← Rena Malik, MD Podcast
Rena Malik, MD Podcast
How to Have AMAZING Sex Even After 50 ft. Sue Goldstein
01:09:12
Dr. Rena Malik, MD and Sue Goldstein discuss how sexual health evolves with age, addressing low desire, painful sex, hormonal treatments, communication, and common myths. The episode offers practical guidance to help listeners better understand their sexual well-being and feel more confident seeking support.
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Focus features in Blumhouse present Obsession When
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I have a crush on a guy
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no one knows, be careful. I wish Nikki loved me more than anyone in the entire world. Who you wish for obsession is 96%
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fresh on rotten Tomatoes. I love you so so so so much.
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It's blood soaked nightmare fuel. Brooke's blood you put on her.
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You have been warned.
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Obsession rated R under 17 animated without
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parent only theaters May 15th with special engagements in Dolby.
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A
I'm 76 years laugh me saying my age. I say my age because I think it's important for people to realize that at 76 you can be vital and having good sex. I realized in my early 50s that we weren't having sex quite as often. And I'm thinking, well, maybe my husband has a little erectile dysfunction now. Mind you, his penis was as hard as it's been 20 years before. But this is what was going through my brain. It never dawned on me it could be me. Women with HSDD don't feel like a whole woman. When your cardiologist tells you you can't fly, climb three flights of stairs without getting a heart attack, that's the only time it's too old to have sex. We're married almost 52 years. We're still changing things up in the bedroom.
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B
52 years. What is the secret?
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A
There's two secrets
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B
most women don't realize when their sexual function changes. They blame their partner. They blame stress. They blame everything except what might actually be going on biologically. But as my guest discovered, at 52 years of age, it wasn't any of those things. It was her brain that caused her to have hypoactive sexual desire disorder. I'm Dr. Rena Malik, urologist and pelvic surgeon and welcome welcome back to the renamelick, Maryland Podcast, your trusted guide for leveling up your health, relationships and sex life with evidence based tools. I'm joined today by Sue Goldstein, educator, clinical researcher, writer and former president of the International Society for the Study of Women's Sexual Health. For over two decades, sue has been at the forefront of sexual medicine research and patient education, helping develop clinical trials, advise pharmaceutical companies on protocol development, and, and most importantly, teach patients that sexual health is just another form of health. In this conversation, we're covering a lot of ground female sexual dysfunction, how to recognize it, the role of hormones in sexual health across your lifespan, why menopause is so misunderstood, how to navigate painful sex, and the truth about testosterone therapy for women. And at 76 years old, sue says her sex life is better now than it's been in decades. But before you get into the conversation, I have to let you guys know about my brand new erectile mastery course. It is literally exactly what I teach my patients in the clinic when they're struggling with erections. We talk about lifestyle supplements, what really works, and what is maybe not ready for prime time yet. So check it out today at learn.renamelicmd.com erectile mastery. Well, sue, thank you so much for joining us today.
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A
Rena, thank you for having me.
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B
So you've worked alongside and been married to, as he's called the goat, Erwin Goldstein, for nearly five decades.
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A
More than five decades.
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B
More than five decades. Over five decades. That's amazing in and of itself to be married to someone for that long. But we'll talk about that later. And you've watched sexual medicine evolve from when Viagar was launched to today. And as somebody who was initially on the outside looking in, what did you see in terms of how people treated the field and how it's evolved over time?
- [03:28]
A
Oh, my goodness. I remember my husband coming home from an AUA meeting in Las Vegas. He had just seen a man inject himself to get an erection. It was the first time they could figure out biologically what was happening to make an erection. And he was so excited. And then when Viagra was being developed, he didn't believe that you could have a pill that would work. And when it did, oh, you know, that changed the world. And in that interim, we went from having a problem, erectile dysfunction, that nobody could talk about, to suddenly being okay to talk about it because there's a treatment for it. And people like Bob Dole went on, Larry King Live came out about it. Time magazine had people on the COVID So now for the first time, you could talk about erectile dysfunction. The problem was when that happened, women started to call and said, what are you going to do for us? And we knew nothing. So here we have a whole field for sexual problems for men and women. And we at that point in 1998, really all we had was help for men with erectile dysfunction.
- [04:27]
B
Do you feel like because we don't have answers for all the problems in female sexual medicine, is that why it's such much less discussed or sort of taken for granted?
- [04:40]
A
So that's a really good question. There are a lot of pieces that go into that. First, nobody knew what to do for women, and so doctors didn't want to have open the conversation, you know, open Pandora's box and not have help for them. So when Viagra came out. My husband was the first author in the New England journal article. And so women started calling his office, and he sent them to the department of gynecology. After six months, he called the chair of gyne and said, what are you doing to these women? He said, I don't know. I'm going to make you a professor of gynecology, too, so you can help these women. And he literally put together a group of experts from around the world. Each one knew a little piece and put them in one room and made a course trying to learn more about women's sexual health. He did it again the next year. Third year he did it. Said, you want to become a society? The second year he said, do you want to become a society? And they said, no. And the third year, and he said, you want to be a society? And he said, yes. And today that's the International Society for the Study of Women's Sexual Health. So we know a lot more than we did in 98 when Viagra came out. The problem is that this field was driven by a urologist, by my husband. Urologists treat with testosterone. They are used to measuring blood levels. They are used to looking at, you know, what does something do when you do that? Intervention. Gynecologists tend to, in general, just do the intervention. I'm not dissing gynecologists, but it's a different background. And so it took a long time for, I think, for gynecologists to become comfortable with the conversations and to understand where this was going. There are still too many gynecologists who have no interest in women's sexual health. The ones that do are involved with this wish. So I think that's part of the problem. Part of the problem is they scare the fear that the Women's Health Initiative put into women, but hormones. And now, finally, we have the black box, the box warning taken off. Huge difference. But you have two decades of OBGYNs who were trained during a time that hormones were a no, no. So that's hundreds and hundreds and hundreds of physicians who have no experience and no understanding whatsoever. And unless they have an interest in it and go to meetings like ISWISH or NAMS or something where they're going to learn about hormones. They have no access to this information, so it's taboo on their part. They're not going to ask the questions. And women, we aren't even taught our body parts. Think about names. You know, it hurts me down there. How someone going to help you? This is one of my pet Peeves that we aren't taught anatomy. Women don't have names. Even if a man says my Peter or my Johnson, you know darn well what he's talking about.
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B
Yeah.
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A
But a woman says her hoo ha or her vajayjay. Thank you, Oprah, very much. What is the vajayjay? Clitoris, vagina, vestibule. We don't know body parts. So women don't talk about their sexual health issues because they don't know what's wrong. They don't understand what's wrong, and they don't know that there may be help for them.
- [07:26]
B
Yeah. And, you know, you said that before Viagra came out, what was it like to talk about erectile dysfunction? Like, what were people coming into the office and talking about it, and how was it treated differently?
- [07:37]
A
So, first, in full disclosure, I did not work in the office until we moved to California in 2007, but my husband always shared things with me at home. Unlike many relationships where you don't talk about work at home, we always did. I used to help residents write papers and things like that. But what I do know is erectile dysfunction was very much a taboo. It was something that if you had had prostate cancer, it was okay to talk about it and treat it. Other than that, it wasn't something that was discussed. Now, it's not that people didn't go to the doctor for help. I mean, we were in Boston at the time. A lot of politicians from Washington flew to Boston for help. Men were seeking help that were savvy enough to know that there was things out there, but you couldn't discuss it. You couldn't be open about having ED unless it was post prostate prostatectomy.
- [08:23]
B
And then what about on the female side? I mean, do you feel like men coming in for ED were. What were people saying in terms of their discussions at home? Like, were their partners? Like, so the. The partner. The partner with the ED got treated with erectile dysfunction. What was the response at home?
- [08:40]
A
One of the problems is, if you're treating an aging male with ED, and if his partner's a longtime partner, she's also an aging partner. She's now experiencing genitourinary syndrome of menopause. So in. In our office today, and we're not talking about, you know, when Viagra first came out in our office today, if we have a male who's aging, will type, you know, is your partner male or female? Is your. Or both? Is your, you know, if your partner is a female, is she, you know, aging? She may need treatment as well. So we always discuss it, but I don't know how many men actually talk about this with their partners at home. And that's another piece. My husband used to joke that golfers are people with ED who don't want to discuss it because then they come home from long day in the golf course, they're exhausted, and that's their excuse for not being able to have an erection. Now, truth or not, you know, I can't address that, but the fact is that couples, as they age, so often become friends. They live like brother and sister. They're, they're, you know, they have companionship and they enjoy their company, but they, they're sexually retired, and there's no reason to be sexually retired. Someone actually once asked me, how old is too old to have sex? I said, well, when your cardiologist tells you you can't fly, climb three flights of stairs without getting a heart attack, that's the only time it's too old to have sex?
- [09:53]
B
Yeah, exactly. I say that too. I tell my patients, like, if you physically can't have sex, and don't ask me for med patients, but if you're physically able to me, you can walk up three flights of stairs, you're okay.
- [10:02]
A
It is your choice whether you want to have sex or not. It is our jobs to help people who want to have sex who can't be able to have sex.
- [10:09]
B
Yeah. So tell me what inspired you to get involved in the actual practice of sexual medicine?
- [10:14]
A
I used to go to the isswish meetings and I would sit in the room. And as a brand new society, we didn't have money and so anything to save money. So I was the gopher. I was the one timing the speakers. I was doing all the Scott work, but I was listening and absorbing everything. And I knew, I knew about ED because my husband had talked about it at home. The family joke when Viagra came out was that I knew more about ED than the average urologist in private practice. Which was true and it still is true. So he had taught me all of this about ed, but I learned all the FSD going to this wish. When we moved to California, my intention. I had always worked part time back east. I was an educator, I was a writer. I had been involved in helping to write sexual medicine papers, but I hadn't been involved in the practice. And when we opened our private practice, I figured I would work part time and help out. And within one week, we had contracted to conduct a clinical trial. And we had a nurse practitioner working on it. And we realized we weren't ready to have a nurse practitioner. This is, you know, just honest from the gut. And she wasn't ready to be working with us. And so she went back to the practice she came from. No harm, no foul. Then my husband looked at me. He says, you've done basic science research, you're going to do our clinical research. And today I do a lot of clinical research. I write protocols, I work with companies to help advise with protocols. It was really the realization that I was helping my husband with his dream to open a biopsychosocial practice and sexual medicine. And one day I woke up and realized it was my dream too. And I just, as an aging woman who was, treated myself for sexual dysfunction. It just became a passion of mine. I am an elementary school teacher by trade, so teaching is my forte. And I've learned the medicine. And I say that the doctors are physicians who've learned how to teach.
- [11:57]
B
Yeah.
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A
And we all play a part and we all play a role. And I love working with patients and helping to teach them. But I really love the opportunity like you've given me today to be able to get the word out on some of the things that are myths, misnomers, not understood. And, you know, for women, learning your body parts and know and not to be ashamed is probably the first step.
- [12:21]
B
Yeah. And teaching your daughters.
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A
Right.
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B
I think that's so important, and I talk about that a lot, is that we have to take ownership of teaching our children about sex. And that starts with teaching them their body parts very early on, because we expect that it's going to be taught in school. And you know this very well. It's not. You get some basic knowledge about consent and preventing pregnancy and STIs and how to put on a condom, and that's pretty much all of it, if you're lucky.
- [12:49]
A
That depends what state you live in. Because the current political atmosphere, that's not even happening in some states.
- [12:54]
B
Correct.
- [12:55]
A
We won't go there. But, you know, the reality is that education, all education should start at home. Whether it's safe sex or who you are. There's a lot of information about menopause people don't know. And I always say, you know, once you become a patient and you learn, you understand. Talk to your sister, talk to your mother, talk to your daughter, talk to your next door neighbor.
- [13:13]
B
Yeah.
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A
It's nothing shameful about sexual health. It's just another form of health. Sexual medicine is medicine.
- [13:21]
B
Absolutely. And you know, it's interesting, my mom's generation didn't talk about their symptoms. Like, I remember my mom having hot flashes. She went into surgical menopause. So I very vividly remember, because it was, like, crazy. But, you know, she never talks about it. She never talks about what that was. Like, she just kind of grinned and bared it, and she just went through it. And so if I don't talk to her about it, I'm never gonna get her experience. And I'll share, like, my aunt. Actually, my mom told me this, that my aunt was having significant pain with sex for years, and she never asked, never talked to me about it. And I was like, why didn't you talk to me? I would have helped you. I would have told you what to do, you know? And. And she was like, yeah, it's miserable. It feels like razor blades. It's just horrible. And I was like, I'm your family, and I talk about sex all the time. Like. Like, if you didn't know to come talk to me or you felt embarrassed to talk to me, who are you going to talk to? Right? And so it's really. It's important for us to even open up that dialogue with our family.
- [14:16]
A
It is. It is. My mother used to say, every Thanksgiving, can we wait until dessert before we start talking about sex? Never happened.
- [14:25]
B
So tell me you've been open about your experience with female sexual dysfunction. Tell us about it.
- [14:30]
A
So it's very funny. I realized in my early 50s that we weren't having sex quite as often. And I'm thinking, well, maybe my husband has a little erectile dysfunction now. Mind you, his penis was as hard as it had been 20 years before. But this is what was going through my brain. It never dawned on me it could be me. And at that time, with the development of drugs for women, was actually the development of flibanserum, which is Addie. They had developed a new questionnaire for patients to fill out to determine whether they had sexual dysfunction or not. The Female Sexual Function Index. And my husband came up. He says, there's a new validated instrument. Take it. Let me just see, for fun. So I answered, and he goes, holy sh. You've got sexual dysfunction. Never dawned in me. Despite everything I knew and understood, it never dawned on me. It was my body changing, resulting in our sexual function not being so great. Didn't dawn on me I was letting him fall asleep before me that sex was good on occasion, but not all the time. And we had been very sexually active. I always tell our patients that my husband practices what he preaches, and I keep him around because he's good in bed. And for those of you who saw the introduction, we'll be married 52 years in June. But the reality is that I had hsdd, hypoactive sexual desire disorder. So I just wasn't all that interested. Once we were having sex, I could. I could be aroused. I could have reasonable sexual activity, but I had no interested. I wasn't initiating sex. And so I started on testosterone, which at the time was the only option we had. And it really did help. And that helped me for about 20 years. And the way I put it is, you know, when you're young, everything is great at this point, sex was great one out of ten times. Good most of the time, but great one out of ten times. And that really allowed. Not only did that, I was having night sweats. It stopped the night sweats. I had one hot flash in my entire life. And that was because there's a chemical in your body called aromatase. And when the testosterone converts through aromatase, it becomes estradiol, all of which helps you with the hot flashes. And my aromatase had stopped working. And it was very early on that we didn't understand that you needed to treat a menopausal woman with testosterone and estradiol. So we started an estradiol. And because I have a uterus progesterone as well, I never had another hot flash. I remember that one because I thought my underwear was soaking in the middle of the airport in Orly in Paris in France. And I. And I said, okay, I'm just nervous because they're sending us to the wrong gate in the wrong gate and go, no, my God, this is the hot flash. And it's so weird to realize it's the only hot flash I've ever had. But starting on the estradiol and the progesterone, you know, and continuing the testosterone, everything was fine. And then I got to the point that the testosterone wasn't helping my desire. This is. Now I've gone from the testosterone. I started about 52, and now we're talking. I guess it's 10 years now. I think that Addy's available. And so flibanserin is for hypoactive sexual desire disorder. So I got a prescription, and what that did was that made sex for us. Instead of 1 out of 10 times being great, it was 9 out of 10 times being great. Now, as a menopausal woman, I can't have sex every day. It's too much physically on my body. I recognize that. But once or Twice, you know, like Friday afternoon and Sunday or you know, even once a week. The sex I'm having is great. I will continue on my hormones. I am on, still on testosterone, estradiol, progesterone, systemically. I have been for many years. I've been on intravaginal DHEA that goes into my vagina to keep my vagina healthy. Also on compounded testosterone and estradiol on the vestibule, which keeps the external organs healthy. So that although I have some resorption of my labor minora, it's very, it's very little resorption because of all the medications. My clitoris is robust, the size it should be, to use the words for genital urinary syndrome and menopause. My. I have normal pallor. I have no erythema. That just means that I'm not red and raw and I'm not pale in color. My rugae, the accordions on my vagina are perfectly healthy. I'm not going to put a baby through that anymore. Actually, I never put a baby through. I had three cesareans, but my body is healthy. If you look at a picture of me from valvoscopy, which is looking at my genitals, I don't look any different than a 35 year old, which is really nice. And because I'm in systemic medications, while we don't necessarily have the evidence anecdotally, I can tell you I have good memory. My mood is perfectly normal. My muscle mass, I've had bone density done and I actually had improvement in my density on my hips. So I'm 76 years old and people laugh me saying my age. I say my age because I think it's important for people to realize that at 76 you can be vital and you can be still learning things and doing things and having good sex.
- [19:21]
B
Yeah, I think that's so important. I think it's so, so valuable that you're open to share that because, you know, you mentioned some things that were so. That really stuck out to me. You said, look, I didn't even realize it was me. You were doing things to sort of avoid sex. And unintentionally you were sort of like, you do not even realize you were letting him go to sleep first. You were whatever. And I think that is so interesting because that is probably a very common experience for people. They just do not want to deal with rejecting their partner. So they will do these other things that they are actually not rejecting them and they are just.
- [19:53]
A
Or having duty sex. Cindy Masten wrote a book A hundred reasons why Women have Sex and duty. Sex is a huge piece. I love my spouse, he needs to have sex, therefore I will have sex with him. Many years ago, I co authored a book on when sex isn't good and interviewing people with different sexual problems. And I remember woman with hsdd. She said, I was beige, my life was beige. I felt like a wallflower. She says, I just wanted to go in the corner. And I told my husband, go out and have an affair. I know you love me, I love you, we'll stay together, but go have an affair so you can have sex. And when she was treated with testosterone, because this was a long time ago, she started wearing cute clothes again. She started being active, she started driving her stick shift car, which sounds so weird, but she just felt like she just wanted to go into a corner. And now she was her bold, whole self. I actually compare and it's not, it's not a fair comparison. But when women have breast cancer, they don't feel like a whole woman when they, when they've had their breasts removed. And obviously HSDD is not something that's going to kill you like breast cancer. But women with HSDD don't feel like a whole woman. Very much the same. The language they use to describe themselves is very much the same as the language that a breast cancer survivor will use to describe herself during that time that she's on a. Robotase inhibitor, inhibitors, tamoxifen, whatever. It's. It can be devastating. We have seen relationships break up, marriages break up, because it's called discordant libido, libido because. Or discordant desire. He wants to have sex, she doesn't want to have sex. That famous Woody Allen scene where she just died. Diane Keaton says, oh, he wants to have sex all the time. He wants sex three times a week. And then Woody Allen goes to the same therapist and says, oh, she never wants to have sex. She only wants to have it three cents, three times a week. And that's what we're talking about. Yeah, I think having an open conversation with your partner, I mean, that's obviously what the therapist in the movie was, was leading to, but you don't necessarily know there's something going on with you, but having that conversation or having your partner start their conversation with you talking about sex shouldn't be shameful.
- [22:02]
B
Absolutely, absolutely. And you know, the interesting thing I'm, I'm getting here is I wonder if people who are feeling this way may attribute their lack of sexual desire to their partner when maybe in reality, it's just biologic.
- [22:16]
A
Yes, yes.
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B
They're like, my partner is the problem, My partner's the problem. And, but they're really suffering from hsdd.
- [22:23]
A
Now that's obviously not always the case.
- [22:25]
B
Sure.
- [22:26]
A
If you have, no, if your desire is totally normal and great when you're with another partner, then clearly it's, it's a relationship issue. Yeah, but yes, I mean, because we as women aren't taught about this, we aren't knowledgeable enough and we know a little bit about erectile dysfunction, we just will often assume that our partner isn't stimulating us enough. Your partner isn't hard enough. And yes, as a man gets older, his erections aren't as firm and so they aren't going to be as stimulating. Stimulating as much. It's going to be harder to enter a unlubricated vagina. I always say that when we hear gray divorce, it's because he's looking for a lubricated vagina for his half limp penis to go into. Yeah, it's okay, that can use this language, that's fine.
- [23:06]
B
But yeah, absolutely. And she's looking for something to make her feel desire and whether it's, you
- [23:13]
A
know, she doesn't understand that her brain has changed. And we like to differentiate between psychologic, which is a neur in your brain and a biologic with, is in your brain. So we, you know, we, we talk about it's in your brain, right? It's in your brain or it's in your head. So in your head would be psychological brain. It'll be chemical changes in your brain, but it all works together. I mean there are neuro, there are, there are changes in your brain that can take place either because of relationship issues or because of chemical issues. And just the same, it can be treated, you know, like HSDD can be treated with therapy or with, with medication or with both. And we actually did a small clinical trial to show that doing them together is much more quick. You know, in the long run it may be the same efficacy, but it's much quicker to change to help you if you have medication. In this case it was Flibanzeran and sex therapy.
- [24:07]
B
Yeah, absolutely. I think sex therapy is so useful for so many people because you need, first of all, you need to find someone that you feel comfortable with. But once you do, having that person to talk to about sex can be transformative. And I feel like we do that too as physicians. The ones who take time to talk to their doctors, they are comfortable with you, they want to talk to you, because you are the only person they literally talk to about something like that. And probably with you too, because you do a lot of education.
- [24:32]
A
I do. I really enjoy working with the patients.
- [24:35]
B
That is wonderful. You took these hormones at a time when it was pretty taboo. Right. Did you get some pushback? Did people think you were crazy? What did people respond to you as well?
- [24:45]
A
It's an interesting question, because people respected my husband. And so nobody really gave pushback to me. But what happened is, is when I would work in the office and women would say, and like, I would sit down to do some menopause counseling, and I said, well, you know, this is really dangerous. I said, honestly, I've been on this for 20 years. Do you think my husband would put me in a position that was dangerous for me? And while everyone has to make an individual decision, we believe in patient centered management. It's not the old days where the old white doctor tells you what to do. My husband is still an old white doctor, but he tries to. But the. But the reality is that having them talk to me is very reassuring.
- [25:23]
B
Yeah.
- [25:23]
A
I didn't experience the pushback because I wasn't out in a world where, you know, I was really exposed to people to have those conversations. I mean, my family knew that, you know, I was on hormones. And my husband actually tried to start my mother on semester dial because she was getting constant urinary tract infections, which we know is a problem, and she was not comfortable doing that. So she didn't. So she had constant urinary tract infections.
- [25:48]
B
Yeah.
- [25:49]
A
But, you know, it was more a matter of me trying to have conversations. I've had these conversations with my daughter, with my daughter in law, with my, my best friend. I mean, that's, that's more important than worrying about what people thought about me, because I don't think people really knew back, you know, back then that I was on hormones.
- [26:08]
B
Yeah.
- [26:08]
A
So.
- [26:09]
B
But did you hear a lot of, I mean, even from your patients, they thought that it was just going to kill them. Like, what did they really think?
- [26:15]
A
Yeah. Patients believe that we're putting them in danger. It's so sad. We actually had a physician, I won't name her, but a physician in San Diego that said, well, I won't put you on hormones because it's illegal, but I'll send you to Dr. Goldstein because he'll do it. And I thought, I'm hoping that was the patient's misinterpretation of what the physician said. And the physician didn't actually say that, but Physicians are afraid of using hormones. So how can we expect our patients to not be afraid? We give them written information. We give them access to papers written on the topic so that when they go home and they talk to their sister, their mother, their, you know, their doctor, and they say, oh, you shouldn't be on that. They can say, no, I've already seen the information. I do want to be on it.
- [26:55]
B
Right.
- [26:56]
A
But we believe in monitoring hormones. And one of the, one of the things I always teach our young students, the importance of monitoring where it comes from. Urologists always gave testosterone. You have to measure what's in the blood. Yep. Gynecologist gave estradiol. But the original estradiol was premarin. Premarin, pre pregnant mare urine. And why it helped women with. With hot flashes. I don't knock it from that point of view. In the 1960s, to have it developed was wonderful.
- [27:26]
B
Right.
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A
But it's not identical to the chemical in your body. You can't measure it. And so gynecologists were taught there's nothing to measure. You just give them the medication.
- [27:34]
B
Right.
- [27:34]
A
Then you have the decades of the gynecologists at a time that we did have bioidentical hormones taught not to use hormones. Hormones at all. And so most of our doctors don't do monitored treatment, don't follow blood tests to make sure they're within safe levels. And so that, I think, is why it can be scary. So one of the things we try to reassure our patients is that we will monitor. We'll monitor signs and symptoms that are going on, we will monitor blood test levels, and we can titrate up or down anything. It's not like this is the only dose that you can have and if you don't tolerate it, you're stuck. Or that we're going to give you a high dose. That's dangerous. If you look at how much estradiol a premenopausal woman has during her cycle, it goes up and down.
- [28:14]
B
Right.
- [28:14]
A
But it's far more than the everyday steady dose that a post menopausal woman is prescribed. When man evolved, you were turned 12, you got married at 13, you had your kid. By the time you were 30, your own kid was married and had a kid and you died. Yeah, we only lived for more than maybe one or two years of menopause with the last 150 years.
- [28:36]
B
Right.
- [28:36]
A
So when people. One of my pet peeves is people say, I want to go through menopause naturally. And I say, if you develop diabetes, would you go through it naturally. If you have developed hypertension, would you treat it naturally? If you had cancer, would you treat it naturally? Why is this any different?
- [28:51]
B
Yeah. Or if you didn't have enough thyroid hormone around.
- [28:54]
A
Right.
- [28:54]
B
Like those are vital hormones similar to these.
- [28:57]
A
Nobody would think twice about treating any of those things. And I respect anyone who chooses not to be treated for their menopause. That's fine. But don't criticize others that do choose to be treated, to be helped. I mean, you. When people ask me how long you're going to take your hormones, I said either till I'm dead or I'm too old. That I convince whatever nurse is taking care of me to give it to me.
- [29:20]
B
You know, you've talked to thousands of patients over your lifetime. What's the one biggest misconception about sex? That you. That people still struggle with this.
- [29:28]
A
This is my. My belief. I think you've asked women, they'd agree. And I don't know if it's a misconception, but to men, all sex is good sex. To women, only good sex is good sex. Bad sex isn't worth having.
- [29:41]
B
Do you think it's because bad sex doesn't lead to an orgasm for women?
- [29:44]
A
I'll put it. Bad sex doesn't lead to sexual pleasure, which may for some women. For many of us, it does involve orgasm or multiple orgasms. For some women, they may never have an orgasm, but they can still derive some kind of pleasure. You know, a man can have a partial erection and still ejaculate and so he gets that pleasure. So, you know, in terms of the orgasm. And a woman can derive pleasure because of great foreplay. Yeah, it doesn't have to be penal vaginal sex. Plus, it doesn't have to. It can be same sex, same sex sex. There are many ways of having intimacy.
- [30:21]
B
Right.
- [30:21]
A
But if it's bad, there's no pleasure in, you know, whether it's orgasm or something else.
- [30:27]
B
Let's define bad sex because I think all the guys listening want to know what is bad sex for women when it's not fun?
- [30:34]
A
I don't know.
- [30:34]
B
I mean, okay, I would say painful. I would say, you know, when there's not enough arousal build up for whatever, whatever that is for your partner. And they should tell you if you're not sure that they're aroused. And that may or may not include lubrication, depending on age, hormone status, a variety of different things. What else am I missing?
- [30:57]
A
Well, peace. Not hard enough, but I want to go back to talk about lubrication. That's one of the misnomers about sex. People think that if they use a lubricant, that means there's something wrong with them. Let me tell you, it's just another form of a sex toy. It's just something else to make it more pleasurable. And we've used the lubricant since in our 30s. It doesn't mean there's something wrong or using or another. Another misnomer. And I'm sorry we're going off the bad sex, but another misnomer is if you use sex toys, a vibrator, whatever, you'll never be satisfied by your partner because you're relying on that, and that's bogus. We're married almost 52 years. We're still changing things up in the bedroom. And it's not necessarily we're doing kinky things, but, you know, you can take the chocolate sauce out instead of the butterscotch sauce, but I always like to say, do it the day before you're going to change your sheets, not the day after. You can use different sex toys ways. You can, you know, change the clothes that you're wearing to be, you know, to look sexy, whatever. There's so many ways to change things up and. No, that's. Those are things that will help you get away from the bad sex. Trying to always, you know, change things. But that vibrator, if that's what you know, that's your concern. Make that part of your. Your play. It. It's not one or another. So. So many things that men are afraid of. The women, if they just talk to their partner, their partner can tell you, no, I still want to have sex with you. Just sometimes I want to use a vibrator, and sometimes I want to use the vibrator that goes in. And sometimes I want to use one that just plays on my clitoris. I mean, there are a lot of different things to do. Sometimes I want you to play with my nipples, sometimes blow in my ear. You know, there's so many ways to change things. Yeah, but going back to your bad, to the bad sex, you're right. Painful sex is always going to be bad sex. Nobody should have painful sex. And we all know that. Women do. Yeah, but when it happens, that's when it's time to reach out to your doctor to get help. Because sex should be pleasurable. Everybody has a right to enjoyable, pain, free, pleasurable sex. Nobody should suffer pain.
- [33:00]
B
Yeah, absolutely. What do you think? If you're talking to women, as someone who does a bunch of Education. What are the. The top, let's say, five things that every woman should know.
- [33:10]
A
So I think first and foremost, let's know about menopause.
- [33:12]
B
Okay.
- [33:13]
A
Women think that menopause is when they have the vasomotor symptoms and when they're over, which for most women is a couple of years, they're now in post menopause. Well, menopause and post menopause are the same thing. And you're in it until you die, because it happens when your ovaries stop producing the hormones. The vasomotor symptoms may adjudicate. But five, six, seven years later, when you start having painful sex, that's from menopause. And women don't associate that with menopause because it's far enough away that they don't know that. And then when we use two different words like menopause and postmenopause, they just assume they're two different things. So that, to me, is a huge problem that women don't understand.
- [33:53]
B
Yeah. And the recurrent UTIs that start years later, and that's also due to lack of estrogen in the vagina. So I would say that's a big one that I see all the time.
- [34:02]
A
Well, as I said, I saw it in my mother, but, yes, it's a real problem. And until physicians are willing to open their eyes and for them to understand and not just keep giving, you know, Macrobid all the time. Cipro all the time. Which have, you know, Cipro has its own side effects.
- [34:19]
B
They both do. Yeah.
- [34:20]
A
Yeah. Well, macrobits, I think a little less, but yeah. I mean, the point is that if you need to look at a situation, you need to listen to a woman. If a woman. If you listen to your patient. This is something my husband taught me many, many, many years ago. If you listen to the patient long enough, he or she will tell you what's wrong. Wrong. So if they're having recurrent UTIs and they're having painful sex, or even if they're not having sex, but they're, you know, they're. They're. They're having, they're having bleeding from, from fissures, things like that, listen to the story and, and figure that out. You know, don't just make the assumption on that. First thing. If there are multiple things going on, then maybe they're all from one problem and not multiple problems. Not always true. There are times there are multiple problems.
- [35:02]
B
Well, it's interesting. Sometimes you. They'll come in for something, but you realize that it's actually affecting their Sex life. And that's not what they came in to talk to you about. They came in to talk about this other thing that's going on. But when you ask like, are you having sex? Like I can't because of this thing. And it could be even very unrelated. It could be like I have an ache here or I have something else going on. But because it's prohibiting them from, you know, it's causing them pain in whatever reason, or they're depressed or they're sad, or whatever that condition is causing for them, it's actually affecting their sex life. And that's what's really the problem. And I wish doctors asked more about
- [35:39]
A
that and they need to ask open ended questions. There's a classic interview study that was done and the doctor said, are you having sex? And she said no, end of story. And then because it was part of a study, she came out and the nurse talked to her. She says, what happened? She said, well, you asked me if I have a having sex. And she said, what'd you say? She says no. She says, well, why aren't you having sex? Just because it's too painful. And in three seconds she found out what the physician didn't because he didn't ask the open ended question, why not?
- [36:09]
B
Right? Absolutely. I ask all the time because we ask, we are taught in medical school, right, Are you sexually active? But then the follow up is why or why not, right? Is it because you don't have a partner, because you don't want to, because it hurts, because it's not working? Right. All those things.
- [36:23]
A
Follow up is so, so important. So we have patients who come to us, young women with hyperactive sexual desire disorder. And many people say, well, just give them a medication. There's no way to examine them. And we are a biopsychosocialist facility at San Diego Sexual Medicine. Every patient sees our sex therapist, sees either my husband or a nurse practitioner for history and for physical. And these women who have been on oral contraceptives, you go in and do a physical and you'll ask them ahead, are you having, experiencing pain with sex? And they'll say no because they've spent their whole life experiencing pain and their best friends are all in OCPs and they all experience pain and they think that it's normal and what a shame that a 19, 20, 21 year old should think pain was. Sex is normal. And you examine them and you touch them with the cotton tip swab around their vestibule and you literally touch it and they hit the ceiling they have so much pain. Well, no wonder they have low desire. Who wants to have sex if it's painful?
- [37:16]
B
Right.
- [37:16]
A
So to me, the most important thing when you, when you give a medication is, you know, full disclosure of its side effects. I mean, informed decision is based on knowing the pros and the cons.
- [37:30]
B
Absolutely.
- [37:30]
A
And while I don't say women shouldn't have contraceptives, I mean, it was my generation that fought. I mean, the, it was the 1960s when I was going off to college that we were on the pill and we need to have contraception, but we need to inform our patients that a certain segment of society of women being put on the pill are going to experience pain. And some of those women will continue to experience pain after they go off the pill. And we could get into that, but it's, it's not really important.
- [37:57]
B
We've talked about it with Irwin and we talked about. Yeah, so we don't need to go over it again. But if you're interested in watching this, check out our podcast with Irwin Goldstein and Rachel Rubin. We talked about these on there. But tell me. So we said menopause. Now let's say you should know side effects of birth control. What are the other things you would say?
- [38:12]
A
Oh, goodness. I mean, I think going back, that it's okay to use lubricants and toys and things like that, that those are things that, that enhance sex rather than saying, you know, like, oh, something's wrong with my sexual function. And so I need these things. In fact, they're just fun, just enhancements. Whether you have sexual dysfunction or not, I think, think it's important to realize that again, sexual medicine is medicine and you shouldn't be ashamed of what's going on. You should be able to be comfortable talking to your doctor. And it's like I like to say, if your doctor doesn't want to talk to you about, it's time to find another doctor.
- [38:47]
B
Yeah.
- [38:48]
A
You know, so many people want to know what is, what is normal and what is normal. Everybody has their own normal. I mean, I'm a multi orgasmic woman, so if I only have one orgasm, that's not my normal experience. But you may have only a single orgasm, and that is your normal, and other people may never experience it. And so, you know, we have women who are upset about the orgasm gap because they don't experience orgasms. And is it because something's wrong with their body or because their partner doesn't know how to stimulate them enough? You know, that's another whole topic. But People will always, always want to know what, you know, what normal desire is. And for you, normal desire may be as soon as your partner walks in the door, you're ready to jump him. And for me, normal desire may be a total response. When I'm in, when I'm in bed with my partner, you know, everybody's normal is different. What I like to say, really what we should be talking about is average. The average response for this, the average results for this versus normal. Because there is no normal with sexual. If it's pleasurable and it's not painful, then that's, that's normal.
- [39:49]
B
Yeah. I think the other thing, we talk about this a lot with our patients and on this channel is like desire is, is a, is very variable and that's okay, right? You may want sex more, your partner may want sex less. If you're both content with that, that's fine. Or you figure out other ways to manage that. But it is sort of being open about what you know, what is going on, what you desire and what's, you know, how can you meet each other's needs and.
- [40:14]
A
But it's variable within a relationship. The same two people. One day I may want to initiate sex, another day I may know you're gonna have to work really hard to turn me on because I'm just not in the mood, but I want to have sex. Or this is our designated time. When you get older, it's not unreasonable to have a date, to have a time when you designate for sex, because otherwise it just may not happen because it's, you know, you may need, you may need to take an oral pill for the guy. He may just need to need to self inject, so he needs planning. She may need to, you know, read a sexy book or, you know, or play with herself a little bit, whatever.
- [40:47]
B
Yeah.
- [40:48]
A
So there's nothing wrong with planning sex. Although it's. When you're young, obviously you'd like to have it be spontaneous. I mean, I wish my sex could be spontaneous, but the fact is I'm 76 years old and I'm just really happy that I'm still having really good sex. So I'm willing to plan it because that, that helps us and our relationship. Relationship.
- [41:06]
B
I think it helps a lot of people because it also allows you to get mentally ready to be in the situation for people who have lower desires. Sometimes it's like, okay, like you said, I can do something to prepare, get myself mentally in the mood. And also I think just without the performance anxiety of it even just being Intimate together is really important. So it doesn't have to always be penetrative sex, but just having time for intimacy.
- [41:30]
A
But I think there are also prevailing in things, things. So maybe you light the candles and maybe you put on certain lingerie versus the stuff you normally sleep with. Maybe you put on certain music and it kind of cues your body and your partner's body. Oh, you know, we're going to have sex. And I there, you know, every couple is different and not everybody's in a relationship and I recognize that. And when you're not in a relationship, your desire in particular may change with partner, but also your arousal, your arousal response to desire, your arousal results can result in an orgasm. All of that is variable. How tired are you? How stressed are you? How long a relationship are you in the partner with the partner. I mean, there's so many variables and so there's no right or no wrong. And it's okay if sometimes sex just isn't good. It's okay. Yeah, it's not okay when sex always isn't good.
- [42:15]
B
Yeah, mediocre sex is okay on occasion. Yeah, it's, it's normal that it's not always going to be mind blowing. And I think that's the real important thing to take home. You always, I mean, you've done clinical research and I think there's, I think it's really important for people to understand how difficult it is to do research on sexual medicine and then specifically on female sexuality. So talk about that a little bit.
- [42:38]
A
It is very difficult. I think the first one of the early clinical trials was a registry of women with hsdd. And women don't understand the difference between desire and arousal necessarily. So just to call out who was an appropriate candidate taught me very early on how confusing it can all be. We have done a lot of desire studies because we have two FDA approved drugs for women with low desire. So we've done a lot of those. And when you see these women, they are so grateful for the intervention that they've been allowed to have. And then it was really hard when the trials would end until it became FDA approved. Arousal. Really hard to call out that particular problem. But there are women who have arousal problems as their primary goal and there are drugs and development for that. There's nothing specifically for orgasm, but the good news is that the drugs currently approved for desire, they also measured the arousal and orgasm, all of which improved. So, you know, that really helps. I think the hardest thing is pain. We've done clinical trials with pain and there's so many etiologies for pain. So if it's menopause, that's pretty straightforward and we've done some very good trials on that. And it's really remarkable to see the improvement in women who had no access to any treatment for general urinary syndrome of menopause and suddenly they're having pain free sex and it's like the world has opened up for them. And that was a lot of fun. We've done some of those that are multi site trials and we've done some in our office that we're the only ones we took intravaginal DHEA for instance, which is something you put inside your vagina and we wanted to see is it going to improve the pain that's on the vestibule, which is the opening to the vagina. So the medication is not prescribed for that and we said, let's just see if it works. And lo and behold, it did. And we were able to publish a paper on that. So while the FDA is never going to say this is an indication for this drug, we can truthfully say this is safe and efficacious for that. So it's fun when you get results like that. Like we went in, we went in with another drug, an oral drug doing with the same study and we were sure it was not going to help for the best and it did. I love when I'm blown away by the results, but when we do a clinical trial, people always say, well, does it work? I said, well, if I knew it worked I wouldn't have to do the research. But I think one of the problems with pain is when we get the younger population with pain, it may be hormonally mediated from oral contraceptives or for whatever. But we also have the neuroproliferative vestibulodynia, which at this point the only effect of treatment is surgery. But there are clinical trials not in women yet. Well, actually there is one that's just starting in women and so it will be really exciting to see that. So the problem is, you know, on the phone you do a phone screen. Yes, I have pain. You have to get enough of a history and then they have to come in and you have to examine them and you have to get blood tests. And men know erectile dysfunction though I will tell you, switching back to men that when we did a study for premature ejaculation and you again, you do a phone screen first because you don't want to waste their time or your time. And I remember talking to a gentleman trying to Figure out if he had PE or if he just had erectile dysfunction because there's a lot of that co ops. Many men will ejaculate early before they lose their erection.
- [45:48]
B
Yeah.
- [45:48]
A
And so it's not premature ejaculation, it's erectile dysfunction. And I was trying to call out the difference in this gentleman and I realized he didn't have a clue what I was talking about. And you have to talk to the language of the person when you're in a clinical trial. And I finally said, do you come before you stick it in? Yes. No. Said, well, how soon after? He says, ah, four or five minutes. But I wish it was longer. At that point it didn't matter what the cause was. But I finally, he finally understood what I was asking. I was trying to use more sophisticated language, more scientific language. And you know, the man didn't meet the criteria to be in the clinical trial.
- [46:21]
B
Right.
- [46:21]
A
But we have to think about that. The language we use, whether it's for a clinical trial or if it's a doctor talking to the patient. You don't want to dumb yourself down. But if you don't use language that the patient can understand, he or she may say, yes, yes, yes, yes. And they haven't got a clue. We always encourage people to come with a partner and let them listen to the educational portion of the visit so that they can help understand. You can talk it over. There's a lot of information. You know, it's the three, three, three rules. You just give three pieces of information, find out first what the patient understands, then give them three pieces of information, then make sure they understood those three pieces before you go on to anything else. We forget. I know my husband's one of the worst. He will overload patients with information.
- [47:03]
B
I do that sometimes too.
- [47:05]
A
And then we give them all the information written down, which is really helpful. And we actually, in our office, we do a follow up, we do a wrap up call. So after they've read all the written information, we have a call a couple weeks later that's considered the end of the first visit. No charge, just they can ask those questions because they were so overwhelmed. And it's so important that physicians realize the patients can be overwhelmed and you know, address that, recognize it and it's, it's not a fault of the physician.
- [47:31]
B
Yeah.
- [47:31]
A
It's like don't take it as your own mistake. Take it as you were in a partnership with you, with your patient. And that partnership is going to look different with every patient.
- [47:42]
B
Absolutely. You also take care of men. So since I asked you the question about what you wish women knew, what do you wish men knew about good sex?
- [47:50]
A
Oh, goodness. I wish men knew that first putting in a prosthesis is not going to guarantee them sex because they have to think about their partner.
- [47:59]
B
She's talking about a penile implant.
- [48:01]
A
Yeah. Yes. I'm sorry. Thank you. Also that a very firm erection is going to end. If you're having sex with a female partner, a very firm erection is going to be easier to enter her vagina than a not so firm erection. So for men who feel like, you know, their erection's pretty good and so they don't want to go to the doctor yet, there's nothing wrong with taking an oral medication. There's lots of them out there in the market now. They're generic, they're very inexpensive. Because a harder penis is going to be more satisfying for your partner and
- [48:33]
B
less likely for you to injure yourself.
- [48:34]
A
Yes, absolutely. You're more, the more, the less hard it is, the more likely that you're going to come down on the woman incorrectly or she's going to come down to you when you're in it, have an injury and have Peyronie's disease. And of course, if you're having peno anal sex, you need a very firm erection as well. So I think those are things that are important. I think for man to know that same messages before using a lubricant, using a vibrator does not mean you are less than. It means that you want to have some more fun during sex. And that's focused on erectile. But there are other issues. There are a lot of weird things that men have and most physicians don't know how to deal with it. Sleep related prolonged erections.
- [49:17]
B
Yeah.
- [49:18]
A
Hard flaccid syndrome, post orgasmic illness syndrome, which happened to men and women, but more frequently in men. These are things that sound crazy but are real.
- [49:27]
B
Yeah.
- [49:28]
A
And we're slowly learning more and more about these things to get help. But for men, please don't joke, please don't, don't go on the Internet and see all this cool stuff to make your penis bigger and longer. And please don't put filler in your, in your, in your penis. All of these things make you bigger. 99% of them are going to harm you. Don't look at your penis and say, I'm not big enough. I'm not good enough. If your partners are satisfied, then you should be satisfied. Men feel like they have to have the, the biggest dick on The. On. On the, you know, on the street. You're not standing in the locker room comparing yourself to everybody else. It's not relevant. All that's relevant is that you're satisfying your partner and that she or he, whether whatever your partner is, is happy with your penis, don't start playing with it. Don't. And the same thing for women, you know, labiaplasty. If you have labia that extrude past your bathing suit, you need to deal with. Don't start having faceless of your penises and your, and your. And your vagina. Well, enough vagina. It's really the. The labia because you're harming yourself. And then you're gonna have sexual dysfunction. And you're going to come to. To people like Dr. Malik and Dr. Goldstein and say, hey, can you help me?
- [50:34]
B
Surgeries are. You can't undo surgery, and you only have one penis and one vulva. And so once you have caused permanent damage, it is very difficult. Now, I will say hyaluronic fillers dissolve. So that is not as scary as the other sort of permanent fillers. But generally speaking, I think there are a lot of. Part of it is because of society really puts a premium on big dick energy. Right. But the reality is that has nothing to do with pleasure for the large majority of people. Of course, there are women who are. Who really prefer a large phallus. Maybe that's not the right person for you. Right. But that's a very small subset of women. The large majority of people are very happy with an average size penis.
- [51:18]
A
And people will be surprised at the average size penis, which does vary by race. But the fact is that unless you have a micro phallus, keep it the way it is. It's fine.
- [51:28]
B
It's perfectly fine. And yeah, doing those things is not going to lead to more pleasure necessarily,
- [51:33]
A
but could lead to harm.
- [51:35]
B
Absolutely, absolutely. What do you think would make doing research in sexual medicine easier or more accessible?
- [51:43]
A
Money.
- [51:44]
B
Yeah.
- [51:44]
A
I mean, the reality is that the nih, the government, has put minimal research into women's health. They do have that. They did have a whole segment of women's health, but within that, nothing for women's sexual health, really. My husband had 25 years of NIH funding for erectile dysfunction, and the moment he switched to female, now, he lost all his funding. Now, that was a long time ago. Now all the funding is gone. But because Viagra had a home run and all the other companies, you know, following it, they all did. Well, when Addie came out, it wasn't a financial home run. And there are a lot of reasons for that. But because of that other companies were Larry. And after Addy we had Bileesi. And again, not a home run. And so companies are scared. Der has, you know, product that they're working on and God bless them that they're continuing to work on that. But other than in Europe right now, this, this, there are pieces that you hear grumbling. I mean, I'm involved in, you know, some things that I can't really talk about. But because there isn't, there aren't pots of money saying, hey, I want to invest, I want to invest. Like they did after the, you know, the PD5s. It's a problem.
- [52:53]
B
Yeah.
- [52:54]
A
So we rely, I mean if we do research in our office, it's either going after a company to get a grant, investigator initiated grant, or the money coming out of our office pockets. We'll do it ourselves. We do a lot of chart reviews because that gives us a lot of information and it costs us very little money. But until this, there are companies willing to invest this research. People don't understand. It's millions and millions and millions of dollars. It's incomprehensible what it takes and you know, only one drug out of 100 will ever get that far. And then it's whether the FDA will even approve it.
- [53:31]
B
Yeah, I definitely think, I mean this is always a challenge. I think people don't really realize how much money goes into research specifically for pharmacologic interventions and device interventions. I mean, there's millions and millions of dollars that go into it. And people are to prove that they're safe and efficacious and people are very leery still despite that. But they will happily take XYZ supplement
- [53:55]
A
that they buy at the gas station.
- [53:57]
B
Yeah, absolutely. Which often get recalled because they have undeclared substances in them. So I always find that really fascinating about human behavior.
- [54:10]
A
Really. I say people spend more time shopping for a used car than they do shopping for a doctor.
- [54:15]
B
Oh yeah, absolutely. Well, there's nowhere for them to look. Right. There's no, I mean we have Google reviews and all that sort of of stuff, but for most doctors, there's not a lot of like human data on their experience with them.
- [54:28]
A
And the reality is that Google reviews will often have a lot of negative reviews because those are the few people who are upset that they didn't have a good result.
- [54:35]
B
Yeah.
- [54:36]
A
And so they will write over and over and over again under different names.
- [54:40]
B
Yeah. And, and doctors are not good At, At.
- [54:43]
A
No.
- [54:44]
B
Soliciting positive reviews?
- [54:45]
A
Absolutely not.
- [54:47]
B
Yeah. So you mentioned joking for men as a big no. No. What do you tell women? What are things that they're doing? Be birth control, which we talked about, that could be harming their sex lives.
- [54:57]
A
I mean, to me, plastic surgery is something you do because you have to. I recently had basal cell carcinoma on my nose and my cheek that was removed. And then I had plastic surgery to repair it. And you know, everyone has their own decisions to make. I would, I would love to have the guts to have a facelift, but there's no way that I would do that. So essentially you're saying you're doing a facelift on your vulva. That to me, you know, it carries its risks and people need to be aware of that. There are nerves down there. When you cut those nerves, the nerves are not gonna grow back. It's just foolish. Unless you're in, you're working with somebody who's really, really skilled. We're lucky. We're in Southern California ourselves. And Dr. Gary Alter is the only double boarded plastic surgeon and urologist. So if we have a patient that needs plastic surgery on the vulva, we will send them to Dr. Alter, put a plug in for a colleague. But the fact is that there are people out there saying, I can make you beautiful, I can do this, I can do that. Do your research and find out is that really true. Whether it's, you know, whether it's a drug you're taking or, you know, a surgery, any, any kind of intervention, you need to do your research before you move forward with it.
- [56:03]
B
Yeah.
- [56:03]
A
You know, I think when we're talking about menopause management and doing hormones, any doctor prescribing hormones has that research at his or her fingertips to show you. Yeah, but some of these other interventions, but I think women don't do as much harm to themselves as mental in the sexual health arena. I mean, that's just the reality because we don't have the same kind of organ that can be damaged so easily.
- [56:24]
B
Right. I do think douching and vaginal steaming, those sorts of things, they can disrupt the microbiome and that could predispose women to more yeast infections, more bacterial vaginosis, which can then lead to sexual dysfunction. It's not direct, it's not directly causing it, but that can lead to problems.
- [56:45]
A
And in my generation, people talked about douching all the time and I never understood why, what purpose it served. You know, I'm going to wash my socks so my feet don't smell, but my vagina is smelling just the way it should.
- [56:58]
B
Yeah, yeah. I mean, there's this again. It's a society thing, right, that you're, you don't smell good. So let me give you all these products to make you smell like a key lime pie and come on like nobody wants to.
- [57:11]
A
You're not supposed to smell like a key lime pie.
- [57:13]
B
Nobody wants that. I don't know what guy wants key lime pie. Maybe there are. I don't want. If that's what you're into, you know, but just don't put sweet things down there. That's not, that's not safe.
- [57:22]
A
Yeah, not internally. I mean, you can play and use, like I said before, the chocolate syrup or the chocolate sauce, maple syrup, whatever.
- [57:29]
B
On the skin.
- [57:30]
A
On the skin. But nothing inside, please.
- [57:32]
B
Yeah, absolutely. So when you have patients that come in, because you see, you must see this all the time, who haven't had sex with sex for years. Right. And then you fix them, but they're now getting back into having sex. What, what sort of advice do you have for those kind of people?
- [57:47]
A
Well, there are a lot of things that are going on. If they're in a relationship, they may need some couples therapy because he may be afraid to touch her. He also may be experiencing erectile dysfunction. So those are things you need to address. But for her, she needs to understand that her, you know, at the beginning, it'll take a while for the hormones to come into play to be able to make the area healthy. If it's post surgery, for instance, and that's why she hasn't had sex for a long time, she may need physical therapy to relax the muscles. The pelvic floor gets very tight. And so even though you can treat the area that's causing the pain, the secondary result of the pain is a high tone pelvic floor. So you may need physical therapy. You may need to use dilators and the physical therapist or the sex therapist can help you with that. I think one of the misnomers with dilators is people think, I'm just going to stick it in and I'm going to go to the next size. And no, they're very specific ways of using dilators. And if your doctor says, here, buy dilators and doesn't give you instructions, then don't do it. You need someone who's going to help you through that. But you know, whether you're young or old, if you haven't had sex in a long time, those are really the, I think the biggest issues. The Psychologic relationship issues and the biologic, you know, getting your body ready.
- [59:04]
B
What about people who are single? Like, let's say, for example, a man who had erectile dysfunction and now he's feeling more confident, but he's still a bit nervous about having an erection that's
- [59:14]
A
going to last, whatever is going on. We often will tell people who have performance anxiety not to be afraid to use an oral pill for the first few times because that will give them the confidence if there's nothing biologically wrong. Now, don't get me wrong, there are young people who look, walk perfectly healthy, are told by their general urologist it's psychologic because they don't have the time or the sophisticated testing. And they come to us because they're desperate and are testing or because of what we can do. They do often have biologic problems, but there are plenty of people who just have performance anxiety. So don't be afraid. You know, take a Viagra, take a Cialis, whatever works for you to give you the confidence that you need. And then after you've had sex a few times, you may try it without it and see if that works. There's nothing wrong with, with taking medicine if it's prescribed by somebody who's knows what they're doing. I know that in a lot of countries those medications are now over the counter because they're really quite safe. I mean, let's be honest, I didn't
- [60:12]
B
know that they're over the counter in,
- [60:14]
A
in Mexico and I think they are in the uk. I know they were fighting to get it in the UK and I'm not sure if they were successful or not, but a lot of our patients will just go across the border to Tijuana and, and buy it. You have to go to the pharmacy. It's behind the counter, but it's over the counter in that you don't need a prescription.
- [60:32]
B
Yeah, I think, you know, I think that there's some, some medications where, like that would probably open up access for a lot of people, you know. Now that you've, you know, you've spent decades in this space, what are you most excited about for the future of sexual health?
- [60:46]
A
I think I'm most excited about the opportunity for the world to get to know more about sexual medicine. I think removing the box warning from hormones gave permission for people to talk about it. My mother always told a story that when Viagra came out, my husband was so lucky that this is when he's working as a urologist because when she grew up, nobody had Ed. I Said that's not true. Everyone had ed but there was no treatment for it. So nobody went to the doctor. I would like to see a world where women understand there are treatments for them and so they can go to their doctor and demand the treatments. I think while we live in a society where we don't talk about our sexual health health that women don't talk about their sexual health, we don't know that there are treatments out there, that there are doctors dedicating their life to treating women with sexual health. And so to me, educating women that it's okay to have a problem, it's okay to see treatment because there are treatments out there. Some are on label, some are off label. We treat men with things that are off label too. That just means that it's a drug that's prescribed, it's approved by the FDA for something else and we're using it for this purpose. That's what we do with testosterone. We use a man's kind of testosterone so we know it's pure, it's FDA approved, but we use it in a dose for a woman. I would like a world where women can feel comfortable talking about sexual health and know that there's care for them.
- [62:05]
B
Well, thank you. Thank you so much. Where can people find out more about you?
- [62:09]
A
Well, I work at San Diego Sexual Medicine, so they can go to www.sdsm.in fox. You can also write to me. I'm not embarrassed to give up my email. Feel free to write to me, sue wgoldsteinmail.com and don't forget the W. Otherwise it goes to a lovely nurse in St. Louis. You can also find out more about what you do from isswish International Society for the Study of Women's Sexual Health. In about three days, I will no longer be immediate past president. My husband and I will be the only presidents probably in history to have husband and wife both having been presidents of the same society.
- [62:41]
B
That's crazy.
- [62:43]
A
But don't be afraid to use online resources. There is a Issuish has patients website called Keeks. I'm sorry Kes is who designed it called Prosela. P R O S A Y L a dot com. There is information out there. And just remember, half of what's on the Internet is garbage, but the other half is good stuff.
- [63:01]
B
Yeah.
- [63:02]
A
So seek and you shall find.
- [63:04]
B
Yeah. So we end our podcast with four things we ask everybody. They don't have to be about sexual medicine. They can be about anything you like. So what is something you know now that you wish you knew? Earlier.
- [63:14]
A
I wish I knew how to raise my kids to be perfect.
- [63:16]
B
No, don't we all?
- [63:19]
A
No, I mean, I think I, you know, the sex. The sex is such an important part of our lives. I guess I wish that I knew it was my body and not my husband's back when I was, you know, my early 50s maybe. I wish I knew how to be more self confident when I was younger. Having been president of VisWish for those two years. Taught me not to have imposter syndrome, which so many women suffer from. Taught me that I am worth something. That I always say to say this wish. It's not that I think out of the box, it's that my box is different than your box and my box has value. And that's something I wish I had known when I was younger.
- [63:52]
B
Yeah, that's very valuable. What's a non negotiable? Something you have to do every day.
- [63:56]
A
Take my meds, brush my teeth, kiss my husband.
- [64:00]
B
That's good. That's good. What's a life hack or health hack?
- [64:04]
A
I think having confidence in yourself that you can do what you want to do and to stay healthy. Because you won't be able to do those things if you aren't healthy. Don't deny. I mean, I had mild hypertension and I only knew it because when I went to the dentist and when I went to have some minor surgery, my, my blood pressure was up and I said, oh no, no, it's normal at home. And it took me six months to finally realize that it's probably not and to go to the doctor and now on a very low dose of antibiotics of antihypertensive. But I think you need to listen to your body because if your body's not healthy, you won't be able to follow your dream.
- [64:38]
B
Yeah. If you couldn't be an educator and a clinical researcher, what would you be?
- [64:44]
A
Well, I think my first big john was being a stay at home mom. Which is why I went back to work part time after. So to me, that was the most important thing I did. Because being a stay at home mom, I was a teacher every day and then a part time mom at home. But what else would I do in this world? I don't know. I love what I do.
- [64:58]
B
You know, Erwin said the same thing.
- [65:01]
A
And for me, this career was really a second career because it really only started when we moved. You know, I was the age of 57 when we moved. And so I'm still, you know, rearing up. Although I made him promise me that we Would no longer take on seven or eight projects at the same time. Because now that we're semi retired and doing a little more traveling, I want to have a little more free time. I don't want to spend my time in the hotel room doing work.
- [65:23]
B
Yeah.
- [65:24]
A
So that's, that's something that I would change. But no, I, I, I love what I do. I love waking up every day.
- [65:29]
B
That's so great. And I'm going to add one question. 52 years. What is the secret?
- [65:35]
A
I will tell you this. I tell people all the time. There's two secrets. He is my best friend. I would rather spend time with him than anybody other than my children and grandchildren. And good sex, because we're having good sex. The fact that he drops his socks in the middle of the living room is meaningless. But if you're not having sex, all those little things add up, and that's why we see divorce. So. So good sex saves marriages.
- [65:56]
B
Saves marriages. Yeah. You know, it's funny to me. I always think that people. I remember one time I was talking to some mom friends and I said, oh, yeah, sometimes I'm like, really tired after work. I don't really want to have a deep conversation, but my husband wants to have a deep conversation, so I'll try my best to be a part of it. And they were like, you talk to your husband? And I remember just being shocked, being literally shocked that these people didn't, like, actually enjoy conversing with the partner they chose to marry.
- [66:26]
A
You know, that is very sad. These are the people who would have have girls weekends all the time. Yeah, I remember it was bedtime, and I started telling my husband something. He says, I don't really need to hear it. I said, no, but I need to vent it. So you need to listen because I need to say it. He says, okay, tell me. Yeah, that's a good partner.
- [66:43]
B
Exactly.
- [66:43]
A
I love my husband.
- [66:44]
B
Yeah. Well, that's so wonderful. Well, thank you so much, Rena.
- [66:48]
A
This was so much fun.
- [66:49]
B
So fun.
- [66:50]
A
Thank you.
- [66:50]
B
Thank you, guys. If you liked that conversation, I need you to do one solid favor for me. Hit that subscribe button, follow button on the podcast platform you're listening on because it does a huge favor for us in helping more people find our content. It takes just a couple seconds and it's completely free. And as always, take care of yourself because you are worth it.
- [67:13]
A
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B
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A
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