If I were a middle-aged man suffering from erectile dysfunction, I could walk into my neighborhood pharmacy and buy a 30-day supply of Sildenafil (the generic for Viagra) for $8.67 out of pocket, and, no, that’s not the insurance copay. That’s the basic cash cost, with a coupon.
A menopausal woman in search of affordable estrogen, however—a requirement not just for her sexual health but for her overall health and well-being—is both a victim of decades of medical ignorance and a cog caught in the wheel of a deliberately confusing grift foisted on her by the pharmaceutical and insurance industries. Not only will many of our doctors be completely ignorant of the benefits of estrogen to alleviate our symptoms, but we will spend hundreds, if not thousands, of dollars on it per year. And that is if we can even procure a prescription.
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Urologist Kelly Casperson, MD, author of You Are Not Broken, finds the whole estrogen racket both infuriating and confusing to her, too. Though she is a well-informed doctor with excellent health insurance, her local pharmacy recently tried to charge her a $265 copay for generic estradiol cream, a local vaginal estrogen. “I know enough,” she said, “because I prescribe this every day, that I pulled up my GoodRx app, typed in the pharmacy, and it was $28. I showed them that and said, ‘I wanna pay the $28 cash price.’ They said, ‘Yep, no problem.’ So number one, my insurance wanted me to pay $265! Number two, the pharmacy isn’t helping me out, right? But I had to know that.”
Before we get into the wheres and hows of procuring affordable estrogen, let’s first define our terms. There are two types of estrogen therapy:
Systemic estrogen: Systemic hormone therapy goes through the whole body and requires progesterone as well, if you have a uterus. (If you do not have a uterus, then you do not need progesterone.)
Local vaginal estrogen: This estrogen stays locally in the vagina and does not require progesterone, whether or not you have a uterus.
“It’s really important that we understand the difference between systemic hormone therapy and local vaginal hormones,” says Rachel Rubin, MD, an activist and urologist who provides clear, frequent, and detailed information about menopausal hormone therapy (MHT) over her social media channels. Rubin believes that every person born with a uterus should receive three prescriptions at their annual physical upon turning 45: one for a colonoscopy, another for a mammogram, and a third for local vaginal estrogen. It was through Rubin, in fact, that I first learned I needed estrogen. No, she’s not my doctor. She read a story I published at the beginning of Covid, in which I mentioned my recurring UTIs in passing, and she reached out to me over Twitter and changed my life.
“Systemic hormone therapy, often called hormone replacement therapy [HRT] or menopausal hormone therapy,” says Rubin, “is given to people who are bothered by hot flashes or night sweats, or are looking for osteoporosis prevention. Local vaginal hormones are used to treat genital and bladder tissue, which is very sensitive to the lack of hormones in menopause. People complain of urinary frequency and urgency, vaginal dryness, and pain with sex, and get recurrent urinary tract infections, which can really cause harm to people’s bodies.”
To give you an idea of what monthly systemic and local vaginal estrogen costs look like on a personal level—because each woman’s needs and symptoms can vary as widely as her insurance coverage, her medical history, and the costs of medications where she lives—allow me to present my own body’s particulars and monthly costs as a typical example.
I just turned 57 years old, I live in Brooklyn, New York, and after years of suffering through adenomyosis, I no longer have a uterus. I am covered by a laughably bad state-sponsored health insurance with a $6,100 deductible. Before starting on estrogen, I was plagued by migraine headaches, hot flashes, brain fog, mood swings, loss of bone density, thinning vaginal tissue, and recurring UTIs. To combat these, I take three types of estrogen, one systemic and two vaginal. (Minus a uterus, I do not need to pay extra every month for progesterone.) My systemic estrogen is called Divigel, a gel I put on my thigh once daily after a shower. Because I recently had to switch my insurance from bad to worse, its cost shot up from an insurance copay of $35 a month to a whopping $144. My two vaginal hormones, which I plan to take “until death do us part”—as Rubin suggests—are as follows: a generic estradiol vaginal tablet, which I insert with an applicator into the vaginal canal three nights a week ($35 for 36 tablets, so approximately $11.67 a month); and a daily generic estradiol cream, like the one Casperson uses, which my doctor just added after my UTIs started coming back. (Falling in love in one’s 50s, while a miracle, can also be a health hazard.) I smear a hefty dose of this cream all over my urethra, labia minora, and vaginal opening every night. I paid a $104.88 insurance copay last month for a tube that should last me three months, so let’s call that $34.96 a month.
That’s $190.63 per month for medications without which I cannot have comfortable sex, physical well-being, or a productive and symptom-free life. At one point last year, I considered flying to Paris to purchase a year’s supply of my menopause medications. When I did the math, factoring in staying with a friend for free, I came out ahead, with plenty of money left over for croissants.
The next important factor to understand about estrogen is that in the U.S., you will need a prescription for both types of estrogen, even though vaginal estrogen is safe enough to be purchased over the counter. The UK, for example, has been providing vaginal estrogen over the counter since September 2022, a move the British Menopause Society called a “landmark reclassification.”
How do you get your prescriptions for either vaginal or systemic estrogen? Several ways. You can visit your own doctor and simply hope they will prescribe it, but many, including gynecologists and urologists, have never had a single lecture in menopausal medicine and may be both ignorant of menopausal symptoms and their treatment and/or misled by decades of misinformation.
The better in-person option is to specifically seek out a menopause specialist in your area, if one exists. My own menopause specialist, gynecologist Molly McBride, MD—whose care I sought after speaking with Rubin—just started a new company, Slán NYC, dedicated solely to the treatment of menopause and its many symptoms.
McBride will also treat any patient from anywhere in the U.S. via an initial half-hour telemedicine consult for $350. Charges after that, she says, will vary by what’s needed, and there may be no further charge. To alleviate these costs, she will attempt insurance prioritization to cover some or most of it. But since practicing menopausal medicine is still an uphill battle with insurance companies, McBride knows she’s in for a fight, albeit one she’s willing to take on for the sake of her patients.
Recently, two excellent but slightly different female-founded online telemedicine start-ups—Odela Health and Midi Health—also launched to help those born with uteruses navigate hormone management in menopause. The difference between Odela and Midi is this: Midi will work with your insurance company to bring down the costs of both systemic and vaginal estrogen, while Odela—a great option for those without insurance or with bad insurance—does not work with insurance and offers local vaginal estrogen, not systemic, at cost. But please don’t be put off by paying for vaginal estrogen out of pocket. As Casperson proved so well, sometimes this is still the cheaper option. It really depends on the vagaries of your insurance coverage and local pharmacy prices.
“We charge zero dollars for a consultation and unlimited follow-ups,” says Ashley Winter, MD, chief medical officer of Odela Health. “We make our money from fulfilling the medication, which costs $49.99 for the first tube (a two-to-three-month supply), and 50 percent more after that.” Winter, a urologist, joined Odela out of sheer frustration from working within the traditional medical system and a desire to make vaginal estrogen accessible and affordable to all, even those with poor or no health insurance. “Every single day, I found myself prescribing vaginal estrogen and enthusiastically having to peel back decades of fear mongering and misunderstanding regarding the risks associated with this medication. Literally every day. But it was overwhelming. The issue felt insurmountable.”
Midi, by contrast, offers online video visits as well but charges for the visit and lets local pharmacies fill the prescription. Joanna Strober, Midi’s cofounder and CEO, says, “The visits are usually covered by insurance, although there is also a self-pay option. When covered by insurance, the cost varies based on the insurance copayment and the deductible, but most women pay less than $40 for their visit. Midi then sends the prescription to a local or online pharmacy, and the medications are covered by insurance as well.” Strober says an estradiol patch, a systemic estrogen, is their most popular choice, and they can usually work with insurance companies to get the copay for that down to around $15 to $20 a month. They will also work with your insurance to get the cost of progestin down to $10 per month with insurance. But again, this depends on the insurance and what each company covers.
For people like me with bare-bones, state-run health insurance and a giant deductible, it makes more sense to pay out of pocket for my estrogen. In fact, it was only in doing the research for this story that I realized I am spending far too much on estrogen copays every month. And I cover this kind of stuff for a living! If it’s been hard for me to navigate this non-transparent system and obtain affordable estrogen, I can only imagine what it’s like for everyone else.
Billionaire Mavericks owner Mark Cuban understands this deliberate obfuscation of drug prices all too well. That’s why he started Cost Plus Drug a little over a year ago, to provide “safe, affordable medicines with transparent prices.” He realized he could both be a healthcare activist and turn a respectable profit. “Women’s health is a specific focus of CostPlusDrugs.com,” says Cuban, whose company also sells affordable birth control. “We consider it critically important to provide as many branded and generic medications dedicated to women as we can.”
The cash prices of generic medications on Cost Plus are often lower—far lower—than an insurance copay for the exact same medication. How? Simple. Cuban purchases generic medicines in bulk directly from the manufacturer, cutting out the middlemen. Then he marks up the cost of each drug by 15 percent—a fair profit—and charges a $3 pharmacy fee and a $5 shipping fee. For the sake of transparency, he publishes all these numbers in an easy-to-read graphic pasted directly below each drug.
Take the generic estradiol cream for which Casperson’s pharmacy tried to charge her a copay of $265. That same vaginal estrogen, on Cuban’s website, costs a grand total of $20.48. Out of pocket! Not a copay! Here’s the breakdown: $15.20 to manufacture it, $2.28 for Cost Plus Drug’s 15 percent profit, $3 for pharmacy labor, and $5 to ship that UTI-busting, vaginal-tissue plumping, lubrication-aiding miracle straight to your door. Minus a 1,000 percent markup.
Even better? “Hopefully, by the time you read this,” Cuban wrote me, “we will be announcing our first branded medications for women’s health!”
Excuse me while I swoon. Yes, with Cost Plus, you will still need to work with your doctor to get your prescription filled, whether in person or over telemedicine, so the cost of those visits have to be factored in, but the minute I finish filing this story, I know what I—with my lame state health insurance and tendency toward recurring UTIs—am going to do. I’m going to contact my beloved gynecologist, and I’m going to ask her to help me find a less costly generic substitute for my systemic estrogen, which will save me that steep $144 copay every month. Then I will set up an online account with Cost Plus Drug and pay for my new systemic estrogen plus my two vaginal estrogens out of pocket, instead of paying the high copays with my current pharmacy and high-deductible insurance.
But that’s just me, and I want to stress that. Depending on where you live, whether you have access to affordable menopausal specialists, what your insurance covers, whether you even have insurance, how high your deductible is, which estrogens you can take—those with hormone-receptor-positive breast cancer, for example, cannot take systemic estrogen, but they can and often should take vaginal estrogen—whether you still have your uterus or not, and the various prices for those estrogens at your local pharmacy, you might be better served by Slán, Odela, Midi, or some other option altogether. I don’t know, and ultimately I can’t tell you until you do some digging into your policies, pharmacies, and health history yourself.
And that, in the end, is both the crime against one-third of all Americans with uteruses and a critical issue of equity: this deliberate complication of what should be so simple. We have a right to our basic health and well-being during and after menopause. And we shouldn’t have to be confused about how to acquire it—or go broke trying to pay for it.
Any content published by Oprah Daily is for informational purposes only and does not constitute medical advice, diagnosis, or treatment. It should not be regarded as a substitute for professional guidance from your healthcare provider.
Deborah Copaken, author of Ladyparts, is a New York Times bestselling author of seven books and the Substack Ladyparts.
In a refreshingly candid conversation with Oprah Daily Insiders, Oprah, Maria Shriver, Drew Barrymore, and doctors Sharon Malone, Heather Hirsch, and Judith Joseph, we set the record straight on all things menopause. Become an Oprah Daily Insider now to get access to this conversation and the full “The Life You Want” Class library.
