as clear on whether this is the same for premenarcheal or perimenarcheal girls. The vaginal pH during menopause is 6.5–7.0 (without hormone replacement therapy), or 4.5–5.0 with hormone replacement therapy. After menopause, the body produces less estrogen. This causes atrophic vaginitis (thinning and inflammation of the vaginal walls), which can lead to vaginal itching, burning, bleeding, soreness, or vaginal dryness (a decrease in lubrication). Vaginal dryness can cause discomfort on its own or discomfort or pain during sexual intercourse. Hot flashes are also characteristic of menopause. Menopause also affects the composition of vaginal support structures. The vascular structures become fewer with advancing age. Specific collagens become altered in composition and ratios. It is thought that the weakening of the support structures of the vagina is due to the physiological changes in this connective tissue. Menopausal symptoms can be eased by estrogen-containing vaginal creams, non-prescription, non-hormonal medications, vaginal estrogen rings such as the Femring, or other hormone replacement therapies, but there are risks (including adverse effects) associated with hormone replacement therapy. Vaginal creams and vaginal estrogen rings may not have the same risks as other hormone replacement treatments. Hormone replacement therapy can treat vaginal dryness, but a personal lubricant may be used to temporarily remedy vaginal dryness specifically for sexual intercourse. Some women have an increase in sexual desire following menopause. It may be that menopausal women who continue to engage in sexual activity regularly experience vaginal lubrication similar to levels in women who have not entered menopause, and can enjoy sexual intercourse fully. They may have less vaginal atrophy and fewer problems concerning sexual intercourse. Vaginal changes that happen with aging and childbirth include mucosal redundancy, rounding of the posterior aspect of the vagina with shortening of the distance from the distal end of the anal canal to the vaginal opening, diastasis or disruption of the pubococcygeus muscles caused by poor repair of an episiotomy, and blebs that may protrude beyond the area of the vaginal opening. Other vaginal changes related to aging and childbirth are stress urinary incontinence, rectocele, and cystocele. Physical changes resulting from pregnancy, childbirth, and menopause often contribute to stress urinary incontinence. If a woman has weak pelvic floor muscle support and tissue damage from childbirth or pelvic surgery, a lack of estrogen can further weaken the pelvic muscles and contribute to stress urinary incontinence. Pelvic organ prolapse, such as a rectocele or cystocele, is characterized