Inside the Perimenopause Industrial Complex

She had embarked on a hiking trip the evening before, scaling Virginia's Old Rag Mountain under the cover of darkness. Upon reaching the summit, they were treated to a breathtaking sunrise over the Blue Ridge range. The women captured photographs, with one image capturing Schrenk standing atop the horizon, her dark hair secured in a ponytail.

This photo exuded an air of triumph, but beneath the surface, Schrenk was grappling with thoughts of suicide. As she descended, a poignant moment occurred when she overheard fellow hikers discussing hormone therapy. One participant recounted how she had endured intense anger, anxiety, and exhaustion before starting hormone replacement therapy (HRT), and subsequently experienced a newfound sense of well-being.

Intrigued, Schrenk began to question whether her own mood issues might be linked to a hormone imbalance. Although she had previously approached her primary care physician about HRT due to her treatment-resistant mood symptoms, she was met with dismissal. Undeterred, Schrenk visited two different gynecologists, but to no avail. The depression worsened.

However, after hearing her hiking companion's account, Schrenk turned to the internet, searching for "HRT-friendly doctors near me." She discovered Midi, a telehealth startup specializing in women's midlife care, and scheduled a video consultation. Schrenk's nurse practitioner was receptive to switching her birth control to hormone therapy, understanding that lower dosages and alternative forms of estrogen and progesterone might yield different results compared to the traditional pill.

Over the subsequent five months, they meticulously adjusted the dosages and delivery methods of the medications to minimize potential side effects. Schrenk attributes this treatment to a significant improvement in her mental health, stating she no longer plans her own funeral. Instead, she finds solace in spending time with her beloved dog, going for frequent hikes, and experiencing a notable increase in happiness even during her commute through Washington D.C.'s congested traffic.

Concurrently, substantial changes were unfolding in the way general populations accessed hormonal treatments. After the 2002 study highlighted the potential cancer risks associated with HRT, its popularity had waned. However, by the end of the Biden administration, medical professionals, liberal feminists, and the Make America Healthy Again movement recognized the previous prescription trend as a grave error.

Millions of women experiencing mood swings, hot flashes, and night sweats were unnecessarily suffering. Last fall, the US Food and Drug Administration removed the so-called "black box" warnings surrounding hormone therapy. At a subsequent press conference, Robert F. Kennedy Jr., the Secretary of Health and Human Services, declared their commitment to evidence-based medicine, challenging outdated perspectives.

Shortly thereafter, the director of the FDA's Advanced Research Projects Agency for Health, Alicia Jackson, championed the cause. A former advocate of pharmaceutical companies during the Trump administration, Jackson now advocated for the potential addition of up to a decade of healthy years to women's lives through hormone therapy.

As a result, demand for HRT skyrocketed. According to a SimilarWeb analysis for WIRED, four prominent startups in the perimenopause space—Midi, Winona, Alloy, and Evernow—experienced a staggering 490% surge in web traffic between 2023 and 2026, attributing this surge to "organic demand." These virtual clinics offering hormone therapy represent a rare instance of national unity, while also offering a glimpse into the future of American healthcare.

Perimenopause typically begins in a woman's forties but can manifest earlier and persist for years, impacting over 43 million women between the ages of 35 and 54 in the United States—a substantial market. Telehealth clinics specializing in hormone therapy are vying for dominance, with some receiving significant funding and others operating on an out-of-pocket subscription model, charging up to $200 a month for customized formulations in various delivery methods.

With turnkey services enabling the rapid establishment of virtual clinics, numerous enterprises can now offer hormone therapy online within days. Midi is among the few providers that accept health insurance, although it does not accommodate Medicare or Medicaid. Most other major players in the industry strictly rely on out-of-pocket payments, commanding premium subscriptions.