← Rena Malik, MD Podcast
Rena Malik, MD Podcast
13% of People Take a Pill that Might Permanently Destroy their Sex Life ft. Dr. Irwin Goldstein
01:40:02
In this episode, Dr. Rena Malik, MD welcomes Dr. Irwin Goldstein to discuss groundbreaking insights into orgasms, erectile dysfunction, and the impact of medications on sexual health. Together, they explore the latest treatment options and emphasize the importance of seeking specialized care for sexual concerns, empowering listeners to take charge of their sexual well-being.
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- [00:01]
Dr. Irwin Goldstein
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- [01:13]
Dr. Reena Malik
So having more orgasms is protecting your brain.
- [01:16]
Dr. Irwin Goldstein
SSRIs raise serotonin, so like depression, which leads to suicide and we can stop suicide. So it's a fabulous drug, right? But its effect on the neuron and on the synapse and on neurotransmitters in about 1 to 3% of people are irreversibly changed. You know, another crazy problem for young people is the dysmorphia of wanting to have a testosterone value of four digits. They love looking at themselves in the mirror. They love competing. They do anabolic steroids and as soon as they get off of them, their testicles shrivel beyond belief. They get scarring of their tissue. They get a severe hypogonadism.
- [01:58]
Dr. Reena Malik
It's 2026 and we're just learning about these phases of orgasm. Did you know that having more orgasms could actually protect your brain and reduce your risk of dementia? Well, today we're going to talk about orgasms and how millions of people around the world are suffering from side effects of medications they were prescribed, sometimes even as young as teenagers. I'm Dr. Reena Malik, urologist and pelvic surgeon. And welcome back to The Rena Malik, M.D. podC, your trusted source for leveling up your health, sex life, and relationships with evidence based tools. Today Our guest is Dr. Irwin Goldstein. He is a pioneer in the field of urology and a sexual medicine specialist who basically founded the field. He has authored over 350 research publications. He's been involved on countless journal editorial boards and received in numerous lifetime achievement awards. I can't even begin to tell you the number of accomplishments this man has. He's authored over 350 publications. He's been involved on countless journals, journal editorial boards, and received numerous lifetime achievement awards from some of the most important organizations in sexual medicine. He is literally one of the giants in our field. Without him, there would be no Viagra. Female sexual dysfunction as a study would not even exist. And he's responsible for training some of the most prolific and impactful urologists of our generation. He is literally saving sex lives everywhere. In today's conversation, we talk about the surprising impacts of multiple common medications which can permanently alter the way your brain neurons communicate and cause sometimes permanent sexual dysfunction. We talk about conditions like post SSRI syndrome, post finasteride syndrome, and hard flaccid. We cover why orgasms can be difficult and what you can do about them. And why we're seeing an alarming rise in erectile dysfunction in young men and the serious dangers of jelking. You don't want to miss this conversation. But before we get into the conversation, I briefly want to let you guys know my erectile mastery course has launched. It is free. Four modules with multiple lectures covering everything you want to know about erectile dysfunction, including lifestyle changes, what to do about it, what happens if you're struggling with erections? Basically, everything I tell my patients one on one when I see them in practice is exactly what you get. So check it out and see if it's something you might be interested in. It's an honor to have you here.
- [04:14]
Dr. Irwin Goldstein
It's an honor to be here because
- [04:16]
Dr. Reena Malik
you are one of the giants in our field and you have. Without you, there would be no female sexual. No female sexual function fellowships. There would be maybe no Viagra. I mean, a few things. Like a few major things that you've lived through.
- [04:33]
Dr. Irwin Goldstein
Yeah, but without you, we wouldn't have the word to do with an equal share.
- [04:39]
Dr. Reena Malik
But thank you. Thank you so much for taking time out to be here.
- [04:42]
Dr. Irwin Goldstein
Thank you. We happen to be around your corner.
- [04:44]
Dr. Reena Malik
I know. Worked out. So let's talk about orgasms.
- [04:47]
Dr. Irwin Goldstein
Oh, we love orgasms.
- [04:48]
Dr. Reena Malik
We love orgasms. So let's talk about what's happening in the body that leads us up to Orgasm. I love the way you describe it when you teach us about it. So I think it's a wonderful thing to share.
- [04:58]
Dr. Irwin Goldstein
So if swish International Society, Society for the Study of Women's Sexual Health puts on consensus development sort of subjects and we realized we had studied things like low interest, we realized we had studied things of low arousal but we haven't yet studied orgasm. So I'm one of the three CO chairs and we have I think 19 people, world experts in all these sort of regions.
- [05:26]
Dr. Reena Malik
Yeah.
- [05:26]
Dr. Irwin Goldstein
And we're just putting together, hopefully it'll come out in 2026. Really fascinating.
- [05:30]
Dr. Reena Malik
Amazing.
- [05:32]
Dr. Irwin Goldstein
We just sent it to all the players and we got back feedback and now we're doing one on one interviews for what's there.
- [05:39]
Dr. Reena Malik
Yeah, it's good to see what goes on behind the scenes. Right.
- [05:42]
Dr. Irwin Goldstein
Because people see these guidelines come out
- [05:44]
Dr. Reena Malik
but there's a lot of work that goes behind.
- [05:46]
Dr. Irwin Goldstein
There's a process. Yeah. But what's come out of it is totally fascinating. So we've redefined orgasm, we redefined the newer pathology parts of orgasm. We're consensing newer development strategies and treatment and that's fascinating. So I hope. Well, what I share today hasn't been consist but I think it will be.
- [06:17]
Dr. Reena Malik
Yeah, that's okay. I'm sure we can fact check you
- [06:20]
Dr. Irwin Goldstein
at the end of it for sure.
- [06:23]
Dr. Reena Malik
But yeah, tell us what we know and what we.
- [06:25]
Dr. Irwin Goldstein
So. So it turns out that there are multiple different definitions of orgasm. Different societies have put together explanations but they're not clinically relevant. That's the, you know, we're physicians trying to help people and we have a lot of things that, that focus on the physiology, you know, the muscle contractions, the sensations, that stuff. But it doesn't get you to sort of help the patient.
- [06:54]
Dr. Reena Malik
Right.
- [06:55]
Dr. Irwin Goldstein
So we realized that orgasm is the sensory motor experience, especially orgasm during or sexual orgasms. Because there's actually non sexual orgasms. Like a sneeze is virtually an orgasm, a yawn is an orgasm. They're all reflexes that make you feel good. Really? Yeah, they provide you pleasure. I mean a good yawn is actually very, very refreshing.
- [07:16]
Dr. Reena Malik
It can be, yeah.
- [07:18]
Dr. Irwin Goldstein
Swallowing you could argue is one of them. But the, the. So the sexual orgasms we could divide into faces and we've never had that concept. So there's the build, the sort of climb the mountain. There is this very incredible arousal process. And why I say it's incredible is because there is no physiology equal to what's going on. So just as an example, classically let's Say you go to the bathroom, okay? So that's parasympathetic. You're activating, emptying your bladder, emptying your bowel. But you turn off the sympathetic when you do that. Or let's say you're in Ukraine shooting Russians or Russians shooting Ukraine's, depending. Then you're sympathetically driven. And you're not going to have bowel movements and not have your name. So they're usually sort of opposites.
- [08:07]
Dr. Reena Malik
Right.
- [08:07]
Dr. Irwin Goldstein
This is one of the physiologies where during orgasm your heart is beating, your, your, your blood pressure's up, your respiration rates are high. So that's all sympathetic, but you're lubricating from your vagina, your pupils are dilated. There's a million other things going on that are parasympathetic. So you have for really one of the first times in physiologic history, the sort of duality of sympathetic and parasympathetic. And one of the most fascinating parts of. Here, take your pen. No, no, you keep it.
- [08:41]
Dr. Reena Malik
Okay.
- [08:42]
Dr. Irwin Goldstein
And take your finger and put the sharp end into your pulp. And it hurts, right?
- [08:48]
Dr. Reena Malik
Yeah.
- [08:49]
Dr. Irwin Goldstein
You could take that while you're having sex with your perfect partner or by yourself, and you could jam it into your finger and you won't feel it. So there is this amazing excitation. But to get to another level of excitation, you have to provide inhibition.
- [09:10]
Dr. Reena Malik
Yeah.
- [09:11]
Dr. Irwin Goldstein
And it's inhibition of pain, really. But then you have to excite more, and then you inhibit more, and you excite more and you inhibit more. And this duality of excitation, inhibition is completely opposite of what normally happens when you excite something. You turn off inhibition, like desire. The paradigm is sort of like a seesaw. You excite, but you have to turn off inhibition. But not in orgasm. It's completely different.
- [09:35]
Dr. Reena Malik
So interesting.
- [09:36]
Dr. Irwin Goldstein
And you have not only. So if you did an FMRI during someone in that phase, the preorgasmic phase. So there's sympathetic, there's parasympathetic, but there's oxynergic, there's serotonergic, which is inhibition. There's your activation of the adrenal gland. You're now producing hormones. So you got all of this stuff going on. I mean, if you do FMRI data, there's 120 brain regions called Broadman areas, and you basically activate every one of them. And there's nothing like that. There's no. Like, we're talking. So our brain speech region is activated.
- [10:16]
Dr. Reena Malik
Right.
- [10:16]
Dr. Irwin Goldstein
But a lot of other things aren't. Doing anything. Whereas in orgasm pretty much the entire brain is activating. So let's get into a real important take home message. Okay. Providing oxygen to your brain is good. Dementia is bad.
- [10:32]
Dr. Reena Malik
Right.
- [10:33]
Dr. Irwin Goldstein
There's reasonable information that the more orgasms you have, the more brain oxygenation you provide, the less brain dementia you're going to have. Just to tell you.
- [10:44]
Dr. Reena Malik
So having more orgasms is protecting your brain. It's protecting your brain.
- [10:48]
Dr. Irwin Goldstein
We believe that to be the case.
- [10:49]
Dr. Reena Malik
That's amazing.
- [10:50]
Dr. Irwin Goldstein
That's a separate concept. All right, so there's a pre orgasm phase which is like magnificent physiology that doesn't exist. The entire brain is going sympathetic, parasympathetic, oxygen, serotonergic, dopaminergic, noradrenergic, hormonal. I mean all these things are going on and they're all sort of organizing to get to a point of excitation that you can't achieve in any other case. There's no way to get more excitation than during orgasm because for man you have to activate ejaculation. So that requires an amazing amount of brain information. Women have ejaculation, but they don't have to get so high to have orgasm. Women get more orgasms, like two or three at a time as they approach. But let's just stay with the concept that there's the pre orgasm phase.
- [11:43]
Dr. Reena Malik
Yes.
- [11:44]
Dr. Irwin Goldstein
Then there's an orgasm phase which is basically you have this intense arousal and then you have muscle that contracts but then relaxes. It's that contraction relaxation of muscles that's really pleasurable. Satiety is built into this process. Then you have to return to the real world again. You have this refractory period to get a new one. But you have to resolve all of this.
- [12:11]
Dr. Reena Malik
Yeah.
- [12:12]
Dr. Irwin Goldstein
So you go from a very high adrenergic, very high adrenergic, dopaminergic and, and noradrenaline, urgic, adrenergic to a very high serotonin state, which is the inhibition. Yeah, that's the satiety thing. But you got to get out of that phase because there are a group of people who can't get out of that phase and they have this post orgasm illness syndrome. Anyways, by dividing orgasm into phases, finally for the first time, we can now define conditions within each phase that if you listen carefully to the patient will tell you what's wrong with them, which is really cool. That's never happened before. And then deciding on how to manage based on the characterization of their problem has never happened before because it was just fod female Orgasm disorder. And it was just this mush of conditions, but now we're separating and dividing the conditions, which is kind of cool.
- [13:08]
Dr. Reena Malik
That is cool. And it seems like also for men, right? It's the same. I think they're trying to come up with a new nomenclature for male ejaculatory disorders too. But I don't know that there's a real clarity on ejaculatory disorders versus orgasm disorders.
- [13:24]
Dr. Irwin Goldstein
Well, because they're separate, independent, like especially after radical prostatectomy, you can still have orgasm, but you can't really ejaculate fluid because there's no fluid. But yeah, they're separate. You can have orgasm without ejaculation, Ejaculation without orgasm. So what happens is the pre orgasmic phase. We've recognized four conditions, so they're kind of cool. One of them is called excitation insufficiency.
- [13:51]
Dr. Reena Malik
Okay.
- [13:52]
Dr. Irwin Goldstein
These are people who start the climb and they get somewhere in the climb, 50%, 70%, but they can't make it. Yeah, they don't get high enough. It's probably the most common form of orgasmic dysfunction is excitation insufficiency. As stated, it's missing the excitation chemical component in the brain. So we have a slug of therapies to help them. Then we have inhibition.
- [14:19]
Dr. Reena Malik
Before I move on from that one. Is that a lack of arousal contributing to that excitation?
- [14:25]
Dr. Irwin Goldstein
Whatever. There's partner issues, there's hormonal issues, there's. Yeah, so there's multiple reasons for excitation insufficiency. But at the end of the day, looking through all the therapeutic interventions, we can give dopamine, we can give. For people can't focus. We can give Adderall, for example. So it's kind of an amphetamine, you know, noradrenaline activating drug. We can block serotonin with like Buspar or Lebanson. We can give bupropion, which is the dopamine agonist and norepinephrine receptor inhibitor. I mean, there's lots of stuff we can do. So that's for excitation and sufficiency. Then we have the, the. The.
- [15:12]
Dr. Reena Malik
So because. Sorry, before we move. So because it's so common, right?
- [15:16]
Dr. Irwin Goldstein
It is.
- [15:17]
Dr. Reena Malik
If someone is struggling with this, how do they. Obviously there's not a lot of doctors prescribing.
- [15:22]
Dr. Irwin Goldstein
Yeah, you gotta find an orgasm dude.
- [15:24]
Dr. Reena Malik
Yeah. So going on the Ishwish website is a great place to start to look for a doctor. But also there's all these multitude of things. None of Them, they're all off label. Right.
- [15:32]
Dr. Irwin Goldstein
There's no, there's no single drug and there will never be an FDA approved drug to help your orgasm. It's not part of the FDA's thing.
- [15:41]
Dr. Reena Malik
Right. So obviously dealing with the psychological factors and the arousal insufficiency separate if they want to try a medication, what have you had the most success with in your experience?
- [15:50]
Dr. Irwin Goldstein
This is a great question. Okay, So I would ask questions like is your excitation insufficiency in part related because you can't focus like in the middle of sex you're thinking of the super bowl or you're thinking of paying the bills or the laundry or buying stuff for the kids that need for their Monday morning work or something. So with that we use Adderall. It's one of my favorite drugs. It's off label obviously, but you get amazing focus on this. And you just have to take it before sex. You don't like live on it like, like an ADHD or ADD person would. We use low dose, we use 5mg, 2.5mg. If you can get away with it and you only use it when you're having sex. So it's not like we're the psychology or psychiatry people working with adhd. We also do dopamine. So there's brimalanotide, the subcutaneous injection. Fabulous drug for this. Oh my God. Of all the agents on earth that have done double blind placebo controlled multi institutional studies on hsdd. But since they collected the fsfi, which has other domains, we have data on organs.
- [17:06]
Dr. Reena Malik
That's a valid questionnaire that we use in research to look at all these various domains of female sexual function.
- [17:12]
Dr. Irwin Goldstein
Female Sexual Function index. Correct. I shouldn't have used the acronym, sorry. But anyways, the FSFI has shown the intended outcome which was to study the low interest state hsdd, Hypoactive sexual desire disorder. But at the same time we got data on orgasm. So this is the first drug to have thousands of people in a placebo controlled way. So we just finished the publication, it's accepted and about to be printed. So I'm not giving away the secrets here, but it's one of those few products where since you use it only at the time of sex, the placebo response doesn't march upwards like Viagra and Cialis. Those drugs constantly had higher and higher. The more you involved yourself in the research trial, the more placebo. This was a flat placebo and a rising treatment. It's really an exciting outcome curve. So we have the most data with. It's called filisi, but it's called subcutaneous premolanotoid. It's in an EpiPen thing. But we have Parkinson's drugs that, you know, Parkinson's disease is, is a low dopamine state. So yeah, we have, you know, ropinirole, we have cabergoline. We have a myriad of things. L. Dopa. Yeah. That are useful to raise dopamine. Then we have like bupropion, also raising dopamine. We have the opposite buspar, serotonin antagonists. And then we have like oxytocin. So instead of going to labor and delivery and get a pitocin drip, we put in a lozenge and you suck on it just before sex. So it's a pitocin lozenge or oxytocin lozenge. We have testosterone, which is commonly a reason for excitation insufficiency. So we would measure that and supply it. We have arousal gels. This new topical sildenafil. I know you're aware of that. It's called Dare to Play.
- [19:10]
Dr. Reena Malik
I know there's some new papers about it. Yeah.
- [19:12]
Dr. Irwin Goldstein
So they'll have that at a swish. And then there is actually in Los Angeles, there's a product called Vella V E L L A, which is Liposobel Cannabidiol. It's really cool.
- [19:21]
Dr. Reena Malik
Yeah.
- [19:23]
Dr. Irwin Goldstein
It sort of releases the cannabidiol vasodilator over time because of its liposomal delivery and on and on. I mean, I don't remember the whole list as I'm sitting here.
- [19:33]
Dr. Reena Malik
I guess my question was, which ones do you find to be most effective? So in that big list.
- [19:37]
Dr. Irwin Goldstein
Yeah. So it's a combination. I'm sort of the Campbell's soup dude. I don't like doing one at a time. I don't like failure.
- [19:44]
Dr. Reena Malik
Yeah.
- [19:44]
Dr. Irwin Goldstein
I like success. So. And I think synergy is important in this thing. So we would do the amphetamine, we would do the dopamine, dopamine. We would use the bupropion. We use five or six things and just get them across the finish line to have an orgasm. And then we can pull one at a time and see what is it really that's active in this individual. And if there's side effects, we would hold back. But it's a lot of communication. It's a lot of time and energy.
- [20:11]
Dr. Reena Malik
It's.
- [20:13]
Dr. Irwin Goldstein
Our model is three hour visits. So it's not like people are coming in for 10 minute visit. You got to figure this stuff out. All right, moving on. There's excitation insufficiency, the most common. But there's this really cool thing called inhibition insufficiency. So remember we talked about you can put the pen against your finger and it hurts, but as you arouse, that exact same thing wouldn't hurt. There are people who can't inhibit. For reasons unclear, they can't inhibit. We don't understand that one. But we do have inhibitors to help them. So that's really cool. So there's a, there's a drug for men who have premature ejaculation. Sadly, it's not available in the US but it's available in entire world. Prilogy is the name and it's dapoxetin and it's 30 and 60 milligrams and it's all over Europe and Canada, U and Mexico. But I don't know what happened with us. Yeah, another FDA thing. So dapoxetine is an inhibitor, it's an SSRI, but only lasts for a short period of time versus the 24 hour version of SSRI. So dapoxetine IS very helpful for inhibition insufficiency. They present like they're climbing the mountain. They don't get very far, but they can't go further because it hurts them too much.
- [21:27]
Dr. Reena Malik
Yeah. So they feel like they've had like sort of an.
- [21:30]
Dr. Irwin Goldstein
They try, they try hard. It's too sensitive and I don't want to do it anymore is what they say. So they're not excitation insufficiency, they're inhibition insufficiency emergency. It's not that common, but it's not that uncommon. We see a reasonable amount of this. So we would provide tramadol for these people. Basically it's the same treatment for men who have premature ejaculation. Quite honestly, it's an opioid and it's an ssri. And we would just use Tylenol and ibuprofen, anything to sort of get rid of pain.
- [22:01]
Dr. Reena Malik
Got it.
- [22:03]
Dr. Irwin Goldstein
And they would just take that before sex. And the two other parts of the pre orgasm phase, pathology, which is excitation and inhibition insufficiency is delayed orgasm. Why is that a common problem? You try, you try, you try. It takes 30 minutes, it takes 45 minutes. And if you finally get there, it's a pretty good orgasm, but it just takes forever. So our, I mean, other than drugs which are, you know, SSRI use or five or alpha blockers or medications, common problem. We're finding lumbosacral disc disease is really important in this condition. Basically, you have a disc. It's pushing out on the dura. It's in the cauda equina somewhere, like L4, L5, L3, L4 something. And it somehow picks on a afferent sensation. Genital nerve. It's either pelvic pudendal, typically. And it interferes with the need for all this amazing sensory information going to the brain to start this reflex. So we've done spine surgeries on the endoscopic spine surgery of these patients. But what we do is we do neurogenital testing. We have these weird tests that we do. It's perceptions of vibration, hot and cold from the genitals. We also do a bubble cavernosis reflex, and we do sensory testing of the sciatic nerve. Anyways, we do that stuff, and then we get an MRI. Our spine surgeon, Dr. Cho Kim, God
- [23:41]
Dr. Reena Malik
bless him, he's been on the podcast before.
- [23:43]
Dr. Irwin Goldstein
Oh, he has? He's so good. Yeah, he does his own stuff too. I think he'll read the mri, but then we'll send the patient for a steroid injection at the level of their lumbosacral disc region. So that lessens the inflammation. Theoretically, that allows more sensation. And they have better orgasms.
- [24:01]
Dr. Reena Malik
Yeah.
- [24:01]
Dr. Irwin Goldstein
How much. How cool is that? That's pretty cool, too. And then, if needed, he could then operate.
- [24:06]
Dr. Reena Malik
And you're seeing this in men, too, as you age.
- [24:09]
Dr. Irwin Goldstein
The prevalence of lumbosacral disc disease is bizarrely common.
- [24:12]
Dr. Reena Malik
Right.
- [24:13]
Dr. Irwin Goldstein
So. Yeah, it's. It's what. It's what delayed orgasm ends up being from our point of view.
- [24:20]
Dr. Reena Malik
Right.
- [24:21]
Dr. Irwin Goldstein
Independent of partners and independent of drugs and independent hormones. Yeah. And then the. The fourth one is women have. And men have these premature ejaculates, little blippy things. They. They get an orgasm with minimal stimulation.
- [24:38]
Dr. Reena Malik
Yeah.
- [24:38]
Dr. Irwin Goldstein
And they go back to where they are and they try again and boop. And they. And yeah, so it's kind of. It's kind of a. We call that excitation insufficiency along with inhibition insufficiency. We think we. We don't understand that one, but it's clearly a lesson.
- [24:56]
Dr. Reena Malik
Intense and premature.
- [24:59]
Dr. Irwin Goldstein
Yeah. And they're muted. Less intense. Muted and premature. Okay, so those are the four things we believe. We can at least say, I'm sure there's 20 more, and we haven't figured them out yet. And then the ones that occur during orgasm, that's the most problematic. That's called anhedonia. Anhedonic orgasm. They have the Orgasm, it's just like drinking water. I mean the pleasure doesn't happen and that's a big problem. Ssri. We have this condition, pssd post ssri sexual dysfunction. Anhedonia is really common.
- [25:35]
Dr. Reena Malik
Yeah.
- [25:35]
Dr. Irwin Goldstein
We believe it's wherever the reflex is in the brain. And Barry Kamazara could tell you more
- [25:42]
Dr. Reena Malik
exactly where he was also on the podcast before.
- [25:44]
Dr. Irwin Goldstein
He's great. Barry's amazing.
- [25:46]
Dr. Reena Malik
Yeah.
- [25:46]
Dr. Irwin Goldstein
But ascending. Ascending pathways from sort of lower in the brain to cortical is somehow messed up in these patients. And it's really hard to figure it out. And I think what's going to end up being is ketamine, the hallucinogens, that type of stuff is going to be where we're going to go with anhedonia. But lack of pleasure in orgasm is awful. It's just like a nightmare.
- [26:12]
Dr. Reena Malik
Yeah.
- [26:13]
Dr. Irwin Goldstein
And it often coincides with anhedonia of other things. Like they used to enjoy going for Greek food or Chinese food or something. Get all excited by it or go to roller coaster and get all excited. But they don't have that anymore. Anymore.
- [26:27]
Dr. Reena Malik
I wonder if we know that the GLP1s, their use is becoming very, very common. And I wonder if it affects desire for many things. Right. Food for some people who are alcoholic. Yeah.
- [26:39]
Dr. Irwin Goldstein
You may be inducing orgasmic dysfunction.
- [26:41]
Dr. Reena Malik
I wonder. Right.
- [26:42]
Dr. Irwin Goldstein
Are we pretty sure we've seen this already?
- [26:44]
Dr. Reena Malik
Yeah. And so do you think that we're going to see more and more of this?
- [26:47]
Dr. Irwin Goldstein
Yeah, I think so.
- [26:48]
Dr. Reena Malik
Yeah. Because I think people are. I mean there are so many benefits to the medication, obviously. But also this one is very under discussed.
- [26:55]
Dr. Irwin Goldstein
Drugs causing anhedonia is commonplace. Like we see it with finasteride. We see it with the ssri post patient use and then the final orgasm. So we have six named orgasm disorders. Is post orgasm illness syndrome. That's just an awful condition.
- [27:16]
Dr. Reena Malik
It is.
- [27:17]
Dr. Irwin Goldstein
It's like the weirdest concept that you have this amazing orgasm. You get the satiety, you get the amazing pleasure and then you're stuck in that state for seven to 10 days. You have brain fog, lethargy, you can't concentrate, you can't think. Attorneys can't be attorneys. Sports people can't play their sports. I mean this is their income, their lives. They have an orgasm and they're done for six to 10 days. So we can't get them out. So we, we don't understand. It's called poise poa. Post orgasm illness syndrome. We're finding that IgE blockers, solar X, O, L, A R. Is this cool New way to deal with this. It's a mast cell thing.
- [28:06]
Dr. Reena Malik
Interesting.
- [28:07]
Dr. Irwin Goldstein
But other than that excitation, like giving them dopamine because they're, they're stuck in a high serotonin state. In their dopamine, adrenal oxytocin are zero. So we give them lozenges, we give them Adderall, we give them stuff to excite, to get out of this stupid serotonin state. Yeah, but there's some relationship to allergies to mast cells that just is kind of fascinating. The last guy we had with poise had about 11 mast cell conditions. He has TMJ, he has IBS, he has asthma, he has, I mean, all of these sort of histamine things. And I don't know, this is a fascinating field. It's kind of like now that we're uncovering a rational clinical strategy, theoretically it'll just take off and people will just say, oh my God, I remember seeing this patient, but I used that therapy. Let's sort of publish that way.
- [29:10]
Dr. Reena Malik
Well, I think post orgasmic illness syndrome, it's ideally some sort of abnormality in the hormones after. Right. In that inability to raise, as you mentioned, dopamine. It's interesting because, you know, people talk about post nut clarity and I think that's like the normal. What we would expect is that because you're no longer in that like focused state of being so hyper focused on getting sex and getting to the orgasm, that now you're able to focus on other things. But this is like the complete 180 of that. And you're stuck in that and you're stuck.
- [29:42]
Dr. Irwin Goldstein
And even just nocturnal emissions gets you into this really.
- [29:46]
Dr. Reena Malik
But that's like not even controllable.
- [29:48]
Dr. Irwin Goldstein
Well, that's the whole point. These people are kind of screwed for a while. We really have to help them, but we have to help orgasm disorders. And it's very under discussed, understudied, one of the very common sexual dysfunctions. But we focus on erectile dysfunction, Peyronie's disease, things that we at least can understand and treat. But orgasm is sort of pushed aside as, oh, okay, well, you have that too.
- [30:14]
Dr. Reena Malik
Sorry, it is 2026 and we are just learning about these phases of orgasm.
- [30:18]
Dr. Irwin Goldstein
Is that weird?
- [30:19]
Dr. Reena Malik
Right?
- [30:20]
Dr. Irwin Goldstein
It is all because of freaking iswish. I mean, if it wasn't for Ipswich, I don't know where we'd be.
- [30:25]
Dr. Reena Malik
Right. But thank God. Yeah, we have people wanting to do this research. But if we're not doing research, if we're not making these things a priority and we're not funding them, and we're not taking sex seriously. Like, it's. It's a problem. Right. Because people are suffering in silence.
- [30:41]
Dr. Irwin Goldstein
Yeah.
- [30:41]
Dr. Reena Malik
Yeah. And there's not enough people treating these patients.
- [30:45]
Dr. Irwin Goldstein
Welcome to America.
- [30:46]
Dr. Reena Malik
Yeah.
- [30:46]
Dr. Irwin Goldstein
Sexual medicine.
- [30:47]
Dr. Reena Malik
Well, the. The world. Forget it. Forget America.
- [30:50]
Dr. Irwin Goldstein
That's a good point.
- [30:51]
Dr. Reena Malik
Well, I do want to talk about the medications that you said cause sexual dysfunction. So SSRIs, which are antidepressants, are given widely like water.
- [31:01]
Dr. Irwin Goldstein
So how do people add to people who are minors?
- [31:04]
Dr. Reena Malik
Yes.
- [31:05]
Dr. Irwin Goldstein
This is a nightmare.
- [31:06]
Dr. Reena Malik
Right.
- [31:06]
Dr. Irwin Goldstein
These are people who, you know, say it's 1 to 3% of all users will have this PSSD thing, which is a disaster. SSRIs raise serotonin, so, like depression, which leads to suicide, and we can stop suicide. So it's a fabulous drug. Right. But its effect on the neuron and on the synapse and on neurotransmitters, in about 1 to 3% of people are irreversibly changed.
- [31:37]
Dr. Reena Malik
Why is it irreversible?
- [31:40]
Dr. Irwin Goldstein
Well, we're writing the paper on this right now. We're deep, deep into it. And you just have to study the animal studies that they do. They provide it, and they find neuronal synapse and neurotransmitter changes that you don't ever get back. So there's something about the drug in genetically susceptible people that irreversibly changes their function. So that's a problem because we have tons of people who have taken this drug because they were unhappy changing schools, and the parents gave them an SSRI so they would have less stress. Okay, but without the knowledge that for the rest of their lives they would have no pleasure during orgasm. Give me a break. Then you have to put the risks and the benefits together.
- [32:36]
Dr. Reena Malik
Well, yes, I think if someone's severely depressed and suicidal, that's an abs. I mean, you got to weigh the risks and the benefits. Right? I tell my patients all the time, look, you have to weigh the risks and the benefits.
- [32:44]
Dr. Irwin Goldstein
But it's stressful at school. No suicidality.
- [32:49]
Dr. Reena Malik
I think we just need to be very, very thoughtful.
- [32:51]
Dr. Irwin Goldstein
Or broke up with someone who's 14 years old, you know?
- [32:54]
Dr. Reena Malik
Yeah.
- [32:55]
Dr. Irwin Goldstein
They had their first love. I don't know, because I see the people who said, I did not make this decision, and I'm never gonna have a sex life again. Wow. Woe is me. I mean, we see that over and over again.
- [33:09]
Dr. Reena Malik
And have you seen patients where they've just taken it for a short period of time? And it's like, how long does it take for this neuronal.
- [33:15]
Dr. Irwin Goldstein
So this is the weird part of pssd. It could take three years for this to happen and it could take, take a month or a few weeks on this drug. So who knows, right?
- [33:26]
Dr. Reena Malik
Because I've definitely seen patients where they've been fine for years and then three years later they've started noticing that their whole, you know, their whole sexual milieu has changed.
- [33:34]
Dr. Irwin Goldstein
Yeah. And it's not like when we studied ed, we had patients who had ed, they had normal libido, normal orgasm, normal sensation, normal pleasure during orgasm. It was in the ED soul. Sexual dysfunction. Boy, oh boy. Pssd, it's this, this bizarre multi dimensional thing. No libido, poor sensation, anhedonia erectile dysfunction, I don't know, whatever you can think of, it's not working. It's awful. It's so broad. So it's so individual how people present, but people do.
- [34:13]
Dr. Reena Malik
Some people get better, Right.
- [34:15]
Dr. Irwin Goldstein
So what I tell patients, because we see a lot of PSSD now as our paper is coming, but it's like this paper, it's kind of like this thing that has been gone for like six years we've been developing this thing. But whatever the, the. Each person has a unique presentation of pssd. It's not a, you know, like a cookie cutter. All PSSD people are the same. They are not, they're, they're way. Some people have no ED and some people, their prime thing is ed. Some people, it's. They can't feel their genitals, but it's not that they can't feel it because if you touch it, they can feel it, but they can't, they don't get this. You touch your genitals and it's supposed to be a pleasurable thing. It's supposed to be different than touching your arm. It's like touching their arm, right? And it's not like this special thing and on and on, it just keeps going. But we'll address each issue. So I'm not gonna cure people with psst. They're not going to be back like they once were if they ever had, which is like the minor people have never had, which is very frustrating. But like people who are 25 and 30 who make the decision to go on, but they've had sex, they're not going to get back to the way they were, but they're going to be way more functional. We're so good with erections. We can really help people. I mean they may have to take a pill or a shot or something or a Subcutaneous injection, something. But we can get them functional that way. As we talked about orgasm issues. We can do that. We can help their libido because, you know, straight up.
- [35:46]
Dr. Reena Malik
But you think that they're on their own. Like, with time, things won't improve.
- [35:50]
Dr. Irwin Goldstein
Well, that's why they're presenting, because things on their time are not improving. It could be that there's a subpopulation of people who do improve, but we're not going to see them. So our bias is we're getting the other population. The. No improved version. Yes. So beyond SSRIs, there's these five alpha reductase inhibitors. Boy, are they bad.
- [36:10]
Dr. Reena Malik
Yeah. Finasteride being the most common.
- [36:12]
Dr. Irwin Goldstein
Finasteride being the most common, Dutasteride being. And then you have the Accutane group and the. You have the minoxidil group. They're kind of all the same. They. Well, they influence. So the way it's proposed to the physician by the pharmaceutical groups are that this 5 alpha reductase is designed to impact negatively on the synthesis of dihydrotestosterone, period. Like nothing else is bothered. But there's like 10 biochemical reactions that, that depend on the activity of 5 alpha reductase, including stuff in the brain, for which we get back to the PSSD thing. There's a kind of an interesting similarity between what we call PFS post finasteride syndrome and PSSD post SSRI sexual dysfunction. Because of the influence negatively of SSRIs on the brain and 5 alpha reductase on the brain, there is a lot of biochemical reactions that would otherwise be used that can't be used because of 5 alpha reductase. And then we get into the reality that dihydrotestosterone is really an important hormone for the corporal, the penis, smooth muscle cell. Without it, apoptosis or cell death happens, which turns into scarring, which turns into erectile dysfunction. That becomes permanent, or we can't really change the collagenization of the erectile tissue that leads to this thing called venous leakage. And it's very frustrating, you know, and these are people who are 16, 18, they look at themselves. Their father's bald, their uncle's bald, they don't want to be bald. And they just go to the Internet because you don't need to see a doctor for five alpha reductase inhibitors. They're not given any information on side effects or just briefly, and they end up with this PFS thing.
- [38:07]
Dr. Reena Malik
Is that also permanent in your experience?
- [38:10]
Dr. Irwin Goldstein
I believe it to be the exact same kind of concept.
- [38:13]
Dr. Reena Malik
Irreversible neuronal changes.
- [38:14]
Dr. Irwin Goldstein
Well, let's just say that in many cases their DHT remains low despite them being off the drug. So they have changes to the enzyme that may be irreversible. Yes. So the thing is, like Viagra is an enzyme inhibitor, but it's a reversible one.
- [38:32]
Dr. Reena Malik
Okay.
- [38:33]
Dr. Irwin Goldstein
The five alpha reductase inhibitors are irreversible enzyme inhibitors. They cause suicidal changes to the enzyme.
- [38:40]
Dr. Reena Malik
Gosh.
- [38:42]
Dr. Irwin Goldstein
Yeah.
- [38:42]
Dr. Reena Malik
So there's a lot of. I'm sure physicians listening to this, they're going to say, you don't. This is all false.
- [38:48]
Dr. Irwin Goldstein
Oh, it's all false.
- [38:49]
Dr. Reena Malik
Yeah.
- [38:49]
Dr. Irwin Goldstein
Well, that's fine. I have no problem with them saying that. It's just they don't take care of these people. Right, right. And they may be invested in the value of the drug. For example, psychiatrists see the suicide.
- [39:03]
Dr. Reena Malik
Yeah.
- [39:03]
Dr. Irwin Goldstein
I see the side effects. I see the sexual dysfunction. So my perspective, bad drug. Their perspective is good drug.
- [39:10]
Dr. Reena Malik
Yeah.
- [39:10]
Dr. Irwin Goldstein
And then there's these hair. People, you know, people want hair. But I, they're saying how fabulous the drug is and I say, whoa, I'm seeing all the sexual side effects.
- [39:20]
Dr. Reena Malik
Right.
- [39:21]
Dr. Irwin Goldstein
So I know it's just on. The reality is the drugs cause these things.
- [39:26]
Dr. Reena Malik
There's just no way for us to predict who's going to be the.
- [39:28]
Dr. Irwin Goldstein
Yeah, that's the night that's the problem.
- [39:29]
Dr. Reena Malik
Right. Because it's a small subset of people, like less than 1% probably.
- [39:33]
Dr. Irwin Goldstein
It's just that millions of people are on these products.
- [39:36]
Dr. Reena Malik
Right, right. It's given out like candy, a lot of these medications.
- [39:39]
Dr. Irwin Goldstein
So if 50 million people are on these products, you know, and 1% are having. That's a lot of people. People.
- [39:47]
Dr. Reena Malik
Yeah, it really is. That. That fibrosis thing is really crazy to me. That's really scary.
- [39:53]
Dr. Irwin Goldstein
Yeah. So we, we have a, a brand new ultrasound strategy. So there's urologists perform intracavernosal injections and then you get an erection and then you do what's called the Doppler ultrasound. So it looks at the blood flow, but ultrasound, that's Doppler, that's blood flow related is a sort of a nuance. It's sort of a new thing. The old ultrasound was grayscale. Black, white, gray. You looked at a baby, you didn't look at the blood flow to the baby. You looked at the facial features, you looked at the shape of the head, the arms, the legs. That's grayscale. So for reasons unclear to me, grayscale has been Ignored by the urologic community studying this stuff. So we purchased a device that is a very high frequency. It's 15.4 MHz. So it has amazing resolution with the probe touching the penis. Like when you examine a baby, you put the probe on the pregnant abdomen and you're like a foot from the intended target. So you don't need fancy equipment for that.
- [41:01]
Dr. Reena Malik
Right.
- [41:01]
Dr. Irwin Goldstein
But when you want to get high resolution with 1 millimeter from the contact point of the probe to the erect penis, you need a fancy piece of equipment. And not everybody has that.
- [41:12]
Dr. Reena Malik
Yeah.
- [41:12]
Dr. Irwin Goldstein
So we have probably no one. We have the ability. We bought this $150,000 thing that allows us to get high resolution grayscale of the erect penis. So if you can get people in a rigid sustained direction with intracavernosal agents and you do grayscale with the device, if it's all gray, perfect. That's where blood goes everywhere. That's erectile tissue. If you take a person with five days of priapism and he's got kind of a dead penis and you ultrasound that, you see basically black.
- [41:47]
Dr. Reena Malik
Yeah.
- [41:48]
Dr. Irwin Goldstein
Blood can't go.
- [41:49]
Dr. Reena Malik
Just for clarity. A priapism is an erection that doesn't go away when you've had it for five days, it means that there's no more blood flow going in or out. And all the tissue is probably fibrosed and scarred.
- [41:58]
Dr. Irwin Goldstein
And if you're listening and you have it for more than four hours, get your body to an emergency room.
- [42:03]
Dr. Reena Malik
Yes, please. It's not fun. Go to the ER scar immediately.
- [42:06]
Dr. Irwin Goldstein
Okay. Having said that, in the state of priapism for multiple days, which is just an awful state, the tissue's basically dead.
- [42:14]
Dr. Reena Malik
Yeah.
- [42:14]
Dr. Irwin Goldstein
So it's all basically scar tissue at this point. So no blood goes to those regions. So on grayscale, you'll see dark. Like black.
- [42:23]
Dr. Reena Malik
Yeah.
- [42:23]
Dr. Irwin Goldstein
Okay, so we have. We have now a discrimination between healthy, healthy tissue, gray and black tissue, which is sort of non healthy tissue.
- [42:34]
Dr. Reena Malik
Or dead. Yeah.
- [42:34]
Dr. Irwin Goldstein
Okay, so we have these thing called the erection hardness scale. I spent like multiple years on this crazy thing. You push down on a series of rods. One rod, when you push down, does not buckle. And we call that 4 out of 4 erection hardness scale. And that's like the normal physiologic boner version erection.
- [42:56]
Dr. Reena Malik
Yes.
- [42:56]
Dr. Irwin Goldstein
And then three out of four, you press down on it, it buckles a little bit, but it's still able to have penetration. You press down on the 2, there's even more buckling, and you can't really proceed. But it's close to being good. Just not good enough. And then one out of four is this nightmare. Like you press down and it has no rigidity.
- [43:18]
Dr. Reena Malik
Like a noodle.
- [43:19]
Dr. Irwin Goldstein
Like a noodle. Okay, so there we go. So what we've now done is divide the grayscale by the erection hardness scale. So the 4 to 4 erection is all gray. The complete horrible thing is pretty much all black. And then there's gradations of gray and black on the tweeners, we call them. So grade three out of four is mostly gray, but a little bit of black. Two out of four is a little more black. So we now are doing ultrasound on our PFS patients. Patients and her PSSD patients.
- [43:53]
Dr. Reena Malik
Yeah. And what do you say?
- [43:54]
Dr. Irwin Goldstein
So now we're finding that they get scarring.
- [43:57]
Dr. Reena Malik
Wow.
- [43:58]
Dr. Irwin Goldstein
Which is the scary part. Their ED is the irreversible version. It's not the psychologic one, it's the irreversible. So from the 5 Alpha Reductase community, the apoptosis, the cell death that leads to the scarring is due to inability to synthesize DHT dihydrotestosterone, which is the goal of the drug. So you don't have acne in one end or you don't lose hair on the other end, but you don't have penis smooth muscle in 1 to 3% of patients who are susceptible wild. So that's horrible. And then the PSSD community, we've identified oxygen radicals. So O2 is the normal oxygen. If you make it O3 negative, it's really an aggressive chemical or molecule and it goes after smooth muscle causing apoptosis. So it's the same concept as 5 alpha reductase. Hurting tissue as SSRIs hurting tissue. So yeah, accessorize is supposed to act on the brain. Guess what they also act on? Penis.
- [44:58]
Dr. Reena Malik
Ah, gosh.
- [45:00]
Dr. Irwin Goldstein
So we're stuck in craziness. Right?
- [45:03]
Dr. Reena Malik
Well, let's take it back a little bit. You were actually the senior author on the Viagra paper.
- [45:09]
Dr. Irwin Goldstein
Yes, it was May 14, 1998. I can tell you exactly that.
- [45:14]
Dr. Reena Malik
That's amazing. First of all, such a huge accomplishment. But that changed the game for men's sexual health.
- [45:20]
Dr. Irwin Goldstein
Yeah, I mean it was the first ever oral product. It wasn't designed for patients. This was to get the word out to practitioners. We haven't ever published the Phase 2 and Phase 3 data from the multi institutional Phase 2 and Phase 3 trials that the FDA requires, so that was the first time it was published. By the way, there's a whole story
- [45:43]
Dr. Reena Malik
to this Yeah, I want to hear the story.
- [45:45]
Dr. Irwin Goldstein
So I submit. I was first author and the New England Journal's in Boston. Boston, right. So I'm in Boston. I was in Boston at that time. Now in San Diego. Happy.
- [45:54]
Dr. Reena Malik
Especially right now where it's snowing and like negative.
- [45:57]
Dr. Irwin Goldstein
Could not be any more pleasant to be here. So we submitted it and we said okay, a no brainer. Everyone would realize how important this was. It got rejected really by the New England Journal. They wanted this. So we changed this and then we resubmitted. Seven rejections. Seven can say it took us, I don't know, but, but seven, eight months to get it through the New England Journal editorial board. I have to tell you, they are not easy.
- [46:21]
Dr. Reena Malik
I'm sure not.
- [46:22]
Dr. Irwin Goldstein
But what happened with the New England Journal is really fascinating because what they required at the end of the day was our data was based on the iief. We talked earlier on the FSFI Female Sexual Function Index. But the International Index of Erectile Function was developed by Pfizer. To get it through the fda, which required a questionnaire had to be validated. That takes another few years to do a few dollars. But it was a validated questionnaire, the iif. And we passed all the standards of placebo this way, sildenafil that way. Statistically significant difference. And the New England Journal said there isn't a doctor on earth to know what the F you're talking about with an improved iif. If you want to get this through, you're going to have to go back to each and every patient's diary, find out. Because we had their erection hardness data. I took the pill and my erection was almost hard. That would be three. Or my erection was really soft and couldn't be used. That was the one. Or my erection was this boner thing and that was erection four. But we had all that data. But we never used that data. It was just, just, you know how that they collected that. So we had to go back to the thousands of people, all their uses of the medication and get their diaries to identify when, when they had a two, you know, to be in the triad of ed. So a lot of people were onesies and twosies.
- [47:54]
Dr. Reena Malik
Yeah.
- [47:55]
Dr. Irwin Goldstein
But then on the drug or placebo they could be a three or a four. So we took people who had a three and a four as the people who were able to have sex and how often that happened on active drug and how. And with that we got approval. But boy, oh boy, that was an issue. But actually it made it more real, I think The New England Journal. Is the New England Journal. Because it is the New England Journal.
- [48:20]
Dr. Reena Malik
Yeah.
- [48:21]
Dr. Irwin Goldstein
So do you know what. Do you know the. I'll never forget this. What was the percentage of active drug users, Sildenafil, to get them from a 1, a 2 to a 3 and a 4?
- [48:32]
Dr. Reena Malik
60%.
- [48:33]
Dr. Irwin Goldstein
69. It was a great number, of course. 69%. And I said, you know, this was made to happen.
- [48:41]
Dr. Reena Malik
So true.
- [48:42]
Dr. Irwin Goldstein
And it was only like 23% for placebo, something like that.
- [48:45]
Dr. Reena Malik
What was the response by one, the medical community and then patients.
- [48:50]
Dr. Irwin Goldstein
Yeah. So I was the first author. So I was the communication person.
- [48:55]
Dr. Reena Malik
Yeah.
- [48:55]
Dr. Irwin Goldstein
We didn't have cell phones and stuff then. It was phones.
- [48:58]
Dr. Reena Malik
Yeah.
- [48:58]
Dr. Irwin Goldstein
So our office was insane. I mean, my poor staff hated me, but we fielded every call and. But they were from women. That was the crazy part.
- [49:11]
Dr. Reena Malik
Yeah.
- [49:12]
Dr. Irwin Goldstein
I assumed everything would be men, men, men. But the women were saying, okay, Viagras for them, I don't have orgasm. I have pain when I have orgasm. I have arousal problems. I can't. I. In this. Boy, it really hurts when it penetrates me. I mean, all the gamut of female sexual dysfunction things were brought up and my response was, hey, I'm a urologist. I deal with men. Go to your gynecologist. Someone will help you.
- [49:39]
Dr. Reena Malik
Yeah.
- [49:40]
Dr. Irwin Goldstein
And inevitably, most phone calls came back and were saying, gynecologist says go see you. I don't deal with this stuff.
- [49:48]
Dr. Reena Malik
It's so interesting to me because I also mistakenly thought for a long time that gynecologists dealt with all the menopause issues.
- [49:57]
Dr. Irwin Goldstein
I thought you were going to say sexual health.
- [49:58]
Dr. Reena Malik
Well, that too, but you already addressed it.
- [50:00]
Dr. Irwin Goldstein
They do not.
- [50:02]
Dr. Reena Malik
But. So that was what put the onus on me to really start learning all this stuff because I was like, well, who is the.
- [50:08]
Dr. Irwin Goldstein
Well, the AUA has guidelines now.
- [50:09]
Dr. Reena Malik
Now they do. But even when I trained, there was not. There was not anything.
- [50:15]
Dr. Irwin Goldstein
We just lectured in the government. Kimbrough thing. I gave the whole menopause thing.
- [50:20]
Dr. Reena Malik
That's great.
- [50:21]
Dr. Irwin Goldstein
Because the AUA has guidelines now.
- [50:22]
Dr. Reena Malik
Yes.
- [50:23]
Dr. Irwin Goldstein
Well, just for the general, Gynecology does not have guidelines.
- [50:26]
Dr. Reena Malik
Yes. Yeah.
- [50:27]
Dr. Irwin Goldstein
Isn't that weird?
- [50:28]
Dr. Reena Malik
That's crazy.
- [50:29]
Dr. Irwin Goldstein
That's pretty weird. Anyways, the phone calls from the Viagra led to the realization that we had to deal with women, that the parallel tract urology is attractive in sexual medicine. At this presentation, there's a sexual medicine group of abstracts presented and talks given. They have stones, they have cancers. But there's a track called sexual medicine, and that comes from 1970s when we started doing penile implants, it became a part of urology. There's no part of gynecology in sexual medicine. It's so weird. So it's just like a big hole in teaching and understanding and education in gynecology.
- [51:11]
Dr. Reena Malik
Well, I've always believed that the people who do fellowship in female pelvic medicine, like urogynecology, they don't get this. They should, though, right? We're taking.
- [51:20]
Dr. Irwin Goldstein
Should I get.
- [51:20]
Dr. Reena Malik
I mean, we're literally operating in the vagina and we're.
- [51:25]
Dr. Irwin Goldstein
But, you know, it's like radical prostate patients. They don't necessarily want to know what evil they're doing. There's a lot of evil. When you put a sling across the urethra, that's as if the urethra doesn't matter. But let me not go there right now. We'll do that lecture another day.
- [51:41]
Dr. Reena Malik
That's another day.
- [51:42]
Dr. Irwin Goldstein
Okay. So from the point of view of Viagra, it led to it, because where I'm going is we realized there was no knowledge in this area and we put together a course. Over a thousand people showed up. And then we started isswish. So yswish was started in basically 1998. So it's 28 years now. Crazy.
- [52:04]
Dr. Reena Malik
That is crazy. Let us talk a little bit about erectile dysfunction in men. Nowadays we're seeing a lot more young men with issues with erections. Why do you think that is?
- [52:15]
Dr. Irwin Goldstein
Shocking. Finasteride pssd. Yeah, we're seeing that. You know, another crazy problem for young people is the dysmorphia of height, of wanting to have a testosterone value of four digits.
- [52:34]
Dr. Reena Malik
Right?
- [52:35]
Dr. Irwin Goldstein
Like, they love looking at themselves in the mirror. They, they, they love competing. They do anabolic steroids, and as soon as they get off of them, their testicles shrivel beyond belief. They get scarring of their tissue. They get a severe hypogonadism. They're. They're the. They're like PFS patients. They don't have testosterone support of their smooth muscle. So their smooth muscle dies. Yeah, it, it's. And then, Then there's this other weird thing about young people. In fraternities especially, there's a thing called jelqing. J, E, L, Q, I, N, G. It is the most bizarre thing on earth. You have exercises to lengthen your penis, to stretch your penis, to grow your penis, because at some level, you're only going to date people because you have this very long penis that if you have a short penis, you don't get that. So it's really weird. But they do a lot of damage to their penis. Ah. Introduce another sexual dysfunction called hard flaccid syndrome. Yes, that's one of my favorite topics. I love hard flaccid. Not that I love it in, in the sense I love working with these patients because no one understands them, no one deals with them. It's sort of this, this new entity. But it's, it's, it's ostensibly the first sexual dysfunction that's not in the erect state. This is a flaccid state prone. Their penises are shriveled, cold, there's this unpleasant discomfort because of the shriveled state. They can't pee, they can't have a bowel movement. Their scrotum is riding high. They're like miserable with this stuff. And it's called hyperactivity of the hypogastric nerve. That's what HFS is. That's why I'm fascinated with it. It's another neurologic nerve. They can't pee because the bladder neck is closed. They can't have a bowel movement because the hypogastric nerve is activated. Their penis is shriveled because the smooth muscles under. Amazing contraction from the hypogastric nerve. And then it's basically a game, a detectives game to find out why. Which region is this coming from. Actually the greatest discovery that has happened in sexual medicine is region based medicine. And we developed that with the PGAD in 2021. But it applies to everything. Where is the trigger for all of this happening? The Jelqing injury. That would be region one, the end organ. We see hard flaccid in people who have bicycle riding like they do the marathons, the triathlons, the whatever you're doing with biking, the 600 miles a month. Biking, crazy stuff. And they have numbness as they're riding their bike. They get pudendal neuropathy. And then the people with back injuries, that's region three, the caud equina. Region four is the spine. Region five is the brain. But region based medicine to find the trigger is really cool. With this other group, srpes, that's these are sleep related painful erections. These people have sleep deprivation. Their penis is rigid, rigid, rigid. When they sleep they have to get out of bed, walk around, pee. Then erection goes down. Two hours later it's back up and causing them pain and waking them up. So region based medicine will tell us where the SRP is coming from. PGAD at gpd, the genital pelvic dysesthesia. The weird Feelings coming from the genital pelvic area. That's region based. So it's opened up the trick to understanding all these unusual sexual dysfunctions.
- [56:12]
Dr. Reena Malik
Well, until recently, we didn't even have treatments for some of these region based
- [56:16]
Dr. Irwin Goldstein
issues, but now we do, which is because the amazing contribution of sexual medicine to medicine is region based medicine.
- [56:26]
Dr. Reena Malik
How do you think in terms of hard flaccid. Since you mentioned it, do you think there's a pelvic floor dysfunction contribution?
- [56:32]
Dr. Irwin Goldstein
Region two. That would be region two.
- [56:34]
Dr. Reena Malik
Yeah. Because that's what I see a lot is where these. They're very tense in their pelvic floors and they're causing this basically involution of their penis almost because it's so tight.
- [56:44]
Dr. Irwin Goldstein
Guess what we've done? We've identified an objective test for hfs. This is why I love this catastrophe. It's so fun. So we have this thing called forward looking infrared. I don't know if you've ever heard of. It's flir. The way I explain it to patients is in Boston, there was someone who, near the finish line of the marathon, threw a bunch of bombs and really made horrific deaths and dismembering. And then they escaped into the Boston neighborhood. And a helicopter had a thermal camera and found a guy lying in a boat. I don't know if you remember the story, but he was lying in a boat. That was because it wasn't ready for the season to put the boats in the water. He was in the guy's backyard, but he had found his way into the inside of the boat. But they found him there and they captured him through sort of the thermal imaging. So we do thermal imaging of men's penises and the glands in hard, flaccid states. But 80 degrees, supposed to be 98.6 degrees, by the way. Yeah. And then when we treat them, their penis becomes 98.6.
- [57:55]
Dr. Reena Malik
Wow.
- [57:56]
Dr. Irwin Goldstein
So we now have an objective test where it's kind of cool. And we have a metric for seeing the effect of a therapy.
- [58:03]
Dr. Reena Malik
I heard that when you were learning about this, you actually used some cold gel.
- [58:07]
Dr. Irwin Goldstein
Yeah, myself.
- [58:08]
Dr. Reena Malik
Yeah. On yourself.
- [58:10]
Dr. Irwin Goldstein
So I don't know if you've ever done this you can put on your clitoris, I guess. It's really awful. I mean, I put. I put this very cold call. I put the ultrasound gel in the freezer and it was really cold. And they put on my penis and I started seeing patients. It was really hard to concentrate. It's really. It's an impactful condition. I think that Was one of the good reasons why I studied it because it's truly a problem and it's completely ignored. I mean, doctors think.
- [58:38]
Dr. Reena Malik
They just think they're crazy.
- [58:39]
Dr. Irwin Goldstein
They just think they're crazy.
- [58:40]
Dr. Reena Malik
Yeah. So what have you found to be obviously pelvic chlorophysical therapy we've sort of
- [58:44]
Dr. Irwin Goldstein
touched on, but region two, so region one, when it's typically a jelqing thing. So it's a dorsal nerve neuropathy, basically is what it ends up being. And so we do what's called prolotherapy, 5% dextrose into the area of the nerve injury. We do shockwave therapy to that area. We do alpha blockers, we do PT stuff.
- [59:09]
Dr. Reena Malik
Anyways, we have reasonable treatment in my textbook.
- [59:12]
Dr. Irwin Goldstein
So, you know, we take care of them. Trying to think what. There's a fourth thing that's that we do a lot of. But, oh, we're developing. Yeah, this is another cool thing. We're working with a pharmaceutical guy. He's developing an L arginine based warming gel. So if you can get rid of the cold, you can get rid of the feedback cycle that it's cold, which is uncomfortable, which is causing more hyperactivity of the hypogastric nerve, the sympathetic activation, which perpetuates this whole thing. So if you break the cycle by putting a warming gel, which is just a vasodilator, L arginine, like completely safe, it warms the penis so you can see the temperature go up on the flir camera. And they have the penis now, doesn't shrivel anymore. Kind of cool.
- [60:01]
Dr. Reena Malik
Very fascinating.
- [60:02]
Dr. Irwin Goldstein
We'll figure all this out, I promise. Give me some time.
- [60:08]
Dr. Reena Malik
Do you think porn is playing a role in this new erectile dysfunction we're seeing in young guys?
- [60:12]
Dr. Irwin Goldstein
Oh, boy. That's a great controversial topic. There's people who view porn as positive. It's allowing them to learn because there's limited education. And there's people who view it as completely the opposite, as evil and addictive and all that stuff. I'm going to stay out of this conversation. It's not biologic focused. We use porn so patients can get erections in the office. So from my point of view, it's this fabulous thing. But I'm not qualified to talk about
- [60:44]
Dr. Reena Malik
the addiction somewhere in between.
- [60:47]
Dr. Irwin Goldstein
Well, I mean, it's like everything else. You, you have access to the Internet and you know, if you use it appropriately. Look, you do. You do social media. There's some perfect social media like Rena's work. And there's some less perfect that discusses the role of spinning around, facing east and then you get cured that way. Okay.
- [61:09]
Dr. Reena Malik
Yeah. Venus leak, that's a huge problem that we're seeing. And I think we're learning more and more that a lot of erectile dysfunction is actually Venus more so arterial dysfunction. I mean, you've mentioned some causes of venous leak, obviously, but I think people are just perplexed, like how do we. Because there's not, it's very difficult to treat it with traditional means. Right. They don't respond as well to medications or injections as people who have really, truly arteriogenic dysfunction. So what do we do about it?
- [61:38]
Dr. Irwin Goldstein
So venous leakage is the equivalent of you're a firefighter, you're in the city of Los Angeles, it's the summer, and all you do is breathing smoke. You have pulmonary fibrosis. It's excess collagen in your lungs. Okay. Or you're a drinker and you have liver cirrhosis and you have excess collagen in your liver. Or you have a heart attack. You stop blood flow to the muscle, the muscle turns into scar tissue. And when your heart pumps, instead of the, the, the, the ventricle squeezing, getting all the blood out, the ventricle squeezes only a little bit. That's heart failure. They have lung failure, you have of liver failure, you have heart failure. Let's say you drink a lot of mercury and now, and now your kidney turns into mush and it's full of scar tissue. Basically venous leakage or accumulation of connective tissue within the erectile tissue is the failure of like every other organ. We're just like a part of all organs. They fail by getting connective tissue. The physiologic impact is that, that the tissue can't expand. It is a requirement to expand. The penis, unlike the liver, spleen, kidney changes volume and physiology. Does your liver change in a 24 hour day?
- [62:56]
Dr. Reena Malik
I hope not.
- [62:57]
Dr. Irwin Goldstein
Yeah. Do your fingers, do your arms, your muscles? I mean, nothing changes. It changes for a reason. It's not because it's fun that it gets wider and longer. It gets wider and longer because that's how it blocks the tissue. It's expansion against the capsule stops the space that, where the veins live, which is just the, the space between the tissue and the capsule. So it's called the subtunical space. The subtunical venues only. It's a sponge. Blood is getting into the sponge. The only way it can drain is the peripheral spaces because each space just communicates to Another space. The only way out is the peripheral spaces. But if the peripheral spaces are squished by the expansion, then you trap. I mean, essentially the penis is the only organ that has a closed compartment during its physiology. Every organ's blood in, blood out. If you have blood in, blood out with the penis, you're kind of screwed.
- [63:51]
Dr. Reena Malik
Yeah.
- [63:52]
Dr. Irwin Goldstein
So they're essentially all of ED is that. And it's a degree of how much scar. And now with ultrasound, I could tell you how much scar you have in your penis. And basically you have two choices. You have a choice called symptomatic treatment. You magnify whatever muscle you have, its ability to maximize relaxation. So four treatments for that. You have your pills. You stick needles in your penis and inject vasodilators. You have subcutaneous bremelanotide, I think we've talked about that with the orgasm. And we have intracavernosal Botox. All those things maximize muscle relaxation. Then we have another strategy called disease modification where we can grow muscle. If we can grow muscle, we can change the ratio between the muscle and the connective tissue. You want as much muscle as you can to lessen the effect of the too much connective tissue. So for that we have shockwave and prp, more or less. You have six treatments for ED before you get to the implant. And you play with those strategies.
- [64:56]
Dr. Reena Malik
Are there supplements that you recommend for erections?
- [65:00]
Dr. Irwin Goldstein
I mean, truthfully, if you want to do evidence based medicine, you got to do placebo controlled double blind things. And there's no data on supplements. It's kind of like snake oil a bit. I'm sure there are some supplements that are good. Supplements can be bad. There are supplements that are basically five alpha reductase inhibitors. And there are supplements who are used for depression. And we've already talked about some of those not being so perfect.
- [65:29]
Dr. Reena Malik
Yeah. And the supplements have a wider range of activities that you can't necessarily quantify as well as you can with pharmacologic agents. And they're adulterated sometimes.
- [65:38]
Dr. Irwin Goldstein
You know what's fascinating about supplements, I love this. I'm glad you brought this up. So there are people who took finasteride and they're screwed. There are people took SSRIs, they're equally screwed. And their conclusion is drugs are bad, but they'll do a million supplements as if magically supplements are not harmful, which is completely false.
- [66:00]
Dr. Reena Malik
Completely false.
- [66:01]
Dr. Irwin Goldstein
Supplements.
- [66:01]
Dr. Reena Malik
We've seen liver injury, we've seen just so many horrible things. And I actually read a paper that people who have too much Copper, it actually causes erectile dysfunction. And some of these supplements have a lot of copper in them.
- [66:15]
Dr. Irwin Goldstein
Even I'm learning. I didn't know this.
- [66:16]
Dr. Reena Malik
Yeah. I read this paper and I was like, oh, that's so interesting. So people think, oh, it's just a mineral. Right. It's just a. It's not a big deal. But yeah, you mentioned shockwave and prp. So let's talk a little bit about.
- [66:29]
Dr. Irwin Goldstein
We do a lot of that.
- [66:29]
Dr. Reena Malik
Yeah.
- [66:30]
Dr. Irwin Goldstein
So tell us about two machines. I'm part of the International Society for the Study of Medical Shockwave Therapy. I love this.
- [66:37]
Dr. Reena Malik
I didn't even know there was a society.
- [66:38]
Dr. Irwin Goldstein
Oh, God, it's huge. And so it was in Amsterdam last year. Of course, getting to Amsterdam, it's just fun.
- [66:45]
Dr. Reena Malik
Yeah.
- [66:46]
Dr. Irwin Goldstein
So there's a reason to join the ismst, but so I'm meeting cardiologist, actually a cardiac surgeon. Okay. And basically it's a life changing meeting. You know, sometimes you go to a lecture and you sit there and it's boring. And sometimes you go to lecture and say, holy God, I'm listening to something. That's unbelievable.
- [67:07]
Dr. Reena Malik
Yeah.
- [67:08]
Dr. Irwin Goldstein
So here's this cardiac surgeon who shows movie of him opening the chest, having the beating heart. This is on all his videos. And he takes a shockwave device and he shocks the beating heart.
- [67:21]
Dr. Reena Malik
Okay.
- [67:22]
Dr. Irwin Goldstein
So his, his paper, which is published, takes people with heart failure. Their muscles are kind of dead, they have too much scar tissue. We've had this conversation and guess what? Shockwave therapy does it fixed. It fixes their thing, they generate more muscle, their contractions increase, they get out of heart failure, they're able to run and do all the things that, that otherwise they could never do. And what was the treatment? Shockwave therapy. So it's the first human example of the capability of the regenerative nature of muscle growth in vascular tissue. I think it was. I walked out of that lecture, I went straight B right to the guy, shook his head, took a photo with him and I said, I want to know everything you're doing because we're going to do the same thing in the penis. So that's what we ended up doing. Double blind placebo controlled trial with shockwave. Was fun to do the placebo, by the way, like shockwave, you could feel. So we had to figure out a way to do shockwave where we're not doing shockwave.
- [68:23]
Dr. Reena Malik
Yeah. So how'd you figure it out?
- [68:24]
Dr. Irwin Goldstein
So we put people in a curtain so they couldn't see what they were doing. We had noise reducing headphones. So they couldn't hear. We put the probe on their penis, activated a recorder of the sound of. Of the shockwave. And we're putting it on and moving it up and down as if something's happening. And the sound makes it sound like something's happening. But nothing happened. Which was very cool when we analyzed the data, because we do before and after ultrasound to see if the ultrasound reduced the black and increased the gray. We have already talked about gray is good. So we couldn't change the ultrasound by doing no treatment to the patient, of course. Well, of course, yes, but who knew, right? You had to test that.
- [69:09]
Dr. Reena Malik
That.
- [69:09]
Dr. Irwin Goldstein
And the only way we could increase the gray was to do shockwave.
- [69:13]
Dr. Reena Malik
I think. I mean, we've had decade, over a decade of data on shockwave. What frustrates me is that we're still not. It's still not shown to be. It's still not in the guidelines for erectile disease.
- [69:25]
Dr. Irwin Goldstein
They made new guidelines, which are even worse now. They're saying, don't do it.
- [69:29]
Dr. Reena Malik
Yeah.
- [69:30]
Dr. Irwin Goldstein
So I think the attitude of regenerative therapy is sort of incorrect. Trying to make it a therapy like Viagra, this independently can improve erections and sort of cure you. I think shockwave therapy and PRP therapy are therapies that help your current state of too much collagen to lessen the collagen and make injections, which didn't work now work to make Viagra, which didn't work now, if you view it that way.
- [70:04]
Dr. Reena Malik
Same thing with the Botox tox.
- [70:05]
Dr. Irwin Goldstein
It's. It's the concept of avoiding a penile implant. Now there are people who say, I just want my implant. Just do it. This is torture, all these crazy things. It's also expensive because none of these are really covered. But there are people who say, I'm not doing the implant. I had my radical prostatectomy. I'm done with surgery down there. You. You make me have erections and figure out how to do it. I think these are valid ways to help you people.
- [70:32]
Dr. Reena Malik
Yeah, I. I definitely am convinced by the shockwave prp. There has been some controversial. There's been some randomized controlled trials that were negative. So what. What do you think about that? Do you think it works?
- [70:43]
Dr. Irwin Goldstein
Well, we do before and after ultrasound with prp. We do before and after ultrasound with. With shock. If in our population, I could show you benefit.
- [70:51]
Dr. Reena Malik
Okay.
- [70:51]
Dr. Irwin Goldstein
I think it's the same thing, more or less. They activate mesenchymal stem cells, which then make downstream muscle cells. And that's essentially what you want. But do you make it in a degree to which you now can walk around and be a 12 year old boy. No, it's not going to happen.
- [71:08]
Dr. Reena Malik
Do you think if there's guys listening who are like, I want to have the best erection possible, is there value in someone who's normal using these therapies?
- [71:14]
Dr. Irwin Goldstein
That's a fabulous question. If you're normal, you shouldn't be doing anything that has risk and obviously anything that you do has some risk if you ask the question. If you are on Viagra and you already have a problem, should you now consider to do prophylactic improvement of your smooth muscle health? I think you have an argument there.
- [71:34]
Dr. Reena Malik
Yeah.
- [71:35]
Dr. Irwin Goldstein
Because you're already on a therapy and you're already down that slippery slope of evil. Because I'm on ismst, this medical shockwave therapy, my brain is saying to me that the current strategy, where the equipment is bizarrely expensive, you have to go to a doctor's office, you gotta get multiple treatments and then you go home. That's not the correct way to do shockwave. I believe shockwave therapy is something that you do, like insulin. You just keep doing it, you keep activating stem cells. More than stem cells are being activated inevitably because all stem cells are being activated. I think it's the thing you do at home. Like you exercise, like you eat well, like you shockwave regularly. It needs to be a home device.
- [72:22]
Dr. Reena Malik
Well, there are home devices, but they're not the same.
- [72:25]
Dr. Irwin Goldstein
No, they're not. Shockwave. That's bullshit. Excuse me, didn't mean that word.
- [72:28]
Dr. Reena Malik
I just want to be clear because people might hear this and say, oh, I should just go buy that shockwave therapy.
- [72:32]
Dr. Irwin Goldstein
It's called Phoenix and it's a complete waste of time. It's radial ballistic pressure waves. They do nothing. They have no expensive massage, double blind, placebo controlled radial ballistic pressure waves don't do anything.
- [72:45]
Dr. Reena Malik
Right?
- [72:45]
Dr. Irwin Goldstein
Yeah, it's like massage. You massage your penis many ways, like Jelqing. But true, genuine shockwave, for reasons unclear, is they make bells and whistles. They make it expensive. It really needs to be a home thing. It needs to be declared by the fda, not a device. Class two, which means you have to have a physician involved. But class one, which is what radial ballistic pressure waves are, you need to make them the same.
- [73:11]
Dr. Reena Malik
So as of right now, if anyone is giving you a device at home, it is not a shockwave, formal shockwave machines.
- [73:17]
Dr. Irwin Goldstein
It's a kind of a waste of your time.
- [73:19]
Dr. Reena Malik
I think the other challenge is there's a lot of. So there's cheaper shockwave machines that are radial versus focus and people.
- [73:25]
Dr. Irwin Goldstein
Well, they're not shockwave. Don't make that mistake.
- [73:28]
Dr. Reena Malik
But that's what they're calling them.
- [73:29]
Dr. Irwin Goldstein
Yeah, but it's not shockwave. They're lying.
- [73:32]
Dr. Reena Malik
Right. So. But for the average consumer, it's very difficult.
- [73:34]
Dr. Irwin Goldstein
They're called acoustic waves and they look
- [73:36]
Dr. Reena Malik
the same, they sound the same.
- [73:37]
Dr. Irwin Goldstein
By the way, a radio is an acoustic wave. It's cheaper to take a radio next to your penis. By the way, it's the same. You're saving a lot of money.
- [73:46]
Dr. Reena Malik
Right. So just make sure you ask that you are getting focused shockwave. Because I think what happens is these people get taken for a loop. They get, oh, I'm getting shockwave.
- [73:55]
Dr. Irwin Goldstein
It's cheaper than if it's in your shopping mall.
- [73:58]
Dr. Reena Malik
It's probably not if there's no doctor involved.
- [74:03]
Dr. Irwin Goldstein
In our office at San Diego, sexual medicine, only providers provide shockwave. We don't have techs doing it.
- [74:09]
Dr. Reena Malik
Yeah, I do it myself too.
- [74:11]
Dr. Irwin Goldstein
I think it's a lot of fun actually. But another conversation.
- [74:14]
Dr. Reena Malik
Well, it's like a good chat with your patient and hang out. So you already told us about how you switched over to female sexual dysfunction.
- [74:22]
Dr. Irwin Goldstein
Well, we broadened the version of sexual medicine for men to sexual medicine for both genders. I think that's the way to think of it.
- [74:30]
Dr. Reena Malik
What do you think is the most misunderstood thing about female sexual function?
- [74:35]
Dr. Irwin Goldstein
That there's no help you can get. Because there is plenty of help you can get. You just have to find it. I think the nightmare is the provider availability is pretty limited. Ishwish, if you're a woman, find an iswich provider. You have the best chance.
- [74:50]
Dr. Reena Malik
Absolutely.
- [74:51]
Dr. Irwin Goldstein
But there's so much we can do for hsdd for arousal, for orgasm. Now for specifically the pain disorders.
- [74:58]
Dr. Reena Malik
Do you think we over psychologize sexual dysfunction?
- [75:01]
Dr. Irwin Goldstein
I hate to get involved in that because psychology is just so important and it's intimately involved with everything.
- [75:08]
Dr. Reena Malik
Yeah.
- [75:09]
Dr. Irwin Goldstein
It's all. All sexual dysfunctions are 100% psychological.
- [75:14]
Dr. Reena Malik
Absolutely.
- [75:14]
Dr. Irwin Goldstein
But a lot of them are biologic. And the biologic is the trigger. That sort of manifests the psychology.
- [75:22]
Dr. Reena Malik
Right. Once you have a problem, you can't stop thinking about it.
- [75:25]
Dr. Irwin Goldstein
Yeah. And it just festers.
- [75:27]
Dr. Reena Malik
What I mean is I think that a lot of people go see their doctor and they're told it's all in your head.
- [75:31]
Dr. Irwin Goldstein
Yeah. Well, that's the nightmare.
- [75:33]
Dr. Reena Malik
That's the problem.
- [75:33]
Dr. Irwin Goldstein
It would be wiser for doctors say, geez, I'm not trained in this. I don't know, I don't know. And then rather than give people the it's in your head thing.
- [75:42]
Dr. Reena Malik
Yeah, I'm sure. You say I don't know, and I say I don't know all the time to patients because there's things that we don't know.
- [75:47]
Dr. Irwin Goldstein
But then I go on, AI.
- [75:50]
Dr. Reena Malik
But it's not perfect.
- [75:51]
Dr. Irwin Goldstein
It's not perfect.
- [75:52]
Dr. Reena Malik
It's not perfect. You know, open evidence is a great tool that we have. I don't know if you've used it.
- [75:56]
Dr. Irwin Goldstein
I don't.
- [75:57]
Dr. Reena Malik
It incorporates all the research from like Journal, JAMA and New Angel. Like, it gives you very, very detailed.
- [76:04]
Dr. Irwin Goldstein
I don't think they're really good. Open evidence and sexual metaphor, they're not
- [76:08]
Dr. Reena Malik
great, but meaning you can ask the same question on different computers and get different answers. So it's not always perfect. Yeah. You've talked a lot about oral contraceptives and how they impact female sexual function. Now, I think they're great in giving women the ability to decide when they want to get pregnant. But there are some women who have real sexual dysfunction after using them. Can you talk about that a little bit?
- [76:31]
Dr. Irwin Goldstein
Hormonally based contraception goes back to the 1960s where you were able to stop ovulation. So if you could stop ovulation with medication, you can't get pregnant.
- [76:44]
Dr. Reena Malik
Right.
- [76:45]
Dr. Irwin Goldstein
Okay. But magically, for reasons unclear, 100% of hormonal based contraceptives raise a protein from the liver called sex hormone binding globin. And I don't mean raising it from 25 to 28. The normal value is in nanomoles per liter 25, it goes to 400 or 500. Okay. So sex hormone binding globulin is a globulin, a protein with lots of amino acids that binds sex hormone binding to sex hormones. It binds sex hormone of the things that binds is testosterone, rendering it not available. So whatever you have in your body, it's all sort of stuck on this protein and not really available. Okay, that's 100% of users. There's 50 million users. So 100% of 50 million people have low testosterone. Okay. But not everybody has sexual dysfunction. God bless those who don't have sexual dysfunction. Their androgen receptors are very happy dealing with low testosterone. They'll still make the protein needed based on their testosterone. But there are a bunch of people who have really lousy androgen receptors. I studied this, we measured the antigen receptors and people on this product called Yaz who did and did not have symptoms and what discriminated from them having and not Having was the quality of their androgen receptor. So people with crappy androgen receptors require higher testosterone to make the protein, but they're not getting it at 50 million people. So yeah, it's kind of a nightmare. So there's a thing called lark. I don't know if you promote larks or discuss larc. Long acting reversible contraceptives. There have no side effects effect sexually. So if you had to pick and choose between a hormonal birth control, which can 100% lower your testosterone. Not can, but does.
- [78:36]
Dr. Reena Malik
And that manifests in low sexual desire,
- [78:39]
Dr. Irwin Goldstein
low sexual desire, depression. How many young kids are in college with depression? Guess what they go on while they're on hormonal. They go on SSRIs. That's double nightmare. Yeah, Double jeopardy for these people. People. Yeah. So it's a drug causing another drug problem. Yeah. Welcome to America. And to women and their sexual problems.
- [79:01]
Dr. Reena Malik
Well, let's talk about low sexual desire.
- [79:03]
Dr. Irwin Goldstein
Okay.
- [79:03]
Dr. Reena Malik
What is your. I think we've heard it too much. Go, go drink a glass of wine and relax. Which is all bullshit. What do you do for women with low sexual desire?
- [79:15]
Dr. Irwin Goldstein
Well, we listen to their story, ask them lots of questions. They're not wanting to walk, want. So whatever their reason is, at the end of the day, it's like orgasm. It's a central thing. There's an imbalance in excitation and inhibition. Remember we talked about orgasm where they both work together, These ones work opposite. So if you want to be interested, you got to access your excitation chemicals and you got to turn off inhibition. So there's two, amazingly enough, FDA approved products that activate excitation or turn off inhibition. So one of them, the first one was flibanserin, which by the way, at this year's this wish, you're gonna watch a movie called the Pink Pill. I don't know if you've actually probably already seen it.
- [80:00]
Dr. Reena Malik
Yeah, no, I, I, I, I.
- [80:02]
Dr. Irwin Goldstein
You'll see it again.
- [80:03]
Dr. Reena Malik
I'll see it again.
- [80:03]
Dr. Irwin Goldstein
It's really cool.
- [80:04]
Dr. Reena Malik
Yeah.
- [80:05]
Dr. Irwin Goldstein
So Flubanserin is an agent that's FDA proof for that. It's a daily pill. So a lot of people like the concept of, of not dealing with it at the time of sex. Just take it all the time. And then there's the subcutaneous pre melanotide. FDA approved for hsdd. But a lot of people like the idea of taking it only when they have sex. It's kind of like a Viagra concept for men. It's very, it's not A stretch to say I want a better performance, let me take my Viagra. So women will say let me take my violesio in a discreet way that well, they'll do the EpiPen injection and have many hours of lots of dopamine. So they'll have excitation more than their current inhibition. So yeah, it's a, you have to discuss if it's situational or if it's lifelong or if it's, you know, you have to get into the meat of all of this. But we do have two products and then of course testosterone is an agent that clearly is involved in desire. And there's a lot of people on birth control pills who have done away with their testosterone by raising this binding protein. So there's lots of stuff to do
- [81:26]
Dr. Reena Malik
and that raise and that binding protein doesn't go away right after.
- [81:29]
Dr. Irwin Goldstein
So yes, now we're getting into another drug and it's nightmare is it doesn't ever return it to its value prior the body learns to stay with high shbg. So as that person ages, the price for taking birth control pills at a young age is a permanent elevation of SHBG or a permanent if you like, low testosterone state. So that leads to depressions and low interest and bone disease and muscle disease and tiredness and blah blah, blah, blah. It's horrible.
- [82:01]
Dr. Reena Malik
That is horrible.
- [82:03]
Dr. Irwin Goldstein
And add to the sad state that there's no FDA approved treatment for testosterone. No one's even measuring testosterone because they have nothing to treat with. Unless you don't mind going off label and using bail testosterone products.
- [82:19]
Dr. Reena Malik
Yeah, which work?
- [82:21]
Dr. Irwin Goldstein
Yeah, which work and are widely used in our office.
- [82:24]
Dr. Reena Malik
Yeah, same. How do you feel now? I think we're having at least more discussions about testosterone in women and more people are prescribed on it. Do you worry about, I mean I think what I've heard from people where they accidentally will take more than needed and they feel great. Do you worry about people being on super physiologic doses of testosterone?
- [82:42]
Dr. Irwin Goldstein
Do you ever ask that question about men?
- [82:44]
Dr. Reena Malik
I do, yeah, absolutely.
- [82:46]
Dr. Irwin Goldstein
You're not picking on women?
- [82:48]
Dr. Reena Malik
No, of course.
- [82:51]
Dr. Irwin Goldstein
I mean, you know, it's a risk benefit, it's side effects. What is supraphysiology? We haven't even established what is the physiologic levels.
- [83:01]
Dr. Reena Malik
Very true.
- [83:02]
Dr. Irwin Goldstein
Certain women need more and it's because of their shbg, so blessedly high and some need less and some have bad receptors and need more. So I don't know, I, we go by side effects and benefits and we ask them are you happy being where you are? Some people will say, my best friend is the person who takes hair off my face. So because I love the testosterone, I pay the price of having a little bit of a mustache. But my. Whatever you call these people, ologists for hair estheticians, or laser things that they do for their mustache. It's what's important.
- [83:49]
Dr. Reena Malik
Do we actually know what normal is in women? I know we always sort of Generalize and say 10% of men's dose.
- [83:56]
Dr. Irwin Goldstein
So I did a study.
- [83:57]
Dr. Reena Malik
Yeah. Because I know there's like a few studies.
- [83:58]
Dr. Irwin Goldstein
Yeah. With Andy Gay, who is not with us at this moment in life, but brilliant guy. We took nurses and we gave them the FSFI. And if they scored greater than 26, that's the level consistent without sexual dysfunction. So to engage in this trial where we drew their bloods, you had to have an FSFI greater than 26.
- [84:21]
Dr. Reena Malik
So you had to be normal without sexual dysfunction.
- [84:24]
Dr. Irwin Goldstein
The word normal.
- [84:25]
Dr. Reena Malik
Weird, because considered. Yes. Without a dysfunction.
- [84:27]
Dr. Irwin Goldstein
Without a dysfunction. So we then drew their blood test. 0.8 nanograms per deciliter was the calculator for ET of this population.
- [84:36]
Dr. Reena Malik
Okay.
- [84:37]
Dr. Irwin Goldstein
And it's what I'm calling the blood test result consistent with out of sexual dysfunction.
- [84:46]
Dr. Reena Malik
And what was the total testosterone? Do you remember?
- [84:49]
Dr. Irwin Goldstein
Well, everybody's SHPD is all over the map. So we focused on free testosterone. Got it a little more practical. Practical. It was really frustrating to have someone who has a total test. Classically, it's 40 nanograms per deciliter, but let's say it's 65. So they say, oh, you have ovarian polycystic ovary thing with high LH or something. But it's not true. For some people whose testosterone is 65, they're good. And for some people whose SHPG is still 400 from their birth control pill use, 65 is not. Not even anywhere near enough. So it is confusing.
- [85:29]
Dr. Reena Malik
Over your lifetime, received innumerable awards for all your amazing work.
- [85:34]
Dr. Irwin Goldstein
My highest award is speaking on your show, by the way.
- [85:39]
Dr. Reena Malik
But what I wanted to know is more than that. What have you been most proud of in your career?
- [85:44]
Dr. Irwin Goldstein
Oh, my gosh. Most proud of in my career. It was working with my wife. I guess that has been my biggest honor. I mean, we met at age 19, and we're still together. We have sex all the time. Still. May I announce? Yeah. Everything I do is because we work together and talk about it, and we have this bizarre life where our work is our life and our life is our work. So it's been really fun.
- [86:12]
Dr. Reena Malik
That's awesome.
- [86:13]
Dr. Irwin Goldstein
Yeah.
- [86:13]
Dr. Reena Malik
That's so good.
- [86:14]
Dr. Irwin Goldstein
It's been a good thing.
- [86:14]
Dr. Reena Malik
Yeah, yeah. What's something that you believed early in your career that you now know is completely false?
- [86:24]
Dr. Irwin Goldstein
So. Pfizer. So we published in 1991 that the chemical released by the nerve that caused penile erection was nitric oxide. We were the very first lab JCI Journal of Clinical Investigation, 1991. It was the first ever, no sort of identification of what led to penile erection. And that led us to Pfizer, who was developing. It's a phosphodiesterase type 5 inhibitor. But it required no. To make all things work. And they were studying it for angina. So we were contacted by Pfizer and worked very carefully with them to switch their development from angina to ed. So we had lots of meetings. So I would go to the meetings saying, whatever you're doing, God bless you, it's impossible to develop an oral pill. Okay. And I got up and I'll still tell you, this is what I said, There's 5 liters per minute going through your body. That's your cardiac output. 30 or 40% goes to your liver, 20% goes to your. Whatever some other major organization. Now the penis gets maybe 5mls of that. That's 0.1% of the cardiac output. Okay. You're going to take a pill, it's going into your mouth and 0.1% gets to your penis. Give me a break. How is that going to get enough drug to make this. It was an impossibility. Plus, at that era, in the 1990s, the only way we were getting erections was by injection. So you had to have sufficient smooth muscle relaxation by the injection. How could you get something systemically that wouldn't cause you hypotension that was causing smooth muscle relaxing? So I publicly said multiple meetings. I'm so happy to work with you on this project. It will never happen. I just need you to know this is 100% waste of everybody's time. And of course, yeah, history shows me to be extremely wrong.
- [88:30]
Dr. Reena Malik
But was it during the angina trials that they saw these guys were having spontaneous erections and not returning the medication at day. The of the end. End of the trial, because they were happy about it.
- [88:38]
Dr. Irwin Goldstein
But. But that was. Yeah, so right. They got the signal, but we were developing, so we didn't know if they were ED or they were normal. They're just getting better erections or something. But to take a population of men with ed, you Know radical prostate patients or, you know, just vascular paths. Hypertension, high cholesterol, diabetes, obesity. You know, the community that we all see and love, giving them a drug to help their ED that isn't going to affect everything else seemed beyond reality. And I couldn't have been more wrong.
- [89:18]
Dr. Reena Malik
Well, it does affect other. I mean, there's some data that it may improve muscle blood flow, cardiac blood flow.
- [89:25]
Dr. Irwin Goldstein
Only positives prevent heart attacks.
- [89:30]
Dr. Reena Malik
Yeah, I already know the answer. But do you have any concerns about people being on these medications long term?
- [89:35]
Dr. Irwin Goldstein
Oh, God, no. I think, to be quite honest, I think every male should be on this all his life. Yeah, I'll go on record as saying that.
- [89:45]
Dr. Reena Malik
I mean, I think Tadalafil is a wonderful medication.
- [89:48]
Dr. Irwin Goldstein
I think you don't have to think about it. You get nocturnal erections from just taking a pill. I mean, it lasts 36 hours. So it's one of those things that. It's like vitamin tea, vitamin T or vitamin C. Cialis. I guess it's a better way to say it. Right.
- [90:08]
Dr. Reena Malik
The other thing, some people are still worried about taking these medications because they worry about their heart. But God bless them, no. But is there any indication where you would say, no, I can't give you this medication?
- [90:19]
Dr. Irwin Goldstein
Well, sure. Nitrates. Yes, of course. Yeah, that's the biggest thing.
- [90:23]
Dr. Reena Malik
What about if they're their heart.
- [90:26]
Dr. Irwin Goldstein
But nobody takes nitrites anymore, so it's rare.
- [90:29]
Dr. Reena Malik
It's rare. There are still some people who take them, but. But what about cardiovascular disease? Is there a. I know there's a consensus statement, but what is the point where you'd say, hey, we got to sort of talk to you.
- [90:40]
Dr. Irwin Goldstein
You're going to be the rare condition, but in general, incredibly safe and incredibly helpful and in my opinion, should be very widely used.
- [90:54]
Dr. Reena Malik
I think that what I say is if you can have sex, if you're like physically able to have sex, you should be able to take the medications. If you can't get through a sexual.
- [91:01]
Dr. Irwin Goldstein
That's a good point.
- [91:03]
Dr. Reena Malik
Through a sexual encounter because you're so, you know, physically exhausted or then probably not.
- [91:08]
Dr. Irwin Goldstein
That's a good message. I should steal that from you.
- [91:10]
Dr. Reena Malik
Yeah, you're welcome to it. I'm sure I've stolen stuff from you. Okay, if you could put up a billboard tomorrow about sexual medicine for everyone to see, what would it say?
- [91:22]
Dr. Irwin Goldstein
Don't beat your head against the wall because you have a sexual dysfunction. Get help. Help. Because we're really good at this. The, the nightmare is there's not enough sexual medicine providers. But if you could actually find a sexual medicine provider. We're pretty good at helping people, so I think the billboard would be yeah. To seek help. Yeah, go for it.
- [91:48]
Dr. Reena Malik
Yeah. Where can people find your work, find you if they want to see you? Where can they learn more about you?
- [91:54]
Dr. Irwin Goldstein
You go to you San Diego Sexual medicine. I do 619-265-8865. That's our.
- [92:04]
Dr. Reena Malik
Put all the information in the description.
- [92:05]
Dr. Irwin Goldstein
God bless you.
- [92:06]
Dr. Reena Malik
We end our podcast with four questions we ask you. They don't have to be about sexual medicine. They obviously can be. But what is something you know now that you wish you knew earlier in life?
- [92:15]
Dr. Irwin Goldstein
I'm in love with the region based medicine stuff because it allows me, as I'm hearing a patient talk, trying to put where's this trigger coming from? And we didn't know that at the beginning and it was very confusing and so confusing that we ignored it. We said, oh, but I'm going to stick with the answer that what we know now, Region based medicine is the model for figuring all these unusual cases out like hard flaccid or SRPES or PSSDS or pffs, all these stupid acronyms. We're only good at that because of region based thinking.
- [92:55]
Dr. Reena Malik
Yeah. What's a non negotiable Something you have to do every day?
- [92:59]
Dr. Irwin Goldstein
Take phone agra. Have sex frequently. Orgasms regularly. Yeah. I think there is health to having sex.
- [93:10]
Dr. Reena Malik
Well. And your brain. Protect your brain.
- [93:12]
Dr. Irwin Goldstein
Protect your brain.
- [93:13]
Dr. Reena Malik
You mentioned it earlier.
- [93:14]
Dr. Irwin Goldstein
It gets you the blood flow.
- [93:15]
Dr. Reena Malik
Yeah. What's a life hack or health hack? You share. It can't be have sex because you
- [93:20]
Dr. Irwin Goldstein
already said that I can't repeat have sex frequently. It's what I would say.
- [93:26]
Dr. Reena Malik
That's why I prefaced it because. Okay, we'll let you have it. Have sex frequently. If you couldn't be a urologist or researcher, a entrepreneur starting your own practice, what would you be?
- [93:40]
Dr. Irwin Goldstein
A sex researcher.
- [93:42]
Dr. Reena Malik
I said researcher. You can't be a researcher.
- [93:45]
Dr. Irwin Goldstein
I, I wouldn't be anything else. This is, this has been a journey with wave after wave after wave of. Yeah. So. So we're fortunate in urology because the penile implant happened in 1973. I was a resident in that era.
- [94:01]
Dr. Reena Malik
Yeah.
- [94:02]
Dr. Irwin Goldstein
My chairman did all the penile implants west or east of the Mississippi in Boston. We got everything. So as a resident, I was evaluating men with impotence. We didn't use the word ED then. And I've essentially not done anything else in my life from day one. Sexual medicine and then the Viagra turning to do both Men and women has really cemented that concept. It's completely fascinating.
- [94:33]
Dr. Reena Malik
Oh, I know. I forgot to ask you. I'll edit it in.
- [94:36]
Dr. Irwin Goldstein
You didn't have an orgasm recently, that's for sure.
- [94:42]
Dr. Reena Malik
Does Viagra work for women?
- [94:44]
Dr. Irwin Goldstein
Does Viagra work for men? So we're finding that topically it does with enhancement promoter to get it through the skin of the clitoris and vagina orally. I don't know. We studied it a lot. Arousal is not the prime issue for women. They walk into the office with, I'm not interested in. It hurts, I can't have orgasm. They've rarely. It's not impossible, but it's more of a rare thing that my arousal's off. Whereas a man. My inability to get aroused. Erection is kind of the premier thing. So it's boy girl, different.
- [95:25]
Dr. Reena Malik
I do think, though, that it's difficult for women to quantify arousal because they don't have.
- [95:30]
Dr. Irwin Goldstein
Oh, I'm sure that's true.
- [95:31]
Dr. Reena Malik
Right. So they don't have a visual that they're aroused and so they may be conflating some of their low libido maybe also due to low arousal.
- [95:38]
Dr. Irwin Goldstein
I'm sure that's true.
- [95:39]
Dr. Reena Malik
So I wonder. I just don't think we have the right tools to really assess because it's probably a combination of things.
- [95:47]
Dr. Irwin Goldstein
I'm sure that's true, but it isn't what people complain of. And Viagra has failed every time. But getting aroused is important to start the orgasmic arousal process. Not that arousal is not important, it is just not the complaint.
- [96:03]
Dr. Reena Malik
The other thing I wonder is for women, we know that erectile dysfunction is a canary in a coal mine for men with cardiac disease, and it is probably the same for women. And I wish that that message would get across more because we might be saving lives by talking to them about their sex lives. If we identify that they are at risk for heart disease, we might. We might be changing the game for them.
- [96:26]
Dr. Irwin Goldstein
Well, if this year's Zswish, they're doing how to assess blood flow to the clitoris. They're doing ultrasound of the clitoris. Ideally, it picks up early vascular disease. So your canary in the coal mine may still work, but you need an
- [96:40]
Dr. Reena Malik
ultrasound machine, but then you need to get the clitoris erect. So are you going to be doing well?
- [96:45]
Dr. Irwin Goldstein
You have to arouse.
- [96:46]
Dr. Reena Malik
Yeah, yeah. So are you going to be doing intracavernosal?
- [96:49]
Dr. Irwin Goldstein
No, I think the topical sildenafil may have a diagnostic role.
- [96:53]
Dr. Reena Malik
Okay, yeah, Fascinating. All right, well then, will topical sildenafil work in Men.
- [96:59]
Dr. Irwin Goldstein
So I don't know the answer to that. It hasn't yet.
- [97:03]
Dr. Reena Malik
It's been tried, right?
- [97:04]
Dr. Irwin Goldstein
There's been some topical things. Yeah, topicals have been tried. It's just that the oral works so much better. So much better. Yeah.
- [97:11]
Dr. Reena Malik
Yeah. There was that topical Oroxan, which there was a lot of hope for, but I think it fell flat.
- [97:16]
Dr. Irwin Goldstein
It based itself on a placebo. It's not really the active drug. Kind of weird.
- [97:21]
Dr. Reena Malik
It was weird. Yeah. All right, well, thank you so much, Reena.
- [97:25]
Dr. Irwin Goldstein
Thank you. God bless you for having so many people. You know, at the end of the day, we do the research, but we don't get the data. So we're in partners in this thing.
- [97:33]
Dr. Reena Malik
Absolutely.
- [97:35]
Dr. Irwin Goldstein
Getting it out is very important.
- [97:36]
Dr. Reena Malik
Absolutely. And I feel honored to be able to sit down with you and get your time and your insights because, you know, you've worked your whole career in doing all this stuff, and it's. It's so helpful to.
- [97:47]
Dr. Irwin Goldstein
So the word work is probably not correct. I've enjoyed the journey. It's. It's been. It's. It's just been fun, really.
- [97:53]
Dr. Reena Malik
That's. That's great.
- [97:54]
Dr. Irwin Goldstein
We don't work.
- [97:55]
Dr. Reena Malik
I think the people who. Who do the. Do the most, affect the most change love their work.
- [98:01]
Dr. Irwin Goldstein
Yeah. Right. Well, as you do.
- [98:03]
Dr. Reena Malik
Yeah. I mean, it. It's true. Right. You have to love it, otherwise you just won't keep going. So.
- [98:08]
Dr. Irwin Goldstein
All right, well, thank you.
- [98:09]
Dr. Reena Malik
Thanks. Thank you guys so much for joining me on today's episode of The Rena Malik, M.D. podcast. Really quickly, if you like this podcast joining, just make sure you are subscribing or following the podcast. It is a huge difference maker for us because it shows people that this podcast is really worth watching. It makes us higher on the podcast charts and so more people can find us. And as always, take care of yourself because you're worth it.