Perimenopause, Menopause & Postmenopause

Perimenopause is the transition leading up to menopause. It most often begins in the 40s, but symptoms can technically begin in the 30s and may continue for years before the final menstrual period. [1] During this stage, ovarian function becomes less predictable. Ovulation may not occur every month, progesterone production can change, and estrogen can rise and fall dramatically rather than simply declining in a straight line.

You can still have regular periods and be in perimenopause. As the transition progresses, periods may become heavier, lighter, shorter, longer or less predictable. Hot flashes, night sweats, sleep disruption, brain fog, anxiety, mood changes, decreased energy and changes in body composition may appear.

Sexual changes can begin here too. Some women notice lower libido, less lubrication, changes in genital sensation, painful sex or more difficulty reaching orgasm. In one prospective study, the percentage of women with scores indicating sexual dysfunction rose from 42% early in the menopausal transition to 88% later in the transition. [2]

Perimenopause cannot always be diagnosed from a single hormone test. Estrogen and other hormone levels can fluctuate substantially, so laboratory results need to be interpreted alongside symptoms, menstrual history, age and medical history.

For some women, perimenopause may overlap with postpartum recovery or breastfeeding. Lower estrogen during breastfeeding, pelvic floor changes, sleep disruption and postpartum sexual changes may occur during the same period that the menopause transition is beginning. Symptoms should not automatically be dismissed as stress, motherhood or getting older.

Menopause is technically one point in time. Natural menopause is diagnosed after 12 consecutive months without a menstrual period when there is no other explanation. The average age of natural menopause in the United States is approximately 51. [5]

Menopause affects far more than menstruation. As the hormonal environment changes, women may experience hot flashes, night sweats, sleep problems, mood changes, brain fog, vaginal dryness, painful sex, urinary symptoms, changes in libido and difficulty reaching orgasm. Bone, muscle, metabolism and cardiovascular health also become increasingly important.

Mental health deserves particular attention. Women in the Study of Women’s Health Across the Nation were two to four times more likely to experience a major depressive episode while perimenopausal or early postmenopausal than while premenopausal. [3]

These changes should not automatically be dismissed as aging. Menopause is an important health transition, not an expiration date.

Postmenopause begins after menopause and lasts for the rest of a woman’s life. A woman who reaches menopause around age 51 may spend 30 years or more postmenopausal. [5] For many women, this is one of the longest stages of adult life, yet postmenopause is often treated as though the difficult part is simply over.

Some symptoms may improve, while other effects of lower estrogen and changing androgen balance can persist or progress. Bone loss and osteoporosis become increasingly important. Muscle and body composition can change. Cardiovascular and metabolic health deserve attention, and genital and urinary tissues may continue to change.

Vaginal tissue can become thinner, drier and less elastic. The vagina may become shorter or narrower, while the clitoris, labia and vaginal opening may become smaller. [6] These changes are part of genitourinary syndrome of menopause (GSM), sometimes still described as vaginal atrophy. GSM can cause vaginal dryness, burning, painful sex, decreased lubrication, urinary frequency and recurrent urinary tract infections. [6]

Changes in tissue health may also affect sensation, arousal and sexual pleasure. Postmenopause is not simply the period after menopause when nothing more can be done. This may represent decades of your life, and those decades deserve a plan.

What was does not have to determine what comes next. With the right evaluation and treatment, what can be may actually be better than what was.

Estrogen gets most of the attention during menopause, but it is only part of the story. Progesterone and testosterone matter too, and the balance between these hormones changes across perimenopause, menopause and postmenopause.

Estrogen

During perimenopause, estrogen can fluctuate dramatically. After menopause, ovarian estrogen production becomes much lower. Declining estrogen contributes to hot flashes and night sweats and can affect sleep, bone health, genital tissue, urinary tissue, lubrication and sexual function.

As estrogen decreases, vaginal tissue can become thinner, drier and less elastic, with changes also occurring in the clitoris, labia, vaginal opening and urinary tract. [6] Menopausal hormone therapy, often called hormone replacement therapy or HRT, remains the most effective treatment for hot flashes and night sweats and can help prevent bone loss in appropriately selected women. [13]

Progesterone

Progesterone is closely connected to ovulation. As ovulation becomes less predictable during perimenopause, progesterone production may also become less predictable. For women with a uterus who use systemic estrogen, progesterone or another appropriate progestogen is generally needed to protect the uterine lining. [13]

Testosterone

Testosterone is not just a male hormone. Women naturally produce testosterone throughout their lives, and it plays an important role in sexual desire, arousal, sexual responsiveness and tissues throughout the body that respond to testosterone.

Testosterone is part of a hormone group called androgens. In women, circulating testosterone can be substantially more abundant than estradiol, especially after menopause as estrogen levels fall. Focusing only on estrogen can therefore miss an important part of the hormonal picture.

Unlike estrogen, which drops sharply around menopause, testosterone generally declines more gradually with age. Research on testosterone in women and female testosterone replacement therapy, or TRT, is expanding rapidly, with growing evidence supporting benefits in sexual function and emerging research examining arousal, lubrication, genitourinary health and tissue integrity.

Female genital tissues are also testosterone-sensitive. The clitoris, vestibule, urethral and periurethral tissues, parts of the vaginal wall and pelvic floor contain androgen receptors, which helps explain why testosterone may affect more than libido alone.

Dr. Bawa looks at testosterone as part of the full picture, alongside estrogen, progesterone, blood flow, tissue health, pelvic floor function and the other factors that influence desire, sensation, lubrication and orgasm.

If something has changed, talk to Dr. Bawa. You do not have to simply accept less because you are getting older. There is always something that can be done.

Sex can change during perimenopause, menopause and postmenopause because hormones, blood flow, genital tissue, pelvic floor strength and the brain all affect sexual response. Dr. Bawa may prescribe estrogen, progesterone or testosterone when appropriate, but the world-renowned Bawa Method looks beyond hormones alone.

As hormones change, vaginal and vulvar tissue can become thinner, drier and less elastic. The vagina may become shorter or narrower, the clitoris and labia can become smaller, blood flow may decline, and lubrication, sensation and orgasm can change. These changes can also contribute to painful sex, urinary leakage and lower desire

Women are already dealing with an orgasm gap: only 33% of heterosexual women said they always orgasm, compared with 75% of heterosexual men. [4] Menopause can make that gap even harder to overcome.

Dr. Bawa may combine hormone optimization with BawaWave®, BawaRF®, the BawaShot® and BawaTone® to address blood flow, tissue health, sensitivity, sexual response and pelvic floor function. Understanding what has changed can also remove blame in a relationship and help both partners reconnect.

Cancer treatment can intensify hormonal, tissue, sexual and emotional changes, especially when it overlaps with perimenopause, menopause or postmenopause. And that is unacceptable. Dr. Kanwal Bawa is a pioneer in advancing treatment for women whose sexual health has changed after cancer. Patients travel to Bawa Medical in Boca Raton, Florida, from across the United States and around the world for her specialized care.

Sex may feel different, but there is always something that can be done.

Dr. Bawa’s approach to perimenopause, menopause and postmenopause looks beyond isolated symptoms. Depending on what has changed, treatment may address hormones, blood flow, tissue health, sexual response, pelvic floor function and long-term wellness together.

• Hormone Optimization
• Vaginal CO2
• BawaWave®
• BawaRF®
• BawaShot®
• BawaTone®
• Medical Weight Loss

1. The Menopause Society. Perimenopause and 2026 educational materials noting that symptoms may begin as early as the 30s.

2. Dennerstein L, Randolph J, Taffe J, Dudley E, Burger H. Hormones, mood, sexuality, and the menopausal transition. Fertility and Sterility. 2002;77 Suppl 4:S42-S48.

3. Bromberger JT, Kravitz HM, Chang YF, et al. Major depression during and after the menopausal transition: Study of Women’s Health Across the Nation (SWAN). Psychological Medicine. 2011;41(9):1879-1888.

5. American College of Obstetricians and Gynecologists. The Menopause Years; Vulvovaginal Health.

6. American College of Obstetricians and Gynecologists. Vulvovaginal Health. Genitourinary syndrome of menopause and menopausal genital changes.

7. Handa RJ, et al. Metabolic benefits afforded by estradiol and testosterone in both sexes: clinical considerations. 2024. PMCID: PMC11364390.

8. Lanoff J, Simon JA. Testosterone in Women: Clinical Evidence and Practice Guidelines. Obstetrics and Gynecology Clinics of North America. 2026;53(3):393-410.

9. American College of Obstetricians and Gynecologists. Treatment of Urogenital Symptoms in Individuals With a History of Estrogen-dependent Breast Cancer. Clinical Consensus.

10. American Society of Clinical Oncology. Statement on hormone replacement therapy and implications for cancer care. 2025.

11. Beste ME, Kaunitz AM, McKinney JA, Sanchez-Ramos L. Vaginal estrogen use in breast cancer survivors: a systematic review and meta-analysis of recurrence and mortality risks. American Journal of Obstetrics & Gynecology. 2025;232(3):262-270.e1.

12. Calaf J, et al. Safety of vaginal estrogen in breast cancer survivors: Current evidence on systemic absorption and oncologic outcomes. Maturitas. 2026.

13. American College of Obstetricians and Gynecologists. Hormone Therapy for Menopause.

14. American College of Obstetricians and Gynecologists. Compounded Bioidentical Menopausal Hormone Therapy. Clinical Consensus No. 6.

15. O’Connell HE, Hutson JM, Anderson CR, Plenter RJ. Anatomical relationship between urethra and clitoris. Journal of Urology. 1998;159(6):1892-1897.

16. O’Connell HE, Sanjeevan KV, Hutson JM. Anatomy of the clitoris. Journal of Urology. 2005;174(4 Pt 1):1189-1195.