Rising Demand for Menopause Hormone Therapy
The growing awareness of the benefits of menopause hormone therapy (MHT) has led to a significant increase in demand for treatment. This surge has been so substantial that manufacturers are struggling to keep up, prompting New Zealand’s drug-funding agency, Pharmac, to implement temporary rationing of supplies.
Most women today are prescribed body-identical hormones, such as transdermal estradiol (in the form of patches or gels) and progesterone capsules, to manage menopause symptoms like hot flushes or night sweats. Estrogen helps alleviate these symptoms, while progesterone protects the lining of the uterus and may also improve sleep quality.
There are two main factors driving this increased demand. First, there is greater confidence in MHT, supported by reassuring long-term data from the Women’s Health Initiative trial and other studies. Second, there is more open conversation about menopause, with midlife women becoming more aware of available therapies and their additional benefits for bone health. As a result, they are demanding better care and support.
However, apart from the current supply shortages, there are still significant gaps in both research and the training of healthcare professionals.
Changes in MHT Over Time
The initial findings from the Women’s Health Initiative trial were published in 2002. These results caused widespread concern among women, as they indicated an increased risk of breast cancer, stroke, and blood clots in those taking combination hormone therapy for five years compared to a placebo. The trial also suggested that hormone therapy did not protect against heart attacks, as previously thought.
However, long-term follow-up data from the Women’s Health Initiative trial, including 18-year results, have provided reassurance. These findings showed no overall difference in mortality between individuals who took five years of MHT and those on a placebo. Studies of transdermal estrogen treatments, such as patches and gels, have also found little to no association with stroke and blood clots.
Clinical guidelines have evolved significantly over time. When I was training as a gynaecology specialist in Canada in the late 1990s, we offered hormone therapy to all women. After the Women’s Health Initiative trial, we limited its use to women with the most severe symptoms. Later, we expanded access but at the lowest dose and for the shortest duration possible.
Today, I prescribe MHT to all menopausal women with symptoms after thoroughly discussing the risks (primarily breast cancer) and benefits (bone health). The current recommendation is to use the minimum dose required to achieve full symptom relief. The duration of treatment should be tailored to each individual, with decisions to continue or stop made annually between the patient and their healthcare provider.
MHT can now also be considered a first-line therapy for preventing menopause-related bone loss.
Improving Menopause Care
These changes have led to a rise in MHT prescriptions compared to two decades ago. In the past, following the initial trial results, prescriptions declined sharply. Doctors became less familiar with prescribing MHT, and new doctors did not receive adequate training on menopause management. There was little focus on menopause education in medical schools.
This lack of training means some healthcare providers do not have the knowledge or experience to effectively discuss menopausal symptoms with their patients, prescribe appropriate treatments, or optimise menopause care.
Currently, four out of ten medical schools in the UK do not include mandatory menopause education in their curriculum. A survey in the US found that most obstetrics and gynaecology training programmes lack modules on menopause.
To address these gaps, especially in the New Zealand context, we have developed a short online training course on menopause care for nurses, nurse practitioners, and doctors. We are also incorporating new content for medical students. Additionally, we are advocating for more funded MHT options.
However, there is a lack of evidence about women’s experiences in New Zealand. We need up-to-date data on who is using MHT, what women expect from their healthcare providers, and how menopause symptoms impact whānau, workplaces, and communities.
Most studies on MHT focus on women who are already in menopause (12 months or more without a menstrual period). There are no long-term, high-quality trials on women in perimenopause (the transition to menopause, when symptoms begin), nor on women taking contemporary MHT regimens—such as estrogen patches and progesterone capsules affected by recent shortages.
Counselling is often based on older studies of outdated therapies that do not reflect New Zealand’s population.
New Zealand released a women’s health strategy in 2023, aiming to “support women to live longer in better health” and prioritising improved menopause care. However, many women continue to report being dismissed by their healthcare providers.
We need New Zealand-specific research on menopause and better education and training for healthcare professionals. Midlife women are no longer willing to tolerate undiagnosed and untreated menopausal symptoms.
The menopause course received a small unrestricted educational grant from a pharmaceutical company.
