The research, published in BJOG: An International Journal of Obstetrics & Gynaecology, brought together evidence from 53 studies conducted across more than 20 countries to explore who is most and least likely to use HRT. Drawing on data from hundreds of thousands of women over several decades, the study is the largest review of its kind and offers a global snapshot of menopause care.
What emerges is a clear pattern of inequality. Across countries and healthcare systems, HRT use varied widely, but certain groups of women were consistently less likely to receive treatment. Ethnicity stood out as one of the strongest factors. On average, Black women were around half as likely to use HRT as White women, while women from other non-White ethnic backgrounds also had substantially lower uptake. These gaps persisted even when data from different regions were combined, suggesting that structural barriers – rather than individual choice alone – may be shaping access to menopause care.
Health conditions also played an important role. Women living with obesity, diabetes, or a history of stroke or venous thromboembolism were significantly less likely to use HRT. While caution is appropriate for some medical conditions, the authors note that modern clinical guidance recommends alternative HRT formulations for higher-risk groups. The findings therefore raise concerns that some women who could benefit from treatment may not be receiving it.
Dr Jenny Hirst, Senior Research Fellow in the Department and senior author of the study, said:
'Menopause affects everyone differently, but our findings show that who gets access to treatment is not equal. Too often, women’s background or health status appears to influence whether they are offered or take up HRT, rather than their symptoms and individual needs.'
In contrast, HRT use was higher among women who were already closely engaged with healthcare services. Women who attended regular gynaecology appointments or mammography screening, had previously used oral contraception, or were physically active were more likely to take HRT. Uptake was also higher among women with osteoporosis or depression, conditions for which HRT can offer important benefits. Together, these patterns suggest that awareness, healthcare access and continuity of care strongly influence whether women receive treatment during menopause.
The study also captures how attitudes to HRT have shifted over time. In older studies published before 2002, smoking was associated with higher HRT use. That link disappeared in more recent research, reflecting changes in prescribing practices following major safety studies and evolving clinical guidance in the early 2000s.
The authors emphasise that these differences in HRT use are unlikely to have a single explanation. Cultural beliefs, access to care, affordability, representation in menopause messaging and clinician confidence all likely play a role. In many settings, women from minoritised ethnic groups report feeling under-represented in mainstream menopause information, which may affect awareness, help-seeking and conversations with healthcare professionals.
As menopause gains increasing attention in public health and policy, the findings highlight an important challenge. While HRT can significantly improve quality of life for many women, this study suggests that those who might benefit most are not always the ones receiving it.
The researchers conclude that improving menopause care must go beyond increasing availability of treatments. Addressing gaps in HRT uptake will require better information for women, support for clinicians to make individualised prescribing decisions, and a stronger focus on equity in women’s health research and policy, particularly in low- and middle-income countries where evidence remains limited.
Read the full paper, 'Factors Associated With Hormone Replacement Therapy Use: A Systematic Review and Meta-Analysis' in BJOG: An International Journal of Obstetrics & Gynaecology.