Dr. Mohit Khera on Why Sexual Health Is a Team Effort for Couples

Hey y'all, it's me, Dr. Sminer, my gyno girl. Excited today for another episode of Gyno Girl Presents, Sex, Drugs and Hormones. I have a very special guest today. don't...

Mohit Khera (: 00:25

Thank

Mohit Khera (: 00:36

Nice.

Dr Sameena Rahman (: 00:47

I don't often have urologists on the show, even though I love them all. Actually, that's not true. had Dr. Goldstein on recently. But I'm excited to have Dr. Milhera here today from Baylor. You guys heard my intro. He's an amazing urologist, a sex med specialist. Like I said, he's the president, or outgoing president of SMSNA, so the sexual medicine side of North America. Welcome, Mo. Thank you for being on my show.

Mohit Khera (: 01:14

Thank you. Thank you for having me on the show.

Dr Sameena Rahman (: 01:16

You know, we were just talking before starting the recording about all the stuff that we need to talk about, but I'm glad I got to finally meet you at SMSNA, even though it was just like for 10 seconds. We missed each other at the World Sexual Medicine Society meeting, which I actually was hoping to run into you in Brazil, but I think we missed each other. But let's talk a little bit about, well, first I want to bring up this idea that, you know,

Mohit Khera (: 01:27

Thank you.

Dr Sameena Rahman (: 01:43

When you think about female sexual medicine, it was actually like a urologist who really made the field flourish. And so I think, I'm a gynecologist, I was trained by other gynecologists and under a patriarchal system, because I think that traditionally you would think that we would know how to treat women's sexual health and none of us did until really the urologist spoke up and said, why aren't you guys treating women's sexual health? Can you tell us like,

What is the difference in approach? Like it seems like to me that the approach is like really different when it comes to how we, you know, treat men and women when it comes to their sexual health, how we offer hormones to men and women when it comes to their sexual health. You know, there's all these underlying themes of like protecting women, we're like, you treat both. So tell me a little bit about breathing.

Mohit Khera (: 02:33

Yeah, so first of thank you once again for having me on the show. I think there's a significant amount of disparities between the research we have in men and women. It is what it is. If you look at the testosterone research, the research in female sexual dysfunction that we have compared to the research in ED, it's night and day. And I tell people this all the time, sexual dysfunction is a couple's disease, right? And so I tell this story quite often. When I finished my residency,

Dr Sameena Rahman (: 02:42

Sure.

Dr Sameena Rahman (: 02:49

Totally.

Mohit Khera (: 03:00

I was so proud of myself. was able to get these men these great erections, these great libidos, and go home and they said, I have no one to have sex with, my wife and I haven't had sex in 10 years. And now they started fighting and he caused conflict at home. And one woman called me one day and she said, look, know, everything was great until he met you. We had the best relationship. We had the best relationship. But now he sex all the time. I don't want to have sex with him. And you can solve the problem. And first I thought to myself, that doesn't make any sense. But she was right. You know, it's okay.

Dr Sameena Rahman (: 03:04

Right.

Dr Sameena Rahman (: 03:22

Yes. Yeah. Yeah.

Mohit Khera (: 03:29

Samina to leave both libido's low. That's fine. It's okay to have them both high. But what you don't want is one high and one low. That's a problem. So that's I went out to Dr. Goldstein also, like you did, and started learning female sexual dysfunction. This was 16 years ago. And I treat both of them. You treat the couple. I think it is a disservice to treat one partner without even asking about the other partner's sexual relationship. What are you accomplishing? What are you really accomplishing?

Dr Sameena Rahman (: 03:35

Right. It's a disparity.

Dr Sameena Rahman (: 03:54

Absolutely. Yes.

Mohit Khera (: 03:59

Sexual dysfunction is a couples disease. look, we both know that treating men and women are slightly different. I will tell you that men typically optimize their hormones, you optimize their lifestyle modification, meaning diet, exercise, sleep, stress reduction, and you can put them on PD-5 inhibitors and they do quite well. I there's many things you can do. In women, it's more the biopsychosocial model where you have to focus a little bit more on other factors and you focus on not only libido but arousal, orgasmic dysfunction, and pain.

Dr Sameena Rahman (: 04:28

Great.

Mohit Khera (: 04:28

The difference is, between men and women, women go through menopause. And that in itself is a set up for FSD. So there's no choice. What's inevitable is that every woman will go through menopause. And at that point, her risk of FSD skyrockets, which is different than men. And so these are the nuances you have to take into account when you're treating the couple.

Dr Sameena Rahman (: 04:32

huge yes

Dr Sameena Rahman (: 04:44

Mm-hmm.

Dr Sameena Rahman (: 04:49

Absolutely. And whenever I talk to people about treating, you know, women in the midlife, I'm always like, you got to ask about the partner. Like if you're not asking who they're having sex with, then you're not doing a service to them. So I appreciate you bringing that up. Let's talk a little bit about like, what are some of the, you know, for those people listening for their partners, tell us a little bit about, you know, what are the biggest sexual dysfunctions that you find? Cause I talk a lot about female dysfunction issues here in menopause.

Mohit Khera (: 05:17

Yeah.

Dr Sameena Rahman (: 05:18

What are some of the significant dysfunctions that you find in men? Obviously, people talk about erectile dysfunction. If you want to talk about that a little bit, be great. And peronies is something I often see that my patients, spouses suffer with too. But maybe enlighten my audience a little bit about that as well.

Mohit Khera (: 05:35

So most people when they think about sexual dysfunction for men, think about erectile dysfunction. But it's not just erectile dysfunction. There's Peyronie's disease. Peyronie's disease affects 9 % of all men in the world. That's a significant number of men. What is Peyronie's disease? It's an abnormal curvature of the penis when it's erect. These men are severely depressed. Many of suffer from severe depression. It's a disfigurement. And when the curvature is greater than 60 degrees, it's prohibitive for intercourse. So that can be a big problem.

Dr Sameena Rahman (: 05:45

down.

Dr Sameena Rahman (: 05:55

Dr Sameena Rahman (06:02.229)

Sure.

Mohit Khera (: 06:04

We have only one FDA approved treatment for pronies disease, is a XyFlex injections. And then everything else is off label besides surgery. There's orgasmic disorders. 30 % of men suffer from premature ejaculation. 30 % of men. Discrepancies, the average ejaculatory time in men is 5.4 minutes in the US, 13.4 minutes in women. So there's a big discrepancy, of course. so premature ejaculation is defined as ejaculating less than two minutes.

Dr Sameena Rahman (: 06:17

future.

Dr Sameena Rahman (: 06:25

Yeah.

Dr Sameena Rahman (: 06:33

Thank

Mohit Khera (: 06:33

self-control and you have to be bothered by it. It's a big deal, 30 % of men, and there are excellent treatment options for this, but you can imagine that men who suffer from this can have a significant impact on their sexual relationships. then delayed orgasmia can be an even anorgasmia, in other words, having a long time to achieve an ejaculation. Some men can have sex but cannot ejaculate or cannot orgasm. So that's a problem as well. So there's many disorders and sexual dysfunction.

Dr Sameena Rahman (: 06:38

Thank you.

Dr Sameena Rahman (: 06:47

Sure, absolutely.

Dr Sameena Rahman (: 06:56

Mm-hmm. Right.

Mohit Khera (: 07:03

But you are correct. The most common one is erectile dysfunction. This is really important. So the stats are alarming. 40 % of men at 40 have some degree of erectile dysfunction. That's a lot of men. 50 % at 50, 60 % at 60, 70 to 70, 100%. If live long enough, has an aggressive disease. And many times it's the acquisition of comorbid conditions. Because if you look at a graph with ED rates,

Dr Sameena Rahman (: 07:16

Mm-hmm.

Dr Sameena Rahman (: 07:20

Wow, Yeah, you'll have it.

Mohit Khera (: 07:31

you can look at a graph on obesity, diabetes, and metabolic syndrome, and decade by decade, they're just going up and going up significantly. So maybe we're just becoming a more unhealthier population, particularly as we get older, and then ED kind of sets in. But ED to me is more than just about sex. So ED is the first sign of cardiovascular disease in many men. ED is the first sign of diabetes in many men. And ED is the first sign of anxiety or depression. So it's not...

Dr Sameena Rahman (: 07:35

Yes.

Dr Sameena Rahman (: 07:51

Mm-hmm. Mm-hmm.

Mm-hmm.

Mohit Khera (: 08:00

just about sex. If you know someone who has ED, they could have underlying medical problems and this could be the first sign.

Dr Sameena Rahman (: 08:10

Right. And do you mind talking about some of the most common people think about Viagra and some of the PD-4, PD-5 inhibitors, what are those really just the most common? Are there other things that people should be looking at? How effective are they really?

Mohit Khera (: 08:25

Yeah, I always talk about it as like minimally invasive to more invasive and the least spectrum are sex therapy, there are supplements that may be beneficial and pills. Then we move into injectables and then we move into penile prosthesis, right? And that's not the spectrum. And so we always start typically in this order, but essentially the pills do work. Now look, Viagra is not a cure for ED. Let's just be very clear.

Dr Sameena Rahman (: 08:43

Mm-hmm.

Mohit Khera (: 08:55

I give the example, if you break your leg, I have two choices. I can fix your leg or I can give you a Vicodin. If I give you Vicodin, you can still walk until the Vicodin no longer works and then you're done, right? That's what Viagra is. It's not curing you. It's just covering the problem that night while the disease gets worse and worse and the Viagra stops working. So, one drug that I do like quite a bit is daily Tadalafel or daily Cialis.

Daily Scalps has been shown to cause hypertrophy of the smooth muscle. It protects the endothelial lining. By the way, it's also FDA approved for BPH. It's also approved for pulmonary hypertension. So yeah, it's a great medication. So I put patients on that medication for anything protective to help improve the blood flow and the muscle within the penile tissue. So that's level one. Level two is injections where men can inject a medication, try and mix edicts into the penile tissue and it induces an erection.

It was invented at Baylor in: 1973

to look for cures for ED, because all these are really not cures. And so we moved into a field of regenerative medicine, meaning stem cells, PRP, shockwave therapy. We're starting to look at radiofrequency, which I think has a lot of merit. There's a lot of ways, these are things that we can do to reverse the ED process, as opposed to putting a band-aid like the Vibra, as I mentioned earlier. So you're gonna see a lot of these, but be careful. A lot of these...

are not what I call valid machines or they're not effective machines. And unfortunately, patients don't know the difference between a real machine and a not real machine. And so I think you just have to be careful.

Dr Sameena Rahman (: 11:00

Yeah. And I think that's sort of the difficult when it comes to sexual dysfunction for men and women is there's so many predatory markets out there where you can get some of these medications or some of these treatments without the people either really understanding the disease process or just treating so that maybe people can make more money than they possibly should, I think. But what do you think about

Mohit Khera (: 11:23

I

Dr Sameena Rahman (: 11:25

the access to testosterone because it seems like testosterone is having its moment for women nowadays. I know it's something that men are always looking for. Can we talk a little bit about testosterone and some of the myths around testosterone?

Mohit Khera (: 11:32

Yeah.

Mohit Khera (: 11:37

Yes, one my favorite topics. So testosterone has been around since 1935. When someone comes into my office and says, this is a new drug, say it invented in 1935, used in the late 1930s by men and women. So women were using this earlier. In 1940s, Goldblatt, many were using pellets in women, earlier reports of great results. And in men, unfortunately, most of the research has been in men for testosterone replacement therapy.

Dr Sameena Rahman (: 11:54

Mm-hmm.

Mohit Khera (: 12:07

And we do know, let's start with men, men with low testosterone are much more likely to have erectile dysfunction, low libido, increased fat deposition, decreased muscle mass, depression, some poor sleep. These are signs and symptoms of men with low T. But I want you to know that it goes way more than that. I call it the five. There are five medical conditions that also are associated with low testosterone. Non-negotiable men with low testosterone levels are much more likely to have a cardiovascular event. No negotiation.

Men with low T are much more likely to have a heart attack. Men with low T are much more likely to have diabetes. They're much more likely to have a bone fracture. They're much more likely to have depression. We wrote that study. And it's also associated with anemia. There's also an association with low testosterone and prostate cancer. Samina, think about this. I can't think of another blood test that's more indicative of a man's overall health, right? It's not you'll go up in A1C. It's not thyroid. It's not lipid.

Dr Sameena Rahman (: 13:01

True, yeah.

Mohit Khera (: 13:05

I'm telling you it affects him symptomatically with erections, libido, muscle mass. And then I'm also telling you it's the first sign of heart attack, diabetes, bone fracture, depression. Show me one blood test that can predict a man's overall health. in my opinion, testosterone is the best marker of a man's overall health. Every man over the age of 40 should have an annual testosterone level checked. Unfortunately, that's not a standard test. They check a TSH every year, which has much less value.

Dr Sameena Rahman (: 13:24

this.

Dr Sameena Rahman (: 13:30

Yeah.

Mohit Khera (: 13:34

than checking a testosterone level. I do think it's important to check testosterone in men and if they are low have the discussion if they're symptomatic. Remember, testosterone does cause infertility. So if you give a man exogenous testosterone, it will shut down his natural production. So when they come in, you have a couple options to raise their testosterone naturally. Those options are either lifestyle modification or two pills. And the two pills are either Clomaphene Citrate

Dr Sameena Rahman (: 13:57

Mm-hmm.

Mohit Khera (: 14:04

or HCG. I really don't like using anastazol very much as monotherapy. So you can't use pills. I said, Mr. Smith, we're going to use these pills not to give you testosterone. We're going to use these pills to make you make testosterone. And if we do that, I'll actually preserve your own fertility as well. So that's something to think about. But if you pick my favorite way, I like lifestyle modification. It's just that people don't stick to it. And the biggest ones are diet, exercise, again, sleep.

Dr Sameena Rahman (: 14:09

Okay.

Dr Sameena Rahman (: 14:31

Sure.

Mohit Khera (: 14:33

stress reduction, but weight loss has a profound effect on T levels. Did you know that if a man loses 10 % of his body weight, he will gain almost 85 ng per deciliter testosterone? If 15 % of his body weight, it's 250 ng per deciliter, so it's curvilinear, but the problem is the same as the reverse. So if you gain weight, you will lose 85. If you gain 15 % of your body weight, then you'll lose 250.

Dr Sameena Rahman (: 14:37

Yes.

Dr Sameena Rahman (: 14:47

wow.

Dr Sameena Rahman (: 14:54

you

Mohit Khera (: 15:02

It's bi-directional, but weight loss has a profound effect on T levels. It's just not many times sustainable. What we are seeing though now is with the GOP1s is that they are getting the weight off and the T levels are going up and it's more sustainable. But again, know, T is very important. But you mentioned something important about women. So what about women? You you and I walk into Walgreens today and we say, me the testosterone for men. They'll put, you know, 15, 20 things on the counter. We say, give me the testosterone for women.

does not exist, not a single FDA-approved product. And so, if you read the Ishwish guidelines, if you read the global consensus, what is the recommendation? The recommendation is to get a man's testosterone and give him 1 tenth. That's not ideal. If you ask him to try and give you 1 tenth, he's like, I think I'm using 1 tenth. Yeah, it's a little tricky, you know? But to say that women don't suffer from low T like a man, or women don't benefit,

Dr Sameena Rahman (: 15:43

Right. It's not. Yeah, it's like a little alchemy you gotta like. Yeah.

Mohit Khera (: 15:59

from tea like men is ludicrous. It doesn't make any sense, Testosin is the, women make more testosterone than any other hormone in their body, any other hormone. And to say that if she's deficient, I will not allow her, we should be very careful in giving it back to her, but she could be deficient in any other hormone, estrogen, cortisol, insulin, thyroid, and we won't hesitate to give it to her. But if she is deficient, well, that's just sometimes, right? It's not regulated.

Dr Sameena Rahman (: 16:07

Yes.

Dr Sameena Rahman (: 16:21

Yeah, well estrogen sometimes people have testosterone for sure.

Mohit Khera (: 16:27

But there's no FDA approved testosterone product in the United States. So if she's low, wait a minute, can't give it to her, but she used to make it and she used to make this more than any other woman. No, it's too dangerous, she can't give it to her. But what's wrong with putting it back in the normal range? No, we don't know, we're not sure. So that's the problem I have. Now the good news is the issuers came out, global consensus, and the recommendation is that you can put women in the normal premenopausal range.

Dr Sameena Rahman (: 16:31

Yeah.

Dr Sameena Rahman (: 16:35

Mm-hmm.

Dr Sameena Rahman (: 16:40

Exactly.

Mohit Khera (: 16:55

if they suffer and the one indication most would agree with is HSDD. So if she does have low libido, for that indication, it's acceptable. However, I do think that women benefit from testosterone way beyond just HSDD. And I think the reason why when you read these articles and many of the articles is because we just don't have the data. Like if I only have very limited data, then I'm gonna have to say I don't have the data to suggest that it's safe. And I think...

Dr Sameena Rahman (: 17:08

I agree. I agree.

Dr Sameena Rahman (: 17:17

Yes.

Mohit Khera (: 17:24

Unfortunately, we just need more research in tea and women. That's what we need. And a product, right? mean, yeah. Yeah. Libby Gel was, Libby Gel was, and Trinzo was, and both got shut down. And Trinzo came to the UK, then got shut down. Androfem was available. Now it's only available in Australia. But I think some countries are coming along, I think more and more.

Dr Sameena Rahman (: 17:29

Right, right. And a product if we can get it. mean, you know, there have been so many that have been up for, you know, potential FDA approval and they get knocked down.

Dr Sameena Rahman (: 17:48

Yes.

Mohit Khera (: 17:53

people are prescribing testosterone for women because they're understanding the benefits. Now, let's be fair, there is abuse also. There's a lot of abuse and there many patients that are being kept at very high superphysiologic levels, which is inappropriate. But if you're going to put a woman who has a very low T-level back into the normal range, I don't find anything wrong with

Dr Sameena Rahman (: 18:03

Absolutely. Yeah.

Dr Sameena Rahman (: 18:09

Right.

Dr Sameena Rahman (: 18:18

Yeah, I agree with you. And for what I see, I mean, obviously, I always ask about their sexual function. And even if, you know, they're, well, it's a little low, I'd like it to be better. But I'm really concerned about my muscle mass, or I'm really concerned about this. And I'm like,

Well, let's try it for your low libido and let's see if we get some improvement in your muscle mass or let's see if you get more cognitive, like, you know, clarity, because I find that, you know, we all know libido is a mood and so if it can improve your libido, it might also improve other parts of your brain function. And that's what I see sometimes, you know, people are like, all of a sudden I can remember things.

Mohit Khera (: 18:48

I agree. I think men and women are not that different. If you're telling me, low testosterone increases on man's risk for osteopenia osteoporosis and giving him testosterone may help osteopenia osteoporosis, why is that different for women? Intuitively, it doesn't make sense. There are studies looking at estrogen plus testosterone versus estrogen alone to help women with bone mineral density, showing that the combination is much more effective. So there's a hint that it may be a

Dr Sameena Rahman (: 19:09

Yes. Yes.

Mohit Khera (: 19:18

better. But you know, there's some data suggests that, good data suggests that low T in men induces depression. And there's some data suggests that when you give a man testosterone, it may help with depression. Well, why is that so different for women? Like if she has low T, shouldn't she have the, it shuffling depression and giving it to her may help. We can't really say because we don't have the studies, but you can assume, but I can tell you clinically, I see it, you know, I've been a woman with testosterone for 16 years and they

Dr Sameena Rahman (: 19:40

Right.

Yes, me too.

Mohit Khera (: 19:47

many women will report an improvement in depression. Many women will improve their mood. They will put their sleep better. Cognition will be improved. So I think that we do need to invest in the research for women. There is a nonprofit, should look at, the Testosterone Project. It's great to get testosterone for women in the U.S. It's looking also to, know, testosterone is a class C.

Dr Sameena Rahman (: 19:54

Right.

Dr Sameena Rahman (: 20:02

I saw that recently.

Dr Sameena Rahman (: 20:11

I know, it's a little frustrating.

Mohit Khera (: 20:16

just as like a narcotic. So you have to deregulate. We're trying to deregulate if we can. And so again, it's one of the missions. And testing, I think that we should test people for low T, particularly if they're symptomatic. And it's not a standard screen, as I mentioned earlier, but men and women should have their testosterone level screen, particularly if they're symptomatic.

Dr Sameena Rahman (: 20:18

Yeah.

Dr Sameena Rahman (: 20:39

Absolutely, I agree with you and I think you know for those of us that do what we do find You know some profound differences in how they feel over time when they're using it in the appropriate manner And really can improve the quality of their life tremendously And so, you know, I think that that is something we always have to keep in the back of our mind that you know I and I like to stack hormones. I don't usually replace everything at once so I'll usually do the estrogen and the progesterone replacement and then

Mohit Khera (: 20:53

I agree.

Dr Sameena Rahman (: 21:07

know we'll bring in the testosterone but I do find it frustrating that you know we always have to bring in my little tube of testosterone and show them the one pea size amount and I put it on the back of my thigh and show how I do it.

Mohit Khera (: 21:20

Yeah, yeah, it's a little bit hard to do that. I think it's two problems with that. One, it's hard to estimate, you know, and two, you know, they have to, it's not covered by insurance, so have to pay cash, whatever that may do. And so it is a little bit cheaper because using the man's formulation, lasts much longer, but still, you know, it would be nice to have an FDA approved product for women with testosterone.

Dr Sameena Rahman (: 21:44

I agree. I agree. I don't know what it will take to get there because it feels like, you know, the studies that have been done were pretty good and they still close it down, you know, and the one was that the patch was in.

Mohit Khera (: 21:52

Yeah, think, know, intrinsic has shut down because it was right during the Women's Health Initiative. So even though intrinsic showed great safety data, it was right at the time with the Women's Health Initiative. they said, we're not going to even though the safety data was there. I think LibbyGel missed its efficacy endpoints. And so because it missed the efficacy endpoints, it didn't go through. But LibbyGel had a very nice study looking at women who had at least two cardiovascular risk factors.

Dr Sameena Rahman (: 21:57

Yeah.

Dr Sameena Rahman (: 22:05

Forget it.

Dr Sameena Rahman (: 22:10

Yes. All right.

Mohit Khera (: 22:21

and it was a long-term study looking at high-risk women showing no increased adverse events in cardiovascular events or breast cancer. So, you know, there are concerns, just like we had these concerns for men with prostate cancer and cardiovascular disease, there are still concerns with women with cardiovascular disease and breast cancer, and I agree we need more studies, but the initial studies look very favorable. If not no increased risk, even a slight decreased risk.

Again, more studies are needed. These are typically smaller. But if you saw the one that came out last year, this is by Agarwal and Cohn. Dr. Cohn is my fellow this year. Large database study, 16,000 women getting testosterone, showing that there was a decrease in cardiovascular events and breast cancer in this large database study. But again, I don't want someone to say, it's 100 % safe. We obviously need a large trial. We had the traverse trial for men. We don't have a traverse trial for women. But again, the hint.

so far is that it may potentially be safe.

Dr Sameena Rahman (: 23:23

Yeah, actually, can you mention that because I know there is that myth about testosterone for men, you know, potentially contributing or causing prostate cancer. So if you don't mind reviewing that for people listening.

Mohit Khera (: 23:32

Right? started in 1941, Huggins published a paper showing, and he later got the Nobel Prize, that testosterone increases the risk for prostate cancer cells to grow. And when you pull the paper, effectively what you'll see from 1941 is it was based on one patient. One patient. And for many years, it was believed that testosterone increases prostate cancer risk. And it wasn't really until 2018

when the American Urological Association put out guidelines and a statement on the guidelines said that patients should be informed that testosterone does not increase the risk of prostate cancer and that was a strong recommendation. So finally, in the guidelines, strong recommendation, testosterone does not increase the risk of prostate cancer. Now, that's a little different than giving it to a man who has a history of prostate cancer, radical prostatectomy, radiation. And the second statement behind that one is if he's had a history of prostate cancer, we don't know

Dr Sameena Rahman (: 24:16

Mm-hmm.

Mohit Khera (: 24:31

if it's safe or not. So that's a different beast. But I'll tell you something that is a very interesting thing I want you to read about called BAT therapy in my literature. BAT therapy stands for Bipolar Androgen Therapy. And in 2015, Dr. Dan Meads group at Johns Hopkins, what they started doing was treating men with metastatic prostate cancer with high doses of DIP. Really interesting. they give them high dose of testosterone and at the same time they have luparons that would come down.

Dr Sameena Rahman (: 24:54

huh.

Mohit Khera (: 25:00

They go up again once a month and just give them 400 milligrams of testosterone. And what they found on that initial study was a 50 % reduction in the PSA, a 50 % reduction in metastatic disease just by giving them high doses of testosterone. obviously, I'm not asking this is in a clinical trial and it was done in this way, but pretty shocking that you are going to use high doses of tea to treat metastatic prostate cancer when we were always taught that tea causes prostate cancer. So again,

Just a different way of thinking.

Dr Sameena Rahman (: 25:31

Yeah, it's very interesting actually, because you wouldn't expect that to be the case.

Let's talk a little bit about depression though, because you were mentioning depression a lot and we know how depression can impact sexual function. So people that have complete anhedonia may not wanna have intercourse, may not feel like their libido is there. But also the medications for depression actually cause sexual dysfunction. So it's a fine balance. Do you wanna address that a little bit as well? Because all of our patients I feel have some level of depression they enter these.

Mohit Khera (: 26:02

Yeah, it's such an important point. So we know that low testosterone has certain symptoms that are identical to the signs and symptoms of depression. So for example, low energy, low libido, sexual dysfunction, right, poor sleep. These are all signs of low T. They're the exact same signs of depression. And I tell...

many clinicians, if you're treating a man who comes in with these symptoms, we always jump, the urologist jumps to testosterone. The psychiatrist jumps to, must be depressed. We jump to different things because that's what we do, right? But we have to share. So I tell patients, how do you know he's not also suffering from depression, right? And so screen patients who come in for hyperglycaemia for depression. Screen them all, because they have the exact same signs and symptoms of depression.

Dr Sameena Rahman (: 26:37

Mm-hmm.

All right. All right.

Dr Sameena Rahman (: 26:49

Yeah.

Dr Sameena Rahman (: 26:58

It's so true.

Mohit Khera (: 26:59

And I tell the psychiatrist, and I tell primary care, get a T on people who come in with signs of symptoms of depression. Get a testosterone level. You should do the same, because we're just living in our silos and just doing the things that we do. But the reality is that many patients have one or the other or both low T or depression, right? So work them both up. We do know that they are also correlated. Low T can cause depression, and the traverse trial was 51%.

Dr Sameena Rahman (: 27:07

Yeah.

Dr Sameena Rahman (: 27:13

without.

Mohit Khera (: 27:28

In one of my trials, 92 % of men who had low T increased the risk for depression. And then when you give T, many studies have shown that it can actually improve depressive symptoms. In the study that we published in 2011, we had 850 patients. We showed that even men who were on an antidepressant, like an SSRI, if you put them on T, they also saw significant improvements in PHQ-9 questionnaire, suggesting maybe some synergy between SSRI and testosterone.

Dr Sameena Rahman (: 27:39

Yeah.

Mohit Khera (: 27:56

Again, I'm not advocating to treat major depressive disorder with testosterone, but I'm simply advocating that if a man comes in with signs and symptoms of low depression, check his T-level. Like that's all. Just check the T-level. But literally the same, Samina. If someone comes in and she has low energy, low libido, some sexual dysfunction, you can say, me work her up for FSD and check her for depression. I mean, that's DSD screener also. Part of it is she's not depressed, you know?

Dr Sameena Rahman (: 28:08

Absolutely. Yeah, just check. Yeah.

Dr Sameena Rahman (: 28:20

Yeah.

Yes. Right. Right. No, it's true, I mean, that's very interesting thinking about how all of these hormones work on your brain. I think I heard you speak once about also like even medications we use for hair loss. Like, you know, when we talk about some of these medications and how they may... Did I hear you speak about post-finasteride?

Mohit Khera (: 28:26

Yeah.

Mohit Khera (: 28:44

It's finasteride. So I'm really against the use of finasteride for many reasons. You we were taught in medical school that finasteride blocks the conversion from testosterone to hydrotestosterone, or DHT. But that's not the whole story. There are actually six pathways that are blocked, not just that one. Six pathways. And then those six pathways go on to something called neuro steroids. And neuro steroids in the brain, so essentially you're 12 pathways.

by giving a patient finasteride. The problem with the neuro steroids is that they're responsible for anxiety, depression, and so in many cases, suicidal ideations. Many countries have put on the package insert of finasteride that increases suicidal ideation. And just so you know, I ran a large trial with post-finasteride syndrome and during the trial, two patients committed suicide during that trial. It was devastating.

Dr Sameena Rahman (: 29:20

Mm-hmm.

Dr Sameena Rahman (: 29:40

wow.

Mohit Khera (: 29:42

And I just feel like this drug may have more negative impacts than we understand. really, I just think that it's really not a bad drug.

Dr Sameena Rahman (: 29:54

Yeah, no, that's terrible. Actually, that's really sad. Actually. When you talk about sort of lifestyle modifications, you know, we all know, you know, the impact of like, you know, lack of muscle wasting as we get older or, you know, lack of sleep. You know, we all have midlife women have so much sleep disturbance. Can you talk about some of these modifications and what you see in men or women as well? Like what and how it may improve their overall sexual function?

Mohit Khera (: 30:20

Yeah. it's germane to both sexes and there is nothing more powerful than lifestyle modification. It's sustainable. It reverses the disease process. And everyone's looking for this magic pill, but the magic pill really is just the diet, the exercise, the sleep, and the stress reduction. There are many diets that you can use. I gravitate a little bit more towards the Mediterranean diet. Mediterranean diet is a very anti-inflammatory diet.

Dr Sameena Rahman (: 30:34

Yes.

Mohit Khera (: 30:49

and it's focusing, if you look at the pyramid, more on whole grains, fruits, vegetables, very modest consumption of poultry, and very rarely red meat, right? Alcohol in moderate consumption, up to two glasses of wine per day, which is, you so you'd think. And the Mediterranean diet has been shown to actually reverse erectile dysfunction. So Esposito was the first to show just the Mediterranean diet versus a placebo arm.

Dr Sameena Rahman (: 30:59

Yep.

Yeah, yeah.

Mohit Khera (: 31:17

two years significant improvement in IIEF scores just by diet and exercise alone. Then she did this great study called the Medida trial. And the Medida trial was men and women, men and women randomized to the Mediterranean diet or a high fat diet, a low fat diet. And what she found was, and these were all diabetic, 214 patients, all diabetic, and the rate of sexual dysfunction in men and women significantly dropped.

if you're on the Mediterranean diet as opposed to any other diet. So you slow the progression down as well. think the Mediterranean diet is very good. I also think that weight loss is extremely important. And so I think that was very helpful. In terms of exercise, this was a paper that I published about last year. It's 160 minutes a week, moderate to vigorous exercise. And you can divide it into 40 minute sessions, four times a week.

hundred and forty to sixty minutes. If you can give me a hundred sixty minutes, and it took six months, significant reversal of erectile dysfunction, and those men that had the more severe ED saw the greatest improvements in sexual dysfunction. So wow, now you're telling me if I just exercise a hundred sixty minutes a week, I can actually reverse ED. And I'm telling you that's what you can do. Wow, you're telling me if I just take the Mediterranean diet and do a less inflammatory diet.

I can reverse ED. That's exactly what I'm telling you. And then what about sleep? So there was a very nice study looking at sleep disorders, sleep quality, and sleep duration, and sleep quantity. If you sleep less than six hours a night, men or women, your sexual dysfunction will go up. It's inflammatory as well. If you slept seven to eight hours, it actually was helpful and protective. If you try to sleep more, you say, well, if I sleep more, then maybe I have improved erections.

Dr Sameena Rahman (: 32:46

Right.

Mohit Khera (: 33:12

So I'll say 12 hours tonight. There was no benefit after 9. There's no benefit so plateaus, right? So under six is bad seven to eight optimal above nine no benefit. So Sleep is extreme and sleep quality is actually very important as well and part of the quality is dictated on going to bed at the same time every night and waking up at the same time of day and getting your REM sleep and your deep sleep and You know there if you want to look at a great website go to the sleep

Dr Sameena Rahman (: 33:12

Alright. Yeah. Not bad. Yeah.

Dr Sameena Rahman (: 33:23

Yeah.

Dr Sameena Rahman (: 33:33

Mm-hmm.

Mohit Khera (: 33:42

The SleepFoundation.org has 20 tips on sleep hygiene. They're awesome. Don't eat three hours before you go to bed. Make sure that you are not, alcohol consumption, caffeine, they give you all these tips. Those tips are amazing and they will definitely help raise the sleep quality. And then obviously sleep disorders like sleep apnea or insomnia. Sleep apnea had the highest score, the worst.

Dr Sameena Rahman (: 33:48

Really?

Dr Sameena Rahman (: 33:56

I'm going to use that for my patients.

Mohit Khera (: 34:09

in terms of impact on sexual dysfunction. But what's really nice about sleep apnea is that sleep apnea is treatable. That's easy. So I just think that sleep is underrated and I take care of a lot of people and they're really good at their diet, they're really good at their exercise, but they're lousy at sleep and stress. Like just lousy. And so I think they need to take...

Dr Sameena Rahman (: 34:16

Yeah.

Dr Sameena Rahman (: 34:30

stress. Yeah.

Mohit Khera (: 34:34

sleep and stress more seriously. Stress is hard. There's so many stressors. mean there's no... But finding things to do, meditation, mindfulness, deep breathing, these are all very helpful tips.

Dr Sameena Rahman (: 34:39

Yes.

Dr Sameena Rahman (: 34:46

No, you're right. Actually, think that's the that's what I feel like most of my patients struggle with is like the stress of being midlife and, you know, older parents, children that are getting older, like just balancing careers and all of things. It's a it's very debilitating for some people and then you throw in the mix of like, your hormones are totally going crazy. Like, good luck to you. It's very

Mohit Khera (: 34:59

Yeah.

Mohit Khera (: 35:07

Right? No, I agree. It's very stressful. You know, we're in a generation, you and I are, where we're in a generation, we're caught in the middle. We're in the middle where we're taking care of our parents and we're taking care of our kids. Like, we're caretakers on both sides. Right? And then that in itself is very stressful. You know? That's very stressful.

Dr Sameena Rahman (: 35:17

Yes, yes, the sandwich, we call it the sandwich dinner. Yeah.

Dr Sameena Rahman (: 35:26

Absolutely. Yeah, I totally agree with you. And I think that's something that's harder to modulate than anything else. And it's too bad we don't have a magic pill for that one. But it's unfortunate.

Mohit Khera (: 35:37

Yeah.

Dr Sameena Rahman (: 35:39

Anyway, think I want to be cognizant of your time because I know we both have, you know, other meetings or patients to see. So I really appreciate you being here. If you had to give one piece of advice to midlife men or women seeking sexual medicine care, because I kind of feel like that's always an obstacle. I know it's a big obstacle for women, like trying to find someone that will actually listen to their sexual concerns and give it any validity. I'm sure you see it with men like it's harder for men to I think even

to come forward with their problems because of so much embarrassment around it. What kind of advice would you give to those listening around trying to find the right clinician to help guide you through this journey?

Mohit Khera (: 36:20

The biggest thing I would say is that many people with sexual dysfunction are suffering in silence. They're two pairs. We have to destigmatize sexual dysfunction. It's okay. It's normal to have sexual dysfunction as we get older, but the majority of patients do not seek help from their doctors. They don't tell their doctors. Many times when they do tell their doctors, it's typically dismissed many times. That's a problem. And sometimes you'll see, I think we talked about this earlier,

Dr Sameena Rahman (: 36:25

Mm-hmm.

Dr Sameena Rahman (: 36:31

Yep.

Dr Sameena Rahman (: 36:37

Yeah.

Dr Sameena Rahman (: 36:42

Right. Right.

Mohit Khera (: 36:46

A great study showed that only 44 % of men at one point would tell their partner that they had sex with a woman. What they do is just avoid sex because they're too embarrassed to deal with it. So I think it's okay to have this condition. You don't need to suffer in silence. There are amazing treatment options, both for men and women. Whether it be off label or labeled, it doesn't matter. You and I have things that we can do to make it better. You just have to raise your hand and ask for help, and it's very treatable. And remember,

Dr Sameena Rahman (: 36:51

Yeah.

Right. Right.

Dr Sameena Rahman (: 37:04

Right. Yes.

Yes.

Dr Sameena Rahman (: 37:13

Sorry. All right.

Mohit Khera (: 37:16

that it is a couple's disease. So if you're suffering from sexual dysfunction, just remember, so is your partner from your sexual dysfunction. Right? I mean, it's not just you, right? And so by treating you, we're actually treating your partner as well. That's important.

Dr Sameena Rahman (: 37:18

Yes.

Dr Sameena Rahman (: 37:23

Mm-hmm. Yep. Right. Yep.

Dr Sameena Rahman (: 37:31

Yes, absolutely. Yeah, I agree. And I love it when the couples come in together actually, because you can find that really supportive husbands or partners that come in. sometimes they'll say, well, I don't know how to get my Peyronie's disease looked at. I'm afraid to do these injections. then you can kind of guide them in the right direction. Yeah.

Mohit Khera (: 37:53

Yeah, no, I'm great.

Dr Sameena Rahman (: 37:55

But anyway, thank you so much, Mo. I appreciate you being here. In the show notes will be how to get in touch with you or contact you. You guys have to listen to his TEDx talk. It was amazing on Sex Fan. think it's on, we'll put it in the show notes. It was really nice. And I really enjoyed listening to that as well. But I appreciate everything you're doing. I appreciate your advocacy. I appreciate everything you did for SMSNA in the past year. And I look forward to collaborating with you in the future.

Mohit Khera (: 38:10

day.

Mohit Khera (: 38:22

Thank you so much. Thank you for having me on the show.

Dr Sameena Rahman (: 38:24

Yeah, I appreciate it. Remember, I'm Dr. Smita Mungino girl. I'm here to educate so you can advocate for yourself. Please join me again next week for another episode.