How Hormones Took Over Your Feed

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1:35in all the years i've made this show i don't think i've ever shown a guest my social media feed it was just too intimate but kate nibs at wired convinced me otherwise i would love i'm very very eager to hear what you are seeing on your instagram kate wrote a story that describes what i am being served every day. She calls it the perimenopause industrial complex. I'm a 50-year-old woman, so this is what I get every day. Where you put your HRT estrogen patch matters. Dr. A, I actually didn't know this. Will you show me where to put my estrogen patch? So first of all, it depends on your... Birth control as HRT for early perimenopause.

2:20That's a separate one. symptoms and why our clinicians are always pushing birth control pills is really unbeknownst to me. I think probably vaginal estrogen minus the applicator. I had two patients today who mentioned that they were probably made by someone that did not have a vagina. The stage before perimenopause that no one is talking about. The hormonal stage right before perimenopause. Don't know who this person is. Early perimenopause often starts very subtly. Your periods may still be coming every month. And so you may have been told everything is normal. Then I got another one. Old me eats one hard boiled egg.

2:54New me knows that one egg has six grams of protein. You want to eat four to five eggs to get 30. This is my whole algorithm. Was that Gaston from Beauty and Beauty? It's just middle-aged women lifting weights, eating protein and talking about hormone. What is going on in my algorithm? It knows too much. It knows too much. I mean, I'm getting the same thing and I'm turning 40 later this year. And one of the reasons why I really wanted to write this story was because I was having all of these conversations with people in my life who are around the same age, a little older and a little younger. Women mostly were seeing a lot of different advertisements and promotional content on Instagram, TikTok, elsewhere on social media.

3:40It's like flooding even my Facebook now. It seemed like something that was exploding on the internet and only going to keep exploding. According to an analysis conducted for Wired, four leading startups in the perimenopause space saw their web traffic spike a whopping 490 % between 2023 and 2026. And this push for hormones as a miracle cure, at least for some people, is fully bipartisan. There is this sort of flank of Maha that sees hormone therapy for perimenopause as cool and good and something we should pursue, while casting a very politicized eye on trans health care and birth control, which again, are using the same substances.

4:29Today on the show, inside the explosive growth of the perimenopause industry. Is it a godsend for people who've long been ignored by doctors? Or more predatory tech preying on our vulnerability? I'm Lizzie O 'Leary, and this is What Next TBD, a show about technology, power, and how the future will be determined. Stick around.

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5:42Based on the rules you set up, of course. Blocking bad actors, welcoming good customers, keeping more of your revenue, your revenue. Learn more about fighting fraud with Stripe at stripe.com slash radar.

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7:06For our non-initiated audience, what is perimenopause? You know, first we should define menopause, which is literally when someone who menstruates ceases to do so. So menopause is actually a brief moment in people's lives. Like it's just that moment when you stop menstruating. And then there's all of these post-menopausal symptoms. And then perimenopause is this much longer period leading up to the cessation of your period. And during perimenopause, your hormone levels, your estrogen levels fluctuate wildly. Yeah, they're on a roller coaster. Yeah, you're on a roller coaster. So, and it can last up to a decade, you know, for most people, it's more of a concentrated period of a few years, but it can start, you know, when you're in your thirties even.

7:58And so it's this period of life that really was ignored for a long time and is often really difficult and people don't know what's happening to them, why they feel the way they feel. And there's this whole huge laundry list of symptoms that can potentially be attributed to perimenopause. Some of them are like classic menopause symptoms. Right. Hot flashes. And you're probably seeing some of this in your Instagram feed. But like some of them can be like being sad, being tired, having brain fog. These things that are kind of very common experiences for most people. But sometimes the cause is perimenopause.

8:38I think one of the things, and I am in numerous group chats about paramenopause, that can be so hard is that they are so kind of diffuse in the way you describe them. Although I think my particular personal favorite was the time I forgot the words for coffee table and told my husband that something was located on the square thing in the living room with the books on it. Like it really does make your brain into Swiss cheese. Yes. There was like, so actually since paramenopause and menopause are having such a moment, there've been like a lot of celebrities talking about it. And I saw Olivia Wilde and Penelope Cruz doing like a junket for the invite.

9:16And they were talking about like shoulder freezing and how that can be. Oh yeah. Frozen shoulder. Yeah. Which I didn't even know. That didn't even. My left shoulder froze. So there's so many, yeah, there's so many different things that can happen to the body that might be because of your hormone fluctuations. So I think to really dig into your story, we actually have to go back a generation to 2002 and this extremely consequential study called the Women's Health Initiative. What did it say? So that study ended up really changing a lot of people's lives for the worse because it instilled a pretty widespread fear that HRT was dangerous for women.

9:59Did we give you cancer, right? Yes. It was a little bit misleading about cancer risks and overestimated cancer risks. And so it kicked off this several decade long period where people who really would have benefited from hormone therapy often weren't prescribed it, didn't even know about it in some cases because of this study. There's this really wonderful article by Susan Dominus in the New York Times Magazine from a few years ago that looked at exactly how this study changed medicine for the worse and sort of asked for a re-examination. And in the past few years, there has been this acknowledgement that the study was flawed.

10:39When would you say things started to really shift?

10:44Kate Knibbs: So Susan Dominus' article was seriously a huge turning point. And when I was writing this piece, I read it a bunch of times because I found it to be like very inspirational. Recently, though, like there's been this huge push because the government removed a black box warning from some of the hormone therapies. Um, the Robert F. Kennedy Jr. and the HHS did this, you know, reappraisal of these therapies and determined that there, because the risks had been overstated, they didn't need these scary black box warnings anymore. And that set off like a second wave of enthusiasm. And while that was happening, I have to talk about GLP ones.

11:32Kate Knibbs: And while this reappraisal of progesterone and estrogen for menopause was going on, the GLP-1 boom happened. And people realized that people just started talking about hormone health and also got really used to getting medicine over the internet from doctors, specifically hormones, GLP-1s. And so there was this sort of cultural shift where people got a lot more comfortable with doing like a quick zoom call or even just filling out a questionnaire and then being sent hormones and taking them at home. And so now we're in this moment where, okay, there's been this reappraisal. Doctors are a lot more enthusiastic about hormone therapy.

12:17There's now this increasingly growing

12:20Kate Knibbs: telehealth infrastructure and doctors and nurse practitioners who are willing to participate in the telehealth infrastructure. And like people are also way more used to just doing a quick zoom phone call, getting meds and taking them. And it's set up this moment where hormones are almost ubiquitous on the internet. I think, you know, I think back to the experiences of people I have heard in my own life. And there's a woman in your piece about like this who went to their traditional provider and said, hey, I think I'd like some hormones because hormones do help, can help with things like brain fog and muscle loss and just feeling a little bit more like yourself.

13:00I mean, that seems to be what the research says. I don't want to overpromise. But often people felt rejected from their providers. And some of that seems like a hangover from that earlier study that we talked about. And some of it just seemed like sexism, just sort of like, well, women have suffered through this and you can too. That feels to me like it really primed people for these telehealth operators that you're talking about.

13:26Kate Knibbs: Yes, totally. There are so I talked to a lot of different specialists in women's health doctors who for years have been talking about the need to treat menopause and paramenopause more seriously. And they all were stressing that just the medical community in general is still playing catch up here. There are a lot of doctors that simply aren't in the know about the potential benefits of hormone therapy. And so a lot of women are feeling extremely validly frustrated with their in-person health care or their like traditional GPs or OBGYNs when they're going and they're really excited about the potential for hormone therapy to help them.

14:09Kate Knibbs: And they're just kind of getting dismissed. And then they go on the Internet and it's really, really easy to get the hormones. So they're feeling this huge disconnect, too. And their algorithm is probably like mine. That's like, go get your hormones, baby. They're like, what the heck? Yeah. Yes. So that is a real ongoing problem. I know that there are big pushes to better educate mainstream doctors. And I think that the medical community is making a good effort to catch up. But it's still a really frustrating experience that a lot of people are having. We'll be back after a quick break.

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16:00Let's talk about these platforms that people are going to online. Who are the big players in this space?

16:08Kate Knibbs: So I heavily focus on MIDI in my story because they're like the first menopause unicorn. It's this company that's really women's health focused. They are definitely a leader in the space. for perimenopause and menopause. There are companies like HIMS and HERS that are obviously not focused on menopause. Like HIMS started out as an ED company. Right. You get Viagra. Yeah. So now they are making a big push into women's health with HERS and they are, you know, a popular place for people to get hormone therapy for perimenopause and menopause. There's like Winona, Alloy. Actually, you or I could go ahead and launch a hormone company now in like shockingly little time.

16:48Kate Knibbs: There are all of these different, yes, there are all these different companies that offer like turnkey telehealth infrastructure. And one of the big categories is hormones. So there's like too many players to list, but MIDI is a big one. Winona, Alloy, EverNow are other big ones. And then like the GLP juggernauts, telehealth juggernauts, like hims and hers are are also making inroads. And then like apart from the companies that are selling hormones, there's also this whole like tech infrastructure where like the aura ring has perimenopause insights. Now I got pitched for a wearable that's specifically devoted to tracking symptoms of perimenopause.

17:33Like there are new entrants in the field every day. How big a market are we talking about here? It's been kind of hard to pinpoint because a lot of times when the markets are discussed, they're just focused on menopause. So I don't have like a really good figure for you about paramenopause, but I mean, women are half the population and everyone that menstruates will go through menopause. So the customer base is pretty big. I'm so interested in the customer base in part because we talk about this stuff more than people did a generation ago. But also, I think that the pressures on people who menstruate and on middle-aged women are different, right?

18:16Like I have a full-time job, a young child, maybe you're taking care of aging parents, whatever it is, that might be very different than someone who was going through perimenopause 25 years ago. And so there seems to me like this sort of perfect storm that has made this such a vast and growing business. I mean, life is really hard for a lot of people. And middle-aged women often have it really tough because, yeah, sometimes we're caretakers to young children. Sometimes we're caretakers to aging parents or both. We often work demanding full-time jobs and we're expected to perform at high, high levels.

18:58And like our culture is also so obsessed with optimization of self and feeling your best. And there has been this whole, um, embrace of like biohacking and the quantified self and, you know, people are wearing aura rings and trying to feel better. And, um, thinking of perimenopause is like something you can hack, I think is becoming increasingly popular and seeing it as like part of, you know, health and wellness and like health span. And people are just, you know, we all want to feel better. And if you learn about perimenopause, it can often be really clarifying to be able to point to a reason why you're feeling so many different lousy ways.

19:48I think like the most, the trickiest part of reporting this story was the fact that perimenopause has so many symptoms and is a like historically ignored life period. And the introduction of all of these startups offering hormones online has made this really essential medicine more accessible to people and that's extremely important. But also now there are some doctors who are concerned that there is almost an overcorrection going on in some ways and then just some, you know, questionable tactics from some of the telehealth companies where they will be over attributing symptoms to perimenopause or they'll be offering like in addition to traditional hormone therapy, they'll be offering like supplements and less proven, you know, treatments for perimenopause.

20:52It's a moment that needs nuance to discuss. And it's like kind of just so wild to watch unfold. I am really curious about that and the sort of regulatory oversight that exists for any of these companies. I mean, you talked to one doctor who described some of these platforms, the asynchronous prescribing ones, as pill vending machines. The MIDI executives are taking great pains to distinguish themselves from some of the other startups that have different approaches. And one of those approaches is asynchronous care. Yeah, some of the places that you can go online to get these hormones, all you have to do is fill out a questionnaire and they'll send them to you.

21:36And in some cases, that's totally fine. Like it's important to say like hormone therapy for perimenopause and menopause tends to be essentially like a much lower dose of birth control. It's the same substances. So it's not this really scary medication that's been understudied. Most people, even if you don't necessarily need it, would probably be fine taking it. But yeah, we are in a situation now where you can just fill out a questionnaire and get it. And there's not like continuation of care with your other providers. There might be something that actually would make you a bad candidate for hormone therapy and a questionnaire isn't going to catch it.

22:13So it has, we are in this world now where people should be approaching the, the like more loosey goosey providers with caution, because sometimes it really is to your benefit to like have a doctor walk you through, um, your, your care and, and which medicines you should take and have a doctor to actually call if you have side effects versus like the 1-800 number that a fly-by-night hormone operator might have running. And the asynchronous care companies are pretty wild because it's not just hormones, like they do peptides now. It's a whole wild west. I want to ask you about the sort of strange bedfellows aspect of this because there is a crossover in the sort of interest in perimenopause between evidence-based clinicians who are, you know, looking at rigorous studies and MAHA.

23:14I'm so curious how you think that Venn diagram came to be. It does seem strange at first, but I don't know if you remember like Suzanne Summers, who's kind of like one of the godmothers of the Maha movement. Her whole thing was bioidentical hormones for like happy midlife and later life. She was a huge proponent of bioidentical hormone therapy. And that is something that a lot of these companies now offer. And she was really dismissed as a quack for a long time by mainstream medical practitioners and like the mainstream medical community. But there always was this idea that bioidentical hormones had their place in medicine and they actually sort of were part of the alternative medicine and wellness worlds for decades before this moment.

24:10So that's where the dovetail is coming in. And it's kind of hard for me to understand how someone could be so enthusiastic about hormone therapy for perimenopause and then also be part of a movement that often like villainizes birth control and trans health care because those are also using these substances, you know, progesterone, estrogen, testosterone. I mean, I am a 50-year-old woman who has an estrogen patch from her OBGYN and I put a testosterone gel on my shoulder because my OBGYN recommended it for me and prescribed it to me. And I think, wait, I am a cis woman and I can get this no problem prescribed by my doctor.

24:54And yet there are tons of trans people seeking care who cannot get that exact same thing. It's so ridiculous. And it's honestly one of the more depressing threads of this story. is that there is now this huge push and awareness of how helpful hormones can be for so many people. And then there's still this villainizing of health care for an already marginalized community. Yeah, it's wild. There are actually some telehealth companies that specifically exist to serve trans people and help them get health care. And for a while, I wanted to go on a whole tangent about that in this piece. But then I was like, that actually deserves its own story.

25:40and um i know that it i was kind of hoping that some of the players in this story would would also be um trying to serve those communities more explicitly but i think um in a lot of cases like they're scared of the culture wars where is all of this going because on the one hand as i've said cards on the table like hormones have been super helpful for me um I feel like myself again. On the other hand, there was something you wrote in this piece that was so interesting that this isn't just about filling one need. This might be about creating like a whole healthcare system that sort of runs parallel to the traditional healthcare system and really just depends on growth.

26:28That seems frightening. Yes. So one of the parallels that I kept coming back to while I was writing the story was how similar MIDI actually was to HIMSS. HIMSS started out as a men's health company with a focus on ED. And now they've expanded to this huge telehealth juggernaut and they're serving all sorts of patients for all sorts of things. And Joanna Strober, who's the CEO and founder of MIDI, has these big ambitions for that company too, to sort of widen the aperture and be not just a menopause and paramenopause company, but a at first a women's health company, but then like, who knows, maybe the whole population.

27:08And so these VC funded startups are trying to be these one-stop telehealth shops and they are pretty successful right now. And as people get increasingly used to getting all of our medication online, I think that they're going to continue finding wider customer bases. And then it, yeah, it's good in some aspects when it comes to some people are like seriously finding really, really life-changing care through these venues that they wouldn't otherwise have access to. But it's like, what is going to happen to our healthcare system when GPs aren't a thing anymore? And we're all just going to different telehealth platforms and doing like this a la carte pick and choosing.

28:02I'm going to get this prescription here, this prescription here. There's no continuity of care. Some of the companies, including most of the biggest telehealth brands, they also do things like they sell supplements. They sell their own branded versions of things. They're not, you know, these they're not non-for-profits. They are trying to sell us things in addition to provide care. And so perimenopause was a good case study in how a segment of the medical sector could be like commercialized and brought online in a way that I think we're going to see way more segments of the medical care system in America be brought online and commercialized.

28:49Kate Nibs, thank you so much for coming on and talking with me. Thanks for having me. Kate Nibbs is a senior writer at Wired. All right, that is our show for today. What Next TBD is produced by Evan Campbell, Madeline Thames-Ducharm, Patrick Fort, and Micah Phillips. Paige Osborne is the senior supervising producer for What Next and What Next TBD. Mia Lobel is the executive producer of podcasts here at Slate, and Ben Richmond is the senior director of podcast operations. I'm Lizzie O 'Leary. You can find me on all the internet platforms where I am at Lizzie O 'Reilly. Thanks so much for listening.

29:26Talk to you soon.

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