FemTech is such an exciting field within Healthcare, and, together with the Newsletter Digital Health Insider, we hosted our second roundtable with top industry leaders that shared their views regarding "FemTech: Innovation and Opportunities to Close the Gender Gap."

We counted on a tremendous amount of diversity across experiences in this panel. The experts joining us were:

• Mitzi Krockover, MD, Founder of Beyond the Paper Gown.
• Marissa Fayer, CEO and Founder at HERhealthEQ.
• Mira Kaufman, Investment team at Insight Partners.
• Josefina Ruiz, Investment team at Light-it.

In this blog post, we will dive deep into the different topics we discussed during the roundtable, such as the Gender Data Gap, Opportunities for Innovation in FemTech, Investing in FemTech, Tools and Resources to always stay updated in FemTech related issues, and more.

Read the recap and main insights below:

What is the Gender Health Gap?

Marissa Fayer related the gender health gap to research, data, and knowledge. She explained, "The gender health gap is the fact that women and men have different health and that there's a gap associated with it." So, it's a very literal definition.

The exciting part of this, she continued, is that in 1993, women were only allowed first to start participating in clinical trials, and that's only been 30 years from now. It seems like a long time, but the data is lagging, and only 41% of clinical trial participants are women, and that's across the entire health system. In the early stages, it's only 25%.

Women are 51% of the whole population, but without research, there is no data; without data, there are no new markets, products, innovations, or investments. Ultimately, without any of those things, everything stays the same, meaning things haven't been built for women, by women, or designed with women in mind.

Thus, women have worse health outcomes. And so this gender health gap means that women have disproportionately less care and fewer options for healthcare needs.

FemTech Beyond Reproductive Health

FemTech is usually associated with reproductive health, but there's more than that, and Mitzi Krockover explained it.

As an internist, she focuses on the whole woman, outside of what we now call "bikini medicine," though bikini medicine is critical.

Mitzi Krockover defined women's health in three buckets:

1. Diseases or conditions that both women and men suffer from but manifest differently in women. For example, in heart disease, women tend to have different symptoms, and the diagnosis and treatment may also need to differ. Another example is substance use disorder, as women metabolize drugs and alcohol differently than men.
2. Diseases or conditions that are predominant in women. Some examples of these can be autoimmune diseases like lupus, arthritis, and multiple sclerosis. Another example that disproportionately affects women can be Alzheimer's, as 66% of people with Alzheimer's are women, and also 80% of people with osteoporosis are women.
3. Diseases or conditions that just affect women fall under "bikini medicine." These are obviously very important to all women, and these are, for example, reproductive health from puberty, menstruation, pregnancy, menopause, breast cancer, and some mental health issues like postpartum depression as well.

Shocking Stats Regarding Gender Data Gap

Each panelist in the roundtable shared some of the statistics and facts that shocked them the most regarding FemTech and the Gender Data Gap; here's the recap:

• Women are 50 to 75% more likely to have adverse drug reactions than their male counterparts.
• One of the first studies to prove that women are not simply small men, or in other words, that you can't simply change the dosing of medications based on body weight, was not published until December 2022.
• There's such a public education gap and opportunity for women to be educated about symptoms and how they could be presented differently.
• Only 4% of research goes to women, and half of that goes to oncology. So, in reality, 2%, besides oncology, is the money going for research.
• The absolute number of individuals living and dying from cardiovascular disease is higher for women than men. Actually, it is the number one cause of death in women, but women's clinical outcomes have not improved at the same rate as men.
• We're missing diagnoses because it's a different disease in women.
• In some cases, it may affect the smaller vessels than the larger vessels, but the diagnostics that we have really are looking more at the larger vessels. That may be one of the reasons.
• Another significant issue is, for example, peripartum cardiomyopathy, heart disease during pregnancy. We don't know why that is caused, it could be a genetic link, but it's too soon to tell. Yet, that will not only affect a woman during her pregnancy but also pass her pregnancy and into later life. So, cardiovascular disease, in general, is a huge data gap.

Main Causes of Gender Data Gap in FemTech

Mira, part of the investment team at the VC Insight Partners, explained some critical causes of such a gender data gap in FemTech, pointing out that it wasn't until 2014 that the NIH came out with recommendations for sexual parity in preclinical research either. At every level of innovation, starting within bio in a Petri dish through clinical trial exclusions up until 1993 and also through medical school curriculums that predominantly teach off of male anatomy, women are not equally nor proportionately included in research.

Given that women are half the population, that women have more incidents of chronic conditions, that women spend more on Healthcare, and that women make most healthcare decisions, the only reasonable conclusion that we can come to around how we got here and why we got here, is to talk about the institutionalized sexism that manifests and perpetuates shame and taboo around women's bodies and their lived experiences; because the market opportunity and the need certainly do not paint that picture.

FemTech Research and Initiatives Rise

Over the last couple of years, there has been a rise in research in new companies and FemTech initiatives, and it is essential to ensure that all these findings are actually incorporated into the healthcare landscape.

How? Mitzi mentioned that awareness is first and foremost. The revitalization of the National Health Institute (NHI) didn't come to fruition until 1993 when a concerted effort was made to include minorities, women, and other underrepresented individuals. And just in 2016, the NIH announced a policy on sex as a biological factor. So we have much catching up to do.

"Policy makes a difference, whether it be making these policies in terms of that you're not gonna get funded unless you include this data," she mentioned. We also have policies that increase funding for specific research, and there is a dearth of funding for specific women's health issues such as endometriosis, menopause, fibroids, etcetera. So, we can all impact the amount of research and the kind of research by educating our legislators and policymakers and voting.

We need more women in leadership, science, entrepreneurship, and consumers. And although it's not at the rate that we want it to be, the good news is that we're seeing inroads. "I feel that we are now focused on women's health, that we're seeing more research in women's health and more products provided, is because we have more women, including in clinical practice as well."

Inclusivity and Accessibility for Women in Healthcare

As FemTech continues to grow, we can ensure inclusivity and accessibility for women with diverse backgrounds, including marginalized communities. How? "Simply by just including them," said Marissa. She emphasized: "For the people designing the trials, including women. For the people who want trials, include women. Even for the investors that require any information, they need to include a diverse set of management teams and people from around the world (it doesn't just have to be for the United States). It sounds simple, but just do it".

It takes time and lots of work to have a diverse team or board, but we just need to demand it, ask for it, and show the facts that management teams with diversity perform better.

By diversity, we mean not just diversity of thought, but geographic diversity, product diversity, and many more. Even when innovating new products, we need to think about the rest of the world besides the United States because, although it is the most extensive consumer base, it's one country among hundreds. So, to sum up, demand it, require it, and do it.

Another critical factor discussed in the roundtable was the importance of consumers being more conscious and educated when spending money on healthcare products. "There are certain products that I would like to use, but I won't because they haven't done that testing or their management doesn't include women. And I know I'm in a place of privilege to be able to do that, but people need to start doing that". Marissa shared. So, it's crucial to spend your money based on your values.

However, recognizing that you need inclusion is just the first piece; we must go further and ensure we make it easy. Mitzi emphasized that we need to make it easier for those individuals to participate, which has been a massive challenge regarding barriers to participating in clinical trials.

Then, the following step is to create accountability. "Don't just tell your team internally, "This is a goal." "This is something that we're gonna try to do." But put a stake in the ground, set a goal, and hold yourself accountable to it," added Mira. Whether that's setting a public goal and following through, or at least communicating across your teams, it should have a real downside or risk if there's no follow-through on this.

So, the final thought shared in this sense was, "We as women, and any other diverse populations as well, have to pull other people up by including them and also by making it easier for others, " said Marissa.

Opportunities to innovate in FemTech

The health gap translates into a market opportunity. Mira shared that the silver lining to the unfortunate massive set of problems within women's health is that the awareness of the gender data gap is massively increasing. "When you de-stigmatize women's lived experiences from our periods, it's a powerful and important society issue, and in market terms, it creates pressure on governing bodies," she mentioned. Thus, the importance of voting to update care guidelines. Also, it creates pressure for payers to increase coverage of therapeutics and diagnostics.

We don't want another wave of innovation that comes out of our pockets. The reality is that standards of care don't simply change because innovation happens; it takes public pressure and efforts across stakeholders to move the needle. "I think we've seen massive success in terms of when and how frequently you should get screened for breast cancer, but many more conditions should have that type of attention and public outcry. And what enables this is powerful data".

Mira also explained that hundreds of thousands of clinical trials have been conducted since 1993, and with each edition, we gather more and more data on women's health. So, we have the opportunity to create a virtuous cycle where there have been so many shortcomings by demanding better research and better care, and the more pressure we put on the system from every direction, the more we reduce the gender data gap, the more we improve clinical outcomes, the more we improve and increase payer coverage for women's health. We need all of these things to happen in tandem to see massive market unlock.

Women's health issues have been overseen and are a business opportunity now. "I'm excited about people starting to focus on menopause. I think it's something nobody spoke about for many years and still doesn't, and it's an anomaly. People don't understand it", Marissa shared.

Also, "personalized medicine is fascinating as well," she continued. One of the silver linings to Covid-19 was the ability, and the frequency, to have at-home diagnosis, monitoring, and testing, which allowed the understanding that home health care is a thing. It saves on anxiety and time and functions at clinics so that they're not as overburdened. So, personalized medicine is especially exciting in women's health, and people are starting to pay attention to it again "because we're not just little men."

Unfortunately, women have to care for aging families disproportionately, so aging care is a vast space affecting women. And as mentioned before, Alzheimer's and dementia disproportionately affect women. "So we need to figure out what that means."

Preteen and teenage health is an exciting opportunity to innovate because "we can understand periods early" and how girls in sports get affected, or as women grow, what the different hormones will potentially affect healthcare outcomes.

Last but not least, AI in oncology is another fascinating point. AI in oncology and radiology is the first sector that will transform and adopt it, which it has already started.

How AI can help FemTech

We dove deep into this topic with Marissa at the roundtable. Indeed, AI helps us do what humans cannot, or we'll take too much time. We can help the computer see more and create information that we cannot see physically. Thus, it allows us to get better information and better data crunching, making it faster to commercialize products. So, when considering women's health, AI enables rapid data processing and visualization, particularly in areas such as cancer research. This technology can gather essential information for personalized healthcare while swiftly rectifying data discrepancies that would require significant time and effort. This accelerated process significantly enhances the accessibility and utilization of critical information.

And here, when we mention AI, we're not referring to generative AI. Instead, we're focusing on the AI that has been in use over the past 15 years. It's important to emphasize that there exists a significant distinction between AI and machine learning, with machine learning being a subset of AI. AI isn't a novel concept; we've been incorporating it into various applications for 15 to 20 years. However, the recent buzz has been around AI, generative learning, and machine learning. AI has become an integral part of our lives, even on our phones, through platforms like Google. Our daily activities increasingly rely on AI-based processes, which have brought about substantial advancements. Considering this, embracing enhanced innovation in Healthcare is essential.

Mitzi also shared that one concern is the validity of the data that feeds into AI systems. As the saying goes, "Garbage in, garbage out." If our data sets are inadequate or outdated, the AI's output might not be reliable or accurate. This is particularly worrisome because our research and data sources might lack up-to-date information. Additionally, if these sources have not included diverse groups like women and others, the data we rely on could be flawed. This presents a significant challenge as we could be working with flawed data, which is a major concern. Hopefully, this situation will improve over time. However, we must also exercise caution and implement filters to mitigate this issue to some extent.

Another aspect to consider is the presence of bias. As observed, pulse oximetry, for instance, tends to be less accurate in individuals of color. Similarly, certain technologies may sometimes struggle with accurately diagnosing skin lesions. This underscores the need to remain mindful of these biases and their potential impact. Marissa added to this by explaining that this is where we must be extremely precise and purposeful by guaranteeing the inclusion of diverse data in trials. This principle applies not only to pharmaceuticals but also to any medical device undergoing testing and validation. Take, for instance, the pulse oximeter. Surprisingly, it has never been tested on individuals of color throughout its 50- to 60-year history. It's doubtful if even one woman was included in the initial trials. This raises the question: why? Why hasn't this been addressed? The reality is that if you input flawed data, you'll inevitably get flawed results. Thus, we should ensure that the data we feed into these processes is marked by the diversity we seek.

Developments and Innovations in FemTech

Furthermore, we delved into the realm of FemTech, highlighting the captivating advancements and innovations currently shaping the field. Mitzi initiated the conversation by sharing an intriguing development in menopause. This encompasses menopause-related apps, counseling services, and innovative wearables designed to alleviate symptoms. For example, an incredibly fascinating breakthrough involves a plant-based estrogen alternative. This could be a boon for individuals unable to undergo hormone treatments, offering a potential solution for managing their symptoms.

Pharmaceutical interventions also surfaced as a significant topic. Promisingly, new pharmaceutical options have emerged, eliciting excitement within the field. There's notable progress in pregnancy and endometriosis diagnosis through blood tests. This potential game-changer promises early detection and preventive measures, ultimately leading to more patient-centric treatments.

Emerging technologies are poised to revolutionize aspects such as screening tests and the exploration of the vaginal microbiome, signaling a promising shift in sexual health beyond the scope of vibrators and applications.

The conversation extended to encompass mental health as well. Notably, a digital treatment for postpartum depression is under consideration for FDA approval, underlining the potential of technology to address critical mental health challenges.

We also touched upon the area of breast cancer. An algorithm geared toward predicting breast cancer in younger women garnered significant attention. This particular advancement holds immense value, given the substantial necessity for improved predictive tools in this demographic.

There are notable advancements in various other domains. For instance, a device rooted in NASA science has emerged to address osteoporosis by mitigating bone loss. Similarly, solutions for incontinence have also gained traction. The list could continue.

Another aspect worth considering, which may or may not be classified as innovation, particularly resonates with Mitzi as a clinician. She finds great interest in exploring novel models of care tailored to women's health. These evolving models of care extend beyond conventional approaches and may encompass specialized focuses, such as infertility or reproductive health. Moreover, they cater to specific demographics like women over 65 and even the Generation Z cohort.

All these healthcare software developments, opportunities hold immense promise, presenting numerous opportunities for comprehensive advancements across the spectrum of women's health.

What are investors looking for in FemTech?

Furthermore, after learning about different innovations and opportunities regarding FemTech, we well know that to make them a reality, we need investment, but there is a massive gap in investment. Yet, a glaring disparity exists in funding, with a mere 4% of US Healthcare R&D expenditure allocated to Women's Health. Mira told us all about what investors look for in femtech companies. As different investors will be looking for different things in terms of the business model, the stage that they invest in, and the type of return profile they're anchoring.

In the first place, Mira shared that "you need to have a clear right to win, and there needs to be alignment between the value you're creating and who's paying." So, who are you creating it for, for example, your patient, who's paying, and how is their alignment across that value?

Secondly, she emphasized the importance of gaining "traction with your Target and Market ."Because of the lack of education around the Women's Health Market, founders have been encouraged to build Direct to Consumer Market early on to prove that the market exists when really, that's not what they want to go after, she continued. "A series A, a growth investor, cannot underwrite future B2B traction on historical detraction". So, focus on the type of company you want to build, and if you're trying to build for a specific End Market and trying to raise, you need to have proof points or clear rights to win in that End Market.

Thirdly, Mira highlighted the necessity for scalability. How can a solution you've created not just serve a small population or proof of concept, but what does it look like at scale? "You need to have a sense of what your Profit and Loss Statement looks like right now, what you think it can look like, and how you get there ."Whether you're working with software or other models, elucidate how you anticipate achieving substantial gross margins or substantiate your sustainable profit margin strategy. Prove how you reach a sustainable profit margin and what that journey looks like.

Lastly, Mira circles back to clinical outcomes. "If you don't have a clear right to win if you don't have traction with your target End Market, and if your solution isn't scalable, you could still have an exciting clinical outcome in the early stages, but it's never going to reach a critical mass of the population that you're going after", she explained.

So, Mira concluded by stating that "it's an interesting push-pull where I wouldn't want to invest in a company that has the first, second, and third points, but if you have the fourth and don't have the first three, do you have clinical outcomes?".

Angel Investments in FemTech

Mira and Marissa, with vast experience in Angel Investment in FemTech, continued the roundtable explaining from their perspective.

"I'm always looking for something new and different that's not another me-too product" Marissa expressed. She highlighted that there's a lot out there that's very similar, and the goal isn't solely to introduce the latest and exclusive innovation but rather to address genuine market needs. When entering the Women's Healthcare Market, a crucial self-assessment is, "Is it really solving a problem, or is this just a duplicate of something?". Even if there's a presence of numerous competitors, it doesn't dismiss the potential value of your idea. However, identifying the precise pain point becomes imperative amidst the vast landscape of opportunities.

In the realm of women's health investments, Marissa stressed that the focus extends beyond the Direct-to-Consumer sphere. Most of these advancements occur within hospital systems. So, we need to understand that "if this isn't going into the hospital system, how does it get into the hospital system, and what is the ease of that?" Getting into multiple hospital systems is very difficult if it's not easy. So, "What is the work you've done to make it easy for them to adopt it? Because it might be the most brilliant solution, but if nobody wants to adopt it, it doesn't matter", she explained. People need to start with the first and easy indication and accessible entry point and then continue to build value on top of there, as that's what multiple following products look like. "You have to make it easy for adoption; otherwise, you'll have a brilliant company, and you're going nowhere. As an investor, that's what I look for: who will use this, how easy it is for them to use it." Marissa concluded.

In the same sense, Mitzi added to this point by saying, "One of my investor pet peeves arises when a presentation deck concludes without any mention of competitors ."There is always competition, which tells the investors that they never did their research and looked at it or do not have a big enough differentiator.

Mitzi followed by saying that another key point she takes into account as an Angle Investor when considering to invest or not is, for example, "if you have a digital app or something where you have to engage the individual to get the outcome, that's one of your customers and the second customer is the payer. She explained that it could be a health system, an employer, or it could be a health insurance company, but "the bottom line is that you need to keep both of those customers in mind because if you don't get the engagement of your primary customer and whatever change you're looking for and the subsequent outcome, it's not going to be paid for by the payer." Then you don't have a revenue stream in which an investor will want to invest.

Fundraising in the FemTech Industry:

We delved into the other perspective, and Marissa shared in the roundtable that she is in the fundraising process and explained her experience. "As a woman, it's difficult. I get asked way more questions. I've had my CFO pitch, I've had myself pitch, and I've also had our chief strategy officer, who's a male and one of the founders, and they just don't get the questions", she explained.

Lack of women in executive positions:

Moreover, Marissa explained that this is closely tied to the underrepresentation of women in venture capital (VC) firms, particularly the lack of trust placed in women occupying executive positions. Many individuals posing these questions are men, with a noticeable absence of women. When engaging with angel investors, especially in the initial stages, one should anticipate that not all contracts are finalized, and investments might not hinge solely on contractual agreements. "While we are fortunate to have that flexibility, most companies do not share the same advantage. It's worth acknowledging that many investments still gravitate towards men."

Women pitch differently, and "I've tailored mine almost to pretend I'm a man, which I shouldn't have to, but that's what you have to do when speaking to all men. You have to speak in that, we have to lean on data, and we have to lean on dollars," Marissa pointed out.

She added, "Another issue I've encountered is that a lot of the dollars and the revenue that I share gets discounted more because I'm a woman than a man, which is ironic." She explained it's ironic as women are far more grounded in truth and fiscally responsible, often in projections, than men are. "It amuses me when I'm questioned, "You really think you can make $3 million next year? Yes. Because if I were a man, that number would've been $12 million because I'd rather exceed your expectations than not".

Also, Marissa emphasized that "You also have to go after the investors that make sense for you and your company ."Crafting an elaborate pitch to woo Series D investors prematurely would be a waste of time if you know you are too small. "We have to be very intentional in whom we're going to speak with ."She further broadened her scope beyond women's health investors, acknowledging the limited size of that segment. "Now I'm looking for health investors because that's a much bigger pocket of people to speak to." she finished by sharing that "it's going well, but do I think that if I was a man or had a different personality would it be different and easier? Yeah, probably."

Be direct with Investors

Mira continued the roundtable by saying, "We talked about deep looks, and we aligned on the discrepancy and stage." Her key message, in this sense, was for investors to be direct. Have that conversation at the onset of the call. If the most useful thing you can do is give time back, give time back. If you can be useful in other ways, be useful in other ways. "From an investment side, we're always talking about deal flow and our right to win, our right to earn a spot on a cap table, so earn it," she mentioned. The women's health community is really powerful, we indeed are a community, and because there are so many obstacles and barriers, we need to band together and help each other. "So, even if you don't necessarily have alignment on stage or business model or expertise in one way or another, figure out how you can be useful to founders on their journey" she finished.

How to entirely focus on the patient while still being profitable and attractive for investors: focus on patients

When creating a company, the solution needs to be patient-centered. Mitzi shared some great insights on ensuring you're all about the patients while making the business profitable and attractive to investors. In a nutshell, she explained that "That's your win. It's not an either-or; it's and. You have to have those outcomes, and to get them; you have to have the engagement of your patient, employee, or whatever it's your end user. If you can do that, you're showing that you can make things better or more efficient – whatever your measure of success is.  

"Whether you're dealing with a company's health insurance or a provider, it ends up being a win for everyone. And guess what? That means more money coming in, which is exactly what investors want," she explained. But here's the kicker: The individual you're really focusing on has to be your user– in this case, let's say it's a woman. Everything, from how they experience your product to what the product actually does, needs to be something they want to be a part of.

Golden Tips to Thrive in the FemTech Industry

Coming up to the end of the roundtable, we wanted to invite our panelists to share, from their experience, one golden tip, and these were the key points discussed:

1. Mitzi: no matter if you are an investor, an entrepreneur, designer, consumer, scientist, or clinician, there's one question you always need to ask, and that is: "What is the impact on women?" What is the data on women? And any other intersections, whether it be race, ethnicity, or geography. If we're really going to get to personalized medicine, and we're going to get to inclusive medicine and health, we have to, all of us ask that question because if we don't, we're never going to find those answers.
   
2. Mira: Founders: know your audience and cater your pitch to investors, but do it around what will resonate the most with them and you. You shouldn't open or anchor to what an investor looks for; if they're not the right fit for you, then learn that early on. Move on. But there can be, should be, and are many really special things about what you're building, and different components resonate differently with other answers.
   
3. Marissa: be clear; communicate your "why" of yourself and the company. Now your value proposition and stick to it. Know your audience, know whom you are speaking to, know your value, and especially as an entrepreneur and a founder or aspiring, don't litter yourself down. If they're not the ones and they don't get it, they don't get it. They're not for you, and it's totally fine. And it's not just for investors, it's partners, it's other commercial partners as well. So, I think you need to consider your value. Don't be arrogant about it, but know what it is. Communicate it clearly and go for it. Shoot for the stars, and if you hit the moon, it's still amazing.

Q&A:

To finish with, we were excited to jump into the questions our attendees have been sending through the roundtable, and here where the results:

1. Q: Can you elaborate on the current applications of AI in oncology?

A: Marissa: It's actually one of the most significant areas where AI is making a massive impact in Healthcare, which is exciting. AI is being heavily employed for image analysis, particularly in oncology, where many images are captured. Whether it's from mammograms, ultrasounds, CT scans, or MRIs, these images are abundant and packed with information. There's a wealth of details to sift through. Specifically, various AI solutions focus on identifying potentially suspicious lesions in cases of cancer or other oncological diseases. These solutions are popular.

Moreover, AI is stepping in to provide oncology drug treatment recommendations. It's all about analyzing extensive datasets, extracting valuable insights, and swiftly determining the effectiveness of specific approaches. The beauty lies in rapidly assessing and differentiating what works and what doesn't across diverse cases.

2. Q: What resources would you recommend for those looking to become more engaged?

A: Mira: I'd suggest subscribing to FemTechInsider – it's a fantastic resource. And for a more targeted approach, they collaborate with another company called Intros, which specializes in connecting you with professionals from various backgrounds within the realm of women's health. It's a wonderful community to be a part of.

3. Q: Could you share your thoughts on pharmaceutical economic data?

A: Mira: This is crucial for expanding payer coverage. It's an insightful question and undoubtedly plays a part in shaping investor sentiment.

4. Q: When it comes to clinician investment, what would you suggest?

A: Mitzi: A significant step is to indicate your interest on your LinkedIn profile. Additionally, begin following the resources mentioned by Mira. We'll also have additional recommendations that we can provide. I'm aware that there are companies emerging with innovative contributions from various fields. So, you can never have too many clinicians involved, as they are at the forefront of patient care.

It was such an exciting opportunity to share with top industry experts from various points of view! Huge thank you to the +230 attendees that joined us virtually, and thank you, Mitzi Krockover, Marissa Fayer, Mira Kaufman, and Josefina Ruiz, for sharing such interesting insights and joining DHI and Light it to shed light on such critical topics. Stay tuned for the next DHI and Light-it roundtable!