Timeless Intimacy® Podcast

Timeless Intimacy®

Hosted by Dr. Edward Tangchitnob

Listen to the Timeless Intimacy® podcast here!

Transcript: 

Dr. Edward T.: Hormones or chemical messengers are created by the body for the intent of communicating to a different portion of the body. Historically, we've thought of hormones as something that's bad because of either bad press release or information in the media that has been misconstrued. But ever since we were young, hormones have been created from our body for the sole purpose of maintenance and for function.

Dr. Edward T.: Can't live without them. It's very unfortunate I think that we are now as a society, we say unfortunate, unfortunate that we're living past our hormones now. If this was the 1600s, I mean, we would essentially not even be alive after the age of 30, but now we're living past our hormones. So I think as a society, we are now seeing the effects of what happens when the hormones run out. We're seeing cardiovascular disease. We're seeing issues with depression, which is really, a lot of times, a reflection of hormones running lower in your body. In our case and in our practice, we specialize in a lot of female intimacy, receiving issues with intimacy, both in the women and the men.

Dr. Edward T.: So to say that hormones are unimportant is complete oversight. I mean, hormones are everything. They really determine how we feel. They determine body function, and being as such, I think it's important that the first chapter in the book talks about hormones and what they are.

Dr. Edward T.: I like to start right from the top with testosterone. When I think of testosterone, I think of it as the get-up and go hormone. It's the hormone that makes you kind of want to get up and go in the morning. It gives you drive to go out, live life, seek intimacy. We think of the word libido or desire for intimacy. Well, that's mediated by hormones, by testosterone. A patient of mine once told me... Actually, when I was trying to talk to her about hormone replacement, I remember she was her early 40s, and she said, "I don't want that male hormone. I mean, I don't want to turn into the incredible hulk or grow hair all over my body. That hormone is for men." I asked her a very simple... I asked her if at 21 she felt manlike in any way, and she said, "Actually, that was the time I felt the most alive. I felt very sexy and attractive." I disclosed to her that, "Well, actually that's the time that testosterone is the highest in your blood."

Dr. Edward T.: It was that simple understanding I think for my female patients that once they understand that when testosterone is highest, they feel they're most attractive, they have libido, they have energy, and they have the ability to basically seek activity both physical and sexually that the conversation of testosterone begins. Another way I explain testosterone is that it can also help with libido, and whereas in the beginning when you... I had a patient best described as, when I would come home, before I sought out to social in place, when I'd come home, I'd see my husband like, "Who is this guy? Why did I marry him?" Then you replace the testosterone, and she comes back and says, "I remember. You're looking kind of good right now."

Dr. Edward T.: So that's a very simple explanation of what testosterone makes you feel. It doesn't make you feel really sexual when it's replaced, but it's very important for energy. In some cases, it can also mediate pain. So one of the original medications for endometriosis was a modified testosterone called Danzen that can actually have an anti-inflammatory effect. Testosterone could also affect mood. Many of the patients are coming in with this time who are on a low dose SSRI are often question how long they've been on it for, and when they start describing the symptoms that led them to be prescribed the SSRI, the serotonin selective reuptake inhibitor, they say it's because they have no desire in sex. They don't want to go work out. They don't want to leave the house. I asked him very simply if they've had their testosterone checked over, and many of them will say no. So in our practice, we actually have a protocol to slowly wean patients off their antidepressants as long as they are... as long as we are looking at their testosterone. So testosterone is very, very important hormone.

Dr. Edward T.: Next on the list is estrogen. In our practice, we try to assign patients a hormone a week. You learn a hormone a week until you kind of understand all the hormones. Estrogen is very important too because estrogen traditionally now is considered to be the female hormone. But again, men have estrogen too, and we have to have estrogen in a certain number, a certain range to be optimal, and estrogen is very important for vasomotor symptoms. So lack of estrogen could cause patients or women to undergo hot flashes. They could get mood changes to some degree in correlation with testosterone and is also responsible for determining the quality of certain tissues, particularly the vaginal mucosa.

Dr. Edward T.: So when you talk about the vaginal epithelium, the vaginal mucosa, that lubrication coefficient in part is determined by how much systemic estrogen is in your body. As estrogen begins to decline, women will often cite that they have pain with intercourse, it's very painful, it feels very dry. At the same time, if not kind of leading up to that period, they also start to complain, chief complaint of urinary continence, feeling or having the sensation that things are falling, things are sliding because estrogen does have the ability to maintain the collagen and elastin fibers that are responsible for the system down below. Estrogen also is cardioprotective. It can help protect the heart. There's aspects of estrogen that you cannot see, but for most women coming in when they're kind of what we call the estrogen dominant type, estrogen deficient dominant type presentation, they usually complain of the vasomotor symptoms, the hot flashes, some mood changes, issues with sleep, they have insomnia. Some patients will complain that they can fall asleep but can't stay asleep. Some patients can fall asleep or stay asleep but have trouble falling asleep.

Dr. Edward T.: So those are all estrogen-mediated complaints as well. Estrogen can also affect our feeling or women's feeling of mental clarity. So that's also another estrogen-mediated symptom. Overall, estrogen is essential and traditionally has been considered the female hormone, although, in some regard, the men also have to have an optimal estrogen.

Dr. Edward T.: Another hormone.

Dr. Edward T.: Next hormone that's often overlooked is thyroid. Thyroid is critical for the body's function. In fact, thyroid can determine the basal metabolic rate or how fast your body performs. That's the way I explained to my patients. Two parts, we look at the TSH, which is often the classic way doctors look at thyroid, the thyroid stimulating hormone. It's very confusing to patients because when the doctor tells the patient that your thyroid is low or high, they don't always tell the patient whether they're referencing the TSH or not, and so the patients are always leaving the practices not understanding whether thyroid low, high or is normal. A common category that I'm finding are patients now is sick euthyroid syndrome in which the patients have normal lab values, that is the lab values are all within a predetermined reference range of the labs, but they don't feel normal.

Dr. Edward T.: So what I mean by that is these patients are coming in with low energy. They have cold intolerance. They had brittle nails. They're losing their hair. These are symptoms of a low thyroid. You could also have too high of thyroid in which you actually have the opposite. You could have GI symptoms. You could have diarrhea. You could have GI upset. You could have heart palpitations, again, the thyroid, and there are many different receptors throughout the entire body for thyroid, including the heart, parts of the brain, the female genital tract also has thyroid receptors in it. So thyroid is also extremely important in terms of determining intimacy performance.

Dr. Edward T.: So when we look at thyroid, I think the most important marker, my professional opinion, is really looking at the free T3 and optimizing that to above four. That whole point could be made into a whole book by itself is to talk about thyroid. But in terms of optimal intimacy performance, I think thyroid needs to be looked at and kept to be optimal.

Dr. Edward T.: The next hormone is prolactin. So we don't always think of prolactin as an important part of intimacy, but we also certainly don't want to miss a prolactinoma in the brain. So if the part of the basic hormone [inaudible 00:10:47] it's traditionally drawn includes prolactin, if the prolactin is several standard deviations above mean, it's worth looking at other causes for that. Now, particularly in the brain, there can be a space-occupying mass or lesion that could push on a portion of the optic chiasma or the portion of the brain that is very nearby where these hormones are produced causing downstream the release of prolactin. This can actually inhibit or interfere with orgasm or intimacy.

Speaker 2: Or even libido, right?

Dr. Edward T.: It could also inhibit libido.

Dr. Edward T.: Correct.

Speaker 2: It's the hormone that men make when they ejaculate. So that tired, sleepy, want to go to [crosstalk 00:11:28]-

Dr. Edward T.: The refractory period. Absolutely.

Dr. Edward T.: Correct.

Speaker 2: Not so good. Okay. Keep going.

Dr. Edward T.: When that's often missed. The next hormone is oxytocin. Now, oxytocin is really known as the love bonding hormone, and this is released generally after orgasm. It gives you this sense of bonding or compassion between the two partners, and men and women actually release this post-orgasm. I suppose Mother Nature's created this system in such a way that there is a sort of refractory period after having intimacy for the purpose of couple bonding. So that's oxytocin really in a nutshell. Oxytocin can also be given exogenously. It can be given orally to promote this feeling of couple bonding. Those are kind of the... That is kind of the generalized approach to looking at hormones with regard to intimacy and optimizing intimacy.

Dr. Edward T.: I have. Yes. Absolutely.

Speaker 2: Okay. Good. So you already mentioned that too. Okay. So alright. Did you talk about progesterone yet?

Dr. Edward T.: Progesterone will be next. Yeah.

Dr. Edward T.: Next hormone to be looked at is progesterone. Progesterone is also one of the feel-good hormones. I'm particularly interested in progesterone as a gynecologist because many of the patients coming in really reflect progesterone issues. What I mean by that is when I look at my younger patients who have say an ovulatory cycles, whereas they are not releasing eggs every month, they actually are lacking progesterone. Because they're not releasing eggs, they never complete the menstrual cycle. So they come in with abnormal uterine bleeding, all sorts of hormone imbalance presentations, and just simply giving them the birth control pill that has progesterone in it could help alleviate a lot of their issues. With women who are perimenopausal, almost at the other end of the spectrum, where they are starting to have ovarian failure, so their ovaries are beginning to give out, they also are lacking progesterone. They start having sleep issues. That's a big one, sleep issues, insomnia. They also have abnormal uterine bleeding for a similar but different reasons.

Dr. Edward T.: So for this group of patients, just simply giving them or prescribing them oral progesterone, micronized progesterone 200 milligrams every night makes them fall asleep. They achieve sleep better. They just feel happier, and it helps with their abnormal uterine bleeding. So progesterone is something that's very important, and the decrease in progesterone really signifies a instability of the ovarian function. The body, particularly the female endocrinologic system likes more steady state in terms of hormones, and so when there is a decline or there's a change in the steady state of hormones, problems ensue. Progesterone is a great example of that. The lack there of progesterone could really affect the female intimacy portion of their lives.

Dr. Edward T.: So testosterone levels have the... Okay. Women who are on the birth control pill actually end up increasing the sex hormone binding globulin portion of the bloodstream. And what I mean by that is as women take the combined oral contraceptive, which has estrogen and progesterone in it, it causes the liver to increase the release of sex hormone binding globulin. Now, this molecule ends up going through the bloodstream and mopping up free testosterone, and we talked about how this is an issue earlier. With declining levels of testosterone, there's actually a decrease in libido. This does not happen to all women, fortunately, and sometimes we joke in our practice that the birth control you're going to take probably has two different effects, right? It decreases the rate of ovulation as well as decreasing your interest. So yeah, it almost serves as a dual birth control effect.

Dr. Edward T.: But that being said, in my practice, I take care of a lot of polycystic ovarian syndrome patients in which they have almost too testosterone. By nature, they have a hormone imbalance presentation. We use the oral contraceptive to decrease the testosterone in order to decrease their facial acne, their hirsutism or their facial hair, and many of these symptoms that are associated with a hormone imbalance state with too much free testosterone.

Dr. Edward T.: Well, with this patient, I will go back and forth on several different kinds of oral contraceptives. We might try to go to a continuous route in which they skipped their cycle. We will off-label draw their total testosterone. Some of my patients who want to use the oral contraceptive because they deem it as a benefit but then still want to have that higher libido, we will also do testosterone pellets, so almost do a combination-

Dr. Edward T.: ... almost a combination therapy.

Dr. Edward T.: You take away the birth control pill.

Dr. Edward T.: Which, in our practice, we do a lot of pellets. So by the time they decide that, the pellets would have already worn out.

Dr. Edward T.: Exactly.

Dr. Edward T.: Not many do, actually. Then-

Dr. Edward T.: ... they don't.

Dr. Edward T.: Correct.

Dr. Edward T.: So vitamin D, it's one of my favorite vitamins. It works more like a hormone. If you look at the levels that are determined for normalcy, generally speaking, we think of a vitamin B more than 20 is sufficient. But that really has been established years ago, centuries ago, when that was the very minimum so that you would not have rickets. But I haven't seen or we haven't seen rickets in the community for centuries now. So to have a vitamin D threshold of 20 doesn't do anyone any service. So vitamin D serves as a co-factor for many of the biochemical processes of the body. It can also be involved in the bone metabolism, so it's very good for bone health.

Dr. Edward T.: It's also involved in mood, energy. In general, we in our practice like to see the vitamin D over 70. We think that's an optimal number. There are many sources of vitamin D not being said. Much of the food nowadays is devoid of iodine vitamin D, and many of our patients when they're seeking a optimal intimacy experience end up supplementing with a nutraceutical grade vitamin D to get their vitamin D up to 70, not just 20.

Dr. Edward T.: So in conclusion, hormones are extremely important part of how we feel as human beings and how we function in terms of the body. With regard to intimacy, the lowering levels of hormones with every decade of life truly have a impact and have implication on intimacy and desire for intimacy, and to that regard, also intimacy function. We've kind of touched upon the fact that estrogen, for example, helps maintain the integrity of the vaginal mucosa and the lining, and when these hormones begin to decrease, we are also seeing a correlation with the lack of desire for intimacy as well as the comfort of intimacy itself. So in the next... Sorry. So maintenance of these hormones in optimal and not normal levels are going to be critical for having a timeless intimacy experience in which intimacy and sex is both pleasurable as well as desired.

Dr. Edward T.: So if you're interested in having your labs looked at or a listing of all the different hormones that we just talked about in this chapter, you could go to www.tangchitnobmd.com/hormones.

Dr. Edward T.: Okay. So when we talk about having optimal intimacy-

Dr. Edward T.: Yeah. Yeah.

Dr. Edward T.: When we talk about having optimal intimacy, there's an anatomical component to this issue. It's very easy to see on a woman's face as she ages the wrinkles and the loss of volume in her face. It's almost undeniable that as you get older, you could recognize an older face from a younger one just by virtue of the loss of volume that occurs. Very easily, you could say a women's face is beginning to lose volume or sag. The same process actually happens down below. It's just not as apparent. Now, when we talk about the phrase or the term uterovaginal prolapse, what we are really referring to is the fact that as the hormones begin to decrease in the body, particularly estrogen and testosterone, these hormones that once held up ligaments and tissue quality, that held up the bladder, the uterus and parts of the tissue that hold up the rectum and the small bowel space that prevents a enterocele begin to change.

Dr. Edward T.: One of the possible ways of treating this, actually a very common way is to insert a space-occupying pessary that actually comes in different shapes, sizes, blocks, and this can hold up the uterus and parts of the bladder that are falling to some extent. It's very inconvenient to the sense that women have to come back at least once every two to three months for cleaning. These pessaries are made usually with inert silicone material, but as such can become kind of infected, could change the pH and the flora intra-vaginally, and it needs some kind of cleaning. They're different shapes, like a Gellhorn pessary to a classically described cube that could hold up the prolapse symptoms, but as you can imagine are not very conducive to sex because if you cannot take it out or on some shapes that are not amenable to taking out, you cannot have sex.

Dr. Edward T.: In terms of other possibilities, you can use physical therapy to actually help with some of the prolapse symptoms. But beyond a grade one or very, very mild grade one prolapse, the tissue and the musculature of that area have gone beyond just physical rehabilitation. So we talk about, for example, kegels muscles, but really the kegel exercise itself just works out the urethra and does nothing really for the tightening of the vaginal vault, which is involved in intimacy. We talk about surgery. I like to counsel patients on the different approaches to surgery starting from outside in for patients who come in for primarily the complaint of having their labia minora. There's two parts to the labia. There's a labia majora, which is on the outside, and the minora, which are classically described as the lips, but different complaints will ensue.

Dr. Edward T.: For example, I have a patient of mine who comes in, and her left labia is much larger and longer than her right. She's a horseback rider. So every time she does horseback riding, she has pain because that left labia would come out, and she would sit on, and it was very, very painful for her. So a possible surgical procedure is to perform a labiaplasty depending on the degree to which we address or trim the labia, you could trim it all the way down below the base of the labia majora. I was trained by a Dr. Red Alinsod, who has pioneered many of the novel approaches associated or novel approaches for performing labioplasty, a rim appearance to the labia in which just a portion of the labia that's protruding the most is trimmed or a combination, which was actually one of the most popular approaches in my practice, a hybrid labiaplasty.

Dr. Edward T.: After this predetermined amount of labia's, cut what we call the labiaplasty, we then close the labia with stitches. We use a combination of monocryl and vicryl stitches, which are absorbable suture, and that really constitutes labioplasty. It's important to make the designation. This is just an outside approach to genital surgery or intimacy surgery and is really part of the timeless intimacy protocol or the assessment rather because many patients have intimacy issues just from the labia being either too long or asymmetrical that really bothered them.

Dr. Edward T.: Kind of moving on up, a vaginoplasty is a modified, what we call classically described anterior-posterior, but... I'm sorry. A vaginoplasty is a modified posterior repair in which the bulbocavernosus muscles are reapproximated to a certain diameter, usually predetermined in terms of finger breadths. So patients will describe that they would want to quantify the amount of tightness preordained to be one-finger breadths, two-finger breadths, three-finger breadths. We generally try not to perform the vaginoplasty beyond what they were when they were younger in their mid-20s to early 30s, for example. In our practice we will counsel the patients on vaginoplasty with regard to their partners as well. I mean, very simple asking is your partner unusually large can also determine how much a tightening to perform, but this is what we call a vaginoplasty.

Dr. Edward T.: The rest of this diagram that's a here also addresses the anterior compartment which has the bladder. The bladder can also fall to some degree, so we can perform an anterior repair or a cystocele repair in which we open up the excess vaginal mucosa, which is the shell, the vaginal vault, and begin to put stitches and placate them to bring up the bladder. In the poster compartment in-

Dr. Edward T.: Got it.

Speaker 2: I did this with males. I said something to the effect, was trying to build my [inaudible 00:29:19] practice. Go to my page. We can see what a natural looking beautiful mouth looks like, what the characteristics of them are and see what I've done to correct the aging mouth, the asymmetric mouth.

Dr. Edward T.: got it.

Dr. Edward T.: Okay. So if you are interested in seeing what a youthful or restored labia look like, check out www.tangchitnobmd.com/intimacysurgery.

Dr. Edward T.: Vaginoplasty is often criticized and generally regarded as simply a way to tie in the vault for the man's pleasure, from the perspective of restoring normal gynecologic and optimal function prior to childbirth, which is often a risk factor for uterovaginal prolapse and intimacy symptoms. The vaginal vault has elastin, collagen, and fibers that really constitutes a certain shape to the canal. As this shape deviates from the shape in which the woman was born, the ability to have a sensation from intimacy begins to change. So by bringing together the walls of the vaginal vault closer together, both in the anterior, posterior, and lateral aspects as well as deep towards the cervical region, what we call the apical component or the apex, this really brings the vaginal vault to its more restored form prior to childbirth or prior to the onset of menopause and perimenopause. Our intent is not always to overtighten the vaginal canal in such a way that it's unnatural, but rather restore the normal anatomical shape as well as function of the vaginal canal to take on the younger, pre-vaginal delivery state.

Dr. Edward T.: This is an attempt to bring the distance, actually the clitoral anterior vaginal wall distance a little bit closer together as well as promote the stimulation of the typically described the G-spot or the Grafenberg spot so that there is more sensation right underneath the mid-urethral meatus.

Dr. Edward T.: Now, when we look at the anterior component... Actually, we went over that part already. So I think we had offered maybe just a paragraph, let me think, about the surgical, oh, the robotic part, so the colpopexy.

Dr. Edward T.: Our approach or the timeless approach to surgery really involves procuring as minimally invasive approach as possible. Oftentimes a concomitant hysterectomy is needed, which actually precludes women or patients from pursuing surgery because yes, they would want their anterior, posterior repair in vaginal vault to be reconstructed or create it in such a way that it's optimal again, but the thought of the H-word, the hysterectomy is often daunting to them. So, in our practice, as part of the timeless intimacy approach, we perform a robotic hysterectomy. We go through the belly button and make small incisions that are less than five millimeters and with the robotic approach are able to perform hysterectomy and take out the urine specimen out vaginally and perform a colpopexy that is suspending the anterior apical aspect of the vaginal vault up so that it stays and does not fall.

Dr. Edward T.: So our approach is very complete in the sense that we do address the apical component that does fall, whereas traditional vaginoplasty or vaginal only approaches may only address the vaginal walls and not address the apex with the highest component of the vaginal canal itself.

Dr. Edward T.: The benefit of the patient is that they're able to get to life sooner. The recovery is faster. We also have pioneered the use of platelet-rich plasma, which we pour all over the vaginal cuff right after robotic hysterectomy. The reason that we do this is oftentimes the weakest part of the hysterectomy is the vaginal vault or the vaginal repair, and we have found that in our approach, by pouring platelet-rich plasma onto the interspaces of the stitches of the vaginal vault, which is the vaginal cuff, which is the weakest point, it actually strengthens the repair. We are measuring it based on the post-hysterectomy pain scores as well as the decrease in this spotting that happens after using platelet-rich plasma on the vaginal cuff.

Dr. Edward T.: Correct.

Dr. Edward T.: So our novel approach to robotic hysterectomy coupled with the vaginoplasty procedure really enables the patients to recover faster, have less pain after surgery, and have the most complete approach to performing those issues that patients present with when it comes to uterovaginal prolapse that really precludes them from having intimacy or having intimacy that feels different or is no longer as pleasurable as it was pre-pregnancy state.

Dr. Edward T.: So if you are interested in seeing images of our before and afters for labioplasty, for vaginoplasty and our patients who have completed the timeless intimacy surgical sequence, check out www.tangchitnobmd/intimacysurgery.

Speaker 2: Good. Then just kind of a little bit about the videos. I know Dr. Miami shows his whole surgeries on SnapChat and such. But maybe that's what you want to do with the videos that live there or more explanatory PowerPoint presentations or something that leave out some of the core so they're not scared off by... If you notice, I don't really have any videos, even though we talk about videos all the time. You don't really see me... I don't think I have one video where I'm sticking somebody's face [inaudible 00:37:39] that patients look at, not now.

Dr. Edward T.: Okay. Cell Biology. Cell biology is critical to the vaginal mucosa, which is the lining of the vaginal canal or the vaginal vault itself. The microenvironment of the vaginal canal is also very important. In fact, Lactobacilli is known as one of the good organisms that maintain this slightly acidic pH. When the vaginal flora gets perturbed, either by exogenous means, sometimes patients take antibiotics and could change the flora, you could have yeast infection. You could get bacterial vaginosis in which the pH of the microenvironment begins to change. So the microorganisms within the vaginal canal, the vaginal vault, are extremely important.

Dr. Edward T.: That being said, in addition to that, the quality of the vaginal mucosa itself is also important. In fact, the integrity begins to change not only from infection, but because of the decrease in hormone as patients and as women age. The collagen, elastin fibers of the vaginal mucosa itself are maintained by an interplay of testosterone, estrogen, and thyroid. When these hormones, and we'd mentioned this earlier, begin to decrease, the quality of the tissue begins to change. In addition to that, the lubrication factor which also contributes to the intimacy experience itself also determines whether intimacy is uncomfortable or comfortable. Many times we know this to be true because patients are often finding themselves going down that long island CVS with all the different kinds of lubes and oils that they try to put in. In fact, I had a patient of mine try to put in olive oil and use that as a lubricant, but only found that within a day or two would get a UTI like symptoms because it can be very irritating to the urethra.

Dr. Edward T.: So to go back to this cellular biology aspect of the vaginal mucosa, this component of it has to be optimized. In our practice we always start with the least invasive and kind of work our way up. Talking about the vaginal mucosa itself, you could restore some of the tissue integrity by using a compounded vaginal estrogen. This comes in the form of creams, vaginal inserts. There's a small pill that's absorbable that could go inside the vaginal mucosa. This can be absorbed intra-vaginally and has some effect on the vaginal epithelium as well as the vaginal mucosa. In addition to that, DHEA, which gets converted intra-vaginally to both testosterone and estrogen has really become more popular recently in the last year, and that can also help at the cell level because it begins to restore some lubrication factors. There's some healing factors that are involved as well as begin to affect elastin and collagen fibers.

Dr. Edward T.: Yeah. In fact, many of the literature and citation really site DHEA as the only intra-vaginal suppository that has effect positively on the FSFI, the functional...

Dr. Edward T.: Female sexual social index, whereas vaginal estrogen alone does not. So that's kind of a selling point to our patients. Another way to restore the vaginal mucosa is to use the heat-based approaches, and I separate that into two different categories, laser-based or radio frequency. Historically, erbium laser has been used.

Dr. Edward T.: So, to take that point further, the lubrication factor of the vaginal vault is maintained by the skin's glands as well as the Bartholin's glands. Those are the two primary sources of the lubrication. As women begin to age, the hormones that cause vasodilation to these glands and blood flow to these glands that really cause it to opt in functionally begin to decline. So, by restoring, at least at the local level of the vaginal mucosa itself, some of this missing hormone, we're seeing the increase in lubrication because these glands really get better blood flow. Actually, the whole vaginal canal improves in blood flow, and the glands begin to secrete more of the vaginal fluid that

Dr. Edward T.: I think it might be more related to-

Dr. Edward T.: Yeah, no, no. This ones would be next because heat would be a separate thing. We're on more biologic. Okay.

Dr. Edward T.: Okay. Okay. So this would be five. Now, there are other approaches to restoring the cellular biology of the vaginal vault. We've mentioned earlier the use of very specific all hard hormone replacements that come in the form of creams or inserts. Another approach, and actually approach that we've often used in the timeless intimacy sequence is the use of both platelet-rich plasma as well as micronized fat. So starting with platelet-rich plasma, what is platelet-rich plasma? Well, it's the component of blood that contains all the necessary healing factors that we are able to isolate using a centrifuge. So our patients, we will draw a certain amount of blood on them, spin the blood into a special centrifuge and actually isolate out the component that is enriched with healing factors which we call platelet-rich plasma.

Dr. Edward T.: Now, an O-Shot can be performed from this. An O-Shot is a very specific injection in which platelet-rich plasma that has been isolated from the patient is injected into the anterior vaginal vault at the G-spot as well as the clitoral body. The combination of these two injections performed under just very local anesthesia constitute the O-Shot or the orgasm shot. As you can imagine, the suburethral meatus which lives right in the region of the urethra has some effect on the continents mechanisms, such that when we perform the O-Shot, it actually has some positive effect on urinary incontinence.

Dr. Edward T.: Fat can also be harvested. Generally it's harvested from the lower back in small amounts and then micronized through a sieve and re-injected particularly in the area of the vaginal vault, in the G-spot. It can be combined with or without platelet-rich plasma or the O-Shot, by which the combination of an O-Shot plus the injection of micronized fat into the G-Spot yield optimal results.

Dr. Edward T.: Perfect.

Dr. Edward T.: Okay. So, bringing it all together, we discuss the understanding, the cellular biology of the vaginal mucosa and how it plays in with having optimal intimacy. You should talk to your doctor, actually bring it up if you have any issues in terms of lubrication or pain during intimacy. Oftentimes patients will describe a sensation of dryness, and this should be brought up after having been evaluated for surgical intervention or having your hormones looked at. So I think that the use of platelet-rich plasma, especially when it's your own, really begins the conversation of the use of... or the approach of regenerative medicine in which we are using our own bodies to heal ourselves.

Dr. Edward T.: Okay. So the surgery doesn't always cure everything. Particularly when it comes to painful intimacy, having a surgery or offering surgery does not. There are very specific conditions and situations which surgery may help. The most common one would be a large fibroid that is space-occupying that pushes the uterus all the way down can cause pain, particularly with deep penetration or certain positions just due to the size and mass effect of a large fibroid. The second one is endometriosis, which is generalized pelvic inflammation. They could actually extend all the way down to the rectovaginal septum, which is this small separation between the vagina and the rectum. If that's not properly treated or resected, that can cause a lot of pain or dyspareunia during sex.

Dr. Edward T.: A third one is to have a ovarian mass that could actually swing down and occupy the cul de sac, which is the small space right below the uterus itself. If that is occupying, we've actually in our own practice have taken out large teratomas before, or dermoid cysts actually can cause a lot of pain during penetrative sex. So these are examples of gynecologic presentations and pathologies that if not treated surgically can preclude patients from having an optimal timeless intimacy experience.

Speaker 2: Perfect. Yeah. So, again, you want to leverage your strengths and part of it is you're a hardcore expert surgeon, and these teratomas make interesting photographs [crosstalk 00:55:41]-

Dr. Edward T.: I've got lots. Yeah. Actually, I took one out two weeks ago with a robot. It was a 21-year-old. She came for a second opinion. The GYN in the town was going to open her, and we ended with a robot and pulled out teeth hair. It looked like a whole little, I don't know what it looked like. It looked like an alien. I remember at the very end of the surgery, she looked at me. I couldn't tell her that we're going to save the ovary, but she looked up to me afterwards, and we did robotics. She said, "You saved my ovary, didn't you?" I was like, "Yeah, we did." So we took a picture of it, and she asked for a picture of it postop. It was a immature teratoma. So she was happy, and we were happy and really saved the ovary.

Dr. Edward T.: Great.

Dr. Edward T.: Okay. New Chapter, six, heat and energy approaches to painful intimacy. So the idea of applying heat to the vaginal vault is nothing new.

Dr. Edward T.: So new chapter, chapter six. So heat energy for intimacy. So, when I approach the discussion of the application of heat-based therapies to sex and intimacy, I generally counsel the patients that there's two large groups. It's the use of a laser into the vaginal vault or radio frequency. Now, the idea of using a laser is not anything necessarily new. Historically, erbium-based lasers have been used in different parts of Europe and in the Middle East for restoration of the vaginal mucosa, restoration indices include, lubrication indices, some tightening, particularly with the vaginal epithelium, as well as sensation. Because of the use of the vaginal laser targeted right underneath the urethra, we've also seen in some cases the improvement of urinary incontinence. Radio frequency is also another great approach, also heat based, although the heat-based approach to this is not targeted in the way the laser is, but more rather, the use of radio frequency along the whole vaginal vault with bulk heating effect.

Dr. Edward T.: We have seen that in the aesthetic literature that radio frequency has been used oftentimes on jelling lower face the neck, parts of the face that seemed to sag with intent of developing elastin and collagen fibers really collaneogenesis through bulk heating. Now, going back to the vaginal vault itself, the radio frequency wavelengths really go all the way down to the lamina propia and are said to help increase, to some extent, angiogenesis, well, as does the laser therapies.

Dr. Edward T.: Got it.

Dr. Edward T.: The last part of this, because right now, I feel as if this was many different parts and different ingredients, but I haven't made the meal. So the meal comes from the fact that timeless intimacy as the sequence is a combination of vaginoplasty as well as robotic surgery and bringing the patient back a week later in our series and giving them a pellet, whether it's testosterone, estrogen, or testosterone only, and then waiting six weeks afterwards to perform a series of three vaginal lasers separated by 30 days. During the vaginoplasty robotic surgery, the patients are asleep, so we also perform on O-Shot. So in summary, the timeless intimacy sequence, which is trademark by our practice is vaginoplasty with robotic surgery, concomitant O-Shot, bringing the patient in for hormone replacement systemically with a pellet and followed by a series of Femilift vaginal laser CO2 treatments in the office.