Beyond Libido: Testosterone, Desire, and Whole-Body Health with Dr. Nikitha Paluri, MD

I’d like to share a direct quote from today’s guest. And it’s this We talk about testosterone in women as if it only matters for libido, but that conversation is too small for the biology. Yes, sexual symptoms have the strongest evidence, but women have testosterone receptors throughout the body, and women’s hormones were never as simple as medicine or the wellness industry has made them sound.

Women have testosterone too, and it deserves a fuller conversation. Today we’re talking about testosterone, desire, menopause, metabolism, nervous system, health, pelvic pain, and the space that women too often fall into, that space between emerging biology, outdated systems, and symptoms that are still being dismissed.

Welcome back to the Vocal Pelvic Floor. I’m Dr. Ginger Garner, and this season we’re continuing our deep dive into sexual health. Not as a luxury, but as something, and not as something as separate from the rest of the body, but as a very vital part of women’s health, identity, quality of life, and nervous system safety. Today’s conversation is about testosterone for women and more. It is also about something much bigger, which is

how we talk about women’s hormones, desire, metabolism, menopause, and the symptoms that women are too often told to just tolerate. My guest today is Dr. Nikitha Paluri, a board certified internal medicine physician, educator and founder of Lemira Health, and Dr. Niki’s Botanica. Welcome.

Dr. Nikitha Paluri, MD (01:45)

Thank you.

Dr. Ginger Garner PT, DPT (01:46)

I’m so glad you’re here. And listeners, ⁓ we’re both in North Carolina. That like that hardly ever happens. So I’m I’m pretty excited. I’m pretty stoked to have ⁓ a colleague on the show who is also doing great work in North Carolina. So let me tell you all a little bit more about her. Dr. Nikitha is a board-certified internal medicine physician, educator, and founder, like I mentioned, of Lemura Health.

Dr. Nikitha Paluri, MD (01:54)

Yeah.

Dr. Ginger Garner PT, DPT (02:15)

And Dr. Niki’s Botanica. She’s passionate about helping women better understand hormones, metabolism, nervous system health, and integrative wellness through an evidence-based whole body approach. Dr. Paluri graduated from the Medical University of the Americas in I’m not gonna mess this up. It’s in West Indies, but how do you pronounce that name properly? Nevis Nevis, West Indies, and completed her residency at Medstar Harbor Hospital Center in Baltimore, Maryland.

Dr. Nikitha Paluri, MD (02:36)

Nevis. Yeah, it’s Weston Nevis, yes.

Dr. Ginger Garner PT, DPT (02:45)

Her work is rooted in a desire to support people in vulnerable moments, and sexual health is certainly one of those, with compassionate, thoughtful care. Outside of medicine, she enjoys spending time outdoors hiking and exploring nature with her two daughters. Welcome again, Niki Yeah. You know, I wanted to start out with kind of context. Like, why does the conversation matter? ⁓

Dr. Nikitha Paluri, MD (03:04)

Thank you so much.

Dr. Ginger Garner PT, DPT (03:15)

Because people will argue all the time, well, women before this didn’t have access to it. Why does it matter now? It’s just a natural thing. You should just let nature take its course, right? I’d like to tackle those things. ⁓ in a in a 2025 article, this was out of Europe, the Society of Medicine said reframing testosterone as a hormone vital to both sexes rather than exclusively male is essential for optimizing women’s health, longevity, and overlaw.

quality of life. And I quoted your post ⁓ on Instagram and I just want to revisit that for a second. You recently wrote we talk about testosterone in women like it only matters for libido, and that the conversation is too small for the biology. What prompted that post?

Dr. Nikitha Paluri, MD (04:03)

So I’ve been doing a lot of research on testosterone this past year because I’ve been giving it out and I usually get very nervous giving out something new because I don’t know everything, especially if I don’t know everything about it. And the more I research, the more I realize there’s one thing that…

the article, states for fact that all menopausal women only need testosterone for hypoactive sexual disorder. But then there’s another thing where you look at actual testosterone receptors and you see, my gosh, wait a second, they’re in our brain, they’re in the bones. There’s so much research in men where it comes to testosterone and how it activates osteoblasts to form that bone structure. And then you’re like, wait a second, testosterone’s everywhere. So why are we only talking about

Dr. Ginger Garner PT, DPT (04:47)

Yeah.

Dr. Nikitha Paluri, MD (04:49)

libido? Why is that the only conversation? And I completely understand there’s wonderful researchers out there. They’re saying everything else is probably, you know, just placebo, that there is not enough research beyond ⁓ helping your libido. And I understand that I respect that. But there is no research up until now does not mean there won’t be in the near future.

because there was no research, even the amount of research we have right now did not exist a couple of decades ago, right? Our parents, our grandparents did not get the liberty or even the option to be able to use hormone therapy in general.

Dr. Ginger Garner PT, DPT (05:26)

Yeah. Yeah.

That’s a big

Well, that’s a big exhale. It just makes you go because it’s it’s generations of of people missing out on care.

Dr. Nikitha Paluri, MD (05:36)

This is not…

Right, right.

It’s not just missing out. It’s suffering. We have generations of suffering and it goes beyond just a generational thing It’s also a gender thing. I hate to bring up the gender, but it’s true, right? It absolutely plays a role in it

Dr. Ginger Garner PT, DPT (05:49)

Mm-hmm.

Dr. Nikitha Paluri, MD (05:55)

women have a role in our society or they were told historically that they have a role in our society. one of the things that women have been told again and again is this is normal. You just suffer every month until you have babies and then you suffer through the postpartum phase and then you suffer when you hit the transition into menopause. But now we’re kind of changing that narrative. We’re saying, a second, just because you have to go through it doesn’t mean you have to suffer through it. Right. So it’s that little change in your mindset

Dr. Ginger Garner PT, DPT (06:21)

Mm-hmm.

Dr. Nikitha Paluri, MD (06:25)

is truly I feel is helping our ladies now versus before.

Dr. Ginger Garner PT, DPT (06:29)

Yeah.

Yeah. Which is really important when you look at things like nursing home admissions. and the number one reason for nursing home admissions in women being incontinence, you know, families unable to take care of that. And a lot of what we’re talking about with hormones would actually go on to support prevention of that. So women have actual longevity instead of spending the last 10 to 20 years of their life.

in some kind of you know assisted nursing situation or feeling like they’re gonna be such a heavy burden on their families. And then and then you see, you know, higher rates of Alzheimer’s dementia in in women as well. And and we can’t ⁓ necessarily draw those direct correlations yet, but we do know things like women with vasomotor symptoms, hot flashes, night sweats do have higher rates of dementia later. So it’s like, you know, paying attention to those little details and going,

How many, you know, if I look back in my family or any female, you know, that that’s concerned about this, which it should be all of them, how many women in their family that did they see decline rapidly because of those things? You know?

Dr. Nikitha Paluri, MD (07:41)

Absolutely, 100%. And I mean, you know, one of the biggest things is also like recurrent UTIs. When I was inpatient, I can’t tell you how many times I saw E. coli become like a UTI with E. coli enter the blood and now you have sepsis and patients don’t do well, especially when you’re, you know, when you’re a certain age, your body’s not going to recover the same way.

Dr. Ginger Garner PT, DPT (07:46)

Yes.

Mm-hmm. It doesn’t take that much. And those recurrent UTIs are the thing that is  that one can can quickly become too much for yeah,

Dr. Nikitha Paluri, MD (08:12)

Absolutely,

Dr. Ginger Garner PT, DPT (08:14)

So another thing that I think is important to touch on too is that and I wanna get your thoughts on this, is why do we think testosterone in women has been reduced almost entirely to sexual desire?

Dr. Nikitha Paluri, MD (08:28)

That’s a very interesting question. Now I think, I mean, I hate to do the whole gender thing, but I’m going to bring it up because I think that directly affects our male counterparts, right? You see that, okay, why is my wife not having sex with me? Am I allowed to say that word? I don’t know. Okay, cool. Okay, thank you.

Dr. Ginger Garner PT, DPT (08:45)

yes. yes. And you can swear if you want.

Dr. Nikitha Paluri, MD (08:51)

I actually had an older Hispanic lady, which is another thing, you know, getting into different cultural norms and things like that brings out so many other nuances and other issues. But I had an older Hispanic lady. mean, when I say older, she was maybe in her late fifties and she was telling me towards the end of our conversation, Hey, my husband thinks I’m cheating on him because I don’t want to lay in bed with him. So I don’t know what’s wrong with me. You know, I think something’s going on.

Dr. Ginger Garner PT, DPT (08:56)

Cultures.

Dr. Nikitha Paluri, MD (09:20)

I said, mama, no, this is normal, right? But you don’t have to, just because it’s a normal transition doesn’t mean you have to suffer through it. Let me help you. And she had no idea. She didn’t even have any idea that low testosterone could actually cause a little libido and that could happen after menopause.

And this directly affects the men, right? So I honestly think this is one of the biggest reasons we’ve actually studied the low libido in post-menopausal women because it affects the male gender. hate to say it out loud, you know?

Dr. Ginger Garner PT, DPT (09:56)

Yeah, yeah. I

I I’m glad we just got straight to the heart of it. I feel the same. It’s negatively impacting men and their ability to have sex with their partners. So they’re like, Hey, dude, we should research this.

Dr. Nikitha Paluri, MD (10:07)

Right, if

our bones were falling all over them, they would research that more. ⁓

Dr. Ginger Garner PT, DPT (10:12)

Yeah,

yeah, exactly. So I think we just have a delay in in research because, you know, it’s been kind of self-selected. Hey, let’s study this because it impacts us negatively. So when you say women’s hormones were never as simple as people made them sound, what would you want women, what do you want the listener to understand about that?

Dr. Nikitha Paluri, MD (10:36)

So there’s two sides of the coin always, right? First thing is, yes, your hormones start fluctuating as early as, you know, for some women if they have premature ovarian insufficiency in their early 30s and all the way up until menopause, which is for an average person, it’s around 51. And those hormone fluctuations can be very hard on the body.

So how do we make sure that the hormones are fluctuating less? One thing is actually birth control pills. And I talk about this and nuance of hormones in general, right? Birth control pills get such a bad rep. But if you’re very sensitive to the fluctuations, birth control pills are probably your best bet, not menopause hormone therapy. Because I actually just made a video about this today that if you have a vessel and…

the vessel’s filling up with water and emptying it by itself randomly, then putting menopause hormone therapy on top of that may or may not help depending on whether the vessel’s empty or full, right? Because if it’s already full, then you’re just putting more water in there when you put menopause hormone therapy into your regimen. Whereas birth control pills will make sure that there’s always a little bit of fluid in that tank, but there’s a more consistent level of fluid in that tank. So although I personally don’t like birth control for myself,

because I’ve had poor reactions with it, I understand the benefit of birth control pills. And those are also hormones. Now, when it comes to menopause hormone therapy, some people do really well with it. And I mean, ⁓ my goodness, it’s amazing what people have come to me with and have said, hey, estrogen and progesterone cured it. And it’s like magic to me, right? Someone who has only been doing this for a couple of years, I’m just like always so positively influenced

keep doing this you it’s it’s beautiful to see that kind of change however I’ve also had ladies come to me and say hey I’m way more depressed now I actually can’t even function after starting my my hormone therapy what the heck what do I do so I’ve had both ends of the spectrum and that’s why it’s such an important conversation to have when it comes to the nuances because every single person is so different

Dr. Ginger Garner PT, DPT (12:44)

Mm-hmm.

Dr. Nikitha Paluri, MD (12:55)

And we’re different based on our genetics. We’re different based on what we eat, how much we sleep, what we do for a living, how stressed are we, how many kids do you have? Do you exercise? It’s so much. It’s so many things to consider.

Dr. Ginger Garner PT, DPT (13:05)

Yeah.

Yeah, yeah,

it is. And I think that that is compounded when they go into a visit, when women go into a visit and they, you know, sit down and say, you know, medicine, you know, whoever whoever that it is, but let’s just c distill it down to medicine. It could be a practitioner or whatever, and they they just say essentially, I don’t feel listened to. You know, they’re not listening.

So what are some of the things, what are women telling you in your practice that medicine, practitioners, et cetera,  healthcare still isn’t listening closely enough to?

Dr. Nikitha Paluri, MD (13:48)

So if we’re talking about women, unfortunately, this is with men and women. And it comes back to what we were talking about earlier. I think most of us want to help. We just think we’re doing our best. And the reason we think that is because we just don’t know what we don’t know. So there is such a big gap in our knowledge still. And it goes back to what we’ve been hearing online.

We just haven’t been taught in med school how to take care of certain conditions. We haven’t been taught in residency how to take care of certain conditions. And because of that, there is this knowledge gap and we’re trying to fill that knowledge gap right now with going out by ourselves and trying to learn things. ⁓ And a lot of times my patients will come to me and say, hey, I can’t believe I finally found someone. And I hear this so much and it feels good. It’s really good for my ego to be honest with you, but at the same time,

This is a problem because they come to me and they say hey, you’re the first person that has heard me in years

Dr. Ginger Garner PT, DPT (14:50)

Yeah.

Dr. Nikitha Paluri, MD (14:53)

That’s a problem. Again, I love that they say that about me. Makes me feel like God, right? It’s like, okay, but this is a problem because there’s other providers out there that are not able to provide that kind of care for this patient. Now, the healthcare system, as we all know, is broken.

Dr. Ginger Garner PT, DPT (14:58)

Mm-hmm.

Mm.

Dr. Nikitha Paluri, MD (15:16)

So this could be because of lack of education, lack of time, because of the corporate world, breathing down your neck about stats. It could be a number of things, or it could just be a bad provider. Hey, we’re all human. I tell my patients advocate for yourself. I’m just human. I might be missing something. I might be having a bad day, and I might not be hearing you properly. I’m aware of that. Like, we’re all human. So patients need to advocate for themselves no matter where they go as well.

But I do think a lot of it is just like not talking and actually hearing what the patient is saying, which seems like a lot of us are still not doing. ⁓ Could be a number of reasons again. And so yeah, I do hear that a lot every day, all day. Hey, like no one’s heard me. Like I’ve been complaining about this forever. I’ve had patients, goodness, and this really gets under my skin. I’ve had patients who’ve had hysterectomy.

and I’ve spoken about this multiple times before and the uterus shares blood supply to the ovaries. So when you take that uterus out, those hormones can still go down even though you have ovaries. And I’ve had people who’ve had this surgery done in their 30s and they’ve been struggling with

lack of sleep, mood issues, and now they’re on trazodone, they’re on melatonin, they’re on SSRIs. I’m like, my goodness, I was like, girl, I think you might just need hormone therapy, okay? Right? And it works, it really works. So, you know, I think just realizing, okay, like, trying to look for patterns and trying to realize when did these symptoms actually start? And

Dr. Ginger Garner PT, DPT (16:39)

Yeah.

Dr. Nikitha Paluri, MD (16:53)

why are they even having these symptoms? Just being able to have the ability to do that and understand the patient and really sit there and just let them speak can really, really help our patients in general.

Dr. Ginger Garner PT, DPT (17:07)

Yeah. Well, let’s start with testosterone and sexual health, because that’s something that obviously ⁓ test use of testosterone is supported for. you know, and starting where the evidence is the strongest and that’s sexual symptoms. So when might  testosterone be an appropriate part of a sexual health plan and what changes are women gonna notice if it’s appropriately, you know, monitored and prescribed?

Dr. Nikitha Paluri, MD (17:35)

Yeah, if we’re speaking strictly for about libido, which is also insane to me because you just said we do have research for it. So why do we not have an FDA approved female female product, right? I don’t know. So right now, you know, as we know, we’re using male products for ⁓ for HSD. So if you have low libido, which is the main indicator to start testosterone.

Dr. Ginger Garner PT, DPT (17:44)

Exactly.

Dr. Nikitha Paluri, MD (18:01)

you just, you start using the male ⁓ products, but we dose it for the females. You’re not using like a full packet of gel or you’re not using as much as a man would.

and then you just rub it on your skin, which is the most common form. I know people also do injections and pellets, but I don’t do injections or pellets yet. I’m only doing the cream, the testimogandrogel, and you just rub it on your skin, and honestly, sometimes it can take up to three months, so just be patient. Be patient with the change in symptoms, and you should start feeling like you want your husband to touch you again.

That’s our biggest goal with this. We want to make sure that you’re sexually satisfied, that your marriage is doing well. Or your wife, whatever your sexuality is. We want to make sure you’re sexually happy and content. So you will start seeing those symptoms as early as like two weeks, one to two weeks, and as late as three months or so. I’ve had someone say it was just like one time she put it on and she was like, woof, I’m ready, let’s go.

Dr. Ginger Garner PT, DPT (19:04)

Mm-hmm.

Dr. Nikitha Paluri, MD (19:05)

⁓

So she said she saw a difference in just one day. So I think there is ⁓ a wide variation. Now testosterone does give you energy as well.

And there’s separate research about that, right? It does give you like improve your mood, brain fog and things like that. So no, it has not been studied extensively in menopause ladies or menopausal women, but we know for a fact testosterone does boost certain other aspects of your life as well, which also I see a lot, a lot.

Dr. Ginger Garner PT, DPT (19:36)

Yeah,

I think that’s ⁓ I think that’s important. Like l moving beyond libido now. ⁓ you know, your your post pointed out ⁓ something really important that we’ve already touched on. And I think that women don’t even realize estradiol receptors are everywhere, but testosterone receptors are also found throughout the body. And the listener may not necessarily have heard that phrase before, a receptor, like what is that? And then elaborate on, you know, what does that actually mean?

Dr. Nikitha Paluri, MD (19:41)

Yeah, yeah, yeah.

Dr. Ginger Garner PT, DPT (20:06)

you know, practically for them.

Dr. Nikitha Paluri, MD (20:08)

Yeah, it’s a receptor is like a lock, right? And then your hormone is like a key. So when that hormone goes and kind of like gets into that lock, it can open doors. It can open your mind. It can open your sexual health, you know, you know, it sounds weird when I say it that way. But you understand what I’m saying. It’s basically a receptor is a lock and your hormones are like a key that are able to open your mind into two other realms or into other rooms.

Dr. Ginger Garner PT, DPT (20:37)

Yeah, and so you think about symptoms like fatigue, low motivation, brain fog, mood changes, ⁓ decreased strength, loss of vitality. You know, without over promising what testosterone can do, what are some of the areas beyond libido that you have seen that’s emerging evidence that supports use of testosterone?

Dr. Nikitha Paluri, MD (20:58)

Yeah, so, you know, I’m really obsessed with bone health these days, so I’ve been doing a lot of research. And like I said earlier, we do have research in men when it comes to how testosterone actually helps the bone health. The main driver is still estrogen, so I’m not taking that away from estrogen. Estrogen’s still our main girl when it comes to bone health. But testosterone is definitely a contender as well. And there isn’t enough information, and guess what? We need our bones for everything.

We need our bones until the day we leave this world. ⁓

That’s like a huge passion of mine right now. And there is hopefully budding research in that area. And if we can say, hey, this happens in men, we can also maybe say, hey, this also happens in women soon enough. ⁓ Energy levels, unfortunately, there’s not a lot of research right now that says, hey, this is not just placebo. Most of the research out there says this was just placebo. It’s not statistically significant. But again, there’s one thing the studies say one thing. And these studies, have over 8 billion people now, I think, in the world.

So these studies are looking at a thousand people maybe out of eight billion people. I don’t know if it’s fair to extrapolate those results to those eight billion people. So it’s one of those things. Like if I see someone and they say, oh my gosh, I can’t function. I have so much brain fog. I just need something. I have no energy all of a sudden. Which by the way, we see in men with low testosterone.

Dr. Ginger Garner PT, DPT (22:04)

Yeah.

Mm.

Dr. Nikitha Paluri, MD (22:25)

these symptoms, same symptoms, right? Low libido, no energy, not able to exercise anymore, ⁓ loss of muscle. We see all this in hypogonadism when men experience low testosterone.

Dr. Ginger Garner PT, DPT (22:36)

Mm.

Dr. Nikitha Paluri, MD (22:39)

So for me, seeing that and treating men with testosterone and seeing them being able to exercise and gain muscle strength and them having clarity in their mind, them being able to go to their wives and have sex and satisfy them, that tells me the same thing could happen in women, right? Just because we do not have research so far. So I explain that to my patients, right? I say, hey, we don’t have research, but it could because I’ve seen it clinically happen.

Dr. Ginger Garner PT, DPT (23:08)

Mm-hmm.

Yeah.

Dr. Nikitha Paluri, MD (23:09)

And sometimes

that’s more important than what a piece of paper says. I mean, people are going to hate me saying that, but it’s, I think it’s true.

Dr. Ginger Garner PT, DPT (23:13)

Right. I mean, well, N of N of one

always matters. And just like in any other, you know, diagnostic process that we’re trying to move through and help patients, everyone responds differently. And because we don’t have enough research on women for basically many medications, you know, not just testosterone and hormones in general, that ⁓ it it really we have to pay attention to how it impacts, you know, this the single person that’s sitting in front of us.

Dr. Nikitha Paluri, MD (23:33)

it.

Yeah, I mean we use

antidepressants now for like GI issues, know, to treat some GI issues. There’s some research on it, but it’s mostly off-label use, some of these medications that we use.

Dr. Ginger Garner PT, DPT (23:53)

Yeah. Well and that’s where, you know, our research questions and ⁓ our evidence base becomes informed from is the clinical practice, because too often clinical practice is out ahead five years, ten years or whatnot from research. Sometimes I feel like it’s decades.

Dr. Nikitha Paluri, MD (24:06)

more honestly look

because I mean look at when women actually breakening starting starting to get included in studies it wasn’t that long ago I can’t remember the exact you yeah it was maybe like honestly it was probably like 1990s it probably was not yeah so it’s just so insane to me that we weren’t even really included in studies and it takes a long time to actually monitor you know side effects and

Dr. Ginger Garner PT, DPT (24:16)

It’s it was it feels like yesterday.

It was like nineteen ninety six, I think. Yeah.

Mm. ⁓

Dr. Nikitha Paluri, MD (24:36)

is

it actually working and kind of extrapolate that data over multiple different cultures and multiple different ages and things like that.

Dr. Ginger Garner PT, DPT (24:44)

And that brings up another important point because not only is clinical practice out ahead of the research ⁓ very, very often, and it is where it is what informs good research questions and studies, but once the research is published, the time of that publication to practitioners adopting it, learning it, adopting it, and practicing it can be up to like two decades.

Dr. Nikitha Paluri, MD (25:07)

Isn’t that crazy? Sometimes I feel like I’m practicing in medieval times, especially when I hear all these cool new, new age things that are out there that I haven’t even heard of. There’s so much stuff out there right now that I haven’t even heard of. And there’s no research on it, but people are practicing it and they’re doing well with it and patients are loving it. So there’s always a huge gap between traditional and new age medicine.

Dr. Ginger Garner PT, DPT (25:11)

Yeah.

Yeah, there is. I mean, so that that kind of highlights the fact that there is a gap. There’s a gap on both sides. There’s a gap in need for research, but then there’s a gap when the research is done to actually the the FDA listening and acting and practitioners actually practicing it. And so something I keep thinking about over and over is medicine moves slowly, guidelines move slowly, insurance moves even slower.

Dr. Nikitha Paluri, MD (26:01)

I don’t want to talk about insurance.

Dr. Ginger Garner PT, DPT (26:02)

I know.

I know that’s a whole other podcast and that’ll be next season. And patients are are suffering in the space. You know.

Dr. Nikitha Paluri, MD (26:10)

Yeah, we are, right?

I mean, I’ve been a patient ⁓ that has required a lot of care in the past. And it’s always interesting, you know, looking at…

the way everything works from the other side of the room and it sucks. It’s really not that fun. There’s long waits, no one actually listening to you, poor, care, people laughing in your face. There’s a whole lot of stuff. I’ve seen it all, I’ve dealt with it all. ⁓

I think part of that is why I try, really try even on my bad days to have patience, which again, I am human, I do have bad days and you know, ⁓ but I really do try to have patience because it’s not fun to be a patient.

Dr. Ginger Garner PT, DPT (26:58)

Yeah. No, it’s not. I’ve I’ve had the same, you know, experience being a mom of three and having many of the things. ⁓ my my listening audience ⁓ knows quite well by now. I I’m one of those one out of nine women with endometriosis and so y you can get gaslit and d you know, delayed diagnosis can be, you know, ⁓ easily over a decade. And the other thing that happens when women fall through the cracks is when their labs are just called

normal, but they do not feel normal.

Dr. Nikitha Paluri, MD (27:30)

Yeah, actually I had, I felt horrible because I had this 20 year old come to me the other day. She’s like, I don’t feel good. I feel horrible. I feel horrible. And I did all her labs and I sat with her and I said, your labs look normal. I was like, no, I’m that person right now. But I was like, there’s nothing in here that I could even like point to and say, ⁓ my gosh, like there’s something wrong. But then we sat down and we kind of like looked at her nervous system.

Dr. Ginger Garner PT, DPT (27:44)

Yeah.

Dr. Nikitha Paluri, MD (27:58)

to see what was going on in her mind because physiologically, like, I did some wild tests on her too. Like everything came back normal, but I remember like sitting with her and those words came out and I was like, no, I can’t believe I just said that. ⁓ So no, I understand and I’m guilty of it for sure. I’ve said this multiple times even though they haven’t been feeling well. And a lot of times we don’t have time to sit down and

Dr. Ginger Garner PT, DPT (28:12)

Yeah. ⁓

Dr. Nikitha Paluri, MD (28:28)

you know, try to like do nervous system regulation with our patients, which in today’s world, I mean, I get burnt out from social media some days and I need to like take a break because it’s a lot. We have news, we have social media constantly keeping us updated, constantly keeping us in a fight or flight.

where it’s like, so and so person died or like so and so person got murdered or my gosh, 10,000 kids died there or like, know, there’s, we’re about to start. Like, you know, we take all that in. So yes, I agree with you, labs being normal is like a thing that we just automatically say, but I think people have been so annoyed and frustrated because they don’t feel normal and they don’t feel good still. And that’s when we need to also look at other things like.

Hmm. Are you, are you actually like, okay? Are you doing okay? I know so many people who aren’t antidepressants now because of the news. They just can’t cope. They’re not going to feel normal no matter what I throw at them, you know?

Dr. Ginger Garner PT, DPT (29:32)

Mm-hmm.

There’s a lot of noise and how we take in information becomes part, it should be part of kind of our longevity plan, you know, our our wellness routine. It’s where I see, and this is what I’ve seen very interesting. So let’s just go with the nervous system for just a second and say that someone is having like tachycardia, like, you know, heart rate, heart racing is how your you know, our patients will describe it. ⁓

Dr. Nikitha Paluri, MD (29:39)

Mm-hmm.

Mm-hmm.

Dr. Ginger Garner PT, DPT (30:07)

And they’re talking about something stressful. And of course, you know, I’m in ortho and and pelvic therapy. And I will be imaging them, you doing ultrasound imaging. I’ll be doing ultrasound imaging in office because I’m looking at their bladder or the, you know, whatever it might be, looking at pelvic floor status, bladder neck height, you know, translation under different, you know, ⁓ pr interabdominal pressures and forces.

Dr. Nikitha Paluri, MD (30:19)

Okay, yeah. ⁓

Dr. Ginger Garner PT, DPT (30:35)

and they’ll start to talk about something because I also monitor the pressure system of the voice because how someone talks impacts the pressure gradient on the pelvic floor. And sometimes just the the the way they talk can you know create a situation of a situation of prolapse or leakage or sexual dysfunction.

Dr. Nikitha Paluri, MD (30:45)

Hmm.

didn’t know that. That’s interesting. You gotta tell me later what exactly that means so I don’t talk like that.

Dr. Ginger Garner PT, DPT (30:56)

Yeah. Yeah. Yeah.

well, here’s an example. I was, they’ll talk about something stressful. And I say they because this is multiple patients. This is, you know, all genders, doesn’t matter what their sexual status is or anything. They’re on the table. I’m imaging them, ultrasound, and they start talking about something stressful. And I’ll start to see like,

The fascia, the fascial planes around the muscles start to tighten. And then the bladder base starts to rise. And the pelvic floor, I see sometimes the hip muscles, even the obturator internus will get involved. And I start to see the bladder base just rise. And it’s not just a couple of millimeters, it’s like 10 millimeters, 16 millimeters, which is a lot. It’s a lot of movement that’s involuntary to them.

Dr. Nikitha Paluri, MD (31:25)

me.

Thanks.

Hmm.

Dr. Ginger Garner PT, DPT (31:53)

That when I end up doing an internal, you know, an intravaginal or intra rectal exam, there’s so much resting muscle tension that they’re unaware that’s there and they’re not able to let it go. And it wasn’t even that they were moving around, they were relaxed, they were comfortable. I’m being very trauma sensitive, you know. ⁓ they weren’t in fight or flight. They were just resting and they already had that amount of tension. So I think.

With all the information they’re getting, maybe their partner’s not supportive and their job is stressful and their kids are all over the place. What what is what do they feel like then? You know, like it must be pretty bad.

Dr. Nikitha Paluri, MD (32:33)

Yeah, it’s, you know, I actually, I’m the, I’m a biggest advocate for nervous system regulation. And the main reason being I have a hard time regulating my nervous system. I have like, you know, I’m the person who like stresses out with every little thing like neurosis being in medical field doesn’t help.

you know, struggle with a little bit of anxiety. My husband would say a lot of anxiety, but I think it’s just a little bit, or high functioning anxiety anyways. And so I just did clinical hypnosis training with American Society of Clinical Hypnosis because I feel like we don’t talk enough about nervous system regulation and it affects everything. From the first thing when you wake up, you reach for your phone,

Right? Or when you wake up, you’re automatically like, ⁓ let me see what’s going on on the news or let me see what’s going on social media. That itself is like a huge X for me. Right? Again, I do, I try not to, but some days I do. That’s, that’s me. I’m guilty of doing it. First thing you want to do from the second you wake up is try to train your brain to relax as much as possible.

Dr. Ginger Garner PT, DPT (33:31)

Mm.

Mm.

Dr. Nikitha Paluri, MD (33:48)

So go get some sunlight, even if it’s just for 30 seconds. Go drink a nice cup of water with maybe some lemon or whatever you want to wake up those senses. Don’t bombard your system from the first go with a bunch of information, because then you’re going to be fight or flight. That’s going to set you up for the rest of the day, and everything is going to depend on that. What you eat, how much you eat. Are you, you know, because if you’re stressed out,

Most of us tend to eat more when we’re stressed, right? ⁓ Because we’re in that fight or flight response. ⁓ How your day goes at work or at school or whatever you’re doing in life. How patient you are when you’re interacting with your family members. What kind of issues are going to come up if you’re all stressed out all day? Are you paying attention? Are you present in the moment? If your kids are talking to you, are you present in the moment? Or are you…

Okay, leave me alone. I’m really stressed out right now. I had a really long day. So what’s going on that’s affecting your other relationships and what is the consequence of that? So it’s like a negative loop, right? If you can’t regulate yourself, if you can’t take a deep breath and say, okay, I’m going to try to relax. I’m going to be in the moment. Something will happen the way you react and every reaction has another reaction.

Right. And it’s just, feel like it’s a negative loop. And then now you may not sleep properly because you’ve had this very stimulated day. So you don’t sleep well, the next day starts off even worse. So I do think like a lot of it is just like, we got to learn, we have to learn to kind of find our center. My husband’s very good at it. I’m not, I’m an advocate of it. And I try really hard, but I’m not nearly as good as he is. ⁓

But nevertheless, it doesn’t stop me from preaching and advocating. ⁓

Dr. Ginger Garner PT, DPT (35:42)

Well, we’re

all we’re all learning all the time. And I think what it comes down to is being able to identify how your body because we usually will know when our mind goes askew, you know, if you just tried to sit down and mindfully breathe, you might be thinking of all different kinds of things, which is not necessarily a bad thing. So I think it’s more easy, ⁓ more easily felt in the mind when you’re not self regulating.

But sometimes it’s it’s the the key to changing the way our nervous system processes stress and interprets threat is to know how it feels in the body. To drop down into what the sensations are in the body. And and I think that when you’re going through when when we’re talking about sexual health as whole body health, it becomes really important to know: like, are you one of those people that if

Dr. Nikitha Paluri, MD (36:35)

Yes.

Dr. Ginger Garner PT, DPT (36:41)

You know, if you had that transducer on your belly and I was imaging you, would would the pelvic floor be yelling when you didn’t even know that it was yelling? You didn’t even know it was tight. But you might have back pain, hip pain, digestive, you know, pain, or you just have that heart rate racing because, you know, the vagus nerve with its you know, vagus nerve means wandering nerve for a reason, ⁓ with it it’s everywhere impacting, you know, basic.

Dr. Nikitha Paluri, MD (37:05)

Right, it’s everywhere.

Dr. Ginger Garner PT, DPT (37:10)

body functions and and that comes around to I mean it’s like your psychoemotional safety and which impacts libido goes back around to sexual health ⁓ just I I think that if we begin to understand that then we can shift everything. That’s where I see some of the biggest changes I think you know in my patient population is being able to show them here is that you’re not making this up. It’s not just in your head.

your body is actually holding stress in this area and it is negatively impacting, you know, sexual health.

Dr. Nikitha Paluri, MD (37:46)

That’s, I love that you’ve said that because it’s so interesting, right? So if you can, that’s just one part of the body you were able to measure at that time that showed stress. What about all the other parts of the body that we didn’t measure at that time? There’s no way that they’re not holding stress as well, right? So it’s, you know, actually took this week off for a number of reasons and

Dr. Ginger Garner PT, DPT (37:55)

Yeah. Yeah.

Right.

Mm.

Dr. Nikitha Paluri, MD (38:10)

The first three days, all I did was nervous system regulate and I haven’t been this happy in so long until I broke my thumb. But you know, I was just so happy and I was, you know, felt like myself again.

Dr. Ginger Garner PT, DPT (38:16)

⁓ that’s awesome. I love it.

Yeah.

Dr. Nikitha Paluri, MD (38:25)

So I didn’t need fancy medications or anything like that to feel like myself. Sometimes it’s just as simple as unplugging and just focusing on yourself. Like the kids were off at school, my husband was working. I just literally just focused on myself. Honestly, it just took one day for me to be like, whew, man, I haven’t felt this good in so long.

Dr. Ginger Garner PT, DPT (38:32)

Mm.

Mm-hmm. So

It it brings up it made me think what you just said, it made me think of an article back in I believe it was 2016 in Sexual Medicine ⁓ reviews that talked about in order to create sound, you needed two motor systems. You needed a voluntary motor system, you need an emotional motor system. And

Dr. Nikitha Paluri, MD (39:12)

love that.

Dr. Ginger Garner PT, DPT (39:13)

Yeah. And so when you looked at the parts of the brain without getting too nerdy ⁓ or in depth, like for listeners, the same part of your brain is in control of everything from bowel, bladder function, birth, sexual function, creation of sound, which is using your voice. Yeah.

Dr. Nikitha Paluri, MD (39:19)

Now let’s just get married again.

That’s beautiful. I love that. Yeah. You know,

I think our society, think it’s time that there’s some sort of change in our society in general. I

I mean, I know that this may not probably happen anytime soon when I’m about to suggest, but I really think women in healthcare or corporate world or anywhere where they’re just high stress jobs. I feel like companies just need to give us like a day off per week just for ourselves. Okay. I think that’ll be good for everyone involved. I can’t tell you how many high functioning women I’ve seen with very stressful jobs. just not doing well.

Dr. Ginger Garner PT, DPT (40:14)

Yeah. It it definitely speaks in the United States to what people define as work ethic or wearing busy as like a badge of honor. When I was speaking with ⁓ a patient recently, she was talking about family members that live in Scotland and how many days off a year that this particular family member was like over forty two. It was like forty-two days.

Dr. Nikitha Paluri, MD (40:34)

Gosh. Tell me.

Woo! Let’s just move there. He’ll be okay.

Dr. Ginger Garner PT, DPT (40:43)

And you know, they have all this time for work life balance. And of course, my first book was published in Edinburgh, in, you know, in Scotland. And so and I worked with my editor who was also in Ed Edinburgh. I do have, yeah, a large part of my genetic makeup is Scottish. Yeah, my great grandmother was ⁓ a Bruce. So yeah, yeah. And her mother in law was a Stuart. So I got a lot of Scottish blood, ⁓ so to speak. But ⁓

Dr. Nikitha Paluri, MD (40:52)

Are you Scottish?

⁓ that’s awesome, I love that.

⁓ very cool.

Thank

Dr. Ginger Garner PT, DPT (41:13)

I guess the the point was, you know, when I was working with my editor, like they always they had this work-life balance that was really beautiful. And we’re not really we don’t get the time the days off. Like my first job, I had five days off. That’s it. With yeah, with with the whole year. Yeah. It was terrible. And the next year you earned like another five days off. But I didn’t even last nine months. It was the most horrible experience of my life. I even thought about leaving healthcare altogether and I realized it was just a crappy job.

Dr. Nikitha Paluri, MD (41:27)

the whole year. my gosh. Okay.

Yeah,

there’s something wrong. I worked with a nurse before. She had two weeks off postpartum and she had to go back. I don’t think it’s sustainable. I mean, I don’t know. I’m from India originally. I was there for first 10 years of my life. So I don’t have that much data to go by, but we work six days a week there, not five. But people are happier.

People get off work and they go do whatever they do. They’re partying it up on weekdays. They don’t care. They’re just like enjoying life. So I don’t know what it is here that’s making us so overstimulated. I really don’t. If they’re working six days a week, but still finding time to relax and have fun and just party all the time, like why are we not able to do that? I don’t know.

Dr. Ginger Garner PT, DPT (42:23)

Mm.

It’s definitely you know, a a huge i i it boils back down to I think if we take this bigger conversation that we’re having about hormones and sexual health and work life balance, the ability to filter out noise, the ability to know how you feel in your body so that you can self-regulate.

Because that impacts everything about us. If you can’t self-regulate, you’re not gonna co-regulate with a partner. And your sexual health and relationship is definitely gonna be off. So I think it all comes down to safety. Do we feel safe in our spaces, in our workplaces, with our healthcare providers? And when you think about, you know, something like testosterone therapy, like coming back around to that, you know, before

Dr. Nikitha Paluri, MD (43:13)

Very true, very true.

Let’s go.

Dr. Ginger Garner PT, DPT (43:24)

we even consider whether a woman is appropriate for testosterone therapy, what are the physical like safety indicators there? What should be evaluated first? Are there any labs, risk factors, symptoms? Like what should be considered if someone’s like, you know what, testosterone might be my my thing, right? What should they consider?

Dr. Nikitha Paluri, MD (43:43)

Yeah, absolutely. So I always get baseline labs. If you’re doing gel, then you don’t really need to worry about like liver function and things like that because it doesn’t really go through the liver. There’s actually oral pills now too that are bypassing the liver system and they’re going through your lymphatic system instead. So it’s kind of cool. I haven’t tried it on any of my females yet, but for the gel and the cream, the only real things I look at is your free testosterone, your total testosterone and your sex hormone binding clobulin.

Dr. Ginger Garner PT, DPT (44:00)

Mm. Yeah.

Dr. Nikitha Paluri, MD (44:13)

Now if you have ⁓ PMOS, right, then you may not actually be eligible for testosterone because a lot of these people already have higher testosterone levels. But apart from that, I don’t really see any other reasons where actively I would deprive anyone of testosterone. Now the SHBG, unfortunately some people

Dr. Ginger Garner PT, DPT (44:25)

Mm-hmm. ⁓

Dr. Nikitha Paluri, MD (44:38)

have been taking birth control pills for a long time. This is one of those, we spoke about some positives of birth control. One of the negatives is it can actually raise your sex hormone binding globulin.

And you know, I was at the Harvard Menopause Conference and Dr. Rachel Rubin was saying it can raise it up to a year. some people she’s seen, they have stopped taking their birth control pills like a decade before, but their sex hormone binding globulin is still elevated. It’s still high. So this is important because it’s the car where all your testosterone sits in and it can’t really get out to work on your tissues. So it can’t really help your libido or your strength or your mood if it’s just sitting in the car. So if your sex hormone

Dr. Ginger Garner PT, DPT (45:01)

Still high.

Dr. Nikitha Paluri, MD (45:17)

binding globulin is high, then it’s going to bind that extra testosterone, that free testosterone, that is not free to do what it needs to do. So it’s one of the biggest things I monitor. The free testosterone ⁓ lab, I do it. ⁓ I was doing it rather. I’m doing more calculated free testosterone now because the lab assays are just not as reliable. But those three are the main things I would look at.

If they have active androgen sensitive cancer, then I don’t get testosterone, obviously. That’s very, very rare to know that I have had anyone come to me and said, okay, I’m going through cancer therapy, I want testosterone. It’s not where their mind’s usually at, you know, so.

Dr. Ginger Garner PT, DPT (46:00)

Right,

right. And there there’s, you know, because if we have to you’re prescribing this off label. And there are, you know, other delivery modes. I have seen some rather just speaking very frankly, ⁓ disastrous ⁓ outcomes from pellets.

Dr. Nikitha Paluri, MD (46:19)

Yeah, so I just actually made a post about pellets because so many people love pellets. So my goal I feel as an educator is not to bash one route over the other, but to educate you and let you decide. It’s your body. I don’t do pellets, but if you want to go do it, just know the side effects and the dangers associated with it.

Dr. Ginger Garner PT, DPT (46:25)

Mm.

Dr. Nikitha Paluri, MD (46:42)

lot of people love it because you just, it’s like place and forget, right? So you don’t have to worry about daily applications or injections or anything like that. And ⁓ with pellets, your numbers may go much, much higher, like three to four times the physiological range. Now the biggest thing that worries me is, and the reason why I don’t endorse pellets or I practice them myself is some of these side effects could be irreversible. So.

If you’re doing gender affirming care, that’s one thing. But if you’re not doing gender affirming care, don’t, unless that’s okay with you, you may not want your voice to be super deep all the time, or you may not want your clitoris to be super enlarged. Not that there’s inherently anything wrong with it, just so you know that those things can happen. And if you’re okay with that, okay, cool.

Dr. Ginger Garner PT, DPT (47:24)

Mm.

Yeah, yeah.

Dr. Nikitha Paluri, MD (47:33)

But I

know a good friend of mine, she does pellets and she says she keeps a very, very close eye on the levels. So I think if you find someone who you can trust and who does great, and if that’s something, if you’re okay with potential risks, sure. But I’m not really convinced that that’s for me.

Dr. Ginger Garner PT, DPT (47:54)

Yeah, yeah. And you know, what about some of the other methods like ⁓ you know, buccal ⁓ you know delivery methods? Mm-hmm.

Dr. Nikitha Paluri, MD (48:02)

Yeah, the troches that everyone’s talking about. So, you know,

the thing with those are you just like put them under your tongue or you put them, you know, on the side of your like tobacco, right? And firstly, some of that you’re going to swallow. So you will have that first pass liver metabolism. So then you do want to check your liver functions and possibly your cholesterol and things like that.

⁓ Secondly, it’s not reliable, right? Like how long do you put it in your mouth? Do you know how much you’re actually absorbing? Are you drinking water or eating anything right after? You don’t know how much of it is actually absorbing into your body? It might give you a quick high because we have these tiny capillaries right underneath our tongue, which really are amazing at absorption in general, right?

You don’t have to worry about going through a GI system that way. And they just absorb it right into your blood and you’ll, you’ll feel the effects right away. So that’s why I think people do like it because it’s like, it’s like caffeine, like, my gosh, I feel so good. testosterone does have that effects like, ⁓ my gosh, I feel great.

Dr. Ginger Garner PT, DPT (48:55)

Mm-hmm.

Dr. Nikitha Paluri, MD (49:04)

But I’m not a huge fan of it mainly because yeah, it’s not a reliable, like you may have peaks and valleys, right? Because we don’t know how much is actually getting absorbed. And just as quickly as it gets absorbed, it’s gonna drop just as quickly. So yeah.

Dr. Ginger Garner PT, DPT (49:10)

Mm-hmm.

Mm-hmm. Yeah.

Have you seen anyone that isn’t absorbing? Like you have like progesterone resistance where they they cannot tolerate oral micronized progesterone and then we’ve got to look at something else. But have you seen that in testosterone where creams or gels are not being absorbed? I’ve seen that in a couple of cases of patients where they’ve been on it for like a year or two years and it’s nothing’s moving.

Dr. Nikitha Paluri, MD (49:39)

And no.

Yeah, and I think it’s it hasn’t maybe just do with how their skin absorbs things in general, probably. And injections subq, especially are great alternative for those patients. You may have to do it twice a week. Unfortunately, that’s the only disadvantage, but they might do really well with those. If you’re not absorbing the cream properly, again, you could check your sex hormone binding globulin calculated free T Total T is what’s recommended. But I have started calculating free T because it gives me that idea of like, okay,

Because I’ve seen so many where total T is absolutely fine, but then that free T is still not So the total T could be like 80 or 90, but the free T is like 2 so okay Well, let me go ahead and up that dose so if their free T is normal if their sex hormone hormone binding globulin is not super high ⁓ Then yeah, they’re just probably not absorbing it. I have personally not seen it yet, but again. I’ve only been doing this for Testosterone. only been doing about a year

Dr. Ginger Garner PT, DPT (50:16)

Yeah.

Yeah.

Dr. Nikitha Paluri, MD (50:39)

Menopause hormone therapy longer, but yeah, I haven’t been giving out testosterone as long.

Dr. Ginger Garner PT, DPT (50:44)

Yeah, what is the upper limit that you’re finding on the total testosterone that seems to, you know, provide the results needed?

Dr. Nikitha Paluri, MD (50:52)

So

I actually talking to Dr. Kelly Kaspersen about this. She’s amazing and she’s so down to earth. I love her. But she was saying, ⁓ again, we have the traditional values and then we have the new age values, right? They’re both ends of the spectrum. The traditional says the highest shouldn’t be any more than 70-ish. Whereas the new age says go up to 200, 300, it’s fine. ⁓

So Dr. Kelly Kaspersen, she was saying, you know, most of the studies that we’ve seen, if you actually look at the free T, or sorry, the total T, it’s around 100 is when women are feeling really well. So after she said that, I kind of kind of go by that. And again, I do calculate my free T. And ⁓ I mean, she brought up another great point. She said, you know, even if your free T was was normal and

even if your total T was great and you know that doesn’t mean even then it doesn’t mean the testosterone is actually reaching the tissues. So I asked her I said so how do I check if the testosterone is actually reaching the tissues and I googled it while waiting for her and it said biopsy. She’s like she’s like yep that’s the only way right now we don’t have a good way to even test if the tissues are actually responding to the testosterone well.

Dr. Ginger Garner PT, DPT (51:50)

Yeah.

my

Right.

Dr. Nikitha Paluri, MD (52:06)

So

we just don’t know enough. So there is a lot of nuance there, going back to your question about what if you’re not absorbing enough through your skin or you’re just not feeling well with the topical testosterone. And yes, it could be that you may need to change the route, but it could just be that your tissues aren’t responding to testosterone the right way. Why that is, I don’t know. Yes, don’t know.

Dr. Ginger Garner PT, DPT (52:29)

Another research question to be researched, right? Yeah.

I just it’s ⁓ that’s really good information because ⁓ you know I want women to feel encouraged. And of course this applies to men too, because so many men need it as well. They aren’t getting tested either, and they seem to have an equally difficult time accessing pelvic health care in general, you know.

Dr. Nikitha Paluri, MD (52:45)

Thank

Yeah.

Dr. Ginger Garner PT, DPT (52:58)

They either

don’t wanna talk about it or they don’t know what’s available. Many men are like, I didn’t even know you existed, you know, I didn’t even know there was such a thing as pelvic PT or

Dr. Nikitha Paluri, MD (53:06)

I don’t think I’ve ever referred

a man to for pelvic health, is, know, it’s a big gap, right? Cause I, like, I wouldn’t know if like, you know, when do I even refer them for like UTIs and stuff? I understand, but when else could I refer them? I don’t know. I really don’t.

Dr. Ginger Garner PT, DPT (53:24)

Well, the the the ⁓ the answer for that is there’s a lot of indications. I mean, obviously if they are they’ve had a prostatectomy, they’re going to have problems, they’re gonna have incontinence, they’re gonna have sexual dysfunction. And so that’s almost that’s an automatic referral. But there are a lot of other situations. For example, I’ve had younger men who noticed that they thought they had low testosterone. It’s tested and it was fine, and they still aren’t getting the they’re having erectile dysfunction.

Dr. Nikitha Paluri, MD (53:52)

this

function interesting.

Dr. Ginger Garner PT, DPT (53:53)

They are still

not getting what they need or want out of it. It wasn’t as strong as it used to be. They’re not, you know, waking up with that in the morning, you know, the the as and but their vascular system is fine, right? ⁓ painful erections, painful ejaculation, you know, inability to reach orgasm where it’s not as strong anymore. Those are just some of the like garden variety things, in addition to I’ve had.

all kinds of incontinence, stress incontinence, urgent continents, mixed incontinence, overflow incontinence. I’ve had ⁓ musicians, voice actors, people who really use their voice and they were taught to breathe incorrectly. So they’re either over breathing or they’re paradoxical breathing. And that’s creating such a stress point for their ⁓ when I again see them on imaging that for their for their bladder base and their pelvic floor that

I mean I had a young twenty, he was mid twenties, and the urologist’s answer for him was to just catheterize every time he needed to urinate because he couldn’t.

Dr. Nikitha Paluri, MD (54:58)

That’s

what we’ve learned. That’s what we’ve learned, right? yeah, so this is, know, I know I speak a lot about women’s health, but there is such a big gap in men’s health too. And that’s the truth. There might be, there’s definitely more in women’s health, but there is a big gap in men’s health.

Dr. Ginger Garner PT, DPT (55:00)

Mm-hmm. Yeah.

Yeah. Yeah, so

There is.

And so for him it was like, well, that’s not very sustainable solution, thinking you’re going to catheterize yourself to empty your bladder for the rest of your life. So his his case ended up being very simple. I think we had two visits after that where I taught him how to do his own intrarectal r work and release, and he was like, good to go.

Dr. Nikitha Paluri, MD (55:30)

That’s amazing. I love that.

Dr. Ginger Garner PT, DPT (55:33)

Yeah. So if you’re if you are listening and you know you ⁓ have a pelvic floor issue and you thought there’s nothing that can be done about it, once you check those testosterone levels, once you check those labs, once those things are clear and you’re still having issues, there’s a lot that can be done, which is good. It’s

Dr. Nikitha Paluri, MD (55:52)

Honestly,

I think everyone needs pelvic PT.

Dr. Ginger Garner PT, DPT (55:55)

Yeah, you know, we all have a pelvis, we all have a pelvic floor.

At some point, it’s probably gonna revolt.

Dr. Nikitha Paluri, MD (56:01)

Yeah,

no, I just like how we have to how we focus on like muscles outside. We muscles inside that need workout too.

Dr. Ginger Garner PT, DPT (56:08)

Yeah, yeah. One of my my

best friends and colleagues calls it orthopedics in the cave. You know, it’s just orthopedics in the dark.

Dr. Nikitha Paluri, MD (56:17)

Yeah.

Well, no, I mean, it’s so true because we’re all, mean, 90 % of us have incontinence later on, if not more. I don’t know. I’m just throwing that number around. But I feel like I do a lot of geriatrics and I feel like most of them have incontinence. Right. So.

Dr. Ginger Garner PT, DPT (56:28)

Yeah.

Mm-hmm.

They have incontinence. And what’s terrible about it is they’re told, just like with the hormones and the lack of hormones and the lack of sexual health, lack of orgasm. Yeah, it’s like, ⁓ well, you’re past 45, or you’re postpartum, or you’re menopausal. What should what do you expect? Or, you know, any of a number of things. And I’m like, no, like rarely does age ever matter. It’s what you’re doing with it. It’s how you’re taking care of it. And that’s what makes sexual health whole body health.

Dr. Nikitha Paluri, MD (56:41)

It’s normal. Deal with the…

Yeah.

Yeah.

Dr. Ginger Garner PT, DPT (57:03)

⁓ I say this quite often. It’s not on the it’s it’s it’s on Maslow’s hierarchy of needs at the base for a reason, you know. so we can’t separate sexual health from whole body health. ⁓ you know, women and and men too need to look at loss of libido not as a personal failure, but information from the body.

Dr. Nikitha Paluri, MD (57:29)

Absolutely. Our bodies are constantly talking to us. I’m very into the whole holistic whole body approach because I truly believe that we’ve strayed so far from it and we’re continuing to stray now with AI and everything that we’re forgetting who we are and where we came from. could be very, the simple things, the things that are so obvious right in front of our eyes could really help us out in day to day life.

Dr. Ginger Garner PT, DPT (57:54)

Yeah.

Yeah. So definitely don’t dear listener, don’t accept it’s just aging as a reason for pretty much anything.

Dr. Nikitha Paluri, MD (58:04)

Yeah, yeah,

just put a diaper on is never the answer. Yeah.

Dr. Ginger Garner PT, DPT (58:07)

No, it’s

not. There’s a multi million dollar ⁓ you know, ⁓ adult diaper industry for a reason, you know.

Dr. Nikitha Paluri, MD (58:15)

Yeah, and you go, gosh, I don’t even want to start talking about that. It’s not good for you, right? Not good for the T. Lots of Destin. And for older people, I’ve given a lot of the Destin ⁓ prescriptions out, oxide prescriptions out for my older patients. It’s just not good for the skin.

Dr. Ginger Garner PT, DPT (58:19)

Right. Yeah, if we

Yeah. Yeah. In

if we had a public health awareness campaign of the things we just talked about on this podcast, as much money as is put into the adult diaper marketing industry, we could really shift everything overnight. Yeah. So quick quick fire, rap last rapid question quick fire kind of rapid question, last one, is can you give like both red flags?

Dr. Nikitha Paluri, MD (58:42)

Let’s do it. ⁓

Dr. Ginger Garner PT, DPT (58:58)

And green flags that you’re in good hands when it comes to being taken care of with, you know, we’ve been talking about testosterone and sexual health, but the the overarching theme of what someone should look for if they’re seeking testosterone for, you know, help. What are the green flags and red flags?

Dr. Nikitha Paluri, MD (59:15)

Okay, the biggest thing, the green flag is if the provider is, you’re talking about seeking provider help, right? Yeah, yeah, yeah. If the provider is talking to you about the pros and cons. On the contrary, red flag would be if they’re just talking about the pros or just talking about the cons, right? Because you’re gaslighting either way. You have to talk about both things. Second is if they’re not checking your labs before giving it to you, that’s a red flag.

Dr. Ginger Garner PT, DPT (59:22)

Yes.

Dr. Nikitha Paluri, MD (59:42)

On the contrary, they need to check your labs before you get testosterone. Okay. I’m not saying do a full panel, but just make sure that your sex hormone binding globulins, ⁓ you know, normal, get it, get a total T and you can calculate the free T as well if you want it to. ⁓

Third thing would be, red flag is talk to the patient about what exactly they’re feeling and when it started, like get a good history. If you feel like they’re not getting a good history, then they may not be, they might be treating the wrong thing. Not everything is testosterone, right? Low testosterone. There’s so many other things out there. So if your libido is the only issue you want to check, you know, at some point also thyroid, about your ferritin, anemia.

Things like that. There’s not just one thing that causes a symptom. There’s so many other things. Another thing is actually that starts in menopause is sleep apnea. Not starts in menopause, but you are more susceptible to have sleep apnea after menopause because of the way your body’s fat storage ships.

and that can sometimes cause libido issues and fatigue and brain fog. So are they asking you questions to screen you for that? If they’re not, red flag. If they are, green flag. Absolutely. look into also like honestly diet and exercise. know it sounds like a broken record because we’ve been saying this for centuries probably. Like are you eating well? Are you getting enough exercise and movement?

but you do need to focus on that. It can’t just be like, you have a libido, here’s some testosterone, I’ll see you in a month, right? You have to talk about what are they eating, are they moving their body, because exercise can actually improve your libido, it decreases your stress levels in general. So I think that covers pretty much everything I do, unless I miss something, but yeah, that’s pretty much everything I look at.

Dr. Ginger Garner PT, DPT (1:01:20)

That’s right.

Mm-hmm.

Yeah, that that’s

that’s great because we we wanna make ⁓ we w I want to make sure that you know testosterone can be an important part, is an important part of the conversation. ⁓ and we’ve been talking about women, but but obviously there’s a pelvic health gap for men too. And I think they just accept that, I’m older, testosterone’s gonna decline, somebody told me it was age, whatever. Not true, not true, not true. You know, especially when

They’re not where they wanna be. It’s different if sexual health is less important. But if it’s important to you, and if it’s persistent, it’s distressing, it it it’s not gonna be ⁓ then there are answers, you know. And of course testosterone can’t be reduced to a trendy cure all single lab value thing. But I think that people deserve a fuller conversation. Women deserve, you know, fuller conversation, you know. ⁓ everyone deserves a full conversation.

Dr. Nikitha Paluri, MD (1:02:10)

Very important to know.

Absolutely. And libido is a psychobiological process, right? So you have to look into that too. What are your stressors like? Do you even like your husband anymore? Because there’s a possibility you actually may not. And it may not be testosterone. I was saying. You know what’s really funny?

Dr. Ginger Garner PT, DPT (1:02:37)

Mm-hmm.

I thought it was low testosterone.

It turns out it was just

Dr. Nikitha Paluri, MD (1:02:50)

I gotta

share the story with you. I started someone on MHT, including testosterone, a few months back. She came back, I see both the husband and the wife, she came back a monthish ago and she said she’s leaving her husband. She said the menopause hormone therapy cleared her mind and she realized she just doesn’t like him. I said, my God, I’m sorry, I don’t know what to say. I guess I’m like, was like, okay, I just, as long as you’re happy with your decision, I’m happy for you, right? But…

Dr. Ginger Garner PT, DPT (1:03:13)

Congratulations.

Dr. Nikitha Paluri, MD (1:03:20)

Yeah, so it can go both ways. It’s not like, fixes your libido and your mood, but you may actually realize you don’t like who you’re with. So that’s probably why you’re having low libido to begin with. That is also a possibility.

Dr. Ginger Garner PT, DPT (1:03:23)

Mm-hmm.

Yeah.

We’ll take that clarity too. I mean, talk about eliminating brain fog.

Dr. Nikitha Paluri, MD (1:03:38)

Right, exactly.

Dr. Ginger Garner PT, DPT (1:03:40)

Because sometimes low libido is not just low libido. Sometimes it’s the body asking us to listen more deeply deeply. Yeah, it could be a relational issue, you know? It could be much more than that. ⁓ my goodness. ⁓ thank you so much for being here today. It’s been it’s been a great conversation. Can you let everybody know where they can find you?

Dr. Nikitha Paluri, MD (1:03:48)

Absolutely.

Thank you for having me. You’re so much fun to talk to. Yeah.

Oh, you can find me in Cary, just kidding. So you could find me on my social media at nikithapalurimd and I don’t really have a website just yet. Tried multiple times to build it. It’s just taking forever. And I think I might just have to pay someone to do it at this point, yeah, really. Thank you. Gosh, I’ve tried SquareSpace. I’ve tried like WordPress. I’ve tried even like Hostinger, which is supposed to be like an AI website builder, but didn’t really. Yeah.

Dr. Ginger Garner PT, DPT (1:04:21)

I can help with that. Yes.

⁓ yeah.

Women

supporting women in healthcare is we gotta do it. So yeah, absolutely.

Dr. Nikitha Paluri, MD (1:04:36)

So I will hopefully

soon have some sort of website, but for now just find me on social media I’ll be loud there. My practice hasn’t gone fully live I just have like papers the ducks in the road, but I haven’t started seeing patients through my Lumira health yet But I should within the next month or so

Dr. Ginger Garner PT, DPT (1:04:53)

Fantastic. Well, thank you so much, Dr. Nikitha Paluri, for and for ⁓ joining us today on the show. Thank you, thank you.

Dr. Nikitha Paluri, MD (1:04:56)

Yeah.

Thank so much, Dr. Garner. Yes, thank

you. Thanks, everyone.