Racial Disparities in Hormone Replacement Therapy Utilization Among Menopausal Women: A Nationwide Retrospective Analysis Using Epic Cosmos [ID 4045]

INTRODUCTION: Hormone replacement therapy (HRT) is the most effective treatment for menopausal vasomotor symptoms but remains underutilized with evidence of racial inequities. We aimed to quantify national differences in HRT and alternative therapy use across racial groups. METHODS: Using Epic Cosmos (298M patients; 1,715 hospitals; 40,100 clinics), we identified women aged 45–60 years with a menopause diagnosis (ICD-10: E28.31, E28.310, E28.319, N95.*, Z78.0) between May 23, 2020, and May 22, 2025. Women with contraindications were excluded. Hormone replacement therapy use was defined by ICD-10 Z79.890. Chi-squared tests assessed differences across racial demographics; Bonferroni-adjusted Z-tests and relative/odds ratios compared groups to non-Hispanic White women. RESULTS: Among 1,857,770 eligible patients, 9.6% used HRT. Rates varied significantly by race ( P <.0001). Non-Hispanic White patients had the highest utilization (10.8%), followed by Other Race (9.1%) and American Indian/Alaska Native (7.7%). Lower rates were seen among Asian (6.2%), Native Hawaiian/Other Pacific Islander (6.4%), and Black patients (5.4%). Compared with White women, Asian and Black women were less likely to receive HRT (relative risk [RR] 0.62, odds ratio [OR] 0.56; RR 0.33, OR 0.59). Black patients were more likely to be prescribed selective serotonin reuptake inhibitors or fezolinetant (OR 1.85; 1.82) or treated with gabapentin, a non-FDA-approved option (OR 1.42). Asian women were most likely to receive no pharmacologic therapy ( P <.001). CONCLUSIONS/IMPLICATIONS: Substantial racial disparities persist in menopause treatment. Black, Asian, and Indigenous patients remain undertreated with HRT and disproportionately prescribed HRT alternatives, underscoring systemic inequities and concerns for social determinants of health. Targeted strategies are urgently needed to promote equitable menopause care.