Women from Black African backgrounds are almost six times less likely to receive hormone replacement therapy than white women, and those in the most deprived areas are half as likely as those in the most affluent, according to the largest study of HRT prescribing inequalities in England.
The research, led from our department and published in BMJ Medicine and funded by the National Institute for Health and Care Research, analysed GP records for 1.98 million women aged 40–60 and reveals large, measurable gaps in HRT access that persist despite government commitments to ensure menopause support "benefits all women, regardless of socioeconomic background or ethnicity."
The findings come at a crucial time, as tackling health inequalities in women's health has been made a key government priority for 2024-2025, with ministers acknowledging the £11 billion annual cost of women's health conditions to the UK economy.
HRT uptake ranged from just 3.9% in Black African women to 22.6% in white women, and from 10.9% in the most deprived areas to 24.2% in the most affluent. Overall, 19.2% of women received two or more HRT prescriptions during the study period (2013–2023).
The study provides the first national, individual-level evidence across nine ethnic groups of who receives HRT in England – giving commissioners the granular data needed to target support and reduce unwarranted variation.
London had the lowest prescription rate (11.7%), with all other English regions significantly higher after adjustment for age, ethnicity and deprivation.
Clinical consequences revealed
Crucially, the research uncovered a treatment-type gap with direct clinical consequences: women in more deprived areas were significantly less likely to receive transdermal HRT (patches or gels) compared with oral preparations – despite having higher underlying cardiovascular risk, where transdermal HRT is often clinically recommended.
In adjusted analyses accounting for age, deprivation and region, all minority ethnic groups had lower HRT prescribing than white women (adjusted hazard ratios 0.85–0.92). While gaps have narrowed slightly since 2016, they persist throughout the study period.
The research also found that more women from minority ethnic groups, and from deprived areas, received only one HRT prescription and did not continue, signalling potential barriers at both initiation and follow-up.
Dr Jennifer Hirst, Nuffield Department of Primary Care Health Sciences, University of Oxford, and lead author, said: "These findings show that the women who may need HRT most – those with higher cardiovascular risk – are often the least likely to receive appropriate treatment. This demands urgent system-level action."
Dr Hirst added: "We now have the detailed evidence that policymakers and NHS commissioners need to tackle these inequalities head-on. These aren't just statistics – they represent many thousands of women who could benefit from better access to menopause care."
Dr Sarah Hillman, co-author, GP and associate Professor of Women's Health and Primary Care, University of Birmingham said, "This study highlights the need for holistic, culturally sensitive and timely menopause care for all women."
Policy implications
The research suggests that making HRT more accessible and affordable – while important steps – may not be sufficient to close inequality gaps without targeted interventions addressing system-level barriers.
These barriers may include differences in how women access consultations, awareness of treatment options, cultural factors, and variation in clinical decision-making across different communities and regions.
Dr Hirst said: "The ethnic disparities we've documented help NHS commissioners to know where they might need to focus interventions. Women from minority ethnic groups face barriers not just in accessing HRT initially, but in continuing treatment – giving us a clear roadmap for targeting support where it's most needed."
Why this matters
HRT is an effective treatment for troubling menopausal symptoms, prescribed based on individual need and preferences. The research provides commissioners, clinicians and communities with the evidence to focus outreach, information and service design so that women who could benefit from HRT can access it equitably.
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Funding & collaborators:
NIHR Research for Patient Benefit (NIHR204901). Collaborators included the University of Birmingham and Queen Mary University of London.