← unPAUSED with Dr. Mary Claire Haver
unPAUSED with Dr. Mary Claire Haver
The Sex Life Nobody Warned You About: What a Top Sexual Medicine Expert Wants You To Know
00:58:08
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- [00:00]
Dr. 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. 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. 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.
- [00:52]
Dr. Mary Claire Havertz
The views and opinions expressed on Unpause are those of the talent and the guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis or treatment.
- [01:12]
Podcast Host / Narrator
Women in midlife face questions that don't come with easy answers. Conflicting research on hormone therapy, financial decisions relationship shifts Questions about your own health that require real thought, not just a quick search. Claude is an AI built for that kind of thinking. When you're trying to understand why experts disagree or work through something personal and complicated, Claude doesn't give you a quick answer and move on. It sits in the complexity with you, asks follow up questions, helps you think through the trade offs and anthropic. The company behind Claude has committed to keeping Claude AD free. Claude's responses will not be shaped by advertisers or third parties. When you're making decisions about your life, that integrity matters. Try Claude for free at Claude AI Unpaused to see why problem solvers choose Claude as their thinking partner. This podcast is supported by FX's Love Story, John F. Kennedy Jr. And Carolyn Bessette the new limited series from executive producer Ryan Murphy. It explores the complex courtship of the iconic couple considered to be American royalty, whose love story captured the attention of the nation. Their fairytale romance would unfold in front of the public eye, where their private love would also become a national obsession. FX's love story John F. Kennedy Jr. And Carolyn Bessette watch now on FX, Hulu and Hulu on Disney for bundle subscribers.
- [02:59]
Dr. Mary Claire Havertz
Today on Unpaused. I am lucky enough to have as
- [03:02]
Podcast Host / Narrator
my guest one of the most experienced
- [03:04]
Dr. Mary Claire Havertz
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 evolve with age, this is the conversation you've been waiting for. Dr. Simon is a professor of obstetrics and gynecology at George Washington University. He's a board certified OB gyn, a reproductive endocrinologist, and a certified sexual counselor. He is also a past president of the International Society for the Study of Women's Sexual Health and one of the
- [03:45]
Podcast Host / Narrator
most published clinicians in modern menopause care. I'm Dr. Mary Claire Havertz, a board
- [03:50]
Dr. Mary Claire Havertz
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
- [04:04]
Podcast Host / Narrator
what it really takes for a woman to thrive in the second half of life.
- [04:10]
Dr. Mary Claire Havertz
Welcome to Unpaused.
- [04:12]
Dr. James Simon
Thank you for having me.
- [04:13]
Dr. Mary Claire Havertz
You've been doing this work for decades. You've written numerous papers. I've lost count.
- [04:17]
Dr. James Simon
800.
- [04:18]
Dr. Mary Claire Havertz
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?
- [04:29]
Dr. James Simon
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.
- [04:47]
Dr. Mary Claire Havertz
And then where'd you do your training? Why OB gyn?
- [04:50]
Dr. James Simon
I saw a lot of misbehavior during my time both with my uncles and making rounds with them in the hospital in the way that I thought women were being treated. A lot of strong women in my family and didn't like the way they were being treated in the hospital and I was going to save them from the medical profession.
- [05:11]
Dr. Mary Claire Havertz
And then you went on and did a fellowship in reproductive endocrinology?
- [05:14]
Dr. James Simon
I did.
- [05:15]
Dr. Mary Claire Havertz
So most people who do this fellowship now end up going strictly into infertility. You've deviated from that a bit and
- [05:22]
Dr. James Simon
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.
- [05:38]
Dr. Mary Claire Havertz
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?
- [06:17]
Dr. James Simon
I felt just as you had suggested here. I finished medical school. I didn't know anything about sex, about women's sexuality. And I was going to go into obstetrics and gynecology. And looking at the programs, even the best ones, they didn't even mention it. So I figured I better get juiced up on that before I went because I was gonna come out as you did, with little or no training. And that's when it all started for me.
- [06:44]
Dr. Mary Claire Havertz
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 wanna 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 received zero training. So they kind of wing it. And it doesn't go well for most. Talk to me about sexual aging, desire, pain, all, all the things. And you treat couples?
- [07:17]
Dr. James Simon
I do.
- [07:17]
Dr. Mary Claire Havertz
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?
- [07:31]
Dr. James Simon
So I don't think anyone listening to us would disagree with the fact that men and women are different. I want to celebrate that difference. I don't want to denigrate it or I just think it's different and it's important that it's different. Intimacy is highly Individual. So whatever I'm going to say to you is not going to ring true to everybody. But there are some generalities that I think can be important baselines for our audience. First is the longer a man or a woman or both are in a relationship, the less important, based on the frequency of events sex becomes. That could be because of physical changes. That could be because of emotional changes. That could be situational changes.
- [08:23]
Dr. Mary Claire Havertz
And you're talking quantities, number of experiences, events. But is the quality dropping as well?
- [08:29]
Dr. James Simon
I don't know. I suspect depends how you define quality. For example, time to orgasm, as you probably discussed, is shorter if your partner knows his way around your body. Or you are more comfortable in the presence of that person relaxing and helping or participating. So it really depends how we define quality. But quality also involves novelty. And this is where I think aging couples need a self help course. I'll give you my favorite example. 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. And so what happens to couples is they develop a sexual script in general. In general, the longer they're together, they develop a script. He does this, she does that, he does this, she does that, he does this, she does that. He has 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.
- [10:23]
Dr. Mary Claire Havertz
How do you counsel your patients about that?
- [10:25]
Dr. James Simon
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 going to call an erotic surprise. You have the script? I actually have them write it out, by the way. Okay. Separately, two different pieces of paper. Write out what happens step by step in the bedroom. Write out what happens step by step in the bedroom. And I compare Notes, it's the same. Nine times out of 10, it's exactly the same. They know the script. Well, if you know the script, there's no surprise. There's no novelty. There's nothing exciting happening. You know what's happening next. So here's the two scripts. I give them back the scripts. I show them each other's. You got it right, guys. You know what happens then? You gotta 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, right? Okay. Just a twist in the plot. Don't tell him. Don't make it too weird. Don't tell her. Don't make it too weird. Just a twist in the plot. Some little twist. 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 him or give it to her now. You gotta do it.
- [12:13]
Dr. Mary Claire Havertz
How does that go? I've never done this with a patient. I've seen the women.
- [12:16]
Dr. James Simon
It's totally different for different couples. You can tell them to plan an erotic surprise, see them back a month or two later, and they didn't do anything. Well, how can I help you if you're not going to even try some of these things? Sometimes, and this is a different approach, I'll say to them, look, when you first got together, you didn't just take off all your clothes and get in bed and have sex. Sometimes they did. I get messed up. But most of the time that's not the way it happens. What happens? There's kissing first, then there's touching, then there's something else. I don't know. Tell me what happened. Now I want you to try and get back there, because there was excitement, there was novelty. Neither of you knew what was going to happen next. That's anticipation. Then try and get some of that into their bedroom. Try and listen as a practitioner very carefully to what they said and how they said it, and try and transplant that back into their script because they've lost it.
- [13:23]
Dr. Mary Claire Havertz
So if we have clinicians that are listening, I mean, you have extra training, as in sexuality. I did not. What resources would you recommend to them or to lay people?
- [13:33]
Dr. James Simon
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. 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.
- [15:00]
Dr. Mary Claire Havertz
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.
- [15:13]
Dr. 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, it's 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. 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 and that's what's normal. So you're not normal means common. 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.
- [17:19]
Dr. Mary Claire Havertz
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?
- [17:35]
Dr. James Simon
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.
- [17:50]
Dr. Mary Claire Havertz
We're socialized to do that.
- [17:51]
Dr. 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% 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 brushstroke. It's not exactly 50, 60, 78.
- [18:18]
Dr. Mary Claire Havertz
Close enough for our audience, our listeners, what is erectile dysfunction?
- [18:21]
Dr. 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. 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. 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.
- [20:48]
Podcast Host / Narrator
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Dr. Mary Claire Havertz
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- [23:13]
Dr. Mary Claire Havertz
So you've done a ton of prescribing of testosterone.
- [23:16]
Dr. James Simon
Yep.
- [23:16]
Dr. Mary Claire Havertz
And you've done research in the area as well.
- [23:19]
Podcast Host / Narrator
Talk to me.
- [23:20]
Dr. Mary Claire Havertz
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 it. And what really testosterone is helpful for 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, 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.
- [23:54]
Dr. 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. It doesn't mean that she can't have sex. It just means she can't have painful aspects of sex. And by and large, there are lots of things that she and her partner can do that don't include having pain. Yeah, 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.
- [24:43]
Dr. Mary Claire Havertz
Yeah. How do you counsel your patients for testosterone? What do you say it helps with and won't help with.
- [24:48]
Dr. James Simon
We're talking about women.
- [24:49]
Podcast Host / Narrator
Women.
- [24:49]
Dr. Mary Claire Havertz
Sorry.
- [24:50]
Dr. James Simon
No problem. So the best and most abundant scientifically proven information is about sexual desire. It's documented best in women who had their ovaries removed. It's documented, but less well in Women who have a normal natural menopause with their ovaries. But it works in both for sexual desire, I want to have sex, or remember our neutrality story? It helps tip them in the direction of yes, let's go. Okay. It is also beneficial for downstream sexual issues. How much of that is related to the testosterone itself and how much is related to their brain desiring. Having sex is less clear. So for example, 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.
- [26:12]
Dr. Mary Claire Havertz
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.
- [26:24]
Dr. James Simon
Again, 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.
- [26:39]
Dr. Mary Claire Havertz
There's a lot of stuff floating on the Internet about the other other potential benefits of testosterone. One, mood. You know, what do you feel in mood in general? What is the data set?
- [26:51]
Dr. 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. Cause 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.
- [27:35]
Podcast Host / Narrator
That's me.
- [27:36]
Dr. 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, 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 30. At 40. But menstruating women as opposed to menopausal women. Mood, energy, well being, body composition, fat versus lean, bone density. There's some data for all of them. Not rising to the level of what we were talking about with sexual desire, but there's data, it's more robust data. If they're getting male levels of testosterone or 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.
- [29:14]
Dr. Mary Claire Havertz
Those of you listening, yeah, he's pointing to his hair and his beard, his
- [29:19]
Dr. James Simon
lack of hair on his head and his beard.
- [29:21]
Dr. Mary Claire Havertz
What have you learned from the long term data? I remember early in the days when I was considering prescribing to testosterone, there was worries about cardiovascular disease and I think that's been taken off the modern formulations of testosterone.
- [29:33]
Dr. James Simon
So if testosterone levels are within that normal reproductive female range, and what would that range be? So it really depends on the laboratory because it's quite difficult to measure testosterone. And this is a little bit of a side light, but I think it's worth talking about it for your audience. The quick and dirty testosterone tests that are easy to order were designed for measuring testosterone in men. They are not good enough to measure testosterone in women. But all the national laboratories, the laboratories that you would send your bloods to that are worth their weight, they have a test that can be done for women and provide an accurate total testosterone value for women. For those women on the podcast or their practitioners, these are testosterone measurements that are called lcms or gcms. You don't need to know what they stand for, it just needs to be measured by that technology. And the big national laboratories like LabCorp and Quest Laboratories, laboratories have those assays and you can get a good number for women.
- [30:51]
Dr. Mary Claire Havertz
That's what we use in our clinic
- [30:52]
Dr. 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, et cetera, at significant cost.
- [31:24]
Dr. Mary Claire Havertz
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.
- [31:40]
Dr. 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 gonna get that FDA approved before I kick it. And I think it's actually gonna 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 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 their reproductive lives on birth control pills which raise sex hormone binding globulin.
- [33:29]
Dr. Mary Claire Havertz
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?
- [33:51]
Dr. 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.
- [34:12]
Dr. Mary Claire Havertz
It's really high.
- [34:13]
Dr. James Simon
Where did you come up with that? 170 Dr. Simon, I'm going to tell you 10,000 patients. No, actually, if you go back into the testosterone patch development studies, we had hormones on all of them and there were no positive, sexually positive responses in any woman. Any woman on those testosterone patches that had an SHBG 170 or higher. Zero out of, I don't know, six, 7,000.
- [34:48]
Podcast Host / Narrator
Wow.
- [34:49]
Dr. James Simon
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.
- [35:05]
Podcast Host / Narrator
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- [37:11]
Podcast Host / Narrator
All right, let's.
- [37:12]
Dr. Mary Claire Havertz
Let's go to vaginal maintenance and sexual pain we touched on it a little bit earlier. So GSM for our listeners, if 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 gonna 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.
- [37:41]
Dr. James Simon
I stand by that.
- [37:42]
Dr. Mary Claire Havertz
Walk us through your practical ladder for vaginal and urinary health.
- [37:45]
Dr. James Simon
I don't think it's that complicated.
- [37:47]
Dr. Mary Claire Havertz
Yeah, it's so easy.
- [37:48]
Dr. James Simon
We have a number of really good long standing 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 serm. You mentioned it. Ospemafene, 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, hard to get to. 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 treatment. 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.
- [39:34]
Dr. Mary Claire Havertz
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, to decrease the chafing.
- [39:52]
Dr. 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. Cause they're still afraid of the boxed warning. I can agree with that. Until they have urinary tract infections or until it's not good enough. And I'm a big believer, as you mentioned, in preventing loss of anatomy, preventing loss of healthy tissue. So I would start most of those women who need it on estrogen or DHEA or omafene to prevent loss. The timing is a little unusual. So, for example, most women who have. They're gonna 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 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.
- [41:12]
Dr. Mary Claire Havertz
So we have the vaginal estrogen products. We talked about the ospinophene and then the dhea. Cover that real quick because it's a little bit special.
- [41:18]
Dr. James Simon
Yeah. So dhea, French Canadian doctor Ferdinand Lebree, 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. And by the way, men have.
- [42:16]
Podcast Host / Narrator
Well, they're analogous.
- [42:17]
Dr. James Simon
They're analogous.
- [42:18]
Dr. Mary Claire Havertz
Men and women have the same parts.
- [42:21]
Dr. James Simon
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 Ms. 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 Ms. 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. 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 were 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.
- [43:43]
Dr. Mary Claire Havertz
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.
- [43:58]
Dr. 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. Okay? We're fighting gravity all the time. Breasts 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 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 gotta 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, spiking. 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. 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. 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 that carries over from when we're age 3 to when we're age 53 and having problems with our sex lives.
- [47:08]
Dr. Mary Claire Havertz
I feel like they're just the pelvic floor. Physical therapists who are highly specialized are just the unsung heroes of women's sexual health. And the more we can talk about them and drive more patients there, I think the better off when we're.
- [47:21]
Dr. 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, 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. Many women have pelvic floor hypotonic or loose muscles. They have a different set of sexual problems. But the answer is there's plenty of them. They tend to be women who are not your Physically fit women, they can be totally normal. Otherwise they may have had big babies or have had a lot of weight
- [48:21]
Dr. Mary Claire Havertz
gain, chronic obesity, smoking.
- [48:22]
Dr. James Simon
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.
- [48:59]
Dr. Mary Claire Havertz
So when is it time for a sexual medicine specialist?
- [49:02]
Dr. 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 and then
- [49:13]
Dr. Mary Claire Havertz
how would they find one?
- [49:14]
Dr. James Simon
So a couple 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. 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. Because as you mentioned, we have very few people that are properly trained in any or all of these disciplines.
- [51:00]
Dr. Mary Claire Havertz
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.
- [51:14]
Dr. 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 have been simple, just needed some hormones for her vagina, has now become a problem for Mr. 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 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 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.
- [53:03]
Dr. Mary Claire Havertz
What is? Outer course.
- [53:04]
Dr. 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. 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 outercourse, 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. 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.
- [55:16]
Dr. Mary Claire Havertz
And they're still happy, and they're still
- [55:17]
Dr. James Simon
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.
- [55:32]
Dr. Mary Claire Havertz
If you could redesign a midlife clinical visit, you know, what would high quality sexual care look like?
- [55:40]
Dr. James Simon
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 at what he thinks she wants. Now, Mrs. Smith could tell him, honey, you're doing it too hard. That's blaming, and that's not going to be very helpful in her getting what she wants. Or she could say, honey, I really like it softer. The use of what we call 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 I 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.
- [57:14]
Dr. Mary Claire Havertz
I think that's radical, you know, and genius. But, you know, asking a couple to have that conversation outside of the bedroom.
- [57:22]
Dr. 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 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
- [58:03]
Dr. Mary Claire Havertz
and just creating a safe environment to have that conversation.
- [58:06]
Dr. James Simon
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, this is another barrier I got across.
- [58:25]
Podcast Host / Narrator
Digging.
- [58:26]
Dr. James Simon
Exactly. I got a hole before I even get to flat ground. That's use of body language to help get to the place where everybody wants to be.
- [58:36]
Dr. Mary Claire Havertz
Well, thank you for coming on Unpaused. Our listeners going to love this so much and I think you're going to change some lives here.
- [58:42]
Dr. James Simon
Great. Thank you very much for having me. I really appreciate it.
- [58:47]
Podcast Host / Narrator
You can find Dr. Simon on Instagram
- [58:49]
Dr. Mary Claire Havertz
at Menopause Whisperer and through his website, www.intem medicine.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, Dr. Maryclair and get honest, accurate information on health, fitness and navigating midlife@thepauselife.com My upcoming book, the New Perimenopause, is available for pre order on Amazon.
- [59:20]
Podcast Host / Narrator
If you're loving this podcast, I have an important request.
- [59:23]
Dr. Mary Claire Havertz
Take a moment to follow Unpaused on your favorite podcast app.
- [59:27]
Podcast Host / Narrator
Following and listening is what pushes this information to more women who who need it. So if this podcast has helped you feel seen, understood, or supported, hit follow
- [59:38]
Dr. Mary Claire Havertz
right now so you never miss an episode.
- [59:40]
Podcast Host / Narrator
Thank you for being here with me. Let's keep going.
- [59:43]
Dr. Mary Claire Havertz
Unpaused. Unpaused is presented by Odyssey in conjunction with pot people.
- [59:49]
Podcast Host / Narrator
I'm your host, Dr. Mary Claire Haver.
- [59:52]
Dr. Mary Claire Havertz
The views and opinions expressed on Unpause are those of the talent and the guests alone, and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis or treatment.
- [60:10]
Progressive Advertiser
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