Menopausal women of Chinese and black African backgrounds are about 80% less likely to receive hormone replacement therapy than white women, according to a large-scale study.
HRT is one of the most common treatments for menopausal symptoms such as hot flushes, mood swings, poor sleep and vaginal dryness. It can also help maintain muscle strength and prevent osteoporosis.
But a 10-year study of nearly 2 million women in England has found worrying inequalities in women’s access to HRT.
Academics at the University of Oxford examined HRT prescriptions issued in England to 1,978,348 women aged 40 to 60 over a 10-year period.
Findings presented at the World Congress on Menopause in Melbourne on Monday revealed that between 2013 and 2023, almost six times as many white women were prescribed HRT than black women, and more than twice as many women in affluent areas were offered HRT than those living in socially deprived areas.
While previous studies have identified unequal access to HRT, the academics believe this is the first study to quantify the likelihood of receiving it, having adjusted for age, deprivation and ethnicity.
Over the 10 years they found that, compared with their white counterparts, women of Chinese backgrounds were 82% less likely, and those of black African backgrounds 79% less likely, to receive HRT. Women from Pakistani, Bangladeshi and Indian backgrounds were respectively 70%, 64% and 61% less likely to be on HRT.
Since 2016, guidance from the National Institute for Health and Care Excellence (Nice) has recommended HRT as a potential treatment for menopausal symptoms.
But the study found the guidance did not improve access to HRT. “[We did not find that] women were suddenly all getting the same care since there’s been the Nice guidance, which is what it should be doing,” said Dr Jennifer Hirst, a senior primary care research fellow at the University of Oxford. “It should be more of an equaliser, [but] that’s not what’s happened.”
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In fact, the trend has worsened. Over the five years since 2016, women of Chinese, black African, Indian and Pakistani backgrounds or those in the most deprived neighbourhoods were even less likely to get HRT compared with their white counterparts and those in the most affluent neighbourhoods.
Nina Kuypers, the founder of Black Women In Menopause, said: “Many Black women tell us that when they go to their GP, they feel dismissed or unheard, with their symptoms often being misinterpreted or overlooked. Instead of being recognised as part of menopause, their experiences are sometimes attributed to unrelated conditions, such as diabetes or high blood pressure, which are prevalent in the Black community.
“There is also a lack of culturally competent care, with many healthcare professionals untrained in understanding the unique ways menopause manifests across different racial and ethnic groups. Furthermore, Black women are often underrepresented in clinical trials, meaning that treatment guidelines do not always reflect their specific needs. As a result, they face delays in receiving appropriate treatment for their menopausal symptoms, compounded by socioeconomic barriers that make accessing specialised care even more difficult. These factors lead to prolonged suffering, further misdiagnosis, and a lack of trust in the healthcare system.”
Janet Lindsay, the chief executive of the charity Wellbeing of Women, said the “huge disparities” demonstrated a “worrying trend towards a two-tier system of menopause care”.
The menopause expert and campaigner Kate Muir, the author of Everything You Need to Know About the Menopause (But Were Too Afraid to Ask), said: “This inequity is compounded by the fact that black women have an increased rate of symptoms including hot flushes, and latest research shows hot flushes can increase the risk of poor brain health in later life, so early intervention matters more. Asian women have a higher risk of osteoporosis, but are far less likely to use HRT, which is recommended by the NHS to keep bone density high and reduce the risk of fracture.”
Campaigners including Muir believe that discussing periods and menopause at the 40-plus health check for all women could make a big difference.
The MP Carolyn Harris agrees, but called on the government to go further. She said: “My mission is that every area of social policy acknowledges menopause as an issue, every medical discipline includes comprehensive training for their practitioners to understand menopause, and every woman is given the opportunity to understand what the menopause is and what the options are.”
Prof Kamila Hawthorne, the chair of the Royal College of GPs, said the findings were disappointing, though not surprising. “Working to address health inequalities is a strategic priority for the college,” she said.
Dr Sue Mann, the NHS national clinical director for women’s health, said it was vital that all women had equal access to support and were fully informed about the risks and benefits of the different treatment options for menopause, including HRT.
“We know there is more work to do to increase awareness and reduce inequalities in access, and that’s why we’re rolling out women’s health hubs to provide extra care within communities, as well as tools to help women to manage their symptoms,” she said.
