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

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.

In this conversation, Dr. Simon explains why long-term couples develop a "sexual script" that quietly kills desire, and what it actually takes to break out of it. He breaks down the shift from spontaneous to responsive desire in perimenopause and menopause — why so many women find themselves feeling indifferent to sex, why a diagnosis of hypoactive sexual desire disorder (HSDD) is more common than most realize, and why that is normal, not broken. The conversation covers testosterone therapy for women, including what it genuinely helps with, why accurate measurement matters, the difference between physiologic and supraphysiologic dosing, and the ongoing push for an FDA-approved testosterone product for women.

Dr. Simon also addresses erectile dysfunction in aging men, how it ripples through relationships when female partners blame themselves, and what women need to understand about male sexual aging. The episode covers genitourinary syndrome of menopause, vaginal estrogen, DHEA, sex hormone binding globulin, and why it is always easier to maintain vaginal health than to restore it. Dr. Simon explains the full spectrum of pelvic floor dysfunction and why pelvic floor physical therapy remains one of the most underutilized tools in women's sexual health. And he closes with his concept of "outercourse" — a framework for aging couples who can no longer rely on penetrative sex, and a practical approach to helping partners finally say what they need using "I language" outside the bedroom.

Guest links:

• James Simon (IntimMedicine Specialists)
  
• James Simon (Instagram)
  
• James Simon (YouTube)

Books:

• “Restore Yourself: A Woman's Guide to Reviving her Sexual Desire and Passion for Life,” by James Simon and Victoria Houston

Articles:

• What if the Women’s Health Initiative had used transdermal estradiol and oral progesterone instead? (Menopause)
  
• Erectile Dysfunction (StatPearls)
  
• Should we be prescribing testosterone to perimenopausal and menopausal women? A guide to prescribing testosterone for women in primary care (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 (The Journal of Clinical Endocrinology & Metabolism)

Other Resources:

• Women’s Health Initiative
  
• The North American Menopause Society Releases Its 2022 Hormone Therapy Position Statement (NAMS)
  
• International Society for the Study of Women's Sexual Health (ISWSH)
  
• FDA panel rejects testosterone patch for women on safety grounds (The BMJ)
  
• The Saga of Testosterone for Menopausal Women at the Food and Drug Administration (FDA) (The Journal of Sexual Medicine)
  
• Sexual Medicine Society of North America (SMSNA)