Menopause Care in Primary Care: Closing Diagnosis and Treatment Gaps

Menopause was documented in fewer than 8% of outpatient encounters involving midlife women at a large academic health system, with significant differences in coding rates across clinical specialties, racial and ethnic groups, and insurance types, according to research presented at The Menopause Society 2026 Annual Meeting in San Diego.

The retrospective electronic health record (EHR) study, conducted by investigators at the University of Pennsylvania Health System, analyzed 666,606 outpatient encounters among 109,937 women aged 45 to 60 years at cohort entry between January 2022 and April 2026. Overall, just 7.8% of encounters included a menopause-related diagnosis code, while 28.0% of patients had at least 1 encounter with such a code during the study period.

Menopause coding was nearly 4 times more likely in obstetrics/gynecology encounters than in family medicine visits (adjusted odds ratio [aOR], 3.88; 95% CI, 3.73-4.04). Black, Asian, and Hispanic patients, as well as those with Medicaid or Medicare coverage, also had lower adjusted odds of menopause coding.

Investigators additionally identified concerning prescribing patterns. Among patients with a documented contraindication to hormone therapy (HT), 3.8% received HT or combined contraception at the index menopause encounter. The rate of such prescribing increased from 3.2 per 10,000 encounters in 2022 to 14.8 in 2025 and 23.1 through April 2026.

The findings underscore opportunities to improve menopause-related documentation, clinical decision-making, and treatment safety in primary care.

Patient Care Online spoke with Arina Chesnokova, MD, MPH, assistant professor of obstetrics and gynecology at the University of Pennsylvania, about the findings, potential contributors to disparities in menopause care, and her team's efforts to develop clinical decision support tools that help primary care physicians deliver evidence-based treatment.

Study Findings and Gaps in Menopause Care

Patient Care Online: Can you provide an overview of the research you presented at The Menopause Society 2026 Annual Meeting?

Arina Chesnokova, MD, MPH: Some of the data we're presenting are from the University of Pennsylvania Health System, which is a large, urban, and very diverse healthcare setting.

We wanted to look at what menopause care looks like in this very large academic healthcare setting. We wanted to see who's prescribing hormone therapy, who's diagnosing menopause, what the rates are, and whether there's evidence that we're providing evidence-based care or potentially deviating from it.

We were also developing methodology, which is really important. It's quite difficult to parse out all the different ICD codes and medications and make sure that the information we're pulling from these very large, complex datasets is reliable and actually tells us the truth.

We wanted to classify medications and conditions, look at rates over time, and attribute care to certain specialties. It's basic descriptive work to understand where we might need to focus our attention if we're trying to improve evidence-based menopause care.

Patient Care Online: What were the most significant findings from your analysis?

Arina Chesnokova, MD, MPH: We found that menopause diagnoses are quite rare and don't really correlate with the symptom burden that we know patients experience.

We know, for instance, that hot flashes and night sweats are experienced by at least 80% of people who go through the menopausal transition.

When we look at our health system and women between the ages of 45 and 60, most of them should be experiencing the menopausal transition at some point.

In the first year we examined, 2022, menopause was coded in only about 4% of encounters in family medicine, OB/GYN, and internal medicine. That rate increased over time, and in 2026, we're closer to 12%.

But again, it's nowhere close to reflecting the symptom burden that people experience as they undergo the transition.

Patient Care Online: What prompted your team to investigate menopause diagnosis and prescribing patterns across primary care and OB/GYN settings?

Arina Chesnokova, MD, MPH: As a clinician in the health system, I see a lot of patient volume and referrals, and I think some routine menopause care should be addressed by all of us who exist in the primary care space, whether that's family medicine, internal medicine, or general OB/GYN.

We wanted to see whether that was happening, whether there were differences across specialties, and what the overall rates looked like.

We also wanted to understand where to focus our attention when it comes to supporting clinicians in providing more evidence-based care.

We assumed we would find fairly low rates of prescribing and coding. The question was, once we identified those gaps, where should we focus our efforts?

Supporting Primary Care Physicians With Clinical Decision Tools

Patient Care Online: Given the low rates of menopause coding in outpatient settings, how can primary care physicians become more comfortable addressing menopause during routine visits?

Arina Chesnokova, MD, MPH: This is part of a larger portfolio of research. We started by identifying who's providing care, how frequently menopause is being addressed, and where the gaps exist.

From there, the question becomes how we design a learning health system that provides support, algorithms, and prompts that make it easier for clinicians to participate in menopause care safely, without creating additional burdens.

After looking at the numbers, we conducted qualitative interviews with primary care clinicians. That work hasn't been published yet, but we're analyzing it.

Most primary care clinicians we spoke with said they would love to provide more menopause care and believe it belongs in primary care. We interviewed close to 30 clinicians across different practice settings and experience levels.

They see patients asking for this care, but they often don't feel confident providing it.

What they want is something simple that can be brought into their workflow—an algorithm that risk-stratifies patients into different care pathways. If someone falls outside those pathways, clinicians would have an opportunity to refer them to a specialist.

Based on these data and the interviews, we're preparing to launch a pathway that addresses some of those gaps and needs.

Patient Care Online: Can you explain how that clinical pathway would work in practice?

Arina Chesnokova, MD, MPH: There's a platform called AgileMD that's used by many health systems with Epic-based electronic health records.

You can design what is essentially a flowchart that clinicians can pull up within Epic.

The menopause pathway walks clinicians through questions such as whether the patient has a uterus, whether they're in the appropriate age range, whether they have a high risk of breast cancer, and whether they have contraindications to hormone therapy.

If a patient has a contraindication, the pathway directs the clinician toward other options. If they don't, it identifies appropriate treatment options.

It also considers whether the patient is still menstruating.

The goal is to ensure that clinicians follow a relatively simple but evidence-based and safe algorithm that leads them toward a prescription or treatment option that can help patients manage their symptoms.

Addressing Disparities in Menopause Diagnosis

Patient Care Online: Your study found lower rates of menopause coding among racially minoritized and publicly insured patients. What factors might explain these disparities?

Arina Chesnokova, MD, MPH: That's a great question. There are probably many reasons, and I couldn't give you one definitive explanation.

One possible contributor is racism or implicit bias. A clinician may see someone who doesn't look like them or whom they don't relate to and assume menopause isn't a concern for that patient.

Patients from minoritized populations and those with public insurance may also have higher rates of comorbidities. During a short primary care visit, there may be many competing priorities.

If someone is overdue for breast cancer screening, cervical cancer screening, or colorectal cancer screening, menopause care might not be addressed.

That's something I heard frequently from primary care colleagues working in lower-resource settings or caring for predominantly publicly insured populations. There's a lot to accomplish in a very short visit.

There are also differences in how patients approach their appointments. By the time someone comes to see me, they may have already seen other clinicians or researched their symptoms and treatment options.

Patients in primary care may not always come in saying, "I've read about this, and this is what I want."

Even when patients bring up hot flashes or night sweats, the care that's offered may not always be culturally sensitive or aligned with their individual background and needs.

All of these factors could contribute to disparities in menopause care.

Improving Evidence-Based Menopause Prescribing

Patient Care Online: What health system interventions could help primary care physicians deliver more consistent, evidence-based menopause care?

Arina Chesnokova, MD, MPH: Some of these EHR-based tools can be really helpful.

That's consistently what we heard from clinicians during our interviews. They want an algorithm that guides them through clinical decision-making and ultimately leads to an easily accessible order.

But they also want the ability to counsel patients and quickly provide relevant information.

Ideally, the tool would connect screening, determining whether a patient is eligible for a particular therapy, prescribing, and patient education.

For example, it could automatically generate information specific to the treatment being prescribed or the patient's symptoms.

Importantly, it also needs to provide support when clinicians encounter a situation they're not comfortable managing.

That was another thing we heard frequently. Clinicians would say they wanted to provide more menopause care but sometimes had questions about progesterone dosing, different estrogen patches, or what to do when an initial treatment wasn't effective.

They want somewhere to turn for help.

Even if primary care physicians can manage the majority of menopause care, they still need access to higher-level support. An algorithm can't exist by itself without human support as well.

Funding Challenges and the Future of Menopause Care

Patient Care Online: You mentioned that this study is part of a larger effort to make menopause care and prescribing easier in primary care. How have recent funding challenges affected those implementation efforts?

Arina Chesnokova, MD, MPH: This work was part of a larger grant that supported learning health system science, including training and projects across multiple health systems.

I was one of the people who received a training grant through a larger funding mechanism supported by the Agency for Healthcare Research and Quality.

Although the grant was peer-reviewed and approved, some of the funding that was supposed to support this work never arrived.

A lot of the support I was receiving from the health system and the grant is no longer available.

The recipients of the grant tried to piece together funding from different sources to keep the work going, and they were able to do that for several months. But ultimately, we ran out of money.

More than a million women enter menopause every year in the United States, and many of them see primary care physicians.

It's difficult to get an appointment with an OB/GYN. There aren't enough of us, and primary care physicians provide an enormous amount of women's healthcare.

I think specialists should be available for patients with contraindications, those who have tried several treatments without success, and those who have more complex questions.

We should be the second or third tier of care, while enabling our primary care colleagues to address symptoms quickly.

Menopause symptoms can be debilitating right now. Patients can't necessarily wait 6, 8, or 12 months for an appointment.

I'm still moving this project forward with very limited resources, but this work needs funding.

Patient Care Online: Despite those challenges, what progress do you hope to make, and what should primary care physicians understand about providing safe menopause care?

Arina Chesnokova, MD, MPH: We're going to continue making progress in smaller steps.

Hopefully, the clinical pathway will become available within our health system. My intention is that once it's been tested, it could be made available for other health systems to implement.

We're also exploring other funding opportunities.

But we want this to be done well. We want the pathway to be rigorously tested, to make sure it's implementable and actually makes a difference.

The goal is to support clinicians in delivering evidence-based care.

I see patients all the time who have contraindications to hormone therapy but received prescriptions elsewhere without an appropriate evaluation.

It's very easy to prescribe something because you see a patient who's struggling and you want to help.

But my goal isn't for everyone to suddenly start prescribing hormone therapy. My goal is for people to provide care that's evidence-based.

That takes time, resources, and funding.

Key Takeaways for Primary Care Physicians

Patient Care Online: What are 1 or 2 key takeaways you want primary care physicians to remember from this study?

Arina Chesnokova, MD, MPH: I know that many primary care physicians feel inadequate or uncomfortable in this area. That's something we heard repeatedly during our interviews.

And it's okay to recognize that you don't know something.

If you can't deliver care in an evidence-based way, it's important to refer the patient or find someone in your network who can provide that care.

There are continuing medical education resources available, but I also recognize how busy clinicians are and how difficult it can be to find time for additional training.

Another important finding from our study is that prescribing hormone therapy to patients with contraindications is increasing.

I don't want to overstate that finding because the raw numbers are still quite low.

But we observed an increase in prescribing among patients with contraindications such as a history of breast cancer, blood clots, heart attack, or active liver disease.

Although the overall number of these prescriptions remains small, the rate is rising.

We're seeing more hormone therapy prescriptions being written, but we're also seeing more potentially inappropriate prescribing.

I want clinicians to recognize that hormone therapy prescribing is not necessarily a benign intervention. We need to be careful and make sure we're providing safe, evidence-based care.

Reference:

Chesnokova A, Bayes B, Blady S, Hamm R. Patterns of menopause diagnosis and prescribing in a large academic health system. Abstract P-19. Presented at: The Menopause Society 2026 Annual Meeting; October 20-24, 2026; San Diego, CA.