The 228% isn't the story. Why it took this long is.

A response to Manulife's "Menopause hormone therapy: benefits and risks."

Manulife Canada recently reported something remarkable in its own claims data: between 2021 and 2025, hormone replacement therapy claims among Canadian women aged 45 to 54 rose 228%. Their article walks through the benefits and risks of hormone therapy in a careful, measured way. Credit where it's due, it's more balanced than most of what circulated twenty years ago.

But the framing deserves a counter, because the framing is the story.

Rising claims aren't a trend. They're a correction.

When an insurer reports a 228% increase in anything, the instinct is to ask "why the sudden spike?" The honest answer is that nothing sudden happened to women's bodies. What changed is permission.

In 2002, the Women's Health Initiative trial made headlines worldwide, and hormone therapy prescriptions collapsed almost overnight. A generation of women, and a generation of doctors trained during that era, absorbed one lesson: hormones are dangerous. Later re-analysis of that same trial complicated the picture considerably, especially for women under 60 or within ten years of menopause. (What the WHI actually found, and what it didn't.) But fear moves faster than follow-up research. The baseline Manulife is measuring from isn't normal demand. It's two decades of artificially suppressed demand.

A 228% rise off a suppressed baseline isn't women flocking to something new. It's women finally reaching something that was there all along.

And it isn't one age group. Manulife's data shows the rise spread across every band: 46% for women 35 to 44, 66% for those 55 to 64, with the sharpest increase in every group coming in the past two years. (Benefits and Pensions Monitor, Sept. 3, 2026) Catch-up, not a fad.

Claims data counts what's covered, not what's needed

An insurance database is a precise record of one thing: people whose plans pay and whose clinicians prescribe. What it can't see:

• The woman paying out of pocket because her plan or her province doesn't cover the option that suits her. (Coverage varies wildly across Canada. Here's the province-by-province picture.)
• The one who left the third appointment with nothing and stopped asking.
• The one who mentioned mood, sleep, or brain fog and left with an antidepressant and no conversation about perimenopause.
• The one who never raised it at all, because she assumed this was just aging.

If the covered, persistent, successfully-prescribed population grew 228%, the unmet need behind it is larger. Insurer data is useful, and we're glad Manulife published it, but it's a floor, not a measure.

And the clinical record isn't a better witness. A September 2026 scoping review in Menopause looked at how menopause actually gets documented in electronic health records and found that menopause status is rarely written down as a fact. It's usually inferred from an age band, a diagnosis code, or a prescription. Symptom detail, when it's captured at all, sits in free-text notes instead of a structured, comparable field. Read that alongside the claims number and you get the real problem: in a lot of health systems, a prescription is the closest thing to a record that a woman is in menopause. So the woman who wasn't prescribed anything isn't just missing from Manulife's dataset. She's close to invisible in her own chart too. (This is why we built our record differently.)

"Benefits and risks" shouldn't be the front door

Here's the subtle thing about risk-first framing: it feels responsible, and it quietly does harm. When the conversation opens with danger management, many readers never get to the part about what treatment could give back. Sleep, focus, the ability to feel like yourself at work and at home. They close the tab with one more reason to wait.

Risk belongs in the conversation. It belongs in a real conversation, with a menopause-trained doctor or specialist who knows your history, your symptoms, and your profile. (If your first appointments haven't got you there, here's how to ask for one.) It doesn't belong as the headline of the only article a person reads before deciding it's easier to push through.

A better front door: What are your symptoms costing you? What are your options, hormonal and not? (Here's the full range, in plain language.) Which of them fit your body and your life? Those are questions with answers.

The symptom nobody puts in the headline

Every insurer article lists hot flashes and night sweats, because they're easy to count. But ask women what actually sent them looking for help and you'll hear something else: I don't feel like myself.

That phrase isn't soft or vague. "Not feeling like myself" (NFLM) was validated as a perimenopause symptom in a 2024 study published in Menopause, drawing on the Women Living Better survey. Mood shifts, cognitive changes, and a loss of confidence that has nothing to do with competence are among the most common, and most dismissed, experiences of this transition. Any framing of hormone therapy that starts and ends with hot flashes misses the reason most people are in the room.

England shows what the counting misses

England has the numbers Canada doesn't, and they point the same way. NHS Business Services Authority data published on 5 August 2026 shows HRT prescribing there has more than doubled since 2020/21, from 781,170 women aged 40 and over to 2,038,025. Underneath that national rise, the gap is wide. In the 20% most deprived areas of England, about 8.8 in every 100 women over 40 receive HRT. Everywhere else it's 14.2 in 100. Newham sits at 4.5 in 100. Brighton and Hove sits at 23.4.

Ethnicity widens it further. A Menopause All-Party Parliamentary Group report found Black women are five times less likely to be prescribed HRT than White women (5.2% against 23.3%), and Asian women four times less likely (6.2%). Pharmacists interviewed by The Pharmaceutical Journal describe what sits behind those figures: appointment access, clinician confidence, language barriers including the need for a translator a woman is comfortable with, faith and cultural attitudes, and the lingering breast cancer message doing its own quiet work. Mahendra Patel of the Royal College of Pharmacy makes the point carefully, that low prescribing doesn't automatically mean unmet need, and that cost is unlikely to be the whole explanation.

That's the same blind spot, measured better. A prescribing rate tells you where the medication landed. It takes a separate effort to find out what happened to the women it didn't reach. (This is part of why we write about who gets left out of the data.)

The same APPG inquiry went further than prescribing rates. It heard evidence from disabled and neurodivergent women whose symptoms get attributed to their existing condition, from LGBTQIA+ people whose care pathways say nothing about gender-affirming hormone therapy, from women without ID or a fixed address who can't register with a GP at all, from domestic abuse survivors receiving care that isn't trauma informed, and from women in prison, a population aged 50 and over that grew 179.5% between 2003 and 2023. Every one of those groups shares the same fate in a claims database or a prescribing table. They appear as an absence. The report's own conclusion is that the research needed to describe them properly hasn't been funded yet. (Rebuilding trust: tackling inequity in menopause care.)

The bottom line

We're not arguing with Manulife's data. We're arguing with the scale it's read on. The 228% doesn't show a country suddenly interested in hormone therapy. It shows a country where the information finally caught up to the need, and where the need was always bigger than the claims ever showed. (We mapped the Canadian care gap in more detail here.)

If you're weighing your options: you deserve the full picture, in plain language, with the risks in their proper place. In the room, with a doctor or specialist who actually practices menopause care, not in the headline.

References

All-Party Parliamentary Group on Menopause. (2025). Rebuilding trust: Tackling inequity in menopause care. https://www.wellbeingofwomen.org.uk/news/rebuilding-trust-tackling-inequity-in-menopause-care/

Ashton, S., et al. (2026, September 2). Bridging the menopause data gap: a scoping review of status, symptoms, and trends in electronic health records. Menopause. https://menopause.org/wp-content/uploads/press-release/MENO-D-25-00418-003.pdf

Benefits and Pensions Monitor. (2026, September 3). Hormone replacement therapy claims from women aged 45 to 54 climb 228 percent in five years. https://www.benefitsandpensionsmonitor.com/news/industry-news/hormone-replacement-therapy-claims-from-women-aged-45-to-54-climb-228-percent-in-five-years/394095

Coslov, N., Richardson, M. K., & Woods, N. F. (2024). Not feeling like myself in the menopause transition: what does it mean? Observations from the Women Living Better survey. Menopause, 31(5). https://pubmed.ncbi.nlm.nih.gov/38531011/

Hirst, J., Mtika, W. M., Coupland, C., Dixon, S., Hippisley-Cox, J., et al. (2025). Inequalities in hormone replacement therapy prescribing in UK primary care: population based cohort study. BMJ Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC12481343/

Manulife Canada. (2026). Menopause hormone therapy: benefits and risks. https://www.manulife.com/ca/en/personal/insights/health-and-wellness/menopause-hormone-therapy-benefits-risks

Meredith, S. (2026, August 5). HRT prescribing doubles as access gaps persist. Medscape UK. https://www.medscape.com/viewarticle/hrt-prescribing-doubles-access-gaps-persist-2026a1000qr8

NHS Business Services Authority. (2026, August 5). Hormone replacement therapy - England (statistical collection, including prescribing inequalities by deprivation and region). https://www.nhsbsa.nhs.uk/statistical-collections/hormone-replacement-therapy-england

Rossouw, J. E., et al. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA, 288(3), 321-333. https://pubmed.ncbi.nlm.nih.gov/12117397/

Rossouw, J. E., Prentice, R. L., Manson, J. E., et al. (2007). Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA, 297(13), 1465-1477. https://pubmed.ncbi.nlm.nih.gov/17405972/

Manson, J. E., Aragaki, A. K., Rossouw, J. E., et al. (2017). Menopausal hormone therapy and long-term all-cause and cause-specific mortality: the Women's Health Initiative randomized trials. JAMA, 318(10), 927-938. https://pubmed.ncbi.nlm.nih.gov/28898378/

The Pharmaceutical Journal. (2026). Why do women in England's poorest areas have lower rates of HRT prescribing? https://pharmaceutical-journal.com/article/feature/why-do-women-in-englands-poorest-areas-have-lower-rates-of-hrt-prescribing