Sexless Marriage

Needed information about how to make things better...

Maureen McGrath: It's been said if you never want to have sex again, get married. Sex is one of the most contentious issues in marriage today, second only to finances. There are many married couples that have not had sex for months, even years, and that's okay as long as they're okay with it and happily married. The problem arises when one person in the relationship wants sex and the other doesn't. According to a national newspaper survey of approximately 10,000 respondents, mostly married men, 75% were satisfied in their relationship but more than 50% were dissatisfied with their sex lives. We're having sex, don't get me wrong, we're just having sex at the wrong time and with the wrong people, I'll get to that later.

We're having sex before we get married, 10 years on average, so we are effectively in a long term relationship and potentially quite sexually bored before we even mess up the marital bed. That has its consequences. Most brides today do not have sex on their wedding nights, and 50% of men would not have married their spouse had they known their marriage was going to be sexless. So, everybody wants to know, just how much sex are married people having, whether they are in heterosexual relationships or same sex unions, you all want to know what's going on at the Jones'? Well not much.

Only about 7% of married couples set the sheets ablaze. Most married couples have sex a little more than once a week for the first decade of their marriage, it decreases after that. So they have sex about 58 times a year, and 20% of marriages meet the criteria as a sexless marriage. That, defined by the experts, is sex less than 10 times a year. So why aren't we having sex in our marriages? Well, there's a little known chemical in the brain conveniently called PEA, or PEA. It's responsible for the elation, the excitement and the euphoria that you feel when you meet somebody that you are sexually interested in.

It's a fantastic feeling, this chemical is scourging through your blood vessels, you are so happy, that's how powerful this little chemical is. What happens after two years, that chemical diminishes as does sexual frequency. That's just about the time you might get married or might have conflict in your relationship and that is why communication is key to great sex. There's another reason we're not having sex in our relationships, that has to do with the sex education that we provide. I'd like to share a story about myself, when I was a teenager my mother came racing into my bedroom and she said, “Maureen, please tell me you have not allowed a boy to french kiss you!” She was feeling terrible that this sex education came a bit late, I was feeling horrifically guilty as an Irish catholic girl that I'd french kissed a number of boys by that stage.

We teach girls and women that sex is dirty and sex is bad or it's overrated. We say, you're just going to get a sexually transmitted infection anyway, or you might get pregnant! This whole fear based thing frightens women from enjoying sex and we never talk about pleasure with girls and women, or orgasm. In fact, some women say orgasm is not important and that the journey is just as good as the destination. I disagree. Of course. I'm the one who french kissed all the boys as an Irish catholic girl. It's like getting on a train with your lover, and you are going to the most pleasurable place on the planet. You are so excited, you're getting lubed up with all the free drinks they're giving you, this is amazing. Just before you reach your destination, he gets off and you don't. You get my point.

Now, the sex education we have for boys and men, that's entirely different. It's a global program, it's free, it's accessible to everybody and it's known as internet pornography. Fantastic. It does nothing to teach men and boys about intimacy which is really important to men and boys, or how to make love to anybody, also we have a paucity of information about sexual health for our LGBTQI community and we need to add to that. Now marriage can rapidly go from holy matrimony to holy hell with the finances, the kids, the houses, the illness. You may have signed up for sickness and health but that was long before you'd ever witnessed a man cold, and how about that richer or poorer thing? Ladies we're going to have to start going for richer.

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Most women today are working inside and outside of the home. We're doing the lion share of the housework because according to research, men don't feel they're that good at it. We're bridging the gap between growing children and aging parents. We're exhausted doing it all and never doing it, and when we are doing it, we're checking our smartphones. 10% of people check their smartphones during sex. 35%immediately afterward. We are connected to the internet. We are connected to the internet and disconnected from our would be lovers. Maybe this is the reason that the most common sex position for married couples is doggy style. No, no, no. It's not what you're thinking. Get your minds out of the gutter.

This is the one where he's on all fours and begs and she plays dead. I have a clinical practice where I see patients that have sexual disfunction and there are two questions that I ask everybody. The first one is, are you sexually active? That's obvious. When I ask women they never say yes or no. Well, they never say yes. But they never say yes or no. They say; sometimes, sort of, I'm not sure, he is or they say “I'm married.” I say well that means no to me. They say yes you're right, it is no. Most men complain that women never initiate sex. The reason for this is because once again the sex education we provide to women, women falsely believe that female sexual interest, desire, precedes sexual activity when in actuality, it is sexual activity that prompts sexual interest and desire. Sexual arousal emerges as a result of sexual activity.

So, you guys I know, intimacy is important to you. The most important question that reflects this that I receive from you is, “How much masturbation is too much masturbation?” So I just say as long as you can go to work, you should be fine. Then I realize, that that's perhaps all that you're doing at work. So I know intimacy is important, you want to come home and you want to make love to your wife if you're in a heterosexual relationship, so after a long and quite possibly very hard day, you come home to a bit of chaos perhaps, you've just got sex on the mind and she says, “Did you remember the milk?” You're like darn, the milk! I forgot the milk. Don't beat yourselves up about it, if not for the milk we have Facebook, hormones, I'm feeling a little tired tonight, my stomachs sticking out I'm feeling kind of fat, can't do it tonight, didn't we have sex last month? You're like, that was actually last year. You don't get it. Literally, you don't get it.

You're like she's amazing, she works in and outside of the home, she does a great job with the kids, she volunteers, she even has time for girls nights out. So, I brought a friend home after one such girls night out. As we approached her house, drove up she looked up to her bedroom window, saw that the lights were on and she said, “Donny's waiting up for me, do me a favor, drive around the block a few times until the light goes out” I said listen, “You get in there and make love to your husband before somebody else does” Because that is one thing that will increase a woman's sexual desire, when someone else wants her man. Still unconvinced she said, “I decided to extol the health and beauty benefits that sex has for a woman, a youthful glow, better sleep, wrinkle free skin. Keep driving” She said.

There is a device that will increase anybody's sexual desire and that happens to be the Mercedes Benz 4MATIC convertible SL and it comes in 64 colors. If that doesn't do it, the desire to have a baby will rev up any woman's sex drive. The problem is, having that baby is likely to kill it along with any marital eroticism a couple may have had. A lot of people believe that motherhood and being sexual is incongruousness. John, John followed me on LinkedIn for two years before he mustered up the courage to make an appointment about his sexless marriage. He'd been married for seven years and they had never consummated the relationship. Their parents were pressuring them to have parents because they wanted grandchildren. When they came into my clinical practice, the second question that I ask everybody that enters my clinical practice most unfortunately is, “Have you ever experienced sexual abuse or unwanted sexual advances as a child?”

This was the first time this gentle man had learned that his wife had experienced sexual abuse as a six year old at the hands of her best friend's father. She thought sex was dirty, she hated sex, we need a worldwide moratorium on ending sexual violence on our children, boys and girls, because it happens to both. Healing from sexual abuse takes a lifetime. Ella had lived a lifetime. A widow, she said she wasn't sexually active but she hoped to be. I thought, fantastic! Somebody is going to have sex here, but she said, “The problem Maureen is that these old guys can't get it up anymore” I said well Ella, you might have to go for a younger guy. She said, “What's younger when you're 84? 70?” Yes some of you are saying.

The hard truth is that men in their 30s and 40s may experience erectile dysfunction. Ella is going to have to go for a millennial. So you're all probably thinking, “What's the big deal, why treat my erectile dysfunction?” Well I liken the penis to a plane, if a pilot can't get the plane up in the air, and keep the plane in the air for the entire trip, there's probably a problem with the engine. So if you can't get your penis up and keep it up for the entire sexual experience, there's likely a problem with your engine. That's your heart. Erectile dysfunction is the canary in the coal mine and it may signify cardiovascular disease. It may also indicate diabetes. These two medical conditions in addition to low testosterone, stress, substance use and abuse, excessive alcohol consumption, unresolved conflict, financial issues, all of those may contribute to low sexual desire and you may end up in a sexless marriage.

George presented to my clinical practice at age 40, he decided to settle down. He was marrying a beautiful and accomplished woman in a few months. There's only one problem, George was gay. George could not bear to tell his family that he was gay because he felt it would have shamed the entire family. I said, “George, you're going to end up in a sexless marriage!” He said, “Tell me something I don't know!” George said to me his plan was this, “Well, when my parents die I'm then going to divorce this woman and I'm going to marry the man that I love” And I said, “George, you are not thinking straight.” Sex is the barometer of the state of affairs in a marriage. People who live in sexless marriages report feeling frustrated, unloved, undesirable, unattractive and the worst of all, lonely.

Loneliness has been shown to increase vascular resistance and elevate blood pressure and lead to an early death. You're more likely to die from loneliness than you are from obesity or excessive alcohol consumption. When I educate women and I say, “If you're not having sex with your husband, someone else may” They get upset and they say that I'm blaming women for men's bad behavior when in actuality I'm doing a community service. You see, men in sexless marriages cheat to remain in that marriage in general. Women cheat to leave a sexless marriage. Women cheat too, nobody ever thinks we do but we're just sneakier about it, we just don't get caught or socialize very differently, this is one thing we have on you guys. Women cheat with other men and women cheat with other women.

Technology has made cheating accessible for everybody, from the politician to the stay at home parent, that quick swipe right can lead to an online passionate love affair. From texting to sexting to secret phone conversations. The more two people communicate online, the more likely an in-person encounter will occur, but you can always blame your genes. The gene DN4N has been isolated in cheaters and the sexless marriage, just the environment to turn on that gene. It's based on a system of pleasure and reward. The stakes are high, the rewards substantial. It is the perfect cocktail to turn that love drug back on, PEA and the cycle begins again. Historically, marriage was not based on mutual love but rather it was an institution to acquire of all things in laws, property and physical labor. At the turn of the 20th century, in America, egalitarian ideals and the emerging Hollywood movie industry burdened marriages with promising romantic love forever.

Now we're living forever, fantastic, congratulations, you get to have sex with the same person for the rest of your life. The second most common question that I hear from patients is, "When does sex end?" Well a 44 year old asked me, he said, " When does sex end Maureen, 65?" I answered him this way, a 22 year old asked me, "When does sex end Maureen, 35?" Everybody's older until you get there. I'm here to tell you that sex never ends. If you're healthy, you can have a great sex life well into your 80s and 90s. Sex is good for you, sex is healthy, yet sex is shrouded in shame. In the ancient aristocracies, the wealthy men had courtesans for pleasure and concubines for quick sex. The way we're going, computers will be our concubines, internet pornography our mistress of the day. Technology is fast replacing human connection at high speed.

So how do you rev up the sexless marriage?

  • Sex is about blood flow, sexercise. Every day you want to have a daily workout. It increases your agility, your stamina, women will experience more sexual sensation when blood is flowing to the genitalia. It also helps to treat erectile dysfunction.
  • Also get help for any of the sexual dysfunctions you may have [& for men],  vaginal dryness, it's an issue that happens to women who are on the oral contraceptive pill, who are breastfeeding, perimenopausal, postmenopausal and there are treatments for you.
  • Pay more attention to your spouse than you do your smartphone.
  • Spend more time in your bedrooms than you do your boardrooms or your bedrooms are going to become bored rooms.
  • Deal with your marital issues.
  • Go to sleep in the same bed at the same time and don't bring anything or anyone into your marriage except for a great sex toy and a darn good sex therapist.
  • You must establish guidelines that govern those moments when you are struck by someone's attractiveness outside of your marriage, but don't think for a second that you have to have sex with the same person for the rest of your life. That's not what I mean. In your mind, that is. Fantasy is key. Your brain is your largest sex organ, and one more thing.
  • I would like to leave you all off with a bang. Settle all marital arguments in the bedroom, naked.

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O-Shot® for Improved Sexual Function. International Society of Cosmetogynecology. Vegas 2018

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Transcript

Dr. Marco Pelosi III: Our next speaker is probably best described as the Michael Jordan of platelet rich plasma, Dr. Charles Runels from Alabama, that pioneered the O-Shot® [Orgasm Shot®], the Vampire [Face]lift®, the P-Shot® [Priapus Shot®], and he's taken all the abuse and he's given the world some very, very useful procedures for everyone. He's going to talk about the studies he did and the studies done in platelet rich plasma in regards to sexual function. Dr. Runels, it's a pleasure to have you here.

Dr. Runels: Thank you for having me.

I'm going to go through a whirlwind look at research that's been done where people have used PRP to help with sex. Much of the research has been done by the people in our group, and I've described many of them in this room who have done this research. It's a for-profit organization, but we pay for research, we pay for education, we pay for marketing for our providers. Just to echo what you just heard, sex is much more than about just having fun. Rainer Maria Rilke said it's just so correlated to the creative experience that it's affecting how we do our work, how you do your presentation, and how - of course - relationships and families.

I want to echo that sentiment, and remind us that back in 1980, if you look in 'Urology' - this was 'Urology' 1980 - the most common cause for erectile dysfunction was thought to be 85% psychogenic. Here's a quote from 'Urology' where urologists were encouraged to become counselors, because most of erectile dysfunction was thought to be psychogenic. Of course, I'm echoing the penis stuff because if you take a penis and shrink it and unzip it, that becomes a clitoris. I'm thinking most of the research will eventually apply to that. Certainly, our attitude is applying because we're back in the ... We're not, I'm preaching to the choir, but many of our colleagues are back in the 1980's and saying the main thing we have for sexuality for women is counseling.

My thinking that perhaps, as you guys do, some of the pathology that applies to the penis may apply to the clitoris, and maybe some of these women are suffering from actual genital histopathology, not just psychogenic problems. We have this one FDA approved drug now for female sexual dysfunction that's a psych drug, flibanserin. It's a useful drug, but obviously, we need much more and maybe we should think in terms of systems, like we do for the rest of the body.

Platelet Rich Plasma.

Obviously, this is not a new idea. This is from, this month, over 9,000 papers indexed in PubMed about platelet rich plasma. Our orthopedic colleagues, our dentist, our facial plastic surgeons have worked with this, and all we have to do is take their ideas and then hopefully people in this room will extend what I'm about to show you and just take those ideas and adapt them to the genital space. Here's some of the growth factors we know about. There are many more. They have these effects. These are good things for the genitalia. Down-regulating autoimmune response, proliferation of fibroblasts, new angiogenesis, the adipocytes enlarge and multiply - think labia majora, collagen production, neurogenesis and maybe some glandular function.

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There's never, in all those 9,000 papers, I still cannot find one serious side effect. No granulomas, no serious infection. PRP is what your body makes to heal when you do your surgeries and help prevent infection. Obviously, there are always certain things that can happen, bruising and such, but if you have a serious life-threatening complication from PRP, you will have the first recorded in all of that 9,000 plus papers. That's a nice thing.

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We have commercially available methods for preparing it, within 5 or 10 minutes of the bedside, and the devices are FDA approved. So you guys don't get confused, obviously the FDA does not approve your procedures. That's a doctor business. They don't approve blood that belongs to you, just like your spit and your saliva and your skin. They tried, at one time, to control eggs and the gynecologists said, "Hell no." So they don't control eggs and they don't control blood, but you should use an FDA approved device if you do this [approved for preparation of PRP to go back into the body].

Autoimmune Disease

Here's some of the ideas about down-regulating autoimmune response. We have split-scalp studies showing that PRP helps alopecia areata better than triamcinolone. More hair growth that comes in thicker. Here's rat studies looking at rheumatoid arthritis. What do we have in the genital space? We have lichens sclerosus. We did some before and after pictures where you use stem cells mixed with PRP, and before and after pictures show improvement. Of course, that's two variables because you have stem cells and you have the PRP.

We took the same idea and just used PRP. Andrew Goldstein worked with me on this, and we had two blinded dermatopathologists. The protocol was biopsy, PRP, wait six weeks later, another PRP injection, and then six weeks after that, another biopsy. Two blinded dermatopathologists out of George Washington University did not know the before or the after. We showed statistical improvement in both the histology and symptomatology. Here's our histology. You can see obviously, that's the same magnification and we're showing decreased hyperkeratosis. That's obviously healthier tissue. A layperson could tell that's better. Of course if you look at the gross pictures, lady on the left as you guys know, she has pain wearing her blue jeans. The lady on the right is back to making love to her husband. They've invited me into their close Facebook groups and I saw a post a few months ago. Quote says, "I was sitting next to my husband, whom I love, last night. I was afraid to hold his hand because I was afraid he would become aroused and I'm bleeding and hurting today." That's what you guys are helping.

We published that in 'Lower Genital Tract Disease'. We extended it because it worked. We published this past January in the journal of the American Academy of Dermatology. You have some science to go do this now.

One of our providers, Kathleen Posey, who's a gynecologist out of New Orleans, took this idea and then she said, "Let's do some dissection in the office", and she presented this in Argentina, published it in the same journal 'Lower Genital Tract Disease'. Here's one of her patients, where you can introduce [inaudible 00:06:44]. It had been 12 years since she had had sexual intercourse, penis and vagina intercourse, with her loving husband ... 12 years. She was being followed by a dermatologist on high dose clobetasol. Kathleen dissected it out in the office and then injected PRP ... 8 weeks later, she's having comfortable sex with her husband. She's now 3 years out. She's had to be treated with PRP, not repeat surgery ... PRP now, 2 other times a year apart to maintain that result. She now has a series of 60 or so patients that she's now going to publish with similar results, where she's dissecting out - as you guys know how to do - treating the [inaudible 00:07:27], but then following that with PRP injections to help the healing and decease the autoimmune response.

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That same doctor, Casabona, repeated his study with lichen sclerosus in men [BXO], and showed with just PRP alone ... This study of 45 men with repeat treatments ... It is cumulative, 2 to 10 treatments, the same thing. All of them stopped their steroids. None of them started back. Only one went on to have circumcision.

Peyronie's

Peyronie's disease, another autoimmune disease ... This came out this month out of Wake Forest, where they took men and they followed their results with Peyronie's disease. Not only did their Peyronie's improve statistically, but they also improved their erectile dysfunction by 5 on that scale of 5 to 25 that the urologists use. For some reason, thankfully, they threw in one woman just for good measure, and showed that it helped her incontinence. They just tucked that in as an aftermath.

Ronald Virag, as you guys know as the legendary vascular surgeon who was first to present the idea of intracavernosal injections for erectile dysfunction, out of Paris. His big thing now is PRP for Peyronie's. He just published a study where he showed that this is comparing PRP with Xiapex, which is a $50,000 series of injections, FDA approved version of collagenase. He showed that PRP works better with few side effects. There's a risk of about 1 in 30, that actually go from a bent pencil to a fractured pencil and a limp noodle. You don't see that with PRP. You see the side effect is the erectile function improves. He showed the same thing, actually, in his studies that erectile dysfunction improves by an average of about 7 on that 5 to 25 point scale.

Wound Healing/Scar Resolution

Let's think about the [inaudible 00:09:29] literature. Look at this, there's so much of this out there. This is looking at post-operative adhesions, lots of studies looking at scarring with microneedling and PRP. This is a split-face study comparing PRP with microneedling verus PRP ... Excuse me, microneedling with saline or Vitamin C serum and split-faced studies in PRP wins. Dr. Sclafani did some studies in the cosmetic space looking at increased collagen production and fibroblast activity, and never a neoplasia documented. People worry about that. This is not indiscriminate blindness blind growth. You don't worry about carcinogenesis when you do surgery and it's the same PRP that's causing healing. There's actually some helpful immune processes that go on, that you could argue actually might help prevent cancer. I'm not going to make that argument but it might need to be made one day.

If you look further, here's a wound healing study looking at reepithelialized exposed bone and tendon of the foot and ankle. When I took that and applied, this is a hypertrophic scar that was a year old from cortisone, and then using PRP and Juvederm or HA filler, this is a few days later, a month later, and that's a year later. Now, take that and think, "How could I use that in the genitourinary space?" Doing that anecdotally, we have many of the members of our group are seeing help with episiotomy scars or dyspareunia, pelvic foreplay instead of injecting that pelvic floor tenderness with triamcinolone. Physiatrist for the past ten years has been using PRP, your sports medicine doctors. Now, when you palpate it, consider injecting with PRP instead. Dyspareunia from mesh and that unknown dyspareunia, we're seeing this is where we need you guys to help extend the research. The science is there that it should help and it seems to be helping. Not 100%, but about 80% in people with dyspareunia.

Mesh Pain

Here is a look at a gentleman who did ... He took the mesh out and then he patched the hole with a gel form of PRP and showed benefit. We're finding anecdotally - no one's done this study yet, here's another one for you to pick up ... I'm giving you low hanging fruit. We're seeing anecdotally that if you inject in the distribution of the pudendal nerve, which seems to be inflamed in some women with mesh pain, that their pain will frequently go from 9 out of 10 down to 1 or 2 out of 10, without even taking the mesh out. Just another place where we need some research done.

Interstitial Cystitis

Here, we have rat studies looking at inflammation. Let's think about this one. Here's a rat study where they modeled cystitis and we are seeing in chronic interstitial cystitis without even infiltrating the bladder, just infiltrating in the periurethral space, some of our women are getting better. I've had two separate urologists call me and say, "Charles, I can't believe it. I was doing this and expecting not this to happen. I have these patients now who have had chronic interstitial cystitis pain for years, and it's gone." Not 1005 but finding out who's going to respond and who's not and why, there's a lot of variables that need to be thought about that you guys will hopefully do the research.

Penis Growth

Here's a study that came out in the 'Journal of Sexual Medicine', where a guy took ... the [inaudible 00:12:51] men who have an erection of 3 inches or less and then he treated them with PRP, combined with a pump, and showed that if you repeated it every time you did it, it grew by about 7 millimeters. I've always thought if I could give you a guarantee half an inch to an inch with anything, I'd get my picture on a postage stamp. I don't have that yet, but I can tell you that we're seeing about 60% of the time we do this procedure, men will see some sort of growth.

If you look at the neovascular space, there was a study out of Southern California that was published in the 'Journal of Sexual Medicine' where they transferred adipocyte stem cells to the penis of diabetic rats. They showed new endothelial cell growth and increased nitric oxide activity in the dorsal nerve. Would that be helpful in the clitoris? Probably, but the interesting thing is the adipocyte-derived stem cells were attacked and they died. The postulate was the improvement was from the growth factors.

Penile Rehabilitation and Erectile Dysfunction

I have seen what [inaudible 00:13:52] have seen in that when you inject this in the penis, erectile function goes up on the average of about 5 to 7 per injection. Think about nerve repair. We have rat studies modeling prostrate surgery, showing that the nerves improved with PRP and so we have, again, another clear place where we need studies if you add this now to the usual protocol for rehabilitating the penis post-prostate surgery ... would you see benefit? We have seen that in some of our patients who are a year or two out who failed the rehabilitation part of that. Would that help your patients who have, say, numbness and decreased function from riding their bikes too much, or trauma? I don't know, but it's worth thinking about and publishing research about.

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In thinking about where to put this, where we do our O-Shot, when we do PRP to the anterior vaginal wall, we're putting it as distal from the bladder as possible. We found that it works better. We're essentially making a liquid sling. Think infiltrating and getting ready to put in the mesh. That's what we're doing. Very simple, only we're using a material that has never caused a granuloma ever. Doing that, frequently our patients will have their incontinence go away that day from the actual liquid and as it's replaced with new tissue, it never recurs. Usually, you'll have to repeat the procedure at a year or two out depending on the etiology. Sometimes it lasts longer.

The interesting idea is what might be happening with those [inaudible 00:15:21]. They become more active, and does that help with sexual function? The other place we put it is in the actual corpus cavernosum of the clitoris. We use [inaudible 00:15:29] ultrasound visualization and see it flow down into the body of the clitoris by the pubic ramus and the wave form goes to what you see in a flaccid penis to what you see in an erect penis.

Improved Orgasm & Libido in Women

That's my time, almost done. Just 30 more seconds. Here's a pilot study we did where we showed that in women with female sexual distress, that it dropped by an average of 10 and female sexual function went up by 5 when you do what I just showed you. Here's a study that Dr. Neto, who may be here, published where he looked at incontinence and sexual function down in Brazil and showed that 94% of the people loved it. The question here is how would you combine it with your energy source? It works great in the face if you do laser and follow it with PRP ... better results, faster healing. Is it going to ... We need people to help us work out the algorithms. Not everybody has laxity, but when you have something, when do you use which treatment and when do you combine it with PRP? We need those answers, because I don't have them yet. This is possible helps.

I am done. Thank you very much for having me. I put all these references at that website, if you want to go download them. Thank you. You guys have a wonderful conference.

Dr. Marco Pelosi III: Thank you Charles. Beautiful

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Dr. Runels (inventor of the O-Shot® procedure) & Nory Talk about Female Orgasms & Spirals that Go Up & Spirals that Go Down.

Transcript...

Nory: So, Dr. Runels, let's begin by you telling our readers a little bit about your medical background and anything else you'd like to share with them.

Dr. Runels: As far as my background as a scientist and a physician, I had a strong math interest and worked for three years as a research chemist, and then I went to medical school and wound up doing emergency medicine for 10 years or so, 12 depending on when you want to start counting. My boards were in internal medicine, so I started doing some research and opened a practice, did some research with hormone replacement, so 18 years ago, before Suzanne Somers wrote her first book I was doing testosterone pellets and did some research projects with growth hormone. That's what made me in tune with women's sexuality. I didn't set out to be a sex doctor. I set out to take very good care of women as a physician.

I don't really even like the word. I don't like when people say that's "alternative medicine." This isn't alternative medicine. This is medicine that looks for what works, and if it happens to be something not in a bottle that you buy at the pharmacy that doesn't make it alternative. So, if I'm using, say, nutrition, how is it that two milligrams of medicine can be more powerful than the pounds of food that you put in your body? Or, if I'm using exercise or if I'm using your blood in the case of these procedures, if I'm using things that are backed up by research, like walking three miles a day has been proven to do more for your heart and your blood pressure and your risk of heart attack than any drug on the market, including blood pressure and diabetes drugs. So, that's not alternative, that's science.

So, anyway, I have a strong science background and I was doing research, but I also had a background, i used to work as a trainer at the YMCA, so I understood physiology and exercise from a personal standpoint and from coaching a lot of people back in my college days as an exercise guru sort of guy. So, all those things sort of meshed together and as I was taking care of women in the most excellent way I could think of, using science, but not always medicine. I'm not anti medicine, but using science and hormone replacement all of a sudden I had a flood of women 18 years ago realizing that somehow they were getting better and their friends were getting much better than what was being done down the road by what was done for women 20 years ago which was just Premarin, basically, don't do any blood tests, throw a little estrogen at you and hope that your hot flashes go away.

So, that's sort of how I got to where I am as far as being attuned to women's sexuality because they would come crying to me about what was happening with their life, and you can't do their hormone replacement, in my opinion you can't take care of people well unless of think of endocrinology and you can't do endocrinology and hormones without asking questions about sex. It turns out that those questions I was comfortable asking about sex were unusual, and I didn't know it at the time but most doctors are afraid to talk about sex. They don't want to talk about sex. And research shows that if a woman asks their doctor about sex, which most of them never do, only 14% ever ask their doctor a question about sex, even though half of them have problems, research shows that the doctor will change the subject after answering the first question over half the time.

So, I didn't realize I was being unusual in listening and trying to heal the relationships when women would come crying and say, I love my husband so much but I'm afraid to tell him that I'm having pain when we have sex or that I'm not aroused, because I love him and I don't want to tell him, I don't want to hurt his feelings. And they've never told their doctor, their husband, or their preacher or their best friend.

So, that's sort of the quick version of how I got to be the guy that's now ... has done research in this area and working with a couple thousand doctors in 50 countries.

Nory: What gave you the idea for the O-Shot®?

Dr. Runels: The O-Shot® was a sort of a coming together of ideas, one, with the research background as a chemist I was already into instrumentation. I actually did some work, one time considered becoming a biochemical engineer, not a biochem but a medical engineer, designing instrumentation. So the centrifuge has fascinated me. I ran a wound care center at a hospital nearby when I was a [inaudible 00:04:51] so I was into healing of wounds. Then I had the women crying about their sexuality and I had an injection practice because I found that women oftentimes want to quit losing weight, because when they lose the weight in their face their wrinkles start to show up more. So I had made myself an expert at cosmetic injections, not just for the benefit of that but to help encourage women to continue to lose weight with me when I got their metabolism right.

 So, now you got wound care, injections, and all those things come together, and I thought, oh, wow, what if you took this technology where you're using platelet rich plasma and heal tissue and I pulled it over and used it in this arena where women have problems with pain or sensation or function of the genitourinary space. So, that's kind of how it all came together.

Nory: I read a story about the Priapus Shot® and feel free to tell this or not, and we don't need to include it in the interview but I sort of remember that you had a partner, wife or a girlfriend who said, hey what about me?

Dr. Runels: I gave you the short version. So I'll fill in the blanks. So, when I was first introduced to platelet-rich plasma someone was telling me ... because I was doing cosmetic injections, use it like Juvederm in the face, you get new volume, new blood flow, and there's never been a documented side effect, serious. So, to this day there's still with over 9,000 research papers, now getting to Priapus or the penis shot, but there's never been, in 9,000 published research papers one serious side effect from platelet-rich plasma, as in no infections, no necrosis, no neoplasia, no granulomas. But you get new blood flow. It's been documented in multiple biopsy studies you get new blood flow, you get healing, all the [inaudible 00:06:47] regulation hyperimmune status and other things.

So, when he told me that, new volume and new blood flow, I thought, well, I've got a better place than my face for a new volume and blood flow, thinking like a man. So, I thought I'm going to do things with the face before I try this in my penis. So, for four months I injected faces and I watched and yeah, people would come back and their face would be glowing, and they would tell me their friends and family were saying their face was glowing. So I thought, okay, let's try it. It took me a while to get up my courage because I thought when it makes this matrix, which it forms a yellow goo like surrounding a scab, when the matrix forms, that goo forms, that's what holds the growth factors in place. But if that's in a wound say, on your hand, you've got blood flow coming from beneath so it's not a big problem. I was thinking if that goo formed inside a penis it may cause necrosis or cause something bad to happen, maybe an erection that won't go away or priapism or something.

But I tried it and it worked. It seemed that it was helping a little bit with size and a little bit with erection and some of my patients, a lot. So, I had been doing that for a few months, and following the other part, because I actually, to this day, take care of more women than men. I was doing this for selfish reasons, thinking how to make things better for men, and I thought shoot, if I could make it to where the average man could grow his penis a half an inch I'll get my picture on a postage stamp.

Three Categories of Women Who Suffer with Sexual Dysfunction

So, I'm working on that but I'm still mostly taking care of women, and I have a heart for women and actually part of what led to me taking care of the men is that, when I would get women happy and make them ... take a woman who's 40 pounds overweight, she's 40 years old, she feels tired and her sex drive is low. When she loses the weight and her sex drive is high and she can think well again, three things could happen. I got to where I could almost tell when the woman walked in the room, which of the three it is.

Okay, picture that woman. If she's got a lover who's kind to her, who's healthy, who has a good sex drive, they could live happily ever after, there's nothing left for me to do. If she's got a lover who's been abusive to her because she's been overweight and low self esteem and now she gets her sex drive back, she's out the door, there's probably nothing I should try to do. I don't know, but there's probably nothing I can do because she's been kind of under the thumb and now that she's got her sex drive and her health back she's gone.

The thing that bothered me was the third category, and that's the woman who comes in and she loves her husband and he's not well. Now, you make her well, she's got a sex drive, and the man or woman that she loves can't keep up with her. Now you got a problem, because they love each other and you've created a mismatch that's causing a conflict. That bothered me. So, for that reason I made myself an expert at men's sexuality.

I'm working on that part of it but I have been following what has been done for injecting around the urethra. That's been done for the past 15 years, with collagen, with hyaluronic acid fillers, with collagen, with hyaluronic acid fillers, with, it's really what you're doing with the sling. It's just a way of changing the contour of that area with some of the surgeries. So, finally I had this girlfriend at the time, who said, "Hey, I want to try that." So I said, "Okay, let's try it." And the first 24 hours she was so, I mean, she was always a good, she always enjoyed sex, but she became really almost like she was on some sort of drug. If you think about it, drugs are, you know the only bad thing about drugs is that they make you sick, they get you put in jail, but what if you had a drug that was legal, that made you happy, and wasn't going to put you in jail? That'd be a good thing.

You could say running becomes a drug like that for some people. The endorphins from running. So all of a sudden, here's something I've done that in theory should make her body healthier, but it was like a sex drug to her. So I thought, and she was just insatiable for about the first 48 hours, so I thought, I should try this with some people that have problems, because it makes sense it should work. So the first woman I treated after my lover had been abused by her ex-husband in the genitalia. She was scarred in the vagina and the anus to the point where she couldn't have relations without horrible pain, so she came over on her lunch hour and I treated her and a few months later she was literally engaged to an old high school lover because the pain was gone, and something that took me 30 minutes on her lunch hour just changed her life.

She's the one who actually said, "Hey, this has made my incontinence go away. I've lost weight because I'm running again." I thought, 'Well Josh should've thought of that.' So my patients, the people, the women and men who've trusted me are really the people who are responsible for this coming about, because they trusted me enough to let me do what the science said should work. Again, [play the 00:12:02] words, plasmids, that's been researched for the past 15 years for wound healing, but using in that space was a new idea and the people who loved me and trusted me enough to do that were really the ones who taught me the procedure.

I had an old teacher that told me, he said, "You know, if you want the best textbook, it's not the textbook, it's the patients you're taking care of." And my patients, if you're writing the textbook, then you're writing it from what your patients are teaching you, and that's what's happened with me.
(Chapter 15 introduces the O-Shot® Procedure & is Written by Dr. Runels)

Nory: You know, it's just a beautiful philosophy and your humbleness is, tells me a lot about you.

Dr. Runels: Well, I don't know, it's really, there's really no, I don't know if you can call it humble when there's really nothing that I can claim, except maybe tenacious, being tenacious. Because you know, I didn't go make this brain, I came with it, and I, the people who've been around me gifted me with their trust, but it's kind of you to say. But I still think most of what we have is a gift from somewhere, wherever you decide that's from is your philosophy, but I feel like most of the good things we have are gifts. Then we decide if we're going to take care of them or not. That's kinda how it works.

Nory: You know, Erin told me, this is a little off subject and we don't need to include it in the video if you don't want, but she called you a 'transcendentalist.'

Dr. Runels: Oh, I don't, I'm not even sure I'm 'good,' but I think that ... Emerson had it right when he said really our goal in life should be to be a perfect pipe. But the pipe becomes most useful when it becomes as empty as possible. I don't know what that makes me; maybe just makes me an Emerson fan, but that's kinda my goal.

Nory: Well I come from a Unitarian Universalist background so I just said, "He's close to my heart."

Dr. Runels: Yeah, he's an amazing guy. I think he came pretty close to being an empty pipe, didn't he? Or clean pipe.

Nory: Getting back to our interview, I think you've answered a lot about how your women patients' problems impact their lives, but I'm curious to know, besides the O-Shot® and the nutritional supplements and the hormonal supplements and the other [techniques 00:14:43] you use with them, do you use any other technologies besides the O-Shot®?

Dr. Runels: ... The things that can go wrong with sexual function really almost cover almost everything that can go wrong with the body. Sexual function is, I consider it like the cherry on the top of good health. For example, if someone's depressed, for whatever reason; hypothyroidism, tragedy, whatever it is, sex drive's gone. If someone's in pain, for whatever reason, there's no sex drive. If someone's got a fever. The sex drive, in my opinion, it can be faked, it can be maybe become artificial through some drug like cocaine or whatever, or maybe through someone being drunk or high or something, but true, healthy sex drive evolves out of many things that have to do with good health, good relationships, good connections. The best, even on a spiritual plane.

So as far as, when you say 'what other modalities would I use?' Let's just take, for example, a problem like can't have an orgasm. That could be low testosterone, and in that case they need testosterone. It could be pain because they've got a scar from having a big baby and they're associating sex with pain, so that's not gonna lead to orgasm. In that case the O-Shot® may help. It may be decreased sensation in which the O-Shot® might help. Maybe from previous surgery or childbirth. It could be they're recoiling from sex because they were abused at some point. At which point sexual therapy might help or some other form of family counseling.

So I like to think of the O-Shot® as a tool, and when the dysfunction involves any sort of dysfunction of the tissue of the genitalia, then that tool comes into play. Now, there's this dichotomy of thought, and I think you can tell I respect the idea. I mean, I'm a big fan of Erickson as well, I respect the idea that the mind is very powerful ...

and can do things that we're probably very not close to understanding at this point, but the idea to try to cure something with therapy that might be made better with something, a physical thing, seems to me like taking things ... Jefferson, Thomas Jefferson, 'I always grab things by the smooth handle.' The smooth handle is not always therapy. But sometimes it is THE handle. So, for example, if someone has, back to that example, if someone has trouble with orgasm and they have the pain from intercourse, sending them to therapy is not the right thing. I like to think of it like a system. On the other hand, if they were abused and their genitalia is working normally, the O-Shot® is not the right thing.

I've been in situations where the therapist somehow had the impression that I thought I had a magic shot that makes everything better. I don't, but on the other hand I don't think therapy necessarily makes everything better either. I like to think of it as a system, and it's a very complex system. For example, we think of a respiratory system, and if you said you're short of breath, that could be because you're anemic. It may not have anything to do with your, if you're profoundly anemic because you're, whatever, you've had colon cancer for the past 20 years or 5 years and you, without anyone knowing it, your red cell count is low, you can't carry oxygen, so you're short of breath because you're anemic. Where another person it may be bronchoconstriction. So one person needs a blood transfusion and iron and a colonoscopy, and the other person needs a bronchodilator.

I think because, again, because of these archaic, almost Middle-Age attitudes that it's not okay to take care of a vagina, it's not even okay to say the word 'rejuvenation' in the same sentence with the vagina, even though it's okay to say it with a face, it's okay to 'rejuvenate your face,' but let me talk about 'rejuvenating your vagina' and somehow I'm doing something ethically wrong, that's just archaic. In my opinion.

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To avoid that sort of 'I've got a hammer so everything's a nail' mentality, I like to think of a system. You can have a respiratory system but I think because of that archaic thinking, no one's ever said, "Hey, let's think of an orgasm system." It's a pretty complicated thing, and it involves having ... Let's talk about the respiratory system; the nervous system has to be working, sending the signals to breathe, which can be changed by lots of things. You have to have ... Bronchials have to be the right diameter. You have to have the right amount of red cells flowing through your blood stream. A lot of things have to do with respiration.

In the respiratory system, you have a neurovascular system, a nervous system, and endocrine system, and the reason we think about systems is because it emphasizes the interplay of lots of different components, and there in my opinion, there's an orgasm system. Testosterone has to be high enough, prolactin has to be low enough, you need a little dab of estrogen for some carrying, probably need a little bit of oxytocin for some love in there. At the same time you need to have sensation. You need to be conscious, you need to be not in pain. You need to have the right serotonin and dopamine, mill you and your brain to have libido. You get it. There's this whole complicated system, and all the O-Shot® does, all it does is make the tissue, that part, those receptors, and the functionality of the genitalia more healthy. That's all it does.

Orgasm & Spirals Up & Spirals Down

Having said that, it can have profound effects on all of it because we were taught ... I was taught in medical school, this is how sexuality works. You have arousal, then you have a plateau, then you have an orgasm, then you have a refractory period. There's this up, flat, and then down like that. It's actually much more complicated than that, especially for women. With men, maybe we're more simple minded. I feel pretty sure we are, actually. What we know for sure, that women are much more sex machines. How many men can have five orgasms back to back to back, with no refractory period? That's not so uncommon for a woman. How many men feel energized after an orgasm? Very common for a woman.

There seems to be, no matter what you want to say the cause of it, there seems to be a different ... I can talk to you a few hours about what I think it is, and what's going on there, but there seems to be a different reaction to sex. That's just the orgasm part. That's not even counting all the rest of it. What I'm getting to, and how the O-Shot® may affect multiple components, including the psychological ... If a woman, there's a spiral and it go up and down, if a woman has arousal, and then she has sex, and then it's a bad experience, she's ... For whatever reason. We can think of lots of horrible reasons it might be bad. But, it's a bad experience for her. Then, she doesn't go back to baseline. She's at a level now to where it's more difficult to even become aroused.

Let's say she tries again, and it's another bad experience. She's spiraling down. I think there's some women that are spiraled so far down because of abuse, and they attempt something with a lover and maybe they're abused again, or something bad happens, and they're so down, they just spiraled, spiraled down. Now, the other side of that, someone becomes aroused, a woman, and she has an encounter and she's ... It's glorious for her. She's respected, she's loved. She has this beautiful experience. Physically, emotionally, spiritually. Now, when it's time for possible sex again, she's at a different state. She's more easily aroused and there's a spiral up.

Women's Health Talks About the O-Shot® (Orgasm Shot®) Procedure

That spiral up and down, that's not my idea. That was actually presented, and its been talked about for a few years in the Journal of Sexual Medicine, and other places. What might be new is that, I think it's possible, that in some women my O-Shot® can help break the trend down. Or maybe help accelerate the trend up. For sure, I've seen it in women who have pain, break the trend down. We do the procedure, and then I have some techniques that I tell them to do so that they can test the waters, so to speak, on their own. Then they find, "Oh. Maybe I'm not having pain." Maybe they tentatively have sex with their lover and, "Oh. Wow. I didn't have pain." That doesn't mean they're not still worried about it, but they spiraled up a notch.

The next time they're not as tentative. There are ... Maybe that might apply, in even cases that don't have to do with pain. I think we're seeing our shot affect other areas because of that complicated system. It triggers other things in the mechanism. It's still not a magic shot.

Nory: Remarkably complex. Remarkably complex, the woman's ... The whole ethos. Not just her sexual response, but all that goes into making that ability to orgasm, or not. You're painting a very much bigger picture for me than I had had.

Dr. Runels: I think it's really ... It's very ... Prideful for us to think we have a deep understanding. Even when you expand it this broad, for example, we know that if you have a massage, your oxytocin level goes up. It makes people more open to pleasure. Oxytocin’s a small peptide chain made by the pituitary gland, which is attached to the brain. You might as well say it's part of the brain. There are over 200, that's 2 with 2 zero's behind it, peptides made by the pituitary gland. When we do some extensive blood tests, we get 20 blood values back. Oxytocin, DHEA, free and total testosterone, on and on and on. Still, just Kindergarten compared with what's going on up there.

The idea that you might push one button and it affects 10 other things ... For a simplistic example, if I raise your growth hormone level because you've had brain trauma and it's low, it's going to lower your thyroid level. If I raise your testosterone level, it's going to lower your thyroid bonding globulin, and you'll have more thyroid because I gave you testosterone. It will probably also increase your insulin like growth factor I, or your Somatomedin C because you'll probably create more growth hormone. That's just one example, of one hormone affecting two others.

Who knows what's happening with the other 200. That pituitary gland, remember, is attached to your brain. When you get fearful, and your heart rate goes up, it's because your cortex said, "Hey. I'm afraid." And your pituitary gland spat out some stuff that told your adrenal glands to release some stuff. It all started up here. I don't mean to say that what's going on up here is not important. I think it's extremely important. I do think there are ways to push buttons, whether it's hormonally or physically with our O-Shot® that have rippling effects throughout the whole system that can be beneficial.

Nory: That seems like a pretty good place to conclude the interview. I know that you're a little pressed for time.

Dr. Runels: I was honored to speak with you, Nory. I commend you ... I know we had some conversations earlier, so before we wrap it up I just want to commend you for having the courage to, one, talk about sex, because it's a courageous thing to do. Just bringing ... Broaching the topic will bring criticism, even to healthcare people like ourselves. Whether it be writers, therapists, doctors, doesn't matter. When people broach the subject of sex, there becomes a recoil that you can't even run ... I've been banned from Facebook. You can't run an ad, even if it's bringing people to something that's a medical procedure. I can't ... My Facebook ads have been banned because I talk about sex.

It's troublesome that there's this idea that ... As we spoke earlier, there's somethings that people can have go wrong, and they invite the utmost sympathy from everyone. You can have the flu, and people want you to get well, and you let them know without hesitation. They send you get well cards, or you can have cancer. Try getting schizophrenia. Or bipolar disease. And even though those are chemical imbalances, that it's not fault of the person, there's no reason to be ashamed of it, nevertheless, there's ... Continuing, we're not in the ... This is not the middle ages where we should be saying these people are witches or something, or they're possessed with the devil, but it's a chemical balance. They shouldn't have to be ashamed of it, but they are.

Many of them are. And they're ... In the same way, sexual problems, you won't see anybody posting to Facebook. They might post they got the flu, or they broke their arm, come sign my cast. You aren't going to see anybody post to Facebook, "Oh. I've got painful intercourse. Would you pray for me today." Or, "I couldn't have an orgasm last night with my husband. Would you give me a prayer?" Have you ever seen that on Facebook? You'll see broken arms all day long. And it's because there's a social stigma for it. But yet, that same thing, is so critical ... Emerson said sex and beauty is the ... He actually just said beauty, but I throw in the sex part, because I think that was his generic way of saying sex. But he said beauty was the scaffolding of love.

Yeah, you may reach a place where you don't need the scaffold, but I think most mortals need the scaffold to build a relationship. That's why I think more younger women, and older women complain. That's my long way of bragging on you, for you having the courage to talk about this. I'm happy to wrap it up, but it should go through this. If there are other questions that you get from your readers, or that just occur to you, we'll do Volume II. Anytime you want. Or III or IV.

Nory: You know, this was amazing. I didn't expect ... I was not expecting the depth. It was not what I asked for, but it was beautiful.

Dr. Runels: Thank you.

Nory: I feel way more optimistic I think, than you. Honestly, I do. I feel very optimistic. And I'm waiting for those bullets that you say are coming, those arrows. I know it would probably feel really good to you, to punch some people who have those attitudes about vaginal rejuvenation. Would you like ... Would you appreciate the opportunity to write a forward for my book? A short one, that does a little of that punching back?

Dr. Runels: Yes. I would love to write you a forward. The answer to that is yes. I would love to write a forward. As far as my, the way I visualize it, I see it more as ... When I was working in the ER, if someone came in just drunk and stupid, because of some drug they were on, and they would often try to hurt me. My goal is not really to punch back, it was just to control them from hurting anybody until they got their brain back. I look at these people, they're just so blinded by ... It's crazy to me.

I'll meet them in a thing and they'll say, "When you publish some research, then I'll start doing this." I'll say, "Well, you know we've already published five papers. And there's 9,000 papers about PRP. Have you read any of them? Or are you reading Marvel comics? What are you reading?" You're not reading any of this if you're reading Superman and Revenger. It's so funny to me that we're ... That's the way I look at it. It's not really punching back, as much as it is ... Anticipating their daggers, and building the intellectual shields to neutralize it until they get their brain back.

Nory: No. No. You're so nice. You're so nice, and I'm so grateful. I can't tell you.

Dr. Runels: All right. So, let's do this thing. I look forward to talking again, and I'll make this recording where you can take whatever you want and share it.

Nory: You are the best. Please give my regards to Erin. She's wonderful, too.

Dr. Runels: Thank you, Nory. Goodbye

Nory: Bye-bye.

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Transcript of Video...

Charles Runels: Hello, this is Charles Runels, and I'm extremely honored, very privileged and excited to be able to introduce Dr. Michael Goodman, who really needs no introduction. I've seen him lecture now on many occasions to other world-renowned gynecologists, and he always commands respect. He recently released a textbook that he edited about female genital plastic and cosmetic surgery.

One of the true pioneers who blazed the trail for the people who are doing it now, and I consider him to be actually one of the premiere physicians living today, and paved the way with some of his research for what's now widely practiced worldwide when it comes to cosmetic surgery in the female genitalia, and not just because it looks better, but how it actually contributes to a woman's functioning.

When I asked him to talk about the procedures he does, surgery versus the various devices, versus, of course, the O-Shot, how he uses those various modalities, combines them, and how he thinks about those modalities affecting a woman's sexual function. Of course, that has extremely far-reaching affects on her whole personality and her life, her family, and her career, and all that research has been done, but specifically how he combines these different modalities.

Hang on until the end, because when he's finished with demonstrating his ideas, I would like to ask him some more in depth questions about particularly how some of this relates to orgasms. Hang on until the end, and we'll some question and answer time.

Michael Goodman: What fun, Charles. I get to speak with you, one of my favorite people, about two of my favorite things, orgasms and vaginas. Without further ado, let's talk about that. Those of you that are looking at this podcast are well aware of orgasms. That's one of the reasons, probably, why you're looking at it and why you're either considering administering the O-Shot or are already.

Let's talk a little bit about how things really work, or the biomechanics of the whole process, and the physiology of orgasms, and the different types of orgasms. They certainly relate to the O-Shot, and they certainly relate to the whole idea of vaginal tightening. I really like to use that word, vaginal tightening, rather than the ubiquitous word vaginal rejuvenation.

That's an unfortunate choice of terms, because that term, vaginal rejuvenation, has been stolen out from under us by pretty unscrupulous marketers, who will have you think that all you need to do is put a wand in the vagina, either radio frequency and laser, and you will tighten the vagina, and you will improve orgasms, and no, that will not work.

Let's talk a little bit about terminology first. The term vaginal rejuvenation, by the way, refers to surgery alone, period. Vaginal rejuvenation was first popularized by one of the fathers of dental plastic and cosmetic surgery, David Matlock from Los Angeles, and was called Laser Vaginal Rejuvenation. By that, Dave meant the use of a Touch carbon dioxide laser as a cutting tool for surgery. Understand, vaginal rejuvenation refers to surgery. If someone's saying they're going to rejuvenate your vagina not using surgery, they are wrong, they will take your money.

Let's talk about why these operations work. If you look at the first slide, you see this lady had labioplasty also, we're not talking about labioplasty, which can happen [inaudible 00:04:01]. Why do vaginal tightening operations appear to improve sexual function and improve orgasms?

First, what are they? We talked a little bit about that. I got on my soapbox, which I tend to do when we're talking about that term vaginal rejuvenation. Really, a wonderful term is colpoperineoplasty, which is Jack Pardo's term from Chile. We don't use that that much, but really the best terms I feel, in my opinion, are perineoplasty and vaginoplasty.

Basically, these are surgical procedures designed to reapproximate the levator muscles, do basically a levatorplasty, bringing them together over the thinned out vaginal floor, decompress the rectocele, bulk and elevate the perineal body, to push up the penis or any inserted object to the anterior vaginal wall, excise all the scar tissue, to utilize a space closing, plicating 3-layer closure designed basically to tighten the outer half or two-thirds of the vaginal barrel, to result in greater stretch of the clitoral bulb and the anterior vaginal wall, and to result in greater penetration of the penis against the anterior vaginal wall and the cervix.

Additionally, and here's where these non-invasive technologies really may be helpful, is non-invasive technology such as radio frequency and fractional CO2 laser can be used in the far upper vagina, or what we call the [inaudible 00:05:50] of the vagina. That area of the vagina that has no musculature, that really has little fascia, that's only just mucosa, way up at the top.

That [inaudible 00:06:00] the skin. All these technologies do is resurface skin, and can increase collagen and elastin fibers way up at the top of the vagina, and also increase the stretchability and increase the elasticity underneath the base of the bladder, and certainly has been shown to help with minimal and modest urinary incontinence. Combining these two ends up with a really good procedure.

Again, we talked a little bit about the names of these procedures. I like, again, perineoplasty and vaginoplasty. The next slide I'm going to show you comes from my friends, Rob Moore and John Miklos from Atlanta. They are premiere vaginal reconstructive surgeons. I put down this quote in its entirety, because it really says a lot.

We can read it together. Vaginal rejuvenation surgery, again, surgery, is one of the latest trends in elective vaginal surgery for women. It is a repair of the vaginal caliber in women who suffer from decreased vaginal sensation, or of feelings of laxity, basically, that affects their sexual life. In many instances, women who present with these symptoms also have other pathology, such as prolapse. That must be addressed in any repair that's contemplated.

Sexual dysfunction, or decreased sexual sensation, may be one of the first symptoms that women suffer from in this progression from laxity to prolapse. There's ample evidence in the literature that prolapse and vaginal relaxation can create sexual dysfunction, and that repair may reverse these changes in many women. We're dealing with these early changes. When dealing with sexual dysfunction and the caliber of what's in the vagina, the surgical, underlining surgical, repair must be meticulous and exact to enhance sensation and function, and not impair it. This truly is the art of surgery.

With that introduction, what are the mechanics that we're talking about? This is a cross-section of a normal female nulliparous, in other words, no kids yet, anatomy. If you take a look here, and I'm not sure if you can see my arrow on the screen, hopefully you can. I'll put it all up.

Charles Runels: Yes, they can see your arrow.

Michael Goodman: Cool, good arrow. If this woman were supine you'd see that her vaginal barrel goes downwards. The angle of the vaginal barrel is downward. When a man is mounting her or she's on top of him, there is pressure, especially because of the angle, especially because of the pelvic floor, and very especially because of this robust perineal body here. There is pressure against the anterior vaginal wall, the G-spot, the internal clitoris, and then the dorsum of his penis, as you can see right here, the dorsum of his penis, the top of his penis, has pressure against there, has pressure against the clitoral glans, the clitoral body, and his pubic bone has pressure in that area, and all is fine.

But, but, but, with childbirth, or multiple childbirths, things change. The angle of that vaginal barrel no longer goes down, but is horizontal. It's lax. The floor is lax. You don't get that pressure against the anterior vaginal wall, you don't get the pressure against the G-spot, you don't get the pressure against the clitoris. It results in less stretch on these anterior vaginal wall receptors that we'll talk about in just a little bit. This is basically what I see, and what occurs frequently after childbirth. The procedure that we're talking about, perineoplasty and vaginoplasty can be performed ...

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Speaker: We're talking about perineoplasty and vaginoplasty can be performed in the hospital under a general anesthetic. I perform virtually all of these, as does Red Allensade perform these. Red and I, I believe are the only two that perform these in the office under local anesthesia and kudos to my friend Red Allensade, who's also, by the way, written and helped to edit an excellent textbook on genital plastics. Red took a already existing tractor system, The Lonestar, changed it a little bit and made it a wonderful system for exposure that does allow performance of these procedures in the office, under local. As has another friend, Marco Pelosi, who's designed an amazing retractor that can be used.

So just very briefly walking you through what we're talking about when we talk about a perineoplasty and vaginoplasty, this is not meant to teach you how to do this operation. It just shows you a little bit about what we mean as a basis, as a foundation when we talk about the physiology and the biomechanics in just a little bit.

So here's a woman with a paris vagina, a little bit of laxity, a little bit of gaping. In making the incision, what we can't quite see is the perineal incision. This starts just inside of the hymenal ring, just inside the introitus at about 4:00, 4:30, goes down on the outside encompasses lax perineum to the nadir, just above the anal verge. Comes down also from around 7:30 or 8:00, that comes down on the outside, then we'll make a line. A horizontal line between these two. Size that line with different instruments. I like a radio frequency needle electrode. Make that incision. Go ahead and undermine. You can see the retractor system in place. We'll undermine. We'll go to above the rectocele. I get in six, seven, eight centimeters inside. We'll go ahead, we've already removed part of the vaginal mucosa. We will remove this other part, you can see the rectocele a little bit over here. You can see it better in the next slide. What I've done is I have just a stay suture on the recto-vaginal fascial layer. So you can sort of see the rectocele. The levator muscles, bulbocavernosus, ischiocavernosus, and so forth. The levators are against the pelvic side wall and they come this way.

They're not transverse, they're vertical and they stretch apart. So basically what you're doing in this repair is you are putting in vertical sutures way over here. We can retract and expose that. Suture goes in here, it comes across to the other side, it's tied, and that basically will bring the levators as a levatorplasty and cover over, build up the pelvic floor, cover over the rectocele either with that same layer or a separate layer. We will bring the rectovaginal fascia that we dissected down off of the vaginal mucosa. We'll bring that over to cover up the floor. The other thing we'll do, after we've developed the perineum, is to get rid of all of this scar tissue from lacerations and episiotomies. We'll take out a plug of tissue that literally is about two centimeters by two centimeters from this whole area. So when everything's brought together it's going to snug up the vaginal barrel. So here you see just finishing the procedure, again this is not teaching you how to do the procedure, just giving you an idea of what we accomplished.

So what we've done, again we're only looking at the outside, what we've done is we've built up this tissue. We've re-approximated the transverse perinealis muscle. We've re-approximated the perianal musculature. Inside we've brought the levators together and we've rebuilt the pelvic floor. So to understand why these procedures work, it's nice to understand a little bit about the physiology of orgasms. And understand that, again arguably there's a lot of argue about this. My opinion is that, and many opinions, many people's opinion is that basically there are two types of orgasm, clitoral and vaginal, or perhaps better said vaginally activated orgasms. And certainly the two can work in concert.

So many of you have maybe seen this, certainly if you've attended my lectures you've seen this slide before. There are a lot of things that go on in women's orgasm. And what we're going to do today is talk a little bit about the clitoris, both the external clitoris and also the internal components of the clitoris. Here's a slide that is seen in many different places. It's a wonderful slide. But the clitoris is not just the little pink button that you see. The clitoral glands, you know if you look at a woman's clitoris real closely, it's like in looking at a mini penis. It looks exactly like a tiny little penis. And like a penis, it's not just the head. There's the body, the clitoral body, and that comes down underneath, and really it wraps these internal organs of the clitoris, wrapped around the urethra and really make up part of the, I like to call "G" area rather than G spot.

There are the true ... There's a crus on one side, a crus on the other side. Together they're called cruri, or corpus cavernosum. There's the bulbs of the clitoris, these are in loose, a realer tissue. But both of these consist of erectile tissue. And you can get an idea of the formation of this. This is innervated by the clitoral nerve, a branch of the pudendal nerve, which comes out from the spinal column around a little bit from L4, mostly L5, S1, S2. But a very important thing to understand, and this is probably one of the most important slides of the whole presentation. Is this concept of unity, in just a moment I'm going to show you a slide of a reference, it's a wonderful reference to look up with this concept of unity. The distal or the outer vagina and the vulva. The clitoris, the urethra are not separate, really they have a shared blood supply, a shared innervation, and they really respond as a unit to stimulation.

The urethra orifice is a very sensitive area in a woman, as is obviously the clitoris, the vulva, many different areas. But really it's a shared, this is a shared concept. So it's really a complex, and I really like to talk about the clitoro, this is a mouthful, the clitoro-urethro-vaginal concept. Clitoro-urethro-vaginal complex, which is really a unit, an anatomic and a functional unit. And that unit is activated by stretch. The greater stretch, you see what we're getting to soon, the greater stretch, the greater activation. So the vulva outerlies the wrapping, there's the urethral orifice surrounded by erectile tissue of the clitoral bulbs. The clitoris is not just the glands, it's an important distinction. All of these have erectile tissue components. And please understand they don't have a single innervation. There are really two sets of nerves. In the whole body there's two sets of nerves. There's somatic or skeletal nerves, and there's the autonomic nervous system. Two separate nervous systems.

The nervous system that tells you when your bladder is full or when you have to have a bowel movement is very different than the nervous system that tells you that you've been punched in the face and you get ready to punch back. So the somatic nervous system as I said comes from the dorsal clitoral nerve, which is a branch of the pudendal nerve. Supplies the skin and some of the underlying stretchers. The more visceral, autonomic fibers come by a cavernous nerves, by the inferior hypogastric plexus, branches of our old friend the vagus nerve. For you doctors that are looking at this, you remember the vagus nerve. It starts at the top it goes to the bottom and innervates everything. So vascular engorgement involves both somatic and visceral nerves. And there's a reflex arc here with cutaneous and somatic afferants and visceral efferents. And this is the reference I was talking about, Helen O'Connel and [inaudible 00:19:18] Patriots, this is an article 2008, Journal of Sexual Medicine, called The Anatomy of the Distal Vagina Towards Unity. It's a wonderful article that talks about the clitoro-urethro-vaginal complex.

So let's talk a little bit about our friend the anterior vaginal wall, and it's sensitivity, and Charles knows a lot about this because he puts, he and several of us put platelet-rich plasma okay, which has growth factors and angiogenic factors, and where do we put it? Into the anterior vaginal wall. Why do we do it? Because of proximity to peri-urethral tissue.

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Michael Goodman: -do it because of proximity to peri-urethral tissue, proximity to the clitoral bulbs and the crurae, and again, in this area there is both a skeletal and an autonomic nerve supply. While this slide is up I want to talk just for a minute about the peri-urethral glands, AKA Skene's glands. Skene's glands have their opening, their ducts, just around the urethral meatus. If you look real carefully, not in all women, you can see these little gland openings. Every once in awhile, they'll get plugged, and you can have a Skene's gland cyst, but female ejaculation, and not all women have well-developed Skene's glands, but there's a difference between squirting and ejaculation, and that's not the purpose of this to talk about. Squirting is losing urine. Female ejaculation is discharge of prostatic light fluid from the Skene's gland, little detour there.

So remember in medical school, at least I remember back in ancient times when I was a OBGYN resident, we were told that the vagina is poorly innervated, and indeed, one can go into a woman's vagina, one can visualize a woman's vagina, and can take a scalpel and cut that vagina, and the woman will not know that that happened. Okay. But that doesn't talk about stretch receptors, which certainly that organ, the vagina, has. So this organ, especially in its outer portion, and I love this quote. This is one of the best quotes I've seen from Glorida D'Amati and Emmanuel Jannini, two beautiful Italian women, and only an Italian, I guess could say it this way.

"This organ, especially in its outer portion, contains enough nerves to participate in sexual response as well as the whole biochemical machinery known to mediate excitation and arousal in the male copulatory organ."

What a wonderful quote. Do you have anything to say about that, Charles?

Charles Runels: Yeah. So I'm a big fan, as you know, of Dr. Gräfenberg, for whom the G-spot is named, but if you read Dr. Gräfenberg, he doesn't talk so much about a spot. He thought what was going on is exactly what you're saying. It really had to do with the whole complex, and especially the entire urethra, and not so much some magical spot. As a matter of fact, I think personally that the spot changes sometimes day to day in the same woman, but he was all about the whole urethra, and if you think about it, not only do you have this excitatory response from the stretch receptors itself, but by bringing those structures next to the vagina closer to what is making the stretch, if it's a man having sex with a woman, then you're going to have more pressure in the corpus cavernosi of the clitoris as well as on the urethra.

So lots of things are happening. That's why I like your phrase the ureal, clitoral, vaginal complex, because you get not only excitation from the stretch receptors on the vagina, but that stretch brings pressure simultaneously on the part of the clitoris that wraps down next to the vagina, as well as on the urethra. So absolutely. I'm over here cheering for you.

Michael Goodman: And I didn't need you to say that, but that just sort of segues into what we're going to talk about in just a little bit, which is vaginally-activated orgasm. I like the term "vaginally-activated orgasm" better than vaginal orgasm, but we're talking about the same thing. Again, these are relationships between clitoris and vagina. There is a reflex called a vaginal-cavernosus reflex, so what this is, is when there's vaginal distension, I mean inserting an object, that induces contractions of the bulbocavernosus, the ischiocavernosus, and the magnitude of that contraction, and this is research data, increases with the volume of vaginal inflation, therefore if there's increased inflation, or increased pressure from a tightened vagina, a large penis, or growth factors and androgenic factors in the anterior vaginal wall, this increase contact between the vagina and the congested clitoris leading to vaginally-activated orgasm caused by contact of the internal portions of the clitoris, again, somatic, skeletal innervation, and in the anterior vaginal wall stretch receptors, which are autonomic innervations.

This is research-based, and these slides have that research on them. Odile Buisson and Pierre Foldes, Emmanuel Jannini have done a lot of work on that, as have others.

So again, not to beat a dead horse, but there is a clear reciprocal relationship between the clitoris and the vagina, and remember, functional [inaudible 00:25:40]. Let's talk about these different types of orgasms.

Clitoral orgasm, caused by both digital stimulation, external stimulation, again clitoral nerves from the pudendal are warm, electrical kind of feeling. Vaginally-activated orgasm, arguably more intense, more internal, more deep, more throbbing, and this is triggered by stimulation and expansion of the vagina, the G-area. Anterior vaginal wall, autonomic innervation. Very interesting. Very interesting. It's research that's been done by Barry Komisaruk and Bev Whipple out of New York City. I think, Charles, you know probably Barry. I don't know if you've met Bev. They did seminal research where they studied women that had spinal cord transection. They had spinal cord transection above L4, L5, and found that ... So what you're doing there is cutting off any input from the pudendal nerves. Well, they don't have any innervation from the pudendal, and these women were still orgasmic, really proving that it's not all the pudendal nerve, proving that the activation and innervation from the autonomic nervous system plays a big role here. That was really seminal research that Whipple and Komisaruk did.

So we talked a lot about the anterior vaginal wall. I won't beat that again. This is research, again, from Pierre Foldes and Odile Buisson. So in contrast to clitoral orgasm, vaginally-activated orgasm is orgasm triggered purely by penile, vaginal intercourse or a surrogate. Very interesting and very controversial research is this study down here by [Stuart 00:27:54] Brody and I don't know Weiss. I haven't met Weiss. Stuart I know. This is from University of West Scotland in Paisley. Brody has written a lot. It's very controversial, and basically Brody feels that women enjoy men who have larger penises, that women have greater orgasm response, especially vaginal orgasm, in men who have larger penises. Why? Because there's more stimulation of the anterior vaginal wall.

What are we doing when we do vaginal tightening operations? I don't think we're increasing the size of men's penises, but Charles, you've commented a lot about that, and you certainly have research in that, and you are working in an area that actually does increase the size of men's penises, certainly by tightening the vaginal barrel, lifting up the perineal body, you're doing about the same thing. You're not making the penis larger, you're making the vagina tighter.

So basically, relaxed vagina, relaxed perineum, less penile pressure against the pubis, the clitoris, less stretch on the receptors of the anterior vaginal wall. So the goal then, of a vaginal tightening operation, is to reestablish the angle and to increase the anterior vaginal wall and cervical pressure, but one other thing that I haven't mentioned is that just tightening the vagina, just doing that surgical operation I think is leaving half the job undone. We're bringing these muscles in together, but just bringing the muscles in together is doing nothing but strengthening the muscles, so just doing an operation without working with that women, her pelvic floor, strengthening exercises, working with her or working with a pelvic floor physical therapist who works with her, I think it's imperative for really doing the job right.

So I'm going to show you a few of my photos [inaudible 00:29:57] labioplasties in addition to their pelvic floor operations. You obviously cannot see inside the-

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Michael Goodman: -their pelvic floor operations. You obviously cannot see inside the vaginal barrel, but looking at this you can get a little idea of what we were talking about, what's accomplished with vaginal tightening operations.

With perineoplasty, working on the outside, that's perineoplasty, building up, reestablishing the angle, building up the clitoral body, bulking the clitoral body, doing an aesthetic repair of the opening, and then vaginoplasty, tightening the vaginal barrel.

These are just a few before and afters. Again, some of these have had minor labioplasties, or major labioplasties at the same time.

Different cameras, obviously here. We didn't do any work at all on the top. The labia are just so splayed outward here, where they're inward here, but you can get an idea of what's been done from here to here, as opposed to what obtains over here.

Same thing here. She's healing from her labioplasty. Again, this kite-shaped incision, we did no work to diminish these folds. This is just the incision that reconstructs the opening, builds up the perineal body.

You can see especially here, we've done no work on the anterior vagina, and this is a urethra seal, and there's nothing you can do really about a urethra seal, but we certainly have supported the perineal.

So concluding this part of the presentation, these so-called vaginal tightening operations, AKA perineoplasty, vaginoplasty, vaginal rejuvenation, surgical vaginal rejuvenation, appear to have good outcome via both mechanically tightening the barrel, forcing the penis more tightly against the anterior vaginal wall in Gräfenberg's area. Thanks, Charles. Which contain erectile tissue of the bulb and [inaudible 00:32:02] of the clitoris, as well as that rich autonomic supply, reestablishing the downward angle of the barrel with greater stimulation of the external clitoral structures by the top of the penis and by the partner's pubic bone.

So with that, I'm done with what I had to say. Any questions are welcome.

Charles Runels: Yes, okay. So-

Michael Goodman: And just one last thing before [inaudible 00:32:32]. There's no way on Earth that I could do the work I do without Nicole Sanders and Rachel Davis. Nicole's worked with me for 14 years, Rachel for five. They scrub on surgery. They work with women in every possible way, and we are truly a team, so I'll shut up.

Charles Runels: Beautiful. Well, it's a very elegant presentation, and the mechanics, when I talk with physicians, it's amazing how many physicians would have trouble drawing a clitoris, and the entire thing, and how many gynecologists have told me that they prefer to not talk about sex. I'm not so sure that's a bad thing. Perhaps they're more interested in treating ovarian cancer and sex is off-topic, but as you know, it's not always a comfortable thing for people to speak about, and I salute you for blazing the trail for making it more acceptable.

Now, what I would like to address is some of the objections that people have about what you and I do. Now, for example, there are those that would say we shouldn't pay attention to the labia's appearance at all, and what I think you did was lay out a very good explanation about why it's not just about appearance. It's truly about function, and I know you've published in this arena, but if you wanted to talk about the appearance itself, talk about what you've seen, what the research has shown about how appearance affects function.

Michael Goodman: Oh, [inaudible 00:34:18]. I'm going to go talk about something that I very recently had contact with and then back up a little bit. I review for some medical journals, and I just reviewed for the Journal of Bioethical Investigation. I just reviewed an article for the Journal of Bioethical Investigation, one of the top bioethics journals. This is done by a bioethicist, who is not a surgeon, has no interest in female plastic and cosmetic vaginal surgery, and looked into the area of adolescents and whether they should have labioplasties or not.

I've had the opportunity to operate on a modest number of adolescents. We're talking about young women between the ages of 14 and 18, and adolescents really come in with the largest labia of all the women that I've operated on. They come in with their moms who couldn't believe what they were talking about at first, and then understand. Basically, what this article talks about is the feeling that other people have that, "Well, if it's a big functional problem and it really causes infections and so forth, then maybe you should operate on it, but if it's a psychological problem, then you shouldn't."

And this group of bioethicists begged very strongly to differ, saying that we do a lot of procedures for people because of significant psychological situations, psychodynamic situations, self-esteem situations, and felt that there's really no difference between functional and self-esteem/psychological reasons. Certainly, that is borne out in the literature. We did a study several years ago, now seven or eight years ago. It still is the largest study in the literature on about over 250 women and 345 procedures, of which about 150 were labioplasties.

We took a look at sexual satisfaction in women that had labioplasties and the reasons for labioplasties are usually either psychological, meaning, "I don't like how it looks. It makes me very self-conscious. I don't want to have sex in the light. I don't want him to go down on me. I just don't feel good about it." And none of these men are complaining. We guys, we're just happy to be there, and we love our partners for who they are and whatever's attached to them is fine, but women feel very different about this, so we looked at sexual ... enhancement of sexual function, enhancement of sexual satisfaction with validated questionnaires in women that had vaginal tightening operations, separate issue, and women that had labioplasties.

And women that had vaginal tightening operations, these operations enhanced their sexual function in our study by 87.5%, in [Pardeau's 00:37:35] study by 90%, and interestingly, we asked the men, who were happy to begin with, but 82% of the men felt that these tightening operations enhanced sexual function.

Well, then we also looked at labioplasties. Now, you'd figure that a vaginal tightening operation, one would hope, would enhance sexual function, but a labioplasty, we're just doing appearance. It shouldn't do anything with sexual function, but in women, two thirds of the women, 67% felt that the labioplasty had either a moderate or a significant enhancement on their sexual function and sexual satisfaction, and we banged our palm on our forehead and said, "Of course." If a woman feels more self-confidence, if a woman feels that, even if the guy hasn't said anything, if a woman feels that she's prettier down there, and she's not worried about her labia escaping from her thong, her lacy thong underwear, she is going to be much more participatory and much happier in her sexual function.

The other thing we did is published a couple studies, and others have published studies looking at body image and sexual satisfaction in women that undergo genital plastic and cosmetic surgery, and it's well-known that if someone has a sexual dysfunction, true sexual dysfunction, or if someone has body dysmorphia, true body image issues, you're not going to cure that with surgery. Period. We know that. Plastic surgeons know that. Well, very interestingly in our last study, which was well [inaudible 00:39:13] and well brought out in time, this was on 120 women. We followed these women for two years. We got feedback prior to surgery. They filled out four questionnaires that looked at sexual function, looked at body image, looked at body image, body dysmorphia, sexual function, and I'm sorry. I'm blocking out one other thing.

We looked at them before surgery, six months, 12 months, and 24 months, and these women as a group, qualified as body dysmorphic. If you looked at the validated questionnaire we utilized for body dysmorphia, these women-

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Michael Goodman: Questionnaire we utilize for body dysmorphia. These women were body dimorphic and their sexual function was generally poor. One would think that surgery would not change that, but at all points in time, moderately at six months, but very significantly in 12 and 24. This was a level two study. It was controlled. It was a controlled study that by 12 and 24 months the body image dissatisfaction, the so called body dysmorphia, had totally disappeared. This was not true body dysmorphia. This was body dissatisfaction, very different than body dysmorphia. Now, it disappeared and the sexual satisfaction went up to and actually went beyond that of the control group. I can go on, but hopefully that answered your question.

Charles Runels: Well, very elegantly and much of that research, I know that you spearheaded. I hear other physicians who are in hardcore science forums where they're talking about like Lichen sclerosus and other diseases. That will sing your praises because until that research was done, a lot of people did assume that anybody who wanted to change the appearance of their labia must have a psychological problem and they're better off with a psychiatrist than doing something about the labia. This research demonstrated that not to be the case. 67% is a strong number and still a year out and farther still working.

There are others that, as you know, strong movements among some of our colleagues, I think becoming more and more the minority, that we shouldn't even have before and after pictures of the labia or even say anything about it on the internet, which goes back, I think, more to do with relationships with sex than with medicine because, as you know, there was a time in the not so far past, 20, 30 years ago, where before and after pictures of the face with facial cosmetic surgery was considered to be unethical. Things changed because we realized you can't really demonstrate to a patient what's possible and what's not possible without photographs. I think this idea that it's okay to change a person's face to make them feel better about themselves, and obviously even facial plastic surgeons, as you said, they're not going to do surgery on someone who's psychologically, and we can find this out with an interview, they're not going to get better no matter what you do with them. They're going to have surgery after, surgery, after surgery and there's a way to discover that about a person with an interview.

There are those who get a legitimate facelift of something done cosmetically, they get their Botox or whatever, and it makes them feel better about themselves. If you think about it, the concept that it's okay to do that with the face, but yet if you apply those same ideas to genitalia, somehow that's wrong. It smacks or some Victorian era. It always surprises me that that idea still exists even though you've done the research to show the same thinking applies. The idea that a woman can go buy a dress and feel sexy and want to have intercourse tonight, but yet you couldn't make her feel better about her vagina to me just seems a little bit hypocritical. I'm just saying amen. I know that you did that research, which is why I wanted to bring that out and get it out there for people to think about.

When I post this video, I'll put some of those links to some of that research under the video so people can educate themselves. Just one other comment I'd like for you to elaborate upon. Let's just scenario here. People get married. They're 20, 30, whatever age, but let's say it's a typical young love. You get married, and you have children, and then you stay together. Now you have this soul mate of 10, 20, 30 years, 40 years. We see people 50 years in our office married, but the universe plays a bad joke, in my opinion, because by the time a man reaches 65, he loses half of the endothelium of penis. A woman delivers a child or two and estrogen levels change. His penis is literally shrinking and her vagina is growing. By the time they've been together for a while, these lovers who may have matched when they were younger now don't.

Again, the idea that you shouldn't do something about that because it's genitalia, where it's perfectly okay to do things to change your waistline or your neckline, to me, just seems a little bit hypocritical. Could you elaborate a little bit on this matching idea? That's why one guys penis may be too big for one woman and too small for another. If you're just thinking in terms of those stretch receptors, but when you think about these other modalities, like laser versus surgery versus the O-Shot, and talking to the woman about this matching of her lover, could you tell me maybe a few stories about people you've taken care of and integrate with it the way you think about the science?

Michael Goodman: Yeah. An interesting paper that I just reviewed for The Journal of Sexual Medicine and unfortunately was rejected by the editors, I think it should have a place in that journal, hopefully it'll be rewritten and resubmitted out of China, where they attract the anatomic changes of the relationships of different parts of a woman's vulva to her age as far as distance, distance between the pubic bone and the clitoris, distance between the clitoris and the vaginal opening, distance between the urethra and the perineum, distance between the perineum and the anus. What you mentioned anecdotally is true anatomically, that yes, with age, women's vaginas do fall down a little bit. The opening gapes a little bit. It becomes a little bit more relaxed and more open. That is saying that she's hormonally complete. Obviously if a woman after menopause is not on any hormone therapy at all, then sometimes the vagina can shrink if she's not sexually active.

As you mentioned, the size of a man's non-erect penis becomes somewhat smaller, so I understand, though I've not seen studies on that. Certainly a man's erection becomes less robust. I love that word, although you can use it both ways. A man's erections, for many reasons, become less robust. Certainly I work with men and a lot of times it's the partners of the women that I'm working with during their menopausal transition, where they weren't terribly interested in sex with all that was going on with menopause. Now they're feeling a whole lot better and a whole lot sexier, and the fact that now their partner can't either get or maintain an erection is an issue. Certainly working with testosterone, working with PDE5 inhibitors. I have not personally had experience with the Priapus Shot. You certainly have. Adding the Priapus Shot into that can all serve to increase the size of a man's penis.

There's a lot of things that couples can do. Obviously the use of fantasy, the use of toys. Love making is love making. Physical intimacy is physical intimacy and it doesn't all mean intercourse. It can mean using a toy in addition to the penis in the vagina to increase the stretch receptors. It can mean getting a Priapus Shot. It can mean taking testosterone and PDE5 inhibitor. It also can mean, for a woman, doing a surgical procedure to tighten the vagina. Obviously there's different age demographics. Certainly the age demographic for women who have having labiaplasties in my experience, and I've done about 750 labiaplasties and close to 200 vaginal tightening operations, the age demographic in women that are having labiaplasties is younger than women that are having vaginal tightening.

I've done vaginal tightening operations in women in their early 60s. I have not yet done it in women that are a more advanced age. I'm in my early 70s. My partner is in her early, mid 60s. Men and women in their 80s and 90s have sexual intercourse. A long winded way of saying, Charles, that there's a lot of different things you could do. That's the joy of sexual medicine is working with couples to improve their intimacy, which can be all of these different things.

Charles Runels: Yeah, it's so rewarding. We've both been involved in what others would consider to be more hardcore, life threatening type situations, but nothing has been more rewarding to me than having a couple to me than having a couple that's been married for any number of years, 10, 20, 50 years, come back to me and say, "We're rediscovering our bodies because they're responding more like they did when we were younger." Well, we could go on and on, but I just wanted to add that Dr. Goodman has several ways you can learn more from him. I highly recommend his book if you don't have it yet, of course. That's the place to start. Then he has hands on classes in his office where he mentors surgeons who want to learn more of the nuances of these procedures. He's been teaching for a long time. Many of the people who teach are his students. He's not also offering some didactic classes for those who qualify who can learn some of how we do the O-Shot, how to integrate that with some of the other methods that he's discussing with surgery.

I think your next class is coming up in Atlanta. There'll be others who will be posting and so I highly, highly recommend that, even if you've done these classes before, if you have the opportunity, spend some time with Dr. Goodman. He's recognized as the godfather of a lot of these procedures. Yes, sir?

Michael Goodman: I'm teaching classes in Atlanta in October and April and in Sacramento in January and July. The classes are excellent accommodations at airport hotels. They're two different classes. They're both didactic and experiential. I have full length surgical videos. The whole idea is to work with surgeons, whether they're cosmetic surgeon, gynecological surgeons, to basically teach the technique and to discuss how to work with women. We also talk about noninvasive techniques. We talk about platelet rich plasma for different indications including the O-Shot. We talk about the use and misuse of noninvasive laser and radio frequency. There's wonderful uses of both of them, and there's some misuses.

Charles Runels: Yeah. This is going to be some amazing stuff and I know there'll be other classes after that. I'll post links to them all. With that, I'll just tell you thank you. Unless there's something else, we'll end this call and I'm sure you'll be hearing from some of the people watching this video. Thank you very much, Dr. Goodwin.

Michael Goodman: Awesome. Thanks very much. It has truly been a pleasure.

 

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Orgasm, Mechanics, Surgery, & O-Shot® (Discussed with Dr. Michael Goodman)

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Charles Runels: Hello, this is Charles Runels, and I'm extremely honored, very privileged and excited to be able to introduce Dr. Michael Goodman, who really needs no introduction. I've seen him lecture now on many occasions to other world-renowned gynecologists, and he always commands respect. He recently released a textbook that he edited about female genital plastic and cosmetic surgery.

One of the true pioneers who blazed the trail for the people who are doing it now, and I consider him to be actually one of the premiere physicians living today, and paved the way with some of his research for what's now widely practiced worldwide when it comes to cosmetic surgery in the female genitalia, and not just because it looks better, but how it actually contributes to a woman's functioning.

When I asked him to talk about the procedures he does, surgery versus the various devices, versus, of course, the O-Shot, how he uses those various modalities, combines them, and how he thinks about those modalities affecting a woman's sexual function. Of course, that has extremely far-reaching affects on her whole personality and her life, her family, and her career, and all that research has been done, but specifically how he combines these different modalities.

Hang on until the end, because when he's finished with demonstrating his ideas, I would like to ask him some more in depth questions about particularly how some of this relates to orgasms. Hang on until the end, and we'll some question and answer time.

Michael Goodman: What fun, Charles. I get to speak with you, one of my favorite people, about two of my favorite things, orgasms and vaginas. Without further ado, let's talk about that. Those of you that are looking at this podcast are well aware of orgasms. That's one of the reasons, probably, why you're looking at it and why you're either considering administering the O-Shot or are already.

Let's talk a little bit about how things really work, or the biomechanics of the whole process, and the physiology of orgasms, and the different types of orgasms. They certainly relate to the O-Shot, and they certainly relate to the whole idea of vaginal tightening. I really like to use that word, vaginal tightening, rather than the ubiquitous word vaginal rejuvenation.

That's an unfortunate choice of terms, because that term, vaginal rejuvenation, has been stolen out from under us by pretty unscrupulous marketers, who will have you think that all you need to do is put a wand in the vagina, either radio frequency and laser, and you will tighten the vagina, and you will improve orgasms, and no, that will not work.

Let's talk a little bit about terminology first. The term vaginal rejuvenation, by the way, refers to surgery alone, period. Vaginal rejuvenation was first popularized by one of the fathers of dental plastic and cosmetic surgery, David Matlock from Los Angeles, and was called Laser Vaginal Rejuvenation. By that, Dave meant the use of a Touch carbon dioxide laser as a cutting tool for surgery. Understand, vaginal rejuvenation refers to surgery. If someone's saying they're going to rejuvenate your vagina not using surgery, they are wrong, they will take your money.

Let's talk about why these operations work. If you look at the first slide, you see this lady had labioplasty also, we're not talking about labioplasty, which can happen [inaudible 00:04:01]. Why do vaginal tightening operations appear to improve sexual function and improve orgasms?

First, what are they? We talked a little bit about that. I got on my soapbox, which I tend to do when we're talking about that term vaginal rejuvenation. Really, a wonderful term is colpoperineoplasty, which is Jack Pardo's term from Chile. We don't use that that much, but really the best terms I feel, in my opinion, are perineoplasty and vaginoplasty.

Basically, these are surgical procedures designed to reapproximate the levator muscles, do basically a levatorplasty, bringing them together over the thinned out vaginal floor, decompress the rectocele, bulk and elevate the perineal body, to push up the penis or any inserted object to the anterior vaginal wall, excise all the scar tissue, to utilize a space closing, plicating 3-layer closure designed basically to tighten the outer half or two-thirds of the vaginal barrel, to result in greater stretch of the clitoral bulb and the anterior vaginal wall, and to result in greater penetration of the penis against the anterior vaginal wall and the cervix.

Additionally, and here's where these non-invasive technologies really may be helpful, is non-invasive technology such as radio frequency and fractional CO2 laser can be used in the far upper vagina, or what we call the [inaudible 00:05:50] of the vagina. That area of the vagina that has no musculature, that really has little fascia, that's only just mucosa, way up at the top.

That [inaudible 00:06:00] the skin. All these technologies do is resurface skin, and can increase collagen and elastin fibers way up at the top of the vagina, and also increase the stretchability and increase the elasticity underneath the base of the bladder, and certainly has been shown to help with minimal and modest urinary incontinence. Combining these two ends up with a really good procedure.

Again, we talked a little bit about the names of these procedures. I like, again, perineoplasty and vaginoplasty. The next slide I'm going to show you comes from my friends, Rob Moore and John Miklos from Atlanta. They are premiere vaginal reconstructive surgeons. I put down this quote in its entirety, because it really says a lot.

We can read it together. Vaginal rejuvenation surgery, again, surgery, is one of the latest trends in elective vaginal surgery for women. It is a repair of the vaginal caliber in women who suffer from decreased vaginal sensation, or of feelings of laxity, basically, that affects their sexual life. In many instances, women who present with these symptoms also have other pathology, such as prolapse. That must be addressed in any repair that's contemplated.

Sexual dysfunction, or decreased sexual sensation, may be one of the first symptoms that women suffer from in this progression from laxity to prolapse. There's ample evidence in the literature that prolapse and vaginal relaxation can create sexual dysfunction, and that repair may reverse these changes in many women. We're dealing with these early changes. When dealing with sexual dysfunction and the caliber of what's in the vagina, the surgical, underlining surgical, repair must be meticulous and exact to enhance sensation and function, and not impair it. This truly is the art of surgery.

With that introduction, what are the mechanics that we're talking about? This is a cross-section of a normal female nulliparous, in other words, no kids yet, anatomy. If you take a look here, and I'm not sure if you can see my arrow on the screen, hopefully you can. I'll put it all up.

Charles Runels: Yes, they can see your arrow.

Michael Goodman: Cool, good arrow. If this woman were supine you'd see that her vaginal barrel goes downwards. The angle of the vaginal barrel is downward. When a man is mounting her or she's on top of him, there is pressure, especially because of the angle, especially because of the pelvic floor, and very especially because of this robust perineal body here. There is pressure against the anterior vaginal wall, the G-spot, the internal clitoris, and then the dorsum of his penis, as you can see right here, the dorsum of his penis, the top of his penis, has pressure against there, has pressure against the clitoral glans, the clitoral body, and his pubic bone has pressure in that area, and all is fine.

But, but, but, with childbirth, or multiple childbirths, things change. The angle of that vaginal barrel no longer goes down, but is horizontal. It's lax. The floor is lax. You don't get that pressure against the anterior vaginal wall, you don't get the pressure against the G-spot, you don't get the pressure against the clitoris. It results in less stretch on these anterior vaginal wall receptors that we'll talk about in just a little bit. This is basically what I see, and what occurs frequently after childbirth. The procedure that we're talking about, perineoplasty and vaginoplasty can be performed ...

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Section 2 of 5 [00:10:00 - 00:20:04](NOTE: speaker names may be different in each section)

Speaker: We're talking about perineoplasty and vaginoplasty can be performed in the hospital under a general anesthetic. I perform virtually all of these, as does Red Allensade perform these. Red and I, I believe are the only two that perform these in the office under local anesthesia and kudos to my friend Red Allensade, who's also, by the way, written and helped to edit an excellent textbook on genital plastics. Red took a already existing tractor system, The Lonestar, changed it a little bit and made it a wonderful system for exposure that does allow performance of these procedures in the office, under local. As has another friend, Marco Pelosi, who's designed an amazing retractor that can be used.

So just very briefly walking you through what we're talking about when we talk about a perineoplasty and vaginoplasty, this is not meant to teach you how to do this operation. It just shows you a little bit about what we mean as a basis, as a foundation when we talk about the physiology and the biomechanics in just a little bit.

So here's a woman with a paris vagina, a little bit of laxity, a little bit of gaping. In making the incision, what we can't quite see is the perineal incision. This starts just inside of the hymenal ring, just inside the introitus at about 4:00, 4:30, goes down on the outside encompasses lax perineum to the nadir, just above the anal verge. Comes down also from around 7:30 or 8:00, that comes down on the outside, then we'll make a line. A horizontal line between these two. Size that line with different instruments. I like a radio frequency needle electrode. Make that incision. Go ahead and undermine. You can see the retractor system in place. We'll undermine. We'll go to above the rectocele. I get in six, seven, eight centimeters inside. We'll go ahead, we've already removed part of the vaginal mucosa. We will remove this other part, you can see the rectocele a little bit over here. You can see it better in the next slide. What I've done is I have just a stay suture on the recto-vaginal fascial layer. So you can sort of see the rectocele. The levator muscles, bulbocavernosus, ischiocavernosus, and so forth. The levators are against the pelvic side wall and they come this way.

They're not transverse, they're vertical and they stretch apart. So basically what you're doing in this repair is you are putting in vertical sutures way over here. We can retract and expose that. Suture goes in here, it comes across to the other side, it's tied, and that basically will bring the levators as a levatorplasty and cover over, build up the pelvic floor, cover over the rectocele either with that same layer or a separate layer. We will bring the rectovaginal fascia that we dissected down off of the vaginal mucosa. We'll bring that over to cover up the floor. The other thing we'll do, after we've developed the perineum, is to get rid of all of this scar tissue from lacerations and episiotomies. We'll take out a plug of tissue that literally is about two centimeters by two centimeters from this whole area. So when everything's brought together it's going to snug up the vaginal barrel. So here you see just finishing the procedure, again this is not teaching you how to do the procedure, just giving you an idea of what we accomplished.

So what we've done, again we're only looking at the outside, what we've done is we've built up this tissue. We've re-approximated the transverse perinealis muscle. We've re-approximated the perianal musculature. Inside we've brought the levators together and we've rebuilt the pelvic floor. So to understand why these procedures work, it's nice to understand a little bit about the physiology of orgasms. And understand that, again arguably there's a lot of argue about this. My opinion is that, and many opinions, many people's opinion is that basically there are two types of orgasm, clitoral and vaginal, or perhaps better said vaginally activated orgasms. And certainly the two can work in concert.

So many of you have maybe seen this, certainly if you've attended my lectures you've seen this slide before. There are a lot of things that go on in women's orgasm. And what we're going to do today is talk a little bit about the clitoris, both the external clitoris and also the internal components of the clitoris. Here's a slide that is seen in many different places. It's a wonderful slide. But the clitoris is not just the little pink button that you see. The clitoral glands, you know if you look at a woman's clitoris real closely, it's like in looking at a mini penis. It looks exactly like a tiny little penis. And like a penis, it's not just the head. There's the body, the clitoral body, and that comes down underneath, and really it wraps these internal organs of the clitoris, wrapped around the urethra and really make up part of the, I like to call "G" area rather than G spot.

There are the true ... There's a crus on one side, a crus on the other side. Together they're called cruri, or corpus cavernosum. There's the bulbs of the clitoris, these are in loose, a realer tissue. But both of these consist of erectile tissue. And you can get an idea of the formation of this. This is innervated by the clitoral nerve, a branch of the pudendal nerve, which comes out from the spinal column around a little bit from L4, mostly L5, S1, S2. But a very important thing to understand, and this is probably one of the most important slides of the whole presentation. Is this concept of unity, in just a moment I'm going to show you a slide of a reference, it's a wonderful reference to look up with this concept of unity. The distal or the outer vagina and the vulva. The clitoris, the urethra are not separate, really they have a shared blood supply, a shared innervation, and they really respond as a unit to stimulation.

The urethra orifice is a very sensitive area in a woman, as is obviously the clitoris, the vulva, many different areas. But really it's a shared, this is a shared concept. So it's really a complex, and I really like to talk about the clitoro, this is a mouthful, the clitoro-urethro-vaginal concept. Clitoro-urethro-vaginal complex, which is really a unit, an anatomic and a functional unit. And that unit is activated by stretch. The greater stretch, you see what we're getting to soon, the greater stretch, the greater activation. So the vulva outerlies the wrapping, there's the urethral orifice surrounded by erectile tissue of the clitoral bulbs. The clitoris is not just the glands, it's an important distinction. All of these have erectile tissue components. And please understand they don't have a single innervation. There are really two sets of nerves. In the whole body there's two sets of nerves. There's somatic or skeletal nerves, and there's the autonomic nervous system. Two separate nervous systems.

The nervous system that tells you when your bladder is full or when you have to have a bowel movement is very different than the nervous system that tells you that you've been punched in the face and you get ready to punch back. So the somatic nervous system as I said comes from the dorsal clitoral nerve, which is a branch of the pudendal nerve. Supplies the skin and some of the underlying stretchers. The more visceral, autonomic fibers come by a cavernous nerves, by the inferior hypogastric plexus, branches of our old friend the vagus nerve. For you doctors that are looking at this, you remember the vagus nerve. It starts at the top it goes to the bottom and innervates everything. So vascular engorgement involves both somatic and visceral nerves. And there's a reflex arc here with cutaneous and somatic afferants and visceral efferents. And this is the reference I was talking about, Helen O'Connel and [inaudible 00:19:18] Patriots, this is an article 2008, Journal of Sexual Medicine, called The Anatomy of the Distal Vagina Towards Unity. It's a wonderful article that talks about the clitoro-urethro-vaginal complex.

So let's talk a little bit about our friend the anterior vaginal wall, and it's sensitivity, and Charles knows a lot about this because he puts, he and several of us put platelet-rich plasma okay, which has growth factors and angiogenic factors, and where do we put it? Into the anterior vaginal wall. Why do we do it? Because of proximity to peri-urethral tissue.

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Section 3 of 5 [00:20:00 - 00:30:04](NOTE: speaker names may be different in each section)

Michael Goodman: -do it because of proximity to peri-urethral tissue, proximity to the clitoral bulbs and the crurae, and again, in this area there is both a skeletal and an autonomic nerve supply. While this slide is up I want to talk just for a minute about the peri-urethral glands, AKA Skene's glands. Skene's glands have their opening, their ducts, just around the urethral meatus. If you look real carefully, not in all women, you can see these little gland openings. Every once in awhile, they'll get plugged, and you can have a Skene's gland cyst, but female ejaculation, and not all women have well-developed Skene's glands, but there's a difference between squirting and ejaculation, and that's not the purpose of this to talk about. Squirting is losing urine. Female ejaculation is discharge of prostatic light fluid from the Skene's gland, little detour there.

So remember in medical school, at least I remember back in ancient times when I was a OBGYN resident, we were told that the vagina is poorly innervated, and indeed, one can go into a woman's vagina, one can visualize a woman's vagina, and can take a scalpel and cut that vagina, and the woman will not know that that happened. Okay. But that doesn't talk about stretch receptors, which certainly that organ, the vagina, has. So this organ, especially in its outer portion, and I love this quote. This is one of the best quotes I've seen from Glorida D'Amati and Emmanuel Jannini, two beautiful Italian women, and only an Italian, I guess could say it this way.

"This organ, especially in its outer portion, contains enough nerves to participate in sexual response as well as the whole biochemical machinery known to mediate excitation and arousal in the male copulatory organ."

What a wonderful quote. Do you have anything to say about that, Charles?

Charles Runels: Yeah. So I'm a big fan, as you know, of Dr. Gräfenberg, for whom the G-spot is named, but if you read Dr. Gräfenberg, he doesn't talk so much about a spot. He thought what was going on is exactly what you're saying. It really had to do with the whole complex, and especially the entire urethra, and not so much some magical spot. As a matter of fact, I think personally that the spot changes sometimes day to day in the same woman, but he was all about the whole urethra, and if you think about it, not only do you have this excitatory response from the stretch receptors itself, but by bringing those structures next to the vagina closer to what is making the stretch, if it's a man having sex with a woman, then you're going to have more pressure in the corpus cavernosi of the clitoris as well as on the urethra.

So lots of things are happening. That's why I like your phrase the ureal, clitoral, vaginal complex, because you get not only excitation from the stretch receptors on the vagina, but that stretch brings pressure simultaneously on the part of the clitoris that wraps down next to the vagina, as well as on the urethra. So absolutely. I'm over here cheering for you.

Michael Goodman: And I didn't need you to say that, but that just sort of segues into what we're going to talk about in just a little bit, which is vaginally-activated orgasm. I like the term "vaginally-activated orgasm" better than vaginal orgasm, but we're talking about the same thing. Again, these are relationships between clitoris and vagina. There is a reflex called a vaginal-cavernosus reflex, so what this is, is when there's vaginal distension, I mean inserting an object, that induces contractions of the bulbocavernosus, the ischiocavernosus, and the magnitude of that contraction, and this is research data, increases with the volume of vaginal inflation, therefore if there's increased inflation, or increased pressure from a tightened vagina, a large penis, or growth factors and androgenic factors in the anterior vaginal wall, this increase contact between the vagina and the congested clitoris leading to vaginally-activated orgasm caused by contact of the internal portions of the clitoris, again, somatic, skeletal innervation, and in the anterior vaginal wall stretch receptors, which are autonomic innervations.

This is research-based, and these slides have that research on them. Odile Buisson and Pierre Foldes, Emmanuel Jannini have done a lot of work on that, as have others.

So again, not to beat a dead horse, but there is a clear reciprocal relationship between the clitoris and the vagina, and remember, functional [inaudible 00:25:40]. Let's talk about these different types of orgasms.

Clitoral orgasm, caused by both digital stimulation, external stimulation, again clitoral nerves from the pudendal are warm, electrical kind of feeling. Vaginally-activated orgasm, arguably more intense, more internal, more deep, more throbbing, and this is triggered by stimulation and expansion of the vagina, the G-area. Anterior vaginal wall, autonomic innervation. Very interesting. Very interesting. It's research that's been done by Barry Komisaruk and Bev Whipple out of New York City. I think, Charles, you know probably Barry. I don't know if you've met Bev. They did seminal research where they studied women that had spinal cord transection. They had spinal cord transection above L4, L5, and found that ... So what you're doing there is cutting off any input from the pudendal nerves. Well, they don't have any innervation from the pudendal, and these women were still orgasmic, really proving that it's not all the pudendal nerve, proving that the activation and innervation from the autonomic nervous system plays a big role here. That was really seminal research that Whipple and Komisaruk did.

So we talked a lot about the anterior vaginal wall. I won't beat that again. This is research, again, from Pierre Foldes and Odile Buisson. So in contrast to clitoral orgasm, vaginally-activated orgasm is orgasm triggered purely by penile, vaginal intercourse or a surrogate. Very interesting and very controversial research is this study down here by [Stuart 00:27:54] Brody and I don't know Weiss. I haven't met Weiss. Stuart I know. This is from University of West Scotland in Paisley. Brody has written a lot. It's very controversial, and basically Brody feels that women enjoy men who have larger penises, that women have greater orgasm response, especially vaginal orgasm, in men who have larger penises. Why? Because there's more stimulation of the anterior vaginal wall.

What are we doing when we do vaginal tightening operations? I don't think we're increasing the size of men's penises, but Charles, you've commented a lot about that, and you certainly have research in that, and you are working in an area that actually does increase the size of men's penises, certainly by tightening the vaginal barrel, lifting up the perineal body, you're doing about the same thing. You're not making the penis larger, you're making the vagina tighter.

So basically, relaxed vagina, relaxed perineum, less penile pressure against the pubis, the clitoris, less stretch on the receptors of the anterior vaginal wall. So the goal then, of a vaginal tightening operation, is to reestablish the angle and to increase the anterior vaginal wall and cervical pressure, but one other thing that I haven't mentioned is that just tightening the vagina, just doing that surgical operation I think is leaving half the job undone. We're bringing these muscles in together, but just bringing the muscles in together is doing nothing but strengthening the muscles, so just doing an operation without working with that women, her pelvic floor, strengthening exercises, working with her or working with a pelvic floor physical therapist who works with her, I think it's imperative for really doing the job right.

So I'm going to show you a few of my photos [inaudible 00:29:57] labioplasties in addition to their pelvic floor operations. You obviously cannot see inside the-

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Section 4 of 5 [00:30:00 - 00:40:04](NOTE: speaker names may be different in each section)

Michael Goodman: -their pelvic floor operations. You obviously cannot see inside the vaginal barrel, but looking at this you can get a little idea of what we were talking about, what's accomplished with vaginal tightening operations.

With perineoplasty, working on the outside, that's perineoplasty, building up, reestablishing the angle, building up the clitoral body, bulking the clitoral body, doing an aesthetic repair of the opening, and then vaginoplasty, tightening the vaginal barrel.

These are just a few before and afters. Again, some of these have had minor labioplasties, or major labioplasties at the same time.

Different cameras, obviously here. We didn't do any work at all on the top. The labia are just so splayed outward here, where they're inward here, but you can get an idea of what's been done from here to here, as opposed to what obtains over here.

Same thing here. She's healing from her labioplasty. Again, this kite-shaped incision, we did no work to diminish these folds. This is just the incision that reconstructs the opening, builds up the perineal body.

You can see especially here, we've done no work on the anterior vagina, and this is a urethra seal, and there's nothing you can do really about a urethra seal, but we certainly have supported the perineal.

So concluding this part of the presentation, these so-called vaginal tightening operations, AKA perineoplasty, vaginoplasty, vaginal rejuvenation, surgical vaginal rejuvenation, appear to have good outcome via both mechanically tightening the barrel, forcing the penis more tightly against the anterior vaginal wall in Gräfenberg's area. Thanks, Charles. Which contain erectile tissue of the bulb and [inaudible 00:32:02] of the clitoris, as well as that rich autonomic supply, reestablishing the downward angle of the barrel with greater stimulation of the external clitoral structures by the top of the penis and by the partner's pubic bone.

So with that, I'm done with what I had to say. Any questions are welcome.

Charles Runels: Yes, okay. So-

Michael Goodman: And just one last thing before [inaudible 00:32:32]. There's no way on Earth that I could do the work I do without Nicole Sanders and Rachel Davis. Nicole's worked with me for 14 years, Rachel for five. They scrub on surgery. They work with women in every possible way, and we are truly a team, so I'll shut up.

Charles Runels: Beautiful. Well, it's a very elegant presentation, and the mechanics, when I talk with physicians, it's amazing how many physicians would have trouble drawing a clitoris, and the entire thing, and how many gynecologists have told me that they prefer to not talk about sex. I'm not so sure that's a bad thing. Perhaps they're more interested in treating ovarian cancer and sex is off-topic, but as you know, it's not always a comfortable thing for people to speak about, and I salute you for blazing the trail for making it more acceptable.

Now, what I would like to address is some of the objections that people have about what you and I do. Now, for example, there are those that would say we shouldn't pay attention to the labia's appearance at all, and what I think you did was lay out a very good explanation about why it's not just about appearance. It's truly about function, and I know you've published in this arena, but if you wanted to talk about the appearance itself, talk about what you've seen, what the research has shown about how appearance affects function.

Michael Goodman: Oh, [inaudible 00:34:18]. I'm going to go talk about something that I very recently had contact with and then back up a little bit. I review for some medical journals, and I just reviewed for the Journal of Bioethical Investigation. I just reviewed an article for the Journal of Bioethical Investigation, one of the top bioethics journals. This is done by a bioethicist, who is not a surgeon, has no interest in female plastic and cosmetic vaginal surgery, and looked into the area of adolescents and whether they should have labioplasties or not.

I've had the opportunity to operate on a modest number of adolescents. We're talking about young women between the ages of 14 and 18, and adolescents really come in with the largest labia of all the women that I've operated on. They come in with their moms who couldn't believe what they were talking about at first, and then understand. Basically, what this article talks about is the feeling that other people have that, "Well, if it's a big functional problem and it really causes infections and so forth, then maybe you should operate on it, but if it's a psychological problem, then you shouldn't."

And this group of bioethicists begged very strongly to differ, saying that we do a lot of procedures for people because of significant psychological situations, psychodynamic situations, self-esteem situations, and felt that there's really no difference between functional and self-esteem/psychological reasons. Certainly, that is borne out in the literature. We did a study several years ago, now seven or eight years ago. It still is the largest study in the literature on about over 250 women and 345 procedures, of which about 150 were labioplasties.

We took a look at sexual satisfaction in women that had labioplasties and the reasons for labioplasties are usually either psychological, meaning, "I don't like how it looks. It makes me very self-conscious. I don't want to have sex in the light. I don't want him to go down on me. I just don't feel good about it." And none of these men are complaining. We guys, we're just happy to be there, and we love our partners for who they are and whatever's attached to them is fine, but women feel very different about this, so we looked at sexual ... enhancement of sexual function, enhancement of sexual satisfaction with validated questionnaires in women that had vaginal tightening operations, separate issue, and women that had labioplasties.

And women that had vaginal tightening operations, these operations enhanced their sexual function in our study by 87.5%, in [Pardeau's 00:37:35] study by 90%, and interestingly, we asked the men, who were happy to begin with, but 82% of the men felt that these tightening operations enhanced sexual function.

Well, then we also looked at labioplasties. Now, you'd figure that a vaginal tightening operation, one would hope, would enhance sexual function, but a labioplasty, we're just doing appearance. It shouldn't do anything with sexual function, but in women, two thirds of the women, 67% felt that the labioplasty had either a moderate or a significant enhancement on their sexual function and sexual satisfaction, and we banged our palm on our forehead and said, "Of course." If a woman feels more self-confidence, if a woman feels that, even if the guy hasn't said anything, if a woman feels that she's prettier down there, and she's not worried about her labia escaping from her thong, her lacy thong underwear, she is going to be much more participatory and much happier in her sexual function.

The other thing we did is published a couple studies, and others have published studies looking at body image and sexual satisfaction in women that undergo genital plastic and cosmetic surgery, and it's well-known that if someone has a sexual dysfunction, true sexual dysfunction, or if someone has body dysmorphia, true body image issues, you're not going to cure that with surgery. Period. We know that. Plastic surgeons know that. Well, very interestingly in our last study, which was well [inaudible 00:39:13] and well brought out in time, this was on 120 women. We followed these women for two years. We got feedback prior to surgery. They filled out four questionnaires that looked at sexual function, looked at body image, looked at body image, body dysmorphia, sexual function, and I'm sorry. I'm blocking out one other thing.

We looked at them before surgery, six months, 12 months, and 24 months, and these women as a group, qualified as body dysmorphic. If you looked at the validated questionnaire we utilized for body dysmorphia, these women-

Section 4 of 5 [00:30:00 - 00:40:04]

Section 5 of 5 [00:40:00 - 00:52:42](NOTE: speaker names may be different in each section)

Michael Goodman: Questionnaire we utilize for body dysmorphia. These women were body dimorphic and their sexual function was generally poor. One would think that surgery would not change that, but at all points in time, moderately at six months, but very significantly in 12 and 24. This was a level two study. It was controlled. It was a controlled study that by 12 and 24 months the body image dissatisfaction, the so called body dysmorphia, had totally disappeared. This was not true body dysmorphia. This was body dissatisfaction, very different than body dysmorphia. Now, it disappeared and the sexual satisfaction went up to and actually went beyond that of the control group. I can go on, but hopefully that answered your question.

Charles Runels: Well, very elegantly and much of that research, I know that you spearheaded. I hear other physicians who are in hardcore science forums where they're talking about like Lichen sclerosus and other diseases. That will sing your praises because until that research was done, a lot of people did assume that anybody who wanted to change the appearance of their labia must have a psychological problem and they're better off with a psychiatrist than doing something about the labia. This research demonstrated that not to be the case. 67% is a strong number and still a year out and farther still working.

There are others that, as you know, strong movements among some of our colleagues, I think becoming more and more the minority, that we shouldn't even have before and after pictures of the labia or even say anything about it on the internet, which goes back, I think, more to do with relationships with sex than with medicine because, as you know, there was a time in the not so far past, 20, 30 years ago, where before and after pictures of the face with facial cosmetic surgery was considered to be unethical. Things changed because we realized you can't really demonstrate to a patient what's possible and what's not possible without photographs. I think this idea that it's okay to change a person's face to make them feel better about themselves, and obviously even facial plastic surgeons, as you said, they're not going to do surgery on someone who's psychologically, and we can find this out with an interview, they're not going to get better no matter what you do with them. They're going to have surgery after, surgery, after surgery and there's a way to discover that about a person with an interview.

There are those who get a legitimate facelift of something done cosmetically, they get their Botox or whatever, and it makes them feel better about themselves. If you think about it, the concept that it's okay to do that with the face, but yet if you apply those same ideas to genitalia, somehow that's wrong. It smacks or some Victorian era. It always surprises me that that idea still exists even though you've done the research to show the same thinking applies. The idea that a woman can go buy a dress and feel sexy and want to have intercourse tonight, but yet you couldn't make her feel better about her vagina to me just seems a little bit hypocritical. I'm just saying amen. I know that you did that research, which is why I wanted to bring that out and get it out there for people to think about.

When I post this video, I'll put some of those links to some of that research under the video so people can educate themselves. Just one other comment I'd like for you to elaborate upon. Let's just scenario here. People get married. They're 20, 30, whatever age, but let's say it's a typical young love. You get married, and you have children, and then you stay together. Now you have this soul mate of 10, 20, 30 years, 40 years. We see people 50 years in our office married, but the universe plays a bad joke, in my opinion, because by the time a man reaches 65, he loses half of the endothelium of penis. A woman delivers a child or two and estrogen levels change. His penis is literally shrinking and her vagina is growing. By the time they've been together for a while, these lovers who may have matched when they were younger now don't.

Again, the idea that you shouldn't do something about that because it's genitalia, where it's perfectly okay to do things to change your waistline or your neckline, to me, just seems a little bit hypocritical. Could you elaborate a little bit on this matching idea? That's why one guys penis may be too big for one woman and too small for another. If you're just thinking in terms of those stretch receptors, but when you think about these other modalities, like laser versus surgery versus the O-Shot, and talking to the woman about this matching of her lover, could you tell me maybe a few stories about people you've taken care of and integrate with it the way you think about the science?

Michael Goodman: Yeah. An interesting paper that I just reviewed for The Journal of Sexual Medicine and unfortunately was rejected by the editors, I think it should have a place in that journal, hopefully it'll be rewritten and resubmitted out of China, where they attract the anatomic changes of the relationships of different parts of a woman's vulva to her age as far as distance, distance between the pubic bone and the clitoris, distance between the clitoris and the vaginal opening, distance between the urethra and the perineum, distance between the perineum and the anus. What you mentioned anecdotally is true anatomically, that yes, with age, women's vaginas do fall down a little bit. The opening gapes a little bit. It becomes a little bit more relaxed and more open. That is saying that she's hormonally complete. Obviously if a woman after menopause is not on any hormone therapy at all, then sometimes the vagina can shrink if she's not sexually active.

As you mentioned, the size of a man's non-erect penis becomes somewhat smaller, so I understand, though I've not seen studies on that. Certainly a man's erection becomes less robust. I love that word, although you can use it both ways. A man's erections, for many reasons, become less robust. Certainly I work with men and a lot of times it's the partners of the women that I'm working with during their menopausal transition, where they weren't terribly interested in sex with all that was going on with menopause. Now they're feeling a whole lot better and a whole lot sexier, and the fact that now their partner can't either get or maintain an erection is an issue. Certainly working with testosterone, working with PDE5 inhibitors. I have not personally had experience with the Priapus Shot. You certainly have. Adding the Priapus Shot into that can all serve to increase the size of a man's penis.

There's a lot of things that couples can do. Obviously the use of fantasy, the use of toys. Love making is love making. Physical intimacy is physical intimacy and it doesn't all mean intercourse. It can mean using a toy in addition to the penis in the vagina to increase the stretch receptors. It can mean getting a Priapus Shot. It can mean taking testosterone and PDE5 inhibitor. It also can mean, for a woman, doing a surgical procedure to tighten the vagina. Obviously there's different age demographics. Certainly the age demographic for women who have having labiaplasties in my experience, and I've done about 750 labiaplasties and close to 200 vaginal tightening operations, the age demographic in women that are having labiaplasties is younger than women that are having vaginal tightening.

I've done vaginal tightening operations in women in their early 60s. I have not yet done it in women that are a more advanced age. I'm in my early 70s. My partner is in her early, mid 60s. Men and women in their 80s and 90s have sexual intercourse. A long winded way of saying, Charles, that there's a lot of different things you could do. That's the joy of sexual medicine is working with couples to improve their intimacy, which can be all of these different things.

Charles Runels: Yeah, it's so rewarding. We've both been involved in what others would consider to be more hardcore, life threatening type situations, but nothing has been more rewarding to me than having a couple to me than having a couple that's been married for any number of years, 10, 20, 50 years, come back to me and say, "We're rediscovering our bodies because they're responding more like they did when we were younger." Well, we could go on and on, but I just wanted to add that Dr. Goodman has several ways you can learn more from him. I highly recommend his book if you don't have it yet, of course. That's the place to start. Then he has hands on classes in his office where he mentors surgeons who want to learn more of the nuances of these procedures. He's been teaching for a long time. Many of the people who teach are his students. He's not also offering some didactic classes for those who qualify who can learn some of how we do the O-Shot, how to integrate that with some of the other methods that he's discussing with surgery.

I think your next class is coming up in Atlanta. There'll be others who will be posting and so I highly, highly recommend that, even if you've done these classes before, if you have the opportunity, spend some time with Dr. Goodman. He's recognized as the godfather of a lot of these procedures. Yes, sir?

Michael Goodman: I'm teaching classes in Atlanta in October and April and in Sacramento in January and July. The classes are excellent accommodations at airport hotels. They're two different classes. They're both didactic and experiential. I have full length surgical videos. The whole idea is to work with surgeons, whether they're cosmetic surgeon, gynecological surgeons, to basically teach the technique and to discuss how to work with women. We also talk about noninvasive techniques. We talk about platelet rich plasma for different indications including the O-Shot. We talk about the use and misuse of noninvasive laser and radio frequency. There's wonderful uses of both of them, and there's some misuses.

Charles Runels: Yeah. This is going to be some amazing stuff and I know there'll be other classes after that. I'll post links to them all. With that, I'll just tell you thank you. Unless there's something else, we'll end this call and I'm sure you'll be hearing from some of the people watching this video. Thank you very much, Dr. Goodwin.

Michael Goodman: Awesome. Thanks very much. It has truly been a pleasure.

 

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Drs. Andrew Goldstein & Charles Runels Discuss O-Shot® Research

Discussed in the Video...

About Orgasms with Dr. Amy Brenner, MD, FACOG

1. Medications that may interfere
2. Surgical causes of problems with orgasm
3. Why gynecologists may avoid talking about sex.
4. The best treatments for depression that won’t interfere with orgasm
5. Does hysterectomy interfere with orgasm.
6. Medical causes of problems with orgasm.

Transcript...

Dr. Amy Brenner, MD, FACOG Talks About Orgasm

Charles Runels: So I'm honored to be talking with Dr. Amy Brenner, who's an amazing gynecologist whom I met about a year ago, coming up on a year. She lectures around the world. She is stationed ... Or her office is based near Cincinnati. Tell us about your practice and then let's ... You know, this whole interview we're celebrating Orgasm Day. But before we get to that, just tell us more about you and your practice.

Dr. Amy Brenner: Sure. I've been a practicing gynecologist for 15 years and about five years ago, I decided to focus on gynecology. I still practice traditional gynecology and do surgery and have a large hormone practice with bioidentical hormones and medi-spa and currently cool flow team and we use functional medicine and started offering PRP procedures such as the O-shot and P-shot and the empire procedure, about a year ago.

Charles Runels: Beautiful. And you have physicians working there with you right? I just want people to understand that you're a hard core gynecologist. You have a new surgeon gynecologist working with you, you have a family practitioner physician who helps you with some of the hormone part of your practice, plus you have... Tell me more about what goes on in your office. I want people to understand how busy you are.

Dr. Amy Brenner: Sure. Well, busy place. There's about 45 people that come to work every day. I have a gynecologist who also did additional training in GYN surgery and then a fellowship in minimally invasive gynecology. I have a family practice physician who also does aesthetics and focuses on integrated medicine and bioidentical hormones. Then four nurse practitioners that do the routine GYN care and pap smears and FPD management and just typical gynecology and their main focus is also on hormones as well. Then we have three aestheticians and two wellness counselors.

Charles Runels: That's just amazing. Now that people understand that this is not... you're not just someone who read about orgasms yesterday, and you have literally thousands of women who come through your office and you have... I mean most people if they had 45 cars in their parking lot that would be a busy day, that's just your staff. So I have a lot of respect for your ideas and your experience in gynecology and I know you came and I shared some ideas about the O-shot and that's worked well for you. But before we talk about that, just talk with me about orgasms in general. Maybe, let's start with why you think they might be important or maybe they're not important. Just what do you hear women say about orgasms?

Dr. Amy Brenner: Sure. I mean being a gynecologist for 15 years, I'll be honest, up until about five years ago, when people would talk to me about their problems with libido or just any sexual problems, my only answer was you should go on a date with your husband. That's all I had in my toolbox. I know traditional gynecologists still feel like that and maybe think that [Addie 00:03:38] is their only alternative. About five years ago when I started with hormones, women came out of the woodwork which is why I feel like we've been so successful in such a short period of time, in Cincinnati, of doing something that really not a lot of people were doing. I've heard it over and over that people say that their sex life now is better at 40 from the tools that we've been able to give them from before.

Issues with libido and sexuality is something that me personally seeing patients here at least 10 times a day. So multiply that by seven providers and that's a lot of women who are talking about issues with sexuality on a daily basis.

Charles Runels: Talk more about, because as you know I did research in that area as well, and it always surprised me how many women would come to me and say, "Well, the doctor told me all hormones are normal." And they would've come from a very expert, well respected gynecologist, but who just thought a little bit differently about how to measure acute hormones. I don't think I was smarter than somebody, but as you know there's different schools of thought. Tell me, does that happen in your office with new patients and what's the difference between thinking the way you do now and the way you thought say six, or seven, eight years ago?

Dr. Amy Brenner: So first of all, that conversation happens every day, which is again, why I think we have a lot of patients because we don't feel like that. We hear all the time, "My doctor said that I'm fine and there's nothing to do."

Charles Runels: Yes.

Dr. Amy Brenner: That's what I used to tell people too. I think it's because in OB/GYN there's a lot of education going on by drug reps rather than doctors seeking out their own answers. Up until five years ago I didn't think there was a problem with birth control pills of SSRIs or sleeping pills, let alone what it does to your sex life.

Charles Runels: So talk to me... back to the sex part and the orgasm part, before we get into the details of the way you think about the hormones, the different medicines, because you just mentioned SSRIs, which to interpret for some of our people, so you're referring to some of the anti-depressants. Before we get into the details, tell me more about some of the things that you hear women tell you about how orgasm problems, however you want to define that, interfere with their life. Either difficulty having one or can't have one.

Dr. Amy Brenner: Well, I think just women's sex life and their libido and their relationship with their significant other is a huge part of their relationship. I hear from patients who's life goes better when their sex life is better. They get along better with their significant other, just life is better when people are having good sex.

Charles Runels: Isn't that interesting. I have people tell me that they're not as... they sleep better, they think better, their work goes better. Do you hear those things? Can you elaborate on that or am I making that up?

Dr. Amy Brenner: I think that the patients that are coming in, it's more of the negatives of things aren't as good because I'm not having good sex. Or I don't want to have sex or sex is painful. It can create controversy in a marriage. It can create disappointment and frustration. I'm hearing more of the these are the negative things than that type of thing, of what's missing and please help me because it's not good.

Charles Runels: And then after they get well, what do these women tell you that's different about their life?

Dr. Amy Brenner: They may tell me I'm the best doctor ever.

Charles Runels: Because what's happening in their life. I know they love you.

Dr. Amy Brenner: Because we helped them and we're willing to look outside of the box when their other doctor may have said that's just part of getting old and that's just how it is.

Charles Runels: So when you say you helped them, specifically, what do they say is better about their life because their sex is better? I think you sort of said it already with relationships, but can you expand on that? Can you think of a story of someone, something someone told you about what happened with their life?

Dr. Amy Brenner: Well, I think I told you about this one patient that always comes to mind of... as a couple, I treated both the husband and the wife. Her exact words were, "You're the only person that's helped me. I haven't had good sex and we've basically had a sex-less marriage just until you helped me because I was having pain with sex and it became this vicious circle of I had pain and I didn't want to have sex and it didn't feel good so I never did it. And it created emotional distance with my husband." With some things we did with hormones and the O-shot for her and the P-shot for him, basically they rekindled things and things were better than ever.

Charles Runels: So when you say rekindled, tell me more what that looks like in their house. What did it look like?

Dr. Amy Brenner: Well I guess for them it's not really rekindled, it was just started to begin with, because she basically said they had a sex-less marriage because of issues with pain.

Charles Runels: So now they're having intimacy and they're happier together.

Dr. Amy Brenner: Going to Cancun with just the two of them.

Charles Runels: Oh fun.

Dr. Amy Brenner: You know the story.

Charles Runels: That sounds happy. That's rewarding isn't it? Tell me about, if a woman were to say to you, or if a woman were to say to another woman, because I see this on the blogs a lot, shouldn't worry about that because you're just trying to please your husband. What would you say to that? You're just trying to please a man. It shouldn't bother you that you can't have an orgasm. You should just be happy. And, let's face it, there becomes this thing-- one of my favorite stories is the Velveteen Rabbit. So, you reach this place where you're 100 years old or you're 80 years old or something, although people have sex at that age, but you can reach a place where a love relationship goes without sex. On the other hand, the five-year giving up, was you see it on the blogs and you hear women tell other women, even some therapists telling women that you shouldn't worry about it because you're just trying to please a man. If you're happy without sex, just be happy. Does that resonate or am I just making that up? You ever see those comments on the blogs?

Dr. Brenner: I guess-- I don't know. In my practice, I'm not really seeing that--

Dr. Runels: I know it's not the way you think but I see it in some of the sex therapist comments.

Dr. Brenner: Yeah, I would say that, that's not what I'm seeing from my patients. My patients want to have good sex. So I'm not really seeing--

Dr. Runels: For their own self.

Speaker 2: -- that.

Dr. Runels: That's what I'm looking for.

Speaker 2: And if they were saying that, I would say that there's a lot of health benefits to having an orgasm a day. I think I heard somewhere that you should have an orgasm a day to keep the doctor away rather than an apple a day. So--

Dr. Runels: Yeah, I do think it helps mental health. Well, I know there is this idea in my feeling from what I've been able to observe in people have been together a long time, often times, the man wants the woman to be well just because he loves her and she doesn't feel whole. Not to please him, but she wants her body to function. And so I know that's the way you think but I see some judgment going sometimes against women who are trying to make things better.

So anyway, so let's talk about if you were talking to a woman who wanted orgasms to be better or just can't have an orgasm and you were looking at her medications for things that might be throwing her off, what medicines would you be very suspicious could be causing the problem? And, again, I don't want anybody stopping their medicine just for watching this video, but yet they maybe haven't asked for a physician about changing something and this could prompt them to ask their doctor when they go. So what medicines would you worry about interfering with sex?

Speaker 2: The two most common things are anti-depressants. I find it really hard for women to have a good sexual experience for either from libido or orgasms when people are taking anti-depressants. And so I think there's a lot of other options that can help with mood other than anti-depressants. So in our practice, [inaudible 00:12:53] can start talking about what we're going to do to treat people. I like to get people to talk about other alternatives to anti-depressants. And then the other are synthetic hormones like birth control pills or synthetic progestins.

Dr. Runels: Yes. So birth control pills are going to drop testosterone levels, right? Which are going to, even in a young woman. It's not a [inaudible 00:13:17]. It's just a thing that will happen. It's going to drop because that's how it works, right? So there's this feedback loop to drop [inaudible 00:13:25] testosterone falls, and so that is the thing that will happen and has an effect on women and we know it's a thing that's going to happen. So that's going to affect the libido. Tell me, so if you had an anti-depressant, which anti-depressant would you think would be least likely to interfere? So if someone's takin an anti-depressant--

Speaker 2: If someone has to take an anti-depressant, we like to switch them over to Wellbutrin.

Dr. Runels: Yes. Yeah, I never asked you that question before so I was seeing if you could [inaudible 00:13:56] it. Absolutely. It's the one that is least likely to interfere [inaudible 00:14:01]. Of course testosterone can act as an [inaudible 00:14:04] as a-- it helps depression when you correct low levels. So you know, I just wanted to--

Speaker 2: The next couple of other ones, like if somebody's taking chronic pain pills I think that can suppress testosterone and or things like tamoxifen if somebody has had breast cancer, or-- those are some other things that can negatively affect.

Dr. Runels: Yeah. So the narcotics populates the [inaudible 00:14:33]so there is less stimulation to make testosterone as well. So let's say that they have their medicines with them. You've gotten them the best you can get them. Tell me some other things that you would do to improve orgasms as a physician. I don't want to discount, we both realize that relationships, sex therapy, family therapy can be extremely huge. And is much underused, but still thinking as a physician with procedures and medicines at your disposal, what other ideas would you have to make things better? So you have testosterone, what else?

Speaker 2: So first I just want to look at other things in their medical history, like other physical or anatomical things that could interfere with orgasm or stimulation or things like that. So anything that causes atrophy or loss of estrogen in the vagina and vulva can make sex painful and painful is certainly not enjoyable. So any kind of hormone deficiency that can cause atrophy or any kind of scarring in the vagina either from prior procedures, hysterectomy, child birth, or even other medical problems that can cause scarring in the vulva, lichen sclerosus or other more rare skin diseases that can interfere with the anatomy and--

Dr. Runels: So you, along those lines, you've treated some of these painful conditions with the O Shot is that correct or no?

Speaker 2: That is correct. Or no?

Dr. Runels: So tell us some stories, tell us what you've seen. How do you think it might be healthy? Explain it as a scientist, what you've seen and what you think has happened when you've done this?

Speaker 2: So I'll just tell you about our most recent lichen sclerosus patient, who had decades of itching, and vulvar pain, and she periodically used a topical steroid, and I think periodically is she didn't find it was really helpful so she wasn't really compliant with it because she really didn't notice that it made a big difference for her.

Dr. Runels: Let me stop you for just a second right there. I just want people to stop and think about that for a second. A decade of itching, and burning, and an uncomfortable genitalia. Just stop and think about how miserable, I mean I would be angry. I can tell you as a child I used to always get chiggers because I live in the south where it's like being in the swamp. We played in the forest and my little genitals would just be swollen and scratchy and it was just the most miserable, miserable thing, and so the last thing that someone like that would want to do is have sexual relations and it's horrible isn't it? So tell me, so you're thinking of a particular person who had this [inaudible 00:17:59]for a decade. I'm sorry, so I just wanted people think about that.

Speaker 2: Yeah. Most women can relate to having a yeast infection, that's miserable and you usually have that for a day before you get cured.

Dr. Runels: Yeah.

Speaker 2: So this was feeling like that every day, so she wasn't looking to make her sex life better, she just wanted-- that wasn't even part of the discussion. She just wanted not to be itchy and in pain every day, so, but when I talked to her about sex, no, I don't even think like that. So recently I treated her with the O Shot and PRP to the vulva and within a month she's not itchy anymore.

Dr. Runels: Oh wow, that's so beautiful, and you know we just. I think I've told you already, but last week we had our research paper that was accepted by the Journal for the American Academy of Dermatology, so that will be out this year. Probably within a month or so, so I'm excited about that. About lichen sclerosus, so hopefully more people will know how to do what you're doing, and we've talked about you and you're at such an expert level and so busy, you haven't had time, but I'm hoping you can give a speech to [inaudible 00:19:20]. I see you as being an excellent teacher. So tell me more about, have you treated anyone who had scarring from childbirth or from surgical procedures with the O Shot or not?

Speaker 2: You know, just that couple I was telling you is, she just had a long history of just painful sex that we didn't really have a good anatomical reason why. She didn't have atrophy, she didn't have a cirrhosis, she never had a hysterectomy, but she had pain and it did get better for her.

Dr. Runels: What did that do for her? Is she married?

Dr. Amy Brenner: Yeah, that's the lady I told you about that's now going on to Mexico.

Dr. Runels: Oh, that's going to Cancun. Isn't that wonderful?

Dr. Brenner: Yeah.

Dr. Runels: I've had several of our doctors tell me, because we've both with life and death sort of situations. Not sort of. Truly. You're a surgeon. [inaudible 00:20:21] Delivering a child can be life and death, but bad things happen and [inaudible 00:20:26] for 12 years, but I have found that patching up these relationships and giving people their sexuality back is as rewarding or more so than anything I've ever done in medicine. Are you feeling that, or am I making that up for [inaudible 00:20:40]? I mean, do you find that very rewarding?

Amy Brenner: No, [inaudible 00:20:45] when you bring couples back together sexually.

Dr. Runels: It's wonderful, isn't it?

Amy Brenner: It just makes their relationship better, it makes their [inaudible 00:20:55] better, and when it's broken it's just not the same.

Dr. Runels: Yeah. All right, so another thing I want to talk with you as a scientist. So there is still a debate about whether female ejaculation is a thing or not. Actually, when I went to medical school, I was there at UAB in Birmingham and we'd had a two month class on sex, and guess what the first day was shown to us? A movie of a woman ejaculate, and our teacher who was a Ph.D. teaching our class said, "I do not want anyone leaving this medical school thinking that female ejaculation is not a reality."

I didn't really think that much about it, but since we've been doing the O-Shot, I've had more women tell me they're experiencing it, written about it, thought more deeply about it actually before the O-Shot [inaudible 00:21:51]. Tell me what you think. First of all, is it a thing? Second of all, is it a thing, what do you think is causing it, and do you think the shot makes it more likely to happen? I mean, talk to me. I mean, I know that's sort of a ... Maybe you don't want to talk about it, but because it's getting ...

Okay, let me stop right here. Let's change the subject for just a second. Do you know any gynecologists that do not want to talk about sex?

Amy Brenner: That do not want to talk about sex? Most gynecologists [crosstalk 00:22:24] [inaudible 00:22:26].

Dr. Runels: Yeah, it's most of them. Yeah, I was setting you up for that.

Amy Brenner: Because they don't know what to do about it, so ...

Dr. Runels: Most of them don't want to talk about it, do they?

Amy Brenner: No.

Dr. Runels: And so I want to brag on you for now for just a second, because I can tell that question is getting close to your edge, but I want to brag on you about this for a second because you are comfortable and being very brave, because I know that the majority of gynecologists are, first, they're afraid to talk about sex because they're not comfortable with their own sexuality. Number two, they don't understand how to treat sexual problems. Even though they might be amazing gynecologists, it wasn't part of their curriculum and new ideas have come along, and so they're not sure what to say. They're not comfortable saying it. So I just want to double brag on the fact that you're being very brave, not only just embracing these ideas. You're helping to think about them.

I've never asked you to think openly in public about this phenomenon, so if you want to decline the question, you can. But if you want to tackle it as a scientist, tell me what you think about it. And talk not as if you're talking to me. Talk as if you're talking to a woman who's wondering, "Is this a thing? Is it worth thinking about? Would the shot help me, and if so, tell me more about how to think about it."

Amy Brenner: Well, I don't think doctors are taught about sex, let alone female ejaculation, so I think that's an advanced topic.

Dr. Runels: And they're not getting the basics down.

Amy Brenner: Yeah. That's for the experts to talk about.

Dr. Runels: Well, maybe we should just skip it. We'll skip it. Let's see, what else can we talk about? You tell me. What else have you seen in the area of sexuality that on a daily basis you find frustrating, that you wish more women knew about? So you mentioned the hormone piece of it. Anything else along those lines? Maybe with relationships or medicine, any piece of it?

Amy Brenner: I think I've talked to you about this before. I think using the O-Shot and PRP for incontinence and dryness is just a chip shot. It's so easy, because there's not a lot of other factors that go into that. Either you notice that your dryness improves or it doesn't, and so using PRP and the O-Shot to treat those medical problems that, again, is something ... That conversation I have multiple times a day about treatment options for incontinence and treating for vaginal dryness, and it's so easy to treat those.

But I think it is a little bit more tricky to talk about sex and what goes into a good sex life and good orgasm, because although the O-Shot helps with the physical part with blood flow and nerves, there's just so many other components to that.

Dr. Runels: Yeah. I'm glad you brought that up, because we don't get everybody well, do we? What do you think is the most difficult problem to treat? I have an idea, but what do you think is really difficult to treat?

Amy Brenner: Well, just last week I saw somebody for a follow-up for the O-Shot and the first words out of her mouth were, "I don't think it works." And I'm like, "Okay, well, tell me more about that, because I know we're also wanting to help incontinence." And she's like, "Oh, yeah, that's better. I don't need the oxybutynin anymore. I don't even leak at all." And she's like, "And the dryness is better, but I've never been able to have a orgasm with my husband and I still can't."

Dr. Runels: Yeah.

Dr. Brenner: That part is out of my control.

Dr. Runels: Yes. What's the lab rate on that [inaudible 00:26:29]? Because that is one of the things. Although it happens, the women who have difficulty having orgasm with their lover's penis inside of them ... We don't have control over the lover, do we? What he knows or she knows about her lover's anatomy, how they're sensitive to it, and so we can't control that piece, can we?

Dr. Brenner: No.

Dr. Runels: But it does happen. But that's hard. I think the other one is the woman who's never had an orgasm in her life. I think it's more difficult to figure out how to help that one. There is this system. I like to keep reminding people there's an orgasm system. It involves everything you just said. The relationship, the lover, the lover's anatomy and understanding of her body, hormones. Tell me some more of the surgical things that you would think about from the surgeon that might cause problems when you have your surgeon hat on with sex.

Dr. Brenner: Yeah, I mean, certainly when somebody has a surgical menopause, that instantly takes their hormones to zero, so-

Dr. Runels: So if they have their ovaries taken out.

Dr. Brenner: Yeah, or even just a shortened vagina that can lead to pain with sex. Radiation for cancer, that can interfere with things, or even just childbirth and vaginal lacerations. I've seen women with scar tissue that ... Sometimes I examine them and I don't even know how they're having sex, let alone it's enjoyable, so I don't even know how they're doing it.

Dr. Runels: Okay.

Amy Brenner: Trauma. I mean, it's rare, but ...

Dr. Runels: What about ovarian cysts or fibroids? Do those interfere very much, because I'm not a surgeon, so I have [inaudible 00:28:28].

Dr. Brenner: [inaudible 00:28:31] pain.

Dr. Runels: Yeah, I've seen pain. I'm a big believer in surgery, actually. I think it's a natural treatment. I always tell women, "Well, after you pass about 35, I can probably do your hormones better than your ovaries can. And if you get them out, we don't have to keep worrying about ovarian cancer, and that one goes off the radar. And if you have a hysterectomy, we can quit thinking about cervical cancer." Although some women argue that the cervix has something to do with orgasm. What are your thoughts on that? 'Cause I'm still making up my mind on that.

Dr. Brenner: Yeah. I think that when you read about physiologically what happens to it when women get aroused and what happens with orgasm, certainly that's described, but that hasn't been my experience of women saying that everything changed when you take their cervix out. I do like to take women's cervix out when I do a hysterectomy because if you leave it in place, then 20 to 30 percent of the time, they still have bleeding. That's another physical [inaudible 00:29:37] that can interfere with sex, too. Somebody's bleeding all the time, they don't ... It's embarrassing. It's messy and ...

Dr. Runels: It's like they're still having their period.

Dr. Brenner: Yeah.

Dr. Runels: If you're gonna have a hysterectomy, why still put up with a menstrual period? I'm with you.

Dr. Brenner: Right. I mean, most people don't want to have a gynecological exam when they're bleeding, let alone be intimate with somebody when they're bleeding, so if somebody's bleeding for seven days out of the month, then you're like, "Okay, well, I'm not doing it that week, and this week I might have PMS," so you're down to ... Bleeding issues can also interfere, just 'cause ... embarrassing, and people don't like that.

Dr. Runels: Well, I see your sweet baby walking by, so I'm gonna let you go, but before I do I wanted to thank you. I consider you one of the top GYNs on the planet, and I consider myself blessed to know you and work with you and share ideas with you. Anything else you want to say about the celebration of Orgasm Day, or just anything else about what we're doing before you take off?

Dr. Brenner: Yeah. Everybody should have an orgasm on Orgasm Day.

Dr. Runels: That sounds fun. Okay, Doctor Brenner. You have a wonderful day. Bye-bye.

Dr. Brenner: Bye.

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Anorgasmia. The 4-Step Treatment Formula

Dr Charles Runels, (the "Orgasm Doctor") explains a "4-Step Treatment for Anorgasmia"...

Results May Vary. Discuss with Your Private Physician. Educational Only. Not a Substitute for Seeing a Physician...

Transcription of the Video ...

Hello. I'm Charles Runels. I'm a physician who has for over the past 25 years taken care of over 10,000 women, and I'm here to talk to you about what I consider to be a very serious, very disturbing problem that some women suffer with. Around one in 10 called anorgasmia, or anorgasmic. An as in no orgasm.So you might think, well, no orgasm. Not a big deal. You just don't get that pleasure, but you still have the pleasure of relationships, and you still have the pleasure of sex.

The problem is that research shows, and what I have seen, not just the research, but when I see women crying in front of me, saying, "I want, I love my husband dearly. My lover, he's my lover, he's my best friend, and we want to experience an orgasm together, but I've never had an orgasm in my life. I cannot have an orgasm, ever. Can't have one."

And that is really bothersome. It's not just bothersome because they're lacking the pleasure. They want that experience, and research shows that sexual dysfunction to the point to where it's distressing the woman, it makes her feel broken. Even though she might have a healthy body, she might be brilliant with her career, a wonderful wife and mother, still, that's a part of her psychology, part of her physical thing that's broken. It's like, it's an analogy, if you have a car, everything's perfect, but one window won't roll down. And that one thing is broken, and so the rest of the car is great, but that part is not working properly.

So maybe not a good analogy, but still, if you have a part of your psychology that's that important, and it's not just the pleasure part. We know that when people have an orgasm, there's a bond that takes place. There's an opening. There's even one research study that shows that men who are on a ship, as a, in the Navy, who are exposed only to men, by having an orgasm, some of them become ... They start having sex with men because that's all that's available, and by having orgasms with a man, they then become attracted to that man. There's a bonding that happens with an orgasm.

Whatever is presented to you when you have an orgasm, because there's this release of oxytocin and all these things happening with prolactin, and who knows what-all, because the pituitary gland makes over 200 hormones. 200. So when you go to your doctor, and they measure six or seven or eight or even 10 hormones, we're still really in kindergarten about what's going on here when there's sexual attraction, when there's sexual arousal, when there's an orgasm.

This is not the end of the world, but no orgasm is something to be taken very, very seriously. So what are the treatments for it. First of all, it is helpful to have at least an understanding. So a sex therapist, a sex educator, there's a wide variety of skillset and understanding here, and so this can be helpful.

There's a ... What I've seen with my patients and with my own personal life is that once a woman has an orgasm, it's sort of like if you go to the forest, and you see a path, if people are walking down the same area, the path becomes smooth. But before there's a path, it might be difficult to walk in an area where there's no path.

We now know there are neurological pathways that are associated with an orgasm, and what I've seen is that once a woman finds that, and she breaks through the brush of what's limiting her from having an orgasm, then the path becomes more open, and it becomes so much easier to have the second and the third, and by the time she's had several orgasms, it becomes easier and easier and easier. But getting to that first orgasm can be very frustrating. And to make it even more frustrating, trying to get there seems to limit the ability to get there.

So there needs to be a letting go and a surrender, which doesn't sound politically correct, but it has to be a surrender of the woman's body to the process of her body functioning in that way. Try to imagine urinating and trying to keep from urinating at the same time. It's another bodily function. To urinate or to defecate, you have to let it go. And again, it may not be the most glamorous analogy, but you can't let go and hold back at the same time.

Now a woman can drive herself mad trying to figure out how to let go and trying to get there at the same time, but that's where a therapist and certain exercises and educational processes that can be done with the woman and her lover that we aren't born knowing. These specialists are trained to help in that arena, and I highly recommend that you consider consulting with one who is licensed in this area. Not just some person, but someone who's properly trained and licensed.

Now, so how can we break through and get to that path. Another thing that's very, very important, and like I said, I've done research in this area. Over 25 years of taking care of women, and embarrassingly, too many lovers, and what I can tell you is that from seeing all this that it's very, very difficult for a woman to have arousal or orgasm without a hormone. And you might think it might be estrogen or progesterone. It's not. The main hormone for orgasm is without a doubt testosterone, and thankfully, due to Suzanne Somers and others who have made this more widely known. I'm very grateful to her, because doctors can do the research, but oftentimes it takes a celebrity to help make the public aware, and that's one of, I think, their great function, is that they have a wide audience, and they can help educate people.

And Suzanne Somers did a lot to educate people about how women need testosterone. The part of the vagina that's called the introitus, the part that you go as you ... So you have the labia on the outside. So if you're looking at a vagina, you got urethra and the labia minora and the labia majora and the clitoral hood, and right there is the vagina, okay?

Right here, this area here between the vagina and the labia minora, that is biologically exactly like the inside of the urethra of a man. So the inside of his penis, where the urine comes out, that is biologically the same as this tissue, and it is responsive to testosterone. Testosterone.

Another thing that happens is women on birth control pills, birth control pills, we know it. It's not a guess, it's not some of the time. It's a thing that's going to happen. If you pour water on you hand it will get wet. If you take birth control pills, a thing that will happen is your testosterone levels will fall.

The reason birth control pills work is it tricks your pituitary gland into not releasing the hormones that stimulate the ovary to make hormones because you don't ovulate. And so it stops that, but the woman doesn't have hot flashes, and she still has a menstrual period because the uterus is seeing the hormones that are coming from the birth control pills. All right? You with me?

So birth control pills tells the pituitary gland to quit talking to the ovary. So pituitary gland, here's pituitary gland up here. Here's the brain. Pituitary gland makes LH and FSH, and these go to the ovary and tell the ovary to make all these hormones. Estrogen and testosterone, all these things get made. DHEA. Things get made.

Now, when you take birth control pills, see, these feed back until, when they get at the right level, they tell the pituitary gland to quit making so much of this, so there's a feedback loop. Now, if you take estrogen or some progesterone-like material, and you feed it, and now the pituitary gland sees that, it thinks it's coming from the ovary, it cuts this off, and so the ovary shuts down, but guess what else turns off? So the ovary quits making so much estrogen because it's getting it from the birth control pill. So estrogen quits being made, but guess what else quits being made? Testosterone.

There's a little bit made from the adrenals and from the glands by the kidney, but much of the testosterone level gets cut back, and so that makes the woman not only more susceptible to weight gain and loss of sex drive and migraines, but it also makes her, sometimes there's actually a syndrome where they start to have pain with intercourse, and often it doesn't go away when she stops the birth control pills. That research has been done. And it can make some women more difficult to have an orgasm.

So a lot of ladies might start on birth control pills, say, for their acne, or they become ... Their menstrual periods are heavy and painful as a teenager, so they start on birth control pills, and in the process, this testosterone drops, and it can make it so the woman never is able to achieve an orgasm, not knowing that her testosterone level is low.

So testosterone is huge, and now that it can be measured, and what you should ask your doctor, to know if your doctor knows what he or she is doing, this is your test to see, they should measure free and total, or measure total, this is even more accurate, and calculate the free by also measuring testosterone binding globulin, or sex binding globulin, so and then they calculate the free.

Now you don't have to understand all that. All you need to know is this. Did your doctor measure your free testosterone level in some way, and if he or she did not, and you cannot have an orgasm, you should go back and ask your doctor to measure those levels, or ask your doctor to refer you to someone who both will measure them and know what to do with them. Your free testosterone levels should be in the upper 25% of normal, or you're going to have more difficulty with orgasm and libido more likely.

Doesn't mean lots of women with a low testosterone having crazy fun sex, but if you're having trouble, and you need to see if this can be corrected, because correcting it, I've seen over and over again can take a woman who's suffering with these problems, and now all of a sudden, she's having a crazy, ecstatic, and the word I hear a lot is exploding orgasms. Not exploding as in like a water balloon explodes and leaves the bedroom wet, but exploding like in your mind exploding, with a great ecstasy, and that comes about through testosterone.

There are receptors on the brain tissue for testosterone, in the brain for testosterone, and the brain remodels and becomes more erotic and more susceptible, or receptive, to both arousal and orgasm. So testosterone.

Now, how can ... So you've seen the therapist, preferably with your lover, and you're exploring some of the amazing exercises that they can teach you, and you're taking testosterone, but you still haven't found the path or created the path. And remember our analogy is you're in the forest, there's lots of brush, there's no pathway, and you have to break through the brush with your first orgasm. And now, once that neural pathway is made in your brain, you go down that path over and over and over again until it's well worn, and it becomes very easily to go down to this, through this path.

So what are other ways you can get to the path? Another was is with a vibrator. Now vibrators are not a new thing. Actually, ancient Greece, you can find where they had dildos. They weren't electrically powered. It wasn't till around the 1940s that we had electrical powered vibrators. Hamilton Beach actually started out, their first product was a vibrator.

So vibrators have been around a long time, and there's some things that make people, and I'm going to tell you in a second about what I think the best vibrator is to break through and find the path to the first orgasm. But let me tell you first of all another thing that can make the vibrator ... Become I get to the vibrator I think is best, let me tell you another thing that might help it work better, it as in your body.

So you got testosterone, you got a therapist, another thing is called our O-Shot, or orgasm shot, o for orgasm, or if you want to keep it G-rated, you can say o for orchid. Think about your labia like an orchid.

So or, o for orgasm. Orgasm shot. Say it. Orgasm. All right? It's easier to have an orgasm if you're able to say the word orgasm and not blush. If that makes you blush, practice saying that word. Orgasm, orgasm, orgasm. Okay?

Now, O-Shot for orgasm. All that I did, and I was the one to create this procedure, all that I did was say, okay, there's these process of taking platelets out of the blood stream and injecting them into [hartiel 00:14:20], like the knee, there's not a lot of blood flow in the knee or the cartilage of the knee, and so orthopedic surgeons, when they have an NFL football player, or veterinarians, when you have a million dollar racehorse, if you want to see what's working in medicine, you just look at how they take care of million dollar racehorses, or men who make 20 million dollars a year. If you miss a day of work, and you're making 20 million dollars a year, somebody is paying you, and they're losing millions of dollars.

So if you want to know what really works, look at what they do for NFL football players, and what they do to make them well from a knee injury is they take the blood out, they extract the platelets, and then they activate those platelets, and the platelets release these rejuvenating growth factors that tell the stem cells to grow new healthy tissue.

That's a mouthful, but if you want to know what that looks like, imagine when you scraped your knee as a child, there was this crusty yellow material there. It's called [inaudible 00:15:18] fiber matrix, and what that was, remember, you grew skin back. That told your body to grow the skin back. It didn't seal up. I grew new skin. That means blood flow, blood vessels, nerves, collagen, everything that makes up skin.

The growth factors that came from those platelets. There's over 20 of them we know about so far. Chemotactic factors that fight infection, you have, and it whistles for stem cells to come out of the bone marrow, migrate to the area, and then grow into that new tissue to skin. All right?

So it's not the platelets, it's what's in the platelets. So we always thought platelets and that scab was just to keep you from bleeding to death. Nope. It was not just to keep you from bleeding. It's like a balm, and embedded into that balm, that yellow goo that your mother told you not to pick at, but you did anyway, and that glue is these growth factors that were whistling and activating the stem, whistling for and activating the stem cells, and you grew new skin.

So back to the NFL football players. You can make that goo in five or ten minutes at the bedside by extracting your blood, just like you did when you get your blood drawn for tests at the laboratory to see if you're anemic or not, and then you put it in a syringe, and it's your body. It's your blood. No one's ever had a serious side effect ever from platelet-rich plasma, and there's been over 8,000 research papers done about platelet-rich plasma.

We published three so far about how this works with the vagina, but when you inject it, then what happens is the tissue of the vagina rejuvenates, and the nerves wake up, and the blood flow comes in, and the collagen grows, and it becomes healthier. And this alone, we've seen around 30%.

Now, here's the thing. We can get close to 100% for treating stress incontinence with the same shot, the O-Shot. We can get closer to 90% treating lichen sclerosus. For someone who has pain from a episiotomy or a tear from delivering a baby, close to 100%. But for a woman who's never had an orgasm, the O-Shot alone, it's about 30 or 40%, with that by itself. Just waking up the vagina.

But, so if we're still have close to 60% that the O-Shot is not working by itself, then we need other procedures. But I would include make sure that you see a therapist or an educator, that your testosterone, your free testosterone is in the upper 25th percentile, the upper one-fourth percentile, free is calculated by calculating sex binding globulin and total testosterone. If your doctor doesn't know how to do that, get referred to a doctor who does.

The O-Shot, now you have all this in place, get you a vibrator. If you want to start with a vibrator, that's fine too. But think about this as sort of a recipe for making the new path.

Now, here's the thing, and I'm going to tell you about the best vibrator, I think, for making an orgasm, and this is not from ... Obviously, I don't have a vagina, all right? I have a penis. So I don't know, but how I do know is 25 plus years of talking to women, over 10,000 of them in great detail and measuring their hormones and doing research and having them tell me what happens and how their marriage gets better, so this is not ... And also personal experience with lovers.

So this is not me making up something, and this works. It absolutely works, and it will change your life. All right? Back to the thing.

So this is the analogy, because here's how people go off track. They'll say, "Well, I got my testosterone fix, and that didn't work," as if that was the wrong thing. So why is it not a wrong thing if it didn't work.

Here's my favorite analogy for that. Suppose someone said, suppose you had never seen a fire in your life, and someone said, "Hey, you know what? To make a fire, you just need a match." And you went out, and you struck a match, and you got a little fire. It lasted a few seconds and went away, and you thought, "Uh. That didn't work very well. I don't have a fire. It just was there for a second, it's gone," and someone else says, "You know, to have a fire, what you need is a big stack of wood." And so you go throw a bunch of wood down, no fire. And someone says, "No. What you really need is some lighter fluid," and you go, and you squirt some lighter fluid around, and nothing happens. Well, you're getting the point, right?

And then finally, someone who knows the whole recipe says, "No, what you really need to do is, listen, you take the wood and you stack that up first. Then you put the lighter fluid, and then you put the match, and you'll get a fire."

So here's the thing. If you do one thing, and it doesn't work, as in doesn't work because you're not seeing the thing happen that you wanted to see happen, as in your first orgasm, breaking through the pathway, it doesn't mean that doesn't help. It just means you haven't found the rest of the recipe that what you need. And it could be that your testosterone level is out the roof, but maybe you have scar tissue from delivering a baby, and so the nerves are damaged. A mid-urethral sling. Now we know those slings you put to help with incontinence, I'm not saying that should never be done, but I can tell you research shows that that interferes with sensation to your clitoris. It can in many women damage the nerve supply to the clitoris. Well, that O-Shot helps grow the nerves back.

So back to this recipe. If you do a thing, and it doesn't give you the result, it doesn't mean the thing doesn't work. Keep doing that thing. Like, if you put down the wood, and you don't get a fire, it doesn't mean you don't use the wood, let's keep the wood there, and let's figure out what we need to add to that to make a fire. This, in my opinion, is a pretty good recipe that would cure almost all women and help them find and orgasm.

But if you could leave, you could possibly leave any one of these things out and still not get it. Like, I could put wood and lighter fluid, still not get a fire. I could put a match and lighter fluid and no wood, and I would have a fire for a few seconds, and it would go away. But if I want a blazing, you know, roast marshmallows fire and have sex by the fire with my lover, I need wood, lighter fluid, and a match. I need all three. And in my opinion, this is your recipe to have an orgasm, all right?

So the O-Shot, you can read about elsewhere on the O-Shot website. The testosterone, I just told you what you need. The sex therapist or family therapist. You need someone who's licensed that doesn't blush that can talk with you and your lover and help you find exercises you can do, and now, what's my favorite vibrator to help people find an orgasm?

Now, vibrators are personal, and remember, I don't have a vagina, so I'm reporting to you from what I've heard from my patients, and not just my patients. We now have over 1,000 doctors in 41 countries that I've helped train, or people I've trained have trained, to use platelet-rich plasma for the O-Shot and some other procedures that I've created.

So this is, what I'm about to tell you about this vibrator is from patients, it's from lovers, and it's from other doctors around the globe. New Zealand, Taiwan, India, France, Spain, Canada, Mexico, the US, Hawaii, Alaska, and other places. We have physicians in all those places that do the O-Shot, and I'm learning from them as well. Multiple universities. So just want you to know this is not something I'm making up.

So here's my favorite vibrator now. It may change if something better comes out. Here's the best one. So it's an Intensity, and when you take it out of the box, you have a nice little bag here that you can keep it in, and it comes with instructions. You won't really, you can read them, but you won't really need that after I show you what you do.

So, comes wrapped up in plastic, and if you've never used a vibrator before ... The other thing. Wow, that's a scary looking thing, and I don't even know what's going to happen when my children find that on the bedside table. So I don't know. You have to hide it I guess. But eventually, when they get old enough, you'll just have to tell them what it is, right? It's actually been shown that the sooner you talk about sex with your children, the less, the more likely they are to have a healthy sex relationship. So what I would recommend as a guide is when they ask a question, that's when they're ready to hear the answer. So you give them an answer as they ask the question and make it safe for them to talk with you.

So here's the way this works. These little electrodes here, can you zoom in on that? So these metal electrodes here act like a [inaudible 00:24:20] unit, but not to cause tingling. They actually cause an electrical current that causes muscle contraction. So another thing that can help you find an orgasm is to do Kegal exercises to both stimulate, exercise, and become aware of some of the muscles of orgasm. But you can't do a Kegal on your uterus, which also contracts when you have an orgasm.

What this does, there's a lot of women, they think they're doing Kegals, but they're really not. This, because this causes the muscles to contract, it makes you use the muscles you would normally do when you have an orgasm. Kind of fun, right? So this gel is to make contact with that. So you put a little bit of the gel on here, just a dab, about like that. Just enough to sort of cause it to make contact, okay? You put that on both sides. You don't need a lot of it. This is not a lubricant. This is not to lubricate your vagina. You could use a different lubrication if you want. This is a contact gel to make it so that there's electrical, passage of electrical activity from the device into the tissue.

So then, what you do ... Actually, the way to think about what this does, if you've ever seen those ads in the magazines where you're supposed to be able to put a little, stick a little wire on you, and it makes your muscles jump, and instead of having to go to the gym, it exercises for you. Well, it really does make the muscles jump. And that's what this does. It teaches your vagina muscles to jump.

And so you can set the rhythm of that here, and then it also functions as a vibrator. And this little thing called a rabbit, this goes onto the clitoris, and these top two, it's like a three-pronged hand, like this. And the top two go sort of under the clitoral hood, and the clitoris would fit right in there like that. So that pushes the clitoral hood back, and then this third little thumb finger goes on the clitoris itself, and what's going to happen is you'll have your little clitoris sitting in there like that, with these two going under the hood, sort of hold the hood back. And so now you have all three of those little fingers wrapped around the clitoris like that. Isn't that cool?

So that's the way it'll be, so this is clitoris, these are those three little fingers. The clitoral hood would be on top of these fingers like that. Beautiful, beautiful.

Now this is vibrating, this is making your muscles. Now it has a little thing here to pump this up. You can see when I pump that, it gets bigger, like that, and when I push this black button, it deflates it.

So you would pump that up to make contact with the vaginal wall. See that? And this would deflate it. So it's going to go in like this, and you can see the length of this would be, if your husband's worried that you're going to fall in love with your vibrator, husband, if you're there listening, let me talk with you for a second. What's going to happen here, obviously this right here, most people have an erection that's, you know, at least this big. So it's not like this is going to be suddenly a replacement for your penis. The other thing that's going to happen is, you'll find that as your lover learns to not be an or without orgasm, but becomes orgasmic.

She's not going to fall in love with this. What this does is once this helps her break through the brush, and now she has a path that she can go through and down. Once that happens, [inaudible 00:28:11], once that happens, now it becomes easy for her to find the path, and this can go away, or it could be something that you bring out sometimes.

So this can be a toy. She can be using this while you kiss her. You can be fondling her breast. You know, she can be using this while she's giving you fellatio. There's all sorts of scenarios where this becomes part of the bedroom scene, but don't worry. She won't leave you for this, and I can promise you, if you become accepting and encouraging about anything that is not dangerous, but yet leads to better health and better relations, even if she has an orgasm from this while she is kissing you, she won't fall in love with this. She will fall in love with your face if you're kissing her while she has an orgasm with that, and she will come to associate you with that orgasm, and the path will become easier to find and easier to follow, the neurological pathway up here, and it will come to where she can have the orgasm with you and without that. All right?

So this becomes a pleasurable tool, but it also becomes more importantly a therapeutic method to help all these things work better so you find a deeper relationship. So it's called an Intensity, and I hope you make it part of your metabolic, psychological bonding way to find a deeper relationship.

I've found, you know, I worked in the emergency room for 12 years. I've saved lots of lives, but I've found nothing more rewarding that saving the relationship of two people in love with each other or helping someone find healing, even if she's just loving herself.

Lots of women have come to us who have O-Shots who live alone. Sexuality is very empowering, and there's nothing that says that having an orgasm has to be about a man and a woman. It's okay for a woman to find sexual energy that then she uses for ... Rainer Maria Rilke talked about it being important for the creative process.

Napoleon Hill talked about it being important in his Think and Grow Rich book, about sexual energy helps people make more money or be more creative in their business endeavors.

Emerson called sex and beauty the scaffolding of love.

So a woman can be in love with herself and should be in love with herself, and it's okay for her to make love to herself, whether it's learning how to have an orgasm this way, or after she's learned, having an orgasm this way, and I hope that you'll contact us if we can help you further. Contact the physicians if you get an O-Shot. You should make sure, make sure, sure, sure that they are listed as one of our certified providers.

We've become very, very popular, and a lot of doctors, for some reason, either because of ill-intent or not, just unknowingly, they'll advertise as if they're in our provider group when they're not, and they're using kits that were not FDA approved for preparing plasma. They don't understand where we're putting that plasma, and it's very offensive. It can hurt women tremendously. I don't like it. I spend a lot of money on lawyers to shut them down, but still, they're out there, so before you see someone for an O-Shot, even if they're combining it with another device, like a laser, or ThermiVa, or radio frequency device. If they're putting plasma into your vagina, you should make sure they're listed as one of our certified provided, or what you're getting may not be good plasma, and it may be getting put in the wrong place. So be careful with that.

But consult our certified providers at O-Shot. OShot.info, and I'll put links to all this below, links to about the testosterone, links to therapists, links to where to get this vibrator, links to where to find certified providers, and again, thank you very much. This is precious, precious, sacred, sacred, very important material, and the fact that you have an interest in my ideas is very humbling, and I'm honored, and I hope you will contact us, us as in our organization and me personally, you'll let me know how this helps you and your relationship with yourself and with your lover.

1. Sex & Family Education

2. Testosterone Levels Corrected

3. O-Shot® Procedure

4. Intensity. Personal Orgasm Trainer and Pelvic Floor Muscle Strengthener

intensity-box-device-gel-325x233-325x233

  • Pelvic Muscle (Kegel) Exerciser
  • Inflatable Shaft
  • 10 Levels Of Muscle Stimulation
  • Clitoral & G-Spot Vibrators
  • 5 Speeds – 20,000 RPM Max
  • 100% Medical Grade Silicone
  • Made In The USA
  • Super Long Battery Life
  • Easy Cleaning
  • Requires 4 AAA Batteries

$247 (including free 2-day delivery in discrete package in the US)
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Improve Male & Female Sexual Function

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