I'm Dr Rita Malik urologist and pelvic surgeon today's podcast is all about low desire we talk about how often we see low sexual desire in fact is it more common in women like we suspect it is or is it pretty similar in women and men what changes do we see in the brain of people who have low sexual desire and what's the role of testosterone in sexual desire what are the causes of low desire and what are the number of different things that can affect desire and how can you assess for those and improve those I then go over tools and techniques that you can use to improve desire at home we also talk about the role of diet as well as supplements in improving desire and lastly I review pharmacologic treatment options for low desire I hope you guys enjoy low sexual desire what exactly does that mean so it's typically the lack of motivation or interest in sex or the desire to have sex now this can be absent spontaneous desire like you see your partner you want to have sex with them you used to feel that way and you no longer do or even responsive desire being intimate with your partner and then usually that used to spark some sort of Interest or excitement in Sex and that no longer does it's also the absence of motivation to try and go have sex so some people will say I used to like actually want to look sexy or try to initiate with my partner and no longer do that but the most important thing is that there is bother associated with that low sexual desire because if you or your partner are not bothered by the absence of Desire well then it's not a problem it is totally normal for you as long as you are not bothered by it now how common is it well in women we we see rates of women describing low sexual desire or low libido as high as 40% but only about 12% are bothered by it in terms of men we see it in about 8 to 15% of men so it's not uncommon in men it's just less talked about so interestingly there was this study done to look at low sexual desire comparing men and women and the way they did this study which was done in 2007 was they took both men and women and they randomized them to give answers that they thought were going to be reviewed by a peer group give answers anonymously or give answers that were going to be hooked up to a lie detector test now it wasn't truly going to be a hooked up to a lie detector test but they thought it was going to and they asked about 200 people questions like how often they masturbated did they have a partner did they watch pornography and interestingly when the group thought that they were going to be reviewed by peers women tended to often answer in the negative whereas when they were being told it was going to be anonymous or go through this bogus test the lie detector test they more often answered and had more similar answers to their male counterparts and so through this study the belief is that essentially men and women tend to have similar sex drives now this study was done in a younger age group so this may not be to True through the lifespan but essentially starting out seems to be that men and women have similar interest in things like masturbation pornography and having sex so when you think about desire desire is really complex and there's a number of different areas in the brain that are involved in sexual desire so when you are interested in having sex parts of your brain light up and release certain signals one of the most common ones is dopamine and this is balanced by sexual inhibition areas and these are typically areas that light up most often after you've just had sex you're satiated you're not in the mood to have another round of intercourse or sexual experience with your partner and these involve a number of hormones mainly being serotonin and even opioid receptors so when we think of having more inhibition or less inhibition in some cases if you're thinking about hypersexuality and there's issues actually in those areas of the brain in fact they've done MRI studies of women and they've looked at areas that highlight or light up when they're shown erotic videos and women with hypoactive sexual desire disorder which is essentially the clinical condition associated with low sexual desire these women actually had less of these sexual excitation areas light up knowing this certain medications can actually alter desire so things that may decrease dopamine increase serotonin or in increase stimulation at opioid receptors can cause decreased sexual desire so the first thing you want to think about when you're seeing a patient or yourself are having sexual desire is are you taking any medications that could affect desire these can include things like ssris or anti-depressants antis psychotics opioid medications or even B dipin like valium or Adavan that tend to be used for anti-anxiety now there are some medications that I often see as a urologist that can sometimes cause these issues now it's not across the board so I'm not saying these are bad medications but there are a subset of people who really suffer from decreased desire when taking these medications now this includes oral contraceptives for women and the way this works is because oral contraceptives cause an increase in sex hormone binding globulin and sex hormone binding globulin binds up testosterone and in fact women have more testosterone in their bodies than they do estrogen and testosterone is not only an important hormone for desire in men but it's also an important hormone for desire in women so when they take oral contraceptives they see this problem the other one in men often is things like finasteride or dutasteride or propia is the brand name these are medications are used either for an enlarged prostate or for hair loss and these work by blocking the conversion of testosterone to dihydro testosterone and these can cause changes in your hormonal milu that can lead to decreased sexual desire when was the last time a doctor spent an hour with you and truly focused on what your goals are when was the last time that you left the doctor's office feeling like you really understood what's going on with your body and had a clear plan of what was going to happen next at my practice Reena Malik MD I aim to give you just that I specialize in sexual dysfunction bladder conditions hormone management and pelvic pain for all genders and I want to revolutionize how we take care of patients and really get to know each and every one of you that's why at my practice when you come to see me I'm 100% present with you for an entire hour and after after you leave if you forgot to ask me something or need clarification don't worry I'll respond to your issues and concerns quickly through our secure messaging portal with no extra fees or hidden costs you don't even have to call the office to make an appointment just go online at www.md.com appointments and schedule your appointment today we see patients in Newport Beach California and virtually for patients located in the states of California Florida Illinois Maryland New York New Jersey and Virginia if you aren't located in those States consider making an educational visit where we can talk about your conditions generally but I can't diagnose or treat you as a patient I can't wait to see you now other things that can affect desire are relationship issues if you're having relationship issues with your partner it's very common for people not to feel desire for their partner because they may feel resentment or discouragement or unhappiness when they see their partner and that ultimately doesn't lead to wanting to have sex with them which makes total sense also stress fatigue things that are ongoing in our lives will decrease desire because when you are stressed your body increases the release of cortisol now cortisol is released all the time in our bodies when we're doing stressful things when we're working out but usually it goes back to normal but when you have Chron chronic release of cortisol due to chronic stress that inhibits the production of testosterone that by nature of decreasing testosterone and both men and women will decrease desire so it's really important to work on reducing stress in your life now the more important things that when you see a doctor need to be ruled out are things like psychiatric or psychological disorders so depression and anxiety are huge Inhibitors of desire and as I mentioned earlier the medications that you take for these issues often have side effects that lead to low sexual desire it's important if you are taking any medications for depression or anxiety and experiencing low sexual desire to talk to your doctor that prescribed them because very often it's a dose dependent phenomenon now what that means is that as you get a higher dose you're going to have more decreased desire and so so you can either continue taking that medication at a lower dose or try to find another medication that doesn't often have those side effects now one of the medications that we often recommend is well Butrin or buproprion which doesn't seem to have as significant side effects as some of the other options now the other issue that's important to rule out is other what we call endocrinopathies and that means other abnormalities in hormones within your body Comm ly things like low testosterone or having abnormal thyroid function or abnormal prolactin these are hormones that are related to the hypothalamic pituitary axis so when you have abnormalities in any of these they can affect sexual desire and so getting these treated can immediately improve sexual desire now immediately meaning that after you've gotten normal levels or the endocrinopathy is corrected you may see Improvement in your sexual desire now other issues or other medical problems have been associated with low sexual desire these can include stroke diabetes high blood pressure post-traumatic stress disorder which is sort of a psychological condition but more specific seizure disorder renal failure heart disease and heart failure and HIV also eating disorders and doing significant endurance exercise and eating disorders can cause real major problems in your hormonal environment which can lead to decrease desire now the way diabetes can affect desire is it can also lead to decreased genital sensation so you can actually find that things that used to make you aroused or certain pressures or types of stimulation on the genitals that used to give you arousal no longer does and when you don't feel that it can make you less interested in having those sorts of activities because you're not getting the same outcome now this leads me to discuss that if you have other sexual dysfunctions which are very commonly associated with low desire it can create sort of a feedback loop so for example in men very often if you're having erectile dysfunction or premature ejaculation you could start having a lot of stress and anxiety around having sex and then when you come around and try to have sex the next time you're preoccupied with the idea that am I going to be able to last long enough or am I going to be able to keep an erection and that will then decrease your desire for sex in women if you have other issues like genitor urinary syndrome of menopause which I talked about on my last solo episode about estrogen or you're having urinary incontinence or you're having pain with sex or other abnormalities in your function down there even urinary leak leage it can make you have less desire because you find yourself either having discomfort or feeling less desirable and that's also where body image issues can come into play if you are having concerns about being unhappy with your body image you're going to have less desire to proceed with sex because you're worried about how your partner May perceive the way you look and I think the important thing to take away is that sex the most powerful organ of sex is your brain brain it's not your genitals it's not your penis it's not anything else it's your brain when you have an orgasm it's a completely mindful moment which means that when you orgasm you can physically not think about anything else you are in the moment and completely Mindful and so if you can't be mindful during sex meaning you can't stop thinking about all the things you have to do or the way you look or the pain you're having or whatever it is or how much you hate your partner that day then you're not going to be able to be mindful and enjoy sex and that may translate for you as low desire now interestingly pregnancy and childbirth around that time there is a significant change in women's body and in fact in a study of women resuming sex after giving birth they look at 3 months and 6 months at 3 months the rates of either pain with sex or low desire are as high as 80% and when you go to six months out it's still upwards of 60% so what does that mean and why does that even happen well one of course you're sleep deprived you're busy taking care of a child your body has changed and those things can definitely affect you and I can tell you that you know I've had two children and during that time particularly that first year after having children you are so sleep deprived the last thing you really want to do is have sex particularly if you're lactating you know your breasts are uncomfortable your nipples are uncomfortable and it can cause a low estrogen state in the vagina so what that means is that you can have thinning of the vaginal tissues which can make lubrication less which can make sex more uncomfortable and then of course you don't want to have sex if you're going to be uncomfortable now the good news is that if you are experiencing pain with sex during that period there are many options particularly vaginal estrogen that can help with thickening those tissues that you don't have discomfort with sex and that you have more increased lubrication you can also use vaginal moisturizers or you can get assessed by your urologist or gynecologist for pelvic floor dysfunction which can happen after giving birth because after giving birth very often you can have weakening of the pelvic floor just from having carried that baby for 9 months or pushing it out through the vaginal Canal alternatively sometimes people develop pelvic Flor dysfunction because of of all the stress related to taking care of a newborn the pelvic floor can tense up and cause pain and discomfort and both of those can be treated with pelvic floor physical therapy now let's talk about men for a second very often people automatically think low desire low testosterone now that's common but it's not the only reason for men to have low desire now based on Research we know that when testosterone on average dips below about 432 nanog per death liter men will start developing symptoms of hypogonadism specifically low libido in order to have issues with erections the average testosterone that we're seeing men having issues is below about 230 nanograms per Deiter now I tell you these numbers but you are not a textbook and people may experience symptoms at higher levels of testosterone and it's very reasonable to evaluate that and then assess if you have response to testosterone replacement therapy and testosterone is not only beneficial for sexual function or desire and we have endogen receptors all over our body it's important for cognitive Health mood it's important for bone health and muscle mass so there's lots of benefits to testosterone so if you have low or borderline low testosterone it may be valuable to consider either natural ways to boost testosterone or considering testosterone replacement therapy now I will make a dedicated podcast on testosterone but briefly here testosterone can be replaced in a number of different ways it can be treated most commonly either with topical gels or topical patches it can be given by injection therapy so given injections twice a week every week and there's different formulations of that there's also testosterone oral therapies and nasal sprays there's also pellets that you can have implanted in inside your body that will release testosterone for up to 3 to 4 months and then you get them replaced so there's lots of different options for testosterone replacement therapy and it can be very beneficial in all areas that I discussed so for mood for cognition for bone health for increasing muscle mass and so if you are having issues in these areas like you're feeling depressed have low energy have issues with desire have difficulty getting muscle in the gym even though you're lifting a lot of Weights it may be a sign of low testosterone and so it's important in these cases to get evaluated and if you are a candidate decide with your doctor if testosterone replacement is right for you and then make sure you continue to be followed testosterone therapy is not something you just take and then you just manage it on your own we have to evaluate one that your testosterone is improving two that your symptoms are improving and three that you're not having any Adverse Events or effects of taking testosterone now there can be side effects with testosterone particularly if it's too high that can be things like acne it can cause Arroyos or increase in your blood cell count which is a problem it can cause a slight increased risk of stroke and so these are things that we need to sort of evaluate make sure testosterone doesn't go too high or become super physiologic where it can become detrimental now the other important thing to realize is that testosterone works on testosterone receptors so at some point when those receptors are fully saturated now we don't know what that point is for every individual we don't have a way to test it but above and beyond that more testosterone is not going to be better and so it's important to realize that like okay you might feel good but taking more may not make you feel better and may just give you harm are you loving the Rena Malik MD podcast well I love each and every one of you and I'm truly honored that you choose to spend a bit of your day or a bit of your week with me did you ever hear the actual story of why I started making content online well when I was a resident I remember having a patient who had bladder cancer and in order to treat her bladder cancer we had to remove it and then reconstruct a new bladder called an Indiana pouch now with this new bladder she would have to catheterize herself through a sto or an opening on her abdomen in order to empty her bladder so after surgery immediately she did great she went home and no major issues but subsequently over the next couple months she started getting readmitted over and over again to the Intensive Care Unit and we were really wondering what was going on eventually we figured out that she didn't truly understand that she now had to catheterize herself to empty her bladder just the simplest thing that was so pivotal she didn't understand that and it was then that I realized as a urologist I could do the perfect surgery but if my patient didn't understand the consequences of that surgery then I failed as their doctor and once I started practice I realized that I couldn't teach people everything they needed to know in the 15 or 30 minutes I saw them in my office and that's when I started creating all my Reena Malik MD content to offer free education to people around the world and I can tell you that it has been truly one of the most rewarding experiences in my life and in order to keep providing free content we need your help if you are getting value out of this podcast or my other content I encourage you to to join our premium membership as a member you'll get early access to the audio and video of the podcast completely add free transcripts of all the episodes and exclusive access to ask me anything episodes that occur once a month and during those episodes I answer questions that are asked only by premium members so join us today at Reena malik. supercast docomo men who have nor normal testosterone levels now in men who have reduced libido and have sort of always been that way or as long as they can remember but they have normal testosterone levels there's actually been a study that looked at what things are more correlated with these types of men and what they found is these men tend to have more post-graduate school education so they're Highly Educated they have more problematic relationship issues or family issues specifically they may have a partner with reduced libido or a partner who doesn't climb as often they tend to actually be quite healthy they have really good glycemic control I meaning they have very good blood sugars and low triglyceride levels and they tend to have more of what we call somatized anxiety so they may have issues like abdominal pain or headaches or physical manifestations of their anxiety and so this can and this sort of tells me that all of these issues are probably all causing problems within libido and so in these cases it can be very valuable and we'll talk about this a little later is to seek the care of a sexual therapist or a psychologist with expertise in low libido or low desire and in these cases it can be very valuable to seek the care of a sex therapist or a psychologist who has expertise in sexual medicine to help you kind of figure out and navigate these complex issues and optimize the relationship conflict and optimize the anxiety so these issues have less of an impact on low desire but what else can you do so let's talk about in all genders what are things that can help number one is sleep in today's society sleep is not prioritized in fact in Matt Walker's book why we sleep he mentions that we're the only species that actually actively tries to not sleep every other species actually goes to sleep at the normal time based on the Arcadian Rhythm now it's not completely our fault right we're surrounded by bright lights and we're not outside as much as we used to so we're not getting exposure to the Sun that tells us it's morning time or it's night time and so our brains are still wired and wide awake at night time and now with the Advent of phones we're often scrolling our phones before bedtime which doesn't help us fall asleep and more and more stress in today's society is causing us to ruminate right before bedtime when we finally let ourselves think about what's going on in the world and then people have more trouble sleeping now we know quite significantly that sleep deprivation can lead to mood issues including depression anxiety and low libido and particularly even obstructive sleep apnea so when you look at men who have obstructive sleep apnea about 23 to 25% have low libido so getting your sleep apnea treated can actually help your libido now how would you know that you have sleep apnea so very often if you have a very thick neck circumference that's a sign that you may have sleep apnea also if you find that your partner is telling you that you wake up in the middle of the night and gasp for air and then fall back asleep that may be a sign that you have apnea and also if you're really tired all the time during the day or falling asleep or having issues with staying awake that's another indication to see a sleep specialist and get your sleep evaluated now there have been a couple studies that have looked at sleep deprivation and its effects on testosterone now these studies are primarily done in young healthy men but they look at men who sleep for maybe 5 hours a night and compare them to men who have slept for 8 hours a night and they see a significant decrease in testosterone now it's not consistent across all studies we do know that if you have acute sleep deprivation like you don't sleep for 24 to 48 hours that you're going to see decreases in testosterone but based on the data we know about low testosterone the number one thing you can can do to improve your hormones is to sleep and get good quality sleep for at least 7 hours so that's uninterrupted sleep good quality sleep meaning minimizing your caffeine intake so you don't have caffeine on board prior to bedtime and that means actually afternoon because if you take or drink coffee or have any sort of caffeine afternoon the halflife is about 5 to 6 hours so you could still have caffeine on board at around midnight when you're trying to go to sleep or even earlier so it's really to try to minimize caffeine intake afternoon you will see a difference in your overall Sleep Quality when you reduce your caffeine intake alcohol late also will affect Sleep Quality of course as I mentioned looking at Blue Lights prior to bedtime and looking at screens or TVs will affect your Sleep Quality as well so trying to have a very dark environment in your bedroom and then trying to get outside in the early morning to expose yourself to sunlight and expose your eyes and your brain and your body to sunlight to let them to kind of let yourself know that it is morning time it is daytime will help you be more arousable during the day the next thing you can do is exercise now think about exercise right when you exercise your heart rate increases your respiratory rate increases and also you activate your sympathetic nervous system now this is your fight or flight system think about when you're aroused your heart rate increases your respiratory rate increases so this can actually increase arousal even onetime acute exercise can increase desire right after exercise now in terms of chronic exercise there's lots of benefits one is that it can improve body image right so if you're having body image issues there will actually alleviate them because now you look good and you feel good the other thing is it actually increases blood flow it increases blood flow throughout your body but also in your genitals and so that can over time allow you to be more arousable when you're trying to have intercourse it also causes stress reduction increases energy and allows for better sleep when you work out you're more tired when you get to bed and you can have better quality sleep but we also know that exercise improves testosterone and other hormones so when you do exercise particularly resistance exercise with heavy uh large muscle groups and heavy weights you can actually see boosts in test testosterone which can then improve overall desire if you do very strenuous endurance exercise this can actually over time cause decreased desire and this is because it will cause chronic cortisol elevation which can then cause decreases in testosterone and decreased desire so it's important to do moderate intensity exercise you can do moderate high-intensity exercise at times but not all the time and you want to include resistance training into your regimen for optimal desire and optimal Sexual Health the next thing to consider is meditation now meditation is the act of going about things without judgment so going through activities without any judgment so when you are having sexual activity things may happen but not have placing any judgment on them now this takes practice you can't just practice mindfulness during sex and expect it to work so very often people will do mindfulness meditation to help sort of build that skill and how does it actually help well one it actually reduces issues about body image because you're no longer focused on the way your body looks you're actually focused on Pleasure and how things feel during sexual intimacy or sexual intercourse rather than thinking about what your body feels like you're completely present during the act in fact they did a study of about a thousand undergraduates college students and they found that people who did practice mindfulness had better self- perceived performance during sex and self-perceived body image and there's also a bunch of studies that have looked at mindfulness in helping sexual dysfunction in fact in a study of 1,700 women they saw that women who practiced mindfulness had lower sexual dysfunction and overall better satisfaction with their sex lives and particularly when looking at women who actually had sexual dysfunction implementing mindfulness-based therapies caused improved arousal increased desire and increased lubrication and they generally help decrease fear around sex now this can be common when you have sexual dysfunction there can be a lot of fear around is it going to hurt is it going to feel good am I going to orgasm um am I whatever it is and so having mindfulness practices and incorporating them in the bedroom can actually help you not be scared and actually just take things as they are now what about food right so people talk about Foods all the time they say eat oysters eat this eat that and these are aphrodisiacs now some of the reasons they will suggest that foods work is because they're shaped like genitalia and they allow you to help sort of think about genitalia and may increase arousals sometimes they talk about spicy foods because they're hot and they make you again have maybe a little increased heart rate a little increased respiration and may increase desire now these haven't really been studied so I can't tell you if they work or don't work but there's no real physiologic mechanism for them to work the other things that they will recommend are foods high in zinc or magnesium now these things when they are deficient when you don't get enough zinc or magnesium can affect your hormones and so in people who are deficient increasing zinc or magnesium through food can benefit their overall testosterone levels and subsequently improve desire and so if you you know if you're looking for foods that have you know more zinc you can think of things like oysters shellfish or fatty fish are high in zinc you can also Google what are foods that are high in zinc or magnesium and consider trying to incorporate them in your diet or otherwise take a zinc or magnesium supplement now the other things that you could try to do again are not always Fe ible for everybody but can make a big difference we know that sleep and stress can affect sexual desire as well as issues with privacy so if you can try to reduce your hours at work or get help at home with child care or household duties you may notice that freeing yourself up allows you to have more desire for sex because you're not stressed about something else if you don't have a lock on your bedroom door get one on your bedroom door then you're not worried about your children or someone else walking in the bedroom while you're trying to be intimate with your partner another thing is desire right people think that desire needs to be like we see on the movies you see your partner you're like oh my God they're so hot I can't wait to jump them and have sex with them but that tends to fade over time and not everyone has this what we call spontaneous desire and certainly it can wax and Wayne there can be times in your life where that's exactly true and other times particularly when you're in a long-term relationship where that's no longer the casee and so what you may have is responsive desire and so what that is is when you actually get aroused Like You Lie together you touch each other you cuddle you feel a little bit like oh I I used to like that and then you start feeling desire like oh I want you now now that we've started touching or kissing or snuggling it's actually Awakening that desire in me and that is completely normal but in order to have that happen you need to dedicate time to snuggle be intimate right otherwise it's not going to happen and we are so good at scheduling everything else look at your calendars on your phone or wherever you keep your calendar you will see you've probably scheduled brunch dates you've scheduled all your meetings your doctor's appointments maybe your workout time but have you ever thought about scheduling time for intimacy with your partner now when I talk about this a lot of people are like that sounds so weird like I don't want to schedule sex and it's not about schedu sex right it's about scheduling time to be intimate think about when you were in high school or college and maybe you didn't have a place to go meet your partner or maybe you had to arrange a place to meet your partner um because you didn't own your own place and so you would set a date to see them You' get super excited you'd prepare right women you'd shave guys you'd take a good shower get your good cologne whatever it is right you'd prepare and you would be super excited you'd be like oh my God I'm going to see them it's it's going to be so hot and whatever right and and so you got excited you were ready for it and then when you saw them you were amped up you were like oh yeah I can't wait I can't wait to kiss you I can't wait to be with you and then it was even more exciting so scheduling time for intimacy in the beginning you know it might be like wow this is a little weird but if you accept it as like hey we're just being together date night doesn't have to be going out to dinner date night can be being intimate in the bedroom or getting a hotel room or whatever you want it to be but actually scheduling time to be together now it doesn't have to be scheduling sex because scheduling sex puts pressure on people it can put pressure on someone who maybe has lower desire and feels like what if I'm not into it I have to have sex it can put pressure on somebody with sexual dysfunction if they're stressed about having to perform and so you don't want to schedule sex you just want to schedule time for intimacy and if intimacy leads to sex that's great and ultimately likely it will but it may not happen the first time you schedule it bottom line this is a great way to reinvigorate your sex life and sometimes people have it like it's not so written in stone but you know that when your partner puts on a movie for the kids that you guys can leave the kids alone and they're not going to bother you and that's a great time where you can go be intimate together or whatever the situation is the kids are at whatever you know a game or a sleep over whatever this gives you the opportunity to try and be intimate together and in the same vein you actually have to talk to each other right so we were never taught to talk about sex we never did no one taught us how it is super awkward because we just never talk about it and so if you don't tell your partner like hey I'd love to just have this time with you can we just kind of have this time to be intimate and try this and they have to be on board right because if you go in all excited and they're like what are you doing you didn't talk talk to me about this I thought we were just going to go have dinner like our usual date night they may be a little put off and that may just turn you off right you be like oh man I was so excited and they didn't go with it well you never talked to them about it how are they going to know and talking can't be right in the moment it has to be prior to the event you have to talk in a neutral location so not in the bedroom um usually like in the kitchen or ideally when you're on a walk or driving together where they can't escape you and you can start having a conversation and realize that talking about sex is awkward people often feel attacked or feel very awkward about it and so they may not respond the way you expect them to but give them time and give yourself time it's a skill that takes practice so vibration actually causes blood vessels to dilate or stretch out and allows increased blood flow to the genitals so when you use toys or Aids that have vibration you will no notice that there may be increased blood flow to the area that will then allow this increased arousal now that's not going to necessarily automatically lead to desire but it may enhance it somewhat and not only will it increase desire but it may improve orgasm quality so something to consider trying out like I said it's not specifically designed for desire but if you're having difficulties with orgasm that can obviously lead to decreased desire and so in incorporating vibration can improve orgasm quality and make you more excited than to have more orgasms and have more sex if you're having stronger orgasms so interestingly there's actually been studies that have looked at women adult women and they found that in those women who've used vibrators in the last month they actually reported higher sexual desire scores on a validated questionnaire called the female sexual function index now this is a validated questionnaire that's been studied rigorously that correlates with issues of desire it has multiple dimensions in it but it does have specific questions for desire that correlate with the presence or absence of hypoactive sexual desire disorder in men as well they've studied vibration and they found that it improves a valid questionnaire called the iie international index of erectile function now this is not necessarily specific to desire but that means that they're having better quality of erections and more confidence interactions which is also a great plus and they also looked at sexual desire and they found that those men who used vibrators had higher sexual desire scores than those who had never used vibrators now of course people who use vibrators may be different than people who don't use them right they may actually have more interest in sex they may actually be more open to trying different things during sex and may be open to talking more about sex and have better communication skills so it's not a perfect study but certainly a reason to try new novel things now new novel things or novelty in the bedroom or in with sex can actually increase desire right boredom occurs when you do the same routine over and over again but when you introduce novelty that can make things more exciting and then enhance desire so whether it's vibration whether it's mutual masturbation whether it's trying different positions um or introducing things in the bedroom that maybe you haven't tried before to change enhance or alter Sensations like feathers can be helpful now what about supplements everybody wants to know are these gummies and pills and whatever that's out there going to improve sexual function so I'm going to talk about some supplements that are very often seen in these formulations now the most common one is called Maca so Maca is is essentially cruciferous vegetable and there's two different species of it and they've looked at it in terms of sexual desire now people say this is great for sexual desire but I actually looked at the studies and the first study was done on eight endurance athletes young healthy men who received Maca and these men who got two grams of 5 to1 Maca over 2 weeks had higher rates of self-reporting they felt their libido was better now they did the study to assess if it would improve their cycling performance which it didn't but it did tend to improve libido now they've also looked at it in a study for women but these women tended to have sexual desire decrease due to ssris or medications and it was effective in these 45 women but again it was not necessarily all women with low desire the next one is ashwagandha now this is a stress relieving adaptogen that's from Southeast Asia Middle East India it's known as withania snra from a family called withanolides now it's believed to have antioxidant anti-inflammatory properties but the big thing is that it reduces stress by reducing cortisol levels and so when you think about things that reduce cortisol levels cortisol is basically works the opposite of testosterone so when cortisol is up testosterone goes down and vice versa so decreasing cortisol levels can improve testosterone but of course there's other benefits to reducing stress right redu stress is a big factor in decreasing desire so ashwagandha has had some purported benefits in increasing libido so there's been a couple studies the first one was done on women and it was 50 women who got ashwagandha or what's called ksm66 compared to Placebo they got 3 and a MIG s twice a day and their Improvement was assessed on that same validated questionnaire called the female sexual function index and they saw improvements in arousal lubrication orgasm and satisfaction and even the number of successful sexual encounters in the women who received the ashwag gandha after 8 weeks another similar study was done in men again 50 men that were randomized to received the same ashwagandha ksm66 versus placebo and they were then again assessed after 8 week weeks in terms of their testosterone levels their prolactin levels as well as a questionnaire about sexual function they did see an improvement in testosterone levels as well as overall sexual function now these studies are really small they're typically done by people who are associated with those that will be selling the compound and so take it with a grain of salt but it may be useful if you're experiencing stress and maybe worth trying for a short period of time cycling on and off I would not continue taking asag gandha for long periods of time because it can we don't want long-term reductions in your body's cortisol production also you ideally don't want to take it first thing in the morning because that's when you have a natural cortisol Spike and we actually want that right now what about pharmacology so I already talked about testosterone replacement which can be very effective if you have low testosterone now women can also use offlab testosterone as I mentioned before women have more testosterone in their bodies than estrogen and when they have decreased testosterone they actually get decreased desire so at the same level that men get they have about a tenth of the amount of testosterone that men have so when we replace testosterone the options the most common option that's used is typically a topical cream or gel at Tenth of the dose of men that's rubbed in on the back of the calf the upper thigh or the outer buttock and it has been shown in studies to improve desire but essentially it's really important to assess blood levels with testosterone as well as symptom Improvement when getting off-label testosterone because it is delivered transdermally and not everybody has good uptake transdermally now pellets are not recommended for use in women at this time based on guidelines there's also two medications that are approved for premenopausal women with low desire now we use these off Lael for post-menopausal women as well as men the first one is bremelanotide so bremelanotide was FD approved in 2019 and it's a melanocortin receptor Agonist it's basically administering what's like an EpiPen that you give yourself about 45 minutes before you want to want now most people it works within 45 minutes some people it does take long longer and so it's important the first time you take it to kind of figure out what that timing is because it may be useful to figure that out it can last for 24 to 48 hours so important to sort of I tell people do it on a weekend where you can have a lot of sex like your partner's ready for it you're ready for it and just see how it works now it does have some side effects the most common one is nausea up to 40% of people who take it get nausea so often I will prescribe Zofran or what's called antiemetic at the same time so you can take it and ideally avoid the nausea or you could try it once see how you feel and if you do okay the next time you can either take the zran or not people can also get uh flushing headache and hyperpigmentation now remember it's a melanocortin receptor Agonist but the only people who get hyperpigmentation based on the studies were those who took more than eight doses a month so if you took more than eight doses a month then you were likely more likely to get hyperpigmentation so it's not recommended that you take it more than eight times a month the other medication is called fanin or Addie now this is an oral medication that is both a serotonin receptor Agonist and antagonist it works on different serotonin receptors at the brain level to help improve desire this is a medication you take every single day before bedtime 100 milligram once a day at night before bed it has the added benefit of maybe increasing Your Sleep Quality because it does make you a little drowsy so you don't want to take it at other times you also don't want to take it if you've had more than two alcoholic beverages in an evening uh within an hour or two of taking the medication now fanin works in about 60% of people who take it and it can take about 3 months to see full effect and the effect is not quite as marked as you would if you took something like brenti which would give you instant increased desire this is going to be like oh I was doing the dishes and all of a sudden I thought about my partner and I was like oh I kind of want to go have sex or I saw something on TV that made me want to have sex and I haven't felt that way in a long time so it will give you sort of a slow increase in desire over time now side effects are pretty low most commonly is feeling fatigue or somnolence like you're very tired uh small subset of people less than 2% felt nausea or dizziness and so overall pretty well tolerated in addition to increasing desire it also increased lubrication desire orgasm overall satisfaction and decreased pain associated with sex so when it works it works pretty well interestingly they did a subset analysis and they also saw that about 20% of people saw at least a 5% reduction in weight which was sort of an added benefit to taking this medication another off Lael medication is buproprion now buproprion is an anti-depressant but when used for off Lael reasons for increasing desire they saw about 63% of people showed an increase in sexual desire after taking buproprion and interestingly it actually showed more Improvement in men than women about 86% of men saw an improvement in sexual function compared to about 40% of women and people generally had mild side effects which included weight loss nausea agitation and insomnia associated with taking the medication but overall very well tolerated and lastly off Lael is DHEA so DHEA is what we call a pro hormone and this is broken down into a number of hormones one of which is testosterone and it has a multitude of effects including Improvement in libido and arousal now this the issue with DHEA is it is not regulated so it's in the supplement Market which is unclear if uh things are exactly what they say they are on the bottle so when we look at studies looking at variability in supplements compared to what's on the label you can sometimes see variability as little as very small percentages of the item on the bottle up to 400% of the dose that's on the bottle so we cannot really recommend DHEA supplements but vaginal DH for women or prasterone has been shown to improve sexual desire part particularly in post-menopausal women who are suffering from low estrogen symptoms or genitor urinary syndrome of menopause I hope you guys enjoyed that podcast and learned so much please do me a favor and comment on the YouTube video on what else you want to learn about on the podcast are you enjoying the podcast do you have feedback from me because I would love to hear it and if you are enjoying the podcast a great completely zeroc cost way to support our podcast is to share my podcast with your friends and family the more people we get to listen the more people we can give evidence based accurate information about their health you can find the podcast on any podcast platform as well as on YouTube and you can also find me on Instagram Facebook Tik Tok threads and any of a variety of social media platforms where I create more short form content more content about my 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