Dr. Michael Goodman, MD, FACOG

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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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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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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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