Why so few women start hormone therapy, and what the new guidelines change

By Kevin Wolfe, Founder & CEO

Reviewed by Kindr Health Clinical Team

Published November 4, 2026 · Updated November 4, 2026

Only about 1 in 5 women start

A new study in Obstetrics & Gynecology looked at insurance claims for 318,621 women aged 45 to 60 who had a menopause diagnosis. The data came from the MarketScan databases and covered 2009 to 2022. Only 21.7% of these women started systemic hormone therapy (HT) within a year.

Among women who did start, many stopped early. Half had stopped by about 6.6 months, and 38.8% were still using it at 12 months. The authors also found that Black women were less likely to start HT, and Black and Hispanic women were more likely to stop sooner. The authors think real-world use is probably even lower than these numbers show, because menopause care isn't always coded in claims.

So hot flashes and night sweats are common, and an effective treatment exists. Why do so few women use it?

Where the hesitation came from

Much of it goes back to the early 2000s. In 2002, results from the Women's Health Initiative (WHI) study linked hormone therapy to higher risks of stroke and breast cancer. The headlines were alarming, and for about two decades many doctors stopped offering hormone therapy, and many women stopped asking about it.

Since then, researchers have looked more closely at who was in that study. The women in the WHI were older on average, and many started hormones about a decade after menopause. Newer analyses that break risk down by age show the risks were highest in women over 60. ACOG says misconceptions about HT risks have made some clinicians less willing to prescribe it, and some patients less interested in using it.

What's different now

Two major medical groups updated their guidance this fall, in slightly different ways.

• The American College of Physicians (ACP), in a guideline published October 5, 2026, recommends estrogen (combined with a progestogen for women who have a uterus, or estrogen alone for women who don't) as first-line treatment for women seeking help with hot flashes and night sweats. ACP found these options had the most favorable balance of benefits and harms.
• The American College of Obstetricians and Gynecologists (ACOG) published its most comprehensive menopause guidance to date on October 15, 2026. It covers hormone therapy, nonhormonal medicines, and non-drug approaches for hot flashes, sleep, and mood. It supports hormone therapy as an option for many women, chosen through shared decision-making.

Timing is central. If a woman and her clinician choose hormone therapy, ACOG recommends starting it before age 60 or within 10 years of the start of natural menopause, for women without reasons to avoid it. One of the guideline's coauthors told the Boston Globe that timing is "the central message."

It's still an individual decision. Both groups stress shared decision-making. ACOG says the choice should weigh your symptoms, your age and medical history, your baseline risks of heart disease, breast cancer and blood clots, and your own goals. ACOG also says decisions about when and how to stop HT should be made individually with your clinician.

"First-line" does not mean "risk-free." Hormone therapy still has risks, and they depend on who you are, when you start, and what you take. In November 2025, the FDA asked makers of menopausal hormone therapy to change their labels. The change removes language on heart disease, breast cancer and probable dementia from the boxed warning. But labels for systemic products keep the cardiovascular and breast cancer warnings, and estrogen-alone systemic products keep a boxed warning about endometrial cancer. This change applies only to FDA-approved products.

Who shouldn't use hormone therapy

Hormone therapy isn't right for everyone, and it has known risks, including blood clots, stroke and, with some estrogen-plus-progestogen regimens, breast cancer. Estrogen taken without a progestogen raises the risk of endometrial cancer in women who have a uterus. According to ACOG, as reported by CBS News, women with a history of blood clots, stroke or liver disease should not use it, and people with a personal history of breast cancer should also avoid it. Other standard reasons not to use it include unexplained vaginal bleeding, active liver disease, and a current or past heart attack. If you have a complicated medical history, such as a past breast cancer or a clotting disorder, bring it up with your clinician early.

Nonhormonal options

If you can't use hormones or prefer not to, there are other evidence-based choices. ACOG's guidance reviews several, and ACP ranks them:

• SNRIs and SSRIs. These are antidepressants that can also reduce hot flashes. ACP suggests an SNRI (desvenlafaxine or venlafaxine) as second-line, and an SSRI (escitalopram or paroxetine) or gabapentin as third-line. ACOG notes these may help with both hot flashes and depression. Some antidepressants can interact with tamoxifen, so tell your clinician about all your medicines.
• Neurokinin receptor antagonists. This is a newer class of medicines that act on the brain's temperature-control center. ACOG's guidance includes recommendations for them, and ACP lists them as a third-line option.
  • fezolinetant (Veozah), which carries an FDA boxed warning for rare but serious liver injury and requires liver blood tests. Prescribing information
  • elinzanetant (Lynkuet). It can cause sleepiness and other nervous-system effects, requires liver blood tests before starting, and must not be used during pregnancy. Its label also warns: "Seizure was reported in patients taking LYNKUET... Use LYNKUET with caution in patients with a history of seizures or with conditions that potentially lower the seizure threshold." Prescribing information

ACOG also recommends non-drug approaches, including cognitive behavioral therapy, mindfulness, exercise, clinical hypnosis and acupuncture, usually alongside medication. ACOG says the evidence does not support the safety or effectiveness of herbal supplements or phytoestrogens for menopause symptoms.

Questions to bring to your clinician

• Are my symptoms likely related to perimenopause or menopause?
• Given my age and how long it's been since menopause started, is hormone therapy a reasonable option for me?
• Is there anything in my personal or family history that would make hormone therapy unsafe for me?
• What are the benefits and risks for me specifically, and how do they compare with nonhormonal options?
• Which form (pill, patch, gel, spray or ring) would make sense, and do I need a progestogen?
• What follow-up and tests will I need, and how will we decide when to stop?
• If I don't want hormones, which nonhormonal option fits my health history?

The bottom line

Only about 1 in 5 women with a menopause diagnosis in a large new study started hormone therapy within a year, and fears rooted in headlines from more than 20 years ago are part of the reason. Today, ACP recommends HT as a first-line treatment for bothersome hot flashes and night sweats, and ACOG's guidance supports it for many women, especially when started before 60 or within 10 years of menopause, for women who can safely use it. It isn't right for everyone, and good nonhormonal options exist.

If hot flashes or night sweats are disrupting your days or your sleep, you can talk with a board-certified Kindr Health clinician. They can help you look at all your options, hormonal and nonhormonal, including their benefits and risks, and decide whether any of them fits you. Kindr Health clinicians may prescribe compounded hormone therapy; compounded medications are not FDA-approved, and the FDA labeling changes described above apply only to FDA-approved products.

For education only, not medical advice. Talk with a licensed clinician about your situation.

Medically reviewed by Kindr Health Clinical Team
Last updated: November 4, 2026