Dr. Irina Malek, I’m really excited to have you on and we’re just talking offline for a number of reasons. Number one, you’re a female talking about sexual health and I think right now the scope is there’s a lot of discussion on TRT for men and when we talk about sexual health, everybody talks about erections, but from the female perspective, I would say it is really underrepresented, not even spoken about, maybe people are embarrassed. 

Yeah, I mean, I think there’s a lack of knowledge, right? Like, I don’t think there are videos I’ve made on the basics of female anatomy and I can’t tell you how well they’ve done because people don’t know the basics of female anatomy, that the clitoris is the organ for pleasure, that is the homologue of the penis, meaning that how you stimulate the penis to get an erection and to get orgasm is the same way you’re going to stimulate the clitoris to get an orgasm from a female. And it’s like things that are just so simple that are not taught, not educated about, and then people don’t know their bodies or how to pleasure themselves or their partners and it can be really traumatic. It can be a situation where you feel like you’re broken because things are not working the way they should or that you think they should. And what’s fascinating is it’s a whole medical field and I was reviewing before you came on the podcast and I will say that my husband was so excited that you’re coming on the podcast because you are a superstar. Thank you. You did pelvic, so you are a trained urologist. Correct. You went to NYU Medical School. You went to, I think you did a residency at University of Chicago, which is one of the best in the country, if not the world. Then you did a fellowship at UT Southwestern. Just right nearby. Right 

nearby, right down the street in pelvic and reconstructive surgery. Correct. And you’re also trained in sexual medicine. Yeah. Yeah. And it’s an honor. It’s an honor to be able to have gotten through the training, have wonderful mentors, and then have great friends who also taught me a lot, colleagues. I think you keep learning and that’s really the most exciting part about being in this privileged position to take care of patients. And I’m sure you feel the same way. I do. 

My first question too is why sexual medicine and why, so there’s sexual medicine. And then for the listener, pelvic reconstruction is a very specialized field. Why those two? Yeah. So when I was in residency, I really liked all of urology. But I realized that as a female urologist, there’s only 10 to 11% of us in the country that are practicing urologists who are female. So a really small number. And I knew I was going to see female patients, right? Whether I wanted to specialize in men’s health or not, I was going to see female patients. And I wanted to, and I really enjoyed reconstructive surgery and wanted to be able to give them a really good quality surgical experience and medical experience. And so I did a fellowship in female pelvic medicine reconstructive surgery where I learned all about the bladder, incontinence, prolapse for women, and all those sorts of things that occur when you have reconstructive issues that could be like fistulas or diverticulum or other sort of anatomic abnormalities. And then as I was in practice, I started seeing a lot of sexual medicine. And we learned enough sexual medicine in residency, but mostly it’s focused on men, right? It’s a lot of like, how do you get erections to come back? But we don’t talk a lot about orgasm. We don’t talk a lot about ejaculation. We don’t talk a lot about desire. And that’s changing. We’re definitely seeing more of it in our curriculum now. But I realized that people really had questions and had a lot of self-consciousness around these issues. And even for them to come to the doctor was such a big step and to talk about it, which is why I started my channel, right? I wanted to be able to educate people so they felt empowered, like they were at least able to get some knowledge sitting at home in their bedroom, on their couch, without having to go to the doctor. And maybe that education would let them feel empowered that they could actually take that step to get help and learn what’s normal in their bodies. And what’s so interesting is you are a practicing physician, but also an educator. And it sounds like you became an educator because of need. There was a need and a lot of, you know, you had mentioned before, where do we get our sex education? Yeah. And I think I’ll share a story. So when I was a resident, I remember, you know, you would learn, you would learn the surgical techniques, you would learn how to talk to patients, but you only had so much time with patients. Right. And so I remember doing this surgery on a patient. She had bladder cancer and we did a reconstructive surgery where we made what’s called an Indiana pouch. So reconstruct the, the bow from bladder and there’s a little stoma or opening on the abdomen that you have to catheterize. And so you had to now empty your bladder through that little hole on your belly with a catheter or tube. And this woman was so sweet. She did great after surgery, but she kept getting readmitted to the hospital and getting admitted to the ICU. And then we, we sort of figured out later on that she just didn’t know that she had to catheterize herself through her stoma. So I realized at that moment, that was like that pivotal moment where I was like, you know what, we can do the perfect surgery. We can do the best job we can. We can give the patient the right medications, but if they don’t understand either the side effects, the sequelae, how their quality of life is going to change, then we failed. And so that’s sort of where I realized that education was such an important part of it. You know, it’s such a huge part and you just don’t have the time to spend the time you want with patients one-on-one and you know, people forget things like they don’t have it. They can’t then revisit that discussion you had because it’s over. And so it allows, you know, educating online allows you to have, you know, things for people to refer to. How long have you been doing that? Educating online. It’s been about five years now. Okay. Yeah. Do you remember the first video you put out? Like, Oh my 

gosh, I don’t know if anyone’s going to watch this and I don’t even know if I should put that out there. Yes, I very much remember. And it’s funny, you know, now you look at people who have these wonderful production values. I started with a window, right? I had my light was a window. I use my cell phone camera. I had horrible audio and it’s still up. You can look it up, but it’s like, you know, I’m just talking to the camera and you know, you learn, you sort of figure out what people want to know and what they want to learn about. And that’s sort of how I got into talking more about sexual health. I initially started talking about bladder health, but as I realized people really wanted to learn about sexual health, like that was really important to them. And so I started really making more content for them. But yeah, you sort of, you’re like, is this, is this okay? What are my colleagues and I think am I going to, am I going to mess up? And you know, you sort of get over that pretty quickly. And by the way, we do mess up. We’re human and science is always changing, but that’s all part of it. Do you remember your first video? 

I don’t, but I do remember my first moment of actually having to post something. My armpits were sweating. I was just like, what am I doing? You know, this is going to be the worst idea I’ve ever had. And then I did it anyway. And I realized I had made a lot of worse decisions than talking about protein or muscle or something else. 

So I was looking at some of the data and if these numbers are correct, 40 to 50% of adult women across the lifespan have some kind of sexual dysfunction. That is correct. Now the that’s a lot, but that doesn’t mean that everyone’s bothered by it. So when you look at the data about 40, the most common sexual dysfunction for women is low libido or lack of sexual desire. So 40% of women will report low libido, but only 12% will be bothered by it. And that’s still a large number, not to minimize that at all. But it is very, very common. And unfortunately, until this field of female sexual medicine, which unfortunately is actually pretty young, like when you think about it. When did it start? I don’t know the exact date, but you know, it wasn’t popularized. There was only a few people doing female sexual medicine. There’s still only a few. Like I went to this year to the International Society for the Study of Women’s Sexual Health Meeting and it’s a small meeting. There was what, five people there? 

No, no, the hundreds, but it’s small. It’s small compared to other meetings, right? Compare it to other society meetings, you’re going to see a lot more people. And so I’m glad it’s growing. It’s definitely growing. And there’s definitely a lot more interest in studying women. But there’s been this disparity where we’ve been studying men and erections and sexual function for much longer and more intensively and with more scientific rigor than we have for females. And I think that’s really part of the reason why it’s such a young field. And that makes a lot of sense. And you had mentioned that the equivalent for a male, for a female, would be the clitoris. And there’s a lot of talk about erectile dysfunction. What would be the equivalent for a woman? 

So in terms of erectile dysfunction for men, the equivalent would be lack of arousal for women. And the difference in the man and the female is when you have arousal, your blood flow increases to the genitals. So for men, their penile tissue muscles relax, blood flows in and it becomes erect. And that erection then is sustained because the firmness of the erection is 

preventing blood flow from leaving the penis. The same thing happens to the clitoris. You get increased blood flow to the clitoris. It expands and gets firm and erect just like a male penis does. And so that is sort of the equivalent. Now I think that lack of arousal in women is pretty understudied. And the reason being is we talk about it in terms of lubrication. And that’s one sign of arousal for women, absolutely, having adequate lubrication. But it’s not the only sign, right? It’s the sensation of feeling aroused. And any woman you talk to can tell you what that feels like. You feel sort of that tension in the pelvic region. You might feel your nipples become erect. There’s sort of a whole cascade of sensations that you’re going to have. And so is lubrication alone truly an indicator of arousal? Probably not. 

 

And lubrication can vary from person to person, whether it’s genetic, whether it’s due to hormonal changes. So if you’ve just had a baby, for example, your estrogen is going to be lower, you’re going to have less lubrication. Same thing when you’re going through menopause. Your estrogen drops and your lubrication lowers. But it doesn’t mean that just because you’re not well lubricated, you’re not feeling desire necessarily, which is very often correlated. So more lubrication, men or women will often correlate that with more desire. And that’s not always true. So there’s the arousal piece, which sounds like it’s more of a physiological response. And then there’s the desire piece, which sounds like it’s more of a cognitive or top-down brain function approach. Would that be fair to say? Absolutely. So desire is exactly what you think it is, wanting to have sex. And that is definitely correlated with the brain. And so when we think about medications that we use for low desire, those are all working on brain receptors. They’re working on our brains, not on our genitals. Whereas if you’re focusing on arousal specifically, like, for example, men who have erectile dysfunction, they’re taking medications that increase blood flow to the genitals. They’re not doing anything to the brain. That’s interesting. And the medication is for men, I’m assuming you’re talking about, to dalafil. 

What about the medications for women? 

So for low desire? Low desire is really complex. And I don’t want to just jump to medications, because I think there’s really multifactorial issues that cause low desire. And so yes, we have medications. And we’ll talk about those. But I think when you’re thinking about low desire, first is like, what does that mean? What does low desire mean? Are you bothered by the fact that you have low desire? Has it changed? Has it always been stable? And you’re like, I just don’t feel like that’s normal? Is it just, are you comparing yourself to what you think normal should be? And then what exactly, desire is different. So when we see TV or movies, we see, you see your partner, you get turned on, you want to rip off their clothes and have sex, right? You have desire, then you have arousal. But sometimes it’s the opposite, right? It’s what we call responsive desire. So you see your partner, you become intimate with them, you become close, you touch, you’re like not necessarily wanting sex, but you want closeness. And then you’re receptive. You’re like, oh, I finally feel, oh, I feel that desire now. Yeah, I’m having sex, I’m really enjoying it. But it wasn’t there in the beginning. And that’s normal. That’s completely normal. Especially in long term relationships, that’s completely normal. So I think a lot of times we think, oh my God, I don’t have that desire I used to. But you’ve been with the partner for a long time, things change in your life. You’ve got kids, you’ve got aging parents, you’ve got other, you’re busier at work, whatever it is, those things will detract from your ability to have desire. 

That’s fascinating in the way that it is. That’s very complex, especially as you transition through life. 

Have you found things, I guess, from a more, I don’t want to say holistic perspective, that’s not the right word, but a more integrative perspective that can help women increase their desire because as a practicing physician, is that one of the first things that you hear? 

Do they say I have low libido or do they say I just am not desiring? I just don’t want to have sex. Yeah, I just don’t want to have sex and usually it’s my partner wants it and I don’t or sometimes it’s like I used to be really into sex and now I’m not and I’m wondering what happened and I miss that. 

And so what things I tell people, the easy stuff is like, first of all, look at your life. Where are your stressors? Because when you think about sex, men look at sex as a stress relief. They’re like, oh, I’m going to have sex, I’m going to feel better afterwards. Women are like, this is something I got to do that’s going to be like a task, right? It’s another task to do. It’s like a chore. And not all women think this, but like, you know, that is sort of the way that we women and men perceive sex differently. And so you want to think about how can you reduce stress so you can actually enjoy sex like sex is supposed to be fun. It’s supposed to be play. It’s not supposed to be this like stressful event, like, oh my god, I got to do this again, like, it should be something we look forward to. It’s funny because we’re talking about it. Hey, guys, we’re giving you insight for the men, for the male listeners, we are giving you insight into the female psyche. Yeah. 

As you know, and I’m just curious from your perspective, when you started thinking about this and talking about this for you, like, whoa, I, this is kind of uncomfortable. Yeah, you know, I think as a urologist, you know, you pick your field because you’re comfortable with it, you know, like, I talk a lot about penises and all kinds of things. This is all very true. So I think it’s different. Like, when I talk to people, I think they’re more uncomfortable than me, you know, because not so much. And it’s funny because, you know, I’m South Asian, we don’t talk about sex a lot. It’s sort of very taboo. And now I talk about sex very openly. Are your parents like, oh, she’s, she’s talking about that thing again. Well, you know, they’re very proud of me, which is which is surprising, because, you know, I talk about sex, but they’re very proud of me. But then when people come up to them and tell them, oh, I love your daughter, I watch her all the time. They’re like, I don’t want to know, like, I don’t really want to know. Yeah. And you’re like, but but yeah, no, I think so back to your question about like, what can you do holistically? So I think one is reduced stress. And so whether that means offloading some of your responsibilities, hiring out or having your partner take up more responsibilities, whatever it is, that can be helpful. And some of that relies on, you know, figuring out ways to have boundaries, all those sorts of things. And then, you know, sleep is really important. So we know that sleep quality and duration are correlated with our hormones, right? So when you have more, more than seven hours of high 

quality sleep, you’re going to have higher levels of testosterone. Testosterone is the hormone of desire, right? So when women have testosterone, the same as men do, but women have actually more testosterone in their bodies and estrogen. And so it’s really important for both men and women to get good quality sleep. And I think we pride ourselves on like, I’ll sleep when I’m dead. I know, like we need to sleep, right? And so it’s kind of a luxury, but it shouldn’t be. But again, I mean, we’re the only species that actually purposely delays sleep, like no other animals or anything, they go to sleep, right? Like we’re the only ones like, I got to stay up and scroll my phone or like, get one more thing done or whatever it is, right? And so that’s one. Another one is exercise, which you talk about a lot. But we know that exercise increases desire in the long term and in the short term. So if you work out, you’re getting increased blood pressure, increased heart rate, and your body’s getting primed for arousal. So you’re going to have more arousal when you’re ready to have intercourse with your partner because you’ve worked out. And so those things are really, really useful in terms of integrating things that you can do every single day. Now diet is for all people important for every aspect of your body. And you know, you’re an expert on that, but diet is super important. And then the other thing is mindfulness. So there’s been actually a lot of high quality data. You can look up Laurie Brato’s work on mindfulness. And they’ve looked at women, like thousands of women, and said, you know, if we implement a mindfulness practice over eight weeks, you find that they improve desire significantly. And the interesting part about it is you’ve read a lot of studies, you’ll notice that a year later, if they contact these women who were part of the study, a year later without any prompts, they’re still doing mindfulness practice because it improves their lives in so many immeasurable ways that they’ve continued it without any input from the study or anything like that. 

So it’s really valuable and something that you can incorporate pretty easily. I mean, it takes time, it takes effort, it takes dedication. But again, you’re investing in yourself. If you want a better sex life, if you want to have that desire, if you want to be able to be in the moment with your partner and enjoy sex, which is going to obviously increase desire when you’re having more fun during sex, you’re going to want it more, then you know, you got to do things to make that happen. 

What I’m hearing from you say is that sleep is really important. 

Exercise is also really important and mindfulness. Those are very easy things. I was looking at some of the data for nutrition, no surprise. And what I found was it seems like iron plays a role. I don’t know if you’ve seen any of the data talking about anemia and potential change in sexual function. Have you seen any of that? I mean, that makes sense, right? If you’re anemic because you’re iron deficient, then you’re not going to have the energy and you’re not going to have the, you know, if you don’t have the energy for sex, you’re not going to have desire for it. Yeah. So I’ll just put that out there and we’ll link one of the studies that it’s available on PubMed. And again, I just thought that that was so interesting. 

What do you then counsel people? So they’ve done all of these things. They’ve said they’ve come to you and they’ve said, I have low desire or low libido. Would you say, first of all, is there an age range that this seems to happen typically? Yeah, it’s more common in women as they’re 

like in like a longer term relationships and sort of in the midlife, right? Because they’ve got a lot of responsibilities around that time. They’ve got aging parents, they’ve got young kids. And so that tends to be the time when the stress level is the highest and then around menopause, right? Because you have this dramatic change in hormones. 

Testosterone, as I mentioned, is the hormone for desire, but that decreases steadily over your lifetime. 

And so that’s also coming down along with estrogen, which will cause a lot of changes in the quality of your tissues, vaginally, which can cause discomfort and pain and lack of feeling like just not yourself, right? And so I think all those things together play a big role in sexual desire. And this might not be an evidence-based question, but I’m curious as to what your opinion is. When individuals go through menopause, it’s different for an aging male. An aging male, their testosterone might not decrease. Maybe their sex hormone binding globulin increases, but testosterone levels can remain stable. For women, there is a clear delineation when a woman has achieved menopause. So yes, there’s a decrease in estrogen, decrease in testosterone, decrease in progesterone. All of these things happen over time. Do you think that there’s a biological driver, for example, should women then not have sex? So I’m trying to frame this in the right way. So we know that these hormones decrease. There’s changes in tissue that happen, probably not preventable, right? Is there things that we could do or is this going to be an inevitable process that happens? And is that kind of the human species saying, “Okay, well, no more sex?” Yeah, so I think, well, first off, can it be preventable? I’m not sure that you can’t prevent the change in hormones, but you can prevent the loss of tissue quality by doing a variety of things, which will increase blood flow to the genitals, right? So the same things that we talked about, exercise and sleep and diet quality, those things will improve blood flow overall. So we know, for example, in men, right, they reduce blood flow to the genitals because of comorbid conditions, like high blood pressure, diabetes, high cholesterol, and all those things. Same thing for women, although it hasn’t been studied as rigorously, it’s probably exactly the same, right? We’re homologues. Our genitals are identical. If you look at them, if you cut them on an anatomic section, they look the same. And so, you know, preventing those conditions is going to keep good blood flow to the genitals. And we know that at night, women and men are having tumescence or women are having erections and women’s clearances are getting hard, right? And so that’s a sign of good blood flow to the area. And so probably if you keep yourself healthy in terms of like avoiding those comorbid conditions, you’re probably going to have better quality tissues because you’re going to get better blood flow. 

In terms of like, can you, should you not have sex? No. I mean, I think just like we maintain our bodies in other ways to live a long, healthy life, you can maintain your vulvar tissues to have a high quality, good functioning tissue and continue to have sex and pleasure. Now, does it have an evolutionary purpose? Probably not, right? You’re not having children. But that doesn’t mean you shouldn’t enjoy pleasure because orgasms have really benefits, right? They decrease, they decrease mood, poor mood symptoms, they decrease your blood pressure, they improve your focus, they might help you sleep. Like there’s a lot of benefits to having orgasms and they’re natural. Like you don’t need to take a pill, just go have an orgasm. 

Where is Rina? She’s busy right now. She’s improving her mood.

That is fascinating. And I think that from a male perspective, we hear a lot about erectile dysfunction as the first barometer for cardiovascular disease.

Forty percent of men age 40 or so will have some kind of erectile dysfunction. And again, it goes up by decade for women. And the clitoris, could one say that if you are unable and I don’t know if women know when their clitoris gets erect, but if could that potentially be an early sign of heart disease? Yeah, it could be, but I think it’s more about, you know, I don’t think we wake up like men do with erections. I think sometimes you feel sort of congestion or like a feeling, a tingling, a fullness, a feeling in the pelvic region. And you sort of know your clitoris is getting erect and you can, it’s sort of the same thing when you’re aroused, right? And so, but it’s harder, I think, because women don’t like wake up and notice an erection. And so they can’t sort of monitor if this is changing over time necessarily, but they may notice that they’re having, you know, more like difficulty getting aroused or that feeling, that sensation of blood rushing in or that feeling of fullness or tingling or whatever, you know, everyone has their own identifying feeling, but that changes or becomes muted. Maybe that’s a sign, right? And we don’t have that data, I think, yet. But ultimately, I think that, yeah, if things are changing in your sex life, you should see a doctor, even if it’s just to get your heart checked. And it would be fair to say, again, you said that it’s homologous. So the male counterpart from all of these things, whether it’s the penile tissue and the clitoris and these feelings of desire arousal,

are all intertwined. But from a medical perspective, would you say that it is under-disgust as an indicator of other potentially comorbid conditions? Absolutely. 100%. I mean, I think, you know, cardiologists know this, urologists know this, some primary care doctors know this. But honestly, they’re not, I mean, unless you’re specifically saying, hey, go, like, I will actually screen all my patients, right, for cholesterol, diabetes, when they come in with sexual dysfunction, because it’s so intertwined, right? And I’ll say, you know, go get an EKG from your doctor. Like, these are simple things you can do, maybe in a stress test. But like, these are things you should do. And this is an indicator and a sign for it. But I don’t think everyone is necessarily making that connection. They’re sort of like, oh, you have a problem. Let’s fix that one problem. They’re not thinking about the big picture. And part of that is the way our medical system is run, you know, that you don’t have enough time to address every issue that a patient comes in with. And I think one question that would be a normal question that potentially is listeners are thinking about this, do we know what normal is? For example, how often should a woman be aroused? How often should she be able to achieve orgasm? Do we have a framework for thinking about what would be considered healthy versus not healthy or a spectrum? Yeah, so there’s no specific like, how often should you have sex? But there is, you know, how often are people we can extrapolate from male data, men are having three to five nocturnal erections at night, right? And so women should be having three to five clitoral tumescence episodes at night. So we don’t have yet the technology to monitor that. But, you know, I know there are some companies working on some at home devices that will be able to do that.

So that’s sort of interesting. And then in terms of like, how often should people always want to know, like, how often should you be having sex? So there’s no perfect barometer of that, right? It is as much as you and your partner decide is good for you. But if you want to know the average, the average American probably has sex who’s in a partner relationship once a week. So 52 times a year. If you’re doesn’t sound like very many. Yeah, I mean, I think it’s that’s the average. But when you’re in your 20s, that’s about 80 times a year. So maybe twice a week or once a week. And then when you’re in your 60s, it’s 20 times a year. So maybe twice a month. So it changes over a lifetime. And again, there’s no right or wrong amount. It’s really about you and your partner and, you know, wanting because people’s desire is different. Right. Some people want sex every day. Some people want it every other day. Some people want it once a week. And there’s no right or wrong. As long as you and your partner are happy about it, that’s what matters. And I think it probably saves a lot of marriages when you address both parties. You got to talk about it, right? No one taught us how to talk about sex. No one told us, like, how do you have a conversation with your partner about, like, what’s well, what’s going well, what’s not? What do you want to try? How often should you have sex? And then it leads to this, like, passive aggressive sort of communication or frustration. And that’s never a good thing. Right. And I think that we would save a ton of marriages if people just taught other people how to talk about sex. You’re doing a great job. So there you go. We talked about the natural ways in which we could approach decreased desire, low libido, moving from the natural ways of lifestyle. What would be the next step? So a patient comes to you and is like, hey, I have low libido. I am sleeping eight hours a night. I’m exercising and I’m meditating. Yeah. OK. So then first of all, I want to make sure that they are not having any other issues. Like, it’s not painful during sex. We would address that, right? They’re not having any other concerns. And on their exam is everything normal, right? So are they having changes of low estrogen that may need to be addressed? Because again, if sometimes you perceive that you’re not aroused because your lubrication is less, there’s a big brain connection, right? We’ve our whole lives been used to like having a certain feeling of arousal and say now the lubrication is not there. You might think you’re just it’s not the desire is less because you’re having less arousal, right? And so addressing those issues. So if you’re having symptoms of low estrogen on your vulvar tissues, using hormones like vaginal estrogen are very, very safe and very, very effective. And it’s, you know, there’s been a lot of misinformation about estrogen hormone therapy, but vaginal estrogen is so safe that we’re now recommending it for once you’ve been clear of cancer and breast cancer, that it’s safe to give people. And it’s the amount of estrogen that goes in your bloodstream is so minimal. It’s like a drop in the bucket, right? It’s nowhere near your premenopausal levels. And so it’s so safe. And so using vaginal estrogen, either a cream, a ring or a suppository can be transformative for people. And I tell people you got to use it from now till death do you part. Like you never stop. Just like you put your face cream on every day. You’re going to put your vaginal cream in every day or suppository twice a week, whatever it is. And you’re going to use it and it’s going to be, it’s going to help your tissues stay healthy and vibrant. And all kidding aside, I’ve been reading some recent data that estrogen cream for the vulva tissue might also be good for the face. Yes, there is some data on that. Yeah.

And just putting that out there. If anyone’s interested in new face cream, probably you should get two different tubes. But for the physicians listening, obviously we’re not giving medical advice, but what would you say that the starting dose of estrogen or estradiol cream would be? So one gram once a day for two weeks and then twice a week till death do you part. 

You know, you’d mentioned that testosterone is the hormone of desire. Yeah. 

Are you compounding or are you seeing individuals, the literature, other of your colleagues using both estrogen and testosterone cream? Absolutely. So I use it all the time for what we call vestibulodynia. So we sometimes see that women during menopause or if they’ve taken birth control pills or that can change your hormones, that will affect the area called the vestibule, which is the outer opening of the vagina. And that can become sensitive. And so that can cause pain, discomfort with sex. And so when you apply estrogen and testosterone compounded cream to that area twice a day, you can then restore the normal hormonal milieu. And that can make your tissues feel more comfortable and less less discomfort. And I think that vaginally too, like we you can use a prostrone, which is has similar androgenic and estrogenic effects vaginally. And we see that you can use that for a general urinary syndrome of menopause or pain with sex. And we see that that also works very, very well for these changes in the tissues. So I think ultimately, yes, there’s absolutely value for that. And then testosterone alone, you can use compounded or you can use the male one tenth of the male dose of like androgen or the gel formulation of testosterone. And you can apply that transdermally for symptoms of low libido off label on your skin or on the vulva. So you can usually put it on your lower on your calf or the back of your inner thigh and you apply it there and you rub it in. And that is sufficient for getting changing the systemic amount of testosterone, which can, as I mentioned, decreases over a lifetime. And so you can check testosterone levels. They should be about one tenth of the male dose, a male amount of testosterone. So you just want to check and see if they’re low and you can always supplement them and see how the patient does. And there’s other benefits outside of libido to testosterone. We believe in testosterone replacement in my clinic. The benefits are tremendous. Absolutely. Increase skeletal muscle mass. And we’re not talking about high doses. We’re talking about doses all within range. Yeah, we’re just trying to make you normal. We’re not trying to make you super physiologic. And I think that’s really the key. And there’s data on, you know, a whole host of things. Yeah, muscle mass, as you mentioned, brain fog. But there’s a lot of benefits to testosterone. And there’s data. And the issue is that, you know, it’s very challenging to get these things approved through the FDA. And and there have been challenges, particularly with I mean, some of these medications we’re going to talk about for low libido, getting even them approved. There was like this huge was very challenging. And they had to put a lot more money into these medications to get them approved for women than they did, for example, so Denafil or Tidalafil for men. And so there’s these challenges. But ultimately, it’s very safe when used appropriately when monitored and assessing, making sure your levels don’t go too high. That’s really all we need to do. You know, you mentioned levels going too high. Do you think and again, this is just a personal perspective. Do you think that the the ranges are appropriate in lab values? So yeah, I mean, I tend to go by symptoms and like as long as they’re not having adverse side effects like hair growth, acne, those sorts of things that are bothersome to them, like facial hair, not hair growth on their head, unfortunately. I want that.

Testosterone replacement is not going to make that happen. In fact, it might do the opposite. Well, actually, interesting you bring that up. So I just looked into this and in fact, testosterone with hair loss is really only expecting the genetic risk of hair loss. So it’s not if your if your family has a good head of hair and they didn’t lose their hair, taking testosterone is probably not going to cause hair loss for you. So that’s that’s some good news.

Very good news for for many people. So you feel that potentially you go on symptoms. I do as well. I’m not sure how I think for men, the established range range of testosterone. Again, they seem to continue to lower what would be considered low testosterone and they don’t move the high level of testosterone, whether it’s 900 or depending on what lab that you look at. But for women, because I do feel that we’re really behind the eight ball in terms of and I think that the evidence would support that just studying women. You know, I always wonder, are those ranges for women appropriate? Because I will tell you in my clinic, women seem to feel better on the higher end of free testosterone and the issue with free testosterone.

We’re not I mean, that’s not even in the data, right? People are saying like, oh, just use total testosterone. But free testosterone is really what’s available to your body. So I think there’s a lot we don’t know what the receptors look like. We can’t study the receptors. We can’t study how sensitive they are to the testosterone we’re giving. And everyone’s a little bit different. And that’s why I think you and I both look at symptoms, because as long as you’re monitoring symptoms, making sure they’re not having adverse effects, checking, you know, their their other lab values to make sure there’s no adverse effects. You know, that is what safe monitoring is. But ultimately, you’re trying to improve your quality of life. Absolutely. And I think that the other biomarkers that you’re mentioning are hemoglobin, hematocrit, that you would see with a higher dose of testosterone, typically the doses for women we don’t. Yeah, I’m not really seeing any kind of I think with the gel, especially if that’s what you’re using, you’re not going to see much of much of that versus an injection. I think that that’s a really good point, depending on how you utilize the cream, whether it’s injection or gel.

But whether it’s sub-Q or I am also changes the risk, the potential risk.

When it comes to thinking about estrogens and you’d mentioned that estrogen is really important for the vaginal tissue.

What if a woman overall is young and healthy? What would your step be? Would estrogen be safe for her? Would testosterone be safe for her? How do you kind of risk stratify what the next step would be, whether you’re choosing a medication that’s non-hormonal like Addy versus hormone replacement? Yeah, so I think it depends individually, right? Like, do they have other symptoms of low estrogen and low testosterone? What are their lab values look like? What are their tissues look like? Did they just have a baby? Are they lactating? Do they have other systemic diseases that might lower their hormones, right? And so then you can actually check hormones. Whereas, I think less often we’re checking in menopause because we sort of know what’s happening, right? But I think in the perimenopausal space, checking labs can be helpful. 

And then I think in terms of other options, then there are non-hormonal options like you can use moisturizers. I think they’re just like a band-aid. You know, they’re good. I mean, the lubricant? No, well, so there’s moisturizers and there’s lubricants. So there’s vaginal moisturizers. This is great. I don’t know. So there’s vaginal moisturizers you can buy over the counter. They’re usually made with hyaluronic acid. They come as like either a cream or like a suppository. And sometimes use them daily, sometimes every three days. And they just they just moisturize like your skin, right? Use hyaluronic acid products on your skin. You’re doing the same thing vaginally. So they’re a band-aid. They’re going to make things feel better in the interim, but they’re not going to like change the tissues. Right. So those are available. You can use lubricants during sex. I encourage everyone to use lubricants. I think they make sex more fun. There’s, you know, multiple different kinds of lubricants. You can get water-based lubricants, silicone-based, oil-based. Water-based are the cheapest. And usually you can find ones that are very good for sensitive skin or sensitive tissues. And so those are great, but they do evaporate. So like you need to reapply. So people don’t realize that they use the lubricant and it dries up and like, oh, yeah. So there’s that. They’re silicone-based, which lasts a little bit longer. They’re more slippery and they do like, you know, they can stain your sheets a little bit. But you just want to be careful not to use them on silicone-based sex toys. And then oil-based lubricants also last longer. You don’t want to use them with a condom because they can degrade condoms. But they also can stain your sheets a little bit, but they last longer. And so they come in the coconut oil varieties and other oil-based lubricants. But there’s so many different kinds. And I think just finding what works for you is really useful. Are you worried about any of the preservatives or any of the ingredients? So it’s on that tissue that. Yeah, I think glycerin for some people can put you at higher risk for yeast, recurrent yeast infections. So if you find yourself someone who gets yeast infections, often avoid that preservative. And then generally just try to get ones that have the least amount of ingredients. Right. And those are going to be the best options. Rina has a lubricant coming out soon. I should. Although you should. It would make a lot of sense. Those are the lubricants. You had mentioned something. I do want to also talk about medications and those other options. But you mentioned something interesting and I don’t want it. I don’t want to gloss over it. 

You had mentioned pregnancy and then lactation. And I’m assuming the reason that you mentioned that is because during lactation, prolactin is high. Does that affect a woman’s ability to get excited or desire? Why would lactation or potentially prolactin affect sex? Yeah, so the high prolactin is then decreasing your estradiol, right? And decreasing your estrogen. And so you’re having the same sort of symptoms as you would during menopause. You’re getting less lubrication. You’re getting thinner tissues, vaginally more friable tissues, what we call vulval vaginal atrophy that can happen during lactation. And so these the vaginal estrogen or even moisturizers or lubricants can be helpful during that time. 

That is very good to know. Let’s talk about some of the medications and then there’s the medications. And then I do also have another question about intranasal oxytocin. I don’t know if that is utilized for desire or arousal. It’s mostly for orgasmic difficulties, right? So you can use if you’re having trouble with orgasm, these are sort of things that you can try. Intranasal oxytocin can be helpful. There’s sort of a whole host of things you can try that are all off label. But ultimately, I think first off is when you’re talking about orgasm, it’s like, well, is this have you lost your orgasm or have you never had one? And then sort of identifying. Do women know? I mean, how many women have never had an orgasm? About 12%. Wow, 12% of women? Yes, a lot of 

women. So they’ve never had an orgasm. And is that because they’re not getting adequate stimulation of the clitoris? Is that because they’re not getting enough foreplay? We know that it takes women about 25 minutes for full arousal and to make sex comfortable, right? Because the vagina widens and lengthens during sex, almost double in size. Really? I do not know that either. Yes, it almost doubles in size. The cervix moves up and out of the way. For some people, if you’re hitting the cervix with the penis, it can be uncomfortable. Some people find it pleasurable. But there is a sort of variation there. And so ultimately, if you’re not letting your body become fully ready, then it’s going to be less likely that you’re going to have an orgasm or if you’re not having stimulation for long enough. So it takes women, when they look at data, about 12 to 14 minutes to orgasm versus men ejaculate within five to six minutes. And so if you’re not prioritizing female stimulation, they’re not going to orgasm. 

Wow. 

That definitely seems to be a time difference. Yeah, absolutely. Five minutes to 14 to 25. 

Really, really important conversation. 

Medication. So you’ve tried everything. People are doing all the stuff. Talk to me about the medications used for sex. Yeah. So we talked about off-label testosterone. There are two medications that are FDA approved for female– it’s pre-approved for pre-menopausal low-desire. Not that it’s not going to work in post-menopausal women. It’s just that’s what they studied in the studies. And so one is called phlebanserin, or Addy is the brand name, which you mentioned. That is a pill you take every single night. And it is going to increase desire after about eight to 12 weeks. It takes some time. It takes time. So you have to sort of commit to taking– I tell people three months. Commit to taking it for three months. You take it once a day at night. Why at night? Because it makes you sleepy. So it helps you sleep for some people. And so you take it once a night. You want to avoid having more than two drinks of alcohol before taking it, at least within an hour. If you take more than that, skip it that night. And so you take that. And about 60% of women will see an improvement in desire. And it’s not going to be like a sudden, oh, my god, this dramatic change. It’s more like, oh, I’m doing the dishes. And oh, I suddenly feel like I want to have sex. Or my partner is doing the dishes. Yes. 

Or I’m watching something that I never used to make me arouse. And I finally feel like, oh, I feel that little tingle, that little excitement, right? And so that’s sort of what you’re going to feel with that medication. But I think people tolerate it quite well. And it is somewhat costly sometimes because of insurance. But not too cost prohibitive, I think. And then both of the medications have really great websites where you can get a telemedicine provider and they can help you get the medication. So that’s one. The other one is violecy or bremelanatide. And that’s an injection, correct? That’s it. Injection, it’s like an EpiPen. So you give it to yourself 45 minutes before you want to have sex. And it causes a significant increase in desire. Both of these medications work 

on the brain. So they work centrally. They’re not working on the genitals. They’re working on the brain. 

The phlebancirin is the mixed serotonergic agonist, antagonist. And basically what it does is when you think about the brain, right, there’s some signals that are prosexual and some signals that are inhibitory. So dopamine is positive for sex and serotonin is negative for sex. So we’re reducing serotonin, increasing dopamine. 

And so with the bremelanatide, it’s working on the melanocortin receptors in the brain, which then by pathways, increased dopamine. And so that is a more of all of a sudden increase in desire. Take it 45 minutes before you want to want. And it can last for 24 to 48 hours. So I tell people, when you take it, make sure you have a weekend to play with, right? And then there is a high rate of nausea with it. So I often prescribe Zofran at the same time because the worst thing you want to be is horny and nauseous, right? So it’s like– That sounds like being pregnant. 

Terrible. But it works again, probably 60% of people. But when it works, people are happy. Like it works well. Does the nausea go away? Yeah, so usually if you have nausea the first time, you’re still going to have it, but it’ll be a little better. And then if you don’t have it, you probably won’t get it with subsequent injections. And you’d mentioned medications on the flip side. So things that would potentially decrease individuals desire to have sex or orgasm would– sounds like would be an SSRI. Yes, so anything that’s going to increase serotonin, anything that’s going to increase opioids, those are negative for anti-sexual or they inhibit those pathways. And so anything that does that, so increasing serotonin, SSRIs, anti-anxiety meds, oral contraceptives, which we can talk about– I would love to. That’s on my list. Those can all decrease desire. And oral contraceptives decrease desire, particularly when low estrogen doses of oral contraceptives, we find that they decrease desire because they decrease our amount of free testosterone. Because when oral contraceptives– one of the side effects that increases sex hormone binding glabulin, which then sort of binds up more of that testosterone, so you have less free testosterone available. And the issue with oral contraceptives is when you take it, not everyone has this, right? I just want to clarify. There’s a lot of people who take oral contraceptives, have no problem with desire, so I don’t want everyone to freak out. No, no, there’s no freaking out. And listen, there’s a lot of nuance that goes on with these conversations and just thinking about it. We don’t have 10 hours to do it. Well, we might. I’m sure we’ll do more. But for the listener, we’re talking in broad generalizations, but trying to give perspective. Exactly. Yeah, so I would say that– but it is serious. So I actually did a study on orgasmic difficulty. In women, we analyzed Reddit threads. And one of the big themes that came up was that women did have these issues with oral contraceptives, and they were dismissed by their doctors. So I think it’s really important to bring up, but I just don’t want to make people really fearful of oral contraceptives, because they’re a great way to prevent pregnancy, right? And they’re effective. But if you ask me, I’d prefer you do some sort of long-acting formulation for contraception, because that’s not going to have those side effects. Of what would be an example? Like an IUD. An IUD. Yeah. 

Or an implant, if you want. So I think in terms of that, then people who do then get off the oral contraceptives, sometimes their sex hormone binding lab for some time. So that’s sort of the bigger issue with that. And we can work around that. It’s just that if you’re on these medications and you’re feeling low desire, this might be the reason. And talking to your doctor and getting off those medications or picking an alternative is very reasonable. And sometimes it’s dose-dependent for SSRIs. So you can decrease the dose. Oftentimes, we’ll use bupropion, which as an alternative to SSRIs for anxiety or depression. And if you can get good clinical success with those medications, then you can get off the SSRIs. 

And then talk to your primary care doctor about that. But ultimately, that’s important. And it’s a big cause of low desire. 

You mentioned the oral contraceptives, because they lower testosterone. Is that right? What about medications that individuals use for skin, like spironolactone, to affect circulating testosterone? Will that also impact desire? Yeah, it can. It can, absolutely. So basically, when you go to see your doctor, you want to say, hey, are any of these medications maybe affecting my desire? Like, is that a reason? And thankfully, we are in the age of Google. So you can Google your medications and see– Of Dr. Google. Yes, yes. There’s benefits and there’s negatives. We’re obviously online, because people can search and find quality information. And so yeah, you can easily find the potential adverse effects of medications that is on reputable websites. And so that’s a reasonable thing you can do yourself if you’re struggling. I think that that makes a lot of sense. I think recently, there’s been a lot of– not pushback, but a reevaluation of oral contraceptives as, is that the best use? Yes, it prevents pregnancy, but it just seems to have potentially– it has the potential to have longer term side effects that– Yeah, I think it’s hard, because that’s, for some people, all they may have access to. Like, they go to Planned Parenthood. They hide it from their parents. That’s all they have access to. And having it on Planned Pregnancy is not desirable either. And so there’s a lot of controversy. There’s many people who don’t believe this is an issue. But like I said, people do have normal sex drives on oral contraceptives. So it’s like, how do you find the person? And I think that’s where the study should be. Like, how do you find the person that might be more sensitive to an oral contraceptive? Because that’s really the question we need to be asking. That’s a wonderful point. 

Who knows? I mean, maybe it would be a genetic test. We’re probably not even close to there. I don’t think we’re anywhere near there. But you know, I mean, just figuring out, like, maybe do you do hormone levels before you put them on oral contraceptives? Like, maybe they have some sign. But I don’t know. I have no idea. But we have so many people. Like, I wonder if you could do a retrospective review of a large database and find some signal that may be correlated. Yeah, it would certainly be interesting and make a ton of sense. The medications like Addie, would an individual be able to utilize it if they were on an SSRI? 

Absolutely. So there’s no issues. You also mentioned in passing alcohol. 

I’m curious also about cannabis. Do these substances affect sexual desire? Yes. Sexual functioning. So in low amounts, right? Alcohol is a sedative, right? So if you’re taking alcohol and you’re having a lot of it, it’s going to be a sedative. It’s not going to make you– it’s not going to make you wake enough, right, to have sex or have desire. So yes, alcohol can decrease desire. Some people obviously will say, like, no, I have a drink, and I feel more uninhibited. And the same thing with cannabis. I feel more uninhibited so I can have more desire. And yes, in small doses, that’s probably the case. Now, when you increase the dose of marijuana or cannabis or alcohol, you’re going to start seeing negative effects on your libido. And so ultimately, any of those substances and other drugs, like, can affect your other recreational drugs, let me specify, can decrease your libido. And so, like, yes, sometimes we’ll see young people who are using chronic cannabis, and they’re like, yeah, my libido is not there. And it’s because over time, it’s giving you more of a depressant effect. And then that’s making it less likely for your brain. Your brain pathways are wired either for normal response, or you’re changing your brain response to things that would normally give you desire. 

What about over time? Do we know that those pathways can be reversed? Unlike, say, for example, sex hormone binding globulin, when you come off of this, it may go back to normal. It may not. What about we are seeing an increase in use in cannabis across the board? 

Can those individuals that have been using revert back to a more stable desire? Yeah, I think you can. There’s a lot of neuroplasticity, right? So I think that you can, but it’s going to maybe take a little bit of bridging with maybe some pharmacologic systems of some of the medications we’ve tried, maybe mindfulness, maybe other things. You’re going to have to work at it a little bit to get back to the way you were. But that doesn’t mean you’re hopeless. Do we know, is there a dose of alcohol or a dose of cannabis that would affect the body? And by the way, does it affect testosterone levels? In terms of a dose, I don’t have a specific dose for you. I mean, we know like chronic alcohol, you don’t want to have more than seven drinks a week for alcohol. Come on friends, less than that. I mean, there’s really no amount that’s safe now, we know. But for a cancer prevention. But ultimately, yeah, I think no. We don’t know the exact dose specifically that this amount is going to cause you to have– low libido on this amount is not. And the same thing with testosterone. If you use any sort of chronic substance, it will reduce your testosterone levels. And particularly, I also want to call it smoking. So smoking is really bad for our genitals. Particularly, I can give you the definition that what we see in men is that over time, their tissues become less elastic. So they’re going to feel like their penis is shorter because it’s not stretching as much when they get erections. And so probably the same thing is happening with our clitoral tissue, with our vulvar tissues, the quality of our tissues in general when you’re smoking. So if you want to have a great sex life, quit smoking. Did you guys hear that? 

And also, I could say that if you want to maintain the size of your penis, you would also stop smoking. Is that fair to say? Absolutely. Yeah. I’m saying I’m trying to frame this in a way that is deeply professional, which you are much more skilled at because, let’s face it, on the daily, I don’t talk about genitalia often. At least not publicly. I always say, seriously, if maintaining your penis length is not enough of a strong suggestion for you to quit smoking, I’m not sure 

anything is. Because that’s something that people deeply care about. And it’s smoking not nicotine use, because there is also a huge uptick in nicotine, right, Matthew? 

Just talking about zen over here, that doesn’t have an impact. It truly is the– It’s a chemicals in the smoke. It’s a chemicals in the smoke itself that are causing– I mean, nicotine hasn’t been studied. But my hypothesis would be that it would be just from the actual chemicals in smoking or cigars or from the smoke itself. Is there anything else that you want to mention about female dysfunction? Because I do want to chat about men’s sexual health in part because we’ve discussed a lot about women’s. But is there anything that you want to mention? Yeah. I think one is I would empower all the women 

and look at their vulva. Know their anatomy. One, because you should know what you look like down there. And two, what if you have an issue down the road? You want to be able to compare it to something. So that’s one, because people will have skin conditions. They’ll develop lichen sclerocysts. And they won’t know. They’ll just think it ages, it hurts. And what is lichen sclerocysts? It’s a dermatologic condition. It’s usually autoimmune. And it basically causes these sort of white plaque changes in your tissues. And it causes– it can even, at very severe extremes, cause the vaginal opening to close up or get very small. And so essentially, you may not know. You might just think it itches down there, hurts down there. You might think you have an infection. You might think you have something else going on. You might be going to doctors all the time saying, I have a UTI. I’m sure I have a UTI. And if they don’t see it, they don’t know. They don’t examine you. Nowadays, sometimes women are going to the doctor and not even getting an exam. So it’s horrible. Are they really? Yes. I can’t tell you the number of times I’ve had women come to me. And they’d be like, oh, nobody ever looked. Nobody ever examined me. I haven’t had it. Because they’re older, they don’t need pop smears anymore, no one’s even looked at their vulva. So that’s one thing. And two is look at the clitoris and look at the clitoral hood. Because sometimes women can develop like smegma underneath the hood. And that is just dead skin oils. And if you have sons or you have had any experience with uncircumcised men, sometimes they will develop smegma. Because there’s dead skin cells or oils that build up. And they usually see that. They clean it off. Women, if we don’t look, it could build up. And it can cause pain. It can cause difficulty having an orgasm. And it’s as simple as just gently pull it back and see if you can– if you see anything, just clean it up. And I think that can save a lot of people. People who come to me who end up having these issues, no one ever told me. No one ever talked about it. We don’t know that you should do it all the time. But why would you not? It’s a simple thing to do, like in the bathtub or whatever. Just gently pull it back and make sure there’s nothing building up there. What about cancers? How common are– there’s a lot of discussion about penile cancer or bladder cancer. What about cancer of the female genitalia? Yeah, I don’t know the statistics, because that usually goes to gynecology more than me. But certainly, there are vulvar cancers. And genital cancers are generally delayed in diagnosis, because people are either ashamed, scared, or they don’t see it. For penile cancer, we know that men show up very delayed, because they’re scared. They’re scared. And penile cancer is very aggressive. It’s very uncommon. So that’s great news. But when it does happen, it’s often very delayed. And because it’s so aggressive, it means that you may have to have a very serious intervention. So I just encourage you, if you think something’s wrong, please don’t delay. And it’s scary, right, thinking you might have a cancer or something horrible. It inhibits people from going. I know doctors who’ve waited too long to take care of things and had issues, right? 

And so you’re not alone. This is a normal physiologic– normal behavioral thing that people do. But you’ve got to push yourself a little bit. 

And that is good advice. You shouldn’t delay any kind of screening at this point. Absolutely. I was going to switch to men, but I recognize that there’s so much on women that we haven’t covered, like orgasm, like G-spot, 

is penetration necessary for an orgasm, all of these things that actually we should probably take a moment to chat about. Let’s talk about it. And then you can come back on and talk about guys. Sure. So with orgasm– let’s talk about orgasm– we know that 85% of women need some sort of clitoral stimulation to have an orgasm. So whether it’s by itself or with penetration at the same time, they’re usually incorporating some clitoral stimulation. Now, there are women who can have orgasms from vaginal stimulation. I don’t like to call them vaginal orgasms, because an orgasm is an orgasm, and it’s just from stimulating a different part of the body. And so vaginal orgasms are typically from stimulating what you call the G-spot. It’s actually a zone. It’s called the G-zone. And what part is the tissue different in the zone? The zone. So in basically two to three centimeters of the upper vagina, of the anterior vagina– so when you are looking at the vulva and the urethra is on top and then the top of the vagina there, 

two to three centimeters in is where the G-zone is. And that’s basically where a few things are. So one is the skein’s glands. And these are these glands that are between the urethra and the vagina that have a lot of nerve endings. And they’re similar to the male prostate. So you may have heard some men orgasm through prostate massage. Not everybody. You don’t hear about men needing prostate massage to orgasm. It’s sort of an option. Similarly, vaginal stimulation– I don’t think I talk about that. I mean, they don’t, but there are some people who are into that. And so there’s a reason for it. There’s nerve endings there that can be pleasurable. And then there’s also your clitoral body. So what you see of the clitoris is just the head. Think about the penile glands. All you’re seeing is the glands of the clitoris. There’s a full body that goes deep into the pelvis. And then there’s the little legs that go around the vaginal canal. And so that, as it gets more tumescent during arousal and during foreplay, that also is pushing against that area of the vagina. And so when you stimulate that area through either penetration or manually, some women will achieve orgasm that way. And then other ways that women often achieve orgasm is through cervical stimulation. So some people find it painful, but some people find it quite pleasurable. And they can orgasm through stimulation of the cervix. And so these actually, when you look at the anatomy, they all have different nerves that go to the spinal cord and the brain. And so the orgasm quality may be a little different, because your brain’s getting stimulation from a different nerve. And some people will say, the cervical stimulation gives me this cosmic feeling of orgasm, and it’s a little different. And the G-spot stimulation, G-zone stimulation, is a different type of orgasm. But ultimately, they’re all orgasms, orgasms being a buildup of tension in a release, 

and a powerful release. And that’s very pleasurable. And so ultimately, you should experiment with yourself. Figure out what you like. So you can train your partner on what you like. And the 

one way we know that there is this discrepancy in terms of women getting adequate stimulation is when you think about first-time encounters for sex. Women and men, 95% of the time, men orgasm. 45% of the time, women orgasm. 

90%– so first-time encounter. Yeah. A man orgasms 95% of the time. A woman orgasms 45% of the time. OK, so then you might say, well, maybe it’s just the woman, right? But you look at lesbian first-time encounters, and it’s 95%. Wow. Yeah. So really, it’s just understanding probably in part anatomy? Exactly. And communicating, right? And there’s another thing, right? We don’t feel comfortable communicating during sex, right? So like, move your head this way, or move your hand this way, or this is not feeling as good, or whatever it is, right? And you don’t need to be negative, but certainly guiding your partner and giving them instruction, whether it’s verbal or nonverbal, can be positive. But we don’t know how to talk about it. And like, first-time encounters, generally speaking, 

people are nervous. They’re usually more inhibited, and so they’re not going to communicate as well. And that’s why actually, as women age, one, they’ve had more experience, and they feel more confident. They also know what they like, and they tend to have better sex. And could an individual who has an orgasm, and then they’re experimenting with these different– let’s just call it nerve endings, or spots, or zones– 

once an individual orgasms, do they become better at orgasming? Yeah, I mean, I think you know how to stimulate yourself, right? You know what stimulation needs to happen. And then also experimenting with different types of stimulation. So whether it’s manual, oral, using a vibrator, using temperature, these are also in different parts of the spinal cord, right? So kind of playing around with that and figuring out what you need in order to achieve climax. And if you need a vibrator, that’s OK. You don’t need to feel bad about it. That’s totally reasonable. You’re having an orgasm. That’s the point. You’re enjoying pleasure, right? And so I think that’s really what we need to focus on. 

I’m going to ask a question because I don’t know if I have an alternative answer to this question. If someone is thinking, OK, well, where can I learn about that? Where would we send them? Yeah, so there’s a couple really good online courses. One is called OMG Yes, and one is called Bejucated. I’m not paid by either of them. I’m just thrilled that you actually have an answer for this because I’m like, is she going to say that website that I think that we all are thinking about? 

No, no, no. Not going to say it. I saw your search history, Matthew. No, she’s kidding. 

I’m kidding, mostly. Anyway. Yeah, so I mean, there are these sort of– one of these is actually created by doctors and created with input from doctors. So these are really great guides in educating yourself on what are different ways you can stimulate yourself if you don’t know how. And I don’t think– I think you’re alluding to pornography, and I don’t think that is a great educational tool because that is a production. That is entertainment, and that is not real life. And unfortunately, a lot of people are learning about sex through pornography, which is not a good thing because then they go into their encounter and like, why did my body not do that? Why did I not respond like that? Or why did it not last as long? Or why did I not squirt? Or why did I not– That’s a really good perspective. And so– and then they come to– I see young men, mostly young men, who come in like, I have ED. And it’s because they’re so stressed and anxious about performance, or they’re like, it didn’t go the way I thought it would, that they’re now having issues because your brain is super powerful. It’s the most important organ for sex. And so ultimately, I don’t recommend pornography as an educational tool. I think it’s fine for adults to use and use for pleasure and for enjoyment and knowing that it is a fake experience. And these people are professional actors and actresses who’ve chosen to be porn actors and actresses. So they’re very good at what they do. 

And so you don’t have to aspire to that to have pleasure or enjoyment. And it doesn’t mean that you’re having bad sex. I think that’s important because that’s where I’m assuming everybody goes to get whatever, information or visuals, you name it. But now what I’m hearing you say is that you’ve recognized, or the medical community or people have recognized that there needs to be a different place to educate. Yeah, absolutely. That’s pretty amazing. I mean, I think there needs to be more places to educate. And I’m hopeful that– one thing I’m working on is hopefully making a sex ed course that’s more comprehensive. Incredible. Because I think that that’s really needed. I mean, young people have so much more access to these things than they did when we were younger. And that’s a problem because if it’s so accessible, first of all, your brain’s not fully developed. You don’t know what exactly you’re seeing. And you can’t differentiate real life from fake life necessarily all the time. And then that’s what they’re learning. So in fact, I interviewed Debbie Herbeneck, who is a researcher in Indiana. And she does a lot of this research. And she found that choking has become like vanilla sex now. Really? Yeah. Yeah. You and I are way too old for that. 

But it’s because they’re seeing a lot of it. And even in mainstream music, you’re hearing about choking and it being like a normal thing. And it’s actually– some people find it pleasurable, but not all. And they’re not having great communication around it. So it could be dangerous. 

Let’s talk about some potentially embarrassing things for people that would make them feel uncomfortable having sex, like discharge, like smell, maybe even an STD. What are some of the things that inhibit people from enjoying sex or things that they would potentially be embarrassed to talk to their A partner or be their doctor? Yes. So for women, the number one insecurity is smell, which is– we’ll talk about the second insecurity is body image. So breast size, butt size. And then followed by, am I experienced enough? And then what about the noises I’m making? So these are all insecurities that people have. And I think the older thing is a real problem because we have a natural, normal scent that we should have. And you should know your normal, natural scent. That’s what you’ve always had. If it changes, see your gynecologist 

or your primary care doctor and say, hey, I’m noticing a change. You may have an infection. But the issue is that in society, we’ve now been told that our scent should be something different. It should smell like flowers or key lime pie or peaches or whatever. And like people are douching and doing all these things that actually disrupt the vaginal microbiome and are probably causing more harm than good. We have a certain scent that secretes certain pheromones that is supposed to be pleasant for our partner. And so I think this is all really a media thing. We felt like there’s something– women need to be clean. We don’t talk about periods. We don’t talk about menses. We don’t talk about smells. We don’t talk about discharges. But women make discharge every single day. And that’s normal, like a teaspoon of discharge up to a tablespoon in a full day. That’s normal. That’s normal physiology. And that’s OK. You shouldn’t be ashamed of it. And we’re going to make noises during sex. Sex is a funny, fun place to be. But things are going to happen. That’s normal. Laugh it off. It’s play. It’s OK. And then in terms of body image stuff, that takes some time. But I think ultimately, just realizing sex doesn’t need to be so serious. Sex is supposed to be fun. And you’re supposed to be having fun doing it. And your partner should be having fun doing it. And if you’re not, then that’s not the right person for you. Then you might need to go back to the matchmaker or find a different way forward. Different way forward. 

What is coming up in the field? Where do you think that we are going? We’ve covered a lot in this interview. We’ve talked about low libido, hypo sexual, desire disorder, many different things, orgasm, what to do, what your partner should do, things like dishes. Where is the field going? Yeah, I think there’s a lot of areas of interest right now. I think one is certainly looking at the genital pelvic pain disorders, which we haven’t talked much about. But certainly, we’re finding more and more links with spinal pathology, like having tar-love cysts or annular tears, being correlated with some people who have this chronic pelvic pain or orgasmic difficulty. And there’s very few people that are working on this. But I think that it’s pretty fascinating and really interesting. So Erwin Goldstein is the pioneer in this area. And there’s very few surgeons who will operate on these things. But ultimately, I think that’s an area that’s really interesting. And I think that’s hopefully going to change a lot of lives once we get some strong data on that. And when you mention pelvic pain, you’re not talking about necessarily pain on sex. Well, so pelvic pain can present in a whole bunch of different ways. We call them dysathesias. So it can be pain during sex. It can be just chronic pain. 

It can present as a difficulty with orgasm. 

And these are sort of like, again, they usually are presenting with other symptoms, because they’re spinal. So you may have urinary symptoms at the same time. And people maybe won’t put those together. But you’ll be like, oh, they’ve got sort of a whole bunch of different symptoms that maybe they’re coming from the spine, right, rather than being a local neurologist or something like that. And so I think that’s an interesting area where we’ve not done enough research. And pain in general needs a lot more research. And I think those people are suffering, and they really need good help. 

What’s next for you? What’s next for me? 

For now, I think I just want to keep educating. And like I said, doing the sex ed course is something on my bucket list, because I think it’s so important. 

But yeah, I mean, I see patients in South Florida. And I– south– let me say that again. 

I see patients in Southern California. And I have telemedicine practice as well in multiple states– New York, New Jersey, Florida, Illinois, Maryland, Virginia. And so seeing patients there– I work at the Veterans Hospital, which I love, and we talked about before. And I do my YouTube and podcast, which is still ongoing. 

Dr. Reena Malek, I’m really, really happy that I have a chance to sit down with you. You’re extraordinary. Thank you. So are you. Thank you so much for coming on the show. You’re welcome.