Key takeaways:
- The meta-analysis is based predominantly on studies from North America, Europe, and Australia, with no African data represented—a significant gap that limits global applicability and identifies a clear priority for future research.
- Clinicians should move away from broad, WHI-derived risk framing toward individualized absolute risk assessment that accounts for formulation, duration of use, and the specific needs and symptom burden of each patient.
- Current decision-support tools for HRT counseling are insufficient across many comorbidity profiles, and development of accessible risk calculators and communication aids is a priority for improving individualized prescribing.
The disparities in HRT uptake documented in a recent meta-analysis are largely drawn from high-income country data—a limitation that constrains global applicability and points to significant evidence gaps in lower-income settings where cultural norms, prescribing models, and access to care differ substantially, according to Jennifer Hirst, BSc, MSc, DPhil, whose findings were reported in a prior installment.1
With the core findings and clinical interpretation covered in the first article, Hirst, a senior research fellow at the University of Oxford's Nuffield Department of Primary Care Health Sciences, addressed the generalizability of the evidence, the lingering influence of the Women's Health Initiative on prescribing behavior, and the need for better decision-support tools to enable individualized HRT counseling.
Of the 53 studies included in the meta-analysis, the majority were from North America, Europe, and Australia. A small number came from Asia and South or Central America, and none were from Africa.
"Prescribing models and cultural norms and stigma around discussing menopause and HRT are going to be very different in different settings," Hirst said. "We can't extrapolate to other continents in that way." She identified the absence of data from lower- and middle-income countries as a meaningful gap in the literature—one that future research will need to address before the findings can inform global policy.
On the persistence of WHI-era risk concerns in clinical practice, Hirst acknowledged the study's impact while noting its well-documented limitations.
"It resulted in lower prescribing for quite some time," she said. The WHI did not examine different HRT formulations or durations of use—distinctions that are central to contemporary individualized risk assessment.
"It's really important for every clinician to discuss the absolute risks to that woman, rather than looking at a broad sweep of what was found in the past," Hirst said. For women with severe menopausal symptoms, the benefit-risk calculation may clearly favor treatment; for others, ongoing review over time—including consideration of when to stop—is equally important.
The review's finding that comorbidity labels are associated with differential prescribing raises a more fundamental concern: whether clinical decision-making is being driven by categorical risk factors rather than individualized absolute risk. Hirst identified the scarcity of available decision aids as a structural barrier.
"There are a limited number of tools available—decision aids that are available for every health condition—to be able to have that discussion with a woman," she said. She called for development of individualized communication aids—risk calculators, checklists, or similar formats—that help clinicians understand and explain risks in accessible terms.
"Both the clinician can understand the risks, but also explain them in a really easy-to-interpret way to their patients."
Reference:
1. Mtika WM, Allen D, Tranter E, et al. Factors associated with hormone replacement therapy use: A systematic review and meta-analysis. BJOG. 2026 Jan 22. doi:10.1111/1471-0528.70160
