Axios AM Deep Dive: "Femtech" lifts women's health

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When it comes to women's health, Americans — and the advertisers that market to them — are getting blunter. 

What's happening: Women's health is undergoing a generational cultural change. Younger women talk more openly about their periods and sexual health concerns — and more companies are marketing to them with messages that women only whispered about a few years ago.

Why it matters: The shift in conversation, and what people feel comfortable addressing head-on, could ultimately lead to changes in the health care women receive.

"Consumers and women are more empowered today than they ever have been to speak about issues that historically have been stigmatized or spoken about in a shameful manner," said Varsha Rao, CEO of Nurx, a women's telehealth company.

Much of this shift has come with changing expectations among Gen Zers.

A survey of more than 2,000 women ages 18 to 38 by menstrual cup company Lunette found 83% of Gen Zers felt periods are a totally natural process and should be discussed by everyone, including men. In comparison, only 72% of millennials agreed.

There's a "profound seismic shift" from previous generations, Deena Shakir, a partner at Lux Capital, told Insider. 

There has also been an increase in understanding about the market power of women's health in recent years.

Female-led health care brands such as Maven, Elvie and Nurx have become more common in recent years, raising hundreds of millions of dollars in venture capital for technology solutions directed at women's health concerns.

In 2019, the “femtech” industry generated $820.6 million in global revenue, according to PitchBook.

State of play: Accompanying this shift are messages from marketers that are far franker than years' past.

Just a decade ago, the menstrual hygiene company Kotex had its ads banned from airing in the U.S. because it used the word "vagina."  

But last year, the period underwear brand Thinx launched an advertisement depicting women experiencing stained sheets from their periods before discovering their product.

Far from using the euphemisms of intimate washes, Lume Deodorant ads encourage women to apply the product to fight their "crotch and butt smells."

Schitt's Creek actress Annie Murphy tells viewers, "Welcome to my vagina," before extolling the benefits of non-hormonal birth control gel Phexxi, while an ad for estrogen therapy drug Imvexxy exclaims: "Your vagina is queen."

That level of openness can be valuable in setting the tone for conversations with health providers.

It can empower "women to be thoughtful about their pelvic health in ways that aren't embarrassing to them," Verywell Health chief medical officer and OB/GYN Jessica Shepherd told Axios.

Rao of Nurx said that "around here, we talk about gonorrhea the way some people talk about the common cold."

"What we've found is, when you start talking about these issues, it's very liberating and it's when you're able to deliver the best care possible."

Yes, but: Some subjects are still off-limits. Pitchbook wrote last year that Facebook rejected an ad by Lily Bird, a subscription startup delivering bladder leakage products to women in menopause, that exclaimed, "Laugh more and leak less."

Language restricts. A Columbia University Irving Medical Center study from 2020 found that women who identify as being non-heterosexual may not seek preventative sexual and reproductive health care at the same rates as their heterosexual peers because their providers aren't using inclusive language.

Inequities persist. A 2020 study from Indiana University-Bloomington found that Black women reported having conversations about their sexual activities (e.g., condom use) and were offered sexually transmitted disease testing more often than white women. 

The bottom line: We've come a long way, but we've still got a long way to go.

1. A generational shift on women's health

Younger women talk about it more openly, and more companies are marketing to them.

Illustration of an abstract collage of medical and mathematical diagrams.

Deep Dive: How women's health is changing

When it comes to women&#x27;s health, Americans — and the advertisers that market to them — are getting blunter. What&#x27;s happening: Women&#x27;s health is undergoing a generational cultural change. Younger women talk more openly about their periods and sexual health concerns — and more companies are marketing to them with messages that women only whispered about a few years ago.

The U.S. faces a range of health care flashpoints — unaffordable drugs, opioids, vaping — as we debate whether to adopt universal care. For now, the Affordable Care Act is the law of the land, but Republicans want to issue it a final death blow.

Health

The lingering legacy of clinical trials failing to include women as participants, combined with frequent gaslighting by doctors and a general lack of research on women's bodies, has led many to mistrust medicine.

Why it matters: This mistrust plus a constant barrage of misinformation can influence women's health decisions, including deciding not to follow recommendations for the COVID-19 vaccine.

Case in point: Trust in the COVID-19 vaccines has eroded for some people because of misinformation linking the shots to infertility and growing anecdotes about temporary changes in menstruation — causing confusion and hesitancy.

"For many women, their minds go there right away because, one, we're primed by all the misinformation that is very intentionally put out there to try and weaponize views like fertility concerns ... to undermine the vaccine," says Alice Lu-Culligan, an M.D.-Ph.D. student at Yale School of Medicine who is researching the topic and wrote in the New York Times (subscription).

"And then, as humans, they often will default to being conservative and being safe, especially with something as vague and weighty as fertility," she adds.

While the COVID vaccine trials did include a roughly equal proportion of women and men, the decision in the early clinical vaccine trials to exclude pregnant women fueled hesitancy, several experts tell Axios.

Between the lines: While it's a good example, distrust goes beyond the topic of COVID-19 vaccinations and stems from a number of factors, including...

1. Gender differences are often ignored in trial analyses for drugs in a system that "has sexism embedded in it," leading to a loss of key knowledge, says Namandjé N. Bumpus, director of the Department of Pharmacology and Molecular Sciences at Johns Hopkins University School of Medicine.

Women and even female animals were excluded from trials for a long time in the belief that a women's menstrual cycle or an animal's estrous cycle could affect outcomes, says Viki Male, lecturer in reproductive immunology at Imperial College London. 

2. Representation in trials is particularly low for transgender women and women of color, who often are not given proper access or encouragement to join these trials, Bumpus says.

"So, you're telling me that half [of COVID vaccine trials] are women. That's great, but what is the breakdown when we're talking about these groups that are historically underrepresented?"

"I do think that is a major issue [for] Black women, Latinas, Asian women and Indigenous women. Those folks are still being left out of clinical trials in many ways. So, I think that data needs to be reported," Bumpus adds.

3. A lingering taboo over talking about certain topics surrounding women's biology, combined with lack of research, can lead to ignorance.

"We don't understand enough about female biology in general, and we definitely don't know enough about all the things that can affect menstruation and what the mechanisms are," Bumpus says.

"There's not enough research. But, even with what we have, I don't think we talk about it enough," Male says. "A lot of people don't even know what the normal range is with respect to menstrual cycles."

Lu-Culligan agrees. Many women have noticed that if they get sick or stressed out, or alter their exercise routine, their period may change, but "we don't know exactly why" because the mechanisms are unknown, she says.

And, when women do want to talk about symptoms or problems, they often face gaslighting from their doctors — something shown over and over again through studies on pain treatment or disease diagnoses, as well as via personal stories.

The big picture: "We don't know a lot about women's biology, about reproductive health, about research in menstruation and research in pregnancy. But, on a positive note, research in all those topics is expanding," Lu-Culligan says.

2. Medicine's trust problem among women

Mistrust stems from a legacy of not being included in trials, doctor gaslighting, and miscommunication campaigns.

Illustration of two medical diagrams of hands reaching for each other across an abstract background.

Public health

Coronavirus

The lingering legacy of clinical trials failing to include women as participants, combined with frequent gaslighting by doctors and a general lack of research on women&#x27;s bodies, has led many to mistrust medicine.Why it matters: This mistrust plus a constant barrage of misinformation can influence women&#x27;s health decisions, including deciding not to follow recommendations for the COVID-19 vaccine.

A look at the scientific breakthroughs changing the world, explorations in space and in worlds beyond our own and the threats posed to us by our own planet, both out of our control and of our own making.

Science

Data: Myers Abortion Facility Database on OSF; Map: Thomas Oide and Sara Wise/Axios

Now that a Texas law has banned abortion in the state after six weeks, more states are expected to follow suit, making access to women’s health care in certain parts of the country even harder than it already is.

Why it matters: Large areas of the U.S. — particularly in the central region of the country — already have no options within a 250-mile drive, and some counties are at least 350 miles from the nearest abortion provider.

West Texas, Oklahoma, Kansas, Nebraska, North Dakota and South Dakota all have large areas that are at least a four-hour drive from an abortion provider.

Divide County and Burke County, North Dakota, are each 350 miles away from the nearest provider, as is Sheridan County, Montana. Andrews County and Terrrell County, Texas, are both more than 300 miles from the nearest provider.

Conversely, there are still counties on the coasts where people are likely to live close to an abortion provider, including Kitsap County, Washington, and Hudson County, New Jersey — both under a mile away.

3. The vanishing access to abortion providers

Some areas have no options within a 250-mile drive.

Now that a Texas law has banned abortion in the state after six weeks, more states are expected to follow suit, making access to women’s health care in certain parts of the country even harder than it already is.Why it matters: Large areas of the U.S. — particularly in the central region of the country — already have no options within a 250-mile drive, and some counties are at least 350 miles from the nearest abortion provider.

The pandemic may have put millions of more women — particularly young women — unknowingly on track for heart disease complications.

Driving the news: Several studies have emerged in the past year sounding alarms on how pandemic stressors like the increasingly difficult work-life balance, caregiving burdens and social isolation have left women bearing the brunt of this epidemic. 

"As time goes on, we are going to see the impact of the stress and lack of self-care that women have had to endure, which will predictably lead to the number one killer of all women, heart disease," warned one study from Mount Sinai in May.

By the numbers: Even before COVID, heart disease was already at the top of the list for women across all races and ethnicities, according to preliminary data from the CDC.

About 20% of both men and women have heart disease in the U.S., but many women of color and young women are at a higher risk.

Between 2015 and 2018, there were about 4 million women stroke survivors compared to 3.5 million men. About 3 million women had heart attacks within the same time period.

Now, the stresses on women have only gotten worse during the pandemic — and a study by two researchers at the Louisiana State University Health Sciences Center notes that there's a "clear link between psychological stress and heart disease."

The heightened pandemic stress is being caused by everything from job insecurity to the social pressure to care for children and older family members — and even gender-based violence as everyone has been stuck at home.

"[I]t is expected that with the given unprecedented levels of stress associated with the COVID-19 pandemic, women's [cardiovascular] health will be significantly compromised," the study warns.

Cardiologists are already seeing it in their offices.

"Women were suffering from great levels of stress before 2020, and I just feel like so many of my patients gained so much weight during the pandemic, alcohol intake went up, exercise went down, stress levels were higher," Malissa Wood, a cardiologist for Massachusetts General Hospital's women's heart health unit, tells Axios.

The big picture: Before the pandemic, women disproportionately died from heart disease when their symptoms and concerns about their cardiovascular health were ignored or even misdiagnosed. 

Within five years of a heart attack, nearly 50% of women will die compared to 36% of men, according to the American Heart Association. 

Women younger than 55 who arrived at emergency departments with chest pain waited 10 minutes longer to be seen, were less likely to be seen by a specialist, and were less likely to be admitted to a hospital or kept for observation compared to men, an NYU Langone study found in May.

What's next: Despite biological research milestones on women's heart health, researchers and doctors see a growing need post-pandemic to specialize in cardiology for women, enroll more women in clinical trials and change the culture in treatment options.

About 50% of women who come into the emergency room with symptoms concerning a heart problem don't have blockages in their main arteries and are usually sent home, a major flaw in cardiology, Samit Shah, an interventional cardiologist and assistant professor at the Yale School of Medicine, tells Axios.

This is because hospitals and emergency departments fail to look at a patient's smaller blood vessels where microvascular disease could be causing symptoms. 

"All of the testing we do as cardiologists is based on looking for blockages. They’re not really tailored to women," he says. 

4. Women's heart disease risk rises with COVID

Experts are worried the pandemic has put more women at risk.

Illustration of COVID and linear diagrams on a teal background. 

The pandemic may have put millions of more women — particularly young women — unknowingly on track for heart disease complications.Driving the news: Several <a class="gtmContentClick" data-vars-link-text="studies" data-vars-click-url="https://www.frontiersin.org/articles/10.3389/fgwh.2021.606833/full" data-vars-content-id="dbd65010-c915-46e6-93c1-892a633cc159" data-vars-headline="Women&#x27;s heart disease risk rises with COVID" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.frontiersin.org/articles/10.3389/fgwh.2021.606833/full" target="_blank">studies</a> have emerged in the past year sounding alarms on how pandemic stressors like the increasingly difficult work-life balance, caregiving burdens and social isolation have left women bearing the brunt of this epidemic.

Fewer women are uninsured (10.5%) nationally than men (13.4%), due in large part to Medicaid providing pregnancy coverage for low-income women. 

By the numbers: 16.1% of women are on Medicaid, compared with 12.7% of men, according to census data analyzed by the Kaiser Family Foundation.

Yes, but: Large swaths of the South still have restrictive Medicaid coverage or didn't expand Medicaid under the Affordable Care Act, leaving 1 in 5 women without insurance in states like Oklahoma and Texas. 

And while Medicaid pays for 43% of all births, that coverage can be short-lived for women since Medicaid coverage ends after 60 days postpartum.

5. Medicaid's safety net for pregnant women

Fewer women are uninsured (10.5%) nationally than men (13.4%), due in large part to Medicaid providing pregnancy coverage for low-income women. By the numbers: 16.1% of women are on Medicaid, compared with 12.7% of men, according to <a class="gtmContentClick" data-vars-link-text="census data" data-vars-click-url="https://www.kff.org/other/state-indicator/health-insurance-coverage-of-women-19-64-cps/?currentTimeframe=0&amp;sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D" data-vars-content-id="00c4bb36-5100-4dc8-addb-bf96fa022ad0" data-vars-headline="Medicaid&#x27;s safety net for pregnant women" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.kff.org/other/state-indicator/health-insurance-coverage-of-women-19-64-cps/?currentTimeframe=0&amp;sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D" target="_blank">census data</a> analyzed by the Kaiser Family Foundation.

One of the best-known protections of the Affordable Care Act was a requirement that contraception be 100% covered by insurers — but that doesn't always mean women are able to access the birth control their doctor prescribed for them.

The catch: In many cases, the newest contraceptives on the market are not covered — even when they are recommended by the patient's doctor — because an insurer's formulary calls for an older version of the same method.

The law requires insurers to cover at least one form of the 18 existing birth control methods at no cost to the patient, but not all of them.

State of play: Advocates say insurers are falling short of the law's requirement that they provide an "expedient exceptions process" when they reject full coverage. 

But no insurer has such a process in place, said Mara Gandal-Powers of the National Women's Law Center.

Instead, insurers use their established prior authorization processes, which can be lengthy for providers and result in a denial of the contraceptive they were trying to prescribe at least 50% of the time, advocates say.

The law center set up a hotline for women to report their experiences trying to access their birth control benefits. In some cases, women say the method, such as an IUD, may be covered but the insertion of the device is not.

In other cases, women say they're told by their insurers they need to follow what's called step therapy, which requires the patient to try and fail on other drugs before the insurer is willing to pay for the preferred drug.

This week, a group of House committee chairs wrote a letter calling for HHS Secretary Xavier Becerra and his counterparts at the Department of Labor and Treasury to ensure they are enforcing the law.

HHS declined to answer specific questions regarding the issue. In an emailed statement, an HHS spokesman said: "We take very seriously allegations related to this coverage and will continue to enforce the ACA mandate."

Between the lines: This issue isn't just about a personal preference for women. 

With a 50% unintended pregnancy rate in the U.S., there's clearly a problem with what women are currently able to access. 

"Some of the contraceptives have side effects that are just not tolerable to women," said Kimberly Whelan, vice president of policy, advocacy and access for Agile Therapeutics.

Many of the newer contraceptives that have come out in the last decade have important innovations that improve their safety and efficacy or reduce side effects, patient advocates and pharmaceutical companies say.

"When people don't have the method that works for them, they stop taking their birth control, and we know that's when unintended pregnancies happen," Gandal-Powers said.

That's the case Agile is making for Twirla, their birth control patch that got FDA approval in December.

The patch provides a lower dose of estrogen than other patches on the market, and it has a better adhesive to keep it attached to the skin. Both improvements can help reduce the side effects and improve the efficacy of the drug, Whelan said.

But many insurers are refusing to cover the patch at all, while others will offer partial coverage with patient cost-sharing.

The other side: "Twirla falls into an already-defined category of contraception," said Kristine Grow, a spokeswoman for America's Health Insurance Plans, or AHIP. 

"Patients have coverage for contraceptive patches without cost-sharing. Health insurance providers may cover Twirla as a non-preferred brand," she said, adding that just because an insurer requires some cost-sharing does not mean it isn't covering a drug. 

6. The ACA didn't solve birth control access

Many women are having trouble getting the right birth control.

Illustration of a medical diagram of a uterus with pills falling all around it. 

One of the best-known protections of the Affordable Care Act was a requirement that contraception be 100% covered by insurers — but that doesn&#x27;t always mean women are able to access the birth control their doctor prescribed for them.The catch: In many cases, the newest contraceptives on the market are not covered — even when they are recommended by the patient&#x27;s doctor — because an insurer&#x27;s formulary calls for an older version of the same method.

Axios AM

Good afternoon, and welcome to our Axios AM Deep Dive on women's health and the state of their access to critical health care. 

This edition is led by Tina Reed, author of our daily Vitals newsletter (subscribe here), and reporters from our health care and science teams.

A look at women's health and the state of their access to critical health care.

Illustration of a human heart medical diagram surrounded by various abstract shapes