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Transcription of our conversation with Loewen Cavill, Co-Founder and CEO of Amira:
Immad Akhund: Welcome to the Curiosity Podcast, where we go deep on a wide variety of technical topics with the smartest leaders in the world. I'm Immad Akhund. I'm the CEO and co-founder of Mercury.
Rajat Suri: I'm Raj Suri. I'm the co-founder of Lima, Presto and Lyft. And today we're talking to Loewen Cavill, who is the co-founder and CEO of Amira. This is an innovative company that helps women manage their menopause symptoms. They use a wearable that women use while they sleep that helps reduce hot flashes, connects to a mattress that helps cool them down while they're getting these hot flashes, and helps them get better sleep. She's invented this system, has a background in nuclear fusion, Google X. Immad, what are you interested to talk to Loewen about today?
Immad Akhund: you know menopause is not something that like i know a lot about you know my mom actually had a pretty difficult menopause i remember being a kid and like what the hell's going on i think it's really cool to see kind of people go after uh these kind of practical problems and although it sounds complicated it is hardware and it is kind of medical yeah i think it's like actually like a pretty pretty obvious solution that, you know, try to detect the hot flash and cool, cool people down so that they can get better sleep. And I think those type of kind of improvements are going to really help a lot of people. So that, yeah, that got me like pretty interested in this kind of conversation. How about you, Raj?
Rajat Suri: Yeah, I mean, it's obviously a subject I know almost nothing about. I actually haven't experienced, I think, menopause myself, in my family. I'm sure my family hasn't experienced it. My mom experienced it. But it wasn't, I think, a big deal in my family. But it's obviously a big deal to every woman going through it. And it's not something that is talked about that much. It's certainly not something that I don't think I've ever heard a woman talk about it in the workplace and say, hey, I'm going through menopause and this is something you should be aware of. It's not something that, but it obviously has a big impact on women. This company is solving a problem around that or one of the major symptoms, which is hot flashes. And I'm just curious to learn a lot more about menopause and its effects and the technology that can help reduce the symptoms or make it a little bit easier. So yeah, excited to talk to Loewen and with that, let's welcome her. Welcome to Loewen Cavill.
Immad Akhund: All right, welcome Loewen to the podcast.
Loewen Cavill: Excited to be here. Thanks for having me.
Immad Akhund: Give us a quick history and tell us more about what Amira does.
Loewen Cavill: Yeah, so Amira was started about a year and a half ago. Amira is never something that I planned to do, never planned to be working in menopause and I can get more in my background after, but Amira is about unlocking women's potential through technology, starting with menopause in a demographic that is most under addressed. What we do is we predict symptoms and then we preemptively counteract those, starting with hot flashes and then moving into hormones into the future.
Rajat Suri: We would love to understand why you started the company. What motivated you to do this?
Loewen Cavill: Yeah, it's a really good question. So I think, like, zooming back, I was, you know, a kid obsessed with mathematics and the potential that technology can have in unlocking human potential. And I was obsessed with human potential and being at that maximally through athletics and college. So this is something that I was like, always a little bit especially tuned into or obsessed with. And then I saw my aunt go through menopause, and this was the biggest dumpster fire train wreck maze that I had seen, and like in college I'd seen this world of autonomy where you have all this autonomous robots, autonomous drones, autonomous delivery of all things but then you see one of these women go through menopause and you see how bad the state of the art is and you know our technology is better than that, you know our engineers are better than that, but the problem was like how many engineers are working on aging women's health today and it's actually very very few. And menopause has one of the highest rates of aging in any other time period. We have this like huge obsession with longevity, but less so, kind of like strategically going after it. I think that menopause is the clear low-hanging fruit when it comes to unlocking human potential. And if we bring more engineers to this space, I think there's a much, much higher reward when it comes to engineering effort put in to output or unlock of that potential.
Immad Akhund: So from my understanding, there's a wearable you put on your wrist and then there's a mattress cover or something that adjusts the temperature. Is that how it works?
Loewen Cavill: Yeah, so we kind of believe this is the 2.0 of wearables. Getting past the wearables that tell you the next morning, hey, you slept bad, or you woke up this many times. And I think the 2.0 is really wearables that respond to you in real time so that you don't have to. You don't have to lift a finger. You don't have to think about it. There's no guesswork. So what we do is we predict sleep disruptions and then preemptively counteract that through thermal regulation. So we predict a hot flash and then cool the bed down through like a cooling pad on top of the bed and then that can actually counteract sleep disruptions from hot flashes.
Immad Akhund: Well that's cool. How do you predict a hot flash?
Loewen Cavill: So most people would guess we do temperature. We tried every temperature sensor out there. Then we tried like infrared lasers through the ear to get our core body. None of those worked. No existing wearables worked. So what we ended up doing is we ended up modifying some sensors from brain computer interfaces using dry electrodes to detect the bioimpedance of the skin. This is kind of, I think, a really under explored area of science and it's really popping up right now is by electricity. So figuring out how our biology interfaces with electricity and that's kind of what we do. We send micro amounts of electricity into the skin and you can see any like micro core changes or moisture that pops up earlier than you would be able to see any temperature changes.
Immad Akhund: Oh, interesting. So the idea is someone starts sweating a little bit that changes the resistivity on the electricity. And that's a good enough predictor to like pre preemptively try to cool the person down?
Loewen Cavill: Yeah and the brain actually works quite quick at like starting to regulate and hot flashes start in the brain. So unlike the external environment being really hot, the hot flash is triggered inside the mind and that's where you see some of these like really fast response from the skin itself.
Immad Akhund: So the body thinks it's hot, even before it's hot, because that's what's causing the heat?
Loewen Cavill: Exactly. Yeah. And it's all from hormonal imbalances that start to trigger some of these.
Immad Akhund: I guess why not go after the hormonal imbalances directly? Why go after, this is like more of a symptom.
Loewen Cavill: That's 2.0. So one thing that I learned, I used to work at Commonwealth Fusion Systems. They're a nuclear fusion startup that recently raised like $2 billion. They did a phenomenal job of acknowledging hardware is hard. And to accomplish some of these like moonshot hardware goals, you have to break it down into small pieces. Since if you've ever debugged like a robotic system, you don't know if it's the wires, you don't know if it's the hardware itself, you don't know if it's the software behind it. So what we've done is we've kind of like broken out our Amira strategy into these like discrete stepping stones that each can be economically viable in their own right. So our first step is measuring the bioimpedance, like the amounts of sweat, and then 2.0 of that is this new blossoming field where we start to monitor what's inside the sweat itself. And through measuring what's inside the sweat, you can pick up not just hormones, but metabolics, proteins, concentrations of nutrients, heavy metals. So that's where we plan to go into after. But that is very much like a moonshot technological approach that is best done if you've already kind of de-risked the steps before.
Rajat Suri: Can you explain the concept of bioelectricity?
Loewen Cavill: Yeah, so bioelectricity is this field that's changed pretty dramatically in the last couple of years. So this is founded by, not necessarily founded, but really pushed forward by Michael Levin and Nick Lane. I think these are two scientists that are very much quickly on the rise for bringing this new concept of electricity actually has a huge importance in our biological workings inside. It is what transmit things in and out of the cell. It's what differentiates a cell in the first place. So, electricity turns out is a huge part of our inter workings and we're now starting to look at our body from like, almost like an electrical circuit and how that might work. I first learned about this when I took this, like. biological circuit design class. And then you realize that there are these overlaps in areas that you wouldn't expect as much. And I think every time that you apply a new lens of science, where let's have electrical engineers look at the body, I think that there's huge breakthroughs that come from that new emergence. And we're starting to see that in this like new field of bioelectricity, where there's all these breakthroughs that come from seeing how electricity and biology are intertwined. And that's very, very core to the essence of Amira, is we are built on bioelectricity. That's what our technology is betting on. And we're lucky that some scientists are pushing this field forward in front of us.
Rajat Suri: Sounds good. And how many of these are out there, these mattresses?
Loewen Cavill: Yeah, so we just kicked up our factory in China. My CTO is moving there to live on the ground floor of the factory next week. So we've had about 50 women use our product today, but the next stage of that is making a bunch more units so that it can expand beyond those 50 and go wherever those women are.
Rajat Suri: Sounds good. And how long have they been using it? What have the results been for the 50?
Loewen Cavill: Yeah, we've had one woman that's used it about 200 nights? I would say that we've learned that it's quite difficult when you have so few units to be able to make testers happy, because you give it to them and they're like I'm able to sleep for the first time and I don't know how long and like now you're taking it away. So that's been a little bit unfortunate but also very rewarding to see how much it changes their sleep. And I think we realize that like in recent years through people like Matt Walker talking about why we sleep, sleep is the cornerstone of all things. So not Is it just they feel more energized the next day, but they're able to be far more productive. A lot of their mood swings are gone. Their weight fluctuations are more in check. They're able to go to the gym again, able to be their full selves in all these different aspects of life. So that's something that we've seen a lot of excitement around. It's not just the sleep itself, but all the byproducts of that.
Rajat Suri: Got it. So you said you know you were taking some units away from folks, is it like less than 50 units out there? How many do you have out there right now?
Loewen Cavill: We have about 10 units that were rotating between women we had one woman in Alaska who was having about 12 hot flashes a night, and what this means is for each hot flash that she would have, she would go run out and sit in a snowbank in the middle of the night to mitigate this hot flash. And once you bring something like this to those women, not only are they like not running out into a snowbank 12 times a night, but they're able to just sleep entirely through it. So like the step function shift that you get when you can eliminate some of those sleep disruptions is really, really large for those women.
Rajat Suri: Explain a hot flash to me, because I've never had one, or maybe I've never had one. Is it like, you know, how hot do you get in a hot flash? Like, is there a temperature actual change? It's like getting a fever?
Loewen Cavill: Yeah, so there is a core body temperature change. The core body temperature change itself is a 0.1 Celsius temperature increase in the body. So it's actually small from a biological perspective. But for women and men, there's no question what is going on. I've talked to many women about their first hot flash. And they're like, there was no doubt in my mind that this is a hot flash because it was so far from anything that I've experienced before. So it feels like a raging hurricane, women become drenched with sweat in seconds of this hot flash starting. And it’s not just found in menopause, men and women experience hormonal imbalances. So prostate cancer will have like hormonal treatments that they'll have to go on or off during this time. And then they'll start experiencing hot flashes as well. My grandpa is experiencing hot flashes. I don't really know why, but hormonal imbalances start to pop up a lot more these days, especially as you age. So it's found in many demographic groups outside of just menopause.
Rajat Suri: Do people have it during the day as well, or is it just at night?
Loewen Cavill: Yeah, so women have it during the day, but it's most prevalent between two and four a.m. It is what we think is most inconvenient because you're supposed to be getting sleep. So if you can enable them to have those like full windows of sleep, where it's like the 90 minutes that you have to get to, to get to REM sleep, that's where you start to get some of those huge benefits, reducing brain fog, reducing fatigue in the day, increasing mental clarity as well.
Rajat Suri: Got it. And before I turn over to you, what percentage of women have hot flashes during menopause? I'm guessing all women go through menopause, right? But how prevalent is this issue?
Loewen Cavill: Yeah, so all women go through menopause. It starts much earlier than people realize. Most symptoms for women start around 45 or 47. And then about 80% of women will experience hot flashes. And one thing that people don't realize is how long this stage of life actually lasts. On average, menopause lasts 7.4 years, which means they will be having these symptoms for 7.4 years. And if you look at what is available for these women today, it's quite abysmal, and they have like the highest disposable income during this time, they're at the peak of their careers, right when they should be promoted to senior positions in boardrooms, but so many of them are having to dip out of the race. Somewhere between 1% and 10% of women are actually quitting their jobs due to menopause right now. And I think that if you bring back their sleep, this number is drastically reduced because they're able to stay in their careers. They are able to stay functioning at peak performance.
Immad Akhund: You mentioned you were at a fusion startup. Was that just before this?
Loewen Cavill: So I was there right before I was at Google X. So I went from the nuclear fusion company, which was an incredible experience. And then I was building out a data prognostics team at Google X's drone delivery company, right before.
Immad Akhund: I mean, yeah, I feel like fusion is so future-focused and more scientific, whereas what you're doing now is very practical and kind of solving people's direct needs. Do you feel like people do too much on the kind of, oh, let's do this far-future cool thing, rather than like, hey, this is a practical thing that we could fix for humans? How do you think about the relative investment that we make into each?
Loewen Cavill: No, it's a really really good question, and I had this like existential moment when I was working in nuclear fusion about like existential risks as a human civilization and thinking about like how can we increase the odds that humans are around a thousand years into the future, 10,000 years into the future. And I think fusion is a really big part of that. But there's so many engineers working on that. I felt like I was kind of like a small drop in the ocean on like relative value that I could create. And then I looked at 50% of the world's population at the peak of their careers and was shocked by how many of these women are having to dip out of their value-add time to society due to menopause. I think that it is very, very critical that we have a balance of feminine and masculine in capitalism. Capitalism is kind of like the young toddler when it comes to when you look in like the long term of society and I think that one thing that we'll need for capitalism to really feed our population and be a long-standing entity is have some proponents of the we and I think the feminine is a really good proponent of the we and having women that are like in those decision-making rooms thinking about oh should we go to war should we blow each other up should we you know be destructive. I think that women can sometimes be more of the bearers of how we can protect our future offspring and our future offspring's offspring. And that voice, I think, is really missed right now when it comes to those decision-making rooms in capitalism. And I think what is the biggest unlock that I can have? It's unlocking those women during this time period that they have the biggest value add to society.
Immad Akhund: What did you learn from nuclear fusion that you've applied at your startup?
Loewen Cavill: Yeah, I think it's really the steps that you have to take. We saw in fusion with ITER where they went for the full thing from the start. And the amount of money that has been dumped into that project is massive. And we've been working on that for like 30-40 years. And I think this is what kind of in some ways gives fusion a bad rep. These are constantly saying fusion is just 10 years away. And then we've had this company that's like made so little progress over those last 30, 40 years. And Commonwealth, what they've really changed is this sprint mentality across these different stepping stones. So starting with one smaller magnet, and then starting with one smaller reactor where you can just get two above one for the first time, and then one larger reactor at the end where you get commercially viable energy. And I think by taking those small step zones and having the entire company aligned on those you can really de-risk very risky technologies. And I think about our company and what's the really risky technology that we're going after. It's really being able to see into the internal fluids through sweat like that is a huge technological moonsault if that like we no longer have to take blood tests we'll no longer have to get blood draws and can instead see what's in the internal fluids of our sweat but it's quite complex so it's really important to break this up into bite-sized pieces and i think commonwealth has done a phenomenal job of that has there been papers done on like what's in your sweat and what information you can get out of it and like you know what are the top two or three applications of like sweat information that you can think of Yeah, this is something that's changed pretty dramatically in just the last six months. I didn't expect the field to pick up as quickly or all of a sudden as it has. People are coming at it from different approaches. So one approach is cortisol, others are looking at caffeine. The earliest of days, so like a year ago, people were looking at like electrolytes and sweat. But I think once you start looking at things like cortisol, which are changing on a minute by minute basis, that enables you to have much higher control over yourselves. And think about our modern environments today and our modern jobs today, where you're having to jump into all these different contexts of being, where you're supposed to, you know, hop on a sales call, then you're supposed to go to the gym, you're supposed to give a performance review to one of your employees. All these require a very different version of you. And I think once we can read real time into our hormones and chemical signaling agents, that can give us a higher level of control where we can modulate that in real time for whatever we need to be in that next moment. So do we need to be more empathetic? Do we need to be more energized at the gym? Do we need to be super confident? All of that can be regulated externally if we can read into our body with precision.
Immad Akhund: I mean, let's say you had a perfect measure of someone's cortisol, like practically speaking, what would you do? Like you'd be, you'd say, Oh my God, your cortisol spiking, like go chill out. Like, is that, is that the kind of feedback you would be trying to give?
Loewen Cavill: No, I'm not as much of a believer of like adding to people's to-do lists or adding stressors in their environment. I think telling them is one thing, but acting on it for them is where you get huge unlocks. So I think what we'll be doing in the future is we'll have this patch that has small molecules jostled into it, but you can control it in real time through like Pi's electric materials and pumps, where you can unlock a higher presence of small molecules into the skin in a different time. so that you can keep individuals at the optimal amount of cortisol or estrogen or caffeine or whatever is needed in that moment through this like external modulation.
Immad Akhund: You're saying like you would go like oh cortisol's spiking that's…?
Loewen Cavill: Yeah, so we're going to regulate it for them. Or maybe like, hey, they have this thing where they need to be really energized for, and they're kind of low cortisol right now. So we might pump up some of the caffeine or something so that they're kept at that optimal threshold. And I think that where we unlock next levels of productivity is when you're able to switch into these different environments or these different ways of being at a much faster rate.
Immad Akhund: That's interesting. I would have thought you'd want to try to get people to change the environment that gets them to optimal performance rather than regulate them. But maybe there's a combo of both.
Loewen Cavill: Yeah, and I think that there's a lot of like environmental changes that you can do. Like our starting product is, you know, changing something in their environment, like changing the temperature of their bed. And there's versions of that that you can do in the environment. But where I am really excited to go in the long run is getting into like changing some of your biology as well.
Immad Akhund: Do you try to do the science itself? Uh, in the sense, like even for your kind of normal device, you're like measuring the impedance of the skin. Was that science that someone else did and you just, you know, you took that paper or whatever, and you were like, okay, I'm going to try to turn this into a product. Uh, or did you have to do kind of this original science to like figure out like, what was the, yeah, what was the exact kind of measurement and how to do it?
Loewen Cavill: It was a little bit of both. So there are hot flash, like, big hot flash measuring devices found in laboratories today and what we did is we like drastically miniaturized this and kind of modified some of the sensors to be able to detect this. But I would not say we invented a new entire modality of sensing and this was like something that's always a little bit of a tug and pull when you have very technologically inspired individuals. And I would say a lot of our team is of that orientation, where the first choice is not to go off the shelf, but some of the highest impact is found off the shelf. And that ramp up from having something that works one time to working reliably all the time for tens of thousands of individuals is a huge ramp up. And dedicating teams to do that ramp up, it's most efficient to go a little bit more off the shelf than inventing it from the start. And then like our next stage of this, it depends where the scientific field goes, but we're seeing a lot of progress in some of these labs such as Caltech on some of the sweat sensing technologies. And some of this will be made available to the public. Some of them will be invented in companies. It's too early to tell exactly how off the shelf we can be, but I think that some more invention will have to occur.
Rajat Suri: So what products kind of inspire you in this space? Like women's health products. Again, this is another space I'm too familiar with. What are the most successful products in this space that are tech enabled?
Loewen Cavill: I think one of my favorite companies of all time is definitely Medtronic. I think they kind of founded this space on how we can bring in physical crutches to our body, and then like, unlock full potential that way, in a way that like really prolongs lives. And I think every person at that company truly knows that they are doing good for humanity. There's like no question about that.
Rajat Suri: What does that company do?
Loewen Cavill: So they make medical devices. They're a rather old company now, but they were kind of the founding of the medical device space. Started in a garage in Minnesota, don't quote me on this, but like four years ago, maybe 50 years ago.
Immad Akhund: It's a $113 billion company in terms of market cap.
Loewen Cavill: I think that's a very beautiful, elegant company.
Rajat Suri: Oh, what are the products?
Loewen Cavill: We've done like the pacemaker enabling people with like heart palpitations. They've done a lot of those innovations. So anything that like goes inside of the body or regulates the body externally, pretty much they've done.
Rajat Suri: Pacemaker sounds pretty important. Yeah. That's a good one.
Loewen Cavill: And then in the menopause space specifically, there's been a pendulum shift. So previously all women were on hormone replacement therapy. That was the default. Every woman, when she got into her mid forties, the doctor prescribed some sort of estrogen and progesterone replacement because the ovaries stopped producing those after the years that the child is being produced. And then this horrible study came out. It was so misdone. It was leaked early before the results were out. And then all doctors stopped prescribing it. Women were scared of it. And women today are still scared of it. I believe less than 4% of women in the US are on some sort of hormone replacement therapy for menopause. This is changing that we've had a lot of companies pop up recently that are starting to kind of like change the conversation around hormone replacement therapy and different medicines that women can go on during this stage of life. Midi is an example. They just raised a 60 million series B, I would say. I think it was a series B. And I think that they are really bringing so many women back to their full selves, which I think is very, very exciting.
Rajat Suri: And what do they do? What's their product?
Loewen Cavill: Their product, they're essentially a telehealth clinic. And one of their primary offerings from this telehealth clinic is hormone replacement therapy. Hormones are so critical to the operating system of our body. Some would argue that the only longevity drug that's actually been discovered is hormone replacement therapy for menopause. But it's not really branded that way. So it's less popular in the Silicon Valley communities.
Immad Akhund: Why did HRT get a bad rap? Was it linked to cancer or something?
Loewen Cavill: Yeah, there's this horrible study done in like the 90s where it linked it to breast cancer. And then if you look into the statistical significance of this study or how this study was run, it was all done wrong. Like they were prescribing hormone replacement therapy far too late where there's actually a risk. But once you bring women on to hormone replacement therapy, as their hormones are starting to decline, it's very, very safe and can reduce many of the chronic conditions such as heart disease or osteoporosis. It was a very bad PR stunt.
Rajat Suri: It would be interesting to hear, like, what are your thoughts on the future of women's health products and health care? What would you like to see, you know, 10 years from now in terms of products available to women? And how do we get there?
Loewen Cavill: I think women's health is such a fascinating engineering problem is when you look at the complexity around all these hormones orchestrating themselves and like constantly changing environments and like changing by the day, changing by the hour, I think you get a level of complexity that we don't know how to respond to quite yet. And women were actually kept out of studies until the 90s because of this complexity. They're like, it enters too much noise, we don't know how to deal with this, so we're just going to exclude it. So now we actually have no women's health data. because it's been excluded for hundreds of years before. So I think that we are seeing kind of like the dawn of women's health by first enabling women to be in studies where they're testing different drugs or observing how heart disease manifests. So that's step one, is getting the data to act. And then I think we have this huge unlock where you can act on that data, and there's many different medical devices that could come into place there, different medications, different lifestyle interventions. So I think that's one huge thing that we'll see after some more of this data comes in, unlocks around women's health. And I think that For whatever reason, women's health is viewed as niche still, but if you look at where the dollars are actually spent, 80% of healthcare dollars are controlled by women. And I think we're starting to see a lot of these front companies come out and reap massive financial rewards. And I think now that we have some of these players that show, hey, there's money here, it's worthwhile to invest in this space, I think that we'll see a really, really big unlock in the companies that come out. And a lot more technical companies will hopefully come out. I think in early days it's been a lot of like branding differently or talking differently around women's health, which is important. But I think we'll see a lot more like deep tech, heavy engineering companies come into this because what people don't realize is actually really technically complex. Like I thought nuclear fusion was complex and then I saw the endocrine system and how it changes and menopause and I was pretty blown away by the level of complexity there. And I think what we really need is more technologists in this space to make some of these breakthroughs.
Rajat Suri: Is there some kind of metric or quantification of how much more complex a woman's endocrine system or hormonal system is versus a man's? I'm curious because it seems like it should be much more complex, but I don't know how much more.
Loewen Cavill: Yeah, I can show you some charts on this. And we kind of see this a little bit with andropause. So andropause is men's menopause. For men, their testosterone decreases pretty regularly. It looks pretty linear over time. We'll see that decrease. But then when you see women's hormones and that going through menopause, it is like a hurricane. It's crazy how complex it is. where you'll have progesterone skyrocketing and estrogen going who knows where the next day and the testosterone dropping and like that switching almost on an hourly basis. And you see this through the symptoms. So there's 48 plus symptoms of menopause. I would argue that there's many, many more because all of these hormones control every organ of the body. They control our bone strength. They control our heart health. They control our mind. They are the operating system of the body. And during menopause, they're learning a new operating system. In that transition, is extremely rocky for many of these women. After menopause, their hormonal day-to-day looks a lot more like a man because it's flatlined, and then before it changes on like a monthly cadence. And then that in-between, it's everything in-between. From a perspective where you get a ton of learnings on what hormonal imbalance even is, how it shows up, what happens when you have these crazy assortments of hormones. So I think that where you can learn the most about the operating system of the body from a hormonal perspective, it's during menopause because you see it at that edge case.
Rajat Suri: Fascinating. Thanks. Over to you, Immad.
Immad Akhund: Is the U.S. healthcare system good at being helpful with these things? Like, I mean, just to take your product, is there, would they pay for a product like this, or is like kind of making your sleep better something that's like completely outside, like what health insurance companies care about?
Loewen Cavill: Yeah, so unfortunately the system is very much an antiquated, older system where the incentives aren't always aligned for innovative change right now. A lot of the medical billing codes. still don't quite see sleep as the cornerstone in health, even though a lot of our recent scientific understanding has validated that as the case. And same with menopause. Menopause has not been historically acknowledged as a medical condition due to its taboo nature and lack of conversation. I think we're starting to see this change really, really quickly. But from a business building perspective, I think that kind of like the flip side of the coin is the regulatory looseness that you have in menopause. And I think businesses can actually move much, much faster in these new spaces that haven't been super regulated historically. So we are kind of seeing this menopause gold rush kick off right now due to some of those missing regulations. Which as a woman, I'm like, we should have some more of those. That's a good idea sometimes. But from a business building perspective, it enables you to go faster.
Immad Akhund: Is that downside to not having regulation? Are there people out there that are making like promises that are not true?
Loewen Cavill: For example, I mean, how I originally got into the space is my aunt, she was waking up from hot flashes about five times a night. this sleep loss and sleep deprivation extended on for a period of like four years to the point of where she was getting sick all the time you could like so visibly know that she was not herself anymore but like meanwhile had no idea she was going through menopause because menopause is taboo and she ended up having to quit her job it was this whole thing and she'd spend hours each week searching for solutions that might help her buying everything she could off the internet, going to every doctor she could possibly find, going to these like naturopaths, I mean like witch doctors, everything that she could do because she was so desperate to get better. And then one of the things that she tried in the do-it-yourself approach, since the healthcare infrastructure and medical community was so unhelpful during this stage of life, actually sent her to the hospital for the side effects. So I saw this happen in my aunt. It was like the lack of regulation and the lack of support or educated expert support that women have during this stage of life. And when you look at what you're kind of asking about our health care system today and how our health care system is set up for something like this or is not set up for something like this, like right now, less than 20 percent of OBGYNs have any training in menopause. menopause is a stage of life that lasts for like 10 years, seven and a half years, and it's insanely complex. So if no doctors have any training on it, then they're not able to give any support. And if you look at what it takes to change how doctors are educated, it's very, very difficult. When symptoms are not aligned, it would mean that someone from like the heart disease department would have to give up, you know, hours of their lectures. And that becomes a very bureaucratic, bureaucratic ego battle that I don't see changing anytime soon.
Immad Akhund: I guess if you could control either health insurance companies or the law, what would you change that you think would make it more helpful to people going through menopause?
Loewen Cavill: definitely the insurers. I would have a lot more like billing codes that would enable women to get treatment for this and I think there would be a huge payback for insurance companies to this as well. These are the number of women that are getting CT scans during this time because they think that they have Alzheimer's or dementia or the women that are getting rushed to the ER because they think they're dying when it's just a regular symptom of menopause is actually quite high. There's a huge amount of added medical costs during the stage of life. And then additionally, so many chronic conditions come in the long run if menopause is not treated properly. I was looking at this one study where I was talking about women with nighttime hot flashes versus women with just daytime hot flashes. And women that were like regularly waking up from these nighttime hot flashes had a huge risk of diabetes later on. It was drastically the women that didn't have those constant awakenings. And it's frustrating for insurance companies to acknowledge simplicity of sleep sometimes and the simplicity of some of these like easy menopause treatments, but it would save them so much money in the long run if those were funded.
Immad Akhund: Yeah, I just read this book called Outlive. Raj actually read it too. And I think it talks about a link between menopause and dementia. Like people who had HRT and better menopause treatment had a lower risk of dementia, which I thought was kind of an interesting link that I would not have expected.
Loewen Cavill: Yeah, if we looked at it purely from an engineering perspective, like we took a step back and looked at long-term health outcomes, we would save so much money, bring so many more years, have so much more productive output to society if we were better about treating menopause.
Immad Akhund: Yeah, that's interesting. It's hard to fix the US health system though.
Loewen Cavill: Wow, it turns out it's a little nuanced.
Immad Akhund: So right now people are just paying for Amira out of pocket.
Loewen Cavill: Yeah. And I think that's where we're actually seeing a lot of these health care innovations is in some of these self-pay models. We're seeing these like health tech companies pop up and get a lot more traction because individuals know what they their problems and that their problems are not being solved by existing healthcare systems. And I just read this stat that like less than 50% of women in our demographic have primary care providers anymore because they're not being served by that. And I think that the incentives are of our healthcare system don't have our doctors spending as much time with us as we need or don't have them evaluating the full plethora of data that they could get. But, some of these health tech models do. They are able to take more of a full suite of data. They're able to give you a view of your health and how to solve it in a way that our current medical system doesn't have the time for. And they're like, incentives are not aligned for that data-driven, more time-consuming care.
Immad Akhund: Why is menopause a taboo topic? I had no idea that it was a taboo topic.
Loewen Cavill: Yeah, it's quite interesting. And like, the proof of it being taboo is like, how many times in the last month have you talked about menopause? Like, I looked at my career, and I never learned anything about menopause. And I would think that I'm a relatively well educated woman. But right now, society loves the young, fertile women. and kind of casts aside the infertile, menopausal women. And those women don't feel enabled to talk about this hardship, don't feel enabled to talk like, hey, yes, I'm in this state of aging. So right now, those women are a little bit silenced and aren't welcome to talk about these issues. And I would say that if menopause wasn't taboo, we'd be hearing about menopause on like, you know, a daily basis because so many women are experiencing it with such levels of intensity.
Rajat Suri: Curious where you want to go with the business. What's your goal? How do you plan to make it available to women going through menopause? It's kind of an interesting, you know, you have this trial that you've done and now you're looking to make it generally available. Is it going to be just available on your website to buy or how are you planning to sell it?
Loewen Cavill: Yeah, so us engineers try to do go to market from a very engineering perspective since traditional marketing was not a real house. So what we ended up making is kind of like an AI doctor or a menopause coach is what we call it. And this is actually really picked up in a way that I didn't totally expect to see the usage and for so many different types of women for having someone that like regularly checks in on their health. and like regularly is there alongside them to help them make these commitments to their health or help them follow through that. That's been quite interesting. Like we had one woman yesterday talk about how to Amy. Amy is our like AI menopause coach. She told Amy, like, hey, thank you so much for being here with me during this stage of life. Like, my mom was always the one that I'd come to about these areas of health that I feel like I couldn't go elsewhere, but she's gone now. So you really stepped in and replaced some of that, like, spots that were missing due to my, like, dead mother. So there's huge, huge, I think, opportunity in this space because One, we see a massive gap in menopausal care. There's like 1,500 menopause providers globally with one billion women in the world experiencing menopause. I think that type of gap is not solved by like training more doctors. I mean like that'd be awesome if we had more medical doctors. But I think that's like a really long difficult bureaucratic process to push forward. But A.I. has the opportunity to scale that vacuum and being able to expand expert medical care.
Rajat Suri: You're saying that like somebody, someone is getting an AI doctor from you, like a woman experiencing menopause? How do they access the AI doctor?
Loewen Cavill: Yeah, so it's called an AI menopause coach. So one thing that we're starting to see in some of this more concierge medicine is where doctors weren't just available in like the waiting room or in the doctor's office, but they're actually the white text. So this is something that we saw picking up is like really enjoying that like text-based access. So then we actually created a LM menopause coach that is available through text like many of those concierge doctors and what women love about this is like when they're up at 4 a.m. and they can't sleep because of their menopause. this menopause coach, Amy, responds instantly and is like by their side answering all their questions. And we even have menopause doctors using Amy because they haven't got this education. Menopause is so complex. They don't know the answers all the time. So for more edge cases, we see doctors using this to help give better treatment to their patients.
Rajat Suri: So this is something that's live right now. Like Amy exists. Anybody can text a number and talk to Amy.
Loewen Cavill: Yeah, yeah, it's live right now. We launched this in October and have been pretty surprised by some of that traction there. And then this is something that like from a go to market perspective, as a woman builds a relationship with Amy, like I was checking some of our numbers yesterday, we've had one woman that sent 1024 messages with our Metapulse coach. And once you have that level of trust, when Amy becomes their friend, that's when they really buy into anything that Amy vouches will be helpful to their health, such as our Terra wearable system.
Rajat Suri: Got it. So your go-to-market is to make Amy popular, and then Amy will recommend the Terra system to them. And so there's a conversion funnel there. Is that right?
Loewen Cavill: Exactly. Yeah. And Amy's a pretty easy sell. And it's like an educational tool that I think fits into a popular narrative on democratizing some expert care that isn't being found elsewhere. I think this is something that we could monetize but I think it actually better serves us in the long run to make that for free now.
Immad Akhund: [Laughs] You're dropping Amy on us in the last five minutes there, Loewen? How did you train up Amy? Is it just off-the-shelf LLM, or did you have to train her a lot to this data?
Loewen Cavill: I mean, initially it was off-the-shelf LLMs, but there's so much extra work that you have to do to not accidentally give medical like care that only a doctor is allowed to give and so there was like a lot a lot of like guardrails set in place a lot of like fine-tuning how an individual speaks to Amy and how Amy responds once you're getting into this kind of like doctor companion model there's a lot of psychological questions that pop up And I think once you kind of like fit into the lower levels of human psychology, you're able to have huge unlocks from a capitalistic perspective.
Immad Akhund: So what is a question that Amy can answer that's not medical? Like if someone says, hey, I just had a hot flash, like, can you give me kind of three things I could do to try to like reduce it? Is that something it could answer? Would that be considered like medical?
Loewen Cavill: And it can tell women that the pathways can include hormone replacement therapy and other drugs, but Amy does not prescribe drugs or tell women to take drugs. They say that this is an option, give some education on that, and then we recommend that they go talk to their doctor about that. And one thing that we see a huge usage when it comes to Amy is helping prepare women for that conversation with their doctor. I would actually argue that, like, how can we train more doctors? It's easier to train more doctors who are giving women the tools to understand their health because then they can go to their doctor and they're like, I know these are the options. This is how it works. This is what I want and makes that interaction much, much more efficient, beneficial for the women and also beneficial for the doctor. But, you know, changing the medical education that they got 30 years ago, that's actually much more difficult.
Immad Akhund: Are hallucinations a problem? Is sometimes advice way off?
Loewen Cavill: We built this eval system, so that's something that we evaluate for. simulate and check our models against is, are there any hallucinations? In early days, there were some hallucinations around recommending our Terra system, it would sometimes, like, make up what our Terra system is. And we're like, no, Amy, that's not it. But we've trained her and now there's like very, very few, if any.
Immad Akhund: Is this like an open source LLM? Like what are you using and how are you fine tuning it?
Loewen Cavill: Yeah, so initially we are on ChatGPT using OpenAI models since we're seeing so many of the earliest advancements there. But now the open source model community is like really, really popping up here. I mean, Google actually just open sourced some of their models today, making it much more cost affordable for individuals and like small companies to use some of these off the shelf models. So we're migrating off of OpenAI right now, because some of these alternative options, you can get it for much cheaper, faster, with relatively similar performance.
Rajat Suri: This has been great. Thank you, Loewen. I really enjoyed this chat.
Loewen Cavill: Yeah, this was fun. Thanks for taking the time, you guys.
Immad Akhund: Yeah, thanks, Loewen. This was really interesting. I feel much better educated. So I have a wife and two girls. So I guess I will point them to this podcast if this happens.
Rajat Suri: Thanks, Loewen. Really helpful. Thank you.
Loewen Cavill: Okay, well, great chatting.
Immad Akhund: Well, that was a really interesting chat. Raj really came in not knowing much about menopause. He was like, what is menopause? Honestly, I didn't know that much either. I had no idea that it lasts for so long, like seven years, right? Seven and a half years. That's crazy. Yeah.
Rajat Suri: I don't know how intense it is throughout the 7.4 years and what the standard deviation is. That's one question I'm still wondering about. Is there like a peak in a few months or is there like a long peak over 7.4 years experiencing the same symptoms? I think that's something that would be interesting to dig into. But yeah, it was interesting. I learned a lot about women's health. I think one thing Loewen mentioned, women's health is a serious topic, big topic. And, you know, women do go through these massive hormonal changes. It's pretty clear that it's way more intense than men. And we probably could use a lot more solutions around that. So, you know, I think just fascinating to learn about a serious topic that affects half the population.
Immad Akhund: In a previous episode you were a little skeptical of hardware startups. Do you think this one is a little better because like presumably a higher pain point, higher price point that these people would pay or do you think still like pretty hard to get like a hardware startup working in this field?
Rajat Suri: Yeah, consumer hardware is like the hardest of the hard categories. There's such a large graveyard of companies in this space. Think about all the sleep tracking companies and all these various IoT companies and device companies. Very few of them make it to the promised land. And that doesn't mean people shouldn't try, but you got to know. I mean, remember companies like Jawbone and there was a camera tracking company that helped make camera focus better. It's just very hard. And you know, the Pebble, the smartwatch company, like these guys, you can do almost everything right, but if you get one detail wrong, your company can die. And that's the problem with hardware.
Immad Akhund: I mean, I think the interesting thing is, you know, medical devices is a huge market, right? Medtronics is a multi hundred billion dollar, well, more than hundred billion dollar company. I think the tricky part is actually getting access to those medical insurance revenue streams. Like, you know, there's a lot of money in it, but I don't know how many people are wealthy enough and are willing to go above like, you know, they're already paying health insurance. Are they also going to pay more for their health care? I think that part is tricky. If they could get medical insurance companies to kind of underwrite this and have a billing code, I think it would be a lot easier.
Rajat Suri: Yeah. And I think that the benefit also of being integrated into the system, the health insurance system, is that it solves a marketing problem, which is a huge problem and major cost. Yeah, and I think crossing that chasm is going to be critical for this company, Amira, to succeed. Getting doctors to talk about it, which I think one of my concerns would be, is this solving the problem in a direct enough way? Is this even going to come up in a medical conversation with a doctor? You could try this product and sleep. I'm not sure. It may, it may not. because it's not a serious medical condition or a serious medical thing that is happening here. It's obviously uncomfortable, but it's not life-threatening or massively debilitating.
Immad Akhund: I mean ideally, you know, it would be kind of word of mouth and viral, like women probably know each other, they're going through menopause. So the question of like how taboo is it, is like an interesting question, like a societal kind of question. And I do think it's like actually a surprisingly taboo topic. Like, you know, heart conditions are not a taboo topic even though, you know, lots of people go through them and people talk about it. But yeah, it's very rare to hear women talk about menopause at all, like for it to show up in a tv show or something like that.
Rajat Suri: Yeah, well maybe they just don't talk about it publicly and they only talk about with each other you know. I guess you and I would never know, but I mean you would hope they would talk about it and it would be an accepted topic that you know people should talk about, including by the way, I think periods. I think women don't talk about periods in general, like some women have very bad periods they don't show up to work And that should be OK. I mean, that's just a part of life. And if you can't show up to work because you have a period, I don't think I've ever heard a woman say that. But I do know that women have serious periods. And so that's another thing.
Immad Akhund: I mean, you might be a cool CEO that's OK with that. But I think there's a fear, and probably rightly so, that a woman would feel like she's not going to be treated as an equal if she's complaining about health conditions and things like that. So yeah, I think that's wrong though. One thing that I really liked about this idea, it's so obvious in some ways, like I've heard of hot flashes. I didn't know how severe the symptom was but you know, for something that affects so many people you know, we have like other companies that are doing mattress cooling just because people don't like being hot at night, right? It seems so obvious to try to actually build this for a pretty severe medical condition. So often in startups, you think the obvious things have been done, and then you hear an idea, and you're like, wow, this is an obvious thing that should exist. Doesn't mean it'll be successful in it, but often I find that the obvious ideas are the big ones.
Rajat Suri: Yeah, it is obvious, you're right. And I think the key is getting to a scale that keeps the company interesting to both Loewen and her investors and not dying along the way. So that's going to be the key. It's great to see entrepreneurs trying to solve this problem. And I think Loewen is right about many things in that Women's health is very important and women are going to be at a very productive phase in their career during menopause and having them go through this is highly problematic from a society and productivity perspective. We should, as a society, want to solve this problem or make this transition easier.
Immad Akhund: Yeah, 100%. With that, I think we can end the podcast. Please subscribe and review us on whatever channel you're listening to us on. Thanks for joining as always.
Future of Women’s Healthcare and Biowearables with Loewen Cavill, Co-Founder and CEO of Amira