Embracing Change: Navigating Sexual Health and Menopause with Dr. Sadaf Lodhi

Welcome to the Get Healthy Tampa Bay Podcast with Dr. Kerry Reller! This week I am joined by Dr. Sadaf Lodhi to delve into the challenges and misconceptions surrounding sexual health in menopause, explaining the benefits of hormonal therapies and the impact of cultural and educational backgrounds on sexual perceptions and experiences. Additionally, Dr. Lodhi explores the complexities of libido in women, the role of mindfulness and emotional connection in intimate relationships, and the significance of communication in enhancing sexual health and intimacy.

Dr. Sadaf is a board-certified OBGYN and executive coach for women based in New York. She graduated from the University of Michigan with honors, receiving a Bachelor’s of Science in Biochemistry. She acquired her Doctorate in Osteopathic Medicine at Michigan State University and completed her residency in gynecology and obstetrics in Michigan. She earned her certification as a life and executive coach from Rutgers University. 

She is a sex counselor and educator. As a practicing OBGYN in New York for over 20 years, her mission has always been to empower and educate women. Most recently she has opened up a telehealth practice serving patients in NY and Michigan for sexual and menopausal health and a private practice to be opening in Spring 2024. She helps women remove mental and physical barriers so that they can find pleasure in their relationship. She believes that all women, regardless of their backgrounds, have the potential to live life to its fullest.

Connect with Dr. Lodhi
Tiktok and IG: @drsadafobgyn
YouTube: @drsadafintimacycoach and @themuslimsexpodcast
Website: drsadaf.com
Facebook: DrSadafintimacycoach
Podcast: The Muslim Sex Podcast
Email: drsadaf@drsadaf.com

Connect with Dr. Reller
My linktree: linktr.ee/kerryrellermd
Podcast website: https://gethealthytbpodcast.buzzsprout.com/
Facebook: https://www.facebook.com/ClearwaterFamily
Instagram: https://www.instagram.com/clearwaterfamilymedicine/
Clearwater Family Medicine and Allergy Website: https://sites.google.com/view/clearwaterallergy/home

Subscribe to the Get Healthy Tampa Bay Podcast on Apple podcasts, Spotify, Amazon music, iheartradio, Stitcher, Google Podcasts, Pandora.

#SexualHealthAwareness #MenopauseMatters #IntimacyCoaching #WomensWellness #HealthyAging #MindBodyConnection #HormoneHealth #EmpowermentInMenopause #LibidoBoost #OBGYNInsights

Transcript

Kerry: 0:29

All right. Hi, everybody. Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller. And today we have a very special guest, Dr. Sadaf Lodhi. Welcome to the podcast.

Sadaf: 0:41

Thank you so much for having me on. I really appreciate the opportunity and I'm so excited to be on.

Kerry: 0:47

Thank you for coming. And why don't you tell us a little bit about who you are and what you do?

Sadaf: 0:52

Absolutely. So I am a board certified OBGYN. I'm currently in New York, and I focus on sexual health and menopausal health, and I am also an intimacy coach. As you and I were talking right before the show, you know, a lot of physicians, a lot of us don't get very much training in sexual medicine or menopausal medicine. And so I really had this passion for both of them. And I went ahead and took a course through the University of Michigan that spanned the course of a year and really, you know, delve deep into sexual counseling and education. And then I also became an Ishwish fellow. which stands for the International Society for the Study of Women's Sexual Health. And then I also became a Menopause Society Certified Practitioner so that I could better help and assist my patients through their journey of going into menopause.

Kerry: 1:46

That is a lot. I also read that you did sort of a life coach type thing at Rutgers.

Sadaf: 1:52

Absolutely. Yes. So I, yeah, thank you. I sometimes forget. So yes, I did coaching. So there's a coaching program through Rutgers University and I did that coaching program. And so I'm also an intimacy coach, a sex coach. So yes, I wear all those many hats. Yeah,

Kerry: 2:09

Overqualified, if you will, for what you're doing. But I'm looking forward to educating us on, you know, your specialty today. So why don't you just Tell us a little bit how you got into this. What, why'd you get interested in like doing these things? So,

Sadaf: 2:25

really it started like in 2021. I remember that because I was switching jobs. I was leaving my academic position and I was totally burned out and I couldn't figure out what I wanted to do next. And I had some coaching in the past and I felt like that was really helpful, really beneficial. And one of the key things that I learned through all my coaching that I've had is that so much of what we learn and what we do it has to do with mindset and you and I are both in a coaching program and our coach always talks about that as well as really a lot of what we're thinking throughout the day has to do with the things that we think we're capable of and and one of the most powerful things that I ever learned from a coach that I had is that we get to choose our own thoughts. And I think that's so powerful, because a lot of times we go through the day, and we have like these gazillion thoughts just running around in our head. And we think that we don't have any control over that. But actually, we do. And, if we stop to just assess our own thoughts, and think about it, and wonder if these thoughts are serving us or not and then realize that we have the power to change those thoughts to something that does serve us and empowers us instead of bringing us down, then that can really change the way that we feel. And then if it changes the way that we feel, then it'll change our actions as well. And so with my own coaching program, I really focus on cognitive behavioral therapy and really changing the thoughts in our heads as they relate to sexual intimacy and sexual relationships. And oftentimes patients will grow up with sex negativity, whether it's because of their upbringing or whether they've experienced some trauma or abuse and really trying to change their thoughts about what sex means to them and what their relationships mean to them and whether or not those thoughts are serving them. And if they're not, then we work toward ways of changing those thoughts so that they can be more empowering and help those individuals.

Kerry: 4:26

yeah, I totally agree. Everything is really based on the mindset and how you're thinking about things. And I have listened to lots and lots of life coaches and everybody, explains it in a similar way that you do and that you get to choose your thoughts. Right. And I try to tell my kids these things too. And they don't get it yet, but you know, I will say that not just life coaching, but also the books reading to helping us with the mindset and things like that. In particular, like soundtracks, that book, I forget the author, but

Sadaf: 4:54

Acuff.

Kerry: 4:55

is it?

Sadaf: 4:56

Yeah,

Kerry: 4:57

got me. Okay. Yeah, it is. Okay. Anyway my husband was listening to it. And so he's kind of on board with how we choose our thoughts and things like that. So how do you how do you take that mindset and like translate it into working with your patients and clients and improving their sexual health?

Sadaf: 5:14

So, you know, specifically one of the instances which I think mindset plays a huge, huge component is when we are talking about sexual medicine is in vaginismus. So vaginismus is a condition where the muscles around the surrounding the vagina will tighten up in anticipation of some type of penetration, right? Whether it's with a pelvic exam, a tampon insertion, or penile vaginal intercourse. And so with vaginismus a lot of it is the anticipation of fear, right? Like what's, what's going to happen and especially for patients that perhaps may have experienced trauma or abuse. That is a huge component, right? So not only is it those muscles tightening up, but it's also the brain telling those muscles to tighten up. And obviously it's involuntary, but you know, a lot of it has to do with what's going on in your head. And so the way that we work through that is, we assess those thoughts and I'll talk to the patients about, what they're thinking and what type of fear that they're having. And we'll explore that a little bit. And then, we'll go through what that brings up for them, where in their body it brings that up and try to work through all of that. But along with the coaching is the anatomical portion of it, right? So you can work through and we say in sexual medicine all the time that the brain is the biggest sexual organ because it really controls not only our physiologic response, but also our physical response. Once we kind of start to manage those thoughts, and then the feelings and then the actions, because if we can control that, or even change it a little bit, because, you know, working with vaginismus is not just an overnight thing, it takes quite a few, sessions to kind of work through that fear and to work through those thoughts. And once you get a handle on those thoughts, you still have that physical response and the brain does control it and perhaps it doesn't become as strong, but you still have to work through the anatomical part of it. And so that's where a pelvic floor therapist comes in. So in conjunction with working with say a sex coach and also a sexual medicine doc, you'd want to work with a pelvic floor therapist that could slowly introduce like different types of dilators and slowly increase the girth of that dilator so that a person could experience or have if they wanted penile vaginal intercourse. So that is just one way that I use that intimacy coaching. A lot of times also people that grow up in very conservative communities, may have grown up with the idea that sex is wrong, it's dirty, it's shameful, and so that they never even look at, say, for a woman, say, you know, will never even look at their own vulva because they think it's dirty or they think it's wrong. And you'd be surprised and maybe you wouldn't that how many women have come to my office and don't realize that they don't urinate through the same orifice as the one that a baby comes out of. So they don't even realize that they have three openings down below. And I think that has a lot to do with the fact that, our sex education, but even for women that perhaps have grown up outside of the U. S., right, perhaps they never even had sex education. And if they had grown up in an environment where it was very sex negative then everything relating to sex is wrong, right? And so they have to really work through that. I recently did a podcast with a woman that does a lot of work on female sexuality and has written papers. She's actually a professor at St. John's University and she talked about how she had, she met a woman who thought that was told by her husband that the only way she could have a baby is if she performed oral sex on him. And so it's really just for you and I as clinicians, you know, it's perhaps mind blowing that somebody would, one say that and to kind of really like core somebody into doing something that maybe perhaps she didn't want to but you know, he told her that that was a means to an end. And so a lot of it, you know, for people that have grown up with in cultures that they don't teach much about sexual education or they don't have very much information. It's really hard to switch over that mindset. So I work a lot with women that have grown up in those types of cultures and traditions and and really help them come to a more sex positive thoughts and then their actions and their feelings and their actions then follow. I've also had women that have grown up in not just like but just conservative societies in general, in a purity culture where again they were taught that if they had sex before marriage they were going to hell. And so they've kept that with them. I counseled a woman very recently, actually with for vaginismus and she and I started talking and she grew up in a very strict Christian household and she herself was a devout Christian and she couldn't understand why she was having vaginismus. And it was really bothering her and she was in a relationship, she was engaged to the man, and she kept experiencing it. And so she came to me and she said, you know, I want to be able to have intercourse with him without feeling so much pain and feeling this vaginismus that she was experiencing. And what we realized once we started talking together is that the thoughts that she was having about sex being wrong before marriage, even though she was, she's in her 60s and this is this was her second, she had been divorced and now this was a person that she was going to marry and she was engaged to him, but that the thoughts that she had that, sex was wrong before marriage. And that she shouldn't be doing this, all of those thoughts kept coming into her head anytime she tried to be intimate with her partner. And so then she realized the things that were important to her, whatever values she carried with her were more important. And so she decided that she would not be involved and this was the decision that she made for herself is that she decided that she wouldn't try to force herself to have intercourse with this person before marriage because her mind was telling her no and for her to feel better, for her to be in alignment with her values, she decided that that's what she wanted. But what was the kind of breakthrough for her was that she finally understood why she was having experiencing vaginismus, why those thoughts were coming to her and why she was having that involuntary contraction of those muscles. And she realized that it was because of these thoughts that she had about that sex was wrong before marriage And so that really helped her because she knew that she was able to have intercourse with her husband before, but that was because she was in a marriage, she was in a committed relationship. And even though she was engaged to this gentleman, she just couldn't force herself to have intercourse because she felt like in her mind it was wrong. So that's how intimacy coaching really works with issues that women may be having with sexual health and and relationships.

Kerry: 12:24

Yeah, I mean, a lot of trying to unpack what you said, right? So it is not surprising that I also have had patients come to me not knowing their own anatomy and not knowing you urinate through the urethra and that there's other holes there. And I think sometimes they get so worried that, you know, They don't know that and then something comes up and they're like concerned that something is wrong. And yet it's just a normal anatomic feature. I actually had a recent experience with a patient kind of thinking like her cancer was back or any, something like that. And the truth is, is that she just wasn't aware of the anatomy. So luckily reassurance is okay. But and then you mentioned like the, you know, growing up in a certain culture and, you know, I grew up, Catholic and same thing. Like we had sex education was really not useful it's like, this is how a baby is born, right? It doesn't really teach you anything. And I honestly don't know what they do yet cause my kids are too young, but they are, you know, in Catholic school. And I hope that they will learn the right things so they don't have these problems in the future. But I have yet to experience that of the teaching side of these things. So, I mean, it's difficult. I think when we grow up in a way where, you know, you learn these things are wrong, it's hard to kind of get it out of your head, so I can totally see how that can contribute to it. And it's really I guess, important to break through these barriers. And luckily, people like you exist, because I'm sure there's plenty of people that don't talk about it.

Sadaf: 13:53

Absolutely. Absolutely. And I think just giving women permission to experience pleasure, I think oftentimes they don't give themselves permission. And especially if you're thinking that something is wrong, dirty or shameful, you're going to think that even if you experience pleasure, it's wrong and that you shouldn't be experiencing that pleasure. So I think that that is a huge component of the coaching that I do. Okay. And I think also as it relates, you and I were speaking a little bit about menopause and about how women, you know, if we're lucky enough to make that transition into menopause, that a lot of times women will experience vaginal or vulvar, like burning and itching and pain with intercourse. And what a lot of times women don't realize is that that all has to do with the low estrogen state in our bodies and we have a decreased blood flow going to our vulva region and to the genitals and the way to improve that is by going on vaginal estrogen. And why that's important is because that vaginal estrogen will increase the blood flow going to the vulvar region, but it also increased lubrication, decreased pain, decreased the friction, decreased the pain with intercourse, help with bladder health, all of those things. We know that as women get older, They also become susceptible to increased urinary tract infections. And that's because the urethra actually grows bigger, becomes bigger in postmenopause. And everything else seems to shrink, like our vulvar region, right? The labia, they start to shrink the vagina, everything becomes that tissue becomes more of what we call friable or thinner. And the pH increases and you're more susceptible to bacterial infections as we go through menopause. And all of that can be prevented with a little bit of vaginal estrogen. And I know a lot of times women are worried that is it going to cause breast cancer and that was the big thing with the W. H. I. Study that came out in two thousand and two. And we know that the W. H. I. Study, actually the authors have retracted most, if not all of the statements that they made. It's unfortunate because a whole generation of physicians, myself included, were not taught how to help women in menopause, were not taught how to dose hormones for women, because of that study, because I happened to actually be in residency at the time when it came out. And my attendings, my teachers at that time were like nobody's going to go on hormones anymore. It causes breast cancer, causes invasive breast cancer. And Overnight, they took their patients off of hormones and What that led to was an increase in cardiovascular disease. You and I both know that cardiovascular disease is the number one killer of women. It's not actually breast cancer. And it led to increase in osteoporotic fractures, right? It led to increase in hip fractures. It led to increased cognitive decline, Alzheimer's for women. So there were a lot of things that happened as a result of the decrease in estrogen that women were prescribed. I think that one of the important things to know and to learn, and I just had a physician on, he's a medical oncologist, Dr. Blooming from California on my pod. I also have a podcast. So he came on and he talked about estrogen. He actually wrote a book called Estrogen Matters. And he talks about how the WHI study just did such a huge disservice to women and for women's health in the sense that women just were not prescribed estrogen and that estrogen actually is preventative. If estrogen is given within 10 years of the last menstrual period and or between the ages of 50 through 59, if it started, it has a huge protective effect on our bone health. In fact the estrogen is the only FDA approved medication for osteoporosis. It's also approved for These are motor symptoms, which we know are hot flashes, night sweats, mood swings, all of those things. And it's the gold standard for also genitourinary syndrome of menopause, which I mentioned earlier, which is that when women have the vaginal dryness, the itching, the pain with intercourse, right? All of that has to do with the tissue in the vagina and how it becomes thinner when we have that lack of estrogen.

Kerry: 18:26

So does the vaginal estrogen also help with those symptoms or is it have to be the oral or systemic or patch or

Sadaf: 18:35

Thank you for clarifying that. I appreciate it. So yeah, the vaginal estrogen only works in the vagina. There's very little systemic effects, meaning like it doesn't really go all over the body. And it's really important to understand that because, and of course this is not medical advice and you do need to talk to your own doctor, but it is even in women that have had breast cancer in the past, they can take vaginal estrogen. So really important to discuss that with your own doctor, but it is safe because the dose of estrogen that you're getting is really just localized to the vagina. And it is so small that it's really, it's not really going to make a difference. In fact, sometimes women think that If they're getting the vaginal estrogen, then perhaps they need progesterone with that to counteract that and for the vaginal estrogen alone, you do not need progesterone because the dose is so low that it's not going to result in, what we worry about with endometrial cancer cancer of the uterus. It won't result in that. For the symptoms, like you had mentioned For the hot flushes, the night sweats, the mood swings the prevention of cognitive decline, all of that, that is more with the systemic. So, we're talking about either oral estrogen or we're talking about the transdermal. There's so many different ways to take estrogen. You can either get a patch. There's rings, there's gels, there's sprays. So there's different ways, you know, whatever works for you to get that estrogen on. Transdermal or the patch estrogen tends to be probably the safest. I'm sure the cream and the gels are probably of similar efficacy. The reason why that is because it doesn't go through the liver. So it's lipid neutral. It doesn't have what we call the first pass effect going through that liver and affecting your cholesterol and even women. that have high blood pressure that is well controlled can actually go on estrogen via the patch. Of course, you have to talk to your doctor before that. So there are lots of ways to get that estrogen if you want it. For me, I just think it's so important because it's actually preventative, right? It's preventing your cognitive decline that could possibly result in Alzheimer's later on in life. It could, it actually decreases colon cancer risk. It also decreases osteoporosis. It will help you with your symptoms that you're having with painful sex and intercourse. I mean, it does so much. It helps with, again, brain health, it helps with like joint pain. There's so many things that estrogen does, and there's so many estrogen receptors throughout our whole body that it really behooves us to really understand the benefits of estrogen and what it does for you. I don't typically recommend pellets only because the American College of OBGYNs and the Menopause Society don't recommend pellets. So I go based on what their recommendations are and the research that they've done. I know a lot of people do, do pellets. I don't. And the reason why that is, is because they believe that we don't really know the amount that is in each pellet that a patient will get, right? So, at least with an FDA approved medication, you know exactly the dosage of the medication that that patient is receiving whereas with non FDA approved medications, we don't really know. And of course, if you take estrogen and you have a uterus, make sure that you are taking progesterone as well because, like I mentioned earlier, Unopposed estrogen can lead to uterine cancer. So you always want to make sure that you're taking progesterone along with that to prevent any type of hyperplasia, what we call, or that increased growth in that lining of that tissue for the uterus. So to make sure that you don't, you know, get something like uterine cancer, but anytime you have unexplained vaginal bleeding post menopause. really, really need to go and get evaluated by your doctor to make sure there's nothing else going on and that you don't have some type of cancer or something like that. And so to make sure that you absolutely get evaluated and just so that everyone is on the same page you know, menopause is what we call a retrospective diagnosis, meaning that You have to go a whole year without your period to be in menopause. And so you really don't know if you're in menopause until you've gone a whole year. But the symptoms that women have happened way before menopause. And so that's when you know that you're starting to experience that. And one of the first things that women experience, I'm sure Kerry, it's might be the same in your practice is irregular menses. Women always come in for irregular menses and typically perimenopause can start any time after the age of 35, which I know is surprising for a lot of people, but women can start to experience symptoms very early.

Kerry: 23:29

Okay. A couple of comments and questions. You said so much. One comment is like I was saying earlier, it kind of blows my mind that you, a trained OBGYN did not get any like menopause education on how to use hormones. Just blows my mind. I can't believe that doesn't happen. And then another thing about the pellets is that usually I think that you kind of can't take it away. So if it's like a wrong dosing thing is usually problematic, that's kind of how I think I don't really recommend them either. But there's definitely plenty of hormone places around where I live and work. And lots of my patients are on them. And then a couple questions for you is one Okay. Do you normally, is it okay, like people might want to start estrogen prior to having that official menopause diagnosis? You said the symptoms present earlier, well, do you wait till, you know, it's been 12 months to treat the patient, or how do you manage that?

Sadaf: 24:25

Yeah, no, not at all. What I recommend is women can actually even go on birth control, right? So remember that if you're still having your periods, but you're having all those symptoms of the hot flashes, the night sweats, the mood swings all of those things, joint pain, there's so many different symptoms, anxiety, depression, new onset depression. All of those things can happen in perimenopause menopause. And so no, I wouldn't wait. You can start say if you want to go on estrogen, you can start that in that time period, you don't actually have to wait, but if you do wait, the best time to start it is within 10 years of your last menstrual period, like you don't have to wait. You can actually even go on a low dose birth control if you wanted to replace that estrogen progesterone. But of course, the things that happen with birth control and there was that New York times article, I don't know if you saw it, but it talked about decreased libido with birth control and also pain with sex that can happen with birth control. And the reason why that is, is because Birth control pills increase the sex hormone binding globulin that's released from the liver. When that is increased, you have decreased testosterone that's floating around in your body. When we have decreased testosterone in our bodies, which also happens in menopause that can result in decreased libido and decreased interest in sex. And so that's why birth control pills will sometimes and for a lot of women will decrease their libido. Also, that pain with sex that can sometimes result as a result of birth control pills is due to, again, that decrease in testosterone. Are there's something called the vestibule, which Honestly, I didn't even learn about, and I just recently learned about taking all my sex ed courses. I don't know if you know what the vestibule is. The vestibule is that region that is with the labia minora, and it's the tissue that extends down in toward the vagina, okay? And that is considered the vestibule, and it actually goes all the way around and actually underneath the urethra as well. And so that is actually tissue that is a bladder origin, which I learned as well, which is responsive to hormones and specifically responsive to testosterone. And if you don't have that testosterone, there's a decreased testosterone, you can get something called vestibulodynia, And so if you have that, then you have pain with insertion of you know, it could be like a tampon or it can be pain with sex, right? Penile, vaginal intercourse. So that's why sometimes women may experience pain with intercourse being on birth control and, or they can experience decreased libido being on birth control.

Kerry: 27:14

Interesting. I don't think I saw the article, but I do remember that term from anatomy. Do you think it's vestibule, vesicle, like bladder that kind of maybe termed in the same manner? I don't know Latin, but like the Latin phrase, maybe that's why it was named that if it's actually bladder origin tissue. Does that make sense? Yeah, interesting. So you were saying OCPs or oral, sorry, oral contraceptives increase the sex hormone binding globulin, okay, which decreases testosterone and then makes that tissue, what,

Sadaf: 27:48

So it makes it sensitive.

Kerry: 27:50

Sensitive.

Sadaf: 27:50

that makes it sensitive and it can create pain. So that's why it's called vestibulodynia. So it's pain of the vestibule and it because it is sensitive to hormones. And so when those hormones go down and we don't have those hormones, then it can cause pain.

Kerry: 28:06

Do patients like taking, I don't know if you use testosterone for women, but is that something that you might use that in that case?

Sadaf: 28:15

Yeah, yeah, you could do a little bit of testosterone there. There's

Kerry: 28:18

Mm hmm.

Sadaf: 28:19

called intra rosa that sometimes women will do and that's a DHEA moisturizer that is converted to testosterone and then to estrogen via the aromatase 5 alpha reductase. I don't know if you remember all that. I had to review it myself. But anyways so sometimes that is used for that vestibulodynia and or sometimes women will go off of the pill and use like, say, like an IUD.

Kerry: 28:45

Mm hmm.

Sadaf: 28:46

IUD or a progesterone only IUD so that they don't experience that pain with intercourse.

Kerry: 28:53

Mm hmm. So this brings me to my other question was, well, do you do any lab work before you do anything or you don't go by clinical symptoms?

Sadaf: 29:03

For what? Menopause?

Kerry: 29:04

Yeah,

Sadaf: 29:05

Yeah. So for menopause, you don't actually need blood work. It's really like a clinical diagnosis of perimenopause. What's really interesting is that, so there's a swan study, which is still ongoing. And that was started in 1994 and it looked at women through midlife. So the changes that happened in midlife, you know, psychological wellbeing, anatomical, everything, all this stuff that happens to women in midlife. And it's a multi center study, and so there's like a center, Brigham and Women's in Massachusetts. There's the University of Michigan in Ann Arbor. There's lots of several centers where they've enrolled women and are taking a look at them. And what they notice is that women of different ethnicities go through perimenopause differently. And for a different length of time. For example, African American women tend to go through perimenopause the longest amount of time, for 10 years. They start earlier and they go later. Hispanic women, they go for about 8. 9 years, so about 9 years and same thing. They start earlier, they go later. Caucasian women, about 7 years. Asian women, those of like Japanese and Chinese descent, tend to go for about five years. I think it may be due to their diet and increased consumption of tofu. But yes, different women tend to undergo different lengths of time for perimenopause. What's also interesting is that there's a thought that women that have experienced generational trauma, for example, African Americans with slavery. People that have been starved, starvation, famines, wars, things like that. That trauma is then transcribed into their DNA and could be a reason why they experience perimenopause for a longer period of time and also are susceptible to other types of diseases. For example, high blood pressure, diabetes it could be due to the fact that it's actually transcribed, the trauma is transcribed into their DNA. For example, South Asians are known to, I mean, like just being South Asian is a risk factor for having heart disease and for getting diabetes. And I think it's because South Asia was colonized by the British and experienced famine and starvation and because of that, that trauma was transcribed into their DNA and makes them more at risk for the diabetes and the heart disease. So with this perimenopause, we know through the swan study that different ethnicities experience the perimenopause period for longer periods of time and for a longer duration and really and how strong, I would say, I don't know, it's the brain fog, the perimenopause but how often they experience those basal motor symptoms and how strong they come on really also is due to the fact of you know, their ethnicity and genetics and things that oftentimes we can't modify.

Kerry: 32:00

That is so interesting. I had no idea. Like, different ethnicities had different lengths of menopause and, the whole historical point of trauma. I mean, that's crazy. Wow.

Sadaf: 32:09

fact go to that SWAN study in 19, that's done in 1994 and they have a whole thing on vasomotor symptoms and menopause and it'll show you the different lengths of time that different ethnicities go through perimenopause. So really, the reason why I bring that up is that it's important for physicians and for anyone that's listening. That their symptoms are valid, right? A lot of times our patients just come to us to just validate their symptoms and their experience of what they're going through. And so for us as clinicians to know that, you know what, it's not just women that are 45 and over that are going to be going through these perimenopausal symptoms. It could actually be somebody that's much younger that could be going through them, right? They could be experiencing heart palpitations. I think Oprah's first symptom were like heart palpitations. The woman in the New York Times that wrote that, women have been lied to about menopause. Her first symptom was brain fog, so different women experience perimenopause differently. And so it's really important for us as clinicians to be able to validate their experiences. And then of course, be able to also help them and treat them. And there's lots of other treatments for menopausal symptoms. Not only hormonal, but there's also non hormonal. In fact the menopause society has even recommended as an evidence, a cognitive behavioral therapy for vasomotor symptoms, so that's really interesting to see how that might work for somebody that doesn't want medication. There's also SSRIs or something called Paxil that we use for hot flashes. There's also a medication that's non hormonal that just came out last year, which is called Bezoar.

Kerry: 33:37

Yeah.

Sadaf: 33:38

Exactly. So many things there are, you know, so what I want to anyone listening to this podcast is to know that there are options out there for, if you're going through perimenopause and experiencing all these symptoms that there are medications that can help you and that, really it just starts with a conversation with your practitioner to discuss what's happening and so that they can best treat you.

Kerry: 34:02

I do have one question regarding all the medication and treatments. And a lot of these, I guess, hormone clinics around us, they kind of charge a lot and they're using compounded things. And I want to know from your standpoint, what is the kind of most cost effective approach of treating it? Like, I know that there's FDA approved things that are reasonably priced to get and how, you know, what is your comment on that? Like, if you're talking about

Sadaf: 34:29

Absolutely. So you know what I think the compounded pharmacy medications kind of would go in the same realm as the pellets,

Kerry: 34:37

Mm hmm. Mm

Sadaf: 34:39

you know, a lot of times with those bioidenticals, the pharmacists will compound that, but honestly, again, it's the same thing where you don't know exactly how much you're getting in each dose. And so the societies again, they actually advise against it and especially because those are probably going to be more expensive than what you can get through an FDA approved medication. FDA approved medication oftentimes are way less than compounded medications as well as pellets. They're going to be less expensive and you know they're approved and you know the dosage that you're going to be getting with every time you take that medication. So that's what I would recommend I would just go with FDA approved medication. And there's so many different pharmacies. I think there's also something good Rx, right, which you can cheaper medications. And so I would definitely advise patients to look elsewhere and. I wouldn't do compounding just because I wouldn't know what's going into my body. And when we talk about bioidenticals, you know, so estradiol is the estrogen made from our ovaries. Which if you're looking for a bioidentical, I mean, we have bioidentical. We have the estradiol patch, right, which is the same thing. If you're looking for, you know, progesterone, we have the micronized progesterone, which is the prometrium that you would take. And so we do have those and they're FDA approved and they're safe. So I'd recommend that patients take those before venturing out.

Kerry: 36:08

I guess I don't know if you touched on as much on libido during menopause or perimenopause as you wanted to.

Sadaf: 36:14

yeah, we can definitely

Kerry: 36:15

we have a minute.

Sadaf: 36:17

Yeah, I don't know how long you want to go, but, you know, so just really, well, so I love talking about libido because it is actually, it's not a quick fix, unfortunately. In sexual medicine, when we talk about libido, there are so many things that go into it. And we actually go through, look into it through a biopsychosocial lens. In sexual medicine, everything is via biopsychosocial. And what that means is that you're looking at the biological part of the individual. So, you know, it could be their anatomy, right? It could be the medications that they're on. It could be what's going on for them in terms of their physical health. The psychological part of it is are they experiencing anxiety? Are they experiencing depression? Are they taking meds for that could be affecting their libido. The social part of that is, you know, are they a single mom that's trying to juggle like four jobs? And then at the end of the day, she's going to be exhausted and not have any bandwidth to be getting into like an intimate relationship with anyone, right? So that is like the biopsychosocial model where we take a look at the whole individual. You're taking a look at their medications, you're taking a look at everything to assess them. And so that's why libido is not an easy fix. There's so many different things that can affect it. Like I mentioned, also there are medications. Okay. So once you go to a practitioner that knows how to evaluate you for your decreased libido, there are medications. So there are two currently FDA approved medications. And then testosterone is also used as an off label. The way that so we have Addie, which is a medication, it's a flibanserin a hundred milligrams that you would take at night daily. And what that does, it's what we call a it's a serotonin agonist antagonist. Basically, it increases the dopamine and the norepinephrine in the brain and it decreases the serotonin. We know that, sSRs, which are like Paxil and Prozac and Zoloft, they will decrease libido because they prevent serotonin, which decreases libido. They prevent it from being taken back up in the brain. So with this Addy, what it does is it decreases your serotonin. So it increases your libido by increasing your dopamine and your neuroepinephrine. And so that's the way it works. It acts on the brain basically. In the end it acts on the brain and it's a medication that you take daily. But if it's not doing anything, usually your patients tend to see results within like four weeks, but if they don't see an increase in libido or what they quantify as a, sexually satisfying event, then the medication is usually discontinued after eight weeks. So if it's not going to work, you know, either it's going to work or it's not going to work. There's another medication called Vyleesi, which is an injectable. It's a subcu injection, and it's usually done 45 minutes before an anticipated sexual encounter. The side effect with that is sometimes you can have nausea and vomiting. And again, it works in the brain on the melanocortin receptors in the brain. And increases libido that way. And it's only taken when you anticipate sexual activity. So you don't have to do it any, every day, but it's an injection. So you have to inject it either into the thigh or into the abdomen. So those are the two FDA approved medications. Those are actually approved for premenopausal women, but sometimes they're used off label. A lot of times they use the off label in postmenopausal women as well. Again, if it doesn't work, then you stop using them. The last thing is testosterone. So testosterone, the way that it's dosed, and you want to make sure that you go to a practitioner that knows how to dose testosterone. But the way that that's dosed is that you take a 10th of the dose that's recommended for men. But it's not oral, it's a cream and the way that you do it is so you, you know, you allocate, you take out and the physician that recommends it for you will know how to dose it for you and we'll teach you, but you take a little bit of that cream. And you place it on the back of the calf or the thigh and you have to make sure that you wash your hands right away because it is transferable that that testosterone that's on your hand. But again, what you have to do with that is you can monitor levels. You have to go to a provider that will monitor your levels. And also, if you start to experience, I mean, it's a very low dose. So it's unlikely that you're going to have these side effects, but some of the side effects of having too much testosterone can be increased in acne, deepening of voice, clitoromegaly, and so male pattern baldness. So that's really, if you have like very high levels of testosterone circulating in your body, it's unlikely with this small dose of testosterone that you're getting, but that is used off label to increase libido.

Kerry: 41:07

Wow, I didn't. Well, I think I remember hearing back about all the different newer FDA. They're pretty new, right? The FDA approvals

Sadaf: 41:14

They are in 2015 is when Addy was FDA approved and in 2019 is when Vylessi was approved so yes, they are very recent. It's not like Viagra that was approved way long ago right for men, unfortunately for women's women's health always seems to take much longer. So, yes,

Kerry: 41:35

Yes, absolutely. That's a whole nother topic.

Sadaf: 41:37

Yes

Kerry: 41:38

as far as the software, and so it's important to check the levels with that one, right? Whereas the labs for the other things weren't, as more as as needed. Okay. Well, that's good. Well, is there anything else you'd like to share with everyone? I mean, we can probably split it into two episodes at this point. Mm

Sadaf: 41:56

I mean, you know, I would, what I'd love to say is that, you know, just going back a little bit to that intimacy coaching. is that, you know, there's, there's really easy ways. So with libido and, you know, there's a spontaneous desire and responsive desire. And it's important to understand that as we get older and once we're in long term relationships, that it's really responsive desire that comes about. And what that means is that you may not You know, feel like you're in the mood for any type of sexual intimacy. But once that sexual stimuli starts to happen, that desire and that arousal and oftentimes arousal will happen before the desire. And that that's normal. What we see in TV with spontaneous desire and people jumping on, each over like on top of each other and all this stuff, having this crazy mind blowing sex is really not what happens in longterm relationships. And so it does require a little bit more effort. And, you know, really Another thing that I want people to understand that, in menopause, menopause does not, is not synonymous with abstinence. You don't have to be absent. A lot of times I'll have patients come in my office and I'll ask them if they're sexually active. They'll be like, Oh no, I gave that up, as if they're like giving up chocolate or something like that. Oh no, I gave that up, you know, no longer. I don't need that part of my life anymore. I'm in menopause, And that's not the case. It doesn't have to be like, if you're okay with that, and your partner's okay with that, then that's fantastic. That's what works for your relationship, but if it's not what you want, and you want to improve your own libido, and you're seeking help, then there are ways to seek help. And it's important to talk to your doctor and really, if you're having decreased libido, really just schedule an appointment for that specific cause, you don't want to go to your doctor and be like, Hey, I'm here for my annual and my pap smear, my mammogram, my breast exam. And oh, by the way, I have decreased libido, like that's not going to work. So you have to really just go in for that specific complaint because unfortunately, a lot of doctors only have like 15 minutes to spend with you and your appointment. And so you really need to be focused on why are you going there and what type of help you're seeking. But I think that the intimacy comes from a lot of things. So we have physical intimacy, but there's also like intellectual and experiential and there's emotional and there's different ways to do that. They are easy enough to do it. Like you don't have to spend like hundreds of dollars on expensive vacations. You can just take a walk outside with your partner, right? Just holding hands. It's all about that experience and, and being together and focusing on each other and really being mindful and present, that's what it really boils down to. And in fact, there was a study done in 2013 by Rosemary Basin, who actually created the circular model of the female sexual response. And she did this group study of these women and there were these 90 minute group sessions and what she noted is that when women practiced mindfulness and just really being present without judgment in like the specific situation that they were in. So, let's say you're in a situation where you're about to become intimate with your partner, right? If you focus just on that situation, where you are, forget about the children, forget about the chores, forget about the laundry, all that stuff, but just focus on that particular moment, just focusing and being present, increased arousal, increased libido, increased lubrication, all of that, and increase the amount of satisfying sexual events that they experienced. So just being present and creating that emotional intimacy with your partner really leads to people seeking out more sexual stimuli and becoming more closer with their partner. And that's, you know, really what I want to emphasize. And I think that Even just like a physical touch, holding hands, eye contact that increases emotional intimacy. Establish being, you know, allowing yourself to be vulnerable with your partner, right? Just being honest, sharing your innermost thoughts and feelings, I think is really important. Having that spiritual connection exchanging ideas. All of those things are really, really important. And another concept that I think is important, and sometimes we forget, is that sex will change as we get older and that's okay, right? And as Emily Nagoski says, pleasure is the measure. So if you're experiencing pleasure, then however you experience pleasure with your partner or by yourself or whatever, then that's what's good for you, right? And sexual intelligence is knowing that as we get older, things are gonna change. But again, that's okay. And they always say that, right? Comparison is like the stealer of joy. What is that

Kerry: 46:42

I'm not sure.

Sadaf: 46:44

But what's really important is what's right for you, what's working for you, and what's creating that emotional bond between you and your partner. And when you feel more connected to your partner, you're going to want that physical connection as well. And that's going to lead into that increase in libido.

Kerry: 47:00

Yeah, I like that phrase. Who is Emily?

Sadaf: 47:03

Nagoski. So Emily Nagoski is is a famous author. She wrote the book, Come As You Are. And she's really big in sexual medicine and sex therapy. She's a psychologist, I believe. And so she's written two books. She wrote that come as you are. She's also done some Ted talks and she wrote a new book called come together. And she was also featured in the New York times most recently talking about how her relationship, she talks about relationships and how to improve relations, all this stuff. And she talks about how in the midst of doing all of that, her relationship fell apart. And so it was really amazing to see how vulnerable she was to kind of let readers into her own life and see how she kind of picked up the pieces with her partner and kind of brought them. And that was the impetus for her book called come together and really showed how just, you know, really making an effort with your partner because I think a lot of times we take our partners for granted, I know I do but And so when you really make that effort with your partner and you really become intentional and spend time that quality time It will improve the relationship and I know that a lot of people balk at the idea of like date nights With their partners, but it's so important because especially when you have a partner that is has low libido and somebody that has high libido. And the reason why that's important, those date nights is because the person with the low libido knows that okay they can anticipate that, this night we're going to have sex, right? The person with a high libido can be like, okay, at least this night we'll have sex, right? Because the person with the high libido always feels rejected by the person with the low libido because that person with the low libido is always like, no, I'm too tired. No, I, You know, I didn't get enough sleep. No, I have a headache. No, there's always so many reasons and so then the person with the low libido then is afraid to even give a hug or a kiss to the person with the high libido because they're like, Oh no, I don't want to tell them that, you know, I want to have sex because I don't want to have sex. I just need a hug or I need a kiss. And the person with the high libido, it starts to become resentful. And it's like, well, this person is never ready to have. sex and that's when they start to think like, well, is there something better outside of this relationship rather than this person never wants to have sex with me. And so when you have this date nights, at least it gives the one with the high libido hope and the person with the low libido, at least they knew and they can anticipate and then they can get ready. And when you anticipate something, right? So I don't know if you remember when you were first dating your partner, your spouse, when you went out on dates, right? You actually prepared for it. You got ready. You look nice. You maybe you put on your favorite perfume and you kind of anticipated what the day was going to right. And that's the same thing for the person that It has the low libido. And if you have those date nights, they can at least start to anticipate it, start to kind of get in the mood, give themselves time to kind of process that, okay, you know, this is what's going to happen. This is what I like, what I don't like. And so then it allows the two of them to come together. And that's why those date nights are so important.

Kerry: 50:09

I laugh, but you're right. It is so important. And I think everybody's so busy. And if it has to be scheduled in, it's got to be scheduled in right to make effort for it. Absolutely.

Sadaf: 50:20

Has to go on our CEO calendar, right?

Kerry: 50:22

Yes, exactly does. All right. I have homework to do. So I will be doing that. But yeah, thank you so much. I mean, is there anything else you want to share? Because this has been great. And I have a feeling we can split it into two episodes to make make the most of it as well. So I'm so thankful for stealing all of your time.

Sadaf: 50:40

Yeah, no problem. I'm just trying to see if there's anything else. Yes. Okay. So just a few more power thoughts and then I'm done

Kerry: 50:47

I'm happy. Yeah, we're good.

Sadaf: 50:49

All right, so sometimes People ask me like what are some you know power thoughts and women can start thinking about that will help them Increase intimacy and that's kind of a little bit what we talked about before but practicing mindfulness does increase your pleasure and arousal and it's been proven Through research accepting and loving yourself right now. So I think that's one of the biggest things that a lot of times people will say like, Oh, you know, I'm waiting to lose those 10 pounds to feel good about myself again, or I'm waiting for that next job, that next promotion, whatever. And it's just really just accepting and loving yourself where you are right now and knowing that you are worth it, right? You are worthy of that love. And I say this to my kids all the time is that, you really have to be your own biggest fan. You have to really love yourself to then be able to exude that energy out into the world. And then you'll get back what you, you know, you'll get back what you put out. But it's really, really so important to really just love yourself where you are right now in this moment. And also what we talked about with sexual intelligence that realizing that love and intimacy will look different as we age and it's a normal process of life and to not compare yourself to what others are doing or what you think others are doing right. A lot of times people will talk but really when you pull the curtains back their lives may be not as fantastic as what they make it seem so really just not compare yourself to others and just realize that things change as we get older. But that's okay. It doesn't matter. It's whatever is working for you. Write down what you want. Make sure you communicate. There was a study that was done that they wanted to know what was the number one factor in improving your sexual experience with your spouse or your partner and the number one reason was communication. So that, that is the one thing that really improves your sex life really with your partner. And making time for sex and date nights. I think that oftentimes when we start to talk to our partners or whoever about, our relationship, our intimate relationship and about sex people automatically go to the negative and be like, Oh no, there's something wrong. Like what's wrong, what's wrong with this guy. And we have to try to move away from that and realize that this is just a communication and open communication, right? Sharing what your wishes are, what you want, or maybe something that you like, maybe something that you don't like. Never discuss what you don't like in bed together, right? That's like a joy kill, kill joy. But I mean, really, you want to discuss it outside of the bedroom. And what I always say is whatever is happening outside of the bedroom is also happening inside of the bedroom. If you're not talking to your partner, if you're stonewalling them, if you're not sharing what your deep thoughts are, what your concerns are, what you want, what your wants are, then that's probably also happening inside the bedroom, right? If not more there. And so learning to just enjoy the moment learning to ask for help when you need help with chores or whatever it is to take off things off your own plate so that you can really enjoy being intimate and creating that emotional and physical intimacy with your partner.

Kerry: 53:53

Those are all such beautiful things. I want to summarize it completely, but I don't know if I can capture it all. But I do think, yeah, I will certainly, put it in the show notes but I mean this was great. Such a great discussion here from libido to menopause to just intimacy. It's just amazing. We've covered so much and I really thank you. How can people reach out to you? How can they find you if they want to work with you? Or how does that work?

Sadaf: 54:18

So as an intimacy coach, I can work nationally. There's no license restrictions there. So you can reach out to me at Dr. Sadaf at drsadaf. com. That's my email. If you want to follow me, I'm on Instagram at Dr. Sadaf OBGYN. I'm also on YouTube at Dr. Sadaf intimacy coach. I have a podcast called the Muslim sex podcast, where I talk about relationships and Trying to think yeah, and I do webinars, so I host those. So definitely people could DM me, but probably the easiest thing is to go on to my email, which is drsadaf at drsadaf. com, and I have a website at drsadaf com. And if you are a patient, I'd love to see you, like if you're thinking you need help with sexual health or menopausal health, I am licensed in both Michigan and New York.

Kerry: 55:06

Very good. Okay. And I feel like we failed to mention that you have your own podcast, the Muslim sex podcast. Everybody should check that out as well. And we'll just put everything in the show notes and thank you so much for coming on.

Sadaf: 55:19

Yes. Thank you.