Pod Insights unPAUSED with Dr. Mary Claire Haver The Sex Life Nobody Warned You About: What a Top Sexual Medicine Expert Wants You To Know About this episode Most women go through decades of marriage, menopause and midlife without ever having an honest conversation with a doctor about their sex life. Not because they don't want one — but because most physicians were never trained to have it. This week on unPaused, Dr. Mary Claire Haver sits down with Dr. James Simon, a professor of obstetrics and gynecology at George Washington University, board-certified OB-GYN, reproductive endocrinologist, and certified sexual counselor with more than 800 published papers in menopause and sexual medicine. Dr. Simon is a past president of the International Society for the Study of Women's Sexual Health (ISSWSH) and one of the most published clinicians in modern menopause care.
Dr. Simon has spent his career treating what most doctors never address — the full picture of how sex, desire, pain and intimacy change for both women and men as they age. He treats couples together, and what he has witnessed across thousands of relationships is that the problems are rarely one person's fault, rarely unsolvable, and almost always rooted in something nobody warned them about.
Guest links:
James Simon https://intimmedicine.com/our-team/james-a-simonmd/ (IntimMedicine Specialists)
James Simon https://www.instagram.com/menopause.whisperer/?hl=en (Instagram)
James Simon https://www.youtube.com/playlist?list=PLCwPULqh8u5GfrBGgVO-wKj0umOOX22P1 (YouTube)
Articles:
What if the Women’s Health Initiative had used transdermal estradiol and oral progesterone instead? https://journals.lww.com/menopausejournal/abstract/2014/07000/what_if_the_women_s_health_initiative_had_used.14.aspx (Menopause)
Erectile Dysfunction https://www.ncbi.nlm.nih.gov/books/NBK562253/ (StatPearls)
Should we be prescribing testosterone to perimenopausal and menopausal women? A guide to prescribing testosterone for women in primary care https://bjgp.org/content/70/693/203 (British Journal of General Practice)
The Benefits and Harms of Systemic Testosterone Therapy in Postmenopausal Women With Normal Adrenal Function: A Systematic Review and Meta-analysis https://academic.oup.com/jcem/article-abstract/99/10/3543/2836321?redirectedFrom=fulltext (The Journal of Clinical Endocrinology & Metabolism)
Other Resources:
Women’s Health Initiative https://www.whi.org/
The North American Menopause Society Releases Its 2022 Hormone Therapy Position Statement https://menopause.org/wp-content/uploads/press-release/ht-position-statement-release.pdf(NAMS)
International Society for the Study of Women's Sexual Health https://www.isswsh.org/ (ISWSH)
FDA panel rejects testosterone patch for women on safety grounds https://pmc.ncbi.nlm.nih.gov/articles/PMC535443/ (The BMJ)
The Saga of Testosterone for Menopausal Women at the Food and Drug Administration (FDA) https://academic.oup.com/jsm/article-abstract/17/4/826/6973691?redirectedFrom=fulltext (The Journal of Sexual Medicine)
Sexual Medicine Society of North America https://www.smsna.org/ (SMSNA)
Books:
“Restore Yourself: A Woman's Guide to Reviving her Sexual Desire and Passion for Life,” https://www.amazon.com/Restore-Yourself-Womans-Reviving-Passion/dp/0425181790 by James Simon and Victoria Houston
“The New Perimenopause,” https://thepauselife.com/pages/the-new-perimenopause-book by Dr. Mary Claire Haver
<a href="https://www.amazon.com/New-Menopause-Navigating-Through-Hor ...
Transcript Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.
0:00 Speaker 00 So no one really wants to have pain. No. 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. 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. 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 intercourse.
0:52 Dr. Mary Claire Haver? The views and opinions expressed on Unpuzzled 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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2:25 Dr. Mary Claire Haver? Today on UnPaused, 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
3:10 Dr. Mary Claire Haver? and one of the most published clinicians in modern menopause care. I'm Dr. Mary Claire Haver, a board-certified obstetrician 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 UnPaused, 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.
3:36 Dr. Mary Claire Haver? Welcome to UnPaused.
3:37 Speaker 00 Thank you for having me.
3:38 Dr. Mary Claire Haver? You've been doing this work for decades. You've written numerous papers, I've lost count.
3:43 Speaker 00 Eight hundred.
3:44 Dr. Mary Claire Haver? You've trained hundreds of residents, I'm sure, medical students, seen tens of thousands of patients. But before we get into the big topics, tell me where you started. Where'd you grow up? Why'd you go into medicine?
3:55 Speaker 00 So I grew up in suburban Chicago. I went into medicine having a long line of medical doctors in 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.
4:13 Dr. Mary Claire Haver? And then where'd you do your training? And why OB-GYN?
4:15 Speaker 00 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. I have 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.
4:37 Dr. Mary Claire Haver? And then you went on and did a fellowship in reproductive endocrinology?
4:40 Speaker 00 I did.
4:40 Dr. Mary Claire Haver? So, most people who do this fellowship now end up going strictly into infertility. You've deviated from that a bit.
4:47 Speaker 00 And decided to be a reproductive endocrinologist, which took me very easily into menopausal medicine, osteoporosis work and sexual medicine, which is fascinating as it relates to the hormonal impact it has on sex.
5:03 Dr. Mary Claire Haver? I learned almost nothing in a four-year residency and I was a resident from 98 to 2002. And we learned almost nothing about female sexual function or, you know, how to treat a patient. And then I graduate, pass 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?
5:43 Speaker 00 I felt, just as you had suggested, here I'm 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. So, I figured I better get juiced up on that before I went, because I was going to come out, as you did,
6:06 Dr. Mary Claire Haver? Yeah.
6:07 Speaker 00 with little or no training. And that's when it all started for me.
6:10 Dr. Mary Claire Haver? I didn't even realize it would be a problem. You know, like, I had 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 OB-GYN. Who is doing their best but receive 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.
6:42 Speaker 00 I do.
6:43 Dr. Mary Claire Haver? 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 does sexual aging really look like for her versus him?
6:57 Speaker 00 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, 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.
7:42 Speaker 00 That could be because of physical changes. That could be because of emotional changes. That could be situational changes.
7:49 Dr. Mary Claire Haver? And you're talking quantity, like number of experiences.
7:52 Speaker 00 Events.
7:53 Dr. Mary Claire Haver? Is the quality dropping as well?
7:55 Speaker 00 I don't know. I suspect depends how you define quality. For example, time to orgasm, as you've 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.
8:37 Dr. Mary Claire Haver? Okay.
8:38 Speaker 00 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'd probably have a limited number of things that you'd 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.
9:18 Speaker 00 And so what happens to couples is they develop a sexual script.
9:26 Dr. Mary Claire Haver? In general?
9:26 Speaker 00 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. Gotta change it up.
9:49 Dr. Mary Claire Haver? How do you counsel your patients about that?
9:50 Speaker 00 So it really depends on the couple. Because you gotta 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. First, I'll say to him, or her, or them, each of you have to plan what we're gonna 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 happened step by step in the bedroom. Write out what happened step by step in the bedroom, and I compare notes. It's the same.
10:34 Speaker 00 Nine times out of 10, it's exactly the same. They know the script. Well, if you know the script, there's no surprise.
10:42 Dr. Mary Claire Haver? Yeah.
10:43 Speaker 00 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 show them each other's. 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 the script. It's not too strange.
11:11 Dr. Mary Claire Haver? Right.
11:12 Speaker 00 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 that'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.
11:38 Dr. Mary Claire Haver? How does that go? I've never done this with a patient. You know, I'm judging the women.
11:42 Speaker 00 It's totally different for different couples.
11:44 Dr. Mary Claire Haver? Yeah.
11:45 Speaker 00 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, 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.
12:30 Speaker 00 That's anticipation. Then try and get some of that into their bedroom.
12:38 Speaker 00 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.
12:49 Dr. Mary Claire Haver? So if we have clinicians that are listening, I mean, you have extra training as in sexuality.
12:54 Speaker 00 Right.
12:54 Dr. Mary Claire Haver? I did not. What resources would you recommend to them or to laypeople?
12:58 Speaker 00 Couple of things. If you're a practitioner, the International Society for the Study of Women's Sexual Health, ISWSH, 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.
13:32 Dr. Mary Claire Haver? Fire hose.
13:32 Speaker 00 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.
13:42 Dr. Mary Claire Haver? Yeah.
13:42 Speaker 00 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 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.
14:25 Dr. 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. Or in my DMs, a lot of women say, "I don't care if I never do it again."
14:39 Speaker 00 So this is important and I think um generalizable but not universal. So as women age, they are less likely to have spontaneous sexual desire. The 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. Uh but the answer is, I can't wait to get home and have sex. Okay, internal, it's drive, it's lust, it's libidinous thoughts and fantasies. Those tend as women age, and particularly as after menopause,
15:20 Speaker 00 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.
16:04 Speaker 00 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. And that's what's normal. So you're not broken.
16:22 Dr. Mary Claire Haver? Yeah.
16:22 Speaker 00 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.
16:45 Dr. Mary Claire Haver? So on the male side, how, you know, how often is male sexual Aging, quality, timing, recovery, you know, erectile dysfunction is 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?
17:00 Speaker 00 Oh, all the time. So women, I think generally, and obviously, I'm going to get crucified by this 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.
17:15 Dr. Mary Claire Haver? We're socialized to do that.
17:16 Speaker 00 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-olds, 70% of 70-year-olds, 80% of 80-year-olds. It's a broad brush stroke. It's not exactly 50, 60, 70, 80, close enough.
17:44 Dr. Mary Claire Haver? For our audience, our listeners, what is erectile dysfunction?
17:47 Speaker 00 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
18:29 Speaker 00 that then becomes either peronis, 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.
18:45 Dr. Mary Claire Haver? They're not there.
18:46 Speaker 00 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. Use them, okay? Don't give up sex. You want to have sex? Great.
19:31 Speaker 00 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.
20:19 Dr. Mary Claire Haver? So you've done a ton of prescribing of testosterone.
20:22 Speaker 00 Yep.
20:23 Dr. Mary Claire Haver? 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, you know, raging in my little world, pro and against, and what really testosterone is helpful for. The way I counsel my patients is, we know that in someone with hypoactive sexual desire disorder, 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, 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.
21:00 Speaker 00 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.
21:27 Dr. Mary Claire Haver? Yeah.
21:29 Speaker 00 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.
21:41 Dr. Mary Claire Haver? Yeah.
21:42 Speaker 00 But they gotta 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.
21:50 Dr. Mary Claire Haver? Yeah. How do you counsel your patients for testosterone? What do you say it helps with and won't help with?
21:54 Speaker 00 We're talking about women.
21:55 Dr. Mary Claire Haver? Women, sorry.
21:56 Speaker 00 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?
22:26 Dr. Mary Claire Haver? Yeah.
22:27 Speaker 00 It helps tip them in the direction of, yes, let's go. Okay?
22:33 Speaker 00 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, 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.
23:18 Dr. 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.
23:32 Speaker 00 Very well documented, whether that's because they're having desire and reward orgasm.
23:39 Dr. Mary Claire Haver? Yeah.
23:39 Speaker 00 Or it's a central nervous system effect of testosterone is less clear, but it's absolutely true.
23:46 Dr. Mary Claire Haver? There's a lot of stuff floating on the internet about the other, other potential benefits of testosterone. Um, one that mood, you know, what do you feel in, in mood in general? What is the data saying?
23:57 Speaker 00 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 some, 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
24:41 Dr. Mary Claire Haver? That's me.
24:43 Speaker 00 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.
24:53 Dr. Mary Claire Haver? Okay.
24:53 Speaker 00 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.
25:22 Dr. Mary Claire Haver? At thirty.
25:23 Speaker 00 At thirty, at forty, but menstruating women as opposed to menopausal women. 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.
25:51 Speaker 00 Or supraphysiologic 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." Bald and bearded.
26:20 Dr. Mary Claire Haver? There's, if you're listening, yeah, he's pointing to his hair and his beard.
26:25 Speaker 00 His lack of hair on his head and his beard.
26:27 Dr. 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, that's been taken off the modern formulations of testosterone.
26:39 Speaker 00 So if testosterone levels are within that normal reproductive female range.
26:46 Dr. Mary Claire Haver? And what would that range be?
26:47 Speaker 00 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.
27:12 Dr. Mary Claire Haver? Okay.
27:12 Speaker 00 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.
27:43 Dr. Mary Claire Haver? That's what we do.
27:43 Speaker 00 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.
27:57 Dr. Mary Claire Haver? That's what we use in our clinic.
27:58 Speaker 00 And that's what you should be using. So those. 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, et cetera, at significant cost.
28:30 Dr. Mary Claire Haver? There's also a problem with we don't have an FDA approved formulation for females. So in our clinic, we borrow, I say we borrow the men's version. So we're basically microdosing either the T-STEM gel or the AndroGel, depending on what we can get for them from the pharmacy.
28:47 Speaker 00 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,
29:28 Dr. Mary Claire Haver? Yeah.
29:28 Speaker 00 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,
29:49 Dr. Mary Claire Haver? Yeah.
29:50 Speaker 00 in New Zealand, in South Africa, and most recently in the United Kingdom.
29:56 Speaker 00 And if we can get it in the United Kingdom where their first language is at least English, it's English.
30:04 Dr. Mary Claire Haver? Yeah.
30:04 Speaker 00 I think we have a good chance of getting it over here.
30:08 Dr. Mary Claire Haver? Good.
30:09 Speaker 00 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.
30:35 Dr. 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's, it can be a problem. Are you measuring SHBG and free and total testosterone in all your patients?
30:58 Speaker 00 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.
31:19 Dr. Mary Claire Haver? Really high.
31:19 Speaker 00 Where did you come up with that 170, Dr. Simon? I'm gonna tell you.
31:24 Dr. Mary Claire Haver? 10,000 patients.
31:25 Speaker 00 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, 7,000.
31:55 Dr. Mary Claire Haver? Wow.
31:55 Speaker 00 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.
32:17 Dr. Mary Claire Haver? All right, let's, 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's great, desire's 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.
32:46 Speaker 00 I stand by that.
32:47 Dr. Mary Claire Haver? Walk us through your practical ladder for vaginal and urinary health.
32:51 Speaker 00 I don't think it's that complicated.
32:53 Dr. Mary Claire Haver? Yeah, it's so easy.
32:54 Speaker 00 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 CERM, you mentioned it, ospimafine,
33:33 Speaker 00 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.
33:57 Dr. Mary Claire Haver? Or hard to get to.
33:58 Speaker 00 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.
34:26 Dr. Mary Claire Haver? Yeah.
34:26 Speaker 00 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.
34:40 Dr. Mary Claire Haver? I hike a lot in the summer.
34:41 Speaker 00 Yeah.
34:41 Dr. Mary Claire Haver? In Colorado, 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.
34:58 Speaker 00 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.
35:18 Dr. Mary Claire Haver? Mm-hmm.
35:18 Speaker 00 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 ospermophene to prevent loss. The timing is a little unusual. So for example, most women who have, they're, 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 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
36:03 Speaker 00 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.
36:17 Dr. Mary Claire Haver? So we have the vaginal estrogen products. We talked about the ospermophene and then the DHEA. Cover that real quick because it's a little bit special.
36:24 Speaker 00 Yeah, so DHEA, a French-Canadian Dr. Ferdinand LeBrie, 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
37:03 Speaker 00 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. And by the way, men have a lot of
37:21 Dr. Mary Claire Haver? They're analogous.
37:22 Speaker 00 They're analogous.
37:23 Dr. Mary Claire Haver? Men and women have the same parts.
37:25 Speaker 00 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
38:06 Speaker 00 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 DHEA inserts was determined 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.
38:49 Dr. 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.
39:04 Speaker 00 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. Okay, we're fighting gravity all
39:45 Speaker 00 the time. Breast sagging is another. Okay, it's gravity. Blame Mother 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 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.
40:28 Speaker 00 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. 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.
41:09 Speaker 00 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.
41:20 Dr. Mary Claire Haver? It's too tight.
41:21 Speaker 00 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, she'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
42:05 Speaker 00 that carries over from when we're age three to when we're age 53 and having problems with our sex lives.
42:13 Dr. 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.
42:26 Speaker 00 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, et cetera. 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, hypertonus muscles.
43:06 Speaker 00 Many women have pelvic floor hypotonic or loose muscles. They have 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 weight gain.
43:27 Dr. Mary Claire Haver? smoking.
43:28 Speaker 00 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. 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.
44:04 Dr. Mary Claire Haver? So when is it time for a sexual medicine specialist?
44:08 Speaker 00 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.
44:17 Dr. Mary Claire Haver? And then how would they find one?
44:20 Speaker 00 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.
45:04 Speaker 00 And the psychotherapist and psychiatrist is another group that can often help because it's the whole picture. 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
45:49 Speaker 00 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 in any or all of these disciplines.
46:05 Dr. 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.
46:19 Speaker 00 Yeah, so I do get really challenging patients and I'll just bring up one challenge and 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, etc. So now what was just pain for Mrs. Smith, which might have been simple, just needed some hormones for her vagina, has now become a problem for Mr. Smith
47:04 Speaker 00 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 a 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 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, send him to psychotherapy if he has psychological erectile
47:46 Speaker 00 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, hearken 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.
48:08 Dr. Mary Claire Haver? What is intercourse?
48:10 Speaker 00 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
48:47 Speaker 00 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. 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 intercourse, which could be anything from kissing, to genital kissing and pleasuring, to everything else in the sexual armamentarium.
49:32 Speaker 00 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. 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,
50:15 Speaker 00 just because they can't have what historically has been the end of their sexual activity intercourse.
50:21 Dr. Mary Claire Haver? And they're still happy.
50:22 Speaker 00 And they're still happy and they still wanna 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.
50:37 Dr. Mary Claire Haver? If you could redesign a midlife clinical visit, you know, what would high-quality sexual care look like?
50:45 Speaker 00 So, we gotta get rid of pain. We gotta get rid of symptoms. We gotta get rid of shame, both men and women. We gotta 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 of what he thinks she wants. Now, Mrs. Smith could tell him, "Honey, you're doing it too hard.
51:31 Speaker 00 That's blaming and that's not gonna 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 "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 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
52:15 Speaker 00 breakfast table when the kids aren't there, on the couch when you're watching TV.
52:20 Dr. Mary Claire Haver? I think that's radical, you know, and genius, but I, you know, asking a couple to have that conversation outside of the bedroom.
52:28 Speaker 00 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.
52:48 Dr. Mary Claire Haver? Yeah.
52:48 Speaker 00 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. Eye language and looking away.
53:09 Dr. Mary Claire Haver? And just creating a safe environment to have that conversation.
53:12 Speaker 00 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. Couple comes in and they face their chairs, looking at each other, I'm in trouble as a practitioner.
53:28 Dr. Mary Claire Haver? Mm-hmm.
53:28 Speaker 00 This is another barrier I got to cross.
53:31 Dr. Mary Claire Haver? Sticking.
53:32 Speaker 00 Exactly. I got a hole before I even get to flat ground.
53:35 Dr. Mary Claire Haver? Yeah.
53:35 Speaker 00 That's use of body language to help get to the place where everybody wants to be.
53:41 Dr. 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 their lives here.
53:48 Speaker 00 Great. Thank you very much for having me. I really appreciate it.
53:53 Dr. Mary Claire Haver? You can find Dr. Simon on Instagram at menopause.wisprer and through his website, www.inchemmedicine.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 thepauselife.com. My upcoming book, The New Perimenopause, is available for preorder on Amazon. If you're loving this podcast, I have an important request. Take a moment to follow UnPaused on your favorite podcast app. Following and listening is what pushes this information to more women who need it.
54:38 Dr. Mary Claire Haver? 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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