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With her motto, “Sexual health is health,” Dr. Sally Greenwald aims to optimize orgasms for the women of Silicon Valley.

Sally Greenwald likes to say that she is the happiest gynecologist in America. She is certainly sought after, having attracted a following of high-powered Silicon Valley women of a certain age with her motto, “Sexual health is health.” Recently, Greenwald was the guest of honor at a small luncheon hosted by one of her patients, the tech entrepreneur and philanthropist Gisel Kordestani, in Atherton, California, one of the wealthiest towns in the country. The event took place in the stately, pillared home Kordestani shares with her husband, Omid, the former chairman of Twitter.

Kordestani, who has long, light-brown hair and was wearing platform Prada sneakers, apologized that her co-host, a fellow Greenwald patient named Nicole Lacob, who runs the philanthropic foundation of the Golden State Warriors (her husband, Joe, is the majority owner), wasn’t able to come at the last minute. She had flown to Paris to attend the début runway show of Matthieu Blazy, the new designer for Chanel.

The other women in the room murmured in understanding. Ranging in age from late thirties to mid-fifties, they were accomplished, confident—the kind of women for whom “Fake it till you make it” had long ago morphed into “Make it better and better.” When I moved to Silicon Valley from New York, fifteen years ago, I was astonished by the widespread conviction that everything—even one’s body, aging and mortality notwithstanding—must and will improve, like each new iteration of iPhone.

Greenwald, who is forty and has a spirited demeanor, perched on the edge of a chair, ready to field questions. “Use my brain!” she told the women, her high blond ponytail bouncing. “Meander me wherever you want to go.” The doctor, who grew up nearby, in Los Altos, fit in easily with the group. Her sparkling Jimmy Choo flats peeked out from under a long, rainbow-striped dress, and her language immediately signalled that she shares Silicon Valley’s obsession with optimization and innovation—“perseveration on perfection,” she calls it, a determination to bring the entrepreneurial mind-set into every aspect of one’s life. The women at the lunch were not content to enjoy good health; they were looking for a way to level up. (The latest term for this is “healthmaxxing.”)

One difference between Greenwald and the dozens of biohacking doctors who treat the area’s billionaire tech bros is that she wants to achieve this goal, in part, through orgasms. (Lube, she likes to say, is as essential to one’s routine as sunscreen.) Rather than concentrate on increasing life span, she focusses on what she calls a woman’s “sexspan.” Her concierge gynecology practice—which is situated on the Stanford campus, where she is an assistant clinical professor—views women’s sexual health as a way to well-being and, ultimately, to longevity. She makes the case that “bro science” culture typically relies on research that excludes data about women. (Rock-star longevity doctors like Peter Attia and Andrew Huberman come to mind.) Part of Greenwald’s approach involves using cutting-edge hormone therapy, among other interventions, in unconventional ways. She also counsels women to have more and better sex, devising stratagems like F*ck-It February, a prescription to have sex as often as possible in the year’s shortest month. New patients pay tens of thousands of dollars a year to join her practice, if they manage to get off of a wait list. Some have sought Greenwald out after hearing her speak at private gatherings hosted by fans like Priscilla Chan Zuckerberg. Last fall, after a fierce auction, Greenwald received a seven-figure book advance from HarperCollins. Sheryl Sandberg is writing a blurb.

Sandberg described Greenwald to me as “brilliant, energetic, passionate,” adding, “She’s unafraid to broach topics in ways that other people, I think, have been afraid to do.” In the past few years, as her wait list blew up, Greenwald started jokingly referring to her practice as the B.V.C.—the Billionaires’ Vagina Club. Some patients found the name amusing, but the billionairesses apparently did not. Greenwald stopped using it.

Seated in Kordestani’s grand living room, the lunch guests told Greenwald about their frustration with their primary-care doctors, whom they viewed as old-fashioned disease chasers. “I like biohacking,” Kordestani said, but complained that her doctors were dismissive. The women wanted physicians who were disease preventers, and doctors who were attentive to the difficulties wrought by menopause, which have been increasingly found to leave women vulnerable to other ailments. (I first met Kordestani at a book group that was reading “All Fours,” Miranda July’s 2024 novel about a woman teetering on the estrogen cliff of perimenopause, ditching her husband and child in the process. The book-club members roundly disliked it, indignant that the character was being driven mad by perimenopause, as if hormone-replacement therapy didn’t exist. Did July just have a bad gynecologist?)

Outside Kordestani’s glass doors, a gigantic inflatable flamingo moved back and forth in an infinity pool. Inside, one young woman asked Greenwald, “How do I know when I’m in perimenopause?”

“My goal is that my patients never know,” Greenwald answered, segueing to her enthusiasm for hormones. She told the group that she had several Olympic athletes as patients. As soon as their schedules for the 2024 Paris Games were released, she used an ovulation medication to synch their cycles so that they would compete on days nine through fourteen—the time when estrogen peaks and women are suffused with energy. In perimenopause, she said, the pattern shifts: fluctuating hormones can cause days and days of angsty P.M.S., followed by spikes of anxiety. “Fortysomething women can get quite a reputation,” she noted. “These are badass women like yourselves, who run companies, run households with a lot of children, have M.B.A. careers and whatnot, and all of a sudden they’re freaking out at everyone.

“I’m super excited about using hormones, maybe forever,” Greenwald went on. “I will humbly bow my head when the data come out to prove the opposite, but I really think we’re onto something.”

When she is talking about scientific innovations, Greenwald warns her listeners that she is prone to “go super dorky.” Although the women she treats are data-driven, they are impatient—unwilling to wait a decade for randomized controlled trials, then years more for prescribing habits to change and insurance companies to catch up. She makes treatment recommendations based on a combination of what she calls “biological plausibility”—a theory of why something would work—and new data. “There’s a lot of cool new meds on the market that I’m super excited about that few doctors are using,” she said. “But I am!

“I want to be very clear about when I’m speaking as a U.C.S.F.-trained physician with lots of randomized control trials behind what I’m saying, versus when I’ve entered the ‘woo-woo’ world of concierge medicine and I’m going into anecdotal evidence and observational studies,” she said, fluttering her hands. “You guys are a very smart room here.”

A woman mentioned that some of her friends were paying for their young daughters to freeze their eggs, as a graduation present.

“Super interesting! That’s a great idea!” Greenwald said. “This is my favorite example of population-based health versus concierge health.” Research shows that most women who freeze their eggs before the age of thirty-seven don’t end up using them. “But suppose we don’t care what the cost is?” Greenwald asked. The calculus becomes simpler. Everyone knows twenty-one-year-old eggs are better.

Cori Bates, a trustee of the Asian Art Museum who is married to the C.E.O. of the software company Genesys, leaned forward. Bates was wearing a scarlet dress and kitten-heeled flip-flops, and she spoke up to say that, after learning that she was at a high risk for ovarian cancer, she funded a study to assess whether risk for the disease can be reduced by removing one’s fallopian tubes.

Greenwald praised the study, and Bates took the opportunity to ask if the doctor would take her as a patient. Greenwald beamed: “I’m so, so flattered. I would love to. But I’m completely full.” She promised to try to find room for Bates in the future.

Someone asked Greenwald how she felt about hormone-monitoring apps, and she answered that the technology is not there yet and that the apps on the market are unreliable. She addressed her audience: “Please, make a good app for teen-age girls—and for perimenopause and menopause.” The women smiled, then everyone filed into the dining room. Greenwald left before dessert so that she could be home in time to meet three of her four sons at their bus stop.

Imet Greenwald three years ago, when she was consulting once a week for the primary-care practice where I was a patient. She strode into the room looking like a television doctor in a chic blue-print dress and flats. (She favors prints, she told me, because they disguise splashes of bodily fluid.) By then, I was skeptical of gynecologists. I had consulted three about insomnia, brain fog, and vaginal atrophy, which made sex painful and left me with recurrent infections, only to be told that the ill effects of menopause are just a “natural stage of life” which could not be medicated away. Then the doctors would bustle out to see their more appealing patients—the cheerily pregnant ones, whose deliveries constituted the bulk of their income and whose babies would be added to the collage of photos decorating their office walls. Greenwald told me that, even though I had been prescribed some hormones, she felt that I had been undertreated, because doctors often use hormones too sparingly; she prescribed five different forms of hormones to me, and my old life resumed.

I texted my middle-aged friends the details of my prescriptions: estrogen patch (estradiol, 0.075 mg.), vaginal ring (Estring, 7.5 mg.), estrogen cream (estradiol, 0.01 per cent), oral progesterone (Prometrium, 100 mg.), compounded testosterone cream (start at 1 mg., then move to 2 mg.—up to 10 mg.). They pressed their own doctors, who hedged or shrugged but eventually wrote the prescriptions for them. When my friends found relief, they were thrilled—and infuriated. Why were they getting this information from me and not their doctors?

For many women, menopause marks a retirement from active sexuality. They may still have sex, in the way a retired athlete may still throw a ball around the back yard, but the drive is gone. Greenwald wants to get these women back into the game, because research shows that a healthy sex life brings a variety of benefits that can contribute to longevity. Her methods combine treatments with sex tips. “How many sexually active years do you want to have?” she asks patients. “If having orgasms in your eighties is on your bucket list, you have to work at it.” A faltering sex life can also put a marriage at risk, and statistics suggest that people who stay partnered live longer. In the 2024 General Social Survey, nearly two-thirds of married adults reported having sex less than once a week, and twenty-eight per cent answered that they had sex rarely or not at all.

Women’s sexual health has been under-researched, and in recent years federal research money into women’s health issues has been slashed. But menopause is finally having a moment. Last November, the F.D.A. removed the “black box” warning (the agency’s strictest safety alert) against H.R.T., and earlier this month Melinda French Gates announced a two-hundred-million-dollar menopause- research initiative. A 2024 meta-analysis published by the Bulletin of the World Health Organization looked at sixty-three studies and found strong correlations among over-all health, well-being, and sexual activity. A study from the same year in the Journal of Psychosexual Health analyzed government data and found that women who had low sexual frequency had a forty-six per cent higher mortality risk. It seems obvious that healthier people might be more sexually active, but Greenwald believes that the association is bidirectional: that good sex leads to good health. Orgasms improve mental health, suppressing stress hormones like cortisol and releasing dopamine and oxytocin; women with robust sex lives report less depression and anxiety. Studies show that orgasms also relieve menstrual pain, lower blood pressure, enhance circulation, correlate with better cardiac functioning, and burn calories equivalent to thirty minutes of brisk walking. Orgasms also activate parasympathetic pathways that promote deeper and longer sleep. There are measurable health benefits to orgasms through masturbation, but those benefits compound in partnered sex, which supports satisfying long-term relationships, which in turn correlate with better health and longevity.

“The argument is not: sex equals longevity,” Greenwald said. “It is: sex equals sleep, stress reduction, cardiovascular engagement, relational fulfillment, and pelvic-floor health, and each of those equals health.” She likes to note, however, that sixty years after the so-called sexual revolution, the sex lives of straight women are hardly thriving. Whereas straight men climax in almost all sexual encounters, heterosexual women in relationships fail to climax a third of the time. The widespread assumption has always been that the female orgasm is innately tricky, but data show that lesbians climax almost as often as men do.

A number of Greenwald’s patients told me that they’d never had a gynecologist who thought of sexual satisfaction as a medical issue. But she considers sex coaching to be a part of her job, just as an internist might advise a patient with high blood pressure to get more exercise.

There is a girlfriendly “pass it on” quality to the way word has spread about Greenwald’s treatments, which include birth-control pills—such as Nextstellis and Natazia—that contain a new natural form of estrogen, not the synthetic formulation in most pills; compounded testosterone cream for a “kick-ass sex-drive booster”; magnesium glycinate for sleep; temperature-controlled mattresses; her preferred vibrator for postmenopausal women (a long-handled model with seventy-to-a-hundred-and-fifty-hertz frequencies); and silicone-based lube. Greenwald has been known to draw diagrams for patients, showing them how to find their G-spot.

“Experts describe sex in biopsychosocial terms,” Greenwald told me. “I tell my patients, ‘Think bio.’ ”

Nicole Lacob, the wife of the Warriors owner, started seeing Greenwald over a year ago, when she was fifty-six—just in time, in terms of starting hormone-replacement therapy. (For women more than ten years into menopause, H.R.T. can boost mood, libido, and bone health, but it also presents cardiovascular risks, among others.) “I wish I’d had her when I was forty-five,” Lacob said. At the time, she recalled, she was too depressed to even shower: “I was crying over things all the time, and I had no idea that it was even perimenopause.” Lacob was seated with her legs tucked underneath her on a fluffy couch in the living room of her Mediterranean-style estate. She has a cascade of dark hair, and wore platform Uggs. (At Warriors games, she is often seen on camera dancing in glittery thigh-high boots beside her husband.) “I think I would probably even look ten years younger now if I had had her then,” she said.

Lacob had always liked the house warm—she used to tease her husband that, if he ever wanted to see her naked, he’d need to keep the heat cranked up. Suddenly, she was always too hot and couldn’t sleep because of night sweats. She’d had breast cancer in her thirties and, consequently, had been warned away from H.R.T., which has been thought to be unsafe for cancer patients. But Greenwald explained that there is only a modest increased risk of recurrence. (This is a controversial position and one that many oncologists oppose, in the belief that data are still emerging and that even a modest risk is not worth taking.) She prescribed an estrogen patch to alleviate the night sweats and an estrogen ring, which is placed inside the vagina and releases local doses of the hormone. “Then Sally asked me questions that I never thought to ask myself, um, regarding desire,” Lacob said.

“I was shell-shocked the first time,” Nathalie Dompé, the Italian-born head of a pharmaceutical business and the wife of the tech entrepreneur Chamath Palihapitiya, told me, laughing at the memory of just how graphic Greenwald’s questions can be. “The best part is when I go home and repeat all my new learnings to my husband, who looks at me, shocked.” She appreciated the way Greenwald “puts it on the radar and says, ‘This is part of how you take care of your life.’ ”

Isat in on one of Greenwald’s appointments, with a patient I’ll call Kristen, the wife of a celebrity. She had been suffering from depression and mood swings triggered by the hormonal fluctuations of perimenopause. She confessed that she sometimes found “the mental load of being a mom”—she has teen-agers—almost unbearable. Greenwald had been treating her for a few years, and they were, Greenwald said, “making progress as a doctor-patient couple.” She had evened out Kristen’s cycles with birth-control pills, and Kristen’s mood and energy had improved. She’d even picked up some old interests again, like exercise and crafting. But not sex.

Greenwald hears this story again and again. After they became mothers, her patients tell her, their focus transferred from their romantic lives to their children. Kristen’s husband’s life was full of glamour and limelight, whereas her life was all behind the scenes. He was taking testosterone to keep up his physique; his libido was stronger than ever. But satisfying him felt like one more chore.

Seeing Kristen’s shoulders slump, Greenwald smiled. “When you’re, like, ‘Help a sister out with her sex life,’ know that you’re in good company.” Greenwald said. “Just imagine my very sexy life with my four kids and three jobs!”

Kristen said that when she accompanies her husband on work trips without the kids, she feels pressure to be a sex goddess. “I can tell, after the first night, that he’s thinking, That was fun, but no one was swinging from the chandelier,” she said. She missed having “the desire for more spontaneous, fun, crazy sex.” When she was younger, alcohol helped, but these days drinking made her fall asleep more than it loosened her up.“I still like my guy, and I think he’s cute,” she said shyly. “And I want him to only be with me.” But she said that, when he asks if she wants to have sex, it seems that he’s not really asking about her desires. She feels like saying, “No, I don’t. And now you’re annoyed because that was the least sexy answer I could give. But your question was manipulative.”

Greenwald jumped in, completing Kristen’s thought: “Does it look like I want to have sex? I’m sitting here ordering groceries. What about me ordering groceries says, ‘I want to have sex’?”

Then Greenwald made a characteristic pivot. In fact, she always tells patients, any time is a good time to have a certain kind of sex—what she calls “efficient sex.” She believes that the best way to improve sex is to drop the romantic notion that it requires a special frame of mind. Better to have a quickie, even if you’re reluctant, because an orgasm can improve your mood, and ultimately your health and your relationship.

“I’m not going to talk about chandelier sex,” Greenwald added. “That’s a good hobby, and, if you have that, rock on.” She continued, “We’re going to stick to super-heteronormative, vanilla, white-picket-fence sex that has data behind it.” She had suggestions on how Kristen could “curate” her own arousal. Spontaneous desire, she said, disappears in eighty-five per cent of women in partnerships after about eighteen months. But women retain responsive desire—which comes from being stimulated, or from stimulating themselves. “If I were to write a porn for women in our forties, fifties, and sixties, it would start with a vibrator and some lube.” Think of it like exercise, she said: you never want to do it, but, once the trainer arrives and you begin, you get in the mood.

Kristen nodded: “Before my trainer gets there, I’m, like, F*ck you!”

Greenwald went on, “But why do you show up? You’re thinking, Once I start to exercise, I know how good I’ll feel afterward.” She counselled Kristen to hop into bed with a vibrator, then, after warming up, text her husband and ask him to come to the bedroom for a few minutes.

“I know that you’re, like, That doesn’t feel sexy,” Greenwald said. “But it’s showing up at the party, even if you don’t think you want to go, and then having a good time.” She continued, “I know it’s awkward in the MeToo era.” She realizes that her message—“Just try it, even though you don’t want to”—can sound retrograde, misconstrued as an update on “Close your eyes and think of England.” But, for a middle-aged woman in “a committed relationship with a nice partner,” she believes that it’s a sound approach to improving a couple’s sex life.

Greenwald told Kristen that she needed to do some cognitive reframing. “Instead of asking, ‘Do you want me?’ ”—an epic question, requiring an epic answer—“couples should practice asking, ‘Hey, do you have five minutes?’ ” Sex, Greenwald often says, begets more sex. Her date-night tip: when out to dinner with their husbands, women should carry some travel-sized lube and pop into the ladies’ room to apply it right before dessert. “It’s hard to walk around with a wet vagina and not feel turned on,” she said.

One of Greenwald’s strategies is getting patients to practice inwardly narrating the sequence leading up to sex: He’s rubbing my back. I’m breathing a little faster. I feel warm. The goal is to banish the more common inner-mom monologue: He’s touching me. Did I remember those snacks for tomorrow? How will my daughter feel if no one asks her to prom? As with meditation, Greenwald said, patients gain control over their thoughts: “If it’s a Tuesday night before sports pickup, this is how you create good, efficient bedroom sex with your spouse that doesn’t involve a whip and leather boots.”

To keep the routine going, she advises couples to replace postcoital sweet nothings with compliments like “I love how efficient we were!” The idea is to tap into “that reward system where you have sex, you sleep well, you wake up more energized, you guys kiss before he goes off to work, you feel more loved by him, and the next night happens.” Describing why Greenwald’s methods work, Nathalie Dompé reached for an Italian phrase, “La fame vien mangiando”—the hunger comes while you’re eating.

It’s no surprise that expensive concierge medical care is better. It’s a particularly distressing example of how, in our society, necessities are becoming luxuries. Concierge care is innately problematic; when the wealthy can buy their way out of public-health problems, it reduces pressure to fix them. Gynecologists typically book fifteen-minute appointments: five minutes to do a breast exam and a Pap smear, five minutes to talk, and five minutes to document the visit. Greenwald gives patients as much time as they need, often an hour or two per visit.

“I think the system is broken,” she told me. Greenwald’s medical career was a form of response, stemming from her own experiences. When the COVID-19 pandemic hit, she felt herself beginning to crack.

Growing up near Stanford, in a close-knit family, as the granddaughter of a Stanford doctor, Greenwald had a vision of herself being an ob-gyn at the university—delivering babies at the same hospital where she was born—and having four sons. She became chief resident at the ob-gyn program at the University of California, San Francisco, and married a pediatrician, Daniel Imler. Throughout the eighty-hour workweeks of the residency, where she was permitted to take off only a month after the birth of her first son, she found herself going against protocol to co-sleep with the baby, because it was the only time she saw him. Passionate about health equity, she did a master’s degree in public health at Tufts, but she became disenchanted with the population-based approach it taught: she saw suboptimal high-volume care, in which the health of the individual was sacrificed to cost considerations, everywhere.

Medicine suited her personality. “I’m a little hyper, driven, anxious,” Greenwald told me. “But it works in medicine, because I am always worrying about excellence, perseverating on my patients.” In a public-health setting, that was the wrong mind-set. Only easy patients got good care, because time-consuming workups or expensive tests—let alone innovation—were prohibitive.

At thirty-two, Greenwald joined a Stanford health-care practice made up of four women and a man in Menlo Park. There, she saw up to twenty-five patients a day. She and her partners were perpetually overworked, and there was tension in the group because they had to cover for one another if they or their kids were sick. Back-to-back overnights left Greenwald exhausted and depressed.

When she was thirty-six weeks pregnant with her second child, Greenwald was in the middle of a seventy-two-hour shift—subsisting on saltines and cranberry juice between deliveries—when she went into premature labor. “He went home at four pounds,” she recalled, of her son. When COVID began, she discovered that she was pregnant again. Wearing an N95 mask so that she could nap in the hospital during patients’ long labors, she was anxious about her fetus.

At one point, the head of the practice asked Greenwald to pay special attention to a wealthy patient, and so, for once, she was able to practice medicine the way she wanted to, spending extra time on the case and catching issues that might have gone unnoticed. Greenwald wasn’t able to give herself, or her regular patients, that level of care. After overnight deliveries, she would find herself driving home too fast in order to get there in time for her husband to leave for work; she would remind him to give the boys the breakfast she had prepped the night before and to get them to preschool, and then she’d try to squeeze in a twenty-minute nap before returning to the office. One day in 2022, she fell asleep at a red light with her boys in the back seat and finally decided to quit her job. But she needed to work, and she still wanted to practice medicine. By then, her husband was the medical director of Stanford’s Pediatric Emergency Department, but they had little savings. Their money had gone into a cozy Craftsman house in Menlo Park, and repaying medical-school debt and the salary for their nanny ate up the majority of Greenwald’s take-home pay.

Greenwald decided to open her own concierge gynecology practice with no obstetrics, initially setting a thousand dollars a year as a membership fee. Hers was the only such practice in the area, and she didn’t know if it would work. On the side, she consulted for primary-care concierge practices and spent three days a month at Santa Clara Valley Medical Center, teaching and delivering babies for underserved populations, a commitment that she has continued.

At her own practice, she decided that patients would never wait, that she would be available from 6 A.M. to 9 P.M., and that she would never have to cancel because she was delivering a baby. The office would provide spa-fluffy robes, heated towels, and premium teas. She would answer texts and calls at all hours, including on weekends, and would travel to patients’ pool houses for a quick infection check or meet them on the tarmac when they flew, in a private jet, up from L.A.

Greenwald obtained medical licenses in New York and Florida so that she could take care of patients’ extended families. She sees her patients’ adolescent daughters, arranging anesthesia for IUD placements (prescribed to treat painful periods)—something that is rarely done, even though the insertion can be excruciating. She advises inexperienced teen-agers that lubes containing additives are dehydrating and create micro-abrasions that can increase the transmission of S.T.D.s, and she helps them navigate hookup culture, in which choking, polyamory, and anal sex have become mainstream. Ella Hale, a recent college grad who started seeing Greenwald at fifteen, told me, “She said, ‘If you feel any psychological or physical discomfort during sex, I want to know.’ ”

Greenwald tracks all of her patients’ metrics: blood tests to check that hormones are balanced; Oura rings to show resting heart rates and sleep scores; glucose monitors to keep tabs on blood sugar; food-tracking apps for logging daily protein targets. She sends them to get thousand-dollar Grail blood tests (the fact that they are not covered by insurance is not an issue for the B.V.C.), which may detect cancer years before it appears on any scan, and full-body MRIs (two thousand dollars), and she reminds them to pick up sunscreen on vacations abroad, because European formulations are more effective than what we can get here. Because there is heart disease in Gisel Kordestani’s family, Greenwald referred her to a preventative cardiologist who had her take the Cleerly cardiovascular test, an A.I.-based analysis of heart CT scans which yields new insights. Kordestani told me that she didn’t care about wasting time or money: “Now I know my cardio risk is zero.”

Greenwald focussed on optimizing her own well-being, too, waking at four-thirty to work out, and then answering patient e-mails while sipping bone broth or water mixed with psyllium husk (for fibre) and creatine. She attended conferences and pored over the latest research.

She had a fourth son, and her time felt more valuable than ever. She raised her prices a few times. Consultations became a thousand dollars, then two thousand. She decided to accept new members with tiered annual fees, starting at ten thousand dollars and exceeding thirty thousand for the most extensive care, which can involve assembling a specialized care team to monitor complex comorbidities. Then she stopped accepting the ten-thousand-dollar patients. What was the market price for this kind of care, she wondered. The influencer and doctor Peter Attia has a longevity practice with patients who pay six-figure membership fees. Clearly, there was room to keep going up.

One afternoon, I sat in on another appointment of Greenwald’s, this time with a patient in her fifties who had been diagnosed with early-stage breast cancer. The woman, whom I’ll call Lily, was agonizing between having a lumpectomy, which would entail taking the estrogen-blocking drug tamoxifen for five years, or getting a double mastectomy. Her oncologists were hedging, telling her that it was a personal choice. She knew that tamoxifen would curdle her sex life by inducing abrupt menopause; she was already struggling with symptoms of perimenopause, which her primary-care doctor had dissuaded her from treating.

Lily had an active life of golfing, skiing, and boating with her family. In the examining room, she sat on the table with Dior sunglasses perched on her head, wearing a ruffled, checked blouse and jeans—a California trad-wife look. Greenwald got her talking about her life, and her hopes for grandchildren one day. After a moment’s thought, Greenwald told her to do the lumpectomy—and the tamoxifen, which would cut the chance of cancer recurrence in half. She surprised Lily by recommending that she simultaneously do hormone therapy—a vaginal application, such as estradiol cream—to mitigate her symptoms. “Take some tamoxifen and know that, if you need a partner to respond to whatever shitty symptoms you’re dealing with, I’ve got you,” she said. “We’ll be creative.” She offered to send Lily a new academic paper on H.R.T. and cancer risk. If Lily ended up losing her sunny disposition, Greenwald said, they could explore solutions, such as Duavee, an estrogen replacement now in trial with high-risk women; contrary to conventional wisdom, emerging data seem to indicate that this form of estrogen is associated with a decrease in breast cancer.

“Duavee is blowing my freaking mind,” Greenwald said.

While mainstream oncology supports using local vaginal hormones that have little systemic absorption (although some doctors remain reluctant), the use of systemic hormones for women who have had breast cancer is contentious. “This is a Pandora’s box,” Mark Moasser, a U.C.S.F. oncologist and cancer researcher, told me. “It remains a field with different data sets and studies and different opinions and judgments. There shouldn’t be a ‘one size fits all’ guideline. It’s a matter of judgment between the doctor and the patient. I can’t say it’s ‘safe’ because we simply don’t know.”

Having dealt with Lily’s cancer questions, Greenwald pivoted to her sex life. Was it A+? Greenwald suddenly included me in the conversation, breezily asking, “Do you two have internal orgasms?” Lily and I both looked at her, agog. Greenwald has a crisp, matter-of-fact manner. With her practiced explanations and gestures, she could almost be a flight attendant explaining preflight safety protocols.

Only one in five women climax through internal stimulation alone, Greenwald said. Many never find the mysterious G-spot. But the G-spot becomes increasingly important in middle age, because women can’t rely on their old sexual responses to stay the same. “The clitoral nerve has two different nerve fibres, right?” Greenwald went on, as Lily and I nodded dumbly. This nerve root runs both internally and externally, ending in the clitoral nub, and it contains two different types of fibres, one of which responds to light touch and warmth, and another that senses vibration and pressure. But as we age, she noted, the fibre that responds to light touch and heat degrades, whereas the one that senses vibration and pressure maintains sensitivity. After menopause, with insufficient estrogen to nourish the tissue and facilitate blood flow, the clitoris starts to lose its sensitivity, resulting in poor-quality orgasms. (I had never heard of poor-quality orgasms.)

“So you’re going to come in here at some point, be it on your tamoxifen journey or when you’re eighty-five, and say, ‘We’ve done this position for forty years, and now it isn’t working.’ ” Greenwald counsels women to practice finding the G-spot and stimulate the deep internal nerve fibres that remain robust.

“Do you have a vibrator?” she asked Lily. The answer was an enthusiastic yes, and Greenwald offered to provide instructions for exercises to try at home. If the G-spot proved elusive, Lily should come back and Greenwald would show her where it is. Wrapping up, Greenwald said, with feeling, “I support you and your energy and your sex life and your orgasm quality and your vagina and your pelvic floor.” She looked Lily in the eye to make sure she heard it. Her parting words: “I’m on your team.”

With four boys under the age of nine, Greenwald has organized her family life so that it functions like a well-run startup. One night, she invited me to her house for dinner. Wearing sweatpants and a T-shirt, she jiggled her plump baby and showed me a mudroom where each of the boys has a cubby near a refrigerator that holds their lunches. “I am obsessed with systems,” she said. Outside the mudroom is a large touch screen that her sons are supposed to stop at and check off tasks on a schedule (“Eat breakfast and clear dishes.” “Sit on toilet and count to 30!”); each time, the screen rewards them with an explosion of confetti. Greenwald coaches the boys on social behavior: “Look at Melanie when you talk! Can she see your eyeballs?”

The house is colorful, with wallpaper covered in giant leaping zebras. One of her sons showed me his pet rabbit; another introduced a large parrot squawking in a cage. There is also a lizard, four hermit crabs, a toothed frog, and a wall-size fish tank that the kids built with their father; its filtration system is based on the workings of a kidney. Greenwald’s husband had just returned from a monthlong stint in Rwanda, teaching pediatric urgent care. Their nine-year-old had joined him, playing the role of patient. Like his wife, Imler is plainspoken and believes in cutting to the chase. “Sometimes I hear doctors cloak the news of a child’s death in so much flowery language that the parents don’t grasp what’s happened,” he told me.

Imler said that he admired how Greenwald likes to talk about “difficult things with people because it feels real”; he is amused by what he described as her impatience with fiction and art. “Her response to ‘Phantom of the Opera’ is ‘There’s a phantom—why are we singing about it for hours? Put him in jail!’ ” He thinks that part of her appeal to patients is that she is unfazed by their net worth. “Sally will not bow to you,” he said. “And people love that.”

Greenwald regularly gets together at a restaurant with concierge-doctor friends. At a recent gathering, over drinks and meze, they talked about the coolest new things they are doing for their patients. Justin Lotfi, a primary-care physician to a fortunate few, offered that he’d been experimenting with a nasal procedure using an anesthetic that, with repeated applications, can break a cycle of migraines.

“I love being in concierge medicine, because practicing at the top 0.001 per cent—that’s where innovation happens,” Greenwald told me. “I get to sit around and think about these things.” She went on, “I am always, like, ‘What’s next? What’s better? Why don’t we try this?’ ” She added, “But at some point the system needs to evolve so other people can access this kind of care.”

Midi Health, a virtual-care platform for women in menopause and perimenopause which was founded in 2021, offers the same sorts of hormone treatments that Greenwald does, including options for cancer patients, and it accepts insurance. Joanna Strober, the entrepreneur behind Midi, supports Greenwald’s approach, but told me, “I am sad that women believe they have to pay all that money to get menopause care.” She added that Midi does most everything that Greenwald does “without the in-person component.” When Strober was raising money to start Midi, male venture capitalists told her that menopause was “niche”; now Midi has a billion-dollar valuation.

To help close the gap in medical care, Greenwald is trying to publicize her ideas, through her book and public speaking. Last fall, she was a guest on Peter Attia’s popular medical-and-life-style podcast, “The Drive.” When she got to the importance of lube for vaginal health, Attia pushed back, repeatedly questioning whether young women needed lube, since reduced friction might detract from a man’s enjoyment of sex. Greenwald held firm. The episode ended up having “The Drive” ’s highest ever Day One-download count on Apple metrics. Three months later, when a batch of files about Jeffrey Epstein was released by the Department of Justice, Attia’s name turned up more than seventeen hundred times. In one bit of banter from 2016, Attia e-mailed Epstein, “Pussy is, indeed, low carb. Still awaiting results on gluten content, though.” In another exchange, Epstein muses to Attia that he’s not sure why “women live past reproductive age at all.”

After the Epstein news broke, the Post published a snarky piece about Greenwald’s episode of “The Drive,” and internet critics piled on. Greenwald declined to comment on Attia, with whom she shares patients, but said that she is eager to engage with the manosphere, including on platforms associated with toxic masculinity. That, she said, would be “a great way for me to push this agenda to an audience that is not typically listening. If there are chances to spread my message that sexual health is health, I’ll take that opportunity every time.”

But the president of the central bank said she would stay on during turbulent times for the eurozone economy

European Central Bank President Christine Lagarde said she won’t rule out leaving her position early to offer her voice in the French presidential election in 2027.

When asked by French business newspaper Les Echos if she would take part in the French political debate if geopolitical turbulence eases, Lagarde said: “It’s possible.”

“I believe that a European voice needs to be heard in the French presidential debate,” she said in an interview published late Thursday and posted on the ECB website.

“If this debate were to reveal a more limited vision of France’s place within Europe, I think it would be necessary to explain why that would be a painful path for our country and for our fellow citizens,” she added.

Incumbent French President Emmanuel Macron’s second term finishes next year, with contenders to replace him potentially emerging from far-left and far-right parties skeptical of more European integration. Central-bank chiefs typically steer clear of discussing politics directly.

Former Bank of France Governor Francois Villeroy de Galhau this year left his post early, allowing his replacement, Macron ally Emmanuel Moulin, to be selected before next year’s presidential election.

Speaking to The Wall Street Journal in February, Lagarde dispelled speculation that she would resign early after reports that she could leave to run the World Economic Forum.

However, Lagarde repeated previous comments that she would stay on during a difficult environment for the eurozone’s economy.

“Given that we are once again going through a turbulent period, I believe the captain of the ECB ship must stay on board,” she told Les Echos.

The central bank last month raised its key interest rate after surging energy prices due to the closure of the Strait of Hormuz pushed inflation higher.

But some economists have argued that the ECB raised borrowing costs unnecessarily given that oil prices have returned to prewar levels after the ceasefire agreement between the U.S. and Iran.

“We are confident that we made the right choice,” Lagarde said. “All the data we have received since then have confirmed our analysis.”

The company is looking at options that could continue to build its hematology franchise and targets in solid tumors too

French drugmaker Ipsen IPN -0.23%decrease; down pointing triangle sees gaps in its portfolio and has the financial means to fill them, its chief business officer said, signaling more deals are in the pipeline after a pair of acquisitions this week.

The Paris-based company this week reached agreements to buy Kartos Therapeutics and Memo Therapeutics for a combined sum that could exceed $2.55 billion if targets are hit, adding drug candidates for a rare blood cancer and a viral infection common in kidney transplants.

Ipsen’s chief business officer, Philippe Lopes-Fernandes, said the company is working on deals to continue to build its existing franchises in oncology, rare diseases and neuroscience.

“We have a lot of firepower left,” Lopes-Fernandes said in an interview.

The structure of this week’s acquisitions—with fixed initial payments that represent a fraction of the total potential price, and the rest subject to hitting certain development, regulatory and commercial goals—means the company can still fund more, Lopes-Fernandes said.

After both deals, Ipsen is expected to end the year with a gross cash position of about 1.5 billion euros ($1.72 billion), and net cash of around 500 million euros, according to an estimate by analysts at RBC Capital Markets.

Ipsen, like many of its bigger rivals, sold its consumer-healthcare arm years ago, honing its focus on more lucrative—but also riskier—innovative specialty-care medicines. The company typically goes after niche disease indications.

Oncology is Ipsen’s biggest business by sales, with more than two-thirds of the group’s total, and the company is expanding into blood cancers through deals like Kartos and last year’s purchase of ImCheck Therapeutics.

“We are building this [hematology] franchise and we are looking at a few things that could continue to build that,” Lopes-Fernandes said. “But we have very good expertise in solid tumors and we are looking at targets there.”

In rare diseases, Lopes-Fernandes said Ipsen is trying to widen its portfolio beyond liver drugs. The segment—assembled mostly through dealmaking—is the group’s fastest-growing, thanks to the rising uptake of two medicines for rare liver diseases that were approved in recent years.

“We are going to continue to see what we can add to rare liver [diseases], but we are looking at adjacent areas,” he said.

For neuroscience, Ipsen relies mainly on its internal research-and-development efforts, but Lopes-Fernandes said the company might pursue select transactions to strengthen its pipeline.

Several big drugmakers have set their sights on China to secure rights for innovative ideas for medicines to treat cancer, obesity and other diseases. Lopes-Fernandes said Ipsen has been active in the country in the past and is evaluating a few potential deals right now, but that competition from big pharma companies has pushed up the price of Chinese assets.

“We don’t make it such a priority as other companies, first because we have the luxury not to need to do hundreds of deals every year, and also because we have a strong belief that there’s other places, like Europe for example, where there’s very interesting innovation,” Lopes-Fernandes said.

The Louis Vuitton Dolomites Classic Run will culminate with a parade on the Autodromo circuit at Monza.

PARIS — Louis Vuitton is ready to hit the open road again.

The world’s biggest luxury brand will stage a 600-kilometer classic car run in Italy in September to coincide with the Formula 1 Italian Grand Prix, reviving a tradition that had been dormant since 2012.

Pietro Beccari, chairman and chief executive officer of Louis Vuitton, said one of the first events he took part in after joining the brand in 2006 as marketing and communications director was the Boheme Run between Budapest, Vienna and Prague.

Since 1993, Vuitton has showcased “the art of travel” with automobile excursions to destinations including the Malaysian jungle, the rice terraces of the Yunnan region in China, and the vineyards of Tuscany.

Ever since returning in 2023 to take the helm of the brand, following stints as CEO of Fendi and Christian Dior Couture, Beccari has dreamed of staging another classic car rally. Parent company LVMH Moët Hennessy Louis Vuitton’s 10-year sponsorship deal with Formula 1 provided the perfect foil.

“It’s very important to reiterate our link with the automobile world, which dates back to the birth of automobiles, because in fact Louis Vuitton trunks were the tool boxes and the spare tire boxes of the modern car at the time — so actually there is a link which is absolutely meaningful,” he told WWD.

“I thought that this was a good year to really insist on this message,” Beccari added.

The house is inviting the owners of 25 classic cars to take part in the Louis Vuitton Dolomites Classic Run. It will depart on Sept. 1 from Villa Pisani near Venice, and arrive on Sept. 4 in Monza, where the cars will parade on the Autodromo circuit during the opening of the Grand Prix.

They will spend two days crossing the Dolomites, taking in scenic vistas of alpine passes and lakes. The region, which returned to the global spotlight during the 2026 Milano Cortina Winter Olympics, means a lot to Beccari.

“I have a house in the Dolomites, and I love to go there whenever I can. It’s my place of heart,” he said, noting that a 2024 Vuitton campaign featuring Rafael Nadal and Roger Federer was shot near the Aman Rosa Alpina hotel in San Cassiano, where the race participants will stop over.

“So there are many memories that tie me, not only personal, but also now workwise. It’s going to be fantastic and the Dolomites are a UNESCO World Heritage Site. Not everybody knows them,” Beccari noted. “It’s going to be also the occasion to reinforce the visibility and awareness of this mythical place.”

Vuitton is collaborating with leading Italian heritage sites to add a cultural element to the proceedings.

The race will be the first event held at Villa Pisani in Stra, along the Riviera del Brenta, following the completion of its renovation works. Beccari has personally called on Massimo Osanna, the head of national museums at Italy’s culture ministry, to ensure the location is ready on time.

“Venice is very dear to our house,” he said, noting that Vuitton opened a shoe factory in Fiesso d’Artico, a stone’s throw from the villa, in 2008. “Fiesso d’Artico is a jewel of the Italian industry of shoemaking, and a symbol of our savoir-faire, and Villa Pisani is a great patrimony of the Venetian heritage.”

Guests and journalists will have an opportunity to visit both sites, as well as Milan’s Castello Sforzesco, where the prize-giving ceremony will be held, and the Villa Reale in Monza, where the cars will be on public display on Sept. 5 and 6.

Participants will have to stick to an average speed of below 50 kilometers an hour, on roads open to regular traffic, and will be submitted to time controls, passage checks, average speed trials and regularity trials.

The trophy, designed by Dutch artist and designer Sabine Marcelis, will be produced by Murano glassmaker Venini and will be presented in a Louis Vuitton trunk — epitomizing its “Victory travels in Louis Vuitton” slogan.

Beccari said Bugatti, Maserati and Ferrari will be among the featured car models, all of them manufactured up to 1970. While the race will be free to join this time around, going forward, collectors will be asked to contribute a participation fee, he said.

Vuitton, which is active in disciplines ranging from soccer to sailing, has been racking up high-profile sports deals, cementing its positioning as a “cultural” brand as consumers switch their focus from status-conferring luxury goods to once-in-a-lifetime experiences.

Its link with the automobile world dates back to 1897, with the launch of Georges Vuitton’s pioneering Malle Auto car trunk made of durable Vuittonite canvas. Vuitton subsequently took part in competitions like the 1908 New York to Paris Race, and cemented its association with the sport by partnering with the Automobile Club de Monaco in 2021.

“I see a natural link of sharing codes and also a set of values with our clients,” said Beccari, noting that classic cars attract a passionate audience. “It’s like a club of initiates, but there is a following which is far beyond the people that can afford the cars.”

While he admires classic cars from afar, Beccari may honor Monza’s passionate Ferrari fan base by riding in one of its cars. “I will go on the safe side,” he quipped.

U.S. startups announced sizable funding rounds at a steady clip during a truncated holiday week, with energy and AI leading the way.

Houston-based energy startup Joulent secured the biggest round, a $1.75 billion strategic financing, followed by Together AI, a developer of infrastructure for companies running open source AI models, and LeapXpert, a provider of compliance tools for enterprises.

Other big rounds were for companies focused on therapeutics, homebuilding, and even lacrosse.

1. Joulent, $1.75B, energy: Houston-based Joulent, a provider of energy infrastructure focused on the demands of artificial intelligence and other compute-intensive industries, raised $1.75 billion in a strategic investment backed by National Grid through its National Grid Ventures arm.

2. Together AI, $800M, AI infrastructure: Together AI, developer of an infrastructure layer for companies running open source AI models, secured $800 million in Series C financing. Aramco Ventures led the round, which set an $8.3 billion post-money valuation for the San Francisco-based startup.

3. LeapXpert, $180M, compliance: LeapXpert, a provider of tools for tracking enterprise communications for compliance needs, closed on $180 million in growth financing. Riverwood Capital led the financing for the New York-based company.

4. 8090 Solutions, $135M, AI software development: Redwood City, California-based 8090 Solutions, developer of a platform for building enterprise software with coordinated AI agents under human-led oversight, picked up $135 million in a round led by Salesforce . The company, founded in 2024, counts prominent startup investor Chamath Palihapitiya as co-founder and CEO.

5. Beeline Medicines, $126M, biotech: Boston-based Beeline Medicines, a startup focused on precision therapies for autoimmune and inflammatory diseases, secured $126 million in Series A extension funding backed by Bain Capital, CPP Investments and Bristol-Myers Squibb. The financing follows a previously disclosed $300 million Series A.

6. (tied) Premier Lacrosse League, $100 million, professional sports: The Premier Lacrosse League, a men’s professional lacrosse league in North America, closed a $100 million Series E financing round led by Ares Management and Joe Tsai. New York-based PLL said the deal represents the largest capital raise in the history of professional lacrosse.

6. (tied) Twelve Labs, $100M, video-based AI: Twelve Labs, a San Francisco-based startup developing AI systems trained on video archives, raised $100 million in a Series B round co-led by New Enterprise Associates and Naver Ventures.

8. Higharc, $95M, AI for homebuilding: Higharc, a developer of AI-enabled tools for designing homes and managing workflows around homebuilding, picked up $95 million in Series C funding. Insight Partners led the financing for the Durham, North Carolina-based company.

9. Flare Therapeutics, $85M, biotech: Cambridge, Massachusetts-based Flare Therapeutics, a startup targeting transcription factors to develop treatments for cancer and other ailments, raised $85 million in Series C funding led by Third Rock Ventures and Nextech Invest.

10. Venice, $65M, AI privacy: Venice, developer of a platform enabling private, surveillance-free access to a wide array of AI models, secured $65 million in Series A funding led by Dragonfly. The round set a $1 billion valuation for the 2-year-old Sheridan, Wyoming-based startup.

Key Points

Chancellor Friedrich Merz and his senior Social Democratic partner, Labor Minister Bärbel Bas, were quick to endorse a 33-point blueprint released by the blue-ribbon Pension Security Commission on June 23. The plan indexes retirement age, currently 67 for most workers, to increasing life expectancy and ends an early-retirement option for those in the workforce for 45 years.

Most important, it ushers in mandatory contributions to personal retirement accounts that will be invested in securities markets, the so-called Swedish model. Employees and employers will each kick in 1% of salary after a four-year phase-in period.

That’s not all. This spring, Merz’s government enhanced incentives for tax-advantaged private pension savings. The two initiatives together could pump a gross 80 billion euros ($91 billion) annually into capital markets, calculates Jan Schildbach, head of financial markets research at Deutsche Bank macro research.

“All of a sudden, this makes German savers also investors,” adds Carsten Brzeski, global head of macro for ING Research.

It has also set off a scramble among asset managers for a piece of the pending action. “Every provider is working on a product offering,” Schildbach says.

Merz could badly use a reset after 14 months in power. The world’s No. 3 economy remains stuck around pre-Covid levels in real terms. The Dax 40 stock index has barely budged since he assumed the chancellorship in May 2025, while the S&P 500 has climbed by a third.

The 70-year-old German leader has been slammed by circumstances beyond his control: The U.S.-Iran war delivered a fresh energy shock. Germany’s vaunted auto makers keep wilting before Chinese competition. Volkswagen CEO Oliver Blume upstaged the government’s pension announcement, flagging 100,000 pending job cuts and the closure of four German factories.

Merz and the government have made things worse by letting red tape tie up their signature infrastructure program, says Robert Timper, global fixed-income strategist at BCA Research. “Payouts have been limited by bureaucratic processes,” he says.

Pension reform might just mark the start of a comeback, argues Marion Mühlberger, Deutsche’s head of European policy research. The government already passed a phased-in 5% cut in its corporate tax rate, which is the highest among large European economies. It’s wrangling over an income-tax revision that could save middle-income earners €450 a year. “This shows the government is embarking on structural reform,” she says.

“Germany absolutely has a path to a turnaround,” agrees Eoin Drea, senior researcher at the Wilfried Martens Centre for European Studies. Government debt remains by far the lowest among large advanced economies at just over 60% of gross domestic product. That leaves plenty of space to keep pumping up infrastructure and defense. German companies are global leaders in growth industries including green technology (Siemens Energy), semiconductors (Infineon Technologies), and pharmaceuticals (Merck).

Merz’s problem is that the turnaround could take more time than he has before facing voters again by March 2029, moving at Germany’s congenitally measured pace and with the Alternative for Germany, or AfD, party gaining strength to his right. “It’s very hard to see that this government will last long enough to reap the benefits of structural reforms,” ING’s Brzeski says.

The pension contributions are an engine that should only accelerate over time, though.

Cheap Drones Are Upending the Defense Sector. These 4 Battle-Tested Stocks Are Leading the Charge.

The Iran war proves that America’s ability to spend heavily on elaborate weapon systems no longer cuts it in conflicts dominated by cheap drones.

Key Points

• Cheap drones, exemplified in Ukraine and Iran, are challenging the U.S.’s traditional military dominance based on expensive, high-tech weapon systems.
• The U.S. is rapidly increasing drone investment, with the DAWG budget rising from $225 million to $55 billion, fostering new defense industry opportunities.
• While drone start-ups thrive, traditional defense firms adapt via venture funds and focus on advanced autonomous platforms like CCAs and subs.

Cheap drones have tilted the battlefield against America’s high-cost military.

For decades, the U.S.’s ability to spend the most on the best, most exquisite weapon systems led to American military hegemony. In the air, the F-22 Raptor fighter jet, costing some $150 million, can knock threats to a billion-dollar B2 Stealth Bomber jet out of the sky before the enemy sees either plane, while Patriot missiles, costing $4 million a pop, destroy enemy cruise missiles aimed at U.S. bases or allies.

At sea, the U.S.S. Gerald R. Ford aircraft carrier, costing $13 billion and powered by two nuclear reactors, can launch hundreds of missions a day, while multibillion-dollar nuclear submarines carry cruise missiles 1,000 feet beneath the waves. And on land, M1 Abrams tanks, costing millions, can fire three-foot-long shells at the enemy while rolling 40 miles an hour, protected by multiple layers of armor including ultradense depleted uranium.

But if the wars in Iran and in Ukraine have taught the U.S. anything, it’s that all this military firepower doesn’t assure battlefield domination. Cheap drones, often costing as little as $10,000, now make it possible to hold superpowers at bay for years or drive them to the negotiating table to end an unpopular war.

In Ukraine, homegrown drones have destroyed thousands of Russian tanks and military vehicles, killed tens of thousands of troops, and turned the Russian invasion into a multiyear stalemate. In Iran, Shahed drones managed to shut the Hormuz Strait—the world’s most important transit point for oil—by making the risk of crossing too high for tankers. And the U.S. has been unable to destroy all the decentralized manufacturing for the Shahed—it’s like trying to swat 100% of the flies at a summer picnic.

Iran’s victory, and it should be considered a victory given the regime’s survival, ability to control the strait and world energy prices despite being pummeled by the U.S. and Israeli militaries, shows that the Pentagon needs to adapt—and adapt fast.

A host of new companies are going to help the U.S. fill the gap, gunning for business that traditional defense companies can’t—or don’t want to—fill. Drone-focused start-ups will compete with old-guard defense companies to provide the weapons of postmodern war, upending what was once a straightforward sector for investors. Companies with the ability to move quickly, adapt and keep costs low should thrive, while those that can’t could struggle in the years ahead. Suppliers able to boost output to meet insatiable demand for parts, displacing parts coming from China, will do even better.

“You’re looking at a step change in military philosophy,” says Bill Birmingham, managing director at Rex Shares, an asset management firm offering the REX Drone exchange-traded fund, which is down about 7% since the ETF launched in late October. The push for American “drone dominance has opened the door to so much innovation.”

Just how much that innovation is needed has been on display in Iran. While the U.S. and Israel were able to kill key political and military leaders, knock out conventional defenses, and destroy the Iranian navy, they couldn’t prevent Iran from using homegrown drones to terrorize Gulf states and shut the Strait of Hormuz. Iranian drones left America unable to keep oil flowing from the Middle East without a peace deal, imperiling the world economy.

The cost advantage of the new weapons of war is too big to ignore. The U.S. fired hundreds of million-dollar interceptor missiles in days, which will take months to rebuild, leading to fears of depleted stocks, denials of depleted stocks, deals to expand missile production, and the president invoking the Defense Production Act. It is a contributing factor to President Donald Trump’s proposed $1.5 trillion fiscal 2027 defense budget, up about 50% from the 2026 defense budget.

In July, Defense Secretary Pete Hegseth unveiled America’s plan to achieve dominance by quickly getting drones into the hands of the American soldier. His announcement followed Trump’s July executive order calling for American industry to beef up its manufacturing capabilities. The Defense Autonomous Warfare Group, or DAWG, which was created through a Biden-era drone initiative originally called Replicator, is set to see its budget explode from $225 million in fiscal year 2026 to $55 billion in fiscal year 2027.

William Blair analyst Louie DiPalma estimates the U.S. market size for lower-cost drones at nearly $100 billion annually, including those that can still be carried by a soldier. There will be additional spending for more sophisticated drones, including General Atomics’ Predator and Reaper, and Boeing’s new autonomous Ghost Bat, a collaborative combat aircraft, or CCA, being developed with the Royal Australian Air Force to fly recon or bombing missions with or without manned fighter jets.

Even before the war with Iran started, a group of companies gathered in February at Fort Benning in Georgia to compete in a drone competition, Gauntlet I, designed to put low-cost, one-way attack drones into the hands of American soldiers.

The winner wasn’t American. It was Shrike, a first-person-view strike drone that uses a 12-mile fiberoptic tether to prevent jamming and provide the operator with clear imagery. It was built with Ukrainian drone tech and scored a near-perfect 99.3. Ukraine is making millions of drones a year and could make millions more if the parts were available.

Still, “despite four years of unprecedented visibility into Ukrainian battlefield innovations, and the recent war in Iran, Western forces have not institutionalized key lessons into doctrine, force structure, or procurement priorities,” says Mick Ryan, senior fellow for military studies at the Lowy Institute, an Australian think tank.

For the U.S., building drone-war dominance must start at home. To jump-start that initiative, the U.S. government banned nonmilitary drones from DJI, a Chinese manufacturer with 70%-plus market share. The ban wasn’t to protect America from the security risks of using Chinese technology, but to signal to American industry that the time had come to make, rather than import, the devices that will determine the outcome of conflicts in the coming age.

“We need to be a great manufacturing superpower,” says Ethan Thornton, founder of privately held Mach Industries, which uses flexible manufacturing to produce drones and munitions. “The gap between us and China is only increasing.”

A host of companies—new and old—will be vying to become those manufacturers. Many of them are private. Entrepreneur Palmer Luckey’s Anduril is the most valuable privately held defense start-up and aims to be the department store for the U.S. military, building weapons with off-the-shelf commercial technology, including drones.

Shield AI is merging artificial intelligence “hive-mind” tech with low-cost drones. Los Angeles-based Neros Technologies took second place in Gauntlet I with its Archer quadcopter. The U.S. military has deployed Virginia-based Napatree Technology’s drone interceptors to hunt other drones.

Investors have more than enough drone stocks to choose from—at least a dozen—but the best stocks are likely to be from the drones that have been battle-tested, says Byron Callan, managing director at Capital Alpha Partners. “The Good Housekeeping seal of approval is if [the drones] have actually been used in Ukraine.”

Four meet that threshold: AeroVironment, Aevex, Red Cat Holdings, and Swarmer. The latter three are recent start-ups, with the potential to grow into big business, but the risk that comes with companies that are only beginning to boost revenue.

Swarmer, which is connected to Blackwater founder Erik Prince, builds artificial-intelligence-based command-and-control software to link drones, letting one operator command an autonomous swarm. Its tech has been deployed hundreds of thousands of times in missions for Ukraine. Swarmer, which went public in March, has a market capitalization of $500 million and trades at 20 times 2027 revenue of $25 million. Only one analyst, Lucid Capital Markets’ Alex Fuhrman, covers Swarmer shares. He rates the stock Buy, and his $60 price target suggests a 33% rise from a recent $45.

Aevex’s Phoenix Ghost provides a kamikaze drone capable of loitering for up to six hours in the air while it waits for a target to appear. The company, which has a market value of $2 billion, went public in April, and its shares have traded in a range from roughly $17 to $42.

Part of the issue is the boom/bust cycle of Ukrainian demand. Roughly 50% of Aevex’s sales of $606 million will come from Ukraine in 2026, but those sales could dry up in 2027, according to Jefferies analyst Sheila Kahyaoglu, as Ukraine turns from a drone importer to a drone exporter. Despite the loss of Ukrainian business, Aevex’s sales are still expected to grow more than 10% between 2026 and 2027. Aevex is the cheapest of the four at roughly 30 times estimated 2027 earnings, and all nine of the analysts who cover the stock rate it a Buy.

Red Cat, which went public in 2021, makes reconnaissance drones, first-person-view attack drones, and drones that work when GPS doesn’t. Its maritime division also makes the Variant 7 maritime drone, which was modeled on Ukrainian technology. Red Cat trades at eight times 2027 sales of $218 million, and all the analysts covering the company rate the shares Buy. Clear Street analyst Brian Dobson sees the company benefiting from the DJI ban, and his $19 price target, up from a recent $10.50, is 10 times his 2028 sales target.

AeroVironment, which went public in 2007, was one of the first American contractors to bring hardware to the front lines. Its Switchblade loitering munitions have helped take out Russian tanks and other weapons, while its Raven and Puma drones provide real-time intelligence for warfighters on the battlefield. It is expected to have sales of about $2 billion in calendar year 2026 and $2.4 billion in 2027, and 17 of the 20 analysts who cover the $8 billion company rate its shares a Buy.

AeroVironment also has the benefit of making antidrone technology, which is becoming as important as drones themselves. That includes everything from radar jamming to edge computing—which untethers enemy drones from GPS—to low-cost drone interceptors. AeroVironment’s Locust lasers have already been deployed in Iran. The ‘directed energy’ weapon, which can be used on ships or mounted on a truck, can burn through the hull of an incoming drone. “We probably are pretty close to Star Wars…I don’t know how long before it’s hand-held,” says Adrian Helfert, chief investment officer of wealth manager Westwood Group.

Ondas is another beneficiary of higher spending on antidrone technology. Its reusable Iron Drone Raider system literally catches incoming drones in a net. It also supplies radio-signal jamming technology. Oppenheimer analyst Tim Horan rates shares Outperform and has a $16 price target, up from a recent $9, valuing the stock at about 17 times estimated 2027 sales. It isn’t expected to be profitable until 2029.

But with technology changing so quickly, buying suppliers, in a picks-and-shovels approach to the drone sector, may be the best way to bet on the nascent drone technology in the U.S., says Jefferies’ Kahyaoglu. Two of her favorites are diversified defense prime contractor L3Harris Technologies and Kratos Defense & Security Solutions. L3 is spinning out its missile business in an IPO expected later this year. That will give investors a new company that makes missile hardware, electronics, and solid rocket motors. Kratos is a drone leader, developing the XQ-58A Valkyrie, a collaborative combat aircraft, which won’t be disrupted by new start-ups making lower-cost guidable munitions. It also makes propulsion systems for drones and missiles.

Kahyaoglu’s target for Kratos is $80, up more than 50% from a recent $51. Kratos stock, at 50 times estimated 2027 earnings, trades like a high-growth drone company. L3 trades like a traditional defense prime at a reasonable 22 times.

Two start-ups supplying parts are Arxis and Applied Aerospace & Defense. Arxis makes highly engineered electronic and mechanical parts for any drone or missile platform. Wells Fargo analyst David Strauss rates Arxis stock Overweight and sets a $52 price target, up from a recent $46. He calls the company a “purpose-built industrial compounder,” meaning he expects it to parlay its cash flow into acquisitions to drive higher growth. It is priced for growth, with shares trading for about 54 times estimated 2027 earnings, which are expected to double from 2026.

Applied Aerospace, which completed its IPO in early June, supplies structural components for companies that make autonomous weapons systems. It’s so new that Wall Street hasn’t yet picked up coverage. Shares have struggled out of the gate, trading for a recent $18, below the IPO price of $20.

While the Iran war has put the spotlight on the shiny new toys, it also revealed the limitations of the established defense companies. Between the end of February and Trump’s June 14 announcement of an Iran memorandum of understanding to end hostilities, Lockheed Martin and Northrop Grumman stocks were down 18% and 14%, respectively. The iShares U.S. Aerospace & Defense ETF fell 4%, while the S&P 500 rose 8%.

Part of the problem is that the stocks were already priced for a lot of good news—the iShares ETF was up 57% in the 12 months before fighting in Iran broke out. The war also raised Democrats’ odds of retaking part of Congress in midterm elections, which could generate pushback on ever-rising military spending.

Iran’s Shahed drones might deserve credit for the declines, too. Just how many $30 million tanks does a military need if they can be ‘neutralized’ with a $5,000 quadcopter? A lot. While money will go to new drones, there will still be plenty for more advanced jets, ground vehicles, and boats.

“Views that drones will massively displace spending on manned platforms ignore institutional and political biases on military power,” says Capital Alpha Partners analyst Byron Callan. “Israel, Russia, and Ukraine, which are the three most drone-savvy militaries, aren’t abandoning manned weapons.”

That leaves a lot of potential upside for the traditional defense giants, which might not be able to—or want to—compete with start-ups rushing to strap explosives to quadcopters. The Air Force, for instance, plans to buy thousands of collaborative combat aircraft, sophisticated autonomous wingmen assisting manned fighter jets, helping maintain American air dominance. Autonomous subs and ships are also on the Navy’s docket. Many of those will be made by the usual suspects, including Northrop, Lockheed, and Boeing, with parts supplied by RTX and others.

While defense contractors might not be able to move at the speed of start-ups, they have capital, helping them function like a technology incubator. Lockheed has a venture fund, which has helped seed more than 120 companies since its founding in 2007. Lockheed recently increased the size of its fund from $400 million to $1 billion.

“Our investments help create a pipeline of cutting-edge technologies that create a resilient industrial base, drive growth, and ultimately help the United States and its allies deter the most pressing emerging threats,” says CFO Evan Scott. That fund has helped make Lockheed a favorite of Westwood’s Helfert, who recommends the stock.

Ultimately, war is a never-ending race to achieve technical superiority over the enemy. Drones of all shapes and sizes for land, sea, and air will proliferate for decades.

As the war with Iran has highlighted, the drone wars are just beginning