The problem is that many women interpret this shift as something being wrong with them, and many partners interpret it as rejection. Neither is true.
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Take Our QuizDr. James Simon has spent decades studying what happens to our intimate lives as we age. Here is what he wants every woman and couple to understand.
When Dr. James Simon sits across from a couple in his office, he is often seeing the end result of a problem that started small and quietly snowballed. A woman develops vaginal pain. Her partner misreads her withdrawal as rejection. He starts to lose confidence, then erectile function. The relationship strains. What might have been a straightforward hormonal fix has now become a layered emotional crisis.
Dr. Simon, a professor at George Washington University, reproductive endocrinologist, certified sexual counselor, and past president of the International Society for the Study of Women's Sexual Health, has published over 800 papers and treated thousands of couples navigating exactly these dynamics. In a recent conversation on the unPAUSED podcast with Dr. Mary Claire Haver, he shared insights that most people never hear from a doctor. Here are the five most important takeaways.
1. Losing Spontaneous Desire Is Normal, Not a Sign Something Is Broken
One of the most relieving things Dr. Simon said is also one of the least understood: as women age, especially after menopause, spontaneous sexual desire tends to fade. That urgent, "I can't wait to get home" internal drive becomes less frequent or disappears entirely.
But this does not mean desire is gone. What replaces it is what he calls a state of sexual neutrality, "I can take it or leave it." The key distinction is that women in this state can absolutely be moved toward interest and participation, given the right environment, enough emotional warmth, and adequate foreplay, which does not even have to involve physical touch.
The problem is that many women interpret this shift as something being wrong with them, and many partners interpret it as rejection. Neither is true. Understanding that responsive desire is a completely normal pattern at midlife can change the entire conversation a couple is having.
2. Pain Is the Most Underaddressed Reason Women Stop Wanting Sex
Dr. Simon made a point that sounds obvious once you hear it, but that goes unspoken in far too many clinical encounters: if sex hurts, of course a woman does not want to have it. He compared it to touching a hot stove. You do it once by accident at age three and never do it again. The avoidance is not psychological dysfunction. It is a perfectly rational response.
Genital urinary syndrome of menopause (GSM) causes tissue thinning, dryness, and pain that can make penetration feel like "knives in the vagina," as Dr. Haver put it. The good news is that this is highly treatable with vaginal estrogen, DHEA inserts, or an oral option called ospemifene, all of which restore tissue health and comfort.
Dr. Simon also made an important clinical point: fixing desire before fixing pain is a mistake. Increasing a woman's libido when intercourse is still painful only makes things worse. Vaginal health comes first.
3. Every Long-Term Couple Falls Into a Sexual Script, and It Is Killing Their Sex Life
Here is a concept that may make you think differently about your own relationship. Dr. Simon has couples write down, separately, exactly what happens step by step in the bedroom. Nine times out of ten, both scripts are identical. Both partners know what comes next. There is no surprise, no novelty, no anticipation.
He compares it to eating at your favorite restaurant every single day. Even the best meal becomes boring when you know exactly what you are going to order. The same is true of intimacy.
His solution is what he calls an erotic surprise: a small, planned twist in the script that the other person does not see coming. It does not have to be dramatic. It just has to break the predictable pattern. For couples who have lost connection more broadly, he encourages them to remember what they did before intercourse was even part of the picture, the kissing, the anticipation, the not knowing what came next, and try to bring some of that energy back.
4. Testosterone Matters for Women's Desire More Than Most Doctors Acknowledge
Testosterone is not just a male hormone. It is the primary hormone of sexual desire in both men and women, and it declines significantly after menopause. Dr. Simon has been involved in research and clinical trials on testosterone therapy for women for decades, and the evidence for its role in treating low desire (clinically called hypoactive sexual desire disorder) is robust.
In addition to boosting desire, studies have shown that testosterone therapy improves arousal, orgasm intensity, and something perhaps even more meaningful: sexual self-image. Women report feeling like a sexual being again, not just more interested in sex, but more connected to their own identity as someone who is allowed to have a fulfilling intimate life.
The catch is that there is still no FDA-approved testosterone product for women in the United States, though one is approved in the UK, Australia, New Zealand, and South Africa. Clinicians in the US currently use low-dose versions of male formulations. Dr. Simon is actively working to change the regulatory situation in the US and believes it is within reach.
5. Intercourse Is Not the Only Option, and Letting Go of That Expectation Can Save a Relationship
Dr. Simon has coined the term "outercourse" to describe something he sees as increasingly important for aging couples: all forms of intimacy and sexual pleasure that do not involve penetrative intercourse. Kissing, touching, oral pleasure, manual stimulation, any and all of it counts.
For couples where arthritis, cardiovascular disease, diabetes, or other health conditions make traditional intercourse difficult or impossible, the tendency is often to stop being physically intimate altogether. Both partners silently grieve the loss. But as Dr. Simon pointed out, orgasm is entirely achievable without intercourse, for both partners.
The cultural fixation on intercourse as the "real" version of sex leaves a lot of pleasure and connection on the table, especially in the second half of life. Letting go of that framework and returning to a broader, more playful definition of intimacy can genuinely transform a couple's relationship.
A Final Note on Communication
Woven through all of Dr. Simon's advice is a communication principle that applies as much outside the bedroom as in it. He calls it "I language": framing sexual preferences and needs as personal desires rather than criticisms. "I really love it softer" lands very differently than "you're doing it too hard." And counterintuitively, he recommends having these conversations side by side, looking at the same wall or TV screen, rather than face to face. Direct eye contact during vulnerable conversations triggers a confrontational response in humans and animals alike. A little shift in body language can make one of the hardest conversations a couple can have feel much more approachable.
Sexual aging is not a problem to solve. It is a transition to navigate, with the right information, the right care, and a willingness to keep showing up for each other in new ways.
For access to the full unPAUSED episode, The Sex Life Nobody Warned You About: What a Top Sexual Medicine Expert Wants You To Know, visit unPAUSED wherever you listen to podcasts.
