I write about the ways women abandon themselves, and what it costs our health. We over-function. We drink to take the edge off. We work past exhaustion, chase perfect, stay busy, and call it strength. Each one is a bargain, and the body keeps the tab in cortisol, sleep, desire, and disease. It’s a health hazard to be a woman. I want to know why, and how we come back to ourselves. That’s what I love to write about and I’m so glad you are here.
Wendy sat on the edge of my exam table last year and told me she hadn’t had sex in two years. It hurt, then it burned for a day afterward, and then she started finding reasons to go to bed early. She’d told her gynecologist, who suggested a lubricant and moved on to her mammogram. So she stopped bringing it up, and somewhere along the way she stopped wanting to, and she decided this was simply who she was now.
Her husband thought she’d stopped wanting him. She thought her body had made the decision for both of them.
Wendy had made a bargain most women make somewhere around 45 to 50, one that very few women make deliberately. We agree that the part of us that held desire and pleasure, that gave birth or grieved the births that didn’t come, that carried us through first love and marriages and the nights we chose ourselves, will be allowed to go dry and thin and silent. We agree that the polite thing is to stop mentioning it. We call it aging, and from my side of the exam table it looks a lot more like abandonment.
In residency, I was not taught what Wendy’s gynecologist did: offer a lubricant and move on. I was taught to prescribe vaginal estrogen, either estriol or estradiol. Since OB/GYN residency in 1994-1998, more hormones were shown to be helpful, including DHEA. And I was taught when needed, to consider a vaginal cocktail of estradiol and testosterone when estrogen alone doesn’t help.
There’s a name for what Wendy had. Genitourinary syndrome of menopause, or GSM, is the dryness, burning, pain with sex, urgency and repeat urinary tract infections that follow the loss of estrogen in the vulva, vagina and bladder. A 2023 review in JAMA finds it in more than 45 to 77% of women in the menopause transition[1], and Mayo Clinic physicians put it at more than half of postmenopausal women [2]. In my 30-plus years of clinical practice, I’d put it closer to 95% of women who aren’t on treatment.
The published numbers run lower than what I see because the rate depends on someone who asks about it, and most women are never asked. When researchers tally symptoms directly, estimates run as high as 84% [3]. Across 27 studies, individual symptoms range from 13% to 87%, a spread that tells you more about the questions than about the women [4]. GSM also grows with time: about 4% of women in perimenopause, 25% a year after the final period, 47% at three years [5]. Hot flashes eventually fade. GSM progresses and stays [6].
A major review in Science this month, part of a special issue on women’s health, makes the same point at the scale of the whole body. It describes menopause as a transition that reaches nearly every organ, and it lists recurrent UTIs, urinary urgency, painful sex and vaginal thinning among the symptoms that can persist long after the hot flashes stop.
Most women don’t know that perimenopause menopause can cause bladder and vaginal problems.
The *Science *review found that fewer than half know about the affect of perimenopause and menopause on the bladder and vagina [7], and if a doctor doesn’t ask you, you are unlikely to get help. The checklist many doctors use to assess menopause covers just 11 symptoms or fewer. If a symptom isn’t on the list, nobody asks about it, it never makes it into your medical record, and no treatments are offered or prescribed.
Now the part that should make you angry. When researchers looked at more than a million Medicare beneficiaries in 2025, only 9% of women with a GSM diagnosis ever filled a prescription for vaginal estrogen, the standard of care, and those who did waited a median of 15 months after diagnosis [8]. The women most likely to get one were the women whose symptoms were vaginal [8]. Doctors treat the complaint they’ve been trained to recognize, and a 70-year-old woman with a bladder on fire goes home with an antibiotic and an appointment she’ll need again next month. In a 2026 analysis of electronic health records, women with recurrent UTIs who were prescribed vaginal estrogen had lower rates of sepsis, hospitalization and death in every age group [9]. The study was observational, so it can’t prove cause, but sepsis and death are not small outcomes to leave on the table.
Effective, FDA-approved treatment exists. Vaginal estrogen, vaginal DHEA (prasterone) and oral ospemifene all improve symptoms, according to a 2024 systematic review done for the federal Agency for Healthcare Research and Quality [10]. Generic vaginal estradiol is inexpensive, it works, and most women will never be prescribed it. While I find that about 5% of women react to the propylene glycol in it, 95% of women do well on it.
This is what I mean when I say it’s a health hazard to be a woman. A condition that will touch most of us for the rest of our lives, with a safe and inexpensive fix, goes unaddressed and untreated in nearly everyone who has it. Medicine treats the vagina as optional. That needs to end.
Here’s what the numbers can’t show you. Pain is a teacher, and the nervous system is a fast learner. After a few painful encounters, the pelvic floor starts bracing before anyone touches you, the body reads intimacy as threat, and arousal, which needs safety to switch on, never gets the signal. What starts as thin tissue becomes a story about desire, and then a story about a marriage. Wendy still wanted her husband. Her body had learned to protect her from something that hurt, and nobody offered her a way to unlearn it.
Your vagina doesn’t have an expiration date.
When I’ve written about what I prescribe one-on-one with a woman in my medical practice, many of you ask me what to do about it. This is my answer, the protocol I’ve used with patients for years and in my own body: three things, together, that I call the vagina trifecta.
• Hormones to rebuild the tissue.
• Bacteria to restore the ecosystem that protects it.
• Light to wake it back up: blood flow, collagen and repair.
Most women get one of these, if they get anything. The third, light therapy, is the newest, and it may turn out to matter most.
At the end of our first visit, Wendy asked me the question I hear more than any other in my practice: “Is it too late for me?”
I told her the truth: No, but it depended on what we did over the next twelve weeks.
Everything we did is below, for paid subscribers: the estradiol forms and schedules I use, how and why I add testosterone at the clitoris, what the L. crispatus trial I co-authored found and where it falls short, the two red light protocols with exact wavelengths and doses, the home device I use, a week-by-week protocol to print, and the scripts to say to your clinician. I use this protocol myself. And the timing matters, because GSM doesn’t plateau. Every year it goes untreated, the tissue thins further and the pelvic floor gets more practiced at bracing [6].
