00:00:24
Speaker 1: This show is not a substitute for professional medical advice, diagnosis, or treatment. It is for informational purposes. Please consult your healthcare professional with any medical questions. Also, in this show, we use women as shorthand for people with XX chromosomes. We understand sex and gender are more complex. and acknowledge the experiences we describe reach beyond that word.
00:00:54
Speaker 2: They think we forget that sex is supposed to be fun.
00:00:57
Speaker 3: We forget that it's supposed to be silly and joyful and weird and weird smells and weird noises and it's just supposed to be fun. It's adult playtime. So if you are not having fun, the question is, do you want to make it better?
00:01:09
Speaker 4: That's Dr. Rachel Rubin. She's a urologist and one of only a handful of physicians who specialize in sexual medicine professionally. for all genders. Dr. Rubin brings so much enthusiasm, candor, and curiosity to this field. And there's a surprising amount we already know about women's sexual health that simply isn't being shared widely enough. I have to say, I smiled a lot during our conversation because yes, we're talking about medicine, but we're also talking about pleasure, anatomy, relationships, hormones, and so much more. Caring for our sexual health has the potential to bring great joy to our lives. Here's our conversation. So you're one of only a handful of physicians who have specialized training in sexual medicine for all genders. What drew you to this area of medicine? Yeah, it's a great question.
00:02:05
Speaker 3: You know, you always wake up every morning and say, how did I get here? How did my life journey get me into penis doctor mode? It's a very strange thing, not something every little girl dreams of.
00:02:15
Speaker 2: I don't know.
00:02:16
Speaker 3: I think we were middle schoolers who talked about it. The boys talked about it. The girls talked about it. There was no shame or stigma. And then I think when I got into the medical world, I realized that was weird.
00:02:25
Speaker 2: That was strange. Not a lot of people felt that way.
00:02:28
Speaker 3: And then when I did my rotations and I realized I didn't like delivering babies and what OBGYNs do is astronomically challenging.
00:02:36
Speaker 2: And I enjoyed urology.
00:02:38
Speaker 3: I enjoyed the quality of life discussions. I enjoyed talking about people's sexual health. And I was able to take care of men and women when we did that. And so we really have been working to advance the knowledge and the research in women's sexual health the way that we have in men's sexual health, although we still have a long way to go for both of them.
00:02:58
Speaker 4: So why do you think we are so uncomfortable talking about women's anatomy just in general?
00:03:03
Speaker 3: Yeah, I think there's probably many reasons that can aim from the fact that the nerve to the genitals that innervates the penis and the clitoris and the vulva and the perineum and the rectum in all genders, it's called the pudendal nerve, which means shame in Latin. So I think you can look back to sort of our history and how we think about genitals. You could talk about politics and puritanism and And at the end of the day, it's really hard to see your genitals. Like men's penises are just out and proud and they can see every bump, every vein, every change that happens. And I think that women, it's a little bit hidden from us. You have to kind of do gymnastics to look down there. And we're not really taught to look down there. And then I don't know about how you were trained, but I was trained to look under the hood, right?
00:03:50
Speaker 2: Give a sheet.
00:03:51
Speaker 3: And so you kind of give a patient a sheet and you look between their legs and You hide themselves from themselves. And so you never learn about your own anatomy. And I think we miss an opportunity with young people and older people to teach them about their own bodies.
00:04:06
Speaker 2: My sex ed was pretty crappy. I don't know about yours.
00:04:09
Speaker 3: But we don't do a really great job of teaching and talking about it.
00:04:13
Speaker 4: Yeah, it's so funny that you mentioned the sheet because to this day, that's the way I was trained and I always drape a sheet. And actually, it is a total disconnection. I've learned two new things from you. Pedendal, I did not also realize was shame. There's some medical verbiage that we maybe need to change. Hysterectomy is another one, I think. Yeah, hysteria.
00:04:33
Speaker 3: No, I think the language really matters here, right? And how we think about it. I give women a mirror and I show them their own genitals as I'm doing the exam.
00:04:41
Speaker 2: This is your labia majora. This is your labia minora. This is your clitoris. This is your pelvic floor.
00:04:45
Speaker 3: And just having a mirror and showing them what I see gives them access to language that they never had before. So the best example I came up with recently was you never show up to the doctor with face paint. right? You would not go to the dentist if you had an eye problem. You would not go to the dermatologist if you needed an ear, nose, and throat doctor. And yet we think of it as down there, right? We don't even have the language to really understand it. Everyone calls it a vagina, right? Everyone calls a vulva a vagina. And there's a comedian, I love this so much, I'm going to steal it. There's a comedian who says, Calling the vulva a vagina is like calling the face the.
00:05:29
Speaker 2: Throat, right?
00:05:31
Speaker 3: Oh, your throat looks beautiful today. I love the way you have makeup on your throat today, right? That doesn't make any sense. But that's essentially what happens, right? The vagina is the inside part. The vulva is the outside part. And yet so many people just call it all a vagina.
00:05:45
Speaker 4: You bring up like immediately three great, really important points. Do you see this conversation changing at all?
00:05:53
Speaker 3: I mean, we're having this conversation, right? How beautiful that we're having this conversation. How beautiful that I get invited to speak at the FDA and I can say words like sexual medicine and talk about vaginal estrogen and UTI prevention and sexual symptoms.
00:06:09
Speaker 2: And so, of course, it's changing. And I think.
00:06:11
Speaker 3: Social media is very terrible in many ways, but is also helping to create more equalized access to information. And I think some of it good, a lot of it bad, but there's more information. I don't see as many patients of, oh, I've had pelvic pain for 20 years and no one's diagnosed me. They're coming to us sooner. So I do think there's hope, but it will require an army of human beings to help us continue to move it forward.
00:06:38
Speaker 4: Yeah, it's interesting how social media and many aspects of women's health has just opened the dialogue finally. And I think that professionals need to also be part of that dialogue, you know, participate in that with further education, that type of thing. Let's talk about women's sexual health and function. There's so much focus placed on men's sexual health. We know more about it. Is it because women are more complex or we just haven't studied it or people just not interested? Why are we where we are?
00:07:04
Speaker 3: Yeah, I often show this slide when I give lectures. The top bar is an on-off switch, like men's sexual health on-off switch. And then the bottom is all these buttons and levers and dials. And it was like women's sexual health. It's so complicated. And it's actually not complicated at all. And there is so much biology that we actually do know about that we just don't teach anyone and we don't explain it to people. It's really actually very fun being a urologist in this space because I was trained on male genitalia and the female genitalia and the male genitalia are exactly the same. right? They're a little bit in different sizes and different orders, but there are connections. So the scrotum is the same as the labia majora. The clitoris is the same as the penis. And so when something goes wrong with one, you can actually use that information to help you understand how to take care of the other. Now, there actually is a lot about men's sexual health that we don't understand. So whereas we understand the biology of erectile function much better than we used to, thanks to Viagra, We still don't understand a lot about male orgasm, male ejaculate, even libido in general, right? There's a lot of biology that's not fully figured out. The same is true for women. So we understand libido a little bit. We understand the hormonal importance to the genitals and the bladder health. But when it comes to like really understanding the neurobiology of orgasm, I think we have a long way to go. So I have two frustrations. One is there's a lot we don't know. My real frustration though is we don't teach the stuff we do know. We actually have great options for pelvic pain and vulvar pain conditions. We have great options for the genitourinary syndrome of menopause and to help people prevent UTIs. It's no one's writing the damn prescriptions. Right.
00:08:47
Speaker 2: No one's actually following guideline driven care.
00:08:50
Speaker 3: Nobody learns it. And the medical students aren't learning it. The residents aren't learning it. And how can they learn it if there's no one there to teach them? And so that is my biggest frustration.
00:09:00
Speaker 4: And so what's your answer to that? How do we fix that?
00:09:03
Speaker 3: We roll up our sleeves and we do the work ourselves. So the truth is there are no grownups coming to save the day. There is no body or organization that's going to come and fix it and magically make it better. And so what do I do? I just do everything I can.
00:09:16
Speaker 2: I do podcasts.
00:09:17
Speaker 3: I go teach at CME courses. I make my own CME courses that people can take from their home. I have a whole research team. We call it the sexual medicine research team, where we have hundreds of med students from all over the country. I'm planting all the seeds. I'm trying to create a grassroots movement. of students, of researchers to say this matters. And if it matters to you, we can collaborate and work together to make this better. And so I think it will take time and it will take inspiring others to want to do the work. And I think it's explaining to people that it's work. It is work to see patients every day and write prescriptions. It is work to explain to patients the benefits and safety of hormone therapy. It is work to change the messaging and we have to change policy.
00:09:58
Speaker 2: I'll give you an example.
00:09:59
Speaker 3: Right now there's a patch shortage where women cannot get their estrogen patches and we're encouraging them to write to the FDA, write to the FDA, here's how to write to the FDA. And yesterday the FDA put out a statement and said we're listening and we've reached out to the six manufacturers. That means that we got people loud, not just me, but everybody got people loud. And people wrote in, they wrote into the FDA, they wrote about their experiences. And so this is this, I have goosebumps of the advocacy That you just have to keep pushing, pushing, pushing, pushing. You just can't give up. You just got to keep finding little holes wherever you can, I suppose.
00:10:36
Speaker 4: What can we learn about a woman's overall health by assessing her sexual health?
00:10:41
Speaker 2: Oh, I love that question.
00:10:42
Speaker 3: And the fact that you asked that question shows that we are so much farther along than we were five or ten years ago. So we know, again, I'm a urologist, so I often go back to what I know about male genitalia, but we know that the penis is a marker for overall health. So erectile dysfunction, which 50% of 50-year-olds have erectile dysfunction, 70% of 70-year-olds have erectile dysfunction, we know that erectile dysfunction is a sign that there is something going wrong with your cardiometabolic system. And so I think of it like this. the arteries to your heart are three millimeters. The arteries to your penis are one millimeter. So what's going to clog first? Your small pipes are going to clog before your big pipes.
00:11:23
Speaker 2: So men who.
00:11:24
Speaker 3: Have erectile dysfunction, this may be a sign that you're going to have a heart attack in 10 years. And so I absolutely think that the same is true for women, but we do not talk to women the same way. We don't ask them about their arousal. But if you ask, and I ask every single one of my patients, has your arousal, your engorgement, your lubrication, the tinglys that you feel in your genitals, has it diminished?
00:11:46
Speaker 2: Has it changed? Is it muted?
00:11:48
Speaker 3: And as women go older and older, as their cardiovascular risk goes up, their response to their arousal problems also goes up. But we don't even talk to women in that much detail about their sexual health. But my guess is it's absolutely a marker. We also know that arousal is going to decrease when you don't have hormones. Estrogen, testosterone are so important for the health of the vulva, of the genitals, of the vagina, of the bladder. And so when you don't have hormones, it gets thin, it gets raw. The microbiome changes and your risk of pain with sex, vaginal dryness go up, but also you get urinary frequency, urinary urgency, leakage, and urinary tract infections. And so these changes, these sexual health changes are a sign that bad things are to come.
00:12:34
Speaker 4: About what ages do sexual health issues begin to arise for women in terms of arousal or response or libido? Do you see these in the early perimenopausal transition or years after the final menstrual period, or is it just dependent on the woman?
00:12:50
Speaker 3: Yeah, so we see sexual dysfunction throughout the lifespan in different ways. We see pelvic pain happen for different reasons. We see hormone changes happen for different reasons. And then we see women on birth control pills. Birth control is great. I love birth control, but it works by shutting your ovaries down and it doesn't give you back testosterone. And so we see a certain percentage of women on birth control pills have low libido, vaginal dryness, and pain with intercourse because these medications block testosterone. And so our job is to really say what's going on with you and can we figure out the biology to help you live your best life, not to mention all the psychosocial stuff that happens with trauma and and abuse and lack of knowledge and education, all sorts of things obviously can happen.
00:13:33
Speaker 2: So really there is no age.
00:13:34
Speaker 3: With which sexual discussions are not relevant and the biology can't affect someone.
00:13:42
Speaker 4: Well is our healthcare system set up to manage this? Is it the PCP, the internist, the OBGYN? I mean, you're so special because you're a urologist with a special interest. That's a unicorn, right? I think for many individuals, like who owns this? Who should be addressing this with women and helping women in this area?
00:14:02
Speaker 2: You know, I'll ask you, how much did you learn about this in your training?
00:14:05
Speaker 4: It is all self-taught. Well, I'm an oncologist, so it is all 100% self-taught. Anything I know about pelvic floor dysfunction and sexual health is everything that I was curious to learn about.
00:14:15
Speaker 3: And bless your heart, right? Thank God we need you. And we're so grateful to have your curiosity and your interest. And that's why part of this is to get people like you curious and interested.
00:14:24
Speaker 2: And we have.
00:14:25
Speaker 3: We've got more oncologists and pain doctors and all sorts of different kinds of clinicians who are interested in this because Sexual health is everybody's responsibility. Sexual health affects all organs. It affects your brain. It affects your heart. It affects your muscles and your joints and your pelvic bones. And I need orthopedic surgeons to care about this. And so it's everyone's responsibility and no one's doing it. Everyone's really busy with other stuff. And as a society, we have decided that your pap smear is more important and we've decided that your mammogram is more important and we've decided that your colonoscopy is more important. And I understand why those things are important But the problem becomes everybody has some relationship to sexual health and human life happens because people have sex. And yet we have no specialty that focuses on women's sexual health like it doesn't exist. And so it's kind of wild when you think about it and that we've ignored the science and the clinical aspects of this issue. It shouldn't be a handful of us right there. There should be many, many, many of us. And it shouldn't take a curious oncologist to say that sexual health is important because what patient with cancer isn't completely wrecked in their sexual health, whether it's from chemotherapy, radiation therapy, and what that does to their relationship, their connection, and the discussions that we have before, during, and after treatment.
00:15:46
Speaker 2: As you know, right, are incredibly powerful.
00:15:49
Speaker 4: Yeah, and your sense of, I think, for oncology, too, especially, it's like your sense of being alive and connected. It's so important. Like, you want to be alive. You want to be connected. You want to have sex for most of us. and that's where it can really go awry. And so we really need to understand it when there's other issues involved, such as cancer. What are the signs of sexual dysfunction that really shouldn't go ignored, that women really should address with somebody?
00:16:14
Speaker 3: Sex should not be painful, full stop. It should not feel like shards of glass. Penetration should not feel a scratchy, burny irritation, painful like they're hitting a wall.
00:16:24
Speaker 2: It should not hurt.
00:16:25
Speaker 3: You know, that's, to me, the biggest sort of warning sign. This isn't just use some lidocaine to cover it up or just drink in order to have sex. There should be a formal diagnosis. So that's the biggest one I would say. And then if you're bothered by something, it matters and it deserves a serious discussion with a serious clinician who cares about this issue. So if you go to your primary care and you say you have a low libido, they're going to minimize that complaint because in their mind, low libido is not a major medical problem. because the patient right before them has liver cancer, the patient two before them is in diabetic shock, the patient three before them just lost a spouse. And so when you come in to talk about your libido, they're like, okay, well, you know, go to therapy. But the truth is, if you're bothered by your low libido, it is a medical diagnosis with medical treatments that span biopsychosocial toolbox, and it deserves a conversation and it deserves education and treatment strategies. And so It may mean, though, in 2026, that sexual problems, you have to think of like rare diseases and you have to go find the people who study those rare diseases. So there are sexual medicine doctors, although they can be hard to find. But if it's important to you, and it's not important to everybody, but if it's important to you, it deserves a partner that will champion.
00:17:48
Speaker 2: It with you.
00:17:51
Speaker 4: We need to take a quick break. When we return, we'll talk solutions. for some of the most common sexual health concerns like painful sex and low libido. Stay with us. Let's talk about pelvic pain or pain with sex. There can be entry pain and deep pelvic pain. Can you unpack those for us and tell us the causes of entry pain, the causes of deep pelvic pain, and what some of the treatments would be for that?
00:18:29
Speaker 2: Absolutely.
00:18:30
Speaker 3: And I think it's an important distinction, and you can have both. I always joke that I'm kind of like a sex detective. this idea of listening to the patient, spending time because your sexual health care, your pain deserves more than a 10 minute visit with your legs up in stirrups. So we really have to get to the history. Like oncologists get this because they get time with patients, but a lot of other doctors don't get time. And so it is the history that helps guide us of what's going on with the patient.
00:18:57
Speaker 4: And it's quite simple.
00:18:58
Speaker 3: It's the physical exam that then speaks very loudly. If I can find your pain, if I can touch your pain, if I can look at exactly where your pain is, it helps to give me an idea of what might be causing your pain. And so entry pain is often, like almost always, due to a strip of tissue that lives inside the labia minora around the urethra at the entrance of the vagina called the vulvar vestibule. And the vulvar vestibule, many doctors, if you're listening, have never heard this term before, but it's essentially where the skin of the labia turns into the bladder tissue. And so the vulvar vestibule is actually endodermal bladder tissue that is delicate. So the outside of your cheek is a nice rough skin, and the inside of your cheek is a very delicate mucosa. And you have your lip that connects the two. Your lip is different than your cheek, which is different from the inside of your mouth. It's a transition point in the type of tissue. So your labia is this beautiful transition point where your skin becomes your bladder, and then past your bladder is the vagina, which is different tissue altogether. Now, just like the inside of your cheek is super thin and delicate, that tissue at the opening of the vulva is very delicate. It's very sensitive to hormonal changes. It's very sensitive to inflammation and irritation. And sex, which is a contact sport, You have this rubbing up against that tissue and this inflaming that can happen causes symptoms, pain with sex, irritation, burning, urinary tract infection symptoms from when this bladder tissue gets irritated. And hormonal changes like menopause, breastfeeding, birth control pills can really affect this tissue. So that's entry pain. But we also see pelvic floor muscles, which live underneath the tissue, can be really tight and tense, just like you can have a knot in your shoulder. You can have knots in your pelvis from sitting the wrong way or from having irritation somewhere in your body. And so we use a lot of pelvic floor physical therapists to help us treat these patients. And then deeper pain is often a sign that something's unhappy. Whether it's endometriosis causing scar tissue all throughout your pelvic floor, whether it's a big heavy uterus that has adenomyosis or irritable bowel or something that's causing deeper pain and pelvic floor tension, it's really getting to the bottom of what's causing your pain. And with a good history and a good physical exam and a curious doctor or care team, sometimes we can figure it out. Sometimes we can't, but a lot of times we can.
00:21:29
Speaker 4: If you're having vestibular pain, how do you treat that?
00:21:32
Speaker 3: Yeah.
00:21:32
Speaker 2: So it's really understanding the cause.
00:21:34
Speaker 3: So the most common reason the vulvar vestibule hurts is hormones. And so whether it's a birth control pill, spironolactone, breastfeeding will cause vestibular pain, menopause, perimenopause.
00:21:47
Speaker 2: So if it's a hormone problem, we add hormones.
00:21:49
Speaker 3: So we'll either do a local vaginal DHEA, which is very supportive of this tissue. We'll often try to get women to change their birth control option to like an IUD or something non-hormonal. There's a little data that just a vaginal estrogen cream can help this tissue, but the receptors in this tissue are very androgen-based as well. And so it's actually the one place where I'll compound an estrogen testosterone a very low dose compound that they rub directly on this tissue. And it is miraculous to help this problem. Now, when it's not hormones, sometimes it's inflammation, whether it's an allergic reaction or they've had lifelong inflammation in that tissue. We're very interested in mass cell dysfunction, which is often a whole body issue. But we will have to cut this tissue out when we cannot fix it through topical hormones and things like that. And we do vestibulectomies for those patients. Now, if it's all vestibular pain from muscle tightness, then physical therapists are our best friends. We put in pelvic floor Botox and all sorts of out-of-the-box ways to think of this problem.
00:22:51
Speaker 4: Let's talk a little bit about pelvic floor dysfunction. You touched on it, but it's a word that we're seeing more and hearing more about, I think. So for our listeners, tell us what pelvic floor dysfunction is and tell us how it's treated.
00:23:01
Speaker 3: Yeah, so pelvic floor dysfunction is is no different than saying, I have back pain or my back is in spasm, right? Because the truth is, is you have muscles all throughout your back and a lot of reasons you might have back pain. And so if your pelvis hurts or you have pelvic floor problems, there's a million different reasons why you have that problem. And so it's really figuring out what your problem is and why you have it. So your pelvis is bones that look like a bowl, essentially, and it's the muscles that line the bowl of the pelvis. And there are these big, thick groups of muscle, right? They're pretty beefy muscles and they're responsible for a lot. They make sure that you're not peeing randomly. They make sure that you don't fart in a meeting. They make sure that you don't have a bowel movement when you're not supposed to. They hold up all of our organs. They allow for babies to not just fall out, but then they get stretched out when babies do come out, right? They're amazing what the pelvic floor does. And yet none of us We're trained on exercising our pelvic floors. We don't think of those muscles as muscles that can be trained. And so pelvic floor dysfunction could be I leak when I cough, laugh, or sneeze. It could be urinary urgency. It could be pelvic pain. It could be pain with intercourse. It could be weakness. So it could be prolapse. So this is where a pit crew is important to be able to really look at you from multiple angles because there are many different things that can cause it.
00:24:25
Speaker 4: Let's talk a little bit about low libido. I find it to be the most difficult issue that I help people with because I don't think it's always clear what's going on. Unfortunately, a lot of women are told, oh, it's just a normal part of aging, which I don't accept. Tell us a little bit about low libido and how you assess it, how you treat it, and what women should expect when they review low libido with the physicians who help take care of them.
00:24:51
Speaker 3: I'll tell you, I have a toolbox that I work with. It is a biopsychosocial toolbox. So if your partner is a jerk, it's gonna be hard to have a great libido. If you do not have safety, so if you're not safe in your home, if you don't have access to safety, it's real hard to.
00:25:09
Speaker 2: Have a good libido.
00:25:10
Speaker 3: If you are working a million hours a week and you're taking care of aging parents and children and you don't even have time to take a walk around the block for yourself, it's really hard to have a great libido. And so it's really getting to know my patients and figure out what did libido look like before? What do you want it to look like now? And how much effort and work do you want to do to try to improve your libido? The patients get to decide what they want to do. And so we work wonderfully with sex therapists. We work with medications, whether it's the FDA-approved medications for low libido. There's two, one called flibanserin or Addi, the other one called Bilesi or Bremelanotide. We love testosterone for libido.
00:25:49
Speaker 2: It works. It works so well. Tell me how I know. I use it myself.
00:25:53
Speaker 3: And what's interesting, it also language matters because libido can be libido with.
00:25:58
Speaker 2: Your partner and it can also be with yourself. So it's not uncommon.
00:26:02
Speaker 3: I'll talk to a patient and they'll say, I have low libido and my partner and I haven't had sex in three years. I said, well, have you had any interest in having an orgasm in three years? And they'll be like, oh yeah, it helps me fall asleep at night. So three times a week I get my vibrator out and I have an orgasm and I'm reading my sexy romance novels. And it's like, okay, your libido is actually pretty good, right? Like your libido is awesome. It's just not translating into partnered libido. And so you have to decide, is that good enough? Or do you want to work on having more fun with your partner? And that's really, it's again, one of the things I love about sexual medicine is it doesn't matter what I think about sex. I have to know what you think about sex and what you want it to look like. And so if I don't know the type of sex you're having or what you want it to look like, How can we build you a toolbox.
00:26:48
Speaker 2: To improve it?
00:26:49
Speaker 3: And I think we're all very prim and proper and we don't get really detailed with our questions. We sort of talk about it in broad strokes, but like, can you have an orgasm? Is it just from clitoral stimulation? Do you use devices? Can you have multiple orgasms? Is penetration pleasurable for you?
00:27:06
Speaker 2: What do you like?
00:27:08
Speaker 3: I've never been asked those questions before. I'm sure you've never been asked those questions before in a medical setting. And I think that is biology and medicine, and we just don't really think of it like that.
00:27:19
Speaker 4: So talk to me a little bit about testosterone and libido. We all know that women who have very high levels from pellets and such have great libidos. And testosterone went through the FDA a number of years ago and wasn't approved for libido for women. So what do you find that there's a particular level? Are some people more responsive to it? Do you have to dose higher? What is your take on the efficacy of testosterone for libido in terms of ranges that you need to get into? Or is it just all increase it? And if it works for you, great, stop there. How do you dose it?
00:27:54
Speaker 3: Yeah. You know, 20 years ago, they came out with a testosterone product. They put a billion dollars into it and studied it for five years. And it worked for libido and it was completely safe. And it was around the time the Women's Health Initiative scared everyone away from hormones. And the FDA said, ooh, we're just a little nervous about this. So we want five more years of data. It was going to be another billion dollars and no company wanted to do it. And so we've had 20 years of no product that has gone to the FDA to approve testosterone for women, even though it's approved in Australia, New Zealand, South Africa and England. And so it's a challenge because we don't have a product that is dosed appropriately for women here in the United States.
00:28:35
Speaker 2: And it's a controlled substance. But many of us use testosterone. We use male testosterone at female doses. It's a tube.
00:28:43
Speaker 3: It looks like a tiny tube of toothpaste. And a man would use the whole tube every day. My female patients and myself, I take a blob, you know, like a chickpea size or a thumbnail size, and I make this tube last about a week or 10 days. And that's about five milligrams of testosterone. And what I find in my clinic is that when you give people that level of testosterone, and it takes about four to six.
00:29:05
Speaker 2: Months, in my opinion.
00:29:07
Speaker 3: You see that improvement. And it's libido gets better, but arousal and orgasm get better. Mood tends to get better. Energy tends to get better. It is the thing that I see the most commonly in my practice where people say, I feel like myself again. Now, usually I do it in conjunction with estrogen and progesterone for people who have menopausal symptoms, but it really can work. Now, again, when we don't have a product, it becomes challenging to know as precision of what is the exact level that we're trying to get to?
00:29:37
Speaker 2: I don't know.
00:29:37
Speaker 3: If you're not having side effects and you feel good, I'm not really worried about causing you harm. We have people who take 10 times the dose of testosterone. They're called men and trans men, and they're doing just fine, right? And so as long as you're not having side effects, I'm not really super afraid of harming people. I don't do pellets in my clinic for a number of reasons, but the most common reason is they're not regulated by the FDA. And so I have no idea what's in them. It means I have to trust a company that tells me what's in them and I'm going based on vibes. And I never like, unless I have to, I don't like going based on vibes.
00:30:13
Speaker 2: And so that's my reason.
00:30:14
Speaker 3: Not that pellets couldn't work. It's just that if they're dosed too high, you can't take them out. And so patients may get side effects from them.
00:30:21
Speaker 4: Do you check levels at all?
00:30:22
Speaker 3: I do.
00:30:23
Speaker 2: I check levels for two reasons.
00:30:24
Speaker 3: The guidelines, the global consensus guidelines do say to check a total testosterone. And the reason they do that is that you want to make sure that they're not super physiologic already, right? That they may not have too high of a testosterone. But there is no number you wouldn't treat if somebody had symptoms. I do check a level for two reasons. One is it's a nice baseline. But it's really nice to see people absorb. There is a certain percentage of men who do not absorb through their skin very well. And we do injections. We do oral testosterone. We do all sorts of things for men because we have like 30 products. And so for women, there is a percentage of women who don't absorb estrogen and testosterone through their skin very well. So, for example, when I checked my testosterone a couple of years ago, it was 11%. which if we have 10 times less testosterone than men, it would be like a man having a testosterone of 110, which is a 10 alarm fire in America, right? If a man has a testosterone below 300. And so mine was 11. And I said, oh, I wonder how I'll feel if I add testosterone. And I started taking testosterone. I got my levels up to about 50 or 60. And again, that would be like 500 or 600 for a man, which is totally reasonable, normal testosterone. And after about five or six months of using it, it was sort of like, oh, this is good. This is working for me, right? And so I was able to see that my body was absorbing it by the numbers, but I didn't feel any different for about.
00:31:45
Speaker 2: Five or six months.
00:31:47
Speaker 3: And what's interesting is the first thing I noticed, and I have had patients tell me this, and there is some data behind this, my stress incontinence got better. And so I had very mild stress incontinence from having two babies. And when I coughed, I didn't have to brace myself. I didn't leak urine. And it's because the urethra is rich in testosterone receptors.
00:32:07
Speaker 4: And it makes so much sense.
00:32:08
Speaker 3: So when we say testosterone is just for libido, no, testosterone is a chemical that exists in that your ovaries and your adrenal glands make and that has receptors throughout the whole body and we just have the most data that we've collected on libido and so it's just such a fascinating conversation because there's so many feelings people have so many feelings about testosterone but they don't have the same feelings about thyroid hormone or insulin or you know any other hormones out there yeah.
00:32:35
Speaker 4: I feel comfortable i use it a lot in our practice but But many people don't feel very comfortable giving testosterone. They're worried about safety issues and such. And I think that there's safety data from that previous FDA data that was presented when they were using the patch, right? Let's talk a little bit about the clitoris. Why is it so misunderstood? And what is its role in women's sexual health? And then talk to us a little bit about vaginal orgasms versus clitoral orgasms.
00:33:02
Speaker 2: Yeah, absolutely.
00:33:03
Speaker 3: So the clitoris is so misunderstood mostly because it's been hidden from us. The only thing that we can see on the outside is the tip of the tip of the head. just like the head of the penis is the tip of the iceberg. If you have sex with men, you don't just touch the tip of the tip of the penis in order for them to have pleasure. There's a shaft, there's an internal penis, goes all the way down to the butt bones, and the clitoris is the same, but it's all internal. So you do have a shaft, which you can feel above, like beyond when you touch the head of the clitoris, but then you can't really feel those inner legs that go all the way down to your butt bones. And the clitoris is erectile tissue.
00:33:40
Speaker 2: It gets erect. It gets hard. It engorges.
00:33:43
Speaker 3: And just like if you stimulate a penis enough, you can create an orgasm and ejaculate in a man. If you stimulate a clitoris enough, you can create an orgasm in a woman. And so most women, the majority of women have orgasms from their clitoris, just like most men have orgasms from their penis. We don't rub the man's inner thigh for them to have an orgasm. Very few men can have an orgasm when you rub their inner thigh. It's close to the penis, but it's not the penis. And so when the vagina is penetrated, it's close to the clitoris, but it is not the clitoris. And so most women, the normal way of having an orgasm is not with penetration, though there is a percentage of women who can orgasm with penetration. And if you're one of them, you are a ninja unicorn, you are amazing, and everybody's jealous of you. But my theory is that their body is just more sensitive. Their neurobiology is more sensitive. And so you can activate the clitoris from the inside to create that orgasm. And there are other parts of the body that can be pleasurable for some women. The cervix can be pleasurable for some women. The anterior vaginal wall, the top of the vagina called the G-spot, though we're calling it a G-zone now, can be pleasurable probably for people with higher testosterone because it is androgen-sensitive tissue like the prostate. And so if you have different areas that give you pleasure, you're amazing. And if you don't, you're not broken. You can explore other areas. Just like the penis is the path to orgasm in men, that doesn't mean men can't have pleasure from prostate stimulation or rectal stimulation or scrotal touch. But their orgasm is predominantly from their penis. Most women's orgasms are predominantly from the clitoris.
00:35:24
Speaker 4: What percentage of women haven't had an orgasm or perceive themselves as not being able to have an orgasm? And how do you help them?
00:35:32
Speaker 3: Yeah, about 20% of women will say they can't orgasm or they have an orgasm problem. And it always becomes the question, is it education? Because many women come in thinking that penetration should be the path to orgasm. Is there a biological issue, so a hormonal issue, a nerve issue, a pelvic floor issue? You know, the percentage of men who can't orgasm is much lower. And so if we think the bodies are similar, then the question is, why the difficulties? And is it an activation issue? Is it a vibration issue? Now, when I exhaust all of my biological toolbox and my psychosocial toolbox and they still can't orgasm, the thought of those patients keep me up at night trying to figure out what are we missing and can we help these patients? But I think they can be very challenging to figure out.
00:36:17
Speaker 2: Is it education? Is it anatomy? Is it physiology? What's the issue?
00:36:21
Speaker 4: You just mentioned vibration problem. What is that?
00:36:24
Speaker 5: Yeah.
00:36:25
Speaker 3: So we know that more than 50% of women use vibrators or devices that help them have an orgasm. And that's because, remember, the clitoris is mostly internal. So if a penis was completely internal and there was nothing for a man to hold on to and nothing that he could penetrate, how would a man have an orgasm? How would he stimulate his penis for an orgasm? And that's essentially what a clitoris is. And so vibration has been known about for millennia that if you vibrate the area around the vulva, you can stimulate a reflex. Just like a sneeze is a reflex, you can stimulate an orgasm reflex that is very pleasurable for people. So devices are an incredibly helpful way to have an orgasm. And the vibration nerves are the most robust the older you get. And so vibration can become an incredibly useful tool to Older people who may have arthritis or not be able to use their hands or their mouths as much for pleasure, they use vibration to maintain that sexual health.
00:37:24
Speaker 4: Still to come, how to talk to your doctor about sex, even if it feels awkward. Plus, making room for more pleasure, connection, and fun in our lives. What conversations should a midlife woman have with her care providers about her sexual health? What are the key questions that she should have answered? And then how do you have women get a little bit more comfortable with a conversation that they might not be so comfortable with?
00:38:03
Speaker 3: I mean, I think I am biased here because I forget how easy it is for me to talk about all these things because I talk about sex like it's high blood pressure and diabetes because that's what it is. Your high blood pressure and diabetes affects your sexual health. And so I'm very comfortable talking about and very matter-of-factly talking about these issues. What I find as a doctor is if you show up confident and competent, you're listening and you show that you care, people will tell you just about anything and you can guide them through conversations. Now, I am biased because people come to my office with a sex problem. They know I'm a sex doctor. They know they can say anything to me. It's a little hard when you're talking to someone who delivered your babies or who you've known for 25 years. It can be incredibly intimidating. But if it matters to you, then it matters. And sometimes you may want to see a specialist, right, who does this for their job. And that's why we're trying to train more people how to do this because we can't just have it be a handful of people who are focused on these issues.
00:38:59
Speaker 4: So let's talk about solo sex or masturbation. Health benefits to that? Should women be masturbating? What is your advice?
00:39:07
Speaker 3: Masturbation has lots of health benefits if it's helpful and fun for you. Anything that gives you stress and frustration and hurts you, don't do it. Don't do things just for your partner, right? You want to do things because you want them, not just for your partner. But if you find pleasure in a buildup and release situation, of tension, that's a good thing. Just like getting a massage is a good thing for your health. Sex and orgasm are typically very helpful, good feeling things. If it's painful, if it's not pleasurable, if it's not safe, then no, it's not a good thing. I would say I'm less on the like, you have to be on a masturbation schedule and a routine No, but if you want to be, if you care about it, if you want to have that part of your life maintained, there are many things in our toolbox to help you.
00:39:49
Speaker 4: How do you guide the people that you care for at Who maybe the libido and the desire for sex is not aligned. Like you have one partner who wants to have sex and the other one whose libido is not as high.
00:40:02
Speaker 2: It's very common.
00:40:03
Speaker 3: I would say it's very hard to find a couple who is perfectly aligned for their entire span of their relationship. Because life happens and there's a lot of roller coaster things that happens to sexual health. Somebody gets a cancer or somebody breaks a hip or somebody has hormonal changes or goes through perimenopause or menopause. And so I think it is the norm to have some mismatch of desire. And one of the things I love about being a urologist is I can take care of every couple, whoever you are, whatever genitals you have, let's work and make sure we optimize what you want. Because if you help one side of the couple, if I give a man who has low testosterone, testosterone, and I make him a horny guy who chases his wife around the house and she has pain and low libido, I have hurt that relationship majorly. And so it's really important that we look at everybody. Now, one of the analogies I really like for mismatch is imagine you got a new golden retriever puppy, right?
00:40:57
Speaker 2: Cutest puppy in the world.
00:40:59
Speaker 3: That puppy is going to want to play fetch with you all day, every day, all day. And it's cute for about 20 minutes. But at some point, you got to make dinner. At some point, you got to go to bed. At some point, you have to go to work, right? You cannot play fetch with this puppy all day, every day. And you have to set boundaries. But this puppy is always going to want to play fetch. And it is never going to want to stop. And I think sex is sometimes like that, where you may have a partner that wants to be sexual with you all the time, that is so excited by your presence, that really cares about you and wants to hump your leg all the time.
00:41:29
Speaker 2: But you may not want to.
00:41:31
Speaker 3: And it's a wonderful thing that that puppy loves you, that partner loves you and cares about you.
00:41:36
Speaker 2: And that's a good thing. But you have to hold up boundaries.
00:41:39
Speaker 3: The person with the low libido does not have to reach to the height of the person with the high libido. You do not have to do fetch with the puppy whenever the puppy wants to play fetch with you. You have to set boundaries with the puppy and come to an understanding of what makes sense for the two of you because you are not like any other relationship in the history of the world. And so I think it's that understanding of like, you guys aren't broken. You just have to figure out what is the cadence?
00:42:01
Speaker 2: What is the balance?
00:42:02
Speaker 3: And what is the fun? Because I think we forget that sex is supposed to be fun. We forget that it's supposed to be silly and joyful and weird and weird smells and weird noises. And it's just supposed to be fun. It's adult playtime. So if you are not having fun, the question is, do you want to make it better?
00:42:19
Speaker 4: I love that adult playtime. Talk to me a little bit. I once spoke to a sex therapist and she said to me, you know, Dr. Pointer, We're not meant to be monogamous. And in every relationship, the libido tapers off and trails off. Can you comment on that statement?
00:42:34
Speaker 3: Here's the deal. If you love creme brulee, right? It's the most delicious dessert you've ever had. You can have creme brulee alone and it tastes great. And you can have creme brulee with your spouse and it tastes great. And it's like really fun. But what if creme brulee is the only thing that you are served every day for a year?
00:42:53
Speaker 2: It's the only thing you get to eat. At some point, you are going to wish for another something to eat, right? Something else.
00:43:00
Speaker 3: And so I do find that people get into their habits, their routines, you know, and that's why I ask them about what does sex look like, right? The stories that I get. Well, you know, once a week, my partner will kind of tap the bed in a certain way.
00:43:14
Speaker 2: And I'll have to decide, do I feel bloated? Do I want to have sex tonight? It's been about a week. Okay.
00:43:20
Speaker 3: What time do I have to get up tomorrow? All right, I guess I'll do it. And I guess it'll be fun, right? You do that chess mental calculation. And it can get boring, right? And then you're just having sex the same way every time. And it's not, you don't talk about it. You don't really plan for it. And so that doesn't seem fun. But of course, you know, you see a hot, sexy TV show or a porn movie, or you see someone walking down the beach and you're like, oh, there's spontaneity.
00:43:45
Speaker 2: Oh, there's danger. Oh, there's fun. Oh, I'm at a business meeting and someone's flirting with me. This feels exciting. This is, I feel seen.
00:43:52
Speaker 3: I feel like someone, you know, sees me as a person and not just a mom or not just a this So it's human nature. And I think when we don't talk about it, when it's the unspoken about thing, when we don't bring it up, then the brain goes wild and the issues go out. So I think communication is the path to change it. And you have to decide what you want.
00:44:12
Speaker 4: What is the biggest myth on the internet about women's sexual health that you would like to see not on social media?
00:44:22
Speaker 5: I think this idea that supplements are the magic tool for your libido, that somehow you could spend money on a supplement and it's going to make you wild in bed and somehow turn into this vixen is not really helpful.
00:44:35
Speaker 2: I want women to believe in science and data and to use science and data. And we do have.
00:44:40
Speaker 3: Data that there are medicines that can help with sexual health and there are medicines that can hurt sexual health. So I think there's a lot of stake oil being.
00:44:46
Speaker 2: Peddled on social media. And I would like to see some of that gone.
00:44:52
Speaker 4: A lot of women at midlife may have some altered body image. Do you think that that is important in libido and sexual health for women? And then if it is, how do we make that better for women? I always ask about it. It's part of my intake when I talk to patients. I ask about their body image and their relationship with food and things like that. I think we have a big problem in our society and how we think about these things. People still deserve pleasure and joy and intimacy.
00:45:19
Speaker 3: And I think if your partner says, you are beautiful and I love you and I want to have sex with you, believe them. Believe them because they are so happy to be in the room. They're so happy to be connected to you. You do not have to be a Hollywood perfect in order to deserve pleasure, love, intimacy, and connection. And I will tell you, Having met people in Hollywood, they are not having better sex than you. They are not having more connected sex than you. And they also struggle with the body images stuff that you do. And at the end of the day, have fun. You deserve fun. You deserve pleasure. You deserve joy. And you are robbing yourself of that because you are not a certain weight on the scale.
00:45:56
Speaker 2: Is a nightmare.
00:45:57
Speaker 3: And so we have to fight against that. Don't wait until you look a certain way to be happy. Be happy now and work towards your goals, whatever your goals are. But really connect with yourself of why are these my goals? Are these my goals because society says it should be my goals?
00:46:11
Speaker 2: Or are these really my goals?
00:46:13
Speaker 4: I love that. Where can women find resources? Where should we guide them to?
00:46:18
Speaker 2: Absolutely.
00:46:19
Speaker 3: So I would say ISWISH, the International Society for the Study of Women's Sexual Health, is a great resource But they have a website called prosayla.com. It's P-R-O-S-A-Y-L-A.com. And you can find a doctor who cares about women's sexual health. Now, there may not be one in your area. I think Boston is a dead zone for ISWISH providers. But we're trying to train more. And as a society, a medical society, we're growing in numbers, which is very exciting. And many of our members are students, which is even better. And so we're trying to train and inspire the next generation of people to do this. On my website, rachelrubinmd.com, we have so many resources, both for patients and clinicians. We really are trying to teach people how to do this. It doesn't matter if I know how to do this. I have only so many hours in the day, and I can't see all the patients. And so we have to train others. So if you're a clinician listening, please take one of our trainings, come join ISWISH, be a part of this movement, because it is It is so joyful. I can't tell you how joyful it is. I had a patient come to see me once. I'll never forget it. And she said, Dr. Rubin, I came to you for pain with sex. And yeah, yeah, it doesn't hurt anymore. But I didn't think I would like it again. I didn't think I would want it again. I didn't ask you for that. And I can't believe I have it. And I think that speaks so beautifully for this. She didn't even know she could ask for it. She didn't even know it was in the toolbox of things I could offer her. She just wanted it not to hurt anymore. And I love that story because when you work with a clinician who can see beyond what you can see and they can support you and cheerlead for you, it changes so much. So it's the most fun field in the world. I love what I do, but we need more help.
00:48:05
Speaker 4: I loved what Dr. Rubin just said about her patient who was looking for relief from painful sex. And along the way, rediscovered pleasure, desire, and joy. We talk a lot about women's health in terms of what can go wrong, but our sexual health is also about quality of life. Pleasure, intimacy, connection, and yes, fun. And if something has changed, maybe it's pain, libido, arousal, or orgasm, you don't have to just accept it and live with it. As Dr. Rubin said, if it matters to you, it matters. I hope this conversation makes it a little easier to bring these things up with your doctor, with your partner, and even with yourself. Decoding Women's Health is a production of Pushkin Industries and the Atria Health and Research Institute. This episode was produced by our team, showrunner Alexandra Gerriton, editor Amy Gaines-McQuaid, and producer Rebecca Lee Douglas. Fact-checking, concept, and creative development by Siobhan O'Connor. Mastering by Sarah Bruguier. Our theme song was composed by Hannes Brown. Special thanks to Vicki Merrick, Alan Tisch, David Saltzman, Dr. David Dodik, Sarah Nix, Jacob Goldstein, Leah Rose, Jordan McMillan, Morgan Ratner, Owen Miller, Eric Sandler, and Greta Cohn. I'm Dr. Elizabeth Poynter. Thanks for listening, and until next time.
Speaker 1: This show is not a substitute for professional medical advice, diagnosis, or treatment. It is for informational purposes. Please consult your healthcare professional with any medical questions. Also, in this show, we use women as shorthand for people with XX chromosomes. We understand sex and gender are more complex. and acknowledge the experiences we describe reach beyond that word.
00:00:54
Speaker 2: They think we forget that sex is supposed to be fun.
00:00:57
Speaker 3: We forget that it's supposed to be silly and joyful and weird and weird smells and weird noises and it's just supposed to be fun. It's adult playtime. So if you are not having fun, the question is, do you want to make it better?
00:01:09
Speaker 4: That's Dr. Rachel Rubin. She's a urologist and one of only a handful of physicians who specialize in sexual medicine professionally. for all genders. Dr. Rubin brings so much enthusiasm, candor, and curiosity to this field. And there's a surprising amount we already know about women's sexual health that simply isn't being shared widely enough. I have to say, I smiled a lot during our conversation because yes, we're talking about medicine, but we're also talking about pleasure, anatomy, relationships, hormones, and so much more. Caring for our sexual health has the potential to bring great joy to our lives. Here's our conversation. So you're one of only a handful of physicians who have specialized training in sexual medicine for all genders. What drew you to this area of medicine? Yeah, it's a great question.
00:02:05
Speaker 3: You know, you always wake up every morning and say, how did I get here? How did my life journey get me into penis doctor mode? It's a very strange thing, not something every little girl dreams of.
00:02:15
Speaker 2: I don't know.
00:02:16
Speaker 3: I think we were middle schoolers who talked about it. The boys talked about it. The girls talked about it. There was no shame or stigma. And then I think when I got into the medical world, I realized that was weird.
00:02:25
Speaker 2: That was strange. Not a lot of people felt that way.
00:02:28
Speaker 3: And then when I did my rotations and I realized I didn't like delivering babies and what OBGYNs do is astronomically challenging.
00:02:36
Speaker 2: And I enjoyed urology.
00:02:38
Speaker 3: I enjoyed the quality of life discussions. I enjoyed talking about people's sexual health. And I was able to take care of men and women when we did that. And so we really have been working to advance the knowledge and the research in women's sexual health the way that we have in men's sexual health, although we still have a long way to go for both of them.
00:02:58
Speaker 4: So why do you think we are so uncomfortable talking about women's anatomy just in general?
00:03:03
Speaker 3: Yeah, I think there's probably many reasons that can aim from the fact that the nerve to the genitals that innervates the penis and the clitoris and the vulva and the perineum and the rectum in all genders, it's called the pudendal nerve, which means shame in Latin. So I think you can look back to sort of our history and how we think about genitals. You could talk about politics and puritanism and And at the end of the day, it's really hard to see your genitals. Like men's penises are just out and proud and they can see every bump, every vein, every change that happens. And I think that women, it's a little bit hidden from us. You have to kind of do gymnastics to look down there. And we're not really taught to look down there. And then I don't know about how you were trained, but I was trained to look under the hood, right?
00:03:50
Speaker 2: Give a sheet.
00:03:51
Speaker 3: And so you kind of give a patient a sheet and you look between their legs and You hide themselves from themselves. And so you never learn about your own anatomy. And I think we miss an opportunity with young people and older people to teach them about their own bodies.
00:04:06
Speaker 2: My sex ed was pretty crappy. I don't know about yours.
00:04:09
Speaker 3: But we don't do a really great job of teaching and talking about it.
00:04:13
Speaker 4: Yeah, it's so funny that you mentioned the sheet because to this day, that's the way I was trained and I always drape a sheet. And actually, it is a total disconnection. I've learned two new things from you. Pedendal, I did not also realize was shame. There's some medical verbiage that we maybe need to change. Hysterectomy is another one, I think. Yeah, hysteria.
00:04:33
Speaker 3: No, I think the language really matters here, right? And how we think about it. I give women a mirror and I show them their own genitals as I'm doing the exam.
00:04:41
Speaker 2: This is your labia majora. This is your labia minora. This is your clitoris. This is your pelvic floor.
00:04:45
Speaker 3: And just having a mirror and showing them what I see gives them access to language that they never had before. So the best example I came up with recently was you never show up to the doctor with face paint. right? You would not go to the dentist if you had an eye problem. You would not go to the dermatologist if you needed an ear, nose, and throat doctor. And yet we think of it as down there, right? We don't even have the language to really understand it. Everyone calls it a vagina, right? Everyone calls a vulva a vagina. And there's a comedian, I love this so much, I'm going to steal it. There's a comedian who says, Calling the vulva a vagina is like calling the face the.
00:05:29
Speaker 2: Throat, right?
00:05:31
Speaker 3: Oh, your throat looks beautiful today. I love the way you have makeup on your throat today, right? That doesn't make any sense. But that's essentially what happens, right? The vagina is the inside part. The vulva is the outside part. And yet so many people just call it all a vagina.
00:05:45
Speaker 4: You bring up like immediately three great, really important points. Do you see this conversation changing at all?
00:05:53
Speaker 3: I mean, we're having this conversation, right? How beautiful that we're having this conversation. How beautiful that I get invited to speak at the FDA and I can say words like sexual medicine and talk about vaginal estrogen and UTI prevention and sexual symptoms.
00:06:09
Speaker 2: And so, of course, it's changing. And I think.
00:06:11
Speaker 3: Social media is very terrible in many ways, but is also helping to create more equalized access to information. And I think some of it good, a lot of it bad, but there's more information. I don't see as many patients of, oh, I've had pelvic pain for 20 years and no one's diagnosed me. They're coming to us sooner. So I do think there's hope, but it will require an army of human beings to help us continue to move it forward.
00:06:38
Speaker 4: Yeah, it's interesting how social media and many aspects of women's health has just opened the dialogue finally. And I think that professionals need to also be part of that dialogue, you know, participate in that with further education, that type of thing. Let's talk about women's sexual health and function. There's so much focus placed on men's sexual health. We know more about it. Is it because women are more complex or we just haven't studied it or people just not interested? Why are we where we are?
00:07:04
Speaker 3: Yeah, I often show this slide when I give lectures. The top bar is an on-off switch, like men's sexual health on-off switch. And then the bottom is all these buttons and levers and dials. And it was like women's sexual health. It's so complicated. And it's actually not complicated at all. And there is so much biology that we actually do know about that we just don't teach anyone and we don't explain it to people. It's really actually very fun being a urologist in this space because I was trained on male genitalia and the female genitalia and the male genitalia are exactly the same. right? They're a little bit in different sizes and different orders, but there are connections. So the scrotum is the same as the labia majora. The clitoris is the same as the penis. And so when something goes wrong with one, you can actually use that information to help you understand how to take care of the other. Now, there actually is a lot about men's sexual health that we don't understand. So whereas we understand the biology of erectile function much better than we used to, thanks to Viagra, We still don't understand a lot about male orgasm, male ejaculate, even libido in general, right? There's a lot of biology that's not fully figured out. The same is true for women. So we understand libido a little bit. We understand the hormonal importance to the genitals and the bladder health. But when it comes to like really understanding the neurobiology of orgasm, I think we have a long way to go. So I have two frustrations. One is there's a lot we don't know. My real frustration though is we don't teach the stuff we do know. We actually have great options for pelvic pain and vulvar pain conditions. We have great options for the genitourinary syndrome of menopause and to help people prevent UTIs. It's no one's writing the damn prescriptions. Right.
00:08:47
Speaker 2: No one's actually following guideline driven care.
00:08:50
Speaker 3: Nobody learns it. And the medical students aren't learning it. The residents aren't learning it. And how can they learn it if there's no one there to teach them? And so that is my biggest frustration.
00:09:00
Speaker 4: And so what's your answer to that? How do we fix that?
00:09:03
Speaker 3: We roll up our sleeves and we do the work ourselves. So the truth is there are no grownups coming to save the day. There is no body or organization that's going to come and fix it and magically make it better. And so what do I do? I just do everything I can.
00:09:16
Speaker 2: I do podcasts.
00:09:17
Speaker 3: I go teach at CME courses. I make my own CME courses that people can take from their home. I have a whole research team. We call it the sexual medicine research team, where we have hundreds of med students from all over the country. I'm planting all the seeds. I'm trying to create a grassroots movement. of students, of researchers to say this matters. And if it matters to you, we can collaborate and work together to make this better. And so I think it will take time and it will take inspiring others to want to do the work. And I think it's explaining to people that it's work. It is work to see patients every day and write prescriptions. It is work to explain to patients the benefits and safety of hormone therapy. It is work to change the messaging and we have to change policy.
00:09:58
Speaker 2: I'll give you an example.
00:09:59
Speaker 3: Right now there's a patch shortage where women cannot get their estrogen patches and we're encouraging them to write to the FDA, write to the FDA, here's how to write to the FDA. And yesterday the FDA put out a statement and said we're listening and we've reached out to the six manufacturers. That means that we got people loud, not just me, but everybody got people loud. And people wrote in, they wrote into the FDA, they wrote about their experiences. And so this is this, I have goosebumps of the advocacy That you just have to keep pushing, pushing, pushing, pushing. You just can't give up. You just got to keep finding little holes wherever you can, I suppose.
00:10:36
Speaker 4: What can we learn about a woman's overall health by assessing her sexual health?
00:10:41
Speaker 2: Oh, I love that question.
00:10:42
Speaker 3: And the fact that you asked that question shows that we are so much farther along than we were five or ten years ago. So we know, again, I'm a urologist, so I often go back to what I know about male genitalia, but we know that the penis is a marker for overall health. So erectile dysfunction, which 50% of 50-year-olds have erectile dysfunction, 70% of 70-year-olds have erectile dysfunction, we know that erectile dysfunction is a sign that there is something going wrong with your cardiometabolic system. And so I think of it like this. the arteries to your heart are three millimeters. The arteries to your penis are one millimeter. So what's going to clog first? Your small pipes are going to clog before your big pipes.
00:11:23
Speaker 2: So men who.
00:11:24
Speaker 3: Have erectile dysfunction, this may be a sign that you're going to have a heart attack in 10 years. And so I absolutely think that the same is true for women, but we do not talk to women the same way. We don't ask them about their arousal. But if you ask, and I ask every single one of my patients, has your arousal, your engorgement, your lubrication, the tinglys that you feel in your genitals, has it diminished?
00:11:46
Speaker 2: Has it changed? Is it muted?
00:11:48
Speaker 3: And as women go older and older, as their cardiovascular risk goes up, their response to their arousal problems also goes up. But we don't even talk to women in that much detail about their sexual health. But my guess is it's absolutely a marker. We also know that arousal is going to decrease when you don't have hormones. Estrogen, testosterone are so important for the health of the vulva, of the genitals, of the vagina, of the bladder. And so when you don't have hormones, it gets thin, it gets raw. The microbiome changes and your risk of pain with sex, vaginal dryness go up, but also you get urinary frequency, urinary urgency, leakage, and urinary tract infections. And so these changes, these sexual health changes are a sign that bad things are to come.
00:12:34
Speaker 4: About what ages do sexual health issues begin to arise for women in terms of arousal or response or libido? Do you see these in the early perimenopausal transition or years after the final menstrual period, or is it just dependent on the woman?
00:12:50
Speaker 3: Yeah, so we see sexual dysfunction throughout the lifespan in different ways. We see pelvic pain happen for different reasons. We see hormone changes happen for different reasons. And then we see women on birth control pills. Birth control is great. I love birth control, but it works by shutting your ovaries down and it doesn't give you back testosterone. And so we see a certain percentage of women on birth control pills have low libido, vaginal dryness, and pain with intercourse because these medications block testosterone. And so our job is to really say what's going on with you and can we figure out the biology to help you live your best life, not to mention all the psychosocial stuff that happens with trauma and and abuse and lack of knowledge and education, all sorts of things obviously can happen.
00:13:33
Speaker 2: So really there is no age.
00:13:34
Speaker 3: With which sexual discussions are not relevant and the biology can't affect someone.
00:13:42
Speaker 4: Well is our healthcare system set up to manage this? Is it the PCP, the internist, the OBGYN? I mean, you're so special because you're a urologist with a special interest. That's a unicorn, right? I think for many individuals, like who owns this? Who should be addressing this with women and helping women in this area?
00:14:02
Speaker 2: You know, I'll ask you, how much did you learn about this in your training?
00:14:05
Speaker 4: It is all self-taught. Well, I'm an oncologist, so it is all 100% self-taught. Anything I know about pelvic floor dysfunction and sexual health is everything that I was curious to learn about.
00:14:15
Speaker 3: And bless your heart, right? Thank God we need you. And we're so grateful to have your curiosity and your interest. And that's why part of this is to get people like you curious and interested.
00:14:24
Speaker 2: And we have.
00:14:25
Speaker 3: We've got more oncologists and pain doctors and all sorts of different kinds of clinicians who are interested in this because Sexual health is everybody's responsibility. Sexual health affects all organs. It affects your brain. It affects your heart. It affects your muscles and your joints and your pelvic bones. And I need orthopedic surgeons to care about this. And so it's everyone's responsibility and no one's doing it. Everyone's really busy with other stuff. And as a society, we have decided that your pap smear is more important and we've decided that your mammogram is more important and we've decided that your colonoscopy is more important. And I understand why those things are important But the problem becomes everybody has some relationship to sexual health and human life happens because people have sex. And yet we have no specialty that focuses on women's sexual health like it doesn't exist. And so it's kind of wild when you think about it and that we've ignored the science and the clinical aspects of this issue. It shouldn't be a handful of us right there. There should be many, many, many of us. And it shouldn't take a curious oncologist to say that sexual health is important because what patient with cancer isn't completely wrecked in their sexual health, whether it's from chemotherapy, radiation therapy, and what that does to their relationship, their connection, and the discussions that we have before, during, and after treatment.
00:15:46
Speaker 2: As you know, right, are incredibly powerful.
00:15:49
Speaker 4: Yeah, and your sense of, I think, for oncology, too, especially, it's like your sense of being alive and connected. It's so important. Like, you want to be alive. You want to be connected. You want to have sex for most of us. and that's where it can really go awry. And so we really need to understand it when there's other issues involved, such as cancer. What are the signs of sexual dysfunction that really shouldn't go ignored, that women really should address with somebody?
00:16:14
Speaker 3: Sex should not be painful, full stop. It should not feel like shards of glass. Penetration should not feel a scratchy, burny irritation, painful like they're hitting a wall.
00:16:24
Speaker 2: It should not hurt.
00:16:25
Speaker 3: You know, that's, to me, the biggest sort of warning sign. This isn't just use some lidocaine to cover it up or just drink in order to have sex. There should be a formal diagnosis. So that's the biggest one I would say. And then if you're bothered by something, it matters and it deserves a serious discussion with a serious clinician who cares about this issue. So if you go to your primary care and you say you have a low libido, they're going to minimize that complaint because in their mind, low libido is not a major medical problem. because the patient right before them has liver cancer, the patient two before them is in diabetic shock, the patient three before them just lost a spouse. And so when you come in to talk about your libido, they're like, okay, well, you know, go to therapy. But the truth is, if you're bothered by your low libido, it is a medical diagnosis with medical treatments that span biopsychosocial toolbox, and it deserves a conversation and it deserves education and treatment strategies. And so It may mean, though, in 2026, that sexual problems, you have to think of like rare diseases and you have to go find the people who study those rare diseases. So there are sexual medicine doctors, although they can be hard to find. But if it's important to you, and it's not important to everybody, but if it's important to you, it deserves a partner that will champion.
00:17:48
Speaker 2: It with you.
00:17:51
Speaker 4: We need to take a quick break. When we return, we'll talk solutions. for some of the most common sexual health concerns like painful sex and low libido. Stay with us. Let's talk about pelvic pain or pain with sex. There can be entry pain and deep pelvic pain. Can you unpack those for us and tell us the causes of entry pain, the causes of deep pelvic pain, and what some of the treatments would be for that?
00:18:29
Speaker 2: Absolutely.
00:18:30
Speaker 3: And I think it's an important distinction, and you can have both. I always joke that I'm kind of like a sex detective. this idea of listening to the patient, spending time because your sexual health care, your pain deserves more than a 10 minute visit with your legs up in stirrups. So we really have to get to the history. Like oncologists get this because they get time with patients, but a lot of other doctors don't get time. And so it is the history that helps guide us of what's going on with the patient.
00:18:57
Speaker 4: And it's quite simple.
00:18:58
Speaker 3: It's the physical exam that then speaks very loudly. If I can find your pain, if I can touch your pain, if I can look at exactly where your pain is, it helps to give me an idea of what might be causing your pain. And so entry pain is often, like almost always, due to a strip of tissue that lives inside the labia minora around the urethra at the entrance of the vagina called the vulvar vestibule. And the vulvar vestibule, many doctors, if you're listening, have never heard this term before, but it's essentially where the skin of the labia turns into the bladder tissue. And so the vulvar vestibule is actually endodermal bladder tissue that is delicate. So the outside of your cheek is a nice rough skin, and the inside of your cheek is a very delicate mucosa. And you have your lip that connects the two. Your lip is different than your cheek, which is different from the inside of your mouth. It's a transition point in the type of tissue. So your labia is this beautiful transition point where your skin becomes your bladder, and then past your bladder is the vagina, which is different tissue altogether. Now, just like the inside of your cheek is super thin and delicate, that tissue at the opening of the vulva is very delicate. It's very sensitive to hormonal changes. It's very sensitive to inflammation and irritation. And sex, which is a contact sport, You have this rubbing up against that tissue and this inflaming that can happen causes symptoms, pain with sex, irritation, burning, urinary tract infection symptoms from when this bladder tissue gets irritated. And hormonal changes like menopause, breastfeeding, birth control pills can really affect this tissue. So that's entry pain. But we also see pelvic floor muscles, which live underneath the tissue, can be really tight and tense, just like you can have a knot in your shoulder. You can have knots in your pelvis from sitting the wrong way or from having irritation somewhere in your body. And so we use a lot of pelvic floor physical therapists to help us treat these patients. And then deeper pain is often a sign that something's unhappy. Whether it's endometriosis causing scar tissue all throughout your pelvic floor, whether it's a big heavy uterus that has adenomyosis or irritable bowel or something that's causing deeper pain and pelvic floor tension, it's really getting to the bottom of what's causing your pain. And with a good history and a good physical exam and a curious doctor or care team, sometimes we can figure it out. Sometimes we can't, but a lot of times we can.
00:21:29
Speaker 4: If you're having vestibular pain, how do you treat that?
00:21:32
Speaker 3: Yeah.
00:21:32
Speaker 2: So it's really understanding the cause.
00:21:34
Speaker 3: So the most common reason the vulvar vestibule hurts is hormones. And so whether it's a birth control pill, spironolactone, breastfeeding will cause vestibular pain, menopause, perimenopause.
00:21:47
Speaker 2: So if it's a hormone problem, we add hormones.
00:21:49
Speaker 3: So we'll either do a local vaginal DHEA, which is very supportive of this tissue. We'll often try to get women to change their birth control option to like an IUD or something non-hormonal. There's a little data that just a vaginal estrogen cream can help this tissue, but the receptors in this tissue are very androgen-based as well. And so it's actually the one place where I'll compound an estrogen testosterone a very low dose compound that they rub directly on this tissue. And it is miraculous to help this problem. Now, when it's not hormones, sometimes it's inflammation, whether it's an allergic reaction or they've had lifelong inflammation in that tissue. We're very interested in mass cell dysfunction, which is often a whole body issue. But we will have to cut this tissue out when we cannot fix it through topical hormones and things like that. And we do vestibulectomies for those patients. Now, if it's all vestibular pain from muscle tightness, then physical therapists are our best friends. We put in pelvic floor Botox and all sorts of out-of-the-box ways to think of this problem.
00:22:51
Speaker 4: Let's talk a little bit about pelvic floor dysfunction. You touched on it, but it's a word that we're seeing more and hearing more about, I think. So for our listeners, tell us what pelvic floor dysfunction is and tell us how it's treated.
00:23:01
Speaker 3: Yeah, so pelvic floor dysfunction is is no different than saying, I have back pain or my back is in spasm, right? Because the truth is, is you have muscles all throughout your back and a lot of reasons you might have back pain. And so if your pelvis hurts or you have pelvic floor problems, there's a million different reasons why you have that problem. And so it's really figuring out what your problem is and why you have it. So your pelvis is bones that look like a bowl, essentially, and it's the muscles that line the bowl of the pelvis. And there are these big, thick groups of muscle, right? They're pretty beefy muscles and they're responsible for a lot. They make sure that you're not peeing randomly. They make sure that you don't fart in a meeting. They make sure that you don't have a bowel movement when you're not supposed to. They hold up all of our organs. They allow for babies to not just fall out, but then they get stretched out when babies do come out, right? They're amazing what the pelvic floor does. And yet none of us We're trained on exercising our pelvic floors. We don't think of those muscles as muscles that can be trained. And so pelvic floor dysfunction could be I leak when I cough, laugh, or sneeze. It could be urinary urgency. It could be pelvic pain. It could be pain with intercourse. It could be weakness. So it could be prolapse. So this is where a pit crew is important to be able to really look at you from multiple angles because there are many different things that can cause it.
00:24:25
Speaker 4: Let's talk a little bit about low libido. I find it to be the most difficult issue that I help people with because I don't think it's always clear what's going on. Unfortunately, a lot of women are told, oh, it's just a normal part of aging, which I don't accept. Tell us a little bit about low libido and how you assess it, how you treat it, and what women should expect when they review low libido with the physicians who help take care of them.
00:24:51
Speaker 3: I'll tell you, I have a toolbox that I work with. It is a biopsychosocial toolbox. So if your partner is a jerk, it's gonna be hard to have a great libido. If you do not have safety, so if you're not safe in your home, if you don't have access to safety, it's real hard to.
00:25:09
Speaker 2: Have a good libido.
00:25:10
Speaker 3: If you are working a million hours a week and you're taking care of aging parents and children and you don't even have time to take a walk around the block for yourself, it's really hard to have a great libido. And so it's really getting to know my patients and figure out what did libido look like before? What do you want it to look like now? And how much effort and work do you want to do to try to improve your libido? The patients get to decide what they want to do. And so we work wonderfully with sex therapists. We work with medications, whether it's the FDA-approved medications for low libido. There's two, one called flibanserin or Addi, the other one called Bilesi or Bremelanotide. We love testosterone for libido.
00:25:49
Speaker 2: It works. It works so well. Tell me how I know. I use it myself.
00:25:53
Speaker 3: And what's interesting, it also language matters because libido can be libido with.
00:25:58
Speaker 2: Your partner and it can also be with yourself. So it's not uncommon.
00:26:02
Speaker 3: I'll talk to a patient and they'll say, I have low libido and my partner and I haven't had sex in three years. I said, well, have you had any interest in having an orgasm in three years? And they'll be like, oh yeah, it helps me fall asleep at night. So three times a week I get my vibrator out and I have an orgasm and I'm reading my sexy romance novels. And it's like, okay, your libido is actually pretty good, right? Like your libido is awesome. It's just not translating into partnered libido. And so you have to decide, is that good enough? Or do you want to work on having more fun with your partner? And that's really, it's again, one of the things I love about sexual medicine is it doesn't matter what I think about sex. I have to know what you think about sex and what you want it to look like. And so if I don't know the type of sex you're having or what you want it to look like, How can we build you a toolbox.
00:26:48
Speaker 2: To improve it?
00:26:49
Speaker 3: And I think we're all very prim and proper and we don't get really detailed with our questions. We sort of talk about it in broad strokes, but like, can you have an orgasm? Is it just from clitoral stimulation? Do you use devices? Can you have multiple orgasms? Is penetration pleasurable for you?
00:27:06
Speaker 2: What do you like?
00:27:08
Speaker 3: I've never been asked those questions before. I'm sure you've never been asked those questions before in a medical setting. And I think that is biology and medicine, and we just don't really think of it like that.
00:27:19
Speaker 4: So talk to me a little bit about testosterone and libido. We all know that women who have very high levels from pellets and such have great libidos. And testosterone went through the FDA a number of years ago and wasn't approved for libido for women. So what do you find that there's a particular level? Are some people more responsive to it? Do you have to dose higher? What is your take on the efficacy of testosterone for libido in terms of ranges that you need to get into? Or is it just all increase it? And if it works for you, great, stop there. How do you dose it?
00:27:54
Speaker 3: Yeah. You know, 20 years ago, they came out with a testosterone product. They put a billion dollars into it and studied it for five years. And it worked for libido and it was completely safe. And it was around the time the Women's Health Initiative scared everyone away from hormones. And the FDA said, ooh, we're just a little nervous about this. So we want five more years of data. It was going to be another billion dollars and no company wanted to do it. And so we've had 20 years of no product that has gone to the FDA to approve testosterone for women, even though it's approved in Australia, New Zealand, South Africa and England. And so it's a challenge because we don't have a product that is dosed appropriately for women here in the United States.
00:28:35
Speaker 2: And it's a controlled substance. But many of us use testosterone. We use male testosterone at female doses. It's a tube.
00:28:43
Speaker 3: It looks like a tiny tube of toothpaste. And a man would use the whole tube every day. My female patients and myself, I take a blob, you know, like a chickpea size or a thumbnail size, and I make this tube last about a week or 10 days. And that's about five milligrams of testosterone. And what I find in my clinic is that when you give people that level of testosterone, and it takes about four to six.
00:29:05
Speaker 2: Months, in my opinion.
00:29:07
Speaker 3: You see that improvement. And it's libido gets better, but arousal and orgasm get better. Mood tends to get better. Energy tends to get better. It is the thing that I see the most commonly in my practice where people say, I feel like myself again. Now, usually I do it in conjunction with estrogen and progesterone for people who have menopausal symptoms, but it really can work. Now, again, when we don't have a product, it becomes challenging to know as precision of what is the exact level that we're trying to get to?
00:29:37
Speaker 2: I don't know.
00:29:37
Speaker 3: If you're not having side effects and you feel good, I'm not really worried about causing you harm. We have people who take 10 times the dose of testosterone. They're called men and trans men, and they're doing just fine, right? And so as long as you're not having side effects, I'm not really super afraid of harming people. I don't do pellets in my clinic for a number of reasons, but the most common reason is they're not regulated by the FDA. And so I have no idea what's in them. It means I have to trust a company that tells me what's in them and I'm going based on vibes. And I never like, unless I have to, I don't like going based on vibes.
00:30:13
Speaker 2: And so that's my reason.
00:30:14
Speaker 3: Not that pellets couldn't work. It's just that if they're dosed too high, you can't take them out. And so patients may get side effects from them.
00:30:21
Speaker 4: Do you check levels at all?
00:30:22
Speaker 3: I do.
00:30:23
Speaker 2: I check levels for two reasons.
00:30:24
Speaker 3: The guidelines, the global consensus guidelines do say to check a total testosterone. And the reason they do that is that you want to make sure that they're not super physiologic already, right? That they may not have too high of a testosterone. But there is no number you wouldn't treat if somebody had symptoms. I do check a level for two reasons. One is it's a nice baseline. But it's really nice to see people absorb. There is a certain percentage of men who do not absorb through their skin very well. And we do injections. We do oral testosterone. We do all sorts of things for men because we have like 30 products. And so for women, there is a percentage of women who don't absorb estrogen and testosterone through their skin very well. So, for example, when I checked my testosterone a couple of years ago, it was 11%. which if we have 10 times less testosterone than men, it would be like a man having a testosterone of 110, which is a 10 alarm fire in America, right? If a man has a testosterone below 300. And so mine was 11. And I said, oh, I wonder how I'll feel if I add testosterone. And I started taking testosterone. I got my levels up to about 50 or 60. And again, that would be like 500 or 600 for a man, which is totally reasonable, normal testosterone. And after about five or six months of using it, it was sort of like, oh, this is good. This is working for me, right? And so I was able to see that my body was absorbing it by the numbers, but I didn't feel any different for about.
00:31:45
Speaker 2: Five or six months.
00:31:47
Speaker 3: And what's interesting is the first thing I noticed, and I have had patients tell me this, and there is some data behind this, my stress incontinence got better. And so I had very mild stress incontinence from having two babies. And when I coughed, I didn't have to brace myself. I didn't leak urine. And it's because the urethra is rich in testosterone receptors.
00:32:07
Speaker 4: And it makes so much sense.
00:32:08
Speaker 3: So when we say testosterone is just for libido, no, testosterone is a chemical that exists in that your ovaries and your adrenal glands make and that has receptors throughout the whole body and we just have the most data that we've collected on libido and so it's just such a fascinating conversation because there's so many feelings people have so many feelings about testosterone but they don't have the same feelings about thyroid hormone or insulin or you know any other hormones out there yeah.
00:32:35
Speaker 4: I feel comfortable i use it a lot in our practice but But many people don't feel very comfortable giving testosterone. They're worried about safety issues and such. And I think that there's safety data from that previous FDA data that was presented when they were using the patch, right? Let's talk a little bit about the clitoris. Why is it so misunderstood? And what is its role in women's sexual health? And then talk to us a little bit about vaginal orgasms versus clitoral orgasms.
00:33:02
Speaker 2: Yeah, absolutely.
00:33:03
Speaker 3: So the clitoris is so misunderstood mostly because it's been hidden from us. The only thing that we can see on the outside is the tip of the tip of the head. just like the head of the penis is the tip of the iceberg. If you have sex with men, you don't just touch the tip of the tip of the penis in order for them to have pleasure. There's a shaft, there's an internal penis, goes all the way down to the butt bones, and the clitoris is the same, but it's all internal. So you do have a shaft, which you can feel above, like beyond when you touch the head of the clitoris, but then you can't really feel those inner legs that go all the way down to your butt bones. And the clitoris is erectile tissue.
00:33:40
Speaker 2: It gets erect. It gets hard. It engorges.
00:33:43
Speaker 3: And just like if you stimulate a penis enough, you can create an orgasm and ejaculate in a man. If you stimulate a clitoris enough, you can create an orgasm in a woman. And so most women, the majority of women have orgasms from their clitoris, just like most men have orgasms from their penis. We don't rub the man's inner thigh for them to have an orgasm. Very few men can have an orgasm when you rub their inner thigh. It's close to the penis, but it's not the penis. And so when the vagina is penetrated, it's close to the clitoris, but it is not the clitoris. And so most women, the normal way of having an orgasm is not with penetration, though there is a percentage of women who can orgasm with penetration. And if you're one of them, you are a ninja unicorn, you are amazing, and everybody's jealous of you. But my theory is that their body is just more sensitive. Their neurobiology is more sensitive. And so you can activate the clitoris from the inside to create that orgasm. And there are other parts of the body that can be pleasurable for some women. The cervix can be pleasurable for some women. The anterior vaginal wall, the top of the vagina called the G-spot, though we're calling it a G-zone now, can be pleasurable probably for people with higher testosterone because it is androgen-sensitive tissue like the prostate. And so if you have different areas that give you pleasure, you're amazing. And if you don't, you're not broken. You can explore other areas. Just like the penis is the path to orgasm in men, that doesn't mean men can't have pleasure from prostate stimulation or rectal stimulation or scrotal touch. But their orgasm is predominantly from their penis. Most women's orgasms are predominantly from the clitoris.
00:35:24
Speaker 4: What percentage of women haven't had an orgasm or perceive themselves as not being able to have an orgasm? And how do you help them?
00:35:32
Speaker 3: Yeah, about 20% of women will say they can't orgasm or they have an orgasm problem. And it always becomes the question, is it education? Because many women come in thinking that penetration should be the path to orgasm. Is there a biological issue, so a hormonal issue, a nerve issue, a pelvic floor issue? You know, the percentage of men who can't orgasm is much lower. And so if we think the bodies are similar, then the question is, why the difficulties? And is it an activation issue? Is it a vibration issue? Now, when I exhaust all of my biological toolbox and my psychosocial toolbox and they still can't orgasm, the thought of those patients keep me up at night trying to figure out what are we missing and can we help these patients? But I think they can be very challenging to figure out.
00:36:17
Speaker 2: Is it education? Is it anatomy? Is it physiology? What's the issue?
00:36:21
Speaker 4: You just mentioned vibration problem. What is that?
00:36:24
Speaker 5: Yeah.
00:36:25
Speaker 3: So we know that more than 50% of women use vibrators or devices that help them have an orgasm. And that's because, remember, the clitoris is mostly internal. So if a penis was completely internal and there was nothing for a man to hold on to and nothing that he could penetrate, how would a man have an orgasm? How would he stimulate his penis for an orgasm? And that's essentially what a clitoris is. And so vibration has been known about for millennia that if you vibrate the area around the vulva, you can stimulate a reflex. Just like a sneeze is a reflex, you can stimulate an orgasm reflex that is very pleasurable for people. So devices are an incredibly helpful way to have an orgasm. And the vibration nerves are the most robust the older you get. And so vibration can become an incredibly useful tool to Older people who may have arthritis or not be able to use their hands or their mouths as much for pleasure, they use vibration to maintain that sexual health.
00:37:24
Speaker 4: Still to come, how to talk to your doctor about sex, even if it feels awkward. Plus, making room for more pleasure, connection, and fun in our lives. What conversations should a midlife woman have with her care providers about her sexual health? What are the key questions that she should have answered? And then how do you have women get a little bit more comfortable with a conversation that they might not be so comfortable with?
00:38:03
Speaker 3: I mean, I think I am biased here because I forget how easy it is for me to talk about all these things because I talk about sex like it's high blood pressure and diabetes because that's what it is. Your high blood pressure and diabetes affects your sexual health. And so I'm very comfortable talking about and very matter-of-factly talking about these issues. What I find as a doctor is if you show up confident and competent, you're listening and you show that you care, people will tell you just about anything and you can guide them through conversations. Now, I am biased because people come to my office with a sex problem. They know I'm a sex doctor. They know they can say anything to me. It's a little hard when you're talking to someone who delivered your babies or who you've known for 25 years. It can be incredibly intimidating. But if it matters to you, then it matters. And sometimes you may want to see a specialist, right, who does this for their job. And that's why we're trying to train more people how to do this because we can't just have it be a handful of people who are focused on these issues.
00:38:59
Speaker 4: So let's talk about solo sex or masturbation. Health benefits to that? Should women be masturbating? What is your advice?
00:39:07
Speaker 3: Masturbation has lots of health benefits if it's helpful and fun for you. Anything that gives you stress and frustration and hurts you, don't do it. Don't do things just for your partner, right? You want to do things because you want them, not just for your partner. But if you find pleasure in a buildup and release situation, of tension, that's a good thing. Just like getting a massage is a good thing for your health. Sex and orgasm are typically very helpful, good feeling things. If it's painful, if it's not pleasurable, if it's not safe, then no, it's not a good thing. I would say I'm less on the like, you have to be on a masturbation schedule and a routine No, but if you want to be, if you care about it, if you want to have that part of your life maintained, there are many things in our toolbox to help you.
00:39:49
Speaker 4: How do you guide the people that you care for at Who maybe the libido and the desire for sex is not aligned. Like you have one partner who wants to have sex and the other one whose libido is not as high.
00:40:02
Speaker 2: It's very common.
00:40:03
Speaker 3: I would say it's very hard to find a couple who is perfectly aligned for their entire span of their relationship. Because life happens and there's a lot of roller coaster things that happens to sexual health. Somebody gets a cancer or somebody breaks a hip or somebody has hormonal changes or goes through perimenopause or menopause. And so I think it is the norm to have some mismatch of desire. And one of the things I love about being a urologist is I can take care of every couple, whoever you are, whatever genitals you have, let's work and make sure we optimize what you want. Because if you help one side of the couple, if I give a man who has low testosterone, testosterone, and I make him a horny guy who chases his wife around the house and she has pain and low libido, I have hurt that relationship majorly. And so it's really important that we look at everybody. Now, one of the analogies I really like for mismatch is imagine you got a new golden retriever puppy, right?
00:40:57
Speaker 2: Cutest puppy in the world.
00:40:59
Speaker 3: That puppy is going to want to play fetch with you all day, every day, all day. And it's cute for about 20 minutes. But at some point, you got to make dinner. At some point, you got to go to bed. At some point, you have to go to work, right? You cannot play fetch with this puppy all day, every day. And you have to set boundaries. But this puppy is always going to want to play fetch. And it is never going to want to stop. And I think sex is sometimes like that, where you may have a partner that wants to be sexual with you all the time, that is so excited by your presence, that really cares about you and wants to hump your leg all the time.
00:41:29
Speaker 2: But you may not want to.
00:41:31
Speaker 3: And it's a wonderful thing that that puppy loves you, that partner loves you and cares about you.
00:41:36
Speaker 2: And that's a good thing. But you have to hold up boundaries.
00:41:39
Speaker 3: The person with the low libido does not have to reach to the height of the person with the high libido. You do not have to do fetch with the puppy whenever the puppy wants to play fetch with you. You have to set boundaries with the puppy and come to an understanding of what makes sense for the two of you because you are not like any other relationship in the history of the world. And so I think it's that understanding of like, you guys aren't broken. You just have to figure out what is the cadence?
00:42:01
Speaker 2: What is the balance?
00:42:02
Speaker 3: And what is the fun? Because I think we forget that sex is supposed to be fun. We forget that it's supposed to be silly and joyful and weird and weird smells and weird noises. And it's just supposed to be fun. It's adult playtime. So if you are not having fun, the question is, do you want to make it better?
00:42:19
Speaker 4: I love that adult playtime. Talk to me a little bit. I once spoke to a sex therapist and she said to me, you know, Dr. Pointer, We're not meant to be monogamous. And in every relationship, the libido tapers off and trails off. Can you comment on that statement?
00:42:34
Speaker 3: Here's the deal. If you love creme brulee, right? It's the most delicious dessert you've ever had. You can have creme brulee alone and it tastes great. And you can have creme brulee with your spouse and it tastes great. And it's like really fun. But what if creme brulee is the only thing that you are served every day for a year?
00:42:53
Speaker 2: It's the only thing you get to eat. At some point, you are going to wish for another something to eat, right? Something else.
00:43:00
Speaker 3: And so I do find that people get into their habits, their routines, you know, and that's why I ask them about what does sex look like, right? The stories that I get. Well, you know, once a week, my partner will kind of tap the bed in a certain way.
00:43:14
Speaker 2: And I'll have to decide, do I feel bloated? Do I want to have sex tonight? It's been about a week. Okay.
00:43:20
Speaker 3: What time do I have to get up tomorrow? All right, I guess I'll do it. And I guess it'll be fun, right? You do that chess mental calculation. And it can get boring, right? And then you're just having sex the same way every time. And it's not, you don't talk about it. You don't really plan for it. And so that doesn't seem fun. But of course, you know, you see a hot, sexy TV show or a porn movie, or you see someone walking down the beach and you're like, oh, there's spontaneity.
00:43:45
Speaker 2: Oh, there's danger. Oh, there's fun. Oh, I'm at a business meeting and someone's flirting with me. This feels exciting. This is, I feel seen.
00:43:52
Speaker 3: I feel like someone, you know, sees me as a person and not just a mom or not just a this So it's human nature. And I think when we don't talk about it, when it's the unspoken about thing, when we don't bring it up, then the brain goes wild and the issues go out. So I think communication is the path to change it. And you have to decide what you want.
00:44:12
Speaker 4: What is the biggest myth on the internet about women's sexual health that you would like to see not on social media?
00:44:22
Speaker 5: I think this idea that supplements are the magic tool for your libido, that somehow you could spend money on a supplement and it's going to make you wild in bed and somehow turn into this vixen is not really helpful.
00:44:35
Speaker 2: I want women to believe in science and data and to use science and data. And we do have.
00:44:40
Speaker 3: Data that there are medicines that can help with sexual health and there are medicines that can hurt sexual health. So I think there's a lot of stake oil being.
00:44:46
Speaker 2: Peddled on social media. And I would like to see some of that gone.
00:44:52
Speaker 4: A lot of women at midlife may have some altered body image. Do you think that that is important in libido and sexual health for women? And then if it is, how do we make that better for women? I always ask about it. It's part of my intake when I talk to patients. I ask about their body image and their relationship with food and things like that. I think we have a big problem in our society and how we think about these things. People still deserve pleasure and joy and intimacy.
00:45:19
Speaker 3: And I think if your partner says, you are beautiful and I love you and I want to have sex with you, believe them. Believe them because they are so happy to be in the room. They're so happy to be connected to you. You do not have to be a Hollywood perfect in order to deserve pleasure, love, intimacy, and connection. And I will tell you, Having met people in Hollywood, they are not having better sex than you. They are not having more connected sex than you. And they also struggle with the body images stuff that you do. And at the end of the day, have fun. You deserve fun. You deserve pleasure. You deserve joy. And you are robbing yourself of that because you are not a certain weight on the scale.
00:45:56
Speaker 2: Is a nightmare.
00:45:57
Speaker 3: And so we have to fight against that. Don't wait until you look a certain way to be happy. Be happy now and work towards your goals, whatever your goals are. But really connect with yourself of why are these my goals? Are these my goals because society says it should be my goals?
00:46:11
Speaker 2: Or are these really my goals?
00:46:13
Speaker 4: I love that. Where can women find resources? Where should we guide them to?
00:46:18
Speaker 2: Absolutely.
00:46:19
Speaker 3: So I would say ISWISH, the International Society for the Study of Women's Sexual Health, is a great resource But they have a website called prosayla.com. It's P-R-O-S-A-Y-L-A.com. And you can find a doctor who cares about women's sexual health. Now, there may not be one in your area. I think Boston is a dead zone for ISWISH providers. But we're trying to train more. And as a society, a medical society, we're growing in numbers, which is very exciting. And many of our members are students, which is even better. And so we're trying to train and inspire the next generation of people to do this. On my website, rachelrubinmd.com, we have so many resources, both for patients and clinicians. We really are trying to teach people how to do this. It doesn't matter if I know how to do this. I have only so many hours in the day, and I can't see all the patients. And so we have to train others. So if you're a clinician listening, please take one of our trainings, come join ISWISH, be a part of this movement, because it is It is so joyful. I can't tell you how joyful it is. I had a patient come to see me once. I'll never forget it. And she said, Dr. Rubin, I came to you for pain with sex. And yeah, yeah, it doesn't hurt anymore. But I didn't think I would like it again. I didn't think I would want it again. I didn't ask you for that. And I can't believe I have it. And I think that speaks so beautifully for this. She didn't even know she could ask for it. She didn't even know it was in the toolbox of things I could offer her. She just wanted it not to hurt anymore. And I love that story because when you work with a clinician who can see beyond what you can see and they can support you and cheerlead for you, it changes so much. So it's the most fun field in the world. I love what I do, but we need more help.
00:48:05
Speaker 4: I loved what Dr. Rubin just said about her patient who was looking for relief from painful sex. And along the way, rediscovered pleasure, desire, and joy. We talk a lot about women's health in terms of what can go wrong, but our sexual health is also about quality of life. Pleasure, intimacy, connection, and yes, fun. And if something has changed, maybe it's pain, libido, arousal, or orgasm, you don't have to just accept it and live with it. As Dr. Rubin said, if it matters to you, it matters. I hope this conversation makes it a little easier to bring these things up with your doctor, with your partner, and even with yourself. Decoding Women's Health is a production of Pushkin Industries and the Atria Health and Research Institute. This episode was produced by our team, showrunner Alexandra Gerriton, editor Amy Gaines-McQuaid, and producer Rebecca Lee Douglas. Fact-checking, concept, and creative development by Siobhan O'Connor. Mastering by Sarah Bruguier. Our theme song was composed by Hannes Brown. Special thanks to Vicki Merrick, Alan Tisch, David Saltzman, Dr. David Dodik, Sarah Nix, Jacob Goldstein, Leah Rose, Jordan McMillan, Morgan Ratner, Owen Miller, Eric Sandler, and Greta Cohn. I'm Dr. Elizabeth Poynter. Thanks for listening, and until next time.
