Ahana had seven days to build a company from scratch.

She was twenty, in the middle of her master’s thesis deadlines, and she’d just pitched an AI note-taking app to Y Combinator in San Francisco. How married are you to this idea? they asked, at 2am her time. Her response was diplomatic to say the least: there wasn’t a market-leading solution in that space yet, but if she was better suited to solve a different problem, she’d pivot. The verdict came back a few hours later. Good progress, wrong idea. Come back in a week with something better.

So she had seven days to pivot. Ahana chose to go back to a problem she really understood.

It’s More Than Skin Deep

Ahana is candid and open about the way she previously struggled with her skin growing up. She had tried every medication and product under the sun. Moving countries during her adolescence meant that her medical records never followed her, and she was sometimes re-prescribed the exact same drugs that hadn’t worked before, because she didn’t recognise the names and had never tracked anything. The problem was that neither she, nor anyone else, actually knew which of them were working.

She’d come to believe the skincare industry ran almost entirely on marketing rather than evidence. Whoever had the biggest budget, or could pay the right influencer, won, regardless of what the product actually did on skin. No brand would fund a study that included a competitor’s product, and because real people use multiple brands at once, there was no mechanism anywhere to capture an honest, brand-agnostic picture of what was actually working.

That was the thesis: we lack a good skincare app, and the dataset underneath it.

“Which skincare products are working, and for who?” That’s the question, in her own words, that the entire company still exists to answer.

In the four days between her two YC interviews, she made unbelievable progress. Before AI could build you a landing page in thirty seconds, she built hers by hand, got 200 people onto a waitlist, and ran 60 in-depth interviews with people from the Facebook groups and Reddit threads she’d already been part of for years. “I’m the expert in spamming and begging,” she says of that stretch. She made more progress on what would become Clear in those four days than she had in four months on the note-taking app. The second interview ended the way the first had, abruptly, no goodbye. Two minutes later they told her: incorporate in the US, open a bank account, leave your degree. Her first question was “Are you sure?” Her second was “Which company do you want me to build?”

It’s your company. Figure it out.

What Clear Has Become

Clear is a free app that works the way a period tracker or a fitness tracker does, except the thing being tracked is your skin. You log the products you’re using and any medications you’re on, then take photos over time. The app analyses changes in those photos across hundreds of parameters, and cross-references them against tens of thousands of other users doing the same thing, to surface which products are actually working, for people whose skin looks like yours.

That consumer layer is also the foundation of the whole business, though it’s less transactional than that sounds. Clear runs on a free app and a premium tier, and it gets more useful for everyone the more people use it. The collective data the community builds together is part of what users get back: sharper, more relevant insight the larger that community grows. The same dataset unlocks real value further afield too. Brands use it to understand how their products perform on real skin at scale, unfiltered by which influencer they’ve paid, and to get R&D feedback before or after a launch. Pharmaceutical companies use it in a similar way, and dermatologists use it to track outcomes across large patient populations, or for a specific patient, to help inform treatment.

Biggest Lessons From YC

One of the biggest lessons she took from her time at YC was build something people want. Find ten people who love what you’re building, not a hundred who are lukewarm about it. Focus on product-led growth over anything else.

She’s blunt about why that mattered specifically to her. A lot of people become founders for the wrong reasons, she says: how much they’ve raised, which investors sit on their cap table, the ego of the title itself. YC, for all its reputation as a Silicon Valley institution, actively pushes against that. Retention. A solid product. “Write code, talk to users.” That was the definition of success she was given at the start, and it’s the one she still measures the company against.

That’s the philosophy. What’s worth slowing down for isn’t the mantra, it’s the machinery she built underneath it, the actual method she used to work out what the app should be.

The Two-by-Two Matrix

For the first three months, she didn’t write a single line of code. “I still run the company like a lab experiment,” she says, and that discipline started on day one, well before there was a company to run.

She started with one problem statement: people don’t know which products to use, or whether what they’re using is working. Her first proposed solution was an AI tool that would simply hand back a recommendation, not unlike asking a chatbot what skincare to buy today. Then she wrote down every assumption that had to be true for that version to succeed: that people would trust an AI recommendation, that they’d photograph their skin weekly, that they’d log every product into an app.

Each assumption went onto a two-by-two matrix, plotted by how confident she was in it against how much the whole idea depended on it being true. “People trust AI recommendations” landed in the worst possible quadrant: high impact, low certainty. If that one was wrong, nothing else in the plan mattered.

So she tested it, not by asking people directly if they trusted AI (a leading question that tells you nothing useful), but by asking what they’d actually done. Tell me about the last three skincare products you used, and why. When you make decisions elsewhere in your life, what do you turn to? The same answer kept surfacing across the same Reddit threads and Facebook groups: skincare decisions were almost always community-driven. A friend, a parent, an influencer, something seen on someone else’s shelf. Nobody trusted a black box that produced an answer with no context behind it.

She built a community of 300 people this way and ran around ten interviews a day. Every evening she logged, assumption by assumption, what had been validated and what had been quietly killed. The AI recommendation engine didn’t survive the process. What replaced it was simpler and more honest: a diary where you logged what you used, and a way to filter for people with skin like yours to see what had actually worked for them.

She kept going until the interviews stopped teaching her anything new, roughly three months, and only then did she start building. That discipline hasn’t left the company since. Ship a version, define what would prove or disprove it, watch the data, adjust fast. She’s said outright that she thinks the speed at which a founder iterates is the single biggest determinant of whether the product succeeds, and the two-by-two matrix is really just a structure for making that speed disciplined instead of chaotic.

Ask The Stupid Questions

“It’s not a zero-sum game.” That’s her read on the startup ecosystem, and it’s why the other thing she took from YC was less about method and more about how she operates day to day.

Ahana’s cohort at YC included people who’d already built and exited companies before, and she describes having no issue asking what she calls stupid questions. By definition, everyone building a company is creating value somewhere, so helping another founder costs you nothing, and the culture rewards exactly that, during an accelerator and long after it ends. She’s still asking people the same kind of questions years later, and treats being generous back as part of the job, not a nice-to-have.

For anyone building in health, where the regulatory, clinical, and commercial questions rarely have a clean playbook, this matters more than it sounds. The founders who move fastest tend to be the ones borrowing the most judgment from people who’ve already made the mistakes.

No ads, ever.

The discipline shows up again in how she thinks about revenue. In her first funding round, several investors pushed her to monetise with advertising. She said no, not just on principle, but because the reason a business like L’Oréal could never build something like Clear is structural: they would never let a competitor’s product show up on their own platform. That’s the entire moat. If Clear ever let brands pay for visibility, it would lose the one thing that makes its data worth anything, honesty, and the users who make the dataset possible would have no reason to trust it. Trust generates the data. The data is the business. “I am my own user,” she says, and it shows in how easily she turned the offer down.

So there’s still no mechanism, years in, for a brand to pay for placement or ranking on Clear. The company monetises instead through premium subscriptions on the consumer side (data exports, before-and-after tracking, routine insights, the Strava-premium model) and a referral commission when users are matched with dermatology partners for problems the app itself isn’t equipped to treat. On the brand side, the real money is in data: unbiased testing programmes, and broader studies into what a given market of users actually wants and uses.

One of those studies had nothing to do with a skincare brand at all. A makeup founder building a line for Indian classical dancers, herself a dancer, had spent months frustrated that foundation ranges were built around a narrow set of standard skin tones and never matched real Indian skin. Clear already had years of skin-tone data from tens of thousands of Indian users. What came out of that analysis was six shade recommendations for a brand launch nobody had planned for, built entirely on data collected for something else.

That, more than any pitch deck line, is the proof of the original thesis: a dataset like this doesn’t exist anywhere else, and once it exists, you can’t fully predict what it will be worth.

Someone said it plainly: it’s your company. Figure it out.

She did just that.

She was a competitive golfer, part of the England performance squad, and she was struggling. With her cycle, with symptoms she couldn’t name, in an environment where naming them wasn’t really an option. Under 16, surrounded mostly by men, she stayed quiet but the questions didn’t go away.

Years later, she built a career out of answering them. Now a sports scientist and researcher at Northumbria University, Kelly works across the full female lifespan: puberty, the menstrual cycle, hormonal contraception, perimenopause, postmenopause. The thread running through all of it is the same. Women’s bodies have been under-researched and peripheralised in sport and exercise science. The consequences are not abstract.

What does 6% mean to you and I?

On the first Sunday of May, Venus Williams walked into the Met Gala as co-chair. Swarovski crystal gown, diamond neckpiece modelled after the Wimbledon women’s singles trophy, and earrings that said 6%. She told the camera: “Can you imagine?”

Only 6% of sports science studies have been conducted exclusively on female participants. It’s the figure that Dr Emma Cowley, Kelly and fellow co-authors work helped establish. It has now escaped the paper entirely: cited in parliamentary debates, worn on a red carpet, made the basis of a Gatorade research initiative with Venus as its first ambassador. The number has escaped the paper.

What tends to get lost in all of that is what Kelly and her colleagues found when they looked underneath it. Within that already-small 6%, only around 9% of studies focused on perimenopausal or postmenopausal women. Sports science had been studying a very specific kind of female: naturally menstruating, aged 18 to 30. Everyone else, the majority of the female lifespan, was quietly excluded. Not through policy. Through the accumulated weight of a thousand methodological choices nobody thought to interrogate.

That framing matters, because it shapes what we think we know and who we’re designing for when we talk about “female athletes.”

© AFP

A Quality Problem Inside a Volume Problem

The first major output of Kelly’s PhD was a systematic review and meta-analysis on the menstrual cycle and exercise performance, published in Sports Medicine in 2020. The question seemed tractable. Does physical performance change across the cycle? The existing literature said yes. It also said no. Frequently in the same review.

What Kelly and her co-authors found was a trivial reduction in performance during the early follicular phase, days one to five, when menstruation is happening, compared to all other phases. Slightly lower strength outputs, slightly lower endurance performance, a marginal effect that was real but small.

The finding that matters as much as the finding itself is this: most of the studies contributing to it were rated low quality. Not just sparse. Methodologically weak. The field isn’t only dealing with a volume problem, a deficit that time and funding might eventually close. It’s dealing with a quality problem sitting inside the volume problem, making it harder to extract anything reliable from what does exist.

This is why the review couldn’t produce the standardised guidelines everyone wanted. The evidence base didn’t support them. What it recommended instead was a personalised approach, which consistently frustrates people who came looking for a protocol, but is the only honest conclusion available.

Cycle syncing sits in even more contested territory. The premise that training should be tightly periodised around hormonal phases isn’t currently supported by evidence. In a population that already struggles to train consistently, adding restrictive phase-based rules carries real risk. The conversation has outrun the science by some distance, which is not a new problem in women’s health, but remains a costly one.

Direct and Indirect

The more practically useful thing to come out of Kelly’s work is a conceptual distinction: the difference between the direct and indirect effects of hormonal fluctuations on performance, and why that difference changes what we should actually be trying to do.

The direct story is the one the field has chased for years. Oestrogen and progesterone bind to receptors throughout the body, in muscle, the nervous system, the brain, theoretically influencing every system that sport demands of us. It’s a compelling hypothesis. The performance-level evidence for it, however, remains inconsistent even after decades of research trying to find it.

The indirect story is less exciting and considerably more useful. Those same hormonal changes produce symptoms. Bloating, breast pain, back pain, mood shifts, disrupted sleep, fatigue. For women who carry a significant symptom burden across their cycle, that burden can become the performance variable. Not because hormones are directly impairing muscle function, but because pain and poor sleep and low mood can impair performance through any mechanism. That’s a different problem with a more tractable solution: not optimising around hormonal concentrations, but managing symptoms well enough that they stop becoming obstacles. It reframes what “cycle support” should actually mean.

What Tracking Can’t Fix

The normalisation of menstrual cycle tracking is largely a good thing. Women having better data about their own bodies tends to be better than the alternative.

But Kelly raised something that rarely surfaces in the mainstream version of this conversation: tracking isn’t a neutral act, and the evidence for its athletic benefits is considerably thinner than its adoption would suggest.

In clubs where teams introduced cycle monitoring, a pattern sometimes emerged. Athletes who hadn’t previously noticed their symptoms began noticing them. Directed attention created new signal. A variable that hadn’t been interfering with performance started to, not because anything physiological changed, but because the structure of awareness did. You can’t unknow what you’ve started measuring.

This isn’t an argument against tracking. It’s an argument for being honest about who it serves. We don’t have menstrual health tracking tools that are fit for purpose or systems (e.g., ethics, data handling, who should have access to this data etc.

What the Research Actually Says About the Pill

Hormonal contraception has become one of the more charged areas of online health discourse, and the gap between what social media implies and what the literature shows has grown wide enough to be its own problem.

Kelly contributed to a 2024 systematic review and meta-analysis led by Dr David Nolan on hormonal contraceptive use and training adaptation. The finding: no significant difference in muscle hypertrophy, power, or strength between pill users and naturally menstruating women. The study got pushback. Women felt their lived experience was being flattened into a null result.

The frustration is understandable, and the criticism is partially valid. Population-level meta-analyses detect average effects across heterogeneous samples. They aren’t designed to capture individual variation, and individual variation in response to hormonal contraception is well-documented clinically even where group-level performance effects aren’t apparent. The meta-analysis is one carefully bounded data point. Treating it as a verdict misunderstands what it is.

There’s also a sampling problem in the literature that deserves more scrutiny. Around 60% of exercise science studies on hormonal contraception have focused on the combined oral contraceptive pill, despite long-acting methods now being among the most commonly used forms. Hormonal IUDs, implants, injectables: barely studied in a sport and exercise context. The copper coil, non-hormonal and increasingly popular, barely registers. We’re generating guidance from a sample that no longer reflects how most women actually use contraception, and handing it out as though it does.

Menopause Doesn’t Need a Rebrand. The Gym Does.

Kelly’s postdoctoral work moved into perimenopause and postmenopause, and produced a finding that cuts against a significant amount of what the wellness industry has been selling: there is no evidence that menopause-specific exercise programming outperforms standard training.

Strength training, cardiovascular exercise, moving consistently: these are the best-evidenced interventions for the cardiovascular changes, bone density loss, and mood disruption that can cluster around the menopause transition. The evidence isn’t menopause-specific. It’s evidence for exercise, applicable across the lifespan. The menopause modifier being attached to supplements, studio classes, and coaching programmes isn’t coming from the research. It’s coming from a market that found a newly visible and underserved population and moved fast.

What the qualitative work surfaced was more interesting than the programming question anyway. When Kelly’s team talked to women during perimenopause and postmenopause about what they actually needed, they didn’t ask for different exercises. They asked for a different environment.

Flexibility, because symptoms don’t schedule themselves around class bookings. Spaces that didn’t feel like they’d been designed for someone else. Community with women at a similar life stage, not structured as therapy, just as a social fact. And, tellingly, they didn’t want it called a menopause workout. Not from shame, but because the word had accumulated associations of limitation and decline that they weren’t interested in training under.

Kelly’s team ran a programme for six weeks, two sessions a week, online option available, shorter duration, an education component folded in. Women who had never deadlifted ended up joining gyms. The programme worked not because it was menopause-branded, but because it was built around what the women themselves said they wanted, which turned out to be rather different from what the industry had assumed they needed.

Girls Are Already Telling Us

Dropout from sport accelerates at puberty. Periods are one of the most consistently cited reasons. This has been known for years. The structural response has been slow.

Kelly’s team worked with girls aged 11 to 16 across North Wales, co-designing education sessions with cheerleading clubs, football teams, Brownie groups. The sessions were designed by the girls. They wanted the basics of the cycle explained clearly, an overview of what products existed, practical guidance on symptoms. They didn’t want a classroom. At the football club, period questions got answered by scoring into different goals.

What struck Kelly was generational. These girls talked about periods and their bodies with a directness she hadn’t had access to at their age. The questions she’d stayed quiet about on a golf course in her early teens, they were asking without hesitation. Whether that openness translates into sustained engagement with sport as they move through adolescence is still genuinely unknown. What projects like this are trying to do is make sure the infrastructure is there when they arrive.

Your Own Scientist

The thread running through everything Kelly has built is that the evidence, for all its growth, keeps arriving at the same honest place: individual variation is large, it is real, and population-level findings don’t resolve it.

Reviews and meta-analyses tell us what is probable across a group. They don’t tell you what is true for your body, your symptom profile, your response to training across the cycle, your experience of the pill, your perimenopause journey. The call for personalised approaches frustrates people who want a protocol. But it’s the honest conclusion of a field that has looked hard at the data and found that human variation is not a rounding error.

What Kelly actually advocates for is something more demanding than following a programme and more empowering than waiting for the science to catch up: becoming rigorous about your own data. Collecting it. Looking for patterns. Using the population-level evidence as orientation rather than instruction. Interrogating the protocols not built for your body.

Venus Williams wore 6% on the red carpet and asked: can you imagine? Most women in sport didn’t have to. They’d been living it. Kelly McNulty spent a decade making sure we could finally count it.

Kelly McNulty is a postdoctoral researcher at Northumbria University. Follow her work at @periodoftheperiod.

But there has undoubtedly been a wave in consumer health and wellness that has moved faster than the evidence. Products and programmes labelled “menopause” have opportunistically seized this moment, and a lot of them don’t have the clinical validation to justify what they’re claiming. Pagliano, who has spent 26 years in this field, is careful about how she says this. But when it comes to menopause-specific fitness programmes and products marketed at women without robust evidence behind them, she says it plainly:

“When you actually get in the nuts and bolts and the research, it just doesn’t have legs to stand on. But again, that’s all marketing.”

She is talking specifically about the proliferation of branded systems built on the premise that hormonal change requires a fundamentally different approach to exercise, one that only this programme, this coach, this supplement stack has cracked. The premise feels intuitive. It has the texture of personalised medicine. It speaks directly to the experience of women who tried generic fitness advice and found it didn’t fit, who felt unseen by an industry built around male physiology and young female bodies.

The problem is that the evidence does not support the central claim.

The Muscle Loss Myth

The claim you’ll encounter most often in menopause fitness content: oestrogen decline causes accelerated muscle loss, and you need a specific programme to address it.

The evidence doesn’t support it.

“We actually don’t have any evidence to say that muscle mass loss is because of menopause. It’s at the same rate as men.”

Age-related muscle loss begins in the fourth decade and progresses at roughly the same rate regardless of sex. What changes during the menopause transition is not the biology of muscle loss but the context around it. Women in perimenopause are sleeping badly, managing vasomotor symptoms, dealing with joint pain. They move less. They train less consistently. The muscle loss that follows is real. Its primary driver is reduced activity, not oestrogen.

“Do you need a menopause-specific strength programme? No. Is it menopause why you’re losing muscle mass? No. It’s because you’re getting older and you’re getting less active.”

A clinician who works in this space every day is telling you the boring answer is correct. Lift heavy. Eat enough protein. Sleep better. Address the symptoms making those things harder. The intervention doesn’t need a brand name.

To be clear: Pagliano is not arguing that hormones are irrelevant. Oestrogen affects connective tissue integrity, pelvic floor function, urethral health, and bone density, all covered in Parts 2 and 3. These are real, and they matter for how active women train and recover in midlife. But none of them require a proprietary twelve-week programme to address.

People Mistake Testing for Caring

Dr Jen Gunter, OB/GYN and author of The Menopause Manifesto, has been making this argument for years. She describes what she calls the “wellness industrial complex,” an industry that has learned to exploit the historical underfunding of women’s medical research by stepping into the gap it created. Her phrase stays with me: “people mistake testing for caring.” It applies beyond diagnostics. Women mistake the feeling of being understood for being well-treated. A supplement brand that names your symptoms and validates your experience has done something your GP probably didn’t, which is make you feel seen. That emotional transaction is real. It just isn’t the same as effective care.

The menopause wellness industry, at its most cynical, has learned to perform the first while selling you the second.

The Validation Economy

Here is what actually happened. Women in their forties and fifties were failed, systematically, by mainstream medicine. Symptoms dismissed. Appointments too short. HRT conversations shut down by fears that were never adequately corrected after the Women’s Health Initiative study derailed the field in 2002. Women left without diagnoses, without treatment plans, without information.

Into that void came coaches, clinicians, influencers, supplement brands. Some excellent. Some opportunistic. Most somewhere in between, doing genuine good while running a business that requires them to sustain your belief that you need them specifically.

“We love to be validated and we want somebody who understands us. And you’ve got to see what the motivation is behind that, unfortunately.”

A fitness programme with monthly subscriptions has a structural incentive to frame generic evidence-based advice as proprietary insight. A supplement brand has a structural incentive to overstate the ways hormonal change creates needs that standard nutrition can’t meet. No individual bad faith required. The incentive structure does the work.

And critically: the wellness industry exists partly because the healthcare system created the conditions for it. “Ours is just so broken,” she says of the US. Pagliano runs a private practice. The wait to see a pelvic health physiotherapist through the US system is now six to eight months. The NHS wait is similarly grim.

The women spending money on wellness programmes are not being irrational. They are responding to a genuine absence of care with the resources available to them. Fix the access. Train more pelvic health physiotherapists. Treat menopause as a medical condition rather than a life stage to be self-managed with adaptogens. The market for proprietary solutions to questions that already have evidence-based answers would shrink considerably.

How to Tell the Difference

Before you buy in, ask three things.

Does the claim have evidence behind it, and is that evidence in the population it’s claiming to address? Postmenopausal research doesn’t automatically apply to perimenopausal women. Research in sedentary older women doesn’t automatically apply to active women in their forties.

Is this intervention actually menopause-specific, or is it good general advice wearing a menopause label? If the menopause version is materially different from the general version, ask why.

Is the person offering it making money from your continued belief that you need them specifically? Not disqualifying, everyone in a service profession makes money from clients. But it’s worth knowing which side of that relationship you’re on.

Carrie Pagliano has been in perimenopause for two and a half years. She describes it as drinking from a fire hose, which is a striking thing to hear from someone who has spent 26 years treating the symptoms she is now experiencing herself, who founded a pelvic health residency programme, who served as president of the national professional body, who has read every paper, seen many presentations.

Even she didn’t recognise it at first.

She had been on continuous hormonal contraception for seven years. Came off it. A couple of months later, she started waking at 2am every night. She would surface from sleep hot and agitated, and blame the dog, a Border Terrier they’d had for four years. “It’s not the dog,” she says now. She started having sudden bouts of anxiety that were out of character. Her leakage on runs increased, which was new. None of it, individually, pointed obviously to perimenopause. She wasn’t tracking her cycle changes, because she didn’t have a cycle to track. The contraception had masked that entirely.

“Even having changes with increased leakage with running, which was new for me.”

This is the thing that gets women. Not the headline symptoms, the night sweats, the hot flashes, the ones that now appear in lifestyle supplements and menopause wellness campaigns, but the accumulation of smaller, stranger changes that don’t obviously cohere. The anxiety. The insomnia. The joints that suddenly ache. The mood that shifts without reason. The pelvic floor that behaves differently than it did six months ago. Individually, each one has an explanation. Together, they have a name.

The Postpartum Mirror

The clinical insight Pagliano returns to repeatedly, and the one that genuinely reorients how you think about both conditions, is that perimenopause and the postpartum period share the same hormonal destination.

Both involve low oestrogen, most profoundly in the postpartum period when breastfeeding is involved. As soon as the placenta is delivered, oestrogen and progesterone plummet within 24 hours. In breastfeeding women, they stay there: prolactin suppresses oestrogen production for as long as lactation continues. In perimenopause, oestrogen becomes erratic, spiking unpredictably before declining overall, until it drops and stays low at menopause. The physiology is different in its trajectory. The tissue-level consequences are strikingly similar.

“A lot of the symptoms that you’re having that people don’t talk about in early postpartum are very commonly understood as perimenopause and menopause symptoms. Hot flashes, night sweats, hair loss, sudden anxiety, insomnia.”

This is not a metaphor. It is a mechanistic parallel recognised in the clinical literature, recent enough that researchers have only just proposed a formal term for the postpartum version: genitourinary syndrome of lactation, to sit alongside genitourinary syndrome of menopause. The pelvic floor changes in the postpartum period, tissue integrity, oestrogen receptor activity, urethral function, mirror what happens in the genitourinary tissues during perimenopause. Women who experienced pelvic floor symptoms after childbirth and recovered are not immune from experiencing them again in midlife. The hormonal conditions that created those symptoms are returning.

And women who are currently postpartum and perimenopausal simultaneously, which is more common than the wellness industry acknowledges, given that the average age of menopause is 51 and many women are having children in their early to mid forties, are navigating both at once, with almost no time between the two low-oestrogen states.

“You could be backing up postpartum with perimenopause with very, very little time in between.”

The clinical utility of recognising this parallel is significant. It means that some of what pelvic health physiotherapy learned from postpartum care, specifically the importance of local oestrogen in maintaining urethral and pelvic tissue integrity, maps directly onto perimenopause management. It means that practitioners who understand one understand the other, and that the research evidence from postpartum can, carefully, inform treatment decisions in perimenopause while the menopausal research catches up.

“The more I started to understand about perimenopause, I was going back and starting to look at postpartum in a completely different way.”

The Inner Tube

Pagliano has a way of describing the effect of oestrogen withdrawal on urethral tissue that is both clinically precise and unexpectedly vivid. She talks about the urethra as an inner tube. Oestrogen gives it integrity, firmness, elasticity, the capacity to seal under pressure. As oestrogen falls, the inner tube deflates. The seal becomes less reliable. The system that was managing continence without effort begins to need more effort. And then it begins to fail.

This is the mechanism behind genitourinary syndrome of menopause, a cluster of symptoms that includes vaginal dryness, pain with sex, recurrent UTI-like symptoms without infection, urinary urgency and frequency, and changes in continence. It affects between 40 and 84% of postmenopausal women. It is chronic and progressive without treatment. And it is, despite this, still widely undertreated and underdiagnosed, partly because women don’t report it, partly because clinicians don’t ask, and partly because it has historically been filed under “inevitable consequences of ageing” rather than under “treatable condition.”

The systemic hormone therapy that addresses hot flashes and night sweats, combined oestrogen and progesterone for women with a uterus, does not reliably reach the local pelvic tissues. The concentrations required locally are higher than what systemic therapy delivers. This is why topical, local oestrogen, applied directly to the vaginal and urethral tissue, is a separate and necessary conversation. “Local topical oestradiol cream can be incredibly helpful in kind of replenishing those local oestrogen receptors and can improve symptoms really quickly.”

This is also, notably, not a conversation most women have with their GP.

The Blood Test Myth

One of the most persistent and consequential misconceptions about perimenopause is that it begins when the blood tests say it does. Pagliano is direct about this. “People think you need a blood test, or that the first symptom has to be a loss of regular cycle.”

Neither is true. Perimenopause is a clinical diagnosis. Hormone levels fluctuate so dramatically during the transition that a single blood test captures a single moment in a wildly variable picture and cannot rule anything in or out with confidence. A woman who has intact, regular cycles but is waking at 3am, experiencing new anxiety, and leaking on runs she has completed symptom-free for fifteen years may be in perimenopause. The absence of a changed cycle does not mean the absence of the transition.

The contraception problem compounds this significantly. Women on hormonal contraception, particularly the Mirena coil or the combined pill, may have no cycle changes to notice because hormonal contraception suppresses or eliminates the cycle entirely. The mask is complete. The only signals available are the secondary ones: the sleep, the mood, the joints, the pelvic floor. For women who don’t know to connect those signals to hormones, the picture remains incoherent for years.

“A lot of providers, for a long period of time, if women were girls were not having regular cycles, they would put them on the pill and be like, ‘all right, that fixes it.’ And you really still have this underlying issue.”

Progesterone and Sleep

There is a small, practical detail in Pagliano’s account of her own treatment that is worth pulling out because it is useful and rarely stated clearly.

Once she was seen by a menopause-certified provider and started hormone therapy, the progesterone component helped with the sleep disruption. Not immediately, not perfectly, but meaningfully. The mechanism is well-established: progesterone is converted in the brain to a metabolite called allopregnanolone, which acts as a positive modulator of GABA-A receptors, the same receptors targeted by benzodiazepines. The result is a calming, sedative effect. This is why progesterone-dominant phases of the menstrual cycle tend to be associated with better sleep, and why its withdrawal during perimenopause correlates with the 3am waking that is so characteristic of the transition.

It is also, Pagliano notes, not something a clinician in the US can prescribe for sleep disturbance alone. It comes as part of the combined hormone therapy package, justified by the broader symptom picture. The system requires you to present a full constellation before it will offer you the single component that might have the most immediate quality-of-life impact.

This is not unique to the US. It is a feature of how hormone therapy is currently navigated in most healthcare systems, cautiously, bureaucratically, with the burden of proof sitting with the patient rather than the clinician.

The System Won’t Save You. The Information Might.

What Pagliano offers is not a solution to the structural inadequacy of how perimenopause is managed, in the NHS, in US insurance systems, in a research landscape that is only now beginning to generate the data that should have existed twenty years ago. She is operating within the same broken system as everyone else. Six to eight month waits to see a specialist. Patients self-diagnosing from Instagram. The wellness industry filling the vacuum with products that have no evidence base and a very clear commercial motivation.

What she offers is the map. The understanding that what you are experiencing has a mechanism, that the mechanism has a name, that the name connects to an intervention, and that the intervention can genuinely help. That the leaking is not permanent. That the anxiety is not who you are now. That the sleep will not always be this bad. That the parallel to postpartum is not coincidental but physiological, and that if the postpartum symptoms resolved, there is reason to believe these can too.

“I think the more I started to understand about perimenopause, I realised it very much mirrors a lot of what we navigate in postpartum.”

She didn’t recognise her own perimenopause for months. A double board-certified pelvic health physiotherapist with 26 years of clinical experience, and the transition still arrived sideways, disguised as a hot dog and a bout of unexplained anxiety at 2am.

If she missed it, the system is definitely missing it. The question is what you do with that information.

Part 4: we’ll take a look at Menowashing

The reason it doesn’t feel real, in part, is that the conversation about bone health tends to reach women too late, framed around treatment rather than prevention, and anchored in an age range, post-65, post-fracture, when the window for meaningful intervention has already started closing.

Dr Carrie Pagliano has been watching this happen for 26 years. And something that surprised me during our conversation was that running doesn’t do much for your bones.

“Surprisingly enough, running does not do much to help with bone density. It’s right up there with swimming, to be honest, which is really surprising.”

This is where the conversation about bone health for active women gets interesting and urgent.

The Window

Bone is not static tissue. It is constantly being broken down and rebuilt, a process called remodelling that is exquisitely sensitive to mechanical load, hormonal environment, and nutritional status. The critical period for building peak bone mass is childhood through to the late twenties. “Most of our bone health is built up to age 30,” Pagliano says. After that, the capacity to increase bone density diminishes, though it doesn’t disappear. “We have the ability to alter and modify it, improve it, up through menopause.”

This is the window. It is not closed after 30. But it is narrowing. And the behaviours that matter most for protecting bone in midlife, specifically the kind of mechanical loading that actually stimulates bone remodelling, are not the ones most active women are doing.

Swimming: minimal skeletal benefit. Cycling: minimal skeletal benefit. Running: less than people think, because despite the repetitive impact, the loading stimulus per step is not sufficient to drive meaningful bone adaptation at the intensities most recreational runners train at. What drives bone remodelling is heavy load or high impact, think ground reaction forces of multiple times bodyweight, applied rapidly.

Think jumping. Think heavy barbell work. Think the things that also, inconveniently, tend to make perimenopausal women leak.

The Plyometrics Catch

This is the clinical trap Pagliano watches active women fall into repeatedly. They get the message, finally, after years of the evidence being ignored in mainstream women’s health, that they need impact training and strength work to protect their bones. They go to the gym. They start jumping. They leak. They stop.

“They’re trying to do the right thing, but then this pelvic floor catch comes up.”

The leap she needs them to make is that the leaking is also fixable, that it’s not an immutable feature of their postpartum or perimenopausal body, but a coordination problem with an intervention. The pelvic floor and the skeleton are not in opposition. Solving one does not mean sacrificing the other. But the two problems need to be addressed in the right sequence, and most women never get told that both conversations can be had, let alone simultaneously.

Powerlifting adds another layer. Women lifting heavy enough to compete, loading the spine and hips with multiples of their bodyweight, occasionally develop leakage not because something has gone wrong, but because the system is being pushed to its limit. “In some situations, it’s because they’re lifting so, so, so heavy, just the system’s being overloaded.” This is a different problem from perimenopausal leakage. It has different solutions. The existence of both presentations in the same category, women who leak during exercise, is part of why the generic advice is so unhelpful.

The Scan Question

In both the UK and the US, a DEXA scan, the gold-standard measure of bone mineral density, is not routinely available until 65. Pagliano is direct about what she thinks of this. “It’s almost too late at that point.”

She got her own scan early because of family history. She describes navigating the system, finding the right primary care physician who would tick the right box to get insurance to cover it, knowing a colleague who runs body composition scans for figure athletes and includes bone density as part of the panel. This is the reality for women who want this information before menopause: it requires knowing where to look, having the right conversations, and often paying out of pocket.

For women without that access, history does significant work. A previous stress fracture. A history of disordered eating or underfuelling. Irregular or absent periods. These are the signals that should trigger the conversation much earlier, regardless of what the system offers.

“I have never seen so many women walking around in boots,” she says, meaning the orthopaedic boots that follow stress fractures. “This just doesn’t seem right.”

The Skinny-Is-Fast Reckoning

The stress fracture conversation leads somewhere darker, and Pagliano follows it there without flinching.

She’s talking about a generation of female distance runners, her generation, who trained through an era in which low bodyweight was synonymous with performance. “Skinny was fast, or was supposed to be that way.” The fuelling strategies of the 1990s and early 2000s recreational running scene were not strategies at all. They were restrictions, often bordering on or crossing into disordered eating, normalised by a culture that rewarded lightness.

She mentions Kara Goucher’s memoir and Lauren Fleshman’s book, both elite athletes who have written candidly about underfuelling, stress fractures, and the long shadow of those years. “They don’t call it low energy availability. They don’t identify it as that at the time, because we didn’t know.” What we now call RED-S, Relative Energy Deficiency in Sport, was, in that era, called thinness. Sometimes it was called discipline.

The damage, it turns out, is not always contained in the past. Pagliano references research, published in the last couple of years, suggesting that disordered eating patterns can resurface in ultra runners in later years. Body image pressure doesn’t disappear at perimenopause, it often intensifies, as bodies change in ways that are rapid and unasked for. “Body image is a huge issue going into perimenopause and menopause because things are changing, random weight gain out of nowhere, that kind of stuff.” The threads carry through. They don’t dissolve.

For women who got through their twenties and thirties running hard on not enough food, the bone density story is more complicated. The window for building peak bone mass was precisely the period in which their nutritional status was compromised. What they’re managing now is not just normal age-related loss, they may be starting from a lower baseline than they realise, at an age where the tools for recovery are more limited.

This is where the DEXA conversation becomes not just useful but necessary.

The GLP-1 Signal

There is a newer strand to the bone and muscle conversation that Pagliano raises. She is beginning to have DEXA discussions with patients who are starting GLP-1 medications, the weight loss drugs now being prescribed at scale to women in midlife.

“We know that muscle mass is going to drop.” The evidence on GLP-1s and lean mass loss is consistent enough that she is now recommending baseline scans before patients start, to have the data to monitor against. She describes putting her hands on a patient she’d been working with for some time, who had been on a GLP-1 for a while without her knowledge. “Just the quality of her muscles felt like she was 70 and she was 40. And that just, at the time, I couldn’t process it.”

She is not making an argument against GLP-1s. She is making an argument for not starting them in a data vacuum. Muscle mass and bone density are not vanity metrics, they are functional longevity markers. If a drug is changing them, you need to know where you started.

Doing the groundwork

The answer, unglamorous as it is, is heavy loading and impact. Progressive resistance training with barbells. Plyometrics, jumping, bounding, hopping, applied progressively and with enough volume to drive bone adaptation. Weighted vests have some evidence behind them, particularly for postmenopausal women, though the perimenopausal research is thin. “Almost all the research is on postmenopausal women,” Pagliano notes. “Perimenopause is different, hormones are in flux, bone loss starts, and everyone’s experience is unique.”

The research is catching up. It is not there yet. Her clinical advice in the interim: don’t wait for it.

“Start strength training now while the research catches up.”

She has been lifting for ten years, since after her hip surgery, a labral repair following marathon training eighteen years ago. The surgery was the consequence of a running life built without the counterbalance of strength work. “I got better after I started lifting weights.” The pivot was personal as much as professional.

The women she treats are, increasingly, the same story at a different stage. They have run for decades. They are now being told, firmly, that running is not enough. The gym is unfamiliar territory. The equipment is unfamiliar. The culture can feel alien. And then, when they try the jumping, they leak.

The answer to the leaking is in Part 1. The answer to the bones is: start now, load heavy, don’t let the leaking stop you from doing the thing that the leaking is interrupting.

Both problems are solvable. That’s what 26 years in this field teaches you.

Part 3: low oestrogen, different decades.

The Coordination Problem

Carrie sees the same pattern walk into her clinic over and over. A woman who's done the kegels. Seen a physio. Worked with a trainer. Still leaking. The assumption, hers and everyone else’s, is that she hasn’t tried hard enough. Pagliano’s argument is that she has been treated for the wrong problem.

Pagliano has been a pelvic health physiotherapist for 26 years. In that time she has had hip surgery after marathon training, navigated her own pelvic floor dysfunction after two pregnancies at a moment when she was the person other women came to for answers, and is now, at nearly 50, two and a half years into perimenopause. Drinking from the fire hose, as she puts it. She is double board-certified in orthopaedics and women’s health, founded the pelvic physiotherapy residency at MedStar Georgetown University Hospital, served as president of the Academy of Pelvic Health Physical Therapy, and coaches CrossFit on the side.

She has spent her entire adult life inside this problem, professionally and personally. So when she says that what most women are told about the pelvic floor is wrong, it’s worth paying attention.

The Hammock

Ask most women to picture their pelvic floor and they’ll describe something passive. A hammock, strung between the tailbone and pubic bone, that sags when it should be tight. The fix, naturally, is to tighten it. Hence kegels. Hence the advice handed to women after childbirth, during perimenopause, after a prolapse diagnosis, after the first embarrassing incident on a run.

Pagliano is unambiguous. “The pelvic floor, I think for a long time had this idea of, oh, it’s just a hammock. And it’s so much more than that.”

The pelvic floor is anticipatory. It fires before you jump, before you laugh, before you cough, before you lift, because it has to. It reads the intention of movement and responds before the movement happens. Which is why the instruction to “do a kegel before you jump” is physiologically incoherent. By the time you’ve thought about contracting, the window has closed. The floor should already have fired.

It also sits inside a pressure system. When intra-abdominal pressure rises, during a heavy squat, a sprint, a sneeze, the floor counters that pressure to maintain continence. It does this automatically, continuously, as part of a system that includes the diaphragm and the deep abdominals. Treating it as a single isolated muscle that needs more squeezing is a fundamental misunderstanding of what it actually does.

Two Buckets

When Pagliano meets a new patient, she listens to the story first. “I often think they have the answer. It’s just up to me to find it.”

What she’s listening for is which of two buckets the patient sits in.

The first is low tone. Underactive, lacking strength, lacking support. This is the bucket kegels were designed for, and the one most women are assumed to be in regardless of their actual symptoms.

The second is high tone. Overactive, poorly coordinating, unable to relax fully between contractions. And here’s where it gets counterintuitive: women with stress urinary incontinence, the classic leaking-when-running-or-jumping picture, frequently sit in this second bucket. Not because the muscle is weak. Because it can’t let go.

“What we looked at for so long as a strength issue, actually probably truly is a coordination issue.”

A pelvic floor that can’t release fully between efforts can’t generate the rapid recoil needed to respond to load. The result isn’t a strength deficit. It’s a timing problem. Giving that floor more kegels is like telling a muscle in chronic spasm to contract harder. The symptom doesn’t improve because the intervention is wrong for the diagnosis. And the diagnosis was never made in the first place.

The signals for high tone are audible in the history, if you know to listen. Pain with penetration or tampon use. Back or hip problems. Urinary urgency or frequency rather than simple leaking. Constipation. Birth trauma. “Those are sorts of things that are going to tend to go in a higher tone bucket,” Pagliano says, “which is going to be treated very, very differently.”

The Orthopaedic Lens

Pagliano came to pelvic health from orthopaedics. When she started in women’s health in 2001, she took the job because there weren’t many others going and she needed one. The field was in two boxes. Leakage or prolapse: kegels. Pain with sex: maybe some manual therapy. That was it. And often, she says, it didn’t work.

“Gynaecologists don’t look at these muscles like an orthopaedic therapist would. Like a muscle that can contract and activate and load eccentrically, like elongate or shorten. They don’t look at it that way.”

The orthopaedic training gave her a different frame. The pelvic floor as a muscle like any other. One that can be underactive or overactive, that responds differently to eccentric and concentric loading, that sits within a kinetic chain, that connects to the hip and the lumbar spine in ways that matter clinically. A woman with leakage and a hip impingement isn’t presenting two separate problems. She may be presenting one.

“It’s incorporated in our pressure system. It’s also just a muscle like everything else.” The nervous system is involved. Hormones are involved. The cardiovascular system is involved. “It is holistic at its truest sense” — and she means it as a clinical description of genuine complexity, not a wellness platitude.

The Diagnostic Gap

Pagliano describes three groups of women who find her work. Those educating themselves before problems begin. Those looking for basic solutions to early symptoms. And those who have done everything they were told, and it hasn’t worked. “We need to empower them to demand more,” she says, “cause the basics weren’t enough.”

The basics weren’t enough because the basics assume everyone is in bucket one. They assume leakage equals weakness equals more contraction. They skip the history, skip the assessment, skip the question of what the pelvic floor is actually doing, and go straight to the prescription.

What gets missed is subtle. Pagliano describes high-tone dysfunction with clinical precision that happens to also be unexpectedly vivid. “A deflating marshmallow. A slow leak. A gradual let down. That’s how I describe it to patients when I feel that subtle delay in pelvic floor relaxation after a contraction. It’s not dramatic. It’s not even obvious at first.”

But it’s there. And it’s the thing the kegel won’t fix.

Retrainable

The kegel narrative carries a weight it was never designed to bear. Women who don’t improve are quietly blamed. For doing them wrong. For leaving it too late. For too many pregnancies, the wrong kind of birth, too little discipline. Framing pelvic floor dysfunction as a deficit of effort obscures what Pagliano is actually describing. A coordination problem. A neuromotor problem. A problem of timing and sequencing and learned movement patterns that have, for reasons that can be understood and addressed, gone wrong.

Those are not problems of weakness. Not problems of not trying hard enough.

And unlike a structural deficit, they can be retrained.

She has been doing the work of retraining for 26 years, in patients, in the profession, and in herself. The job she has today, she says, did not exist five years ago. The job she has in ten years, she can’t yet imagine.

That’s probably the most interesting thing about pelvic health right now.

Dr. Carrie Pagliano is a pelvic health and orthopaedic physical therapist with 26 years of clinical experience. Find her work at carriepagliano.com.

Part 2: the bone density window of opportunity, and looking after your skeleton.

Gaia spent years at Adidas building exactly that kind of thing. As Global Marketing Director, she was in the business of turning products into universes. Things people don’t just buy. Things they belong to.

I sat down with her to understand how, and what it means for those building in women’s health.

She didn’t start in marketing. She started in international politics, in Sweden, wanting to change the world, before realising that sport and brand were their own form of culture-making. That reframe shaped everything that followed.

The Muse Comes First

Before anything else, before the logo, the tone of voice, the campaign, Gaia starts with the muse. Not a demographic or psychographic. A person.

“Who are you serving? What is their painpoint? What is their story?”

It sounds obvious. It isn’t. Most health brands start with the product and work backwards to the person. Gaia argues that’s the wrong order entirely. You map the human first, then you look at who’s already serving them and, crucially, where they’re being failed. That gap is where your brand lives.

In women’s health it’s in the very nature of how we define intersectionality, those gaps are not hard to find. They’re structural, clinical, cultural. The question is whether you’re building something that genuinely fills one, or something that performs filling it.

The Skeleton

Once you know who you’re serving and why you’re different, the work is to build what Gaia calls a brand identity, a framework, a set of non-negotiables that don’t move.

“It’s your ID. Your birth date, your name and surname. That doesn’t change.”

Brands that pass the test of time have a skeleton underneath everything else. It can flex, it has to flex, but the core doesn’t shift with the trend cycle. The brands that fail, she says, are the ones chasing everything. Standing for everything means standing for nothing.

This is where trend navigation becomes a discipline in itself. Gaia talks about three modes: trends that belong to you and you should own, trends you can hydrate, take and make yours, and trends you should step away from entirely. The skeleton is what tells you which is which. The customer recognise the brand they know and trust because the skeleton keeps this on track.

This is a particular trap in women’s health, where there’s enormous pressure to be all things to all life stages, all conditions, all women. The more you try to hold, the less you’re actually holding anything.

The Campfire

The most useful reframe Gaia offered wasn’t about positioning. It was about what a brand actually is.

“A brand brings people together, shoulder to shoulder, exchanging experiences, building memories. As the brand you are there to facilitate that.”

The product, in this model, is almost secondary. It’s what makes the fire burn better. But without the warmth of the universe around it, it’s just a product. Replicable. Forgettable.

Gaia draws a hard line between an audience and a community. An audience is top-down, the brand speaks, people receive and talk back. A community is infrastructure. You build the campfire, step back, and let people find each other while they get warmed up.

“It’s not me as a brand speaking to you. It’s me providing the infrastructure, and you coming together.”

That distinction matters enormously in health, where peer experience, the woman who’s been through it, who tried the thing, who knows what the NHS appointment actually feels like, carries a kind of credibility that no campaign can manufacture. The brands getting this right aren’t broadcasting. They’re hosting.

The Internal Revolution

When I asked Gaia about pink-washing and tokenism, how to spot it and how to avoid it she pointed to Adidas’s breast gallery campaign, a bold, product-free piece of communication that showed breasts of different sizes, shapes and skin colours, and led with values before it led with anything to buy. What most people didn’t see was the internal revolution that made it possible. New sizing curves. Redesigned supply chains. Retail rethinks. Factory re-education.

“What you see as an outside revolution is often also an internal revolution for a brand.”

This is the uncomfortable truth about authentic brand-building: the external work is downstream of the internal work. If the values aren’t structurally embedded, in how you formulate, how you hire, how you make decisions, the campaign is cosplay.

In women’s health, this plays out in a specific way. Brands that centre women’s physiology in their marketing but not in their product development, their clinical advisory, their evidence base, are making exactly this mistake. The communication naturally flows from products/services built intentionally with the end consumers’ needs and paintpoint in mind.

Built With, Not For

One of the most quietly radical things Adidas did, and one of the least discussed, was co-creation. In the Always Originals campaign, women didn’t just front the collection. They designed parts of it. Their claim, their motto, their community baked in from the start.

Amongst the talents, Taqwa Bintali, a creative director, who designed an apparel collection, activated in Europe, an event at the Adidas flagship in Paris, carpets, a full sensory experience, sold out immediately. Then, the partnership evolved with two shoes designed together. The community showed up because it was genuinely theirs.

This is the model that women’s health brands claim to follow and rarely do. Co-creation isn’t a focus group or a beta tester programme. It’s structural. It means the person you’re serving has shaped what you made, not just validated it after the fact. It’s the difference between a brand that says “we see you” and one that can prove it.

Global Vs Local

Scale introduces a tension that Gaia navigated at every level of her Adidas career: what stays consistent globally, and what has to flex locally.

The answer isn’t a compromise. It’s a framework. You define the non-negotiables, the skeleton, at the global level, and you give local teams genuine room to interpret everything else. A consumer in the UK and a consumer in Mexico are not the same person. The brand truth can be the same. The expression of it shouldn’t be.

For women’s health brands thinking about scaling, even from London to Edinburgh, let alone across markets, this matters early. Build the framework tight enough that it travels. Keep it loose enough that it lands authentically and with meaning.

The Marble

Gaia ended with a beautiful reference to Michelangelo, that the statue was already inside the marble, the work was removing what didn’t belong.

“You start by sourcing your piece of marble. The more you speak with people, the more you try things, you remove, and then your brand comes out.”

This is the advantage that smaller brands have. You can be specific. You can be flexible. You can build in public, iterate in real time, stay close to the person you’re building for, in a way that no multinational with investor oversight and a global supply chain ever can.

Gaia calls it navigating puberty. You’re still forming. That’s not a weakness. That’s the condition that makes genuine brand-building possible, because you haven’t yet calcified into what the market expects you to be.

And if your why is personal, if the consumer you’re serving is your younger self, your mother, a version of you that didn’t have access to what you’re now building, that’s not a liability. That’s the thing that can’t be replicated by bigger brands.

Gaia Manzone is a former Global Marketing director at Adidas and Puma and founder of BAB. Follow BAB on Substack and Instagram!

Throughout this conversation the thing that stuck with me was how Megan described sport as a microcosm of our society. It’s a thread that reminds us that we can pick this apart.

A thought experiment I kept coming back to after reading the report.

A thirteen year old girl watches the Red Roses lift the Rugby World Cup at Twickenham. 5.8 million people watching on BBC, the crowd electric. She is viscerally inspired. She goes home and looks up local rugby clubs.

There isn’t a single girls’ team within thirty miles.

That gap between the dream and the reality of what sport offers girls is what Women in Sport’s Let Her Dream data has been tracking for six years. In 2025, the year of the most extraordinary summer of women’s sport in British memory, girls’ dream rates fell to their lowest point ever recorded. Twenty-three percent. Down from thirty-eight the year before. The gender dream gap, the distance between how many girls and boys dream of reaching the top of sport, is now thirty percentage points. The largest since tracking began.

I spoke to Megan Watters, who leads children and young people’s research at Women in Sport, about what the data is saying, what it isn’t, and what it could say instead.

The Start Line Was Never Equal

The modern Olympics was not built for women. Pierre de Coubertin, its co-founder, believed an Olympiad involving women would be “impractical, uninteresting, unaesthetic and improper.” In his vision, the Games existed for the exaltation of male athletes. Women were only welcome as spectators.

That is the foundation on which women’s sport has had to build. And it matters, because the system we’re seeing today still carries that legacy. Which is why the Paris Olympics felt significant. For the first time, male and female athletes were allocated equally. Girls’ dream rates jumped nine percentage points in a single wave. The whole country, briefly, felt like it was moving in the right direction.

“So coming from that, to now seeing this more equal visibility, it obviously inspired so many young people, particularly girls.”

The spike was real. The aspiration it produced was real. But what the years of Let Her Dream data show is that a short-term moment of visibility, however powerful, cannot on its own sustain what is a longer-term structural challenge. The dream rates that rose in 2024 reflect a system that still hasn’t changed enough at its foundations to hold them.

What Visibility Is Actually Doing

The counterintuitive finding buried in the data: it isn’t disengaged girls whose dreams have fallen furthest. It’s the ones who love sport most.

Among girls who described themselves as loving sport and already participating, dream rates dropped thirty-five percent in a single year. For boys in the same group: six percent. The girls most invested in sport are the ones opting out of dreaming, which means the system is failing even those it is already reaching.

Megan’s explanation reframes the whole story.

“As more women are getting into elite sport, the abuse is becoming more visible. Young girls are also more aware that the pay gap exists. As a young girl, why would I want to be a top performing athlete if I still have to have another job? If I still don’t even get sanitary bins put in the toilets when I’m performing.”

What the data suggests is that visibility is doing two things at once. It’s inspiring girls. And it’s showing them exactly what they’d be signing up for. The dream is more legible. So is the cost of it.

Megan sees this as evidence of something important: young people are paying close attention.

“A couple of years ago, you’d maybe see one or two comments in our research around young people talking about equality. In the latest report, the amount of boys and girls talking about equality and their understanding of what misogyny is has come on.”

This cultural shift has a wider backdrop worth naming, even if it sits outside the research itself. Adolescence, Netflix’s drama about a thirteen year old boy radicalised into incel culture, brought the manosphere into mainstream conversation in a way nothing had managed before. Louis Theroux’s Inside the Manosphere, released this March and described by Theroux himself as sitting “in the precinct of what the boy in Adolescence might have been watching,” has extended that conversation into living rooms, school canteens and family group chats. The infrastructure of misogyny that has always shaped girls’ experience of sport is now, finally, something people can name.

Sport, as Megan puts it, is a microcosm of wider society. What girls are seeing in the sporting landscape isn’t separate from what they’re encountering everywhere else. It’s a reflection, and sometimes an amplification.

The Boys in the Room

Forty-two percent of boys surveyed agreed that women are not as good at sport as men. Up five percent since 2023. This is the number that sits uncomfortably beneath the momentum narrative. You can have the most inspiring role models in history on your television screen, but if gender bias is structurally entrenched, visibility alone won’t shift it.

But the data does something more interesting than confirm what we already suspected. The same boys filling in that statistic are, in significant numbers, also moved by women’s sport. Six in ten who watched the Rugby World Cup felt frustrated that women’s rugby isn’t shown more often. Boys and girls are almost equally likely to say the tournament made them feel hopeful about the future of women’s sport. Boys described watching it as a generational moment.

What this points to is not simply a representation problem. It’s a valuation problem. It’s not enough for girls to be visible in sport. They need to be seen as credible, skilled and capable. And boys need to genuinely see female athletes that way too, not just as present, but as fully worthy of their attention and respect.

“It’s about showing boys that women don’t just suit certain roles. They can be great coaches. They can coach boys and men. There’s such a big educational piece around that.”

The moment is there. The question is whether sport is willing to meet it.

The Puberty Cliff

One number keeps coming back when we talk about the grassroots picture.

1.3 million girls who once loved sport drop out as teenagers.

Puberty is the exact moment when sports could be building self-belief, resilience and physical confidence that stays for life. It’s also the moment the infrastructure most visibly fails, not just in terms of access and opportunity, but in how girls feel they belong. Or don’t. Identity, fear of judgement, social pressure, the quiet message that this space was not designed with you in mind.

Changing facilities that feel unsafe. Kit that was never designed for a developing female body. Sports bras still not considered standard school sports kit, girls wearing two at once, or not participating at all. The message this sends about whose body was considered when the kit list was drawn up is not subtle.

Then there’s the period problem. Vast, under-supported, and a more significant barrier to girls’ engagement than most systems fully recognise. For many girls, PE is the only opportunity to be physically active, which makes the impact particularly visible there. But across sports more broadly, many girls miss out on even these limited opportunities because of their period, regardless of how sporty they are.

“It’s having those spaces where girls know they’re going to be understood and listened to. Not have that fear of judgement.”

The religious and cultural dimensions compound this. A girl managing period shame in a culture where periods aren’t discussed. A girl navigating kit designed without her religious or cultural identity in mind. When we talk about girls in sport, we are not talking about a monolith. We are talking about layers of exclusion that stack up.

The Hidden Opportunity Map

Here is something that should concern anyone who thinks more investment in women’s sports is a straightforward fix: we still do not have a strong enough picture of the opportunities actually available to girls.

Women in Sport’s opportunity mapping research found a lack of consistent data across the sector on what sporting opportunities exist for girls, where they are, what format they take, and who they are really serving.

That matters because opportunity is not a vague idea. It is whether there is a team nearby. Whether it is girls-only or mixed. Whether it is affordable. Whether it feels safe. On paper, a mixed session may look like an opportunity for everyone. In reality, it may not offer girls a fair, welcoming or developmentally appropriate experience.

“A lot of the funding goes towards mixed sex. But mixed sex is generally designed for boys and dominated by boys. It makes things seem better than they really are.”

Women are fifty-one percent of the population. Not a minority. But routinely grouped within EDI (Equality, Diversity, and Inclusion) budgets as though they were one. Provision nominally aimed at girls frequently excludes them in practice. Girls’ opportunities should not be treated as an afterthought, or hidden under broad assumptions about inclusion. Design sports properly for women and girls, and you make the whole system better for everyone.

2 Million Girls Are Already Ready

Around two million girls in the UK say they would play rugby if given the chance. Not if they felt more inspired. If given the chance.

The demand exists. The imagination exists. The dreams, even diminished, even falling, are there. What isn’t there is the supply.

“I’ve spoken to so many girls saying they started rugby this year because of the Red Roses. There’s so much good happening. Sometimes it’s really easy to look at what’s not going well.”

Towards the end of our conversation Megan says something I find genuinely hopeful. Women’s sports is almost becoming its own thing. Not a lesser version of men’s sports. Something built differently, with its own history and its own meaning.

“Why should it be compared against the men’s at all? It’s simply different. And great in its own right.”

What the Data Could Say

Dream rates are not fixed. They moved dramatically in 2024. They can move again.

What would it take? Megan is clear that the system is complex and layered. There is no single solution. The answer lies in a combination of changes. More accessible, local, girls-first opportunities. Female coaches who are trained, retained and respected. Appropriate kit and facilities that meet all girls’ needs,. Pathways designed by women, for women, that don’t set them up to leave.

And boys who have been shown, by sports, by school, by the culture we are slowly building together, that female athletes have something worth watching. Worth learning from. Worth dreaming alongside.

There are girls already dreaming. Not as many as there should be, and fewer than last year. But they are watching and feeling something real. They are paying close attention to everything sports is telling them about where they belong.

The work is not to manufacture inspiration. It is to build an infrastructure worthy of the imagination, passion and commitment that is already there.

Megan Watters leads young people’s research at Women in Sport. The Let Her Dream 2025 report is available at womeninsport.org. Follow Women in Sport on Twitter and Instagram at @womeninsport_uk. If you love what they do and want to support their work, consider donating to the charity here.

Söker Data is her answer to that gap.

“The vision,” she says, “is that we become the biggest dataset holder when it comes to data from women and ethnic minorities. So that anyone designing a drug, running a clinical trial, thinking about market access, someone around the table asks: have you checked Söker Data?”

The Grammarly Problem

Elsa has a way of making the abstract feel urgent. Her favourite analogy right now is Grammarly.

“You know how Grammarly made bad spelling embarrassing? That’s essentially what we’re trying to do with health datasets. Constantly highlight where the gaps are. Remove the excuse of not knowing.”

Because the excuse of not knowing is running out. Women have been mandatorily included in clinical trials only since 1993. Black and ethnic minority populations were largely excluded from COVID vaccine trials, a failure that became impossible to ignore when vaccine hesitancy split along exactly those demographic lines. Regulators are pushing for more inclusive data. But Elsa’s argument is that the real pressure isn’t coming from regulation. It’s coming from the market.

“Pharmaceutical companies are beginning to see the buying power. An ageing population in the West. Africa with a younger, growing population. By 2030, a significant proportion of the global population will be of African origin. If you want to expand your market access, you need data from these populations. Full stop.”

Oranges and Orange Juice

Söker Data pulls from three sources: publicly available datasets that Elsa’s team aggregates and cleans, electronic health records from hospital partnerships, and direct patient reporting on adverse events. The focus right now is breast cancer, cardiovascular disease, and GLP-1s, three areas where data gaps for women and ethnic minorities are both well-documented and commercially significant.

The GLP-1 point lands hard. The MHRA issued a warning about a high rate of adverse events in women of childbearing age on GLP-1 medications. The data simply wasn’t there at the point of trial. It showed up later, in yellow card reports, in real-world use, in bodies that weren’t in the original study.

At the core of what Söker does is biomarker visualisation across demographics, helping drug discovery and clinical trial teams see where their data has blind spots before those blind spots become clinical failures. Drugs developed with biomarker selection are twice as likely to progress through development. The data infrastructure to do that well, across diverse populations, is what Elsa is building.

“Getting the data is one thing,” she says. “That’s the oranges. But are you going to sell oranges, or are you going to make orange juice? We’re in the business of how much orange juice we can make.”

Trust Is the Product

The harder conversation is about why the data gaps exist in the first place. Elsa is direct: this is a trust problem, and trust was broken long before Söker Data existed.

“To take a vaccine and not question it is second nature to some of us. To others, that’s level five or six on the priority list. They’re starting from: what are my odds of dying in childbirth? That’s level one. You can’t ask someone to trust clinical research at level ten when you haven’t met them at level one.”

She learned this the hard way. Early on, she approached the problem as a scientist education, use cases, clear communication. Communities listened, understood, and still said no. “And then I had to ask: okay, help me understand.”

What she found was that the responsibility for rebuilding trust doesn’t sit with any single institution. It sits with all of them; government, pharmaceutical companies, community leaders, scientists, and it has to be built continuously, not reactively. “We do so much during a crisis and then it dies. We wait for the next pandemic to start again. That’s not serious.”

She’s also candid about the individual-level complexity. She’s spoken to community organisation leaders who wouldn’t share their own data with her. Not because they didn’t understand the mission, but because trust, once broken at the level of basic healthcare access, doesn’t recover just because the science has improved. That bridge has to be rebuilt first. Everything else comes after.

The Moment We’re In

Elsa is clear that Söker Data isn’t just well-timed by accident. There’s a specific convergence happening right now that she’s building into.

“For change to happen, you need both technological advancement and cultural movement. And in women’s health, we actually have both — at the same time, in our favour.”

The cultural side is visible. Women’s health has reached a boiling point of public interest — in media, in investment, in the conversations women are having with each other and demanding with their doctors. The technology side is moving just as fast. LLMs, AI-assisted drug discovery, real-world evidence platforms, the infrastructure to do something meaningful with diverse datasets now exists in a way it simply didn’t a decade ago.

And the commercial proof points are stacking up. Oura didn’t set out to be a women’s health company. Then they looked at their data and found women were 56% of buyers, tracking cycles and recovery and sleep with a granularity the product hadn’t been designed for. A women’s health department followed. “They found out they’d been missing a market,” Elsa says. “And here we go.”

The regulatory tailwinds are there too. But Elsa is less interested in compliance as a driver than in commercial logic. Regulation tells you what you must do. Markets tell you what you can’t afford not to.

You Can’t Do This Alone

There’s something Elsa keeps coming back to, and it doesn’t sound like a talking point. It sounds like something she’s learned.

Building Söker Data; a company whose entire premise is that the health system has systematically failed certain populations, is not a solo project. It can’t be. The data gaps are too entrenched, the trust deficits too deep, the commercial and regulatory and cultural threads too tangled for any one founder to pull on alone.

“Looking back, everyone says: I can see how it all connects,” she says. “But looking forward? It doesn’t feel like that. It just feels like you’re figuring it out.”

What has made the difference, she says without hesitation, is the people. Scientists who flagged datasets. Clinicians who opened doors to hospital partnerships. Founders who shared what didn’t work. Community leaders who pushed back and made her think harder. “The number of people in this ecosystem who have supported me to get to this stage, I cannot count them.”

She’s not being modest. She’s being precise. This kind of infrastructure-level change, the kind that means a drug developed in 2035 actually works for the body it’s prescribed to requires an ecosystem, not a hero. “We’re fighting the patriarchy. We keep moving. But we all need each other.”

The Call

If you work with data from women or ethnic minorities, in any therapeutic area, Elsa wants to talk. Söker Data is building the bank, and the bank needs deposits.

The ask isn’t abstract. It’s a dataset. A conversation. A referral to someone who has one. The infrastructure for more inclusive medicine exists. Now it needs filling.

Dr Elsa Zekeng is CEO and founder of Söker Data. If you have access to relevant datasets or have experienced adverse events on medication, reach out via soker-data.com.

“That’s what I mean,” Dr Sesay says quietly, “by literally dying of embarrassment.”

It is a phrase she has used before, in videos, in her TEDx talk, in the campaign she has built around the belief that language is a matter of life and death. But hearing her say it in conversation, after everything that led to it, it lands differently. This is not a tagline. It is a clinical reality she has watched play out, more than once, in her own consulting room.

Health Literacy as a Determinant of Health

Dr Sesay’s platform, Talks with Dr Sesay, began during the first wave of the COVID pandemic, initially as Zoom talks for her community, then an Instagram page, then something much larger. The first video to go viral was about cervical screening: what a speculum looks like, what the brush does, what the appointment actually involves. Simple information that, for many women, had never been clearly explained.

“There was so much misinformation,” she says. “Young people not wanting to go out of fear. And it didn’t need to be that way.”

But it was a different patient who crystallised why she needed to go further, a woman who had been silently suffering with thrush for years. Not because the treatment was complicated. Because she was embarrassed. She had never told anyone. She didn’t think she could come to a doctor about it.

When Dr Sesay diagnosed her and gave her antifungal treatment, the woman came back, not because she needed anything else, but to say thank you. She was so grateful for something so simple.

“I remember being so taken aback. And whenever I think of it, I get upset. Because it’s so ridiculous. And it’s upsetting that I still have patients, in the last few weeks, who’ve done the same exact thing. It just needs to stop.”

She says it often, and she means it each time: health information is a determinant of health. What you know is the difference between life and death.

They’re Not Bad Words

The campaign Dr Sesay built around this idea is called They’re Not Bad Words and it is, improbably, one of the most joyful things in the women’s health space.

It started as a t-shirt. Then came a TEDx talk with the same name, examining how shame and stigma cost lives. Then a song, born when one of the TEDx hosts, enamoured by the talk, said she wanted to sing the word vagina. Someone filmed it. A music producer commented on the post. The rest followed: studio sessions, a track, net proceeds going to fund menstrual health workshops in Sierra Leone, where Dr Sesay is from.

“In my home country, girls don’t come to school when they’re on their period because they don’t have the products,” she says. “We taught them the correct anatomy, taught them that periods aren’t dirty, gave them the materials to make their own period products at home.”

Then came the gynaecology-themed obstacle courses, held in a park, volunteers in They’re Not Bad Words t-shirts, participants answering anatomy questions to complete each station. Then pocket vulvas, sold online as Christmas stocking fillers, sold out in under a week.

None of it, she is clear, is done for shock value. “It’s genuinely not to be obnoxious or extreme, even though the reactions can be funny sometimes. It’s three things: remove the shame and stigma. Normalise the language so people come forward. And protect our children.”

That last point matters more than people often realise. Using correct anatomical language with children, vulva, penis, not “foo foo” or “cookie”, is a safeguarding issue. She describes a case where a child was being abused by a family member and kept telling her mother he was “playing with my cookie.” The mother didn’t understand until it was almost too late. Research supports what Dr Sesay has observed clinically: sexual predators tend to avoid children who use correct terminology, because it signals they’ve been taught about body safety.

“My daughter is seven,” she says. “She will say to me, mummy, I have an itching on my left outer labia. She can say it. And I feel like everybody should be able to say those things.”

The Algorithm Doesn’t Like Empowered Women

Here is the absurdity at the centre of Dr Sesay’s work: she is a GP, an honorary senior clinical lecturer, an ambassador for the Eve Appeal and Wellbeing of Women, a World Health Organisation contributor, I could continue. And she has to use a crochet vulva model to avoid being shadowbanned.

“If I just type the words vagina, vulva, or clitoris, it automatically alerts the algorithm that this is something inappropriate,” she says. “I had a sensitivity cover put on one of my posts, the how-to-check-your-vulva video, using my crochet model. They said it might offend some viewers. It was crochet.”

In the early days, she tried to beat the algorithm, spacing out letters, writing “vu lva” instead of vulva, to get the content seen. She stopped.

“I cannot be saying ‘use the correct words’ and then censoring myself. It doesn’t make any sense. I can’t be part of the problem.” She pauses. “It means my content isn’t as visible sometimes. But I won’t do it.”

What makes the censorship particularly indefensible is what sits alongside it. Hypersexualised content gets through. Erectile dysfunction advertising runs freely. Women’s health information, clinical, evidence-based, potentially life-saving, does not.

“It almost seems like the algorithm says: no, no, no, that is empowering women. We’re not going to let you showcase that.”

She supports the CensHERship campaign, the alliance of women’s health creators and organisations pushing for platform accountability, and is clear that individual workarounds are not enough. The system needs to change. “If it means we go to the top, so be it.”

Triple Threat

Dr Sesay describes herself, matter-of-factly, as a triple threat: Black, Muslim, and a woman. “Especially in this country, with the way things are right now.”

She grew up within the same culture of shame she now spends her career dismantling. This is not something she arrived at fully formed. When her aunt first saw her videos, she was horrified. Now she wears the t-shirt.

“It takes time. It takes a lot of courage and perseverance.” She is honest about the days when she almost gives up. “I would be lying if I said there aren’t days I’m completely disillusioned. But then I get a DM, or someone tells me they were diagnosed with lichen sclerosus because of my video. And I think about my daughter. I don’t want her to grow up in a world where this is still the case.”

She believes change is possible, not through force, but through conversation. When people push back, she gets curious rather than defensive. Where does that shame come from? How did it get here? Why do we need to keep it? “Usually just having that genuine conversation, I can see them changing right in front of me.”

How to Keep the Conversation Going

During our conversation I told Dr Sesay about our plan to draw a vulva on Strava around London on 24th April, in protest at the very censorship she has spent years fighting.

This morning, it became clear just how many people are paying attention. The Independent reported today that over 600 women’s health leaders have signed an open letter demanding that social media platforms end the systematic censorship of medically accurate women’s health content. Posts about menstruation, fertility, menopause, postpartum recovery and sexual wellbeing are routinely misclassified as adult content and removed, while explicitly sexual content targeting men circulates freely. In response, leading brands including Clue (whose CEO Rhiannon White I spoke to earlier this year about women’s health data and the femtech industry), Hertility, Essity and Daye have formed a new coalition, the Women’s Health Visibility Alliance, to push back against what they describe as systemic bias in platform moderation.

Dr Sesay is among the signatories. Her message to the platforms is the same one she has been delivering for years: “Online censorship perpetuates the narrative that women’s and gynaecological health is inappropriate and should remain taboo. This amplifies the embarrassment that already surrounds these topics. Women are dying of embarrassment because they’re not coming forward about their problems due to shame, and when they present late, outcomes are poorer.”

Clio Wood, co-founder of CensHERship, put it plainly in the letter: visibility is not a nice to have. It is fundamental to public health, innovation and gender equity.

Shame and stigma are costing lives. The words are not bad words. And today, 600 people put their names to that.

Dr Aziza Sesay’s campaign They’re Not Bad Words and her platform Talks with Dr Sesay can be found at talkswithdrsesay.com and @talkswithdrsesay on Instagram. Her TEDx talk, also titled They’re Not Bad Words, is available on YouTube. Read the open letter and the full Independent story here.

Dr Annabel Sowemimo is a sexual and reproductive health consultant, academic lecturer, and now a mother who recently navigated the very maternal health system she critiques. Our conversation ranged from the brutal origins of the speculum to the eugenic foundations of family planning, from algorithmic bias in AI to the venture capital pressures warping femtech.

As a medical student trying to make sense of what I was learning—and what I wasn’t—about women’s health, I found Annabel Sowemimo’s podcast Decolonising Contraception. Then I read her book Divided: Racism, Medicine and Why We Need to Decolonise Healthcare, an analysis of how race and medicine have always been entangled. It reshaped how I understood racial disparities, reproductive healthcare, and power. It’s probably one of the reasons I decided to pursue an MSc in Women’s Health.

Divided points to the roots of modern medicine; how the evidence base and clinical practices were shaped by exclusion and extraction. Today, this history demands urgent interrogation. We’re training algorithms on the same flawed data that serves white populations better than minoritised ethnicities, the same racialised risk categories, the same biases and assummptions about pain that disproportionately impact Black women’s health outcomes. We’re automating clinical decisions without asking whose bodies built the baseline, whose outcomes defined “normal,” whose pain was systematically undertreated and then encoded as ‘evidence’.

If we don’t interrogate these origins, we risk building tools that amplify historical inequalities.

The Groundwork: Why History Isn’t Prologue

“A lot of the time people jump first head in with a lot of issues, but they haven’t necessarily done the groundwork to understand what’s really foundational,” Annabel tells me. This is the core argument of Divided—you cannot address present inequalities without understanding their origins in race science, eugenics, and colonial extraction.

Take the speculum, the instrument of gynaecological examination. Its modern form was developed through experiments on enslaved Black women—Anarcha, Lucy, and Betsey—who were subjected to repeated, unanesthetised surgeries by J. Marion Sims. “We’re not saying we can’t use any form of speculum simply because it’s been derived on enslaved populations,” Annabel clarifies. “But it’s about recognising that we may have developed a tool that is not designed to put the patient at the centre, because we’re developing an instrument on enslaved populations which were dehumanised.”

The design, she argues, is “probably brutal or a bit more brutal, because it wasn’t made to preserve that person’s comfort. It was made for the viewer.” Understanding this history doesn’t mean abandoning every tool with a troubling origin—it means recognising their limitations and rebuilding with different priorities.

The same logic applies to metrics like BMI, derived from Belgian military personnel and now used as a cutoff for surgery, medication, and IVF access across wildly different populations. “You’re not definitely unhealthy because you have a high BMI,” Annabel notes, pointing to athletes with high muscle mass. “The landscape is more complex than we give it time for.”

This matters profoundly as we move toward algorithmic medicine. If our reference ranges, diagnostic criteria, and risk calculators were all built around white European bodies—and we train AI on that same data—we’re not creating objective tools. We’re automating bias.

From Family Planning to Reproductive Coercion

If medicine’s tools carry colonial DNA, so too do the systems meant to expand reproductive choice. Annabel’s PhD research focuses on Black women’s experiences with long-acting reversible contraception (LARCs) in Britain, but the patterns she identifies echo across marginalised communities.

“Family planning was never gaining momentum when we considered it as a women’s rights issue,” she explains. “But when it was tied to the eugenics movement—the idea that we can improve the human race through selective breeding and limiting the reproductive potential of different groups—then the family planning movement had a lot more money behind it.”

That eugenic logic hasn’t disappeared; it’s evolved. State-led coercion still happens—Annabel points to the 2017 revelation that Inuit women and girls in Greenland were forced to use intrauterine devices by the Danish state. But more commonly, coercion manifests in clinical encounters: providers refusing to remove painful or unwanted contraception, young women or women with disabilities being told they shouldn’t get pregnant, patients forced to return multiple times before their bodily autonomy is respected.

“I’ve recently presented cases at conferences where this logic is leading people to try to self-remove contraception,” Annabel says, “because they’re going to providers and providers are telling them no because they don’t think that they’re suitable enough people to get pregnant.”

The consequences extend beyond the individual consultation. “If patients feel that they can’t maintain autonomy within their consultation, then they stop turning up,” she warns. Trust, already fragile for communities historically harmed by medicine, erodes further.

Childbirth as Amplified Inequality

Nowhere are these dynamics more concentrated than in maternal healthcare. Black women in the UK are nearly four times more likely to die in pregnancy or childbirth than white women—a statistic that has barely budged despite decades of documentation.

Annabel, who gave birth to her son 19 months ago, experienced this firsthand despite all her professional knowledge. “I did not have a good delivery,” she tells me. “Labour is essentially a reflection of how people are treated within society as a whole. It’s just an amplification of wider inequities we see in healthcare, but in this area, everything’s of a magnitude because you’re bringing life into the world.”

The mechanism is insidious. Assert yourself, and you’re seen as angry—a stereotype that haunts Black women across contexts. Express anxiety, and you’re dismissed as overreacting. Meanwhile, pain is undertreated, symptoms are minimised, legitimate concerns are pathologised.

“You’re not given the leeway to be assertive like other people would be in that situation when you’re labouring,” Annabel explains. “Or you’ll be seen as overreacting and over-anxious and they’re like, ‘Oh, she doesn’t know enough, we just need to calm her down. She’s not understanding her body.’”

This isn’t just individual bias, it’s also structural. Medical training teaches pattern recognition, which in practice often means stereotyping. “The Black person comes in and they’ve come from South Africa and they’ve got lymphadenopathy and fever, they’ve got HIV,” Annabel says, describing a common teaching scenario. “That is what we’re taught to do.”

In labour wards, these stereotypes collide with acute vulnerability and power imbalance. “You have a labouring Black woman, you have a health professional in a position of power, and you have a really major thing going on that the Black person feels particularly worried and protective about.” The result: the same stories, in different hospitals, in different trusts, reported again and again in inquiry after inquiry.

The question becomes urgent when we think about AI triage systems, risk prediction algorithms, pain management protocols being automated. If human clinicians already stereotype based on incomplete pattern recognition, what happens when we encode those same patterns into machines and deploy them at scale?

AI: Scaling Inequality at Machine Speed

Annabel’s chapter on AI in Divided cuts deeper than most critiques. She doesn’t start with biased datasets—she starts with the ground underneath them.

“Fundamentally, the technology just from the ground up is a problem,” she tells me, “because the materials and resources required to even build AI healthcare drives inequity. You’re not going to improve health inequity if your technology is furthering that.”

Water deserts created by data centres. Rare earth mineral extraction devastating the Global South. AI’s foundation is colonial before a single line of code is written.

Then there’s who’s building these systems. Annabel references Empire of AI, which examines the ideologies driving healthcare AI development. “The people building these systems don’t necessarily subscribe to the same ideals and values that I subscribe to,” she says. “A lot of them subscribe to Darwinianism—and some people maybe are not as worthy of getting equal access.”

It’s about whose bodies train the models, whose outcomes define “normal,” whose pain gets coded as significant. When you encode those decisions into systems designed for scale, you don’t just replicate bias—you industrialise it.

Even the engineers often can’t fully explain how these models work. “They can know that things work,” Annabel says, “but they don’t understand all of how it gets to the answer. They might only understand sometimes 80 percent, and that’s concerning.”

That 20 percent uncertainty is the difference between a Black woman’s chest pain being triaged as urgent versus anxiety. Between adequate analgesia and being flagged as drug-seeking. Between being believed and being dismissed.

When a human doctor dismisses pain, there’s a mechanism for accountability—however imperfect. But when an algorithm does it, embedded in a risk score that determines who gets escalated, the harm becomes invisible, unchallengeable, scaled across thousands of interactions.

The Fix Femtech Needs

Femtech is a sector born from a need to solve women’s health problems mainstream medicine had ignored. Instead, Annabel argues, it’s often reproducing the same exclusions in digital form.

“The origin story is often a good one,” she acknowledges. “It’s often patients or people with conditions that feel disillusioned with the pre-existing healthcare system.” They step outside, frustrated with being dismissed or overlooked, and build alternatives.

But then capital enters. “In order to develop, you need investment, and investors want to see how you’re going to turn a profit. And usually they want it in a fairly good amount of time.”

The result: platforms monetise quickly, sometimes compromising medical robustness or safety. They position themselves as alternatives to the NHS rather than complementary services, avoiding integration even when patients need that continuity. Standards lower because clinical researchers aren’t involved in what is, fundamentally, medical work.

“We’re not in this futuristic digital utopia,” Annabel points out. “We have the NHS that naturally does the bulk of our medical work, and actually a lot of the time people do a bit of testing on a platform and they need to go back into the NHS because it’s not fully autonomous.”

The venture capital model of rapid scale, quick exits is fundamentally misaligned with the patient-centred innovation that drove many founders into femtech in the first place. “Capital and money is at the heart of quite a lot of issues that emerge,” Annabel says, “but then I also feel that particularly within reproductive health, misogyny is played upon a lot in terms of what drives people to exit the sector, but then it also kind of reinforces itself.”

The women who can afford premium period trackers and AI-powered symptom checkers are often the same women who already have good access to healthcare. Meanwhile, the women most failed by the current system; racialised women, poor women, immigrant women are priced out or excluded by design choices that never considered them in the first place.

What Would Equity Actually Require?

So what does equitable innovation look like? Not performative diversity metrics or bias training modules, but genuine structural change.

For Annabel, it starts with interrogating who’s building these tools and why. “Who has access, who’s coding, who’s doing those things?” These aren’t neutral technical questions—they’re questions about power, about whose bodies and experiences shape what gets built.

It requires integration rather than siloing. Femtech can’t solve women’s health problems by positioning itself as an alternative to mainstream medicine when most people still rely on public healthcare for essential services. “It would be great if we had that interaction and integration and advice from the start,” Annabel says.

It demands different funding models that don’t force patient-centred innovations to compromise medical standards for rapid monetisation.

And fundamentally, it requires that we stop treating equality as an add-on or marketing feature, and instead build it into the foundation—recognising that tools, metrics, and systems designed around one population’s bodies will inevitably fail others.

So what do we actually do? We can’t refuse AI in healthcare—it’s already here. But we can refuse these systems in their current form. We need transparency about whose data trains the models. We need engineers working with clinicians who understand structural inequality. We need frameworks that ask not just “does it work?” but “who does it work for, and who does it harm?”

Most critically: whose bodies are we building for? If we don’t interrogate that now, we’ll automate medicine’s worst patterns faster than we can document the damage.

As our conversation ends, I’m struck by how Annabel is engaged in the harder work of imagining what health justice could actually look. The tools we have are imperfect, built on troubling foundations. But Annabel’s work suggests we don’t have to accept them as unchangeable. We just have to be willing to do the groundwork, to understand where we’ve been before we can build something different.

Could you contribute to the Research?!

Annabel is currently recruiting participants for her PhD research on Black women’s experiences with long-acting reversible contraception (LARCs) in Britain.

Are you a Black woman who has used or discussed LARCs? Or a healthcare provider who counsels patients on LARCs? Your voice matters. Annabel is conducting one-on-one interviews and focus groups to document experiences in what she calls “an information desert.” Participants receive a Love2Shop voucher for their time.

To learn more or participate, visit the research page or email Annabel directly at Annabel.sowemimo@kcl.ac.uk.

But here’s where the optimism hits a wall: only 6% of sports science studies focus exclusively on female physiology. Just 6%. Let that sit for a moment.

The science underpinning how women should train, recover, and perform hasn’t kept pace with the growth of women’s sport itself. National exercise guidelines—the recommendations your GP gives you about how much to move, which exercises prevent osteoporosis, how to reduce cardiovascular risk—are built almost entirely on data from male bodies.

Which is why the recent announcement of the Women’s Health, Sports & Performance Institute (WHSP) in Boston caught my attention. With $50m in backing from philanthropists David and Jane Ott and Clara Wu Tsai, and co-founded alongside physician-researcher Dr. Kathryn Ackerman, it’s significant funding for a field that has systematically excluded half the population.

But it also raises a question: can money alone solve a problem this structural?

I sat down to chat with Dr. Emma Cowley. Her research reveals the extent of this and what it costs women. Something about our discussion that stuck with me was the way she explains sports as a ‘microcosm of our society’

Dr. Emma Cowley’s work examining gender gaps in sports science reveals that the exclusion of women isn’t just about resource constraints, it’s about decades of accumulated decisions about whose bodies matter, whose experiences count, and who gets to be the default. Based at the SHE Research Centre at the Technological University of the Shannon in Athlone Ireland, I spoke with her about why women remain invisible in sports science research, what that costs us, and whether new institutional funding can actually shift the dial.

Photo above is Emma in action

Why Women Are Missing From Sports Science Research

Here’s a statistic that sounds too stark to be true: only 6% of sports science studies focus exclusively on women. Meanwhile, 36% study only men.

You might assume those male-only studies examine male-specific topics – testosterone, prostate health, maybe sperm motility. You’d be wrong. Less than 1% of male-only studies actually require male participants. The rest? They simply chose not to include women.

“99% of the research could have included a woman and they just didn’t,” Emma says. Her research has revealed a pattern of exclusion so pervasive it’s become invisible.

The female-only studies, by contrast, focus almost entirely on topics where male participation is impossible: pregnancy, menopause, breast cancer. Women appear in research only when their biology makes them unavoidable.

How Male-Only Research Shapes Women’s Health Guidelines

It really matters. Those studies inform national health guidelines – the recommendations your GP gives you about how much to exercise, which exercises to do, how to prevent osteoporosis or reduce your cardiovascular risk. Except the data behind those guidelines comes almost entirely from male bodies.

“We’re left with a case where you have national guidelines telling people how much they should exercise when, in reality, we don’t actually know if that’s right for women,” Emma explains. “Women have higher risks of osteoporosis, arthritis, future falls. Maybe women should be doing more resistance training. We don’t know that, because we haven’t done the research.”

It’s another example of what Caroline Criado Perez documented in Invisible Women – except this time, it’s not car crash test dummies or office temperature settings. It’s the scientific foundation for how half the population should move their bodies.

Why Girls Drop Out of Sports: The PE Class Problem

Emma’s interest in this gap started with a simpler observation during her undergraduate degree in Ireland: girls sitting out of PE class.

Some had notes about their periods. Others were sidelined by Gaelic football – the dominant sport in Irish schools, and one that belonged firmly to the boys. “It’s really hard to change that culture within a school,” she reflects. “PE is seen as an additional subject. If people need to study, PE is the class that’s taken away.”

What Teenage Boys Really Think About Girls in Sports

Years later, having completed a Masters and PhD, Emma’s research has come full circle. Recently, she conducted focus groups with teenage boys to understand their attitudes toward girls in sport. The findings were stark.

“Boys want to perform at an elite level. Girls are there to participate and have fun with their friends and don’t take it as seriously,” she summarises. “Basically, girls aren’t as good as boys. So it makes sense that elite athletes are paid less and have worse pitches or facilities.”

These weren’t outlier views. The boys ranged from 13 to 17, and the narrative was remarkably consistent – and traditionally bound.

“These girls aren’t imagining it,” Emma says. “They’re coming into a PE class or a gym and boys are making fun of them. Of course they’re more inclined to sit out. Why would you want to participate in that environment?”

How Childhood Experiences Shape Women’s Relationship With Exercise

Those formative experiences create lasting patterns. The belief that “I’m just not meant to be here, I’m not good enough, I’m meant to be clean and tidy and quiet, not sweat” – it tracks through your entire life. By the time women are adults considering gym membership or participating in research studies, they’re fighting against decades of accumulated messages about who belongs in athletic spaces.

“A lot of times the blame gets put on the individual woman,” Emma notes. “But actually she’s fighting against this massive system.”

Women and Weightlifting: Breaking Down Gym Barriers

Emma’s background is in powerlifting, which led her toward resistance training research – partly, she admits, for selfish reasons. But also because the weights area of a gym is “this weird microcosm of society where the men can be sweaty and wear no clothes essentially and be loud and grunt, and the women can’t. You couldn’t be seen to be taking up too much space.”

The Mental Health Benefits of Strength Training for Women

Working with Dr. Kat Schneider from the Centre for Appearance Research, Emma conducted a mixed-methods study examining women’s experiences in gym weight areas. The participants ranged from teenagers to women in their 50s.

Many described profound transformation. “We had some women who had come from violent relationships, women who had been cheated on by husbands – quite big traumatic life events,” Emma explains. “They talked about the resiliency and determination and grit that weightlifting gives you. It helped them overcome struggles outside of the gym.”

“I’m biased, but the focus is on getting bigger and stronger, where a lot of other sports are about getting smaller. I think that’s what’s really powerful about any type of strength training.”

The New Fitness Pressure: From Thin to “Strong Girl” Standards

But the transformation stories came with complications. While we’ve moved away from extreme thinness as the sole beauty ideal, the pendulum may have swung too far. “It’s almost normalised that people can run 5K in less than 25 minutes and have a six-pack and a huge bum and can lift 100 kilos and weigh 50 kilos,” Emma observes. “There’s only extremes. It’s just another form of pressure being put on women.”

The pressure to be extraordinarily fit, rather than extraordinarily thin, is still pressure. It’s still an impossible standard that most women will never meet.

Why Sports Science Studies Exclude Women

From a researcher’s perspective, Emma understands – though doesn’t condone – why studies exclude women.

Historically, women weren’t seen as interested in sport and exercise. (”It’s only really recently that women are seen in the media or seen to have any interest in sport,” she notes.) But there are practical challenges too.

The Cost of Studying Women: Menstrual Cycles and Research Design

“Because the foundational research is so lacking, a lot of studies now need to control for so many factors like menstrual cycle, and that’s really expensive and really time consuming,” Emma explains. A colleague’s study that took men one month took some women eight months, as researchers tracked participants through multiple menstrual cycles.

Gender Inequality in Sports Science Leadership

Then there are structural issues. “A lot of the professors were men. They owned the research group, had the big grants, set the agenda. A lot of them aren’t interested in perimenopausal women.”

Hidden Barriers: Why Women Don’t Participate in Studies

But beyond researcher preference, study design often creates barriers. “If we’re in the lab and we have fitness testing at whatever time and we don’t provide childcare or free parking or travel passes – those are really systemic barriers for women.”

Even recruitment materials matter. Emma mentions a PhD student whose online survey received four times as many responses from men. “Is it that women don’t recognise themselves? They see the survey and think, ‘Oh, it’s football, it’s athletes. That doesn’t include me’?”

The barriers operate at every level: education (lecture slides showing only male anatomy), funding structures, practical accessibility, and women’s own perceptions of who “counts” as an athlete or research participant.

Why Representation Matters in Fitness Marketing

Representation matters too and not just in mass media. “I’m always aware, going to a conference with women of all different backgrounds, different ages, and all my slides are really fit, low body fat percentage, 20-year-old white athletes,” Emma admits. “Who is relating to those people? Nobody.”

She’s learned to be more intentional. “I’m sure my lecture slides two years ago were the exact opposite of what we’re talking about now. I’m learning over time. We just need to have a much more intersectional approach to really shift the dial.”

These small changes – post-it notes, diverse imagery in presentations, inclusive social media – might seem trivial compared to the scale of the problem. But they matter because they signal who belongs, who’s welcome, who’s seen.

The Future of Women in Sports Science and Fitness

The landscape is improving, slowly. Grant funding now often requires gender statements – researchers must justify why they’re excluding women, or risk not getting funded. Studies on menstrual cycles, pregnancy, ACL injuries, and menopause are expanding. More women hold leadership positions in sport science.

“Dr. Aoife Lane [head of Emma’s department and the SHE Research Centre] is an absolute powerhouse,” Emma says. “There are so many influential women in leadership positions now. We have more women coaches. We’re long off 50-50, but I feel like it’s improving.”

Why Cultural Change Matters More Than 12-Week Programs

“We don’t need another 12-week programme,” Emma says bluntly. “The problem is really cultural. Sports is just a microcosm of our society. If our society is becoming more traditionally bound, where women are at the mercy of men, it’s going to be reflected in sports.”

She’s frank about the reality of the situation. “It’s easy to get more negative about it as I get deeper into it.” The attitudes of those teenage boys. The persistence of exclusion in research. The way women still feel they need to make themselves small, quiet, apologetic for taking up space.

Yet the work continues. One study at a time. One policy change. One lecture slide that shows diverse bodies doing diverse things. And now, one $50m institute designed to systematically address what decades of individual efforts couldn’t fully solve.

Because the invisible sportswoman isn’t invisible by choice. We made her that way – through decades of accumulated decisions about who to study, who to fund, who to welcome, whose body counts as the default.

The question now is whether we’re willing to do the work to make her visible again.

Dr. Emma Cowley is based at the SHE Research Centre at the Technological University of the Shannon in Athlone Ireland. Her research examines gender equity in sports science and women’s experiences in resistance training. She’s currently working on research exploring adolescent attitudes toward gender and sport.

Clue recently published an analysis arguing that Femtech exists not as a lifestyle trend, but as a response to deep structural failures in women’s healthcare. While women experience their health as a continuous journey, they’re forced to navigate two structurally opposite systems: consumer-led Femtech (fast, personalised, self-funded) and traditional healthcare (slow, appointment-based, payer-driven).

In my conversation with Clue CEO Rhiannon White, we discussed how this structural discontinuity plays out in practice and how it might finally be starting to change.

Women Are Already Building the Bridge

Currently, women bridge this gap themselves. Through extensive user interviews, Clue has observed a consistent pattern: women use their tracking data to show up to healthcare appointments better prepared.

“They’re able to come with: this is what I’m experiencing on these dates, this frequency, this intensity,” Rhiannon explains. “The specificity really helps, and it’s making for more data-informed conversations.”

Interestingly, this specificity also helps with being taken seriously.

“It’s much easier to help someone who can give you concrete details, and it’s much easier to get help if you have that,” Rhiannon says.

This matters because research consistently shows women are underdiagnosed and misdiagnosed at higher rates than men, with longer wait times for accurate diagnoses. When someone arrives with clear data rather than vague descriptions of symptoms, it changes the dynamic.

But increasingly, users are asking: why should they have to do this preparation work? Why doesn’t the data flow between systems automatically, with their permission?

Early Experiments: The Clue + Evaro Partnership

Rhiannon sees this evolving gradually, starting with simple partnerships. Clue’s recent collaboration with Evaro, which creates a straightforward handoff for users seeking contraception services, is an example.

“The uptake has been astounding,” Rhiannon reports. “People have been looking for that ease.”

The partnership is remarkably simple: Clue’s UK user base can order contraception through Evaro’s embedded pharmacy infrastructure, accessing free NHS-funded contraception with free delivery nationwide. There’s no data transfer at this stage, just a seamless handoff that offers a remote alternative to existing digital NHS services.

But even this basic integration is proving valuable. It signals what women want: less friction between understanding their health and accessing care.

The roadmap from here is clear:

1. Simple handoff (current state) → test user appetite with zero privacy risk

2. In-app experience → bring services directly into Clue

3. Data handshakes → enable data sharing with user permission via APIs

“From a software point of view, it’s not hard; it’s all APIs,” Rhiannon notes. “It’s around consents and permissioning.”

The Privacy-Convenience Trade-off

But Rhiannon is cautious about moving too quickly. As she explained in our previous conversation, data governance matters more than encryption.

“The thing with data is once the cat’s out of the bag, it’s out of the bag. We need to take it carefully and think about permissions very carefully as we go through.”

This is why Clue is starting with zero data transfer—to test whether users even want these integrations before introducing any privacy risks.

“We always want to get a signal from our users: do they like this? Are they comfortable with it? Do they want it to be easier? Okay, then we’ll take the next step.”

Rhiannon describes this as letting users signal what they’re comfortable with, rather than “charging ahead without testing first.”

The alternative—building flashy integrations that compromise privacy—would undermine everything Clue has built. Trust, once broken, can’t be easily repaired.

Two Mega Trends Making This the Right Moment

Rhiannon identifies two global forces making the next decade particularly pivotal for women’s health innovation.

1. The Economic Imperative

Healthcare spending is rising faster than GDP growth across countries, creating diverging lines that “the power of compounding makes scary.”

This makes preventive care increasingly essential—and women’s health is what Rhiannon calls “canonical” to this shift.

“Women’s health is so often less about acute emergencies and more about systemic, ongoing, episodic issues,” Rhiannon explains.

She points to osteoporosis as a stark example: close to half of all hospitalisations for women in many healthcare systems, yet “very cheaply prevented if you get vitamin D, strength training, and HRT through that quite large window in the 40s and 50s.”

The cost difference between prevention and treatment is enormous, and payers are starting to pay attention.

2. The Data Proliferation

The second trend is the explosion of consumer health data, driven significantly by wearables, and women are the primary consumers.

“Women are the biggest drivers because we’re looking to be our own scientists,” Rhiannon says. “We’re looking for data to build that evidence base.”

Wearables primarily measure vital signs, which Rhiannon describes as “interstitials to hormones, that’s why women are interested in them.”

But the truly game-changing advance will be continuous hormone monitoring devices.

“There are people in animal trials at the moment, so they’ll be in human trials soon,” Rhiannon notes. “That will be really game-changing for women to have that real-time, live, continuous data.”

For women’s health research, this could eliminate a long-standing excuse.

“Instead of being able to say it’s just too hard because hormones fluctuate too much, we’ll be able to say: here’s the data. It’s not hard actually, software can handle data at that scale.”

Health Is Communal, Not Individual

One of the most striking moments in our conversation was when Rhiannon challenged the notion that health is an individual concern.

She calls this “a great pathology in Anglophone countries and continental Europe” and illustrates it with a personal story: her first son was born prematurely, ostensibly her health issue, but one that immediately impacted her son (who couldn’t latch properly), her husband, and their entire household.

“It was a women’s health issue, preterm birth, and yet there were three of us immediately impacted by that. Our health is not somehow locked into individuals—that’s just not true.”

This perspective shapes her view of current cultural trends, particularly the tech world’s obsession with longevity.

“The current obsession in tech culture with longevity is very individual—very ‘me, I will live to who knows what,’” she observes. “I find it a weird motivational driver because I don’t want to live forever if I’m on my own and I don’t have that web of interconnectedness.”

“I’d rather live well than live long.”

I pointed to blue zone research showing that strength of social connections is a key predictor of longevity.

This reframing matters because it changes the economic case for investing in women’s health.

“A woman’s health is the family’s health, the household’s health, the workplace’s health,” Rhiannon explains. “Our health is all interconnected.”

When a woman’s health improves, the benefits ripple outward. When it deteriorates, so do outcomes for everyone around her. This makes women’s health a systemic issue, not just an individual one, and it explains why payers and employers have strong incentives to support integration between Femtech and healthcare.

Women’s Health Hiding in Plain Sight

Some of the biggest businesses in digital health are actually women’s health companies, Rhiannon notes, even if they don’t use that terminology.

MSK disproportionately affects women. Heart health is huge for women, even though people don’t realise.”

This connects back to the communal nature of health. Women make the majority of household healthcare decisions. They coordinate care for children, ageing parents, and often their partners. Their health status affects entire systems.

What Success Looks Like

So what does it look like when companies successfully bridge the gap between Femtech and healthcare?

Rhiannon believes the winners will be those that combine consumer-grade engagement with healthcare-grade trust, creating a continuous experience across the self-care to healthcare journey.

As Clue’s recent analysis argues, “companies that successfully bridge these two markets will win because they’ll combine the volume and retention of consumer engagement with the higher, more defensible margins in the healthcare system.”

But more importantly: “Women will be the better for it.”

This means:

• Data that flows with women’s permission, not siloed in separate systems

• Preventive insights that reduce the need for acute interventions

• Personalised guidance based on individual patterns, not generic advice

• Clear pathways from self-observation to clinical care when needed

• Trust and transparency about what we know, don’t know, and how data is used

It also means refusing to prioritise flashy features over governance, or growth over sustainability.

As Rhiannon explained in our first conversation, this requires “keeping the humanity tangible” even at scale, treating users as real people, not abstract data points.

The Vision

With Verdane’s investment, Clue is positioning itself to help lead this integration - not by disrupting healthcare, but by bridging the gap that women currently have to navigate alone.

“Our vision is we want a world where women live better,” Rhiannon says. “The way we can contribute to that is by building a very trusted women’s health data powerhouse.”

The vision isn’t about having all the answers. “Nothing’s perfect, and nothing ever will be,” Rhiannon acknowledges.

But it’s about creating tools that fit around humans rather than forcing humans to fit around tools. It’s about building trust through rigorous governance. And it’s about advancing women’s health research through large-scale, high-quality datasets that can finally start answering questions that have been ignored for too long.

“Women are never served by not knowing and by being ignorant,” Rhiannon concludes. “So the more that women can have the data and have the insight and know what works for them, the better they will be over the long term. We hope to be part of that.”

As Clue’s recent analysis argues, Femtech was born out of dissatisfaction with a one-size-fits-all healthcare model. That same dissatisfaction is now driving its evolution from gap-filler to system connector.

The companies that successfully make this transition, combining consumer engagement with healthcare integration, maintaining trust whilst enabling data flow, staying human whilst achieving scale, will define the next chapter of women’s health.

Based on my conversation with Rhiannon, Clue is positioning itself to be one of them.

This is Part 2 of a two-part series on Clue and the future of women’s health.

If you missed it here’s Part 1 below:

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The paper breaks down the fundamentals of two structurally incompatible markets: consumer-first Femtech and traditional healthcare. Women are forced to contend with this tension as they plan, navigate, and manage their health and fertility.

Who are Clue?

For anyone living under a rock—Clue is a period tracking app, a trusted menstrual health resource, and a thought leader in Femtech. By combining science and technology, they’re actively changing the way people learn, access, and talk about menstrual and reproductive health around the world.

They’ve “been around for a while,” as Rhiannon puts it, building something huge. Back in December 2023, Clue reached a milestone that their CEO describes with pride: their first cash flow positive month. This achievement represented more than financial sustainability—it validated their approach to building a women’s health business grounded in research, user trust, and rigorous data governance.

Now, with significant investment from Verdane, Clue is positioned to expand its vision: becoming what Rhiannon calls “a trusted women’s health data powerhouse” that serves the goal of helping women live better.

I sat down with Rhiannon to discuss the paper, but we covered SO much ground. What emerged was a conversation about the fundamental challenges in women’s health—and why the solutions require refusing to take shortcuts.

The Foundation: Data Quality Matters More Than You Think

At the heart of Clue’s approach is a principle that sounds simple but is rarely prioritised in consumer health tech: if you don’t put quality data in, you won’t get quality insights out.

Rhiannon notes this is something users intuitively understand. “The biggest driver of churn off the product is usually when people just sort of drift away—they don’t find it easy enough to put the data in, so they don’t get good data out,” she explains. “Women know that if good data doesn’t go in at the top, we don’t get what we need at the other end.”

This insight connects to a broader challenge in women’s health: building evidence-based medicine requires high-quality data. Without it, everything downstream—from AI models to treatments to clinical guidelines—will be compromised.

“It’s only as good as the data that’s in there,” Rhiannon says. And she’s not just talking about Clue—she’s talking about the entire ecosystem of women’s health innovation.

Becoming Your Own Scientist

Rhiannon describes a reality many women face: having to be their own scientists to understand their health.

The female health gap is “a data gap, but we talk about it as the gaping canyon,” she says. “We all live this on an individual basis—not knowing why you’re off, not knowing why things happen, not knowing why things don’t quite feel right.”

This helps explain why tracking has become so popular. After period tracking itself, the top three things users track in Clue are pain, mood, and energy.

“That’s health,” Rhiannon emphasises. “The absence of pain, being in control of your mood and not it being in control of you, and having the energy to do what you want to do.”

What’s particularly striking is that these three things can only be self-observed. “There’s no external test for women’s pain—that’s why women’s pain gets dismissed,” Rhiannon notes. “It’s really interesting that women are tracking these because they’re looking for patterns, and they want to see the data overlaying against their cycle.”

The menstrual cycle, she argues, is “the vital sign of female health in many ways, and women instinctively know that.”

This is the animating principle behind Clue’s tagline: “It’s not in your head. It’s in your data.”

Citizen Science at Scale

Despite having a small science team, Clue collaborates extensively with research institutions globally, with users’ permission and appropriate data protections. The insights emerging from this research are “endlessly fascinating,” according to Rhiannon.

She points to a Johns Hopkins study published in 2024 that examined Clue data and found a strong correlation between severe PMS symptoms and gastrointestinal issues during the luteal phase.

“We wouldn’t have reported this unless they’re tracking it, but to be able to see it at scale and see that it’s not in your head, there is a connection there. It is really exciting.”

Another recent study examined COVID vaccine efficacy based on menstrual cycle timing, suggesting greater effectiveness when administered during the follicular phase versus the luteal phase.

“It’s just the beginning, and more work needs to be done,” Rhiannon cautions. “Would it be replicable with other vaccines? We don’t know. But having these large-scale datasets means we can start to ask these questions and start to find our way in understanding better what we live with every day.”

This is what Rhiannon means by building a “data powerhouse”, not just collecting data for product features, but enabling research that validates women’s lived experiences and generates new hypotheses for clinical investigation.

The Individualisation Problem: Why Clue Won’t Give You Generic Advice

When it comes to advice about optimising health around the menstrual cycle; cycle syncing workouts, eating for your phases, Rhiannon is refreshingly honest about the limitations of current evidence.

“We could get a lot more media coverage if we did pieces on cycle syncing and training optimisation,” she admits. “But there’s no data.”

While there’s some evidence around female athletes and ACL tears during the luteal phase, and research showing immune system changes across the cycle, the reality is more complicated.

“Fundamentally, the body’s not a clock and we’re all individuals,” Rhiannon stresses. “The advice we’re constantly trying to give, which is not sexy and people don’t want to hear, is actually: you need to track yourself and understand what happens for you at each phase in your cycle, what your pattern is, and work from there.”

This creates a tension. People want actionable, concrete guidance. “We’re all trying to get along as best we can, and it’s helpful if someone can serve us something that is straightforward,” Rhiannon acknowledges.

“But it’s just not true.”

As Rhiannon puts it: “It’s hard not to be definitive, but it’s more accurate not to be definitive.”

This refusal to oversimplify is core to Clue’s approach. It would be easy to generate viral content with prescriptive cycle advice. But it would undermine the trust they’ve built with users who come to them for evidence-based information.

AI: Useful, But Only With Individual Data

Rhiannon takes a measured view of AI in women’s health, referencing the statistical principle that “all models are wrong, but some are useful.”

When it comes to women’s health, AI models trained on incomplete or incorrect data will inherit those flaws. “There will be things that are wrong in there, but there’s also things that are really useful,” she says.

The real opportunity isn’t in current large language models providing generic health advice, but in applying AI’s computational power to individual women’s data, combined with established research.

“Being able to say: this is what your patterns show, this is what we do know, this is what we don’t know, this is what the evidence shows, this is what the clinical guidelines are,” Rhiannon explains. “Bringing it together within someone’s own data as opposed to only generic recommendations.”

The goal is to provide women with agency.

“Tracking equals data, data equals insight, and insight equals agency,” Rhiannon says, articulating the founding principle of Clue. “That’s what we want for women—to have agency over their own health. We don’t have a point of view on what an individual woman should do. It’s up to her.”

Data Governance Over Encryption

When discussing data security, Rhiannon makes a crucial distinction that many tech companies miss.

“People talk a lot about encryption, and encryption at rest and in motion is important. But the bit people don’t talk about is governance—data governance matters most in terms of security.”

The logic is straightforward: encryption doesn’t matter if someone has access to the data or has the key.

“Encryption matters, but governance matters most.”

“It’s really important that we think governance first,” Rhiannon emphasises. “What is the purpose for the data? How does this help someone? Is it clear and transparent who has access? We need to go very slowly in that space.”

For the Clue team, this isn’t abstract.

“This is my data in that product too,” Rhiannon says. “There’s stuff in the app that only my husband and my doctor know and not even the other one. We all treat it very seriously. This is not an abstract idea or abstract users. These are women we speak to every week, but also ourselves, our colleagues, our sisters, our mothers, our cousins.”

This personal connection to the data shapes every decision about how it’s collected, stored, and used.

Keeping Humanity at Scale

Despite Clue serving millions of users, Rhiannon is determined to maintain human connection.

“You have to have the scale, but you have to keep the humanity tangible somehow,” she says.

As a team of 55 people, “everybody’s very passionate about being here so we can do something for other humans on the other side of the screen.” Rhiannon is excited about AI’s computational possibilities but insists “the individual humanness needs to be held onto.”

She shares an example: Clue recently ran a promotion featuring Bernie, a team member’s cat.

“You wouldn’t believe the reaction—people wrote in saying it was really funny, that they could see it’s a real photo of a real cat and they’re like, oh, you’re real people.”

“You have to have the scale, but keep the humanity tangible.”

What’s Next

With Verdane’s investment, Clue is focusing on three core areas: product development, research, and expanding reach. For Rhiannon, these aren’t separate initiatives but interconnected elements of a single mission.

“Our vision is we want a world where women live better,” she says. “The way we can contribute to that is by building a very trusted women’s health data powerhouse.”

But Clue’s vision extends beyond building the best tracking app. The company is also grappling with one of the biggest challenges in women’s health: how to bridge the structural gap between consumer health tech and traditional healthcare.

Tomorrow, we’ll explore how Clue and the broader Femtech sector is working to solve this problem, and why the next decade could finally deliver the integrated experience women have been building for themselves.

This is Part 1 of a two-part series on Clue and the future of women’s health. Read Part 2: Bridging the Gap tomorrow.

Hanna Kalesse learned this the hard way. As a medical chemistry student experiencing severe medication side effects the kind that might affect “1 in 1000”, she went looking for alternative treatments through clinical trials.

She had the scientific background, the motivation, and the need. And still, she couldn’t get in.

That frustration became the foundation for TrialMe, a platform that’s rewriting the rules of research recruitment by actually asking women to participate.

From Hackathon to Health Crisis

TrialMe started at HackHerHealth, a women’s health hackathon at the Sahlgrenska Science Park in Gothenburg where Hanna and her co-founder Carlotta Hillger (a software engineer) decided to tackle a problem hiding in plain sight. At the time, Hanna was in the middle of her own health crisis.

“The medication I took was supposed to cause mild side effects for two weeks,” she tells me. “Instead, I stayed awake for two days straight. Then I slept only one hour a night for a week. It caused muscle weakness and a drop in her cognition.. She knew alternative medications existed, her degree told her that much, but finding a clinical trial proved impossible. Studies listed as “recruiting” weren’t actually recruiting anymore. The ‘ecosystem’ was difficult to navigate and the information was scattered across a dozen websites.

At the hackathon, Hanna realised something striking: every woman in the room had never been asked to participate in a clinical trial, even those who would have made perfect healthy volunteers.

“Young women want to contribute to research,” she says. “There is simply no open door for us.”

They built TrialMe to open that door. After placing third, Daya Ventures approached them with a challenge. To turn this into a real company. So two students became founders, taking on one of medicine’s most overlooked problems.

When the Gap Becomes Real

For Hanna, the gender research gap stopped being an abstract concept the moment it affected her ability to study, work, and function normally.

“The system assumed I would react like a ‘default patient,’ and that default patient was not a woman,” she explains. “Trying to find a clinical trial made it even clearer. I had the motivation, the background knowledge, and the need and I still couldn’t enter research. If someone like me struggled, most women would never even try.”

This is exclusion by design.

Barriers in clinical trials

Women face two categories of barriers when it comes to clinical trial participation: emotional and practical.

Emotionally, women aren’t asked to participate. The process feels opaque and intimidating. Most people still think “clinical trial” means high-risk, invasive research for the seriously ill when in reality, many studies are safe behavioural research, device tests, or observational studies.

Practically, the barriers to access crosscut intersections in women’s health and TrialMe helps to overcome these:

∙ Childcare: Who looks after the children during appointments? TrialMe assists with organizing and financing childcare support at clinical sites.

∙ Transport: Women from rural areas are particularly underrepresented. TrialMe refunds public transport tickets or taxi costs.

∙ Scheduling: Instead of endless email exchanges, TrialMe makes booking pre-screenings simple through the app.

∙ Finding the right contact: No more searching across multiple websites. You get a notification with the right contact immediately.

∙ Repeating your health history: The algorithm handles this. You create one profile at the start, not a new one for every search.

TrialMe changes this by giving women a clear, guided pathway into research. One health profile matched to psychological, physiotherapeutic, clinical, or product-test studies. Automatic notifications about opportunities. In-app booking. Childcare and transport support. Transparent education about what participation actually involves.

“Participating in research shouldn’t require courage,” Hanna says. “It should be accessible.”

Building Trust Through Transparency

TrialMe reframes recruitment not just as logistics, but as a relationship between women and science. Trust comes from transparency and Hanna knew she couldn’t ask women to participate in trials if she hadn’t done it herself.

As part of their market research, she joined a clinical trial and recorded the entire journey: the first phone call, the samples taken, what inclusion and exclusion criteria mean, every part of the process.

“Women learn best from other women,” she explains. “So TrialMe connects experienced participants with first-timers and shows the reality of research, not the myth.”

The platform focuses on clarity, autonomy, and the right to choose without pressure. After participation, women receive health insights analysing whether they meet average values, whether they might need adjusted dosage, and a complete overview of the health data collected about them during the trial, translated into language they can actually understand.

Where women are underrepresented

Across nearly all trial types, women are underrepresented. But some areas are especially severe:

∙ Cardiovascular trials

∙ Autoimmune conditions

∙ Mental health research

∙ Early-stage drug development

∙ Dosing and pharmacokinetics research

∙ General healthy volunteer studies

Ironically, even women-specific conditions like endometriosis or PCOS often have underrepresentation of diverse age groups, ethnicities, or symptom profiles. Real-world women’s experiences are rarely reflected in research design.

The Misconceptions That Keep Women Out

Since founding TrialMe, Hanna has noticed patterns that surprised her.

First, many women think their symptoms are “normal” because they’ve been normalised for generations. Pain, fatigue, cycle issues, medication reactions, women endure things they shouldn’t.

Second, most people still assume clinical trials are dangerous or only for the very sick. That misunderstanding alone keeps thousands of women out of science.

“And third, there are so many taboos and hidden topics and shame around women’s health so big that you’re not even aware of it until you come to that age,” she adds. “I can feel that women have so many serious and different health challenges in every decade. TrialMe can bring so much to raising awareness and educating women of all ages on what’s upcoming.”

When Research Helps the Participant Too

Trial participation can be transformative, not just for research, but for the participants themselves.

During her own clinical trial, the doctor diagnosed a menstrual health issue Hanna had considered “normal.” Through the trial, she learned there was medication for it and the medication being tested might even help. She also received extensive health check-ups that helped her understand her body better. One of her friends, after hearing about Hanna’s conversations with the doctor, later discovered she had ADHD.

“Participating in research didn’t just help science, it helped us,” Hanna says. “After the trial, the researchers didn’t stop caring about your well-being. The doctor prescribed me the most similar medication that’s on the market, which made me live my own life again.”

Designing for Women’s Reality

Talking to researchers and recruitment companies made one thing clear to Hanna: everyone knows women are underrepresented, but the system was never designed with women’s life reality in mind.

“To fix that, the solution has to come from the target group itself,” she explains, “and not from institutions guessing that we need the same as men.”

The most unexpected lesson? The research world can feel quite rigid, but the changes needed aren’t complicated. They just require design to take into the consideration the distinct needs of women.

Rebuilding From Scratch

If Hanna could rebuild the clinical research ecosystem from scratch with women at the centre, she’d start with:

∙ Transparent access

∙ Flexible participation options

∙ Childcare and transport support

∙ Clear communication

∙ Women-led recruitment channels

∙ Feedback loops where participants receive results in a meaningful way

∙ Integration with real healthcare pathways instead of isolated “study islands”

“Women shouldn’t have to fight their way into research,” she says. “The system should meet them where they already are.”

What Comes Next

Looking ahead, Hanna’s hope is that TrialMe becomes the natural first step when women want to understand their health, test new women’s health products, or contribute to science.

“I financed vacations through plasma donations, so imagine if women had a safe, transparent, empowering way to participate in research with even more benefits,” she says.

Her vision is that when a woman has a health issue, TrialMe immediately shows her relevant studies where she’ll be cared for, monitored, and supported. Even if the trial medication isn’t right for her, she leaves with better insights about her body and better connections to healthcare.

“The next generation shouldn’t inherit the gender health gap,” Hanna says. “They should inherit a research system built for them. And ideally the following generations don’t need additional medications for side effects or try several medications until they find a suitable one.”

If you want to find out more and participate in clinical trials use this link: https://www.trialme.eu/clinical-trials

Here’s an invitation to a webinar next Thursday about demystifying clinical trials with Dr Rosia Shah. https://luma.com/8zisav72

Thanks for reading!

“100%, I’d argue that’s in pregnancy and postpartum, more so in pregnancy,” she says when I ask where strength training is most underutilised or misunderstood.

The Cultural Baggage We’re Still Carrying

“Traditionally pregnancy across cultures has been treated as a time when women just rest, not even climb stairs,” she explains. “Whilst I’m a big believer that what our ancestors did definitely had wisdom which only now we’re uncovering the science behind, there are some presumptions that were rooted in nothing other than fear and the unknowns.”

We’ve swung from one extreme to another. “Pregnancy is more recently treated as though you’re either fragile or you’re invincible and the truth again is somewhere in between.”

The research gap in women’s health is wide. The research gap in pregnancy is even wider. “We’re only now in 2025 starting to see meaningful guidance emerging. It’s still very, very basic in terms of exercise in pregnancy but we do need to start somewhere.”

Current guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) and NHS recommends that pregnant women who are healthy should aim for at least 150 minutes of moderate-intensity activity per week. This can include strength training, though specific guidance on resistance exercise during pregnancy has historically been limited.

What we know now: training in pregnancy is beneficial for both mother and baby. Research shows that exercise during pregnancy is associated with reduced risk of gestational diabetes, excessive gestational weight gain, preeclampsia, and cesarean delivery, while also improving mental health outcomes.

But there’s nuance to performing safely.

Lamia herself trained at 80% of her one-rep max in terms of lifting until the day before she delivered. “BUT that is not suitable for every pregnant woman depending on her specific pregnancy, complications or symptoms. Just because you CAN do something, SHOULD you? There are trade-offs and things to pay attention to such as pelvic floor dysfunction.”

Her guidance is clear: “It’s completely safe to train in pregnancy. It’s even safe to start training or a new activity. Women need to understand the basics of pregnancy biomechanics, pelvic floor and core health and function so they can choose how to train that aligns with longevity in mind. Because pregnancy is temporary so you want to reap the benefits without the risks.”

She won the Perinatal Practitioner of the Year Award by The Active Pregnancy Foundation for encouraging her obstetric patients to become and stay active through their pregnancies, and living it herself by powerlifting through her own pregnancy.

Running in Pregnancy: The “Should You?” Question

Running is a perfect example of the nuance required.

“Every time you run, there is pressure and that goes upwards and essentially every time you strike the floor, there’s a hit on your pelvic floor,” Zafrani explains. “You already have a growing uterus, you’ve got a foetus, you’ve got additional weight increasing intra-abdominal pressure. On top of that, you’re adding increased pressure from the strike of running.”

During pregnancy, hormonal changes (particularly relaxin) increase joint laxity and pelvic floor tissue extensibility. Combined with the mechanical load of a growing uterus, this creates additional stress on the pelvic floor during high-impact activities.

Does that mean you shouldn’t run? Not necessarily.

“My question to them is, how important is it for you to continue running? If it’s for your mental health, because you’re an ultramarathon runner, it’s part of your training? Okay, fine. As long as you know these are the risks. Let’s see if we can mitigate them in some way. Let’s see if we can add something else into your training that still won’t take away from your overarching goal of getting back to ultramarathons, but maybe you’re not running as much or you’re not running as far in distance.”

The general advice: “Unless you really really want to continue running, maybe reduce the high impact activity from the second trimester onwards because it is adding pressure on your pelvic floor. But that doesn’t mean I will be saying no, you cannot run from the second trimester onwards. It’s, let’s see how we can limit and change the dynamic movements that you’re doing.”

Why Strength Training Matters Even More in Pregnancy

“That’s why I’m a big, big proponent of strength training because if you’re having to take away the load or you’re having to take away the dynamic aspect of the movement for football, for example, then actually you’re still going to be able to retain the strength and function and essentially get back to training for your sport postnatally by incorporating strength training and working around the things that you need to be strengthening to get back to that.”

Strength training, she argues, goes across all sports. “That’s why I love it.”

Even if you have to modify or reduce high-impact activities, strength training allows you to maintain fitness, build resilience for labour and postpartum recovery, and create a foundation for returning to your sport or activity later.

Research supports this: resistance training during pregnancy is safe and associated with beneficial outcomes including reduced back pain, improved glycemic control, and better maintenance of physical function.

The 18-Month Truth About Postpartum Recovery

Here’s something I wish more women knew: physiologically, it takes about 18 months to feel “back to normal” after giving birth and for hormones to normalise.

“Women definitely should not be expecting their body to magically be able to ‘bounce back,’” Dr Lamia says. “It’s a body, it’s just grown and birthed a life. We need to show ourselves and our bodies more respect and grace. But I completely understand the pressures and mental health aspects of being in a body that has changed.”

Breastfeeding prolongs these hormonal shifts. “Hormones affect how ligaments move, how your pelvic floor and core is reacting/behaving.”

The framework she uses? Think of postpartum like rehabbing from a big injury. “So many permanent changes have occurred and these need to be taken into account.”

Postpartum recovery involves not just physical healing from birth trauma (whether vaginal or cesarean), but also hormonal rebalancing, potential continuation of breastfeeding-related hormonal changes, sleep deprivation, and adaptation to new caregiving demands.

The Three Phases: Recovery, Rehab, Rebuilding

With her athletes, Zafrani works within a clear timeline, though she acknowledges athletes don’t always get the luxury of time on their side.

“With athletes we don’t always get the luxury of time, they may have Olympics coming up, a competition they need to be fit to take part in. Sometimes the timeline is guided by what priorities and what competitions they’ve got, what sponsors have said.”

For everyone else not bound by competition schedules, here’s the framework:

Recovery (first 6 weeks post-delivery): Recovering from birth itself. This aligns with the standard postnatal check timeframe at 6-8 weeks.

Rehab (6 weeks to 6 months): “Developing the brain to core connection, the brain to pelvic floor connection and the abs and pelvic floor connection. Rebuilding all of those connections. That doesn’t necessarily involve doing lots of very active movements. Even if you’re post-caesarean section, you’re just getting the breathing right, you’re getting the breathing exercises, getting all the connections rebuilt and realising where there are deficiencies, if there are any.”

What does she mean by “connection”? “It’s the firing of neurons as well as the fact that you’ve accommodated a growing uterus and your rectus abdominis has moved apart.”

Rebuilding (6 months onwards): “That’s when you start, that’s not to say you’re not lifting or you’re not doing sport-specific training, but you’re rebuilding the movement patterns, the connections, everything. You should only really be making plans for competitions essentially nine months onwards. Again, our athletes don’t always get that luxury. So six to nine months is when you would start to say, right, okay, now I can start picking some plans for return to competition timelines.”

Athletes and Pelvic Floor Physio: Non-Negotiable

For athletes specifically, or anyone considering returning to high-intensity training: “Athletes should have pelvic floor physio throughout pregnancy.”

She recommends “some sort of screening in early pregnancy to see if they’re at risk of developing any problems, having pelvic health physiotherapy throughout their pregnancy, and if they’re considering returning to high-impact sports in any capacity, having pelvic health physio postpartum. There’s no need to wait—you can start the rehab process from as soon as you’re able to actually do an abdominal and pelvic floor contraction and the earlier the better.”

Pelvic floor dysfunction affects up to 1 in 3 women following childbirth and can include symptoms like urinary incontinence, pelvic organ prolapse, and pelvic pain. Proactive pelvic floor physiotherapy has been shown to reduce these risks and improve recovery outcomes.

This isn’t optional if you’re serious about long-term pelvic floor health and returning to high-impact activity safely.

Diastasis Recti in pregnancy

Diastasis recti - I might have had a vague memory of this from my obstetrics rotation at med school. Lamia explained it to me as It’s the separation of the abdominal muscles during pregnancy.

“100% of women in pregnancy will get some aspect of the rectus abdominis moving apart. Whether you have a residual diastasis recti that doesn’t go back completely is going to be different for women to women. And whether you have a gap or not is not necessarily as important as whether that gap is causing you functional problems or not.”

Diastasis recti affects the majority of pregnant women, particularly in the third trimester, with prevalence estimates ranging from 30-70% in the postpartum period. However, the clinical significance depends on the degree of separation and functional impairment rather than the mere presence of a gap.

The fear-mongering around diastasis recti suggests you can prevent it or that if it happened, it’s somehow your fault. “It’s a physiological adaptation of pregnancy. It will happen. You cannot actually control whether your muscles go back together or not.”

That said, you don’t want to worsen it. “You don’t want to do lots of high intra-abdominal pressure work during pregnancy, which is why the advice is around minimising intra-abdominal pressure as best as you can. You can still work out, but rather than bracing and doing 80% of your 1RM lifts like I did, I was doing them but I was very much filming myself to see my bracing, I’m not wearing a belt.’

“Because you can do something, should you be doing it? And is it the right time to be doing it?”

Breastfeeding and Training: You Don’t Have To Choose

“A lot of the misconceptions are, oh, you can’t train and breastfeed, you have to give up one or the other. Actually, it’s not that you have to give up one or the other. What usually happens is that women are not able to maintain the caloric intake that’s required to maintain both. So one or the other suffers. Usually their milk supply will go down if they’re training too heavily because they’re not able to supply the calories required for both the training and breastfeeding.”

When you think about how energy-intensive lactation is, this makes sense. “You’re leaching calcium into your milk from your own bones. That’s another additional reason why women are more prone to get osteoporosis just generally.”

Research shows that lactation requires approximately 500 additional calories per day, with calcium requirements also increasing to support milk production. During lactation, bone mineral density can temporarily decrease as calcium is mobilized for milk production, though this typically recovers after weaning.

The caloric requirements: “In pregnancy you need an additional 500 calories in the third trimester, that’s looking at regular women and not taking activity into account. If they’re athletes they’re going to need much, much more than that. If they’re breastfeeding, you need another 500+ calories extra just to maintain breastfeeding on top of whatever your maintenance is. And then if you’re choosing to train...”

Fuelling for Recovery: The Non-Negotiable

This is the bridge to what might be the most important topic in this entire series: underfuelling.

Fuel intake needs to be high enough to support recovery from birth, lactation if applicable, and training.

“Trying to calorie restrict in a bid to bounce back is counterproductive and risks injuries, RED-S, and failed lactation if that is a priority.”

How should women think about rebuilding? “Being active prior to pregnancy and through pregnancy if they’re able to means your return to activity postpartum will physically be easier. Fuel adequately, build good habits that are sustainable around the very real fact that you will be sleep deprived and keeping a baby alive, walks when you can, rehab core and pelvic floor in short chunks when you get a few minutes in your busy day, but mostly to have expectations in check.”

The Crux

Training through pregnancy and postpartum doesn’t require you to be either fragile or invincible. It requires understanding the basics of pregnancy biomechanics, respecting the timeline of postpartum recovery, accessing specialist support for pelvic floor health, and fuelling adequately.

RED-S—Relative Energy Deficiency in Sport—might sound like a niche athletic concern. It’s not. It’s an epidemic hiding in plain sight, affecting recreational gym-goers as much as elite athletes, and the long-term consequences are only now becoming clear.

“If you said which one particular thing is applicable across women’s lifespans, I would say it’s the risk of underfuelling and RED-S, because it’s so easy to fall into because it’s going to be something that women are going to try and do, which is trying to lose body fat,” Zafrani tells me.

What Is RED-S?

RED-S is a sport-specific term for what gynaecologists call hypothalamic amenorrhea. These are big words but essentially these are the loss of menstrual periods due to insufficient energy availability rather than pregnancy, menopause, or anatomical issues.

“It’s basically when you undereat so much that your brain shuts down its reproductive function because you’re not eating enough. It thinks you’re in a famine. It thinks the last thing you want to be doing is trying to get pregnant. It’s the evolutionary protection mechanism.”

The name might be technical, but the mechanism is simple: when you’re not eating enough to support your energy output, your body starts shutting down non-essential systems. Reproduction is first on the chopping block. But the damage doesn’t stop there.

RED-S was first defined in a 2014 International Olympic Committee consensus statement as a syndrome affecting multiple body systems beyond just the reproductive axis—including bone health, immune function, metabolic rate, cardiovascular health, and psychological wellbeing.

How Women Fall Into It

For athletes, it can be genuinely unintentional.

“With female athletes, it might actually just be that they are very high output in terms of their training and they just don’t appreciate how much they need to be taking in to match that output. A lot of RED-S that we see in athletes is just unintentional. It’s not an eating disorder. It’s not intentional in any way. They did not appreciate how much they need to be eating to maintain their output.”

For the general active population, the pattern is depressingly familiar: “It’s usually some aspect of underappreciating how much they need. And because we’ve always been told eat less, move more, you think eating less and less and less is the way to get there.”

You decide you want to lose a bit of body fat. You think: eat less, move more. What you’re actually doing is creating an underfuelling scenario. “There comes a point at which your body normalises the low output, but the way you will know that your body is not fuelling is your injury rates will go up. Your periods will stop—well, they will either become very irregular or they will stop.”

The Warning Signs

How will you know your body isn’t fuelling adequately?

• Your injury rates increase (particularly stress fractures)

• Your periods become irregular or stop (amenorrhea or oligomenorrhea)

• Your performance plateaus or declines despite training hard

• You feel constantly fatigued

• You’re experiencing mood changes or depression

• You’re getting frequent illnesses (impaired immune function)

These aren’t just inconveniences. They’re red flags that your body is in crisis mode.

The Long-Term Consequences: It’s Not Just About Fertility

At the extreme end, “women have undereaten themselves into a menopause-like state, an early menopause. In most cases reversible. In some cases, if it’s been from when they were quite young, it’s affected their reproductive function.”

But new research is revealing even more concerning long-term effects.

Fertility and Egg Quality

“If you have women that had eating disorders or underfuelling, intentionally or unintentionally, in their prime years of late teenage into early twenties, we now know that it actually affects egg quality and egg reserves.”

This is crucial: “It’s not necessarily having an eating disorder affects your ability to get pregnant. Even if you’ve recovered from the RED-S or eating disorder, we are now seeing there’s downstream long-term effects on fertility, even if your periods have returned.”

Research is emerging that suggests energy restriction during critical developmental windows can impact ovarian reserve and oocyte quality, with potential implications for fertility even after menstrual function is restored.

The data shows: “Even if you’re able to get pregnant, because of the effect it’s had on egg quality potentially when you were younger, or uterine lining health, it can increase the rates of miscarriages. We can see there’s now an association correlation with preterm birth.”

The underfuelling you did in your early twenties can affect your pregnancy outcomes in your thirties, even if you’ve “recovered.”

Bone Health: The 20-Year Downstream Effect

“The next biggest one is bone health. I’d argue bone health is probably more important than the fertility, but it depends where you are in your life as to how important these things are.”

In severe cases: “There are cases of severe hypothalamic amenorrhea and RED-S where just giving more calories is not enough to reverse it or the oestrogen has been suppressed for so long that they now have osteoporotic fractures at a young age. We’re having to put young women on HRT as management of their RED-S.”

Think about that. Women in their twenties and thirties developing osteoporosis—a condition we associate with elderly women, because they underate in their teens and early twenties.

Low energy availability impairs bone formation and increases bone resorption, particularly in the context of low oestrogen from hypothalamic amenorrhea. The loss of bone mineral density during adolescence and young adulthood, when peak bone mass should be accumulating, may be setting women up for osteoporosis and fracture risk decades later.

“When it comes to a conversation about healthspan and longevity, bone health is a marker of outcomes for longevity.”

The women who grew up in the 90s, subjected to the “eat less, move more” ideology, are now the ones falling and breaking their hips, developing osteoporosis decades earlier than they should. “Those athletes who were in their teens 20 years ago are now obviously older and seeing the downstream effects of that.”

RED-S Across the Lifespan: The Pattern Repeats

RED-S can shows up at any life stage.

“If you speak to women in different parts of their lifespan—whether they’re a teenager who is having body changes and trying to lose body fat and going ‘I’m going to move more, eat less,’ they’re at risk of RED-S. Then you get the women who are postnatal, trying to lose the body fat they’ve gained in pregnancy—at risk of RED-S. Then you’ve got the women who are perimenopausal who realise their body and hormones are changing and they’re gaining body fat in places they didn’t have before, or they’re losing muscle and retaining body fat so their body composition looks different—at risk of RED-S because they’re going to try and lose weight.”

Teenagers

Body changes at puberty. Cultural pressure to be thin. The “eat less, move more” message is everywhere. They start restricting. Their periods might not even be regular yet, so irregular cycles don’t seem alarming. By the time someone notices, damage to bone density and egg reserves may already be happening.

Adolescence is a critical window for bone mass accrual, with approximately 40-60% of peak bone mass achieved during puberty. Energy deficiency during this period can have permanent consequences.

Postpartum

“The other time that RED-S becomes a problem is postpartum. A lot of women and athletes will not appreciate the amount of calories it takes to recover from birth, to breastfeed or lactate if they choose to. And then if they’re training on top of that, that adds an additional calorie requirement which is individualised.”

As we covered in the last piece, the caloric demands are staggering: recovery from birth + 500+ calories for breastfeeding + maintenance calories + training output. Most women dramatically underestimate this. Their milk supply drops. Their recovery stalls. Their injuries mount.

Perimenopause

Hormones are shifting. Body composition is changing; losing muscle, retaining fat in new places. Women panic and restrict calories while ramping up exercise. But perimenopausal women already have declining oestrogen. Adding underfuelling accelerates bone density loss and worsens symptoms.

Menopause is already associated with accelerated bone loss due to declining oestrogen. Energy deficiency during this transition compounds the risk.

The pattern is the same at every stage: something about your body changes, you decide to “fix” it with calorie restriction and more exercise, and you slide into RED-S.

The Hopeful Shift: Awareness Is Growing

“Because we now recognise underfuelling and RED-S, we hopefully are getting it right for our young athletes now. If we’re aware of RED-S now, when we didn’t talk about this 20 years ago, those athletes who were in their teens 20 years ago are now obviously older and seeing the downstream effects of that.”

Zafrani sees athletes coming in proactively now. “I get a lot of athletes that come and see me purely for a gynae MOT. They’re mostly worried about RED-S. They want to come off their contraceptives just so that they can see whether they have a cycle or not, whether it’s being suppressed by the contraceptive or whether it’s because they’re not eating enough. They’re coming with more knowledge and more body awareness and more wanting to be taking these things into account and addressing them if they are an issue.”

This is progress. Women are asking the right questions. They’re monitoring their cycles as a health metric, not just for fertility tracking. They’re connecting their training, fuelling, and menstrual health.

But we need this awareness to spread beyond elite athletes to every woman who’s active, who’s ever thought “I should probably eat less and move more,” who’s navigating puberty, postpartum, or perimenopause.

The Bottom Line: Respect the Fundamentals

RED-S isn’t just an athletic concern. It’s a public health issue affecting women at every life stage.

The solution isn’t complicated, but it does require fighting against decades of conditioning:

Fuel adequately. Especially during high-output phases: intense training, pregnancy, breastfeeding, growth spurts. Use your menstrual cycle as a health marker—if it becomes irregular or stops, that’s a red flag.

Monitor your cycle. If your periods become irregular or stop, that’s not “convenient”—it’s a warning sign that requires medical attention.

Prioritise bone health. The bone density you build in your teens and twenties is the bone density you’ll have in your seventies and eighties. You can’t make up for lost time. Peak bone mass is typically achieved by age 30, after which bone density can only be maintained or lost, not substantially increased.

Get help early. If you suspect RED-S, see a sports medicine doctor or gynaecologist who understands it. The earlier you intervene, the better the outcomes. Treatment involves increasing energy availability through increased intake and/or reduced exercise, with medical management as needed.

Reject the “eat less, move more” narrative. It’s outdated, harmful, and doesn’t account for the reality of female physiology.

The strength training boom is a good thing. The functional fitness movement is a good thing. Women getting stronger, more capable, more confident in their bodies, all good things.

But none of it matters if we’re underfuelling our way into early menopause, osteoporotic fractures, and decades of compromised health.

You can’t out-train a bad fuelling strategy. You can’t supplement your way out of chronic energy deficiency. And you can’t reverse 20 years of bone density loss.

I’d love to pose a question to you all. If I had known about this a while ago when I first started running long distances it might have prevented injury, a lot of the things we’ve discussed here. How can we make this a key part of the consumer health conversation?

Huge thanks to Dr Lamia Zafrani for her time, expertise, and speaking candidly about these issues. I hope you found this valuable.

If you spend any time in wellness spaces online, you’d think training as a woman requires a PhD in hormonal biochemistry, a team of specialists, and a very expensive stack of supplements tailored to your exact menstrual phase, life stage, and planetary alignment.

Yes, women’s physiology changes dramatically across life stages. Yes, hormones fluctuate. But the fundamental principles of good training stay remarkably consistent.

The Fundamentals Don’t Change (Even If Influencers Say They Do)

“Despite physiology changing, it’s become almost hijacked by influencers that there is some great and complex need for very specific training principles through these life stages,” Dr Lamia says. “Whilst in pregnancy and postpartum there is a lot of nuance, specialised support and modifications needed that do need to be individualised to each athlete, in general terms the principles of good nutrition and good training are actually the same.”

What are those principles?

“Lift heavy as a non-negotiable, strength train. Cardio as you enjoy and for cardiovascular and mental health benefits. Reduce sedentary behaviour for longevity. And recover adequately, eat enough, protein rich, good quality carbs, good quality fats, sleep.”

These principles align with current UK physical activity guidelines, which recommend adults do strengthening activities that work all major muscle groups at least two days a week, alongside aerobic activity.

Importantly “Once you’ve optimised sleep, nutrition fuel, and stress management, most symptoms in these life stages are normally better managed.”

This doesn’t mean there aren’t considerations. For athletes tracking their cycles, there may be injury prevention benefits to adjusting training intensity. “Empirically we do see differences in strength and energy levels in different stages of the cycle, so for those women who do experience this it may be beneficial to sync their training to their cycle or if they suffer with endometriosis and are in pain during their periods it may make sense to have a deload week programmed when they have symptoms.”

But “not all women experience cyclical changes which the cycle syncing apps and influencers will have you believing.”

The Cycle Syncing Problem: Second guessing your body

The evidence on cycle syncing is emerging but still inconclusive.

“We are starting to see that athletes are getting injuries in the luteal phase. We know physiologically certain hormones that are produced that are higher in the luteal phase do change your laxicity of your ligaments, muscles, bones. So they do have biomechanical changes.”

Research does suggest that hormonal fluctuations across the menstrual cycle may affect ligament laxity and potentially injury risk, particularly for ACL injuries. However, the evidence remains mixed, with recent systematic reviews highlighting the need for more robust research before making blanket recommendations.

But here’s the problem: “That does not mean me, you, and every single person needs to literally be held hostage by our cycle and tracking apps.”

Dr Lamia offers a clear framework: “If you have strength and energy changes with your cycle, then by all means you should change how you train to respect that so that you don’t get injured. If, however, you track your cycle and you’re like, genuinely I can’t feel any difference in my strength and energy level in my cycle, but your cycle tracking app is telling you, you must do yoga today and don’t go to the gym and you’re like, well, I feel fine, you’re now not listening to your body and now you’re listening to an app that is trying to make you distrust your body.”

What these apps should be doing, she argues, is validating what you already feel.

“Women were saying they would feel a bit off in the luteal phase, they would feel just before their period that their strength wasn’t there. Now we’re getting the apps telling you, this is the reason why.”

The nuance is important because “women are still individuals. Even our hormones are variable and individual.”

For elite athletes where 0.1% matters, paying attention to cycle-related injury risk makes sense. For the rest of us? Listen to your body first, app second.

The Two Extremes: Cookie-Cutter Plans and Fear-Mongering

When I ask about the biggest mistakes she sees women making, Lamia identifies two dangerous extremes.

“The biggest mistakes I see are on the extremes. A one-size-fits-all that either doesn’t take each individual woman and her life stage or symptoms into account at all, encouraging a push through it mentality, or even worse when individuals without the experience have gotten themselves through a particular life stage or situation and now feel that qualifies them to provide similar cookie-cutter plans to other women. At best simplistic and at worst dangerous.”

On the other extreme: “Treating women in these stages as though they are fragile and need lots of expensive supplements, specific products, again providing blanket recommendations or fear-mongering of a vulnerable population.”

The truth sits somewhere in the middle. “There are general principles of lifestyle optimisation, training principles, and then taking each individual’s symptoms into account and individualising a support plan.”

You don’t need a special menopause protocol if you’re sleeping well, fuelling adequately, and managing stress. You don’t need PCOS-specific training if the fundamentals are working for you. But if you have specific symptoms, heavy periods, endometriosis pain, perimenopausal joint issues, then yes, modifications make sense.

The difference is starting with your body’s signals, not with what someone’s trying to sell you.

Closing the Healthspan Gap: The infrastructure

Women live longer than men but spend more years in poorer health. In the UK, women can expect to live 19.4 years in poor health compared to 16.2 years for men, despite living longer overall. If strength training is genuinely going to close that gap, what needs to change?

Lamia’s answer surprised me: “The problem starts from puberty.”

Dropout rates in physical activity for girls spike at puberty. Research shows that physical activity levels decline significantly during adolescence, particularly for girls, with the steepest drops occurring between ages 11-15.

“Whether that is because girls are not told enough about what to expect, whether the people doing the training, coaches, sports teams, or the infrastructure isn’t there to support girls in staying active through menstruation and puberty, that’s where we’re seeing the first drop-off. Then again at pregnancy and postpartum, and then again at menopause.”

“If we can get girls staying in sport through better education about their own periods and gynaecological health, through better education and infrastructure in the teams or coaches that are providing the support; a lot of them will stop training because their periods are too heavy, but nobody’s helping them with their periods being too heavy. It’s the education as well as the access to care.”

The pattern repeats at every major life transition. Girls drop out at puberty because no one’s helping them manage heavy periods or explaining what’s normal. Women drop out during pregnancy and postpartum because the infrastructure isn’t there; childcare, baby-friendly gym spaces, accessible coaching. Women drop out at menopause because they’re not getting support for the symptoms that make training harder.

The Barriers Are Not Just Biological

Access matters throughout the lifespan. Lamia was only able to train postpartum because she had access to a specific powerlifting gym, quieter, not a commercial gym, somewhere she felt comfortable bringing her baby. It’s not something that’s accessible to everyone.

The barriers are logistical, societal, economic. “Women have more caring responsibilities. They have more responsibilities to their children, their parents. So there is a big socioeconomic reason why this is happening. A lot of it is psychosocial. It’s not just necessarily all medical.”

Research consistently shows that women face greater barriers to physical activity participation, including time constraints due to caregiving responsibilities, lack of childcare facilities at fitness venues, and safety concerns.

She pauses, then adds: “Until we start fixing it literally from where the problem starts, which is at puberty, and then upwards, keeping girls in sports, encouraging them, giving them the care around their puberty and period health, coaches and everyone else having the understanding. The next obstacle being pregnancy and postpartum, having the logistics in place. Having baby and mum friendly spaces where you can actually take your baby and be active. Having the logistics around childcare, simple things. These are the reasons that women state for why they have dropped out of physical activity.”

TLDR;

Training across life stages isn’t as complicated as it’s made out to be. The fundamentals remain: lift heavy, fuel adequately, sleep, manage stress. Listen to your body before you listen to an app. Be wary of both extremes the “push through everything” crowd and the “you’re fragile and need special protocols” crowd.

But complexity isn’t the only barrier. Access is. Infrastructure is. Societal support is.

“The fact that women are taking on strength training, which is longevity promoting, even with all of these other barriers in place, this is still a better way to train for longevity,” Lamia says. “If it’s something that’s encouraged from when they’re young, movement patterns, developing all of that, that’s going to put them in better stead for the rest of their life.”

Now let’s get into the specifics of the two life stages where women need the most support and where the gaps are most glaring: pregnancy and postpartum.

Next up: What training through pregnancy and postpartum actually looks like, not the fear-mongering version, not the “bounce back” version, but the evidence-based reality from a sports gynaecologist who’s lived it.

References

1. NHS. Physical activity guidelines for adults aged 19 to 64. https://www.nhs.uk/live-well/exercise/exercise-guidelines/physical-activity-guidelines-for-adults-aged-19-to-64/

2. Herzberg SD, et al. (2017). The Effect of Menstrual Cycle and Contraceptives on ACL Injuries and Laxity: A Systematic Review and Meta-analysis. Orthopaedic Journal of Sports Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4920965/

3. Chidi-Ogbolu N, Baar K. (2019). Effect of Estrogen on Musculoskeletal Performance and Injury Risk. Frontiers in Physiology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8878739/

4. Elliott-Sale KJ, et al. (2021). The effects of oral contraceptives on exercise performance in women: a systematic review and meta-analysis. Sports Medicine. https://bjsm.bmj.com/content/56/3/169

5. Office for National Statistics. Health state life expectancies, UK: 2018 to 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/healthstatelifeexpectanciesuk/2018to2020

6. World Health Organization. Physical Activity fact sheet. https://www.who.int/news-room/fact-sheets/detail/physical-activity

7. Allender S, et al. (2006). Understanding participation in sport and physical activity among children and adults: a review of qualitative studies. Health Education Research.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6234955/

And we’ve got an expert in the house! I was lucky enough to chat with the wonderful and hugely knowledgeable Dr Lamia Zafrani, an award-winning consultant sports gynaecologist. She is one of only two in the UK. She works with everyone including Olympic athletes, helping them train safely through menstruation, pregnancy, postpartum, and menopause. Oh, and did I mention she’s also a powerlifter who trained through her own pregnancy? She knows this territory from both sides.

Women are stronger than ever. Not metaphorically, literally. More women are lifting heavy, competing in functional fitness events, and building muscle mass than at any point in recent history. The shift has been undeniable and the advantages are huge.

But should we be celebrating yet? Or are we watching another chapter in the endless cycle of women’s bodies being treated as trends?

Dr Lamia Zafrani has a foot in both worlds. As one of only two sports gynaecologists in the UK, she works with elite athletes and recreational lifters alike. As a powerlifter who trained at 80% of her one-rep max until the day before delivering her baby, she’s lived the reality of what it means to push and support your body through major transitions. When we talk about the current strength training boom, she’s cautiously optimistic, but with important caveats.

Cultural Narratives as a 90s Kid

“It’s absolutely fantastic that women are taking part in more strength and functional based training,” Lamia tells me. But she’s quick to acknowledge the complicated history that brought us here.

“As a woman who was a child in the 90s, I saw the detriment of the idealised ‘skinny’ frame, constant calorie restriction and endless cardio that was advertised to women to get them their ‘ideal body’ the normalisation of this way of training being the only way.”

The shift toward strength training has been driven by multiple forces: changing aesthetic ideals, yes, but also women realising the functional benefits, the mental health boost, the community aspect of training together. CrossFit, for all its controversies, played a role in normalising women lifting heavy. So did social media. So did the gradual cultural shift away from “smaller is better.” It’s a tangle of factors, some more empowering than others.

“Whilst I don’t agree with women’s bodies being treated as a fad because they are not,” she explains, “the fact that it became fashionable to be bigger, women started honouring their curves, wanting to gain muscle to gain shape. This alongside CrossFit, which irrespective of one’s opinion on it, did a good job of getting women into weightlifting and providing that support network.”

Her view? “The shift is being driven by changing aesthetic ideals and women using strength and functional training like HYROX for empowerment, realising the benefits functionally and the community aspects that come with taking part in these events.”

But here’s what she really hopes: “Irrespective of what aesthetic or fad is being peddled, once women start taking part in strength and functional training, more will see the benefits firsthand and continue irrespective of what body type happens to be in fashion.”

The Lasting Consequences of Training to Be Small

This matters because we’re living with the consequences of the last “fad.”

“If we’re looking from a public health perspective, the women who grew up in the 80s and 90s and are now older, they’re the ones unfortunately having the falls, breaking their hips, getting osteoporosis,”

“It’s a direct result of this ideology that was fed to them, not lifting heavy, doing lots of cardio, not eating enough, underfuelling. It’s basically been a myriad of creating osteoporosis and eating disorders.”

The link between underfuelling, low body weight, and osteoporosis risk is well-established. Women have lower peak bone mass than men, and inadequate nutrition during critical bone-building years (adolescence and early adulthood) has lasting consequences. Osteoporosis affects approximately 1 in 2 women over age 50, and hip fractures in elderly women are associated with significantly increased mortality rates.

She pauses. “So I’m actually quite glad that we’re reversing some of that and having a different narrative. Hopefully the next generation onwards is going to be strong into their old age.”

But the threat of history repeating itself looms large. With GLP-1 drugs making dramatic weight loss newly accessible and whispers of “heroin chic” creeping back into fashion discourse, are we about to swing the pendulum back again?

“Women’s bodies are not a fad. They’re not something to be played around with just because a certain body type was difficult to obtain so it was idealised in the 90s and 80s, and then a different ideal body type which wasn’t attainable for a lot of people became idealised and pushed plastic surgery and all of that aspect, beneficially strength training, yes. And now because that is becoming easily accessible, and we’ve got access to GLP-1s, we’re trying to swing the narrative back.”

Her diagnosis is clear: “What’s happening is media, it’s society trying to control women’s bodies, essentially.”

The antidote? “Young women need to understand that their bodies are not a trend. You don’t have to be happy with everything you’ve been given, improving yourself is completely fine, but it’s within your genetic limitations and respecting that.”

Why This Time Might Be Different

Here’s what gives me hope: the fact that women are taking up strength training at all, despite persistent barriers, is significant.

Research consistently shows that resistance training improves bone mineral density, reduces fall risk in older adults, and is associated with better healthspan outcomes. Muscle mass is a key predictor of healthy aging, and maintaining strength is crucial for independence in later life.

“The fact that women are taking on strength training, which is longevity promoting even with all of these other barriers in place, this is still a better way to train for longevity,” Dr Lamia says.

But for this shift to be more than just another trend that leaves a generation of women dealing with the health consequences decades later, we need to cut through the noise. We need to understand what actually matters versus what’s being sold to us by influencers and apps. We need to get serious about supporting women through the most vulnerable transitions, pregnancy, postpartum, and the chronic underfuelling that’s affecting women at every life stage.

That’s what we’ll explore in the rest of this series.

Next up: Why training across life stages isn’t as complicated as wellness culture wants you to believe, and how to know what advice to actually listen to.

References

1. Tenforde AS, et al. (2017). Parallels with the Female Athlete Triad in Male Athletes. Sports Medicine. https://pubmed.ncbi.nlm.nih.gov/26497148/

2. National Osteoporosis Foundation. Osteoporosis Fast Facts. https://www.bonehealthandosteoporosis.org/patients/what-is-osteoporosis/

4. Hong AR, Kim SW. (2018). Effects of Resistance Exercise on Bone Health. Endocrinology and Metabolism. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6279907/

5. Srikanthan P, Karlamangla AS. (2014). Muscle mass index as a predictor of longevity in older adults. The American Journal of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4035379/

I rocked up to the Excel Centre, the venue had been transformed into a 1km loop and 8 stations, with music blaring from a live DJ on the decks somewhere.

Instagram had made me think that this was a cult for the ripped gladiators I’ve been seeing on my feed. I was wrong. What I was seeing was an example of a cultural shift where training has stopped being about shrinking and started being about being strong and I’m absolutely here for this.

Women are choosing strength training, chasing PBs. Theres got to be something deeper than being motivated by aesthetics alone to possess you to run 8k intermittent with weight exercises and finish the course with 100 wall balls… 100 wall balls.

We’re seeing narrative shifts that connect fitness and exercise to a conversation about longevity in the way that as consumers we are engaging with events, gyms and studios, wearables and wellness tests and optimisation.

The numbers validate this moment: a 5,614% surge in UK Hyrox participation since 2021, gym membership at an all-time high of 11.5 million, with women now making up 54% of gym members. What I witnessed at Excel reflects this. But beneath the empowerment narrative lies a more complex truth: this revolution is being driven by affluent consumers, and increasingly packaged as a luxury product that leaves half the population behind.

Training for healthspan, not just race day

The global wellness economy has ballooned to $6.3 trillion, projected to reach $9 trillion by 2028. The real story isn’t market size. It’s what we’re buying: not more years of life, but better ones.

The longevity science conversation has gained massive traction. Peter Attia’s Outlive has sold over a million copies, Andrew Huberman has 5.5 million YouTube subscribers, and nearly $5 billion in venture capital flowed into longevity companies in the first half of 2024 alone. The focus has been on metrics like VO2 max, grip strength, and muscle mass.

The science backs this up. Research shows muscle mass index predicts all-cause mortality in older adults: those in the highest quartile have 19-20% lower mortality risk. Grip strength inversely correlates with death. The weakest quintile has 67% higher hazard ratio for mortality.

These metrics matter. Muscle mass, grip strength, VO2 max are predictive of mortality and independence. But the mainstream longevity conversation misses something crucial: women’s bodies don’t optimise the same way men’s do.

We don’t just need the science. We need the science for us. For bodies with menstrual cycles that affect everything from injury risk to nutrient metabolism. For bodies that will lose 20% of bone density in 5-7 years during menopause. For bodies with different cardiovascular risk profiles, different injury patterns, different hormonal landscapes.

The ‘bro science’ approach (lift heavy, track your metrics, optimise your sleep) isn’t wrong. It’s incomplete. Women are done retrofitting male protocols onto female physiology. Especially since only 6% of sports and exercise science studies have been focussed exclusively on female participants.

When women train for competitions like Hyrox (pushing sleds, pulling weights, lunging with kettlebells) they’re not just preparing for race day. They’re building the strength reserves that determine whether they’ll need a walking frame at 75, whether they can get off the floor after a fall, whether they’ll maintain independence or require full-time care.

These aren’t just mortality predictors. They’re independence predictors.

The healthspan gap: why this matters for women

Here’s the paradox: women outlive men by 5 years on average in the UK. Yet women don’t live better. They live longer in poor health; longer lifespans but shorter healthspans.

Strength training directly addresses the risks that disproportionately affect ageing women: osteoporosis, frailty, mobility decline, and loss of independence. For women facing the threat of catastrophic bone density loss and muscle wasting, building strength isn’t about extending lifespan to 120. It’s about avoiding frailty, dependency, and pain in their 80s.

Muscle mass in older adults is more strongly related to hip fracture risk than bone density. Muscle strength declines approximately 1% per year after age 40, correlating directly with increased falls, fractures, and loss of autonomy. Women can lose 3-8% of muscle mass per decade after age 30. During menopause, they can lose up to 20% of bone density in just 5-7 years.

Training for functional fitness builds exactly what ageing women lose first: the strength that prevents falls, the cardiovascular capacity that maintains independence, the muscle mass that protects bones. Every sled push is practice for pushing yourself out of a chair at 80. Every wall ball is practice for lifting shopping bags. Every burpee is practice for getting off the floor without assistance.

The competition provides motivation. The training provides healthspan. For women facing more years lived in disability than men. It’s survival.

Women are driving the market and changing their habits

The data shows a fundamental shift in how women approach fitness. According to 2025 data collected by the Well Hq from Garmin, ClassPass, Tonal, and Strava, women’s exercise habits have evolved dramatically.

Between 2011 and 2021, women lifting free weights increased by 150%. Women’s regular strength training has nearly tripled from 10% in 2000 to 27% in 2024. Despite increased participation, 38% more women than men report hesitancy to lift weights due to fear of building excessive muscle indicating we may not yet be free of the patriarchal tropes that exacerbate these inequalities.

PostNatal classes on ClassPass saw a 77% increase in attendance year-over-year. Women’s bodies require different training approaches across life stages, and the industry is finally catching up.

Now let’s talk wearables; Oura Ring’s customer base flipped from predominantly male to 59% female. The company invested heavily in cycle tracking with 97% ovulation accuracy and perimenopause monitoring. Apple Watch followed with temperature sensors for cycle tracking. The FemTech market reached $60.89 billion in 2025, projected to hit $121.33 billion by 2033.

Women are driving product innovation towards health optimisation and I think it’s really important that we build with integrity, treating females not just as passive consumers but create and iterate with emerging evidence. Women are treating strength training as health data, not just performance data.

Brands respond with gender-specific science

The fitness industry is beginning to respond. Equinox launched ARC (Align, Restore, Condition), explicitly addressing that women’s hormonal fluctuations, joint laxity, and muscle recruitment patterns require different training. The programme tailors workouts to menstrual cycle phases, acknowledges higher female injury rates in traditional strength programmes, and builds training around female physiology.

It’s a stark acknowledgement that decades of fitness science was built on male subjects. Women weren’t training “wrong”. The training was wrong for women.

The shift matters because the science is clear: resistance training reduces fall risk in older women by 30-47%. Higher muscle mass associates with 10-17% lower all-cause mortality risk. Falls are the second leading cause of unintentional injury deaths worldwide, and strength training is the most effective prevention.

The inequality problem

Whilst gym membership approaches gender parity, access splits along class lines.

The data reveals who gets access to this healthspan revolution. Sport England’s 2024-2025 data reveals troubling divergence: affluent women have activity rates of 73%, whilst the least affluent stand at 52%.

Thirty percent of households earning over $75,000 use wearable health technology compared to only 12% earning under $30,000. Consumer health research shows 42% of lower-income consumers cite cost as their primary barrier, markedly higher than middle- or high-income brackets.

The UK fitness industry generated £5.7 billion in 2024. Oura Rings cost £299-£449. Gym memberships average £40-50 monthly. Equinox’s gender-specific training costs £200-300 monthly. When Hyrox announced its first Mediterranean cruise in December 2024, the message was clear: healthspan is becoming a luxury good.

This is particularly cruel because the healthspan gap affects lower-income women disproportionately. They spend the most years in poor health. They can least afford care when independence fails. They need functional strength training most, and they’re being priced out.

A revolution in progress

Women aren’t waiting for permission anymore. They’re flooding into functional fitness not because of biohacking trends, but because they’ve identified what medical research historically overlooked: the specific vulnerabilities of female ageing and the training interventions that address them.

The 5,614% surge in Hyrox participation isn’t just about racing. It’s about women taking ownership of their healthspan, their training protocols, their ageing trajectories. The fitness industry is responding with gender-specific science, cycle-synced training, and life-stage approaches. Technology companies are investing in female health tracking. The cultural shift is undeniable.

The science is clear: strength predicts independence, function, and quality of life in old age. The overlap between fitness training and health optimisation is now impossible to ignore the habits that improve race performance are the same ones that extend healthy ageing.

But when affluent women achieve a 73% activity rate whilst the least affluent women decline to 52%, we haven’t liberated women’s relationship to healthspan. We’ve just made it more expensive. The real transformation will come when every woman, regardless of income or postcode, can access the strength training that determines whether she’ll spend her 80s independent or dependent.

Until then, the question remains: are we liberating women’s relationship to physical power and healthspan, or are we just selling empowerment at a higher price point?