The Sex Life Nobody Warned You About: What a Top Sexual Medicine Expert Wants You To Know

It's a rare person that wants to have pain. I usually say, "When was the last time you purposefully put your hand on a hot stove?"

When I would happen when you were three or four years old but it was by accident and you never did it again.

A woman who doesn't want to have sex is because she's having pain. That's someone that is in touch with her body and she's in her pain fixed. It doesn't mean that she can't have sex. It just means she can't have painful aspects of sex. By and large there are lots of things that she and her partner can do that don't include having pain.

“But they got to get back to those days when they were first dating and remember all the fun that they had before they were taking their clothes off and having injured her.”

The views and opinions expressed on pause are those of the talent and the guests alone.

And are provided for informational and entertainment purposes only.

No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. If you're skin or your nervous system feels a little overwhelmed lately, this may be your sign to simplify. Primarily peers blue tansy products are designed to calm stress to skin using real bio-compatible ingredients that work with your body, not against it. Blue tansy is a calming blue antioxidant that helps sue the inflammation, redness and irritation, which is especially beneficial for sensitive skin or for those people who's products tend to overwhelm rather than help their skin.

Primarily peers soothing collection incorporates this ingredient across face and body, from their effective deodorant to the soothing serum and body oil, creating a cohesive and calming routine. They've become go-toes for our team with simplicity matters most.

“Use code unpause to get 15% off your primary peer purchase. That's www.pri-m-a-l-l-y-p-u-r-e.com, and use code unpause at checkout for 15% off your order.”

Today on unpause, I am lucky enough to have as my guest, one of the most experienced menopause clinicians in the world. Dr. James Simon has been practicing menopause medicine, longer than most physicians have been practicing anything. If you've ever wondered what sexual aging really looks like in long-term relationships, how hormone therapy went off the rails after the women's health initiative, and what really happened with that black box warning, or how testosterone, vaginal health, and desire evolved with age, this is the conversation you've been waiting for.

Dr. Simon is a professor of obstetrics and gynecology at George Washington University. He's a board certified OB-GYN, a reproductive endocrinologist, and a certified sexual counselor. He is also a past president of the International Society for the Study of Women's Sexual Health, and one of the most published clinicians in modern menopause care. I'm Dr. Mary Claire Haver, a board certified off-stetrician and gynecologist and certified menopause practitioner. I'm also an adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch. Welcome to Unpause.

The podcast where we cut through the silence and talk about what it really takes for a woman to thrive in the second half of life.

Welcome to Unpause. Thank you for having me. You've been doing this work for decades. You've written numerous papers at Lost Count. 800. You've trained hundreds of residents. I'm sure medical students seem tens of thousands of patients. But before we get into the big topics, tell me where you started.

“Where'd you grow up? Why do you go in the medicine?”

So I grew up in suburban Chicago. I went into medicine having a long line of medical doctors and my family. And so I went to work summers with my uncles, a general surgeon and a primary care practitioner. And I got the bug to do it. And then where'd you do your training? Why open to my aunt? I saw a lot of misbehavior during my time, both with my uncles and making rounds with them in the hospital.

In the way that I thought women were being treated. A lot of strong women in my family and didn't like the way they were being treated in the hospital. And I was going to save them from the medical profession. And then you went on and did a fellowship and reproductive and a chronology. So most people who do this fellowship now end up going strictly into infertility.

You've deviated from that a bit. And decided to be a reproductive and a chronologist, which took me very easily into medical medicine, osteoporosis work and sexual medicine, which is fascinating as it relates to the hormonal impact. It has on sex. I learned almost nothing in a four year residency and I was a resident from 98 to 2002.

And then I graduate past my boards, blow the top off my boards actually.

And then get into clinical practice and outside of OB, which I was excellent at. Most of my patients were coming in complaining of weight gain, which I had no idea how to help them. Or reluctantly as I walked out the room, they would touch me on the arm and say one more thing I want to tell you. And I had no idea what to say to them. So I was digging for data and information.

I went back to my old textbooks and there was just almost nothing. So it's fascinating to me.

“Did you develop this field or were you there from the birth of it?”

I felt just as you had suggested, here I finished medical school. I didn't know anything about sex, about women's sexuality. And I was going to go into obstetrics and gynecology and looking at the programs, even the best ones they didn't even mention it. I figured I'd better get juice up on that before I went because I was going to come out as you did with

little or no training. And that's when it all started for me. I didn't even realize it would be a problem. You know, like, I have no idea that so many of my patients would want help. It just wasn't even talked about.

And it's become such a huge part of my practice now. All right. Now I want to really dig into your expertise because women really don't get to hear from true specialists about this. They usually have a well-meaning primary care doc or OBGYN who is doing their best but received zero training.

So they kind of wing it and it doesn't go well for most. Talk to me about sexual aging, desire, pain, all the things and you treat couples. I do. And so a lot of this is silo. The woman goes into her doctor.

He goes into his doctor. But I do love that you take them together as a couple. So you've seen thousands of couples like this. So what is sexual aging really look like for her versus him? So I don't think anyone listening to us would disagree with the fact that men and women are different.

I want to celebrate that difference. I don't want to denigrate it or I just think it's different. And it's important that it's different. Intimacy is highly individual. So whatever I'm going to say to you is not going to ring true to everybody.

“But there are some generalities that I think can be important baselines for our audience.”

First is the longer a man or a woman or both are in a relationship.

The less important based on the frequency of events, sex becomes. That could be because of physical changes. That could be because of emotional changes. That could be situational changes. And you're talking quantity.

The number of events of events is the quality dropping as well. I don't know. I suspect depends how you define quality. For example, time to orgasm. As you probably discussed is shorter.

If your partner knows his way around your body. Or you are more comfortable in the presence of that person relaxing and helping or participating. So it really depends how we define quality. But quality also involves novelty. And this is where I think aging couples need a self-help course.

I'll give you my favorite example. Okay. You and your husband go out to dinner. Or you take your kids out to dinner. Or you have a favorite restaurant.

“If you went there every day, it would soon become boring.”

Because you probably have a limited number of things that you like on the menu. You'd have them every single time. And it wouldn't be special anymore. You can't do the same thing with your sex life. You can't, I hate to use this word.

Eat the same thing every meal.

And still enjoy it the same as the first time you taste that delicious morsel of whatever it was at your favorite restaurant.

And so what happens to couples is they develop a sexual script. In general. In general. The longer they're together, they develop a script. He does this.

She does that. He does this. She does that. He does this. She does that.

He is an orgasm. Sometimes she does the script. It's boring. It becomes even more boring. It becomes eating at the same restaurant every single day.

Got to change it up. How do you cancel your patience about that? So it really depends on the couple. Because you got to be a little careful here. I'm not getting in their bedroom with them.

I don't want to be there. But I need to be there figuratively to prompt them to change it up. So I have two different approaches.

Each of you have to plan what we're going to call an erotic surprise. You have the script. I actually have them write it out by the way. Okay. Separately two different pieces of paper.

Write out what happens. Step by step in the bedroom. Write out what happens. Step by step in the bedroom. And I compare notes.

It's the same. Nine times out of ten. It's exactly the same. They know the script. Well, if you know the script, there's no surprise.

There's no novelty. There's nothing exciting happening. You know what's happening next. So here's the two scripts. I give them back.

The scripts I showed them each others. You got it right guys. You know what happens. Then you got to plan an erotic surprise. So if they have sex once a week.

Could be once a month. I don't know.

You first, you second, you third, you fourth.

You have to plan an erotic surprise. It's in this script. It's not to exchange. Right. Okay.

Just a twist in the plot. Don't tell them. Don't make it too weird. Don't tell her. Don't make it too weird.

Just a twist in the plot. Some little novelty. Something new. Sometimes that's all it's necessary. Other times.

I want you to rewrite the whole script. Totally different. But then give it to them or give it to her. Now you got to do it. How does that go?

I mean, it's totally different for different couples. Yeah. You know, you can tell them to plan an erotic surprise. See them back a month or two later and they didn't do anything.

“Well, how can I help you if you're not going to even try some of these things?”

Sometimes, and this is a different approach, I'll say to them, look, when you first got together, you didn't just take off all your clothes and get in bed and have sex. Sometimes they did. I get messed up. But most of the time, that's not the way it happens.

What happens? There's kissing first. Then there's touching. Then there's something else. I don't know.

Tell me what happened. Now I want you to try and get back there because there was excitement. There was novelty. Neither of you knew what was going to happen next. That's anticipation.

Then try and get some of that into their bedroom. Try and listen as a practitioner very carefully to what they said and how they said it and try and transplant that back into their script because they've lost it. So if we have clinicians that are listening, I mean, you have extra training as in sexuality. Right.

I did not. What resources would you recommend to them or to lay people? A couple of things. If you're a practitioner, the international society for the study of women's sexual health ish wish has a fall course.

“Every fall we just had it where you are going to learn everything you need to know”

to intervene in a couple's treatment. Primary care, obstetricians gynecologist, even some specialists. You're all just the whole gamut. You'll learn even though it'll probably feel like drinking from a water from a firehouse. Yeah, exactly.

But the answer is it starts out with what is the sexual response and ends up with secondary

treatments for all kinds of real bad problems? Yes. That's a really good place to start. And then there are really quite a few good books on each aspect of the sexual encounter. And from the psychological approach, sometimes from the biological approach, sometimes from

the social approach, which is why we call it the bio psychosocial approach to sexuality. Find a practitioner with a like interest in your community. Someone that you can count on for pelvic floor physical therapy, psychological therapy, psychiatric treatment with medication. And if you're the obstetrician gynecologist or the urologist, you should have the

biological or easily be able to learn it. Help us separate some of it from reality. A lot of women believe, and I see this a lot of, don't so much in clinic, but I really see it on social media. People feel like they can just say all the things or in my DMs.

A lot of women say, I don't care if I never do it again. So this is important.

“And I think generalizable, but not universal.”

So as women age, they are less likely to have spontaneous sexual desire. The internal lust, I can't wait to get home to take as close off or whatever.

And we've been talking mostly in cisgender terms, but the answer is, I can't wait

to get home and have sex.

Just tend as women age, and particularly as after menopause, to become what we call secondary,

where spontaneous sexual thoughts and fantasies are replaced by a position of sexual neutrality. Sometimes patients say to me, I can take it or leave it, or I'm kind of indifferent. But in the right circumstance, with the right amount of foreplay, which doesn't necessarily even involve touching, foreplay can be environment. They can be moved from that position of sexual neutrality.

Take it or leave it to one of, I want to participate. I'm interested. Let's do it. Or, you know, it's not happening right now. I can't get my head around it.

I'm not feeling bad, I'm not feeling good, I'm whatever, whatever, and it's no.

And that's more likely to occur in longer relationships, older age, and menopause. And that's what's normal. So you're not, you're not, you're not unusual. Yes, you're not broken, you're not weird, you're not unusual. This is what typically happens in long term relationships.

Sometimes my psychological colleagues say, well, all she needs is, I've been transplanted. Okay. And that's getting back to novelty and interest and something new.

“So how do we bring that back, and we already discussed it?”

So on the male side, how often is male sexual aging? Quality timing, recovery, you know, rectal dysfunction, becomes much more common with age. How is that kind of affecting a relationship and how often do you see that kind of being blamed on the woman? Oh, all the time.

So women, I think, generally, and obviously I'm going to get crucified for the statement, but if your audience will just reflect and think about it, there's a lot of truth in it. Women blame themselves for a lot of things. Yes, or specialized to do that. Correct.

And I completely agree that that's part of it, but it's not their fault. Men should know, and their intimate female partner should know, that 50% of 50 year-old men have some degree of erectile dysfunction. 60% of 60 year-old, 70% of 70 year-old, 80% of 80 year-olds. It's a broad, broad stroke.

It's not exactly 50, 60, 78 close enough.

“For our audience, our listeners, what is erectile dysfunction?”

It's the inability to get an erection hard enough for penetration or maintain long enough for penetration. That's a functional definition, not a medical definition, but it's good enough for this context. Now, what I want your audience, largely women, to take home from this more than anything,

is that intercourse, penis and vagina intercourse, with a person who has a non-direct, weak, erect penis, is actually worse for him than it is in terms of the sexual encounter, because she or they can end up with a broken penis that then becomes either peronies, a curved penis, or one that can't properly attain and maintain an erection. So it's really important to not push the limits if biologically they're not there.

And that's a really important take on message.

So first, men are terribly vain in this regard and think that they're superhuman and that

they're 20 years old when they're 70 and believe it or not, they're not 20 years old when they're 70. Take some self-assessment, be realistic, Viagra, Levitrocialis, Stendra, all these drugs, then have and they can treat erectile dysfunction in a high percentage of men of almost any age, not of any age, not with diabetes, not with blood pressure medicines, a bunch

of nuance there, but they're very helpful. Use them. Okay. Don't give up sex. You want to have sex?

Great. You want to use it as an excuse to not have sex, because you've got a mistress or a girlfriend or something. That's a different question, but these drugs are very helpful for men to get a good enough erection for intercourse, if that's the goal.

They have to get them their prescription and testosterone in both men and women goes down with age and testosterone is the hormone of desire in both men and women, but it's also

“very important for erectile function in men, also in women, by the way, but in men, and”

that needs to be checked as those men age.

It took us from an idea to a real business.

“We got set up, I think, in less than a day, with very little effort, we could just focus”

on the supply chain to the product development. Shopify gives us the ability to customize without the complexity. We can change something without introducing fragility or having to pay a developer. Buy a thirsty total, and we leveled up our business with Shopify. Start your free trial at Shopify.com/AU.

Perry Menopause is not early menopause. It is its own distinct biological phase, and it has been largely ignored. My new book, The New Perry Menopause, is about the seven to ten years before your period stop. A transition that is anything but gentle, hormones fluctuate wildly, and for many women,

this is when the anxiety, rainfall, sleep disruption, weight changes, mood shifts, joint pain, and that unsettling feeling of "I don't feel like myself anymore" began. Long before, anyone says the word "menopause." Perry Menopause often starts quietly.

It shows up in the brain first, then the body, then everywhere else.

And too often, women are told, "Nothing is wrong." I wrote the new Perry Menopause because you deserve answers before things spiral. You deserve care before burnout, and you deserve a clear road map for a transition that medicine has ignored for far too long. The new Perry Menopause is now available for pre-order, everywhere books are sold.

Learn more and pre-order your copy at theposlife.com. So you've done a ton of prescribing of testosterone, and you've done research in the area as well. Talk to me because it's so hot on the internet right now, and there's a little bit of a battle raging in my little world, pro and against it, and what really testosterone

is helpful for it. The way I counsel my patients is we know that in someone with hyperactive sexual desire disorder, my patients come in, we screen them before they hit the door. We know if they're having pain, we know what their desire level is, and then we start with the conversation if the vagina's broken, we need to fix that.

So vaginal estrogen or whatever she needs before we kind of get to the testosterone piece of the puzzle. Because the last thing I want to do is increase someone's desire, who's having pain. So no one really wants to have pain, there's a rare person that wants to have pain.

“I usually say, Mary, when was the last time you purposefully put your hand on a hot stove?”

Well, it happened when you were three or four years old, but it was by accident, and you never did it again. Now a woman who doesn't want to have sex is because she's having pain, that's someone that is in touch with her body, and she just needs her pain fixed. Yeah.

It doesn't mean that she can't have sex. It just means she can't have painful aspects of sex. And by and large there are lots of things that she and her partner can do that don't include having pain. Yeah.

They got to get back to those days when they were first dating and remember all the fun

that they had before they were taking their clothes off and having intercourse. Yeah. How do you consider patients for testosterone? What do you say? It helps with and won't help with.

We're talking about women. Women. Sorry. No problem. So the best and most abundant scientifically proven information is about sexual desire.

It's documented best in women who had their ovaries removed. It's documented but less well in women who have a normal natural menopause with their ovaries, but it works in both for sexual desire.

“I want to have sex or remember our neutrality story.”

It helps tip them in the direction of, yes, let's go. Okay. It is also beneficial for downstream sexual issues, how much of that is related to the testosterone itself and how much is related to their brain desiring having sex is less clear. So for example, a rousal tingling and engorgement and lubrication, those are all a rousal

orgasm, facility of orgasm, intensity of orgasm, ease of getting to orgasm and another aspect is sexual self image.

The testosterone studies were amazing in showing not only desire a rousal orgasm, but

that the woman herself on validated tests said that she felt better about her sexual self. I haven't breathed that study, but my patients tell me the same thing, you know, who have had positive response to testosterone, not only are they more interested and maybe initiating which hadn't happened in a long time, but they felt like a sexual being again. Very well documented, whether that's because they're having desire and reward orgasm or

true.

There's a lot of stuff floating on the internet about the other potential benefits

“of testosterone, one that mood, you know, what are you feeling in mood in general?”

What is the data? So for all the following, there are small studies, snippets, secondary effects that aren't documented, but that are in their totality likely, I'll explain what I mean by that. Everybody in this audience has sat in front of a jigsaw puzzle, and it's really easy to put the pieces around the outside because there's a flat edge on most puzzles, and so

we can get the boundary or the border around that jigsaw puzzle. You still can't see what the picture is. When we start to put little pieces inside and soon enough, even though it's not complete,

we can tell what the picture is, or we cheat and look at the box and see what the picture

is. The point here is that we have a lot of those little pieces for some of these endpoints I'm about to talk about, but they don't rise seeing the whole picture. So, mood would be one of those.

“Women feeling better or stronger or more empowered, which helps their mood.”

They're sense of well-being. There are some older studies that actually tested sense of well-being with high doses of testosterone, and it worked for that. So I'm talking now about normal, women's sexually physiologically normal levels of testosterone like they had at 30, at 30, at 40, but menstruating women, as opposed to menopausal.

Good energy, well-being, body composition, fat versus lean, bone density. There's some data for all of them, not rising to the level of what we were talking about with sexual desire, but there's data. It's more robust data if they're getting male levels of testosterone or superphysiologic levels for a female somewhere between what's normal and what's male, a lot of women are getting

those levels, and it's easier to see some of those benefits, but there are risks associated. Most of those risks women would like to avoid. I often say, "Take a look at me. This is a good look on me," at least my wife says, "so it might not be a good look on you." And he's all then bearded. There's a few listening, yeah, he's pointing to his hair and his beard.

His lack of hair on the sad end is beard. What have you learned from the long-term data? I remember early in the days when I was considering prescribing testosterone,

“there was worries about cardiovascular disease, and I think that's been taken off”

the modern formulations of testosterone. So if testosterone levels are within that normal reproductive female range. And what would that range be? So it really depends on the laboratory, because it's quite difficult to measure testosterone, and this is a little bit of a side light, but I think it's worth talking about it for your audience.

The quick and dirty testosterone tests that are easy to order were designed for measuring testosterone in men. They are not, they are not good enough to measure testosterone in women. But all the national laboratories, the laboratories that you would send your bloods to, that are worth their weight, they have a test that can be done for women

and provide an accurate total testosterone value for women. For those women on the podcast or their practitioners, these are testosterone measurements that are called LCMS or GCMS. You don't need to know what they stand for. It just needs to be measured by that technology.

And the big national laboratories like lab core and quest laboratories have those essays, and you can get a good number for women. That's what we use in our clinic. And that's what you should be using. So those levels are typically 20 to 60, maybe 80,

nanograms per deciliter. You don't need to know the units, 20 to 80 is a good enough number. But if you start pushing above 80, particularly above 100, you start getting hairy in places where men are naturally hairy and women, twist, tease, poll, pluck, laser, et cetera at significant cost.

There's also a problem with we don't have an FDA approved formulation for females. So in our clinic, we borrow our, I said, we borrow the men's versions.

So we're basically microdosing either the Tstem Gel or the Andrew Gel,

This is the nail on the head, Mary Claire.

“We were actively involved in developing two different testosterone products for women,”

both of which failed at the FDA, and there's a huge long story about that, but both of them documented. And the one hand efficacy for HSD, on the other hand, at least three years of safety, but together they both failed. And so in the absence of an FDA approved product for women,

we're, you know, microdosing or flying by the seat of our pants. But interestingly, I have committed and I come from a family of very long-lived people that I'm going to get that FDA approved before I kick it.

“And I think it's actually going to happen.”

I'm very encouraged because we now have a testosterone product for women in Australia, in New Zealand, in South Africa, and most recently in the United Kingdom.

And if we can get it in the United Kingdom, where they're first language is at least English,

it's English. Yeah. I think we have a good chance of getting it over here. Good. And I'm pushing for it. So many of your listeners and many of our patients have low sex drive in menopause, because they have very high sex hormone binding globulin, either because they just naturally have high sex hormone binding globulin, or they've spent, you know, their reproductive lives on birth control pills, which raise sex hormone binding globulin.

So for listeners, sex hormone binding globulin is a protein that it's like the car that carries the sex hormones around estrogen. It's a testosterone. And so if you have a lot of cars, you're kind of binding the activity. So you have a lot in your blood, but it's bound to this protein, so it's not active. And yeah, it can be a problem. Are you measuring SHBG and free and total testosterone in your patients? So I'm less concerned about free testosterone,

because it turns out it's very expensive for many patients and difficult to measure. It can be measured. Sometimes I measure it. But a total testosterone and SHBG gives me enough information to know whether they are normal or the SHBG is a problem. Really? Where did you come up with that? 170 Dr. Simon? I'm going to tell you. 2000 patients. No, actually. If you go back into the testosterone patch development studies, we had hormones on all of them. And there were no positive,

sexually positive responses in any woman, any woman on those testosterone patches that had an SHBG 170 or higher. Zero out of, I don't know, 67,000. Wow. So that's pretty telling. And so if a patient

“has a high SHBG, and I've seen them in the 400s, you need to drop it down. And that's a really”

easy, quick and dirty way to get it done. Did you know that hormones can affect your skin? They can affect collagen, hydration, elasticity, all of it. And that's why alloy health created M4. Their prescription skin care line. M4 is made with Estriel. The gold standard estrogen that

your body naturally stops producing in midlife. I first heard about alloy through a close friend

who's a dermatologist. She kept mentioning how few products actually address hormonal skin changes. When she explained alloy's approach, which is grounded in science and hormone physiology, I decided to try it myself. It completely changed how I think about skincare at this stage of my life. I started with the M4 face cream, and now alloy has added two more products, the M4 face serum, and the M4 eye cream. These are not over-the-counter beauty products. These are prescription

strength formulas backed by clinical research and designed specifically for midlife skin. The results? Smoother skin, improved firmness, and a brighter, more even tone. Skin changes over time, and a skin care routine should change with it. Alloy makes that simple. No office visits? No pharmacy lines. Just expert care, delivered straight to your door. Head to FYALOY.com and use the code MCH20. That's MCH20 to get

$20 off your first order.

All right, let's let's go to vaginal maintenance and sexual pain. We touched on it a little bit earlier.

because it can happen postpartum any time you're in a low estrogenic state. So libido's great,

desires great, but if you feel like there's knives for China every time you attempt intimacy is not going to go well for you. You've said something, and I repeat this to my patients all the time. It's easier to maintain vaginal health than to restore it. I stand by that. Walk us through your practical ladder for vaginal urinary health. I don't think it's that complicated. We have a number of really good, long-standing products that are hormonal for maintaining normal vaginal health

is defined by tissue, normality, elasticity, normality, and biome or biologic normality. It's just not that complicated. We have tablets, inserts, vaginal rings, creams. I mean,

“there's a plethora of choices. And one that's often forgotten, and I think it's worth mentioning,”

an oral serm you mentioned it, hospitality, which is a pill you take to make your vagina estrogenized,

which seems a little counterproductive, but it has a number of advantages. Believe it or not, there are a subgroup of women who, for whatever reasons, don't want to touch down there, feel down there, put stuff in their vaginas. They find them. Goopy, messy, junky, dirty, whatever. They get to. And they can take care of their vaginas with one pill a day. Turns out that adherents to that one pill a day is better than most of the other treatments, and the cost is on the lower end

of all the treatments. So it is a couple of advantages for it. In addition, and we might talk about it, it's been documented to treat dryness. Unrelated to sex, unrelated to pain,

“dryness. What we call walking around dryness, your eyes tear, your nose runs, your mouth”

drools, your vaginas supposed to be moist. That's a way to treat it. And not all of the treatments for pain are also approved for dryness. So that's another advantage of that pill. I hike a lot in the summer. Yeah. In Colorado, so we have like a hiking group. And this is one of the things when the lady's hike. We talk about that sometimes it's really uncomfortable, and it's especially depending on what we wear, because of the dryness and the changes in our anatomy of, you know,

and a lot of them are using some of the highly erotic acid products to try to keep things moist to decrease the chafing. You bring up a good point. So there are highly erotic acid products, there are moisturizers, separate from lubricants. And for some women that's all they need, or all they want, or all they feel like they can use, cause they're still afraid of the boxed warning. I can agree with that until they have urinary tract infections or until it's not good enough.

And I'm a big believer, as you mentioned, in preventing loss of anatomy, preventing loss of healthy tissue. So I would start most of those women who need it on estrogen or DHA or ospemothene to prevent loss. The timing is a little unusual. So for example, most women who have, they're going to have their hot flashes either before their last period, or starting most significantly in the

first five years of their menopause, more or less, the women who have the most vaginal or

bowlvar issues, it's about five years later. So they're approaching age 60, if they're not on systemic hormones before they have, those symptoms, and they come out of the clear blue, because they were having sex. Everything was fine, and then all of a sudden, I'm not having sex, and it's not fine, and I'm having problems. And so for them, either preventing or treating with one of those therapies is great. So we have the vaginal estrogen products. We talked about

the ospemothene, and then the DHA. Cover that real quick, because it's a little bit special. Yeah, so DHA, French Canadian, Dr. Ferdinand LeBri, brilliant guy, along with a bunch of us, developed a vaginal product made up of a pre hormone, not an actual hormone, but a pre hormone, DHA. Now, DHA stands for dehydro, p and drosterone, and that's a big long word. It's an adrenal adrenal hormone that is converted, in this case, converted from those vaginal inserts in the

vaginal tissue to both estrogen and testosterone, and it has added effects on the testosterone

“responsive elements of the vagina and Volvo, which are unique and really quite important.”

Let me just say, we don't think of a woman's anatomy as having male parts, but it does. And by the way, men have one. They're analogous, so men and men and women have the same parts. So when we're in

parts. And by the way, they look female. It's only after that second mismenstrual period,

when mom's pregnant with us little boys, that we start to grow the male parts. So we're all ambiguous up to the second mismenstrual period, and all female, and the female maintain some of that ambiguity into adulthood. So they have some parts that would have become penises, had they been boys, and those parts respond to testosterone. So having a little testosterone,

“particularly on the vaginal opening, the vestibule is really important, and some women need it”

directly applied to the vestibule, and some of them can get enough to the vestibule, because the size of those DHA inserts would determine to have a little leakage, a little leakage to the vestibule, to act both because of the amalient properties of the product itself, and also from the testosterone on the vestibule, which is a male remnant in adult women. Talk to me about pelvic floor over activity. I am seeing, and gratefully so, more and more discussion around the pelvic floor.

I'm seeing pelvic floor physical therapists starting to kind of blow up on social and their educational platforms, but most people still don't understand what that means.

“This all started when humans went from walking on force to walking on twos,”

and if you look at our pelvic bones, they're basically a big hole at the bottom. The so-called pelvis, pelvis is a word for bowl, like a bowl of salad, and in this case, the bowl has no bottom. So, the bottoms of our pelvis, both male and female, are comprised only of muscles. And walking on two legs, we are fighting gravity all the time. Just asked me about my turkey neck or women about their jowls. Okay, we're fighting gravity all the time, rest, sagging,

is another thing. Okay, it's gravity, blame other nature. As it relates to the pelvic floor, these muscles have to be trained. I have some grandchildren. I'm doing helping them with their body training. We have to train those muscles to keep our bowels in both gas and feces, to hold our urine because it's natural. And he kid in diapers just lets it all out. And women have the added problem of keeping the gas in the stool and the urine in while they're relaxing their vaginas to let

their partners in. That's complicated. Okay, you got to keep muscles tight and muscles loose at the same time. That's weird and hard, and it doesn't just happen naturally. Enter Pilates, yoga, hiking, biking, our current model of feminine fitness, where the pelvic floor is now very tight, because we want to tight. The core is tight. Think of the abdominal and pelvic floor muscles as a paper bag at the grocery. It's got two sides, a front, a back, and a bottom. But they're all connected.

And if you tighten the front, doing a lot of good crunches, a lot of good core work, heavy weights

in your Pilates. The answer is, it's going to pull up on the floor, the bottom of that bag,

and increase the pelvic floor tightness, which could be good unless she can't relax it. It's okay. If it's too tight, she tends to become constipated. It retains urine. You and I might see a woman who just emptied her bladder for her annual exam, and we do her internal exam. It's got a urine full of bladder fully urine. She just emptied it, because she's not capable of completely emptying because her muscles are so tight. So we need to send her for pelvic floor

physical therapy to learn to keep those nice tight abs. She's been working so hard on and at the same time relax her pelvic floor when she pees, when she poops and when she has sex.

And so the answer is, this is another aspect of learned behavior that carries over from when we're

aged three to when we're aged 53, and having problems with our sex laws. I feel like they're just the pelvic floor physical therapists who are highly specialized are just the unsung heroes of women's

“sexual health. And the more we can talk about them and drive more patients there, I think they”

better off. I think it's very important that pelvic floor physical therapist has to be one that

in vaginas, in anuses, etc. There are some physical therapists who don't do only do external work

“on abs and back and shoulders and neck and things. They're not the right physical therapists”

for the women we're talking about, but those that do internal work are incredibly helpful. We only talked about the pelvic floor tight muscles, hyper tonus muscles. Many women have pelvic floor hypotonic or loose muscles. They have a different set of sexual problems, but the answer is there's plenty of them. They tend to be women who are not your physically fit women. They can be totally normal. Otherwise, they may have had big babies or have had a lot of weekdays.

He's smoking exactly, and they've lost the weight, but they have loose pelvic floor muscles,

and we need to use the pelvic floor physical therapists to treat them to tighten them up and strengthen them up, but without making them so tight that they can't relax them.

“So, two ends of the same spectrum, both with sexual problems as an issue. Two tight”

pelvic floor typically pain, difficulty with penetration, two loose pelvic floor, difficulty with arousal and orgasm, even though penetrative pain is typically not part of that. So, when is it time for a sexual medicine specialist? I have to be very careful about this, because on the one hand, I don't want to be self-serving, and on the other hand, there aren't a lot

of sexual medicine specialists. How would they find one? So, a couple of things. First of all,

if we can try and divide sexual medicine specialists into specialists for men, specialist for women, and pelvic floor specialists, or sexual medicine specialists for psychological or emotional issues, that brings in a lot more potential practitioners. There are very few people who've been trained in psychology and sex therapy, as I have, we just need to get our patients to someone who can help. So, by dividing the women from the men, we can expand our options,

by dividing or segregating out pelvic floor, we can find some people for them, and the psychotherapist and psychiatrists is another group that can often help, because it's the whole picture. So, how do you find someone? There are multiple societies. Each of them have their own listserv of practitioners. So, ishwish has one. We talked about ishwish. The sexual medicine society of North America, they tend to have more urologists and male-focused practitioners on their

listserv. If it's a hormone menopause problem, then we have a listserv for the menopause society, and so a practitioner needs to kind of find someone in their community who's part of one of those organizations that has special training, or what I'm going to suggest is that they do that temporarily and get the extra training for themselves so that they can do a better job themselves, because as you mentioned, we have very few people that are properly trained in any or all of these disciplines.

Tell me, I'd like a typical success story. Patient comes to you. I'm assuming by the time they get to you, it's bad. We don't have very many of James Simon's running around, you know, you're getting the tertiary referrals at that point, but then walk me through a success story. Yeah, so I do get really challenging patients, and I'll just bring up one challenge, and it's a challenge that I see, but others will see also. So let's imagine that Missus Smith

is having sexual pain. Doesn't matter what kind. Missus Smith has no erectile problems. Typically, but now that he's afraid of hurting Missus Smith, now he has erectile problems. The fact that Missus Smith and Missus Smith are not having any intimate contact is now creating problems in their relationship, anger, resentment, et cetera. So now what was just pain for Missus Smith, which might have been simple, just needed some hormones for her vagina,

has now become a problem for Missus Smith and for Missus Smith. So we need something for him, something for her, something for them, and maybe psychotherapy for the couple. This is the snowball

“effect of what might have been an untreated, relatively simple problem. What does a success look like?”

That couple, Missus Smith, come to me. I treat her pain. Could be something straightforward and simple or more complicated, but I treat her pain. We get him to understand. She wasn't rejecting

if he needed, get his erection fixed. If he needs it, send him to psychotherapy. If he has

“psychological erectile dysfunction, get the two of them in treatment or sometimes I'll start that”

process just by getting them to talk to each other, to touch each other, harken back to when they were

first becoming sexually active with each other, which may have been 40 years ago, and get that

process and rolling again and see how far it goes. That's a success. What is outer course? This is my new bandwagon. So my new bandwagon has to do with couples aging gracefully together. In every couple, there comes a time when intercourse can become more trouble than it's worth. That doesn't mean they have to give up on intimacy. So let's give a couple of examples. Mrs. Smith. She doesn't have a driver giant because we've moistened it. She doesn't have a painful vagina because we've estrogenized

“it or given it hormones. But now, Mrs. Smith has such bad arthritis in her hips that she cannot”

spread her legs. Mr. Smith is diabetic on anti-pertensive medicines has peripheral vascular disease from his diabetes and his historical long-term smoking. He cannot get a good erection, not good enough for penetrative sex. So for that couple, intercourse may be not possible. It doesn't mean that all the things that they used to do, what I'm defining as outer course, which could be anything from kissing to genital kissing and pleasureing to everything else in the sexual armamentarium

short of penis and vagina intercourse. What happened to all that stuff? Let's get back to sexual play, sexual touching, other forms of intimacy because what was and in most cultures is the epidemic, the end goal can now be supplanted by or replaced by other things, both which can lead to orgasm, even he can have an orgasm without a good erection. She can have an orgasm without intercourse

for sure. And the answer is sometimes all of that goes to waste or settles into the background.

When neither of them wanted to, just because they can't have what historically has been the end of their sexual activity, intercourse. And they're still happy and they still want to be engaged in that way, but they don't know how to find a way back to what they used to do before they had intercourse now that they've been having intercourse for 10, 20, 30, 40, 50 years. If you could redesign midlife clinical visit, you know, what would high quality sexual care look like? So we got to

get rid of pain. We got to get rid of symptoms. We got to get rid of shame. Both men and women. We got to get rid of the typical paradigm of who starts and who finishes and how and change it up. Get people to think about what they want and how to communicate it to their partner. And that's really hard. I'll give you an example. Mrs. Smith likes everything soft and gentle,

but she's never been able to tell Mr. Smith that she likes everything soft and gentle. So he's

doing everything hard or what he thinks she wants. Now Mrs. Smith could tell him, honey, you're doing it too hard. That's blaming. And that's not going to be very helpful in her getting what she wants or she could say honey, I really like it softer. The use of what we call eye language in psychology always gets you to a better place if you start a sentence with I. I'd like you to take the garbage out. I'd like you to do this. I'd like it softer. I'd like it harder.

I like it this. I like it that as opposed to you're doing it wrong. You never take out the trash, whatever. So use of eye language in couples discussing sex is really important and it shouldn't be only in the bedroom typically best outside the bedroom in a neutral place over the breakfast table

“when the kids aren't there. On the couch when you're watching TV. I think that's radical,”

you know, and genius, but you know, asking a couple to have that conversation outside of the bedroom. And let's add one more nuance, not when they're looking at each other. Sitting on the couch,

If I look at you, Mary Claire and say, you hurt me every time you put your penis inside, that's pretty damning. And aggressive in animals, including humans, face-to-face confrontation is

aggressive. You never see two animals looking each other straight in the eyes. You don't.

It's aggressive walking, hand in hand, looking straight ahead. Honey, I'd really like to talk about our sex life, not threatening. I language and looking away. And just creating a self-environment, talking about that conversation. And by the way, I can do that in the office. They're looking at me across a desk. They don't have to look at each other. A couple comes in and they face their

chairs, looking at each other. I'm in trouble as a practitioner. This is another barrier I got across.

Exactly. I got a hole before I even get to flat ground. Yeah. That's use of body language to help get to the place where everybody wants to be. Well, thank you for coming on and

“paused. Our listeners are going to love this so much. And I think you're going to tune some”

lives here. Great. Thank you very much for having me. I really appreciate it. You can find Dr. Simon on Instagram at menopause.whisper and through his website www.intemmedicine.com. You can find full episodes of unpause on YouTube at Dr. Mary Claire. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire and get honest, accurate information on health, fitness, and navigating midlife at thepauselife.com. My upcoming

book, The New Perry Menopause, is available for pre-order on Amazon. If you're loving this podcast,

“I have an important request. Take a moment to follow unpause on your favorite podcast app,”

following and listening, is what pushes this information to more women who need it. So, if this podcast has helped you feel seen, understood, or supported, hit follow right now so you

never miss an episode. Thank you for being here with me. Let's keep going. Unpause. Unpause is

presented by Odyssey in conjunction with hot people. I'm your host, Dr. Mary Claire Haver. The views and opinions expressed on unpause are those of the talent and the guests alone and are provided for informational and entertainment purposes only. No part of this podcast or in-evaled materials are intended to be a substitute for professional medical advice, diagnosis or treatment. What I want to do is not to be a student,

the master of the laptop, the soft hand, the internet, and so it's a master's real pleasure.

“I'm saying, you can say that you're a hero. You're a master of the science, right?”

But you don't believe it. No. You're a master of the science. You're a master of the science. Do you do a lot of things with this story? And if you then work, you're a kitchen. That's right. Save. What is this story? Hold your money back. Now it costs just out for me.