The most common perimenopausal discomfort is the hot flash (sometimes called hot flush). Hot flashes are the result of sudden changes in the body's "thermostat," the center of the brain that controls temperature regulation. If the brain's hypothalamus mistakenly senses that the woman is too warm, it starts a chain of events to cool her down. Blood vessels near the surface of the skin begin to dilate so that blood rushes to the surface in an attempt to cool the body. This produces the red, flushed look to the face and neck. A woman may also begin to perspire so that the evaporating sweat can also cool the body. An increased pulse rate and a sensation of rapid heart beating may also occur. A cold chill often follows. A few women have only the chill. Hot flashes that occur with drenching perspiration while sleeping are called night sweats. Night sweats and hot flashes may interfere with sleep, even if they are not strong enough to cause awakening. Also, falling estrogen levels alone can disrupt patterns of healthy deep sleep. While it is a myth that menopause itself makes a woman irritable, inadequate sleep causes fatigue, which may lead to irritability. More than two-thirds of North American women have hot flashes during perimenopause. With induced menopause (surgical or chemotherapy-caused), almost all women have severe hot flashes that begin immediately following surgery or ovarian damage. Hot flashes usually have a consistent pattern, but each woman's pattern is different. Some hot flashes are easily tolerated, others are annoying or embarrassing, and still others can be debilitating. Most women experience hot flashes for three to five years before they taper off. Although some women never have a hot flash or have them only for a few months, others may have them for many years. There is no way of knowing when they will stop. Most women are able to identify particular triggers that seem to bring on their hot flashes, such as external heat (eg, a warm room or use of a hair dryer), strong emotions, hot drinks, hot or spicy foods, alcohol, and caffeine. A few drug therapies sometimes prescribed for women, such as tamoxifen (Nolvadex) for cancer chemotherapy and raloxifene (Evista) for prevention or treatment of osteoporosis, can cause hot flashes.

Some non-hormone prescription medications used for other purposes (such as high blood pressure or depression) have been accidentally discovered to improve hot flashes. Clinicians can legally prescribe them for "off label" (nonapproved) indications. An example would be using Catapres (clonidine), a blood pressure medicine, to treat hot flashes. Other prescription drugs are sometimes used: antidepressants such as sertraline (Zoloft) and venlafaxine hydrochloride (Effexor), and neurontin (an anti-epilepsy med).
Some women find relief from hot flashes by using remedies available over-the-counter (purchased without a prescription) at drugstores and health food stores. Black cohosh and isoflavones, may help some women. Some of these remedies are often referred to as complementary and alternative medicine (CAM). Over-the-counter and CAM therapies may take two to six weeks before effects, if any, are felt It is difficult to study how well these therapies work because placebo (dummy) medications relieve hot flashes in up to 40% of the women who take them.

Some women experience menopause-related insomnia, especially if hormone changes provoke hot flashes. Sleep is adequate when one can function in an alert state during waking hours. Treatment of insomnia should first focus on improving sleep routine, such as avoiding heavy meals in the evening and adjusting levels of light, noise, and temperature. Avoiding alcohol, caffeine, and nicotine throughout the entire day (not just during the evening) can help increase sleep efficiency and total sleep time. Daily exercise can also help ease insomnia in many women, but exercising close to bedtime may have the opposite effect.
When lifestyle changes fail to alleviate sleep disturbances, a clinician should be consulted to discuss other options and to rule out disorders such as thyroid abnormalities, allergies, apnea (breathing problems), and anemia, which could be the culprit. Although estrogen is not FDA-approved for treatment of insomnia, ET has been shown to improve sleep in some women.

During perimenopause, some women may begin to notice changes that occur in the urogenital area, which includes the vagina, genitals, and urinary tract. ). In perimenopause and the years after menopause, many vulvovaginal changes can occur as a result of natural decreases in internal estrogen levels. This estrogen decline can cause tissues of the vulva and the lining of the vagina to become thin, dry, and less elastic - a condition known as atrophy. If the thin, alkaline vagina becomes inflamed, it is called atrophic vaginitis. This type of vaginitis is not an infection. However, without treatment, the vaginal lining may deteriorate to a thickness of only a few cell layers, and small vaginal ulcers can occur. In fact, vaginal pain and bleeding during sexual intercourse can intensify to the point where intercourse is no longer pleasurable or possible. Over time, pubic hair becomes less abundant and vaginal walls become shorter and more narrow These urogenital changes can include the following symptoms:

These changes can range from mildly annoying to downright debilitating. There are many possible causes and effective treatments.

At some point in life, at least one-third of all women will experience some vulvovaginal problems, not all due to menopause. For example, an unusual vaginal discharge with an unpleasant odor or with itching and irritation of the vulva could be vaginitis, a vaginal infection. While typically not a serious condition, vaginitis can be bothersome and sometimes recurrent. It sometimes resolves on its own. A clinician's diagnosis is essential to receiving proper treatment.

Other conditions that may cause vulvovaginal problems include:

• Skin diseases, such as eczema and Lichen sclerosis.
• Other diseases, such as Crohn's disease, an inflammatory bowel disorder.
• Pelvic radiation therapy, which can cause severe vaginal dryness and irritation.
• Medications, such as antibiotics, which can lead to a yeast infection.  Tamoxifen taken for breast cancer can cause an increase in vaginal dischargey.
• Vulvodynia (pain in the vulva).
• Allergic reactions to chemicals in soaps, bubble baths, spermicides, condoms, feminine hygiene sprays, or deodorant tampons and pads.
• Irritation from tampons or birth control devices, such as a diaphragm or cervical cap, left inside the vagina too long.

Women near or beyond menopause should not assume that vulvovaginal problems are due to reduced estrogen levels. All vulvovaginal changes should be investigated by a clinician to determine the true cause.

Treatment: Vaginal lubricants and moisturizers available without a prescription may help in milder cases of vaginal atrophy. Regular sexual activity has also been shown to maintain vaginal health. If these measures are ineffective, then the best treatment is to use supplemental estrogen (topical, not systemic. Sometimes the vaginal lining becomes easily inflamed or broken, and may bleed. These vaginal tissues are also prone to injury during sexual relations or even a pelvic examination. Prescription estrogen therapy topical (stays on the vaginal skin, not in the blood stream) quickly restores the thickness and elasticity of these tissues and also relieves vaginal dryness. All dosage forms are effective and FDA approved for this use, but vaginal atrophy symptoms may respond more quickly to the vaginal forms of estrogen (vaginal creams, vaginal tablet, and vaginal ring). In cases of severe vaginal atrophy, several weeks of treatment may be required to restore the vagina to a healthy condition.

As menopause approaches and during the years that follow, lack of estrogen can cause the lining of the urethra, the outlet for the bladder, to become thin. With aging, the surrounding pelvic muscles may weaken. As a result, a woman may have one or more of the following urinary conditions:

• Cystitis or infections of the bladder.
• Urethritis or infections of the urethra.
• Weakening of the pelvic muscles and ligaments due to natural aging or previous damage from childbirth injury.
• Certain prescription drugs, such as diuretics and some tranquilizers.
• Irritated bladder caused by smoking cigarettes, drinking alcohol and/or caffeine.
• Other medical conditions, such as the nerve disorder multiple sclerosis.
• Painful urination.

When urine leakage and lack of bladder control become so problematic they have an impact on hygiene and/or overall well being, the condition is called urinary incontinence. While incontinence can occur at any time, the likelihood of becoming incontinent increases with age because of a variety of factors, including decreasing estrogen.

Stress incontinence - urine leakage upon coughing, laughing, sneezing, or lifting
Although up to 40% of women aged 45 to 64 have urinary incontinence, less than half seek help. This is often because of embarrassment or the misconception that the condition is a normal part of aging and cannot be treated. In reality, diagnosis and treatment can often completely cure the problem. If a cure is not possible, comfort can usually be improved. Incontinence should never be viewed as an inevitable result of aging.
To diagnose the exact cause(s) of incontinence, a clinician obtains a medical and sexual history, and performs a physical examination, including a pelvic exam and analysis of a urine sample. Keeping a voiding diary can be helpful. Additional specialized studies of the bladder are often needed.
Treatment: Today, there are many options to treat urinary incontinence, and more are in development. The best option, however, depends on the cause of incontinence.

Kegel exercises consist of repeated contraction and relaxation of the urogenital muscles, toning the muscles that control urine flow. When done correctly, Kegels are highly effective but must be continued indefinitely. Another potential benefit is improvement of vaginal sexual function.

Prescription medications, such as certain anticholinergic drugs (Detrol, Ditropan) that control abnormal bladder contractions, are FDA-approved for the treatment of incontinence. Estrogen therapy, although not FDA-approved for this use, has been reported to produce improvement in some women with certain types of incontinence, but the evidence is weak. Estrogen may also help reduce the risk of urinary tract infection. Urinary tract infections or infections of the vaginal area brought on by urine leakage are treated with antibiotics.

Surgery is used to correct anatomical defects. When urinary incontinence does not improve with initial treatment, a physician with expertise in female urology or urogynecology should be consulted. A specialist is also recommended when there is a complex condition, such as a neurologic disease or when surgery is being considered.

Devices, such as a pessary (inserted into the vagina to support the uterus or bladder) or those used to block the urethra, can relieve incontinence for some women.

Biofeedback with electrical stimulation of muscles is used to help retrain the bladder.

Periods stop when a woman is past menopause, but taking some hormone treatments can cause bleeding to resume. Unless the bleeding is the typical pattern caused by taking hormones, women who have uterine bleeding after menopause (12 months with no menses at all) should see a clinician immediately to rule out serious causes, such as cancer.

Sexuality is a natural part of living, and sexual feelings, desires, and activities are healthy throughout life. Sexual concerns are common in midlife women.
As mentioned earlier, changes in the vagina brought on by falling estrogen levels at menopause can make intercourse painful. In addition, it is not unusual for male partners to experience sexual problems, including impotence, as they age. Sexual desire (libido) is also an important component of sexual function, and it decreases with age for both sexes. Many women during their 40s and 50s notice they have less sexual desire, but exactly how menopause and hormones may contribute to this change is unknown. In fact, many women remain sexually active well into older age.
Ovulating is a main physical drive for libido in women. Ovulation problems are a main reason women begin perimenopause, and ovulation ends with menopause.  
No correlation has been found between falling estrogen levels and declining libido. Androgen, however, does appear to play a role in women's sex drive, and aging ovaries also produce less androgen, although the decline is not so steep as with estrogen.
The conditions that further decrease internal androgen levels include surgical removal of one or both ovaries prior to menopause, pituitary and adrenal insufficiency, corticosteroid therapy, and chronic illness.

Numerous factors influence a woman's sexual activity and interest during midlife and later, including the following:
Sleep disturbances from hot flashes at night can make a woman tired and irritable, thereby affecting sexual desire. Previous attitudes often dictate a woman's view of her sexuality as she ages. In general, women who enjoyed sex in their younger years continue to do so during and beyond midlife. Those who did not enjoy sex previously may view any midlife reduction in sexual activity as relief rather than loss. Partners may also lose interest in sex or have decreased capacity for sexual activity. Some women, however, have an increased interest in sex. Age-related changes can affect sexual functioning. Although sexual desire generally decreases in both men and women over time, a decline does not mean an abrupt halt, and the rate and extent of any decline is individual.
A woman's perception of her body is an important component of her sexual health. Menopause usually occurs at a time when women are experiencing changes in physical appearance. A woman who accepts her changing body and maintains a positive outlook about it is more comfortable with herself and tends to experience greater sexual enjoyment. Partners, too, are typically changing in their appearance, and-. this can also affect sexual encounters.
Health concerns of both women and men, such as the pain and fear associated with serious illnesses, can significantly interfere with mutual enjoyment of sexual relations. A woman may feel unattractive and may avoid initiating sexual encounters after a surgical procedure, such as removal of a breast or the uterus. Likewise, her partner may avoid intercourse, fearing that vaginal penetration will cause her pain.

Depression, stress and anxiety may have an impact on a woman's primary erogenous zone - her brain - undermining sexual desire.
Many medications, such as those for high blood pressure and depression, can create problems with sexual desire and orgasmic capacity.
Induced menopause can lessen sexual desire.

The following are issues that may be important when discussing sexual function with a clinician:

Types of sexual relations
Types of sexual activities
Status of relationship
Number of sexual partners past and present
Sexual orientation
Habits related to self-stimulation
Ability to achieve orgasm
Changes in sexual interest
Changes in arousal
Adherence to safer sex practices
History of STDs and testing for STDs
Birth control method(s) used
Satisfaction level with current sex life
Medications and remedies used, both prescription and nonprescription
Incontinence can lead to sexual avoidance.
Hysterectomy can affect sexual function, and women and their partners need reassurance that losing the uterus does not mean losing sexual desire and femininity. During intercourse and orgasm, some women may notice a change in sensation after hysterectomy, but in general, these changes do not interfere with sexual functioning or achieving orgasm. In fact, many women have improved sex lives after hysterectomy due to relief from pain and bleeding, and the lack of need for birth control.

The hectic pace of life can interfere with emotional and physical intimacy, and couples can take their sex lives for granted. Good communication is the key for understanding sexual changes. Some couples find that intercourse takes more time or they fail to make time for quality sexual encounters.
Men may experience a lack of sexual interest or difficulty achieving erection or ejaculation, and may need more manual or oral stimulation of the penis. Women, too, may need more stimulation to achieve adequate lubrication or orgasm.
Intercourse does not have to be the primary sexual activity. More attention can be devoted to other sexual behaviors that may be as satisfying, such as oral sex, massage, sensual baths, manual stimulation, and caressing. Women without partners can explore masturbation, a normal and healthy expression of sexual interest. Using a vibrator or dildo may enhance sexual pleasure.
Understanding these factors, making adjustments, and getting any necessary medical treatments can alleviate anxiety and improve sexual activity. It is a myth that sex education is only for the young. An individual's sexual function changes with age, and a need for information accompanies these changes.
While many women find it difficult to discuss the intimate aspects of their sexual relations, healthcare providers are better able to help them achieve optimal sexual health after an open discussion on sexual history and lifestyle. If needed, a referral to a specialist in sexual counseling can be provided.
Drug therapy to improve sexual function is a field still in its infancy, and many studies are being conducted. A small number of studies have produced conflicting results on estrogen's ability to improve sexual drive or arousal. Estrogen probably does not improve sex drive independent of making intercourse less painful by treating atrophy of the vagina. However, adding androgen to estrogen therapy may be helpful in boosting libido.

Discuss sexual history with a potential sex partner; don't let embarrassment compromise health.
Always insist that male partners use a latex condom for genital, oral, and anal sex unless in a long-standing, mutually monogamous relationship; never use petroleum-based oils such as Vaseline or baby oil for lubrication because they can damage condoms.
Choose sex partners selectively.
Keep medically fit by having an annual physical exam, a Pap test when indicated, and tests to identify STDs.
Urge any partner exposed to an STD or with a confirmed diagnosis to be examined and treated.
Protection Is Essential
The risk of pregnancy is eliminated only after menopause has been reached. But protection from pregnancy is not necessarily protection against sexually transmitted infections (STDs). The risk of STDs, including syphilis, chlamydia, gonorrhea, genital herpes, genital warts, hepatitis B, and HIV (the AIDS virus), is a lifelong concern for sexually active women. In fact, postmenopausal women without adequate estrogen levels may be at increased risk for STDs. Delicate vaginal tissue, prone to small tears and cuts, can act as pathways for infection.
Safer sex guidelines are important even if a woman has had a hysterectomy or her ovaries removed. Most STDs are more easily transmitted to women than to men. STDs are also less likely to produce symptoms in women, making them more difficult to diagnose until serious problems develop.

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