Spain's health service covers testosterone and HRT only with a medical diagnosis

Hormones on prescription: the gap nobody will fund

Why does Spain's public health system cover testosterone for men with a diagnosis and hormones for women going through menopause, but refuse both when the reason is cosmetic or performance-related? The answer lies in the fine print of public funding: Osakidetza covers testosterone replacement therapy (TRT) for cisgender men only when there is a justified, diagnosed medical cause. Not for natural ageing, and not for improving athletic performance. The same logic applies to hormone replacement therapy (HRT) for menopause, which in Spain is suffering shortages of drugs such as Lenzetto and Evopad, as the Spanish Agency of Medicines acknowledged.

The shortage that turns patients into detectives

Rebeca Marín, aged 49 and living in Cuenca, has been on hormone therapy since January. First a transdermal estradiol spray, Lenzetto, with 56 doses of 1.53 mg per box. Before the summer, the shortage began. Her gynaecologist switched her to 25-milligram patches, Evopad. She cannot find those either. "I have two boxes left," she says. The Spanish Agency of Medicines promised to resume the supply of Lenzetto in November and to fix the problem "by 2027"; Evopad was due back in pharmacies the week of 5 October. Catalonia gave pharmaceutical companies one month before allowing compounded preparations.

Gynaecologist Jesús Presa, secretary of the Spanish Association for the Study of Menopause, warns that "switching to another treatment is not that simple." Every woman responds individually, and abrupt withdrawal "can increase the cardiovascular risk" and thrombotic risk. The symptoms Rebeca describes —hot flushes, insomnia, migraines, fatigue, loss of concentration, twelve kilos gained without changing her diet— are precisely the ones HRT minimises.

The double standard men are denouncing

On the other side of the scales, part of the debate argues that the public health system funds hormones for women going through menopause while male TRT is treated with suspicion, as if it were a cosmetic whim. "TRT for men is a before and after," the argument goes, "something the State isn't interested in, since men might start wanting to live, not just pay into the system." Against that, the institutional answer is that TRT is only covered with a diagnosed medical cause, not for natural ageing.

Some go further and calculate that women should contribute more than three times as much as men in healthcare costs and life expectancy. The calculation does not hold up without data, but the discussion about who pays for what in the health system is on the table. There are also those who remind us that HRT is not risk-free: "A friend of my mother's got breast cancer two years in and nearly died," one person claims. Scientific evidence links hormone therapy to risks that must be assessed case by case.

What happens if hormone therapy is stopped abruptly?

Abrupt withdrawal is dangerous. It seriously affects quality of life and can increase cardiovascular risk, as well as a thrombotic risk when stopping and restarting. The symptoms of menopause —hot flushes, irregular periods, intense pain, memory loss, insomnia, fatigue, weight gain, migraines— are not disabling, but they wear down daily life. Hormone replacement therapy regulates and replaces the hormones the body stops producing.

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The question is not whether hormones should be funded, but on what criteria. With testosterone covered only with a diagnosis and menopause treated as an illness, the gap between what counts as medical and what counts as cosmetic remains unresolved. And meanwhile, Rebeca goes from pharmacy to pharmacy with two boxes in her bag.