From black box warning to wake-up call: menopausal hormone therapy prescribing patterns at a large academic medical center

Objective: To characterize menopausal hormone therapy (MHT) prescribing patterns over 18 years in a large academic medical center and evaluate demographic and clinical factors associated with MHT prescriptions. Methods: We conducted a retrospective observational study using electronic health record data from January 1, 2007 to December 31, 2024. The cohort included biologically female patients 45 years or older with at least one outpatient encounter (N=305,053). The primary outcome was the proportion of women with any documented MHT prescription. Prescriptions were categorized as local, systemic, or a combination (local+systemic). Associations between MHT prescription race, birth year, comorbidity burden (Charlson Comorbidity Index [CCI]), insurance type, and urinary tract infection history were evaluated using χ 2 tests and multivariable logistic regression. Results: Overall, 6.99% (21,327/305,053) of women had at least one documented MHT prescription. Among MHT prescriptions, 54.61% received local therapy, 37.66% systemic, and 7.37% combination, and 0.37% had an unknown type. In adjusted analyses, African American (adjusted odds ratio [AOR]=0.513; 95% confidence interval [CI]=0.486-0.541), Hispanic (AOR=0.644; 95% CI=0.613-0.676), and Asian women (AOR=0.760; 95% CI=0.688-0.838) had lower odds of MHT prescriptions compared with White women. Each one-point increase in CCI was associated with lower odds of MHT prescription (AOR=0.845; 95% CI=0.833-0.856). Women with a documented history of urinary tract infection had substantially greater odds of receiving an MHT prescription (AOR=11.056; 95% CI=10.556-11.580). Insurance type was also significantly associated with MHT prescribing, with lower odds observed among women enrolled in Medicare Advantage, Medicaid, Medicare, and other insurance categories relative to women with commercial insurance. Conclusions: MHT prescribing remained persistently low over 18 years, with significant racial disparities, lower prescribing among women with greater comorbidity burden, and differences associated with insurance coverage. These findings highlight a sustained gap between evidence-based recommendations and real-world menopause care and may suggest that both clinical and structural factors may influence access to treatment.