Dr. Mohit Khera: How to extend your sexpan and libido

1. 0:00 – 1:59

   Intro

   1. SBSteven Bartlett0:00

      This term sexpan, which I've never heard before, what is that?

   2. MKDr Mohit Khera0:03

      Sexpan is how long you are able to engage in satisfying sexual activity, and most men, most women want their sexpan to last as long as their lifespan, and there's many things you can do to significantly prolong your sexpan, and I call it the four pillars. So let's talk about sex.

   3. SBSteven Bartlett0:19

      Dr. Mohit Hara is a board-certified urologist and professor who specializes in male and female sexual dysfunction. His groundbreaking research has significantly contributed to improving sexual health and fertility.

   4. MKDr Mohit Khera0:29

      Millions of men and women are suffering from sexual problems like infertility and sexual dysfunction. For example, in the US, roughly 43% to 48% of women suffer from female sexual dysfunction which involves four components that we're gonna talk about, but we also know that premature ejaculation affects 30% of men globally, and also 40% of men at 40 will suffer from erectile dysfunction, and it's the first sign of other major adverse medical problems. For example, 66% have some degree of depression, and 15% of them will have a heart attack or stroke within seven years. And if you look at the causes for ED, one of the biggest factors is obesity, which causes testosterone levels to go down, but men need testosterone for sexual function. So do women because low testosterone increases low libido. But the issue is people don't talk about their sexual problems. They suffer in silence, and they start avoiding sex. But it's curable, and I have two ways to raise your testosterone, techniques to significantly improve the quality of your erections and natural ways to improve sexual function in men and women. So number one most important is-

   5. SBSteven Bartlett1:30

      This has always blown my mind a little bit. 53% of you that listen to this show regularly haven't yet subscribed to the show. So could I ask you for a favor before we start? If you like the show, and you like what we do here, and you wanna support us, the free simple way that you can do just that is by hitting the subscribe button. And my commitment to you is if you do that, then I'll do everything in my power, me and my team, to make sure that this show is better for you every single week. We'll listen to your feedback. We'll find the guests that you want me to speak to, and we'll continue to do what we do. Thank you so much. (upbeat music)

2. 1:59 – 2:29

   Who Is Mohit and What Does He Do?

   1. SBSteven Bartlett1:59

      Dr. Mo Hara, who are you, and what have you spent your life doing?

   2. MKDr Mohit Khera2:09

      So I'm a urologist, and I specialize in male and female sexual dysfunction, testosterone replacement therapy, and infertility. For the past 17 years, I've been working as a professor at Baylor College of Medicine in Houston, looking at ways to improve sexual health, improve testosterone, and improve fertility.

   3. SBSteven Bartlett2:27

      And y- we talked just

3. 2:29 – 3:40

   What Is a Sexspan and Why Does It Matter?

   1. SBSteven Bartlett2:29

      before we started recording about this term sexpan, which I've never heard before.

   2. MKDr Mohit Khera2:32

      Yeah.

   3. SBSteven Bartlett2:32

      What is the sexpan, and why do you care about it?

   4. MKDr Mohit Khera2:34

      Yeah, so Stephen, you know what lifespan is. It's how long you're gonna live, right? And you also know what healthspan is, how long you're gonna live in a healthy lifestyle.

   5. SBSteven Bartlett2:43

      Mm-hmm.

   6. MKDr Mohit Khera2:44

      But you may not have heard of the concept of sexpan. Sexpan is, uh, the ability to h- engage in sexual activity, satisfying sexual activity. And so how long you are able to engage in sexual activity is important to most men, right? Um, so let's give you an example. The average lifespan in the United States is 77 years old. The average healthspan in the United States, believe it or not, is 67 years old. In fact, if you look at the CDC, and they talk about how long you'll live without a disability, it's actually 63. So there's a delta here. There's at least 10, 15 years where you will be in some kind of disability and cannot live to your fullest. Now, think about the concept of sexpan, how long you'll have the ability to engage in sexual activity, satisfying sexual activity. We, most men, most w- women want their sexpan and their healthspan to last as long as their lifespan.

   7. SBSteven Bartlett3:37

      Yes.

   8. MKDr Mohit Khera3:37

      So I think it's important.

   9. SBSteven Bartlett3:39

      Mm-hmm.

4. 3:40 – 4:56

   Is It Possible to Make Sexspan Last as Long as Lifespan?

   1. SBSteven Bartlett3:40

      And there's things that I can do to make my sexpan last as long as my lifespan?

   2. MKDr Mohit Khera3:45

      There's many things you can do, and I call it the four pillars. The first is diet, exercise, sleep, and stress reduction.

   3. SBSteven Bartlett3:52

      Mm-hmm.

   4. MKDr Mohit Khera3:52

      I don't have a pill on the planet stronger than diet, exercise, sleep, and stress reduction. And each one of those can significantly improve a man and a woman's sexpan, but also their healthspan and their lifespan. The other is hormones. Testosterone, extremely important. Testosterone supplementation can significantly, uh, improve a man and a woman's sexual function. And unfortunately for women in the United States, we don't have very many options. Actually, globally, eh, for women, there's not many options. Um, but I think it's important, a hormone replacement therapy. And I, uh, one more thing. I think about the couple. Think about sexpan as a couple's disease. Let me give you an example. Tomorrow- Stephen, are, are you married or...

   5. SBSteven Bartlett4:33

      Yeah, well, I'm in a long-term relationship.

   6. MKDr Mohit Khera4:34

      O- y- your partner.

   7. SBSteven Bartlett4:35

      Yeah.

   8. MKDr Mohit Khera4:35

      So let's say your partner tomorrow says to you, "I am no longer gonna have sex with you." Unless, uh, you cheat on her or you leave her, you're not gonna have sex again, right? Think about the importance of the couple. Um, so I talk about this quite often. Keep your partner engaged. Keep your partner healthy if you wanna prolong your sexpan.

   9. SBSteven Bartlett4:55

      So

5. 4:56 – 6:56

   Mohit's Professional Experience and the People He's Worked With

   1. SBSteven Bartlett4:56

      I've got two questions here, the first of which is, who have you worked with in your career? And the second question is, what is your CV? Give me a rundown of your professional experience.

   2. MKDr Mohit Khera5:06

      Yeah, so I started my residency in 2000, and, uh, I did my residency t- since 2000, uh, one year of general surgery. I did five years of urology training, and then I did one year of a fellowship in men's health. Soon as I finished my training, I joined, uh, the university at Baylor College of Medicine, and I started a basic science laboratory where we do, uh, re- basic science research in sexual medicine and testosterone for the past 17 years. And I just started a clinical trial. So I still have a clinical arm where I do clinical research. I see approximately 150 patients a week every week. I do approximately six to eight surgeries every week, and I still work at the VA hospital, so veteran government hospital, one half day a week, uh, working with the veterans. So it's quite busy, um, but you know, my passion really is education, research, and clinical care, and um, and that's what we do. And so, you know, when I started my, or how I really got into this was when I finished my training, I was so proud of myself. I was able to get these men these amazing erections, these great libidos.And, uh, I realized one day, this woman called me and she was frantic, and she said, "Look, uh, you're treating my husband. You're able to, uh, get him these great erections, great libido, but I don't want to have sex with him, and he wants to have sex with me all the time, and now we have a terrible relationship. You've ruined our relationship." And I thought to myself, "Wait a minute, uh, I don't, I... this doesn't make sense." But she was right. You know, it, in, in sexual medicine, either leave both libidos low or raise them both, but don't raise one or the other. It's a setup for disaster. So very quickly that year, I went out and flew out to meet with Dr. Irwin Goldstein, who's considered one of the godfathers of female sexual dysfunction. Spent some time with him, went to his courses, and so for the past 16 years, I've been treating women as well. You can't just treat one patient, uh, without addressing the other. And so therefore, it's a couple's disease.

   3. SBSteven Bartlett6:55

      And give me

6. 6:56 – 11:07

   The Most Popular Things People Ask Mohit and Why They Come to See Him

   1. SBSteven Bartlett6:56

      a, a flavor of the types of conversations you have on day one when they walk into your practice, when they come to see you. What is the issue that they say they have and how do they express it? Like, what are the words that they use? And if you could just give me, like, five of the most popular things people say to you when they come to see you.

   2. MKDr Mohit Khera7:11

      So listen, first of all, men and women are very different in how they express it, you know, so we'll talk with men. Most men, uh... let's backtrack. Most men and women do not get any kind of medical care when they see their primary GP. In fact, most GPs don't address sexual dysfunction. There was a study looking at medical students. Only 65% of US medical students get training, uh, in sexual medicine, and of those 65, 50% of those students said that the training was terrible. So we don't get the sexual medicine training to address the problem for patients. So the majority of patients are never, uh, discussed about their sexual problems. But when men come in, there's, uh, uh, most of them are coming in because they already have tried some medications that haven't worked and they're looking for other solutions. Now, there's a very s- two simple questions you can ask a man. They're very straightforward. Are you able to get an erection sufficient for penetration? It's either yes or no. Now, are you able to maintain that erection till orgasm or pleasure? It's either yes or no. If he answers no to either one of those questions, he suffers from erectile dysfunction, right? And so it's very important to get a detailed history. You wanna ask particularly, "Are you able to get an erection on your own? Are you able to get an erection with masturbation? Do you wake up with morning erections?" If he says, "Look, Doc, I get great morning erections," or, "With masturbation, I have great erections," then this has to be psychogenic, right? "With my partner, I cannot get an erection, but when I'm by myself, everything works fine."

   3. SBSteven Bartlett8:30

      Psychogenic?

   4. MKDr Mohit Khera8:31

      Psychogenic ED. It's a big component. I mean-

   5. SBSteven Bartlett8:33

      What is psychogenic?

   6. MKDr Mohit Khera8:34

      Mainly something in the mind that's bothering you or prehen- in- inhibiting you from engaging in sexual activity. And that's where the sex therapist comes in, right? Because if I, if someone tells you, "I get great erections, uh, by myself, but with my partner, I'm not able to get good erections," psychologically, when with their- where they're with their partner, they're not able to achieve a good erection. Sex for men and women has a huge psychogenic component, a huge psychogenic component. So I think it's very important to get detailed history about, uh, are they able to get an erection? What have they tried? What medications have they tried? You know, you have to query about depression. 66% of men who come in with ED have some degree of depression. 66%, right? And that's important. Anxiety, 35% is very important. And more importantly, we'll talk about this, ED is the first sign of other major adverse medical problems. For example, if a man comes into my office today, 15% of them will have a heart attack or a stroke within seven years. 15%. The day they get ED, 15% will have a heart attack or a stroke within seven years. It's the first sign. Other studies, Dr. Montorsi showed that if a man presents to the emergency room with a heart attack, on average, 39 months earlier, that's when the ED started. So it is the first sign. Now, there are many reasons for this. One theory is called the arterial diameter theory. The penile arteries are the smallest arteries, one to two millimeters. The coronary arteries are three to four millimeters. The carotid, six to seven millimeters. So if you remember from physiology, if you're going to block an artery, 50% occlusion of an artery causes damage. So if you're gonna block an artery, you're gonna block the penile arteries before the coronary arteries. You're gonna block the coronary arteries before you block the carotid, right?

   7. SBSteven Bartlett10:19

      Mm-hmm.

   8. MKDr Mohit Khera10:19

      So men will get ED before they get a heart attack, more li- more likely to get a heart attack before they get a stroke. That's a theory, but it makes sense. So I worry when a man comes into my office, could this man have occult cardiovascular disease? In fact, there was a wonderful study that came out of Greece. They looked at 50 men that walked in, and they gave them an echocardiogram or a stress test. If it was positive, they went i- uh, on to a coronary angiogram. What they found is that roughly 20% of men, one in five, actually had some occlusion in their heart, whether it was a one-vessel, two-vessel, or three-vessel disease. So I think to myself every time I'm writing that prescription, "Is this one of the five that could have some occlusion, and is there a opportunity to intervene at this point?" So it's really important to think about cardiovascular disease as well.

7. 11:07 – 15:16

   Most Common Reason for Low Libido: How Much of It Is Related to Lack of Compatibility?

   1. SBSteven Bartlett11:07

      One of the big subjects that I hear a lot about, even in my friendship groups, is about libido. I've ha- I've got so many stories in my friendship group of either one or both partners losing their libido. So on this subject matter of libido, it's kind of where I wanted to start this conversation, what is the most frequent and popular reason why men and women struggle with libido problems, and how much of, of that is about compatibility?

   2. MKDr Mohit Khera11:35

      Yeah. Good question. Libido is multifactorial. There are many pieces of libido. It's very complex, and I'll give you some important components. First, it could be hormonal, and the mnemonic I teach the residents is PET. The four hormones that can affect someone's libido are prolactin, estrogen...... thyroid, and testosterone. So you have to check the pet. If the prolactin's elevated, the libido goes down. If the testosterone's low, the libido goes down. So maybe it's a hormonal issue-

   3. SBSteven Bartlett12:03

      Hmm.

   4. MKDr Mohit Khera12:03

      ... which could be it. And particularly, many women who go through menopause suffer from hormonal issues, and it could be a hormonal issue. The second is something called neurotransmitters. So in other words, serotonin, norepinephrine, dopamine. Dopamine goes up, libido goes up. Serotonin goes up, libido goes down. So these all regulate how someone's libido will function. So one of the biggest, um, uh, culprits for low libido are antidepressants. What do antidepressants do? They increase serotonin and they decrease libido. So sometimes, it's a medication or something that a patient's taking that will shut down their libido. For example, a medication that men take for urinary function called finasteride shuts down their libido. So that is, there are certain things you have to look at. The other components are, um, lifestyle, diet, exercise, sleep, and stress reduction, particularly fatigue and stress. If a woman is tired and she's exhausted and she has to choose between sex and sleeping at night, many times she may choose sleep. If-

   5. SBSteven Bartlett13:04

      Me as well.

   6. MKDr Mohit Khera13:04

      (laughs) Right? I'm just saying, like-

   7. SBSteven Bartlett13:05

      Yeah, yeah, yeah.

   8. MKDr Mohit Khera13:06

      ... so fatigue is important.

   9. SBSteven Bartlett13:07

      Yeah.

   10. MKDr Mohit Khera13:07

       Stress. And there's this, uh, cliché, this mnemonic, this, this saying that, um, with stress it's kinda interesting. Typically, if a man has a very stressful day, he will want to have sex to relieve his stress. Uh, women have to relieve their stress to engage in sexual activity. It's kinda the opposite. You know what I mean? So I tell men, "If you really wanna have sex with your wife, uh, do the dishes, take out the trash, uh, do everything you can to tuck the kids in bed early. Relieve her stress, because that will significantly increase her desire to engage in sexual activity." But the other one is, uh, psychogenic. And so, you, you know, we talked about that earlier, you know, sex has a huge mental component, your relationship with your partner, your, uh, your, the, how close you feel with your partner. So sometimes patients come to me and they're in an abusive relationship, and say, and they say, "Give me the pill that improves my libido." I say, "I, it's not gonna work." I mean, the, the essence, the core, the foundation is not working. And therefore, it's really important for them to see a sex therapist. One thing for men that actually c- shuts down their libido is when they start developing erectile dysfunction. So if a man starts getting erectile dysfunction, let's say he gets a good erection 50% of the time and he's starting to have some problems. And it's 10 o'clock at night and he says, "Look, I can try to engage in sexual activity, but it may not work and it may be frustrating and embarrassing, or I can just go to sleep." He's probably just gonna go to sleep, right? And it becomes a vicious cycle, because the less sex he has, the more difficult it is to engage in sexual activity later on. And so you may interpret this as a low libido, but he's really just avoiding it because he doesn't wanna deal with it, right?

   11. SBSteven Bartlett14:43

       Hmm.

   12. MKDr Mohit Khera14:43

       But the partner also, uh, looks at this as, "Maybe I'm not attractive anymore. Maybe there's something about me that's not appealing," and it becomes a vicious cycle. So one thing you can do is significantly improve the quality of the erections in a man, and that actually helps improve his libido. So for example, if I tell a man, "If every night you, uh, have an ere- great erection, and every morning you wake up with a great erection, what are you gonna probably do? You're probably gonna use it." Right? So libido inherently goes up.

   13. SBSteven Bartlett15:12

       Mm-hmm.

   14. MKDr Mohit Khera15:12

       Right? So I think E- ED and libido are tied very closely.

8. 15:16 – 15:36

   What Is Libido?

   1. MKDr Mohit Khera15:16

   2. SBSteven Bartlett15:16

      How do you define the term libido in simple terms?

   3. MKDr Mohit Khera15:17

      It's a desire to engage in sexual activity-

   4. SBSteven Bartlett15:20

      Okay.

   5. MKDr Mohit Khera15:20

      ... right, for men and women. And they have to, you know, w- when it's a true problem, they have to be bothered by the condition. So I just wanna be very clear. There are women who have low libido and say, "I really don't care. I'm happy that I have a low libido." Well, then it's not an issue, right? You have to be bothered by the issue.

   6. SBSteven Bartlett15:35

      So on this psychoge-

9. 15:36 – 18:35

   Connection Between Erectile Dysfunction and Low Libido

   1. SBSteven Bartlett15:36

      genic element where it becomes a vicious cycle, I've seen this in my own life, um, several times. Well, at least once. And I've seen it in m- some of my friends where, because there's a bedroom issue, when you go to the bedroom, you're both a little bit anxious, and then one of you can't perform. And if you can't perform, it exacerbates the issue and it creates this sort of vicious downward spiral of like, it makes the bedroom like a really awkward place to be, and this is how I think about when you're talking about psychogenic component. So in the- in the case of erectile dysfunction, if you're thinking as a man, "God, if I go to the bedroom, I'm not gonna be able to get it ha- hard. I'm not gonna keep it up. It's gonna be embarrassing. She's then gonna ask me questions. She's gonna think I- I'm not into her," s- which all just makes it even harder, because as a man, like, I perform best when I'm really not thinking about it and I'm s- like, not anxious or-

   2. MKDr Mohit Khera16:26

      Right.

   3. SBSteven Bartlett16:26

      ... when I'm stress-free.

   4. MKDr Mohit Khera16:27

      Right.

   5. SBSteven Bartlett16:28

      And i- it seems to me that the like, antithesis, the opposite of great sex is, like, overthinking it. (laughs)

   6. MKDr Mohit Khera16:36

      You're 100% correct. And this is what happens. Let's say a man gets ED just one time, just one time, young man. He says, "That was really odd and I, I, I... What's wrong?" Do you know what he does next time he has sex? As he's having sex, he says to himself, "I hope I don't lose my erection. I hope I don't lose my erection." The second he says that to himself s- as he's having sex, he's gonna lose his erection, right? Because he's so worried that he's gonna lose the erection and not enjoying the experience. So now, it's happened twice. So now he engages in sex for the third time, and now he's even more freaked out because it's happened twice, and it happens again. And we call this the vicious cycle, right? Because the m- and now sex has become an anxiety event, an anxiety-provoking event. And so you really have to work on decreasing that anxiety and not thinking about it. That's where sex therapy comes in hand, and that's where a medication called daily Cialis has become unbelievably helpful for my young patients, because daily Cialis is a medication that men take daily. You've heard of da- uh, Cialis, right?

   7. SBSteven Bartlett17:32

      It's like the Viagra pill.

   8. MKDr Mohit Khera17:33

      Yeah, it's like Viagra, right? So there's Viagra, there's Cialis, Levitra, there's Stendra. There's four different brands, but one of the four is meant to be given daily. It's a lower dose, five milligrams every day, and the larger dose is 20 milligrams. When you give a man Cialis, five milligrams every day, what it does is essentially is having that medication on board all the time. When he engages in sexual activity, he doesn't have to take a pill. He just has sex whenever he wants to. And I found that to be unbelievably helpful in breaking psychogenic ED, 'cause now-

   9. SBSteven Bartlett18:05

      Is that-

   10. MKDr Mohit Khera18:05

       That's exactly what that is.

   11. SBSteven Bartlett18:06

       ... on the table?

   12. MKDr Mohit Khera18:06

       Yeah, that's exactly what it is. Yeah. And so these are, these are, these are pills. Um-... that are in the US. But what's nice is, they used to be very expensive. Uh, now, they... with... you look at Mark Cuban and a lot of the, uh, good RX, um, companies, they... men can get 90 pills for $15 or $20, which is very cheap.

   13. SBSteven Bartlett18:24

       You used the word young men.

   14. MKDr Mohit Khera18:25

       Yes.

   15. SBSteven Bartlett18:25

       Young men s- presumably shouldn't be taking pill- pills.

   16. MKDr Mohit Khera18:28

       They shouldn't. But what happens when they have psychogenic ED, 'cause they think about it the most, is they need to break the cycle.

   17. SBSteven Bartlett18:34

       What's the

10. 18:35 – 21:15

    What Are the Side Effects of ED Pills?

    1. SBSteven Bartlett18:35

       cost? 'Cause I'm a... I've gotta be honest, I'm a pill skeptic.

    2. MKDr Mohit Khera18:37

       Yes.

    3. SBSteven Bartlett18:38

       So I try and avoid taking pills to solve my problems-

    4. MKDr Mohit Khera18:40

       Yes.

    5. SBSteven Bartlett18:41

       ... if I can.

    6. MKDr Mohit Khera18:41

       Right.

    7. SBSteven Bartlett18:42

       Obviously, there's gonna be situations where I can't-

    8. MKDr Mohit Khera18:43

       Right.

    9. SBSteven Bartlett18:44

       ... and I accept that. But my bias is towards figuring out if there's another way before I take a pill.

    10. MKDr Mohit Khera18:48

        Right.

    11. SBSteven Bartlett18:49

        Um, because everything in life comes with a cost, all things.

    12. MKDr Mohit Khera18:52

        Yeah.

    13. SBSteven Bartlett18:53

        So there must be a cost to taking a pill to solve this problem.

    14. MKDr Mohit Khera18:55

        Well, the, the actual monetary cost is unbelievably cheap.

    15. SBSteven Bartlett19:00

        M- monetary cost is-

    16. MKDr Mohit Khera19:01

        (laughs)

    17. SBSteven Bartlett19:01

        I'm thinking about, like, do, do I get... then get dependent on this?

    18. MKDr Mohit Khera19:04

        Yes.

    19. SBSteven Bartlett19:04

        Do I have to take this for the rest of my life?

    20. MKDr Mohit Khera19:05

        So, so, so, th- there's no dependency. Let me tell you why I think that drug is so important. That... daily Cialis has one of the only things, in my opinion, that actually reverses erectile dysfunction. So let's backtrack. Let me give you an example. Let's say today you break your leg, okay? I have two options, Steven. I can fix your leg or I can give you Vicodin, a narcotic. And if I give you the Vicodin or the narcotic, you'll still be able to walk until the Vicodin no longer works and we're in trouble. Viagra is a Vicodin. It is not a cure for your erectile dysfunction. It's just masking the problem. Daily Cialis, in my opinion, is one of the few things that helps cure ED. If you look at studies and you look at a penile tissue and we biopsy the tissue and then you biopsy three months later on daily Cialis, it physically gets stronger. So let's say you go to the gym today and I ask you to lift dumbbells. What's gonna happen to your arm? It will hypertrophy. With daily Cialis, we see hypertrophy of the smooth muscle, meaning it gets physically stronger. So in my opinion, it's one of the best things to prevent ED in the future, help reverse the ED process. More importantly, daily Cialis protects the endothelium And we have to spend some time talking about that. That is the lining of the blood vessels. It's the brains. And the lining of the blood vessels is very important because once that gets injured, you start getting clot or plaque, which you'll get a heart attack, a stroke, and erectile dysfunction. So it protects the lining of the blood vessels. Two other indications. It's FDA approved to help a man urinate better, FDA approved, and it's FDA approved to protect the heart in terms of something called pulmonary hypertension. So in my opinion, it's an excellent medication. Patients say, "Do I get dependent on it?" I say, "You do not get dependent on it." And ha- and I feel like you're better had you taken it than had you not. You take it for three months, you get strengthening of the penile tissue.

    21. SBSteven Bartlett20:50

        What happens if I stop taking it?

    22. MKDr Mohit Khera20:51

        If you stop taking it, uh, there's a wonderful study by Aversa. And what he showed was that those patients that stopped taking it after three months versus placebo still had benefit in terms of endothelial function protection and erectile function protection than those people that took placebo. So thinking about saying, "Hey, if I go to the gym and I work out for three months, what happens if I stop?" I say, "Well, Steven, you're better off had you gone to the gym for three months." That's my opinion.

    23. SBSteven Bartlett21:14

        What is the

11. 21:15 – 21:41

    The Biggest Side Effect of Cialis

    1. SBSteven Bartlett21:15

       downside?

    2. MKDr Mohit Khera21:15

       There's side effects. So every drug has side effects, right? But they're low with five milligrams. Back pain, stuffy nose, um, uh, headache can occur in these, but it's quite small. But I do think that this is one of the medications that really can make an impact, uh, in men's health. Think about it. If I told you there's a medication that protects your heart, helps your prostate, and helps men with erections, and it's affordable, I think that most men would say, "I'm in."

    3. SBSteven Bartlett21:40

       What are

12. 21:41 – 23:24

    Who Shouldn't Take Cialis?

    1. SBSteven Bartlett21:41

       the big side effects that people report when they're on Cialis?

    2. MKDr Mohit Khera21:44

       So on, on the larger dose, headache, stuffy nose. Back pain is more common with Cialis than other medications, um, but it can be reported. Remember, you shouldn't take these medications if you ha- you're taking a nitrate, 'cause it can drop your blood pressure. Um, but other than that, these are very commonly used medications throughout the world.

    3. SBSteven Bartlett22:01

       And they're not suitable for certain people that have certain cardiac disorders, I'm guessing?

    4. MKDr Mohit Khera22:04

       Well, you know, the way this was invented, uh, this came out... The first one, Viagra came out in 1998. Viagra was, in the clinical trials, designed to be a blood pressure medication.

    5. SBSteven Bartlett22:12

       Mm-hmm.

    6. MKDr Mohit Khera22:13

       And accidentally, men were getting erections in the trial.

    7. SBSteven Bartlett22:16

       Right.

    8. MKDr Mohit Khera22:16

       So these medications are, in my opinion, cardioprotective. A guy name... uh, a very famous, uh, uh, physician named Dr. Kloner published an article recently showing that those men who took daily Cialis had a 13% reduction in cardiac events and a 25% reduction in mortality, ju- just came out, because of the potential effects of protecting the endothelial lining of the blood vessels.

    9. SBSteven Bartlett22:39

       How does this work to solve for the sort of psychogenic component that we talked about, that vicious cycle-

    10. MKDr Mohit Khera22:44

        Yeah.

    11. SBSteven Bartlett22:44

        ... people get into with, like... I'm guessing you're telling me that it, it increases your probability of having a good erection?

    12. MKDr Mohit Khera22:50

        Right.

    13. SBSteven Bartlett22:50

        But this still isn't really working on a libido, is it?

    14. MKDr Mohit Khera22:53

        Right. So let's say, um, you started falling through the vicious cycle and you started having ED, and it was two times, three times. And now I put you on this medication. And every time you have sex, you have the most amazing erection of your life.

    15. SBSteven Bartlett23:05

        Mm-hmm.

    16. MKDr Mohit Khera23:05

        And 30 times, 40 times, three, six months go by and you're having these amazing erections, you're relaxed and you're calm. Then I start going to every other day, you still get amazing erections. Then I go to once a week, you still get amazing erections. Then I stop, you still get amazing erections. Right? I just need to show you that everything is perfect again.

    17. SBSteven Bartlett23:21

        Mm-hmm.

    18. MKDr Mohit Khera23:22

        And that has a huge value.

    19. SBSteven Bartlett23:23

        What about for women?

13. 23:24 – 25:34

    Treatment for Sexual Dysfunction in Women

    1. SBSteven Bartlett23:24

    2. MKDr Mohit Khera23:24

       This is the unfortunate part. We don't have a lot of treatment options for women. And if you look about it, if, if... I wanna give you an example. In 2015, if you and I went into the drug store i- in the US, Walgreens, and said, "Give me all the drugs to treat women, t- treat men for sexual dysfunction." They would put 30 drugs on the counter, "These are all the wonderful treatments for men." In 2015, there was not a single FDA approved drug to treat women for any sexual dysfunction. Very sad. In 2015, the first drug to treat women for female sexual dysfunction came out, and it was called Addyi or filbanstion. And filbanstion basically is a drug that a woman takes every day and increases her desire for sex. That's it. That's the FDA indication, increases her desire for sex. Several years later, the second drug for women came out. This was called, uh, Vyleesi or bremelanotide.Essentially, it's an injection that she takes 45 minutes prior to intercourse and it increases her desire for sex. But again, we have only two drugs. The reason being is because the research, the funding that we have for female sexual dysfunction is far less than we have for male sexual dysfunction. And it's unfortunate because, a- as I mentioned earlier, this is a couple's disease.

    3. SBSteven Bartlett24:35

       Mm-hmm.

    4. MKDr Mohit Khera24:35

       And so many times, I have to use drugs that I use for men to help treat women. So I do use Viagra for women, but Viagra for women helps arousal. So let me explain. Female sexual dysfunction has four components. One is decreased libido, the second is decreased arousal, third is orgasmic dysfunction, and the fourth is pain with intercourse. These are the four. If a woman has any one of these four and she's bothered by it, she suffers from female sexual dysfunction. In the US, roughly 43 to 48% of women suffer from female sexual dysfunction. Significant number. Only 19% seek therapy, will get therapy. So there's a huge number of women that I say are suffering in silence. They suffer from the condition, they don't know where to get help, and unfortunately, there are not many treatment options available, right? So it's a big problem and a big unmet need.

    5. SBSteven Bartlett25:32

       And on the hormonal component,

14. 25:34 – 27:02

    Connection Between Stress and Dopamine

    1. SBSteven Bartlett25:34

       you talked about how if dopamine is up, we're much more likely to be aroused, and if serotonin is up then we're much-

    2. MKDr Mohit Khera25:43

       Less likely.

    3. SBSteven Bartlett25:44

       ... less likely to be aroused.

    4. MKDr Mohit Khera25:44

       That's correct.

    5. SBSteven Bartlett25:45

       So, this kind of ties into something I was thinking when you were talking about stress and tiredness. When I'm stressed and tired, is my dopamine down?

    6. MKDr Mohit Khera25:52

       It can be. Your cortisol goes up, right?

    7. SBSteven Bartlett25:55

       Okay.

    8. MKDr Mohit Khera25:55

       Your corti- cortisol goes up. So your ability to get excited will go down, your fatigue goes up, so it makes it much more difficult. These d- n- d- And there's more than just dopamine and serotonin. There's norepinephrine, there's melanocortin, uh, there's many other neuro- neurosteroids, and it's really just what we call a plus-minus game. If I-

    9. SBSteven Bartlett26:14

       Like a scale.

    10. MKDr Mohit Khera26:14

        ... have more positives-

    11. SBSteven Bartlett26:15

        Yeah.

    12. MKDr Mohit Khera26:15

        ... than negatives, I'm gonna have desire and I'm also gonna have orgasm, right? That's important also. So if you give someone, uh, too much serotonin and it goes this way, not only does the libido go down, but it's difficult to achieve climax or an orgasm. So one of the ways I treat premature ejaculation is I give them an antidepressant because it delays the orgasm. So we have to be very careful on these neurotransmitters, how we use them, but if you talk about Addyi, the drug I mentioned, all it does is it increases dopamine and norepinephrine, which increases libido. So they increase neurosteroids. Many women, particularly with a history of breast cancer, like this because they don't want to use testosterone or estrogen hormones. This is non-hormonal, right? It's just neurosteroids increasing the desire for sex.

    13. SBSteven Bartlett27:01

        Can I think about

15. 27:02 – 29:18

    Types of Activities That Raise Dopamine Levels

    1. SBSteven Bartlett27:02

       dopamine and serotonin as like a scales-

    2. MKDr Mohit Khera27:04

       Yes.

    3. SBSteven Bartlett27:04

       ... where if I, if I put weight on one end, the other one goes up, and if I put weight on the other end, the other one goes up?

    4. MKDr Mohit Khera27:09

       Yes. There is a very famous, uh, uh... S- Michael Perelman came up with the tipping point and it's basically a scale looking at the pluses and the minuses, and if you have more pluses th- than minuses, libido goes up, orgasmic function goes up. If you have more minuses, essentially your ability to orgasm and your libido will go down.

    5. SBSteven Bartlett27:25

       So I want my... If I want to be aroused and have a desire for sex and have good sex, then I want my dopamine levels to be high.

    6. MKDr Mohit Khera27:31

       Dopamine high, oxytocin high, norepinephrine high, serotonin low.

    7. SBSteven Bartlett27:35

       What are the types of activities that make my dopamine high?

    8. MKDr Mohit Khera27:39

       Uh, well, um-

    9. SBSteven Bartlett27:40

       Or should I-

    10. MKDr Mohit Khera27:41

        ... exercise, exercise-

    11. SBSteven Bartlett27:42

        Okay.

    12. MKDr Mohit Khera27:42

        ... is, can be, uh, uh, uh, uh, really high dopamine. Other things increase dopamine as well, right? So, um, uh, gambling. There's, there's certain things that are highs, like gambling, anything that gives you a high. Uh, certain foods will cause a dopamine rush, um, but they're temporary, right? And so-

    13. SBSteven Bartlett27:57

        And that's a problem, right? 'Cause if it goes up and then goes back down.

    14. MKDr Mohit Khera27:59

        It goes back down. A crash. So you want your dopamine to go up in men and women, so we use medications like Wellbutrin. Have you heard of Wellbutrin? It's an antidepressant. But that antidepressant increases dopamine. So I use that to help men increase their libido or women to increase their libido or sexual function. I use Addyi in men and off-label, uh, in men and in women to increase dopamine. If-

    15. SBSteven Bartlett28:22

        I don't want to do drugs though.

    16. MKDr Mohit Khera28:23

        Yes.

    17. SBSteven Bartlett28:23

        I don't want to take any pills.

    18. MKDr Mohit Khera28:24

        So then I would say that, "I need you to exercise." And you do, but exercise is critical. "I need you to sleep. I need you to, um, reduce your stress." Right? Those things will significantly improve, uh, your libido.

    19. SBSteven Bartlett28:35

        So what things then lower dopamine? Because I, I've spoken to a few, like, dopamine exp- experts on the show before, and they talked to me about this sort of... I mean, Andrew Huberman was telling me that-

    20. MKDr Mohit Khera28:44

        Yeah.

    21. SBSteven Bartlett28:44

        ... when you do an exercise like, let's say, gambling or go on TikTok, your dopamine's gonna go up, but then it's gonna crash below the base point.

    22. MKDr Mohit Khera28:51

        Yes.

    23. SBSteven Bartlett28:51

        And some of us live in this kind of dopamine roller coaster where we're doing these dopamine-inducing activities-

    24. MKDr Mohit Khera28:56

        Yes.

    25. SBSteven Bartlett28:56

        ... our dopamine goes up, it then crashes below.

    26. MKDr Mohit Khera28:58

        Yes.

    27. SBSteven Bartlett28:59

        And when it gets low, we have cravings for dopamine-inducing activities.

    28. MKDr Mohit Khera29:02

        Yes.

    29. SBSteven Bartlett29:02

        So we go out and wanna gamble or go on TikTok again or eat something, and then it goes up again and then we k- And we kind of live in this kind of roller coaster of dopamine. One of the things that I was told by a dopamine, um, expert on the show recently that does that as well, that links to some things I found in your work, is pornography.

    30. MKDr Mohit Khera29:17

        Yes.

16. 29:18 – 30:50

    How Much Does Pornography Contribute to Low Libido?

    1. MKDr Mohit Khera29:18

    2. SBSteven Bartlett29:18

       And when we talk about this psychogenic component, we talk about, um, d- dopa- dopamine levels. How much is pornography causing this libido crisis?

    3. MKDr Mohit Khera29:32

       Yeah. Pornography and ED and libido is somewhat controversial. There's some data to suggest that it does not cause an issue and there's some data to su- suggest that it does. The first question I ask a patient when... I ask a man, I say, "Is your ED present with pornography also?" So if he says, "Look, I have erectile dysfunction with my partner and I have erectile dysfunction with pornography," that's very different than when he says, "I have erectile dysfunction with my partner and I have amazing erections with l- uh, pornography." Right? Because then I know that there's a psychogenic component as well. This is what I believe. I believe that when a man watches excessive amounts of pornography, what his expectation is becomes here and his reality becomes here, and that delta-... causes them to have e- erectile dysfunction and low libido. They're not getting what they're expecting to get. So many times, I question men when they come in, uh, all, when all men who come in for ED, I ask, "How much pornography are you watching?" In men who watch excessive pornography, if I ask them to stop watching pornography for a while, many will report improvements in their erectile function and libido. So again, I do think that pornography in excess can have a negative impact only because of your expectation and your reality. The delta, uh, can be an issue.

17. 30:50 – 32:12

    Why Do People Have Less Sex Nowadays?

    1. MKDr Mohit Khera30:50

    2. SBSteven Bartlett30:50

       I'm reading some stats here from JAMA Network that says the percentage of men between 18 and 24 reporting no sexual activity in the past year increased from roughly 18% to roughly 30% in the space of what looks like just a few years. And simil- similarly, the average number of times American adults engage in sexual activity per year has decreased from 60 between 1989 and 1994 to 50, roughly 50, between 2010 and 2024. These shifts suggest a notable shift in sexual behavior over recent decades. Why do you think this is happening?

    3. MKDr Mohit Khera31:27

       I think it's multifactorial. So I think one is I think that ED and sexual dysfunction is on the rise. Uh, and if you look at, uh, the causes for ED, uh, it's very simple. You look at, uh, obesity, diabetes, metabolic syndrome. It's a pandemic. It's an epidemic. There are... If you look at just diabetes from 19, uh, 90 to 2022, uh, 100%, 7% to 14% of the population, one out of eight people globally are obese. One out of eight people. So these can make it very difficult, uh... As obesity and diabetes are, go on the rise, what happens? Testosterone levels go down. Right? So testosterone levels go down. So the ability to engage in sexual activity, the desire to engage in sexual activity, will be impaired by these, uh, uh, conditions.

    4. SBSteven Bartlett32:11

       I've got some,

18. 32:12 – 36:24

    Role of Pornography in Shifting Sexual Behaviors

    1. SBSteven Bartlett32:12

       some graphs here-

    2. MKDr Mohit Khera32:13

       Yeah.

    3. SBSteven Bartlett32:13

       ... um, which show global obesity trends, global diabetes trends. I'll put them on the screen for anyone that's watching on video. Um, also, there's been an increase in pornography consumption from what I was able to tell from doing some research. A 2020 s- study by the University of Antwerp found that 40% of people aged 35 to 45 who watched 300 minutes of porn a week had erectile dysfunction. In a 2021 study by German Public Health and-

    4. MKDr Mohit Khera32:39

       Yeah.

    5. SBSteven Bartlett32:39

       ... Surveillance on 3,400 men between 18 and 35 years old, 20% of the participants suffered from erectile dysfunction. And researchers found that the greater the viewing frequency of pornography, the greater the development of this dysfunction.

    6. MKDr Mohit Khera32:51

       Yeah. And that's 300 minutes is quite a bit of time a week. Five hours-

    7. SBSteven Bartlett32:54

       300 minutes is five hours. (laughs)

    8. MKDr Mohit Khera32:56

       ... or f- five hours a week, right? So that's, (laughs) so that's quite a bit. Yeah. That's quite a bit.

    9. SBSteven Bartlett33:00

       How important do you think that is as a component to this sort of fracturing in relationships? If we think about people having sex with each other less-

    10. MKDr Mohit Khera33:07

        Yeah.

    11. SBSteven Bartlett33:07

        ... we're heading towards w- a world of, like, virtual reality and AI.

    12. MKDr Mohit Khera33:10

        Yes.

    13. SBSteven Bartlett33:11

        What role do you think that's ge- genuinely playing? And you, you must have private conversations with men-

    14. MKDr Mohit Khera33:14

        Yes.

    15. SBSteven Bartlett33:14

        ... that are really suffering with these things.

    16. MKDr Mohit Khera33:16

        Yes. So I, I definitely think it's, it's a role, and it definitely, it plays a factor, but not as much as the epidemic of diabetes, obesity, metabolic syndrome. We are, as a population, becoming more and more unhealthy, right, as time goes on. And I look at it, again, as a pie. It's multifactorial, all right? Um, most of us now are not... Our socialization is virtual, and so we are not engaging and going into s- seeing each other. Everything is done virtually. And so, I think that's an issue. Um, and so I really believe that pornography is a component, but the, uh, the decline in overall health is a major component. The decline in testosterone levels decade by decade is also another component as well.

    17. SBSteven Bartlett33:56

        It's pretty terrifying that young kids at the age of like 12, 13, 14, when they open their phones these days, will be exposed to sexually graphic images-

    18. MKDr Mohit Khera34:05

        Yeah.

    19. SBSteven Bartlett34:05

        ... whether they ch- chose to seek them out or not.

    20. MKDr Mohit Khera34:07

        Yes.

    21. SBSteven Bartlett34:08

        And I've, I've always wondered what that's doing to a developing brain, you know, how it's adjusting your expectations, how it's creating some of those psychogenic factors that are making you less aroused. And, um, and it's difficult, right? It's difficult to go out and find a partner. You have to, like, put on the aftershave, shave, take care of yourself. You have to, like, risk rejection-

    22. MKDr Mohit Khera34:26

        Right.

    23. SBSteven Bartlett34:26

        ... spend some money-

    24. MKDr Mohit Khera34:27

        Right.

    25. SBSteven Bartlett34:28

        ... be interesting.

    26. MKDr Mohit Khera34:29

        Right.

    27. SBSteven Bartlett34:29

        So it seems like if, from a evolutionary perspective, if I was just trying to, like, get my nut off or, like-

    28. MKDr Mohit Khera34:34

        Yeah.

    29. SBSteven Bartlett34:35

        ... I don't know, m- m- ejaculate, I've got this really easy way now.

    30. MKDr Mohit Khera34:38

        Yeah.
19. 36:24 – 39:04

    Connection Between Obesity and Sexual Dysfunction

    1. SBSteven Bartlett36:25

       talk about obesity then-

    2. MKDr Mohit Khera36:26

       Yeah.

    3. SBSteven Bartlett36:26

       ... 'cause these, these stats here are pretty shocking. Um, this one shows the g- global obesity trends, which just shows them going straight up-

    4. MKDr Mohit Khera36:33

       Yes.

    5. SBSteven Bartlett36:34

       ... which is horrific. This one shows global diabetes ch- trends, which is pretty much straight up as well.

    6. MKDr Mohit Khera36:40

       Yes.

    7. SBSteven Bartlett36:41

       Has there been any stu- studies done that show the link between being overweight and your probability of having low libido and some kind of sexual dysfunction issue?

    8. MKDr Mohit Khera36:51

       Yes, numerous, and so let's start with this. So obesity, it's not surprising that diabetes is going up because as obesity goes up, it causes insulin resistance, so obesity and diabetes typically go hand-in-hand. The problem with obesity is the following. Obesity significantly drops testosterone levels, so fat cells contain something called aromatase. Aromatase eats up the testosterone and converts it into estrogen.

    9. SBSteven Bartlett37:15

       Right.

    10. MKDr Mohit Khera37:15

        So the more fat you have, the less testosterone you'll have because you'll convert it into estrogen. Fat cells also secrete something called cortisol and leptin, which shut down your own natural testosterone production. So as, it's not surprising that decade by decade, as you see an increase in obesity, you see a decline in testosterone levels in men because the testosterone levels will come down as people become more obese.

    11. SBSteven Bartlett37:37

        And t- low testosterone equals low libido?

    12. MKDr Mohit Khera37:39

        Low testosterone increases low libido. The number one driver or the number one hormone for libido in men and women is testosterone. It's a strong driver that-

    13. SBSteven Bartlett37:46

        Men and women?

    14. MKDr Mohit Khera37:47

        Men and women, and don't forget that testosterone's also signifi- really important in erectile function. Men need testosterone for sexual function. So do women, right? It's extremely important. So now, I have a hormone that's going down that's gonna make it more difficult to get an erection. I have a hormone that's going down that's gonna decrease my libido, and it's mainly due to this obesity that's occurring, one of the biggest factors, so obesity. Obesity also, um, uh, if you look at the risk factors for ED, obesity, diabetes, cardiovascular disease, these are all risk factors. And so as obesity goes up, erectile dysfunction goes up, and the number one condition is diabetes. Diabetics are four times more likely to have ED than any other population, four times. So I get worried when we see this obesity, diabetes, uh, pandemic going up because it's increasing only the erectile dysfunction. Um, Stephen, if you look at the obesity, the group that's having the greatest rise in obesity is adolescence obesity, not adult obesity. The kids, younger and younger ages are having, that gr- age group has the greatest rise of obesity. So what does that turn into? The younger population are starting out at lower T levels, and it has an implication on fertility because you need s- uh, testosterone to produce sperm. That's very important.

    15. SBSteven Bartlett39:03

        So if I

20. 39:04 – 40:11

    Losing Weight Boosts Testosterone Levels

    1. SBSteven Bartlett39:04

       just lose a little bit of weight, that'll have a big impact on my testosterone levels?

    2. MKDr Mohit Khera39:07

       Let's talk about that. It's not a little bit. So the best study was out of the European Male Aging Study, Fred Wu, and what he showed was this. It's a bidirectional relationship. If you lose 10% of your body weight, you can actually gain 85 nanogram per deciliter in serum testosterone. If you lose 15% of your body weight, you can actually gain 250 nanogram per deciliter in serum testo- It's actually significant if you can lose, but it also goes the other way. You gain weight, you drop the T proportionately as well. The only issue is I can get the patients to lose the weight, but I can't get them to sustain it. Many times, they gain it back, right? But if they can keep the weight off, it significantly increase, uh, the testosterone levels. The wi- the best data we've seen is in the bariatric surgery data. If I do bariatric surgery on a patient-

    3. SBSteven Bartlett39:55

       Which is?

    4. MKDr Mohit Khera39:56

       ... uh, to help them lose weight, you can sh- uh, shrink the stomach. We do surgery to help them lose weight. They lose a quite a bit of weight. Their T levels go quite up, right? And so again, there is a strong correlation between weight and testosterone.

    5. SBSteven Bartlett40:09

       Have you got any examples

21. 40:11 – 42:19

    Impact of Testosterone Therapy on Sexual Activity

    1. SBSteven Bartlett40:11

       of patients where you've given them testosterone treatment in some form, you've done something to increase their testos- testosterone, and you've seen a remarkable reported difference in their sex life?

    2. MKDr Mohit Khera40:21

       All the time. Yeah, so, so first, let's backtrack. There's two ways to give a person testosterone. Uh, if I give a young man testosterone, remember, it causes infertility, so you would never give someone testosterone if they're planning to have children. Right? That's very important. Right? So I have two ways to raise their testosterone. I can give you medications to raise your natural testosterone. There's several. There's a pill called clomiphene citrate. There's hCG. I can use medications to raise your own natural testosterone, and they preserve your fertility. The second option is I can give you medications like testosterone. There's seven of them, uh, but they will shut your natural production down. Not only will they shut your natural testosterone production down, but they will shut down your, uh, uh, sperm production. Now, if you've already had your kids, you're 60 years old, your testosterone level's already low in the first place, what are you preserving? Okay, it makes a lot of sense, and there's seven ways to do it. My favorite way are the injectables and the oral testosterone. They are fantastic. Oral testosterone's quite interesting. You know, first of all, testosterone was invented in 1935. This is not a new drug. 1935. And, uh, oral testosterone initially was feared because it would actually cause liver toxicity and liver cancer, and it wasn't till the 1970s when they were able to make oral testosterone undecanoate. And what's nice about undecanoate, it bypasses the liver, no cancer, but it had to be taken three to four times a day. It was available in the UK as a drug called Andriol all over the world, but not the US. The US, we did not get our first oral testosterone till 2019, and then 2022, we received two more, and now, we have Talando, uh, Jatenzo, and Kyzatrex is our oral. They're taken twice a day with a meal. What's nice about Kyzatrex, it's actually available in the UK. So in the UK now, they can actually get Kyzatrex as well. But oral testosterone, most patients don't mind taking a pill, uh, and it seems very easy to do.

    3. SBSteven Bartlett42:18

       So should

22. 42:19 – 44:13

    Should Someone Like Steven Be Taking Testosterone?

    1. SBSteven Bartlett42:19

       someone like me be taking testosterone?

    2. MKDr Mohit Khera42:21

       If your levels are low-

    3. SBSteven Bartlett42:22

       Yeah.

    4. MKDr Mohit Khera42:23

       ... and you're symptomatic, and I think that's very important. If a man comes in with low levels of testosterone and says, "I feel great. I have no symptoms," I said, "I'm not giving it to you." These are the symptoms, low energy-

    5. SBSteven Bartlett42:34

       Yeah.

    6. MKDr Mohit Khera42:34

       ... low libido-... erectile dysfunction, decreased muscle mass, increased fat deposition, poor sleep, and depression. These are some of the common symptoms you'll see. Most sensitive se- symptoms are the sexual symptoms, erectile dysfunction and low libido. So if he says, "I have these symptoms, and my levels are low," and I recheck it and confirm that it's low, that man is a candidate for testosterone therapy. But if he's young, hasn't had, hasn't had children yet, I'm gonna say, "Look, let's hold off on giving you testosterone and use medications to make you make testosterone. And if you don't wanna take medications, actually there are many things you can do on lifestyle modification to raise your testosterone level." We talked about weight loss as well. So let's live in this area here. You are too young to take testosterone now. But conversely, let's say a patient comes in and has every single sign and symptom of low testosterone, but his testosterone levels are normal. I'm not giving him testosterone because it could be something else. Maybe he's depressed, maybe he has a low thyroid, something else is going on. So you must have signs and symptoms and a low T-level to be a candidate. And if you fit that, then you may benefit.

    7. SBSteven Bartlett43:40

       What about women?

    8. MKDr Mohit Khera43:42

       So this is important. In 1935 when testosterone was invented, uh, it wasn't many years later till they actually started using testosterone in women. And early reports of testosterone in women were actually quite remarkable. The earlier manuscripts d- describe, uh, improved, uh, quality of life, improved libido. And if you and I walked into the drug store today and said, "Give me the testosterone for women," it does not exist. There is not a single FDA-approved testosterone for women in the United States, um, but we have well over a dozen for men. Whe-

    9. SBSteven Bartlett44:12

       Can you explain this to

23. 44:13 – 47:07

    Testosterone Therapy in Women

    1. SBSteven Bartlett44:13

       me? Just 'cause I wanna make sure I'm clear.

    2. MKDr Mohit Khera44:15

       Yeah.

    3. SBSteven Bartlett44:16

       Why would a woman take testosterone? 'Cause when I think of test- testosterone, I think of men.

    4. MKDr Mohit Khera44:20

       Yes. So women make more testosterone than any other hormone in their body. Make more testosterone than any other hormone in their body, right? And when women have higher levels of testosterone, they tend to see a greater improvement in libido, muscle mass, bone mineral density, uh, sense of wellbeing, uh, some have reported improvements in cognition. As the testosterone level goes down, we start seeing these symptoms, particularly low libido. If you give a woman back her testosterone, she will... Many of these women see a significant improvement in their libido. But the issue is that we don't have an FDA-approved product for testosterone in the United States. I think in the UK you call it off-license. We call it off-label. Now in the UK they did have one. They had a wonderful patch called Intrinsa and then the women in the UK could get the patch for testosterone, go into the drug store. NHS covered it and it was fine. Uh, then they had AndroFemme and AndroFemme was actually approved and now no longer is approved. So now in the UK you d- also don't have an on-license medication. The, uh... You can still get AndroFemme from Australia but unfortunately, uh, it's very difficult to get. So what do we do? We use the drugs for men and we give it to the women in one-tenth the dose. That's all we do. So if we have a packet that's, a man puts on a day, we say use one-tenth of the packet every day for the women and they can see significant improvements. It is not illegal to give a woman testosterone. It's just considered off-label or off-license. But they, they see significant improvements.

    5. SBSteven Bartlett45:48

       In what?

    6. MKDr Mohit Khera45:49

       Sexual function by far the most. Libido goes up, no question. I s- many women report that. Muscle mass. If you think about testosterone, bodybuilders take testosterone for a reason. Why? It significantly improves muscle mass. It can decrease fat deposition. Many patients will report improvements in cognition. It can help with bone mineral density as well in men and women, and I also believe in depression. So I think, uh, testosterone does help with depression. I just wanna just, uh, make a very important point. Testosterone's not just about sex. There are five other things that you need to think about, uh, in men and women and I'll t- wanna talk about those. Men with low testosterone levels are much more likely to have a heart attack. Non-negotiable. Men with low testosterone levels are much more likely to have diabetes, obesity. Men with low testosterone levels are much more likely to suffer from depression. Men with low testosterone levels are much more likely to have a bone fracture. So it's not just about sex. It's about their overall health. And if you were to check one blood test to assess a man's overall health, it's his testosterone level. One blood test to check his overall health. It would be... 'Cause I have- it affects heart, diabetes, obesity, um, bone mineral density, energy, muscle mass, erections, libido. One blood test. I can't think of another blood test that is a better barometer of overall health.

    7. SBSteven Bartlett47:05

       I wanna get clear on something 'cause I've heard

24. 47:07 – 48:47

    HRT for Women

    1. SBSteven Bartlett47:07

       people talking on my podcast before about HRT.

    2. MKDr Mohit Khera47:10

       Yeah.

    3. SBSteven Bartlett47:10

       And women taking HRT because of menopause and things like that. Should they be... Does HRT have testosterone in it?

    4. MKDr Mohit Khera47:18

       No. So typically when we say HRT, we're talking about estrogen and progesterone typically.

    5. SBSteven Bartlett47:23

       Yeah.

    6. MKDr Mohit Khera47:24

       And typically when we talk about TRT, testosterone replacement therapy, it's a little bit different. In a woman, there's something I call the triangle, and it's just basically estrogen, progesterone, and testosterone. Just simple. And if you have a woman who's deplete in estrogen, testosterone, and, uh, proge- estrogen, progesterone, testosterone and replace it, many of those women feel better. Right? So many of them do. There are other hormones that are also important. I call it the outside circle. Cortisol, thyroid, growth hormone. We look at those as well. And so I think those are also very important and I tell them, "We're gonna optimize your, uh, hormones but what you're... And we're gonna optimize your medical condition, but that is only 50% of the story." The other 50%, again, is diet, exercise, sleep, and stress reduction. And if you do your part and I do my part, we're on fire. We're absolutely on fire. But you have to do your part. Same with men. I put you on the testosterone, I will optimize your medical conditions and... But you gotta exercise. You gotta eat right.

    7. SBSteven Bartlett48:22

       But why aren't women being prescribed testosterone then?

    8. MKDr Mohit Khera48:25

       Right. Because it's considered... Uh, well, in many countries it's au- in Australia it's available, in the UK it was available and many women are being prescribed testosterone.

    9. SBSteven Bartlett48:33

       Okay.

    10. MKDr Mohit Khera48:33

        It's just off-label.

    11. SBSteven Bartlett48:34

        It is the first time that I've seen someone...... on my show anyway, really emphasized the point that testosterone isn't just for men, it's for women as well. Um-

    12. MKDr Mohit Khera48:43

        And it can significantly improve their quality of life.

    13. SBSteven Bartlett48:46

        Talking about

25. 48:47 – 50:19

    The Decline in Testosterone

    1. SBSteven Bartlett48:47

       testosterone, one of the big conversations that's rattling on, on the internet is about this decline in male testos- testosterone-

    2. MKDr Mohit Khera48:53

       Mm-hmm.

    3. SBSteven Bartlett48:53

       ... over the last couple o' years. What exactly is that decline? If you had to, sort of quantify it?

    4. MKDr Mohit Khera48:59

       If you look at the original studies, we call it the Framingham Heart Study, back in the '70s, testosterone levels were roughly around the 700s. Average man between the ages of 18 and 40 were around the 700s, and every decade we're starting to see a decline almost by 15 nanogram per deciliter. And so the latest in 2015 numbers were roughly in the mid-400s, so we've seen almost a 300 nanogram per deciliter decline in serum testosterone, which is significant because it has two implications: uh, it's not just about, uh, the way you feel and, um, energy, muscle mass, erectile function, but that low testosterone can have implications on fertility. That's really important, so we need to talk about that. But fertility, testos- sperm need testosterone. Low testosterone decreases your sperm count. Sperm counts have also been on the decline as well. So, you know, I think it's really a testament to the fact that decade by decade, we're becoming a more unhealthy population.

    5. SBSteven Bartlett49:53

       Do you think that's really the heart of it, is that, is this sort of our diets and the way we live and becoming more sedentary, less exercise, more, um, processed food, et cetera?

    6. MKDr Mohit Khera50:00

       I-

    7. SBSteven Bartlett50:00

       Do you think that's the heart of it?

    8. MKDr Mohit Khera50:01

       I think that's the key. That's absolutely the key. The types of foods we eat, the processed foods that we eat, high fructose, high carbohydrate diets, um, in- and if you, and- and- and the way we know that is just look at the obesity, look at the obes- look at the diabetes. There has to be a reason why it's on the rise, right?

    9. SBSteven Bartlett50:18

       And

26. 50:19 – 55:35

    What Lifestyle Changes Should We Make to Increase Fertility?

    1. SBSteven Bartlett50:19

       on that point of fertility, I'm in a s- season of life where I'm ch- gonna be trying to have kids pretty soon. What's the most important things I should be thinking about from a lifestyle perspective in your view?

    2. MKDr Mohit Khera50:29

       Yeah. So I- I tell patients Darwinism. In other words, survival of the fittest. Healthier people are more fertile, right? You're passing on the genes. So, uh, so- so essentially, uh, we tell patients, the number, well, the number one cause of infertility in wo- in the world for men is varicocele. A varicocele is the swelling of the veins around the testicle. You know how women sometimes can get swelling of the veins in their legs? You see those veins that are kind of obvious? Well, men can get those veins dilated around the testicle, and those varicoceles can impair sperm production. Now 15% of men in the world walk around with varicoceles, but up to 40% of men with infertility will have varicoceles. So it's really important to assess for the varicoceles. But lifestyle modification, each one again, diet, exercise, sleep, have been shown to help improve fertility in men as well. So I say healthier people are more fertile. I need you to start getting healthier. That's very important. We raise the testosterone level in many of these men naturally, we don't give it to them, to help improve their fertility as well. But check, S- Stephen, check your semen analysis. That's the simplest thing you can do.

    3. SBSteven Bartlett51:31

       Done that.

    4. MKDr Mohit Khera51:31

       Check it, right?

    5. SBSteven Bartlett51:31

       I did that.

    6. MKDr Mohit Khera51:32

       Yeah. It's a great predictor. It's not just, you know, there were so many amazing studies showing that a semen analysis is a phenomenal predictor of overall health. Many studies showing that if your semen analysis today is impaired, it's a predictor of you having comorbid conditions today like diabetes, obesity, metabolic syndrome. It's also a predictor of prostate, I mean s- cancer. So we know that if you have, uh, infertility, you're at a higher risk of having testicular cancer than those that don't have infertility, and it's also a predictor of who will have problems in the future. Mike Eisenberg once showed a very nice study, men who have low sperm counts, uh, can have a 30% increased risk in diabetes, 50% increased risk in ischemic heart disease in the future. Uh, Tom Walsh showed those men can have 2.5 times higher risk of high grade prostate cancer in the future. So again, to me, it's just a marker of overall health. Check the semen analysis.

    7. SBSteven Bartlett52:23

       I did that and it was quite, I was actually a bit, to be honest, I was really quite nervous about it because as someone who's, you know, in my early 30s and wants to have kids, I was really scared that it would come back and say that like, my sperm is, um, dysfunctional-

    8. MKDr Mohit Khera52:36

       Right.

    9. SBSteven Bartlett52:36

       ... and I've got a huge amount of empathy and, um, you know, feelings for people that do those analysis and get bad results back.

    10. MKDr Mohit Khera52:45

        15% of all couples in the world, 15%, suffer from infertility. That's a lot. And if you think about it, um, 30% of the time it's a male factor, 30%. 20% of the time, it's a male and a female factor combined. So indirectly, a male is involved 50% of the time when you have infert- in a infertile couple, and it can be devastating for that couple. I mean, psychologically devastating. And what's also interesting is that, um, most couples, most couples, 50% of couples don't seek therapy and of those couples that do seek therapy, this is globally, only 25% of those couples, uh, actually go forward. Uh, and- and- and- and so I call this a group of individuals that also suffer in silence. They should know that there are excellent treatment options available.

    11. SBSteven Bartlett53:30

        Th- this, um, this graph that I had printed out is just shocking to me. It's going back-

    12. MKDr Mohit Khera53:35

        Yeah.

    13. SBSteven Bartlett53:35

        ... to the point about testosterone but the- the really shocking thing is how quickly this has happened-

    14. MKDr Mohit Khera53:40

        Yeah.

    15. SBSteven Bartlett53:41

        ... because this is the year 2000 and this is the year 2015, '16 there-

    16. MKDr Mohit Khera53:45

        Yeah.

    17. SBSteven Bartlett53:46

        ... and the decline there is from roughly 600 nanograms, is it?

    18. MKDr Mohit Khera53:51

        Yes. Nanogram per deciliter.

    19. SBSteven Bartlett53:53

        Nanogram per deciliter to roughly, for some age groups here, 400-

    20. MKDr Mohit Khera53:58

        Yes.

    21. SBSteven Bartlett53:58

        ... nanograms per deciliter and that's only in 16 years.

    22. MKDr Mohit Khera54:01

        Yes.

    23. SBSteven Bartlett54:02

        So if you play that forward another 16 years-There's gonna be a bit of an infertility crisis.

    24. MKDr Mohit Khera54:07

        There is. Fortunately, on that graph, it's plateauing a little bit, which makes me feel a little comfortable. (laughs)

    25. SBSteven Bartlett54:11

        Okay. Oh, yeah, it is actually, yeah.

    26. MKDr Mohit Khera54:12

        It's plateauing just a little bit. Um, but you're right. It could be a significant crisis. Um, and again, as I mentioned, it's the adolescents, the younger folks, who are having the greatest rise of obesity, and that's where fertility comes in because fertility... Obesity in someone in 60s is not concerned about fertility, but a young patient who has infertility, that obesity will have a higher risk of infertility.

    27. SBSteven Bartlett54:35

        If you're an entrepreneur, you're probably gonna wanna listen to this. It's a message from one of our sponsors on this podcast, which is LinkedIn. If you've listened to me on this podcast for a while now, you'll know that I've been on a bit of an evolution as a business owner and entrepreneur. And one of those evolutions that has become clearer and clearer as I've matured is that the single most important thing in building a business, in building a company, is hiring. The definition of the word company is actually group of people, and that is the first responsibility and job that any entrepreneur has and should focus on. But surprisingly, most don't. About 80% of my team have been hired from LinkedIn, and I think there's very few platforms, if any, in the world that can give you that diversity of candidate with that much information and data on their profiles. It usually costs money, but for the entrepreneurs that are listening to me, I've got you a free job ad post for your company on LinkedIn. Just go to linkedin.com/doac to post your free job ad today. That's linkedin.com/doac. Terms and conditions apply. If

27. 55:35 – 59:53

    If a Couple Came to You With Sexual Problems, What Would You Focus on Naturally?

    1. SBSteven Bartlett55:35

       me and my partner came to you, and we said, "Listen, we've got sexual problems in the bedroom," um, what are the steps that you would... the things you'd look at that we haven't focused on so much today?

    2. MKDr Mohit Khera55:45

       Yeah.

    3. SBSteven Bartlett55:45

       Is there anything in particular you'd say, "Okay..." And I- I'm trying to stay away from being prescribed a pill, so I wanna do anything natural I can-

    4. MKDr Mohit Khera55:51

       Yeah.

    5. SBSteven Bartlett55:52

       ... before I get to that, and then we'll talk about some of the other more-

    6. MKDr Mohit Khera55:54

       Yeah.

    7. SBSteven Bartlett55:55

       ... drastic measures one can take.

    8. MKDr Mohit Khera55:55

       So let's talk about natural things 'cause everyone wants to know about what's the natural things I can do. So when we talk about diet, there's certain diets that have been helpful to improve sexual function. For me, it's the Mediterranean diet. The Mediterranean diet is rich in whole grains, legumes, um, fruits, vegetables. And if you look at red meat and sweets, it's once a month. If you look at poultry, it's maybe once a week, but mainly fish. Those diets have typically been anti-inflammatory diets. Many studies have shown that that diet can significantly improve erectile function, and one study, the MEDITA trial, actually showed that it improves sexual function in men and women. So, I'm a big believer in using the Mediterranean diet. When, uh, Esposito did her first trial, it was a prospective trial, 110 be- obese men. 55 men get, uh, the Mediterranean diet. 55 men, uh, don't get any intervention at all. She follows them prospectively for two years. What does she find? Not only a significant improvement in endothelial function, remember that lining of the blood vessel, but a significant improvement in erectile function in these men. No Viagra, no pills, nothing. Simply changing the diet improved the erectile function, and the same with sexual function in women. So, that's an important one. The second is sleep. Let's talk about sleep. So, studies show that if you're getting less than six hours of sleep a night, it significantly increases your risk for sexual dysfunction in men and women. Right? Your ideal amount of sleep should be seven to eight hours. Now, let's say you say, "Well, that makes sense. Maybe I'm gonna get sle- sleep for 9 to 10 hours 'cause the more sleep I get, the better my sexual function." But that's not true. It plateaus. So, e- if a- above nine hours, it does not increase your ability o- or sexual function. So, seven to eight hours of sleep a night, I need you to get. Third is I really need you to focus on, um, uh, exercise. So I published a very nice study looking at, uh, it was a meta-analysis on how much exercise one needs and what type of exercise to actually improve erectile function. In this study, typically, you need 160 minutes a week, so 40 minutes four times a week, for a course of six months of moderate to severe exercise, vigorous exercise. And so most people can get 160 minutes in a week of exercise, but that's getting your heart rate up and doing the exercise. Significantly improved erectile function in men if you did that, and the more severe your ED was, the greater improvement you saw in erectile function strictly by exercise alone. No other interventions even, just exercise. So, here you have a patient that now starts doing some exercise, starts sleeping better, starts changing their diet. It's all additive. You are now significantly improving erectile function just by lifestyle modification alone.

    9. SBSteven Bartlett58:31

       Hmm. Pretty profound that exercise can have such a big impact, isn't it? Is that the same for women?

    10. MKDr Mohit Khera58:36

        It is true because, uh, many of the things... So unfortunately, once again, the research we have in women is not close to what we have in men. But the MEDITA trial was also in women. The sleep studies were also in women. Um, and so these studies also show that sexual function can be improved with, um, uh, sleep and with diet. Um, I think that men and women are not that different. I mean, if you see a significant improvement in a male's sexual function, uh, with diet, exercise, sleep, um, you can also see it in women as well. Actually, there was a great study. This looked at 110 women, and they had coronary artery stenosis. They did angiograms on 110 women, and they showed that the greater her stenosis she had, the worse her sexual function. So, the greater the blockage in her heart, the worse her sexual function. They put those women on a cardiac rehab program to actually improve their cardiac function, so a diet and exercise program. And those women that actually put through the pro- were on through the program, fourfold increase almost in their sexual function.

    11. SBSteven Bartlett59:33

        What, 400%?

    12. MKDr Mohit Khera59:34

        Fourfold. Yes, sir. 'Cause we use a questionnaire called the FSFI, which is a questionnaire. So, significant improvement in sexual function just on improving cardiac function. So remember, cardiac function and sexual function are related, and it's bidirectional. You improve one, you improve the other. That's very important. We did... We talked about this earlier. 40%

28. 59:53 – 1:01:19

    40% of Men at 40 Will Have ED

    1. MKDr Mohit Khera59:53

       of men in the, in the world at 40 will suffer from erectile dysfunction.

    2. SBSteven Bartlett59:57

       40%.

    3. MKDr Mohit Khera59:57

       40%.

    4. SBSteven Bartlett59:58

       Jesus.

    5. MKDr Mohit Khera59:59

       50% at 50. 60% at 60. 70 at 70. 80 at 80. You do the math. It essentially is a very prevalent condition. This condition-... is associated with increased cardiovascular events. It's the first sign of a heart attack, we talked about that. This condition is associated with two and a half times more likely to be anxious, three and a half times more likely to suffer from depression. And this condition is also si- associated with diabetes. In other words, men with ED, two times more likely to have undiagnosed diabetes, and yet only 50% of men even talk about it because they're so embarrassed. So you show me another condition in the world that affects more men's lives, that's associated with more adverse conditions, and they're too embarrassed to speak about it, they suffer in silence, there's not another condition. There's not another condition, but yet we're embarrassed to discuss it. I used to give these lectures and I would re- look out to the audience, I'd say, "Please raise your hand if you suffer from hypertension." And, uh, many people raise their hand, they have high blood pressure. And I'd say, "Okay, please raise your hand if you suffer from sexual dysfunction." No hands go up. But statistically, you know that over 50% of those people had sexual dysfunction. So why is okay to raise your hand if you have hypertension, but not okay to raise your hand if you have sexual dysfunction? It's gotta stop. We have to destigmatize. It's okay to have sexual dysfunction. It's a common condition. It's curable.

    6. SBSteven Bartlett1:01:18

       Why

29. 1:01:19 – 1:03:12

    The Stigma Around ED

    1. SBSteven Bartlett1:01:19

       don't men raise their hands from a psychological standpoint? Why is that?

    2. MKDr Mohit Khera1:01:22

       I think they're embarrassed.

    3. SBSteven Bartlett1:01:23

       Why?

    4. MKDr Mohit Khera1:01:23

       I think they, I think that w- historically sexual dysfunction looks as like a weakness, "I'm not a man, less of a man."

    5. SBSteven Bartlett1:01:29

       Mm-hmm.

    6. MKDr Mohit Khera1:01:29

       You know, if you have hypertension, it doesn't mean you're less of a man, right? But they have this assumption that it's, uh, a weakness, uh, less of a man. And I, and I think that it's okay. You have to be comfortable saying that you have sexual dysfunction. There are amazing treatment options for sexual dysfunction, amazing, that work very, very well. You just have to raise your hand and let me know that you have it. I just wanna make one other comment about diabetes. There was a study that came out of St. Louis looking at young men, 18 to 40 years old, and they were screening them for erectile dysfunction. And what they found was within those men came in for erectile dysfunction, 30% of those men had prediabetes or diabetes on that day, on the day they were being diagnosed, 30%.

    7. SBSteven Bartlett1:02:13

       Wow.

    8. MKDr Mohit Khera1:02:14

       And I thought to myself, "Young men do not go get screened." I remember when I was 30 years old, I didn't go in for my annual blood pressure check and my annual sugar check. There's no way I'd get my glucose checked. But if a young man gets erectile dysfunction, he is at my front door first thing tomorrow morning. They show up. It's the first thing they're gonna do, because it's a very big condition to them, and they wanna get treated. And that is the opportunity to treat these young men and treat the condition. If you see a young man or someone who ha- comes in for ED, and you screen them for, uh, di- diabetes, and I catch the diabetes at 30 as opposed to 40, that is 10 years of damage on the vessels that you're saving because you catch the disease early. So ED is the gateway to men's health and to treating men early, before it's too late. So I really use sexual health as a tool, a vehicle to improve overall health, because men take sexual health much more seriously, particularly young men.

    9. SBSteven Bartlett1:03:11

       Have you ever had sexual

30. 1:03:12 – 1:05:49

    Personal Experiences With Sexual Dysfunction

    1. SBSteven Bartlett1:03:12

       dysfunction?

    2. MKDr Mohit Khera1:03:12

       I have not.

    3. SBSteven Bartlett1:03:13

       Never in your life?

    4. MKDr Mohit Khera1:03:15

       I have not.

    5. SBSteven Bartlett1:03:15

       I have (laughs) .

    6. MKDr Mohit Khera1:03:16

       (laughs) I have not.

    7. SBSteven Bartlett1:03:17

       I've been in situations where I've come across... (laughs)

    8. MKDr Mohit Khera1:03:18

       But, but d- but it doesn't mean that it's not-

    9. SBSteven Bartlett1:03:19

       Yeah.

    10. MKDr Mohit Khera1:03:19

        It's, but it's okay if I did. It's not, it's n-

    11. SBSteven Bartlett1:03:21

        Yeah.

    12. MKDr Mohit Khera1:03:21

        There's nothing wrong with it. Right? There's nothing... It's normal, it's okay. And it's transient. It can be temporary and come back, right? It's, it's nothing wrong with having sexual dysfunction. We must destigmatize it. It's completely okay.

    13. SBSteven Bartlett1:03:33

        The reason I'm sharing this is because if anyone else has been in the situations, the situations I've been in are, um, generally my sex life has been, been good my whole life. But there's been certain times with certain partners or, you know, you might be drunk a little bit, or-

    14. MKDr Mohit Khera1:03:47

        Yeah.

    15. SBSteven Bartlett1:03:47

        ... uh, back in the day when I was single, there was like the odd person who, for some reason, it just wasn't working for me. And, or there was other instances w- in a previous relationship where near the end of the relationship, I'd like lose my r- erection during sex, and that became a little bit bothersome for me 'cause I was like, "Oh my god." Like, it almost made me not want to have sleep-

    16. MKDr Mohit Khera1:04:11

        Yeah.

    17. SBSteven Bartlett1:04:11

        ... with this person, or it convinced me that maybe I don't like them anymore, or something else was going on.

    18. MKDr Mohit Khera1:04:15

        Right.

    19. SBSteven Bartlett1:04:16

        And for me, it has always been, what's the word you used, psychogenic?

    20. MKDr Mohit Khera1:04:19

        Yes.

    21. SBSteven Bartlett1:04:20

        It's always been in my head that the problems have arose. And the other part of thing that I've experienced a lot is, in terms of libido, I have like no libido when... Actually, it's like different. When I'm s- when work is very, very busy and I'm very, very tired and I come home very, very late, it's not that I'm not horny, but I just, the act of sex is just really unappealing.

    22. MKDr Mohit Khera1:04:48

        But you're just like everyone else. You're not unique when it comes to that.

    23. SBSteven Bartlett1:04:51

        Yeah.

    24. MKDr Mohit Khera1:04:51

        Right? The key-

    25. SBSteven Bartlett1:04:52

        But that, much of my life is like that.

    26. MKDr Mohit Khera1:04:53

        Yeah.

    27. SBSteven Bartlett1:04:53

        Like, I'm, I'm, I come home late a, a lot-

    28. MKDr Mohit Khera1:04:55

        Right.

    29. SBSteven Bartlett1:04:56

        ... and so I'm, I'm stre- I'm like tired-

    30. MKDr Mohit Khera1:04:58

        Right.
31. 1:05:49 – 1:06:45

    The Impact of Kids on Sex Lives

    1. SBSteven Bartlett1:05:49

       kids, so I've not experienced-

    2. MKDr Mohit Khera1:05:51

       Yeah.

    3. SBSteven Bartlett1:05:51

       ... the impact that kids can have on libido.

    4. MKDr Mohit Khera1:05:52

       Which can have a significant impact.

    5. SBSteven Bartlett1:05:53

       Really?

    6. MKDr Mohit Khera1:05:54

       Right. Because it increases your stress, right?

    7. SBSteven Bartlett1:05:56

       Right, okay.

    8. MKDr Mohit Khera1:05:56

       Particularly for your, many times for the partner as well. So if you both are stressed because of the children, sex goes lower and lower on the totem pole.

    9. SBSteven Bartlett1:06:03

       And under slept as well.

    10. MKDr Mohit Khera1:06:04

        Right. (laughs)

    11. SBSteven Bartlett1:06:05

        If you're not sleeping-

    12. MKDr Mohit Khera1:06:05

        Yeah.

    13. SBSteven Bartlett1:06:05

        ... if you're having to wake up-

    14. MKDr Mohit Khera1:06:06

        Yes.

    15. SBSteven Bartlett1:06:06

        ... in the middle of the night, oh gosh.

    16. MKDr Mohit Khera1:06:07

        Right.

    17. SBSteven Bartlett1:06:07

        Isn't there stats that say like when someone has a kid-... a sex life, like, vanishes for 18 months or something.

    18. MKDr Mohit Khera1:06:12

        I don't know. I'm not familiar with that-

    19. SBSteven Bartlett1:06:13

        I read-

    20. MKDr Mohit Khera1:06:13

        ... stat, but I believe it.

    21. SBSteven Bartlett1:06:13

        ... I read something that-

    22. MKDr Mohit Khera1:06:14

        I believe it. I believe it.

    23. SBSteven Bartlett1:06:15

        I read something about, uh, m- post having a kid libi-

    24. MKDr Mohit Khera1:06:18

        Yeah.

    25. SBSteven Bartlett1:06:18

        ... libido, but also-

    26. MKDr Mohit Khera1:06:19

        Yeah.

    27. SBSteven Bartlett1:06:19

        ... just, like, sexual function.

    28. MKDr Mohit Khera1:06:20

        It makes sense. I see it in-

    29. SBSteven Bartlett1:06:22

        Really?

    30. MKDr Mohit Khera1:06:22

        ... in, in couples. And particularly, you know, many times, um, it can take years for them to start engaging sexually because the stress is so high, particularly when they r- originally have the child.
32. 1:06:45 – 1:09:57

    Premature Ejaculation

    1. SBSteven Bartlett1:06:45

       premature ejaculation?

    2. MKDr Mohit Khera1:06:47

       Let's talk about it. Very important. 30... So sexual dysfunction. We've been talking about ED today, right? But there are many different types of sexual dysfunction. There's premature ejaculation. There's Peyronie's disease. There's delayed ejaculation. We're just focusing on one aspect. Premature ejaculation affects 30% of men globally, 30% of men.

    3. SBSteven Bartlett1:07:06

       How do you define that?

    4. MKDr Mohit Khera1:07:07

       There's two ways to think about it. When they come in, you have to figure out, is this lifelong, going their whole life, or is this acquired? It's very important because it takes me down two different roads. If you say, "Look, I've never had premature ejaculation, and yesterday, it started," that's very different than if you come to me and say, "My whole life, I had premature ejaculation." And we now define premature ejaculation as having an ejaculation less than two minutes, used to be one minute, less than two minutes. You have to have a loss of control, like, "I couldn't control it," and you have to be bothered by it. So if you tell me, " Stephen, look, I ejaculate in 30 seconds, and I'm happy," I say, "Great, then we're done." You know, you are content. You have to be bothered by the condition. The ejaculate... The average ejaculatory time in the United States is 5.4 minutes on average, right? The average time for a woman to achieve orgasm is typically 13.4 minutes, so there's a big discrepancy here, as you can see.

    5. SBSteven Bartlett1:07:54

       Mm-hmm.

    6. MKDr Mohit Khera1:07:54

       Right? So 30% of men suffer, uh, but we know that only a small percentage of these men, 9% of these men, will ever seek therapy. And it can be a significant problem in a relationship, um, uh, and that needs to be addressed.

    7. SBSteven Bartlett1:08:07

       Okay, so there's not, like, a time limit. It's not like, okay, if you're coming within two minutes, then you got a problem.

    8. MKDr Mohit Khera1:08:12

       Well, let's say you're not bothered by it. Let's say you and your partner are completely satisfied with it. What's the problem?

    9. SBSteven Bartlett1:08:17

       Okay.

    10. MKDr Mohit Khera1:08:17

        What's the problem? And, and sometimes le- if you think about acquired, um, means that typically we define it as 50% less than your normal time. So if you say, "Look, I typically used to ejaculate in eight minutes, and now it's four minutes, and it's bothering me," I'd say, "Okay, that, that's an issue." Um, you know, so d- uh, we talk... It's relative what, what's comfortable for you, and some men will say, "You know, it, it..." So I think that it's very important to look at the definition. The treatment options are actually quite simple. One of the best treatment options is sex therapy because we can train your mind. We can train you to delay that ejaculation. There's techniques, the start-stop technique, the squeeze technique, how we can delay it. No, but there is. But most men say, "Just give me a pill. I don't, I don't have the time for this. Just give me a pill." But there are ways to do it with sex therapy, which I think are fantastic. Sex therapy is a cure. The pill is just a bandaid, right? Sex therapy is a cure. But the pills that we use, the most commonly used pills are antidepressants because they increase serotonin and make it harder to ejaculate. Well, that's what we want in this situation. We want to delay the ejaculation, so we can use antidepressants. They sometimes have to be taken daily, which work better, or you may have to take it on demand. But if you take it on demand, six to eight hours ahead of time, so you need some notice.

    11. SBSteven Bartlett1:09:32

        But there's gonna be s- qu- significant side effects of taking-

    12. MKDr Mohit Khera1:09:35

        There are.

    13. SBSteven Bartlett1:09:35

        ... antidepressants.

    14. MKDr Mohit Khera1:09:35

        Yeah, there are side effects of antidepressants, so I try to stay away from them, and the other ones I try to use are topical lidocaine sprays because if I decrease the sensitivity of the penis, you're more likely to be able to engage in sexual activity for a longer period of time. So those are commonly used. So sex therapy and sprays are very easy to use. You don't need a prescription for sprays, uh, and they're commonly used.

33. 1:09:57 – 1:11:22

    Is Testosterone Dangerous?

    1. MKDr Mohit Khera1:09:57

       Y- uh, one thing that we have to talk about that's really important is the TRAVERSE trial. It's really big. Everyone historically has always said that testosterone is dangerous. It causes prostate cancer, and it causes a heart attack and a stroke. In 2015, there were some studies that suggested testosterone may cause a heart attack. Before 2015, all the studies suggested that there was no increased risk. So in the United States, they mandated that there be a large trial, 5,200 patients, six years long, strictly to decide does testosterone increase the risk of a heart attack? So myself and eight others designed the study, ran the study for six years, and we published it last year. It finally came out. And it showed that there was no significant increase in cardiovascular events, finally. But until that time, until that came out, many people said, "I still believe that testosterone causes a heart attack." But when the TRAVERSE trial came out, the largest randomized placebo-controlled trial ever published, we finally showed that giving testosterone did not increase the risk of a heart attack. In fact, the study also showed it did not increase the risk of prostate cancer. Many people are worried that testosterone causes prostate cancer. And no negative effect on urinary symptoms. So many people have thought that, "If I give testosterone, the urinary symptoms will become worse." The study showed no worsening of urinary symptoms. So very important study, the TRAVERSE trial finally came out. It's the largest trial in men ever published on testosterone.

    2. SBSteven Bartlett1:11:21

       Will

34. 1:11:22 – 1:13:34

    Will Testosterone Injections Reduce My Lifespan?

    1. SBSteven Bartlett1:11:22

       it reduce my lifespan?

    2. MKDr Mohit Khera1:11:24

       Well, uh, low testosterone, I believe, will reduce your lifespan.

    3. SBSteven Bartlett1:11:28

       Uh, I mean, taking, like, testosterone injections and stuff. Sometimes I think about, like, again, I don't, don't-

    4. MKDr Mohit Khera1:11:33

       Yeah.

    5. SBSteven Bartlett1:11:33

       ... really know what I'm talking about here, but I think about s- athletes taking steroids.

    6. MKDr Mohit Khera1:11:38

       Different.

    7. SBSteven Bartlett1:11:39

       Okay.

    8. MKDr Mohit Khera1:11:39

       Those athletes are taking supraphysiologic steroids, so the normal range is typically 300 to 1,000, is the normal range. And they will take testosterone levels to much higher, 2,000, 2,500.

    9. SBSteven Bartlett1:11:50

       Okay.

    10. MKDr Mohit Khera1:11:51

        And there's a reason for that. Um, there's something called the plateau effect. So if you take testosterone and you have better libido, you intuitively would think, "If I take more testosterone, I'll feel even, um, better libido." But that's not true. There's a certain point at which it plateaus. So the more you take, your body's hitting on-off button, you've hit it, you're done. The exception is muscle.... the more testosterone you, your body sees, the more it upregulates, uh, androgen receptors in the muscle, and you put on more muscle. So bodybuilders are addicted to higher levels of testosterone. But they're also taking other off-label medications, Anavar, Deca, Winstrol. They're taking other medications, and those testosterone formulations have a lower androgenic ratio. Androgenic means facial hair, acne. They're more anabolic. So it's very different than what you're taking. You're simply... or what you would be taking, is just, all you're trying to do is take a medication that you had before and put yourself back into the normal range. Nothing fancy.

    11. SBSteven Bartlett1:12:49

        So I, the more I've learned about testosterone, the more I started to think that maybe when I've had my kids and I'm done having kids, and maybe I am 45, um, I should consider it, providing that my levels are low.

    12. MKDr Mohit Khera1:13:04

        And you're symptomatic.

    13. SBSteven Bartlett1:13:05

        And I'm symptomatic.

    14. MKDr Mohit Khera1:13:05

        If you're 45 and you say, "I feel great."

    15. SBSteven Bartlett1:13:08

        Yeah.

    16. MKDr Mohit Khera1:13:08

        I'm gonna say, "Steven, you're not getting it," right? "I feel great." So if you say, "Look, I'm 45. My levels are low, and I'm starting to have symptoms," I say, "Okay, now's the time to consider taking the medication."

    17. SBSteven Bartlett1:13:20

        Those symptoms you said were like tiredness, energy levels.

    18. MKDr Mohit Khera1:13:22

        Well, the most specific are, my libido's gone down.

    19. SBSteven Bartlett1:13:25

        Okay, so your libido, okay.

    20. MKDr Mohit Khera1:13:25

        My erections are worse. My, uh, energy's gone down. Increased fat deposition, decreased muscle mass, poor sleep, and depression.

35. 1:13:34 – 1:14:55

    Links Between Depression and Testosterone

    1. MKDr Mohit Khera1:13:34

       And we have to talk about depression. So, uh, early on in my career, I conducted a very large trial looking at depression and testosterone. And we had almost 850 patients. And we showed that men with low testosterone levels were much more likely to suffer from depression. Almost 92% of those men with low testosterone had some degree of depression. And when we treated... 17% of those men actually had severe depression. We treated these men for one year with testosterone supplementation, and that 17% dropped down to 2%. Now, I'm not advocating to treat major depressive disorder with testosterone. But what I am advocating for is to at least check a testosterone level in men who are depressed, because it can help them. In fact, in our study, even the men who were on an antidepressant, uh, like say Prozac, we put them on testosterone, those men also saw significant improvements in depression. So may be some synergy between testosterone and what we call SSRIs. So again, it's very important to check a testosterone level in men who suffer from depression.

Episode duration: 1:38:29