Along with rounder, softer hips and thighs and a straighter line where we once may have had the curve of a waist, our breasts change shape during perimenopause. Breast tissue is very sensitive to estrogen, and with estrogen’s decline, it loses some of its density and becomes fattier. Women with full breasts may find that their breasts appear to sag, and smaller-breasted women are often surprised when their breasts seem to become smaller still.

I’m often asked if hormone replacement therapy reverses changes in breast tissue. The answer seems to be that it won’t restore the dense tissue we had in our breasts when we were younger. In fact, some women report having uncomfortable cyclical breast changes when they are on HRT, particularly if they are taking synthetic hormones. (But the softer, less dense breast tissue found in older women does make mammograms easier to read and breast changes easier to detect.)

There are several pieces of advice I give to women who are dismayed about their changing breast shape, like Pauline, who worried that her “drooping” breasts signaled that unwelcome changes were in store for the rest of her body. First we have to acknowledge that breast changes may be harder to deal with than some of the other physical changes in perimenopause, because they suggest a loss of youth, sexual appeal, and ability to nurture. I reminded Pauline that when her body began to change in preparation for puberty, breast changes were probably unsettling to her then too. Walk through the halls of a middle or junior high school, and you will see a number of young girls who either walk or dress in a certain way to conceal their developing breasts. The feelings we have in our forties are very different¡ªsadness or poignancy, as opposed to confusion or embarrassment. But the reasons are the same: parts of our bodies are changing, and we need to give ourselves the time to adjust.

It’s also important to think about your whole body, without compartmentalizing your breasts or any part of yourself as somehow separate from the rest of you. Your breasts are sexual, yes, but a change at the cellular level doesn’t necessarily affect your subjective experience of your sensuality. Even before your breasts changed, they were not your sole means of giving or receiving sexual pleasure, or the single definition of your sensuality, and they won’t be after they change either. If you feel regretful or nostalgic about your younger breasts that nursed children, remember that breasts are only one aspect of your deeply feminine side. Your nurturing role has grown now and is becoming more complete with the capabilities that come with wisdom and experience. Nurturing in our forties extends to our creativity in business, art, medicine, and science, whatever we choose. We enrich our relationships with children, partners, colleagues, and friends with new honesty and intimacy that couldn’t have been ours earlier in our lives because we hadn’t experienced enough. Changes in our breasts do signal an important passage, but it is one to celebrate rather than to regret.

The third suggestion I give to women who have concerns like Pauline’s is to know that we can refuse to make our breast changes a freighted issue, or to imbue our breasts with more significance than other body parts. One patient of mine returned from a vacation in France where she was struck by the fact that women from 5 to 75 swam and sunbathed topless on the beach, completely unconcerned about the size, shape, or firmness of their breasts. And I have traveled twice to African countries where women do not wear tops at any time. Among the women in several African villages, I remarked on the lack of sexual current surrounding their partial nudity. We can take a cue from other cultures by choosing to regard our breasts as one part of a whole body that is beautifully healthy and resilient, and that has and will continue to be the source of so much pleasure and strength in our lives.