The Renegotiation:
Why Women's Intimate Health Now Require Explicit Skills
Full disclosure: I cofounded Good Kitty Co. four years ago with Dr. Meghan Blake. If you want to know more about what we’re building, it’s at goodkittyco.com. But this essay isn’t about that. It’s about all of us with lady parts.
My friend started getting heart palpitations in her early forties. The usual thing: heart racing, skipping beats, sometimes mid-sentence in a meeting, sometimes lying in bed at 2 a.m. She did what you’re supposed to do. She went to her doctor.
Her doctor sent her to a cardiologist. The cardiologist ordered an EKG. The EKG was normal. So they ordered a Holter monitor (the heart-rate recorder you wear for days). That was normal too. So they ordered an echocardiogram. Normal. So they ordered a stress test. Normal. By the time someone finally suggested it might be hormonal, she had spent thousands of dollars and months of anxiety on a medical workup that found nothing because nothing was wrong with her heart.
She was perimenopausal. Heart palpitations are a documented symptom of declining estrogen. The fix was a prescription that costs less than her last cardiology copay.
Nobody had told her this. Not her primary care doctor. Not the cardiologists. Not her mother, not her older sister, not any woman she’d known. The information existed in medical literature. It was knowable. It just wasn’t part of the conversation.
I had a version of this too. Heart palpitations a few months ago. And itchy fucking skin. I only found out because my cofounder, Dr. Meg, recently wrote an article about the strange menopausal symptoms no one talks about. So I talked to my doctor, we tweaked my HRT, and the palpitations stopped. The itchy skin has lessened, but it’s still hanging around. Dr. Meg has been dealing with electric-shock sensations shooting up through her head. Itchy skin shows up in another column of the same list. The symptoms are bizarre, specific, and barely acknowledged in mainstream medical conversation. Estrogen receptors are everywhere in the body. When the estrogen goes, all manner of strange symptoms can crop up, and they can be weird.
Between Dr. Meg and me, we’ve had over a hundred UTIs in our adult lives. We’re now moving into midlife, perimenopausal, along with our friends, discovering that years of unexplained symptoms may be attributed to a hormonal collapse no one had warned us about. Welcome to women’s intimate health in 2026. The information is available. Kind of. The cultural script that would have made it accessible doesn’t exist.
Welcome to the renegotiation.
The Cultural Shift, Briefly
I’ve been thinking about a pattern in modern life that some strategists I follow call “the implicit becomes explicit.” The shared cultural scripts that used to tell us how to do things, how to date, how to marry, how to raise children, how to age, how to be a man or a woman, have collapsed without being replaced. Everything that used to be implicit, the assumed knowledge embedded in shared culture, has to be made explicit now. Negotiated out loud. Named, articulated, agreed upon, taught.
It’s a broad cultural argument and it applies almost everywhere. But there’s one place it applies with particular force, and that’s the topic I keep finding myself writing about: women’s intimate, sexual, hormonal, and bodily lives.
The cultural scripts that used to govern this domain were never adequate to begin with. They weren’t built by women, and they were constructed to keep women’s bodies polite, quiet, and available. Women suffered through, did what they were told to do, and got the symptoms they got, all without the language or permission to name what was happening. The information existed; the cultural script didn’t include sharing it.
Now that the script is collapsing, the question is what we’re going to replace it with.
What Women Were Never Told
Consider what women have been culturally trained to expect, or perhaps not to expect.
We weren’t told that perimenopause symptoms include heart palpitations, electric shocks, itchy skin, joint pain, brain fog, vertigo, tinnitus, formication (the sensation of insects crawling on your skin), restless legs, mouth ulcers, frozen shoulder, sensitivity to body odor, sudden food sensitivities, and dozens of other things that send women to specialist after specialist for workups that find nothing because the answer isn’t in any single specialist’s domain. The information lives in obscure medical journals and the occasional menopause-specific podcast. It doesn’t live in the cultural script.
We weren’t told that recurrent UTIs are not a normal part of being a woman, that the cycle of antibiotic prescriptions our doctors offered us for years for lack of a better solution is part of the problem, that non-antibiotic prevention is now the AUA-recommended first-line strategy for recurrent infections, or that there’s a clinical threshold of A-type proanthocyanidins from cranberry that actually works (and that most supplements miss it by a factor of ten). The information exists. The cultural script doesn’t include sharing it.
We weren’t told that vaginal estrogen reduces UTI recurrence by 50 to 60% in postmenopausal women, that the FDA’s black box warning on prescription estrogen was based on data from systemic oral estrogen and doesn’t apply meaningfully to the local cream, that the cream is safe and effective and most women who would benefit from it never get prescribed it. The information exists. The cultural script doesn’t include sharing it.
We weren’t told that orgasm is physiologically inhibited by chronic anxiety, that bodies dealing with low-grade infections and under-treated perimenopausal symptoms don’t respond to sex the way they would otherwise, that the slow degradation of women’s intimate experience in their forties isn’t an inevitable feature of aging but a treatable consequence of neglect and misunderstanding of the nature of arousal. The information exists. The cultural script doesn’t include sharing it.
We weren’t told what to say in bed, how to ask for what we want, how to tell a partner that something hurts, how to discuss prevention without killing the mood, how to integrate care for our bodies into the erotic life rather than treating them as separate phases. The information exists, in scattered sex-positive corners of the internet and a handful of books. The cultural script doesn’t include teaching it.
This is not a list of small omissions. This is what an entire cultural system of implicit assumption looks like when it’s optimized to keep women uninformed about their own bodies. That the script we inherited was designed to fail us isn’t an accident. It was designed to keep certain things invisible.
The Renegotiation Forced by the Information Age
What’s changed is not that women’s bodies have changed. It’s that the conditions that produced the old cultural script have changed.
Information is no longer scarce. It’s everywhere. An entire library of peer reviewed literature on perimenopause is one search away. The research on UTI prevention is one paywall away. The vocabulary of explicit sexual communication is in every podcast, every Substack, every group chat. The information was always asymmetrically distributed; now the asymmetry is breaking down.
And the women experiencing the symptoms are no longer willing to suffer in silence because the script said to. We’re naming things. We’re comparing notes. We’re showing each other lists of symptoms and saying, “this... this is what’s happening to me. Is this happening to you.” The implicit becomes explicit because we are making it explicit, woman by woman, in group chats and DMs and frank conversations and Substack essays like this one that look more like manifestos than essays.
This is the renegotiation. And like all renegotiations after a long period of implicit consensus, it’s uncomfortable. The old script told women to be quiet, accommodating, modest, available, and to interpret their own bodies through the limited vocabulary the culture offered. The new condition asks women to do work the old script never required: to know our own bodies in greater detail, to advocate for ourselves with providers who sometimes don’t know what we know, to ask for what we want in bed, to name symptoms that don’t have names in the public conversation, to make explicit what was supposed to stay invisible.
It’s exhausting. It’s also the only way out.
What the Renegotiation Actually Requires
If the cultural script has collapsed and we’re in the renegotiation phase, what does that actually look like? What skills does this new condition require?
I’ll be specific.
Body literacy. Knowing what’s happening in your body. Not in a hypochondriac way, but in the way an athlete knows her sport. The symptoms of perimenopause. The mechanism of recurrent UTIs. The function of vaginal estrogen. The difference between a UTI and a yeast infection and bacterial vaginosis and urethral irritation. The role of the vaginal microbiome. The relationship between gut health and bladder health. None of this used to be required knowledge for ordinary women. Now it is, because the health providers who should have learned it didn’t, and the cultural script that should have transmitted it doesn’t.
Provider advocacy. Being willing to advocate for yourself in conversations with your health care provider. Not deferring to a clinician who learned about perimenopause for three hours in medical school twenty years ago and hasn’t updated since. Asking for what you need by name. Bringing printouts of guidelines if necessary. Switching providers when the current one can’t or won’t. This can be uncomfortable work. The cultural script trained women to be cooperative patients. The new condition requires us to be informed consumers of medical care.
Explicit verbal communication during sex. Saying what you want. Saying what you don’t want. Saying what feels good and what doesn’t. Saying when something hurts. Saying when something feels amazing. Naming desires and limits out loud. The cultural script trained women to perform pleasure rather than have it; the renegotiation requires the actual having, which requires the actual naming.
Explicit prevention as practice. Treating your body as a system that responds to deliberate inputs, not as something that either works or doesn’t. Daily UTI prevention. Daily vaginal estrogen application if you’re peri- or post-menopausal. Lube before sex when you need it. Care after sex when your tissues need it. Hydration, nutrition, sleep. The implicit script positioned all of this as either too much fuss or too clinical for an erotic life. The renegotiation positions it as the infrastructure that makes the erotic life possible.
Naming things that have no public name. Aftercare. Sex kits. The lubrication problem. Hormonal heart palpitations. Electric-shock sensations. The peri-pause window between perimenopause and menopause where most of the symptoms cluster. The post-orgasmic recovery period for women. Cervical mucus quality across the cycle. The way certain medications affect arousal. All of this is happening to women’s bodies and most of it doesn’t have widely used vocabulary. We’re building the vocabulary in real time.
Relationship-specific negotiation. Asking your partner to participate in your care. Not in a needy way, in a “this is what intimacy looks like now” way. Letting your partner know what your body needs. Letting your partner know how to ask. Letting your partner know that prevention can be foreplay, that aftercare can be enjoyable, that the previously hidden bodily work of being a woman in your forties is part of what you’re inviting them into. The cultural script told us to keep all that hidden so we could remain attractive. The renegotiation says the work of being visible is part of being seen.
What This Looks Like in My Actual Life
I want to get specific about my own version of this, because the abstract argument is easier to make than the actual living of it.
I use Fountain HRT, a telehealth service that runs a full hormone panel as a baseline, prescribes bio-identical hormones, and follows up monthly to adjust based on how I’m responding. They test for fourteen-plus biomarkers, the kind of comprehensive workup that should be standard for any woman over forty. My regular doctor never ordered any of this. My insurance doesn’t cover the meds. I pay out of pocket for the entire program because the alternative was continuing to wait for the medical system to catch up to research it’s been ignoring for two decades. It’s pretty bullshit that this is the situation. The cost is real. I can afford it; many women can’t, which is its own problem worth naming. But waiting for the system was a worse option than paying my way around it. I started after my first hot flash, two years ago. I should have started at forty. Most women I know who are doing this work started even later than I did, after years of symptoms they’d been told to ignore. We are figuring this out blindly because the institutions that should have figured it out for us didn’t.
That’s just one piece of it. I also use Alloy for M4 estriol face cream, the prescription topical that supports facial collagen and skin barrier function as estrogen declines. I use Happy Head for custom topical treatment and oral supplements for the hair thinning that comes with perimenopausal estrogen loss, because the hair changes are real and most dermatologists don’t connect them to hormones. Between Fountain HRT, Alloy, and Happy Head, plus the assorted out-of-pocket costs for everything else (lab work, the occasional specialist visit, the supplements that aren’t covered), I spend over $4,000 a year on what amounts to baseline maintenance of my hormonal and bodily function. None of this is luxury. All of it is treatment for documented medical conditions that the regular healthcare system should be handling. Women I know who can’t afford this are doing without. That’s not a personal choice they’re making. It’s a systemic failure imposed on them.
There’s a friend group dimension to this too. A perimenopausal woman tells her best friend, who tells her sister, who tells her group chat, that the bizarre electric-shock sensations she’s been having down her arms are a documented symptom of estrogen decline. Three women in that chain make appointments with menopause specialists in the next month. The renegotiation looks like women being at the heart of a new cultural infrastructure that circumnavigates the holes in our medical system. We are doing the unpaid labor of writing the script that should have been here all along.
What It Costs and What It Returns
The renegotiation is exhausting. I want to acknowledge that.
The old implicit script asked very little of women, intellectually. You followed it, you stayed quiet about your symptoms, you accommodated, you suffered through what you were supposed to suffer through, and you tried not to make a fuss. The cost was your body’s experience, but the cognitive load was light.
The new condition asks a lot. Know your own anatomy in detail. Know the research on whatever you’re dealing with. Advocate with providers who don’t always know what you know. Ask for what you want in bed. Name what hurts. Make the previously hidden visible. Educate your partner. Educate your friends. Help build the cultural script that should have already existed. This is real work and it’s unfairly distributed; women shouldn’t have to do their own medical education plus their partners’ sex education plus bolster the broader cultural conversation, on top of everything else they already do.
But here’s what the work returns.
Fewer UTIs. Less menopausal misery. Better sleep. Less anxiety. Heart palpitations that go away once you address the actual cause. Sex that gets better instead of worse over time. Relationships that deepen rather than calcify. The cognitive freedom that comes from no longer suffering through symptoms you don’t have words for. The political power of being a woman who actually knows what’s happening in her body. The ability to look at the medical system, the supplement industry, the wellness influencer economy, the culturally produced anxieties of being a woman in midlife, and see through them.
The renegotiation isn’t a trend. It’s the unfinished work of women’s autonomy, finally being done. The implicit scripts that failed women were never going to update themselves. The women refusing to follow them are doing the cultural infrastructure work that the institutions wouldn’t.
This is the moment to be building the explicit version of women’s intimate life. The vocabulary, the products, the practices, the rituals, the conversations, the relationships, the medical knowledge, the brands that respect us, and the political demand that the established institutions catch up.
My friend got her cardiology bill last month. She paid it because she had to. But she texted me a photo of it with a single message: “Imagine if someone had just told me, could be your hormones.” That’s what the renegotiation feels like from the inside. Imagine if someone had just told us. Now we tell each other. We make the implicit explicit. We build the script that should have been here all along. We are the script now.
And we are very, very ready.
I’m 48. I’ve been writing Perfectly Unsuitable for less than a year now and I cofounded Good Kitty Co. four years ago. I’m not separate from the renegotiation I’m describing. I’m in the middle of it. So is every woman I know. If you want to talk about this, the comments are open.
More From Perfectly Unsuitable
If this essay resonated, here are a few others you might want to read next:
censHERship Part I: The Algorithm Blushes →
censHERship Part II: The Economics of Silence →
Building Good Kitty Co. With My Bestie →
Nihilism as a Business Strategy: UTI Prevention, Chokers and Meaning Making →
A note on attribution: The framework I’m borrowing in the first section, “the implicit becomes explicit,” comes from Concept Bureau’s Exposure Therapy publication. Their broader cultural work is worth subscribing to if you think about these patterns professionally. Find them at exposuretherapy.com. The application to women’s intimate health is mine.
Only as it applies to s.e.x. am I polite, quiet and available….and I’m not making any promises on the polite and quiet front!