Let’s Talk About Sex

Introduction to February sex talk 0:00

Good. And welcome everybody. This is our February, we already passed Valentine's Day, but it was supposed to be February thinking about romance, thinking sex. Sometimes we do heart month for February but this year we're focusing on sex and it's sometimes a tough topic to talk about. So I'm going to give you some ways to approach it. But most of you know that I used to be an obstetrician-gynecologist. And I had a defining moment, you guys, which I'm embarrassed to admit. A patient said to me, I haven't had an orgasm.

I don't have orgasms, and I didn't know I'd ever had one. my sexual function training, even though I spent four years taking care of women, doing their deliveries, during their GYN exams, prescribing birth control, dealing with menopausal symptoms, I think I had two hours of sex education, and it was actually at an outlying rotation, not even my main hospital. And that defining moment I said, ''I am never gonna be in this position again. I don't even know what I told the person.'' But I said, I am never gonna be in this position again where I don't know what to do when somebody asks me a question like that.

And so I really went on a quest to find out about women's sexual function. It took me across the country. I spent a day with one of the biggest doctors of women sexual wellness and sexual functioning, Dr. Erwin Goldstein. I joined the International Society for the Study of Women's Sexual Health. I got really involved with them and was actually a reviewer for some of the articles in the Journal of Sexual Medicine. And I took a really deep dive. We had a sex therapist come out and give a private educational to four of us, myself and colleagues, some were psychologists, other physicians, to teach us what to tell patients and how to approach the issue of women's sexuality.

The best for me. Excuse me, yes, somebody needs to be muted, thanks. And so I got a lot of knowledge, I've got lot more comfortable and for a while I devoted part of my GYN practice to women sexual health and of course it wove all through my gyn practice because these issues come up all the time. So one of the things that practitioners need to understand is that we hardly get any sex education at all. So you kind of on your own to learn about it. The other issue is it takes a lot for somebody, a patient, to say they have a sexual problem.

It's a difficult thing to bring up. That puts the burden on us as practitioners to ask questions. Are you sexually active? What does that mean? Are You having any problems? Have you had any history of sexual trauma?

Defining sexual wellness and communication 3:34

All of these things are going to play a really important role and taking care of somebody. And so I was actually appalled years ago that a friend of mine, I really liked her, became a therapist, an MSW therapist. I said, what do you do with your couples therapy in terms of dealing with their sexual issues? Because I wanted to refer people to her and she said I don't bring it up unless they do first. And so I was, well, I can't refer to her because somebody that won't bring it up first, at least to question, are there sexual issues?

Is there a problem? Do you wanna talk about it? Really is not the person to send somebody who has a sexual problem. So I'm gonna go through with you some of what, how we are viewing sexuality these days, what we know about women's sexual function and the problems that women have as they go through various, through their lifespan and what can do about it. So I am going to screen share of a slideshow. Here we go. You all know we're the Sklar Center for Restorative Medicine. I don't have to tell you that.

And we are going to talk about sex in bright lights. This talk is aimed at really midlife women and the partners who are trying to figure things out. So the first thing we have ask us is what is sexual wellness. The World Health Organization has a definition, they actually have the definition of wellness in general, and they have a define of sexual wellness. And the same applies to both. It is a state of physical, emotional, mental and social well-being. and for sex in relation to sexuality. And it is not merely the absence of disease dysfunction or infirmity, because unfortunately a lot of conventional medicine views us as, well, if you don't have a problem, then you're okay.

All of what we're doing at the Star Center with functional and restorative medicine is it not just being okay, you wanna be optimized. You wanna to be your best you at any age. That's what help you do to the best of our abilities. So sexual health requires a positive and respectful approach to sexuality and there is sex positive approaches that practitioners can take and sex negative approaches. I have to say that previously I was a sex-like, not positive or negative, I a was sex zero doctor. I with a six ignorant doctor until I started learning more about women's sexuality in a way that I could use to help them.

And sexual health is also sexual relationships as well as the possibility of having pleasurable and safe sexual experiences, free of coercion. And we've seen so much in the Me Too movement about what constitutes consent. What is coercive, what does no mean? What do you have to say besides no? And issues of discrimination and of course, violence and sexual trauma, which affects a lot of people, mostly women, but also men. So really the essence of sexual wellness is communication because no matter where you are in life, no, whether what your functionality or not functionality, you.

Are going to need to communicate. And of course, I mean, there's nothing wrong with having sex with yourself either, but we're talking about, and you need communicate with your self too, about what you like and don't like, And what do you think is pleasurable and what's okay. And this is not communication when two people are on their phones together talking to other people. So not that kind of communication. Though I will give you some tips, both medical and kind emotional and I guess psychosocial on how to optimize your sexual wellness.

So what's okay, viewing sex as a positive aspect of a person's existence. One of the issues that people have is that sex was not viewed as positive during their growing up. So they got messages about sex, that's sex is dirty and sex should be hidden and that should not be talked about. And so, First is to acknowledge this is a positive aspect of our existence. This is an essential part of existence, not just for reproduction, but for closeness, for blossoming, our emotional well-being, and I'll give you some examples later about our physical well being.

Every aspect has to be acceptable, consensual, does not create distress. You may have agreed to something, but then you start to feel really uncomfortable. You're distressed. It needs to end. it needs change. And what we're talking about is the actual act of sex, which has many forms, attachment, attachments to our partners or mates, affection, and most of all, intimacy. there is a very expansive range of sexual and romantic relationships, including asexual, like I said, having sex with yourself, being in a monogamous relationship, or agreeing that you're not going to be monologous.

And part of the responsibility of us as clinicians is even if that does not fit with our view of what's okay or normal, We have to suspend that in terms of dealing with patients and this person in dealing, with patience and the people that we take care of and mainly being sure that they're safe, consensual and not distressed by what's going on. What's not okay is viewing sex as shameful or dangerous. And like I said, judging sexual behaviors and attitudes when they don't conform what you think is normal.

Common causes of sexual dysfunction 10:40

There's a really wide range of normal, and we tend to get locked into our view is right, but we have to open up and become more expansive. So there have been studies, it turns out 20% of Americans have engaged in consensual non-monogamy. A couple is agreed, they're gonna see other people. You may not think that's the best way to have a relationship, but people agree that it's okay, then it is okay. As long as somebody is not distressed by it, as long somebody has not been physically hurt by and agrees to it.

5% of Americans identify as asexual or gender minority. I think, that is probably an old study and I that that probably much larger number now. And there was a study in Canada where half the participants said they have engaged in a paraphilia, and parophilia can be anything from pedophilism, which is never okay, to things like BDSM, Which is bondage, discipline, or dominance, sadism and masochism if two people agree to it. Some people want that. You may think it's weird, but some people That's what gives them sexual pleasure and stimulates them.

And so it needs to be done safely and with consent. There was a study done in 2000 that shows that sexual dysfunction, meaning things are not working right. think they're problematic issues in your sex life occur in 43% of women and 31% men. That's a lot of people. A lot people are having problems and these problems affect your relationship, your happiness in life. It can affect you work life if you're unhappy. I remember years ago I was doing actually drug studies with testosterone and I had a woman that I told her I had good news and bad news, I said you don't fit the criteria for the study, but the good new is that we can give you testosterone to help your libido and we didn't treat her and she said.

after a few months, oh my gosh, if I had known about this sooner, I don't think my marriage would have ended. And it was really heartbreaking that the use of a hormone that we use all the time now at this Clark Center could have saved somebody's marriage and the grief that comes from having a marriage breakup. Menopausal women are especially liable to having sexual problems. And so what's in this kind of chartreuse, greenish yellow, are women with sexual problem. Early menopause, so the average age of menopsis is about age 50, 49 to 51. So this is in the first year of Menopaus, the mean age, of the women in study, and there were 430 some women, in a study.

After a year of menopause, 42% of them were having sexual function problems and 58% were still doing okay. Fast forward seven years, the mean age of this group is now 57 and 88% are having some problem. Only 12% still functioning well. That's a huge percentage of women having a problem! We want to involve the audience, but you don't need to raise your hand or put anything in the chat. But I want you to ask you what you think so far. Do you feel embarrassed by me talking like this? Do feel uncomfortable?

I hope not, I can tell you it's a common response. You know, giggling, kind of wanting to withdraw into a shell like a turtle. There are a lot of responses, but ask yourself, because this will help you know whether you can go on to the next step. Because if you're feeling embarrassed and uncomfortable, it means some work needs to be done. And it's fine. We're all about work and improving ourselves here at the Smarr Center. So I'm going to give you a couple of examples. I have taken care of so many women that have these typical problems.

Here's somebody 51 years old. She's been in a really loving marriage for 25 years. And with menopause, women lose, well, first of all, testosterone levels are going down through life in men and women. Then with Menopausal, half of the testosterone that gets made by your ovaries abruptly stops. So boom, you're down by half. For a lot of women, this creates problems in terms of their interest in sex. And even Suzanne Summers, I don't know if you've read any of her books, but you know, she said I'd rather have an ice cream cone and have sex.

That was how I felt. Lest I dead, which people call down there, you, know which is like, we've got to talk about euphemisms. You know it's your vagina and your vulva and clitoris feel dead. Not down. Anyhow, this is a story I've heard so many times where a male partner may still be interested, The woman is just like, couldn't care less if she ever had sex again. And then this is somebody who started her menopause transition two years ago. So remember what I told you, the first year into menopus, there were 48% of people had a problem with sexual functioning.

The longer you go into Menopaus, further away from that transition, that stopping your menstrual period, the more problems pile up. And some people do not wanna be on hormones and this woman decided she wanted the natural route, which worked out at first. I can tell you that the estrogen that was left from your ovulations and menstrual periods probably lasts about a year in terms of your vaginal linings being still moist and elastic and comfortable during penetration. But then after two years, things start to thin, the vaginal lining thins, The blood flow is decreased.

And what happens is using lubricating jelly is great for feeling dry. But sometimes some women, even with using lubrication, sex feels like, I just read an example where somebody, a woman said she felt like a cactus was penetrating her. Or I've had people, women tell me it feels sandpaper rubbing, really. painful. And it makes you wonder if you can ever have penetration again. Which, I mean, there's more to sex than penetration. But this is very fixable. I've talked to so many women when I tell them, this easy to fix.

They go, really? Yeah. estrogen cream put around the vaginal opening, I give it two or three months, and generally function is almost back to where you want it. So the common symptoms that happen to women through midlife, sometimes around postpartum, having had a baby, because one of the things that happens when you have a You don't have periods and not only don' you have period, you don have estrogen. Your estrogen levels are like a menopausal woman. And so if you're nursing three, six, nine months, your vaginal linings can end up looking like those of a metaposal women.

Very thin, very painful to penetration or intercourse. Loss of desire, not being interested, Low arousal, meaning what happens during the sexual response is usually touching, will start to stimulate the tissues of the small lips, the smaller vaginal lip called the labia minora, smaller, and the clitoris and blood flows into the area and area becomes full of blood in what we call turgid or full and it makes the nerves in that area much more sensitive. And so arousal and responsiveness is dependent on blood flow among other things.

And there are of course a lot of psychological and other aspects of it, but the things that happen with menopause are this lack of estrogen, lack bloodflow, linings that are thin and not elastic enough, and sometimes even split open and bleed. Like I mentioned, vaginal dryness and having pain. These are the things that happen in midlife women and especially, like I said, with menopause. Decreased estrogen testosterone goes down as life goes on, as the years go by. So does DHEA. D HEA is an important hormone for libido or interest insects.

It converts into testosterone. We have DHEA creams to use vaginally for women for one reason or another are not using estrogen creams and D HEA works well to condition the vaginal opening, the linings inside the vagina so that sex is not so painful. And then with these changes, there is decrease in the genital blood flow that I just told you about. What else happens as we age? All kinds of things that affect our blood vessels. This is true, especially for men. So when men start having erectile dysfunction, it's not just a sexual issue.

It can be a harbinger of plaque in the blood vessel because you have to have good blood flow to having an erection. So anybody with any man with erectile dysfunction needs to be evaluated for their cardiovascular system, their blood vessels and other areas. Diabetes can cause the laying down of plaque at an accelerated rate, which can impair the blood flow in arteries and impair arousal in women and erections in men. high blood pressure and the medications that are used to treat it can result in erectile dysfunction in men.

And the things that go along with cardiovascular disease and arterial disease like high cholesterol and smoking can affect the condition of your blood vessels. The other things can happen are medications like antidepressants. which especially the serotonin reuptake inhibitors, things like Zoloft and Prozac inhibit orgasms by interfering with some of the neurotransmitter pathways. Surgery like a hysterectomy. Unfortunately with hysterectomy, sometimes the nerves that innervate the cervix, the vagina become damaged and there is diminished sexual response and sexual feeling.

Menopause, hormones, and treatment options 22:48

For men with prostate surgery, this is huge. There's a tremendous incidence of erectile dysfunction following prostate injury. And I really support a conservative approach to high PSA levels, prostate specific antigen levels. which is followed by some urologists these days because the effects of treatment for prostate surgery can be devastating, erectile dysfunction, and urinary incontinence. So you really have to be sure that whatever you have going on in your prostate really is worth and serious enough to require treatment.

And I'm happy to offer referrals if anybody has questions about which doctors do conservative and careful watchful waiting. The other thing a lot that happens with women and I think it affects women more than men is low self esteem and poor body image. So gaining weight and feeling less attractive, getting older and less attracted Your partners may think you look great and sexy and wonderful, but if you don't feel it, it can certainly impact your desire to have sex if don t feel desirable. So how do you know if have a problem?

Sometimes people don' t really realize they have problem. They have disagreements in their relationships, they're unhappy but they haven't really pinpointed it. So some of the ways you can know if you have a problem that involves your sexual functioning is number one, if sex doesn't feel good, and it used to. If you had pain during sex, If have difficulty becoming excited, that has a number of components all the way from desiring sex to the blood flow in the genital area, to the nerve sensitivity all the way to orgasm.

How else do you know if you feel like you lack intimacy in your relationship? If your relationships started out as a romantic relationship and now you're living as friends and didn't agree to it, there may be a problem. If you are not really talking, This happens to a lot of couples go to work. You both go work, you come home, your tired, You do what has to be done around the house, kids, whatever. Do you really sit down and talk to each other about how you feel? Do really tell each of your innermost thoughts anymore?

Or is it just basically, a functional relationship? If you're missing these things, then You have a problem. And female sexual dysfunction is very complicated and depends on a lot of different things. So you can look in the upper left-hand corner, there are the physical issues. We've talked about a number of them, physiological and physical issue. There are psychological issues in upper right- hand corner. Just being depressed makes you not want to have sex. if you have a history of sexual or physical abuse or trauma.

Alcohol or substance abuse can create sexual function problems, as well as just general stress in life and the self-esteem issues that I talked about. This bottom right-hand corner is sociocultural influences, and those are the things that are super important. What were the messages about sex growing up? Are you in a cultural or particular religious group that has a particular view of sex, such as you don't have sex before marriage or masturbating is a sin? And so these are things that can affect us throughout our lives.

And then, of course, interpersonal relationships. Now I know that when a woman tells me she's having a sexual problem, the first thing I ask is how's your relationship? Because you know what? If you hate and resent your partner, you're probably not going to want to have sex with them. So number one is, how are you getting along with your partners? because if you are not liking your partnership and you have a lot of conflict, that needs to be addressed. Sometimes it's a matter of technique. So what I know now, if somebody says, I don't have orgasms and maybe I never have, that maybe never I have is, do you touch yourself?

Do you know what feels good to you? Have you tried using a vibrator? have you experimented? What were the messages you got growing up? Were you told that sex was bad growing? And, is are you happy with your partners, your partner caring and wanting to help you have an orgasm? And some of it is education, which is most women don't have orgasms during intercourse. And that is our expectation. That is what society teaches us and pornography teaches, and TV shows teach us. It doesn't even have to be porn.

The sex scenes on TV where people are, you know, having intercourse and they both have orgasms. For a lot of people, it doesn't happen like that. Either a partner needs to stimulate your clitoris and you need to simulate your Clitorus and it may not happen while you're actually having inner course. So for a of women, It's a big relief just to know that cause they thought something was wrong with them because they didn't have organisms during penetration or during inter course And this was a study, a really big study.

31,000 men, aged 53 to 90. They were mostly white professional men. So we're always concerned about whether studies like this are applicable to other groups. But anyhow, just to give you some ideas of sexual function in men the things that increased risk for erectile dysfunction were some of the thing I've talked about like diabetes, having had a stroke, which means you're Your arteries are compromised, there's plaque in them. Being on antidepressants, I talked about. But other things, lifestyle things like getting no or little exercise, being overweight and watching TV more than 20 hours a week.

So those are risk factors for men for erectile dysfunction. The decreased risk for frequent and vigorous exercise, being a non-smoker and moderate alcohol. And I say that very carefully because it's not a license to go get blotto. Moderate alcohol is one or two drinks for a woman and two or three drinks from a man and probably not every day. This is of important facts for men. So this is the percentage of participants in another study who had erectile dysfunction. And you can see the top line with the circles, the dots that are being connected, connect the dot, are men who have had prostate cancer and at every age group.

whether it's 50 to 54 on the bottom left or up to 85 to 90, there is a really high rate of sexual problems of erectile dysfunction. Even at younger ages, like age 50-54, 65% of the men had erectiles dysfunction problems after prostate cancer. The other things that are shown on here are people with chronic disease, people who are healthy, but some risk factors, and people are very healthy without risk factor. And pretty much the line is the same for all of them. There's a fairly low incidence of sexual function problems at age 50 to 54, maybe 10%. And then it just goes up in pretty a straight line all the way until 80 to 90 when it's 80% of men.

You know, the men listening, you know some of the things you can do to enhance your sexual function, which is to exercise, don't smoke, keep your weight under control, Don't watch 20 hours of TV a week, be up and moving. And some men's sexual functions issues are due to low testosterone. We see that hormone levels in men decrease throughout their lifespan. And then there are the issues of adequate arterial blood flow, which is sometimes sarcastically called plumbing. So the question is, so what could be done about this?

And the answer is a lot. I'm gonna take a little break and ask you to think about you feeling like this is helping your understanding. Is it applicable to your situation? Do you feel like it's guiding you toward a solution? I would hope so. Because knowledge is power, for sure. And you know, we're always educating you at the Sklar Center because with the power of knowledge, you are propelled into taking action much more than if somebody just tells you to do something. If you really understand the whys, So what are some of the things that can be done?

Well, there are obvious things like decreasing dosages or changing medications if they are interfering with sexual function. There is hormone treatments for men and for women. The topic of this talk tonight is pretty much women, but all of these hormones, which I listed previously, play a role in our sexual functions. estrogen, testosterone, progesterone, and DHEA, the bioidentical hormones that we use as part of our regimens here at the Sklar Center. And there are also some herbal treatments, which in my experience work 50-50, like some people, half the people it makes no difference at all, but half of the People notice a significant change and maca is one of them and Maca, is an herb that is known for helping energy, sex drive and a whole variety of other things, especially in menopausal women.

And there is a product called libido stim that's made by the company designs for health and it has a number of various herbal components. And here's libido, stim and maca and something called Zestro, which is an herbal lubricant that has some studies that the company did that shows in fact, it really does help with lubrication and sexual function. So it's a, these are non-hormonal approaches. There is, so you wanna be careful with your lubricants just like any of your health and beauty age. You don't want them to have parabens and phthalates and things that are bad for your body because what you put in your vagina is like what put on your skin anywhere in you body, it gets absorbed.

And so good clean love is a personal lubricant that has no harmful components to it. There's also something called scream cream that I found out about when I got into functional medicine and it's basically a DHEA And it's a DHEA small amount of estrogen and arginine. And argenine is a nutraceutical that dilates blood vessels. So scream cream helps with improving blood flow to the general area in women to help enhance sexual function and orgasms. So this is a talk that I started giving like 10 years ago or more.

And back then there were all these medications specifically for male sexual dysfunction. There is Viagra and Cialis everybody knows about, there's cavergectin injection, There are testosterone, testim, and androgel that are commercially available testosterone products. And the slide for women used to have nothing on it because there was nothing that was FDA approved. When we use testosterone for woman's sexual function, it is not an approved use of testosterone. We're able to use things off-label.

It's considered good practice, but I can tell you nobody has gone for an FDA approval for testosterone, for the women, because it's just not enough money in it. So they did come up with these FDA approved medications in the last few years. And one is called Addi and you have to take it every day and it costs $543 a month. The studies with it showed in drug studies, they have a placebo group who got something that didn't really have the active drug in it. Addy group that took the Ady and they found that for $543 a month, women on Addi had one more satisfying sexual encounter per month.

So if that's worth $543, well, okay. The other one that came out, and these are all both for pre-menopausal women, not shown to be effective in post-Menopause women. the other is Bylesi, Brevalanetide, and it's an injection that you give yourself when you want to have sex so that we feel in the mood. And it is only $774 per injection. It has a few side effects, like nausea, dizziness.

Practical strategies for better intimacy 38:08

You are going to be in good enough shape to even have a sex after you have this injection, so you can see what extreme drug companies have gone to to try to come up with solutions for women. And really so much of it is in the slide I showed you in bioidentical hormones and herbal treatment. So there are a lot of alternatives for sex. You can have sex with yourself. Vibrators could be a great addition and people can experiment. Locally, there's a sex shop on Second Street and the people in there really professional and will help you out, try to pick what might work for you.

And so if you wanna expand your sexual repertoire, you might wanna think about vibrators. There was an article in the New York Times. It was a couple of weeks ago called Sex Over 70. And they interviewed a number of couples of all sexual, heterosexual, homosexual, a whole variety of sexual disposition and wrote a really quite comprehensive article. That is the first article I've seen in mainstream press that talks about sex over 70 and they talked about the issues people have, the disabilities or difficulties people had because of health problems, how people overcome that, what couples do about it.

And really the upshot of the article was actually really inspiring because basically people found more peace of mind more sexual satisfaction and more happiness, which we know happens later in life. That has been shown in a number of studies as they got older. I also heard a really good talk put on by a local sex therapist, and she mentioned this This is an organization and they put out an ebook called pleasure able device manual that has tremendous guidance about how to have sex in general and all kinds of devices, everything from if you can't really use your hands.

things to strap onto your arms so that you can hold devices to people who were in wheelchairs and various kinds of swinging chairs they can be in so they have sexual intercourse and go back and forth. It was chock full of great information and we can send you a link to the download. I was really impressed with it. So the other issue that I mentioned before is that If you're angry and resentful at your partner, you are not gonna wanna have sex. So that has got to get cleared up. The other thing is that people use their bedrooms as a Super Bowl party, especially since the pandemic, our work area, and who knows what else.

You really want to set up your love nest, where you have, it can be candles, a romantic light, some music, but something that takes you away from the humdrum every day of your life and creates a special environment and sets the stage. And people hate it when I say this one, but I schedule time for sex. They go, oh, that is so unromantic. But you know what? If you're busy and your partner's busy, and you are at work all day, then you have all kinds of responsibilities. And then, you come home exhausted.

It repeats itself over the weekend, because there are other responsibilities over weekend. Sex is going to get squeezed out of the picture. and you schedule everything else, don't you? Schedule your meetings at work and, you know, your lunch with the mother-in-law and take the kids to soccer. And you need to schedule this. You need plan it. Maybe a date night. If you have responsibilities, caretaking a parent or children, maybe somebody can take over for you for a couple of hours and let you. Have a scheduled time for romance.

So what's sexual wellness? It is really the fulfillment of basic needs for intimacy, pleasure and love. Basic human need. And it has physical, emotional, spiritual and intellectual components. It's not always about achieving climax. Some people feel like failures if they don't have orgasms. There are all different kinds of ways to have sexual satisfaction. One of the gentlemen in the New York Times Magazine actually says he doesn't have orgasms and ejaculate, or if he has an orgasm, he does it actually ejackulate with it.

But he said sex is better than it ever was because of kind of communication and closeness he had with his partner. So it's not about achieving some goal and you fail if you don't. If you've had a close, wonderful bonding relationship, that's it, And for some, especially as we get older or as our physical body changes through illness or accidents or aging, it may mean coming to an understanding with your partner that sex is gonna be different than it used to be. It may means lying next to each other and cuddling.

That's great. And I've had couples tell me that, well, I hear from the woman because she's the one that's a patient of, they have a great sex life and they cuddle. So you have to change your expectations of what the media shows you or what you might've learned in college or wherever you got your sex education, which most of us didn't really get sex eduction, but to your ideas about what sex is. And sex has wonderful positive impacts on our lives in terms of boosting our self-esteem, creating closer emotional relationships with our partner.

And actually studies have shown improved physical and psychological health. Our immune system's stronger, our cognition is stronger. In women, are cardiovascular system is healthier. The risk of prostate cancer is decreased. It improves sleep, reduces stress and creates that intimacy that I think is a basic human craving. So how to find a healthcare provider who can help. This is from a survey of actually the medical students organization did this survey, of medical schools and found out that 85% of the students get less than five hours of training about sexual health and education.

And I must say, even in an OBG, well, we didn't have anything in medical school, and even an ob-gyn where you're dealing with women's reproductive organs and sexual organs, We got virtually nothing. So you want to find a doctor or a therapist who's experienced with sexual problems, number one. how to get the most out of your appointment. So you really want to plan this because if, and what happens is you're hesitant to talk about it because it's uncomfortable. You go have your visit, you know, your annual GYN exam and you have the doctors wrapping up and say, well, here's your thing for your mammogram.

Here's a paper read mammagram. And you'll check out at the front desk and then you go, oh, can I just ask you one more thing? And it is what we call in medicine and oh by the way, it's not a good way to ask about sexual function problems. So you really want to set aside a time to bring it up and you want stay focused on your questions. You can write down a list of questions and write the answers to the question because it is difficult to talk about. If you feel put on the spot, It'll be interesting to see if your provider gets put on the spot.

Hopefully, if you find somebody who's experienced, they'll comfortable with it. But it's important to know how to approach it at an appointment. And what else to ask about? Ask about whether any of your chronic illnesses could be affecting your sexual function, like your high blood pressure, your diabetes, or your cardiovascular disease. Asking about medications, could they be playing a role in sexual function problems? And always, if you're looking at surgery, ask how this will affect sexual functions.

And, always get a second opinion. So, this is the last of our audience surveys. Do you feel like you have a better idea now about how to approach talking about sex? And did this presentation give you the courage to start the conversation? I hope so. I also have a book called Difficult Conversations. Actually, I should have put it in here. It's a really good book. They recommend it. So what it comes down to really the essence of sexual wellness is communication. Communicating about what makes you feel good.

Communication about, what you don't want. communicating about how the other person feels. And I have a gratitude exercise and we have handout to give you that gives you kind of a synopsis of what I just talked about, about how to talk about sex. But this is a great gratitude to exercise. If you have partner, you can do it with your partner and if you don't, can you do with yourself. So you wanna set aside some time and it doesn't have to be long. It could be like 10 minutes. And you're gonna sit face-to-face looking into the eyes of your partner.

And, you are each gonna take turns. What went well during your day? You're each going to say what went, well. Then you gonna look your partners in the eye and tell them what you grateful for in them. The last thing is you going take a paper and pen and take turn writing down with each of you wants. And this is a fabulous exercise that is almost surely bound to start opening up conversation and communication. So that's the end of the talk. If you would like to get a handout, a copy of how to talk about sex with the gratitude exercise at the bottom, write handout.

If you want to get on our email list and aren't right list, and if you would like to have a consult with us right console and put your name, phone number and email and text it to 562-280-2191. And I see there are a lot of messages in the chat and let's start working on them. Let's see here. Yeah, so you don't want to put hand out in the chat. You want a text it to me at 562-280-2191. And let's see. So yeah, one of our listeners, and you put it out to everyone, yes. Lisa, thank you for posting that.

That was really courageous to put that down, that you're not embarrassed, but still aware of the shame that impacts your relationship with sex and sexuality and a Catholic home. that kind of background makes it difficult for you. Absolutely. And let's see. Oh, let see, Shelly, you can relate to Sally. Well, lots of people can related to Sallie and hopefully you've learned something that can do about it. And Yvonne, yes, YVonne I saw that you came in late and yes we recorded this and it will get posted on YouTube.

And also on Facebook. Let's see, thank you for naming that, I did think something was wrong with me and we need to hear you say that. Yes, helping, Yes to helping my understanding and good advice, that's great. Yes. And yeah, so there is a commercially available cream called Jolva, J-U-L-V-A that has DHEA in it. It also has some various herbs in, it so people can either get JOLVA online or we have a compounding pharmacy make it up and we can control the components that are in. Well, this is great, Diane.

The information you're providing is very helpful in giving you tips for discussion with your husband.

Q&A and closing advice 52:18

That right there, Ben, it was all worthwhile preparing this talk. I am so glad. So yeah, so Nancy, what to do if your partner does stimulate your clitoris, but you have the feeling like you'd have acrophy? And so, That has a couple of reasons. So one is that you may be lacking the effect of estrogen around the clitoris, because the Clitorus, your urethra, the small lips are all under estrogen control. And estrogen affects the elasticity, The moisture and the blood flow. The other thing that is in that area are nerves.

And we always think of testosterone in men, but women have nerves around their clitoris and small lips that are sensitive to testosterone. So we have our testosterone cream made up, our compounding pharmacy puts it in a very inert base that's basically whipped up olive oil, so very non-irritating. And one of the places you can put a testosterone cream is on your clitoris and small lips. And that actually increases the sensitivity of nerves of cliteris. So you need a combination of estrogen and taking estrogen in a patch or a gel and putting it on you arm may often is not sufficient in conditioning the linings around the vaginal opening, the clitaris, and the small lip.

you need to put the cream, the estrogen, right on the area. And the same thing goes with testosterone in terms of sensitizing, making those nerves more sensitive, because it sounds like what you're describing is like not enough is happening when your clitoris gets stimulated, and testosterone can help those nerve become more sensitivity. The other thing is if you are having difficulty getting stimulate, sometimes a a vibrator will help because it's increased stimulation. Let's see. And the New York Times article, thought it was an okay article but not what you'd expect from the new York times.

Yeah. The same thing Venus says. I don't know who Esther Pearl is. So I'll have to look into that. Right, so what about when the vagina is stretched and sex isn't as pleasurable because the partner can't be felt during sex? So there are a lot of GYN procedures to help kind of tighten or what's called rejuvenate the vagina. And I'm honestly, I am not sure that those are necessary, but they're actually big business. That's part of what worries me is that they are big businesses. Sometimes pelvic floor therapy where you learn to isolate and tighten and relax the muscles of the pelvic floors can help with being able to grasp your partner or whatever's being penetrated inside you, whether it's a penis or a vibrate or finger, help you grasp it and feel it better.

So it may be a matter of lax pelvic floor muscles. That is also something to be looked into. You guys have great questions. Yes, and I agree, a pelvic-floor physical therapist. what you named, most women do not have orgasms through intercourse. Thank you for saying that. Yep. I know we feel like failures, cause it's like, what's wrong with me? Like I'm supposed to be doing this. This is what they show in the movies. Is this what show on TV now? And why isn't it happening? Because it doesn't always happen.

It doesn' happen for most woman. Oh, my goodness. So you got the text reply for Burning Mouth. That was a glitch on my part, but we will still get so if you text us to this number, you're going to get an auto reply about Burning mouth. I'm so sorry I did not change it. And so but if You text this, we'll still Get your message and know what you want. Just know that it's the wrong auto Reply. so I will go in and change It when we're done. But That's why that's happening, but we'll still get it and we will still send you the information.

As far as what percentage of testosterone in a topical cream, we generally use like a 1% cream maybe slightly higher or slightly lower. So that would be 10 milligrams and 100 grams. Yeah, right, a one percent cream and sometimes more. Right, so esterase cream and testosterone gels helped a lot. Right? I'm sure. Zella cream. Let me look that up. I have not heard of it. Oh, I'm looking that up. Yeah, pelvic sanity, they're very good. That's a pelvic floor therapy in Orange County. Yep, thanks Riley.

You don't have to text again, we'll get your message. I am just so sorry that we hit the wrong text message! Let's see, Bella Women's Pleasure Serum, hadn't heard of this. What do they say is in it? It has, uh, see what's in that. Oh, CBD. Um, Wow. They do make a lot of claims. Works deep beyond your skin and relaxes your vaginal and clitoral smooth muscle tissue and the result more frequent, intense and satisfying orgasms. You know, I've been to a number of cannabis courses and I'm not sure. I have seen some CBD creams work well for vaginal dryness I'm not sure their whole promise of improving orgasms necessarily is true.

So there is some aspects of CBD that will help with blood flow and conditioning the vaginal lining. And sometimes, and the clitoris, that might help, but I don't, it's just like estrogen cream. It's not enough for a lot of people to improve their orgasm, especially the testosterone cream, Let's see, the topical testosterone. We are usually using 10 milligrams per gram. So it would be 10 grams in a hundred. Yeah, about a 1% solution. Thank you. Welcome. Any other questions? Well, you guys have been a really wonderful, engaged group.

I'm really pleased and it sounds like this talk has, for some of you, made a difference and I really hope it can help open things in your relationships. And I'd really appreciate you all attending. Thank you so much. Let's see, there are more in the chat. Great. Thanks so much. I really appreciate it. And Dr. Oliva I'm happy to talk to you about how to present this in your residency program because this is so important. Awesome. Yay. Yeah.