Given the global decline in the use of hormone therapy among women, aimed to determine the prevalence of use of prescription therapies for menopausal symptoms.A cross-sectional questionnaire-based study of 2,020 Australian women was conducted between October 2013 and March 2014. Women aged 40 to 65 years who were able to complete a questionnaire in English were recruited from a large dynamic database derived from the Australian electoral roll. The main outcome measures were use of prescription therapies for menopausal symptoms and the Menopause-specific Quality of Life questionnaire.A total of 5,850 women were invited (by telephone) to participate: 2,911 agreed to participate, and 2,020 completed questionnaires were returned. Demographic characteristics show that participants were representative of all Australian women of this age. For this analysis, only 1,491 perimenopausal and postmenopausal women were included. Moderate to severe vasomotor symptoms (VMS) were reported by 17% of women, and 18.3% of women reported moderate to severe sexual symptoms. Among all participants, 11.3% used hormone therapy, mostly oral estrogen (68.5%). Among all women, 1.1% used compounded estrogen and/or compounded progesterone, 0.9% used androgen therapies (dehydroepiandrosterone or testosterone), 0.9% used tibolone, 0.9% used nonhormone therapies, and 4.5% used vaginal estrogen. Hormone therapy use was associated with surgical menopause (adjusted odds ratio [AOR], 3.27; 95% CI, 2.0-5.44), and moderate-severe psychological symptoms (AOR, 1.83; 95% CI, 1.19-2.80. Current smoking (AOR, 0.53; 95% CI, 0.29-0.96) and a BMI ≥ 40 (AOR, 0.35; 95% CI, 0.14-0.87 were inversely associated with hormone therapy use. Extrapolating our findings to 3.7 million Australian women aged 40 to 64 years, we found that 455,000 women are likely to have moderate to severe VMS, with most women (385,000) remaining untreated.Most women with severe menopausal symptoms remain untreated despite the availability of safe nonhormone therapies and safer low-dose transdermal hormone therapies. Vaginal estrogen therapy is underprescribed.