Handout 01 · The Next Chapter Clinic

Estradiol (Estrogen Therapy)

Estradiol replaces the estrogen your ovaries make less of in perimenopause and menopause. It is the most effective treatment for hot flashes and night sweats, and it protects your bones.

What it can help with

• Hot flashes and night sweats
• Sleep that is broken by night sweats
• Vaginal dryness and painful sex
• Bone loss (estrogen helps prevent osteoporosis)
• Many women also notice better mood, less joint aching, and clearer thinking

If you still have your uterus

You must also use progesterone (or have a hormonal IUD). Estrogen alone can thicken the lining of the uterus and raise the risk of uterine cancer. Progesterone prevents this. Never stop your progesterone while you are still using estrogen.

How to use it

If you miss a dose

• Patch: put on a new patch as soon as you remember, then go back to your usual change days.
• Gel, spray, or tablet: use it when you remember the same day. If it’s already the next day, skip it. Don’t double up.
• Patch fell off: put on a new one and keep your usual schedule.

When you’ll notice a difference

Common side effects

These are most common in the first 1–3 months and usually settle on their own:

• Breast tenderness or swelling
• Bloating
• Headache
• Nausea (more common with tablets)
• Spotting or irregular bleeding
• Skin redness or itching under a patch

If a side effect doesn’t improve after 2–3 months, let us know. Changing the dose or form often fixes it.

When to get help

Call 911 for:

• Chest pain or sudden shortness of breath
• Sudden weakness or numbness on one side, facial droop, trouble speaking, or vision loss

Go to the emergency department the same day for:

• Pain, swelling, or warmth in one leg
• A sudden, severe headache

Message us in the portal for:

• Bleeding heavier than a period, or bleeding that continues past 6 months on daily progesterone
• Any bleeding after you had stopped having periods
• A new breast lump or nipple discharge
• Side effects that don’t settle after 2–3 months

Tips

• Avoid lotion or oil where you put your patch. Baby oil removes leftover adhesive.
• Hot tubs, saunas, and heating pads over a patch can increase how much medicine you absorb.
• Gel and spray can rub off onto children, partners, and pets. Let it dry fully and cover the area.
• Keep up with your yearly mammogram.
• Tell any surgeon or other doctor that you use estrogen.

Handout 02 · The Next Chapter Clinic

Progesterone

If you still have your uterus and use estrogen, you also need progesterone. It keeps the lining of the uterus thin and protects you from uterine cancer. Many women find it also helps them sleep.

What it does

• Protects the lining of your uterus while you use estrogen
• Micronized progesterone (Prometrium) often improves sleep and can ease anxiety
• Some forms (Slynd, hormonal IUD) also prevent pregnancy

Never stop your progesterone while you are still using estrogen, unless we have talked about it first.

Your options

What to expect with bleeding

• Monthly (cyclic) schedule: a period-like bleed usually comes a few days after your progesterone days end. This is expected.
• Every-night (continuous) schedule: light, irregular spotting is common in the first 3–6 months, then usually stops.

When you’ll notice a difference

• Sleep often improves within the first 1–2 weeks with micronized progesterone.
• Bleeding patterns usually settle by 3–6 months.

Common side effects

• Drowsiness or dizziness (take at bedtime)
• Breast tenderness
• Bloating
• Mood changes in some women. Tell us if you feel low or irritable; another form often works better.

When to get help

Call 911 for chest pain, sudden shortness of breath, or signs of stroke.

Message us in the portal for:

• Bleeding heavier than a period
• Mood changes that worry you

Tips

• Take Prometrium at bedtime, not before driving.
• If you have a peanut allergy, tell us before starting Prometrium.
• Set a phone reminder, especially for a monthly schedule.

Handout 03 · The Next Chapter Clinic

Combination Hormone Products

Combination products put estrogen and uterine protection in one pill or patch, so you only need one medication. They are for women who still have their uterus.

What they can help with

• Hot flashes and night sweats
• Sleep, mood, and joint aches
• Vaginal dryness
• Bone loss
• Protection of the uterine lining is built in, so you do not need a separate progesterone

Your options

Using a patch

Apply to clean, dry skin on the lower belly or upper buttock. Press for 10 seconds. Change it on the same days each week, and use a new spot each time.

If you miss a dose

• Tablet or capsule: take it when you remember the same day. If it’s already the next day, skip it. Don’t double up.
• Patch: put on a new one as soon as you remember, then go back to your usual days.

When you’ll notice a difference

Common side effects

Most common in the first 1–3 months and usually settle:

• Breast tenderness
• Bloating
• Headache or nausea
• Spotting or irregular bleeding
• Skin irritation under a patch

When to get help

Call 911 for: chest pain, sudden shortness of breath, or sudden weakness, numbness, facial droop, trouble speaking, or vision loss.

Go to the emergency department the same day for: pain, swelling, or warmth in one leg, or a sudden severe headache.

Message us in the portal for:

• Bleeding heavier than a period, or spotting that continues past 6 months
• A new breast lump
• Side effects that don’t settle after 2–3 months

Tips

• Take your tablet at the same time each day. Bijuva works best taken with an evening meal.
• If you take Angeliq and a blood pressure medication, we may check your potassium.
• Keep up with your yearly mammogram.

Handout 04 · The Next Chapter Clinic

Vaginal Estrogen and Vaginal Health

Low-dose vaginal estrogen treats dryness, burning, painful sex, and frequent urinary symptoms caused by low estrogen. This is called genitourinary syndrome of menopause (GSM). It works locally, so very little reaches the rest of your body.

What it can help with

• Vaginal dryness, burning, or itching
• Pain or discomfort with sex
• Needing to urinate often or urgently
• Repeated urinary tract infections

Unlike hot flashes, these symptoms usually don’t go away on their own. They tend to get worse over time without treatment. Vaginal estrogen is safe to use long term.

Your options

Tips for using cream

• A small amount of cream can also be rubbed on the vulva (outer area) for burning or irritation.
• Use it at bedtime so it stays in place.
• Pick the same days each week, such as Monday and Thursday.

If you miss a dose

Use it the next night, then go back to your usual days. Don’t double up.

When you’ll notice a difference

Keep using it even after you feel better, because symptoms return if you stop.

Common side effects

• Mild vaginal irritation or discharge at first
• Light spotting (uncommon)
• Breast tenderness (rare at these low doses)

Do I need progesterone?

No. At these low doses, vaginal estrogen doesn’t need progesterone, even if you have your uterus.

What about breast cancer?

Vaginal estrogen at these doses has not been shown to raise breast cancer risk. If you’ve had breast cancer, we’ll talk with your oncologist before you start.

When to get help

Message us in the portal for:

• Any vaginal bleeding after menopause
• Symptoms that haven’t improved after 3 months
• Itching, sores, or skin changes on the vulva
• Burning with urination plus fever or back pain (this could be a kidney infection, so seek care the same day)

Handout 05 · The Next Chapter Clinic

Veozah (Fezolinetant)

Veozah is a non-hormonal pill for moderate to severe hot flashes and night sweats. It works on the brain’s temperature-control center, which becomes overactive when estrogen drops.

What it can help with

• Hot flashes and night sweats
• Sleep that is broken by night sweats

Veozah does not treat vaginal dryness or protect your bones the way estrogen does.

How to take it

• 1 tablet once a day, at about the same time each day
• With or without food
• Swallow whole with water; don’t crush or chew
• Missed dose: take it as soon as you remember the same day. If it’s already the next day, skip it. Don’t take two in one day.

Liver blood tests are required

In rare cases, Veozah can cause serious liver injury. To catch problems early, you need blood tests:

• Before you start
• Every month for the first 3 months
• At 6 months and 9 months

We’ll send the lab orders and remind you. If tests are not done on time, we can’t send your refill.

When you’ll notice a difference

Many women notice fewer hot flashes within the first week. The full effect usually shows by 4–12 weeks.

Common side effects

• Stomach pain or diarrhea
• Trouble sleeping
• Back pain

Medicines to check first

Some medicines change how your body clears Veozah and can’t be taken with it. Tell us and your pharmacist before starting any new medicine, including antibiotics, acid reducers, and antidepressants.

When to get help

Stop Veozah and message us right away, and get your labs within 1 business day, if you notice:

• Yellow skin or eyes
• Dark urine or pale stools
• Itching all over
• Unusual tiredness, nausea, or loss of appetite

Go to the emergency department the same day for pain in the upper right side of your belly with fever or yellow skin.

Handout 06 · The Next Chapter Clinic

Lynkuet (Elinzanetant)

Lynkuet is a non-hormonal capsule for moderate to severe hot flashes and night sweats. It calms the brain’s temperature-control center, and many women find it also helps them sleep.

What it can help with

• Hot flashes and night sweats
• Sleep that is broken by night sweats

Lynkuet does not treat vaginal dryness or protect your bones the way estrogen does.

How to take it

• Take both capsules together once a day at bedtime
• With or without food
• Swallow whole with water
• Missed dose: skip it and take your next dose at bedtime the following night. Don’t double up.

Before you start

• We check a liver blood test before you begin.
• If there’s any chance you could become pregnant, you need reliable birth control while taking Lynkuet and for 2 weeks after stopping.

When you’ll notice a difference

Many women notice fewer hot flashes and better sleep within the first 1–2 weeks. The full effect usually shows by 12 weeks.

Common side effects

• Sleepiness or tiredness, which is why it’s taken at bedtime
• Headache
• Dizziness
• Diarrhea or stomach upset

Don’t drive or do anything that needs you to be alert until you know how Lynkuet affects you.

Foods and medicines to avoid

• Grapefruit and grapefruit juice can raise the level of Lynkuet in your blood.
• Some antibiotics, antifungals, seizure medicines, and St. John’s wort change how your body clears Lynkuet. Tell us and your pharmacist before starting any new medicine or supplement.
• Alcohol and sleep aids can add to the drowsiness.

When to get help

Stop Lynkuet and message us right away if you notice:

• Yellow skin or eyes, dark urine, or pale stools
• Unusual tiredness with nausea or loss of appetite
• A positive pregnancy test

Go to the emergency department the same day for pain in the upper right side of your belly with fever or yellow skin.

Handout 07 · The Next Chapter Clinic

SSRIs and SNRIs for Hot Flashes and Mood

These medicines are best known for treating depression and anxiety, but at low doses they also reduce hot flashes. They’re a good choice if you can’t or prefer not to use hormones, or if you want help with mood and hot flashes at the same time.

What it can help with

• Hot flashes and night sweats (usually a 50–65% reduction)
• Low mood, irritability, and anxiety

Your options

How to take it

• Take it at the same time every day, with or without food.
• If it upsets your stomach, take it with food. If it makes you sleepy, take it at bedtime; if it keeps you awake, take it in the morning.
• Missed dose: take it when you remember the same day. If it’s almost time for the next dose, skip it. Don’t double up.
• Don’t stop suddenly. Stopping abruptly can cause dizziness, irritability, flu-like feelings, and “brain zaps.” We’ll taper the dose if you want to stop.

When you’ll notice a difference

Common side effects

Most improve within the first 2 weeks:

• Nausea or upset stomach
• Headache
• Trouble sleeping or feeling sleepy
• Dry mouth
• Lower sex drive or trouble reaching orgasm (tell us, because this can often be managed)

Medicines to check first

Tell us and your pharmacist about all your medicines, including over-the-counter and supplements. Some can interact, including tramadol, triptans for migraine, St. John’s wort, other antidepressants, blood thinners, and tamoxifen.

When to get help

Call or text 988, or call 911 if you are in danger, if you have:

• Thoughts of suicide or harming yourself

Antidepressants can rarely cause new or worsening thoughts of suicide, especially in the first weeks or after a dose change.

Go to the emergency department for:

• High fever, agitation, confusion, fast heartbeat, muscle twitching or stiffness, or heavy sweating (signs of serotonin syndrome)

Message us in the portal for:

• Side effects that don’t settle after 2 weeks
• Mood getting worse, or new restlessness
• Easy bruising or unusual bleeding

Handout 08 · The Next Chapter Clinic

Gabapentin for Hot Flashes and Sleep

Gabapentin is a non-hormonal medicine that reduces hot flashes and night sweats. Because it causes drowsiness, it’s especially helpful if night sweats are waking you up.

What it can help with

• Night sweats and hot flashes
• Falling and staying asleep

How to take it

• Most women start with a low dose at bedtime and increase slowly over 1–2 weeks to reduce dizziness. Follow the schedule above.
• With or without food.
• Missed dose: take it when you remember, unless it’s almost time for the next dose. Don’t double up.
• Don’t stop suddenly after taking it regularly. We’ll lower the dose over about a week.

When you’ll notice a difference

Sleep often improves within the first few nights. Hot flashes usually improve over 2–4 weeks as you reach your full dose.

Common side effects

Most are strongest in the first 1–2 weeks:

• Drowsiness
• Dizziness or unsteadiness
• Swelling in the feet or ankles
• Weight gain (in some women)

Don’t drive or do anything that needs you to be alert until you know how it affects you.

Safety

• Avoid alcohol, because it adds to the drowsiness.
• Don’t combine with opioid pain medicines, benzodiazepines, or sleep aids without talking to us. Together they can slow your breathing.
• Antacids with aluminum or magnesium (Maalox, Mylanta) lower how much gabapentin you absorb, so take gabapentin at least 2 hours after them.

When to get help

Call 911 for slow or shallow breathing, or being very hard to wake up.

Call or text 988 for thoughts of suicide or harming yourself.

Message us in the portal for:

• Dizziness or sleepiness that doesn’t improve after 2 weeks
• New or worsening mood changes
• Swelling that bothers you

Handout 09 · The Next Chapter Clinic

Oxybutynin for Hot Flashes

Oxybutynin is a bladder medicine that, at low doses, also reduces hot flashes and sweating. It’s a non-hormonal option, and it can help if you also have an overactive bladder.

What it can help with

• Hot flashes and sweating
• Urinary urgency and needing to go often

How to take it

• Usually 2.5–5 mg twice a day, or as prescribed.
• With or without food.
• Missed dose: take it when you remember, unless it’s almost time for the next dose. Don’t double up.

When you’ll notice a difference

Hot flashes usually improve within 1–2 weeks. The full effect may take up to 4–6 weeks.

Common side effects

• Dry mouth
• Constipation
• Dry eyes
• Drowsiness or blurry vision
• Trouble emptying your bladder (uncommon)

Sugar-free gum or lozenges, plenty of water, and fiber help with dry mouth and constipation.

Safety

• Oxybutynin can affect memory and thinking, especially in women over 65 or those taking other similar medicines. Tell us if you notice confusion or memory changes.
• It can reduce sweating, so take care in hot weather or during hard exercise to avoid overheating.
• Alcohol can add to drowsiness.

When to get help

Seek care the same day for:

• Unable to urinate
• Eye pain with blurred vision or seeing halos around lights
• Signs of overheating: confusion, very hot dry skin, or feeling faint in the heat

Message us in the portal for:

• Confusion or memory changes
• Constipation that doesn’t improve
• Side effects that don’t settle after 2 weeks

Handout 10 · The Next Chapter Clinic

Testosterone Gel for Women

Women make testosterone too, and levels fall with age and menopause. A small daily dose of testosterone gel can restore it to the normal range for women and may improve low libido and other symptoms.

What it can help with

• Low sex drive, arousal, and satisfaction
• Some women also notice better energy, mood, and sense of well-being

Testosterone for women is prescribed using a product made for men, at about one-tenth of the men’s dose. This is a common and accepted way to prescribe testosterone for women, because no product is FDA-approved for women in the U.S.

How to use it

• Apply your measured dose once a day, at the same time, to clean, dry skin on your forearm, lower abdomen, thigh, or calf. Rotate spots.
• Rub it in and let it dry fully, about 5 minutes. Then cover the area with clothing.
• Wash your hands with soap and water right away.
• Don’t shower, swim, or sweat heavily for 2 hours after applying.
• Missed dose: apply it when you remember the same day. If it’s already the next day, skip it. Don’t double up.

Your supply lasts about 10 months, because one tube holds many of your daily doses. Use it only as directed.

Protect others from contact

Testosterone gel can rub off onto children, partners, and pets through skin contact and cause unwanted effects in them.

• Always cover the area after it dries.
• Wash your hands after every application.
• Wash the skin before close skin-to-skin contact.
• Call us if a child shows early puberty signs (body hair, acne, voice changes) or a partner notices new acne or hair growth.

When you’ll notice a difference

We check a blood level 3–6 weeks after starting to make sure you’re in the normal range for women. If you notice no benefit by 6 months, we’ll stop it.

Possible side effects

Most are mild and go away when the dose is lowered:

• Acne or oily skin
• Increased hair growth where you apply it or on the face

Stop and message us right away if you notice:

• Thinning hair on your scalp
• A deeper or hoarse voice
• Enlargement of the clitoris

Voice changes may not reverse, so let us know promptly.

Controlled medication rules

Testosterone is a controlled substance, so a few rules apply:

• Store it out of reach of children, ideally locked.
• Early refills can’t be given. Tell us right away if your medication is lost or stolen.
• You need a visit at least every 6 months and a blood test at least every 12 months to keep getting refills.
• Don’t share it with anyone. Dispose of unused gel at a pharmacy take-back site.

Other safety notes

• Testosterone must not be used during pregnancy. If there’s any chance you could become pregnant, use reliable birth control.

Handout 11 · The Next Chapter Clinic

GLP-1 Medications (Wegovy and Zepbound)

Wegovy (semaglutide) and Zepbound (tirzepatide) are once-weekly injections that reduce appetite and help your body manage blood sugar. Along with protein-rich eating and strength training, they lead to meaningful, lasting weight loss for most women.

What it can help with

• Weight loss and less “food noise”
• Blood sugar, blood pressure, and cholesterol
• Lower risk of heart attack and stroke (shown for Wegovy in people with heart disease)

How to take it

• Inject once a week on the same day, any time of day, with or without food.
• Inject under the skin of your belly (at least 2 inches from your belly button), thigh, or the back of your upper arm. Use a new spot each week.
• We start at a low dose and increase every 4 weeks to help your body adjust. Don’t increase on your own.

If you miss a dose

If you miss 2 or more weeks in a row, message us before your next dose. You may need to restart at a lower dose.

Storage

• Keep unused pens or vials in the refrigerator. Don’t freeze.
• If needed, Wegovy pens can stay at room temperature up to 28 days; Zepbound pens and vials up to 21 days.

When you’ll notice a difference

On average, women lose about 15% of body weight on Wegovy and about 20% on Zepbound over a year and a half. Results vary.

Common side effects

Most are mild and happen after starting or increasing a dose:

• Nausea
• Constipation or diarrhea
• Heartburn or burping
• Feeling full quickly
• Tiredness
• Hair shedding a few months in, from rapid weight loss (usually temporary)

Tips that help

• Eat smaller meals and stop when you feel satisfied, not full.
• Start each meal with protein. Aim for protein at every meal to protect your muscle.
• Limit greasy, fried, and very sugary foods, which worsen nausea.
• Drink plenty of water and eat fiber to prevent constipation.
• Avoid lying down right after eating.
• Do strength training 2–3 times a week.

Important safety notes

• Birth control: Zepbound can make birth control pills less effective. If you use the pill, switch to another method or add condoms for 4 weeks after starting and after each dose increase.
• Pregnancy: stop at least 2 months before trying to conceive, and tell us right away if you become pregnant.
• Surgery or procedures: tell your surgical team you take a GLP-1. Food can stay in your stomach longer, which matters for anesthesia.
• Diabetes medicines: if you take insulin or a sulfonylurea, your blood sugar can go too low. Know the signs: shaking, sweating, confusion.
• Don’t use if you or a family member has had medullary thyroid cancer or MEN2.

When to get help

Go to the emergency department the same day for:

• Severe pain in the upper belly that may spread to your back, with or without vomiting (possible pancreatitis). Stop the medication.
• Pain in the upper right belly with fever or yellow skin or eyes (possible gallbladder problem)
• Vomiting for more than 24 hours, unable to keep fluids down, or very little urine
• Swelling of the face, lips, or throat, or trouble breathing (call 911)

Message us in the portal for:

• Nausea or constipation that keeps you from eating or drinking normally
• A lump or swelling in your neck, trouble swallowing, or a hoarse voice
• Low mood or thoughts of harming yourself (for a crisis, call or text 988)

Handout 12 · The Next Chapter Clinic

Compounded GLP-1 Medication

You chose a compounded form of semaglutide or tirzepatide, made by a licensed compounding pharmacy and drawn up from a vial with a syringe. It works the same way as the brand-name medicine. Because you measure each dose yourself, getting the amount right is the most important part.

Your dosing schedule

Your dose is measured in units on a U-100 insulin syringe. When drawing up your dose, always use the number of units on the dosing schedule we give you, not the number of mg.

If your new vial has a different strength than your last one, the number of units changes. Check the label every time, and message us before injecting if the strength doesn’t match your dosing schedule.

How to draw up and inject your dose

1. Wash your hands. Wipe the vial’s rubber top with an alcohol swab.
2. Pull the syringe plunger back to the number of units you need, to fill it with air.
3. Push the needle through the rubber top and inject the air into the vial.
4. Turn the vial upside down and slowly pull the plunger back to your exact number of units.
5. Tap out any air bubbles and adjust to the exact line.
6. Clean your injection spot (belly, 2 inches from your belly button; thigh; or back of the upper arm) and let it dry.
7. Pinch the skin, insert the needle straight in, and push the plunger slowly all the way down.
8. Put the used syringe in a sharps container. Never reuse a syringe.

Storage

• Follow the storage directions on your pharmacy label. Most compounded vials are kept in the refrigerator.
• Note the date you opened the vial, and don’t use it past the beyond-use date on the label.
• Don’t use it if the liquid looks cloudy, discolored, or has particles.

What you should know about compounded medicines

• Compounded medicines are not FDA-approved. The FDA does not review them for safety, effectiveness, or quality before they are sold.
• They’re made by a state-licensed pharmacy for you specifically, based on your prescription.
• Your formula also contains vitamin B6 or B12 as an added ingredient.

If you miss a dose

If it’s been 4 days or less, take it now. If it’s been more than 4 days, skip it and take your next dose on your usual day. If you miss 2 or more weeks in a row, message us before your next dose.

Side effects and safety

Side effects, timing of results, and warning signs are the same as for the brand-name medicines. See the GLP-1 Medications handout in your packet.

Go to the emergency department or call us if you think you took too much, especially if you have severe nausea, vomiting, dizziness, or can’t keep fluids down.

Handout 13 · The Next Chapter Clinic

Minoxidil for Hair Loss

Minoxidil lengthens the growth phase of your hair and is the most proven treatment for female pattern hair loss. It comes as a foam or liquid you apply to your scalp, or as a low-dose pill.

What it can help with

• Slowing hair loss
• Thicker, fuller hair over time, especially along the part and crown

How to use it

Topical (Women’s Rogaine and generics)

• 5% foam: apply half a capful once a day to a dry scalp, along the thinning areas.
• 2% solution: apply 1 mL twice a day to a dry scalp.
• Massage it in and let it dry fully before styling or lying down. Wash your hands afterward.
• Wait at least 4 hours before washing your hair or swimming.
• Hold off for 24 hours before and after hair coloring or chemical treatments.

Oral (low-dose tablet)

• Take your tablet once a day at about the same time, with or without food.
• Your tablet may need to be cut in half or quarters. A pill cutter from the pharmacy makes this easy.
• Missed dose: take it when you remember the same day. If it’s the next day, skip it. Don’t double up.

When you’ll notice a difference

Keep going for at least 6 months before judging results. If you stop, the hair you gained will gradually shed within a few months.

Common side effects

Topical:

• Scalp itching, dryness, or flaking (the foam is usually gentler than the solution)
• Unwanted hair on the forehead or face if the product drips, so apply carefully

Oral:

• Unwanted hair growth on the face or body (about 1 in 5 women; reverses if the dose is lowered)
• Mild ankle swelling
• Feeling your heart beat faster, or lightheadedness when standing up

Keep pets safe

Topical minoxidil is highly toxic to pets, especially cats, even in tiny amounts. Don’t let pets lick your scalp, hands, pillow, or bedding, and store it out of their reach.

When to get help

Call 911 for chest pain, fainting, or trouble breathing.

Message us in the portal for:

• Swelling in your feet or legs that doesn’t go away, or sudden weight gain
• A racing or pounding heartbeat
• Dizziness or lightheadedness
• Unwanted hair growth that bothers you

Handout 14 · The Next Chapter Clinic

Spironolactone

Spironolactone blocks the effects of androgens (hormones like testosterone) on your hair follicles and skin. It’s used for female pattern hair loss, adult acne, and unwanted facial hair, and it pairs well with minoxidil.

What it can help with

• Slowing hair thinning and supporting regrowth
• Adult acne
• Unwanted facial or body hair
• Reducing ankle swelling from oral minoxidil

How to take it

• Take it once a day (or split into two doses if prescribed), with food to avoid stomach upset.
• Take it in the morning if it makes you urinate more.
• We usually start at 50 mg and increase every 4–8 weeks to your goal dose.
• Missed dose: take it when you remember the same day. If it’s the next day, skip it. Don’t double up.

Blood tests

Spironolactone can raise potassium. We check a blood test before you start, and may recheck 2–4 weeks after a dose increase, especially if you’re over 45 or take blood pressure medicines.

When you’ll notice a difference

Common side effects

• Urinating more often
• Dizziness or lightheadedness when standing, so stand up slowly
• Breast tenderness
• Irregular spotting or period changes (if you still have periods)
• Tiredness

Important safety notes

• Pregnancy: spironolactone can harm a developing baby. If there’s any chance you could become pregnant, use reliable birth control.
• Potassium: avoid potassium supplements and salt substitutes (such as NoSalt or Nu-Salt) unless we approve them.
• Tell us before starting blood pressure medicines (especially ACE inhibitors or ARBs), NSAIDs taken daily (ibuprofen, naproxen), or birth control with drospirenone (Yaz, Slynd).
• Stay hydrated. If you have vomiting or diarrhea and can’t keep fluids down, skip your dose that day.

When to get help

Go to the emergency department for:

• Muscle weakness, an irregular or very slow heartbeat, or tingling (possible high potassium)
• Fainting

Message us in the portal for:

• Ongoing dizziness
• Spotting or bleeding that bothers you
• A positive pregnancy test (stop taking it)

Handout 15 · The Next Chapter Clinic

Finasteride for Hair Loss

Finasteride lowers DHT, the form of testosterone that shrinks hair follicles. For women after menopause, it can slow thinning and improve hair density, especially combined with minoxidil.

What it can help with

• Slowing female pattern hair loss
• Thicker hair along the part and crown over time

Finasteride is FDA-approved for men’s hair loss and used off-label for women. It’s prescribed for women who are past menopause or who can’t become pregnant.

How to take it

• 1 tablet once a day, with or without food, at about the same time each day.
• Missed dose: skip it and take your next dose as usual. Don’t double up.

When you’ll notice a difference

If you stop, any improvement gradually reverses over the following months.

Possible side effects

Most women have few side effects. Some notice:

• Lower sex drive
• Low mood
• Breast tenderness
• Headache

Important safety notes

• Pregnancy: finasteride can cause birth defects in a male baby. It must never be taken, or even handled as a crushed or broken tablet, by anyone who is or could become pregnant.
• Mood: depression and, rarely, thoughts of suicide have been reported. Tell us right away about any change in mood.
• Don’t donate blood while taking finasteride or for 1 month after stopping.

When to get help

Call or text 988, or call 911 if you are in danger, for thoughts of suicide or harming yourself.

Message us in the portal for:

• Low mood, anxiety, or loss of interest in things you enjoy
• Changes in sex drive that bother you
• A breast lump or nipple discharge

Handout 16 · The Next Chapter Clinic

Nutrition and Protein in Midlife

As estrogen falls, your body loses muscle more easily, stores more fat around the middle, and becomes less sensitive to insulin. Eating enough protein and fiber, and limiting alcohol, are the changes that make the biggest difference.

Protein: the foundation

Protein protects your muscle, bones, hair, and metabolism, and it keeps you full longer.

• Spread it out: aim for 25–40 grams at each meal, since your body uses protein best in smaller amounts through the day.
• Start each meal with your protein.
• If you have kidney disease, check with us before increasing protein.

Fiber: for gut health, blood sugar, and cholesterol

• Fill half your plate with vegetables.
• Choose beans, lentils, berries, oats, chia or flax seeds, and whole grains.
• Increase fiber slowly and drink more water to avoid bloating.

Build a balanced plate

• ¼ plate: protein
• ½ plate: vegetables and fruit
• ¼ plate: whole grains or starchy vegetables
• Plus: a small amount of healthy fat (olive oil, avocado, nuts, seeds)

A Mediterranean-style eating pattern (fish, olive oil, vegetables, beans, nuts, and whole grains) has the strongest evidence for heart and brain health.

Alcohol

• Alcohol can trigger hot flashes, disrupt sleep, and raise breast cancer risk.
• Less is better. If you drink, keep it to no more than 1 drink a day, and have several alcohol-free days each week.

If you’re taking a GLP-1 medication

• Eat protein first at every meal. Your smaller appetite makes this even more important to protect your muscle.
• Eat smaller meals and stop when you feel satisfied.
• A protein shake can help on days your appetite is very low.
• Drink plenty of water; dehydration is common.
• Limit greasy and fried foods, which worsen nausea.

Simple swaps

Handout 17 · The Next Chapter Clinic

Strength Training and Bone Health

Women can lose up to 10% of their bone density in the first 5–7 years after menopause, and muscle declines too. Strength training is the single best thing you can do to protect both, along with enough calcium, vitamin D, and protein.

Why it matters

• Strength training builds muscle, which keeps your metabolism up and protects your joints.
• Loading your bones with weight signals them to stay strong.
• Stronger muscles and better balance prevent falls, the main cause of fractures.
• It also improves blood sugar, mood, and sleep.

Getting started

Aim for 2–3 strength sessions a week, working all major muscle groups, plus regular walking or other activity on most days.

How heavy?

• Choose a weight you can lift 8–12 times with good form, where the last 2 reps feel hard.
• When it gets easy, increase the weight a little. Steadily lifting heavier over time is what builds bone.
• Bodyweight and resistance bands count when you’re starting out.

Impact helps bones too

If your joints allow, add short bursts of impact a few times a week, such as brisk walking with a few jogging intervals, stair climbing, or small jumps.

Safety

• Start light and learn good form. A trainer or physical therapist can help, especially at first.
• If you have osteoporosis, avoid deep forward bending and twisting with weight, and ask us about a supervised program.
• Stop if you feel sharp pain, chest pain, or shortness of breath.

Calcium

• Aim for about 1,200 mg a day, mostly from food. Too much from supplements can raise the risk of kidney stones.
• Good sources: milk or fortified plant milk (300 mg per cup), yogurt (300–400 mg per cup), cheese (200 mg per ounce), canned salmon or sardines with bones, tofu made with calcium, leafy greens.
• If you take a supplement to fill the gap, take no more than 500 mg at a time, with food.

Vitamin D

• Helps your body absorb calcium. Most adults need 600–800 IU a day, and more if your level is low.
• We’ll check your level and tell you if you need a supplement.

Bone density testing

• A DXA scan is recommended at age 65, or earlier if you have risk factors such as early menopause, a past fracture, low body weight, smoking, or long-term steroid use.
• Hormone therapy helps prevent bone loss while you take it.

Other ways to protect your bones

• Don’t smoke.
• Limit alcohol.
• Get enough protein.
• Make your home safer: good lighting, no loose rugs, grab bars in the bathroom.

Handout 18 · The Next Chapter Clinic

Sleep and Hot Flash Tips

Sleep problems are one of the most common complaints in perimenopause and menopause, often driven by night sweats, anxiety, or changing hormones. These everyday strategies work alongside any treatment we’ve started.

Cool down hot flashes

• Dress in layers you can take off quickly; choose breathable cotton or moisture-wicking fabrics.
• Keep your bedroom cool, around 65°F (18°C). Use a fan, cooling pillow, or moisture-wicking sheets.
• Keep ice water by your bed and sip at the start of a hot flash.
• Notice your triggers. Common ones include alcohol, spicy food, caffeine, hot drinks, stress, and warm rooms.
• Try paced breathing when a flash starts: breathe in slowly for 5 seconds, out for 5 seconds, for a few minutes.
• Don’t smoke. Smoking makes hot flashes worse.

Approaches with good evidence: cognitive behavioral therapy (CBT) and clinical hypnosis both reduce how much hot flashes bother you. Ask us for a referral or app suggestions.

Skip: black cohosh, soy supplements, and evening primrose oil haven’t been shown to work better than placebo.

Build better sleep

If you can’t fall back asleep

• If you’re awake for more than about 20 minutes, get up and do something calm in dim light, like reading or listening to something quiet. Go back to bed when you feel sleepy.
• Don’t watch the clock. Turn it away from you.
• Keep a notepad by your bed to write down worries.

CBT for insomnia (CBT-I)

CBT-I is the most effective long-term treatment for insomnia, more effective than sleeping pills. It’s available through therapists and digital programs. Ask us for options.

When to tell us

Message us in the portal if:

• You snore loudly, gasp or stop breathing during sleep, or feel very sleepy during the day. These can be signs of sleep apnea, which becomes more common after menopause
• Your legs feel restless or jumpy in the evening
• Poor sleep is affecting your mood, work, or safety
• You’re using sleep aids or alcohol most nights to fall asleep

Handout 19 · The Next Chapter Clinic

Mood, Brain Fog, and Stress

Irritability, anxiety, low mood, and trouble concentrating are common in perimenopause, often before hot flashes start. They’re real, they’re linked to changing hormones and poor sleep, and they’re treatable.

What’s normal

• Mood swings, irritability, or feeling “not like yourself”
• New or worse anxiety, sometimes with a racing heart
• Forgetting words or names, losing your train of thought, trouble focusing
• Feeling overwhelmed by things you used to handle easily

Brain fog in menopause is common and, for most women, improves after the transition. It is not a sign of dementia.

What helps

Everyday brain fog tips

• Write things down using lists, calendars, and phone reminders.
• Do one thing at a time instead of multitasking.
• Keep keys, phone, and glasses in the same place every day.
• Take short breaks during long tasks.
• Keep learning. A new skill, language, or hobby builds brain reserve.

Managing stress

• Breathe: slow breathing (in for 5 seconds, out for 5 seconds) calms your nervous system within minutes.
• Move: a 10-minute walk can reset a stressful day.
• Say no to what you can, and ask for help with the rest.
• Protect downtime: schedule something restful the way you schedule appointments.
• Try mindfulness: free apps and short guided practices can help.

When to reach out

Call or text 988 right away, or call 911 if you are in danger, if you have thoughts of suicide or harming yourself.

Message us in the portal if:

• You feel down, hopeless, or anxious most days for 2 weeks or more
• You’ve lost interest in things you usually enjoy
• Mood changes are affecting your relationships or work
• Memory problems are getting worse, or others have noticed them

You don’t have to wait for your next visit. Depression and anxiety in midlife are common and very treatable.

Handout 20 · The Next Chapter Clinic

Flibanserin (Addyi)

Flibanserin (brand name Addyi) is an FDA-approved daily pill for premenopausal and postmenopausal women with hypoactive sexual desire disorder (HSDD), a persistent lack of sexual desire that causes personal distress. It works on brain chemistry, not hormones, and is taken every night at bedtime.

What it does

• Acts on serotonin and dopamine receptors in the brain to increase sexual desire
• Does not work like Viagra; it does not increase blood flow and does not work in the moment
• Takes 4–8 weeks of daily use before you notice a meaningful difference
• Approved for HSDD, not for low desire caused by relationship issues, medical conditions, or other medications

How to take it

What to expect

• Improvement is gradual; most women who respond notice a difference by 4–8 weeks
• The effect is modest: studies show an increase of roughly 0.5–1 satisfying sexual events per month compared to placebo
• It does not work for everyone; about 10% of women experience meaningful benefit

Common side effects

• Dizziness or lightheadedness (especially if taken during the day or with alcohol)
• Sleepiness or fatigue
• Nausea
• Dry mouth
• Low blood pressure, most likely if alcohol is consumed

Important interactions

• Alcohol: Absolutely avoid. The combination can cause severe low blood pressure and fainting.
• Fluconazole and some antifungals: Can raise flibanserin levels significantly; tell us about any antifungal prescriptions.
• CYP3A4 inhibitors (certain antibiotics, antifungals, some heart medications, grapefruit juice): Can increase flibanserin levels. Review all medications with us before starting.

When to get help

Call 911 for fainting, severe dizziness, or loss of consciousness.

Message us in the portal for:

• Persistent nausea or dizziness that interferes with daily life
• No improvement after 8 weeks
• Any new medications started while on flibanserin

Tips

• Set a bedtime phone reminder; consistency matters.
• Tell your pharmacist and any other prescribers you are on flibanserin before starting new medications.
• Keep alcohol off the table entirely while on this medication, not just on days you take it (it is taken every day).
• HSDD is a real medical condition. Low desire that causes you distress is worth treating.

Handout 21 · The Next Chapter Clinic

Bremelanotide (Vyleesi)

Bremelanotide (brand name Vyleesi) is an FDA-approved injectable medication for premenopausal women with hypoactive sexual desire disorder (HSDD). Unlike flibanserin, it is used on-demand: you inject it about 45 minutes before anticipated sexual activity, not every day.

What it does

• Activates melanocortin receptors in the brain to increase sexual desire
• Used only when needed, not as a daily medication
• Approved for HSDD in premenopausal women; we may also discuss it for postmenopausal patients on a case-by-case basis
• Does not work like Viagra; it works on desire, not physical arousal or blood flow

How to use it

What to expect

• Some women notice increased desire within 45 minutes; the effect can last several hours
• Nausea is the most common side effect and usually peaks about 12 minutes after injection and resolves within an hour
• A temporary increase in blood pressure occurs in most users; it lasts about 12 hours, which is why it is not recommended in women with cardiovascular disease or uncontrolled hypertension
• Not everyone responds; if you do not notice any effect after several attempts, let us know

Common side effects

• Nausea (most common, affects about 40% of users)
• Flushing, warmth, or tingling
• Temporary rise in blood pressure
• Headache
• Injection site bruising or redness
• Transient darkening of the skin on the face, gums, or breasts (focal hyperpigmentation), more common with repeated use

Important considerations

• High blood pressure or cardiovascular disease: Bremelanotide is not recommended. Tell us about any heart or blood pressure history before starting.
• Nausea management: Taking it on an empty stomach may worsen nausea. A light snack beforehand can help.
• Naltrexone: Bremelanotide can reduce the effectiveness of naltrexone (used for opioid or alcohol use disorder). Tell us if you take it.
• Skin changes: Focal hyperpigmentation can be permanent with long-term use. Let us know if you notice darkening patches.

When to get help

Call 911 for severe chest pain, sudden shortness of breath, or a significant spike in blood pressure with symptoms (severe headache, visual changes).

Message us in the portal for:

• Nausea that is unmanageable or persists beyond a couple of hours
• New skin darkening or patches
• No effect after several uses
• Any concerns about blood pressure

Tips

• Practice the auto-injector technique before you need it; the instructions are in the box and we can walk you through it at your visit.
• Keep a light snack handy for before injection if nausea has been a problem.
• Do not use more than one dose per day, even if the first dose did not seem to work.
• Store extras at room temperature; do not refrigerate.
• HSDD is real, and wanting to feel like yourself again, including sexually, is a valid and important part of midlife health.