Video URL: https://www.youtube.com/watch?v=IgW1jepnJp4
this term sex pan which I've never heard before what is that sex span is how long you are able to engage in satisfying sexual activity and most men most women want their sex fan to last as long as their lifespan and there's many things you can do that significantly prolong your sex fan and I called it the four pillars so let's talk about sex Dr moit Cara is a board certified urologist and Professor who specializes in male and female sexual dysfunction his groundbreaking research has significantly contributed to improving sexual health and fertility millions of men and women are suffering from sexual problems like infertility and sexual dysfunction for example in the US roughly 43 to 48% of women suffer from female sexual dysfunction which involves four components that we're going to talk about but we also know that premature ejaculation affects 30% of men globally and also 40% of men at 40 will suffer from erectile dysfunction and it's the first sign of other major adverse medical problems for example 66% have some degree of depression and 15% of them will have a heart attack or stroke within 7 years and if you look at the causes for Ed one of the biggest factors is obesity which causes the testosterone levels to go down but men need testosterone for sexual functions so do women because low testosterone increases low Lio but the issue is people don't talk about their sexual problems they suffer in silence and they start avoiding sex but it's curable and I have two ways to raise their testosterone techniques to significantly improve the quality of your directions and natural ways to improve sexual function in men and women so number one most important is this has always blown my mind a little bit 53% of you that listen to the show regularly haven't yet subscribed to the show so could I ask you for a favor before we start if you like the show and you like what we do here and you want to support us the free simple way that you can do just that is by hitting the Subscribe button and my commitment to you is if you do that then I'll do everything in my power me and my team to make sure that this show is better for you every single week we'll listen to your feedback we'll find the guest that you want me to speak to and we'll continue to do what we do thank you so
much Dr Mo Hera who are you and what have you spent your life doing so I'm a urologist and I specialize in male and female sexual dysfunction testosterone replacement therapy and infertility for the past 17 years I've been working as a professor at Baya College of Medicine Houston looking at ways to improve sexual health improve testosterone and improve fertility and we talked just before we started recording about this term sex pan which I've never heard before what is the sex pan and why do you care about it yeah so Stephen you know what lifespan is it's how long you're going to live right and you also know what health span is how long you're going to live in a healthy lifestyle but you may not have heard of the concept of sex span sex span is the ability to engage in sexual activity satisfying sexual activity and so how long you are able to engage in sexual activity is important to most men right um so let's give you an example the average lifespan in the United States is 77 years old the average Health Span in the United States believe it or not is 67 years old in fact if you look at the CDC and they talk about how long you'll live without a disability it's actually 63 so there's a Delta here there's at least 10 15 years where you will be in some kind of disability and cannot live to your fullest now think about the concept of sex span how long you'll have the ability to engage in sexual activity satisfying sexual ity we most men most women want their sex span and their health span to last as long as their lifespan yes so I think it's important and there's things that I can do to make my sex span last as long as my lifespan there's many things you can do and I call it the four pillars the first is Diet exercise sleep and stress reduction I don't have a pill on the planet stronger than diet exercise sleep and stress reduction and each one of those can significantly improve a man and a woman's sex span but also their health span and their lifespan the other is hormones testosterone extremely important testosterone supplementation can significantly improve a man and a woman's sexual function and fortunately for women in the United States we don't have very many options actually globally
for women there's not many options um but I think it's important a hormone replacement therapy and I one more thing I think about the couple think about sex ban as a couple's disease let me give you an example tomorrow Stephen are are you married or yeah well I'm in a long-term relationship you're your partner so let's say your partner tomorrow says to you I am no longer going to have sex with you unless uh you cheat on her or you leave her you're not going to have sex again right think about the importance of the couple um so I talk about this quite often keep your partner engaged keep your partner healthy if you want to prolong your sex fan so I got two questions here the first of which is who have you worked with in your career and the second question is what is your CV give me a rundown of your professional experience yeah so I started my residency in 2000 and uh I did my residency in 2 one year of general surgery I did five years of Urology training and then I did one year of a fellowship in men's health soon as I finished my training I joined uh the University at Baylor College of Medicine and I started a basic science laboratory where we do a basic science research in sexual medicine and testosterone for the past 17 years and I just started a clinical trial so I start have a clinical arm we do clinical research I see approximately 150 patients a week every week I do approximately 68 surgeries every week and I still work at the VA hospital it's a veteran government Hospital one half day a week working with the veterans so it's quite busy um but you know my passion really is education research and clinical care and um and that's what we do and so you know when I started my where how I really got into this was when I finished my training I was so proud of myself I was able to get these men these amazing erections these great libidos and uh I realized one day this woman called me and she was frantic and she said look uh you're treating my husband you're able to get him these great erections great libido but I don't want to have sex with him and he wants to have sex with me all the time and now we have a terrible relationship you've ruined our relationship and I thought to myself wait a minute uh you know I this doesn't make sense but she was right you know in
in sexual medicine either leave both Le low or raise them both but don't raise one or the other it's a setup for disaster so very quickly that year I went out and flew out to meet with Dr Irwin Goldstein who's considered one of the Godfathers of female sexual dysfunction spent some time with him went to his courses and for the past 16 years I've been treating women as well you can't just treat one patient without addressing the other and so therefore it's a couple's disease and give me a flavor of the types of conversations you have on day one when they walk into your practice when they come to see you what is the issue that they say they have and how do they express it like what are the words that they use and if you could just give me like five of the most popular things people say to you when they come to see you so listen first of all men and women are very different how they express it you know so we'll talk with men most men uh let's backtrack most men and women do not get any kind of medical care when they see their primary GP in fact most GPS don't address sexual dysfunction there was a study looking at medical students only 65% % of us medical students get training in sexual medicine and of those 65 50% of those students said that the training was terrible so we don't get the sexual medicine training to address the problem for patients so the majority of patients are never uh discussed about their sexual problems but when men come in there's a most of them are coming in because they already have tried some medications that haven't worked and they're looking for other Solutions now there's a very two simple questions you can ask a man they're very straightforward are you able to get an erection sufficient for penetration it's either yes or no are you able to maintain that erection to orgasm or pleasure it's either yes or no if he answers no to either one of those questions he suffers from erectile dysfunction right and so it's very important to get a detailed history you want to ask particularly are you able to get an erection on your own are you able to get erection with masturbation do you wake up with morning erections if he says look doc I get great morning erections or with masturbation I have great erections then this has to be
psychogenic right with my partner I cannot get an erection but when I'm by myself everything works fine psychogenic psychogenic Ed it's a big component what is psychogenic many something in the mind that's bothering you or inhibiting you from engaging in sexual activity and that's where the sex therapist comes in right because if I if someone tells you I get great erections uh by myself but with my partner I'm not able to get good erections psychologically when with their whe they're with their partner they're not able to achieve a good erection sex for men and women has a huge psychogenic component a huge psychogenic component so I think it's very important to get detailed history are they able to get direction what did they try what medications have they tried you know you have to query about depression 66% of men who come in with Ed have some degree of depression 66% right and that's important anxiety 35% is very important and more importantly we'll talk about this Ed is the first sign of other major adverse medical problems for example if a man comes into my office today 15% of them will have a heart attack or a stroke within 7 years 15% the day they get Ed 15% will have a heart attack or a stroke within seven years it's the first sign other studies Dr monori showed that if a man presents the emergency room with a heart attack on average 39 months earlier that's when the Ed started so it is the first sign now there are many reasons for this one theory is called the arterial diameter Theory the penal arteries are the smallest arteries 1 to 2 mm the coronary arteries are 3 to 4 mm the kateed 6 to 7 mm so if you remember from physiology if you're going to block an artery 50% occlusion of an artery causes a damage so if you're going to block an artery you're going to block the penina arteries before the coronary arteries you're going to block the coronary arteries before you block the kateed right so men will get Ed before they get a heart attack more more likely to get a heart attack before they get a stroke that's a theory but it makes sense so I worry when a man comes into my office could this man have a cult cardiovascular disease in fact there was a wonderful study that came out of Greece they looked at 50 men that walked
in and they gave them an echocardiogram or stress test if it was positive they wanted onto a coronary angiogram what they found is that roughly 20% of men one in five actually had some occlusion in their heart whether it was one vessel two vessel or three vessel disease so I think to myself every time I'm writing that prescription is this one of the five that could have occlusion and is there opportunity to intervene at this point so it's really important to think about cardiovascular disease as well one of the big subjects that I hear a lot about even in my friendship groups is about libido I've I've got so many stories in my friendship group of either one or both Partners losing their libido so on this subject matter of libido is kind of where I wanted to start this conversation what is the most frequent and popular reason why men and women struggle with libido problems and how much of of that is about compatibility yeah good question libido is multifactorial there's many pieces of libido it's very complex and I'll give you some important components first it could be hormonal and the pneumonic I teach the residents is pet the four hormones that can affect someone's libido are prolactin estrogen thyroid and testosterone so you have to check the pet if the prolactin is elevated the libido goes down the testosterone's low the libido goes down so maybe it's a hormonal issue which could be it and particularly many women who go through menopause suffer from hormonal issues and it could be a hormonal issue the second is something called neurotransmitters so in other words serotonin norepinephrine dopamine dopamine goes up libido goes up serotonin goes up libido goes down so these all regulate how someone's libido will function so one of the biggest um uh culprits for low libido are anti-depressants what do anti-depressants do they increase serotonin and they decrease libido so sometimes it's a medication or something that a patient's taking that will shut down their libido for example a medication that men take for urinary function called finasteride shuts down their libbido so that is there are certain things that you have to look at the other components are um lifestyle diet exercise sleep and stress reduction
particularly fatigue and stress if a woman is tired and she's exhausted and she has to between sex and sleeping at night many times she may choose sleep if me as well right I'm just saying so fatigue is important stress and there's this cliche this pneumonic this this saying that um with stress is kind of interesting typically if a man has a very stressful day he will want to have sex to relieve his stress uh women have to relieve their stress to engage in sexual activity it's kind of the opposite you know what I mean so I tell men if you really want to have sex with your wife uh do the dish just take out the trash H do everything you can to tuck the kids in bed early relieve her stress because that will significantly increase her desire to engage in sexual activity but the other one is uh psychogenic so you know we talked about that earlier you know sex has a huge mental component your relationship with your partner your uh your the how close you feel with your partner so sometimes patients come to me and they're an abusive relationship and say and they say give me the pill that improves my libido I said I it's not going to work I mean the the essence the core the foundation is not working and therefore it's really important for them to see a sex therapist one thing for men that actually shuts down their libido is when they start developing erectile dysfunction so if a man starts getting erectile dysfunction let's say he gets a good erection 50% of the time and he's starting to have some problems and it's 10 o'clock at night and he says look I can try to engage in sexual activity but it may or not work and it may be frustrating and embarrassing or I can just go to sleep it's probably just going to go to sleep right and it becomes a vicious cycle because the less sex he has the more difficult it is to engage in sexual activity later on and so you may interpret this as a low libido but he's really just avoiding it because he doesn't want to deal with it right but the partner also uh looks at this as maybe I'm not attractive anymore maybe there's something about me that's not appealing and it becomes a vicious cycle so one thing you can do is significantly improve the quality of the erections in a man and that actually helps improve his libido so for example
if I tell a man if every night you uh have anere great erection and every morning you wake up with a great erection what are you going to probably do probably going to use it right so libido inherently goes up right so I think e Ed and libido are tied very closely how do you define the Tam labido in simp it's a desire to engage in sexual activity right for men and women and you have to you know when it's a true problem they have to be bothered by the condition so I just want to be very clear there are women who have low libido and say I really don't care I'm happy that I have a low libido well then it's not an issue right you have to be bothered by the issue so on this psychogenic element where it becomes a vicious cycle I've seen this in my own life um several times Well at least once and I've seen it in some of my friends where because there's a bedroom issue when you go to the bedroom you're both a little bit anxious and then one of you can't perform and if you can't perform it exacerbates the issue and it creates this sort of vicious downward spiral of like it makes the bedroom like a really awkward place to be and this is how I think about when you're talking about psychogenic component so in the in the case of erectile dysfunction if you're thinking as a man God if I go to the bedroom I'm not going to be able to get it hard I'm not going to keep it up it's going to be embarrassing she's then going to ask me questions she's going to think I I'm not into her which just makes it even harder because as a man like I perform best when I'm really not thinking about it and I'm like not anxious when I'm stress free right and if seems to me that the like antithesis the opposite of great sex is like overthinking you're 100% correct and this is what happens let's say a man gets Ed just one time just one time young man he says that was really odd and I I what's wrong you know what he does next time he has sex as he's having sex he says to himself I hope I don't lose my erection I hope I don't lose my erection the second he says that to himself as he's having sex he's going to lose his erection right because he's so worried that he's going to lose the erection and not enjoying the experience so now it's happened twice so now he
engages sex third time and now he's even more freaked out because it's happened twice and it happens again we call this the Vicious Cycle right because the now sex has become an anxiety event anxiety provoking event and so you really have to work on decreasing that anxiety and not thinking about it that's where Sex Therapy comes in hand and that's where a medication called daily Calis has become unbelievably helpful for my young patients because daily Calis is a medication that men take daily you've heard of Cialis right it's like the Viagra yeah it's like Viagra right so there's Viagra there's Calis Levitra there's stender there's four different brands but one of the four is meant to be given daily it's a lower dose 5 milligrams every day and the larger dose is 20 milligrams when you give a man Calis 5 milligrams every day what it does is essentially is having that medication on board all the time when he engages in sexual activity he doesn't have to take a pill he just has has sex whenever he wants to and I found that to be unbelievably helpful in Breaking psychogenic Ed now that's exactly what that is on the table yeah that's exactly what it is yeah and so these are these are these are pills um that are in the US but what's nice is they used to be very expensive uh now they if you look at Mark Cuban and a lot of the uh good RX um companies they men can get 90 pills for5 or $20 which is very cheap you use the word young men yes young men presumably shouldn't be taking pill shouldn't but what happens when they have psychogenic Ed cuz they think about it the most is they need to break the cycle what's the cost cuz I'm a I'm got to be honest I'm a pill skeptic yes so I try and avoid taking pills to solve my problems if I can right obviously there's going to be situations where I can't and I accept that but my bias is towards figuring out if there's another way before I take a pill right um because everything in life comes with a cost all things yeah so there must be a cost to taking a pill to solve this problem well the the actual monetary cost is unbelievably cheap monetary cost is I'm thinking about like do I then get dependent on this do I have to take this for the rest of my life so so there's no dependency let me tell you why I think that drug is so important that daily
seis has one of the only things in my opinion that actually reverses erectile dysfunction so let's backtrack I give you an example let's say today you break your leg okay I have two options Stephen I can fix your leg or I can give you vicadin a narcotic and if I give you the vicad or the narcotic you'll still be able to walk until the vicadin no longer works and we're in trouble Viagra is a vicadin it is not a cure for your erectile dysfunction it's just masking the problem daily seis in my opinion is one of the few things that helps cure Ed if you look at studies and you look at a penal tissue and we biopsy the tissue and then you biopsy three months later on daily seals it physically gets stronger so let's say you go to the gym today and ask you to lift dumbbells what's going to happen to your arm it will hypertrophy with daily seal we see hypert of the smooth muscle meaning it gets physically stronger so in my opinion it's one of the best things to prevent Ed in the future help reverse the Ed process more importantly daily Calis protects the endothelium and we have to spend some time talking about that that is the lining of the blood vessels it's the brains and the lining of the blood vessels is very important because once that gets injured you start getting clot or plaque which will get a heart attack a stroke and a rectile dysfunction so it protects the lining of the blood vessels two other indications it's FDA approved to help a man urinate better FDA approved it's FDA approved to protect the heart in terms of something called pulmonary hypertension so in my opinion it's an excellent medication patients say do I get dependent on I say you do not get dependent on it and H I feel like you're better had you taken it than had you not you take it for three months you get strengthening of the penal tissue what happens if I stop taking it if you stop taking it there's a wonderful study by a versa and what he showed was that those patients that stopped taking it after 3 months versus Placebo still had benefit in terms of endothelial function protection and erectile function protection than those people that took Placebo so thinking about saying hey if I go to the gym and I work out for three months what happens if I stop I say well Stephen you're better off had you gone to the gym for
three months that's my opinion what is the downside they're side effects so every drug has side effects right but they're low with five milligrams back pain stuffy nose um headache can occur in these but it's quite small but I do think that this is one of the medications that really can make an impact uh in men's health think about it if I told you there's a medication that protects your heart helps your prostate and helps men with erections it's affordable I think that most men would say I'm in what are the big side effects that people report when they're on seis so on the larger dose headache stos back pain is more common with Calis and other medications um but it can be reported remember you shouldn't take these medications if you have you're taking a nitrate because it can drop your blood pressure um but other than that these are very commonly used medications throughout the world and they're not suitable for certain people that have certain cardiac disorders I'm guessing well you know the way this was invented uh this came at first one Viagra came out in 1998 Viagra was in the clinical trials designed to be a blood pressure medication and accidentally men were getting erections in the trial so these medications are in my opinion cardioprotective a guy named a very famous uh physician B Dr cloner published an article recently showing that those men who took daily seis had 133% reduction in cardiac events and a 25% reduction in mortality that just came out because of the potential effects of protecting the endothelial lining of the blood vessels how does this work to solve for the sort of psychogenic component that we talked about that vicious cycle people get into with like I'm guessing you're telling me that increases your probability of having a good erection right but this still isn't really working on a liido is it right so let's say um you started falling through the Vicious Cycle and you started having Ed and it was two times three times and now I put you on this medication and every time you have sex you have the most amazing erection of your life and 30 times 40 times three six months go by and you're having these amazing erections you're relaxed and you're calm then I start going to every other day you still get amazing
erections then I go to once a week you still get amazing erections then I stop you still get amazing erections right I just need to show you that everything is perfect again and that has a huge value what about for women this is the unfortunate part we don't have a lot of treatment options for women and if you look about it if I want to give you an example in 2015 if you and I went into the drugstore in the US Walgreens and said give me all the drugs to treat women to treat men for sexual dysfunction they would put 30 drugs on the counter these are all the wonderful treatments for men in 2015 there was not a single FDA approved drug to treat women for any sexual dysfunction very sad in 2015 the first drug to treat women for female sexual dysfunction came out and it was called ad or fanin and fanin basically is a drug that a woman takes every day and increases her desire for sex that's it that's the FDA indication increases her desire for sex several years later the second drug for women came out this was called VII or brontide essentially it's an injection that she takes 45 minutes prior to intercourse and it increases her desire for sex but again we have only two drugs the reason being is because the research the funding that we have for female sexual dysfunction is far less than we have for male sexual dysfunction and it's unfortunate because as I mentioned earlier this is a couple's disease and so many times I have to use drugs that I use for men to help treat women so I do use Viagra for women but Viagra for women helps arousal so let me explain female sexual dysfunction has four components one is decreased libido the second is decreased arousal third is orgasmic dysfunction and the fourth is pain with intercourse these are the four if a woman has any one of these four and she's bothered by it she suffers from female sexual dysfunction in the US roughly 43 to 48% of women suffer from female sexual dysfunction significant number only 19% seek therapy will get therapy so there's a huge number of women that I say are suffering in silence they suffer from the condition they don't know where to get help and unfortunately they're not many treatment options available right so it's a big problem and a big unmet need and on the hormonal component you
talked about how if dopamine is up we're much more likely to be aroused and if serotonin is up then we're much less likely to be ared correct so this kind of ties into something I was thinking when you were talking about stress and tiredness when I'm stressed and tired is my dopamine down it can be your cortisol goes up right your C cortisol goes up so your ability to get excited will go down your fatigue goes up so it makes it much more difficult these and there's more than just dopamine and serotonin there's norepinephrin there's melen Corton uh there's many other neuro neurosteroids and it's really just what we call a plus minus game if I have more positives than negatives I'm going to have desire and I'm also going to have orgasm right that's important also so if you give someone uh too much serotonin and it goes this way not only does a libido go down but it's difficult to achieve climax or an orgasm so one of the ways I treat premature ejaculation is I give them an anti-depressant because it delays the orgasm so we have to be very careful on these neurotransmitters how we use them but if you talked about ad the drug I mentioned all it does is it increases dopamine and norepinephrine which increases libido so they increase neurosteroids many women particularly with the hisyory breast cancer like this because they don't want to use testosterone or estrogen hormones this is non hormonal right it's just neur steroids increasing the desire for sex can I think about dopamine and serotonin as like a scales yes where if I if I put weight on one end the other one goes up and if I put weight on the other end the other one goes up yes there is a very famous uh Michael Perman came up with the Tipping Point and it's basically a scale looking at the pluses and the minuses and if you have more pluses than minuses liido goes up orgasmic function goes up if you have more minuses essentially your ability to orgasm and your liido will go down so I want my if I want to be aroused and have a desire for sex and have good sex then I want my dopamine levels to be high dopamine High oxytocin High norepinephrine High serotonin low what are the types of activities that make my dopamine High uh well um exercise is can be really high dopamine other things increase dopamine as well right so um gambling there's
there's certain things that are highs like gambling anything that gives you a high certain foods will cause a dopamine Rush um but they're temporary right and so that's a problem right because if it goes up and it goes goes back down it crash so you want your dopamine to go up in men and women so we use medications like Wellbutrin have you heard of Wellbutrin it's an anti-depressant but that anti-depressant increases dopamine so I use that to help men increase their libido or women to increase their libido or sexual function I use ad e in men and off label in men and in women to increase dopamine I don't want to do drugs though I don't want to take any pills so then I would say I need you to exercise and you do but exercise is critical I need you to sleep I need you to um reduce your stress right those things will significantly improve uh your libido so what things then lower dopamine because I've spoken to a few like dopamine expert experts on the show before and they talked to me about this sort of I mean Andrew hubman was telling me that yeah when you do an exercise like let's say gambling or go on Tik Tok your dopamine's going to go up but then it's going to crash below the base Point yes and some of us live in this kind of dopamine roller coaster where we're doing these dopamine inducing activities dopamine goes up it then crashes below and when it gets low we have cravings for dopamine inducing activi so we go out and want to gamble or go on Tik Tok again or eat something and then it goes up again and then and we kind of live in this kind of roller coaster of dopamine one of the things that I was told by a dopamine um expert on the show recently that does that as well that links to some things I found in your work is pornography yes and when we talk about this psychogenic component we talk about um do dopamine levels how much is pornography causing this libido crisis yeah pornography and Ed in libido is somewhat controversial there's some data suggest that it does not cause an issue and there's some data suggest that it does the first question I ask a patient when I ask a man I say is your Ed present with pornography also so if he says look I have rectile dysfunction with my partner and I have a rectile dysfunction with pornography that's very different
than when he says I have a rectile dysfunction with my partner and I have amazing erections with uh pornography right because then I know that there's a psychogenic component as well this is what I believe I believe that when a man watches excessive amounts of pornography what his expectation is becomes hair and his reality becomes hair and that Delta causes them to have erectile dysfunction and low libido they're not getting what they're expecting to get so many times I question men when they come in uh all when all men who come in for to ask how much pornography are you watching in men who watch excessive pornography if I ask them to stop watching pornography for a while many will report improvements in their rectile function and libido so again I do think that pornography in excess can have a negative impact only because of your expectation and your reality the Delta uh can be an issue I'm reading some stats here from jamama Network that says the percentage of men between 18 and 24 reporting no sexual activity in the past year increased from roughly 18 % to roughly 30% in the space of what looks like just a few years and simil similarly the average number of times American adults engaged in sexual activity per year has decreased from 60 between 1989 and 1994 to 50 roughly 50 between 2010 and 2024 these shifts suggest a notable shift in sexual behavior over recent decades why do you think this is happening I think it's more multifactorial so I think one is I think that Ed and sexual dysfunction is on the rise uh and if you look at uh the causes for Ed uh it's very simple you look at uh obesity diabetes metabolic syndrome it's a pandemic it's an epidemic throughout if you look at just diabetes from 1990 to 2022 uh 100% 7% to 14% of the population one out of eight people globally are obese one out of eight people so these can make it very difficult uh as obesity and diabetes that go on the rise what happens testosterone levels go down right so testosterone levels go down so the ability to engage in sexual activity the desire to engage in SE activity will be impaired by these uh conditions I've got some some graphs here um which show Global obesity Trends Global diabetes Trends I'll put them on the screen for
anyone that's watching on video um also there's been an increase in pornography consumption from what I was able to tell from doing some research a 2020 study by the University of ant found that 40% of people aged 35 to 45 who watched 300 minutes of porn a week had erectile dysfunction in a 2021 study by GMA public health and surveillance and 3,400 men between 18 and 35 years old 20% of the participants suffered from erectile dysfunction and researchers found that the greater the viewing frequency of pornography the greater the development of this dysfunction yeah and that's 300 minutes is quite a bit of time a week 5 hours minutes five hours five hours a week right so this so that's quite a bit yeah that's quite a bit how important do you think that is as a component to this sort of fracturing relationships we think about people having sex with each other less yeah we're heading towards a world of like virtual reality and AI yes what role do you think that's genuinely playing and you you must have private conversations with men that are really suffering with these things so I I definitely think it's it's a role and it definitely plays a factor but not as much as the epidemic of diabetes obesity metabolic syndrome we are as a population becoming more and more unhealthy right as time goes on and I look at again as a piie it's multifactorial right um most of us now are not our socialization is virtual and so we are not engaging and going into seeing everything is done virtually and so I think that's an issue um and so I really believe that pornography is a component but the the decline in overall health is a major component the decline in testosterone levels decade by decade is also another component as well it's pretty terrifying that young kids at the age of like 12 13 14 when they open their phones these days will be exposed to sexually graphic images yeah whether they CH chose to seek them out or not yes and i' I've always wondered what that's doing to a developing brain you know how it's adjusting your expectations how it's creating some of those psychogenic factors that are making you less aroused and um and it's difficult right it's difficult to go out and find a partner you have to like put on the After Shave shave take care of yourself you have to like Risk rejection
spend some money right be interesting right so it seems like if from a evolutionary perspective if I was just trying to like get my nut off or like yeah I don't know ejaculate I've got this really easy way now like it's so easy yes three clicks on a computer We're Off to the Races versus like all the effort and rejection and pain of of trying to find an actual human being to have sex with right and then when I do do approach number one when I log on to some website and click a couple of times I'm getting no headache I'm getting whatever I want I can order from a endless list of menus and I'm sure in the near future I'll even be able to make my own yes and in not so distant future I'll have I'll have it in my house and it'll talk to me yes yeah so it's a problem and you think about the it's it's making it more difficult for people to socialize right so in other words now when patients or people engage in sexual activity um and they're usually having sex on the Internet or with pornography when you actually have actually engage in sexual activity with another person it can be cause anxiety right you get anxious it's not something that you're doing regularly and so I think that it can become an issue I amum I saw an article this week from an only fans Creator who posted that one one customer of hers had given her $4 million this year oh my God and you think about like you think about what it would take for you to spend $4 million on a parasocial relationship with an only fans Creator sending you explicit pictures and I don't I don't quite believe we fully understand what's around the corner I agree these stats I think are nothing compared to what's what's around the corner um and I I don't know I think about it a lot because when I read these stats about erectile dysfunction being on the rise and I I read that we're having sex less and less um and then I see this rise in these parasocial relationships I go [ __ ] know I think think we're just at the start of an exponential curve um let's talk about obesity then yeah because these these stats here are pretty shocking um this one shows the global obesity Trends which just shows them going straight up yes which is
horrific this one shows Global diabetes Trends which is pretty much straight up as well yes has there been any studies done that show the link between being overweight and your probability of having low libido and some kind of sexual dysfunction issu yes numerous and so let's start with this so obesity it's not surprising that diabetes is going up because as obesity goes up it causes insulin resistance so obesity and diabetes typically go hand in hand the problem with obesity is the following obesity significantly drops testosterone levels so fat cells contain something called aromatase aromatase eats up the testosterone and converts it into estrogen so the more fat you have the less testosterone you'll have because you'll convert it into estrogen fat cells also secrete something called cortisol and leptin which shut down your own natural testosterone production so as it's not Sur surprising that decade by decade as you see an increase in obesity you see a decline in testosterone levels in men because the testosterone levels will come down as people become more obese and low testosterone equals low libido low testosterone increases low libido the number one driver the number one hormone for libido in men and women is testosterone it's a strong driver men and women men and women and don't forget that testosterone is also signif really important in erectile function men need testosterone for sexual function so do women right it's extremely important so now I have a hormone that's going down that's going to make it more difficult to get an erection I have a hormone that's going down that's going to decrease my libido and it's mainly due to this obesity that's occurring one of the biggest factors so obesity obesity also um uh if you look at the risk factors for Ed obesity diabetes cardiovascular disease these are all risk factors and so as obesity goes up erectile dysfunction goes up and the number one condition is diabetes diabetics are four times more likely to have Ed than any other population four times so I get worried when we see this obesity diabetes pandemic going up because it's increasing only the erectile dysfunction um Stephen if you look at the Obesity the group that's
having the greatest rise in obesity is adolescence obesity not adult obesity the kids younger and younger ages are having that age group has the greatest rise of obesity so what does that turn into the younger population are starting at at lower tea levels and has an implication on fertility because you need testosterone to produce sperm that's very important so if I just lose a little bit of weight that'll have a big impact on my testosterone levels let's talk about that it's not a little bit so the best study was at the European male aging study Fred woo and what he showed was this it's a bidirectional relationship if you lose 10% of your body weight you can actually gain 85 nanogram per deiler in serum testosterone if you lose 15% of your body weight you can actually gain 250 nanogram per deciliter in serum so it's actually significant if you can lose but it also goes the other way you gain weight you drop the tea proportionally as well the only issue is I can get the patients to lose the weight but I can't get them to sustain it many times they gain it back right but if they can keep the weight off it significantly increase uh the testosterone levels the the best data we've seen is in the bariatric surgery data if I do bariatric surgery on a patient which to help them lose weight weight you can shrink the stomach we do surgery to help them lose weight they lose quite a bit of weight their tea levels go quite up right and so again there is a strong correlation between weight and testosterone have you gotten examples of patients where you've given them testosterone treatment in some form you've done something to increase their toest testosterone and you've seen a remarkable reported difference in their sex life all the time yeah so so first let's backtrack there's two ways to give a person testosterone uh if I give a young man testosterone remember it causes infertility so you would never give someone testosterone if they're planning to have children right that's very important right so I have two ways to raise their testosterone I can give you medications to raise your natural testosterone there's several there's a pill called chopine citrate there's HCG I can use medications to raise your own
natural testosterone and they preserve your fertility the second option is I can give you medications like testosterone there's seven of them but they will shut your natural production down not only will they shut your natural testosterone production down but they will shut down your sperm production now if you've already had your kids you're 60 years old your testosterone level is already low in the first place what are you preserving okay it makes a lot of sense and there's seven ways to do it my favorite way are the injectables and the oral testosterone they are fantastic oral testosterone is quite interesting you know first of all testosterone was invented in 1935 this is not a new drug 1935 and oral testosterone initially was feared because it would actually cause liver toxicity and liver cancer and it wasn't until the 1970s when they were able to make oral testosterone uno8 and what's nice about uno8 it bypasses the liver no cancer but it had to be taken three to four times a day it was available in the UK as a drug called andreal all over the world but not the US the US we did not get our first oral testosterone till 2019 and then 2022 we received two more and now we have tando jatenzo and Kaiser Trex is our oral they're taking twice a day with a meal what's nice about Kaiser TRX it's actually available in the UK so in the UK now they can actually get Kaiser TRX as well but oral testosterone most patients don't mind taking a pill uh it seems very easy to do so should someone like me be taking testosterone if your levels are low yeah and you're symptomatic and I think that's very important if a man comes in with low levels of testosterone and says I feel great I have no symptoms I said I'm not giving it to you these are the symptoms low energy yeah low libido erectile dysfunction decreased muscle mass increased fat deposition poor sleep and depression these are some of the common symptoms you'll see most sensitive symptoms are the sexual symptoms erectile dysfunction and low libido so if he says I have these symptoms and my levels are low and I recheck it and confirm that it's low that man is a candidate for testosterone therapy but if he's young hasn't had has have children yet I'm going to say look let's
hold off on giving you testosterone and use medications to make you make testosterone and if you don't want to take medications actually there are many things you can do on lifestyle modification to raise your testosterone we talked about weight loss as well so let's live in this area here you are too young to take testosterone now but conversely let's say a patient comes in and has every single sign and symptom of low testosterone but his testosterone levels are normal I'm not giving him testosterone because it could be something else maybe he's depressed maybe he has a low thyroid something else is going on so you must have signs and symptoms and a low tea level to be a candidate and if you fit that then you may benefit what about women so this is important in 1935 when testosterone was invented uh it wasn't many years later till they actually started using testosterone in women and early reports of testosterone women were actually quite remarkable the earlier manuscripts describe improve uh quality of life improve libido and if you and I walked into the drugstore today and said give me the testosterone for women it does not exist there's not a single FDA proof testost for women in the United States um but we have well over a dozen for men can you explain this to me just because I want to make sure I'm clear why would a woman take testosterone because when I think of T testosterone I think of men yes so women make more testosterone than any other hormone in their body make more testosterone than any other hormone in their body right and when women have higher levels of testosterone they tend to see a greater Improvement in libido muscle mass bone mineral density uh sense of well-being uh some of reported improvements in cognition as the testosterone level goes down we start seeing these symptoms particularly low libido if you give a woman back her testosterone she will many of these women see a significant Improvement in their libido but the issue is that we don't have an FDA approved product for testosterone in the United States I think in the UK you call it off license we call it off label now in the UK they did have one they had a wonderful patch called intrinsa and then the women in the UK could get the patch for testosterone go into the drugstore NHS
covered it and it was fine uh then they had andram and andram was actually approved and now no longer is approved so now in the UK you also don't have an onli medication the uh you can still get andram from Australia but unfortunately uh it's very difficult to get so do we do we use the drugs for men and we give it to the women in on10th the dose that's all we do so if we have a packet that's a man puts on a day we say use one tenth of the packet every day for the women and they can see significant improvements it is not illegal to give a woman testosterone it's just considered off label or off license but they they see significant improvements in what sexual function by far the most libido goes up no question I many women report that muscle mass if you think of testosterone bodybuilders take testosterone for a reason why it significantly improves muscle mass it can decrease fat deposition many patients will import improvements in cognition it can help with bone mineral density as well in men and women and I also believe in depression so I think testosterone does help with depression I just want to just make a very important Point testosterone is not just about sex there are five other things that you need to think about uh in men and women and I want to talk about those men with low testosterone l levels are much more likely to have a heart attack non-negotiable men with low testosterone levels are much more likely to have diabetes obesity men with low testosterone levels are much more likely to suffer from depression men with low testosterone levels are much more likely to have a bone fracture so it's not just about sex it's about their overall health and if you were to check one blood test to assess a man's overall health it's his testosterone level one blood test to check his overall health it will be because I have it affects heart diabetes obesity um bone mental density energy muscle mass erections libido one blood test I can't think of another blood test that is a better barometer of overall health I want to get clear on something because I've heard people talking on my podcast before about HRT yeah and women taking HRT because of menopause and things like that should they be does HRT have testosterone in it no so typically when
we say HRT we're talking about estrogen and progesterone typically yeah and typically when we talk about trt testosterone placement it's a little bit different in a woman there's something I call the triangle and it's just basically estrogen progesterone and testosterone just simple and if you have a woman who's deplete in estrogen testosterone and pro estrogen progesterone testosterone and replace it many of those women feel better right so many of them do there are other hormones that are also important I call it the outside Circle cortisol thyroid growth hormone we look at those as well and so I think those are also very important and I tell them we're going to going to optimize your uh hormones but what you're going we're going to optimize your medical condition but that is only 50% of the story the other 50% again is Diet exercise sleep and stress reduction and if you do your part and I do my part we're on fire we're absolutely on fire but you have to do your part same with men I put you on the testosterone I optimize your medical conditions and but you got to exercise you got to eat right why aren't women being prescribed testosterone then right because it's considered well in many countries it's on in Australia it's available in the UK it was available and many women are being prescribed testosterone it's just off label it is the first time that I've seen someone on my show anyway really emphasized the point that testosterone isn't Just For Men it's for women as well um and it can significantly improve their quality of life talking about testosterone one of the big conversations that's rattling on on the Internet is about this decline in male test testosterone over the last couple of years what exactly is that decline if you had to sort of quantify it if you look at the original studies we call it the Framingham heart study back in the 70s testosterone levels were roughly around the 700s average men between the ages of 18 and 40 were around the 700s and every decade we're starting to see a decline almost by 50 nanogram per deciliter and so the latest in the 2015 numbers are roughly in the mid 400 so we've seen almost a 300 nanogram per deiler decline in serum testosterone which is significant because has two
implications uh it's not just about uh the way you feel and um energy muscle mass erectile function but that low testosterone can have implications on fertility that's really important so we didn't talk about that but fertility Testo sperm need testosterone low testosterone decreases your sperm count sperm counts have also been on the decline as well so you know I think it's really a testament to the fact that decade by decade we're becoming a more unhealthy population do you think that's really the heart of it is that is the sort of our diets and the way we live and becoming more sedentary less exercise more um processed food Etc do you think that's the hard of I think that's the key that's absolutely the key the types of foods we eat the processed foods that we eat high fructose High carbohydrate diets um in and if you and and the way we know that is just look at the Obesity look at the look at the diabetes there has to be a reason why it's on the rise right and on that point of fertility I'm in a season of life where I'm going to be trying to have kids pretty soon what's the most important things I should be thinking about from a lifestyle perspective in your view yeah so I I tell patients Darwinism in other words survival of the fittest healthier people are more fertile right you're passing on the genes so uh so so essentially uh we tell patients the number well the number one cause of infertility in in the world for men is a verical a verical is the swelling of the veins around the testicle you know how women sometimes can get swelling of the veins in their legs you see those veins that are kind of obvious well men can get those veins dilated around the testicle and those varicoses can impair sperm production now 15% of men in the world walk around with varicus seals but up to 40% of men with infertility will have verical so it's really important to assess for the varic casales but lifestyle modification each one again diet exercise sleep have been shown to help improve fertility in men as well so I say healthier people are more fertile I need you to start getting healthier that's very important we raise the testosterone level in many of these men naturally we don't give it to them to help improve their fertility as well but check Stephen check your SE
analysis that's the simplest thing you can do check it right I did yeah it's a great predictor it's not just you know there was so many amazing studies showing that a semen analysis is a phenomenal predictor of overall health many studies showing that if your semen analysis today is impaired it's a predictor of you having comorbid conditions today like diabetes obesity metabolic syndrome it's also predictor of prostate I mean Cancer so we know that if you have infertility you're at a higher risk of having testicular cancer than those that don't have infertility it's also a predictor of who will have problems in the future Mike Eisenberg once showed a very nice study men who have low sperm counts uh can have a 30% increased risk in diabetes 50% increased risk in hemic heart disease in the future uh Tom wall showed those men could have 2.5 times higher risk of high-grade prostate cancer in the future so again to me it's just a marker of overall health check the Sean analysis I did that and it was quite I was actually to be honest I was really quite nervous about it because as someone who's you in my early 30s and wants to have kids I was really scared that it would come back and say that like my sperm is um dysfunctional and I've got a huge amount of empathy and um you know feelings for people that do those analysis and get bad results back 15% of all couples in the world 15% suffer from infertility that's a lot and if you think about it um 30% of the time it's a male Factor 30% 20% the time it's a male and a female Factor combined so indirectly a male is involved 50% of the time when you have infer an infertile couple and it can be devastating for that couple I mean psychologically devastating and what's also interesting is that um most couples most couples 50% of couples don't seek therapy and of those couples that do seek therapy this is globally only 25% of those couples uh actually go forward uh and and and and so I call this a group of individuals that also suffer in silence they should know that there are excellent treatment options available this um this graph that I had printed out is just shocking to me it's going back to the point about testosterone but the the really shocking thing is how quickly this has happened
yeah because this is the year 2000 and this is the year 20156 year and the decline there is from roughly 600 nanograms is it yes nanogram per deciliter nanog per deciliter to roughly for some age group groups here 400 yes m per deciliter and that's only in 16 years yes so if you play that forward another 16 years there's going to be a bit of an infertility crisis there is fortunately on that graph it's plateauing a little bit which makes me feel a little comfortable okay oh yeah it is actually fling just a little bit um but you're right it could be a significant crisis um and again as I mentioned it's the adolescence the younger folks who are having the greatest rise of obesity and that's where fertility comes in because fertility obesity in someone in 60s is not concerned about fertility but a young patient who has infertility obesity will have a higher risk of infertility if you're an entrepreneur you're probably going to want to listen to this it's a message from one of our sponsors on this podcast which is LinkedIn if you've listened to me on this podcast for a while now you'll know that I've been on a bit of an evolution as a business owner and entrepreneur and one of those Evolutions that has become clearer and clearer as I've matured is that the single most important thing in building a business in building a company is hiring the definition of the word company is actually group of people and that is the first responsibility and job that any entrepreneur has and should focus on but surprisingly most don't about 80% of my team have been hired from LinkedIn and I think there's very few platforms if any in the world that could give you that diversity of candidate with that much information and data on their profiles it usually cost money but for the entrepreneurs that are listening to me I've got you a free job ad post for your company on LinkedIn just go to LinkedIn .c doac to post your free job ad today that's linkedin.com doac terms and conditions apply if me and my partner came to you and we said listen we've got sexual problems in the bedroom um what are the steps that you would the things you'd look at that we haven't focused on so much today is there anything particular you'd say okay and I I'm trying to stay away from being
prescribed a pill so I want to do anything natural I can before I get to that and then we'll talk about some of the other more drastic measures one can take natural things because everyone wants to know about what's the natural things I can do so when we talk about diet there's certain diets that have been helpful to improve sexual function for me it's the Mediterranean diet the Mediterranean diet is rich in whole grains legumes um fruits vegetables and if you look at red meat and sweets It's once a month if you look at poultry it's maybe once a week but mainly fish those diets have typically been anti-inflammatory diets many Studies have shown that that diet can significantly improve erectile function and one study the medita trial actually showed that it improves sexual function in men and women so I'm a big believer in using the Mediterranean diet when Esposito did her first trial it was a prospective trial 110 be obese men 55 men get the Mediterranean diet 55 men uh don't get any intervention at all she falls in prospectively for two years what does she find not only a significant Improvement in endothelial function remember that lining of the blood vessel but a significant Improvement in erectile function in these men no Viagra no pills nothing simp simply changing the diet improved the erectile function the same with sexual function in women so that's an important one the second is sleep let's talk about sleep so studies show that if you're getting less than six hours of sleep a night it significant increases your risk for sexual dysfunction in men and women right your ideal amount of sleep should be 7 to8 hours now let's say you say well that makes sense maybe I'm going to get sleep sleep for 9 to 10 hours because the more sleep I get the better my sexual function but that's not true it plateaus so if above 9 hours it does not increase your ability or sexual function so 7 to eight hours of sleep at night I need you to get third is I really need you to focus on um uh exercise so I published a very nice study looking at uh it was a metanalysis on how much exercise one needs and what type of exercise to actually improve erectile function in this study typically you need 160 minutes a week so 40 minutes four times a week for a
course of six months of moderate or to severe exercise vigorous exercise and so most people can get 160 minutes in a week of exercise but that's getting your heart rate up and doing the exercise significantly improved erectile function in men if you did that and the more severe your Ed was the greater Improvement you saw in erectile function strictly by exercise alone no other intervention St just exercise so here you have a patient that now starts doing some exercise starts sleeping better starts changing the diet it's all additive you are now sick significantly improving erectile function just by lifestyle modification alone pretty profound that exercise can have such a big impact isn't it is that the same for women it is true because many of the things so unfortunately once again the research we have in women is not close to what we have in men but the med trial was also in women the sleep studies were also in women um and so these studies also show that sexual function can be improved with um uh sleep and with diet um I think that men and women are not that different I mean if you see a significant Improvement in a male sexual function uh with diet exercise sleep um you can also see it in women as well actually there was a great study this looked at 110 women and they had coronary artery stenosis they did angiograms on 110 women and they showed that the greater her stenosis she had the worse her sexual function so the greater the blockage in her heart the worse her sexual function they put those women on a cardiac rehab program to actually improve their cardiac function so a diet and ex exercise program and those women that actually put through the were through the program fourfold increase almost in their sexual function well 400% fourfold that's right because we use a questionnaire called the fsfi which is a questionnaire so significant Improvement in sexual function just on improving cardiac function so remember cardiac function and sexual function are related and it's bidirectional you improve one you improve the other it's very important we didn't we talked about this earlier 40% of men in the in the world at 40 will suffer U from erectile dysfunction 40% 40% Jes 50% at 50 60% at 60 70 at 70 80 80 you do the math it essentially is a very prevalent
condition this condition is associated with increased cardiovascular vents it's a first sign of a heart attack we talked about that this condition is associated with two and a half times more likely to be anxious three and a half times more likely to suffer from depression and this condition is also associated with diabetes in other words men with Ed two times more likely to have undiagnosed diabetes and yet only 50% of men even talk about it because they're so embarrassed so you show me another condition in the world that affects more men's lives that's associated more adverse conditions and they're too embarrassed to speak about it they suffer in silence there's not another condition there's not another condition but yet we're embarrassed to discuss it I used to give these lectures and I would look out to the audience I'd say please raise your hand if you suffer from hypertension and many people raise their hand and they have high blood pressure they say okay please raise your hand if you suffer from sexual dysfunction no hands go up but statistically you know that over 50% of those people had sexual dysfunction so why is it okay to raise your hand if you have hypertension but not okay to raise your hand if you have sexual dysfunction it's got to stop we have to destigmatize it's okay to have sexual dysfunction it's a common Condition it's curable why don't men raise their hands from a psychological standpoint why is that I think they're embarrassed I think that I think that we're historically sexual dysfunction looks as a like a weakness I'm not a man less of a man you know you have hypertension it doesn't mean you're less of a man right but they have this assumption that it's a weakness a less of a man and I and I think that it's okay you have to be comfortable saying that you have sexual dysfunction there are amazing treatment options for sexual dysfunction amazing that work very very well you just have to raise your hand and let me know that you have it I just want to make one other comment about diabetes there was a study that came out of St Louis looking at young men 18 to 40 years old and they were screening them for erectile dysfunction and what they found was when those men came in for erectile dysfunction 30% of those
men had pre-diabetes or diabetes on that day on the day they were being diagnosed 30% and I thought to myself young men do not go get screened I remember when I was 30 years old I didn't go in for my annual blood pressure check and my anual sugar check there's no way I'd get my glucose checked but if I young man gets erectile dysfunction he is at my front door first thing tomorrow morning they show up that's the first thing they're going to do because it's a very big condition to them and they want to get treated and that is the opportunity to treat these young men and treat the condition if you see a young man or someone who comes in for Ed and you screen them for uh diabetes and I catch the diabetes at 30 as opposed to 40 that is 10 years of damage on the vessels that you're saving because you catch the disease early early so Ed is the gateway to Men's Health and to treating men early before it's too late so I really use Sexual Health as a tool a vehicle to improve overall health because men take Sexual Health much more seriously particularly young men have you ever had sexual dysfunction I have not never in your life I have not I have I have not it doesn't mean that it's not but it's okay if I did it's not it's there's nothing wrong with it right there's nothing it's normal it's okay and it's it can be temporary and come back right it's it's nothing wrong with having sexual dysfunction we must destigmatize it it's completely Okay the reason I'm sharing this is because if anyone else has been in the situations the situations I've been in are um generally my sex life has been been good my whole life but there's been certain times with certain Partners or you know you might be drunk a little bit or in the day when I was single there was like the oldd person who for some reason it just wasn't working for me and or there was other instances in a previous relationship where near the end of the relationship I'd like lose my erection during sex and that became a little bit bothersome for me because I was like oh my God like it almost made me not want to have sleep with this person or it convinced me that maybe I don't like them anymore or something else was going on and for me it has always been what's the word used psychogenic yes it's always been in my
head that the problems have arose and the other part of thing that I've experienced a lot is in terms of libido I have like no libido when actually slight different when I'm when work is very very busy and I'm very very tired and I come home very very late it's not that I'm not horny but I just the act of sex is just really unappealing but you're just like everyone else you're not unique when it comes to that yeah but that much of my life is like that like I come home late a lot and so I'm I'm I'm like tired and stressed quite a lot right but what if I took you and your partner and put you on a beautiful island in Hawaii for two week we have great sex okay yeah so that's what we kind of like how we've orientated our life honestly okay that's genuinely how we've orientated our life because I just don't think the way I obviously want to make lifestyle changes to make sure that I'm not always coming home tired and stressed at 11: p.m. but one of the things that's really helped us is you know going away on the weekends right and going away maybe on Friday and coming back on Monday and getting out of the same context so like getting out of the house going to a even like going to a hotel room it's actually a bit of a game changer that you can just like go to a hotel room in the same city like a Booker station yes and that seems to have a big impact because it just removes you from the context right and then like yeah going away for the weekends holidays and stuff a lot of my friends say to me they go when they're struggling with their sex life they just like book A book a local a local sort of station yeah and I wonder why also I don't have kids so I've not experienced the impact that kids can have have a significant impact really right because it increases your stress right particularly for your many times for the partner as well so if you both are stressed because of the children sex goes lower and lower on the totem slept as well right if you're not sleeping if you to wake up and like oh gosh isn't there stats that say like when someone has a kid their sex life like vanishes for 18 months or something I don't know I'm not familiar with that St but I believe it I believe it I believe it I
read something about post having a kid liido but also like sexual function it makes sense I see it in in couples and particularly you know many times um it's take years for them to start engaging sexual because the stress is so high particularly when they originally have the child there was a British study done that found over 80% of women experienced sexual problems 3 months postpartum with nearly two3 still affected at 6 months yes which is which is a lot of it's a lot of women a lot of women and that's significant amount of time so what about premature ejaculation let's talk about it very important 30 so sexual disfunction we've been talking about Ed today right but there's many different types of sexual dysfunction there's premature ejaculation there's Peron disease there's delayed ejaculation we're just focusing on one aspect premature ejaculation affects 30% of men globally 30% of men how do you define that there's two ways to think about it when they come in you have to figure out is this lifelong going their whole life or is this acquired it's very important because it takes me down two different roads if you say look I've never had premature ejaculation and yesterday it started that's very different than if you come to me and say my whole life I had premature ejaculation and we now Define premature ejaculation as having an ejaculation less than 2 minutes used to be 1 minute less than 2 minutes you have to have a loss of control like I couldn't control it and you have to be bothered by it so if you tell me Stephen look I ejaculate in 30 seconds and I'm happy I say great then we're done you know you are content you have to be bothered by the condition the EAC average ejaculatory time in the United States is 5.4 minutes on average right the average time for a woman to achieve orgasm is typically 13.4 minutes so there's a big discrepancy here as you can see right so 30% of men suffer uh but we know that only a small percentage of these men 9% of these men will ever seek therapy and it can be a significant problem in a relationship um uh and that needs to be addressed okay so there's not like a time limit it's not like okay if you're coming within two minutes then you got a problem well let's say you're not bothered by it let's say you and your partner are completely satisfied
with it what's the problem okay what's the problem and and sometimes let if you think about acquired uh means that typically we Define it as 50% less than your normal time so if you say look I typically used to ejaculate in 8 minutes and now it's 4 minutes and it's bothering me I'd say okay that that's an issue um you know so we talk it's relative what what's comfortable for you and some men will say you know so I think it's very important to look at the definition the treatment options are actually quite simple one of the best treatment options is sex therapy because we can train your mind we can train you to delay that ejaculation there's techniques the start stop technique The Squeeze technique how we can delay it no but there is but most men say just give me a pill I don't I don't have the time for this just give me a pill but there are ways to do it with Sex Therapy which I think are fantastic sex therapy is a cure the pill is just a Band-Aid right Sex Therapy is a cure but the pills that we use the most common Ed pills are anti-depressants because they increase serotonin and make it harder to ejaculate well that's what we want in this situation we want to delay the ejaculation so we can use anti-depressants they sometimes have be taken daily which work better or you may have to take it on demand but if you take it on demand 6 to8 hours ahead of time so you need some notice but there's going to be significant side effects of taking anti-depressants there are side effects of anti-depressants so I try to stay away from them and the other ones I try to use are topical Liane sprays because if I decrease the sensitivity of the penis you're more likely to be able to engage in sexual activity for a longer period of time so those are commonly used so sex therapy and sprays are very easy to use you don't need a prescription for sprays uh and they're common use one thing that we have to talk about that's really important is the Traverse trial it's really big everyone historically has always said that testosterone is dangerous it causes prostate cancer and it causes a heart attack and a stroke and in 2015 there were some studies that suggested testosterone may cause a heart attack before 2015 all the studies suggested
that there was no increased risk so in the United States they mandated that there' be a large trial 5,200 patients six years long strictly to decide does testosterone increase the risk of a heart attack so myself and eight others designed the study ran the study for six years and we published it last year it finally came out and it showed that there was no significant increase in cardiovascular events finally but until that time until that came out many people said I still believe that testosterone causes a heart attack but when the Traverse trial came out the largest randomized speciic control trial ever published we finally showed that giving testosterone didn't not increase the risk of a heart attack in fact the study also showed it did not increase the risk of prostate cancer many people were worried that testosterone causes prostate cancer and no negative effect on urinary symptoms so many people have thought that if I give testosterone the urinary symptoms become worse the study showed no worsening of urinary symptoms so very important study the Traverse trial finally came out it's the largest trial in men ever published on testosterone will it reduce my lifespan will at low testosterone I believe will reduce your lifespan I mean taking like testosterone injections and stuff sometimes I think about like again I don't don't really know what I'm talking about here but I think about athletes taking steroids different those athletes are taking super physiologic steroids so the normal range is typically 300 to a th000 is the normal range and they will take testosterone levels to much higher 2, 2500 okay and there's a reason for that um there's something called a plateau effect so so if you take testosterone and you have better libido you intuitively would think if I take more testosterone I'll feel even better liido but that's not true is's a certain point at which it plateaus so the more you take you've already hit an onoff button you've hit it you're done the exception is muscle the more testosterone you your body sees the more it upregulates uh Androgen receptors in the muscle and you put on more muscle so bodybuilders are addicted to higher levels of testosterone but they're also taking other off Lael medications anavar
Deca wistol they're taking other medications and those testosterone formulations have a lower androgenic ratio androgenic means facial hair acne they're more anabolic so it's very different than what you're taking You're simply what you would be taking is just all you're trying to do is take a medication that you had before and put yourself back into the normal range nothing fancy so I The more I've learned about testosterone The more I've started to think that maybe when I've had my kids and I'm done having kids and maybe I'm 45 um I should consider it providing that my levels are low and you're symptomatic if you're 45 and you say I feel great I'm gonna say Stephen you're not getting it right I feel great so if you say look I'm 45 my levels are low and I'm starting to have symptoms say Okay Now's the Time to consider taking the medication those symptoms you said were like tiredness energy levels well the most specific are my libido's gone down my are worse my Energy's gone down increased fat deposition decreased muscle mass poor sleep and depression and we have to talk about depression so uh earlier on in my career I conducted a very large trial looking at depression in testosterone and we had almost 850 patients and we showed that men with low testosterone levels were much more likely to suffer from depression almost 92% of those men with low testosterone had some degree of depression and when we treated 17% of those men actually had severe depression we treated these men for one year with testosterone supplementation that 177% dropped down to 2% now I'm not advocating to treat major depressive disorder with testosterone but what I am advocating for is to at least check a testosterone level in men who are depressed because it can help them in fact in our study even the men who were on an anti-depressant uh like say Prozac we put them on testosterone those men also saw significant improvements in depression so may be some Synergy between testosterone and what we call SSR eyes so again it's very important to check a testosterone level in men who suffer from depression you wrote a book called recoupling yes a couple's four-step guide to Greater intimacy yes
and better sex yes what are the four steps in this book and you wrote this alongside over 10 years ago yes so I wrote it with the sex therapist she's an amazing sex therapist her name is Mary Joe Rini and we decided to write a book together to really help couples get through so the four steps really are number one foremost communication you got to communicate you got to at least be able to tell each other did you know that only 44% of men who start developing Ed even tell their Partners now think about that You' say what do you mean they don't tell their partner you know what they do they just start avoiding sex they just start avoiding sex so they got to communicate number one and making excuses right I if if I lost my reaction i' I'd probably say oh sorry I'm just tired or you know because I want to just on this point there's much of the reason why it's hard to communicate is because it it can sound a lot like blame and it also can make someone feel like you're not into them right so if I said and maybe you're not that into them and also maybe you're not like that attracted to them so like that could be yeah that's an issue and that's why the sex therapist is amazing right that's what they do right that's what they do they work through these issues with couples and they're fantastic but the number one step we put in the book was communication you have to communicate the second chapter was my main chapter what I wrote about what can we do to improve sexual dysfunction in men and women testosterone placement therapy using Viagra vaginal lubrications local vaginal estrogen therapy we didn't talk about that it's critical for postmenopausal woman local vaginal estrogen therapy is very important decreases this risk of UTI decreases pain with intercourse um so very important um the third chapter really sir what is that vaginal so uh younger women have estrogen in the vagina that estrogen is so important it keeps all the bad bacteria away and keeps the good bacteria within the vagina it keeps the W the lining of the wall thick it allows for the vaginal wall to function with arousal properly and as she gets older and she goes through menopause the estrogen goes away the bad bacteria come in the risk of urinary tract infections
go up the wall starts to atrophy means gets thinner it's more susceptible to injury and tear it hurts okay right so you can't ask a woman to enjoy sex if it hurts every time she has sex a lot of women I've heard a lot of women talking about that about this idea that the reason they don't like to have sex is because it hurts it hurts because when they lose the estrogen the wall gets very thin and it can tear it hurts but even young women young women but it's usually typically a different reason they could suffer from vaginismus there's other things that could cause the cultis but in old older women the most common cause is atrophy of the vaginal wall because of the lack of estrogen so what do you do you give back local estrogen therapy it can be in the form of a suppository form of a cream it doesn't happen overnight I tell my patients it can take up to three months but after three months they notice a difference and the urinary tract infections go away the pain goes down right so these are simple things that women can do to help because again if someone's having pain with intercourse man or woman they will tend to avoid it right it's an important concept so the second chapter is really important on what are the many different things that you can do to improve your sexual function uh the third chapter is really about intimacy it's the really the intimacy and the fourth chapter really is uh ways to improve uh your sexual experience it was written by my sex therapist she talks about vibrators masturbation so there's a four-step guide um that I think is very helpful and I think what's unique about this book is that really it's it's really two perspectives it's one who is the um the medical care that I provide and the psychological care that she provides now she's obviously handling the psychological side of things and she's not here but just on this point of improving communication what is the best advice you give to people that are currently in a situation where they're both kind of suffering in silence because they're just not communicating with each other number one most important is time we don't spend enough time it's basically the shadows in the night you coming in I'm going out and it's you have to make time that's
extremely important and the second one is open dialogue you have to be able to express to your partner what you're suffering from otherwise you can't get treated you just have to be able to express it but time I think is important and open communication and dialogue um there's nothing embarrassing about this it really is um something that needs to be D destigmatized and the consequences of addressing it so couples who engage in regular sexual activity have a significant Improvement in their quality of their relationship they tend to be happier and suffer from less uh me uh depression I mean there's there's there are physical and emotional benefits from regular sexual activity in the um opener of the book where you start talking about communication there's a sentence that says when sex isn't going well it can become 90% of the relationship and couples seldom know how to communicate about any of these problems and that is true you know we've done a couple of conversations now on the DIY about sex and Intimacy in these subjects and the amount of messages that I get from couples saying that everything else in their relationship is great yeah everything is great love this person so much but there's this massive elephant in the room right no pun intended which is um the lack of sexual intimacy now when we talk about sexual intimacy does it mean penetration yeah it doesn't because we with the definition of sex span is the ability and the desire to engage in satisfying sexual activity I have patients that come to me and say we do not have penetrative sex but we have a wonderful sex life I say great if this is working for you because it's satisfying sexual activity you're set right it's if you want penetrative sex and you cannot have it then we will address it and we can fix it but you get to Define Stephen you define what is satisfying sexual activity on chapter four where you talk about things like vibrators and stuff like that um I know that was the a chapter handled by your sex therapist according to what you said is there any risk that using vibrators or other toys and tools will impact normal intimacy without vibrators like is there any studies that say okay you get desensitized to the real thing if
you start using a vibrator yeah I've seen the opposite I've seen that the studies showing that vibrators and these kinds of uh Toys can actually enhance the ability of the relationship so that you can because you're communicating as you're doing it right so you're communicating with your partner what is giving me pleasure what is not giving me pleasure you're learning about each other it's a great tool to use to learn about each other so when you're engaging a sexual activity you're more aware I think it was a a game changer to me I'm going to be honest I think like just having having other things do you know why do you know why it's a game changer and I'm not just talking about vibrators I'm talking about all toys in the bedroom whether it's like dice or handcuffs or whether it's something else or blindfold is just because novelty doing new things for me is so critical as it relates to being excited sexually yeah and there's only so many things you can do there's kind of there's a a a relatively limited list of things you could do if you're not bringing in other tools and toys and stuff you know so I think that for me it actually has helped me to prolong the novelty of my sexual um relationship in a way that nobody told me about before yeah because I think think as a guy especially I think you kind of think that toys are something your partner buys for herself maybe yeah something she uses for herself and now I think if anything I'm the instigator of using other things yeah that's chapter four I mean and we and we prescribe vibrator for men we use something called vict it helps with men with delayed orgasmia these toys can be very helpful in a relationship I think she prefers the toys to me personally but that's another conversation for another time in terms of energy there are so many reasons why I'm a big matcha fan if you don't already know by now and so much so that I actually invested in the UK's leading matcha company called perfect Ted and one of my favorite perfect Ted products is these delicious matcha pouches that come in every flavor from salted caramel to Peach flavor to mint flavor to Berry flavor one of my favorites is this vanilla flavor which I'm going to make in just two seconds you just take this
mixer here get a little bit of the powder pop it on top of the shaker like that put the lid on shake shake shake delicious if you haven't tried this yet you can find perfect Tad at Tesco and Holland Barrett stores or online where you can get 40% off with my code diary 40 head to perfect ted.com and put in code diary 40 to try this delicious multi-flavored match now highly recommend and if you do it please tag me send me a message online what's the um what's the most important thing we haven't talked about that we should have well there's a couple things I want to talk about one is we didn't talk about Peroni disease it's an important disease 9% of men in the world suffer from Peron disease 9% of men in the world Peron disease is an abnormal coverture of the penis when it's erect so I want you to think about this the way I can describe it is I have a balloon I put a piece of tap tape on the balloon I blow the balloon up what's going to happen it's going to curve in the direction of the tape right so if a penis curves greater than 60 degrees it's prohibitive for intercourse these men are suffer many of these men suffer from severe depression it's disfigurement it's disfigurement of the penis right so think about it 9% of men in the world suffer from this condition and most men have never even heard what Peron disease is and uh essentially in the US we have now one FDA approved treatment for this it's an injection called collagenase where we can put an injection into the Rock plaque and break it up there are surgeries that we can do to make the penis straight again but again it's very important to realize that patients who have Peron disease are also suffering in silence they don't know where to get the treatment and there are many good treatment options whether it be surgical or medical to solve this condition so you know my whole takea away from this is this is that I know that millions of people right now men and women are suffering from sexual dysfunction I know they're silent and they're not saying a word because they don't know where to go they don't know what to do but they have to realize that there are excellent treatment options available and they should seek therapy they're not
suffering alone what else I want you to think about sexual dysfunction as no no longer a Band-Aid uh we are not looking for Viagra we are looking for a cure we want a cure for ED and a cure for ED could be based on many things as I mentioned earlier diet exercise sleep stress we've also moved into a new generation of regenerative Therapies in my field stem cells PRP shock wave therapy now we're starting to look at radio frequency in our laboratory we're looking at hyperbaric oxygen men are looking for ways to cure this condition they no longer want to take a pill uh to solve the problem and so I think that's very important um and many of these uh new therapies are promising I think Shockwave therapy is very promising where we have a device that deliver shocks to the penal tissue we' been doing this it's like um [ __ ] like said that but but I'll tell you it we've been doing it now for 5 years um and uh it was invented in 2010 it's actually quite brilliant if I take your finger and I take a hammer and I hit your finger multiple times what do you think your finger is going to do your finger is going to start bringing in new blood vessels and new ways to heal your finger so before Urology the cardiologists have been doing it for the heart for many years and they would shock the heart many times and you would see new blood vessels formed it's called neoangiogenesis orthopedic surgeons have been doing it for a long period of time in terms of injury in terms of healing injury that use shock wave therapy we are new to the game but what we see is when you give these shocks it can potentially improve the blood flow and sexual function in men and I think the new era could potentially be hyperbaric oxygen therapy and also radio frequency radio frequency is a a way to increase heat within the tissue and improve sexual function as well so again I think what you're going to see uh 5 to 10 years as we move forward is new ways to cure erectile dysfunction stem cells potentially have some promise as well but patients don't want a pill anymore one thing we haven't talked directly about but we've talked about it indirectly is the role that trauma plays in sexual dysfunction and Trauma in all of its forms um I think I had a partner
who was very public again about the fact that the reason why they had sexual dysfunction was because in their view because they had been through a sort of traumatic experience how often do you see that in your office how long often do you see a patient come to you man or woman with a some kind of trauma we we we query all men and women if they've had any kind of trauma sexual or just physical trauma it doesn't have to be sexual trauma be any kind of physical trauma um I will tell you that most patients don't disclose or not very commonly described to have having it but they will many times disclose it to the sex therapist and I'll find out on the back end to be honest with you um but I think when someone discloses sexual trauma or trauma it takes more of a relationship and time on the first visit sometimes they're not forthcoming what's that that you haven't in front of you on the desk it's I've been hesitating talking about it so this is a penal implant oh gosh and this yes that's exactly what it is and this is a device that was invented in 1973 by a very famous uh urologist named Dr Brantley Scott Brantley Scott I will have to brag a little bit was from my institution at Bay College of Medicine and this has been around for 51 years and the the penis actually has two bodies sitting on top and they has the urethra sitting on the bottom and those two bodies have muscle inside them or casing and what this device is a surgery that I warm quite often where we put these balloons or cylinders into those two bodies and fill them up there's a small pump that goes into the scrotum and there's a small Reservoir that just holds water normal saline that goes behind the pubic bone typically when a man squeezes this he starts filling up these cylinders with water and it gives him a very rigid very good erection when he finishes engaging in sexual activity he'll press this button here and it will actually release and all the fluid will come out of the penal bodies and go back into that Reservoir so theoretically anyone who's willing to have this surgery we can cure Ed but it's a surgery and what's the consequence and cost of that in terms of sexual experience monetary cost I would say that in the US Medicare covers this product so that's that's actually quite
good in terms of pleasure and Men report no significant decline in pleasure if you look at overall satisfaction is greater than 92% for patient and partner with uh with the penal prosthesis so um it is a very um it's a GameChanger it really is a GameChanger most patients have never heard of it or most people have never heard of this uh penal prosthesis um but you know let's be honest you know if you had a bad shoulder you'd get a prosthetic if you had a bad hip you get a prosthetic it's a prosthetic that fixes an organ um and it Stephen it the satisfaction rate is extremely high but I'll tell you something you owe me something because when I brought this on the plane uh and I went through security they made me pulled us out and explain what this was and nobody had heard of it no one had seen this um yeah well I had to explain it and I had to pump it up and show them and uh but I had a little bit of an audience but um yes but I will tell you this this is a this is something that really has revolutionized the way we treat men for rectile dysfunction but this is surely like a last ditch attempt it is because it is a lastage attempt because if I take it out no other treatments will ever work again oh really it's it's the end right so if I take it out no other the treatments will work again so I want you to try every single option before we come to this what situation does someone have to be in for you to insert this into their penis so remember when I told you that 40% man at 40 50% at 50 and most patients will take Viagra but I told you Viagra is not a cure it's a Band-Aid so what's going to happen that Viagra is just like that pain pill and that pain pill eventually going to happen is you can't walk well the same thing happens with Ed eventually the meds stop working so once the meds stop working and then the second level we use something called penal injections some manual we use penal injections once you've tried everything and nothing works what are you going to do okay so this is like a last what are you going to do if you still want to get but if I look at satisfaction rates if I give men questionnaires for the pill for the injections vacuum reduction device for the implant High highest satisfaction with the
implant at what point how what you mean how satisfied from the starting point to right if I because from starting at a point where I'm completely unable to get an erection right if anyone helps me get that thing up my satisfaction is going to be really high right but let's say you have an erection with a pill you get an erection with an injection you get an erection with a vacuum and you get an erection with this all all four you know over time gave you an erection which gave you the best erection and which which one were you most satisfied with this will win it's crazy and can you still ejaculate with this yes no issues gosh no I mean again I have I have tremendous sympathy because it's ruins people's lives right it does if if you can't perform in that way and it destroys your relationships and relationships are like the essence of life so but essentially you're taking someone who can't have sex who can now have sex again and some would argue that they can have sex whenever they want as long as they want with this device right it only goes down when you tell it to go down Dr Mo we have a closing tradition on this podcast where the last guest leaves a question for the next guest not knowing who they're going to be leaving it for yeah and the question that has been left for you no is have you ever experienced anything that you cannot explain from a position of rational materialism yeah I mean I think so many things in science that we can't explain so many things that are idiopathic that I have no explanation for um uh for example for fertility which is something we talked about 40% of men who come to me our explanation is no explanation we don't know why you're infertile right so obviously that's very uncomfortable for many patients to hear that but many things in science I have no explanation for um and many things that I do have an explanation for we find out 10 years later were wrong um so I think that's what comes to mind what about any personal experiences at all in your life spiritual religious yeah um I'm very spiritual I'm very religious um sometimes death it's hard to explain hard to understand why um it's real I see it every day uh you know we see it we do at work um my I see it
personally in my own life my father passed away at an early age um from idiopathic pulmonary fibrosis um it's a very it's a condition where your lungs start to scar it's probably the worst condition you could asked for and um and he had have a lung transplant at 70 so he pretty young um and he retired at 69 um and said you know one he worked very hard he was a general surgeon single you know solo practice and um he said one day I'll enjoy one day I'll enjoy and then at 69 he retires he's ready to enjoy at 70 gets idiopathic pulm fibrosis at 70 gets a lung transplant and lives for five years with someone else's lungs um which is pretty tough um and his one message was you know don't wait till the end enjoy the ride I wish I'd enjoyed the ride because waiting to the end um sometimes there may be no end and by that I interpreted that to me that he had worked his whole life very very hard extremely hard and he sort of delayed the gratification to a point that right it didn't really come necessarily he thought it would come at 70 and he' enjoy the last 15 years and enjoy but at 60 9 he got idiopathic pulmonary fibrosis at 70 we got a lung transplant and at 75 he passed away and I think that um if anything I Learned was don't wait to the end enjoy the ride are you doing that I am every second I can and how how do you do that sort of practically when you're so busy so I make time I meditate every morning I work out every morning I have my own time to myself I pray I'm very religious I think those are very important things to keep me going um I spend I I it's it's God family work patience I mean it's an order my family is extremely important to me and I make time for them as well and uh I think that keeps me grounded Dr Mo thank you thank you for the work you're doing because as you say in your work there's a huge proportion of people couples men women that are suffering in silence and there are in search of answers and there's not a lot of people in your friendship group that are necessarily going to know this stuff or even talk about their own experiences with this I think it's important to have these kinds of conversations um that anyone in the private or comfort of their own home or with their airpods on can tune into to get a better understanding if there was a closing
message for for those people that are suffering in silence in some way whether they're couples individuals what is that closing message to them it's okay to suffer from sexual dysfunction it's normal as we age and there are many treatment options good treatment options that can help you today and I ask you to seek therapy raise your hand tell your doctor you suffer from sexual dysfunction because they're excellent treatment options and if people want to learn more about you and your work where's the best place for them to find you well uh it's my website Dr drit cara.com and um sexan health.com I have sexan health.com where you can learn all the different ways to improve lifestyle modification I started a nonprofit I just want you to know called the testosterone project just so you know that uh it's really geared at education advocacy for testosterone we're trying to get testosterone approv for women in the United States I that's important we're trying to get testing done uh as well we want everyone to be tested for testosterone it should be Norm as well and we're trying to get it deregulated so the test aom project.com is a great way to get information as well I'll put all of those links below Dr May thank you so much for the work you're doing and please do keep doing it because it's so incredibly important Stephen pleasure to talk to you thankk you do you know that 80% of New Year's resolutions fail by February it's because we focus too much on the end goal and we forget the small daily actions that actually move us forward those actions that are easy to do are also easy not to do in life it's easy to save a dollar so it's also easy not to making one small Improvement each day one tiny step in the right direction has a big difference over time and that is the 1% mindset which is why we created the 1% diary a 90day journal designed to help you stay consistent and focus on the small wins and make real progress over time it also gives you access to the 1% Community a space where you can stay accountable motivated inspired along with many others on the same jour Jour we launched the 1% diary in November and it sold out so now we're doing a second drop join the wait list at theed diary.com and you'll be the
first to know as soon as it's back in stock I'll put the link below [Music] oh [Music]