Why Do Women Suddenly Lose Interest In Sex — Even In Happy Relationships?

Summary

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Podcast Summary

Rena Malik, MD Podcast

Episode: Why Do Women Suddenly Lose Interest In Sex — Even In Happy Relationships?
Air Date: May 15, 2026
Host: Dr. Rena Malik (urologist & pelvic surgeon)
Guest: Dr. Tammy Roman (Associate Professor of OBGYN, UCSF—expert in menopause & sexual medicine)

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Episode Overview

This episode dives deep into the complex topic of low sexual desire in women, especially examining why women may experience a sudden drop in libido—even in happy, stable relationships. Dr. Malik and guest Dr. Tammy Roman, a leading expert in sexual medicine, discuss the interplay of hormones, psychological and relational factors, medical misconceptions, evidence-based treatment options, and the vital importance of open, nuanced conversations in women’s healthcare.

Listeners are guided through not only the science of sexual desire (including medications, hormones, and the role of neurotransmitters) but also the stigma and communication barriers faced by women, and practical advice for patients and clinicians alike.

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Key Discussion Points & Insights

Understanding Female Sexual Desire

• Sexual Desire as a Human Urge:

  • “Sexual desire, it's a natural part of being human. I mean it is a primary urge, right? Things like wanting to eat, wanting to sleep and wanting to have sex actually are all really natural and make sense for any animal and especially humans.” — Dr. Roman [00:00]
  • Sexual desire loss is often likened to "the light went off," and profoundly affects sense of self.

• Psychological & Social Weight:

  • Many women feel shame, anxiety, or embarrassment when seeking help for low desire—often feeling dismissed or fearing no treatment will be offered. [02:34-03:17]
  • Connection, not just sex, is critical to health: “The number one predictor of long term health is your relationships with other people. So sex is directly related to that.” — Dr. Roman [00:24, 04:44]

• Desire Loss Feels Like Loss of Self:

  • Women describe feeling out of sync with themselves and often don’t realize recovery of libido can lead to feeling “like themselves again.” [03:17, 03:47, 04:24]

The Biopsychosocial Approach to Low Desire

• Medical Evaluation Process:

  • Dr. Roman outlines assessing baseline desire (acquired vs. lifelong), biological causes (neurotransmitters, hormones), psychological factors (depression, anxiety), and social context (relationship factors, stressors). [06:30]

• Major Inhibitors:

  • “The number one predictor of low sexual desire is depression.” Untreated depression or sexual pain must be addressed before desire-specific treatments. [08:29, 09:54]
  • “There's nothing I can give you that's gonna overpower what pain will do.” — Dr. Roman [09:54]

• Gray Zones:

  • Often, it’s not one clear cause: "We try to treat everything. We offer treatments that are available to women regardless of if they also have psychological concerns." — Dr. Malik [07:54]

• Vacation Test:

  • “If you were on vacation and you were away from all the stresses... would you want sex?... If they say no, that to me is Hypoactive Sexual Desire Disorder (HSDD).” — Dr. Roman [10:57]

Common Myths & Gender Stereotypes

• Myth-Busting:

  • Desire is not purely psychological for women, nor purely mechanical for men. Treatments and needs are more nuanced. [13:14]

• Emotional Connection Not Universally Required:

  • There’s enormous diversity—some women require emotional connection, others do not. [15:24-15:33]

• Sexual Concordance:

  • Physical arousal (lubrication, erection) and mental desire can be discordant, particularly in women. The body can respond even when the mind does not, sometimes as an evolutionary protective mechanism. [16:10-19:11]
    • “If a woman is lubricated, that doesn't mean that she necessarily wants intercourse.” — Dr. Malik [18:35]

The Hormone Conversation: Evidence, Misconceptions, and Treatments

FDA-Approved Medications

• Flibanserin (Addyi) & Bremelanotide (Vyleesi):
  • Both target neurotransmitters—primarily in the brain (dopamine, norepinephrine), not sex hormones directly.
  • Flibanserin is daily; bremelanotide is as-needed (injector pen). Approval varies by age group due to study designs, not biological rationale. [23:07-26:53]
  • “The brain is the biggest sex organ and it communicates with itself via neurotransmitters.” — Dr. Roman [24:05]

Testosterone in Women

• Controversies & Evidence:

  • Testosterone can increase desire in postmenopausal/perimenopausal women; evidence in younger women is far less robust. [27:10-28:39]
  • Data for muscle, mood, and cognition benefits is mixed or neutral for normal-range supplementation. [29:08-32:51]
  • Dosing, monitoring, and lack of standardized female formulations are key challenges. [36:02]

• Testing Limitations:

  • Hormone levels are difficult to interpret—wide normal ranges, poor assay accuracy, effects of oral contraceptives, etc. [29:08-31:19]
  • “Just because I can't explain it physiologically doesn't mean it's not real.” — Dr. Roman [35:06]

Birth Control/Biological Effects

• How Oral Contraceptives Work:

  • They suppress ovulation using synthetic hormones (ethinyl estradiol, progestins) because natural hormones alone aren’t strong enough.
  • Oral contraceptives increase sex hormone binding globulin, lowering free testosterone, which can reduce desire in some. [51:26-55:24]

• Bone Health & Perimenopause:

  • Birth control can lower bone density if used in adolescence before full bone development, but generally neutral or protective in adults. [60:07-61:19]
  • Hormone therapy for menopause should be evaluated based on individual needs and risks—not universally prescribed. [38:44-39:17]

Progesterone: More Than a Uterine Protector

• Benefits Beyond the Uterus:
  • Affects sleep (via GABA receptors), mood, seizure threshold, gut, and more.
  • Micronized progesterone (Prometrium) is preferred for many, but oral absorption and side effects must be considered. Not all progestins have the same risks; medroxyprogesterone acetate increases breast cancer risk, but natural progesterone does not (per available data). [75:00-78:48]

Evidence vs. Marketing

• Social media often promotes misleading “universals” (everyone should take hormones, etc.), creating fear, confusion, and unnecessary stress.
• Many “studies” cited online are methodologically weak, or conclusions are overstated—patients (and providers) need more critical appraisal skills. [39:17-45:28]

“Hormone Testing”

• Hormone levels are context-dependent, hard to interpret, and over-testing can create more confusion and anxiety. [95:28-96:48]

Practical Pearls & Clinical Recommendations

• First-Line Treatment for Desire Loss:

  • Begin with lifestyle factors (exercise, sleep, diet), address inhibitors (depression, pain), and then consider medications. [23:07]
  • Use the “vacation test” to tease out social vs. biological drivers. [10:57]

• Cervical Cancer Screening:

  • At-home HPV self-swabbing is now an effective option for low-risk women—equally effective as office testing, with certain caveats for high-risk groups. [88:20-91:54]

• Supplements:

  • Vitamin D’s benefit in sexual function is unproven, but worth supplementing if deficient for overall health.
  • DHEA: Evidence is mixed but may help some. [92:41-94:57]

• Social Connection & Stress Reduction:

  • Strong relationships, regular exercise, and reducing stress are powerful, underappreciated determinants of sexual (and overall) wellbeing. [69:31-71:53]

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Notable Quotes & Timestamps

• On Patient Experience:
  • “They're probably really nervous because... they’ve probably been dismissed by somebody at some point... I think they're quite anxious.” — Dr. Roman [02:34]
• On Dismissing Women’s Concerns:
  • “Just because I can't explain it physiologically doesn't mean it's not real.” — Dr. Roman [35:06]
• On Sex as Health:
  • “Sex is directly related to [health]... the number one predictor of long term health is your relationships with other people.” — Dr. Roman [00:24]
• On Exercise:
  • “Exercise is the number one aphrodisiac on multiple levels.” — Dr. Roman [23:07, 69:12]
• On Hormone Therapy Myths:
  • “There's so much confusion... the highest estrogen levels I have ever seen are in perimenopause.” — Dr. Roman [56:08]
• On Evidence-Based Medicine:
  • “Evidence based medicine is not just the science... it is the interpretation and the communication to patients.” — Dr. Roman [99:30]

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Timestamps for Key Topics

| Topic | Timestamp | |--------------------------------------------------- |------------------| | Why loss of sexual desire matters | 00:00–05:19 | | What happens for women experiencing low desire | 06:21–10:26 | | Biological vs. psychological causes | 10:47–13:14 | | Gender myths/stereotypes in sexual dysfunction | 13:14–17:21 | | Physical vs. mental arousal (“sexual concordance”) | 16:10–19:11 | | The role of lubrication and misconceptions | 19:11–20:54 | | FDA-approved treatment options for desire loss | 23:07–26:45 | | Testosterone in women: what we know and don’t | 27:10–36:27 | | Testing, “normal levels,” and birth control | 29:08–36:27 | | Hormone therapy in perimenopause/menopause | 56:08–64:00 | | Progesterone’s roles/cycling rationale | 75:00–86:21 | | At-home cervical cancer testing | 88:20–91:54 | | Supplements & vitamin D | 92:41–94:57 | | Social factors: connection & loneliness | 69:31–71:53 |

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Tone & Closing Thoughts

The conversation is evidence-based, candid, and respectful of patient experiences while challenging simplistic or marketing-driven advice. Both Dr. Malik and Dr. Roman emphasize that “one-size-fits-all” solutions are inappropriate—women’s sexual health is an interplay of biology, psychology, and social context. Empowerment, open dialogue, respect for nuance, and strong relationships form the backbone of a holistic approach to sexual wellness.

Final Memorable Pearls

“If a woman says to me, my cognition, I feel so much clearer and better taking this medication, I would never say, ‘Oh, no, you don’t. Because the data doesn’t show that.’ That’s gaslighting. And so we have a tendency to keep doing that now and we keep saying, well, the data shows that this doesn’t do anything. So therefore all these women that are reporting a benefit are somehow wrong. And that’s just not. Not okay.” — Dr. Roman [32:51]

“There's no absolutes in medicine, right?... It’s about: is this right for me? This is what I’m experiencing. This is why I think I should be on it. And then, you know, let your doctor talk to you about it – have a conversation about it.” — Dr. Malik [38:44]

“Exercise. Exercise with someone else. It’s really good to exercise, but make it a community event.” — Dr. Roman [71:33]

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Key Takeaways

• Sexual desire has biological, psychological, and social roots—each must be honored.
• Stigma, dismissal, and incorrect assumptions damage patient care.
• Evidence for testosterone and other hormone treatments in women is nuanced; individualization is key.
• FDA-approved medications for low desire are effective for select women, acting on the brain’s chemistry.
• Hormone levels and tests are a flawed marker for most women; symptom-based, not lab-based, care is favored.
• Lifestyle factors—exercise, sleep, connection—are as potent as any intervention.
• New tools, like home-based cervical cancer screening, are expanding access and agency.
• “One right way” does not exist: seek providers willing to contextualize science and partner with you in care.

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Transcript

[Dr. Tammy Roman]

Sexual desire, it's a natural part of being human. I mean it is a primary urge, right? Things like wanting to eat, wanting to sleep and wanting to have sex actually are all really natural and make sense for any animal and especially humans. But the truth is the number one predictor of long term health is your relationships with other people. So sex is directly related to that. The hallmark of perimenopause is fluctuating hormone levels. And so I think about the ovaries and as spread buttering cart. The highest estrogen levels I have ever seen are in perimenopause. Just because I can't explain it physiologically doesn't mean it's not real.

[Dr. Rena Malik]

People want to want to have sex, but sometimes their brains don't cooperate. And sexual desire is much more complex than you give it credit for. I'm Dr. Rena Malik, urologist and pelvic surgeon and welcome back to The Rena Malik, M.D. podcast, your trusted guide for leveling up your health, sex, sex life and relationships with evidence based tools. Today I'm bringing you a deep dive into female sexual health and Hormone Science with Dr. Tammy Roman, Associate professor of Obstetrics and Gynecology at UCSF, a researcher with over 1700 citations, an expert in sexual medicine, menopause and the medical director of gynecologic surgery at her institution. In this episode we cover the neuroscience of sexual desire and the two FDA approved medications that target it, how birth control actually works in your body and why it affects testosterone levels, the difference between perimenopause and menopause and why testing hormones is often useless, what testosterone really does for women and what it doesn't and why progesterone is the most underrated hormone in the conversation and how to separate evidence from marketing when it comes to hormone therapy. This is a conversation about feeling like yourself again and understanding what's actually happening beneath the surface. Guys, if you're struggling with any sexual dysfunction, I made an app for you is called the Better Sex App. Now this app is designed for any issue you're having. Basically if you're struggling with low desire, erectile dysfunction, hormone issues, you put in the issue that you're having and the app formulates to help you with that specific problem. It is completely trained by me and all my knowledge so that you can get the help you need from a board certified expert in sexual medicine. So check it [e-mail] Rena so I've been thinking a lot about low sexual desire lately for women and I want to get your thoughts. I have My own. But what do you think it feels like for your patients when they come in complaining of low desire?

[Dr. Tammy Roman]

I think there's probably a lot of things going through their head. The first I would say is they're probably really nervous because for most of them they've probably been dismissed by somebody at some point and maybe not a provider, but at least people in their life. And so I think they're quite anxious in terms of what is my response going to be. Now they know that I'm an expert. Right. So they know I'm familiar. But even then they'll sometimes be like, this is tmi, too much information, I'm gonna make you uncomfortable. And you know, so. So a lot of anxiety, I think. And then I also think that they probably wonder if this is even something to talk about in the doctor's office or something that should be taken seriously. And I think they're probably worried that there may or may not be a treatment for them that I can offer. So those would be my first thoughts about what they are coming in with.

[Dr. Rena Malik]

Yeah. And I think that interestingly, I think we, you know, as a society think like low sexual desire is like not a big deal. Right. And I think interestingly, I was thinking about this the other day and I was thinking, well, I feel like when someone is normally like finds themselves to be a sexually vibrant human being and then goes into feeling low sexual desire, they really just don't feel like themselves and they don't really know where to. Like, they don't realize that that may be part of it. And then when they get that back, like they go through treatment and they get that back, they feel like themselves again.

[Dr. Tammy Roman]

Yeah, I think that, you know, sexual desire isn't. It's a natural part of being human. I mean, it is a primary urge. Right. Things like wanting to eat, wanting to sleep and wanting to have sex actually are all really natural and make sense for any animal and especially humans. And so when it goes away, we describe it as like the light went off. And one of my favorite psychologists, Cheryl Kingsburg, will say they want to want. And it's on a day to day basis, just going around in the world, the idea of having desire, especially if you know what it's like to have spontaneous desire, want. When it's gone, you notice that it's gone.

[Dr. Rena Malik]

Yeah, yeah, absolutely. And I think people feel, I mean, when you think about depression, anhedonia is a symptom of depression, which is lack of desire for things you used to enjoy. Right. So while it may not be as severe because you're not feeling it globally like you do with depression. I think that it does sort of mimic that feeling of loss, like something in your life is missing.

[Dr. Tammy Roman]

Yes. And I would say that it's, you know, it's not just about the desire for sex. It's the desire for connection. And one of the things that we, I think, think miss a lot of the time is understanding the importance of sex and connection in relationship building. And as physicians, we can say, oh, well, that's not us, because that's not a cardiac issue and it's not diabetes. But the truth is, the number one predictor of long term health is your relationships with other people. So sex is directly related to that. And so it's actually incredibly relevant for us as medical providers.

[Dr. Rena Malik]

Absolutely. And it is. I mean, we know there's an abundance of data on people who have more sex, live longer, have, you know, better health outcomes. And so it's, it's, it's, it's just unacceptable to put it in a box. You know what I mean? Like, we need to be talking about. And I think the same, I think this feeling that we're describing is for both genders. Like, I see it in men all the time, I see it in women, and they feel sort of ashamed to say, like, something's wrong with me, because again, sex is viewed as this extracurricular activity, like you should just be lucky if you're having sex, when in reality it's like a huge part of our being, especially when you're in a relationship with someone else.

[Dr. Tammy Roman]

Yeah, I absolutely agree. And I think that, you know, one of the things I love about knowing urologists, and I happen to be married to one, is I think it gives me as an ob GYN a lot more perspective on the male experience because it's just as important for men and it's even more so. But we stereotype it and we sometimes make it a negative thing, you know, like there's too much focus on sex. And then we do the opposite for women where we kind of diminish the desire and the importance of sex for women when there actually is a balance for both.

[Dr. Rena Malik]

Absolutely. So let's talk about it. A woman comes into your office office saying, I don't feel like myself. I don't have any desire for sex. How do you sort of walk her through that experience?

[Dr. Tammy Roman]

So I talk about first. What did you used to feel like? Right. I want to know what her baseline was and so what is her experience like? And there's really two types of Hypoactive sexual desire. If that's what she has, there's acquired and then there's just generalized primary. Right. So there are people who've never experienced sexual desire. And that's a little bit trickier because sex, spontaneous desire is not experienced by everybody. You know, I think there's a stereotype that women don't have spontaneous desire, and that's not true. There's plenty of women who do, but there are some who really don't. So then I'm looking at responsive desire, right? So I wanna know what she was like before. If she says, I don't feel this anymore. Well, what did it used to be like? What did you used to think about? What would be your ideal? And then we start teasing out this idea of the biopsychosocial model of sexual dysfunction. If I think she truly has a dysfunction, which means you have a problem and it is causing distress, I want to know what are the main causes. And so could it be something biological? The neurotransmitters, could it be something psychological? Does she have a history of depression, anxiety, body image issues? And then socially, I want to know what's going on, what's happening in her relationship, what's happening in her relationships with other people. And so then I'm really trying to tease out for me as a medical provider, if I'm going to look at this from a medical lens or from a psychosocial lens. Now, those shouldn't all be put in boxes, but I want to. What's the primary driver of her low desire?

[Dr. Rena Malik]

Yeah. And the interesting thing, you know, I, I was talking to someone the other day and I was saying, you know, she was saying, well, we should make sure we correct all the psychological stuff before we correct the biologic. And I was like, no, no, no, I don't. I mean, that's not how I treat men, right. And that's not how I treat women. It is, it is a global thing. We try to treat everything. We offer treatments that are available to women regardless of if they also have psychological concerns. Right? If it's completely psychological, that's one thing, Right? And differentiate that for someone if you think that, like this is all in their head, versus there's also a biological problem.

[Dr. Tammy Roman]

Well, I would, I would say that it, it's all in their head either way, Right. And so when it comes to desire, and it's probably the same for men, but it's different because the treatments for men are not actually targeting the brain, they're targeting the penis. Right? And so that's different for women. The. The. The driver of desire in women and. And women and men are the same. They desire sex the same way. But the. The drivers are the neurotransmitters in. When we think about sex in general and any natural urge, eating, sleeping, having sex, you think about things that stimulate that desire. They're excitatory, and things that are inhibitory, something that would drive down your desire. And the truth is, everybody has a different approach. But my approach is that if I'm thinking that I want to give a treatment that could potentially stimulate or be excitatory, I worry if there is some other factor that is going to overpower that. That it is so inhib. Inhibitory that if I give them something, it won't work. And so an example is depression. If somebody is really depressed, the number one predictor of low sexual desire is depression. And so I can tease out pretty quickly. I have a lot of experience doing this. If it seems like depression is happening concurrently and it's severe and untreated. Now if it's treated, that's different. But if it's untreated, I would say, actually, I want to treat the depression because I don't believe the therapies I have will overpower what the depression is.

[Dr. Rena Malik]

Right.

[Dr. Tammy Roman]

Similarly, sexual pain, huge issue. And this comes up a lot. People come in and say, well, I don't want sex. And I say, well, you know, how do you experience sex? Well, it hurts. Well, of course you don't want something if it hurts. And I always say, there's nothing I can give you that's gonna overpower what pain will do. Right. Pain tells the brain to avoid and stay away from something. So I do actually subscribe in my practice to. I need to treat those really significant inhibitors before I can give you a treatment that would be excitatory.

[Dr. Rena Malik]

Sure. Well, I think more like the sort of gray areas. So, like, yeah, maybe my relationship's not where it was 10 years ago. Maybe I am having a little bit of, like, stress in my life, but I also feel the significant change in desire. Right. And I think that's where we often see this sort of like, oh, we'll fix those things first, and then I'll give you these other options where it could be both.

[Dr. Tammy Roman]

I think that's a very reasonable approach. I mean, I think that there's. I think it's a very reasonable approach, especially if, well, my relationship's not. Not doing well because I don't have desire.

[Dr. Rena Malik]

Yeah.

[Dr. Tammy Roman]

That said, you know, one of the main questions I Ask, and this is what I teach people is, is how do I separate and tease these things out. One question I ask is, if you were on vacation and you were away from all the stresses in your life and you had, you know, a nice meal and you were relaxed, would you want sex? And they say no. That to me is hsdd. Right. Like you eliminated all those other things. But if they say, well, yes, I would, then that triggers, well, how can we think about the stresses? Right. Because clearly the stresses are getting in your way. Doesn't mean I won't give other treatment, but I'm going to focus, I'm going to give more attention to those. Whereas if they say, no, I still don't want it, then it's a pretty straightforward diagnosis for me.

[Dr. Rena Malik]

Yeah. And I would just clarify now, you mentioned that for men we're treating the organ, but actually for desire, we're not necessarily treating erections. Right. Because that's not going to get their desire 100%. You know, we may talk about testosterone and we may even use some of the same medications for men that women use off labels, you know.

[Dr. Tammy Roman]

Yeah. And I, I understand the treatments for men. And what I think is really interesting about men is there's no. And you are a urologist, so you can correct me, but my understanding is there is no FDA approved product for sexual desire in men. And so we always, you know, there's the stereotype like, oh, there's all these treatments for men and there's none for women. And I'm like, actually, let's correct that narrative. Right. Testosterone isn't approved for sexual desire. Right. The PD5 inhibitors are not for sexual desire. And we, we really do a disservice to men by not acknowledging that, you know, there's a neurological, you know, and psychological component to this as well. Just because they might have an erection doesn't mean they want sex. And we should be thinking about how we can help them if they also have low desire.

[Dr. Rena Malik]

Absolutely. And yeah, I, you know, I always talk to these companies that have made these medications for women and I said, you really should, and some of them have done studies on men. But I was like, you really should consider doing larger scale studies on men. Like, this is an unmet need. And interestingly, this, at this meeting we were at, they had topical sildenafil for women. And I was like, have you studied this for men? Because of course, men would love to have a topical cream that doesn't have systemic side effects for erections. And they're like, oh, no, just, just to make sure it doesn't rub off on them. And I was like, well, come on. Like, we need to be studying this for men. Like, it would be a great, it would be a great option if it worked as well as the oral medications. So it was interesting.

[Dr. Tammy Roman]

Yeah. I think it just goes to show that we stereotype both genders excessively. Right. We make it real simple for men that it just comes down to their erection. And we make it real simple for women that it just comes down to their psychology. And those are both completely untrue.

[Dr. Rena Malik]

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[Dr. Tammy Roman]

I honestly think that there's too much variety and diversity of experiences to make any generalization. So no, I actually don't agree with that.

[Dr. Rena Malik]

Yeah, Yeah, I agree with you. I mean, I think that it's. It's. It's variable. Right. Some people do say that, obviously, but I don't think it's universal across the board. Let's talk about sexual concordance. So what that is is the difference between physical arousal and mental desire. Because we just sort of talked about that. Right. A man can have an erection, but he might not want sex. And the same can happen for a woman. She can have lubrication and she can, like, have the body responding to something, but she may not actually want sex. So let's talk a little bit about that. Why do. Why does that happen? And why do we see that oftentimes for women, it's. It's less concordant.

[Dr. Tammy Roman]

Yeah. So there's great studies on that. Right. And so we talk about it in sexual medicine as arousal, subjective, objective. Right. Or cognitive versus genital arousal. They're two different things. And so there's actually lots of data showing that if you show women erotica and you measure the blood flow to their genitals and then you measure their brain activity, that they are not concordant, and it is more so than for men, as you said. Right. So objective data shows this. Cindy Meston at UT Austin actually has done a lot of studies on this. And at the end of the day, it's because, you know, are. We're complex humans. You know, our genitals are going to have a response to something, and our brain may not even recognize that it's happening. But there's a lot of processes going on at once. I think one of the things that's, you know, fascinating in general about women, and again, I don't like making stereotypes is it's. It almost is to me, the multitasking. You know, our brains can be in multiple different places at once, and that means they can be kind of separate from what's happening in our bodies. So I don't think we have necessarily the scientific explanation for why it is, but it kind of makes sense just given how many different places our brains oftentimes want to go and how disconnected we can sometimes be from our body in the process.

[Dr. Rena Malik]

Yeah. I've also heard the theory that it's evolutionary, like, it's protective to be aroused easily in case, you know, you do encounter sex, that, like, your body is not going to get injured, which is a sort of a sad thing, but, like, it's sort of a protective mechanism to protect your body from injury, like, if your body is ready for sex. I don't know how accurate that is. But there is a theory, I guess.

[Dr. Tammy Roman]

I see it a little bit of. It's unlikely to be injured because it takes a lot to injure somebody during sexual activity. It would be. I could see it as a. That you are more able to tolerate it and that you're lubricated. Not painful.

[Dr. Rena Malik]

Exactly.

[Dr. Tammy Roman]

I think we're saying the same thing.

[Dr. Rena Malik]

I don't mean injury like you're gonna, like, break something, but injury as in, like, it's gonna hurt and it's gonna be really painful. Yeah, yeah, yeah.

[Dr. Tammy Roman]

And I mean, we know this. That it's, you know, this. This sad truth that people are really uncomfortable talking about. But, you know, people can have significant arousal even during sexual assault, and then they feel incredibly guilty about that. Right. Like, that's an awful thing. Your brain is not there. Right. That is not what your brain is doing. Your body is, you know, having that experience, and it can be incredibly traumatizing to women. And it's. You know, you could look at it from that evolutionary perspective, which is a really sad way of looking at it.

[Dr. Rena Malik]

It's sad, but it's protective, you know, And I don't think. I don't think. I think that's actually. If you think about it that way, it's like, well, it's just my body protecting me, and it's not my brain saying, like, I want this. And I think that's actually. Could be somewhat empowering. I mean, it's sad that it happens, but it does happen. And I think it's important for people to know, like, if a woman is lubricated, that doesn't mean that she necessarily wants intercourse. And I think that's important for everyone to know because there's a lot of discussion about lubrication and what that means. Right. And. And, oh, if she's well lubricated, that's great. It's all me. And if she's not, well, lubricated, well, that's. That's me, too. Or that's her. And she's broken.

[Dr. Tammy Roman]

Right. I'm fascinated by this, honestly. And I actually talked to my urologist husband about the focus that men have on women's lubrication. And again, not to make stereotypes, but it's, you know, you have an objective measure. Right. Men talk about their erection like, how hard am I? You know? And so we try to do the same thing for women. Right. How wet are you?

[Dr. Rena Malik]

Yeah.

[Dr. Tammy Roman]

And these are two different things.

[Dr. Rena Malik]

Very different.

[Dr. Tammy Roman]

And it's really hard for women who lose their lubrication. Right. And I see this as women get older where they're losing their lubrication, they're coming into me, and they're really upset about it because they're turned on by their lubrication, Their partner's turned on by their lubrication, and they wonder if it means there's something sexually wrong with them. And I have to explain that this is just your biology. As we discussed, some people are lubricated without being aroused, and now some people are aroused without being lubricated.

[Dr. Rena Malik]

Absolutely. And also, it can be even not during just aging. It can be on certain medications or when you're lactating or, you know, a variety of different things. And so I think I always tell patients, like, look, let's go through your medications. Let's look at what else is going on. It is not that you're broken. And I think that's so important to understand. The same thing with erections, right? It's not that you're not desirable, your partner. There is a. Could be a very. Could be a biological issue going on, and we need to address that. Right.

[Dr. Tammy Roman]

And it's.

[Dr. Rena Malik]

It's an opportunity. I tell people this is an opportunity to sit down and talk about these things and figure out what the issue is so we can fix it. And it's not that there's something wrong with your sex drive or your sex or your. Your sexual biology necessarily. It could be biology elsewhere that we need to address. There's just such a disconnect between how women think and how men think. And. And they don't really intermingle very often because we don't talk about sex. Right. And I think it's so fascinating because when I'm in a room, women, and they say something, I'm like, wow. Because I spent a lot of time talking to men about sex. I'm like, oh, my God, I had no idea people think this way.

[Dr. Tammy Roman]

Right.

[Dr. Rena Malik]

Like, for example, there was a discussion during the meeting we were at where someone got up and said, well, women don't like semen. And they don't. They don't like that they don't want to get pregnant, which is fair, but they don't want it. You know, they don't want it inside them all day and dripping out. And I was like, oh, I had like, you know, I didn't realize this was like, a thing that, like, universally women complained about to their doctor because no one had complained to me about it. And I was like, oh, wow. These are things that, like, if you don't. You don't talk about it. You don't really know.

[Dr. Tammy Roman]

No, I love this. And again, I need to stop bringing up the fact that I'm married to a urologist. But I spend a lot of time at sexual medicine meetings and I learn about men in ways that I am fascinated by how turned on by turned on men are by their own ejaculate. And so one of the lectures that we just heard at the meeting was about an ejaculation, right. And how distressing that is for a man. And you know, all the women I'm sitting with are like, nobody would mind. We'd like them to have an orgasm, you know, but it's like nobody's enjoying the fluid, right. If it's an oral sex or even, even if it's in, you know, penetrative sex. But what I always thought was interesting is if you take the women out of the picture and you talk about what, you know, gay men and their experience, how that's it's such a big deal if they lose their ejaculate, you

[Dr. Rena Malik]

know, and it's a part of their pleasure, right. What I've come to realize is because even when I was in training, I had no idea, right? And we would, a lot of people would prescribe medications that affect ejaculation and not even talk about it, right. And then I realized, obviously, as I learned more about sexual medicine, that this is like a big deal. And I talk to all my patients about it and interestingly, a large majority, like, I don't want that. And some people will be like, it doesn't matter to me. But a lot of guys are like, no, that's a part of my pleasure, right? That emission of fluid that comes out, it feels very pleasurable. And that's fine, that's great, right? We don't want to take that away from anybody. But it is really interesting and that part of it is so fascinating to me because yeah, sometimes it's like they're distressed and they feel like they're not enough because they think their partner is going to feel some type of way. And oftentimes, as you mentioned, like, they don't really care that much. And so that's, I think, why what we do is so important, right? We try to normalize normal for people and what they understand. Yes. So let's go back to female desire. What are some of the things that you found if someone is experiencing biological issues with desire? What are the most effective treatment options?

[Dr. Tammy Roman]

So the first I would think about our non pharmacologic treatment options, right? So I really start thinking About. I know it sounds cheesy to talk about lifestyle, but I really want to know what they're doing, what are their health habits? Right. Because the number one predictor of sexual health is physical health. So I want to know, are they exercising? Exercise is the number one aphrodisiac on multiple levels. So it stimulates your body's endogenous opioids. It's, you know, it stimulates your body's natural dopamine, which is the main neurotransmitter that is involved in desire. I'm asking about sleep, I'm asking about diet. So that is a big, important thing. And I really do want to give empower people to think about how optimizing those could really improve their desire. And then we start talking about the pharmacologic options. And they're actually two FDA approved medications for low sexual desire, Brimalanotide and flibanserin. So they work on the neurotransmitters in the brain. And then we also talk about testosterone therapy depending on the age of the patient.

[Dr. Rena Malik]

Yeah, and then how do these work?

[Dr. Tammy Roman]

All of them work centrally in the brain, but they work a little bit differently. So, you know, we oftentimes think about, oh, hormones are the reason that people want sex. But the brain is the biggest sex organ and it communicates with itself via neurotransmitters. Right. So those are chemicals that are exchanged between neurons. And the main players in desire are dopamine and norepinephrine. And how do we know that? Because if you give medications that alter those, you affect sexual desire. All right, so SSRIs are the classic. Right. So SSRIs actually inhibit the dopamine and norepinephrine. And so we can say, we know there's a biological issue here. If you give drugs that stimulate dopamine, anti Parkinsonian drugs, for example, people will get hypersexual. So the medications that are approved, the first one was flibanserin. It was approved in 2015, and it targets serotonin receptors in a way that allows for more dopamine and norepinephrine. And so it makes physiologic sense that it would stimulate desire. And it does. It's been shown in multiple randomized control trials to stimulate desire. It was initially approved for premenopausal women, not because it didn't work for postmenopausal women, but because in order to get a drug approved for postmenopausal women, you need to go through the hormones, hormone branch of the FDA and Then they treat it like a hormone and you have to prove that it doesn't cause breast cancer.

[Dr. Rena Malik]

That's crazy.

[Dr. Tammy Roman]

Did anyone do that with Prozac? That's a serotonin drug. No.

[Dr. Rena Malik]

Yeah.

[Dr. Tammy Roman]

Recently it got approval finally for women up to 65, because we have randomized control. Up to 65?

[Dr. Rena Malik]

Oh, up to 65.

[Dr. Tammy Roman]

Unfortunately, it's not all women. Right. It was previously. It was pre menopausal, which I thought was hysterical. Right. The, the pre and postmenopausal brain doesn't have different dopamine receptors. Right. I just said that. That's what drives desire. They work the exact same, same. So it makes sense that you give a drug, it would work in both of them. It's not a hormone. Remalantide is a different drug that targets the mel. Melanocortin receptors. So melanocortin are they're receptors and it's a kind of a molecule that's all over the body and it stimulates the. The dopamine receptors as well, or dopamine release in the brain. This drug is different than flanserin. Flibanserin is a daily medication and so you take it every day. Remelantide is a prn, which means it's as needed and it's a little auto injector. Everybody that's familiar with GLPS is probably familiar with these now. And so it works similarly to kind of cause a big release in dopamine as needed. And usually it can last for up to 24 hours. It is only approved in premenopausal women. They do not have the approval for papa past menopause.

[Dr. Rena Malik]

Do you know why they stopped at 65? Is there a different FDA branch that has to approve above 65?

[Dr. Tammy Roman]

I think it's because the postmenopausal study was only in up to 65.

[Dr. Rena Malik]

I see.

[Dr. Tammy Roman]

It doesn't mean you can't use it off label in terms of flavanserin. The main thing is that all medications have more side effects if you use them when you're older. And so that's my clinical experience. I think flanserin works great. I think brimalanotide works great too, even in postmenopausal women. But you're going to see more side effects effects.

[Dr. Rena Malik]

Yeah, yeah, absolutely. And then what about testosterone?

[Dr. Tammy Roman]

So testosterone works in the brain doing kind of similar things where it actually stimulates dopamine release. Right. So the brain doesn't talk to itself via testosterone. So it's doing something very similar. And so the issue with testosterone is that we know that if you give it to postmenopausal women in the absence of any other hormone therapy, that you will see an increase in sexual desire and satisfying sexual events. And we can talk about. About what that means, but. And then in premenopausal women, that's where the data is a little bit stickier. There is only one study that ever showed that testosterone supplementation improved sexual desire, mainly in perimenopausal women. They were being given higher doses than we typically recommend. And that's a whole other controversy that we can talk about in terms of how we dose, how we monitor. But in younger than that, that a lot of data suggests that it's not testosterone driving sexual desire in younger women, 20s and 30s, that it may be estradiol. And we see this over the course of the menstrual cycle on what people. How people have sexual desire. And it tracks very much with their estradiol levels, which look a little similar to testosterone, but. But there's always this chicken in the egg because testosterone turns into estradiol, actually. So testosterone plays a really important role in this. And I think the best benefit would be in perimenopause and menopause.

[Dr. Rena Malik]

Yeah, I think testosterone is such a controversial discussion. Not discussion. I think there's controversy for a lot of different reasons, but one being that there is data, but there is sort of. It's not as clean as the data, let's say, for male testosterone. Like, there's not an abundance of patients that have been studied. There's not the same sort of rigor around the design of the study. But I think that ultimately, I think it is clear that it improves desire. What about sort of other aspects like muscle growth, brain health, that sort of stuff?

[Dr. Tammy Roman]

Such great questions. So whenever I go to these sexual medicine meetings for men, I just sit there in awe because I'm like, wow, you are 30 to 50 years ahead in the amount of data and rigor and science. And we get criticized in sexual medicine that we're not scientific enough on the women's side. And I'm like, well, no one's funding these studies. You know, like, we don't have the resources you have. So we would love to. Love to be there, but I'm hopeful we might get there. So there actually is a lot of data looking at correlation between testosterone levels and a lot of the outcomes you mentioned, as well as testosterone supplementation and the outcomes you have mentioned. I think people want the data to suggest something that it doesn't at this point, because we Say, oh, there's not enough data. And I would say, actually there's a lot of data. So if you look at lean muscle mass, for example, there is no evidence that testosterone levels levels correlate with lean muscle mass. But there is evidence that if you give people excess testosterone so levels that you see higher than normal in women, that they will have an, you know, increase in lean muscle mass. And that makes sense. We know the same for men. This is a performance enhancing drug. It's a trophic drug. If you give people excess amounts, they will form more.

[Dr. Rena Malik]

Well, in men, we see that they do get lean muscle mass when they're hypogonadal and you give them testosterone. We do see improvements in lean muscle mass.

[Dr. Tammy Roman]

I think that's a very good point. I think the difference is that they're, they're. There is a clear definition of hypogonadal, right? In men.

[Dr. Rena Malik]

Yes.

[Dr. Tammy Roman]

In women, the range of normal is between, you know, the levels are, you know, if you look in U.S. measurements, 15 to really 55, if you Google it, it would say, you know, 15 to 70 nanograms per deciliter. The issue, that's a very broad range. And 15. And for those of us in sexual medicine would say, oh, well, that's low. It's actually not. It's within the range of.

[Dr. Rena Malik]

Well, there's only a, like two studies that look at normal.

[Dr. Tammy Roman]

Right?

[Dr. Rena Malik]

Yes, there's only. And they're like decades, like.

[Dr. Tammy Roman]

And they were using the wrong assays years ago. Yeah. And they were using terrible. So that's why this level thing.

[Dr. Rena Malik]

And they're not taking SHBG levels into consideration. And we know that oral contraceptives affect that permanently. Yeah. For, for most women. And so I think there's, this is where. I don't know, I can't, like, yes, there is data, but the data is not taking those things into consideration. Right.

[Dr. Tammy Roman]

I think that's a very good point. I mean, I think the data shows that if you give people excess testosterone and again, it's just, I do a lot of testing of people who are not, do not have low desire, who have other gynecologic issues. And so I see a big range of what normal looks like. And so if we give people back to those levels that they were in their 20s and 30s, it doesn't suggest it. If you give them more. It does. Absolutely. And it makes physiologic sense. Body composition. Multiple studies have come out and they basically show it's neutral. It doesn't change, you know, your, your Weight. And that can be so frustrating because especially in perimenopause, where we know testosterone levels have gone down, we know estrogen levels are fluctuating kind of wildly. Weight gain is such a huge part of that. And we keep talking and hearing about how this is hormone related. And that somehow implies that, well, if you then give the hormone back, it could fix it, and it doesn't. There are just so many studies that show you may redistribute some of the fat, like it may not all go central, but you're not going to have any effect on weight loss. Now, you may be in a better mood, you may feel better, and then maybe you might be more motivated to exercise. Exercise and diet. And again, I don't want to put this on, you know, people. There's a lot of reasons why people may gain weight, but if you just treat with hormones, it doesn't make a difference. Cognition and mood. Also, if you look at the data, and there are a lot of studies that, that have looked at this, that the, the, the studies are really mixed for cognition. So that means some show worse cognition. And, and these are all various studies, number recall, shopping list, memory, which is so stereotypical that that's how they test women's cognition.

[Dr. Rena Malik]

I can't.

[Dr. Tammy Roman]

Yeah, but they all come out on an average of, of neutral. And, and the truth is that's because it's group data. And this is one of the challenges of this. You know, in the mood data, you see that it looks like it trends to improve mood if you give people testosterone. But again, the confidence interval, if anyone knows statistics, crosses 1, which means that even if it shows like, oh, it looks like it's better, the statistics say, well, that could just be due to change chance. And this is where it gets really tricky in talking to people. Because if a woman says to me, my cognition, I feel so much clearer and better taking this medication, I would never say, oh, no, you don't. Because the data doesn't show that. Right. That's gaslighting. And so we have a tendency to keep doing that now and we keep saying, well, the data shows that this doesn't do anything. So therefore all these women that are reporting a benefit are somehow wrong. And that's just not. Not okay. Yeah, right. You know, I use the example as my favorite example. Birth control is the perfect example. If you look at the data on birth control, it really comes out that it affects sexual health at a neutral level. Because there are a group of women whose sexual health gets better. They feel better on birth Control, and they're not worried about pregnancy. And so that's great. And then there's a group that really have negative side effects. Their libido changes, their orgasm changes. And then there's a group that's neutral. So what's the average neutral? But we can all say, if a woman comes to us and says, I'm having really significant sexual side effects from my birth control 10 years ago, 20 years ago, she probably would have been dismissed. But now I lecture all over the world on this. Every person would say, absolutely, I've seen it. And I respect that. You wouldn't say, oh, no, it's not true. Because the data on birth control, of which we have robust literature, shows it's neutral.

[Dr. Rena Malik]

Yes. This drives me nuts because it's like, why don't we believe our patients? Right? Like, I had a patient the other day come in with a weird side effect, and I was like, okay, I've never seen it, but I believe you. I mean, this is clearly a change. So let's stop this medication. Let's try something different, right? There's no reason to say you're making it up or whatever. There's a clear temporal relationship. You started this medication, you had this side effect, okay? So maybe every side effect of this medication hasn't been documented. And your biology is not universal to everybody. Everybody else. So, okay, I believe you. That's it. That's the end of story.

[Dr. Tammy Roman]

What I say, I'm very clear. I'm like, just because I can't explain it physiologically doesn't mean it's not real. Right? And that's what we do a lot of in medicine. And we sometimes say, I can't explain what's happening to you. And that can be frustrating for people. Even on the opposite of, instead of taking something away, we'll say, well, I don't know why this is happening, but let's treat it.

[Dr. Rena Malik]

Yeah, I find it this to be universal in hormones, though. I feel like whether it's man or woman, people, when they're like, I want to try a hormone, there is this big fear. And this, oh, the data doesn't support it and I can't write it for you. And some of that's based in not knowing how to manage it. And some of it's based in like, well, I was taught this 20 years ago when I was in training. And so I just don't do it because it could, you know, cause you X, Y, Z. And I think the reality is, like, just because you don't feel comfortable doesn't mean you should go around saying, like, no, just send them to someone who, who can help them, Right. Or who can give them the data. If you don't know it, that's okay.

[Dr. Tammy Roman]

I think that's a really good point. I do, do think that when it comes to hormones, it can be tricky, especially so when it comes to testosterone, the biggest issue is we have no female formulation of it, right? So the vast majority of people out there are like, how would I even prescribe something like this? Because there's nothing that is dosed appropriately and there's no female formulation. I also think that there. We oftentimes now are seeing more and more women coming in asking, should I be on testosterone? Someone told me I should be on it.

[Dr. Rena Malik]

Right?

[Dr. Tammy Roman]

And that is a much harder. Right. Any person that comes in and says, should I be on this medication? Right? Your response is, well, what am I treating?

[Dr. Rena Malik]

Right?

[Dr. Tammy Roman]

Why am I doing this? And that's where I think there's a lot more nuance here. Because if someone wants to be on it for a specific reason or a specific symptom, I'm more than happy to talk to them about what the evidence shows, what the risks are. But if it's, should I be on it because I'm this age or I'm menopausal? And testosterone, especially because there is this. This assumption that because you're in menopause or you're going through menopause, somehow now you've run out of testosterone, it needs to be replaced. That is actually not based on physiology. Testosterone does not behave the way estrogen and progesterone do, where they kind of bounce along in perimenopause and then fall off a cliff. Testosterone doesn't do that. It starts to decrease in your 30s, and it holds relatively low and steady throughout your 40s. And it does not change through menopause. So your body, from a testosterone perspective, does not know when it went through menopause. It mean we shouldn't treat with testosterone. But the idea of, now I'm in menopause, I can't, you know, I have to be on it doesn't. Doesn't make sense physiologically. And remember, testosterone is made in two places, in the ovaries and in the adrenals. So even for people that don't have ovaries or have ovarian suppression, they can still be making testosterone.

[Dr. Rena Malik]

Yeah, absolutely. I think, I think this is such an important conversation, and really, I think the most important thing for the people who are listening is like, like, just understand that like, if you first of all feel comfortable with the doctor you're seeing, if they give you an answer, one, you can ask them why, of course. But, you know, find someone who you feel comfortable with. And there's no absolutes in medicine, right? Like, there is no, like you should be. Everyone should be on this. Even, even aspirin at some point. We thought everyone should be on aspirin after a certain age, and now we've taken that back. Everyone should have a multivitamin. We've taken that back. There's very few things that universally we say everyone should do. Diet, exercise. Yes, universal. But in terms of taking a substance and putting it in your body, whether it's a supplement or a pill, there's very few universals. So I think it's about, you know, is this right for me? This is what I'm experiencing. This is why I think I should be on it. And then, you know, if you feel like that's what's going on, then let your doctor talk to you about it, have a conversation about it, because that's so important.

[Dr. Tammy Roman]

Yeah, I so appreciate you saying that because I think one of the confusions that keeps happening now in the mental menopause and perimenopause space is these universal absolutes. Everybody should be on hormones. Everybody should be on this treatment. And, you know, I've been doing this a very long time now, and I happen to see it a little bit differently. And I don't begrudge the people who think everyone should be on it, but I also think that we should have space for those like me who say, actually, no, I don't think everyone has to be on these hormones. I think that we should have conversations about the pros and cons and people get to make a choice and they get to make an informed decision.

[Dr. Rena Malik]

Absolutely. And this is the, I think the other part of it is we're in the short form video era of the world, right. And so people are getting bits of information over less than three minutes or even less than 60 seconds, and they're like, oh my God, you know, and then they see the next three minute video and the next three minute video, and they're not even watching the whole thing. And like, so they're getting these little bits of information. This is why I still do podcasting and long form video, because I just feel like they're so, so much nuance to things that we're not allowing people to get. You know, they're not getting it in a one minute bite and, and people can sound really confident and show you a picture of a study. And you and I know this in medicine, if I need to give a talk, right? You know, there's a lot of. For people who don't know, there's a lot of debates in medicine. We will do this in academic meetings where we'll debate and you'll put one, you know, expert talking about the pros and one expert talking about the cons. They may not even agree with the pro or the con completely, but they will literally make the most convincing argument. And if I showed you those videos, you would listen to a pro video and be like, oh, I'm pro. You'd listen to a convict. Oh, I'm con. And at the end of the day, like, everyone at the meeting knows, like, okay, there's no absolute. But now we're putting these pros and cons videos basically on social media with a very confident speaking physician or influencer and with maybe a PubMed article in the background. And you're like, oh, well, there's a study on it. And, oh, well, there's, you know, and that's the challenge. It's like, good. It is important to give context and information, and it's great to talk about studies. I love it. But. But also, like, realizing there's so much more to it.

[Dr. Tammy Roman]

Well, I love that you said that. So I have been reluctant to be on social media for years, and, you know, I've been very busy in academics. I've been publishing and teaching and lecturing. And it started to become clearer and clearer to me that people were not getting their information from the articles I was writing or from the lectures I was giving, giving. They were getting it from social media. So I finally went on, you know, I think in September of last year, so less than six months ago. And it has completely blown open my world and mind to understand what's actually happening and why. And a lot of what I do on social media is talk about the things that you just said, right? Where I talk about, okay, if someone shows you a study, you cannot just look at the conclusions, right? Because that is what the authors are telling you. They want you to believe. Believe. And I've been editing journal articles. I was an associate editor, and now I'm on editorial boards for years. And one of the main focuses that people send me articles for is looking at methodology. And this is so nuanced and so technical of what are the methods of this study. And if the methods are problematic, right? If you're comparing one group of people, and I see this all the time. Well, my patient population had this outcome and I'm comparing it to what I would have expected them to have. Have based on some other population. Those are apples to oranges, right? Those are not the same patients. You can't actually draw a conclusion. And something I learned very young because I come from, you know, pretty well educated family and I and my parents disagreed about a lot of things. My parents split when I was little and they were in the medical field and one does alternative medicine, one was very Western medicine and.

[Dr. Rena Malik]

Oh, that's so interesting.

[Dr. Tammy Roman]

Oh, yeah. Oh, yeah. So our, our dinner conversations were not normal. I have been, I have been taught how to interpret literature from a very young age. And one of the things that my stepfather actually, who's an OB GYN told me when I was little that always has rung true is he's like, Tammy, if someone has an opinion, they will find a study to back it up.

[Dr. Rena Malik]

Yep.

[Dr. Tammy Roman]

And that is what you have to see when people are out there showing and educating on different research. Right. Because this is them finding oftentimes, not all always finding a study or seeing a study that they really like. Right. I really like these results. And I'm going to talk about it now. We should be talking about research. I'm doing it too, online. But a lot of times people are just looking at the abstract or they're looking at the conclusions and they're not. And what I would love to see more of is people critically analyzing a paper saying, this is what this study showed. But let's talk about where there might be some gaps or holes or more questions that arise. But that's hard to do in three minutes.

[Dr. Rena Malik]

It is really hard. But yeah, I think it is really challenging. And the hard part is that oftentimes you don't even know where. Like, for the average person, they don't know. Is this a rigorous journal? Is this a journal? And who reviewed this paper?

[Dr. Tammy Roman]

Right.

[Dr. Rena Malik]

And I think just in the Journal of Urology in the last couple years, we started like putting out who the reviewers were of the articles. But that's a relatively new thing. And it's interesting because I know when I was on the other side submitting paper, you'd be very frustrated because it was not blinded. You knew who the authors were when you were reviewing the studies. And so if it was your buddy or it was someone that was really well respected in the field, you felt like, oh, I should believe this data even more. And there was a bias there. Right? Completely. And you know, some journals do this. Some journals give you blinded research some. You know, there's a whole variety. But I remember getting review articles as a resident, and I'm sorry, as a resident, you should not be reviewing. Reviewing articles. Right. But I had written a paper, I was first author, so they just like, look at who authors are and they send out reviews. And that's just not really.

[Dr. Tammy Roman]

That's.

[Dr. Rena Malik]

I mean, the whole process is a little bit flawed. And I think that really, if people knew the inner workings of all that, I think it'd be a little bit more clear. Like, okay, there's not every journal is the same. Not every reviewed article is really worthy sometimes. And I think that it's important to know that. And you can page to. To publish papers. Right. There are journals where you can pay and, and get your article published. And it could be like a throw. What we call throwaway journal. Right. And people don't know that. They just see, oh, it's published, it's in. It's in the literature, it's peer reviewed.

[Dr. Tammy Roman]

Exactly.

[Dr. Rena Malik]

And so it should be.

[Dr. Tammy Roman]

I see it all the time. There is a. Again, because I, I come from a very dynamic family of people with lots of different opinions, lots of people involved in medicine where they're trying to send me articles all the time. And I'm like, let's, let's not do this, because I will, I can break this down. But one thing that's interesting, and this is separate from medicine, is, you know, our processes is flawed. Right. Because it's really hard. It's free labor. When I review articles, no one's paying me for this. Like, they're trying to give me credit for it. And I'm like, I just, you know, do I really need, you know, CME credit? Not really. But interestingly, in law, like law review journals in academia, all of those articles were reviewed by law students.

[Dr. Rena Malik]

Really?

[Dr. Tammy Roman]

Yeah. We don't realize that, that like all the, like the hype and the prestige and the hierarchy and like, oh, I got it into the Harvard Law Review. Well, the people reviewing that were, were Harvard Law students. You know, that's it. They're. They don't. The senior people don't review articles. The law students do. Can you imagine medical students being the peer reviewers on our articles? Oh, my God.

[Dr. Rena Malik]

No.

[Dr. Tammy Roman]

Yeah, so we actually, I mean, we had a better process. It's very flawed, but it's really interesting when you look at other fields.

[Dr. Rena Malik]

That's crazy. Yeah.

[Dr. Tammy Roman]

And.

[Dr. Rena Malik]

But you know, the other thing is sometimes people will send articles to prominent urologists and they will have their fellows review it.

[Dr. Tammy Roman]

Or 100, you know, so 100 does happen.

[Dr. Rena Malik]

Granted, a fellow is much better than a student, but still.

[Dr. Tammy Roman]

Well, and it's also awful that then those people get credit for being a reviewer like that. To me, to me, it feels very unethical, but when I was. I almost went into a fellowship, and that was part of one of the fellowship processes is like, you will review this many articles, you know, that get sent to this attending. And I'm like, that seems kind of strange.

[Dr. Rena Malik]

It would be fine if it was like a discussion point, right. If you're going to talk about it. But if it was just to review it and hand it off like it's

[Dr. Tammy Roman]

an incredibly good learning opportunity, I mean, this was. This was one of the hardest parts for me of being an associate editor was finding reviewers. People don't want to do it. But the reason that I, again, I'm not perfect, and there's plenty of things that I miss when I review articles, but the reason I do think I'm quite a good analyst and skeptic and able to communicate research is because I've done. Done so many reviews and because I published myself.

[Dr. Rena Malik]

Yes, absolutely. And that's. That's important, right? Like when you're in the weeds and you've received reviews and given reviews, you really understand that process a little better. And. And you can be a little bit more critical when you're reading other articles, you know, Anyways, it's so off track on this, but it's good. Good.

[Dr. Tammy Roman]

You can see if you want. How. You want to edit it.

[Dr. Rena Malik]

No, no, it's perfect. It's perfect. Okay, so let's talk a little bit about hysterectomies. And I think the. I've always. When I was told this as a fellow, when I was taught this, that some women, after they have a hysterectomy, especially if they take their cervix, they can lose the ability to orgasm because they get cervical orgasms. I was like, oh, my God. I had no idea. And women were getting hysterectomies all over the place and never taught this. So what do we know about sexual function after hysterectomy?

[Dr. Tammy Roman]

That's a great question. So I'm actually the medical director of gynecologic surgery at my institution. I. I probably do the most hysterectomies, actually, of all the benign surgeons. I know all my surgeons do a lot, but I. I do a lot. And so what we know is if you look at the data, there is an improvement across the board when it comes to sexual function after a hysterectomy. And that includes both removing the cervix or leaving the cervix behind. But we've talked about already this idea of group data versus individual data, right. If you take 100 women, the vast majority are going to get better, better, but there will be a subset that if you take out their cervix, they may get worse. And those are the people that enjoy cervical pleasure or cervical palpation. This idea of cervical orgasm is a little bit different. I would just say that they're people who get pleasure out of their cervix and they do feel like they achieve orgasm by the cervix being palpated. Yes. I think the orgasm is the same. It's just how they get there. Right. And so the key is identifying those patients. And that's really all it comes to down to is when I talk to a patient about hysterectomy, I talk about, you know, I'm like, this is an elective surgery. I show them a picture of the cervix, the uterus, the tubes, the ovaries. And I say we get to pick and choose. Now, that's for certain indications. If someone has a cancer or a precancerous lesion, then it's really not in their best interest to leave the cervix behind, because the cervix has, you know, it can get cancer and it has endometrial tissue. So if it's elective, if we're doing it for abnormal bleeding or fibroids or gender affirmation, for example, they can leave it behind. And so then I say, you know, the. What we know is that the only reason that I would think to leave the cervix behind is for this sexual purpose. Now, some people think that if you leave the cervix behind, you're less likely to get prolapse or that it's an easier procedure. Those things have all been proven false. No difference in prolapse rates. If you leave the cervix behind, you can still have bleeding, you still need, you know, cervical cancer screening. So it's really just comes down to asking, and this is what I teach all my trainees, you know, and sometimes they'll say, oh, I never knew that it was even an option. And I'm like, everybody should be counseled. And I counsel everybody the same way. You know, this is what we have, and this is why we should consider it.

[Dr. Rena Malik]

Yeah. And the same thing can be said that taking out the cervix isn't going to cure prolapse either. No, because a lot there was a. So I trained in female pelvic medicine, reconstructive surgery. And there was a lot of women who came in being like, oh, I got my prolapse read. They took out my uterus, and that was the whole treatment. And then they would come back with a prolapse, and what. I got it treated. So. So that's a huge. Just. If your doctor is saying we're just taking out your uterus and there's no, like, additional procedures to support your pelvic floor or the ligaments, then that's not going to work.

[Dr. Tammy Roman]

I. Yeah. And this is something I talk to everybody about because I've seen it done a variety of ways. Right. And I was in training, and it was actually a urogy. Not a female urologist, but a urogyne, who told me very early on, like, no matter what you do, you need to do something to support. And so I have a special closure where what I do is I attach the top of the vagina to the ligaments that were holding up the uterus, and then I close the space in between.

[Dr. Rena Malik]

Right.

[Dr. Tammy Roman]

And that's a kind of special closure. And I do most of my hysterectomies vaginally. Most hysterectomies now are being done laparoscopically or robotically where they try to get those ligaments. They can't close the space in between. But it'll be interesting to see. Actually, the best data we have shows that if you close the space in between, you might have a better result. It does not cure to just remove the uterus, because then there's nothing holding up the vagina.

[Dr. Rena Malik]

Let's talk a little bit about birth control. We talked about it earlier a little bit. What people don't really understand is what's actually happening when someone takes, for example, an oral birth control pill, what's going on in their bodies. I think there's a lot of fear about synthetic hormones and things of that nature. So maybe you could break that down for us.

[Dr. Tammy Roman]

Yeah. So, you know, the traditional birth control pill is a combination of ethanyl estradiol and some kind of progestin, and that's not universal. And the reason I bring those two up is that if we understand the menstrual cycle, which I know not most people do, the menstrual cycle involves a really beautiful interplay between the two hormones, estrogen and progesterone. Estrogen's job is to stimulate the lining of the uterus. And then after an egg is released, halfway through. Through progesterone comes in, stabilizes the lining of the uterus, and gets it ready for a pregnancy. If you don't get pregnant, estrogen and progesterone drop, and the bleed is the withdrawal of those hormones. And so there's a, you know, this beautiful dance between the pituitary gland in the brain, the ovaries that are making the hormone, and then the uterus. Right. Which is where a pregnancy would live. So when you. When you're trying to suppress that, essentially you want to prevent. Prevent pregnancy. The goal is to prevent an egg from being released. If the brain sees the hormones that are made after an egg is released, it has this thing called negative feedback, right? So the brain says, oh, wait, those hormones are in the body. I don't need to get an egg ready.

[Dr. Rena Malik]

Yeah.

[Dr. Tammy Roman]

The issue is that we cannot give people natural estrogen, which. The most abundant form in the female body is estradiol and natural progesterone, because they are not strong enough to feed back on the brain and suppress ovulation.

[Dr. Rena Malik]

Right?

[Dr. Tammy Roman]

So it is not a plot to give people synthetic hormones because we don't want to be giving them something that's, quote, natural. It's that what is our goal here, right? And the goal is to suppress ovulation. And it's not just about birth control. Suppressing ovulation prevents recurrent ovarian cysts. It actually prevents ovarian cancer because the cells are turning over less. It even prevents uterine cancer, endometrial cancer, people who have painful periods. I mean, there's many reasons why there's a benefit benefit, but you have to have synthetic hormones to get the benefit, and that's where it gets messy. Ethanylestradiol is a form of estrogen that is incredibly strong. And so it binds to the estrogen receptors and it holds on real tight. All right? And so. And if you take it orally, and even actually, if you take it transdermally, vaginally, or through the skin, when the liver sees it, the liver's like, oh, my God, there's all this estrogen, and it. It puts. Puts out clotting factors, and that's why we see a, you know, increased risk of clots. The original birth control pills had 100 to 150 micrograms of this stuff. They. This was new. Nobody knew how much you really needed. Yeah, that is a huge amount. Now we have 35, 30 or less. Right. These are all lower doses. So the you know, the biggest fear about clots is with the older forms.

[Dr. Rena Malik]

Yeah.

[Dr. Tammy Roman]

Similarly, the progestin is really the key component. You cannot suppress ovulation without a progeny progestin, and that is a synthetic form of progesterone. So it looks, it targets the progesterone receptors in the brain, in the uterus and other parts of the body, and it is the driver that suppresses ovulation. Ethanol, estradiol also will do that. The combination of them together also is very good at suppressing bleeding because the biggest side effect from all birth control forms is abnormal bleeding. The uterus wants to bleed. It's really, really difficult to control bleeding. And anyone that's been on birth control knows even on birth control control, you might still have bleeding.

[Dr. Rena Malik]

Right.

[Dr. Tammy Roman]

And so that's where we see the issue. And the other biggest issue in sexual medicine is if you are taking these pills and the liver sees it, not only is it making clotting factors, it's making sex hormone binding globulin. Right. And that means the liver says, oh, there's all this sex hormone, there's all this estrogen. I need to make a protein to bind it up. Well, that protein prefers testosterone to estrogen. So it's going to bind up all of your natural circulating testosterone before it's going to tackle the estrogen. Which means every person on these medications has lower testosterone. That doesn't mean it's going to cause a problem. Right. But for some, it actually does.

[Dr. Rena Malik]

Yeah, yeah, that's a great, great description. It's very, very clear because I feel like, again, there's just so much misinformation around contraceptives and contraceptives are valuable and useful and helpful for many, many, many women and have really changed, changed. Basically a sexual revolution. Right. Women can have sex and be free, like without the fear of pregnancy, which is huge.

[Dr. Tammy Roman]

They're the original sex med drug.

[Dr. Rena Malik]

Yeah, absolutely. So I think we sometimes forget that, you know, and so in terms of, you said there, there are a lot higher doses of, of hormones. So in women who are perimenopausal and on these medications, are they seeing a benefit? Do they still need to go on menopausal causal therapy if they want hormones?

[Dr. Tammy Roman]

That's such a great question. There's so much confusion around this. So, you know, the hallmark of perimenopause is fluctuating hormone levels. And so I think about the ovaries and as sputtering cars. I've been saying this forever, but I think many people in the menopause world Say this. So it's just spitting out hormone. That's why testing hormones is just impossible. The highest estrogen levels I have ever seen are in perimenopause. And when I just got out of practice, I thought people had tumors. I thought they had ovarian tumors. Until then, I looked at the literature to say, well, what actually happens in perimenopause? And it was exactly that. It was these crazy high and low levels, and that's what's driving the symptoms. People are also skipping menstrual cycles or. And their progesterone levels are getting low, and they oftentimes have mood symptoms associated with that. And so it makes a lot of physiologic sense to say, well, we could actually stabilize this whole thing if you just. Just took an oral contraceptive, right? It would. Then you're not having any of those fluctuations. Birth control hijacks your pituitary system. Your natural hormonal milieu is. Is. It's not happening. That's why you can't test. People want their hormones tested on birth control. You can't, like, you're not making any hormones, you're taking hormones, right? And so there's a really big benefit to doing that. For some people, it really helps with abnormal bleeding. It really gives them a steady state of hormones, hormone. And for a lot of the perimenopausal symptoms, like hot flashes, it makes it a lot better. Now, some people may still have hot flashes just because the ethanol estradiol works a little bit differently in the brains and in the bone, but it really, for the most part, controls the vast majority of perimenopausal symptoms. And it works as a birth control. And people in perimenopause can get pregnant. So that's the argument that the people who are the universalists. Right, we just said that. You know, some people say everything should be this way. That's the argument they make, make that all people in perimenopause should be on birth control. I see it differently because I'm not an absolutist about anything. It's what are my goals for this particular patient. So in general, if someone's on birth control, I would not add in additional hormone therapy. If they're having hot flashes, then there are other medications that can target the hot flashes. You know, in particular, if they're having other effects that they oftentimes come in and say, well, I'm perimenopausal. You know, I'm having brain fog. And then we have to add kind of Tease out why that might be. Again, just because hormonally I can't explain it. I'm not going to say it's not happening, but I don't have a physiologic explanation because they are not deficient in hormones when they're on hormonal birth control.

[Dr. Rena Malik]

Right.

[Dr. Tammy Roman]

That said, there are some people who don't need a birth control or they're on another form of contraception. They have an intrauterine device. They, you know, had a salpingectomy, their partner has a vasectomy and they're monogamous. Like there's, you know, not everybody has to have a birth control method. And for those patients, I may recommend more traditional menopausal hormone therapy in the form of a natural estradiol and progesterone. So it's just very person dependent.

[Dr. Rena Malik]

Do they need to be at higher doses during perimenopause in terms of if you're giving them menopausal therapy?

[Dr. Tammy Roman]

That's a great question. It really depends on what their symptoms are in general. You know, the way I think about this is a lot of this, the menopausal transition symptoms, especially the hot flashes and vasomotor symptoms, I think about as the fluctuations. And so I, you, you know, we, I will see people say, oh, if you're in perimenopause, you should be on high doses. The way I think about it is if you're a wave, I your wave to not crash as low.

[Dr. Rena Malik]

Right.

[Dr. Tammy Roman]

So I'll give you a treatment that gets your estrogen up to a certain amount. You're still going to have the spikes. Menopausal hormone therapy does not suppress ovulation. It will not suppress the hormonal fluctuations. Right. If you're giving just traditional estrogen and progesterone. Now there are other ways to do this. I could give you a progestin. So there are progestin only pills that were designed for birth control or for controlling bleeding that will suppress ovulation regulation. Right. And so they actually will suppress those spikes, which is kind of cool. And then I can add on some, you know, natural estradiol. And so that will be usually where I tend to go because I prefer natural estradiol.

[Dr. Rena Malik]

Yeah, yeah. What about the bone benefit? So obviously we know that menopausal therapy is FDA approved for prevention of osteoporosis. So if someone's on birth control, because I just had Vonda write on and she talked about how bone loss can occur very early in life. They still getting benefit to their bones.

[Dr. Tammy Roman]

They absolutely are. It's a great question. So birth control, the ethanyl estradiol, does not work as well in the bones as natural estradiol. And we don't, you know, this is one of these things that we have to start getting honest about.

[Dr. Rena Malik]

Yeah.

[Dr. Tammy Roman]

There are studies in adolescent women and again, I am totally pro birth control for many different reasons, but there are studies in adolescent girls that if they're on birth control, starting from early ages, they have lower bone mineral density than their peers who are, are not. This doesn't mean they shouldn't be on it, but it is something we all need to be aware of. And there is some evidence, even when they stop that they don't catch up right away. There's, you know, other ways in which they would catch up.

[Dr. Rena Malik]

Is it affecting, is it, is there a reason their bone mineral dentist is low?

[Dr. Tammy Roman]

Yeah, because the, the natural estradiol is better at bone development. They're not making natural estradiol. Yeah. So remember, the whole pituitary system is, is suppressed. That's why if you test it, you're not going to find estradiol in the, their blood because they're not making it. They have an estradiol.

[Dr. Rena Malik]

It's gonna look really low.

[Dr. Tammy Roman]

Yeah, it's gonna look really low. Yeah. So in, in development it seems to be more of an issue. We don't see the same issue once the bones are fully developed. So once you're in your 20s and 30s, there is not a deficit in terms of people taking birth control in terms of their bone health. So in perimenopause, I suspect your bones are already grown, that it is not, you know, that you're going to have, you know, it's probably a neutral at most effect. And so you're probably preventing the loss that could be happening if estradiol is going down. But remember, estradiol is actually kind of all over the place. So we lose bone. If you're going to be having a steady state with a birth control, it's probably protective. And so that's really the best I would say about it.

[Dr. Rena Malik]

And then in terms of IUDs or any other long acting birth control where you're not bleeding, I think that's very difficult for women to identify when they're in perimenopause. Especially now where there's all this discussion about, about perimenopause and, and oh, you should start treatment sooner or there's, you know, like, there's a lot of fear, I think, unfortunately, about going into perimenopause so how can women who have these sort of birth control methods where they're not bleeding identify when they're going into perimenopause?

[Dr. Tammy Roman]

So it's. So going into perimenopause is just a complicated issue in general because we have no good definition of perimenopause. Right. It's really when they go, you know, when you say, when are you in menopause? And so, you know, the definition of menopause is one year without bleeding. If you have an IUD and you're not bleeding, you don't know when that one year was. Right. So then it's really symptom based. And now some people go through menopause with no symptoms. I know it's hard to believe, but it really does happen.

[Dr. Rena Malik]

Yes.

[Dr. Tammy Roman]

And so people wouldn't know. So then you would, you know, you don't have to test levels. You really don't. You could, you know, and what you're looking for is a follicle stimulating hormone, which is the hormone the brain produces. I think of it as how hard is the pituitary telling the ovary to make estrogen and get an egg ready. And you can imagine if there's no eggs and no estrogen, it's going to be high, it's working hard. Right. So we think of an FSH. We want it to be above 25 on two occasions, not just one occasion. Because in perimenopause we see it go up, but it fluctuates. Right. So you want two FSH levels six months apart. Primary ovarian insufficiency is a little bit different in younger women if they don't have an IUD and they have irregular cycles. You only need one level of an elevated FSH to say we're worried about the OV and that would suggest perimenopause. But if you're still having bleeding, it's not quite menopause. So that's really the answer. There's no way that you need to know either. Right. Everyone's like, I need to know when I went through menopause, really, what are we treating? Right. I don't like. If you want hormone therapy for various reasons, you don't need to be in menopause to get it. You could be in perimenopause, you know, so that's. That. That would be my answer to that.

[Dr. Rena Malik]

Yeah. I suspect that people want to know because they may feel like they're having some symptoms. And some of these symptoms that people are discussing are quite vague. Right. Like trouble sleep, or they're not necessarily having hot flashes, but they're like, maybe brain fog, maybe trouble sleeping, maybe just not feeling quite like themselves. And so they're like, oh, am I in perimenopause? And that's. I think that the real question is like, am I? And should I go talk to my doctor about potentially getting hormones?

[Dr. Tammy Roman]

I think it's a great point and certainly for younger patients, because people, you know, will go through early. You know, we call it premature menopause if you're before 40, early menopause if it's before 45. And those are the patients that are going to benefit significantly from hormone therapy. And, you know, I said, you know, is birth. You know, what's the benefit of birth control? A lot of those patients. Patients take birth control and they're going to. Absolutely. We're talking about bone health. Have a significant benefit from using, you know, oral birth control pills. You know, if they're going through it early. And most people will get prevention of bone loss. So for those patients, yes, they should get treatment. The. The bigger issue, or not treatment, but evaluation. The bigger issue is the ones who are in the natural age of menopause. Right. Like, that's more of the, you know, that's where it's. Are you. We're going to universally say, if everyone should be on hormone therapy, well, then, sure. But if not everyone should be on hormone therapy and you're tolerating your symptoms or you're barely noticing them, is it necessary, not necessarily going to benefit you?

[Dr. Rena Malik]

And I think the thing that I'm hearing from other women is, well, I want to make sure I'm protecting my bones. I want to make sure I'm protecting my heart. I want to make sure I'm protecting my brain. And we know the data is sort of mixed on heart and brain, but definitely for bones. And so I understand their concerns, and I think they're just like, well, I want to get ahead of it, right?

[Dr. Tammy Roman]

I want to get ahead of it. I hear that all the time. Yeah, I want to get ahead of it. I want to get ahead of it. It. I mean, you know, at the end of the day, there's a lot of ways to get ahead of things. And so, yes, absolutely. So hormone therapy will absolutely prevent bone loss. So we. We know that it actually will treat bone loss first. You know, the guidelines don't say that it treats. Not to. They don't say to use it for treatment of osteoporosis, even though it does treat osteoporosis.

[Dr. Rena Malik]

Yeah, they don't say that.

[Dr. Tammy Roman]

They don't say it, and it's not. And I've gotten into it with people and they're like, well, when I say, can I show. I'll show you the data that it does treat it, they'll be like, well, here are the guidelines that say that don't include using it. I'm like, guidelines are very different from evidence. Right. Like, the reason the guidelines say not to use it is because they think the risks outweigh the benefits in older women because they're still stuck on the whi. Right. But it actually is a treatment for osteoporosis if you look at the multiple randomized controlled trials. But again, either way, we know it is preventative. There's many ways to prevent bone loss. Right. And so, you know, weight bearing, exercise is a huge one. You know, you know, calcium, vitamin D. There's, you know, all kinds of mixed data on this, but there's other ways to get ahead of things. But if you want to be taking hormone therapy to prevent bone loss, I think it's a very reasonable thing to do. But you're not behind necessarily. You can build up some bone if you, you know, are waiting to see whether or not you want to take hormone therapy. So I think that, you know, this is where we have to have the argument is, should people be using this for primary prevention of something? And I think think that's up to them. There are side effects to these hormones. You know, so some people get really bad breast tenderness. Some people get really bad headaches. There's, you know, you can get abnormal uterine bleeding. So as long as people understand that, that it's not some universal, you know, good without any other side effects, I think it's very reasonable to want to be taking this for the preventative benefits. The cognitive. The. The cognitive benefits. If you're having brain fog, it's therapeutic. I will. I have a big issue with the dementia claims because we know that, you know, biologically, if you look at what estrogen does to the brain, it seems to be protective. We know that. We see this in lab studies. We see this. You know, we see that there are significant brain changes that happen when people go through perimenopause and menopause. The problem is we have no data that shows that giving estrogen actually prevents dementia. Yeah, I really want us to have that data, and we don't. And it's not a. It hasn't been looked at. It's been looked at.

[Dr. Rena Malik]

Right.

[Dr. Tammy Roman]

And so the issue now Is. Is it a formulation issue? Right. Because the older way we gave it is different than how we give it now. We gave it with different progestins as opposed to the natural progesterone we oftentimes use now. So I. I'm very excited for the day that I'm going to be proven wrong for questioning this dementia claim. But I'm a very, you know, scientific person and I understand it physiologically, I understand what, why it makes plausible sense. I just think that most of the data has not shown, and I think

[Dr. Rena Malik]

my theory is that, and this is sort of substantiated by the data, is that if you really do have terrible hot flashes that are keeping you up at night, that you're not sleeping well. Well, we know sleep is great for preventing dementia. Right.

[Dr. Tammy Roman]

So 100%.

[Dr. Rena Malik]

If you're sleeping because you're treating your hot flashes. Absolutely. You're protecting yourself.

[Dr. Tammy Roman]

Yes. And vasomotor symptoms also correlate with other outcomes, cardiovascular risk as well. And so. So that's why you can't, like, you know, this idea of giving it to asymptomatic women hoping to get a benefit. The people who are most symptomatic are the ones at most risk. Right. And so it's really hard to tease that out if we say we're going to give this universally to people, because the data shows that those that took it may have had a benefit. Well, they also may have had more risks.

[Dr. Rena Malik]

Yeah. I think generally, if your symptoms are bad, you should be treated 100%. Absolutely.

[Dr. Tammy Roman]

The other thing that also prevents dementia is exercise. And I'll say it over and over again.

[Dr. Rena Malik]

Had I've had friends on who are experts in brain health, and they will say exercise, even over sleep. Like, if you have to wake up early to exercise and lose an hour of sleep, it's actually better for your brain. So exercise above all else.

[Dr. Tammy Roman]

So, I mean, that's the thing, is there's so many things we can do, Right. We pin it down. And again, this is a toolbox, Right. So we focus so much on hormone therapy, but there are all these other things you can do. You know, it's the same as, you know, women who are at increased risk of breast cancer. You know, I know people who are like, I'm so worried about breast cancer, so should I get a mastectomy? Should I, you know, get all this treatment? And the breast cancer docs are fabulous now, and they'll just look at you and say if you exercise and you don't, you know, you cut down on your alcohol. You literally cut that model risk in half.

[Dr. Rena Malik]

Yeah, absolutely. And. And I think the other thing we don't talk about enough is stress. And I think sometimes all of this information is just creating so much stress

[Dr. Tammy Roman]

for people because there's a. Should I. Do I. Should I get that everyone's coming in. Should I be on this? Someone's telling me I need to be doing this, and if I'm not, I'm putting myself at risk. Yeah, right. And that creates a lot of stress.

[Dr. Rena Malik]

And they'll just hear a clip of something big. Oh, my God. Like, it protects my brain, it protects my heart, whatever it is. And they're like, I should be doing this. And then I'm not. And then, oh, I got to get to the doctor. And the doctor tells me no, because maybe for a good reason, maybe they don't need it or maybe, you know, whatever, but then they're like, oh, no, my doc. You know, there's. There's so much stress around it.

[Dr. Tammy Roman]

And it's also that I miss the boat. I'm older now, and there's a lot of resentment and anger, you know, understandably, in patients that were harmed by the whi. Right. Who were told and removed from the hormone therapy, are told they couldn't get it, and now they want to get it, and they're past the point where we see those benefits. Doesn't mean it's harmful to give it to them. I think that's up for debate, but they're past the beneficial point in terms of prevention. Right. And, you know, we talked a little bit about what makes people age well, and I think about this a lot in my own family, and everybody's got anecdote, but I have a lot of. Of aunts in my family, and I have mothers in my family, and I see I have the most thriving, healthy women in my family. And they are these models to me. And what I think is so neat about them is some of them are on hormone therapy, some of them weren't. Some of them exercise a lot, some of them don't. But they thrive because the most important thing to them is their relationships with other people. And so I just. And their community. And I see this, and I just want to say it over and over again, you know, and I. When I tell people to exercise now, I'm like, exercise, Exercise with someone else. It's really good to exercise. But make it a community event. If you're an older woman and you want to have longevity, because we're. We're. We're Talking about all these kind of self centered things we can do for ourselves. And it oftentimes can isolate people from actually the most important thing and the number one predictor of happiness, which is your relationships with other people.

[Dr. Rena Malik]

Yeah. Or it can be a place to meet people. Like. Yeah, I find that I talk to a lot of people at the gym. Like, you know, you just have a conversation, you just chat and you make friends and it's, it's lovely and it could be going for a hike or going for a walk, but always, you know, trying to do it with somebody can be so helpful. And I agree, I think we really underplay the value of connection and the value of, of, of just having a stress free, like reducing stress. I think those two things are not talked about enough. And we spend so much time talking about these other things. But the reality is like, that's a huge part of our life. And if this is stressing you out, like turn it off, go do something else. But, you know, hopefully it's helping. You know, I just want to talk quickly. You mentioned ovarian cysts and I think a lot of people don't know why you get an ovarian cyst. I didn't know that birth control prevents ovarian formation. So why do women get them? And are how often are they symptomatic?

[Dr. Tammy Roman]

Yeah, so when you're ovulating, right. So every single month an egg develops and it develops in a cyst. It's called a follicular cyst. So literally every single month an ovarian cyst is made sure. Right. Whether it becomes symptomatic is just depends on the individual. And so symptomatic cysts usually are. After ovulation, you're left with a corpus luteum cyst. Every single time you ovulate, you have a cyst. Sometimes that cyst ruptures and bleeds. And that is a symptomatic cyst. And it can bleed a lot into the belly and it is very painful. And so the way to prevent that is to prevent ovulation. And that's what birth control does most birth control. Now some birth controls don't, so IUDs are a great, great example. Right. So if you get an IUD that has hormones, it will suppress the lining of the uterus so that you don't bleed. But the majority of people are actually still ovulating and they is there's a slightly increased risk of cyst formation with an iud. And so sometimes people will start getting recurrent cysts that are symptomatic. And then you have to, you know, give something to suppress ovulation that is different than something like pcos. And this is a misunderstanding. Understanding polycystic ovarian syndrome is not a bunch of big cysts in the ovaries that ca. That rupture and cause bleeding. It's when the eggs actually don't reach maturity, you don't ovulate. And so you see a peripheral redistribution of a bunch of small little cysts in the ovary that enlarges the ovary, but they're not symptomatic. So a lot of times people are like, oh, I make cysts, therefore I have pcos. No, actually, if you may have. You have asymptomatic cysts, you're much less likely, because people with PCOS don't ovulate usually.

[Dr. Rena Malik]

But normally that corpus luteum cyst goes away.

[Dr. Tammy Roman]

Absolutely.

[Dr. Rena Malik]

Right. Like on its own.

[Dr. Tammy Roman]

It lasts for about 10 to 12 days normally. And it's actually the involution of it and the drop in hormones that will lead to your period. And so if you see. If someone has a hemorrhagic cyst, if they're bleeding, you check it in six to eight weeks, and it's. It's gone. It'll be completely gone.

[Dr. Rena Malik]

I do want to talk a little bit about progesterone, because I think. I think people. Which is true. It is. It is given in hormone therapy for the protection of the endometrium. But there's more to it than that.

[Dr. Tammy Roman]

A lot more to it than that.

[Dr. Rena Malik]

Yeah.

[Dr. Tammy Roman]

Yeah.

[Dr. Rena Malik]

So tell me, what are the benefits of progestins?

[Dr. Tammy Roman]

So. So progestins and progesterone are a little bit different, but we already talked about the fact that, you know, when the egg is released, the corpus luteum makes progesterone and it stabilizes the lining of the uterus. And this is key because we talk about the safety of estrogen, estrogen all the time. And it is. It's incredibly safe, except at the level of the uterus.

[Dr. Rena Malik]

Right.

[Dr. Tammy Roman]

And so if you take excess estrogen, you will develop endometrial hyperplasia, which can lead to endometrial cancer. And so, you know, when I talk about that estrogen, you know, does it cause breast cancer? No, but it causes uterine cancer. Yes. And I've seen it and I've diagnosed it. So you have to take something to protect the uterus. And so we have traditionally given a pretty progestin, which is a synthetic progesterone. That targets the receptors, works better than natural progesterone, but has more side effects sometimes. So I just. With that said, we oftentimes then say, well, the only role of progesterone or progestins is to protect the uterus. And natural progesterone does so much more than that. There are progesterone receptors all over the body. So there's progesterone receptors in the brain. It affects how we respond to our own neurotransmitters. It raises the seizure threshold, which means that it actually prevents seizures. There are progesterone receptors in the lungs that facilitate gas and oxygen exchange. There's progesterone receptors in the gut that help with smooth muscle relaxation. That's why people get so constipated in pregnancy, because it's a high progesterone state. And so you can just see that there's progesterone receptors in the pancreas and in the liver, all over the place. Right. So it's not just the uterus's protector. And for some people, they really do get a benefit from taking progesterone in. In for other reasons. And so in perimenopause especially, I do see that that progesterone can be incredibly beneficial to help with sleep. It targets GABA receptors. It's very relaxing. And so if the only symptom people have is sleep, which is oftentimes the first symptom of perimenopause, I just treat them with natural progesterone. Now, the key is that that natural progesterone, if you take it orally, it metabolizes right away. And so you can't get a therapeutic benefit. So it is micronized. It is broken up into smaller molecules, so it will last longer. So that is micronized progesterone. Prometrium is the brand.

[Dr. Rena Malik]

Yeah.

[Dr. Tammy Roman]

Micronized progesterone is not that well absorbed. So there are some people who still get the endometrial. The lining of the uterus grows and they might have bleeding off on it. And there's also other people that don't tolerate its side effects. So when it is metabolized in the body, it metabolizes into neurose sedatives, which means it makes you sleepy. And for some people, it makes them too sleepy. And for some people, it makes them incredibly depressed. And I've had patients where they cannot tolerate it. In that case, we use things like a progestin. So it's synthetic. Maybe it won't have those side effects. And it also can sometimes help better with bleeding. The issue then is some people still have really bad side effects. And in the older progestins, especially Provera, which worked the best in the uterus, that there was concern that that could stimulate breast cancer. And that was the whole culprit in the WHI of the increased risk of breast cancer was due to that progestin. Oftentimes that gets extrapolated and saying to progesterone. So you'll see me in like every reel and every talk I give be very specific. Are we talking about pretty progestins? Are we talking about progesterone? Because progesterone does not seem to increase the risk of breast cancer. We only have up to five year data, but even in lab studies it doesn't stimulate breast cancer cells the way some of the synthetic progestins do.

[Dr. Rena Malik]

And is it all the synthetic progestins, the specific ones? Yeah, yeah.

[Dr. Tammy Roman]

No. So the biggest culprit was medroxyprogesterone acetate and that is Provera. And that's the one that was used to store in almost all hormone therapy because it works very well at protecting the uterus. And that one is has been seen in lab studies to stimulate breast cancer cells. It's also vasoconstrictive. And so we don't talk about this, but in the whi, those on Provera had higher rates of cardiovascular disease. We always say that the WHI the risk was higher in women over 60, but it was worse from the estrogen alone group. And then the estrogen and progestin group had worse outcomes. Similarly, dementia risk.

[Dr. Rena Malik]

Yeah.

[Dr. Tammy Roman]

In when they gave hormone therapy to women over 65 to prevent dementia. The estrogen alone, it didn't prevent it. It didn't make it worse, but it didn't prevent it. And it was not natural estradiol, it was conjugated equine estrogen. But when they added in the Provera it made it worse. They had more dementia. So like this is just not the progestin to use for long term hormone therapy. Yeah. Other progestins like north enduro and acetate is one that I really like. Doesn't seem to have as stimulatory effect, but it does have a little bit of an effect on breast cancer cells. But there's no study using it exclusively to show that that would increase the risk of breast cancer because it's just not used that much in hormone therapy.

[Dr. Rena Malik]

Yeah.

[Dr. Tammy Roman]

And then drospirenone is another commercially available progestin that is really Used for birth control. So we don't have any data on what it does to the breast cancer.

[Dr. Rena Malik]

Yeah, yeah. But isn't. Nor thone also used for birth control?

[Dr. Tammy Roman]

So northendrone, but not. Nor thorone acetate. So they're. They're there, but it could be. So. So this is just where you get into the nuance. I love progestins. Like, this is my favorite topic. So north syndrome is the mini pill, and it's in a 0.35 milligram dose. It works to thin the lining of the uterus, thicken the cervical mucus. It works kind of like an iud, honestly. And it doesn't suppress ovulation in everybody. It has no. Never been studied as a hormone therapy. Uterine protector. And I, I wouldn't use it for that just because it's so low dose. Yeah. Norone acetate, on the other hand, is actually more potent and it's. It is available in 5 milligram pills that you can cut in half. And in birth control, it's in 1 milligram. And so. And the reason that's important is that nor acetate has never independently been studied as a birth control, even though it probably works.

[Dr. Rena Malik]

Yeah.

[Dr. Tammy Roman]

But what it's fabulous for is dysmenorrhea and abnormal uterine bleeding treatment. And then I also think that it works great as a hormone therapy. And it's also transdermal in the combi patch. So you can combine it with estradiol and get that nice benefit.

[Dr. Rena Malik]

Yeah.

[Dr. Tammy Roman]

You cannot absorb natural progesterone through the skin.

[Dr. Rena Malik]

Yes.

[Dr. Tammy Roman]

So that's something that, you know, people will get their progesterone creams and they're like, I'm protecting my uterus. And no, it's too big of a molecule. The skin doesn't want things to get through it. You cannot absorb it through the skin. It will get absorbed through the vagina. So if you place micronized progesterone in the vagina, it will absolutely get absorbed into the uterus. But putting a cream on your skin will not help your uterus.

[Dr. Rena Malik]

Absolutely. And there's a lot of people selling these creams and they're not really. I mean, I don't know what the benefit would be for a progesterone cream.

[Dr. Tammy Roman]

I mean, people think it's natural, it's transdermal. They should get terms of.

[Dr. Rena Malik]

Besides what people think, is there any benefit? No. Right. There's none. Okay.

[Dr. Tammy Roman]

Yeah. Not that I know of. I mean, again, people might feel good and I'm not going to Tell them they don't feel good on it. I'm just going to say that, like, if I tested their blood levels, I once had a patient who didn't, you know, really was reluctant for me to try to get her off of it. So she's slathering the cream like four times the amount that she's supposed to be using and then checked a blood level. And the blood level was somebody who barely ovulated. Right. And so I can say, look, if you're trying to get the blood level of what, like a natural cycling woman is, you can't even get, get that by pouring the stuff all over your skin.

[Dr. Rena Malik]

Yeah, yeah, that's. It's so sad. It's so sad that people are even offering it. Like, there's really no benefit.

[Dr. Tammy Roman]

There's a lot of marketing.

[Dr. Rena Malik]

Yeah. And the placebo effect is real. Right. Like, we obviously know it from the men's health data. Like, if I give you a pill and tell you it's going to help your erections, 40% of guys are going to get erections. Right. And so similarly with most medications, you know, if you think it's going to help you.

[Dr. Tammy Roman]

But estrogen is a carcinogen. Like, again, I think it's a fabulous drug. Estradiol is wonderful, but if you have a uterus and you are taking estradiol, you are putting yourself at significant risk if you're not taking something to protect the uterus. And I know there are people out there that are like, well, I'll just monitor the uterus. I'll just do an ultrasound every year and I'll just say over and over again, this is my practice. Ultrasounds don't prevent cancer, nor do they diagnose it. You have to do a biopsy. Those are horribly painful, you know, and so to me, I wouldn't give somebody a medication that I know for a fact will cause cancer. Right. There's, there's questions. We can have debate, right, about whether or not things are dangerous. There's this open debate about testosterone because we don't have long term studies on the breast. I think the data is very reassuring. But that's not. The estradiol is not a question. It's not equivocal. It will cause uterine cancer if you take it, you know, unopposed for a long period of time.

[Dr. Rena Malik]

But cycling progesterone for like 12 or 14 days, is that sufficient?

[Dr. Tammy Roman]

So it is if it's the appropriate dose. And so, you know, there's, there's an argument that people make that you should be cycling progesterone for a couple different reasons. One is that's what the body is used to. Right. I told, we've been talking about the menstrual cycle, this whole talk. Right. That you cycle, you get about 12 days of progesterone exposure in a normal ovulating woman. Right. So that's one argument people make. So that's the natural way to do it. The other argument people make, and it's a real one, is that progesterone does downregulate estrogen receptors. And so there is this idea that if you're taking progesterone every day, maybe your estrogen isn't as effective. So if you cycle it, maybe it'll be more effective. Two things I have to say about that. And this is again, just, this is just person dependent. This is how I practice. Our bodies were never used to ovulating and cycling this much. Women were always either pregnant or breastfeeding for almost all of history until a hundred years ago. And so this idea that it's good for us to be having these cycles, I don't know if that's true. Right. That's not what our bodies were doing for most of humans, human history. Right. So what's natural is being pregnant or breastfeeding. Not that's a good thing. Right. But that's, that's my response to that, that we're actually either used to being in a constant progesterone state that is pregnancy, or an anovulatory state that is breastfeeding. Right. Okay. Then the other issue is the cycling, you know, are you releasing the estrogen receptors? I understand that argument. The issue is if you cycle the progesterone you have to take, you might have to take a little bit more of it. Certainly if you're taking micronized progesterone, you do, you have to take twice as much. The studies are very. Either 100 milligrams daily or 200 milligrams cyclically are the best regimens. Some people need more than 100 milligrams. Just as I said, it doesn't get absorbed as well. But my experience is sometimes when people cycle, they have more side effect to the medication. And these are the patients that I've seen be like, well, I don't like the effect of progesterone, so I'm just going to stop taking it. And those are the ones that I've diagnosed with uterine cancer later.

[Dr. Rena Malik]

And they don't realize.

[Dr. Tammy Roman]

No, they, I'm sure someone told them, but then they Were, you know, they didn't. And someone then kept prescribing them unopposed estrogen. And so that's my response to it. I, I am someone who has diagnosed enough endometrial cancer that I am a little bit more of a fan of taking something regularly. And also the benefit of daily progesterone, especially for sleep, if you're taking it at night, that's oftentimes what I'm trying to get people. And you won't get that if you're taking it cyclic.

[Dr. Rena Malik]

No, absolutely. The other thing I want to ask you about is estrogen cream on your face.

[Dr. Tammy Roman]

Yeah.

[Dr. Rena Malik]

So there is not a ton of data on this in my understanding. So what are your thoughts on it?

[Dr. Tammy Roman]

So there was a good review, actually. I don't know if it's. There was. It was in pre release in the Journal of Dermatology that was kind of looking at all the different studies and you know, the way most people are doing it is they're taking the cream that's like the dosages that are placed in the vagina and just putting it on your face. We know that estrogen is really helpful for collagen production. We, we know the skin changes greatly when you go through menopause and that menopausal hormone therapy can, can really help with that. So it makes sense that putting it on your face does. And all of most, not all. Most of the studies have shown that to be a benefit. And so I think there is evidence for it. The question people have is about safety. Right. So there's this concern we kept talking about. If you get a blood level of estradiol, could that stimulate the lining of the uterus? Do you need to protect it with progesterone? My response to this, that is I, you know, I talked about how hard it is to get hormones absorbed through the skin. And if we're putting the same concentration that we put in the vagina that we know doesn't cause a blood level or causes risk.

[Dr. Rena Malik]

Yeah.

[Dr. Tammy Roman]

Putting it on the face. It is real hard for me to imagine how that could be a risk. Right. This is keratinized skin. The vagina is not. Right. So it is. I am not particularly worried about the safety and I think the efficacy seems to, to be there in most studies.

[Dr. Rena Malik]

Yeah, yeah, I, I agree with you. I think it's. But there are, I think from what I remember reading is that some people do have like, I forget what they skin.

[Dr. Tammy Roman]

Melasma.

[Dr. Rena Malik]

Yes. With it. So I think hyperpigmentation just to, to consider if that's safe for you if you are already someone who's at risk for hyperpigmentation or you get, maybe you want to talk to your dermatologist.

[Dr. Tammy Roman]

Yeah. And, and, and hyperpigmentation melasma happens for people that take birth control and for people who are pregnant. And so if you're someone, you know, if you're someone, someone who's prone, you wouldn't have known that.

[Dr. Rena Malik]

Yeah. At least when you were pregnant.

[Dr. Tammy Roman]

At least when you were pregnant. But some people do get it just when they start taking the cream on their face as well.

[Dr. Rena Malik]

Yeah, yeah, absolutely. There's some news in gynecology that there are now at home cervical screening tests, which I think is really exciting, but I don't know that everyone knows about it. So tell us how does it work and is it effective and how can people do it?

[Dr. Tammy Roman]

Yeah, so the, you know, the main cause of cervical cancer, 99% of cervical cancer cancers are caused by the HPV virus. And so everybody that's had sex essentially has been exposed to the HPV virus. So the main thing to understand is that most people, when they get infected with the HPV virus, their body clears the infection, but if they don't, it is persistent in the cells and you can find the HPV proteins in the cells on the cervix. Now historically when we were testing for cervical cancer, we weren't looking for hpv, we were looking for changes in the cells. That's what a Pap smear is. What has changed is that we now can actually test those cells for HPV and if they are not expressing hpv, the chance that you will get cervical cancer in the next five years is essentially zero. Cervical cancer is a very slow growing cancer. So the reason this is important is that we don't have to do a Pap smear anymore. We don't have to take a swab of cells and put it under a microscope. We can take a swab of cells, cells and test it for hpv. So we've been doing that in the clinic, in the office for a long time now, for many years. And now you can do it from home. The idea is that if you just put a Q tip essentially into the vagina and as high as you can swab it around and then send it to a lab, you, they can test those cells for HPV and if it's negative, it is showing to be as effective as doing it in the clinic. And you know, we have been doing self swabs in the clinic and now we're moving towards doing self swabs at home. But the caveat is it's, we have to reserve this for lower risk people, for people that we, we want to make sure we're, you know, if they're higher risk, we might miss something if we're not doing something in the clinic. And so if you're immunocompromised on long term steroids, for example, or have hiv, we're not recommending this. You know, if you're someone that has a history of cervical cancer or cervical dysplasia, we would be less excited. And instead of, of waiting five years, we're going to say we want you to repeat it in three years because we just don't have the confidence to say we can wait five years. Like if we collect it in the

[Dr. Rena Malik]

clinic and it's as effective. Meaning that as long as you follow the instructions, it's going to, yeah, it's

[Dr. Tammy Roman]

going to show the same results that we would do in the clinic.

[Dr. Rena Malik]

That's awesome.

[Dr. Tammy Roman]

It's awesome. It's amazing.

[Dr. Rena Malik]

It's so funny. I will share this with you. I was talking to a couple physicians, male physicians yesterday about this and they were like, well what, they're just going to swab it wrong? And I, I was like, if I asked a man to do something, you would never say that to me. You would never say they're gonna, they're never gonna, they're not gonna do it wrong. Like we, I think we are motivated to not have to have a pap smear if possible.

[Dr. Tammy Roman]

And again, this is, I mean this is not an evidence free zone. This has been studied with like thousands of women showing that like you give them the instructions, they do it and if they came into the clinic, it looks exactly the same.

[Dr. Rena Malik]

Yeah, yeah. And that's great. And they just get it from their doctor like a prescription. How does it work?

[Dr. Tammy Roman]

So there's different at home kits, but it usually would be given by the do. My guess is we're going to start seeing, just send home kits. And, and, and now the, the idea is that you would drop it at your doctor's office. There's probably going to be movement towards just sending it into a lab. The issue then becomes follow up. Right. And so that's why it's so nice. If you drop it at the doctor's office, the doctor provides it for you because you are not the doctor but the provider. You have that relationship. So if there's an abnormality, this is the biggest issue is if it comes back positive, then there is, is additional Testing that needs to be done. So it's really important to have a relationship with somebody who can help get that testing done.

[Dr. Rena Malik]

Absolutely. And, you know, on occasion, like, I'm sure you've been on the receiving end of this, like, your labs don't come in or they don't get faxed correctly. Same thing can happen with this. Right.

[Dr. Tammy Roman]

So, I mean, it happened to me at my institution when I was a medical student. Nobody told me what my results were, and that was kind of a big deal.

[Dr. Rena Malik]

Yeah. I mean, I'm grateful now that people are giving their record to the patient. So, like, if I don't get the labs, like, my patient will be like, hey, I didn't get. Did you get my labs? I'm like, no. They'll, like, literally attach them and send them to me because they've gotten them, which is great.

[Dr. Tammy Roman]

Well, in the state of California, there's a law that people have to get their results even before the doctors do. And I've got mixed feelings because patients will get results that can be really scary for them to see before I've had a chance to review.

[Dr. Rena Malik]

Yeah.

[Dr. Tammy Roman]

But I think that it's. It's wonderful because things do get missed. Right. And it is. It is important for patients to get their results so that it's not long lost in the space somewhere.

[Dr. Rena Malik]

Absolutely. I want to lastly talk about vitamin D. There's some research that vitamin D is. If you have vitamin D deficiency, it's linked to sexual dysfunction in women. So what do we know? And. And does supplementation actually help?

[Dr. Tammy Roman]

So there. There is epidemiologic data, and this is. Again, we keep talking about levels. Right. And we talked about this with testosterone. Right. So if we say, well, there's an association with low levels and sexual dysfunction, does supplementation then improve? And unfortunately, the data. And there have been studies on it, do not, not suggest that if you supplement vitamin D that you necessarily have an improvement. But that's because I would argue that sexual dysfunction is incredibly multifactorial. I think that people should get vitamin D if they're deficient because it has benefits in lots of other ways. And this, again, gets down to group versus individual data. There are some smaller studies that I've seen that suggest. I've seen them published that suggest that it does make it better. And so it's mixed. Right. And my guess is, is there are some people for whom they do feel better and it does improve their sexual function. But right now, I've seen negative studies, I've seen positive studies. I'm really kind of neutral on whether or not this is a primary treatment. But I don't think it's harmful in any way. And it can be beneficial for many other reasons.

[Dr. Rena Malik]

Are there any other micronutrients or even supplements that you find are helpful for women's sexual health?

[Dr. Tammy Roman]

So DHEA has been studied extensively. And so this is a pro hormone, so it metabolizes into testosterone. Testosterone and estradiol. And there are several studies that have looked at dhea, and they are either neutral, too positive. Right. So if you combine them all together, it's going to be the same story. Oh, it's neutral, but they're actually a couple positive studies. And I have a few patients that suggest that do experience a benefit. Supplements are always tricky because they're not regulated. I don't know what my patients are actually getting when they're buying supplements, and that's one of the biggest issues. So it's harder for me to make recommendations about those, but that's the main one. And then there is a product called Restella that is marketed. You can. People can buy it online, and it's got a couple different herbal products in it. And there are actually some clinical studies that suggest benefit. And a lot of anecdote from my patients.

[Dr. Rena Malik]

Yeah, interesting. Yeah. I just saw that some of that data, and I was pretty impressed.

[Dr. Tammy Roman]

Yeah. I mean, anecdotally, my patients are getting a benefit, so I think that there's something. Something there.

[Dr. Rena Malik]

You know, when you talk about dhea, I was just complaining about this with some colleagues that I was like, you know, people come in with their labs from somebody else. They've gotten a dheas, and they've gotten all these other labs, and I'm like, okay, well, if your DHEA is low, what am I gonna do about it? Right. Because the data on DHEA is not clear, and there are some potentially serious side effects. So sometimes testing everything is not a good idea. Right. Because then you fixate on, well, why can't we fix that one Problem. Problem. And, you know, there's probably something else that we really need to look at.

[Dr. Tammy Roman]

I agree. And the other thing is, like, DHEA does not do anything except turn into other things.

[Dr. Rena Malik]

Exactly.

[Dr. Tammy Roman]

And so, like, DHEA is not active at any receptor. You know, when we talk about hormones, there is an estrogen receptor, an androgen receptor. It's not testosterone, it's androgen receptor, and a progesterone receptor. DHEA is going to metabolize into things that target those receptors, but it doesn't actually do anything on them. So it's not a biologically active substance in the body. The only reason to test things like DHEAS and testosterone is because DHEAS is actually the most abundant androgen in the body and it's made by the adrenals. And so if a woman has symptoms of pcos, there's often this confusion about, you know, well, I don't like the stereotype, but they talk about like lean versus not lean pcos. The real issue is, is the excess and androgen coming from the ovary or the, the adrenals? And you can tease that out by testing dheas, because if the DHEAS is elevated, it's adrenal overproduction. But if testosterone is elevated and DHES isn't, it's ovarian. That's just. You just tease it out. That way the treatment's going to be the same.

[Dr. Rena Malik]

Right. Is it just knowledge?

[Dr. Tammy Roman]

It's just knowledge. And it can help you figure out where it's coming from.

[Dr. Rena Malik]

Interesting.

[Dr. Tammy Roman]

Or an adrenal tumor, for example. Right. If somebody has hyperverilization.

[Dr. Rena Malik]

There's reasons we have these tests.

[Dr. Tammy Roman]

Exactly.

[Dr. Rena Malik]

But they're not, they're not for just the average healthy person.

[Dr. Tammy Roman]

No.

[Dr. Rena Malik]

Okay. What are you working on now that you're excited about?

[Dr. Tammy Roman]

So we're setting up at ucsf. There's a UC Wide Menopause Collective. One of the leaders at UCLA has just done a really incredible job of trying to integrate a lot of menopause care into, into their clinics. And they're, you know, overwhelmed, as we all are with patients. But we've organized now all the UC providers doing, doing this, and this state just gave us money. I mean, the state of California just put in their budget to give each UC money to start a menopause program. And so, you know, I've said this before, like the people who did that were women. I don't want to talk. You know, I think that we. Representation matters. There's lots of different ways we can support women. But I think it was really interesting who drove this. Right. In terms of the legislatures, I think men can play a huge role in supporting women's health, and I hope they do. But that's a really exciting thing.

[Dr. Rena Malik]

It's great. And, you know, I actually had a conversation. I remember I said, like a party. I met with someone who works in California, state government level, and she got so excited about menopause. She's like, okay, I'm going to take it back and we're going to do a program for the employees. And. And she's she's done it, she's worked on it, she's been building it, and it all started from a conversation. Right. And it's, it's really exciting to see that happen. And I think it needs to happen for women's health, men's health. Everything right there needs to be, to be quality, evidence based management of these issues. And, and we need to be prioritizing them.

[Dr. Tammy Roman]

Yeah, we need to think about quality of life. I will say, you know, menopause is the only condition that every single person with ovaries will go through. Right. So I can, I'm the expert in pregnancy. I am great with cancer, I'm great with abnormal uterine bleeding. That will happen to a lot of people. But you know, when I hear like people give lectures on, look how common this condition is, it affects 12% of the population. I'm like a hundred percent of women are gonna go through menopause at some point. And so it can't just be me. And you know, all the people you've been interviewing that are the experts, everyone has to be the expert that are taking care. It needs to be embedded in everything we do in healthcare to talk about how this condition affects all these other parts. It's not, it's not an OBGYN issue. Right. It's everywhere. And so that's why I love seeing urologists get involved and endocrinologists get involved. And I, you know, I was recently made president elect of the International Society for the Study of Women's Sexual Health. That's the next, you know, exciting thing I'm doing. And there's, it's so multidisciplinary. Everyone is, you know, coming in and we're spreading it and we're not just relegating this to some, you know, corner of medicine and healthcare. It's becoming more universal.

[Dr. Rena Malik]

Absolutely, absolutely. What is something about women's sexual health that you've completely changed your mind on from when you, you started?

[Dr. Tammy Roman]

I think that I've changed my mind on thinking about that there's one way to do things for people, you know, and we've talked about that a lot today. And so I think when it comes to, to sexual health, I've probably evolved over time in terms of thinking about what the appropriate treatments are for the appropriate patient and really understanding the importance of nuance and the, and limitations of quote, evidence based medicine. And it's a. Evidence based medicine is not just the science. Right. Evidence based medicine is the science, it is the interpretation of it and it is the communicating it to patients. But I have gotten much more comfortable with nuance and the limitations of what scientific studies show. So I could talk about it in numerous ways in different women's healthc care. But you'll hear me talk about this a lot. I still 100% believe in science. I contribute to the science. But what has changed in my mind is that if a study is negative. Right. Or that there's a neutral outcome outcome, does that necessarily mean this treatment isn't working or will not work for somebody? And I don't want to encourage people to ignore data because it's so incredibly important. But I want us to think about the limitations of what a study has. And that's really been the change in me over time in becoming a little more patient centric and really thinking about what are the pros and cons to different treatments.

[Dr. Rena Malik]

Yeah, I think being open to saying, okay, this physiologically makes sense. We can try it and see how you do.

[Dr. Tammy Roman]

Right.

[Dr. Rena Malik]

And I think that's a lot of the times where that's how like new innovation is figured out. Right. People have experience with their patients and they design a study. Then they, you know what I mean? Like, that's how it happens. So I think it's okay to use your brain and think about things critically and figure it out. Where can people find out more about you and your work?

[Dr. Tammy Roman]

Well, they can find me online if they want to follow me on social media. I'm Dr. Tammy Rowan on Instagram and Tik Tok. I'm not on any of the other things because I'm still used to getting used to this world. I am at UCSF as a clinician. If people want to see me as a clinician, they oftentimes will start. If they want to see me for menopause or a quality of life issue, they may start with one of my colleagues before they see me because my colleagues are very capable. If they want surgery with me, they can usually just make a request for that and they can get in quite quickly for surgery. But that's where I'm clinically practicing. And then if people want to be involved in ISSWISH and come to our lectures, any medical providers, I would say get involved with ISSwish and then I do a lot of speaking for a CME company called Symposius Medicus as well. And I give lectures with the International Society for Sexual Medicine in lots of different places.

[Dr. Rena Malik]

Amazing. So we end our podcast with four questions we ask everybody. They don't have to be about sexual medicine. They can be about whatever you want. So what is something you know now that you wish you knew earlier?

[Dr. Tammy Roman]

I would say I wish I knew earlier the importance of the lifestyle choices that we make make. And so the, the things like exercise and sleep that we all talk about now that, you know, you. You can't know when you're younger how important those things are, but I kind of wish I did and how good they make you feel.

[Dr. Rena Malik]

Yeah. I wish I had built those habits earlier. Yeah. Right. I think that you didn't need it as much to feel good, whereas now I think it's more of a, like a mandatory thing.

[Dr. Tammy Roman]

I agree. I also, for me, I think I probably did other things to feel good.

[Dr. Rena Malik]

Yeah.

[Dr. Tammy Roman]

And since I've discovered, you know, I took up running really seriously in the last year or two and I cannot believe how good it makes me feel. And I wish I had discovered this before my body was gonna break down from it.

[Dr. Rena Malik]

What's a non negotiable something you have to do every day?

[Dr. Tammy Roman]

Get outside and move my body usually.

[Dr. Rena Malik]

Yeah. What's a life hack or health hack you would share with people?

[Dr. Tammy Roman]

I think a life hack is. Is trying to. And it's more of a social thing, is try to ascribe positive intent. And so it's really easy to get negative and angry about things. And I would say really try to look at something, especially something someone else might have done or said or things that are happening and try to ascribe positive intent and see it from another perspective. So we stop being so angry about everything and acknowledge that people are allowed to have different perspectives. We may disagree with people's actions a hundred percent, but that just because somebody has a particular belief does not make them good or bad.

[Dr. Rena Malik]

Yeah, I agree 100%. I feel like because of social media there's a lot more siloing and echo chambers. And it, it can be very. It can. It can increase negativity in your life. And so I try to really curate what I'm seeing in my feed and spend less time on social media and more time with things that make me feel good.

[Dr. Tammy Roman]

Yeah. And talk to people who have different beliefs than you do. We dehumanize each other. When we don't do that, we, you know, people will ask me, like, I have family members that have wildly different beliefs than I do. And people are like, how can you talk to them? Why would I not talk to them? They're my family member. You know, these are good people. People are allowed to disagree on things and still share joy and love.

[Dr. Rena Malik]

And I think often we think we can change people's minds. And sometimes, you know, maybe, but for the most part, you're not going to change anyone's mind. So don't stress out about being a failure in changing someone's mind. Because I think early on, when we were young, younger, we spent a lot of time being like, oh, fighting these arguments, or how could you think that way? And the reality is, most people are not going to change their minds.

[Dr. Tammy Roman]

No. And it's not our job to make them change our minds. I always think you show people by example. If what you're doing is right and good, you show them by example. And so it's this idea to me of attraction rather than promotion. Right. Be an attractive person rather than a promoter.

[Dr. Rena Malik]

Absolutely. If you couldn't be a physician, a researcher, what would you be?

[Dr. Tammy Roman]

I'd probably be a preschool teacher. Yeah, yeah, yeah. You know, I always said I'd be like some sort of therapist or some sort of helper at some point, but I. After having children, I mean, I've always loved children, but I cannot believe how much I love children. And the idea of, you know, kind of watching them do that, or I would. I understand. My mom became a child psychologist after having kids, and I get now why she did. And so I could see myself doing something like that. Something related to child development. Human development is fascinating and so important.

[Dr. Rena Malik]

Right. These people who take care of our kids, whether they're educating them or being psychologist, school, even school psychologists, they're so undervalued and they're so valuable in society. They're so valuable. Well, thank you so much.

[Dr. Tammy Roman]

Thank you for having me.

[Dr. Rena Malik]

If you're enjoying this podcast, do me one solid favor. Go on whatever you're listening to or whatever you're watching, and hit the subscribe or follow follow button. This lets podcast platforms know that this is a podcast worth listening to, and it shares it to other people, and that's how we get the message across. So it takes no time and it's completely free. So please, if you're enjoying this content, do it for me. And as always, I'm going to take care of yourself because you're worth it.