Utilisation of hormone replacement therapy in Arab countries: a systematic review

Background: Menopause is a major transition in women's health and may be associated with vasomotor symptoms and increased risk of osteoporosis and cardiovascular disease. Hormone replacement therapy (HRT) is an effective treatment option, yet uptake is reported to be limited in many settings. This systematic review aimed to synthesise evidence on factors associated with HRT uptake and utilisation in Arab countries and to summarise proposed strategies to support informed decision-making. Methods: We searched Embase, MEDLINE, WHO IRIS, Cochrane Library, PubMed, and Scopus for studies published up to March 2025. Eligible studies examined HRT uptake/utilisation, knowledge, perceptions, or attitudes among women in the 22 Arab countries. Two reviewers screened records using Covidence, with disagreements resolved by a third reviewer. Study quality was assessed using the Newcastle-Ottawa Scale adapted for cross-sectional studies. Findings were synthesised thematically. PROSPERO: CRD420251007430. Findings: Fifteen cross-sectional studies met inclusion criteria. HRT uptake was generally low; in 11 studies fewer than 20% of participants reported use, with reported prevalence ranging from 0% to 48% across settings. Factors positively associated with uptake included higher educational attainment, employment, healthcare provider influence and access to consultation, and greater baseline knowledge of menopause and HRT. Barriers included risk concerns, cultural conservatism, and preference for herbal or "natural" remedies. In several studies, media was a primary source of menopause-related information, while physician-led counselling was less frequently reported. Conclusion: Evidence from Arab countries indicates predominantly low HRT utilisation, shaped by knowledge gaps, risk perceptions, and socio-cultural factors, alongside variable healthcare-provider engagement. Studies most commonly recommended community education and strengthened clinician communication to support informed decision-making. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251007430, PROSPERO CRD420251007430.