Menopausal hormone therapy (MHT): How clinicians can address fear, misinformation, and treatment hesitancy

Although menopausal hormone therapy (MHT) is the first-line treatment for vasomotor and genitourinary symptoms of menopause, fewer than 4% of eligible women aged 50–59 used it in 2023.¹ This underuse reflects not lack of efficacy, but persistent fear, misinformation, and missed clinical conversations following early misinterpretation of landmark studies.^1,2 Understanding why women refuse or abandon MHT—and how clinicians can address this reluctance using evidence‑based behavioral strategies—is a central challenge in menopause care.

Why do women refuse or abandon hormone therapy, and what psychological barriers drive this behavior?

Fear is the dominant driver of MHT avoidance, and its origins are well defined. The 2002 Women’s Health Initiative (WHI) publication and the 2003 Million Women Study triggered an estimated 80% decline in MHT prescribing worldwide, due to concerns about the reported risks of cardiovascular events and breast cancer.² Relative risk figures were widely misinterpreted, data from older, asymptomatic women were applied to younger populations, and media amplification entrenched exaggerated perceptions of harm. The psychological impact of these events persists decades later.²

Fear of breast cancer is the most frequently cited reason for declining or discontinuing MHT, followed by cardiovascular disease and thromboembolic risk.³ International surveys indicate that more than half of women associate hormone therapy with side effects and consider MHT as dangerous, and many believe menopausal symptoms are inevitable or untreatable—reflecting a form of fatalistic acceptance that suppresses help-seeking behavior.

Behavioral barriers viewed through capability, opportunity, and motivation

While the COM-B model (Capability, Opportunity, Motivation) is not explicitly applied in menopause guidelines, the barriers described in the literature align closely with its core constructs and help structure clinical understanding of why fear translates into non‑use.⁹

• Capability-related factors include gaps in knowledge and understanding. Many women report difficulty interpreting complex and evolving data on MHT, uncertainty about age‑specific risks and benefits, and confusion caused by conflicting information from healthcare professionals, media, and online sources.³ Poor understanding of absolute versus relative risk further impairs informed decision‑making.
• Opportunity-related barriers arise largely within clinical encounters. Time constraints, competing priorities in consultations, and clinicians’ reluctance to initiate conversations about menopause mean that symptoms—and treatment options—are often not discussed unless raised by the patient.³ Embarrassment, cultural norms, and stigma surrounding sexual and genitourinary symptoms further reduce opportunities for dialogue.
• Motivational influences are predominantly emotional and belief‑driven. Fear of adverse events, negative associations reinforced by peer narratives, distrust of pharmaceuticals, and long-standing cultural narratives that frame menopause as something to be endured all shape women’s willingness to consider MHT.³

These barriers are further compounded by widespread exposure to misinformation. The expanding femtech and wellness marketplace often promotes unregulated compounded hormones, routine hormone testing, and “anti‑aging” narratives that conflict with international guidelines.^2,4 Professional societies have warned that this environment may increase confusion, reinforce fear of regulated MHT, and offer a false sense of safety through unproven alternatives—making high‑quality, evidence‑based counseling even more essential.^2,4

How clinicians can reframe MHT risk and build confidence

Effective risk communication requires shifting from relative to absolute risks, fear‑based framing to patient‑centered framing by use of open-ended questions to elicit patients’ concerns and preferences and presenting evidence about benefits and risks in language the patient can understand, and monologue to dialogue—strategies may lead to improve understanding, reduce decisional conflict, and support adherence.³

For example, in the WHI estrogen‑progestin trial, invasive breast cancer occurred at 0.43% per year with MHT treatment versus 0.35% with placebo—an excess of ~9 cases per 10,000 women per year,⁵ classified as uncommon or rare by CIOMS (The Council for International Organizations of Medical Sciences) standards.⁶ Clinicians should also emphasize that initiation before age 60 or within 10 years of menopause carries a distinct benefit–risk profile compared with later initiation.^{2, 5}

The OARS framework from motivational interviewing (Open questions, Affirmations, Reflective listening, Summarizing) provides a practical structure for menopause consultations, adding minimal time while improving engagement and trust.³ Visual aids (pictographs, icon arrays) and positive framing further enhance comprehension, especially for patients with limited health literacy.³

How does shared decision-making improve adherence and patient satisfaction with hormone therapy?

Shared decision‑making (SDM) can enhance adherence and satisfaction by aligning treatment with patient values and goals. Examples from other preference‑sensitive areas of medicine suggest that incorporating patient preferences is associated with better follow‑through, supporting the relevance of this approach to MHT.³

The 2023 Practitioner’s Toolkit for Managing Menopause supports shared decision‑making by presenting both hormonal and non‑hormonal options in structured, non‑prescriptive algorithms that emphasize patient choice and preference‑sensitive care.⁷ FIGO and IMS guidance emphasize that MHT decisions should be individualized and regularly reassessed, with annual review recommended once symptom control is achieved.^2,7,8

How can HCPs recognize and address their own biases to avoid unconsciously reinforcing treatment hesitancy?

HCP bias is a real and documented contributor to undertreatment. The REDLINC VII survey of gynecologists across 11 Latin American countries found that while 85% favored personal or partner use of MHT for menopausal symptoms, only 49% actually prescribed it to symptomatic patients — a profound disconnect between personal conviction and professional practice.³ Female gynecologists and their male counterparts differed in which risks they rated as most significant, and postmenopausal female gynecologists were more likely to prescribe MHT than their premenopausal counterparts.³

Equity and health literacy

Implicit bias also operates along other factors such as socioeconomic lines. Women from low- and middle-income countries are disproportionately less likely to be offered evidence-based MHT counseling or to access specialist menopause care.² The IMS White Paper highlights the global inequity in MHT access and calls for culturally sensitive, region-appropriate approaches to manage menopause that do not implicitly embed high-income country assumptions.²

Clinical application

Individuating — consciously attending to the specific characteristics of the individual patient rather than applying group-level assumptions — is the foundational bias-reduction technique in clinical medicine.³ Perspective-taking, the deliberate attempt to understand the patient’s viewpoint before responding, enhances objectivity in treatment recommendations and has been shown to improve clinical decision-making in bias-prone contexts.³ For healthcare professionals, pausing before a consultation to ask “What assumptions am I bringing into this encounter?” and “Am I offering this patient the same options I would want for myself?” is not merely a values exercise — it is a patient safety practice.

Obstetrics and gynecology training programs globally have been identified as providing inadequate menopause education, leaving many residents and early-career practitioners unprepared for nuanced MHT discussions.³ Continuing professional development in menopause medicine — using tools such as the IMS IMPART program and the 2023 Practitioner’s Toolkit — is both a professional obligation and a structural response to bias arising from knowledge gaps.^2,7

How does a symptom-driven, patient-centered approach overcome the misinformation that disrupts treatment-seeking behavior?

A symptom‑driven, patient‑centered approach counteracts misinformation by prioritizing lived experience over ideology or commercial claims. Menopause is a clinical diagnosis in women over 45 with typical symptoms; routine hormone testing adds no diagnostic value and can mislead treatment decisions.⁴

Common myths—that all hormones are dangerous, compounded preparations are safer, hormone testing is required, or MHT prevents aging or chronic disease—conflict with international guidelines.² Compounded bioidentical hormone therapy is not recommended due to safety, quality, and regulatory concerns, and any perceived benefits can be achieved with regulated body‑identical MHT.²

Presenting a full range of options—lifestyle measures, non‑hormonal therapies, and appropriately selected MHT—reassures patients that care is individualized rather than agenda‑driven.⁷

What you can do

• Use open-ended questions at the start of every menopause consultation to elicit the patient’s existing beliefs, fears, and goals before presenting clinical information.³
• Present risks in absolute terms (events per 10,000 women per year) rather than relative terms, and contextualize against the patient’s age, time since menopause, and individual risk profile.⁵
• Apply positive framing: lead with what is preserved or gained, not only what might be risked.³
• Use visual tools (pictographs, risk-benefit graphics) to improve comprehension, particularly for patients with limited health literacy.³
• Offer a full menu of evidence-based options — hormonal and non-hormonal — at every consultation, explicitly including cognitive behavioral therapy and licensed non-hormonal pharmacotherapies, and guidance on healthy lifestyle measures such as good nutrition, physical activity, smoking cessation, alcohol moderation, and stress management.⁷
• Practice OARS: ask open questions, affirm the patient’s experience, reflect back what you heard, and summarize before prescribing.³
• Be alert to your own biases: check whether you are offering this patient the same standard of care you would want for yourself or your partner.³
• Gently correct misinformation about compounded preparations and hormone panel testing using neutral, non-judgmental language that preserves the therapeutic alliance.^2,4
• Schedule follow-up at 6–12 weeks after initiating any treatment to assess symptom relief, side effects, and ongoing concerns.²

Conclusion

Menopausal hormone therapy underuse is not primarily a problem caused by a lack of scientific evidence — it is a behavioral, communicative, and systemic one.¹⁰ The evidence supporting symptom-focused, individualized menopausal hormone therapy is substantial and reflected in consistent recommendations from international organizations including IMS, FIGO, The Menopause Society, and the Practitioner’s Toolkit.^1,2,7,8 However, persistent gaps in communication, misinformation, and clinician–patient engagement continue to hinder implementation of this evidence in practice. Integrating behavioral science frameworks such as COM-B and shared decision-making into routine care may help improve treatment confidence, address misconceptions, and support informed, preference-sensitive decisions.^3,4,9,10

This article was written with the assistance of generative AI technology and reviewed for accuracy.

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