The role of treatment intentions and concerns about side effects in women's decision to discontinue postmenopausal hormone therapy

Menopausal hormone therapy trends before versus after 2002: impact of the Women's Health Initiative Study Results

OBJECTIVE

To better understand how to educate patients and providers about study findings relevant to treatment guidelines, we assessed pre- versus post-Women's Health Initiative (WHI) differences in menopausal hormone therapy (MHT) initiation and continuation and their correlates, and in women's reasons for initiation and discontinuation.

METHODS

We analyzed survey data from up to 14 approximately annual visits over 17 years (1996-2013) from 3,018 participants in the Study of Women's Health Across the Nation, a prospective cohort study. We used logistic regression to compare pre- versus post-WHI associations of covariates with MHT initiation and continuation, and to compare pre- versus post-WHI reasons for initiation and continuation.

RESULTS

MHT initiation dropped from 8.6% pre-WHI to 2.8% post-WHI (P < 0.0001), and the corresponding decrease in MHT continuation was 84.0% to 62.0% (P < 0.0001). Decreases in MHT initiation and continuation occurred across a range of participant subgroups, consistent with wide dissemination of post-WHI recommendations. However, contrary to current guidelines, we found large declines in MHT use in subgroups for whom MHT is often recommended, that is, younger women and those with more vasomotor symptoms. Post-WHI, women's reasons for MHT initiation and discontinuation reflected concerns highlighted by WHI results. The largest declines in initiation reasons were for reducing risks of osteoporosis and heart disease, whereas the largest increases in discontinuation reasons were for media reports and provider advice.

CONCLUSIONS

Immediate post-WHI recommendations for MHT use were widely adopted. MHT risks documented in older women, however, may have led younger symptomatic women to forgo MHT for symptom relief.

New generation nonhormonal management for hot flashes

Hot flashes are very common in women in menopause and can have a detrimental effect on quality of life. Hormone therapy (estrogen with or without progestin) remains the gold standard treatment for hot flashes, but concerns for the risk of hormone therapy have resulted in its decline and a demand for nonhormonal treatments with demonstrated efficacy for hot flashes. Several nonhormonal therapies have been tested in randomized placebo-controlled trials including nonpharmacologic approaches and pharmacologic nonhormonal agents. Among them, two classes of nonhormonal medications have been demonstrated to effectively alleviate hot flashes: γ-aminobutyric acid (GABA) analogs and selective serotonin reuptake inhibitors (SSRIs). This article discusses the superior efficacy of the newer nonhormonal prescriptions for the treatment of hot flashes when compared with estrogen replacement therapy, and provides some recommendations regarding use of them in peri- and postmenopausal women.

How to define and measure concordance between patients' preferences and medical treatments: A systematic review of approaches and recommendations for standardization

OBJECTIVE

The purpose is to systematically review the methods used to calculate the association between patients' preferences and treatment choices and to present a set of recommendations for definition and measurement of this concept.

METHODS

A systematic review of the literature from 1967 to 2007 identified articles that reported a relationship between patients' preferences and their treatment choices. Potential citations were identified from electronic databases, the Cochrane Collaborative review, and identified experts. Relevant articles were abstracted by two reviewers independently using standard forms.

RESULTS

The search identified 3114 unique citations, the full text of 180 articles was examined, and 49 articles were included. These 49 studies used a variety of definitions of preferences and choices, and calculated concordance in different ways. Half of the studies tied their method to a theoretical framework. There were problems with many of the studies that limit the ability to generalize or make comparisons across studies.

CONCLUSION

There is no consistent method for defining or calculating the match between patients' preferences and treatment choices. There is a need for more clarity in the definition and reporting of this type of concordance in measures of decision quality.

PRACTICE IMPLICATIONS

The match between an informed patient's preferences and treatment choices is a key component of patient-centered care. Valid and reliable measures of the level of concordance are needed.

Advances in hormone replacement therapy: weight benefits of drospirenone, a 17alpha-spirolactone-derived progestogen

Hormone replacement therapy (HRT) remains the most effective treatment for menopausal symptom relief, and may provide cardiovascular benefits in younger women initiating treatment soon after menopause. However, large surveys indicate that many symptomatic women refuse or discontinue HRT prematurely owing to fear of weight gain. A continuous combined HRT containing 17beta-estradiol (E(2)) 1 mg plus drospirenone (DRSP) 2 mg is effective in relieving menopausal symptoms and preventing postmenopausal osteoporosis. DRSP is a unique synthetic progestogen with a pharmacological profile similar to that of natural progesterone, including antialdosterone activity, a property not exhibited by other synthetic progestogens. DRSP can therefore reduce estrogen-related sodium and water retention in postmenopausal women receiving HRT via the renin-angiotensin-aldosterone system, which regulates sodium and water balance. This may translate into weight benefits. Pooled data from two placebo-controlled clinical trials (n = 333) indicated statistically significant weight loss of -1.5 kg at 6 and 12 months in postmenopausal women receiving E(2)/DRSP vs. placebo (p < 0.001). In a third randomized controlled trial (n = 1147), women receiving E(2)/DRSP maintained or lost weight, whereas weight increases were observed in women receiving E(2) monotherapy (p < 0.0125). E(2)/DRSP could help maintain or even slightly decrease body weight during treatment, potentially improving HRT acceptance and compliance.

Advances in hormone replacement therapy with drospirenone, a unique progestogen with aldosterone receptor antagonism

Unlike other currently available progestogens, drospirenone (DRSP) has a pharmacological profile, which closely mimics that of endogenous progesterone, most notably potent anti-aldosterone and anti-androgenic effects. Consequently, DRSP, when combined with 17beta-estradiol (E2) as hormone replacement therapy (HRT), offsets E2-related water and sodium retention by blocking the mineralocorticoid receptor. This review evaluates the potential benefits offered by DRSP as the progestin component of HRT with respect to its anti-aldosterone activity, which translates into positive effects on body weight and blood pressure in clinical trials of continuous, combined E2/DRSP in post-menopausal women. In a 1-year, large-scale, randomised, controlled trial, E2 1 mg/DRSP 2 mg significantly decreased mean body weight by 1.2 kg versus baseline (P<0.001), whereas patients receiving E2 1 mg gained weight. E2 1 mg/DRSP 2 mg also significantly lowered mean systolic blood pressure (SBP) by 9.0 mmHg from baseline (P<0.05) versus 3.7 mmHg in the E2 1 mg group (P=0.220) in a sub-group of hypertensive women. In addition, E2/DRSP was not associated with hyperkalaemia (potassium > or =5.5 meq/L) irrespective of concomitant use of ACE inhibitors, angiotensin II receptor antagonists or non-steroidal anti-inflammatory drugs, and co-morbid diabetes mellitus. In summary, as well as effectively treating climacteric symptoms, DRSP 2 mg combined with E2 1 mg has shown positive effects on body weight and blood pressure in clinical trials, most likely due to DRSP's anti-aldosterone properties. This combination may therefore offer an alternative therapeutic option with additional benefits beyond current HRT agents for symptomatic post-menopausal women.

Women's attitudes to hormone replacement therapy in the aftermath of the Women's Health Initiative study

AIM

This paper is a report of a study conducted in 2004 on the determinants of attitudes towards hormone replacement therapy in the aftermath of the report on the findings of the Women's Health Initiative study.

BACKGROUND

The unexpected findings of the Women's Health Initiative study, published in July 2002, showed that the risk of using combined hormones exceeded their benefits. This complicated women's decision-making about hormone use and made it important to study the determinants of their attitudes to hormone therapy, as these are likely to influence their behaviour.

METHODS

A cross-sectional design was conducted with a sample of 561 women drawn from the National Registry of Iceland. A self-administered questionnaire, measuring attitudes towards hormone replacement therapy, attitudes towards menopause, extent and source of menopausal education, symptom experience, health and lifestyle and knowledge about the findings of the Women's Health Initiative, was used. The overall response rate was 56%. Attitudes to hormone replacement therapy were compared using anova, t-tests and correlations.

RESULTS

Participants generally had positive attitudes. Knowledge about the Women's Health Initiative study was not associated with more negative attitudes. However, receiving the information from and discussing it with a doctor were associated with more positive attitudes. Positive attitudes towards hormone therapy were also associated with higher age, time since last menstrual period and current use of hormone replacement therapy. Negative attitudes were associated with use of natural remedies and receiving information from or discussing hormone therapy with family or friends.

CONCLUSION

Research is needed to identify the dynamics of the medical interview, and the nature of input from friends, spouse and other family members. The content of these messages may be different and conflicting, for example, between doctors and family members. The nature of this conflict and conflicts of interests need to be identified in order to inform women's decision-making. In addition, action needs to be taken in order to strengthen the advisory role of nurses.

Continuation of hormone replacement therapy in Slovenia: A prospective, randomized, controlled trial—1-year follow-up

OBJECTIVES

To evaluate the influence of educational intervention on the hormone replacement therapy (HRT) continuation rate in Slovenia after the publication of WHI results.

METHODS

We enrolled 125 early postmenopausal women in a 12-month prospective, randomized, controlled, multicentric study in Slovenia. The study group women (n=62) attended educational lectures; the control group women (n=63) did not. Data were collected from three types of questionnaire: before starting HRT, at follow-up visits at 3, 6, 9 and 12 month, after the educational lecture (study group). The continuation rate was measured on the basis of women's self-reports. The results were analyzed according to the "intention-to-treat" principle. The Cox proportional hazard model was used for the final analysis.

RESULTS

A gynecologist's suggestion, climacteric symptoms and quality of life were the prevailing reasons for starting HRT. The prevailing factors affecting continuation of HRT were: no or irregular previous OC use (hazard ratio 3.7), no educational lectures (hazard ratio 2.0) and climacteric disorders as the reason for start HRT (hazard ratio 2.1). In the women who discontinued HRT within the first 3 months, the fear of endometrial cancer, breast cancer and bleeding problems were statistically more significant than other factors (P=0.034). In the women who stopped HRT use within 6-12 months, the fear of breast and endometrial cancers increased substantially (P=0.002).

CONCLUSIONS

Previous OC use and educational lectures on menopausal problems and HRT significantly improve the HRT continuation rate. The main reason for discontinuing HRT is fear of breast cancer, intensified by media.

Changes in attitudes, knowledge and hormone replacement therapy use: a comparative study in two random samples with 6-year interval

OBJECTIVES

To study changes in: (i) the prevalence of hormone-replacement therapy (HRT) and (ii) women's attitudes and knowledge about the climacteric. Design. Cross-sectional comparison was performed on two populations of women both aged 46-62 years and resident in the same urban Swedish population over a period of 6 years.

MATERIAL AND METHODS

In 1992, a random sample of 5990 women, from five birth cohorts, 46, 50, 54, 58, and 62 years in the city of Göteborg, were assessed using a postal questionnaire technique. In 1998, the same technique was used and a similar questionnaire was sent to another cohort of women (n=5411) of the same ages, resident in the city of Göteborg. The overall response rate was 76%. Information was obtained regarding climacteric symptoms, HRT use, and attitudes and knowledge.

RESULTS

The prevalence of HRT use with medium-potency estrogens had increased from 13% (1992) to 31% (1998). The highest prevalence was reported in women 54 years of age (46%). The most common reasons why women started HRT were: hot flushes and sweats, depression/irritability, sleeping disturbances, and vaginal dryness. Forty-four percent of the women in this study were prepared to consider extended HRT if the treatment was free from withdrawal bleedings (35%, 1992). Eighty percent believed that the risk of osteoporosis decreased during HRT use (61%, 1992) and 68% thought that the risk of breast cancer increased (58%, 1992).

CONCLUSIONS

A marked increase in the use of HRT was reported between 1992 and 1998. Women's attitudes to HRT were more positive in 1998 compared to 1992. Knowledge about HRT among women had increased during the same 6-year period.

Therapeutic decisions for menopause: results of the DAMES project in central Massachusetts

OBJECTIVE

To investigate the factors that influence therapeutic decisions at menopause, particularly those related to the burden of menopause symptoms, in a population of women living in Massachusetts, as part of the multisite DAMES (Decisions At Menopause Study).

DESIGN

A survey using face-to-face interviews with a randomly selected sample of 293 women aged 45 to 55 who are members of the Fallon Community Health Plan in Central Massachusetts. The instrument combined closed- and open-ended questions and elicited information about a number of health topics, including the symptoms experienced by respondents over the preceding month and the decisions they made regarding therapies.

RESULTS

Symptom reporting was found to be relatively high, with more than half of the sample reporting hot flashes, sleep disturbances, joint pains, and headaches in the month preceding the survey; one third to one half of the women reported palpitations, night sweats, fatigue, and numbness. The highest frequency of symptoms occurred during perimenopause. Nearly four fifths of the women consulted a healthcare provider, and one fifth used hormone therapy. More than half of the respondents said menopause is a difficult phase, and about half found decisionmaking about it to be difficult.

CONCLUSIONS

This study documents a relatively heavy burden of symptoms in a relatively healthy population and provides an update on earlier studies in Massachusetts.

Oestrogen and progestogen hormone replacement therapy for peri-menopausal and post-menopausal women: weight and body fat distribution

BACKGROUND

Hormone replacement therapy (HRT) is commonly prescribed to treat menopausal symptoms and to prevent post-menopausal bone loss. However, many women are concerned about hormonal replacement therapy because they believe that such treatment will result in weight gain. The effect of HRT on weight and body fat distribution has not yet been examined in systematic reviews. It is an important topic since many women decline oestrogen therapy due to their concerns about resultant weight gain, and thus forego its potential therapeutic benefits.

OBJECTIVES

To evaluate the effect of unopposed oestrogen or combined oestrogen and progestogen hormone replacement therapy (HRT) upon the weight and body fat distribution of perimenopausal and postmenopausal women.

SEARCH STRATEGY

The search strategy of the Menstrual Disorders and Subfertility Group was used for the identification of randomised controlled trials (RCTs). Computerised searches of MEDLINE, EMBASE, Current Contents, Biological Abstracts and CINAHL were performed. Attempts were made to identify trials from citation lists of review articles and relevant papers already obtained. In most cases, first authors of each eligible trial were contacted for additional information. All those trials that had been located as at August 1998 were examined for eligibility.

SELECTION CRITERIA

All randomised, placebo or no treatment controlled trials that detailed the effect of HRT on weight or body fat distribution, including studies where HRT was combined with other therapy such as diet, supplements or exercise. Studies were eligible for consideration even though the main focus of the trial may have been on another aspect of HRT. Previous HRT use should have ceased at least one month (in the case of patches, cream or gel) or three months (for oral preparations or subcutaneous pellets) before commencement of the study.

DATA COLLECTION AND ANALYSIS

Twenty two RCTs were identified that fulfilled the inclusion criteria for this review. The results of one trial were not available in a form that allowed it to be included in the meta-analysis; however, it has been included in the text of the review for discussion. Twenty four RCTs are awaiting assessment pending additional information from first authors. Two reviewers extracted the data independently, and the weighted mean differences for continuous outcomes were estimated from the data. Results for unopposed oestrogen and combined oestrogen were analysed separately, and the effect of each treatment regimen on body weight, BMI, waist-hip ratio, fat mass and skinfold measurement was examined where available. The effect of differing dosage levels on these parameters was also examined.

MAIN RESULTS

Outcomes were evaluated separately for unopposed oestrogen and oestrogen/progestogen regimens. Statistical analysis was performed using the weighted mean difference for continuous outcomes as recommended by the Cochrane Menstrual Disorders and Subfertility Group. No statistically significant difference was found in mean weight gain between those using unopposed oestrogen and non-HRT users (0.66 kg, 95% CI -0.62, 1.93). No significant difference was found in mean weight gain between those using oestrogen/progestogen therapy and non-HRT users (-0.47 kg, 95% CI -1.63, 0.69). Insufficient data exist to enable meta-analysis of the effect of unopposed oestrogen on BMI. The reviewers found no statistically significant difference in mean BMI increase between those using oestrogen/progestogen and non-HRT users (-0.50, 95% CI -1.06, 0.06). Insufficient data exist to enable meta-analysis of the effect of HRT on waist-hip ratio, fat mass or skinfold thickness.

REVIEWER'S CONCLUSIONS

There is evidence of no effect of unopposed oestrogen or combined oestrogen on body weight, indicating that these regimens do not cause extra weight gain in addition to that normally gained at menopause. (ABSTRACT TRUNCATED)