Sex, Libido, and Relationships: A Functional Medicine Approach

Welcome everyone. I'm Noah Reed, vice president of sales and marketing for the Dutch test, and thank you all for joining us for this Dutch webinar featuring our friend Dr. Sarah Godfrey. Today, Dr. Godfrey will be addressing the topic of sexual wellness. She'll cover the normal sexual responses for men and women, describe the different types of male and female sexual dysfunction, identify the hormone signatures of the most common types of sexual dysfunction, and review evidence-based treatments that are currently available.

Before we begin, let's dive into some new Dutch educational resources that are now available exclusively to registered Dutch providers. The Mastering Functional Hormone Testing Course and the new Dutch Interpretive Guide are designed to help providers confidently use the Dutch test to treat their patients with actionable results in each report. Providers can now sign up for a self-paced online course that walks through how to interpret the Dutch results for a variety of patient types. The Dutch Interpretive Guide is a supplement to the core course. It gives detailed information about report interpretation for complex symptoms and offers support considerations so you can better treat your patients. If you are not already a Dutch provider, you can get started here today. Just click the link that's in the chat to become a provider and gain access to the Mastering Functional Hormone Testing Course and the Dutch Interpretive Guide. Current providers can download both of those or sign up for the course in our provider portal.

Now, let me introduce today's speaker. Dr. Sarah Godfrey is a physician, researcher, and educator. She graduated from Harvard Medical School and MIT and completed a residency at UCSF, but is more likely to prescribe a continuous glucose monitor and personalized nutrition plan than the latest pharmaceutical. Dr. Godfrey is a global keynote speaker and the author of four New York Times best-selling books about trauma, hormones, and health. She is a clinical assistant professor at the Department of Integrative Medicine in Nutritional Sciences at Thomas Jefferson University and director of Precision Medicine at Marcus Institute of Integrative Health. Her focus is the interface of mental and physical health, N-of-1 trial design, personalized molecular profiling, use of wearables, and how to leverage these tools to improve health outcomes.

Thank you so much for joining us today, Dr. Gottfried. We're ready when you are.

My pleasure. Thank you so much, Noah, for that kind introduction, and I love the Dutch test, so I'm really delighted to be with you all to talk about sex, love, and relationships: a functional medicine approach. We are going to be talking about learning objectives that Noah read already, so we don't have to do that again. But I, I want to talk about the, the state of affairs when it comes to sexual health first. And what's amazing is that since the 1980s, I started medical school in 1989, I'm going to date myself here. You know, that period of time, the free love of the 60s and the 70s, we've really been declining in terms of formal sexual education. And that has a pretty major cost. It's led to a couple of generations of medical students, clinicians who just aren't very comfortable asking about sex. And so that sets up this disconnect because most people who are going to their clinician want information about sexual health. They want to be asked about it. They may not ask themselves about it, and so they want to be asked about it. We know this from surveys. And yet, many of us just weren't trained to do it adequately. So that leads us to the point where we have to teach ourselves how to do this. And so one of the best practices is to think about the six P's when it comes to taking a sexual history from your clients or patients. And that includes, uh, partners, practices, protection from, uh, STIs, past history, prevention of pregnancy, and then a plus. The plus is kind of the, the term that applies to all the things that are not in those previous five P's, and that includes important things like trauma. So I use an ACE questionnaire, Adverse Childhood Experiences, on all of my patients. Doesn't matter if you're an executive or a professional athlete or a stay-at-home mother, I'm going to ask you to fill out an ACE questionnaire. I ask a lot about traumas in adulthood. I ask about, um, a number of other things: sexual satisfaction, history, violence, gender identity, sexual orientation. And while I'm going to be mostly talking about those who are born female today, I just want to make sure that, uh, you understand my commitment to being inclusive about body, sexuality, and the way that we talk about sex and gender. So that is incredibly important to me.

So this situation where not a lot of clinicians are asking about sex has led to this problem where we've got this real gap. And that's where you come in because you're able to fill this gap by attending this webinar, by understanding some of the best questions asked, how to frame it, how to get into a discussion about sex, what are the statistics, what are the metrics that are important to go about, and then very importantly, how do you make a diagnosis? How do you assess the hormones in someone who's got sexual dysfunction? And the punchline here is that about 70% of those with sexual dysfunction have a hormonal reason for it, which you can find from testing, including the Dutch test.

If so, let's begin with what's normal because it seems like such an easy thing to define, but it's not really. So there's a number of studies that I want to share with you. The first is the Rancho Bernardo study. So this one is kind of famous. It's a total of 1,303 people, women, those who are born female at birth, mean age of 67. So these were mostly post-menopausal women, but the age range from 40 to 80. This was in Rancho Bernardo, it's just kind of a reflection of the community there. And what they found was that only about half of these people had had sex in the past month. So 49.8%. They found, not surprisingly, that the likelihood of sex decreased with age. So I share that with you because it was one of the findings in the study. But my experience with my clients and patients is that that's not necessarily the case. I've got lots of patients who are in their 70s, 80s, 90s, who are having the best, best sex of their lives. So I would say even though it's common, it's not necessarily normal, and it's not necessarily what your clients and patients want. So about 40% of these women have no sexual desire whatsoever. 40%. So that's pretty high. They found that sexual desire was associated with hormone use, so the use of hormone therapy. And maybe not surprising, but I think it's worth mentioning, is that when you have more sex, you have more desire. And I'll explain why that is in a moment. So for instance, if I've got a client who tells me that she's got no desire, like she'd rather mop the floor than have sex with her partner, one of the things I'm going to do is I'm going to suggest that she start having more sex because we're not going to be able to assess the interventions like use of bioidentical estrogen and progesterone, maybe testosterone. We're not going to be able to assess that unless she's got, you know, kind of this tableau of having sex. So that piece is really important.

So the study in Rancho Bernardo was then followed up with a clinic visit and added some additional clinical detail. So at this point, a mean age of these participants, it was a smaller subset of the original 1,300, total of 376 women, mean age 73. They found at this point that fewer were sexually active, 39%. And also, really critical to understand is the role of comorbid disease. So about 42% of these women had metabolic syndrome, and that was associated with less sexual activity, less desire, and lower satisfaction. So I do a lot of research on metabolism, and I often find that the way that you do your metabolism is the way that you do everything. So for women who've got at least one or or two diagnostic criteria for metabolic syndrome, you can just imagine that their vascularity is not the same. They might have hypertension, they might have high glucose levels, high insulin levels, associated all of which are associated with decreased sexual desire.

I think it's also important to emphasize what's normal in terms of anatomy. So, you know, what a lot of women and men get exposed to is, uh, porn or airbrushed versions of female genitalia. So I always spend a lot of time talking about the sizes of female genitalia to normalize it. So just look at this, for instance. If we look at the width of the labia minora, the mean is 13 millimeters, but the standard deviation is eight millimeters. So that's a pretty wide range. Look at the, um, yeah, it's right and laughter listed here. The clitoris can really range in terms of size with the 4.6 standard deviation of 2.5. Minimum and maximum we're listed here. So, you know, the kind of the kind of images that a lot of men see, and then by extension women, they're not necessarily normal. So I think it's important for us to normalize the range that we can see.

Let's talk about female sexual response. I want to start first with Masters and Johnson. This is kind of the classic sexual response that they defined for both men and women. It was mostly defined in men and it was assumed to apply to women until we realized that was not the case. So you can take a look at this graph, sexual excitement and tension as a function of time. And desire here is what you might imagine. It's the presence of sexual thought, it's, uh, fantasies, the innate urge to experience sexual tension and release. These are all really, I would say, mostly male terms. And so the way that Masters and Johnson defined sexual response is that it starts with desire, it builds to arousal, it then gets to a plateau, and then you can peak to an orgasm, which is illustrated in this little blip here. There are some fortunate folks among us who have multiple orgasms depending on refractory period that includes both men and women. And men, of course, can separate ejaculation from orgasm. They're two separate events. That's a different talk. We're not going to talk about that today. Usually, I get a two-hour talk on sex where it's an hour on women and an hour on men, but we only have time for an hour today, mostly 45 to 50 minutes, and then I'm going to take your questions. And then it, it goes on to a resolution phase. So this can range from what I think of as the two-minute climactic sneeze where you come really fast with the vibrator to lovemaking that can last for 30 minutes to hours. But what I want you to understand is the contribution of Rosemary Basson. And that is illustrated here on the right. So she is a professor at the University of British Columbia. She's in the sexual medicine program. And when she published her model of the female sexual response, I just had one of those aha moments of, oh, thank goodness, this makes so much more sense. In this, you know, kind of U-shaped curve with a little orgasmic peak described by Masters and Johnson. So let me take you through it. So what she says is important for most women, not all, but for most women, is that sexual response starts with emotional intimacy. That's where it begins, not with desire. And emotional intimacy, the way I think of this is my partner is equally sharing in the tasks around the house, maybe doing the dishes on a regular basis, involved in child care. All of those things create sexual intimacy for me, emotional intimacy. And so you want to be asking your, your patients, what creates emotional intimacy for you? And emotional intimacy then creates sexual neutrality. So not desire, not arousal, but neutrality, like you're, you're more open to it. This then leads to, uh, receptivity to sexual stimuli. There's then biological and psychological factors that influence processing in the limbic system, including the history of trauma. My next book is about trauma, so I'm obsessed with trauma right now. It includes hormonal factors. It includes kind of your, you know, what's going on with your particular cocktail of estrogens, progesterone, androgens. Oxytocin is peppered in this. Then leads to sexual arousal. This can then build to more arousal and desire for more. As some leads to satisfaction, physical and emotional. And this then positively reinforces emotional intimacy. So two very different models. And I think it's important to understand that women don't start with desire, they start with emotional intimacy.

So as women transition from normal to dysfunction, I want to hit a few highlights. So the first is that as a precision medicine doctor, I've been practicing functional medicine about 20 years. I've been doing, uh, genetics and how that interacts with the environment for about that period of time. What other things we know that seems to be a factor is the androgen receptor. So do you have the kind of androgen receptor that a friend of mine who's a gynecologist describes as the Hummer type of receptor? So that androgen receptor is not fuel efficient. So if you drop below a certain level of androgens, particularly testosterone, that Hummer type of androgen receptor is not going to work well. It's going to be, it's going to say, listen, I don't have enough gas, I don't have enough testosterone, I'm just going to shut down. Whereas other women have what I think of as the Prius type of androgen receptor. So it's super efficient. So a low level of gas, a low level of testosterone, they still have that emotional intimacy, that build to, um, you know, sexual pleasure. So those folks tend to have not many symptoms, whereas the people with the, the Hummer type of androgen receptor do. So some of this might be related to something called CAG repeats. We're not going to have a lot of time to talk about that. I've got a slide a little bit later that we might have time for, but it's just something that I put on your radar because I think at some point in the future, we'll be doing some additional genetic testing in our patients with decreased libido. In Rancho Bernardo, the study I just presented to you, about 33%, so one in three, had low or no sexual desire. But overall, 61% were sexually satisfied. So that's a bit of a disconnect, right? So 33% low or no desire, and yet many of them were having sex and they were satisfied. So there's probably a lot of different reasons for that that we can get into, but it's important to know that sexual motivation is complex. I want to be careful not to overly reduce it. It's not just hormones. I've had plenty of patients in my practice who, uh, came to me with hormonal dysfunction and decreased libido, and together we got them to a place where they were optimized in terms of their hormones. You know, what I think of as like a perfect hormonal specimen, and they still did not have normal libido or libido that they were happy with. And often that is because of relational issues, communication issues. I can think of one woman in particular where we had to very slowly titrate her in perimenopause to get her estrogen or estradiol level to a normal range, to a range that, you know, helped with her symptoms, and then, you know, a companion dose of progesterone that protected her endometrial lining, and then we started to slowly titrate testosterone because she had some cystic acne, we had to be careful with that. And then she ended up loving no interest in her partner, and she ended up divorced. So it's important to realize that this context of hormonal change that can be associated with decreased libido and sexual dysfunction is in this broader context of relational needs as well as other motivations. And certainly trauma is so important when it comes to sex. Women with a history of childhood sexual abuse show higher levels of distress, even in the context of good sexual functioning. So that makes sense. You know, if your earliest experience of sex and exploration was traumatic, that creates a neural network that can make it really difficult to have a satisfying sex life. Fortunately, a lot of trauma-informed treatment now, it all presents some of the data that we have, uh, if we have time. And then a lot of people think that sex ruins sexual function, but that is not necessarily the case. Surgical menopause overall improves sexual function. You know, there's a lot of debate when I was going through my residency about, should you have a supracervical hysterectomy versus total hysterectomy? Because maybe the cervix was involved in orgasm and you were, you know, basically mutilating a woman if you were taking out a normal cervix. And the evidence really doesn't support that. So especially for women who have chronic pain, pelvic pain, fibroids, bulk symptoms, really heavy periods, what we find is that when they have surgery, when they have an ablation or hysterectomy, often there's sex improvement because they just don't have all these other things that they're managing in addition to their sexual health.

So this study, the PRESIDE study, was really important. There are several reasons. First, it was published by one of my mentors, Holly Thomas, who's at Massachusetts General Hospital. So this stands for Prevalence of Female Sexual Problems Associated with Distress and Determinants of Treatment Seeking, or PRESIDE. So this was a much larger study than the Rancho Bernardo. It was a total of 31,581 women, all adults, uh, they were 18 or older, and they found that 43% described a sexual problem. So you might have heard that statistic, that 43% of women are having sexual dysfunction. It comes from this study. So about 22% of the sexually related personal distress, uh, was occurring, not surprisingly, in perimenopausal menopause. So this was around age 45 to 64. And there were certain correlates of sexual problems, including poor self-assessed health, low education level, apparently more education makes you sexy, which is good for those of us that are practitioners who went to school forever, depression, anxiety, thyroid conditions, and urinary incontinence. So I mention this because when you have a patient with depression, anxiety, hypothyroidism, urinary incontinence, you want to be asking about sex because these are, you know, killer whales that kind of travel together. And give you my Pacific Northwest analogies here. I used to live in Seattle, so I've got a few of them.

So let's get into the details in terms of diagnosis. Female sexual dysfunction. The way that we define it, the way that we classify it, is with four different, uh, groupings: desire, which is the most common, arousal, orgasm, and pain. So this is from DSM. It's also from, uh, the Obstetrics and Gynecology, the American College of Obstetrics and Gynecology, of the American Psychiatric Association. So we've got these diagnostic criteria that we use for female sexual dysfunction. We've also had a change in some of the names, which makes things totally confusing, and I'll clarify that for you. So here's some additional information on the androgen receptor. You've got this in the slide deck, so I'm not going to spend a lot of time on this, but I'll just give you the takeaway, which is that in a study of about 529 women aged 19 to 65, the increasing number of CAG repeats were correlated with increased sexual function. So this is something that is not ready for prime time in terms of making a diagnosis for a patient, but it's something that might be coming in the future.

So what are the common causes of female sexual dysfunction? What are some of the risk factors? So you've got them listed here. We've mentioned a few of them already: anxiety disorder, diabetes, blood sugar dysregulation, depression, female genital mutilation. And you might have heard me talk before about birth control pills, which I think can be a form of genital mutilation because it disrupts hormones so significantly. Most women are not given informed consent about that. And about 20%, now let me say that right, women on the birth control pill on average have about a 20% shrinkage of the clitoris. So I find for women that are on the fence about whether to continue the birth control pill or not, that gets them almost every time. So I think women need informed consent about different forms of contraception, and we could talk more about that in the Q&A. I'm a big fan of IUDs. History of sexual abuse, hypertension, hysterectomy, intimate partner violence, medications, negative sexual attitudes, neurologic disease, personality traits like perfectionism and self-loathing, postpartum period. I don't even know if that should be listed here. I feel like women should be offered, uh, retirement for some period of time after they have a baby. Premature ovarian failure. We don't call it that anymore. We call it premature ovarian insufficiency. Psychological sequelae of gynecologic cancer and breast cancer, relationships, or that's a big one, stress, emotional or environmental stress, urinary incontinence, then of course, substance use disorder.

So this slide is really the most important one in the deck because we've been looking for the hormonal correlates of decreased libido during my entire career and even before that. In this paper, also published by Rosemary Basson, showed that DHEA and cortisol are critical biomarkers from the saliva of the HPA axis, the hypothalamic-pituitary-adrenal axis dysregulation in women with low desire. So let me take you through this because I think it's so critical. So they studied all the things that I get on my favorite test, which is the Dutch Plus. So this study looked at HPA axis function, morning and evening cortisol in the saliva, DHEA, the cortisol awakening response, diurnal cortisol slope, the cortisol DHEA ratio. And they then looked at the relationship with sexual functioning in 275 women, half with and half without what was known as hypoactive sexual desire disorder. So we don't call it that anymore. We now call it sexual interest and desire disorder. So just keep that in mind because I'll show you some of the DSM slides that, uh, don't use this term anymore, but some of the older research, this was published in 2019, used HSDD, hypoactive sexual desire disorder. So what they found was that for the women who had hypoactive sexual desire disorder, they had lower morning cortisol. And I've got a case of a woman who's got, they had lower morning DHEA, they had a flat diurnal cortisol slope, and they had a lower cortisol awakening response. So those are four biomarkers that you can be testing for in your patients, your clients, who have decreased sexual interest. And I think that's really critical, along with the history that you take, that really thorough sexual history that you take, to be looking at these correlates. And of course, we also want to measure total and free, maybe bioavailable testosterone in the serum because that is the gold standard. But I would say this particular study was good news to me because it really showed quite, uh, significantly what changes in women. It's not just in their HPA axis. It is, uh, scientifically proven.

In fact, let's, uh, talk about a case. This is a 46-year-old woman. Let me give you some of her statistics. So she, uh, was in the early stages of perimenopause. And I'll explain more about this. So 46, and if you are accustomed to looking at a Dutch, then you're going to be able to go, you know, straight to the estradiol level. You're going to see their estradiol is a little bit elevated, which is so common in the first half of perimenopause. We see these wild fluctuations of estradiol. So it depends on where you catch a woman. But this woman in particular is obese. So she's five foot four, 265 pounds, regular cycles, so didn't have oligomenorrhea like we might expect with something like polycystic ovary syndrome. She has a low normal progesterone, not enough to balance that estradiol, and a low normal testosterone. So a couple of other things that she's got that I think kind of fits with the clinical picture that we're building: high blood pressure, adrenal dysregulation, and chronic fatigue, especially in the morning, hypothyroidism, decreased libido, depression. So when I hear all of those things, I then look at the adrenal hormones. And what we want, you can see this black line, the high range limit, and then another black line, low range limit. This is salivary cortisol as a function of time. This is the cortisol awakening response when you first wake up, 30 minutes later, and then 60 minutes later. And this woman is low. So she's outside of the normal range. So this is a low cortisol awakening response, just like what Rosemary Basson predicted. So this woman has a number of criteria that fit with what, uh, what she just, what Rosemary described: a low cortisol awakening response, loss of the diurnal pattern of her, uh, cortisol path. And then, um, you've got the numerical values listed here on the right. And I just want to point out the DHEA was on the low end of the range. And when I'm looking at cortisol, I'm also looking at this total salivary cortisol. I think of this as the cortisol load. So this is the sum of five values. And what I'm wanting with my patients, I want them to be right in the mid-range. I like to see a number around 15. And this woman is way below that. She's had about a third of where I want her to be. She's also got a high metabolized cortisol, which fits with her obesity. So she's got her metabolites listed here. I'm not going to spend a lot of time on this, but here's that low DHEA, which also fits with what Rosemary Basson talked about in terms of biomarkers of low sexual interest and desire disorder. And then because she's got such high estradiol, we then want to think, well, if she's obese, maybe with the fat, she's got high estrone. And that indeed is the case, as shown here. And then her metabolites, her two-hydroxy estrone is a little bit elevated. So, um, I'm not going to get into the details of how to deal with that because that's less relevant to our conversation today, but the main takeaway is that you can use the Dutch to look for these biomarkers, especially of low interest and desire disorder.

Here's some commentary. Causes. We've talked about hormonal root causes. There's also neurogenic, psychogenic, vasculogenic, I mentioned that related to problems with blood sugar, medications, genetic, we talked about CAG repeats. And then there's the classifications from the DSM that include female sexual interests and arousal disorder. That's the term that replaced hypoactive sexual desire disorder. Female orgasmic disorder, where it's hard to have an orgasm or impossible. Genital pelvic pain penetration disorder. Substance medication-induced sexual dysfunction, and other. So these are the five different categories that the DSM currently uses to classify sexual dysfunction in women.

Let's talk about some of these criteria. I'm just going to spend a few minutes on this because you're not, you know, going to become a sexual therapist from a 60-minute training, but it's important to know about these. So the, the DSM defines female sexual interests and arousal disorder as a lack of or significant decrease in sexual interest with at least three of the following: so interest in sexual activities, sexual or erotic thoughts, initiation of sexual encounters, and responsiveness to a partner's initiation, excitement, or pleasure during all or almost all sexual activity, interests in arousal in response to internal or external sexual or erotic cues, genital or non-genital sensations during sexual activity in almost all or all sexual encounters. And the symptoms have to persist for a minimum of six months or, and sorry, so minimum six months plus cause clinically significant distress to the individual. So there's some women who have this and they don't care, like they're retired. So we don't have to treat. Um, but I think it's important to know these criteria for female sexual interests and arousal disorder.

So this is the most common situation that you're going to encounter. And I want to present a second case here. This is, um, a 51-year-old woman who came to me and said, I feel flat. So she, she met criteria because her interest in sexual activity had declined. She had a significant decline in her sexual or erotic thoughts. Her interests or arousal in response to internal or external sexual or erotic cues was diminished. And this persisted for six months. It caused a lot of distress for her. She was newly divorced, and she wanted to get back in the game. So I diagnosed her with sexual interest and desire disorder. And we'll circle back to her later.

Female orgasmic disorder. It's pretty self-explanatory. It's a marked delay in or infrequency or absence of orgasm or reduced intensity of orgasmic sensations, once again, persisting for six months, causing clinically significant distress. Genital pelvic pain penetration disorder is also what you might imagine: difficulty having intercourse, vulvovaginal or pelvic pain during intercourse or penetration attempts, a lot of fear and anxiety that builds up around this, and also, uh, can include tensing or tightening of the pelvic floor muscles during attempted vaginal penetration. Once again, persisting for six months, causing clinically significant distress. So I had a patient who had two of these, not three, and she had an agreement in her marriage for how to satisfy each other that did not include penetration. So I think it's important to realize that there are some people who don't have significant distress associated with a condition related to pain and penetration. So that's where, you know, taking a full history and really understanding the patient's values and where they're coming from is essential.

Substance medication-induced sexual dysfunction. I'm not going to spend a lot of time on this. It's just important to be aware of it. This does not require the six-month timeline because some people, for instance, go on an antidepressant, they find within six weeks, yeah, it's really hard to have an orgasm, or they just don't have any interest anymore. And so that's a situation where you want to assess and, you know, get into the details. Information. So there's some medications that are listed here. I already talked about birth control pills and how that can diminish your, uh, the size of the clitoris by 20%. And this is related to, um, the fact that oral estrogen raises sex hormone-binding globulin, that's like a sponge that soaks up free hormone, free testosterone, and also free estradiol. So, uh, psychiatric medications such as antidepressants and others, anti-hypertensives, cholesterol-lowering medication, sleep medications, pain medications. And importantly, we talked about the PRESIDE study and how in the PRESIDE study, women were, um, the women who had the most distress were 45 to 64. And those are the women who are often getting started on some of these medications like the anti-hypertensives, the cholesterol-lowering medications, sleep medications. So we want to be thinking about how do we address the root cause? That's really the, the fundamental part of functional medicine, to address the root cause because the root cause for 45 to 64 is often hormonal. So we need to start with some of those, but we want to be thinking of other things too, like hormone blockers, alcohol, cannabis, narcotics, all of those diminish sexual function.

How do you approach a patient who's got sexual dysfunction? I tend to start with, I screen all of my patients. I use the PROMIS 8-item checklist that's listed here. And just so you have a script and some language to, to bring this up with your patients, you can say, "Many women experience concerns about sex. Are you experiencing any issues? What is concerning you?" So that opens the door. Sometimes it opens the floodgates. So ask it early in the appointment, and, you know, for someone who's ready to talk about it, it really offers such a huge service to that woman. I mean, you can also say this to a man, but I think it's important to realize that sometimes you gotta ask that question a few times before they're willing to open up about it. And then you can dive into a comprehensive sexual history. So I always do a physical examination. I do comprehensive testing. I recommend a combination of serum testing, since that's the universal language of mainstream medicine, and then I do dried urine, saliva testing. You want to look at the timing of symptoms, especially if it's been six months or longer, except with the medications, substances. Psychological referral can be helpful, maybe not as helpful as you might think. I wish we had more really skilled sex therapists who could teach sexual skills training, cognitive behavioral therapy, mindfulness-based therapy. There's also, in the state of California, this is not true in Oregon, we have sexological body workers who are licensed by the state who use gloves and they teach people about sexual function. I refer a lot to sexual sexological body workers. So it's only, uh, legal in California. We're one of those Megatron states, what can I say? And then hormone therapy. So I would say most of my patients who've got sexual dysfunction, I'm going to start them on some hormone therapy. There's also genitourinary syndrome of menopause. We used to call this vaginal atrophy, and that's one of those value-laden terms that we should no longer be using. So you probably know this is where you have estrogen deficiency that involves changes to labia, clitoris, the opening of the vagina, the clitoris, the vagina, urethra, and bladder. For the vaginal atrophy is just one component of genitourinary syndrome of menopause. So I mention this because it's so underdiagnosed and it's so easy to treat. So a lot of these women get offered lubricants, moisturizers, which hardly work. I think low-dose vaginal estrogen therapy is the way to go. You can also use testosterone, you can also use DHEA. In fact, I've got, I think I've got a little DHEA cream here. So here's some examples of some DHEA cream. You can either do it compounded, you can also buy it online because DHEA is over the counter. You can ask me about that in our Q&A.

In terms of hormone therapy, I typically give estradiol therapy, um, sometimes I give DHEA therapy, especially locally. So you can think of that in terms of local and systemic. I give progesterone, I give testosterone. I don't treat the SERMs. I did 20+ years ago, I don't do that anymore. So I'm going to skip over some of the points about testosterone. You've got a couple of slides here. How serum testosterone does predict clinical outcomes related to muscle mass, libido, but there's a lack of correlation between testosterone levels and sexual function. That's why the paper by Rosemary Basson, I think, is such an important contribution. A couple of papers. We also know that inflammation, when it's excess, diminishes desire. That's not a big surprise. One of my favorite solutions for women is orgasmic meditation. It's something that we study at Thomas Jefferson University. We do brain scans of pairs that are doing orgasmic meditation. So you can ask me about that in our Q&A, which we're going to get to in just a moment. This is one of our professional MRI studies that was just published with another paper coming out soon. You've also got the North American Menopause Society 2022 position statement, and they basically support the use of systemic hormone therapy and low-dose vaginal estrogen therapy for people who are trying to improve sexual function generally. What they recommend is about three to six months of therapy, a trial to see if it makes a difference. So there's a guideline to support your use of bioidentical hormone therapy. These are all level one recommendations, look at that. So randomized trials, multiple randomized trials to support these recommendations. We don't always have that when it comes to bioidentical hormones. Uh, the quality of evidence is a little bit less for genitourinary symptoms, but certainly low-dose vaginal estrogen preparations are effective. And I'm going to skip over some of these slides. If you've got some information on testosterone, and I want to, um, tell you about Julian. So we talked about her earlier. What I did with her was offer transdermal estradiol, oral progesterone because she had a uterus. We started with a kind of a moderate dose estradiol, micronized progesterone 100 milligrams at night. That got her about a 50% improvement in terms of her sexual dysfunction. And so then we added some topical testosterone. I have a transdermal here, but it was topical, and we slowly titrated her up, and she found that her life was in Technicolor, that her, her erotic self, she was able to reconnect to her erotic self. And I love hearing that from my clients. It's, um, a beautiful thing. So that's Julian. I wanted to mention that this Rosemary Basson model about motivation for sex has even made it into the American College of OB GYN practice bulletin. So hooray for that. This circular sexual response cycle. If you learn nothing else today, I hope you learned these two points from Rosemary Basson. Number one, that women don't respond to sex the way that men do. They respond to emotional intimacy, and it creates this circular sexual response cycle. And then number two, from Rosemary Basson, is these biomarkers, especially low cortisol awakening response, low AM cortisol, low DHEA, and loss of the diurnal variability. Those are the things that are associated with hypoactive sexual desire disorder, also known as sexual interest and desire disorder.

So you've got a slide on kisspeptin. This was a paper that just came out a few months ago. There's always new information about different hormones, and kisspeptin injections are kind of the new kid on the block. So you've got some information about that here. And I think what I'll do is I'll close with briefly this case study, and then we're going to shift into your questions.

A comment about Dutch testing. This next patient is a 51-year-old woman. She's still cycling regularly. So she's got her last menstrual period shown here at the upper right. So she's got a much lower estradiol than the previous case that I showed you. So if you read Dutch, you know that you want to be in this green area between the two stars. Post-menopause is shown in purple. This woman is between those two. So that fits with age 51 and perimenopausal. And if you don't know how to interpret a Dutch test, what I recommend is that you order one on yourself and then you go over it with one of the clinicians at Dutch. They're super helpful. So she also has a little progesterone. She's got a low normal testosterone. She's got some issues with her cortisol awakening response, not quite as bad as that last case. And then she's also got a low cortisol load. So this woman had three out of three low sex drive. And they always like use the lawnmower right at the most important point in the webinar, right outside my door. So, um, she's got not terrible estrogen metabolism. I would probably try to raise her two-hydroxy estradiol and I'd be tracking that with hormone therapy. But this is someone I would consider starting on hormone therapy if she's a good candidate and kind of depending on her values and what, what it is she wants in the rest of her history.

So I'm just going to summarize before we shift to our Q&A that you really want to consider these differences in normal sexual response for men versus women and how women really respond to emotional intimacy, how that creates this, uh, sexual neutrality, which is very different than what men experience. And I'll put it another way: women need to feel connected to be open to sex. Men often need sex to feel connected. So it's this disconnect that happens between the sexes that we want to be aware of and we want to help our, our patients with. We want to recognize these different types, these five different types of female sexual dysfunction, while we're aware that sexual interest and desire disorder is by far the most common. And then you want to focus on testing and the hormone-based root causes and treatments. And I would frame those as low progesterone, low estrogen, low testosterone, low DHEA, and then dysregulated cortisol, like an abnormal cortisol awakening response or a loss of the diurnal variation.

So with that, I'm going to end and I'm going to turn things over to Noah.

I know it. Yes, hi, how are you? Thank you so much for this wonderful webinar. We do have some questions, so we'll try to get to as many of those as we can in the next 10 minutes. But as a reminder, don't forget about the exclusive hormone education for Dutch providers. We have three awesome new resources for you: the Dutch Interpretive Guide, the Mastering Functional Hormone Testing Course, and our group mentorship sessions. Those are exclusive to Dutch providers, so make sure you sign up today. Become a Dutch provider and have access to those in your provider portal.

So let me try to get to these in a way that will make the most sense so that we can have a good conversation. Um, the first question that came to mind for one of our listeners was, what do you think about vaginal estriol for GSM?

Okay, I like vaginal estriol. Vaginal estriol has a really interesting history. Let me back up for a minute. So estrogens, as you probably know, are a family of different hormones. So the most common, the most potent, is estradiol. That's what we make during our reproductive years. Estrone, or E1, is primarily made in fat. So that's what, uh, in the first case that I presented, she had a really high estrone level and she was obese. And then E3, or estriol, is what you make primarily, and it's considered a less potent estrogen, uh, in terms of its binding affinity for the estrogen receptor. And, side note, there's now at least six different estrogen receptors, so not just ER alpha and ER beta, there's also the G protein-coupled receptors. So with estriol, I remember, I think it was back in the 1990s that, um, or maybe even before that, where the New England Journal of Medicine published a randomized trial showing that vaginal estriol prevented recurrent bladder infections in women. So I was thrilled to see that because often with natural medicines, with bioidentical hormones, we don't get good randomized trials, and certainly not published in the New England Journal of Medicine that show a favorable outcome. So I'm a big fan of vaginal estriol. I've got patients that I use it in who are maybe afraid of estradiol, they've got a family history of breast cancer. I've got one more, a couple of women with multiple sclerosis, and estriol has been shown to be helpful with multiple sclerosis. So I'll use vaginal estriol on most women. So I don't use it as commonly as vaginal estradiol, but I certainly use it. It's one of the tools in the toolkit.

Noah, are you still there?

I am. I pulled the, uh, the old "leave yourself on mute and ask a question" thing. So I apologize about that. It was a great question. So let me ask it again. Uh, there's a brief mention of hypothyroidism or hyperthyroidism in the case. What is the role of thyroid hormone in levels in sexual function?

Yeah, this is a great question because I did a webinar about 10 years ago with, um, Tina Nolan. Gina was one of the Baywatch actresses, and she had hypothyroidism related to Hashimoto's, and she had no sexual interest. And once, once her hypothyroidism was corrected, she found that it really changed her libido. And that got me to look at the literature. So the literature is not that helpful, I think, because so many endocrinologists do the research on hypothyroidism. So that interface of sexuality and thyroid dysfunction is not well mapped or defined. I don't mean to throw endocrinologists under the bus, it's just that I see it so commonly in my patients that they've got thyroid dysfunction and problems with sexual function. So the, the two tend to go together, and we have to be asking about it. So I think you asked about hyperthyroidism, although in the case that I presented, she was hypo, so low thyroid function, hypothyroidism. But I, I see at both extremes, hyperthyroidism and hypothyroidism, sexual dysfunction. And anything else I want to say about that? So I don't take care of many patients with hyperthyroidism. I actually refer that to endocrinologists, like Graves' disease, because I'm just not, it's not one of my areas of expertise. But I, I treat thousands and thousands of people with hypothyroidism.

As a follow-up question, someone else asks specifically about speaking to hypothyroidism and men on Clomid presenting with T levels that are normal but have little to no sexual desire.

So I take care of men, but when I start to see, you know, for somebody who's being treated with Clomid, my experience with Clomid is primarily in women. So in this particular case, with someone who's got normal T levels, it sounds like they're taking Clomid to increase their T, which is a common treatment, and they've got hypothyroidism. You know, what I would do is I would make them euthyroid. And the way that the way that I define euthyroidism is, and there's data to support this, is the TSH between 0.3 and 1.5, and a free T3 and a free T4 that's in the top half of the normal range, and a reverse T3 that's in the bottom half of the normal range. So someone like this who's on Clomid, it's beyond my area of expertise. So I would call my friend Miles Barr, who's like an expert at men's health, and I would ask him about it, and I'd probably refer that person out.

Wonderful. Do you recommend a topical progesterone for women without a uterus if the progesterone is low on Dutch and they are on an E2 patch?

I do. And the reason for that is we have evidence to suggest that progesterone is such an important part of the way that estrogen is metabolized and the way that the receptors are cycled through on a cell. I think that progesterone is very important. I think based on the evidence, if you look at the evidence in its totality, in terms of the risk of breast cancer, I do not think that breast cancer is increased by the use of, uh, natural progesterone. I think it's increased in response to synthetic progestins. Now, that is a controversial statement. I've got lots of studies to support that assertion. The conventional party line, and I'm still a board-certified obstetrician gynecologist, is that if you've got a woman with a hysterectomy who's got, um, who has vasomotor symptoms or some indication for taking hormone therapy, that you don't give any progesterone. And I disagree with that. So that's the situation where I use transdermal progesterone.

Wonderful. All right, well, that, uh, concludes a lot of the questions that, that were asked. A lot of them were the same, so we'll go ahead and close up with that question because that was helpful. Uh, thank you again for joining us today, Dr. Gottfried, and all of our attendees. Make sure you check your inboxes tomorrow for a link to the webinar recording and to download the slides. Additionally, please visit the "Become a Provider" tab at Dutchtest.com and complete the steps to become a provider if you have not done so already, so that you can gain access to all of our new educational resources that we have available. Thank you all again, and thank you for joining us today.

Thanks, everyone.