Perimenopause is the time in a woman's life when she begins to experience the changes that lead to menopause. Smoking and shorter menstrual cycles can cause earlier menopause, while multigravidity and use of oral contraceptive pills are associated with later menopause. There may be additional factors, including cultural differences that influence the age of menopause. The menstrual and urogenital changes associated with perimenopause can be very distressing. Menstrual patterns are altered in many ways, including menorrhagia, menometrorrhagia, oligomenorrhea, intermenstrual bleeding, polymenorrhea, postcoital bleeding, and postmenopausal bleeding. In one small survey, 93% of women reported one of these changes in the five years prior to menopause. The challenge for the provider is to distinguish between normal and abnormal bleeding. Ultrasonography has become the standard test in the evaluation of dysfunctional uterine and postmenopausal bleeding. Hysterectomy is the only way to stop menorrhagia completely.