Summary
Content warning: This story includes references to suicidal ideation. 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 150 out of pocket for a three-month supply. Jen Gunter, a prominent ob-gyn and author of the book The Menopause Manifesto, is an outspoken critic of Midi, in part because she disagrees with the choice to sell supplements and face creams, as well as the company’s embrace of compounded GLP-1 medications. “I will always maintain that selling women inadequately studied products under the guise of closing the gaps in health care and using misleading language is predatory and misogynistic, as misinformation robs women of agency,” she wrote in a post outlining her issues with the company. Gunter doesn’t dislike telemedicine writ large; she’s spoken positively about the platform Gennev, which offers HRT. For platforms she sees as lacking, though, she offers sharp rebukes. (Gunter declined to participate in this story. Midi said that no clinician it works with is incentivized or advised to push any product, “only to deliver the best possible care.”) Even Jackson, from her perch within RFK Jr.’s department, has concerns about bad actors in the industry she was part of just a year ago. She worries that some platform owners see this lane as an easy way to make money. Scouting for the highest profit margins is now a common prerogative. “The incentives are set up to drive people to want to do that, and those companies are more likely to win,” she says. And Heather Hirsch, Midi’s former chief medical innovation officer, now speaks skeptically of venture-capital-funded telehealth startups like her previous employer. “Those companies are pressured to return that investment tenfold,” she says. “The slippery slope is slippery.” Hirsch offers hormone therapy through her own concierge practice and endorses it as a longevity aid, but she stresses that it must be used alongside a healthy lifestyle and draws the line at selling supplements, lotions, or the other extras favored by some of the big virtual clinics. Lisa Schrenk still sees her hormone therapy as a savior. She has turned into a dogged advocate for the kind of care she’s received through telehealth. When Schrenk found out that the primary care doctor who had initially denied her request for HRT started a new job at a menopause-focused clinic, she was aghast. “I wrote her a letter stating my concerns about her negligent care when I inquired about HRT,” Schrenk told me recently. She was surprised when the doctor’s hospital followed up with a letter. She’s still hiking her way through Virginia, too, and recently took a trek in the Appalachians near the border of North Carolina. Once again, Schrenk had a conversation about hormone therapy on the hike. “A woman in the group started advocating for HRT,” she says. “Without any prompting.” These conversations are happening all across the country. And they have implications that go beyond expanded access to one type of medication. The virtual clinics driving the rapid expansion of hormone therapies aren’t just a novel distribution method for conventional health care; they are also vectors for a distinct philosophy of medicine. The perimenopause revolution is happening in parallel with the explosion of interest in peptides, at-home blood test platforms, and MRI startups—all part of a swing toward an ever more commercialized, preference-driven version of health care for those who can afford it. And make no mistake: This is an effort to eclipse the current health care system. When I asked Midi’s Strober about how the company planned to become profitable, she shrugged the question off. Like industry-disruptor startups before it—Uber, for example—it’s focused on growth, with a goal of becoming a one-stop shop for at least half the population’s health needs. “We’re building out a national specialized primary care company for women,” she said. A lofty goal, but one that Midi and its competitors’ track records suggest is possible. In a few short years, hormone therapy for perimenopausal women swung from inaccessible to inescapable. Every day, as the number of women taking hormones rises, they join an ongoing treatment group that is more experimental than perhaps they know. When it comes to doling out estrogen and progesterone, the goal for clinicians is balance. The industry employing them, however, is zeroed in on its growth chart going up, and up, and up. 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