Reclaiming Intimacy, Innovation in Women's Sexual Health. Okay. Alright, everybody wake up. Tincture! Herb. Yo, I don't think we should talk about this. Come on, why not? People might misunderstand what we're trying to say, you know? But that's a part of life, baby. It's life, baby. It's business. Yeah, baby. Come on. Let's talk about sex, baby. Let's talk about you and me. Let's talk about all the good things and the bad things that may be. Hey, let's talk about sex. Let's talk about sex. Let's talk about... All right. That might date me a little bit, but I think I was in grade school when that song came out. Actually, I think it just made a rerun, though, on some commercial or show. So we're going to talk about female intimacy, which is unfortunately not talked about enough. I mean, how many commercials, TV ads, social media ads do you see on ED? Right? A ton. Where's all the talk about female sexual dysfunctions and problems with female intimacy? We don't talk about it. We're actually censored from talking about it. I literally yesterday had a post taken down on TikTok, which I just started diving into because I just didn't want to deal with it, but I'm trying. And it got taken down because it was deemed inappropriate, even though their policy says it's okay to talk about health versions. Okay? And there's tons of other things out there. I had to fight it, like I do on all social media accounts, Facebook and Instagram, to keep it out there. And it was about health versions, right? I'm not talking about porn. I'm not talking about even sex toys or things like that, which why I can't if we talk about ED, but that's a whole other talk. But just saying it is a problem. We can't talk about it. It's very difficult. And a lot of us aren't comfortable talking about it, even though we're gynecology trained. And we absolutely should be. So when we do surgeries, and we do all these other therapies, why are we not talking about sex? So sexual wellness is critical and overlooked. Over 40% of women experience some form of dysfunction, and it's, of course, multifactorial. Hormonal, psychological, relationships, physical. I always tell my patients, I can help you with a lot of things, but I can't do a husbandectomy, so if you don't like your spouse, gotta go to another office. Okay? Lawyers down the street. But, you know, in 1999's study, in the American Medical Association study journal, 33% of women in the United States experience some form of dysfunction. That's nearly half. Right? That's a lot. And that's a lot of people we're not talking about. So hopefully after today you'll feel a little more comfortable with it and bring it up more with your patients. The other thing is, sexual well-being in women has been shown to decrease depression by nearly a third. Depression and anxiety by nearly a third. And it's been shown to increase our immune systems, believe it or not. So the endorphins, the dopamine, the serotonin, it matters. Okay? And not only does it do that, it's better intimacy with your relationships and forms better bonds. But FSD rates increase with age, and for obvious reasons we'll talk about a little bit, and we did talk about quite a bit earlier, particularly during the menopause transition. Pre-menopausal women, or about 24% of pre-menopausal women were found to have dysfunction, but it rises to close to 40% perimenopause and 45% post-menopausally. And that's even higher in countries where there's inequities between male and female sexuality, as you can imagine. What are the common issues? Number one is hypoactive sexual desire disorder tends to hit women, I'd say mostly over 40 in that perimenopause age. Arousal disorders, orgasmic dysfunctions, and the dyspareunia in GSM as we talked about earlier. So top causes, hypoactive sexual desire affects about 30% of all women in the United States, one in 10 women. Up to 12% of pre-menopausal women and then it rises. So what are underlying causes? Because we can't forget there can be some reasons for it other than menopause or don't like my partner. Hormonal and endocrine disorders, birth control pills. Most people don't realize the longer women are in birth control pills, it suppresses the normal axis for hormone production and decreases sexual drive. Thyroid disease, so I always screen my patients for thyroid disorders when they're coming in with these complaints. If they haven't, diabetes, PCOS certainly changes the testosterone and estradiol balance. And then hyperprolactinemia is one of the things I'll also test for, especially in my younger patients who are coming in, something to keep in mind. And then of course psychiatric. If they're depressed they don't want to have sex. So that's a nice cycle because no sex leads to more depression. Anxiety, same thing. PTSD of course. A lot of patients come in who've had prior sexual problems in the past or abusive relationships or abuse in general as children. And so I do have to go into those delicate topics and discuss that as a problem and therapy is often required. MS creates a lot of issues with sexual functioning. And Parkinson's. Pelvic and urogynecologic conditions, as we all know, can affect sexuality. A lot of it actually being more mental. A lot of women are afraid to have sex because they're afraid it's going to make it worse or they're not sure what it is or self-esteem issues, knowing that they have prolapse and they avoid it. Or even just obstruction. They can't. So lots of reasons there. And of course incontinence. Women are very embarrassed that they have stress incontinence. Some of them also have coital incontinence. And sometimes they can't orgasm without urinating. So then they're holding back. Chronic pelvic pain of course is another one. Did you guys know that orgasm and the pain pathway are the same pathway? And one affects the other. So if you're in pain it's harder to orgasm. And if you orgasm it helps pain. Kind of an interesting thing. Same pathway. Neurologically. Of course cardiovascular and metabolic conditions. So if you have atherosclerosis just like in men, it increases ED. It can decrease sexual response for women in blood flow. Hypertension, obesity, metabolic syndrome, all kind of going into that basket. And then of course cancer patients for a whole nother reason. They're getting aromatase inhibitors, decreasing their estrogen, and that's a whole world of change. Chemo and radiation effects. So those are probably your toughest patients to work with and to improve. And then medications. A ton of patients on SSRIs these days. And I can't tell you how many patients when I ask them, well when did your problem start? Five years ago. When did you start your antidepressant? Oh, about four or five years ago. So that's a big one and again a very difficult one to negate. Antipsychotics and antihypertensives can actually have an effect, which most people don't think about. And then of course psychological relationship stressors. Home stress, life stress. Stress does not equal good sexual function for men or women. So we talked a little bit about how to affect quality of life. It's huge. Decreased emotional well-being, relationship challenges, self-esteem, and it's under-reported due to stigmas or they're afraid to bring it up. If you don't have a welcoming atmosphere, if you don't have anything on your website about it, if you don't bring it up in your questionnaires when people come in, they're not going to want to talk to you about it because that's the cultural norm. Even men have trouble with it, even though it's all out there. I have a lot of patients whose husbands won't go see a urologist even though they have ED and now their spouses are upset about it. Their female spouse is seeing me and they can't convince them to go. So even with all the talk for men, even men are afraid to talk about it to their physicians. It's a really difficult thing to talk about and if people don't ask, I find if you're more proactive and ask about it, you'll get a lot more, yeah, I have a problem with that. The other thing that was interesting is you know that increased sexual activity, and it doesn't have to be a lot. Most studies are actually showing once a week it can boost immune system response. There's a lot of benefits beyond just emotional well-being. Where do we start? We've tested for those other things. You've ruled out they're not on the antidepressants or they don't have cancer or all these other obvious medical conditions. Well, why are they having the sexual dysfunction? We talked earlier about GSM and treating dryness, of course, because if they're dry and having pain, who wants to have sex? So certainly addressing the vagina and the vaginal estrogen or whatever approach you want to take there. Then what about systemic? When do women start noticing the difference? Perimenopause and menopause, and what's changing? Estrogen is dropping, progesterone is dropping, and testosterone has been dropping since the early 30s. I'm a fan of HRT. I do HRT routinely. I'm on it myself. I do everything. I live the dream. I teach what I do, and I do what I teach. It makes a difference. Having that balance is important. It's not just estrogen. It's not just progesterone. It's not just testosterone. It's all of it in balance. Off-label use of testosterone for hypoactive sexual dysfunction has been done for decades. There are actually 36 randomized controlled trials involving over 8,000 women that support it in increasing desire. Testosterone improves not only desire, but arousal, orgasm, and overall satisfaction in postmenopausal women, but you have to do it carefully. There has been no increase in adverse effects in cardiovascular health or breast health outcomes, and I'll show you in the next slide a little bit about that. But again, the balance dosing is necessary. Testosterone can't aromatize, so if you go too high on testosterone, the estrogen can go up. Same thing in men. I will actually do male pelleting for testosterone. We have to watch the estradiol levels in men. It can be problematic if you do not. Some men can't aromatize, especially if they have a high body fat content. Same thing with women. So as long as you have it in balance, it all works quite nicely. Testosterone non-oral, and most people don't realize this, has actually been shown to be breast cancer protective. By nearly 40%, it decreases breast cancer rates, and it does this because it restrains estrogen cell growth, it reduces inflammation in the breast, and it modulates receptor activity. Testosterone in general reduces inflammation in the body. It actually reduces your immunogenic response. My husband found this out in a funny study that came out a few years ago, and he thought it was great. He said, men don't have the same response to infections, which is why men get more infections. It's real. There's a lot of common cold, and men actually can get more severe infections. Did anybody remember during COVID men had a worse response than women? There's some truth to that. Estrogen is immunogenic. It actually increases your immune response to some degree, which is good and bad. That's again why we need the balance, because if you have too high an estrogen level, you're going to be immunogenic. High estrogen levels are actually why we think women have more autoimmune conditions than men. Testosterone stops it. If you have them in balance, things are good. That's female testosterone decline with age. By the age of 50, female testosterone is about 50% of what it was in their 30s. You can see it peaks around late teens, early 20s, and then just is a gradual decline. Now, it may never go to zero, although I have some patients that are. Some of my post-menopausal patients are at five. That's really common. I'd say five to 15 nanograms per deciliter. They're all symptomatic, but who's symptomatic at what level differs. It's not equal. I can have patients symptomatic at 30 just as much as at 5. You really have to go by the patient, and that's where it gets a little more difficult, because we can't go by a direct number. We just know it's lower than they were when they were happy and in their early 20s, and sex wasn't a problem. Tonight's forecast, especially with 100% of, no, not tonight. That's what my patients are coming and telling me about, and they're really upset about it. It's a real strain on their relationships. What's the only FDA-approved medicine out there or treatment? There's only one. There's one for women, Adge. I'm not personally a huge fan. It doesn't work that well. You have to take it every day. It has to be at bedtime. It's rebalancing serotonin and dopamine, so it's working centrally. It only shows a modest increase in sexually satisfying events, so maybe one a month, maybe, but the side effects are really the problem. It's dizziness, somnolence, and hypotension, and it really can't be taken with alcohol. That's sometimes a problem for some of my patients. They're not giving up that drink once or twice a week or maybe every night, so it's not perfect by any means, and it's the only FDA-approved drug, so hence why we have to talk about things outside the box because these women are out there in droves, and they want help. Let's talk about OSHOD. Not only is hypoactive a problem. They don't have the desire. Well, now they have the desire, but they can't respond. That's really common, and if you start asking, you'll hear about it, so it's much harder than it used to be. I hear that every day in my practice because I cater to these patients, so I hear it a lot, but this happens again, typically in that period of post-menopausal era. It just takes forever. I can't do it anymore, even with their own stimulation sometimes. This is a PRP, regenerative therapy, and it's injecting PRP, their own blood. You spin down the blood in special tubes that separate the platelet-rich plasma, so it's their own blood products that you then re-inject, so PRP's being used in tons of things. I get it into my knee at least once or twice a year. It's regenerative. It's actually been equivalent to gel treatment, so PRP is really helpful in lots of regenerative techniques. It was brought by Dr. Runnels and tried with the OSHA, and he came up with this interesting idea that it can improve arousal, lubrication, and orgasm by increasing neurogenesis and blood flow. We need studies. There's no large, randomized, controlled trials on this, so it'd be very hard to do a blinded one for sure, but it has promise, and there's a lot of data out there in general on PRP and regenerative technique. And then there's vaginal laser therapy. That's more for the dyspironia atrophy patients. It's not going to necessarily bring a lot for orgasm, but it can improve incontinence, some mild laxity, and the GSM. It can increase a bit of tissue perfusion, so you may get some more blood flow and neocologenesis, but this is more for your patients who are avoiding intercourse because of dyspironia. Radiofrequency may be different. Remember that one penetrates a bit deeper, so that heat-induced collagen remodeling can enhance lubrication and tightness and sexual function, and there's a few more studies on that one with sexual function to support although, again, evidence is still a bit limited, but we're going to see more and more of that hopefully coming up. What about shockwave and acoustic therapy? So shockwave is being used in male ED for a while, and basically the standard of care is the low intensity extracorporeal shockwave, which definitely has been shown to promote angiogenesis and blood flow, and think about what happens during sexual arousal, it's increased blood flow initially, so it can stimulate the blood flow and then enhance the nerve regeneration, and again all these things keep coming from ED because we know the clitoral area is basically the penis in the women during embryogenesis, so pilot studies have shown improvements in the SFFI scores, particularly in arousal and orgasm domains. Really hard thing to treat is arousal and orgasm, so that's pretty amazing. There's also soundwave, which is acoustic wave therapy, related but not quite the same as shockwave, claims to enhance clitoral sensitivity and response, but doesn't penetrate as deeply. Marketed as non-invasive and painless, whereas shockwave is a bit more stimulatory, a bit more uncomfortable, so no downtime with any of them. But again, we need some large-scale randomized trials. I know Gaines Wave is out there right now focusing on female now, which was just male, so they're starting to cross these things over into female sexual function, and it's just an external treatment essentially. If you see the clitoris, you realize it's not just the clitoral glands, it's the bulbs and vestibules as well, and so you're basically treating with a wand that entire area a couple times a week for a couple weeks. And then there's hyphen therapy, so high-intense focused electromagnetic therapy, that question came up a little bit earlier about that. Approved for incontinence by the FDA, but during those studies of which I was a part, we found it started improving sexual function. And it's because that electro, it's essentially like magnetic resonance or MRI type technology. It's bringing the blood flow. You actually can't put a woman on the chair when they're during their period. I mean, you can, but they're going to hemorrhage. So it brings so much more blood flow that their periods get very heavy. Or sometimes if they're close to their period, they can hemorrhage very easily. So that blood flow that it brings, and also the strengthening of the levator muscles can enhance orgasm intensity afterwards. So if those muscles are strong, that helps orgasm. So I always say that's a happy positive for my patients who are doing the chair for incontinence. I'm like, hey, let me know if your orgasms get better, because it can help. I actually have more men calling me now to have those therapies, because they're looking for alternatives for ED and for post-prostatectomy treatment for male incontinence, because there's not a lot of options that are non-surgical for them. So the benefits can persist up to six months. There is maintenance, of course. It's just like going to the gym with a trainer and then stopping. So they have to continue the treatments in some sort of maintenance phase, or do their Kegels on their own, which we all know nobody does. So I usually recommend they come in for maintenance. And that's where some of the questions lie. We don't really know what maintenance should be. And we're all trying to figure that out once a month, twice every three months. It depends on the patient and how great their muscles improved to begin with. I think the other thing that's difficult with some of these things like this is not everybody. You start with six treatments. That's twice a week for three weeks, is the standard protocol. Well, not everybody's starting at the same beginning, right? Beginning point. Whether it's for incontinence or sexual function, some people probably need more, and they're not going to get the same response in the six. So let's talk a little bit about vaginal laxity. So I get a lot of consults for vaginal laxity. And it's something that, for some reason, we don't really like to talk about in our field. But we should, because a lot of women complain about it. They don't necessarily have prolapse. But they come in, and they say, I don't feel the same since having my kids. And I really have very little sensation during intercourse. And what do you say to that? Some people just, oh, you're normal. It's fine. Everything looks fine. That's what a lot of them are told, unfortunately. And they're dismissed. So a lot of women don't necessarily have pathologic findings on your exam. And not every woman feels it the same after childbirth or maybe is in tune with it as much as others. And I see a wide degree. Some have severe laxity, and some have fairly mild laxity that I'm surprised sometimes that they're bothered when a lot of other patients in that same category may not be. But again, everybody's different. And some of them come in saying, well, I don't care as much about sex, but my husband's complaining. He actually talked to me about it. And the spouse is actually saying, hey, what can we do? Oftentimes, it's both of them. But sometimes, they're worried about how their spouse is feeling. So we have energy-based devices. And radiofrequency is more tightening, goes deeper, can help the tissues. That's going to help more the milder patients. I don't steer my severe patients into energy-based treatments, because they're not going to see as much of a difference, and they're not going to think it worked. When they're severe, changing their vaginal caliber a couple of millimeters doesn't make a difference. When they're severe, the only thing you can do is a surgical fix. And vaginoplasty is how you do that. So vaginoplasty is something that's been around for a while, too. We don't have a ton of studies, but there are certainly some prospective cohort studies that I have listed showing significant improvements in sexual function, with no increase in dyspareunia, which is what we always want to be careful of. Interestingly, there was a study last year that looked at the impact of vaginoplasty on women and their male partners. And they saw significant improvement in both. And that's not something we get to see very much. I don't get to ask the husbands very often how they feel about it. So that was a very cool study to read. But it also reduced anxiety in women. Women are very anxious and self-conscious about their bodies, right? Their whole body, but especially there. And if they feel like they're not satisfying not only themselves, but their spouses or their partners, they're anxious now. They're upset. They don't even want to do it. So sometimes they're avoiding sex because of that. So kind of interesting way to look at things. You have to be a bit open-minded when you're treating these issues. But those patients are generally very happy. What about pelvic floor dysfunction and vaginismus? So a lot of patients, another subset, are talking about painless sex. Maybe they've had a history of abuse. I often find that in some of those patients. Or maybe they're just high anxiety. They're IC. A lot of our IC patients have levator dysfunction and vaginismus. So first line has been pelvic floor therapy and biofeedback, which we do offer. Never can't hurt. And it's a good conservative way to start. Along with vaginal dilators, vaginal estrogen, if indicated, myofascial release techniques. So we will do kind of a massage myofascial release technique into the muscles and the connective tissues on vaginal exam during the biofeedback. The vaginal dilators we talked about. But they have to use them daily, at least daily, if not twice a day, and be religious about it. If those patients are kind of just playing with dilators, they're doing them here and there, it's not going to help. And if they're not going up in size, it doesn't help. And if they're using it like a sex toy, it's not going to help. It has to be inserted held with pressure for at least 10 minutes. It's not in and out. This isn't playtime. This is working the tissues. Now, playtime helps. If they are stretching the tissue sexually, it helps too. Oftentimes, we'll use vaginal suppositories that I get made from a local compounding company. So vaginal Valium or Baclofen or things to help relax the pelvic floor can be very helpful. And we'll often do that before therapy. So if they're really tense, I'll have them do it before they come in for their biofeedback and myofascial. And then trigger point injections. So I'll start with traditional steroid, lidocaine, or myocaine-type trigger injections, but not everybody responds well. Some people do, and some people don't. And often in the ones who don't or the ones who want it to last longer, we switch to Botox. Botox is not covered, unfortunately, for this indication. It's considered investigational still. But I definitely have seen patients do well, and you need to use a fairly high dose. 50 is not going to do it. We're talking 100 to up to 200. Cognitive behavioral therapy and psychosexual counseling, super important for the patients with PTSD, history of abuse. And even ones who maybe just high anxiety, just that mindfulness reduction. And then also getting out of their head. A lot of these women, any woman who's in her own head, or a man, is not going to do well with sexual activity. But these people, in particular, are really focused on it because they've had trouble. So they're having pain, or they're not responding, or they're worried about their spouse not enjoying it. Whatever it is, if they can't get that out of their head, they're never going to enjoy it. So pelvic floor physical therapy certainly treats the musculoskeletal contributions to pain and dysfunction, the myofascial release, and the neuromuscular reeducation, super important. And then strengthening the pelvic floor for the ones who you're able to, to improve tone and blood flow and increase response, and increase orgasmic and heighten orgasm potential. It's been shown to enhance the sexual functioning surely by increasing vaginal tone in those who need it and relaxing it in those who need it, and then reducing pain with intercourse, for sure. And then PT has been shown to improve orgasm mobility and frequency in women with vaginismus and vulvodynia. What about some other off-label therapies? So a lot of, and there's actually a company right now that just came about that's selling vaginal estradiol. OK? We met with a physician. It's one of these new telehealth things that are out there. But they're also selling basically what I call Scream Cream. That's what we always call it. We used to get it compounded. And they're just making their own form of it. I don't believe theirs has testosterone in it. I think it's all more of a compound. And I think it's all more kind of botanical and natural products. But compounded testosterone has been used for a while. And you can actually apply it clitorally. Now, if you go too overboard, you'll get clitoromegaly. So you have to be careful. And you have to let your patients know that. But it has been used off-label to enhance not only libido, especially systemically, and mucosal thickness, but also response of the clitoris for orgasm and sensitivity. Topical lidocaine we use in the opposite patients who are over-responsive or who have dyspareunia and vulvodynia. And of course, that doesn't last. But it can sometimes help just during intercourse itself. And then neuropathic pain agents, of course, if they're not responding to conservative treatments, such as gabapentin, amitriptyline, and the vaginal suppositories and the muscle relaxants. What about other regenerative therapies? So we talked a little bit about PRP. So that's injection into the vaginal wall, as well as the orgasm, Datto Limited. Exosomes are the new up-and-coming thing, but not approved for injection right now. Exosomes are still made from human products. They're usually coming from the Wharton's jelly or from adipose tissue. There are some plant-based exosomes now, too, as well as now lab-generated exosomes, which is where I think it's all going to go, because you don't have to worry about human compatibility issues or worries there. So eventually, I think we're going to see more of that happening. And PRP is only as good as you are. So if you're young, your PRP is excellent. If you're older, it's not. So if I'm dealing with a 60-year-old patient versus a 30-year-old patient, I have to think about that. And then stem cell therapy is not yet validated, but you can get products from your own adipose. And that's being done quite a bit out there, too, with fat grafting and so forth. Now, there's a bunch of nutraceuticals and supplements, like some of the things that company is putting in there, cream. But also, you can get at your local GNC. Maca root has been shown to enhance desire and mood. Genseng may improve arousal and energy. L-arginine is often in those products, because it's nitric oxide precursor and can cause vasodilation and increased blood flow. And I have never seen the other one, tribulus terrestris, more androgenic support, probably kind of like a DHEA. Fenugreek we've all seen in supplements before to increase sexual arousal, and saffron, actually. So if somebody's more interested in holistic approaches, these are things they consider. And then maybe some topicals, like the concocted creams with L-arginine. There's a lot of CBD-infused products out there now. I haven't had a lot of experience with those to speak to, but there's anecdotal reports that they can help, especially in the relaxation phase. So maybe patients who have the vaginismus issues, that might be a good option. And then topical DHEA is investigational right now, as far as sexual benefits. So the evidence really varies widely. We need more of it. The effects are generally modest, and often we don't have a lot of placebo-controlled trials, but we don't have many options, right? Well, literally the only thing out there that's approved is Adyei. That's it. So if those of us here don't start doing those studies or start using these things, we'll never know the answers fully. And most of them are low-risk things to try. We talked a little bit about these earlier, as far as treating GSEM and local conversion for DHEA to androgens and estrogens, as well as asphena. So again, more treating the dyspareunia and atrophy and lubrication side of things. And then hyaluronic acid. I actually just saw a study today that they were injecting hyaluronic acid into the vaginal wall and into the vestibule for atrophy. It's very cool. So things are on the uptick, as far as this field of medicine and what can help. And again, common brands like Good Clean Love, they have a lot of interesting products that seem to be friendly, and that patients do well with. And they have an hyaluronic acid as well. So we all hear about Reverie, but there's a lot of other ones, as I listed, out there, and that may be even cheaper or just as good. And most studies are showing HAs to be very comparable to estradiol. So a multimodal approach really works best, right? And that happens in so many aspects of our care. So oftentimes, we have to combine these outcomes. We have to combine, say, hormone therapy in a menopausal woman and PT, or PRP and laser, or RF, counseling, physical intervention. And these conversations take time. And unfortunately, that's tough when you're in a busy clinic, and patients can get very, it's an intimate moment with a patient that's hard to cut off when you start getting into some of these discussions, but it's super important, and the women really, really appreciate it. So we're gonna do a little case vignette. So this is a 42-year-old perimenopausal woman, low libido, and starting to have GSM complaints, no medical history of medications, pretty straightforward. So what are we gonna do for her? So maybe we'll try some vaginal estrogen. If she's not willing to do that, we might consider one of the radio frequency or laser procedures. And if she's 42 perimenopausal, she still has decent blood flow, decent nerve activity, I would hope. So I might consider a nose shot in her. Maybe pelvic PT or Imcella, okay? PT won't be covered unless she has incontinence, unfortunately, but Imcella, she could do, it's out of pocket. We're gonna strengthen the pelvic floor, increase her blood flow, give her good angiogenesis and nerve regeneration in the clitoral area, and keep her vagina healthy with vaginal estrogen. How about a 52-year-old menopausal woman, low libido, difficulty with orgasm, already on estrogen patch, relationship's fine. That's why I'd add testosterone therapy, and if they don't wanna do that, do DHEA. I might consider a O-shot, especially once I get her hormones regulated, and I might consider sound wave or shock wave therapy in that patient. So here's an interesting, and I just had this patient, which is why I put it on here. So this is about a 30-year-old patient with difficulty climaxing by herself or with a partner. She used to be able to climax without any difficulty, said she actually had a high sex drive and high sexual function compared to her friends, she thought, and she noticed this stopped right away after one week of being placed on an SSRI, one week. This was three years ago. She still can't climax. She is very frustrated and came to see me. So there is something called post-SSRI sexual dysfunction, and it can be long-lasting, not just short-term in patients. It can be irreversible, which is super sad. So the only treatment for her is off-label medications. So you can actually, believe it or not, it's kind of like the hair of the dog, right? We're gonna give her bupropion, of all things. Interesting. Or buspirone or low-dose riprapzol. You can do dopaminergic agents or oxytocin. Those are under investigation because what's happened is the SSRI has decreased her dopamine. It suppresses the dopaminergic axis. So by giving a dopaminergic or bupropion, which actually increases dopamine, it may help. And then of course, she's already done PT and all these other things. PRP injections, I wouldn't necessarily expect to improve her since it's central. But if she still has trouble, we may add that. So I'm thinking central on that, and that's where we're starting with her treatment. And there are defined cases like this. I was pretty interested to find some other case reports. So I thought that I'd bring that here because it was an unusual one. So key takeaways, sexual dysfunction's super common. It is complex, but it is treatable. And it's really rewarding when you do help some of these women. New technologies in regenerative therapies are offering more hope and options. But an individualized integrative care technique is essential. So thank you, and if you have any questions, happy to answer. Thank you. I have so many questions. First, can you tell us exactly where are you injecting for this O-shot? Like, where? Clitoris and anterior vaginal wall in the G-spot area, yeah. Like, across that whole, like? Pretty much. It floods right under, interestingly, it floods right under the bladder and can help stress incontinence and OAB. And then when you're doing Botox injections for pelvic floor, you mentioned higher dosages, 100 to 100. Are you saying in one spot or across all muscle groups? Yeah, across. I don't like to do less than 25 units in an individual injection, so that's about my goal. So I try to find all those trigger locations on exam and hit those areas. And last question, somewhere in Botox FDA world, like labeling world, says not to have more than 360 units in three months. Do you ever tow that line, or have you even? I honestly don't need to go over that usually, so it hasn't been an issue. So yes, I guess I do tow the line without really having to think about it. I won't repeat it sooner than three months anyway, and I don't go over that.

women's sexual health

female sexual dysfunction

hormonal changes

pelvic floor therapy

regenerative techniques

personalized treatment

relationship satisfaction