In pregnancy, estrogen levels become very high, several thousands, and that's the only time in a woman's life where estrogen exceeds testosterone. Men have 10 times more testosterone than women, but testosterone is our main sex hormone.
Heads up, this episode covers adult topics and isn't meant for little ears. So pop in some headphones if you've got kids around. I'll wait. Now today, we are talking about sex. That's right. That means low sex drive, trouble with orgasm, hormone shifts. These are all real issues that are affecting real women, possibly like you, and no, it's not in your head. So I have with me today doctor Christine Vaccaro.
She is a board certified urogynecologist and women's sexual health specialist, and she is here with me today talking about sexual dysfunction. She and I both carry so much compassion for women who have been to other providers and feel brushed off or misunderstood or have no idea what the next step is. She lays it all out for us so clearly why we have sexual dysfunction, what to do about it, when to use testosterone therapy, and why you're not crazy for wanting to fix it. If you've ever felt alone in this part of your health, you're not alone, and there is such good help out there for you. So tune in. You will not want to miss this episode. This will be helpful for you or someone you know. I guarantee it.
Let's get started. You need to know what self pleasure feels like for you and what you can tell your partner is this feels good for me, this feels good for me. But it shouldn't be up to a partner to figure out a woman. The woman should feel empowered to know herself what that feels like.
Well, Dr. Vaccaro, thank you so much for joining me. I'm really excited for this conversation. You are such a wealth of information and specialized information, so we're very lucky to be talking to you today. So thanks for coming on.
It is my honor to be here. I'm excited. It fills my cup to educate women everywhere.
So Oh, I love it. I love it. And nothing better to educate about than the most taboo topics in women's health we could think of. I mean, I'm sure we could think of some others, but these are the ones that people that women generally don't get super excited to bring up. Right? For sure.
So the first one we're gonna talk about is sexual dysfunction. Tell us first how you became interested in this specialized field that you're in that really focuses on sexual dysfunction and then urinary incontinence. How did you come to fall in love with this field?
Yeah. That could be a long or short story. I'll keep it short. I had a really great mentor in med school who got me interested in urogyne and I just fell in love with the quality of life aspects of women, and again, talking about those embarrassing things that a lot of women don't want to bring up, so we bring it up and they feel more, empowered to talk about it. So that was one, and then in my fellowship for your gynecology, I had a faculty member that was really interested in female sexual dysfunction, so I paired up with her and we did a lot of, testosterone replacement for women in our clinic, so that got me really excited about that aspect, for improving libido, and we were actually a trial site for testosterone gel for women, which is a whole separate topic. So I really saw firsthand how much it improved women's quality of life. And I also at that time was very curious about clitoral anatomy and asked, what do we know?
And it was like, what do you mean what do we know? We don't know anything. Yeah. So then I, yeah. What do you wanna know?
Like it's, yeah. So I got really involved with MRI studies of clitoral anatomy back in the late two thousands. And so that kinda just built on, you know, my curiosity because there was very little known. So it was exploring areas that were unknown so we could enhance women's understanding and medicine, you know. We don't Yeah.
Have enough understanding about female genital anatomy. Well, thank you for doing that and spending your time studying these things so you can help us out. Yeah. Now, when you say you've studied sexual dysfunction, women's sexual dysfunction, I don't think that's a phrase that a lot of people will know is a thing. What is it exactly, and what do women need to know about that?
Yeah. So there's really four main categories. There's disorders of libido, disorders of arousal, disorders of orgasm, and then sexual pain disorders. So really it's four main things, but each one of those things could be like a whole separate, you know, talk in and of itself. I would say the majority of patients I see are for low libido, but there's a huge amount of sexual pain disorders.
So those, really those are the big four when we're talking about female sexual dysfunction. Well, that's great. So let's start with number one. With low libido, I agree. That's the number one that I see in my clinic as well.
If people are coming in with low libido, how do you first establish, like, well, what's non low libido? Like, what is the goal here? Yeah. How do you establish that with them so they know what the treatment goal is? Yeah.
That's a really good question, and this is where we break it down to the biopsychosocial model of libido. Right? It's not just biology, oftentimes it is, but sometimes it's the partner, sometimes it's stress. There's so many things that factor into, you know, the relationship even to figure out what is going on. So really we start with a really good history to make sure we understand the psychosocial factors, and then use our extensive team of clinicians to help the patient.
But when it comes down to just like biology, oftentimes I'm seeing low testosterone issues, oftentimes I'm seeing medication side effects from other things like, antidepressants. Those are the probably the two most common, and then I also see a lot of problems with oral contraceptive pills lowering testosterone. So those are kinda like the three most common things I see, as well as obviously sexual pain. If you're having sexual pain, we have treat the pain first so that we can Yeah. Hard to have good libido when it hurts.
Exactly. Yeah. So tell us about the testosterone side of that because that is such a big buzz right now and women wanna know about it. Number one, why would someone's testosterone be low and what what age group do you start seeing that show up as a problem? So it's very interesting that both in men and women that testosterone starts declining because they're just, like, gonadal, structures that they start declining in the late twenties.
I think it's really shocking, most people don't know that, but really the late thirties is a huge drop off for women, and then it just kind of continues to trickle down, it doesn't jump off, you know, the cliff so to speak like estrogen does, but it just continues to slowly decline, and oftentimes women don't even notice, right, they've been like, oh it's been like ten years since I've felt those sexual thoughts and fantasies. A lot of women tell me, who are on birth control pills that as soon as they started birth control that their libido was zapped. You know it's great to, to feel free from a pregnancy prevention standpoint, but then when you have no thoughts or desires it's like, oh, that doesn't feel good, and as soon as they come off Double contraception. Yeah. Yeah.
They notice it rebound, so, I talk a lot about non hormonal birth control methods of patients that have those, sexual side effects. And then I think again another big category is just again the the SSRIs, so, Zoloft, Celexa, Paxil, Prozac, all those medications, Lexapro, etcetera, etcetera. Generally, again, when people are feeling great, they don't also go towards, sexual stimuli because it's just like, I feel good right now. Why would I do that? I feel really wonderful right now.
And it also decreases and makes orgasm more difficult. So SSRIs are kind of not tricky for yeah. Yeah. I mean, obviously, mental health is really important. We wanna support mental health, but there is there a way we can work with their, mental health team to support their mental health but also not cause sexual side effects?
Yeah. You don't want women to have to choose between, listen, you can either have mental health or sexual health. Which one would you prefer? No. Yeah.
For sure. And oftentimes, sorry, we'll get into this, but oftentimes we can add on something to help combat those neurotransmitter imbalances so that we don't have to sacrifice, the mental health. If this is like, you know, if a woman tells me like I've been on everything under the sun and this, you know, Lexapro is the only thing that works for me, it's like okay, great, we're gonna work with that and we're gonna help your neurotransmitters by giving you, potentially a medication to help with your neurotransmitters. Let's just go there so we don't forget to come back. What how do you approach that?
Yeah. So this is generally my premenopausal patient, who is again on antidepressants for x, y, and z reasons and has noticed a decline and doesn't have low testosterone also. Right? So a lot of time with the younger patient group, I will start with neurotransmitters first especially if it's a SSRI related issue. And there's a wonderful medication called Fluvanserin, the trade name is Addy.
It's been out for over ten years. It basically stimulates dopamine and norepinephrine which are generally the areas that are needed to increase desire for women. And these are the areas that SSRIs negatively impact. So it's like we're giving them back something to help rebalance, to help desire increase. Blobanserin was initially studied as an antidepressant, but they've noticed all these women reporting their libidos going up and it didn't really change depression that much, but it really helped with, sexual desire, so, it was rebranded for sexual desire.
Extremely safe medication, my colleagues and I always chat about, like, I can't believe this isn't more commonly used. You know, when it first came out, it was dubbed the pink pill, whereas Viagra is the blue pill. It was gonna be, like, the next latest and greatest, and it really just hasn't caught on. I have lots of theories about why that happened, but is a very safe, medication. Patients that do have mild depression also notice a bump in their mood as well.
So it's it's a really lovely night. How do you manage how do you manage the cost of that? How do you help people manage the cost? Yeah. We use a special specialty pharmacy that generally helps get things approved and in premenopausal patients, oftentimes, again, if we ruled out other causes, it is approved by their insurance.
If it's not, again, we go through the hoops to get prior authorizations and get it covered for them. The trickier patients are the postmenopausal patients because right now the labeling is for just premenopausal patients so that is very frustrating because obviously women that are postmenopausal are still having sex and still wanting to have connectivity with their partners. So that part is frustrating and there are, things in place right now to try to change the labeling so that it is on label for all women, not just premenopausal women, but that's not quite there yet. And, ma'am, bless the hearts of of those of of those of you. I know you and your colleague, doctor Rachel Rubin, have have gone to bat for women in a lot of different ways for these medications and for other ways.
So thank you for your for your efforts there. What about when people are using ADDIE and they find that it's helpful, or flabanserin, do are they staying on it long term or are they coming off of it at some point? Generally, they're staying on it. If they, we have about sixty percent responders, meaning sixty percent of women will say, oh my god. This is this is amazing.
This is how I used to feel. I feel like myself again. And those patients will generally love love it, and they'll stay on it. About forty percent of patients will say, you know, I didn't have any side effects, but I just I didn't feel anything different. Right?
So those are non responders, and and we'll have them come off. But yes, as long as they're, you know, again, if they're taking an SSRI and we're using this medication to sort of combat the sexual side effects, I'll have them stay on as long as they're on SSRI. If they come off SSRI for some reason, we can always do a trial off. So it just really depends on the clinical scenario. But you can use it in women without SSRIs as well?
Of course. Yes. Of course. Tell us then, go back to testosterone, how are you assessing someone's testosterone level? So so generally the best and most easily reproducible is a total testosterone.
If you order a free or a bioavailable testosterone, it really depends on the lab and their calculation and it's very hard to reproduce per lab. So the most reproducible is a total testosterone and then we also add in a sex hormone binding globulin so that we can do a calculation if needed to calculate the free androgen index. A lot of times, SHBG is really high in women that have had oral contraceptive history even if it was years ago, it still can remain high. And that basically binds testosterone and makes what's active or freely moving, and able to work on end end organ tissues, really low. So we have to get both of those bits of data to get a full picture.
If I just got a testosterone level and without the SHBG, it would give me an incomplete picture. So if someone has normal testosterone, total testosterone levels, but their SHBG is really high, then it's as if they had low testosterone. Correct. Absolutely. Yep.
So what level are you going for? Assuming a normal SHBG, what what level are you targeting or considering adding additional testosterone therapy? I like to see a testosterone around 60. There's no perfect number. And again, every woman just like an estrogen and progesterone, it's really how you feel.
Yeah. But, if I have a woman that's over 60 and she's been on testosterone for several months and she's not experiencing a benefit for libido, I start trying different things just because at that level there should be some biology happening in the brain to turn that light switch on, so to speak. Most women in their twenties, have a testosterone around 55 to 60. So that's kinda the Should have. The should have.
Yes. Yeah. That's like the target. I know a lot of people that go much higher, and it's it's safe to go higher. We don't wanna go into male ranges, which are generally over 200.
So, you know, somewhere in that gray zone is also acceptable. If a woman's like, yeah, I feel benefit, but I would like a little more, you know, we can always have that discussion as well. But, you know, this is where we play no benefit and it's already at 60, then you don't just keep driving it, driving it, driving it. Correct. The art of this too is I think people expect things like, you know, I'm gonna put this gel on tonight and I'm gonna have libido tomorrow.
Mhmm. Does not work that way. We really need to lead, give it like several months. We usually stay around four plus months. We wanna make sure we give it enough time.
The body really needs to up regulate the receptors in the brain to have enough receptors to turn that light switch on. At the tincture of time, which nobody likes to hear, right, like, come back to see me in four months. It's like, woah, you know, like, four months seems like an eternity, but really that four months does seem to be the magic. And do you find that women, it's helping with orgasm or more so just libido? Yeah.
So here's what I'd love to say, we have great data in men about how testosterone works, and men are human and so are women, so therefore, what it does in men, you know, testosterone in men works for mood, it works for energy, it works for maintaining muscle mass and bone mass, and improves sensitivity and orgasmic ability, right, it does all these things, and we are very similar, right, we are the same, so it should work in all those. And we do have some data on that women, but really the majority of the data we have is on libido. And it's so funny because we're in similar organizations, right, that have these advisory committees and it's so funny because a lot of them will still say that testosterone will not help women's energy, will not help women's mood, will not help them build muscle. And that's certainly not the anecdotal experience. Exactly.
Yes. There are lots of women who will come back and say, this changed my life. And I'll say, how? Yes. And they list it off.
So like is it just placebo or does that actually feel better in them? You know, you hear it over and over and you're like, this isn't placebo. Yes. And we need more studies. That's for the bottom line.
Right? We need our studies. An area I'm super curious about, I'll be honest, is I'm super curious about this, and I just got invited to review a paper about this, similar topic is testosterone for pelvic floor disorders. Right? Mhmm.
So the elevators are a big, muscle group, the urethral sphincter is a big, you know, is a big, an important muscle, I shouldn't say big muscle, an important muscle, and we anecdotally hear all the time that women's stress incontinence gets better with, with testosterone, because again, it's a muscle. And why do women that have a delivery twenty years ago, all of a sudden around menopause and when testosterone is really starting to decline start getting stress incontinence? You know, it's like, what has changed? Really We just blame estrogen for everything, but Right. But, you know It could be multifactorial.
Absolutely. So I'm curious about that. We don't have an answer yet. Well, let us know when you do. Thanks for your work.
Yeah. Tell us what's the earliest that you check a testosterone level age wise, young? Oh, age wise, age wise. Yeah. So really, if they're complaining of low libido and they have any reason why I'm suspicious, I I check.
I have very low threshold to check. You know, we have hypogonadal patients, we have, patients that, again, are on OCPs, like there's for me, it's a really easy test. But, you know, we check thyroid tests all the time for almost no reason at all. Right? No reason at all.
And it's like why are we not just checking these when a patient says, hey. I have low libido. I mean, I think it should be one of the first things we check. I agree. And it's not an expensive test.
It's not a big fancy expensive test. It's quite inexpensive. And in my experience, insurance will typically pay for it. Yes. Have you had a problem with it?
We have not. We do always use other fatigue as a code just to make sure because it is, generally covered that way. Yeah. What what about what's the earliest you'll give testosterone? That's another place that our advisory bodies have pretty mixed opinion.
Some people say abs well, more opinions rather than guidelines that not to give it below 35 because we don't have data. And even in 35 to 40 to be cautious. Yeah. I I think here is where you used your decision making in the art of medicine. I think there's always a concern, like, well, what if what if she gets pregnant, and could we have some, you know, masculinization of a female fetus?
I mean, there's there's these concerns, right, in women that are 35 are more likely to to be pregnant. So I think that's part of the concern. I think it's also we don't have a ton of data. Most of the data we have is in menopausal patients with low libido. But again, I think you shared decision making and you put all the data points together and if it's like, I got an OCPs, even despite my stopping, I'm I don't feel any better, and I had the libido.
And, oh, by the way, my SHBG is 200, which is, like, three times normal, and I just feel terrible. No energy. No no libido blah blah blah. Like, why would you not give this patient testosterone? Do you know what I mean?
I think clinical decision making. Yeah. And I also think if you're testing and you have someone who started with a level of 15 or 20 and you're giving them physiologic levels of testosterone, that it's certainly a little more reassuring that even if, you know, they do get pregnant, that you stop it, of course, when they get pregnant. But Yeah. If you're not driving their levels to super physiologic, then it seems unlikely.
Totally agree. Yes. What what do we know about why these testosterones drop? I know we say it's age related. But in my experience testing for this, because I test for it all the time, for usually for low sex drive, but I get a lot of women with low sex drive.
Mhmm. When we tested, I have been surprised at how varied it is, how many 20 year olds and 30 year olds have really low levels. And on the flip side, I've been surprised by sometimes how many of my 60 year olds have really robust testosterone levels. So Mhmm. Why why is it do we have any understanding of why it tanks like it does, other than just age related decline?
Yeah. I wish I had an answer for you. I I don't have an answer for you either. I know there's people doing some really interesting study on trying to extend the longevity of gonads, you know, to prevent menopause from occurring. They might have a better answer just on the ovarian biology, but, unfortunately, I don't have a perfect answer for that.
I don't think we have enough data there. But replacing it, definitely. Yes. A lot of women like it. I've also found and I'm curious about your opinion or your experience rather.
I've also found that because testosterone is such a topic of conversation in the media right now, that a lot of women assume it is the magic bullet, And I have found it to be a little more variable. I'm very willing to give testosterone, and I I do drive it up to higher levels. But I still find it to be maybe sixty, forty, seventy, thirty. You know, maybe seventy percent of women will come back and kiss you on the cheek, you know, and say you changed my life. Yeah.
And then there's there's a decent percentage of women who are like, meh. Yeah. I don't think I noticed anything. What is your experience with, like, how effective for what percentage of women? Yeah.
I think your numbers are very similar to what I see. I think it works great for some patients, and some patients, they need more either the neurotransmitters right or off. It's not just hormones. And also, again, that's the psychosocial thing, and that sometimes that needs to be really dived into. So again, working with a good sex therapist, working if there's any sort of marital discord or other financial stressors, stressors with the, you know, parents or young children, like whatever job I mean, I'm I'm in the DC area, so right now people's stress level is, like, maximally engaged.
So I think sometimes you have to just peel back the layers. There's always something. Right? There's always something to tweak, and whether that's neurotransmitters or whether that's the psychosocial side. Yeah.
The last question I have about testosterone, unless you have anything else to add, is, of course, the question of how do we deliver it. So troches by mouth, some people do it orally by pills, gel, cream through the skin, injection, and then pellets. Did I miss any? And then translabial or transvaginal, which are different. Yep.
Will you will you explain those? Yes. I think this is where it's controversial because there's no, exact right answer, but, the Ishwish clinical practice guidelines, favor transdermal gel. Which is a sexual health, society. Mhmm.
And, International Sexual Health Society. In our practice, we use the transdermal gel, which is basically an FDA approved male product, that comes in a a tube. The man would use the entire tube per day, but since women have a tenth of the amount that men do, we use a tenth of the tube a day. The nice thing about this is because it is FDA regulated, it's very consistent, it's also generic so it's really inexpensive, and it's topical. So it just seems very easy and convenient.
The reason we don't recommend oral pills, that is swallowing pills again is the same thing as birth control pills. When you take a pill orally, the liver has to engage and rev up sex hormone binding globules, so you're sort of you're not helping the the free testosterone issue. I think something delivered through the mucosa, the oral mucosa, is an interesting idea as well. Compounded, you know, creams, I think this is a place where since we don't have a female approved product, that using a compounding pharmacy to get a female testosterone cream, I think that's perfectly acceptable. Where we don't really love going is pellets.
The reason being, one, they're not FDA approved and two, once you put a pellet in you can't take it out. So you have an adverse event or you get a really super physiologic level, you can't really go in and pluck it out. Additionally, it's usually kinda costly and it hurts, and a lot of women have scarring from multiple pellet injections. So until there's robust FDA approved pellets, we don't favor pellets even though they are very convenient. Convenient.
Mhmm. And certainly not wrong if a patient's doing great on a pellet and their levels are great and they've been doing it and they just love it. Like, I'm not gonna say, like, you shouldn't do pellets. Right? But if a patient's coming to our clinic for the first time, we're gonna recommend gel, and discontinue it.
If you have any adverse effects, we can increase it, decrease it pretty easily. Rarely, but I have a few patients, they don't absorb the gel well, so this is where we go to injections, and I just But you do that based on the level, not on their I mean, if they don't if their level is normal and they're not responding, then it's not because they're absorbing it. It's Correct. This is where, we can't get their levels high, and they're using quite a bit of gel. Yeah.
I I'm so glad to hear you speak about this in the way that you're speaking about it, especially where it comes to pellets because I think it's really confusing for women to hear these really stark we hear some doctors saying, like, pellets are the worst. They're not recommended. Don't even go near them. They're dangerous. And I think that that's just really confusing for patients when they hear from their neighbor who's like, this changed my life.
I've never felt so good. Yeah. And so I like to hear you say that. I think that the only time I would ever consider a pellet is if you're already established on your level. I think to do a pellet very first is you're totally guessing, and you're guessing with something that you can't change.
And although we like testosterone and a lot of people feel great, not everyone does. You know? Yeah. Right. Some people can have really negative side effects.
And if it's a pellet, you can't undo it. So Right. I don't recommend pellets either. But but exactly like you said, if someone comes in and they're doing amazing, then I don't think it's that it's evil or wrong or that you're gonna, like, cause harm per se. Right.
So that's because again yeah. Because again, just to hit your point, it they are gonna feel amazing because we're replacing with body identical hormones, you know. Yes. Whether we're replacing that under the skin or through the skin, it's getting them to back to feeling like themselves because they were deficient. But just like we've mentioned, it's, I wish it was FDA approved, I wish we had more data in women, you know.
So until that day, we're gonna sort of preferentially go down the transdermal gel route. And then one day hopefully we'll have an on label testosterone product for women. I mean, again, in my in my fellowship, which was in the late two thousands, again we were a trial site, and we had five years of excellent safety data, took it to the FDA, and FDA said, yeah, this looks really safe and effective, but how about you give us five more years just to really make sure? And, of course, the drug companies pulled out. But there's three three countries in the world that have an on label product for women, for testosterone, and those are New Zealand, Australia, and South Africa.
So, you know, if you, you know, fancy moving to those countries, you can get your testosterone on label because it's not it shouldn't be scary, and it shouldn't be something weird. It is a human hormone. Yeah. And in fact, women have more testosterone than estrogen at all time points in their life, and I think I wish more women knew that. Yeah.
Yeah. Yeah. Thank you for that. So so the interesting thing about I'll just elaborate on that. Yes.
You know, pregnant in pregnancy, estrogen levels become very high, several thousands, and that's the only time in a woman's life where estrogen exceeds testosterone, which, again, estrogen, that's why when women say, oh, you're glowing, your hair is so lush, you know, that's all the estrogen benefits. But again, testosterone usually gives women again energy, sex drive, all the other things that sometimes again start waning in the late thirties slash forties midlife. But again, men have 10 times more testosterone than women, but testosterone is our main sex hormone. Thank you for clarifying that. It's also you know, when we do this testosterone replacement therapy, most people are gonna continue it throughout their lives.
And so going back to the pellets, they're so much more expensive, like, vastly more expensive. So if you're gonna do it for the next, you know, ten, twenty, forty years, like, it it's worth considering considering that as well. And just to elaborate on that just a a touch more, it costs women about $10 per month to get generic testosterone. I'm gonna have to ask you how you're doing that because I've not been able to I've not been able to find that. I can get $30 a month, but I run into a lot of problems with pharmacies.
They won't break up the box. So it comes in a male prescription, which is one tube a day for thirty days. Right? And then the Yeah. The boxes then 30 tubes.
Yeah. And many pharmacies won't break it up and so the woman has to buy ten months worth. Yeah. So if you use a GoodRx coupon Mhmm. And just have them buy the entire entire box.
So you'll they'll get, you know, ten months supply for about a $100. Yeah. I've not I've not found that in our area, but now I'm gonna look again because it's always been 300. I mean, at least in our area, it's it's about a $100 for a ten month supply, which is about $10 a month. Yeah.
Now I'm gonna I'm gonna look again, but it's it's one of those things. It's a little it's a little hacks that actually make the biggest difference. Right? It's a big difference for people. If if you go and it's like, it was $400.
I don't really wanna do it. It's like, ugh. Right? It's like a $100. Most people are like, a $100?
Okay. It's gonna last ten months? I'll do that. Right? Totally.
Yeah. Totally. It is a big deal. Especially when you're adding to that other HRT. You know, you tell people, like, okay.
Here's your prescription for progesterone. This one's estrogen. This one's vaginal estrogen. Here's your testosterone. Like, it's it's it's a lot for women.
Yeah. So we wanna make sure it's as cost effective as possible. Hey. It's Mallory. Can you do us a big favor?
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Well, we've spoken a lot about libido and testosterone. We spoke a little bit about other medications that are out there. Is there anything else we could go on forever about libido with the psychosocial component. But from the biological component, is there anything else that you wanna say about libido? Yeah.
There's just one other medication that, has been approved since, I think, 2019 or might have been 2020. Anyway, it's called Vyleesi. It's, an on demand injectable, and it hits a neurotransmitter in the brain called melanocortins. Demand version, similar to, you know, men for Viagra. It's on demand.
Right? This is sort of the on demand for women. I've had a few patients that absolutely love it. It's like, oh my god. There it is.
There's my libido, and it works for about twenty four hours. It's just it does have, for a lot of women, the side effect of nausea that can be quite severe, so that limits its use in most patients, but when I do find the patient that doesn't have extreme nausea and just loves it, it's it's wonderful, but it is it is one of the only two FDA approved medications, for women. So there's again Flavanserin, the pill, and Vyleesi, which is also free melanotide generic available for women. So And that one can be a little costly as well. It can.
Yes. And not as many workarounds for that one, I've noticed. Mm-mm. I also find patients are sometimes weirded out by, like, so what you're gonna do, when you wanna have sex, you're gonna take this shot. You're gonna jab it in.
You Yeah. It's it doesn't have to be that violent, but a lot of people are like, yeah. That's so great. And also you might have considerable nausea. And so take this anti nausea you know, there's a lot of prep work with it.
But it's gonna be great because you'll have sex. So you just take the shot. Right? Like, it's a little weird. It it it is.
And again, I feel like it's the the last thing I try just because of all those, potential issues. I'm glad it exists though. I mean, I think women should know about it and know that there are these options. So I wanna talk a little bit more about the anorgasmia and and orgasm disorder in general. Mhmm.
Tell us about how much of that is, like, related to biology versus, we'll say, skill set. How much of it is, like, figuring out how to have Yeah. If a woman can't have an orgasm, either consistently, we definitely have patients who will say, I don't think I've ever had an orgasm. How tell us about it. How do you approach that?
Yeah. This, first, just the biology side. So the biology side again, looking at their medication history. Again, SSRIs notoriously come with, you know, anorgasmia or delayed orgasm, which is very frustrating. So looking at the meds first.
We also like to do a very comprehensive clitoral exam just to make sure there's not clitoral adhesions, so a lot of women will say, you know, I just feel like I've lost sensitivity over time, sometimes they'll say, my partner thinks, you know, there's something wrong with my clitoris or something of that nature. Patients that typically have lichen sclerosis which is a vulvar skin condition will oftentimes have advanced clitoral adhesion, so some of it's the biology, like looking at the clitoral anatomy which again, the clitoris is the penis, right, for, anatomic terms so that is the, most sexually sensitive area on a woman. There's 10,000 nerve endings on the clitoral glands. There's 18,000 the entire human hand. So, again, it's a very condensed area of sensitivity.
That's such a good comparison. Yeah. So if we can't access it because there's an adhesion, we need to sometimes correct that, which we do, for our patients. So will you explain that a little more? Because I don't think people understand the idea of, like, the the comparison between the foreskin and the penis and then the clitoral hood and the clitoris.
Yeah. So just like It's hard to do without showing up. I know. Make sure you'll Yeah. I wish I had a sleeve on.
Sometimes I do it with a sleeve. I don't have a sleeve on. But, but men that have a foreskin are always told pull the foreskin back because if you don't, you can get, you know, stuff that gets trapped under there and can cause phimosis or adhesions around the gland, so men are always given that information. Women are sadly never told anything about their genitals and certainly not anything about their clitoris. So oftentimes when we're examining them, it's the first time they've ever, you know, looked at their genitals and have they've never seen their clitoris.
So, again, it's like, you know, asking a woman, well, did it always look this way? And oftentimes, it's like, I don't know. I've never seen it before. So, again, lots of, shame with the genitals, which there shouldn't be, it's a body part, but, I think I lost the train of thought there because I could go down this this rabbit hole for Yeah. Talking about clitoral adhesions, how how do they occur?
Yeah. So, smegma, dead skin cells get trapped under, the clitoral hood in in boys or men and then over time that creates a little inflammation and then things just get sticky. When smagma dehydrates, it can become really firm and cause keratin pearls which is think of like little pieces of sand, so to speak, that get trapped under the hood. So oftentimes we also have women that have a lot of clitoral painless with stimulation. So I use the analogy of like having a, you know, a piece of sand in your eye and if you rub your eye, that hurts a lot, right?
Yeah. A foreign body there, so usually sexual stimulation feels really bad, they have a lot of pain, and oftentimes on exam we'll find adhesions and if we correct the adhesions, which we do in the office, that all that goes away because we can remove the keratin pearls and debris, so they can return to pleasurable sensations instead of painful sensations. So going all the way back to orgasm, if you're having clitoral pain, you're certainly not gonna wanna continue that because that, you know, it hurts, and if you can't access the area that feels good, it's hard to achieve orgasm. So oftentimes, women will have to only use, you know, vibrators or some sort of vibratory, device so that they can have enough sensation to achieve orgasm. So I hear this oftentimes with my patients that have adhesions.
Look, every woman should use a vibrator. I love vibrators. I just read a paper on vibrators. Vibrators are great. But if that's the only way that you can achieve orgasm and you used to be able to use, you know, manual, or used to be able to get in a certain position with your partner, and now the only way you could do is with a vibrator, you know, it makes me think of, is there a clitoral adhesion?
Do we need to look, for other things? You know, there certainly can be other nerve problems coming from the back, coming from the pelvis, you know, so there's nerves and then there's also blood flow, right? So then I also think about, you know, at what stage of menopause are they in, do we need more hormones to the tissue, and oftentimes I'm replacing estrogen, and sometimes I'm doing a compounded estrogen testosterone if if we've made sure there's no adhesions or we've freed the adhesions, they're still having sensitivity issues to help give back some, support to the tissue. So if you have someone who's never been able to have an orgasm, and we both have these patients, it's been ten years. Right?
They've never been able to have an orgasm. What percentage of those do you feel do you would you guess have some sort of clitoral adhesions as as the main cause? Yeah. I I don't have any data on that question specifically, but I do have data on a similar idea. So in patients, we did a study on our patients and we had, I can't remember exactly how many patients we had in the have never had an orgasm category, but forty percent of those after we did the lysis of adhesions were able to regain orgasm.
So that's the best data. Percent of them. Correct. Yeah. That's a big percent.
It is a big percent. That's not five percent, like, you're gonna clear clitoral adhesions on a 100 women and five of them are gonna have benefit. No. It's it's a good amount, but again, that's a very limited data set, we just don't have a lot of data on this patient population because again, we just started studying the clitoris in 02/2005, literally that was like the very first paper, about the clitoris, so, you know, we're a little bit behind, we're doing a lot of great research, but we're not, we don't have all the answers yet. So the other patient population I see is again those patients that have never in their entire life achieved orgasm, and those are generally, take quite a few visits to figure out, peel back the layers.
A lot of times, again, there's been religious trauma, there's been cultural trauma, there's been other things where they just didn't feel comfortable exploring their body. So oftentimes we have to refer to sex therapists, we give them a lot of resources, there's a great website that I often refer to called 0mgs.com, which has really tasteful videos about self stimulation for women. Say that again because it sounded like the wrong thing. It's 0mgyes..com. Yeah.
Not s, but yes. Yes. 0mg,yes,.com. Great resources, and it shows all the variety of ways that women achieve self pleasure because every woman's different, and every woman's self pleasure looks different. It gives them ideas and tools to explore themselves, and it gives them permission to explore themselves too.
I think oftentimes I hear, you know, I just haven't found the right partner, my partner doesn't know what to do, and my response is, you need to know what self pleasure feels like for you and what you can tell your partner is this feels good for me, this feels good for me, but it shouldn't be up to a partner to figure out a woman. The woman should feel empowered to know herself what that feels like. But again, oftentimes women aren't given the permission or feel ashamed or etcetera etcetera, cultural pressures, upbringing pressures, etcetera. 100%. And I also think it's kind of I mean, I get why the expectation is there that, like, our partner should figure out how to pleasure us.
But if you think about what we're talking about I mean, if you think about sexual pleasure and it's building and you're starting to get up to a climax, there's no external proof of that. Like, in a male, you might see he's starting to get aroused. Right? You might notice that his he's getting an erection, but how on earth would a man know that a woman was was having any sort of advancement in her pleasure unless she tells him or or shows him or and so even the most wonderful man who's trying real hard to figure out how to arouse her or stimulate her, like, it's just not a lot of feedback there. So really to explore your own body and figure it out, it's just a lot easier.
You know, you're getting that feedback whereas he he doesn't have any idea if something's working. So he just sometimes men will try the same thing harder or faster or and you're like, not not doing it. You know? So just a plug for that self exploration. Absolutely.
Because every woman's different. Right? And just because a a male partner did one thing in one woman and it worked great doesn't mean it's gonna work great in the next woman. So again, it's communication, communication, communication, which is what Emily Nagoski, she wrote the book Come As You Are and We Come Together was her second book and, her TED talk recently I listened to is really just like, you know, if you want a good relationship, have sex and communicate. That's Yeah.
Really the two main things, that we need in a intimate partnership. Those two things. And oftentimes again, couples will talk about everything else except sex. Mhmm. And and I hear that all the time.
It's like I've had this partner for thirty years, we've never talked about sex. Like Yeah. Oh my goodness. And it's funny because it's not just the prudish couples that that happens. And I mean, we kind of have this idea that it's in people who had a specific religious upbringing or really conservative upbringing.
They're the ones that don't know how to talk to their partners about sex. But I find it to be a lot all over the spectrum. Absolutely. I just think it's not something we ever figure out. I mean, it's not something we're taught.
Yeah. I think that's the thing. We don't have the words. We're not taught. Again, it's that permission and feeling okay to explore.
So again, we're in our own little worlds doing some things, right, but I think culturally it's gonna take a little while. I wanna go back to the clitoral, the clitoral part of the conversation for a minute because I think it's so important. Will you just give us an idea? So I'm trained as an OB GYN. You were trained as an OB GYN and then a fellowship in urogynecology and then advanced training in in sexual health and other other anything else?
Sexual health is above that. And this is not something that we are taught. So if you go to your OB GYN and probably even a urogynecologist, the idea of clitoral adhesions and and it's it's just not going to be a thing that they're going to bring up. Will you kind of tell us about that? Yes.
So I think, our training is very similar, the OBGYN part which is, you know, we're doing preventative health, we're doing, speculum exams, doing pap smears, right, so we're mostly looking at the cervix. We do a maybe a very cursory external exam, but we really were sort of, at least I was taught, like, don't touch your clitoris, it's sensitive and it's, you know, it makes women uncomfortable. Keep it alone. Yeah. Where, again, urologists are handling penises day in and day out.
Right? Like, that's what they do. So it was kinda just like, oh, don't don't touch it. Don't, you know, just be real careful. So that made us feel uncomfortable if we needed to do an exam, and it makes women uncomfortable And you wouldn't really know what to do as an OBGYN.
I mean, what are you looking at anyway? Maybe for lichen sclerosis or Yeah. Skin changes, but otherwise, you're just like, looks like a clitoris. Right. And, you know, if you don't look routinely and you don't know what normal looks like, it's hard to know what's abnormal.
Mhmm. You know, so one of my prior fellows and I are publishing on normal vulvar anatomy, taking every measurement of everything including the glands, the hood, all the things, right, the labia majora minora, all the things, and what we found was about fifteen percent of women had significant clitoral adhesions. So it's not just like a really small subset, like this happens a lot because again, women aren't told about their genitals, we're not told how to perform hygiene in our genitals, we're not examining our genitals, so, again, over time adhesions can build up because we're not told how to properly care for, our genitals. And it's not a complicated exam to see the adhesions. Will you It's not.
Can you walk through that and and tell what you're doing there to do that exam? Yeah. So, if you separate the labia minora and, just walk up a little bit from the urethra, you'll see the hood which is kind of just a Looks like a hood, like you're walking around. Yeah, like a little, like, exactly, I'm like, oh, it's like this. And then you have to generally pull that back, and then the glands, as long as there's no severe adhesions, will present itself.
Mhmm. And there should, the hood should be completely free, meaning if you pull on one side or the other it shouldn't be tethered. So oftentimes we'll pull on one side and the, the glands will pull back because it's tethered to the glands. Mhmm. It should be able to fully retract to see all around the corona, which is the full of glands.
Yeah. So that's how we do it. Thank you. Yeah. So so pain with with clitoral stimulation, inability to orgasm or loss of orgasm or delayed orgasm, those are all things to consider.
Consider in this evaluation. Okay. Absolutely. Anything else you wanna say about, anorgasmia or difficulty with orgasm? I think we still have a lot of work to go on, like, spinal pathologies and evaluating for spine conditions.
There's so many nerve Yeah. Connection there. Because we have so much, low back pain disease and dysfunction. Again, all these nerves originate from the spine. So if you had a spinal compression and the nerves that go from the lower spinal column down to the sacrum could be impinged there.
Also patients that do a lot of like Peloton, I love a good workout but, they're putting a lot of pressure on the ischial tuberosis which are those sitz bones and injure the pudendal nerve which is the nerve that goes and innervates the clitoris. So sometimes it's, especially very thin patients that don't have a lot of Cushion. Cushion there, are more at risk of injuring those nerves. So sometimes it's a nerve issue and I don't think sometimes we think about the nerves as much as we should. Nor are we very good at treating it.
What what tools do you have available in those situations where you feel like it is nerve related? Yeah. So if it's, for sure Peloton writing or I had a patient that was, a a, a drummer, and she sat on this little tiny narrow stool for hours at a time, you know. Sometimes it's just, can we use a memory cushion, can we use other Yeah. Can you do a standing desk?
You know, it's simple things sometimes if they're having just really intermittent issues, But I mean, if they have a true spine pathology, then I'm referring them to, you know, a spine surgeon. Yeah. Okay. So you mentioned the other two types of sexual dysfunction, which I don't think we have sadly, don't have a lot of time to get into. Mhmm.
But I do wanna go back to just the overarching idea of sexual dysfunction. Because you see so many women, I'd like to help women understand their their own lived experience and kind of kind of just relate to women a little bit. I know that you see a lot of women who probably you are not their first encounter for sexual dysfunction. Right? Very likely, they've already been somewhere.
You know, they've tried to find help somewhere. What are they being told out there about their sexual dysfunction, that that maybe is maybe we could do better? Yeah. Well, obviously, you know, we could do better, and I think it starts with education. I think all doctors are good.
Okay. Bottom line, we went into medicine because we wanna help people. Okay. But we don't, if we don't have the tools or training to help people, we then rely on anecdotal evidence or our own, you know, experience that might not be medically based, and we don't give great information, and when we don't validate their symptoms, and it and it honestly can just be validating, like I'm so sorry that, you know, you're having either sexual pain or libido or whatever. I'm gonna refer, I don't I don't have the skill set and I wanna help you, I'm gonna refer you to someone that I know can help you.
But oftentimes of course I hear, especially for sexual pain issues, when an exam looks normal, but the patient's experiencing pain, they're often gaslit and told, you know, you're normal, you need to just relax, you need to drink a glass of wine, yoga, blah blah blah blah. Right? And the woman feels totally broken. And that is shameful, in my opinion. We should not make women feel broken.
We would never do that to a man. We would not say, I'm sorry, your penis isn't working, and you're broken, and I'm not giving you any treatments. Right? Then we would never do that. You should, yeah, you should do better.
That would fix it. Right? Like if a man can't orgasm, like, well, you should do better. Yeah. Exactly.
So I think we need to really evaluate how we treat women and the disparities, and we also need to educate more in medical school, so that's, one of my big pushes, and of course my partner Rachel Ruben's push as well, to educate so we have more people in this space so we can educate more physicians on sexual medicine so it's not just a few small little pockets that know, anything about this. There are two OB GYN focused sexual medicine fellowships though in the country now. One is in Cleveland and one is in DC, so that's exciting. Mhmm. Most sexual medicine fellowships are strictly male focused.
Some have some female in them as well, but most of them are male focused. So there are now two fellowships for sexual dysfunction focusing on women, so that's exciting. I don't I don't wanna be too negative here and focus on the negative, but I do think it's a question that comes up as like, this is 2025. This is not like the early days of medicine. Like, what do you see as the barriers to both?
Because, like I said, you and I both trained. Mhmm. I don't know how long ago you trained. I trained a while ago now. And, like, there was I'm trying to think of of really any significant training I had on sexuality and sexual dysfunction.
And I I mean, I'm not sure I had any. Yeah. I remember Maybe vaginal estrogen? I remember because I was interested. I gave the talk in my residency on sexual dysfunction.
Yeah. I had to educate myself. I had to, like, find any resources, any articles I could, and that was in the two thousands. And, it hasn't really advanced sadly that much more, but I did just give a talk to my prior medical school on sexual dysfunction, so that was exciting, right? So I think all we can do is do things like this, like joining joining on your podcast, which thank you again for having me, right?
The more we educate women, the more they're gonna demand answers, and the more it's gonna push the medical field. I think also more women getting into medicine has been helpful. Yeah. And I do think that's also driving the train a little bit. So and having having strong, bold female urologists, meaning they are themselves female, I think is also helping driving this train because it really highlights the disparities and, we need some smart vocal people like my partner in this space.
Yes. And I really appreciate the way that you and and you you mentioned your partner, doctor Rachel Rubin. I so appreciate the way that you're going about it because you are playing by the rules. Mhmm. You know, you're you're doing the studies.
You're doing the research. You're getting it out there so that it can be, you can't argue against it. You know? It it's it we will have the data to say, like, women deserve this care and women deserve better. And, you know, there's some of us that are like, I I am only in clinic.
I am only seeing patients. And so I have a lot of respect for for folks like you who are still in the world of research and are really making that a priority because in a lot of ways, it can be really, thankless. You know? Yes. And intimidating.
You know? Research, I think, when I went into fellowship, I was so intimidated. I was like, oh my god. Research. I don't know what to do.
And and it's a team and you have mentors and, it's always a team that gets things done. So now I love research because I'm curious and we can find answers to research that, advance women's health. So Yeah. I think a lot of women get a hard they are given a hard time at doctor's offices. And you and I have both, I'm sure, been in other conversations with other doctors where doctors kind of mock patients a little bit for doing their Googling.
You know? Yeah. Oh, my patient came in and they they, of course, knew what the problem was because they Googled it. But, like, I actually think we live in a day and age where women can get pretty accurate information and when women where women can champion their own health. So just to, like I I applaud women who take command of their own health and say, like, I'm not happy with that answer.
I went to the doctor. They told me there was nothing wrong. I know that my sex drive is, like, not normal. It's not how I want it to be. It's not how it should be.
And and they keep trying other doctors, and I so wish they didn't have to. I wish they could hit the right doctor the right time and get the answers, but but I I really applaud women who do the research themselves. And I think fortunately with the Internet being what it is now, you can often get pretty good information. Absolutely. That AI now, I'm telling you Yeah.
Almost anything in, it gives you references and everything. So I think, the times of, oh, they did a Google search are gonna be like, we can't say that anymore because actually Yeah. AI has gotten so good that it can give lots of good information. And honestly, there's lots of great information on social media too. If you follow the right people, you can get a lot of wonderful information.
It's not all, but but again, I think in mainstream medicine, if you have patient goes to their doctor and say, oh, I saw this on social media, it's like Yeah. Right? It's like you can see the eyes rolling back, but really, there's a wealth of information if you're following the right people. Yeah. And there is.
And it unfortunately, it doesn't mean even if the patient knows, like, this is what I need, it doesn't mean the doctor knows, you know, that if that doctor has not received that education, we talk about what is it? A ten year lag or a fifteen year lag between data to application of doctors. And I I do think that patient advocacy, you know, patients advocating for themselves is going to help that if if doctors will listen because those studies that you're completing, they won't be buried in some journal and waiting for our our governing, you know, guidelines of ACOG and, you know, whoever else. We're not gonna have to wait for them because patients are gonna say, hey. Here's this article.
This is a this is published. It's a validated article. You know, it's in a great journal. And if you find good doctors, like I I think both of us are Yeah. I'm gonna take that and be, like, honest about it.
Like, you know what? I haven't heard about this, but let me read about it, and I'll get back to you. And that's gonna disseminate and train doctors in ways that we kind of wish it wasn't that way, but, like, I think it's gonna help, honestly. I love it when patients bring me things I haven't seen. Yeah.
Because I'm like, thank you so much. I have never seen this before and there's no way every doctor can see every bit of literature. It's the amount of journal articles that are published each month is staggering. So there's no way we can see it all. So I always appreciate when patients bring me things so I can better myself.
Yeah. Well, of course, there's so much more to say here, but is there anything you feel like we've really skipped over that needs to be said when we're talking about sexual dysfunction? We didn't go anywhere near pain which is Yeah. Been such a long conversation. It is.
Anything else you wanna just touch on? I just I'm just gonna echo just being an advocate, continuing to speak up for yourself, continuing to ask your physician team if there's other people that you need to be referred to, if they're not skilled in the area that you need to just keep advocating. That's all I would say. Yeah. And that you are not broken and you just haven't found the right physician yet.
Oh, I love that. I love that. Well, will you tell us, doctor Christine, doctor Pacarro? Yes. Will you tell us, where people can find you and where they can find your clinic and and continue?
I know your partner, doctor Reuben, is so big into patient education, so tell us all of the goods there. Yeah. So our practice is, outside the DC area in Bethesda, Maryland. That's where you find us, and well, we have four physicians in our group. One is in LA, three are in DC, but one of our providers is going to LA, so it's gonna be just myself and doctor Rubin, in the DC office, and then we have doctor Winter and doctor Klaus in the LA office.
I'm the only gynecologist trained, the other three physicians are urology trained, but we're all women. I love it. And what is the social what's the best way to learn more about what your practice is doing? Yeah. So it's really easy.
It's all of our names, on social media and Instagram, so it's, I'm doctor Christine Vaccaro. It's doctor Rachel Rubin, doctor Catherine Kloss, and doctor Ashley Winter. Awesome. Well, I am so grateful. I you are such a wealth of information.
I'll say I know a fair bit about this topic, but I have learned a lot from you. So I really appreciate that. I hope others also feel like they have learned so much today. And, we did not cover, I don't know, maybe 25% of what I really wanted to pick your brain about. So, we will definitely have to invite you back and see if we can steal a little more of your time because this is important.
It's important that people know these things about their bodies, and it's not just like a casual conversation that's, like, sort of interesting. This is, like, people should feel better and people shouldn't have to live with these these issues that are sometimes hard for them to bring up and hard to talk about. So the more we can normalize, I'm so grateful. Yeah. I always say, sexual health is health, and sexual health matters.
That's actually a slogan from a sexual, board that I'm on. So if if you want more information about a nonprofit that's doing great stuff in this space, the Sexual Health Education Plus Foundation, She Plus is doing a lot of good work in this space too. Oh, I love it. Thank you for sharing that. We'll be sure to put that in the show notes as well.
Yeah. Wonderful. Thank you so much for having me. Absolutely. Thank you.
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