In November, 2025, the Food and Drug Administration (FDA) announced it would remove black box warnings from estrogen-based Hormone Replacement Therapy (HRT) products.^[1] Due to this change, products that had until then been considered high risk when used for treatment were now considered safer and more advisable. The removal of the warning was then followed by an upsurge in demand for these treatments, which, according to media outlets and many healthcare professionals, led to a shortage of estrogen patches.^[2] This is not, however, the first shortage of these treatments in recent history, as the past 10 years have been marked by interruptions in the supply chain and many occurrences of estrogen scarcity internationally, mainly of patches and injectables, which have mostly been attributed to increases in demand.^[3] The tendency of growth in demand has been building up for over a decade, as usage of estrogen for HRT treatments for menopausal, pre-menopausal, and trans women has slowly risen after a dip in the early 2000s as these products were considered to be of high risk or dangerous.^[4]

While the lack of supply of estrogen-based HRT is linked by many to the higher demand from women who need these products, these women are also the people most affected by them, as discontinuation of HRT therapy can result in health issues ranging from difficulties in sleeping to increased risk of cardiovascular complications.^[5] The reasons for the shortage, however, might not lie in the healthcare needs that many women experience. The pharmaceutical industry plays a much bigger role in the availability of supplies and access to treatment than patients’ demands do, as the motivations from profit and private property determine who produces and has access to medical products. By analysing the dynamics that underlie HRT shortages, we can better understand the involvement of companies that control the pharmaceutical industry and offer a response that supports everyone’s right to have their healthcare needs met.

Patents, Profits and Pharmaceuticals

Women who demand estrogen-based treatments find themselves at the end of a large and complex supply chain. This chain starts in China and India, where the raw materials to make the Active Pharmaceutical Ingredients (APIs) of estrogen-based medicines, soya bean and yams, are gathered and processed.^[6] China and India are the main suppliers of APIs for estrogen and many other medicines that get imported to Europe and the USA, as lower labor and infrastructure costs, together with more relaxed quality control and environmental policies, make outsourcing the production much more efficient.^[7] The lack of local production, while not one of the most unsafe parts of the supply chain, reveals its structural weaknesses, as any global logistics obstacle (as seen not long ago during the COVID-19 pandemic) can result in scarcity due to APIs not arriving on time.

After the raw materials are used to create synthetic estrogen, the chemical is sent to be turned into one of the different forms of administration of HRT. However, not all forms of administration are created equal, as injectable estrogen requires a complicated process of sterilization for its containment, and patches have to go through a highly technical process of assembly, limiting the number of manufacturers that can make those specific products.^[8] While these limitations could be overcome if the technologies and facilities necessary for these products were invested in, estrogen-based treatments are generic medicines; that is, none of their currently existing forms of administration are under a patent anymore and can be produced and sold by any company in the pharmaceutical industry, making them considerably cheaper and resulting in lower profit margins for companies. This makes it less beneficial for companies to invest in strengthening the infrastructure they would need to make complex forms of HRT instead of other products. In many cases, especially for generic injectable medicines, companies may have to wait for years before seeing any profitability from them.^[9] The bottleneck in the supply chain is generated by the economic risks that the investment in assembling specific forms of HRT administration carries, leading to a global infrastructure that is highly vulnerable to quick changes in demand.

While the supply chain of estrogen-based HRT is itself weak in certain points due to capitalist dynamics, geographically specific dynamics of the market and financial institutions are also influential factors in the hormonal treatment shortage. In the European medical market, access to generic pharmaceuticals is made easier through rigid regulations and procurement methods that make medicine providers compete for contracts, lowering their prices.^[10] These methods, however, can result in many suppliers being driven off the market due to low returns on their investment and becoming unable to compete with contract winners. The scarcity of suppliers then makes the system less resilient, as a loss in supply for one pharmaceutical company may lead to shortages due to no other suppliers being able to substitute it.^[11] The American market shows a very different side of capitalist health management, as the most powerful Pharmacy Benefit Managers (PBMs), the companies that mediate between manufacturers, insurance, and pharmacies, are themselves owned by health insurance companies, dominating 79% of the market between the top 3 PBMs and over 90% between the top 6.^[12] PBMs can negotiate with medicine manufacturers for priorities in insurance formularies, which they give in exchange for discounts when buying the products, causing manufacturers to increase their base selling prices to be able to obtain benefits after accepting the discount. Generic pharmaceuticals, which compete with low profit margins, can see themselves under heavy pressure from the PBMs, making suppliers less likely to participate in the market and less able to invest in the supply chain. American pharmaceutical market dynamics also lack resilience, just like the European ones. While Low- and Middle-Income Countries also face shortages, the lack of adoption of HRT in many insurance formularies, sociocultural conditions that stigmatise HRT, and lack of affordability are more relevant factors in making estrogen-based treatments unavailable.^[13]

As demand rises, the system that has been set up through the capitalist market for the production and distribution of estrogen cannot respond due to the way the profit motive has shaped the supply chain. Both the European model of regulation and the American model of market negotiation lead to weak infrastructures that depend on scarce suppliers and cannot support investment into strengthening the production of estrogen patches and injectables. While estrogen tablets do not face these difficulties, they also carry secondary effects that carry increased risk for patients as they pass through the digestive system, being metabolized in the liver.^[14] The solution to the shortage that this system can offer is, then, to continue the treatment in worse conditions, rather than provide the resources necessary to prevent shortages from happening again. This is not just the case of HRT, but of many other pharmaceuticals that become unavailable due to shortages or inflated prices, an occurrence that has become increasingly common. The capitalist system cannot deliver on promises of the right to healthcare as economic benefits make supply chains vulnerable.

How Should Socialists Manage Healthcare?

When looking to develop new ways of understanding healthcare, history can show us experiences from different models that can teach us very important lessons. Among them is the Semashko model, developed in the USSR as a way to give workers power over healthcare, and implemented in several socialist countries. The Semashko model was characterized by the free provision of healthcare through a unified service managed by the state, focusing on preventive care to protect workers from illnesses.^[15] The introduction of five-year plans for the industrialization of the country also integrated healthcare management into economic planning. Healthcare was then coordinated alongside other fields that were also influential on health, such as food production and distribution and labor productivity. The pharmaceutical industry was also economically coordinated alongside other sectors through the pharmaceutical socialist enterprises, which, after the nationalisation of pharmaceutical factories, were all government-owned and formed a joint stock trust.^[16] Pharmacists collaborated with doctors and government officials to work out the pharmaceutical needs of the country and plan medicine production. In East Germany, production reached between 80% and 90% of the country’s pharmaceutical needs and was able to export some of its products, as well as offer foreign aid to other nations.^[17] This model of pharmaceutical production was not flawless, however, as it suffered from poorly planned resource allocation and a lack of many specialized products. Healthcare was also associated with socialist values and policies, and the health of women was given more relevance through legal reforms guaranteeing employment for women, legalizing abortion (as well as decriminalizing homosexuality), and giving childcare priority too. Similarly to the Semashko model, the Beveridge model, developed in Europe and inspired both by liberal political projects and labor movements that inherited the ideas of socialist revolutionaries, also focuses on providing universal public access to healthcare. The Beveridge model, nowadays applied in countries like Spain and England, is based on decentralised healthcare financed by the government through tax payments, allowing for the provision of free healthcare for the whole population.^[18] This model does have some differences in relation to Semashko, mainly the focus on primary care rather than specialized care and the lack of integration of the pharmaceutical industry in the model. While medicine prices are highly regulated in countries where the Beveridge model is applied, the production of pharmaceuticals is organized by private companies.

For healthcare to be a right that is guaranteed to everyone, it must be freed from profit motivations and planned according to the needs of patients. Pushing for public pharmaceutical production and free public healthcare should be a baseline demand in the struggle against medical shortages. Pharmaceutical production is currently dominated by private companies that orient their output towards making profits. Both market regulations regarding the number of different medicines that can be offered and public investments in the production of specific pharmaceuticals to be distributed by the state can be a first step in having increased control not only over medicine prices, but also over what pharmaceuticals are being produced and in what quantities. There are already initiatives that work on similar frameworks from the perspective of public-private partnerships, like the Gavi Vaccine Alliance, which work through financing the development and production of vaccines so they can be freely distributed and shaping markets to make medical equipment and medicines more affordable.^[19] The Drugs for Neglected Diseases Initiative is also interesting, as it pays for the development of pharmaceuticals under the condition that the patent will be as permissive as possible, thus blocking companies from having a monopoly on those medicines and lowering prices.^[20] The Medicine Patents Pool, while not working on financing medical developments, negotiates licenses on patents held by private companies so that their products can be made more affordable, especially in LMICs.^[21] These perspectives can be taken into account when developing socialist health policies that work towards reinforcing workers’ control over the production of pharmaceuticals, directing it towards rational production based on people’s needs. When it comes to payment for medicine, while copayment methods are supposed to alleviate the economic burden for people with low incomes, they still generate inequality and obstacles for many to access treatments.^[22] Payment for medicine could increasingly be done by the government through more inclusive versions of copayment, and eventually fully funding pharmaceuticals for everyone and making them free. This should be accompanied by investing in the creation of infrastructure for pharmaceutical production, such as laboratories and technology necessary for complex products. To sustain rational production of medicines, enough equipment to make those medicines in the amounts necessary must be built. This situation greatly affects pharmaceuticals like injectable or patch-based HRT, although many others are also in the same circumstances. Creating the facilities and technologies that can ensure that production won’t keep on experiencing bottlenecks should be another relevant point in the socialist development of healthcare.

The aim of socialist health management must be to develop a nationalized, centrally planned model of healthcare and pharmaceutical production that can offer care and medication for free based on the needs of everyone, and that invests in building the necessary resources to do so regardless of economic benefits. The Beveridge model currently being employed in many countries is a great example of the public integration of the financier and provider of healthcare by having the government pay for healthcare provision and creating networks of publicly owned hospitals. The producer of medicines, however, is not integrated into the system, and is left in the hands of private corporate interests, causing pharmaceutical shortages among other issues. A socialist healthcare project must integrate pharmaceutical production back into its model like the Semashko system once did. A nationalized system of pharmaceutical production under a workers’ party does not need to generate profits in the same way that private companies do, and can work while experiencing losses or delayed returns. Central planning and coordination can also serve to better organize the supply of different pharmaceutical products and prevent scarcity or react to it much faster by coordinating medicine producers, distributors, and users while investing in the necessary resources to meet demand without taking low or non-existent profits as a risk.

State ownership of pharmaceutical production is ultimately necessary for it to be coordinated with the other aspects of healthcare. By establishing a program that progressively works towards separating the production and distribution of pharmaceuticals from profits and strengthening the power workers can have on these processes, a universal and guaranteed healthcare system can be developed in which pharmaceutical production is not owned by corporations, but by a workers’ party. Other measures have to be pursued that support the establishment of such a model and make it free from discrimination, like improving education on both cis and trans women’s health and hormonal needs, legally protecting the right of trans people to healthcare, and developing support for people who experience menopause, menstruation, or pregnancy.

Fighting the Shortage

While the current scarcity of estrogen-based patches is attributed to women being in need of these products, exploring the supply chain of HRT reveals the infrastructural vulnerabilities that generate shortages in the capitalist pharmaceutical industry. Profit-motivated production of medicines is unable to respond to quick rises in demand, as the necessary investments for a reliable system are not lucrative enough for companies or governments to make them. The current conditions of HRT are not exclusive to hormone-based treatments, but are rather common to many other pharmaceuticals which are made in the same supply chains and provided by the same companies and agents. This situation makes patients dependent on a production model that cannot guarantee availability of the medicines they need, as these become scarce and unaffordable.

Socialist healthcare management models, however, give us directions on how to combat these issues and guarantee proper healthcare. Increasing investments in the production of pharmaceuticals based on needs, working towards more open-license patents, and building the necessary infrastructure to support the production of complex products are all policies that can increase workers’ power over the medicines they need. These steps must lead to the nationalization and rational planning of healthcare and pharmaceutical production, and their coordination with other fields like food production or childcare that are essential pillars for the health of workers. To guarantee that everyone can access the medical treatments they need, perspectives on healthcare must change their motivations, prioritizing public, free, and planned production. Healthcare must be free, universal, and guaranteed, and capitalism has failed to deliver.

1. Zeeshan, FNU, and Ali Saqlain. 2026. ‘FDA’s 2025 Removal of Black Box Warnings on Menopausal Hormone Therapy’. Annals of Medicine and Surgery 88 (2): 2222–23. https://doi.org/10.1097/MS9.0000000000004749.

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2. Cuevas, Karina. 2026. ‘Estrogen Patches Face Shortage as More Women Seek Hormone Therapy’. PBS News, April 7. https://www.pbs.org/newshour/show/estrogen-patches-face-shortage-as-more-women-seek-hormone-therapy.

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3. Manasan, Althea. 2025. ‘Worldwide Shortages of Hormone Replacement Medication Leave Women Struggling’. CBC Radio, August 9. https://www.cbc.ca/radio/day6/hormone-replacement-therapy-shortage-1.7602722.

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4. Ameye, Lieveke, Caroline Antoine, Marianne Paesmans, Evandro de Azambuja, and Serge Rozenberg. 2014. ‘Menopausal Hormone Therapy Use in 17 European Countries during the Last Decade’. Maturitas 79 (3): 287–91. https://doi.org/10.1016/j.maturitas.2014.07.002; Miller, Korin. 2026. ‘Researchers Say This Once-Controversial Therapy Has Doubled In the Last Decade’. Women’s Health. https://www.womenshealthmag.com/health/a73419275/hormone-therapy-doubled-decade-study/.

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5. Heesewijk, J. O. van, R. E. S. Geels, M. den Heijer, K. M. A. Dreijerink, and B. P. C. Kreukels. 2026. ‘Psychological and Physical Effects of Short-Term Discontinuation of Feminizing Gender-Affirming Hormone Therapy among Older Transgender Women: A within-Subject Clinical Trial’. Human Reproduction 41 (8): 1387–96. https://doi.org/10.1093/humrep/deag087; Mikkola, Tomi S., Pauliina Tuomikoski, Heli Lyytinen, et al. 2015. ‘Increased Cardiovascular Mortality Risk in Women Discontinuing Postmenopausal Hormone Therapy’. The Journal of Clinical Endocrinology & Metabolism 100 (12): 4588–94. https://doi.org/10.1210/jc.2015-1864.

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6. Kollewe, Julia. 2022. ‘HRT: Inside the Complex Global Supply Chain behind a $20bn Market’. Business. The Guardian, September 24. https://www.theguardian.com/business/2022/sep/24/hrt-inside-the-complex-global-supply-chain-behind-a-20bn-market.

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7. For an account of the outsourcing of API production from the USA, see Pratap, Aayushi. 2025. ‘Raw Materials from China and India Fuel the Production of Medicines Used in the US’. Chemical & Engineering News, January 21. https://cen.acs.org/pharmaceuticals/Raw-materials-overseas-fuel-production/103/web/2025/10; Sardella, Anthony. 2021. ‘The US Active Pharmaceutical Ingredient Infrastructure Report’. Clarivate. Biopharma. Clarivate. https://clarivate.com/life-sciences-healthcare/lp/the-us-active-pharmaceutical-ingredient-infrastructure-report/. For studies that explain the European case of outsourcing, see Fantasia, Anais. 2022. ‘A Strong European API Industry Can Achieve Strategic Autonomy of the EU Health System’. EFCG. https://efcg.cefic.org/mediaroom/a-strong-european-api-industry-can-achieve-strategic-autonomy-of-the-eu-health-system/; Toshev, Atanas, Anna A. Mihaylova, Vasil Madzharov, et al. 2025. ‘The European Union‘s Dependence on Imports of Active Pharmaceutical Ingredients from Third Countries – Challenges and EU Initiatives’. Pharmacia 72 (October): 1–6. https://doi.org/10.3897/pharmacia.72.e172383.

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8. This is a common issue for many pharmaceuticals that are administered through these methods. For an explanation of the difficulties for injectables, see Fox, Erin R., and Milena M. McLaughlin. 2018. ‘ASHP Guidelines on Managing Drug Product Shortages’. American Journal of Health-System Pharmacy 75 (21): 1742–50. https://doi.org/10.2146/ajhp180441; Woodcock, Janet, and Marta Wosinska. 2013. ‘Economic and Technological Drivers of Generic Sterile Injectable Drug Shortages’. Clinical Pharmacology and Therapeutics 93 (2): 170–76. https://doi.org/10.1038/clpt.2012.220. Paatches also experience manufacturing difficulties, as can be seen in Roy, Mrinalika, and Sriparna Roy. 2026. ‘Patients Scramble to Find Estrogen Patches as Shortage Worsens after US FDA Champions Use’. Healthcare & Pharmaceuticals. Reuters, April 9. https://www.reuters.com/legal/litigation/patients-scramble-find-estrogen-patches-shortage-worsens-after-us-fda-champions-2026-04-09/; Therapeutic Goods Administration (TGA). 2024. ‘About the Shortage of Transdermal HRT Patches’. Text. Therapeutic Goods Administration, March 15. https://www.tga.gov.au/safety/shortages-and-supply-disruptions/medicine-shortages/major-or-ongoing-medicine-shortages/about-shortage-transdermal-hrt-patches.

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9. Holtkamp, Nicholas, and Murphy. 2024. ‘An Examination of the Return on Investment of Generic Injectable Prescription Drugs’. ASPE, December 31. http://aspe.hhs.gov/reports/roi-generic-injectable-prescription-drugs.

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10. OECD. 2010. ‘Generic Pharmaceuticals : Key Findings, Summary and Notes’. OECD Roundtables on Competition Policy Papers, ahead of print, October 4. https://doi.org/10.1787/fb859097-en.

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11. 2025 EAHP Medicines and Medical Devices Shortages Survey. 2026. European Association of Hospital Pharmacists. https://eahp.eu/policy-hub/medicines-shortages/; Ferrario, Alessandra, Guillaume Dedet, Tifenn Humbert, Sabine Vogler, Fatima Suleman, and Hanne Bak Pedersen. 2020. ‘Strategies to Achieve Fairer Prices for Generic and Biosimilar Medicines’. Analysis. BMJ 368 (January): l5444. https://doi.org/10.1136/bmj.l5444.

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12. Pharmacy Benefit Managers: The Powerful Middlemen Inflating Drug Costs and Squeezing Main Street Pharmacies. 2024. Federal Trade Commission. https://www.ftc.gov/reports/pharmacy-benefit-managers-report.

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13. Delanerolle, Gayathri, Snehal Ghosh, Paula Briggs, et al. 2026. ‘A Perspective on Economic Barriers and Disparities in Access to Hormone Replacement Therapy in LMICs (MARIE-WP2b)’. Scientific Reports 16 (1): 19272. https://doi.org/10.1038/s41598-026-49559-z; Pathiraja, Vindya, Om Kurmi, Teck-Hock Toh, et al. 2025. ‘Exploring the Availability and Acceptability of Hormone Replacement Therapy in LMICs Using Insights of Pharmacists (MARIE Sri Lanka WP2a)’. Scientific Reports 15 (October): 37944. https://doi.org/10.1038/s41598-025-18083-x.

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14. Goldštajn, Marina Šprem, Mislav Mikuš, Filippo Alberto Ferrari, et al. 2023. ‘Effects of Transdermal versus Oral Hormone Replacement Therapy in Postmenopause: A Systematic Review’. Archives of Gynecology and Obstetrics 307 (6): 1727–45. https://doi.org/10.1007/s00404-022-06647-5; Goodman, Michael P. 2012. ‘Are All Estrogens Created Equal? A Review of Oral vs. Transdermal Therapy’. Journal of Women’s Health (2002) 21 (2): 161–69. https://doi.org/10.1089/jwh.2011.2839.

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15. Heinrich, Andreas. 2022. ‘The Emergence of the Socialist Healthcare Model After the First World War’. In International Impacts on Social Policy: Short Histories in Global Perspective, edited by Frank Nullmeier, Delia González de Reufels, and Herbert Obinger. Springer International Publishing. https://doi.org/10.1007/978-3-030-86645-7_4.

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16. Conroy, Mary Schaeffer. 2004. ‘The Soviet Pharmaceutical Industry and Dispensing, 1945-1953’. Europe-Asia Studies 56 (7). https://doi.org/10.1080/1465342042000294329; Conroy, Mary Schaeffer. 2006. The Soviet Pharmaceutical Business During the First Two Decades (1917-1937). Peter Lang.

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17. ‘“Socialism Is the Best Prophylaxis”: The German Democratic Republic’s Health Care System’. 2023. Tricontinental: Institute for Social Research, February 14. https://thetricontinental.org/studies-2-ddr-health-care-2/.

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18. Tsiachristas, Apostolos, Karsten Vrangbæk, Pamela Gongora-Salazar, and Søren Rud Kristensen. 2023. ‘Integrated Care in a Beveridge System: Experiences from England and Denmark’. Health Economics, Policy and Law 18 (4): 345–61. https://doi.org/10.1017/S1744133123000166; Wallace, Lorraine S. 2013. ‘A View Of Health Care Around The World’. Departments. The Annals of Family Medicine 11 (1): 84–84. https://doi.org/10.1370/afm.1484.

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19. ‘Gavi, the Vaccine Alliance’. 2026. August 21. https://www.gavi.org/.

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20. ‘DNDi – Best Science for the Most Neglected’. 2019. October 15. https://dndi.org/.

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21. Patent Pooling & Voluntary Licensing for Public Health - MPP. 2020. March 2. https://medicinespatentpool.org/what-we-do/licensing-for-public-health.

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22. Pinilla, Jaime, Christian González-Martel, Beatriz González López-Valcárcel, Félix Lobo, and Jaume Puig-Junoy. 2025. ‘Análisis de Equidad y Sostenibilidad Presupuestaria Del Sistema de Copago Farmacéutico En España’. Gaceta Sanitaria, Special Issue on Health Economics, vol. 39 (January): 102427. https://doi.org/10.1016/j.gaceta.2024.102427.

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