While pregnancy becomes less and less frequent as woman age, 40 is not the time to stop using birth control unless a pregnancy, while not planned, would be welcome. I have delivered far too many babies to woman who thought they were too old to conceive because they were 40.

Technically speaking, a five-year-old, a teenager, and a 30-year-old are all PRE, or before, menopause, but that is not the true meaning of the word. Premenopause is used to describe women in their later reproductive years, or early to mid-40s, who are still having regular menstrual cycles -- They are not yet old, but definitely no longer young. They are full-on adult women in what many would consider the prime of their lives: vital and productive forces of nature, mothers, mentors, leaders, and builders with experience bordering on wisdom.

Many of my patients who are considering timing of their pregnancy request blood work because they want to “check my fertility.” These tests, anti-Mullerian hormone (AMH), follicle stimulating hormone (FSH) and estradiol are, in some ways, an indirect measure of your ovarian reserve. Levels in the “normal” range suggest that you have sufficient reserve and are, therefore, potentially fertile. Note: a “normal” value does not guarantee that you can get pregnant, just that your levels are in the “normal range” for people who can conceive. It is also only a snapshot in time. If it is “normal” this year, it may not be “normal” in another year. If it is abnormal, you might have to reconsider your timing or speak with a specialist about potentially “freezing your eggs,” otherwise known as fertility preservation, or using a donor egg.

Technically speaking, a woman is menopausal a year after her last menstrual period. From that point forward, she is technically postmenopausal and no longer produces estrogen in any meaningful amount. This does not happen overnight. Years may pass before there is no measurable estrogen in your system. Alas, there is no more pretending. Welcome to the club! You are now officially old in some people’s minds.

The average age in the US for the last menstrual period is 51, but the range can be from 48–52. This is where things start to get real for women, their partners, their families, and their coworkers as changes begin to occur, including menstrual cycle irregularities, hot flashes, sleep disturbances, muscular/joint aches and pain, and mood swings. How long a woman remains perimenopausal varies considerably, ranging from a few months to a few years.

A "hot flash" is a misnomer. They are not simply just “flashes.” They are intense and prolonged SURGES of overwhelming heat that can make an otherwise sane woman want to strip naked and stand in front of an open freezer, something most people do not want to see a 50+ year old woman do!

Experience several “hot flashes” throughout the day? Turtlenecks are a no-no at this time. You may think they’ll help hide the sweat running down your neck, but trust me you’ll regret having any extra fabric touching parts of your skin when a flash happens! Sleeping with one foot out of the covers helps a lot of women. Ceiling fans can become your next BFF.

Many menopausal women complain of waking at 3 or 4 o’clock in the morning for no apparent reason. Be assured that millions of other women are awake at the same time wondering why.

There are very few women (or men) over the age of 30 who haven’t noticed that they can no longer eat what they want and not gain weight. By 40, many realize that even when they watch what they eat, they gain weight. By 50, the game is over. Simply looking at food seems to put on pounds. There is a maddening tendency for weight to deposit around the middle during peri-and post-menopause because of lower estrogen levels. Even if you don’t gain a pound, the distribution of your weight will change as you approach and go through menopause.

As usual, gynecologists advise that women eat right, exercise regularly, avoid stress and lose weight. All of these things are great in general, like chicken soup, it couldn’t hurt. But I must say, for most it’s like the Wizard of Oz telling Dorothy to get the witch’s broomstick. No way was she going to do that, but she couldn't go home until she did. If you keep making up excuses for why you gained weight—it’s my hormones, it’s the pill, it’s whatever it is—you won’t sign up for the difficult and consistent changes required. Bottom line is nature does not care what your excuse is...as my father used to say: “That’s an excuse, not a reason.”

Depending on family history, ethnicity and lifestyle, after menopause you may soon find yourself developing osteopenia, a condition where bone loss or density (which is measured by DXA scan) is lower than what is considered healthy, but not yet to the point where fractures occur with minor trauma as in osteoporosis. Weight-bearing exercise, adequate calcium (aka 1,000–1,200 mg per day) and vitamin D consumption along with smoking cessation can help you maintain and/or rebuild your bone density.

Fortunately, most bleeding that occurs in the first year or two after menopause is likely related to that last egg that didn’t get "asked to dance" for a reason. You may suddenly start to feel premenstrual, get cramps, and then have a bleed reminiscent of a period. However, any bleeding that occurs a year or more after menopause needs to be investigated. This is because the risk for uterine cancer or precancer (atypical endometrial hyperplasia) increases with age.

An alternative to HRT is antidepressants. I personally found that an antidepressant provided what I will call a “20% discount”. The flashes were either 20% less frequent or 20% less bothersome. Fortunately, at this point, my symptoms were less frequent and less severe, so I continued.

While changing hormone levels clearly have something to do with vasomotor symptoms, their exact role is still not completely understood. Clearly, it is not the total lack of estrogen, otherwise five-year-old girls and 90-year-old women and all men would have them. Imagine how challenging it would be to live in a household if everyone, regardless of their age or gender, were having hot flashes!

While many peri- and postmenopausal women get hot flashes, most can either learn to live with them, try lifestyle changes, over-the-counter medications or the alternative medications. For those with symptoms that interfere with life in a meaningful way, they should consider temporary use of hormone replacement therapy (HRT). Why? Because it works! It has risks and side effects, but it works.

Hormone replacement therapy (HRT) does not “replace” your estrogen, it simply provides you with enough to treat the symptoms created by the irregularity/loss of estrogen at the time of menopause. Only a small fraction of what you made before menopause is required to treat the symptoms. Measuring the levels in your blood is an unnecessary expense. What you need to treat your symptoms is what you need, no matter what your measured levels are. Average starting doses are generally enough for most women, though many can get along with less and some will need more.