Episode #50 Two GYNs, Real Chat (Part 1) with Dr. Erin Keyser

Episode #54:

Two Gyns Real Chat (Part 2): Let’s Talk About Sex, Baby! with Dr. Erin Keyser

This week, my fellow Board-Certified OBGYN and the director of the Brooke Army Medical Center OBGYN Residency program Dr. Erin Keyser is back for part two of our conversation. Last time, we talked about menopausal transition, hormone therapy, and we scratched the surface of vaginal care in menopause. Today, we’re dovetailing from that conversation and we’re talking all about sex.

When we look at common trends of sexual function, they usually peak at menopause. Changing hormones present some new challenges around sex for women, both physically and mentally affecting our sex drive. So, what are the solutions?

Tune in this week to discover how Dr. Erin and I help our patients understand the sexual dysfunction that generally comes along with menopause, how we treat the physical symptoms, and why medication generally isn’t the answer for a low libido. We’re discussing some practical tips for getting in the mood if you’re a woman with a low libido.

WHAT YOU’LL DISCOVER

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How hormone changes present challenges when it comes to sex during a menopausal transition.

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The difference in how men and women are treated around sexual function.

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Why there is no truth to the idea that you’re too old to have and enjoy sex.

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How we help our patients maintain sexual function as they age.

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Why medication isn’t necessary for most women wanting to raise their libido.

FEATURED ON THE SHOW

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Dr. Erin Keyser

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Episode #50: Two Gyns Real Chat (Part 1) with Dr. Erin Keyser

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North American Menopause Society

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Come as You Are by Emily Nagoski

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Becoming Cliterate by Laurie Mintz

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Addyi® Flibanserin – medication



Vyleesi – medication

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INTRAROSA® – medication



Wellbutrin – medication



JJ Virgin

TRANSCRIPT

Dr. Keyser: We need to redefine that. That it's like I'm sorry, 90% of time your time, men, should be spent on the woman's clitoris and not having intercourse. Not having penetration.

Dr. Crockett: There you go.

Dr. Keyser: So yes.

Welcome to Becoming Virtuosa the podcast with Dr. Susan Crockett. You are listening to episode number 54, Two Gyns Real Chat, Let's Talk About Sex Baby, an interview with fellow Board Certified OBGYN and the director of the Brooke Army Medical Center OBGYN residency program. Please welcome Dr. Erin Keyser.

Welcome to Becoming Virtuosa, the podcast that encourages you to become your best virtuosa self. Each week Dr. Susan Crockett goes where the scalpel can't reach, exploring conversations about how to be, heal, love, give, grow, pray, and attune. For the first time ever, she's bringing the personal one on one teaching that she shares with individual patients to you on this broader platform. A weekly source of inspiration and encouragement designed to empower you.

By evolving ourselves as individuals. We influence and transform the world around us. Please help me welcome board certified OB-GYN specializing in minimally invasive GYN surgery, internationally in the top 1% of all GYN robotic surgeons, a certified life coach, and US News top doctor, your host Susan A. Crockett, MD.

Dr. Crockett: We have my amazing guest, Dr. Erin Keyser, with us today from Brooke Army Medical. We are two OBGYN in San Antonio, Texas. What could go wrong? What could go wrong with this conversation? What could go right? We're going to talk about sex you guys. This is going to be really fun. Hang on, hang on to your hat. So we're calling, what are we calling this?

Dr. Keyser: Let's talk about sex.

Dr. Crockett: Let’s talk about sex. So if you haven't seen part one, I'm going to have you go back and listen to part one. We're not going to do a whole big introduction again. But basically Dr. Keyser runs the OBGYN residency program at Brooke Army Medical Center. I proctor her residents. I work as one of their local nonmilitary physicians, and they come and learn surgery for me, robotic surgery. So that's how we know each other. You've got a little disclaimer.

Dr. Keyser: Oh, yeah. So I am in the military. So I need to say that the views expressed today are of mine and not of the military or the Department of Defense or any of those things.

Dr. Crockett: Yeah. Neither one of us have any skin in this game about any of this. We're not selling any sex products. Promise that's not the way my GYN practice runs. I have friends who do.

Dr. Keyser: We’re probably going to use real terms because I remember my husband’s not medical, and the first time we were like out to dinner he's like you just can't be saying vagina all the time. I'm like, really? Why not?

Dr. Crockett: That’s just a normal word.

Dr. Keyser: So we might be using a lot of terms.

Dr. Crockett: Yeah. Because we're doctors, we're going to use the regular terms. We're not going to throw in hoo-ha. I can't say that.

Dr. Keyser: No. No. We're going to use vagina and vulva and clitoris.

Dr. Crockett: Okay. All right. So we are kind of dovetailing this conversation off of the prior one that we just had, which is about menopause and menopausal transition, hormone therapy. We kind of got a little into taking care of the vagina as we go through menopause.

Dr. Keyser: Well, I think it's a good segue because when we look at the incidence of sexual dysfunction, it usually peaks at menopause, right? As hormones are changing, that's kind of the time when sexual dysfunction and women kind of peaks. So they do kind of correlate together.

Dr. Crockett: Yeah, so we get vaginal dryness. So it becomes painful. We get fatigue so we don't have as much libido. We're not sleeping as well. We're hot and sweaty. Hot flashing anyway.

Dr. Keyser: Not feeling super sexy.

Dr. Crockett: Not feeling super sexy. Yeah, so it's peaking about this midlife time.

Dr. Keyser: I mean other big times are like postpartum, right, because you're sleep deprived from having a baby at home, and you're breastfeeding, and you maybe just had a tear. So yeah. That's another time where, like we see a lot of sexual dysfunction.

Dr. Crockett: Yeah. Then our male counterparts, for those of us that are in heterosexual relationships, they're also seeing testosterone decreasing. But from my side of my practice, I'm seeing a lot of women coming in with their partners being on more testosterone and Viagra and all of these enhancers. They're like give me something.

Dr. Keyser: It's a sad state of affairs. I mean, there's like, I think, over 100 FDA approved products for men sexual dysfunction, and there's like two for women. It's a very unfair market out there. Yeah. It's like we need to pay attention to women's sexual function. Yeah.

Dr. Crockett: Yeah, we do. So that's what we do.

Dr. Keyser: Yeah.

Dr. Crockett: So you do more on the hormonal side because you're one of the Menopausal Society people. We'll link that here like we did in the other one. For me, it's more surgical. They come in needing surgery for uterectomy, that's what we're calling hysterectomy now. Or they have prolapse issues, bladder issues, and I'm doing reconstruction to fix it. They're like how can I maintain sexual function?

Dr. Keyser: Yeah. Is this going to change my ability to have sex?

Dr. Crockett: Yeah, so that I pay attention to that. Even, it used to surprise me when patients that were in their upper years, 70s and 80s, were concerned about that, but now I just expect it. Everybody gets the question asked about what this is for priority for them. There is a way more sexually active octogenarian, is that how you say it, population, people in their 80s than I ever would have imagined when I was just starting my practice.

Dr. Keyser: Well, I hope when I'm 80, I'm still having sex.

Dr. Crockett: Right? That's a lovely thought, isn't it? So tell me a little bit about how you handle patients coming in during this time.

Dr. Keyser: Yeah, I feel like there's been a big push maybe in the media. I definitely feel like there's a lot more patients coming in with low libido or saying they have no desire, and they want a pill for it. Right? Or they want like a magic pill. I think it's really common. I think if you take all comers, probably 60% of women would say they have less desire than their male counterparts or their men.

I think there's a small percentage of people will probably actually have like a true pathologic or physiologic issue. I think, just in general, women and men’s sexual drive and sexual desires just are very different. Like men, it's a very linear thing. Like they might see a magazine or a bra and they're horny. Women, it's like most women are not just like horny every day. They're not the Samantha on Sex in the City thinking they're like they want to have sex all the time.

Dr. Crockett: You know, I heard somebody talking. It may have been a podcasts I recently heard. I'm sorry, I can't remember who it was right now. But they were talking about that men have just that direct like sight to desire. Women have two different levels of arousal. One of them can be that sight to arousal, but the other one is much more subtle and takes time and thinking about it, pondering it, going over and over it, and feeling safe. That was a really big thing.

Dr. Keyser: Yeah. Because if you think about, you're like well, do I want to have sex? Well, was my partner helpful? Did they help with the chores or the dishes? Are my kids home? There's so much like kind of supratentorial like, in our heads. We have to feel safe. We have to feel like respected. We have to feel, you know, if I'm feeling overweight or fat or whatever, I'm not going to feel sexy.

So there's so much more than like, you have to feel self-confident. You have to feel respected and safe by your partner. I mean, there's so much that goes into it. So there's no like magic pill. People can take Viagra. I'm like well Viagra gets the man an erection and gets blood to his penis, but it doesn't actually make him horny. Like, it just allows him to have an erection.

Dr. Crockett: It's just supporting the horniness he already has with the end organ function.

Dr. Keyser: Yes.

Dr. Crockett: There you go.

Dr. Keyser: Some people are like oh, I can take Viagra, but it's like well this doesn't really work. So there are some medications that have come out that are FDA approved. There's some that are non-FDA approved and supported by different organizations. But most of the time, I would say for the majority of women, they don't need medication. That simple things like communicating with your spouse. There's a great book written by a sex therapist called Come As You Are. C-O-M-E, come as you are.

Dr. Crockett: I love that.

Dr. Keyser: She talks about how everyone has accelerators and brakes, right? In general, like for generalizing, men have more sensitive accelerators, right? They see a bra, and they're like oh. Women tend to have less sensitive accelerators and more sensitive brakes. So you need to identify what are your accelerators? What gets you excited? What are your brakes? Not just identify them, but then share that with your partner, right? So like, for me, I have two boys at home. If my boys are home and I know they could walk in, huge brakes for me.

Dr. Crockett: Yeah, that would be big brakes.

Dr. Keyser: So now it's like my husband and I joke, we're like hotel sex. Or like the kids aren’t home because we’re like no one’s going to walk in. The brakes are gone. So like, my husband is not like oh, she's not attracted to me anymore. She doesn't want to have sex with me. It's like no, I know now that when the kids are home, she's just like that's a turnoff for her. So just be able to communicate that.

Then the other thing is like sometimes just reading erotica. Sometimes it's as simple as that. Reading, watching a movie. It doesn't have to be like hardcore porn, but just like a little bit of erotica. I even think like Colleen Hoover, some of these other ones just like really subtle, but it's like enough that sometimes that's all it needs.

Dr. Crockett: To get the brain going on that pathway. It just needs the little thinking about it. You know one trick that I had heard a long, long time ago that I've used in my practice is planning it ahead of time so that like the day before you plan time with your partner. So the partner is already looking forward to it. But for the woman, it's especially important because then she starts thinking what am I going to wear? Where's it going to be? The thought, that is the same kind of idea that the brain starts focusing on it and gives that longer warmup that we need to anticipate and be able to enjoy it.

Dr. Keyser: A lot of women, a natural response for them is like, a lot of women they're not like I'm horny. I want to have sex. It's like once we get going and we're doing foreplay, then I'm into it. Then I love it. Right? If that's for you then sometimes it's like you know what? You might just need to do it.

I use that the gym analogy a lot with my residents. Like they make fun of me, but I'll tell patients if it's like once you get going and you enjoy it then you’re able to have an orgasm. You're like oh, now I feel great. I have those endorphins.

Sometimes it's like going to the gym. I'm not one of the people who loves to go to the gym and exercise. I exercise because I have to pass my army fitness test. So like, every morning alarm goes off, and I'm like I don't want to go, but I put on my tennis shoes and I go the gym. Afterwards, I'm like I feel amazing. I'm going to do this every day.

Then what happens the next day? You're like I don’t want to go. So sometimes it's like you’ve got to go to the gym with your partner twice a week or once a week. You just got to like put on your big girl panties and be like I'm going to go to the gym.

Dr. Crockett: You know what? I'm glad you brought that up because I've used that for a long time with my patients to help differentiate when they're having sexual dysfunction versus just this kind of midlife, not the horny 20 year old anymore kind of thing. The vast majority of time they'll say oh, no. It's good once we get going. I'm like okay, that doesn't need a medication.

Dr. Keyser: Exactly.

Dr. Crockett: There's not a medication that can fix that.

Dr. Keyser: Yeah.

Dr. Crockett: So some of the medications that I manage in my office with my patients include vaginal estrogens for atrophy. We do a little bit of testosterone, although that's not my favorite thing. I don't prescribe testosterone very often. I wanted to know your thoughts about those along with any others.

Then DHEA has an adrenal for helping with testosterone or any other things like that that are non-testosterone things that help stimulate our androgen production from our adrenal glands once our ovaries aren't working anymore.

Dr. Keyser: Yeah, so there are two FDA approved medications for low libido or hypoactive sexual desire disorder.

Dr. Crockett: In women.

Dr. Keyser: In women. Yes. I really don't love either of them, but one is called Addyi, A-D-D-Y-I.

Dr. Crockett: We’ll put that down in the show notes.

Dr. Keyser: Sure. That is a medication you take once a day. So you take it daily.

Dr. Crockett: What did you say the name was?

Dr. Keyser: Addyi.

Dr. Crockett: Flibanserin.

Dr. Keyser: Flibanserin.

Dr. Crockett: Flibanserin.

Dr. Keyser: Flibanserin, F-L-I-B-A-N-S-E-R-I-N.

Dr. Keyser: Okay, that's a good one.

Dr. Keyser: Flibanserin. So it's a pill you take daily, it's a daily medication. Really, in studies it like led to like maybe one more satisfying sexual encounter a month. You have to limit alcohol because it lowers your blood pressure. So you can't take like a second downer. So I know when it came out, I was like I think I'd rather drink than have sex. So that’s one.

Then the other one is Vyleesi, which is it's an injection. So it's like an autoinjector sub-Q that you take, I think, like an hour before your anticipated sexual encounter. So that one was more, but I also think there's probably a little bit more placebo in there because like if I just gave myself a shot like we're doing it.

Dr. Crockett: I went to all this effort.

Dr. Keyser: I went to all the effort. I gave myself a shot. So that one, but that one's more like Viagra, right? Like you take it right before you plan to have relation whereas the other one, you're like taking it just daily and hoping things change, you know. So those are the two FDA approved. I don’t know how great they are.

But I totally agree. Vaginal estrogen. I think anyone going through menopause and has any vaginal dryness, without that estrogen, you lose that elasticity, I think, easy.

Dr. Crockett: Now, I don't know how you do it, but I usually have my patients use a bioidentical esterase cream or estriol if they're breast cancer survivors. I have them do three weeks of daily so that it rehabs the skin. We talk about that like that's what it takes to get the skin to respond with the increased blood circulation and increase the elasticity.

Then I teach them about starting to do stretching exercises or dilators or to have intercourse with, yeah, with. Then they go down to just using, most of the time they can get by with just a small pea sized amount at the vaginal opening without having to use the whole applicator up inside thing. They just do it like two or three times a day, a day, a week.

Dr. Keyser: A week. Yes.

Dr. Crockett: For maintenance.

Dr. Keyser: Yeah, that's exactly what I do. I usually ask them. I'm like there's basically comes, it can be a cream, it can be a tablet, it can be a vaginal ring. I usually kind of feel out their preference.

Some people like the idea of the vaginal ring because then they just leave it in for three months. They don’t have to think about it and worry about like twice a week. Did I already do it this week? You know? Other people feel like the cream might be messy. I mean, everyone's different. So I just kind of asked them which of those they want.

Dr. Crockett: Awesome.

Dr. Keyser: But then there's, so there's a two FDA approved. Then there's several non-FDA approved medications for sexual dysfunction that are supported by like the American College of OBGYNs and the Menopause Society. So I feel like those are reasonable things to try. But, again, I think 90% of women can be fixed by just what we talked about, like communication and recognition of some of these things.

But if is really affecting their quality of life, there's some other options. So Wellbutrin is an option. It's an antidepressant, but it's also been used for like nicotine addiction.

Dr. Crockett: Yeah and over eating.

Dr. Keyser: Yeah. So Wellbutrin has been shown to improve sexual desire. So that's one. The base medication that is associated with sexual loss of sexual function is SSRIs or the antidepressant. Yeah, so like Zoloft, Paxil, Lexapro, in men and women. So, if you have SSRI induced sexual dysfunction, and you can't stop it because we need to treat your depression, you know. I mean, mental health issues is probably the number one thing associated with sexual dysfunction as well.

Dr. Crockett: Right.

Dr. Keyser: So you got to treat that to you can add Wellbutrin to it. There's also been a study that showed taking Viagra, if it's SSRI induced sexual dysfunction, you can use Viagra. I think it's like you take it 30 minutes before your planned thing, and it's supposed to help.

Dr. Crockett: I did not know that.

Dr. Keyser: Yeah, so that's listed as like a non-FDA approved option.

Dr. Crockett: That’s cool.

Dr. Keyser: Then the last one is testosterone. So testosterone, the Menopause Society and ACOG support it in postmenopausal women. So not premenopausal women, but in postmenopausal women. Unfortunately, there's not an FDA approved version for women. So we have to use a compounding pharmacy because it has to be made, basically, like 1/10 a dose of what men use. So it's the 1% testosterone cream. You're supposed to do it to like point five milligrams daily I think is what the dose is, but I know HEB has compounded it for my patients.

Dr. Crockett: Yep. I have a couple transgender patients who have gone male to female. So they're in menopause as women. They've done some depo-testosterone injections that are also compounded. So I see patients asking for testosterone for a couple reasons. One is just the libido idea, but I was always taught that it only helps in like less than 50% of people. It's not like a sure thing.

Dr. Keyser: Yes. Well, I mean, I can give you enough testosterone to make you as horny as like a 12 year old boy in a locker room, but you're also going to grow beard.

Dr. Crockett: You're going to have a lower voice.

Dr. Keyser: You're going to have a deep voice, and your clitoris is going to enlarge, and you're going to probably have a heart attack and a lot of issues. So it's like you need to just get a small amount. So before you start it, you need to check your cholesterol. You need to check to testosterone levels. You need to check your renal function. You need to check all these things, and then trial it for six months, follow those labs making sure it's not harming you. Then if it's helping, you can continue it. But if it's not, then you probably should stop it.

Dr. Crockett: So the other reason I see people wanting it, women in menopause wanting testosterone, is for maintaining muscle and metabolism because our metabolism starts shifting. I heard a physician on a podcast the other day making the point that women are not just like men. Menopausal women are not men. We are not the same, even in menopause.

In fact, men have a dip in their testosterone, but then it creeps up as they get older, into their 70s and 80s. There is no such thing in women, and we have a drastic stop or gonadal function. Our ovaries just quit working. That's what menopause is.

Dr. Keyser: Sometimes I wonder too like the benefits that are seen from the testosterone. Is it the testosterone, or is it the estrogen? Because I don't know if everyone knows it like testosterone in women is converted to estrogen in your adipose tissue.

Dr. Crockett: In case you didn’t have enough in your adipose tissue alone.

Dr. Keyser: So I find it funny. They're like I want testosterone. Oh, I would never take estrogen. I'm like well, that's what you're taking. So it's like would the estrogen itself help with your muscle tone and all that stuff that we talked? I mean, I don't know.

Dr. Crockett: Yeah.

Dr. Keyser: I mean there is some evidence that like the hormones improve weight in women, menopausal women. So I'm like is that or I don't know.

Dr. Crockett: I'm being my own experiment here. I'm starting to do more weight training, less aerobic exercise. I've been watching some JJ Virgin videos about how she's managing. She's a nutritionist that's popular online. She recommends using creatine monohydrate for muscle building. None of this has anything to do with sex other than maintaining muscle tone may make it more, you know, easier to do it longer.

Dr. Keyser: The whole self-confidence, right? You have to have a good body image to feel comfortable, right? If you don't feel comfortable in your own skin and you don't find yourself beautiful, like how do you expect your partner, you know?

Dr. Crockett: Yeah.

Dr. Keyser: It's like your self-talk.

Dr. Crockett: It's a pretty physical activity.

Dr. Keyser: That too.

Dr. Crockett: It is the ultimate physical activity. So I think as women age that keeping the muscle tone to be able to still be fit and like how we look is an important thing, but it's also sustainability of our function. To be able to.

Dr. Keyser: Yeah. And for your bones. I mean osteoporosis, bone health, I mean having, continuing to do like weight bearing exercises is so important.

Dr. Crockett: Yeah.

Dr. Keyser: So you mentioned the other testosterone, the other androgen. So the other male hormone that women produce is the one from the adrenal gland, the DHEAS, dehydro, I'm not trying. But there is that medication. It's called Intrarosa, and it's FDA approved for painful intercourse due to atrophy.

But what's interesting about Intrarosa is the initial studies, which was not the suppository, it was like a cream, was looking at desire because it does have an androgen in it. It actually showed improvement. But then when it went for FDA approval, they just got it approved for the painful intercourse. So I do think it has the potential to also help with desire.

Dr. Crockett: Cool.

Dr. Keyser: It's like a daily suppository that you place vaginally, and it's that. But, again, I think it helps the vagina because it's converted to estrogen.

Dr. Crockett: Yep.

Dr. Keyser: But does the androgen also help with desire? Maybe. I mean, so all of those are reasonable options that you can try.

Dr. Crockett: I think we've gotten to the end of this topic.

Dr. Keyser: Yeah. But I think one other key point I just want to say is a lot of it is trial and error. Whether it's with the hormone therapy or with treating sexual function, like you maybe found a hormone patch that you feel great on. But like someone else may need to try three different types to see which one they have the least side effects with and which one feels best for them. So sometimes it's like trial and error and just being patient and trying different things.

Dr. Crockett: I think that's true. You know, thought of one more thing I want to bring up.

Dr. Keyser: Yeah.

Dr. Crockett: So this was conversation in the operating room yesterday. It was a good day in the operating room. So we were talking about men taking testosterone and how there's such a drive now for men to be on testosterone in their 50s and 60s, and that the natural decrease in their sexual activity or libido that used to mirror more than women's declining and drive is now being overridden by these guys who are really heavily on testosterone.

So all of a sudden, this is the norm that they're pushing is that there's something wrong with our female patients, or with us as women, if we're not like meeting them at that expectation. Which is to continue like 20 year olds up into their 60s.

I just wanted to kind of talk a little bit about that because I see it as having created problems with how my patients are seeing themselves and their own sexuality. Is there something wrong with me?

Dr. Keyser: Yeah, and I think a lot of the TV and the media, like they push out that we're all supposed to be super horny. I mean, they also push out that intercourse is the be all for women when it's actually like the clitoris is where women are going to orgasm from.

Dr. Crockett: Thank you.

Dr. Keyser: That's usually not touched during most people having intercourse. So most people are not going to orgasm during sex at the same time as their partner. Like that's not reality, but that's what the TV and movies show. Another great book, clitoracy Becoming Clitorate.

Dr. Crockett: I love that title.

Dr. Keyser: But it was all about how like we need to redefine that. That it's like I'm sorry. 90% your time, men, should be spent on the woman's clitoris and not having intercourse. Not having penetration.

Dr. Crockett: There you go.

Dr. Keyser: So yes. So I also think if you know you're not going to orgasm because your partner just wants to have penetrative sex then I probably wouldn't want to have any desire either. You know? It's like that's part of the whole libido desire is like I want to enjoy it.

Dr. Crockett: Yeah. Yeah, lots to unpack here. Thanks for.

Dr. Keyser: So many things.

Dr. Crockett: So many things. Thank you so much for joining me for sexy talk today.

Dr. Keyser: Let’s talk about sex.

Dr. Crockett: Let’s talk about sex. It was awesome. Thanks for having a good time with us on the show.

Dr. Keyser: Yeah, thanks so much.

Dr. Crockett: I hope you come back another time, and we'll find something.

Dr. Keyser: Find something else fun to talk about.

Dr. Crockett: Thanks you guys. We'll see you next week. Have a wonderful week.

Thanks for listening to this episode of Becoming Virtuosa. To learn more, come visit us at DrCrockett.com, or find us on YouTube for the Dr. Crockett Show. If you found this episode helpful or think it might help someone else, please like, subscribe, and share. This is how we grow together. Thanks, and I'll see you next week. Love always, Sue.

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