A national probability survey of American Medical Association gynecologists and primary care physicians concerning menopause

Prevalence of offering menopause hormone therapy among primary care doctors and its associated factors: A cross-sectional study

BACKGROUND

Guidelines recommend Menopausal Hormone Therapy (MHT) as the most effective treatment for menopausal symptoms. However, a local study found that the usage of MHT among menopausal women was low (8.1%), with one of the main reasons being it is not recommended by doctors. Therefore, the objectives of this study are to determine the prevalence of offering MHT in treating symptomatic menopausal women among primary care doctors (PCDs) and its associated factors.

METHODS

This cross-sectional study involved PCDs from the Federal Territory of Kuala Lumpur, the Federal Territory of Putrajaya and the state of Selangor. All PCDs provided services in government primary care clinics from the three states were invited through the doctor in charge of each clinic. An online survey links was provided for the participants to the self-administered questionnaire. The questionnaire included PCDs' demographics, their menopause management practices, attitudes towards MHT, perceived barriers in offering MHT, knowledge of related guidelines and received training on menopause management. The outcome variable was offering MHT which defined as either prescription of MHT or referral to hospital for MHT initiation. Multivariate logistic regression analysis was performed to determine the factors associated with offering MHT.

RESULTS

The response rate was 42.9% (559/1301). Of those who participated in the study, 77.8% of PCDs were female and 89.1% were medical officer. Although 66.9% of the participants reported offering MHT to their patients, the actual prescription rate was low (0.9%). Most PCDs (66%) would refer the patients to hospitals. 87.1% of PCDs (487/559) reported that MHT was not available in their clinic. In the past 12 months, 83% of PCDs had not received any related training. Female PCDs (AOR:2.5, CI: 1.51-4.13, p<0.001), perceiving MHT as preference treatment for menopause symptom (AOR:3.6, CI: 2.13-6.19, p < 0.001), having likelihood to recommend MHT to family and friends (AOR:3.0, CI: 1.87-4.83, p < 0.001), and receiving training on menopause management (AOR:2.7, CI: 1.30-5.56, p = 0.008) were the positive predictor of offering MHT. The negative predictors in offering MHT were no-experience in prescribing MHT (AOR: 0.4, CI: 0.15-0.87, p = 0.024) and lack of information regarding MHT for the patient (AOR: 0.4, CI:0.20-0.67, p < 0.001).

CONCLUSION

The study revealed a low rate of MHT prescription among PCDs, with many relying on referrals to hospitals for managing menopausal symptoms. The findings underscore the need for strategies that includes fulfilling professional training gaps, improving MHT availability, and improving information dissemination for patient.

Resident training to optimize patient-focused menopause management: a multispecialty menopause curriculum to enhance knowledge and preparedness

OBJECTIVE

Surveys of residents in obstetrics and gynecology, internal medicine, and family medicine have demonstrated low levels of knowledge and comfort in treating patients with menopausal symptoms, suggesting a need for improved training during residency. To address this problem, we used a flipped classroom design to deliver a novel menopause curriculum for medical residents. The curriculum included six podcast episodes followed by an interactive case-based classroom session. We then assessed effects of the curriculum on the residents' knowledge and preparedness to manage menopause symptoms.

METHODS

We targeted 200 residents (43 obstetrics and gynecology, 86 internal medicine, and 71 family medicine) from six residency programs from 2019 to 2020. Of these, 115 (58%) completed both pre- and postcurriculum assessments, including a 15-item knowledge test and self-ratings of their knowledge, comfort, and preparedness to manage menopause.

RESULTS

Following the curriculum, the proportion of correctly answered knowledge questions rose from 60.8% to 79.1% (+18.3%; 95% confidence interval, 15.4-21.2; Cohen's d = 1.2). Improvement did not significantly differ by specialty or year of residency. There were higher gains for residents who listened to the entirety of all six podcast episodes ( b = 11.4, P < 0.001) and who attended the classroom session ( b = 11.6, P = 0.003). Residents' self-ratings of knowledge, comfort, and preparedness also improved following the curriculum across all medical specialties (Cohen's d = 0.47-1.2). Residents rated the podcast format as convenient (73%) and effective (65%) compared with an equivalent amount of reading.

CONCLUSIONS

Pairing a podcast with a classroom discussion was found to be an effective combination for improving menopause knowledge.

Herb-drug interactions between androgenic Chinese herbal medicines and androgen receptor antagonist on tumor growth: Studies on two xenograft prostate cancer animal models

Our previous study revealed that Epimedii Folium (EF) and Codonopsis Radix (CNR) significantly promoted tumor growth on a subcutaneous mouse model of prostate cancer (PCa) via enhancing the mRNA and protein expressions of androgen receptor (AR), while Astragali Radix (AGR) inhibited tumor growth via suppressing the protein expression of AR. In the present study, we aimed to investigate the potential interactions between EF, CNR or AGR and AR antagonist (abiraterone acetate [ABI]) on the tumor growth using subcutaneous and orthotopic PCa mouse models. EF, CNR, AGR and ABI were intragastrically given to mice once every 2 days for 4 weeks. The pharmacokinetics of ABI were evaluated in the plasma of rats when combined with EF, CNR, or AGR. Our results demonstrated that EF or CNR could weaken the anti-tumor effects of ABI via increasing the AR expression involving activation of the PI3K/AKT and Rb/E2F pathways and decreasing the bioavailability of ABI, while AGR could enhance the anti-tumor effects of ABI through suppressing the AR expression via inhibiting the activations of PI3K/AKT and Rb/E2F pathways and increasing the bioavailability of ABI. These findings imply that cautions should be exercised when prescribing EF and CNR for PCa patients.

Improving management of the genitourinary syndrome of menopause: evaluation of a health system-based, cluster-randomized intervention

BACKGROUND

Genitourinary symptoms are common in postmenopausal women and adversely affect the quality of life. National surveys and data collected from our healthcare system indicate that postmenopausal women with the genitourinary syndrome of menopause often fail to receive appropriate diagnosis or treatment.

OBJECTIVE

To promote greater detection and treatment of the genitourinary syndrome of menopause, we created and tested a clinician-focused health system intervention that included clinician education sessions and a suite of evidence-based electronic health record tools.

STUDY DESIGN

Using a cluster-randomized design, we allocated primary care (16) and gynecology (6) clinics to the intervention or control group. From September to November 2014, we provided training about the diagnosis and treatment of genitourinary syndrome of menopause in face-to-face presentations at each intervention clinic and in an online video. We developed clinical decision support tools in the electronic health record that contained an evidence-based, point-of-care knowledge resource, a standardized order set, and a checklist of patient education materials for the patient's after visit summary. The tools aimed to facilitate accurate diagnostic coding and prescribing (SmartSet, SmartRx) along with relevant patient information (SmartText). Clinicians who only performed visits at control clinics received no training or notification about the tools. Our primary outcome was vulvovaginal diagnoses made at well visits for women at the age of 55 years and older from November 15, 2014 to November 15, 2015. We also assessed urinary diagnoses, vaginal estrogen prescriptions, and use of the electronic tools. There was departmental support for the intervention but no prioritization within the healthcare system to incentivize change.

RESULTS

In the 1-year period, 386 clinicians performed 14,921 well visits for women at the age of 55 years and older. Among the 190 clinicians who performed well visits in the intervention clinics, 109 (57.4%) completed either in-person or online educational training. The proportion of visits that included a vulvovaginal (7.2% vs 5.8%; odds ratio, 1.27; 95% confidence interval, 0.65-2.51) or urinary diagnosis (2.5% vs 3.1%; odds ratio, 0.79; 95% confidence interval, 0.55-1.13) or vaginal estrogen prescription (4.5% vs 3.7%; odds ratio, 1.24; 95% confidence interval, 0.63-2.46) did not differ between study arms. There was a significant interaction for primary care and gynecology, which revealed more vulvovaginal diagnoses by gynecology but not primary care intervention clinics (odds ratio, 1.63; 95% confidence interval, 1.15-2.31), but there was no significant interaction for prescriptions. Clinicians in the intervention clinics were more likely to use decision support tools than those in control clinics-SmartSet (22.2% vs 1.5%; odds ratio, 18.8; 95% confidence interval, 5.5-63.8) and SmartText for patient information (38.0% vs 24.4%; odds ratio, 1.91; 95% confidence interval, 1.10-3.34). A per-protocol analysis revealed similar findings.

CONCLUSION

Overall, the intervention did not lead to more diagnoses or prescription therapy for postmenopausal genitourinary symptoms but did result in greater distribution of patient information. Gynecology clinicians were more likely to address genitourinary symptoms generally and were more likely to make a vulvovaginal diagnosis after the intervention. Further efforts for improving care should consider ongoing clinician education beginning with enhanced menopause curricula in residency training. Additional interventions to consider include greater access for postmenopausal women to gynecologic care, addressing treatment barriers, and development of national performance metrics.

Effects of Korean Red Ginseng (Panax ginseng C.A. Meyer) on Menopausal Symptoms in Premenopausal Women After Gynecologic Cancer Surgery: A Double-Blind, Randomized Controlled Trial

Objectives: Korean red ginseng (KRG) has been widely used as an alternative medicine to relieve menopausal symptoms. However, there is still a lack of clinical studies showing the effects of KRG on menopausal symptoms after gynecologic cancer surgery. Therefore, the authors investigated the effects of KRG on surgical menopause symptoms in premenopausal women with gynecologic cancer. Design: A double-blind, randomized, placebo-controlled clinical trial was conducted. Settings/Location: The study was performed at Severance Hospital at the Yonsei University College of Medicine in Seoul, Korea. Subjects: Fifty-five premenopausal women diagnosed with gynecologic cancer were enrolled in the study. Interventions: Patients were randomly assigned to a KRG (n = 29) or a placebo control group (n = 26). Subjects were administered either KRG (a total of 3 g per day) or placebo supplements for 12 weeks. Outcome measures: Patients' physical measurements (height, weight, and blood pressure) and blood samples (lipid profiles, hormone profiles, biochemical profiles, and neutrophil-to-lymphocyte ratio) at baseline and at 12 weeks were compared. Changes in menopausal symptoms based on the Menopause Rating Scale (MRS) were also compared between these two time points and two groups. Results: After 12 weeks, the MRS score was significantly reduced in each group (p = 0.001 and p = 0.001, respectively), but there were no significant differences between the two groups (p = 0.661). No adverse events were observed in either group. After comparing 11 MRS symptoms between the two groups, the KRG group seemed to be superior to the placebo group on the subscale of sexual complaints (p < 0.05). Conclusions: Through the study, KRG did not show absolute relief of surgical menopause symptoms in premenopausal women after gynecologic cancer surgery. However, the study did demonstrate that KRG may be effective in reducing sexual complaints. Further studies are required to evaluate the long-term effects of KRG in a larger patient population.

Evaluation of the effects of androgenic Chinese herbal medicines on androgen receptors and tumor growth in experimental prostate cancer models

ETHNOPHARMACOLOGICAL RELEVANCE

Many prostate cancer (PCa) patients in Mainland China and other Asian countries often use Chinese herbal medicines as an adjuvant treatment while receiving Western medicines. However, concerns have been raised about the potential herb-drug interaction when using herbal medicines containing phytoandrogens.

AIM OF THE STUDY

This study aimed to investigate the effects of the selected 21 Chinese herbal medicines on the proliferation and tumor growth using the relevant in vitro and in vivo models of PCa.

MATERIALS AND METHODS

After treatment of LNCaP and 22Rv1 cells with different concentrations of 70% ethanol extracts of the 21 selected herbal medicines for 48 h, the proliferative activity, the effects on androgen receptor (AR) and prostate specific antigen (PSA) were determined. The anti-tumor effects of the 21 herbs on PCa growth were also investigated on a subcutaneous mouse model of PCa.

RESULTS

The results showed that Epimedii Folium (EF) and Codonopsis Radix (CNR) could significantly increase the cell viability in LNCaP cells (p < 0.05 for both) and 22Rv1 cells (p < 0.05 for both), protein expressions of AR in LNCaP cells (p < 0.05 for both) and 22Rv1 cells (p < 0.05 for both), and PSA (p < 0.05 for both) in LNCaP cells. EF, CNR, and Cistanches Herba (CCH) markedly accentuated the tumor growth (p < 0.05 for three drugs) and AR expression (p < 0.05 for three herbs) in tumor tissues. On the other hand, treatment with Astragali Radix (AGR), Chuanxiong Rhizoma (CXR) and Bruceae Fructus (BF) significantly inhibited the cell viability in LNCaP cells (p < 0.05, p < 0.05 and p < 0.001, respectively) and in 22Rv1 cells (p < 0.05, p < 0.05 and p < 0.001, respectively), and the protein expression of AR in LNCaP cells (p < 0.05 for three herbs) and 22Rv1 cells (p < 0.05, p < 0.05 and p < 0.001, respectively), and the protein expression of PSA (p < 0.05 for three herbs) in LNCaP cells, as well as tumor growth (p < 0.05 for three herbs) and the AR expression (p < 0.05 for AGR and CXR, p < 0.001 for BF) in tumor tissues.

CONCLUSION

Our results revealed that AGR, CXR and BF suppressed the PCa development via inhibition of AR expression, while EF, CNR and CCH promoted the development and progression of PCa via enhancement of AR expression. The results strongly suggest that caution should be exercised when using androgenic Chinese herbal medicines in PCa patients.

Focus group reactions to an arts-based educational exhibit on menopausal hot flashes

OBJECTIVE

To assess public reactions to an arts-based educational exhibit designed to immerse and engage people in scientific facts to increase their conceptual understanding of hot flashes. Our ultimate goals were to stimulate learning and conversations about menopausal hot flashes to change interactions between menopausal women and providers, and menopausal women and other people (family, friends, etc). Focus groups reacted to the concept art (graphics, miniaturized model); and a questionnaire for quickly assessing reactions.

METHODS

Using a qualitative descriptive methodology, six focus groups of diverse people (n = 50) aged 13 to 64 years described their reactions to the art and questionnaire. Recruitment methods were word of mouth, advertisements on university websites, and a university-based participant registry. Data were analyzed using qualitative content analysis and inductively derived codes.

RESULTS

Reactions to the concept art were generally favorable. Participants remarked on appealing and less appealing aspects and age appropriateness. Appealing aspects were resonance with women's experiences, clear information, use of symbolism, and overall design. Less appealing aspects lacked resonance, contained confusing information, or unappealing design elements. Participants felt the exhibit should be open to all ages. The final questionnaire reflected participants' descriptions of the art's ability to stimulate learning, dispel myths, spur dialog, and increase empathy.

CONCLUSIONS

The concept art is an appropriate tool for improving knowledge and communication about hot flashes. Displaying the concept art and/or future full-scale exhibit in healthcare settings or public venues may facilitate learning and communication among three groups-menopausal women, healthcare providers, and others.

Public survey reactions to an arts-based educational menopausal hot flash exhibit

OBJECTIVE

The aim of this study was to obtain public survey reactions to concept art for an exhibit about menopausal hot flashes designed to stimulate learning, dispel myths, spur dialogue, and increase empathy.

METHODS

Immediately before viewing the art, participants provided demographic information and answered one open-ended question. Immediately after viewing the art, participants answered the same open-ended question, one additional open-ended question, and completed quantitative survey questions.

RESULTS

Overall, public reactions to the concept art were positive. Qualitative and quantitative data indicated that the public thought the exhibit was appealing, stimulated learning, dispelled myths, spurred desire to have conversations about hot flashes, and increased empathy for women with menopausal hot flashes.

CONCLUSIONS

The exhibit concept art was appealing and was reported to have a positive impact on the public. Study findings provide support for building the exhibit full-scale as a traveling educational resource that might change public discourse around menopausal hot flashes.

Efficacy and side effects of chinese herbal medicine for menopausal symptoms: a critical review

This study evaluates 23 (9 Chinese and 14 non-Chinese) randomized controlled trials for efficacy and side effects of Chinese herbal medicine on menopausal symptoms. Menopause was diagnosed according to western medicine criteria in all studies while seven Chinese studies and one non-Chinese study further stratified the participants using traditional Chinese medical diagnosis "Zheng differentiation." Efficacy was reported by all 9 Chinese and 9/14 non-Chinese papers. Side effects and adverse events were generally mild and infrequent. Only ten severe adverse events were reported, two with possible association with the therapy. CHM did not increase the endometrial thickness, a common side effect of hormone therapy. None of the studies investigated long-term side effects. Critical analysis revealed that (1) high-quality studies on efficacy of Chinese herbal medicine for menopausal syndrome are rare and have the drawback of lacking traditional Chinese medicine diagnosis (Zheng-differentiation). (2) Chinese herbal medicine may be effective for at least some menopausal symptoms while side effects are likely less than hormone therapy. (3) All these findings need to be confirmed in further well-designed comprehensive studies meeting the standard of evidence-based medicine and including Zheng-differentiation of traditional Chinese medicine.

Complementary medicine in the primary care setting: Results of a survey of gender and cultural patterns in Israel

OBJECTIVE

The purpose of this study was to examine the use of complementary and alternative medicine (CAM) in a primary care practice in Israel to determine prevalence and patterns of use.

METHODS

Trained research assistants invited all patients attending the administrative, medical, pharmaceutical, or nursing services of 7 clinics in urban and rural areas of northern Israel over a 16-month period, from April 1, 2005, through August 1, 2006, to complete a 13-item written questionnaire about CAM use and beliefs about CAM safety and efficacy. CAM was defined as therapies often referred to as alternative, complementary, natural, or folk/traditional medicine, and which are not usually offered as part of the medical treatment in the clinic, including herbal medicine, Chinese medicine (including acupuncture), homeopathy, folk and traditional remedies, dietary/nutritional therapy (including nutritional supplements), chiropractic, movement/manual healing therapies (including massage, reflexology, yoga, and Alexander and Feldenkrais techniques), mind-body techniques (including meditation, guided imagery, and relaxation), energy and healing therapies, and other naturopathic therapies. The Pearson chi(2) test and multivariate logistic regression were used to assess univariate associations with the odds ratios of CAM use among Arab and Jewish women. A t test was performed to determine whether there were any differences in the continuous variables between the 2 groups.

RESULTS

Of 3972 consecutive patients who received the questionnaire, 3447 responded; 2139 respondents (62%) were women. Of the female respondents, 2121 reported their religion (1238 respondents [58%] self-identified as being Arab, and 883 [41.6%] as being Jewish). Compared with men, more women used CAM during the previous year (46.4% vs 39.4%; P < 0.001). Women were more likely to use CAM and to be interested in receiving CAM at primary care clinics. Arab women reported less CAM use than Jewish women but were more interested in experiencing CAM, had a higher degree of confidence in CAM efficacy and safety, and more frequently supported the integration of CAM practitioners in primary care clinics.

CONCLUSIONS

In this study, women visiting primary care clinics in northern Israel used CAM more often than men did. Arab women reported less use of CAM than did Jewish women but also reported greater confidence in CAM efficacy and safety.

Undertreatment of menopausal symptoms and novel options for comprehensive management

OBJECTIVE

There is currently a gap in treatment options for menopausal symptoms and a need for comprehensive therapies that are safe and effective for postmenopausal women. This review discusses challenges in the management of menopausal symptoms and the effect of the Women's Health Initiative (WHI) study findings on current treatment patterns. It also examines present and future therapies.

RESEARCH DESIGN AND METHODS

A literature search was conducted using Medline, the Cochrane Database, and the National Heart Lung and Blood Institute WHI website with the following search terms: primary care, menopause, vasomotor symptoms, hormone therapy, osteoporosis, and vaginal atrophy. Searches were limited to articles published between 1995 and 2009.

RESULTS

Comprehensive therapies that target several aspects of menopause, such as vasomotor symptoms and chronic disease prevention, are currently hormone based. These hormone-based approaches are considered more effective than currently available nonhormonal therapies for the relief of menopausal symptoms. However, hormone therapy is not recommended for women at high risk for venous thromboembolic events, cardiovascular disease, and/or breast cancer. A need exists for novel therapies that mitigate menopausal symptoms, provide protection from osteoporosis, and encourage patient compliance without promoting cancer, heart disease, or stroke. Emerging modalities and strategies, such as the tissue selective estrogen complex (TSEC), Org 50081, MF101, and desvenlafaxine, may provide improved options for postmenopausal women.

CONCLUSIONS

Several new menopausal therapies that may help to address the ongoing unmet need for safe and effective therapies for postmenopausal women are currently in development. In particular, the TSEC, which provides the benefits of both a selective estrogen receptor modulator and conjugated estrogens with an improved tolerability profile, may offer advantages over currently available treatment options. Limitations of this review include the narrow search criteria and limited search period.

Intra-professional and inter-professional referral patterns of chiropractors

BACKGROUND

With the increasing popularity of chiropractic care in the United States, inter-professional relationships between conventional trained physicians (MDs and DOs) and chiropractors (DCs) will have an expanding impact on patient care. The objectives of this study are to describe the intra-professional referral patterns amongst DCs, describe the inter-professional referral patterns between DCs and conventional trained medical primary care physicians (MDPCPs), and to identify provider characteristics that may affect these referral behaviors.

METHODS

A survey instrument to assess the attitudes and patterns of referral and consultation between MD primary care physicians (MDPCPs) and DCs was developed and sent to all DCs in the state of Iowa. Multivariable logistic regression models were built to assess the impact of provider characteristics on intra-professional and inter-professional referral patterns.

RESULTS

Of all DCs contacted, 452 (40.7%) participated in the study. Close to 8% of DCs reported that they never send a case report when referring a patient to another DC, while 13% never send a case report to a MDPCP. About 10% of DCs never send follow-up clinical information to referring doctors. DCs that perform differential diagnosis were significantly more likely to have engaged in inter-professional referral than DCs who did not perform differential diagnosis.

CONCLUSION

The tendency toward informality, in both referral practices and sharing of clinical documentation for referred patients between MDPCPs and DCs, is an explicit marker of concerns that need to be addressed in order to improve coordination and continuity of care for patients shared between these provider types.

Referral patterns and attitudes of primary care physicians towards chiropractors

Background

Despite the increasing usage and popularity of chiropractic care, there has been limited research conducted to examine the professional relationships between conventional trained primary care physicians (PCPs) and chiropractors (DCs). The objectives of our study were to contrast the intra-professional referral patterns among PCPs with referral patterns to DCs, and to identify predictors of PCP referral to DCs.

Methods

We mailed a survey instrument to all practicing PCPs in the state of Iowa. Descriptive statistics were used to summarize their responses. Multivariable logistic regression analyses were conducted to identify demographic factors associated with inter-professional referral behaviors.

Results

A total of 517 PCPs (33%) participated in the study. PCPs enjoyed strong intra-professional referral relationships with other PCPs. Although patients exhibited a great deal of interest in chiropractic care, PCPs were unlikely themselves to make formal referral relationships with DCs. PCPs in a private practice arrangement were more likely to exhibit positive referral attitudes towards DCs (p = 0.01).

Conclusion

PCPs enjoy very good professional relationships with other PCPs. However, the lack of direct formalized referral relationships between PCPs and chiropractors has implications for efficiency, continuity, quality, and patient safety in the health care delivery system. Future research must focus on identifying facilitators and barriers for developing positive relationships between PCPs and chiropractors.