The Hormone Grift is Coming for Millennials in Perimenopause

0:00 Today we're talking about the permenopausal industrial complex and how it affects you as a human who presumably exists on the internet. This comes from a Wired investigation that looked at the explosion of companies and influencers who specifically profit on the space around industry expansion of permenopausal symptoms which are notably a bit vague. You can have symptoms that are related to your hormones because of pmenopause, but you also will see huge overlap in those symptoms with many other things in life. So, let's talk about it. Inside the pmenopause industrial complex, Lisa Shrek didn't know yet, but as she

0:47 trudged down a dirt trail last August, her life was about to change. She'd set out the night before with her hiking group, and they were going up Virginia's Old Rag Mountain. It was pitch dark. They reached the peak in time that get to watch the sunrise over the Blue Ridge. And afterward, they took some photos. In one, she's looking out over the horizon. She's got a long dark-haired ponytail. And it's supposedly a very beautiful image. However, she had not shared with her friends and family at the time that she had been thinking about harming herself. And she at the time was an IT specialist. She was working for the government. She was setting aside belongings for friends and family, organizing financial affairs, clearing out her office, doing all these things to prepare to leave this world without

1:32 any of them knowing. She on the way back down that mountain overheard some of the other hikers talking about being on hormone therapy. And one of them said how they had been suffering from really intense anger, anxiety, exhaustion, as I was saying, symptoms that can very much overlap with other things not always related to pmenopause or hormones in general. And that she started a course of hormones that would typically be offered to people after menopause. These are women presumably in their 40s who are not menopausal yet. That's why we're calling it pmenopause. There's no way to specifically diagnose pmenopause. You can't do a blood test and say, "Yep, you're in per menopause." That won't stop unethical providers from ordering blood tests and telling you that they

2:19 say that. But there is no definition of these are the hormone profiles that mean you're permenopausal. Does that make sense? There also is a plethora of urine tests often sold by influencers that also do the same thing. There's no way to diagnose permenopause from a lab test. What's the typical age range? Usually people would start experiencing permenopausal symptoms in their 40s. The average age of actual menopause is 51. That means some people it's earlier, some people it's later. That's the average age. Pmenopause is the year surrounding when you stop menrating. The definition of menopause is when you've had a full year without a menstrual cycle and it's not attributable to other things like pregnancy or cancer therapy or radiation or whatever. Anyway, so we've got Lisa. She's hiking with her friends. She hears them talking about

3:06 getting prescribed hormones that usually would be given to people who are menopausal and they seem to be improving in some of the symptoms that she specifically also is experiencing. So she at that time wonders, okay, well maybe I should look into this before I exit myself from the world. And she had already gone to her primary care provider and told them about her symptoms that she was having. She wanted to try the hormone therapy at that time because she thought that some of her mood changes and things like that might be related to it and she was potentially approaching menopause and thought her estrogen levels might be fluctuating enough to cause some of these symptoms. In the article it says until recently hormone therapy was broadly referred to as hormone replacement therapy. We now

3:51 try to call it menopausal hormone therapy if it's postmenopausal or just hormone therapy if it's before that. She was already taking an one of the most common treatments for permenopause symptoms which is an oral contraceptive pill because a lot of times when people start experiencing permenopause it's from fluctuating hormones and being on a lowd dose combined estrogen and progesterine contraceptive pill can be helpful. Her doctor told her no you don't need to switch and okay so she asked it seems like to switch to bioididentical hormones and this is really the same thing. They're lower doses. It's a marketing thing. Okay. Bioididentical hormones don't inherently have any significant benefit over any other hormones that we prescribe. They are however quite a bit more expensive most of the time and often pushed as

4:38 superior by people who don't care that that's not supported by the data we actually have on these. She had asked a couple of other doctors. They said no. One of them suggested she try a different birth control brand. It didn't make any difference. She just kept getting more and more depressed. So when she was on this hike and she started hearing everybody talk about it, she started searching online for HRT friendly doctors near her and found Midi. It's a teleaalth startup that's focused on women's midlife care and she signed up for a video consult. She cried through her first appointment was she says sobbing with tears and snot falling from my face. her nurse practitioner was willing to switch her birth control to hormone therapy, recognizing that the lower dosage and different style of estrogen and progesterine might have a

5:24 different effect for her than she was experiencing with the pill. So, I vaguely remembered when I read this article, I believe they wanted to sponsor the channel. I'm real picky about who I will accept a sponsorship from because I never want to cross into a line of supporting something that I personally can't get behind, no matter how much money they would pay me. And believe me, these hormone people and women's health things, they will pay you. And so I'm just looking through the email chain here and they have these general talking points that they wanted to go over and it's about exactly what she's describing. I don't know what happens in the rest of this article. To be fair, I have not read to the end of it, but they wanted me to advertise their women's midlife hormone care thing. And so I always go and look at

6:12 the source for what is actually being asked of me to promote and Midi Health. So this is what I get from them as a brand overview. Midi Health is a virtual care clinic created by women for [music] women. Their mission is to truly see, hear, and understand women's unique health challenges. Offering personalized care for issues like hormonal changes, skin health, and midlife transitions. With insurance coverage in all 50 states, affordable pricing, and no hidden costs, MIDI is redefining midlife care to make it accessible for women and effective for all women. Now, listen, that was me reading what they've written about themselves. Okay? I'm not paid by them. I turn down sponsorship for them. And I'm just explaining to you their tactics behind the scenes that lead to what we're about to read in this article. And I said, "Hey, I have a

6:58 blanket policy against pushing supplements, and it kind of crosses an ethical gray area for me. I'm not willing to push that line. They said, "Well, that's fine. You don't have to talk about supplements. You can just talk about their platform." Like, just talk about their mission. My response is, I'm still hesitant. I don't know how heavily they push supplements in their care visits. I think the only way I'd be willing to do this is if I tried the service out and was truly impressed with it. However, I'm not even sure that I'm excited about that. It seems like they essentially push supplements and I don't like it. And it just the conversation kind of ended there. I said, "I'll look into it more." And then never went back to it. And I'm interested now to see what comes of that because my initial impression, obviously from these emails, I couldn't remember off the top of my head, but my initial impression was they

7:44 seem like they're pushing supplements. Um, but the brief they sent me, like if I hadn't gone directly to the platform's website, the brief they sent me was nothing like that. It was like, "Oh, we just support people getting care that they, you know, things that I would, you know, not unlike Zdok, who I work with all the time, right? They they want to improve people's ability to get care." And that's something I can totally get on board with. This is the thing, and this is what we talked about in the hormone hoax video. Like, most of these are solving a real problem. It's just that they're doing it for the wrong reasons. Right? So, I'm here. I'm solving a real problem. I actually happen to also make money solving that problem because I make YouTube videos. But I didn't come here because I want to create an audience that now someday I can push supplements on them, right? But

8:31 if I did that, if I came here today and I took advantage of your trust and I said, "I am selling this supplement now and it costs $45, but it will revolutionize your life." I would be probably very rich, but I don't want to take advantage of the trust that I've built with my audience because the trust that I've built with my audience means a lot to me. And I'm only going to tell you things that I really believe. It doesn't matter if I could make a ton of money on it. That's not what I'm here for. Let's go back to the article cuz now I'm certainly not [clears throat] stuck to my I won't go on a tangent thing. So, she found Medi Health. She signed up for a consultation. She discussed this with a nurse practitioner that she met with. And over the next 5 months, she met regularly with this person, was changing the doses and

9:16 delivery methods of the medication she was on, trying to minimize all of the side effects and things like that. And she says, "I'm better. I'm no longer planning my own funeral. Instead, she's spending time with her dog. She's going on hikes and she's feeling noticeably happier even when stuck in DC traffic. Does this mean it worked? Well, yeah. I mean, by some accounts, certainly it helped. But is it the supplements that she's paying a lot for? Is it the medication changes? Or is it just simply finding a practitioner who will listen to you and believe you when you say, "What I'm doing right now isn't working. Can we do something different?" I don't know. The data on this would say it's probably the latter because there's no inherent benefit of supplements and bioididentical hormones over other things. But we don't know everything and data can change. I'm not here to on

10:02 anyone's individual therapy. I think it's the industrial complex around pmenopause and hormone health in general that I'm raging against at the moment. Around the same time, she was noticing that she was having lots of things that were changing like hormone wise. And she also noticed that around the time was having her personal permenopause revelation, huge changes were taking place in how the general ovary having public access to this kind of medication. That's a sentence. That is a sentence. Hormone therapy was out of favor for a while. So this people who otherwise would have qualified for usually in this case it would be worth discussing menopausal therapy were not getting treated and that's a problem too. Undertreatment of menopausal and permenopausal symptoms is a real

10:47 problem. It's just when you add in capitalist medicine and large corporations that are making money off this, you're going to lose the people in the process at some stage. Yeah. That Women's Health Initiative study in 2002 kind of led to people thinking that it was dangerous to prescribe menopausal hormone therapy and it became really out of favor to prescribe it. And when I was in residency, which was 2012 to 2017, we were kind of the revolution. It took 10 years to get there, but we were kind of the generation of medical trainee who were trying to spin it back around where it was normal to treat indicated permenopausal and menopausal symptoms and it wasn't dangerous as long as you

11:33 understood the medications, the risks and who they applied to. But what I saw at that time was people just not getting treated when they needed it because everybody's terrified after that study came out. And they went on to clarify some of the findings and distill down some of the populations they looked at that made it obvious that there are inherent risks to specific points and ages. But the general public had already seen the media headlines and doctors and everybody who wasn't fully plugged into changes in the actual science just got very attached to those headlines where they weren't treating menopause at all. It's better now, but it's almost like in everything in medicine, we swing the pendulum one way. We're not treating hormones are dangerous. And now it's swung the other way. Like influencers

12:19 are treating you with hormones. Women all over the US and the world were quitting [snorts] their hormone therapy because they were terrified. And with good reason. But anyway, by the end of the Biden administration, pretty much everyone had agreed that that was a disaster. And there were lots of people who now were living [clears throat] with these very treatable symptoms of menopause that could have safely been taking medications to avoid that. And these aren't just like hot flashes aren't just annoying, right? These interfere with your life and ability to do normal things. These are quality of life killers. It's terrible. Sometimes people have trouble sleeping to the extent that they can't function at work the next day. It can be really lifealtering. So, this all leads to last

13:04 fall, the FDA in the US took the blackbox warning that had got put on the box for estrogen and progesterine hormone therapy. They took it off because it had been put there as a direct consequence of the alarm from that study that was not meaningless. There was lots of meaningful that study is not like a debunked study. It's a very important study. It's just it shouldn't have led to what it led to because it didn't achieve the conclusions that it led people to think it did. So, Robert F. Kennedy Jr., who we know is the incredible health and human services secretary, announced it at a press conference. We're challenging outdated thinking and recommitting to evidence mass medicine. I'm sure you are, Robert. [laughter]

13:50 Some of us are, but thank you for taking off the blackbox warning. I think this is [clears throat] very valuable. I don't think you are committed to challenging outdated thinking or recommitting to evidence-based medicine. It would be lovely for us if you were. Okay. So, since then, the demand for hormone therapy has spiked. And that is largely in part because this brought a lot of attention back to the women's health initiative. It took away a lot of fear that people who prescribe hormone therapy had with prescribing it, which in my personal opinion that fear is a red flag personally because I don't have any fear prescribing those medications even with the blackbox warning because I understand the data and who is appropriate to get that medication. So, this immediately, although it just looks

14:36 like a throwaway sentence in this article, this alarms me because it means a lot of people who prescribe this went, "Oh, look, it's safe now." But the fact that they couldn't prescribe it before because they didn't know how to safely prescribe it means it's going to inevitably get prescribed to people who fall outside of that safe range. You have to understand that medications aren't just safe or dangerous. There are some that are safe or dangerous, but a lot of medications, it's highly dependent on who you're treating, what you're treating, how old they are, what their history is. This is important to safe prescribing. Right? So, since then, the demand spiked and Wired uh led a

15:22 analysis and they looked at the four leading startups in the pmenopause space. Midi, Winona, Alloy, and Evernote. I've only heard of Midi, probably because they reached out, but I wouldn't be shocked if I searched my email inbox for those other three and found something there. There was a 490% uptick in traffic from 2023 to 2026. It's not in our heads. I've been telling my friends this whole time and they didn't believe me. Now, we have proof. So in addition to providing rare approximation of national unity, the parameopause teleaalth boom offered something else, a glimpse into the future of medicine in America. It's not all just from the blackbox warning being removed, right? Something else was happening around that time. 2020 COVID

16:09 happens, teleaalth booms because we recognize the need for people to be able to access health care providers, not just in person. And it became even more important. So 2020 to 2023 was like an integral time in development for accessibility of online and phone call visits with physicians. I personally think this is great. In the old days doctors used to come to your house right now. They can still come to your house but without the manual output of needing to go to 100 people's houses a week. And this is really good. I think the boom of tellahalth that came from co is one of the really important things that co brought us that is not directly related to just an understanding of pandemics. So that collision of tellahalth boom and

16:58 the perry menopause explosion on the internet created this rich market for people to profit off of hormones. Whether you're doing scary content about hormones, selling supplements, doing startups, whatever it is, that was the natural intersection of the perfect time to be in that space. Although per menopause, they say, is a transitional phase as universal as puberty, it only recently became a full-blown buzzword. So, that's what we're talking about here. And after the FDA's recent removal of the blackbox warnings, there were some big changes that set the stage for basically a rebrand of permenopause. I promise I did not pre-eread, but as the article says, since the pandemic, Americans have embraced teleaalth, making virtual clinics run-of-the-mill,

17:43 and that helped to make this something that could happen. There's also uh more acceptance of so-called compound products and compounding pharmacies and clinics, and that became a big deal when the GLP1s like Ozic were able to be made much less expensive when they came from compounding. A lot of people used to really think that that was a really risky like weird thing to do and it can be, but for the most part compounded medications are really useful and we use them in medicine a lot. It's just now they're more accessible. There are some concerns with it, but they do have a place that is important. MIDI is one of the they say is one of the few online hormone therapy providers that accepts

18:28 health insurance but won't work with Medicare or Medicaid. Most of the other startups are out of pocket and for a lot of them it's kind of a bespoke or a concierge medicine setup which warning although I'm sure there are some important things that concierge medicine provides this is something I would like to put a warning out about because it is a very lucrative business for people to get into and as somebody who thinks medicine should not be capitalist at all I have a problem with it but It solves a problem, but I think it creates a bigger one. Carrying on, they go through all the things that could be related to pmenopause. Night sweats, low libido, random tears brought on by watching a movie, making a sandwich, or seeing a dog. Right. So, yeah. Can these be

19:15 permenopause symptoms? Absolutely. Can they also be symptoms of a whole lot of other things? 100%. Irritability, anxiety depression asthma recurring UTI, weight gain, sensitive teeth, tiredness, trouble falling asleep, dry skin. this is the things they profit off of because it's these are common things and sometimes they're hormone related and sometimes they aren't. Some hormone purveyors will prescribe medications asynchronously which means you fill out a questionnaire, a doctor approves it and there's no visit required. Vending machine prescriptions when an executive calls them. One might be forgiven for wondering what isn't a symptom of pmenopause. As we were saying, no lab test can reveal Oh, thank thank god thank you wired. Oh my god, I'm so happy. No lab test can reveal whether someone is or isn't reaching that life stage because unpredictable variations in hormones are normal. So instead, we

20:01 have to be tasked with deciding this largely based on what a patient tells us. And some people think that anybody could be prescribed hormone because of anything they come in with essentially. And there's not a lot of oversight. So is this an unsafe practice? Well, not necessarily. It depends whose hands it's in. Right? So, we've already discussed how this could be really, really dangerous if the person who's prescribing the medications doesn't understand the populations in which they are safe or unsafe, the combinations in which they are safe or unsafe, side effects that would be red flags, things like that. And when you start just doing it as a checklist or this is your money-making model instead of I care for people and this is one of the conditions that's in my repertoire of

20:47 understanding. It becomes I treat people with this. That means everyone you see is going to have it. So you're not filtering through other things that could be causing those symptoms. It's a bias that doesn't allow you to filter through other things because this is your income model treating a specific condition. anyone who is specifically treating a special condition but isn't like an expert in that like there's not many people who are experts in single conditions except very obscure conditions right so you can't just treat only pmenopause otherwise everyone you see will have it you need to be able to understand a broader context of health and be able to work through a differential diagnosis and treatment plan so the director of Mayo Clinic's center for women's health and also the

21:33 medical director of the menopause society Stephanie Fabian says, "The Parmenopause height machine has gotten completely out of hand." I would 100% agree with that and how it pushes hormone therapy for longevity or ailments like fatigue. We're running into a danger zone for all of these symptoms to be permenopause. 100% agree. And there's not a lot of studies on pmenopause specifically. So, we don't have a lot of data on what it means to start people on various hormones for this. We have really good data on menopausal hormone therapy, but does that directly translate into people who are younger? I don't know. We have a lot of data on hormonal contraceptive. Does that translate into parameopause? I don't know. We don't know. Yell School of Medicine professor and also a

22:18 gynecologist called Mary Jane Minkin is someone who is very passionate about menopause and she is very well known in this space. But she also worries about the marketing and the media hype and has a very I think important quote here that this is convincing anybody who is old enough to remember 9/11 that if they feel crappy sometimes they need to be on hormones and that is not necessarily the truth. I think that if you've ever come across Jen Gunter she's a great resource for this as well. I'm not going to read it all. We're going to go through it a little faster. So she says probably nothing terrible will happen if you take hormones that you don't actually need. But she kind of sees pmenopause medicine as an area that needs a little bit more awareness. And she is hesitant as I am

23:04 to either defend or reject the idea of these treatments being used in that group of people. Evernau founder turned Trump appointee Alicia Jackson who was quoted earlier from that press conference when the FDA removed the blackbox warning. She says the earlier you start hormone therapy the greater the benefit. Now this isn't necessarily true. [laughter] It's not. And there could there is a grain of truth in that. And that's the same thing with all of these, right? So once you're menopausal, if you're going to be on hormone therapy, the earlier you start it, the more beneficial it is. So, Jackson says that she was frustrated with what she saw as the medical establishment's timidity and weird paternalism of doctors who wouldn't prescribe hormone replacement therapy as

23:50 it was previously called. And I agree with that. I mean, we've talked a lot about that in this video about how that women's health initiative really swung the pendulum excessively one way, but that doesn't mean that it's better earlier in every situation. So, MIDI occupies an unimposing physical space in a boring looking mixeduse building in Palo Alto. There you go. If your startup is in Palo Alto, it probably deserves consideration of their goal is not health treatment. Their goal is money, which is okay. It's like I don't necessarily take issue with that. It's just the overlap of health care being the pathway to that for so many people really makes me angry. They were meeting with the FDA to discuss the shortage of estradile patches and said that more than half of their customers are

24:35 prescribed some sort of hormone therapy and they had done a survey within Medi Health to their consumers that went out to a lot of their customers and 4,000 of those women reported back that they were having trouble filling their prescription. So that's a problem, right? I that's a problem when it's any kind of medication that somebody needs. This is a problem though that they helped to create and I worry about the menopausal patients who have a very clear indication for these treatments not being able to get their medications because it's being prescribed in such high volumes to people. It might help but we might not help. So yeah, it says this June progesterone supplies tightened in response to the surge in interest in hormone therapy. Suppliers were not prepared nor were they especially incentivized to meet that

25:21 demand. Strober is a veteran of the startup world. Before Midi, she sold a children's weight loss app to Weight Watchers. This is who we have running our women's health platforms. Love that. Man, the way they describe her is very interesting. I can get like a image of this person just by reading that. That she's a veteran of startup world and once 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, no data to support that. She lifted her leg up on a chair and pulled up her pant cuff to show me a black boot encasing her foot and leg. Oh my god, I'm cringing. I I just know if I look up this person, I know what she will look like and I know I would be miserable if I had to sit down and have

26:07 a conversation with her. I didn't start hormones early enough. Without adequate estrogen, bones don't get the message to maintain mineral density. True, however, is very clearly not a indication for use of hormones because the safety profile does not support using hormone therapy specifically in a general population sense for prevention of bone density loss even though it can have a positive impact on that. I love the writer of this. Longevity has a lot of different meanings to different people. Jordan cut in. I prefer to use the words health and wellness. Okay, health and wellness then. Whatever the word choice, both women agreed that hormone therapy could be prescribed to catalog permenopause symptoms. While I was reporting this story, my algorithm started surfacing parmenopause content constantly. I noticed the overlap between the way

26:52 creators described discovering they were permenopausal with the tone of videos focused on late in life autism and ADHD diagnoses. There's a tendency to treat the condition as an identity marker. Hormone levels too high or too low and didn't just cause issues. They influenced everything. After a while, I started to seriously consider whether I too would benefit from hormone therapy, although I'm statistically unlikely to hit parmenopause soon. That's a really clearly written and important part of this entire wired investigation into the pmenopause industrial complex, right? They are essentially saying like, I went into this as a skeptic. I'm still a skeptic. I was discovering all these things about it that I really didn't like. And lo and behold, by the time I was done, algorithms had convinced me that I needed to be on hormones. We need to find women where they are and they

27:37 trust Instagram. They feel like doctors have dismissed them and their symptoms and so they are more likely to trust an influencer. 100% agree. That's why I exist on the internet, right? That is my mission on the internet. At some stage, Medi was claiming quote 91% of patients find relief within 2 months and that is obviously an exaggerated claim and it got them in trouble. Discourse around parmenopause and longevity feels very maja coded and both Joe Rogan and uh the US armed forces have extoled the benefits of testosterone therapy for men. At the same time, hormone therapy for trans people which uses the same hormones is vilified. And that leads me to another thing on the list of reproductive topics today. Dransition clinic in Texas and making it illegal to prescribe trans people their hormone

28:23 therapy. Like why can I not prescribe hormone therapy for someone who has a very clear and scienceup supported indication but I can just give it to anybody I want cuz they come in on a tellaalth visit check off a list of symptoms and tell me I'm parmenopausal something I can't even like fully diagnose what is live Mayo Clinic Fabian cited an example of estrogen face cream which she flatly called garbage when we spoke we don't have enough data to support estrogen face cream use we just don't the cream can cost $150 out of pocket for a 3mon supply we don't even know if you can accurately and effectively absorb estrogen through your face cream, but they're selling it on Midi's website. Oh, good. They quote Jen Gunter. Perfect. So, Jen Gunter, who is a very well-known OBGYn, arguably the first OBGYn on the internet. She is an

29:10 outspoken critic of MIDI and she doesn't like the supplements and the face creams as well as the embrace of compounded GLP1. Direct quote from her. I will always maintain that selling women inadequately studied products under the guise of closing the gaps in healthcare and using misleading language is predatory and misogynistic. I cannot say it any better. So even Jackson, who is now a Trump appointee, has concerns about bad actors in that industry that she helped essentially give roots to. Scouting for the highest profit margins is a common prerogative. I mean, that's what anyone starting a business is, right? So then that's the problem with medicine being a capitalist business. [gasps] Public health offers hormone therapy through her own concierge practice and endorses it as a longevity aid, but stresses it must be used alongside

29:56 healthy lifestyle and draws a line at selling supplements, lotions, or other extras favored by some of the big virtual clinics. So you're going to use an unsupported claim that being on hormone therapy will make you live longer, but draw the line at selling supplements and lotions. May it make sense? So Lisa Shrink, who we started this article talking about, still sees the hormone therapy as a savior. And let's be realistic here, okay? Maybe it is for her. That can be a truth that exists within the greater context of this discussion where maybe it is life-saving for some people. But how many people do you have inadvertently thrown onto hormone medications who don't actually need them? and what is the negative outcome that could be

30:42 associated with that? Virtual clinics are driving rapid expansion of hormone therapies and are vectors for a distinct philosophy of medicine. The perry menopause 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 towards even more commercialization and preference driven medicine which we know skyrockets the cost of healthcare and does not improve outcomes. US already has the highest spend per capita on healthcare of anywhere else in the world anywhere on the planet. The US spends the most on healthcare per person per capita and has outcomes that do not reflect that as a sensical investment. Now is that all just because of capital

31:28 medicine? Not completely. Part of it is also because of the medical legal side of things in the US, but it's certainly not helped by things like this. And make no mistake, this is an effort to eclipse the current healthcare system. When I asked Mini 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 the goal of becoming a one-stop shop for half the population's health needs. We're building out a national specialized primary care company for women. A lofty goal, but one that MI and its competitors track records suggest is possible. In a few short years, hormone therapy for permenopausal women swung from inaccessible to inescapable. Every day, as the number of women taking hormones rises, they join an ongoing treatment group that is essentially an

32:15 experiment because pmenopause hormone therapy does not have large data sets for it. So, when it comes to doullling out estrogen and progesterine prescriptions, the goal is balance. And this is what I've been talking through the whole time. If you're a doctor who's practicing gold standard medicine, that doesn't mean you're never going to prescribe off label hormone therapy to somebody who is permenopausal and doesn't have a standard indication for it. It just means you're going to balance that with a wider, more broad knowledge of the fact that my money comes from treating people for things that are causing them problems, not my money comes from giving you hormones for per menopause. The industry, however, is zeroed in on growth, not balance. and that becomes the problem. That was a

33:00 really really great article. Thank you Kate Nibs for writing that. I'm very appreciative and hopefully that makes a video that you will learn something from and will prompt you to think critically when you are served these things in the algorithm.