At the turn of the century, nearly 18 million women in the United States were battling hot flashes, night sweats, and other symptoms of menopause with hormones. But in 2002, the therapy went into a free-fall when a landmark trial suggested treating menopause with estrogen and progesterone increased the risk of breast cancer and cardiovascular disease. The study was shut down early — and a year later, prescriptions had plummeted to nearly half what they had been in 2001.
More than two decades later, menopause experts have come to think about the results of the trial very differently. Newer research points to more benefits than risks for many healthy women under 60 treating menopause symptoms with hormone therapy. But many women who are good fits still aren’t getting treatment. “The pendulum has been slowly — too slowly — swinging back,” said OB-GYN Mike Green, chief medical officer of menopause telehealth company Winona.
Winona is part of a new generation of virtual-first health care companies aiming to give that pendulum a push. In the last five years, more than a dozen telehealth companies have started up to serve women in and approaching menopause, including with hormone therapy.
“Women fall through the cracks,” said internist Lisa Larkin, president-elect of The Menopause Society and founder of concierge women’s health network Ms. Medicine. “That’s why the telemedicine business is booming.”
The most successful startups caught the wave of virtual care adoption set off by the pandemic at the same time menopause has become far more visible as an undertreated health concern. And while these nascent companies haven’t garnered the same beefy investments as broader telehealth offerings, investors are starting to see that menopause is far from a niche market.
“The market is enormous,” said Trish Costello, founder and CEO of venture investing company Portfolia. “There’s a number of research groups that have defined menopause just as hot flashes and hormone replacement and supplements, and they’ll look at it as maybe a $15 to $18 billion market. But when you start looking at all the parts of women’s health that are impacted, you’re getting into what some people consider a $600-plus billion dollar market.”
But women’s health experts harbor some concerns about virtual care for menopause, including its ability to integrate into a patient’s long-term care. “There’s just all these gaps in this potential care that I really worry about,” said Larkin, whose own patients pay in cash and primarily see providers in-person. And the pendulum that’s slowly reintroducing hormone therapy to more women? “It will swing too far,” she said, “because the business model incentivizes writing the prescriptions.”
Since 2002, systemic hormone therapy’s image has been rehabilitated — at least among menopause experts. Some participants in the Women’s Health Initiative trial, which was designed to study the impact of HRT on chronic disease, did show an increased risk of heart attack, stroke, and breast cancer. But after the study was shut down early, and the data examined more closely, experts realized those risks appeared mostly in women who started hormone therapy well after their periods had stopped.
When researchers analyzed the data by age, it was clearer that for younger women — those who were younger than 60 and started therapy fewer than 10 years after menopause onset, “the benefits typically outweigh the risks,” said Stephanie Faubion, medical director for The Menopause Society and director of the Mayo Clinic’s Center for Women’s Health.
Still, few providers understand menopause and are comfortable prescribing hormone therapy today. “Most providers, whatever the specialty — OB-GYN, internal medicine, or family medicine — do not feel comfortable managing menopause,” said Faubion.
These new telehealth companies — with names like Evernow, Alloy, and Midi Health — see virtual care as a force multiplier. “Telehealth at its best is going to amplify access to expert care and to actually understand the nuances of each situation,” said internist Kathleen Jordan, chief medical officer for Midi Health. Some companies also have providers and patients talk by text, making it possible to treat even more people.
That efficiency is critical as founders anticipate more women demanding the care they know they deserve.
“The millennial menopause is obviously going to be different,” said Andrea Berchowitz, co-founder of U.K.-based Vira Health. The oldest millennials have crossed the threshold into their 40s, when women start to experience the symptoms of perimenopause, including sleep problems, vaginal dryness, and hot flashes. Berchowitz expects they will continue to expect more from their providers and employers — just as they have when it comes to fertility and parental support.
Meanwhile, the number of menopause-age women in the workforce is growing, making its symptoms both more visible and more costly to employers. “Instead of menopause happening in the home and behind closed doors, it’s now happening in the workplace,” said Berchowitz. Work led by Faubion recently pegged the annual cost of lost U.S. work time due to menopause symptoms at $1.8 billion.
“I think that the market — or like, the need — is starting to be understood,” said Alloy co-founder Monica Molenaar.
For entrepreneurs, meeting that need means balancing the long-deferred benefits of hormone therapy with their potential risk. “It’s something that everyone’s grappling with,” said Alicia Jackson, founder of Evernow, an online menopause care provider that last year raised $28.5 million.
“Medical culture is very, very different from startup culture. And blending those two cultures together … is quite a challenge.”
Alicia Jackson, founder of Evernow
“Medical culture is very, very different from startup culture,” Jackson said. “And blending those two cultures together — one that is incredibly risk-averse, very rule-based, with a bunch of people literally trying to start something that never existed before — is quite a challenge.”
To safely prescribe hormone therapy under current guidelines — typically for bothersome hot flashes and night sweats — providers need to know if a woman has a contraindication like high cardiovascular risk, or a history of breast cancer or other hormone-dependent cancer. “If they’ve got diabetes and they’re obese and they’re hypertensive and hyperlipidemic and their blood pressure is not well controlled, that’s not really a great candidate for hormone therapy,” said Faubion.
So to start, most telehealth companies that will prescribe systemic hormone therapy — which delivers estrogen, with or without progesterone, throughout the body — have potential patients fill out a questionnaire that asks about their medical history. That is used to guide a conversation with a provider, who might rule out hormones as an option. A patient’s history could also help determine which prescription is best — someone at low risk of cardiovascular disease could get the cheaper oral delivery methods, while a person at moderate risk could instead be a fit for transdermal patches or gels, which can be given in lower doses because they are metabolized differently.
Many companies also require that patients provide a recent mammogram or attest to having a clear scan in order to receive a prescription. “This is not an online vending machine for patches and pills,” said Jill Herzig, chief brand officer for Midi Health.
Some providers worry, though, that women seeking care will stumble on online marketplaces that overprescribe hormone therapy — and that some could be harmed as a result. As virtual care platforms proliferate, that problem has emerged in direct-to-consumer telehealth platforms for other conditions, including mental health and obesity.
“My concerns are, do they really take enough time to find out about these women’s past medical histories, their family histories, so they can really assess risk versus benefit,” said Faubion. Allowing patients to self-report their medical history carries the risk of missed information. And not every company will deny treatment in the absence of up-to-date pap smears or mammograms, even if they strongly recommend the screenings. Winona’s Green said he doesn’t feel it’s right to “hold their hormone replacement therapy hostage to checking this box.”
Others, including Larkin, worry that there’s no way to keep financial incentives from coloring prescribing behaviors when they’re tied to a telehealth company’s limited formulary, especially when it may make money by selling its own compounded medications.
Given those complexities, some think that telehealth isn’t a good fit for systemic hormone therapy at all. “My point of view is that that’s not a good use of telemedicine when there is a higher risk medication that’s being offered,” said May Allen, co-founder and CEO of Interlude.
Allen and her co-founder decamped from Evernow in late 2021 to start their company, which offers scripts only for low-dose vaginal estrogen, which is used to treat menopause’s genitourinary symptoms, including vaginal dryness, itching, and urinary urgency. “From the telehealth standpoint, beginning with the topicals was definitely considered the safest,” said urologist Ashley Winter, chief medical officer for Odela, another company that sticks to vaginal treatments.
Their competitors say it’s very possible to support safe prescribing of systemic hormone replacement therapy over the internet — and that it’s critical to keep refining those processes.
“Is my top worry overprescription of hormone therapy? No,” said Evernow’s Jackson. “I still think the top worry by far is there are so many women who aren’t on hormone therapy and aren’t getting the long-term benefits of it.”
To move forward, companies will need to do the hard work of integrating virtual hormone therapy prescriptions with necessary in-person and long-term care.
“If you’re going to be providing through a telehealth environment something with risk, and if you yourself don’t have a brick-and-mortar option, then have community health care provider relationships,” said Winter. “Then when you do recommend that somebody has their mammogram, you have partnerships to make sure that your patients are doing the things that they need to do to undergo your treatment with a safety net.”
Larkin believes that telehealth has an important place in women’s midlife care, but said that trying to access her patients’ records from some telemedicine platforms prescribing hormone therapy has proven “a black hole.”
“The problem that I see with many of these standalone companies is that they’re piecemeal visits,” she said, with no process to connect patients to in-person local care.
“It’s really not coordinated in any way, shape, or form,” said Faubion. “So I think it’s still a little bit the wild west. We still don’t know what the overall impact on women is or will be.”
With the right guardrails, though, telehealth leaders think their platforms can help drive not just more care for women going through menopause, but better care.
“A good telehealth company will be amplifying this expert care through protocols, through clinical education, through patient education tools,” said Midi’s Jordan. “Telehealth can really elevate the care experience, plus make it accessible.”
Larkin acknowledged that her own business model, a cash-pay, concierge network, is no way to solve the access problem. “Look, we wish every woman could have her own concierge physician that she could call up every single day, who also has seen 100,000 patients in their lifetime and has all that knowledge,” said Jackson. “Unfortunately, we don’t live in that world.”
For now, every women’s health provider can agree there’s a need for better solutions, as long as women in the United States still live in a menopause management vacuum.