Shamed by a Doctor

The same month two new papers on the physical and economic ravages of menopause were published, a physician whose care I sought spoke enraging words I will never forget.

[Editor’s note: I was going to call this story “Slut Shamed by a Doctor,” but then I tried sending it with this headline to Dr. Mysorekar, the researcher I interviewed below, to fact check her words, and it didn’t make it past her spam filter. Just know that this was my intention, to name it thus, and that this story does, indeed, describe an incident of slut shaming by a medical professional. Related: AI should learn that “slut shaming” is neither a racy term nor one that requires filtering by spam folders. It is a virulent form of discrimination we women experience often.]

You’d think with all of my experience writing about doctors; dealing with doctors; thinking about menopausal health; writing about menopausal health; calling out the medical establishment for ignoring the ravages of menopause on women’s bodies; reading all of the latest medical studies I can get my hands on; and urging women to self-advocate with their physicians that I would be the least likely person to be caught in a humiliating interaction at a doctor’s office.

Hahahahahaha! You would be wrong. So wrong. I will tell you how wrong, but first, before we get to that—and because the science part of this publication will always be free for all subscribers—let’s go over two important and related new papers, just published, on menopause.

First, there was this Mayo Clinic study, published last week, which detailed the economic toll of menopause on American women: we lose an estimated $1.8 billion in working time per year. And no wonder. When we’re not managing the brain fog, night sweats, migraines, and recurring UTIs of menopause, we’re taking off time to visit doctors who often belittle our symptoms or tell us it’s all in our head or, in my case—read on—try to slut shame us or make us feel crazy for wanting to engage in a normal sex life. Then it’s onto the next doctor, as we seek answers, medications, understanding, empathy, and relief. Rinse, repeat. That is, if we can even afford these visits and medications, which many of us cannot.

Take the cost of estrogen, which, as my recent story on accessing hormone therapy in Oprah Daily detailed, is often outrageously steep. Or take my migraine medication, Aimovig, a CGRP-inhibitor monoclonal antibody which has been, no joke, a miracle drug. I went from having over fifteen post-menopausal migraines a month to zero, once I started injecting the drug back in 2019, but its copay recently rose from $5 a month to $499 a month. So I have been rationing my monthly Aimovig shots, taking one every month and a half instead of every month. (And yes, this has led to a few breakthrough migraines.)

Second—and related to the first—if you’ve been reading these missives, you know I’ve been a loud and proud proponent of vaginal estrogen to prevent the recurring UTIs of menopause. For me, personally, the use of vaginal estrogen has not completely eliminated UTIs, but it has greatly reduced them from near-constant—one after the other with sometimes only a day or two in between—to infrequent enough that I can now live my life and do my work without continual fear of the next one striking. (I still fear the antibiotic resistance I’ve built up before anyone told me about the benefits of vaginal estrogen—thanks, Dr. Rachel Rubin—but that’s for another day and another post.)

Still, even as my UTI incidents tapered down to manageable, I kept asking both myself and my doctors the same questions: Why are people in menopause more prone to UTIs than others? What is the relationship between thinning vaginal tissue and the sneakiness of E. coli finding its way into the bladder and causing a ruckus? Could the foreshortening of the menopausal urethra be to blame? Is it a question of an imbalance of the flora in bladder? And why, even when I am meticulous about UTI prevention—installing a bidet in my home, showering before sex, asking my partner to do the same, peeing before and after sex, taking a post-coital Macrobid, downing D-Mannose, smearing vaginal estrogen all over the urethra and vulva every night, etc., etc.—am I still struck by the occasional E. coli infection?

As usual, a lack of funding for the study of female bodies; a lack of disaggregation of data between male and female bodies; and the fact that only 8.5% of urologists are female play major roles in the difficulty of figuring out the whys. Then, this month (hallelujah!), The Journal of Urology came out with a groundbreaking study. Turns out, menopausal bladders are particularly prone to something called cystitis cystica, a chronic inflammatory change in the lining of the bladder. In essence—and I’m greatly summarizing here—menopausal bladders prone to UTIs sometimes grow tiny lymph nodes inside them. Wait, what? Lymph nodes in the bladder? I contacted Dr. Indira Mysorekar, one of the researchers of this paper, who studies the pathogenesis of infections, to break it down for us laypeople:

“UTIs are very common in women but as we get older and post-menopausal they become even more common,” she told me. “And even though this has been known for a long time we don't really know why and how. They say, ‘Oh, it's because you're menopausal,’ but what does that mean?” Because mice in menopause are similar to humans in menopause, Dr. Mysorekar and her team dug into their tiny menopausal bladders to hunt for clues. “One of the things that we found that was very dramatic,” she said, “is that there were these big lymphoid follicles lesions inside the bladder, made up of lymphocytes called T cells and B cells, which make antibodies. The bladder is essentially filled with these antibodies.”

Next, the team looked at human bladders in menopause to search for similar antibodies, and there they found the kinds of lesions that any urologist familiar with a cystoscope might have seen in the menopausal bladder for decades, but here’s the thing: they thought these lesions were ‘incidental.’ “So we went and biopsied those little lesions,” said Dr. Mysorekar, “and found that they were these little lymph node structures in the in the postmenopausal female bladders!”

What this means, in a nutshell, is that the menopausal bladder has its own specific risks and ecosystem. And doctors who are dealing with post-menopausal women with recurring UTIs need to show extra care and diligence when figuring out what’s going on inside. It’s not enough to simply prescribe yet another antibiotic after a patient pees in a cup, and the test comes up positive or negative for E. coli. They have to look inside the bladder with a camera to see what, if anything, might be growing in there and then biopsy the lining if necessary. They have to understand that the post-menopausal bladder can actually, according to Dr. Mysorekar, shed some of its lining. They have to realize that sometimes the infected post-menopausal bladder will not produce a positive urine test.

In other words, once again, doctors must think outside the box when it comes to their post-menopausal patients: something most doctors in specialties outside of gynecology—and even those often inside gynecology, alas—have never been trained to do. For example, I had to visit three different neurologists until I found one willing to entertain the notion that my migraines could be related to menopause and estrogen fluctuation. One neurologist literally rolled her eyes when I suggested this back in 2017.

Which brings me to my most recent cautionary medical tale.

A month ago, I visited my (beloved!) gynecologist with my second UTI in a single month. She urged me to get a cystoscopy this time, just to see what was going on. For the sake of ease—and because I’m a lazy idiot who doesn’t take her own advice to thoroughly research all physicians before seeking their care—I made an appointment with the urologist who shares my doctor’s office facilities. He was a man, and I am wary of male doctors after too many bad experiences with men, but I figured cystoscopies are rote procedures; I just needed someone to perform it; and the fact that he was on the same portal system as my gynecologist would make it easy for them to share information back and forth.

From the moment I interacted with this man, however, my Spidey sense told me something was off. I felt unheard and dismissed, for one—this not unusual, unfortunately—but it was our last interaction that had me crying in the middle of midtown Manhattan as I fled his office, enraged.