Dear Vulva – An Apology

Dear, Vulva. As I continue to struggle my way through perimenopause and come to terms with the fact that my 50th birthday is mere months away, I feel compelled to apologize. Yes, to you. There are so many reasons for this apology I’m not quite sure where to begin.

Perhaps best to start with the fact that until the age of 46, I very much took you for granted. I assumed you would just always be the same as you always have been without any attention or care. I guess that became glaringly obvious to you after giving birth vaginally twice; I had thought you would just ‘sort yourself out’ without assistance and go back to being you despite experiencing rather significant trauma.

Seek Treatment?

It never occurred to me that, beyond some frozen feminine pads to numb the throbbing pain that is common with most vaginal births, you might need me to seek treatment. When the public health nurse gasped at a routine inspection of you, my external genitalia, after baby number 2 due to the level of bruising, the amount of swelling, and the number of stitches, perhaps I should have asked her to elaborate on the wincing face she made at me while uttering ‘more Advil and frozen pads’.

I could, and should, have done better. I am sorry.

It wasn’t until 7 years later that I would seek help after over a year of urinary symptoms (peeing myself) when I undertook a jumping jack or came down with a bad cough. It took me far too long to find a pelvic floor specialist, book an appointment, and let her help me discover you.

An initial pelvic exam and several follow up visits allowed my pelvic floor specialist to help me better understand you, and how you function. More importantly she taught me what I needed to do to keep you healthy and address the kind of warning signal you had been sending me. One of the biggest takeaways was to practice double voiding, where I use a short breathing exercise and spend some extra time ensuring I have completely emptied my bladder.

I should have paid attention sooner. I am sorry.

The Mother of All Signals.

More Than Urinary Incontinence

I wish I could say that peeing my pants was a sufficient wake up call to start being proactive about your wellbeing and care, but we both know that didn’t happen. Yes, I was diligent with the advice from the pelvic floor specialist, but I wasn’t proactive about what else you might need and how you might continue to change.

I know that is why you sent me the mother of all signals in the spring of my 48th year. Attention grabbed? CHECK.

There had been some mild urinary incontinence, but I ignored it AGAIN because I had been doing what the pelvic floor specialist had advised. You could say lesson ‘not learned’. And so, you went to defcon 1 – you know, ‘nuclear war imminent’.

Vagina and Vulva – Two Different Things

The burning that felt like I was passing shards of glass when urinating really piqued my interest, but I have to say that the combination of vulvar itching, burning, and pain that made sleep impossible was what really got my attention.

I hope you don’t mind, but I need to mention your colleague, Vagina, who also deserves an apology as my vaginal tissues were also burning, itching, and painful. I couldn’t even think about inserting a tampon. Sexual intercourse? Hard no. And I know you two get confused for one another, so I wanted to make clear that you both were suffering, and you both deserve an apology. Your names are not interchangeable, and as per Google courtesy of Oxford Languages mean different things:


the muscular tube leading from the external genitals to the cervix of the uterus in women and most female mammals.


female external genitalia.

For using your names interchangeably, I am sorry.

UTI? Nope.

Urinary Tract Infections? Vaginal Infections?

I did seek medical attention immediately from both a medical doctor and a naturopath. Both were stumped. They talked about vaginal infections and urinary tract infections at length. They thought it might be a yeast infection and/or a UTI, but those tests came back negative. They asked if my periods were irregular or if I was having hot flashes. Again, negative.

Genitourinary Syndrome of Menopause

Over the course of a week, I had gone through a large tube of hydrocortisone cream and consumed enough ibuprofen to take down an elephant. I realized that if you and Vagina were going to get help, I had to figure this out on my own.

I researched and read and finally determined that I had genitourinary syndrome of menopause (GSM), formerly known as atrophic vaginitis or vaginal atrophy. Yes, atrophy! I learned that a loss of estrogen and a reduction in blood flow to the vulvar and vaginal tissue can cause a bunch of symptoms including incontinence, urinary frequency and urgency, frequent urinary tract infections (UTIs), pain when urinating, bacterial overgrowth, vaginal dryness, thinning skin that can crack and bleed, burning, itching, pain, and according to an Instagram by Dr. Rebecca Lewis in the UK, severe cases can result in nerve damage. WTF?! Sitting can become uncomfortable, as can wearing underwear. Intercourse? Impossible! How is this not widely known?!

For not knowing and recognizing these symptoms, both I and my medical providers are truly sorry.

Vaginal Estrogen Therapy

Turns out that treatment was relatively easy for me with vaginal estrogen therapy. I had to push my doctor to prescribe because they seemed unwilling to acknowledge that I was in perimenopause and that this was genitourinary syndrome of menopause, vaginal atrophy or atrophic vaginitis, but having ruled out other possible causes they agreed.

Symptoms of Genitourinary Syndrome of Menopause Should Never Be Ignored

Thankfully you had the good sense to go to defcon 1 and provide signals I could not ignore. Thanks to your warnings and my due diligence, I dare say you and Vagina are working better than ever.

I think it is important to mention that a doctor I met recently said, only half jokingly, that ‘every woman 45 and over should be using vaginal estrogen therapy as a preventative measure!’ I am sure that statement will cause significant debate, but the point is that no vulva or vagina should ever suffer in this way. EVER.

I am sorry I was not more prepared and proactive. And I am sorry that the medical community is not better educated about your needs. There are several reasons for this that I plan to dig into at another time, but for now, let me say again, I am sorry.

We should all be sorry.

Dear Vulva
You Were Banished From Our Thoughts, Our Mirrors, and Our Vocabulary.

Let’s leave the medical community aside for now and focus on the person who should know you best. Why don’t I know more about you? Actually, why didn’t I know anything about you?! Why couldn’t I name all your parts before my GSM nightmare? Why does your name not roll off the tongue? Why did it take until I was in my late twenties for me to look at you? I mean really see you!


I have thought about this for some time, and it really comes down to one word: shame. It comes from many places, and I believe is deeply rooted in most women.

We are socialized to feel badly about our bodies. We were, and are still, taught that our body parts should be spoken only in a whisper and only when necessary. And certainly not in the name of pleasure. I know, I know, one of your main functions is to provide women pleasure, and yet it is still a negatively held view for most societies. Sometimes in the extreme.

At Some Point We Each Need to Take Responsibility

I can point to my religious upbringing. To growing up in an age when what everyone else thought was treated as the most important need to be met. To adults who thought they were protecting me. And I won’t get into the more insidious forces at play (again, that’s for another time), but at some point, we each need to take responsibility.

First, responsibility for taking care of our own bodies and not assuming that someone else will. We can’t sit and wait for a doctor to bring up perimenopause, or assume that they know absolutely everything about us and about all aspects of medicine, or even everything about genitourinary syndrome of menopause (vaginal atrophy or atrophic vaginitis). That is naïve at best and frankly an unreasonable expectation.

Do we need more medical practitioners trained to understand, diagnose, and treat menopausal symptoms and medical conditions associated with menopause?

Abso-freaking-lutely. And I plan to provide my thoughts on this topic soon.

Stop The Cycle of Shame

We also need to take responsibility for stopping the cycle of shame, and in some cases intergenerational trauma. Those cycles taught us, particularly women, to always put others’ needs first otherwise you were selfish. We were taught to never make anyone uncomfortable; to respect authority; to fit in; even conform. And somewhere in all of that you were banished, from our thoughts, our mirrors, and our vocabulary.

I Had To Fight To Make Your Name Heard.

When I first started saying your name beyond a whisper and in mixed company, I had to fight to make your name heard, my throat constricting with my learned shame. But I find that the more I say your name, the less constricted my throat becomes.

The more I learn about how you work, the miracles you and your colleague perform, and how to keep you safe, I want to tell everyone about you. I just wish it hadn’t taken me almost 50 years to be proud of you and my full self.

I am so sorry I shunned you for so many years.

I will do everything in my power to stop this insidious cycle. For my daughter and my son, for my friends and family, and hopefully countless others. And even if these efforts extend to only one person beyond me, and you, it will have been worth the effort. I am sorry that I took you for granted. I am sorry that I ignored your needs.

I am sorry that I used to be embarrassed to say your name. Not anymore: Vulva.

Call To Action

See your doctor at least once a year to set a baseline and be able to monitor any changes to your health. It is always important to discuss symptoms with your doctor, not only to get the appropriate support and solutions, but also to rule out other medical conditions that can mirror the signs and symptoms of perimenopause and postmenopause.

The Hero Bit

Everyone should see a pelvic floor specialist after giving birth – full stop. Everyone should see a pelvic floor specialist when discomfort with sex, incontinence, pain, or any of the multitude of GSM symptoms show up. They should also see their doctor for these reasons and at the first sign of vulvar and/or vaginal changes. GSM is a medical condition that needs attention. Left ignored, it can cause so much pain and trauma that sitting can become uncomfortable.

Let me repeat that: sitting down can become a problem.

Treatment Options

There are a variety of treatment options. As per the Menopause Manifesto, vaginal estrogen therapy is the gold standard for treatment of symptoms of GSM. There are a variety of options when it comes to vaginal estrogen. It may take some trial and error before you find the right solution for your symptoms. It also takes some time for the estrogen to work and take full effect. There are other medications available to treat GSM, and milder cases of dryness or irritation may only need a good lubricant, moisturizer, or gentle cleanser. Ask your doctor to review the full list of available solutions in the context of your medical and family history. Then you can determine how you would like to proceed with treatment.

Suggestions To Support Your Journey

If you are looking for a good read that will scare anyone into being proactive, pick up a copy of Me and My Menopausal Vagina by Jane Lewis. This true story of one woman’s journey with GSM is as funny and insightful as it is shocking. And both of Dr. Jen Gunter’s books, The Vagina Bible and The Menopause Manifesto provide detailed advice and information about GSM, the vagina, and the vulva.

Finally, learn to name the parts of your vulva. The more information you can provide your medical provider about the problems you are having, the easier it will be for them to help you.

Oh, and one last thing, practice saying it out loud: Vulva.

V is for Vulva
V is for Vulva


  1. The Menopause Guide Book, 9th Edition, The North American Menopause Society
  2. The Menopause Manifesto, Dr. Jen Gunter
  3. Me & My Menopausal Vagina, Jane Lewis
  4. Dr. Rebecca Lewis, Instagram