I had the pleasure of attending a conference on sexual health and perimenopause and menopause over the weekend. Presenters included Fellows from the Kinsey Institute, MDs who specialize in sexual health, urologists, and more.
You guys. I was overwhelmed by information.
I signed up for this conference because this year I've had a sudden influx of perimenopausal, menopausal, and post-menopausal women showing up in my office for sex therapy. Some of the most common complaints being pain during sex and relationship tension caused by desire discrepancy (most often looking like the male partner wanting more sex, the female partner noticing a decline in interest overall, and a global desire to understand and be understood).
Many people might not realize that schooling and training for a therapist does not include mandatory classes on relationships or couples. It definitely doesn't require any training at all in sexual health. We have to voluntarily seek out this training ourselves.
I am an AASECT Certified Sex Therapist, which included two years of additional specified, supervised training in sex therapy....and still the things that I learned, from anatomy to hormones to relationships, this past weekend BLEW MY MIND.
And this gap in training isn't exclusive to mental health… Fewer than 5% of medical doctors (and that's apparently a generous estimate) routinely ask patients about sexual health, wellness, pain, desire, and overall sexual functioning. LESS THAN 5% ASK.
Not only that…but there’s also a significant gap in medical education when it comes to vulvar anatomy. Anatomy. Like, the names of parts of the body and what those parts look like. Many providers receive shockingly little education on what typical vulvar anatomy actually looks like, including the tremendous amount of normal variation. If you don't know what healthy looks like, how are you supposed to confidently recognize when something isn't?
I was actually embarrassed to find how little I actually knew about menopause. Particularly, I was embarrassed to realized that I didn’t know HOW MANY symptoms can accompany perimenopause and menopause. More than 100 symptoms have been attributed to the menopausal transition. MORE THAN 100. We're talking about so much more than hot flashes and night sweats. Changes in sleep, mood, cognition, joints, skin, sexual functioning, urinary health, and so much more. And I think so many women (and providers, for that matter) have no idea just how extensive this list actually is. We don't recognize the symptoms, we don't connect them to hormonal changes, and we don't know what can be done about them.
One of the things that really stuck with me was learning more about Genitourinary Syndrome of Menopause (GSM). GSM is a collection of symptoms related to declining estrogen that affect the vaginal, vulvar, and urinary tissues. It can look like vaginal dryness, burning, irritation, inflammation, painful sex, urinary urgency, and recurrent UTIs.The vulvar vestibule (the tissue surrounding the vaginal opening) is also affected.
Here's the kicker, GSM can actually mimic a UTI. Women experiencing urinary burning, urgency, frequency, and discomfort may believe they have a chronic UTI when the symptoms are actually related to GSM. And to make matters more complicated, GSM can ALSO increase a woman's susceptibility to actual, recurrent UTIs.
You guys. This matters. We’ve habitually and chronically misdiagnosed, and therefore, mistreated women, significantly impacting quality of health and life.
In fact, the 2025 clinical practice guidelines released by the American Urological Association (AUA), in collaboration with the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) and the American Urogynecologic Society (AUGS), specifically speak to this. The guidelines acknowledge that GSM has historically been mischaracterized or diagnosed as overactive bladder or recurrent UTIs in urology.
Let that sink in. This is a recognized gap in clinical care that major medical organizations are now specifically addressing.
So we're talking about women who may be repeatedly seeking treatment for what they believe are UTIs, sometimes receiving antibiotics, without anyone considering whether declining estrogen and GSM could be contributing to what's happening.
There are treatment options. Local vaginal estrogen, for example, can improve GSM symptoms and reduce the risk of recurrent UTIs. Vaginal DHEA is another treatment option for certain symptoms, including painful sex.
Have you heard of this? Did you know? Me either. AND I HAVE A VULVA for goodness sake! I'm a woman. I'm a sex therapist. I've spent years pursuing additional education and training in sexual health. And I had NEVER heard of this…no one had ever told me.
How is it possible that something affecting the vaginal, vulvar, AND urinary health of women during a completely predictable and guaranteed stage of life is something so many of us know so little about?
How many women are walking around experiencing these symptoms, assuming they're just part of getting older? How many are repeatedly treating UTIs without anyone considering GSM? How many have stopped having sex because it hurts, without knowing there may be a treatable physiological explanation?
This isn't some obscure condition affecting a handful of people. It's something that deserves to be part of routine conversations about perimenopause and menopause.
My grandmother passed away this year. She struggled with what I understood to be recurrent UTIs for a reallyyyyy long time. She was hospitalized for the last time due to a UTI and then picked up Staph, which eventually took her.
And I can't help but wonder if any doctor had ever explored GSM with her in her lifetime. Whether some of what she experienced could have been related to untreated hormonal changes...whether vaginal estrogen, or other treatment options, could have improved her quality of life.
I'll never know. And I'm not suggesting I can retrospectively diagnose her. But I do wonder. And it pissed me off….cause there’s more…
The recent history of hormone therapy.
For years, women of my grandmother's generation and my mom's generation were taught to be afraid of hormones following a Women's Health Initiative (WHI) study published in 2002. The findings, which involved specific hormone formulations and a study population with an average age of 63, were widely generalized to women of all ages and across different types of hormone therapy.
In 2003, the FDA added boxed warnings to estrogen products. Those warnings, and the fear surrounding them, contributed to a dramatic decline in hormone therapy use. For many women, this meant never even exploring treatments that could have significantly improved their quality of life.
Think about what that means for women who were already experiencing GSM, but were never told what it was or that treatment existed.
In November 2025, the FDA announced it would begin removing certain risk statements from the boxed warnings on menopausal hormone therapy products. In February 2026, the first six products received updated labeling.
There is still a lot to understand about hormone therapy, and treatment decisions should be individualized. But women deserve accurate information about the risks and benefits, not blanket fear that prevents them from even exploring their options.
We have to stop convincing women that being female means pain and discomfort.
We have to stop allowing couples to buy into the idea that the "change of life" is a curse on their bedroom.
And of course, we have to stop telling women they are undesirable as they age.
Perimenopause and menopause can bring significant changes to a woman's body, sexual functioning, desire, and relationships. But these changes don't mean her sex life is over. They don't mean she has to accept painful sex. And they don't automatically mean something is wrong with her or her relationship.
We have options and treatment and information. And we have to do a much better job of making sure women, their partners, and the professionals caring for them know that.
While I am over the moon excited to begin applying all the information I've learned, I’m sitting with grief that life-changing information and solutions have been held so quietly for so long.
And after this weekend, I was reminded that I do this work in part because our grandmothers and mothers weren't given the opportunity to be educated on their own anatomy or hormones, much less their sexual health.
So today, as I step into a full day of sex and couples therapy, I’m honored to help educate and spread a word of hope.
For you, Grandma.
