A smartphone with a blank screen resting on a beige linen sofa cushion

What Should You Do If a Lab Result in Your Patient Portal Looks Critical?

On October 30, 2026October 8, 2026 By Dr. Scott RennieIn Healthcare System & TechnologyLeave a comment

If a result in your patient portal is marked critical, or you see a number that looks dangerously high or low and you feel unwell, do not wait for a callback. Call the clinician who ordered the test right now. If you also have chest pain, trouble breathing, confusion, fainting, or severe weakness, call 911 or go to the nearest emergency department.

If you feel fine and the result is only flagged high or low, it is usually not an emergency. A message or phone call during business hours is the right speed.

The hard part is telling those two situations apart when the result lands on your phone at 9 p.m. and nobody has explained it. So here is how it works, which numbers matter, and what to do.

Why results show up before anyone has called you

The 21st Century Cures Act information-blocking rules changed the default. The prohibition began applying on April 5, 2021, and from October 6, 2022 it covered the full electronic health information in the designated record set rather than a narrower list of data elements (1). Federal guidance does not tell health systems to push every result to you the moment it posts. It does say that once a patient asks for access, the response has to be timely, and in practice you may see a result at about the same time the ordering clinician does (2).

Holding results back for clinician review is hard to defend as a blanket policy. The same federal FAQs say a routine several-day delay across a broad range of results does not qualify for the Preventing Harm exception (3). An individual clinician can make a specific determination that releasing one result would put someone’s life or physical safety at risk, and a patient can ask for a delay on their own results (3,4). Enforcement is no longer theoretical either. Provider disincentives tied to Medicare programs were finalized in July 2024, and HHS announced in September 2025 that information-blocking enforcement is a priority (5).

Patients, for what it is worth, mostly like this. In a four-center survey of 8,139 people, 95.7 percent wanted results in the portal immediately, even before a clinician reviewed them. But 16.5 percent of people with not-normal results reported being more worried afterward, against 5.0 percent of those with normal results (6). That worry is what this post is for.

What does “critical” actually mean?

A critical value is a lab result that suggests something imminently life-threatening. Federal lab regulations under CLIA require the laboratory to immediately alert the person who requested the test when a result indicates an imminently life-threatening condition, or a panic or alert value (7). The Joint Commission describes a critical value as one requiring immediate communication of results (8).

Notice who gets the call. The lab calls the ordering clinician, not you. One hospital laboratory described its rule as a technologist phoning the ordering practitioner within 30 minutes, with escalation if that person cannot be reached (8). Each lab builds its own list and its own cutoffs, and accreditors including the College of American Pathologists and the Joint Commission expect an alert system to exist (8). That obligation runs separately from whatever your portal shows you.

What the portal shows is a different matter. ONC’s safety guide for test result reporting recommends that critical values be flagged differently from ordinary abnormal values in the record clinicians use (9). Whether your portal does the same depends on the system. Do not count on a special color or the word “critical” appearing.

Flagged does not mean dangerous

Reference ranges are built from the central 95 percent of results in a healthy group. By definition, that labels 5 percent of healthy people as abnormal on any single test (10). Order a panel of 20 tests and about 64 percent of healthy people will have at least one result flagged (10). MedlinePlus puts it plainly: it is common for healthy people to sometimes have results outside the reference range (11).

So the red H or L next to your result is a prompt to look, not a verdict. A potassium of 5.6 mmol/L, for example, sits in the mild band (5.5 to 5.9) of the UK Kidney Association’s hyperkalaemia grading, and the same guideline says most mild or moderate cases found in the community can be managed without admission unless the person is acutely unwell (12). A sodium of 132 falls in the mild hyponatremia band, 130 to 135 (13). Both are real findings that deserve a conversation. Neither is a 911 call in a person who feels well.

One more trap. A hemolyzed blood sample can make potassium read falsely high, and that guideline recommends paired samples when this pseudo-hyperkalaemia is suspected (12). A surprising potassium in someone with no symptoms and normal kidney function is a reasonable one to repeat before anyone panics.

Which numbers can be truly urgent?

Labs call a wide range of analytes. Electrolytes, especially potassium, hemoglobin, high blood glucose and positive blood cultures were all on one laboratory survey’s list of commonly called values (8). I am not going to hand you a universal cutoff for each, because your lab sets its own. But the published guidelines give a sense of where the danger starts.

Potassium first. The UK Kidney Association grades severe hyperkalaemia as 6.5 mmol/L or higher and recommends urgent hospital assessment for anyone with that level found in the community (12). Sodium next. The European hyponatraemia guideline calls a serum sodium below 125 mmol/L profound, and notes that symptoms become more common below that level. Nausea, confusion and headache count as moderately severe symptoms. Vomiting, seizures, deep sleepiness and coma count as severe (13).

Glucose runs both directions. The American Diabetes Association defines level 2 hypoglycemia as below 54 mg/dL, and level 3 as an event with altered mental or physical status that needs another person’s help, whatever the glucose number says (14). On the high side, the ADA says to seek immediate care if you cannot keep fluids down, have ongoing vomiting, or have altered mental status (14). Those symptoms matter more than the number.

Hemoglobin is context-heavy. In the 2023 AABB guideline, the transfusion threshold for stable hospitalized adults is below 7 g/dL (15). That is a transfusion trigger and not a lab’s critical cutoff, but it tells you what kind of low is alarming. A slowly developed anemia and a bleed produce very different pictures at the same number.

Troponin deserves its own warning because patients see it more often now. Each assay has its own 99th percentile cutoff, reported in ng/L, and a value above it means myocardial injury. It is sensitive for a heart attack but not specific for one (16). If you see an elevated troponin in your portal and you have chest pressure, shortness of breath, or pain spreading to the arm or jaw, call 911 immediately (17). My view is that an unneeded trip to the emergency department is a much better outcome than a delayed one.

Some results always get a phone call from me: a critical blood sugar, a critical potassium, a critical kidney function result, or another electrolyte in the critical range. It is easier to reach someone during office hours, but I treat a critical result as urgent no matter what time it comes in. A critical number can occasionally be a mistake, too. A lab error, or a hemolyzed sample, where red cells broke open after the draw, can show an artificially high potassium. That is one reason earlier results help so much. For new patients I try to get their previous lab work, so I have something to compare against when I order new tests. It isn’t always possible.

What to do, in order

Start with how you feel, not with the number. Any chest pain, trouble breathing, fainting, new confusion, seizure, or severe weakness means 911, whatever the result says.

If you feel okay, check the reference range printed on your own report and read the lab’s comment, if there is one. Then call the office that ordered the test. Portal messages are the wrong tool for anything you think might be urgent. Pick up the phone.

After hours, call anyway and ask for the on-call clinician. If no one can be reached and the value is in the range described above (a potassium of 6.5 or higher, or a sodium under 125), go to an emergency department. A drawn glucose is old news by the time you read it, so for glucose, how you feel right now decides. Bring the result, your medication list, and the name of the ordering clinician.

Do not wait for the next business day with a severe value because you assume someone has already been called. The lab alert exists, but a phone number can be wrong and a message can sit in a queue.

When a virtual clinician ordered the test

Telehealth adds a wrinkle. The lab you walked into is probably near your home, while the clinician who ordered the test may be in another city or time zone. The ONC guide says the ordering clinician is responsible for follow-up of outpatient results unless that responsibility is delegated to someone else, and the delegation should be documented and accepted (9). That is the right principle. You want to know that someone actually holds it.

Ask which phone number the lab has on file for the ordering clinician, and whether that number is monitored when the clinician is not in a visit. Make sure the lab has your current cell number. And know where you are during a video visit, because a clinician who needs to send help has to know your physical address.

When a lab I ordered comes back critical, I try to reach the patient directly, especially after hours, because they need to know. They may know before I do, since the lab sometimes releases the result to them first. I also try to loop in their primary care physician if they have one. And a local emergency contact in the chart helps in the situations where the patient can’t be reached.

Ask before the blood draw

The single best question is “Who calls me if a result is critical, and from what number?” Ask it when the test is ordered, not when the portal pings you.

Follow with three more. Will I see results before you have read them? Who covers if you are unavailable? And if I would rather talk first, can the release wait? Federal guidance treats a patient’s own request to delay as likely not an interference, as long as the delay lasts no longer than necessary to meet that request (4). Some people genuinely prefer to hear a frightening result from a person first. That is a legitimate choice.

For patients, and for clinicians

If you are the patient

Know your own phone number on file, keep your ringer on after a blood draw, and decide ahead of time who you will call. Write the question “who calls me if it is critical” in your notes app before the next lab visit. Treat symptoms as the deciding factor.

If you are the clinician

Tell patients when you order that results may post before you have seen them, since the evidence shows abnormal results raise worry more often (6). Keep your critical-value contact information current with every lab you use, and make sure patients know who is covering when you are not. The SAFER guide asks organizations to have policies for timely patient notification of both normal and abnormal results, with the timeliness monitored (9).

When I order labs, I tell patients which tests are on the list. For my patients that usually means a fasting lipid profile, a comprehensive metabolic panel, a TSH, a hemoglobin A1c, and a high-sensitivity C-reactive protein, plus two special lipid tests: lipoprotein(a), which the 2026 ACC/AHA dyslipidemia guideline recommends measuring at least once in every adult (18), and apolipoprotein B.

The Bottom Line

A result marked critical, or a very high or low number paired with symptoms, means call the ordering clinician now, and call 911 for chest pain, trouble breathing, confusion, or fainting. A result that is merely flagged high or low is common even in healthy people and can usually wait for a conversation.

Cures Act rules mean you will often see results first, so ask before the blood draw who calls you if something is critical, from what number, and what happens when they cannot reach you. For telehealth patients, that answer matters even more.

Sources

Department of Health and Human Services. Information Blocking and the ONC Health IT Certification Program: Extension of Compliance Dates and Timeframes in Response to the COVID-19 Public Health Emergency. Federal Register, November 4, 2020. https://www.govinfo.gov/content/pkg/FR-2020-11-04/html/2020-24376.htm
ASTP/ONC. FAQ: Are actors (for example, health care providers) expected to release test results to patients through a patient portal or API as soon as the ordering clinician can see them? https://healthit.gov/faq/are-actors-example-health-care-providers-expected-release-test-results-patients-through-patient/
ASTP/ONC. FAQ: Would the Preventing Harm Exception cover a blanket several-day delay in the release of laboratory or other test results? https://healthit.gov/faq/would-preventing-harm-exception-cover-blanket-several-day-delay-release-laboratory-or-other/
ASTP/ONC. FAQ: Can an actor grant a patient’s request to delay the release of the patient’s test results? https://healthit.gov/faq/can-actor-grant-patients-request-delay-release-patients-test-results-eg-laboratory-or-image/
Liebler AJ, Sullivan S, Boyer MD, Doe K. Information Blocking Enforcement Enters a New Phase: What Digital Health Stakeholders Should Expect in 2026. Alston & Bird Health Care Advisory. February 23, 2026. https://www.alston.com/en/insights/publications/2026/02/information-blocking-enforcement-2026
Steitz BD, Turer RW, Lin CT, et al. Perspectives of patients about immediate access to test results through an online patient portal. JAMA Netw Open. 2023;6(3):e233572. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2802672
42 CFR 493.1291. Test report (CLIA), paragraph (g). https://www.law.cornell.edu/cfr/text/42/493.1291
Association for Diagnostics & Laboratory Medicine. Critical result notification preferences. Clinical Laboratory News. September-October 2024. https://myadlm.org/cln/Articles/2024/SeptemberOctober/Critical-result-notification-preferences
ONC. SAFER Guides: Test Results Reporting and Follow-Up. August 2024 self-assessment. https://www.healthit.gov/sites/default/files/topiclanding/2025-01/8.%20Test%20Results%20Reporting%20Final.pdf
Doles N, Ye Mon M, Shaikh A, et al. Interpreting normal values and reference ranges for laboratory tests. J Am Board Fam Med. 2025;38(1):174-179. https://pmc.ncbi.nlm.nih.gov/articles/PMC12096374/
MedlinePlus. How to Understand Your Lab Results. Updated September 4, 2025. https://medlineplus.gov/lab-tests/how-to-understand-your-lab-results/
UK Kidney Association. Clinical Practice Guideline: Management of Hyperkalaemia in Adults. Updated July 2026. https://www.ukkidney.org/sites/default/files/documents/FINAL%20VERSION%20-%20UKKA%20CLINICAL%20PRACTICE%20GUIDELINE%20-%20MANAGEMENT%20OF%20HYPERKALAEMIA%20IN%20ADULTS%20-%20UPDATED%20JULY%202026_0.pdf
Spasovski G, Vanholder R, Allolio B, et al. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Eur J Endocrinol. 2014;170(3):G1-G47. https://doi.org/10.1530/EJE-13-1020
American Diabetes Association Professional Practice Committee. 6. Glycemic goals, hypoglycemia, and hyperglycemic crises: Standards of Care in Diabetes-2026. Diabetes Care. 2026;49(Suppl 1):S132-S149. https://doi.org/10.2337/dc26-S006
Carson JL, Stanworth SJ, Guyatt G, et al. Red blood cell transfusion: 2023 AABB international guidelines. JAMA. 2023;330(19):1892-1902. https://doi.org/10.1001/jama.2023.12914
Sandoval Y, Apple FS, Mahler SA. High-sensitivity cardiac troponin and the 2021 guidelines for acute chest pain. American College of Cardiology. July 14, 2022. https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2022/07/14/18/12/high-sensitivity-ctn-and-2021-chest-pain
Centers for Disease Control and Prevention. About Heart Attack Symptoms, Risk, and Recovery. October 24, 2024. https://www.cdc.gov/heart-disease/about/heart-attack.html
American College of Cardiology. Lower Sooner: How the 2026 Dyslipidemia Guideline Changes Practice. July 1, 2026. https://www.acc.org/latest-in-cardiology/articles/2026/07/01/01/prioritizing-health

A bedside table in soft morning light with a folded linen cloth, a glass of water and two books

Vaginal Dryness After Menopause: Why It Doesn’t Go Away

On August 29, 2026September 11, 2026 By Dr. Scott RennieIn Menopause & Women's HealthLeave a comment

Half the women who have it have never used a single treatment. Among the never-treated, close to three quarters have never mentioned it to a clinician. Both come from EMPOWER, a survey of 1,858 postmenopausal American women with genitourinary symptoms; most who stayed quiet assumed it was aging they had to live with (1).

That assumption is wrong in one specific way. Hot flashes usually fade. This does not.

Why the name changed in 2014

Genitourinary syndrome of menopause was coined at a 2013 ISSWSH and NAMS conference and endorsed by both boards in 2014 (2). It replaced vulvovaginal atrophy and atrophic vaginitis. Those terms implied an infection that is not there, and left out the urethra and bladder entirely (2).

Somewhere between 27% and 84%

That is the range cited by The Menopause Society and the 2025 AUA/SUFU/AUGS guideline (1)(3). A three-fold spread is less a number than a confession that case definitions vary wildly. One firmer figure: 84% of women six years past menopause had it (1).

Then the sentence that belongs on every package insert, verbatim from the 2020 position statement: “In contrast to vasomotor symptoms (VMS) that usually improve over time, GSM is generally progressive without effective therapy” (1). Generally, not always, but the direction is the point, and the 2025 guideline treats GSM as chronic (3). Untreated, it is also associated with women avoiding Pap smears (3). A complaint nobody raised becomes a screening gap.

What I can settle over video. What I can’t.

I practice entirely by telemedicine, so let me be direct about limits. The Menopause Society says diagnosis “requires the presence of both characteristic examination findings and bothersome symptoms” (1), and the 2025 guideline requires a genitourinary examination (3). No camera does that half.

Nearly everything else works remotely: the focused history, a medication review catching aromatase inhibitors and GnRH agonists, self-administered instruments like the Cervantes-GSM (3). And one free question: did the symptoms start before menopause? If so, another diagnosis is likelier (1). The mimics are the problem. Lichen sclerosus reads like GSM in a history and carries carcinoma risk. Postmenopausal bleeding I never close out on video. No guideline addresses telemedicine for GSM, so that division of labor is my own reasoning, not a society position.

So here is my position, and it diverges from the letter of the guideline. I recommend that a patient be examined in person for these symptoms. I also do not hesitate to treat her when what she describes is clearly GSM to me. The exam still needs to happen, and I say so. It does not have to happen first.

Red flags are where I hold the line. Bleeding after menopause, a visible lesion, or symptoms that predate menopause need eyes on them before anything else.

Start in the drugstore aisle

Lubricants and moisturizers get confused constantly. A lubricant goes on at the time of sex to cut friction. A moisturizer goes on a schedule, sex or no sex, to rehydrate tissue over time (1). Oil-based lubricants erode condoms. Hyaluronic acid sells at a premium with no evidence it beats products without it (1).

The humbling part. MsFLASH randomized 302 postmenopausal women to a 10-microgram vaginal estradiol tablet, a moisturizer, or dual placebo. At 12 weeks nothing beat placebo (P = .25 and .31) (4). The Menopause Society notes the placebo gel likely lubricated (1). The lesson survives: plenty improve on a drugstore moisturizer, which is why the guideline recommends them (3).

Low-dose vaginal estrogen

Most evidence, strongest recommendation (3). Vagifem (10 micrograms) and Imvexxy (4 or 10) run daily two weeks, then twice weekly; the Estring ring lasts 90 days; creams taper to two or three times weekly (1). After 14 days of daily use, serum estradiol on the inserts measured 3.6 and 4.6 pg/mL against 4.3 on placebo (1). Across 20 trials and 2,983 women exposed up to a year there was one endometrial cancer, and no progestogen is needed (1)(3).

The gap nobody advertises: the longest randomized trial of any vaginal estrogen ran 52 weeks (1), and this needs years of treatment. Reassurance past that is observational: 18 years of Nurses’ Health Study data found no excess chronic disease (5). Cochrane graded 30 trials low to moderate quality (6). Consistent direction, mediocre trials.

My own preference is the vaginal tablets. That is my preference and nothing stronger, and Cochrane found no efficacy difference between the preparations anyway (6). What decides it is what the patient prefers and what it costs her.

About that boxed warning, precisely

On November 10, 2025, FDA announced it was initiating removal of boxed warning language on menopausal hormone therapy, including low-dose vaginal estrogen, covering cardiovascular disease and breast cancer, plus probable dementia (7). The Menopause Society agreed, calling the warning a likely deterrent to a safe, effective therapy (8).

Implementation is running product by product. As of August 29, 2026, FDA’s updated-labeling list holds six drugs, and Estring is the only vaginal estrogen among them, its label updated April 27, 2026 (9)(10). Vagifem, Imvexxy and Premarin Vaginal Cream still carry the full boxed warning (11)(12)(13). Fill a prescription this week and you may find that warning in your own package. The paperwork has not caught up. Two things not to conflate: systemic estrogen-alone products keep a boxed warning for endometrial cancer, and ospemifene was never part of this action (7)(14).

DHEA, ospemifene, and the limits of systemic therapy

Vaginal DHEA (prasterone, Intrarosa) is a 6.5 mg insert used once daily, and endometrial sampling stayed inactive or atrophic in all 422 women studied for 52 weeks (1). It has never carried a boxed warning, and that predates the recent FDA action (15). Ospemifene (Osphena), the only oral option at 60 mg daily, holds the guideline’s weakest recommendation grade (3), causes hot flashes in 7.2% versus 2% on placebo (1), and its own boxed warning for endometrial cancer and cardiovascular disorders stands (14).

If you take systemic hormone therapy for hot flashes, do not assume it covers this. Some get inadequate GSM relief from it, and the guideline recommends adding local estrogen or DHEA (3). You will see percentages quoted for this. I could not trace one to a primary source, so I am not repeating one. The add-on rests on expert opinion, with no data on the combination’s risk (3).

Lasers

In a sham-controlled trial, 85 women were followed 12 months after three CO2 laser or sham treatments. Symptom severity fell 17.2 points with laser and 26.6 points with sham (16). Read that again. The point estimate favored sham, and the biopsy histology showed no difference either, so the collagen-remodeling mechanism they are sold on was never shown in tissue. The 2025 guideline calls them experimental outside trials (3), and no energy-based device is FDA-cleared for any gynecologic indication (17). Cash pay, expensive, and the widest gap between marketing and data here.

The best evidence here is about UTIs

Recurrent UTI means two culture-proven infections in six months, or three in a year (1). Vaginal estrogen for prevention is the only Grade B statement in the 2025 guideline; every other one is Grade C or expert opinion (3). Raz and Stamm, 1993: 93 postmenopausal women randomized to intravaginal estriol or placebo, infections falling to 0.5 episodes per patient-year against 5.9 (18). Estriol, oddly, is not sold as an FDA-approved product here (3), so the field’s cleanest result came from a drug Americans cannot prescribe. Pelvic floor physical therapy suits coexisting pelvic floor dysfunction, though its direct GSM evidence is one single-arm feasibility study (3).

After breast cancer, especially on an aromatase inhibitor

Aromatase inhibitors produce what the 2020 statement calls a profound estrogen-deficiency state, and severe GSM in most survivors (1). ACOG’s 2021 clinical consensus, which replaced its 2016 committee opinion: nonhormonal treatment first line; if that fails, low-dose vaginal estrogen may be used after breast cancer, including on tamoxifen, and in aromatase inhibitor users after shared decision-making between patient, gynecologist and oncologist (19). ACOG reviewed seven studies covering more than 4,000 survivors, median follow-up two to seven years, tamoxifen and aromatase inhibitor users alike, with no increased recurrence, and calls low-dose vaginal estrogen safe in women with hormone receptor-positive disease at low risk of recurrence (19).

The caution traces to one Danish cohort: 8,461 women with early ER-positive breast cancer, 1,957 of them vaginal estrogen users. Overall recurrence risk was not raised, relative risk 1.08 (95% CI 0.89 to 1.32); in the subgroup on adjuvant aromatase inhibitors it was 1.39 (95% CI 1.04 to 1.85), with no rise in mortality (20). The finding is contested; JNCI published four separate comments responding to it. It is an observational subgroup, and a 2024 meta-analysis of eight studies found no such increase (3). I will not tell you it is settled. Neither ACOG nor the urology panel did. Both put the oncologist in the room.

So who starts that conversation. She raises it with her oncologist, and I make sure that conversation starts from evidence rather than a package insert. ACOG puts that squarely on the prescriber: provide “data on the safety of low-dose vaginal estrogen to patients and their medical oncologists” (19). It matters because the warning FDA only began removing in November 2025 is still printed on three of the products named above, and an oncologist reading it has every reason to say no.

If you are the patient

Bring it up. That is the whole intervention, and most women never do. Say the words: dryness, burning, painful sex, urgency, recurring infections. Expect any prescription to work over weeks and to continue indefinitely.

Notes for clinicians

The screening question is the treatment. Asking costs thirty seconds. Two habits worth changing: stop ordering estradiol and FSH to diagnose this (3), and warn women about the boxed warning before the pharmacy does (1).

Here is mine, word for word.

“Do you experience vaginal dryness more now than you used to? Sometimes this can be a common side effect of menopause which can be related to painful intercourse.”

The Bottom Line

GSM reaches a quarter to four fifths of postmenopausal women and generally does not improve on its own. Half of affected women have never treated it, mostly because nobody asked. A drugstore moisturizer is a legitimate first step. Low-dose vaginal estrogen barely reaches the bloodstream and has 18 years of observational safety behind it, though most packages still carry a boxed warning FDA has already directed off. Lasers lost to sham. And a woman on an aromatase inhibitor deserves a real conversation with both her physicians, not a blanket no.

Sources

1. Menopause Society 2020 GSM position statement. https://menopause.org/wp-content/uploads/default-document-library/2020-gsm-ps.pdf

2. Portman DJ, Gass ML. Maturitas. 2014;79(3):349-354. https://pubmed.ncbi.nlm.nih.gov/25179577/

3. AUA/SUFU/AUGS GSM guideline, 2025. https://www.auanet.org/guidelines-and-quality/guidelines/genitourinary-syndrome-of-menopause

4. Mitchell CM, et al. MsFLASH. JAMA Intern Med. 2018;178(5):681-690. https://pubmed.ncbi.nlm.nih.gov/29554173/

5. Bhupathiraju SN, et al. Menopause. 2019;26(6):603-610. https://pubmed.ncbi.nlm.nih.gov/30562320/

6. Lethaby A, et al. Cochrane Database Syst Rev. 2016;(8):CD001500. https://pubmed.ncbi.nlm.nih.gov/27577677/

7. FDA labeling change request, 11/10/2025. https://www.fda.gov/drugs/drug-alerts-and-statements/fda-requests-labeling-changes-related-safety-information-clarify-benefitrisk-considerations

8. Menopause Society comment on the FDA announcement. https://menopause.org/press-releases/the-menopause-society-comments-on-the-fda-announcement-on-hormone-therapy

9. FDA list of MHT products with updated prescribing information. https://www.fda.gov/drugs/drug-safety-and-availability/menopausal-hormone-therapies-updated-prescribing-information

10. DailyMed, ESTRING label, Apr 27, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=110b9865-5a07-4d45-b560-e89947f12600

11. DailyMed, VAGIFEM label, Feb 12, 2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e5ad3cf6-dd96-4e64-af21-c1eee38d0b88

12. DailyMed, IMVEXXY label, Sep 18, 2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=104be9f2-a8f6-430e-9e01-2ee7cc1861f1

13. DailyMed, PREMARIN VAGINAL CREAM label, Jun 02, 2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=96609623-528e-4aba-cabe-7254aed816d5

14. DailyMed, OSPHENA label, Feb 17, 2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9accbcc9-78ee-4f84-9b7e-704f2ab1c413

15. DailyMed, INTRAROSA label, Aug 03, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ada639d4-bac0-2ad0-e053-2a95a90afce7

16. Li FG, et al. JAMA. 2021;326(14):1381-1389. https://pmc.ncbi.nlm.nih.gov/articles/PMC8511979/

17. FDA CDRH letter to Inmode MD Ltd., July 24, 2018. https://www.fda.gov/files/medical%20devices/published/Inmode%20MD%20Lotd%20IHCTOA%20Letter.pdf

18. Raz R, Stamm WE. N Engl J Med. 1993;329(11):753-756. https://pubmed.ncbi.nlm.nih.gov/8350884/

19. ACOG Clinical Consensus Number 2, December 2021, “Treatment of Urogenital Symptoms in Individuals With a History of Estrogen-dependent Breast Cancer” (replaces Committee Opinion 659, March 2016). https://www.acog.org/clinical/clinical-guidance/clinical-consensus/articles/2021/12/treatment-of-urogenital-symptoms-in-individuals-with-a-history-of-estrogen-dependent-breast-cancer

20. Cold S, et al. J Natl Cancer Inst. 2022;114(10):1347-1354. https://pubmed.ncbi.nlm.nih.gov/35854422/

Unlabeled blister pack of six white oval antibiotic tablets beside a plain paper pharmacy bag on a kitchen table

I hear it almost every day now. “I think I just need a Z-Pak.”

On January 2, 2026September 11, 2026 By Dr. Scott RennieIn Infectious DiseaseLeave a comment

Sometimes it’s phrased as a question. Sometimes it isn’t. In telemedicine especially, many patients request azithromycin by name within the first minute of the visit. The symptoms are familiar. Runny nose. Congestion. Post-nasal drip. Scratchy throat. Maybe a cough that started yesterday. No fever. No shortness of breath. No focal findings anyone could reasonably point to as bacterial.

But they’re convinced the Z-Pak will help them get better faster. They’ve taken it before. It worked last time. Or at least they felt better a few days later and connected the dots.

This didn’t happen by accident.

Azithromycin earned its place in outpatient medicine because it was easier to tolerate than older antibiotics like erythromycin, had fewer drug interactions than clarithromycin, and came packaged in a way that felt efficient. Six pills. Five days. Done. The Z-Pak became a symbol of modern medicine that didn’t slow you down.

Over time, it also became the antibiotic people expected.

In telemedicine, that expectation is even stronger. There’s no exam table. No stethoscope. No labs. No chest X-ray down the hall. The visit is brief by design. When a patient feels sick and wants something tangible, the Z-Pak becomes the path of least resistance. Prescribing it can shorten the encounter. It avoids a long explanation. It reduces the risk of a bad review. It keeps patient satisfaction scores high. It keeps supervisors and clinic managers happy. Everyone moves on to the next visit.

I understand why this happens. I’ve seen it from the inside.

But convenience doesn’t make a treatment safe or appropriate.

Azithromycin does not treat viral infections. It does not help the common cold. It does not clear post-nasal drip. It does not shorten the course of uncomplicated upper respiratory infections. When patients feel better after taking it, they almost always would have improved anyway.

What it does do is expose people to real risk.

Azithromycin can prolong the QT interval. That matters. QT prolongation can predispose patients to dangerous heart rhythms, including torsades de pointes and sudden cardiac death. This risk is higher in people with underlying heart disease, electrolyte abnormalities, or those taking other QT-prolonging medications, but it is not zero in otherwise healthy adults. Large observational studies have shown an increased risk of cardiovascular death during azithromycin treatment compared with other antibiotics or no antibiotics at all.

That risk is invisible to patients. They don’t feel their QT interval getting longer. They just know they want something to help them feel better.

Antibiotics also carry more familiar side effects. Nausea. Diarrhea. Abdominal cramping. Yeast infections. Rashes. Allergic reactions. These are not rare, and they are not trivial when the medication wasn’t needed in the first place.

Then there’s resistance. Every unnecessary antibiotic course applies selective pressure. Azithromycin resistance is already a growing problem in common respiratory pathogens. When we reach for it reflexively, we make it less useful for the patients who actually need it.

The harder part of these visits is the explaining.

It takes longer to walk someone through why their symptoms are viral. Why time, fluids, nasal saline, antihistamines, or intranasal steroids actually help. Why rest matters. Why antibiotics won’t fix inflammation or mucus production. Why feeling miserable does not automatically mean something dangerous is happening.

It’s much faster to send a prescription.

But faster is not better medicine.

I get patients asking for Z-Paks every day that I work in telemedicine. It’s so common that it happens at least once a day, if not three or four times a day. One example sticks with me. A patient requested a Z-Pak for congestion and sinus pressure that had been present for two days. No fever. No facial pain. No worsening course. When I explained why antibiotics wouldn’t help, they were frustrated at first. We talked through what sinus infections actually look like and when antibiotics are appropriate. We discussed symptom control instead. Two days later, they messaged to say they felt better and were glad they didn’t take an antibiotic they didn’t need.

That outcome required time. It required education. It required saying no.

Not every visit goes that smoothly. Some patients remain disappointed. Some leave poor reviews. That pressure is real, especially in high-volume telemedicine environments.

But prescribing antibiotics to keep the peace comes at a cost. It shifts risk onto the patient. It shifts harm into the future. And it reinforces the idea that medicine should always offer a pill, even when the best treatment is patience and support.

Azithromycin became dominant because it was easy. That same ease is why we need to be more careful with it now.

Menopause Care by Telemedicine: What a Virtual Visit Can and Cannot Do

On November 6, 2025September 29, 2026 By Dr. Scott RennieIn Menopause & Women's HealthLeave a comment

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.

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

A pharmacist standing in front of shelves of medicines

Compounded Semaglutide and Tirzepatide: What to Know Now

On October 17, 2025September 29, 2026 By Dr. Scott RennieIn Weight Loss & Metabolic HealthLeave a comment

When patients ask me about compounded weight loss drugs like semaglutide and tirzepatide, I take a deep breath. The topic is complicated and keeps changing. I won’t just tell patients to avoid them. They’re already looking for these options, and my job is to help them navigate the risks safely.

Dr. Beverly Tchang’s “swim safely” analogy fits well. We can’t stop people from diving into the ocean of compounded products, but we can at least give them floaties: information, caution, and tools to make better decisions. (Tchang, Medscape)

Here’s how I explain it to patients and colleagues, updated with the most recent data.

Why compounded versions exist

When semaglutide and tirzepatide injections were in short supply a few years ago, patients turned to compounding pharmacies that offered custom formulations, often at a lower price. (GoodRx)

In late 2024, the FDA ended the declared shortage of tirzepatide. (Stat News) By early 2025, semaglutide (Ozempic and Wegovy) followed. Once the shortages ended, enforcement ramped up against compounded versions. (GoodRx)

Now, compounded versions are only legal in narrow circumstances, such as when a patient has a medical need that can’t be met by an approved product. (GoodRx)

In December 2024, the FDA sent warning letters to several companies selling unapproved GLP-1 drugs labeled “for research use only.” (Reuters) Some of these contained no active ingredient, incorrect salt forms, or inconsistent potency. (Verywell Health)

Key risks and what to look for

Not all compounding pharmacies operate at the same standard. A friendly local pharmacist doesn’t necessarily mean the product is safe. Dr. Tchang’s checklist gives a good framework for evaluating any compounded GLP-1 medication. A simplified version: look for a pharmacy where the medication is prescribed by a licensed provider, there are no disciplinary actions on file, the pharmacy has been in business for more than a year, only semaglutide base is used (not a salt form), and the facility is FDA-registered or FDA-inspected; it should also be able to ship sterile drugs safely to all 50 states.

If a compounding pharmacy cannot meet these criteria, that’s a red flag. Ask directly for documentation. If they can’t provide it, walk away.

Some compounders also mix in vitamins or preservatives to make their product “different” from the brand name; that may sound harmless, but combining untested additives with peptides can change how the drug behaves. (GoodRx)

A few are promoting oral or sublingual forms of semaglutide and tirzepatide. These seem attractive for patients who don’t like injections, but they haven’t been validated in clinical trials, and absorption is unpredictable. (Omada Health)

Even small changes in formulation or dosing can interrupt treatment and cause rebound weight gain or side effects.

How I approach this with patients

When a patient says, “I found a compounding pharmacy that sells it for half the price,” I acknowledge their concern. Access and cost are real issues. But I explain that the regulatory situation has changed. If an FDA-approved version is available, that’s the standard we should use first.

I encourage patients to ask the pharmacy for their certificate of analysis, sterility test results, and ingredient source; if the pharmacy hesitates or says it’s proprietary, that’s enough reason to stop.

One patient of mine was on a compounded semaglutide microdose that wasn’t commercially available, at least as she described it to me. I never could pin down what she was actually getting. The compounder wouldn’t release potency data either. We moved her to a low-dose commercial version instead. Weight loss slowed a little. Safety and consistency improved, and I knew what was in the pen.

We also reviewed manufacturer assistance programs and insurance coverage. Many patients don’t realize that drug makers often cap out-of-pocket costs for brand medications; cost confusion is one of the biggest drivers behind compounded use.

The FDA’s BeSafeRx campaign

The FDA has an ongoing public safety campaign called BeSafeRx, designed to help patients and providers verify the legitimacy of online pharmacies and compounded drug sources; it offers tools to check pharmacy licenses, identify red flags, and report suspicious products.

It’s a good resource for anyone considering buying compounded or online medications; I often share it directly with patients so they can see what trustworthy sourcing looks like.

You can find the BeSafeRx information at:

https://www.fda.gov/drugs/buying-using-medicine-safely/besaferx-your-source-online-pharmacy-information

What’s changed recently

The REDEFINE trial (NEJM, 2025) studied cagrilintide combined with semaglutide (CagriSema) and showed about 20.4 percent weight loss over 68 weeks, compared with 14.9 percent with semaglutide alone; that kind of data will shape treatment algorithms going forward. GoodRx reports that the FDA’s grace period for compounding GLP-1s has officially ended for both tirzepatide and semaglutide, though some pharmacies still market “custom” or “non-identical” formulations, and regulators are watching closely.

Approach this without judgment if you’re a clinician. Patients are trying to find affordable solutions. And they often trust what they see on social media more than official channels; we can help most by staying informed, asking questions, and documenting carefully. Patients should be cautious for a different reason. Ask your provider to review any compounded medication before you use it, make sure your pharmacy meets every item on that checklist, and use resources like the FDA’s BeSafeRx to verify safety.

Knowledge and transparency remain the best safeguards.

Perimenopause and Menopause Symptoms and How to Manage Them

On August 27, 2025September 29, 2026 By Dr. Scott RennieIn Menopause & Women's 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.

What Is an Obesity Medicine Board Certified Doctor?

On August 6, 2025September 29, 2026 By Dr. Scott RennieIn Weight Loss & Metabolic HealthLeave a comment

More family physicians, myself included, are choosing to become certified through the American Board of Obesity Medicine. The credential looks small on paper. What sits behind it is a real change in how we handle obesity and the conditions that travel with it.

ABOM certification is open to physicians who can show advanced knowledge in preventing, evaluating, and treating obesity. There are two routes. One is 60 hours of continuing medical education credits in obesity-related topics, half of which must specifically address obesity treatment. The other is an accredited obesity medicine fellowship. Either way, candidates then sit for a 4-hour exam covering the physiology and pathophysiology of obesity, nutrition and behavioral treatment, medications, surgery, and bias in care.

Why go through all that? We are the ones patients come to first. About 40% of U.S. adults have obesity, and it is tied to diabetes, heart disease, infertility, arthritis, and worse outcomes with infections. Yet most of us had very little structured training on obesity in medical school or residency. I certainly didn’t. ABOM fills that gap with something more useful than repeating “eat less, move more.”

Patients are also asking harder questions than they used to. GLP-1 medications like semaglutide and tirzepatide changed the conversation. People have worked out that weight regulation is physiology, not character. They want to know whether medication makes sense for them, what the risks are, and what else they should be doing. Certification puts you in a better position to answer that honestly and to build a plan that lasts longer than a few months.

For me, the certification built confidence. I know how to adjust anti-obesity medications, screen for related conditions like PCOS or fatty liver, and talk about weight without stigma. Patients notice. They feel taken seriously when obesity gets treated as the chronic medical condition it is.

One case stays with me. A patient in her fifties came to me with obesity and prediabetes, worn down after years of failed diets. Using what I’d learned, I recognized she was a candidate for pharmacotherapy. We started semaglutide, and we built a plan around meal structure, activity, and sleep. Within months her A1c had come back into the normal range and her energy had returned.

Colleagues are seeing benefits too. A physician I know in rural Missouri became ABOM-certified and quickly became a regional referral point. Practices in nearby towns began sending her patients rather than having them drive hours to an urban obesity clinic. In an underserved area, that is the difference between getting treated and not.

For doctors considering it, the field is growing quickly. More than 11,500 physicians in the United States and Canada now hold the certification, up from roughly 9,800 a year earlier. Insurers are beginning to recognize obesity medicine, which means more treatments get covered when a certified physician is guiding them. You also end up connected to a national group of people working on one of the largest drivers of chronic disease we have.

So the certification is a line on a CV. It is also the reason I practice differently than I did before I sat the exam, and that is the part that reaches patients.

Is Yo-Yo Dieting Bad for You? Weight Cycling Explained

On May 10, 2025September 29, 2026 By Dr. Scott RennieIn Weight Loss & Metabolic HealthLeave a comment

A lot of my patients describe the same arc. They work hard, lose weight, feel good for a while, and then months or years later it comes back. That repeated loss and regain is weight cycling. It is common, and it is hard on people both physically and emotionally.

The question I hear most often is whether it is even worth trying if the weight is coming back anyway. The research answers that more clearly than it used to, and the answer is yes.

Weight cycling generally means repeated intentional loss followed by unintentional regain. Some researchers set the bar at a 10 percent change in body weight occurring three or more times. Depending on the study, it affects 20 to 35 percent of men and up to half of women (Montani et al., 2015).

Why does the weight return? Biology pushes back harder than most people anticipate. After weight loss, resting energy expenditure falls further than body size alone would predict, and this metabolic adaptation can persist for years, meaning the body burns less than expected (Fothergill et al., 2016). Hormones move too. Leptin drops, hunger hormones climb, and patients end up hungrier and less satisfied by meals than they were before (Sumithran et al., 2011). The body also tends to compensate for exercise by raising appetite. Together these explain why maintenance is the hard part, not the losing (Thomas et al., 2012).

The real question is whether the cycling itself does damage. Large reviews and cohort studies have not found strong evidence that weight cycling raises mortality or major chronic disease risk when the weight loss is intentional and supervised (Mehta et al., 2014). Some work suggests regain may favor fat over muscle, visceral fat especially, though the findings are inconsistent (Mackie et al., 2017).

The psychological picture is better than most people assume. Foster and colleagues found that patients who regained weight still reported improvements in mood, hunger, and eating behavior after the loss phase (Foster et al., 1996). Other work has found no consistent long-term harm from the pattern itself (Osborn et al., 2011).

So should patients keep trying? The National Task Force on the Prevention and Treatment of Obesity concluded in 1994 that weight cycling should not deter people from attempting weight loss, and that position has held up (National Task Force, JAMA 1994). The benefits of intentional loss, lower blood pressure, better lipids, better glucose control, better quality of life, generally outweigh the risk of regaining.

One of my patients lost about 8 percent of her body weight through diet and walking. A year later most of it had come back. During the stretch she kept it off, though, her blood pressure normalized and she came off one of her antihypertensives. The weight returned. The benefit she got during that window was real and measurable, and the research says her experience is the rule rather than the exception.

What I steer patients toward is sustainable habit rather than another aggressive diet. Regular activity, consistent eating patterns, decent sleep, and watching the trend line instead of the daily number. A setback does not undo the progress. Staying connected to support, whether that is a clinician, a dietitian, or counseling, matters more than most people expect.

Weight cycling is real and it is discouraging. It is not a reason to stop. Even temporary weight loss buys real health, and the useful reframe is to treat weight management as ongoing care rather than a project with an end date.

Does Chronic Stress Cause Weight Gain? A Doctor Explains

On April 25, 2025September 11, 2026 By Dr. Scott RennieIn Weight Loss & Metabolic HealthLeave a comment

Obesity gets described as a balance of diet and exercise, and stress plays a far larger role in it than most people are told. I have seen patients who eat well and stay active and still lose ground the moment their stress rises. Research from Dr. Rajita Sinha at Yale explains a good deal of why. Chronic stress produces measurable biological change, well past anything you would call a mood.

Stress acts on the brain circuits governing emotion, motivation, and self-control. Those circuits overlap with the ones handling food reward and craving, particularly for calorie-dense processed food (Sinha et al., 2022). Cortisol climbs under chronic stress. Ghrelin rises with it while leptin falls. What you end up with is a body primed to eat more, in an environment where high-calorie food is always within reach.

Calling that emotional eating undersells it. In Sinha’s lab work, people exposed to stress through guided imagery ate more snack food afterward, and participants who were already overweight were the most affected. Their cravings and calorie intake tracked with measured increases in cortisol and ghrelin. The stress reached past how they felt and changed how their brains and bodies handled food.

The pandemic ran this experiment at national scale. Nearly half of U.S. adults gained weight over that period, with worse effects among people who already had higher BMIs (Khubchandani et al., 2022). Children were not spared; CDC data showed the rate of BMI increase doubling against pre-pandemic years (Lange et al., 2021). The predictors of gain were emotional distress, having children at home, and how long it had been since someone last weighed themselves.

Work outside the pandemic points the same way. In one community study, people with higher baseline cortisol and greater insulin resistance were more likely to gain weight over the following six months (Chao et al., 2017). Those markers did more than correlate with obesity. They predicted it.

That has pushed researchers past the eat-less-move-more framing toward treatments aimed at the stress itself. Mindfulness-based stress reduction lowers food cravings, perceived stress, and blood pressure in people with obesity (Tuit et al., 2011). There is even evidence in parenting: a small study of low-income mothers found mindful parenting reduced parental stress and was associated with healthier BMI outcomes in their children (Jastreboff et al., 2018).

Medical and surgical treatment still matter, and the evidence suggests they perform best alongside strategies that reduce stress reactivity and support executive function. Stress management belongs in the treatment plan rather than tacked onto the end of it.

I have seen patients who feel defeated because they are certain the weight they gained under stress was a personal failure. The science says otherwise. Stress reshapes brain pathways, moves hormone levels, and changes eating behavior in ways we can measure. None of that makes change impossible. It does mean compassion is not optional in this conversation, and that treating stress as part of the disease moves the discussion off blame and onto something we can actually act on.

Why results show up before anyone has called you

What does “critical” actually mean?

Flagged does not mean dangerous

Which numbers can be truly urgent?

What to do, in order

When a virtual clinician ordered the test

Ask before the blood draw

For patients, and for clinicians

If you are the patient

If you are the clinician

The Bottom Line

Related Reading

Sources

Why the name changed in 2014

Somewhere between 27% and 84%

What I can settle over video. What I can’t.

Start in the drugstore aisle

Low-dose vaginal estrogen

About that boxed warning, precisely

DHEA, ospemifene, and the limits of systemic therapy

Lasers

The best evidence here is about UTIs

After breast cancer, especially on an aromatase inhibitor

If you are the patient

Notes for clinicians

The Bottom Line

Related Reading

Sources

Related Reading

The diagnosis is a conversation, not a lab draw

What I can prescribe without ever being in the room

One boxed warning came off. One did not.

The thing a video visit cannot do, and it just got harder

What the visit actually looks like

For clinicians

The Bottom Line

Related Reading

Sources

Why compounded versions exist

Key risks and what to look for

How I approach this with patients

The FDA’s BeSafeRx campaign

What’s changed recently

Related Reading

Related Reading

Related Reading

Related Reading

Related Reading