Welcome to Menopause Reimagined. I’m your host, Andrea Osky. I’m a nutritionist for more than 18 years, and I’m in menopause. I’m a menopause educator, menopause researcher, and the co-founder of weam morphous.com, a company that helps to empower you to take control of your health and symptoms with nutrition, lifestyle, supplements, and research. Today I’m speaking with Dr. James Simon. He’s a board certified obstetrician gynecologist and reproductive endocrinologist. His private practice in Washington DC in medicine specialist focuses on reproductive endocrinology, menopause, sexual function, and intimacy. Dr. Simon is an asset certified sexuality counselor. Beyond his clinical work, Dr. Simon participated in more than 400 clinical research trials, grants, and scholarships from a wide range of sponsors, including the NIH, the American Heart Association, the Heinz Foundation, and the pharmaceutical industry. He’s the only physician to serve as president of both the North American Menopause Society and the International Society for the Study of Women’s sexual Health, he’s the author or co-author of more than 600 articles, abstracts, chapters and proceedings, including several prize-winning papers, as well as the paperback book, restore Yourself a Woman’s Guide to Reviving Her Sexual Desire and Passion for Life. Now, here’s Dr. Simon. Welcome to Menopause Reimagined, Dr. Simon.

Thanks for having me. It’s a pleasure.

Well, I’m very excited to have you because I met you at a conference not too long ago and you are literally the highlight of the conference. You’ve made me laugh so much. We had a really good time. So I’m excited that you’re coming on the show because I found you not only entertaining, but obviously super, super informative and you’ve been in this industry for a very long time, and I thought what you would have to contribute to our podcast and to share with us would be so important. So being somebody who is an expert in sexual health, I thought we would start there and if you could share with us what happens. Libido is a very big issue. It’s in the top 10 most common symptoms of perimenopause and menopause that our libido decreases. Can you explain what happens to many of us as we go into this phase of life and what happens to our libido?

I like to think of this from the biological, the psychological and the social aspect because all of them are important to a woman’s sexual wellbeing and happiness. So from the biological point of view, first, when a woman is in the perimenopause and menopause, she may have a reduction in her two most sex related hormones, those being estrogen and testosterone, and we can talk further about that. She may have disturbed sleep because of hot flashes or night sweats or kids that are giving her problems and staying up late in her house or aging relatives and parents. These are psychosocial problems, but if they disturb sleep, no one’s really interested in sex if they’re exhausted. So it’s an important co-factor. Then other issues have to do with changes in her lifestyle, her body shape, her sense of herself as a sexual being, both in relationship to her colleagues and friends and her community, but also in relationship to her chosen sexual partner and all of those change at menopause and not necessarily for the better vis-a-vis her sexual self or sense of sexual self. So let’s dig in a little deeper wherever you want, but that’s how I think about the big picture. It’s a very challenging time for women in western society and in first world countries because there’s a lot happening. There’s things happening to her and her body and her being things happening to her children and things happening typically to her aging parents and other relatives. So just really challenging,

So multifactorial, which definitely makes sense. So yeah, let’s talk

About, and sex is not required for life. It might be required for one’s wellbeing and healthy life and certainly relationships, but I don’t know of anybody who died from not having sex. So it’s one of the things that can go or be sidelined or put on the back burner and still surviving. And that’s another problem is if circumstances are such or wellbeing is such sleep is such that it goes to the back burner. Then we got a whole problem of how do you bring it back to the front burner and communicate with your partner who’s understood that there were challenges, but now it’s time for re-engagement.

I’ve had women who’ve said in our community that their vaginas are dead, their sex drive is dead like it is gone. So to your point of how do we bring it back? So let’s dive deeper. Let’s talk about the hormones. You were talking about estrogen and testosterone. Let’s start there.

Sure. So as women go through menopause, their periods stop. And for most women that’s a good thing. Life is challenging, life is busy. Many women have days or even a week out of every month when they have their period when they’re not sleeping, they’re having cramps, they’re having bleeding, they don’t feel like themselves, a whole bunch of things, and many of those burdens go away, which should be a relief after menopause. But when the hormones go away and it is those hormones that are driving one’s menstrual cycle, the drive in many women for interest in sex also goes away. So for some of your listeners and viewers and your community who may have really good sense of their own bodies and are still menstruating, they know there are certain days of their menstrual cycles when their sexual interest is at its peak or at its highest, and mother nature has provided that those days are typically right around ovulation and those are hormonal triggers. Estrogen is highest right before ovulation. Testosterone is also highest right before ovulation, and those trigger what mother nature is thinking is reproduction and making babies and women may notice that as a desire to have sex, those hormones, estradiol and testosterone go away almost entirely as it relates to estradiol after menopause and are typically 50% or less of what they were during reproductive life after menopause. So testosterone goes 50% or 60% lower, not completely away until about age 60, but estrogen nearly completely gone after menopause.

I interviewed a thyroid expert, her name is Danielle, and she was saying that it also, thyroid has a lot to do with it. So like the changing hormones and thyroid and when we have a low thyroid or a hypothyroid, that can also influence our libido. So there’s so many things going on in our body due to our hormones that are contributing to this

As it relates to thyroid. It’s true, but low thyroid happens to a small-ish group of women after menopause or during their lifetimes. A hundred of women who get to menopause live long enough, they lose those hormones,

Lose those hormones. And I want to go into what are the things that we can do, and I know you’re a fan of hormone therapy because that’s something you and I had talked about when we were at the conference. So is hormone therapy, I mean, there’s many different ways. I’m guessing that we can help talk a little bit about how hormone therapy helps with libido.

So let’s start at the bottom and work up, which may be the opposite of what most people would do, but as a gynecologist and reproductive endocrinologists, I see a lot of women after menopause who have dryness or pain with any kind of sexual activity. And I just like to say, when was the last time you put your hand on a hot stove on purpose? And the answer is never. I would never do that. I got my hand burned when I was three or four years old by accident. I learned my lesson for the rest of my life. Well, for a woman that’s having pain or who loses the ability to have pleasure with sex, her interest, her likelihood of wanting to go there is much lower, very painful, especially if it’s pain and even if it’s just loss of pleasure or orgasm used to be work or at least used to come, sometimes come COME come sometimes, but now it’s never or almost never. And so those women lose the pleasurable reward they used to get, which is sometimes disincentive to engage in sexual activity. So that’s bottom up. And we have really good simple, even over the counter treatments for dryness and pain. We will go into them if you want a little later, but yeah, let’s do

It. Yeah,

I’d like to moisturizers. Most women who are menopausal, they put moisturizer on their face, on their skin all over. This is the number one group of women that use moisturizer day, night, summer, spring, winter, fall. But the answer is the vagina sometimes would benefit from some moisturizer also, and particularly if pain’s not an issue and it’s just dryness, make it moist. It’s not that complicated. In addition to moisturizers, which are a kind of vaginal application that just draws moisture into the vagina and keeps it there, just like moisturizer you put on your face draws moisture into your skin and keeps it there. That’s different from a lubricant which they may need in addition to a izer for sex, sometimes the tissues aren’t as stretchable, sometimes they’re not as moist. Even with a moisturizer, a lubricant can be the way to go, and that’s used only at the time of sexual activity, whereas a moisturizer is used whether a woman’s having sex or not.

(12:32)
And lubricants come in a variety of different kinds. It can be important for women who are single and unpartnered. It’s very important that they use a moisturizer and a lubricant that are condom safe. If they’re having sex with someone that’s a new relationship, don’t want to go home with HIV just because you have a dry vagina, that’s not a good exchange. And so using a lubricant at sex, that’s condom safe and it might be important what kind of sex they’re having. So lubricants of some kinds may be better for vaginal sex, other kinds better for anal sex, other kinds just may be better for a particular couple. I’ll give you an example. If we’re talking about a heterosexual couple and he tends to be very quick, we won’t define what that means, but quick then a short acting water-based lubricant can be perfect because it doesn’t need to last a long time.

(13:51)
On the other hand, let’s imagine that same woman is having sex with someone for lack of a better term, who is slow. Then a longer lasting lubricant like a silicone based lubricant may be very important because you don’t want to be stopping in the middle to reapply lubricant because the water in the water-based lubricant dries up. So these are subtleties that make a huge difference. Bottom up. In addition, hormones specifically for the vulva, the vagina, the clitoris, et cetera, can be very important to maintaining those tissues in a responsive way, not only to keep them healthy and painless and moist, but also they need to respond with sexual activity. So they need to engorge and tingle and get ready for sexual activity. And those are all hormonally based responses and hormone vascular responses that every woman learns to know when she’s younger and can’t understand why they go away when her hormones go away.

Let’s go back for a minute. This is such a good discussion. So let’s go back a minute to the moisturizers and then I want to continue with the hormones. So when you have a moisturizer, so for women who are listening now, I’m going, you know what? It makes sense. We put moisturizer all over our body as we go into this phase of life. Why wouldn’t we put it into our vagina? And I don’t know if I should have asked you this before we started recording, do you have any props or anything? Because it would be really good to understand how it’s applied. So is it to the outside, to the vomit when we’re looking as making it as part of our daily routine? How are we applying these moisturizer? Oh, you do? Okay, good.

I have props. You’re

Watching us on, you can come to YouTube. We’ll put a link below to our YouTube. If you’re listening to our podcast, you can listen, but you can see if you want the props. I like the props. Alright, go for it.

This is called a vulvar puppet. It is what it is. There’s a clitoris hiding underneath there, and these are the lips out here. The skin is out here, and skin moisturizer as you’d put on your face, can be put on this part of the skin down there

On the outer part of it,

Right? Wherever there is or was hair is a good place, good way to remember. It’s just skin. Then the lips themselves can use moisturizer like what you use on your skin also, although they’re much more sensitive. So you can’t use a moisturizer with a lot of added ingredients. Need some pure stuff.

Yeah, you want to be careful. No phthalates, parabens, perfumes, any of that anyway. That is

Correct.

Yeah,

The moisturizer I’m talking about goes in the vagina.

Okay.

It’s usually applied with an applicator, so it goes all the way up inside. Sometimes the applicator just looks like a tampon inserter and the material that goes inside, all it does is stick to the vaginal wall or what we call the vaginal barrel. And the vaginal barrel when it adheres to that, draws moisture from underneath the surface to the surface where we want the moisture. So the best ones don’t have preservatives, don’t have sense, other additives. And all they do is draw moisture from the subcutaneous tissue or the sub vaginal tissue into the opening of the vagina, making it moist.

And you should apply this daily.

No moisturizers usually can be applied twice a week, once a week or as that woman needs. And everybody’s a little bit different, but they’re not, most women do not need them every day. So I usually tell them, I would say, Andrea, let’s make Sunday your moisturizing day,

Vaginal moisturizing

Day. So you put some vaginal moisture in your vagina on that day. The other thing is that most women of this age are not having sex every day. If they’re in a longstanding relationship, they’re not having sex every day. Maybe they’re in a brand new relationship, they’re having a lot more sex. But most women who are not having sex every day, so sometimes these moisturizers can be messy. And so they want to avoid using them on the day that they are having sex. Or if they know that they only have sex on the weekend, do it on Monday or Tuesday, make that your moisturizing day. And then you don’t have to worry the rest of the week.

So you should put it in before. But I know I’d use, and I’d love to, if you have brands to recommend, I would love to, you can share here or after, and I could put links below because I know that that’s a question that comes up is what are we looking for? What should we buy? And you put it in before bed. So obviously if it could be messy, then put it in before you go to sleep.

Sure. That’s typically what women do. Although I hate to tell women when it’s best for them to do it. You can recommend it at bedtime, but there’s nothing magic about Ben time except you’re lying flat. And it’s less likely to leak out if it’s causing a lot of moisture or not infrequently. A woman can use half an applicator full or a quarter of an applicator full, save the rest. Don’t throw it out. Even if the applicator’s been used, it’s your applicator. You’re not sharing it with somebody, put it in a Ziploc bag and wait until the next week. If you’re worried about the bacteria or something, throw it in the back of the fridge. No one will go in there in a sealed bag, but don’t forget to let it warm up before you use the other half.

Exactly. Then it’s cold. But I would think because it’s so dry down there for so many of us, that it would probably get absorbed pretty quickly that

So the moisturizers aren’t really absorbed. They sit on the surface of the vagina and draw fluid into them, but they’re not absorbed, not in the way we will talk about hormones that are used in the vagina or on the vulva. So that’s a good segue to the next issue. There are creams, gels, vaginal tablets, vaginal inserts that are waxy, et cetera, and they go in the vagina, they’re hormonal, almost all of them are estrogen, the same estrogen that was lost at menopause, and they are both absorbed into the tissue. And they also are dissolved in the normal vaginal secretions, which then flow down when one stands up and applied by virtue of that to the rest of the vagina to the barrel of the vagina. And some of them that are messy are actually getting on the lips on the outside, which can ultimately be good, even though they may seem messy. So finding the balance between, it’s getting enough of the outside that it’s not feeling goopy or messy. And at the same time, getting everything you need covered can be a bit of a challenge. Or you can use cream on the inside and Jen, just apply a little with your finger on the outside as you would moisturizer or cream on your face.

When you say apply cream on the inside, do you mean moisturizer like on the inside and then the

Hormones on the side Could be moisturizer, but on what I’m talking about hormones, they too, hormones come in, tablets, cream gel, et cetera. And you would use those typically on days when you weren’t using your moisturizer specifically.

Okay. So if we’re doing vaginal moisturizer, let’s say twice a week or once a week or whatever it is, how often should we be applying the hormonal?

So it depends on which ones we’re talking about, but most of the time the hormonal treatments that go in the vagina are meant to go in there daily for two weeks and then twice a week, whatever days are appropriate or reasonable. There are a couple of the medications that are used daily, daily all the time daily, but no one can manage no one. And I mean no one can typically manage to use anything daily. We forget our pills, we forget are this, we forget our that. And most of them work equally well, five, six or seven days a week.

Okay. And you were mentioning it’s usually estradiol, but there’s also estriol. Are there certain ones we should be asking our doctors for? I’m assuming this is by prescription. So how do women who are listening going, yes, I want to try this. How do they go about getting it and what are they asking for?

So that’s a very good question, and it’s one that may be different in Canada and in the US where I’m sitting, but Estriol cream is not available in the us. Estriol is a very, very weak estrogen that in the US is very difficult to prove benefit above and beyond just a normal carrier like a creamy substance with no activity of its own. So it’s not been approvable by FDA as effective above and beyond just a moisturizer. Estradiol is a much more potent estrogen. And for it in both US and Canada, we have tablets, little teeny tablets, they come on an applicator. The tablets are about the size of a baby. Aspirin. We have creams, several different kinds. I know you have them in Canada as well. We have vaginal rings, can’t make this stuff up, Andrea. It’s a ring little squishy vaginal ring that goes in the vagina and just stays there, can stay there for as long as three months.

And that’s inserted by a physician,

Nope, inserted by the woman herself. And it’s not difficult sometimes a little mental block about putting something in there and leaving it. But the answer is they’re used for contraception, they’re used for menopause, they’re used for menopause both locally just in the vagina. And they’re used for menopause more systemically also depending upon the design of the ring. And there will be a lot more rings coming to the market in the future because they’re very convenient. They’re kind of the set it and forget it. And more and more younger women are using them for contraception and getting comfortable with putting them in and taking them out for contraception. So it’s an easy transition to using them for menopause.

Interesting for women who are concerned. Now we know a lot of the information there.

There’s one more thing I want to mention. And then in particular, because it’s a Canadian company,

(26:43)
There are two things I want to mention. Both Canadian companies. One is a vaginal insert that is not estrogen and not testosterone, but in the tissues of the vagina becomes estrogen and testosterone and it’s called prasterone. Prasterone was developed actually in French Canada by a very famous researcher there who’s now passed on. But it’s a Canadian product. It’s available in the US and around the world prasterone in the US it’s called Intrarosa, but it’s estrogen and testosterone in a precursor hormone. And then the other is another Canadian company, Duchenne, also French Canadian company. And it’s actually a pill you take that works on your vagina. So it skips the rest of the body. It just goes, if you can imagine this, it’s a pill you take and it moisturizes the vagina and can treat pain with sex and vaginal dryness.

What’s in the pill?

It’s, it’s a medication that’s both an estrogen and an anti-estrogen. And it just turns out that it’s an estrogen in the vagina, an estrogen in the bone, but it’s an anti-estrogen in the breast where people are most worried about taking estrogen.

Is that part of the er, the selective estrogen receptor modulators?

You are way ahead of me here. Yes, it is AER reading about it, A selective estrogen receptor modulator. The name of that is sine, it’s in the same family as Tamoxifen and oxen. Those are drugs that are used for other purposes, but this one’s used for vaginal dryness and vaginal pain with sex in menopausal women. And it’s available both in Canada and the US for treating vaginal dryness and sexual pain with intercourse.

How would women know which ones to use? There’s so many options. So how do we make that decision?

Here’s what I always say, where there’s a real lot of options. It means that none of them are perfect for everyone. And my answer to patients is pretty simple. What do you think what the patient think would be easiest for you? A ring, a pill, a whatever. I mean you pick because most women are candidates for any and all of them. And the other thing is if it’s not working, you can change it. We can try something else. This is where a person can express her own preference from what she thinks before she actually tries it and then can change your mind if it’s either not working for her or it’s too messy for her or she can’t remember to take it or use it or change it or insert it. Or maybe she has an allergic reaction to something. I mean, these problems, and this is a really important point, these problems do not go away. They just get worse. And so taking good care of one’s vulva, vagina, what a lot of my patients call nibbly bits, taking good care of that is a lifelong proposition. Even if you’re not having sex, it’s like you want to take care of all parts of your body. That one, because it’s in your pants, in your clothes doesn’t mean you can just forget it. You want to take care of it. And there’s a really important, a sub discussion here, and that is that women as they age tend to get more urinary tract infections. For example. It’s a really big problem in nursing homes,

(31:14)
And one of the reasons for that is that the vagina has its own defense system against bacteria, viruses, and fungi if it’s kept healthy. And what keeps it healthy is hormones and a normal pH that is to say a very acid environment, second most acid place on the human body after the stomach. And that acid kills off all the bad stuff. But when a woman doesn’t have hormones and is aging, the acid goes away and the bacteria can grow there and cause urinary tract infections. So some of these treatments, even though we’ve been talking about younger women, sex drive, interest in sex, pain with sex, et cetera, many of these women in nursing homes, they’re not having sex. They’re in nursing homes because they’re sick or incapable of caring for themselves, but they still could be at risk for urinary tract detections and we want to avoid those.

So in that case, so in that case, the medication like you were talking about, might be a good option if they wanted to turn to the hormone. So we know, I know you were the past president, the Menopause Society, we know that the Menopause Society now says that you could start hormones within 10 years of going into menopause. Does that apply to vaginal hormones as well?

So that’s a very good question. I would say you can start vaginal hormones at any age, but just like every other part of your body, if you maintain good health, it’s easier to maintain it than restore it once it’s gone awry. So if one maintains their vaginal health from early after menopause through and beyond until they’re older, it’s much easier to maintain that vaginal health and that vaginal acidic environment to prevent urinary tract infections than it is 10 years later. When you’re 65 and you’ve just had your first urinary tract infection, or maybe you have your first boyfriend in a decade, it’s much easier to maintain it and then have it be usable than it is to have to rejuvenate it after a long period of no treatment.

You know what? My mom was just, I was just talking to my mom this morning, interesting that it comes up today is she’s 76 and she’s been getting a lot of UTIs and she has to go on antibiotics and the antibiotics are just brutal on her body. She has terrible side effects. She’s allergic to penicillin. And anyway, she’s having some severe side effects from the antibiotics, but it’s getting rid of her UTI. So I’m going to definitely share obviously this podcast with her because she was just saying she wants to talk to her doctor to see what can she do to stop it. It’s happened a lot recently, especially.

Yeah, so she could start with a moisturizer which can increase the acidity of the vagina without medicine, and then all the hormones tend to acidify the vagina as well.

Can you take vaginal estrogen and HT hormones at the same time, like menopause hormone therapy, or is it a one or the other?

It’s a good question. Something like 80% of women who are on systemic hormones get enough benefit of those systemic hormones on their vagina and vulva to avoid needing more down there. But about 20% need both. You can start with local and if you need systemic change to systemic and see if then you can get rid of the local or not. But 80% of women can avoid local treatment if they’re on systemic treatment. Systemic treatment could be pills, could be patches, could be a special vaginal ring that’s both local and it could be transdermal gels. These are all totally reasonable ways to get hormones.

I noticed that I did hormones for almost a year, and it definitely for me, and I was already managing my other symptoms through supplements and nutrition and lifestyle. But I would say the biggest thing for me was the vaginal dryness. I noticed it. I would say that was the biggest benefit for me. I unfortunately had to go off the hormones for a bit, but I definitely noticed that it made a big difference for the vaginal dryness. And I’m always trying different things. I’m like, oh, what’s going to increase vaginal dryness? Like the get rid of the vaginal dryness. Can you talk a little bit about bacterial vaginosis?

Sure. Bacterial vaginosis is basically just an imbalance of the normal bacteria that live in the vagina and the pathologic bacteria that also live there. I’ll give you a different example. Everyone in your community has heard of or has had a strep throat. Strep throat just is an overgrowth of a certain pathologic kind of bacteria in your throat. It’s there all the time, everybody’s got it, but only small amounts lives in your nose, lives in your throat. But when our immune system is under distress or pressure, or if we’ve just been sick or if we’ve had a course of systemic antibiotics that upset the normal balance, sometimes the bad bacteria either in a strep throat or in the vagina can flourish, whereas the good bacteria have been somehow injured, suppressed, treated with antibiotics, and that bacterial vaginosis gives rise to an abnormal vaginal environment.

And what would be some symptoms? I actually had it quite a bit in perimenopause. What would be some symptoms that women could look for?

So the most common symptom that a woman might notice is a change in her vaginal moisture and discharge, particularly if it has a fishy odor. And that fishy odor is very characteristic of a certain kind of bacteria that makes ammonia like substances in the vagina and ammonia. It’s a good cleanser ammonia, but it’s a basic cleanser, not an acidic cleanser. And so we want a nice acid environment, and that’s why maybe many individuals in your audience who have been told to or needed to use a douche once in a while, vaginal douche, it’s an acidic douche with water and vinegar. Vinegar is an acid, and that acid can help reestablish the balance between basic and acidic that is away from bacterial vaginosis toward a more acid environment.

I see on, I mean, again, this, I always say that it’s out of my lane, so I’m not a doctor and I see people speaking about boric acid suppositories. There’s all the, do we cleanse the area? Can you talk a little bit about that? Because I find it interesting, but I actually want to know what some answers are.

So boric acid is a acid just like a vinegar and water douche. It’s an acid can reestablish an acidic environment in the vagina, and we use them all the time in women who for whatever reason don’t have an acid enough vagina or who can’t use hormones. Remember, hormones tend to make the vagina more acid also. So that’s the boric acid story. You can buy boric acid capsules on Amazon. They’re relatively inexpensive and for most women, they’re not harmful at all. I’m not saying women need them. Defacto healthy women, particularly younger women that are menstruating, their vaginas take care of themselves by and large, they take care of themselves. You want an acid vagina,

You want an acid vagina. So somebody can do boric acid if they have bacterial vaginosis, is that

Yes. And sometimes that can actually treat bacterial vaginosis. So a woman could potentially treat her own bacterial vaginosis. But I would also say if it’s coming back over and over and over again, she might need medical intervention because it may mean a different bacteria has now really got a foothold in her vagina and suppressing it with boric acid is not curing it.

Okay, for those who are listening who are saying, you know what, I don’t really want to do systemic hormones, I might be open to doing vaginal hormones. Does the hormones that we put on our vaginal area, does it get absorbed systemically? How does it work? Is it just local? I’ve heard both. So I’m curious for is it safe for everyone to use? I’d love your opinion.

My opinion is particularly well-informed because I helped to write the guidelines for the Menopause Society on this very subject. And it’s not a simple answer. I wish it were a simple answer, and it may be why you’re getting two different answers from different people. So the creams, the estrogen, vaginal creams, even at relatively low doses tend to be more systemically absorbed than the other local vaginal treatments. Those include local vaginal rings, local vaginal tablets, local vaginal inserts, and in the case of that Canadian vaginal insert, that’s a pre hormone. It even has a FDA approved label that says it can be used within breast cancer survivors who may even be estrogen sensitive breast cancer survivors.

(42:30)
All the estrogens that are inserted vaginally that I’m talking about are largely or entirely local, have a label in US and Canada that says that you shouldn’t use them if you’re sensitive to or not allowed to, for some reason, use systemic estrogens and the menopause society and other societies don’t agree with that and believe that these very low dose vaginal estrogens are safe even in women who can’t use systemic or don’t want to use systemic estrogens. But that’s a difference between what the label says and what the science says. And so that may be kind of where you’re getting people talking out at both sides of their mouth as an explanation.

Thank you, Dr. Simon. So that talked about the bottom up. What about from the top, bottom to the bottom?

So the treatments that we’ve talked about should eliminate or dramatically reduce dryness and pain with S, and those should eliminate one of the major barriers to engaging in sexual activity, loss of spontaneous desire. I can’t wait till he or she comes home before we have sex. I want to have sex. I want to want to have sex. That is also affected by menopause because those hormonal triggers are gone. The hormonal triggers, we talked about during the mid cycle of menstruation when Mother Nature wanted women to get pregnant and make babies and have sex, right?

(44:23)
So without those triggers, because the menstrual cycle has stopped, we can improve normal sexual desire by giving women systemic estrogen, by giving her systemic testosterone or by giving her both. And in the US we have a couple of non-hormonal treatments for increasing spontaneous sexual desire, spontaneous sexual thoughts, fantasies, et cetera. One of them is called Banin or Abby, A DDY, I think it’s called the same in Canada. It’s a daily pill whether you’re having sex or not. It’s a daily pill and it increases sexual desire and has a side effect, if you will, of weight loss, which by the way is a very appealing side effect in menopausal women who have problems with weight gain at menopause. Maybe we can have a talk about that at a different time and how to ameliorate that and the impact of hormones. That’d be great. Love to do it.

Yeah, love to have you on to talk about it.

And the other is a self administered injection. It’s a little teeny mini injector that’s called VII or bide, and it’s injected into the abdomen and stimulates for the next several hours, an increase in sexual desire. It was originally developed for men. The compound was developed for men as a nasal spray, but then Viagra came, and so that went away and was on a shelf for a while until the company decided to try it in women that then went from a nasal spray to a auto-injector. But it works for sexual desire, arousal and orgasm, as does addie, the daily pill. And so those are non-hormonal treatments for low desire. And then we have estradiol and testosterone, systemic hormones for sexual desire. But I also want to bring a very important point to your audience.

(46:59)
Spontaneous internal sexual desire sometimes becomes responsive desire in aging or older women. Let me explain. There’s a difference between I’m horny, I want to get it on with my partner versus, well, I’m not all that interested, but I really love him or her and the partner has desire and I’ll just engage and we’ll see where it goes. But then once the juices get flowing and you’re in contact with your lover and it feels good, then you have desire in response to what’s going on. And that change is very common in menopausal women, whereas they used to have those triggers from their menstrual cycle or they used to have more spontaneous desire. Now it’s more responsive or reactive desire. And by the way, that was originally described by a Canadian from Vancouver, British Columbia, Rosemary Sal. So this is a normal phenomenon in women as they get older. And if it’s not bothering them to have lost their spontaneous desire, they’re completely normal. They don’t need to treat it unless they want to want it back.

That makes sense. So initially it comes from us internally and internal trigger, whereas now this is more of an external trigger, you’re saying?

Yes. And there are a large group of women, by the way, even if they have their own internal trigger from their cycle, they are more likely to engage in a reactive or responsive way. That’s just their way. Doesn’t make it right, doesn’t make it wrong. So I don’t want to pathologize a menopausal woman who has great sex with her longstanding husband, boyfriend, girlfriend, whatever, but doesn’t initiate anymore because her spontaneous desire is gone, but it’s not bothering her because she’s having enough good sex in response to her partner.

What about vibrators and toys? How do they come into this?

So very important question. We could have a whole session on vibrators and toys. I hate the use of the word toy. These are tools. They are not toys, they are tools. And they’re there to help a woman or her partner or the two of them because we have tools for men too to have pleasure in sex. And here’s the key message. As we humans age our sensation, our sensation gets less. We are more likely to fall. We are less likely to touch, find little things and be able to fix them. A gold chain that used to be able to untangle with your hands is give it to my kids, let ’em untangle it, whatever. We get less sensitive in our sense of touch. But one of the sensations that is preserved long, long, long after the sensations generally are decreasing is the sense of vibration.

(50:54)
So whereas a woman used to be able to respond to have an orgasm just with intercourse, by the way, that’s a minority or a woman could respond to have an orgasm with clitoral stimulation by her partner, by herself, by a tongue, by a mouth, by something. Now the sensation that’s left is largely vibratory. So what do you use? You use a tool that provides vibratory stimulation. That’s something that everyone can enjoy, a tool that vibrates regardless of the age of the person. But remember, we’re talking about aging and women going through menopause and vibratory sensation is still maintained until you die, largely speaking. Therefore, what kind of tool do we need? One that vibrates.

Interesting. That’s really interesting. Okay, last question before we go, because I want to be mindful of your time, increased libido. I know that a lot of women have said that that is a symptom as well, that their libido increased. What is responsible for that? And is it a small percentage? Because I’m thinking it’s a smaller percentage, but I’d love to hear your thoughts.

So I see those women sometimes, and I see women that think it’s increased, but it’s not so increased compared to what increased compared to her girlfriends, which may be very true. It might be increased because now the kids are off at school and there’s privacy and they’re not being interrupted or the kids are off to school or living on their own and they actually have sleep and the energy to have sex,

(52:53)
Or they have the spontaneity that comes with sex because they don’t have to worry about anybody else in the house that might give her the impression that she has an increase in her sexual desire when in fact it was not an increase in her sexual desire. It was a decrease in those things that were preventing her sexual desire in the perimenopause before the last menstrual period occurs, there’s actually an increase in sexual hormones, estrogen and testosterone go up before they go down. And that can in our discussion as before, trigger those increased desire in the same way they did when she was menstruating regularly. And then last but not least, there are a subgroup of women for whom the changes in their bodies and the bleeding of menstruation are ugly, dirty, a problem, et cetera. And when their periods stop, that is gone also. So a woman that believes, and this is not my words, but we have this colloquially in English in both Canada and the US that believe her periods are a curse. She may not be interested in having sexual relationship for two weeks out of her menstrual cycle when she feels premenstrual, and then when she’s menstruating and if that goes away, now she’s a different woman in that context. And so she may have a great weight lifted off of her in terms of her interest and willingness and ability to have sex, and then she’ll have more, but the ones that really have a big increase in their drive, pretty small.

Thank you so much for doing this today, and I will definitely have, I’d love to have you back. There’s so many different topics I want to talk about and I appreciate you offering it. So thank you so much for doing this, and I’ll see you soon. I’ll have you back on soon.

It’s really my pleasure. Thank you very much. And I hope that your patients can find someone in their area who can help them with these issues. If not, they can contact my office. We can do some kind of a zoom with them and find a way to get them the treatment that they need, either over the internet or by their local practitioners.

Yeah, we’ll definitely put your link below. And for all of you who are listening, we’ll definitely introduce you to Dr. Simon’s office. And thank you, Dr. Simon. I really appreciate you doing

This. It’s really my pleasure. Good luck to you. And for all your American listeners, happy Thanksgiving to everyone.

That was amazing. I have been wanting to talk about vaginal health and libido for a while, so I am super grateful that Dr. Simon came on our show to share his vast knowledge with all of us. If you enjoyed the interview as much as I did, please share it because the more you share shows you care. And please leave a review. I read each and every one of them. Thank you for spending the last hour and a bit with me. I am so grateful for you, and I’ll see you at the next interview.

For more information about menopausal health, contact Dr. Simon at IntimMedicine Specialists. To schedule an appointment, call our office at (202) 293-1000 or https://intimmedicine.com/contact-us/.