Hormone replacement therapy for all? Not for everybody

Postmenopausal hormone therapy: who now takes it and do they differ from non-users?

BACKGROUND

Considerable changes in hormone therapy use have taken place in the last few years.

AIMS

To determine current usage of postmenopausal hormone therapy and assess the trend and rate of change in hormone therapy usage over the last 13 years. Additionally, to assess differences between current users and non-users for health-related and risk factor variables.

METHODS

Questions regarding hormone therapy use have been included in an annual face to face population health survey of South Australians eight times since 1991. In 2004, additional questions on health status and quality of life were included.

RESULTS

In 2004, current use of hormone therapy was 15.4, 19.8 and 31.2% in all women over 40, 50 and 50-59 years, respectively. Ever use of hormone therapy among all women over 50 years was 46.5% with a mean duration of use of 7.46 years. Hormone therapy users did not differ from non-users in chronic disease indicators, body mass index, complementary medicine or therapist use, other health service use, socioeconomic status or quality of life. Increased hormone therapy use was associated with higher income, better educated, employed and married women in their sixth decade. Current use has varied over the years, with an increase to 2000, but a drop in 2003 and 2004.

CONCLUSION

Apart from menopausal symptoms, there is no evidence to support differences between users and non-users in terms of quality of life or health characteristics, requiring more appropriate selection of women for hormone therapy.

Hormone replacement therapy and symptom reporting in menopausal women: a population-based study of 35-65-year-old women in mid-Sweden

OBJECTIVE

To measure the prevalence rate of hormone replacement therapy (HRT) in the general population and to see whether HRT users report less symptoms, better general health and less use of other palliative than non-users and previous users.

METHODS

The study was performed in 1995 as a cross-sectional postal questionnaire study in seven counties in mid-Sweden. The questionnaire was sent to a random sample of 4200 35-64-year-old women of whom 2991 responded. The age distribution of responders and non-responders was similar 49.6+/-8.5 and 49.8+/-8.7 years, respectively. The main outcome measures were vasomotor and general symptoms in relation to menstrual status and HRT.

RESULTS

Fifteen percent were on HRT and 2.3% had stopped treatment during the past year. Thirteen percent used other palliatives. Twenty-five percent of premenopausal women experienced any vasomotor symptoms, as compared with 51% of menopausal and 40% of postmenopausal women. Those on HRT reported higher frequencies than non-users of all symptoms except for sweating during the daytime. In addition, menopausal women experienced more of other symptoms, usually not associated with the menopause, than premenopausal and postmenopausal women. HRT users reported a significantly worse perceived health and they took other palliatives drugs to a larger extent than HRT non-users.

CONCLUSION

HRT seemed to be effective in relieving some vasomotor symptoms but did not affect the prevalence of other symptoms or perceived health, in spite of the fact that women on HRT supplemented their therapy with palliative drugs to a larger extent than other women.

Hormone replacement therapy: prevalence, compliance and the 'healthy women' notion

BACKGROUND

The objective of this study was to assess the current trends of hormone replacement therapy (HRT) use, including rates of use, length of use, continuation rates and characteristics of users and non-users and to examine the hypothesis that 'healthy women' are more likely to be users of HRT.

METHODS

Analysis was carried out of three representative South Australian population studies in 1991, 1993 and 1995 comprising 3019, 3004 and 3016 personal interviews, respectively.

RESULTS

Current use (and ever-use) of HRT in all women aged 50 years and over rose from 13.2% (26.7%) in 1991, to 21.2% (31.9%) in 1993 and 26.0% (40.5%) in 1995. Highest use is now in the 55-59-year age group where, in 1995, current use was 50.9% and ever use was 69.0%. Median compliance rates with HRT rose from 24 months in 1991 to 60 months in 1995 for current users aged 50 years of age or above. The pattern of increasing use of HRT is not consistent across age groups. Analyses of the 1995 data show that, in contrast with increasing rates of current use in women over 55 years, there was no overall change in rates for women below this age. There were no statistically significant differences in health indicators, e.g. blood pressure, smoking, cholesterol levels or body mass index between users and non-users of HRT. However, users reported significantly higher rates of previous osteoporosis and hysterectomy.

CONCLUSIONS

Prevalence rates of HRT use are increasing together with compliance rates and this may reflect increased confidence with HRT therapy. Users of HRT have an increased rate of mammography compared to non-users and this may contribute to earlier detection and, therefore, increased estimates of breast cancer in HRT users. There was no support from the 1995 data for a 'healthy women' hypothesis among HRT users.

Health status of hormone replacement therapy users and non-users as determined by the SF-36 quality-of-life dimension

BACKGROUND

The objective of this study was to compare the health status of women who use and do not use hormone replacement therapy (HRT).

METHOD

The 1994 South Australian Health Omnibus Survey (a population health interview survey) was used to administer the short form-36 health survey questionnaire (SF-36) to users and non-users of HRT. A representative sample of 813 women aged 40 years and older were interviewed. The response rate of the survey was 72.4%. Eight health dimensions of the SF-36 were measured: physical functioning, social functioning, role limitations owing to emotional problems, role limitations owing to physical problems, mental health, vitality, pain and general health.

RESULTS

The mean score for all eight health dimensions was in the bottom 50% of the population for HRT users while non-users were in the upper 50%. Users of HRT had significantly poorer scores for physical limitations, body pain, general health, vitality, social functioning and mental health.

CONCLUSION

Women who use HRT are less healthy than non-users when measured by a generic health status measure.

Perimenopausal bone density screening--will it help prevent osteoporosis?

OBJECTIVE

To estimate the potential efficacy and cost-effectiveness of hormone replacement therapy (HRT) in the prevention of osteoporotic fractures, with and without the assistance of perimenopausal bone mineral density (BMD) screening.

METHOD

Residual lifetime fracture experience of a hypothetical cohort of 100,000. British women aged 45 years at baseline, modelled using prevailing UK mortality and fracture rates. Appropriate fracture risk gradients were used to estimate the distribution of future fragility fractures (distal forearm, proximal femur and clinically diagnosed vertebral fractures) according to quarters of baseline bone density measured at fracture specific sites. We assumed that 72% of the population could be contacted and would attend for HRT counselling, with or without bone densitometry, that 10 years of continuous HRT use would reduce fracture rates by 50%, and that compliance with HRT might vary between 10% and 50%. Universal recommendation of HRT was compared to selective treatment protocols offering HRT to those women whose BMD fell below the 25th, 50th or 75th percentile of BMD at the lumbar spine, femoral neck or distal forearm, measured either singly or in combination.

RESULTS

The proportion of future fractures averted was closely related to compliance with therapy, but for any given level of compliance, universal treatment always achieved the greatest reduction in fractures. If compliance was 10% universal HRT was also the most cost-effective strategy, but if compliance was higher or if the unit cost of HRT increased, selective strategies were often more cost-effective. The sensitivity of BMD screening in identifying women at risk of future fracture could be increased by relaxing the BMD decision threshold, or expanding the number of skeletal sites measured, or both. However increments in test sensitivity were always accompanied by reductions in specificity.

CONCLUSIONS

If BMD measurement does not influence compliance, then universal treatment with HRT is likely to prevent more fractures, at a similar or lower average cost per fracture averted, than selective therapy. However, if BMD screening leads to increased compliance, or if more expensive forms of treatment were used, then our model suggests a favourable impact of screening on the numbers and/or net cost of fractures prevented.