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

Dr. Simon strongly emphasizes a sequence: treat pain first, then address desire. He makes the analogy that a woman who avoids sex due to pain is like someone who avoids touching a hot stove—she is in touch with her body and needs the pain removed, not her desire pathologized. In his clinic, patients are screened before they come through the door for pain, desire level, and other factors. He often starts with local vaginal estrogen, DHEA, or ospemifene to restore tissue health. Only after the vagina is 'fixed' does he consider systemic testosterone for desire. He also notes that many pleasurable sexual activities do not involve painful penetration, and couples should remember those.

Dr. Simon has extensive experience in testosterone research, including the development of two failed FDA products. He explains that the best evidence is for sexual desire, particularly in oophorectomized women, with secondary benefits on arousal, orgasm ease and intensity, and sexual self-image. He describes the SHBG 170 cutoff as a key learning from the patch trials. He walks through the jigsaw puzzle analogy for emerging data on mood, energy, body composition, and bone density—tantalizing pieces but not yet a complete picture at physiologic doses. He notes that some women seeking these off-target benefits are pushed to supraphysiologic (male-range) levels, which increases risk of irreversible virilization. He remains hopeful that an FDA-approved product will come soon, citing recent approvals in Australia, NZ, South Africa, and the UK.

Dr. Simon notes that hot flashes typically peak in the first 0–5 years after menopause, but vaginal symptoms tend to appear about 5 years later, around age 60. He stresses that maintaining tissue with early treatment is key, because once atrophy sets in, restoring it is harder. He lists options: vaginal tablets, inserts, rings, creams, the oral SERM ospemifene, and DHEA inserts. He highlights that ospemifene is particularly useful for women who dislike touching their genitals or find topicals messy; its once-daily pill has good adherence and is on the lower end of cost. He also mentions that ospemifene is approved for dryness unrelated to sex (general vaginal dryness), which not all local products are. OTC hyaluronic acid and moisturizers are acceptable for mild symptoms, but when UTIs or significant pain begin, he moves to prescription hormones.

Dr. Simon describes how modern fitness (Pilates, crunches) can pull the pelvic floor up into a chronically tight state. He uses the paper bag analogy: the abdominal wall and pelvic floor are connected; tightening the front pulls the bottom. He describes examining women who have just voided and finding their bladder still full because they cannot relax. He strongly advocates for pelvic floor physical therapists who do internal work, inserting fingers to release trigger points and teach patients to voluntarily relax during attempted penetration or voiding. For the opposite problem—hypotonic floor from large babies or weight loss—PT strengthens muscles without overdoing it. He calls these PTs the 'unsung heroes of women's sexual health.'

Dr. Simon illustrates the damage of blaming language: if a woman says 'You hurt me every time you put your penis inside,' it is damning and aggressive. Instead, she should say 'Honey, I really like it softer.' He recommends having these conversations outside the bedroom, in a neutral environment, while doing something that avoids direct eye contact—like walking together, sitting on the couch watching TV. In his office, he arranges chairs so the couple looks at him, not at each other, to de-escalate. He notes that when a couple voluntarily sits facing each other, it signals conflict and he has to work to diffuse before he starts. This body language and communication technique is part of his biopsychosocial approach.

Dr. Simon emphasizes that erectile dysfunction is extremely common and age-related, and that many couples stop sex because of it. He warns women that intercourse with a non-rigid penis can actually cause penile fracture or Peyronie's disease, so forcing the issue is harmful to both. He says men often act as if they're still 20, but they're not, and urges them to accept treatment. He notes that sometimes, the man's ED only begins after he fears hurting his partner, and that creates a cycle: her pain → his anxiety → his ED → less intimacy → more resentment. Breaking that requires treating both partners.

Dr. Simon educates that the quick, easy testosterone test designed for men is inaccurate in women. He directs practitioners to order testosterone by LCMS or GCMS, available at major national labs. He explains that he orders total testosterone and SHBG, and that gives him enough information without needing the more expensive free testosterone. He references the SHBG 170 cutoff discovered in the testosterone patch trials. This is the protocol he follows before initiating therapy.

Dr. Simon explained that many menopausal women have elevated SHBG, either naturally or from decades of birth control pill use, which binds testosterone and makes it inactive. In the development trials for the testosterone patch, researchers had hormone levels on all participants. When they stratified by SHBG, they found that women with an SHBG of 170 or higher had no positive sexual responses—zero out of roughly 6,000–7,000 women. This finding is so powerful that he uses a total testosterone plus SHBG to make clinical decisions. He notes that SHBG can be lowered fairly easily, suggesting that sometimes lowering the SHBG is all that's needed before adding testosterone.

Dr. Simon describes how, in long-term relationships, couples unconsciously develop a sexual script: he does A, she does B, then they proceed through a predictable sequence ending in intercourse. The script becomes boring, like eating at the same restaurant every single day. In his practice, he has each partner write down the step-by-step script on separate pieces of paper. He then compares them, and nine out of ten times they are identical—both know exactly what happens. He gives them back the scripts to show them how predictable it is. Then he tasks them: if they have sex weekly, each takes turns planning an 'erotic surprise'—just a small twist in the plot, not something too strange or threatening. If that fails, he tells them to rewrite the whole script and give it to the other person to enact. He also urges them to recall the early days of dating when kissing, touching, and foreplay happened without the immediate goal of intercourse, to bring that anticipation back.

Dr. Simon explains that in every long-term couple, a time may come when penetrative intercourse becomes more trouble than it's worth. For example, a woman with severe hip arthritis may not be able to spread her legs, or a man with diabetes and vascular disease may not achieve a rigid enough erection for penetration. Often both partners then assume sex is over. Dr. Simon defines outercourse as everything from kissing to genital kissing, manual pleasuring, oral sex, and other forms of mutual pleasure leading to orgasm—everything short of PIV. He notes that both partners can reach orgasm without intercourse, even the man without a full erection. The key is to help couples remember that earlier in their relationship, they engaged in all these activities before intercourse became the routine conclusion, and they can still be satisfying and intimate.

Dr. Simon explains that human pelvic floors are a sling of muscles at the bottom of the bony pelvis, fighting gravity because we walk upright. Modern fitness culture emphasizes a tight core: Pilates, crunches, heavy lifting. He uses the analogy of a paper bag where the abdominal wall and pelvic floor are connected sides and bottom; tightening the front (abs) pulls up on the floor, increasing pelvic floor tightness. While some tightness is good, hypertonus prevents the muscles from relaxing—necessary for comfortable penetration, urination, and defecation. In his gynecologic exams, he routinely finds women who have just emptied their bladder but still have significant urine in it because their overactive pelvic floor blocks complete voiding. These women benefit from pelvic floor physical therapy with a specialist who does internal work, teaching them to maintain abdominal strength while deliberately relaxing the pelvic floor.

Dr. Simon recalls working with Dr. Fernand Labrie on the development of vaginal DHEA. He explains that DHEA, a pre-hormone from the adrenal gland, is converted within the vaginal tissue to both estrogen and testosterone. The estrogen addresses dryness, elasticity, and tissue fragility, while the testosterone acts on androgen-responsive elements of the vulva and particularly the vestibule (vaginal opening). He notes that embryologically, both sexes start with female-appearing anatomy; the tissues that would become the penis in males remain as the clitoris and vestibule in females. The DHEA inserts were intentionally sized to allow a small amount of leakage onto the vestibule, providing both physical emollient properties and local testosterone to tissues that are evolutionarily homologous to male structures and still responsive to androgens. This dual action makes DHEA uniquely suited for some women whose symptoms are not fully relieved by estrogen alone.