Menopause Hormone Therapy Use Has Fallen to a Fraction of Those Who Might Benefit

Use of menopausal hormone therapy has fallen steeply over the past two decades, dropping from around 4.4% of women in 2007 to 1.7% by 2023. Even among women aged 50 to 59 -- the group for whom the benefit-risk balance is most favourable -- only about 3.5% were using it.

How the collapse happened

The fall traces back to the initial reporting of the Women's Health Initiative in 2002. The trial's early results were communicated as a broad warning about breast cancer and cardiovascular risk, and prescribing dropped sharply within months. Subsequent analysis complicated that picture considerably: the average participant was well past menopause when treatment started, in her sixties rather than her fifties, and the risks reported did not transfer cleanly to a woman starting treatment as her symptoms begin.

What the current position is

Professional bodies now take a more nuanced line, generally holding that for women under 60 or within ten years of their final period, and without specific contraindications, the benefits of systemic hormone therapy for troublesome vasomotor symptoms outweigh the risks. Hormone therapy remains the most effective treatment available for hot flushes and night sweats, is first-line for genitourinary symptoms in its low-dose local form, and prevents the bone loss that accelerates after menopause.

Risk that is still real

It is not risk-free, and the caution applies to specific situations rather than to everyone. Formulation, dose, route of administration and timing all change the calculation -- transdermal oestrogen, for instance, carries a different clotting risk profile from oral. A personal history of breast cancer, of oestrogen-sensitive cancer, of venous thromboembolism, or of unexplained vaginal bleeding all require specific assessment.

The gap this leaves

Menopause lasts years and its symptoms are not trivial. Disrupted sleep, cognitive complaints and vasomotor symptoms affect work and relationships, and a substantial number of women reduce their hours or leave work over them. A treatment that works, being taken by under 4% of the group most likely to benefit, describes an information problem rather than a clinical one.

Bottom line

If menopausal symptoms are affecting your life, hormone therapy is worth a proper conversation -- one that covers your own history, the formulation and the route, rather than a headline from 2002.