Improving Sexual & Urological Health in Males and Females | Dr. Rena Malik

1. 0:00 – 4:04

   Rena Malik

   1. AHAndrew Huberman0:00

      (uptempo music) Welcome to the Huberman Lab Podcast, where we discuss science and science-based tools for everyday life. I'm Andrew Huberman, and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. Today, my guest is Dr. Rena Malik. Dr. Rena Malik is a board-certified urologist and pelvic surgeon. She is an expert in both male and female urological, pelvic floor, and sexual health. During today's episode, Dr. Malik answers the most commonly asked questions about urinary, pelvic, and sexual health, for instance, how to avoid getting UTIs, urinary tract infections. We also discuss pelvic floor anatomy and function as it relates to overcoming an overly tight or an overly relaxed pelvic floor. This is a key distinction that most people aren't aware of. Many people hear about the need to so-called strengthen their pelvic floor, but in fact, many people need to do the exact opposite. They need to learn to relax their pelvic floor in order to achieve proper urologic and sexual function. So, today you'll learn about that. You will also learn about sexual health as it relates to erectile function, as it relates to things like vaginal lubrication, as it relates to orgasm. We separate out, very carefully, the difference between psychological desire and arousal that occurs within the genitals themselves, and Dr. Malik highlights some important misconceptions about sexual dysfunction, for instance, that many people believe that hormones are responsible for sexual dysfunction. But in reality, hormone dysregulation is responsible for only a very small percentage of sexual dysfunction, and yet pelvic floor and blood flow-related issues can account for a large number of cases of sexual dysfunction in both males and females. So, I assure you that today's discussion is going to illuminate many new areas of information, many new tools and protocols that I'm guessing most people have not heard of. We talk about the neural, vascular, that is blood flow-related, and muscular aspects of bladder function, prostate function, Skene's glands. We talk about vaginal health as well as penile health. We talk about these things as it relates to different stages across the lifespan. It is a far-reaching and in-depth and practical conversation that I'm certain everyone will glean important takeaways from. Now, before we go any further, I do want to highlight that the content of today's episode is sexual in nature. We talk very directly about different types of sexual behavior, and we talk about it from the standpoint of the clinician and biologist, so it is a medical/scientific discussion. That said, we can't be aware of where this podcast is being played and who is listening, and I assert that there are certain themes within today's discussion that would not be suitable for young children. How young? Well, that is certainly not for us to discern. We realize that different parents and different households should be the arbiters of what sorts of information their children are exposed to or not. So my suggestion would be that if you have any concern whatsoever that the content of today's episode would not be appropriate to be heard by some member of your family, that you please listen to the podcast first or at least check the timestamps where we've detailed what specific topics are covered and then to make your decision accordingly. I should mention that not only is Dr. Malik still an active clinician. She sees patients daily out of her clinic in Southern California, and we've provided a link to that clinic in the show note captions. She's also authored dozens of high-quality peer-reviewed publications in the fields of urology, pelvic health, and sexual health, and we've also provided a link to that bibliography in the show note captions. And she's also a spectacular public educator. She provides zero-cost content about sexual health, pelvic floor health, and urology as it relates to both men and women on her YouTube channel, and there, too, we've provided a link to Dr. Malik's YouTube channel in the show note captions to this

2. 4:04 – 7:45

   Sponsors: ROKA & Helix Sleep; HLP Survey

   1. AHAndrew Huberman4:04

      episode. Before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is, however, part of my desire and effort to bring zero-cost to consumer information about science and science-related tools to the general public. In keeping with that theme, I'd like to thank the sponsors of today's podcast. Our first sponsor is ROKA. ROKA makes eyeglasses and sunglasses that are of the absolute highest quality. I've spent a lifetime working on the biology of the visual system, and I can tell you that your visual system has to contend with an enormous number of challenges in order for you to be able to see clearly. ROKA understands this and has developed their eyeglasses and sunglasses so that you always see with perfect clarity. In addition, they are extremely lightweight, and they won't slip off your face if you get sweaty. Indeed, ROKA eyeglasses and sunglasses were initially designed for performance in sports, but now they include aesthetics and styles that are really designed to be worn any time. I, for instance, wear readers at night. I'll sometimes wear sunglasses during the day when I drive. And of course, I do not wear sunglasses when I do my morning sunlight viewing, which I highly recommend everyone do their morning sunlight viewing. If you'd like to try ROKA eyeglasses or sunglasses, you can go to ROKA, that's R-O-K-A .com, and enter the code HUBERMAN to save 20% off your first order. Again, that's ROKA, R-O-K-A .com, and enter the code HUBERMAN at checkout. Today's episode is also brought to us by Helix Sleep. Helix Sleep makes mattresses and pillows that are customized to your unique sleep needs in order to allow you to get the best possible night's sleep.Now, sleep is the foundation of mental health, physical health, and performance. When we are sleeping well and enough, mental health, physical health, and performance all stand to be at their best. One of the key things to getting a great night's sleep is to make sure that your mattress is tailored to your unique sleep needs. Helix Sleep has a brief two-minute quiz that if you go to their website, you take that quiz and answer questions such as, "Do you tend to sleep on your back, your side, or your stomach? Do you tend to r- run hot or cold in the middle of the night?" Maybe you don't know the answers to those questions, and that's fine. At the end of that two-minute quiz, they will match you to a mattress that's ideal for your sleep needs. I sleep on the Dusk, D-U-S-K, mattress, and when I started sleeping on a Dusk mattress about two years ago, my sleep immediately improved. So if you're interested in upgrading your mattress, go to helixsleep.com/huberman, take their two-minute sleep quiz, and they'll match you to a customized mattress for you. And you'll get up to $350 off any mattress order and two free pillows. Again, if interested, go to helixsleep.com/huberman for up to $350 off and two free pillows. We are always striving to make the Huberman Lab Podcast better, and to that end, we need your help. Over the next month, we are going to be carrying out a survey. The purpose of the survey is to improve the Huberman Lab Podcast according to your feedback. We put together a brief survey to understand what you love about the podcast, hopefully you love a few things at least, or maybe just one thing, as well as what you think could be improved, or perhaps the many things that you think could be improved about the Huberman Lab Podcast. Basically, what we are asking is to get your feedback so that we can improve any and all things about the Huberman Lab Podcast. The survey does not take long and every single response will be reviewed. As a thank you for completing the survey, we are offering two months free of the Huberman Lab Premium Channel. If you're already a member of the Huberman Lab Premium Channel, do not worry, you will get an additional two free months for carrying out this survey. You can find the link to the survey in the show notes for this podcast episode and on our website, hubermanlab.com. So if you would be so kind as to take a few minutes to fill out the survey and help us continue with bringing you the best possible content here at the Huberman Lab Podcast. And as always, thank you for your interest in science. And now for my discussion with Dr. Rena Malik.

3. 7:45 – 14:13

   Pelvic Floor: Urination & Sexual Function

   1. AHAndrew Huberman7:45

      Dr. Rena Malik, welcome.

   2. RMRena Malik7:47

      Thank you. Thank you so much. It's an honor to be here.

   3. AHAndrew Huberman7:49

      Oh, I'm delighted to have you here. I'm a huge fan of your content. I find that you are able to deliver critical information about sexual health, urology, pelvic floor, libido, and so many other things that are of immense interest to people, but that ordinarily people don't really know where to get the high quality information, and coming to you for that information means they are going to get the highest quality information. I truly believe that because, as everyone will soon hear, today, we're going to have a, a very frank discussion, but one that's really grounded in science and medicine around sexual health and related topics. These are topics that typically people learn about perhaps a little bit in school, maybe at home, from friends, usually overhearing things as opposed to direct exploratory conversation, online, pornography, and at least in my experience growing up, you know, there was education around sexual health, reproductive health, et cetera, that was more oriented toward the fear of things like STIs, fear of unwanted pregnancy, all of which, of course, is extremely important for people to learn about, but far less about, um, sort of the healthy versions of sexual health, right?

   4. RMRena Malik9:11

      Yeah, absolutely.

   5. AHAndrew Huberman9:12

      So this is an especially important conversation. Uh, it's also one that I think has a backdrop that we should just acknowledge right off the bat, that because the information is gleaned from multiple sources and because there are, um, let's just say, uh, influences out there that relate to the m- morality of different practices, that there can be shame, there can be misunderstanding, there can be secrecy, and that further leads to misinformation. So I'm confident that today, uh, you can clarify things for us and we're going to stay out of those, um, trenches. And the last thing I'd like to say is that 'cause a number of terms will certainly come up that I think some people, um, they're not used to hearing in general discourse. I'm just gonna get them out of the way now. Penis, vagina, anus, prostate. (laughs) You know, what else is there? Uh, we're go- we're going to talk about libido, we're going to talk about intercourse, oral sex, anal sex. We're going to talk about all of that, so I just want to get that out there so that, um, we can reduce the, uh, shock, uh, the shock response, um-

   6. RMRena Malik10:19

      I love it. We gotta-

   7. AHAndrew Huberman10:19

      ... as, uh-

   8. RMRena Malik10:19

      ... talk about all of it.

   9. AHAndrew Huberman10:20

      Great.

   10. RMRena Malik10:21

       (laughs)

   11. AHAndrew Huberman10:21

       So to start things off, in anticipation of this episode, I solicited for questions on social media and I got thousands of questions, but there was a lot of overlap in the questions. So to start off, I'd like to talk about pelvic floor, okay? Because both males and females have a pelvic floor, and my understanding is that there's a muscular component, there's a neuromuscular component, there's a blood flow component. What is a healthy pelvic floor? What does a healthy pelvic floor do? And then we can talk about some of the health issues that an unhealthy pelvic floor creates and some of the ways to ameliorate an unhealthy pelvic floor.

   12. RMRena Malik11:00

       Absolutely. So a pelvic floor, very simply, is basically a bowl of muscles that's connected to bones that hold up all your organs. So basically, in your pelvis, there's all these muscles there and their function is essentially many. It, it helps with urination, defecation, sexual function. It helps with posture. And so having a strong, healthy pelvic floor can mean that you're having normal urination, you're having normal defecation, you're having great sex, and that you are also not having ailments like back pain or issues related to those s- those functions and those organs. And so, you know-... pelvic floor is, is so important in so many different aspects, and we deal with it a lot as urologists, because it's so integral to these functions that we take care of. And so when you have an unhealthy pelvic floor, it can vary from person to person, and while you hear about it a lot in women, men also suffer from pelvic floor dysfunction or problems with the pelvic floor. So basically, pelvic floor dysfunction happens a lot when you're doing things, like if you were to go to the gym and do repetitions of, of any sort of exercise and you didn't rest, then that muscle would become contracted and short. Very similarly, if your pelvic floor is overstrained, it can become contracted and short, and tight all the time, and you may not know it. It may just be a function of stress, anxiety, um, or overuse or s- posture problems, things of that nature that can affect your pelvic floor. And so this can lead to issues, let's start with urination. You can have symptoms of urgency, frequency, uh, meaning you have to go a lot to the bathroom or you have to go and have a sudden desire that you can't delay, sometimes even have leakage. In some cases, it can make it difficult to urinate because the pelvic floor is so tense.

   13. AHAndrew Huberman12:51

       Or perhaps to incompletely vacate the bladder?

   14. RMRena Malik12:54

       Correct.

   15. AHAndrew Huberman12:54

       Like, you go to urinate and then you go back to your desk or, and then five minutes later, you have to urinate again.

   16. RMRena Malik13:00

       Exactly.

   17. AHAndrew Huberman13:00

       Something of that sort.

   18. RMRena Malik13:01

       Well, it can be either that you're not emptying completely or that the pelvic floor muscles are so tense that they're stimulating the bladder so it feels like there's more to go. So it's not always that you're not evacuating it. It can present in a number of different ways. And then with, uh, with sexual function, it, if it's very tense, you can have pain, so you can have pain with sex, you can have pain with erections, you can have pain with ejaculation. Sometimes it can be a lot of different kind of pain syndromes and you're like, "W- I have all these different things going on," and it's really just pelvic floor dysfunction. Um, with s- with GI function, you can definitely have constipation and then often you can also have back pain. Um, and so all of these things can happen when your pelvic floor is too tense. Sometimes your pelvic floor can be too weak, and that can be often because of, we see this in women a lot because of childbirth, delivering children, um, with some people who have neurologic disorders, they can have weak pelvic floors or connective tissue disorders like Ehlers-Danlos syndrome, for example. These sorts of things can cause weakness to the pelvic floor which can then cause very often what I see is, like, urinary incontinence or leakage, um, which can then, you know, create problems for people down the line.

4. 14:13 – 19:44

   What is a Healthy Pelvic Floor?

   1. RMRena Malik14:13

   2. AHAndrew Huberman14:13

      Thank you for that. So first question, how does somebody know if their pelvic floor is too tight from a, uh, over contraction or chronic contraction of the muscles there versus too weak? Um, and one of the challenges in having this conversation is that if we were talking about contraction of the calf muscle or the bicep, I think everyone intuitively knows because they've seen the shortening of the muscles when the muscle is "flexed" and the lengthening of the muscles when it is relaxed. Um, is there a way to describe pelvic floor muscular shortening in a way that everyone can understand? Would this be like, um, like I said, we're going to be direct today, would this, like, be like tensing up one's, um, uh, anus and bow- the opposite of, of the movement that one would do before initiating a bowel movement and relaxation is sort of the pattern of pelvic floor muscular, um, relaxation just prior to initiating a bowel movement?

   3. RMRena Malik15:12

      So I will say most people can't recognize it because it's very difficult to notice. It's sort of, uh, gradual.

   4. AHAndrew Huberman15:19

      Mm-hmm.

   5. RMRena Malik15:20

      And so it can, over time, become noticeable with these symptoms, but otherwise it's very difficult because it's not a muscle that we were ever trained to recognize, right? Like you hear about Kegel exercises, for example, and people talk about how to do them, but that's all you ever hear about the pelvic floor and so you don't really know how to kind of do things in a way that protects your pelvic floor or, um, or kind of what, how to even tell when it's too tight or not relaxing and so that takes a l- sort of training and so usually when people come to... First you get an examination to see if your pelvic floor is tight. So for women it's a pelvic exam and for men it's usually a rectal exam.

   6. AHAndrew Huberman15:57

      How does, how does that exam go?

   7. RMRena Malik16:00

      So you know, it's essentially palpating the muscles and also looking at the function. So we'll say for-

   8. AHAndrew Huberman16:05

      So digital palpation where, that's a medical technology for fingers are called digits. (laughs) Uh, so, um, you know, I'm old enough to, uh, to recognize what a digital prostate exam is, right?

   9. RMRena Malik16:17

      Mm-hmm. Mm-hmm.

   10. AHAndrew Huberman16:17

       The physician inserts their fingers through, i- into the anus and, and, and feels the prostate to see whether or not it's swollen or not.

   11. RMRena Malik16:24

       Mm-hmm.

   12. AHAndrew Huberman16:25

       And, and as I'm saying this, I'm realizing, you know, sometimes we think of me- medicine, "modern medicine" is so evolved. This has basically be- basically been the practice for what, 50 years, 60 years, maybe 100 years?

   13. RMRena Malik16:35

       Uh-huh.

   14. AHAndrew Huberman16:35

       In the same way that the, the old school practice for glaucoma-

   15. RMRena Malik16:38

       Mm-hmm.

   16. AHAndrew Huberman16:38

       ... excessive eye pressure, was for the physician to just touch the eyeball.

   17. RMRena Malik16:42

       Mm-hmm.

   18. AHAndrew Huberman16:42

       So, uh, folks, for those of you that think that medicine has evolved much, uh, it clearly has in many ways, but, um, in any event, so a prostate exam goes as I just described. What would a, what would a pelvic floor exam for a male and a pelvic floor exam for, uh, a female, um, involve at a kind of granular level here?

   19. RMRena Malik17:00

       Yeah.

   20. AHAndrew Huberman17:00

       Yeah.

   21. RMRena Malik17:00

       So for, for women, you can feel the pelvic floor muscles through the vagina, so you can feel the iliococcygeus, the pubococcygeus, the levator ani. Those are all names of different muscles in this bowl, and so-

   22. AHAndrew Huberman17:12

       This is the physician who can feel them-

   23. RMRena Malik17:13

       Correct.

   24. AHAndrew Huberman17:13

       ... with their fingers.

   25. RMRena Malik17:14

       Correct, and y- you know, you could too. You could put your finger in, but you don't have a reference of normal, right? So you wouldn't know what a normal pelvic floor feels like versus a tight one versus a weak one and so you can assess the tenseness based on, you know, palpation. You can also see if there's tenderness and so you can assess that based on just a, a general physical examination and then also you can observe. So I can say contract your b- uh, squeeze your pelvic floor up and in. I can look and see are they squeezing or are they pushing? Like are they coordinated or not, right? Because that's a, a function of normal use of the pelvic floor and sometimes you'll see that they're discoordinated. Um, you can also assess for sensation in the area and things like that that could be consequences of dysfunction.

   26. AHAndrew Huberman17:55

       Can there be dysfunction in laterality like the-

   27. RMRena Malik17:57

       Mm-hmm.

   28. AHAndrew Huberman17:57

       ... pelvic floor is pulling up and to the right or up and to the left?

   29. RMRena Malik18:00

       Absolutely. So what, typically when you see a pelvic floor therapist, now I'm not a pelvic floor therapist, but these are the people who do the work, right? They, they work with you on a prolonged basis to help you normalize the function of your pelvic floor. It's like going to the gym with a trainer, right? They really work with you to get your pelvic floor functioning correctly and the first step to that, a lot of pelvic floor therapists will just align your bones and, and your, your kind of the way you sit and walk to make sure that you're not straining those muscles by pulling in different, in different directions.

   30. AHAndrew Huberman18:32

       And if a...Male goes to the physician to get a pelvic floor exam. Um, there's obviously, um, uh, difficulty in putting fingers into the urethra, one would hope (laughs) . Uh, too small an opening. So how are they doing the pelvic floor exam? Is it external to the body or is it through the anus?
5. 19:44 – 24:08

   Kegels, Benefits & Risks, Urinary Incontinence

   1. RMRena Malik19:44

   2. AHAndrew Huberman19:44

      Let's talk about Kegels. Um, first of all, who's Kegel?

   3. RMRena Malik19:48

      (laughs) So he is a, uh, gynecologist. Uh, I don't remember all the specifics, to be quite honest, but basically he came up with Kegels, which are a strengthening exercise for the pelvic floor. And so what it is, what we describe it to for patients is we say, "You're going to..." There's a few different ways to describe it. "You're going to use the muscles that you use when you urinate, but try to stop the flow." But you don't want to do them when you're urinating, 'cause that can create dysfunction. You want to learn what the muscles are, and then you squeeze those muscles and relax, eh, you know, in between sets, so, so to speak. And so you'll do it... The other way people describe it is pulling up and in, in the-

   4. AHAndrew Huberman20:25

      Mm-hmm.

   5. RMRena Malik20:25

      ... like the vagina. Or for men, sometimes you'll say it's like the feeling that you're trying to lift your penis off the floor without touching it, right? So those are kind of using-

   6. AHAndrew Huberman20:33

      That's a good way to describe it.

   7. RMRena Malik20:34

      Yeah.

   8. AHAndrew Huberman20:34

      Yeah.

   9. RMRena Malik20:35

      So those are kind of the ways that you can describe those muscles. And so you can squeeze for five seconds and relax for five seconds and do them in repetitions. And they're just like any sort of exercise you do, you don't want to start doing 100 of them, right? You want to do them... I tell them, people, I tell patients, do them lying down so that you're only focusing on those muscles. You're not working on your posture, you're not doing anything else. And as you get better with them lying down, you then sit up and do them. And then once you're good with them sitting up, you can do them standing, and start with, you know, 10 to 15 at a time, like once in the morning.

   10. AHAndrew Huberman21:08

       10 to 15 repetitions?

   11. RMRena Malik21:09

       10 to 15.

   12. AHAndrew Huberman21:09

       So yeah, let's talk sets and reps.

   13. RMRena Malik21:11

       Yeah (laughs) .

   14. AHAndrew Huberman21:12

       (laughs)

   15. RMRena Malik21:12

       So yeah, 10 to 15 repetitions in the morning, 10 to 15 repetitions at night. Uh, maybe one more during the middle of the day, but don't overdo it because just like anything, especially when you're starting out, you can, and if you're doing tons and tons of Kegels, then you will get a tight, short pelvic floor muscles, and you will then develop pelvic floor dysfunction. So it's really important to kind of understand those mechanics, which is why a lot of people think they know how to do Kegels, but they really don't. And so I always encourage people, if you have the time and the resources, to go to a pelvic floor physical therapist so they can really work with you and make sure you're doing them correctly.

   16. AHAndrew Huberman21:48

       What are some of the benefits of Kegels for those that need them?

   17. RMRena Malik21:51

       Yes, so they are typically prescribed for urinary incontinence, specifically stress urinary incontinence. So leakage that occurs when you have an increase in your intra-abdominal pressure, like a Valsalva or coughing, sneezing, lifting heavy things, jumping on a trampoline. Um, so for those purposes, we use Kegels to strengthen the pelvic floor, and also in women, pelvic organ prolapse, so when you have weakness of the pelvic floor that leads to a bulge that you can visibly see or feel in the vagina. For men, we often prescribe them for people who have had a prostatectomy, who then subsequently develop leakage after the prostatectomy. That is, again, stress urinary incontinence. Now, a lot of people use Kegels recreationally because eh- improving the pelvic floor musculature can lead to more intense pelvic floor contractions during orgasm, which can be more pleasurable, and so some people do it for those purposes. But again, I caution people not to overdo it, uh, because then you can lead to a more tense pelvic floor, which is not where we want to end up.

   18. AHAndrew Huberman22:53

       Yes, I will underscore, uh, that cautionary note. Years ago, I heard about Kegels. I was like, "Okay, I'll try it." Sounds all good, right? I only heard good things about Kegels. Um, and what it quickly resulted in was painful urination, and I thought, "This is weird. Everyone's saying Kegels are so great."

   19. RMRena Malik23:14

       Mm-hmm.

   20. AHAndrew Huberman23:14

       Um, and the best thing I could do for my pelvic floor, it seemed, was to avoid Kegels.

   21. RMRena Malik23:19

       Yes.

   22. AHAndrew Huberman23:20

       Um, and a little bit later, I'll, when we're talking about prostate, I'll, I'll explain, um, at least what my experience was as it relates to the prostate. Um, but I guess the take-home message that I'm gathering from what you're telling us is that strengthening the pelvic floor is great if you have a weak pelvic floor. Strengthening your pelvic floor further, if you have a strong pelvic floor, can be detrimental.

   23. RMRena Malik23:44

       It can be. It can be, if, if you overtrain it, just like if you overtrain anything else. And so, um, you just have to, if you really want to do Kegels, if you have any symptoms at all, like you described, painful urination or the things I've described, like pain with erections, pain with ejaculation, pain, uh, difficulty emptying, any of those symptoms, stop and go see a urologist so that they can kind of assess your pelvic floor.

6. 24:08 – 28:03

   Pelvic Floor Relaxation; Exercise & Pelvic Floor

   1. RMRena Malik24:08

   2. AHAndrew Huberman24:08

      What is the anti-Kegel? I- in other words, if somebody decides that they have a tight pelvic floor...... how can they learn to relax their pelvic floor?

   3. RMRena Malik24:18

      So there's a lot of different sort of things that you can do. So for, uh, women, you can do massage of the area. You can use vaginal dilators to help relax the muscles. You can take suppositories that have medications like Valium or Baclofen, which are muscle relaxants, and, um, that can help as well. Although they're not treatments, they're more of a Band-Aid, but they can help with the symptoms that you're having. And then, um, you can also, I think, the best thing is to work with a physical therapist 'cause they can teach you certain exercises that will help downtrain the pelvic floor. For example, one of the ones I tell my patients is, like, happy baby pose. It actually, you know, stretches and elongates the pelvic floor muscles. So doing these exercises regularly will help you lengthen the pelvic floor muscles.

   4. AHAndrew Huberman25:06

      One thing that I've experienced extreme pain from, and that stopping was one of the best things that ever happened for my pelvic floor (laughs) , was to not do any kind of crunching movement with my legs crossed. I would go to these yoga classes-

   5. RMRena Malik25:23

      Mm-hmm.

   6. AHAndrew Huberman25:23

      ... at one point in my life, and I, they'd have everybody do these crunches. And I've always done some abdominal work here and there during the week if I'm being diligent. But they would have us cross our feet, and that seemed to lead to some pelvic floor discomfort that was similar to what I had experienced when I did the Kegels.

   7. RMRena Malik25:41

      Yeah.

   8. AHAndrew Huberman25:41

      So again, for me, ceasing the Kegels was one of the best decisions I ever made (laughs) . I only did them for a short while. I was like, "Okay, this is clearly not for me." And I guess that's another point, um, that, uh, tell me if you agree, uh, or not, that if you hear about something online or on this podcast or anywhere else, and you tried, and it seems to be sending things in the wrong direction, e- either you're doing it wrong, or it might not be the right thing for you.

   9. RMRena Malik26:02

      Exactly.

   10. AHAndrew Huberman26:03

       Right? You know, I think all too often we hear, "This thing is great," and people jump on that bandwagon, and then they end up worsening their problems or developing problems where they didn't have them previously. But is there anything about the anatomy of the neuromuscular connections or, or vasculature of the pelvic floor that would provide support for my experience there?

   11. RMRena Malik26:21

       Yeah.

   12. AHAndrew Huberman26:21

       That doing crunches with legs crossed is essentially, um... Is it possible that it's creating asymmetries in the pelvic floor? Um, and now I'm sure I'm, uh, angering yoga teachers-

   13. RMRena Malik26:30

       (laughs) .

   14. AHAndrew Huberman26:30

       ... and, um, cr- crunch, crunchanistas everywhere, but, you know, hey, um, if it's a question of your pelvic floor or a few extra, um, delineations in your abs, you know where my vote's going.

   15. RMRena Malik26:40

       (laughs) Yeah. So there's a couple things here that we should dive into. One is that people don't often breathe correctly during exercise, right?

   16. AHAndrew Huberman26:47

       Mm-hmm.

   17. RMRena Malik26:47

       And so diaphragmatic breathing is, is really important, which is, like, a deep breath that expands the diaphragm, not kind of shallow breathing that's just in your mouth and throat, and that is actually when you b- you know, when you do any sort of exercise, the, your trainer will tell you, "Exhale on the effort," right?

   18. AHAndrew Huberman27:04

       Mm-hmm.

   19. RMRena Malik27:04

       And there's a reason for that. Because when you inhale, your pelvic floor relaxes. When you exhale, your pelvic floor contracts. And so it actually, that contraction stabilizes the pelvic floor, so whatever intraabdominal pressure you're, you're causing to increase from the exercise, whether it's a squat or a s- crunch or whatever, you're increasing your abdominal pressure, your pelvic floor is then t- contracting to help stabilize that. And so part o- part of the reason people tend to hold their breath during crunches, right? They don't do the appropriate breathing, and so that can be part of it. The other thing that can happen with certain things is that there are, you know, nerves and arteries, particularly the pudendal nerve and the pudendal artery that run through the pelvic floor. So when you get pelvic floor dysfunction, you can cause decreased blood flow to the, to the pelvic floor muscles, which can affect sexual function, and you can get nerve inflammation as well that can also cause pain. And so this is kind of how it all comes

7. 28:03 – 36:10

   Desire vs. Arousal, Erections: Psychology, Hormones, Blood Flow & Nerves

   1. RMRena Malik28:03

      together.

   2. AHAndrew Huberman28:04

      I'm so glad that you mentioned blood flow. I think our entire discussion today should be framed up, at least in the back of our minds and the minds of our listeners and viewers, as involving at least three things. You know, any time we're talking about erectile function or dysfunction, or pelvic floor function or dysfunction, or vaginal lubrication or lack thereof, we need to think about the hormonal influences, the blood flow-related influences, and the neural influences, including the neural influences that come from the brain, the signals of arousal, for instance-

   3. RMRena Malik28:37

      Mm-hmm.

   4. AHAndrew Huberman28:37

      ... or lack of arousal, um, and so on. So, um, we won't be overly systematic in, in our, uh, parsing of all this, but I, I think what you just mentioned raises a really important point, that sometimes in an effort to do something that's good for the muscles, like strengthen the muscles, one will cut off blood flow. In fact, one of the more common questions I got, and I consulted with a couple of, um, exercise physiologists about this, and they confirmed that a lot of people who squat and deadlift heavy in the gym, or even who just tense their pelvic floor when they're doing things like dumbbell curls-

   5. RMRena Malik29:11

      Mm-hmm.

   6. AHAndrew Huberman29:11

      ... or other exercises, and especially people who seem to do a lot of abdominal work, reported to me in the questions that they experienced things like erectile dysfunction.

   7. RMRena Malik29:24

      Mm-hmm.

   8. AHAndrew Huberman29:24

      That they experienced things like pain during vaginal intercourse. That essentially, they had created some sort of what sounds to me like a hypercontraction of the muscles in that area-

   9. RMRena Malik29:35

      Mm-hmm.

   10. AHAndrew Huberman29:35

       ... that were impeding all the things that they wanted as either side effects or direct effects of exercise, because many people are exercising for aesthetic reasons and health reasons. But nowadays, it seems, especially on the male side, but we also talk about the role of testosterone on the female side, a lot of males lift weights in order to increase their testosterone, and for reasons that are obvious, also want to have healthy sexual function. And here they are doing this thing that's very good for increasing testosterone if they're doing it correctly, and testosterone is involved in libido in the male sexual response and the female sexual response, of course, but they are impeding their erections. So (laughs) you can start to see how, um...... there are probably a lot of confused and maybe even distraught people out there. They're trying to do all the right things and they're setting up roadblocks, and even, um, sending themselves backward in some cases. So, the question is, how does one know whether or not something like, um, let's say, low lubrication or pain during vaginal intercourse, or, um, loss of erectile strength or some sort of erectile dysfunction, whatever it may be, 'cause it can take on different forms, as we'll talk about, how does one know if it's blood flow-related, hormone-related, or neural-related? And if it's neural-related, how does one know if it's an issue of lack of appropriate signals from the brain, over-suppression or lack of s- of arousal from the brain, or whether or not it's some peripheral neural thing of innervation of the penis or vagina?

   11. RMRena Malik31:04

       So, I think there's, there's a lot that we can go into here. But essentially, first you want to find out, like very specifically, what is going on. Are you getting aroused? Are you having erections? Are you masturbating? Like, there's all these questions-

   12. AHAndrew Huberman31:19

       Mm-hmm.

   13. RMRena Malik31:19

       ... that will help us go down the route.

   14. AHAndrew Huberman31:21

       Sorry to interrupt. When you say aroused, um, for sake of this discussion I just want to make sure that we distinguish between psychological arousal, the desire to-

   15. RMRena Malik31:29

       Correct. Mm-hmm.

   16. AHAndrew Huberman31:30

       ... to, um, I guess here we also have to be precise, um, arousal to engage in intercourse and arousal to, um, desire, essentially-

   17. RMRena Malik31:39

       Sure.

   18. AHAndrew Huberman31:39

       ... that I think people learn to recognize. Or are we talking about arousal as the response of the genitals?

   19. RMRena Malik31:45

       Correct. So, so desire and arousal, this is a very important concept, doesn't always go in one direction. Sometimes you can feel arousal, meaning you have the telltale signs of arousal, your nipples get erect, you have more lubrication if you're a female, y-

   20. AHAndrew Huberman32:02

       Do both male and female nipples get erect during arousal?

   21. RMRena Malik32:05

       I believe so.

   22. AHAndrew Huberman32:06

       I think so, yeah. Yeah.

   23. RMRena Malik32:07

       I believe so. Um, you know, y- you maybe get the sex flush, right? You get some, some redness or, or warmth feeling. That's your body's response, right, to arousal, and sometimes that can be an erection and sometimes that's not. Not having an erection does not mean you're not aroused. It may mean other things. But certainly that's part of it. And then desire, do you want to have sex? Do you have d- like when you think about your partner or wh- whoever you want to engage with, does, is there a desire to actually do that, right? Or is it just more of obligation or other things? And does the desire, it doesn't matter if the desire comes after arousal. For some women in particular, we see that they may not have the desire right away, but they want to be intimate or close with their partner, and so they'll start just being close with them and then arousal will come, and then, "Oh, yeah, you know, I like this." So then the desire comes after. And that's normal. That's totally fine. Um, so you want to kind of parse that out. And then for men you can ask, "Are you getting erections at night?" Because that will tell us the function of your organ at night versus during the day where you have also psychogenic components, right? You can really get in your head about erections. When you have a problem in the bedroom with performance, it becomes a vicious cycle, right? So you, you have a problem, the next time you're really stressed, you're not present, you're not mindful in the moment with sex and you're thinking about, "Oh my God, am I gonna perform okay? Am I gonna perform okay?" And then it doesn't perform again and you're just, it's getting worse and worse and the anxiety is through the roof and that's actually causing your sexual dysfunction. So, I think it's, it's important first to identify those issues and then also for, uh, blood flow, a lot of times we can, we can assess based on, well, what other comorbidities do you have? Do you have other issues ongoing that may be affecting your blood flow? Most common, high blood pressure, diabetes, heart disease and if you smoke. All of those things will affect blood flow to the genitals. And so that will point us-

   24. AHAndrew Huberman34:06

       Negatively.

   25. RMRena Malik34:06

       Negatively.

   26. AHAndrew Huberman34:06

       Yeah.

   27. RMRena Malik34:06

       Negatively. So, so that will point us to a more vascular issue. Hormonal issues are, are very important for desire and, and, you know, as far as sexual function in terms of erections, there's only 3% of erectile dysfunction that's related to hormones. So it's actually more-

   28. AHAndrew Huberman34:23

       But that's pure erect- uh, rectal function.

   29. RMRena Malik34:25

       Correct.

   30. AHAndrew Huberman34:25

       As opposed to desire.
8. 36:10 – 37:07

   Sponsor: AG1

   1. RMRena Malik36:10

   2. AHAndrew Huberman36:10

      Mm-hmm. As many of you know, I've been taking AG1 daily since 2012, so I'm delighted that they're sponsoring the podcast.AG1 is a vitamin mineral probiotic drink that's designed to meet all of your foundational nutrition needs. Now, of course, I try to get enough servings of vitamins and minerals through whole food sources that include vegetables and fruits every day, but oftentimes, I simply can't get enough servings. But with AG1, I'm sure to get enough vitamins and minerals and the probiotics that I need, and it also contains adaptogens to help buffer stress. Simply put, I always feel better when I take AG1. I have more focus and energy, and I sleep better, and it also happens to taste great. For all these reasons, whenever I'm asked, "If you could take just one supplement, what would it be?" I answer, "AG1." If you'd like to try AG1, go to drinkag1.com/huberman to claim a special offer. They'll give you five free travel packs plus a year supply of vitamin D3K2. Again, that's drinkag1.com/huberman.

9. 37:07 – 40:15

   Pelvic Floor: Medical Professionals & Physical Therapy

   1. AHAndrew Huberman37:07

      Gosh, lots there to unpack, um, and I'm glad you mentioned th- the relationship itself, because, um, there are all sorts of things that can impact the arousal response. Um, novelty. Not everyone's in a committed relationship. Um, whether or not people are engaging in a lot of masturbation to the point of ejaculation or climax or not, um, pornography, et cetera, we- we will get into that. (laughs) It's a, it's a vast space to explore. Before we go any further, I want to make sure, however, that we cue people to... where and how they could find a really good, let's say, pelvic floor, uh, therapist, um, and where they could find a really great urologist to do the sorts of exams and perhaps the sorts of treatments that we've talked about. Because, um, at least as far as I understand, much of what people want to learn on this podcast is how things work and what happens when things break down, but also how to resolve those issues. So, let's say somebody wants to, um, check out their pelvic floor, figure out what's going on there. Maybe they're having issues, maybe they're not. Th- if they are male or female, where do they go? What- oh, is there a place online that has a great list of th- of some of the best ones in one's area? Can it be done over telemedicine? Um, you know, how, how does one go about that?

   2. RMRena Malik38:24

      Yeah, so in terms of your pelvic floor, it's good to get assessed by a physician who specializes in pelvic floor. Now, that could be a urologist, that could be a gynecologist, or even a physical medicine rehabilitation doctor that specializes in pelvic floor health. So typically, you'll see, um, in urology, you'll look for people who are board certified in female pelvic medicine and reconstructive surgery if you're a woman. If you're a man, maybe sexual medicine, f- uh, someone who specializes in sexual medicine would be a good place to look. For a gynecologist, again, you want to look at someone who has interest in this area, who ha- you know, does manage pelvic floor. And then, in terms of pelvic floor, uh, physical medicine rehabilitation, at least when I was in training, there was about 20 PM&R doctors around the country who really focused on this. So it's not a lot of people. If you can go to a pelvic floor physical therapist, and you have one near you, that's great as well. You, um, you do want to make sure that, one, they do, are certified in pelvic floor physical therapy and that they have taken care of your gender. So if you have male anatomy, then you want to go to someone who's actually seen men, because a lot of the pelvic floor physical therapists tend to treat a lot of women. And so that's kind of what I tell my patients, generally speaking. There's no, at least to my knowledge, no great resource, and maybe we'll, we'll look that up and see if we can find one.

   3. AHAndrew Huberman39:40

      That's very helpful. Thank you. Um, because again, going back to what I said at the beginning of our conversation, I think there's a lot of, you know, shame or at least a lack of clarity as to how one gets help for issues that, uh, relate to the genitals, right? (laughs) Because if you have a headache or you're having an eye issue, I mean, you sort of know where to go.

   4. RMRena Malik39:58

      Yeah.

   5. AHAndrew Huberman39:58

      Um, hopefully your headache doesn't warrant going to a neurologist, but it might. Um, you know, eye stuff tends to be ophthalmologist/optometrist, right?

   6. RMRena Malik40:07

      Yeah.

   7. AHAndrew Huberman40:07

      Um, so I don't think we hear often enough about where to access the best quality care for these things. So, thank you for that.

10. 40:15 – 43:13

    Sexual Dysfunction, Erectile Dysfunction, Orgasm Difficulty

    1. AHAndrew Huberman40:15

       In thinking about sexual dysfunction, I'd like to have that conversation more or less in parallel, if we can, around male sexual dysfunction and female sexual dysfunction, and I want to make sure that before we do that, that I'm creating the correct parallel construction, as they say. (laughs) Erectile dysfunction in males is clearly a form of sexual dysfunction. What is the parallel to erectile dysfunction in females? Is it lack of vaginal lubrication and lack of relaxation of the vagina to have non-painful intercourse? I mean, is there a, is it even possible to have a parallel conversation about these two things?

    2. RMRena Malik40:50

       So, it's different. I- in, in some circumstances, they're, they're ho- homologues, right? So the penis is the homologue of the clitoris.

    3. AHAndrew Huberman40:58

       Right.

    4. RMRena Malik40:58

       So the clitoris is the, I, you know, essentially the same sort of spongy erectile tissue that you see in the penis. It gets erect with-

    5. AHAndrew Huberman41:05

       Mm-hmm.

    6. RMRena Malik41:06

       ... arousal, and it is, it actually extends very deep into the pelvis. So it's not just a small little organ. It's actually quite long. And so you can, in men, you can have erectile dysfunction 'cause you can see it. But in women, you may have difficulty with orgasm. And it's, uh, not exactly a parallel, but difficulty orgasming in women is multifactorial, and we'll, we can get into that. But I think they are, they're, they're different, and I think also sexual dysfunction presents differently in both genders. So when you talk about men, they're very... Th- the one visual they see of arousal is erections. And so it becomes very ingrained in your psyche that, "If I don't have an erection, I'm not aroused," right? But there's a lot of reasons that you might not have an erection that we've sort of touched on, vascular problems, hormonal problems, neurologic problems, um, psychogenic issues, and other medications you're taking. So there are issues that can affect erectile function. Um, and, and so that can be a part of it, where, you know, you might feel like you have low desire because your arousal's not there, and that becomes a little bit confusing. For women, what they can assess is their level of lubrication, if sex hurts, and if they get an orgasm.

    7. AHAndrew Huberman42:17

       Mm-hmm.

    8. RMRena Malik42:17

       And so those are kind of the ways you can look at it.

    9. AHAndrew Huberman42:20

       Thank you for flushing all of that out. You know, years ago, I worked on sexual differentiation and in particular the role of hormones in sexual differentiation, and indeed as you described, we learned because we were taught, and I think, um, people still generally agree that if one looks at the embryological origins of the penis and the clitoris, they are essentially analogous structures-

    10. RMRena Malik42:40

        Mm-hmm.

    11. AHAndrew Huberman42:40

        ... um, and that a lot of male genital development involves literally the regression, the disappearance of the female sexual genitalia and associated organs, Müllerian ducts and things like that, and what would become the ovaries become the testes, et cetera, et cetera. Those are anatomical parallels, but what you just described for us, uh, very beautifully is the sort of functional parallels as it relates to sexual function and dysfunction. So I'm hoping with that framing that we can, uh, that we can, uh, knock down a few of these pins, uh, in a little less time, um, because there's a lot to tackle

11. 43:13 – 52:20

    Desire & Arousal Issues; Erectile Dysfunction, Viagra, Cialis (Tadalafil)

    1. AHAndrew Huberman43:13

       here. First off, I'd like to address the hormonal issues. You mentioned that only 3% of erectile dysfunction, and by extension can we say also, um, female, uh, issues with sexual arousal are hormonal in origin. Is that right?

    2. RMRena Malik43:29

       So with desire, yes.

    3. AHAndrew Huberman43:31

       Okay.

    4. RMRena Malik43:31

       They are hormonal in, in general, and arousal i- in terms of lubrication, if you're using that as a, as a barometer, yes, you can see less vaginal lubrication due to hormones. And I guess I'd say 3% to 6% more, you know, up to 6% we see of erectile dysfunction is hormonal. It's a small percentage of the entire- entirety of erectile dysfunction.

    5. AHAndrew Huberman43:51

       Okay, so I think in looking on the landscape of social media and podcasts and, and just in the common, um, mindset, we've all come to believe that testosterone is pro-libido, it's pro-desire in men and women. I think now people are starting to appreciate that it's pro-desire in women as well, um, but certainly in men, and that dopamine is also associated with desire, and the general public tends to have this view of estrogen as being sort of anti-libido or anti-male, which is frankly false. In fact, uh, and I've covered this on the podcast with Dr. Kyle Gillett and with Dr. Peter Attia and, um, another fellow, uh, YouTuber, uh, Derek from More Plates More Dates has talked a lot about the fact that if people... if men, excuse me, take drugs like anastrozole to suppress their estrogen thinking that, "Oh, it's all about having high testosterone, low estrogen," oftentimes they crush their libido.

    6. RMRena Malik44:46

       Yeah.

    7. AHAndrew Huberman44:46

       Just abolish it-

    8. RMRena Malik44:47

       Yeah.

    9. AHAndrew Huberman44:48

       ... which, um, has led to a, a slowly growing, but, um, I think positive shift in how people are thinking about estrogen. Estrogen is great for brain function. Estrogen is great for libido in men and women.

    10. RMRena Malik44:59

        Correct.

    11. AHAndrew Huberman45:00

        Um, and that is a revision of I th- I think how most people think of the male sexual response. It's more in keeping with how people think about the female sexual response. "Oh, estrogen and the female sexual response, that, that makes sense." But what we're trying to do here is clarify some of the, um, misconceptions. Now, the reason I mentioned dopamine is that my understanding is that dopamine is involved in the arral- excuse me, the desire response. We will distinguish desire, the psychological arousal from genital arousal, physical arousal, and that prolactin is associated with the refractory period during which erection can't occur and other, perhaps orgasm can't occur in females, et cetera, but my understanding is that's also not that simple, and we need to take a step back perhaps and just talk about the physiological underpinnings of the desire and, and arousal response. So I'll tell you what I was taught and then you can tell me where it's wrong.

    12. RMRena Malik45:52

        Sure.

    13. AHAndrew Huberman45:52

        I hope. I was taught that the erection response and the vaginal lubrication response is generated by the parasympathetic nervous system, the relaxed, the rest and digest aspect of the nervous system. Hence why some people can get psychogenic sexual issues of lack of erection or lack of vaginal lubrication, but that there are individuals out there for whom a lot of alertness, maybe even, and this is a controversial thing, but for some people, even some sense of aggression or kind of edginess or excitement, adrenaline in other words, can stimulate erection or vaginal lubrication. So it gets tricky, I w- it's not like the textbooks, it's not like they taught us in high school as far as I know. I was taught that the arousal response in males and females is initiated by a parasympathetic sort of relaxed tone, and that as sexual desire and arousal and s- sex or masturbation progresses, that it shifts more towards the sympathetic nervous system, which has nothing to do with emotional sympathy and has everything to do with arousal, that catecholamines, dopamine, norepinephrine and epinephrine also called adrenaline and noradrenaline are released, and that the climax response, which may or may not include ejaculation, we have to separate that out, is one that is really of the stress system of the body, and then in the post-coital or post-ejaculatory or post-climax phase, then there's a shift back to the parasympathetic nervous system.

    14. RMRena Malik47:24

        Mm-hmm.

    15. AHAndrew Huberman47:25

        Um, that's where, um, the, uh, pillow talk and the, uh, the exchange of, uh, odors and tastes and other molecules is known to enhance pair bonding through things like oxytocin, vasopressin and so on.

    16. RMRena Malik47:36

        Mm-hmm.

    17. AHAndrew Huberman47:37

        And what I just described is exceedingly oversimplified, I realize, but is that more or less how the physiology works?

    18. RMRena Malik47:45

        Yeah, so the way we're taught in medical school is point and shoot. So point is the parasympathetic-

    19. AHAndrew Huberman47:51

        I love it.

    20. RMRena Malik47:51

        ... nervous system.

    21. AHAndrew Huberman47:52

        All your... all the male audience-

    22. RMRena Malik47:53

        (laughs)

    23. AHAndrew Huberman47:53

        ... will like that one, you know?

    24. RMRena Malik47:54

        And then, you know, you go on to the sympathetic nervous system, but it makes sense. And the reason that I think you're hearing about this aggression or, or these things that are leading to arousal is because there needs to be a stimulus, right? A visual stimulus, a tactile stimulus, some sort of stimulus that you're getting that is then causing the release of nitric oxide from the parasympathetic nervous system, and that could be for some people aggression or, or, you know, some form of that, right? Some form of-

    25. AHAndrew Huberman48:21

        Could you tell people about nitric oxide because we'll get into this when we talk about, um, drugs that increase blood flow.

    26. RMRena Malik48:26

        Mm-hmm.

    27. AHAndrew Huberman48:27

        Uh, Cialis, Viagra, and also, um, non-prescription drugs, things like, uh, L-citrulline-

    28. RMRena Malik48:32

        Mm-hmm.

    29. AHAndrew Huberman48:33

        ... arginine, and, um, watermelon for that matter, right?

    30. RMRena Malik48:36

        (laughs)
12. 52:20 – 54:09

    L-Citrulline, Supplements

    1. RMRena Malik52:20

    2. AHAndrew Huberman52:20

       And what about L-citrulline? I hear about L-citrulline use. It's an over-the-counter supplement, um, and it's in the arginine pathway.

    3. RMRena Malik52:28

       Mm-hmm.

    4. AHAndrew Huberman52:28

       And, uh, my understanding is that it works similarly to things like, uh, Cialis, Viagra, but is perhaps not as potent. I also just... Uh, a cautionary note out there, L-citrulline can give people vicious cold sores and canker sores. Vicious. Uh, you hear about this on the internet.

    5. RMRena Malik52:45

       (laughs)

    6. AHAndrew Huberman52:45

       It's been verified by grotesque images that you do not want to Google for. Um, and not everyone tolerates it well.

    7. RMRena Malik52:53

       So these actually work by increasing nitric oxide. So they're not in this... They're not later down the pathway. They're actually increasing the availability of nitric oxide. So L-arginine is the more direct pathway, but it's very low bioavailability. L-citrulline converts to L-arginine, but it is... It lasts much longer in the bloodstream, which is why people tend to use L-citrulline. Now, you know, in, in sexual medicine, these supplements, while there's been some studies on them and they are effective, there's no regulation on the supplement industry. So, you know, we can recommend them, but we just can't say that for sure that the supplement is exactly what's said, uh, on the bottle. We see lots of studies where they'll say... You know, I read one about melatonin, and there's, you know, a variation of melatonin from like what's on the bottle to 400% times more. And so that's kind of the struggle that we as medical doctors have, and I know we get a lot of slack for it, that we don't talk about supplements, but it's really... The challenge there is, like, finding the quality supplements.

    8. AHAndrew Huberman53:47

       A great site is... Uh, which I have no, uh, relationship to, uh, except that I mention them all the time, um, is examine.com-

    9. RMRena Malik53:55

       Mm-hmm.

    10. AHAndrew Huberman53:56

        ... um, which, uh, has references to human studies and where there's a lot of efficacy shown, and-

    11. RMRena Malik54:02

        Right.

    12. AHAndrew Huberman54:02

        ... we'll get into some side effect issues. Does... Can't address br- um, you know, quality by brand issues, but, um, thanks for mentioning that. What

13. 54:09 – 58:58

    Erectile Dysfunction & Cialis; Prostate Health; Females

    1. AHAndrew Huberman54:09

       percentage of males who take Cialis, um, t- AKA Tadalafil or Viagra for erectile dysfunction get, um, relief?... from that. Um, because you mentioned only three percent of erectile issues in males are hormonal i- in origin. Um, but what percentage are likely to be blood flow related in origin?

    2. RMRena Malik54:33

       So, a l- large percentage are blood flow related. That doesn't mean that the medication will be effective for everyone. If you look at the large percentage are, are vascular in nature, right? That's the number one cause in, in as men age. So we know that about 50% of 52% of men over the age of 40 will have erectile dysfunction and that continues to increase as you age. So, um, 50% of 50-year-olds, 60% of 60-year-olds, and so on and so forth. So it's very, very common and the success rate in the studies is about 60 to 70%. So when you give someone medication, they will have sustained erections that are sufficient for penetrative intercourse which is the way we kind of discuss erectile dysfunction in studies and in, you know, with patients is, is about 60 to 70%. So not everyone will have success, but not all of that is because the medication doesn't work. Um, sometimes people are not taking them correctly, sometimes people need to try different doses, and then there's still this issue of, you know, your brain is still active and so if you're having anxiety or having other issues or stress in your life, that can have an effect on your ability to create an erection, so there's lots of factors that go into it. Um, but generally speaking, they are effective and they do work quite well and they're tolerated pretty well. Uh, so-

    3. AHAndrew Huberman55:46

       And 60 to 70% is not a small number.

    4. RMRena Malik55:48

       Yeah.

    5. AHAndrew Huberman55:48

       That's a, that's a significant number. That's the majority, uh-

    6. RMRena Malik55:51

       Yeah.

    7. AHAndrew Huberman55:51

       ... by a-

    8. RMRena Malik55:52

       Right.

    9. AHAndrew Huberman55:52

       ... by a significant margin. Is there a basis for the use of, um, Cialis, uh, tadalafil, Viagra, um, L-citrulline, um, in females?

    10. RMRena Malik56:03

        So yeah, there- there's not a lot of data on this, but certainly, you know, if you have surmised that there is a blood flow issue and they're having difficulties with orgasm, it's certainly something you can try off-label and certainly people do try, uh, try these medications off-label to see if they improve sexual function for women, but there's not a whole bunch of robust, you know, randomized controlled trial studies on women with, with these medications.

    11. AHAndrew Huberman56:28

        A little bit later, we will talk about prostate health specifically, but I'm just going to, um, make a note here that, um, nowadays there's, um, increasing use of low dosage, um, Cialis/tadalafil. Um, so rather than, uh, what I found online was that the erectile dysfunction treatment dosage of Cialis/tadalafil is somewhere in the, you know, 15 to 20 milligram range. What we're talking about here is, um, daily use of, um, 2.5 to 5 milligrams of Cialis/tadalafil for prostate health, and I learned in researching for this episode that, um, tadalafil, Cialis was actually developed as a drug for the treatment of prostate health to, um, essentially increase blood flow to the prostate to increase prostate health, not for the treatment of erectile dysfunction, so I, I found that to be somewhat interesting, um, and a lot of people are now starting to use that. I also learned that, um, if you dive into the, uh, the guts of the internet, um, one can find that now there's a growing use of combined low dosage Cialis and apomorphine which is a pro-dopaminergic agent, and we'll get back to dopamine a little bit later. But, um, is there any basis for low dosage, say 2.5 to 5 milligram daily use of Cialis/tadalafil in females?

    12. RMRena Malik57:49

        Yes. So, well, let's talk about it in- for males and females. I think low dose daily Cialis is excellent for erectile function in men even if they-

    13. AHAndrew Huberman57:58

        Is that true even... Uh, sorry to interrupt.

    14. RMRena Malik57:59

        Yeah.

    15. AHAndrew Huberman57:59

        But is that true even for men that are not experiencing erectile dysfunction?

    16. RMRena Malik58:03

        It's not indicated for that purpose, but there's a thought that, you know, it's increasing blood flow to the area so people... I, I've personally used it for men who have pelvic pain to help with increasing blood flow. You can also use it, uh, potentially as a preventative, so some people have, you know, kind of thought, "Okay, it's increasing blood flow, it's preventing fibrosis of that erectile tissue that can happen with age or other vascular problems," so it may be beneficial for that as well. Although again, that's off-label and not something that we generally, um, promote. Uh, as far as for women, there's, you know, again it can help with blood flow. So if you're having issues or if you have a female who's having sexual dysfunction and she's got kinds of vascular problems like she's got, uh, diabetes, high blood pressure, she smokes, then yes, it's certainly reasonable to try and see how they do. We usually want to give at least a four-week trial to see if there's any benefit with those medications.

    17. AHAndrew Huberman58:55

        Great. Thank you for that. Um,

14. 58:58 – 1:01:37

    Erectile Dysfunction in Young Men

    1. AHAndrew Huberman58:58

       why is it that I get so many questions about erectile dysfunction from males who are in their 20s and 30s? Because everything you said up until now was mainly focused on men 40 years and older. Is it from lack of physical activity, overuse of nicotine? By the way, vaping as far as (laughs) we know, um, vaping and smoking bad for erectile function and perhaps sexual health in males and females generally because nicotine is a vasoconstrictor.

    2. RMRena Malik59:25

       Mm-hmm.

    3. AHAndrew Huberman59:26

       Nicotine does have certain benefits and I covered this in an episode on nicotine, um, neurocognitive benefits in, uh, the elderly in particular, but it is a vasoconstrictor so it runs against all of the, uh, sexual arousal stuff that we're talking about. Um, but okay, let's assume that, um, a male in their 20s or 30s is sleeping enough, you know, six to eight hours a night, is exercising, isn't doing anything to punish their pelvic floor in the gym, um, you know, and they're not doing, uh, legs crossed kegels while doing crunches or something while inhaling on the crunch.

    4. RMRena Malik59:59

       (laughs)

    5. AHAndrew Huberman59:59

       (laughs) Um, uh, that was a quiz by the way-

    6. RMRena Malik1:00:03

       (laughs)

    7. AHAndrew Huberman1:00:03

       ... folks, um, for earlier, uh, topics covered. Um, let's assume they're, you know, eating pretty well, majority of their foods are coming from n- non-processed or minimally processed foods, um, they're doing a little meditation each day, they're engaging in hopefully healthy relationships, they're not masturbating like crazy to porn and, um-... uh, you know, let's assume that they are, you know, not on any SSRI. Why are all these 20 and 30-year-olds on the internet asking mainly you-

    8. RMRena Malik1:00:34

       Mm-hmm.

    9. AHAndrew Huberman1:00:34

       ... 'cause you, this is-

    10. RMRena Malik1:00:35

        (laughs)

    11. AHAndrew Huberman1:00:35

        ... they mainly run to you. Um, but also to my direct messages about their erectile issues.

    12. RMRena Malik1:00:41

        So, I will say, I have seen a lot of young men in my clinic, and I will say that they very often have pelvic floor dysfunction. So, they, even though they're doing all the right things, they're, they do have, I mean, we're in a stressful society, so you can try all the things to be, to decrease your stress, but lot of us are sitting long periods of time, especially during COVID. I mean, people sat for months, right? Years. Like, (laughs) just sitting at their home computer. And so, um, you know, exercising one hour is not gonna offset the day full of sitting. And so all of those things can affect pelvic floor function, so my theory is that that's probably the more common cause.

    13. AHAndrew Huberman1:01:17

        So, walk more.

    14. RMRena Malik1:01:19

        Yeah.

    15. AHAndrew Huberman1:01:19

        I've actually heard that-

    16. RMRena Malik1:01:20

        Or use a standing desk.

    17. AHAndrew Huberman1:01:21

        Yeah, yeah.

    18. RMRena Malik1:01:21

        Yeah.

    19. AHAndrew Huberman1:01:21

        Yep. Yeah, walk more, standing desk. Um, wha- okay, so, um, and then my guess is that there's some psychogenic feedback loop.

    20. RMRena Malik1:01:30

        Absolutely.

    21. AHAndrew Huberman1:01:30

        Which is just nerd speak for, things aren't working as well as they would like, then they're stressing about it, and the stress is making things worse.

15. 1:01:37 – 1:07:16

    Pornography, Masturbation & Ejaculation; Healthy Sexual Behavior

    1. AHAndrew Huberman1:01:37

    2. RMRena Malik1:01:37

       Absolutely. And, you know, you mentioned that people are not masturbating or are using porn, but a lot of people learn about sex through porn. Whether it's good or bad, we can't, you know, it's not a great thing, but like, that's accessible now. When we were growing up, you had to find a VCR, you had to find a quiet room that no one was gonna walk in, like- (laughs)

    3. AHAndrew Huberman1:01:55

       Well, I'm old enough to remember when the kid down the street, I won't mention him, um, uh, by last name, but yeah, the kid down the street, you know, had porno magazines.

    4. RMRena Malik1:02:04

       Yeah, or magazines.

    5. AHAndrew Huberman1:02:05

       And then there was actually a library of these, goodness, I shouldn't say where they were, um, in the town that I grew up in, where kids would stash them in, um, in specific locations in parking lots, and then, you know, boys would bike or skateboard over or walk over, and then they would like take terms, look, take turns-

    6. RMRena Malik1:02:23

       Yeah.

    7. AHAndrew Huberman1:02:23

       ... excuse me, looking at them. But that, that actually is to raise, uh, perhaps a more important point, um, which is that looking at pornography is different than masturbating to pornography, which is also different than masturbating to pornography to the point of ejaculation, right? Because, um, I also get a lot of questions from people about their porn addiction issues.

    8. RMRena Malik1:02:45

       Mm-hmm.

    9. AHAndrew Huberman1:02:45

       And there's a growing theory out there that overuse, that meaning not just looking at, but, um, masturbating to pornography to the point of ejaculation is creating a deficit of seeking out and, um, d- cultivating healthy real world sexual interactions.

    10. RMRena Malik1:03:07

        Yeah, so I wanna, I wanna start this before I get into that is, is to say that if you're masturbating to porn and you have normal, healthy relationships and you're going to work and you're, have a great, you know, a partner and you're, everything's great in your life, it's okay. Like, shame is a real problem.

    11. AHAndrew Huberman1:03:22

        Yeah.

    12. RMRena Malik1:03:22

        And I think that-

    13. AHAndrew Huberman1:03:22

        And maybe they're watching pornography together.

    14. RMRena Malik1:03:24

        Yeah, so I think, you know, I think it's important though that w- at least in the literature, they describe, they don't describe porn addiction. They call it por- problematic pornography use, and it's only described in about 4% of people in these studies. So, it's, it's a small subset of people. I think it's becoming more common because pornography is so accessible, and it, it activates the dopamine pathways just like any other sort of addiction, where you, you watch pornography, you get a dopamine response, your brain then says, "Oh, I want s- I want that again." And you keep seeking more novel, more aggressive, different types of pornography to get that same response, but it doesn't happen to everybody. And so-

    15. AHAndrew Huberman1:04:02

        But also, I would say, um, i- sorry to interrupt, but, um, that the dopamine response as a, as a hardwired biological mechanism, um, for adaptive behaviors including ... and let's just define healthy sexual behavior, because I feel like, um, there's such a range on that depending on one's background, religious beliefs-

    16. RMRena Malik1:04:21

        Mm-hmm.

    17. AHAndrew Huberman1:04:21

        ... et cetera.

    18. RMRena Malik1:04:22

        Right.

    19. AHAndrew Huberman1:04:22

        Um, any time we talk about sex on this podcast, I like to say that involves at least four things. Obviously consensual, age appropriate, context appropriate, species appropriate.

    20. RMRena Malik1:04:36

        (laughs) Yes. Absolutely. Absolutely. That, and thank, really glad you brought that up. So, I've heard you say that before, but it's very important. And so, I think, you know, there is a spectrum, a, a large spectrum of people who watch pornography, ejaculate to pornography, and have a normal life. And so that's fine. I think that, you know, if we shame those people, we're creating problems, right? We say like, "Oh, you, you do that. That's horrible." And then they're in their head, right? And then they're causing problems in their life because they're, because of shame. And so there's, I, I think there's a little bit of, um, cultural shame that comes of this discussion, and so, you know, it's a problem in the long term if we, if we say that, "Oh, this is gonna create problems," 'cause not everyone has, there's so many people who watch pornography and have no problems. Who, you know, have normal, healthy relationships, great sex with their partner, and it's fine. Or they watch porn-

    21. AHAndrew Huberman1:05:21

        Or they're between, or they're between relationships.

    22. RMRena Malik1:05:23

        Yeah.

    23. AHAndrew Huberman1:05:23

        And they're relying on masturbation specifically.

    24. RMRena Malik1:05:25

        Right.

    25. AHAndrew Huberman1:05:26

        Um, are there any data that distinguish between, um, just pure imagination fantasy versus visual fantasy, um, as it relates to developing or inhibiting sexual health? And here we're talking about the desire aspect. Let's assume physical arousal is, you know, handled.

    26. RMRena Malik1:05:44

        So, I think-

    27. AHAndrew Huberman1:05:44

        No pun intended.

    28. RMRena Malik1:05:45

        (laughs) So, I think that, um, the, the, the thing about young people w- w- I wanted to get back to that, then w- I'll answer your question, but the thing about young people who are watching pornography, that's what they think sex is supposed to be like. They don't get an education about what sex is, right? No one has a conversation with their kids like, "Hey guys, this is what happens when you have sex. This is how long it should take. This is what foreplay is." And this is like not normal. This is a production. This is a produced product that's meant to arouse you, right? And, and to give you, uh, ideally an ejaculation or an orgasm, right? So, um, no one has that discussion, so then go to relationships like, "Why did my partner not react like that woman did on the porno?" Right? Or, "Why did I not react like that woman did on the porno," right?

    29. AHAndrew Huberman1:06:31

        Or "Why didn't he react-"

    30. RMRena Malik1:06:33

        Yeah.
16. 1:07:16 – 1:08:22

    Sponsor: InsideTracker

    1. RMRena Malik1:07:16

    2. AHAndrew Huberman1:07:16

       I'd like to take a quick break and acknowledge our sponsor, InsideTracker. InsideTracker is a personalized nutrition platform that analyzes data from your blood and DNA to help you better understand your body and help you meet your health goals. I'm a big believer in getting regular blood work done for the simple reason that many of the factors that impact your immediate and long-term health can only be analyzed from a quality blood test. However, with a lot of blood tests out there, you get information back about blood lipids, about hormones, and so on, but you don't know what to do with that information. With InsideTracker, they have a personalized platform that makes it very easy to understand your data, that is, to understand what those lipids, what those hormone levels, et cetera mean, and behavioral supplement nutrition and other protocols to adjust those numbers to bring them into the ranges that are ideal for your immediate and long-term health. InsideTracker's Ultimate Plan now includes measures of both ApoB and of insulin, which are key indicators of cardiovascular health and energy regulation. If you'd like to try InsideTracker, you can visit insidetracker.com/huberman to get 20% off any of InsideTracker's plans. Again, that's insidetracker.com/huberman to get 20% off.

17. 1:08:22 – 1:12:57

    Arousal Habituation, Masturbation, Addiction

    1. AHAndrew Huberman1:08:22

       I asked whether or not imagined, you know, pure imagination based arousal versus, um, visual arousal, um, and for some people, the sounds of, of people having sex is extremely arousing.

    2. RMRena Malik1:08:35

       Mm-hmm. Mm-hmm.

    3. AHAndrew Huberman1:08:35

       If you've ever lived in a major city, um, like New York, (laughs) which I spent summers in New York, you hear a lot, you hear more, more often than you do in, um, areas where people are living further apart, you hear people having sex.

    4. RMRena Malik1:08:47

       Yeah.

    5. AHAndrew Huberman1:08:48

       It's pa- it's part of the, um, part of the auditory landscape.

    6. RMRena Malik1:08:52

       Yep, you're very close together. So, (laughs) um, but yeah, so there's not exactly, at least to my knowledge, I don't know of the data that looks at fantasy versus visual versus auditory, but I will say that you can get habituated to certain things, and there is that data that maybe you can get habituated to watching a certain type of thing to get aroused, and then normal things do not get you aroused, right? Like, you may watch pornography, and then you may have difficulty getting aroused or turned on when you see your partner. Uh, you may get used to masturbating a certain way, right? So if you use certain vibratory stimulation or certain pressure sensation every single time you masturbate, you can get habituated to that, and you might not be able to replicate that during penetrative intercourse. Um, and so I think that's really important, and I think the take home is to try and vary what you're doing. Masturbation is fine, healthy way of self-exploration, again, with the caveat that as long as you're not masturbating to excess and avoiding your obligations or your family or your partners or your friends, right, like, you are just masturbating for the, the benefits of maybe sleep improvement, mood boosting, reduction in anxiety, those, those, those things are great. And so I think, um, with that being said, you just want to be thoughtful about varying it up.

    7. AHAndrew Huberman1:10:07

       One of the issues with masturbation that I've talked about when I was a guest on other podcasts, um, mainly in the context of male masturbation, and, um, perhaps with pornography, perhaps not, is that it's pretty clear based on the data surrounding addiction that anytime there are big increases in dopamine without a lot of effort required to generate that dopamine, like turning on pornography on the internet versus, you know, asking someone out on a date, going out on a date, you know? Again, we're talking about going through the conversations and the mating ritual that is the human mating ritual that, of course, in the context of healthy interactions involves getting mutual consent and these kinds of things, right? That you could imagine how wi- without placing any moral judgment on it, without shaming anybody, you could imagine that if somebody exclusively masturbated and didn't develop the skills of courtship and building healthy sexual relationships, that pornography and/or masturbation could start to create, quote unquote, "problems," right, whereby somebody only felt comfortable in those domains.

    8. RMRena Malik1:11:18

       Yeah.

    9. AHAndrew Huberman1:11:18

       And, and I think that's what I'm hearing more and more about when it seems to be young men reach out.

    10. RMRena Malik1:11:25

        Absolutely, and I think you're, you know, it's definitely the ease of access, right? But I think that's pervasive in the young society now. Like, you don't have to actually go and find a mate. You can just go on an app and look for somebody, right? Like, there's, there's many-

    11. AHAndrew Huberman1:11:39

        Well, that's a form of finding a mate.

    12. RMRena Malik1:11:40

        (laughs)

    13. AHAndrew Huberman1:11:40

        I mean, I, I was weaned in the era when, uh, you know, no smartphones or anything.

    14. RMRena Malik1:11:45

        (laughs)

    15. AHAndrew Huberman1:11:45

        And, um...

    16. RMRena Malik1:11:46

        No, my, my point is I think that we've become very, um, connected to technology in our world, which also means that we're having less conversations. The younger generation is having less conversations and more online conversations, and I think that's a skill that needs to be developed as well, and I think part of that is, is contributing to all this as well.

    17. AHAndrew Huberman1:12:04

        Mm-hmm. Well, one thing that I can attest to is that, you know, I grew up in a community of mostly male friends, I have female friends, always have, um, where a lot of what we learned about sex came from older, my case, guys.

    18. RMRena Malik1:12:16

        Mm-hmm.

    19. AHAndrew Huberman1:12:16

        My sister probably learned a lot about sex from her female friends. Um, and there was always that one guy who would just say stuff that years later I realized was incredibly misleading.

    20. RMRena Malik1:12:28

        (laughs)

    21. AHAndrew Huberman1:12:28

        Right? Maybe even just detrimental.

    22. RMRena Malik1:12:30

        Yeah.

    23. AHAndrew Huberman1:12:31

        And I just want to remind people that when you are on Reddit or anywhere on the internet, and there's...... people saying things with certainty. Um, they might be that guy.

    24. RMRena Malik1:12:41

        Yeah.

    25. AHAndrew Huberman1:12:41

        Right?

    26. RMRena Malik1:12:41

        Absolutely.

    27. AHAndrew Huberman1:12:42

        And, um, and if you look at the lo- if I look at the long arc of those people, that guy's life, it, it didn't speak to, um, tremendous success in the domain for which they were asserting such confidence.

    28. RMRena Malik1:12:55

        Yes.

    29. AHAndrew Huberman1:12:55

        Let me put it that way.

18. 1:12:57 – 1:17:22

    Female Arousal Response, Orgasm, Coolidge Effect

    1. AHAndrew Huberman1:12:57

       Okay, um, I'd like to slightly pivot to a different aspect of this conversation, because it's just really critical, which is the female sexual response. You know, this is something that, um, does not get enough discussion.

    2. RMRena Malik1:13:13

       Absolutely.

    3. AHAndrew Huberman1:13:14

       And there's a, a lot of stereotypes, right? The stereotype that we hear about is, "Oh, you know, they need more foreplay," which can be true.

    4. RMRena Malik1:13:23

       Mm-hmm.

    5. AHAndrew Huberman1:13:24

       Some cases, is not true. Um, the stereotype is that women are more, um, intimacy and relationship based in their sexual response. That can be true. I have female friends and have known women who also are just really interested in having sex for sex' sake-

    6. RMRena Malik1:13:42

       Mm-hmm.

    7. AHAndrew Huberman1:13:43

       ... at times.

    8. RMRena Malik1:13:43

       Yep.

    9. AHAndrew Huberman1:13:44

       Or maybe all the time. Um, I think ... I like to think that we are past the stage of human development where the stereotypes around this are, um, are fixed, right?

    10. RMRena Malik1:13:56

        Yeah.

    11. AHAndrew Huberman1:13:57

        And I ... And e- and we hear more about this and we see more about this now, but what is the real deal around the female arousal response? And then we will talk about female orgasm response. And there, I'm just going to earmark now that, um, anytime we say something like arousal or orgasm, there are multiple forms of that, right? Um, and we will talk about the multiple forms of female orgasm.

    12. RMRena Malik1:14:23

        Yeah, so if you talk about the response cycle, you can go back to the research of Masters and Johnson. And so, what they did, this was way back when, and they actually watched sex workers have sex, and this was, I guess, okay back then.

    13. AHAndrew Huberman1:14:36

        Female sex workers.

    14. RMRena Malik1:14:37

        Yeah, with men.

    15. AHAndrew Huberman1:14:38

        Yeah. Yeah.

    16. RMRena Malik1:14:38

        Yeah, so they, they watched and t- they took note of the, the cy- the kind of the steps of the female arousal or sexual response. And so the first phase is excitement, right? And during that phase, your heart rate goes up, you're breathing a little heavier. There's this sex flush. You can see redness in areas like y- you know, in the vulva, in the breast, eh, I mean, in the nipples, and then you go to sort- and that can last e- a variety of different times. You'll also start seeing some lubrication vaginally, right? And then the plateau response is when, you know, that is kind of at its peak and it kind of stays steady, and then you reach orgasm. And so orgasm essentially is a response of the body where you will have, again, increased sympathetic response and you will have pelvic floor muscle contractions, which are rhythmic, about 0.8 seconds or so, you're having a rhythmic pelvic floor contraction along with the sensation of orgasm. And then you'll have your recovery period, which you talked about briefly earlier, which can have, you know, sort of a refractory time period at which point you can no longer, you know, orgasm again, if you'd like to, or for men, e- to obtain another erection again for a short period of time. And that can be kind of an absolute refractory period, so where it's definitely not happening, and then a relative refractory period where you need something more novel and exciting to then, again, resume that cycle again.

    17. AHAndrew Huberman1:15:58

        The Coolidge effect.

    18. RMRena Malik1:15:59

        Yeah. (laughs)

    19. AHAndrew Huberman1:15:59

        We will talk ... I've talked about the Coolidge effect before on this podcast. I'll just cue people to it. A, a timestamp link in the show note caption so we don't go the, down the path, but one thing that's really important to understand is that the Coolidge effect is present in both males and females. Meaning if a male ejaculates and, um, is of the feeling that they can't have another erection for some period of time, the presentation of a novel w- I guess we should say partner, because we could be talking about homosexual relationship here, and not just heterosexual, but, um, a novel sexual partner, female or male, depending on their, um, their proclivities, um, can override the refractory period, um, and they can have another erection and ejaculation. Um, similarly, a female will have a post-orgasmic refractory period if they're, um, given an adequate stimulus (laughs) , right? Uh, something arousing enough, they can, um, e- experience arousal and orgasm again. And we know, based on really good pharmacology, that this is a, uh, dopamine-driven, um, thing. The prolactin is essentially establishing the refractory period, and the dopamine is essentially overriding the refractory period. Fascinating neurochemistry there, um, and speaks to the incredible extent to which the brain is controlling the genitals.

    20. RMRena Malik1:17:14

        Yeah.

    21. AHAndrew Huberman1:17:14

        Um ...

    22. RMRena Malik1:17:14

        I mean, we, we always say in sexual medicine that the brain is the most powerful organ for sex. Not, not your genitals, but the brain, because it is so powerful,

19. 1:17:22 – 1:22:25

    Priapism, Melanocyte Stimulating Hormone; Women & Low Libido Medications

    1. RMRena Malik1:17:22

       and I'm not sure if we're going to touch on this later, but I'll bring it up now. There are some centrally acting medications now available for, uh, they're FDA approved for premenopausal women with low libido.

    2. AHAndrew Huberman1:17:32

       Oh, but maybe just throw those out, because the one that I'm aware of, um, is, uh, in, that's often used in, let's say niche cultures, um, is melanocyte-stimulating hormone in men-

    3. RMRena Malik1:17:43

       Mm-hmm.

    4. AHAndrew Huberman1:17:43

       ... um, which gives people a tan-

    5. RMRena Malik1:17:44

       Mm-hmm.

    6. AHAndrew Huberman1:17:44

       ... makes them erect. Um, that melanocyte-stimulating hormone, that MSH, comes from the medial pituitary, if I'm not mistaken. Um, one of those w- weird regions.

    7. RMRena Malik1:17:53

       (laughs) Yeah.

    8. AHAndrew Huberman1:17:53

       No, everyone talks about anterior posterior. Uh, but ... And people are now injecting this as a peptide.

    9. RMRena Malik1:17:59

       Mm-hmm.

    10. AHAndrew Huberman1:17:59

        It can cause priapism. I have not had that experience. I've never tried this, um, MSH, but I'm told that it, it ... People are getting cavalier with it. They can, um, have issues, uh, priapism being enduring and perhaps even final.... erection. Is that true? Is that pre-

    11. RMRena Malik1:18:14

        So, uh, priapism-

    12. AHAndrew Huberman1:18:16

        Priapism. Sorry.

    13. RMRena Malik1:18:17

        ... or priapism, I mean, it's actually from Priapus, the Greek god who was often ph- photographed with a really big erection. Um, it's where it came from. (laughs)

    14. AHAndrew Huberman1:18:23

        Oh, wow. We didn't hear enough about that Greek god in school. Um, priapism.

    15. RMRena Malik1:18:26

        (laughs) But, um... Or is it Roman? Roman or Greek. But anyways, so-

    16. AHAndrew Huberman1:18:29

        Either way.

    17. RMRena Malik1:18:29

        ... um, it's an erection that lasts longer than four hours, and it is actually a surgical... Or it's, uh, not a surgical, but it's an, actually an emergency. If you have an erection that lasts longer than four hours in the absence of, you know, sexual arousal, then it is important to get to an emergency room, because at that point, you can, you can start developing decreased blood flow and ultimately n- changes to the actual tissues, scarring, fibrosis. Uh, so it's really important to actually go to the em- emergency room. Don't wait 'cause you're embarrassed. Um, really get there and get treated.

Episode duration: 2:54:29