Many changes during perimenopause are normal and natural. They usually start when a woman is in her 40s, sometimes even in her 30s. As a rule, most will not continue far beyond menopause, and will stop without treatment. Some changes are problematic and need treatment. All changes, however, signal the need for a medical evaluation because it cannot be assumed that hot flashes and other changes are caused by approaching menopause. Some changes can be signals of disease or can be caused by other ailments, such as a thyroid disorder. Therefore, it is advisable to report any changes to a healthcare provider.
A woman's response to the physical changes of the perimenopausal years, while not genetically determined, can often be predicted by her mother's response. Women whose mothers describe their menopause as terrible may become conditioned to have a similar experience. Hot flashes or other discomforts of menopause are very real, yet the level of distress that a woman experiences is partly based on her expectations.
For some women, menopause just means the end of menstrual periods. To others, it means uncertainty about what to expect and an unwelcome reminder that they are aging. But women who embrace the changes, rather than dreading them, are the ones who find menopause to be an event that brings about better relationships and greater personal fulfillment, and they are more likely to make lifestyle changes that will improve their health for the rest of their lives. Women today are living in an era when menopause is better understood than ever before, and they have the advantage of being able to talk openly about it.

Beginning late in their 30s, women's fertility typically begins to wane significantly, primarily due to aging eggs in the ovaries. While there are many fertility-enhancing techniques available for midlife women, they are expensive, have some risks, and are
not always successful. At the same time, the risk of spontaneous miscarriage begins to rise, reaching about 50% by age 45. Also at this age, the risk of a genetic abnormality in a fetus is 1 in 40, and there is an increased chance of pregnancy complications, such as gestational diabetes, stillbirth, and the need for cesarean section.

Information about birth control in a menopause booklet may seem surprising. But, despite a decline in fertility during perimenopause, women are not totally protected from an unplanned pregnancy until menopause is reached. If pregnancy is not desired, it is important to choose an effective, safe, and appropriate method of birth control, particularly in midlife when pregnancy can have an impact on health far beyond the reproductive years.

Midlife women have a wide range of effective birth control options. A healthcare provider can help determine the best birth control choice based on a woman's medical history, lifestyle, and sexual habits. It should be noted that only one method - condom use - provides protection from HIV and other sexually transmitted infections (STDs). Options include the following:

Sterilization methods include tubal ligation (for women) and vasectomy (for men).
Pros: These methods are safe and have a very low failure rate of about 4 to 8 in 1,000. Tubal ligation (having tubes "tied") does not cause menopause.
Cons: They are surgical procedures and have to be considered permanent.

Barrier methods include the diaphragm, cervical cap, spermicides, and the male and female condom.

Pros: These methods are highly effective if used during every act of vaginal sex, although spermicide alone is less effective. A condom is the only method proven effective as protection against both pregnancy and STDs when used during vaginal, oral, and anal sex. Condoms can be used in combination with other birth control methods, and they are available without a prescription.

Cons: A few women and men are allergic to latex condoms or certain spermicides. These methods must be used during every act of sex, and condoms may break, leak, or spill when removed.

Oral contraceptives, sometimes called birth control pills, contain either one hormone (progestin) or two  (progestin plus estrogen) for contraception.

Pros: These prescription products provide effective contraception; after discontinuing use, there is a rapid return of fertility. Modern low-dose pills that combine estrogen and progestin are safe for healthy, nonsmoking, midlife women, and are highly effective when taken as directed. Noncontraceptive benefits include reduced risk of ovarian and endometrial cancer, fewer fibrocystic breast changes, and reduced rates of postmenopausal bone density loss. They may also help regulate periods and reduce hot flashes during perimenopause. Long-term use will not significantly increase cardiovascular risk in healthy nonsmokers. Most studies do not show a significant relationship between use of birth control pills and risk of breast cancer.

Cons: Contraindications include history of blood clots or coronary artery disease, breast cancer, jaundice during previous birth control pill use, pregnancy or suspected pregnancy, uncontrolled hypertension, and cigarette smoking in women over age 35. Possible side effects include nausea, breast tenderness, new or worsening headaches, and spotting between periods. Using birth control pills can mask changes in a woman's period, and thereby mute her natural signal of approaching menopause. Birth control pills also invalidate the FSH test that is often used to confirm menopause. Because of the difficulty in knowing when menopause is reached, most clinicians advise women to stop birth control pills at age 51, the average age of menopause. Heart attack and stroke are rare but serious side effects, especially in smokers and with the use of older high-dose pills. The mini-pill, which contains only a progestin, may be better for women at risk for blood clots in the legs (phlebitis). However, the mini-pill is slightly less effective in preventing pregnancy than the combination pills and may not offer the same noncontraceptive health benefits.

Progestin injections. An injectable birth control option is available: Depo-Provera. It contains progestin for effectiveness, and a healthcare provider needs to give the injection into a large muscle (typically the buttocks). 

Pros: A single injection of one of these products provides more than 99% contraceptive effectiveness for several weeks (up to one month for Lunelle and up to three months for Depo-Provera). Long-term use is associated with lower uterine cancer risk. After discontinuing use, fertility returns  within 10-18 months for Depo-Provera.

Cons: Contraindications include pregnancy, vaginal bleeding of unknown cause, breast cancer, liver disease, and blood clotting disorders. Common side effects include weight gain, hair loss, and changes in menstrual cycle, especially during the first few months of use. Other possible effects are fatigue, headaches, nervousness, and dizziness. They also require regular visits to the healthcare provider for injections.

Intrauterine devices (IUDs) can be placed inside the uterus by a clinician. Different devices use different materials for effectiveness, such as copper or a progestogen.

Pros: IUDs are highly effective for long-term pregnancy protection (up to five years for one progestogen device, 10 years for copper). Today's IUDs are much safer and more effective than older devices, and there is no evidence of increased risk of pelvic inflammatory disease or cancer. When removed, contraception is reversed and fertility rapidly restored.

Cons: Contraindications include pregnancy or suspicion of pregnancy, history of pelvic inflammatory disease, not being in a mutually monogamous relationship, abnormality of the reproductive system (which includes an unresolved abnormal Pap test), abnormal genital bleeding, anemia, and infection of the fallopian tubes or ovaries. Possible side effects of cramping or spotting may occur initially after insertion. In addition, menstrual periods may be heavier and last longer while the IUD is in place, although one of the progestogen-containing IUDs has been found to reduce bleeding by up to 90%. The office procedure for insertion may be uncomfortable, and cramping or spotting may occur initially. The user must periodically check the string that remains outside the uterus in the vagina to ensure the IUD is in place. The string is sometimes felt by the partner. IUD use requires at least an annual exam by a clinician.

Progestin implant system. One implant system,Implanon, is available for birth control and consists of one progestin-releasing capsule  surgically implanted by a clinician under the skin of the inner, upper arm.

Pros: The implants, which can be removed by the clinician at any time, offer 98% contraceptive effectiveness. When removed, fertility returns rapidly.

Cons: Contraindications include pregnancy, history of blood clots, unexplained vaginal bleeding, breast cancer, or liver disease. Side effects include headaches, nausea, weight change, acne, increased vaginal dryness, and irregular uterine bleeding, typically in the first 9 to 12 months after insertion. Some medications used for epilepsy may make the implants less effective. The system's costs include purchasing the product plus the office surgery to insert and remove the capsule. Implants must be removed after five years, and there is a possibility of permanent scarring at the insertion site.

Methods that use no drugs, devices, or surgery include natural family planning, such as rhythm or periodic abstinence.

Pros: There is no cost, no need to take drugs or use devices, and no need for surgery. There are no contraindications or side effects.

Cons: When using the rhythm method, it is especially difficult to predict unsafe days during perimenopause when periods are irregular.

“Emergency contraception" can be effective if used within 72 hours of unexpected, unprotected sex or a condom accident. These "morning-after" pills should not be used as regular birth control.

During the reproductive years, two of the hormones made by the ovaries - estrogen and progesterone - play important roles in the menstrual cycle. In preparation for a fertilized egg, estrogen causes the endometrium (lining of the uterus) to start to thicken. Progesterone then causes a ripening or secretion of nutrients. If a fertilized egg is not received in the uterus, the ovaries stop making these hormones, and the uterine lining is shed as the menstrual period. Each woman has a pattern to her periods, which differs from woman to woman.
A few women simply stop menstruating one day and never have another period. Most women, however, go though a longer perimenopause and experience changes or irregularities in their menstrual periods. These irregularities are caused by secretion of erratic levels of ovarian hormones and decreased frequency of egg release (ovulation). Initially, the menstrual changes can be subtle. Usually a woman's cycle will get shorter, with periods occurring more often than every 28 days. Bleeding may last fewer or more days than previously, and blood flow may be heavier, lighter, or just spotting. Late in perimenopause, skipping periods becomes common. However, some women skip several cycles and then menstruate regularly again. Any menstrual pattern is possible - but each woman will know that, for her, a change has occurred.

Hormonal imbalance. Irregular or heavy bleeding can be caused by the poor ovulation that occurs as the ovaries begin to decline.

Hormonal contraceptives. Use of products such as prescription contraceptive pills, implants, injections, and intrauterine devices can cause spotting or breakthrough bleeding, particularly in younger women. Spotting refers to a small amount of bleeding from the vagina that occurs at the monthly time for a period. Breakthrough bleeding occurs at a time other than the monthly time for a period. Until menopause is reached, pregnancy can occur and cause abnormal uterine bleeding as well as missed periods. For most women, these changes are natural and normal during perimenopause, and no treatments are needed.

These noncancerous growths in or around the uterus are a very common cause of abnormal uterine bleeding. While some fibroid tumors produce no symptoms, others can produce dramatic changes in periods (such as prolonged and/or heavy bleeding), menstrual cramps, back pain, and difficulty with bowel movements or urination. While the cause of fibroids is unknown, their growth can be stimulated by estrogen surges that sometimes occur during perimenopause. Fibroids may shrink after menopause when the ovaries reduce production of estrogen. Occasionally, estrogen replacement therapy stimulates their growth once more.
Other uterine lining (endometrium) abnormalities. Noncancerous growths, such as polyps, in the endometrium can result in abnormal uterine bleeding. In a very small percentage of cases, some types of cancer in the uterus, vagina, and cervix can cause abnormal bleeding from the uterus and/or vagina. Regular pelvic exams and Pap smears are particularly helpful in diagnosing these serious diseases early enough for effective treatment. Factors that interfere with blood clotting sometimes cause uterine bleeding. In addition, although bleeding passing from the vagina usually comes from the uterus, it is possible for the vagina or cervix to be the source of bleeding.

There are several procedures a clinician can use to determine the cause of abnormal uterine bleeding, including the following:

This is a widely used procedure often performed in a clinician's office, and no anesthesia is needed. A small sample of the uterine lining is removed through the cervix (opening to the uterus from the vagina) then examined by a pathologist. Endometrial biopsy is often used to exclude cancer, and it can sometimes identify other reasons for bleeding.

In this surgical procedure, the cervix is dilated and the uterine lining removed by scraping or by suction and scraping. Because it usually requires anesthesia, D&C has decreased in frequency due to endometrial biopsies.

In this procedure, a tiny telescope is inserted into the vagina and through the cervix to view the uterine lining directly. A biopsy can usually be done at the same time if there are any observed abnormalities.

This painless procedure uses sound-generated images, similar to the ultrasound images used during pregnancy. The images are obtained with a probe inserted into the vagina. Although it is less invasive than surgery, transvaginal ultrasound can sometimes miss small abnormalities.

In this variation of ultrasound, saline is infused into the uterus to enhance visualization of the uterine cavity.

When abnormal uterine bleeding is caused by internal changes in levels of estrogen and progesterone, it can often be regulated with prescription hormones, such as low-dose oral contraceptives. Other prescription hormonal drugs, such as progestogens, are also sometimes used for short-term treatment.
If nonsurgical treatments fail, several surgical procedures are available, depending on the cause of the abnormal bleeding. If fibroids have been diagnosed, the decision to surgically remove them depends on their size, number, and location, as well as the severity of symptoms and a woman's desire for more children. Many of these procedures are used to remove fibroids, but they can also be used to evaluate and treat other kinds of abnormal uterine bleeding.

A tiny telescope (laparoscope) is inserted through a small incision in the abdomen. Pelvic organs can be viewed through the laparoscope and, sometimes, fibroids or ovarian cysts can be removed.

A laser or electrical loop is inserted into the uterus through the cervix. Growths or polyps that bulge into the uterine cavity can be removed.

The uterine lining is destroyed by freezing, heating, or cauterization. It cannot be used when fibroids are the problem, unless the fibroids are also removed.

Valuable in the past for determining the cause of abnormal uterine bleeding, but as a treatment, it seldom cures the condition of severe, consistent abnormal bleeding. Today, other surgical treatments are generally considered better options.

Uses an abdominal incision to remove uterine fibroids (typically performed under general anesthesia).

Uses small plastic beads inserted into the uterine artery to block the blood flow to the fibroids, causing them to shrink. Indicated for women with fibroids who can't  or don’t want to undergo surgery. Usually performed on an outpatient basis.

About 30% of all hysterectomies in the United States are performed for fibroids, and others are done for abnormal uterine bleeding. The uterus (and sometimes the cervix) is removed along with any fibroids that may be present. Afterward, pregnancy is no longer possible. The ovaries may or may not be removed (Oophorectomy). If both ovaries are removed (bilateral Oophorectomy), immediate surgical menopause occurs.

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.

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.

There are many myths associated with menopause. One is the myth that mental health problems, such as depression and anxiety, are inevitable as hormone production decreases. In reality, there are no scientific studies to support the belief that natural menopause contributes to true clinical depression, anxiety, severe memory lapses, or erratic behavior.
However, many midlife women do suffer from feeling blue or discouraged. Others suffer from sleep deprivation and overwork, leading to fatigue and sometimes irritability. Support and encouragement can help women find their way through any difficult time to thrive once again during what can be the best years of their lives.
During reproductive years, most women become accustomed to their own hormonal rhythm, but during perimenopause, this rhythm changes. These hormonal fluctuations, although normal, can contribute to mood swings. The unexpected timing of menopause can also be upsetting. For some, the hormone-related changes coincide with other stressors and losses in life. Women in midlife are not unaccustomed to stress, but some women can be especially vulnerable to stressors that may arise.

In addition, in today's youth-valued society, getting older can be difficult. Midlife women often experience changes in self-concept, self-esteem, and body image. They may start to think about their own mortality and become introspective about the meaning or purpose of their lives.
Although these changes can be opportunities for positive transformation and growth, some women react by feeling overwhelmed, out of control, angry, and/or numb. They may look for refuge in alcohol or drugs and, thus, compound their problems.
In fact, women are more likely than men to drink more in response to feeling blue, experiencing loss or divorce, or children leaving home. Thus, although not caused by menopause, psychological problems can arise during midlife.

Emotional health during perimenopause requires a balance between self-nurturing and the obligations of work and caring for others. Many women are able to identify and describe sources of tension and symptoms of stress, but they often find it difficult to take care of themselves during these times. Recognizing a problem can lead to understanding its causes and developing new coping mechanisms. Although many stressors cannot be altered, coping skills can be learned to make a woman feel empowered to meet life's challenges. A renewed sense of self-confidence can restore balance and harmony.

Sometimes, coping skills are not sufficient to relieve the symptoms of stress. These feelings may be a side effect of medication, a symptom of a medical condition, or the result of depression. A healthcare provider can help determine the cause of mental health stressors, assess options, and prescribe appropriate treatment.

The psychological disturbances reported most often by perimenopausal women are irritability and blue moods. These can often be relieved through lifestyle changes. Relaxation and stress reduction techniques help many women cope with life stress factors during this time of hormonal fluctuation. Mood disturbances brought on by sleep deprivation resulting from hot flashes usually improve when hot flashes are treated.
Clinical depression is not related to menopause, but it is associated with a chemical imbalance in the brain. If medication is needed for mild to moderate depression, herbal remedies such as St. John's wort may help. If the depression is more severe, one of a variety of effective prescription antidepressant medications can be prescribed to correct the chemical imbalance. Although several weeks are usually needed for the drug's full effect, most women show a marked improvement with these medications with relatively few side effects. Antidepressant medication is best used in combination with counseling or psychotherapy.

• Eat three nutritious meals a day, don't skip meals
• Snack on healthful, crunchy foods, such as apples and raw carrots
• Find or renew a creative outlet or activity that fulfills mental and spiritual needs.
• Try stress reduction and relaxation techniques, such as deep breathing and meditation
• Get adequate sleep each night
• Laugh as much as possible

Hormone therapy, as part of a comprehensive treatment plan, is reported to help some women with depression. Many women respond well to estrogen therapy, but it may actually worsen mood in some women who are clinically depressed.
The prescription hormone progestin, a synthetic progestogen, may also worsen mood, particularly in a woman with a history of mood changes prior to each menstrual period during younger years. Women who must take progestin to protect the uterus from cancer and who have mood problems while taking one drug regimen may find relief by trying different forms, doses, or regimens of progestogens. No hormone is FDA-approved for relief of psychological symptoms.

Anxiety - an agitated sense of anticipation, dread, or fear - is experienced by everyone at one time or another. Perimenopausal women may have more anxiety due to physical and psychological changes as well as a variety of stressors. Although this anxiety usually resolves on its own without treatment, it may accompany or be a warning sign of another medical illness, such as panic disorder. Panic disorder can result in shortness of breath, chest pain, dizziness, heart palpitations, and/or feelings of "going crazy" or being out of control. Sometimes the unsettling feelings that precede a hot flash can trigger feelings of panic or an attack of anxiety. Sometimes anxiety symptoms can be related to depression.
Women with severe symptoms of anxiety can usually find relief through therapeutic approaches, including prescription drug treatment, relaxation techniques, stress reduction techniques, counseling, and psychotherapy.

Perimenopausal women frequently report difficulty concentrating and minor memory problems (especially remembering something that was very recent). These difficulties often frighten women, who may think they are beginning to have early symptoms of Alzheimer's disease. This is rarely the case. More research is needed to determine the cause of these complaints. They may be more related to stress and aging than to the menopause transition. Some women report that estrogen therapy provides relief, but estrogen is not FDA-approved for this use. Also, lowered estrogen levels may be associated with memory problems and Alzheimer's disease later in life, although research in this area is contradictory.

Although some individuals may feel embarrassed or even ashamed about revealing their mental health problems, no one should suffer in silence. Women should seek help from their healthcare provider, who will be better able to help when given as many facts as possible about family and personal history. Most healthcare providers are not specifically trained in the management of mental health disorders. A consultation with a mental health professional is sometimes appropriate. For a specific problem, such as marital trouble or an eating disorder, a counselor with expertise in that area is best. Consultation with a mental health professional is not a commitment to long-term treatment, and getting an expert opinion can be reassuring.

Perimenopausal women often report other health changes that may or may not be attributed to approaching menopause. Among these changes are weight gain, heart palpitations, joint pain, headache, and changes in the skin, eyes, hair, and teeth.

In their 40s and 50s, women often gain weight and sometimes attribute this gain to menopause or hormone therapy for menopause-related conditions. However, the notion that menopause or hormone therapy is responsible for weight gain is not supported by scientific evidence. Midlife weight gain appears to be mostly related to aging and lifestyle. Studies reveal the following:

• Behavioral factors, particularly decreased exercise and increased alcohol consumption, are more closely linked to weight gain than either menopause or hormone therapy.
• Body shape typically changes with aging - from a "pear" (wide hips and thighs) to an "apple" (wide waist).

Muscle mass often decreases, while fat often increases. Although this shift may not increase weight (muscle weighs more than fat), body size will go up. The loss of muscle mass also decreases metabolic rate and lowers a woman's caloric need, which can lead to weight gain. Exercise seems to have the most beneficial effect on minimizing fat increases and maintaining muscle (thereby minimizing body size and increasing caloric need). Women, both perimenopausal and postmenopausal, who are looking for a lower fat-to-muscle ratio will find more reward in resistance type exercises, such as weight lifting.
In general, fewer calories are needed after menopause, when less energy is expended. Thus, a woman can eat the same amount and gain weight.

There is no scientific evidence linking heart rhythm abnormalities (palpitations) with the diminished hormone levels of menopause. However, an increase of 8 to 16 beats in heart rate can occur during a hot flash, which some women may interpret as a heart problem. Palpitations may also be the result of thyroid disease or anxiety experienced with mood changes or from more serious psychological upset. It is unlikely that palpitations experienced at this time are related to heart disease. Nevertheless, women experiencing heart palpitations should report these feelings to their healthcare provider to rule out serious illness.

There are no studies linking menopause and joint pain. However, the risk of osteoarthritis - the most common form of joint disease - increases with aging. Suffering from joint pain is not inevitable. A woman's healthcare provider can recommend the best type of exercises to help alleviate pain and, if needed, over-the-counter and prescription therapies.

Studies suggest that perimenopausal hormonal fluctuations may play a role in headaches. Women at special risk for hormonal headaches during perimenopause are those sensitive to hormone fluctuations, which is usually indicated by a history of headaches at the same time each month during their menstruating years. Some nonhormonal causes of headaches are infection, dental problems, or sinus problems, and some can be a sign of more serious conditions, such as hypertension.

Most headaches are minor, but some can be more severe and interfere with daily life. These include the following:

• Tension headaches - Squeezing or pressing pain across the forehead or around the head that often occurs upon waking; the headache can last from 30 minutes to several days.
• Migraine headaches - Severe, throbbing pain, typically located one-sided at the temple, that occurs periodically; the headache may be accompanied by nausea, vomiting, and sensitivity to light and noise.
• Cluster headaches - Multiple episodes of short-lived but severe one-sided pain.

Most headaches either do not require treatment or can be treated with nonprescription pain medications. Hormonal headaches that are related to hormone fluctuations of perimenopause can sometimes be relieved through hormone therapy that attempts to level the fluctuations. With migraine headaches, estrogen may either make them better or worse. Estrogen is not FDA-approved for treatment of headaches, but there are several other prescription drugs approved for this use.

The skin undergoes normal changes with aging, including loss of collagen and elasticity, creating slight sags and wrinkles. Skin becomes more dry and flaky. Drinking plenty of water and using skin creams will help keep skin moisturized. Long-time smokers have even greater skin damage, particularly wrinkles around the lips and dark circles under the eyes. Maintaining skin health is yet another reason not to smoke. Aging skin becomes more prone to sun damage, so protecting the skin from harmful UV rays through use of a good sunscreen is more important than ever. Any dark or changing moles should be evaluated by a clinician.
A small percentage of perimenopausal women report irritating sensations to the skin, ranging from severe itching to phantom symptoms of "ants crawling under their skin." This condition, called formication (from the Greek word for ant), is difficult to diagnose and even more difficult to treat. There are no scientific studies to guide clinicians. Sometimes hormone therapy or antihistamines will help.

Getting older increases the likelihood for hair to become gray and more brittle. In addition, excessive hair growth can occur in areas of the body where hair follicles are most androgen-sensitive, such as the chin, upper lip, and cheeks. Women often report a large "rogue hair" on their chin that seems to grow to a great length almost overnight. Hair thinning may also occur, a condition that is typically genetic and in response to a shift in the internal balance between estrogen and androgen. After menopause, the increase in the androgen-to-estrogen ratio may cause hair thinning to worsen. However, the tendency for hair thinning may decrease for women experiencing surgical menopause because the internal androgen levels plummet after the ovaries are removed. Androgen therapy may result in hair loss; some women also have hair loss with estrogen therapy. Eating a healthy diet, adding a daily multivitamin, and avoiding harsh chemicals and sunlight that dry the hair will help keep hair healthy. Treating severe hair loss is more of a challenge because finding the cause is often difficult. Women suffering from this condition should consult a dermatologist.

Aging often results in the need to wear corrective lenses. There is also an increased risk of eye diseases such as cataracts and macular degeneration. Some women report dryness, scratchiness, and burning of the eyes, as well as light and cold intolerance. Use of eye moisturizers can help for this dry eye syndrome. If symptoms persist, an ophthalmologist should be consulted.

After menopause, there is an increase in tooth loss, the need for dentures, and gingival bleeding and inflammation. Thus, good dental hygiene and regular checkups are as important as ever. Some dental changes may be related to diminished levels of internal estrogen. Often, tooth loss is a sign of underlying bone disease, such as osteoporosis. A woman's primary healthcare provider needs to be kept current on any changes observed by her dentist.

For more information, go to the North American Menopause Society at www.menopause.org

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