Medically reviewed by Mark Strehlow, MD, Medical Director — November 2026
Hormone therapy used to start in a doctor’s office. Today you can also start it online, or at a med spa that offers it alongside cosmetic treatments. From the outside these programs can look alike. Their prices and convenience are easy to compare. The care behind them is harder to see.
This page explains how the main kinds of programs work, how they grew, and what published studies, regulators and medical societies have found about them. It ends with questions worth asking any clinic. We’re a physician-led concierge clinic in Leawood, Kansas, one of the kinds of program described here, so our own answers are in one clearly marked section.
At a glance
- What matters most
- Who evaluates you, and what happens before and after the prescription.
- What guidelines call for
- An evaluation, screening for reasons not to start, a talk about risks, and regular follow-up with labs.
- What studies found
- Online testosterone services vary. In one 2022 study, most offered testosterone to a man with normal levels.
- What regulators say
- Telemedicine care must meet the same standard as in-person care, under Kansas law and national board policy.
- What to do
- Ask any clinic the questions near the end of this page before you start.
Three ways hormone therapy is offered today
Most programs fit one of three models, and many mix features of more than one. These are descriptions of models, not of any particular business.
Physician-led clinics
A physician practice that prescribes hormones as part of its medical care. That includes family medicine, internal medicine, gynecology, urology and endocrinology offices, and clinics that focus on hormones and longevity. Visits happen in the office, by video, or both. Some bill insurance. Concierge practices charge a membership fee, and some of them bill insurance as well (Health Affairs, 2025).
Direct-to-consumer telehealth services
Companies that offer hormone therapy online, usually by subscription. In the one published study that went through these services as a patient would, the steps were an online intake form, a blood test at a commercial lab, and a consultation by phone or video (JAMA Internal Medicine, 2022).
Med spas
Businesses that offer cosmetic treatments, such as injectables and lasers, under a medical director, and increasingly wellness services such as IV therapy and hormone therapy. The American Med Spa Association counted 10,488 med spas in the US in 2023, up from 8,899 a year earlier (AmSpa, 2024).
How this market grew
The concierge model
In a concierge practice, patients pay the practice directly, usually through an annual or monthly membership, and each clinician cares for fewer patients so there’s more time for each one. The model is often traced to a practice founded in Seattle in 1996. By 2004, the Government Accountability Office could find 146 concierge physicians in the country. They reported caring for an average of 491 patients each, down from 2,716 before they switched (GAO, 2005).
The model has grown since. Concierge and direct primary care practice sites grew by 83% from 2018 to 2023, to at least 3,036, and almost all of their physicians practice primary care (Health Affairs, 2025). The American Medical Association’s Code of Medical Ethics accepts these “retainer” practices as one of many models, and notes that they “can also raise ethical concerns about access, quality, and continuity of care.” It asks physicians to “take care not to imply that more or better medical services will be provided under a retainer contract” (AMA, Opinion 11.2.5). We’ve written this page with that in mind.
Menopause hormone therapy since 2002
In 2002, the Women’s Health Initiative stopped its trial of estrogen plus a synthetic progestin early, after the risks were judged to outweigh the benefits (JAMA, 2002). Prescriptions fell fast: in the first half of 2003, prescriptions for the combined product used in the trial were down 66% from a year earlier (JAMA, 2004). Among US women 40 and older, use of hormone pills fell from 22.4% in 1999-2000 to 4.7% in 2009-2010 (Obstetrics & Gynecology, 2012).
Longer follow-up of the same trials added to the picture. After 18 years, the women who had taken hormones had no higher risk of dying from any cause, from cardiovascular disease or from cancer (JAMA, 2017). In 2022, The Menopause Society concluded that for women under 60, or within 10 years of menopause, with no reason to avoid it, the benefits outweigh the risks for bothersome hot flashes and for preventing bone loss (Menopause, 2022). In November 2025, FDA asked the makers of menopausal hormone products to remove boxed-warning language on cardiovascular disease, breast cancer and probable dementia, and in February 2026 it approved the first six revised labels (FDA, 2026). The boxed warning about uterine cancer with estrogen alone remains. These changes apply to FDA-approved products.
Testosterone’s rise, fall and return
Among insured US men 40 and older, testosterone use more than tripled from 2001 to 2011, from 0.81% to 2.91%, and about one in four new users hadn’t had a testosterone level measured in the year before (JAMA Internal Medicine, 2013). Television advertising was linked to more testing and more men starting treatment, including without recent testing (JAMA, 2017). After FDA’s 2014 safety warning and its 2015 label changes, use fell from a peak of 3.20% of insured men 30 and older in 2013 to 1.67% in 2016 (JAMA, 2018).
In 2023, the TRAVERSE trial of 5,246 men with low testosterone and high heart risk found no increase in heart attacks, strokes or cardiovascular deaths with testosterone gel over about 33 months, though atrial fibrillation, acute kidney injury and blood clots in the lungs were more common (New England Journal of Medicine, 2023). FDA removed the cardiovascular boxed-warning language from testosterone labels in February 2025 and added a blood-pressure warning (FDA, 2025). In June 2026 it asked makers to update the labels again, including removing the limitation of use for age-related low testosterone (FDA, 2026).
Use is climbing again. Across 25 states, the number of people dispensed testosterone rose 27% from 2018 to 2022, with the largest increases among younger people, mostly men. In the Midwest states studied, Kansas among them, it fell 7% (PLOS ONE, 2024).
Telehealth after 2020
In March 2020, Medicare began paying for telehealth nationwide (CMS, 2020), and federal rules began allowing clinicians to prescribe controlled substances, testosterone among them, by telemedicine without first seeing the patient in person (Federal Register, 2023). By April 2020, 43.5% of Medicare primary care visits were by telehealth, up from 0.1% in February (ASPE, 2020). No published data yet show how much hormone therapy online services prescribe: the prescription studies above can’t separate online prescribing from office prescribing.
Key dates
| Year | What happened |
|---|---|
| 1996 | The concierge model is often traced to a Seattle practice founded this year (GAO, 2005) |
| 2002 | The Women’s Health Initiative stops its estrogen-plus-progestin trial early, on May 31 (JAMA, 2002) |
| 2003 | The AMA adopts ethics guidance on retainer (concierge) practices (GAO, 2005) |
| 2013 | Testosterone use among insured US men 30 and older peaks at 3.20% (JAMA, 2018) |
| 2015 | FDA requires testosterone label changes and urges caution in using it for low testosterone due to aging (FDA, 2025) |
| 2020 | Clinicians may prescribe controlled substances, including testosterone, by telemedicine without an in-person visit, from March 16 (Federal Register, 2023) |
| 2022 | The Menopause Society’s position statement on hormone therapy (Menopause, 2022) |
| 2023 | The TRAVERSE testosterone trial is published (NEJM, 2023) |
| 2025 | FDA removes the cardiovascular boxed-warning language from testosterone labels (February) and asks makers of menopausal hormone products to revise theirs (November) (FDA) |
| 2026 | FDA approves the first six revised menopausal hormone labels (February; FDA); the state medical boards’ federation issues guidance on med spas and similar practices (May; FSMB); FDA asks for new testosterone label updates (June; FDA) |
| Dec. 31, 2026 | The current federal rule allowing telemedicine prescribing of controlled substances without an in-person visit ends, unless it’s extended or replaced (eCFR) |
What guidelines call for
Medical societies’ guidelines describe the steps of good hormone care. None of them addresses telehealth directly.
Testosterone for men (Endocrine Society, 2018; American Urological Association, 2018, validity confirmed 2024):
- Before starting: symptoms or signs together with consistently low testosterone on morning blood tests, a search for the cause, a hematocrit (a measure of red blood cells) and, in the AUA’s guideline, a PSA test for men over 40.
- Reasons not to start: plans to father a child soon, breast or prostate cancer, a high hematocrit, untreated severe sleep apnea, uncontrolled heart failure, a recent heart attack or stroke, or a blood-clotting disorder, among others.
- After starting: a review at about 3 months, then every 6 to 12 months or yearly, rechecking testosterone and hematocrit. A hematocrit of 54% or higher calls for a change.
Hormone therapy for menopause (The Menopause Society, 2022; ACOG, 2026):
- Before starting: a review of symptoms, age and time since menopause, personal and family history, and the risk of heart disease, breast cancer and blood clots, with the decision made together with the patient.
- Reasons not to start: unexplained vaginal bleeding, breast cancer and some other cancers, heart disease, stroke or blood clots, liver disease, or pregnancy.
- After starting: a review at about 3 months and then yearly. Women who have a uterus take a second hormone with estrogen to protect the uterine lining, and bleeding that continues after the first 6 months is checked.
What studies have found
Online testosterone services
- A secret-shopper study (2022). A researcher posed as a 34-year-old man with low energy and libido who wanted children someday, with normal testosterone levels, and went through seven online services. Six offered him testosterone. One asked about recent heart problems, and one asked about plans for children. Of the six that offered it, five didn’t discuss the risk of too many red blood cells. Consultations were in some cases “guided by nonmedically licensed individuals with unclear oversight.” On the other side, all seven checked a hematocrit before treatment, and all six planned follow-up labs. It was a small study with one script (JAMA Internal Medicine, 2022).
- Not every service is the same. A review of three services’ published processes found them “largely following practice guidelines” (Journal of Sexual Medicine, 2022). A 2024 systematic review found “a varying level of adherence” and very little research (World Journal of Men’s Health, 2024).
- What clinics advertise. Of 253 websites offering testosterone worldwide, 9.9% said they prescribe it for men whose testosterone is normal: 13.7% of US sites and 5.3% elsewhere (Journal of Clinical Endocrinology & Metabolism, 2026). Among 223 men’s health clinic websites in the US, 20.1% didn’t list their providers (Urology, 2023).
- Who studies it. A 2026 review of 103 studies of direct-to-consumer virtual care found that 31.1% reported financial ties to the industry, and that little is known about its effect on quality of care (BMJ Open, 2026).
We found no published study that tested online menopause or women’s hormone services the same way.
Med spas
We found no published study of how med spas prescribe or monitor hormone therapy. Studies of med spas’ cosmetic services find that a physician is usually affiliated but often isn’t there: in Missouri, 94.59% of med spas were affiliated with a physician, and 22.52% had one on site for cosmetic treatments (Dermatologic Surgery, 2025). Nationally, 63% of med spas were owned by people who aren’t physicians or surgeons in 2022 (AmSpa, 2023). An article on the med spa association’s website, written by a compounding pharmacy, tells med spas they can “launch your bioidentical hormone therapy in a month or two,” with a 15-hour course practitioners take at their own pace (AmSpa, 2026).
What the law and regulators say
Telemedicine has to meet the same standard
- Nationally: The Federation of State Medical Boards’ model policy says care by telemedicine “must meet the same standard of care” as care in person, that prescribing based solely on static online questionnaires is “not acceptable,” and that reasons not to treat must be identified before treatment (FSMB, 2022).
- In Kansas: the Telemedicine Act applies the same standards to telemedicine as to in-person care and requires guidance on follow-up care (K.S.A. 40-2,212). The Board of Healing Arts says “There is not a separate standard of care for telemedicine” (KSBHA Policy 21-02). Under the Kansas Pharmacy Act, “A prescription issued solely on the basis of an internet-based questionnaire or consultation without an appropriate prescriber-patient relationship is not a valid prescription order” (K.S.A. 65-1626).
Testosterone is a controlled substance
Testosterone is a Schedule III controlled substance under federal and Kansas law; estrogen and progesterone aren’t (21 CFR 1308.13; K.S.A. 65-4109). Federal law has required at least one in-person medical evaluation before a controlled substance is prescribed over the internet, with some exceptions (21 U.S.C. 829). Temporary rules since 2020 have set that requirement aside for video visits. The current extension runs through December 31, 2026 (Federal Register, 2025), and a final rule creating a special registration for telemedicine has been under review at the Office of Management and Budget since August 2026 (OIRA). If the temporary rule ends with nothing in its place, the DEA and HHS have described the result as “the reinstatement of the pre-pandemic restrictions” (Federal Register, 2025).
Med spas: who owns, prescribes and supervises
- What counts as medicine. In Kansas, the healing arts include treatment for the “enhancement of a condition or appearance” (K.S.A. 65-2802), so cosmetic treatments are medical care in Kansas, just as hormone therapy is.
- Who may own it. In general guidance, not a Board ruling, the Board of Healing Arts’ general counsel advises that “Any business offering medical services can only be owned by a physician, or co-owned by the physician with other specified licensed professionals” (KSBHA).
- Who may prescribe. Since July 1, 2022, Kansas advanced practice registered nurses, such as nurse practitioners, may prescribe on their own, including controlled substances such as testosterone (K.S.A. 65-1130). So whether a physician is involved in your care depends on the clinic.
- Who supervises. A Kansas physician may delegate only what the other person can competently do, within the physician’s own specialty and under the physician’s supervision (K.S.A. 65-28,127). We found no Kansas law or regulation specific to med spas.
- What the medical boards’ federation says. Its 2026 guidance for IV clinics, med spas and similar practices, which names hormone implants among them, says “Standing orders and clinical protocols must not replace individualized clinical evaluation, diagnosis, or medical decision-making,” and “Business or ownership interests must not interfere with medical judgment, and supervising physicians retain ultimate responsibility for delegated care” (FSMB, 2026).
Questions to ask any hormone clinic
These work for any program: a physician practice, an online service or a med spa, including ours.
| Ask | Why it matters |
|---|---|
| Who will evaluate me, and what is their license? | In the 2022 secret-shopper study, some consultations were guided by people without a medical license. One in five men’s health clinic websites didn’t list their providers. |
| Will a physician be involved in my care? | In Kansas, nurse practitioners may prescribe on their own, and med spa studies find physicians are often affiliated but not on site. |
| What do you test before you prescribe, and who goes over the results with me? | Guidelines call for an evaluation and labs before testosterone. Six of seven online services offered it to a man whose levels were normal. |
| What else could be causing my symptoms? | Fatigue, low libido and poor sleep have many causes. Guidelines call for a search for the cause before treatment. |
| Will anyone examine me in person? | An exam can change a diagnosis. For testosterone, federal law requires an in-person evaluation before prescribing over the internet, with limited exceptions; the temporary rule that waives it ends December 31, 2026. |
| What would make hormone therapy wrong for me? | Guidelines list reasons not to start, and the medical boards’ model policy says they must be identified before treatment. One online service in seven asked about recent heart problems. |
| I may want children. How does that change the plan? | Testosterone can lower sperm production. Guidelines advise against it for men planning a child soon. One service in seven asked. |
| What are the risks for me, and how will we watch for them? | Five of six services that offered testosterone didn’t discuss the risk of too many red blood cells, which guidelines say to check. |
| When is my first follow-up, and how often after that? | Guidelines call for a review at about 3 months, then regular reviews with repeat labs. |
| How do I reach someone between visits, and how soon will I hear back? | Kansas law requires guidance on follow-up care with telemedicine, and questions don’t keep to a visit schedule. |
| Who owns the clinic? | Kansas limits ownership of medical businesses to physicians and certain other licensed professionals. Nationally, most med spas are owned by people who aren’t physicians. |
| What does the fee include, and what costs extra? | Programs differ in what’s covered: visits, labs, medicine and messages. Ask for it in writing. |
How we answer these questions
This is our own practice at Rock Creek Wellness in Leawood, Kansas. It’s here so you can hold us to the same questions.
Concierge care, the way we practice it. Dr. Mark Strehlow founded Rock Creek Wellness in 2003 because, in family practice, he never had nearly enough time with his patients. Our hormone care is a membership, HRT-Only or Premier Care, and we don’t bill insurance, so the length of a visit and the tests it calls for are decided by you and the people caring for you. We apply the concierge model to hormone and longevity care. We aren’t a concierge primary care practice: Premier Care includes limited primary care, but it doesn’t replace your primary care physician.
- Who evaluates you: Premier Care patients see Dr. Mark McPhee, Dr. Angela Barnett or Hannah Osborn, APRN, and HRT-Only patients see Hannah Osborn, APRN. All of our providers prescribe hormone therapy. Their training is on our About page.
- Physician involvement: A physician oversees every patient’s care, and our physicians talk through cases with each other. Our team includes on-site physicians.
- Testing before we prescribe: Your first-visit labs are drawn before your first visit: 14 tests for HRT-Only, and about 35 tests covering more than 100 biomarkers for Premier Care. Your provider goes through every result with you, and you keep a copy.
- Looking for the cause: Fatigue, poor sleep and low libido can come from thyroid problems, sleep disorders, medications or stress, so we test before we prescribe. For men, we confirm low testosterone with symptoms and lab testing. Age alone isn’t a reason to start.
- In person: Your first visit is at our clinic, whichever plan you choose. A first Premier Care visit is scheduled for four hours, with an EKG and a DEXA scan. Many follow-up visits can be done by video.
- Reasons not to start: We don’t start hormone care for anyone under 18, anyone with active cancer, or anyone pregnant or breastfeeding. A history of blood clots, stroke or certain cancers gets a careful review first. If hormones aren’t the answer, we’ll tell you.
- Plans for children: Testosterone can lower sperm production and fertility, so tell us if you’re planning a family.
- Risks: Your provider goes over your risks with you before you start, and your follow-up visits watch for them.
- Follow-up: Your first follow-up is about 6 weeks after your first appointment, then every 3 months until your levels are on track, then twice a year with labs. Every clinic visit starts with your vitals, including blood pressure. We check red blood cell counts with blood tests, and PSA for men.
- Between visits: Call us or message us through the patient portal, and you’ll hear back within one business day. If you need an extra visit, it’s covered by your membership.
- Ownership: Rock Creek Wellness is owned by its founder, Dr. Strehlow.
- What it costs: Our membership prices are published on our hormone therapy page. Labs are separate, and medication cost depends on the form you’re prescribed. You can pay with an HSA or FSA card; your plan decides what qualifies.
More about our care: hormone replacement therapy, for women, for men, Premier Care, and the research behind it on our Clinical Evidence page.
About this page
Rock Creek Wellness offers hormone therapy, so we have an interest in this subject. We’ve described kinds of programs, never a particular business, and kept our own practice in the section marked as ours. Every finding links to the study, law or regulator it comes from. This page is educational and isn’t medical advice. Individual results vary.
Rules on this subject are changing. The federal telemedicine prescribing rule above ends December 31, 2026, and FDA is revising hormone labels. We review this page at least every six months and whenever one of these rules changes.
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