Objective: To analyse prescribing trends for oral and transdermal hormone replacement therapy (HRT) in Wales from 1996 to 2023, including predictors of discontinuation within one year of initiation. Design: Observational study using the Secure Anonymised Information Linkage (SAIL) databank. Setting: Primary and secondary care data from Wales, encompassing 86% of the population. Population: Annual HRT prescription rates from 1996 to 2023 were assessed for all women in Wales. Predictors of HRT discontinuation within one year were assessed in women aged 40–65 (n = 103,114), excluding those with oophorectomy, hysterectomy, or premature menopause. Methods: HRT prescription rates were normalised per 1000 people and categorised by HRT type, age groups, and deprivation quintiles. Predictors of discontinuation were assessed using zero-inflated negative binomial regression. Main Outcome Measures: Annual HRT prescription rates and predictors of discontinuation, including age, deprivation, time period, and HRT type. Results: From 1996 to 2023, 189,593 women were prescribed oral or transdermal HRT in Wales. Transdermal prescriptions rose exponentially post-2021, while oral prescriptions declined post-2002. Discontinuation rates followed a curvilinear trend: increasing at ages 40–43 and mid-50s onwards and decreasing in mid-40s to early 50s. Oral formats were linked to decreased discontinuation, while transdermals showed increased discontinuation. Deprivation reduced HRT prescriptions overall. Prescriptions post-2000 predicted increased discontinuation, with highest rates seen post-2021. Conclusions: Disparities in HRT prescribing patterns reflect GP and patient perceptions of safety. Women in mid-40s to early 50s, often at a natural menopause stage, adhered better, particularly to oral tablets, suggesting administration route and symptom relief influence adherence. Socioeconomic deprivation remains a barrier to HRT access. Time trends highlight the influence of widely publicised studies and media on uptake, albeit adherence has continually declined since 2001. Additional research is needed to tackle socioeconomic inequalities and assess strategies for achieving cost-effective and efficient HRT prescribing practices.