I’m struggling right now. It’s the uncertainty of things that really needles me.
You can likely guess how well I’ve been sleeping. Has anyone else been having crazy dreams lately?
My husband and I are embarking on a move in the next two months, but now we can’t go look at possible places. And professionally, I am concerned about the welfare of my team. Are they able to be the parents they need to be right now with all that I’m asking of them? Am I reaching out to them enough to let them know I care?
Gennev is a business as we’re an online clinic for women in menopause, and recently we added gynecology and primary care services too. We see you as “essential workers” in this crisis. In addition to your “day-job”, you’re likely the primary care giver, meal planner and online-learning specialist.
But even more, we’re a community.
We started as a community in 2016. And, it’s still the heart of our organization. Sometimes it gets overshadowed by the telehealth services and the products we offer. But it’s still our core.
There is a reason why Zoom happy hours have become so popular. People need people!
So, I’m dedicating this Friday letter to community and how you can get what you need, when you need it.
Weekly Webinars. These are new. Our healthcare team is hosting specialists to talk through meal-planning, strengthening your immune system, managing isolation and grief, etc. As long as you keep coming and asking for more, we will keep tackling new topics and offering AMAs.
Community forums. These are messaging boards for questions and answers. The cool thing is, they’re moderated by our health care team as AND as they’re safe and confidential. You can ask whatever you feel comfortable, and it won’t show up in your Facebook feed. Our latest forum has begun on COVID-19, which lists all our COVID-19 resources.
COVID-19 Resources. When it comes to women in midlife, we have our own health concerns around COVID-19. We’ve published some helpful podcasts, videos and articles”¦and we’ll keep adding to them over time.
Midlife & Menopause Solutions. This is our private Facebook group for those of you who like daily discussion in a less structured environment. We monitor who joins, so it’s safe. It’s still Facebook, but we do our best to ensure that women who rely on one another for advice are the only ones allowed in. No selling. No trools.
Instagram, Facebook (public), Twitter. These are our public channels. If you like to keep updated on happenings, tips and announcements from Gennev and the women in our community, please follow/join/like. We’ll like you back.
Menopause library. Our trusty library of long-standing, original menopause education is and always will be there. And, like all the other community resources I listed, it’s free”¦and searchable. Use it when you need it. Weekly we publish new articles, podcasts and video.
What kind of community do you need? With us, you have options.
Personally, I’m a lurker on social channels; I’m a consumer of podcast interviews and webinars (where I can multi-task), and from time to time, I like a good forum chat. I don’t need to engage, but I like to know what’s going on.
What’s missing from our approach? Human-to-human contact. You’re going to see more options for small group sessions and forum boards with the Gennev team very soon.
Isolation is real right now. And I think we’re learning that technology isn’t enough. We still need people.
I kind of love how we’re getting back to the essentials of life. It feels more inclusive to me.
If there are aspects to how we do community that you’d like to see changed or improved, email me at jill@gennev.com. Yes, that’s my personal email. Human to human.
Be well,
JIll
April is Financial Literacy Month as because who doesn’t get a jolt of reality every year when Tax Day rolls by (or over) us?
Women learning to manage money is especially important as they tend to outlive male partners and spend more years in retirement. And women generally have less to retire on (called “superannuation”), because of the pay gap between men and women, because more women than men take time out of their careers to care for children or aging parents, and because more women will take lower-paying jobs or work for employers who don’t offer retirement plans.
Money management may seem a little off-topic for a menopause site, but your financial health has direct impacts on your quality of life. We’re all about whole-woman wellness at Gennev, and you can’t be at your fabulous best if you’re stressed about your economic wellbeing.
So what can you do to prepare for your financial future? First, take a deep breath. Hold it. Little longer. Little longer”¦. There. Let it out. You can do this.
According to a 2016 Fidelity study, only 37% of women are confident in planning for retirement. But likely close to 100% of us want to be financially secure in our golden years, so let’s review four steps to get us started.
Tackling your finances can be a daunting task as and, quite frankly, a potentially dull one. But with more of us living longer, it’s never been more important to secure our financial futures. Here’s to your long, healthy, happy life!
That thing you’re doing that’s “good” for you? It’s not. Stoppit.
There’s so much information out there, from so many sources, it’s difficult to know what’s true and what’s false when it comes to taking care of our health.
So”¦we talked with our awesome physical therapists, Brianna and Meagan, to find out what things women are doing in an attempt to be healthier, and why they really shouldn’t. Turns out, some very “normal” things really aren’t good for you.
The problem: incontinence or urgency. One of Brianna’s clients was suffering from urgency as needing to urinate very badly and occasionally not making it to the bathroom in time. She assumed she was simply drinking too much water.
The wrong solution: intentional dehydration. To fix the problem, she pretty much stopped drinking water and other fluids while at work. The problem with doing this, says Bri, is it means the small amount of urine she is producing is much more concentrated, increasing her risk of urinary tract infections, for example.
The right solution: water. It turned out that her problem wasn’t caused by drinking too much water; she was actually drinking too little, and her bladder was constantly irritated. Bri worked with her to slowly and properly increase her fluids, ending the irritation and getting her back to walking to the bathroom instead of sprinting.
The problem: pain during intercourse. Meagan’s client was experiencing pain during sex as well as overall vaginal irritation.
The wrong solution: douching. Meagan explained to her client that the vagina has its own balanced system to keep it clean, and that the douching was only causing more irritation. “She was doing it more out of hypervigilance. She believed she could smell something,” Meagan tells us. “I examined her, and there was nothing abnormal or to be concerned about. Douching is not something we encourage. You’re messing with the delicate balance of the vaginal tissues, and you’re risking infection both on the outside and deeper within the vagina.”
The right solution: promote and protect healthy tissue. Sometimes the issue with painful intercourse is the tissues around the vulva are thin and delicate due to too little blood flow to the area. Pelvic floor exercises, Kegels, vibration and massage helped make the vaginal tissue healthy and more durable. Once that was resolved, the client no longer felt she had unusual discharge or sloughing of tissue, the issues which had led to her deciding to douche in the first place.
Irritation can also be resolved often by simply switching to cotton underwear, using a fragrance-free detergent, using the right intimate soap, and ditching the thongs, Bri adds. PS: this applies to steam cleaning of the vagina, according to Meagan as not necessary and potentially damaging to sensitive tissue.
The problem: wanting six-pack abs. While there’s nothing wrong with six-pack abs, a lot of us damage our bodies in the quest to get them.
The wrong solution: over-exercising our core and pelvic muscles. We hold our stomachs in, do too many crunches, over-exert our core muscles and basically put our pelvic muscles in a state of constant spasm. This can actually cause pain, incontinence, and urgency issues. “Hold weights over your head for 30 minutes, then tell me your arms don’t hurt,” Meagan says. “It’s the same with your pelvic floor as muscles need to clench and relax in order to become stronger.”
The right solution: exercise your core properly. Learn how to exercise your abdominals properly. Consult with your doctor or a pelvic floor specialist if you’re not sure.
The problem: painful intercourse. Pain during intercourse can happen for a number of reasons: vaginal dryness due to hormonal change, birth control, or medical procedures; pelvic floor issues such as spasms, etc.
The wrong solution: endure. “Too many women think painful sex is normal and they should just “grin and bear it’,” Bri says. “They go somewhere else mentally and just endure it, but it really ends up hurting them, hurting the relationship.”
The right solution: education, openness, and lubricants! Painful intercourse doesn’t have to be your new normal after menopause or for any other reason. “Gals feel like they should be able to have intercourse without any supplemental lubrication,” Meagan says, “and they’re ticked off that their bodies don’t make what they need. They don’t want to deal with using lube, reapplying lube”¦ The problem is they’re causing all these micro tears in that tissue, and pain, increasing risk of infection. Just use a lube!”
The problem: painful intercourse, coupled (ha ha) with a desire to use “natural” lubricants.
The wrong solution: olive oil. Olive oil has exfoliating properties, meaning it causes the skin to slough off dead cells. This is not a part of the body one should exfoliate, Meagan says; nature has already taken care of that. Bonus info: jojoba isn’t the best choice either, as it’s wax based, and the small amount of wax can build up internally.
The right solution: do your research. If you prefer to go the natural route, there are choices that may well work for you. Just be sure you read research from credible sources, test any substance on another body part first, start small to test for a reaction, and report any unexpected or unwanted reactions to your doctor right away.
[Choose a lube that fits your needs and your lifestyle. Check out this lubricant info sheet from A Woman’s Touch]
The problem: yucky public toilets. Few of us are completely comfortable trusting our bare bottoms to a public toilet seat or outhouse, no matter how picturesque. We’ve all heard horror stories of people picking up strange diseases or at least sitting in something suspiciously moist.
The wrong solution: hover. To keep our tushies safe, we hover above the seat when it’s time to urinate. Not a good idea, say our PTs. “If you’re not in a relaxed, sitting posture or full-on squat position, the muscles through your hips and pelvis aren’t relaxing. This means you’re having to generate extra abdominal pressure to push and force the pee out,” says Meagan. “This recruits the wrong muscles and totally messes with how normal peeing should happen.”
WHO KNEW???
The right solution: sit, Ubu, sit. Layers of TP on the rim. Know that if you don’t have an open sore at a contact point, the chances of contracting anything are pretty minimal. You’ll be fine. Or you can squirt some hand sanitizer on a piece of TP and give the seat a quick cleanse (but wait for the surface to dry to avoid skin irritation). Just don’t hover.
The problem: lack of Vitamin D in the nether region. Apparently women feel their vaginas aren’t getting enough Vitamin D.
The wrong solution: exposing one’s genitals to sunlight or tanning beds. The real problem? THIS ISN’T A PROBLEM. This part of the body is hidden and shaded for a reason as nature intended it that way. A burn in that area can be extremely painful and damaging to very delicate tissue over the long term.
The right solution: get enough Vitamin D in the usual ways. Exposing the skin to sunlight is good, when done carefully to avoid damage. But maybe bare only the skin that nature and culture have deemed reasonable. ?
Did you know there are foods to avoid in menopause? Depending on whether you knew or not, this could be good news or not so good news. Let’s start with the good news and what happens when you limit or remove these foods from your diet. Many common menopause symptoms decrease in severity and/or frequency. That’s huge when you’re talking about an experience where one often feels powerless. So, good because power. But bad because one link of sausage rather than two. We don’t know about you, but it feels like the possible positives far outweigh the negatives.
If you need a personalized diet or plan, a menopause-certified health coach can be helpful. Book 30 minutes for your personal consultation with a health coach.
The six foods listed below aren’t “bad” when consumed in moderation. Yet, it’s easy to overdo it when it comes to all six. In fact, at least one of them has been labeled more addictive than cocaine. Not exactly a selling point, and yet another reason to think twice about what you put in your mouth.
Now, it’s feasible that we’re about to tell you many of your favorite edible options need to either exit your diet all-together, or, at the very least, make far fewer appearances in your meals. And that’s hard. We get it. So we’re also going to look at how best to go about removing/restricting these foods from your life, and what to replace them with. Remember, the likelihood of less severe and/or lower frequency menopausal symptoms. And the added bonus of taking out the non-nutritional trash and increasing your intake of the healthy fuel your body needs to be strong, stable, and ready to support you through whatever comes your way. Let’s get started!
Caffeine isn’t so bad when consumed in moderation. In fact, it boasts plenty of health benefits. Most people can consume about one cup of coffee a day without any side effects. Sadly, Americans generally drink much more than their recommended share of caffeine.
Coworkers crowd around the coffee machine in break rooms, Starbucks can be found on every block in major cities, and beverages such as sodas and even kombucha have caffeine, too.
Because chocolate and coffee flavoring often contain caffeine, your late-night ice cream snack or pudding cup may need to go. Even your pain reliever could be hiding caffeine, which is great for speeding relief, but less so when you’re trying to minimize hot flashes in menopause and/or night sweats. The reason? Experts suggest caffeine consumption exacerbates menopausal vasomotor symptoms–hot flashes and night sweats that occur due to the constriction or dilation of blood vessels.
Alcohol plays a major role in our society. We toast the new year with a glass of bubbly, socialize with coworkers and friends at happy hour, and some even drink a sip during the sacrament at church.
Again, drinking alcohol in moderation is perfectly fine. But even in moderation, it can really amp up menopause symptoms such as headaches, hot flashes, night sweats, and mood swings. It can even contribute to depression if you’re drinking heavily. As for why alcohol can increase menopausal symptoms? The jury is still out, but two theories include alcohol impacting our already fluctuating hormones and dilation of blood vessels (we do recommend you try Libeeration beer for menopause symptoms!)
Potato chips. Donuts. Frozen pizza. What do these delicious items all have in common? They’re part of the processed foods group, which the U.S. Department of Agriculture defines as “any raw agricultural commodity that has been subject to washing, cleaning, milling, cutting, chopping, heating, pasteurizing, blanching, cooking, canning, freezing, drying, dehydrating, mixing, packaging, or other procedures that alter the food from its natural state.”
That’s a big list, so let’s narrow it down by what to watch out for. Inflammation, bloating, weight gain symptoms, and fatigue can all intensify thanks to the unhealthy levels of sugar and sodium found in most processed foods.
Processed sugar (sugar not occurring naturally in foods such as fruit, but rather sugar added to foods and beverages) can make your blood sugar levels higher, which can lead to more intense/frequent hot flashes, sweating in general, and brain fog. With the sugar industry deciding to not play fair by employing 60 different names for sugar on product labels, you might find it tricky to track how much of the white stuff you’re taking in.
This one is pretty easy to figure out. Under normal circumstances, foods that rate high on the heat scale can cause sweating, flushing, and elements found in hot flashes. So, for a menopausal woman who’s already dealing with hot flashes and night sweats, it’s probably best to get rid of the ghost peppers and make use of spices that add flavor without the heat, like cumin, turmeric, curry, and basil.
Everyone knows that fatty meats are high in saturated fat, which can cause all sorts of health issues, including weight gain. But did you know it can also lower anger attacks? And lower serotonin levels in menopausal women can lead to a lack of mood control (anger, irritation, rage). Not good. Not good at all.
So, skip the marbled steak and thick-cut bacon and go for the leaner meats, like turkey, chicken, even ground beef–as long as it’s 90% lean or better.
Now for the foods that you need during midlife. The key at this stage is to not only eat foods that might help ease menopausal symptoms, but also ones that provide the nutrients vital to carrying you gracefully through this transition and beyond. For example, there are a ton of great foods to ease hot flashes.
As estrogen levels decline, your risk of fractures goes up. So calcium-rich foods, like yogurt, cheese, and milk are essential for bone health. It’s also possible that dairy products improve sleep quality in menopausal women. They’re high in the amino acid glycine, which can encourage deeper sleep.
Pescararians, rejoice! Foods high in omega-3 fatty acids, such as salmon, mackerel, and anchovies, have been shown to decrease the frequency of hot flashes and severity of night sweats. Other foods high in omega-3 include seeds–hemp, chia, and flax.
Packed with vitamins and minerals, fruits and vegetables are a menopausal woman’s friend. Especially cruciferous veggies (broccoli, brussel sprouts, cauliflower, collard greens, cabbage). Many women experience a decrease in hot flashes when they introduce more fruits and veggies into their daily diet.
Fiber is good for everyone. But it’s especially good for women in midlife when it comes to depression. Foods rich in fiber, like beans, nuts, oatmeal, broccoli, berries, avocados, and apples have been shown to lower the occurrence of depression in menopausal women.
Declining estrogen is at it again, this time causing decreased muscle mass and bone strength. To combat this, get plenty of lean protein. Look to foods we’ve already mentioned, such as fish, legumes, and nuts. Also, try out eggs, lean meat (no red), and tofu.
It’s always a good idea to have an awesome supplement on your side, and never more so than during menopause. Even when you stick to a strict diet, it’s likely that you’re not getting enough of this or that. So let a supplement put your mind at ease.
Our Vitality Menopause Supplement aims to improve energy, mood, sleep, and inflammation while making sure you’re getting all the good stuff your body deserves.
There are three camps of thought when it comes to balancing our indulgences and cutting back on the foods to avoid in menopause. Read below for details on all three, then set up an appointment with your doctor or specialist for menopause near you to discuss the best way to go about putting your plan into place.
If you don’t already have a doc, get connected with a Gennev menopause-certified gynecologist who will give you a trusted opinion. Book an appointment here.
Some experts believe that making “too-sudden changes” without a plan can lead to failure. If you up and decide that tomorrow you’re going to go cold turkey on three things you might be both chemically and emotionally addicted to, quitting without a plan could lead to quitting.
Instead, pick a date in the future to make big dietary changes. Do some research. Try to find recipes that will satisfy your sweet tooth and utilize fruits or other natural sources of sugar. Create a list of virgin (or extremely low-alcohol) cocktails that give you a refreshing kick. Or, consider switching to decaf coffee a few times a day to trick your body into thinking you’re still getting your cozy cup of Joe–without the caffeine.
Many experts believe that waiting until a certain date isn’t the best tactic. One of the ideas behind this is that you’ll probably indulge even more between now and then. Knowing that you won’t be able to enjoy your 3 PM cup of coffee might make you want to drink even more of it between now and stopping time.
Similarly, knowing you’ll miss your happy hour glass of wine or cocktail in the future might encourage you to drink too many right now “ which could lead to menopause dehydration or hangovers. So this plan says there’s no time like the present!
There’s another group of experts that believe there’s a happy medium when it comes to indulgence. Begin by seeking some support from your doctor* or coach. Make a plan together. Enjoy a glass of wine at dinner (or happy hour) and don’t “go cold turkey” and deprive yourself in the future.
If you tell yourself that you can eat one cookie today, knowing there will be more cookies tomorrow, you’ll be better able to stop after just one. It’s when we deprive ourselves that we go into panic mode and eat all the cookies.
The truth is, change is one of the few constants in our lives. And having foods to avoid in menopause is just another tweak necessary to keep you on track toward health and happiness. Will this journey be challenging? Absolutely. But a very worthwhile one. Your future self will thank you for your health, energy, and focus.
How are you improving your health this year? Quitting caffeine? Modifying sugar intake, doubling your daily hydration? We’d love to hear about it, and support you, in our Community forums.
*It is not Gennev’s intention to provide specific medical advice, but rather to provide users with information to better understand their health and their diagnosed disorders. Specific medical advice will not be provided, and Gennev urges you to consult with a menopause clinic, qualified physician for diagnosis and for answers to your personal questions.
If you think you are experiencing perimenopause, then take our menopause assessment test to join over 100,000 women and learn more about your symptoms and where you are in the menopause journey!
The red cup is back at Starbucks, and you know what that means: the holidays are just around the corner.
Finding gifts for everyone on your list can be enough to put even the most seasoned shopaholic in a bad mood.
And if you traditionally use Thanksgiving as your cue to start shopping, we have bad news: there are only 26 shopping days between Thanksgiving and Christmas in 2019.
And Hanukkah starts on December 22 this year.
Hooray! “Tis the season for an extra layer of emotion slathered over everything. It may be your first December without a loved one or the annual reminder of rough times with your ex. Family expectations are high, and your mother-in-law still hasn’t forgiven you for marrying her favorite child.Staying relaxed is easier said than done, but stress is both no fun and a big trigger for hot flashes.
If listening to music calms you, bring your headphones while you shop. Take a break for self-care: get a massage, soak in the tub, or go for a long walk before you start to feel burnout.
We’re hoping this list helps, as well.
Who really wants to wake up at 4 a.m. to beat the Black Friday (November 29) crowds? Cyber Monday (December 2) has become a solid alternative. You’ll get great deals, save gas, and you can do it in your PJs with a cup of (decaf) coffee.
And you don’t need to wait: many retailers already have their Black Friday discounts listed online. For example, Cnet has curated a few ideas from favorite retailers like Walmart and Amazon, and TechRadar has predictions about upcoming Cyber Monday bargains.
Fear not, procrastinators: even if you snooze on the post-Thanksgiving deals, you can take advantage of Free Shipping Day on December 14.
Online shopping makes it easier than ever to cross off everyone on your holiday list without leaving the house.
But when your partner or kids have prying eyes, you want a one-of-a-kind gift that can only be bought in a brick-and-mortar location, or you’re desperate for a new outfit to wear to the office holiday party, you need to put on your big girl pants and get out there.
Whether you’re hitting the mall or the mom-and-pop shops on Main Street on Small Business Saturday (November 30), write out what you want from each store and in which order to visit them to save time, gas, and stress.
Hitting the mall can be a great way to get in your steps. Exercise during menopause is important for bone health, weight management, and to lower your risk of breast cancer. Make shopping work to your advantage!
Take the stairs or walk up the escalator. To really get a workout when shopping during the day, park as far from the entrance as you can, or on the opposite end of the side that you’re planning on visiting.
But”¦
Safety first, always! Law enforcement professionals remind you to park in well-lit areas, keep your hands free and keys and cellphone easily accessible, roll your windows all the way up when parking, store gifts and bags in your trunk, and always lock your car.
Cybersecurity experts remind you to use trusted websites, make sure the site is SSL encrypted (you’ll know because the URL will start with “https’ and you’ll see a locked padlock in the address bar), and other best practices when shopping online.
Who can resist the alluring smell of Cinnabon? When that cinnamon-sugary aroma wafts across the food court, it can be hard to resist, especially when you’re stressed. Unfortunately, sugar, caffeine, and other mall delights can lead to hot flashes and midlife weight gain.
Stash a few snacks filled with fiber, protein, vitamins, and healthy fats in your bag: nuts, apple slices, dried fruit, hardboiled eggs, a cup of yogurt or cottage cheese, string cheese, or single-serve hummus and carrots are all portable and healthy.
You’ll feel better and make better shopping decisions.
Thirst has a funny way of sometimes coming across as hunger, and water is good for your brain, body, and holiday spirit. It’s extra important that you stay hydrated in perimenopause, menopause, and beyond.
You can always count on Santa to let you know what the wee ones want. Teenagers and adults, not so much.
Time to do some sleuthing. Your friends and family members’ “Likes” on Facebook or “Hearts” on Instagram can give you insight into what they would like to find under the tree.
We promise this doesn’t make you a stalker. Well, maybe a little bit, but finding a thoughtful, inspired gift that the recipient will cherish makes it cute, not creepy.
Many of us in midlife find ourselves wanting to get in touch with our roots or explore our family tree. DNA tests have become a popular gift in recent years, and the most popular services offer deals around the holidays.
These tests can provide amazing genealogic and health insights but may be problematic as unsolicited gifts.
Perhaps your sister is trying to shed a few post-menopausal pounds, or your best friend is getting hit hard by hot flashes. Maybe makeup and nail polish are easy stocking stuffers for your daughter or niece.
We’ve written about how makeup, nail polish, and other cosmetics can be a bummer for breasts. Pick products that are free of parabens, phthalates, phenols, and other potential toxins.
Use this as an opportunity to help your friends swap out bad for better, such as alternatives to plastic (which may be full of cancer-causing chemicals). [A few ideas for reusable gifts]
And browse our gift ideas for women in midlife and menopause or our menopause wish list; from float sessions to cooking classes to smart vibrators (oh my), we’ve got you (and your sister, and your girlfriends) covered.
What do you get for the person who has everything? Sometimes the answer is nothing”nothing besides memories and experiences.
Sure, you can’t give everyone on your list a vacation or spa day, but there are plenty of experiential options for all budgets, for kids, and for the entire family.
You could also give cold, hard cash, but what’s better than getting $5? Giving $5 to charity. Research shows that the pleasure of receiving money fades, while philanthropic contributions leave a warm and lasting glow. Charity Navigator can help you find reputable non-profits and causes that will resonate with your friends and loved ones’ areas of interest.
And you can’t go wrong with a homemade gift from the heart–even if you aren’t crafty enough to upcycle an apron, you can have a lot of fun putting together a DIY bubble bath set.
You can score seasonal cheer at a deeply discounted rate after Christmas… while you buy yourself what you really wanted from Santa. If you have the space, stock up on holiday decor and evergreen gifts to save your future self some of the stress you’ve just vanquished.
While there is some truth behind the idea of retail therapy, don’t shop if you know you aren’t in the right headspace for it. The holidays can be hard, and your mental and physical health needs to come first.
While you’re at it, feel empowered to skip the office holiday party. Unless you found that perfect outfit on your shopping adventures.
If you’ve mastered the art of stress-free holiday shopping, help a buddy out and share it with us in our community forums!
Does using birth control delay menopause? Does it increase the risk of breast cancer or heart disease in menopausal or perimenopausal women? After many years on the Pill, how will I know it’s safe to go off it?
For answers to our birth-control-and-menopause questions, we turned to Dr. Sherry Ross, award-winning OBGYN and author of the book >She-ology, a look into women’s health beyond the doctor’s office.
Dr. Sherry Ross
“First,” Dr. Sherry told us, “be sure you understand this: until you’ve had no periods for a year, you can still get pregnant.
“Part of the confusion is around definitions: The true definition of “menopause’ is when you don’t have a period for one full year, but many women suffer from disruptive symptoms for a few years leading up to full cessation of periods”that’s called “perimenopause.’ As I said, until you are officially in menopause”meaning no periods for a full year”you can potentially get pregnant, so be sure to use some form of contraception. If you are single and dating while in menopause, you may not have to worry about getting pregnant, but you do have to protect yourself against sexually transmitted infections, so make sure your partner wears a condom.”
So, re: birth control, keep on keeping on until one year with no periods, and re: condoms, always always always outside of committed, monogamous relationships. Check.
” Oral contraceptives and an IUD like Mirenacan mask some of the symptoms of perimenopause and menopause,” Dr. Sherry told us. “That’s one of the benefits. Women on the Pill may have fewer, less-intense hot flashes, more “normal’ periods when other women are all over the menstrual map, and they might have more modulated emotional swings, which can be a huge benefit in their personal and professional lives. That’s why many doctors”myself included”prescribe low-estrogen birth control pills women having a rough menopause and don’t smoke or to make the transition into menopause easier.”
Short answer: No. Here’s why:
“Menopause is a time when your ovaries stop producing estrogen and your female hormone reserves are depleted. Known factors that can affect what age you enter menopause include your genetic predisposition, knowing when your mom went through the change, chromosomal abnormalities such as Turner Syndrome, very thin or obese women, long smoking history, needing chemotherapy or radiation therapy, those with autoimmune diseases and epilepsy.
“It’s clear that short- and long-term stress, such as extreme weight loss and weight gain, can offset your hormones, causing irregular periods. The extent this type of significant stress has on your endocrine system, causing hormone adrenal depletion and possibly affecting menopause, is not as clear.
“There is an association between extreme and long-standing exercising causing weight loss which can offset your hormones and cause early menopause. Excessive exercising creates a hormonal imbalance, causing irregular ovulations. It’s less likely short-term exercising mixed in with months of not exercising could cause a cascade of events leading to an early hormonal depletion.
“So there are some things that can bring on early menopause, but being on the birth control pill does not affect when you begin menopause. The Pill can mask the symptoms of menopause and, as I said, many women depend on it to help ease the transition into menopause.”
“The best way to know if you are in menopause while taking the birth control pill is to check your hormonal levels at the end of the pill-free week. Some women may even notice hot flashes during the pill-free/placebo week since they are not taking estrogen that’s normally in the active pills. Your doctor can conduct a simple blood menopause test that determines if your follicle-stimulating hormone level (FSH) has reached menopausal levels.”
If you need a trusted opinion, determine if medication is right for you, and possible prescription support. Book an appointment with one our Gennev menopause-certified gynecologist doctors here.
“
Says Dr. Sherry: “As long as you’re not a smoker over the age of 35, and you don’t have any contraindications of being on the Pill (high blood pressure, a history of blood clots, liver disease, breast or uterine cancer, strokes or migraine headaches), there are no health risks to taking the Pill during the first couple of years of menopause. The birth control pill stabilizes your hormones and keeps you physically and mentally balanced.”
And, according to Dr. Sherry, there’s even more good news.
Wait. There’s good news? About menopause?
“There’s evidence that taking birth control pills reduces the risk the risk of ovarian and uterine cancers. It may also help with rheumatoid arthritis.”
OK, that’s all terrific, but there have to be drawbacks.
Said Dr. Sherry: “As I said, hormonal birth control is not for women who smoke, particularly if they’re 35 or older. Birth control pills may increase your risk of strokes and blood clots, and that risk is exponentially higher for smokers over 35. Yet another reason to quit!”
We completely agree. Anything else?
“Studies are still being conducted into hormonal birth control and breast cancer. But unless a woman has a history of breast cancer or other factors that make her high risk, she should feel comfortable taking low-dose birth control pills to control perimenopausal or menopausal symptoms,” Dr. Sherry told us.
“The best first step is to have a frank and open discussion with your menopause doctor. And don’t be embarrassed or shy”I can tell you from personal experience that almost nothing shocks a doc! Menopause is a normal, natural process and part of life, though women may experience it differently. Your doctor is here to help you understand what’s happening and alleviate symptoms that are interfering with your quality of life. There are solutions. You can feel better. And that’s the best news of all.”
Sheryl A. Ross, M.D., “Dr. Sherry,” is an award-winning OBGYN, author, entrepreneur and women’s health expert. The Hollywood Reporter named her as one of the best doctors in Los Angeles, Castle Connolly named her as a Top Doctor in the specialty of Obstetrics & Gynecology, and she was selected as a 2017 Southern California Super Doctor. Dr. Sherry continues the conversation of women’s health and wellness in her monthly newsletters and on DrSherry.com.
Dr. Sherry Ross blogs for Huffington Post, Maria Shriver, Greatist, SheKnows, HelloFlo, Today Show, All Things Menopause, and Gurl, and we are thrilled to welcome her to the Gennev community!
The information on the Gennev site is never meant to replace the care of a qualified medical professional. Hormonal shifts throughout menopause can prompt a lot of changes in your body, and simply assuming something is “just menopause” can leave you vulnerable to other possible causes. Always consult with your physician or schedule an appointment with one of Gennev’s telemedicine doctors before beginning any new treatment or therapy.
Gout? Isn’t that something men suffer from? Do woman get gout?
It is. And more and more women are getting diagnosed with gout as well.
In the last 20 years, cases of women with gout have more than doubled. According to the Arthritis Foundation, “…Two million women as and 6 million men as in the U.S. have this inflammatory form of arthritis that causes joint swelling and telltale pain at the base of the big toe.”
Gout is, as noted, a form of arthritis. Gout occurs when high levels of uric acid increase in the blood and form needle-shaped urate crystals in the joints or a joint’s surrounding tissue.
How does uric acid get produced?
When your body breaks down purines “ naturally-occurring substances in your body and in some foods “ uric acid is produced. The normal function includes this uric acid being dissolved in the blood, transferring to the kidneys, and then getting eliminated through your urine.
The body could be out of balance and develop gout by producing too much uric acid, or by excreting too little of it in the urine.
A flare-up can swell the joints making it painful to walk or move, and can increase stress and frustration levels, which may then exacerbate other menopause symptoms like insomnia, night sweats, hot flashes, etc. Definitely not the direction to head in if you can possibly avoid it.
Joints may also swell, radiate heat, and flush red in color as well. A gout flare-up may also feel as though a joint is on “on fire,” like a joint-specific, localized hot flash of sorts.
If left untreated, gout pain may worsen and joint damage could ensue. Best to get it checked.
Is gout hereditary? If your family history includes gout, The Mayo Clinic notes you’re more likely to develop this disease.
In men, gout is often described as a sudden, severe attack, usually in the night, with intense pain in one of the joints, commonly the big toe. But this isn’t always the case with women.
In women, it can be a sudden attack, but it may also develop more slowly over time and in multiple joints. Brian F. Mandell, MD, a rheumatologist at the Cleveland Clinic in Ohio and board member of The Gout & Uric Acid Education Society, shares:
“In women, it seems there is a greater prevalence of the initial episode of gout being in multiple joints. It may not always be the typical swollen great toe. In the hands, this is often misdiagnosed as inflammatory osteoarthritis when it may actually be attacks of gout.”
Women frequently experience gout in the ends of their fingers, wrists, knees, and toes and are more prone to gout after menopause.
Ready to focus on your health in midlife and menopause? Work with a Gennev Menopause Health Coach.
Estrogen in premenopausal women and those on estrogen replacement therapy helps to flush the uric acid out of the system, according to the Arthritis Foundation. After menopause, uric acid levels tend to rise.
If a person with a uterus develops gout before going through menopause, it’s usually due to other conditions such as having a history of taking diuretics, high blood pressure, diabetes, kidney disease, and obesity.
When it comes to diet, gout, and overall health, definitely get into your doctor’s office to talk about your health specifically. Especially if you have other health conditions.
Foods to avoid, limit, or moderate regarding gout
Some of the foods recommended to moderate or minimize may have health benefits that outweigh the risk for gout (like the omega 3s in sardines may be more important to brain health than sardines’ risk of gout). Knowing your levels, getting screenings, and having regular conversations about your health with your doctor or nutritionist will be your best way forward.
On alcohol and gout
The topic offoods to avoid in menopause like alcohol comes up regularly in our content since it can spike the intensity and frequency of symptoms such as”¦ hot flashes, headaches or migraines, and mood swings (well, rage, really). It’s especially important to note for those prone to developing or who are actively managing gout.
Researchers out of the Boston University School of Medicine examined data on 2,476 female and 1,951 male participants in the ongoing Framingham Heart Study, which has followed residents of Framingham, Massachusetts, since the late 1940s. Over an average of three decades of follow-up, 304 cases of gout were reported, with one-third of those cases occurring in women.
Further reporting from the Framingham Heart Study shared that:
“Drinking 7 or more ounces of spirits a week — roughly five drinks — doubled the gout risk in men and tripled it in women. Heavy beer drinking was associated with a doubling of risk among men and a sevenfold increase in risk among women.” [emphasis ours]
Foods to include
We recommend weight loss,if you need it, for healthy menopause weight management. “Being overweight increases the risk of developing gout, and losing weight lowers the risk of it. Research suggests that reducing the number of calories and losing weight “ even without a purine-restricted diet “ lower uric acid levels and reduce the number of gout attacks. Losing weight also lessens the overall stress on joints.”
Recommended eats & drinks:
Talk with your doctor, or one of our doctors, and your menopause health coach, about specific concerns about gout, joint pain, and other forms of arthritis. Talk with them sooner rather than later if obesity, high blood pressure, diabetes figures into your current state of health and well being.
Your health, mobility, and well being are worth it.
Join the Gennev Community Forums to weigh in on this topic, ask questions, and understand more about menopause with others on the path.
I’ve been thinking about community a lot lately.
How much do we need it? As women, most all of us thrive on connection.
And when we’re going through life’s transitions, connecting with others going through the same thing kind of makes it more palatable.
Personally, I’ve got my community of women to whom I go to with the most personal of things. I’ve got a very small handful of friends (like 3-5 max) that I share life’s ups and downs. Things about my marriage, my family, even shameful mistakes that I’ve made. I’ve learned that I feel better when I share with others that I trust”¦even if there is no amount of advice that can help me recover”¦quickly.
But how about going through menopause? Is it something that you want to share with others?
For menopause and health topics, I broaden my net. I’m willing to share my experiences with other women of all levels of closeness to me, because women’s health is a “sisterhood” type of topic that creates a common bond, even when a personal relationship doesn’t exist.
Menopause levels the playing field. We’re all going to go through it.
I commonly find that my role with Gennev makes me a safe place for women to share all types of gnarly health symptoms including mood swings, painful sex, vaginal dryness, and the all-too-common insomnia that especially nails women in the workplace.
One woman even went so far to call me “the vagina whisperer.”
I’m struggling to land on what our Gennev community needs to be as we grow beyond the thousands of women we serve today. Is it a support group or health Q&A forum?
Do you find comfort in sharing/listening in a closed Facebook group, like the one Gennev hosts called Midlife & Menopause Solutions?
Or would you rather browse a general menopause FAQ forum to seek out questions and answers from health practitioners and like-minded women?
And is a menopause community something you want to bring your friends into, or something that you want to do anonymously?
I want to hear what you want your community to be. Is it simply a place to connect with like-minded women? Or a place to get answers and solutions for feeling better in your body?
Email me at jill@gennev.com
Have a great weekend!
JIll
Do your jeans irritate you right at the waistband, and not because of the fit? Do you stand at the sink and feel pain or irritation when you lean against the counter?
It could be the scar from that C-section or appendectomy that’s giving you trouble, even if the surgery is years or decades in the past.
Internal and external scars, even long-since healed, can cause sensitivity, pain, and reduced mobility. Knowing the proper way to manage scar tissue can help you reduce or resolve those issues, on any scar, anywhere on your body. Practicing scar massage on new incisions (once healed) can help avoid problem years in the future.
To learn more about “restricted scars” and how to handle them, Gennev turned once again to our fabulous physical therapists, Brianna Droessler-Aschliman PT, DPT, CMTPT and Meagan Peeters-Gebler PT, DPT, CSCS, CMTPT.
First, it’s important to know a scar is more than just a line on your skin, says Meagan. Our bodies are made of numerous layers, and there may have been several incisions to get to whatever tissue or structure or organ the surgeon was trying to fix. So the “problem” scar may actually lie deep inside.
Second, it helps to understand how scar tissue is formed. “Think of a mud puddle,” Meagan says. “To cover it up, you throw a bunch of straw on it. It covers the hole, but the pieces of straw land every which way and end up lying in different directions. That’s how scars form.”
Plus, says Bri, the cells that form a scar matrix are often tougher and more fibrous. This makes the scar tissue less flexible than the tissue around it.
“Scars can even pull on surrounding skin and tissue and form adhesions,” says Bri. The pain, burning sensation, or restricted movement happens when you try to pull or twist against that adhesion.
Scar massage helps by realigning existing scar tissue so the fibers are neatly organized and running parallel and perpendicular to one another, making the matrix of scar tissue much more flexible and elastic. Second, massage helps break up adhesions, freeing up restricted muscles, organs, and fascia for greater range of motion. Finally, massage can help establish a framework so any new tissue that’s created becomes part of this organized pattern. No more jumbled straw!
Restricted scar pain can go undiagnosed for years, since people often don’t associate new pain with an old wound. A doctor or physical therapist will likely be able to feel the restricted scar by pushing on the painful area with their fingertips.
A healthy, well-healed scar should feel and move like the skin around it, according to our PTs. “I shouldn’t feel a barrier, no raised ridge, no wad of tissue or puckering. If I pull it one direction or another, it should move easily, without causing pain,” says Meagan. “If it doesn’t, a restricted scar is where I’ll start.”
“Most people aren’t told about the importance of scar massage,” Bri adds, “so we see this problem pretty often. But it’s really avoidable. People can be taught to start massaging their own scars as carefully as as soon as the incision is healed to keep adhesions from forming in the first place.”
Hang on, before you go diving in: if this is a new incision, is it fully healed? As Meagan says, be sure it’s fully closed, with no draining, oozing or crusting, and no risk of eruption. If you’re not sure, consult with your doc.
Begin by desensitizing the area. Nerves may be flaring and angry from the surgery or injury; you want to calm them so the area can tolerate scar massage a little further down the road. Start the desensitization by rubbing the area lightly with a very smooth, silky fabric. Do that for a few days, then increase the sensory input by moving to cotton, then denim, then wool. Once it can tolerate that level of irritation, you can move on to massage.
According to Bri, most folks are ready for scar massage about 6 weeks after surgery. You’ll want to consult with a physical therapist to learn to do this right. Happily, once you’ve mastered the art of scar massage, you can carry on on your own.
The trick is to find areas of resistance, according to our PTs. When you find one, gently press and hold. You can continue doing this until you feel it start to release. Bri suggests finding a good topical cream to make massage easier and promote healing (oddly, a combination at frankincense and emu oil seems particularly effective, she says).
Fortunately, even very old scars respond to manipulation and massage. And no scars are “off bounds.” Had an episiotomy? Go for it.
We wanted to talk about this topic now, in recognition of breast cancer awareness month and the far too many women and men who wear the scars of mastectomies and biopsies.
“Scar massage is really useful for mastectomy and post-radiation healing,” Meagan says. “With mastectomy, women can have challenges with breathing, with rib-cage mobility, arm motion, even just reaching overhead. Plus superficial nerves can get entrapped in scar tissue, and that can cause lots of pain and problems. Knowing how to do scar massage can help avoid a lot of issues later on.”
For many of us, just looking at a scar is difficult, much less touching or massaging it.
This is where working with a PT can really help. “Often we’re the first to touch a new scar, even before the patient,” says Bri. “They want to know that it’s OK to touch it, that they won’t open it or cause themselves more pain. We can show them how to touch it, when it’s OK; we tell them, this is what it’s supposed to feel like, this is what you can expect, this is how it should move. Once they know all that, it’s easier to be open to the massage and to taking over their healing themselves.”
“It makes sense that it’s hard,” says Meagan. “We associate that mark on our body with a traumatic event. Even if it happened during the happy birth of a child, scars change our body and how we view it. But think of it a different way: a scar is proof that your body is healing, and that’s good. When you can’t bring yourself to touch your scar, it’s like you’re an open circuit, and all that good energy is being lost. Once you can touch it, you complete the circuit, allowing the energy to flow through your body. That’s what healing is.”
Have you practiced scar massage, and did it work for you? Tell us EVERYTHING. Share with the community in the comments below, or fill us in on Gennev’s Facebook page or Midlife & Menopause Solutions, Gennev’s closed Facebook group.
Want more from Meagan and Bri? Well, of course you do, they’re awesome. Check out if you’re peeing normally and what to do if you’re not. Here are some steps to take to improve your sex life (and how to orgasm better! – like, a lot). And learn why why your sleep is screwy. Discover why you need good sleep and how to get it. And be sure to read Brianna’s article on “Managing Scar Tissue“ for Nature’s Pathways magazine.
When hormone levels change, it seems like your whole body changes, doesn’t it?
This is especially true for women with diabetes who are entering the beginning stages of menopause, perimenopause. True still and again for pre-diabetic women entering the same life transition. Hormones have a whole lot to do with both menopause and diabetes, and it’s baffling at times to navigate new symptoms and identify what they are in your body, in addition to living your busy, awesome life.
In 2015, of the 30.3 million adults who had diabetes, 23.1 million were diagnosed, and the remaining 7.2 million were undiagnosed.
What will serve you through this is your awareness and attention to what is going on in your body.
If a new diagnosis of diabetes coincides with the onset of menopause, you may be navigating some similar symptoms. For instance, you may experience a symptom of foggy thinking both menopausally and diabetically. The element to zoom in on might be to determine if and/or when there is a difference in it being a diabetic symptom vs a menopause symptom. So much is new, and not much is fun.
Still, staying informed and aware of symptoms and changes in your body is where your power lies in making good choices and taking good care of yourself. We do recommend talking with your doctor and getting your blood sugar levels checked, especially if your risk is higher for diabetes.
Whether you’ve been diagnosed with pre-diabetes, diabetes, or menopause (or not), there are a few things you can do to help your overall health until you talk with your doctor or check in with our telemed team (but please, do talk with a doc. Soon). What can you do? Self-care, support, processing, and testing.
Your health journey is a precious and vibrant part of your life (and quality of life). The attention and care you take to feel better will serve you in both the long and short run.
We’d love to hear your experience – both the good and the challenging – around diabetes, pre-diabetes, menopause”¦ life!
Join us in the Community for shared knowledge, wisdom, and support.
What if you could relax more easily, decrease anxiety, symptoms of depression, fall asleep easily, improve the quality of your sleep, even signal increased anti-inflammatory and self-regulatory body responses at will? We can.
And…bonus! It’s free and easy to do.
We almost don’t have to think about it to get the benefits.
While scientific research and verification are still underway, it might be worth attempting to activate the vagus nerve regularly with simple breathing exercises in order to engage the parasympathetic nervous system. This will begin to take us into a “rest and digest” mode, and out of the sympathetic system’s “fight, flight or freeze”.
Chances are good you’re more familiar with your sympathetic nervous system. This system is the one that boosts the body’s heart rate, directs blood flow to key systems and organs, and increases alertness, via rapid hormone release. All of this is in order to prepare the body for the fight, flight, or freeze response in a dangerous or stressful situation.
Feeling wired-but-tired may be an indicator that your sympathetic nervous system is working harder than it needs to, especially if you’ve got that feeling in non-stressful, non-emergency situations. Perhaps you’ve felt it while watching television, or while trying to fall asleep in the comfort and safety of your home. Or maybe you find it challenging to rest or get to a state of relaxation in general.
Dr. Deepak Chopra, notes that “Our society is on sympatheic overdrive.” Meaning, many of us are in a constant or chronic state of high alert. What else does this mean for our bodies to be in an almost constant state of emergency alert?
It increases our risks for high blood pressure, inflammation throughout the body, heart disease, cardiac arrhythmias. Getting out of the sympathetic nervous system and into the parasympathetic system takes little effort, and we’re all halfway there by breathing all the time anyway. With a tiny bit of modification, we may reap the benefits of improved health and wellbeing, reduce our risks for heart disease, symptoms of anxiety, and depression.
Which is the longest nerve in your body, with a path to almost every organ? It’s the 10th cranial nerve in the body and it wanders from above the mid-brain throughout your body, all the way down to your colon: the vagus nerve. Ta-da!
As a part of the parasympathetic nervous system in our bodies, the vagus nerve influences lung, heart, gut, and diaphragm activity, not to mention facial expressions, speaking and swallowing functions. And it’s possible to activate, support, and bring balance into our bodies regularly by engaging and activating the vagus nerve.
Breathing slowly and deeply is the path to engaging the vagus nerve and improving what’s known as vagal tone.
Breathing in and out through your nose, inhaling and exhaling to the count of 4. Spend 2-ish minutes and breathe 10 breaths of inhale and exhale at the count of 4 for each, and see how you feel.
Play with it. Perhaps you can slow your number of inhales and exhales per minute even more by inhaling to a count of 5 and then exhaling to a count of 6 or 8 for another series of 10 breaths.
It provides a balancing effect on your nervous system. When you practice this type of breathing, and other non-invasive methods to activate your vagus nerve, improve your heart rate variability (HRV), so your body can relax faster and easier after a period of stress. This breathing exercise can also help you to relax and fall asleep.
There are medical procedures and devices that have been adopted to stimulate the vagus nerve in order to treat epilepsy and mental health including depression. There was a study done in 2016 for those suffering from rheumatoid arthritis as well.
Ongoing research is currently underway for inflammatory diseases such as Crohn’s, Parkinson’s, Alzheimer’s, as well as rapid cycling bipolar and anxiety disorders.
How to incorporate a new practice that may ease menopause symptoms, and even help to decrease inflammation, reduce the risk of heart disease? Maybe all you need are a few suggestions to prompt you to engage your parasympathetic nervous system during the day? You could begin to breathe slowly and deeply when you:
Where else, and what else, might prompt you to take a more conscious, deeper breath?
Additional ways to engage your vagus nerve and your parasympathetic nervous system:
Coaching and additional support may be of help as you navigate through your menopause transition. Make a simple start by slowing and deepening your breathing. The hardest thing about this suggestion may be remembering to do it.
What did you discover when you tried to engage your parasympathetic nervous system via your vagus nerve? We’d love to hear what you’ve experienced in our Community forums. Join, and share.
“You get about 15 minutes between pimples and wrinkles. Enjoy it.” as my mom
Turns out, mom was wrong. While we all expect wrinkles with aging, menopause acne can occur or recur for the first time since our teens. Sigh.
Whether it’s prom night or project presentation day, pimples can suck your self-confidence, and no one’s got time for that. So, what’s going on and what do we do about it?
I talked with Dr. David Lortscher, MD, board-certified dermatologist, and creator of Curology. While Dr. Lortscher focuses on individually tailored treatments for acne, he shared with us some information on lifestyle choices that can help women in menopause handle changes in their skin.
As estrogen declines in midlife, so do collagen and elastin, meaning your skin may become thinner, drier, and looser than before. Hence, wrinkles. But estrogen decline also takes with it our skin’s ability to ward off acne, sometimes leading to acne during and even after menopause.
According to Dr. Lortscher, “As women transition into menopause, as at puberty, a relative predominance of androgens (male-type hormones that all women have) is responsible for acne breakouts in some. In general, androgens stimulate oil production and can worsen acne, while estrogens counter that effect.”
As with all things menopausal, there are a variety of treatments ranging from lifestyle changes to over-the-counter or prescription medications, to more significant medical interventions. But many women can control breakouts by making simple changes to diet, getting more sleep, and dealing differently with stress.
Looking for prescription menopause acne treatment? A Gennev menopause-certified gynecologist can give you a trusted opinion, determine if medication is right for you, and they can provide prescription support. Book an appointment with a doctor here.
Other remedies are ones you’ve heard before: sleep more. Stress less. Stop smoking. Hydrate. By doing a combination of all of the above, you have a strong chance of reducing or eliminating midlife acne, and you will certainly be doing good things for your overall health. Plus, spearmint tea tastes really nice.
For those whose acne doesn’t yield to lifestyle changes, you may also want to consider adding over-the-counter remedies to your menopause skin-care regimen: look for creams that include benzoyl peroxide (but use sparingly, as this can further dry your skin) or salicylic acid to unclog pores. Or go another step to a personalized treatment plan. Sometimes hormonal acne treatments can be effective, but do not work for everyone and should be carefully evaluated before going that route. Acne after menopause is often treated in this manner, but to varying results.
Thank you to board-certified dermatologist Dr. David Lortscher, MD and creator of Curology.
The information on the Gennev site is never meant to replace the care of a qualified medical professional. Hormonal shifts throughout menopause can prompt a lot of changes in your body, and simply assuming something is “just menopause” can leave you vulnerable to other possible causes. Always consult with your physician or schedule an appointment with one of Gennev’s telemedicine doctors before beginning any new treatment or therapy.