Dr. Rena Malik: Improving Sexual & Urological Health in Males and Females
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Welcome to the huberman lab podcast, where we discuss science and science space tools for everyday life. I'm Andrew huberman en and am a professor neurobiology and optimal gy at stanford school of medicine today. My guest is doctor reno a league.

dr. Reno a league is a board certified neurologist and pelvic surgeon. She's an expert in both male and female europe gc pelvic floor and sexual health.

During today's episode, dr. League answers the most commonly asked questions about urinary, pelvic and sexual health. For instance, how to avoid getting uti urinary tract infections.

We also discuss pelvic floor anatomy and function as IT relates to overcoming an overly tight or an overly relaxed evc floor. This is a key distinction that most people learn to aware of. Many people hear about the need to so called strength in their public floor, but in fact, many people need to do the exact opposite.

They need to learn to relax their perfect floor in order to achieve proper europe, gic and sexual function. So today you will learn about that. You also learn about sexual health. As IT relates to erectile function, as IT relates to things like vaginal lubrication, as IT relates to orgasm. We separate out very carefully the difference between psychological desire and arousal that occurs within the genitals themselves, and dot highlights some important misconceptions about sexual.

This function for incense that many people believe that hormones are responsible for sexual disfunction, but in reality, hormone, this regulation is responsible for only a very small percentage of sexual diffunce, and yet pelvic floor and blood flow related issues can account for a large number of cases of sexual this function in both males and females. So I sure you that today's discussion is going to illuminate many new areas of information, many new tools and protocols that i'm think most people haven't not heard of. We talk about the neural vascular, that is, blood flow related and muscular aspects, a blatter function, prostate function schemes, glands.

We talk about vaginal health as well as penal health. We talk about these things as IT relates to different stages across the lifespan. IT is a far reaching and in debt and practical conversation that i'm certain everyone will mean important takeaway from now.

Before we gone you 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. We talk about IT from the standpoint of the clinical and biologist.

So this 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 that there are certain themes within today's discussion that would not be suitable for Young children.

How Young? Well, that is certainly not for us to design. We realized that different parents in different households should be the arbiters of what sort of information children are exposed to or not.

So my suggestion would be that if you have any concern whatsoever ver, but the content of today's episode would not be appropriate to be heard by some member of your family that you please listen to the podcast first or at least check the time stamps where we've detailed what specific topics are covered and then to make your decision accordingly. As you mentioned that not only a dr. League, still an active clinic, SHE sees patients daily out of her clinic in southern alive nia.

And we provided a link to that clinic in the shown at captions. She's also offered a dozens of high quality p reviewed publications in the fields of neurology, public health and sexual health. We've also provide a linked to that bibliography in the showed captions, and he is also a spectacular public educator.

SHE provide zero cost content about sexual health, public floor health and neurology as IT relates to both men and women on her youtube channel. And there two, we provided a link to doctor league youtube channel in the shower 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 desired effort to bring zero cost to consumer information about science and science related tools to the general public. In keeping with that theme, i'd like to thank the sponsors of today's podcast. Our first sponsor is element.

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Today's episode is also brought to us by waking up, waking up as a meditation APP that includes hundreds of meditation programs, mindfulness trainings, yoga, eda, recessions and n sdr non sleep depressed protocols. I started using the waking up up a few years ago because even though i've been doing regular meditation since my teens, and I started doing yoga ea about a decade ago, my dad mentioned to me that he had found an APP turned out to be the waking up APP, which could teach you meditations of different durations, and that had allowed of different types of meditations to place the brain and body into different states, and that he liked IT very much. So I gave the waking up up a try, and I too found IT to be extremely useful, because sometimes I only have a few minutes to meditate, other times have longer to meditate.

And indeed, I love the fact that I can explore different types of meditation to bring about different levels of understanding about consciousness, but also to place my brain and body into lots of different kinds of states, depending on which meditation I do. I also love that the waking up up has lots of different types of yoga eda sessions. Those who you don't know, yogananda is a process of lying very still, but keeping an active mind.

It's very different than most meditations. And there is excEllent scientific data to show that yogananda, and something similar to IT called non sleep deep breath or n sdr, can greatly restore levels of cognitive and physical energy even, which is to a short ten minute session. If you'd like to try the waking up, you can go to waking up that com slash huberman and access a free thirty day trial.

Again, that's waking up dot com slash huberman to access a free thirty day trial. And now for my discussion with doctor reno, a league. Doctor reno molech, welcome.

Thank you. Thank you so much as an honor to be here.

Delighted 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, PVC, 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 here today, we're going to have a very Frank discussion, but one that really grounded in science and medicine around sexual health and related topics. These are topics that typically people learn about, perhaps a little bit in school, maybe at home from friends, usually overhearing things, as opposed to direct explorer, tory conversation, online pornography.

And at least in my experience growing up, you know, there was education around sexual health, reproductive health, of that was more oriented toward the fear of things like us, to fear of unwanted pregNancy, all of which of courses 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 backstop that we should just acknowledge, read off the bat that because the information is cleaned from multiple sources and because there are less to say, a influences out there that relate to the morality of different practices, that there can be shame, there can be misunderstanding, there can be secrecy, and that further leads to misinformation.

So i'm confident that today you can clarify things for us, and we're going to stay out of those trenches. And last thing i'd like to say is that because a number of terms will certainly come up. And I think for some people, they're not used to hearing in general discourse, i'm just going to get them out of the way.

Now penis, vagina annis protest. Know what else is there? We're we're going to talk about lubet. We're going to talk about intercourse, oral sex, anal sex. We're going to talk about all of that. So I just want to get that out there so that um we can reduce the shock, the shock response.

I love IT. We going to talk about .

all of the great. So to start things off and anticipation in this episode, I solicited for questions on social media, and I got thousands of questions, but there was a lot of overlap in the questions. So to start off, i'd like to talk about pell voc 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 a really rate an unhealthy public ic floor.

absolutely. So PVC floor, very simply, is basically a bowl l of muscles that connected to bones that hold up all your organs. So basically in your pavement is all these muscles there, and their function is essentially many IT. IT helps with urn, nation deficit, 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 deviation, you're having great sex, and that you are also not having elements like book pain or issues related to those those functions and those organs. And so pelvic loris is so important in so many different aspects, and we deal with that a lot as europe gist because it's so into girl to these sfc care that we take care of. And so when you have an unhealthy povy floor, IT can vary from person to person.

And while you hear about IT, a lot women, men also suffer from povy floor, this function or problems with the povy floor. So basic public sort function 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 that, that muscle would become contracted. In short, very similarly, if you're perfect, floor is overstrained IT can become contracted in short and tight all the time and you may not know IT IT may just be a function of stress, anxiety um or overuse or posture problem, things of that nature that can affect your pelvic floor.

And so this can lead to issues. Let's start with your nation. You can have symptoms of urgency. See a meaning if to go a lot to the bathroom, or you have to go and have a sun, desire that you can't delay, sometimes even have leakage, in some cases, that can make IT difficult to urinate because the povy flour is so tense.

or perhaps to incompletely vacate the blade, like you go to urinate, and then you go back to your desk, and five minutes later you have to urinate again.

exactly. But I can be either that you're not empty completely or that the public for muscles are so tense that they're stimulate blood. So IT feels like there's more to go.

So it's not always that you're not evacuating IT IT can present in the number of different ways and then with uh with sexual function. And 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 there can be a lot of different kind of pain syndromes. And you're like, I have all these different things going on. It's really just pelvic floris function with with gi function, you can definitely have constipation and then often you can also have back pain um and so all of these things can happen when you're poc floor is too tense. Sometimes your public floor can be too weak and that can be often because of, we see this in women, a lot, because of childbirth, delivering children with some people who have neurologic disorders, they can have weak PVC floors, or connective tissue disorders like ella's down, low synergy, for example. These sorts of things can cause weakness to the pElvis floor, which can then cause very often what I see is like urinary containers or leakage, which can then you know, create problems for .

people done line. Thank you for that. So first question, how does somebody know if their pellet floor is too tight from a uh, over contraction or chronic contraction of the muscles there versus too weak um and one of the chAllenges in having this conversation is that if we were talking about contraction of the cafe muscle or the bus up, I think everyone intuitively knows because they would ve seen the shorting of the muscles when the muscles quite flexed and the lengthening of the muscles when IT is relaxed.

Is there way to describe pell VC floor muscular shortening in a way that everyone can understand? Would this be like like a we gonna be direct today. Would this like be like tenser up once um annis and the opposite of the movement that one will do before initiating a ballot movement. And relaxation is sort of the pattern of top floor mosquito relaxation just prior to initiating a ball movement.

So I would say most people can't recognize that because it's very difficult to notice it's sort of a gradual and so IT can over time, I become nosier with these symptoms, but otherwise, it's very difficult because it's not a muscle that we were ever trained to recognize, right? Like you hear about kidal exercises, for example, and people talk about how to do them, but that's all you ever hear about the perfect floor.

And so you don't really know how to kind of do things in a way that protects your pelvic floor or um or kind of what how don't 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 examine to see if your power c florist type for women, it's a povide exam and for minutes.

usually erected exam. How how does that exam go?

So you is essentially power ping the muscles and also looking at the function.

So we'll say for digital patient that medical technology for fingers are called digits. So um you know i'm all enough to to recognize what a digital prostate exam, right the physician insert their fingers through IT into the anus and and and feels the prostate to see whether or not its swoon international and and i'm saying that I realized as we think of medicine and modern man and so evolved, this is basic basically been the practice for what fifty years, six years, maybe one hundred years, in the same way that the old school practice for glow, a excessive high pressure, was for the physical to just touch the eyeball. So folks, for those who think that medicine has evolved much IT, clearly IT has in many ways. But in any event, so a prostate exam goes, as I just described, what would what would a pelvic flor exam for a male and a pelvic floor exam for a female involve at a kind of ground level?

So for women, you can feel the public form muscles through the vagina, so you can feel the alio coxes, the puo coxyde as the elevator. And, and those are all names of different muscles in this ball.

This is the physician who can feel them with their fingers.

right? And, you know, you could do, you could put your fingers, but you don't have a reference of Normal, right? So you wouldn't know what a Normal public floor feels like versus a tight one versus a week one.

And so you can assess the tense ness based on pale patient. You can also see if there's tenderness. And so you can assess that based on this of a general physical examination.

And then also you can observe, so I can say, contract your bus, squaze your public floor up and and I can look and see, are they squeeze or are they pushing that? Are they coordinated or not, right? Because that's A A function of Normal use of the perfec floor. And sometimes you'll see that they're discord ated. You can also access for sensation in the area and things like that, that could be consequences of this function.

Can there be dis function in laterality like the pallet flow is pulling up into the rider.

up into the left? absolutely. So what? Typically when you see a poc floor serapis, not not a poc floor service, but these are the people who do the work, right? They they work with you on a prolonged is to help you Normalize the function of your public float.

Like, go in the gymnast, a trainer, right? They really work with you to get your public flour functioning in incorrectly. And the first step to that, a lot of power floor therapies will just alike your bones and and your you're kind of the way you sit and walk to make sure that you're not straining those muscles by pulling .

in different in different directions. And if a male goes to the physician to get a pelvic floor, um there's obviously a difficulty in putting fingers into the throw, one would hope too small and opening. So how are they doing? The public for exam is IT external to the body, is through the some.

the anus, you can feel the muscles through the annis, then you can feel the paranoia area and feel the muscles there as well.

Sensation so in the area, so from the outside of the body, the region between the scrotton and the ae s, yes. okay. So IT sounds to me like if people want to get a high quality assessment of whether not their pell VC floor is healthy or not, they need to see a pelvic flor specialist. That is not the sort of thing that they could into on their own necessarily .

IT would be difficult. I mean, so there are things you can buy online, like probes that you can insert in the vagina, that will teach you what to do, key go exercises and give you some read, you know, some reading. But they're not really mental diagnose.

They usually something people use if they they have a weak perfect 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 eagles.

first of all, who's key GLE. So he is a ecologist. I don't remember all the specifics to be quite on as but basically he came up with tigers, which are uh strengthen the exercise for the pallet floor.

And so what IT is what we describe IT to for patients. As we say you are going to there's a few different ways to describe IT. You are going to use the muscles that use when you urinate, but try to stop the flow, but you don't want to do that when you're uniting because that can create this function.

You want to learn what the muscles are, and then you freeze those muscles and relax. You know, in between sets, sort of speak. And so you'll do the other way. People described IT is pulling up and in in the, like the vagina. Or for men, sometimes you will say it's like the feeling that you're trying to lift your penis off the floor without touching IT, right?

So those are kind of use describe .

yeah so those are kind of the ways that you can describe those. And so you can freeze for five seconds and relax for five second names and do them in repetitions. And they're just like any sort of exercise you do.

You don't want to start doing one hundred of them, right? You want do them. I tell that people, I tell patients, do them lying down so that you're only focusing on those muscles, that 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 ten fifteen at a time.

like ten fifteen repetitions. So you talk that in so .

ten fifteen repetitions in the morning, ten fifteen repetitions at night, maybe one more during the middle day. But don't overdo IT because just like anything, especially when you're starting out, you can and if you're doing tones and tons of eagles, then you will get a tight, short pelvic floor muscles and you will then develop pelage floor is function. So it's really important to kind of understand those mechanics, which is why a lot of people think they know how to do eagles, 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 therapy so they can really work with you and make sure you're .

doing them correctly. What are some of the benefits of eagles for .

those that need them? Yes, so they are typically prescribed for urinary content, specifically stress urinary continent. So leakage that occurs when you have have an increase in your interview domino pressure like a cl va or cough, fing, sneezing, lifting heavy things, jumping on a trapline. Um so for those purposes, we use eggs to strengthen the pervy floor and also in women, pelvic organ polaks.

So when you have weakness of the poc floor, that leads to a bulge that you can visibly see or feel in the vagina for men, we often prescribed them for people who have had a prost attack to me, who then subsequently developed leakage after the process tacked me. That is, against stress earing content. Now, a lot of people use kidders recreationally, because improving the public floor musculature can lead to more intense public floor contractions during orgasm, which can be more pleasurable. And so some people do IT for those purposes. But again, I caution people not to overdo IT, because then you can lead to a more tense elva floor, which is not where we .

want to end up. Yes, I will underscore that cautionary note. Years ago, I heard about eagles like, okay, try IT sounds all good, right? I only heard good things about eagles.

And what IT quickly resulted in was painful year in nation. And I thought, this is weird. Everyone saying kiko are so great. And the best thing I could do for my public floor seemed was to avoid pickles. yes.

Um and a little bit later when we're talking about prostate or i'll explain um at least what my experience was as IT relates to the prostate. But I guess the take message that i'm gathering from what you're telling us is that strengthening the public floor is great. If you have a weak pelvic floor. Strengthening your PVC floor further if you have a strong pelvic floor can be detrimental.

IT can be IT can be if you overtrained IT, just like if you overtrained anything else. And so um you just have to if you really want to do eagles, if you have any symptoms at all, like you described paint, urination or the things i've described, like pain with erections, pain with a jaculation paint, a difficulty empty, any of those symptoms of stop and go see a urologist so that they can kind of assess your public floor.

What is the anti ego? In other words, if somebody decides that they have a tight pelvic floor, how can they learn to relax their public c floor?

So there's a lot of different sort of things that you can do. So for a women, you can do massage of the area. You can use regional dilly's to help relax the muscles. You can take the potteries that have medications like volume or backlift in which are muscle relaxation. And that can help as well, although they're not treatments and more of a band, but they can help with the symptoms that you're having. And then um you can also, I think the best thing is to work with the physical therapy because they can teach you certain exercises that will help IT down train the private floor. For example, one of the ones I tell my patients is like happy baby post IT actually you stretches and elongate the pavet floor muscles, so doing these exercises regularly will help you length the povy 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 politic floor, was to not do any kind of crunching movement. With my legs crossed, I would go these yoga classes and more point in my life, and I, you'd have everybody to do these crunches. And i've always done some abdominal work here and there during the week, if i'm being diligent, but they would have us cross our feet.

And that seemed to lead to melvil floor discomfort that was similar to what I had experienced when I did the key goles. Yeah so again, for me, seeing the key goles was one of the best decisions I ever made. I only did them for a short while. Es, I could. This is clearly not for me. And I guess that's another point um that you tell me if you agree or not, that if you hear about something online or on this podcast anywhere else and you tried and IT seems to be sending things in the wrong direction, either you're doing IT wrong or IT might not be the right thing for you exactly. And I think all too often we hear r this thing is great, and people jump on that and wagon, and then they and worsening their problems, developing problems where they didn't have them previously. But is there anything about the anatomy of the nerve muscular connections or or vac cultor of the palate floor that would provide support for my experience there ah that doing cunners with legs cross is essentially um is IT possible creating asymmetry in the pelvic floor um and now i'm sure i'm uh anger yoga teachers and conscious does everywhere but hey, if it's a question of your perfect floor, a few extra deliniates your ABS you know where my votes going.

So there's a couple things here that we should dive into. One is that people don't often breathe correctly during exercise, right? And so die thermax breathing is is really important, which is like a deep breath that expands the diagram, not kind of shallow breathing that just in your mouth and throw.

And that is actually when you when you do any sort of exercise, the trainer will tell you x hail on the effort, right? And there's a reason for that because when you in hail, your pelvic floor relaxes when you x hail your perfect floor contracts. And so is actually that contraction stabilizes the health floor.

So whatever interval inal pressure your your causing to increase from the exercise, there is a squad or as crunch or whatever, you're increasing your abdominal pressure, your public floors then contracting to help stabilize that. And so part part of the reason people tend to hold their breath drawn 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 nervous and arteries, particularly the pretender nerve and the potential artery that run through the povy floor. So when you get povy floor this function, you can cause decreased blood flow to the, to the public floor muscles, which can affect sexual function. And you can get nerve inflation tion as well that can also cause pain. And so this is kind of how IT all comes together.

I'm so glad that you mention blood flow. I think our entire discussion today should be framed up at least in the back of our minds and the minds of our listeners and viewers, as involving at least three things.

You know, any time we're talking about erectile function, or dis function, or pElvis or function, or disfunction, or vaginal lubrication, or lack there of, 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 our seal, for instance, or lack of arrow, so and so on. So we won't be overly systematic in in our parsing of all this. But I I think what you just mention the raises a really important point that sometimes in an effort to do something that's good for the muscles, like strengths and 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 physiologist about this, and they confirmed that a lot of people who squat and dead lift heavy in the gym, or even who just tense their pelvic floor when they're doing things like dumbbell curls or other exercises. And especially people who seem to do a lot of abdominal work reported to me in the questions that they experience things like erect tile this function, that they experience things like pain during vaccination inner course, that essentially they had created some sort of what sounds to me like a hyper contraction of the muscles in that area, that we're impeding all of the things that they wanted as either side effects or direct effects of exercise, because many people are exercising for esthetic reasons and health reasons. But nowadays, IT seems especially on the male side, but we all stuck by the world.

testosterone. On the female side, a lot of males lift weights in order to increase their just astre one, and for reasons that are obvious, also want to have healthy sexual function. And here they are doing this thing that's very good for increasing testosterone, if they're doing IT correctly.

And testosterone is involved in libido and the male sexual response and the female sexual response, of course, but they are impeding their erections. So you can start to see how um there are probably a lot of confused and maybe even destroy people out there. They're trying to do all the right things and they're setting up road blocks and even sending themselves backward in some cases. So the question is how does one know whether not something like um let's say low lubrication or pain during bagging al winter course or um loss of erector le strength or some sort of erectile disfunction whatever IT may be because I can take on different forms as will talk about how does one know it's a blood flow related, hormone related or neural related and if it's neural related, how does one know if it's the issue of lack of appropriate signals from the brain over suppression or lack of of arousal from the brain or whether not at some peripheral neural thing of innovation of the piano or Regina.

So I think there's there's a lot that we can go into here. But essentially, first, you want to find out like very specifically what is going on. Are you getting aroused? Are you having erections? Are you mater bating like there's all these questions that will help us go down the road into .

that when you say aroused for seek of this discussion, I just want to make sure that we distinguish between psychological arrows of the desire to to I guess here we also have to be precise um rose to engaging record s to desire essentially I think people learn to recognize or are we talking about a rosel as the response of the genitals .

react so so desire and arousal, this is a very important concept. Doesn't always go in one direction. Sometimes you can feel a ousel meaning you have the tell tale signs of arousal. Your nipples get erect.

you have more liberation of your female .

um you know you maybe get the sex flush right you get some some redness or or warm feeling that your body's response right to arousal and sometimes that can be interaction and sometimes that's not not having interaction does not may you're not arouse IT may mean other things, but certainly that's part of IT and then desire do you want to have sex? Do you have the like when you think about your partner or whoever you want to engage with? Is there are desired to actually do that right? Or is that just more of obligation or other? And does IT IT doesn't matter if the desire comes after arrival?

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 closed with the. And then arrows will come and then, oh yeah, you know, i'd like this.

So then the desire comes after and that's Normal. That's totally find. So you want to kind of pass that out. And then for men, you can ask, are you getting erections at night? Because that will tell us the function of your organ at night versus during the day, where you have also psychogenic c components, right?

You can really get in your head about directions when you have a problem in the bedroom with performance IT becomes a vicious cycle, right? So you you have a problem the next time you're really stressed, you're not present. You're not mindful in the moment with sex and you're thinking about, oh my god, i'm gna perform OK i'm magna perform okay and then IT doesn't perform again and you're just it's getting worse and worse.

The anxiety is through the roof and that's actually causing your sexual diffunce. So I think it's it's important first to identify those issues and then also for blood flow. A lot of times, we can we can assess based on well, what other commodities ties do you have? Do you have other issues ongoing that may be affecting your blood flow? Most common high blood pressure, diabetes disease.

And if you smoke, all of those things will affect blood flow to the genitals. And so that will point negatively, negatively. So so that will point us to a more vascular issue. Hormonal issues are are very important for desire. And and as far as sexual function, in terms of erections, there's only three percent of erect house functions is related to hormones.

So it's actually real function court as opposed to desire.

Psychology is predominantly modulated by the hormones 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 test stone is very important for both men and women for a variety reasons.

And so you are using that discussion with the patient will help you kind of identify where you're headed in terms of um what you need to focus on for a treatment. There are you know certain things you can use to assess blood flow. You can do dopper ultrasounds of the penis as well as the clitoris to see if there is good blood flow.

You can assess the peaks estop c bali, which will tell you if there's a problem with article inflow versus the end diastolic velocity. We'll tell you if there's a problem with Venus outflow. And so that can assess those things.

There are some test you can do for a nerve functional, although they're very uncommonly done because mostly we can kind of get that through clinical report. And unfortunately, if you are having nerve problems, sometimes that depends on what as them, but sometimes they can be very difficult to reverse. And that kind of a problem.

We know that as people age, your sensation becomes less so just through aging the nerves, the receptors become less sensitive. And so you will generally have less responsiveness to the same sensations you did when you were Younger. And so that kind of overlays all of this. Uh, so it's complex. But really a lot of IT comes from the discussion you have with your patient or you know you kind of really doing a deep dive and what's going on like really thinking about each of those and also what's going on your relationship and what's going on in, you know, your life dressed anxiety. Like how are those playing a role?

I'd like to take a quick break and acknowledge one of our sponsors, athletic Greens. Athletic Greens, now called ag one, is A A vitamin, mineral, probiotic drink that covers all of your foundational nutritional needs. I've been taking athletic Greens since two thousand and twelve, so i'm delighted that they're sponsoring the podcast.

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And they'll give you a year supply of vitamin d 3k two again， that's athletic Greenstock comm slash humans to get the five travel packs in the year supply of vitamin d three k two gosh lots there to a pack. Um and i'm glad you mentioned the relationship itself because there are all sorts of things that can impact the arrow will response a novelli not everyone's in a committed relationship whether not people are engaging in a lot of mastermaid to the point of evacuation or climb acs or not. Um pornography is said.

We will get into that. It's a vast space to explore before we go any further. I want to make sure, however, that we quee people to wear and how they could find a really good, let's say, pelvic floor a therapist um and where they could find a really great error gist to do the sorts of exams and perhaps the sorts of treatments that we've talked about because um at least as far as I understand, much of what people want to learn on this podcast is how things work and what happens when things break down, but also had to resolve these issues.

So let's say somebody wants to um check out their pelvic floor, figure out what's going on there, maybe having issues, maybe they're not but if they are male or female, where do they go? Is there a place online has a great list of of some of the best ones one's area can be done over um yeah how does want to go about that? Yeah so in .

terms of your private floor, it's good to get assessed by a physician whose specializes in private floor. Now that could be a erotic gist, that could be A N legist or even a physical medicine rehabilitation doctor that specializes in pavia flour health. So typically you'll see um in neurology you will look for people who are board certified in female pelvic medicine and reconstructive surgery.

If you're a woman, if you man, maybe sexual medicine, a someone whose specialized in sexual medicine would be a good place to look for going to cause you again, you want to look at someone who has interest in this area, who you know does manage povy floor. And then in terms of povy flor, uh, physical measure rebilitate, at least when I was in training, there was about twenty P M. In our doctors around the country who really focus on this.

So it's not a lot of people, if you can go to a perfect floor physical therapies and you have one near you, that's great as well. You um you do want to make sure that when they do are finding topic flour 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 poc flor physical therapy end to treat a lot of women. And so that's kind of what I tell my patients. Generally speaking, there's no at least to mind knowledge, no great resource and maybe will look that up and see if we can find one.

That's very helpful. Thank you. And because again, going back to what I said at the beginning of our conversation, think there's a lot of shame or at least a lack of clarity as to how one gets help for issues that, uh, relate to the genitals, right?

Because if you have a headache or you having an eye issue, I mean, or nowhere to go and hopefully your headache doesn't aren't going to all just but IT might um you know my stuff tends to be of the modest of interest yeah um so I don't think we hear often enough about where to access the best quality care for these things. So thank you for that. In thinking about sexual disfunction, i'd like to have that conversation more or less in parallel if we can run male sexual disfunction and fee male sexual diffunce.

And I want to make sure that before we do that, that i'm creating the correct parallel construction. As they say, erectile, this function in males is clearly a form of sexual disfunction. What is the parallel to erect? Al, this function in females is a lack of VGA lubrication and lack of relaxation of the vagina to have none painful intercourse. Mean, is there, is that even possible that a parallel conversation .

about these two things, so it's different in in some circumstances there are humala gues, right? So the penis is the humala gue of the country. So the car is the, you know, essentially the same of sponge erect tile tissue that you see in the panis.

IT gets erect with arousal and IT is IT actually extends very deep into the pElvis. So it's not just a small little organic, actually quite long. And so you can in men, you can have a rect tell this functions because you can see IT.

But in women, you may have difficult with orgasm and it's not exactly a parallel, but difficulty orgasm ing. And women is multifactorial and we can get into that. But I think they are they're different. And I think also sexual defunctive presents differently in both genders. So when you talk about men, they're very the one visual they see of arousal is directions.

And so IT becomes very ingrained in your psyche that if I don't have an erection, i'm not aroused, right? But there is a lot of reasons that you might not have an direction that we sort of touched on vascular problems, hormonal problems nor logic problems, psychogenic issues and other medications are taking. So there are issues that can affect direct tile function um and and so that can be part of IT where you you might feel like you have low desire because your arousal not there are not become a little bit confusing for women. What they can assess is their level of lubrication if sex hurts and if they get an orgasm. And so those are kind of the ways you can look at IT.

Thank you for fleshing all of that out. You know, years ago I worked on sexual differentiation and in particular the role of hormones in sexual differentiation and indeed, as you describe, we learned because we were taught and I think people still generally agreed that if one looks at the embryological origins of the penis and the clarus, they are essentially and all structures um and that a lot of male genital development involves literally the regression, the disappearance of the female sexual genitalia and associated or get malaria docks and things like that.

And what would become the over is become the test. Is that SAT ta, those are in automobile parallels. But what you just described for us very beautifully as the functional parallels has that relates to sexual function in this function.

So i'm hoping you with that framing that we can that we can knock down a few these pins in a little less time because there's a lot to tackle here. First off, i'd like to address the hormonal issues. You mention that only three percent of a recordist function and by extension, can we say also um female uh issues with sexual or hormonal in origin, is that right?

So with desire, yes. So they are hormonal in in general and arouse in terms of lubrication. If you're using that as as a parameter, yes you can see less vaginal lubrication due to hormones and exactly three to six percent more you know up to six percent we see of a redis functions is harmony. It's a small percent age of the entire entirety of a .

rec tile dis function. okay. So I think in looking in the landscape of social media podcast and interest in the common um mindset, we've all come to believe that testosterone is prohibited, pro desire in men and women. Think now all people are shy. Appreciate that prodest re and women as well percerin inly men and that doping is also associated with desire and the general public can have this view of estrogen is being sort of anti libido or anti mail which is Frankly false in fact.

And i've covered this on the podcast with doctor collegiate and with doctor Peter tea and um another fellow a youtube R A direct from more plates, more dates, has talked a lot about the fact that if people, if men, excuse me, take drugs like an astra all to suppress the restriction, thinking that oh, it's all about having high testosterone, low estrogen, often times they crush their libido. Just a bolar shit which has LED to a slowly growing but I think positive shift in how people are think about as an estrogens graph for brain function estrogens grape for libido in men and women um and that is a revision of I I think how most people think of the male sexual response. It's more in keeping without people think about the female actual response, oh, estrogen and the feemale actual response that makes sense.

But over trying to do here is clarify some of the misconceptions. Now the reason I mentioned dopamine is that my understanding is that doping is involved in the arrow, excuse me, the desire response. We will distinguish desire, the psychological l from genital area, so physical isl, and that proactive is associated with refractory period, during which direction can taker and other perhaps orgasm canto cki and females at at a.

But my understanding is that also not that simple. And we need to take a step back perhaps, and just talk about the physiological underpinnings of the desire and and arousal response. So i'll tell you what I was taught, and then you can tell me where it's wrong. I hope I was taught that the direction response and the vaginal lubrication response is generated by the per sympathetic 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 a lack of baggini liberation's.

But that there are individuals out there for whom a lot of alertness may be even, and this is a controversial thing, but for some people, even some sense of aggression or kind of eines or excitement, a journal in, in other words, can stimulate direction or rational library ation. So he gets tRicky. I 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 paro sympathetic sof relaxed tone, and that as sexual desire and arousal and sex or mastermaid progresses, that IT shifts more towards the sympathetic nervous, which has nothing to do with emotional sympathy. And as everything to do with arouses cata, ooman, doping, north and afan and epanchin's, also called a journey and north journey are released, and that the climate x, which mayor may not include accusation, 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 a jack laty or post climax phase, then there's a shift back to the per sympathetic nervous system. Um that's where um the pillow talk and the ah the exchange of orders and taste and other molecules is known to enhance their bonding through things like oxytocin vasa president on and what I just described is exceedingly oversimplified, I realized. 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 paris audience like .

and then you know you go .

on to the sympathetic nerve stem, but that makes sense. And the reason that I think you're hearing about this aggression or or these things they're leading to arousal is because there needs to be a stimulus, right, a visual stimulus, attack stimulus, some sort of stimulus that you're getting that is then causing the release of nitric oxide from the paris simple nervous system. And that could be for some people, aggression or or you know some and you tell .

people about nature oxi because we'll into this when we talk about um drugs that increased blood flow, see Alice biagi and also um non prescription drugs things like l rine argenton 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 actions, the ignition for erections that we if you the reason I talk about directions more often when you look at the data, in fact, there was a paper on this where they looked at the number of articles that came up when you put in the word pennies, and the number of articles that came came up when you put in the word clatters. And there was fifty thousand about penis and two thousand about the claro.

This was actually a major section of the comments yeah on when I asked for questions on instagram um in comments on comments and yeah how come um why not um it's said a is that because the urology and sexual health field was dominated by men that's going to be the presumption or is IT because it's easier to study somehow? I mean, what's going on here?

Yeah I think there's been a lot of I mean, you can go back to like fridge where he thought that that the female sexy response was less valuable and and so there .

are some valuable I know IT was .

out of different IT.

but IT was more .

about the male sexual response than the female sexual response. And so in general, yes, there is there were more men in medicine. There was more.

And IT is easier to study, right? You can stay the clear, quite as easy as you can study the male pean's response, because you can see IT visually. You can inject IT and see interaction response, right? We do this for people who have read out this function theyll. Take medications that increase word flow, like try max and you'll injected into the pens and you'll see interactions. So you can actually try mix, try me.

So there's it's the entire male is just went to what do you?

So there there are there are three basically brand names of intercom nosal injections that we use for a rec .

table function. I hear injection, and I think I like to think that IT reflects a natural man of taking a back and know mabe there's a public flor contractions and there's some place.

So so IT is IT is scary to hear about. Its a very small needle. IT is very well tolerated. I've done IT to patients in the office and they look at me so you're done like they don't even know it's it's not as painful as IT seems.

And when you are not having erections and you've tried multiple things, people get to the point where they're willing to try that, you know. And so IT is very effective as the most effective non on surgical treatment we have for a rec tile dis function. And it's usually you one medication, two medications are three. So you can have you a procedure covering and one .

that's OK we can look at. Someone will put in in the comments, surely they will. What what is IT designed to do is IT is IT um a vida atter .

of so so they they work in different mechanisms, but similar to the medications that we have, P D five inhibitors. P D inhibitors work in the direction cascade. What happens actually? Let's take you back to the night ric oxide thing.

We will get there. So night ric oxide essentially is released by the endothelium in response to a visual, tactile stimuli. Late q right? And so your body releases night exide, which then sets off the casket for the erection.

And so that releases C G M P, which is, which is causes the direction and is degraded by fast for diastole. And so medications that inhibit fast steris, like viagra and C L S, tend to prevent the breakdown of that C G M P C. You have longer lasting directions. And so similarly, these medications work sort of similar to that. Some of them, we don't know exactly how they worked, but they worked by in increasing C G M P R C N P that are involved in those l cran.

I hear about elsa. I use IT IT over the counter supplement, and it's in the argentina. And my understanding is that IT works similarly to things like c olivieri agra, but is perhaps not as potent.

I also just cautionary note out there. L sirin can give people vicious cold source and canker source vicious and you hear about this on internet. It's been verified by grow text images that you do not want to tell the google for um and not everyone tolerate IT. Well.

so these actually worked by increasing nitric x ides. So there not they're not later down the pathway. They're actually increasing the availability of night tric oxide. So l argento is the more direct pathway, but it's very low by availability. I'll literally converts tell arginine, but IT is last much longer in the bloodstream, which is why people tend to use lcr ili.

Now you know in in sexual medicine, these supplements, while there has been some studies on them and they are effective, there is no regulation on the supplement industry. So you know, we can recommend them, but we just can't say that for sure that the supplement is exactly what said on the bottle. We see lots of studies where they will say, I read one about melatonin and there's a variation of melatonin from like what's on the bottle to four hundred hundred percent 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 a relationship to accept that I mention them all the time. Um is examined that com, which has references to human studies and where there's a lot of effective y shown and will get into some side effect issues, does can't address you know quality by brand issues. But thanks for mentioning that what percentage of males who take seals to A K to dollar phl or viagra for rediffusion get um relief from that um because you mention only three percent of erectile issues and males are hormonal in origin, but what percentage are likely to be blood flow related in urgent?

So a large percentage of blood flow related, that doesn't mean that the medication will be effective for everyone. If you look at the large percentage are our vast killa in nature, right? That's the number one cause in in as men age.

So we know that about fifty percent of fifty two percent of men over the age of forty will have a rectius function, and that continues to increase as you age. So um fifty percent of fifty year old, sixty percent of sixty old and so on and so forth. So it's very, very common.

And the success rate in the studies is about sixty to seventy percent. So when you give someone a medication, they will have sustained directions that are sufficient for pantry up in a course, which is the way we kind of discuss the rector. This function in studies and you with patients is is about sixty to seventy percent.

So not everyone will have success. But not all of that is because the medication doesn't work. Um sometimes people are not taking them correctly. Some of people need to try different doses. And then there are still this issue of you know your brain is interactive. And so if you're having anxious, you're having other issues or stressed in your life that can have an effect on your ability to create direction. So there's lots of factors that go into IT, but generally speaking, they are effective and they do work quite well and they're tolerated pretty well.

And six to seventy percent is not a small number, a significant number. That's the majority significant margin. Is there a basis for the use of CS to dolphin viagra l sitchin um in females? So yeah there there's .

not a lot of data on this, but certainly you if you have surmise that there is a blood flow issue and they're having difficulties with orgasm is certainly something you can try off label. And certain ly people do try I try these medications off able to see if they improve sexual function. Women, but there's not a whole bunch of robust you randomised control trial studies on women with with these medications.

A little bit later, we will talk about prostate health specifically, but i'm just going to make a note here that nowaday there's um increasing use of low dosage. Um C L is slashed to dollar hill. Um so rather than what I found online was that the erectile dsf unction treatment dosage of co dolphs somewhere in the fifty to twenty milligram range, what we're talking about here is daily use of um two point five to five milligrams of ceos dolphin for prostate health and I learned in researching for the episode that um to del phil cialis was actually developed as a drug for the treatment of prostate health to essentially increase blood flow, the prostate to incase prostate health, not for the treatment of erectile this functions. So I have found that to be somewhat interesting um and a lot of people are now starting to use that. I also learned that if you dive into the the guts of the internet, one can find that now there is a growing use of combined load sage seals and April morphine, which is a pro dopamine tric agent and will get back to dopamine a little bit later. But um is there any basis for low dosage, like two point five to five milligram daily use of seela dolphin in females?

yeah. So well, let's talk about IT in females and females, I think low dose daily scala is excEllent for erectile function in men. Is that true?

Even a started interview. Is that true? Even for men that are not experiencing erect tile.

this function is not indicated for that part. But there is a thought that you it's increasing blood flow to the area. So people I i've personally used IT for a men who have tovit pain to help with reason blood flow.

You can also use IT potentially as a preventative. So some people have have thought OK it's increasing blood floats preventing fibrosis of that erectile tissue that can happen with age or other regular problem. So IT may be benfica al for that as well.

Although again, that's off lab and not something that we generally um promote. As far as for women, there's you know again I can help with blood first if you're having issues, if you have a females having sexual disfunction and she's got signs of vascular problems like she's got, uh diabetes, high blood pressure, SHE smoke. And yes, it's certainly reasonable to try and see how they do usually want to give at least a four weeks, al, to see if there's any benefit with those medications.

great. Thank you for that. Why is IT that I get so many questions about erected function from males who are in their twenties and thirties? Because everything you said up until now, I was mainly focused on men forty years and older is IT from lack of physical activity over use of nicotine by the way, vapors as far as we know um waving a smoking bad for a function and perhaps sexual health males and females generally because nicot is zav o constrictor nickey does have certain benefits and I covered this in an episode on nikon neocon benefits in the elderly in particular IT is a visual constrictor.

So IT runs against all of the sexual ousel stuff that we're talking about um but okay, let's assume that um male in their twenty years or authorities sleeping enough 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 key goles 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 there, you know eating pretty well.

Majority their foods are coming from non process or minimally process foods. They do a little meditation each day. They're engaging and hopefully healthy relationships. They're not masturbating like crazy to born. And uh, you know, let's assume that they are you know not on any sss why are all these two and thirty year oles on the internet asking mainly you this is they mainly run to you um but also to my direct messages about their reptile 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 to the flat function. So they even though they're doing all the right things, they do I mean where in a stressful society, so you can try all the things to be to decrease your stress. But lot of us are sitting long periods of time, especially during covet I mean people that for months, years just sitting up their home computer.

And so um you know exercise one hour is not going to offset the day full of sitting. And so all of those things can affect public floor function. So my theory is that that's probably the more common cause.

So walk more yeah I actually a .

standing desk yeah .

yes yeah walk more standing desk um what okay so and then my guess is that there is some psychogenic feed back loop, which is just nerd speak for things aren't working as well as they would like. They're stressing about IT and the stress .

is making things worse. absolutely. And you know you mention that people are not masturbating or or using point, but a lot of people learn about sexy 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, you had to find A V, C, R. You had to find a quiet room that no one was .

going to walk the kid down the street. I won't mention him by last name, but yeah, the kid down the street, you know, had porno magazines.

yeah or magazines.

And then there was actually a library of these good sessions, say, where they were in the town I group and where kids would stash them in in specific locations in parking lots. And then you know, boys would biker skate board over, will walk over and then they would like take terms, take terms. Use me looking at them. But that actually is to raise perhaps some more important point um which is that looking at pornography is different than masturbating to pornography, which is also different than masturbating to pornography to the point of event lation right because um I also get a lot of questions from people about their porn addiction issues and there is a growing theory out there that overuse that meaning not just looking at but um masterminding to pornography to the point of a accusation is creating a deficit of seeking out and um cultivating healthy real world sexual interactions.

yes. So I I want to start this before I get into that is is to say that if you're mastering the porn and you have Normal healthy relationships and you're going to work and you have a great a partner and your everything's great in your life, it's like shame is a real problem .

and maybe they watching pornography together.

yeah. So I think you know, I think it's important though that IT listen a literature they describe they don't describe porn addiction. They call IT problematic pornography use.

And it's only describing about four percent of people in these studies. So it's it's a small subsidy of people. I think it's becoming more common because pornography is so accessible and IT IT activites a dopamine e pathways, just like any other sort of addiction.

You you watch pornography, you get a dopamine response. Your brain then says, I want, 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 everybody .

but also I would say is sorry at janua but that the dopamine response as as a hardwork biological mechanism um for adaptive behaviors including and this just define healthy sexual behavior because I feel like there's such a range on that depending on one's background religious beliefs that um any time we talk about sex on this podcast like to say that involves at least four things obviously consensual, age appropriate, context appropriate, species appropriate.

Yes, absolutely absolutely. That i'm getting really good that you brought that up. So i've heard you say that before, but it's very important.

And so I think you there is a spectrum, a large spector, of people who watch pornography, ejecting to pornography and have a Normal life. And so that's fine. I think that, you know, if we shame those people were creating problems, right? We say like, oh, you do that, that's horrible.

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

there between or there are between relationships yeah and they're relying on mastermaid specifically. Are there any data that distinguished between just pure imagination, fantasy versus visual fantasy as IT relates to developing our inhibiting sexual health? And here were talking about the desire aspect, let's assume, physical alls, all this handled pan intended.

So I think that the, the, the thing about Young people answer question, but they think about Young people who are watching pornography. That's what they think 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 sexes. How long IT should take? This is what four play is.

And this is like, not Normal. This is the production this is a produced product that's meant to arouse right and to give you ideally in event lation or an orgasm. So um no one has that discussions.

We've then go to relationships like why did my partner not react like that woman did on the corner? right? Why did I not react .

like that one? The why did he react yeah when, you know, like they were important? Because going, I think females are were watching important as well. And I think I so I think you raise a really critical point, which that the shame can extend both ways.

And so I think to that and that's a problem. And and because it's so accessible and I think we need to have conversations, I think that needs to be open. We have to talk about our sex and that's what kind of what I do, what I do. We have to have these conversations so people know what Normal is.

Thank you for that. I do think that people need to know what Normal is and what the range on Normal is. Keeping the constraints that we talked about place earlier because I do think those are universal, healthy constraints, right? Consensual, age appropriate, context appropriate, species appropriate.

I asked whether or not imagined the appear imagination based social versus visual arts um and for some people, the sounds of people having sex is extremely arousing. You've ever lived in a major city like new york, which I spent summers in new york. You hear a lot you hear more more often than you do in um areas where people are living further but you hear people having sex. Yeah it's part it's part of the part of the auditory landscape.

Yeah you're very close together. So um but yeah so there's not exactly at least to my knowledge, I don't know of the data that looks at fantasy versus visual versus auditory, but I will see that you can get habituated to certain things. And there is that data that maybe you can get habituated to watching a certain type of thing to get rose 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. Um you may get used to master ating a certain way, right? So if you use certain barbatus stimulation or certain pressure sensation every single time you master bit, you can get habituated to that and you may not be able to replicate that during penetrated in our course.

Um and so I think that's really important and I think the takeoff is to try and vary what you're doing. Masturbation is find healthy way of self exploration again with the cabin as long as you're not master ating to access and avoiding your obligations or your family, your partners, your friends, right like you are just masters ating for the the benefits of maybe sleep improvement, mood boosting, reduction and anxiety. Those things are great. And so I think with that being sad, you just wanna be thought full about wearing that.

One of the issues with master ration i've talked about when I was gest another podcast, mainly in the context of male exhibition and um perhaps with pornography y perhaps not is that it's pretty clear based on the data surrounding addiction, that any time there are big increases in doping without a lot of effort required to generate that dove mine like turning on pornography on the internet versus, you know, asking someone out on a date, going out on a date, you know, again, trying about going through the conversations and the meeting 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 judgement on IT, without shaming anybody, you could imagine that if somebody exclusively masturbated and didn't develop the skills of courtship and building healthy sexual relationships, that pornography and or mastering ation could start to create coding quality problems, right? Thereby somebody only felt comfortable in those domains. yes. 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 you know it's definitely the ease of access, right? But I think that's pervasive in the Young society now like you don't have to actually go and find a mate, you can just go on an APP and look for somebody right like there's that's .

a form of finding you make. I mean, I was wind in the era when you know no smart phones or anything. And no.

my point is I think that we've become very um 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 skills 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 to test you is that I grew up in a community of mostly male friends. I have three mile friends always have um where a lot of what we learned about sex came from older mike guys.

My sister probably learned a lot about sex from her female friends. And there was always that one guy who would just say stuff that years later I realized was incredibly misleading, maybe even just detrimental. And I just want to remind people that when you are on redit or anywhere on the internet and there's people saying things with certainty, um they might be that guy yeah right.

And if you look at the if I look at the long ark of those people, that guy's life IT didn't speak to tremendous success in the domain for which they were asserting such confidence. Let me put in that way, okay. I'd like to slightly pivot to a different aspect of this conversation because it's just really critical, which is the female sexual response.

You know, this is something that does not get enough discussion. And there's a lot of stereotypes, right? The stereotype that we hear about is, oh, you know, they need more four play, which can be true.

Some cases is not true. The stereotype is that women are more intimacy relationship based on 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 yeah or maybe all the time.

Um I think i'd like to think that we are past the stage of human development where the stereotypes around this are um are fixed, right? And and and we hear more about this and we see more about this now. But what is the real deal around the female arousal response? And then we'll talk about female orgasm response. And there i've just going to your mark now that any time we say something like a rosa or orgasm, there are multiple forms of that right um and we will talk about the multiple forms .

of female orgasm yeah so if you talk about the response, like you can go back to the research of masters and Johnson and so what they did this was way back when, and they actually watched sex workers have sex. And this was, I guess, okay.

but yeah with .

me yeah so they watched and they took note of the the site, the kind of the steps of the female arouse or sexual response. And so the first phase is excitement, right? And during that phase, your heart rate goes up.

You're breathing little heavier. There is the sex flush. You can see redness and areas like in the volva, in the breast, I mean, the nipples, and then you go to sort, and that can last a variety of different times.

You'll also started seeing some lubrication baggini, 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 to the body where you will have, again, increased sympathetic response.

And you will have pelvic flor muscle contractions, which are rithmetic about point eight seconds or so. You're having a rythmic public floor contraction along with the sensation of orgasm. And then you'll have your recovery period, which you talked about briefly earlier, which can have you know sort of a refractory time period, at which point you can no longer you know orgasm again if you'd like to, or for men obtain another direction again for a short period of time. And that can be kind of an absolute factory period. So where is definitely not happening and then a relative of factory period where you'd need something more novel and exciting to then again.

resume the college effect of the large effect before on this podcast, i'll just cue people to time stamp link in the shown of caption so we don't go down the path but one thing that truly important understand is that the cool ge effect is present in both males and females meaning if a male jaculation and um is of the feeling that they can't have another direction for some period of time. The presentation of a novel.

But I guess we should take partner because we could be talking about homosexual relationship here and not just had a sexual but a novel sexual partner. Female male depending on their um their proclivities um can override the reactor period um and they can have another direction and ejaculation um similarly, a female will have a postal gasnier reactor period if they given an adequate stimulus right, are something arousing enough. They can um experience arizon orgasm again.

And we know based on really good pharma logy that this is a dopamine driven um thing. The process is essentially establishing the refectory period and the dopamine is essentially overriding the refractory period. Fascinating news chemistry there and speaks to the incredible extent to which the brain is controlling the genitals yeah I mean we .

we always say in sexual medicine that the brain is the most powerful organ for sex, not your genitals, but the brain, because IT is so powerful. And i'm not sure we're going to touch on this later, but i'll bring that up now. There are some centrally acting medication. Now available for the F T. Approve premenopausal en with low libido.

maybe rather out. The one that i'm aware of is in that often used in this nish cultures is milanese stimulating hormone in men, which gives people a ten, makes them erect. The milano simula hormonal mesage comes from the media patti, if i'm not mistaken.

Um one of those weird regions know everyone is my inter. But but and people are now injecting this as a peptide IT can cause proposal. I have not had that experience. I've never tried this msa, but I told that IT people are getting cavalier with that. They can have issues preparation on being enduring and perhaps even final erection .

is that you freeze ism? I mean, it's actually from prior pst, the greek god who is often fit hot graphic with a really big direction.

hear enough about that. Got school.

对 that roman， roman, agree. But anyway, is so and is an direction that last longer than four hours. And IT is actually a surgical or it's not a surgical, but it's an actually an emergency.

If you have an erection last longer than four hours in the absence of sexual arousal, then IT is important to get to an emergency room because at that point you can start developing decreased bd flow and ultimately not changes to the actual tissues scaring fibrosis. Uh, so it's really important to actually go to the EMS. Don't wait because you embarrass, really get there and get treated. However.

if i'm not mistaken, earlier you mention that IT is exceedingly rare, that people who take seal slashed to dollar hill or vaga for erections are getting true. Prepare m correct .

and it's mostly from uh, those inject tables we talked about earlier, those intercom nosal injections. People can get prior ism from those a little bit more commonly. And so that's something we always count on. And also certain medications like treason or if you have sickle selenium, those are the most common reasons that we see people coming in the Price.

Don't really OK to refrain from my desire to figure out that one. So I don't take us down rabid hole here.

I want to go back to the M. S. H. There is actually an after approved medication called brim. Anti is the brand name vi. C is the a the sorry brima has a generic name.

VC is the brand name which is f proved for women with with low the hypo active sexual desire disorder permanent puzzle women premenopausal because that's what they studied. But IT is basically the same appetite, right? So IT is a mulan o cotton recept agonist and IT works stop on the the brain pathways to increase desire.

It's taken as an injectable, again, just like we said, about an hour forty five minutes before want. When you want to want, you take IT forty five minutes before. And IT works quite effectively in increasing desire.

How long does IT last?

About twenty four hours. Some people may be up to forty eight has been.

I mean, I know men using multi simulator hormone peptide. I also really want to caution people about obtaining grain market peptides. Sorry for this uh insertion here, but um there are a lot of peptides available without a prescription on the internet.

They are almost all contaminated with something called L P S sloppy police sacrist, which is not something you want to be injecting a lot over time. That's actually how we induce immune sense in animals in the laboratory. Um and IT is amazing to me how many websites are selling this stuff and IT um arise to you easily.

You just bite on the internet says not for human or animal use. Some people are injecting IT and h the lp s issue is something I think is potentially gona 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 equality physician.

exactly. Because we have three millennia we can prescribe that for men as well. Uh, so sometimes we are off label for men who are having delayed accusation, because IT will help achieve orgasm a little bit Better.

And so, you know, this is available for permanent positive women. The other h medication that's available for low level is completely ancon, also known as add, is the brand name. And that also works on stage.

No, it's got kind of a mixed response, serotonin and dopamine e gic areas of the brain, and essentially works as a daily medication taken before bedtime, hundred million grams a day, that actually helps with decreasing hyperactive sexual desire disorder. Works in about six, forty five to sixty percent of patients. And you need to take IT for some time.

Now, both of these are brand name medications, so they are a little bit costly. And sometimes insurance doesn't cover them, but they are available. I think very few people know about them, and I think they're really great and useful tools in the toll box.

And these are for desire.

Therefore, yes, they are after approved for what we call hypo active sexual desire disorder, which is essentially low libido, that causes distress and bother.

I don't want to take us off course about vaginal um lubrication arison free orgasm bot, as long as we're talking about a ousel and reduced arousal that requires treatment. I have to ask this now anytime we talk about a ousel in the beto, there's no BMI which by the way, the body master index is probably not the best tool either um but there's no chart. It's not like a therm eder that says you're ninety eight point six plus or minus two degrees.

You're good if it's too high, much higher than that, you have a fever, much lower than that you're hypothetic so my understanding my um I don't want say nave understanding, but um my understanding is that one determines whether not their libido is Normal high or low, largely based on some intuitive understanding of what their partner or partners desire, whether not they can meet those desires. And if they sort of a crew enough of a sample size, they get 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 compared to how they felt in earlier years or different times of the year under different psychological conditions and stress conditions, that kind of thing.

But we really don't have a benchmark for this, right? Mean, we can't say that, for instance, that if a people are not desire 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 is that is that so there's no right or wrong basically .

what you are think there is no right or wrong amount of libido. There's many people who identifies sexual and they are happy with that. There are people who are 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 diffunce, you can using like validate questionnaire, the fs F I, you can actually see that about forty percent of people qualify for having sexual is functions.

But really bother is only seeing about twelve percent. And you can be bothered because you're bothered. You can be bothered because your partner is bothered, but it's really up to you, right? Like if you feel like there's something that you want to improve on, then that's when you go see a doctor, but there is no right or wrong answer, right? This is very subjective and a lot of times you will see couples who have miss match libidos. Now does that mean one person right and one person is wrong? No, it's just a matter of like, well, how do you if you want to come to a point where you agree, how do we get there, you know and what is what is your uncle?

yeah. I later will talk a little bit more about chemistry, which I find infinitely fascinating. Because in my life experience, i've just been struck by the fact that occasionally you have a physical interaction with someone.

Someone is not even physical interaction and they are just so unbelievably arousing to you or somewhere between for sometimes IT is just serve ain't there or it's just not there that much? Or nobody likes to talk about this or is 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, I, I hope he 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 wants to sleep with somebody again. Be by sleeping with them.

And here we're not talking about traumatic experience, right? So you know again that the discussion about lebel as you um so apply pointed out engaging what is healthy levels of living has a lot to do with what oneself desires as well as the hopes and expectations of the people that we are sexually involved with so we'll get back to that a little bit leader in the context of chemistry because I find it's so fascinating and it's something that isn't talk about enough. But thank you for that. Let's get back to female sexual role response and organs.

So physiologically what happens to the body is at prepares for penetration. Now that could be penis, that could be a sex toy. That could be a digit finger um to be more specific.

So IT what IT does is the serviced moves up and out of the way, the the inner one third, two thirds of the vagina lengths and along gates to allow for penetration. And they can actually do nearly double size of the of the baseline vaginal length. And so IT is preparing for that.

So if you and so that's part of IT. In some people who have painful inner course, it's because they haven't had adequate time for arousal. And so they're the penis penetrating before they've had those adaptations to occur and also the laya open up to allow for that penetration.

Tions of these things actually happen physica logically 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 for play. And not everyone is the same.

But I think it's important to have that discussion with your partner. And you know lubrication is one of the ways that people assess arrow, but that's not the ball and all some people just make a lot of luber action and some people don't. And certainly that changes with age and hormones.

So if um certainly we know that after menopause with a drop in australian and testosterone, you will see a decrease in lubrication. And sometimes if people are on medications that can alter their home mono access, they may also see changes and lubrication. After during breast feeding, you can see changes and lubrication. And again, this is not a they're not a rows necessarily. This is like a physiologic problem that .

there can we distinguish between a role based lubrication. Let's take sexual row based lubrication. And again, folks, forgive me for being so hyper specific language, but there are other forms of a rose besides sexual rosel that.

Um we know from h it's not a pleasant topic from um reports following sexual salt that you know often times the victim is demonized for having been um lubricated and they will say, well then people will that somehow they wanted that interaction and that's not true in those cases it's clear that those the lubrication occurred independent of libido type rosal. exactly. okay. So let's set that aside.

And unpleasant topic, but one that's important to to um to to flag are there forms of non label type rose lubrication that allow for non painful or even pleasure for penetration that are important to distinguish from the arrow based liberal ation in other words, I have to imagine um that women will have sex and I can be pleasurable or at least not painful and that might relate in some way to baseline levels of lubrication. And here we had been talking about lubrication mainly in the context of arousal, postmenopausal reductions in lubrication. But are there also postman oppole reductions in baseline lubrication?

Are some people s vagina is just more lubricated at um I say at rest is like a scientist in me when they're sleep, for instance. I mean, men are having erections in their sleep. Are women getting vaccinated liberians in their sleep periodically I guess is yes.

Well, they're definitely getting clear endorsement, right? They are getting little engorgement. There has been some studies on that, that they are also getting that terminal two mesons right.

Just like men do as far as lubrication, know the data, at least from what I understand, like there is a protective mechanism weren women, when there is any sense that there may be penetration, that their body will immediately start creating lubrication. And that is protective to avoid, you know, trauma and injury. Uh, there is also baseline vaginal discharge that's completely Normal.

Women will make physiologic discharge. In fact, in our examinations when we examine will say Normal physiologic discharge because we see IT, there's always discharge and IT is IT can be up to like five million. So it's not a small amount. IT can happen. IT can be quite .

a lot mental cycle dependent in terms of the the city.

And yes, IT changes over the cycle and IT can be different in color and different thickness. And that's completely Normal and I think that's a real problem in the feminine hygiene, dusty. Um you don't need to smell a certain way or or reduce that discharge.

This is like completely Normal, healthy. And you talked about chemistry and I know it's like not a ton of date on this is a very mones, right? There are sense that are coming from you, which are actually attractive to a partner potentially in whatever physiologic.

I know there's a lot of turn date on this, but like there is that part of IT. So um you know there's a lot of marketing towards women that you're dirty, you should be smelling like peaches or whatever. And there's a lot of marketing.

Maybe this is generational thing, but I learned early on me I think about behavioral neuroscience courses that baggini librarians were part of. The aral response for both at these were always rained in the context of heterosexual relationships but both partners let us see both partners because this could be a homosexual female relationship too right? We want to make the conversations brought out as possible um and that the owner wants to be Frank here um the older and the taste um played a role in both arousal but also the carbonic response that would establish future.

And anyone that's ever been in a in a relationship that want to say had healthy sexual relations, I like to think his experience remembering somebody smell or thinking about somebody smell and that itself can be very rousing, yes, partners, even i'm smelling different articles of each other's clothing and that being rousing, yes. So I mean, this is the stuff of a real ology. We're not making this stuff up.

right? But there is there is a lot of marketing towards women that they should use do shing or other things to clean themselves and IT is it's damaging, right? It's actually one IT can affect the vaginal microbiome of their PH is changing and that can affect you know they are risk for uti or bal vaginosis and um and and so they are they're buying these spending their money on these things because they are being told that they're not clean and they come to the doctors think, oh, I think I have A S T D, but it's like Normal physiologic discharge. Um and so I think it's important to say that this is Normal and and it's Normal to have an older that is distinct to you and that there's of course, if you have like a fishy older that maybe a sign of like a very strong new novel older that wasn't there before that maybe a sign of a sexy transmit infection. But if is your general older that you've .

always had that Normal, what about ast infections or bacteria infections of the um got a number of questions about Michael plasma, a infections which we don't hear that often .

about but yeah so you can see if your discharge has changed and become more chees like or there's you IT all the symptoms like itching um or discomfort, then you those are signs to go get evaluated Michael plasmic, another infection that we see in the vagina. But we also actually sometimes see in the urine. And while it's not we routinely test for when we have people who have symptoms of urinary tracked infection and they're not improving, sometimes we will check for microplate ma that could be causing similar in the you rethinking s self.

We've had a couple episodes about the gut microbes. My college, Justin sander stanford, his laboratory, directly above for me as experts to get 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 that means international zal into visual and try your reiterated in males and females.

There's an ano microbial. There's a microbiome on your skin, on your eyes. And you mentioned ducking and other are in other ways of, I say, and cleaning IT because that language falls in line with the idea that is a good thing. You're telling me it's a bad thing in many cases um because wiping out the microbial, what are some of the things that are females can do in order to promote the health of the vaginal microbiome?

So it's it's really um our body's are amazing. The vagina is a self cleaning of IT. You don't have to do anything.

You just love that the vagina is a self cleaning up. I'm not going i'm not onna repeat that too often into many different context.

but i'm going to remember you you 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, lets will be water run down. You don't need to do anything. Your body will .

take care of IT itself. I pull my parents in the bathroom and I said, and they still talk about this, I said, I want to know everything about sex. I want know everything and they were like, oh my god, what are we dealing with and on there for at my dad just, just looked at me, he's argentina. He said, just remember, kids are the one thing in life you can't give back. That.

well, I will tell you, my discussions of my sons are my son. My older son has been much more graphic than that.

I tell him, yeah mazing. Well, I went into the world and, anyway, figured that out. Let's spend a few minutes or more talking about female orgasm, one of the more cyp tic topics on the internet, not because IT isn't discussed but because I think that the new ones of IT isn't disgust often enough or in full depth.

So let's take the time we need um to pass this. I think that the simplest way to party is going to be from the anatomical standpoint, glitter al orgasm versus so called the spot or penetration based orgasm. But of course penetration based orgasm is also a bit of a mommer because um there can be uh literal stimulation by pelvic pressure or by digit.

We're fingers as digits because we're both in the medical slash science profession. But what I have fingers here or something else right by brad toy, whatever i'm told for IT depends on flexible. You are I don't know. But the point being um that I think the simplest way to go about this is going to be to talk about the distinction between catering orgasm and g spot orgasm, however those are achieved um and to also talk about this idea of graded versus absolute. Okay, so this has actual parcel to neuroscience where we talk about communication between neurons.

Graded, meaning it's kind of you one level than a higher level than a lower level or all or none, right? How shall I say? This IT is clear in my life experiences and observation that there are multiple kinds of female gash, 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 describe as Cliff type orgasms, where there is a refractory period. I think that's a fair way to frame this. And clearly, there are different responses to the orgasm response.

Some people get sleepy, some people get energize, some people IT heightens their desire for more. Some people they need A A period of time in which um they become hypersensitive to touch. Um so uh lots of different things going on there psychologically, physiologically and tell us all of IT. So in terms of orgasm.

right, I think it's important to distinguish that there is orgasm and then there is different areas that you've stimulate to achieve orgasm. So some people will stimulate the clatters is probably the most reliable form of stimulation that will achieve orgasm.

And when you look at the data, again, you know, female sexual st function data, not super robust, but what we find is that about eighty five percent of women require literal stimulation order to climb acs. So very few actually climax through just vaginal penetration tion alone. And so this is, you know, a real problem we're seeing on the media that you you you have sex and you penetrate a mely.

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, there are this podcast that clarus is the homology of the peneus or the penis. The mla, however, you want to say .

good on you for getting in both directions. Yes, I probable screw that one up.

yes. So, so cruel stimulation is just like female stimulation for a women that is very reliable. And there's a huge orgasm gap for men.

It's pretty consistent that when they have first time sexual encounter, ninety five percent of men are having an orgasm. We need at first time sexual encounters for women with in heterosexual relationships, it's about forty five to fifty percent are having in orgasm. And when you look at homeless sexual relationships of women, it's again ninety percent. So there's clearly some lacking .

in ninety percent of um female homosexual interactions that are first time interactions. Ninety percent are having oria on correct really because they understand the anatomy of other, by the way of understand the anatomy of self.

So the .

biology and psychology of that.

But there is a huge gap there. And so I think to to bring IT home is the clear stimulation is the most reliable way. As you mentioned, when you're stimulating vaginally, you're often in the class is like a wish bone and IT goes round the vagina.

And so you're stimulating those. The crew is what we call the legs, I guess, for lack of a Better term of the clatter. And so you're stimulating that you're also stimulate the catering shaft, which goes deep in of the provis.

The g spot is um is an area as an original zone where it's kind of in the anti while the vagina about two to three centimeters. Then that's the location of these period ual gLance called the skins gLance 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 pot stimulation.

Now that's a universal right. Not all men enjoy prost state play, and not all women are going na be aroused by just flat stimulation. And so I think there is a huge um a huge variety of ways you can stimulate stimulate anyone that can be man or woman.

Some people will have orgasms just nipple stimulation alone. Some will just hear something or see something and be able to achieve an orgasm. And it's it's so varied from person to person. And I think that the big take home from this for people listening is like you have to talk to your partner. And this is the hardest thing.

We never learn how to talk about sex, like what do you like? What do you not like? And and don't take IT personally, right? Like I think a lot of times people feel like you have to orgasm to have pleasure, which may not be the case for everybody.

And if IT is, you know, how do you prioritize that for your relationship? So I know if I got track there, but that kind of um I think the the tape comes for this. And also the vagina inal penetration tion is actually usually from survival stimulation, not necessarily vages inal because the large density of innovation, the vagina is the first outer third of the vagina, the deep or two thirds of the vagina has has much less innovation.

And yet there is such a thing as a orgasm. So in the server being further up the the vaginal canal um is several orgasm, specifically the one of the stimulation and the positive and orgasm that starts in the back of the aga is that yes.

so from stimulation of the service through whatever means, right? And that can be pleasurable and will lead to orgasm and again, orgasm you know is is defined differently, right? But the one thing we know is that there are perfect or contractions which are measurable. So you can kind of tell that your partner is having an orgasm if you have a female partner, because you can actually feel those contractions, right, whether it's on your digit or your organ or a sex way. Super nerdy .

question here um years ago and I worked on hormone based sexual differentiation which by the way we done episode the podcast on previously you I learned that the elevator any muscle um is the muscle that controls erection and males and presuming a catering to masses and an encouragement 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 um nerve routes contracting? The reason I asked this is that eventually in this conversation we're going to migrate upward the brain but because this is a science and health podcast, when we talk about orgasm, of course many people recognized that as their experience of IT in their recognition of IT and other people um and descriptions that at a but um are we talking about a response want that originates at a foci can't like in in the brain we talking about a season you know starting at a focus of foci and then spreading out um or we talking about a bunch of different nerve roots and brain centers firing in synchro and that's why some people experience IT as behind their forehead and in their genitals yeah or as a whole body response and here we're not talking about the flood of of neurochemicals into the body i'm talking about during those moments of orgasm um what is happening nearly I mean that does have certain parallels to seizure .

right IT does IT does so let me go back to your first part of the question which was um about orgasm and erection and two mesons being little little levity or A I so actually what happens during the reason you get an erection and presumed ly could have stimulation the same way blood flows in to the erectile tissue and the tuna, which is the outer layers of the of the of the erector tissue. Which two basically slenderly shape structures in the penis and in the clitus they will fill with blood and then that tinea will compressed veins on the outside to prevent level from leaving. So not a muscular event is an actual blood flow event.

Then how come when we wanted to study direction behavior in rodents, we would um give them injections of testosterone, females or males, and observe changes in sexual behavior accordingly? Reaction and literal two mesons. Although it's harder, harder to measure and road and there's a way of indirectly measuring that and then we would measure that the size and weight of the elevator ani muscles as a read out of how energy ized that whole system was in other, what is the role .

of elevatory? So, so those muscles are part of the pelvic floor, right? And so those contract when you when you climb x, right? So whether it's orgasm, female or female, are contracting and they are exercising, right? There are.

So that's how they would increase their their strength. They're their density um if you're measuring that through the actual climax of which you can see in rodents, right? So like you're kind of using as a surgit in that way.

So that's what happened. Those muscles contract as a response and climax is a brain initiative. Organ is a brain initiated.

So that's why to answer your second part, you obviously feel vocal response, but you also can feel a variety of responses because all coming from the brain, it's not a kind of the way you described as like a rip effect. Um it's more of like it's the way your body responded. That particular stimulus actually like the ultimate form of mindfulness.

You can't think of anything else when you're orgasm ing, right? So it's like you have this moment of clarity and and and everything, you are very present in that moment. And so people will feel difference simulations depending on you know how they're how they kind of how sense of their nerves are .

their sensations are in things like that is perhaps a good time to um mention dopamine we talked about a few times um earlier when talking about the arouse arc that starts with paris synthetic sort of calm and then move typically starts as common and moves to um the orgasm response. We know that the orgasm response is associated with release of dopamine and then proactive, which. Set up the relative or absolute reactor period.

The a the interesting thing and I got some questions about this is that um there's literature, as I understand about the elevation in dopamine caused by say anti depression like well utrum pryin, which increases dopamine erp and american um people who recreationally use drugs like cocaine or other stimulus um people who take um adorable vivants or other drugs that increase um levels of doing because I did hold epo de about those drugs and they are different forms of anti unless we're talking about ridin which is a little bit different and I got a lot of questions about people who experience feeling a lot of desire so of rosel but not being able to achieve the physical real erection or region library ation so it's almost as if they're sitting further along that arousal art henzy importance I think of people learning to have calm um states of mind when going into sexual interactions now I realize that in saying that he might be confusing because a lot of people think that that's anything but calm right sexual houses anything but calm but maintaining enough calm that they can um write that arc um for whatever duration is appropriate for that interaction in them right because again, when we should probably get back to this. You know um you know some people will have sex for a long periods of time, some for shorter periods of time, and here people don't really know what other people are doing except by way of pornography and self report and discussion. So um is that the case that drugs that increased dopamine can inhibit the sexual response? Do they intend to promote the sexual response? Because I also mentioned earlier, there's this a growing trend of people taking by way a prescription of course from a physician um combined apple morph e which is a dopa energy c drug um with the dolphin which is a um P D five inhibited.

So it's going to increase blood flow and i'm hearing about men and women, but mainly men doing this. So ramping up their dopamine, ramping up their blood flow to their genitals in order to have presumedly more reseal and sex. Does that makes sense as a mechanism?

yes. So in terms of April morphine, um the that has been studied and it's mostly been approved outside of the united. So we don't use IT very often here in the united because that after approved um but its a very complex responsibility that I mention that um flavor in which is a centrally acting medication IT actually has not only in hibbing ory and not only stimulatory but also in hibbard ory effects on dopa means so the way is sort of works to enhance interest or label is sort of complex and kind of confusing the when I was actually approved IT was IT was being studied for an anti depression. And what they found was that women were actually having, you know, Better interest in sex or more interest in sex. And so that kind of how I was discovered, similarly, vaga was actually studied for high blood pressure and when they went to um IT was horrible blood pressure medication. But then the people the men who took IT actually didn't return the samples for the study so they realize I can what's going on here and I was because they .

are having Better direction. Is IT true that um at some error gy meeting that the first um description of viagras a treatment for article diffunce involved speaker actually coming out from behind the podium and revealing his erection is that a true story?

Yes I don't think he was bagger. I think IT was an intricacy nosal injection though I think he came out um IT is the true story. There's is actually a publish article ascended to you so you can shared if you .

would like they want to but will read the article there.

There's a published article about people who are attending at the meeting and he came out and at the time, like IT was mostly men in neurology but there were like spouses I guess in the audience which is not typical now but um so there were women in the audience and he came out with a full on direction to show that you know IT worked well.

I supose that the neurology meeting um or B G one meeting where a woman comes out and reveals her enhanced original liberation. Then we will have we will have uh gender and sex baLance at the meetings is on your ology um will be interesting to attend one of those someday. Differences in arousal as a function of stage of the monster cycle, really interested in that side did a long episode on fertility.

We're going to have a few other ivf experts, fertility experts on the park cast. But clearly um there are differences in hormones across the recycle. We know that for sure yeah um clearly there can be psychological variation according to those hormones were probably other things across the mental al psycho and is always at an imperfect experiment because you know we aren't laboratory rats and people are having different interactions across the menstrual cycle.

Is there any known correlation between desire and stage of the metro cycle? There are some obvious assumption that one might make a priority ovie tion at that around the time of vision. Um but what about the other direction to um is our category of women that are very interested in sex, a certain stages of the mental cycle and then not at all interest in sex, other stages.

mental cycle all that i've heard and maybe a guan colleges could speak more on this because they study those variations a little Better. But there is data to suggest that libo does increase prior to evolution and during emulation. I think it's a couple days prior because that's the optimal time for a fertility. So yes, there is needed to suggest that in terms of like completely a lack of interest. I don't believe that day, but i'm not mature.

Is the 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 an interesting that whenever there is 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 catering stimulation as more a more common route to orgasm.

But of course, there can be literal stimulation with penetration lately, right? And depending on the physical arrangement, there can be literal stimulation purely by way of penetration through pElvis contact. You know finger is at at a so yes, how how do we how should we think about this? How should we talk about IT?

So there was an interesting city that I just read recently where they gave women words for these things, right? So um there's like the rocking stimulation so that can also stimulate so meaning that the you're penalty, but there's like a rockings motion that can also that glitter is there is a stimulation of just the outer part of the vagina which again, as I mention the g spot is there is more highly innovated so that can be more stimulating.

There's also ways to align yourself so that when you're panting ting, you're putting pressure on the clarity and then there's no stimulation with like actual stimulation of the class, like intentional stimulation either by yourself or by the partner. And so there are multiple different ways to do that, right? Um and so there I think that it's important to really um kind of it's okay to explore and not always be a home run. I think that's like when you get into relationship where you maybe second, third, fourth time having inner course 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 think is is plays a huge role in in this because we know ourselves Better than anyone else so you can tell your partner what you like and I think that that we have never been taught .

how to do that yeah um such important conversations for so many reasons and as you point out, definitely not something they teach people in school except they might say something about you know communication is important and that almost always circles back to the the key for things we talk about earlier, which is that is you consent in age appropriate, context appropriate these kinds of things and um and obviously substance is like alcohol and other drugs can strongly confound those issues and so that will just leave that as as a kind of ban obvious one um as long were talking about communication around sexual interactions um perhaps you will be useful to people to cultivate A A language or a ommen catch there are two to facilitate that some of the language that i've heard that is um quite useful as things like um 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 between where sometimes people sort of either don't know because they haven't tried IT or haven't thought about IT or there are sort of curious but kind of unsure or IT might work in the right context, but maybe not all the time. Um so is there any kind of structure that's been put out there as a way to improve communication around sexual and reactions?

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, know a sense of insecurity for the other person, right? Do I do something wrong and something go wrong here?

So you want to kind of move those to a neutral location? So like kitchen table in the car, whatever, somewhere where you know sex is not going to happen um at least for that particular moment. And we have .

most listening some chAllenging conversations on this post china previously chAllenging because that you know you're trying to get things clear and as clear as possible. This one is chAllenging because there are so many copy ots to everything, right? Don't of course we'll have sexy cars, right.

Um or they did when I was growing up and sometimes that they still do. Okay, please. Ue, yes.

So that's one. And then too, like when you're discussing IT, I mean, this is kind of goes for any difficult conversation is like you make eye statements, right? You say I like IT when this I don't like IT with this is not something you did, right?

It's like you didn't do this, you didn't do that, that makes the kind of an animal sy sort of situation and then no, I think also part of IT is like being open about those things that I may it's not going to happen in one conversation. I think that's the hard problem. Like you think you're onna have a conversation is going.

So great and things are going to be Better. It's gona be like multiple conversations and some of them are not going to go well, right? So like um that's another place where you can actually get the help of a sex therapist and there is a website for that is A A S E C T A sex org where you can look for a sex therapy near you and you can even do those things virtually um and so that can be really helpful when you're having difficulty having .

a conversation yeah I think um again in such important conversations and then when people differ in terms of their level of experience, IT gets potentially problematic but also IT can be potentially um educational um and then of course there are the twist in terms that occur with when one is asking about somebody else is aroused temper, often times as you'll learn things about people's sexual past and that can be either neutral, stimulating or reverse IT, right that can open up all sorts of other issues relate to the psychological interview.

So there's no way we can parse all of those. Now I just think it's worth highlighting um that it's understanding able why those conversations are chAllenging and IT also is understanding why pornography isn't involve those conversations, right? Going conversations there between your brain, your hands and your eyes and a rear not going to highlight any particular order there.

I want to to switch years slightly um and talk about ut S I got a lot of questions about urinary tract infections. Let's to make IT be laid to both females and males because yes, males get your in ary tract infections, females get them more. Females asked about you retract infections.

How common are they? Should they always be treated with antibiotics? Is crambry really a good treatment?

If so, why are the other things that are Better? Is that relates to the actor or our community? Um how does one prevent getting ut s? Can you get them from swimming? Should you urate after sex tells about uts and how not to get them and how to .

get rid of a happy too. So ut s are very common in women, are probably up to fifty percent of women get at least one uti in their lifetime and up to a third of them get recurrent ut s 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 um until you're having recurrent U T S just have one a year or you have one every few years. It's not a huge issue in men. However, ut s are much less common and that's because the rethoric is longer. So there's less um entry from the outside world into the bladder which causes infections.

And so um the when men get a uti is concerning, like why is a man getting A U T I? 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 abNormalities with the batter that's causing the in terms of prevention, uh, there are kind of major things that are hired in the guidelines that we all, we all talk about. So one is hydration.

So making sure you're drinking about two, three years of fluid, ideally water a day, because the illusion is the solution to the pollution, right? So drinking more fluid is gone to get that bacteria and you're going to pear IT out. It's going to help keep, not let that sit around the blood very often. Another thing in women who have altered states of s rogen, whether its post manos surgical menopause or maybe have uh reduced gen for post party or other reasons.

About during the second half of the metro cycle.

not necessarily for those specific people but for those specific times, but because it's pretty short lived, I guess you could use IT, but is is vaginal estrogen. So vaginal estrogen, meaning egan, is applied in the vagina either a cream as a positive or a ring is is highly effective in reducing the occurrence of recurrent utils. And this is because when you have low estrogen, the P, H in the vagina goes up.

And the P H in the vagina goes up because there's less conversion of gygax interlaced. Because I, and then those like to billa are preventive for U. T.

S. So essentially you want to reduce the P H back to Normal acetic PH. And vagina inal action is very effective at doing that. In fact, in our clinics will actually check a vagina inal PH you to see if there is an indication that their PH is too high, that maybe they do need.

Vaginal action, particularly on the Perry menopause, is hard to televised by looking if they are really heading into a lower estrogen state sometimes. And so that's very, very effective and very, very safe. So when you look at estrogen, the women's health initiative way back when sort of made a big stink about how australia laid to cancer.

However, um vaginal action has never ever been a reported breast cancer, uterine cancer or any other blood clot, any other adverse event associated with the vaginal assurance in you can get some breast tenderness st some discharge, those things can occur. But the absorb amount vignal 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 vegal action is extremely safe and it's pretty affordable. You could actually use coupon ds if your insurance doesn't cover IT through you know good arx or more human pharmacy and get IT very, very affordably and it's very effective. IT does take about three months to work.

So you know you have to be consistently you applied about twice a week at night, sometimes three times a week um and it's it's very effective, the ring you put in once in the last for three months. But so gently speaking, that the most effective option for low estrogen states, other kind of simple things, are trying to make sure you're completely empty your bladder ter. So over a lifetime, people can developed a mild, perfect flotus function right now to create pain or discomfort.

But maybe they're not eating completely, right, because maybe they used to hold their year in for a long periods of time when they were kid, or maybe they always hovering over the toys they I want to see on IT at work and over time, that can create a little bit of mild this function, which can make IT more difficult to completely empty the blood. And when you're in a sitting in the battle for a long periods of time, it's basically food for bacteria to grow. And so bacteria growth and then you get recurrent uti. So making sure you completely empty by sitting relaxing on the toilet, sometimes leaning forward and then maybe going a times. So standing up, sitting back down again and again, even for men, sometimes trying to sit and see if you completely empty, because sometimes standing you're not .

able to empty completely. Wo a lot of are going because there is IT was fun to research for the subset because there are entire discussions on redit about what percentage of males sit while you're donating. I mean, by understanding, based on having visited many male bathrooms in my lifetime and just being in the world, that that I assumed that men stood up in order to to unit. But there are decent percentage and that are down to IT.

There are an in that is variable, like country, and probably the reasons become more interesting lately. media. So a certain country was recently surveyed, thing was germany.

But essentially this recent, like, picked up by the media that germans sit more often to p and so you know that people like always is Better for me to sit to p or stand. And there is a whole big discussion on the media. But the reason being is, when you're sitting, your public flour is most relaxed.

And so if you're having any issues, empty your blood, you're gonna pee Better. Also, you have an in large prostate, which i'm sure we going to talk about, prostate enlargement that can sometimes allow you to develop a little bit more into abdominal pressure because you're sitting and you can learn forward to overcome sort of a block kage. And and so there are some some indications were sitting is Better.

But if you're being fine in your standing, that's fine to I don't think you have to I think is just something that, you know, in other countries they do more and here we don't. And I don't think it's right. Wrong IT just depends on .

your individual circumstance. Can spaces or condoms or both increase the frequency of U T S for females?

So firm sides, absolutely so firm sides. If your condom has permission or you're using sperm sides, that is a known risk factor for ut s um other things I want to touch and you do to ask about cranberry.

So cranberry actually in the american neurological association guidelines for prevention of recurrent uses and women, now how does cranberry work? right? Like do I just drank? Choose it's actually a specific active ingredient in the crane berry, which is called pro.

And those scientists ans or PC, and in order, they're actually looked at the amount of pas you need and what formulation. So you need thirty six milligrams of pac in a soluble form. So a lot of the supplements on the market will say that there are thirty six milgram of p, but they're like the whole barry. So they're using the the skin of the berry and the stem of the berry, and that's not going to help you. So you need to make sure that the supplement using is a soluble form of the crown berry and it's actually very, very effective at .

reducing the risk of capture like a jail cap.

Uh yeah it's a capsule um that you take once a day and there is some, although not as much data, that if you're having them around sex, which some women do always have post quote um 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. Um so that's kind of the the guidelines.

Now there's a ton of other things that you can do to help prevent that our kind of available and have some data behind them. So demands is one of them when you take um you know about two grams the day of d manos and you'd drink IT and that actually helps uh reduce uti has been setting small randomized control trial to be effective and um and so those are kind of the bigger ones. There's other things that people use like probiotics, but there's a lot of head orientation, as you know, in probiotics s and what to taken, are they really effective vaccines uh in the Flora there.

So those are kind of the big things. And there is a actually a lot of microbiome study in U T S going on actual U C L A um. Where they're looking at the microbial of people who are more at risk for ut s or even overactive blood or other conditions like that.

They're trying to figure out like is there is something here that we can target or that we can figure out is is causing problems because sometimes we just can't figure out why it's happening in terms of wiping from front to back and swimming and ping after sex. There's no good data and any of those things um wiping from front to back. I think IT does create a little bit of like shame, like it's not a big deal if you wipe back to front as long as you're not like, as long as you've like clean yourself, so to speak. So I think it's less of an issue.

We're try if you're referring to any contamination from any bacteria around the yeah and a lot .

of women who have recurrent us like tend to come and feel very dirty, like something wrong with them. I go, I wash all the time. I'm really clean and believe this.

And you know it's not something they're doing. It's probably a microbiome factor, hormonal a factor. You know there is something going on that we need to investigate further. IT could also be an anatomically problem where you're not empty the blood correctly. So there's lots of different factors that could mean it's like very infrequent, I would say, like i've never seen a patient who dirty and there is getting ut s perhaps even the .

opposite is too they're cleaning too much based on what you told us are earlier and they're eliminating the got microbe excuse me, just rolls off the tone again. No intended um perhaps it's they are a bolt shing the local microby on the skin, too much cleaning laminate the microbial on the skin not that we don't want to wash.

But when sun and berg was a guess on this podcast, he said actually kids can develop a very healthy good microbiome and general microbiome, often times by, sorry, parents not washing their hands before eating, if they've been playing with soil outside or rr, a little bit of that is actually healthy pets actually offer for microbiome ort. This is so weird. I know that sounds dirty, but we have to imagine how we evolved as a species was not with antibacterial soups and alcohol swab everywhere.

And obviously we don't want infections. But over cleaning can disrupt microban, which presumed ly can lead to uti. So perhaps someone who is cleaning excessively is more at risk than somebody who is cleaning a little less.

absolutely. And actually the cleaning can irritate the dormice, right? So you can actually get contact romantic type symptoms from over cleaning.

And so that's one of the, you know, things for that. I I definitely have A U. T.

I definitely have one. Will, no, you don't. But there's A A host of other things that I could be. One of them could be that another very common one that we already touch on. This perfect floor is function.

So very often in povy floor is functions just like you had pain with nation, women can also develop pain with your nation. That doesn't go away. And I can start where they had a uti that triggered the pelvic floor. And then the public floor just didn't.

With the pain just triggered the power of tents up, I didn't relax because, again, we're not taught how to relax our pelvic floor and and then we've developed the the florist function like why is the U T I not going away? Why is that keep coming back? And so that's another common thing that we see um in people who have quote and quote recurrent ut s but don't really have them. To be clear.

I experienced the pain in urination as a consequence of trying those damn key goals. Everyone is about stopping. That was informative in two directions. One IT relieve the pain very quickly, so that was good.

The other was I realized that IT is possible to have a perfect floor that's neither hyper contracted nor over relaxed, and in some cases, just not doing anything for IT is is the best circumstance, right? So and the only reason I mentioned that is because obviously this discussion is not about myself elvie floor. This discussion is about fact that some people perhaps need to clean less.

Some people may be more, but probably not based on what you said. Some people might need to strengthen their public floor. Some people might need to um relax their public public flour and some people's pelvic floor is probably a OK.

You know any discussion about um anything medical or you know especially hormones stuff. This happens along the discussions around that. I get into IT seems with with males they like every male now seems to wonder if their test fast one is too low cept the ones that are blasting test host room because they know it's successively high. And as you point out earlier, at least in terms of sexual function, that's unlikely to be the case, maybe less desire, but but in terms of genital based rosal function.

yeah and I mean, you've talked about this something a lot on the podcast, so i'm sure your audience knows very well the multitude benefits for a test after. So I think there is value in assessing hormones panels and assessing your level of free to section to the stone and assessing if you're having simpers are not always sexual right IT can be depression IT can be weight gain that you're not gaining a muscle mass um you can have cognitive changes. So those things can still be a sign of lotus and and very valuable, important to assess.

That reminds me of another thing, and then will get back to uts. And I want talk about kidney stones. But i've heard of women using a small amount of testosterone cream directly on the glitter us as a way to amplify the maybe it's the a desire and real effect, or perhaps just one or the other.

So i've uh the way that we discuss teater news and there are like consensus statements and there's actually an abundance of data and testers on use IT particularly imposed many apostle women for low libido or low sexual desire. And it's all been very positive and then there's been increased a sexual desire based on validate questionnaire in increased number of sexually satisfying events with testosterone news.

Now the range of testa tran women is about a tenth of the the amount of testers on man needs, right? So teater an cream is systemically absorbed wherever you IT. And so the way we generally recommend women to try this if they are having low libido, and we've ruled out other issues that may be psychologic, but in a relationship, other issues that can affect little medications, there's a lot of things obviously that go into.

But if we said and we've checked their his astonied appears to be low for physiologic levels for women, which again is one tenth of the mill level, then we can actually prescribe off label testosterone. And the guidelines are the consensus statements are not a true guidelines, but they recommend using transl testosterone so getting you know android jell tubes from the pharmacy and putting a tenth of one tube on the back of the cave or the upper outer buttock harless area um for absorption that can improve desire overall. And then the other place we use testosterone and women who have, uh, what we call vestibulum ia, the vestibule is the area outside the vagina, which is very active.

There's lots of energy receptors there. And you can actually, when you have hormonal issues, mean lower test astride and action in that area. IT can cause pain. And so actually applying a combined or component external testosterone cream to that area over time can reduce that pain and discomfort. So as you know, to certain receptors or or energy receptors all over the body, much in the generals, very much in the brain, and they're very useful to a very useful place to treat women for those issues.

Thank you. Kidney stone, I hope they never have one. People get them. How do you avoid getting them and how do you get .

rid of them? So kidney stones very often are they um they can be for a right of different metals lic disorders, right? So I can be one donation is a very common cause of IT. So uh dehydration combined with maybe a slight metaphoric Normality where you're creating more calcium or oxley in your urine can result in um in kidney stones.

And so how can you prevent them, I mean, to each person's individual, if you get a kidding stone, typically we do with called twenty for our your own analysis, some blood work to assess what is the metal BOC Normality. So we can target that either with diet or with medication. And so that kind of general recommendations for people who have kidney stones, one is increased your fluid and take to two to three years.

Again, the same number I told you before you wanted, decrease your oxalate and take me your google oxy, you going to find million things that you eat that have oxford in them, but the big ones are spinage and rubies. B, I was seeing a lot of nuts too, that are, you know, people eating lot more nats to get more protein. So you cutting back, it's impossible to get rid of all of that.

You die. But if having like a spinner salad every day, well switch IT a different Green right don't need spinage everyday. Um also you want to increase your city trade index that's an inhibited of kidney stone information.

So increasing fruits and um and things like that to increase sita vegetables as well. That actually one easily accessible thing is Crystal light. IT has a high c rate composition so you can drink Christal light with that two three leaders and that can be helpful.

Um you want to decrease your protein intake. So high levels of peans or purisima meets like red meat and things can also pursue a higher risk. So these are kind of the general sort of preventative measures we talk about for kidney stones um if you have a kidney stone.

So a lot of times people were going to have kiddy 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 are getting very large or they are starting to move into the europe or of the tubbs that drain the kidney.

Often times there, they are company with pain, quite a bit of pain um and IT can be very uncomfortable in those cases. Um we can, if they're not having any infection symptom, think there's no signs of a urinary tracked infection. There's no no fevers, no chills.

We can treat IT conservatively with pay medication and also um there are medications like flow max as you use for uh in large process as well, that actually relaxes the erl smooth muscle to allow the stones to pass a little bit Better. Um if you're having an infection, you've got to a treat right away. If you can get very sick very quickly. In fact um i've seen Young healthy patients like they're healthier than me walk in the in the E R with the kinney one and within twenty four hours they're .

in the I C because they're really sick because tea color. Blood in the urine yeah all of those are important warning things that you ideally don't get to .

yeah blood in the urine, I mean, doesn't always mean infection that could just be irritation from the stone, but certainly fevers, chills or you have a sign of the infection and the stone looks like it's blockers. So if you get imaging and you see what's called hydrogen ces or pressure behind the kidney and you you have these signs of infection, we don't want to wait because you can get sick pretty quickly um and then you once a to treat the Kitty son's three major options, one is shock waves, another is you read ocock's. We go in with a camera, we have a small laser.

We break up in a small pieces and camera through.

create deep under anesthesia. So you don't have to yeah saw .

the winds and then .

percutaenous nephila omy, 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 through the back with a small like small incision and with a specialized camera that goes in and uses ultrasonic lethal trip y to break up that still in kind of suck IT out that way.

They are extremely helpful. Bit of information or not even bits. These are this, an enormous amount of useful information.

I like to pit again for sake of bread. We can go into extreme depth on everything, but appreciate your wilderness to to follow this care. Sell with me. Oral contraception. Previously on this podcast, I hope to female physician guest who offered both sides of female oral contract action discuss some of the benefits, discuss some of the risks. I made the decision to post clips about both on the internet and wow, wow, wow was I surprised but also Frankly a bit shocked and then finally um intrigued by how polarized the discussion is around female oral and female contract action in general.

So new verron nor plant um the pill brought category of things there but for sake discussion the pill eeta I mean IT seemed that approximately fifty percent of responses which seem to come mainly from women, where of the this stuff is terrible IT ruined my life IT ruins lives and destroyed you IT has immense um risk and then the other half um seem to say, no there's reduced risk of certain forms of cervical cancer um this has allowed me the several choices and lifestyle that I prefer without risk of pregnant Y I mean IT was astonishing to the point where I thought, well if only I could post both clip sim multi ea sleep so obviously I don't know what the answer is um but I do know that this is among the more polarize zing topics available for discussion um so what is the story meaning? What are the data about oral contracts? tion? Why so much controversy and what's the real deal here?

yes. So that is a very polar ized topic. And there is abundant data, abundant. Da, in fact we given to a study and again, this is um not like high quality the evidence, but we looked at red IT threads and we looked at sexual diffunce tions specific low libido orgasm ic difficulties and we like red hundreds of threads and we did like a quality tail analysis to see in females to see like what are people talking about and problems with oil contracts, tips and anti depressions leading to low libido.

And and being very, as you described, very like this ruined my life, was very common. And so the theory is that taking oral contraceptives increases the amount of sex hormone binding globulin, which finds testosterone and astringent, and that actually makes testosterone less available, which is, as we ve talked about, a very important hormonal for desire. And so in some subset of people, they're seeing very significant consequences of taking oral contraceptive. Now I think that there is, we don't know which women are going to have this problem, and we don't know how it's probably a very small subset of people, but we do know that this does happen and that when you measure S H B G levels, they're up and that even after they stop the old contraceptives, you'll see elevated S H B G levels from baseline. For how long do for like at least four months afterwhile, you'll still see elevate to S H B G level.

So we don't know, but not infinite. I know we don't know. Yeah, the underground systems, weird. Because IT, we assume everything as a short term effect, but there is some plassy in the system because because it's a neural indicate system. So yes, okay.

so I think there's some neural plastics ity there that occurs as well. And so we do see this. And I think that the other side of this yeah absolutely oil counties are amazing right there.

They're helpful for sexual freedoms for for preventing pregNancy, for you, for a lot of things and particularly other conditions too like and and other problems. All conceptor are amazing. And they have changed you know psychotic logy and management of these women for in in a very positive way. And so I think yes, I do think that there is oral contraceptive ted sexual dis function, usually low dose r gen um sort of contraction tips are the culprit. Uh but you know I think that it's it's again the data female ual destruction literature is just not as robust as male sexual diffunt literature.

I saw a lot of comments about how oral contracts tion had had to depressive like symptoms or just kind of a highly an apathy, not just low lower libido. I can imagine how that would be the case through the elevate sex more more banning global in which is preventing disaster n asteroid from being free literally yeah and exerting their effects on not just the body but the brain. But is there any evidence that all contracts tion can disrupt no transmitters? I'm not aware of any.

I don't think so, not to my knowledge. O O, K.

well, IT sounds to me like oral contracts tion for women because that's where we Normally hear about IT. IT sounds like there's a very good response in a highly individual I certainly d partners that love the pill or at least in seem to mind IT. I've had some that hated IT and like like no way tried that never will um or just went with other forms of contract action or for whatever reason, we're not using contract action.

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 the ring um uh copper I U D um so any sort of long acting .

or contraceptives we've been that's what we counsel patience on if they're having issues with the world contraceptive, even if they come with pelvic pain and they are on oral contractors, i'll tell me, know what, I just stop because may be the end. The effective on the energy captors or other interceptors is affecting the the vacation to other things were not sure, but you know why you stop IT and go get a long .

acting contraceptive method, I R R U D, R R U D safe. And here we should probably say, okay, copper R U D is one form, you want to mention a few .

of the other forms. I don't describe I U D, but genuinely seeking, they're very safe. Of course, there's risk with any sort of you know, it's a procedure you're inserting in I U D. So there's obviously some small risks associated with IT, but IT is a safe and effective form of contraction.

If people are wondering why the copper ud is an effective form of contracts tion a copper is um like the third rail for sperm as I understand IT so much so that um I was able to find some evidence for this in the medical textbooks that um in the old days as I say um prostitutes wanted to avoid um pregNancy would put copper pennies in the vagina really now I don't recommend that anyone please and um I don't think it's a full perform of of uh contraction tion um but there is evidence that that um did happen so which is amazing that means that people somehow figured out the copper sperm relationship which is into good one for the sperm .

and deduce .

from that of behavior yeah that's I am not suggesting we will do that I think is just an interesting medical factoid ah I can tell you want to move on from this pic so we will um before discussing prostate and anal sex, not stated next to one another for any particular reason, I want to talk about s sr S.

A lot of people over the last twenty thirty years have been prescribed selective serotonin reuptake inhibitors and other antidepressants um that have disrupted their sexual function or their sexual desire seems in particular um do you see a lot of this in your clinic to hear about IT? Um what can people do about IT? Um you know often times these sexual a arousal or dis function issues associated with accessorized another medications make those medications .

prohibitive for people. So you know serota is kind of the anti to orgasm. And so in fact, we will use accessory off label for people who are having premature ejaculate. So IT delays ejaculation and then there's also other sexual diffunce tions we see with IT and IT does happen absolutely. It's dose dependence.

So um in some cases, when someone comes in with essa related to function, if they're doing well, you can either try to reduce the dose or switch them to a another anti depression for example, while bw train that does not have such severe effects on sexual function. Um and so you can also use like c Alice and viagra, like you have talked what we've talked about for actual function as an addition, if we can change their medication management because no and IT gets a little bit complicated because we know iraq tell this function and depression are very interrelated. Now what's causing what and what you know where do we like? Maybe somebody went to see their doctor for depression, was also having issue directions. And now what you if you fix the directions, do you help with the depression? Like what you know.

what I mean is so everywhere shouting, yes.

So I think so I think that there is a lot of discussion has to be had. There is a lot easier to talk to your primary care doctor about depression, that IT is about your erections. And so I think it's important to like really digg into that a little bit.

Um but yes, there IT is definitely unknown thing. We use IT to our advantage when needed and um and IT can be helpful to to switch medications. Or I reduced to .

those you mentioned earlier that treason can cause a sustained direction um and is treason in the category of of touching that the serotonin transmission system.

you know I don't remember the mechanism but interestingly, treason is also used for off label like as a third of fourth line for premature speculation as well. So so I I don't remember the the mechanism of my hand.

Let's talk about. Prostate and prostate health earlier I cut up that um there's a growing trend toward I would team more progressive male physicians or physicians who treat males excuse me.

thanks. yeah.

Prescribing loads two point five to five. Milgram, C, L, S, which is to dollar fill which may assist with directions, but the the rational al for this low dose daily low dose is not centered around directions per say. It's really about um prostate health, improving blood float of the prostate, reducing prostate us um maybe even reducing the probability of prostate cancer. Um what other sorts of things are you encouraging men to think about when thinking about their protest?

So before I forget, I want to mention that los to deliver is actually treating for a red this function. In fact, IT works quite well, particularly men who are having a lot of psychogenic ic issues. One because you have to remember to take a pill before sex.

It's always on board and you know you're taking five billion ms every day and IT has a thirty six hour half life. So over you know you're kind of increasing those so can actually work quite well and is a great option for a rect tst functions. So I do want to make that cavy at in terms of prostate health, IT has been shown to be effective for B P H or in large prostate.

This is a very common condition. In fact, if you look at autopsy, eighty percent of men and eighty having a large prostate, like it's very, very common. Now does everyone get symptoms? And what's the long term concerns of IT? And you know, what can you do about IT? So typically, as the protest in large is right around the rethrocide law that shaped gland, it's underneath the blood around the area.

Throat and IT can narrow the area threat of 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, your king from a straw, if you have a wide diameter straw, it's really easy to drink. If your straw gets really arrow like so you take a coffee strong and you drink out of that, it's very difficult to drink very similarly, IT can become very difficult to earn if you have in a large prostate.

Now what causes a large prostate? There's a whole host of factors. Lot of them are genetics. So if your father, grandfather had a large prostate, you're probably more likely to have an large prostate.

Um do we know exactly um 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 earning and sometimes you'll see overactivity.

So you'll see um your blood's responding to having to push heart against that narrow your y threat to push your and out. So it's having more urgency like sudden desire to go the bathroom that you can't delay. You may be 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 more difficult to empty the blade. You might see some hesitant see like you're waiting for your stream to start or stop and start.

Um and so those you know or you're just that I can't empty like it's not because is drips or a very weak stream. And so those are kind of the things that can happen over a lifetime. Now what what are some things that you can do to help um you know C L S helps relax those those the fire of smooth muscle of the projects that that allows you're going to pass more easily.

There's also other medications that you can treat very often. Flow max um or other alpha blockers are helpful in that area um in terms of like things that you can do in general for a blood health, prostate health there certain things that are your tends to that area. And so what I tell people, not everyone's affected the same way, so I don't want people to be like or I got to stop all these delicious things I eaten drink.

But certainly IT can be useful to just pay attention. So like if you say you drink coffee every day and you find yourself ferry in the bathroom a lot, if you limit your caffeine and take, you might see that you're not going the bathroom quite as often because caffeine is a blood or irritant. So that can be coffee, tea, chocolate, know things of that nature that have cafe in them, energy drinks and as we'll forget, they have caffeine in them um and so limiting that may improve your symptoms.

Um alcohol also is a blood irritant and these have actually been sitting in animal models. You'll see that the blood contracts more often when they're given these sorts of substances um 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.

And someone who drinks IT every once in a while um other things can be uh sometimes carbonated beverages, spicy foods or citic foods. Those sorts of things can also ette the battleline. 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 past state may be in sexual this function.

Is that still a thing? I thought they put grooves into the the seats um but i've also in reading on the internet I didn't do a deep dive on redit. But um seems women are reporting some batter and continents from excessive bicycle seat use. Maybe even a exercise bike doesn't have to be roadside ke.

Yeah so this is a great point. So cycling if you think about IT, right you're sitting on your paranoia which is that space for men between the throat of and the aias for women between the vagina and the aias and right there runs your predal artery in your pretender nerve, which are again responsible for blood flow and nerve function to the area.

So the most common things, we the people who are you know um who are really high volume cycle is now the studies have looked at like maybe there are three hundred fifty kilometer race or they there you know biking three times a week for sixty months. But there's no like consistency. But they're seeing pretty high rates general nominee's.

So like up to fifty percent. And also in men, or act this function in women, you'll also see nameless. But because sensation is a big part of arousal, you'll also see kind of decrease vacation, maybe decrease sal as well in women.

And so how can you prevent that? The reason is because when you're sitting, particularly if you're leaning forward, like competitive bikers who were are riding, you're putting pressure on the the beak of the bicycle seat. And that's where you know most of the is not your weights not distributed evenly.

So the goal is to take a bike seat that allows you to sit comfortably on your issue to and posture is a huge part of your public life and we didn't talk about that earlier. But sitting you know with good posture and not um kind of slow ching or leading forward can actually really do wonders for your profit floor. So focusing on posture helpful, but also when biking posture is helpful.

So they've actually looked at this data. They found that people who are ride mining forward um are people who use narrow bike seats are more likely to have issues. And so you want to get kind of a noseless seat in a wider seat. The the cut outs actually, when they looked at kind of mechanics of the cut outs, you'll see higher pressure around the opening. So it's actually not good to have A A bike with a cut out, uh, a bike seat with a cut out because they've seen at least with some of the cut out, 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 salt bike for which has the big seat yeah for a few minutes. But I just .

at one thing because I think that I don't want to make people not cycle. I think it's really valuable. Cycling as a great erodium exercise has lots of for cardio askar health.

But um there was actually another study that looked at people who were parts of sports clubs, so they were like swimmers, runner and and cyclist and they looked at rates of dsf unction and they found that actually the rate of iraq keller's function was not different between runners, swimmers and cycler. So maybe know because those other things were just looking at cyclist that maybe it's just the general rate of rock teller function in that population at that point time. So I don't with the nameless ss is definitely issue directly this function maybe maybe not.

So I just have a couple of more questions for you. And by the way, you've been incredibly generous with your time and information here. Thank you.

So really appreciated, as i'm sure our listeners do as well. Anal sex. You recently did a post describing the multiple reasons why women do or do not have anal sex.

Yes, very interesting post. Very interesting study that you covered and you explaining that 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 uh, maybe if you could just uh, offer some of the the key bullet points that you've learn from the literature, from your clinical practice. Um you know how frequent is IT?

Uh with protection without protection, how safe is IT? 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 is there are interesting data educators.

So anal sex, let's talk about IT um well, when you when you talk about anal sex, the reason people if become more and more common, let's say it's more and more head over sexual couples are doing that. We know that um male homosexual couples are having any sex and I think that one thing is that it's safe in terms of pregNancy, right? You're not going to get pregnant from anal sex in which is one of the reasons people do engaging .

anal sex do you think are doing more frequently?

No, I think that one of the people one of the reasons but um in general the issue with anal sex is that people forget to use protection like a condom for example because sex reusable infections are actually more likely with anal sex than they are with vegal penetrative inner course because the anal tissue is very thin and fyve.

So when you penetrate the aim is particularly if you have any trauma um you can have you you can have blood loss and that blood loss can then easily more easily transmit sexually in the in infection. So it's really important to use a condom and use adequate lubrication. The the anus does not make any of its indigenous lubrication.

You have to use lubricant. The other interesting thing about anal sex is that the N S P H is different from the vag inal PH. So you want to use specific lubricant that are I saw us moler to anal people so you can actually look up anal lubras and we can talk about lubricants. But gently there is water based silicon based oil based lubricants. Water based are the most easily accessible um silicon based a little more slippery and last little longer, and oil based also last longer but are not good freeze with condoms.

So definitely using lubricants and always kind of making sure to um be in the context of course have been consensual, but also like never force, always take your time and in 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 not in common uncomfortable.

Probably we're not seeing as much of IT because they are not coming to the emergency of they're having issues unless it's really serious. Um so I think it's really important one to prevent from that sexual transmit infections to to be thoughtful and cautious. And sometimes that requires some preparation.

If you're going to penetrate ananus, it's going to you not going to start with A A large girls item. You're going to start with something smaller and kind of work your way up. And then I think ultimately, why people have anal sex.

So as I mentioned earlier, the prostate is highly innovated and can be a source of pleasure. So some people enjoy that, particularly men may enjoy enjoy penetration. Women as well may enjoy penetration because of the innovation around there, the pelvic floor um and and you know so that's certainly reasonable to do so as far as why people engage in sex.

So sometimes it's because, as I mentioned, they're trying to avoid vago penetration, either to avoid pregNancy or maybe um my strap or other reasons. Um sometimes it's because people wanted 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 maybe something kind of like a gift or something like that.

Sometimes it's almost like they feel like they they have to. And this particularly day, they look at there's actually not a lot of studies on why people engaging sex. And this particular study that talked about my channel or my instagram was um talking about why they they specifically recruit drug users.

And so a lot of people had used drugs priority using to engaging in anal sex. And I think that that's not ideal. You always want to be kind of in the right date of mind for consent and um and safety purposes and so um those were in the common reasons.

What about infection not relate to sexually transmitted infection? Um my presumption is there is a higher risk with anal sex um then there is with other um other visual and of course oral sex eta um what is the evidence for that?

Um not necessarily. It's more about sexual transmitted infections more than anything else. It's rare. You can sometimes are in the rare things that people have kind of comedy like anal and continents temporarily or things like that. Very rare mostly it's it's just sexually transmitted infections because you know you can have more it's more easy to create leading three o sex if you're not careful.

And are people doing animals before anal sex to prevent bacteria infection? Or is that just like it's .

some people are some people are not? I think it's you know people are making sure they're evacuated fully. Um there's some you know media articles about like what you should eat before to kind of keep your gut you know healthy and avoid kind of lose tools and things like that. Um but generally speaking, you know there's there's lots of things you can look up to make IT safe and healthy again.

I'm sure some people are listening to this and there maybe the'd turned IT off already. But and I think we can expect a very response to this discussion, but is happening out there apparently with the increasing frequency.

yes. And I don't know that because of the increasing availability of pornography. Y where is visualized more or if um I don't really know why, but we do know that there is more going on in heroic sexual couples than prior.

As a final category of question, I was really interested in some of the posts you've done about urbs and supplements in the context of sexual desire and sexual function on this podcast. I always say always always um we emphasize behavioral tools, first dozen dots right because those are the foundation of mental health YSL health and performance um in all context um there is of course a role for prescription drugs. Sometimes, often noise.

People can do the things and avoid that certain things they want to because of depressive states, anxious states and prescription drugs can serve a role but I do believe the goal is always um behaviors first then of course things like adequate sleep, nutrition, healthy social interaction, all of that stuff exercise. But we do often talk about supplements because they represent um I think an important category of you know over the counter compounds that can play a role. And um i've talked before about tonga, ali, this indonesian erb, I think I can be malaysian as well but this indonesian um there is typically the one that I where best for a mild libido enhancement um sometimes um especially in the case of people taking access arise um I can enhance libido to override some of the um chAllenges with accessory induced reduction in libel.

And generally unif people aren't unnecessary. Ze I hear from people take toner ali and get libel increases. Also seems like mac ka root which we don't really know how these things work exactly. Probably some freeing up of his astro with tongue, maybe some court is all suppression as well. Maybe some extra generic tor modulation with mocker route, maybe some dopo energy tone changes slog um this iovine tic erb um which there is at least one study um that um I think is done well that shows increases in fs h focal stimulating harmon with SHE log use. What are your thoughts on things like toner alimaymon route shi how do you talk to your patients about this stuff?

Yeah so I think that you know I see least my patient population is is still in the behavioral management place, right at the biggest cause of sexual disfunction, whether it's protester retail this function, sexual this function is often commodities ties, right?

So managing high blood pressure, managing divides with diet, which you talk about a lot, but the best study diet is the medtronic and diet, at least in the sexual is function literature exercise like doing you know both cardiovascular erodium exercise but also doing resistance training, particularly a legal large muscle groups um and and then uh you know really working on reducing blood pressure and and preventing diabetes and those things I think you're really keen. I know we you talk about them on this podcast. I will tell you that when people are getting ready for, for example, we do a surgery for rectors function called piano prodigy.

So this is like end of the line, things working, they can get direction at all. And I can be of and and they may have diabetes as a cause of IT. When we say, you know, you have to get to hima global, a one sea below a certain level to do surgery. I cannot tell you how quickly these change their behaviors .

for sake of action.

for sake of erections. So I think that really, if I can say one thing before you do h supplements so I don't have a problem with, I think that it's reasonable to try them. And I would try wanted 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 onna work immediately. If you take something that work immediately, it's probably got a pd five mixed there. And so it's onna 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, that boosts testosterone. And even you know, you mentioned this all the time, but getting early morning light, but it's it's beneficial for test as well because your helping release us starting with the circadian biology. So I think that those things like I can't stress enough like how valuable they are.

And if you're smoking, quit smoking IT will kill your erection. Wapping, yeah. And then last, if you are developing true organic impotence that there's A A biologic problem that's causing your sexual disfunction, then it's really important to get your cardiovascular health assessed.

Because about fifteen percent of men who develop a req tile this functions seven years later will have a cardiovascular vad. IT is the canary in the coal mine, meaning that, you know, it's a that you may be developing. Cardiovascular problems are like endothelial dis function that first presenting in the penis or in their sexual organs, and know this probably is the same for women. We just don't have the data again.

I know a good number of women that take tongue in part, I think on the recommendation, although I want to be clear, I never recommended IT. IT was an offer of something that people could try if they're doing everything else correctly and could assess um with consulting your physician, of course.

Um and they do some of them have reported improvement in libido and desires well also ah and the cheese is less known about the distinguishing quality versus low quality. Sources of sheedy is harder. Dosing is harder comes as a tar typically.

Um maybe more science on Chloe will come out in the next few years. We could um get get behind IT a bit more right now. I'm sort of on the maybe try. It's not one that I Normally threw at .

the top of the list. Yeah I think that like elsa rine is is pretty good. Ash aganda for stress reduction, which also has implications for sexual function.

Tom kali has a reasonable data. Um I think there you know there is reasonable da on these things. I think the website you talk about all the time exam and up com is a great place to look at that.

Um and you know like I said, I think it's reasonable. They're smaller studies. They're not um is biased many studies. But there there is effort done in this area. There's never going to be uh really high quality science and no one's going to a really fun of that, I think so I think our expectations to be a little tempered when .

IT comes to that stuff. Well, reno doctor music, I want to to thank you ever so much um for this discussion today you provide us so much useful information um and really have transcended the divide between you know the mysterious thing that everyone wants to know about sex and sexual health, genitals and genital health prosor you read through ut s all these topics that many people are just afraid to. To raise and to confront directly.

And you've you've taught us so much about how to promote the health of this incredibly important system. One thing we know for sure, either in vivo, in a dish, we're all here because of sperm and egg and uh and um and of course there are other reasons why people engage in sexual activity. They have nothing to do with a reproduction but um surely this court our biology and our psychology and well being.

So thank you so much and also thank you for the work you do day and a 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 think finally, there's somebody who's providing the kind of information that everybody wants in in a fought'st gc clear and respectful way.

Um so on behalf of all the listeners and viewers and on behalf of myself, I just wanted 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, is an honor to be here. Thank you so much.

Thank you for joining me for today's discussion with doctor reno olic, all about neurology, PVC floor and sexual health. If you're learning from indoor enjoying this podcast, please submit our youtube channel that's a terrific zero cost way to support us. In addition, please subscribed to the podcast on spotify and apple and on both spotify and an apple.

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