Menopause is having a hot moment

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JOANNA STROBER: Well, let’s talk about sex, Bob. Let’s just go there, right? As we age, and estrogen goes down, for about 80 percent of women, sex becomes painful. What happens then? Then women don’t want to have sex anymore. 

Menopause means you have not had your period for a year. Perimenopause is the period of time starting around 35. What I want women to know is at a much younger age, start thinking, ‘If I’m not feeling right, this could be perimenopause, and I should be getting treatment for it.’ Because you don’t have to suffer. Honestly, I think there’s a huge acceptance in society of women’s suffering. The amount of money that’s gone into erectile dysfunction versus the amount of money that has gone into sexual wellness for women is just totally unbalanced. 

SAFIAN: That’s Joanna Strober, CEO of Midi Health, which has raised $100 million to help women with menopause. The topics that Joanna and I discuss in this episode aren’t often explored in business media. But that’s just the point. Discomfort about addressing menopause is both a cultural limitation and a business opportunity. Joanna explains why 2024 has been a hot year for menopause, how historical errors have stopped women from getting treatments that can improve their lives, and why 10% of women have left the workplace as a result. She also shares insights about risks worth taking, embracing controversy, and the biggest mistake founders make when fundraising. There’s a lot to learn, so let’s get to it. I’m Bob Safian and this is Rapid Response.

I’m Bob Safian, and I’m here with Joanna Strober, the CEO of Midi Health. Joanna, thanks for joining us.

STROBER: Thank you. Happy to be here.

Copy LinkThe mistakes behind the 20-year-old hormone therapy study

SAFIAN: So Midi Health is focused on an area that candidly, we don’t discuss much on this show or in society overall, which is menopause. But this year, there’s been like a sequence of headlines, you know, Halle Berry on the steps of the US Capitol to promote a new bill for menopause research. A 20 year old study that scared women and doctors away from hormone drugs for a long time being debunked. Even a New York Times article recently asking If menopause provides a key to longevity, it feels a little strange to say this, but is menopause having a moment?

STROBER: Have you seen my t-shirt? It says ‘menopause is hot.’ And I wear it to the supermarket and the woman at the checkout stand will go, “It is!.” 

SAFIAN: But like, why now? Do you have a sense about why there is, you know, attention being paid to something that maybe attention should have been paid to a long time ago, but finally that there’s some momentum?

STROBER: So a lot of it does have to do with the Women’s Health Initiative study that you initially referenced. When that study came out in 2001, pretty much all research into estrogen and women’s health stopped. That study was just wrong. Not just a little wrong, horribly wrong and horribly misinterpreted. And so you have 20 years of women. who have not gotten the right treatments. You have 20 years where no research happened. So a lot of it, I think, is women kind of angry, saying, “look, like, we’re really suffering here and we deserve better care and it’s time that you start to give it to us.”

SAFIAN: I mean, I remember when that study came out and it was like increased risks everywhere — cancer, heart attack, like it just made it sound like this is just a terrible idea. 

STROBER: The reason we started the company a few years ago was that my co-founders and I read the new information and we said, we want access to this medication. It protects our bones. It protects our brain. It protects our heart. We were earlier than everyone talking about it now. But we read the revised information and realized how wrong the perception was.

SAFIAN: Why was it so wrong? 

STROBER: You know, they had good intentions. They were studying the wrong aged people. So, almost all the women on the study were over 65. They just didn’t interpret the information correctly. And so it actually turns out that women who were within 10 years of menopause and on estrogen actually had a reduced breast cancer risk. And then they looked at the progesterone and they realized that the progesterone was actually causing this. And now we don’t even use that same progesterone anymore. It’s a completely different progesterone that we use. So it was just a confluence of events, the wrong age, the wrong medication, the wrong data. Many people think it’s one of the biggest miscarriages in healthcare in the last 25 years.

SAFIAN: And the revision was like with the same data, just looking at it differently because there hadn’t been any new data collected because no one was using it?

STROBER: That’s right. No, it’s just looking at the data differently. People are very scared of breast cancer. So as soon as there was any indication at all that perhaps this was causing breast cancer, panic and everything stopped.

SAFIAN: Does that mean that studies have to be done all over again to know what’s healthy and what’s not? Like I can imagine, and when I told some friends who are women about having this conversation, they were like, “yeah, but do I know that it’s safe?”

STROBER: There’s no new information needed to understand that the data was misinterpreted. There is data that’s still missing, a lot of it having to do with the preventative aspects of estrogen.

We know that women have 30 percent more cardiovascular issues than men. And there’s some speculation that that’s also connected to estrogen. So now there’s research getting started on that. Can you use estrogen in order to prevent heart issues? For bones? Honestly, it’s just 100 percent established that taking estrogen prevents your bones from weakening. So I have osteopenia. I started on taking the hormones and my bones stopped deteriorating. I have to tell you, I’m never stopping taking my estrogen because as soon as I stop, my bones will start going down again. And we don’t want that.

So, you know, what we’re telling our patients is do everything you can possibly do. to keep your bones strong, whether that means, you know, weightlifting or more protein or weighted vests, but estrogen can be a big part of that too.

Copy LinkMedical issue or cultural issue?

SAFIAN: Menopause has been almost like a taboo subject in some ways. How much of what you’re trying to address is a medical issue versus a cultural issue? 

STROBER: Well, let’s talk about sex, Bob.

SAFIAN: All right. 

STROBER: Let’s just go there, right? When women, as we age, and estrogen goes down, for about 80 percent of women, sex becomes painful. It’s because the vaginal wall becomes thin, and sex starts to hurt. What happens then? Then women don’t want to have sex anymore. It hurts, right? So is that a physical thing or is that a cultural thing? And why is it that when women go to their marriage therapist, the first thing the marriage therapist doesn’t say is, “have you considered estrogen in your vagina? Because if you try estrogen in your vagina, you might actually enjoy sex more and then you don’t have to come talk to us every week about the mismatch in sexual desire.” 

So, I want to like, it is all tied together. You can’t just say, you know, ‘is it just physical?’ ‘Is it just emotional?’ It’s all very connected. Honestly, it’s the same thing if you’re not sleeping because your estrogen is making it so you don’t sleep at night and you’re having hot flashes all night and then you don’t want to have sex. There you go. It’s another reason. So, it is all very tied together and it’s not just about sex, but that’s just one thing that I think about because women have been told just, you know, “it’s okay, your libido goes away.” But that’s actually not the case. It’s just that you need things that can help you along. 

Copy LinkExplaining the lack of menopause specialists

SAFIAN: This has been something that has sort of been misunderstood by cultures for centuries.

STROBER: Well and like one thing that I’ve learned that’s pretty interesting: So as women age, our skin gets thinner and that’s directly related to estrogen. So there were some early studies done that actually show putting estrogen on your face actually thickens your skin and takes wrinkles away. But because dermatologists take care of skin and they don’t learn about hormones and OBGYNs take care of other parts of your body but they don’t think about your face, no one was making this connection and saying well actually you could put the same type of product on your face as you could in your vagina and you can actually help people feel better. So we’re actually making a skin that does that and it works. I mean it absolutely works. The science is there. 

So there are a lot of just things that are not interconnected or seen as interconnected in our bodies because of how medicine is structured, right? Well, you have a skin doctor or you have a breast doctor and they’re not looking at you as a whole body.

SAFIAN: Are there medical specialists, like trained in menopause? Or are you just going to an OBGYN or a gynecologist that’s not sort of specialized in that stage of life?

STROBER: Yeah, so the average OBGYN gets two hours of training of menopause in medical school. When they go to become OBGYNs, they’re learning about babies. That’s their job is to deliver babies. So what we have found is that we have to put together a lot of different specialties in our care to basically do this because we have to include hormone specialists and bone specialists and brain health specialists and cardiovascular health specialists. And they each know a little component of it, and then we put it all together. But there’s not one group of doctors who have been trained in this.

SAFIAN: Part of what you do is recruit and train clinician? Like you are training them about how to engage with menopause?

STROBER: We are. You can’t hire people who are trained. So we have an entire training system that we’ve built out. It’s actually quite extensive. Because they don’t come to us knowing how to do this. 

Copy LinkWhat differentiates Midi Health from competitors

SAFIAN: You said earlier that menopause is hot. You raised $60 million in May as part of a series B round. You’re continuing to talk with big name, strategic investors, as I understand. 

STROBER: We’re very mission-driven at our company, and our goal was really to find investors who were really quite mission aligned. We are a menopause company. We are also a perimenopause company because women don’t even know they’re in menopause and so they start having symptoms around 35 and 40 and they need a place to go. But then, honestly, we’re also a longevity and preventive care company because as I said, women want to stay longer, healthier. And the question is: How can we help them do that as well? 

SAFIAN: There are a slew of virtual options for obtaining supplements and hormone patches and other things that promise relief. So can you describe what makes Midi different?

STROBER: We’re the only one that has national insurance coverage. So most of those other companies make money selling you the patch. Or they make money like a concierge company. We are the only national virtual care company covered by insurance. By the end of this year, 70 percent of all women on commercial payment plans will be covered by Midi. And then next year, we hope to go into Medicare. We are very focused on democratizing access to great care and the way to do that is to have insurance coverage. 

Copy LinkHow Midi Health is expanding its product line

SAFIAN: You’re also expanding into new products, into weight loss treatments like Wegovy and Ozempic and Menjaro, and maybe even testosterone. Can you talk about what you’re exploring and why? 

STROBER: So I joke a lot that our core issues are hormones, weight, and sex. Those are the top three that women are interested in. You can’t take care of one without taking care of the other. So, we saw that 87 percent of the women who came to us, weight was one of their top three concerns. We wanted to make sure they had access to weight loss medications if appropriate. If not appropriate, we also have a whole apothecary of other things that they can take to help their weight if they don’t qualify for the weight loss medications. So, we’ll talk to them about berberine, about metformin, about intermittent fasting. We have a whole weight loss protocol for people who are eligible for the medications and those who are not.

SAFIAN: Weight gain is often something that comes along with menopause, right?

STROBER: It’s incredibly frustrating. Women come to us and they say, “I’m not eating any different, I’m not exercising any different, I’m gaining a lot of weight.” And so, actually, hormones can be a very good solution to that. There is actually evidence that just taking hormones can help you lose weight. There was another study that came out recently that said the best weight loss for women in menopause is combining both hormones and the GLP-1 medications, and then testosterone. I mean, testosterone is really important. 

So every woman has testosterone, not just men. Women have testosterone. It’s been proven that testosterone works to increase libido, but there is emerging evidence, and I want to be careful how I say this, there is emerging literature and evidence that testosterone can be good for our mood, for our bone health… And while testosterone is not FDA approved for women, it is possible to do it in very slow doses and monitor closely and we’re seeing that women are really interested in this and they really feel good on it. So by August we should be in 20 states with testosterone.

SAFIAN: So it’s not an on-label FDA use of the testosterone? Am I understanding that the right way?

STROBER: Exactly. Why they are regulating it the way that they do, but it is not approved for women. Despite the fact that there is research that shows that it absolutely does have proven benefit for increasing your libido. So, we do it in a compounded solution and women are very interested in it. 

SAFIAN: Joanna isn’t shy about calling out inequities — or taking steps to address them, even if that means off-label use of testosterone. That fact that Midi has had to take on training medical professionals about menopause illustrates the gaps in women’s healthcare. It’s also smart business, creating expertise that is in short supply. After the break, Joanna talks about how menopause impacts the workplace, and the biggest lessons she’s learned in fundraising. We’ll be right back. 

[AD BREAK]

Before the break, Midi Health CEO Joanna Strober explained why menopause is having a moment in 2024. Now, she talks about how COVID rules enabled Midi to get off the ground, the overlooked impact of menopause in the workplace. Let’s jump back in. 

Copy LinkJoanna Strober’s personal experiences that led to Midi Health

SAFIAN: Midi is your second start-up, you built a digital service for childhood obesity, Kurbo — spurred by some personal experience in your family, which you sold to Weight Watchers. And Midi was also spawned from personal experiences, I understand. Is that right?

STROBER: Yeah, so Midi initially came out of my co-founder Sharon Mears and I trying to get hormones. We were both experiencing some pretty bad menopause symptoms and we were doing the research and we’re like ‘wow, we really should get the access to these medications’ and we couldn’t get it. I ended up going to my primary care doctor. I said, “look, I’m not sleeping. I’m having anxiety.” They said, “go get a sleep test. You can have some sleep medication once in a while and go to therapy.” And I didn’t need therapy. So I said, “well, what about hormones?” And they said, “well, we don’t prescribe that.” 

So eventually, I went to San Francisco and I paid $750 to go to a hormone specialist. And two weeks later, my entire life was better. I mean, I hadn’t slept for years and I was sleeping through the night. All these symptoms went away within two weeks. This all happened during COVID and we realized that the COVID laws were changing. And so the opportunity for this company was now for the first time, you could offer insurance covered visits. We started with just two providers. We got them licensed in 50 states and we just started doing visits. You know, we’re growing insanely fast. It’s super exciting. But we just started just with two providers and we got a lot of feedback from women — what they liked, what they didn’t like, how they wanted their care to be different. And so we’ve just iterated and iterated to try to make sure that we have something that women really respond positively to. 

Copy LinkWhy Joanna Strober is focused on providing people with choice around treatments

SAFIAN: You know, I’m thinking about your initial start-up, Kurbo, which garnered some controversy around it. You know, the notion of getting kids to diet, sort of, that idea kind of sparked backlash. And Midi and what it’s doing around menopause, I mean, there’s potential controversy with that also. You’re not phased by the idea of there being controversy or naysayers?

STROBER: I’m not. You know, I think it’s really important to give people choice. I guess that’s really what it comes down to. If a child wanted to lose weight and that’s what they wanted, I wanted to give them an option of a safe, effective way to do that. And if a woman wants to live a life that she feels good and she is able to sleep and she does not have anxiety and her bones are strong, and there’s a medication that is out there for that, I think she should absolutely have access to that. If someone wants to lose weight, they deserve access to a weight loss medication that works. I guess I feel really strongly that people deserve that access to things that make them feel better and then you can make those choices whether they’re appropriate for you. But I don’t think that we need to be paternalistic about it. I do feel really strongly about giving people access to things that help them to live a healthier, happier life.

There’s a lot of research that shows that women’s careers actually often get destroyed in their 40s because of these menopause symptoms. When you can’t think straight because you’re having brain fog and you’re not sleeping, you’re not performing as well at work as you want to and then actually a lot of times women quit. And there’s some research that say that 50 percent of women think about leaving their jobs because of menopause symptoms. And 10 percent actually do leave their jobs because of this. So it’s not innocuous, right? This is not just something about, ‘oh, we just want to help them feel better.’ It’s really to help us thrive, to help us provide for our families. Like, it’s a really important thing, this care.

Copy LinkWorkplace accommodations for menopause?

SAFIAN: I was looking at a study by another women’s health company recently, Bona Fide about, sort of, the lack of workplace accommodations for menopause. Is that another thread of where Midi hopes to have impact?

STROBER: So I’m going to be a little controversial here: If you use the appropriate medications, you don’t need accommodations. I believe really strongly that there are medications, there are hormones, there are non-hormonal medications, there are supplements, there’s lifestyle, there are things you can do to help feel better in menopause. And I am very focused on that. Not on making accommodations for women. I think that could be more stigmatizing than necessary. I’m more interested in asking them to give access and paying for this care so that women can just thrive at work.

Copy LinkWhat’s misunderstood about menopause

SAFIAN: My experience of menopause personally is a reflected one from the women in my life. It’s not something that I’ve personally been through. What are the things that you think people misunderstand about menopause — whether women who haven’t been through it or men like myself who will never go through it? 

STROBER: Okay, menopause means you have not had your period for a year. That’s all it means. Perimenopause is the period of time starting around 35 when your hormones start to go like this. Right? And they’re slowly working their way down, but they’re a little jagged. So, you don’t actually know that you’re in perimenopause. And so what happens is that women stop sleeping, they start becoming angry a lot, they go through mood changes, a lot of things happen to our bodies and we don’t really understand them. And what I want women to know is at a much younger age, start thinking: If I’m not feeling right, this could be perimenopause, and I should be getting treatment for it early.

Because you don’t have to suffer. And you don’t have to feel like shit for years, quite honestly. Which is what most women do. They don’t need to suffer. And also, honestly, I think there’s a huge acceptance in society of women’s suffering. Like, we seem to just think it’s okay for women to suffer. They’re just told, you know, ‘this is just what it’s like as you grow older.’ And that’s just not true. So, I feel really strongly that we just need to like really be clear with women that if something doesn’t feel right, you should find the right provider who can help you and can help you find the right medication so you don’t have to suffer.

SAFIAN: Is there a test you can take that shows if you’re perimenopausal?

STROBER: That’s the problem. Women want a test. So they come to us and they say, “I want a test.” And our providers will say, “well, there is no test.” And they will say, “I want a test.” And the provider will say, “well, I can give you a blood test, but whatever it shows is just going to be a point in time. And whatever that point in time is, is not going to tell you if you’re in perimenopause or no”t. 

The menopause tests, which is when you haven’t had your period for a year. That is clear, but it’s the 15 years beforehand that’s not clear and women need to be looking for care much earlier.

Copy LinkHow Joanna Strober learned to think bigger in regards to Midi Health’s potential

SAFIAN: As a business, I’m curious, like women entrepreneurs have a harder time raising money than men. But you have done a very good job in raising a fair amount of capital relatively quickly. Do you take a particular tactic when you’re facing, you know, the reality that like, it’s harder as a woman entrepreneur, there are less dollars that tend to go to women? 

STROBER: Yes. I actually went to a pitch session a year ago before I raised this most recent round, and it was done by David Hornik. He did something called the Lobby for Women, and he was training women on pitching. He had venture people sitting in rooms and you went in and you pitched to them. And you know what, the first two people that I pitched to were super nice —-  “this is nice, great business, blah, blah, blah.” The third and the fourth one were like, “this is not gonna get funding, you have not nailed your story. It is not big enough, you don’t understand how to tell a story that is big enough…”

And they were really honest about what mistakes I was making, and I just remember driving home and I was just, ‘wow, like that was very helpful.’ It was a little discouraging, but it was very helpful, and I think a lot of times women probably are like me. We’re very practical. and we’re very thinking about our margins, and we’re thinking about, you know, the business that we’re building, and you know, one of these men is like, “well, you’re not telling me why you’re going to be a 10 billion company.” I was like, “well, we could be”, and he’s like, “well, you didn’t tell me that in your story.” And it was a little humbling, but it was actually incredibly helpful. 

I think a lot of times, we don’t tell the story, we women, don’t tell the story big enough, and I really did go back and say, ‘look, every woman in this country is going through menopause. Every single one of them. And, if you look at what’s going on in the country with the decrease in OBGYNs. Half of the counties don’t even have an OBGYN in this county. And in most of the other places, they have nine month waiting lists. And then you look at the decrease in primary care, and you realize that we have a massive shortage in primary care. And so when you look at that, and you look at, we have this population, aging population of women. Every woman in the country could actually be my patient. And, so, why am I only saying it’s X sized business when it really could be X times 100? 

And so, this actually was incredibly helpful, and it really helped me think about, like, ‘what does it take to build a big company?’ But I have this massive audience, I have actually a group of workers who really want to come work for us, we are also the recipient of all the burnout in the healthcare industry. So those women come to us because they want to provide care in a different way. So, I don’t know, for me in this last round, I was able to say, ‘I think this can be a really big company and I do truly believe this can be a really big company.’ And so it made the fundraising easier. Now we’re just growing really fast. So now it’s a different story because we’re just able to raise money based on numbers, not necessarily just on, on telling a big story.

Copy LinkWhat’s at stake for Joanna Strober right now?

SAFIAN: So what’s at stake in this moment for Midi, for those of you trying to elevate the profile and investment in menopause, what’s at stake right now? 

STROBER: Oh, goodness. Personally, I feel a lot at stake. I have to prove this works. I have a lot of pressure on me to prove this works. I believe that if I do, a lot more companies will get funded to do these type of things. We need to prove that we can build a really big company focused on women’s health. And I think we can, but it is not insignificant that we are the first ones to try to do that, and we need to prove that out. 

The Biden administration has started to put some money into women’s health, which is very exciting, but the numbers are still very small. When you talk about a hundred million dollars of research, you know, that’s the marketing budget for, what, a month of HIMS marketing for erectile dysfunction? Like, the amount of money that’s gone into erectile dysfunction versus the amount of money that has gone into sexual wellness for women is just totally unbalanced. So, the amount of money that they’re talking about is piddly. And honestly, when you start thinking about what I was talking to you about earlier: Alzheimer’s prevention, cardiovascular disease, all these are really big things and women are disproportionately impacted and we need research dollars to go into those things to prove that we can make an impact here.

SAFIAN: Well, Joanna, thank you. This has been great. I really appreciate you talking with us.

STROBER: This was fun. Thank you.

SAFIAN: I really wasn’t sure about doing this episode, as a man talking about menopause. Even saying the phrase “vaginal estrogen” feels a little inappropriate. But it shouldn’t be, any more than erectile dysfunction is, which is what Joanna is encouraging. Personally, I learned a lot in this episode, not just anatomical but commercial and economic. Topics that are taboo aren’t always worth engaging in, but in this case, something experienced by every woman on the planet, it’s kind of mind boggling that it hasn’t gotten more attention–from doctors, from researchers, from business. Midi’s opportunity, and all our opportunity, is to address that oversight, quickly. I’m Bob Safian, thanks for listening.