sexual dysfunction by Dr. Rachel Rubin. Dr. Rubin will present for 45 minutes and the last 15 minutes will be dedicated to Q&A. Dr. Rachel Rubin is a board certified urologist and sexual medicine specialist. She's an assistant clinical professor of urology at Georgetown University and works in private practice in Washington, DC. She's one of only a handful of physicians fellowship trained in male and female sexual medicine. Dr. Rubin is a clinician, researcher and vocal educator in the field of sexual medicine. She completed her medical and undergraduate training at Tufts University, her urology training at Georgetown University and her fellowship training under Dr. Erwin Goldstein in San Diego. In addition to be the educational chair for the International Society for the Study of Women's Sexual Health or ISWSH, she also serves as an associate editor for the Journal of Sexual Medicine Reviews. Before we begin, I'd like to review some housekeeping items. This webinar is being recorded and live streamed. Please use the Q&A feature of the Zoom webinar to ask any questions to our speaker. And if you're having any technical issues, use the chat feature as the AUG staff will be monitoring this and can assist. So take it away, Dr. Rubin. Hello, everybody. Oh my goodness, it is such an honor. This is like a big show for me. I want you to know that I am so honored to be here. I'm so thrilled to be here. I'm gonna share my screen. And Dr. Fock, can you just say thumbs up that you can see my screen in slide mode, the correct mode? Looks good. Woo-hoo, I did it. Technology is not an easy thing, nor is it easy to talk to the void of empty Zoom faces. So I wish I were seeing all of your faces. I am so humbled and honored to be here. And I will say it's a little bit intimidating because everything I have to teach you, you all do every day. You see these patients every single day and you do a great job at taking care of these patients. So from the bottom of my heart, I thank you for all that you do in sexual medicine. And so all I'm here to do is see, can I help with any tips and tricks? Can I help you feel more comfortable writing certain prescriptions or knowing the pros and cons of different things? I really don't believe I'm going to teach you anything new today. If I do, I'm happy to teach you more as we go. So my title today is really just Female Sexual Medicine for the Already Amazing Urogynecologist. My email is on there. All of my social media is on there. Please reach out and follow me so I can then follow you and tag you and get your voices out there and heard in the world because there needs to be way more of us and there's just not enough people around. So I'm going to start again by saying, we must never forget the severe consequences of sexual medicine. And many of you have seen me post this slide before, but it's a little different. And this was my kids at the beginning of pandemic when everything shut down. And I tried to send them back on Amazon to Jeff Bezos, which he would not accept, unfortunately. And this is them close to today. And it's crazy. So all of you who have children or are working during this crazy pandemic, just thank you. The fact that you're even on a webinar tonight or listening to this after the fact, you are amazing in everything that you do and you should be applauded. So really just thank you. Also, please go to the chat and ask questions. I like interaction. Tell me where you're from, who you are, say hello. As I said, speaking to an empty computer screen is not so easy, but I'm trying really hard to get better at it. These are my disclosures. My big disclosure is that I love the organization ISWSH, the International Society for the Study of Women's Sexual Health. All of you should be members of ISWSH. We need you. We need surgeons. We need urogynecologists. We need scientists. We need everyone who gives a crap about women to really care about women's sexual health. And so if you've never been to an ISWSH course or conference, please send your, it's free for your residents, for your trainees, for your medical students. Please consider coming to a course or a meeting. It will blow your mind. It's an amazingly positive and motivating group of people. I'm actually, I just recorded a lecture a couple of days ago for a men's health conference. And I'm invited, this is the second year I was invited to give a 15 minute lecture of women's sexual health for the men's health specialist, okay? So 15 minutes of a three-day conference, all about erections. And they give me 15 minutes to talk about the partner. And it got me really thinking about men's health and women's health and what do those really mean? And so when I did a quick Google search into men's health fellowships, my friend Matt Coward's andrology fellowship shows up and it says that it focuses on urologic microsurgery, male infertility, Peyronie's disease, erectile dysfunction, male sexual function, difficult penile prosthesis, urethral strictures, fistulas, and a comprehensive men's health evaluation. Okay, so men's health means sex, right? Penis, erections, all of those things, maybe some urination. And then when you type in women's health fellowships, right, ACOG comes up and I will tell you, I looked very carefully. There is not a single mention of the word sex. There's a lot of innuendo, so no real mention of the word sex. And the second thing that comes up is the Cleveland Clinic Specialized Women's Health Fellowship for Internists, which does a lot of things. Bones, they do urogynecology clinics, special gynecology clinics, psychiatry, cardiology, sportsmen, orthopedic, endocrine, breast, and menopause clinic. So again, like women's health means the whole woman, men's health means penis. And so we have a little bit of a problem of who's responsible for taking care of women's sexual health. But for men's sexual health, we actually have really good outcomes. I didn't post them here, but we have really good health outcomes that single men, divorced men, and widowed men have horrible health outcomes compared to married men. Okay, and so it kind of gets you thinking that if you really wanna be a really good men's health specialist, and I know y'all are not men's health specialists, but to me, it seems like we should invest in women's healthcare, right? Because if we keep female partners alive, potentially we could keep men alive and healthier a lot longer. So when do people typically get divorced? Well, between 40 and 60. Hmm, what's happening between 40 and 60? Menopause, right? And so who is taking care of these menopausal women? Who is actively managing women's sexual health concerns and the answer is not that many people. And so, you know, as urologists, we are very used to feeling bad for people who are on androgen deprivation therapy. So you take away a man's testosterone, he gets low libido, erectile dysfunction, hot flashes, osteoporosis, cardiovascular disease, diabetes, body habitus changes. We feel terrible for these guys. Well, this is every woman over 50, right? And so, and we know that when they are asked that literally only, you know, 6.8% of trainees in gynecology and internal medicine and family medicine do not feel adequately prepared to manage women in menopause. And so menopause is more than just gynecologic care or urogynecologic care, but it's everything, right? It's cardiovascular disease and hair and skin and nails and bones and bladder. And yet there aren't that many people who are doing this really important work. And when it comes to sexual health, we know that early in menopause, sexual dysfunction is incredibly common. Well, as soon as you're eight years through, you know, it's 88%, it's the norm. So I wanna do a quick poll. Maybe you guys can say yes or no in the chat. Do I routinely prescribe systemic hormone therapy in my practice? Come on, let's see some honest answers here. I'm watching, I'm looking at the chat. I've got a lot of nopes. Yeses, yes, yes, no, no. Oh my gosh, thank you all for answering. It's so nice when people interact. Routine sometimes, yes, no, no. Oh, Meredith Wasserman is here. I love you, Dr. W. Yes, yes, no. Okay, so the answer is it's not, if you are doing it, you got some special training that was not universal to all gynecologists or all urogynecologists, for example. And I think that's a little bit of a problem. I think we need to be better at really taking care because there are so many things that systemic hormones can help with and who better to truly understand that than someone in the women's health sort of world. And the problem with sexual medicine is this is who's teaching people sex, right? I remember, I remember my middle school teacher who taught it to me. Funny enough, the only word I remember from that class is the word smegma. And even funnier is I'm actually going to give a sexual health lecture to my middle school and high school next week, which is gonna be kind of fun. And it's always the hardest audience because no one ever laughs and these awkward teenagers are really uncomfortable, but I still get asked every year to do it. So if it's not the middle school sex ed teacher, then really this becomes our premier sex educator in the world is the wonderful Gwyneth Paltrow, who if all of you aren't making vomit emojis, it's a problem, right? She is peddling snake oil and people are paying billions of dollars to take her snake oil because there is no alternative. Nobody is out there giving good evidence-based healthcare. And we have a lot of evidence around women's sexual health, but nobody cares enough to do it. And so, listen, we have to get more comfortable with the biopsychosocial approach to women's sexual healthcare. I'm a urologist. I deal in the biology of men's sexual health all day, every day. It's blood flow, it's nerve, it's muscle, it's testosterone. Men's sexual health is biological. We as a society have decided women's sexual health is all psychosocial, all of it. And the answer is that's ridiculous, right? They are both biopsychosocial. It is women, we need way more research and way more things to the women's biology, but we also need a lot more psychosocial on the male side. I was at the VA today and I did a lot of come to Jesus talk therapy sessions with these guys of really getting them to change their mindsets around sex and what does it mean? This is what a vibrator is and this is why you need one because of your diabetes. And it's important. It's important to do that psychosocial education. Now, of course, none of you have time to do this. Medicine is so broken and I ache in thinking about what you can accomplish in a 20 minute visit and you are all surgeons. And so the question really is, who does this? Who is responsible for the medical management of women's sexual healthcare? And the answer is no one wants it. Everyone just loves to say not it, not it, and it's just so sad because there is, you see these patients every single day in your clinic. You all probably saw 30 of them today in your clinic, which again, don't know how you see so many patients, but they all really need you. And so my big push is getting people to understand the biology behind women's sexual health and to understand that, yes, the psychosocial stuff is important. I'm not discounting that in the least, but we must get comfortable understanding the biological basis for women's sexual health. And so when I see patients in my clinic, this is no different than any gender of my patients, whether any gender is gonna come in with issues of desire, issues of arousal, issues of orgasm and issues surrounding pain. And there's a lot of overlap, but you can really understand the biological basis of all of these things. And it's pretty common, right? This is about 40% of people have low desire, only about 10% are bothered by it, but mostly because no doctor has ever asked them about it and most people don't think there's any medical solutions. Arousal problems about 25%, 21% of women have orgasm problems, 43% of all, half of women all have sexual problems. It's probably much higher than that, but this is the preside study. And I've seen data said so much as like 75% of women have pain with sex at some point. And so we must get better at managing these issues with patients. And one thing that I think is really helpful, and this is how I do it in my clinic. And I think it's a little bit of a paradigm shift in I break it down in my head when I see someone with a medical problem. So any problem I think can be solved by this picture. And what I mean by that is when someone comes with a complaint, I take a moment, you really listen to their story and then you break it down in your mind and you say, okay, where is the problem? Is this a problem that I can see, that I can touch, that I can recreate on physical exam in the genitals? Is there a weird nerve distribution going on with this exam, with this story? Is there pain in the back of their legs? Is there sciatica? Is there something else going on that could be coming from the nerves in the spine? Or is this all in the brain? And the brain is not all psychosocial. I mean, the brain has a lot of things with dopamine and different medications and all sorts of interactions for things. And so really breaking it down, I believe I'm a big believer that even psychosocial issues have a biological basis in the brain, but really letting patients understand and hear their stories and kind of break it down of where are these issues? And of course, many patients can have multiple issues. So if we break it down into libido, orgasm, arousal and pain, let me just give you kind of a little overview of the kinds of things that we do in sexual medicine and the kinds of tools that you have for your toolbox in your really, really busy urogynecology practices. So libido is actually my least favorite topic typically to talk about. Why? I'm a surgeon. I'm a urologist. I care about genitals. What am I gonna deal with libido and brain? It's all psychosocial stuff. And then I kind of had an aha moment, I'll be honest. And of course it was my mentor, Erwin Goldstein, who always gives me these aha moments, but he got in front of a lecture at ISWISH and he said, it's not magic, it's network, right? It's not magic, it's network. And then proceeded to really explain the neurobiological basis for desire. And it's pretty simple. And sort of my brain was like, oh, well, we all agree that antidepressants can cause sexual problems, right? I saw like three guys in clinic today who took their antidepressant and had delayed orgasm, decreased libido and erectile dysfunction. So we all can agree that antidepressants can cause sexual problems. Many of you have used bupropion as a medication to try to boost sexual function or have seen patients on a medication like BuSpar or bupropion or some of the newer SSRIs that have fewer sexual side effects. So if we believe that there is a medication that hurts sexual function, could there be a medication or medications that boost sexual function? And the answer is, of course there are, of course there can be, of course there are. And we do have two FDA approved options in addition to those off-label medications that I just mentioned. And desire is an interesting one. Yeah, it's complicated. Some women have innate desire where they say, oh my gosh, I'm interested in sex. Many of our patients do. And many of our patients identify as having more responsive desire. Ooh, that Bridgerton episode, season two is coming out. I didn't watch season one, I'm sorry, but season two is about to come out. I just saw a headline. Ooh, I'm watching that Bridgerton episode. Ooh, I'm kind of in the mood right now. Or my partner initiates. Ooh, I can get into this. This sounds pretty good. So that's kind of that responsive desire. And when you do big studies on those two things, some women have responsive desire, some women have innate desire. And guess what? Some women, most women actually say, none of those things define me. It's kind of all of them. Sometimes I'm one way, sometimes I'm the other way. And so we also know that around mid cycle when ovulation is happening, there's a boost of testosterone, which improves libido. And so testosterone is important for women's sexual health. Actually, that's going to be probably my thesis statement tonight is, testosterone is important for women's sexual health. And I'm gonna present some interesting slides on the importance of bladder, urethra, and vestibule health as well. But testosterone is really important for the brain. As a men's health doctor, men's health, right? I prescribe tons of testosterone for guys. And what does it do? It helps. It helps with desire and it helps with arousal when there is low testosterone in the setting. Is it the fountain of youth? Is it the greatest thing in the world that cures everything? No, of course not. But does it help? Absolutely. Do women need testosterone? Absolutely they do. And we just need to get more comfortable prescribing and talking about it and doing it in evidence-based ways. Now the problem, and this is why, what keeps me up is we need more, we have no FDA approved options for testosterone for women. So women go to snake oil, they go to pellet clinics, they go to shock clinics, men do too. And we have the Gwyneth Paltrow's of the world sort of leading the charge when there is good evidence-based strategies to give women a testosterone back and to do so in safe physiologic levels. But I use this slide all the time for both all gendered patients where you've got dopamine here. And if you can boost dopamine, you can improve desire and arousal. And we do this from a number of different areas. So serotonin, many of our SSRIs are negative to this. We know melanocortins, which we'll talk about, there's one medication that acts on melanocortin receptors. We know that we have medications that act on serotonin receptors. We know systemic hormone therapy, estrogen, progesterone, and testosterone can help with this as well. And so we use this diagram to really help us boost sexual function in our patients. And holy crap, people, it works, it really works. Just follow me on Instagram and see the testimonials that we get when we use FDA approved evidence-based products. And so this is brain chemistry. When you show a healthy person who doesn't identify as having HSDD or hypoactive sexual desire disorder, her brain lights up in a certain way. And when you show that same sexy movie to someone who has HSDD, her brain does not light up the same way. And so there is a biological basis for low desire. So think depression, right? Depression in the 1980s, what did we tell people? Pick yourself up by your bootstraps. You've got this, just get out of bed. Just kind of work harder, and you can get out of your depression. And then antidepressants came out, and no, there can't be a pill that works for depression. All the psychologists said, no, they're gonna take us out of a job. This doesn't work. But what happened? We still need the psychologists. We still need the medications. And like synergy, they work better together. So I believe HSDD is sort of having its depression in the 1980s moment, where people are very angry about the idea that there are medications to boost sexual function. And so they focus on the psychosocial because that's what feels comfortable and what they know. But we have data, really good data, and clinically speaking, these medications work when they work. Not all antidepressants work for everybody, but if you can get 50 to 60% of your patients having improvement in their libido, they are very happy patients, and they write very nice testimonials for Instagram. And so we have guidelines, we have processes of care, which are really helpful. So if you have people in your practice who like recipes. They like to kind of look at things in disguise. These things are wonderful when you're teaching residents and medical students. ISWSH, the International Society for the Study of Women's Sexual Health, came out with a process of care and dealing with HSDD. And it takes you kind of step-by-step of this is how we manage women with low desire. And it's a very biopsychosocial-based approach. Listen, there are many women on this call tonight. Has a doctor ever asked you about your libido? Has a doctor ever asked you if you could have an orgasm? No one's ever asked me, and most of my doctors know what I do for a living. And so if no one's asking me, I should be the most comfortable, right? Okay, someone put in the chat. They've never been asked, right? Has any, what would it feel like for you to be in a doctor's appointment? For a doctor to ask you pleasure-based questions in the sense of, you know, it's not just all about pain. It's not just all you have to come to me with a complaint. But what if you ask open-ended questions about sexual health, you know? And it could take two seconds. Any concerns about your libido? Any concerns about your orgasm? Any concerns with pain? And boom, if they say no, they say no. But if they say yes, you will be the only provider who's probably ever asked them. And so really, it doesn't take long, and it really can change lives. So here's the things that we use. So therapy works great, right? If you can boost dopamine, you know, it's funny. No, but younger generations are not having sex anymore. We're actually in a big sex recession, and there's a very cool book that's being written about it right now. And the reason, there's a lot of reasons behind it. Some of them good, like young people are not having bad sex anymore, so they're having no sex. Other than are bad, right? They're getting all their dopamine likes from Instagram and social media and Snapchat, and so they're not having any sex anymore. But this idea that dopamine, you can boost dopamine a lot of ways in your brain, right? And so how do we get the midbrain, the middle of the brain, that lizard part of your brain really boosted, and how do we calm down your PFC, your prefrontal cortex? I know all of you right now, or half of you are working on your Epic inboxes, and half of you are emailing with patients, and most of you are not listening to what I have to say, because your PFC, your prefrontal cortex is always going, and it's really hard to calm it down and turn it off. But we know these things work. So testosterone works. We have two FDA-approved medications. One's called bremelanotide, one is called flobanserin. They work in, one's on melanocortin receptors, the other works on serotonin receptors to boost dopamine in the brain. Then we have off-label things like buspirone and bupropion, which have been used for years to improve sexual health. Although I just saw a study published on Buspar that did not help breast cancer patients with their FSFI scores, but that doesn't mean it hasn't worked for other people in the past. Hormone therapy works. So for all of you who don't prescribe systemic hormone therapy, it's not hard to do. I'm a urologist, and I learned how to do it, and it is the most pleasurable thing I do in my practice, because I take miserable early 50-year-old women who are so unhappy. I had one yesterday who said, Dr. Rubin, I didn't know how badly I felt. My, I wasn't sleeping. My joints felt horrible. I had no interest. I never thought I would have sex again. Like, unbelievable, these testimonials that you get. And I didn't do anything hard. I put a fem ring in her. She gets progesterone at night. She uses a tiny bit of FDA-approved topical testosterone, and that is all I did for, and I think she's on flubanserin, and that is all I did for that patient, and I changed her whole life. She's having comfortable, pain-free sex. She is like, her husband actually emailed me and said, hey, can, do you know anyone who does this for men? Because I can't keep up with my wife anymore, and you've changed our lives. And I was like, I do, I help men. And that was kind of funny, because I'm a urologist, right? I routinely, primarily treat men. So we know that systemic hormone therapy improves sexual function. So the KEEP study that came out, it shows that it matters what type of hormones you use. So oral synthetic hormones, like birth control pills, don't help sexual function the same way a transdermal product, so a patch, or a ring, or something that, or a gel that is estradiol. And the reason is, or we think the reason is, is that SHBG. So when you take an oral pill like birth control, it boosts sex hormone-binding globulin in the liver, which binds to all your testosterone, and it kind of eats it up so it doesn't keep sexual function as good. And I see this clinically. I have a patient, they'll come in, they'll on oral estrogen, I'll say, let's just tweak things around a little bit. Boom, they do great. And they really do notice a difference. So really encourage you to consider learning how to do a routine systemic hormone therapy. We all think of this picture a lot, right? Men have tons of testosterone. Women have only a tiny bit of testosterone. But really, we're speaking the wrong language. So when we talk about estrogen, we're of course talking picograms per milliliter. And when we're talking testosterone, we're talking nanograms per deciliter. So we're all talking the wrong units. And so actually, when you really look at it, women have way more androgens and testosterone in their body than they do estrogen, right? If we put everything in picograms per milliliter, we have way more androgens, but we don't routinely talk about androgens in women. Does that mean they don't exist and they're not important? No, it doesn't mean that at all. There was an amazing paper that was put out in 2019, which all these societies, the endocrine society, the menopause society, all these societies got together, and they put out a global position statement on the use of testosterone therapy in women. And what's fascinating about it is it reads just like the male testosterone guidelines. It works, okay? It works a little bit. It works when you do it for the people who need it in physiologic levels. And we just don't have FDA approved products for women. The first author, Susan Davis, she's in Australia, and there is approved testosterone use in Australia. And so it's really one of the only countries that has it available. And so ISWSH put this together. Again, these are all free open access papers that you can go find on the ISWSH website, but this is a guide, a literal recipe of how to prescribe testosterone therapy for your female patients. It is a step-by-step guide. I'm gonna take a quick break. There's a question. It says, I missed what you said. Did you say patients using the birth control patch have less sexual side effects than the pill? Ooh, it's a great question. I think the patch may also affect SHBG. I would have to get back on that data, but we typically see birth control patches also causing problems with vestibulodynia and some testosterone issues. So the only birth control that I tend to tell patients that I love is IUDs. The Nexplanon seems to be okay. And we can certainly answer questions about that. I'll talk a little bit more about my thoughts on birth control. Great for preventing babies, but birth control during a pandemic, as you know, is of utmost importance. So I love birth control, but I also know that there can be sexual side effects, just like there are sexual side effects for antidepressants. I still love antidepressants when they're needed. Birth control is very similar. So I encourage you to look at, and it's a great question, look at this testosterone paper. It's a really step-by-step guide. And so I'm not gonna go over all of the summary and key findings, but I'll put the slide up there for you to look at later. But really, testosterone in women is not scary. There are no major risks. There are no major problems. Maybe a little oily skin and acne, if you dose it correctly, if you do, we give super physiologic testosterone to our transgender men all the time. And yes, you can get cleromegaly and voice changes, and that's a wanted thing in those patients. But when you're using 110th a dose, you're not gonna have those same findings for your post-menopausal women. And so this is how I do it. I prescribe a generic testosterone 1% gel for my female patients. I give them a 30-day supply for a man, because a man would put this tube on his chest every single day, the whole tube. And my female patients, they make it last for 10 days. So they take a little pea size on their calf and they make this tube last for 10 days. And if they go to CVS and they type it into GoodRx, they get a coupon for $140, which is a 10-month supply of testosterone. So for $14 a month, you can't find a compounding pharmacy that does it better. So you can use FDA-approved products that are regulated. Yes, they're regulated for men, but they are regulated and they have been studied in women at length and it's approved in Australia. So if it's good enough for the Australian government, I think it's good enough for us. Now, this 1% testosterone does come in a little packet, like a ketchup packet. I don't know about you, hard to make ketchup packet last 10 days. So I tend to write on my prescription tubes only, and I tell the patients to really look in that box and crack it open before you get it home, because a lot of my patients, they end up with two ketchup packets and it's no fun, no bueno. All right, so non-hormonal ways of, I know we're taking a long time with HSDD since I said I hate HSDD, but it's actually changed my practice for the better and it works and patients are so happy and it's really fun to see it happen. Gosh, I had a patient who we put on flobanserin and it takes about two months to kick in. So I say, okay, we'll talk in two months. And I did a Zoom call with her. And it's funny, because I was on this computer in this exact room doing a virtual Zoom call with her. And she just sat there and she had like a light in her face that I just hadn't seen before. And she said, oh my God, Dr. Rubin, I'm not averse to sex anymore. I said, what do you mean? She said, you've been telling me to do sex therapy for years. And she said, and I never saw the path forward. I never saw that it would work. And she said, I took this medication and in two months she thought, she said, I'm at work and I just have sexual thoughts. She said, I all of a sudden understand like I'm excited for my partner to come home. And she's like, it was just like, again, these life-changing stories that can happen with these medications. Do they work in everybody? No, but in 50 to 60% of patients they do. And there are really few side effects. And so the real question is what do you have to lose? I always tell patients, well, what if it works? Because the side effects, these drugs have been out for a while. Nobody died, nobody's gone to the hospital. Hell, I prescribed Viagra. People go blind, people have heart attacks, all sorts of things happen with Viagra. Y'all do really scary things in your clinical practices and really scary surgeries and amazing things that you do. These medications are not scary and they don't hurt people. And when they work, they work really well. So the first one is the newer one is called Bremelanotide. It acts on melanocortin-4 receptors. It's an auto-injector. So it's more of the, you use it when you want to want. So say I'm doing date night and I really am gonna need a hit of dopamine. You give yourself a little injection. It's not painful in your thigh or in your belly. And I will tell you, when you present it to women, they will, women who truly have HSDD and just want to want, they'll do anything. They'll do pills, they'll do injections. They really just want, I mean, think about it. They buy all the snake oil on the internet that Gwyneth tells them to buy. They, so they are on all these supplements. They read all these books. They buy all these things and they just want to feel excitement. And this has been FDA approved to show that it improves not just a desire, but it improves orgasm, lubrication, and arousal because it's more than just these desire drugs. And we do see this in clinical practice. In fact, it works on my male patients as well for orgasm, for erections. And it's being studied more and more in the male population. And so again, biological basis of desire, it's a real thing. Now, flibanserin, which was the first one to the market at the FDA, it's a partial serotonin agonist antagonist in the way that it works. And so basically, again, the idea is it boosts dopamine in the brain. Now, this is a pill you take every night at bedtime. And so it's really a nightstand medication. I will, I won't lie. I actually have patients who don't necessarily notice the libido effects, but get the best night's sleep ever. And they get off their melatonin, they get off their trazodone, they get off their Ambien and they're just sleeping great. And they feel well-rested the next day. The FDA made them do a driving study. They said, oh my God, moms are driving carpool. They can't be sleepy because they took a sex drug. And so they did a driving study and women on the drug were better drivers than the women on the placebo, which is a little bit funny and pathetic and sad and misogynistic, but anyway. So I like the sedating side effects of this medication. And I use that actually as a selling point for many of my patients. When you respond to this drug, remember I said it's about a 40 to 60% response rate. You really get an increase in sexual satisfying events, an increase in desire and a decrease in distress. And what I will say is I don't really love the idea of sexual satisfying events because I have patients who are already having a lot of sex, but it's mercy sex or duty sex. They don't really want to be having it. And when they're responders that they have more interest on their own, they have more, it's not about their partner getting it in more. That is not kind of my goal here. It's really to improve their desire and decrease distress. And in two to three months, you actually do see these clinical changes. With the injection, you see it right away. And these drugs are no different than the antidepressants that these women are getting prescribed over and over and over again. They're the exact same side effect profile because they all work on the CNS. So again, happy to answer questions. I know the reason I spent so much time on this is because this is not a part of your clinical care pathways but it doesn't take long to have these conversations with patients. And it is amazing when they work and when your patients get benefits from it. So in terms of arousal and orgasm, we'll shift gears just a little bit. We all know, nobody knows better than you and I that we have a severe gender pay gap in this country, right? We get paid so much less than our male counterparts. It's total bullshit. You get paid less for the surgeries that you do when you compare it to the urology surgeries that we do. And it is total ridiculous. In fact, I left my practice, I just started my own medical practice because I'm just tired of dealing with all of this and I just want to do it my own way. And so we don't just have a pay gap in this country but we have an orgasm gap in this country. It's serious, right? So for every orgasm a heterosexual man has in a sexual encounter, a woman has 66% the number of orgasms, 65 here, 65% the number of orgasms. So it's a little better when you are a woman who has sex with other women or a bisexual woman and obviously on the male side as well. But women can have multiple orgasms and yet they are having 66% the number of orgasms as men is having. That is insanity, right? That is insanity. And so I believe if we can fix the orgasm gap, we can fix the pay gap because if women don't value their own pleasure and they don't value their own orgasm, their orgasm is not as important as their partner's orgasm, we have a problem here, right? Big problem. And I believe education is one of the tools to fix this problem because it's all about education. If we let society keep telling us that women orgasm from penetration, we're in trouble, right? If we let society keep telling us that women have to finish within the time that it takes a man to have an orgasm, we have a problem. The late Marcel Waldinger did a paper where he gave every man in the world a stopwatch and he determined that the average time man enters vagina, clicks on, clicks off when he orgasms is five and a half minutes, okay? Five and a half minutes. In the U.S. it's about seven minutes. USA, I know this is a American organization, but that's it, it's about five and a half minutes. Well, the same study was repeated for women in 2019 in the journal or 2020 in the Journal of Sexual Medicine. And it was 13 and a half minutes for a woman to have an orgasm. 17% of the people asked never had an orgasm in their life. And of course, as all of us know, penetration was not sufficient to reach orgasm in the majority. And so we have a timing issue, right? If we all, the word foreplay is ridiculous. Why is there a word foreplay? It should all just be called sex. And so the way we think about sex is so broken and backwards. And women are not orgasming and having any pleasure because they are taught that their pleasure is not valuable, that it doesn't matter. And so we know from Debbie Herbenik's data that less than 18% of women even orgasm from penetration. And I spend a lot of time teaching men why, and it's because of anatomy, hello, anatomy. The penis and the clitoris are exactly the same thing. They are totally the same in every way. And so I tell my male patients, I said, well, let's rub, why don't you rub the inside of your leg over and over again for five and a half minutes? Are you gonna have an orgasm? And he's like, no, no, Ruben, what are you crazy? I said, no, but really pound the inside of your leg for 10 minutes, like go crazy, go 10 minutes. Are you gonna orgasm? No, I said, why not? Well, it's not my penis, Dr. Ruben. I said, no shit, it's not your penis. I said, okay, how about a vagina, a penis going into a vagina over and over again? Is she gonna have an orgasm? No, why not? Because it's not her clitoris. It's not the part of the erectile tissue that sort of stimulates orgasm. Now there are women who can experience orgasm and they should be, they are unicorns and incredible women and it should be supported and everyone should be after more pleasure. And you can, this is the problem because when you do all of your slings and your repairs and your prolapse repairs and hysterectomies and all of those things is most women are fine with orgasm because most women orgasm from clitoral stimulation and it's their pudendal nerve that helps them orgasm. But you will find a percentage of women, it's small, but it's there who enjoy anterior vaginal wall stimulation, who enjoy their cervical orgasm or their uterine orgasm. And I beg you, I'm not saying don't do your surgeries, keep doing your surgeries because we know that it helps sexual function, but ask, ask how they orgasm, ask how they enjoy anterior vaginal wall stimulation, ask them that question because if you get that one in 10 patient who really likes her G-spot, right? And you put a sling in there, you may hurt it and you don't want that patient. You don't want that. If your patient still wants the sling, but you warned her about it, she's a lot happier than if you didn't warn her about it. So I am a big believer in devices. There's a great paper by my friend, Susan Kellogg, where it was in the Green Journal, I believe. And it's all about how to counsel people on devices. Sexual devices are, in my opinion, medicine and we need to start promoting them in our practices really, really vigorously because penises like vibrators, clitorises like vibrators, everybody likes vibrators and devices and so much more pleasure can be had. It's good for the pelvic. There's a paper coming out, hopefully, showing that it improves pelvic floor health and continence. Like, oh wait, I'm sure there's tons of indications where vibrators are helpful. And I think we definitely need to expand the literature on that. So I literally will, let's see, I think I have a little thing here. This is a website. This is what I need for my men's health talk. Everyone does a premature ejaculation spray. Well, we lobbied to them to put devices on their website and now they have devices for all couples. I'm certainly not promoting this website in particular, but again, there are so many websites that talk about devices. So back to orgasm, right? We've got an orgasm gap. Women aren't orgasming as much. It's an education problem, but sometimes it's like a physical problem, like a functional problem. And we know that about 23% of all women have some degree of clitoral adhesions and clitoral thymosis. This hurts, right? This is painful. Smegma gets stuck under here. They get balanitis, they get irritation, and this is a penis when it gets it. Also, these guys come running in for topical therapy or surgical therapy. And so we did a pilot study where we asked, so we often will give women the option of having an office-based lysis of adhesion procedure, where we stretch open their clitoral hood so that they can then heal from it and then access their clitoris, because here now it's all internal. And so we knew the incidence was 23%, but there is no data. The data starts and stops at that point. And so we said, okay, what happens when you actually fix it? So we did a pilot study where we sent it to about 60 women who had this procedure. 76% of these women reported improvement in their pain. We got about 40 patients responding. 71% of women reported improvement in satisfaction with sex. These were women who reported pain. 63% of women reported improvement in sexual arousal. No participant reported any worsening of their sexual pain or sexual arousal. 64% of women reported improvement in their ability to achieve orgasm. Nobody got worse. And this is my favorite data point here, and I'm excited to present this at the upcoming ISWISH meeting, is 16 participants said that they were unable to orgasm from clitoral stimulation before the procedure. And six of those women were able to after the procedure. That was a show. As soon as the medical students presented that to me, I died a million deaths. That is amazing, right? So this may be something that we do need to add to our clinical practice. I know I only have a few minutes left because I do want to answer questions, but sexual pain is something y'all see and do every single day. And again, I really want you to understand that it's all about the vulva. It's all about the hormonal aspects and the pelvic floor. And we have to get comfortable to say that this is actually also an androgen problem. So it's not just an estrogen problem, but an androgen problem. So the vestibule is endodermal tissue. So it's, it's made of endoderms, similar to bladder tissue, urethra tissue, which is different than the mesoderm of the vagina or the ectoderm of the skin. There are animal studies that are basically helping us see that the androgenic activity may be more nerve and density issues, the vaginal wall contractility, collagen compactness, think about it, muscle. You got Arnold Schwarzenegger, right? Testosterone is good for muscle health. And the estrogen that's obviously we know super helpful for the vaginal pH and the epithelium and for treating GSM. And so this is where thinking more than just estrogen for your patients may be helpful. These are biopsy studies of the vagina and that vestibule tissue that shows that it's rich in androgen receptors. And so there are so many androgen receptors in this tissue. And as we said before, women have way more androgens in their body when you put it all in picograms per milliliter, then they do estrogen. And so ISWSH, I know I'm talking a lot about ISWSH tonight, really did a nice review of the importance of androgens when we are treating a GSM. And for anyone who's heard me talk knows GSM is my favorite topic. And this is something you all do every day. I'm not going to teach you how to prescribe vaginal estrogen, I promise. But as, but, but the key is don't just do the sling and the prolapse surgery and not see the patient back. Make sure the patient understands that vaginal hormone therapy is for life because your sling will erode, your prolapse repair will, you know, your mesh will erode if that tissue is not strong and healthy. So that's the biggest mistake I ever see your gynecologist make. And it's not your fault. You probably told her, but she no longer comes to see you. She goes to her gynecologist. She now says, well, this is expensive. Why should I refill it? And I think it's an education problem. And so this is the picture I want burned into everyone's brain about genitourinary syndrome of menopause is we can fix the vulva on the right. It doesn't have to be that way. And of course the amazing AUA and Sufu and everybody came together and did a UTI guideline. That said, we should be giving vaginal estrogen to prevent urinary tract infections. So I will probably get tomatoes thrown at me by all of you, but I'm a believer that a dab of estrogen cream on the urethra is not enough. It's not enough to acidify the vagina. It's not enough to treat GSM fully. Please use the correct dosing. And for anyone, you know, I really believe at least a gram every day for two weeks and twice a week till death do they part. I'm a big believer in sort of the already dosed out things like the estradiol tablets and the DHEA and the rings because patients don't have to kind of, they're not goopy. The patients don't have to really dose it out, but whatever her insurance will pay for, whatever she will use is the correct GSM therapy. Always, always, always. And we know there's no systemic absorption. And we also know there's no increased risk of cardiovascular disease, cancer, any problems with this preaching to the choir. I know I don't have to teach all of you. And so, um, I know we didn't cover absolutely everything, but I just want you to know that sexual health is health. You see these patients all day, every day, break it down in your head, desire, arousal, orgasm, pain. It takes two seconds to ask them. And you'll be the only one, whoever does think biopsychosocial, have your pelvic floor PTs on speed dial, have sex therapists, send me patients tons, right? If you need referrals in your practice, go meet every sex therapist in the world and they will help you get more patients. Please consider joining a SWISH or coming to a course or a conference. I will teach all of this. I will as much smarter people than me will teach you all of this in full detail. Um, and really just what an honor it is to talk to all of you. This is just such a dream. Um, and, um, happy to answer any questions. Dr. Ruben, we now have about 15 minutes for questions and audience members. Um, you can submit your questions in the Q and a section below. Um, so to get started here, our first question, uh, going back to testosterone therapy, um, uh, somebody asked what about testosterone therapy for trans women who don't have testicles post vaginoplasty? Is it the same kind of, uh, can we use this for sexual dysfunction in the same way with the gel? Well, I love that question so much. And that I I'm a big believer that our transgender patients are going to teach us so much about sexual medicine, because again, when we talk about systemic hormones, I use this example all the time. When does Caitlyn Jenner go off her estrogen therapy, right? When is Caitlyn Jenner told that it's not safe for her to be on estrogen anymore? She's 72 years old. She's not stopping anytime soon, right? Nor I want to meet the doctor. Who's going to tell her to get off, right. That's not going to go so well. And so why are we telling women that they absolutely cannot be on systemic hormones, but, but, but, but Caitlyn Jenner can't, it makes no sense. And so it's going to push our comfort with hormones in a way that we've never seen before, which is really wonderful. And so absolutely for the patient, you know, I spend with the trans patients. I spend a lot of time thinking, okay, what is the anatomy here? And what does this tissue need? We know the male urethra needs needs testosterone, right? There've been studies on urethroplasties and that those patients do better with when their testosterone is normal. And so I see it all the time, the trans male who has no ovaries and no uterus with horrible GSM, right? Horrible because that person wants their estrogen zero. Whereas men have an estrogen of 25, right? We need men need estrogen for their bones, for their brains. And so not this idea that testosterone is for men and estrogen is for women is ridiculous. We both need both. And so getting comfortable with that. So absolutely. I think, um, you have to play with it in terms of what the patient is willing to try and what actually will work. I don't know if the dosing for a vestibule will be the same for a vaginoplasty. It kind of depends on what tissue you're using. And so if it's skin and ectoderm, it may not work the same way that endoderm is going to work because there's different receptors there. So it depends. I'm not totally up to date on all the surgeries and where it's all the graphs are coming from, but happy Kathy to kind of talk, talk it over with you. And I love the question. So another question here about testosterone that got asked a couple of folks. So one is, um, somebody asked about DHEA vaginal suppositories. Um, you know, there've been some studies that show that, and apparently that can't, Canada will soon approve it. Um, number one and number two with that testosterone for vulvodynia, what kind of dose do you prescribe if you're using testosterone for that? I have, I have that slide and I'll put that slide. And that was my vestibulodynia was the one piece I didn't get to. So I'm happy to show that slide. And thank you for asking. So I love DHEA. I'm going to put it out there. I absolutely love DHEA. The reason is it's the only FDA approved product that has androgen in it, right? And we know the bladder, the urethra need androgen, and there's emerging data. There's a paper to show improvements in OAB. There is emerging data on a decrease in urinary tract infections, just like vaginal estrogen. And, uh, I just saw a paper presented that, uh, women it's, I believe out of Spain, women who were on vaginal estrogen, who weren't getting better than switched to DHEA and got like a lot better on their, on their GSM. And we know that vestibule, I see tons of menopausal women on vaginal estrogen who have a lot of vestibulodynia. And that's when I will either switch them to DHEA or that topical estrogen testosterone that was just asked about. And let me just share my screen so you can see. And I believe it's magic. Um, and, and, and we need more, uh, more of it to more vestibules. And so this is what I use everyone. Let me put it big. So y'all can take screenshots of it. And so this is for your birth control patients. You get them off birth control. I'm a big believer in IUDs, either hormonal or non-hormonal the progestin based IUDs don't seem to cause vestibulodynia. And I compound it's one of the few places where I do compound because there's other than the DHEA, there's no real option here. Um, it's a 0.01% estradiol. So similar to your estrous creams. And I do a 0.1 testosterone. Remember systemic testosterone is 1%. This is 0.1%. You're not causing clitoral medley with this. You're not getting facial hair with this. This is a baby dose. It's a baby's baby dose of testosterone. Um, and you are basically rubbing it onto the vestibule once or twice a day. And over the next 12 weeks, you will see magic happen. And if the patients, you have to make sure patients know where their vestibule is, because you will see everything. You will get patients. You'd barely know where a vestibule is. I barely know where a vestibule is. How are the patients going to know? Um, uh, they will rub it here. They will rub it here. They will rub it everywhere, but their vestibule. And so I tend to bring them in at about six weeks or so and just reeducate them with a mirror. Um, I think the most in the best investment I can ever make in a practice is getting a hand mirror and every patient looks at every exam because then they become a part. Every exam is an opportunity for education, for their prolapse, for their leakage, for every, for their GSM, when they see it, they understand what's happening. So that is the, um, and see, I say here, you can also consider a nightly DHEA, which has an androgen and a little bit of data that it does help with vestibulodynia occasionally. Um, uh, you know, I'll load the boat and do both because the patients just want to get better so quickly. Thank you. When we, uh, another question here about medications for the, um, HSDD. So the Flobanserin and the Bromelotide, are there any comorbidities that you would not recommend them in? Yeah, it's a, it's a great question. And again, the more you get comfortable with these medications and you hear of other people prescribing it, then you get a little bit braver. And if you just prescribed one here and one there, you don't usually see, and then you never see the patients back. You don't really get that feedback. And so you never prescribe it again. And so, um, you gotta get comfortable. So for Flobanserin, um, the biggest there, there is no, um, no drugs where they're absolutely contraindicated. Um, and, and again, happy to connect you to any, the reps that you can talk to. Um, there's one OCD medication called Luvox that they say not to use it in. Um, but other than that, there's almost no contraindication. You tell women if they're going to drink really heavy at night, don't take your pill that night. So if you're having a glass or two at dinner, you know, just take your pill at bedtime, like you're supposed to. But again, I want to stress, nobody has died from this drug. Nobody's gone to the hospital. There have been no major adverse events reported period, end of story, right? So, so we haven't seen it. Bremelanotide, the only real concern is with, um, uncontrolled hypertension. So again, similar to you've gotten used to doing, um, your beta agonist kind of things and worrying about blood pressure. It's no different. And is it a big deal? Probably not. But if you have an uncontrolled hypertensive patient, maybe you want to not use it in that patient. So that's pretty much it. But, um, again, these are not scary drugs. These are not major, um, uh, they're not causing major issues and, and you're not having to like triple check yourself, you know, when prescribing them. Somebody asked, does insurance cover these medications? Well, they're actually pretty well covered. And so that's another reason to consider if you can work with a rep to work with a rep, because often it'll flag a, um, prior off for your staff. And here's the, here's the God bless America moment. When I see a patient with low libido, I use the R code for low libido because F codes don't pay well. Right. Um, and so when you're prescribing the drug and doing the prior off, you have to use the F code for HSTD. And so if you use the R code for low libido, it'll bounce back and sometimes won't get covered, but the, the, they will help. They have, um, systems in place where they'll flag it and say, Oh, Dr. Rubin, you screwed this up. Can you just, you know, switch this because you're doing the same thing. Low libido is low libido. Um, and so they're actually way better covered than I think we realize in that they were covered maybe, um, uh, five years ago when they came out and they have off late off-label pricing. So if you have a menopausal woman or a man that you want to prescribe it to, it's $199 for a three month supply. So for 66 bucks a month, right. It's a, it's, I basically say it's a $200 experiment to see if it helps, because if it helps, they happily pay the 199 for three months supply. If it doesn't help, then they spent $200 on a hope and a prayer, which they're already doing, you know, in other ways, uh, you know, with different, uh, dinners and movies and things like that. There are several questions here, Dr. Rubin about, um, birth control, the patch versus pill, some of the sexual side effects and questions on how, how does that contribute to the vestibulodynia? All right. I knew, I knew I shouldn't have skipped that part. You guys see, you've only gave me 45 minutes. Has this been helpful? Can I get like a, a yes or a thumbs up? Because again, it's so hard to speak into the void. Um, uh, and, um, not know, not know if it's being helpful. So I hope it's been helpful. So vestibulodynia is, um, this, this red part, right. It's the endoderm and we have algorithms. And, um, I know I've been talking a lot about process of care and algorithms, but, but it's helpful. It's helpful to have care pathways, um, just like for OAB or for prolapse and things like that. So we let the exam guide us. And so the key is if they have pain everywhere, you know, the three main causes of pain in the vestibule are hormone problems, pelvic floor problems, and too many nerve endings. And so the most common thing I see in my practice is birth control pills. You get them on the reason it's the SHBG story. Again, you take a birth control pill. It pumps through your liver, pumps out SHBG, which eats up all the free testosterone in your body. The vestibule needs testosterone. It's got lots of androgen receptors. They're not getting to where they need to go. So we stopped the offending medication. We consider an IUD, which mostly is fine. I see someone asks, um, the sexual side effects of Mirena use anything can cause anything. The only Mirena you'll see dry vagina a lot. A lot of people will complain of dryness, but otherwise it's typically pretty well tolerated. And probably the least it's all vasectomy people, vasectomy is the best, uh, best possible birth control pill for women. Um, um, so, um, the, the estrogen testosterone, like I said, here's the, um, the percentage of the compound that I use in my practice and a methyl cellulose base. Um, and, or you could use vaginal DHEA and it takes time. Just let these people know they're building up tissue, right? It's like GSM, GSM management takes two months to work. Uh, when do you stop brushing your teeth? When do you stop using sunscreen? When do you stop wearing your seatbelt? You never do. And you never stop your GSM therapy similar to this local therapy. You have to keep it going for at least, you know, 12 weeks. And I want them better for like six months before I try taking them off of it. Um, and you really do see these miraculous changes. Um, it's really important. You'll see pain go from pain everywhere to then just pain at five, six, and seven o'clock at the bottom of the vestibule. And this is where then pelvic floor takes over. So now the tissue is better, but the pelvic floor is driving the pain now. And that's where the pelvic floor physical therapy is so important, right? Is it a tissue problem or is it a muscle underneath problem? And that's where your exam can be really helpful. Um, I think the biggest, um, innovation in my practice in the last two years has been using a botulinum toxin into the pelvic floor. It's fricking magic, um, for the right patient. If you put it in a patient with a hormone problem, it's not going to fix it. If you put it in a patient with that, with a neuroproliferation, it's not going to fix it. So that diagnostic skill, when you have pain really at this bottom here in these muscles, putting some botulinum toxin into these muscles, it's super easy to do. I use a 30 gauge half inch needle and I use three CCS of saline and I put it one boom, one, two, three. It's not chat. You guys do way crazier things. Um, and then the third, uh, least common reason someone has vestibulodynia is those people who first tampon, you know, first, any kind of penetration, horribly painful. There's no hormone issue. Um, there's no muscle problem. That's when a vestibulectomy is going to be your gold standard. And they work when for the right patient, they work and they work really well. Um, but if it's a hormone problem, don't do surgery. If it's a muscle problem, don't do surgery, right? Do physical therapy. And so you really want to diagnose, do a good diagnostic exam, uh, which is really helpful. Did that help? Was that, um, helpful? And thank you for knowing which slides I didn't show. I think there weren't that we've time for one last question. And somebody just asked what dose of Botox do you use when you inject into the pelvic floor? So I prior was using a hundred units just for cost issues. Um, cause usually it's not covered and it gets really expensive. My guess is, Oh, Tovia Smith's here. Oh my God. Hello in Richmond. You're amazing. Um, my guess is 200 probably would be way better. Um, I, in my clinical practice, cause we did a clinical trial and it convinced it was unbelievable. Oh my God. And it was with dysport cause, uh, Allergan didn't support this study in women's health. So Boo Allergan, um, yay, a dysport, they did do the study, which they cut early because of pandemic and finances, but it was pretty amazing to watch. Dysport is 300 units versus a hundred units of Botox. And it's a little tiny bit cheaper. Um, and clinically it is a game changer for my practice. So I actually have switched to not using the brand name Botox, but I use the brand name dysport. Wonderful. On the behalf of Oggs, I like to thank Dr. Rubin and everyone for joining us today for a full list of upcoming webinars series, please visit the Oggs website to sign up, but thank you everybody. And thank you, Dr. Rubin.

sexual dysfunction

desire

arousal

orgasm

pain

biopsychosocial approach

treatment options

therapy

testosterone therapy