Tag: Telemedicine

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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
Glass of water and digital thermometer on a bedside table

Measles Is Back: What Urgent Care and Telemedicine Clinicians Need to Watch For

On By Dr. Scott RennieIn Infectious Disease1 Comment

Measles is back in our daily practice in a way many of us have never seen in our careers. In just the first weeks of 2026, the United States has already recorded more than 900 confirmed measles cases, with most linked to active outbreaks rather than isolated travel related infections. Those numbers are not abstract. They reflect real patients who often first appear with what looks like an ordinary viral upper respiratory infection.

In Virginia, where some of my colleagues practice, the health department has already confirmed 10 measles cases this year, the majority in young children in the Northern region. Public exposure sites in that region now include grocery stores, urgent care centers, emergency departments, churches, and big box retailers, with symptom watch dates stretching into early March. That list reads like a map of daily life, which is exactly the point. Measles is circulating in the same spaces our patients and our own families move through every day.

Clinically, we know this pattern. Early measles often looks like influenza or another common respiratory virus, with fever, cough, coryza, and conjunctivitis. The rash, when it appears, typically starts on the face or hairline and then spreads down the body over several days. The catch is timing. Patients are contagious for about four days before the rash and about four days after it appears, which means they have already spent several days at work, school, religious services, or stores while shedding virus. On a virtual visit, we are often meeting them right in the middle of that window.

On a 24/7 virtual care platform, measles usually does not present with a red flag label in the chief complaint. Instead, it shows up as “fever and cough,” “pink eye,” or “rash on face” typed into a symptom field at 10 p.m. A typical encounter might start with a parent worried about a toddler who has had three days of high fever, a worsening dry cough, a streaming nose, and eyes that are red and watery. The parent may have tried acetaminophen and fluids at home and is now concerned because the child just looks wiped out. At that point there may be no rash, or the parent might mention a few faint spots on the forehead that they are not sure about.

The current outbreaks highlight just how contagious measles is. The virus lives in the nose and throat and is released into the air when an infected person breathes, coughs, or sneezes. It can remain viable in the air or on surfaces for up to two hours after the person leaves. This is why unannounced walk ins to clinics or emergency departments are so risky and why strict infection control and coordination with public health are not optional. One infectious patient who sits in a crowded waiting room can trigger a long chain of secondary cases.

From an epidemiologic standpoint, the current U.S. numbers are sobering. As of mid to late February 2026, national case counts have passed 900 and are now over 1,100, with infections documented in more than two dozen states. A large share of these cases are tied to ongoing outbreaks that began in 2025 and spilled into this year. The vast majority of patients are unvaccinated or have unknown vaccination status, often children and adolescents. Hospitalization rates vary by age, but recent CDC data show that even in 2024, several percent of cases required inpatient care, with higher risk among young children and adults. Measles can lead to pneumonia, encephalitis, and death, even in high resource settings.

On the Virginia Department of Health dashboard, six of the ten cases reported in 2026 have occurred in children under five years old, a group that cannot always be fully immunized yet and that we worry about the most. That number is the one I keep coming back to. Exposure notifications list locations like a grocery store in Lorton, multiple retail sites and restaurants in Manassas, a church, and an office building in Alexandria, each with specific time windows and follow up symptom watch dates 21 days out. It is easy to imagine the scenarios. A preschooler with early measles sitting in a shopping cart. A young adult with mild symptoms walking into an urgent care center after work. These are ordinary moments that turn into public health events.

For virtual care clinicians, the practical question is what to do when that next “simple viral illness” consult pops up in the queue. First, we cannot afford to ignore vaccination status. Every patient with upper respiratory symptoms, especially in outbreak regions, should be asked directly about MMR doses and prior measles infection. This includes adults who vaguely recall “getting shots as a kid” but are not sure which ones. Second, we need to look closely at risk factors: unvaccinated or incompletely vaccinated patients, infants who are too young for full immunization, immunocompromised individuals, pregnant patients, and anyone with recent travel to areas with known outbreaks or exposure to crowded settings.

When clinical suspicion is high, escalation needs to happen quickly and in a structured way. Patients should be referred for immediate in person evaluation and diagnostic testing in a setting that is prepared to implement airborne precautions. Instead of showing up unannounced at a clinic or emergency department, patients should call ahead, so infection prevention teams can arrange safe arrival and isolation. Coordination with local health departments is key. I haven’t hit real friction getting a family to follow that plan, since I haven’t had a suspected measles case reach that point yet. What I do run into, often, is patients, mostly kids, who are unvaccinated because a parent made that choice on purpose and says so plainly when I ask. On the Virginia site, there is even a specific survey link for people who may have been exposed, which triggers public health follow up. Similar mechanisms exist in other states and are often underused.

Virtual clinicians also have a clear boundary here. On the Teladoc platform, for example, management of suspected or confirmed measles is explicitly prohibited, and all such cases must be referred to in-person care. That restriction exists because measles care and infection control require physical assessment, access to testing, immunoglobulin and vaccine for post-exposure prophylaxis, and the ability to initiate supportive treatment for complications, none of which can be delivered over video.

Vaccination remains the core prevention strategy. Two doses of MMR vaccine provide about 97 percent protection against measles. Breakthrough infections can occur, but they are uncommon, and most cases in the current outbreaks are in people who are unvaccinated or not fully vaccinated. The Virginia data show that over 90 percent of the state’s population, and roughly 95 percent of kindergarteners, are vaccinated against measles, yet small pockets of under vaccination have still allowed the virus to spread. In every virtual encounter, we have a chance to answer questions, correct misinformation, and nudge patients toward getting up to date on their shots.

I haven’t personally managed a confirmed measles case over telemedicine. But here’s the kind of scenario clinicians in virtual care should be watching for, a hypothetical built from the pattern these outbreaks produce, not a real patient of mine: A college student logs on late at night with a fever, sore throat, and mild cough after returning from a service trip where they worked in crowded community settings. They mention that their university recently sent out an email about a measles exposure but they “think” they had all their vaccines as a child. As the clinician, you dig a little deeper, learn there is no documentation of a second MMR dose, and find that the student has started to notice a faint rash near the hairline. In that moment, treating this as a routine viral upper respiratory infection would be a miss. Instead, you walk the student through the concern for measles, arrange urgent in person evaluation, instruct them to call ahead before arrival, and notify your internal public health liaison to coordinate with the local health department. That single decision can prevent dozens of secondary cases in a dormitory and on campus.

The current surge of measles cases is a reminder that this disease remains an ongoing threat, one that follows gaps in vaccination and public health infrastructure. For those of us working in virtual care, our role is to keep it on the differential, ask the extra questions, recognize the pattern a day or two earlier, and move swiftly when suspicion is high. The work can feel routine until it is not. Two years ago I wasn’t asking about immunization status at every visit. I do now, at any health-related visit, and especially with kids. I’ve also changed how I handle a rash over video, because video alone is generally not as good quality as a high-resolution photo. Getting a usable photo takes some coaching. The patient needs to stand back far enough, get the angle right, and hold the phone steady so it isn’t blurry. I like a distance shot to see the whole pattern and a macro shot up close if the patient can manage it.

Centers for Disease Control and Prevention. Measles Cases and Outbreaks. Updated February 26, 2026. Available at: https://www.cdc.gov/measles/data-research/index.html. Accessed February 27, 2026.

Centers for Disease Control and Prevention. Measles Vaccination. Updated December 29, 2025. Available at: https://www.cdc.gov/measles/vaccines/index.html. Accessed February 27, 2026.

Centers for Disease Control and Prevention. Measles, Mumps, and Rubella (MMR) Vaccination: Information for Healthcare Professionals. Updated January 25, 2026. Available at: https://www.cdc.gov/vaccines/hcp/by-disease/mmr.html. Accessed February 27, 2026.

Virginia Department of Health. Measles. 2026. Available at: https://www.vdh.virginia.gov/measles/. Accessed February 27, 2026.

Virginia Department of Health, Office of Emergency Preparedness. VDH OEP Weekly Situation Update. Published February 19, 2026. Available at: https://www.vdh.virginia.gov/emergency-preparedness/2026/02/20/vdh-oep-weekly-situation-update-137/. Accessed February 27, 2026.

Virginia Department of Health. Virginia Health Officials Investigating Two Confirmed Measles Cases in Northern Virginia. News release, February 18, 2026. Available at: https://www.vdh.virginia.gov/news/public-relations-contacts/2026-regional-news-releases/virginia-health-officials-investigating-two-confirmed-measles-cases-in-northern-virginia/. Accessed February 27, 2026.

Robinson A. VDH: Measles outbreak not likely in Northern Virginia despite uptick in cases. ALXnow. Published February 22, 2026. Available at: https://www.alxnow.com/2026/02/23/vdh-measles-outbreak-not-likely-in-n-va-despite-uptick-in-cases/. Accessed February 27, 2026.

WSBT / Sinclair Broadcast Group. Measles cases surpass 1,100 so far in 2026 as outbreaks continue to spread. Published February 26, 2026. Available at: https://wsbt.com/news/nation-world/us-measles-cases-surpass-1100-so-far-in-2026-health-experts-warn-centers-for-disease-control-and-prevention. Accessed February 27, 2026.

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.

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 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.

Scott Rennie, D.O.

Sources:

Ray WA, Murray KT, Hall K, Arbogast PG, Stein CM. Azithromycin and the risk of cardiovascular death. New England Journal of Medicine. 2012;366:1881-1890.

Sax PE. How the Z-Pak Took Over Outpatient Medicine. Substack lecture notes and essay.

Svanstrom H et al. Use of azithromycin and death from cardiovascular causes. New England Journal of Medicine. 2013;368:1704-1712.

FDA Drug Safety Communication. Azithromycin and risk of potentially fatal heart rhythms. US Food and Drug Administration. 2013.

CDC. Antibiotic use in the United States: Progress and opportunities. Centers for Disease Control and Prevention.

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.

Menopause Treatment by Telemedicine: How It Works

On By Dr. Scott RennieIn Menopause & Women's 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.

Compounded Semaglutide and Tirzepatide: What to Know Now

On 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.

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.

Shifting to Telemedicine: Reflections for Fellow Physicians

On By Dr. Scott RennieIn Healthcare System & TechnologyLeave a comment

Not long ago, two of my medical school classmates reached out to me. One is an emergency room physician. The other is a dermatologist. Both wanted to talk about telemedicine and whether they should make the transition. Their questions reminded me of my own when I started, and it got me thinking about how different this kind of work really is compared to in-person care.

Telemedicine has real upsides. The flexibility is genuine: you can work from anywhere with a reliable internet connection, from home while helping with your kids, or on the road while staying productive. The lack of a commute alone changes your day. No traffic, no wasted time. Hours flex more easily when family emergencies or illnesses come up. Exposure to infectious disease drops significantly too, a lesson plenty of us learned the hard way during COVID. On top of that, paperwork drops. Charts are streamlined and forms are lighter, which frees up the time you’d otherwise spend on documentation to actually talk with patients; if you’re efficient, the pay is good, and seeing more patients per day brings a sense of making a difference on a large scale. You can meet people from all over the country, provided you are licensed in multiple states. For many providers, this is one of the best work-life balance opportunities in medicine.

Some patients treat telemedicine like a transaction, logging on expecting a specific medication and pushing back when your judgment doesn’t match what they came for. That’s one of the real downsides. You lose the camaraderie of the clinic or hospital, the in-person interaction with colleagues that a lot of physicians miss. Hands-on procedures disappear entirely. Loved draining an abscess, suturing a laceration, placing a central line? You won’t get that satisfaction here. Some days it feels like you’re redirecting more patients than you’re treating, sending people in for care you’d rather deliver yourself; and the liability is identical to an in-person visit, just with fewer tools to manage it.

The monotony can creep in too. During winter, you may see upper respiratory complaints on repeat. You have to be skilled at quickly identifying the patient who sounds much sicker than they realize. That judgment call, who can be safely treated virtually and who needs in-person evaluation, has to be made fast and accurately. Get it wrong and the consequences can be serious.

Guidelines from telemedicine companies like Teladoc, MDLive, and Amwell are conservative for a reason: they steer providers toward in-person evaluation whenever there’s doubt. It keeps patients safe. It protects the practice of telemedicine itself, too. You have to be comfortable following those guidelines, even if it feels restrictive at times.

I have had both frustrating and rewarding cases.

One that stands out was a patient who logged on for hives. Her husband was telling the story while she was in the background, but when she finally spoke, her voice was high-pitched and strained. I realized she was in anaphylaxis. She had access to her child’s epinephrine auto-injector, used two doses, and her breathing improved almost immediately. EMS was called. She got the care she needed. That visit was one of my first telemedicine visits. I was still working 1099, part time, treating telemedicine as something on the side. Walking away from that call believing I might have just saved someone’s life is what changed my mind, and I went looking for a full-time W2 telemedicine role not long after.

Rashes and Telemedicine: A Special Challenge

One of the trickiest areas of telemedicine is dermatology. Rashes seem like they should be simple. A patient shows you a patch of red skin or bumps, you identify it, and you prescribe a cream. The reality is that it is rarely that easy.

The biggest issue is image quality. Patients often upload photos that are poorly lit, out of focus, or taken from too far away; sometimes they only capture a tiny area of skin without showing the bigger picture; diagnosing a rash accurately takes more than a photo: distribution, texture, timing, and whether there are associated systemic symptoms all factor in; and without good photos and without the ability to do a full physical exam, we are often working with incomplete information.

I ask for photos for telemedicine rashes rather than relying on video alone. Video is generally not as good quality as a high-resolution image. The challenge is getting a patient to take that photo well: right distance, multiple angles, not blurry. I like a distance shot and a macro shot up close if I can get one.

History-taking matters just as much: was the rash itchy or painful, did it spread quickly, was there a recent medication change, a new detergent, an insect bite, or outdoor exposure? Even careful questioning doesn’t always yield the full story. Some rashes are harmless. Others can be signs of serious systemic illness. Sorting out which is which over video can be challenging and sometimes unsafe. One diagnostic call that turns entirely on photo quality: angular cheilitis. It can be hard to distinguish from perioral dermatitis without a close-up image. A good macro shot of the corners of the mouth and the two conditions look different. A blurry photo taken from three feet away, and you are guessing between them.

That is why tele-dermatology has emerged as a subspecialty. Some telemedicine companies, including Teladoc, now offer patients access to board-certified dermatologists who can focus exclusively on skin issues; having a dermatologist review high-resolution photos, sometimes with dermatoscopic images, makes accurate diagnosis and treatment more reliable. Even so, patients need to understand that when the photo quality is poor or the history is incomplete, a referral for in-person evaluation may still be necessary.

Would I tell my classmates to make the switch? Yes, eyes open. Real flexibility and real reach, but you give up procedures, in-person camaraderie, and full control over what you can safely rule out on a screen. Know the limits, tell patients the truth about them, and telemedicine works, for them and for you.

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.

Why Some Conditions Need an In-Person Visit, Not Virtual Care

On By Dr. Scott RennieIn Healthcare System & TechnologyLeave a comment

Telemedicine has become part of everyday care, and for good reason; it allows patients to connect with a physician from home, from work, or while traveling; and many problems can be managed safely and effectively through video visits. But not everything belongs in a virtual setting.

I follow guidelines, like the ones Teladoc, MDLive, and Amwell use, that help decide what’s safe to manage online and what has to be seen in person. Those rules aren’t arbitrary. They’re built around safety, the limits of a video encounter, and the risk of missing something serious.

What Actually Keeps a Visit Off Camera

Some diagnoses depend on a tool or a test that doesn’t exist on a video call. An ear infection needs a direct look at the eardrum through an otoscope. Ear pain alone could just as easily mean wax buildup, dental pain, or referred throat irritation, and without visualizing the drum, the real cause gets missed (swimmer’s ear is the exception, along with cases where a family can upload a high-quality otoscope photo). A suspected blood clot in the leg, deep vein thrombosis, has exactly one way to confirm or rule out: an ultrasound, which no video visit can provide. Pneumonia works the same way. A cough that persists, worsens, or comes with fever and shortness of breath needs a chest x-ray and sometimes labs. Neither of which exists on a screen. Pediatric urinary tract infections need a urine sample tested before treatment. And abnormal uterine bleeding, which can signal serious gynecologic issues, usually needs labs or imaging to sort out.

Other conditions need hands-on assessment. Looking is not enough. Post-operative pain that’s worsening rather than expected can mean infection, bleeding, or a wound problem, and a physical exam is needed to check for swelling, drainage, or fever. Post-op patients are safest going back to their surgeon. Mastitis is similar. Breast pain and redness in a breastfeeding patient could be simple mastitis or could be an abscess that needs drainage. And a virtual exam cannot reliably tell the difference. Any laceration or wound that needs stitches has to be assessed and repaired in person; so do animal bites, dog, cat, or human, because of the infection risk and sometimes rabies exposure; and wound care, tetanus updates, and rabies prophylaxis all have to happen in the room.

A third group can turn dangerous fast and needs hospital-level resources. A fever over 103°F, or any systemic illness, can point to sepsis, meningitis, pneumonia, or another serious infection needing immediate labs, imaging, or IV treatment. Suspected meningitis, headache with fever and a stiff neck, needs immediate hospital evaluation with spinal fluid testing and IV antibiotics. It cannot be managed on a screen. Croup in a child, the barking cough and stridor, can worsen quickly enough that treatments like racemic epinephrine or oxygen have to happen in person and urgently. A skin abscess on the face, or periorbital cellulitis, can spread to deeper tissue including the brain and needs urgent evaluation, often with IV antibiotics. Suspected sepsis or a bloodstream infection has to be treated urgently in a hospital, full stop. Unexplained abdominal pain could be appendicitis, gallbladder disease, a bowel obstruction, or another emergency. And usually needs imaging and labs to sort out. Chest pain gets taken most seriously of all. It can represent a heart attack, a pulmonary embolism, or another life-threatening problem, and it gets an urgent in-person evaluation every time. The same logic covers a headache described as the worst of someone’s life, which can mean bleeding in the brain or meningitis; a concussion or closed head injury, which needs a neurologic exam and sometimes imaging; and eye problems like a foreign body, a chemical burn, sudden vision loss, or trauma, all of which need immediate in-person evaluation.

A last group has nothing to do with how sick someone looks and everything to do with what has to happen in a room. Controlled substances, stimulants, opioids, benzodiazepines, carry real risk of misuse and dependence. So regulations require in-person visits for initiation and refills. Some STD treatments need an in-office procedure; genital warts are the clearest example. And anything tied to a work-related claim, FMLA paperwork, workers’ comp, a disability determination, usually needs physical documentation and an in-person exam to be valid.

What About Rashes?

Rashes are a gray zone in telemedicine. Sometimes they are straightforward, like ringworm or athlete’s foot, and can be treated virtually with antifungal creams. Other times they are difficult to interpret. Safely treating a rash through telemedicine depends heavily on two things. The quality of the photo the patient uploads and a detailed medical history.

If the picture is blurry, poorly lit, or taken at the wrong angle, it may be impossible to tell the difference between something benign and something serious. Something like shingles or cellulitis. Even with good photos, asking the right questions, when it started, whether it itches, spreads, or comes with fever, can take time to sort out.

Diagnosing rashes virtually can sometimes be challenging, which is exactly why tele-dermatology has become its own field. Companies such as Teladoc now offer access to board-certified dermatologists who specialize in skin conditions. Patients can upload high-quality images and receive expert input, which improves accuracy and treatment options.

Conditions That Can Often Be Managed Virtually

Plenty of complaints are safe to handle over video: viral upper respiratory infections, sinus infections, uncomplicated urinary tract infections, mild to moderate asthma exacerbations, vaginal yeast infections, bronchitis without red-flag symptoms, most pink eye, cold sores, sprains and strains, seasonal allergies, skin conditions like eczema, ringworm, and jock itch, uncomplicated headaches or low back pain, and early or uncomplicated dental infections.

When a “Simple” Complaint Turns Out Not to Be

Patients don’t always see the warnings that some conditions can’t be managed online, and even when they do, some push back because getting to a clinic in person is inconvenient or expensive. Sometimes what looks straightforward at first turns into something else once the clarifying questions start: a “sinus infection” complaint that turns out to be severe facial swelling, a “back pain” complaint that turns out to come with fever and urinary incontinence. In my own practice, abdominal pain is the one that converts to an in-person visit almost every time, because it needs a hands-on exam. Boils and abscesses, febrile urinary tract infections, and rashes I can’t visualize well enough on a photo make up most of the rest.

Where These Guidelines Come From

Companies such as Teladoc, MDLive, and Amwell built their red-flag lists after years of clinical review. The goal is to prevent missed diagnoses and keep telemedicine a safe, effective model of care. These rules protect both patients and providers.

Telemedicine is powerful. It expands access and provides convenience. But it has boundaries. When I recommend that a patient be seen in person, it’s because safe, thorough care sometimes needs tools and testing. A video screen simply can’t provide them. When a patient pushes back, I tell them plainly that an in-person evaluation is needed for their own safety. If they keep insisting on staying virtual, I decline and explain that telemedicine has its own standards of care, similar to an in-person visit, built around guidelines that protect patients. Most understand. Not all of them agree.

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.

Can Telemedicine Diagnose Strep Throat and Ear Infections?

On By Dr. Scott RennieIn Healthcare System & TechnologyLeave a comment

Telemedicine changed how patients reach care. It connects people quickly, saves the drive, and handles a wide range of problems well. It also has limits, and two of them show up constantly: sore throats and ear pain.

Seeing a patient virtually costs me the physical exam. With strep, looking directly at the tonsils and the back of the throat is how I separate viral pharyngitis from bacterial infection. With ear pain, I can’t see the eardrum or check for fluid behind it. Small details. They’re also the ones that decide the diagnosis.

Palpation is the other thing I lose. In clinic, I’d press along the neck for lymph node swelling, and in front of and behind the ear for tenderness. On video I can only ask the patient to describe what they feel. Sometimes they will press the area themselves and report back, which helps, and it’s not the same as an examiner’s hands.

The differential for sore throat is wide. Viral infections dominate and usually arrive with cough and congestion. Group A strep climbs the list with fever, swollen tonsils, or white patches, and no cough. Mono belongs in the picture when there is heavy fatigue and node swelling. As of 2023, COVID-19 stayed on the list whenever fever came with loss of smell. Peritonsillar abscess is uncommon and worth real attention: severe pain, trouble swallowing, a muffled voice. And not every sore throat is an infection at all. TMJ dysfunction refers pain to the throat often enough to catch people out.

Ear pain has its own list. Otitis media brings pain and sometimes fever, usually trailing a cold. Otitis externa hurts when the outer ear is touched, and there’s often a swimming history behind it. Wax occlusion produces fullness. Eustachian tube dysfunction gives pressure and muffled hearing rather than a sharp ache. Mastoiditis is rare and serious, with severe pain, swelling behind the ear, and fever. TMJ turns up here too.

Separating otitis media from otitis externa without seeing the ear is genuinely hard. Patients hand me useful clues, and pain on tugging the outer ear points toward otitis externa, but a virtual diagnosis carries far less certainty than I’d like.

Which is why in-person evaluation still matters. When symptoms are severe, persistent, or simply not adding up, an office visit allows a clinician to look directly at the throat or ear, palpate the neck, and run a rapid strep test. That’s what produces an accurate call, whether the answer turns out to be antibiotics, symptom control, or reassurance.

None of this makes telemedicine less useful. Patients who describe their symptoms carefully give me a real chance at guiding early care, and for mild or clearly viral illness a virtual visit saves an unnecessary trip. The boundaries just need saying out loud. Some problems require hands and an otoscope.

Scott Rennie, D.O.

Sources

  • Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):1279-1282.
  • Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical practice guideline: otitis media with effusion. Otolaryngol Head Neck Surg. 2016;154(1 Suppl):S1-S41.
  • Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2014;150(1 Suppl):S1-S24.

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.

Prescription bottle next to virus with red X overlay indicating medication ineffective

Why Won’t Antibiotics Cure a Viral Infection? Doctor Explains

On By Dr. Scott RennieIn Infectious DiseaseLeave a comment

Antibiotics changed the course of medicine. They save lives daily against infections that used to kill people: pneumonia, urinary tract infections, strep throat. The catch is narrow and absolute. They work on bacteria. Viruses are untouched. So an antibiotic prescribed for a cold or influenza does nothing useful, and it can still do harm.

The Risks of Misuse

Overuse drives resistance. Bacteria adapt fast, and repeated exposure teaches a population how to survive the drug that used to clear it. Those are the organisms we call superbugs. They make ordinary infections harder to treat, and healthy patients aren’t exempt from that. In its 2019 threats report, the CDC counted more than 2.8 million antibiotic-resistant infections a year in the United States and over 35,000 deaths.

Side effects are the nearer problem for most patients. Antibiotics disturb the gut microbiome, and nausea, diarrhea, and abdominal pain follow. Sometimes that disruption opens the door for Clostridioides difficile and a severe colitis.

Yeast overgrowth is common too. Clear out the normal bacterial balance and Candida fills the space, showing up as oral thrush or a vaginal yeast infection. I’ve had patients relieved that their original infection improved, only to be frustrated by new symptoms a week later.

Using Antibiotics Wisely

The goal is correct use, not avoidance. That’s what antibiotic stewardship means in practice.

Step one is deciding whether the infection is even bacterial. A sore throat is usually viral pharyngitis. Fever with swollen tonsils and no cough moves strep up the list, and a rapid strep test settles it rather than leaving it to impression. Ear pain needs a careful look to separate a viral picture from bacterial otitis media.

Prevention cuts the need in the first place. Vaccination, hand hygiene, safe food handling. I keep telling patients that washing hands before eating and after being out in public does more to keep them off antibiotics than anything I prescribe.

When antibiotics are the right answer, they’ve got to be taken as directed. Stopping early, skipping doses, and saving leftovers all undermine the course and feed resistance. Sharing a prescription with a family member is its own category of mistake.

Where This Leaves Us

Antibiotics remain among the most powerful tools in medicine, and they aren’t free. Misuse buys resistant bacteria, gastrointestinal misery, and yeast overgrowth. Careful prescribing, honest patient education, and prevention are what keep these drugs working for the people who will need them next.

Scott Rennie, D.O.

Sources

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.