• Patient has classic presentation of a perimenopausal woman (menses become irregular, vaginal dryness, ~52 years of age)
• Key idea: Perimenopausal woman can sometimes be treated with hormonal contraceptives to manage irregular bleeding, but this patient is over 35 and an active smoker, which is a contraindication to estrogen-containing OCPs
• Key idea: Patient would be candidate for topical vaginal estrogen therapy (which does not carry same risks as systemic estrogen therapy)
• Red flags requiring further work-up: Abnormal uterine bleeding (bleeding between periods, prolonged periods, or heavier bleeding during periods), especially in a patient with risk factors (obesity, PCOS, unopposed estrogen, etc.)

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