It Was Never Your Fault

“I’m bleeding, and I don’t know why.”

My mother stated this very matter-of-factly over the phone. Her words came out choppy, broken by audible breaths. She was always calling me from her stationary bike.

“From” breath “my” breath “vagina.”

At age 75, my mother had made vigilance regarding her health a full-time job, which I found ironic since one year earlier she and my stepdad had relocated from the Bay Area, where they received much of their healthcare through Stanford, to the small town of Gardnerville, Nevada. In that one year, they had paid more visits to medical specialists than in their decade in Half Moon Bay. They were now collecting diagnoses like the sea glass they used to gather from the Pacific coastline. SVT. Arthritis. And now post-menopausal bleeding, NOS. I had been concerned about their move from Stanford’s healthcare oasis to a real and figurative desert, but they wanted to be closer to family and far from California taxes.

Mom took a deep breath, and I heard the whirring of the bike stop. “The weird thing is I can’t even tell where it’s coming from, but it’s bright red.”

The differential diagnosis ran through my head, starting with the worst. I knew it wasn’t uterine cancer, because she’d had a partial hysterectomy at age 44. (More on that story in another Substack. It’s worthy.) But it could be kidney stones or bladder cancer, or possibly something inflammatory.

Before I could start down my usual “have you talked to your primary care doctor” line of questioning, she continued, “So I saw my PCP last week, who trained at UC Davis, which is a GREAT medical school, who sent me to a urologist who I think trained at UCSF, also GREAT, who said it’s not kidney stones or bladder cancer or anything to do with my urethra, and next week I’m seeing an OB-GYN. I can’t remember where she trained, but it wasn’t anywhere I’d really heard of.” I could feel her smile, anticipating my approval. I once withheld sending her skincare products for a year until she got her screening colonoscopy.

I breathed a small sigh of relief. “Are you in any pain?” I asked, puzzling over her presentation.

“No more than usual,” she replied — an answer that could truly mean anything between a 0 and a 10 on the pain scale, in her book. This was not helpful.

“I was just so glad it wasn’t bladder cancer. I guess I probably should have asked about my bladder leakage, but I think that’s just because I’m 75. Anyway, I thought you’d want to know the good news!”

Good news? I thought. Bladder leakage? Before I could ask follow-up questions about the latter — including why her urologist never asked about any urinary symptoms — I heard the whirring of the bike again, and Mom was back in the saddle.

“But anyway, I’m good. And I liked the doctor, but it’s just not Stanford. Stanford was the ultimate.”

She changed the subject quickly to her book club’s latest pick, which led to asking me if I was reading anything that wasn’t about menopause or from the Women’s Fiction section, which led to the usual closing of our conversation. “You really should have been a writer, Corinne.”

“Maybe someday, Mom. I love you. Call me after your gynecology appointment.”

After we hung up, I thought more about her symptoms. Bright red blood, urinary incontinence, pain level clear as mud in a 75-year-old woman. I knew my mom had used an estrogen patch for a while after her hysterectomy, until a primary care doctor in Macon convinced her to stop.

I also knew she’d once had a prescription for Premarin cream, because one night she called me in a panic.

“I’ve mixed up my tretinoin for my face and my Premarin cream for my vagina!” she exclaimed. “Am I going to be okay?”

I suppressed a laugh, acknowledging her genuine concern. “I think a one-time mix-up will be fine. Maybe keep them in separate drawers, though, and don’t apply them in the dark.”

“Well, I guess I’m gonna be tight!” she said, and we laughed. One of the qualities I admire most about my mom is her ability to meet an uncomfortable situation with an unflappable sense of humor.

It felt like the conversation happened yesterday, but thinking back to where I was at the time, at least eight years must have passed.

The days that followed passed quickly in the usual mix of clinic, kids, and the never-ending tasks that come with running a dermatology practice. But in those moments between patients and parenting, I worried about my mom. I had been the supportive listening ear for my friends whose parents were facing new cancer diagnoses. Two years before, my aunt, my mother’s only sister and younger than her, lived with us for eight months while going through breast cancer treatment. If this was cancer arriving again at our family door, we would be as ready as one can be for such often-unpredictable beasts.

Mom called the next week, once again a little breathy. My youngest sister, an RN, was visiting her from Baltimore, and they had just returned home from the gynecology appointment.

I was anxious, still concerned that her urology work-up had been too thin for the level of reassurance she’d received.

“Hi Mom, how did it go?” I asked, straining to keep my voice supportive and measured despite my concern.

“You’ll never believe what they prescribed for me!” By the excitement in her voice, I expected her to say medical cannabis or a month on the Italian Riviera.

“What did they say?” I asked, genuinely curious about what could create such ebullience after a speculum and a manual exam.

“They said I have a,” she paused to think, “oh, something vagina. It doesn’t sound like a medical word. Your sister said it means it’s like tissue paper and bleeds easily.”

“Erosive?” I guessed.

“No, that’s medical.” Having been married to a pathologist for 25 years, my mom prided herself on an impressive grasp of medical vernacular.

I thought harder. “Friable?” It met criteria.

“YES!” she exclaimed. “I have a friable vagina, and she prescribed me YOUR FAVORITE CREAM! Estrogen! Can you BELIEVE IT?”

I couldn’t believe it. I was speechless. All of the worry that had built up since she shared her symptoms disappeared into the ether, replaced initially by relief, and then by confusion. This was all related to atrophic, fragile, bleeding skin.

“All this time and I could have been using this estrogen cream and not had this happen.” Her voice lowered to a quieter, confiding tone. “The doctor even said it will help my leakage issue and help certain things feel better!”

While I appreciated her subtlety in referencing her sex life, I was encouraged to hear that this mattered to her. Then I cringed at how uncomfortable that must have been for her, given the diagnosis. I did not inherit that tolerance level.

I heard her speak to my sister off to the side: “I’m talkin’ to Corinne and telling her all about my friable vagina.” In the background, my sister said something about taking her boys for a ride on the ATV. “OK, y’all have fun! I’m finishing my ride and will see ya later! I’m back,” she said. “The boys are having a blast out here. When are you coming to visit?”

“August,” I said, relieved to have an acceptable answer to that often-contentious question.

“Oh, wonderful! Well, that’s just great!”

And then she said something that took my breath away.

“I just feel so stupid for not using it all these years. I used to have a prescription for it, but when my gynecologist left Half Moon Bay, I never thought to ask for a new tube.”

She felt so stupid? She was taking ownership of this oversight. I was dumbfounded. In what medical system — academic elite or small-town private practice — should a post-menopausal woman hold the blame for not having a prescription for vaginal estrogen? How, across all her years of care, even with the Stanford-trained physicians she still calls the ultimate, had vulvovaginal pain, bleeding, and leakage never come up? Even if she never mentioned it herself, something conceivable for a woman of her generation and sense of propriety, there was only one explanation. No one ever asked, and clearly, given the current state of her vulvovaginal tissue, no one ever took a careful look.

I thought of the women I had seen for inflammatory vulvovaginal conditions like erosive lichen planus, inverse psoriasis, lichen sclerosus, allergic contact dermatitis. Different pathologies, but a shared experience of quiet misery. I have always known my mother to be a strong, resilient woman in times of distress, but this level of resignation shocked me.

“Mom, that sounds very painful. Have you been in pain?” I had definitely seen patients with skin conditions that looked worse than they felt, and then some whose symptoms far exceeded the appearance. But the symptoms of vulvovaginal skin conditions were almost universally disruptive to quality of life.

She thought for a moment. “I mean, no more so than usual. I just thought it was normal. But not the bleeding. Nope, I knew that wasn’t normal. And boy was I right.”

I tried to swallow, but her words felt like a lump of dry cotton in my throat. This is what she thought was normal for her age. A brilliant woman with a higher medical IQ than some physicians I know had just accepted this constellation of symptoms as what 75 must feel like.

As a physician, I felt the culpability of the medical field. As a daughter, I felt an immense sense of concern. What else had she — and other women of her generation — folded into the narrative of normal aging? Had she not started bleeding, how long until the UTIs started? Would she have gotten help then? Or would it have taken a hospital admission and urosepsis?

As a woman, I felt rage.

“This is NOT your fault, Mom. I can’t believe you’ve been suffering for this long. I’m so relieved that there is an easy treatment, and that it’s not….” I paused. The words anything serious had almost escaped. But this was serious. The blood from her atrophic vaginal tissue was blood on the medical system’s hands. Sure, she could have asked or brought it up. But as a physician, I know that patients rarely volunteer symptoms involving their genital area. It is our job to ask. Missing it falls completely on us.

“I’m so glad that it’s not cancer,” I said. “I am just so relieved.”

And angry. And terrified for what this implies about the women without her level of awareness and access. But I kept that quiet. I focused on gratitude that intervention had arrived upstream of any life-threatening consequences. Her symptoms weren’t life-threatening — but their impact on her quality of life was serious, and, thankfully, surmountable.

“I KNOW,” she said. “I mean, I knew it was probably something really silly, so anyway, the cream will come next week, and I’ll keep you posted! Had to order it because our pharmacy doesn’t keep it in stock. Gotta go make dinner!”

So silly? I thought. The pharmacy doesn’t keep it in stock?

The hits keep coming. We have a lot of work to do.

Three weeks later, I called my mom on my way home from clinic. “How are things going?” I asked. “Are you feeling any better?”

She was back on her bike, an activity that I couldn’t imagine enduring at altitude before both her SVT and her vaginitis had been diagnosed and treated. Once again, her resilience surprised me.

“Oh, Corinne. I’m a whole new woman! EVERYTHING feels better, if you get my drift. Even my leakage is less. I just can’t believe it! I just still feel SO STUPID!” She laughed.

She sounded happy, joyful even, and possibly less out of breath than usual. She sounded more like herself than she had in the past few years. Just as she had accepted her daily symptoms as her new normal, I realized I had accepted her fatigued voice as her age-appropriate baseline.

I felt a resurgence of fury at all of her doctors who hadn’t looked or asked over the past decade, outrage at the doctors still not looking or asking about vulvovaginal symptoms, but a new emotion entered, more powerful and pervasive than the anger.

I felt ashamed. Ashamed I had not asked more questions over the years, or visited more frequently, or been there with her at appointments. Should I have been running a review of systems as part of our regular phone calls? In addition to asking about her succulent garden, am I supposed to inquire if intimacy reminds her of a cactus?

Outside of fielding family photos of rashes and breakouts, which I’m happy to help triage, I try to play the role of daughter, sister, niece, more than physician. I need this for my own balance and perspective, but in doing so, I couldn’t help but wonder if that was now selfish. The boundaries I had tried to establish felt as foolish as a line carved in the sand during a hurricane.

I also felt ashamed for all of the years I cared for women and didn’t ask these questions or do a thorough vulvovaginal exam. Prior to my shift into menopause dermatology, how many times had I done skin exams on women and not done a thorough vulvar exam? How many times had I not even thought to ask if they had any symptoms or concerns in the genital area? How many times had I assumed their gynecologists had it covered?

The answers to those questions filled me with nausea. Many, many times. For years, I was just as culpable as the doctors I had been silently raging toward since learning of my mom’s symptoms. Hot tears rushed into my eyes and blurred my vision as I approached a traffic light.

“I’m just so, so sorry, Mom. I should have asked more questions.”

“Corinne, my vagina is not your responsibility. I’m not telling you this to make you feel bad. I’m telling you because I’m proud of the work you are doing. Women need to know about vaginal estrogen, and take it from this woman, we don’t know. And as you know, I know A LOT about medicine. I know you try to be perfect, but there is a reason they call it a practice of medicine. Keep doing what you’re doing, and don’t feel bad.”

“Okay, then,” I said, my eyes refocusing on the road as the light turned green. “I won’t feel bad if you stop feeling stupid.”

We chatted more about her book club’s current pick, and I preemptively shared that I was halfway through an Elin Hilderbrand beach read and loving every page.

“A creative writing major at Stanford who reads Elin Hilderbrand,” she mused. “Well, Elin did go to the Iowa Writers’ Workshop, which is THE BEST.”

We hung up as I turned into my driveway, my three doodles rambunctiously greeting me with wags and barks, ready to pounce. I saw my son inside through the dining room window, working on his Legos. My daughter ran out on the breezeway barefoot, waving a dog bone to lure the pups away from my car.

Before stepping out of the conversation still reverberating in my brain and into the chaos of my home, I reflected on the path forward. Flanked by the memory of my mom’s words on one side and my nine-year-old daughter’s joyful chirrups as she scooped up the smallest of the pups on the other, I felt the weight of age and the buoyancy of youth. But at the same time, I appreciated a lightness uniquely possessed by time and experience. At any moment, my daughter could stub her toe in a strange new way and feel irrevocable despair, while my mother has lived through physical and emotional traumas enough times to trust that things can be mended. At age 45, I was very much in the middle — made heavy by things I once didn’t know, but lifted by confidence in my ability to change, learn, and do better.

I sifted through the reasons women’s health has ended up in this fragmented state. The black box warnings stating estrogen causes cancer, strokes, and dementia. The misguided WHI headlines that brought hormone therapy and research to a halt for over 20 years. The doctors never trained in hormone therapy because of the aforementioned risks, emblazoned across everything from vaginal estradiol cream to patches to pills.

It only took three weeks of a local vaginal estrogen cream to heal my mom’s atrophic vaginitis, reduce her incontinence, and relieve discomfort with intimacy. How long, and how much unnecessary suffering, will we endure before we find the salve to solve the erosive state of women’s health?

When I embarked on this journey into midlife women’s skin health, I thought the road to hell for women looked a lot like the adult diaper aisle, always placed conveniently beside the tampons and maxi pads as if they were the next step in our genitourinary development. Now I realize the real road to hell is one in which doctors cling safely to the barricade of how we were trained to do things, while women drive on through, only to find an unfinished bridge on the other side.

I turned off my car and opened the door to admit the smallest, loudest dog, George, into my lap. After all, the squeaky wheel gets the grease.

As women, we need to take a lesson from George and squeak louder. I’m grateful my mother drew the line at unexplained bleeding and got checked out. I hope women develop a lower threshold of concern and feel safe asking their doctors about urinary habits, painful sex, and vaginal bleeding. I hope we are met with validation and action, rather than unchecked reassurance or yet another referral. I hope that we as physicians learn to ask women the questions they may hold back out of shame, or because they’ve simply accepted these changes as part of aging.

But hope is not a strategy, and I know as well as anyone that there are real barriers to meaningful change. The doctors on the front lines of women’s health face the responsibility of relearning menopause medicine while seeing a growing volume of patients and watching reimbursement rates fall. Many physicians with the passion and interest to manage menopause rehome their practices in the direct-pay or concierge model. Telehealth platforms are rapidly arising to meet the need, often praised for showing up and then lambasted for monetizing menopause care. The preoccupation with how imperfect the current solutions are is now itself a disease, parasitizing the energy of those trying to move forward.

I don’t say this because I have a solution. I think everyone is right and wrong in some ways, that all of the above are true. That we can’t possibly provide adequate women’s healthcare within the confines of the managed-care model, and yet we have to find a way to make it work. Yes, people will make money, and loads of it, with industry-disrupting business models. We will look back on many schemes selling invalidated, snake-oil menopause supplements and grimace.

“How could we have been that stupid?” we will ask.

That’s the most dangerous narrative, and the one we must drown out. We were not, and are not, stupid for not knowing what we didn’t know, for not knowing it was okay to ask an uncomfortable question, and for not knowing that the new normal we had accepted was an undershoot.

My mom has been right about most things regarding my path in life. She was right about my not marrying fiancé number one, or number two. She was right about quitting alcohol, and that I would be much happier without it. She was right that she never needed to tell me these things, that I would figure them out for myself.

She was also right about writing. When we share our stories, we turn our private, quiet misery into something powerful. We turn it into agency. If one woman reads this and it encourages her to ask whether she is really destined for diapers, or whether there is a better way to live, then the hours of reflection and shame spiraling have been worth it.

The medical field will either catch up and adjust, or be replaced by alternative paths. As a doctor, I do my part to educate and inform, within and beyond my practice walls, about menopause, skin health, and learning to read the changes we see on our skin as early warnings that can prevent a larger problem.

Thank you, Mom, for sharing your story with me and letting me share it with women reading this everywhere. Stay in the saddle, Mom, and remember that it was never your fault.