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Becoming ill while traveling is an unfortunate but common event, with gastrointestinal, febrile, dermatologic, and respiratory symptoms predominating. However, many illnesses acquired abroad can be prevented or controlled with evidence-based preventive measures and judicious use of appropriate self-care and local medical care. It is important that travelers know how to use international medical care and are aware of available tools to help them identify appropriate medical care in another country. Discussion of evacuation insurance is a crucial part of the pretravel medical evaluation. Epidemiology, prevention, and management guidelines of common travel-related illnesses, such as travelers diarrhea and febrile illnesses, should be addressed. Traveler counseling regarding the early management of serious but underrecognized considerations, such as accident-related trauma, sexual health, and mental health, should be included in the pretravel assessment. Important aspects of appropriate counseling and management of the traveler returning from an extended visit abroad include addressing reverse culture shock and evaluating symptoms that could be part of a delayed presentation of an illness acquired abroad.

Risks during travel depend on travelers' comorbidities and trip activities. Travel on cruise ships, for pilgrimages or large events, or into the wilderness carries unique risks. Asking travelers about what activities they have planned or may do during travel can tailor the subsequent pretravel counseling points and help guide decisions about vaccines and drugs. Some prescriptions (eg, doxycycline for prophylaxis against leptospirosis) depend on the planned activities while abroad. Travelers should be prepared for potential emergencies and should be encouraged to research unique customs and laws in the countries they plan to visit before departure. The US State Department's website has resources that Americans traveling abroad should be familiar with, including information about the laws and customs of the destination country. It is important that travelers investigate the different insurance options or coverages before a trip, in case emergencies arise.

Before the COVID-19 pandemic, international travel was increasing at a brisk rate. After a lull, it is picking up again and predicted to continue to climb as it had previously. International travel presents some unique health hazards, including infectious diseases, chronic disease exacerbation, environment-related illness, accidental injuries, and transportation-related illness. Many travelers appropriately seek medical consultation for advice and interventions to decrease their health risks during travel. The pretravel consultation consists of risk identification and preventive interventions. Although these consultations traditionally have occurred with infectious disease specialists, family physicians can and should provide this care. Pretravel consultations should review a patient's medical conditions, how travel can affect them, and what the patient can do to address medical needs that may arise while abroad. Balancing the risks likely to be encountered with the individual traveler's risk tolerance, patients and family physicians can collaboratively develop a strategy to mitigate these risks and increase the likelihood of an uneventful (and enjoyable) sojourn.

Certain conditions (eg, asthma, diabetes, physical disability, immunocompromise, severe allergies, pregnancy) may increase the risk of travel, but do not necessarily preclude it. Typical age-related physiologic changes also can increase the chances of serious injury or illness. For example, infection with malaria can result in more severe parasitemia in HIV-positive, pregnant, or older travelers. Physicians should evaluate each traveler as an individual, assessing risk tolerance and helping patients decide if the benefits outweigh the definite and potential costs. Extremes of climate and altitude, changes in time zones, and unfamiliar foodstuffs should be given particular attention. The well-prepared traveler should explore options for supplemental insurance, obtain necessary medical records and supplies (including their regular drugs and an appropriate first aid kit), receive education on how to recognize and what to do in the event of a medical emergency, and understand where to find high-quality care abroad.

The marked decrease in estrogen levels in menopausal women can cause bothersome symptoms that affect daily life. More than 75% of women experience menopausal symptoms, which can include vaginal dryness, itching, discharge, dyspareunia, mood changes, hot flushes, and night sweats. Menopausal hormone therapy (MHT) is the most effective treatment for vasomotor symptoms. Benefits include decreased risk of osteoporotic fractures and vaginal atrophy, improved glycemic control, and decreased vasomotor symptoms. However, recent research on risks associated with MHT has shown increased risk of venous thromboembolism and breast cancer. MHT typically is an option for patients younger than 60 years or within 10 years of menopause onset with bothersome vasomotor symptoms. The decision to start MHT should be made on an individual basis after a thorough evaluation and counseling. Oral, intramuscular, transdermal, and intravaginal formulations are available. The goal of therapy is use of the lowest dose for the shortest time that effectively manages symptoms. The patient and physician should regularly assess the risks and benefits associated with MHT and ensure that the benefits of its use continue to outweigh the risks.

Approximately 0.6% of adults (1 to 1.4 million adults) in the United States identify as transgender, and 2% of high school-aged individuals (150,000 to 300,000 individuals). Gender-affirming care for transgender and gender- diverse patients can include support with social transition or physical presentation, legal steps, and medical treatments (eg, hormone therapy) and surgeries. Adolescent and adult patients who request gender-affirming hormone therapy must meet several criteria. One is confirmed persistence of gender dysphoria or gender incongruence. Also, the patient must have reached the age of legal medical consent and be able to consent to therapy. For adolescent patients who are minors, meeting of additional criteria is recommended. In eligible adolescent patients, gender-affirming hormone therapy consists of two phases, pubertal suppression and then feminizing or masculinizing hormone therapy. Before puberty, hormone therapy is not recommended. When puberty begins, patients can receive a gonadotropin-releasing hormone agonist to suppress puberty (ie, puberty blocker). Feminizing or masculinizing hormone therapy, which usually is initiated at age 16 years, consists of estradiol or testosterone, respectively. For adult patients requesting gender-affirming hormone therapy, a thorough evaluation should be performed to assess for contraindications and conditions that may increase therapy-associated risks. Feminizing hormone therapy includes estrogen and an antiandrogen, and masculinizing therapy consists of testosterone. These patients should undergo regular monitoring. Cancer screening is based on risk factors, organ inventory, and screening guidelines.

Testosterone levels decrease as men age. When the testes fail to produce an adequate level of endogenous testosterone, men develop hypogonadism. Although the definition of a low testosterone level varies among guidelines, a serum total testosterone level of less than 300 to 350 ng/dL on two separate morning blood samples is considered a low level. To receive exogenous testosterone replacement therapy (TRT), patients should meet criteria for hypogonadism, which is defined as a low testosterone level and signs or symptoms of hypogonadism. Management discussions should be individualized to address patient needs and goals. Counseling before therapy should include shared decision-making regarding risks, benefits, and expectations. Numerous testosterone formulations are available, ranging from topical gels to intramuscular injections. The choice of formulation depends on factors such as cost and patient preference. Use of TRT is limited by contraindications, adverse effects, and a lack of long-term safety data. Patients receiving this therapy require close monitoring. For patients who wish to avoid use of exogenous hormones, are not candidates for TRT, or are unable to tolerate its adverse effects, several nonhormonal pharmacotherapies are available.

Given their association with aging, growth hormone (GH), dehydroepiandrosterone (DHEA), and melatonin (N-acetyl-5-methoxytryptamine) have been evaluated as potential antiaging treatments. It has been hypothesized that declining endocrine function, specifically the decreases in hormone production and secretion seen with aging, plays a role in development of frailty. This physiologic decrease in hormone levels differs from a pathologic decrease due to a condition or disease. However, the signs and symptoms can be similar. Hormone replacement therapy is a well-established treatment for many conditions, but its role in the healthy aging process remains unclear. Off-label use of these hormones has shown some short-term benefits, such as improved body composition, mood, neurocognition, and sexual function and decreased oxidative stress. However, there are no recommendations for routine measurement of these hormone levels or for hormone replacement therapy because of a lack of high-quality evidence. Long-term studies are needed to evaluate the efficacy and safety of GH, DHEA, and melatonin if they are to be used as antiaging therapies.