Getty ImagesHigher awareness of the benefits of menopause hormone therapy (MHT) has led to rising demand for treatment – so much so that manufacturers can’t keep up and New Zealand’s drug-funding agency Pharmac had to temporarily ration supplies.Most women today are prescribed body-identical hormones, including transdermal estradiol (patch or gel) and progesterone capsules, to treat menopause symptoms including hot flushes or night sweats. Estrogen relieves symptoms, while progesterone protects the lining of the uterus and may have benefits for sleep.I believe there are two main drivers for the surge in demand. One is greater confidence in MHT, following reassuring long-term data from the Women’s Health Initiative trial and other studies.The second is more open dialogue about menopause. Midlife women are now more aware of therapies and their additional benefit for bone health and they are demanding better care.But apart from the acute shortages in supply, there are other significant gaps in research and the training of health professionals.Changes in MHT over timeThe initial Women’s Health Initiative trial was published in 2002. The results scared women off using MHT for decades because the trial found an increased risk of breast cancer, stroke and blood clots in women taking combination hormone therapy for five years, compared to a placebo. It also suggested hormone therapy did not protect from heart attacks as hypothesised. However, long-term follow-up findings are reassuring, as are newer studies. The 18-year data from the Women’s Health Initiative trial found overall mortality was no different between people who took five years of MHT versus placebo.Studies of transdermal estrogen treatments such as patches and gels have found little to no association with stroke and blood clots. Subsequent changes in clinical guidelines have been significant. When I was training to become a gynaecology specialist in Canada in the late 1990s, we offered hormone therapy to everyone. But after the Women’s Health Initiative trial, we offered it only to women with the most severe symptoms. Later, we offered it to more women but at the lowest dose and for the shortest time possible. Now, I offer MHT to all menopausal women with symptoms after full discussion of risks (primarily breast cancer) and benefits (bone health). The current recommendation is to use the dose required to achieve full symptom relief. The duration of MHT treatment should be personalised and the decision to continue or stop should be made on an annual basis between a well-informed woman and her health practitioner. MHT can now also be considered a first-line therapy to prevent menopause-related bone loss. Improving menopause careThese changes have led to more MHT prescriptions compared to two decades ago. Back then, following the initial trial results, prescriptions dropped. Doctors got out of practice of prescribing MHT and new doctors didn’t learn. There was little teaching about menopause at medical school. This means that some doctors don’t have the training or experience to adequately discuss menopausal symptoms with their patients, prescribe treatments and optimise menopause management.Currently, four out of ten medical schools in the UK don’t have mandatory menopause education in the curriculum and a survey in the US found most obstetrics and gynaecology training programmes lack modules on menopause. To answer the call for better care in a New Zealand context, we have developed a short online training course on menopause care for nurses, nurse practitioners and doctors and new content for medical students. We are also advocating for more funded MHT options.But we are missing evidence about women’s experience in New Zealand. We lack up-to-date data on who is using MHT, what women want from their health practitioners and how symptoms affect whānau, workplaces and communities. Most studies on MHT include women who are already in menopause(12 months or more without a menstrual period). There are no long-term, high-quality trials of women in perimenopause (the transition to menopause, when symptoms start), nor of women taking contemporary MHT regimens – the estrogen patches and progesterone capsules affected by recent shortages. Currently, counselling is also based on older studies of outdated therapies in demographics that don’t reflect New Zealand’s population.New Zealand released a women’s health strategy in 2023 with the goal of “supporting women to live longer in better health”, prioritising better support for menopause. But women continue to report being dismissed by their health practitioners. We need New Zealand-specific research about menopause and better education and training for health practitioners because midlife women are no longer willing to tolerate undiagnosed and untreated menopausal symptoms.The menopause course received a small unrestricted educational grant from a pharmaceutical company.