Reconsidering Menstruation - Dr. Sophia Yen, CEO of Pandia Health

SHIV GAGLANI: Hi, I'm Shiv Gaglani and today on Raise the Line I'm happy to be joined by Dr. Sophia Yen. Dr. Yen is one of the co-founders and CEO of Pandia Health, a one-stop shop for women's recurring medications, starting with birth control. She's also board certified in adolescent medicine with more than 20 years of experience in medicine, as well as a clinical associate professor of Pediatrics in the Division of Adolescent Medicine at Stanford Medical School. I'd also like to thank Justin Gordon for introducing us in the first place. Thank you, Sophia, for taking the time to be with us today.

SOPHIA YEN: Thank you so much for having me. I'm excited.

SHIV GAGLANI: So, Sophia, can you start by telling us a bit more about your background, how you got into medicine and then specifically decided to focus on pediatrics?

SOPHIA YEN: Yes. So, I've wanted to be a physician since about fourth grade. And I love that it was an excuse to buy stickers. So, I would buy stickers, not for myself, but for my future patients. And I couldn't buy just one sheet. I had to buy three sheets because it would be sad if a patient took one sticker and there weren’t extra stickers for the next patient. It was a great way to milk my parents for stickers. The true, I think, calling was that I love people and I love science and each person is a different story. Each person is a different challenge to help them optimize their health. My mom was a nurse, and she said, "Don't be a nurse, be a doctor. Because the nurses do all the scut work and the doctors get all the credit." So, I was like, "Okay, I'll be a doctor.

But my tip to people out there is if you're going to do just general primary care, don't be a doctor, be a nurse practitioner. Because you can do everything a doctor does with less education, and you're unionized. But if you want to be more specialty, then maybe go for the doctor. But that is how I became a physician. Then about six years ago, I was giving a talk to a bunch of physicians, "Why don't those pesky women take their birth control?" and one of the top reasons that came up from the research was because they didn't have it in their hand. My friend and I were like, "We can solve this. We will just ship it to women, and keep shipping it to them until they tell us to stop." When we ran ads for free birth control delivery, 60% of the people that responded didn't have a prescription.

As an entrepreneur, I didn't want to miss out on 60% of the customers, and as a physician, I could write the prescription. And thus Pandia Health was born. The end-to-end solution for birth control. If you already have a prescription, we just deliver it. We bill it to your insurance. We ship it to your door. If you don't have insurance, it's roughly $15 a month per pack, less than 50 cents a day. Then if you need a prescription, to catch that 60% that didn't have a prescription, we can do it online. What's different is it's asynchronous. So, you just fill out a questionnaire, 24/7, at your convenience, give us a self-reported blood pressure in the past 365 days, then our doctor looks at it 24/7 at their convenience.

If it looks good, we write the prescription, ship it to our partner pharmacy, bill it to your insurance or to your credit card, send it to your door. Set it and forget it. Let Pandia Health worry so you don't have to. It's because I saw a problem, and we wanted to solve it. We wanted to make women's lives better. We are the only women found and women led. The only doctor led company in the birth control delivery space.

SHIV GAGLANI: Wow. You've definitely preempted my question around Pandia and how you started, and pretty fascinating and clearly aligned with consumer-centric, healthcare trends, which we've been talking about. Can you talk a bit about the size and scope of Pandia so far? How many patients have you reached, whatever you can share. I know you're a physician. Are there other physicians at the company who are also reviewing these forms that the patients fill out?

SOPHIA YEN:  So, the company came up with the idea six years ago and then four years ago started this female-founded, female-led, doctor-led company. I think this is one of the few companies out there that had five founders, because I want to make sure we had everybody necessary. We had a pharmacist, a physician, a chief marketing officer, a COO and myself to provide all the expertise that could possibly be out there. And then from there we decided to build it. Came up with the company March, 2016, launched in July, 2016. So, just four months later. My CTO is amazing.  We’ve grown since that time. We are aiming for 10,000 customers by January or so to meet our series A metrics. 

In terms of who's prescribing, I've personally prescribed, thanks to this company, 2,000 birth control prescriptions in the past two years. Because we're the only doctor-founded, and I think only academic doctor-founded company in this space, I've been looking at the data. As physicians, we usually prescribe this birth control, but I'm learning that if you're Asian, African-American, or Latino, you actually do better on this birth control, so now we're asking our patients to self-report their ethnicity so that we can look at, is there a correlation between a specific birth control pill and side effects? If we start you on this one, do you have a better journey on your birth control journey? Because my goal is to have the patient be as happy as possible and use the medication and prevent unplanned pregnancy. But if we start you on one that gives you nasty side effects, or you have to go through three or four or five different ones to find the one that works for you, that's going to be a far more negative experience. And if we go based on our research, this is the one that is going to go for you. So we found one that 90, 95% of women do really well on.

SHIV GAGLANI: Wow, that's also fascinating. Can't wait to see the results as you publish them. Obviously, COVID has accelerated a lot of the trends around both telehealth consumer-driven healthcare, and then companies like obviously Medlio and Amazon's PillPack. I've seen a huge spike, Capsule is another one, in terms of being able to provide that convenience to customers who don't have to go to the clinic and get risk of exposure to COVID, but rather can stay at home and just like they get furniture delivered to them, they can get birth control delivered to them. Can you talk to us a bit about COVID and the impact that that's had on Pandia health so far?

SOPHIA YEN: So, we are one of the lucky companies where COVID has been an absolute tailwind, and has dropped our customer acquisition costs, I think because everybody's on social media. 70% of our traffic comes organically because, as I like to say, I live, breathe, eat, and prescribe birth control. So, it's in my blood and I'm thinking it 24-7and given 20 plus years in the field, I can talk about it to the end of time. So, we have created on our websites frequently asked questions. We've created on YouTube videos with 200,000 views with no advertising, no promotion, simply because we know the questions that are on the mind of those who are looking at the birth control pill, patch, or ring. Like “first time, don't take it on an empty stomach in the morning, and make sure you take it at the same time every single day,” and other kinds of useful tips like that.

We're also doing an Instagram, or Facebook Live or Instagram Live every Tuesday in Espanol at 5:00 Pacific time, and at 5:30 in English to answer frequently asked questions about birth control. "What's the latest and the greatest? Will it make me infertile? Will it make me gain weight?" And so we have been able to capture people's interests that way organically. We're also running Facebook and Google ad words, and they've become more effective as more people are sitting in front of it. But as you mentioned, COVID has driven people to understand asynchronous telemedicine. Before they didn't know the word asynchronous, but now everybody knows about it because of asynchronous learning. Before then telemedicine was seen as horrible and pushed away by the general medical establishment. But given the need for safety, they're seeing an understanding and accepting it. 

The key that I want people to understand about telemedicine is not all telemedicine companies are created equal and that you should look at who is the CEO? What is their goal? Are they driven purely by profit or are they here to make your lives better? I like to say, as the only MD/CEO of a birth control company, we will always tell you what's best for your health even if it doesn't benefit our bottom line because I will make money for my investors, but I don't have to push something you don't need or withhold information from you. 

So, when consumers are looking at telemedicine, one, who is the CEO? What is their mission? How much is mission-driven? How much is profit driven? And then, two, transparency. Do they list their physicians -- first and last name -- and their training? Because if they don't, why don't they? Then if you're going to see a regular doctor via telemedicine, go right ahead, because I presume that you've vetted them. But if you haven't, it'd be nice to look up who are these people and is the CEO, chief medical officer, an ophthalmologist for a birth control company?

Just because they have the chief medical officer that's in the field, does that chief medical officer go through that process and understand the way it's been implemented? Because we've seen stuff that is not standard of care. In telemedicine you should do everything you can do in the office to the best of your ability, and one of them is informed consent. So for birth control, they should offer you the pill, the patch, the ring. On the telemedicine side, as a doctor, I can write whatever the heck you want and send it to whatever pharmacy you want. On the pharmacy side, I can choose not to fill the pill and the patch, or patch or ring or whatever, because I lose money on it. But on the telemedicine side, I should give you all your options and I should send it to whatever pharmacy you want. And then to separate the pharmacy side and be like, "Oh, well I'm only going for the ones that make me money." 

So, make sure you have a telemedicine company that is ethical and following the standard of care…that they were giving you all your options. Also, it's unusual to go to a doctor's office and they go, "Do you want this drug?" They don't say that. They're like, "Do you want a cholesterol lowering drug?" They don't say, "This drug." And so, if they're saying “this drug”, you’ve got to wonder. Look at their relationships with that drug company, see what the situation is. 

SHIV GAGLANI: That's super interesting. That's the first time I've heard those criteria. Can you tell us a bit more about the types of people you are reaching? You were trained in pediatrics, and adolescent medicine, which is when a lot of people start taking birth control, obviously. But then, do you prescribe to people who are much older? And then also, I know one reason for birth control is obviously actual birth control, but you've launched this #PeriodsOptionalInitiative. Can you tell us a bit more about that?

SOPHIA YEN: Those are very good questions. So, as an adolescent medicine practitioner, trained in pediatrics, I'm fine with the little ones up to maybe 25 or 30. Well, one of the reasons we created this company was to make sure we could bring birth control wherever you have internet and a mailbox, but also because that birth control is safe, and it should be over the counter. And that's what the American College of Obstetrics and Gynecology said back in 2012, and again, in 2016 and again, 2019. So, we feel comfortable with a drug that should be over the counter, as long as you ask these 20 questions -- the same questions I would ask you in my office -- and as long as you get a self-reported blood pressure that's within the normal range. On our platform, we don't tell you what normal is because we feel you might just check that box.

We want you to give us a number so we can make sure that it's safe for you, and that no one dies or anything like that. We are comfortable prescribing from age 14 to about 45, 50, 55. Then 55 and up, you really shouldn't be using birth control for birth control, but you're actually using it for menopause. We're looking at it at the other side, but for menopause, you need a lower dose simply because the estrogen does give you an increased risk of blood clots, and whatnot. But it's crazy, I just realized this looking into it, that the menopausal dose is far more expensive than the birth control pills. So, the standard birth control pill is $15 per pack per month. But if you want the 10 microgram one, those are all still brand name and they're like $150 a month. But they're one-third the dose of the normal birth control pills. So why don't we just cut the birth control pill, right? But it's America, and it's about capitalism and they charge whatever the heck that you can. 

So, as you mentioned, Periods Optional is a way to look at birth control not for birth control. This is hormonal treatment. For anyone with a uterus out there, we're about to blow your mind, and anybody who deals with anybody with a uterus. I had the realization, when I was trying to get pregnant with my first child, that the only reason that those of us with uteri bleed…we build that lining, wait for embryo, oh -- no embryo, bleed, right? Then we do this every single month from about age 12 and a half, in the United States, to about 26. But for those of us who have extra education and healthcare, it took a while to find our significant other, it’s 35 years old. 20 years of build and slough, and build and slough, and pop out an egg.

Every time you build that lining, you risk endometrial cancer. Every time you pop out an egg, we don't know if it's the pop or the heal, you risk ovarian cancer. Why are we doing this if we're only on average making a baby twice in our lives, right? This incessant menstruation is a modern construct. In our natural state, we used to have 100 menstruations in a lifetime. Now we're having 350 to 400 menstruations in our lifetime because we're starting our periods at 12 whereas in the natural state, we would start at 16. We would have eight babies, now we're only having two. We would breastfeed 12 to 18 months and now we're breastfeeding zero, three, or six months. How many menstruations or bleeds does a person with a uterus have when they're pregnant? Zero. When they're exclusively breastfeeding? Zero. 

So sharing this information with anybody with a uterus will increase their productivity. The number one cause of missed work and school under the age of 25 is menstruation. A lot of women go, "Whoa, it just runs in my family and is the way it should be." And it's like, just because it runs in your family, it doesn't mean it has to be that way. If your family runs like my family, blind as a bat, let's use technology to make your life better. So we now have the technology to turn off that monthly bleed. In my world, you would only bleed when you're trying to get pregnant. So for me, it just took three months, each time.

So, six menstruations in a lifetime, versus 350 to 400 menstruations. So, if you guys want to learn more about it, pandiahealth.com/periodsoptional. On the bottom is my TEDx talk that I gave on the moonshot of having fewer periods. This opens it up to hormonal treatment rather than birth control, but it also can be for bad, evil, heavy periods. Every time I give a talk to a bunch of those with uteri, a room of 30, 3 women will come up afterwards and be like, "Oh, I'm so tired and cold when I have my period, do I tell my team about it as a CEO?" and I was like, “You're a CEO, right? You should have health insurance. Why don't you go talk to your health provider?” And at least first-line treatment is ibuprofen 600 milligrams with food up to three times a day for five days to decrease the blood loss by 30%. Failing that, then go to some sort of hormonal treatment to control it.

For the parents out there, I have a 14-year-old and now an 11-year-old and I ask you, is your young person going to do better on the SAT bleeding or not bleeding? Or on a talk or a pitch, bleeding or not bleeding? On a sport, bleeding or not bleeding? The example I gave is, as a pre-med, I was at MIT taking my biochem final, all of a sudden... blood! And I'm like, "Do I run to the bathroom or do I finish the exam?" And you know the answer as a pre-med or pre-health student. You finish the exam. But was I a little distracted? Yes. And I looked to my left. I looked to my right to non-uterine bearing beings and they had nothing to worry about. Meanwhile, I'm freaking out. I want my daughters to be on equal playing ground with everyone next to them.

I don't want them randomly hit with blood one week out of four for 20 years of their lives. I’m not saying that women can't do it. I love the favorite saying, "I can do everything you do bleeding." But I'd rather not be bleeding. I'd rather not risk anemia, I'd rather not risk iron deficiency anemia, and I'd rather be at my full functional capacity. So, I think that is the huge pearl I have to share with everybody listening today is, anybody with a uterus, definitely know that #PeriodsCanBeOptional, and that you should look into it if you are bleeding once a month.

SHIV GAGLANI: That is fascinating. That's the first time I've heard someone explain that so passionately and like, yeah, for people like me who don't have uterus, that's fascinating. Really instructive. I'm curious, we had Eric Topol on the show a couple of weeks ago who I'm sure you know. He wrote one of his three most famous books “The Patient Will See You Now”, about the consumerization of healthcare and having patients take a more active role in their own healthcare and not have go to their priest to communicate to God, if you were to use that analogy, but rather learn about it themselves, which is, I think, what a lot of the companies like Pandia are helping people do, obviously with the guide. But I'd love to hear your take as an academic professor on when you learn at places like MIT or Stanford, there is a hierarchy there.

I was at Harvard undergrad and then Hopkins Med School, definitely a hierarchy because it gives power. And also sometimes there's an attitude of like, "Doctor knows best." Which they do, because they train. But there's an attitude that the patients, the more patients that look up their symptoms on a WebMD or something, the more sort of annoying they become, more cyberchondriac they become. I know it's obviously not black or white, but where do you stand on the consumerization of healthcare? And everything from 23andMe, to what Pandia is doing to Ro and Hims, and those kinds of companies.

SOPHIA YEN: Yeah. I love data. If you'll talk to my team, I'm always about collecting more rather than less data. And I think 23andMe offering information is fine, but it has to be done safely, right? If I give you a result and you freak out and kill yourself, that's not cool. Or if I give you a result and you don't truly understand it. I have a colleague at the New York Times and her interpretation of the research of COVID antibody results was that children make a lesser response. My interpretation of that study was not that they make a lesser response. They make a more specific response of this specific IgG, as opposed to a whole bunch of different IgGs, which then have collateral damage and stuff like that.

So that is the danger of consumers, is they didn't go to medical school, right? They didn't study virology. They don't understand pharmacology. I do believe that you sometimes have to be educated. The example that I give is specifically with emergency contraception. I am passionate about birth control and so I call myself the “God of Emergency Contraception for Young Adults”. I gave a talk to a bunch of 60 Stanford physicians. Only one out of 60 -- this wasn't like med students, these were residents -- one out of 60 knew about the four different types of emergency contraception. So, one is the copper IUD, two is prescription emergency contraception, everybody knows about the third one, Plan B and its generics. But if you go into a doctor's office or the ER, do you want the third most effective emergency contraception?

No, I want number one or number two, and number one is invasive, but it is 99.999999% effective. Number two is twice as effective as plan B and its generics. Because I'm an academic always up-to-date on the literature, the latest and greatest information is that if you have a body mass index of 26 or greater, Plan B and its generics are as good as if you took nothing. This is very important to the 60% of America that is overweight or obese. One, know your BMI. Two, if it's 26 or greater, Plan B and its generics are as good as a Tic-Tac at preventing pregnancy. On the side, you can double up on it, but why not get the prescription emergency contraception ahead of time? Right now under the Affordable Care Act, it is free. No copay, no deductible. But knowing about the BMI of 26, knowing about the fact that prescription emergency contraception exists when your doctor might not because there's so much for the physician to know. 

So it's good, I think, to know about your particular disease, to get together with other patient groups to share, "This has worked for me, et cetera.” To try to figure out what you have is also doable as well. But you have to be careful what websites you go to. How trustworthy are those websites? When were they updated? Are these academic physicians or these other physicians? And do they have a secondary cause? Are they selling you a vitamin or supplement that is not FDA approved, that has not been tested in randomized clinical trials? Because I see people going after fads, and particularly a lot of Asians in Taiwan and Hong Kong love to buy the latest apple vinegar, or this vitamin or this thing and it's a fad because it wasn't tested.

SHIV GAGLANI: That is fascinating. I wish we had more than 30 minutes to talk through all this stuff. I've been really enjoying seeing the innovations happening in women's health, right? I think five, 10 years ago, when I was writing for Medgadget before starting Osmosis, there wasn't as much discussion around it. Women's health, I think especially in the last two or three years has seen this massive renaissance. Everything from companies like yours, Pandia Health, which are pioneering in this way, NurX, to Ula Health and Poppy Seed, which have popped up as well. So, I'm very excited to watch this space over the next two, three years and see how it evolves. 

Given that you are a physician and you teach so many residents and medical students, what advice would you give to them about meeting the moment, meeting the challenges that COVID has brought and beyond? And it could be around women's health, it could be in general.

SOPHIA YEN: I think that telemedicine is here to stay, and we need to know our limitations. As a physician, I've always been skeptical about telemedicine, because it is so easy to do a telemedicine visit and say, you covered everything, but you didn't. You didn't listen to the heart. You didn't look at the ears. You didn't really get a good look at their throat. You weren't able to do a sample. You didn't even get their vitals. If they have asthma, can you really listen to their lungs? Certainly, the equipment is coming and when that equipment is here, yes. But before then, we need to admit our limitations. We need to not say we did a whole visit when we didn't do a whole visit and we need to realize when people need to come in. 

One big problem with consumer driven healthcare is Yelp, and other reviews.Because those of us in medicine know, sometimes you have to be the bad guy, right? If we are in an obesity clinic and you continue to gain weight and you continue to not adhere to my suggestions, I need to be the one that says, "No, you need to change your ways." Are you going to give me a five out of five Yelp review? No. And as a pediatrician, we see it all the time because we're like, "No antibiotics for you." And you're like, "But I want antibiotics." But 95% chance you've got a virus, and if you had a bacteria, I would see these signs on this blood test or this kind of symptoms and stuff like that, based on my experience and based on my teaching. And if I don't give you the antibiotic, what are you going to do? You going to fire me. Right?

And if you ask for a particular drug, because the drug rep sold it to you online and pushed it into your brain or is giving you an incentive, and I don't give you that drug because it's not in your best interest, or not the most cost-effective medicine, I'm going to get dinged. And so that is, I think, something we need to look at and tackle. We see it both in person and also by telemed. But if the consumer is paying for that visit, they're going to expect results, and they get very upset if you don't give them what they want. But sometimes what you want is not in your best interest.

SHIV GAGLANI: Yeah. I couldn't agree more. That was a lesson I learned as a second-year med student at Hopkins.  We had a psychiatry professor who dedicated his career in Baltimore to treating people with heroin addictions. Clearly, patient satisfaction -- when you're denying someone certain drugs -- is not going to be the way to measure your success. 

Is there anything else you want to be able to share with our audience while we have you on the podcast today, Sophia?

SOPHIA YEN: I would love to see more support of female-founded, female-led companies. I would like to see more people of diverse backgrounds in both gender and ethnicity and socio-economic status and education make it into healthcare as well as into the startup world. I hope that if you're given two companies that are the same, that you will choose the female-founded, female-led, and that you will look for quality in your telemedicine providers.

SHIV GAGLANI: Those are some great messages. And just off the top of my head, I would love to give a shout out to the venture capital firms I know that do prioritize that. People like Jeff Bussgang and Chip Hazard at Flybridge who have a specific fund for female founders. And as you may know, Chelsea Clinton is on the Board of Directors too, and she started Metrodora Ventures, which is named after what they say is the female Hippocrates, Metrodora, who too few people know about. 

So, in any case, Sophia, thanks so much for taking the time to be with us today. This was definitely one of my favorite episodes. I love meeting people who are so passionate about what they do, and clearly you are one of those people.

SOPHIA YEN: Thank you so much for having me and letting me share Periods Optional and emergency contraception and to talk about quality telemedicine.

SHIV GAGLANI: Definitely. And with that, I'm Shiv Gaglani. Thank you for checking out today's show, and remember to do your part to flatten the curve and raise line, since we're all in this together. Take care.