Dr Mohit Khera Links Falling Male Testosterone Levels to Rising Obesity

Mohit Khera 博士指出男性睾酮水平下降与肥胖率上升密切相关 不良饮食和肥胖导致几十年来男性睾酮水平持续下降，这不仅直接威胁生育能力和性功能，更是整体健康状况的重要风向标。 Mohit Khera 博士探讨了导致全球性健康、生育能力和睾酮水平下降的系统性生理、心理及生活方式因素。他强调，勃起功能障碍等病症通常是糖尿病和心血管问题等代谢性疾病的早期预警信号，而非孤立存在的问题。讨论涉及基于循证医学的干预措施，从地中海饮食、优化睡眠和运动，到睾酮替代疗法、局部阴道雌激素以及泌尿外科再生疗法。最后，Khera 博士呼吁消除对性功能障碍的病耻感，鼓励伴侣间坦诚交流，并在延长整体寿命的同时积极延长个人的性健康寿命。 睾酮是衡量男性整体健康的关键风向标，直接影响心血管功能、糖尿病风险、骨密度以及思维清晰度。 (46:45) 近几十年来男性睾酮水平急剧下降，从20世纪70年代平均约700 ng/dL降至近年来的400多 ng/dL，这在很大程度上是由肥胖增加、加工饮食及久坐生活方式导致的。 (48:47) 男性生育能力与整体健康密切相关，精索静脉曲张或精子数量偏低等状况可作为糖尿病和心血管疾病等更广泛健康问题的早期预警。 (50:19) 生活方式的调整——包括地中海饮食、7至8小时睡眠以及每周160分钟的中高强度运动——可以自然逆转或显著改善勃起功能障碍。 (55:35) 勃起功能障碍极为常见，且遵循与年龄相关的患病率经验法则（例如40岁男性中有40%、50岁男性中有50%患病），它常作为未确诊代谢性疾病的早期诊断窗口。 (59:53)

Urologist Dr. Mohit Khera argues that extending "sexspan"—the years of satisfying sexual function—requires treating sexual health as a barometer of vascular, metabolic, and psychological wellness rather than relying on quick pharmaceutical band-aids. Erectile Dysfunction as a Cardiovascular Warning System (6:56) Dr. Khera defines sexspan as the period of life during which an individual is physically and mentally capable of engaging in satisfying sexual activity, which ideal medical care aligns with overall lifespan. Erectile dysfunction (ED) frequently serves as the earliest clinical warning sign of systemic cardiovascular disease due to the arterial diameter theory. Penile arteries measure 1 to 2 mm in diameter, compared to coronary arteries at 3 to 4 mm and carotid arteries at 6 to 7 mm. Because arterial blockages affect smaller vessels first, a 50% occlusion impairs penile blood flow years before producing angina, heart attacks, or strokes. Clinical data indicates that ED prevalence tracks chronological age: 40% of men experience it at age 40, rising by 10% each decade up to 80% at age 80. Furthermore, approximately 30% of 40-year-old men presenting with ED have undiagnosed pre-diabetes or diabetes. Despite these urgent systemic implications, Dr. Khera notes that only 50% of men with ED discuss it with healthcare providers, primarily due to social stigma. Metabolic Drivers of Decadal Testosterone Decline (36:24) Historical population data demonstrates a steep secular drop in male testosterone. Baseline measurements from the 1970s Framingham Heart Study averaged around 700 ng/dL for men aged 18 to 40, whereas 2015 cohorts dropped to the mid-400 ng/dL range—a decadal loss of roughly 50 ng/dL. Dr. Khera attributes this downward trajectory to rising rates of obesity, metabolic syndrome, and high-carbohydrate diets. Adipose tissue expresses aromatase, an enzyme that converts circulating testosterone into estrogen, while fat cells secrete cortisol and leptin that further suppress testicular signaling. This hormonal reduction is clinically reversible through lifestyle intervention. Citing the European Male Aging Study, Dr. Khera notes that a 10% loss of body weight produces an average serum testosterone gain of 85 ng/dL, while a 15% reduction yields a 250 ng/dL rebound. For clinical testosterone replacement therapy (TRT), Dr. Khera cites the six-year, 5,200-patient Traverse trial—which he co-investigated—demonstrating that physiological TRT does not increase the risk of major adverse cardiovascular events, prostate cancer, or worsening urinary symptoms. Overcoming Disparities in Female Sexual Dysfunction (23:24) Female sexual dysfunction (FSD) affects an estimated 43% to 48% of American women across four categories: decreased libido, impaired arousal, orgasmic dysfunction, and sexual pain. However, only 19% of affected women receive medical care. Dr. Khera emphasizes a persistent therapeutic gap: in 2015, pharmacies carried roughly 30 FDA-approved medications for male sexual dysfunction and none for women. While two medications (Addyi and Vyleesi) have since been approved for low female desire, the U.S. still lacks an FDA-approved testosterone formulation for women, despite women producing more testosterone by weight than any other single hormone. Consequently, physicians frequently prescribe male testosterone formulations off-label at approximately one-tenth of the male dose to address diminished female libido, bone density loss, and fatigue. For postmenopausal dyspareunia (painful intercourse), Dr. Khera identifies estrogen-deficient vaginal atrophy as the primary physical driver. Localized vaginal estrogen therapy—administered via creams or suppositories—rebuilds tissue thickness, resolves intercourse-related pain within roughly three months, and significantly reduces recurrent urinary tract infections. Interventions from Psychogenic Cycles to Surgical Restoration (15:29) Sexual desire depends on a balance between excitatory neurotransmitters (dopamine, norepinephrine) and inhibitory signals (serotonin, cortisol). A single erectile failure can trigger an avoidance cycle driven by performance anxiety, while hyper-stimulated digital expectations from pornography can create an expectation delta that blunts partner-directed libido. To disrupt psychogenic performance anxiety, Dr. Khera prescribes low-dose continuous daily Cialis (5 mg), which maintains round-the-clock vascular readiness and improves endothelial function without the acute pressure of on-demand dosing. When conservative and medical approaches fail, treatment advances along a structured hierarchy. While regenerative modalities such as low-intensity shockwave therapy are increasingly utilized to induce neoangiogenesis (new blood vessel formation) in penile tissue, end-stage vascular ED is treated with surgical penile prostheses. Invented in 1973 at Baylor College of Medicine, the three-piece hydraulic implant allows on-demand rigidity while preserving natural sensation and ejaculation, generating patient and partner satisfaction rates exceeding 92%. Dr. Khera stresses that sexual dysfunction in both men and women is a treatable medical condition rather than an inevitable personal failure. Significant clinical and regulatory hurdles remain, however, including the absence of FDA-approved female testosterone products and the reality that approximately 40% of male infertility cases remain medically unexplained.

泌尿外科与男科专家 Dr. Mohit Khera 指出，个体的“性健康期”（sexspan）应当与总体寿命及健康期相匹配；勃起功能障碍等性问题不仅关乎生殖健康，更是心血管硬化与代谢紊乱的首发早期预警。通过纠正激素失衡、调整神经化学状态以及消除伴侣间的心理回避，多数性功能退化均能通过阶梯式医学干预得到逆转。 性健康期概念与勃起障碍的心血管警报 (6:56) Dr. Khera 将“性健康期”定义为个体在身体与心理上能够维持满意性生活的年限。目前美国人群的平均寿命约为 77 岁，健康期约为 63 至 67 岁，而性健康期往往更早衰退。延长性健康期的四大基石包括生活方式（饮食、运动、睡眠与减压）、激素优化、将性视为伴侣共同议题，以及针对性医学干预。 在临床诊断中，勃起功能障碍（ED）常作为全身心血管疾病的前驱指征，其机制源于“动脉直径理论”：阴茎动脉直径仅为 1 至 2 毫米，冠状动脉为 3 至 4 毫米，颈动脉为 6 至 7 毫米。若发生 50% 的管腔狭窄，管径最小的阴茎血管会最先出现血流不足，比心肌梗死或中风提前数年显现。临床数据显示，因 ED 就诊的 40 岁男性中，约 30% 在初筛当天被查出未确诊的糖尿病前期或糖尿病。ED 发病率呈现随年龄每十年递增 10% 的规律（40 岁约 40%，50 岁约 50%），但受病耻感阻碍，仅半数患者会主动求医。 欲望神经化学、心理恶性循环与外部干扰 (11:07) 性欲受激素与神经递质共同调控。Dr. Khera 提出调控欲望的激素助记词“PET”（催乳素 Prolactin、雌激素 Estrogen、甲状腺素 Thyroid 与睾酮 Testosterone），催乳素过高或睾酮低下会严重削弱性冲动。在神经化学层面，多巴胺、去甲肾上腺素和催产素属于促进性兴奋的兴奋信号，而五羟色胺与高皮质醇则为抑制信号；因此，升高五羟色胺的 SSRI 类抗抑郁药与保法止等药物常诱发性欲抑制。此外，男性常将性作为减压机制，而女性通常需要先舒缓压力才能建立对性的接纳。 表现焦虑极易诱发心理性 ED，并引发“害怕失利—焦虑加剧—再次失利”的回避型恶性循环。若男性在晨间或自慰时勃起充血正常，但在与伴侣相处时无法勃起，通常指向心理性原因。针对此类情况，Khera 建议每日小剂量服用 5 毫克他达拉非（Cialis），通过维持全天候血药浓度解除临场服药的心理负担，同时修复内皮血管。此外，过度依赖色情制品会造成现实刺激与视觉幻象之间的落差，诱发获得性性功能障碍；短期完全停用色情制品有助于神经系统重置并恢复对伴侣的自然反应。 睾酮时代性骤降、代谢关联与安全澄清 (48:47) 流行病学数据显示男性睾酮水平近数十年呈整体下滑。从 1970 年代 Framingham 心脏研究记录的平均约 700 ng/dL，降至 2015 年的 400 多 ng/dL，相当于每十年下降约 50 ng/dL。高糖高碳水饮食与肥胖流行是关键推手：脂肪细胞富含芳香化酶，能将天然睾酮转化为雌激素，且脂肪细胞释放的瘦素与皮质醇会抑制下丘脑-垂体促性腺轴。欧洲男性衰老研究（EMAS）证实减重具有双向调节效应：体重减轻 10% 可使血清睾酮平均回升 85 ng/dL，减重 15% 可回升约 250 ng/dL。 针对外源性睾酮补充疗法（TRT）的安全性，由 5,200 名男性参与、历时 6 年的 Traverse 随机对照试验表明，生理剂量的 TRT 不会增加主要不良心血管事件、前列腺癌风险或加重下尿路症状。Khera 强调应区分生理治疗（恢复至 300 至 1,000 ng/dL 的正常受体饱和范围）与运动员滥用合成类固醇（常超过 2,000 ng/dL）。对于尚未生育的年轻男性，外源性睾酮会直接抑制精子生成并致不育，应选用克罗米芬或人绒毛膜促性腺激素（HCG）刺激内源睾酮分泌。 女性性健康缺口与激素多维干预 (23:24) 女性性功能障碍（FSD）在临床上长期存在诊疗缺口。全美约 43% 至 48% 的女性受其困扰，但仅有 19% 寻求治疗。截至 2015 年，FDA 批准了约 30 种男性性药物，女性专用药物为零；目前仅批准了氟班色林（Addyi）和布美诺肽（Vyleesi）两种用于低性欲的药物，导致临床常超说明书使用小剂量西地那非等男性药物来改善女性局部血流。 Khera 指出，按绝对重量计算，睾酮是女性体内产生最多的单种激素，其缺乏会导致性欲丧失、骨质流失与脑雾。目前美国尚未批准针对女性的睾酮制剂，临床实践多采用常规男性剂量的约十分之一进行超适应症替代。在更年期管理中，除雌激素与孕激素外，睾酮构成了激素优化的关键“三角”。此外，绝经期雌激素断崖式下跌常导致阴道黏膜萎缩、组织撕裂及反复尿路感染；局部使用阴道雌激素软膏或栓剂（通常需两至三个月显效）能有效重建局部微环境，从根源上缓解因疼痛引发的性回避。 阶梯式干预体系与伴侣亲密关系重构 (74:55) 针对各类型性功能障碍，临床遵循从基础生活方式到高阶外科技术的阶梯式治疗。针对全球约 30% 男性存在的早泄（PE，射精潜伏期小于 2 分钟），行为疗法（动-停法或挤压法）是根本治疗途径，选择性五羟色胺再摄取抑制剂（SSRI）或利多卡因喷剂可作为药物辅助。针对器质性病变，如患病率达 9% 的佩罗尼氏病（阴茎硬结症），可采用胶原酶注射破坏斑块或手术矫正；而低强度体外冲击波治疗等再生医学手段，则通过局部微损伤诱导新生血管形成。若口服药与注射均失效，三件套可膨胀阴茎假体植入术历经 50 余年发展，患者与伴侣满意度超过 92%，可实现受控的人工充血且保留完整感觉与射精功能。 在生理治疗之外，打破伴侣间的沉默至关重要。调查显示仅 44% 遭遇 ED 的男性会向伴侣坦诚，多数人选择回避亲密并找借口推托，从而引发信任危机。Khera 强调满意性生活不应被狭隘限定为插入式性交，引入情趣玩具、探索非插入式性愉悦与共同就诊，均能有效降低表现压力并修复亲密关系。 Dr. Khera 强调性机能衰退并非不可逆的自然衰老代价，而是一种与生活方式、微血管病变和内分泌系统高度绑定的可治愈病症。尽管阶梯式治疗和再生医学已提供丰富手段，但男科中仍有约 40% 的不育症属于医学暂无法完全阐释的特发性病因；消除社会病耻感、落实常规睾酮筛查并推动女性性激素疗法的法规完善，仍是当前性医学领域悬而未决的核心议题。

## Background 本期内容由知名商业与访谈播客《The Diary Of A CEO》（主持人 Steven Bartlett）于 2025 年 1 月 9 日在 YouTube 平台发布。节目特邀贝勒医学院泌尿外科教授、性医学专家莫希特·凯拉博士（Dr. Mohit Khera），深入探讨性寿命（Sexspan）、睾酮水平暴跌、男女两性性功能障碍的成因及科学应对方案。 ## TL;DR 凯拉博士指出，勃起功能障碍（ED）并非孤立的生理问题，而是心血管疾病与代谢紊乱的早期关键预警哨兵，其与肥胖、低睾酮及心理焦虑深度交织。性功能障碍本质上是一种“伴侣共同疾病”，单纯给单方开药往往会激化关系矛盾，必须男女同治并结合饮食、运动、睡眠与减压这四大自然基石。访谈全面剖析了低剂量每日他达拉非的组织修复机制、女性性功能障碍长期被忽视的医疗现状、睾酮替代疗法（TRT）的科学真相，以及从冲击波再生疗法到充气式阴茎假体植入的完整治疗阶梯。 ## Atmosphere & style 整场对话在严谨的临床医学实证与极其坦诚私密的个人剖白之间游刃有余地穿梭，褪去了传统性话题的暧昧与尴尬，呈现出一种充满同理心且高度理性的科学质感。主持人 Steven 毫不避讳地分享自身在疲惫与亲密关系中的困惑与体验，凯拉博士则以权威而温暖的医者姿态破除病耻感，并在尾声借父亲因过度推迟享受而早逝的遗憾，将医学探讨升华至对当下生命与亲密关系的深情凝视，令人震撼且倍感治愈。 ## Bulletin - [09:09](https://www.youtube.com/watch?v=IgW1jepnJp4&t=549s) 勃起功能障碍（ED）是心血管危机的早期预警哨兵，由于阴茎动脉管径仅1至2毫米，其堵塞往往比冠状动脉早数年发生，15%的初诊ED患者会在7年内遭遇心梗或中风。 - [18:34](https://www.youtube.com/watch?v=IgW1jepnJp4&t=1114s) 与按需临时服用伟哥不同，每日小剂量（5毫克）他达拉非（Cialis）可修复海绵体平滑肌并保护血管内皮，研究显示其可使心血管意外风险降低13%、全因死亡率降低25%。 - [39:04](https://www.youtube.com/watch?v=IgW1jepnJp4&t=2344s) 过去半个世纪中成年男性平均睾酮水平暴跌近300 ng/dL，而肥胖中活跃的芳香化酶会加速睾酮向雌激素转化，EMAS研究证实减重15%可使睾酮显著回升约250 ng/dL。 - [01:09:56](https://www.youtube.com/watch?v=IgW1jepnJp4&t=4196s) 历时6年、纳入5200名受试者的Traverse试验证实，规范的睾酮替代疗法（TRT）既不会增加心血管疾病风险，也不会诱发前列腺癌或加重排尿障碍。 ## Key takeaways - [02:01](https://www.youtube.com/watch?v=IgW1jepnJp4&t=121s) 性寿命（Sexspan）是维持高满意度性活动的时间跨度，其衰退往往早于健康寿命，构筑饮食、规律运动、优质睡眠与减压四大基石是延长老龄性寿命的核心。 - [03:40](https://www.youtube.com/watch?v=IgW1jepnJp4&t=220s) 性功能障碍本质上是一种“伴侣疾病”，孤立提升单方性欲往往会加剧关系矛盾，治疗必须同时兼顾男女双方的心理与生理状态。 - [06:56](https://www.youtube.com/watch?v=IgW1jepnJp4&t=416s) 若早晨晨勃良好或自慰正常但面对伴侣时疲软，确诊为心理性ED，往往源于单次失败后的“表现焦虑”，使房事转变成交感神经兴奋的高压考核。 - [11:07](https://www.youtube.com/watch?v=IgW1jepnJp4&t=667s) 男女在应对压力与性欲上存在生理差异：男性倾向于通过性爱缓解压力，而女性通常必须先脱离慢性压力才能唤起性欲。 - [29:18](https://www.youtube.com/watch?v=IgW1jepnJp4&t=1758s) 长期过度观看色情内容会拔高大脑多巴胺刺激阈值，产生无法在现实中兑现的虚幻预期，是诱发年轻人心理性ED的重要诱因。 - [30:50](https://www.youtube.com/watch?v=IgW1jepnJp4&t=1850s) 全球年轻一代性活动频率骤降，除数字化与拟社会关系影响外，根本诱因是代谢综合征与肥胖率飙升导致的整体生理素质及睾酮水平下滑。 - [40:11](https://www.youtube.com/watch?v=IgW1jepnJp4&t=2411s) 有生育需求的年轻男性绝对禁用直接补充外源性睾酮（会抑制精子生成），而应采用促内源性生成药物（如氯米芬或HCG）来保留生育力。 - [44:13](https://www.youtube.com/watch?v=IgW1jepnJp4&t=2653s) 睾酮是两性健康的底层晴雨表，女性体内生成的睾酮总量甚至高于其他单一激素，但针对女性低睾酮的专用处方药在英美等国长期面临准入空白。 - [50:19](https://www.youtube.com/watch?v=IgW1jepnJp4&t=3019s) 精液质量是全身代谢与心血管的早期警报器，精子计数低下的男性未来罹患糖尿病和缺血性心脏病的几率显著提高。 - [55:57](https://www.youtube.com/watch?v=IgW1jepnJp4&t=3357s) 地中海饮食与每周160分钟中高强度运动通过恢复全身血管内皮功能，能够带来不亚于药物的勃起硬度及女性性功能评分提升。 - [01:06:45](https://www.youtube.com/watch?v=IgW1jepnJp4&t=4005s) 早泄是全球约30%男性的困扰，男女生理高潮时间差（平均5.4分钟对比13.4分钟）放大了该问题，动-停法等行为治疗相比单纯药物更为治本。 - [01:13:19](https://www.youtube.com/watch?v=IgW1jepnJp4&t=4399s) 睾酮与抑郁症存在紧密生理联系，近850例临床追踪显示92%的低睾酮男性伴随抑郁，补充睾酮可协同增强SSRI类抗抑郁药的疗效。 - [01:16:00](https://www.youtube.com/watch?v=IgW1jepnJp4&t=4560s) 绝经后女性的性交疼痛多由雌激素断崖式下跌导致的阴道组织萎缩引起，局部外用阴道雌激素治疗3个月可有效修复黏膜并缓解疼痛。 - [01:23:35](https://www.youtube.com/watch?v=IgW1jepnJp4&t=5015s) 佩罗尼氏病（阴茎硬结症）困扰着全球约9%的男性，纤维斑块导致勃起弯曲超过60度时将丧失性交能力，可通过胶原酶注射或手术矫正。 - [01:27:52](https://www.youtube.com/watch?v=IgW1jepnJp4&t=5272s) 可充气式阴茎假体植入是重度难治性ED的终极阶梯疗法，虽然具有破坏海绵体平滑肌的不可逆性，但保留了神经快感与射精能力，满意度位居所有疗法之首。 ## Detailed walkthrough ### [00:00](https://www.youtube.com/watch?v=IgW1jepnJp4&t=0s) 什么是“性寿命”与性健康危机的警钟 在访谈开篇，莫希特·凯拉博士（Dr. Mohit Khera）抛出了一个许多人从未听闻的概念——“性寿命”（Sexspan）。所谓性寿命，是指一个人一生中能够持续参与并享受令人满意的性活动的时间跨度。绝大多数男女都渴望自己的性寿命能与整体寿命一样长久，但现实中性功能障碍的普遍程度却令人震惊。在美国，大约有 43% 到 48% 的女性饱受女性性功能障碍的困扰；全球范围内约有 30% 的男性面临早泄问题；而到了 40 岁，多达 40% 的男性会出现不同程度的勃起功能障碍（ED）。 更关键的是，勃起功能障碍往往是人体其他重大潜在健康危机浮出水面的“第一信号”。在出现 ED 的男性中，高达 66% 伴有不同程度的抑郁症，更有 15% 的患者会在确诊后的 7 年内遭遇心脏病发作或中风。肥胖是导致 ED 的关键推手之一，它会直接引起睾酮水平断崖式下跌，进而扼杀男女性的性欲。然而，由于强烈的羞耻感与病耻感，无数人在痛苦中保持沉默、刻意逃避亲密接触。凯拉博士强调，这些问题并非不可逆转，通过科学手段提升睾酮、改善勃起质量以及自然调理生活方式，完全可以让性功能重获新生。 - **43%–48%**：美国女性中受女性性功能障碍困扰的比例。 - **30%**：全球男性中受早泄影响的比例。 - **40%**：男性在 40 岁时遭遇勃起功能障碍的比例（此比例随年龄增长逐年攀升）。 - **重大疾病预警**：ED 患者中有 66% 伴随抑郁，15% 在 7 年内发生心肌梗死或中风。 --- ### [02:01](https://www.youtube.com/watch?v=IgW1jepnJp4&t=121s) 寿命、健康寿命与性寿命的差距 作为贝勒医学院（Baylor College of Medicine）专注于男女两性性功能障碍、睾酮替代疗法以及男性不育症领域长达 17 年的教授兼泌尿外科专家，凯拉博士向主持人史蒂文·巴特利特（Steven Bartlett）深入剖析了寿命的三重维度。大众通常熟知“寿命”（Lifespan，即生存年限）以及“健康寿命”（Healthspan，即健康无疾的生活时长），但极少关注“性寿命”（Sexspan）。 以美国为例，人口平均寿命约为 77 岁，但平均健康寿命仅有 67 岁；若参考美国疾病控制与预防中心（CDC）关于“无残疾生存时间”的数据，这一数字甚至只有 63 岁。这意味着普通人生命末期往往存在长达 10 到 15 年的“残障差距”（Delta），在此期间身心受限、无法充分享受生活。对于性寿命而言，若缺乏主动干预，其衰退往往比健康寿命来得更早。实现“性寿命与健康寿命、自然寿命齐平”，正是现代性医学追求的核心目标。 ```mermaid flowchart LR accTitle: 寿命、健康寿命与性寿命的差距模型 accDescr: 展示自然寿命、健康寿命以及残疾差距之间的年限对比 subgraph Timeline["美国人口平均生存维度"] A["无残疾寿命<br/>63 岁 (CDC)"] --> B["平均健康寿命<br/>67 岁"] B --> C["平均自然寿命<br/>77 岁"] end Delta["残障/失能差距<br/>10-15 年"] -.-> B Delta -.-> C Sexspan["理想目标：性寿命 (Sexspan)<br/>同步维持至自然寿命终点"] === Timeline ``` --- ### [03:40](https://www.youtube.com/watch?v=IgW1jepnJp4&t=220s) 延长性寿命的四大基石与“伴侣疾病”假说 当史蒂文询问是否有切实有效的方法能让性寿命贯穿终生时，凯拉博士明确指出，关键在于构筑坚不可摧的“四大基石”：饮食、运动、睡眠与减压。他直言：“在这个星球上，没有任何一种药物的功效能够超越饮食、运动、充足睡眠与减压的综合作用。”这四大基石不仅能显著拉长男女双方的性寿命，更是维系健康寿命与自然寿命的根本底气。在此之上，荷尔蒙（尤其是睾酮）起到了决定性的驱动作用，合理的激素补充疗法能够大幅改善两性性功能，但令人遗憾的是，目前全球范围内针对女性的荷尔蒙治疗手段依然极度匮乏。 凯拉博士进一步提出了一个深刻的临床视角：性功能障碍本质上是一种“伴侣疾病”（Couple's Disease）。他给史蒂文打了个生动的比方：假设你的伴侣明天突然单方面宣布再也不想和你发生性关系，除非你选择出轨或分手，否则你的性生活将就此终结。这证明性绝对不是单打独斗的事，个人的性寿命在很大程度上受制于伴侣的状态。“如果你想延长自己的性寿命，就必须确保你的伴侣同样保持参与度与身心健康。” --- ### [04:56](https://www.youtube.com/watch?v=IgW1jepnJp4&t=296s) 职业生涯的顿悟：治疗必须同时兼顾双方 在回顾自己的履历时，凯拉博士介绍了他严苛的医学训练之路：自 2000 年进入住院医师阶段，他先后完成了 1 年普外科培训、5 年泌尿外科专科深造，以及 1 年男性健康临床研究员（Fellowship）训练。随后他加入贝勒医学院组建基础科学实验室，17 年来一手搞前沿学术转化，一手抓临床试验。目前他的日常极为充实：每周接诊约 150 名患者，主刀 6 到 8 台手术，并固定每周在退伍军人事务部医院（VA Hospital）服务退伍军人半天。 谈及为何会同时涉足女性性功能障碍，凯拉博士分享了一段戏剧性的临床转折点。当年刚完成专科培训时，他凭借高超医术帮助众多男性重获坚挺的勃起和旺盛的性欲，内心充满成就感。然而某天，一位患者的妻子情绪崩溃地打电话痛斥他：“你给我丈夫治好了，他现在勃起极好、性欲冲天，可我根本不想做爱！他成天缠着我，导致我们现在的关系糟糕透顶，你彻底毁了我们的婚姻！” 这通当头棒喝让凯拉博士瞬间顿悟：性医学的铁律在于“要么两人的性欲都维持在低水平，要么同时提升两者；千万不能只拔高一方，否则就是一场灾难”。认识到不能孤立治疗单方后，他立即飞赴圣地亚哥拜访被誉为“女性性功能障碍教父”的欧文·戈德斯坦博士（Dr. Irwin Goldstein），潜心进修女性性医学。自此 16 年间，他始终坚持男女同治的整体诊疗理念。 --- ### [06:56](https://www.youtube.com/watch?v=IgW1jepnJp4&t=416s) 初诊问诊艺术：辨别生理性与心因性 ED 凯拉博士指出，大部分普通人在家庭医生（GP）那里根本得不到有效的性健康指导。全美医学生的调查数据显示，仅有 65% 的医学生接受过性医学培训，而在这些人当中，又有半数直言所学课程质量极差。因此，医生面对患者时的问诊技巧至关重要。多数找上门的男性患者，都是在自行尝试壮阳药失败后前来求助其他方案的。 在初诊评估时，凯拉博士通常使用极为直截了当的“两个黄金问题”来迅速筛查勃起功能障碍： 1. 你能否获得足以插入的勃起硬度？（是 / 否） 2. 你能否将该勃起维持到达到性高潮或获得快感？（是 / 否） 只要任何一个回答为“否”，医学上即可认定其患有勃起功能障碍。随后，必须深入挖掘患者的勃起细节以判断其病因属性： - **自发/晨勃情况**：是否能自主勃起？早晨醒来是否有晨勃？ - **自慰情况**：在独自手淫时能否达到良好的勃起状态？ 如果一名男性的回答是：“医生，我晨勃非常好，一个人自慰时硬度完全没问题，但只要一面对伴侣就彻底软掉”，这就确凿无疑属于**心因性勃起功能障碍（Psychogenic ED）**。心因性 ED 的根源在于大脑中的精神压力、焦虑或心理防御机制抑制了性中枢的正常激活。在这种情况下，单纯依靠生理药物收效甚微，往往需要专业的性治疗师（Sex Therapist）介入，解开患者面对伴侣时的心理枷锁。凯拉博士感叹，无论是男性还是女性，心理因素在性反应过程中都占据着举足轻重的分量。 ### [09:09](https://www.youtube.com/watch?v=IgW1jepnJp4&t=549s) 勃起功能障碍（ED）：心血管危机的预警哨兵 ```mermaid flowchart LR accTitle: 动脉直径理论示意图 accDescr: 展示血管直径大小与堵塞发生先后顺序的关系 subgraph Arteries ["动脉血管直径对比"] direction TB P["阴茎动脉<br/>(1-2 mm)"] --> C["冠状动脉<br/>(3-4 mm)"] --> K["颈动脉<br/>(6-7 mm)"] end subgraph Symptoms ["临床表现出现顺序"] direction TB ED["勃起功能障碍 (ED)"] --> HA["心脏病发作 (心梗)"] --> ST["中风 (脑卒中)"] end P -.->|早期堵塞| ED C -.->|中期堵塞| HA K -.->|晚期堵塞| ST ``` Mohit Khera 医生指出，ED 绝非仅仅是局部的性功能障碍，它与男性的心理健康及全身心血管系统紧密相连。在就诊的 ED 男性中，高达 66% 伴有不同程度的抑郁症，35% 伴有焦虑症。更关键的是，ED 往往是重大潜在器质性病变的“第一警讯”。临床数据显示，如果一名男性今天因 ED 来到诊室，其中 15% 的人会在未来 7 年内遭遇心肌梗死（heart attack）或中风；而在因突发心肌梗死被送进急诊室的男性中，Montorsi 医生的研究证实，他们平均在发病前 39 个月就已经出现了 ED 症状。 这一现象在医学上有一个极具说服力的解释——**动脉直径理论（Arterial Diameter Theory）**。人体的阴茎动脉管径非常细小，仅有 1 至 2 毫米；心脏冠状动脉管径约为 3 至 4 毫米；而颈动脉则达到 6 至 7 毫米。从血管生理学来看，当动脉管腔发生约 50% 的闭塞时就会产生缺血性损伤。因此，相同的全身性动脉粥样硬化病变，必然会最先完全影响管径最狭窄的阴茎动脉，随后波及冠状动脉，最后才显现于颈动脉。希腊的一项临床研究评估了 50 名新发 ED 的男性，在通过超声心动图或负荷试验筛查阳性后进一步进行冠状动脉造影，发现大约 20%（即每五人中就有一人）已经存在不同程度的冠脉堵塞（单支、双支或三支血管病变）。因此，Khera 医生每次在给 ED 患者开处方时，都在警惕对方是否属于那 20% 潜伏心血管疾病的患者，并试图抓住这个早期干预的黄金窗口。 - 就诊 ED 患者中抑郁发生率达 66%，焦虑发生率为 35%。 - 确诊 ED 的男性在 7 年内心脏病发作或中风的概率为 15%。 - 心肌梗死急诊患者平均在心梗发作前 39 个月就已出现 ED。 - 血管直径阶梯：阴茎动脉（1-2 mm） < 冠状动脉（3-4 mm） < 颈动脉（6-7 mm）。 - 希腊临床研究显示，约 20%（1/5）的初诊 ED 患者经造影证实存在隐匿性冠状动脉硬化狭窄。 --- ### [11:07](https://www.youtube.com/watch?v=IgW1jepnJp4&t=667s) 性欲减退的多重诱因：激素、神经递质与生活压力 针对 Steven Bartlett 提出的朋友群体中常见的性欲减退及“伴侣契合度”问题，Khera 医生明确表示性欲（Libido）是一个多维度的复杂生理与心理网络，主要受四大因素驱动： 1. **内分泌激素（用记忆口诀“PETT”归纳）**：必须系统排查四种关键激素——催乳素（**P**rolactin）、雌激素（**E**strogen）、甲状腺素（**T**hyroid）和睾酮（**T**estosterone）。如果催乳素偏高或睾酮偏低，性欲就会直接跳水。绝经期女性的性欲低迷常深植于激素的急剧波动。 2. **神经递质平衡**：多巴胺（Dopamine）、去甲肾上腺素（Norepinephrine）与五羟色胺（Serotonin）直接调控大脑的性冲动。多巴胺升高会激发性欲，而五羟色胺上升则会抑制性欲。最典型的反面教材是抗抑郁药，由于其机制是提升体内的五羟色胺水平，极易重创患者性欲；此外，男性用于治疗脱发或前列腺增生排尿问题的药物非那雄胺（Finasteride），也会显著扑灭性欲。 3. **生活方式与压力分歧**：长期的疲倦、不良饮食、睡眠匮乏和高压力是性欲杀手。当一名精疲力竭的女性在夜晚面临“做爱还是睡觉”的选择题时，她往往会本能地选择睡眠。在此，男女在压力宣泄模式上存在鲜明对比：**男性通常渴望通过性爱来缓解压力，而女性则必须先彻底摆脱压力才能产生投入性爱的欲望**。Khera 医生常对男性建议：“如果你真的想和妻子做爱，就主动去洗碗、倒垃圾，帮她把孩子早点哄上床睡觉——帮她减压，才是激发她性欲的最有效方式。” 4. **心理与关系危机**：亲密关系中的信任、情感连接至关重要。若患者身处充满虐待或冷暴力的关系中，跑来诊所索要“提升性欲的药丸”，医生只能明确告知这毫无用处，因为关系的基石已经坍塌，此时必须求助于专业的性治疗师。 - 性欲（Libido）的简明医学定义：进行性活动的欲望与主观冲动。 - 只有当性欲低下对当事人本人造成困扰（Bothered）时，在临床上才被视作需要干预的疾病；若女性性欲偏低但自身安之若素，则不构成病态。 --- ### [14:07](https://www.youtube.com/watch?v=IgW1jepnJp4&t=847s) 心理性 ED 与回避心理：从“表现焦虑”到恶性循环 ```mermaid flowchart TD accTitle: 心理性勃起功能障碍恶性循环 accDescr: 表现焦虑引发心理性ED并自我强化的闭环过程 A["单次偶发勃起不良 (疲劳/饮酒/偶然)"] --> B["下次房事产生表现焦虑: '千万别软'"] B --> C["注意力脱离快感，交感神经兴奋导致疲软"] C --> D["失败经历确认恐惧，加剧下一次焦虑"] D --> E["性活动彻底沦为'压力触发事件'"] E --> F["男性本能回避房事，被误读为'性欲丧失'"] F --> G["伴侣产生自我怀疑: '是我没有吸引力了吗'"] G --> B ``` Khera 医生指出了男性性欲与勃起能力之间极易被误解的隐秘联系：**很多时候男性的“低性欲”并不是真的没有欲望，而是一种源于 ED 的逃避机制**。当一个男人发现自己的勃起成功率降至 50% 时，到了晚上 10 点，面对可能失败的挫败感和尴尬，他会本能地选择倒头大睡以避免直面问题。这种回避不仅使性生活频次骤降，还会波及伴侣——伴侣会开始怀疑是否是自己失去了外貌吸引力，进而让双方陷入互相猜忌的死结。相反，如果能切实改善男性的晨勃与夜间勃起质量，让他每天清晨醒来都感受到强烈的生理冲动，他自然会重新产生使用它的欲望，性欲随之被实质性唤醒。 Steven Bartlett 深有感触地呼应这一观点，指出卧室里最致命的毒药就是“过度思考（Overthinking）”。男性的性表现往往在完全放松、毫无杂念时达到巅峰。而一旦发生过一次意外的疲软，男性的大脑就会在下一次房事中开启灾难化的内心独白：“上帝啊，希望我这次不要软掉。”正是这种对自己身体失控的极度担忧，瞬间把性爱从愉悦的体验扭曲成了高压考核，导致大脑交感神经过度兴奋，阴茎血管迅速收缩而再度疲软。这种一次又一次的强化，构成了极其顽固的“心理性 ED（Psychogenic ED）恶性循环”。 --- ### [17:18](https://www.youtube.com/watch?v=IgW1jepnJp4&t=1038s) 破局之道：小剂量每日一次他达拉非（Cialis） 为了打破这一由焦虑铸造的牢笼，除了心理层面的性治疗（Sex Therapy），Khera 医生在临床上极其推崇一种药物策略——**每日一次小剂量他达拉非（Daily Cialis）**。 市面上常见的 PDE5 抑制剂主要有四种商业品牌：西地那非（Viagra / 万艾可）、他达拉非（Cialis / 希爱力）、伐地那非（Levitra / 艾力达）以及阿伐那非（Stendra）。其中，他达拉非因其长达 17.5 至 36 小时的超长半衰期，拥有独一无二的“每日疗法”剂型： - **按需高剂量**：20 mg，在临场性活动前临时服用； - **每日维持剂量**：5 mg，每天固定时间服用一粒。 每日服用 5 mg 他达拉非的精妙之处在于，男性的血药浓度始终维持在一个稳定起效的基线水平上。这彻底解除了年轻男性“临场必须掐点吃药”的心理重压与仪式感——他不需要在床头尴尬地倒水吞药，也无需在做爱前计算药效何时起效，随时随地只要兴致到来，就能自然而然地完成勃起。这种“药物随时在后台护航”的安全感，极大地消解了年轻人的表现焦虑，成为斩断心理性 ED 恶性循环的高效利器。 此外，Khera 医生提到，过去这类原研专利药物价格极其昂贵，但得益于 Mark Cuban 创办的 Cost Plus Drugs 以及 GoodRx 等平价仿制药平台的普及，如今在美国获取 90 粒仿制药仅需 15 至 20 美元，这让该疗法在年轻人群体中具备了极高的可及性与实用性。面对 Steven 关于“年轻人本不该依赖药物”的困惑，医生明确指出：当年轻人陷入深度的心理性 ED 时，首要任务是借助药物强行“重置”恶性循环，帮助他们重建对自身机能的信心。 ### [18:34](https://www.youtube.com/watch?v=IgW1jepnJp4&t=1114s) 每日西力士与万艾可的本质区别：修补组织还是掩盖症状 面对药物治疗，主持人 Steven Bartlett 直言自己是一个“药片怀疑论者”（pill skeptic），在生活中总是倾向于寻找非药物手段来解决健康问题，因为任何药物介入必然伴随着某种代价。他最直接的疑虑在于：长期服药是否会导致身体产生依赖性，让人不得不终生服药？莫希特·克拉（Dr. Mohit Khera）医生对此明确澄清，这类药物绝不存在生理成瘾或药物依赖性。相反，他认为每日服用小剂量西力士（Cialis，通用名他达拉非 / Tadalafil）是临床上极少数真正能够“逆转”勃起功能障碍（ED）的干预手段之一。 克拉医生用骨折打了一个生动的比方：如果一个人摔断了腿，医生面前通常有两种处理方式——要么彻底接骨复位，要么开具麻醉止痛药维柯丁（Vicodin）。服用止痛药固然能让人在药效期内忍痛行走，但骨骼本身的问题并未解决，一旦药效减退或耐药，后果将极其严重。在克拉医生看来，按需服用的万艾可（Viagra，通用名西地那非 / Sildenafil）就像那片维柯丁，它只是临时掩盖症状；而每日规律服用低剂量西力士则是在真正修复底层损伤。阴茎组织活检实验表明，连续每日服用西力士 3 个月后，阴茎海绵体平滑肌会发生物理性肥大（hypertrophy）并显著增强，其机制宛如去健身房规律举哑铃锻炼手臂肌肉，让组织实质变得更加强健。 更关键的机制在于对血管内皮（endothelium）的长期保护。内皮细胞被克拉医生形容为“血管内壁的大脑”，一旦内皮受损，血液中就容易形成斑块与血栓，进而直接诱发心肌梗死、中风以及勃起功能障碍。每日西力士不仅有助于逆转 ED 进程，还获得了美国 FDA 的另外两项适应症批准：改善男性前列腺增生引起的排尿困难，以及治疗肺动脉高压。意大利学者安东尼奥·阿维尔萨（Antonio Aversa）的研究进一步证实，患者在连续每日服药 3 个月后即便彻底停药，其血管内皮功能与勃起功能的改善依然显著优于安慰剂对照组，证明其带来了持久的生理修护红利。 - **组织增强效应**：每日服用 5 毫克西力士可在 3 个月内促进海绵体平滑肌肥大，使勃起组织在器质层面恢复力量。 - **血管内皮保护**：通过维护血管内壁的生理完整性，减少斑块沉积风险，从根源上延缓并逆转血管源性 ED。 - **多重 FDA 认证**：不仅针对男性勃起障碍，亦获批用于治疗良性前列腺增生（改善排尿）与肺动脉高压。 - **停药残留获益**：阿维尔萨博士的临床对照试验证实，服药 3 个月停药后，患者的血管和勃起机能依旧长久优于未服药组。 --- ### [21:15](https://www.youtube.com/watch?v=IgW1jepnJp4&t=1275s) 心血管获益与打破心理性勃起障碍恶性循环 谈及西力士的潜在副作用，克拉医生指出，在每日 5 毫克的常规低剂量下，不良反应通常轻微且短暂，偶见背痛、鼻塞或头痛；高剂量时背痛的发生率相对略高。临床上绝对的用药禁忌是正在服用硝酸酯类药物（Nitrates）的患者，因为两类药物协同会导致血压急剧骤降。然而，针对 Steven Bartlett 提出的“心脏病患者是否完全不能碰此类药”的疑虑，克拉医生给出了恰恰相反的临床背景：万艾可于 1998 年研发之初，原本就是作为降压与心血管保护药物进入临床试验的，是在试验过程中意外发现了促进男性勃起的副反应。 知名心血管专家罗伯特·克洛纳博士（Dr. Robert Kloner）近期发表的一项重磅研究更指出，规律服用每日西力士的男性，其心血管意外事件发生率降低了 13%，全因死亡率更是降低了 25%，这充分印证了其通过改善全身微循环内皮细胞所带来的心血管保护价值。克拉医生形象地总结道：“如果有一种药能保护心脏、改善前列腺，还能帮助男性重获优质勃起，而且价格极其低廉，大多数男性都会毫不犹豫地选择尝试。” 除了生理学重塑，低剂量每日西力士也是斩断“心理性 ED 恶性循环”的有力武器。当一名男性因为偶尔一两次失败而陷入恐惧，每次亲密接触都会诱发皮质醇与交感神经兴奋，导致进一步失败。此时通过每日用药，能够保证他在接下来的 3 到 6 个月内、在三四十次性生活中连续获得“人生中最完美的勃起体验”。当成功经验不断积累、大脑重新找回安全感与松弛状态后，医生便可以指导患者逐步降低用药频次——从每天一次减至隔天一次，再降至每周一次，最终彻底停药。即便摆脱了药物，曾经的心理心结也早已被多次成功的身体记忆彻底重塑。 --- ### [23:24](https://www.youtube.com/watch?v=IgW1jepnJp4&t=1404s) 严重滞后的女性性功能障碍治疗：从氟班色林到布美诺肽 转入女性群体时，克拉医生的语气变得沉重。他坦言，现代医学在女性性健康领域的资源投入极其匮乏。以 2015 年的美国药店为例，如果走进 Walgreens，药剂师能在柜台上摆出 30 余种针对男性性功能障碍的 FDA 批准药物；而在 2015 年之前，获得 FDA 批准用于治疗女性性功能障碍的药物数量是：零。 直到 2015 年，全球首款治疗女性性功能障碍的药物 Addyi（通用名氟班色林 / Flibanserin）才姗姗来迟，这是一种通过每日睡前口服以改善性欲低下的药物。几年后，第二款药物 Vyleesi（通用名布美诺肽 / Bremelanotide）问世，采用性生活前 45 分钟皮下注射的形式激发性欲。迄今为止，获得官方批准的女性药物仅此两款。由于性功能障碍本质上是“伴侣共同疾病”（a couple's disease），克拉医生在临床中经常不得不超适应症使用男性药物来帮助女性，例如使用万艾可来增强女性骨盆区域血流，从而改善其生理唤起。 克拉医生系统梳理了女性性功能障碍（FSD）的四大核心维度： 1. **性欲低下（Decreased libido）**：缺乏性冲动与心理欲望。 2. **唤起障碍（Decreased arousal）**：缺乏生理润滑与局部充血反应。 3. **高潮障碍（Orgasmic dysfunction）**：难以或完全无法达到性高潮。 4. **性交疼痛（Pain with intercourse）**：包括阴道痉挛、外阴前庭炎等导致的生理疼痛。 统计数据显示，全美有高达 43% 至 48% 的女性长期受到上述至少一种问题的困扰，但在这一庞大人群中，最终寻求或获得正规医疗帮助的女性仅有 19%。绝大多数女性因为羞耻感、缺乏诊疗渠道以及可选疗法的匮乏，长期处于“在沉默中受苦”（suffering in silence）的艰难境地。 --- ### [25:34](https://www.youtube.com/watch?v=IgW1jepnJp4&t=1534s) 神经递质的“天平效应”：多巴胺、五羟色胺与性冲动 在探讨性冲动的生物化学机理时，Steven Bartlett 提出疑问：压力和疲劳是否会直接压制体内的多巴胺？克拉医生对此表示认同，当机体处于慢性压力时，皮质醇水平飙升，伴随疲劳感加剧，个体感受兴奋与唤起的能力会急剧受挫。然而，性欲与高潮的调控远不止多巴胺那么简单，还涉及五羟色胺（血清素）、去甲肾上腺素、黑素皮质素（melanocortin）以及多种神经类固醇。 性反应在神经中枢内本质上是一场“正负对抗的博弈”。著名性心理学家迈克尔·佩雷尔曼（Dr. Michael Perelman）曾提出著名的“临界点理论”（The Tipping Point Model），形象地将性冲动描绘为一座天平：天平的一端是促进性冲动的“正向递质”（多巴胺、催产素、去甲肾上腺素），另一端则是抑制性冲动的“负向递质”（主要是五羟色胺）。当正向信号超越负向信号时，人便会产生欲望并顺利体验性高潮；反之，如果五羟色胺过度占据主导，不仅性欲会大幅减退，高潮的到来也会被严重延迟甚至完全阻断。克拉医生指出，临床上利用抗抑郁药（SSRIs）治疗男性早泄，正是利用了其提升五羟色胺以延迟射精与高潮的这一中枢机制。 ```mermaid flowchart TD accTitle: 神经递质性功能天平模型 accDescr: 展示正向兴奋性递质与负向抑制性递质如何共同决定性欲望与高潮功能 subgraph Positive ["正向激发端（促性反应）"] DA["多巴胺 (Dopamine)<br>驱动奖赏与欲望"] NE["去甲肾上腺素 (Norepinephrine)<br>提高中枢唤醒度"] OXT["催产素 (Oxytocin)<br>促进亲密依恋"] end subgraph Negative ["负向抑制端（压制性反应）"] SER["五羟色胺 (Serotonin)<br>延迟高潮、钝化冲动"] CORT["皮质醇 (Cortisol)<br>由慢性压力/疲劳触发"] end Positive --> Balance{"佩雷尔曼临界天平<br>(The Tipping Point)"} Negative --> Balance Balance -->|"正向递质占优"| Success["性欲旺盛 / 顺利达到高潮"] Balance -->|"负向递质占优"| Impaired["性欲减退 / 高潮障碍 / 早泄延迟"] ``` 女用药物 Addyi 正是基于这种神经化学调控逻辑设计的非激素疗法：它通过精准上调多巴胺和去甲肾上腺素、下调五羟色胺来重新点燃欲望。对于有乳腺癌病史或忌惮补充雌激素、睾酮的女性而言，这类纯粹调节神经递质的药物提供了极具吸引力的安全替代方案。当 Steven 追问日常生活中哪些行为能自然拉高多巴胺时，克拉医生指出，高强度体育锻炼是非常有效的提升手段，而诸如赌博等具有不确定奖励性质的刺激性活动同样能强烈刺激多巴胺释放，这也揭示了多巴胺双刃剑般的生物学特质。 ### [27:50](https://www.youtube.com/watch?v=IgW1jepnJp4&t=1670s) 多巴胺过山车与性欲调节药物 赌博、特定高热量食物等即时奖赏行为都会引起强烈的多巴胺激增，但这只是暂时的快感。这种瞬间的高峰往往伴随着急剧跌落甚至崩溃，从而无法持续支撑健康的性冲动。对于男性和女性而言，性冲动都需要稳定充盈的多巴胺水平。在临床实践中，Dr. Mohit Khera 有时会开具抗抑郁药安非他酮（Wellbutrin）——该药具有提升多巴胺的作用，能够有效唤醒男性或女性的低迷性欲；此外，他也会在男性和女性身上超说明书使用一些治疗注意力缺陷（ADD）的药物来提升多巴胺。 当患者明确表示不愿依赖药物时，非药物的生活方式干预就成了关键防线。Dr. Khera 会向患者严肃强调：规律且高强度的运动是绝对不可或缺的核心基石，同时必须保证充足的高质量睡眠并主动减轻精神压力，这些自然的调节方式能显著扭转性欲低下的局面。 针对多巴胺的波动机制，Steven Bartlett 联想到神经生物学家 Andrew Huberman 此前在节目中的科普：刷短视频（TikTok）、赌博等高刺激行为会瞬间拉大多巴胺释放量，但紧接着多巴胺基准线就会跌破原有的基准水平（baseline）。为了摆脱这种低迷带来的空虚与焦虑，人们便会产生强烈的渴求感，不得不再次打开手机刷短视频、去赌博或过度进食，从而深陷在“刺激-崩溃-匮乏-再刺激”的多巴胺过山车恶性循环中。 ### [29:18](https://www.youtube.com/watch?v=IgW1jepnJp4&t=1758s) 色情内容对性欲与勃起功能的心理冲击 过度观看色情内容（Pornography）是否是导致当代人性欲危机的罪魁祸首？在医学界，色情作品与勃起功能障碍（ED）及性欲下降的关系一直存在争议。Dr. Khera 在门诊接诊男性患者时，首先会提出一个极具鉴别诊断意义的问题：“你面对色情片时是否也会发生勃起功能障碍？” 如果患者在面对伴侣和面对色情片时都无法勃起，说明存在显著的器质性病变；但如果患者面对伴侣时无法勃起，面对色情片却能获得“极佳的勃起”，这就明确提示存在深层的心理因素（Psychogenic component）。Dr. Khera 指出，大量阅览色情内容的最大危害在于人为拉大了“预期与现实的落差”——大脑在极端刺激画面的浸泡下，建立起了不切实际的超现实预期，而真实的人类伴侣永远无法达到这种经过剪辑和表演的幻想。当现实与预期的巨大差距（Delta）显现时，患者便会出现心理性 ED 和性欲衰退。在临床上，许多严重依赖色情片的男性在遵循医嘱彻底戒断一段时间后，勃起状态与伴侣间的性欲都得到了立竿见影的恢复。 ```mermaid flowchart TD accTitle: 色情成瘾导致心理性勃起功能障碍的机制 accDescr: 展示过度观看色情片如何通过预期与现实的落差导致性功能障碍 subgraph Stimulation["过度感官刺激"] A["高频接触色情内容"] --> B["多巴胺阈值被动拔高"] B --> C["建立虚幻、过高的性预期"] end subgraph RealityGap["现实脱节与落差"] C --> D["面对真实伴侣的现实互动"] D --> E{"预期与现实的差距 (Delta)"} end subgraph Dysfunction["功能障碍"] E -->|现实无法匹配幻想| F["心理性性唤起受阻"] F --> G["勃起功能障碍 (ED) 与性欲衰退"] end ``` ### [30:50](https://www.youtube.com/watch?v=IgW1jepnJp4&t=1850s) 性行为频率的全球性暴跌与生活方式危机 近几十年来，人们的实际性生活频率正在发生剧烈萎缩。相关流行病学数据揭示了这一令人震惊的现实：年轻一代的无性生活比例正在急速飙升，全美成年人的年均性生活次数也出现了不可逆转的断崖式下滑。 面对这一现象，Dr. Khera 直言这是一个多维度复合问题（Multifactorial），但色情内容只是冰山一角，最致命的根本诱因是全球整体健康水平的急剧滑坡。肥胖、糖尿病和代谢综合征正在全球范围内像瘟疫一样蔓延。从 1990 年到 2022 年，糖尿病的患病率翻倍上升，全球每八个人中就有一人属于肥胖人群。肥胖和代谢紊乱会直接造成全身胰岛素抵抗，并重创人体的睾酮分泌机制。睾酮水平在全人群中逐十年递减，直接抹杀了人们开展性生活的生理本能与渴望。 - 《美国医学会杂志》（JAMA Network）数据显示，18 至 24 岁的年轻男性中，自述在过去一年内完全没有性生活的比例在短短几年内从约 18% 暴增至约 30%。 - 美国成年人的年均性生活次数，已从 1989 至 1994 年间的平均每年 60 次，下降到 2010 至 2024 年间的每年仅约 50 次左右。 - 全球肥胖人群占比已达八分之一（约 12.5%），糖尿病患病率在 1990 至 2022 年间从 7% 飙升至 14%，增幅高达 100%。 ### [32:12](https://www.youtube.com/watch?v=IgW1jepnJp4&t=1932s) 虚拟社交、拟社会关系与现实互动的退化 针对色情消费的研究同样印证了这一行为转变对身体的实质损害。比利时安特卫普大学（University of Antwerp）2020 年的一项研究发现，在 35 至 45 岁的人群中，每周观看色情片达 300 分钟（整整 5 小时）的人群里，有高达 40% 患有勃起功能障碍；2021 年发表在《JMIR 公共卫生与监测》针对 3400 名 18 至 35 岁男性的研究也显示，20% 的受访者饱受 ED 困扰，且观看色情片的频率越高，出现性功能障碍的几率就越大。 Steven 进一步指出，在过去，寻求性伴侣需要冒着被拒绝的心理痛苦去打扮、花钱、展示自我魅力；而在当今的数字化时代，“只需在电脑上点三下鼠标”就能毫不费力地在无穷无尽的视觉菜单中获得即时满足，甚至未来还有人工智能（AI）和虚拟现实（VR）的全方位填补。Steven 提到本周的一则新闻：一名 OnlyFans 创作者透露，其单个粉丝在一年内就为她打赏了惊人的 400 万美元。人们正沉湎于这种无需承担现实风险的拟社会关系（Parasocial relationship）中。 Dr. Khera 表示，现实社交和真实亲密接触正在被虚拟世界全盘解构。现代人由于习惯了在屏幕前完成性发泄，一旦置身于与真实人类坦诚相见的真实卧室环境中，反而会滋生巨大的社交焦虑与性表现焦虑。然而他再次重申，尽管色情作品影响深远，但在导致性功能障碍的整个大饼图中，占支配地位的依然是人口健康素质的全面倒退与睾酮的大幅下挫。 ### [36:24](https://www.youtube.com/watch?v=IgW1jepnJp4&t=2184s) 肥胖如何从生理上摧毁睾酮 随着全球肥胖率与糖尿病发病率曲线呈现垂直上升的可怕趋势，医学界已有大量严谨的研究证实了超重与低性欲、性功能障碍之间的直接因果关联。肥胖并非单纯的外形改变，而是一场席卷全身内分泌系统的灾难。 Dr. Khera 解释道，肥胖与糖尿病往往形影不离，因为过量的体脂会直接诱发严重的胰岛素抵抗。更致命的是，脂肪细胞中富含一种被称为“芳香化酶”（Aromatase）的催化酶。芳香化酶在人体内就像一个吞噬雄性激素的机器，它会疯狂消耗血液中的睾酮，并将其直接转化为雌激素（Estrogen）。一个人体内的多余脂肪越多，体内的芳香化酶就越活跃，导致睾酮水平断崖式下跌，雌激素水平异常升高。与此同时，肥胖引发的脂肪细胞还会分泌一系列破坏性物质，从血管内皮与激素轴全面摧垮机体的性反应机制。 ### [37:21](https://www.youtube.com/watch?v=IgW1jepnJp4&t=2241s) 肥胖与睾酮下降的恶性循环：糖尿病与青少年肥胖危机 在生理层面上，过量的体脂会分泌皮质醇（Cortisol）和瘦素（Leptin），这两种激素会直接抑制人体自身天然睾酮的生成。莫希特·赫拉（Dr. Mohit Khera）指出，几十年来随着全球肥胖率的一路攀升，男性体内的平均睾酮水平呈现出与之平行的逐年跳水态势。睾酮是人体中驱动性欲的最核心激素，不仅对男性至关重要，在女性体内同样是性冲动的头号发动机。当体脂不断挤压睾酮分泌，伴随而来的就是性欲断崖式下滑与勃起功能的显著受损。 更严峻的问题在于，肥胖往往与糖尿病、心血管疾病紧密捆绑，而这些正是诱发勃起功能障碍（ED）的最主要病理诱因。赫拉医生特别强调，糖尿病患者出现 ED 的概率是普通人群的整整四倍，这种由肥胖引发的代谢紊乱正演变成一场席卷全社会的性健康危机。尤为令人揪心的是，当前肥胖率飙升速度最快的人群并非成年人，而是青少年群体。这意味着年轻一代从青春期起就处在极低的睾酮起点上，不仅提前遭遇性功能困扰，更因为睾酮是精子生成的必备激素，直接为未来的生育能力埋下了严重隐患。 - 肥胖组织释放的皮质醇与瘦素会阻断下丘脑-垂体-性腺轴，抑制天然睾酮分泌。 - 睾酮是男女两性性欲（Libido）的第一驱动激素，缺乏睾酮会导致性冲动与勃起机制双重受阻。 - 糖尿病患者罹患勃起功能障碍的风险高出常人 4 倍之多。 - 全球青少年肥胖率的剧增导致低睾酮呈现严重年轻化，直接威胁下一代的精子生成与生育力。 --- ### [39:04](https://www.youtube.com/watch?v=IgW1jepnJp4&t=2344s) 减重与睾酮的双向回升：EMAS 研究与减重手术 当主持人史蒂芬（Steven）好奇是否“只要稍微减点重就能大幅改善睾酮”时，赫拉医生纠正道，这绝非轻描淡写的改变，而是具有非常严密的剂量效应。欧洲男性老龄化研究（European Male Aging Study, EMAS）的主导者弗雷德·吴（Fred Wu）的研究证实，体重与睾酮之间存在着极其显著的双向动态关系： ```mermaid flowchart LR accTitle: 体重变化与血清睾酮波动关系 accDescr: 展示减重10%、15%与体重增加对血清睾酮水平的双向影响 subgraph WeightLoss ["体重下降（正面收益）"] WL10["减重 10%"] --> T10["血清睾酮增加 ~85 ng/dL"] WL15["减重 15%"] --> T15["血清睾酮增加 ~250 ng/dL"] end subgraph WeightGain ["体重增加（负面影响）"] WG["体脂上升 / 体重增加"] --> TD["血清睾酮按比例成倍下跌"] end ``` 这种关联立竿见影：只要减掉 10% 的体重，血清睾酮即可提升约 85 ng/dL；若能减掉 15%，睾酮增幅更可高达 250 ng/dL。然而反向机制同样无情——体重一旦反弹，睾酮便会成比例骤降。赫拉医生在临床中最常遇到的瓶颈并非“如何让患者减重”，而是“如何让他们长期保持不反弹”。为了印证这一点，他提到了减重代谢手术（Bariatric Surgery）的长期随访结果：那些通过缩胃手术大幅削减体重的重度肥胖患者，术后体内的睾酮水平均出现了极为惊人的戏剧性反弹，这进一步坐实了体脂与雄激素之间密不可分的生物学联动。 --- ### [40:11](https://www.youtube.com/watch?v=IgW1jepnJp4&t=2411s) 睾酮疗法的双轨选择：保留生育力与口服药的历史演进 针对史蒂芬关于“补充睾酮后性生活是否会有天翻地覆变化”的提问，赫拉医生给出了极其肯定的答复：“一直如此，屡试不爽。”但在开具处方前，医生必须做出至关重要的技术路线分流。外源性睾酮会直接关闭下丘脑的促性腺信号，从而彻底阻断人体自身睾酮分泌并导致精子生成停滞。因此，如果面对的是有生育计划的年轻男性，直接补充外源睾酮无异于引发人为不育，这是临床绝对禁忌。 针对不同需求，临床治疗存在两大截然不同的路径： ```mermaid flowchart TD accTitle: 男性低睾酮治疗的两大临床路径 accDescr: 展示促自身分泌疗法与外源性替代疗法在适用人群、药物及对生育力影响上的对比 A["确诊低睾酮且有症状的男性"] --> B{"是否有生育需求？"} subgraph PathA ["途径一：内源性促分泌疗法（保留生育力）"] B -- "是 / 年轻男性" --> C["使用促内源性生成药物"] C --> D["枸橼酸氯米芬 (Clomiphene Citrate)"] C --> E["人绒毛膜促性腺激素 (HCG)"] D & E --> F["刺激睾丸自主造睾，完整保留精子生成能力"] end subgraph PathB ["途径二：外源性睾酮替代 (TRT)"] B -- "否 / 年长已育 (如60岁以上)" --> G["直接补充外源性睾酮 (共7种剂型)"] G --> H["肌肉注射制剂 (Injectables)"] G --> I["新型口服制剂 (Oral Testosterone)"] H & I --> J["关闭自身分泌轴与精子生成，但起效强效平稳"] end ``` 赫拉医生尤其推崇注射剂与新型口服制剂。他谈到了口服睾酮曲折的发展历程：睾酮最早于 1935 年被人工合成，但早期的口服制剂存在致命弱点——具备极强的肝脏毒性，甚至会诱发肝癌。直到 1970 年代，科学家开发出了十一酸睾酮（Testosterone Undecanoate），该分子绕过肝脏代谢经淋巴系统吸收，彻底解决了肝毒性问题。然而该药最初需要每日服用三至四次（在英国以 Andriol 品牌上市并畅销全球，但迟迟未获美国批准）。美国直到 2019 年才迎来首款新型口服睾酮 Jatenzo，并在 2022 年相继批准了 Tlando 和 Kyzatrex。如今这些新型口服药仅需每天随餐服用两次，极大改善了依从性，目前英国患者也已能够获取 Kyzatrex。 --- ### [42:19](https://www.youtube.com/watch?v=IgW1jepnJp4&t=2539s) 谁才是睾酮治疗的真正候选人？ 面对史蒂芬抛出的直球提问——“像我这样的人需要补充睾酮吗？”赫拉医生明确划出了严格的诊疗红线。使用睾酮的先决条件必须是**实验室生化指标低下**与**典型临床症状**同时具备，缺一不可。 赫拉医生强调，若一位男性在体检中查出睾酮读数偏低，但本人精神饱满、没有任何不适感，他绝不会为其开具睾酮药物。低睾酮的核心症状包括： - 精力匮乏与极度疲劳 - 性欲断崖式下滑（最敏感、最具特征性的警示信号） - 勃起功能障碍（ED） - 肌肉量衰减与脂肪异常沉积 - 睡眠质量恶化 - 情绪低落与抑郁状态 ```mermaid flowchart TD accTitle: 睾酮疗法临床准入评估决策树 accDescr: 严格呈现实验室检查与临床症状联合评估的流程 Start["患者前来就诊"] --> Check{"综合评估：低睾酮数值 + 典型临床症状"} Check -- "仅数值低，完全无症状" --> No1["拒绝给药（无需干预）"] Check -- "症状典型，但数值完全正常" --> No2["拒绝给药<br/>（排查甲减、心理抑郁等其他病因）"] Check -- "数值低下且症状确凿（复查确认）" --> Candidate["确认为睾酮治疗合资格人选"] Candidate --> AgeCheck{"年龄与生育规划"} AgeCheck -- "年轻 / 尚未育有子女" --> Young["首选减重与生活方式干预<br/>或使用保留生育力的促排药物"] AgeCheck -- "年长 / 无生育需求" --> StandardTRT["实施标准外源性睾酮替代治疗"] ``` 反之，如果一位患者集齐了所有上述低睾酮症状，但经过复查血清睾酮水平完全在正常范围内，同样绝不能盲目补充睾酮。赫拉医生提醒，这很可能是其他潜在隐患在作祟，例如甲状腺功能减退（Hypothyroidism）或是原发性临床抑郁症，必须对症下药。 --- ### [44:13](https://www.youtube.com/watch?v=IgW1jepnJp4&t=2653s) 被忽视的女性睾酮疗法与全身健康基石 进入女性健康领域时，赫拉医生揭示了一个违背绝大多数人直觉的生理真相：**在女性体内，自然生成的睾酮总量实际上超过了其体内任何其他单一激素！** 大众习惯性地将睾酮打上“男性雄风”的标签，却忽略了它在女性体内扮演着至关重要的角色。当女性体内睾酮维持在理想水平时，她们的性欲、瘦体重、骨密度、日常认知清晰度以及整体幸福感都会处于极佳状态；而一旦睾酮匮乏，性冷淡和疲倦感便会接踵而至。 然而现实却存在着令人震惊的医疗脱节： - 全美有十几种针对男性的 FDA 批准睾酮药物，但在美国任何一家药店里，都**找不出一款专门获批用于女性的睾酮制剂**。 - 英国过去曾拥有名为 Intrinsa 的女性睾酮贴片，曾被纳入 NHS 医保体系，但后来由于商业等原因退市；此后获批的 AndroFeme 霜剂目前在英国也已失去准入，仅能从澳大利亚艰难代购。 - 迫于这种无奈现状，专科医生只能广泛采用超说明书用药（Off-label / Off-licence）：将男性规格的外用睾酮凝胶药包严格减量，让女性患者每天仅涂抹大约 **十分之一（1/10）** 的剂量。 通过这种微量调整，大量女性患者的性欲、性满意度获得了肉眼可见的质的飞跃，伴随着肌肉形态改善与思维钝化的减轻。 在访谈尾声，赫拉医生严肃地纠正了一种长期存在的狭隘认知：“睾酮绝不仅仅关乎床笫之事，它关系到生命的整体根基。”无论是男性还是女性，长期处于低睾酮状态都会给机体带来毁灭性的代谢打击： - **心血管意外：** 低睾酮男性罹患心肌梗死（心衰与冠心病）的风险大幅飙升，这是不可妥协的医学事实； - **代谢综合征：** 低睾酮直接与重度肥胖、胰岛素抵抗以及 2 型糖尿病的形成深度交织； - **精神心理创伤：** 低雄激素环境极易诱发严重的临床抑郁倾向与神经机能减退； - **骨骼衰退：** 骨矿物质密度严重流失，极易引发严重骨质疏松并造成脆性骨折。 睾酮不仅是维持性功能的钥匙，更是维系男女全身心血管稳态、代谢防线与生命活力不可或缺的底层支柱。 ### [46:44](https://www.youtube.com/watch?v=IgW1jepnJp4&t=2804s) 睾酮作为全身健康的晴雨表与女性激素“金三角” 当谈到如何评估一个男性的整体健康状况时，莫希特·赫拉（Dr. Mohit Khera）医生给出了一个毫不犹豫的答案：如果只能做一项血液检查，那绝对是测定体内的睾酮（Testosterone）水平。在赫拉医生看来，没有任何其他单项血液指标能像睾酮这样全面地充当整体健康的“晴雨表”——它深度牵涉到心脏机能、糖尿病隐患、肥胖风险、骨矿物质密度、体能精力、肌肉量、勃起功能以及性欲。 斯蒂芬·巴特利特（Steven Bartlett）由此提出一个经常被大众忽视的问题：在女性更年期治疗中备受关注的激素替代疗法（HRT）是否也包含睾酮？赫拉医生澄清，常规概念中的 HRT 通常仅指补充雌激素（Estrogen）和孕激素（Progesterone），而针对睾酮的补充被称为 TRT（Testosterone Replacement Therapy）。在女性内分泌调理中，赫拉医生提出了一个直观的模型——“内圈三角形”与“外围圆环”。女性体内的核心金三角正是雌激素、孕激素与睾酮，三者协同作用；许多体内睾酮枯竭的女性在适量补充后，精神状态与生活质量会发生质的飞跃。 ```mermaid flowchart TD accTitle: 女性激素调控与健康优化模型 accDescr: 展示以雌激素、孕激素、睾酮为核心三角形，皮质醇、甲状腺与生长激素为外环，结合临床与生活方式各占50%的整体健康架构。 subgraph Hormones["内分泌优化 (医疗干预占50%)"] subgraph Triangle["核心三角形 (内圈)"] E["雌激素 (Estrogen)"] --- P["孕激素 (Progesterone)"] P --- T["睾酮 (Testosterone)"] T --- E end subgraph Outer["外围圆环 (监测指标)"] C["皮质醇 (Cortisol)"] TH["甲状腺素 (Thyroid)"] GH["生长激素 (Growth Hormone)"] end end subgraph Lifestyle["生活方式干预 (患者职责占50%)"] D["均衡饮食 (Diet)"] EX["规律锻炼 (Exercise)"] S["优质睡眠 (Sleep)"] SR["压力管理 (Stress Reduction)"] end Hormones --> Result["综合疗效爆棚 (On Fire)"] Lifestyle --> Result ``` 赫拉医生向患者强调，医疗手段和激素优化往往“只占整个拼图的 50%”，而剩下的 50% 则完全依赖于患者自身的生活方式基石：饮食、运动、睡眠与减压。“如果你做好你那一部分，我做好我这一部分，我们就会状态爆棚（we're on fire）。”针对斯蒂芬提出的“为何极少有女性被开具睾酮处方”这一疑惑，赫拉医生指出，虽然澳大利亚已有正式批准的女性睾酮药物，但在英美等许多国家，该疗法仍处于超说明书（off-label）用药状态，并未得到应有的广泛重视。 --- ### [48:47](https://www.youtube.com/watch?v=IgW1jepnJp4&t=2927s) 男性睾酮水平的世代暴跌及其与生育力的关联 互联网上近年来对“男性睾酮大倒退”的讨论不绝于耳。赫拉医生引用了流行病学基石——弗雷明汉心脏研究（Framingham Heart Study）以来的长期队列数据，给出了令人触目惊心的量化指标：在 20 世纪 70 年代，18 岁至 40 岁之间健康成年男性的平均总睾酮水平大约维持在 700 ng/dL 左右；然而在此之后的每十年里，人群平均值都在以近 50 ng/dL 的速度稳步缩水。到了 2015 年前后的最新测算中，这一数字已经跌落至 400 多 ng/dL 左右，相当于整体下滑了近 300 ng/dL。 这种断崖式下跌绝不仅仅关乎疲劳、力量丧失或勃起障碍，它更对人类繁衍构成了直接威胁： - **精子生成停滞**：精子的成熟与发育高度依赖睾丸局部的睾酮浓度，睾酮低迷会直接造成精子数量急剧减少，这也解释了为何全球男性精子浓度呈现同步暴跌。 - **全民体质恶化**：这一趋势是现代人群健康状况代际恶化的铁证，其最核心的祸根在于高果糖饮食、超加工食品、久坐不动以及缺乏运动的生活方式，这些不良因素催生了爆炸式增长的肥胖与 2 型糖尿病。 --- ### [50:19](https://www.youtube.com/watch?v=IgW1jepnJp4&t=3019s) 精液分析的健康预警价值与精索静脉曲张 面对斯蒂芬提到自己正处在准备备孕的人生阶段，赫拉医生从演化生物学（达尔文主义）切入：“身体越健康的人，生育能力就越强，因为你在传递基因。”如果希望通过生活方式提高生育力，必须先排查物理病因，并把精液分析作为洞察系统性健康的关键窗口。 在男性不育的所有解剖学诱因中，全球发病率第一位的是**精索静脉曲张（Varicocele）**——即阴囊内睾丸周边的静脉异常丛状扩张，其机制与女性腿部下肢静脉曲张如出一辙。扩张的静脉团导致阴囊局部温度升高并淤积代谢废物，严重破坏精子工厂的微环境。全球约有 15% 的普通男性患有精索静脉曲张，但在不育男性群体中，这一比例高达惊人的 40%。 赫拉医生极力敦促斯蒂芬以及所有男性及早进行全面的精液分析（Semen Analysis）。多项里程碑式的临床研究证明，精液不仅关乎繁衍，更是男性全身健康的“早期预警机”： - **当前共病预警**：精液指标异常与当下的肥胖、胰岛素抵抗、代谢综合征高度重合，且不育男性罹患睾丸癌的基线概率显著高于健康同龄人。 - **未来心血管与内分泌风险**：迈克·艾森伯格医生（Dr. Mike Eisenberg）的研究指出，精子计数低下的男性在未来罹患糖尿病的风险上升 30%，罹患缺血性心脏病（Ischemic Heart Disease）的风险骤增 50%。 - **恶性肿瘤远期预测**：汤姆·沃尔什医生（Dr. Thomas Walsh）的研究发现，精液质量极差的男性在步入老年后，患侵袭性高恶性度前列腺癌（High-grade Prostate Cancer）的几率是正常男性的 2.5 倍。 听到这里，斯蒂芬坦承自己不久前刚做了这项检查，在拆开检验报告前内心充满了巨大焦虑与恐惧，生怕自己年纪轻轻就出现精子功能障碍。 --- ### [52:45](https://www.youtube.com/watch?v=IgW1jepnJp4&t=3165s) 全球不育现状与断崖式数据背后的危机 不育症正在以隐秘而残忍的方式撕裂无数家庭。赫拉医生披露，全球约有 15% 的夫妇正深受不孕不育的困扰： - **责任归属平分秋色**：在所有无法受孕的案例中，单纯女方因素仅占一部分，约 30% 纯粹是由男方因素引起，另有 20% 是男女双方共同问题；换言之，在多达 50% 的不育病例中，男性都直接或间接地承担着病理责任。 - **巨大的心理孤岛**：许多夫妻背负着毁灭性的心理重压却“在沉默中受苦”（suffer in silence）。全球范围内有一半的不育夫妇从未踏进过专科诊室寻求医疗援助；即便迈出就医第一步的人群中，最终也仅有 25% 能够坚持接受规范治疗，而实际上现代医学已经拥有了非常丰富的应对手段。 斯蒂芬向赫拉医生展示了一张随身打印的图表，直观呈现了 2000 年至 2016 年仅短短 16 年间，各年龄组男性睾酮水平从接近 600 ng/dL 急转直下至 400 ng/dL 的惊人曲线。赫拉医生对此表示，虽然曲线在近年似乎有略微趋平的微弱迹象，但青少年肥胖率的激增依旧是一枚巨大的定时炸弹——60 岁的人肥胖或许不再波及生育，但青少年时期的肥胖与内分泌紊乱，正在将年轻一代推向生殖健康的悬崖边缘。 --- ### [55:35](https://www.youtube.com/watch?v=IgW1jepnJp4&t=3335s) 探索自然改善性功能的新起点 随着谈话层层深入，斯蒂芬将焦点带入每对伴侣最切身的生活场景：如果一对男女走进诊室，坦白两人的卧房亲密生活遭遇了严重的性功能阻碍，但在考虑求助万艾可等药物或其他剧烈的医疗干预之前，他们迫切渴望通过全天然、非药物的手段力挽狂澜，医生会为他们开出一张怎样的行动清单？赫拉医生开始从生理机制与亲密关系的双重视角，系统拆解那些无需处方即可实践的逆转之道。 ### [55:57](https://www.youtube.com/watch?v=IgW1jepnJp4&t=3357s) 自然改善性功能的三大基石：地中海饮食、睡眠与规律运动 当探讨如何在不依赖药物的前提下自然提升性功能时，莫希特·凯拉博士（Dr. Mohit Khera）明确指出了改善生活方式的核心力量。首先在饮食方面，他最为推崇的是地中海饮食。这种饮食结构富含全谷物、豆类、新鲜蔬果，以鱼类为主要蛋白质来源，家禽肉类每周仅食用约一次，而红肉和甜食则严格限制在每月一次左右。作为一种公认的抗炎饮食，大量临床试验已证实它能显著改善勃起功能。在著名的 MEDITA 试验中，研究人员甚至观察到该饮食对男性和女性的性功能均有双向改善。凯拉博士特别提到了埃斯波西托（Esposito）博士主持的一项前瞻性随机对照试验：研究纳入了 110 名肥胖男性，其中 55 人接受地中海饮食干预，另外 55 人维持原状作为对照；随访两年后，未服用任何万艾可（Viagra）或类似药物的干预组不仅血管内皮功能大幅提升，勃起功能也出现了统计学上极为显著的改善。 第二大关键因素是睡眠管理。现有医学证据显示，每晚睡眠少于 6 小时的男性和女性，患性功能障碍的风险会显著攀升。人体的理想睡眠时长应维持在 7 至 8 小时。然而，睡眠并非越多越好，超过 9 小时后其带来的性健康益处便会进入平台期，继续延长睡眠并不会进一步提升性表现。第三大基石则是高强度、足频次的体育锻炼。凯拉博士曾发表过一篇高引用率的荟萃分析，系统评估了运动量和运动类型对勃起功能的影响。结果表明，每周进行 160 分钟（即每周 4 次、每次 40 分钟）的中高强度或剧烈运动，持续 6 个月，就能使男性的心率达到有效靶区并显著逆转勃起功能障碍。尤为关键的是，患者原本的勃起功能障碍越严重，从单纯运动中获得的改善幅度反而越显著。当饮食、睡眠与运动三者叠加时，生活方式的综合改良能发挥出不亚于药物的协同疗效。 ```mermaid flowchart TD accTitle: 生活方式干预对性功能的改善机制 accDescr: 展示地中海饮食、优质睡眠与中高强度运动如何协同改善内皮功能并提升男女两性性功能 subgraph Lifestyle["三大自然干预手段"] A["地中海饮食<br/>(全谷物/蔬果/鱼类/低红肉)"] B["规律睡眠<br/>(每晚 7 至 8 小时)"] C["中高强度运动<br/>(每周 160 分钟 / 40分钟×4次)"] end subgraph Physiology["心血管与代谢生理机制"] D["抗炎反应增强"] E["血管内皮功能恢复"] F["心肌灌注与血流改善"] end subgraph Outcome["临床结局"] G["男性勃起硬度与血流显著提升"] H["女性性功能评分 (FSFI) 大幅改善"] end A --> D B --> E C --> F D --> E E --> G E --> H F --> G F --> H ``` ### [58:35](https://www.youtube.com/watch?v=IgW1jepnJp4&t=3515s) 女性性功能与心血管健康的隐秘关联 针对主持人关于“运动与饮食对女性是否同样有效”的追问，凯拉博士给出了绝对肯定的答复。尽管医学界在女性性健康领域的研究投入和文献体量长期落后于男性，但现有的 MEDITA 饮食试验与多项睡眠追踪研究均明确涵盖了女性群体，并展现出高度一致的积极反馈。两性在心血管生理机制与微循环灌注层面并没有本质上的鸿沟。只要内皮细胞健康得到恢复，全身的血流分布与性器充血反应便会同步恢复。 为了印证这一点，凯拉博士援引了一项涉及 110 名患有冠状动脉狭窄女性的开创性心血管造影研究。该研究发现，女性冠状动脉的狭窄与堵塞程度，与其性功能障碍的严重程度呈现出严格的正相关——心脏供血越差，性生活质量就越低。随后，研究团队让这些患病女性加入了包含饮食调控与运动训练的心脏康复计划。在改善心功能之后，通过标准的女性性功能评估量表（FSFI, Female Sexual Function Index）进行复测，这些女性的性功能评分竟然实现了接近四倍（即约 400%）的爆发式飞跃。这一惊人数据充分证明，心血管健康与性功能是密不可分的双向互动系统，修复其中一端，另一端必然随之逆转。 ### [59:51](https://www.youtube.com/watch?v=IgW1jepnJp4&t=3591s) 勃起功能障碍的患病率法则与普遍的病耻感 凯拉博士重申了临床上令人震撼的年龄患病规律：全球范围内，40 岁的男性中有 40% 患有不同程度的勃起功能障碍（ED），50 岁群体对应 50%，60 岁对应 60%，70 岁对应 70%，80 岁则高达 80%。作为一种患病率极高的病理状态，ED 不仅是心血管事件的早期预警信号（往往是心脏病发作的第一前兆），更与心理健康深度交织。流行病学数据显示，患有 ED 的男性出现焦虑症的概率是常人的 2.5 倍，患抑郁症的概率高出 3.5 倍，同时其患有未确诊糖尿病的风险也高出整整两倍。 然而，在遭受如此巨大身心折磨的庞大人群中，仅有大约 50% 的男性敢于主动向医生或伴侣开口求助，绝大多数人都在羞耻中默默忍受。凯拉博士在举办公开医学讲座时经常做现场测试：“如果我让台下有高血压的人举手，大批听众会毫不犹豫地举起手；但如果我让患有性功能障碍的人举手，现场往往没有一个人举手，即便从概率统计上看，在座至少有一半以上存在性问题。”他尖锐地指出，这种病耻感源于陈旧的男性气概观念——社会常将高血压视为单纯的生理疾病，却将性功能问题片面等同于“软弱”、“缺乏男子气概”甚至“丧失做男人的资格”。凯拉博士大声呼吁社会必须对性功能障碍彻底去污名化，因为它既是一个极其普遍的生理信号，又具备高度可治愈的现代医学方案，患者唯一需要迈出的就是举手承认的第一步。 - **年龄患病率阶梯**：40 岁约 40%、50 岁约 50%、60 岁约 60%、70 岁约 70%、80 岁约 80%。 - **共病风险倍数**：焦虑风险增加 2.5 倍，抑郁风险增加 3.5 倍，未确诊糖尿病风险翻倍（2 倍）。 - **社会沟通阻碍**：由于文化耻感，至少 50% 的男性患者从未向专业医生透露过病情。 ### [01:01:51](https://www.youtube.com/watch?v=IgW1jepnJp4&t=3711s) ED 是男性整体健康的“早期警报门禁” 凯拉博士强调，勃起功能障碍在现代预防医学中承担着关键的“前哨”角色。圣路易斯（St. Louis）曾针对 18 至 40 岁年轻男性进行过一项专项筛查研究，专门监测因勃起问题初次就诊的人群。令人震惊的临床发现是：在这些年轻人踏入诊所寻求 ED 帮助的当天，经血液筛查，竟然有整整 30% 的人当场被确诊为糖尿病前期或早期糖尿病。 年轻群体往往自恃身强力壮，极少主动前往医院进行定期的血压测定或空腹血糖监测；凯拉博士坦言自己 30 岁时也从不主动做生化体检。然而，一旦男性的阴茎无法正常勃起，出于巨大的心理恐慌，他们第二天一早就会冲进泌尿科诊室。因此，ED 往往成为敦促年轻男性接触医疗系统的唯一动力。医生如果在 30 岁时通过 ED 敏锐捕捉到患者潜伏的代谢异常并及时干预，就能为患者避免整整 10 年高血糖对全身微血管网的不可逆侵蚀。性健康因而成了撬动男性整体健康管理最为有效的杠杆。 ### [01:03:10](https://www.youtube.com/watch?v=IgW1jepnJp4&t=3790s) 坦白心因性困扰：焦虑、疲惫与性欲的生理分离 当主持人史蒂文·巴特利特（Steven Bartlett）询问凯拉博士自身是否遭遇过性功能障碍时，博士坦诚表示自己尚未经历过，但也大度补充道：“就算我经历过也完全没问题，因为这是极其正常的生理波动，往往也是暂时的，公众必须打破对其附带的道德包袱。” 这番探讨触动了主持人史蒂文的共鸣，他罕见地在播客中分享了自己真实的情感与生理体验。史蒂文坦言，尽管自己整体性生活十分正常，但在特定阶段也曾遭遇困扰：有时是在醉酒状态下，有时是年轻单身时期面对某些特定伴侣，身体会毫无由头地“罢工”；而在一段以往感情走向终点的阶段，他在性交过程中偶尔会出现中途疲软的尴尬现象。这种挫败感曾一度让他陷入过度反思，自我怀疑是否不再喜爱对方。在凯拉博士的点拨下，史蒂文确认这些阻碍本质上全属于“心因性（Psychogenic）”问题。此外，作为高强度工作的创业者与媒体人，史蒂文提到自己经常在深夜极度疲惫、压力满载的状态下归家，那时他能感到身体的本能欲望依然存在，但对真正付诸性行动却感到索然无味、心力交瘁。凯拉博士对此报以理解的微笑，安慰他这完全符合普罗大众的真实人性，绝非不可调和的器质性缺陷，若将双方置于毫无压力的放松环境中，这种受挫状态自然会烟消云散。 ### [01:05:01](https://www.youtube.com/watch?v=IgW1jepnJp4&t=3901s) 环境改变与育儿压力对性生活的深远影响 主持人史蒂芬·巴特利特（Steven Bartlett）分享了自己的亲身经验：当他与伴侣在夏威夷的海岛上度假两周时，两人的性生活品质极高。这种体会彻底改变了他们安排生活的方式——为了不让自己总是在晚上 11 点筋疲力尽、满身压力地回到家，他们开始高度重视打破原有生活情境（Context）。即使只是从周五到周一在同城预订一家酒店度过周末（Staycation），也能产生立竿见影的“游戏规则改变者”效应。脱离柴米油盐和工作压力的物理空间，是许多朋友在遭遇性生活低谷时的自救良方。 随后两人将话题转向了家庭生活中的巨大变量——孩子。莫希特·凯拉博士（Dr. Mohit Khera）指出，育儿对夫妻性生活的冲击极为显著，核心原因在于压力骤增和严重睡眠不足。当双方都被照顾孩子的琐碎日常消耗殆尽时，性生活在生活优先级中就会一降再降。不仅是凯拉博士在临床上屡见不鲜地看到夫妻在产后数年都无法重拾性生活，史蒂芬也引用了一项英国权威研究：高达 80% 以上的女性在产后 3 个月经历过性问题，甚至到了产后 6 个月，依然有近三分之二的女性深受其扰。 - **脱离固定情境的力量**：即便不出远门，仅在本地预订酒店度周末也能有效切断日常压力源，唤醒亲密感。 - **产后性生活困境**：英国研究表明，产后 3 个月超过 80% 的女性存在性功能障碍，产后 6 个月仍有近两成至三分之二受影响。 --- ### [01:06:45](https://www.youtube.com/watch?v=IgW1jepnJp4&t=4005s) 认识早泄：定义、时间落差与多元解决方案 凯拉博士强调，性功能障碍绝不仅限于勃起功能障碍（ED），还包含佩罗尼氏病（阴茎硬结症）、射精延迟以及发病率极高的早泄（Premature Ejaculation, PE）。全球约有 30% 的男性受早泄困扰，但由于羞耻感，仅有 9% 的人会主动寻求治疗。临床上，早泄首先被划分为终身原发性（Lifelong）与后天获得性（Acquired，通常表现为射精潜伏期较以往正常水平缩短 50% 以上）。现代医学对早泄的诊断标准包含三个核心要素：射精时间少于 2 分钟（过去标准为 1 分钟）、失去控制力、且当事人或伴侣对此感到痛苦困扰。如果射精时间只有 30 秒但双方都乐在其中，医学上便不视其为疾病。 男女生理反应的天然时间差进一步放大了这一矛盾：美国男性的平均射精潜伏时间约为 5.4 分钟，而女性达到性高潮的平均时间通常长达 13.4 分钟。在治疗方案上，凯拉博士极力推崇性心理行为治疗（Sex Therapy），如运用“动-停技术”（Start-Stop Technique）或“挤压法”（Squeeze Technique）重新训练大脑对高潮反射的神经控制。许多患者出于急躁往往直接要求开药，但药物只是“创可贴”，行为治疗才是治本之策。如果采用药物干预，常使用能提高五羟色胺水平的抗抑郁药，但其存在需每日服用或提前 6 到 8 小时按需服用以及全身性副作用的缺点；相较之下，局部外用利多卡因喷雾（Lidocaine spray）无需处方，通过温和降低龟头敏感度来延长维持时间，是更为简便安全的选择。 ```mermaid flowchart TD accTitle: 早泄临床评估与治疗路径 accDescr: 展示早泄的诊断标准、分类以及从行为疗法到药物治疗的应对路径 subgraph DIAG["诊断与评估"] A["核心诊断要素"] --> A1["射精时间 < 2 分钟"] A --> A2["缺乏射精自主控制力"] A --> A3["双方或个人主观感到困扰"] A --> B{"发病类型鉴别"} B --> B1["原发性 (终身存在)"] B --> B2["获得性 (较以往缩短 50% 以上)"] end subgraph TREAT["干预与治疗方案"] C["首选治本方案"] --> C1["性治疗与行为训练<br/>(动-停法 / 挤压法)"] D["外用对症方案"] --> D1["局部利多卡因喷雾<br/>(降低敏感度，非处方)"] E["全身药物方案"] --> E1["抗抑郁药物<br/>(提升五羟色胺，需权衡副作用)"] end DIAG --> TREAT ``` - **平均生理时间差异**：美国男性平均射精时间为 5.4 分钟，女性达到性高潮平均需要 13.4 分钟。 - **就医率严重倒挂**：全球 30% 男性饱受早泄困扰，但只有 9% 的患者真正走进诊室寻求专业帮助。 --- ### [01:09:56](https://www.youtube.com/watch?v=IgW1jepnJp4&t=4196s) 里程碑式的 Traverse 试验：打破睾酮的安全谣传 在男性健康领域，睾酮替代治疗（TRT）长期笼罩在致病恐慌的阴影之下。医学界历史上曾根深蒂固地认为外源性补充睾酮会诱发前列腺癌、心脏病发作及中风。尤其是 2015 年几项小型研究提出睾酮可能引发心血管危机后，争议达到顶峰。为此，美国监管机构强制要求进行一项决定性的大规模临床试验。凯拉博士作为主要牵头人之一，与其他八位顶尖专家共同设计并主导了耗时六年、纳入 5200 名患者的“Traverse 试验”（Traverse Trial）。 这项迄今为止全球规模最大、证据等级最高的随机双盲对照试验结果终于正式发表，彻底颠覆了过往的陈旧认知。数据清晰表明，规范的睾酮治疗并未导致心血管事件风险的任何显著上升；与此同时，研究还确证了睾酮治疗既不会增加前列腺癌发生率，也不会加重男性的下尿路排尿症状。Traverse 试验为长期遭受污名化的睾酮替代治疗提供了铁证如山的安全性背书。 - **Traverse 试验规模**：由凯拉博士等 9 位专家联合主持，纳入 5200 名受试者，历时长达 6 年。 - **三大核心结论**：规范补充睾酮不增加心血管疾病风险、不诱发前列腺癌、不恶化泌尿系统排尿症状。 --- ### [01:11:22](https://www.youtube.com/watch?v=IgW1jepnJp4&t=4282s) 治疗与滥用的界限：平台效应与 TRT 的科学指征 当史蒂芬担忧注射睾酮是否会缩短预期寿命、甚至等同于运动员滥用类固醇时，凯拉博士给出了极其明确的医学区分：真正会缩短寿命的反而是长期处于病理性的低睾酮状态。健美运动员和滥用禁药者使用的是超生理剂量（Supraphysiologic Doses），正常男性血清睾酮水平通常在 300 至 1000 ng/dL 之间，而滥用者往往将其强行推高至 2000 至 2500 ng/dL，并混合使用如氧雄龙（Anavar）、诺龙（Deca）、康力龙（Winstrol）等合成代谢类固醇。 凯拉博士特别指出了睾酮在人体生理中的“平台效应”（Plateau Effect）。许多人直觉地以为睾酮剂量越高，性欲和精力就会无限提升，但事实并非如此——对于性欲和神经功能而言，睾酮受体就像一个“开/关”按钮，一旦达到生理饱和阈值便不再有额外收益。唯一的例外是肌肉组织，超大剂量的睾酮会持续上调肌肉中的雄激素受体，从而驱动肌肉不断生长，这也是健美者对超高剂量上瘾的原因。对于普通男性的临床治疗而言，TRT 的唯一目的只是“把身体缺失的水平恢复到原有的正常生理区间”。 面对史蒂芬提出“自己未来 45 岁、生完孩子后是否也应考虑补充睾酮”的设想，凯拉博士强调了最为核心的用药原则：必须同时满足“客观检测指标偏低”与“主观存在明确临床症状”（Symptomatic）两个条件。如果一位 45 岁的男性化验单数值较低，但他自己感觉精力充沛、性欲旺盛，“那你完全不需要补充，我绝不会给你开药”。只有当指标低下且伴随疲惫、性欲减退等症状时，才是考虑接受治疗的真正时机。 ### [01:13:19](https://www.youtube.com/watch?v=IgW1jepnJp4&t=4399s) 睾酮与抑郁症之间的紧密纽带 在探讨低睾酮症状时，除了常见的精力衰退、疲惫不堪，最核心的临床表现还包括性欲骤降、勃起恶化、脂肪堆积增加、肌肉量流失以及睡眠障碍，而其中最不容忽视的正是“抑郁症”。Dr. Mohit Khera 回顾了自己早期开展的一项大规模临床试验，该研究纳入了近 850 名患者，深入探究睾酮与抑郁之间的关联。结果惊人：低睾酮男性中几乎有 92% 伴有不同程度的抑郁症，其中高达 17% 属于重度抑郁。在经过整整一年的睾酮补充治疗后，重度抑郁患者的比例直接从 17% 骤降至 2%。 ```mermaid flowchart TD accTitle: 睾酮补充疗法对抑郁症的改善机制 accDescr: 展示男性低睾酮与抑郁的临床数据以及补充治疗后的改善路径 subgraph Baseline ["基线状况（近 850 例低睾酮患者）"] A["92% 存在抑郁症状"] B["17% 患有严重抑郁症"] end subgraph Intervention ["治疗干预"] C["睾酮补充治疗（为期 1 年）"] D["与抗抑郁药（如 SSRI / Prozac）产生协同增效"] end subgraph Outcome ["治疗后转归"] E["严重抑郁比例降至 2%"] F["抗抑郁药疗效显著增强"] end Baseline --> Intervention Intervention --> Outcome ``` Dr. Mohit Khera 特别澄清，这绝不意味着要直接用睾酮来全面替代重度抑郁症（MDD）的标准治疗，但他强烈呼吁所有临床医生，遇到受抑郁困扰的男性时，**必须至少检测一次睾酮水平**。因为哪怕是已经服用抗抑郁药（如百忧解 Prozac）的患者，在联合补充睾酮后，抑郁状况同样取得了显著改善，这表明睾酮与选择性 5-羟色胺再摄取抑制剂（SSRI）之间存在强大的协同效应。 - 研究涵盖近 850 名男性，92% 低睾酮受试者存在抑郁倾向。 - 17% 受试者患有重度抑郁，经过 1 年睾酮治疗后，重度抑郁比例大幅降至 2%。 - 正在服用 SSRI 类抗抑郁药物（如 Prozac）的患者，联合补充睾酮同样能获得显著增益。 --- ### [01:14:32](https://www.youtube.com/watch?v=IgW1jepnJp4&t=4472s) 《重新连结》：重拾亲密与性爱的四步法则 Dr. Mohit Khera 谈到了自己在十多年前与知名性治疗师 Mary Jo Rapini 合著的畅销书《重新连结：伴侣重获亲密与更佳性爱的四步指南》（*RE-COUPLING: A Couple's 4-step Guide to Greater Intimacy and Better Sex*）。这本书的独特之处在于完美融合了医疗生理干预与心理疏导两个维度。在两人的合作中，Dr. Mohit Khera 负责解决器质与生理医学层面的阻碍，而 Mary Jo Rapini 则专注于心理创伤与情感连结。 他们将亲密关系的重塑拆解为循序渐进的四个核心步骤： | 步骤 | 核心主题 | 主要内容与临床举措 | |:--- |:--- |:--- | | **步骤一** | **沟通（Communication）** | 击碎回避与借口，坦诚面对性功能障碍，避免将生理受挫解读为情感冷淡 | | **步骤二** | **医疗干预（Medical Care）** | 针对男女生理功能障碍进行药物治疗（睾酮替代、伟哥、阴道雌激素、润滑剂等） | | **步骤三** | **亲密感重建（Intimacy）** | 重新定义彼此的情感依恋与身体接触，摆脱单一目的性的焦虑 | | **步骤四** | **性体验拓展（Enhancing Sex）** | 借助情趣玩具、振动棒及自慰等探索手段，丰富性刺激与快感形式 | 在谈及沟通时，Dr. Mohit Khera 抛出了一个令人震惊的统计数据：**只有 44% 出现勃起功能障碍（ED）的男性会主动告知伴侣**。绝大多数男性的本能反应不是倾诉，而是开始下意识地“躲避性生活”。Steven 坦言完全理解这种心态：如果自己突然无法勃起，也会下意识找借口说“抱歉我太累了”，因为直接沟通极易被误解为指责，或是让伴侣觉得“你是不是不再被我吸引了”、“你是不是不爱我了”。这种将生理问题演变为情感危机的恶性循环，恰恰凸显了专业性治疗师协助破局的重要性。 --- ### [01:16:00](https://www.youtube.com/watch?v=IgW1jepnJp4&t=4560s) 破解女性性交疼痛：局部阴道雌激素疗法 在全书第二章医学干预部分，Dr. Mohit Khera 深入剖析了绝经后女性长期被忽视的生理痛苦——性交疼痛（Dyspareunia）。年轻女性的阴道组织含有充沛的雌激素，这种激素扮演着极其关键的生理屏障角色：它维持阴道黏膜厚度、调节内环境以排斥有害细菌并留存益生菌，同时保障性唤起时阴道壁的顺应性与充血滑润。 然而，女性绝经后体内雌激素大幅断崖，随之而来的便是阴道组织萎缩（Atrophy）、黏膜变薄脆弱、微撕裂损伤以及有害菌滋生，导致尿路感染（UTI）风险激增。Dr. Mohit Khera 直言：“如果一个女人每次做爱都痛彻心扉，你根本不可能要求她去享受性爱。”对于年轻女性，性交疼痛多由阴道痉挛（Vaginismus）等原因造成；而绝经后女性最普遍的根源就是雌激素匮乏导致的组织萎缩。 解决这一困境的医疗手段非常简单明了——**局部阴道雌激素治疗（Local Vaginal Estrogen Therapy）**，可通过阴道栓剂或乳膏给药。Dr. Mohit Khera 会叮嘱患者保持耐心，这种局部修复通常需要持续用药约 3 个月方可见效。一旦黏膜厚度与菌群恢复，尿路感染复发率骤降，性交疼痛彻底缓解，女性对性生活的抗拒和回避也会随之冰释。无论是男性还是女性，只要性生活带来的是生理痛苦，逃避就是最自然的生物本能，而医学干预正是消除这一阻碍的基石。 --- ### [01:18:28](https://www.youtube.com/watch?v=IgW1jepnJp4&t=4708s) 卧室沟通的艺术与“房中大象” 当伴侣双方都在沉默中默默受苦、彼此隔阂时，应当如何破局？Dr. Mohit Khera 给出了两条最核心的处方：**第一是留出时间（Time）**，许多伴侣的生活节奏就像“夜色里的影子”，一人进门另一人已经出门，彼此根本没有真正共享的时间，因此必须有意识地在日程中为伴侣创造专属时段；**第二是开放对话（Open Dialogue）**，任何疾病如果无法坦然向伴侣表述，就根本无法启动治疗。他强调性问题没有任何可耻之处，必须全面去污名化。研究证实，保持规律性生活的伴侣在关系满意度、幸福感方面均有显著提升，且抑郁发病率明显更低。 Steven 引用了书中发人深省的一句话：“当性生活出现问题时，它会变成整段关系的 90%，而伴侣们却鲜少知道该如何沟通这些问题。”在节目中，Steven 收到过大量听众来信，倾诉着相似的困境：彼此在其他各方面都极度契合、深爱着对方，但卧室里却始终存在一头“巨大的房间里的大象”（无性或性失调）。 对此，Dr. Mohit Khera 澄清了一个关键概念：**性亲密（Sexual Intimacy）绝对不等于单纯的实质性插入（Penetration）**。正如他所定义的“性寿命（Sexspan）”——指从事令双方满意的性活动的意愿与能力。他有许多患者完全不进行插入式性交，但依然享有精彩绝伦的性生活。对于这种伴侣，他会欣然送上祝福，因为只要双方感到满足与愉悦，那就是完美的性关系；唯有当伴侣双方渴望实质性插入却因功能障碍无法实现时，医疗干预才需要正式介入。满足的定义权，永远掌握在伴侣自己手中。 --- ### [01:20:40](https://www.youtube.com/watch?v=IgW1jepnJp4&t=4840s) 引入情趣玩具：敏感度钝化还是亲密催化剂？ 围绕第四章中提及的振动棒、手铐、眼罩等情趣用品，Steven 提出了许多人的核心疑虑：使用振动棒或高强度情趣玩具，是否会导致肉体对正常、非器械的性接触产生脱敏（Desensitization），进而破坏原汁原味的亲密体验？ Dr. Mohit Khera 明确反驳了这一担忧，指出科学研究得出的结论恰恰相反：**振动棒等辅助用具不仅不会削弱关系，反而是提升亲密度的强大催化剂**。在共同探索玩具的过程中，伴侣双方必然会发生实时的深度沟通——引导对方哪些刺激让人愉悦、哪些动作令人不适，从而建立起对自己和伴侣身体的全新认知地图。 Steven 对此深表赞同，直言玩具的引入对于亲密生活而言绝对是“游戏规则改变者（Game Changer）”。无论是骰子、手铐、眼罩还是振动棒，其深层魅力在于带来了**新鲜感（Novelty）**。人类在性兴奋的激发上极其依赖新异刺激，如果不借助外在工具与多元玩法，传统的性互动形式极其有限，极易陷入单调乏味的疲倦期，而情趣工具恰恰为伴侣解锁了维持长期激情的无限可能。 ### [01:22:03](https://www.youtube.com/watch?v=IgW1jepnJp4&t=4923s) 性玩具在两性关系中的应用与男性振动器 在探讨如何维持亲密关系的新鲜感时，史蒂芬分享了自己的亲身感悟。他坦言，作为男性，过去普遍有一种刻板印象，认为性玩具只是女性买给自己、独自使用的私密物品；然而在深入了解后，伴侣玩具实际上极大地延长了两人关系中的“探索新鲜感”，甚至演变成由他主动在卧室中引入新道具。史蒂芬还开玩笑调侃道，有时他甚至觉得伴侣“比起喜欢我，更喜欢那些玩具”。 莫希特·赫拉（Dr. Mohit Khera）博士对此高度认同，并指出这正是他在著作《重新联结》（RE-COUPLING）第四章中着重探讨的内容。赫拉博士指出，大众往往以为振动器是女性的专属，但事实上在临床医学中，医生同样会为男性开具振动器处方。例如临床上会使用一种名为 Viberect 的专用医用男性振动仪，专门帮助那些患有射精延迟或性高潮障碍（delayed orgasmia）的男性患者。这类辅助工具不仅能改善具体的生理功能障碍，还能显著促进伴侣间的亲密互动与乐趣。 --- ### [01:23:35](https://www.youtube.com/watch?v=IgW1jepnJp4&t=5015s) 佩罗尼氏病：被忽视的阴茎异常弯曲 当史蒂芬询问还有哪些至关重要却尚未讨论的男性健康议题时，赫拉博士毫不犹豫地提出了佩罗尼氏病（Peyronie's disease，阴茎硬结症）。这是一项影响极其深远却极少被公开谈论的男性疾病。令人震惊的是，全球约有高达 9% 的男性遭受该病的困扰，但绝大多数普通人甚至从未听说过它的名字。 为了形象地解释这种病理机制，赫拉博士打了一个生动的比方：如果把阴茎比作一个气球，在一侧贴上一张没有弹性的胶带，当气球被充气吹大时，它必然会朝着胶带紧绷的方向严重弯曲。在勃起状态下，佩罗尼氏病会导致阴茎异常弯曲；一旦弯曲角度超过 60 度，实质上就彻底剥夺了正常进行性交的可能性。这种生殖器官的器质性畸变给男性带来了沉重的精神创伤，许多患者因此陷入重度抑郁。 ```mermaid flowchart LR accTitle: 佩罗尼氏病病理与治疗路径 accDescr: 简要展示佩罗尼氏病从纤维斑块形成导致弯曲，到医疗干预的完整流程。 subgraph Path["病理机制"] A["白膜形成坚硬纤维斑块"] --> B["勃起时组织拉伸受阻"] B --> C["阴茎严重弯曲\n(角度常 > 60°)"] end subgraph Impact["后果"] C --> D["无法进行性生活 / 重度抑郁"] end subgraph Solution["临床干预"] D --> E["胶原酶注射破除斑块\n(FDA批准)"] D --> F["外科矫正手术"] end ``` - **高患病率与认知盲区**：全球约 9% 的男性患有佩罗尼氏病，但绝大多数患者对此一无所知，在极度羞耻和困惑中独自承受痛苦。 - **功能障碍临界点**：弯曲度若超过 60 度，通常会导致无法完成插入式性行为，并伴随剧烈疼痛与严重心理畸变感。 - **现有有效治疗**：在美国，FDA 已批准一种名为胶原酶（collagenase）的局部注射疗法，可以直接注入硬结斑块内部将其分解软化；此外，泌尿外科还拥有成熟的矫正手术方案，能将阴茎重新拉直。赫拉博士呼吁患者千万不要默默忍受，必须积极就医。 --- ### [01:25:05](https://www.youtube.com/watch?v=IgW1jepnJp4&t=5105s) 告别“创可贴”：从伟哥走向勃起功能障碍的再生性根治 谈到性功能障碍的未来走向，赫拉博士严肃指出，现代医学与患者的需求正在经历根本性的范式转变——人们已经厌倦了像“创可贴”一样的临时应对方式（如每次房事前服用万艾可），患者真正渴望的是彻底治愈勃起功能障碍（ED）。除了通过改善饮食、规律锻炼、优化睡眠与舒缓压力等生活方式干预之外，男科学界已经全面迈入了“再生医学疗法”（regenerative therapies）的新纪元。 赫拉博士重点解析了低能量冲击波疗法（Shockwave therapy），这项技术自 2010 年问世以来，在过去五年中得到了极大的推广。他用一个通俗的例子解释其生物学逻辑：如果一个人的手指被锤子多次敲打造成微创伤，机体为了自愈，会自发调集生长因子并促进新生血管生成。心脏病专家早在多年前就将冲击波应用于缺血性心脏，通过诱导新生血管形成（neoangiogenesis）来治疗冠心病；骨科医生也长期用它来加速运动损伤愈合。男科学家将这种低能量震波精准导入阴茎海绵体组织，同样能激活新生微血管生长、修复受损神经，从而恢复自主勃起血流。 此外，赫拉博士透露其研究团队正在实验室中全力探索其他前沿手段，包括高压氧疗法（Hyperbaric oxygen therapy）、利用深层组织热效应改善血供的射频疗法（Radio frequency）、富血小板血浆（PRP）注射以及干细胞疗法。在未来的 5 到 10 年内，摆脱对药物依赖的根治性技术将迎来重大突破。 --- ### [01:26:56](https://www.youtube.com/watch?v=IgW1jepnJp4&t=5216s) 心理与身体创伤对性功能的影响 史蒂芬随后引出了一个此前未被深入展开的话题：创伤（Trauma）在性功能障碍中所扮演的角色。史蒂芬分享说，自己曾有一任伴侣曾公开承认，其严重的性功能障碍本质上源于过去经历的某种创伤事件。他借此询问赫拉博士在日常门诊中遇到过多少因创伤而导致性功能障碍的男女患者。 赫拉博士表示，诊所会对每一位前来的男女患者进行详尽的问卷筛查，仔细询问他们是否遭遇过任何形式的身体创伤或性创伤。然而，真实的临床现状是，绝大多数患者在最初就诊时极其谨慎，甚至刻意隐瞒这些隐秘痛苦。通常只有在患者与性心理治疗师建立了深厚信任、经历多次深入沟通后，真相才会被吐露，最终由心理治疗师反馈给主治医疗团队。赫拉博士强调，面对创伤型性功能障碍，医患之间需要更多的时间与深度的情感联结，绝非一两次普通门诊就能彻底敞开心扉。 --- ### [01:27:52](https://www.youtube.com/watch?v=IgW1jepnJp4&t=5272s) 终极手段：阴茎假体植入与“破釜沉舟”的抉择 访谈桌上摆放着一个让史蒂芬好奇已久的精巧器械，赫拉博士终于揭开了它的面纱——这是一个可充气式阴茎假体（Penile implant / prosthesis）。该装置于 1973 年由赫拉博士所在的贝勒医学院（Baylor College of Medicine）著名泌尿外科专家布兰特利·斯科特博士（Dr. F. Brantley Scott）发明，迄今已有整整 51 年的临床应用历史。 赫拉博士现场演示并拆解了阴茎解剖与假体运作机制：男性阴茎上方为两根平行的海绵体，下方包裹着尿道。外科医生在手术中会将两条特制的高弹性圆柱体（膨胀气囊）置入海绵体内，在阴囊内植入一个微型按压泵，并在耻骨后方植入一个储存生理盐水的小储水囊。当患者需要勃起时，只需隔着阴囊皮肤挤压控制泵数次，盐水便会被压入阴茎海绵体的圆柱体内，瞬间呈现出极度坚硬而自然的勃起状态；性生活结束后，只需轻按泵体上的释放阀门，液体就会自动流回储水囊，阴茎随即完全疲软。 ```mermaid flowchart TD accTitle: 可充气阴茎假体工作原理 accDescr: 解释充气假体如何在储液囊、阴囊控制泵与海绵体圆柱体之间流转液体以控制勃起与疲软。 subgraph Arousal["启动勃起"] P1["挤压阴囊内置微型泵"] --> R1["储液囊释放生理盐水"] R1 --> C1["液体注入海绵体内双圆柱体"] C1 --> E1["阴茎达到极其坚硬的机械性勃起"] end subgraph Flaccid["恢复疲软"] B1["按下控制阀释放按钮"] --> C2["圆柱体内盐水排出"] C2 --> R2["生理盐水回流至耻骨后储液囊"] R2 --> E2["阴茎完全恢复自然自然疲软下垂"] end ``` 赫拉博士分享了一则令人啼笑皆非的个人趣事：为了将这个实体模型带到录制现场，他在机场安检时被安检人员截停，对方从未见过这种器械，强制要求他当场拆开行李、当众向安检人员演示如何泵气膨胀和放气，引来了大批围观人员。 然而，这件“神级器械”的背后是一场不可逆的决断： - **满意度与医保覆盖**：在美国，该手术费用可由联邦医疗保险（Medicare）全额报销。更重要的是，它并不破坏神经末梢，男性的性快感与性高潮感知完全不受损，患者及其伴侣的整体满意度高达 92% 以上。就像置换坏掉的髋关节或膝关节一样，它是一种重建器官机能的精密人工假体。 - **不可逆的终极风险（“破釜沉舟”）**：赫拉博士郑重警示，阴茎假体必须是“最后一道防线”（last ditch attempt）。因为手术植入需要永久破坏并掏空海绵体内部天然的海绵窦平滑肌组织，一旦未来因为感染或其他原因将假体取出，患者将永远丧失任何自主勃起的能力，药物（伟哥等）或注射治疗将永久失效。因此，必须在尝试穷尽所有其他治疗手段毫无效果后，方可考虑此方案。 ### [01:30:44](https://www.youtube.com/watch?v=IgW1jepnJp4&t=5444s) 阴茎假体植入：ED终极阶梯治疗与满意度天花板 Dr. Mohit Khera 继续深入解析勃起功能障碍（ED）的阶梯式治疗逻辑。他重申了一组关键统计数据：40 岁的男性中有 40% 面临勃起问题，到了 50 岁这一比例上升至 50%。绝大多数患者起初都会依赖伟哥（Viagra），但他严肃指出：“伟哥不是治愈手段，它只是一块创可贴（Band-Aid）。”就像长期吃止痛药来掩盖腿疾一样，随着原发血管神经病变的持续进展，患者最终仍会失去行走能力——ED 药物也是如此，药效终究会随着病情加重而失效。一旦口服药物不再起效，治疗便会推进到第二层阶梯，即阴茎海绵体药物注射（intracavernosal/penal injections）；如果连注射也失效了，患者唯一的选择便是阴茎假体植入手术（penile implant）。 ```mermaid flowchart TD accTitle: ED 阶梯式治疗路径与满意度对比 accDescr: 展示从一线口服药、二线注射治疗到三线阴茎假体植入的升级过程及满意度差异 subgraph Step1["一线治疗（初期）"] A["口服药物<br/>（Viagra / Cialis 等 PDE5i）"] -->|"随时间逐渐失效<br/>（治标不治本）"| B["二线治疗"] end subgraph Step2["二线治疗（进展期）"] B["海绵体注射 / 真空负压吸引装置<br/>（Penal Injections / VED）"] -->|"最终失效或依从性低"| C["三线终极治疗"] end subgraph Step3["三线终极方案"] C["充气式阴茎假体植入<br/>（Penile Implant）"] D["满意度调查问卷评估：<br/>• 假体植入满意度最高<br/>• 随心控制勃起时长<br/>• 射精感与性高潮完好保留"] C --> D end ``` Steven 追问植入体的高满意度是否仅仅是因为患者的起点太低——从一个“完全无法勃起”的绝望状态跨越到“能立起来”，自然会感到无比满足。Dr. Khera 反驳了这种假设，他解释道：如果对横跨所有治疗阶段的患者进行标准化问卷调查，让他们对比口服药、海绵体注射、真空负压装置（VED）和阴茎假体这四种方式，在同样能实现勃起的前提下，阴茎假体植入的满意度依旧稳居第一。当 Steven 惊讶地询问植入后是否还能射精时，Dr. Khera 斩钉截铁地回答：“可以，毫无问题。”假体仅仅机械地提供硬度支撑，并不干扰负责射精和性高潮的神经与尿道解剖通道。 Steven 感慨这种障碍对人们生活和亲密关系的摧毁力：“性表现不佳会毁掉人际关系，而人际关系正是生命的核心本质。”假体植入从本质上重塑了一个失去性功能的人，甚至让他们获得了近乎“超能力”的掌控感——患者想什么时候过性生活就什么时候过，想维持多久就维持多久，只有在患者主动按压阀门时，勃起才会消退。 - 口服药物属于对症支持，无法阻止海绵体血管内皮退化，长期来看药效衰退在临床上十分普遍。 - 阴茎假体植入不仅成功率极高，而且是所有 ED 疗法中患者与伴侣综合满意度评分最高的方式。 - 假体不影响阴茎背神经的感觉传导，正常的射精感、高潮反射及尿道排尿功能完全得以保留。 --- ### [01:32:25](https://www.youtube.com/watch?v=IgW1jepnJp4&t=5545s) 播客闭幕提问：理性主义无法解释的未知与迟到的顿悟 在对话尾声，Steven 抛出了播客固有的传统互动环节——由上一位匿名嘉宾留给下一位嘉宾的问题：“你是否曾经历过任何从理性唯物主义（rational materialism）视角无法解释的事情？”Dr. Khera 坦言，科学和医学世界中充斥着太多人类至今无法解释的未知。以男性生育力为例，在来到他门诊的不育男性中，有整整 40% 的诊断结果是“特发性不育”（idiopathic infertility）——即医生在竭尽所有现代医学检验手段后，仍完全找不出病因。更具讽刺意味的是，现代医学现在给出的自以为正确的解释，往往在 10 年后被证明是完全错误的。 谈及个人的超自然或精神信仰经历，Dr. Khera 分享了他对宗教与精神力量的虔诚，以及他与死亡擦肩的深刻体悟。他在日常临床工作中频繁面对死亡，而父亲的过早离世更彻底改变了他的人生哲学。他的父亲是一名普通外科医生，一生都在独自经营诊所并极其拼命地工作，总是把“总有一天我会好好享受生活”挂在嘴边。父亲将一生的满足感无限延后，终于在 69 岁那年决定退休，准备安享晚年；然而命运却在 70 岁时残酷降临，父亲被确诊为特发性肺纤维化（idiopathic pulmonary fibrosis），这是一种肺部迅速纤维化纤维变硬的致命绝症。父亲在 70 岁接受了双肺移植手术，依靠捐赠者的肺艰难挣扎了 5 年，最终于 75 岁辞世。 父亲在临终前留给他最震撼的一句教诲是：“不要等到终点才去享受，享受旅途本身（Don't wait till the end, enjoy the ride）。我真希望我当年享受了沿途的风景，因为一味等待所谓的终点，有时等待你的可能根本没有终点。”父亲将即时满足彻底推迟到了 70 岁，换来的却是短暂的折磨。这段沉痛的亲身经历让 Dr. Khera 发誓绝不重蹈覆辙，无论日程多么繁忙，他每天都会强制留出属于自己的晨间时间：冥想、规律健身、虔诚祈祷，并将人生优先级清晰划定为“上帝、家庭、工作、患者”。他时刻提醒自己脚踏实地，在每一分每一秒中体会当下的生命。 - 临床医学中约 40% 的男性不育症属于病因不明的“特发性”范畴，突显了现代科学的认知边界。 - 延迟满足（Delayed Gratification）过度会导致生命重心的失衡，父亲的悲剧成为他平衡高强度医疗工作与个人生活的终极警示。 --- ### [01:35:35](https://www.youtube.com/watch?v=IgW1jepnJp4&t=5735s) 打破性健康耻感，让睾酮成为全民关注的福祉 针对全球无数在亲密关系中“默默忍受痛苦”（suffering in silence）的伴侣、男性和女性，Dr. Khera 送出了全场访谈最温暖而坚定的寄语： > “饱受性功能障碍的困扰并不可耻，随着年龄增长，这完全是正常的生理现象。如今医学界拥有非常多优秀的治疗方案，请勇敢地迈出第一步，举起手来告诉你的医生，寻求专业治疗。” 谈及未来的工作重点，Dr. Khera 介绍了自己的个人网站（drmohitkhera.com）与专注于生活方式干预的 sexspanhealth.com。此外，他倾注心血创立了非营利组织“睾酮项目”（The Testosterone Project，官网 testosteronproject.com）。该组织致力于全社会的性激素知识普及与法律倡导，当前有三大核心诉求： 1. 推动美国 FDA 正式批准针对女性性功能减退的睾酮疗法，弥补女性荷尔蒙治疗的制度空白； 2. 倡导将睾酮血液检测纳入成年人的常规体检标准，使其成为与血脂、血糖一样的常规生理监测指标； 3. 推动睾酮药物的去管制化（deregulation），破除过时的处方壁垒与用药污名化。 在节目尾声，Steven 结合新年目标回顾了行为心理学中的“1% 法则”：高达 80% 的新年目标在 2 月便宣告破灭，根源在于人们过度紧盯宏大终局，却忽视了每天微小的复利行动。他以此引出为培养微习惯打造的《1% 日记》（1% Diary）90 天践行手账及互助社群，鼓励听众从日常的每一步改变做起，全面夺回生活与健康的掌控权。 ## Notable quotes > [03:40](https://www.youtube.com/watch?v=IgW1jepnJp4&t=220s) 在这个星球上，没有任何一种药物的功效能够超越饮食、运动、充足睡眠与减压的综合作用。 — Dr. Mohit Khera > [03:40](https://www.youtube.com/watch?v=IgW1jepnJp4&t=220s) 如果你想延长自己的性寿命，就必须确保你的伴侣同样保持参与度与身心健康。 — Dr. Mohit Khera > [04:56](https://www.youtube.com/watch?v=IgW1jepnJp4&t=296s) 要么两人的性欲都维持在低水平，要么同时提升两者；千万不能只拔高一方，否则就是一场灾难。 — Dr. Mohit Khera > [11:07](https://www.youtube.com/watch?v=IgW1jepnJp4&t=667s) 如果你真的想和妻子做爱，就主动去洗碗、倒垃圾，帮她把孩子早点哄上床睡觉——帮她减压，才是激发她性欲的最有效方式。 — Dr. Mohit Khera > [14:07](https://www.youtube.com/watch?v=IgW1jepnJp4&t=847s) 很多时候男性的“低性欲”并不是真的没有欲望，而是一种源于 ED 的逃避机制。 — Dr. Mohit Khera > [21:15](https://www.youtube.com/watch?v=IgW1jepnJp4&t=1275s) 如果有一种药能保护心脏、改善前列腺，还能帮助男性重获优质勃起，而且价格极其低廉，大多数男性都会毫不犹豫地选择尝试。 — Dr. Mohit Khera > [46:44](https://www.youtube.com/watch?v=IgW1jepnJp4&t=2804s) 如果你做好你那一部分，我做好我这一部分，我们就会状态爆棚（we're on fire）。 — Dr. Mohit Khera > [01:18:28](https://www.youtube.com/watch?v=IgW1jepnJp4&t=4708s) 当性生活出现问题时，它会变成整段关系的 90%，而伴侣们却鲜少知道该如何沟通这些问题。 — Steven Bartlett > [01:30:44](https://www.youtube.com/watch?v=IgW1jepnJp4&t=5444s) 伟哥不是治愈手段，它只是一块创可贴（Band-Aid）。 — Dr. Mohit Khera > [01:32:25](https://www.youtube.com/watch?v=IgW1jepnJp4&t=5545s) 不要等到终点才去享受，享受旅途本身（Don't wait till the end, enjoy the ride）。我真希望我当年享受了沿途的风景，因为一味等待所谓的终点，有时等待你的可能根本没有终点。 — Dr. Mohit Khera 的父亲 > [01:35:35](https://www.youtube.com/watch?v=IgW1jepnJp4&t=5735s) 饱受性功能障碍的困扰并不可耻，随着年龄增长，这完全是正常的生理现象。如今医学界拥有非常多优秀的治疗方案，请勇敢地迈出第一步，举起手来告诉你的医生，寻求专业治疗。 — Dr. Mohit Khera ## Mentioned Dr. Mohit Khera, Steven Bartlett, Baylor College of Medicine, CDC, Dr. Irwin Goldstein, Montorsi, Cost Plus Drugs, Mark Cuban, GoodRx, Dr. Robert Kloner, Dr. Antonio Aversa, Dr. Michael Perelman, Andrew Huberman, University of Antwerp, OnlyFans, Fred Wu, European Male Aging Study (EMAS), Dr. Mike Eisenberg, Dr. Thomas Walsh, Mary Jo Rapini, Dr. F. Brantley Scott, The Testosterone Project, Cialis (他达拉非), Viagra (西地那非), Levitra (伐地那非), Stendra (阿伐那非), Addyi (氟班色林), Vyleesi (布美诺肽), Wellbutrin (安非他酮), Prozac (百忧解), Jatenzo, Tlando, Kyzatrex, Andriol, Intrinsa, AndroFeme, Viberect, RE-COUPLING: A Couple's 4-step Guide to Greater Intimacy and Better Sex, Traverse Trial, MEDITA 试验 ## Video description Dr Mohit Khera is a Professor of Urology at Baylor College of Medicine specialising in male and female sexual dysfunction. He is also the co-author of the book, ‘RE-COUPLING: A Couple's 4-step Guide to Greater Intimacy and Better Sex’ 00:00 Intro 01:59 Who Is Mohit and What Does He Do? 02:29 What Is a Sexspan and Why Does It Matter? 03:40 Is It Possible to Make Sexspan Last as Long as Lifespan? 04:56 Mohit's Professional Experience and the People He's Worked With 06:56 The Most Popular Things People Ask Mohit and Why They Come to See Him 11:07 Most Common Reason for Low Libido: How Much of It Is Related to Lack of Compatibility? 15:16 What Is Libido? 15:36 Connection Between Erectile Dysfunction and Low Libido 18:35 What Are the Side Effects of ED Pills? 21:15 The Biggest Side Effect of Cialis 21:41 Who Shouldn't Take Cialis? 23:24 Treatment for Sexual Dysfunction in Women 25:34 Connection Between Stress and Dopamine 27:02 Types of Activities That Raise Dopamine Levels 29:18 How Much Does Pornography Contribute to Low Libido? 30:50 Why Do People Have Less Sex Nowadays? 32:12 Role of Pornography in Shifting Sexual Behaviors 36:24 Connection Between Obesity and Sexual Dysfunction 39:04 Losing Weight Boosts Testosterone Levels 40:11 Impact of Testosterone Therapy on Sexual Activity 42:19 Should Someone Like Steven Be Taking Testosterone? 44:13 Testosterone Therapy in Women 47:07 HRT for Women 48:47 The Decline in Testosterone 50:19 What Lifestyle Changes Should We Make to Increase Fertility? 55:35 If a Couple Came to You With Sexual Problems, What Would You Focus on Naturally? 59:53 40% of Men at 40 Will Have ED 01:01:19 The Stigma Around ED 01:03:12 Personal Experiences With Sexual Dysfunction 01:05:49 The Impact of Kids on Sex Lives 01:06:45 Premature Ejaculation 01:09:57 Is Testosterone Dangerous? 01:11:22 Will Testosterone Injections Reduce My Lifespan? 01:13:34 Links Between Depression and Testosterone 01:14:55 The Importance of Communication for Sex 01:16:00 Improving Sexual Dysfunction in Men and Women 01:16:54 Pain During Sex for Women 01:18:28 How Do We Improve Communication in the Bedroom? 01:20:40 Are There Any Risks to Vibrators? 01:23:35 Abnormal Curvature of the Penis 01:25:01 Cures for ED, Not Pills 01:26:53 The Role Trauma Plays in Sexual Dysfunction 01:27:49 Erection Devices 01:32:25 Is There Anything You Cannot Explain? Follow Dr Mohit: Instagram - https://g2ul0.app.link/L3Z03S4WqPb Twitter - https://g2ul0.app.link/JlcpMx8WqPb Website - https://g2ul0.app.link/T7gIUo6WqPb You can purchase Dr Mohit’s book, ‘RE-COUPLING: A Couple's 4-step Guide to Greater Intimacy and Better Sex’, here: https://g2ul0.app.link/xExobrcXqPb DOAC Community Notes: https://drmokhere.tiiny.co You can purchase the The Diary Of A CEO Conversation Cards: Second Edition, here: https://g2ul0.app.link/f31dsUttKKb Join the waitlist to be the first to hear about the next drop of The 1% Diary! https://bit.ly/1-Diary-YT-ad-reads Follow me: https://g2ul0.app.link/gnGqL4IsKKb Get access to exclusive Diary of a CEO content: https://www.youtube.com/channel/UCGq-a57w-aPwyi3pW7XLiHw/join Sponsors: Linkedin Jobs - https://www.linkedin.com/doac PerfectTed - https://www.perfectted.com with code DIARY40 for 40% off [Source](https://www.youtube.com/watch?v=IgW1jepnJp4)

[3:40] Dr. Mohit Khera: 在这个星球上，没有任何一种药物的功效能够超越饮食、运动、充足睡眠与减压的综合作用。 [3:40] Dr. Mohit Khera: 如果你想延长自己的性寿命，就必须确保你的伴侣同样保持参与度与身心健康。 [4:56] Dr. Mohit Khera: 要么两人的性欲都维持在低水平，要么同时提升两者；千万不能只拔高一方，否则就是一场灾难。 [11:07] Dr. Mohit Khera: 如果你真的想和妻子做爱，就主动去洗碗、倒垃圾，帮她把孩子早点哄上床睡觉——帮她减压，才是激发她性欲的最有效方式。 [14:07] Dr. Mohit Khera: 很多时候男性的“低性欲”并不是真的没有欲望，而是一种源于 ED 的逃避机制。 [21:15] Dr. Mohit Khera: 如果有一种药能保护心脏、改善前列腺，还能帮助男性重获优质勃起，而且价格极其低廉，大多数男性都会毫不犹豫地选择尝试。 [46:44] Dr. Mohit Khera: 如果你做好你那一部分，我做好我这一部分，我们就会状态爆棚（we're on fire）。 [78:28] Steven Bartlett: 当性生活出现问题时，它会变成整段关系的 90%，而伴侣们却鲜少知道该如何沟通这些问题。 [90:44] Dr. Mohit Khera: 伟哥不是治愈手段，它只是一块创可贴（Band-Aid）。 [92:25] Dr. Mohit Khera 的父亲: 不要等到终点才去享受，享受旅途本身（Don't wait till the end, enjoy the ride）。我真希望我当年享受了沿途的风景，因为一味等待所谓的终点，有时等待你的可能根本没有终点。 [95:35] Dr. Mohit Khera: 饱受性功能障碍的困扰并不可耻，随着年龄增长，这完全是正常的生理现象。如今医学界拥有非常多优秀的治疗方案，请勇敢地迈出第一步，举起手来告诉你的医生，寻求专业治疗。

[46:45] Dr. Mohit Khera: If you do your part and I do my part, we're on fire [48:47] Dr. Mohit Khera: It's really a testament to the fact that decade by decade, we're becoming a more unhealthy population [50:19] Dr. Mohit Khera: Healthier people are more fertile... Darwinism in other words: survival of the fittest. [59:53] Dr. Mohit Khera: Why is it okay to raise your hand if you have hypertension, but not okay to raise your hand if you have sexual dysfunction? It's got to stop... It's a common condition. It's curable. You just have to raise your hand. [78:28] Steven Bartlett: When sex isn't going well, it can become 90% of the relationship, and couples seldom know how to communicate about any of these problems. [92:25] Steven Bartlett: Have you ever experienced anything that you cannot explain from a position of rational materialism? [93:17] Dr. Khera's father: Don't wait till the end; enjoy the ride.

[0:00] this term sex pan which I've never heard [0:02] before what is that sex span is how long [0:04] you are able to engage in satisfying [0:06] sexual activity and most men most women [0:09] want their sex fan to last as long as [0:11] their lifespan and there's many things [0:13] you can do that significantly prolong [0:15] your sex fan and I called it the four [0:16] pillars so let's talk about sex Dr moit [0:20] Cara is a board certified urologist and [0:22] Professor who specializes in male and [0:23] female sexual dysfunction his [0:25] groundbreaking research has [0:26] significantly contributed to improving [0:28] sexual health and fertility millions of [0:30] men and women are suffering from sexual [0:31] problems like infertility and sexual [0:33] dysfunction for example in the US [0:35] roughly 43 to 48% of women suffer from [0:38] female sexual dysfunction which involves [0:40] four components that we're going to talk [0:42] about but we also know that premature [0:44] ejaculation affects 30% of men globally [0:47] and also 40% of men at 40 will suffer [0:49] from erectile dysfunction and it's the [0:51] first sign of other major adverse [0:53] medical problems for example 66% have [0:55] some degree of depression and 15% of [0:58] them will have a heart attack or stroke [0:59] within 7 years and if you look at the [1:01] causes for Ed one of the biggest factors [1:03] is obesity which causes the testosterone [1:05] levels to go down but men need [1:07] testosterone for sexual functions so do [1:08] women because low testosterone increases [1:10] low Lio but the issue is people don't [1:13] talk about their sexual problems they [1:14] suffer in silence and they start [1:16] avoiding sex but it's curable and I have [1:18] two ways to raise their testosterone [1:19] techniques to significantly improve the [1:22] quality of your directions and natural [1:23] ways to improve sexual function in men [1:25] and women so number one most important [1:28] is this has always blown my mind a [1:31] little bit 53% of you that listen to the [1:33] show regularly haven't yet subscribed to [1:36] the show so could I ask you for a favor [1:38] before we start if you like the show and [1:39] you like what we do here and you want to [1:40] support us the free simple way that you [1:42] can do just that is by hitting the [1:43] Subscribe button and my commitment to [1:45] you is if you do that then I'll do [1:47] everything in my power me and my team to [1:49] make sure that this show is better for [1:50] you every single week we'll listen to [1:52] your feedback we'll find the guest that [1:54] you want me to speak to and we'll [1:56] continue to do what we do thank you so [1:57] much [2:01] Dr Mo [2:04] Hera who are you and what have you spent [2:07] your life doing so I'm a urologist and I [2:11] specialize in male and female sexual [2:13] dysfunction testosterone replacement [2:15] therapy and infertility for the past 17 [2:18] years I've been working as a professor [2:20] at Baya College of Medicine Houston [2:22] looking at ways to improve sexual health [2:24] improve testosterone and improve [2:26] fertility and we talked just before we [2:29] started recording about this term sex [2:30] pan which I've never heard before what [2:32] is the sex pan and why do you care about [2:34] it yeah so Stephen you know what [2:36] lifespan is it's how long you're going [2:37] to live right and you also know what [2:39] health span is how long you're going to [2:41] live in a healthy lifestyle but you may [2:44] not have heard of the concept of sex [2:46] span sex span is the ability to engage [2:50] in sexual activity satisfying sexual [2:52] activity and so how long you are able to [2:55] engage in sexual activity is important [2:57] to most men right um so let's give you [2:59] an example the average lifespan in the [3:02] United States is 77 years old the [3:05] average Health Span in the United States [3:06] believe it or not is 67 years old in [3:09] fact if you look at the CDC and they [3:11] talk about how long you'll live without [3:13] a disability it's actually 63 so there's [3:16] a Delta here there's at least 10 15 [3:18] years where you will be in some kind of [3:20] disability and cannot live to your [3:22] fullest now think about the concept of [3:24] sex span how long you'll have the [3:26] ability to engage in sexual activity [3:28] satisfying sexual ity we most men most [3:32] women want their sex span and their [3:34] health span to last as long as their [3:36] lifespan yes so I think it's [3:39] important and there's things that I can [3:41] do to make my sex span last as long as [3:44] my lifespan there's many things you can [3:46] do and I call it the four pillars the [3:48] first is Diet exercise sleep and stress [3:51] reduction I don't have a pill on the [3:53] planet stronger than diet exercise sleep [3:57] and stress reduction and each one of [3:59] those can significantly improve a man [4:02] and a woman's sex span but also their [4:04] health span and their lifespan the other [4:06] is hormones testosterone extremely [4:09] important testosterone supplementation [4:11] can significantly improve a man and a [4:13] woman's sexual function and fortunately [4:16] for women in the United States we don't [4:18] have very many options actually globally [4:20] for women there's not many options um [4:23] but I think it's important a hormone [4:24] replacement therapy and I one more thing [4:27] I think about the couple think about sex [4:28] ban as a couple's disease let me give [4:30] you an example tomorrow Stephen are are [4:32] you married or yeah well I'm in a [4:34] long-term relationship you're your [4:35] partner so let's say your partner [4:36] tomorrow says to you I am no longer [4:38] going to have sex with you unless uh you [4:41] cheat on her or you leave her you're not [4:43] going to have sex again right think [4:44] about the importance of the couple um so [4:47] I talk about this quite often keep your [4:50] partner engaged keep your partner [4:52] healthy if you want to prolong your sex [4:54] fan so I got two questions here the [4:56] first of which is who have you worked [4:59] with in your career and the second [5:02] question is what is your CV give me a [5:04] rundown of your professional experience [5:06] yeah so I started my residency in 2000 [5:09] and uh I did my residency in 2 one year [5:12] of general surgery I did five years of [5:13] Urology training and then I did one year [5:15] of a fellowship in men's health soon as [5:18] I finished my training I joined uh the [5:20] University at Baylor College of Medicine [5:22] and I started a basic science laboratory [5:24] where we do a basic science research in [5:26] sexual medicine and testosterone for the [5:28] past 17 years and I just started a [5:30] clinical trial so I start have a [5:31] clinical arm we do clinical research I [5:33] see approximately 150 patients a week [5:36] every week I do approximately 68 [5:37] surgeries every week and I still work at [5:40] the VA hospital it's a veteran [5:42] government Hospital one half day a week [5:44] working with the veterans so it's quite [5:45] busy um but you know my passion really [5:48] is education research and clinical care [5:50] and um and that's what we do and so you [5:53] know when I started my where how I [5:54] really got into this was when I finished [5:56] my training I was so proud of myself I [5:58] was able to get these men these amazing [6:00] erections these great libidos and uh I [6:03] realized one day this woman called me [6:05] and she was frantic and she said look uh [6:08] you're treating my husband you're able [6:10] to get him these great erections great [6:11] libido but I don't want to have sex with [6:13] him and he wants to have sex with me all [6:15] the time and now we have a terrible [6:17] relationship you've ruined our [6:19] relationship and I thought to myself [6:21] wait a minute uh you know I this doesn't [6:24] make sense but she was right you know in [6:26] in sexual medicine either leave both Le [6:29] low or raise them both but don't raise [6:32] one or the other it's a setup for [6:34] disaster so very quickly that year I [6:37] went out and flew out to meet with Dr [6:39] Irwin Goldstein who's considered one of [6:40] the Godfathers of female sexual [6:42] dysfunction spent some time with him [6:44] went to his courses and for the past 16 [6:47] years I've been treating women as well [6:49] you can't just treat one patient without [6:51] addressing the other and so therefore [6:53] it's a couple's disease and give me a [6:56] flavor of the types of conversations you [6:58] have on day one when they walk into your [7:00] practice when they come to see you what [7:02] is the issue that they say they have and [7:04] how do they express it like what are the [7:05] words that they use and if you could [7:07] just give me like five of the most [7:08] popular things people say to you when [7:10] they come to see you so listen first of [7:11] all men and women are very different how [7:13] they express it you know so we'll talk [7:14] with men most men uh let's backtrack [7:18] most men and women do not get any kind [7:20] of medical care when they see their [7:22] primary GP in fact most GPS don't [7:25] address sexual dysfunction there was a [7:27] study looking at medical students only [7:28] 65% % of us medical students get [7:30] training in sexual medicine and of those [7:33] 65 50% of those students said that the [7:35] training was terrible so we don't get [7:37] the sexual medicine training to address [7:39] the problem for patients so the majority [7:42] of patients are never uh discussed about [7:44] their sexual problems but when men come [7:46] in there's a most of them are coming in [7:48] because they already have tried some [7:50] medications that haven't worked and [7:51] they're looking for other Solutions now [7:53] there's a very two simple questions you [7:55] can ask a man they're very [7:56] straightforward are you able to get an [7:58] erection sufficient for penetration it's [7:59] either yes or no are you able to [8:01] maintain that erection to orgasm or [8:03] pleasure it's either yes or no if he [8:05] answers no to either one of those [8:06] questions he suffers from erectile [8:08] dysfunction right and so it's very [8:10] important to get a detailed history you [8:13] want to ask particularly are you able to [8:14] get an erection on your own are you able [8:16] to get erection with masturbation do you [8:18] wake up with morning erections if he [8:20] says look doc I get great morning [8:21] erections or with masturbation I have [8:23] great erections then this has to be [8:25] psychogenic right with my partner I [8:27] cannot get an erection but when I'm by [8:28] myself everything works fine psychogenic [8:31] psychogenic Ed it's a big component what [8:33] is psychogenic many something in the [8:35] mind that's bothering you or inhibiting [8:38] you from engaging in sexual activity and [8:40] that's where the sex therapist comes in [8:42] right because if I if someone tells you [8:44] I get great erections uh by myself but [8:47] with my partner I'm not able to get good [8:49] erections psychologically when with [8:51] their whe they're with their partner [8:53] they're not able to achieve a good [8:54] erection sex for men and women has a [8:57] huge psychogenic component [9:00] a huge psychogenic component so I think [9:02] it's very important to get detailed [9:04] history are they able to get direction [9:06] what did they try what medications have [9:07] they tried you know you have to query [9:09] about [9:10] depression 66% of men who come in with [9:13] Ed have some degree of depression 66% [9:16] right and that's important anxiety 35% [9:18] is very important and more importantly [9:21] we'll talk about this Ed is the first [9:23] sign of other major adverse medical [9:25] problems for example if a man comes into [9:28] my office today 15% of them will have a [9:31] heart attack or a stroke within 7 years [9:33] 15% the day they get Ed 15% will have a [9:36] heart attack or a stroke within seven [9:38] years it's the first sign other studies [9:40] Dr monori showed that if a man presents [9:43] the emergency room with a heart attack [9:45] on average 39 months earlier that's when [9:47] the Ed started so it is the first sign [9:50] now there are many reasons for this one [9:52] theory is called the arterial diameter [9:54] Theory the penal arteries are the [9:57] smallest arteries 1 to 2 mm [10:00] the coronary arteries are 3 to 4 mm the [10:03] kateed 6 to 7 mm so if you remember from [10:06] physiology if you're going to block an [10:08] artery 50% occlusion of an artery causes [10:11] a damage so if you're going to block an [10:12] artery you're going to block the penina [10:14] arteries before the coronary arteries [10:15] you're going to block the coronary [10:16] arteries before you block the kateed [10:18] right so men will get Ed before they get [10:20] a heart attack more more likely to get a [10:22] heart attack before they get a stroke [10:24] that's a theory but it makes sense so I [10:27] worry when a man comes into my office [10:29] could this man have a cult [10:31] cardiovascular disease in fact there was [10:33] a wonderful study that came out of [10:35] Greece they looked at 50 men that walked [10:37] in and they gave them an echocardiogram [10:39] or stress test if it was positive they [10:42] wanted onto a coronary angiogram what [10:45] they found is that roughly 20% of men [10:47] one in five actually had some occlusion [10:50] in their heart whether it was one vessel [10:52] two vessel or three vessel disease so I [10:54] think to myself every time I'm writing [10:56] that prescription is this one of the [10:58] five that could have occlusion and is [11:00] there opportunity to intervene at this [11:03] point so it's really important to think [11:04] about cardiovascular disease as well one [11:07] of the big subjects that I hear a lot [11:08] about even in my friendship groups is [11:10] about libido I've I've got so many [11:13] stories in my friendship group of either [11:15] one or both Partners losing their libido [11:18] so on this subject matter of libido is [11:19] kind of where I wanted to start this [11:21] conversation what is the most frequent [11:23] and popular reason why men and women [11:26] struggle with libido problems and [11:32] how much of of that is about [11:34] compatibility yeah good question libido [11:37] is multifactorial there's many pieces of [11:40] libido it's very complex and I'll give [11:42] you some important components first it [11:44] could be hormonal and the pneumonic I [11:46] teach the residents is pet the four [11:49] hormones that can affect someone's [11:50] libido are prolactin estrogen thyroid [11:54] and testosterone so you have to check [11:56] the pet if the prolactin is elevated the [11:58] libido goes down the testosterone's low [12:00] the libido goes down so maybe it's a [12:02] hormonal issue which could be it and [12:04] particularly many women who go through [12:05] menopause suffer from hormonal issues [12:07] and it could be a hormonal issue the [12:09] second is something called [12:10] neurotransmitters so in other words [12:13] serotonin norepinephrine dopamine [12:15] dopamine goes up libido goes up [12:17] serotonin goes up libido goes down so [12:19] these all regulate how someone's libido [12:22] will function so one of the biggest um [12:25] uh culprits for low libido are [12:27] anti-depressants what do [12:28] anti-depressants do they increase [12:30] serotonin and they decrease libido so [12:33] sometimes it's a medication or something [12:35] that a patient's taking that will shut [12:37] down their libido for example a [12:39] medication that men take for urinary [12:41] function called finasteride shuts down [12:44] their libbido so that is there are [12:46] certain things that you have to look at [12:48] the other components are um lifestyle [12:51] diet exercise sleep and stress reduction [12:53] particularly fatigue and stress if a [12:55] woman is tired and she's exhausted and [12:58] she has to between sex and sleeping at [13:01] night many times she may choose sleep if [13:04] me as well right I'm just saying so [13:06] fatigue is important stress and there's [13:08] this cliche this pneumonic this this [13:10] saying that um with stress is kind of [13:13] interesting typically if a man has a [13:15] very stressful day he will want to have [13:17] sex to relieve his stress uh women have [13:20] to relieve their stress to engage in [13:22] sexual activity it's kind of the [13:24] opposite you know what I mean so I tell [13:26] men if you really want to have sex with [13:27] your wife uh do the dish just take out [13:29] the trash H do everything you can to [13:30] tuck the kids in bed early relieve her [13:33] stress because that will significantly [13:35] increase her desire to engage in sexual [13:37] activity but the other one is uh [13:39] psychogenic so you know we talked about [13:41] that earlier you know sex has a huge [13:44] mental component your relationship with [13:46] your partner your uh your the how close [13:49] you feel with your partner so sometimes [13:50] patients come to me and they're an [13:52] abusive relationship and say and they [13:54] say give me the pill that improves my [13:55] libido I said I it's not going to work I [13:58] mean the the essence the core the [13:59] foundation is not working and therefore [14:02] it's really important for them to see a [14:04] sex therapist one thing for men that [14:07] actually shuts down their libido is when [14:09] they start developing erectile [14:11] dysfunction so if a man starts getting [14:13] erectile dysfunction let's say he gets a [14:16] good erection 50% of the time and he's [14:18] starting to have some problems and it's [14:20] 10 o'clock at night and he says look I [14:21] can try to engage in sexual activity but [14:23] it may or not work and it may be [14:24] frustrating and embarrassing or I can [14:26] just go to sleep it's probably just [14:28] going to go to sleep right and it [14:29] becomes a vicious cycle because the less [14:31] sex he has the more difficult it is to [14:34] engage in sexual activity later on and [14:37] so you may interpret this as a low [14:39] libido but he's really just avoiding it [14:41] because he doesn't want to deal with it [14:42] right but the partner also uh looks at [14:45] this as maybe I'm not attractive anymore [14:47] maybe there's something about me that's [14:49] not appealing and it becomes a vicious [14:51] cycle so one thing you can do is [14:53] significantly improve the quality of the [14:55] erections in a man and that actually [14:58] helps improve his libido so for example [15:00] if I tell a man if every night you uh [15:03] have anere great erection and every [15:05] morning you wake up with a great [15:07] erection what are you going to probably [15:08] do probably going to use it right so [15:10] libido inherently goes up right so I [15:13] think e Ed and libido are tied very [15:15] closely how do you define the Tam labido [15:17] in simp it's a desire to engage in [15:18] sexual activity right for men and women [15:21] and you have to you know when it's a [15:22] true problem they have to be bothered by [15:25] the condition so I just want to be very [15:26] clear there are women who have low [15:28] libido and say I really don't care I'm [15:29] happy that I have a low libido well then [15:31] it's not an issue right you have to be [15:33] bothered by the issue so on this [15:35] psychogenic element where it becomes a [15:37] vicious cycle I've seen this in my own [15:40] life um several times Well at least once [15:43] and I've seen it in some of my friends [15:44] where because there's a bedroom issue [15:47] when you go to the [15:48] bedroom you're both a little bit anxious [15:52] and then one of you can't perform and if [15:54] you can't perform it exacerbates the [15:56] issue and it creates this sort of [15:58] vicious downward spiral of like it makes [16:00] the bedroom like a really awkward place [16:02] to be and this is how I think about when [16:03] you're talking about psychogenic [16:05] component so in the in the case of [16:07] erectile dysfunction if you're thinking [16:09] as a man God if I go to the bedroom I'm [16:10] not going to be able to get it hard I'm [16:11] not going to keep it up it's going to be [16:13] embarrassing she's then going to ask me [16:15] questions she's going to think I I'm not [16:16] into her which just makes it even harder [16:19] because as a man like I perform best [16:23] when I'm really not thinking about it [16:24] and I'm like not anxious when I'm stress [16:27] free right and if seems to me that the [16:29] like antithesis the opposite of great [16:33] sex is like [16:35] overthinking you're 100% correct and [16:37] this is what happens let's say a man [16:39] gets Ed just one time just one time [16:41] young man he says that was really odd [16:44] and I I what's wrong you know what he [16:46] does next time he has sex as he's having [16:48] sex he says to himself I hope I don't [16:50] lose my erection I hope I don't lose my [16:52] erection the second he says that to [16:53] himself as he's having sex he's going to [16:55] lose his erection right because he's so [16:57] worried that he's going to lose the [16:58] erection and not enjoying the experience [17:00] so now it's happened twice so now he [17:02] engages sex third time and now he's even [17:04] more freaked out because it's happened [17:05] twice and it happens again we call this [17:08] the Vicious Cycle right because the now [17:11] sex has become an anxiety event anxiety [17:14] provoking event and so you really have [17:16] to work on decreasing that anxiety and [17:18] not thinking about it that's where Sex [17:20] Therapy comes in hand and that's where a [17:22] medication called daily Calis has become [17:25] unbelievably helpful for my young [17:26] patients because daily Calis is a [17:29] medication that men take daily you've [17:30] heard of Cialis right it's like the [17:32] Viagra yeah it's like Viagra right so [17:34] there's Viagra there's Calis Levitra [17:36] there's stender there's four different [17:37] brands but one of the four is meant to [17:40] be given daily it's a lower dose 5 [17:42] milligrams every day and the larger dose [17:45] is 20 milligrams when you give a man [17:47] Calis 5 milligrams every day what it [17:51] does is essentially is having that [17:53] medication on board all the time when he [17:55] engages in sexual activity he doesn't [17:57] have to take a pill he just has has sex [17:59] whenever he wants to and I found that to [18:01] be unbelievably helpful in Breaking [18:03] psychogenic Ed now that's exactly what [18:05] that is on the table yeah that's exactly [18:07] what it is yeah and so these are these [18:09] are these are pills um that are in the [18:11] US but what's nice is they used to be [18:13] very expensive uh now they if you look [18:16] at Mark Cuban and a lot of the uh good [18:18] RX um companies they men can get 90 [18:21] pills for5 or $20 which is very cheap [18:23] you use the word young men yes young men [18:26] presumably shouldn't be taking pill [18:28] shouldn't but what happens when they [18:29] have psychogenic Ed cuz they think about [18:31] it the most is they need to break the [18:34] cycle what's the cost cuz I'm a I'm got [18:36] to be honest I'm a pill skeptic yes so I [18:38] try and avoid taking pills to solve my [18:40] problems if I can right obviously [18:42] there's going to be situations where I [18:43] can't and I accept that but my bias is [18:45] towards figuring out if there's another [18:47] way before I take a pill right um [18:49] because everything in life comes with a [18:51] cost all things yeah so there must be a [18:53] cost to taking a pill to solve this [18:55] problem well the the actual monetary [18:57] cost is unbelievably cheap monetary cost [19:01] is I'm thinking about like do I then get [19:03] dependent on this do I have to take this [19:04] for the rest of my life so so there's no [19:06] dependency let me tell you why I think [19:07] that drug is so important that daily [19:10] seis has one of the only things in my [19:12] opinion that actually reverses erectile [19:14] dysfunction so let's backtrack I give [19:17] you an example let's say today you break [19:19] your leg okay I have two options Stephen [19:22] I can fix your leg or I can give you [19:24] vicadin a narcotic and if I give you the [19:27] vicad or the narcotic you'll still be [19:28] able to walk until the vicadin no longer [19:31] works and we're in trouble Viagra is a [19:34] vicadin it is not a cure for your [19:36] erectile dysfunction it's just masking [19:38] the problem daily seis in my opinion is [19:41] one of the few things that helps cure Ed [19:44] if you look at studies and you look at a [19:45] penal tissue and we biopsy the tissue [19:47] and then you biopsy three months later [19:48] on daily seals it physically gets [19:51] stronger so let's say you go to the gym [19:53] today and ask you to lift dumbbells [19:54] what's going to happen to your arm it [19:55] will hypertrophy with daily seal we see [19:58] hypert of the smooth muscle meaning it [20:00] gets physically stronger so in my [20:02] opinion it's one of the best things to [20:04] prevent Ed in the future help reverse [20:07] the Ed process more importantly daily [20:10] Calis protects the endothelium and we [20:12] have to spend some time talking about [20:14] that that is the lining of the blood [20:16] vessels it's the brains and the lining [20:18] of the blood vessels is very important [20:20] because once that gets injured you start [20:22] getting clot or plaque which will get a [20:24] heart attack a stroke and a rectile [20:26] dysfunction so it protects the lining of [20:27] the blood vessels two other indications [20:30] it's FDA approved to help a man urinate [20:32] better FDA approved it's FDA approved to [20:35] protect the heart in terms of something [20:36] called pulmonary hypertension so in my [20:38] opinion it's an excellent medication [20:41] patients say do I get dependent on I say [20:42] you do not get dependent on it and H I [20:44] feel like you're better had you taken it [20:46] than had you not you take it for three [20:47] months you get strengthening of the [20:48] penal tissue what happens if I stop [20:50] taking it if you stop taking it there's [20:53] a wonderful study by a versa and what he [20:55] showed was that those patients that [20:57] stopped taking it after 3 months versus [20:58] Placebo still had benefit in terms of [21:01] endothelial function protection and [21:03] erectile function protection than those [21:05] people that took Placebo so thinking [21:06] about saying hey if I go to the gym and [21:08] I work out for three months what happens [21:10] if I stop I say well Stephen you're [21:11] better off had you gone to the gym for [21:12] three months that's my opinion what is [21:14] the downside they're side effects so [21:16] every drug has side effects right but [21:18] they're low with five milligrams back [21:20] pain stuffy nose um headache can occur [21:23] in these but it's quite small but I do [21:25] think that this is one of the [21:27] medications that really can make an [21:29] impact uh in men's health think about it [21:31] if I told you there's a medication that [21:32] protects your heart helps your prostate [21:35] and helps men with erections it's [21:37] affordable I think that most men would [21:39] say I'm in what are the big side effects [21:41] that people report when they're on seis [21:44] so on the larger dose headache stos back [21:47] pain is more common with Calis and other [21:49] medications um but it can be reported [21:52] remember you shouldn't take these [21:53] medications if you have you're taking a [21:54] nitrate because it can drop your blood [21:56] pressure um but other than that these [21:58] are very commonly used medications [22:00] throughout the world and they're not [22:01] suitable for certain people that have [22:02] certain cardiac disorders I'm guessing [22:04] well you know the way this was invented [22:06] uh this came at first one Viagra came [22:08] out in 1998 Viagra was in the clinical [22:10] trials designed to be a blood pressure [22:12] medication and accidentally men were [22:14] getting erections in the trial so these [22:17] medications are in my opinion [22:18] cardioprotective a guy named a very [22:21] famous uh physician B Dr cloner [22:23] published an article recently showing [22:25] that those men who took daily seis had [22:28] 133% reduction in cardiac events and a [22:31] 25% reduction in mortality that just [22:33] came out because of the potential [22:35] effects of protecting the endothelial [22:37] lining of the blood vessels how does [22:39] this work to solve for the sort of [22:41] psychogenic component that we talked [22:42] about that vicious cycle people get into [22:44] with like I'm guessing you're telling me [22:46] that increases your probability of [22:48] having a good erection right but this [22:51] still isn't really working on a liido is [22:53] it right so let's say um you started [22:55] falling through the Vicious Cycle and [22:56] you started having Ed and it was two [22:59] times three times and now I put you on [23:00] this medication and every time you have [23:03] sex you have the most amazing erection [23:04] of your life and 30 times 40 times three [23:07] six months go by and you're having these [23:09] amazing erections you're relaxed and [23:10] you're calm then I start going to every [23:12] other day you still get amazing [23:13] erections then I go to once a week you [23:15] still get amazing erections then I stop [23:17] you still get amazing erections right I [23:19] just need to show you that everything is [23:20] perfect again and that has a huge value [23:23] what about for women this is the [23:24] unfortunate part we don't have a lot of [23:28] treatment options for women and if you [23:30] look about it if I want to give you an [23:32] example in 2015 if you and I went into [23:35] the drugstore in the US Walgreens and [23:37] said give me all the drugs to treat [23:39] women to treat men for sexual [23:41] dysfunction they would put 30 drugs on [23:43] the counter these are all the wonderful [23:44] treatments for men in 2015 there was not [23:47] a single FDA approved drug to treat [23:50] women for any sexual dysfunction very [23:52] sad in 2015 the first drug to treat [23:55] women for female sexual dysfunction came [23:57] out and it was called ad or fanin and [23:59] fanin basically is a drug that a woman [24:01] takes every day and increases her desire [24:03] for sex that's it that's the FDA [24:05] indication increases her desire for sex [24:08] several years later the second drug for [24:10] women came out this was called VII or [24:13] brontide essentially it's an injection [24:15] that she takes 45 minutes prior to [24:17] intercourse and it increases her desire [24:19] for sex but again we have only two drugs [24:22] the reason being is because the research [24:24] the funding that we have for female [24:26] sexual dysfunction is far less than we [24:29] have for male sexual dysfunction and [24:31] it's unfortunate because as I mentioned [24:33] earlier this is a couple's disease and [24:35] so many times I have to use drugs that I [24:37] use for men to help treat women so I do [24:40] use Viagra for women but Viagra for [24:43] women helps arousal so let me explain [24:47] female sexual dysfunction has four [24:49] components one is decreased libido the [24:52] second is decreased arousal third is [24:54] orgasmic dysfunction and the fourth is [24:56] pain with intercourse these are the four [24:59] if a woman has any one of these four and [25:02] she's bothered by it she suffers from [25:04] female sexual dysfunction in the US [25:07] roughly 43 to 48% of women suffer from [25:12] female sexual dysfunction significant [25:14] number only 19% seek therapy will get [25:18] therapy so there's a huge number of [25:19] women that I say are suffering in [25:21] silence they suffer from the condition [25:23] they don't know where to get help and [25:25] unfortunately they're not many treatment [25:27] options available right so it's a big [25:29] problem and a big unmet [25:31] need and on the hormonal component you [25:34] talked about how if dopamine is up we're [25:37] much more likely to be aroused and if [25:39] serotonin is up then we're much less [25:43] likely to be ared correct so this kind [25:46] of ties into something I was thinking [25:47] when you were talking about stress and [25:48] tiredness when I'm stressed and tired is [25:51] my dopamine down it can be your cortisol [25:54] goes up right your C cortisol goes up so [25:57] your ability to get excited will go down [25:59] your fatigue goes up so it makes it much [26:01] more difficult these and there's more [26:04] than just dopamine and serotonin there's [26:05] norepinephrin there's melen Corton uh [26:08] there's many other neuro neurosteroids [26:11] and it's really just what we call a plus [26:13] minus game if I have more positives than [26:15] negatives I'm going to have desire and [26:17] I'm also going to have orgasm right [26:19] that's important also so if you give [26:21] someone uh too much serotonin and it [26:23] goes this way not only does a libido go [26:25] down but it's difficult to achieve [26:27] climax or an orgasm so one of the ways I [26:30] treat premature ejaculation is I give [26:32] them an anti-depressant because it [26:33] delays the orgasm so we have to be very [26:37] careful on these neurotransmitters how [26:38] we use them but if you talked about ad [26:40] the drug I mentioned all it does is it [26:43] increases dopamine and norepinephrine [26:45] which increases libido so they increase [26:48] neurosteroids many women particularly [26:50] with the hisyory breast cancer like this [26:52] because they don't want to use [26:53] testosterone or estrogen hormones this [26:56] is non hormonal right it's just neur [26:58] steroids increasing the desire for sex [27:01] can I think about dopamine and serotonin [27:03] as like a scales yes where if I if I put [27:05] weight on one end the other one goes up [27:07] and if I put weight on the other end the [27:08] other one goes up yes there is a very [27:10] famous uh Michael Perman came up with [27:12] the Tipping Point and it's basically a [27:14] scale looking at the pluses and the [27:16] minuses and if you have more pluses than [27:18] minuses liido goes up orgasmic function [27:21] goes up if you have more minuses [27:23] essentially your ability to orgasm and [27:24] your liido will go down so I want my if [27:26] I want to be aroused and have a desire [27:27] for sex and have good sex then I want my [27:29] dopamine levels to be high dopamine High [27:32] oxytocin High norepinephrine High [27:34] serotonin low what are the types of [27:36] activities that make my dopamine High uh [27:39] well um exercise is can be really high [27:44] dopamine other things increase dopamine [27:47] as well right so um gambling there's [27:50] there's certain things that are highs [27:51] like gambling anything that gives you a [27:52] high certain foods will cause a dopamine [27:54] Rush um but they're temporary right and [27:57] so that's a problem right because if it [27:58] goes up and it goes goes back down it [28:00] crash so you want your dopamine to go up [28:02] in men and women so we use medications [28:05] like Wellbutrin have you heard of [28:07] Wellbutrin it's an anti-depressant but [28:09] that anti-depressant increases dopamine [28:12] so I use that to help men increase their [28:14] libido or women to increase their libido [28:16] or sexual function I use ad e in men and [28:19] off label in men and in women to [28:20] increase dopamine I don't want to do [28:22] drugs though I don't want to take any [28:24] pills so then I would say I need you to [28:26] exercise and you do but exercise is [28:27] critical I need you to sleep I need you [28:29] to um reduce your stress right those [28:31] things will significantly improve uh [28:34] your libido so what things then lower [28:37] dopamine because I've spoken to a few [28:39] like dopamine expert experts on the show [28:40] before and they talked to me about this [28:42] sort of I mean Andrew hubman was telling [28:43] me that yeah when you do an exercise [28:45] like let's say gambling or go on Tik Tok [28:47] your dopamine's going to go up but then [28:49] it's going to crash below the base Point [28:51] yes and some of us live in this kind of [28:52] dopamine roller coaster where we're [28:54] doing these dopamine inducing activities [28:56] dopamine goes up it then crashes below [28:58] and when it gets low we have cravings [29:00] for dopamine inducing activi so we go [29:02] out and want to gamble or go on Tik Tok [29:04] again or eat something and then it goes [29:06] up again and then and we kind of live in [29:08] this kind of roller coaster of dopamine [29:09] one of the things that I was told by a [29:11] dopamine um expert on the show recently [29:14] that does that as well that links to [29:15] some things I found in your work is [29:17] pornography yes and when we talk about [29:19] this psychogenic component we talk about [29:22] um do dopamine [29:24] levels how much is pornography [29:28] causing this libido crisis yeah [29:32] pornography and Ed in libido is somewhat [29:35] controversial there's some data suggest [29:37] that it does not cause an issue and [29:39] there's some data suggest that it does [29:41] the first question I ask a patient when [29:43] I ask a man I say is your Ed present [29:46] with pornography also so if he says look [29:49] I have rectile dysfunction with my [29:50] partner and I have a rectile dysfunction [29:53] with pornography that's very different [29:55] than when he says I have a rectile [29:56] dysfunction with my partner and I have [29:58] amazing erections with uh pornography [30:01] right because then I know that there's a [30:02] psychogenic component as well this is [30:05] what I believe I believe that when a man [30:07] watches excessive amounts of pornography [30:10] what his expectation is becomes hair and [30:12] his reality becomes hair and that Delta [30:16] causes them to have erectile dysfunction [30:19] and low libido they're not getting what [30:21] they're expecting to get so many times I [30:24] question men when they come in uh all [30:26] when all men who come in for to ask how [30:28] much pornography are you watching in men [30:30] who watch excessive pornography if I ask [30:32] them to stop watching pornography for a [30:34] while many will report improvements in [30:36] their rectile function and libido so [30:39] again I do think that pornography in [30:41] excess can have a negative impact only [30:44] because of your expectation and your [30:46] reality the Delta uh can be an issue I'm [30:50] reading some stats here from jamama [30:51] Network that says the percentage of men [30:53] between 18 and 24 reporting no sexual [30:55] activity in the past year increased from [30:57] roughly 18 % to roughly 30% in the space [31:01] of what looks like just a few years and [31:04] simil similarly the average number of [31:06] times American adults engaged in sexual [31:08] activity per year has decreased from 60 [31:11] between [31:13] 1989 and [31:15] 1994 to 50 roughly 50 between 2010 and [31:20] 2024 these shifts suggest a notable [31:23] shift in sexual behavior over recent [31:25] decades why do you think this is [31:27] happening I think it's more [31:27] multifactorial so I think one is I think [31:29] that Ed and sexual dysfunction is on the [31:31] rise uh and if you look at uh the causes [31:34] for Ed uh it's very simple you look at [31:37] uh obesity diabetes metabolic syndrome [31:40] it's a pandemic it's an epidemic [31:41] throughout if you look at just diabetes [31:43] from 1990 to [31:45] 2022 uh 100% 7% to 14% of the population [31:49] one out of eight people globally are [31:51] obese one out of eight people so these [31:54] can make it very difficult uh as obesity [31:57] and diabetes that go on the rise what [31:59] happens testosterone levels go down [32:01] right so testosterone levels go down so [32:03] the ability to engage in sexual activity [32:05] the desire to engage in SE activity will [32:07] be impaired by these uh conditions I've [32:11] got some some graphs here um which show [32:14] Global obesity Trends Global diabetes [32:16] Trends I'll put them on the screen for [32:17] anyone that's watching on video um also [32:20] there's been an increase in pornography [32:21] consumption from what I was able to tell [32:23] from doing some research a 2020 study by [32:27] the University of ant found that 40% of [32:29] people aged 35 to 45 who watched 300 [32:32] minutes of porn a week had erectile [32:34] dysfunction in a 2021 study by GMA [32:38] public health and surveillance and 3,400 [32:41] men between 18 and 35 years old 20% of [32:44] the participants suffered from erectile [32:46] dysfunction and researchers found that [32:47] the greater the viewing frequency of [32:49] pornography the greater the development [32:51] of this dysfunction yeah and that's 300 [32:52] minutes is quite a bit of time a week 5 [32:54] hours minutes five hours five hours a [32:56] week right so this so that's quite a bit [32:59] yeah that's quite a bit how important do [33:01] you think that is as a component to this [33:03] sort of fracturing relationships we [33:05] think about people having sex with each [33:06] other less yeah we're heading towards a [33:08] world of like virtual reality and AI yes [33:11] what role do you think that's genuinely [33:12] playing and you you must have private [33:14] conversations with men that are really [33:15] suffering with these things so I I [33:17] definitely think it's it's a role and it [33:18] definitely plays a factor but not as [33:21] much as the epidemic of diabetes obesity [33:24] metabolic syndrome we are as a [33:26] population becoming more and more [33:28] unhealthy right as time goes on and I [33:30] look at again as a piie it's [33:32] multifactorial right um most of us now [33:34] are not our socialization is virtual and [33:37] so we are not engaging and going into [33:39] seeing everything is done virtually and [33:41] so I think that's an issue um and so I [33:44] really believe that pornography is a [33:46] component but the the decline in overall [33:49] health is a major component the decline [33:51] in testosterone levels decade by decade [33:54] is also another component as well it's [33:56] pretty terrifying that young kids at the [33:58] age of like 12 13 14 when they open [34:00] their phones these days will be exposed [34:02] to sexually graphic images yeah whether [34:05] they CH chose to seek them out or not [34:07] yes and i' I've always wondered what [34:09] that's doing to a developing brain you [34:11] know how it's adjusting your [34:13] expectations how it's creating some of [34:14] those psychogenic factors that are [34:16] making you less aroused and um and it's [34:20] difficult right it's difficult to go out [34:21] and find a partner you have to like put [34:22] on the After Shave shave take care of [34:24] yourself you have to like Risk rejection [34:26] spend some money right be interesting [34:29] right so it seems like if from a [34:31] evolutionary perspective if I was just [34:33] trying to like get my nut off or like [34:34] yeah I don't know ejaculate I've got [34:37] this really easy way now like it's so [34:39] easy yes three clicks on a computer [34:41] We're Off to the Races versus like all [34:44] the effort and rejection and pain of of [34:47] trying to find an actual human being to [34:49] have sex with right and then when I do [34:52] do approach number one when I log on to [34:53] some website and click a couple of times [34:56] I'm getting no headache I'm getting [34:59] whatever I want I can order from a [35:01] endless list of menus and I'm sure in [35:02] the near future I'll even be able to [35:04] make my own yes and in not so distant [35:06] future I'll have I'll have it in my [35:08] house and it'll talk to me yes yeah so [35:11] it's a problem and you think about the [35:13] it's it's making it more difficult for [35:14] people to socialize right so in other [35:16] words now when patients or people engage [35:18] in sexual activity um and they're [35:20] usually having sex on the Internet or [35:22] with pornography when you actually have [35:25] actually engage in sexual activity with [35:27] another person it can be cause anxiety [35:30] right you get anxious it's not something [35:31] that you're doing regularly and so I [35:34] think that it can become an issue I amum [35:36] I saw an article this week from an only [35:38] fans Creator who posted that one one [35:40] customer of hers had given her $4 [35:42] million this year oh my God and you [35:45] think about like you think about what it [35:47] would take for you to spend $4 million [35:50] on a parasocial relationship with an [35:53] only fans Creator sending you explicit [35:56] pictures [35:58] and I don't I don't quite believe we [35:59] fully understand what's around the [36:00] corner I agree these stats I think are [36:03] nothing compared to what's what's around [36:04] the corner [36:06] um and I I don't know I think about it a [36:08] lot [36:09] because when I read these stats about [36:12] erectile dysfunction being on the rise [36:14] and I I read that we're having sex less [36:15] and less um and then I see this rise in [36:18] these parasocial relationships I go [36:20] [ __ ] know I think think we're just at [36:21] the start of an exponential curve um [36:25] let's talk about obesity then yeah [36:26] because these these stats here are [36:27] pretty shocking um this one shows the [36:30] global obesity Trends which just shows [36:32] them going straight up yes which is [36:35] horrific this one shows Global diabetes [36:37] Trends which is pretty much straight up [36:40] as well yes has there been any studies [36:42] done that show the link between being [36:45] overweight and your probability of [36:47] having low [36:48] libido and some kind of sexual [36:50] dysfunction issu yes numerous and so [36:53] let's start with this so obesity it's [36:54] not surprising that diabetes is going up [36:56] because as obesity goes up it causes [36:58] insulin resistance so obesity and [36:59] diabetes typically go hand in hand the [37:02] problem with obesity is the following [37:04] obesity significantly drops testosterone [37:07] levels so fat cells contain something [37:09] called aromatase aromatase eats up the [37:12] testosterone and converts it into [37:14] estrogen so the more fat you have the [37:16] less testosterone you'll have because [37:18] you'll convert it into estrogen fat [37:20] cells also secrete something called [37:21] cortisol and leptin which shut down your [37:24] own natural testosterone production so [37:26] as it's not Sur surprising that decade [37:28] by decade as you see an increase in [37:30] obesity you see a decline in [37:32] testosterone levels in men because the [37:34] testosterone levels will come down as [37:35] people become more obese and low [37:37] testosterone equals low libido low [37:39] testosterone increases low libido the [37:40] number one driver the number one hormone [37:42] for libido in men and women is [37:44] testosterone it's a strong driver men [37:47] and women men and women and don't forget [37:49] that testosterone is also signif really [37:52] important in erectile function men need [37:54] testosterone for sexual function so do [37:57] women right it's extremely important so [37:59] now I have a hormone that's going down [38:00] that's going to make it more difficult [38:01] to get an erection I have a hormone [38:03] that's going down that's going to [38:03] decrease my libido and it's mainly due [38:06] to this obesity that's occurring one of [38:08] the biggest factors so obesity obesity [38:11] also um uh if you look at the risk [38:13] factors for Ed obesity diabetes [38:16] cardiovascular disease these are all [38:17] risk factors and so as obesity goes up [38:20] erectile dysfunction goes up and the [38:23] number one condition is diabetes [38:24] diabetics are four times more likely to [38:26] have Ed than any other population four [38:29] times so I get worried when we see this [38:31] obesity diabetes pandemic going up [38:33] because it's increasing only the [38:35] erectile dysfunction um Stephen if you [38:37] look at the Obesity the group that's [38:39] having the greatest rise in obesity is [38:42] adolescence obesity not adult obesity [38:44] the kids younger and younger ages are [38:47] having that age group has the greatest [38:49] rise of obesity so what does that turn [38:51] into the younger population are starting [38:53] at at lower tea levels and has an [38:56] implication on fertility because you [38:58] need testosterone to produce sperm [39:01] that's very [39:02] important so if I just lose a little bit [39:04] of weight that'll have a big impact on [39:06] my testosterone levels let's talk about [39:08] that it's not a little bit so the best [39:10] study was at the European male aging [39:12] study Fred woo and what he showed was [39:14] this it's a bidirectional relationship [39:17] if you lose 10% of your body weight you [39:20] can actually gain 85 nanogram per deiler [39:23] in serum testosterone if you lose 15% of [39:26] your body weight you can actually gain [39:28] 250 nanogram per deciliter in serum so [39:31] it's actually significant if you can [39:32] lose but it also goes the other way you [39:34] gain weight you drop the tea [39:36] proportionally as well the only issue is [39:39] I can get the patients to lose the [39:41] weight but I can't get them to sustain [39:43] it many times they gain it back right [39:46] but if they can keep the weight off it [39:48] significantly increase uh the [39:50] testosterone levels the the best data [39:51] we've seen is in the bariatric surgery [39:53] data if I do bariatric surgery on a [39:55] patient which to help them lose weight [39:57] weight you can shrink the stomach we do [39:59] surgery to help them lose weight they [40:01] lose quite a bit of weight their tea [40:02] levels go quite up right and so again [40:05] there is a strong correlation between [40:07] weight and testosterone have you gotten [40:10] examples [40:11] of patients where you've given them [40:13] testosterone treatment in some form [40:15] you've done something to increase their [40:16] toest testosterone and you've seen a [40:18] remarkable reported difference in their [40:20] sex life all the time yeah so so first [40:23] let's backtrack there's two ways to give [40:25] a person testosterone uh if I give a [40:29] young man testosterone remember it [40:31] causes infertility so you would never [40:33] give someone testosterone if they're [40:34] planning to have children right that's [40:36] very important right so I have two ways [40:39] to raise their testosterone I can give [40:40] you medications to raise your natural [40:43] testosterone there's several there's a [40:44] pill called chopine citrate there's HCG [40:47] I can use medications to raise your own [40:49] natural testosterone and they preserve [40:52] your fertility the second option is I [40:54] can give you medications like [40:56] testosterone there's seven of them but [40:58] they will shut your natural production [41:00] down not only will they shut your [41:01] natural testosterone production down but [41:03] they will shut down your sperm [41:05] production now if you've already had [41:07] your kids you're 60 years old your [41:09] testosterone level is already low in the [41:11] first place what are you preserving okay [41:13] it makes a lot of sense and there's [41:15] seven ways to do it my favorite way are [41:18] the injectables and the oral [41:20] testosterone they are fantastic oral [41:22] testosterone is quite interesting you [41:23] know first of all testosterone was [41:25] invented in 1935 this is not a new drug [41:28] 1935 and oral testosterone initially was [41:31] feared because it would actually cause [41:33] liver toxicity and liver cancer and it [41:36] wasn't until the 1970s when they were [41:38] able to make oral testosterone uno8 and [41:41] what's nice about uno8 it bypasses the [41:44] liver no cancer but it had to be taken [41:47] three to four times a day it was [41:49] available in the UK as a drug called [41:50] andreal all over the world but not the [41:53] US the US we did not get our first oral [41:56] testosterone till 2019 and then 2022 we [42:00] received two more and now we have tando [42:03] jatenzo and Kaiser Trex is our oral [42:05] they're taking twice a day with a meal [42:07] what's nice about Kaiser TRX it's [42:09] actually available in the UK so in the [42:10] UK now they can actually get Kaiser TRX [42:12] as well but oral testosterone most [42:14] patients don't mind taking a pill uh it [42:17] seems very easy to do so should someone [42:19] like me be taking testosterone if your [42:21] levels are low yeah and you're [42:24] symptomatic and I think that's very [42:25] important if a man comes in with low [42:27] levels of testosterone and says I feel [42:30] great I have no symptoms I said I'm not [42:31] giving it to you these are the symptoms [42:33] low energy yeah low libido erectile [42:36] dysfunction decreased muscle mass [42:38] increased fat deposition poor sleep and [42:40] depression these are some of the common [42:42] symptoms you'll see most sensitive [42:44] symptoms are the sexual symptoms [42:46] erectile dysfunction and low libido so [42:48] if he says I have these symptoms and my [42:51] levels are low and I recheck it and [42:53] confirm that it's low that man is a [42:55] candidate for testosterone therapy [42:57] but if he's young hasn't had has have [43:00] children yet I'm going to say look let's [43:02] hold off on giving you testosterone and [43:03] use medications to make you make [43:06] testosterone and if you don't want to [43:08] take medications actually there are many [43:10] things you can do on lifestyle [43:11] modification to raise your testosterone [43:13] we talked about weight loss as well so [43:15] let's live in this area here you are too [43:18] young to take testosterone now but [43:20] conversely let's say a patient comes in [43:22] and has every single sign and symptom of [43:24] low testosterone but his testosterone [43:26] levels are normal I'm not giving him [43:27] testosterone because it could be [43:29] something else maybe he's depressed [43:31] maybe he has a low thyroid something [43:33] else is going on so you must have signs [43:35] and symptoms and a low tea level to be a [43:38] candidate and if you fit that then you [43:40] may benefit what about women so this is [43:42] important in 1935 when testosterone was [43:44] invented uh it wasn't many years later [43:46] till they actually started using [43:47] testosterone in women and early reports [43:50] of testosterone women were actually [43:51] quite remarkable the earlier manuscripts [43:54] describe improve uh quality of life [43:56] improve libido and if you and I walked [43:59] into the drugstore today and said give [44:01] me the testosterone for women it does [44:04] not exist there's not a single FDA proof [44:06] testost for women in the United States [44:08] um but we have well over a dozen for men [44:12] can you explain this to me just because [44:13] I want to make sure I'm clear why would [44:16] a woman take testosterone because when I [44:18] think of T testosterone I think of men [44:20] yes so women make more testosterone than [44:22] any other hormone in their body make [44:24] more testosterone than any other hormone [44:26] in their body right and when women have [44:29] higher levels of testosterone they tend [44:31] to see a greater Improvement in libido [44:33] muscle mass bone mineral density uh [44:36] sense of well-being uh some of reported [44:38] improvements in cognition as the [44:40] testosterone level goes down we start [44:42] seeing these symptoms particularly low [44:44] libido if you give a woman back her [44:47] testosterone she will many of these [44:48] women see a significant Improvement in [44:50] their libido but the issue is that we [44:54] don't have an FDA approved product for [44:56] testosterone in the United States I [44:58] think in the UK you call it off license [45:00] we call it off label now in the UK they [45:03] did have one they had a wonderful patch [45:04] called intrinsa and then the women in [45:06] the UK could get the patch for [45:07] testosterone go into the drugstore NHS [45:09] covered it and it was fine uh then they [45:11] had andram and andram was actually [45:13] approved and now no longer is approved [45:15] so now in the UK you also don't have an [45:18] onli medication the uh you can still get [45:22] andram from Australia but unfortunately [45:25] uh it's very difficult to get so do we [45:27] do we use the drugs for men and we give [45:30] it to the women in on10th the dose [45:32] that's all we do so if we have a packet [45:34] that's a man puts on a day we say use [45:36] one tenth of the packet every day for [45:38] the women and they can see significant [45:40] improvements it is not illegal to give a [45:42] woman testosterone it's just considered [45:44] off label or off license but they they [45:46] see significant improvements in what [45:49] sexual function by far the most libido [45:51] goes up no question I many women report [45:54] that muscle mass if you think of [45:57] testosterone bodybuilders take [45:58] testosterone for a reason why it [46:00] significantly improves muscle mass it [46:02] can decrease fat deposition many [46:04] patients will import improvements in [46:06] cognition it can help with bone mineral [46:08] density as well in men and women and I [46:10] also believe in depression so I think [46:12] testosterone does help with depression I [46:14] just want to just make a very important [46:17] Point testosterone is not just about sex [46:20] there are five other things that you [46:21] need to think about uh in men and women [46:23] and I want to talk about those men with [46:26] low testosterone l levels are much more [46:27] likely to have a heart attack [46:29] non-negotiable men with low testosterone [46:31] levels are much more likely to have [46:32] diabetes obesity men with low [46:34] testosterone levels are much more likely [46:36] to suffer from depression men with low [46:38] testosterone levels are much more likely [46:40] to have a bone fracture so it's not just [46:42] about sex it's about their overall [46:44] health and if you were to check one [46:45] blood test to assess a man's overall [46:48] health it's his testosterone level one [46:50] blood test to check his overall health [46:52] it will be because I have it affects [46:54] heart diabetes obesity um bone mental [46:57] density energy muscle mass erections [47:00] libido one blood test I can't think of [47:02] another blood test that is a better [47:04] barometer of overall health I want to [47:06] get clear on something because I've [47:06] heard people talking on my podcast [47:08] before about HRT yeah and women taking [47:11] HRT because of menopause and things like [47:14] that should they be does HRT have [47:17] testosterone in it no so typically when [47:19] we say HRT we're talking about estrogen [47:22] and progesterone typically yeah and [47:24] typically when we talk about trt [47:26] testosterone placement it's a little bit [47:27] different in a woman there's something I [47:29] call the triangle and it's just [47:31] basically estrogen progesterone and [47:33] testosterone just simple and if you have [47:36] a woman who's deplete in estrogen [47:38] testosterone and pro estrogen [47:40] progesterone testosterone and replace it [47:42] many of those women feel better right so [47:44] many of them do there are other hormones [47:46] that are also important I call it the [47:48] outside Circle cortisol thyroid growth [47:51] hormone we look at those as well and so [47:54] I think those are also very important [47:55] and I tell them we're going to going to [47:57] optimize your uh hormones but what [47:59] you're going we're going to optimize [48:01] your medical condition but that is only [48:02] 50% of the story the other 50% again is [48:06] Diet exercise sleep and stress reduction [48:08] and if you do your part and I do my part [48:12] we're on fire we're absolutely on fire [48:14] but you have to do your part same with [48:15] men I put you on the testosterone I [48:17] optimize your medical conditions and but [48:20] you got to exercise you got to eat right [48:22] why aren't women being prescribed [48:23] testosterone then right because it's [48:25] considered well in many countries it's [48:28] on in Australia it's available in the UK [48:30] it was available and many women are [48:32] being prescribed testosterone it's just [48:34] off label it is the first time that I've [48:35] seen [48:36] someone on my show anyway really [48:38] emphasized the point that testosterone [48:40] isn't Just For Men it's for women as [48:42] well um and it can significantly improve [48:45] their quality of life talking about [48:47] testosterone one of the big [48:48] conversations that's rattling on on the [48:50] Internet is about this decline in male [48:52] test testosterone over the last couple [48:53] of years what exactly is that decline if [48:56] you had to sort of quantify it if you [48:59] look at the original studies we call it [49:00] the Framingham heart study back in the [49:02] 70s testosterone levels were roughly [49:04] around the 700s average men between the [49:07] ages of 18 and 40 were around the 700s [49:09] and every decade we're starting to see a [49:11] decline almost by 50 nanogram per [49:13] deciliter and so the latest in the 2015 [49:16] numbers are roughly in the mid 400 so [49:18] we've seen almost a 300 nanogram per [49:20] deiler decline in serum testosterone [49:22] which is significant because has two [49:24] implications uh it's not just about uh [49:27] the way you feel and um energy muscle [49:29] mass erectile function but that low [49:31] testosterone can have implications on [49:33] fertility that's really important so we [49:35] didn't talk about that but fertility [49:37] Testo sperm need testosterone low [49:40] testosterone decreases your sperm count [49:42] sperm counts have also been on the [49:43] decline as well so you know I think it's [49:46] really a testament to the fact that [49:48] decade by decade we're becoming a more [49:50] unhealthy population do you think that's [49:53] really the heart of it is that is the [49:54] sort of our diets and the way we live [49:56] and becoming more sedentary less [49:58] exercise more um processed food Etc do [50:00] you think that's the hard of I think [50:01] that's the key that's absolutely the key [50:03] the types of foods we eat the processed [50:06] foods that we eat high fructose High [50:08] carbohydrate diets um in and if you and [50:10] and the way we know that is just look at [50:12] the Obesity look at the look at the [50:14] diabetes there has to be a reason why [50:16] it's on the rise right and on that point [50:19] of fertility I'm in a season of life [50:22] where I'm going to be trying to have [50:24] kids pretty soon what's the most [50:26] important things I should be thinking [50:27] about from a lifestyle perspective in [50:29] your view yeah so I I tell patients [50:31] Darwinism in other words survival of the [50:33] fittest healthier people are more [50:35] fertile right you're passing on the [50:37] genes so uh so so essentially uh we tell [50:40] patients the number well the number one [50:42] cause of infertility in in the world for [50:44] men is a verical a verical is the [50:47] swelling of the veins around the [50:48] testicle you know how women sometimes [50:50] can get swelling of the veins in their [50:51] legs you see those veins that are kind [50:53] of obvious well men can get those veins [50:55] dilated around the testicle and those [50:57] varicoses can impair sperm production [50:59] now 15% of men in the world walk around [51:01] with varicus seals but up to 40% of men [51:04] with infertility will have verical so [51:06] it's really important to assess for the [51:07] varic casales but lifestyle modification [51:10] each one again diet exercise sleep have [51:12] been shown to help improve fertility in [51:14] men as well so I say healthier people [51:17] are more fertile I need you to start [51:19] getting healthier that's very important [51:21] we raise the testosterone level in many [51:22] of these men naturally we don't give it [51:24] to them to help improve their fertility [51:26] as well but check Stephen check your SE [51:28] analysis that's the simplest thing you [51:30] can do check it right I did yeah it's a [51:33] great predictor it's not just you know [51:34] there was so many amazing studies [51:36] showing that a semen analysis is a [51:39] phenomenal predictor of overall health [51:41] many studies showing that if your semen [51:43] analysis today is impaired it's a [51:44] predictor of you having comorbid [51:46] conditions today like diabetes obesity [51:48] metabolic syndrome it's also predictor [51:49] of prostate I mean Cancer so we know [51:52] that if you have infertility you're at a [51:54] higher risk of having testicular cancer [51:56] than those that don't have infertility [51:58] it's also a predictor of who will have [52:00] problems in the future Mike Eisenberg [52:02] once showed a very nice study men who [52:05] have low sperm counts uh can have a 30% [52:08] increased risk in diabetes 50% increased [52:10] risk in hemic heart disease in the [52:12] future uh Tom wall showed those men [52:14] could have 2.5 times higher risk of [52:16] high-grade prostate cancer in the future [52:18] so again to me it's just a marker of [52:21] overall health check the Sean analysis I [52:23] did that and it was quite I was actually [52:25] to be honest I was really quite nervous [52:26] about it because as someone who's you in [52:29] my early 30s and wants to have kids I [52:30] was really scared that it would come [52:31] back and say that like my sperm is um [52:35] dysfunctional and I've got a huge amount [52:37] of empathy and [52:39] um you know feelings for people that do [52:42] those analysis and get bad results back [52:45] 15% of all couples in the world 15% [52:48] suffer from infertility that's a lot and [52:50] if you think about it um 30% of the time [52:53] it's a male Factor 30% 20% the time it's [52:56] a male and a female Factor combined so [52:58] indirectly a male is involved 50% of the [53:01] time when you have infer an infertile [53:03] couple and it can be devastating for [53:05] that couple I mean psychologically [53:07] devastating and what's also interesting [53:09] is that um most couples most couples 50% [53:12] of couples don't seek therapy and of [53:14] those couples that do seek therapy this [53:15] is globally only 25% of those couples uh [53:19] actually go forward uh and and and and [53:22] so I call this a group of individuals [53:24] that also suffer in silence they should [53:27] know that there are excellent treatment [53:28] options [53:29] available this um this graph that I had [53:32] printed out is just shocking to me it's [53:35] going back to the point about [53:35] testosterone but the the really shocking [53:38] thing is how quickly this has happened [53:40] yeah because this is the year 2000 and [53:43] this is the year 20156 year and the [53:46] decline there is from roughly [53:49] 600 nanograms is it yes nanogram per [53:52] deciliter nanog per deciliter to roughly [53:55] for some age group groups here 400 yes m [53:58] per deciliter and that's only in 16 [54:01] years yes so if you play that forward [54:03] another 16 years there's going to be a [54:05] bit of an infertility crisis there is [54:08] fortunately on that graph it's [54:09] plateauing a little bit which makes me [54:10] feel a little comfortable okay oh yeah [54:12] it is actually fling just a little bit [54:14] um but you're right it could be a [54:16] significant crisis um and again as I [54:18] mentioned it's the adolescence the [54:20] younger folks who are having the [54:22] greatest rise of obesity and that's [54:24] where fertility comes in because [54:26] fertility obesity in someone in 60s is [54:28] not concerned about fertility but a [54:30] young patient who has infertility [54:32] obesity will have a higher risk of [54:34] infertility if you're an entrepreneur [54:36] you're probably going to want to listen [54:37] to this it's a message from one of our [54:38] sponsors on this podcast which is [54:40] LinkedIn if you've listened to me on [54:42] this podcast for a while now you'll know [54:44] that I've been on a bit of an evolution [54:45] as a business owner and entrepreneur and [54:47] one of those Evolutions that has become [54:48] clearer and clearer as I've matured is [54:51] that the single most important thing in [54:53] building a business in building a [54:55] company is hiring the definition of the [54:58] word company is actually group of people [55:00] and that is the first responsibility and [55:03] job that any entrepreneur has and should [55:05] focus on but surprisingly most don't [55:08] about 80% of my team have been hired [55:10] from LinkedIn and I think there's very [55:12] few platforms if any in the world that [55:14] could give you that diversity of [55:15] candidate with that much information and [55:18] data on their profiles it usually cost [55:20] money but for the entrepreneurs that are [55:21] listening to me I've got you a free job [55:23] ad post for your company on LinkedIn [55:25] just go to LinkedIn .c doac to post your [55:28] free job ad today that's linkedin.com [55:31] doac terms and conditions apply if me [55:35] and my partner came to you and we said [55:36] listen we've got sexual problems in the [55:38] bedroom um what are the steps that you [55:41] would the things you'd look at that we [55:43] haven't focused on so much today is [55:45] there anything particular you'd say okay [55:47] and I I'm trying to stay away from being [55:49] prescribed a pill so I want to do [55:50] anything natural I can before I get to [55:52] that and then we'll talk about some of [55:53] the other more drastic measures one can [55:55] take natural things because everyone [55:57] wants to know about what's the natural [55:58] things I can do so when we talk about [56:00] diet there's certain diets that have [56:01] been helpful to improve sexual function [56:03] for me it's the Mediterranean diet the [56:05] Mediterranean diet is rich in whole [56:07] grains legumes um fruits vegetables and [56:10] if you look at red meat and sweets It's [56:12] once a month if you look at poultry it's [56:14] maybe once a week but mainly fish those [56:16] diets have typically been [56:18] anti-inflammatory diets many Studies [56:20] have shown that that diet can [56:22] significantly improve erectile function [56:24] and one study the medita trial actually [56:26] showed that it improves sexual function [56:27] in men and women so I'm a big believer [56:30] in using the Mediterranean diet when [56:32] Esposito did her first trial it was a [56:34] prospective trial 110 be obese men 55 [56:37] men get the Mediterranean diet 55 men uh [56:40] don't get any intervention at all she [56:42] falls in prospectively for two years [56:44] what does she find not only a [56:46] significant Improvement in endothelial [56:48] function remember that lining of the [56:49] blood vessel but a significant [56:50] Improvement in erectile function in [56:52] these men no Viagra no pills nothing [56:55] simp simply changing the diet improved [56:58] the erectile function the same with [57:00] sexual function in women so that's an [57:02] important one the second is sleep let's [57:05] talk about sleep so studies show that if [57:07] you're getting less than six hours of [57:09] sleep a night it significant increases [57:11] your risk for sexual dysfunction in men [57:13] and women right your ideal amount of [57:15] sleep should be 7 to8 hours now let's [57:18] say you say well that makes sense maybe [57:20] I'm going to get sleep sleep for 9 to 10 [57:22] hours because the more sleep I get the [57:24] better my sexual function but that's not [57:25] true it plateaus so if above 9 hours it [57:29] does not increase your ability or sexual [57:31] function so 7 to eight hours of sleep at [57:33] night I need you to get third is I [57:35] really need you to focus on um uh [57:38] exercise so I published a very nice [57:41] study looking at uh it was a metanalysis [57:43] on how much exercise one needs and what [57:45] type of exercise to actually improve [57:47] erectile function in this study [57:50] typically you need 160 minutes a week so [57:52] 40 minutes four times a week for a [57:55] course of six months of moderate or to [57:57] severe exercise vigorous exercise and so [58:00] most people can get 160 minutes in a [58:01] week of exercise but that's getting your [58:03] heart rate up and doing the exercise [58:05] significantly improved erectile function [58:07] in men if you did that and the more [58:10] severe your Ed was the greater [58:12] Improvement you saw in erectile function [58:13] strictly by exercise alone no other [58:16] intervention St just exercise so here [58:18] you have a patient that now starts doing [58:20] some exercise starts sleeping better [58:22] starts changing the diet it's all [58:24] additive you are now sick significantly [58:26] improving erectile function just by [58:29] lifestyle modification [58:30] alone pretty profound that exercise can [58:32] have such a big impact isn't it is that [58:35] the same for women it is true because [58:37] many of the things so unfortunately once [58:39] again the research we have in women is [58:41] not close to what we have in men but the [58:43] med trial was also in women the sleep [58:46] studies were also in women um and so [58:48] these studies also show that sexual [58:50] function can be improved with um uh [58:53] sleep and with diet um I think that men [58:55] and women are not that different I mean [58:57] if you see a significant Improvement in [58:58] a male sexual function uh with diet [59:00] exercise sleep um you can also see it in [59:02] women as well actually there was a great [59:04] study this looked at 110 women and they [59:07] had coronary artery stenosis they did [59:09] angiograms on 110 women and they showed [59:12] that the greater her stenosis she had [59:15] the worse her sexual function so the [59:16] greater the blockage in her heart the [59:18] worse her sexual function they put those [59:20] women on a cardiac rehab program to [59:23] actually improve their cardiac function [59:25] so a diet and ex exercise program and [59:27] those women that actually put through [59:29] the were through the program fourfold [59:31] increase almost in their sexual function [59:33] well 400% fourfold that's right because [59:35] we use a questionnaire called the fsfi [59:36] which is a questionnaire so significant [59:38] Improvement in sexual function just on [59:41] improving cardiac function so remember [59:43] cardiac function and sexual function are [59:45] related and it's bidirectional you [59:47] improve one you improve the other it's [59:49] very important we didn't we talked about [59:51] this earlier 40% of men in the in the [59:54] world at 40 will suffer U from erectile [59:56] dysfunction 40% 40% Jes 50% at 50 60% at [60:02] 60 70 at 70 80 80 you do the math it [60:05] essentially is a very prevalent [60:07] condition this condition is associated [60:10] with increased cardiovascular vents it's [60:12] a first sign of a heart attack we talked [60:13] about that this condition is associated [60:15] with two and a half times more likely to [60:16] be anxious three and a half times more [60:18] likely to suffer from depression and [60:20] this condition is also associated with [60:21] diabetes in other words men with Ed two [60:24] times more likely to have undiagnosed [60:27] diabetes and yet only 50% of men even [60:31] talk about it because they're so [60:32] embarrassed so you show me another [60:34] condition in the world that affects more [60:36] men's lives that's associated more [60:38] adverse conditions and they're too [60:40] embarrassed to speak about it they [60:41] suffer in silence there's not another [60:43] condition there's not another condition [60:45] but yet we're embarrassed to discuss it [60:47] I used to give these lectures and I [60:48] would look out to the audience I'd say [60:50] please raise your hand if you suffer [60:52] from [60:53] hypertension and many people raise their [60:55] hand and they have high blood pressure [60:57] they say okay please raise your hand if [60:59] you suffer from sexual dysfunction no [61:02] hands go up but statistically you know [61:04] that over 50% of those people had sexual [61:06] dysfunction so why is it okay to raise [61:08] your hand if you have hypertension but [61:10] not okay to raise your hand if you have [61:11] sexual dysfunction it's got to stop we [61:13] have to destigmatize it's okay to have [61:15] sexual dysfunction it's a common [61:17] Condition it's curable why don't men [61:19] raise their hands from a psychological [61:21] standpoint why is that I think they're [61:22] embarrassed I think that I think that [61:24] we're historically sexual dysfunction [61:26] looks as a like a weakness I'm not a man [61:28] less of a man you know you have [61:30] hypertension it doesn't mean you're less [61:31] of a man right but they have this [61:33] assumption that it's a weakness a less [61:36] of a man and I and I think that it's [61:38] okay you have to be comfortable saying [61:40] that you have sexual dysfunction there [61:41] are amazing treatment options for sexual [61:44] dysfunction amazing that work very very [61:47] well you just have to raise your hand [61:49] and let me know that you have it I just [61:51] want to make one other comment about [61:53] diabetes there was a study that came out [61:55] of St Louis looking at young men 18 to [61:58] 40 years old and they were screening [62:00] them for erectile dysfunction and what [62:03] they found was when those men came in [62:05] for erectile dysfunction 30% of those [62:08] men had pre-diabetes or diabetes on that [62:11] day on the day they were being diagnosed [62:13] 30% and I thought to myself young men do [62:17] not go get screened I remember when I [62:19] was 30 years old I didn't go in for my [62:20] annual blood pressure check and my anual [62:22] sugar check there's no way I'd get my [62:24] glucose checked but if I young man gets [62:27] erectile dysfunction he is at my front [62:29] door first thing tomorrow morning they [62:30] show up that's the first thing they're [62:32] going to do because it's a very big [62:33] condition to them and they want to get [62:35] treated and that is the opportunity to [62:38] treat these young men and treat the [62:41] condition if you see a young man or [62:42] someone who comes in for Ed and you [62:44] screen them for uh diabetes and I catch [62:47] the diabetes at 30 as opposed to 40 that [62:50] is 10 years of damage on the vessels [62:53] that you're saving because you catch the [62:55] disease early early so Ed is the gateway [62:58] to Men's Health and to treating men [63:00] early before it's too late so I really [63:02] use Sexual Health as a tool a vehicle to [63:05] improve overall health because men take [63:07] Sexual Health much more seriously [63:10] particularly young men have you ever had [63:11] sexual dysfunction I have not never in [63:14] your life I have not I have I have [63:17] not it doesn't mean that it's not but [63:20] it's okay if I did it's not it's there's [63:22] nothing wrong with it right there's [63:23] nothing it's normal it's okay and it's [63:26] it can be temporary and come back right [63:28] it's it's nothing wrong with having [63:29] sexual dysfunction we must destigmatize [63:31] it it's completely Okay the reason I'm [63:33] sharing this is because if anyone else [63:35] has been in the situations the [63:37] situations I've been in are um generally [63:39] my sex life has been been good my whole [63:41] life but there's been certain times with [63:43] certain Partners or you know you might [63:45] be drunk a little bit or in the day when [63:48] I was single there was like the oldd [63:51] person who for some reason it just [63:54] wasn't working for me [63:56] and or there was other instances in a [63:58] previous relationship where near the end [64:00] of the relationship I'd like lose my [64:03] erection during sex and that became a [64:06] little bit bothersome for me because I [64:07] was like oh my God like it almost made [64:10] me not want to have sleep with this [64:11] person or it convinced me that maybe I [64:13] don't like them anymore or something [64:15] else was going on and for me it has [64:16] always been what's the word used [64:19] psychogenic yes it's always been in my [64:20] head that the problems have arose and [64:22] the other part of thing that I've [64:24] experienced a lot is in terms of libido [64:26] I have like no libido [64:28] when actually slight [64:31] different when I'm when work is very [64:35] very busy and I'm very very tired and I [64:37] come home very very [64:41] late it's not that I'm not horny but I [64:44] just the act of sex is just really [64:47] unappealing but you're just like [64:49] everyone else you're not unique when it [64:50] comes to that yeah but that much of my [64:52] life is like that like I come home late [64:54] a lot and [64:56] so I'm I'm I'm like tired and stressed [64:58] quite a lot right but what if I took you [65:00] and your partner and put you on a [65:01] beautiful island in Hawaii for two week [65:03] we have great sex okay yeah so that's [65:04] what we kind of like how we've [65:05] orientated our life honestly okay that's [65:08] genuinely how we've orientated our life [65:09] because I just don't think the way I [65:11] obviously want to make lifestyle changes [65:12] to make sure that I'm not always coming [65:13] home tired and stressed at 11: p.m. but [65:16] one of the things that's really helped [65:17] us is you know going away on the [65:19] weekends right and going away maybe on [65:21] Friday and coming back on Monday and [65:23] getting out of the same context so like [65:24] getting out of the house going to a even [65:26] like going to a hotel room it's actually [65:28] a bit of a game changer that you can [65:29] just like go to a hotel room in the same [65:31] city like a Booker station yes and that [65:34] seems to have a big impact because it [65:35] just removes you from the context right [65:37] and then like yeah going away for the [65:38] weekends holidays and stuff a lot of my [65:40] friends say to me they go when they're [65:41] struggling with their sex life they just [65:43] like book A book a local a local sort of [65:46] station yeah and I wonder why also I [65:48] don't have kids so I've not experienced [65:51] the impact that kids can have have a [65:53] significant impact really right because [65:54] it increases your stress [65:56] right particularly for your many times [65:57] for the partner as well so if you both [65:59] are stressed because of the children sex [66:01] goes lower and lower on the totem slept [66:04] as well right if you're not sleeping if [66:05] you to wake up and like oh gosh isn't [66:07] there stats that say like when someone [66:08] has a kid their sex life like vanishes [66:10] for 18 months or something I don't know [66:12] I'm not familiar with that St but I [66:13] believe it I believe it I believe it I [66:15] read something about post having a kid [66:18] liido but also like sexual function it [66:20] makes sense I see it in in couples and [66:23] particularly you know many times um it's [66:25] take years for them to start engaging [66:27] sexual because the stress is so high [66:28] particularly when they originally have [66:30] the child there was a British study done [66:32] that found over 80% of women experienced [66:34] sexual problems 3 months postpartum with [66:36] nearly two3 still affected at 6 months [66:39] yes which is which is a lot of it's a [66:41] lot of women a lot of women and that's [66:42] significant amount of time so what about [66:45] premature ejaculation let's talk about [66:47] it very important 30 so sexual [66:49] disfunction we've been talking about Ed [66:50] today right but there's many different [66:53] types of sexual dysfunction there's [66:54] premature ejaculation there's Peron [66:56] disease there's delayed ejaculation [66:57] we're just focusing on one aspect [67:00] premature ejaculation affects 30% of men [67:04] globally 30% of men how do you define [67:06] that there's two ways to think about it [67:08] when they come in you have to figure out [67:09] is this lifelong going their whole life [67:11] or is this acquired it's very important [67:13] because it takes me down two different [67:14] roads if you say look I've never had [67:15] premature ejaculation and yesterday it [67:18] started that's very different than if [67:20] you come to me and say my whole life I [67:21] had premature ejaculation and we now [67:23] Define premature ejaculation as having [67:25] an ejaculation less than 2 minutes used [67:27] to be 1 minute less than 2 minutes you [67:29] have to have a loss of control like I [67:31] couldn't control it and you have to be [67:33] bothered by it so if you tell me Stephen [67:35] look I ejaculate in 30 seconds and I'm [67:37] happy I say great then we're done you [67:39] know you are content you have to be [67:41] bothered by the condition the EAC [67:43] average ejaculatory time in the United [67:44] States is 5.4 minutes on average right [67:48] the average time for a woman to achieve [67:49] orgasm is typically 13.4 minutes so [67:52] there's a big discrepancy here as you [67:54] can see right so 30% of men suffer uh [67:57] but we know that only a small percentage [67:59] of these men 9% of these men will ever [68:01] seek therapy and it can be a significant [68:03] problem in a relationship um uh and that [68:06] needs to be addressed okay so there's [68:08] not like a time limit it's not like okay [68:10] if you're coming within two minutes then [68:11] you got a problem well let's say you're [68:13] not bothered by it let's say you and [68:14] your partner are completely satisfied [68:15] with it what's the problem okay what's [68:17] the problem and and sometimes let if you [68:19] think about acquired uh means that [68:22] typically we Define it as 50% less than [68:24] your normal time so if you say look I [68:27] typically used to ejaculate in 8 minutes [68:29] and now it's 4 minutes and it's [68:31] bothering me I'd say okay that that's an [68:33] issue um you know so we talk it's [68:36] relative what what's comfortable for you [68:38] and some men will say you know so I [68:41] think it's very important to look at the [68:42] definition the treatment options are [68:44] actually quite simple one of the best [68:45] treatment options is sex therapy because [68:47] we can train your mind we can train you [68:49] to delay that ejaculation there's [68:52] techniques the start stop technique The [68:53] Squeeze technique how we can delay it no [68:55] but there is but most men say just give [68:58] me a pill I don't I don't have the time [68:59] for this just give me a pill but there [69:01] are ways to do it with Sex Therapy which [69:03] I think are fantastic sex therapy is a [69:05] cure the pill is just a Band-Aid right [69:07] Sex Therapy is a cure but the pills that [69:09] we use the most common Ed pills are [69:12] anti-depressants because they increase [69:15] serotonin and make it harder to [69:17] ejaculate well that's what we want in [69:18] this situation we want to delay the [69:21] ejaculation so we can use [69:23] anti-depressants they sometimes have be [69:24] taken daily which work better or you may [69:27] have to take it on demand but if you [69:28] take it on demand 6 to8 hours ahead of [69:31] time so you need some notice but there's [69:32] going to be significant side effects of [69:34] taking anti-depressants there are side [69:36] effects of anti-depressants so I try to [69:37] stay away from them and the other ones I [69:39] try to use are topical Liane sprays [69:42] because if I decrease the sensitivity of [69:44] the penis you're more likely to be able [69:46] to engage in sexual activity for a [69:47] longer period of time so those are [69:49] commonly used so sex therapy and sprays [69:51] are very easy to use you don't need a [69:53] prescription for sprays uh and they're [69:55] common [69:56] use one thing that we have to talk about [69:58] that's really important is the Traverse [70:00] trial it's really big everyone [70:03] historically has always said that [70:04] testosterone is dangerous it causes [70:07] prostate cancer and it causes a heart [70:09] attack and a stroke and in 2015 there [70:13] were some studies that suggested [70:14] testosterone may cause a heart attack [70:15] before 2015 all the studies suggested [70:18] that there was no increased risk so in [70:19] the United States they mandated that [70:21] there' be a large trial 5,200 patients [70:24] six years long strictly to decide does [70:28] testosterone increase the risk of a [70:30] heart attack so myself and eight others [70:33] designed the study ran the study for six [70:36] years and we published it last year it [70:38] finally came out and it showed that [70:40] there was no significant increase in [70:42] cardiovascular events finally but until [70:44] that time until that came out many [70:46] people said I still believe that [70:47] testosterone causes a heart attack but [70:49] when the Traverse trial came out the [70:50] largest randomized speciic control trial [70:52] ever published we finally showed that [70:54] giving testosterone didn't not increase [70:55] the risk of a heart attack in fact the [70:57] study also showed it did not increase [70:59] the risk of prostate cancer many people [71:01] were worried that testosterone causes [71:02] prostate cancer and no negative effect [71:06] on urinary symptoms so many people have [71:09] thought that if I give testosterone the [71:10] urinary symptoms become worse the study [71:12] showed no worsening of urinary symptoms [71:14] so very important study the Traverse [71:17] trial finally came out it's the largest [71:19] trial in men ever published on [71:21] testosterone will it reduce my [71:23] lifespan will at low testosterone I [71:26] believe will reduce your lifespan I mean [71:28] taking like testosterone injections and [71:30] stuff sometimes I think about like again [71:32] I don't don't really know what I'm [71:33] talking about here but I think [71:35] about athletes taking steroids different [71:39] those athletes are taking super [71:41] physiologic steroids so the normal range [71:43] is typically 300 to a th000 is the [71:45] normal range and they will take [71:47] testosterone levels to much higher 2, [71:49] 2500 okay and there's a reason for [71:52] that um there's something called a [71:54] plateau effect so so if you take [71:55] testosterone and you have better libido [71:58] you intuitively would think if I take [72:00] more testosterone I'll feel even better [72:03] liido but that's not true is's a certain [72:05] point at which it plateaus so the more [72:07] you take you've already hit an onoff [72:09] button you've hit it you're done the [72:11] exception is muscle the more [72:13] testosterone you your body sees the more [72:15] it upregulates uh Androgen receptors in [72:18] the muscle and you put on more muscle so [72:20] bodybuilders are addicted to higher [72:22] levels of testosterone but they're also [72:24] taking other off Lael medications anavar [72:28] Deca wistol they're taking other [72:30] medications and those testosterone [72:32] formulations have a lower androgenic [72:35] ratio androgenic means facial hair acne [72:37] they're more anabolic so it's very [72:39] different than what you're taking You're [72:40] simply what you would be taking is just [72:42] all you're trying to do is take a [72:44] medication that you had before and put [72:47] yourself back into the normal range [72:48] nothing fancy so I The more I've learned [72:51] about testosterone The more I've started [72:52] to think that maybe when I've had my [72:53] kids and I'm done having kids and maybe [72:56] I'm [72:58] 45 um I should consider it providing [73:02] that my levels are low and you're [73:04] symptomatic if you're 45 and you say I [73:06] feel great I'm gonna say Stephen you're [73:08] not getting it right I feel great so if [73:11] you say look I'm 45 my levels are low [73:14] and I'm starting to have symptoms say [73:16] Okay Now's the Time to consider taking [73:19] the medication those symptoms you said [73:21] were like tiredness energy levels well [73:23] the most specific are my libido's gone [73:24] down [73:25] my are worse my Energy's gone down [73:28] increased fat deposition decreased [73:31] muscle mass poor sleep and depression [73:33] and we have to talk about depression so [73:36] uh earlier on in my career I conducted a [73:38] very large trial looking at depression [73:40] in testosterone and we had almost 850 [73:43] patients and we showed that men with low [73:45] testosterone levels were much more [73:47] likely to suffer from depression almost [73:49] 92% of those men with low testosterone [73:51] had some degree of depression and when [73:53] we treated 17% of those men actually had [73:55] severe depression we treated these men [73:57] for one year with testosterone [73:59] supplementation that 177% dropped down [74:01] to 2% now I'm not advocating to treat [74:04] major depressive disorder with [74:05] testosterone but what I am advocating [74:07] for is to at least check a testosterone [74:09] level in men who are depressed because [74:11] it can help them in fact in our study [74:14] even the men who were on an [74:15] anti-depressant uh like say Prozac we [74:17] put them on testosterone those men also [74:19] saw significant improvements in [74:21] depression so may be some Synergy [74:23] between testosterone and what we call [74:24] SSR eyes so again it's very important to [74:27] check a testosterone level in men who [74:29] suffer from depression you wrote a book [74:32] called recoupling yes a couple's [74:35] four-step guide to Greater intimacy yes [74:37] and better sex yes what are the four [74:40] steps in this book and you wrote this [74:42] alongside over 10 years ago yes so I [74:45] wrote it with the sex therapist she's an [74:46] amazing sex therapist her name is Mary [74:48] Joe Rini and we decided to write a book [74:50] together to really help couples get [74:51] through so the four steps really are [74:53] number one foremost communication [74:55] you got to communicate you got to at [74:57] least be able to tell each other did you [74:58] know that only 44% of men who start [75:02] developing Ed even tell their Partners [75:04] now think about that You' say what do [75:05] you mean they don't tell their partner [75:06] you know what they do they just start [75:07] avoiding sex they just start avoiding [75:09] sex so they got to communicate number [75:12] one and making excuses right I if if I [75:15] lost my reaction i' I'd probably say oh [75:17] sorry I'm just tired or you know because [75:20] I want to just on this point there's [75:23] much of the reason why it's hard to [75:24] communicate [75:25] is because it it can sound a lot like [75:28] blame and it also can make someone feel [75:31] like you're not into them right so if I [75:34] said and maybe you're not that into them [75:36] and also maybe you're not like that [75:37] attracted to them so like that could be [75:40] yeah that's an issue and that's why the [75:42] sex therapist is amazing right that's [75:45] what they do right that's what they do [75:46] they work through these issues with [75:48] couples and they're fantastic but the [75:50] number one step we put in the book was [75:52] communication you have to communicate [75:55] the second chapter was my main chapter [75:58] what I wrote about what can we do to [76:00] improve sexual dysfunction in men and [76:02] women testosterone placement therapy [76:05] using Viagra vaginal lubrications local [76:08] vaginal estrogen therapy we didn't talk [76:09] about that it's critical for [76:10] postmenopausal woman local vaginal [76:12] estrogen therapy is very important [76:14] decreases this risk of UTI decreases [76:17] pain with intercourse um so very [76:18] important um the third chapter really [76:21] sir what is that vaginal so uh younger [76:24] women have estrogen in the vagina that [76:28] estrogen is so important it keeps all [76:31] the bad bacteria away and keeps the good [76:33] bacteria within the vagina it keeps the [76:35] W the lining of the wall thick it allows [76:38] for the vaginal wall to function with [76:40] arousal properly and as she gets older [76:44] and she goes through menopause the [76:46] estrogen goes away the bad bacteria come [76:48] in the risk of urinary tract infections [76:51] go up the wall starts to atrophy means [76:53] gets thinner it's more susceptible to [76:56] injury and tear it hurts okay right so [76:59] you can't ask a woman to enjoy sex if it [77:03] hurts every time she has sex a lot of [77:05] women I've heard a lot of women talking [77:06] about that about this idea that the [77:08] reason they don't like to have sex is [77:09] because it hurts it hurts because when [77:11] they lose the estrogen the wall gets [77:13] very thin and it can tear it hurts but [77:16] even young women young women but it's [77:18] usually typically a different reason [77:20] they could suffer from vaginismus [77:21] there's other things that could cause [77:23] the cultis but in old older women the [77:25] most common cause is atrophy of the [77:28] vaginal wall because of the lack of [77:30] estrogen so what do you do you give back [77:32] local estrogen therapy it can be in the [77:34] form of a suppository form of a cream it [77:37] doesn't happen overnight I tell my [77:38] patients it can take up to three months [77:40] but after three months they notice a [77:42] difference and the urinary tract [77:44] infections go away the pain goes down [77:46] right so these are simple things that [77:48] women can do to help because again if [77:50] someone's having pain with intercourse [77:52] man or woman they will tend to avoid it [77:55] right it's an important concept so the [77:56] second chapter is really important on [77:58] what are the many different things that [77:59] you can do to improve your sexual [78:01] function uh the third chapter is really [78:03] about intimacy it's the really the [78:05] intimacy and the fourth chapter really [78:08] is uh ways to improve uh your sexual [78:10] experience it was written by my sex [78:12] therapist she talks about vibrators [78:13] masturbation so there's a four-step [78:15] guide um that I think is very helpful [78:17] and I think what's unique about this [78:18] book is that really it's it's really two [78:21] perspectives it's one who is the um the [78:24] medical care that I provide and the [78:25] psychological care that she provides now [78:28] she's obviously handling the [78:29] psychological side of things and she's [78:31] not here but just on this point of [78:33] improving communication what is the best [78:35] advice you give to people that are [78:37] currently in a situation where they're [78:40] both kind of suffering in silence [78:41] because they're just not communicating [78:42] with each other number one most [78:44] important is time we don't spend enough [78:46] time it's basically the shadows in the [78:48] night you coming in I'm going out and [78:50] it's you have to make time that's [78:52] extremely important and the second one [78:54] is open dialogue you have to be able to [78:57] express to your partner what you're [78:58] suffering from otherwise you can't get [79:00] treated you just have to be able to [79:02] express it but time I think is important [79:04] and open communication and dialogue um [79:06] there's nothing embarrassing about this [79:09] it really is um something that needs to [79:12] be D destigmatized and the consequences [79:15] of addressing it so couples who engage [79:18] in regular sexual activity have a [79:20] significant Improvement in their quality [79:21] of their relationship they tend to be [79:23] happier and suffer from less uh me uh [79:25] depression I mean there's there's there [79:27] are physical and emotional benefits from [79:29] regular sexual activity in the um opener [79:32] of the book where you start talking [79:33] about communication there's a sentence [79:35] that [79:35] says when sex isn't going well it can [79:38] become 90% of the relationship and [79:40] couples seldom know how to communicate [79:42] about any of these problems and that is [79:44] true you know we've done a couple of [79:45] conversations now on the DIY about sex [79:47] and Intimacy in these subjects and the [79:49] amount of messages that I get from [79:50] couples saying that everything else in [79:52] their relationship is great yeah [79:54] everything is great love this person so [79:56] much but there's this massive elephant [79:58] in the room right no pun intended which [80:00] is um the lack of sexual intimacy now [80:04] when we talk about sexual [80:06] intimacy does it mean penetration yeah [80:10] it doesn't because we with the [80:12] definition of sex span is the ability [80:14] and the desire to engage in satisfying [80:17] sexual activity I have patients that [80:19] come to me and say we do not have [80:20] penetrative sex but we have a wonderful [80:22] sex life I say great if this is working [80:25] for you because it's satisfying sexual [80:27] activity you're set right it's if you [80:30] want penetrative sex and you cannot have [80:32] it then we will address it and we can [80:34] fix it but you get to Define Stephen you [80:36] define what is satisfying sexual [80:39] activity on chapter four where you talk [80:41] about things like vibrators and stuff [80:43] like that um I know that was the a [80:45] chapter handled by your sex therapist [80:46] according to what you said is there any [80:48] risk that using vibrators or other toys [80:51] and tools will impact [80:55] normal intimacy without vibrators like [80:57] is there any studies that say okay you [80:59] get desensitized to the real thing if [81:00] you start using a vibrator yeah I've [81:02] seen the opposite I've seen that the [81:03] studies showing that vibrators and these [81:05] kinds of uh Toys can actually enhance [81:07] the ability of the relationship so that [81:08] you can because you're communicating as [81:10] you're doing it right so you're [81:12] communicating with your partner what is [81:13] giving me pleasure what is not giving me [81:15] pleasure you're learning about each [81:16] other it's a great tool to use to learn [81:19] about each other so when you're engaging [81:21] a sexual activity you're more aware I [81:23] think it was a a game changer to me I'm [81:25] going to be honest I think like just [81:26] having having other things do you know [81:29] why do you know why it's a game changer [81:30] and I'm not just talking about vibrators [81:31] I'm talking about all toys in the [81:33] bedroom whether it's like dice or [81:35] handcuffs or whether it's something else [81:36] or blindfold is just because novelty [81:40] doing new things for me is so critical [81:43] as it relates to being excited sexually [81:46] yeah and there's only so many things you [81:48] can [81:49] do there's kind of there's a a a [81:53] relatively limited list of things you [81:54] could do if you're not bringing in other [81:59] tools and toys and stuff you know so I [82:01] think that for me it actually has helped [82:03] me to prolong the novelty of my sexual [82:05] um relationship in a way that nobody [82:08] told me about before yeah because I [82:10] think think as a guy especially I think [82:11] you kind of think that toys are [82:13] something your partner buys for herself [82:15] maybe yeah something she uses for [82:18] herself and now I think if anything I'm [82:19] the instigator of using other things [82:21] yeah that's chapter four I mean and we [82:23] and we prescribe vibrator for men we use [82:25] something called vict it helps with men [82:26] with delayed orgasmia these toys can be [82:29] very helpful in a [82:31] relationship I think she prefers the [82:33] toys to me personally but that's another [82:35] conversation for another time in terms [82:37] of energy there are so many reasons why [82:39] I'm a big matcha fan if you don't [82:41] already know by now and so much so that [82:42] I actually invested in the UK's leading [82:44] matcha company called perfect Ted and [82:46] one of my favorite perfect Ted products [82:48] is these delicious matcha pouches that [82:50] come in every flavor from salted caramel [82:52] to Peach flavor to mint flavor to Berry [82:55] flavor one of my favorites is this [82:58] vanilla flavor which I'm going to make [83:00] in just two seconds you just take this [83:02] mixer here get a little bit of the [83:04] powder pop it on top of the shaker like [83:07] that put the lid [83:10] on shake shake [83:15] shake delicious if you haven't tried [83:18] this yet you can find perfect Tad at [83:19] Tesco and Holland Barrett stores or [83:21] online where you can get 40% off with my [83:23] code diary 40 head to perfect ted.com [83:27] and put in code diary 40 to try this [83:29] delicious multi-flavored match now [83:31] highly recommend and if you do it please [83:33] tag me send me a message online what's [83:35] the um what's the most important thing [83:36] we haven't talked about that we should [83:37] have well there's a couple things I want [83:38] to talk about one is we didn't talk [83:40] about Peroni disease it's an important [83:42] disease 9% of men in the world suffer [83:44] from Peron disease 9% of men in the [83:47] world Peron disease is an abnormal [83:49] coverture of the penis when it's erect [83:51] so I want you to think about this the [83:53] way I can describe it is I have a [83:54] balloon I put a piece of tap tape on the [83:56] balloon I blow the balloon up what's [83:58] going to happen it's going to curve in [84:00] the direction of the tape right so if a [84:02] penis curves greater than 60 degrees [84:04] it's prohibitive for intercourse these [84:07] men are suffer many of these men suffer [84:09] from severe depression it's [84:10] disfigurement it's disfigurement of the [84:12] penis right so think about it 9% of men [84:14] in the world suffer from this condition [84:16] and most men have never even heard what [84:18] Peron disease is and uh essentially in [84:21] the US we have now one FDA approved [84:23] treatment for this it's an injection [84:25] called collagenase where we can put an [84:27] injection into the Rock plaque and break [84:29] it up there are surgeries that we can do [84:32] to make the penis straight again but [84:33] again it's very important to realize [84:35] that patients who have Peron disease are [84:37] also suffering in silence they don't [84:38] know where to get the treatment and [84:40] there are many good treatment options [84:42] whether it be surgical or medical to [84:44] solve this condition so you know my [84:46] whole takea away from this is this is [84:47] that I know that millions of people [84:50] right now men and women are suffering [84:51] from sexual dysfunction I know they're [84:53] silent and they're not saying a word [84:54] because they don't know where to go they [84:55] don't know what to do but they have to [84:57] realize that there are excellent [84:58] treatment options available and they [85:00] should seek therapy they're not [85:01] suffering [85:03] alone what [85:05] else I want you to think about sexual [85:07] dysfunction as no no longer a Band-Aid [85:11] uh we are not looking for Viagra we are [85:13] looking for a cure we want a cure for ED [85:16] and a cure for ED could be based on many [85:18] things as I mentioned earlier diet [85:20] exercise sleep stress we've also moved [85:22] into a new generation of regenerative [85:24] Therapies in my field stem cells PRP [85:28] shock wave therapy now we're starting to [85:30] look at radio frequency in our [85:31] laboratory we're looking at hyperbaric [85:33] oxygen men are looking for ways to cure [85:36] this condition they no longer want to [85:38] take a pill uh to solve the problem and [85:41] so I think that's very important um and [85:43] many of these uh new therapies are [85:44] promising I think Shockwave therapy is [85:46] very promising where we have a device [85:48] that deliver shocks to the penal tissue [85:49] we' been doing this it's like um [ __ ] [85:52] like said that but but I'll tell you it [85:55] we've been doing it now for 5 years um [85:57] and uh it was invented in 2010 it's [85:59] actually quite brilliant if I take your [86:01] finger and I take a hammer and I hit [86:03] your finger multiple times what do you [86:04] think your finger is going to do your [86:06] finger is going to start bringing in new [86:07] blood vessels and new ways to heal your [86:10] finger so before Urology the [86:12] cardiologists have been doing it for the [86:13] heart for many years and they would [86:15] shock the heart many times and you would [86:16] see new blood vessels formed it's called [86:18] neoangiogenesis orthopedic surgeons have [86:21] been doing it for a long period of time [86:22] in terms of injury in terms of healing [86:24] injury that use shock wave therapy we [86:26] are new to the game but what we see is [86:28] when you give these shocks it can [86:29] potentially improve the blood flow and [86:31] sexual function in men and I think the [86:33] new era could potentially be hyperbaric [86:35] oxygen therapy and also radio frequency [86:37] radio frequency is a a way to increase [86:40] heat within the tissue and improve [86:42] sexual function as well so again I think [86:43] what you're going to see uh 5 to 10 [86:45] years as we move forward is new ways to [86:48] cure erectile dysfunction stem cells [86:50] potentially have some promise as well [86:52] but patients don't want a pill anymore [86:56] one thing we haven't talked directly [86:57] about but we've talked about it [86:58] indirectly is the role that trauma plays [87:01] in sexual dysfunction and Trauma in all [87:03] of its forms um I think I had a partner [87:06] who was very public again about the fact [87:09] that the reason why they had sexual [87:10] dysfunction was because in their view [87:13] because they had been through a sort of [87:14] traumatic experience how often do you [87:16] see that in your office how long often [87:18] do you see a patient come to you man or [87:19] woman with a some kind of trauma we we [87:21] we query all men and women if they've [87:23] had any kind of trauma sexual or just [87:25] physical trauma it doesn't have to be [87:26] sexual trauma be any kind of physical [87:28] trauma um I will tell you that [87:32] most patients don't disclose or not very [87:35] commonly described to have having it but [87:37] they will many times disclose it to the [87:38] sex therapist and I'll find out on the [87:40] back end to be honest with you um but I [87:43] think when someone discloses sexual [87:45] trauma or trauma it takes more of a [87:47] relationship and time on the first visit [87:49] sometimes they're not [87:52] forthcoming what's that that you haven't [87:54] in front of you on the desk it's I've [87:56] been hesitating talking about it so this [87:58] is a penal implant oh gosh and this yes [88:01] that's exactly what it is and this is a [88:03] device that was invented in [88:05] 1973 by a very famous uh urologist named [88:08] Dr Brantley Scott Brantley Scott I will [88:11] have to brag a little bit was from my [88:13] institution at Bay College of Medicine [88:14] and this has been around for 51 years [88:17] and the the penis actually has two [88:19] bodies sitting on top and they has the [88:21] urethra sitting on the bottom and those [88:23] two bodies have muscle inside them or [88:25] casing and what this device is a surgery [88:27] that I warm quite often where we put [88:29] these balloons or cylinders into those [88:32] two bodies and fill them up there's a [88:34] small pump that goes into the scrotum [88:37] and there's a small Reservoir that just [88:39] holds water normal saline that goes [88:41] behind the pubic bone typically when a [88:44] man squeezes this he starts filling up [88:47] these cylinders with water and it gives [88:49] him a very rigid very good erection when [88:53] he finishes engaging in sexual activity [88:55] he'll press this button here and it will [88:57] actually release and all the fluid will [88:59] come out of the penal bodies and go back [89:02] into that Reservoir so theoretically [89:05] anyone who's willing to have this [89:07] surgery we can cure Ed but it's a [89:10] surgery and what's the consequence and [89:12] cost of that in terms of sexual [89:14] experience monetary cost I would say [89:16] that in the US Medicare covers this [89:18] product so that's that's actually quite [89:20] good in terms of pleasure and Men report [89:23] no significant decline in pleasure if [89:26] you look at overall satisfaction is [89:27] greater than 92% for patient and partner [89:30] with uh with the penal prosthesis so um [89:33] it is a very um it's a GameChanger it [89:36] really is a GameChanger most patients [89:38] have never heard of it or most people [89:40] have never heard of this uh penal [89:41] prosthesis um but you know let's be [89:44] honest you know if you had a bad [89:46] shoulder you'd get a prosthetic if you [89:48] had a bad hip you get a prosthetic it's [89:50] a prosthetic that fixes an organ um and [89:53] it Stephen it the satisfaction rate is [89:55] extremely high but I'll tell you [89:56] something you owe me something because [89:57] when I brought this on the plane uh and [89:59] I went through security they made me [90:01] pulled us out and explain what this was [90:03] and nobody had heard of it no one had [90:05] seen this um yeah well I had to explain [90:09] it and I had to pump it up and show them [90:10] and uh but I had a little bit of an [90:12] audience but um yes but I will tell you [90:14] this this is a this is something that [90:16] really has revolutionized the way we [90:17] treat men for rectile [90:19] dysfunction but this is surely like a [90:22] last ditch attempt it is because it is a [90:24] lastage attempt because if I take it out [90:27] no other treatments will ever work again [90:30] oh really it's it's the end right so if [90:33] I take it out no other the treatments [90:35] will work again so I want you to try [90:39] every single option before we come to [90:42] this what situation does someone have to [90:44] be in for you to insert this into their [90:45] penis so remember when I told you that [90:47] 40% man at 40 50% at 50 and most [90:50] patients will take Viagra but I told you [90:51] Viagra is not a cure it's a Band-Aid so [90:53] what's going to happen that Viagra is [90:54] just like that pain pill and that pain [90:56] pill eventually going to happen is you [90:57] can't walk well the same thing happens [90:59] with Ed eventually the meds stop working [91:02] so once the meds stop working and then [91:04] the second level we use something called [91:05] penal injections some manual we use [91:07] penal injections once you've tried [91:09] everything and nothing works what are [91:11] you going to do okay so this is like a [91:13] last what are you going to do if you [91:15] still want to get but if I look at [91:17] satisfaction rates if I give men [91:19] questionnaires for the pill for the [91:20] injections vacuum reduction device for [91:22] the implant High highest satisfaction [91:25] with the [91:26] implant at what point how what you mean [91:30] how satisfied from the starting point to [91:33] right if I because from starting at a [91:35] point where I'm completely unable to get [91:37] an erection right if anyone helps me get [91:39] that thing up my satisfaction is going [91:41] to be really high right but let's say [91:42] you have an erection with a pill you get [91:44] an erection with an injection you get an [91:46] erection with a vacuum and you get an [91:48] erection with this all all four you know [91:50] over time gave you an erection which [91:52] gave you the best erection and which [91:53] which one were you most satisfied with [91:55] this will win it's crazy and can you [91:57] still ejaculate with this yes no [92:02] issues [92:04] gosh [92:06] no I mean again I have I have tremendous [92:08] sympathy because it's ruins people's [92:10] lives right it does if if you can't [92:12] perform in that way and it destroys your [92:14] relationships and relationships are like [92:15] the essence of life so but essentially [92:17] you're taking someone who can't have sex [92:18] who can now have sex again and some [92:20] would argue that they can have sex [92:21] whenever they want as long as they want [92:24] with this device right it only goes down [92:26] when you tell it to go down Dr Mo we [92:28] have a closing tradition on this podcast [92:30] where the last guest leaves a question [92:31] for the next guest not knowing who [92:32] they're going to be leaving it for yeah [92:33] and the question that has been left for [92:35] you no is have you ever experienced [92:39] anything that you cannot explain from a [92:42] position of rational [92:46] materialism yeah I mean I think so many [92:47] things in science that we can't explain [92:49] so many things that are idiopathic that [92:51] I have no explanation for um uh for [92:54] example for fertility which is something [92:55] we talked about 40% of men who come to [92:57] me our explanation is no explanation we [93:00] don't know why you're infertile right so [93:03] obviously that's very uncomfortable for [93:05] many patients to hear that but many [93:06] things in science I have no explanation [93:09] for um and many things that I do have an [93:11] explanation for we find out 10 years [93:13] later were [93:14] wrong um so I think that's what comes to [93:17] mind what about any personal experiences [93:19] at all in your life spiritual religious [93:23] yeah um I'm very spiritual I'm very [93:26] religious um sometimes death it's hard [93:30] to explain hard to understand why um [93:34] it's real I see it every day uh you know [93:38] we see it we do at work um my I see it [93:42] personally in my own life my father [93:43] passed away at an early age um from [93:46] idiopathic pulmonary fibrosis um it's a [93:49] very it's a condition where your lungs [93:51] start to scar it's probably the worst [93:53] condition you could asked for and um and [93:56] he had have a lung transplant at 70 so [93:58] he pretty young um and he retired at 69 [94:01] um and said you know one he worked very [94:03] hard he was a general surgeon single you [94:05] know solo practice and um he said one [94:08] day I'll enjoy one day I'll enjoy and [94:11] then at 69 he retires he's ready to [94:13] enjoy at 70 gets idiopathic pulm [94:15] fibrosis at 70 gets a lung transplant [94:18] and lives for five years with someone [94:20] else's lungs um which is pretty tough um [94:24] and his one message was you know don't [94:26] wait till the end enjoy the ride I wish [94:29] I'd enjoyed the ride because waiting to [94:31] the end um sometimes there may be no [94:36] end and by that I interpreted that to me [94:38] that he had worked his whole life very [94:40] very hard extremely hard and he sort of [94:43] delayed the gratification to a point [94:45] that right it didn't really come [94:47] necessarily he thought it would come at [94:48] 70 and he' enjoy the last 15 years and [94:51] enjoy but at 60 9 he got idiopathic [94:55] pulmonary fibrosis at 70 we got a lung [94:57] transplant and at 75 he passed away and [95:00] I think that um if anything I Learned [95:04] was don't wait to the end enjoy the ride [95:08] are you doing that I am every second I [95:11] can and how how do you do that sort of [95:13] practically when you're so busy so I [95:15] make time I meditate every morning I [95:17] work out every morning I have my own [95:19] time to myself I pray I'm very religious [95:22] I think those are very important things [95:23] to keep me going um I spend I I it's [95:26] it's God family work patience I mean [95:28] it's an order my family is extremely [95:30] important to me and I make time for them [95:32] as well and uh I think that keeps me [95:35] grounded Dr Mo thank you thank you for [95:37] the work you're doing because as you say [95:39] in your work there's a huge proportion [95:40] of people couples men women that are [95:42] suffering in silence and there are in [95:44] search of answers and there's not a lot [95:45] of people in your friendship group that [95:47] are necessarily going to know this stuff [95:48] or even talk about their own experiences [95:49] with this I think it's important to have [95:51] these kinds of conversations um that [95:53] anyone in the private or comfort of [95:54] their own home or with their airpods on [95:57] can tune into to get a better [95:59] understanding if there was a closing [96:00] message for for those people that are [96:02] suffering in silence in some way whether [96:03] they're couples [96:05] individuals what is that closing message [96:07] to [96:08] them it's okay to suffer from sexual [96:12] dysfunction it's normal as we age and [96:15] there are many treatment options good [96:17] treatment options that can help you [96:19] today and I ask you to seek therapy [96:22] raise your hand tell your doctor you [96:24] suffer from sexual dysfunction because [96:26] they're excellent treatment options and [96:27] if people want to learn more about you [96:29] and your work where's the best place for [96:31] them to find you well uh it's my website [96:33] Dr drit cara.com and um sexan health.com [96:38] I have sexan health.com where you can [96:39] learn all the different ways to improve [96:40] lifestyle modification I started a [96:42] nonprofit I just want you to know called [96:44] the testosterone project just so you [96:46] know that uh it's really geared at [96:48] education advocacy for testosterone [96:50] we're trying to get testosterone approv [96:52] for women in the United States I that's [96:53] important we're trying to get testing [96:55] done uh as well we want everyone to be [96:57] tested for testosterone it should be [96:58] Norm as well and we're trying to get it [97:01] deregulated so the test aom project.com [97:03] is a great way to get information as [97:05] well I'll put all of those links below [97:08] Dr May thank you so much for the work [97:09] you're doing and please do keep doing it [97:10] because it's so incredibly important [97:11] Stephen pleasure to talk to you thankk [97:13] you do you know that 80% of New Year's [97:15] resolutions fail by February it's [97:17] because we focus too much on the end [97:19] goal and we forget the small daily [97:21] actions that actually move us forward [97:23] those actions that are easy to do are [97:24] also easy not to do in life it's easy to [97:27] save a dollar so it's also easy not to [97:29] making one small Improvement each day [97:31] one tiny step in the right direction has [97:33] a big difference over time and that is [97:35] the 1% mindset which is why we created [97:38] the 1% diary a 90day journal designed to [97:41] help you stay consistent and focus on [97:43] the small wins and make real progress [97:45] over time it also gives you access to [97:47] the 1% Community a space where you can [97:49] stay accountable motivated inspired [97:52] along with many others on the same jour [97:53] Jour we launched the 1% diary in [97:55] November and it sold out so now we're [97:57] doing a second drop join the wait list [98:00] at theed diary.com and you'll be the [98:02] first to know as soon as it's back in [98:03] stock I'll put the link below [98:05] [Music] [98:24] oh [98:25] [Music]