Women’s Health: An Investing Whitespace

Stephanie Sirota: November 2025—the U.S. Department of Health and Human Services announced the FDA would remove the misleading black box warnings on hormone replacement therapy (HRT) for menopausal women. This was a major step forward for public health and one that also underscores the broader economic and innovation opportunity in women's health care.

But where do we go from here? How can we responsibly course correct after decades of care gaps and ensure that women are set up for a healthier and more informed future?

Welcome to the RTW Podcast where we aim to keep our audience healthy, wealthy, and wise.

I'm your host Stephanie Sirota, Chief Business Officer and Partner at RTW Investments. Today, I'm very excited to welcome another Stephanie to the podcast, Dr. Stephanie Lam. She's a board-certified OB/GYN at Carnegie Women's Health in NY. Stephanie, thanks for joining us.

Dr. Stephanie Lam: Thank you for having me.

Dr. Lam’s Path to OB/GYN

Stephanie Sirota: You're an OB/GYN providing services to women throughout their lives. And you also specialize in perimenopausal and menopausal care and minimally invasive surgical techniques. Let's maybe start with what led you to go into this.

Dr. Stephanie Lam: I thought I wanted to be a pediatrician. When I finally got into medical school, I did a rotation in OB/GYN. And I fell in love.

So, I did my residency in OB/GYN.

I loved a little bit of everything. I would do some gynecology. I would take care of OB patients. Never, back when I first started, did I ever think that we would be heading in the realm of where we are now. Which is really spending such a good and significant amount of time on women entering their 40s and 50s, because we never concentrated on that before.

Stephanie Sirota: When did you start to see this shift?

Dr. Stephanie Lam: In the last five years, there was so much with regard to social media and in the news talking about women, and how do we better take care of them.

And thanks to women like Dr. Mary Claire Haver, and movies coming out from Tamsen Fadal talking about why women have to suffer in perimenopause, I must spend 90% of my day talking to women both in the peri age and the menopausal age.

Defining Menopause and Perimenopause

Stephanie Sirota: What is perimenopause and how do you know you're in it?

Dr. Stephanie Lam: Now, that's a little tricky because some women don't have a uterus. And some women may be on medications and such that prevent your periods from coming.

But by definition, menopause is one year without your period. The average age of menopause is around 51 years of age. Perimenopause is the years leading up to it. And that time period could be three to eight years. Our hormonal system is a beautiful dance: we get our periods, we go into ovulation, we go into a period again.

It's kind of like a wave. During perimenopause there is this intense fluctuation by which you have erratic flows of estrogen and progesterone. And that's when women start to feel quite uncomfortable.

For women who are approaching their menopausal years, periods are really erratic.

A normal menstrual cycle could be anywhere between 21 and 35 days. Patients will start to skip cycles at the end. They may skip two or three months. They may start to come super close, less than 21 days. Periods where they are, on average, somewhere between five and seven days, could last eight, nine, ten days.

The ones that bother women the most: sleep disturbance. Women are waking up at 2:00 am, 3:00 am, wide awake. They're getting intense hot flashes or temperature changes. They start to get joint pain.

We hear of frozen shoulder, back pains, aches and pains. Women start to suffer three, five, seven years before their periods start to fluctuate. Itchy ears, dry skin, hair thinning, mood changes. There are so many symptoms that women suffer with that I don't think are identified as possibly what we consider perimenopause.

Stephanie Sirota: Sounds fun. (LAUGHTER) Tell us a little bit about the health impact and other areas that we should be aware of.

Dr. Stephanie Lam: When we look at women, each of our cells basically have estrogen receptors in them. As women get older and the estrogen volume and the hormonal impact starts to decline, each of our cells can be affected.

And this includes the brain. There's cardiovascular, there's neuro, and there's bone issues if they're not potentially on hormone replacement therapy.

Stephanie Sirota: Does the treatment of women that are entering peri and menopause fall within your care? Or do you see more collaborations with other areas of specialty medicine?

Dr. Stephanie Lam: We would treat them as a team. And I think that would include your cardiologist, potentially an endocrinologist, including radiologists.

So, as a primary caregiver, I see the patient. I examine them. And I spend some time with them. I really listen to them. And I want to hear how they're feeling. And based upon what their symptoms are, there are times where I will draw blood.

Blood is oftentimes very inaccurate because of the cycle. Hormones fluctuate. So, depending upon when we do these bloods, if we're looking for perimenopause, we may not find a lot.

There's a battery of tests that I typically check women for. And then I make sure that they're following up with the primary care doctor. I make sure that they're getting their mammograms, sonograms.

We've been sending women for bone density tests a lot earlier than we ever were, because we want to be proactive on bone health. And then I circle them back with their cardiologists. And now the next hot topic would be the endocrinologists for weight loss. Because women are suffering in perimenopause.

The Health Impact of HRT

Stephanie Sirota: What percentage of your patients are you prescribing HRT? Are they asking you for it?

Dr. Stephanie Lam: Most people are coming in to ask about it. Since the black box warning came off of HRT, I've never been busier. Many women are frustrated because a lot of health care providers just aren't talking about it. And they're not quite up to date yet as far as where do they fit in. You know, is it safe?

Stephanie Sirota: Is there a subset of the population for whom it is not safe?

Dr. Stephanie Lam: This big study came out back in 2002 called the Women's Health Initiative. It was federally funded specifically to look at the outcomes of women who are on HRT (hormone replacement therapy).

The flaw with the study is that they took a bunch of women who were much later in life. By then, they had already been in menopause probably at least ten years.

There probably was already insult on the blood vessels, their brain, their heart, their breast. They didn't get the outcome that they thought they were looking for. And it said that there was an increased risk of breast cancer and potentially blood clots and such.

It was a skewed study. And then everyone stopped.

The hormone replacement therapy that we are giving now is bioidentical, meaning that we're giving estrogen and progesterone that mimics what the body normally makes.

Part of the reason why this black box warning changed, is because there is not the risk that we thought there was. There's only benefit. And so decades of women have lost out on doing hormone replacement therapy.

Stephanie Sirota: And it sounds like timing is also a factor. So, you should—

Dr. Stephanie Lam: Huge.

Stephanie Sirota: —be starting it earlier.

Dr. Stephanie Lam: The studies now show that if you start your hormone replacement therapy while you're in peri, so before your estrogen declines, it can have a positive impact on the breast, the brain, the bones, and the blood vessels in the body.

Women who start hormone replacement therapy earlier are going to have a way better outcome with regards to cardiovascular disease, dementia specifically, bone health and osteoporosis risk, and breast cancer.

So, for women who are scared out there, I think you have to look at your everyday well-being and realize that HRT is not the issue, but it's the whole person.

There are a subset of women who should not take hormone replacement therapy: women who have endometrial cancer, breast cancer, in general, the cancer family. If you had a history of a blood clotting disorder, I think we weigh those patients more carefully about the type of hormone replacement therapy we give. But I think a lot of women should be taking it.

Stephanie Sirota: Before menopause?

Dr. Stephanie Lam: Yes.

Stephanie Sirota: So, what if they are asymptomatic?

Dr. Stephanie Lam: We try to tailor care to the individual patient.

That includes things like exercise, diet, and supplements. There are simple things that all women should be doing in the mid-30s going into their 50s.

If they're not getting in good calcium, they can take a supplement. Your vitamin D should be taken with some vitamin K. Omega-3 fatty acid, which is great for brain health and heart health. Creatine if you can take five grams in a day, it's good for brain. It's good for bone.

And then from there, I look at a patient, and I think, "Are they still fertile? Are they sexually active?" And maybe instead of jumping to a hormonal therapy, we oftentimes give patients birth control pills which can mitigate some mild systems, but also protect them at the same time.

A Holistic View of Women’s Health

Stephanie Sirota: I love that you look at this so holistically. Medicine is moving toward more integration with non-medical interventions, nutrition, fitness, and the importance of sleep. Do you see that as well?

Dr. Stephanie Lam: I do.

If we could look at a woman in a holistic perspective, I think they do great.

Women tackle a lot. To find good sleep and to find good mood and to be able to balance all that is just a challenge.

Stephanie Sirota: And stress management.

Dr. Stephanie Lam: 100%. It is a lot just to get through the day. And then if you look at women who are coming to the office, they're beaten. They're tired. And then on top of it, they're not feeling great.

It's a tough time for women. Oftentimes, they're looked at as anxious, or crazy.

If a woman comes into an emergency room and she's having chest pain, they will oftentimes think that it's anxiety-based as opposed to potentially a real cardiovascular issue. So, in our office we have a full-time nutritionist. We do have great relationships with primary carers, endocrinologists, and mental health therapists. We try to look at the woman as a whole.

Stephanie Sirota: And it's especially important for women to be informed themselves so they don't miss anything.

Dr. Stephanie Lam: The platform that came out of COVID with regards to doing online telehealth and creating companies that made health care more accessible to women is something that has been a blessing.

You can literally go online, find a health care provider who's willing to talk to you for a nominal amount of money.

In the middle of the country, they can get health care that they didn't have before. If you go on Instagram, TikTok, you can find doctors who are talking to you about anything that we're talking about today. That never happened ten years ago.

Stephanie Sirota: Although, you have to be really careful.

Dr. Stephanie Lam: Correct, buyer beware. But then they can kind of go back to their OB/GYN and say, "Hey, where do I fit into this?" And I think if they're not listened to, they have a great accessibility to find other providers now.

Stephanie Sirota: Would you ever consider having a telehealth option for women who do not live in New York City and have access to top docs like you?

Dr. Stephanie Lam: I do Zoom visits one day out of my week.

If a patient lives far and they want to actually talk to somebody, I'm happy to speak to them on the phone and get them started. We’ve done that.

Stephanie Sirota: Is it possible to treat someone that can't see you regularly or at all?

Dr. Stephanie Lam: Yes, as long as you do your blood work. You could set up a follow-up visit.

Where I think you have to be careful is, putting a hand on a patient and doing a breast exam and making sure you're not missing out on a baseline test such as pap smears. So, if they're getting their OB/GYN care with somebody local to them and they could send their labs to us, I think it's great.

GLPs and Women’s Healthcare

Stephanie Sirota: How many of your patients are on GLPs or are GLP curious?

Dr. Stephanie Lam: More and more are exploring the idea of integrating their GLPs with their hormone replacement therapy.

Stephanie Sirota: Why does that work?

Dr. Stephanie Lam: If you eat the same and you exercise the same, it doesn't make a difference. Women will start to gain weight. And that's a basic biological factor. There's insulin resistance. There's cortisol that is fluctuating. And part of it has to do with sleep.

If we find a woman is a great candidate for this hormone replacement therapy, and you start it, they start to feel better. They start to sleep better. Their body is metabolizing better. And then you integrate a GLP.

It's been shown that you have an improvement of greater than 25% in the outcome, both of the drug and the hormone replacement therapy together.

The long-term health benefits also from the GLPs are outstanding. There's going to be studies that look at breast cancer, Alzheimer's, inflammation, how you feel. They're amazing drugs.

These drugs have been on the market for a long time in the diabetes world. It's just that they've kind of shifted into the realm of weight loss management and optimization of weight.

Stephanie Sirota: That's right. They've been around for 20 plus years.

Dr. Stephanie Lam: Correct.

Stephanie Sirota: So, we have a good basis of understanding of what long-term side effects are. And they're safe.

Dr. Stephanie Lam: Very safe, if you're under the care of a good provider, you're eating well, you're exercising. I think in general you have to be cautious with any drug that you give.

If you lose weight too quickly you can get sarcopenia, which is the loss of muscle mass.

That's where you can integrate things like the protein you're taking in, which is hugely important. I never talked more about protein in the last three to five years. It's outstanding.

The word "cottage cheese," it's crazy. So, 30 grams of protein, give or take, in the morning. You want to have it throughout the day.

Stephanie Sirota: That's a lot of protein.

Dr. Stephanie Lam: That helps out with the side effects of the GLP. Because you want to maintain that muscle mass.

The frustrating thing for women in this space is for a doctor to say, "You need to watch your calories and exercise more," these are not dumb women. These are women who are implementing this in their daily life. And they're hitting a wall.

That five pounds creeps. It is exponential. And it's not their fault. They're not sitting around eating bonbons.

As far as the companies go, making it way more accessible for women or men. I think in the end is going to be hugely beneficial from a health care perspective in the long-term. Whether it's fatty liver, we know body fat which produces hormones, can have a direct impact on cancer.

Stephanie Sirota: So, a lot of people ask about longevity. I think the GLPs as a class of drugs are probably the closest thing that we have today to a true life extender. Certainly, a health span extender.

Would you put HRT in that same category?

Dr. Stephanie Lam: The longevity play of whether you're looking at it from a glucose perspective with GLPs or whether you look at it from a HRT perspective when it looks at bones or heart, or brain. The number one killer of women is not breast cancer. The number one killer of women is cardiovascular disease.

I think women are scared to pieces of the dementia aspect. Because we have women who are working longer and later and more professional.

And if anyone's been through perimenopause, brain fog is no joke. Your loss of words, your loss of ability to run your job and to exist becomes almost impossible.

The risk of osteoporosis, women falling and breaking a hip who are admitted to a rehab facility and then unfortunately dying from a complication is tremendous.

If you are a person who does their research and feels a systemic bioidentical hormone replacement therapy is not for them, you at least should be looking at vaginal estrogen.

Vaginal estrogen for women will maintain vaginal health. It decreases burning, pain with intercourse, and it decreases urinary tract infections, which for women are a major cause of sepsis and admission to hospitals. It's not systemically absorbed, offers you no risk in general, and it gives you a ton of protection from the bladder and the vaginal perspective.

Investment Whitespaces in Women’s Health

Stephanie Sirota: There are options. I don't know that the medical and the scientific community ever really wanted to spend that much time on menopause because women after the age of 50 were not running companies or countries. Society has changed a great deal, thankfully.

There is a lot more information available. What do you see as still being potentially underfunded?

Dr. Stephanie Lam: Making hormone replacement therapy accessible to women, there's a huge shortage because so many women now are taking it.

So, if I called in a patch for a woman, they couldn't get it, there would be a pause in their care, and therefore they would feel lousy and then have to restart. So, making sure that the drug was consistently accessible.

I work out of Mount Sinai. There's a whole women's division now that was created. Northwell is going to be putting a ton of money into their women's division. Large academic institutions want to rally around the longevity of women and create a space where they have endocrinologists, primary carers, cardiologists, OB/GYNs, radiologists, et cetera.

Stephanie Sirota: What other gaps come to mind as we discuss more broadly women's health?

Dr. Stephanie Lam: If you took the time to ask a patient in the office just in general how they're feeling, a topic that they may be a little nervous to discuss is probably low libido.

That space has been really interesting to hear about as well in the last year to two years.

Stephanie Sirota: That's true. Because when you think about sexual health, it certainly has been a topic for men. (LAUGH)

Dr. Stephanie Lam: Correct.

Stephanie Sirota: I sort of always joke. But I think if menopause happened to men, then it already would have been solved.

Dr. Stephanie Lam: You'd have the top five drugs out there. And-- (LAUGH) and this wouldn't be a Viagra issue, which was basically cured and paid for a way, way long time ago with regards to that. There's a very cool product called the Addyi.

It's a little pink pill. But it's been just FDA-approved recently for libido. The woman who started the company used to work in that realm, but on the other side for male production.

Whether it's prescribing testosterone in small amounts or whether you look for a medication, I think that space is up and coming.

Stephanie Sirota: When funding priorities are shaped by a historically male-dominated system, drugs either don't make it forward, or they come forward like the Addyi, many years later after a Viagra. What else have you noticed has gotten excluded during research and never made it into the pipeline?

Dr. Stephanie Lam: I think mental health probably to some degree to tie it in a little bit.

For women who are suffering with anxiety and depression from their late 30s all the way to 50, rather than putting them on an SSRI as number one, I think the conversation has to be had: "Is there something else going on besides just an authentic or organic mood disorder?"

I think in general women and ADHD, there's so many conversations to be had that when estrogen declines organization and how women think, their brain just isn't functioning as well. And I think a great space to look at for women is the role of how estrogen or medications for ADHD and diagnosing it would be great for women who are in the peri and menopausal phase.

Stephanie Sirota: Do you want to see more research? Do you want to see more clinical testing of therapeutic interventions? Is it all of the above?

Dr. Stephanie Lam: I think it's all of the above. Women are very stoic. They go to the doctor more regularly than men do.

Women show up to the doctor for their annual check-up. And they're very good about going to their OB/GYN. But there's always been more accessibility for good drugs and good health care for men as they get older.

Having a better platform for women and preventative care would be great.

Stephanie Sirota: Maybe you should also come up with widely shared talking points and questions to ask your doctor.

Dr. Stephanie Lam: It's worth writing a list and carving out the time a little bit.

I think the other amazing thing is you can really use AI. If you go onto ChatGPT or Gemini, and you type in your symptoms, it'll give you questions that you can go back and ask your provider and help organize your thoughts.

Because sometimes you don't even know where to start. Not every doctor allocates 30 minutes. You may get 15 minutes and that’s it.

So, you want to be very strategic about going in and asking the questions.

Dr. Stephanie Lam: If your provider looks at you and doesn't have the interest to answer your questions, you feel dismissed. You feel defeated. And you walk out and you don't finish that conversation.

The online platforms have done a beautiful job, because you can book an appointment online. That's where companies are growing. And that's where women are going to build into the space.

Stephanie Sirota: So, it sounds like things are moving in the right direction.

Dr. Stephanie Lam: It’s exciting. The next five years are going to bring some landmark studies. And I think it's going to be really positive.

There's never been more books. There's never been more famous people talking about it. There are celebrities that are talking about the space of perimenopause.

And I think that there's going to be a lot of money invested in this space.

Stephanie Sirota: The more this is talked about, and the more normalized it gets, then the better.

Dr. Stephanie Lam: Well, I'm here for it. The future's brighter than ever.

Stephanie Sirota: Thank you so much.

Dr. Stephanie Lam: You're welcome. It's been great.

Credits: The RTW podcast was produced and recorded by Devon Leaver at the RTW Headquarters in New York and edited by Dominique Guerra, with Production Coordinator, YingYu Lin, and production support by Annabelle Chan. Executive Editorial Advisor was our Partner, Chief Business Officer Stephanie Sirota.

This interview was given by Dr. Stephanie Lam, OB/GYN at Carnegie Women’s Health, and moderated by Stephanie Sirota, Partner, Chief Business Officer at RTW Investments, LP.

Statements reflect RTW's views and opinions as of the date hereof and not as of any future date. All expressions of opinion are subject to change without notice and are not intended to be a forecast of future events or results.

The views expressed by guests are their own and their appearance on the program does not imply an endorsement of them or any entity they represent.