📱💊 Will digital birth control grow beyond the first 1%?
Spilling the tea on femtech digital therapeutics potential
Hello and welcome to Careviser by Marie Loubiere. Years of research summarized in 5-minute emails. Spot emerging opportunities in healthcare.
There are a lot of jokes in pop culture about premenstrual syndrome (PMS). So far it’s been hard to measure if it’s a cultural thing because periods are stigmatized, or if it’s real. Once again, digital health companies have stepped in to offer a first answer…
Pierson, E., Althoff, T., Thomas, D. et al. Daily, weekly, seasonal and menstrual cycles in women’s mood, behaviour and vital signs. Nat Hum Behav 5, 716–725 (2021).
🗝️ Why it matters: Menstrual cycles affect half of the world’s population. As hormones vary through the cycle, women suspect that their moods, behaviors and vitals are impacted. However, as each cycle is individual (beginning, length) it has been very hard to measure it over large samples across regions and seasons in a precise way. Enter period tracking apps such as Clue (who employs/ consults two of the authors) and now we have a way to make the analysis.
🔎 The study: Using Clue, and 499,000 of its users who have entered 88 million data points across at least 12 months. The analysis is based on:
4 types of temporal cycles: menstrual, daily, weekly, seasonal
3 dimensions of behaviors: sleep, exercise, sexual activity
9 dimensions of mood
3 vital signs: resting heart rate, basal body temperature (i.e., the temperature measured in the morning when the user wakes up), weight
✅ Findings:
The menstrual cycle has a greater impact on mood, behavior, and vital signs than all the other temporal cycles (e.g., 3x the amplitude of the weekly cycle). It is also more impactful than “temporal outliers” such as Christmas Day which makes most users happier.
The authors also show that a decrease in happiness occurs before the start of the period in all countries. PMS is not a cultural thing after all.
🚀 Opportunities ahead: Studies of changes in mood, behavior, or vital signs should track menstrual cycles because their results can be significantly impacted by it, and conclusions altered subsequently. This is something researchers are used to doing with general temporal cycles (e.g., they know moods are lower in winter and at night) and they should collect data for the menstrual cycle to make their analysis more reliable.
There are two main reasons why women use period tracking apps:
Birth control (focus of today’s article)
Improving the odds of getting pregnant
When you look at these two use cases, it seems like the potential market for period tracking apps is huge. However, they currently account for less than a percent of birth control methods used by women. Why is that?
📜 Until very recently, Natural Cycles was the only application certified as a birth control medical device. It is certified in the US, Europe, and Australia. Clue was cleared by the FDA earlier this year.
🤒 Natural Cycles birth control algorithm requires the user to take their basal body temperature most days. It means that when the user wakes up, the first thing they have to do is to take and log their temperature. They cannot even stay awake in bed or go to the bathroom as it may affect their temperature. Only a limited number of women are disciplined and motivated enough to do that daily. The app then classifies days between red and green. On red days, users have to abstain from sex or use a condom. The pill is also pretty restrictive as it requires the patient to take a tablet every day. However, if they forgot to take it, they still have 12 hours ahead. Also, any day is a green day. Apps are a high maintenance method of birth control which in my opinion restricts the potential size of the market.
➡️ Clue presents itself as a more user-friendly app. Users don’t need to input their temperature. It only needs to know the first day of each cycle. However, it means that there are more red days which makes it even more restrictive and increases the odds of women having unprotected sex on a red day because they forgot to check the app. It also means that women with irregular cycles or not enough historical cycle data cannot use the app. Overall it is slightly less effective than Natural Cycles.
💵 Cost: Birth control apps are not reimbursed, even by private payers. So the user has to pay around 50 US$ a year for something they could have their health insurance cover.
⭐ Reputation: Birth control apps are definitely not popular among healthcare providers. Their perfect use scores are pretty high (Natural Cycle: 98%, Clue: 97% +), but their typical use scores are way lower (Natural Cycles: 93%, Clue: 92%) meaning that a number of women do not follow the instructions for use (as they are hard to comply with) and are at risk of an unwanted pregnancy. That being said, their typical use numbers are similar or slightly higher than the pill or contraceptive patches. Also, birth control apps suffer from the bad reputation of traditional natural contraception methods which do not include algorithms tailored to the real cycle of each woman and thus have a high failure rate.
The billion-dollar question: can birth control apps get better?
💍 The first obvious improvement is temperature measurement. Natural Cycles is integrated with a few bluetooth devices (e.g., the Oura ring) which means that women do not have to manually take and input their temperature in the app. That’s a significantly better experience but a. it’s expensive. An Oura ring costs more than US$300. b. the user has to wear and charge a device regularly which is a huge constraint.
💰 Reimbursement: it would for sure increase the size of the addressable market
👨🏼⚕️ Educating healthcare providers about their benefits, and developing tools to help them assess if a patient is a good fit for the method.
🚫 But generally, there is no way around the fact that birth control apps can only get better at narrowing which days a woman is fertile. Biologically, even if they can perfectly pinpoint the 5-6 days a month a woman can conceive, users will still have to abstain or have protected sex on these days. The question is: for what for % of women is that constraint too high to consider apps as a sustainable birth control option?
Finally, business-wise, given that women in their fertile years make about 25% of the population. Even if digital birth control only fits 10% of them, that’s still a potential of a billion market in ARR for Europe and the US only.
That’s a wrap for today! Don’t hesitate to reply to this email with comments, I read and answer all emails :)