Exploring the Availability and Acceptability of Hormone Replacement Therapy in Low- and Middle-Income Countries: Insights of Pharmacists Using a Cross-Sectional Study (MARIE-Sri Lanka WP2a)

Background: Hormone Replacement Therapy remains underutilised and under-researched in low- and middle-income countries (LMICs), despite its potential to alleviate menopausal symptoms. Pharmacists, as accessible healthcare providers, play a pivotal role in shaping perceptions and improving access to HRT. This study explored pharmacists' perspectives on the use, cost, and availability of HRT across six LMICs.Methods: A cross-sectional survey was conducted from January 1 to March 31, 2025, as part of the Global Menopause Project. Pharmacists working in community, hospital, and private sector settings in Malaysia, Sri Lanka, Nepal, Nigeria, Ghana, and Tanzania were recruited (minimum n=50 per country) via e-poster invitations. Participants completed an anonymous online questionnaire. The questionnaire was piloted prior to dissemination, assessed HRT availability, pricing, and perceived barriers to use.Findings: A total of 331 pharmacists responded: Ghana (18·4%), Sri Lanka (17·5%), Tanzania (16·9%), Nepal (16·6%), Malaysia (15·4%), and Nigeria (15·1%). The respondents were almost equally distributed between sexes (50·8% were female), and most were aged 26–35 years (49·0%). The majority worked in private community pharmacies (41·7%) or government hospitals (32·6%), and 57·4% were based in urban areas. HRT costs varied widely, with Sri Lanka reporting the highest prices and Malaysia the lowest. Key barriers identified included low health literacy, economic constraints, and limited healthcare access.Interpretation: Significant disparities exist in HRT access and affordability across LMICs, with urban-rural gaps further compounding inequities. Pharmacists’ insights underscore the urgent need for inclusive, equitable strategies in menopausal care and women's health policy in resource-limited settings.