Key takeaways:
- Black women had 53% lower odds of HRT uptake compared to White women (OR 0.47), representing a significant and actionable racial disparity in menopausal care.
- Diabetes, obesity, prior stroke, and VTE history were associated with lower HRT uptake, likely reflecting cautious prescribing—but individualized risk assessment and transdermal formulations may offer safer pathways for eligible patients in these groups.
- Osteoporosis and depression were associated with higher HRT uptake, potentially reflecting both targeted clinical recommendation and the confounding effect of higher socioeconomic status and health care engagement.
Black women are 53% less likely to use hormone replacement therapy than White women, and several common comorbidities—including diabetes, obesity, and prior stroke or venous thromboembolism—are associated with meaningfully lower uptake, according to a systematic review and meta-analysis of 53 studies conducted by Jennifer Hirst, BSc, MSc, DPhil, a senior research fellow at the University of Oxford's Nuffield Department of Primary Care Health Sciences.1
The analysis searched 4 major databases to identify factors associated with HRT uptake among women aged 40 to 60 years, combining results across retrospective and prospective cohort studies, case-control studies, and cross-sectional studies. Among the most striking findings was the racial disparity: Black women had 53% lower odds of HRT use compared to White women (OR 0.47; 95% CI, 0.30–0.73). Diabetes, obesity, history of stroke, and prior venous thromboembolism were each associated with lower uptake (OR 0.71, 0.67, 0.75, and 0.78, respectively). Osteoporosis and depression, by contrast, were associated with higher uptake (OR 1.64 and 1.69, respectively).
"Women of White ethnicity were more likely to be taking HRT compared to women of other ethnic groups and Black ethnicity," Hirst said. "We also found that some comorbidities or health conditions that people are living with may mean they're more or less likely to be taking HRT."
The lower uptake among women with cardiovascular risk factors likely reflects cautious prescribing rather than patient preference alone.
"We suspect there may be some cautious prescribing going on here, because obesity and diabetes are risk factors for cardiovascular disease and more serious other health conditions," Hirst said. She emphasized, however, that contemporary evidence supports individualized rather than categorical risk assessment. Transdermal formulations, for example, carry a more favorable cardiovascular profile than oral HRT—a distinction that blanket avoidance based on comorbidity labels does not capture.
The higher uptake among women with osteoporosis and depression is likely explained by 2 overlapping mechanisms. Clinicians may be proactively recommending HRT for its bone-protective effects in women with osteoporosis or family history of the condition. But socioeconomic factors may also be at play: The review found HRT uptake is associated with higher socioeconomic status, which correlates with greater health care engagement and health literacy.
"Their understanding of their symptoms and ability to articulate that to their GP—it could be both of that going on," Hirst said.
A methodologic limitation of the review is that uptake was defined as ever v never use, precluding analysis of duration, timing of initiation, or formulation type.
"If somebody is suffering from quite severe symptoms, they may feel they need something to alleviate that—and for them it may be okay to take HRT for a couple of years, but they may want to stop after that," Hirst said. "How long women are using HRT is something we still need to know more about."
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
