Transforming Peri/Menopause Symptom Management

Over 50% of the population experiences perimenopause and menopause. Yet, like with most women's health issues, there's not enough data and information. Thus stumping clinicians and women alike. Dr. Alicia Jackson is the founder of Evernow, a telehealth platform, supporting women in this stage of life. Evernow conducted a survey of over 70,000 women to better understand this stage and is using that data to more effectively help the staff at ever now support the women coming through its doors. Dr Jackson and I sat down to discuss Evernow’s survey findings and how women can apply this information into their own care.

Georgie Kovacs: How did you come up with the concept of Evernow?

Dr Alicia Jackson: This is not at all the company I thought I'd be starting right now. I have a deep science background from my life at MIT, investing in biotech through DARPA, I thought I'd be starting in a fertility company right now. I took six months off to do nothing but to study that space and really understand what the opportunities were. During this time period, I came across this really interesting piece of research talking about how to reverse menopause in young women who had gone through chemotherapy. It brought up all these questions, and I knew right then that there was something interesting there and started to research menopause further.

The Women

This is the first generation who may live longer post menopause than in menopause. And seeing how tightly correlated when you go through menopause, and how that's managed, whether you're on hormonal therapies or not, can make a big impact on your risk of things like cardiovascular disease, osteoporosis, neurodegenerative diseases, diabetes, and more.


I had thought this was an experience of women much older than in their 40s. Women start going through perimenopause, that period of time when your estrogen starts fluctuating and decreasing in your 40s, and then the average woman in the US hits menopause at 51. That's right in the smack in the middle of your life when you're going full steam.


I read stories of women struggling to find a physician who really is up to date on the latest science and research, who understands how to treat and recognize the symptoms of not only perimenopause and menopause, and who understands the greater health impacts not right, not just right then in the moment, but for the longer term.


Their Doctors

I also spoke to physicians who reinforced that they had had very little training in menopause and many who had had very little training since their residency, which might be 20 years ago, and our understanding of menopause and the role of estrogen and women's bodies and its role in protecting us against a lot of these diseases of aging, like osteoporosis, neurodegenerative disease, and diabetes, that many doctors just had knowledge that was out of date.

There is great data showing that if you have a family history of challenging menopausal symptoms, you are much more likely to have those challenging menopausal symptoms.

The Healthcare System

This is compounded by the fact that a lot of the medical system is not situated around, around being able to provide the care that's necessary during menopause.


I concluded that women need access to treatments and great care. Let's build a company to do that, and it's going to leverage telemedicine. We're going to create world class menopause care and medical care and deliver it to women 40+, and that was the creation of Evernow.

Georgie Kovacs: We’ve covered the dynamics of the healthcare system and its impact on women’s care. Tell us about the findings which surprised you most in your 70,000 person survey.

Dr Alicia Jackson: When women are going through that period of perimenopause, their symptoms are going to differ from what they might experience when they're in the thick of the menopausal transition, when they're going through a year without a period. When they're in perimenopause, they still may be cycling. A lot of women are going to have an abnormal period, though, and that's a really good signal.

We are also seeing a lot of symptoms manifesting in the brain. This is because estrogen is a key driver of energy metabolism in the brain, which is full of estrogen receptors. Yet this is the time when your estrogen levels are just fluctuating wildly, which is why we see high incidences of brain fog, anxiety, and depression. Over 70% of women report having these symptoms, and two thirds of those report these to be severe or very severe.


This is such an incredibly busy time in women's life. They're taking care of their kids, they're taking care of their aging parents, they're in the middle of their career, there's a pandemic going on. And so many women are like, "Well, of course, I'm stressed out of course, I'm suddenly having panic attacks, or I feel depressed because my life is so busy and so stressful dealing with all these things." But what they may not realize is that these are also the canonical symptoms of perimenopause and that they can do something about them to help treat those symptoms.


The good news is, those symptoms do tend to dampen down as you get into the menopausal transition. Now other symptoms pop up like hot flashes and night sweats that you have to deal with, but it is good that a lot of the ones that really have to deal with the mood will start to level out over time.

Georgie Kovacs: What helped women experiencing these symptoms?

Dr Alicia Jackson: We found that women who decided to take hormonal therapy found over a 72% reduction in those symptoms within two months. So hormonal therapy, if that is if it is perimenopause that is really driving those symptoms, a little bit of hormonal therapy and we're talking like a sixth of what you might have in birth control can really help to level those out. It's not going to get rid of the stress, but it's going to help in terms of how you can deal with that stress.

Georgie Kovacs: Tell us about the data related to hysterectomies.


Dr. Alicia Jackson: There was a strong correlation between women who had had hysterectomy in weight gain. We found that women who have had a hysterectomy were 27% more likely to have a BMI over 30 compared to women who had not had a hysterectomy. And this is something that we had heard a lot anecdotally, but I think is really powerful when you see it borne out in the data, and when you go and look at the scientific literature as to why this might be happening.

What we've definitely seen in, for example, animal studies, such as mice or different forms of monkeys is that if you take out their ovaries, which is one form of hysterectomy, you do see a huge decrease in energy metabolism nearly overnight. So it shouldn't be shocking that when women have a hysterectomy, and over 25% of women end up undergoing a hysterectomy, it is one of the most common gynecological surgeries.

Shockingly, many women are not counseled about the health effects. Essentially overnight, your estrogen levels drop rapidly. One health effect that you can have includes very rapid weight gain. It's important for women to be counseled on this, and it doesn't mean they shouldn't have a hysterectomy, but they should probably be counseled that you should definitely be on hormonal therapy immediately after hysterectomy to really help to buffer out that very rapid transition.


We've had so many women come through Evernow telling us they really felt, in their words, "Bamboozled" after they got a hysterectomy. They were told, “You'll have a hysterectomy. This will solve whatever gynecological issue you're having right now.” But they weren't really told about the after effects. And it's more than just weight gain. It's also symptoms like brain fog, hot flashes, vaginal dryness, painful sex, inability to sleep, and it's all due to this very rapid, essentially deprivation, of estrogen for your body overnight.

Georgie Kovacs: Tell us what else you learned about BMI.


Dr Alicia Jackson: First, this really deserves a lot more study and research. We found that women with higher BMI tended to have worse vasomotor symptoms from menopause. These include hot flashes, night sweats, and anxiety.


And this goes against conventional medical training and thinking our fat cells produce a form of estrogen known as estrone. It was always assumed that women who were heavier, who had a higher BMI, would have lesser menopausal symptoms because they also had their fat cells creating estrogen, not just their ovaries. But what we've actually found is quite the opposite, which is that it does seem to be that women who are heavier and have more adipose tissue, have a higher BMI, tend to have worse menopausal symptoms.


There's some deep science to be done here as to why that is, but it also might mean that women who are heavier need a different dosing of hormonal therapy or a different protocol hormonal therapy if she chooses to take that to deal with her menopausal symptoms.

Georgie Kovacs: It is tragic women are not consulted more about hysterectomies.

Have you looked into the typical rationale for hysterectomies? I’m not asking to judge or say hysterectomies are not needed, but it would help to understand what tends to drive the need for them.

Dr Alicia Jackson: We have not to date collected that information, but I agree wholeheartedly we need to have that type of data. We do know that there are geographic differences as to rates of hysterectomy, which are where there tends to be more hysterectomies done in the South rather than, for example, the Northeast.


Georgie Kovacs: Do you have data on other predictors for what may impact the symptom severity outside of what you're finding with the BMI?

Dr Alicia Jackson: There is great data showing that if you have a family history of challenging menopausal symptoms, you are much more likely to have those challenging menopausal symptoms. Additionally, any amount of smoking results in higher levels of menopausal symptoms - worse hot flashes, worse anxiety, etc.

Georgie Kovacs: We started by talking about a challenging healthcare system based on how physicians are educated, and what we even understand about research that women know, because you're surprised, I was surprised when I started researching this. And now we have all these issues women are facing.

Now let's get into the solution. How does Evernow know if a woman is struggling with symptoms directly correlated to perimenopause or if it is something else? With telehealth, you can’t draw blood, unless, I assume you send the woman to a lab.

Dr Alicia Jackson: This is such a good question, because we have so many women coming through Evernow who have the exact same question, which is, "Don't you need to know my blood levels?" And I think, intuitively to all of us, at first glance, that totally makes sense.

Of course, you'd want to know your blood levels. The challenge is that everybody's setpoint for where they feel good, on estrogen is different. There's the normal range, but the normal range is really large. In fact, during the normal course of your cycle, that normal range can vary nearly up to 10 times. So you could go from a one on estrogen to a 10 on estrogen all in the course of a month. What that means is that, yes, we can take a blood test and we can find out whether you are in the normal range or not. The challenge is, it is just not that helpful.

To really understand how you're doing and how you're feeling, you would need to be tracking estrogen every single day. And at the same time, tracking how you're feeling and doing every single day. Unfortunately, there's just not a really easy, simple way to do that right now that's accurate and infeasible.


\And to be honest, you're a great barometer for how you're feeling and how much estrogen you have right now. If you have a lot of estrogen, you will know. You will be bloated, you will not feel well, you will be crying and weeping.


So it really is about your age, your periods, and your symptoms. And that is for most women, not for all women, that is enough to be able to make a clear diagnosis of where you are.

Georgie Kovacs: Tell us how Evernow works.

Dr Alicia Jackson: When we set out to build out Evernow and what we could offer women, we really set out to rethink how we could deliver care in a way that really solved women's needs. So number one, access number two. And by access, we mean, you can talk to a great medical provider anytime no matter where you're located. Number two, world-class medical service and knowledge. The standard I use is "do I feel comfortable sending my own mother here?" And then number three really being, really creating a service that was continual. So it wasn't just one visit one moment of time, but we'd really be on that journey with you.

The great thing about telemedicine is that it hits all of those points.


We have a core group of OB GYNs, many of whom are NAM certified - North American Menopause Society - certified, who've been practicing in menopause for many years, many of whom are reproductive endocrinologists, so they have a really deep knowledge of hormones and hormonal therapies. And then we also have a phenomenal group with nurse practitioners who are highly skilled and trained and are really partners in health with our members.

Additionally, because it's telemedicine, you can text us whenever you're having an issue any time, day or night.

When women contact us, we take them through a comprehensive health intake, which was developed by OB GYNs. We ask:

  • What are your symptoms and goals?

  • What do you care about?

  • What is bothering you the most?

People might have hot flashes, but it might be the weight changes or the sleeplessness that is bothering her the most, and that's important for us to know.


We also collect a bunch of biographic data - height, weight, age, last period, medications, and recent surgeries.

It's very comprehensive and that helps us to understand whether you are a great candidate for Evernow and determine the best treatment plan for you. Not all women are going to be great candidates. You may have other things going on in your health, where we think you should go see an in-person provider, and we provide you a list of other providers that you can go see in your area.


Should this be a fit, you sign up for the service, we connect you with one of our medical providers, and we ask any follow up questions that we might have for you. It's a time for our members to ask any questions of the medical practitioner. And then at that point in time, we send a script to one of our pharmacies and the treatment is shipped to your home.

We check in with you every few days, especially after you start the treatment. And so we really try to work with women along this pathway, especially because if it's been, let's say, a year since you've been in menopause, and suddenly you start taking a hormonal therapy again, you're definitely going to have some side effects as you ramp up on that hormonal therapy.

Georgie Kovacs: When I researched your website, it seems as though it's prescription forward, not so much around supplements. Tell us about that.

Dr Alicia Jackson: Yes, it is true. That is our starting place, and it's that way for two reasons.


Number one is we saw a real need around hormonal therapies and physicians who knew how to prescribe them. They are the gold standard. It is amazing how well they work, and it makes sense you're losing estrogen. And so if we replace the estrogen, your symptoms are going to go away. They are scientifically proven to remove and eliminate symptoms in 80% of women and decrease symptoms in the remaining 20% of women. That's phenomenal for any sort of therapy that's out there.

That doesn't mean I don't want to move into other areas. In fact, we do critically want to but part of our promise to women is that we're only going to offer the things that are scientifically backed by the best medical research. And unfortunately, we're not quite there yet with a lot of supplements. That is something I personally want to change because not all women can take hormonal therapies. Not all women want to take hormonal therapies, I completely respect that. But what I want to be able to offer women is okay, if you can't or do not want to take hormonal therapy, what can we offer you that will be effective for you.

There's some really interesting things out there like soy isoflavones and black cohosh, but we really need to get much more solid evidence on it because I want to make sure whatever we're prescribing for you is going to work.

Georgie Kovacs: That makes a lot of sense, and this is the frustration with women's health. It's why I bring on different types of experts like functional medicine experts and MDs, because they do vary in perspective on how they treat various conditions and symptoms.

So when Evernow is doing the intake form, do you try to gather information about the type of treatment women want, whether they want supplements, or they're okay with being prescription forward?

Dr Alicia Jackson: We do find women kind of self-selecting. We're very clear on our website that we're very prescription forward. We aim to meet a woman where she’s at..

Georgie Kovacs: Let's talk about access. What I like with telehealth is, regardless of where you live, this allows access to the best of the best. But then there's the other access, which is being able to cover the costs of this care. How does the consumer pay for Evernow’s services?

Dr Alicia Jackson: We have a monthly membership model. You pay a set price every month. We are cash paying right now, but we can also be covered by HSA or FSA, which many women opt for. And we will also help women submit to their insurer if they want to try to get that covered.

The challenge in this space is that unfortunately, many insurers do not cover the cost of many of the menopause prescription treatments, which is frustrating. Thus, for many women, even these very tried and true solutions that can have such a big impact on a woman's health may only be 50% covered by their insurance company.


Given that, we decided that, for now, we would be cash-paying because the overhead, unfortunately, of integrating with an insurer and having to make deals with each insurance company would result in a huge amount of complexity for our company right now. Additionally, we would hamstring what we could offer women because it turns out that unless your insurer is covering one thing or another, we can't offer it to you.

Georgie Kovacs: What do you see as the future for telehealth and women’s health?

Dr Alicia Jackson: This all just plays into the larger story that so much around women's health has been understudied, misunderstood, and is so ripe for finding a lot of interesting insights and impactful insights on women's health. I'm most excited about being able to use our platform as a way to collect this great data on women's health and understand how different treatments and protocols can impact women's health and use that to drive medicine for women forward. That's what I'm lit up about.

I think telemedicine is going to play an increasing role here in terms of moving our medical knowledge forward in a much faster way than we've ever been able to do.


It's very clear menopause is a trigger for a lot of these diseases of aging. And if we can understand how to manage that period of time, the outcomes for women and their lives and their health are just enormous. And I think we can do that very rapidly.


Georgie Kovacs: Wow, that's a perfect way to end this discussion. Thank you so much for your time.

Dr Alicia Jackson: Thank you Georgie. This has been a fantastic conversation and thank you for your support.

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