Part 1, 2 and 3

PART 1

 

PART 2

 PART 3

Hello everyone. I am Dr. Barbara Bartlik, and I am presenting a lecture that I delivered at Mount Sinai Medical Center to the psychoanalytic organizations. And I'm delighted to speak with you today. I would like to briefly tell you about how I became an integrative psychiatrist and sex therapist. Then I'll discuss why integrative medicine is an important approach for healing, sexual problems and an essential tool for therapists. After graduating from the Albert Einstein College of Medicine, I did my residency and research fellowship at NYU. I then studied sex therapy with the sex therapy pioneer Helen Singer Kaplan, and became an associate in her private practice for several years. I then joined the faculty practice at Weill Cornell, where I saw patients with sexual problems and psychiatric issues. In searching for my own solutions to health problems for myself, I became interested in integrative and functional medicine. I started taking vitamins, had mercury fillings removed, changed my diet, and lo and behold, I got better. I went from needing to take antibiotics and steroids frequently for sinus and skin problems, to never needing them again. I began recommending magnesium and other nutritional supplements to my patients and had very positive results. If a person has a deficiency in magnesium or another essential nutrient, they may experience psychiatric problems and other health issues with supplementation.

A person's mood improves. They need less psychiatric medicine if they need it at all, and sometimes they don't have to take it at all. The integrative approach is essential for sexual health because psychiatric medicines almost always have adverse sexual side effects. So the less psychiatric medication you give, the better, as long as the psychiatric symptoms are well controlled. Over the years I attended integrative and functional medicine symposia, I was hungry to learn. I took a qualifying exam, which led to my being grandfathered into the new board certified specialty of integrative medicine. And I attended and presented at the Integrative Healthcare Symposium in Manhattan. This annual meeting held every February presents high quality, scientifically rigorous lectures by leaders in the field, as well as opportunities for professional networking. I highly recommend it. We need more solutions for sexual problems of men and women.

Premenopausal women now have two medications for low sexual desire, which is a great accomplishment, but these medicines are slow to gain acceptance and are not covered by insurance for post postmenopausal women. And those women need help the most. Viagra like medicines are great, but they are not always the answer. The fact that half of the prescriptions are that are written are not refilled is a clear indication of the urgent need for new, more effective solutions. Evidence-based integrative medicine solutions as either standalone or adjunctive therapies could be the answer we need to think outside the box and act. Now, before I briefly summarize these therapies, I'd like to review some of the sexual health concerns that require new solutions. Low libido is an increasingly common sexual complaint. It has long been the number one sexual complaint of women for varied reasons. Relationship problems, restrictive upbringing, concerns about attractiveness, menopausal complaints, vaginal pain, sequelae of cancer, and its treatment and more. Rosemary bean's model of the sexual response, which is not accepted by everyone in the field, indicates that many women do not experience spontaneous sexual desire. Instead, their desire comes about in response to their partner's initiation. But what if their partners are initiating lists due to their own issues? Studies show that the frequency of sexual interaction between married couples and single people in relationships is now at an all time low. It diminished during the pandemic and it remained low significantly.

Men today are reported to have lower libidos now than in the past. There are many possible reasons for this. Anxiety and mood disorders, stress changing roles and relationships between men and women, social and economic impediments to intimate relationships, all of these things can lower testosterone levels. Men also now have more sexual outlets, such as pornography. Many men today are less interested in forming intimate relationships and having sex with real women, which is very distressing to women. Excessive screen time may be another factor, changing couple's behavior, and not only due to pornography, but because screen time is taking time away from normal social and sexual behaviors. Young people tend to spend more time playing video games while older people spend more time watching TV shows and movies. Now I'm going to talk about a big problem.

It's the declining testosterone levels in men. On the slide, you'll see there's that- today, a 22-year-old man has a testosterone level that is the same as a 67-year-old man in the year 2000. That's quite a drop. Testosterone levels have dropped more than 20% in the last 20 years. The average testosterone in 2000 in a man was 600 and, and in, in, oh, let me go over that. I have to start that one again. . Testosterone levels have dropped more than 20% in 20 years. In the year 2000, the average testosterone level was 600.

In 2018, when the study was done, it, it was down to 450. It dropped 150 points on average, that is huge. One in four men today, over 30 years of age, have low testosterone. Sperm counts have declined by 60% in the last 40 years, and male infertility is on the rise. So testosterone, we know how important it's for sexuality, especially in men, but it also affects more than just sex. It impacts mental health, anxiety, insomnia, mood, self-esteem, vitality, energy, and more. So what are the causes of low testosterone? I just mentioned a few earlier, but there are others that are of great interest to the integrative medicine community. . On this slide, you'll see they are endocrine disrupting chemicals such as, BPA, heavy metals, parabens, phthalates, also antibiotics and hormones in meat. These all disrupt the hormones and, and usually diminish testosterone. Also, poor lifestyle choice choices.

People are more sedentary today and we have more metabolic syndrome and more obesity than ever. And this can also lead into diabetes, which is a killer for sexuality. Inadequate diet. People are eating nutritionally depleted, processed foods and contributes to that, contributes to poor health in so many ways. Also, people don't realize it, but the medications they take deplete micronutrients that are needed to make hormones and neurotransmitters. This is very serious. , in my opinion, if a person is on a medication, any medication, psychiatric or otherwise, they should look up what micronutrients are depleted by those medications and consider taking a nutritional supplement of those. Sometimes it's magnesium, zinc, B vitamins, vitamin C, all of those can get depleted by medications. Your body uses up the vitamins in the metabolism, or it makes, makes you excrete these vitamins and minerals the medication, so you, it's really good to supplement, to prevent a deficiency.

Also, testosterone depletion could be due to wifi and cell phones. Some research indicates this, but we, we don't have, but all the data is not in yet, so it's good to wherever possible, turn off your wifi, , and, and minimize exposure, , of your body to your cell phone. An unhealthy diet and lifestyle can contribute or even cause sexual problems. Sometimes clients can be seen as treatment resistant or unresponsive to sex therapy or mental health treatment, when really the problem is an undetected physiologic problem. Clients feel cared for when their therapist helps them find new ways to improve their health. Integrative medicine counseling is perceived as psychologically supportive and it improves anxiety and move mood. When clients improve their lifestyles, they lose weight and often need less medication for psychiatric and medical conditions. And then because they're off medicine or on less medicine, their sexual functioning improves.

The next slide shows you some integrative approaches to improving sexual health. Adequate sleep is very important because during sleep, your sex hormones are produced. Adequate sleep gives you better energy and mood helps prevent weight gain, and it does improve sexual functioning. People who are sleep deprived have sexual problems. We see that in our patients who have sleep apnea syndrome. Also, there are many ancient traditional therapies that have been, have been shown in some research studies to work. They are acupuncture, aromatherapy, Ayurveda, botanical medicine, European hydrotherapy with cold and warm washes, traditional Chinese medicine and others that help sexual problems. Exercise is extremely beneficial for sex. Did you know that anaerobic exercise, such as exercising large muscle groups as in lifting weights and doing squats, increases testosterone in men as much as taking a testosterone supplement? Sometimes, it is possible that anaerobic exercise will also raise women's testosterone, but we have less research on that.

Exercise is associated with better sexual functioning studies of people, men and women going into yoga programs shows that their sexual performance and satisfaction improves as well as their flexibility. And also exercise improves overall fitness appearance, your attractiveness to your partner, weight control, and so on. The Mediterranean style diet is sex positive. That has been proven scientifically, probably because it is anti-inflammatory. And when you have less inflammation, your body functions better. Sexually, alcohol disrupts sleep and it impairs sexual performance. It also strains your liver. So if your liver is busy metabolizing the alcohol, it can't do the other important things it needs to do to pro protect your hormones and other functions. Smoking is bad because it damages your blood vessels, as among other things increases blood pressure. It is just the worst thing you can do. Now, micronutrients on this slide are listed.

Now on this slide- we show the micronutrients that are necessary for good sexual functioning. They balance hormones, they enhance your blood flow and they improve neurotransmitter function. So the vitamins that are the most important for sex are B six, B12 c, d, boron, folate, iron, magnesium, niacin, sodi, and zinc. These have all been shown scientifically to aid sexual functioning. Also, the amino acids that are important for sexual functioning are l-arginine and L-citrulline. These are precursor to nitric oxide. And nitric oxide is responsible for the dilatation of the blood vessels and critical to sexual functioning. Also, omega, also Omega-3 fatty acids support, hormone metabolism, cardiovascular health and neurologic function. So it's very important to get these fatty acids, if not from fatty fish. That's wild caught and safe.

Then from nutritional supplements that are clean. So on the next slide are some of the top botanical medicine supplements that people can take to improve their sexual health. And most of these are supported by research. Ashwagandha, Deana Ginseng, horny Goat Weed, Rhodiola, Sheila Git, and Tribulus. Now cannabis is a favorite. 30% of people who buy cannabis and use it are doing it for sexual reasons because they have, they enjoy how they feel sexually on the cannabis. Alright. , and now that it's available over the counter in various forms, edibles, capsules, tinctures, lotions, lubricants, it's easy to get. And even senior citizens are using it a lot now, where they wouldn't have before when it was illegal. 

CBD is a cannabinoid, but it does not have the hallucinogenic properties that cannabis has. So it doesn't make you high, but it relaxes you. And some people find that CBD is very good for their sexuality and we're finding it now in lotions and lubricants, massage oils and so forth, as well as oral, oral forms. Now, DHEA is a hormone. It's the hormone that gives rise to estrogen and testosterone in the body naturally. And it does enhance sex in research studies. It can be taken orally by men or women or vaginally by women with or without a prescription. There is now a an FDA approved DHEA vaginal cream, which is helpful. , so, and you can also, go to compounding pharmacists and get DHEA from a compounding pharmacist in a vaginal cream.

Oxytocin. The cuddle hormone, or the love hormone, is available by prescription at compounding pharmacies as oral atrocious and nasal sprays. This makes people feel more sexual. It makes people feel more sympathetic, more understanding of others. It's a good thing, but it is very expensive and not covered by insurance. None of these, by the way, are covered by insurance, so you have to be prepared to pay for them. , now, now we're going to the next slide where we, I talk about off-label compounded creams. ? These are creams that men and women can use to enhance sexual functioning. Some of them have been studied in research, others have not. They are mostly medications that dilate blood vessels or enhance hormones. When men take these creams, they have to insert them into their penis through the urethra with a small plunger and no, so that is uncomfortable. Women merely have to massage it into the vulva and cl clitoris and they by, because they dilate blood vessels and enhance hormones, they can have a sex positive effect. So I'm just going to list a few. , they can be made of any combination. You could pick any two or three or four and put the pharmacist can put them into a compounded mixture for you.

Nitroglycerin, L-arginine, Viagra like medicines, phentolamine, theophylline, and niacin B three. , the female cream preparations may include DHEA, estradiol and testosterone. I think the best way to learn about what products are most popular, what combinations is to consult a large compounding pharmacist who handles a lot of patients and ask what preparations are most popular. Since many of these are prescription items, you can't buy them over the counter, but some of the ingredients like niacin and arginine are over the counter and you can get them over the counter, , in creams. , we have over the counter, moisturizers and arousal creams for women. Mostly not evidence-based, not well researched, , but they contain things like hyaluronic acid, vitamin E, coconut oil, cinnamon, which is warming, and peppermint, which is cooling the warming alternating cooling effect can be arousing for some women. Also, cacao, ginger maca, wild yam and many more ingredients are included in these products. We now have an FDA gel for men. It's called oxon and let me start that over. We now have an FDA approved gel for men called Oxon. The mechanism by which it works is through cooling by evaporation. It contains an alcohol product that as it evaporates, makes the head of the penis feel cool. And then there is a warming response that increases penile blood flow.

Now I'm going to tell you on the next slide about a case in my practice. This is a 39-year-old woman with severe premenstrual dysphoria. She's a 39-year-old married mother who was referred to me for treatment of severe premenstrual dysphoria and irritability. She was drinking two glasses of wine a night. She had been sexually abused by an older sibling when she was a child, and she struggled with vaginismus from her late teens till her early thirties. At age 34. After several years with her husband, she underwent treatment with vaginal dilators and she could finally have sexual intercourse. However, after the birth of her child, the vaginismus returned and she could not have intercourse for two years, but she and her husband engaged in other forms of sexual activity treatment. Next slide. I prescribed for her sertraline 50 milligrams. During the luteal phase of her cycle for premenstrual symptoms, she began taking a detox shake and nutritional supplements designed to address female hormone balance, including vitamins DB six, B12 E, vitamin, folate, magnesium, quercetin, and Omega-3 fatty acids.

She also changed her diet from one that was high in carbohydrates to the paleo diet, which is gluten, dairy, sugar, and alcohol free. Her premenstrual symptoms improved after two months, but she still had vaginismus. I put her on 50 milligrams of Viagra orally as needed an hour before sex or more, which was very effective. Effective. She not here, let me start that over. She started 50 milligrams of Viagra orally as needed, which was very effective. She noticed that her vagina felt mushy, more open, relaxed, and lubricated. And after a few tries she had no pain on penetration. Now, after only four months in treatment, she regularly engages in sexual intercourse on Viagra. Her PMS is largely gone and she has lost eight pounds and she's very happy with that. She said that the sertraline increases the amount of time it takes for her to achieve orgasm, but she does not find that a problem.

So in this case, the nutritional supplements that this patient took improved the metabolism of estrogen and reduced estrogen dominance, which is associated with premenstrual symptoms and other female problems. Although women have been taking Viagra like medicines off-label for decades, the research on use in women is mixed. Some studies report that they are effective in treating antidepressant induced sexual dysfunction when taken orally, and others find that they're not effective at all. Viagra is also made into creams that are applied to the vulva and that has been studied and in one study it was found to be helpful. In my opinion, Viagra oral and topical is beneficial for women with pain on penetration. I've also seen it work in menopausal problem. I've also seen it work in menopausal women with this problem, but there's almost no research on this population. I think it warrants further study strengthening the pelvic floor muscles enhances bladder control and improve sexual functioning in both women and men.

However, many people find doing kegel exercises tedious and challenging to perform consistently. 70% of women have some degree of incontinence at, at some point in their lives. So it is a major problem. And the solutions we have for female incontinence are completely inadequate. They are medications with unwanted side effects and surgeries that can have serious consequences. Both can interfere with sexual life. Women need to take action early to prevent incontinence and prolapse. Several new technological devices can strengthen the pelvic floor and improve bladder and sexual functioning. They do this by increasing the blood supply to the genitals and, and enhancing oxygenation and healing. I would like to mention them to you briefly here because I think they are essential for you to know about so you can share the information with your clients. Some clients may ask you about them. Why are these devices considered integrative? Well, primarily practitioners with integrative orientations are using them. They are not yet standard of care. They may have been FDA approved for other indications, but they're considered experimental and are used off-label for sexual dysfunction and pelvic floor problems, even though there is scientific evidence that they work. Next slide please.

Here are some treatments, electronic treatments to improve the pelvic floor muscles, bladder control, and sexual function. I'll do that. Over here are some therapies, electronic therapies to improve the pelvic floor muscles, bladder control, and sexual function. The first is pulse electromagnetic field therapy. In this treatment, a magnetic field stimulates the production of nitric oxide in the endothelial cells, lining the blood vessels, causing them to relax and open high intensity. Focused electromagnetic technology is another form of PEMF. Here a chair delivers electromagnetic pulses causing the pelvic floor muscles to contract. Six treatments are given over two weeks usually.

Then we have neuromuscular electric, no. The next one is neuromuscular electrical stimulation devices. These are similar to tens units. They deliver an electrical current causing the pelvic floor muscles to contract rhythm rhythmically without having to think or put in any effort. So compliance is better. Radio frequency. Thermal treatment is typically performed by gynecologists. A probe delivers painless heat to the vaginal canal and external clitoral and labial tissues. Three treatments are given a month apart. Then there's red light therapy with red or near infrared light. It can be directed towards the genitals or over the whole body. Red light stimulates the mitochondria to produce a TP. It has been shown to improve erectile dysfunction and it increases testosterone levels in studies. These treatments are expensive and not covered by insurance. I'm in the process of forming a nonprofit or organization called Wait. I am in the process of forming a nonprofit organization called pelvic floor rescue.org, where people can learn about their various options.

The next slide shows how you can obtain online integrative functional medicine training. You can go to any one of these institutions to become an integrative health coach or nutrition coach, the Institute of Integrative Nutrition in New York City, the Andrew Weil Center for Integrative Medicine at the University of Arizona, which is mostly online, and the Institute for Functional Medicine. And now for the final slide. I hope this brief overview gives you a sense of how integrative medicine can effectively treat sexual dysfunction. Often a combination of traditional and alternative therapies is the most effective approach due to synergy. For example, the patient might receive psychosexual therapy, pharmaceuticals, nutritional supplements, compounded creams and diet and lifestyle modifications, and where, where, and they might work in combination where any one of them individually might not work. I also recommend, our 2018 book Integrative Sexual Health as a primer for this integrative perspective. All the integrative solutions mentioned above are discussed in this book with supporting evidence. Our forthcoming book, which will be published by Oxford University Press, will be titled Optimal Sexual Health, and it will be updated to reflect the new research. It will be suitable for the general public and will so also serve as an excellent resource for professionals. I'm going to say that one again. It will be suitable for the general public and it will also serve as an excellent research resource for professionals.

Consider incorporating principles from integrative medicine into your practice. You will learn how to improve your health and that of your clients. They will then respond better to therapy for mental health issues and sexual problems. Thank you so much for your attention.