If longevity is the future, why aren’t women leading it?

The menopause market is perceived to be much smaller than the longevity market. Perhaps the solutions need a bigger vision.

Pierina, known to her grandchildren as “Nonna,” emigrated shortly after the Second World War. Life then was shaped by hard work and limited resources. Doctors were only called if things were dire. Health insurance was not available, and anyway, medicines like antibiotics had only recently been introduced.

With her husband and three children, Pierina rented a basement apartment. Each day, she walked miles, toiled at work, and then walked some more. Her day started by preparing a fresh breakfast for her family and then she trekked from the outer boroughs into Manhattan to clean houses. When the kids came home from school for lunch, she would return home too. Then she’d schlep to the city again only to return home to make dinner. After dinner, she left to clean once more—this time, tidying gleaming tall office buildings while her children slept.

Over the years, some things changed. First, an empty nest. Then divorce. But she remained at her quaint townhouse in Queens and thrived. Every day, at eight AM sharp, her downstairs neighbor comes up to join her for coffee. Other neighbors check in throughout the day. On weekends, her house is filled with a squadron of grandchildren.

Now she is halfway into her tenth decade on earth but 94-year-old Pierina does not view her long life as remarkable. Her older sister is 96. Her eldest sister is now 98. They have all lived similarly–and simply. Ask them if they’ve heard of longevity science or biohacking, and they’ll laugh at you.

What’s old is new

Humanity has been chasing longevity for millennia. The Sumerians etched Gilgamesh's quest for eternal life into clay. Leonardo da Vinci delved into our inner machinery, making meticulous diagrams to understand what animates and propels the human body into old age. And while their instruments are different, the ambitions of today’s longevity influencers are essentially the same. Yet for all their guile, they all seem to have overlooked the biggest opportunity in plain sight: women.

Picture today’s longevity influencer. What will likely come to mind is a hyperfit, cerebral, middle-aged man: perhaps Bryan Johnson or Peter Attia or maybe, Mark Hyman, whose startup Function Health just raised a monster round at a $2.5 billion valuation. Dudes like this have secured almost $5 billion in venture capital in the first half of 2024 alone. And the industry’s value is speculated to more than triple over the next decade to several trillion dollars.

On any given day, these men detox, biohack, and cold plunge. They intermittently fast. They build supplement stacks that include creatine, nicotinamide, and magnesium. Their regimens more likely resemble an Avenger training to save the Universe than, say, the average parent just trying to carve out a few quiet moments to eat their daily serving of vegetables.

And that’s the thing. In a world where just being a woman is still associated with having 13% less free time, and the average mom spends more than twice her time on housework and childcare than her male partner…many of their lifestyle suggestions seem unattainable, if not downright laughable.

In parallel, the menopause market is projected to hit $27 billion over the next decade. There is more energy, investment, and testing available than ever before to address people’s symptoms. But while this is encouraging, the menopause market is still defined in narrower terms than longevity, and has less focus on prevention despite sharing similar aims.

This is, in part, a marketing problem. “Conquering menopause” doesn’t have the same zing as reversing mortality, nor is it likely to engage younger generations. But the products and services could use more vision, too. Pierina never went to Pilates or took metformin. Perhaps she and her sisters benefit from good genes. Notably, they also lived healthy lives: eating home-cooked meals prepared from scratch, walking miles a day, surrounding themselves with a community that helped absorb the inevitable bumps on the road.

Modern life makes following their lead difficult. Today, processed foods are everywhere. We spend most of our workdays sitting. Most of our time is spent in relative isolation from colleagues, friends, and even family. Perhaps the most visionary longevity solutions will make it easier for us to get back to the basics. Perhaps they will reach further than the creaks, pains, and hot flashes of aging to help us prevent or at least delay the maladies of old age in the first place.

The aging paradox

Most of us are far more likely to know a grandmother like Pierina than a grandfather who has reached his nineties. Around the world, women consistently outlive men. In the U.S., that gap is five years; in some countries, it is as high as 11 years. Eighty-five percent of centenarians are women. Among supercentenarians (110+), the female prevalence increases to about 90%. But living long isn’t the same thing as living well.

Women are three times more likely than men to get migraines, twice as likely to experience depression and anxiety, and twice as likely to develop Alzheimer’s disease. Women suffer 80% of all autoimmune diseases and 80% of all osteoporosis cases. Women have higher mortality rates after a heart attack and are up to seven times more likely to be misdiagnosed with a heart condition in the first place.

Women spend longer periods than men in poor health. This also means women end up paying more for their health care at significant economic disadvantage. Before the Affordable Care Act ended discriminatory practices in 2010, our health insurance system commonly treated being a woman as a preexisting condition, charging them up to 50% more than a man each month for the same coverage.

Our colleague Dr. Alyson McGregor is an incisive emergency medicine physician who grew frustrated with the largely avoidable ways in which sex-based differences are often an afterthought in medicine. Five years ago, she wrote the book Sex Matters: How Male-Centric Medicine Endangers Women’s Health–and What We Can Do About It.

“In medicine we just hone in on the menstrual period and estrogen, and we give those to ob-gyns, without realizing that cardiologists, neurologists, and orthopedic doctors all need to know about sex too.”

Most of us learn in high school biology class that sperm carries XY chromosomes and eggs carry XX. When we called Dr. McGregor last week, she emphasized how those same sex chromosomes are in all the body's cells, programming how they function.

“They're in the coronary arteries, our immune cells, and our brain cells. The way the heart responds to hypertension is based on estrogen’s response to the mitochondrial DNA,” she told us. “And yet in medicine we just hone in on the menstrual period and estrogen, and we give those to ob-gyns, without realizing that cardiologists, neurologists, and orthopedic doctors all need to know about sex too.” Ignorance of these differences limits our scientific insights and obstructs the systems we have to deliver on them.

Increasingly, women and men alike are turning to solutions that seek to bypass our clumsy, reactive health system with services that promise convenience, personalization, and proactivity. Core to the pitch is that age is just a number and youthfulness can be projected both outwardly and within the body.

Youthful insides

In 2019, Ryan Smith was, in many ways, standing at the top of the mountain. After leaving medical school to found a business, he found himself at the helm of one of the fastest-growing compounding pharmacies in health care. Compounding pharmacies focus on custom medications for individualized, rather than mass-market, needs.

“We were treating many things for aging with exciting peptides and using a lot of unique molecules to do it. But we also always knew that the FDA was a limitation there. At the end of the day, we really needed to prove outcomes,” he told us.

In theory, to conduct a study demonstrating outcomes for longevity, you need to wait for people to live their full lifespan. It could take many decades to demonstrate results. However, that same year, Dr. Steve Horvath and colleagues published a groundbreaking study. They suggested that aging could be observed much faster, and that it could be reversed.

Their insight was based on the idea that deep inside the genetic material of our cells is an “epigenetic clock.” In basic terms, these clocks reflect chemical changes that modify which genes get expressed, a process called DNA methylation. Analyzing hundreds of these changes results in a tantalizing number—your so-called biological age.

Smith was hopeful these clocks could be a way of measuring how peptides were impacting aging without actually waiting around for the process. He tracked Horvath down and knocked on his door to see if this testing was already used for research trials with compounding pharmacies. When the answer was no, he founded his second company: TruDiagnostics, the industry’s leading biological age test.

Epigenetic clocks are now the bread-and-butter of many longevity startups. These companies charge users hundreds of dollars to calculate their biological age, and then recommend actionable advice to improve it—in an ideal world, for example, your chronological age might be 55, while your biological age is 40.

Smith tells us TruDiagnostics sees roughly equal numbers of male and female users—proof that the concept resonates with all genders. We asked him how he accounted for sex-based differences, and he had a ready answer: sex is a controlled covariate in his clock’s calculations, and he would be skeptical of any clock that didn’t treat it as such.

What’s in a number?

Smith takes pride in the accuracy of TruDiagnostic’s tests, yet he is also the first to caution that much of the longevity industry may be trafficking in snake oil. He is wary of tests that base their findings on saliva rather than blood samples, don’t publish their hazard ratios, don’t peer review their algorithms, or account for immune cell changes (like if you just had a cold recently, or drank coffee this morning). Even as he runs us through the differentiators between clinically sound biological tests and unsound ones, it’s hard to know how the average consumer can reliably tell the difference.

Today TruDiagnostics controls 90% of the biological clock testing market and sells the tests whitelabeled to many startups, including Bryan Johnson’s. These startups often combine the test with other services–body scans, nutritionists, health coaches, and medical care. You can also purchase the test directly from TruDiagnostics, and for an extra $50, you can meet with a specialist to explain the report’s findings.

Regardless of how accurate the test is, knowing what to do with it (and actually following through) is the hard part. In 2022, just a few years after his landmark discovery, Dr. Horvath told The Guardian, “Let’s say a medical doctor orders an epigenetic clock test, and it indicates a patient is older than they should be, what should the doctor say? There’s no cure they can prescribe,” he said. And yet, this is precisely what most companies are selling today.

“Let’s say a medical doctor orders an epigenetic clock test, and it indicates a patient is older than they should be, what should the doctor say? There’s no cure they can prescribe,” he said. And yet, this is precisely what most companies are selling today.

But there are things doctors can prescribe to maintain good health and reverse certain effects of aging. These things shouldn’t be as hard as the current health care system makes them to obtain. Take bone health, for example. Fifty percent of women will develop osteoporosis at some point, putting them at significant risk of bone fractures–including a broken hip, which is known to sharply truncate lifespan. Yet doctors don’t routinely recommend bone density scans until women are 65, which is often too late. These tests are relatively inexpensive and accurate, and can prompt simple corrective actions in diet, exercise, supplements, or medicine.

The ideal solution would be to connect all the dots–the right service with the right action and help on the follow-through. So far, longevity startups are mainly focused on a smattering of tests or a singular number. But one thing is certain—living a life in consistent pursuit of good health is hard. Receiving a number, almost like a grade, that puts your work into stark contrast is motivating. So motivating that even Dr. Alyson McGregor hopped on the bandwagon.

When we asked her what she thought about biological age tests, she lit up. “I did that recently! My husband was listening to a lot of longevity podcasts and getting all this blood work. And I was like, well, I want to get that blood work done, too.”

Dr. McGregor is a vegetarian and an avid yogi. “I knew I was going to beat him on all these markers. And I was thrilled to be 10-15 years younger than him at my biological age,” she said.

But she still had a critical eye. When she looked closer at the data, she noted the reference ranges, like so much research on women, are almost certainly off. “Why are my husband and I both considered normal when we have different numbers?” she asked. “But if we can tailor these results to the true physiology of men and women—that’s what I would push for.”

She likens it to when the stethoscope was first invented, and suddenly doctors knew something about patients that the patients themselves could never know. Now, in this new age, biological data is being democratized, and that’s awesome. The key will be to use it well.

What my team is reading, considering, and building against:

• Thank you to the magnificent Leslie Schrock for co-authoring this piece! Consider this a second chapter to her Substack on the topic, which kicked off the conversation and serves as a thorough State of the Union on the sector, but also includes helpful notes on her own longevity journey.

• Eric Topol has long served as a cautionary (but data-driven) canary in the coalmine on longevity science. We are looking forward to reading his new book, but in the meantime, his latest Substack is an excellent primer. As he points out, “Ironically, despite what might be thought of as a ‘kitchen sink’ approach, many tests that could be particularly useful have not been incorporated by these companies.”

• Further proof that every generation sees its own “longevity” movement—recent research suggests that the so-called Blue Zones movement has been debunked. If you’re of a certain age, for a period of time the Blue Zones were inescapable. This interview with the researcher who did the debunking is a remarkable and interesting discussion of the controversy. As he points out: “A lot of research careers are built on examining the oldest old, and even more research careers are built on just assuming that birth-certificate ages are correct. And to show that they’re not correct in an undetectable fashion on such a massive scale threatens a lot of people’s careers.”

• It is a true tragedy that we do not know more about the physiology of why and how women’s bodies age compared to men. But, as noted, we do know some things! For an even more thorough discussion of the differences, last month’s sweeping piece from the wonderful Mohana Ravindranath at the NYT is a great starting point.