Cosmos Study

Hormone Therapy Use Nearly Doubled Since 2017, Led by Women in Their Late 40s and Early 50s

July 30, 2026

Team A:Kersten Bartelt, RNGregory Edwards, PhD

Team B:Becky Leeman, RNDenise Rasmussen, RNJoe Deckert, PhD

Key Findings

Among women seen in outpatient care, the rate of hormone therapy (HT) use rose from 1.7% in January 2017 to 3.6% in April 2026, a near-doubling. The increase was modest through 2022 and then accelerated sharply from 2023 onward.
The rise was steepest among women aged 45–54, where use nearly tripled from about 24 per 1,000 women to 68 per 1,000. Women aged 55–64 and 35–44 roughly doubled, while the youngest (18–34) and oldest (65–79) groups grew more modestly.
Progestin-only and estrogen-only products drove most of the growth, while combined estrogen-plus-progestin and androgen/testosterone products stayed relatively flat. By route, transdermal (patch/gel) and vaginal use tripled, outpacing oral and injectable formulations.

Hormone therapy (HT), long known as hormone replacement therapy, often uses estrogen, progestin, or a combination to relieve symptoms of menopause such as hot flashes, night sweats, and vaginal dryness, and to help prevent bone loss.¹ Its use fell dramatically in the U.S. after 2002, when the Women’s Health Initiative trial reported that combined estrogen-plus-progestin therapy was associated with increased risks of heart disease, stroke, blood clots, and breast cancer, prompting the U.S. Food and Drug Administration (FDA) to add prominent “black box” safety warnings.²^,³ National survey data show that use among postmenopausal women declined from roughly 27% in 1999 to under 5% by 2020.⁴ In the years since, reanalyses of the original trial have suggested that its reliance on an older population overstated the risks for the typical woman beginning treatment in her early 50s. In 2022, the U.S. Preventive Services Task Force reaffirmed that HT should not be used to prevent chronic disease but left using HT for symptom treatment to individual clinical judgment.⁵ Most recently, in November 2025, the FDA removed the black box warnings related to cardiovascular disease, breast cancer, and dementia from estrogen-containing products, citing newer evidence that benefits may outweigh risks when therapy begins within 10 years of menopause onset.⁶ Against this shifting backdrop, it remains unclear how real-world prescribing has changed in terms of frequency, formulation, and target population.

We examined hormone therapy use among 163,348,471 adult women seen in U.S. outpatient care between January 2017 and April 2026. Women with a history of breast cancer, a current pregnancy, or evidence of gender-affirming care were excluded. Because the data do not directly capture menopausal status, we used age bands as an approximation.

Hormone therapy use among women in outpatient care nearly doubled over the study period, rising from about 1.7% in January 2017 to about 3.6% by April 2026, as seen in Figure 1. The trend was relatively flat through 2022, holding near 1.8–1.9%, and then climbed steeply from 2023 onward. The increase was not uniform across age groups and was concentrated among women in the years surrounding the menopausal transition. Women aged 45–54 saw the largest relative rise, nearly tripling, and by the end of the study had the highest use rate of any age group. This is consistent with the typical age of menopause onset in the U.S. and with the demographic for whom recent guidance most strongly supports symptom-directed therapy.⁶ Women aged 55–64 and 35–44 each roughly doubled. Growth was more modest at the extremes of age, with the youngest women (18–34) and the oldest (65–79) having slight growth in usage.

Figure 1

Hormone Therapy Use Rate Over Time by Age Group

Figure 1. The monthly rate of hormone therapy use among women by age group, January 2017 through April 2026.

The growth in hormone therapy was driven mainly by single-hormone products and by non-oral routes. Among hormonal compositions, progestin-only use grew most (about 3.3-fold, from roughly 0.3% to 1.1%) and estrogen-only use rose about 2.3-fold (from roughly 1.1% to 2.6%). Meanwhile, estrogen-plus-progestin and androgen/testosterone products changed little over the period.

Figure 2

Hormone Therapy Use Rate Over Time by Hormonal Composition

Figure 2. The monthly rate of hormone therapy use per 1,000 women in outpatient care by hormonal composition, January 2017 through April 2026.

By route, transdermal formulations such as patches and gels grew fastest (about 3.5-fold, from 0.33% to 1.17%) and vaginal products nearly tripled (from 0.45% to 1.26%), each outpacing oral therapy and injectables.

Figure 3

Hormone Therapy Use Rate Over Time by Hormonal Route

Figure 3. The monthly rate of hormone therapy use per 1,000 women in outpatient care by route of administration, January 2017 through April 2026.

These data come from Cosmos, a dataset created in collaboration with a community of Epic health systems representing more than 307 million patient records from 2,000 hospitals and more than 49,000 clinics from all 50 U.S. states, Canada, Lebanon, and Saudi Arabia. This study was completed by two teams that worked independently, each composed of a clinician and research scientist. The two teams came to similar conclusions. Graphics by Brian Olson.

Menopausal hormone therapy. American College of Obstetricians and Gynecologists. https://www.acog.org/womens-health/faqs/hormone-therapy-for-menopause. Accessed June 30, 2026.
Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-333. doi:10.1001/jama.288.3.321
FDA requests labeling changes related to safety information to clarify the benefit/risk considerations for menopausal hormone therapies. U.S. Food and Drug Administration. Published November 10, 2025. https://www.fda.gov/drugs/drug-alerts-and-statements/fda-requests-labeling-changes-related-safety-information-clarify-benefitrisk-considerations. Accessed June 30, 2026.
Yang L, Toriola AT. Menopausal Hormone Therapy Use Among Postmenopausal Women. JAMA Health Forum. 2024;5(9):e243128. Published 2024 Sep 6. doi:10.1001/jamahealthforum.2024.3128
US Preventive Services Task Force, Mangione CM, Barry MJ, et al. Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Persons: US Preventive Services Task Force Recommendation Statement. JAMA. 2022;328(17):1740-1746. doi:10.1001/jama.2022.18625
HHS advances women’s health, removes misleading FDA warnings on hormone replacement therapy. U.S. Department of Health and Human Services. Published November 10, 2025. https://www.hhs.gov/press-room/fact-sheet-fda-initiates-removal-of-black-box-warnings-from-menopausal-hormone-replacement-therapy-products.html. Accessed June 30, 2026.

Data Definitions

Study period: 1/1/2017 to 4/30/2026

Study population: inclusion

Adult female patients (age 18 to 79) with at least one outpatient face-to-face encounter in the United States during the study period.

Patients were counted as active in a month in which they have one or more eligible encounters.

Study population: exclusion

Any of the following:

History of breast cancer (ICD-10-CM C50*, Z85.3*)
Sex assigned at birth of male
Gender identity indicating transgender or ever history of transgender/gender-diverse diagnosis (ICD-10-CM F64*, Z87.890)
Pregnancy, excluded for nine months on either side where pregnancy is evident

Exposures: Hormone replacement therapy orders and dispenses by hormonal composition, excluding those with a class, subclass, or therapeutic class containing “contraceptive,” “ulipristal,” “antineoplastic,” “Estrogen receptor modulator,” “dietary supplement,” “alternative therapy,” “radiopharmaceutical,” or “hypertrichotic”

Outcomes: Monthly rate of hormone therapy

Stratifications: Age band: 18–34, 35–44, 45–54, 55–64, 65–79
Route
Hormonal composition

Outpatient face-to-face encounter: Encounters with a type of Office Visit, Follow-up, Urgent Care, Walk-in

Hormonal composition

Classification of the exposure into composition groups:

Estrogen: Simple generic name containing “estradiol,” “estrogen,” “estrone,” “estriol,” or “estropipate”
Progestin: Simple generic name containing “progesterone,” “progestin,” “medroxyprogesterone,” “dydrogesterone,” “norethindrone,” “norgestimate,” “drospirenone,” or “norgestrel”
Combination: a medication containing both estrogen and progestin
Testosterone-containing: simple generic name containing “testosterone”

Route: Route of administration, grouped as: oral (oral, enteral, intragastric, nasogastric); transdermal (transdermal, cutaneous, percutaneous, containing “topical”); vaginal (vaginal); injectable (intramuscular, intravenous, parenteral, containing “subcutaneous” or “inject”)

Pregnancy: A pregnancy episode, an encounter flagged as pregnant, perinatal encounter type (initial prenatal, routine prenatal, postpartum visit, fetal care consult, fetal procedure, NST, induction, lactation consult, lactation encounter), or a diagnosis with ICD-10-CM code O*, Z33*, Z34*, or Z3A*

Limitations: The denominator reflects women with an outpatient encounter, which tracks healthcare utilization and shifted over the study period (e.g., the 2020 COVID-19 disruption).
Apparent use trends may be partly driven by changes in who presents for care.
Age is a coarse proxy for menopausal status and does not cleanly separate peri- from post-menopausal women.
Androgen/testosterone capture may be incomplete; these products are inconsistently coded and may be compounded, and route may be unreliable.
Route is inferred from medication name and route strings, which can misclassify formulations (e.g., topical vs. transdermal).
Excluding all breast cancer history removes women who legitimately stop or change therapy; this is a deliberate scope decision for a menopausal-HT denominator.