In this special episode recorded live from the Menopause Society meeting in Chicago, Dr. Sameena Rahman and co-host Dr. Heather Quaile interview two pioneers in female sexual medicine, Dr. Irwin Goldstein and his wife Sue Goldstein. 

The Goldsteins, known as the “real Masters of Sex,” share their incredible journey in advancing women’s sexual health, from founding the International Society for the Study of Women’s Sexual Health (ISSWSH) to groundbreaking treatments for female sexual dysfunction. 

Dr. Irwin Goldstein discusses the evolution of orgasm disorder treatment, the importance of the spine in genital pelvic pain, and cutting-edge therapies like shockwave therapy. Together, the Goldsteins have transformed sexual medicine, and this episode offers a glimpse into their work and the future of sexual health treatment.

Highlights:

• The origin story of ISWISH and the role of Viagra in female sexual medicine.
• New treatment strategies for orgasm disorders, including an upcoming paper.
• Insights into the treatment of persistent genital arousal disorder (PGAD) and other pelvic pain conditions.
• The use of shockwave therapy in sexual medicine and its applications beyond female sexual health.
• The importance of multidisciplinary approaches to sexual health and the Goldsteins’ commitment to education and research.

Don’t miss an episode! Subscribe to Gyno Girl Presents: Sex, Drugs, and Hormones on Apple Podcasts, Spotify, and YouTube. Follow us for updates and behind-the-scenes content on Instagram @GynoGirl. Share this episode with friends or colleagues who need to know more about sexual health and be sure to leave us a 5-star rating! Your support helps us bring you more impactful conversations

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Sameena Rahman (0:0.363)

done your intro so we can get straight to talking. Hi everyone, it's me Dr. Samira Mann, Gyno Girl. Thanks for coming back to Gyno Girl Presents, Sex, Drugs and Hormones. I'm super, super thrilled today. I have so many great people in my presence right now. I Heather Cuell who's going to guest host with me. She has her own podcast. Yes, the Just Ask podcast. Just Ask podcast. Well, we have a dream come true. We have a dream team here today. I'm going to do it like Oprah. Welcome Sue and Erwin Goldstein.

They're amazing. They are the real masters of sex. The OGs, the, you know, the everything. But you guys heard my intro, so we want to get into the good stuff now. So this is a real honor and a privilege, you know, to be among you. You guys have always been welcoming. Heather and I both did preceptorships with you guys. And so we find that like, you know, there's nobody like the Goldstein. There are sex med parents.

Sue Goldstein (0:58.484)

Well, we love both of you, so thank you so much. We're so honored to be here with both of you.

Irwin Goldstein (1:2.796)

We are amazingly honored. Thank you so much. It's so cool. We're gonna have so much fun right now.

Sameena Rahman (1:8.441)

know, I can't Heather and I are at the Menopause Conference, so that's why we're together, but it's great. We're gonna talk, get into it. We wanna start with the first story, like everyone, I've told the story in my own way, but I wanna hear it from the mouth of the two of you. Like how Ishwish began, start with the Viagra story. All the history, yeah, give us a little history. Because Ishwish is gonna be 25 years this year, right?

Sue Goldstein (1:32.032)

Well, it's wish itself isn't 25 years. The start of what became is wish is 25 years. But yes, or when the floor is yours.

Sameena Rahman (1:38.029)

Yes.

Irwin Goldstein (1:39.650)

No, no, no. You tell the story better, to be very honest.

Sue Goldstein (1:43.104)

Sameena Rahman (2:12.439)

You know, that Boston University?

Sue Goldstein (2:13.748)

Sorry, Boston University School of Medicine. And then like six months later, we called the department chair and said, well, what are you doing with these women? He says, I don't have a clue. I'm gonna make you a professor of gynecology in addition to being a professor of neurology. And he said, okay, but he really didn't know a lot. And he thought, well, if I bring in world's experts on all the little different pieces and we sit down in one room, maybe we can start to figure it out. And so he convinced the university

to have a CME course for women's sexual dysfunction. And he brought in people from around the world and they all in the room, they presented and a lot of us were in the audience and listened and said, you know, sort of an aha moment. And then he did it the next year and brought in more people and it was still a course. It wasn't a meeting. And he said, oh, you know what? So many of you are interested. Do you want to become a society? And everyone goes, no way. So then the next year he did it again, the third year.

said, do you guys want to be a society? And everyone said, you know what? Yes. So that was the start. And it was named the Female Sexual Function Forum. the next year with our first board of directors and everything, somebody said, you know, female can imply human and animal as well. And we're really only interested in women. And so it was renamed the International Society for the Study of Women's Sexual Health. And that's how it was born. And what's

Sameena Rahman (3:14.786)

Oh,

Irwin Goldstein (3:19.170)

Puss -f -f -f -f -f.

Sameena Rahman (3:21.123)

That's a bit of a...

Sue Goldstein (3:37.770)

crazy about it is every other group is a medical society, but the rest of us are not physicians. And Heather, you and I can both relate to that. We're sort of secondary citizens. Or research society, it's all PhDs and the rest of us are secondary citizens. And this what she said, we couldn't exist without a lot of people each contributing their little piece of the pie to make that pie whole. And from the ground up, the bylaws were built that we all have equal import. And that's why today,

ISWISH is such a strong society because it doesn't matter what you do as long as you are somehow involved in women's sexual health, you are welcome in ISWISH and can have an opportunity to contribute.

Sameena Rahman (4:18.745)

100%.

Irwin Goldstein (4:19.118)

So our first president was Sandra Lieblam. I if you know her, sex therapist in New Jersey. And she was the one who actually officially first ever described PIGETT. Well, it Pete Sasse at that time, but when it was close enough, she eventually changed it to PIGETT.

Sameena Rahman (4:22.337)

Okay.

Sameena Rahman (4:29.101)

Yeah. It's just the most inclusive, such an inclusive society. Like I just kind of want to go on and on about why it's so important to have like the therapists, the sex therapists, the physical therapists, the doctors, the educators. Like there's, there is a place for everybody in this society. And that's because medicine is a biopsychosocial, right? So we need all the aspects to move it forward.

Sue Goldstein (4:49.770)

So I will say.

Sue Goldstein (4:54.858)

We have had nurse practitioners on our executive committee. We have not had a nurse practitioner president. We've had sex therapists, PhD. had basic, we've had MDs. We've had educators. I was the first president who didn't have an advanced degree. So we've really gone the gamut, but we haven't had a nurse practitioner and we haven't had a physical therapist yet as president. We've had nurse practitioner leadership position, but so we're looking forward to what the future will bring.

Irwin Goldstein (5:3.564)

Good roll, Heather.

Sameena Rahman (5:5.123)

you

Sameena Rahman (5:17.603)

wonderful.

Sameena Rahman (5:24.695)

Next up.

Irwin Goldstein (5:24.846)

Sue Goldstein (5:53.120)

I'm wondering what...

Irwin Goldstein (5:54.446)

But we did one clinic out of the 10 for women. And within two or three months, we had equal distribution of men and women. That's how popular it was to start to see women. our initial management plan was to treat them exactly as we treated men. We drew all their testosterone bloods. We did Doppler ultrasounds. We had a therapist. And it was very successful to some degree. But it ended up that we

Sameena Rahman (5:54.605)

Not anymore.

Sameena Rahman (6:4.153)

Amazing. right.

Irwin Goldstein (6:24.012)

with its wishes, blessings and all this stuff. We ended up doing vulvoscopies and all these other things.

Sue Goldstein (6:30.452)

We had a lot to learn and we're still learning. And that's what's exciting is that the field is still new enough that everyone has an opportunity to make a difference, to discover something new, a new diagnostic test, a new way of doing surgery, a new medication that are current, an FDA approved medication for one thing that's gonna work for something else. There's so much left to learn that the field is wide open for people who are interested in developing new methodologies and things.

Irwin Goldstein (6:56.876)

Interesting story We have a USC medical student Taking a year off to do research once going to urology So she's working a lot with us and one of our projects is to actually formally describe the vestibule now though That sounds pretty weird, but I'm gonna say things to you. You don't even know so the the urethra of a woman

Sameena Rahman (7:16.983)

Yeah, I'm excited.

Sue Goldstein (7:20.722)

Stop for a minute because the people watching this podcast don't even know what a vestibule is. So let's stay with that.

Sameena Rahman (7:25.054)

Yeah. Let's get there. I talked about it before, but just re -introduce them. Tell us what that is for all our people. There you go. Before you. To be able to get to the vagina.

Irwin Goldstein (7:26.881)

Oh, okay.

Irwin Goldstein (7:32.674)

the lobby to the theater, the opening to the house.

It's the, of the embryologic structures, the ectoderm is the skin on the outside, the mesoderm is the reproductive area, pretty much. And then there's an endodermal component that bridges the gap between the two. And we're talking about that bridge. But anyways, we now do vulvascopy with a ruler in place so we can actually determine exact measurements of things. And there is a urethra in the middle of the vestibule.

It's kind of the epicenter of everything now that I'm understanding it better. If you look at a man's penis, it has a urethromyatis surrounded by a fleshy tissue called the glands. And we've never thought of the urethra surrounded by a fleshy tissue in the woman. So there's like a glands clitoris, but there's actually a peri -urethral glands in all women. And we're now starting to describe it and better understand it. And in cases where it's painful, we're removing it.

And we can now determine it's not urethral tissue, it's vestibular tissue. Because it has nerves and mast cells in those people. And it's called periurethral glands. And we're determining the size and dimensions in the next generation of women. Off the superior portion of the periurethral glands are spokes, little flaps that come off in a majority of women. And we're describing the angle and their purpose. And in between the...

Sameena Rahman (9:20.281)

Yeah.

Sameena Rahman (9:24.569)

We don't learn it. don't learn it. studies it, right? And no one is taught to look at the vulva. Like you're just taught, oh, the vagina, here's a speculum, goes Go right in. No one is taught.

Sue Goldstein (9:25.588)

Thank

Sue Goldstein (9:35.232)

How many patients come to you and say, my vestibule hurts? They say it hurts down there, or they say my vagina hurts, even though it's nothing to do with the vagina, because patients don't know when they come in, and we do such a disservice by not teaching them the real anatomy. When one man with scrotal pain comes in and says, it hurts down, it hurts in my penis, a man knows the difference between the scrotum and the penis.

Sameena Rahman (9:55.650)

Yes.

Yeah, exactly. Which I... Yeah.

Irwin Goldstein (9:58.766)

I have a quick story, quick, quick story. A woman yesterday with vaginismus, okay, never of course did a vulvascomy and her legs would, I know you've done these exams, they 100 % come together. And we're doing the study with a vulva scope and she, her eyes were closing, she put a pillow over her head so she couldn't see. We finally asked her to open her eyes and see. We gave her the Q -tip under her own control with no one else doing it.

She was able to do the exam. the beauty of vulvoscopy is not just to, it's to allay fear and provide education to the anatomic structures that are otherwise not seen. And it was so beautiful to watch her do this. Whereas when I tried to do it, the legs came together and the anxiety was there, but when she was in control, she could do it. I thought that was very cool.

That's it. Yeah.

That's did too. It just goes to show how much medical trauma people endure over the years, like over and over again. Absolutely. It's not even like... Not even to imagine beyond medical

Good.

No patience. No patience in women with pain. No patience. You got a seven minute window and...

Sameena Rahman (11:5.569)

I think absolutely.

Yeah. And you're like, it's fine. Open. You're good. Let us just shove this. It's two seconds. You're fine. doesn't hurt. You know what I find so awesome is that you are urologist and you, your paradigm was always men. And so you put that paradigm onto a woman, whereas like, you know, gynecology is still so patriarchal that I'm a product of this learning, you know, and I think I've told you before, like we learned that cervix has no nerve endings, you know, do whatever you want, like all this BS stuff. And it's because like,

And a theme.

It's like this was women's health, you know, the paradigm was women and so it was just different. Like you just treated them differently because of patriarchy, misogyny, whatever you want to call it.

When they come in and they know they've been gaslit, they know that, but they don't recognize how many women experience it. They think they're the only ones experiencing it. it's, know, like at ISWISH, we always talk about just asking that question gives them permission that they know it's a safe space. So starting that conversation and knowing that they are not alone, that in our office, the men have typically been to four or five physicians before they come to us. The women have typically gone to a dozen clinicians before they come to us.

I mean, that is ridiculous, isn't it?

telling.

By the way, yet another story. You brought up urology versus gynecology. Guess which society, and I'm going to say it's the American Urological Association, will make the first ever expert panel management plan for women with GSM, genitourinary syndrome of menopause. Which society will do that? And it's going to come out next year and it'll be groundbreaking, earth shattering, finally giving.

Yes.

Yes.

I'm sure it's AUA, right? AUA for sure,

attention to this area in a manner that's based on, they actually spent more than one million dollars doing a collection, like a meta -analysis of all the data. Amazing work.

The AUA has courses in women's sexual dysfunction for 20 years. And over the last few years, I mean, it started out with just the one that Erwin taught, but over the last few years, they have multiple courses. How many courses in female sexual dysfunction does ACOG offer and does the Mennon -Soyus Society offer? Nothing.

amazing.

Yeah. know what's interesting is that they posted the GSM, the original GSM article by the 12 consensus societies and we know which society's not on there. A lot of the Guyanese in the office were like, I mean the audience were like, oh, ACOG's not on there, but the Royal College of OBGYNs is. And yeah, and I was like, well, that goes to...

in Chicago.

Interesting. I was a panel member. Wow.

So you may want to know, he was the only urologist in the room and tell them why we have the name GSM.

Yes.

Okay, so GSM was founded from vulvovaginal atrophy, vulvovaginitis, all this weird horrible thing. It didn't include, the anatomy was incorrect, vulvovaginal, but the problem is primarily vestibular. And vulvovaginitis, none of that was useful and it was demeaning to women.

Then I'll go to your...

Vagina. Yeah. It's what are you school?

Thanks

So we put together is wish and uh, well was at that time the north bear american menopause society now the menopause study, uh put together meeting in chicago i'm gonna say 2016 but uh

Thanks for watching.

I think it was published in 15, I think the meeting was 14 or published in 16, the meeting was 15, I can't remember.

Yeah. That's it.

a few days ago and So it was a euro urologist We're not invited. I was the only but I was invited as sexual medicine, but I'm a background of your urology and the The new name was going to incorporate Things like the vulva the vagina maybe now the vestibule, but there were no there was no attention to the urinary system

And it was very annoying because the lower urinary tract changes dramatically during an atrophied situation so after a lot of discussion we sort of got rid of the genital only concept and and made it into genital urinary and that was a huge advance because that got the a UA involved and the a UA is now making the guidelines and that was a Huge breakthrough it took a few years for GSM to become popular people were still using VVA and stuff

All right.

Yes. People still use it. I'm like, nobody wants to be told their vagina's atrophic. Okay.

but it's really pretty much there now.

Yeah, there you go.

The equivalent in men was the impotence was the term and the NIH said that's a pejorative term. And in 1992, they put together a panel because Irwin was part of that and renamed it erectile dysfunction, which allowed us to now have a disease state that could be successfully treated. But no one's ever stepped up for women until now really with the AUA.

Yep. And even still, we need more changes to the GSM name because it's outside of menopause. I mean, we had a posterity swish. It's lactation, hormone deficiency. It's our transgender population. Like it needs to go just beyond the word of menopause.

I think after the guidelines come out, it'll be easy to flip them to other similar types of guidelines because the treatments will be the same.

I agree.

Yeah, I think that's the key because still going to be, I GSM still refers to people with menopause, but the point is that we can then say women lactating have the same hormonal loss of hormonal support and compare all the various things. They have the same, and so that should be the same treatment guidelines because it's the same hormonal. You can't change the name necessarily to include all of those disease states because it's really quite different, but.

You know, the menopause society is so busy worrying about bone fracture and hot flashes. And, you know, when you treat them the way we treat them with hormones, then they don't have the issues of the bones in general. I mean, I'm not going to say everybody, but we still live in a world where people think that menopause ends when the vasor motor symptoms are done. And then you go into post -menopause. Well, your ovaries don't suddenly start to work again. It doesn't matter what you want to call it.

Yeah.

You're in menopause

Unfortunately.

I have a story, a cool story. You're at the Menopause Society. So this woman comes to the office and she's 85, okay? And she meets this guy who has a penile implant and at a nursing sort of wherever they are. senior housing, whatever you want to call it. And they fall in love. It's really sort of cute. But she's sore and tender.

senior, senior village.

I love that.

She goes to her Internist and her gynecologist and whatever the hell no one wants to treat her because she's 85 and The guy who had an implant knows me so he said well he does men and women go see me I said I don't understand why we can't treat 85 year old woman. What's the difference you you have all the anatomy? Well, they said you're too old and this and that I said well, we'll just We'll just take more monitoring care of you. We'll see you more often, but I don't know why you can't do it

Sameena Rahman (18:2.807)

Yeah, absolutely.

Anyway, she's now there. There there there. She's in pain free mode now and it's sort of cute. It's really it just goes to show you though that that that some of the the take home messages from W. H. I. Are just so so awful and and they're incorrect and they set up a standard that that shouldn't exist.

I'll wonder what the base is.

We'll

100%. If I'm 85 and still able to have sex and I need hormones, I'll die happy. I will die happy.

Come see me, I'll still be there.

You're not going to be practicing medicine anywhere. Trust me on that one.

Yeah. Right. Everyone, was going to ask like, did you just as a side question, did you ever think Viagra was going to be as big as it is when you were doing it? Cause I never asked you that.

but Selena will take care of

Irwin Goldstein (19:3.234)

You know, it's a it's a it's a question that was extremely obvious because You know through the millennia cavemen Egyptians they all the writings showed a man with his sort of an anatomic part going down so Edie has been a part of all life and it was Obviously horrible and there was no easy solution for it. And when this pill came out, it was the biggest thing

in a man's life ever. it was, was, you know, this just rolled through the FDA in six months, this was approved. Think of that. You want to get testosterone approved for a woman, they mandated a 10 year safety propo. So this just flipped through the, well, cause there's men at the FDA, gather, whatever the reason is, it just flipped through. But

for my time.

Yeah.

Fast Tracks.

All

Yeah, it was going to be big, but we thought it would be bigger. We spent a lot of time and effort and money in developing it for women. We just didn't know how to run the trials. We just sort of said anyone can do it. We didn't realize about pain. We didn't realize about HSDD. Excuse me, low drive, low interest, which is a big problem.

hormones you didn't take into account hormones of hormones but did you did you exclude people that based on hormones?

No, we drew hormones. We definitely drew hormones. Testosterone and all women. I think the issue is arousal is... Arousal is not a driving presenting symptom. you know, if a clitoris... The physiology of the clitoris is it engorges, there's no question it gets larger during sexual arousal. There's lots of studies showing this. But if a clitoris engorges less...

Yes, sir.

Or only 10 % whereas a man that would be a disaster It's still sensitive and it still be orgasmic and provide pleasure So it's not perceived in the same way So the drug never had a chance but it could have been if it was really a home run for both genders This would be the god of the god of all medications The Ozempic of current time

Yeah.

Sameena Rahman (21:9.793)

Yeah. That's exactly where I was going. My head is I'm like, I was Viagra as big as GLP ones, you know? Yeah. Yeah. think it could have been so Samina and I know because we get to know what's coming up for the conference ahead of time. But can we talk a little bit about this exciting paper that's coming down the path that you're doing? What can you tell us about the big O paper? Orgasm.

Oh, the big old paper. Oh, it's so fun. You have no idea what we're going to be doing. we, Baric, Barry, the genius, Dr. Barry Kamasaric, at Rutgers university, neurophysiologist and really master of orgasm. has multiple textbooks on a multiple papers. Uh, what, so, so we have this 19 person committee, which is just outstanding and just so much fun. Um, and we're slowly putting together and I have to,

Yeah, I want to talk a little bit about it and a little teaser for our conference.

Irwin Goldstein (22:4.690)

a bless sue for being the driver to put it all together. But what we're trying to do is make an impact like we did in the persistent genital arousal, genital pelvic dysesthesia paper, where we sort of made an inroad where we could say these conditions could happen in this region and this region and this region and this region. And we sort of made a region -based way to classify the different symptoms.

What we're trying to do is to say okay, you have an orgasm dysfunction But maybe mrs. Jones's orgasm problem is different than mrs. Smith's was different than mrs. Whatever and the point is where we've now divided orgasm dysfunction into five different conditions Which is so exciting and we've developed a strategy that's well, I mean there's lots of different strategies But if it gets to the pharmacotherapeutic realm

soon.

So.

Irwin Goldstein (23:1.112)

There's going to be a specific strategy for that realm. So it's basically failure to excite. Failure to excite, failure to inhibit, failure to excite and inhibit are the three major ones. So you climb the mountain, but you can't get high enough to get to the other side. Failure to excite. You're climbing the mountain in the process of climbing. It becomes hyper intense, becomes painful. You can't go any further. Failure to inhibit.

Sue Goldstein (23:7.404)

Now just leave the teaser, just leave the teaser.

I'm so excited to see you again.

Failure to excite and inhibit you're climbing the mountain. It gets a little intense You have a premature unwanted muted version of an orgasm. We call it the anthill because you never make it up to the mountain Then you have these pleasure and hedonic situations then you have the the post -orgasm illness situations We have names for all these things, but by simplifying it by making it by making it sort of

I

Are you talking to me?

What people could relate to it's been so cool We're gonna create a way where you can listen to women with an organ dysfunction Oh you have failure to blank and here's how we're gonna treat it and we're gonna get better for you And that's never happened before that's so

No.

So he's going to act show it. So for our listeners, he's actually going to be presenting it at our conference. So you need to sign up. Wish, wish, wish, and we're super excited about it. Yeah. So basically all the issues around,

Go there, Swiss! Good job!

Yeah, you're going to change the way you do this. I'll teach you one as soon as you want. Listen, one little story is my wife was in her late 40s and she grabs my phone and she's not happy with her five flashes and all that. And she looks me and grabs me says, you will stop these from happening. I'll never forget that. And that forced me to learn how to do menopause. And it's now 20 something years that she's on menopause management.

See my favorite movie, called Jesus About My

Irwin Goldstein (25:0.908)

And she's vibrant, she's excited, she's sexually intact in a major way. yeah, it's Sue that's driven my, forced me to study and understand and learn and manage. this amazing condition, but it's so much fun. It's so easy to treat and the treatment restored. You know, you take these tissues, they're pallor, they're erythematous, they're raw, they fissure.

Sameena Rahman (25:7.331)

you

Yeah.

They're they're atrophied and with management they all return back to pink Lubricious healthy stretchy. They don't tear anymore. It's it's it's the coolest thing the tissues maintain their their enzymes They're just missing their substrates to start making the the hormones within the cells. I have to tell you It's the coolest condition on earth

It really is. really is. the fact that you can restore it and make it back to functional is amazing. Tell us a little bit about what research you're doing down there, because yours is the biggest, I think, sexual medicine research base in the country, I would assume.

Irwin Goldstein (26:8.462)

Sue, do some stuff. What do you want to talk?

Sue Goldstein (26:9.920)

Okay, so we've got, don't have a lot going on right now. We're almost finished with a trial of a device called EMCELLA that does 11 ,200 KGELs in 28 minutes. And we're looking to see if we're strengthening the pelvic floor will allow us to have better orgasm. So that's the study that's almost done. I'm trying to just talk about the female studies because you know, I noticed in the male.

Alright.

What, can you give us a sneak peek? Like, does it look like it's helping?

Oh, there's definitely people who have better orgasm. By the way, if you have never sat on this crazy device, please do so.

It does.

I know. I sat on it at your office.

OMG. And we just had a guide just yesterday. He has

Yeah, he's fantastic. He'd done it for any men, like off label.

Yes, we're doing it for men and this guy had great difficulty peeing his pelvic floor was extremely tight. I said, I don't know if the M cell would work, but let's just try it. And he got off the cell, went to the bathroom and said, Holy Christ, I have a great stream. Everything's relaxed and was.

Sue Goldstein (27:6.112)

The M .C .O .A .L .A. is not supposed to be.

It's.

It's not supposed to be for a high tone pelvic floor. I we won't let women on it with high tone pelvic floor. And in fact, the company is trying to develop a different protocol because it's computer driven within the device that is for high tone pelvic floor. So we actually, we should tell the company about this because that will help inspire them. So I don't know how this is happening because it strengthens the pelvic floor. Somehow I guess it must've just broken up the knots in his muscles or something to relax, but.

to tell you about the cooler project that we're doing. Can I do that? Am I allowed to?

I will stop you if it's something confidential and if it's the one.

Oh no, not confidential. It's fabulous. So there's this amazing provoked vestibulodynia problem beyond hormonal called neuro proliferative. And I don't know how common it is. In places where surgery is commonly done, you tend to see more of it. But I think that's just a biased perspective.

Sue Goldstein (28:7.046)

They're coming to us specifically because we have the expertise. So we see a lot of people.

So it's a horrible dilemma because you can't see the pathology. It exists underneath the skin lining. It's in the submucosus stroma layer, the nerves and the mesos. So there's just so many nerves that just basically doing an allodinia test, which is just a stroke test, causes huge pain, whereas a stroke test should just tickle. But that's a separate question.

So the question is we're doing surgery, but we're not having a diagnosis in anyone. There's no preoperative requirement to state that they have too many nerves and mast cells. We're doing the surgery. In our facility, everybody gets nerves and mast cell staining, but we only give them their confirmation, say three or four weeks out. It's not logical to operate on people.

diagnosis of exclusion up until recent, basically recent knowledge that that now has changed the way we do it.

Irwin Goldstein (29:6.978)

So we're trying to figure out how to get a biopsy of the tissue. But remember, if you biopsy an area with nerves and mast cells, and it bleeds and you put stitches in, you're putting these people out with a huge amount of pain for a long period of time. So there's gotta be a way to do that. So we're struggling and struggling, and we're looking at the hymen. And who the hell has done any research on a woman's hymen? So if you actually look carefully at the anatomy of a hymen.

It starts, the vestibule starts at heart's line and theoretically the vestibule ends at the hymen, but it's actually not true. On the other side of the hymen is an endodermal vagina, which then leads to a finally a mesodermal vagina. There is this entity below the hymen that is still endodermal. So if you conclude that the hymen resides above and below it as endodermal, a biopsy of the hymen is something that's stupidly simple. It's not painful.

It heals quickly. So what we did in our last 20 vestibulectomy specimens, where our plan is, I think we've done 13, is to take out the specimen and then as the specimen is taken out, take out the hymen from the specimen and send it separately for nerves and muscles. And all 13 have shown nerves and muscles. And the last bunches of hymens from specimens, we've taken a little biopsy gun rather than the whole specimen.

I've done 13 so far.

So now...

They've come back with nerves and muscles. So I have a whole bunch of women. One of them is 61. One of them at 12 years of age, currently now 61 at 12. She couldn't put a tampon in. She couldn't enjoy sex, couldn't have a spectrum. She's just like these 20 year old kids with this classic condition, but she's 61. And she said, you can't operate on me unless you have a diagnosis. So we did a little biopsy of her hymen.

in the office.

Irwin Goldstein (31:0.526)

yet because we just started this concept but we're going to change the paradigm of this entire management for this condition that every human being who is considering surgery should only do it if there's evidence that they have the condition only makes sense and a hymenal biopsy takes less than 10 minutes we put two stitches in it completely heals I before and after pictures of the biopsy site and that's really an exciting advance by the way I have to tell you

Sameena Rahman (31:8.483)

So we're

So when you touch them with the Q -tip, because actually you all know I sent you a patient and I was reading through her note and I know you did that, but anyway long story short, you do the Q -tip testing. Is that also why?

You see your patient, the 61 -year -old? That is your patient.

I'm not saying anything for HIPAA purposes. We'll talk offline. the one that we...

Okay, I think it is.

Yeah, Q has to list its pain, but people who have hormonally mediated vestibulodynia will also have pain with the Q -tip. What he does is he takes a Q -tip and just very softly rubs it. so it should feel the same on your vestibulism as it on your hand, unless you have neuroproliferative vestibulodynia, and then you want to hit the ceiling. It's painful, it's burning, it's some kind of massive reaction just from a very light touch. And that's the big difference.

Irwin Goldstein (32:0.087)

It's a stroke.

between the hormonally mediated and the neuroproliferative that we're finding.

There is one other condition that's positive with the allodenia test. Do you remember it?

I don't know what else it is, not lichens. No, I don't know what else.

Not Likens. All right, Samina, Heather, tell me the answer. Blah, blah, blah. We see a lot of it. Dr. Kim is involved. It's called sacral rad. There you go. Take radiculopathy. If you tickle it, it will cause pain. Those are the two only conditions. Yeah, that's the point. Anyways, let's...

So, was.

Yeah.

because it's a nerve disease. They're both nerve diseases.

So if you actually touch the hymen with the Q -tip, could be neuroproliferative or it could be hormonal.

Irwin Goldstein (33:0.138)

If you tickle the hymen, she will yell at you. But you see, the hymen's a flap. You can easily put lidocaine in it, two seconds. You take your pick up, just cut around the pick up, send that tissue out, put one or two stitches in, they're done. It's over. And then in three weeks, we'll have their diagnosis. And every one of these has shown positive if it's truly conditioned.

Sameena Rahman (33:3.681)

Yes. Interesting.

Sue Goldstein (33:4.650)

Just a

And if you're trying to differentiate between neuroproliferative and sacro -radiculopathy, if you numb the vestibule and it stops the pain, then it's either neuroproliferative or hormonal immediate. And you've used that tickle test to determine that difference. But if the vestibule is still painful, then obviously it's coming from someplace else. That's when you suspect sacro -radiculopathy. Although we do a bunch of neurogenital tests as well to support that. That would never be enough information to address the vast.

What?

about when always

I think you both, Samina and Heather, need to move to San Diego. We'll all work in the same facility.

I would love it. I would love it. I tell you this all the time.

Sue Goldstein (34:2.816)

Well, Samina's husband is pain management. He couldn't work in the building.

Irwin Goldstein (34:5.910)

Oh my god, we could make him a millionaire there.

Sameena Rahman (34:8.759)

Yeah, let's go. I'm ready to move. Retire to Chicago. I'll come out here. We'll meet in the halfway middle. Though their place in San Diego is so beautiful, they're never going to leave. I wouldn't leave either if I was there. Well, Erwin, when you take the Hymen biopsy, what are the pathologists staining it for, for the people that are listening?

CD117, which is a stain that's consistent with muscles, and PGP 9 .5, which is a stain consistent with nerves. And we've done hundreds of these things. Is it?

Is that what you wanted to say? Because I actually asked one of my pathologists, because I'm about to do a vestibulectomy, and he said I could probably do the CD117, but the PG1, he was saying that something about.

So.

They get sent out, the hospital doesn't do that. They get sent out to specialty facility.

Irwin Goldstein (35:0.770)

I think it's in Chicago where it's done. Oh.

Sameena Rahman (35:1.097)

Thank

Sue Goldstein (35:2.814)

No, it's not in Chicago. And the other thing is that normally your insurance will cover the H &E stating that's done in the hospital. And if they do CD117 in your hospital, but the moment it's sent out, the insurance won't pay for it. So either you have to pay the additional fee or your patients have the additional fee, just so you know. It's not all that expensive, but.

Guess what happens if you stain endometrial tissue with CD117 and PGP 9 .4.

Lights up,

Nerves and muscles, lights up, yeah. It's the same condition. That's so crazy.

May the

We have patients with multiple mast cell aberrant activity conditions that have had surgery of endometriosis, one had colon, and so we've sent all of that out and it all looks the same.

It's all right. Well, this is an ish wish abstract my abstract girl right here. Oh, that's awesome. I'm like, I'm so excited about this. This is exciting.

We didn't even let you guys ask more than two questions today, sorry.

Sameena Rahman (36:0.163)

Can you tell us any of other stuff you're doing? I know. I'm like, what kind of abstracts are coming down our pipe? This is me as a shooter.

Sue Goldstein (36:9.463)

Oh, we have to write our talks for the ISSM meeting in two weeks and then we have SMSNA in five weeks and somewhere in there we have to write all our abstracts. I'll tell you.

Ingrade them all and do all the things. Yeah, we got a lot of work to do before the end.

We've never submitted less than eight or more than 12, so you can look for a bunch.

Oh, wonderful. Have fun with Wonderful. Oh, gosh. You guys are so great, actually. And so what else do you guys offer, like, at your center? I know that it's a multidisciplinary center. You're doing your pelvic pain. I pelvic floor for PT. Sex therapy.

We basically say if there's anything keeping you from having the sexual life you would like of any person of any gender, we will take care of that. So all of our new patients have a biopsychosocial assessment. So they meet with our sex therapist who's not performing sex therapy. She's doing an assessment. They meet with Irwin who does a detailed history and then either he or the nurse practitioner or our fellow will perform diagnostic testing. But if we're talking about women,

women with low sexual desire that distresses them, women who have orgasm issues, either they have post -orgasmic illness syndrome or they can't reach orgasm or it's muted, people with pain, we've just talking about all that, but it may not just be vestibular pain, general pelvic dysesthesia. So any kind of weird feelings, dysesthesia is basically weird sensations in the pelvic region. We deal with that.

And when I at this...

Let me give me one second, okay? Yes. I need permission from you, Sue. Permission granted, yes. We have this most amazing relationship with a spine surgeon. tell you, it's the most, I mean, we do many cool things, but it is definitely one of the coolest things. And every Sunday morning, we review cases and go over MRIs and all that. His name is Dr. Chol Kim. And the brilliance of this man is not to be,

Yes.

mission granted.

Irwin Goldstein (38:8.526)

not to be emphasized enough. So we have over 200 surgeries now of individuals with sexual problems whose problems generate from their caudicoina, from the lower part of their spine. success rates are so amazing. I don't know if it yesterday or the day before, we had a woman who had vestibular pain. We were poking and prodding and she had a lot of pain.

He's presented to this wish before.

Yeah, I see that.

She had a back problem an annular tear we did an injection of lidocaine in her l5s1 Whatever her annular tear was she came back in I touched her vestibule and her pain wasn't there anymore This was a vestibulodynia from sacral radiculopathy so cool She had sciatica. She had other symptoms that were consistent with the spine, but it was so cool She came in I think it's her

eight week or I mean eight eight months follow -up and she still has no pain in her vestibule. She has no more sciatica. She has no back pain. She has mobility when she walks. This is just an example of so many people whose problems present as in the genitals and you get frustrated because they don't get better with genital directed therapy or even pudendal directed therapy.

can't find what to do. I women present what they say they have a golf ball in their vagina, and you put a speculum in and there's no golf ball in their vagina. Where is it coming from? Or they have clitoral pain and you know, you're able to retract the hood and there's no there's there are no carrot and pearls under there. Why should everything? They feel like they have knife blades. You know, they're all sorts of weird stuff. And because you can't see it, they're told it's all in your head. You know, you have trauma, things like that. And it's so sad.

Yeah. just want to know how you. Tell us the story about the story about Dr. Kim. Like, how did you convince him that there's something connected? He must have looked at you like. He was like, what are you talking about and what has women's female parts have anything to do with backs? Well, I want to emphasize, like we were talking about the region based approach to genital pelvic abnormal genital pelvic.

He has so embellished our practice of women's sexual health. Dr. Kim, amazing.

Irwin Goldstein (40:9.250)

We took a pair of handcuffs.

pain sensations and persistent general arousal, which I've talked about it at another podcast, but this is the region based approach that you guys have created. how did like, if we were in the room where it happened, how would we know? Our Hamiltonian moment, please. Please. And I want to say

Definitely did not start with region -based. That's new.

Okay, so what that that that

Sue, tell us the story.

Well, I mean, it really started with Barry Kamisaruk, who was doing an MRI study with Tarlif -Cis and found that there was a much higher percentage of people suffering from persistent general arousal disorder with Tarlif -Cis than the general community. And so that became, well, is there something in the spine that's causing the PGAD? But we didn't know that was 2012. That was 2012. In 2016,

Irwin Goldstein (41:5.198)

We had a patient from Copenhagen, I think Anna Maria sent to us, and she had already been signed up for assisted suicide in Switzerland, but her family had basically thrown her out of her house because they thought she was crazy. She had dropped out of her PhD program, so you know she's an intelligent woman, and I believe it was a church community group sponsored her to come to America. And Irwin did every, she had this constant buzzing.

Yeah, 100%.

He did every diagnostic test he could think of. And then at the end he said, well, maybe it's something to do with the Tarluff cyst. But at that point she said, I've had enough. I don't, you I'm out of money. I need to go back to Copenhagen. And she went home and went to assisted suicide and killed herself. And Irwin went with that to Cho Kim and said, you have to help me. We can't lose anybody else with PJD to suicide. And Irwin, can kind of embellish the story.

Irwin Goldstein (42:1.282)

No, no, that's the that is the story When we got the MRI and she had a terrible cyst I called Barry who then referred me to his spine person who said well It's gonna take six months for an appointment and all that sort of stuff Then I looked around in town in San Diego who would do that? No one would do that and I and if nobody would do it it was like this horrible thing and Yeah, so she committed suicide and I said we can't that can't happen

battle again.

And the crazy part was because of Dr. Kamasaric, we had to do an MRI on everyone who had persistent channel arousal. And the specific MRI was called sacral MRI because that's where the turn of cysts was in the sacrum. You got a little peak at L5S1 disc, got even less of a peak at L4L5, but nothing above. In those two discs through the spine MRI,

We would see countless numbers of people with annular tears and herniated disc. So we said, this is stupid. Why don't we get a lumbar MRI? And then we started saying there's like 10 times the number of people with annular tears who have PGAD than who have TARL -O -SYS. But it came backwards because that's the way we entered it through the TARL -O -SYS.

But to get Cho to listen to him, the irony is Irwin had been recruited to this small private hospital, which has since been sold twice, but been recruited by someone who was a former student of ours. He wanted to bring in some really niche players to offer in the hospital some very special services. And so he had recruited us in 2007. He then recruited Cho Kim from UCSD a few years later. so Pedram, this person who had recruited us, showed Cho, look.

this is the person I recruited, look at Erwin Goldstein, look at who he is. And so Cho still laughs about it. He says, when I grow up, I want to be Erwin Goldstein. So he already knew who Erwin was and had a great deal of respect for him. So when Erwin went begging him to please do this, he at least would listen to him. And to this day, as far as we know, he is the only spine surgeon doing spine surgery for sexual health concerns. People ask us all the time, can you recommend somebody nearby? And go, if you find somebody, let us know so we can let somebody else know. But he finally has enough

data to present. I mean, he's presented at ISWISH, he's presented at Sexual Medicine Society North America. He finally has enough data that he's presenting this year for the first time at his spine meeting, which is huge. So whether he'll be booed off the stage or whether people want to learn, he's a little afraid of what the response is going to be. But his hands are incredible.

Oh, that's amazing.

He'll be amazing. That's all.

The Spine Spurgeons will say, we don't do clitorises. I'm sure that's what's going to be said.

Yeah. Or you've lost your ever loving mind, but that's awesome. Do you think they're more, it's more in the annular tear? Are you seeing more of the annual tears causing it or the tar loves this?

Oh, by tenfold, literally.

Yeah, much more common. Because think about how easy it is to develop an annular tear. The disc bulge and the annulus leaks out and causes aggravation. So small that the spine surgeon would say, oh, that's nothing. That's tiny. You don't have sciatica. You don't have back pain. Because just like erectile dysfunction in the penis is the first heart attack before the muscles get so clogged, you have a real heart attack. This is the first nerve damage that you get to the genitals because that's the first place it's affected before you get to the point that you have sciatica.

Yeah, that's actually a very good analogy. I that. That's wonderful. Brilliant. And I want people to know the other things you're doing like Samina and I have been so blessed that we've had the opportunity to precept with you. You still are precepting outside of your fellowship, right? You still take. Yeah.

Come back for more and then plant your all your belongings there and work with us right in the place. We'll have so much fun. Oh my god

I'm

It's a little more challenging for somebody to go into the OR to observe now because the hospital has been bought by UCSD, but we still make it happen. And we still do, I know we were talking about what we did in the office, but we do a lot of diagnostic testing in the office, a lot of treatments, but we also do more surgeries than vestibulectomy based on what is needed. I mean, that's the bottom line and it's still a growing field.

Sameena Rahman (46:8.545)

And he does, he does trans care too. Like when I was there, it was really cool. got to watch and I think it's cool. did some. Yeah. And it's really sad that people need to go in the prison system to get their hormones. So talk, talk a little bit about that amazing stuff that you do. Cause I got to actually experience that when I was there and it was just.

Yes. I love that. One of the better parts of my life.

Yes, so, you know, when when individuals are three, four and five, they're sort of liberated to do whatever they want to do. If they happen to wear their mother's shoes and dresses and put on makeup and they happen to own a biology of a penis and testicles, they're in an awkward situation because when they look at themselves without clothes, they're not happy what they see because their brain is where what is what is what they're playing with.

You're inside the

As they grow up they get struck with society's rules parents rules Religious rules and all that and then they get outcasted and they end up on the streets all they want is hormones and care They're just normal people who who are? Who are really nice actually? so they become People own them in a way and they do bad things and they get into prison

It's gonna be different.

But in prison there they can be outed and and they get protection and so I get to take care of them and many for the very very first time so the privilege and joy of taking someone who knew who they were from day one This was no choice. This was who they bought biologically are And to convert them to to being happy on the outside what they know they are inside. It's such a joy I So enjoy that

the outside match the inside.

Yes. And they're so thick.

You know that if we look at the homeless youth, homeless youth in America, and you take away the ones who are homeless with their families, and just the single homeless youth, somewhere between 70 and 80 % of those homeless youth are gay and trans or LGBTQ, because they don't need parental support. They're thrown out in the street. And it's such a shame, because they're good people with good hearts. And it's not their fault that the biology doesn't match their anatomy.

Uh.

And you can.

So they're increased risk of homelessness and history of runaway. And they're also at increased risk for trafficking. So, you know, that's near and near to my heart.

Mm -hmm.

Yes, it is so sad.

That's so sad. Okay, my last. Yeah.

We help them on the side of it, we do help them.

But the state of California has made a commitment that all trans people in the state of California prisons are entitled to care.

I love it. That was probably one of my favorite things that I mean, and I got to do so many cool things when I was there, but that just that really pulled at my heart a lot. Okay. So tell me one last thing, because I don't want to be cognizant of you guys this time. So we want to just, if you can talk a little bit, because we present on shockwave therapy and the use of shockwave, because you've been doing it in men and now you've been doing it in females as well. So tell us a little bit about like shockwave therapy and

Well, Sue and I, you have to hear this. It's not specifically gender related, it's, I mean, it's orgasmic when I tell the story. was orgasmic to me hearing. Sue and I celebrate our 50th wedding anniversary by taking a river cruise from Switzerland to Amsterdam. And when we arrived in Amsterdam, we go to a meeting called ISMST, which has now become one of my favorite societies.

Oh

International Society for medical shockwave therapy one of the very first lectures We started eight in the morning and go to to basically the evening and it's shockwave of this organ shockwave of that organ shockwave of this or and it's like it's Dramatically exciting. I have to say it's such a cool thing the first one of the first guys his name is whole failed H o l f VLD First name is Yohannes and he stands up. He's like six foot five cardiac surgeon like but really bear it

to them.

Sue Goldstein (50:7.700)

Really cute ladies!

younger guy and he opens up his slide showing a beating heart during coronary artery bypass graft surgery that's what's on the screen and he takes his shockwave device and beats the goddamn beating heart with his shockwave machine and he then gives the story that these are mostly people and They have myocardial infarction. Their their their cardiac muscle has died. They have extra connective tissue

Their other ventricle is going like this rather than squeezing it out the left ventricular ejection fraction is really low versus in a functioning heart So he then gets the shockwave. He doesn't know if he's getting sham versus active shockwave He does one treatment 500 shocks to the beating heart close does his coronary bypass graft closes the chest they recover and That two months and at 12 months. He does left ventricular ejection fraction studies

You wanna guess what the results show?

Sameena Rahman (51:8.953)

That is improved in nature.

Yeah, those people who actually received active treatment have amazing increases in left ventricular ejection fraction. The only way that can happen is if he, first time in history, Nobel Prize, I hope, winner, shows that you can regenerate cardiac smooth muscle with shockwave. That is pretty amazing.

point that they were forced to shut the trial down because it wasn't fair to the people who were getting sham treatment not to get the shock shockwave and now in Austria all people getting open -heart surgery get shockwave one treatment one treatment so

Wow!

Yeah, so it's called mechanotransduction. When you impose a shockwave to a tissue, it contracts and expands. does this movement back and forth. And that mechanotransduction changes the biochemistry of the cell. It makes mitochondria. It makes growth factors, cytokines, and all these things. You make downstream stem mesenchymal cells that grows cardiac smooth muscle. We're proving that it grows muscle in the penis in men with erectile dysfunction.

And that's another study. Actually Sue is first author. She just presented that yesterday or two days ago. It's the three year study that she did with a prospective trial.

I'm like, what can we do for the folks?

Yeah, so the thing is that based on this heart study, shows that improvements continue over time. So one of the things we're doing is we shockwave our women who are having a vestibulectomy once the day before a vestibulectomy, and we have found that they have less opioid needs. Is it because it's healing more quickly? Is it because it decreases the pain? Is it, you know, we...

We know it's biochemical changes that continue over time. And so it's really been remarkable because they do use far fewer opioids. And it's.

Irwin Goldstein (53:1.174)

Oh, I have another story. Whoa, whoa. Sue is the first vagina to receive vaginal shockwave therapy. We've actually figured out how to deliver the shockwave to the vagina.

Well, we didn't do what we were supposed to do yesterday, because we have to test that. But yes, we're playing, trying to figure out how to do a vaginal shockwave.

So for menopausal women, we're going to develop shockwave therapy for them. So at night, I shockwave Sue's vagina. How much fun could that be?

So the thing is that when you do radio frequency, when you do micro -needling, and when you do fractional CO2 laser, you're making controlled wounds that then heal. But that's not what this does. This turns on the mesenchyme stem cells that live there to then go and make healthier tissue. So you're not doing any wounds. So when you do a shock, you may feel a little moment, Terri, and as soon as it stops, you don't feel anything.

Holy holly shit!

That's your

Sue Goldstein (54:0.352)

Yeah, and you know when we did in the vagina, don't really you don't really feel anything So you're making something that is so I don't want to say unobtrusive so mild compared to the other treatments Although I have to say we just we do co2 fractional laser and that there's no pain when you do that in the vagina either But you know to offer one more opportunity

Okay, yeah.

Yes, that's a, that you're making an actual hole into the tissue. You don't do that with shockwave tube.

You're making a good amount of wounds, that's correct. Right, that's the benefit is that you're not doing any kind of wounds. And I'm just thinking, you know what, we should do that in our patients when you do the hymenal biopsy, we should do one vestibular treatment right then to help promote a healing.

It's very clever. See, this is how we grow our research. have conversation. So Heather and Samina, if you do come, I'll do vaginal shockwave therapy. I'll add you to my list.

That's your foreplay is your vaginal shockwave therapy.

before I play with anyone but me, thank you.

No, just Sue. He talked about it with Sue and I'm like, there's their foreplay. You're the true masters in Johnson. I think they're doing that in the spine too, right? Aren't they shocking the spine more and they're doing all sorts of muscles, right?

Irwin Goldstein (55:7.032)

Yes. The people at ISMST are a little skeptical that we're getting through the bone into the spine. So it could be that we're really doing muscles of the spine, but whatever. We do help people with that.

that it relieves the pain, that it doesn't really matter exactly. But I'm going to just say this, Masterson Johnson were married for about two to four years, I can't remember before they were divorced again. So we're married 50 years, definitely not Masterson. He divorced his wife to marry Virginia Johnson, who already had three kids by somebody else. Somebody once came to our office, because California, no one's on their first marriage, said, Oh, Dr. Goldstein has three kids. How many kids do you have? And I looked at him, I said, three kids. Just, oh, between you have six. said, it's the same three kids.

Yes.

Maybe we just need to replace Masters and Johnson in the future and be like, no, Goldstein's. You're the Goldstein's. That's the goal. Yeah. You're the real Masters. You're the real deal.

Okay, go, go,

Sue Goldstein (56:2.272)

So I didn't start out in this world. I started out with my husband coming home every day and talking about what he did. And I just absorbed it. And when ISWIS started, I was the first honorary member because I wasn't working in the field. so I wasn't allowed to be a full member. But I went to every meeting and I absorbed it all. And over time, I learned a lot of stuff. And then when we moved from Boston to California, I wound up running our clinical research because someone needed to do it. And I knew.

bench research because I had done that when I was younger. But I learned all this stuff. And so really, I started my career per se at the age of 57. And at the age of 72, 72, 72, I was president of ISWISH. So no one should ever say I can't make a difference in this world. No one can ever say it's too late for me to start something new. No one should ever say I don't have fancy, you know, I don't have fancy information education, so I can't.

you.

I can't do anything. Because all you have to do is have a heart, have a passion, have a brain to put them all together and be lucky enough to have met somebody. I mean, I was here when I met when we were 19. But we all have an opportunity to help other people. And Samina and Heather, both of you help people in your office every single day.

I am so happy to work with both of you, really. It's so cool.

We love you.

You helped us. absolutely. We really appreciate everything you guys do. Every time I go to Ishwish, even when I repeat fall courses, even when I go to the annual meeting, I always take home a good couple nuggets to use on my patients. Always. It's never a wasted effort. I love it. So thank you so much for all you guys do. You guys are amazing. I wish you many, many, many more years, 50 more years together so that you can.

Thank you.

Thank you. I'll take 25.

Yes, well, this is you know, longevity medicine is like really up and coming. Yes. I hashtag I want to be

Well, the key to longevity is having good sex, by the way.

Yes. There you go.

Sue Goldstein (58:0.778)

When a long marriage is having good sex and being married to your best friend.

Sameena Rahman (58:4.599)

Yes. That's wonderful. think that's a great place to end this. thank you guys so much for giving and there's a very valuable time. So we really appreciate everything. I'm Gyno Girl. Thank you for joining me. Gyno Girl presents sex, drugs and hormones. And I'm Dr. Heather Quayle or I'm Dr. Quayle and P and we are the Just Ask podcast. And we're here to educate so you could advocate for yourself. And so please join us for our next episode. Thank you. Cold states. Thank you. All right. Yay.

Thank you for having

Yay. Thanks. That was wonderful. Thank you so much. I will be in touch. Oh my gosh. Thank you. Thank you. Appreciate you. Hold on.

It's our pleasure and honor. Thank you.

That was fun.

Have a great Friday, you guys.