Utilisation of hormone replacement therapy by women doctors

Are doctors using more preventive medication for cardiovascular disease? A Swedish cross-sectional study

BACKGROUND

Despite decreasing mortality from cardiovascular disease (CVD), there are persistent inequities in mortality between socioeconomic groups. Primary preventative medications reduce mortality in CVD; thus, inequitable treatments will contribute to unequal outcomes. Physicians might contribute to inequality by prescribing preventative medication for CVD to themselves in a biased manner.

AIM

To determine whether primary medications for preventing CVD were prescribed inequitably between physicians and non-physicians.

DESIGN AND SETTING

This retrospective study retrieved registry data on prescribed medications for all physicians in Sweden aged 45-74 years, during 2013, and for reference non-physician individuals, matched by sex, age, residence, and level of education. The outcome was any medication for preventing CVD, received at least once during 2013.

METHOD

Age and the sex-specific prevalence of myocardial infarction (MI) among physicians and non-physicians were used as a proxy for the need for medication. Thereafter, to limit the analysis to preventative medication, we excluded individuals that were diagnosed with CVD or diabetes. To analyse differences in medication usage between physicians and matched non-physicians, we estimated odds ratios (ORs) with conditional logistic regression and adjusted for need and household income.

RESULTS

MI prevalences were 5.7% for men and 2.3% for women, among physicians, and 5.4% for men and 1.8% for women, among non-physicians. We included 25,105 physicians and 44,366 non-physicians. The OR for physicians receiving any CVD preventative medication, compared to non-physicians, was 1.65 (95% confidence interval 1.59-1.72).

CONCLUSION

We found an inequity in prescribed preventative CVD medications, which favoured physicians over non-physicians.

Inhaled corticosteroids can reduce osteoporosis in female patients with COPD

Background

Whether the use of inhaled corticosteroids (ICSs) in patients with COPD can protect from osteoporosis remains undetermined. The aim of this study is to assess the incidence of osteoporosis in patients with COPD with ICS use and without.

Patients and methods

This is a retrospective cohort and population-based study in which we extracted newly diagnosed female patients with COPD between 1997 and 2009 from Taiwan’s National Health Insurance (TNHI) database between 1996 and 2011 (International Classification of Diseases, Ninth Revision – Clinical Modification [ICD-9-CM] 491, 492, 496). The patients with COPD were defined by the presence of two or more diagnostic codes for COPD within 12 months on either inpatient or outpatient service claims submitted to TNHI. Patients were excluded if they were younger than 40 years or if osteoporosis had been diagnosed prior to the diagnosis of COPD and cases of asthma (ICD-9 CM code 493.X) before the index date. These enrolled patients were followed up till 2011, and the incidence of osteoporosis was determined. The Cox proportional hazards regression model was also used to estimate hazard ratios (HRs) for incidences of lung cancer.

Results

Totally, 10,723 patients with COPD, including ICS users (n=812) and nonusers (n=9,911), were enrolled. The incidence rate of osteoporosis per 100,000 person years is 4,395 in nonusers and 2,709 in ICS users (HR: 0.73, 95% confidence interval [CI]: 0.63–084). The higher ICS dose is associated with lower risk of osteoporosis (0 mg to ≤20 mg, HR: 0.84, 95% CI: 0.69–1.04; >20 mg to ≤60 mg, HR: 0.78, 95% CI: 0.59–1.04; and >60 mg, HR: 0.72, 95% CI: 0.55–0.96; P for trend =0.0023) after adjusting for age, income, and medications. The cumulative osteoporosis probability significantly decreased among the ICS users when compared with the nonusers (P<0.001).

Conclusion

Female patients with COPD using ICS have a dose–response protective effect for osteoporosis.

Healthcare Service Utilization for Practicing Physicians: A Population-Based Study

Background

Physicians are considered to be the most informed consumers in the use of medical services since they have more information about diseases or medical technology. However, although plenty of researchers have suggested that different medical seeking behavior exists among physicians, very few empirical studies have been conducted to investigate differences in medical utilization between physicians and the general population.

Objective

We explored differences in the utilization of healthcare services between physicians and the general population using a population-based dataset.

Design

A cross-sectional study.

Participants

Data for this study were sourced from the Taiwan Longitudinal Health Insurance Database 2000. We included 1426 physicians and 1426 sex- and age-matched comparison subjects.

Methods

We used Wilcoxon-Mann-Whitney tests to explore differences in variables of healthcare resource utilization between physicians and comparison subjects. We further used Kruskal-Wallis tests to examine differences in variables of healthcare resource utilization between physician practice location and comparison subjects.

Results

We found that physicians had significantly fewer outpatient visits (13.2 vs. 15.7, p<0.001) and significantly lower outpatient costs (US$477 vs. US$680, p<0.001) than comparison subjects. Furthermore, physicians had lower total health service costs than comparison subjects (US$643 vs. US$1066, p<0.001). This indicates that the mean total health service costs in the year 2010 was 1.66-fold greater for comparison subjects than for physicians. We also found that there were significant differences in the mean number of outpatient services (p<0.001), outpatient costs (p = 0.001), inpatients costs (p = 0.018), and total costs (p = 0.001) among office-based physicians, hospital-based physicians, and comparison subjects. Specifically, Scheffe contrast tests showed that office-based physicians had significantly more outpatient visits (19.3 vs.10.7, p<0.001) and significantly higher outpatient costs (US$656 vs. US$402, p<0.001) than hospital-based physicians.

Conclusions

Physicians had less healthcare utilization than comparison subjects. Furthermore, hospital-based physicians had higher inpatient costs and less outpatient services and costs than office-based physicians.

Attitude of 100 Saudi Female Doctors towards their Health

Objective

To assess the overall health status, lifestyle behavior, and attitude towards menopause, hormonal replacement therapy (HRT) and human papilloma virus (HPV) vaccination among female Saudi doctors.

Materials and methods

This is a cross-sectional study that was conducted over a period of 2 months (November and December 2011). The study population was comprised of Saudi female physicians that are actively working. Ethics approval was obtained prior to conducting the study. A structured self-administered questionnaire was answered by the subjects. Inclusion criteria were any female physician who was willing to participate and was actively practicing at time of the study.

Results

One hundred responses were received. Forty-six subjects were <30 years and 31 subjects were >40 years of age. Obesity was defined as a body mass index (BMI) of >25 and morbid obesity as a BMI >30. Eight subjects had a normal BMI, 27 subjects were overweight, and 16 were morbidly obese. Six subjects were smokers and 13 had chronic illnesses such as diabetes. Only five of the subjects performed regular breast self-examination, and 40 subjects have a breast examination done by a physician. Pap smear was done at least once on only 17% of the subjects. Forty-eight subjects were willing to prescribe HRT to their patients. Sixty-five subjects were willing to administer the HPV vaccination to patients.

Conclusion

The overall health status, lifestyle, and attitude of Saudi female physicians towards their own health is suboptimal. This study shows that even physicians need to improve their lifestyle behavior and attitude towards their own health.

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.

Hormone therapy use among postmenopausal French women before the publication of the Women's Health Initiative study: duration of use and factors associated with discontinuation

OBJECTIVE

Compliance with recent recommendations concerning hormone therapy (HT) requires that we understand the reasons why women receiving HT continue or stop their treatment. Our aim was to estimate the duration of HT use and analyze factors associated with its discontinuation during the period before the publication of articles challenging the safety of HT.

DESIGN

With data from 3 mail questionnaires--at inclusion (in 1990), 3 years, and 6 years--we estimated the cumulative treatment continuation rate by the actuarial method and used the Cox model to analyze the factors associated with discontinuation.

SETTING

French women participating in the GAZEL cohort of employees of the French national power and electricity company (Electricité de France-Gaz de France).

PATIENT(S)

One thousand eighty-three postmenopausal women who were ever-HT users.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Discontinuation of HT.

RESULT(S)

A total of 91.6% of women consulted gynecologists, and 88% continued treatment 5 years after they had begun it. Those reporting hot flashes as a reason for taking HT and those younger than 45 years old at menopause were less likely to stop HT, as were women reporting alcohol use.

CONCLUSION(S)

Our results demonstrate the importance of providing information to physicians, primarily gynecologists, to ensure appropriate treatment of symptoms for menopausal women, especially those younger than 45 years old, while bearing their long-term health in mind.

Menopause: Scientific evidence changes prescribing practice-a comparison of the management of the climacteric and use of hormone replacement therapy among Swedish gynaecologists in 1996 and 2003

OBJECTIVES

To study changes in attitudes, knowledge and management strategies concerning hormone replacement therapy (HRT) among gynaecologists in Sweden.

DESIGN

Comparative questionnaire study.

SETTING

National survey.

POPULATION

Practising gynaecologists.

METHODS

In 1996, gynaecologists in Sweden (n= 1323) were invited to return a postal questionnaire concerning their attitudes, knowledge and management strategies concerning HRT. They were also asked about their own use of HRT. In 2003, a similar questionnaire was sent to practising gynaecologists (n= 1320) in Sweden.

MAIN OUTCOME MEASURES

Attitudes to and personal use of HRT.

RESULTS

The response rate was 76% in 2003 when 11% of the gynaecologists thought that all women without contraindications should be offered HRT compared with 44% in 1996 and 89% found it difficult to evaluate pros and cons with HRT in a clinical situation (74% in 1996). More gynaecologists in 2003 believed that HRT increased the risk for breast cancer (95% vs 71%). Twenty-five percent in 2003 stated that risk factors for osteoporosis were absolute indications for HRT (60% in 1996). Current ischaemic heart disease was considered to be an indication for HRT by 7% in 2003 (60% in 1996). In 2003, current use of HRT was reported by 71% of female menopausal gynaecologists (88% in 1996).

CONCLUSIONS

Swedish gynaecologists were more cautious in their management strategies concerning HRT in 2003 compared with 1996, probably influenced by results from the Heart and Estrogen/Progestin Replacement Study (HERS) and Women's Health Initiative (WHI) studies. Current use of HRT was still high among female gynaecologists, although it had decreased since 1996.

Hormone replacement therapy and breast cancer: estimate of risk

Patients often ask how population risk data apply to them. This analysis will help doctors to answer that question for women considering hormone replacement therapy

HRT and breast cancer: Impact on population risk and incidence

This study has calculated the potential impact of hormone replacement therapy (HRT) on breast cancer incidence in Australia and has estimated how changes in prescribing HRT to women could affect this risk. The effects of HRT on breast cancer incidence was estimated using the attributable fraction technique with prevalence data derived from the 2001 Australian Health Survey and published rates of breast cancer relative risks from HRT use. In Australia, 12% of adult women were current HRT users and in 2001, 11783 breast cancers were reported. Of these, 1066 (9%) were potentially attributable to HRT. Restricting HRT use to women aged less than 65 years, ceasing HRT prescribing after 10 years or limiting combined oestrogen and progesterone HRT to five years (but otherwise keeping prescription levels to 2001 levels) may reduce the annual breast cancer caseload by 280 (2.4%), 555 (4.7%) or 674 (5.7%), respectively. In conclusion, this study has demonstrated that when HRT prevalence is relatively high, the effect on breast cancer incidence in the population will be significant. A small modification in HRT prescribing practices may impact breast cancer incidence in Australia with associated financial and health care provision implications.

Attitudes and practices about postmenopausal hormone therapy among female gynecologists in Brazil

OBJECTIVES

The aim of this study was to investigate the attitudes and practices of Brazilian female gynecologists surrounding their personal use of menopausal/postmenopausal hormone therapy (HT).

METHODS

This study was conducted in February 2001 using a mail survey. Three thousand eighty nine (n = 3089) female gynecologists over the age of 35 years and affiliated with the Brazilian Federation of Obstetricians and Gynecologists (FEBRASGO) were sent a questionnaire inquiring about their demographic, professional, medical, and behavioral background as well as their personal use of HT.

RESULTS

The response rate was 56.3%. Information on the menopausal status was available for 1655 respondents: 755 (45.7%) were postmenopausal, 172 indicated that they had irregular menses cycles (9.2%), and 728 (44.1%) underwent regular menses. Approximately, 47% of the postmenopausal respondents had been subject to a hysterectomy and were above the age of 50 years or had undergone bilateral oophorectomy. When asked about personal HT use, 61.1% and 10.3% of the respondents indicated that they were current or former users, respectively. 28.6% of the respondents had never used HT. The highest frequency of use occurred during their fifth decade. The main reasons for their use of HT included the attenuation of vasomotor symptoms, the prevention/treatment of osteoporosis, or the prevention of cardiovascular disease. Combined estrogen/progestin therapy was the preferred choice for postmenopausal gynecologists with an intact uterus. Family or personal histories of breast cancer or smoking were reported as deterrents against HT use for the female gynecologists.

CONCLUSION

Brazilian postmenopausal gynecologists engage in a high frequency of HT use. High levels of personal use may influence the general population towards HT prescription and compliance.

Hormone replacement therapy and cardiovascular risk

Hormone replacement therapy (HRT) is effective in suppressing postmenopausal symptoms and, in the past, many have claimed that it is cardioprotective. It was thought that the lower incidence of cardiovascular disease in premenopausal women was related to the cardioprotective effect of estrogen. Many of these studies were, however, observational studies. HRT alters many cardiovascular parameters, most beneficially. The mixed effect on these parameters make the overall result on cardiovascular risk difficult to predict. However, recent randomized, placebo-controlled trials have shown not only that HRT does not confer cardioprotection, but that it actually increases one's cardiovascular risk in the short term. Based on the current evidence, HRT should not be recommended in the hope that it will protect postmenopausal women against coronary heart disease.

Comparison of Estonian and Finnish physicians' opinions of menopause and hormone therapy

OBJECTIVE

To compare Estonian and Finnish gynaecologists' and general practitioners' (GP) opinions on and prescribing practices in hormone treatment (HT) during and after menopause.

METHODS

Data was collected using similar postal questionnaires. In 2000 in Estonia, a random sample included 212 gynaecologists and 288 GPs (68% responded); and in 1989 in Finland, 100 male and 100 female gynaecologists, 100 general practitioner specialists and 100 non-specialists (73% responded). Gynaecologists and GPs were compared to each other within the countries, and the two countries were compared within the specialities.

RESULTS

Gynaecologists' opinions of benefits were positive and similar in Estonia and Finland, and more positive than those of GPs. Gynaecologists and GPs in both countries had similar opinions about harms. Gynaecologists were in favour of longer HT than GPs, and longer treatment was recommended in Finland than in Estonia. In both countries a large proportion of physicians (48% of gynaecologists in Estonia and 65% in Finland) stated that they would routinely prescribe HT to all women at menopause without contraindication, regardless of symptoms, and some (31% of gynaecologists in Estonia and 19% in Finland) favoured routine prescribing to all postmenopausal women.

CONCLUSIONS

Estonian physicians' positive attitudes suggest increased use of HT. Comparisons of the two countries and specialities suggest that physicians' positive opinions may long predate increased use.

Hormone therapy prescription among physicians in France and Quebec

OBJECTIVE

Our objective was to compare physician characteristics associated with high-frequency hormone therapy (HT) prescription between gynecologists and general practitioners (GPs) within and between France and Quebec, Canada.

DESIGN

A self-administered mail survey was sent to a representative sample of 2,000 physicians in France and 1,000 physicians in Quebec. High-frequency prescribers were those who reported prescribing HT to more than 70% of their postmenopausal patients. The following characteristics were included in the analysis: country, specialty, age, gender, characteristics of the practice (solo or group, private or public, rural or urban, number of patients seen daily, duration of practice, percentage of women 45 years or older), teaching or research activities, participation in education course on HT, and practice patterns relating to menopausal women (having patient education materials available, providing materials to patients, and discussing the possibility of HT).

RESULTS

The analysis covered 974 physicians in France (389 GPs and 585 gynecologists) and 452 physicians in Quebec, Canada (318 GPs and 134 gynecologists). Despite differences in health care, in both countries gynecologists were more likely to be high-frequency prescribers than were GPs, although this difference was smaller in Quebec. Canadian physicians were more likely to prescribe HT. The difference between countries was greatest among GPs. Except for nationality and practice patterns designed to provide women with information, none of the physician characteristics was associated with high-frequency prescription among GPs. Among gynecologists, only the number of patients per day and the provision of information were associated with high-frequency prescription.

CONCLUSIONS

Notwithstanding a common language, differences in the prescription pattern of HT between countries were greatest at the level of primary care than secondary care. In both countries, specialists were more likely to prescribe HT than were GPs. Implementation of clinical practice guidelines to set baseline standards in the field of menopausal health remains a challenge but will need to take into account cultural characteristics as well as level of medical care.

Attitude towards health and hormone replacement therapy among female obstetrician-gynecologists in Israel

OBJECTIVE

To assess Israeli women gynecologists toward their own health, their health related behaviors and to assess attitude towards and the use of hormone replacement therapy (HRT).

METHODS

Ninety five actively employed hospital and community women gynecologist completed a questionnaire on attitude towards self-health, way of life, smoking habits, and regular breast, blood, pap smear examinations and HRT.

RESULTS

Mean BMI was 25.3 Kg/m(2)+/-4.2, 61% considered themselves above average weight, and only 39% estimated their weight as appropriate. Fifty six percent were on active weight-loss diets, and 35% were current smokers. Blood tests, pap smears and breast evaluations were regularly done by 73.4, 91.5, and 64.1%, respectively. Overall, 74% of the gynecologists had a positive opinion about HRT; 70% of the menopausal subgroup had ever used HRT, and 93.3% of the perimenopausal subgroup intended to use it. The main reason for starting HRT was climacteric symptoms, and for stopping or avoiding HRT were equally bleeding, fear of cancer and adverse reactions towards HRT. By far the oral HRT mode was the most popular and 90% of users expressed satisfaction with treatment.

CONCLUSIONS

Israeli women gynecologists are aware and maintain carefully their health, excluding cigarette smoking. The high rate of use and awareness of HRT among this group is encouraging considering that gynecologist serves as role model for the public and maintains the main source of HRT in the community.

Questionnaire survey of women aged 56–59 years: Consultations in general practice, use of hormone replacement therapy (HRT) and participation in screening programmes

OBJECTIVES

To ascertain attitudes to consultations in general practice and the gender of the doctor. To determine whether women participate in the National Health Service (NHS) screening programmes available to them and their use of hormone replacement therapy (HRT).

DESIGN

Postal questionnaire survey to women aged 56-59 years.

SETTING

The Honiton Group Practice, East Devon, UK.

PARTICIPANTS

Two hundred and ninety-four of the 334 eligible women returned the questionnaire (response rate 88%).

MAIN OUTCOME MEASURES

Women's embarrassment on consulting general practitioners (GPs) and preference for a female doctor. Up-to-date cervical smears and mammography screening in eligible women and use of HRT.

RESULTS

A large majority of women (248/294; 84.4%) were not embarrassed when consulting a GP and did not express a preference to see a woman GP for any problem (240/294; 81.6%). However 123/294 (41.8%) did express a preference to see a woman doctor for 'women's problems'. Sixty-five women had had a hysterectomy, and 218 of the remaining 229 (95.2%) had had a smear in the past 5 years. For breast screening, 267/294 (90.8%) had undergone mammography in the previous 3 years. Ninety-three women (32%) were currently on HRT, and on record searching a total of 146 (49.7%) had at some time been HRT users.

CONCLUSIONS

Embarrassment does not appear to be a major problem for consultations related to female health. A well-organised general practice with motivated patients can achieve very high uptakes of both cervical and breast screening programmes. Interest in HRT has also risen, with half the women aged 56-59 years having used systemic HRT.

Randomised controlled trial of an interactive multimedia decision aid on hormone replacement therapy in primary care

OBJECTIVE

To determine whether a decision aid on hormone replacement therapy influences decision making and health outcomes.

DESIGN

Randomised controlled trial.

SETTING

26 general practices in the United Kingdom.

PARTICIPANTS

205 women considering hormone replacement therapy.

INTERVENTION

Patients' decision aid consisting of an interactive multimedia programme with booklet and printed summary.

OUTCOME MEASURES

Patients' and general practitioners' perceptions of who made the decision, decisional conflict, treatment choice, menopausal symptoms, costs, anxiety, and general health status.

RESULTS

Both patients and general practitioners found the decision aid acceptable. At three months, mean scores for decisional conflict were significantly lower in the intervention group than in the control group (2.5 v 2.8; mean difference -0.3, 95% confidence interval -0.5 to -0.2); this difference was maintained during follow up. A higher proportion of general practitioners perceived that treatment decisions had been made "mainly or only" by the patient in the intervention group than in the control group (55% v 31%; 24%, 8% to 40%). At three months a lower proportion of women in the intervention group than in the control group were undecided about treatment (14% v 26%; -12%, -23% to -0.4%), and a higher proportion had decided against hormone replacement therapy (46% v 32%; 14%, 1% to 28%); these differences were no longer apparent by nine months. No differences were found between the groups for anxiety, use of health service resources, general health status, or utility. The higher costs of the intervention were largely due to the video disc technology used.

CONCLUSIONS

An interactive multimedia decision aid in the NHS would be popular with patients, reduce decisional conflict, and let patients play a more active part in decision making without increasing anxiety. The use of web based technology would reduce the cost of the intervention.

Attitudes to menopause and hormone replacement therapy among Asian and Caucasian women general practitioners

OBJECTIVE

To look for any differences in attitudes to menopause and hormone replacement therapy (HRT) between Asian and Caucasian women standardised for educational background, socio-economic status and access to medical information.

METHOD

Self administered postal questionnaire sent to 144 women doctors (general practitioners) in defined geographical areas.

RESULTS

The overall response rate was 61%. Both Asian and Caucasian women responded in a similar manner for most aspects. A high proportion of these women doctors (over 75%) would seek HRT at the climacteric. More Asian respondents reported a fear of breast cancer (P=0.001), and that a woman feels less of a woman after the menopause (P=0.02). More Caucasian respondents felt positively about the potential for HRT to enhance enjoyment of life (P=0.01).

CONCLUSIONS

The lack of major differences between the ethnic groups in our sample suggests that variations reported elsewhere may be due to lack of knowledge and/or differences in socio-economic status.

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.

Perspectives in hormone replacement therapy

Estrogens have been convincingly shown to be highly effective in preventing and reversing menopause-related conditions, such as hot flushes, urogenital complaints, and postmenopausal bone loss. Observational studies report that long-term, estrogen-containing, postmenopausal hormone replacement therapy (HRT) leads to a substantial reduction in hip fractures, myocardial infarction, and possibly colonic cancer, with important consequences for health and quality of life. Estrogen replacement may postpone the onset of Alzheimer's disease and extend life. While many of these effects are biologically plausible, with a variety of cellular mechanisms being involved, only ongoing and future large-scale randomized clinical trials can and should define the effects of HRT more precisely. Long-term compliance is a key issue for long-term benefits, and offering women a choice of administration routes and regimens can only be beneficial in this respect. Pills, patches, gels, and implants are all widely prescribed. Intravaginal or intranasal forms of administration, which are very easy to use and adaptable on an individual level, are among the new options which could improve long-term continuation of HRT use. Fear of breast cancer and recurrence of vaginal bleeding are real concerns for many women considering HRT. This has led to research into lower-dose, estrogen-containing regimens, into continuous combined regimens, and into the potential of estrogen receptor alpha or beta binding molecules that may help to prevent such problems from arising. The prospects for safe and effective postmenopausal HRT with either estrogens or estrogen-like drugs are very promising when these drugs are used in a patient-tailored, risk profile-based manner.

Evaluation of hormone replacement therapy use by the sales figures

Despite the efficiency of hormone replacement therapy (HRT) to prevent climacteric manifestations and possibly the long-term deleterious influences of menopause, the prevalence of HRT is relatively low, and quite variable, depending on the population studied. Presently, there is no information regarding HRT in Switzerland and in the region of Geneva, which have particularly aged populations, with a life expectancy among the longest in the Western world. In this study, the number of women treated per year in 1993 and 1996, as well as the prevalence of HRT were estimated, based on the total amount of hormone preparations sold for HRT. In Switzerland, for a female population older than 45 years of about 1.45 million, the number of women on HRT was approximately 166,000 in 1993 and 202,000 in 1996. For Geneva, the female population was more than 86,000, and the number of treated women was about 14,000 and 21,000 in 1993 and 1996, respectively. Depending on the age class considered as susceptible of receiving HRT, the prevalence of this therapy may vary between 15 and 20% for Switzerland, and between 21 and 27% for Geneva in 1993. It was estimated between 17 and 24%, and 31 and 41% in 1996. These values are quite comparable to those reported for other countries with a similar socioeconomic level and obtained using different methods of evaluation.

Baseline characteristics of participants in the Women's Health Study

The Women's Health Study (WHS) is a randomized, double-blind, placebo-controlled trial designed to evaluate the balance of benefits and risks of low-dose aspirin and vitamin E in the primary prevention of cardiovascular disease and cancer in women. A total of 39,876 female health professionals, age 45 years or older and without a history of cardiovascular disease or cancer (other than nonmelanoma skin cancer), were randomized in a 2x2 factorial design to one of four treatment groups: active aspirin and vitamin E placebo, aspirin placebo and active vitamin E, both active agents, or both placebos. The process of randomization was successful, as evidenced by the equal distribution of a large number of baseline demographic, lifestyle, and health history characteristics among the four treatment groups. Similar distribution of known potential confounders, as well as the large sample size, provides reassuring evidence that unmeasured or unknown potential confounders are also equally distributed. As expected in a clinical trial, the women in the study are healthier in some respects than the general population, but they have very comparable rates of obesity, hypertension, and elevated cholesterol. With adequate duration of treatment and follow-up, this trial will provide important and relevant information on the balance of benefits and risks of aspirin and vitamin E supplementation in the primary prevention of cardiovascular disease and cancer in women.

The Middle Years Group: a holistic approach to the management of the menopause in primary care

OBJECTIVES

The menopause is attaining greater significance as symptoms and long-term sequelae are amenable to hormone replacement treatment. However, hormone replacement treatment is no panacea and all women undergoing the menopause need to make informed decisions about its use. The aim of this study was to assess the effects of a series of group sessions for women aged 45-55 years, dealing with physical, social, emotional and medical aspects of the climacteric.

METHODS

All women registered at the Roborough surgery were invited to join a group for four sessions, led by the health visitor and counsellor, with a doctor leading one session on hormone replacement treatment. Women's views on the group were obtained by questionnaire. Prescribing data on hormone replacement treatment and antidepressants were analysed for attenders and a matched group of those invited who did not attend.

RESULTS

Twelve percent of invited women attended. All stated that sessions helped an understanding of the physical and emotional changes at this time. No significant differences were found in the use of hormone replacement treatment, antidepressants or in subsequent use of the counsellor's services between the attenders and a matched group of non-attenders.

CONCLUSIONS

This group offered all women at risk the opportunity to discuss, share and learn about all aspects of the menopause. It was well received and made no major differences to the uptake of hormone replacement treatment.

Why do postmenopausal women discontinue hormone replacement therapy?

OBJECTIVES

To study the prevalence and acceptance of hormone replacement therapy (HRT) in the Finnish population and to ascertain the factors leading to premature discontinuation of HRT.

METHODS

A questionnaire survey was conducted among all women aged 50-60 selected from the age-sex register, 1065 women were identified and 884 (response rate 84%) agreed to participate.

RESULTS

111 women were premenopausal and 773 postmenopausal; 302 (39%) were current HRT users, 126 (16%) previous users and 345 (45%) non-users. Of the previous users 27% had used oestrogen for less than 6 months and 46% had ceased treatment within 1 year. The main reason for discontinuation was side-effects; 41% of the women had suffered from them. Fear of cancer (16%), recommendation of a physician (12%), inefficiency (4%), and advice of a friend (3%) were other causes of discontinuation. Of the current users, 20% had continuous side-effects from the treatment and 15% had been advised to discontinue the treatment. Eleven percent of current users and 11% of previous users reported not having received any information about HRT.

CONCLUSIONS

in this survey, more than half of postmenopausal women had used HRT at menopause. Every third of the women had discontinued the treatment, mainly because of side-effects but also because of fear of cancer and advice of physicians.

A general practice pilot audit study to assess advice and treatment offered to women following hysterectomy

BACKGROUND

Current evidence suggests that information and treatment offered to women post-hysterectomy to prevent osteoporosis are poor.

OBJECTIVES

To pilot a general practice audit protocol, to assess its ability to identify hysterectomized women and to offer appropriate information on fracture prevention.

METHOD

A pilot audit study was designed to assess advice offered to hysterectomized women aged 25-64 years. Data on ovarian status were evaluated. Women were recalled for counselling if there was no evidence of advice on fracture prevention and if they were not taking hormone replacement therapy (HRT). Change in HRT usage was used as the outcome measure to assess the impact of the audit.

RESULTS

Baseline data were collated for 5743 women. In 1456 (25%), both ovaries were removed and 4029 (70%) had one or both ovaries conserved; 258 (5%) had incomplete ovarian data. The average age at hysterectomy with both ovaries removed was 43.9 years, and with conservation of one or both ovaries was 40.5 years and 40.1 years, respectively. Some 2888 (50%) were ever-users of HRT (both ovaries removed 70%, one ovary removed 53%, both ovaries conserved 44%). A total of 2083 (36%) were known current users (both ovaries removed 53%, one ovary removed 40%, both ovaries conserved 30%). The mean duration of use in 2620 ever-users was 44 months. This was similar for all the women irrespective of ovarian status. Eighty per cent of those given HRT reported receiving some advice. Seventy-seven per cent of those not given HRT had not received advice. By the end of the audit, 424 had commenced HRT (20% increase). Current use rose to 44% (both ovaries removed 59%, one ovary conserved 46%, both ovaries conserved 39%). Sixty-three per cent of new users chose transdermal preparations.

CONCLUSIONS

The mean age at hysterectomy of between 40.1 and 43.9 years indicates the potential for early ovarian failure. Use of HRT is associated with availability of counselling. Uptake was better than anticipated, but HRT usage was still well below optimum. This audit fulfills its objectives but not without cost implications. Year by year it should achieve significantly improved management and health of hysterectomized women, and improved standards of patient care.

Drug related negative side-effects is a common reason for poor compliance in hormone replacement therapy

OBJECTIVES

The reasons for poor compliance with hormone replacement therapy (HRT) and, in particular drug-related reasons, have not yet been fully elucidated. In this study, a cohort of peri- or postmenopausal women--mainly workers from a small town and surrounding rural area--was studied. The aim of the study was to investigate why some women never start or discontinue HRT, even when great effort has been made to inform and fulfill the demands of the patient.

METHODS

All women who were given a HRT prescription at a gynecological practice between September 1991 and December 1992 participated in a longitudinal study. A written questionnaire was mailed to these patients in 1996. Data from the questionnaire was supplemented with information from the medical records. Care of patients included initial information, follow-up within 4 months, yearly visits supplemented with contacts on demand.

RESULTS

356 women received the questionnaire, among which 92% replied. A total of 2% never started HRT. Seventy-five percent continued the therapy for more than 3 years. Reasons for discontinuing HRT were negative side-effects (35%), desire to find out if climacteric symptoms had ended (26%), fear of cancer and thrombosis (25%), weariness of bleeding (19%) and a wish to deal with the problems 'naturally' (15%).

CONCLUSIONS

Compliance with HRT can be high if adequate information is given and follow-ups are made. The main reason for poor compliance was negative side-effects, most likely progestin-related. The results of this study suggest that the future challenge will be to minimize negative side-effects of HRT.

Educating patients about the benefits and drawbacks of hormone replacement therapy

Hormone replacement therapy (HRT) influences many aspects of health: climacteric symptoms, osteoporosis, cardiovascular disease, breast and endometrial cancer, thrombosis and emboli, and Alzheimer's disease. A decision to use HRT may depend on a woman's individual views of the menopausal transition, the postmenopause and its consequences. It is therefore useful that the health provider inquiries about and discusses these issues in a cultural and family context. Health providers and patients should be thoroughly informed about the symptoms associated with hormonal deprivation, the associated risks of osteoporosis and cardiovascular disease, and the potential of HRT to prevent these afflictions. Recent studies suggest that HRT might be particularly beneficial in women who have an increased risk for cardiovascular disease (because of left ventricular hypertrophy, diabetes mellitus, hypertension or hypercholesterolaemia, or because they smoke) or osteoporosis. In women who are undecided about HRT, a low bone mineral density measurement might help convince them to start using, or to continue using, HRT. There is also a need to discuss with the patient the effect of HRT on cancer risk. In most instances, women can be reassured about the risk of endometrial cancer. The risk of breast cancer should be carefully considered and discussed with each patient before beginning HRT. In most cases, HRT should not be withheld because of fears about breast cancer, because the protective effects of HRT against cardiovascular disease and osteoporosis outweigh the possible increased risk of breast cancer. When HRT is prescribed, individual regiments should be discussed with the patient, who must be warned of the possible adverse effects. In older women, HRT can be started at half the normal dosage and tolerability assessed before increasing the dosage further.

Hormone replacement therapy usage: a 10 year experience of a solo practitioner

The objective of this study was to identify factors affecting hormone replacement therapy (HRT) usage among patients of a single physician. All active patients (n = 330) given a HRT prescription over the past 10 years (1985-1995) by the physician were sent a questionnaire on health knowledge, lifestyle patterns, general medical and reproductive histories, responses to HRT usage and decision-making about HRT use. A total of 214 useful questionnaires were returned giving a response rate of 65%. For this cohort, the length of HRT use for those still taking HRT was 60 months; and for those no longer taking HRT, it was 32 months; and 85% of those ever given an HRT prescription were still using HRT at the time of survey. The educational backgrounds, exercise patterns, health knowledge, medical and reproductive histories of this group were representative of those found among suburban postmenopausal women in central Pennsylvania. Among this cohort, the most important reason for them taking HRT was the physicians' recommendation.

Effect on attendance at breast cancer screening of adding a self administered questionnaire to the usual invitation to breast screening in southern England

STUDY OBJECTIVE

The primary aim of the research described in this paper was to ascertain whether inclusion of a self administered questionnaire with the usual invitation to routine breast screening affected screening uptake. Secondary aims included establishing appropriate questionnaire distribution and collection methods within the framework of the National Health Service Breast Screening Programme and optimisation of questionnaire design.

DESIGN

Randomised study.

SETTING

Oxfordshire and West of London Breast Screening Units.

PARTICIPANTS/METHODS

6400 women invited for routine screening mammography were individually randomised to receive either the usual breast screening invitation alone, or to receive the usual invitation accompanied by a self administered questionnaire, to be returned at the time of screening. Participants were then followed up and attendance rates at screening were compared between groups.

MAIN RESULTS

Screening attendance rates were similar in women who did and did not receive a questionnaire (71% in each group). Of those who were sent a questionnaire and attended for screening, 77% returned a completed questionnaire. Screening uptake was not affected by the way in which the questionnaire was returned or by whether or not personal details and signed permission for follow up were requested.

CONCLUSIONS

The inclusion of a self administered questionnaire accompanying the invitation to breast screening did not adversely affect screening uptake. A high proportion of women completed the questionnaire.

Why do women doctors in the UK take hormone replacement therapy?

STUDY OBJECTIVES

To ascertain the determinants and experiences of hormone replacement therapy (HRT) use by menopausal women doctors.

DESIGN

Postal questionnaire.

SETTING

UK.

PATIENTS

A randomized stratified sample of women doctors who obtained full registration between 1952 and 1976, taken from the current Principal List of the UK Medical Register.

MAIN OUTCOME MEASURES

Current and previous use of HRT; reasons for and against HRT use; menopausal status; hormonal contraceptive use; lifestyle patterns; family and personal history of disease.

MAIN RESULTS

While 73.2% of 471 users had started HRT for symptom relief, 60.9% cited prevention of osteoporosis and 32.7 prevention of cardiovascular disease. Altogether 18.7% had started for preventive purposes alone. Significant predisposing factors to starting HRT were the presence and severity of menopausal symptoms, surgical menopause, past use of hormonal contraception, and a family history of osteoporosis. HRT users were also more likely to use skimmed rather than full fat milk, to try to increase their intake of fruit, vegetables, and fibre, and to undertake vigorous physical activity at least once a week. They were less likely to have had breast cancer. Long duration users were more likely than short duration users to be past users of hormonal contraception and to be using HRT for prevention of osteoporosis as well as symptom relief; they were less likely to have experienced side effects.

CONCLUSIONS

The high usage of HRT by women doctors reflects the fact that many started HRT on their own initiative and with long term prevention in mind. The results may become generalisable to the wider population as information on the potential benefits of HRT is disseminated and understood. However, HRT users may differ slightly from non-users in health-related behaviour and a substantial minority may never take up HRT, at least until the benefit-risk ratio is more clearly established.

Prescribing of hormone therapy in menopause and postmenopause

This article describes the use and prescribing of menopausal and postmenopausal hormone therapy (HT) in one example country, Finland, and the trends and levels of HT use in other western countries for comparison. Previously published studies were reviewed and reanalyzed, and some additional unpublished data from Finnish surveys were compiled. The use of HT increased in Finland up to 1994. In Finland the initiative for HT use came more often from physicians than women themselves, physicians valued HT more than women, women's period of use of HT was shorter than physicians' recommendations, women's reasons for using HT were usually to treat symptoms, but physicians considered HT also useful in the prevention of later diseases. Gynecologists were more favorable toward HT than other physicians. HT has become common in very different times in different countries, but with the exception of the US experience in the 1970s, the trend has been towards increasing use. One motivation to do surveys on physicians' prescribing or women's use of HT has been to facilitate HT use. The large variation in HT use may reflect the uncertainty concerning its true value. The reasons for the large-scale prevention with HT have not been systematically studied, but it is likely due to various social and commercial forces.

Prevalence and characteristics associated with use of hormone replacement therapy in Britain

OBJECTIVE

To describe trends in the prevalence of hormone replacement therapy (HRT) use among women living in Britain between 1981 and 1990, and to determine whether women who receive HRT are different from those who do not.

DESIGN

Population-based, prospective, observational study.

SETTING

Fourteen hundred general practices throughout the United Kingdom contributing data to the Oral Contraception Study of the Royal College of General Practitioners (RCGP).

POPULATION

Prevalence of use: women still under general practitioner observation in the Oral Contraception Study at the end of December 1981 (n = 19,949), 1984 (n = 18,037), 1987 (n = 16,063), 1990 (n = 13,379). Characteristics of users: 3806 HRT users and 3806 never-users matched for age, hysterectomy status and duration of observation in the Oral Contraception Study.

MAIN OUTCOME MEASURE

Ever-use of hormone replacement therapy.

RESULTS

Between 1981 and 1990 there was a threefold increase in HRT use among women both among those who had and those who had not had a hysterectomy. Increasing trends were apparent in all age groups. By December 1990, 19% of all women (36% of those who had had a hysterectomy and 16% of those who had not had a hysterectomy) had ever used HRT; 9% were classified as current users. Forty-one percent of women using HRT who had had a hysterectomy received combined (oestrogen and progestogen) preparations; 31% of those who had not had a hysterectomy received at least one prescription for unopposed oestrogen. Among those who had had a hysterectomy, HRT was more likely to be prescribed in women with a history of smoking, nonpsychotic psychiatric illness, hot flushes, other menopausal symptoms, oophorectomy, migraine or headache. Women with breast cancer were less likely to receive HRT. In women who had not had a hysterectomy, smoking, nonpsychotic psychiatric illness, hot flushes, other menopausal symptoms, migraine, headache and previous use of oral contraceptives increased the chances of HRT being used; a history of breast cancer, ischaemic heart disease or diabetes mellitus reduced the chances. Weaker associations of reduced risk were also found for hypertension and lower social class. The influence of hot flushes and other menopausal symptoms appeared to be stronger in women who used HRT before the age of 50, than in older women.

CONCLUSIONS

HRT use increased dramatically within the cohort during the nine year period. HRT users are different from nonusers in a number of ways which could have opposing effects on a woman's risk of cardiovascular disease.

Use of oral corticosteroids in the community and the prevention of secondary osteoporosis: a cross sectional study

OBJECTIVE

To determine the prevalence of continuous use of oral steroids in the general population, the conditions for which they are prescribed, and the extent to which patients taking oral steroids are taking treatment to prevent osteoporosis.

DESIGN

A cross sectional study with a four year retrospective review of drug treatment.

SETTING

Eight large general practices in central and southern Nottinghamshire.

SUBJECTS

A population of 65,786 patients (52% women) registered with a general practitioner during 1995.

RESULTS

303 patients (65% (197) women) aged 12-94 years were currently taking "continuous" (for at least three months) oral corticosteroid treatment. This figure represents 0.5% of the total population and 1.4% (245/17 114) of patients aged 55 years or more (1.7% (166/9601) of women). The usual steroid was prednisolone (97% (294/303)), the mean dose was 8.0 mg/day, and the median duration of oral steroid treatment determined in 149 patients was three years. The most common conditions for which continuous oral steroids were prescribed were rheumatoid arthritis (23% (70)), polymyalgia rheumatica (22% (66)), and asthma or chronic obstructive airways disease (19% (59)). Only 41 (14%) of the 303 patients taking oral steroids had received treatment for the prevention of osteoporosis over the past four years. Although 37 of the 41 patients were women, only 10% (18/181) of the women over 45 years taking continuous oral corticosteroids were currently taking hormone replacement therapy.

CONCLUSIONS

If our figures are typical then they suggest that over 250,000 people in the United Kingdom are taking continuous oral steroids and that most of these are taking no prophylaxis against osteoporosis.

Individual hormone replacement therapy

Although hormone replacement therapy is widely used in western countries, compliance is not very good; only a minor proportion of women starting the treatment continue it for over 5 years. However, long-term treatment is essential for primary prevention of cardiovascular diseases and osteoporosis. One reason for low compliance is that treatment is not planned individually. After using a fixed estradiol dose, serum levels of estradiol show 10-fold differences between subjects, independently of the routes of administration. This article briefly summarizes the possibility of using tailored treatment and thus improving long-term compliance with HRT.

Women doctors' use of hormone replacement therapy. High prevalence of use is not confined to doctors

Images

Women doctors' use of hormone replacement therapy. May be to enable them to cope with demands of their job

Images