TODAY'S AJENDA #91

A woman walks into a gynecologist's office. She’s there because her previous doctor–the one who prescribed her hormone replacement therapy (HRT)–moved, and she needs her prescriptions refilled. 

The appointment derails within minutes.  

When Your Gyn’s Training Stops at Menopause

As the patient explains how HRT eased her perimenopause symptoms–the night sweats, vaginal dryness, and insomnia–the gynecologist asks her why she’s on HRT if she still has her period. 

Floored, the patient adds how HRT helped her anxiety and depression. 

In a confusing and ‘suboptimal’ encounter, the doctor tells her to: 1) switch to birth control, 2) avoid HRT due to “cancer risk,” and 3) consult a psychiatrist. 

When I saw this story online, I felt frustrated but not surprised. This scenario isn’t uncommon in a world where gynecologists typically don’t get specialized training in perimenopause and menopause care. 

And it’s not because they don’t care. It’s because the healthcare system is not set up to support them in doing so.

This is why I believe in having a clinician with expertise in menopause on your team. Ideally, they can also manage your broader health needs as you get older. 

The good news is that there are primary care practices, such as Amazon One Medical,* for example, that offer menopause specialists nationwide. The difference this makes for women in their 30s-40s and beyond is enormous. 

Here’s why: 

The Difference Between a Gyn and a Menopause Specialist: 

A gynecologist handles reproductive health (Pap smears, breast and ovarian cancer screenings, birth control), and treats the whole woman by screening for heart disease, depression/anxiety, and weight issues. We gynecologists are surgeons, and perform surgery on ovaries, the uterus, cervix and vagina/vulva. Gynecologists are essential to your healthcare. 

A menopause specialist handles everything your gynecologist does, plus the nuances of perimenopause and menopause. Because today, we know more about this stage than ever. 

We understand the neurobiology of hot flashes (that it’s not only about estrogen, but also about a brain chemical called Neurokinin B), the central role of estrogen in metabolic health, bone density, cardiovascular risk, and cognition. We have evidence-based guidelines for hormone therapy, FDA-approved non-hormonal options, lifestyle strategies, and long-term preventive care.

A menopause specialist helps you navigate all of it: 

• Midlife metabolic change (weight gain, insulin resistance, blood sugar changes) 

• Non-hormonal treatments (for hot flashes or vasomotor symptoms of menopause, mood, sleep disturbance, and sexual health) 

• Hormone therapy (Oral estrogen? Vaginal? Transdermal?) 

They also stay up to date on the latest research on menopause. Just last month, the FDA removed the Black Box Warning on all HRT after re-evaluating decades of data. This is the kind of update a menopause specialist knows about immediately. 

Menopause care is not cookbook medicine. It’s individualized, nuanced care that requires a health care provider who is up to speed with the latest advances and guidelines in menopause medicine.

Do I Really Need to See a Menopause Specialist? 

Maybe you’re thinking: “I’ve been seeing my Gyn for years, and I really like her/him. Do I really need to add another doctor?” 

If you were my patient, I’d tell you, yes, you should see someone with menopause training. That could be a menopause-certified primary care provider (so you’re consolidating care, not adding to it), or it could be a standalone menopause specialist. 

Either way, you probably need this expertise earlier than you’d think: 

During Perimenopause: 

Perimenopause starts 8-10 years before your last period. It’s not a slow hormonal fade-out. Your hormones fluctuate, and this volatility can cause symptoms like anxiety, insomnia, brain fog, and more. 

But during this stage, many women are told their symptoms are “just stress” or to “power through.” Fortunately, a menopause specialist recognizes this as hormonal and can treat you. 

The 5-10 Years After Your Final Period: 

Once you reach menopause, bone loss accelerates, cardiovascular risk increases, and insulin sensitivity shifts. This makes it a “window of opportunity” for hormone replacement therapy. 

• Science Says: Research shows that starting HRT within 10 years of menopause significantly reduces all-cause mortality and cardiovascular disease. 

A menopause specialist helps you optimize this window and make decisions today that protect your health for decades. 

Where Women Are Getting This Care 

Finding a menopause specialist can feel overwhelming. What do you Google? Do you need a referral? Does insurance cover them? And why does every provider’s bio sound the same?! 

Unfortunately, many women give up there. But it doesn’t have to be so complicated, especially when primary care practices like One Medical exist. 

When I learned about their platform in menopause care, I knew it was something I should talk about, in the hopes of increasing awareness. (They even have an app that can help you find a menopause-trained clinician in minutes!) 

One Medical’s menopause-trained providers can: 

• Pinpoint whether your symptoms are hormonal, lifestyle-related, or something else. 

• Help decide whether HRT or another treatment is right for you (and which dose is safest!). And if you can’t take hormones or don’t want to take hormones, provide information about FDA-approved non-hormonal options for hot flashes and night sweats due to menopause.

• Build a holistic plan of non-hormonal medications, supplements, and lifestyle changes to help restore your sleep, weight, and sexual health. 

And One Medical’s care isn’t just a one-time thing. After a structured initial assessment, you’ll have regular follow-up visits to evaluate treatment and ongoing maintenance every 6-12 months to assess symptoms and side effects. 

My Final Advice As Your Doctor (And Friend) 

Keep your OB/GYN, but consider having a menopause expert on your team, whether that’s a dedicated specialist or primary care provider with menopause training. You deserve clinicians trained in the health issues relevant to all stages of your life, not just your 20s and 30s.  

While that woman who walked into her gynecologist’s office deserved better, it’s reassuring to know that primary care providers like One Medical are making it easier for women like her to get comprehensive care that doesn’t treat menopause like an afterthought, but as a core part of women’s health. 

Full disclosure: I've been getting Botox since I was 37, and it's a major reason why my forehead is relatively wrinkle-free at 56. Generally, I’m very “pro-tox.” 

Botox itself isn’t new. It was FDA-approved in 1989 and has decades of safety data. What is new is how practitioners use it for women over 50. If you’re considering Botox (or already get it), here are four things worth knowing: 

1. Longer-lasting Botox options now exist. 

Traditional Botox (onabotulinumtoxinA) lasts 3-4 months. Now, there’s Daxxify (daxibotulinumtoxinA-lanm), a neuromodulator that lasts around six months. 

This has pros and cons. The pro: Fewer appointments and less time spent in the chair. The con: If you don’t love the result, you’re married to it for longer. 

2. Choose a practitioner who understands aging anatomy. 

In your 30s and 40s, Botox is mainly used to prevent wrinkles from etching into the skin. But in your 50s, the landscape changes: 

• Zoom In: Menopause dries out the skin and drops collagen production. Our brow also lowers, as do fat pads. 

Translation: Injecting in the “usual spots” doesn’t work anymore. Find a practitioner who understands aging bone structure, fat distribution, and skin quality (not just someone who shoves you a menu of unit pricing).  

3. Space out your Botox treatments. 

While “Botox resistance” is rare, your body can build up a tolerance if you go too often. Most experts recommend: 

• Using the lowest effective dose

• Waiting at least three months between visits 

• Avoiding “booster” top-offs two weeks later as a habit 

I’m not writing this to scare you. I’m being practical! If you love Botox, protect your body’s responsiveness to it. (Personal note: Though I have been getting Botox for almost 20 years, my face has always moved. I would rather have less than more. I always tell my doctors who inject me: “Don’t freeze my face. When I scowl at my kids, I want them to be able to TELL that I’m actually scowling!”)

4. Botox has medical uses beyond wrinkles. 

Botox isn’t just for aesthetics. It can help with everything from spasticity (an increase in muscle contractions) to bladder problems, to excessive sweating, and more.  

• Science Says: Botox can also help prevent chronic migraines. A 2010 study with 1,384 adults found that those with Botox averaged 8.4 fewer headache days per month. 

There’s also emerging research suggesting Botox injections between the eyebrows may help mood and depression. But the science is still very early-stage. Don’t expect your psychiatrist to prescribe Botox anytime soon. 

My Rx If You’re Considering Botox 

Here’s my advice as someone who’s gotten Botox for nearly 20 years (and whose brother is a world-renowned cosmetic surgeon): 

Tip 1) Screen your practitioner. 

Ask them how they approach Botox for women in their 50s or above. Green flags include mentions of the brow position, eyelid heaviness, and muscle balance, as well as “lower doses” and “more precise placement.”  

Red flags: If they push bargain unit sales or give you a fixed number of units.

Tip 2) Know the risks. 

If you have neuromuscular conditions (e.g., myasthenia gravis or ALS), trouble swallowing or breathing, or are considering therapeutic dosing, talk to your doctor. In rare cases, botulinum toxin can spread beyond the injection site. 

Tip 3) Avoid flying within 24 hours of being injected.  

Right after Botox, the product hasn’t fully bound to the targeted nerve endings yet. Being in the air (where pressure changes and you’re sitting upright for a prolonged time) could increase the chance of it migrating slightly from where it was placed. 

To be clear: It’s not dangerous, but since Botox in your 50s is all about small, precise units, better not to risk it! 

Bottom line: Botox isn’t “good” or “bad.” It’s a tool. And like every tool, it works best when the person holding it knows what they’re doing.

Thank you @karentreu for the question! First, know you’re in good company: Nearly 50% of women between the ages of 50 and 79 have some degree of uterine prolapse. There’s nothing to be ashamed of. 

“Why is it so common?” Aging plays a big role. As estrogen falls and connective tissue loses elasticity, your pelvic floor weakens, making it easier for the uterus to descend into the vaginal canal. 

• Zoom In: Factors like vaginal childbirth, genetics, chronic constipation, heavy lifting, obesity, and chronic coughing can raise risk. 

The obvious next question: What can you do about it? Let’s break it down: 

Option 1) Watchful Waiting 

This is a legitimate choice (not a “do nothing” cop-out!). If your prolapse is mild and isn’t causing symptoms, like pressure, bulging, urinary issues, or discomfort, monitoring with a gynecologist or urogynecologist may be all you need. 

• Science Says: Studies show many women with early-stage prolapse stay stable for years, especially when risk factors like constipation and heavy straining are addressed. 

Option 2) Pelvic Floor Physical Therapy 

If you’re picturing awkward Kegels and a lot of discomfort, let me reassure you: Pelvic floor physical therapy is professional, painless, and effective. 

• Science Says: Women who receive 1:1 pelvic floor muscle training report less pressure, bulging, and improvement in bladder and bowel control compared to those who don’t receive training. 

Option 3) Vaginal Pessaries 

A pessary is a removable silicone device placed in the vagina to support the pelvic organs. They come in different shapes and sizes (your provider will help you find the right fit) and you can use them short- or long-term. Think of them like a diaphragm, only for support rather than sperm blockade. 

What I like about pessaries? They’re safe, effective, and a great option if you’d rather avoid surgery. Most women get the hang of inserting and removing them on their own pretty quickly. 

• Science Says: A 2025 study with 130 women with stage II-IV prolapse found that after six months, nearly all women (98.5%) reported symptom improvement.

Option 4) Hormonal Support 

If you’re postmenopausal, vaginal estrogen can be a helpful addition. It improves your vaginal tissue quality, making it thicker, more elastic, and less prone to irritation, dryness, or discomfort from prolapse or pessary use. 

Can’t take systemic hormone therapy? No problem. Low-dose vaginal estrogen stays local with minimal bloodstream absorption, so it’s considered safe, even if pills and patches are off the table. 

Option 5) Surgical 

Maybe your uterine prolapse is severe: Visible bulging, crushing pelvic pressure, bathroom issues that make you dread going, or constant pain in your pelvis and back. 

If that’s you? Surgery may be your best option. Generally, there are two categories: 1) Keep your uterus (uterine-sparing procedures) and 2) Remove your uterus (hysterectomy with pelvic floor repair). 

While these surgeries are mostly effective and safe, surgery is still, well, surgery. There are risks and recovery times you should weigh with your doctor. 

A final important point: Uterine prolapse is rarely an emergency. You have time to ask questions, seek second opinions, and explore conservative options before committing to surgery.

If there’s a takeaway here, it’s that uterine prolapse is common, manageable, and treatable at every stage. 

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ABOUT DR. JEN

In her former roles as chief medical correspondent for ABC News and on-air cohost of “GMA3: What You Need to Know,” Dr. Jennifer Ashton—”Dr. Jen”—has shared the latest health news and information with millions of viewers nationwide. As an OB-GYN, nutritionist, and board-certified obesity medicine specialist, she is passionate about promoting optimal health for “the whole woman.” She has authored several books, including the national best-seller, The Self-Care Solution: A Year of Becoming Happier, Healthier & Fitter—One Month at a Time. And she has gone through menopause…

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