Hand osteoarthritis (OA) is one of the commonest musculoskeletal conditions, primarily affecting women over the age of 50, typically around the age of the menopause. Symptomatic disease can give rise to substantial pain, impairment of hand function and quality of life, leading to significant socioeconomic cost. There is currently no disease-modifying therapy, representing a huge unmet clinical need. The evidence for a relationship between hand OA and the menopause is summarised. Whether there is evidence for an effect of menopausal hormonal therapy on the incidence, prevalence or severity of symptomatic hand OA is critically reviewed, and gaps in our knowledge identified. Lastly, the potential mechanisms by which estrogen, or newer agents such as SERMs, might act to interfere with disease pathogenesis are overviewed. The need for specifically designed, controlled trials of agents in cohorts with symptomatic hand OA, refractory to standard symptomatic management is highlighted.