Women's perceptions of hormone replacement therapy: risks and benefits (1980–2002). A literature review

OBJECTIVES

Many postmenopausal women are reluctant to take hormone replacement therapy (HRT) and those who do are likely to discontinue within 1 year. Setting aside the beliefs and prejudices of the prescriber, women's own perceptions of risks and benefits may influence their willingness to accept and then persevere with HRT. We conducted a systematic literature review relating women's beliefs about HRT to acceptance and adherence.

METHODS

Using standard guidelines for systematic search procedures, we identified 112 papers (published during 1980-2002) from databases such as Medline, PsycINFO and the NHS and Cochrane libraries.

RESULTS

Women hold both positive and negative beliefs about HRT. Their perceptions of benefits are often countered by concerns over potential adverse effects, beliefs that are sometimes at odds with the clinical evidence. The use and discontinuation of HRT are influenced more by short-term symptom relief than by considerations of long-term benefits. Many women who refuse HRT believe that the menopause is a natural event that does not warrant 'chemical' intervention. Doctors and nurses are not used to their full capacity as an education and information resource to counter the possibility of unbalanced stories in the media.

CONCLUSIONS

Addressing women's preconceptions about HRT should be an important part of the process of prescribing and review. Such an approach will help ensure that a woman's decision to start or continue HRT is informed by an understanding of the known risks and benefits, rather than by myths or mistaken beliefs about the menopause or HRT.

[Compliance with hormone replacement therapy in menopausal women: results of a two-year prospective French study comparing transdermal treatment with fixed oral combination therapy]

OBJECTIVES

To evaluate rates of continuation with hormone replacement therapy (HRT) at 2 years in 2 cohorts of female patients, one of which was treated with a set combination of oral oestradiol valerate and medroxyprogesterone acetate and the other with percutaneous 17 beta-oestradiol gel combined with an oral progestogen selected by the prescribing doctor.

PATIENTS AND METHODS

A prospective, randomised, open study, including 885 patients followed for 2 years whose 477 were in the oral HRT cohort and 408 were in the dermal cohort. Randomisation was done by group with prescription of the selected HRT for the cohort. The 2 treatment groups were compared using chi(2) tests and Fisher's exact test for qualitative variables, Student's t test or Wilcoxon's test for qualitative variables and Kaplan-Meier survival curves for continuation of HRT, with comparisons using the log-rank test. The prognostic value of baseline parameters on subsequent continuation of HRT was studied using the Cox model (Wald test, odds ratio). RESULTS; Among the 885 treated patients, 711 received the HRT assigned to their cohort (382 in the oral HRT cohort, 329 in the dermal HRT cohort). After 2 years, 77.9% of the patients in the oral HRT cohort and 73.4% of the patients in the dermal HRT cohort were continuing to take their prescribed HRT (P = 0. 076): 37.9% of patients in the oral HRT cohort and 20.2% of patients in the dermal HRT cohort (P < 0.001) continued taking their treatment without any modification.

CONCLUSION

Although there was no significant difference in the level of compliance in the 2 groups, it is nonetheless worth noting that the HRT compliance with a sequential fixed estroprogestogen combination was, in this trial, at least equal to that with the free combination of a transdermal estrogen and a progestogen whose nature, dosage and sequence duration are selected by the prescriber. On the other hand, treatment modifications occurred more frequently in the cutaneous HRT group, which is logical as free combination affords to adapt the treatment to each patient.

Determinants of hormone replacement therapy duration among postmenopausal women with intact uteri

OBJECTIVE

To investigate factors associated with hormone replacement therapy (HRT) duration among postmenopausal women with intact uteri.

DESIGN

A Cox proportional hazard model on time to HRT discontinuation is estimated for 2,632 postmenopausal HRT users with intact uteri who began a new episode of treatment between January 1990 and December 1994 in Saskatchewan, Canada.

RESULTS

Major contraindicating medical events were highly associated with HRT discontinuation among postmenopausal women. Women who were diagnosed with uterine cancer while taking HRT were almost four times as likely to discontinue HRT, and women who were diagnosed with breast cancer while taking HRT were nearly five times as likely to discontinue HRT. Other statistically significant factors associated with the duration of HRT episodes include administration mode and the ability to try different types and strengths of HRT. Women initiating HRT with a transdermal patch were 50% more likely to discontinue it. Women who were willing and able to experiment with different HRT reduced their likelihood of discontinuing by one-half to three-fourths.

CONCLUSIONS

Although some of the factors associated with the hazard of HRT discontinuation among postmenopausal women who are taking the treatment for preventive benefits are immutable, clinicians may influence HRT continuation rates through initial drug choice or modifications in drug type or regimen over the course of therapy.

Alternatives for women through menopause

Today, 42% of Americans use alternative nonprescription therapies to treat medical conditions; 46% of nonprescription alternative use for principal medical conditions is done without consulting either a medical doctor or a nonphysician practitioner of alternative therapy. Many nontraditional alternatives are used to treat the hot flashes and somatic complaints of menopause, for which options such as hormone replacement therapy and other prescription and over-the-counter drugs are also available. To date, no one agent treats all menopausal symptoms as effectively as estrogen. Selective estrogen-receptor modulators can help prevent osteoporosis but do not relieve menopausal symptoms. However, some women are unwilling or unable to take hormone replacement therapy, and some decide to discontinue therapy. Evidence supporting the use of some nonprescription alternatives for conditions related to menopause is limited. Patients need to be aware of the potential for drug interactions when these alternative therapies are used concomitantly with prescription drugs. The current evidence to support use of hormone replacement therapy, selective estrogen-receptor modulators, and nontraditional alternatives is reviewed here.

Effects of lower doses of conjugated equine estrogens and medroxyprogesterone acetate on plasma lipids and lipoproteins, coagulation factors, and carbohydrate metabolism

OBJECTIVE

To determine the effects of lower doses of conjugated equine estrogens (CEE) alone or CEE and medroxyprogesterone acetate (MPA) on lipoproteins, carbohydrate metabolism, and coagulation/fibrinolytic factors.

DESIGN

Randomized, double-blind, placebo-controlled study.

SETTING

Multicenter substudy of the Women's HOPE trial.

PATIENT(S)

Seven hundred and forty-nine healthy, postmenopausal women.

INTERVENTION(S)

Women were randomized to receive the following doses in milligrams per day: 0.625 CEE; 0.625 CEE/2.5 MPA; 0.45 CEE; 0.45 CEE/2.5 MPA; 0.45 CEE/1.5 MPA; 0.3 CEE; 0.3 CEE/1.5 MPA; or placebo.

MAIN OUTCOME MEASURE(S)

Assessment of lipids, lipoproteins, glucose tolerance, and coagulation/fibrinolytic factors at baseline, cycle 6, and year 1.

RESULT(S)

One year of treatment with any of the CEE or CEE/MPA regimens studied increased high-density lipoprotein cholesterol (HDL-C); the 10% increase in HDL-C for the CEE 0.45/MPA 1.5 group was similar to the CEE 0.625/MPA 2.5 group. Low-density lipoprotein cholesterol was significantly reduced in all of the active treatment groups except the CEE 0.3/MPA 1.5 group at cycle 13. Apolipoprotein A-I and triglyceride levels increased and apolipoprotein B levels decreased in all groups. The lipoprotein (a) level was reduced in the CEE 0.45/MPA 2.5, CEE 0.45/MPA 1.5, and CEE 0.625/MPA 2.5 groups. Minimal changes were observed in carbohydrate metabolism for all groups. Fibrinogen and PAI-1 activity decreased and plasminogen activity increased in all groups. Decreases in antithrombin III and protein S activities were significant for all active treatment groups except the CEE 0.3/MPA 1.5 group.

CONCLUSION(S)

Lower doses of CEE and CEE/MPA induce favorable changes in lipids, lipoproteins, and hemostatic factors with minimal changes in carbohydrate metabolism.

Personal perspective on low-dosage estrogen therapy for postmenopausal women

OBJECTIVE

As evidenced by results from recent clinical trials and epidemiological studies that have examined the physiological and clinical effects of low levels of estradiol, it is now time to replace the widely held belief that less than the standard dosage of estrogen is without benefit.

DESIGN

Review of literature and personal experience.

RESULTS

Studies indicate that low-dosage estrogen can relieve vasomotor symptoms, can prevent bone loss, and may reduce the risk of coronary heart disease. However, to achieve these health benefits, long-term estrogen use is required. Women who use low dosages of estrogens are less likely to have unacceptable side effects, such as irregular bleeding, heavy bleeding, or breast tenderness. Thus, long-term continuance of hormone replacement therapy (HRT) may be improved if lower dosages are given, particularly if the HRT regimen is tailored to the needs of the patient.

CONCLUSIONS

Although standard-dosage estrogen remains the "gold standard" for HRT, having a low dosage as an alternative regimen can be useful. Attention of clinical researchers should focus on the effects of low-dosage estrogen on osteoporotic fractures and other health outcomes.

Persistence with estrogen therapy in a postmenopausal Medicaid population

We evaluated rates of persistence with estrogen replacement therapy in postmenopausal Georgia Medicaid recipients adjusted for age and race. Data files for 1992-1994 were examined to estimate 3-year conditional survival probabilities using the Kaplan-Meier model, and 3800 subjects were identified. Over 54% of women remained compliant over 29 months, and 17% continued therapy for the entire 35 months of observation. Kaplan-Meier predictors indicated that white women have a 70% chance of being compliant for 3 years, whereas black women have a 60% chance. Monthly discontinuation rates ranged from 1-1.5% after the second month of therapy. Younger, white women were the most likely to maintain and comply with therapy.