Lisa Schrenk didn’t know it yet, as she trudged down a dirt trail last August, but her life was about to change.
She’d set out late the night before with her hiking group, scrambling up Virginia’s Old Rag Mountain in darkness. They reached the peak in time to watch the sun rise over the Blue Ridge range. Afterward, the women snapped photos. In one, Schrenk gazes out over the horizon, her long dark hair pulled into a ponytail. The image is deceptively triumphant. In reality, she had been contemplating suicide. Schrenk, a longtime IT specialist for the federal government, had started setting aside belongings for friends and family, organizing her financial affairs, and clearing out her office.
Her hallelujah moment didn’t happen at the summit. It started on the way back down, when she overheard her fellow hikers talking about hormone therapy. One described how she’d suffered from intense anger, anxiety, and exhaustion until she’d started a course of hormones typically offered to people in menopause. Now, she was thriving. “I was like, oh my God,” Schrenk remembers. She was hearing some of her own symptoms listed out. Could this be the answer to her problems, too?
Schrenk had already tried to persuade her primary care physician to consider hormone therapy because she suspected that her treatment-resistant mood issues might be linked to a hormone imbalance. As someone in her early forties, she was potentially approaching or in perimenopause, when the ovaries gradually stop making reproductive hormones, with estrogen levels often fluctuating erratically along the way. (Until recently, hormone therapy was widely referred to as hormone replacement therapy, or HRT.)
But Schrenk was already taking one of the most common treatments for perimenopause symptoms—an oral contraceptive containing synthetic versions of the hormones progesterone and estrogen. Her doctor dismissed the idea of switching her to hormone therapy, which sometimes delivers “bioidentical” versions of the same hormones, often in lower dosages. Undeterred, Schrenk had then gone to two different gynecologists. “Automatic no,” she says. One had acceded to switching Schrenk’s birth control brand. It made no difference. The depression deepened.
After hearing about her hiking pal’s experience, though, Schrenk started searching online for “HRT-friendly doctors near me.” She found Midi, a telehealth startup focused on women’s midlife care, and signed up for a video consultation. “I cried through my first appointment, sobbing with snot and tears falling from my face,” Schrenk says. Her nurse practitioner was willing to switch her birth control to hormone therapy, recognizing that the lower dosages and different styles of estrogen and progesterone might have a different effect than the pill. Schrenk finally felt heard.
Over the next five months, they met regularly, fine-tuning the dosages and delivery of the meds to minimize side effects. Schrenk credits the treatment with a radical turnaround in her mental health. “I’m no longer planning my own funeral,” she says. Instead, she’s spending time with her beloved dog, going for lots of hikes, and feeling noticeably happier even when she’s stuck in DC traffic.
Around the time Schrenk was having her personal perimenopause revelation, huge changes were taking place in how the general ovary-having public accessed this kind of medication. Hormone therapy had been out of favor for years, after a 2002 study led women who might have otherwise asked for the treatment to overestimate potential cancer risks and doctors to prescribe it less frequently. But by the end of the Biden administration, pretty much everyone—medical professionals, liberal feminists, the Make America Healthy Again movement—regarded that prescribing trend as a disaster. Potentially millions of menopausal people were living with mood swings, hot flashes, and night sweats, and they didn’t need to be.
Last fall, the US Food and Drug Administration removed the so-called “black box” warnings that had been in place on hormone therapy. At a press conference announcing the move, Robert F. Kennedy Jr., the secretary of Health and Human Services, said, “We’re challenging outdated thinking and recommitting to evidence-based medicine.” Shortly after, the director of the department’s Advanced Research Projects Agency for Health, Alicia Jackson, stepped up to the podium. Jackson, the founder of a telehealth company called Evernow, had joined the Trump administration less than a month earlier. “Today, we have the opportunity to add up to a decade of healthy years to the life of every woman that you love,” she said.
Since then, demand for hormone therapy has spiked. According to an analysis conducted by SimilarWeb for WIRED, four leading startups in the perimenopause space (Midi, Winona, Alloy, and Evernow) saw a 490 percent uptick in web traffic from 2023 to 2026. SimilarWeb’s analysis concludes that there has been an “organic demand surge.” In addition to providing a rare approximation of national unity, the perimenopause telehealth boom offers something else: a glimpse into the future of medicine in America.
Although perimenopause is a transitional phase as universal as puberty, only recently did it become a full-blown buzzword. Beyond the FDA’s recent removal of the “black box” warnings, a few major changes set the stage for the big rebrand. Since the pandemic, Americans have embraced telehealth, making virtual clinics run-of-the-mill rather than exotic. The public has also warmed up to compounded products sold by virtual clinics, because off-brand GLP-1s are so much cheaper than name brands like Ozempic. Many people who might have previously considered a compounded hormone too risky, or who might have preferred seeing a doctor at a brick-and-mortar location, are now comfortable being prescribed these medications over the internet.
Perimenopause typically begins when people are in their forties, but it can start earlier and last for years. More than 43 million women between the ages of 35 and 54 live in the United States—an enormous market. Virtual clinics offering hormone therapy are jockeying for dominance. Some are flush with venture capital funding, like Midi, the first “menopause unicorn.” Its competitors Alloy and Evernow have also raised money. Larger telemedicine firms like Hers are getting in on the perimenopause action, too. And thanks to “turnkey” services that help new virtual clinics get started, almost anyone can start selling hormones online within days.
Midi is one of the few online hormone therapy providers that accepts health insurance, though it doesn’t work with Medicare or Medicaid. Many other big names in the industry are strictly out-of-pocket, charging subscriptions of up to $200 a month for custom formulations in pills, patches, gels, and creams.
The potential customer base is vast in part because a remarkably long list of ailments are attributed to perimenopause and menopause. In one Midi ad, Amy Schumer (who invests in the company) ticks off a list that includes “night sweats,” “low libido,” and “random tears brought on by watching a movie, making a sandwich, or seeing a dog.” The company’s stance is that there are more than 100 possible symptoms of menopause, including body odor, forgetfulness, bloating, irritability, anxiety, depression, asthma, recurring urinary tract infections, weight gain, sensitive teeth, tiredness, having trouble falling asleep, and dry skin. This expansive list is typical within the industry; Winona sells an estrogen-containing skin care product that it says reduces wrinkles.
One might be forgiven for wondering what isn’t a symptom of perimenopause. No lab test can reveal whether someone is or isn’t reaching this life stage, because unpredictable hormone variation is its hallmark. Instead, clinicians make the appraisal largely based on how their patients tell them they feel. Some doctors worry there are so many symptoms that almost anyone with aging ovaries can qualify as plausibly perimenopausal and that encouraging such a broad group of people to take hormones, sometimes with little oversight, is a recipe for trouble.
Stephanie Faubion, director of the Mayo Clinic’s Center for Women’s Health and medical director of the Menopause Society—practically royalty in this world—says the perimenopause hype machine “has gotten completely out of hand” in how it pushes hormone therapy for longevity or ailments like fatigue. “We are running into a danger zone attributing all these symptoms to perimenopause,” Faubion says.
Another superstar of the menopause world, Yale School of Medicine clinical professor and gynecologist Mary Jane Minkin, is a die-hard evangelist for making patients aware of these treatment options. She runs a blog called Madame Ovary and can monolog for half an hour straight on how vital it is for people to know about their bodies and treatment options. But she, too, worries that marketing and media hype are convincing women that everyone who remembers 9/11 and feels kind of crappy sometimes must need these meds.
The way Minkin sees it, life stressors and emotional challenges are real and shouldn’t be minimized. “But is it attributable to their hormonal milieu? Probably not,” she says. “Attributing everything in the world to perimenopause is tricky, because I can't say it isn’t for sure.” There’s the rub: A 38-year-old woman who feels anxious or just had a rotten night’s sleep might scroll around online and walk away with the conclusion that the problem is her hormones. Statistically speaking, she’s probably wrong. But she might not be!
Also: Are we sure she needs to wait until dipping estrogen levels cause undeniable problems? Her ovaries certainly aren’t getting younger. Many in this space debate when the best time to start someone on hormones really is. While the risks were overstated for many years, they do exist, just as they do for most medications. Side effects can include vaginal bleeding, breast tenderness, and bloating. People with histories of breast cancer, blood clots, or liver disease are advised against taking them. For people without those contraindications, Minkin says, “probably nothing terrible is going to happen” if they take hormones they don’t actually need. Overall, she sees perimenopause medicine as an area that still needs much more awareness, and she is hesitant to endorse or reject expanded uses of hormone therapy. “I'm sort of hedging my bets, as far as saying what's good and what's bad,” she says.
Jackson, the Evernow founder turned Trump appointee, is among many who argue that “the earlier that you start hormone therapy, the greater the benefit.” When I meet her on a drizzly morning at the ARPA-H headquarters in Washington, DC, she says that longevity was central to her thinking about why she needed to start Evernow. She was also frustrated with what she saw as the medical establishment’s timidity—and its “weird paternalism.” Doctors will prescribe birth control “in an instant,” she says. “What always blows my mind is when they're like, no, we shouldn't start women on HRT.”
Joanna Strober, Midi’s chief executive and cofounder, has big ambitions for the company, but a lavish office isn’t one of them. For a tech unicorn, Midi occupies an unimposing physical space in a boring-looking mixed-use building in Palo Alto. When I arrived on an aggressively pleasant morning this past spring, the grand tour took about 30 seconds. I snagged a catered falafel lunch and followed the company’s communications director to a small conference room. Kathleen Jordan, Midi’s chief medical officer, sat across from me. Wearing a sequined denim blazer, auburn hair coiffed, she looked ready to lead a webinar. Strober came in shortly thereafter, wearing a down vest; she looked like she’d just been hiking, except that her foot was in a clunky air brace.
What she’d actually been doing was taking a conference call with the FDA to discuss an ongoing shortage of estradiol patches, a common type of hormone med. “We don’t think they understand the extent of the problem,” Strober said. More than 50 percent of Midi customers are prescribed some sort of hormone therapy by its clinicians; in a recent customer survey, the company found that nearly 4,000 women had difficulty filling their prescription at least once.
The popularity of hormone treatments, driven in part by the rise of companies like Midi, is already squeezing supply. Estrogen patches have been hard to find since the FDA removed the black-box warning label, though they haven’t been officially labeled “in shortage” by the agency. (This June, progesterone supplies tightened in response to the surge of interest in hormone treatments.) Suppliers were not prepared, nor were they especially incentivized to meet demand; most of these medications are off-patent and not big moneymakers. New patients who take the medications—either because they’re in perimenopause or think they are—tend to be far younger than the typical menopausal patient. That means they stay on them for a much longer time, further exacerbating supply issues.
Midi is the most prominent platform offering focused perimenopause care, but whether a person is perimenopausal is less and less a concern. Strober wants Midi to keep expanding its customer base, ideally becoming a platform connecting customers in all stages of life—“women in their twenties, thirties, forties, fifties,” she says—with experts in lots of different categories, including postpartum care. In this way, Midi is similar to one of its competitors, Hims and Hers, which started as a purveyor of specific men’s health products but expanded into a more general-interest platform. In addition to HRT, Midi’s clinicians prescribe GLP-1s, the golden goose of the telehealth world. It also sells a series of supplement products and recently expanded its prescription skin care line.
Strober is a veteran of the startup world (before Midi, she sold a children’s weight-loss app to Weight Watchers) and speaks about the company’s mission with the excitable polish of a TED Talk presenter. When I asked Strober what she thought about people taking hormones preventatively, as a longevity aid, she lifted her leg up on a chair and pulled up her pant cuff to show me the black boot encasing her foot and leg. “I have a fracture because I have osteoporosis,” she said. “I didn’t start hormones early enough.” (Without adequate estrogen, bones don’t get the message to maintain mineral density.)
“Longevity has a lot of different meanings to different people,” Jordan cut in. “I prefer to use the words health and wellness.”
OK. Health and wellness, then. Whatever the word choice, both women agreed that hormone therapy could be prescribed as a protective measure rather than waiting to catalog perimenopause symptoms. “Hormones are a very effective tool for health and wellness.”
