I mean, I certainly feel like everyone thinks everyone's having lots of sex I'd love you to talk to that and I suppose in ways to reassure anyone listening that they're not alone in this situation

yeah I mean that's the reason I wrote the book is because the sex education just doesn't when we get sex education it is you know you're a teenager maybe if you're not like a junior junior teenager You're not in a long-term committed relationship.

Your body's not going through midlife hormone changes.

You don't have a full-time job with stresses and kids.

Midlife sex is a different beast than trying not to get pregnant and trying not to get a disease when you're 17 years old.

Some people still have to worry about that, but that's not all we have to worry about with midlife sex.

And so it's really the adult sex education that we never got.

Yeah.

Oh, we like to win.

We like to win.

Lots of doping going on.

So they put many anabolic, meaning synthetic, synthetic, uh, molecules on this doped ban list.

One naturally occurring hormone got put on that list, and that's testosterone.

And we'll see that reflected, and patients will go to their doctor and they'll say, "Can I try this?" blah, blah, blah.

One of the myths is that it's dangerous, it's addictive, it's, you know, it d- will cause harm.

Yeah, it can be FDA approved if it's totally unrelated.

So what is it doing?

It is working on cellular health.

So I like to define what a hormone is, right? 'Cause other- otherwise, it's this big scary thing with all these myths.

Hormones travel around the body, and they help healthy cells stay healthy.

That's very important, because hormones don't work so well at treating disease.

They work better at maintaining cellular function.

Cellular health, mitochondrial health, changes in the DNA, changes in the function of the cell, and that's in every single tissue.

So it's like every other-

Let's talk a little bit about how female arousal works.

Arousal comes in two forms, brain arousal and pelvic arousal.

So your brain can be willing, wanna do this, and your pelvis can be like, "No, the blood flow is a challenge." Very similar to erections, 'cause that's just like an easier in your face mechanism to see, is like the guy can wanna have sex.

He can have a good libido.

He can be in the moment, but the penis is just not cooperating.

Same time, penis can be hard, and he's like, "Now is not a good time to use this thing." Right? So the brain's not aroused.

So we got brain and we've got pelvis.

That doesn't mean that there's a-- it's just o- being open and receptive to a partner who loves you and, and like allowing desire to come and having good sex after that.

Let's talk a little bit about how female arousal works.

Arousal comes in two forms, brain arousal and pelvic arousal.

So your brain can be willing, wanna do this, and your pelvis can s- be like, "No, the blood flow is a challenge." Very similar to erections, 'cause that's just, like, an easier in your face mechanism to see.

It's like the guy can wanna have sex.

He can have a good libido.

He can be in the moment, but the penis is just not cooperating.

Same time, penis can be hard, and he's like, "Now is not a good time to use this thing." Right? So the brain's not aroused.

It's just o- being open and receptive to a partner who loves you and, and, like, allowing desire to come and having good sex after that.

So can you talk a little bit about age and hormones, and is it ever too late?

Yeah.

When, when do we ever ask men if they're too old or too young for something, right? We're like, "I'm sorry, you don't get sex anymore 'cause you're 74." Like, we don't judge them like that.

So I, uh, I, I'm a urologist, so I ta- I, I take care of all humans, and oftentimes I hold up the mirror and say, "Is this something we would ask a man?" And if the answer is no, then we say, "Why are we asking a woman?" Right? So perimenopause, oh my gosh.

People are like, "What's the, what's the right age?" And you're like, Lord knows, right? We're, we d- we didn't have owner's manuals.

On my book tour, I met a woman in line, it's like a line to that door to sign books, and she was 24, and she went into menopause when she was 19.

And I think about her so often because she's so at this end of the bell curve, but when we put a number on when you can or you should, we exclude people, and that's not right.

Mm-hmm.

that women are the last why are we the ones who are the least basically coming the least, having the least

amount of pleasure.

Well, I mean, it's really gender bias in our society of like, think of what we call women who actually enjoy sex, right? We call them bad words.

Think of what we call women who don't enjoy sex.

We call them bad words too.

Like you're in a pickle just because of your gender, right? You don't want to want it too much, but if you don't want it, then you have an issue also.

Like you're literally in a double bind if you're a female, especially a heterosexual female where the male pleasure is prioritized.

What do people do in that situation? The big myth is

Yeah.

The body hates drastic change.

Thyroid storm, rapid weight loss, postpartum, right? The body really reacts strongly to drastic change.

So if you go from sea level to Everest base camp in one day, it feels really crappy, right? But if you go there slowly, over time, your body really doesn't know it's now at 17,000 feet.

Same with hormones.

So if you don't have any hormones, you don't have many hormones, and then you go to a super high value, your body kinda gets shocked.

When your body gets shocked by that, your body's like, "Uh, let's not make hair anymore," right? Like, let's do drastic things.

Like creatine.

Many of them haven't been able to have sex for years, and they are mad, and they are so annoyed, and they wanna know if they can take hormones, um, or is it too late? And I'd love to know what your approach is to this group of women, and are you seeing an increasing number of this group of women presenting to you?

Yeah.

So boomers are a huge group.

I think millennials are technically bigger now, but b- boomers are bigger than Gen X.

And the average age of boomers when the WHI hit, which again is a big study that caused a bunch of fear, that was in 2002, average age of boomers was like 51, so they were just hitting menopause, right? So now fast-forward 23, 24 years, now they're 74, right? And I have a old podcast episode called The Boomers Should Be Pissed, and I've done some episodes since then because I just started to listen to them, and they're being very much dismissed, right? And there's a couple of reasons for that.

Number one, people assume that they're fine because of the stigma that like, well, hot flashes only last for seven years, right? Aren't, aren't you over that? You're fine, right? And it's like these women aren't fine.

They haven't slept in 20 years.

But, you know, in, in clinical practice, and obviously I know that you work with a, a big group of, um, colleagues who chat all the time, what are the other benefits that you see testosterone giving women in your practice?

Mm-hmm.

So even that, there is a role for it.

But it, it irritates me when people are like, "It's only for libido." Well, it helps people orgasm more, helps arousal, decreases people's distress over their sexual health.

None of that's libido, right? And so that's just pelvic health.

So now we have blood flow to the clitoris, uh, moisture, orgasm, desire, that's a brain one, because testosterone helps nerves.

It helps the myelin sheaths.

It helps glial cells.

Yeah.

If you're not thinking about sex in a way that is, you know, pro-sex, that impairs your sexual health, too.

So biggest sex organ is the brain.

Dopamine pathway is super interesting, 'cause dopamine is released on pursuing something found to be rewarding.

Why is that important with sex? You can't take me out to dinner and feed me cold chicken and mushy broccoli and then say, "Well, why don't you like food, Kelly?" Well, I don't like m- mushy broccoli.

You c- I, I can't desire something that's not rewarding to me.

And so, so many women...

What are the role of, of the neurotransmitters, dopamine, serotonin, and what i- what is the reward pathway?

Yeah.

I'm not overwhelmed as much.

I don't hit a wall at 3 p.m. is what a lot of people say, right? How do you study that? How do you study not hitting a wall at 3 p.m.? And my point is, these hormones are so integral to how the body functions that it's almost hard to study it because the human just feels better.

And let's go into that placebo.

Number one, statins have a placebo effect.

Nobody knows that.

Number two, SSRIs...

The big studies say they probably don't work much more than placebo.

And that's a real problem, isn't it?

Can you talk about, can you just walk us through testosterone, estrogen, progesterone, and what happens when they all decrease at each one?

So the sex hormones, which we hate the word sex in discussing hormones because it makes them feel like they're extra or like, well, I'm not having sex or I'm not having babies.

So do I need these? Right.

We've labeled them because we discovered them in rooster testicles and bull ovaries.

Right.

So like they came from gonads.

So we call them sex hormones.

Can we talk about atrophy of the vagina? What happens and how do you know if your vagina has atrophied?

Mm-hmm.

And then some s- very smart researchers were like, "Ah, I think there's different menu items here." They went up to women and they said, "If we offered you shame free, non-judgmental, safe, no risk of pregnancy, no risk of disease, loving, orgasmic pleasure, would you like that tonight?" All the women said yes.

Ah, I see.

Right? So a mouse has very small mice ovaries.

Elephant has big elephant ovaries.

Human have human-sized ovaries.

There's only so many follicles, so many eggs.

Enough years go by, you've outlived the size of the ovary.

Number one killer amongst women in the UK, though.

Number one killer amongst women in the UK already.

I always joke America has good options of killing people for other reasons.

So we probably would be there, but we kill people for other reasons.

Joking, not joking.

But it's coming, America.

Don't think this isn't coming for us as well.

Yeah.

[laughs]

Right? But I, I think their voices aren't heard or reflected, and the myths are often stronger than the truth.

This podcast is sponsored by Addy.

If your libido is gone and it's bothering you, that matters.

Not should it matter, it does.

There's actually a diagnosis for this, HSDD.

And the better news, there's a treatment.

And one of the things I said to this woman last night, and I say to just about every woman I meet anywhere anymore, is, "Vaginal estrogen, vaginal estrogen, vaginal estrogen." Please tell us again why it matters so much.

Well, what is that about?

Uh, it's just so shameful.

I mean, we know, we gr- we traditionally in America, it's better than some countries, but it's a, you know, pretty puritanical place.

Um, you know, we- there's this big fear that if we teach people about sex then like, you know, the 17-year-olds are gonna go crazy, and the data doesn't s- actually support that.

Um, but we don't get sex education.

We don't get the tools.

We don't know how to communicate about hard things, right? Like we don't get taught how to talk about it, and I would say a large amount of people's sexual issues in midlife is because you've been limping along and then you're kinda doing like the repetitive-...

Like, what did you mean by that, about gendering hormones?