's going to give you like a baseline reading is this normal or abnormal let's talk about keegals um first of all who's keeguil so he is a gynecologist I don't remember all the specifics to be quite honest,

Starting point is 00:16:34 but basically he came up with kegles, which are a strengthening exercise for the pelvic floor. And so what it is, what we describe it to for patients, is we say you're going to, there's a few different ways to describe it. You're going to use the muscles that you use when you urinate, but try to stop the flow. But you don't want to do that when you're urinating

Starting point is 00:16:51 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 it. The other way people describe it is pulling up and in in the, like the vagina. Or for men, sometimes you'll say it's like the feeling that you're trying to lift your penis off the floor without touching it. So those are kind of using.

Starting point is 00:17:12 That's a good way to describe it. Yeah. So those are kind of the ways that you can describe those muscles. And so you can squeeze for five seconds and relax for five seconds and do them in repetitions. And they're just like any sort of exercise you do. You don't want to start doing a hundred of them, right? You want to do them. I tell them people, I tell patients do them lying down.

Starting point is 00:17:31 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 in the morning.

Starting point is 00:17:47 10 to 15 repetitions. So yeah, let's talk sets and reps. 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 kegles, then you will get a tight, short pelvic floor muscles and you will then develop pelvic floor

Starting point is 00:18:10 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 kegles 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 Valcelva or coughing, sneezing, lifting heavy things, jumping on a trampoline. So for those purposes, we use kegles to strengthen the pelvic floor and also in women pelvic organ prolapse.

Starting point is 00:18:53 So when you have weakness of the pelvic floor that leads to a bulge that you can visibly see or feel in the vagina. For men, we often prescribe them for people who have had a prostatectomy, who then subsequently develop leakage after the prostatectomy that is, again, stress urinary incontinence. Now, a lot of people use keegels 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,

Starting point is 00:19:24 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 kegles. I was like, okay, I'll try it. Sounds all good, right? I only heard good things about kegels. And what it quickly resulted in was painful urination. And I thought, this is weird. Everyone's saying kegles are so great. And the best thing I could do for my pelvic floor, it seemed, was to avoid kegles. 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.

Starting point is 00:20:17 Strengthening your pelvic floor further, if you have a strong pelvic floor, can be detrimental. It can be. It can be if you overtrain it, just like if you overtrain anything else. And so you just have to, if you really want to do kegels, if you have any symptoms at all, like you described, painful urination or the things I've described, like pain with erections, pain with ejaculation, pain, difficulty emptying, any of those symptoms, stop and go see a urologist so that they can kind of assess your pelvic floor. What is the anti-kegle? In other words, if somebody decides that they have a tight pelvic floor, how can they learn to

Starting point is 00:20:56 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 Baclifin, which are muscle relaxants. And that can help as well, although they're not treatments. They're more of a band-aid, but they can help with the symptoms that you're having.

Starting point is 00:21:23 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. 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 to these yoga classes at one point in my life and they'd have everybody to do these crunches and I've always done some abdominal work

Starting point is 00:22:08 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 kegles. Yeah. So again, for me, ceasing the kegels was one of the best decisions I ever made. I only did them for a short while. I was like, okay, this is clearly not for me. And I guess that's another point that tell me if you agree or not, that if you hear about something online or on this podcast or anywhere else and you tried it, 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.

Starting point is 00:22:42 You know, I think all too often we hear this thing is great and people jump on that bandwagon and then they end up worsening their problems or developing problems where they didn't have them previously. But is there anything about the anatomy of the neuromuscular connections or vasculature of the pelvic floor that would provide support for my experience there. Yeah. That doing crunches with legs crossed is essentially, is it possible that's creating asymmetries in the pelvic floor?

Starting point is 00:23:07 And now I'm sure I'm angering yoga teachers and crunchinistas 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, you know, 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 intracts, 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

Starting point is 00:24:07 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, you know, nerves and arteries, particularly the pedendal nerve and the pedendal artery that run through the pelvic floor. So, we, 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.

Starting point is 00:24:44 I think our entire discussion today should be framed up, at least in the back of our minds, and the minds of our listeners and viewers, as involving at least three things. You know, anytime we're talking about erectile function or dysfunction or pelvic floor function or dysfunction or vaginal lubrication or lack thereof, we need to think about the hormonal influences, the blood flow related influences, and the neural influences, including the neural influences that come from the brain, the signals of arousal, for instance, or lack of arousal, and so on. So we won't be overly systematic in our parsing of all this, but I think what, what you just mentioned raises a really important point

Starting point is 00:25:26 that sometimes in an effort to do something that's good for the muscles, like strengthen the muscles, one will cut off blood flow. In fact, one of the more common questions I got, and I consulted with a couple of exercise physiologists about this, and they confirmed that a lot of people who squat and deadlift heavy in the gym, or even who just tense their pelvic floor

Starting point is 00:25:48 when they're doing things like dumbbell curls or other exercises, and especially people who seemed to do a lot of abdominal work, reported to me in the questions that they experienced things like erectile dysfunction, that they experience things like pain during vaginal intercourse, that essentially they had created some sort of, what sounds to me like a hyper contraction

Starting point is 00:26:13 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 will also talk about the role of testosterone on the female side, a lot of males lift weights in order to increase their testosterone

Starting point is 00:26:35 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.

Starting point is 00:27:00 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?

Starting point is 00:27:52 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, to, I guess here we also have to be precise, arousal to engage in intercourse, arousal to desire, essentially, that I think people learn to recognize. Or are we talking about arousal as the rest of, 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.

Starting point is 00:28:42 You're both male and female nipples get erect during arousal. I believe so. I think so. I believe so. You know, you maybe get the sex flush, right? You get some redness or warmth feeling. that's your body's response, right, to arousal. And sometimes that can be an erection. And sometimes that's not. Not having an erection does not mean you're not aroused. It may mean other things. But certainly that's part of it.

Starting point is 00:29:04 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.

Starting point is 00:29:31 And then arousal will come. And then, oh, yeah, you know, I like this. So then the desire comes after. And that's normal. That's totally fine. So you want to kind of parse that out. And then for men, you can ask, are you getting erections at night? Because that will tell us the function of your organ at night versus during the day

Starting point is 00:29:50 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 going to perform okay? Am I going to perform okay?

Starting point is 00:30:11 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?

Starting point is 00:30:35 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 us. Negatively. Negatively. Negatively. So that will point us to a more very very. vascular issue. Hormonal issues are very important for desire. And, you know, as far as sexual

Starting point is 00:30:55 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. Correct. As opposed to desire. Psychological arousal. Desire is predominantly modulated by the hormone testosterone for both men and women. In fact, if you, a lot of people don't know this, but women have more testosterone in their bodies and they actually have estrogen. So testosterone is very important for both men and women for a variety of reasons. And so 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

Starting point is 00:31:42 as well as the clitoris to see if there is good blood flow. You can assess the peak systolic velocity, which will tell you if 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 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.

Starting point is 00:32:21 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 your relationship and what's going on in, you know, your life, stress, anxiety, like, how are those playing a role? I'd like to take a quick break and acknowledge one of our sponsors, Athletic Greens.

Starting point is 00:32:54 Athletic Greens, now called AG1, is a vitamin mineral probiotic drink that covers all of your foundational nutritional needs. I've been taking Athletic Greens since 2012, so I'm delighted that they're sponsoring the podcast. The reason I started taking Athletic Greens and the reason I still take athletic greens once or usually twice a day is that it gets to me the probiotics that I need for gut health. Our gut is very important. It's populated by gut microbiota that communicate with the brain, the immune system,

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Starting point is 00:33:51 while you're on the road in the car, on the plane, et cetera. And they'll give you a year supply of vitamin D3K2. Again, that's athletic greens.com slash Huberman to get the five free travel packs and the year's supply of vitamin D3K2. Gosh, lots there to unpack. And I'm glad you mentioned the relationship itself because there are all sorts of things

Starting point is 00:34:11 that can impact the arousal response, novelty. not everyone's in a committed relationship, whether or not people are engaging in a lot of masturbation to the point of ejaculation or climax or not, pornography, et cetera. We will get into that. It's a vast space to explore. Before we go any further,

Starting point is 00:34:30 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.

Starting point is 00:35:06 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? 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

Starting point is 00:35:33 and 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 specialized in sexual medicine would be a good place to look. For gynecologists, again, you want to look at someone who has interest in this area, who, you know, does manage pelvic floor. And then in terms of pelvic floor, physical medicine rehabilitation, at least when I was in training,

Starting point is 00:36:03 there was about 20 PM&R 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 want to go to someone who's actually seen men because a lot of the pelvic floor physical therapist tend to treat a lot of women. And so that's kind of what I tell my patients, generally speaking.

Starting point is 00:36:33 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. 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. Because if you have a headache or you're having an eye issue, I mean, it's nowhere to go. Hopefully your headache doesn't warrant going to a neurologist,

Starting point is 00:36:58 but it might. You know, eye stuff tends to be ophthalmologist, optometrists, 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

Starting point is 00:37:39 of the vagina to have non-painful 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 homologues, 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.

Starting point is 00:38:07 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.

Starting point is 00:38:31 So when you talk about men, they're very, the one visual they see of arousal is erections. And so it becomes very ingrained in your psyche that if I don't have an erection, I'm not aroused, right? But there's a lot of reasons that you might not have an erection that we've sort of touched on, vascular problems, hormonal problems, neurologic problems, psychogenic issues, and other medications you're taking. So there are issues that can affect erectile function. And so that can be part of it, where, you know, you might feel like you have low desire because your arousal's 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.

Starting point is 00:39:17 Thank you for fleshing all of that out. You know, years ago I worked on sexual differentiation and in particular the role of hormones in sexual differentiation. And indeed, as you described, we learned because we were taught. And I think people still generally agree that if one looks at the embryological origins of the penis and the clitoris, they are essentially analogous structures. and that a lot of male genital development involves literally the regression, the disappearance of the female sexual genitalia

Starting point is 00:39:45 and associated organs, mularian 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.

Starting point is 00:40:13 You mentioned that only 3% of erectile dysfunction and by extension can we say also female issues with sexual arousal are hormonal in origin. Is that right? So with desire, yes. They are hormonal in general. And arousal in terms of lubrication, if you're using that as a barometer,

Starting point is 00:40:35 yes, you can see less vaginal lubrication due to hormones. And I guess I would say three to six percent, more up to six percent we see of erectile dysfunction is hormonal. It's a small percentage of the entirety of erectile dysfunction. Okay. So I think in looking on the landscape of social media podcasts, and just in the common mindset, we've all come to believe that testosterone is pro-libito. It's pro-desire in men and women.

Starting point is 00:41:03 I think now people are starting to appreciate that it's pro-discipline. and women as well, certainly in men, and that dopamine is also associated with desire. And the general public tends to have this view of estrogen as being sort of anti-libido or anti-male, which is frankly false. In fact, and I've covered this on the podcast with Dr. Kyle Gillette and with Dr. Peter Attia

Starting point is 00:41:23 and another fellow YouTuber, Derek from More Plates More Dates, has talked a lot about the fact that if people, if men, excuse me, take drugs like an Astrosol, to suppress their 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.

Starting point is 00:41:52 Estrogen is great for brain function. Estrogen is great for libido in men and women. Correct. And that is a revision of, I think, how most people think of the male sexual response. It's more in keeping with how people think about the female. sexual response. Oh, estrogen and the female sexual response. That 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 desire response. We will distinguish

Starting point is 00:42:19 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 an arousal response. So I'll tell you what I was taught

Starting point is 00:42:47 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

Starting point is 00:43:10 lubrication but that there are individuals out there for whom a lot of alertness maybe even and this is a controversial thing but for some people even some sense of aggression or kind of edginess or excitement adrenaline in other words can stimulate erection or vaginal lubrication so it gets tricky it's not like the textbooks it's not like they taught us in high school as far as I know I was taught that the arousal response in males and females is initiated by a parasympathetic sort of relaxed tone and that as sexual desire and arousal and sex or masturbation progresses, that it shifts more towards the sympathetic nervous system, which has nothing to do with emotional sympathy and has everything to do with arousal.

Starting point is 00:43:56 The catacolamines, dopamine, norepinephrine, and epinephrine, also called adrenaline and noradrenaline are released and that the cloboamines, and that the cloboamination, and that the cloboamination, and it's climax response, which may or may not include ejaculation, we have to separate that out, is one that is really of the stress system of the body. And then in the post-coital or post-jaculatory or post-climax phase, then there's a shift back to the parasympathetic nervous system. That's where the pillow talk and the exchange of odors and tastes and other molecules is known to enhance pair bonding through things like oxytocin, vasoporone.

Starting point is 00:44:33 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 one. And then, you know, you go on to the sympathetic nervous system. But it makes sense. And the reason that I think you're hearing about this aggression or these things that are leading to arousal is because there needs to be, a stimulus, right? A visual stimulus, a tactile stimulus, some sort of stimulus that you're getting that is then causing the release of nitric oxide from the parasympathic nervous system. And that could be for some people aggression or, you know, some form of that, right?

Starting point is 00:45:18 Do you tell people about nitric oxide? Because we'll get into this when we talk about drugs that increase blood flow, Seattle, Viagra, and also non-prescription drugs, things like El-citraline, 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

Starting point is 00:45:50 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, 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

Starting point is 00:46:17 was dominated by men? That's going to be the presumption. Or is it because it's easier to study somehow? Or I mean, what's going on here? Yeah, I think there's been a lot of, I mean, you can go back to like Freud, where he thought that the female sexual response was less valuable. And so there are some reasons. Less valuable. I guess I'm not, I don't,

Starting point is 00:46:38 that's the right term. Oh, no, no. I'm not challenging your term. I just meant, I just, you know, he was sort of dismissed. But it was more about the male sexual response than the female sexual response. And so in general, yes, there is, you know, there were more men in medicine. There was more, and it is easier to study, right? You can't study the clitoris quite as easy as you can study the male penis response because you can see it visually. You can inject it and see an erection response, right? We do this for people who have erectile dysfunction. They'll take medications that increase blood flow like trimix and you'll inject it into the penis and you'll see an erection. So you can actually... Trimix?

Starting point is 00:47:13 Try mix? So there's, it's... The entire male audience just went to wait. What do you injecting into the penis? So there are three basically brand names of intravenosal injections that we use for erectile dysfunction. I hear injection in penis and I think it's a, I like to think that it reflects a a natural male response. I sort of taken aback. I don't know. Maybe there's a pelvic floor contractions in there someplace.

Starting point is 00:47:38 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 see you're done. Like they don't even, you know, 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.

Starting point is 00:47:59 is the most effective non-surgical treatment we have for erectile dysfunction. And it's usually either one medication, two medications or three. So you can have, you know, Alprostodil, paparine, and the third one. That's a good. We can look at it. Someone will put it in the comments. Sure. Surely they will.

Starting point is 00:48:17 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, PDE-5 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.

Starting point is 00:48:35 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, causes the erection, and it's degraded by phosphodiorase. And so medications that inhibit phosphodiasterase, like Viagra and Cialis, tend to prevent the breakdown of that CGMP so you have longer lasting erections.

Starting point is 00:49:07 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 L-Citraline? I hear about L-Sitraline 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 Viagra but is perhaps not as potent.

Starting point is 00:49:33 I also just cautionary note out there, L. Citrolean can give people vicious cold sores and canker sores. Vicious. You hear about this on the internet. It's been verified by grotesque images that you do not want to Google for. And not everyone tolerates it well. So these actually work by increasing nitric oxide. So they're not later down the pathway. increasingly availability of nitric oxide. So L-Arginine is the more direct pathway, but it's very low bioavailability. L-citraline converts to L-Arginine,

Starting point is 00:50:04 but it lasts much longer in the bloodstream, which is why people tend to use L-citrylene. Now, you know, in sexual medicine, these supplements, while there's been some studies on them and they are effective, there's no regulation on the supplement industry. So, you know, we can recommend them, but we just can't say that for sure

Starting point is 00:50:22 that the supplement is exactly what's said on the bottle. We see lots of studies where they'll say, you know, I read one about melatonin and there's, you know, a variation of melatonin from like what's on the bottle to 400% times more. And so that's kind of the struggle that we as medical doctors have. And I know we get a lot of slack for it that we don't talk about supplements, but it's really the challenge there is like finding the quality supplement. A great site is, which I have no relationship to, except that I mention them all the time, is examine.com, which has, right, references to human studies

Starting point is 00:50:57 and where there's a lot of efficacy shown and we'll get into some side effect issues. It can't address quality by brand issues, but thanks for mentioning that. What percentage of males who take Cialis, aka to Delafil or Viagra for erectile dysfunction get relief from that? Because you mentioned only 3% of erectile issues

Starting point is 00:51:21 in males are hormonal in origin. but what percentage are likely to be blood flow related in origin? So a large percentage are blood flow related. That doesn't mean that the medication will be effective for everyone. If you look at the large percentage are vascular in nature, right? That's the number one cause 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.

Starting point is 00:51:51 So 50% of 50 year old, 60% of 60 year old, and so on. 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 penetrative 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,

Starting point is 00:52:27 your brain is still active. 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.

Starting point is 00:52:43 And 60 to 70% is not a small number. That's a significant number. That's the majority, but by a significant margin. Is there a basis for the use of Cialis to Dala, Villagra, El Citroline, and females. So, yeah, there's not a lot of data on this, but certainly, you know, if you have surmise that there is a blood flow issue and they're having difficulties with orgasm, it's certainly something you can try off label.

Starting point is 00:53:11 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-Tadalafil. So rather than what I found online was that the erectile dysfunction treatment dosage of Cialis to Dadaul is somewhere in the 15 to 20 milligram range, what we're talking about

Starting point is 00:53:51 here is daily use of 2.5 to 5 milligrams of Cialis to Dadaillifil for prostate health. And I learned in researching for this episode that Tadalophyll 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, that if you dive into the guts of the internet, one can find that now there's a growing use of combined low-dosegialis and apomorphine,

Starting point is 00:54:32 which is a pro-dopominergic agent. And we'll get back to dopamine a little bit later. But is there any basis for low dosage, say 2.5 to 5 milligram daily use of Cialis to Dallophil in females? Yes, so let's talk about it for males and females. I think low-dose daily Cialis is excellent. for erectile function in men.

Starting point is 00:54:54 Is that true even, sorry to interrupt, but is that true even for men that are not experiencing erectile dysfunction? It's not indicated for that purpose. But there's a thought that, you know, it's increasing blood flow to the area. So people, I've personally used it for men who have pelvic pain to help with increasing blood flow.

Starting point is 00:55:11 You can also use it potentially as a preventative. So some people have, you know, kind of thought, okay, it's increasing blood flow. It's preventing fibrosis of that erectile tissue that can happen with age or other vascular problems, so it may be beneficial for that as well. Although, again, that's off-label and not something that we generally promote. As far as for women, there's, you know, again, it can help with blood flow.

Starting point is 00:55:34 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. We usually want to give at least a four-week trial to see if there's any bad. benefit with those medications. Great, thank you for that. Why is it that I get so many questions

Starting point is 00:55:58 about erectile dysfunction from males who were in their 20s and 30s? Because everything you said up until now was mainly focused on men 40 years and older. Is it from lack of physical activity overuse of nicotine? By the way, vaping, as far as we know, vaping and smoking bad for erectile function and perhaps sexual health in males and females generally,

Starting point is 00:56:20 because nicotine is a vasoconstrictor. Nicotine does have certain benefits, and I covered this in an episode on nicotine, neurocognitive benefits in the elderly in particular, but it is a vasoconstrictor, so it runs against all of the sexual arousal stuff that we're talking about. But okay, let's assume that male in their 20s or 30s

Starting point is 00:56:41 is sleeping enough, you know, six, eight hours a night is exercising, isn't doing anything to punish their pelvic floor in the gym, You know, they're not doing legs cross kegels while doing crunches or something while inhaling on the crunch. That was a quiz, by the way, folks, for earlier topics covered. Let's assume they're, you know, eating pretty well. The majority of their foods are coming from non-processed or minimally processed foods. They're doing a little meditation each day.

Starting point is 00:57:14 They're engaging in hopefully healthy relationships. They're not masturbating like crazy to porn. And, you know, let's assume that they are, you know, not on any SSRI. Why are all these 20-30-year-olds on the Internet asking mainly you? They mainly 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,

Starting point is 00:57:48 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, like just sitting at their home computer. And so, you know, exercising one hour is not going to offset the day full of sitting. And so all of those things can affect pelvic floor function. So my theory is that that's probably the more common cause. So walk more.

Starting point is 00:58:16 Yeah. I've actually heard back. The standing desk. Yeah. Yep. Walkmore, standing desk. Okay. So, and then my guess is that there's some psychogenic feedback loop,

Starting point is 00:58:27 which is just nerd speak for things aren't working as well as they would like. Then they're stressing about it and the stress is making things worse. Absolutely. And, you know, you mentioned that people are not masturbating or using porn, but a lot of people learn about sex through porn. Whether it's good or bad, we can't, you know, it's not a great thing. But like, that's accessible now. When we were growing up, you had to find a VCR, you had to find a quiet room that no one was going to walk in.

Starting point is 00:58:52 I'm old enough to remember when the kid down the street, I won't mention him by last name. But yeah, the kid down the street had porno magazines. Yeah, or magazines. And then there was actually a library of these. Goodness, I shouldn't say where they were in the town I grew up in where kids would stash them in 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, excuse 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.

Starting point is 00:59:42 And there's a growing theory out there that overuse, that meaning, not just looking at, but masturbating to pornography to the point of ejaculation is creating a deficit of seeking out and cultivating healthy, real-world sexual interactions. Yeah, so I want to start this before I get into that is to say that if you're masturbating to porn and you have normal, healthy relationships, and you're going to work and you have a great, you know, a partner and everything's great in your life. It's okay. Like, shame is a real problem.

Starting point is 01:00:19 And maybe they're watching pornography together. Yeah. So I think, you know, I think it's important, though, that at least in the literature, they describe, they don't describe porn addiction. They call it problematic pornography use. And it's only describing about 4% of people in these studies. So it's a small subset of people. I think it's becoming more common because.

Starting point is 01:00:38 pornography is so accessible. And it activates a dopamine pathway, just like any other sort of addiction, right? You watch pornography, you get a dopamine response. Your brain then says, oh, I want that again. And you keep seeking more novel, more aggressive, different types of pornography to get that same response. But it doesn't happen to everybody. But also I would say, sorry to interrupt, but that the dopamine response as a hardwired biological mechanism, for adaptive behaviors, including, and let's just define healthy sexual behavior, because I feel like there's such a range on that, depending on one's background, religious beliefs, et cetera. Anytime we talk about sex on this podcast, I like to say that

Starting point is 01:01:22 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, ejaculate to pornography and have a normal life. And so that's fine. I think that, you know, if we shame those people, we're creating problems, right? We say like, oh, you do that, that's horrible.

Starting point is 01:01:54 And then they're in their head, right? And then they're causing problems in their life because they're, because of shame. And so there's, I think there's a little bit of cultural shame that comes of this discussion. And so, you know, it's a problem. in the long term if we say that, oh, this is going to create problems because not everyone has. There's so many people who watch pornography and have no problems, who, you know, have normal, healthy relationships, great sex with their partner, and it's fine. Or they're between relationships.

Starting point is 01:02:20 Yeah. And they're relying on masturbation specifically. Right. Are there any data that distinguish between just pure imagination fantasy versus visual fantasy as it relates to developing or inhibiting sexual health? And here we're talking about the desire aspect. Let's assume physical arousal is, you know, handled. So I think that the thing about young people, I wanted to get back to that,

Starting point is 01:02:49 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, is how long it should take. This is what foreplay 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 then go to relationships and like,

Starting point is 01:03:21 why did my partner not react like that woman did on the porno, right? Or why did I not react like that woman did on the porno? Why didn't he react? Yeah. When, you know, like they would in because, again, I think females are watching porn as well. Exactly. Yeah. So I think that you raise a really critical point, which is that the shame can extend both ways. And so I think to that end, that's a problem. And because it's so accessible, I think we need to have conversations. I think it needs to be open. We have to talk about sex. And that's 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

Starting point is 01:04:03 We talked about place earlier because I do think those are universal healthy constraints, right? Consensual, age appropriate, context appropriate, species appropriate. Absolutely. I asked whether or not imagined, pure imagination-based arousal versus visual arousal. And for some people, the sounds of people having sex is extremely arousing. If you ever lived in a major city like New York, which I spent summers in New York, you hear a lot. You hear more often than you do in areas where people are living further.

Starting point is 01:04:36 You hear people having sex. Yeah. It's part of the auditory landscape. Yep. You're very close together. So, 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.

Starting point is 01:04:55 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 vibratory stimulation or certain pressure sensation every single time you masturbate, you can get habituated to that and you may not be able to replicate that during penetrative intercourse. And so I think that's really important. And I think the take home is to try and vary what you're doing. doing. Masturbation is find healthy way of self-exploration. Again, with the caveat that as long as

Starting point is 01:05:36 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 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 I've talked about when I was a guest on other podcasts, mainly in the context of male masturbation and perhaps with pornography, perhaps not, is that it's pretty clear based on the data surrounding addiction that anytime there are big increases in dopamine without a lot of effort required to generate that dopamine, like turning on pornography on the internet versus, you know, asking someone out on a date,

Starting point is 01:06:28 going out on a date. You know, again, we're talking about going through the conversations and the mating ritual that is the human mating ritual that, of course, in the context of healthy interactions involves getting mutual consent and these kinds of things, right? That you could imagine how, without placing any moral judgment on it, without shaming anybody,

Starting point is 01:06:48 you could imagine that if somebody exclusively masturbated and didn't develop the skills of courtship and building healthy sexual rights, 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

Starting point is 01:07:28 for somebody, right? Like there's, there's many. That's a form of finding. I mean, I was weaned in the era when, you know, no smartphones or anything. And no, my point is I think that we've become very connected to technology in our world, which also means that we're having less conversations. The younger generation is having less conversations and more online conversations. And I think that's a skill that needs to be developed as well. And I think part of that is, 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, in my case, guys. My sister probably learned a lot about sex from

Starting point is 01:08:09 her female friends. And there was always that one guy who would just say stuff that years later I realized was incredibly misleading, right? Maybe even just detrimental. And I just want to remind people that when you are on Reddit or anywhere on the internet and there's people saying things with certainty, they might be that guy. Yeah, right? And if you look at the, if I look at the long arc of those people's, that guy's life, it didn't speak to tremendous success in the domain for which they were asserting such confidence. Let me put it that way. Okay, I'd like to slightly pivot to a different aspect of this conversation because it's just really critical, which is the female sexual response. You know, this is something that does not get

Starting point is 01:09:02 enough discussion. Absolutely. And there's a lot of stereotypes, right? The stereotype that we hear about is, oh, you know, they need more foreplay, which can be true. Some cases is not true. 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. Yep. Or maybe all the time. I like to think that we are past the stage of human development where the stereotypes around this are fixed, right?

Starting point is 01:09:47 And we hear more about this and we see more about this now. but what is the real deal around the female arousal response? And then we will talk about female orgasm response. And there I'm just going to earmark now that anytime we say something like arousal or orgasm, there are multiple forms of that. And we will talk about the multiple forms of female orgasm. Yeah. So if you talk about the response cycle, you can go back to the research of Masters and Johnson.

Starting point is 01:10:19 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 back. 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.

Starting point is 01:10:36 And so the first phase is excitement, right? And during that phase, your heart rate goes up, you're breathing a little heavier. There's the sex flush. You can see redness in areas like, you know, in the vulva, in the breast. I mean, in the nipples. And then you go to sort, and that can last a variety of different times.

Starting point is 01:10:54 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 pelvic floor. contraction along with the sensation of orgasm.

Starting point is 01:11:23 And then you'll have your recovery period, which you talked about briefly earlier, which can have, you know, sort of a refractory time period at which point you can no longer, you know, orgasm again, if you'd like to, or for men to obtain another erection again for a short period of time. And that can be kind of an absolute refractory period, so where it's definitely not happening, and then a relative refractory period where you'd need something more novel and exciting to then again resume that cycle again. I've talked about the coolage effect before on this podcast.

Starting point is 01:11:52 I'll just cue people to a timestamp link in the show note caption 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

Starting point is 01:12:25 period and they can have another erection and ejaculation. Similarly, a female will have a post-orgasmic refractory period. If they're given an adequate stimulus, right, something arousing enough, they can experience arousal and orgasm again. And we know, based on really good pharmacology, that this is a dopamine-driven thing, the prolactin is essentially establishing the refractory period and the dopamine is essentially overriding the refractory period. Fascinating neurochemistry there and speaks to the incredible extent to which the brain is controlling the genitals. Yeah, I mean, we always say in sexual medicine that the brain is the most powerful organ for sex, not 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.

Starting point is 01:13:15 there are some centrally acting medications now available for their FDA approved 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-stit-stimulating hormone in men, which gives people a tan, makes them erect. Melanacite stimulating hormone at MSH comes from the medial pituitary, if I'm not mistaken, one of those weird regions. Everyone talks about anterior or posterior.

Starting point is 01:13:46 And people are now injecting this as a peptide. It can cause Priapism. 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. Priapism being enduring and perhaps even final erection. Is that true?

Starting point is 01:14:05 So a Priapism, preepism, I mean, it's actually from Priapis, the Greek god who is often photographed. with a really big erection. Oh, wow. And we didn't hear enough about that Greek god in school. But is it Roman? Roman or Greek. But anyway, so it's an erection that lasts longer than four hours.

Starting point is 01:14:23 And it is actually a surgical, or it's not a surgical, but it's actually an emergency. If you have an erection that lasts longer than four hours in the absence of, you know, sexual arousal, then it is important to get to an emergency room because at that point, you can start developing decreased blood flow and 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 Cialis slash todala phil or Viagra for erections are getting true priapism.

Starting point is 01:15:01 Correct. And it's mostly from those injectables we talked about earlier, those intercavenosal injections. People can get priapism from those a little bit more commonly. And so that's something we always counsel on. And also certain medications like trazodone or if you have sickle cell anemia, those are the most common reasons that we see people coming in with practices. Trasadone, 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 Brimelanatide is the brand name. Vileisi is the, sorry, Brimelanatine is a generic name, Vileisi is the brand name, which is FDA approved for women with low, hypoactive sexual

Starting point is 01:15:46 desire disorder, premenopausal women, premenopausal, because that's what they studied. But it is basically the same peptide, right? So it is a melanocortin receptor agonist, and it works dope, you know, on the brain pathways to increase desire. It's taken as an injectable, again, just like you said, about an hour, 45 minutes before when you want to want, you take it 40. 45 minutes before and it works quite effectively in increasing desire. How long does it last?

Starting point is 01:16:14 About 24 hours, some people may be up to 48. Has it been, I mean, I know men using melanoste 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, Lippi polysacetopolys which is not something you want to be injecting a lot over time. That's actually how we induce an immune response in animals in the laboratory.

Starting point is 01:16:46 And it is amazing to me how many websites are selling this stuff and it 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 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.

Starting point is 01:17:07 Exactly. And because we have brimelanatide, 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, you know, this is available for premenopausal women. The other medication that's available for low libido is called flabanserin, also known as Adi is the brand name. And that also works on serotonin. It's got kind of a mixed response serotonin and dopaminergic areas of the brain. and essentially works as a daily medication taken before bedtime, 100 milligrams a day, that actually helps with decreasing hypoactive sexual desire disorder. Works in about 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 a little bit costly, and sometimes insurance doesn't cover them, but they are available. I think very few people know about them, and I think they're really great and useful tools in the toolbox. And these are for desire?

Starting point is 01:18:06 Therefore, 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, arousal, and female orgasm, but as long as we're talking about arousal and reduced arousal that requires treatment, I have to ask this now. Anytime we talk about arousal and libido, there's no BMI, which is, by the way, the body mass index is probably not the best tool either, but there's no chart.

Starting point is 01:18:43 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 partners desire, whether or not they can meet those desires. And if they sort of accrue enough of a sample size,

Starting point is 01:19:20 they date enough people where they have sexual interactions, they can, they figure out over time whether or not they have a low, medium, or high sex drive. And people tend to compare to how they felt in earlier years or at different times of the year or under different psychological conditions and stress conditions, that kind of thing. But we really don't have a benchmark for this, right? I mean, we can't say that, for instance, that if 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 a reasonable 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.

Starting point is 01:20:01 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

Starting point is 01:20:43 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 your end Yeah, later we'll talk a little bit more about chemistry, which I find infinitely fascinating because in my life experience, I've just been struck by the fact that occasionally you have a physical interaction with someone or sometimes it's not even physical interaction and they are just so unbelievably arousing to you or somewhere in between or sometimes it just sort of ain't there or it's just not there that much or nobody likes to talk about

Starting point is 01:21:24 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? Right, right.

Starting point is 01:21:46 So, you know, again, the discussion around libido, as you so aptly pointed out, engaging what is healthy levels of libido, has a lot to do with what one's self-desires as well as the hopes and expectations of the people that we are sexually involved with. So we'll get back to that a little bit later in the context of chemistry

Starting point is 01:22:03 because I find it's so fascinating and it's something that isn't talked about enough. But thank you for that. Let's get back to female sexual arousal response and orgasm. So physiologically, what happens to the body is it prepares for penetration. Now, that could be a penis, that could be a sex toy, that could be a digit finger to be more specific.

Starting point is 01:22:25 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 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 the penis is penetrating before they've had those adaptations to a occur and also the labia open up to allow for that penetration.

Starting point is 01:22:59 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, foreplay, 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.

Starting point is 01:23:24 And certainly that changes with age and hormones. So 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, they're not aroused necessarily. This is like a physiologic problem that they're having.

Starting point is 01:23:50 Can we distinguish between arousal-based lubrication? Let's say sexual arousal-based lubrication. And again, folks, forgive me for being so hyper-specific in language. But there are other forms of arousal besides sexual arousal that we know from, it's not a pleasant topic, from reports following sexual assault that, you know, oftentimes the victim is demonized for having been lubricated. And they will say, well, then people will presume that somehow they wanted that interaction. And that's not true in those cases. It's clear that the lubrication occurred independent of libido type arousal. Exactly.

Starting point is 01:24:29 Okay. So let's set that aside, again, unpleasant topic, but one that's important to flag. Are there forms of non-libido type arousal lubrication that allow for non-painful or even pleasurable penetration that? are important to distinguish from the arousal-based lubrication. In other words, I have to imagine that women will have sex and it can be pleasurable or at least not painful and that might relate in some way

Starting point is 01:25:07 to baseline levels of lubrication. And here we've been talking about lubrication, mainly in the context of arousal. You know, postmenopausal reductions in lubrication, but are there also postmenopausal reductions in baseline lubrication? Are some people's vagina is just more lubricated, at, I want to say at rest, it's like a scientist in me.

Starting point is 01:25:26 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 clitoral engorgement, right? They're getting clitorial engorgement. There's been some studies on that that they are also getting nocturnal tumens, right, just like men do.

Starting point is 01:25:42 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 women, 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.

Starting point is 01:26:20 And it's menstrual cycle dependent in terms of the viscosity and the... Yes, it changes over the cycle and it can be different in color and different in thickness. And that's completely normal. And I think that's a real problem in the feminine hygiene industry. You don't need to smell a certain way or reduce that discharge. This is like completely normal, healthy. And you talked about chemistry. And I know there's like not a ton of data on this, but there's like pheromones, right?

Starting point is 01:26:47 There are scents that are coming from you, which are. are actually attractive to a partner potentially. And in whatever physiologic, you know, I don't know there's not a lot of time of data 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?

Starting point is 01:27:07 There's a lot of marketing. Maybe this is generational thing, but I learned early on, I think by behavioral neuroscience courses, that vaginal lubrications were part of the arousal response for both, these were always framed in the context of heterosexual relationships, but both partners, let's just say both partners, because this could be a homosexual female relationship too, right?

Starting point is 01:27:29 We want to 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,

Starting point is 01:27:54 remembering somebody's smell, or thinking about somebody's smell, and that itself can be very arousing. Yes. Partners even, I'm smelling different articles of each other's clothing and that being arousing.

Starting point is 01:28:04 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's damaging, right?

Starting point is 01:28:18 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 so they're buying these, spending their money on these things because they're being told that they're not clean. And they come to the doctor saying, oh, I'm, you know, I think I have an STD, but it's like normal physiologic discharge.

Starting point is 01:28:40 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, you know, of course, if you have like a fish, odor that may be a sign of like a very strong new novel odor that wasn't there before. That may be a sign of a sexually transmitted infection. But if it's your general odor that you've always had, that's normal. What about other infections like yeast infections or bacterial infections? I got a number of questions about mycoplasma infections, which we don't hear that

Starting point is 01:29:09 often about. 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. Mycoplasma is another infection that we see in the vagina, but we also actually sometimes see in the urine. And while it's not something we routinely test for, when we have people who have symptoms of urinary tract infection and they're not improving, sometimes we will check for mycoplasma

Starting point is 01:29:41 that could be causing symptoms in the urethra itself. We've had a couple episodes about the gut microbiome. My colleague Justin Sondonberg at Stanford, whose laboratory is directly above from I, as expert in the gut microbiome, done a couple episodes about this. And he reminded me, and I like to remind people, that every mucosal lining of your body has a robust microbiome. So that means intranasal, intramadrenal, intraurethral in males and females. There's an anal microbiome.

Starting point is 01:30:10 There's a microbiome on your skin, on your eyes. And you mentioned douching and other, in other words, 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 oven. You don't have to do anything. You just watch. The vagina is a self-cleaning oven. I'm not going to I'm not going to repeat that too often in too many different contexts, but I'm going to remember it forever.

Starting point is 01:30:49 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 soapy water run down. You don't need to do anything. Your body will take care of it itself. When I was five years old, I pulled my parents in the bathroom and I said, they still talk about this. I said, I want to know everything about sex. I want to know everything. And they were like, oh, my God, what are we dealing with? And I'll never forget. My dad just looked at me. He's Argentina. 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 was it. Oh, gosh. Yeah.

Starting point is 01:31:23 Well, I will tell you my discussions with my sons are my son, my older son has been much more graphic than that. I tell him. Amazing. Yeah. Amazing. Well, I went out into the world. And anyway. You figured it out.

Starting point is 01:31:34 Okay. Let's spend a few minutes or more talking about female orgasm. One of the more cryptic topics on the internet, not because it, isn't discussed, but because I think that the nuance of it isn't discussed often enough or in full depth. So let's take the time we need to parse this. I think that the simplest way to parse it is going to be from the anatomical standpoint, clitoral orgasm versus so-called G-spot or penetration-based orgasm. But of course, penetration-based orgasm is also a bit of a misnomer because there can be clitoral stimulation by pelvic pressure

Starting point is 01:32:15 or by digit. We're talking 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? Vibrator toy, whatever. I'm toe for, it depends on how flexible you are. I don't know. But the point being that I think the simplest way

Starting point is 01:32:30 to go about this is going to be to talk about the distinction between clitoral orgasm and cheese 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 one level, then a higher level than a lower level,

Starting point is 01:32:55 where all are none, right? How shall I say this? It is clear in my life experience and observation that there are multiple kinds of female orgasm, those that are graded and in some cases cumulative, they sort of build towards a larger and larger orgasm. And then there are what some people have described as cliff type orgasms where there's a refractory period. I think that's a fair way to frame this.

Starting point is 01:33:20 And clearly there are different responses to the orgasm response. Some people get sleepy. Some people get energized. Some people, it heightens their desire for more. Some people, they need a period of time in which they become hypersensitive to touch. So lots of different things. going on there, psychologically, physiologically. Yeah, tell us all of it.

Starting point is 01:33:45 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, female sexual dysfunction data is not super robust, but what we find is that about

Starting point is 01:34:09 85% of women require clitoral stimulation in order to climax. So very few actually climax through just vaginal penetration alone. And so this is, you know, a real problem we're seeing on the media that, you know, you have sex and you penetrate and immediately women are having orgasms. That's not the reality for a lot of women. And in terms of stimulation, so like we've talked about throughout this podcast, the clitoris is the homolog of the penis or the penis is the homologous. malagalactylotid clitoris, however you want to say it.

Starting point is 01:34:41 Good on you for getting it both directions. I probably would have screwed that one up. So clitoral stimulation is just like female 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 in heterosexual relationships,

Starting point is 01:35:04 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 way of understanding the anatomy of self. So there's a huge gap. And physiology and psychology.

Starting point is 01:35:31 Yes, that too, that too. But, you know, there's a huge gap there. And so I think to bring it home is the clitoral stimulation is the most reliable way. And as you mentioned, when you're stimulating vaginally, you're often, the clitoris is like a wishbone, and it goes around the vagina. And so you're often stimulating those, the crura is what we call the legs, I guess, for lack of a better term, of the clitoris. And so you're stimulating that.

Starting point is 01:35:54 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, the anterior wall of the vagina about two to three centimeters in, that's the location of these periorethrogris glands called the Skeen's glands. And they are analogous or homologous to the male prostate. So just like some men have prostate play and enjoy pleasure from prostate stimulation, some women enjoy G-spot stimulation. Now, that's not universal, right? Not all men enjoy prostate play and not all women are going to be aroused by G-spot stimulation. And so I think there's a huge, huge variety of ways you can stimulate anyone. It can be man or woman. Some people will have

Starting point is 01:36:42 orgasms through 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 that the big take home from this for people listening is like you have to talk to your partner. And this is the hardest thing. We never learned how to talk about sex. Like what do you like? What do you not like? And don't take it personally, right? Like, I think a lot of times people feel like you have to orgasm to have pleasure, which may not be the case for everybody. And if it is, you know, how do you prioritize that for your relationship?

Starting point is 01:37:16 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 of the vagina is in 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 orgasms specifically the stimulation and the foci of an orgasm that starts in the back of the vagina?

Starting point is 01:37:53 Is that? Yeah, so it's from stimulation of the cervix through whatever means, right? And that can be pleasurable and lead to orgasm. And again, orgasm, you know, is 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?

Starting point is 01:38:17 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 in males and presumably clitoral tumessence and 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 ask this is that eventually in this conversation,

Starting point is 01:39:00 we're going to migrate up toward the brain. But because this is a science and health podcast, when we talk about orgasm, of course, many people recognize that as their experience of it and their recognition of it in other people and descriptions, et cetera. But are we talking about a response that originates at a foci? Kind of like in the brain we talk about a seizure, you know, starting at a focus, a foci and then spreading out.

Starting point is 01:39:27 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. Yeah. 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 neurily? I mean, it does have certain parallels to seizure, right?

Starting point is 01:39:52 It does. It does. So let me go back to your first part of the question, which was about, orgasm and, sorry, erection and tumessence being related to levator ani. So actually what happens during, the reason you get an erection and presumably clitor 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

Starting point is 01:40:27 leaving. So it's not a muscular event. It's an actual blood flow event. Then how come when we wanted to study erection behavior in rodents? We would give them injections of testosterone, females or males, and observe changes in sexual behavior accordingly, erection and clitoral tumessence, although it's harder to measure in rodents. There's a way of indirectly measuring that. And then we would measure the size and weight of the levitor-any muscles as a readout of how androgenized that whole system was. In other words, what is the role of the levatory ani in the sexual response? So the levator-an-I, or I say livid or a... Well, you would know. So those muscles are part of the pelvic floor, right? And so those contract when you climax, right? So whether it's orgasm for

Starting point is 01:41:18 male or female, they're contracting and they're exercising, right? So that's how they would increase. 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 it's the way your body responds to that particular stimuli. And it's actually

Starting point is 01:42:02 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 were very present in that moment. And so people will feel different stimulations depending on, you know, how they're, how they kind of how their sensors, you know, their nerves are, their sensations are and things like that. It's perhaps a good time to mention dopamine. We've 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.

Starting point is 01:42:48 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 wellbutrin, brupyron, which increases dopamine and norapinephrine, people who recreationally use drugs like cocaine or other stimulants, people who take Adderall,

Starting point is 01:43:18 Vivance 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 arousal, but not being able to achieve the physical arousal, erection or vaginal lubrication. So it's almost as if they're sitting further along that arousal art. Hence the importance, I think, of people learning to have calm states of mind when going into sexual interactions. Now, I realize that in saying that, it might be confusing because a lot of people think, well, that's anything but calm, right? Sexual arousal is anything but calm,

Starting point is 01:44:04 but maintaining enough calm that they can ride that arc for whatever duration is appropriate for that interaction in them, right? Because again, and we should probably get back to this, you know, you know, some people will have sex for long periods of time, some for shorter periods of time, and here 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

Starting point is 01:44:32 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, drug with todalophil, which is a PD-5 inhibitor, so it's going to increase blood flow.

Starting point is 01:44:52 And I'm hearing about men and women, but mainly men doing this. So ramping up their dopamine, ramping up their blood flow to their genitals in order to have presumably more arousal in sex. Does that make sense 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.

Starting point is 01:45:19 But, you know, it's a very complex response. So like I mentioned that phlebancerin, which is a centrally acting medication, it actually has not only inhibitory and not only stimulatory, but also inhibitory effects on dopamine. So the way it sort of works to enhance interest or libido is sort of complex and kind of confusing. When it was actually approved, it was being studied for an antidepressant. And what they found was that women were actually having better interest in sex or more interest in sex. And so that's kind of how it was discovered.

Starting point is 01:45:51 Similarly, Viagra was actually studied for high blood pressure. And when they went to, it was horrible blood pressure medication, but then 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 Viagra. I think it was an intravenosal injection though. I think he came out. It is a true story. There's actually a published

Starting point is 01:46:30 article. I'll send it to you so you can share it if you'd like. I'm not sure I want to see it, 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, like, it was mostly men in urology, but there were like, spouses, I guess, in the audience, which is not typical now, but so there were women in the audience and he came out with a full on erection to show that it, you know, it worked. Well, I suppose at the urology meeting or OBGYN meeting where a woman comes out and reveals her enhanced vaginal lubrication, then we will have, we will have gender and sex balance at the meetings on urology.

Starting point is 01:47:05 It'll 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.

Starting point is 01:47:34 Clearly, there can be psychological variation, according to those hormones, or probably other things across the menstrual cycle. And it's always an imperfect experiment because, you know, we aren't laboratory rats and people are having different interactions across the menstrual cycle. Is there any known correlation between desire

Starting point is 01:47:53 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,

Starting point is 01:48:07 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, the data that I've heard and maybe a gynecologist could speak more on this because they study those variations a little better, but there is data to suggest that libido does increase prior to ovulation and during ovulation. I think it's 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.

Starting point is 01:48:40 Is there evidence that females who perhaps have not experienced so-called G-spot orgasm or cervical orgasm can learn to do that? And I always find it interesting that whenever there's a discussion about different forms of female orgasm, people are careful to point out that many women don't have penetration-based orgasm, and then they separate out clitoral stimulation as a more common route to orgasm. But of course, there can be clitoral stimulation with penetration. Absolutely. Right. And depending on the physical arrangement, there can be clitoral stimulation purely

Starting point is 01:49:17 by way of penetration through pelvic contact, you know, fingers, et cetera. So, yeah, so how do we, how should we think about this? How should we talk about it? So there was an interesting study that I just read recently where they gave women words for these things, right? So there's like the rocking stimulation. So that can also stimulate. So meaning that 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 innovated.

Starting point is 01:49:53 So that can be more stimulating. There's also ways to align yourself so that when you're, you're penetrating, you're putting pressure on the clitoris. And then there's, you know, stimulation with, like, actual stimulation of the clitoris, like intentional stimulation either by yourself or by the partner. And so there are multiple different ways to do that, right? And so there, I think that it's important to really kind of, it's okay to explore and not always be a home run.

Starting point is 01:50:17 And I think that's like when you get into a relationship where you're maybe second, third, fourth time having intercourse with someone that you can try and explore these different things, or if the partner themselves knows, what they like to actually tell the other partner, right? There's a huge part of communication that I think plays a huge role in this because we know ourselves better than anyone else. So you can tell your partner what you like.

Starting point is 01:50:38 And I think that we have never been taught how to do that. Yeah, such important conversations for so many reasons. And as you point out, definitely not something they teach people in school except they might say something about communication is important. And that almost always circles back to the key four things we talked about earlier. which is consent and age appropriate,

Starting point is 01:51:00 context appropriate, these kinds of things. And obviously substances like alcohol and other drugs can strongly confound those issues. And so we'll just leave that as a kind of an obvious one. As long as we're talking about communication on sexual interactions, perhaps it would be useful to people to cultivate a language or a nomenclature there too

Starting point is 01:51:25 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. Yeah. So is there any kind of structure that's been put out there as a way to improve

Starting point is 01:51:58 communication around sexual interactions? Yeah, I mean, there's no like script, but I think in general you want to have the conversation outside of the bedroom. So not like right before sex or right after sex because that leads to like a, you know, a sense of insecurity for the other person, right? Did I do something wrong? Did something go wrong here? So you want to kind of move those to a neutral location. So like kitchen table in the car, whatever, somewhere where, you know, sex is not going to happen, at least for that particular moment. And we have for folks listening, we've been some challenging conversations on this podcast, challenging, previously challenging because, you know, you're trying to get things clear and as clear as possible.

Starting point is 01:52:38 This one is challenging because there's so many caveats to everything, right? We don't, of course, be a lot of sex in cars, right? Or they did when I was growing up. And, sometimes they still do. Okay, please continue. Yes. So that's one. And then two, like when you're discussing it, I mean, this is kind of goes for any difficult conversation is like you make 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, you know, I think also part of it is like being open about those things. And it may, it's not going to happen in one conversation. I think that's the hard part.

Starting point is 01:53:15 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 aasec-t-a-sect-a-Sect.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.

Starting point is 01:53:45 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

Starting point is 01:54:11 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 those conversations are challenging. And it also is understanding why pornography isn't going to involve those conversations. Right, right. The only conversations there are between your brain, your hands, and your eyes and your ears. I'm not going to highlight any particular order there. I want to switch gears slightly and talk about UTIs. I got a lot of questions about urinary tract infections.

Starting point is 01:54:44 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?

Starting point is 01:55:01 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.

Starting point is 01:55:24 And up to a third of them get recurrent UTIs. And what that means is they have two or more in six months or three or more in a year. Now, this is common. And so we'll see a lot of it. And it's not as until you're having recurrent UTIs, say you just have one a year or you have one every few years. It's not a huge issue.

Starting point is 01:55:43 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 a bladder that's causing the UTIs. In terms of prevention, there are kind of major things that are highlighted in the guidelines

Starting point is 01:56:18 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 postmenopause, surgical menopause or maybe have reduced estrogen for postpartum or other reasons.

Starting point is 01:56:48 What about during the second half of the menstrual cycle? Not necessarily for those specific people, but for those specific times, 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.

Starting point is 01:57:19 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, you know,

Starting point is 01:57:39 to see if there is an indication that their pH is too high that maybe they do need vaginal estrogen, particularly on like 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, you know, 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.

Starting point is 01:58:19 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 a 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.

Starting point is 01:58:48 It does take about three months to work. So, you know, you have to be consistent. You apply it about twice a week at night, sometimes three times a week. And it's very effective. The ring you put in once and it lasts for three months. But so generally speaking, that's the most effective option for low estrogen states. Other kind of simple things are trying to make sure you're completely emptying your bladder. So over a lifetime, people can develop some mild pelvic floor dysfunction, right?

Starting point is 01:59:14 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 Bexon. bacteria to grow. And so bacteria grows and then you get recurrent UTIs. So making sure you completely empty by sitting, relaxing on the toilet, sometimes leaning

Starting point is 01:59:43 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 going to, because there are these, you know, it was fun to research for this episode because there are entire discussions on Reddit about like what percentage of males sit while urinating. understanding based on having visited many male bathrooms in my lifetime and just being in the world that I assumed that men stood up in order to urinate, but there are a decent percentage of men

Starting point is 02:00:18 that sit down to urinate. There are. And in fact, it's variable by country and probably the reason it's become more interesting lately as media. So a certain country was recently surveyed. I think it was Germany. But essentially this recent, like picked up by the media, that Germans sit more often to pee. And so, you know, then people are 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

Starting point is 02:00:57 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 peeing fine and you're standing, that's fine too. I don't think you have to. I think it's just something that 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.

Starting point is 02:01:20 Can spermicides or condoms or both increase the frequency of UTIs for females? So spermicides, absolutely. So spermicides, if your condom has spermicide on it or you're using spermicides, that is a known risk factor for UTIs. Other things I want to touch on, you did ask about cranberry. So cranberry is actually in the American Urological Association guidelines for prevention of recurrent UTIs and women. Now, how does cranberry work, right? Like, do I just drink juice? It's actually a specific active ingredient in the cranberry, which is called proanthosyanidens or PACs.

Starting point is 02:01:56 And they've actually looked at the amount of PACs you need. 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. take once a day. And there is some, although not as much data that if you're having them around

Starting point is 02:02:34 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, you know, about two grams a day of de 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,

Starting point is 02:03:17 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 and UTIs going on actually at UCLA where they're looking at the microbiome of people who are more at risk for UTIs or even overactive bladder, 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 that. those things. Wiping from front to back, I think it does create a little bit of like shame.

Starting point is 02:03:58 Like, it's not a big deal if you wipe back to front as long as you're not like, you know, as long as you've like cleaned yourself, so to speak. So I think it's less of an issue. What we're talking about is you're referring to any contamination from any bacteria around the AIS. Correct. Yes. And a lot of women who have recurrent UTIs like tend to come and feel very dirty. Like there's something wrong with them. They're like, oh, I wash all the time. I'm really clean. I'm really this. And, you know, it's not something they're doing. It's probably. a microbiome effect or a hormonal effect or, you know, there's something going on that we need to investigate further. It could also be an anatomical or functional problem where you're not emptying the bladder correctly.

Starting point is 02:04:33 So there's lots of different factors. It could be and it's like very infrequent. I would say like I've never seen a patient who's dirty and that's the reason they're getting UTIs. Perhaps even the opposite is true. They're cleaning too much based on what you told us earlier. Yeah. And they're eliminating the gut micro, excuse me, just rolls off the tongue. Again, no pun intended.

Starting point is 02:04:55 Perhaps 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 Saunenberg was a guest on this podcast, he said actually kids can develop a very healthy gut microbiome and general microbiome, oftentimes by sorry parents, not washing their hands before eating if they've been playing with soil outside or dirt.

Starting point is 02:05:18 A little bit of that is actually healthy. The pets actually offer microbiome support. This is so weird. I know it sounds kind of dirty, 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

Starting point is 02:05:44 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 things. We're like, I definitely have a UTI. I definitely have one. Well, no, you don't, but there's a host of other things that it could be.

Starting point is 02:06:00 One of them could be that. Another very common one that we already touched on is pelvic floor dysfunction. So very often pelvic floor dysfunction, just like you had pain with urination, women can also develop pain with urination that doesn't go away. And it can start where they had a UTI that triggered the pelvic floor. And then the pelvic floor just didn't relax, right? 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.

Starting point is 02:06:24 And then they've developed pelvic floor dysfunction. 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.

Starting point is 02:06:46 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. And 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.

Starting point is 02:07:13 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. You know, I think any discussion about anything medical or, you know, especially hormone stuff. This happens a lot in the discussions around that get into, it seems with males. They're like every male now seems to wonder if their testosterone is too low, except the ones that are blasting testosterone because they know it's excessively high. And as you pointed 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.

Starting point is 02:07:55 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 and testosterone. And, you know, assessing if you're having symptoms that are not always sex. It can be depression, it can be weight gain, that you're not gaining a 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.

Starting point is 02:08:25 And then we'll get back to UTIs and I want to talk about kidney stones. But I've heard of women using a small amount of testosterone cream directly on the clitoris as a way to amplify the, maybe it's the desire and arousal effect. or perhaps just one or the other. So 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

Starting point is 02:08:54 for low libido or low sexual desire. And it's all been very positive in the sense there's been increased sexual desire based on validated questionnaires, increased number of sexually satisfying events with testosterone use. Now the range of testosterone in women is about a tenth of the amount of testosterone of man needs, right? So testosterone cream is systemically absorbed wherever you apply it. And so

Starting point is 02:09:18 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 off-laboration. testosterone. And the guidelines are the consensus statements, they're not like true guidelines, but they recommend using transdermal testosterone. So getting, you know, andro gel tubes from the pharmacy and putting a tenth of one tube on the back of the calf or the upper outer buttock, a hairless

Starting point is 02:10:00 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 air. The vestibule is the area outside the vagina, which is very hormonally active. There's lots of androgen receptors there. And it can actually, when you have hormonal issues, meaning lower testosterone and estrogen in that area, it can cause pain. And so actually applying a combined or compounded estrogen testosterone cream to that area over time can reduce that pain and discomfort. So as you know, testosterone receptors or androgen receptors all over the body, very much in the genitals, very much in the brain. and they're very useful to a very useful place to treat women for those issues.

Starting point is 02:10:46 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.

Starting point is 02:11:09 So dehydration combined with maybe a slight metabolic abnormality where you're creating more calcium or oxalate in your urine can result in kidney stones. And so how can you prevent them? I mean, 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.

Starting point is 02:11:37 And so the kind of general recommendations, for people who have kidney stones. One is increase your fluid intake to two to three liters. Again, the same number I told you before. You want to decrease your oxalate intake. Now, if you Google oxalate, you're going to find a million things that you eat that have oxalate in them. But the big ones are spinach and rhubarb.

Starting point is 02:11:56 We're seeing a lot of nuts too that are people eating a lot more nuts to get more protein. So, you know, cutting back, it's impossible to get rid of all of that in your diet. But if you're having like a spinach salad every day, well, switch it to a different green, right don't eat spinach every day um also you want to increase your citrate intake that's an inhibitor of kidney stone formation so increasing fruits and um and things like that to increase citrate vegetables as well actually one easily accessible thing is crystal light it has a high citrate composition so you can drink crystal light with that two to three liters and that can be helpful um you want to decrease your protein intake so high levels of uh purines or purogenic meats like red meats and things

Starting point is 02:12:38 can also put you at higher risk. So these are kind of the general sort of preventative measures we talk about for kidney stones if you have a kidney stone. So a lot of times people can have kidney stones 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

Starting point is 02:13:00 the urators 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, meaning there's no signs of a urinary tract infection, there's no fevers, no chills, we can treat it conservatively with pain medication and also there are medications like Flomax, which 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've got to get it treated right away.

Starting point is 02:13:35 you can get very sick very quickly. In fact, I've seen young, healthy patients, like they're healthier than me, walk in the ER with a kidney stone, and within 24 hours, they're in the ICU because they're really sick because of a kidney stone. So fever, urinating tea colored urine, so meaning blood in the urine. All of those are important warning signs that you ideally don't get to. Yeah, blood in the urine, I mean, doesn't always mean infection. It could just be irritation from the stone, but certainly fevers, chills,

Starting point is 02:14:03 or you have a sign of an infection and the stone looks like it's blocking. So if you get imaging and you see what's called hydronephrosis or pressure behind the kidney and you 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 take it up.

Starting point is 02:14:28 Where is the camera inserted through the urethra? Correct. You're asleep under anesthesia so you don't have. have to. You saw that. You saw the wince. And then percutaneous nephrolosotomy, which is done, if you have a large kidney stone or a very hard kidney stone that's up in the kidney, you can go in through the back with a small, like a small incision and with a specialized camera that goes in and uses ultrasonic lithotripsy to break up that stone and kind of suck it out that way. These are extremely helpful bits of information, or not even bits. These are, uh, these are

Starting point is 02:15:03 This is an enormous amount of useful information. I like to pivot again for sake of breadth. We can't go into extreme depth on everything, but I 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, discussed some of the benefits, discuss some of the risks.

Starting point is 02:15:33 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, Norplant, the, pill, broad category of things there, but for sake of discussion, the pill, et cetera.

Starting point is 02:16:08 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 and lifestyle that I prefer without risk of pregnancy. I mean, it was astonishing to the point where I thought, wow, if only I could post both clips simultaneously.

Starting point is 02:16:46 So obviously I don't know what the answer is, but I do know that this is among the more polarizing topics available for discussion. So what is the story, meaning, What are the data about oral contraception? Why so much controversy and what's the real deal here? Yes. So it is a very polarizing topic.

Starting point is 02:17:10 And there is abundance data, abundant data. In fact, we even did a study and again, this is not like high quality evidence, but we looked at Reddit threads and we looked at sexual dysfunction, specific low libido, orgasm like difficulties. And we like read hundreds of threads and we did like a qualitative analysis in females. In females. to see like what are people talking about? And problems with oral contraceptives and antidepressants leading to low libido and being very,

Starting point is 02:17:40 as you described, very like this has ruined my life, was very common. And so the theory is that, you know, taking oral contraceptives increases the amount of sex hormone binding 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.

Starting point is 02:18:10 Now, I think that there is, you know, 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?

Starting point is 02:18:30 You know, for like at least four months afterwards, you'll still see elevated SHBG level. So we don't know. But not infinite. We don't know. Yeah, the endocrine system is weird because it, it, we assume everything is a short-term effect, but there's some plasticity in the system,

Starting point is 02:18:45 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 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 freedoms, for preventing pregnancy, for, you know, for a lot of things and particularly other conditions, too, like PCOS and other problems. Oral contraceptives are amazing,

Starting point is 02:19:09 and they've changed, you know, gynecology and management of these women for, you know, in a very positive way. And so I think, you know, yes, I do think that there is oral contraceptive related sexual dysfunction. Usually low dose estrogen sort of contraceptives are the cult. corporate, 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 aedonia and apathy, not just lower libido. I can imagine how that would be the case through the elevated sex hormone binding

Starting point is 02:19:53 globulin, which is preventing testosterone and estrogen from being free, literally, and exerting their effects on not just the body but the brain. But is there any evidence that oral contraception can disrupt no transmitters? I'm not aware of any. I don't think so, not to my knowledge. Okay. Well, it sounds to me like oral contraception for women, because that's where we normally hear about it, it sounds like there's a varied response and it's highly I certainly had partners that love the pill, or at least didn't seem to mind it. I've had some that hated it.

Starting point is 02:20:28 And like, it's like, no way, tried that, never will. Or, you know, just went with other forms of contraception or for whatever reason we're not using contraception. So it seems to me that there's a lot of variation out there. How does one explore that without risk of permanent damage? It sounds like truly permanent damage is unlikely. You know, what are the other options? you know, is the ring copper IUD.

Starting point is 02:20:57 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 endogen, the effect of on the androgen receptors or estrogen receptors is affecting, you know, the lubrication or other things. We're not sure, but, you know, why don't you stop it and go get a long acting contraceptive method. Like an IUD. Like an IUD. And our IUD is, our IUD safe. And here we should probably say,

Starting point is 02:21:27 okay, copper IUD is one form. You want to mention a few of the other forms. So I don't prescribe IUDs, but generally speaking, they're very safe. Of course, there's risk with any sort of, you know, it's a procedure. You're inserting an IUD. So there's obviously some small risks associated with it, but it is safe and effective form of contraception. 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 they say, prostitutes who wanted to avoid pregnancy would put copper pennies in their vagina. Really? Now, I don't recommend that to anyone. And please, and I don't think it's a foolproof

Starting point is 02:22:16 form of contraception, but there is evidence that that did happen. 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 a behavior. I'm 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.

Starting point is 02:22:43 Before discussing prostate and. anal sex, not stated next to one another for any particular reason. I want to talk about SSRIs. A lot of people over the last 20, 30 years have been prescribed selective serotonin reuptake inhibitors and other antidepressants that have disrupted their sexual function or their sexual desire, it seems in particular. Do you see a lot of this in your clinic? Do you hear about it? What can people do about it? You know, oftentimes these sexual arousal or dysfunction issues associated with SSRIs and other medications make those medications prohibitive for people. So, you know, serotonin is kind of the anti-2 orgasm.

Starting point is 02:23:33 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 we've talked about feroxif, as an addition if we can't change their medication management. Because, you know,

Starting point is 02:24:13 And it gets a little bit complicated because we know erectile dysfunction and depression are very interrelated. Now, what's causing what and what, you know, where do we, like, maybe somebody went to see their doctor for depression, but was also having issues with erections. And now, if you fix the erections, do you help with the depression? Like what, you know what I mean? So I think, you know, I think that there's a lot of discussion that has to be had there. It's a lot easier to talk to your primary care doctor about depression than it is about your erection. And so I think it's important to like really dig into that a little bit. But yes, it is definitely a known thing.

Starting point is 02:24:50 We use it to our advantage when needed. And it can be helpful to switch medications or reduce the dose. You mentioned earlier that trazodone can cause sustained erection. And is tracidone in the category of touching the serotonin transmission system? You know, I don't remember the mechanism. But interestingly, trazodone is also used for off-label. like as a third or fourth line for premature ejaculation as well. So I don't remember the mechanism offhand.

Starting point is 02:25:21 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 5,000. Phthalm Cialis, which is to Dallophil, which may assist with erections, but the rationale for

Starting point is 02:25:50 this low dose, daily low dose is not centered around erections per se. It's really about prostate health, improving blood flow to the prostate, reducing prostitis, maybe even reducing the probability of prostate cancer. What other sorts of things are you encouraging men to think about when thinking about their prostate? Yeah. So before I forget, I want to mention that low dose to dalafil is actually a treatment for erectile dysfunction. In fact, it works quite well, particularly men who are having a lot of psychogenic issues. One, because they don't have to remember to take a pill before sex. It's always on board. And you know, you're taking five milligrams every day and it has a 36-hour half-life. So over, you know, you're kind of increasing those. So it can actually work quite well and is a great option for erectile dysfunction. So I do want to make that caveat. In terms of, In terms of prostate health, it has been shown to be effective for BPA 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.

Starting point is 02:26:54 Like, it's very, very common. Now, does everyone get symptoms and what's the long-term concerns of it? And, you know, what can you do about it? So typically, as the prostate enlarges, it's right around the urethra. It's a walnut-shaped gland, sits underneath the bladder around the urethra, and it can narrow the urethra or the p-tube. And so over time, you can imagine, like, if you're, I always give this example, if you're sucking from a straw, right, you're drinking from a straw. If you have a wide diameter straw, it's really

Starting point is 02:27:21 easy to drink. If your straw gets really narrow, like say you take a coffee straw and you drink out of that, it's very difficult to drink. Very similarly, it can become very difficult to urinate if you have an enlarged prostate. Now, what causes an enlarge prostate? There's a whole host of factors. A lot of them are genetic. So if your father or 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's responding to having to push hard against that narrow urethra to push urine out.

Starting point is 02:28:04 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, you know, or you're just like, I can't empty. Like it's not because it drips or a very weak stream.

Starting point is 02:28:31 And so those are kind of the things that can happen over a lot. lifetime. Now, what are some things that you can do to help? You know, Cialis helps relax those, those, the fiber, the smooth muscle of the prostate so that it allows urine to pass more easily. There's also other medications that you can treat very often, Flomax, or other alpha blockers are helpful in that area. In terms of like things that you can do in general for bladder health, prostate health, there are 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, like, oh, I got to stop all these delicious things I eat and drink, but certainly it can be

Starting point is 02:29:08 useful to just pay attention. So like if you say you drink coffee every day and you find yourself right into the bathroom a lot, if you limit your caffeine intake, you might see that you're not going to the bathroom quite as often because caffeine is a bladder irritant. So that can be coffee, tea, chocolate, you know, things of that nature that have caffeine in them, energy drinks, sometimes people forget they have caffeine in them. And so limiting that may improve your symptoms. Alcohol also is a bladder irritant. And these have actually been studying animal models and you'll see that the bladder contracts more often

Starting point is 02:29:42 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,

Starting point is 02:30:02 those sorts of things can also irritants. 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,

Starting point is 02:30:18 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, it, but it seems that women are reporting some bladder incontinence from excessive bicycle seat use, maybe even exercise bike. It doesn't have to be road bike.

Starting point is 02:30:41 Yeah, so this is a great point. So cycling, if you think about it, right, you're sitting on your paroneum, which is that space for men between the scrotum and the anus, for women between the vagina and the anus. And right there runs your pudendal artery and your pudendal nerve, which are again responsible for blood flow and nerve function to the area. So the most common things we see in people who are, you know, who are really high volume cyclers. Now, the studies have looked at like maybe they did a 350 kilometer race or they're, you know, biking three times a week for 60 minutes, but there's no like consistency.

Starting point is 02:31:15 But they're seeing pretty high rates of genital numbness. So like up to 50 percent. And also in men erectile dysfunction. In women, you'll also see numbness, but because sensation is a big part of arousal, arousal, you'll also see kind of decreased lubrication, maybe decreased arousal as well in women. And so how can you prevent that? The reason is because when you're sitting, particularly if you're leaning forward like competitive bikers do or arrow riding, you're putting pressure on the beak of the bicycle seat.

Starting point is 02:31:46 And that's where most of the, it's not your weight is not distributed evenly. So the goal is to take a bike seat that allows you to sit comfortably on your isheal tuberosities. And posture is a huge part of your pelvic floor. know we didn't talk about that earlier, but sitting, you know, with good posture and not kind of slouching or leaning forward can actually really do wonders for your pelvic floor. So focusing on posture is helpful, but also when biking posture is helpful. So they've actually looked at this data and they found that people who arrow ride, meaning lean forward are people who use narrow bike seats are more likely to have issues.

Starting point is 02:32:22 And so you want to get kind of a noseless 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, a bike seat with a cutout, because they've seen, at least with some of the cutouts, the pressure actually becomes higher on the area that's right around it. Very important point. I don't cycle. I don't like the exercise bike. I'll sometimes ride the assault bike, 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.

Starting point is 02:33:00 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 clubs. 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 sites

Starting point is 02:33:26 we're 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 of more questions for you. And by the way, you've been incredibly generous

Starting point is 02:33:42 with your time and information here. Thank you. So I really appreciate it, as I'm sure our listeners do as well. Anal sex. You recently did a post describing the multiple reasons why women do or do not have anal sex. Yes. Very interesting post, very interesting study that you covered.

Starting point is 02:34:03 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 key bullet points that you've, learn from the literature and from your clinical practice. You know, how frequent is it? With protection, without protection. How safe is it?

Starting point is 02:34:34 You know, what are the different reasons people do it? That might seem like a kind of a silly question, but it turns out when it comes to this topic, it's their interesting data. Yeah. Educate us. So anal sex, let's talk about it. Well, when you talk about anal sex, the reason people, it's,

Starting point is 02:34:52 It's become more and more common. Let's say it's more and more heterosexual couples are doing it. We know that male homosexual couples are having anal sex. And I think the one thing is that it's safe in terms of pregnancy, right? You're not going to get pregnant from anal sex, which is one of the reasons people do engage in anal sex. Do you think that's the reason people are doing it more frequently? No, I think that's one of the reasons that people, one, of the reasons people do. But in general, the issue with anal sex is that people forget to use protection, like a conduct.

Starting point is 02:35:22 for example, because sexually transmitted infections are actually more likely with anal sex than they are with vaginal penetrative intercourse because the anal tissue is very thin and friable. So when you penetrate the anus, particularly if you have any trauma, you can have, you know, you can have blood loss and that blood loss can then easily, more easily transmit sexually transmitted infection. So it's really important to use a condom and use adequate lubrication. The anus does not make any of its endogenous lubrication. You have to use lubricant. The other interesting thing about anal sex is that the anus pH is different from the vaginal pH. So you want to use specific lubricants that are isoosmolar to anal pH. So you can actually look up anal lubricants. And we could talk about

Starting point is 02:36:10 lubricants, but generally there's water-based, silicone-based, silicone-based, silicone-based, based, oil-based lubricants, water-based are the most easily accessible, silicone-based are a little more slippery and lasts a little longer, and oil-based also last longer, but are not good 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

Starting point is 02:36:50 emergency room if they're having issues unless it's really serious. So I think it's really important, one, to prevent from sexually transmitted infections, two, to be thoughtful and cautious. And sometimes it requires some preparation. If you're going to penetrate an anus, it's going to, you know, you're not going to start with a large girth item. You're going to start with something smaller and kind of work your way up. And then, you know, you're not. And then, you know, you're not going to start with, And I think ultimately why people have anal sex. So as I mentioned earlier, the prostate is highly innervated and can be a source of pleasure. So some people enjoy that, particularly men may enjoy anal penetration.

Starting point is 02:37:24 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.

Starting point is 02:37:58 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 or on my Instagram was talking about why they specifically recruit 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.

Starting point is 02:38:29 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 vaginal intercourse, oral sex, etc. What is there evidence for that? Not necessarily. It's more about sexually transmitted infections more than anything else. It's rare, you can sometimes, I mean,

Starting point is 02:38:55 the rare things that people have kind of commented on, like anal incontinence temporarily or things like that, very rare. Mostly it's just sexually transmitted infections because you can't have more, it's more easy to create bleeding through anal sex if you're not careful. And are people doing,

Starting point is 02:39:11 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 loose 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. Again, I'm sure some people are listening to this and they're, maybe they've turned it off already. 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

Starting point is 02:39:53 because of the increasing availability of pornography where it's visualized more or if, I don't really know why. But we do know that there's more going on in heterosexual couples than prior. As a final category of question, 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

Starting point is 02:40:25 of mental health, physical health, and performance, you know, 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, et cetera, and prescription drugs can serve a role. But I do believe the goal is always behaviors first.

Starting point is 02:40:47 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,

Starting point is 02:41:12 but this Indonesian herb is typically the one that I am 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 their SSRIs, I hear from people who take Tonga Ali and get libido increases.

Starting point is 02:41:38 Also things like maca root, which we don't really know how these things work exactly, probably some freeing up of testosterone with Tongad Ali, maybe some cortisol suppression as well, maybe some estrogen receptor modulation with maca root, maybe some dopaminergic tone changes. Shealogy, this Ayurvedic herb, which there is at least one study that I think has done well,

Starting point is 02:42:07 that shows increases in FSA, follicle stimulating hormone, with Sheila G use. What are your thoughts on things like Tonga Ali, Makha root, Sheila G? 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, erectile dysfunction, sexual dysfunction is often comorbidities, right? So managing high blood pressure, managing diabetes with diet, which you talk about a lot.

Starting point is 02:42:42 But the best studied diet is the Mediterranean 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 you talk about them all 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.

Starting point is 02:43:15 So this is like end of the line, nothing's working, and 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 erection. So I think that really, if I can say one thing, before you do supplements, which I don't have a problem with.

Starting point is 02:43:41 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 build over time and you're going to see changes over time. But I would say that the number one thing that I recommend for people is improving their diet, exercising, getting good sleep, as you know, it boosts testosterone. And even, you know, you mentioned this all the time about getting early morning light,

Starting point is 02:44:14 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.

Starting point is 02:44:30 And vaping. if you are developing true organic impotence, meaning that there's a biologic problem that's causing your sexual dysfunction, then it's really important to get your cardiovascular health assessed because about 15% of men who develop erectile dysfunction, seven years later will have a cardiovascular event. It is the canary in the coal mine, meaning that, you know, it's the sign that you may be developing cardiovascular problems or like endothelial dysfunction that's first presenting in the penis or in their sexual organs. And, you know, this probably is the same for women.

Starting point is 02:45:03 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 two, some of them have reported improvements in libido and desire as well.

Starting point is 02:45:28 also. Yeah. And Sheila G is less known about the distinguishing quality versus low quality sources of Sheila G is harder. Dosing is harder. It comes as this tar typically. Maybe more science on Sheila G will come out in the next few years. We could get behind it a bit more. Right now I'm sort of on the, yeah, maybe if you are an adventure, you might try it. But I'm not, it's not one that I normally throw to the top of the list. Yeah, I think that like El Citraline is pretty good. aschwaganda for stress reduction, which also has implications for sexual function. Tonkata Lee has reasonable data. I think there is reasonable data on these things.

Starting point is 02:46:07 I think the website you talk about all the time, examine.com is a great place to look at that. And like 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 going to be really high quality science. No one's going to really fund that, I think. So I think our expectations need to be a little tempered when it comes to that stuff.

Starting point is 02:46:31 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, you know, the mysterious thing that everyone wants to know about sex and sexual health, genitals and genital health, prostate, urethra, UTIs, 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 had an egg and, and of course there are other reasons why people engage in sexual activity that have nothing to do with reproduction. But surely it is core

Starting point is 02:47:18 to our biology and our psychology and well-being. So thank you so much. And also thank you for the work you do day in and day out, weekend and week out in your clinic. We will provide links to your clinic. People are interested in working with you directly, as well as online. That's how I initially found you. And when I did, I was just absolutely delighted. I thought, finally, there's somebody who's providing the kind of information that everybody wants in a 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.

Starting point is 02:48:03 Thank you so much. Thank you for joining me for today's discussion with Dr. Rina Malik, all about urology, pelvic floor, and sexual health. If you're learning from and or enjoying this podcast, please subscribe to our YouTube channel. That's a terrific zero-cost way to support us. In addition, please subscribe 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 Huberman 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

Starting point is 02:48:42 this podcast. Not on today's podcast, but on many previous episodes of the Huberman 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 Huberman Lab podcast has partnered with Momentus supplements. If you'd like to access the supplements discussed on the Huberman Lab podcast, you can go to live momentus spelled OU.S, so it's livemometus.com slash Huberman. You can also receive 20% off. Again, that's live momentous spelled ohus.com slash Huberman. 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

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Starting point is 02:50:07 Thank you once again for joining me for today's discussion with Dr. Rino Malik. And last, but certainly not least, thank you for your interest in science.

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

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