What changes, beyond hot flashes

Vasomotor symptoms get the attention, but the transition also affects sleep, mood, cognition, bone density, lipids, blood pressure, body composition and genitourinary tissue. Genitourinary syndrome of menopause differs from the rest in one important respect: it does not improve on its own with time. It progresses. Treating it early is easier than treating it late.

Bleeding changes during perimenopause are expected — but not all of them are benign. Bleeding that is very heavy, that occurs between periods, or that occurs at any point after menopause has been reached needs evaluation, not reassurance.