Women with Medicaid coverage were half as likely to use estrogen or progesterone for menopause treatment as privately insured women, according to a national retrospective study.

Researchers posited that clinicians may erroneously believe Medicaid does not cover hormone therapy for symptoms of menopause such as mood disturbances, changes in sexual function, and urinary incontinence.

The federal Medicaid Drug Rebate Program, however, mandates that the insurance program covers menopause hormone therapy.

“The degree to which insurance was associated with the known existing disparity was surprising,” said Arina Chesnokova, MD, MPH, assistant professor of ob/gyn at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, who led the study. “Something that clinicians in particular can do is reconsider the focus of their practice and whether they’re willing or not to accept Medicaid and reconsider their prescribing practice if it differs depending on insurance.”

The study, published in JAMA Network Open, analyzed a subset of 1666 respondents (mean age, 54 years) of the National Health and Nutrition Examination Survey between 2013 and 2020 who were between 45 and 64 years old, had Medicaid or private insurance coverage, and were eligible for menopausal hormone therapy (MHT) based on their responses about medical history. Women who were pregnant at the time of the survey, had experienced premature ovarian insufficiency, or had medical contraindications to MHT, such as cardiovascular disease, were excluded.

Among the 1391 people with private insurance, 75.5% were White, 9.2% Black, 9% Hispanic, and 5.1% Asian. Of the 275 with Medicaid coverage, 40.8% were White, 25.5% Black, 21.8% Hispanic, and 7.3% Asian.

Participants reported whether they had ever used estrogen or progesterone in pill, cream, patch, or injectable form, for reasons other than birth control or infertility.

In all, 1 in 5 (19.8%) menopausal women reported ever using MHT, and 3.7% reported having an active prescription for a medication in the past 30 days.

Individuals insured by Medicaid had 50% less odds than those with private insurance to report having used the drugs (odds ratio [OR], 0.50; 95% CI, 0.28-0.87).

The study also found that Black participants, who report more severe and frequent menopause vasomotor symptoms, showed lower odds of using one of the drugs than White participants (adjusted OR, 0.72; 95% CI, 0.50-1.04).

“I see in real time that folks in general cannot get excellent menopause care, and it’s even tougher for those who are poor, underserved, marginalized, particularly minoritized as Blacks and African Americans,” Chesnokova said.

The most used formulation was pills (40.4%), followed by creams, suppositories, or injections.

Changing Views on Hormone Risks

Until last year, the FDA required black-box warnings on estrogen and estrogen-progestogen replacement therapies for increased risks for breast cancer, heart disease, and stroke. The label change came in 2003, following publication of two studies by the Women’s Health Initiative (WHI) that found the therapies increased these risks.

The agency initiated removal of the warnings after reviewing subsequent literature showing hormone replacement therapy can reduce the risk for all-cause mortality and fractures and is associated with 50% reduction in the risk for heart attacks and 64% reduction in cognitive decline.

The study looks back at the era of the black-box warning, important context to note, said Debra Somers, MD, assistant professor of clinical obstetrics, gynecology, and reproductive sciences at the Lewis Katz School of Medicine at Temple University in Philadelphia.

Women with Medicaid may be more likely to be cared for by residents, she said.

“In residency, they have to follow FDA recommendations,” Somers said. “Once they are in practice, if somebody is with an older physician who uses hormone replacement therapy” that clinician can help guide them in how to write a prescription.

Prior to the WHI studies, overall prevalence of hormone use was 29.5% and 38.5% in women aged 52-64 years, in comparison to the 3.4% the current study found.

The prescribing pendulum has shifted with the elimination of the black-box warnings. Truveta, a health data and analytics company, reported that between November 2025 and May 2026, prescribing rates for progesterone-containing hormone therapy increased 19.3% from 10.4 to 12.4 prescriptions per 1000 women aged 45 years or older.

Chesnokova suggested that states can enact policy changes, such as increasing Medicaid reimbursement for menopause-related medical visits, to improve rates of prescribing to Medicaid enrollees. States can also determine which medications make it onto formularies and how they are tiered. Illinois enacted legislation last year requiring individual, group, and Medicaid health plans to cover hormone and non-hormone therapies.

Chesnokova and Somers reported no financial conflicts of interest.

Brenda Sandburg is a freelance journalist for Medscape Medical News. She has written about the biopharmaceutical industry and legal issues for the Pink Sheet and American Lawyer Media.