You are 51. You have not had a period in fourteen months, you are waking at three in the morning soaked through your shirt, and the first opening with a gynecologist near you is in March. That gap is most of the reason virtual menopause care exists.
The question comes up in the first couple of minutes of a lot of my video visits. Can this actually be done over a screen? Fair question, and the answer is mostly yes, with one category of exception that matters more than everything else on this page combined.
The diagnosis is a conversation, not a lab draw
If you are 45 or older, your periods have stopped or gone erratic, and you are having hot flashes and night sweats, the diagnosis is clinical. No blood test required. For women in that age group with typical symptoms, routine hormone testing is not recommended, and that is not a corner being cut for the sake of convenience (1).
Patients ask me to check their hormone levels constantly. Almost always they have read something first and done real work on their own, and what they are after is a number that explains why they feel the way they do.
I understand that request better than I used to. It is not really about the lab. It is about wanting proof that this is happening and that she is not imagining it.
Which is exactly why ordering it can backfire. FSH swings week to week in perimenopause, so a single value lands wherever it happens to land that morning. Hand a woman a normal result while she is exhausted and soaked at four in the morning, and you have taken away the validation she came for and given her nothing in exchange. So I tell her what the test can and cannot settle, and then I treat the symptoms, which is what she needed either way.
Under 45 is a different conversation. Early menopause and primary ovarian insufficiency change the stakes, and there I do want labs.
What I can prescribe without ever being in the room
Systemic estrogen, as a patch, gel, spray or tablet. A progestogen alongside it if you still have a uterus, because unopposed estrogen is what drives endometrial risk. Low dose vaginal estrogen for dryness and painful sex, which barely registers systemically and is the most underused prescription in midlife women’s health.
The non-hormonal side has moved recently and plenty of people have not caught up. Fezolinetant (Veozah) was approved in May 2023 and blocks the NK3 receptor (2). Elinzanetant (Lynkuet) followed on October 24, 2025, and blocks NK1 as well as NK3, which is why the OASIS trials picked up an effect on sleep disruption and not only on hot flashes. Dosing is 120 mg daily (3). Where sleep is the dominant complaint rather than the flashes themselves, the agent with an actual sleep signal behind it is the more logical place to start.
Paroxetine at 7.5 mg and gabapentin are both still reasonable, particularly for women who cannot take estrogen at all.
One boxed warning came off. One did not.
On November 10, 2025, the FDA moved to strip the boxed warnings for cardiovascular disease, breast cancer and probable dementia from estrogen-containing menopause products (4). The endometrial cancer warning on systemic estrogen-only products stayed exactly where it was, and that is the part the coverage mostly dropped.
My read is that this fixed a labeling problem rather than a science problem. Nothing underneath changed in November. What changed is that a warning drawn from a trial population averaging 63 years old had spent two decades frightening 52 year olds away from a treatment whose risk profile depends enormously on how old you are when you start it. I wrote about that separately.
The thing a video visit cannot do, and it just got harder
Bleeding after menopause needs an in-person evaluation. Not a phone call, not reassurance, not wait and see.
ACOG updated this in April 2026 and it moved in the stricter direction. Transvaginal ultrasound on its own is no longer considered adequate initial triage for postmenopausal bleeding. The recommendation now is ultrasound together with endometrial tissue sampling in most patients (5). Relying on ultrasound alone appears to miss 5 to 12 percent of cancers, and the old 4 mm endometrial thickness cutoff performed especially badly in Black women, with a sensitivity around 47.5 percent (5).
Read that number again. A triage rule that caught fewer than half the cancers in one group of women was standard practice until this year.
So when a patient tells me on video that she is a year past her last period and bleeding again, the visit stops being about hot flashes and becomes about getting her seen and scanned quickly by someone who can put instruments on the problem. That is not telemedicine failing. That is telemedicine doing the one thing it can do in that moment, which is recognizing what it is looking at and moving.
Same goes for a new breast lump, for pelvic pain, and for anything needing a speculum, an IUD, a mammogram or a bone density scan.
What the visit actually looks like
Expect questions, a lot of them. When your last period was. What the flashes are doing to your sleep and your work. Whether sex has become painful, which almost nobody volunteers unless asked directly. Your personal and family history of breast cancer, clotting, stroke and heart disease. Whether you get migraines with aura.
I will ask what your blood pressure has been running, and if you do not own a cuff I will ask you to get one, because starting systemic estrogen without knowing that number is not something I am willing to do. I will ask when your last mammogram was, and I will ask again at follow-up. The biggest failure mode in virtual menopause care is a woman who feels wonderful on therapy and quietly slides three years behind on screening.
Labs, when they are warranted, get ordered to a draw site near you. Prescriptions go to your pharmacy the same day.
For clinicians
Licensure is the whole ballgame. You need a license in the state where the patient is physically sitting during the visit, not where she gets her mail, and telehealth prescribing of estrogen is otherwise permitted across all fifty states on that basis.
On my own panel, roughly 25 percent of the women arrive already on hormone therapy started somewhere else, usually a direct-to-consumer platform. That number tells you what kind of visit you are actually having. Much of the time you are not initiating therapy, you are inheriting it, and the first job is working out what she is on, at what dose, and whether anyone ever screened her for a contraindication.
Two things worth tightening. Document the contraindication screen explicitly rather than letting it sit implicitly in the note, because the labeling change has patients arriving expecting a prescription and expecting it that day. And build a real handoff to a local gynecologist before you need one. After the April 2026 update, a postmenopausal bleeding referral carries a specific expectation about what the workup should include, and telling someone to go see somebody is not a plan.
The Bottom Line
Most of menopause care transfers to video without losing anything. The diagnosis is clinical, the history is the test, and hormone therapy, the two neurokinin antagonists and the non-hormonal alternatives can all be started and adjusted remotely by someone licensed where you are.
What does not transfer is anything needing hands. Bleeding after menopause is the one to take seriously, and as of April 2026 the standard for evaluating it went up, not down.
If you have been waiting until March to ask someone about this, you do not have to.
Related Reading
FDA Removes Black Box Warning From Menopause Hormone Therapy
Perimenopause and Menopause Symptoms and How to Manage Them
Vaginal Dryness After Menopause: Why It Doesn’t Go Away
Does Menopause Cause Weight Gain, or Is It Just Aging?
Why Some Conditions Need an In-Person Visit, Not Virtual Care
More on Menopause & Women’s 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.
Sources
1. National Institute for Health and Care Excellence. Menopause: identification and management. https://www.nice.org.uk/guidance/ng23
2. U.S. Food and Drug Administration. FDA Approves Novel Drug to Treat Moderate to Severe Hot Flashes Caused by Menopause. May 12, 2023. https://www.fda.gov/news-events/press-announcements/fda-approves-novel-drug-treat-moderate-severe-hot-flashes-caused-menopause
3. FDA Approves Elinzanetant as First Nonhormonal Therapy for Menopause Vasomotor Symptoms. Pharmacy Times, October 2025. https://www.pharmacytimes.com/view/fda-approves-elinzanetant-as-first-nonhormonal-therapy-for-menopause-vasomotor-symptoms
4. 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
5. American College of Obstetricians and Gynecologists. ACOG Publishes Updated Guidance on Evaluation of Postmenopausal Bleeding. April 2026. https://www.acog.org/news/news-releases/2026/04/acog-publishes-updated-guidance-evaluation-postmenopausal-bleeding