Provider attitudes and self-reported behaviors related to hormone replacement therapy

Randomized crossover study investigating resident retention of menopause-related knowledge after completion of learning modules

OBJECTIVE

The aim of this study was to evaluate residents' retention of menopause-based knowledge immediately after, and 3 months after completion of, self-administered modules that varied by menopause-related topic and delivery format.

METHODS

Prospective crossover study of Obstetrics and Gynecology and Family Medicine residents at one institution over the 2017 to 2018 academic year. Residents were randomized to a series of three PowerPoints (Microsoft, Redwood, WA), each <30 slides, administered during regularly scheduled didactics. Each series contained three subjects (Menopause Basics [MB], Hormone Therapy [HT], and Genitourinary Syndrome of Menopause [GSM]) delivered through three different presentation styles (typical presentation [typical], pictures and a narration [pictures], and interactive to reveal information [interactive]). Knowledge and comfort were assessed through baseline, immediate postexposure, and 3-month follow-up surveys containing 24 knowledge questions (multiple choice) and 10 comfort and satisfaction questions (5-point Likert scale and multiple choice). Statistical tests were applied with P<0.05 considered significant.

RESULTS

Thirty-three residents completed the 3-month follow-up. Immediately postexposure, knowledge and comfort increased from baseline for all topics (P < 0.05). When formats were grouped together to investigate retention by topic, the HT topic demonstrated a sustained increase in knowledge on 3-month follow-up (P = 0.047). The typical format of the GSM topic had significantly better retention than the picture format (P = 0.027). All formats were associated with a significant increase in comfort (all P < 0.01).

CONCLUSIONS

Participation in this specialized menopause curriculum led to short-term increases in objectively assessed menopause-related knowledge. Tailoring self-administered learning modules to learning styles did not, however, effectively enhance overall knowledge retention on 3-month follow-up, though comfort in managing menopause remained increased. : Video Summary:http://links.lww.com/MENO/A474.

Recognizing Menopausal Symptomatology

Menopause is a physiological midlife transition for most women. However, many women experience uncomfortable menopausal symptomatology. During this transitional period, some women seek assistance for menopausal concerns from health care providers. Primary care is an important channel for educating and disseminating menopause information. Home health care nurses are in a pivotal position to offer guidance and provide whole person care, where all treatment and treatment goals are consistent with expressed needs, values, faith, and priorities. This article provides an overview of perimenopause and the resultant symptomatology, which are of increasing interest to health care providers.

The medical management of menopause: a four-country comparison care in urban areas

OBJECTIVE

To compare the medical management of menopause across urban areas in four countries which differ by level of income and degree of medicalization.

METHODS

Surveys of health providers who advise women on the menopausal transition were carried out in Beirut, Lebanon (n=100), Madrid, Spain (n=60), Worcester, MA, U.S. (n=59), and Rabat, Morocco (n=50) between 2002 and 2004. Physician characteristics, hormone therapy (HT) prescribing practices, and concerns about the management of menopause were compared across countries using chi(2) and logistic regression analyses.

RESULTS

Across sites, physicians were generally well informed about HT and thought that symptom alleviation and disease prevention were equally important. They had concerns about risks associated with HT, particularly breast cancer, and in 3 sites where the survey was conducted after the WHI (Beirut, Rabat, and Madrid) physicians changed their practices to prescribe HT less frequently, for shorter durations, or shifted to other medications. There were significant differences across sites in the recommended duration of HT, time spent talking with patients, perceived benefits of HT, tests recommended before prescribing HT, and concern about the risks associated with HT. Physicians in Madrid and Massachusetts were more likely to report that decisions about the management of menopause were difficult, but in all sites the main reason for difficulties was concerns about risks. The results also suggest discrepancies between physicians' perceptions and women's reports about the reasons why women consult at menopause.

CONCLUSIONS

Prescription patterns and perceived benefits of HT appear to reflect local medical culture rather than simply physician characteristics. The impact of the WHI study was seen in prescribing patterns and concerns about HT. Physicians in all four countries were generally well informed. Financial support: NIH 5 900 000196.

Changes of the prescription of hormone therapy in menopausal women: an observational study in Taiwan

BACKGROUND

To evaluate the impact of the 2002 Women's Health Initiative (WHI) study results on the prescription of menopausal hormone therapy (MHT) to treat menopause-related symptoms in Taiwan.

METHODS

This retrospective study participant data collected from women interviewed in 2001 Taiwan's National Health Interview Survey (NHIS) and the National Health Insurance (NHI) outpatient claims for women being treated for menopause-related symptoms. We compared prescriptions made for MHI to women seeking outpatient treatment for menopause-related symptoms before and after the publication of the 2002 WHI to study its effect of prescription behavior in Taiwan. There was one dichotomous outcome variable, which was whether MHT was prescribed or not in an outpatient visit to treat menopause-related symptoms.

RESULTS

Our study included 504 women 45 years old or above whose outpatient visits for menopause-related symptoms were covered by National Health Insurance in 2002. In total, these 504 women made 2549 outpatient visits to be treated for these symptoms. The proportion of outpatient visits in which MHT was prescribed dropped from 83.0% (n = 1,155) before WHI to 73.0% (n = 844) after WHI. We found a decrease in likelihood that women would be prescribed MHT for menopause-related symptoms after the release of the WHI report (OR = 0.36, 95% CI = 0.25 to 0.52, p < 0.05). Gynecologists and obstetricians are more likely to prescribe MHT than physicians with other medical specialties (5.34; 95% CI = 3.45 to 8.26, p < 0.05). Women with college level educations or higher became less likely to be prescribed MHT (Model 2; OR 0.30; 95% CI 0.11-0.83), and academic medical centers became less likely to prescribe MHT than other medical care institutions (Model 3; OR 0.15; 95% CI 0.34-0.63).

CONCLUSION

The WHI report caused a substantial decline in the use of MHT to treat menopause-related symptoms in Taiwan. It was found to exert most of its influence in patients with higher educations, physicians with specialties other than gynecologists and obstetricians, and academic medical centers.

Physicians’ views and practices concerning menopausal hormone therapy

OBJECTIVE

To examine physicians' views and practices concerning estrogen+progestogen therapy (EPT).

DESIGN

Questionnaires were mailed to a random sample of physicians in the United States (US) in 2003. A total of 1614 (53.8%) surveys were returned (633 obstetricians and gynecologists (Ob/Gyns), 571 family practitioners, and 410 internists).

RESULTS

Only a minority of the physicians (16%) would offer EPT to menopausal women in the absence of menopausal symptoms (26% Ob/Gyn, 11% family practitioners, 6% internists, p<0.0001). However, many physicians (62%) believed that EPT could be offered "short term" to menopausal women with menopausal symptoms assuming no contraindications (82% Ob/Gyn, 54% family practitioners, 42% internists; p<0.0001). Irrespective of specialty, the strongest contraindications to EPT use reported by these physicians were personal history of breast cancer (93%), thrombosis (92%), cerebrovascular disease (84%), ischemic heart disease (74%), uterine cancer (73%), as well as women's subjective "concern" about breast cancer (57%). Procedures reported as always required by physicians for continuing women on EPT were breast examination (97%), mammogram (96%), blood pressure measurement (94%), and pelvic examination (91%).

CONCLUSIONS

Internists and family practitioners address more contraindications to EPT use than Ob-Gyns. Although many physicians appear to be accepting of short-term use of EPT for menopausal indications in the absence of contraindications, the majority would not prescribe it for prophylactic purposes.

The prescription of hormone replacement therapy in Spain: Differences between general practitioners and gynaecologists

OBJECTIVES

The purpose of this study was to determine the frequency with which hormone replacement therapy (HRT) was prescribed and to identify physician-related factors associated with the prescription of HRT in Spain.

STUDY DESIGN

A descriptive cross-sectional survey based on a personal interview with a structured questionnaire was conducted in April 2005 with physicians aged 25-65 years. A total of 2700 doctors were asked to participate in this prospective study (1350 GY and 1350 GP). This number included 270 gynaecologists (GY group) and 270 general practitioners (GP group).

RESULTS

Only 10% of gynaecologists and 19.4% of GPs had never prescribed HRT. The reasons given for not prescribing HRT were adverse effects and the fear of cancer among GPs and adverse effects and social alarm in the GY group. Phytoestrogens were the most commonly used alternative; however, GPs were more willing to use antidepressants and benzodiazepines than GYs. The frequency of HRT prescription in symptomatic women was significantly higher among GYs. The main reasons for prescribing HRT were climacteric complaints and improvement in life quality for GYs and, climacteric complaints and the prevention of osteoporosis for GPs. Seventy-eight percent of GYs prescribing hormones referred a high degree of satisfaction with HRT, whereas only 50% of GPs expressed a similar attitude.

CONCLUSIONS

Concern for HRT prescription in Spain is high. Adverse effects and the fear of cancer are negative conditioning factors in the prescription of HRT, whereas climacteric complaints, quality of life and the prevention of osteoporosis are positive conditioning factors. GYs are more willing to use HRT than GPs. This contrast may reflect the indecision of GPs regarding the preventive value of HRT.

Brief report: attitudes toward hormone therapy after the Women's Health Initiative: a comparison of internists and gynecologists

In the Women's Health Initiative (WHI), postmenopausal women receiving combination hormone therapy (HT) experienced more adverse outcomes than placebo recipients. To determine whether gynecologists and internists interpreted the WHI differently, we conducted a survey in which physicians responded to a hypothetical asymptomatic woman who asks whether to continue HT. In response to this scenario, gynecologists were more likely than internists to hold permissive views about prescribing HT (66% vs 35%; P<.001). These results suggest that gynecologists may be less concerned than internists about the adverse events associated with HT, or that gynecologists have stronger beliefs about benefits of HT.

Personal use of HRT by postmenopausal women doctors and doctors' wives in the north of Italy

This study aimed to describe the prevalence of hormone replacement therapy (HRT) use by women doctors and doctors' wives in northern Italy, to explore the relationship between their personal characteristics and HRT use, and to gather information about the use of alternative remedies. A questionnaire was mailed to all physicians born between 1935 and 1955 included in the database of the Medical Register of Turin County (Northern Italy). The questions were meant to explore medical, behavioral, and professional characteristics; personal use of HRT; reasons for and against HRT use; side effects and use of other therapies. 56.5% of postmenopausal women who completed the questionnaire had used HRTand 68.3% of them were current users. The median duration of HRT use was 3.7 years. Only 18.5% of the women had used HRT for 5 years or more; in this case, HRT was started significantly earlier than in the other groups. More than 50% had taken oral HRT, while 39% had used patches; estrogens only had been taken by 21.9%. HRT users had a significantly lower basal body mass index and more vasomotor and dystrophic symptoms at menopause onset compared with non-HRT users. More women on HRT were in good physical health and had an active sex life. Previous breast cancer and family history of cardiovascular diseases were inversely associated with HRT use. The main reason for not taking HRT or stopping it was fear of breast cancer (43.7% and 34.8%, respectively); irregular bleeding and weight gain were also frequently reported as a reason for HRT (30% and 22%). Overall, 22% of women had used alternative drugs to alleviate menopausal symptoms or prevent menopause-related diseases, mainly tibolone (21% among never HRT users and 2% among HRT users; p = 0.015) and phytoestrogens. The prevalence and duration of use of HRT by Italian physicians is consistent with the available data from other Western countries, and is much higher than in the general population. This is in contrast with the very low prevalence of use in the general population and may lead, in the near future, to a larger use of HRT in Italy.

Sources of information and HRT prescribing practices among gynecologists in Puebla, Mexico

OBJECTIVE

The purpose of this study was to determine the sources of information and hormone replacement therapy (HRT) prescribing practices of gynecologists in the capital city of Puebla, Mexico.

METHODS

Practicing gynecologists (n=44) in 29 colonias (neighborhoods) in the city of Puebla completed a self-administered standardized questionnaire. Survey topics included primary sources of information about HRT, discussion of patient health practices, awareness of alternative medicines, and HRT prescribing practices.

RESULTS

Medical journals, hospital presentations, and textbook manuals were rated as the primary sources of information about HRT by 69-73% of physicians. Patients were rated as a primary source of information by 25% of physicians, and pharmaceutical representatives by 16% of physicians. Almost all physicians reported a willingness to discuss diet, smoking habits and other health issues with their patients. Natural and herbal medications were recommended by 25% of physicians. Contrary to studies in the US, more male than female physicians reported recommending hormones to 90-100% of their menopausal patients (60 vs. 33%, n.s.).

CONCLUSIONS

This study revealed that physicians utilize a wide range of information about HRT, including patients and pharmaceutical representatives. Physicians' willingness to list patients as a source of information about HRT indicates the degree to which patients are involved in the medicalization of menopause. Reasons given for prescribing HRT (e.g. prevention of osteoporosis) were similar to those identified in studies in the US and Canada. Some variation in physician attitudes and practices related to HRT was apparent within the city of Puebla, Mexico.

Clinical and personal relationships between oral contraceptive and hormone replacement therapy use among US women physicians

OBJECTIVE

To examine relationships between a history of oral contraceptive (OC) use and current use of or intention to use hormone replacement therapy (HRT).

DESIGN

The Women Physicians' Health Study examined a stratified random sample of US women MDs, aged 30 to 70 years (4,501 respondents; a 59% response rate).

RESULTS

Among postmenopausal physicians who previously used OCs, current HRT use was significantly associated ( < 0.05) with being younger, living somewhere besides the East Coast, being sexually active, being an obstetrician/gynecologist, having no history of breast cancer, having a longer use of OCs, and being posthysterectomy. Among premenopausal physicians, intended future HRT use was significantly associated with being white, being an obstetrician/gynecologist, being in good health, living somewhere besides the East Coast, being a longer user of OCs, and having more extensive, recent continuing medical education. Among women who had taken both OCs and HRT, there were no significantly elevated rates in any of the 15 health conditions we examined (after controlling for family history). Postmenopausal physicians who took HRT (and premenopausal OC-using physicians intending to take HRT) were significantly more likely to counsel their patients on HRT use. Among post-OC HRT-users, 44% counseled their postmenopausal female patients on HRT at least yearly versus 22% of post-OC HRT-nonusers (74% v 45% among such primary care physicians).

CONCLUSIONS

Physicians' personal OC/HRT use may strongly affect their patient counseling practices. HRT use after OC use was not associated with any obvious increases in examined diseases in this population.

Asian and Asian-American college students' awareness of osteoporosis

STUDY OBJECTIVE

To quantify Asian and Asian-American college students' knowledge of osteoporosis and preventive health behaviors.

DESIGN

Sixty-four-question survey

SETTING

University of Minnesota.

SUBJECTS

One hundred sixty-eight male and female Asian and Asian-American students, mean age 21 +/- 3.4 years.

MAIN RESULTS

About half of the students consumed 0-1 servings/day of dietary calcium, 42% consumed 2 cups/day or more of caffeinated beverages, 8% smoked cigarettes, and 61% exercised 2.5 hours/week or less. At least 1 serving/day of phytoestrogen was consumed by 80% of the students. Only 11% of students answered at least 75% of osteoporosis fact questions correctly. Women (p = 0.011) and the United States-born participants (p = 0.006) were more apt to change their health behaviors to prevent or treat osteoporosis than men and Asia-born participants. Thirty-eight percent of Hmong participants attributed osteoporosis to fate, chance, or luck whereas Vietnamese participants were more likely to attribute osteoporosis to diet. Most participants (63%) did not know whether their culture objected to estrogen replacement therapy, and 42% said menopause was a natural occurrence for which pharmacologic treatment should not be administered.

CONCLUSIONS

Many Asian and Asian-American college students did not practice health behaviors to prevent osteoporosis, and most lacked sufficient knowledge about the condition.

Use of multiple providers for regular care and women's receipt of hormone replacement therapy counseling

BACKGROUND

Prior research has explored women's lifetime receipt of HRT counseling and correlates of counseling, but has not explored receipt of counseling by current health care provider(s). The number and type(s) of provider(s) that women see for their regular care may be an important enabling factor in women's receipt of HRT counseling.

OBJECTIVES

Whether there is an association between the number and specialties of physicians that women use for regular care and their receipt of HRT counseling by a current regular physician is explored.

RESEARCH DESIGN

A self-administered mail survey was sent to 1,500 female members (ages 40-69) of a Connecticut IPA-model health plan.

RESULTS

One thousand seven completed questionnaires were received (response rate = 69%). Twenty-eight percent of women reported seeing only a family practitioner or internist (no OB/GYN) for their regular care; 11% saw an OB/GYN only; and 59% saw both a family practitioner/internist and an OB/GYN. After adjustment for women's other predisposing and enabling characteristics, women who used both a family practitioner/internist and an OB/GYN were 3.1 times as likely (95% CI, 2.02, 4.66) as those seeing only a family practitioner/internist to have been counseled about HRT by a current provider, and those using only an OB/GYN were 2.5 times as likely (95% CI, 1.34, 4.61).

CONCLUSIONS

The number and specialty of physician(s) that women use for their regular care is an important enabling factor in women's receipt of HRT counseling. Changes in the organization and delivery of women's primary care may help increase the receipt of female-specific clinical preventive services, particularly among women less likely to use an OB/GYN for regular care, such as low-income and older women.

Discontinuation of postmenopausal hormone therapy in a Massachusetts HMO

Long-term postmenopausal hormone therapy alleviates menopausal symptoms, decreases women's risk of osteoporosis and has been shown to reduce cardiovascular morbidity and mortality in more than 30 observational studies. However, nearly half of all women initiating hormone therapy discontinue within the first year. This study was conducted to determine the rate and predictors of hormone therapy discontinuation in a clinical practice setting. We identified 992 women aged 45-59 who began hormone therapy between 1993 and 1995 in a Massachusetts health maintenance organization. Women were followed 2 years from the day they filled a prescription for estrogen. 53% discontinued hormone therapy by the end of the first year and one-fifth stopped after the first prescription. A prescription from a gynecologist (RR = 0.82, 95% CI: 0.68, 0.99) and a mammogram a year prior to initiation (RR = 0.75, 95% CI: 0.63, 0.89) were associated with a lower rate of discontinuation. Women who were using monoamine oxidase inhibitors (MAOI) or selective serotonin reuptake inhibitors (SSRI) antidepressants 3 months prior to initiation (RR = 2.07, 95% CI: 1.26, 3.39) or who had been enrolled in the health plan for less than 3 years (RR = 1.33, 95% CI: 1.10, 1.62) had an increased risk of discontinuing hormone therapy. The year a woman entered the cohort was also associated with a higher rate of discontinuation (RR = 1.40, 95% CI: 1.14, 1.74 for 1994 and RR = 1.95, 95% CI: 1.52, 2.50 for 1995). The results indicate that long-term hormone therapy use is uncommon in clinical practice, particularly when a woman or her physician attempts to use hormone therapy as an alternative to antidepressant therapy, and that the rates of discontinuation of hormone therapy were rising rapidly in the mid-1990s.

What factors account for hormone replacement therapy prescribing frequency?

OBJECTIVES

The purpose of this study was to compare hormone replacement therapy (HRT) prescribing frequency to provider characteristics, attitudes and beliefs about menopause and HRT.

METHODS

There was a mailed survey of providers at a large staff-model HMO in Washington state. Participants included 250 family practice physicians, 22 gynecologists, and 13 women's health care specialists and nurse midwives (83% response rate). The primary outcome, "HRT prescribing frequency" (derived from automated pharmacy and visit data) was defined as: the total number of estrogen prescriptions written by the provider and filled by women aged 50-80 years during the 12 months prior to the survey, divided by the number of visits made to the provider by women aged 50-80 years during that same 12-month period. Covariates included provider characteristics and beliefs about menopause and HRT. Logistic regression was used to distinguish providers in the upper 40% versus the lower 60% of HRT prescribing frequency.

RESULTS

Controlling for age and practice type, HRT prescribing frequency was lower among men than women providers (odds ratio [OR] 0.38, 95% confidence interval [CI] 0.21-0.65), higher among providers who agreed (vs. disagreed or neutral) that a convincing scientific case has been made that HRT prevents heart disease (OR 2.66, 95% CI 1.53-4.61), and higher among those in the upper tertile vs. lower tertiles of an HRT encouragement scale (OR 2.50, 95% CI 1.29-4.85).

CONCLUSIONS

Female providers and providers with positive attitudes toward HRT are the most likely to prescribe it.

Are women being counseled about estrogen replacement therapy?

The U.S. Preventive Services Task Force and several medical professional associations have published guidelines recommending that all women be counseled around the time of menopause about the benefits and risks of estrogen replacement therapy (ERT) so that they may make an informed decision about its use. Despite the proliferation of ERT counseling guidelines, little is known about whether these guidelines are being followed. There were 1,500 female members (aged 40 to 69) of a Northeastern U.S. Independent Practice Association--model Health Maintenance Organization who were surveyed, and 51 percent reported that a health care provider had talked with them about the benefits and risks of ERT. In multivariate analyses, a woman's demographic characteristics (age, race, income), stage of menopause, severity of menopausal symptoms, and body weight were the major correlates of receipt of ERT counseling. Women at greater risk for osteoporosis or heart disease were no more likely to be counseled, although those with diagnosed osteoporosis were. What appear to be selective ERT counseling practices will need to be modified if the goal of providing universal ERT counseling to midlife women is to be attained.

Provider characteristics: impact on bone density utilization at a health maintenance organization

OBJECTIVE

Information from bone mineral density (BMD) is relevant in guiding postmenopausal osteoporosis prevention and treatment, yet many providers do not typically order BMDs. This study was designed to identify physician characteristics associated with utilization of bone densitometry in a northeastern US health maintenance organization (HMO).

DESIGN

Internal medicine primary providers in practice at a northeastern HMO between April 1997 and March 1998 were categorized by BMD utilization, based on the number of BMDs performed during that time per number of women older than 50 years in their patient panel. In one analysis, providers in the highest quintile for this parameter were considered "high utilizers" (n = 25), and those in the lowest quintile, "low utilizers." These groups were compared with respect to provider characteristics and practice composition. In a second analysis, multiple variable linear regression was used to predict the likelihood of utilization of BMD as a function of those parameters for all providers.

RESULTS

The range of BMDs by provider was 0 to 190 per 1,000 women >50 years (median = 34) over this 1-year period. Providers who were high utilizers had a significantly greater number of female patients more than age 50 in their practice (p < 0.05) and were also more likely themselves to be female (62% vs. 48%; p < 0.05). There was no association between BMD utilization and age of provider or years in practice. Female provider gender (p < 0.01) and greater percentage of women more than age 50 in the practice (p < 0.05) were independent predictors of BMD utilization in a multivariate model.

CONCLUSION

BMDs were infrequently utilized by the majority of providers over this 1-year period. Female provider gender was associated with a significantly greater likelihood of BMD utilization that was not simply explained by the greater number of women in these providers' practices. These findings may be relevant to identifying strategies to improve bone health care in this population.