Inside a Walgreens in Pacific Heights, an upscale district of San Francisco, Sydney Larson strolled through the aisles. Her heels clicked on the floor as she circled the cosmetics aisle, looping past colorful tubes of lipstick and fridges filled with two-for-one Vitaminwater. She frowned. She took another loop and continued her hunt for incontinence pads — less kindly known as adult diapers. “This is odd,” she said. “Normally, they’re signposted.”
Larson eschewed the tampons and condoms, and stopped next to a sign for ointments and itch cream — finally she’d found them. She bent down to examine the bottom shelves, and shook her head. “That’s god-awful geriatric marketing,” she said, turning over the bulky boxes in her hands. “Women don’t want to buy that at the register or put it in their bathroom.”
One of the reasons adult incontinence products are so hard to find in the store is because they make the people who need them feel embarrassed and old, says Larson, the co-founder of the Bay Area startup Lily Bird, a subscription service for incontinence pads and underwear. That’s despite the fact that incontinence affects half of all women over 40 — which can be the result of childbirth, stress, and other health issues. Up to 11% of men over 40 deal with it, too. For obvious reasons, most people probably never talk about it.
“Only one in 10 people use any kind of product because of the humiliation of going to the store,” says Larson.
Larson began researching female incontinence in 2018. Her background was in renewable energy, and she was looking for something new to tackle. “I wanted to be solving real problems for real women, not creating life optimizations for the one percent,” she says.
After hearing friends and family members were struggling with incontinence, she had her next idea. In January 2019 she launched Lily Bird with co-founder Jason Holloway, a mobile gaming development entrepreneur. Unlike standard incontinence briefs, which look like oversized Huggies, Lily Bird briefs are low-rise with a subtle lace design. They’re far from glamorous, but comparatively speaking, they’re practically Chanel.
Much investment is targeted at millennial products these days — commuter scooters and fruit-flavored e-cigarettes have reached unicorn status, for example — whereas femtech, which refers to tech-assisted female-focused healthcare startups, is tougher to fund. And just one of the 51 femtech startups highlighted by the market research firm CB Insights in 2017 mentioned menopausal care. In 2018, all femtech startups collectively raised $392 million, according to PitchBook (that’s up 1,604% since 2008), whereas three startups just for male erection pills raised approximately $180 million in 2018.
By 2030, the median age in the U.S. will be 40, up from today’s 37, and there will be more women between the ages of 40 and 64 than women under 18, according to the 2017 U.S. Census projections. Today, women make 85% of all consumer purchases and control 80% of all healthcare decisions. It’s no wonder, then, that the menopause market is finally growing. Still, it’s only predicted to reach $5.28 billion by 2023.
Midlife healthcare resources fall short for the estimated 31 million women currently juggling their symptoms with full-time employment, as well as the 2 million or so American women who enter menopause each year. “Perimenopause and menopause are not well understood by all general practitioners,” says JoAnn V. Pinkerton, executive director of the North American Menopause Society.
“Menopause symptoms did not reflect who I was as a woman,” says Ann Garnier, 54, a health technology executive in San Francisco. In 2017, Garnier started experiencing night sweats, brain fog, and weight gain — all classic signs of menopause. She hated not feeling comfortable in her own skin. After a lifetime of exercising and holistic eating, she felt her body was out of control. Her doctor’s response was that she try hormone therapy, but she pushed back. Was there anything else she could try first? What about lifestyle changes? She says her physician shrugged. Disappointed, she went home and started Googling.
“A lot of marketing to midlife women has been patronizing and dated.”
The information Garnier found was sobering. Less than 7% of women get some form of treatment for their menopausal symptoms, and 12% of women say their symptoms are “debilitating.” Garnier started journaling her symptoms, and she began noticing changes in her body and mood after lifestyle tweaks. She’d always been more of a yoga enthusiast, but after reading a study about the benefits of high-intensity training — classes she was always too intimidated to try — she switched up her workouts. Within six weeks, she lost weight and was sleeping better. But Garnier says she was frustrated that she had to seek out this information on her own. “There’s this shame and silence around menopause; midlife women are supposed to be invisible,” she says.
As women’s hormones change, they experience mood swings, sex can become painful, and their weight might change — but there’s a shortage of trained medical staff who understand what the medical community calls “puberty in reverse.” A 2013 study by John Hopkins researchers discovered that only 20% of OB-GYN residencies cover menopause, and that 80% of medical residents say they’re “barely comfortable” discussing or treating it.
The more Garnier read about this care shortage, the angrier she felt. In response, she founded Lisa Health, an online behavioral change program, to bring her own insights to other women. Her tagline is “Don’t let menopause call the shots.”
“Midlife women are striving to age well — we’re not the women of 20 years ago,” she says. “A lot of marketing to midlife women has been patronizing and dated.”
Unlike Garnier, Larson doesn’t have a healthcare background, so she knew she had a lot to learn. On a Thursday night in fall 2018, she signed in to the Kaiser Permanente building on Geary Boulevard, and made her way to a small classroom designated for a 90-minute session on female bladder health. The class was led by a friendly gynecologist, who handed out small booklets to the 15 or so women in the room. She thanked them for coming, and said that every attendee should be proud that they were actively trying to improve themselves. Larson flipped through the booklet. There were pages about the different types of incontinence, some literature on surgical treatment, as well as preventative measures such as changing one’s diet. The teacher then touched on the product options of the major brands — Poise Extra and Affinity pads — while attendees wrinkled their noses at the accompanying “diaper-esque” photographs.
Larson scanned the women’s reactions, noting their disappointment. At home, she laid out boxes from all the major suppliers on her kitchen table and started unwrapping the pads from their packaging. Then, she took a deep breath, hiked up her skirt, and slipped on a pair. The extra material chafed uncomfortably as she walked around the room. But she committed to wearing a different pair every day for the next few weeks, taking notes on their construction and design. Even though no one could see them on her, she says she felt awkward. She decided she wanted to build something better.
For many women, menopausal care is “not provided in their annual checkup.”
“I want to make women feel more comfortable,” she says. “Like we’re telling women, ‘You’re not old or broken or alone. Sometimes your body is a little unruly; that’s okay, you have options.’”
Lily Bird isn’t the only startup looking to make changes in the incontinence space. There’s Fannypants, Willow, and Modibodi. In November 2015, Thinx, the company that reimagined period panties, released ICON, a line of pee-proof machine washable panties. They’re now available in five styles — including a thong and hip-hugger — and seven colors, and they can hold between three to eight teaspoons of urine. Larson says she’s excited to see the space evolve, and that it’s refreshing to see innovation for Gen X, not just millennials. Her focus groups have found that many women want something disposable, rather than washable, which is why Lily Bird is focused on products women can toss after use.
Pinkerton says she is also pleased that startups are drawing attention to menopausal symptoms. “Many women are afraid to talk about leakage and stop exercising or wearing pads without searching out help,” she says, adding that for many women, menopausal care is “not provided in their annual checkup.”
But Pinkerton is also concerned about user privacy and confidentiality, and whether adequate assessment and full spectrum options are made available.
That’s where Jill Angelo, CEO of Genneve, an online clinic for menopausal women, believes she can make a difference. “Women don’t know who to see about it,” she says. Roughly 49% of U.S. counties lack a single OB-GYN, and by 2050, there could be a 22,000 doctor deficit. Angelo attributes this to the way society views older women. “In the U.S. culture we think of menopause as a stigma; it means you’re getting old and nothing sexy about it,” she says.
Angelo spent 15 years working in media and marketing at Microsoft before taking a sabbatical. During her break, she met former Neutrogena executive Jacqui Brandwynne, which developed into a spirited discussion about the lack of menopausal care. Shocked but inspired by their conversation, the women teamed up to launch Genneve. Today the company makes vaginal dryness products and provides education materials for its 30,000-plus users, and in January 2019, Angelo added a telehealth component that connects women with North American Menopause Society-approved doctors and nurses via a smartphone or computer.
Providing care is important, but so is fueling a cultural shift, Angelo says. “Modern women are more outspoken about their health,” says Angelo. As millennials age up, she expects the shift to be even stronger. “It’s a transformative time for women.”
A major challenge remains, however. As startups go, the market for people in midlife is underfunded. Both Larson and Garnier bootstrapped their companies with angel investors and friends, whereas Genneve has battled investor disinterest to raise just $500,000. “I’ve had investors say to me, ‘It’s a shame you are focusing on such a niche market,’” says Angelo. “And I’m saying, ‘No, this is half the population; every woman goes through this. But they don’t talk about it.’”
Ads for women’s healthcare are removed while companies selling erectile dysfunction pills stay up.
Genneve has also struggled with marketing, because Angelo says its Facebook ads have gotten rejected. “We can’t say ‘hot flash’ or ‘painful sex,’” Angelo says, noting that her ads for women’s healthcare are removed while companies selling erectile dysfunction pills stay up. A March 2019 story from CNBC reported that several similar startups are facing the same ad problem.
Larson acknowledges that people might not want incontinence underwear on their social media feeds, so she’s trying to keep her own marketing and packaging relatively discreet. Inside the apartment of her co-founder, she passed me a box of Lily Bird products to examine. I lifted the lid and scanned the glossy paper flyers that rested on top. “Your good leak charm,” read one. “It’s high time we stop saying sorry for the spritz.”
I dug farther into the box, tearing apart the pink and white tissue paper. At the bottom, inside a plain white box, the Lily Bird pads and briefs were neatly stacked in a row, printed with a green and purple design that resembled menstrual pads. If I didn’t know better, I wouldn’t give them a second look in the bathroom. Which is kind of the point.
“The brand is about being open and destigmatizing the issue, but we also try and meet people where they are,” says Larson. Her goal is to find a better way to get women the products they need without the implied shame that comes with finding those products at a drug store’s bottom shelf. “I’m all about taboo-smashing when it comes to the female body,” she says.