Sexual medicine is underfunded, misunderstood, and often dismissed. But it's also one of the most collaborative fields in healthcare. Dr. Tami Rowen recaps this year's ISSWSH conference and what it revealed about where the field is heading.

Dr. Rowen is the current president elect of ISSWSH and has been instrumental in shaping sexual medicine education and research. We recorded this right after the 2026 ISSWSH conference in Long Beach, which had almost 600 attendeesone of our biggest conferences yet.

We discuss the standout research from the meeting, including award winning work on sexual function after gender-affirming hysterectomy and why most top abstracts focused on sexual pleasure rather than prevention. We talk about the reality of research funding in sexual medicine, why industry support creates conflicts of interest that look bigger than they are, and how lack of NIH funding means we have almost no treatment options for conditions like vulvodynia.

We also dive into testosterone therapy why it's controversial, what the data actually shows versus what social media claims, and why Dr. Rowen doesn't treat hormone levels but rather treats individuals with specific goals. We discuss body image after breast cancer surgery, lymphedema's impact on sexual function, and why technoference is contributing to the lowest rates of sex we've ever seen.

Highlights

• ISSWSH focuses on sexual pleasure and quality of life, not just prevention of pregnancy and STIs.
• Research funding for vulvodynia is $4 million annually versus $800 million for breast cancerthat's one grant versus hundreds.
• Testosterone therapy should treat symptoms and goals, not hormone levels or deficiencies.
• Body image and sexual function outcomes are significantly worse after mastectomy versus lumpectomy, even though cancer outcomes are equal.
• Technoference (technology interference) is contributing to historically low rates of sexual activity.

If you're a clinician interested in sexual medicine, consider attending the ISSWSH Fall Course for foundational education and the annual meeting for cutting-edge research.

If you're a patient navigating any issues and not currently getting help, know that there are practitioners out there who want to help you.

Subscribe to the podcast and share this episode with anyone who wants to learn more about sexual medicine, menopause, or women's health education.

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GSM Collective

Okay, awesome. Hey all, it's me, Dr. Smita Rahman, Gyno Girl. Welcome back to another episode of Gyno Girl Presents, Sex, Drugs, and Hormones. I'm Dr. Smita Rahman. Today I have a wonderful friend and colleague who has been on the show once before, I think two years ago maybe, when I first started. Dr. Tammy Rowan, she's an associate professor of OBGYN at UCSF, the University of California in San Francisco.

and her clinical practice focuses on caring for women with sexual health concerns and chronic illness, as well as GYN surgery and family planning services. Her research is focused on family planning and sexual health practices, both nationally and internationally. And she is the current Ishwish International Study for the Study of Women's Sexual Health president-elect.

I came home because my kids got home early today. Go, go, So I'm not even in my house. Go, please, leave me alone. OK, Carrie, you'll have to re-edit this. She's the current International Society for the Study of Women's Sexual Health president-elect. And I was a former educational chair and the former scientific chair and

has been a huge part of why I'm part of Ishwish. I always appreciate that. Welcome Tammy back to life's show or whatever you want to call it podcast.

Thanks for having me back. good to see you, even though it's been such a short time. I just saw you like less than two weeks ago at Iswish.

I know, and it was such a fun time. think people had a good time. We had a really huge conference this year in Long Beach. And I think we had close to 700 people registered, about 600, almost 600, including the people that sponsored that were there, which is probably one of our biggest conferences, I think.

I think it was our biggest conference and big congrats to you because you were the scientific chair for the meeting.

thanks. you really helped me a lot, too. I was texting her, Matt, every time someone canceled. Tammy, what should I do? Where should we go from here? So I think you're only as good as your scientific committee, honestly. So we had a good committee this year. Well, let's talk about some of the big things that happened. mean, you're the Ishwish president-elect, so congratulations on that. I'm super excited about you becoming the president in two years, I guess, right? Because Dr. Sally McFedrin is now.

There was a lot of discussion and issue which this year we talked a lot about you know research we had the whole research symposium actually let's talk about the research for a minute because your mentees actually won the big Erwin Goldstein award so can we talk about some of the research that you guys did that brought this big award to the students and residents you work with.

Yeah, so it was a project that I led with a team of former medical students, current residents, and then another medical student. And so it had been a question I had actually been curious about for a long time, which is, are there sexual changes after a gender-affirming hysterectomy?

And so we would extrapolate a lot of the data. People oftentimes ask about hysterectomy. It's the most common procedure in the United States, actually, in terms of surgery. And so we have a lot of data looking at sexual function in the cis population. And you have to remember that people are getting hysterectomies because of fibroids or abnormal uterine bleeding or pelvic pain, which is very different than what the transgender and

Mm-hmm.

gender non-binary population is seeking care for. So they're really getting a hysterectomy really to align their body with their gender. They sometimes do have pelvic pain. We figured that out actually in our study and I've seen it clinically for years. And so I was super curious about this question.

And several years ago, I had some incredible students who were interested in sexual medicine who wanted to work on this project. And so we designed the study and I recruited from my clinic and they followed these patients out for up to a year. So they tested them pre-procedure and asked them all kinds of details about not just their sexual practices, but what gives them an orgasm. And then different aspects of...

their sexual health as well as their demographics, you other types of medical problems. And then we were able to survey them actually for several months up to a year after. And what's so exciting about this project is that we had been presenting this data at this wish for the last two years. We had our baseline data one year, we had three months data another year, we had six months data, and then we finally had this month to one year data. And that, you know, previously we were just

.

presenting with posters. And this time we got a podium and not only were we on a podium, we were in like the main program session, because we changed it this year to put the top five abstracts on the podium for the entire meeting. And then it was actually the best abstract of the meeting. So they won an award for it. And so it was this beautiful, beautiful experience because the students who did it are now residents.

Yeah.

It's amazing.

And so they were able to come. And then we had a current student who really kind of sailed the ship home and was getting most of the last nine to 12 month data and helped us put it together. And she was there and was presenting as a second year medical student to win this award from 500 people.

yeah.

was amazing. Yeah, it was pretty amazing. And I think there's so many people didn't even know you get awards for it. They're like, what? People get awards? And I was like, yeah, something to look forward to. So it was great. Yeah. I didn't realize half of them were coming. So yeah, it was a nice, I think, moment there. there were tons. There's tons of great abstracts, I think. Was there anything else that stood out for you when you were thinking about some of the abstracts?

There were a lot of awards given out, and the president gave out like five different awards.

think the top five were all really interesting. I think what really struck me about the top five was that they were almost all exclusively focused on sexual pleasure. There was one that was looking at kind of ET distribution in a general area, which to me was really, if you looked at any provider, I was like.

Thank

You could look at PTs, could look at plastic surgeons, you could look at dentists and you would find that they would be kind of concentrated in wealthier areas. And I think we saw that with physical therapists. But I thought what was so exciting was that in most of those abstracts, we were talking about sexual pleasure and orgasm and in things that we don't oftentimes think about with sex. You know, we were always taught sexual and reproductive health is really about prevention, right? We're preventing pregnancy.

Yeah. All right.

in New York City.

That's right.

Yeah, STDs.

we're preventing sexually transmitted infections. I hear that all the time, that people are like, that's what sexual health is. And I'm like, no, it's not actually. In ISWISH, we don't spend a lot of time talking about it. There's a lot of societies that can do that. We're here to talk about pleasure. And that was what I got out of, from a lot of the abstracts, which I thought was really important.

Yeah. Yeah.

Right. Right. Right.

And that, yeah, that's a really good point. And not even talking about like usually you have some new pain stuff or, know, but this was like really just like what's bringing pleasure to these patients, which is really cool. I like that a lot as well. What do you think? I mean, there was another good abstract. Actually, there were a couple of good ones on social media too. I think you had a couple of medical students present on different aspects of, what was it? Menopause and

Yeah, I mean one of the other topics abstracts was just developing the scale. Samina, we're gonna have to edit this, you're at Samina.

who's giving the education out and I can't remember the details, but I remember that was a pretty good review of what was happening. It was yours too.

Samina, you're cutting out a lot. I'm having a really hard time. Samina, your audio and video are not working for me. So I'm getting like 60 % of what you're saying, but it seems like the connection is really not working.

really?

huh, let's see.

So I'm trying to follow along, but you're blurry and then the audio is not coming through.

really? Huh. Strange. Let me see.

Yeah.

Yeah, mine, like I can see myself, don't know, you know, I just don't know what it is, but it's a little better right now, but what you were just saying, I couldn't hear you. I'm sorry for your editor that you're gonna have to edit this out.

Okay, that's fine. No, what I was saying is, what was I saying? I think I was asking you something. I was asking you about the other abstracts. Okay. So there were also some abstracts about like social media and menopause education. I think that was one of your students as well, right? Yeah, that was pretty cool.

Yeah, we had a couple posters, one that I thought was really neat that was looking at TikTok influencers and menopause content. And so if you look at the top 10 influencers in terms of menopause, only one of them is actually a physician and less than 8 % talk about anything related to sexual health in menopause, which I think really highlights this need because sexual dysfunction absolutely peaks in menopause.

Yeah.

It should be at the top of the list of things that people are talking about. I think people are excited about it. And I'm you know, schooled enough in social media to wonder if, it because it's hard to get sex talked about on social media? The algorithms don't, you know, feed it really well. But that's my suspicion because to me, it would be a total hit if people actually talked about the high rates and the different treatments.

Right.

Yeah.

think there's a lot of.

I agree. Now I think there's a lot to do with the algorithms too, because there's a lot of, you get sort of lost in, they don't put you up front when you talk a lot about sex or some of the, you say vagina too much or something, I don't know. It's unfortunate.

That's why I'm going to be behind in the feeds for people looking at my accounts.

Right. You guys have to just look for Tammy Rowan and then you'll get all the good education. Okay, so as president-elect, know, what do you think makes like Ishwish 2026? How are you going to look toward the future? What do you hope to change? What do you hope to bring about? What do you hope to grow in this organization?

So I think there's a lot of things that we have going for us right now. There's a lot of momentum and interest in sexual health. And what's special about this wish is that we really talk about quality of life in a way that I think is different. And people are hungry for this content. The questions that we answer are the ones that most people coming out of training and taking care of women are just not able to answer.

these really critical quality of life issues. And really I'm an OBGYN, right? And everything in OBGYN really does oftentimes boil down to sexual health, not all the time. But there's a lot of sex involved in what we do. And what's lovely about ISMISH is we really focus on that piece of it, you know? And so what I think we have going for us is that people are more interested in talking about sex and they're looking for content of practically being able to answer the questions that people are asking.

Yeah.

All right.

The special thing about this switch is it is just incredibly multidisciplinary. So, you know, we will, have basic scientists who are doing the lab studies with animals looking at conditions like vulvodynia and sexual health behaviors. We have, you know, internal medicine doctors who are really, they're very focused on menopause and the menopausal changes that happen. We have social science researchers who come to our meetings and we have a lot of psychologists and mental health providers.

Yeah, I'm looking at it, yeah.

are there. And so there's just nothing like it. You know, if you if you look at any other society, and there's a lot of other societies, and I'm not here to knock other societies, but you'll oftentimes see that they're very dominated by one particular group. And even within that, you're dominated by physicians, like it's not even what type of physician physicians, whereas we have a lot of, you know, advanced practice practitioners, we have a lot of psychologists, we have a lot of MDs, we have a lot of deals, we have a huge range, it's just

All right.

Yeah, right.

federally diverse organization.

That's what I love about it. And I think that's why people kind of, we get so many people from so many parts of the country, because they really do, they feel at home. I think that that's what people say that Ishwish feels like home to them. So I love that about it.

Yeah, I mean, my hopes for it is I think that we have so many people coming from the community. I think it's really interesting that we have so many of the people that are really speaking out on social media and promoting a lot of health related content. We also have a lot of people from academia and my goal is to make it a home for all of them. Like I'm not interested in having controversy.

amongst what an expert actually means. I want the people who are doing the research and the people in academia to feel comfortable and at home and welcome. And I want the people who are not doing the research but maybe communicating the research and out there speaking and writing books to feel like they have a home as well. I think we can be a really open, all-encompassing organization that way. And that's really my hope, especially as someone who really straddles mainly the academic world but very much understands the role of

All

know, communication and getting the information out to the masses.

Absolutely, I think that's great.

I think that what was really neat about the program is that we were exposed to kind of more experimental, and this is a plus and a minus, right? Like there were topics, there were these sessions on like, know, pelvic venous disorders and alternative ways of thinking about, you know, breast conserving therapies. Like these are not, you know, necessarily genital straight sex focused topics, but they are topics that...

Yeah.

We think about in all the patients that we see, if you're a sexual medicine expert, you become a pelvic pain expert. And so it's really helpful for us to think about, these patients that we just aren't getting better, are there other modalities, other explanations for their pain, other treatment options that could be out there for them? And then it's really pushing the needle on these kind of new experimental treatments and things that are out there. I loved having the international speakers come. We talked about

I love it so much. Yeah. It's really good.

pornography, you know, and how people use pornography in various ways. We had some really nice sessions on just updating guidelines. So we learned about the new genitourinary syndrome and menopause guidelines that the AUA published. always find it, you know, that those guidelines are so interesting. I didn't, declined being on the, on the guideline committee because I was like, it's AUA, I'm an OBGYN, why would this matter? And it's really neat how AUA does things that ACOG doesn't do in terms of the thoroughness.

Yeah.

the committee. Yeah.

Yeah.

I know, Yeah.

And I didn't realize it ahead of time, know, how well thought out and how important it is because we don't even have a guideline for GSM in obstetrics and gynecology. I think it's because, Samina, I think it's because it's just what we do. Like it never was a question to give everybody vaginal estrogen. Why would we have a guideline on it? Like that was always our primary prevention for recurring UTIs. It was always our treatment for menopausal symptoms.

I know.

Yeah, yeah, that's right

Right. That's also true. Yeah.

So I just think it wouldn't have occurred to anybody that we need a guideline on that. We're so comfortable with it.

That's true too, yeah. But I think some of these OBGYN groups that I'm on on Facebook, people get very triggered by the fact that it's not the OBGYNs that are leading the way on that capacity in some ways.

I mean, I think we just take some things for granted. I mean, there's certain conditions that these wonderful urologists that are out there are naming that we, know, genitourinary syndrome of lactation. We all knew that existed, but it's literally never been published, you know, until Dr. Rachel Rubin and got a team of and she's a urologist to publish this thing. And I'm like, how come we never even described this thing that we've been treating for so long, right? We just, we're, yeah.

Yeah.

Yeah. Yeah.

Yeah.

Yeah, that's true. We've always been giving some, let's take a little eczema dial or whatever that gets right. Yeah, it's very true. Well, I mean, I'm glad those guidelines are available because, you know, with the amount of women in menopause and experiencing it from all different, yeah.

Well, we needed a guideline. mean, I just think, again, this is something that in, I think in obstetrics and gynecology, we've taken for granted that we need to start naming things and guiding people on how to manage them.

That's very true. We don't have that many actually. I feel like we have these ACOG. We have committee practice bulletins. Yeah.

We have a ton of practice bulletins, right? So we have committee opinions. But I would argue that there, I mean, we have such a big range of things that we see in obstetrics and gynecology. So it's probably just the things that you and I are focused on that we don't see a lot of guidelines on that would be really valuable for us to have.

street.

Yeah, that's true. That's true. That's true. Because obviously, you're right. Even though everything we do is around sex, there's very little about sex other than what happens after you have sex or when you can't have sex or whatever the case may be. There was, I think, one of the hottest topics still going around is really around testosterone. You did a great kind of educational course, instructional course, sorry, on that with Dr. Sharon Parrish.

Why do you think testosterone is so controversial in women's health?

I mean, I think the main issue is we don't have a product for women, right? So if you don't have an FDA approved medication for women, it is incredibly confusing to figure out how and why you should use this medication. I think that there's a lot that we would like to treat that happens to us in perimenopause and in menopause. And there's a lot of things that the traditional hormone therapies, the estrogen.

is really the main one we use. We use progesterone mainly to protect the uterus, though I will always argue it does more than that and it plays other important roles in the body.

Sure.

But there still these lingering other symptoms and conditions and concerns that people have. And we know that the ovaries also make testosterone. And so it's very easy to say, well, if we're giving people back their estrogen and their progesterone, why would we not give them back their testosterone? And I very much understand that question. But what I'm seeing more of is most people coming in saying, should I be on testosterone? And I'm like, why should you? Someone told me I should be. And I'm like, we don't tell anybody they should be on anything. I mean, we do it now, I would say, to an extent.

Right.

Right. Right.

We're telling people that everyone should be on vaginal estrogen, but I'm actually of a different mind. I don't think anyone should be on anything. I think that we need to individualize it according to what people's symptoms, priorities, values, concerns are whenever we talk about any treatment. And so I'm not a shoulder, right? I'm just like, you tell me what your symptoms are, what your concern about, what your goals are, and then we can talk about it.

All right.

Right. Yeah, no, I agree with you. I think that's really precision medicine at the end of the day, which is what we kind of, you know, it's not all, you know, one size fits all.

Yeah, we do. But I understand the hype around testosterone. And I've been speaking about this a lot. I think testosterone has a lot of value. But I think that, to be really honest, we need to look at this idea that we have to give it to people because they're in menopause isn't based on physiology. Your body doesn't know from a testosterone perspective that it's in menopause. People who are, it doesn't. It starts to go down in your 30s. It's lower. People in their 40s are going to have a lot lower testosterone than they had when they were in their 20s.

Great.

All right, it doesn't fall off the cliff.

whether or not it's causing the various symptoms that we see people have in perimenopause, I think is very up for debate and very individualized. And then the question becomes, so, you know, it doesn't mean you shouldn't treat people, but we're not treating, I'm also of the mind that we're not treating it deficiency, right? I think that if deficiency is when you look at all people and you see that there's a group that are in the middle, there's a group that are high, there's a group that are low. Every single person in their 40s and 50s is gonna be on the lower end of the spectrum in terms of testosterone.

That's true, yeah.

So to say that they're testosterone deficient doesn't actually really fit the definition of a deficiency. Now whether or not they would get better with testosterone treatment is a different question. That's testosterone is therapy. So this is just my approach. don't begrudge anyone who has a different approach. My approach is we stop talking about that we're treating deficiencies and we start talking about that we're treating individuals with a therapy that has a goal. And so the issue with testosterone, was a

Yeah. All right.

fabulous lecture by Jim Faus at ISWISH that actually showed that estrogen and testosterone do very similar things in the body. Very similar things in the body and we got to be real about that. And not only do they do similar things in the body, but testosterone turns into estrogen. So if you give people testosterone, is it that they are converting it into estrogen and then getting some of those beneficial effects, potentially?

I love them.

That was so good. Yeah.

Right? And so that's where this question of testosterone comes in. Now, there are plenty of people, if you add in testosterone, they will say that my energy is better. I feel like my lean muscle mass is better. My mood is better. Those are all real. And I'm not here to deny anyone having those experiences. But what we talked about in my educational course is if you take a group of people and you give them testosterone and you give another group placebo, you don't see a difference. And so

All right. All right.

So if you want to go based on the data, right, the evidence that this treatment is better than placebo, we don't, and it's not an absence, right? People are like, oh, we don't have the data because no one did the study. No, the studies have been done. We don't have the data because the studies didn't show a benefit because the placebo effect is so strong. But as I talk about, if someone comes to me and says, I started taking testosterone or I want testosterone, I give it to them and they report all of these benefits,

Right.

Strong. Right.

I'm not going to tell them that that's not real, know, that they should not take the medication if they feel good on it without side effects. I think that that is their choice. But what we talked about in the course is that we need to be really honest about what data we have. Do we have long-term safety data on how and why people are using it? We don't. And I am someone who is not as scared of that. I think there's a lot of treatment that we give people that we don't have long-term safety data on.

Yeah.

Right. All right.

But the best part of the course to me was Dr. Parrish as an internal medicine doctor who has a lower level of risk tolerance because she takes care of cardiovascular disease issues and blood clots and things that I don't really take care of as an OB-GYN. And then on the extreme, I just want to say it over and over again that we keep giving trouble to the oncologists for being scared of these treatments. Well, their level of risk tolerance is way lower and it should be.

Yeah.

because they're taking care of people who are dying of hormone sensitive cancers. And so them not wanting to take the risk of giving a medication that could potentially exacerbate or increase that risk, they have every right to be afraid of that. I'm not going to criticize them for that. And so I think that was really my takeaway that I love teaching this course and thinking about. Like, this is where the data is.

Yeah. Yeah.

This is why we do things. This is why if you go to a different provider, you're going to get different levels of advice and concern because different providers have different levels of risk tolerance and ease with uncertainty.

Right? No, it's so true. And I think, you know, it does depend on, you know, amount of experience you have with it and what you've been seeing with it. you know, because there's definitely patients that like I've had a patient get a blood clot on vaginal estrogen and there's no way she should have gotten that, you know, like.

No, and I've had patients that got recurrence of their breast cancer on vaginal estrogen, and those are patients that are never going to take it, and they have every right to not want to take it. And I think it's really hard for them to hear over and over again how it's totally safe for them and how they should be on it, because that is not the case for everybody, right? There are people who have weird things happen and may not want to take these medications, and they shouldn't be told that they need to.

Yeah.

Right, exactly. I think it just goes to show, know, hormones are only as strong or potent as the receptors that are dealing with, they're interacting with, right? And at the end of the day, we don't know the receptor, you know, status of everyone that's using these hormones. And so I didn't say that example to scare anyone from using vaginal estrogen. It's just that there are these outliers that we see that make...

Well, I think that that speaks to this idea of clinical experience on multiple different levels, right? I've seen people, you know, I've always been someone who's like very guidelines based and I don't believe in over-screening, for example, right? Like I think that this, and this is just a different approach. You know, like I'm not somebody who's gonna be over-screening looking for cancers that are.

All right.

we're unlikely to find or we're more likely to get a false positive, but there are other people who very much err on the side of, would rather have hundreds of false positives. you can see, exactly, and you can see this, and this is just, again, our level of risk tolerance. If you look at the data on mammogram screening, if you do a mammogram on every woman starting at age 40, you will find more cancer and you will save about 10 lives, maybe in 10,000 at the expense of

Trinova Galleria.

hundreds, hundreds of extra cancer diagnoses that were clinically insignificant. And there are going to be people who will take that information and say it is absolutely worth hundreds of people being told that they have cancer that actually was clinically insignificant, would not affect their quality of life or life expectancy to save those 10 or less than 10 people. Right? And I very much understand why they would say that.

And there's other people who would say those hundreds of people who are now gonna get surgery and chemo and radiation and all this sequela of that, you know, for an unnecessary cancer diagnosis, it's not worth it to save those 10 people. These are two truths, right? And this is like, this is just the reality of medicine and how we practice. And I wanna make space for the fact that people really take those, level of risk and uncertainty.

Yeah.

and risk and benefit and come out with a totally different conclusion. It is not black and white. Nothing we do is black and

Yeah. And nothing is without risk at all. I think that's what people don't recognize is that anything, all medications have some risks and some side effects. And so to think that you're going to take something and it does nothing to you that's negative is not entirely true for most people. Yeah.

.

Yeah, it's a great, it's a great thought. You know, I mean, I will say, you know, testosterone is so interesting because those of us I've been, you know, I know testosterone is all the hype, but there's a lot of us that have been doing it for a long time before it was hyped. Right. So I've been prescribing testosterone for, over a dozen years to, you know, a lot of people, you know, you're, you know, you're an insurance based system. I mean, I see a lot of patients. I've been giving out a lot of testosterone. And so the results I get are different, I would say, than a lot of a hype. And it's not cause I'm a bad doctor. I'm giving them the same treatment.

Yeah, a long time. Yeah.

Yeah.

Right. Right.

I think that I have some patients who do fabulously on testosterone and they're doing great and I keep them on it. I have other patients who have no effect and I have other patients who have side effects and negative side effects. So I've got a very balanced view of where I see the pros and cons. And so I think that this is really individualized. Everything we do, that's the problem with hormone therapy is that because it's been so under taught for so long, we want to kind of get people up to speed real quick.

Yeah.

And

And so we give them like algorithmic medicine and we say that everyone should be on this dose and should be doing it this way. And it's like, it's just not, that's not how I practice. And I think this is part of the problem in medicine in general.

Yeah, that's true.

Yeah, it's so nuanced. It's really not an algorithm. And that's when AI is going to take over. It's going to be real problem. It's going to be automated. It's going to be automated.

AI is going to take over. It's going to be really, it's a problem. Yeah, it's a problem. I mean, there's a lot you could put in there, but I just like, I don't know how AI is going to talk, you know, be able to figure out people's values. You know, like that's what I see with what's your priority? What symptoms are we trying to treat? What symptoms are you trying to avoid? I mean, I guess you could plug it into a computer, but you know, humans are different. They're going to respond differently to different medications.

Yeah.

Absolutely. I guess that's the end of it is really that you and I both have experience in this. And so I can totally understand everything you're saying in terms of some, there are some people who tell me they see color for the first time when they take testosterone and other people are like, well, when am I supposed to feel something? Like, when is this going to happen? And I'm like, you may not, you you may not. And that might be a reason. And then the other people that come in with chin hair, even though they're on the lowest possible dose.

their own vaginal testosterone and they're getting shin hair and acne and I'm like it's it's like I'm like how is this like what but it happens it stops yeah I mean it was yeah exactly on a you know one-tenth of the systemic dose okay you know and they didn't have acne when they were teenagers and you're just like I don't I don't get it but okay yeah

Yeah.

And then they stop it and it stops. I mean that was it's so weird and again

Yeah. I mean, I have people that start losing hair. Yeah. Or the ones that like you're not your levels didn't even bump at all and they all of a sudden lost hair from it. And you're like, what? Like what is happening?

And while it goes to show that was we talked about that a lot in the course that this is the level issue is, you know, I talk about this a lot. I know people really want their hormones tested. I know people promote it and say that I'm just denying people care, but the hormone testing is really, really problematic. is wildly and precise, inaccurate, both, and it doesn't really give us a lot of always a lot of clinical information. And this is the other part about treating with testosterone is that

Thank

I know.

Mm-hmm. Yes. Yeah.

a lot of the benefit that people are getting, they're seeing at really high levels of testosterone. And so, you know, not at this goal of physiology. But when I started doing more research, even when we looked at studies that gave testosterone transdermally and we pretend it was at a physiologic dose, it was not. was a patch. There were three patches that were tested, 150, 300, 450. And they found that overall the best benefit was in a 300-microgram patch.

I know, yeah.

A lot of those people had superphysiologic levels because we weren't treating them to a level, we were treating them to a dose. And so we have to be really real about that. so instead of this idea to me of, they're deficient, I'm going to get them up to their level when they were in their 20s, I look at it a little differently. And I say, look, a lot of these people are getting superphysiologic levels and we don't have long-term data, even if they were at physiologic, but we certainly don't about superphysiologic.

Yeah.

Right.

And so this is less to me about like replacement or physiologic dosing. And let's just be real that testosterone is a performance enhancing drug. If you're taking it at these higher levels, that's what it's doing. And that's not passing judgment. That's just honesty, right? Like we know that men, it's controlled substance for a reason. Men take it because it builds muscle mass. It's a trophic medication.

Right.

Yeah. Yeah.

If you take it at high levels as a woman, you're going to build muscle mass. If you take it at physiologic level, so the levels you were at when you were in your 20s, that hasn't been shown to build muscle mass. people like this idea like, I need to take it to build lean muscle mass. Just work out. Work out a lot. Not work out a lot, but lift weights. It's not going to harm you. Will it benefit you? Maybe, but the data doesn't show that if you replace it physiologic levels.

and yeah.

Yeah.

for lean muscle mass production, it's gonna make a difference.

Right. All right. No, that's true. I think when you do get, I definitely have patients who sit at like 100, 150 and they feel much better if I drop and if they drop too low, you know, it's like, well, they, of course. Yeah. Right.

Yeah, and the guidelines say you're supposed to drop them. And I'm like, why would I do that? They're not having any side effects. Oh, because we don't know the long-term effects. I don't know long-term effects of them at physiologic ranges either, right? We have no long-term studies on putting someone at a level of 50 when they're in their 50s. We don't have any of that because that's not our physiologic body. Our physiologic body did not sit at 50 for 20 years.

And that's just it. Right.

Yeah.

It's been sitting at 10. And so none of this is actually, this idea that this is evidence-based. I'm like, no, it's not, it's guideline-based. And the guidelines are based on the best available evidence we have. But when you spend time with the testosterone data, I start throwing out this idea of evidence-based, because the evidence is all over the place.

All right.

You're right.

Yeah, that's true too. I mean, I guess that goes to show like, I mean, with that 300 microgram patch that was supposed to be FDA approved. I think it got approved in England, right? Or London? Was that the? Yeah.

Yeah, and it showed, yeah, and I, yeah, it was approved abroad and it, you know, it showed benefits, it showed benefit in terms of desire and satisfying sexual events. So we know that testosterone is better than placebo in those studies, but we don't want to admit that the reason we don't have an FDA approved product is because when a company tried to study it as a gel in the way that we give it to people in a 1 % gel,

Right.

that that product did not do better than placebo. It was equal to placebo, right? But we still recommend using it as a gel, even though the best data that we have is on a patch that isn't approved or a gel that wasn't better than placebo. So I'm not interested in people telling me that like the guidelines are all evidence-based anymore because it's based on all the information that we have. We know we have the patch data. We know that when we give people testosterone and a lot of other studies and we know anecdotally that they're doing better.

and

Right.

But when they did a randomized control trial with an actual product, it wasn't better than placebo. So let's just be real that that was group data, but I'm sure there were individuals in that group that saw a huge benefit. And so if that's my patient, I'm not going to take it away from

Yeah. All right. Yeah.

Okay.

Right, yeah. I mean, that's oftentimes what you hear is like if you tell a patient was low desire, they start feeling better and like, you know, cognitively, I feel much better, but I don't feel more desire at six months. Are you going to take my testosterone away? I'm like, no. You're supposed to, technically, right?

That's what the guidelines tell you to do. this is where, you know, this is where I very, I, I'm, you know, Dr. Parrish was on the guidelines. I know that people who are at the guidelines, respect them. respect everybody who, you know, and I'm just saying we are allowed to have differences of opinion and we are allowed to talk about where there's uncertainty. And I give space for them making those recommendations that they would say, well, you should be off of it because you're not getting the benefit that we prescribed it for. That's legit. I just practice different.

Right.

Right. Yeah. Right. Exactly. I think that you and I are in the same in that respect. What do you think the biggest myth around testosterone? Do you think that's probably the biggest myth is that it benefits more?

Yeah, I think the myth is, yeah, I mean, but again, if you tell somebody it's gonna do all these things, it's gonna be much more likely to do that than if you tell somebody that the data doesn't show that it's better than placebo.

Right.

Yeah, that's true. Yeah, no, you're right.

So this is where, like, this is the study that we really need to do, is take 50 women, tell them it's gonna do it, take another 50, tell them what the data actually shows, and then see what the difference is. Like, that's the study.

Yeah.

That's true. I wonder if that will happen ever. Probably not. So that was a good instructional course. And then we had some instructional courses around complex genital pelvic pain that was done. I think that one actually made a lot of sense to some of us that are treating some of these really complex PGAD patients and genital pelvic patients. I do think some people thought it was a little bit above their

you know, like maybe they haven't seen the patients with it. And so it didn't make, you know, they felt, you know, some of it, it was pretty advanced, but to me, felt like a lot of it made sense. Unfortunately, I feel like we don't have, you know, a lot of extra steps we can take with some of these things other than centrally active.

It was a pretty advanced course.

Well, that's one of the issues that I think came up even for the main sessions, for the pelvic venous disorders and for the potential nerve-sparing breast reconstruction is those of us not in these locations and those of us without very resourced patients, we're not going to be able to access these levels of care that other people are doing for these experimental treatments. And I think that's something that we should be talking about in scientific meetings. We talk about experimental treatments.

up.

all the time. think ISWISH gets criticized for quote, not being evidence-based, even though at most scientific meetings, people are talking about new and experimental things. We also have to be very real about where the funding is. learned, I mean, my takeaway from the meeting, the best talk, best talk by far was Dr. Anderson and Keysard's talk about funding and showing, know, we're replacing funding. And my biggest takeaway was that

All

I know. I know, but it was so good to need.

Yeah.

Volvodynia the entirety of a year's budget at the NIH, $4 million goes to Volvodynia and $800 million goes to breast cancer. And I am not here to knock the importance of breast cancer research. There are zero treatments for Volvodynia, zero. A $4 million grant is one grant to, know, what we call an RO1, right? That's one multi-year study. Research is expensive. I know it's hard for people to understand that.

Bye.

So.

It is incredibly expensive, but the entirety of all the linear research would fund one multi-year study from one investigator. That's why we have no treatments. There's no funding going into it. And so then people criticize us for not having science. And I'm like, well, I can't be a breast cancer symposium. Or people criticize us for having more relationships with industry. And I'm very someone who has.

There's no money going to. Right. Right. There's literally no money.

a lot of ethical concerns about conflicts of interest. You hear me talk about this in our meetings all the time. I work very hard not to have conflicts of interest for multiple different reasons. And yet, in sexual medicine, the only people funding it is industry. And I would also argue it's so few industries that it makes conflict of interest look bigger.

Yeah.

Whereas if you go to other societies, there are so many companies in there that it dilutes it out that everybody has a million different conflicts or is speaking for companies, you know?

Yes.

Yeah.

It's so true. It's so true. It's like the big cancer ASCO. You know, it's always here in Chicago. It's like a block away from my house. We have like 50,000 oncologists that, you know, are in and then so much industry, like the whole city is like one bear, blah, blah, blah, blah, blah, know, and it's like, we have none of that. We have like two or three people and they struggle. It's not like, you know, like Dari Pharmaceuticals, you know, some of the other pharmaceuticals that they're, they have so little money actually. They don't.

Yeah, I they're all really strong. Yeah, it's funny. I have good friend who's a cardiologist and he went to a cancer conference and he was describing like he's just the billions of dollars of pharma and I was like, but you're a cardiologist, right? Like it's like I would give anything to have what cardiologists have at their meetings, right? But it's the hierarchy of where money is in here is really problematic. But again, you know, if you are someone or you know someone, you know, with cancer, you're going to want that money to go there.

Yeah.

Yes, yeah, yeah.

So I really understand that we have finite resources, but sexual medicine, very finite.

Of course.

very fine and that was the big take-home point in Dr. Anderson and in Kiesner's lecture and it was really compelling I think that even the amount of research got cut in the last what 20 24 months or less than that 10 12 months even that so much got research got cut and then on top of that you know you can't even do certain types of research because you can't name certain you know genders or you know groups and so it was really

Yeah.

really compelling and quite sad actually. It was really quite sad, know, but it was, I think it was a good wake-up call for a lot of people. A lot of people really woke up from that. I thought, let's talk just for a few minutes about the symposium on body image. I thought that was pretty interesting as well. We had someone talk about sort of body image when it comes to sexual function as well as

It was very sad.

in.

And this was all in the world of oncology, actually. So was basically an oncology symposium. What were you, what do you think are take home points from that? Where we had, we had someone talk about body image from a psychology perspective. We had a breast cancer reconstructive surgeon who talked about Dr. Anna Pellet, who talked about nipple sparing surgery, which I guess is not as, sorry, nerve sparing surgery. Yeah. And then.

Nerve scaring surgery really.

What was the other one? PT. Yes, talk about lymphedema, which is really cool too. So what do you think the take-home messages that you've kind of went away with on that?

We had a PT.

You know, it was really interesting. I'm someone who's been doing survivorship since I was at the beginning of residency. I've been published on survivorship work. So I've been doing this for a long time. And I think that I didn't and I sometimes don't fully appreciate what breast cancer surgery does to my patients. You know, I saw someone recently who really stuck with me because she was someone who her reconstruction had a complication and she basically can't get to basically lost the

That was

breast and it can't be reconstructed and she didn't have breast cancer she actually had like a pre-cancer and so so there's like an extra layer of like you know everybody assuming she had cancer when she didn't even though it was was pre-cancer and you know and i've been sitting with this and that was just this year i mean i've seen lots of people with different types of reconstruction and so i was my takeaway was that i think that those of us who do survivorship at least i know me i'll just speak for me

Yeah.

didn't fully appreciate what this does to people. And we've been doing it, the switch fall course for a long time. We've been doing these, what these OSCEs, these kind of like practice interviews. And one of the cases that we use is a woman who had breast cancer surgery and is trying to explain to her partner how she doesn't have sensation in her breast anymore. And how do you do that? And so it's like, I've heard it, but I've internalized it.

Mm-hmm.

Yeah.

to such an extent. And I really internalized it this time in a way that I thought was really powerful and important because this is the most common cancer that women get. One in eight women are going to get breast cancer. The vast majority of them are going to be getting these surgeries. The other takeaway that I thought was interesting was this idea between a lumpectomy and a mastectomy, which we talk about and see all the time that there's so much data that lumpectomy with radiation is equal to a mastectomy.

Yeah.

and the date in terms of outcomes of breast cancer recurrence and the outcomes of mastectomy in terms of sexual function and body image are just so bad. And yet people still choose it. And that was really striking to me of like, we have the data showing this isn't better. We have the data showing that your body image and your sexual function is gonna be that much worse. And yet.

They still choose.

people are still making an, they're making an informed choice. And I really kind of internalized that. And I was like, I totally get it. I would probably make that choice too. Cause you'd be like, well, it's not that, know, it's more important to me, especially if you're a young person, right? If you're a young person to not have the level of screening or say you had DCIS and you just don't want to risk this recurrence. But I think that I was really struck by just how obvious the difference is and how much worse these people do.

Yeah.

Right.

But again, people make choices. I don't think that oncologists and surgeons aren't showing them the data. I think they are, at least in my institution. And I still see women over and over again choose my stick.

Yeah.

I mean, do think that everyone's talking? I think people are now talking more, at least the people that spoke with us were talking about sexual wellness after these procedures, but I don't know.

Yeah, I doubt that oncologists talk about sexual illness and body image, but I'm sure they do talk about outcomes in terms of breast cancer recurrence. And it's been known for a long time that lumpectomy plus radiation has the same outcome. For many people, again, I'm not an oncologist or a breast surgeon. For many people. For early, early stage cancer.

Sure. Yeah.

Yeah, that's true.

Right. For many people, yeah. Right, right. Yeah, I think that was very compelling too. And even the talk from the lymphedema physical therapist, I think that was very interesting to hear what she does for it, also the amount of, you just, I mean, we all see patients who have that lymphedema after having their lymph nodes removed or dissected.

Yeah.

But you don't think about the impact it might have on their day-to-day sexual life, all that stuff. Yeah, that was really interesting. Any last, I know because I want to be cognizant of your time because it's already almost close to the hour. Any last minute things that struck you from the conference that you hadn't thought about? I feel like we always learn something new when we go to Ishwish. And so I feel like the pots, we had someone talk about Dr. Alexis Cushens who had a patent on the.

Yeah

I've had her on the podcast talk about POTS, and I'm going try to get Brooke Spencer to talk about pelvic venous insufficiency. So I think that was interesting, and we've all seen this connection. To your point, though, it's hard to figure out who to send these patients to if you think that's what might help them, because there's so few people that really know how to do it or take it seriously.

Yeah, I mean, think my takeaway is that I think as a society and as a community, we have to think about how we speak to people who are just brand new. I mean, I knew so many people that were there that were just brand new. And I always say go to the fall course, because that's where you're going to get the bread and butter of what to do. What we do at our society meeting is different than I think other society meetings sometimes, those of us on the scientific committee and in leadership invite people to speak to us.

Yeah, that's right. Yeah, yeah.

as opposed to invite ourselves to speak to other people, right? And so, so it's, that's, yeah. And I think that that's, you know, that is what we oftentimes do because there's more to learn and we bring people in. And what I'm always excited about with ISWISH is how many of these people in other specialties love coming to ISWISH and agree and, know, and get so much out of it and how we have, you know, incredible attendance and people go to most of the sessions, even though it's exhausting.

Right. Yeah. Yeah, that's true. That's a good point. Yeah.

Yeah.

Yes, yes.

And you know, you think, I'm full. Oh my god, I can't fit anymore. And then you still can. And so that's really my big takeaway with ISWISH and with the scientific meeting. And so I think for us, we need to think about as leaders in the society, you know, is making sure that we still, as education chair, I always tried to focus the education courses on that common denominator of what people, you of people who are kind of new, and then the scientific abstracts are like the, you know, what are we gonna learn? And then in the main sessions,

All right.

thinking about how we strike that balance of like, let's review. And I thought we did a nice job this year. Like we reviewed the GSM guidelines. We reviewed the ICSIM committee guidelines. had, know, speaker from menopause society and we've had, you know, we bring those in and then we have these really cool state of the art or symposium on just, you know, other abstract issues that we hadn't thought about and can learn from people outside the sexual medicine world. So that's kind of my takeaway. think we strike a nice balance and we'll probably continue doing that. And then.

Yeah.

I got POI and that was.

There's nothing like the networking. mean, incredible, wonderful reconnection. It's like a family.

Right, that's fun. Yeah, it really is nice. And I always tell people that too. I'm like, if you really want to learn the stuff, you need to come to the fall course because you might get overwhelmed with the science. But it's always cool just to know what's happening in the world and what's coming up in sexual medicine. the other interesting term that we learned was on digital intimacy and technoference, like how technology is very.

Yeah.

So just, this is a takeaway for you guys. Techno-fearance is causing a lot of problems in sexual health in our communities because technology.

Well, it's why the rates of sex are lower than they've ever been. People aren't having sex because they're on technology. You're getting your dopamine in other ways. It's really a problem.

ever been.

Yeah, absolutely.

It's a big problem actually. So take some, after you listen to this podcast, take some time.

I know, listen to this podcast on your commute. Don't do this late at night. Go have sex.

Don't do it that way. Don't you don't spend time with your family, spend time with your husband, wife, you know, whatever else person you might have in your life. But technoference is real. And I think we all can, like, I can speak to it. Like sometimes, you know, I have to like force myself away from all of this stuff because it can, can consume you otherwise.

Well, again, it's all dopamine. it's like these companies have done a really good job at getting our dopamine fixes done so people aren't getting it in other ways.

It's all dopamine. So is sex. So thank you.

Yeah, absolutely. Well, thank you, Tammy. I appreciate you coming on to talk about Ishwish and talk about our annual meeting that just happened last week. And now you're heading to Porto. I wish I was going, but it's too much for me to do right now. Yeah, of course. Thanks for joining me today, guys. I remember I'm here to educate so you could advocate. Please join me next week on my next episode.

I know we'll miss you, it's too close together. But thank you so much for having me on. It's great to see you.