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

14:02Dr. Mary Claire Haver:I did not. What resources would you recommend to them or to lay people?

14:06Dr. James Simon:A couple of things. If you're a practitioner, the International Society for the Study of Women's Sexual Health, ISHWISH, 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, gynecologists, even some specialists, urologists, the whole gamut, you'll learn even though it'll probably feel like drinking from a water, from a fire hose. 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.

14:50Dr. James Simon: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, some from the psychological approach, sometimes from the biological approach, sometimes from the social approach, which is why we call it the biopsychosocial 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.

15:33Dr. Mary Claire Haver:Help us separate some myth from reality. A lot of women believe, and I see this a lot, not so much in clinic, but I really see it on social media. People feel like they can just say all the things in my DMs. A lot of women say, I don't care if I never do it again.

15:47Dr. James Simon: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 his clothes 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. Okay. Internal, it's drive, it's lust, its libidinous thoughts and fantasies. Those 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.

16:40Dr. James Simon: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. Situation's 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.

17:26Dr. James Simon:And that's what's normal. So you're not broken. 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 colleague says, well, all she needs is a husband transplant. Okay. And that's getting back at novelty and interest and something new. So how do we bring that back? And we already discussed it.

17:53Dr. Mary Claire Haver:So on the male side, how often is male sexual aging? Quality timing, recovery, erectile 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 a woman?

18:08Dr. James Simon: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. unnecessarily.

18:24Dr. Mary Claire Haver:Or socialized to do that.

18:24Dr. James Simon: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 percent of 50-year-old men have some degree of erectile dysfunction. 60 percent of 60-year-olds, 70 percent of 70-year-olds, 80 percent of 80-year-olds. It's a broad brushstroke. It's not exactly 50, 60, 78, close enough.

18:52Dr. Mary Claire Haver:For our audience, our listeners, what is erectile dysfunction?

18:55Dr. James Simon: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-erect, 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 Peyronie's, a curved penis, or one that can't properly attain and maintain an erection.

19:46Dr. James Simon:So it's really important to not push the limits if biologically they're not there. They're not there. And that's a really important take-home 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. They're not 20 years old when they're 70. Take some self-assessment. Be realistic. Viagra, Levitra, Cialis, Stendra, all these drugs men 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.

20:35Dr. James Simon: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 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.

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24:37Dr. Mary Claire Haver:So you've done a ton of prescribing of testosterone. Yeah. 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 and what really testosterone is helpful for it. The way I counsel my patients is we know that in someone with hypoactive sexual desire disorder, my patients come in, we screen them before they hit the door. You know, we know if they're having pain, we know what their desire level is. And then we start the conversation. If the vagina is broken, we need to fix that, you know.

25:10Dr. Mary Claire Haver: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.

25:19Dr. James Simon:So no one really wants to have pain. It's a rare person that wants to have pain. I usually say, Mary Claire, 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. So 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.

26:00Dr. James Simon:Yeah. 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 intercourse.

26:08Dr. Mary Claire Haver:Yeah. How do you counsel your patients for testosterone? What do you say it helps with and won't help with?

26:13Dr. James Simon: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? Yeah. It helps tip them in the direction of, yes, let's go. OK. 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.

27:05Dr. James Simon:So, for example, arousal, tingling and engorgement and lubrication. Those are all arousal. 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 arousal orgasm, but that the woman herself on validated tests said that she felt better about her sexual self.

27:37Dr. Mary Claire Haver:I haven't read that study, but my patients tell me the same thing, you know, who have had a 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.

27:50Dr. James Simon:Very well documented. Whether that's because they're having desire and reward, orgasm, or it's a central nervous system effect of testosterone is less clear, but it's absolutely true.

28:04Dr. Mary Claire Haver:There's a lot of stuff floating on the internet about the other potential benefits of testosterone. One, mood. You know, what do you feel in mood in general? What does the data say?

28:16Dr. James Simon:So for all of the following, there are small studies, snippets, secondary effects that aren't documented, but that are in their totality likely. And 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. Then 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.

29:00Dr. Mary Claire Haver:That's me.

29:01Dr. James Simon: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 to seeing the whole picture. Okay. Okay. So mood would be one of those. Women feeling better or stronger or more empowered, which helps their mood, their 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 40, but menstruating women as opposed to menopausal women.

29:46Dr. James Simon:Mood, energy well-being body composition fat versus lean um 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 supra physiologic 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.

30:35Dr. James Simon:It might not be a good look on you. Bald and bearded.

30:39Dr. Mary Claire Haver:Those of you listening, yeah, he's pointing to his hair and his beard.

30:43Dr. James Simon:His lack of hair on his head and his beard.

30:46Dr. Mary Claire Haver:What have we 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.

30:57Dr. James Simon:So if testosterone levels are within that normal reproductive female range.

31:04Dr. Mary Claire Haver:And what would that range be?

31:05Dr. James Simon: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 good enough to measure testosterone in women. Okay. 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 LC-MS or GC-MS.

32:02Dr. James Simon: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 LabCorp and Quest laboratories have those assays. And you can get a good number for women.

32:16Dr. Mary Claire Haver:That's what we use in our clinic.

32:17Dr. James Simon: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 tweeze, tease, pull, pluck, laser, etc. at significant cost.

32:49Dr. Mary Claire Haver:There's also a problem with we don't have an FDA-approved formulation for females. So in our clinic, I say we borrow the men's version. So we're basically microdosing either the T-Stim gel or the Androgel, depending on what we can get for them from the pharmacy.

33:05Dr. James Simon: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, on the one hand, efficacy for HSDD. 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.

33:56Dr. James Simon: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 their first language is at least English, it's English, I think we have a good chance of getting it over here.

34:27Dr. Mary Claire Haver:Good.

34:27Dr. James Simon: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.

34:54Dr. Mary Claire Haver:So for our listeners, sex hormone binding globulin is a protein that it's like the car that carries the sex hormones around, estrogen and 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 all your patients?

35:16Dr. James Simon: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. Where did you come up with that? 170, Dr. Simon, I'm going to tell you.

35:43Dr. Mary Claire Haver:10 ,000 patients.

35:44Dr. James Simon: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, 6 ,000, 7 ,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 down.

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38:55Dr. Mary Claire Haver:All right, let's go to vaginal maintenance and sexual pain. We touched on it a little bit earlier. So GSM, for our listeners, is genital urinary syndrome of menopause or just the genital urinary syndrome because it can happen postpartum, anytime you're in a low estrogenic state. So libido is great. Desire is great. But if you feel like there's knives in your vagina every time you attempt intimacy, it's 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 and urinary health.

39:29Dr. James Simon:I don't think it's that complicated. We have a number of really good longstanding products that are hormonal for maintaining normal vaginal health as defined by tissue normality, elasticity normality, and biome or biologic normality. You know, 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 CIRM. You mentioned it, ospemophene, which is a pill you take to make your vagina estrogenized, which seems a little counterproductive, but it has a number of advantages.

40:22Dr. James Simon: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.

40:36Dr. Mary Claire Haver:Or hard to get to.

40:37Dr. James Simon:And they can take care of their vaginas with one pill a day. Turns out that adherence 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 there's 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 vagina is 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.

41:18Dr. Mary Claire Haver:I hike a lot in the summer in Colorado. So we have like a hiking group. And this is one of the things when the ladies hike, we talk about that sometimes it's really uncomfortable, 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 hyaluronic acid products to try to keep things moist, to decrease the chafing.

41:36Dr. James Simon:You bring up a good point. So there are hyaluronic 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 because 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 DHEA or ospemophene to prevent loss. The timing is a little unusual. So, for example, most women, 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.

42:29Dr. James Simon:the women who have the most vaginal or vulvar 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.

42:56Dr. Mary Claire Haver:So we have the vaginal estrogen products. We talked about the ospimiphene and then the DHEA. Cover that real quick because it's a little bit special.

43:02Dr. James Simon:Yeah. So DHEA, French-Canadian Dr. Ferdinand Labrie, 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, DHEA. Now, DHEA stands for dehydroepiandrosterone. 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 vulva, 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.

43:58Dr. James Simon:And by the way, men have a lot of...

44:00Dr. Mary Claire Haver:They're analogous. They're analogous. Men and women have the same parts.

44:03Dr. James Simon:So when we're in our mom's womb, up until her mom's second missed period, we are identically anatomic. We have the same parts. And by the way, they look female. It's only after that second missed menstrual 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 missed menstrual period and all female. And the female maintains 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.

44:57Dr. James Simon: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 DHEA inserts would determine to have a little leakage, a little leakage to the vestibule. to act both because of the emollient properties of the product itself and also from the testosterone on the vestibule, which is a male remnant in adult women.

45:27Dr. Mary Claire Haver:Talk to me about pelvic floor overactivity. 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.

45:42Dr. James Simon:This all started when humans went from walking on fours 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 pelvises, both male and female, are comprised only of muscles. And walking on two legs, we are fighting gravity all the time. Just ask me about my turkey neck or women about their jowls. OK, we're fighting gravity all the time. Breasts sagging is another. OK, it's gravity. Blame Mother Nature. As it relates to the pelvic floor, these muscles have to be trained.

46:34Dr. James Simon:I have some grandchildren. I'm doing helping them with their potty training. We have to train those muscles to keep our bowels in, both gas and feces, to hold our urine because it's natural. Any 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 it tight.

47:24Dr. James Simon: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 too tight. If it's too tight, she tends to become constipated, retains urine. You and I might see a woman who just emptied her bladder for her annual exam, and we do her internal exam.

48:13Dr. James Simon:It's got a bladder full of 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 age three to when we're age 53 and having problems with our sex lives.

48:52Dr. Mary Claire Haver: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, you know, drive more patients there, I think they're better off.

49:05Dr. James Simon:I think it's very important that pelvic floor physical therapist has to be one that does internal work, meaning she is likely or willing to put her therapeutic hands, fingers 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, hypertonous muscles. Many women have pelvic floor hypotonic or loose muscles. They have a different set of sexual problems.

49:53Dr. James Simon: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 weight gain. Chronic cough, obesity, smoking.

50:07Dr. Mary Claire Haver:Exactly.

50:07Dr. James Simon: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. Too tight a pelvic floor, typically pain, difficulty with penetration. Too loose a pelvic floor, difficulty with arousal and orgasm, even though penetrative pain is typically not part of that.

50:43Dr. Mary Claire Haver:So when is it time for a sexual medicine specialist?

50:46Dr. James Simon: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.

50:56Dr. Mary Claire Haver:And then how would they find one?

50:58Dr. James Simon:So a couple of things. First of all, if we can try and divide sexual medicine specialists into specialists for men, specialists 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 psychotherapists and psychiatrists is another group that can often help because it's the whole picture, the whole picture.

51:49Dr. James Simon: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 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.

52:35Dr. James Simon:Because as you mentioned, we have very few people that are properly trained in any or all of these disciplines.

52:44Dr. Mary Claire Haver:Tell me like a typical success story. A patient comes to you, I'm assuming by the time they get to you, it's bad. You know, we don't have very many of James Simons running around. You know, you're getting the tertiary referrals at that point. But then walk me through a success story.

52:58Dr. James Simon: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 Mrs. Smith is having sexual pain. Doesn't matter what kind. Mr. Smith has no erectile problems, typically. But now that he's afraid of hurting Mrs. Smith, now he has erectile problems. The fact that Mrs. Smith and Mr. 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 Mrs. Smith, which might've been simple, just needed some hormones for her vagina, has now become a problem for Mr.

53:42Dr. James Simon:Smith and for Mr. and Mrs. 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 the success look like? That couple, Mr. and Mrs. 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 And she wasn't rejecting him. She was having pain. Nobody wants to have sex if they're having pain. Get him on testosterone if he needed. Get his erection fixed if he needs it.

54:20Dr. James Simon: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 rolling again and see how far it goes. That's a success.

54:47Dr. Mary Claire Haver:What is outer course?

54:48Dr. James Simon: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 dry vagina 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 antihypertensive medicines, has peripheral vascular disease from his diabetes and his historical long-term smoking.

55:42Dr. James Simon: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 pleasuring 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 epitome, the end goal, can now be supplanted by or replaced by other things, both of which can lead to orgasm.

56:36Dr. James Simon: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.

57:00Dr. Mary Claire Haver:And they're still happy.

57:01Dr. James Simon: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.

57:16Dr. Mary Claire Haver:If you could redesign a midlife clinical visit, you know, what would high quality sexual care look like?

57:23Dr. James Simon: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.

58:14Or she could say, honey, I really like it softer.

58:18Dr. James Simon:The use of what we call I 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 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.

58:58Dr. Mary Claire Haver:I think that's radical, you know, and genius, but, you know, asking a couple to have that conversation outside of the bedroom.

59:07Dr. James Simon:And let's add one more nuance. Not when they're looking at each other. Sitting on the couch, watching TV together, it's an intimate moment. You're still together. Not looking each other in the face. 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 at 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.

59:46Dr. James Simon:Eye, language, and looking away.

59:48Dr. Mary Claire Haver:And just creating a safe environment to have that conversation.

59:51Dr. James Simon:Correct. 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. Digging. 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.

1:00:20Dr. Mary Claire Haver:Well, thank you for coming on Unpaused. Our listeners are going to love this so much. And I think you're going to change some lives here.

1:00:26Dr. James Simon:Great. Thank you very much for having me. I really appreciate it.

1:00:31Dr. Mary Claire Haver:You can find Dr. Simon on Instagram at menopause.whisperer and through his website, www.intemmedicine.com. You can find full episodes of Unpaused 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 thepawselife.com. My upcoming book, The New Perimenopause, is available for pre-order on Amazon. If you're loving this podcast, I have an important request. Take a moment to follow Unpaused on your favorite podcast app.

1:01:12Dr. Mary Claire Haver: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. Unpaused. Unpaused is presented by Odyssey in conjunction with Pod People. I'm your host, Dr. Mary Claire Haver. The views and opinions expressed on Unpaused 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.

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