Podcast Summary:
unPAUSED with Dr. Mary Claire Haver
Episode: The Sex Life Nobody Warned You About: What a Top Sexual Medicine Expert Wants You To Know
Date: February 24, 2026
Guest: Dr. James Simon

Episode Overview

In this candid and deeply informative episode, Dr. Mary Claire Haver interviews Dr. James Simon, an internationally recognized expert in menopause and sexual medicine. Together, they dig into the realities of sexual health and aging, dispel harmful myths, and arm listeners with actionable advice on navigating midlife sexuality, desire, intimacy challenges, and therapeutic strategies for both women and their partners. The conversation focuses on evidence-based practices, practical resources for healthcare professionals and laypeople, and frank talk about the evolving nature of sex lives in long-term relationships.

Key Discussion Points and Insights

1. Origins and Training (04:10 – 06:44)

• Dr. Simon shares his background, inspired by his family of doctors and witnessing inadequate care for women.
  • Quote: "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." (04:49, Dr. Simon)
• Both Dr. Haver and Dr. Simon note the lack of training in sexual function and menopause in medical residencies, leading to a generation of doctors unprepared to help middle-aged women with sexual issues.

2. Understanding Sexual Aging (07:16 – 15:13)

• Dr. Simon emphasizes that sexual aging is highly individual but offers key generalities:
  • Frequency declines over time in relationships, but quality is nuanced—familiarity with a partner can improve satisfaction, but novelty can wane.
  • Couples develop a "sexual script" that may become repetitive and boring if never refreshed.
    • Quote: "...the longer they're together, they develop a script. He does this, she does that... It's boring. It becomes even more boring. It becomes eating at the same restaurant every single day. Gotta change it up." (09:32, Dr. Simon)
• To revitalize intimacy, Dr. Simon suggests couples plan "erotic surprises" and occasionally rewrite their scripts.
  • Exercise: Both partners independently write out their usual sexual sequence; Dr. Simon compares them and encourages small, novel changes (10:24-12:12).
  • Quote: "If you know the script, there's no surprise. There's no novelty. There's nothing exciting happening." (10:05, Dr. Simon)

3. Resources for Professionals and Laypeople (13:23 – 14:59)

• Recommends The International Society for the Study of Women's Sexual Health (ISSWSH) for professionals seeking real training, alongside biopsychosocial frameworks and trusted pelvic floor or psychological therapists.
  • Quote: "You'll learn. Even though it'll probably feel like drinking from a fire hose." (13:32, Dr. Simon)

4. Female Desire and Myths about Sexual Drive (15:13 – 17:19)

• Dr. Simon explains that with age, "spontaneous sexual desire" wanes, and women more frequently experience "sexual neutrality"—ambivalence, but responsiveness in the right context.
  • Quote: "They are less likely to have spontaneous sexual desire, the internal lust. But in the right circumstance, with the right amount of foreplay...they can be moved from that position of sexual neutrality..." (15:13, Dr. Simon)
• Reinforces this is completely normal, not a pathology.

5. Male Sexual Aging and Relationship Dynamics (17:19 – 20:48)

• Erectile dysfunction (ED) prevalence increases with age; women often internalize blame.
  • Quote: "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..." (17:50, Dr. Simon)
• Defines ED functionally and stresses it's important not to attempt painful intercourse with insufficient erections (20:20).
• Discusses treatment options—PDE5 inhibitors, testosterone therapy—and the need for realistic expectations and partner communication.

6. Testosterone Therapy for Women (23:12 – 34:48)

• Testosterone is most effective for hypoactive sexual desire disorder (HSDD) in women; also benefits arousal, lubrication, orgasm, and sexual self-image (24:49–26:24).
  • Quote: "It works in both [surgical and natural menopause] for sexual desire...It is also beneficial for downstream sexual issues..." (24:49, Dr. Simon)
• Cautions about internet myths: benefits to mood, energy, body composition, wellbeing are promising but less robust than for libido (26:39–29:13).
• Key laboratory guidance: only use accurate LCMS/GCMS testosterone assays for women (29:32–30:51). Stay in physiologic ranges (20–80 ng/dL).
• U.S. lacks FDA-approved testosterone for women, but products exist in UK, Australia, and elsewhere. Dr. Simon is optimistic about approval in the U.S. (31:40–33:28).
• SHBG (sex hormone binding globulin) can bind up testosterone, impacting efficacy; ultra-high SHBG may render therapy ineffective (33:28–34:48).

7. Maintaining Vaginal and Urinary Health (37:12 – 41:11)

• Genitourinary syndrome of menopause (GSM) can cause sexual pain that must be treated before addressing desire.
  • Quote: "It's easier to maintain vaginal health than to restore it." (37:41, Dr. Haver)
• Multiple effective options: local estrogen (tablets, rings, creams), DHEA, and the oral SERM ospemifene, which is especially helpful for those averse to topical therapies (37:45–39:33).
• Lubricants and moisturizers (like hyaluronic acid) may suffice for some until more significant tissue changes arise (39:52).

8. DHEA and Hormonal Conversion (41:18 – 43:43)

• Dr. Simon describes DHEA as a vaginal insert that the body converts to both estrogen and testosterone, uniquely supporting vaginal health—including tissues analogous to male anatomy.
• Importance of addressing testosterone-responsive tissue at the vulvar vestibule for comfortable sex.

9. Pelvic Floor Health and Physical Therapy (43:43 – 48:58)

• Overactive ("hypertonic") pelvic floors are more common now due to fitness trends, core-based workouts, and require retraining to relax for sex, urination, defecation (43:58).
• Underactive ("hypotonic") pelvic floors often result from childbirth, obesity, or deconditioning—these women may need strengthening.
• True pelvic floor physical therapists do internal work; essential partners in treating sexual pain.

10. When to Seek a Sexual Medicine Specialist (48:58 – 50:59)

• Advices triaging based on issue: medical/hormonally-driven, psychological, pelvic floor dysfunction.
• Societies with provider listings: ISSWSH (women), Sexual Medicine Society of North America (men, urologists), and the Menopause Society.

11. Success Story – The Snowball Effect (51:13 – 53:02)

• Discusses a composite case: untreated sexual pain in a woman leads to ED and relationship issues in her partner, which spirals into couple dysfunction. Comprehensive, multi-pronged treatment involving hormones, physical therapy, and sometimes psychotherapy can restore intimacy.
  • Quote: "Get him to understand she wasn't rejecting him, she was having pain. Nobody wants to have sex if they're having pain." (51:49, Dr. Simon)

12. Embracing "Outercourse" in Aging Relationships (53:02 – 55:31)

• Champions the concept of "outercourse"—sexual pleasure and connection without penetrative intercourse, especially for couples with physical limitations.
  • Quote: "Let’s get back to sexual play, sexual touching, other forms of intimacy..." (54:01, Dr. Simon)

13. Clinical Best Practices for High-Quality Sexual Care (55:39 – 58:06)

• Eliminate pain, shame, and rigid expectations; cultivate honest, "I language" communication between partners—ideally outside the bedroom, in non-confrontational settings.
  • Quote: "The use of what we call I language in psychology always gets you to a better place...use of I language in couples discussing sex is really important..." (56:21, Dr. Simon)
• Use of indirect, side-by-side posture (not direct face-to-face) makes difficult conversations safer (57:22).

Notable Quotes & Memorable Moments

• On the monotony of sexual scripts and need for novelty:

  • "It's boring. It becomes even more boring. It becomes eating at the same restaurant every single day." (09:32, Dr. Simon)

• On normalizing ‘sexual neutrality’ in women:

  • "You’re not broken, you’re not weird, you’re not unusual. This is what typically happens in long term relationships." (16:21, Dr. Simon)

• On the prevalence of erectile dysfunction:

  • "50% of 50 year old men have some degree of erectile dysfunction...It's not their fault." (17:49, Dr. Simon)

• On testosterone’s effects:

  • "It is also beneficial for downstream sexual issues...arousal, orgasm, and sexual self-image...that the woman herself...said that she felt better about her sexual self." (24:49–26:11, Dr. Simon)

• On ‘outercourse’ for aging couples:

  • "Let’s get back to sexual play, sexual touching, other forms of intimacy..." (54:01, Dr. Simon)

Timestamps for Important Segments

• 04:10 – Dr. Simon’s background and motivation for women’s health
• 07:31 – How sexual aging manifests differently in women and men
• 09:32 – “Sexual scripts,” novelty, and relationship advice
• 13:23 – Resources for clinicians and the biopsychosocial approach
• 15:13 – Female sexual desire and age-related changes
• 17:19 – Male sexual aging, erectile dysfunction, psychological effects
• 23:12 – Testosterone therapy for women, myths, and evidence
• 29:32 – Proper testosterone measurement and lab pitfalls
• 31:40 – FDA approval challenges and international contrasts
• 37:12 – Genitourinary syndrome (GSM), vaginal maintenance
• 41:18 – DHEA, estrogen, testosterone, and vaginal health
• 43:58 – Pelvic floor physical therapy, hyper- vs. hypotonic issues
• 48:58 – Finding the right sexual medicine specialist
• 51:13 – Success stories and the ‘snowball effect’ in couples
• 53:02 – Redefining intimacy: ‘outercourse’ in lifelong partnerships
• 55:39 – Redesigning the clinical visit: communication and care

Final Impressions

Dr. Haver and Dr. Simon deliver a refreshingly frank and actionable discussion—dispelling myths, embracing normal changes, and empowering women (and their partners) to approach midlife sex with curiosity, compassion, and science-backed solutions. The episode is a must-listen (or read) for anyone seeking to reclaim or improve their sexual health and well-being in the second half of life.