The Diary of a CEODr. Mohit Khera: How to extend your sexpan and libido
Khera, a urologist, on four lifestyle pillars that beat any pill: diet, exercise, sleep, stress. Plus testosterone, the cardiovascular link, and libido.
CHAPTERS
- 0:00 – 4:20
Defining ‘Sexpan’ And Why Sexual Health Matters
Khera introduces the concept of sexpan—the duration of life you can enjoy satisfying sexual activity—and contrasts it with lifespan and healthspan. He argues that most people want all three aligned and lays out his four lifestyle pillars as the foundation of sexual and overall health.
- •Sexpan = how long you can have satisfying sexual activity.
- •Average US lifespan is ~77; disability-free years are much lower, creating a gap where health and sex suffer.
- •Four pillars for extending sexpan: diet, exercise, sleep, stress reduction.
- •Hormone balance, especially testosterone, is crucial for both men and women.
- •Sexual health should be considered at the couple level, not just the individual.
- 4:20 – 14:40
Khera’s Background And Sexual Medicine As Couples’ Care
Khera outlines his training in urology, men’s health, and research, and recounts a pivotal case where improving a husband’s erections worsened the couple’s relationship. This experience pushed him to treat women as well and to reframe sexual dysfunction as a couple’s disease.
- •Career: general surgery year, 5-year urology residency, men’s health fellowship, 17 years at Baylor.
- •Runs both basic science and clinical research programs on sexual function and testosterone.
- •Treats ~150 patients and performs 6–8 surgeries weekly, including at a VA hospital.
- •Realization: raising one partner’s libido alone can damage a relationship.
- •Shifted to also treating female sexual dysfunction and viewing cases in a couple context.
- 14:40 – 27:20
Diagnosing Erectile Dysfunction And Its Link To Heart Disease
The discussion moves into how ED is diagnosed and why it’s a red flag for broader health issues. Khera explains psychogenic vs organic ED, the high rates of depression and anxiety in men with ED, and how penile blood vessel size means ED often precedes heart attacks and strokes.
- •Simple ED screen: can you get an erection for penetration, and can you maintain it to orgasm?
- •Morning/masturbation erections point to psychogenic ED if partner sex fails.
- •66% of men with ED have some depression; 35% have significant anxiety.
- •ED often appears years before cardiac events; about 15% will have heart attack or stroke within seven years.
- •Arterial diameter theory: smallest penile arteries get blocked first, then coronary, then carotid.
- 27:20 – 43:40
Understanding Libido: Hormones, Neurotransmitters, Lifestyle, And Porn
Khera dissects libido as multifactorial, driven by hormones, brain chemistry, lifestyle, and relationship dynamics. He explains the PET hormone framework, the dopamine–serotonin balance, the impact of antidepressants and stress, and how ED can masquerade as low desire. He also tackles pornography’s role in expectations and psychogenic dysfunction.
- •Libido = desire to engage in sexual activity; it's only a ‘problem’ if the person is bothered by it.
- •PET hormones affecting libido: Prolactin, Estrogen, Thyroid, Testosterone.
- •Neurotransmitters: dopamine/norepinephrine up → libido up; serotonin up → libido down and orgasm delay.
- •Antidepressants and finasteride are frequent libido-killers.
- •Fatigue, stress, and relationship quality heavily modulate desire.
- •ED can drive men to avoid sex, which looks like low libido but is actually fear of failure.
- •Excessive porn can raise expectations beyond reality; reducing porn often improves erections and desire.
- 43:40 – 58:00
Breaking The Vicious Cycle Of Psychogenic ED With Daily Cialis
They explore how performance anxiety quickly spirals into persistent ED and how daily low-dose Cialis can help reset confidence and even structurally improve penile tissue. Khera contrasts symptomatic ‘Band-Aid’ pills like on-demand Viagra with daily Cialis, which he argues has regenerative and cardioprotective benefits.
- •One failed erection can create anxiety that causes repeated failures.
- •Daily 5 mg Cialis maintains drug levels so sex can be spontaneous, helping break the anxiety loop.
- •Tissue studies show daily Cialis can hypertrophy smooth muscle in the penis, potentially reversing ED.
- •It protects endothelial lining, with evidence of reduced cardiac events and mortality.
- •Side effects at low dose are generally mild (headache, stuffy nose, back pain).
- •No physiological dependence; benefits can persist after a three‑month course.
- 58:00 – 1:05:20
Female Sexual Dysfunction And Limited Treatment Options
Khera lays out the four components of female sexual dysfunction and highlights its high prevalence and low treatment rates. He reviews the meager set of approved female therapies, the role of neurosteroid drugs like Addyi and Vyleesi, and how he often repurposes male drugs such as Viagra for women’s arousal issues.
- •Four FSD domains: low libido, low arousal, orgasmic dysfunction, pain with intercourse.
- •43–48% of women meet criteria; only about 19% ever seek therapy.
- •First US drug (Addyi, 2015) raises desire by modulating dopamine and norepinephrine.
- •Second drug (Vyleesi) is an injectable taken before sex to boost desire.
- •Research funding for female sexual dysfunction lags far behind male-focused research.
- •Viagra can sometimes help female arousal by improving genital blood flow.
- 1:05:20 – 1:20:40
Dopamine, Stress, Pornography, And The Decline In Young People’s Sex Lives
The conversation widens to societal trends: declining sexual activity among young adults, rising obesity and diabetes, and heavy digital stimulation from porn and social media. Khera acknowledges mixed data on porn but shares his clinical view that heavy use can harm sexual expectations and partner function.
- •US data show rising rates of sexual inactivity and fewer annual sexual encounters.
- •Global obesity and diabetes trends map onto rising ED and falling testosterone.
- •High-fructose, high-processed diets and sedentary lifestyles are central culprits.
- •Dopamine highs from gambling, TikTok, porn, etc. create roller-coaster reward patterns.
- •Teens are exposed to graphic content early, shaping expectations and social anxiety.
- •In many men, stopping heavy porn use improves erectile function with partners.
- 1:20:40 – 1:32:40
Obesity, Diabetes, Testosterone Decline, And Fertility
Khera explains how fat tissue biochemically suppresses testosterone and thus libido, erectile function, and fertility. He presents data on decade-by-decade drops in male testosterone, links sperm count declines to health risks, and offers weight loss as a powerful lever for restoring hormone levels.
- •Fat tissue’s aromatase converts testosterone to estrogen; fat also raises cortisol and leptin, suppressing T production.
- •Diabetics are about four times more likely to have ED.
- •Adolescent obesity is rising fastest, implying future fertility and hormone problems.
- •Losing 10% of body weight can raise testosterone ~85 ng/dL; 15% loss can raise it by ~250 ng/dL.
- •Bariatric surgery shows large testosterone increases alongside weight loss.
- •Semen analysis is a strong predictor of current and future health, including diabetes and cardiovascular disease.
- 1:32:40 – 1:46:00
Testosterone Therapy For Men And Women: Uses, Risks, And Misconceptions
This segment digs into how and when to use testosterone therapy and clarifies important distinctions between restoring normal levels and bodybuilder-style steroid abuse. Khera details oral and injectable options, stresses preserving fertility in younger men, and underscores that women both produce and benefit from testosterone despite the lack of approved products.
- •Two approaches for men: stimulate natural production (clomiphene, hCG, lifestyle) vs give exogenous testosterone.
- •Exogenous testosterone suppresses sperm production; avoid in men planning children.
- •Symptoms plus objectively low T are required before Khera prescribes TRT.
- •Women naturally produce more testosterone than any other hormone and benefit in libido, muscle, bone, and wellbeing.
- •No FDA-approved female testosterone in the US; clinicians use one‑tenth male doses off-label.
- •Low testosterone is linked to higher rates of heart disease, diabetes, obesity, depression, and fractures.
- •TRAVERSE trial (5,200 men over six years) found no increased risk of heart attack, stroke, or prostate cancer from therapeutic testosterone.
- 1:46:00 – 2:01:20
Lifestyle-First Fixes: Diet, Exercise, Sleep, And Sex Frequency
Khera returns to his four pillars, citing specific studies that show Mediterranean diet, structured exercise, and adequate sleep can significantly improve sexual function. He emphasizes their effects in both men and women and links cardiac rehab outcomes to better sexual scores.
- •Mediterranean diet improves endothelial function and ED in obese men; similar trials show benefits for women’s sexual function.
- •Target: at least 160 minutes/week of vigorous or moderate exercise (e.g., 40 minutes, four times a week).
- •Less than six hours of sleep is associated with higher sexual dysfunction risk; benefits plateau after 8–9 hours.
- •Improving cardiac health directly improves sexual health; the relationship is bidirectional.
- •40% of men at age 40 have some ED; prevalence rises roughly 10% per decade.
- •Yet only about half of men with ED will talk to a doctor.
- 2:01:20 – 2:09:20
Premature Ejaculation, Antidepressants, And Behavioral Approaches
The focus shifts to premature ejaculation, its definitions, and treatment routes. Khera distinguishes lifelong versus acquired PE, discusses using antidepressants to delay orgasm, and advocates for sex therapy and topical anesthetics as effective, non-invasive approaches.
- •PE affects about 30% of men; only ~9% seek treatment.
- •Contemporary definition: ejaculation under about two minutes, loss of control, and distress.
- •Average male intercourse time ~5.4 minutes; average female time to orgasm ~13.4 minutes.
- •Sex therapy (start–stop and squeeze techniques) can be a long-term cure.
- •SSRIs delay orgasm by raising serotonin but have systemic side effects.
- •Topical lidocaine sprays reduce penile sensitivity and can prolong intercourse without systemic drugs.
- 2:09:20 – 2:17:20
Safety Of Testosterone: The TRAVERSE Trial And Beyond
Addressing long-standing fears, Khera summarizes the landmark TRAVERSE trial, which found no increased cardiovascular or prostate cancer risk with medically supervised testosterone therapy. He clarifies how physiological replacement differs from supraphysiologic steroid use in athletes.
- •Earlier small studies raised concerns about TRT and heart attack risk.
- •TRAVERSE: 5,200 men, six-year randomized controlled trial, found no increased major cardiovascular events.
- •No signal for increased prostate cancer or worsening urinary symptoms.
- •Therapeutic TRT aims to restore normal range (roughly 300–1,000 ng/dL), not bodybuilding-level doses.
- •Bodybuilders’ regimens use multiple anabolic steroids at very high levels, with different risk profiles.
- 2:17:20 – 2:29:00
Communication, Intimacy, And The Recoupling Framework
Khera describes the four-step framework from his book 'Recoupling,' co-written with a sex therapist, focusing on communication, medical interventions, intimacy, and enhancing sexual experience. He underscores the impact of pain, particularly in postmenopausal women, and the role of local estrogen in reducing painful sex and UTIs.
- •Only ~44% of men with ED even tell their partners; many just avoid sex.
- •Four-step framework: (1) communicate, (2) medical fixes, (3) rebuild intimacy, (4) explore tools/toys and new experiences.
- •Local vaginal estrogen restores the vaginal wall, reduces pain, and lowers UTI risk in older women.
- •Vibrators and toys can enhance communication, discovery, and novelty, benefiting both partners.
- •Regular, satisfying sexual activity correlates with better relationship quality and lower depression.
- 2:29:00 – 2:37:20
Peyronie’s Disease, Implants, And Regenerative Therapies
Khera spotlights Peyronie’s disease—severe penile curvature—as a common but hidden condition and outlines treatment options. He then demonstrates a penile implant as a last-line cure for ED and looks ahead to regenerative approaches like shockwave therapy, PRP, stem cells, and hyperbaric oxygen.
- •Peyronie’s disease (abnormal curvature when erect) affects about 9% of men and can prevent intercourse.
- •Treatments include collagenase injections and surgery to straighten the penis.
- •Penile prosthesis: inflatable cylinders implanted in the corpora, with a pump in the scrotum and reservoir in the pelvis.
- •Implants are a last resort because removing them leaves no other treatment options; satisfaction rates exceed 90% for men and partners.
- •Emerging regenerative methods: low-intensity shockwave therapy to stimulate new blood vessels, PRP, stem cells, radiofrequency, and hyperbaric oxygen.
- •Patients increasingly want cures, not chronic dependence on pills.
- 2:37:20
Trauma, Spirituality, And A Life Lesson About Enjoying The Ride
In closing, Khera briefly addresses how trauma often underlies sexual difficulties but is more readily disclosed in therapy than in initial medical visits. He shares a personal story about his father’s illness and early death, which taught him to prioritize enjoying life now rather than deferring all joy to retirement.
- •Sexual and non-sexual trauma are important contributors to dysfunction but often revealed slowly.
- •Khera is religious and centers his life on God, family, work, and patients to stay grounded.
- •His father’s idiopathic pulmonary fibrosis and short-lived retirement instilled the value of ‘enjoy the ride.’
- •He urges listeners to stop suffering in silence, seek help, and recognize that effective treatments exist.
- •He runs educational efforts like sexspanhealth.com and The Testosterone Project to expand access and advocacy.
