Category: Menopause & Women’s Health

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FDA Removes Black Box Warning From Menopause Hormone Therapy

On By Dr. Scott RennieIn Menopause & Women's HealthLeave a comment

Since the headlines ran, some version of the same question has been opening my video visits. “So it’s safe now, right? I saw it on the news.”

The women asking are usually a few years past their last period, sleeping badly, foggy at work, and frustrated. Somewhere along the way they were told hormones would give them breast cancer, and that was the end of the conversation. Something did change this summer. What changed is not what most people think.

The FDA did not run a new trial. No fresh outcome data landed on anyone’s desk. What happened is better described as a labeling correction: a regulatory acknowledgment that a warning written for one population had been applied, for more than twenty years, to a completely different one. That distinction is the whole story. It tells you how much permission this gives us, and it tells you exactly where the permission stops.

What Actually Happened

On November 10, 2025, HHS and the FDA announced they were initiating removal of the boxed warning from menopausal hormone therapy products containing estrogen. The specific language coming out covered cardiovascular disease, breast cancer, and probable dementia. (1) The move followed a public expert panel the agency convened in July 2025 and a comment period after that.

Then came the slower part, the part that got almost no coverage. Removing a boxed warning is not a press release. It is a product-by-product labeling supplement for every manufacturer. In February 2026, the FDA approved the first batch: labeling changes for six products spanning all four categories of menopausal hormone therapy, including systemic combination therapy, systemic estrogen alone, systemic progestogen for women with a uterus, and topical vaginal estrogen. (2) Twenty-nine companies had submitted proposed changes by that point. (2) More have been approved since.

The new labels also add something that wasn’t there before: age-specific framing, pointing toward initiation within ten years of menopause onset or before age 60 for systemic therapy. (2)

So the headline “HRT is safe now” is doing a lot of work it can’t support. The accurate version is that a warning which never fit a healthy 52-year-old with hot flashes has finally been taken off her prescription.

Why That Warning Was There In The First Place

You cannot understand the correction without understanding the error.

In July 2002, the Women’s Health Initiative stopped its estrogen plus progestin arm early. That trial had randomized 16,608 postmenopausal women with an intact uterus to conjugated equine estrogens plus medroxyprogesterone acetate or placebo. (3) The data safety monitoring board pulled the plug at 5.2 years because the global index crossed a predetermined boundary.

The relative risks made every front page in the country. Invasive breast cancer, hazard ratio 1.26. Coronary heart disease, 1.29. Stroke, 1.41. Pulmonary embolism, 2.13. (3)

What ran in far smaller type, if it ran at all, were the absolute numbers. Per 10,000 women per year of treatment: seven more coronary events, eight more strokes, eight more pulmonary emboli, eight more invasive breast cancers. Also five fewer hip fractures and six fewer colorectal cancers. (3) These are small absolute differences. “A twenty-six percent increase in breast cancer” and “eight additional cases per ten thousand women per year” describe the same finding, and only one of them ended a generation of treatment.

The estrogen-alone arm, which enrolled 10,739 women who had already had a hysterectomy, was stopped separately in 2004. That arm never showed an increase in breast cancer at all. If anything it trended the other direction. (4) The boxed warning went on both.

The dementia language came from WHIMS, the memory substudy. WHIMS enrolled women aged 65 to 79. (5) That is worth reading twice. A finding generated exclusively in women 65 and older became a printed warning handed to women in their early fifties for the next two decades.

The Trial Didn’t Study The Women Who Got The Warning

Mean age at enrollment in WHI was 63.3 years. (3)

Think about who that is. The average American woman reaches menopause around 51. A 63-year-old enrolling in the mid-1990s was, on average, more than a decade out from her final period. Many were two decades out. Most were not symptomatic, which was by design, because WHI was built as a chronic disease prevention trial and not a symptom trial. Participants were also carrying the cardiovascular risk you would expect at that age, including a substantial proportion with hypertension, obesity, and subclinical atherosclerosis nobody had imaged.

Put estrogen into an artery that already has established, possibly unstable plaque and you are not doing the same thing you do when you put estrogen into a 52-year-old’s relatively clean vasculature. That is the biological core of what became known as the timing hypothesis: estrogen appears to be protective, or at least neutral, in healthy endothelium, and potentially destabilizing in diseased endothelium.

The evidence for it isn’t a hunch.

The ELITE trial randomized 643 postmenopausal women to oral estradiol or placebo, stratified by how far out from menopause they were. In women less than six years postmenopause, estradiol significantly slowed carotid intima-media thickness progression. In women ten or more years out, it did nothing. (6) Same drug, same trial, opposite vascular story depending on when you started it.

The Danish Osteoporosis Prevention Study randomized about 1,000 recently postmenopausal women to hormone therapy or no treatment and followed them for ten years. The treated group had a lower composite rate of death, heart failure hospitalization, and myocardial infarction, with no increase in cancer, stroke, or venous thromboembolism. (7) It was open-label, which limits it, and it wasn’t powered as a cardiovascular outcomes trial. But it points the same direction.

And WHI’s own investigators, when they went back and stratified by age, found the pattern sitting in their own data. Women who started in their fifties looked different from women who started in their seventies. (8) The 18-year follow-up of both WHI arms, published in 2017, found no increase in all-cause mortality, cardiovascular mortality, or cancer mortality in either treatment group. (9)

None of this is new. ELITE published in 2016. The mortality follow-up published in 2017. The FDA’s 2025 action was a review of literature that already existed, which is exactly why calling it a labeling correction is fair. The evidence got there long before the label did.

Now The Part Nobody Is Covering: What This Does Not Do

Here is where I want to slow down, because the celebratory version of this story is going to get people hurt.

The endometrial cancer warning did not go away

The FDA explicitly did not seek removal of the boxed warning regarding endometrial cancer for systemic estrogen-alone products. (1) Unopposed systemic estrogen in a woman with a uterus causes endometrial hyperplasia and carcinoma, and the PEPI trial put hard numbers on how fast. Over three years on unopposed conjugated estrogen, 22.7 percent of women developed complex hyperplasia and 11.8 percent developed atypical hyperplasia. Every arm that included a progestogen held hyperplasia under 1 percent. (14) That risk is dose and duration dependent, it is real, and it is almost entirely preventable. Nothing in this label change touched it.

The word doing all the work in that paragraph is systemic, and it is worth slowing down on, because this is the single most muddled point in the entire subject.

Low-dose vaginal estrogen does not need a progestogen. Not for the cream, not for the ring, not for the tablet. A systematic review of 20 randomized trials covering nearly 3,000 women found endometrial cancer in 0.03 percent and hyperplasia in 0.4 percent, which is background noise, and the WHI Observational Study found no association either. (15) The Menopause Society does not recommend adding a progestogen to low-dose vaginal estrogen therapy. Neither do I. If you have a patient on Estring or a small twice-weekly dab of vaginal estradiol cream for dryness and recurrent UTIs, she does not need progesterone, and putting her on it adds side effects for no endometrial benefit.

Here is the part that trips people up. The dividing line is not oral versus topical. It is systemic versus local. A patch, a pump gel, a spray, and a compounded body cream are all systemic estrogen, and they all raise endometrial risk the same way a pill does. Transdermal delivery changes the clot risk, which I will get to in a minute. It does nothing for the endometrium. If she has a uterus and the estrogen is reaching her bloodstream at systemic levels, she needs a progestogen at an adequate dose for as long as she is on it, no matter what the delivery device looks like.

I bring it up because the compounded and direct-to-consumer market blurs exactly that line, and “cream” gets used to mean two completely different products. I have picked up patients well into a compounded systemic estradiol cream, rubbed on the inner arm at a real systemic dose, with no progestogen prescribed and nobody having mentioned that they needed one.

Removing a warning does not remove a risk

Venous thromboembolism with oral estrogen is the cleanest example. The large UK nested case-control analysis of more than 80,000 VTE cases found oral hormone therapy carried an adjusted odds ratio of 1.58 overall, with oral conjugated equine estrogen plus medroxyprogesterone acetate at 2.10. Transdermal preparations showed no increased risk. Head to head, oral was associated with roughly 70 percent higher VTE risk than transdermal. (10)

That finding should change your prescription pad, not your enthusiasm. The route matters here, and this is the one place it does. First-pass hepatic metabolism drives the procoagulant shift, and transdermal estradiol bypasses it. For a woman with obesity, a prior clot, a thrombophilia, migraine with aura, or a family history that makes you uneasy, transdermal isn’t a preference. It’s the answer.

Breast cancer risk was overstated, not erased

The 2019 Lancet collaborative reanalysis of the worldwide epidemiological evidence put it in numbers a patient can actually hold onto. For a woman of average weight starting at age 50 and using therapy for five years, the excess breast cancer incidence through age 69 is roughly one additional case per 50 users of estrogen plus daily progestogen, and about one per 200 users of estrogen alone. (11) Small. Not zero. And dose and duration dependent, which means the conversation at year eight is a different conversation than the one at year two.

For context I give patients, because context is what they are usually missing: that magnitude sits in the same neighborhood as two alcoholic drinks a day, or carrying significant excess weight after menopause. Nobody puts a black box on either of those.

This is still not a primary prevention drug

The approved indications didn’t change. Systemic hormone therapy is indicated for moderate to severe vasomotor symptoms, for moderate to severe genitourinary symptoms of menopause, for prevention of postmenopausal osteoporosis in appropriate candidates, and for hypoestrogenism from hypogonadism or primary ovarian insufficiency. That’s the list.

The USPSTF continues to recommend against menopausal hormone therapy for the primary prevention of chronic conditions, a grade D recommendation. (12) You do not start a 58-year-old on estradiol to prevent her heart attack. If the timing hypothesis eventually earns a prevention indication, it will do so through a trial designed to answer that question, and that trial has not been run.

A boxed warning coming off is not new evidence coming in

There were no new randomized trials behind the November 2025 action. The FDA reviewed what already existed and concluded the label misrepresented it. That is a real and overdue fix. It is not a discovery, and anyone selling it to you as one is probably selling you something else too.

If You’re A Patient: You Can Reopen This

If you were told no in 2009, or 2015, or honestly even in 2023, the answer you got was shaped by a warning that has since been withdrawn. You are allowed to ask again.

A few things worth knowing before that appointment.

The window matters. The risk-benefit math is most favorable for women who are generally healthy, under 60, and within about ten years of their final menstrual period. The further out from that window you are, the more carefully the decision has to be individualized, and for some women the answer will still be no.

Vaginal estrogen is a separate conversation entirely. Low-dose vaginal estrogen for genitourinary symptoms, meaning dryness, painful sex, recurrent urinary tract infections, urgency, has minimal systemic absorption. The Menopause Society specifically welcomed the boxed warning removal for these products, describing them as safe and effective for a condition that affects most menopausal women. (13) If vaginal symptoms are your issue, the systemic risk conversation largely doesn’t apply to you, and you almost certainly do not need to take progesterone alongside it.

There are still real contraindications. A history of breast cancer, an estrogen-dependent tumor, prior stroke or heart attack, active or prior venous thromboembolism, a known thrombophilia, significant liver disease, or unexplained vaginal bleeding that hasn’t been worked up. If any of those apply to you, the answer may genuinely be no, and there are non-hormonal options worth discussing, including the newer neurokinin receptor antagonists for hot flashes.

And bring specifics, even to a twenty minute video visit. How many nights a week you wake up. Whether you have stopped exercising. Whether sex hurts. Whether you are thinking about leaving a job you used to like. A recent blood pressure reading, when your last mammogram was, and what your mother’s and sister’s history looks like. Symptom burden is half the equation, and “I’m having some hot flashes” badly undersells what is usually going on.

If You’re A Colleague: How I’m Counseling Now

I practice entirely by telemedicine, so everything below happens over video, usually in one visit and a follow-up. Here is how I run it in 2026.

I start by asking what she was told before, and by whom. Roughly half of my perimenopausal and postmenopausal patients are carrying a specific prior refusal, and if I don’t surface it, it sits there and quietly undermines everything I say next.

Then I frame the decision around three questions instead of one. Is she in the window? What is her baseline cardiovascular and thrombotic risk? And what is her symptom burden, honestly measured? A woman at 52 with severe vasomotor symptoms and no risk factors is a different patient than a woman at 64 with controlled hypertension and mild night sweats. The label change does not collapse that difference.

The remote setting changes the logistics of that second question, not the standard. Before I start systemic therapy I want a blood pressure I trust, which usually means a home cuff and a few readings rather than one number she remembers from a year ago. I want her mammogram status current, her personal and family history of clot and breast cancer taken carefully rather than checkbox-style, and any abnormal bleeding evaluated in person before we go anywhere near estrogen. None of that requires me to be in the room. All of it requires me to actually ask.

Route selection is where I have gotten more opinionated. Transdermal estradiol is my default for anyone with obesity, hypertriglyceridemia, migraine with aura, gallbladder disease, or any thrombotic history, personal or family. (10) The oral versus transdermal difference in VTE risk is one of the few places in this entire discussion where we can meaningfully reduce absolute harm by changing one line on the prescription.

Progestogen goes with every uterus on systemic estrogen, and only with systemic estrogen. Micronized progesterone is my preference for the metabolic profile and possibly the breast profile, though I will say plainly that the comparative data across progestogens is observational and not as strong as some of the marketing suggests. If she is on vaginal estrogen alone, she does not get a progestogen from me.

I still ask about duration out loud, every year. Not because there is a hard stop at five years, because there isn’t one, and the old “lowest dose for the shortest duration” language has aged badly. But breast cancer risk is duration dependent (11), and the woman who has been on therapy for nine years should be making that choice consciously rather than by inertia.

And I document the shared decision making. Symptom burden, risk factors reviewed, route and rationale, progestogen plan, alternatives discussed. That note protected me before the label change and it protects me now.

One more thing, and it matters more in this setting than any other. The current news cycle is producing a wave of patients who want hormones for reasons that are not on the label. Longevity. Body composition. Cognitive performance. Telemedicine is where most of that demand is landing, and a lot of it is landing on platforms that will ship estradiol after a four-question intake form and never once ask about the uterus. I would much rather have the honest conversation about what the evidence does and does not support than have someone go around me to get a worse version of the same drug.

The Bottom Line

A warning that should never have been applied to a healthy 52-year-old with hot flashes has been removed. That is a genuine correction, and the women who were denied treatment for twenty years deserved it a long time ago.

What did not happen is a change in the underlying biology. Oral estrogen still raises clot risk. Unopposed systemic estrogen still endangers the endometrium, whatever it is delivered in. Breast cancer risk is still small, still real, still duration dependent. Hormone therapy still isn’t a preventive medication.

The label was wrong. The nuance was always right. We just get to have the conversation now without a black box sitting in the middle of the table.

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Sources:

  1. U.S. Food and Drug Administration. HHS Advances Women’s Health, Removes Misleading FDA Warnings on Hormone Replacement Therapy. November 10, 2025. https://www.fda.gov/news-events/press-announcements/hhs-advances-womens-health-removes-misleading-fda-warnings-hormone-replacement-therapy
  2. U.S. Food and Drug Administration. FDA Approves Labeling Changes to Menopausal Hormone Therapy Products. February 2026. https://www.fda.gov/news-events/press-announcements/fda-approves-labeling-changes-menopausal-hormone-therapy-products
  3. Rossouw JE, et al. Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women: Principal Results From the Women’s Health Initiative Randomized Controlled Trial. JAMA. 2002;288(3):321-333. https://pubmed.ncbi.nlm.nih.gov/12117397/
  4. Anderson GL, et al. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women’s Health Initiative randomized controlled trial. JAMA. 2004;291(14):1701-1712. https://pubmed.ncbi.nlm.nih.gov/15082697/
  5. Shumaker SA, et al. Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women: the Women’s Health Initiative Memory Study. JAMA. 2003;289(20):2651-2662. https://pubmed.ncbi.nlm.nih.gov/12771112/
  6. Hodis HN, et al. Vascular Effects of Early versus Late Postmenopausal Treatment with Estradiol. N Engl J Med. 2016;374(13):1221-1231. https://www.nejm.org/doi/full/10.1056/NEJMoa1505241
  7. Schierbeck LL, et al. Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: randomised trial. BMJ. 2012;345:e6409. https://www.bmj.com/content/345/bmj.e6409
  8. Manson JE, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women’s Health Initiative randomized trials. JAMA. 2013;310(13):1353-1368. https://pubmed.ncbi.nlm.nih.gov/24084921/
  9. Manson JE, et al. Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality: The Women’s Health Initiative Randomized Trials. JAMA. 2017;318(10):927-938. https://pubmed.ncbi.nlm.nih.gov/28898378/
  10. Vinogradova Y, Coupland C, Hippisley-Cox J. Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ. 2019;364:k4810. https://pubmed.ncbi.nlm.nih.gov/30626577/
  11. Collaborative Group on Hormonal Factors in Breast Cancer. Type and timing of menopausal hormone therapy and breast cancer risk: individual participant meta-analysis of the worldwide epidemiological evidence. Lancet. 2019;394(10204):1159-1168. https://pubmed.ncbi.nlm.nih.gov/31474332/
  12. US Preventive Services Task Force. Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Persons: USPSTF Recommendation Statement. JAMA. 2022;328(17):1740-1746. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/menopausal-hormone-therapy-preventive-medication
  13. The Menopause Society. The Menopause Society Comments on the FDA Announcement on Hormone Therapy. November 2025. https://menopause.org/press-releases/the-menopause-society-comments-on-the-fda-announcement-on-hormone-therapy
  14. The Writing Group for the PEPI Trial. Effects of hormone replacement therapy on endometrial histology in postmenopausal women: the Postmenopausal Estrogen/Progestin Interventions (PEPI) Trial. JAMA. 1996;275(5):370-375. https://pubmed.ncbi.nlm.nih.gov/8569016/
  15. Constantine GD, et al. Endometrial safety of low-dose vaginal estrogens in menopausal women: a systematic evidence review. Menopause. 2019;26(7):800-807. https://journals.lww.com/menopausejournal/fulltext/2019/07000/endometrial_safety_of_low_dose_vaginal_estrogens.18.aspx

Menopause Treatment by Telemedicine: How It Works

On By Dr. Scott RennieIn Menopause & Women's Health, Senior & Caregiver HealthLeave a comment

For many women, menopause care has long been an afterthought in traditional medicine. The conversation often starts late, if it happens at all. Now, thanks to telemedicine, that’s beginning to change.

Over the last few years, virtual menopause clinics have emerged to fill a long-standing gap in women’s health. Clinics like Midi Health and Menopause RX connect women directly with clinicians trained in menopause care. According to the Centers for Disease Control and Prevention, about 42 percent of women now use telemedicine, and a growing number are using it specifically for midlife and menopausal health (Pevzner, 2025; CDC, 2025).

This shift matters. Research shows that most doctors receive little or no formal training in menopause management. A 2019 Mayo Clinic report found that only 7 percent of medical residents felt prepared to manage menopause (Mayo Clinic Proceedings, 2019). Women often report their symptoms being dismissed or overlooked. In a 2025 survey of 1,000 women aged 45 to 60, nearly 71 percent said their physician didn’t adequately prepare them for menopause or discuss treatment options (Pevzner, 2025).

That’s where telemedicine can help. Virtual menopause clinics provide timely access to clinicians who understand hormonal transitions and can offer evidence-based guidance. As Dr. Sherry Ross, an ob-gyn in California, explained in a Yahoo Health interview, these platforms solve many of the problems in the current healthcare system, particularly access and education (Pevzner, 2025).

Telehealth also reaches women in rural or underserved areas where menopause-certified specialists are scarce. The Menopause Society, formerly NAMS, highlights this benefit in its educational resources, noting that virtual platforms can deliver specialized care to women who might otherwise go without it (The Menopause Society, 2025). On my own panel, roughly 25 percent of women arrive already on hormone therapy started elsewhere; most others are still looking to start when they get to me. That tells me how far this shift has already gone outside primary care.

Virtual visits handle a fairly wide range of these symptoms: hot flashes, sleep disturbance, mood changes, low libido, and mild vaginal dryness lead the list, and each of these can often be addressed through careful history, lifestyle interventions, and evidence-based hormonal or non-hormonal therapies (Pevzner, 2025).

Of course, telehealth isn’t the right fit for everyone. Complex or potentially serious symptoms such as postmenopausal bleeding, abnormal discharge, breast changes, or pelvic pain still require in-person evaluation. As Dr. Robin Noble, a gynecologist in Maine, reminds clinicians, some conditions simply can’t be ruled out without a physical exam (Pevzner, 2025).

That balance is important. Telemedicine can’t rule out postmenopausal bleeding, abnormal discharge, or a breast change over video, and it shouldn’t try to. The best virtual programs integrate follow-up visits, communicate with the patient’s primary physician, and make sure screenings like mammograms and Pap smears stay on schedule (The Menopause Society, 2025).

When colleagues ask how to steer patients toward credible virtual options, I start with licensure: is the provider licensed and, ideally, certified by The Menopause Society (MSCP)? From there, check that the clinic’s data security is HIPAA-compliant, and don’t sign on until there’s a real process for ongoing monitoring and coordination of care (The Menopause Society, 2025).

Here’s where I push back on the marketing a little. Platforms like to say virtual care “closes the gap,” but a same-day video visit doesn’t fix a residency curriculum that gave menopause a few hours of teaching total. It gets a patient to someone who knows the topic faster. It doesn’t fix why so few primary care doctors learned it in the first place.

Some version of this comes up constantly: a woman held off on raising her symptoms because she didn’t want to waste the doctor’s time. Then she gets to someone who takes the question seriously, and what she finds is reassurance and a plan. That’s the kind of access we should all want for our patients: timely, informed, and respectful of their experience.

Menopause care is finally catching up with the rest of modern medicine, and telemedicine is a big part of why.

Scott Rennie, D.O.

References

Pevzner, H. (2025, July 30). Your complete guide to getting menopause help online. Yahoo Health. https://www.yahoo.com/lifestyle/menopause-telehealth-guide

Centers for Disease Control and Prevention (CDC). (2025). Telemedicine utilization data.

Mayo Clinic Proceedings. (2019). Menopause education in residency training.

The Menopause Society (formerly NAMS). (2025). Professional resources and video library.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Why Menopause Care Is Missing From Women’s Checkups

On By Dr. Scott RennieIn Menopause & Women's Health, Senior & Caregiver HealthLeave a comment

I hear some version of the same question most weeks on video visits, patients trying to figure out whether what they’re feeling is actually menopause.

Women often come to me with vague but frustrating symptoms. Trouble sleeping. Brain fog. New anxiety. Irregular or heavy periods. Weight creeping up despite no major changes. Sometimes joint pain, palpitations, or new migraines. Many times, we both suspect something hormonal. The connection to menopause doesn’t always click right away.

Most of us were never taught to see the menopause transition as its own physiologic phase with real preventive implications, not because we don’t care. Medical training gives menopause a brief mention inside reproductive aging, with the emphasis staying on fertility, not on what happens once it ends. Patients ask me about hormone therapy, sleep, mood, or sexual changes, and more often than I’d like, I don’t feel equipped in the moment to explain what’s happening or lay out the options.

The average woman in the United States reaches menopause at about age 51, according to the Mayo Clinic (2024). The years leading up to that point, called perimenopause, can last four to eight years. Hormone levels fluctuate widely during this time. These shifts affect body temperature regulation, brain chemistry, metabolism, and cardiovascular function. Symptoms can begin well before the final menstrual period. A woman in her mid-forties may show up with new anxiety, fatigue, or night sweats. That’s an easy substitution to make instead of perimenopause, and it’s one I watch for now specifically because of how often it happens.

There are several reasons why menopause-related concerns get missed. Many women are still menstruating irregularly and do not yet think of themselves as menopausal; primary care visits are short and filled with competing priorities. The confusion that followed older studies on hormone therapy still lingers. I’d rather be direct about where I land: the newer safety data is solid, and hesitation still rooted in the old fear is outdated. Newer research from The Menopause Society and the National Institutes of Health shows clear safety and benefit for most healthy women under 60 or within 10 years of menopause onset (The Menopause Society, 2023; NIH, Office on Women’s Health, 2024).

I ask every woman in her forties about menstrual changes, hot flashes, sleep, mood, libido, and vaginal or urinary symptoms, because awareness starts with the question, not the answer. Simple questions open the door. If a patient raises the issue herself, I’d rather start the conversation than defer it to a specialist on the spot.

I lean on The Menopause Society’s practical resources and CME, and I’m working through their Menopause Society Certified Practitioner (MSCP) program myself. Reading Menopause Practice: A Clinician’s Guide or reviewing their treatment algorithms has strengthened my own confidence here. Other organizations such as the NIH, AAFP, and Cleveland Clinic also offer free CME courses and case examples.

Treatment doesn’t always mean prescribing systemic hormone therapy right away. I explain the range of choices and personalize them: for some patients that means hormone therapy, for others it’s non-hormonal medications, localized vaginal treatment, or lifestyle interventions. For a symptomatic perimenopausal patient who still needs contraception, I favor continuous combined hormonal contraceptives, since standard menopausal hormone therapy can produce breakthrough bleeding in that setting; a typical low-dose choice is ethinyl estradiol 20 mcg plus levonorgestrel 100 mcg orally once daily, often continuously. If contraception isn’t a factor, my usual starting menopausal regimen is transdermal 17-beta-estradiol 0.025 to 0.05 mg/day plus micronized progesterone 100 mg nightly, continuously, if the uterus is present. Weight-bearing exercise, protein intake, and good sleep remain foundational regardless of what else we add. My job is to know the options well enough to guide that discussion, and to know when a referral actually helps more than I can.

When menopause management becomes part of preventive care, patients feel seen and supported. It becomes a normal part of the health conversation, the same as colon screening or cholesterol management; I try to keep these discussions inside the relationship I already have with a patient, rather than routing her to someone new for something I can manage myself.

Menopause represents a turning point for cardiovascular, metabolic, and bone health, and recognizing it early is a real opportunity to prevent disease later. My honest read on where primary care gets this wrong: it’s decades-old caution about hormone therapy that the newer data no longer supports, not a lack of caring. Women deserve clinicians who treat that caution as outdated and prescribe with the confidence the evidence now allows.

Scott Rennie, D.O.

References:

Cleveland Clinic. Menopause and Preventive Care: What Every Woman Should Know. 2023.

The Menopause Society. Menopause Practice: A Clinician’s Guide, 6th Edition. 2023.

Mayo Clinic. Menopause: Symptoms and Causes. Updated 2024.

NIH Office on Women’s Health. Menopause and Heart Health. 2024.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Perimenopause and Menopause Symptoms and How to Manage Them

On By Dr. Scott RennieIn Menopause & Women's Health, Senior & Caregiver HealthLeave a comment

Menopause comes up on my schedule most weeks, and patients still arrive unsure what to expect from it. So it helps to start with definitions. Perimenopause is the transition before menopause. Hormone levels fluctuate, cycles become irregular, and the phase can run several years. Menopause itself is twelve straight months without a period. The average age in North America is around 51.

Symptoms vary more than most patients expect. During perimenopause, bleeding may be heavier some months and absent others. Hot flashes and night sweats are common. Some women notice mood changes or brain fog. Others raise vaginal dryness or discomfort with intercourse, usually only after I ask directly. Sleep problems come up constantly, and they are often just night sweats wearing a different hat. In full menopause those symptoms can continue, though bleeding stops for good. Skin and hair changes, weight shifts, and urinary urgency show up here too.

One patient in her late forties came to me worried she had a thyroid problem. She felt “off,” with fatigue, poor sleep, and irregular cycles. Her lab work came back normal, but her story fit perimenopause cleanly. That visit turned into the conversation she had actually needed, about what was happening in her body and what we could do about it.

Treatment follows the symptom pattern and the patient’s health profile. For hot flashes, hormone replacement therapy is the most effective option we have, though it is not right for everyone. Non-hormonal options including SSRIs and gabapentin also reduce vasomotor symptoms. Vaginal estrogen, as cream or tablets, works well for dryness and discomfort. Lifestyle changes carry real weight: a cool bedroom, less alcohol, regular exercise, stress management. Cutting caffeine after mid-afternoon sometimes does more than patients expect.

Preventive care deserves attention in this phase. Bone health matters more once estrogen declines, so I bring up calcium, vitamin D, and weight-bearing exercise. DEXA scans depend on age and risk factors. Cardiovascular risk climbs after menopause, which makes cholesterol, blood pressure, and diabetes screening worth staying current on. Breast and cervical cancer screening continue as appropriate. Colon cancer screening tends to land right in this age range as well, and over video I have to ask about it directly, because nobody volunteers that they are overdue.

Menopause is a normal stage of life that still manages to catch people off guard. Family physicians are well placed to normalize the conversation, take the symptoms seriously, and point patients toward both relief and prevention. Medication is not always part of that. Listening and practical support always are.

Scott Rennie, D.O.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Comparison of healthy and osteoporotic bone density showing thick trabeculae with low fracture risk versus thin trabeculae with high fracture risk

Osteoporosis: How to Prevent It and How It’s Treated

On By Dr. Scott RennieIn Menopause & Women's Health, Senior & Caregiver Health2 Comments
shutterstock_138359822 Osteoporosis:  A medical disorder that causes the bones to become weak, thin and fragile.  Bones that are weaker are more likely to break (fracture).  Women are more commonly affected by this disorder because after menopause lower levels of estrogen are produced by the body.  Estrogen is a hormone that helps keep the bones strong. It is very important to detect low bone density (weak bones) because there are treatments available which can protect and actually help build up bone and prevent bone fractures in those people who are at the greatest risk. Why do we care?  Bone fractures, especially in the hip cause a huge change in lifestyle and lead to decreased mobility, decreased ability for patients to care for themselves, and increased risk of death due to physical deconditioning, increased risk of infection (from surgery and also from decreased mobility respiratory illness).   In fact, people who sustain a hip fracture are more likely to die than a person of the same age who does not experience this injury. About 20 percent of people who have a hip fracture die within a year of their injury. It is estimated that only one in four persons have a total recovery from a hip fracture.  Most people spend from one to two weeks in the hospital after a hip fracture. The recovery period may be lengthy, and may include admission to a rehabilitation facility. People who previously were able to live independently will generally need help from home caregivers, family, or may require the services of a long-term care facility. Hip fractures can result in a loss of independence, reduced quality of life, and depression, especially in older people. Fractures that occur in the spine due to osteoporosis can lead to pain and cause changes in the curvature of the spine.  We’ve all seen older folks who have difficulty walking due to having abnormal curvature of the spine and these patients often have osteoporotic fractures in the vertebra of the back. Risk factors for osteoporosis: 1)  Sex – women are more likely to get osteoporosis than men 2)  Age – risk of osteoporosis is higher with increasing age 3)  Race – there is a higher risk of osteoporosis in people of white or Asian descent 4)  Family history – you are at higher risk of osteoporosis if you have a parent or sibling with osteoporosis, especially if there is a family history of bone fracture 5)  Body frame size – men or women who have a smaller body frame size are at higher risk because they have less bone mass to draw from as they age 6)  Hormone levels – osteoporosis is more common in patients who have too much or too little of certain hormones  (estrogen, testosterone, thyroid, parathyroid or adrenal hormones for example) 7)  Low calcium in the diet – a lifelong lack of getting enough calcium increases the risk of developing bones that are thinner and more fragile. 8)  Eating disorder – Patients with anorexia are at increased risk of osteoporosis due to decreased nutritional intake of calcium 9)  Weight loss surgery – those patients who have surgery to help them lose weight are at higher risk of osteoporosis because of a reduction in the size of the stomach or a bypass of some of the intestines.  This may decrease the absorption of calcium or vitamin d. 10)  Certain medications – see below Prevention:  Several important steps to maintaining proper bone formation and density can be done without the need of medication.  These include proper diet, exercise and not smoking. A)  Diet:  Preventing the bones from thinning involves getting enough nutrients, especially calcium and vitamin D.
  1. Calcium:  Most experts agree that men and women who have not reached the age of menopause yet consume at least 1000 mg of calcium each day (combination of diet and supplements).  Women who have already gone through menopause should consume at least 1200mg of calcium each day (combination of diet and supplements).   Foods that have calcium include dairy milk, cottage cheese, yogurt, hard cheese, green vegetables (especially kale and broccoli).  A way to calculate the amount of calcium from food is to multiply the number of servings of calcium rich foods by 300 mg.  One serving size of dairy milk or yogurt is 8 oz.  1oz of hard cheese or 16 oz of cottage cheese is one serving size.
  2. Vitamin D:  Most experts also agree that men over age 70 and women who have gone through menopause consume at least 800 international units (IU) for vitamin D each day.
  3. Alcohol:  Drinking more than 3 drinks per day can increase the risk of fracture due to increased risk of falling and poor nutrition.
B)  Exercise:  We understand that our bones maintain their strength if we continue to use them.  Patients who become immobile are at increased risk of bone fractures because their bones tend to become thinner with decreased use and activity.  Patients who are more physically active are generally stronger and less prone to falling as well.  Exercising 30 minutes or more three times per week or more is recommended to maintain bone strength. C)  Smoking:  Smoking cigarettes is known to speed bone loss.  One study suggested that women who smoke one pack per day throughout adulthood have a 5-10% reduction in bone density by menopause.  If you smoke, I suggest you get help with stopping to help prevent osteoporosis. We can reduce the risk of bone fractures by reducing falls.  Several ways to reduce falls in older adults include: 1)  Avoiding (as much as possible) medications that can cause dizziness 2)  Provide adequate lighting to areas both inside and outside the home 3)  Ensure there are no loose rugs or electrical cords that could lead to tripping or falling 4)  Avoid walking in areas outside that are unfamiliar 5)  Avoid slippery surfaces such as ice or wet/polished floors 6)  Ensure good eye care by visiting an eye doctor regularly Screening for Osteoporosis:  There are several different recommendations for when to start screening for osteoporosis.  The U.S. Preventative Service Task Force (USPSTF) recommends screening women who are age 65 or older who has no increased risk of fracture as compared to a 65 yo women of Caucasian decent.  If a woman has a previous bone fracture or an early family history of osteoporosis (especially a mother with an early bone fracture) or has thyroid disease or take medications that can increase the risk of thinning the bones, screening earlier is generally recommended. Assessment tools:  There are several tools that have been developed by the WHO (World Health Organization)  – (see FRAX) to help assess risk for osteoporotic fractures.  These tools ask questions that relate to risk factors for osteoporosis and attempt to calculate a probability of hip fracture even without knowing exact measurements of bone density measured by special x-ray tests. DXA Bone Mineral Density Test:  A bone density test uses special x-rays to determine how many grams of calcium and other bone minerals are packed into a bone segment.  Bones that are commonly tested include the spine, hip and forearm.  We do this test to identify patients who are at higher risk for bone fracture, as well as to monitor the progress of therapy for patients who are being treated.   Bone density tests are not the same as bone scans.  Bone scans usually require the patient to get an injection before the procedure and are used to detect bone fractures, bone cancer or bone infections. Medications that increase the risk of bone thinning:  If you take any of these medications, ask your doctor about whether you should have your bone density tested: 1)  Glucocorticoids such as prednisone or dexamethasone 2)  Anti-Seizure medications such as Dilantin, Tegretol, Phenobarbital or Primadone 3)  Heparin – medication to treat abnormal blood clotting 4)  Acid reducing medications called proton pump inhibitors (PPIs) such as Prilosec may increase the risk of osteoporosis or fractures but more research is needed. Treatment for osteoporosis:  The treatment really depends on the reason for the decrease in bone density.  We might change the patient’s current medications to different medicines that are safer and have less risk for decreasing bone mineral density.  Correcting a patient’s thyroid, parathyroid or testosterone imbalance may improve their bone density without the need for other medications.  We usually try to ensure that they are getting adequate dietary intake of calcium and vitamin D and may due some lab tests to look for excessive loss of calcium in the urine.  We might test the patient’s vitamin D levels along with the hormone levels mentioned above.  If there has already been a hip or vertebral compression fracture we will also usually check a bone mineral density (DXA or DEXA) scan to confirm the level of osteoporosis. The DEXA scan gives us a numerical value that corresponds to the degree of osteopenia (low bone density) or osteoporosis (greater risk of fracture).  A normal bone density is when the T-score (measured on the bone density test) is between 0 and 1 standard deviation below the mean.  A normal T score may be reported as a T-score of +1 to -1.  If the T score is -1 to -2.4 the patient is said to have osteopenia which means that they have a risk of developing osteoporosis if not treated.  If the T score is -2.5 or less, the patient is diagnosed with osteoporosis.  The lower the T score (higher the negative number), the greater the risk of fracture. Medical treatment of osteoporosis: 1)  Calcium – at least 1200 mg of calcium/day but no more than 2000 mg/day. 2)  Vitamin D – at least 800 international units/day – sometimes very high doses such as 50,000 IU/week may be prescribed if your levels are measured to be very low. 3)  Bisphosphonates such as Fosamax , Actonel  or Boniva are medications that slow the breakdown and removal of bone (bone resorption).  These are taken first thing in the morning on an empty stomach with an 8oz glass for still water.  There has been some concern about the use of bisphosphonates in people who require invasive dental work – it may lead to avascular necrosis or osteonecrosis.  Most experts do not think that it is necessary for most people to stop bisphosphonates before invasive dental work (tooth extraction or implant) because the risk is very small for those people who take bisphosphonates for osteoporosis treatment or prevention.  People who take a bisphosphonate as part of a treatment for cancer should consult their doctor before having invasive dental work however. There is some concern about atypical (stress) hip fractures associated with long-term use of bisphosphonates.  Patients who have been taking them for more than 5 years may need re-evaluation to see if further continuation of the medication is recommended. 4)  Selective Estrogen Receptor Modulators (SERMs) produce estrogen-like effects on the bone.  They include Evista and tamoxifen.  In addition to osteoporosis treatment/prevention there is a decrease in the risk of breast cancer in women who are at high risk.  These medications are not recommended for women who have not started menopause. 5)  Calcitonin is a hormone produced by the thyroid gland that, together with parathyroid hormone, helps regulate calcium concentrations in the body.  This may be administered via nasal spray or injection.  Nasal administration is usually preferred due to ease of use and less chance of nausea and/or flushing.  It’s not clear if calcitonin improves bone in places in the body other than the spine. 6)  Parathyroid hormone (PTH) – (prescription preparation name Forteo) produced in the parathyroid glands(non-prescription form) stimulates bone resorption and new bone formation.  Clinical trials suggest the PTH therapy is effective in both prevention and treatment of osteoporosis in post-menopausal women and men.  It has been proven to reduce spine fracture risk more than any other treatment that we know about.  It does, however require a daily injection and is expensive so it’s usually reserved for patients with severe hip or spine osteoporosis with a T score of  less than -2.5 (higher number) and osteoporosis-related fracture. When taking Forteo, we often check a blood uric acid and calcium level at the start of the medication, after 6 weeks, 6 months later and then after 12 months of therapy. We generally do not use this medication in pediatric and young children whose bones are still growing or in patients with bone cancer,  Paget’s disease of the bone and extreme caution is needed in patients who have a history of recent calcium kidney stones. 7)  Prolia is a medication that helps improve bone mineral density and reduce fracture in postmenopausal women with osteoporosis.  It is an injection under the skin once every 6 months.  It’s usually well tolerated but can have side effects such as skin infections or eczema.  It should not be given to patients who have a low blood calcium level. For more information, please check out the following resources: National Library of Medicine Osteoporosis and Related Bone Diseases National Resource Center National Osteoporosis Foundation National Women’s Health Resource Center (NWHRC) Osteoporosis Society of Canada The Hormone Foundation   I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Doctor speaking with a patient while taking notes at a desk

Health Screenings Women Need and When to Get Them

On By Dr. Scott RennieIn Menopause & Women's HealthLeave a comment
shutterstock_152788025I think it’s important to have preventative screening exams to identify potential health problems before they develop or worsen.  It is often challenging to keep up with the changes in the preventative screening guidelines, so I thought I’d include these guidelines that are the most current as of August 2012 from the USPSTF. Other guidelines from the American Medical Association, Canadian Task Force on Preventative Health Care, American Cancer Society, American College of Preventative Medicine and National Institutes of Health exist and may have other recommendations.  These may be used as a guide but the time of screening may change depending on certain risk factors or the recommendations of your individual healthcare provider. Age 21:  The USPSTF strongly recommends screening for cervical cancer in women beginning within 3 years of the onset of sexual activity or by age 21 who have a cervix. Age 25 and younger:  Routine screening for all sexually active women and other asymptomatic women at increased risk of chlamydial infection. Age 40:  Screening mammography, with or without clinical breast examination (CBE) every 1-2 years for women starting at age 40 if there are no other risk factors for breast cancer such as family history. Age 45:  Screening for high cholesterol and treat abnormal lipids in people who are at increased risk of heart disease. Age 50:  Start screening at age 50 or older for colorectal cancer (earlier if there are increased risks such as family history of first degree relative who is diagnosed with colon or rectal cancer before age 60). Age 65:  Women age 65 and older should be screened routinely for osteoporosis.  Screening should begin at age 60 for women at increased risk of becoming osteoporotic.   I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Doctor talking with a patient across a desk in a clinic office

Bacterial Vaginosis: Most Common Cause of Vaginal Discharge

On By Dr. Scott RennieIn Infectious Disease, Menopause & Women's HealthLeave a comment
Bacterial Vaginosis (BV) is not a sexually transmitted infection.  It is the most frequent cause of vaginal discharge in women, but it can be difficult to know if the discharge is caused by BV or other types of vaginal infections. Definition:  Discharge caused by a large change in the number and types of bacteria in the vagina.  For some reason, the number Lactobacilli (which is a normal bacteria found in the vagina) are actually decreased while other bacteria are increased. Risk factors:  Multiple or new sexual partners, douching, cigarette smoking.  Again, BV is not a sexually transmitted infection, as it can occur in women who are not sexually active. Symptoms:  50-75% of women with BV do not have symptoms.  Those with symptoms may note an unpleasant, “fishy smelling” vaginal discharge that is more noticeable after vaginal intercourse.  The discharge is usually a thin, yellow-white color.  Most of the time it does not cause pain with urination or sex, vaginal itching or intercourse.  Self-treatment with over-the-counter medications such as yeast creams or deodorants are not recommended. Diagnosis:  Physical examination, which usually includes pelvic examination and laboratory testing may be used to test the vaginal secretions to determine if BV is present. Complications:  Bacterial vaginosis is usually not considered harmful but has been associated with some health problems such as: 1)   Increases risks for becoming infected with HIV, genital herpes, gonorrhea or chlamydia 2)   Pregnant women with BV are at higher risk of preterm delivery 3)   Untreated BV in woman who have had hysterectomy or abortion can lead to infection at the surgery site Treatment:  We commonly use one of two different treatment options for treating BV.  Either Metronidazole or Clindamycin can be taken in pill form or with a gel or cream that is inserted into the vagina.   There are more side effects possible if taken orally, but it is more convenient. Sexual partners:  There is no need to treat sexual partners of those infected with BV as it doesn’t decrease the risk of infection coming back.  BV is not a sexually transmitted infection, remember? Relapse:  Within 3 months after resolution of symptoms, 30% of women have recurrence.  More than 50% have recurrence after 12 months.  The reasons for recurrence are unknown.  Relapse may be treated with a more prolonged course of antibiotics and the CDC suggests a treatment regimen different from the initial treatment if recurrence occurs. Some patients use a preventative treatment with metronidazole vaginal gel twice weekly for 3-6 months if they get more than 3 episodes in 12 months. Prevention:  Some recommendations may include the following: 1)   Finish the entire course of antibiotics for the treatment of BV even if symptoms resolve rapidly 2)   Limit the number of sexual partners 3)   Do not douche.  There is no proven benefit to douching and the solution used to rinse the vagina may upset the balance of bacteria and actually flush other bacteria up into the uterus or fallopian tubes and cause other types of infections If you have vaginal discharge or questions, please contact your medical provider.  Do not attempt to treat yourself as this can actually make the situation worse.   I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Pharmacist discussing medication with a patient at a pharmacy counter

Vaginal Yeast Infections: Symptoms, Causes, Treatment

On By Dr. Scott RennieIn Infectious Disease, Menopause & Women's Health3 Comments
shutterstock_128350532Patients frequently present to their health care provider with complaints of yeast infection symptoms.  Other terms that are used to describe yeast infections include yeast vaginitis or vaginal candidiasis.  The symptoms of this type of infection usually include itching and irritation to the vulva around the opening of the vagina. Yeast infections are more common during times of menstruation (having monthly periods) and also after taking antibiotics. There is no evidence that vaginal yeast infections are related to poor hygiene or tight synthetic clothing. Other symptoms of yeast infections: 1)   Pain with urination – can be confused with a urinary tract infection 2)   Itching or irritation around the opening of the vagina 3)   Pain with intercourse 4)   Watery or white colored vaginal discharge 5)   Red or swollen vaginal tissues The symptoms of yeast infection can be confusing because they can be similar to a number of other disorders such as a bacterial infection of the vagina, urinary tract infection, trichomoniasis, or common dermatitis (inflammation of the skin).  Most of the time the patient may not know if the itching or irritation is caused from yeast or another cause and this leads them to see a medical provider. Causes of yeast infection:  Candida is the name of the yeast that causes the infection and it normally lives in the intestines and vagina.  Most of the time Candida causes no symptoms.  If it grows out of control (which can be due to increased stress, antibiotic use, or stress to the immune system), it can overgrow and cause symptoms. Risk factors for yeast infection:  Often there are no underlying health problems that lead to yeast infections in women, but several factors may increase the chances of developing an infection including: 1)   Antibiotics – most antibiotics kill lots of bacteria including those that normally live in the vaginal area.  The bacteria that are normally found in the vagina help protect this area from being overgrown with yeast.  Antibiotics can kill off these bacteria and lead to an increase of the normal flora of yeast in the vagina 2)   Pregnancy can increase the chances of yeast infection because there is a normal increase in the amount of vaginal discharge. 3)   Diabetes causes an elevation of blood sugars which can lead to an increase in the likelihood of a yeast infection 4)   Hormonal contraceptives such as birth control pills, vaginal rings or patches that contain estrogen can sometimes increase the chance of yeast infection in some people. 5)   Contraceptive devices such as diaphragms, vaginal sponges and IUDs can also increase the chance of a yeast infection.  Spermicides usually don’t cause yeast infections, but can lead to vaginal irritation. 6)   Increased sexual activity can lead to a yeast infection.  The reason for this may be related to changes in the concentration of bacteria within the vagina that happen with sexual intercourse.  Yeast infections are not considered a sexually transmitted infection. Diagnosis:  Sometimes women who have symptoms of a yeast infection will diagnose themselves and seek treatment with over the counter medications.  One study showed that only 11% of women accurately diagnosed their infection.  Women who previously had a yeast infection were slightly more accurate (35% correct).  The general recommendation is for women who have symptoms consistent with yeast infection be be evaluated by a medical provider.  The exam usually consists of examination of the vulva and vagina and sometimes a swab is used to collect a sample of the discharge to look for yeast. Treatment:  You may be treated with oral or vaginal medication for yeast infection (or both). Vaginal treatment:  Most of the time the treatment includes a cream or tablet that is placed into the vagina at bedtime with an applicator. There are several different treatment options some of which are 1, 3 or 7 days in duration.  The vaginal treatment seems to be more effective in reducing the vaginal irritation quicker than the oral medications. Oral treatment:  Diflucan is a very common oral medication for treating yeast infections.  Most of the time only one dose is needed, however a second dose given 3 days or so after the first dose may be recommended for some patients. If you’re not feeling better within a few days after starting the treatment, make sure you call the office of your medical provider to let them know. Recurrent vaginal yeast infections:  There are about 5-8% of women who have vaginal yeast infections that come back repeatedly.  If the patient has more than 4 infections in one year, we call this recurrent vaginal yeast infection. There is no evidence that eating yogurt or other products containing live lactobacillus acidophilus or applying these products vaginally will benefit women with recurrent vaginal yeast infections. A persistent infection can be cause from a less common species of Candida called Candida glabrata or Candida krusei and in these less common species, we use different medications to treat them. Treatment of recurrent vaginal yeast infections:  Most of the time we use a longer course of anti-yeast medication in patients who have recurrent infections, often between 7 and 14 days for a topical cream or suppository or if the oral medication is used, it is taken with a 2nd dose 3 days later and possibly a 3rd dose 6 days later.  Some patients are started on preventative treatment with oral or vaginal creams once per week. Treatment of a sexual partner:  Vaginal yeast infections are not a sexually transmitted infection and most experts do not recommend treating a sexual partner. Prevention: 1)   Diabetes:  Keep blood sugars under good control in diabetic patients 2)   Antibiotics:  For patients who frequently get yeast infections after taking antibiotics, we often will prescribe a dose of fluconazole at the start and end of antibiotic therapy to prevent post-antibiotic vulvovaginitis. 3)   Patient awareness:  Patients who are using hormone birth control products or contraceptive devices should be aware of the increased risk of yeast infections with these products.   I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Two IUD devices side by side neutral background

Mirena vs Paragard: Side Effects and Risks Compared

On By Dr. Scott RennieIn Healthcare System & Technology, Menopause & Women's Health1 Comment

shutterstock_78966643by Nicole Evans M.D.

October 16, 2010 Intrauterine devices, or IUDs, are a good choice of birth control for women who want long-term contraception that is not permanent and is not associated with the side effects of contraceptive options that release hormones systemically. In order to choose between the Mirena and Paragard IUDs, the side effects should be evaluated.  Paragard can cause increased cramping and menstrual bleeding, whereas Mirena can cause some unpredictable spotting in the first few months that resolves and also results in lighter periods or no periods.  For this reason, Mirena is also sometimes used as an off-label treatment for endometriosis, dysmenorrhea and menorrhagia.
The Mirena IUD can cause hormonal side effects in some women.  These include breast tenderness, mood changes and acne.  The copper Paragard IUD does not create hormonal side effects but does cause a greater risk of developing pelvic inflammatory disease in women who are exposed to sexually transmitted infections such as gonorrhea and Chlamydia. Paragard IUD is an excellent option for women who want to avoid hormonal contraception options, such as women with recent breast cancer or recent deep vein thrombosis or pulmonary embolism (hormonally-sensitive conditions).  One additional unique feature of the Paragard IUD is that it may be used as emergency contraception and then left in to provide on-going birth control. The fact that IUDs are vaginally inserted does present a few risks.  One is the risk of expulsion (or losing the IUD, especially during menstruation).  This risk is highest in the first year and occurs a bit more often in women who have never had children, at a rate of 2 to 5 percent.  Another risk of IUD insertion is uterine perforation.  This is thought to occur at a rate between 3 in 1,000 to 1 in 3,000 women. Women are usually tested for gonorrhea and Chlamydia prior to insertion.  If positive, they may have the IUD inserted three weeks after treatment and a test of cure. The insertion of the IUD can cause some cramping sensations.  Some women will have cramping a mild spotting up to three days after IUD insertion. Women should contact their physician if the IUD insertion causes severe pain uncontrolled by over-the-counter pain medicines such as Tylenol or Ibuprofen.  Other reasons to seek medical care after an IUD insertion include: -No menstrual period for greater than a month -Can no longer feel the strings -The strings feel a lot longer -The plastic tip of the IUD can be felt. IUD should be removed at their expiration date or at the woman’s request.  Like the insertion of IUDs, the removal is a simple in-office procedure.  Once removed, women may begin trying to conceive right away.  However, it may take two to six months for the endometrial changes to resolve. IUDs are a safe and effective methods of birth control for women who desire a long-term birth control option that is reversible.  IUDs are associated with certain side effects and risks, thus any woman interested in IUD use should work with her physician to determine which means of birth control is best for her individual needs. References: McCarthy, L. Levonorgestrel-Releasing Intrauterine System (Mirena) for Contraception.  Am Family Physician.  May 2006-73(10): 1800-1801. Package Inserts (available online at Paragard.com and Mirena.com)

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.