← BETTER! Muscle, Metabolism, Meals, & Mindset in (Peri) Menopause with Dr. Stephanie Estima
BETTER! Muscle, Metabolism, Meals, & Mindset in (Peri) Menopause with Dr. Stephanie Estima
Orgasms as Medicine: De-Stigmatizing Sex & Pelvic Wellness in Perimenopause with Dr. Rena Malik
01:30:29
Peeing when you sneeze? Check. Low desire? Check. Confused about what's "normal" in menopause? Triple check. Dr. Rena Malik answers EVERY question we're too embarrassed to ask our doctors. This episode is for women and the people who love them. Watch the full episode at https://youtu.be/0Z0hpG9x3bA
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- [00:01]
A
I would say for the majority of people, orgasms are great. They have huge health benefits, they decrease heart rate, they decrease blood pressure, they help you with sleep. For some people, they help with focus because they get this like post orgasmic clarity. But like really they are so beneficial. In fact, like we know they decrease pain, right? So some people who are having pain orgasm and pain goes down. And so we, there's not a lot of studies looking at this because, you know, there's obviously like IRB issues. But like, I think if people looked at orgasms as a medical tool sometimes, like we'd probably see a lot more benefits than we do.
- [00:33]
B
And there are 10,000 nerves that you are not using, ladies.
- [00:37]
A
Yes, absolutely.
- [00:45]
B
Hello my friends. Welcome back to better with Dr. Stephanie tis me, your host as always, Stephanie Estima. And today we are going to be talking all about sex. And so if you are listening to this on your way to dropping off the kitties at school, if there are young ears in the car, I am going to caution you right now that this is not the time to listen to this show. I would definitely be listening to this in your earbuds, your headphones and then maybe you can have a conversation with them afterwards. My guest today is Dr. Rena Malik. She is a board certified urologist, a fellowship trained female pelvic medicine and reconstructive surgery in sexual medicine. She's an assistant professor at the University of Maryland School of Medicine, a recipient of the 2023American Urological Association's Young Urologist of the Year award, and she runs a practice specializing in sexual health and urology. She's a prominent medical educator known for her extensive educational content on platforms like YouTube and Instagram, where she has millions of followers there, as well as her work on podcasts and man as a public speaker. So who is this podcast for? Well, if you are a woman, this podcast is for you. If you are partnered to a woman, this podcast is for you. So this is one of those shows where it's like women and the men who love them. So whether you are in a heterosexual, you are in a homosexual relationship and you have, or you have a, you have a female as a part of your coupleship will say, you are going to learn so much about anatomy, physiology, desire, arousal, the difference between what we're sold on social media and, you know, in films, et cetera, versus real life. In our conversation today, we talk about pelvic floor health. So we talk about urinary incontinence, we talk about stress incontinence, urgency, incontinence we talk about pelvic organ prolapse. We talk about bladder issues. We talk about the genital urinary syndrome of menopause. The things that change in our pelvic region, including our genitalia and sexual function as we move through perimenopause and menopause. We talk about responsive desire, meaning how women respond to sex. And our desire is very different than the male response. We talk about, gosh, so much. We talk about neurological changes, hormonal changes, blood flow changes. We talk about pornography. We talk about issues when we do have low desire. What are some of the solutions that we might have, and how to talk about sex with your kids. Which is why if you are listening right now with young ears, maybe you want to listen to it first. And then there are some strategies that Dr. Malik gives in terms of how we can talk about sex with our children. I learned so much from talking with her. I think that she does such an excellent job of de stigmatizing a lot of the very taboo subjects in the sexual realm. And I think that even if you are not partnered, you are flying solo. You are going to learn more about your body than perhaps you ever thought was possible. So I invite you to listen in, listen again, and without further delay. Please enjoy my conversation with Dr. Reena Malik. Perimenopausal women are notorious for being magnesium deficient, which can lead to lowered hormonal production. More than 80% of us are deficient, and even just having suboptimal levels in the body can contribute to symptoms. And that's because magnesium is related to over 600 biochemical and enzymatic reactions in the body. Many of these reactions influence the production of these key steroid hormones in the body, like estrogen, progesterone and testosterone. Insufficient magnesium levels can also disrupt your thyroid function, and magnesium breaks down cortisol and other stress hormones. So if you don't have enough, you are going to have problems. Poor hormone production and a poor stress response. Bioptimizers is my favorite magnesium supplement because it contains the seven best absorbed magnesiums along with cofactors like B6 that are going to help enhance the absorption of it. It's a simple, effective solution to a very big problem. I personally take two capsules every night for sleep support. For an exclusive offer, go to bioptimizers.com better and use promo code better during checkout to save 15%. And if you subscribe, not only will you get amazing discounts and free gifts, you will make sure that your monthly supply is guaranteed. Once again, that's buyoptimizers.com better and use promo better to save 15%. All right, Dr. Reena Malik, I am thrilled to welcome you to the Better podcast. Welcome.
- [05:35]
A
Thanks so much for having me.
- [05:36]
B
I want to dive right in to the pelvic floor. This is something that I saw a lot, a lot of pelvic floor dysfunction in my practice. And I thought we might just start off with what is a healthy pelvic floor. So let's talk a little bit about the anatomy, the neurology, the function. Why do we want, why do we care about the pelvic floor in general, in midlife?
- [05:57]
A
Absolutely. So the pelvic floor, let's start off with what it is, right? It's a bowl of muscles that sits underneath the pelvis, basically spanning from one hip to the other from the front of the pubic symphysis, which is like the, the bony part you feel right above the mons, all the way to the back, to the, to coccyx. So it goes all the way, attaches at all those places. And so we can think about it is, it's very, it's a part of our core. It incorporates the muscles that are also not just the abdominal muscles, but the back muscles. And it's very important for many different functions, right? It's important for stability. So with every step you take, your pelvic floor is functioning. It's important for, for women during pregnancy, it's important to keep your organs up for stability. It's important during sexual activity. So when you have an orgasm, your pelvic floor contracts, it keeps you continent both with urine and stool. It has so many different functions that really it is very valuable for it to stay healthy. Now, how do you keep it healthy? Right? So I think if you're not having any problems in terms of you're not having any issues with incontinence, you're not having problems with your bowel movements, you are not having hip pain or back pain or needing to rush to the bathroom urgently or frequently. And you're having a great sex life with good orgasms. Your pelvic floor is probably healthy. If you're having an issue in any of those areas, it could be a sign that your pelvic floor is not so healthy. And there's a lot of things that can sort of contribute to unhealthy pelvic floor. So things like sitting all day, right? Not moving functionally normally, regularly, even sitting cross legged all the time or sitting on, you know, sort of on one side, preferentially all these things can affect the pelvic floor. And then things that we do like to manage our day to day. So sometimes people hover to urinate all the time, right? They go to public bathrooms, they don't sleep, sit on the toilet. That can harm your pelvic floor. If you are constantly holding your bladder or your stool, right? Like, you're like holding and holding and it becomes a problem. This, we see this a lot in kids. They start holding their urine or their stool because they don't want to go to the bathroom. But for many people, this persists into adulthood and it creates all these problems. If you have stress anxiety, if you're very type A personality, your pelvic floor can react by tensing up and that can create issues. So generally speaking, good movement, normal function, walking regularly, moving regularly, regularly getting exercise because that increases blood flow to the pelvic floor. Making sure that you are sort of breathing and getting good breath work when you are exercising or lifting, like you're exhaling on exertion. All those things are really important for a good, healthy pelvic floor.
- [08:35]
B
I love it. Okay, so so many questions that came from that. I would think that if you are someone who has had children, so through childbirth, whether you delivered vaginally or C section, you know, you, you were pregnant for the nine months, which of course puts more pressure on the pelvic FL that you are probably in the busyness of motherhood. Maybe not so much paying attention to it, but the pattern that I'm observing is a lot of women, when their children are now entering their teens or maybe even leaving the home, they're like, actually, yeah, I don't, I can't jump. You know, when I jump, a little pee comes out or when I laugh or when I sneeze, something like that. So I thought we might even just talk about incontinence a little bit more because this is wrapped in shame. I have had pelvic floor physios on the show, and when we've put out social content around it, it's like crickets. Like, people are consuming. Like, we see really high and like the data doesn't. We see really high views, really high saves, but like zero comments. Like, no one wants to say, yeah, actually I am peeing my pants when I'm jumping or laughing or sneezing. So can we talk about the different types of incontinence? So you mentioned if you're very stressed, I want to differentiate between urge incontinence and stress incontinence. If we can. Just to start.
- [09:47]
A
Yeah, absolutely. So to start off, incontinence is very, very common, right? One in three women experience incontinence. So the fact that no one's commenting there, this is not uncommon. If you look at my Instagram, for example, you will see no comments like, I put tons of content out. But no one's commenting on sexual dysfunction, on urinary problems, on anything, because they're embarrassed, right? And that's a real problem. We know that. Like I said, one in three women are suffering from leakage. Now, a lot of it is due to childbirth because it weakens the pelvic floor. Childbirth can weaken the pelvic floor. Having. Being obese, having a job where you stand a lot and you're not getting enough, you know, and you're the, you know, doing a lot of heavy activities, sometimes crossfitters, who are really putting a lot of strain on their pelvic floor. And even people who have neurologic conditions like multiple sclerosis can develop issues with weakness in their pelvic floor, which then leads to leakage, specifically stress, urinary incontinence. So that's leakage. When you cough, sneeze, lift, heavy things, you just can't hold it in and it leaks out. Now, it's not dangerous in terms of, like, it's not gonna cause a problem that you need to, like, get your kidneys checked or your bladder checked. This is more of a quality of life issue, right? And it's a big quality of life issue because people start getting very embarrassed. Do I smell like urine? Can I go out? Because I might leak? Do I need to wear a pad all the time? Oh, it stinks. Like, all these things. And they can have a real toll on your mental health because you're, like, constantly feeling ashamed, embarrassed, or even avoiding things that you normally used to enjoy, like, oh, I won't go to the movies where it's gonna be a comedy because I'm gonna laugh and I'm gonna wet my pants, right? So that's. That's one. The other type of leakage is urgency incontinence. And so that is leakage that occurs when you gotta go, gotta go. You can't hold it. You can't delay. Now, everyone has urge, right? We have the urge to go to the bathroom, but sometimes that urge gets so strong that we're, like, rushing, right? And that can be due to a variety of different things. It can be due to menopausal hormonal changes because the bladder itself has estrogen receptors and it's no longer getting as much estrogen as it did before. It can occur because of longstanding health issues like diabetes. It can occur because of just aging. It can occur because of, again, neurologic conditions. So lots of people experience these problems. It can do, you know, and it can basically, again, similar to stress incontinence, cause a lot of quality of life issues. Now, this is, again, rarely a danger to your health, but it is a huge quality of life issue. And with that, this is a bladder problem, whereas the stress leakage is a muscle or pelvic floor problem. And most people, if you look at the data, about half of people who have incontinence have both. So they have both stress and urge. And that gets complicated because you're like, well, I want to fix my leakage. But it's not just one thing. There's two. There's two different causes for that leakage, and we have to approach them with different approaches.
- [12:42]
B
Sometimes you mentioned that this is not an emergency, but it's more of a quality of life issue. Do we have any concerns about it progressing? So maybe there's like a little bit of leakage, maybe there's a little bit of urgency that is uncontrollable. But does that over time, does that prognosis worsen? Where it gets worse over time, and then maybe, you know, maybe it affects, like, your ability to hold your pee overnight or maybe now you need to wear a diaper all the time or, you know, some type of pad all the time. Is there a worry, if it's not fixed, that it progresses and gets worse? Or is it. Is it, you know, a little bit of. With some of the hormonal changes and with midlife, we will see some kind of weakening, let's say, in the pelvic floor. So we are going to see some degradation in quality of life, but it's not going to get much worse than that.
- [13:28]
A
Yeah, absolutely. So what we see and what I see in a lot of people is that they will delay because of life, right? Because, oh, a little leakage is not a big deal. I'm busy taking care of my kids, as you mentioned, taking care of my life, busy at work, taking care of my aging parents. So I'll put myself on the back burner. And a lot of women, while some women will just have that little bit of leakage and it won't get worse, but a lot of women, it will continue to progress because if you don't do anything to strengthen your pelvic floor, for example, then it's just going to continue to weaken. Right. And so you're going to have worse symptoms. Similarly, if you have a condition affecting your bladder, oftentimes that will progress. Right. Because of age, because your nerves are getting older, because your muscles are getting. Your bladder muscles are getting weaker, a variety of different things can play a role. And so I encourage people, if you're bothered and if you're not, I don't give. I don't care. It's fine. But if you're bothered by your symptoms, go see a urogynecologist, either gynecology trained or urology trained, who can help you. Because we have so many things that can improve your quality of life that are just very minimally invasive or even just going to pelvic floor. Physical therapy can be a huge, you know, opportunity for people to improve without having to take a medication or have a surgery or anything like that. But ultimately, there's so much we can offer you. And I think women in particular just delay. They just wait for so long.
- [14:49]
B
Yeah, I sometimes, I think just even identifying that it's a problem, like, you know, if you have, you know, it was. I can just, you know, very transparently, I've talked about this on the show before. I started noticing that every time I would come home and, like, I would put the key in the door, it was like a Pavlovian. I was like, oh, my God, I have to go to the bathroom. You know, and so I would literally go in and like, run to the bathroom. And so I was like, that is, it's. That's a change that never. I never really had that before. But I think just even identifying that that is a change or that is an ab abnormality from your baseline can be difficult sometimes. So this is why I want to have conversations like this. And I just. For completion. We've been talking about stress incontinence. We've been talking about urgency incontinence, which can come from a weakened pelvic floor and bladder issues, as you were saying. And also the opposite, I think, sometimes doesn't always get discussed, which is having a very tight pelvic floor where maybe there's issues with painful urination or constipation or you're. You're straining on the toilet. Can you talk a little bit about how that clinically differs maybe from a weaker pelvic floor, signs and symptoms, what to look out for?
- [15:53]
A
Yeah, absolutely. So a tight pelvic floor is something I see all the time, and I think that it's very underdiagnosed. It's not talked about often enough. And basically what happens is that the pelvic floor muscles tense up and they don't relax. And this can be due to a lot of different things. It can be due to trauma, it can be due to prior, like, stress, anxiety, commuted. Being a type A personality, it's basically like, everyone knows about TMJ dysfunction, right? People clench up their jaw at night and they wake up with headaches or they have. They're grinding their teeth. It's the same type of thing. The muscles are clenching up involuntarily. You're not telling them, like, oh, I'm stressed, like, clench up. They just do it, right? And when they're tight and you can't relax them and they can't function normally, which means they can create issues like your, your bladder sitting right on top of those pelvic floor muscles. So when it's tense, it's like, oh, hey, you gotta go, gotta go, you gotta go more often. It can make it more difficult for some women to empty their bladder because the pelvic floor muscles aren't relaxing when they urinate. It can make it more difficult for women or men to, to, to have bowel movements. They get constipated because again, their pelvic floor is not relaxing when it needs to. It can cause back pain, it can cause hip pain, it can cause even pain with ejaculation for men and orgasm for women because those pelvic floor muscles are contracting already in a tense state. And so that can create pain. Even leakage can present in women with a tight pelvic floor. Because if you think about it, when you do anything that increases abdominal pressure, like coughing, sneezing, lifting heavy things, your pelvic floor muscles contract at that time to keep urine in. But now they're already contracted, so they can't contract more. And so sometimes, you know, instead of actually having a weak pelvic floor, their pelvic floor is too tight or too contracted. So it's important to see a specialist because they can really identify and do an exam and tell you, hey, is your pelvic floor tight? If you are someone who it always hurts when you get a speculum exam, then that may be a sign that you have a tight pelvic floor. If you're someone where sex hurts, especially when you're trying to penetrate, that may be a sign that there's pelvic floor dysfunction. So it's really important to get evaluated because you shouldn't have to live like that, right? These are treatable and correctable issues.
- [18:08]
B
And so what do we do? So let's imagine you have, you know, my Betty's who are listening, you have a 40 something, 50 something year old woman, mother of two or three. So multiparous weakened pelvic floor. Is. Are Kegels the answer? Are there other things that we can be doing? I have a couple of ideas in terms of what I've helped my patients with in clinic and online. But I'd love for you to explain what your thinking is when somebody has a weakened pelvic floor. So maybe they are experiencing some of the leakage that you've been describing or even the urgency incontinence, which we'll talk about bladder issues in, in just a moment with Pop. But talk to us about what are some solutions that we might think about if there is a weakened pelvic floor.
- [18:48]
A
So if you have a, if you're sure you have a weakened pelvic floor, then doing exercises. Pelvic floor muscle exercise. The most popular one is the Kegel exercise, right. Like has the best PR of any exercise I've ever heard of. But basically those. That is just one exercise that you can do to strengthen your pelvic floor. But it is a very popular one and it does work quite well. And it's basically tensing the pelvic floor. The feeling of like trying to pull up and in, in the vaginal canal as if you're like, say you have like you're trying to pull something into your vagina like a blueberry, trying to pluck it up or you're trying to squeeze up and in, right? So those are sort of the cues you can use. Sometimes we'll tell people when you're urinating to stop the stream of urine. And that's how you know that's the actual exercise to do. Now you don't want to do it every time you urinate because that will create dysfunction, but so you can learn what those muscles are. And the key is you're not contracting your abdomen or your butt, right? You're focusing on primarily, primarily the pelvic floor muscles. So these exercises can be very helpful. And fortunately, because of social media and YouTube, we have so much content where you can have people sort of walk you through some of these exercises. But I find that so many women are doing them incorrectly or doing them, you know, without real guidance. And that's where I think it's really, if you have the time and the resources to see a pelvic floor physical therapist, that's gonna help you so tremendously in terms of improving your pelvic floor strength, because they'll also look at you as an individual and say, oh, hey, maybe you are tight on this side and you're weak on this side, or you're. You're misaligned, and you need to sort of realign your pelvis before you can strengthen. Like, there's a whole. That's your whole person, and your pelvic floor muscles are just one component of your entire body. And so we have to look at it as a whole.
- [20:32]
B
It's so funny that I use the exact same cue, which is blueberry. Like, you're trying to pull a blueberry up into the vagina, which is such a. I don't know if we were just all taught that in school, but that's it. Such a colorful and perfect. It's such perfect imagery. And I would love. Not that I have any problem with men. Of course I have. I'm raising two sons. I'm married to men. But I would just love to rename Kegels. I'd love to rename them Puss Ups. That's what I. That's what I would love to do. Because I just feel like. I mean, there's one in a couple.
- [20:59]
A
And men have to do Kegels, too. So I. You can't really.
- [21:03]
B
That's true. I guess that's true. I guess that's true for women. I think, for. Cause I always. It's always the guys who are naming the stuff after themselves. It's like, well, we're just gonna call this a Kegel. And that's my last name. That's my own little. My own little jab there. Okay, so let's. Let's actually talk about pelvic organ prolapse. Very common again, if you've had many children, specifically with the bladder. So talk to us about what POP is or pelvic organ prolapse and how we might know that that is even an. An issue that we're. That we're dealing with.
- [21:31]
A
Yeah. So pelvic organ prolapse is essentially a weakness in the pelvic floor that causes a essential. Essentially a hernia. Right. So you see the vaginal wall coming down into the vaginal canal, and this causes sor. A. A feeling of pressure, like something's falling out. Like you have a tampon falling out of the vagina, sort of. That kind of feeling. And so again, not dangerous for the large majority of people. When it gets really severe, sometimes that can cause more problems. But for the large majority of People, this is a quality of life issue because they feel this pressure. They feel it when they sit, they feel it when they walk, and they're sort of constantly feeling like something's falling out. It can be very uncomfortable. It can make sex uncomfortable. It can just in general make you feel like heav and, and, and even back pain sometimes. And so in those cases, there's absolutely things you can do to improve your pelvic floor strength, like pelvic floor exercises. But also sometimes women will need other options, like a pessary or a device that you put in the vagina that holds things up or surgical interventions to sort of rebuild the pelvic floor.
- [22:37]
B
Actually, that was my question for you as well. So obviously going to a. If you have the resources to go to a pelvic floor phys physical therapist, I think that that's a wonderful idea because one, as you were mentioning, they can do a pelvic exam on, they can say like, like pretend you're sucking up a blue. And they can look to see if there's any asymmetry, any unilateral asymmetry left to right. They can see if the strength is sufficient. They can, you know, they can palpate all the tissue. So I, I love that. And I've also seen, and maybe this is just my algorithm, but I also see that there's like, almost like graded weights that you can almost, you can insert vaginally and try to hold the, hold the weight internally. Is that something that, is that something that would be a useful, a useful tool as well to sort of do in between appointments with your pelvic floor physio or as a replacement for it? I don't know.
- [23:25]
A
Yeah, I don't love the weights because it's not really physiologic. Right. You're not just like, you don't walk around like holding your bicep in a curl for hours at a time. Right. So it's sort of, sort of like that, right? Like, it's not physiologic. When you're doing a Kegel exercise, you're squeezing and holding for like 5, 10 seconds and then you're relaxing. And so the better thing is to do the exercises you're taught from your physiology physical therapist at home. Now, if you want to try like a pelvic floor trainer, some of them have sort of like, you insert it and it, it sort of tells you like, oh, you're squeezing or you're not. And it kind of grade grades, the measurement that can be helpful for some people. But again, I think, I think that there's nothing that can replace actually having someone who's an expert like assess your pelvic floor as a whole structure. Because these, these things work in the, in the average person who has really just, just a weak pelvic floor. But oftentimes it's not just so straight. So that's where I think like, yeah, these can help. Weights I would not recommend. And generally speaking, like if you're gonna use a pelvic floor trainer, that can be helpful. But again, I think if you have the means and you have the time. See a pelvic floor physical therapist.
- [24:32]
B
Yeah, we had, I had a pelvic floor physio on and there was, I don't know, I can't remember the name of the device. It was almost like an S shaped device. And I think it was meant to sort of massage maybe the perineum and then maybe sort of the inside if there was any sort of pain in and around the opening of the vagina. There was, you know, I think I can, I can't remember the name because it maybe you know what I'm talking about.
- [24:53]
A
Pelvic floor wands. Yeah, they're pelvic floor wands. They're, they're basically there's a couple options. There's dilators and there's pelvic floor wands that can be used. Those are mostly used for people who have tension. So they're helping sort of relax the muscles or stretch the muscles if you're very, very tense. And again, I like that you have some direction when you use those things. You don't want to like go ham and not know what you're doing. And so that's where I think it's best if you can have some instruction from a pelvic floor physical therapist. The beauty is now there are some online programs that you can have access to. Even insurances are like giving you access to these online programs. And so I think that it can be helpful. Even though in person exam is better, these are still great as an alternative if you don't have access to like a pelvic floor physical therapist in your town or close by or things like that.
- [25:41]
B
And just walk us through what a pelvic floor exam might look like. Certainly you know, physios can do this. Certainly urologists are doing this as well. For someone who has, who doesn't know what that is, maybe they're scared. You know, walk us through what this looks like.
- [25:55]
A
Absolutely. So in my clinic when women come in, we have them Obviously, get undressed from the waist down. I give them a mirror so they can look, and we go through their anatomy first. We kind of talk about, hey, here's the clitoris. Here's the labia. Here's the labia, the clitoral hood that you can pull back and see if there's any sort of smegma or adhesions where the clitoris is not able to fully retract, because that can sometimes be a problem. We. We look at the tissues. We show them where the urethra is. I then use half a speculum. So all women are familiar with the speculum you see in the gynecologist office. I take off the top part, and I use just the bottom part so we can look at each wall of the vagina with, you know, and be able to look at it and have you actually do functional movements. So I'll have you bear down like you're having a bowel movement. And we'll look at how much does your pelvic floor move, the anterior wall, the posterior wall, meaning the top and the bottom. We'll also have you cough and see if you leak. Right. So we're kind of assessing all that, and then I'll do. And I'm also looking at the quality of the tissue. Like, are there any changes to the tissue either through hormones or are there any dermatologic conditions that might be affecting the pelvic floor and the vaginal skin? And then I'll do an internal exam. So we'll take a gloved, lubricated finger insert to palpate the muscles to see if they're at any baseline tension. And then I may have you squeeze like you're doing a Kegel. So one, I can see how strong your strength is and have you relax. And so that allows me to see, like, okay, are you able to squeeze? And are you able to relax normally? And sometimes we'll see. And you'll even do that without a finger inserted to see, like, externally. Are things working normally? Right. Are things sort of contracting and relaxing as they should with. You know, sometimes people are actually uncoordinated and they're doing the opposite. And so that's also helpful information. So we kind of look at all that, and then we make a diagnosis based on that.
- [27:47]
B
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- [28:15]
A
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- [28:16]
B
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- [30:16]
A
So we obviously get a pelvic exam yearly for well, maybe not yearly, but at least once every three years with your gynecologist to assess for cervical cancer? Right. So that's a very different exam. Typically they're very focused on looking at the cervix and assessing for cancer and then swabbing and testing for Cervical cancer, the pelvic floor exam, usually your primary care, and maybe even a regular gynecologist won't do a pelvic floor exam. For those things, you'll need to go to a specialist, a urogynecology trained specialist. So urogynecologist can be urology trained or gynecology trained. And so you can go to one near you and they will do a formal pelvic floor exam. Now, do you need one? Right. I think I wish everyone could have one. But I think if you're having no symptoms at all, you're feeling great, sex is great, life is good, you're not leaking, you're not having issues with your bowels, you don't need one. Right. But if you are starting to notice these symptoms, then it can be very helpful to have one. And then, you know, dep. It's very individualized. You don't need one every year, but you need one if symptoms change, are getting better, getting worse. If you're already in care with a doctor, we may do exams periodically to just see how things are progressing. Right. But generally speaking, once you've had one, it's again, it's very individualized, depending on how your symptoms change or, or get worse or get better, things like that.
- [31:35]
B
I think. Is there any utility in just having a baseline? You know, like, I, I. Cause I think that there in my neck, and I asked this because my next question you'd mentioned, you know, in, during the exam, you're looking for maybe dermal changes or hormonal changes, which, you know, with a certain amount of confidence, I can say all women are gonna go through some hormonal change at some point. 40s or 50s, we're gonna go into menopause. And there is a very, you know, profound change in our hormonal status. So it would be nice to have some kind of baseline, irrespective of whether there's symptoms or not. I think that that's a nice prophylactic to have or just a nice baseline to sort of know where you are.
- [32:12]
A
Yeah, I mean, I think, you know, there's pathogenumonic findings on a woman who's has hormonal changes. We call it vaginal atrophy. And you can actually see, like, the tissues become more whitish, they become less pink. You can check the vaginal ph with changes, which changes with hormonal changes. So it tells you like, hey, there are active changes, but absolutely, there's no harm in getting a baseline. But I wouldn't want people to be like, oh, I must get One, it's absolutely necessary, right. I think that the, the thing that women need to know is that, you know, we talk about menopause and perimenopause and these symptoms, hot flashes lasting for maybe 10 years, but the symptoms of the vulvovaginal symptoms, what we call the genitourinary syndrome of menopause progresses, so it continues to get worse throughout your life. And 80% of women will have some symptoms from menopause regard in regards to their genital urinary tract. So they might get recurrent UTIs, they might get dryness or discomfort or you know, what we call like lightning crotch, right. Discomfort during sex. They might get urgency and frequency because they're again, like I mentioned, their vaginal estrogen is, is, is de. Depleted and they're not getting as much estrogen to their bladder. So all these symptoms can happen. And it is so simple to treat this. It is so simple and I wish every woman could have access to this easily. Is you can use vaginal hormones, so you can use vaginal estrogen. It's very, very safe. It is very minimally systemically absorbed. There's no risk of breast cancer, there's no risk of ovarian cancer or uterine cancer with vaginal estrogen. It's extremely safe. Now some women do get breast tenderness when they first start it. And, and that's why I don't do. A lot of people will do a loading dose where they'll do it every day. And I think then, yeah, sometimes you get a little bit more systemic absorption, but generally it's twice a week at night till death do you part. And it is very, very safe. So I think that it is so easy to treat that it, it's just a shame that we're not like giving it out like candy. Like it should be just available for everybody.
- [34:08]
B
Yeah, I agree. And I think, well, this is, this just so beautifully leads into what I wanted to talk. So I wanted to also talk about the clitoris and some of the things that we can see in terms of changes as we age. And one of them I think is like sensitivity, right? And so the quality of our orgasms can change because I think that there is a certain amount of clitoral atrophy that can happen. Like you mentioned, the tissue gets, did you say it gets whiter and thinner? You can see the tissue getting less pink. Is that what you, is that what you mentioned?
- [34:34]
A
Yeah, that's for the vaginal epithelium. But the clitoris actually can get smaller. It doesn't really change color necessarily, but it gets smaller. And then, as I mentioned earlier, the clitoral hood, it's sort of like a. A boys. You. You have sons, like, met boys with foreskin. They have. They're taught to pull it back and clean under there. Women are not taught. This is their foreskin. They're not taught to pull back the clitoral hood and clean under there. And so some women form, just like boys do, smegma underneath their. Underneath their clitoral hood. And that can create discomfort, that can mute your orgasm, and then you can get adhesion. So that hood can stick to the clitoris, and then that can create issues as well. So that's one thing. Obviously, you're getting older, so your nerves are getting weaker, but also you're having all these changes in your hormones. Your estrogen is decreasing, your testosterone is decreasing. And these can make your orgasms less intense. Because one, maybe your pelvic floor is not as strong as it used to be, so you're not having as intense pelvic floor contractions when you orgasm. Maybe you're not getting as much blood flow to the clitoris. And we don't talk about this enough. But, like, I can tell you from men, right? Men get less erections because they're not getting blood flow to the penis because of high blood pressure, diabetes, high cholesterol. We women are the same. We're very similar, right? Same tissues, exact homologues, the clitoris and the penis. So if you're not getting good blood flow down there, because you're not, you have high blood pressure, you have high cholesterol, you have diabetes, these are all gonna affect the ability of your clitoris to get engorged. And so you're gonna have weaker orgasms. Cause you're not getting as much blood flow down there.
- [36:04]
B
And I think it's harder, too, for women to notice those changes. Cause with men, you might start to see, and certainly you can speak to this much more, you know, more experience than I can. But I would assume if you're having erectile dysfunction or ed, with men, we know that that's sort of an early sign of cardiovascular disease. Or at least down the line, if you have altered, you know, blood flow to the penis. And that is a. A warning sign, at least for cvd. So I don't know. And. And men can say, okay, like, I had this. I. I know when I'm erect. I know when I'm hard. Women don't necessarily know that. So can you talk to us a little bit about maybe Just the anatomy, like the homologue we mentioned. So like the clitoris and the penis are homologues of each other. And I think that we often just think about the clitoris as like the little button that's outside that we can sort of see externally in our external genitalia, but obviously it isn't. There's. There's stuff in the pelvis. So talk to us a little bit about what that looks like. Do women get erections as well? Like, is there a, is there an equivalent in females?
- [37:06]
A
Yes, absolutely. So the clitoris is identical to the penis. So if you were to look anatomically and you were to do a dissection, the tissues would just be a little smaller, but they're literally identical. There's a shaft, a clitoral shaft that goes deep into the pelvis and then it forks around the vagina and it has these clitoral bulbs and so it's basically like a wishbone. So it goes deep into the pelvis, it goes around the vagina, and it is extremely sensitive. In fact, it has more nerve endings than the head of the penis. So the clitoris has 10,000 nerve endings. It is the only structure in the female body and in any human body that is there solely for pleasure. Right. There's no urethra going through it. There's. It is solely for pleasure. And it is the most reliable route to orgasm. And just like in men where they get erections, women also get increased blood flow when they're aroused to the penis. And their clitoris gets erect and it increases in size just like a penis does. But we don't see much of it. You might see the clitoris get a little bit engorged if someone's looking down there. If you're looking with a mirror, you also feel it, right? Men can feel when they're getting an erection. Women can feel it too. You feel that pelvic pressure, that fullness, that like nice feeling like that, that something is going on there. And so it's sort of the same thing. So when you start noticing like, oh, you're not getting that engorgement of blood flow into the pelvis, you sort of don't feel that same sensation when you're aroused. Now the other issue is that arousal is a little bit different in terms of like, women don't get aroused as easily as men in all cases. So a lot of times what happens is when you're in a long term relationship, women get what's called responsive desire. So they're with their partner and they, they don't like, oh, I see you, I want to jump you. It's more like, hey, I need to sort of like, be intimate with you and be open to being sort of in a. In an intimate moment with you. And then the desire comes after you've sort of started becoming intimate. And that's not wrong. That's completely a normal physiologic response where then now you're starting to feel aroused after you've sort of started initiating some sort of intimacy with your partner. And that's completely fine and normal, but it just takes longer. We think that generally speaking, the blood flow just takes a little bit longer to get to the pelvis than it does for men. And so their arousal takes longer. So for men it might take like five minutes, and for women it might take like 15, 30 minutes. And so there just needs to be a focus on sort of. Of foreplay and even just cultivating an environment of desire so that women can then feel like, oh, you know, I am desired. I. Oh, this feels nice. Oh, it's like, I say, like, it's like going to the gym when you, when you don't want. You don't ever really want to go, but once you're there, you're happy. You did sort of the same thing, right? And. And so, yeah, and it does have erections even at night. So just like men wake up with morning erections, women have. And they have three to five erections at night. Women also have clitoral tumescence throughout the night. And that's your body's way of keeping good blood flow to the clitoris. But, but as you get other comorbid conditions, you get weakened blood flow, then that also decreases in women like it does for men. And that's what causes the clitoral atrophy. In addition to the loss of hormones.
- [40:13]
B
I actually wanna double click on responsive desire because I think that this is so. This is for all the women listening and the men who love them. Because I've seen, I've seen memes online with, you know, a guy doing the dishes, and then like, it pans to the girl and she's like, oh. And then, you know, and then he walks by her and is like, you're so pretty. And she's like, oh, my. And then, you know, so we, you know, there's this like, you know, joke around, like if he's doing the dishes, like, that's like a, a female form of foreplay, right, where you're sort of creating this, like, shared, you know, you're in this Together, you're fighting. It's not all falling on her to do, you know, let's say, the housework in this case. And I think that for a lot of women, you know, you said something really interesting about, you know, we don't ever want to go to the gym, but once we're there, we're really happy. One of the things that I've, you know, even just in casual conversation with friends, but also from my community, I hear this idea that women can kind of go without sex. Like, if they don't have it, they can kind of compartmentalize that and then just kind of get on with things. Whereas men, it's not necessarily the case. Like, they're kind of ready to go. They see you, they think you look pretty. A lot of visual stimuli, and then they're like, let's. Let's, you know, get into. And get into bed together. Is there. Is there. Is that that. Well, first, is that a fair, very broad generalization? I understand it's a very broad generalization, but is that fair to say that that responsive desire for women needs a few more touch points? Like, we're not just always ready to, like, throw off our clothes and, you know, get on the desk or get on the bed or whatever.
- [41:42]
A
It's very common. Yes. I would say, generally, that's probably more common than not. Right. So I wouldn't say all women are like that, but I think that, you know, generally speaking, like, we tend to need sort of a very. We need our minds to be in the moment a lot than men do. Men look at sex as sort of like a stress relief. And women oftentimes feel like it's a chore because they're already dealing with so much else. Right? They're, like, not thinking about the payoff of orgasm necessarily. They're like, oh, man, I gotta do. I gotta do this. It's another thing I gotta do. And one is like, yeah, you have to have sex worth wanting, right? So that's part of it, right? Like, if it's just penetration and you're done, and you don't really feel like it's that fun for you, then you're not gonna want it, right? But if there's, like, this buildup and you feel desired and you feel, like, treasured and, you know, like, you enjoy it, then it's something that you look forward to. What that's one, two is like, yeah. There's a lot of other things that women are dealing with in their life that add stress, right? During that time, they've Got the burden of housework, they've got the burden of childcare, even, and while they're working full time, whereas it often always falls on them, right? So they're. They're just not in the mindset. And so we talk a lot about, like, scheduling time for intimacy, and a lot of people push back, but I'm like, look, look, you schedule a date night, right? You want to go out on a date and have dinner. But, like, what about scheduling just time to be together, right? Where it's so easy to just be, like, I just want to look at my phone and scroll and, like, turn my brain off. But, like, having intentional time with your partner, it actually takes work. Now, we live in a society where, like, your attention can be a hundred different places at once if you want it to be. And you actually have to make it a priority and, like, spend time together and enjoy each other and cultivate that desire because it's. It does, you know, and hormonally, you would think about it, right, like, there may be some evolutionary reason once, you know, when you have your testosterone declining, which is your hormone of desire, when you have no more estrogen, which also contributes to, like, desire in your brain, all these things are. Are playing a role. And, you know, typically when you're going through cycles, you have these ups and downs. So, like, during ovulation, you tend to be more horny because, like, what. That makes sense, right? That's a time when you could have babies. So evolutionary, your. Your body's saying, hey, go have sex so you can make babies. And once those hormones are down, well, now, like, sex is just for fun, and that's great for us in a modern world, but then we have to work at it, and we have to sort of consider optimizing hormones and. And also making our lives, like, a little decreasing stress. Prioritize. Just like you prioritize your health, you have to prioritize your sex life, because otherwise it can very easily devolve. And you can look back and be like, I don't even recognize myself anymore. And I see this all the time. Women are like, I miss my sex life. And they almost feel bad saying it. I'm like, no, you shouldn't feel bad about saying it. Like, it's okay to want to have your sex life back and to want to be intimate with your partner. And so, like, yeah, sometimes you do have to put a little priority on it.
- [44:39]
B
I think we also. You bring up such a good point. And I think we also have to, in some ways, unlearn Some of the societal, like whenever we see people in movies, tv, whenever people are having sex, it's this like super passionate, like they just can't. Everyone's ripping their clothes off and you know, clearing off the desk. You know, like that's famous. You always see that in a, in a variety of different things. And I, and I remember hearing, I think it was Esther Perel who was saying there is such value in maintenance sex, like in long term couples, heterosexual homosexual couples. There's this, to your point, around prioritizing sex, it's not going to be this like I have to throw everything on the desk on the floor. But it is a wonderful way to continue to connect and to, and to, you know, for yourself, but also for that bond, that pair bonding with your, with your, with your partner. Is that something that you talk about with patients or is that something that you've observed in terms of, or maybe counseling your patients around like the importance of. I don't know if it's unlearning, but also just knowing that yes, for sure, when you first are with someone, there's gonna be a lot of like hot and heavy moments. But those hot and heavy moments, those. It changes over time. Maybe. Can you speak a little bit to that? Maybe I'm a little off, but yeah.
- [45:54]
A
No, no, I mean, I think that there is sort of like value, like I said, in putting time into being intimate because we know that like people who have sex more often so weekly compared to less than weekly, live longer. They have less mortality and people have depression, anxiety. If they' having more sex, they actually are less depressed and less anxious than people who don't have sex regularly. Because it is an int. It is part of intimacy, it is part of bonding, it is part of connection. And it makes you feel like you're a part of something, right? And so it's not just the act of sex. It's the act of being close to somebody and feeling that connection. And so I think it's, it's great to have some sort of ritual around reconnecting. Like maybe you. I saw this recently. Vanessa and Xander, they're two sex therapists who have a podcast called Pillow Talks. They talked about how they make out every day for like a few minutes before bed. It's like a ritual they have just to reconnect. And I was like, you know what? That's great. Figure out what works for you. You know, figure out what works for you because that is so important, right? Like just put. Making it a priority. There's nothing wrong with that and what we see on the media is not reality. Right. Like it actually is. Yeah. When you have a new relationship, there's a lot of novelty, there's a lot of excitement. So there's more buildup. Right. And yes, sometimes building that novelty into your own sex life can make it more exciting. Right. It can be role playing or maybe doing it in a different bedroom or doing it in a different position in the bedroom or something. It can be so simple as just like putting your head on the other side of the bed. But it's like, oh, this is something new and different. Like, let me just enjoy this new thing that we're trying. And so I think there's a lot that can be done, but I think it is extremely valuable to maintain a healthy sex life.
- [47:35]
B
I love the, the recommendation of weekly. I think that that is a bare minimum. Like once a week, I think is, I mean, 52 times a year. That. And when you think about it and you're like, oh, that's actually not that much, but you know, once a week I think is wonderful. I just want to go back to one thing you said earlier, which was, you know, sometimes if it's just, if it's sex not worth wanting, you know, if it's just penetration and that's it. Coming back to what you'd said, you know, the clitoris is one of the more reliable ways where we can think about, about a woman being able to achieve orgasm. Let's talk about what's been called the orgasm gap, which is, you know, I think men and women maybe first encounter, you know, assuming a heterosexual relationship first encounters, we see a difference in terms of, you know, men are often orgasming more than women. But we actually don't see that with homosexual couples. So when we see two women that are pairing up, we don't actually see that. So talk to us about the orgasm gap and talk to us about ways that we can maybe even begin to close that for women in terms of like understanding our own anatomy, what we like, asking for, what we like. All these things that are like so diff, I mean, so difficult for women in general. But talk to us a little bit about, about all of that.
- [48:43]
A
Well, so you bring up a great point. So when you look at first time encounters, 95% of men orgasm, where it's 65% of women. But when you look at homosexual encounters, 95% of women orgasms. And so it's not that we're more complicated, it's that we know our anatomy. Right. And so part of it Goes back to like, how are we taught about pleasure and how do we, like in it, sort of conceptualize that in our own minds. And so when you think about, like as a child, you know, if you're caught masturbating and your parents like, oh, no, no, don't do that, right? So you immediately are told that sex is shameful. And whereas, like, boys will joke about sex or their penis size or whatever, even as a young age, they'll be like, oh, my penis is so big. But women don't talk genitals and they don't talk about like these things openly. And so we're not really taught like, how to even. What, what does pleasure mean? Like, how do you even please yourself? We don't get taught female anatomy. So like, you wouldn't know unless you had some guidance, right? And so one is like, a lot of women don't know. They don't know how to pleasure themselves. They haven't spent the time exploring. They haven't. They don't own a sex toy, right? They don't even know. They've never explored themselves. And so how would they communicate that with someone else? Right? Especially in like the older generation. And so I think it's like giving yourself permission to explore and to, you know, figure out what feels good. And as I mentioned, the clitoris is the most reliable route to orgasm. So like, what type of stimulation on the clitoris helps you achieve orgasm? So that's one and two. It's like, you know, how do you talk about it then, right? And I think, like, it's so hyper focused on penetration, as you mentioned. And you see in the media, like, they have sex, they penetrate and they have an orgasm. He orgasms, she orgasms simultaneously, and everyone's happy, which is like, so not reality, right? I think the first time I saw clitoral stimulation in mainstream media was this Netflix show called Sex Life. Was it Netflix or hbo? I can't remember, but Sex Life, it's the first time I actually saw like a man, like, prioritizing clitoral stimulation even during penetration. And I was like, wow, this is, this is like, I don't recall seeing this before that. And so I think, like, we're just not taught that. And so it is so important to, to one, know what you want. And two, then like, you might have to do some education because your part or may have learned from mainstream media, from pornography, which are all entertainment, right? They're meant to do things in a way that's entertaining for the viewer and not necessarily based in Reality. And so it may be like, hey, I think it's really hot when you touch me here. Or hey, I'd love it if you try this. Or even just nonverbal, right? You just like put their hand somewhere or say like, you know, okay. Or like move your body towards them in a certain way. That's suggestive. And so I think it's so important. Like you want to have sex, you want to enjoy sex sex, you want to climax. And so it's okay to ask for things that turn you on. And it might be like, hey, I tell my male patients all the time, like, just ask what turns you on, right? Ask your partner, like, what, what do you like that we do? And then usually like a good partner will ask the same question back to you. And then that begins the conversation. And talking about sex is not a one time thing, right? You have to continually talk about it and like bring it up. And not in the bedroom, right? Not right after having sex. Oh, like I didn't like that. That's not the right time to bring that up. Like bring it up when you're maybe going for a walk or in the car or at the kitchen table, but not necessarily like in the location where you might be very vulnerable after you just had an intimate moment with your partner. And like realizing sex is play, it's supposed to be fun, like it's not that serious. And so I think like, it's okay if something funny happens or it doesn't go the right way. Like it's okay, move on, continue, like try different things. It's okay if it doesn't work.
- [52:28]
B
I think you bring up such a good point about pornography as well. Cause I think there's so many. I remember the first time I, I was like, that's not how I like, I don't respond like that. I don't, you know, my genitalia doesn't, you know, I don't look like that. You know, is there something wrong with me? And I think that there's women who might look at porn, men as well, who might be like, oh, I don't respond the way that she's responding, or oh, I don't look the way that she looks. Like, is there, am I, is there something wrong with me? And of course, because there's no real conversation about things. I mean, usually women often default to there's something wrong with me. Like, we don't do well on a diet. There's something wrong with me. We don't do well, well on the six week bootcamp or the 75 hard. There must be something wrong with me. And I think that this also translates into the bedroom, where we're like, oh, shouldn't. Like, I. She's screaming like, after just like, two seconds. Like, I don't. I'm not even doing that. So is there something wrong with me? So how do we maybe change the conversation, whether it's with our daughters and. And our sons who are getting, like. Who are watching pornhub, who are, you know, all the. All the sites or whatever, who have access on their phones. I mean, I know of, like, you know, my son. Some of their acquaintances are, like, just going. When they go to school, they're, like, watching it in the bathroom, you know, in the school bathroom. So it's. It's all the time and everywhere. So how do we teach? I mean, maybe our kids, which is very uncomfortable, maybe for some. But then also just a broader, you know, if you're a woman who has watched porno or your partner watches pornography, how do we bridge the gap between what is an actual female. Female response to stimulation and orgasm versus the production, like the movie that you're. That you're watching?
- [54:07]
A
Yeah. So I think the one thing to take if you're watching it yourself is like, this is a produced product. They use lubricants. They use all sorts of things to make it look like the camera angles to make it look a certain way. And they're actors. They're acting like they are literally screaming, and they know how to fake an orgasm, and they fake squirting, and they do all these sorts of things. Things that. That. And they also chose this profession for a reason. Right. Maybe they are hypersexual. Maybe they do enjoy. Maybe they are very responsive and they're easy to orgasm. But that is not the norm. Right. The norm for women is that it takes 15 to 30 minutes for full arousal, for their vagina to lengthen and widen, to accommodate and to naturally lubricate to accommodate a phallus. Right. And so it takes time. And again, 85% of women need clitoral stimulation to climax. And so they're not going climax through just vaginal penetration alone. That's what normal is. Right. And I think that's. That's really important. Now, talking about kids, the one thing I will say is I had. On my podcast, we had Dr. Debbie Herman at God, and she wrote this book called yes, your Kid. And it talks about how kids are seeing pornography and. And how they're. How they're. Well, actually talks about how kids are interacting with Others sexually. And a big thing that came up through her research was choking has become very, very common because it's very often viewed on pornographic. And so kids are choking each other. And sometimes it's. Most times it is consensual. But oftentimes when they talk, it's usually the man choking the woman. And the woman is like. They ask each other and she's like, yeah, sure, right. She's not like super turned on by it. And they do it and it's sort of scary sometimes. And sometimes they're like, oh, it was okay. But like, I don't want to say anything. And the reality is, like, most things sexually that you're going to do are not going to harm you. But choking, smoking could really harm you. You're actually like asphyxiating somebody, right?
- [56:02]
B
Asphyxiating, yeah.
- [56:03]
A
And. And so it has to be done in a very thoughtful and. And it can be very pleasurable. I'm not saying it's not, but I'm saying, like, it can be very dangerous when done just flippantly and it may not be erotic to some. And so the reality is that kids are seeing pornography. They're seeing as early as age 10 on average age 10. And so we have to talk to our kids about it, like, whether we like to or not, right? We talk to them about condoms, about safe sex. Like, this has to be a part of the now because it's everywhere and it's so easy to have access to it. Whether you give them access on their phone, they may have a friend who has access to it. They may see it somewhere else. They may just literally see a blurred vision on their YouTube shorts or something and be curious. And so, like, there's so much opportunity for them and it's so easy. They know how to get around all blockers and all sorts of things that they can see these things. But it's our job as parents to like, tell them, okay, you might come across something that is sexual in nature. It might be. Be interesting to you. I would love for you to talk to me about it when you do. And it starts by just like, first, like, I for. I mean, I'm not the perfect. I can't say I'm perfect at this, but I do my best. And I said, when we were kids, were little, I talked to them about the anatomy, right? This is a penis. Women have a vagina, a vulva. These are the structures. This is what happens when people have sex. And then, you know, you move on to when they're a little older. That, okay, you might see like some kissing in a show. What does this mean? Okay, now, you know, they might be. They might, might like, you might see a PG13 movie and they might like, turn off the lights right when they're about to have sex. You know, that's a great opportunity to talk to your kids about it. But also like then talking to them about, you know, what they might see and to have them know that you're going to be able as a resource for them to talk about it and really saying, like, this is not real sex. And when you're ready to have real sex, you're starting to think about having real sex. Talk about it with me because I want to talk to you about it and I want to make sure you feel comfortable. And like, I'm the default parent to talk about. They can absolutely talk to my husband about it, but they come to me because they feel comfortable. And so it doesn't mean that both of you need to do it, but you need to have comfort in having those conversations with your kid. It is just the right thing to do. Right. You want to raise responsible, sexually confident and sexually safe children. Right. Who are participating in sex in a way that's safe and feels good for them.
- [58:23]
B
I love that. I love that. Are you aware of any evidence that excessive pornography use, does that change a woman or a man's ability to orgasm? Does it change their relationship to. If they have a, you know, I'll say in real life, like IRL partner, does that change their ability to connect, whether it's sustaining an erection, if it's a male, or achieving orgasm, male or female?
- [58:49]
A
Yeah. So I would say that excessive is like a very subjective word. What is excessive? Right. For some people, like, they're so bothered by just seeing pornography once because there's so much what we call moral incongruence. Right. They think it's bad. They think it's not good morally to be viewing pornography or to masturbate and so they immediately have discomfort related to watching it even just one time. Right. And that can perpetuate. They can feel bad about themselves and they can. Then when you feel bad about yourself, it's very difficult to get an. Have an orgasm or get an erection. Right. So it doesn't. There's no right or wrong amount to. And the ones we see the most problem is, is those, like, there's no.
- [59:27]
B
Recommendation the way that you were saying, like once a week for sex. But there's no, there's no. Because it's so subjective.
- [59:32]
A
It's so Subjective. So, so like when people have this moral incongruence, like they're told it's bad and they feel guilt, like a lot of shame, that's where we start seeing problems now in terms of like specific effects on sexual function. It's not that like oh, watching the porn is now rewiring your brain and now you're going to have problems that is not accurate. Like that's what a lot of people will say, say. And the reality is you are seeing something that is visually stimulating to you. Your brain is then turning on certain pleasure centers and you can have pleasure with food, you can have pleasure with all sorts of things. Now when you touch yourself and, and you're watching the thing now, you're adding more pleasure centers and more things. But it, it is not nearly as much of a response in your brain as it is in being with a partner, right? There are certain things that like having someone else touch you. Your brain, brain sets off certain nerve fibers, they're called c afferent fibers that can't be turned on with any other type of stimulation. It has to be like a certain type of stimulation by another person and usually sexual in nature. But it's like this slow caressing type thing. So like, I think that's one, I just want to clarify. But two, you know, so when people start having problems and people do, right. The, the, this data would say like 4% of people have what we call problematic porn use. I think it's probably higher than that because we don't have really contemporary data. But what happens is for a lot of people when they have trouble is they are either there's a couple things. One is they are like expecting their expectations have changed of what sex should look like because they've compared it to pornography and now it's not reaching that and they're like, what's wrong with me? And they're perseverating on themselves rather than being in the moment with sex. So that's one, Two is that they get used to a certain type of stimulation, right? They're like seeing things are so novel, so original, erotic, that like can't be replicated in real life, right? So whether they're seeing those things or when they're masturbating to pornography, they're either using a very like high intensity vibrator or they're using a very firm grip if they're a man. And these things can't be replicated by a mouth, a penis, a finger. Right. They just can't get those frequencies. Or you can't get that firmness from another person. And. And so then they're like, they've now become habituated to that sort of stimulation and they are having trouble with their partner. And this is something that you can walk back. Right. You can sort of stop doing those things. Take a break, try different types of stimulation and sort of get, get those things back that you used to find pleasurable. But just realizing like you can't. Like a high powered vibrator, like no one's finger or mouth can do that. Right. It's just not possible. And it's okay. Like you can still use a vibrator with your partner if you're both okay with it and you can still both climax. That's great. In terms of men, like a vagina or a mouth can't replicate a really firm grip. Or if you're masturbating like prone or you're master, which is on your belly or you're masturbating against like hard furniture. Like no, that can't be replicated by human body. And so like you just have to realize like if your body habituates to something, you gotta walk it back and that's okay. Right. You're not, you've not damaged anything. You just have to work at sort of re. Like fixing your habituation and trying different things and taking some time off of that.
- [62:40]
B
Yeah. And just increasing the diversity of, of stimulation. So maybe it's still, maybe it still is part of, you know, your sexual life, but there are other things that you add in. Just like a, you know, diversified financial portfolio. You're not just going to have one stock, you're going to have a couple of different things. Let's talk a little bit about the different kinds of orgasms. I think this is a good place to maybe talk about that, especially for women. I know that there are. And maybe maybe this is in men too. I don't know. But for women and there's like multiple orgasms where there's lots of them sort of very close together, let's say. And then there's usually. Or it can be like a very big orgasm. It's almost like going over a cliff, sort of, so to speak. Talk to us about the differences for women and then is there ways that we can even train up different kinds of. Or is it menstrual cycle related, hormonal related? Like how and why are these different types of orgasms happening? And then I guess does it also happen in men? It would be my third piece.
- [63:32]
A
Yeah. So the interesting part about this is we don't really like. So what those tracker type things are measuring like that, they're measuring your pelvic floor muscle contractions, right? And so I don't think it necessarily contributes to like they're all orgasms, Right. An orgasm has a very sort of pathognemonic finding where when you orgasm, your pelvic floor muscles contract involuntarily at.08 seconds. So when you look at like scientific data on this, there's actually, there's one study, it hasn't been published yet, but Dr. Nicole Prowse was telling me about it, where basically they had women in a vermin. They were allowed to orgasm as many times as they wanted to. They were stimulating themselves and they would like press a button every time they organized orgasms. And so the women who did report multiple orgasms, they thought they were having multiples, but when they got to the, there was only one at the end. And so it, you can get close and you can sort of feel this intense pleasure, but it may not be that sort of full orgasm that's happening now. What does that matter? Right? It doesn't really matter. So in terms of like, what causes different types of stimulation, types of sort of sort of intensity that varies from person to person. So some people will describe, depending on where you stimulate, that you're having different types of intense pleasure. And so if you have, some women will say, like cervical, like when they get really deep penetration, cervical orgasms, it's really just orgasms from cervical, you know, stimulation. They feel like this, like sort of cosmic, like stars and whatever sort of feeling. Some people will have stimulation from the G spot, which is, is this spot 2 to 3 centimeters or inches from the, sorry, anterior vaginal wall, which is where like the Skene's glands are located, where the, the clitoral shaft is and the top of the vagina. And that's sort of analogous to the male prostate. So men can orgasm through prostate stimulation, women can orgasm from G zone stimulation, but not everyone does, right? And so stimulating that for some people can cause a different type of stimulation sensation. Clitoral stimulation is, you know, again, going to give you that sort of pathognomonic orgasm that most people will des, where it's like sort of this overflowing type thing. Now again, I think that the reality is that what you need to sort of experiment with yourself and your partner is like different types of stimulation, maybe combining different zones, combining different areas at the same time and figure out like, what gives you what kind of pleasure, right? And for Some people, they can have orgasms without even touching their genitals, right? It can be through nipple stimulation. It can be through, you know, sort of like caressing these erogenous zones and sometimes doing that at the same time as stimulating your clitoris or your G zone or you're, you know, getting deep penetration in the vagina. All those things. You know, you can do multiple different things and sort of just figure out what, how your body responds and then you can use that, right? You can either do that with your partner, be like, oh, I love this, or you learn by yourself, and then you sort of tell your partner, this is how I really have the best orgasm. Because every partner wants to give their partner a great orgasm. So, like, they're not going to take that negative.
- [66:36]
B
And is there, should we be trying to. I know you mentioned like once a week for sexual encounters. I've heard, and I just, I have to bring this up just because I have the opportunity to ask you, like, I've heard for men, which I can't find any science to, but maybe there is. Semen retention improves quality of orgasm, testosterone levels. You know, it's the basis for like, no nut November. So is there, is there validity to abstain, gaining from orgasm for, for both men and women, or is it like, hey, like, we should be getting as many as we can?
- [67:09]
A
So there's no data. There's one study where they took, I think it was like 10 guys and they had them abstain for 21 days. And then on the 21th day they orgasm, they measured their testosterone and they saw their testosterone went up. Like it was a tiny amount. It was really tiny, like 50 nanograms per deciliter or less. And they, they had more intense or orgasms. But the reality is, like, when you're abstaining, there's also this like, anticipation that builds up and that's a huge part of it, right? And so that's one and two. So there's never been any sort of replication that like, oh, you're abstaining is improving. Testosterone is improving, like intensity of orgasm. But if you think about it, right, if you edge, which a lot of people do, they'll edge, they'll get to the almost climax, they'll hold back, they'll do it again. They tend to have more intense orgasms and it's just sort of like fig. That's the same sort of thing. Now, it can help people have more intense orgasms. That may be a byproduct of it, but a lot of times people are sort of like white knuckling it because they think like, oh, semen, hydrogen is good for you. So they're like tensing up their pelvic floor for days and days and that then creates this like, pelvic floor dysfunction we talked about in the beginning. Right. And so I like, if you find benefit from abstaining, and sometimes what happens is people find that they're now not focused on sex so much because they've made this, like, contract with them themselves. And so then they're like, able to be more productive or they're more focused. Great. If that works for you, by all means, like, do it. Like, I think it's great if you find benefit from it, but I don't think it's a prescription for everybody. Oh, you're going to have better orgasm. Your testosterone is going to go up. You have to do it. Like, no, I think it's a very individual thing and it can create harm too. And so, like, I think there's, there's a lot of bullying. Like, oh, if you want to be like me, you must retain. And like, no, you just do what's right for you. Yeah.
- [68:52]
B
I'm so happy you said that because there's. There's one person in particular. It doesn't matter who it is, but they talk about this all the time online, like, semen retention. For men, testosterone's gonna go through the roof. Quality of orgasms are gonna. And I just, I, I'm, I'm like, okay, I. Show me, show me, show me the mechanism. Show me the evidence. And I, I went, I went into PubMed. I couldn't find anything. And I, I do feel like it can cause a lot of. I don't know what, I don't know what the right term is, but it's something like a holier than thou, like, eye catching can do it. And look at how good this, like, look at how good this is. You know, I'm, I'm. And if you follow this pathway, you too can be as great as I am. And I think that there's, again, it's just another opportunity for shame. Like, to your point, if it works for you and you feel like you can be more focused and you enjoy that, have at it. And don't make claims that aren't there. Like, I can't find any. A shred of evidence to support, you know, increased testosterone. So for, so for women, then would it be. Be. Or I guess for men, is it like the more orgasms typically, which is. Would you say it's loosely related with Better health outcomes, like better cardiovascular outcomes, better hormonal balance, better mood and affect, better sleep. Would you say that that is a corollary?
- [70:02]
A
I would say for the majority of people, orgasms are great. They have huge health benefits. They do like all the things you said. Basically they decrease heart rate, they decrease blood pressure, they help you with sleep. For some people they help with focus because they get this like post orgasmic clarity. But like really they are so beneficial. In fact like we know they decrease pain, right? So some people who are having pain will orgasm and pain goes down. And so we, there's not a lot of studies looking at this because you know, there's obviously like IRB issues. But like I think, you know, if people looked at orgasms as a medical tool sometimes, like we'd probably see a lot more benefits than we do. And so I think, you know, there are so many benefits to it. One, why like intentionally reduce that unless you are gaining some benefit from doing so? And like, I would add that a lot of these people are selling these like very expensive exorbitant courses to teach you how to stop from like retain semen. Like and then like you feel shame when you have a nighttime orgasm because. Or night ejaculation because that's going to happen, right? Either when you abstain, what's going to happen is your semen is going to either get absorbed by your body or you're going to ejaculate at night and have a wet dream and then, oh, have you failed? Like, you know what I mean? No. This is your normal physiology. This is what normally happens.
- [71:14]
B
And there are 10,000 nerves that you are not using, ladies.
- [71:18]
A
Yes, absolutely.
- [71:22]
B
Fueling my body with whole foods is important, but every diet has its nutrient gaps, including mine. That's why I always start my day with AG1. It ensures that I'm covering my nutritional bases and supporting my gut health. Something, ladies, that definitely declines in perimenopause. I trust AG1 because the entire formula is backed by research studies, not just the individual ingredients. In multiple studies, AG1 has shown to double the amount of healthy bacteria in the gut, including two species known for supporting gut health and whole body inflammation. If there's one product I trust to support my whole body, it's AG1. And that's why I've partnered with AG them for so long. It's easy and satisfying. To start your journey with AG1, try AG1 and get a free one year supply of vitamin D3 and K2 as well as five free AG1 travel packs with your first purchase at drinkag1.com forward slash Stephanie. That's drink ag1.com forward slash Stephanie. Let's talk a little bit about. I know we've been talking a lot about orgasms, but I do want to talk about low desire in women because I know that this is a really big issue in perimenopause and menopause. It's, it could be a function of desire lubrication. Maybe it's some of the things we've been already talking about, like painful sex related to testosterone decline as well. So talk to us a little bit about low desire treatment. So clinical signs, pictures, you know, clinical signs and symptoms. And then obviously at the time of this recording, you know, we're in North America. So there is no, you know, there's no testosterone product right now for women at least in the, you know, United States and Canada. I know, I think that there's one in Australia. But talk to us a little bit about what are some of the treatment options? I know that we all like to jump to hormones, which I just did, but are there other things that we also might consider if as a woman you're like, God, like I love my partner, you know, husband, wife, whatever, but I'm just not feeling it. Like it's been like I'm 47 or I'm 52 or whatever. And it's just, it's been rough and I want to connect with him or her, but I can't. What, what, what do we, what options do we, we have for her?
- [73:31]
A
So I think first of all, it's like looking at the big picture right before we jump into hormones, like desire is so multifactorial. Like you have to stress reduce, you have to be sleeping, you have to, you know, be sort of maintaining your health. All the things you have to think about your relationship, think about other things that are building stress in your life. Like midlife is so jam packed with all those things and so you gotta be focusing on those. But I will say so many women come to like, I'm doing it all. Like I'm sleeping, I'm trying my best to sleep. Obviously they sometimes with hormonal changes, not so easy. But like trying my best to sleep. I'm working out, I'm, you know, I'm trying to de. Stress, I'm meditating, doing all the things right and it's still difficult. And as you mentioned, all those things that you mentioned are going to cause low desire, right? Like loss of testosterone, change in, change in the responsive desire. We talked about earlier, like, just, I think also modern society, like, just having so many distractions. All these things can play a role. So I always love to say, like, try to schedule intimacy. That can help. Try to cultivate a like, experience of desire where you're like, talking about it, you're texting each other, you're like engaging in just gentle, like foreplay throughout the day, right? Like sort of cultivating this feeling of being desired from both ends, right? Like from your partner and you giving them the feeling too. But if you then like you've tried all these things or even if you are trying them and you still want some support. There are two on label medications for low desire that are for pre menopausal women. They still work for postmenopausal women. And one of them is in studies right now get approved for postmenopausal women. But one is called Flanserin or Addi is the brand name. It's a medication that works on the serotonin receptors in the brain and it helps with desire. And you take it once a day at night. And usually after about three months, you'll start noticing that there is a. It's more of a subtle change. It's not like, oh, I have this sudden increase. It's like, okay, now I'm like doing the dishes, I'm watching tv and I see an attractive man on the TV and I'm like, oh, I kind of of feel like turned on, which I never used to feel before when I saw that same guy before. And so it's sort of like these sort of subtle changes. And so it works in about 60% of women. So I think, like, it's worth a shot if that's something you're open to. There's Vylisi, which is a injection medication, and it is on demand. So when you want to want, you take this medication about 45 minutes before it's an injection, give it to yourself. And it's very suddenly increases desire. It works well. Also probably similar 60 and it does have some side effects like nausea. So I tell people, like, take an antiemetic or I will write for one at the same time because you don't want to be horny and nauseous. That's not a great combination, but it works. And these are options that can help, right? In women who are struggling with low desire, and they can be covered for women who are premenopausal in the post menopausal space, you may have to pay cash for them, but they have programs. These companies have programs with Certain pharmacies that can help you get it for a reduced cost. And then there's testosterone. Now, we know that testosterone, it doesn't jump off a cliff like estrogen does during menopause, but it slowly declines over the lifetime. And testosterone is a hormone of desire. So when testosterone declines, you will then have a decrease in desire. And so it's very simple to check testosterone. It is a blood test. You take a blood test in the early morning, you make sure it is appropriate for women, because there's two different kinds of blood tests, and one is not really great, at least low numbers. So it's a mass spectrometry, is a testosterone sort of test you want to get and you check. And so we say that while there's no specific guidelines, there are a couple papers looking at, like, the amount of testosterone that's normal for women. But they are, you know, I'm not very convinced that we have a normal yet that is like, robust and clinically validated. What we tend to use is one tenth of the male amount. So if 300 is a normal cutoff for men, 30 is a normal cutoff for, for women. And if you are then decide that, okay, you are truly low and you are symptomatic, meaning you have low desire, then you can get treated with testosterone replacement. Now, it can be, again, these are off label. You can do testosterone, you can do the male dose and take one tenth of it a day, or you can get a compounded testosterone cream and then they'll tell you how much to use every day. And you take that and you see over time and recheck your testosterone. Are you having an improvement in symptoms? And are your. Is your testosterone within an normal range? And the goal is to get you within normal if you're normal, very unlikely to have side effects if your testosterone goes too high. So some people do testosterone pellets and other things, and while these work, for some people, they can get your testosterone very high. And because you can't take it out once it's in, like, you're sort of stuck with that for three months. And so that can then give you acne, can give you sort of mood changes that are like, more aggressive and. And it can even increase your clitoral size. So I've had women who've come to me after having certain pellets and their clitoris gu. Larger voiced.
- [78:29]
B
Right. Their voice will change a little bit if it's for.
- [78:31]
A
If it gets too high. Yeah, yeah. So, like, I think again, it's important to have someone who knows how to manage testosterone, but it can be, it can be very helpful for some women. And so, but it is, I think once you start testosterone, to realize like, you are shutting down your own body's production of testosterone. So you sort of need to think of it as like, I'm going to take this forever now or I'm going to have to wean off and consider other options, maybe off label options to boost my testosterone naturally. But ultimately it's sort of like you just gotta realize that now you're shutting down your own body's natural production. So if you miss your dose, you're gonna feel crappy that day. Cause you're gonna have very low testosterone because it's not just desire. So testosterone receptors are all over the body, in the brain, in the muscle, in the vulva. And so like, for a lot of women, they may see benefits. And it's not evidence based yet. We don't have great data on this. We have some positive data, some negative data on, you know, increasing muscle mass, on brain clarity, decrease in, you know, those sorts of things that we see in men. So we see in men, you know, that improves muscle mass, it improves brain fog, it improves cognition, those sorts of things. And I suspect that we would see the same in women if we had the same, you know, sort of funding for research in women in the same way.
- [79:49]
B
So how do we. Okay, so this is my algorithm, this is my brain going, okay, like, how do we figure that? So desire is multifactorial, so how do we know if it's hormonally driven, it's a blood flow issue, Neurally driven, it's psychogenic. Like, how do we tease all these things? Like, what are some way, are there ways I don't even know that we might look at the root cause of what's causing that desire and not at all. It might not just be one, it could be many of those things.
- [80:18]
A
It's usually multifactorial. Like, even with this. But like, you would say, okay, if sex is painful, we gotta fix that first, right? If you're not, like, if you're having painful sex or discomfort with sex, you're not gonna want sex. So we gotta figure out one. Like, okay, is that, that could be an issue with hormones, right? With hormones, is it, Are you having. Arousal and desire are two separate things, right? So do you get turned on with your partner? Do you feel turned on? Like, does your body respond? Right, like, do you. And this could be challenging because if you're not making lubrication, which often happens, after menopause, you're less lubricated. But do you just generally feel like, the urge, the, the, the, the changes that are happening in your body, that's arousal. Desire is the urge to have sex. And that's somewhat difficult to parse out, but to some degree, yeah, but to some degree, arousal is blood flow, desire is brain. And so that's how you sort of think about it. And sometimes it requires that you sort of work on both ends. So like we. For men, it's very interesting to me that for men, when they have arousal difficulties, right, that's erectile dysfunction, we'll give them pills like Viagra and Cialis. For women, when they have arousal difficulties, we'll give them like topical creams, like scream creams and soldenafil creams. And. But like, they. There's been some small studies in giving women these oral medications and they haven't been so positive. But again, I think it's because it's so difficult to discern is it arousal or is it desire? Right. Because it's only going to fix one of the two issues. And so, yeah, you can consider those options and see if they make a difference. Right. And then for desire, like, again, it's, it's often a brain phenomenon. So then you think about is that could be hormonal or that could be these medications. Now if you try testosterone, it doesn't work. That's okay. Like, within three months, if you get off it, you're not going to like, totally shut down your body's production. Even later on, you will, your body will naturally produce testosterone, gastrode. It just will take some time for it to get back to normal. Right. And so I don't want you to be fearful of trying it if you're, you know, you think it may help.
- [82:15]
B
And I think also when it comes to desire for sort of quality, for sort of categorizing desire as brain, like if you're anticipating bad sex, you know, because it's all, it's just like one way, and it's only been that one way for however many years. I think that that also is gonna play into it as well. So I love that, I love the way that you've delineated between arousal being more blood flow and desire being more maybe neurological or boring or brain. Do we know if maybe an arousal issue for women in the same way that arousal or erectile dysfunction for men is a sign of cardiovascular disease? Is that also, Is that a parallel for women too?
- [82:50]
A
Yeah, probably. We don't know. There's not like a, it's just not studied as well. Right. Because women don't know when they have arousal. Like they don't see an, a less erect clitoris. And so it's just not as well said. But I suspect that yes, if you, you have decrease in arousal, we should be concerned about your cardiovascular health. And so I think generally speaking, like, women should be advocating for themselves in general because women just get. There's a lot of biases in medicine towards women. We know this to be factual. So you do need to advocate for yourself. So you could be like, look, I want to get my, you know, my heart health evaluated because my desire, my sexual. I'm noticing some sexual problems. And you know, a good doctor should evaluate that.
- [83:30]
B
Yeah, I know we've been like, I've just looked at the time and I just, I can't believe how long we've been talking. I do have one more question for you around UTIs and bladder health. I wanted to make sure that we circle into this. Cause this is another big problem that we see women in midlife. I have always, I, I have always heard cranberry juice has a lot of data to. If you have a UTI or frequent UTIs, maybe you can talk to us about cranberry juice versus antibiotics. Are they equated one better than the other? And other things around preventative measures. So should we always, should we always be thinking about urinating after sex to make sure that there's no, you know, possibility of contamination for bacteria to sort of walk back up? Tell us a little bit or bladder training? Is there, is there ways that we might think about reducing the risk of UTIs in midlife and maybe why it happens more frequently in midlife as well?
- [84:20]
A
Recurrent UTIs are very common and a lot of women get like, feel very dirty or very bad, like they're doing something wrong. That's like never the case. So no, if you're suffering and you're listening, you are not dirty. There's nothing wrong with you. It is typically a hormonal and sort of just abnormality in the way your bladder responds to infection. Right. There's nothing that, that you're doing that's wrong. Now there is hormonal changes. So if you are lactating or have a low estrogen state like you're during menopause, your vagina changes ph. It actually becomes more basic. And when it becomes more basic, it's not making as much lactobacilli and it is then not as able to prevent bacteria from the vagina to get into the bladder. It now allows those to flourish and bacteria can more easily get into the bladder. We know without a doubt that giving vaginal estrogen to these patients will reduce the risk of recurrent UTIs. It is safe, it is effective, and it works very, very well. The other thing that works really well is hydration. So if you add 1.5 liters of fluid to your regular intake, you will see a 46% reduction in risk of UTI.
- [85:28]
B
That's 46. 46.
- [85:29]
A
46, yes, 46.
- [85:31]
B
That is incredible. Good.
- [85:32]
A
Yeah. And, and then the other thing is things that you do behaviorally, really the big one is just not emptying completely. So like I said, the hovering back to like when you're not peeing completely, because maybe you're hovering, maybe you're not sitting down and relaxing on the toilet. A lot of women will not really realize they're leaving a little urine behind. So what I tell people is sit, relax, lean forward, pee, stand up, move around and sit down again and pee. Women also get a little bit of sometimes the prolapse we talked about, and sometimes that urine sits underneath a little bit gravity. So moving then moves that urine back into the bladder neck and you can pee it out. So, so those are things that you can do. And then cranberry. So cranberry has been shown in multitude of studies to be helpful. Either the 100% cranberry berry juice, not the ocean spray sugar filled stuff, it has to be 100%. It's very unpalatable, but it works.
- [86:25]
B
Very bitter. Yeah.
- [86:26]
A
Yes. Or you can get a supplement with 36 milligrams of soluble pro anthocyanidines. So it has to have 36 milligrams, it has to be soluble. There's an abundance of data supporting that dosage. But you will see that a lot of pills on the market, especially the ones you can get like at the drugstore, they are either made with insoluble amounts. So it's like the skin and the stems, which doesn't really do anything. So it needs to be from the fruit itself. It's a very effective way to sort of get the cranberry in. And what it does is it coats the bacteria so it doesn't stick to the bladder wall and you pee it out. And so it can be very effective. And so those are really sort of things you can do at home. And then obviously, if you're struggling, see a doctor, see a urologist to get evaluated to make sure there's nothing else going on. Like, make sure you're not holding a bunch of urine behind or you have a kidney stone or other things that could be a source for infections.
- [87:23]
B
This has been like drinking out of a fire hose. There has been so much good stuff in this conversation. Where can people. I know that you have a thriving YouTube channel. Tell people where they can find more about you and your work and all. All the things, all the places.
- [87:39]
A
Absolutely. So you can find me on YouTube, Renamd. I also have a podcast, which I host there, as well as on all the podcast platforms, called the Rena Malik MD Podcast. You can basically find me on any social media platform at Rena Malik MD and love to see you there.
- [87:55]
B
Awesome. Thank you so much, Reena. This has been great.
- [87:57]
A
No problem.
- [88:00]
B
Welcome to the afterparty. And cue salt and pepper. Let's start. Talk about sex, baby. All right, so for those of you that remember that song circa 19, God, what was it, 90? We talked about, you and me, and we talked about all the things that could be. So this. This conversation may be one of the most impactful ones. We've had many, many impactful conversations, of course, on the show. But I love this conversation because this removes any stigma, okay? Any stigma around UTIs and peeing and urinary incontinence and sex stuff. Right. How long should I, you know, should I take to orgasm? All of these different things that we are not, as a country, global community of women talking about. I think Dr. Malik really did a great job of destigmatizing. So a couple things that. That I really loved. I'm so glad that I asked her, like, just tell us what a pelvic exam is. Like, I loved. I mean, maybe this is just the nerd in me, but I loved that she said. And I almost interrupted her, but I didn't. She was like, I removed the top, like, part of the speculum. And I almost said, God bless you, because anybody that's ever had an exam, you know that that speculum is fucking cold. It's effing cold, and it hurts, right? So just loved when she was like. And we just removed the top half of the spectrum. And then I just look at the anterior half of the vaginal wall. I look at the posterior aspect of the vaginal. I look for asymmetries left and right. So hats off to Dr. Malik for removing this. But. And making the pelvic exam just a little bit more palatable. Also loved when we were talking about the genitourinary syndrome of menopause. 80%. And it's probably higher than that. But 80% of women are going to experience some kind of change to their pelvic floor or their pelvic function, reproductive function. So that could be UTIs dryness. She said lightning crotch. Like I feel like that should be a T shirt. Lightning crotch would make a great T shirt. But just understanding that we are going to see changes in menopause and perimenopause and if we can be able to start looking for some of those signs and symptoms now, we can identify them, bring them to our care, our primary care provider, get a referral to a gynecologist or urinary neurologist, etc, and then get the pelvic floor physical therapist and then get the care that we need. A couple other things I really loved was the discussion around how we can have conversations about sex with our partners, but also our children. I, I tried not to react. If you're watching this on video, you'll probably see my reaction. But when she was, was saying that, you know, kids are choking each other now, I literally said in my head, don't react. And I'm pretty sure that you probably see like an eyebrow raise or one half of my face scrunch up. But yeah, I think that these are really, and not to discourage that, like if it's consensual and they're enjoying it and whatever, like fine, like you do, you boo. But we also just want to make sure that we have an open dialogue with our children so that they can become, as she said, you know, competent, educated and informed individuals who have a very healthy, healthy and robust sex life. And she's kind of said it at one point in our conversation too where she's like, orgasms, you know, like we got 10,000 nerves just for our clitoris, ladies. Like, what a shame, what a shame not to put that to good use, whether it's self pleasuring, pleasuring with your partner. And I think that the, the more orgasms that you can get, I've, I've, I talked about this in my first book. Like the more orgasms you can get, I think the better. It has such profound effects on your health. As she was saying, on heart rate, on blood pressure, on blood pressure flow, on, you know, hormonal balance, on your mood, on your affect, on your sleep, all the things I think that it's, it, it's really one of those things I, you know, I talked about in my first book, this idea that our menstrual cycle is a vital sign. I actually think that, you know, we can Maybe start to think about markers that we can aim towards in terms of orgasming. Again, it can be self pleasuring sex toys and vibrators and all the things or it can be be with, you know, partner or partners. I think that for, for women and it seems for men it's like as many as you can get is sort of, sort of the game. So really, really loved it. And I feel myself, this is a conversation for myself to listen to. I feel like this is a conversation that I am definitely going to send to my husband. And I think same with you. I think if you have a, a partner, whether that part, if you are in a heterosexual homosexual relationship, I think that you're just gonna learn a lot about female anatomy, physiology, desire, arousal and how to be a better partner. So I say that this is for all women and for the men who love them. And I really love the way that she just spoke about it in like a frank way. For the Canadians who are listening, you'll remember sue. Is it Sue Johnson, I think is her name. Or Sue Johan. No, Sue Johanson. Sue Johnson. Sue Johansson. You'll remember Sue Johansson who used to come on late night and she would just talk about sex in such a frank way. And honestly, like I listened to every word that Sue Johansson, like I learned about sex in Canada from Sue Johansson. And Reena actually is a reincarnated version if of you, if you will, of, of Su Johansson, the American version of, of that Canadian icon who taught many Canadians about sex and penetration and orgasm and all the things. So I just really enjoyed talking to her and I hope that you enjoyed this conversation and you are going to have action items from it. I know that my new thing now is I am going to set a timer and I'm going to make out with my husband every single evening. That was my big takeaway as well. So let me know what you thought of the episode. We love it all and, and we will see you next time. I'll catch you soon. All right. All right. I hope you enjoyed today's episode and I must give you the obligatory legal and medical disclaimer here. This podcast, Better with Dr. Stephanie, is for general information only and the advice recommendations we discuss do not replace medicine, chiropractic or any other primary primary healthcare provider's advice, treatment or care. In the consumption of this podcast, there is no doctor patient relationship that has been formed and the use and implementation of the information discussed are at the sole discretion of the listener. The information and opinions shared on this podcast are not intended to be a substitute for primary care diagnosis or treatment. In other words, guys, be smart about this. Take it with a grain of salt. Take this information to your primary healthcare provider and have a discussion with him or her to make the best choice. That is for you. Remember, I am a doctor, but I am not your doctor. And these conversations are meant for educational purposes only.