Interview, Podcast
Get Your Sex Life Back! What Everyone Gets Wrong About Sex, Libido & Erectile Dysfunction - Dr Khera
- Definition of "Sexspan": Dr. Mohit Khera defines "sexspan" as the duration a person can engage in satisfying sexual activity, noting that most individuals desire a sexspan that equals their lifespan.
- Sexspan vs. Lifespan Discrepancy: In the US, the average lifespan is 77 years, while the healthspan is 67 years and disability-free healthspan is 63 years; the "sexspan" concept highlights the goal of closing this gap.
- Prevalence of Female Sexual Dysfunction (FSD): Roughly 43% to 48% of women in the US suffer from FSD, which comprises four components: decreased libido, decreased arousal, orgasmic dysfunction, and pain with intercourse.
- Global Premature Ejaculation (PE) Statistics: Premature ejaculation affects approximately 30% of men globally, yet only about 9% of these individuals seek professional therapy.
- Erectile Dysfunction (ED) Prevalence by Age: 40% of men at age 40, 50% at age 50, 60% at age 60, and 70% at age 70 suffer from ED.
- ED as a Predictor of Cardiovascular Disease: ED is often the first sign of adverse medical events; 15% of men diagnosed with ED will experience a heart attack or stroke within seven years.
- Arterial Diameter Theory: Penile arteries (1–2mm) are smaller than coronary arteries (3–4mm), meaning arterial blockage causes ED before it causes a heart attack.
- Clinical Data: A Greek study found that roughly 20% (1 in 5) of men presenting with ED had previously undiagnosed coronary artery occlusion.
- Comorbidities Associated with ED: 66% of men with ED suffer from some degree of depression, and 35% suffer from anxiety.
- Obesity and Testosterone: Obesity is a primary driver of low libido and ED because fat cells contain aromatase (which converts testosterone to estrogen) and secrete cortisol and leptin (which suppress natural testosterone production).
- Weight Loss Impact on Testosterone: The European Male Aging Study found that losing 10% of body weight increases serum testosterone by 85 ng/dL, while a 15% loss increases it by 250 ng/dL.
- Fertility and Obesity: Testosterone is critical for sperm production; the decline in testosterone levels over decades correlates with rising obesity rates, leading to a potential fertility crisis.
- Testosterone Decline Trends: Average testosterone levels in men aged 18–40 have dropped from ~700 ng/dL in the 1970s (Framingham Heart Study) to ~450 ng/dL in 2015.
- Semen Analysis as a Health Marker: Impaired semen analysis predicts higher risks for diabetes (30% increased risk), ischemic heart disease (50% increased risk), and high-grade prostate cancer (2.5x risk).
- VARICOCELE: The number one cause of male infertility is a varicocele (swelling of veins around the testicle), present in 15% of all men but up to 40% of men with infertility.
- Hormonal Drivers of Libido: Libido is regulated by the "PET" hormones: Prolactin (high levels lower libido), Estrogen, Thyroid, and Testosterone (the primary driver for both men and women).
- Neurotransmitter Balance: Dopamine increases libido, while excessive serotonin decreases it; this explains why SSRIs (antidepressants) often lower libido.
- Pornography and Expectation Delta: Excessive pornography consumption can alter expectations, creating a "delta" between expectation and reality that leads to psychogenic ED and reduced libido in real-world interactions.
- Trend in Sexual Frequency: The average number of sexual encounters per year for American adults dropped from 60 (1989–1994) to 50 (2010–2024).
- Treatment for Women (Lack of Options): In 2015, no FDA-approved drugs existed for women; since then, only two have been approved: Addyi (daily pill for desire) and Vyleesi (injectable taken 45 mins prior for desire).
- Off-Label Testosterone for Women: While no FDA-approved testosterone exists for women in the US, clinicians use 1/10th the male dose of testosterone (often via off-label patches) to improve libido, muscle mass, and bone density.
- Testosterone and Depression: A study by Dr. Khera involving nearly 850 patients showed that treating low testosterone in depressed men reduced severe depression rates from 17% to 2%.
- The TRAVERSE Trial (2023): The largest randomized trial to date (5,200 patients) concluded that testosterone replacement therapy (TRT) does not increase the risk of major adverse cardiac events (MACE) or prostate cancer.
- Daily Cialis (Tadalafil) Mechanism: Daily 5mg Cialis is proposed to cure ED rather than mask it by causing smooth muscle hypertrophy and protecting the endothelium (blood vessel lining).
- Clinical Benefit: A study showed patients who stopped daily Cialis after 3 months still retained endothelial benefits compared to placebo.
- Cost: Modern generic pricing has reduced costs to approximately $15–$20 for 90 pills.
- Psychogenic ED Cycle: The "vicious cycle" involves performance anxiety leading to ED, which increases anxiety further; daily Cialis helps break this cycle by ensuring reliable erections.
- Lifestyle "Four Pillars": The most effective non-pharmaceutical interventions are diet, exercise, sleep, and stress reduction.
- Mediterranean Diet: The MedDiet trial showed significant improvements in erectile function in obese men over two years without medication, attributed to improved endothelial function.
- Exercise: 160 minutes per week of moderate-to-vigorous exercise significantly improved erectile function; a cardiac rehab study showed a 400% increase in sexual function in women.
- Sleep: 7–8 hours of sleep is optimal; less than 6 hours significantly increases dysfunction risk, while more than 9 hours shows no added benefit.
- Premature Ejaculation (PE) Definition: PE is defined as ejaculation within 2 minutes, a loss of control, and distress; the average ejaculatory time is 5.4 minutes for men vs. 13.4 minutes for women to orgasm.
- PE Treatments: First-line treatments include sex therapy (start-stop/squeeze techniques) and topical lidocaine sprays; oral antidepressants are used but carry side effects.
- Peyronie's Disease: Affects 9% of men, characterized by abnormal penile curvature (>60 degrees prohibits intercourse); treated with collagenase injections or surgery.
- Penile Implants: The final line of treatment for refractory ED; a surgical implant involving cylinders and a scrotal pump with >92% patient/partner satisfaction.
- Irreversibility: Once inserted, the device cannot be removed without ending all other non-surgical treatment options.
- Communication and Intimacy: Only 44% of men with ED disclose their condition to partners; the primary intervention is open communication and making time for intimacy.
- Local Estrogen Therapy for Women: Post-menopausal women often suffer from vaginal atrophy (thinning walls) and pain; local estrogen therapy (creams/suppositories) restores tissue health and reduces pain/UTIs.
- Trauma and Sexual Dysfunction: Many patients do not disclose sexual or physical trauma initially; sex therapy is often required to address these underlying psychological barriers.
- Non-Profit Initiative: Dr. Khera founded "The Testosterone Project" to advocate for testosterone approval for women in the US and to increase awareness of TRT safety.
- Forward-Looking Therapies: Emerging treatments aim to "cure" ED rather than mask it, including shockwave therapy (to stimulate neoangiogenesis), stem cells, PRP, and hyperbaric oxygen.
- Advice for Couples: Dr. Khera emphasizes that "sexspan" is a couple's disease; treating one partner without addressing the other can destroy the relationship.
- Personal Philosophy: Dr. Khera cites his father's death from idiopathic pulmonary fibrosis as a motivation to "enjoy the ride" rather than delaying gratification, reinforcing the importance of sex and intimacy as part of overall health.