210. Dr. Rena Malik: Why Erectile Dysfunction Could Be an Early Warning Sign of Heart Disease

What if problems in the bedroom were actually an early warning sign of something much bigger happening in your body? Most people think of sexual health as separate from their overall health. But erectile dysfunction, low libido, and changes in sexual performance can reveal important clues about cardiovascular health, hormone levels, metabolic function, and even how we're aging. In this episode, I'm joined by Dr. Rena Malik, a urologist and sexual health expert, to explore why sexual health deserves a much bigger place in the longevity conversation. We discuss her concept of "sex span"—how long we can maintain a healthy, satisfying sex life—and why protecting it may also mean protecting our long-term health. One of the most eye-opening parts of our conversation is the connection between erectile dysfunction and heart disease. Because the blood vessels involved in erections are smaller than those supplying the heart, vascular problems can sometimes appear as sexual dysfunction years before more serious cardiovascular symptoms develop. We also break down the truth about testosterone replacement therapy (TRT), Viagra, Cialis, nitric oxide supplements, pelvic floor health, and the psychological factors that influence sexual performance. In this episode, you'll learn: Why erectile dysfunction can be an early warning sign of cardiovascular disease The five major causes of erectile dysfunction—and why low testosterone isn't always the answer How morning erections and nighttime erections can provide clues about sexual health The difference between Viagra and Cialis, and what these medications actually do What to know about testosterone replacement therapy, including its effects on fertility Whether supplements like L-citrulline and L-arginine can improve erectile function How pelvic floor health, exercise, sleep, and stress affect sexual performance How pornography, masturbation, and performance anxiety can influence arousal Why communication, intimacy, and relationship health matter for maintaining sexual wellness as we age We also discuss emerging treatments for erectile dysfunction, the importance of identifying underlying health problems rather than simply treating symptoms, and the four pillars of sexual health Dr. Malik explores in her book, The Hard Truth. The biggest takeaway? Sexual health isn't just about sex. It's another window into your overall health. When we start treating sexual dysfunction as a potential signal of deeper metabolic, vascular, hormonal, or psychological issues, we create an opportunity to intervene earlier, improve quality of life, and potentially protect our long-term health. Because longevity isn't just about adding years to your life. It's about preserving the health, connection, and vitality that make those years worth living. Learn more about Dr. Shah: Website: drshah.com https://drshah.com Clinic: next-health.com https://www.next-health.com/ Instagram: @darshanshahmd and @extend_podcast Learn more about Dr. Rena Malik: Webiste: renamalikmd.com https://renamalikmd.com/ YouTube: youtube.com/@RenaMalikMD https://www.youtube.com/@RenaMalikMD Instagram: @renamalikmd Book: renamalikmd.com/hardtruth https://renamalikmd.com/hardtruth/ Thank You to Our Sponsors! Next Health: Your destination for cutting-edge health optimization - from IV therapy to hormone balancing. Explore at next-health.com https://www.next-health.com/! Momentous: Head to livemomentous.com https://livemomentous.com and use my code DRSHAH at checkout for up to 35% off!

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:03Dr. Darshan Shah?

  Welcome to Extend with me, Dr. Darshan Shah, a podcast dedicated to cutting-edge science, research, tools, and protocols designed to help you extend your health span. Having become one of the youngest doctors in the country at the age of 21, and trained and board certified at the Mayo Clinic, I've accumulated three decades of practice as a board-certified surgeon and longevity expert. Over that time, I've discovered that a mere 20% of health knowledge yields 80% of the results when it comes to your health span. We're living in a new era where we are creating a new healthcare system, no longer focused on disease management, but achieving optimal health and vitality. Join me as I interview world-renowned experts, offering you a step-by-step guide to proactively avoid disease and, most importantly, extend your health span.

• 0:49Dr. Darshan Shah?

  Dr. Malik, I'm so excited to talk to you today. Thank you for coming.

• 0:52Speaker 01

  I'm so happy to be here.

• 0:53Dr. Darshan Shah?

  Yes, you're such an incredible speaker. I've listened to you on many podcasts and also on stage when I was behind you at stage at A4M. So, I was, the minute I heard you speak on stage, I was like, I gotta get her on my podcast. So, thank you for joining.

• 1:06Speaker 01

  Thank you so much for having me, and thank you for highlighting sexual health, because it's so important.

• 1:10Dr. Darshan Shah?

  Yes, absolutely. And you know, one of the things I'm really excited about doing on this podcast is reframing the sexual health conversation. You're a urologist, you're a physician, and I think when the sexual health topic comes up for physicians, especially, it, sometimes, they, they kind of turn off almost, because they don't really look at sexual health as a measure of physical health, right? I think sexual health is sometimes thought about as something that is more psychological, more just something that is in the bedroom, right?

• 1:41Speaker 01

  Just for fun.

• 1:42Dr. Darshan Shah?

  Yeah, just for fun, right, exactly. And you've kind of reframed the whole conversation around sexual health being undertalked about biomarker of physical health.

• 1:51Speaker 01

  Absolutely, and it's an opportunity, right? So, when people come in with sexual health problems, that's an opportunity where we can actually intervene. One, when a person's motivated to get better, because sexual health is a huge motivator. But two, it also allows us to look at the, the factors that cause sexual dysfunction, which is metabolic, hormonal, you know, vascular, all sorts of different issues that come up that eventually cause that sexual dysfunction, and later down the line, cause heart problems and hypertension, high cholesterol, all the things that we see that ultimately cause bigger health problems.

• 2:24Dr. Darshan Shah?

  Absolutely. So, obviously, you know, I think, for men, the thought around sexual health has a lot to do with erectile dysfunction, right? And erectile dysfunction, most men look at this as an anatomical issue with that part of their body, right? Their penis is not working, right? But that's a little misguided.

• 2:43Speaker 01

  Right. So, I think when I talk about erectile dysfunction, I try to tell patients there's five reasons that you can have problems with erections. Number one, most common cause, if organic cause is vascular. So, meaning the blood vessels are unhealthy, are not working well, not pushing blood in well, or, or letting blood out too quickly. And so, that's usually the most common cause, and that's due to problems with the vessels. So, metabolic disease, things like high blood pressure, high cholesterol, heart disease. And in fact, when this is the cause, we know that it predates heart disease by two to five years. Meaning that if a guy comes in with erectile dysfunction, if he does nothing, very likely in the next two to five years, he's going to develop one of those conditions. And 14% of those guys will have a heart attack within seven years.

• 3:26Dr. Darshan Shah?

  Within seven years?

• 3:28Speaker 01

  Within seven years. So, it's, like I said, it's a huge opportunity to intervene before those things happen.

• 3:34Dr. Darshan Shah?

  Right. So, what you're saying, just to be clear, is that, stated in other ways, if you have vessel problems in your penis, you actually have vessel problems probably throughout the body. It's almost like canary in the coalmine kind of a situation.

• 3:45Speaker 01

  Exactly. And the way to think about it is, the blood vessels to the penis are about half the size, the blood vessels in the heart. And so, when they get problems, you're going to see problems there first, because they're much smaller and they're more fragile. And so, you're going to see issues there. Now, other causes hormonal, which is low testosterone most commonly, people think this is a huge cause of erectile dysfunction. It's actually the sole cause of erectile dysfunction in only 3% of guys.

• 4:10Dr. Darshan Shah?

  Only 3%?

• 4:11Speaker 01

  Solely. Meaning, there is multiple causes, and sometimes it can include hormonal, but it being the only cause is only about 3%. And it's a huge problem, and I'm sure we'll talk about low testosterone, but it's not the only problem. And then, the other one is neuronal. So, these are guys who've had surgery to their prostate, like for a radical prostatectomy, or they have neurologic conditions, like multiple sclerosis, Parkinson's disease, those spinal cord injuries, those sorts of issues will cause nerve problems to the penis. So, you're not getting the signals to get the erection. Then, there's medications. So, a lot of medications cause difficulties with erections, most commonly including antidepressants and antihypertensives. Now, not all of them, but very commonly, those are related to that. And so, so many people are on those medications. So, it's really

• 4:55Speaker 01

  important to look at people's medications. And then, lastly, is psychological, right? And I tell people, every guy who has a problem with erections has a problem psychologically, because the first time you have difficulties, you're thinking about it. The next time you have sex, you're like, oh my God, is it going to come back? Am I going to have problems this time? And so, everyone has a problem. We don't need to make this an embarrassing thing. It is a normal thing. It is a normal fear to have after you've struggled with an erection.

• 5:21Dr. Darshan Shah?

  That's such a great model. I want to dive into all five of those, but before we do so, I want to talk a little bit more about how you connect your sex span, as you call it, with your lifespan. Can you make that connection for us?

• 5:35Speaker 01

  Yeah. So, sex span is basically how long you can have sex for. So, everyone listening, or most people listening, probably like, yeah, I want to have sex when I'm 80, 90 years old. But the reality is, a lot of people at that age are not having sex, either because their partner is not able to have sex, they're not able to have sex, you know, those conditions I talked about, maybe erectile dysfunction, maybe difficulties with ejaculation, or orgasm, or whatever, or because they physically can't, like they're physically not able to deal with the demands of sexual sex, of intercourse. And so, those are the most common reasons, or they're in a relationship where sex has become less of a priority, and so, they don't have access to it anymore. And so, how do you, to be

• 6:17Speaker 01

  able to extend that sex span, or that sexual health span, you have to actually put in work now. You have to put in work at every age, so that you can make sure that you are working in every, all of those areas where you can see dysfunction. And that's what I talk about in the, in the Hard Truth. There's these pillars of sexual health. There's four pillars. So, there's fuel, strength, environment, and confidence. And within each of those pillars, those are the things you need to be working on regularly, to build a strong foundation, so that you can have a sex span, so you can have a long sexual health span. And when you do those things, you're also going to have a long health span, because they're, they're tied in together. And so, that's what I think really is valuable, is to realize, like, hey, we're going to put in the work to have a long sex span,

• 7:00Speaker 01

  but we're also going to, those things are also going to make us healthier.

• 7:04Dr. Darshan Shah?

  Yeah, that makes total sense. So, when you're talking about sex span, how do you like, really measure it? Is it the number of times of sex you're, you know, you're having sex in a week, in a month? And what's considered normal, or what's considered the right number to kind of shoot for, if I, if I can ask?

• 7:19Speaker 01

  Well, so, there's no, there's no perfect number. I think the, the reality is, for each individual person, the amount of sex you're having should be sufficient that you and your partner are having pleasure and are satisfied, right? If you're having sex every day, but it's mediocre sex, like, that's not great. We want to have good sex. And so, it should be that you're having mutually satisfying, pleasurable sex on a regular basis. Now, that can vary from person to person, but if you're like, hey, I have amazing sex once a week, and I'm happy, great. If you're like, I have amazing sex three times a week, that's also great. And I think, really, what, what we do know from the data is that people who have sex once a week, 52 times a year on average, tend to live longer than people who don't. Now, of course, they do try to control for all these different factors

• 8:04Speaker 01

  and studies that look at that, but at the end of the day, you imagine that people who are having sex once a week are probably healthier, probably have better relationships with their partner. And so, those things also play a role, because connection with another human being, we know, affects longevity, right? Having human connection. And so, I think you can't really measure that super well in a study, but I think those things also play a role.

• 8:24Dr. Darshan Shah?

  Yeah, absolutely. And also, sex can be utilized as a way to decrease your stress levels, to your point, increase your intimacy and your physical connection with somebody else, and all those have a direct connection to longevity.

• 8:36Speaker 01

  And improve sleep.

• 8:36Dr. Darshan Shah?

  And improve sleep as well. Yeah, exactly. So, it could be a direct effect, but there are also definitely many indirect effects that it could have positively.

• 8:44Speaker 01

  Absolutely.

• 8:45Dr. Darshan Shah?

  So, you know, when you're looking at, or when you're seeing a patient that is coming to you and saying, hey, you know, I'm not having sex anymore, and I don't know if it's erectile dysfunction or not, you know, maybe I'm in my 50s or 60s. What is some of the advice, or how do you approach that patient? Where do you start, and where do you kind of take them?

• 9:06Speaker 01

  Well, I think the first question is, what's going on when you're by yourself versus when you're with your partner? Are you able to get an erection? Does it, what's happening? Does it last long enough? Does it go away before you ejaculate? Do you ejaculate too soon? A lot of times, people get confused by the two. Sometimes if they ejaculate too soon, they'll think, oh, I have an erection problem, but it's really an ejaculation problem. So one, clarifying what's happening by themselves and with their partner. Because sometimes it's a, it's an issue, and we have to sort of separate those two. And then are you getting nighttime erections? So are you waking up in the morning with erections, or do you get erections throughout the night? That's a really good indicator that all those five things are working well, minus the psychological, because that's asleep, right? You're asleep.

• 9:48Speaker 01

  And so I think, I think that's sort of where I start. But also, like, what is, what's going on that, you know, you're not having sex in the relationship? We have to look at the whole person. It's not just about erections, right? So what's going on with your partner? Is one person initiating and one person, you know, sort of rejecting? Or do you initiate and you have sex, but it's uncomfortable for one of you? Or do you find that like, what is going on in the relationship, basically? And then also, you want to look at what specific thing is, and you have to ask the questions. Like, are you having a problem with ejaculation? Are you having a problem with orgasm? A lot of times, guys won't bring that up, right? You have to ask, like, is it take a long time to ejaculate? A lot of times, that's one that people don't talk about very often. They'll talk about premature ejaculation.

• 10:33Speaker 01

  But delayed ejaculation, I suspect, is more common than we see in the literature. It says about 9%. But there's guys who are like, I'm embarrassed to say that it takes me too long, because it's a, it's considered a good thing to last longer. But then they're struggling, and they're like, man, it takes forever, and it's just not fun anymore. And so you have to ask all these different questions. Is the sensation normal? So you can really investigate what exactly is going on.

• 10:54Dr. Darshan Shah?

  Yeah. Going back to, you know, nighttime erections and morning erections, is there where to measure that? Is there a certain number of nighttime erections? I know there's different tools out there to measure those.

• 11:05Speaker 01

  So on average, a healthy person will have three to five erections throughout the night.

• 11:10Dr. Darshan Shah?

  Right.

• 11:10Speaker 01

  Now, when you're young, they'll last a lot longer, so you'll probably notice they may be, if you wake up in the middle of the night, you're more likely to wake up with an erection. Whereas when you're older, they last a little bit, the duration is shorter. And also, sometimes they get a little less blood flow as you age. But if you're healthy, you should be able to maintain nighttime erections and morning erections. Now, sometimes the morning erections are variable, depending on when you wake up, based on your sleep cycle, because we know they sort of follow your sleep cycle, and they come during REM sleep. And so if you, you know, wake up at an off time, you may not have an erection. But there are tools that you can assess to see if you have them. I think one is just assessing yourself, like, do you wake up with one, and has that changed? There are sort of wearables that guys can get over the counter, that you can wear at

• 11:52Speaker 01

  night, and it will measure how many erections you have, and how, how much the expansion is to assess sort of blood flow. And they'll give you that information. And then, you know, there's tests you can go to the doctor and get done. But I think ultimately, those are not used very often anymore.

• 12:06Dr. Darshan Shah?

  What are some of these wearables? Do you have the names of any of them?

• 12:08Speaker 01

  Yeah, so there's Atom, and there's Firmtek that I know of. And so they're both companies, I, I'm more familiar with Firmtek, but essentially, they're, it's, it's like a cock ring, essentially, that you wear, but it's, you're able to wear it all night, whereas normally, you would only wear a constriction band or cock ring for 30 minutes. And so these are safe to wear at night, and they have sensors, and they essentially will measure how much, you know, the girth, essentially, and how much blood flow is, with that as a surrogate, how much blood flow is going in, and is there girth expansion or not, and how long that lasts.

• 12:40Dr. Darshan Shah?

  Yeah, you know, and the reason I mention this is that I think we live in this new age of like self-quantification, and this is something that people can actually use and measure, and get some real data behind, right?

• 12:51Speaker 01

  Absolutely.

• 12:52Dr. Darshan Shah?

  Because I think a lot of men, maybe they are confused. It's like, you know, how many erections I had last night? Some mornings I have one, some mornings I don't.

• 12:59Speaker 01

  Yeah.

• 13:00Dr. Darshan Shah?

  And it's like, now you actually can get some data around this, that you can then take to your urologist and talk about, like, I measured this, right?

• 13:07Speaker 01

  And you can measure it over time, right? And you can potentially see if an intervention made a difference.

• 13:12Dr. Darshan Shah?

  Right.

• 13:12Speaker 01

  Right? So if you started a medication or a supplement, you can see, like, is there a difference in my nighttime erections or not?

• 13:18Dr. Darshan Shah?

  Yes.

• 13:18Speaker 01

  And so it's, it's a nice tool for that. I just think the one caution I make is, some people are really anxious with data, so you just have to be careful that it's not going to make you anxious, right? Because if you have a bad night, which you can have, that it's, it's not like the end of the world.

• 13:31Dr. Darshan Shah?

  Right, right. So say you're one of those people, you're getting erections, and you're doing fine with that, but there's a problem in the relationship, right? Where many of the things that you mentioned, how does someone approach those problems beyond just talking to your significant other about it? And specifically, I'm just talking about like, finding the right therapist to help with these.

• 13:50Speaker 01

  Yeah, I mean, I think these are really difficult problems, because no one taught us how to talk about sex, right? And not even to our partners, or friends, or parents, or anyone, right? We don't talk to anyone about sex. The only person you might talk to is your doctor, if you're lucky, right? If you have the right doctor that you feel comfortable with. So I think first and foremost, realizing that any conversation you have, especially if it's with your spouse, is going to be awkward, or partner, is going to be awkward the first time. And it's, it's, it's a, it's a skill that takes time and practice. And so if you're going at it on your own, just know that like, the first conversation is going to be awkward, this 10th conversation might be awkward, but it's worth putting in the effort and trying to have a conversation. Now, in terms of getting help, we have lots of great sex therapists, but you have to find one that you connect with. So I think realizing that if you go out on a limb, and you're like, hey, I find a sex

• 14:35Speaker 01

  therapist near me, and there's websites, we can link to asect.org is one of them, where you can find sex therapists near you, they'll do in-person, telehealth, whatever. But if you don't click with them, just like any therapist, like, don't get discouraged, you just need to find the right fit for you. And so, you know, I think looking at that and saying, you know, sometimes we just need help to have these difficult conversations, and it can be super helpful to have a therapist at your side. And there's different types of therapists that use different types of approaches, right? There's some that use cognitive behavioral therapy, there's some that use like somatic techniques and different types of tools. And so you got to figure out what kind of, you know, works for you best. And so doing a little research in that area, and finding someone that you connect with and feel comfortable with. And sometimes it's like, hey, I don't want a female therapist, I want a male therapist,

• 15:20Speaker 01

  or I want a therapist who is more comfortable talking about fetishes and kinks, or whatever it is. But like, really looking at that and saying like, okay, just because one conversation goes bad, I'm not going to give up, I'm going to really work at this. And I think a lot of guys struggle. They don't want to talk to a therapist. Like, I see lots of patients who, it took them so much to come see me, right? They were already stressed about coming to see me, and then I'm like, go see a therapist. I'm like, oh, I'll think about it, you know? And they really, and I'm like, look, I really think it would be beneficial for you, I really think you should, you're already investing in time to see me. And, and eventually, they get there, but it takes, it takes some work.

• 15:53Dr. Darshan Shah?

  Yeah, absolutely. When, you know, I talk to a lot of patients, and a lot of them have struggled with their relationship with their significant other. And they have very positive things to say about like MDMA and assisted therapy. Have you found that to be helpful for some patients?

• 16:09Speaker 01

  You know, I don't know much about that, but I would say that if, I think those are tools that can be helpful in a, in a safe environment where you have oversight. I think that can be very helpful, because it allows you to sort of go in a situation where your inhibitions are lowered, you know? And I think that can be very helpful.

• 16:24Dr. Darshan Shah?

  Yeah, I think it's another tool in the toolbox. But to your point, you got to not give up after one therapy session doesn't work out, find the right person that can really help get you there, and it's going to be a process over time.

• 16:35Speaker 01

  Yeah, and this is really tough. It is really hard, it's very triggering for people, it's very triggering for people when they talk to someone and they get a negative response, and then they, they just shut down, because this is so intimate and personal, and it almost feels like a personal failure. And so I think realizing like, this is just another condition in my body. This is just like high blood pressure or diabetes, and I am going to seek help for this condition. And it is not, it is, it is not a negative thing or a positive thing, it just is. And so trying to look at it from that perspective, and saying like, you know, when someone responds in a way that's maybe not the way you expected, it's about them. It's, it's their, they may be dealing with their own things, they may be stressed about something else, they may be having their own responses to talking about sex. So really just like trying to own what you feel as, this is just facts, this is just

• 17:20Speaker 01

  how I feel, and I'm just going to talk about it. And, and trying to, you know, separate all the emotion, and it's really hard to do. I'm not saying it's easy, but like, I think really trying to separate emotion from this. And I struggle with it too. Like, I think it is challenging to talk about your own personal struggles, and with anything. So I think just, just realizing anything that's worth working for is worth doing the work for, and sex is worth working for.

• 17:43Dr. Darshan Shah?

  Yes, absolutely. And I think also for men, there's a lot of shame around it. I think also, you know, the, the significant other, if it's a female, or even a male, they might think it's them, right? It's them, they're not attractive, they're not performing well, or something like that. So I think, I think there's also, therapy can be very helpful in just bringing out the truth of what's happening.

• 18:03Speaker 01

  Absolutely. It's very difficult. I think in society, we've made it very difficult to be, be vulnerable, for men to be vulnerable. And I think, you know, but I think if you restructure this as a health issue, like, I'm trying to protect my health, then it's less, there's less stigma associated with it.

• 18:19Dr. Darshan Shah?

  That's so true, yeah. That's great reframing. And so, you know, I think we've, what I'd love to do is go back now to these five causes, right? Because I want to do a deeper dive into each one. Let's start with vascular again, if you don't mind. So you had mentioned earlier that a vascular problem in a man's penis can show up way before a heart issue, because the vessels are smaller and more fragile. So does that mean that they can have cholesterol deposits and plaque, just like heart vessels can?

• 18:48Speaker 01

  Exactly. And that's what causes the decreased blood flow. And so when you think about an erection, what happens is, your, your vessels release nitric oxide, and your nerves release nitric oxide, which is the ignition for erections, which happens when you have stimulus, like, you're turned on, right? You're aroused. And so it releases nitric oxide, that nitric Nitric oxide signals to your sends a cascade of signals to send blood flow into the penis. That's what makes the erection and makes it rigid. And then, once you are done, typically, the vessels will, the, the blood flow will slow down, your veins will open up, because the veins get compressed when you get all that blood flow in, and the blood flow will leave. So it can either be a problem with those blood, those arter- arteries being clogged, or, or unhealthy, so the blood flow is not getting in, or it

• 19:32Speaker 01

  can be a problem with the veins not compressing, and that's called a venous leak. And so the blood flow leaves the penis too soon. And so, either way, the treatments that we often use are to increase blood flow into the penis. And so, those are, most of the treatments we have, for the, based on the guidelines, are all Band-Aids. They're not really fixing the problem. They are just getting more blood flow to the area, so that you can get an erection.

• 19:55Dr. Darshan Shah?

  You're talking about like Cialis and-

• 19:57Speaker 01

  Correct.

• 19:58Dr. Darshan Shah?

  Yeah.

• 19:58Speaker 01

  Cialis, Viagra, Levitra, all those medications are essentially Band-Aids, right? They're just getting blood flow to the area for that time period. And even injections like Trimix or Edex, those are just getting blood flow to the area in the moment. They're not fixing the underlying problem, which is, again, back to oftentimes, the vessels.

• 20:17Dr. Darshan Shah?

  Right. And so, what does someone do to actually fix the vascular problems, so they have a long-term solution, and they don't need to be on like, these medications forever?

• 20:25Speaker 01

  Yeah, so, you know, it's not sexy. It's, it's the hard work, right? Like, diet, exercise, making sure that you're, in addition to that, like, making sure your pelvic floor is healthy, that it's not too hypertonic or tense, because that can make it difficult to get blood flow to the penis. So, stress is a big part of it, sleep, stress reduction. And then, the other sort of things that come into play oftentimes, not specific to vascular problems, but like, when, there's a lot of external factors, right? Like pornography and masturbation. And, and so, how do we use that in a way that's healthy, rather than sort of using it as a scapegoat for negative emotions and things like that, which then sets our brain up to sort of look at those things for arousal, and makes it difficult

• 21:08Speaker 01

  to get aroused with a real person, right? And so, we're kind of resetting our, reframing our set point for arousal, when we overuse those things. And so, I think, generally speaking, those are the foundations that we really need to work on, basically.

• 21:21Dr. Darshan Shah?

  So, you know, some of the things, besides the medications like Cialis and, and some of the others, that people have talked about are nitric oxide supplementation. Do you think that that's valuable?

• 21:33Speaker 01

  You know, there's no strong evidence that nitric oxide boosters are like, showing an improvement in erection quality. And I think the challenge here with supplements is, there's a huge placebo response to, to any sort of medication, whether it's a pharmacologic or a supplement. So, in erectile dysfunction, it can be as high as 40%. So, as high as 40% of people will respond to a sugar pill. And so, I think the challenge is, you know, how do we know, right? If it's, because people will come and say, yeah, this is working for me. Great, then it's working. I'm happy it's working.

• 22:03Dr. Darshan Shah?

  Either psychologically or physically.

• 22:05Speaker 01

  Right. And so, but I can only go by the evidence, and right now, there's no great evidence that nitric oxide boosters specifically work. What we see the best evidence in, is sort of amino acids like L-arginine, and L-carnitine, those have shown sort of the most benefit in terms of, of, and L-citrulline have shown the most benefit in trials, in terms of improving blood flow to the penis. And so, those are the ones that I say, if you really want to try something, probably start there, if you don't want to try a pharmacologic. But, I also really like daily Cialis, because it works sort of every single day, behind the scenes, a low dose, and it helps you get blood flow to the penis throughout 24 hours. So, it does sort of help, kind of, throughout the, throughout all 24 hours, rather than just being a Band-Aid.

• 22:50Dr. Darshan Shah?

  Yep. I think there's some observational studies showing that daily Cialis can also lead to potentially better longevity outcomes as well.

• 22:58Speaker 01

  Yeah, they're, they're pretty exciting. I mean, I think there's, there's brain health benefits, there's potential muscle health benefits, there's potential cardiovascular benefits, and time will tell if we see these in randomized controlled trials, but I think there is some potential benefit there. And so, you know, we'll see where that leads, but I certainly think that's another reason, like, if you're getting a benefit on it, keep going.

• 23:17Dr. Darshan Shah?

  Yep. And the low dose Cialis is like, what, 2.5 milligrams? That's like, the minimum to take on a daily basis?

• 23:22Speaker 01

  Yeah, 2.5 or 5.

• 23:23Dr. Darshan Shah?

  Okay, got it. And then, is there any danger of taking Cialis for the long term? Or, you know, a lot of people say, well, I'm just gonna get hooked on it, and I'm gonna need it for every single time. What are your thoughts around that?

• 23:34Speaker 01

  So, I think, you know, there, in some cases, I find, when people are struggling, it helps build their confidence back, right? So, like, if you're struggling, and you're like, I just need a little boost, and I'm struggling mentally, and like, oh, now it makes it a little easier for me to get an erection, and once you get your confidence back, you can sort of wean off. But there are some people who start, sort of, if they're taking it specifically on demand, they get really used to like, I need this pill before sex to have an erection. And so, there are some people who can mentally sort of get that connection, but I don't see it very often. And I think ultimately, I think it is very safe, but there are obviously some cautions. One is that if you're on nitrates, which is a medication that you would take for like, chest pain, that your doctor would prescribe for you, you can't take both of those together, because they can drop your

• 24:16Speaker 01

  blood pressure quite low. And then, also, if, you know, you have very bad heart disease, we want to make sure that your body can withstand that extra blood flow, so you do need to sort of, there's like a Princeton cardiac guidelines that we sort of need to follow to make sure that it's safe for you to take. But, I would say, if you can have sex physically, like, you can do that, then it's probably safe for you to take. And then, there's some new data about daily Tadalphil, and maybe the risk of glaucoma. And I think that's a little unclear yet, because it works in different pathways to increase blood flow and decrease blood flow to the eye. So, remains to be seen, but I would say, if you're taking it daily, probably make sure you're, you're up to date with your eye health as well.

• 24:53Dr. Darshan Shah?

  Yep. And then, what about if you tried this, say, a doctor recommended it for you, and you've tried it, and you still can't get an erection? Then, what's going on there? And what should you do next?

• 25:05Speaker 01

  Yeah, so first and foremost, are you taking it correctly? So, with Cialis, you don't have to worry about food, but if you're taking, let's say, Viagra, or Levitra, or any of the other medications, if you take it with food, it becomes less bioavailable. So, you can still get side effects, but you won't get the benefit. So, you want to make sure you're not taking it with food, that you're on mostly an empty stomach, or a really light meal, if you have to eat, because that's gonna work better. Two, you need to take it an hour or so before, if you're taking it on demand, and you need stimulation. It's not just gonna give you an erection magically. And so, I think what we do see in the data is that, for example, for Viagra, on the first try that people take it, the success rate is about 60%. When you take it up to eight times, that success rate goes up to 80%. So, there is a little bit of a learning curve, so I think, don't like, despair right

• 25:47Speaker 01

  away. And then, I think also realizing that sometimes, you just need a different agent, maybe a different dose. And so, don't give up, like, go back and say, okay, this one's not working, what do I do next? Do I increase the dose? Do I switch to a different medication? And I would start with those things. And then, there are a whole bunch of other options that you can go down the line with. There's vacuum erection devices, there's injections, and then there's newer regenerative therapies that I really think are great and exciting, like shockwave therapy, has some pretty good evidence, but it's still early, in terms of, it's not been accepted by the American Urological Association guidelines. PRP is still very, very early, I think, in terms of erectile function, and stem cells even earlier than that. But, I'm hopeful. I think that the fact that we're looking at this

• 26:31Speaker 01

  data, and we're really investigating it, and we're finding positive results, and a way to actually reverse the problem. So, these things are working by increasing angiogenesis, so they're rebuilding blood vessels in the penis. And so, I think, I'm so glad that we're in that space, because, you know, we need to be. But, on top of it, we still need to be fixing the underlying problem, you know, which is the vascular problem, or the hormonal problem, or the medications that you're on.

• 26:55Dr. Darshan Shah?

  Yep, absolutely.

• 27:00Dr. Darshan Shah?

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• 27:41Dr. Darshan Shah?

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• 27:58Dr. Darshan Shah?

  So I did want to ask you about shockwave therapy because I feel like a lot of people don't know about that. Can you talk about what that is and where you get it done and how does it work? Does it hurt? You know, it sounds painful, but.

• 28:09Speaker 01

  So shockwave therapy is essentially sound waves to the penis and they work by essentially getting deep to the erectile tissue and they create sort of a little focus of mechanical trauma. And then your body sends in these growth factors in to start telling it, hey, build more blood vessels and maybe even build more nerves. But we know, we know blood vessels. And so it sends in these growth factors and then your body over time starts building in new blood vessels and over time your erections get better. Now, there's some caveats. The data would support focused shockwave, which is a specific type of shockwave that gets deeper than the radial shockwave. So it gets deeper to the erectile tissue and that's what we see the most benefit with. The radial, we believe is too superficial to see real benefits, although some people

• 28:52Speaker 01

  still report, there's like some small studies that show some benefit. And so what the protocol is right now is pretty much for mild to moderate vascular ED. So if we know it's because of a vascular cause, we know it's not because of a psychogenic cause, a hormonal cause, or we've ruled all those other things out, that's where we see the benefit. Once you have really severe erectile dysfunction, you're unlikely to see a benefit especially by itself. You may need to do some additional things. And so typically it's once, once or twice a week for, you know, six to nine weeks. And then after that, you know, there's usually a maintenance protocol because what we see is after we do that at one or two years, based on the data, we'd say that about 50% of people still see benefits. So probably to maintain that benefit and about 60 to 70, more like 70% of people will

• 29:37Speaker 01

  see benefit with shockwave therapy initially at the three month mark, but that decreases. And so to keep that benefit, there's probably some maintenance required, but we just don't know exactly what that is. I used to do every, you know, every quarter or every six months, but at the very least every year.

• 29:52Dr. Darshan Shah?

  Yep. And it's probably different by patient too, right?

• 29:55Speaker 01

  Yeah. And I sort of let patients guide, you know, like if they're like, oh, I think, you know, I could use another, you know, I feel like it's not as great as it used to be. It's consistently going down a little bit, then yeah, come on in, we'll do it again.

• 30:05Dr. Darshan Shah?

  And since it's causing regeneration of blood vessels, it seems like PRP or stem cell injection therapy at the same time potentially could even be like synergistic with it?

• 30:14Speaker 01

  Yeah, absolutely. And there's some studies looking at that. So we'll see what they say. Cause I think the PRP data by itself, there's a mixed result. So some will say, yes, we see a benefit. Some randomized control trials have not shown a benefit. So I suspect that we'll see more synergy with, you know, shockwave and PRP, but we don't have the full data on that yet.

• 30:33Dr. Darshan Shah?

  Got it, got it. And is it painful?

• 30:35Speaker 01

  So the shockwave itself is not painful. You do feel it, like you feel sort of this, this occasional twinge, but it should not be like exquisitely painful. And then with the PRP, it depends on how much volume you're putting in, but if you're putting in a large volume, that can be uncomfortable.

• 30:50Dr. Darshan Shah?

  Got it. And you know, you mentioned focus versus radial. The only one I've heard on, heard about is Gainswave, I think is, which one is that? And what are the different like modalities people should be searching for?

• 31:02Speaker 01

  So at home, they're all going to be radial because focus has to be done by a provider. And so if you're using anything at home, which is some of these Gainswave, Gainswave devices, they're radial. And so like I said, there are some studies that show benefit, but the lot, the totality of data would focus on focused shockwave therapy. And so generally speaking, you need to go into a clinic and you need to ask them, are you using a focused shockwave machine? Or ask them what machine they're using so you can look it up because they look and sound the exact same. So you can't tell just by like, when you go in, it's going to be the exact same experience. Sometimes radial is more painful. So that is some, a little way you can sort of differentiate, but you do have to ask.

• 31:39Dr. Darshan Shah?

  Got it. That's really good tip because I don't think people know what are the different devices and where to find them. And usually, like you said, as a practitioner, so you're usually going to like a urologist's office to do this. Got it. Okay. Let's go on to the next cause. I think the next one, we went from vascular to now metabolic, right? Can you talk about metabolic causes of erectile dysfunction?

• 31:58Speaker 01

  Yeah, so metabolic and vascular sort of go together, but guys who have diabetes have three times more likelihood of erectile dysfunction because diabetes not only affects the blood flow, but also affects the nerves of the penis. And so the most important thing is to get your diabetes well controlled so that you don't get the problems with erectile function because once you do, it's very difficult to reverse.

• 32:17Dr. Darshan Shah?

  Really? So what does a diabetic do to reverse this?

• 32:21Speaker 01

  Well, just what your endocrinologist or primary care would tell you, right? You gotta reduce your sugars, diet, exercise, all the things that are tough to do, but, but really what I follow often in my patients is their hemoglobin A1C, which is their marker of their blood sugars over the last three months. And we want it to be as low as possible. And if you are, the other thing that I think guys don't realize is penile implants are a great surgery for erectile dysfunction, but if you're diabetic and your hemoglobin A1C is above eight, you're going to be hard pressed to find a surgeon who's going to operate on you because it's dangerous. It's a higher infectious risk.

• 32:54Dr. Darshan Shah?

  Yeah, absolutely. I do want to talk about penile implants. So why don't we just, since you mentioned it, let's talk about it. I mean, I think that's super scary for most guys to think about it. They think it's only for old people, people that are like on their last leg almost. What are your thoughts and how do you counsel patients on penile implants?

• 33:09Speaker 01

  So I think it is a great option for people who need it, right? So people who are having difficulties with erections, they maybe have tried other things and have failed and they're at the point where like they want to get an erection on demand when they want it. But I always tell my patients, it's not the same as getting your own erection. So like it will give you an erection that's firm enough for intercourse, on demand, lasts as long as you want it to. That all sounds great, but it will never look and feel like the same erection you used to have because that's blood flow that allows for stretching in a different way than an implant can. And so an implant can come in different flavors. The most common is a three piece. So it's a, got a pump in the scrotum and you've got two cylinders in the penis and a reservoir in the lower part of the abdomen that you don't see.

• 33:53Speaker 01

  So when you want to have sex, you pump it up. It takes like 20 pumps to get it fully maximally inflated and then you have sex. And then when you're done, there's a button on there to deflate it and you deflate it and then it looks normal. So for the average person who maybe you're in a new relationship, they don't know, they don't necessarily know because it looks like a normal erection unless you, unless they watch you inflate it or deflate it. And so it is a really good option for guys who are like, I, nothing's working and I just really want to have penetrative sex. Now sex can be pleasurable without penetration. You can still orgasm, you know, there's, there's lots of things there that you can unpack, but there's still many, many guys who just want to have an erection, have penetrative sex. And so this is a great option for them, but there are risks. It is pretty low risk of getting an infection, like less than 3%.

• 34:37Speaker 01

  So it's, it's quite low, but it is an implanted device. And so there are risks and the device usually lasts about 15 years and then something usually like needs a replacement. So, but it is something that, you know, you can get at any age. There's no like, oh, you have to be 50 or you have to be, you know, at any age, if you have really bad erectile dysfunction. So for guys who have like a venous leak, for example, from trauma, those guys could be very young and they could have no erection. And so for them, this could be transformative because they're young and they want to have sex and they have a willing partner. And so I think one is, I want to destigmatize, there's no age for it, but two, it's something you have to take very seriously and ideally find a doctor who does a lot of implants, right? You don't want to go to someone who does like five a year.

• 35:20Speaker 01

  You want to go to someone who does like 50 a year because they are really familiar with all the, you know, that they do it quickly, they do it with the least infectious risk. And so that's what you want.

• 35:29Dr. Darshan Shah?

  Is there newer technology now? I remember like in, when I did my urology residency, I did a couple of these and it wasn't very slick back then, but this was 30 years ago. So I haven't seen one since then. I'm sure the technology's gotten better recently.

• 35:43Speaker 01

  It's, I mean, the pumps have changed a little bit, like they're a little more comfortable and they're easier to pump up and deflate, but I think they haven't changed that much.

• 35:51Dr. Darshan Shah?

  Oh, really?

• 35:52Speaker 01

  So we, we do have, they keep talking about like building a Bluetooth version of it, which remains to be seen. Cause then you have to have a battery and there's, you know, there's other factors, but you know, we'll see.

• 36:04Dr. Darshan Shah?

  And then you have to put a battery in, right? These are fully mechanical devices and not electrical at all in any way. And they're all just air-based, right?

• 36:12Speaker 01

  Fluid.

• 36:13Dr. Darshan Shah?

  Fluid-based, got it.

• 36:14Speaker 01

  Hydraulic essentially.

• 36:15Dr. Darshan Shah?

  Hydraulic, right? Exactly. You know, before getting a penile implant, there's other steps you do first, right? Obviously you try the medications, you try all the lifestyle factors. Maybe you try something like a focus ultrasound. And if that doesn't work, I think another step is there's injectable medications as well, right?

• 36:32Speaker 01

  Exactly.

• 36:33Dr. Darshan Shah?

  Can you talk about that?

• 36:34Speaker 01

  Yeah, so there's what we call intracavernosal injections. So basically you're injecting a vasoactive or an injection that causes increased blood flow, basically locally to the penis. And these work very, very well. So I think a lot of people get very scared and every patient I know, I tell them their eyes widen, you know, they're like, oh my God. And I'm like, look, it is a tiny, tiny needle. It's like an insulin needle. And when I've given them to patients in the office, they look up and like, you're done? You know, like they don't even, they barely feel it. So it's really a small needle and we teach you how to do it in the office. You inject yourself and within about 10 minutes with some stimulation, you get an erection. Now the beauty of these is there's multiple different formulations and different doses. So even if you don't respond to the lowest dose, you can sort of figure out the right dose for you.

• 37:16Speaker 01

  We don't want to overshoot it because with this, there is a real risk of getting a, what's called a priapism or an erection that lasts longer than four hours. And while guys are like joking, this is great, it's not great. Cause at that point you're not getting blood flow in or out of the penis and you're causing permanent damage. And so we tell people, you gotta do one injection at a time. Do not do it again if it didn't work. You gotta wait 24 hours to try another time. And then you don't want to overshoot it. So like if you did 20 units, you don't want to do like 40 the next time. You want to do like 25, you know? Go slowly to find the right dose for you. But they work really, really well. And I think they're really useful for people in terms of like, it works, it's quick, it's consistent and it's reliable.

• 37:59Dr. Darshan Shah?

  Yeah, that makes sense. And I think sometimes people decide whether they want to just stick with injections or go to implantable, depending on their preference. Is that true?

• 38:08Speaker 01

  Yeah. And some people will say, I just don't want injections. And that's okay too. I think anyone is eligible for an implant as long as you know the risks and benefits. So if you're like, I don't want to inject myself, I don't want to try a vacuum erection device. I don't even, you know, I tried medications or I don't do well with medications. It's, it's reasonable to talk about it.

• 38:23Dr. Darshan Shah?

  Yeah. You mentioned vacuum erection devices a few times too. And I know there's a lot of stigma around that as well. Are there like? It sounds like these are almost like in your mind, like a medical device, right?

• 38:35Speaker 01

  They are.

• 38:35Dr. Darshan Shah?

  Like that people can use.

• 38:36Speaker 01

  Yeah.

• 38:37Dr. Darshan Shah?

  And do they have a good success rate? And is there one device that works better than others?

• 38:41Speaker 01

  So they are, they are very successful. Once you get over the learning curve. So the success rate in their literature is like 95%. Because basically what they do is you put on the cylinder on the penis. You pump it up either manually or with an automatic button. And it basically forces blood flow into the penis. And then you take a constriction band and you roll it down onto the base of the penis. So that blood flow that you've now pumped in stays in the penis. And so the difference, the reason that I think some people, one, is there's a learning curve. Like what's all this stuff? I gotta learn how to use this. But two, it doesn't feel exactly like a normal erection. Because it's also pumping Venus blood flow into the penis. So sometimes it feels a little bit cooler. It maybe looks a little bluish. And so it doesn't feel exactly the same. And then it's really figuring out that constriction band, how tight it needs to be. We don't want to be too tight or too loose.

• 39:26Speaker 01

  If it's too loose, that you'll lose the erection. If it's too tight, it's uncomfortable. So I think there is, you know, there's a lot of little steps that you gotta figure out. But once you do, it can be really useful.

• 39:36Dr. Darshan Shah?

  But this is something that, you know, you do immediately before sex. So you and your partner need to have a conversation about it.

• 39:41Speaker 01

  Yeah.

• 39:41Dr. Darshan Shah?

  And it's not something that is like, you know, is that something you just say? Use all of a sudden out of nowhere?

• 39:47Speaker 01

  I mean, you could, but ideally you wanna like, your partner is on board. You could make it part of the experience. Like it's kind of fun, right? You make it part of the foreplay. That's the ideal scenario.

• 39:56Dr. Darshan Shah?

  Got it, got it. And, you know, I love it that we're having this open conversation about this. Because this stuff people don't normally like to talk about.

• 40:02Speaker 01

  Yeah.

• 40:03Dr. Darshan Shah?

  And it's definitely, you know, people don't know the tools that are available. So these are all tools that are available.

• 40:08Speaker 01

  Absolutely, and this is, you know, I think people think of it as a penis pump, right? Penis pumps are more like recreational. This is an actual medical device, right? And so these are like FDA cleared and they, you know, they, they use limiters on the amount of pressure you can use, so they're safe. So I think, you know, think of it as a medical device.

• 40:24Dr. Darshan Shah?

  Right. What are some of the names of the ones, the medical devices?

• 40:26Speaker 01

  So there's like, there's so many, but there's like soma, there's

• 40:32Speaker 01

  tim, there's, there's a bunch of them, but those are the two that come to mind. But you could just type in vacuum erection device on Amazon and look through and see what, you know, try different ones and, and see what you like.

• 40:42Dr. Darshan Shah?

  So, so these are not prescription? These are like, you can actually buy these on Amazon?

• 40:46Speaker 01

  Sometimes you can get a prescription for them. So some insurances will cover a vacuum erection device. So it's valuable to look at, you know, at your insurance and see if they will. Because they can be expensive. They can be anywhere from, probably the, the medical devices are around $400. So it's, you know, if you have insurance coverage, that's nice to have.

• 41:04Dr. Darshan Shah?

  Yeah, makes sense. Okay, let's go on to the other big one now, hormonal testosterone.

• 41:10Speaker 01

  Yes.

• 41:10Dr. Darshan Shah?

  Talk to me how you counsel your patients on testosterone.

• 41:12Speaker 01

  Yeah, so testosterone is very important. I'm sure you've talked about it many times on this podcast. Testosterone is not just important for erections. It's important for mood, for brain health, for bone health, for muscle health. And so when patients come in with low testosterone, they'll usually have one of those symptoms, like brain fog, they'll have fatigue. And these are again, very general symptoms, nonspecific. Loss of sort of depression, increased fat mass, decreased muscle mass, loss of morning erections and loss of erections and loss of sexual desire is very sort of specific to low testosterone. But of course, sexual desire has multiple components. So I think anyone who comes in with those symptoms, we say, okay, this could be low testosterone and how do we test it? We test it with a blood test.

• 41:55Speaker 01

  And so we do testosterone and based on the guidelines, you wanna get it in the early morning, because that's essentially where they've looked at population based data for what's normal. Normal is like 300 to 1,000, right? So it's really like, what's normal? Like, is 301 normal? And so I think that's the challenge is, is understanding that what's normal, based on guidelines, is, is above 300. But what I really love is for the younger guys listening, if you are feeling great, get your testosterone checked now. Get it checked once or twice. So you have a baseline of like what your testosterone is. Because at this time, I don't have a test where I can look at the receptors on your cells, where the testosterone attaches to. Because some people's receptors are more sensitive. Some people have less receptors. Some people have more. And so I can't tell that information.

• 42:40Speaker 01

  And so I have to guess, right? And, and so I think that's a really nice place to start. Because otherwise, I really don't have much to go on. And then the other thing is to really evaluate your, the other hormonal factors. So also checking your estradiol, checking your SHBG, which is a protein in the blood that carries testosterone. When you have a higher SHBG, it takes more testosterone that's not visible to your bloodstream to the, or end organs. And so you wanna, that's your free testosterone. And so checking that or calculating that with SHBG is very helpful. And then if you are low, there are natural ways to boost testosterone. And then there are obviously testosterone replacement therapy. And I think the important thing is a lot of people think, you know, everyone should be on testosterone. It's great. It's like the fountain of youth.

• 43:26Speaker 01

  But there are some, it is a great medication. I love testosterone replacement. But there are some sort of caveats. One is that it will cause infertility in the large majority of guys who are on it. And so it's really important, because a lot of young guys are starting on testosterone replacement without knowing that. And they're not getting counseled on that.

• 43:42Dr. Darshan Shah?

  No.

• 43:42Speaker 01

  And then there are risks of erythrocytosis or the blood getting thicker, which puts you at risk for blood clots and strokes. So you do need to be followed by a doctor. And it can cause testicular shrinkage, because it essentially takes over your body's normal production of testosterone. And so when your body sees all this exogenous testosterone that you're injecting, or you're putting a gel or whatever, or taking it orally, your body says, hey, you have enough testosterone. I don't need to make any. I don't need to send signals to the testicles to make them. And so over time, they can get smaller.

• 44:10Dr. Darshan Shah?

  Yeah, yeah. All things that, you know, we, we should definitely be counseling our patients on before you take it. And I think a lot of people are getting their testosterone now online and they just fill out a form and testosterone shows up at their doorstep, you know? And they don't get the adequate amount of counseling around infertility is a huge one. You never wanna be surprised by that, right? And then also to your point, you know, I think people get very emotional about when they lose their testicles, their testicles shrink. But because no one's told them about it, this was gonna happen, right? And so this is really important to have a really good, in my opinion, a good practitioner. If you're gonna, I'm gonna undergo testosterone therapy.

• 44:46Speaker 01

  Absolutely, and then, you know, making sure that you're picking the right formulation for you. Because there are more than just injections. And a lot of people, they're basically just getting injectable testosterone and understanding like, what are the options? What might be better for your lifestyle? And what might work better for you? Because everyone is individual, right? You can't just get a blanket, like, here's your testosterone, bye, see you later, you know?

• 45:06Dr. Darshan Shah?

  Yeah, I would say 90% of the testosterone that I see is injectable. But there are other forms to your point. So what do you think about oral testosterone now? I think that's coming up now more and more.

• 45:16Speaker 01

  Yes, the oral testosterone, back when we were training, you did not give oral testosterone.

• 45:21Dr. Darshan Shah?

  Because of liver issues, right?

• 45:22Speaker 01

  Right, and now it's going through the lymphatic system, so it's safer. There's three companies that make oral testosterone. Now, I think that the, what I like about oral testosterone is a quick on, quick off, right? So you take it, you get that nice boost and then it goes away. And so in, we believe, it's still not, it's not, we're not sure yet, but that it may preserve some of that testicular size. Because if you take it, you know, there is some time where your body's like, oh, I don't see enough testosterone. And so it may still allow you to maintain some of that. Now, we can't be sure, but I think that's one plus of it. Two, is it easier for travel? And, and so if you are like, I don't like injections, it's a nice option, but you do have to take it twice a day with food. And so that's a big ask for some people, especially if you're fasting or if you just like, don't wanna take something twice a day.

• 46:07Speaker 01

  But I think for some people where that's easy, they like taking pills, it's convenient, I think it's really great.

• 46:12Dr. Darshan Shah?

  Yep, and then the creams?

• 46:13Speaker 01

  That, so there's topical gels that you apply like once a day on your arm. I think these, about 20% of guys, it won't work. It won't absorb through the skin. So I think that's important to realize. You absolutely need to get your testosterone checked. I check everyone a month after they start to make sure that they're rising appropriately. But other than that, they all work pretty similarly. But the one thing you have to be careful with is that if you touch somebody with your bare arm, like your wife or your child, you can transfer that testosterone. And that can be a real problem. There's actually, I remember there was a news article about a baby girl whose clitoris had grown because her dad had testosterone and was holding the baby. And so you have to be really careful about that. And so if you have small kids at home, it's probably not a good idea for you.

• 46:55Dr. Darshan Shah?

  Or pets too, right? Pets can get it too, yeah.

• 46:57Speaker 01

  Yeah, yeah.

• 47:03Dr. Darshan Shah?

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• 47:45Dr. Darshan Shah?

  And you'll get up to 35% off your first order using the code DRSAH.

• 47:54Dr. Darshan Shah?

  And then lastly, there's different forms of injectable testosterone. Can you give us a quick rundown on those?

• 47:59Speaker 01

  Yeah, so the most common is testosterone sipinate because it's most easily accessible. And it works very, very well. Testosterone enanthinate works, has a little bit of less swelling. So sometimes for older patients, it's a nice option, but otherwise they work very similarly. The testosterone enanthinate also comes in this form called Zysted and it comes in an auto injector, which is really convenient for patients. It's once a week and they show really nice steady levels on that once a week dosing. So I think for some people like I don't have the dexterity to do this. I don't want to draw medications. It's a nice option.

• 48:31Dr. Darshan Shah?

  Yeah, the Zysted, right. And then lastly, there's enclomiphine as well. Can you talk about when that could be useful? This is an oral tablet that stimulates your natural production of testosterone. They've talked about it a few times on the podcast. I'd love to hear your perspective.

• 48:44Speaker 01

  Yeah, so essentially how these, there's clomiphine and enclomiphine and they're similar. Enclomiphine is, has less estrogenic effects, which is why we like that a little better. But essentially what they do is they tell your body, hey, you don't have enough estrogen around. They basically block their receptors. And so your brain is like, oh, I need to make more estrogen. How do I make more? I make more testosterone, which then converts to estrogen. And so it is basically telling your brain to do that. Now, the reasons to add that on, to do it alone is if you want fertility, then don't take testosterone, take enclomiphine and potentially HCG. Alternatively, it can also maintain some of that testicular size if guys are worried about that. So that's usually a nice option to add it. Otherwise, it's not, you know, testosterone replacement alone usually works for the large majority of people if you're not worried about testicular size.

• 49:29Dr. Darshan Shah?

  Yep. Is there any side effect of blocking estrogen receptors with these?

• 49:33Speaker 01

  So sometimes, this is with the clomiphine, sometimes what we'll see is that your testosterone number will look great, but you won't get the same benefits in terms of symptom relief. And it's because of the way it affects estrogen and because your brain's not seeing the estrogen, it actually doesn't give you the same symptom benefit. And so that's the thing that we see sometimes with those medications, which is why you do have to be thoughtful because sometimes you'll be like, man, I feel like nothing happened.

• 49:57Dr. Darshan Shah?

  Oh, God, I see what you're saying. So the, if you're using it for maybe more drive, maybe, you know, maybe the symptom is erectile dysfunction and you're taking enclomiphine, you might not get relief of those and that could be a side effect.

• 50:13Speaker 01

  Correct.

• 50:13Dr. Darshan Shah?

  Or not, well, it's just an untoward effect of it, right?

• 50:16Speaker 01

  Yeah, yeah. But I think, I mean, certainly I see guys who have great results with it. So I think it's worth a shot, especially if you don't want to do injections and you want to take it oral. It's cheaper than some other options, especially Clomid is very cheap, right? So like, if you really are like, I'm strapped for cash, I'm just going to try Clomiphine because it's really cheap, that's a reasonable option.

• 50:35Dr. Darshan Shah?

  Right, right. Great. Okay, so that's on testosterone. You know, one of the biggest questions I get from many men that we put on testosterone is, am I going to need to be on this forever? Right? And so that's, that's a tough one for me to really answer, but go ahead. I'd love to hear what you say.

• 50:49Speaker 01

  So I think that within that first three months, if you don't see a benefit on testosterone replacement, I think it's reasonable to stop it because, you know, we don't want you to be on a medication that you're not seeing benefit from because there are risks, right? With anything you're taking. But after that, you know, we start seeing that your body starts shutting down its natural production of testosterone. So if you were to stop cold turkey, you'd feel pretty bad, at least for a few days, if not a few months, depending on how quickly your body revs things up and how long you were on testosterone for. So that doesn't mean that you can't go off of it. It just means that it may be more difficult to go off it and you won't feel good. And so you can sort of like wean off of it with these medications like Clomid and HCG and sort of try to build back up your own production of testosterone.

• 51:31Speaker 01

  But I tell people, if you're going on it, think of it as like a commitment, a lifelong commitment to stay on it because, you know, it's, it's going to shut down your own production.

• 51:41Dr. Darshan Shah?

  Right. And you know, to your point about not feeling benefits and stopping if you don't want it, if you're not feeling anything from it, but what about the things you can't feel from testosterone, right? Aren't there other benefits of testosterone that you maybe don't necessarily feel right away?

• 51:55Speaker 01

  There are benefits in terms of, as you, as I've mentioned, like brain health, muscle benefits and, and, and mood benefits. But I think the challenge is, you know, I don't know what, again, like I said, some people feel great at a low level of testosterone. Like they may be, they come in and their labs are low and like, I feel perfectly fine. So it's hard for me then to say, you need it because I don't know what your receptors are looking like. Are they fully saturated? They might be, right? And so are you still getting a benefit from it? The only thing I can really tell is, are your symptoms better? Do you feel better? And most guys who see a benefit, they feel better. They feel like themselves again, right? I think we hear a lot of this, like people saying for women going through menopause, I don't feel like myself, but it's the same thing for guys. They don't feel like themselves.

• 52:38Speaker 01

  And so finally they're like, oh my God, I'm like energetic, I'm like, I feel like a million bucks and I didn't feel that way for so long. And so usually it's very obvious.

• 52:47Dr. Darshan Shah?

  Yeah, yeah. And I think what's important about testosterone is definitely like a big conversation about risks versus benefit and dosage. There's so much to talk about here and it's so individual. I probably have like, you know, 100 people on testosterone and every single one is a different conversation.

• 53:02Speaker 01

  Absolutely. I mean, some guys feel good at 450, some guys feel good at 600, some guys like, you know, they're like, I really notice it when my testosterone goes below 800, right? And like, I think you do have to believe your patients, right? But I think as long as you're discussing risks and benefits and you're really saying like, hey, this is what we know, this is the, you know, the benefits and risks and, and like, this is, you know, a safe medication if done appropriately, then yeah, absolutely.

• 53:27Dr. Darshan Shah?

  Yeah, absolutely. Okay. So we've covered a lot, vascular, metabolic, hormonal. What was the next one?

• 53:33Speaker 01

  Medications.

• 53:34Dr. Darshan Shah?

  Ah, let's talk about medications. So many people are on blood pressure medications and this can really affect your erectile dysfunction, right? And so talk about, and what are the other classes of medications?

• 53:45Speaker 01

  Yeah, so the two big ones are antihypertensives and, and blood pressure, antidepressants.

• 53:51Dr. Darshan Shah?

  Right.

• 53:51Speaker 01

  So let's start with the blood pressure medications. The big culprits are beta blockers and specifically the older beta blockers like metoprolol and atenolol. So if you need to be on those medications, and it's dose dependent, so you may be on a low dose and it might not affect you. But if you're on a higher dose and you're noticing erectile dysfunction and you need to be on specifically a beta blocker, the newer ones like carvetalol and nabivolol are either neutral or nabivolol may even be beneficial for erection. So you can ask to switch to those. And so those are the big ones with blood pressure. And then always talk to your doctor, like let them know, like, hey, I'm having erectile dysfunction. Can we switch around my blood pressure medications? Don't ever stop them cold turkey because, you know, we don't want you to get in a situation where your blood pressure is sky high and you're in the ER.

• 54:34Speaker 01

  So, so yes, it may be a cause, but like most commonly, those are the, the big culprits.

• 54:38Dr. Darshan Shah?

  So beyond beta blockers though, I mean, most people are now on like ACE inhibitors, they're on ARBs, right?

• 54:44Speaker 01

  Those are better, yeah. Those are safer. ACE inhibitors and ARBs, so captripril, lisinopril, valsartan, losartan.

• 54:50Dr. Darshan Shah?

  Got it. But do they also have like a certain small amount of people that can still get erectile dysfunction while being on them?

• 54:56Speaker 01

  I mean, it's less so. It's very, it's really, it's really, I think, I mean, it's hard to say because so many people have erectile dysfunction, but we haven't found a significant link with those. And so I would say definitely talk to your doctor about that. For blood pressure, for depression, antidepressants, these are a big class of medications that like, they're so great for, for so many people, but they have a lot of side effects in neurology. So one is loss of sexual desire. And so with that loss of sexual desire, if you have no desire, you can't get the arousal necessary to get an erection. And so this is also dose dependent and these are the most common antidepressants, SSRIs, so like Zoloft, Paxil, those types of medications. And so you can talk to your doctor about decreasing the dose.

• 55:39Speaker 01

  You can also talk about switching to something like bupropion, which doesn't have those side effects. But you know, it's, it's a balance because we have to fix your mental health, but we also have to maintain your sexual function. I think the challenge is sometimes like what we don't ask is like, oh, maybe you're depressed because of your erectile dysfunction, right? And so if we'd fixed your erectile dysfunction, you wouldn't even need the medications. Because I see those patients where they're like, oh, you know, I started this medication, but like no one ever, like it was all, I just couldn't get erections and my relationship sucked and I'm depressed because of it. And so, once you fix that problem, you know, that, that improves that they don't need that much antidepressant anymore.

• 56:12Dr. Darshan Shah?

  Yeah, that's a good point, like what came first, right? And lastly, emotional, right? So this is another big category. There's a lot to sort through, but I'd love to hear big picture views on that category. And maybe even talk a little bit about porn and masturbation and how that all ties in.

• 56:29Speaker 01

  Yeah, so I think, you know, the big thing is that once you have a problem, a lot of guys end up sort of spectating, like they're just like really focused on getting the erection and they're just thinking about that. They're not actually in the moment, enjoying the pleasure, enjoying the feeling of their partner. And that's like a normal experience, right? Because they're stressed. And when you're stressed, so I always, when you're thinking about, you probably remember this from medical school, point and shoot, right? So parasympathetic nervous system to get the erection. So parasympathetic is relaxation. So, you know, rest and digest. If you're stressed, you can't get an erection, period. Like it's not going to work. And so you have to reduce stress in some way, shape or form. And, and sometimes, you know, we say this like for, for women a lot, like you want to

• 57:09Speaker 01

  sort of set the stage for desire and like try to just sort of schedule time to be intimate and be together and be physical. And it doesn't necessarily have to be, lead to sex. And I think the same, the same thing is like sort of what some sex therapists will suggest, which is like sensate focus. So you basically are with your partner and you're like, we're going to be intimate, we're going to do everything except for touch and penetrate genitals. We're just going to touch everywhere else. So you're going to really focus on finding other erogenous zones, what feels good and spending time together, right? And being physical. And then once you're not thinking about it, you're like, oh, my erections are great. Now you move on to, okay, now we'll touch genitals. And then, you know, maybe the next few times you're, okay, my erections are great. Now we go on to penetration.

• 57:52Speaker 01

  You're sort of re sort of centering your brain on being mindful and present in the moment. And doing mindfulness activities outside the bedroom can help, too. And so I think those things are, they're tough and they're really hard. And you have to have a partner that's on board with you to work through that. And so it's not easy, but they are a real challenge. And so that's why sometimes I say like giving a low dose of Tadalafil. They don't have to remember to take it. It's just in the background. Sometimes that's enough to give them the confidence that, oh, my erection's there. I don't need to think about it and they can get out of their head a little bit.

• 58:22Dr. Darshan Shah?

  Yeah, that's a good technique because I think getting to that confidence stage can happen with therapy. Tadalafil can help, like couples, therapy can be helpful. All those things need to be used in combination. You have to try all of it.

• 58:34Speaker 01

  Exactly, exactly. And then I think, you know, with pornography, a lot of people use pornography fine. They enjoy it for pleasure. It doesn't detract from their relationship. Some couples watch it together and they have better intimacy because of it. But there are a subset of people where it becomes a problem. And I'm seeing this a lot in younger guys where they're sort of comparing their sexual relationship to what they see on pornography. And then when it doesn't add up, they start feeling like something's wrong with them. It can happen to women, too, right? They're like, I'm not responding like the, the woman on, on the erotic film. And so I think that's a real problem because they're like, oh no, like I don't look like that or it's not responding like that. Now they think something's wrong with them and then that psychological stress carries with them.

• 59:17Speaker 01

  And then the other thing is when they're using the same type of pornography and maybe they're masturbating a certain way, which is not able to be replicated by a person through either oral, vaginal or anal sex, then they are, they're like, oh, I'm not maintaining my erection or I'm not getting hard enough because I'm not getting that same level of stimulation or arousal. So they might get used to a certain type of pornography that's like very exotic. Or they might get used to like a certain type of masturbation, like a very firm grip or masturbating against a hard surface or something like that, which like just a person can't do.

• 59:51Dr. Darshan Shah?

  Like even like a vibrator or something?

• 59:53Speaker 01

  Yeah, so I mean vibrators, I don't like to, if you're using like a really like strong vibrator all the time and that's the only way you masturbate, then certainly your body can get what we call habituated to that, right? But if you look at like in terms of it causing difficulty in sensation or anything like that, it doesn't really persist. So I think that, you know, it's safe to use, but yes, your body can get used to something.

• 1:00:15Dr. Darshan Shah?

  Yeah, yeah. Is there, you know, a number of times that you're masturbating that's too much? Like a lot of people talk about, like on social media, I see this a lot, like, don't use pornography, don't masturbate, save yourself for sex and you'll have better sex. Is that true?

• 1:00:30Speaker 01

  Well, let's be real, there's a lot of people who the only type of sex they're having is masturbation, right? They don't have a partner. And we're seeing in the younger generation, they're having less and less sex. So like if a person wants to have pleasure and orgasms, the only way they're going to have it is through masturbation. So I don't like that idea for all people, right? And I think also there's no magic number, right? I think the real issue is like, is my solo sexual activity starting to create problems for my real life? Like, am I preferring that to going to work? Am I preferring that to having sex with a real person? Is it making me so feel so guilty and depressed because I have this preconceived notion of, I shouldn't do this, it's really bad for me, that now I'm like just feeling horrible about myself? That, those are red flags.

• 1:01:14Speaker 01

  That's when you're like, okay, I need to reevaluate what's going on here and I probably need to talk to a therapist about how to manage this and, and maybe take a break. And so that's, I think, where we say, okay, this is a problem. And I don't want to discount people do absolutely have problems with these things, but there's lots of people who do this without shame, without problem, and they use it as a way to just enhance pleasure for a short period of time.

• 1:01:35Dr. Darshan Shah?

  Right, right. I think it's very good that you spent that just because I think you're right. Like if you don't have a sexual partner, you're not harming yourself by masturbating. It's just getting you through that point in time in your life.

• 1:01:45Speaker 01

  Yeah, exactly.

• 1:01:46Dr. Darshan Shah?

  So, you know, you wrote this incredible book, The Hard Truth. When does this go on sale?

• 1:01:50Speaker 01

  November 3rd.

• 1:01:50Dr. Darshan Shah?

  Awesome. Is it up for preorder right now?

• 1:01:52Speaker 01

  It's up for preorder, yeah.

• 1:01:54Dr. Darshan Shah?

  Okay, great, great. So, you know, if you've a listener and you love what you have to hear on this podcast, then definitely you can get a lot more of this in the book. I do want to touch on if it's not like, if it's okay to talk about your four step protocol that you have in the book, which I think is really kind of cool, right? So if you don't mind telling us a little bit about it.

• 1:02:13Speaker 01

  It's essentially the four pillars of sexual health. So we sort of touched on it briefly throughout this podcast, but there's four main pillars. Fuel, which is what you eat. And what I think is beautiful about the book is I try to make it very, very sort of adaptable. So like you and I grew up eating Indian food, right? So like, you know, there's certain things in our diet that we're going to eat, right? And it may not be chicken and broccoli. And so, so you need to be able to take rules that you can apply to your own diet and, and understand why they work. I think that's the real key is like I go through the science as to why these things are good for you and why certain things are superfoods and why they're not. And, you know, how should you basically make a diet that works for you? With strength, we talk about strength in terms of cardiovascular exercise, resistance

• 1:02:57Speaker 01

  training, as well as pelvic floor strength. And so a lot of people think pelvic floor strength is just kegels. It's actually much more than that. It's, we want to maintain strength of those muscles, but we also don't want to tighten and tense them. I think that's very under discussed, particularly for men, where a lot of guys will have tension in their pelvic floor, just like people get TMJ dysfunction in their, in their jaw and wake up with headaches. They don't know they're doing it. They're just waking up with a stress headache. And the same thing can happen to your pelvic floor. And so really like learning what that is and how to, how to treat your pelvic floor and how to manage it regularly so you don't have problems. And then we talk about environment. So environment, we talked a little bit about masturbation and pornography, but we also talk about what are the things in our environment that we can make meaningful change in to

• 1:03:41Speaker 01

  sort of try to limit exposures because we are exposed to so many things in our environment that affect hormonal health and affect vascular health. And so how can we limit that by drinking out of glass instead of plastic and things like that that are, that are, you know, what is the, the easy things that move the needle, right? And then we also talk about the company you keep. So I think this is something we don't talk about enough, but like it matters. If all your, if all your friends are talking about how they never have sex, well, then it's not a priority for you either, right? So I think generally thinking about the company you keep and how that affects your overall mood and health and sex life is important. And then lastly, confidence. And I think the confidence chapter is so great because it's not just like, oh, I'm going to feel confident because I'm good at sex.

• 1:04:25Speaker 01

  It's, it's understanding like, okay, what makes me good at sex? How do I, what are the skills I need to have? What are the erogenous zones that are really useful? How do I go about this with my partner? How do I introduce novelty? How do I understand female anatomy for the heterosexual people reading the book? And like, how can I deliver pleasure adequately? And how can I talk to my partner about these things? I think this is so important because it's an under discussed and underutilized part of sexuality.

• 1:04:51Dr. Darshan Shah?

  I love that. And definitely like, you know, all of these topics are so important for your sex span and also your health span. And I think to your earlier point at the beginning of this podcast, they're so intimately related. And, you know, ignoring your sexual health, but getting everything else right, you're missing a huge piece of the puzzle.

• 1:05:10Speaker 01

  Absolutely, absolutely.

• 1:05:12Dr. Darshan Shah?

  Well, this was amazing, Dr. Malik. Thank you so much for taking us on a whirlwind tour of sexual health for men. I think we covered a lot of bases here. You know, if people want to hear more from you, you have some incredible podcast episodes out. I think this is another one of them, but they want to dive deeper. How do they learn more from you?

• 1:05:30Speaker 01

  Yeah, so you can find me on any social media platform, Rena Malik M D. My biggest one is YouTube. If you go on my website, RenaMalikMD.com, you can find all the podcast appearances I've been on. But, you know, learn more anywhere you're finding content, you'll see me.

• 1:05:46Dr. Darshan Shah?

  That's awesome. What's your Instagram handle?

• 1:05:48Speaker 01

  RenaMalikMD.

• 1:05:49Dr. Darshan Shah?

  RenaMalik, so it's very simple. And once again, The Hard Truth, your book is coming out in November. It's up for preorder now. Can't wait to get a copy. Thank you so much, Dr. Malik.

• 1:05:58Speaker 01

  You're so welcome.

• 1:06:00Dr. Darshan Shah?

  Thank you so much for listening to the podcast today. Please remember to subscribe if you liked this episode and give us a good review and share a link with your friends. It really helps to support all of our efforts. I also want to remind you that the information shared on this podcast is for educational purposes only and is not intended to replace professional medical advice, diagnosis or treatment. Please consult with your healthcare provider or physician before making any decisions or taking any action based on what you hear today, especially if you have any underlying health conditions or on any medications. Your doctor knows your personal health situation the best and it's always important to seek their guidance.