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

Menopausal symptoms and attitudes toward hormone replacement therapy among Israeli women

Menopause occurs around midlife and is an inevitable component of women's aging. The study aimed to investigate the associations between the lifetime prevalence of menopausal symptoms and health-related characteristics among Israeli postmenopausal women aged 55-75 years. Additionally, this study aimed to estimate the use of hormone replacement therapy (HRT) and women's attitudes toward this treatment. Data for this study were extracted from a cross-sectional national telephone survey conducted in Israel between 2018 and 2020. For the current study, only postmenopausal women aged 55-75 years were included. Multivariate analyses were used to identify demographic and health-related characteristics associated with menopausal symptoms. The study included 688 participants. Most (68.8%) reported one or more menopausal symptoms, specifically vasomotor symptoms (50.4%). According to the multivariate logistic regression analysis, menopausal symptoms were associated with moderate-high anxiety and/or depression symptoms (OR = 2.01, 95% CI 1.12-3.58) and with osteoporosis (OR = 1.78, 95% CI 1.08-2.92). Although most (78.3%) symptomatic women were bothered by their symptoms, 29.1% received any treatment for symptom relief and only 12.6% reported current or past use of HRT. The findings show that menopausal symptoms were associated with a higher prevalence of anxiety and/or depression symptoms and osteoporosis in the years following menopause. Most symptomatic women did not receive any treatment and the majority were against HRT. Knowledge and awareness about menopause and treatment options should be increased among Israeli women. Additionally, the promotion of positive attitudes toward menopause and HRT use among women and healthcare providers is strongly recommended.

Impact of Global Consensus Statement on compliance with hormonal therapy for surgical menopause

OBJECTIVE

Initiation of and compliance with menopausal hormonal therapy (MHT) have been dropping due to the 2002 Women's Health Initiative (WHI) publication. We evaluated the change in practice of MHT for surgical menopause after implementing the 2013 'Global Consensus Statement on MHT' to our institutional guideline.

METHODS

A retrospective study was conducted in surgically menopausal women newly registering at the Siriraj Menopause Clinic in a university hospital, Thailand, from 1995 to 2013. The patients were categorized into four groups according to periods of MHT initiation: 1995-1998 (control), 2000-2003 (WHI affected), 2005-2008 (post WHI) and 2010-2013 (Global Consensus Statement affected). Their 3-year compliance with MHT was compared using forward stepwise regression analysis.

RESULTS

There were 288, 156, 107 and 104 cases in the 1995-1998, 2000-2003, 2005-2008 and 2010-2013 groups. Their mean age at surgery was 42.8 ± 4.7 years. After the first, second and third years, overall compliance was 82.4%, 70.9% and 61.2%, respectively. The 3-year compliance drastically dropped in the 2000-2003 group, and then improved to control level in the 2010-2013 group (51.9% vs. 77.9%, p = 0.035).

CONCLUSION

The initiation of MHT continuously dropped during 2000-2013; however, compliance with MHT initiated during 2010-2013 improved after implementing the 2013 'Global Consensus Statement on MHT' to our institutional guideline. Each institute should have a strategy to encourage the initiation of and compliance with MHT for surgical menopause to achieve long-term health benefits.

Perspectives and decision-making about menopausal therapies in women who had bilateral oophorectomy

OBJECTIVE

The aim of the study was to explore the process of decision-making about menopausal treatments in women who have had surgical menopause as a result of bilateral oophorectomy (≤50 y).

METHODS

We used a descriptive qualitative research design. Women who had a surgical menopause were purposefully selected from the Edmonton Menopause Clinics. Focus groups were held, each with six to nine participants. All sessions were audio-recorded and transcribed verbatim. Data were analyzed using qualitative content analysis.

RESULTS

We conducted five focus groups from June 30 to July 21, 2016 (N = 37). One-third of the women had the surgery within the last 5 years. Almost all women had a concurrent hysterectomy (97%) and were current users of hormone therapy (70%). Four main themes identified were "perceptions of surgical menopause," "perceptions of received support," "being my own advocate," and "concept of adequate support." Women shared that the experience was worse than their expectations and did not believe they were given adequate support to prepare them to make therapy decisions. Women had to "be their own advocates" and seek support from within the healthcare system and outside to cope with their health issues. To make an informed decision about treatments postsurgery, women expressed a need to learn more about the symptoms of surgical menopause, treatment options, resources, avenues for support, and stories of similar experiences, preferably before the surgery.

CONCLUSIONS

We identified several modifiable deterrents to decision-making in early surgical menopause which can help inform the development of a patient decision aid for this context.

Comparison of annual percentage change in breast cancer incidence rate between Taiwan and the United States-A smoothed Lexis diagram approach

Recent studies compared the age effects and birth cohort effects on female invasive breast cancer (FIBC) incidence in Asian populations with those in the US white population. They were based on age-period-cohort model extrapolation and estimated annual percentage change (EAPC) in the age-standardized incidence rates (ASR). It is of interest to examine these results based on cohort-specific annual percentage change in rate (APCR) by age and without age-period-cohort model extrapolation. FIBC data (1991-2010) were obtained from the Taiwan Cancer Registry and the U.S. SEER 9 registries. APCR based on smoothed Lexis diagrams were constructed to study the age, period, and cohort effects on FIBC incidence. The patterns of age-specific rates by birth cohort are similar between Taiwan and the US. Given any age-at-diagnosis group, cohort-specific rates increased overtime in Taiwan but not in the US; cohort-specific APCR by age decreased with birth year in both Taiwan and the US but was always positive and large in Taiwan. Given a diagnosis year, APCR decreased as birth year increased in Taiwan but not in the US. In Taiwan, the proportion of APCR attributable to cohort effect was substantial and that due to case ascertainment was becoming smaller. Although our study shows that incidence rates of FIBC have increased rapidly in Taiwan, thereby confirming previous results, the rate of increase over time is slowing. Continued monitoring of APCR and further investigation of the cause of the APCR decrease in Taiwan are warranted.

The Risk of Breast Cancer in Women Using Menopausal Hormone Replacement Therapy in Taiwan

Menopausal hormone replacement therapy (HRT) increases the risk of breast cancer in Western countries; however, there are fewer reports from the Asian population, which has a lower incidence of breast cancer. A population-based retrospective cohort study was conducted by analyzing longitudinal National Health Insurance claim data of a 200,000-person national representative cohort. A total of 22,929 women aged ≥45 years in 1997 without previous diagnosis of breast cancer were enrolled and stratified into two birth cohorts born before or after 1933. HRT prescriptions were traced in outpatient data files and incident breast cancer cases were identified from 1997 to 2004. The Cox proportional hazards model was used to analyze breast cancer hazard ratio (HR). HRT users were censored after they discontinued HRT. The results showed that women born during 1933–1952 had a twofold increased risk of breast cancer (HR = 2.10, 95% CI = 1.47–3.00) compared with women born before 1933, when adjusted for HRT use. When adjusted for the birth-cohort difference, HRT users had significantly increased breast cancer HR versus non-users after four years of use (adjusted HR = 1.48, 95% CI = 1.03–2.13); the HR further increased to 1.95 (95% CI = 1.34–2.84) after eight years of use. In conclusion, a longer duration of current HRT use was associated with a higher risk of breast cancer independent of the birth-cohort difference.

Towards understanding the de-adoption of low-value clinical practices: a scoping review

BACKGROUND

Low-value clinical practices are common in healthcare, yet the optimal approach to de-adopting these practices is unknown. The objective of this study was to systematically review the literature on de-adoption, document current terminology and frameworks, map the literature to a proposed framework, identify gaps in our understanding of de-adoption, and identify opportunities for additional research.

METHODS

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Cochrane Database of Abstracts and Reviews of Effects, and CINAHL Plus were searched from 1 January 1990 to 5 March 2014. Additional citations were identified from bibliographies of included citations, relevant websites, the PubMed 'related articles' function, and contacting experts in implementation science. English-language citations that referred to de-adoption of clinical practices in adults with medical, surgical, or psychiatric illnesses were included. Citation selection and data extraction were performed independently and in duplicate.

RESULTS

From 26,608 citations, 109 were included in the final review. Most citations (65%) were original research with the majority (59%) published since 2010. There were 43 unique terms referring to the process of de-adoption-the most frequently cited was "disinvest" (39% of citations). The focus of most citations was evaluating the outcomes of de-adoption (50%), followed by identifying low-value practices (47%), and/or facilitating de-adoption (40%). The prevalence of low-value practices ranged from 16% to 46%, with two studies each identifying more than 100 low-value practices. Most articles cited randomized clinical trials (41%) that demonstrate harm (73%) and/or lack of efficacy (63%) as the reason to de-adopt an existing clinical practice. Eleven citations described 13 frameworks to guide the de-adoption process, from which we developed a model for facilitating de-adoption. Active change interventions were associated with the greatest likelihood of de-adoption.

CONCLUSIONS

This review identified a large body of literature that describes current approaches and challenges to de-adoption of low-value clinical practices. Additional research is needed to determine an ideal strategy for identifying low-value practices, and facilitating and sustaining de-adoption. In the meantime, this study proposes a model that providers and decision-makers can use to guide efforts to de-adopt ineffective and harmful practices.

Phytoestrogens in postmenopause: the state of the art from a chemical, pharmacological and regulatory perspective

Phytoestrogens represent a diverse group of non-steroidal natural products, which seem to have some oestrogenic effects and are often marketed as food supplements. Population exposed to phytoestrogens is potentially increasing, in part because an unfavourable risk-benefit profile of Hormone Replacement Therapy (HRT) for prolonged treatments (e.g., osteoporosis prevention) highlighted by the publication of the Women Health Initiative (WHI) trial in 2002, but also because many post-menopausal women often perceived phytoestrogens in food supplements as a safer alternative than HRT. Despite of increasing preclinical and clinical studies in the past decade, appealing evidence is still lacking to support the overall positive risk-benefit profile of phytoestrogens. Their status as food supplements seems to discourage studies to obtain new evidence, and the chance to buy them by user's initiative make it difficult to survey their prevalence and pattern of use. The aim of the present review is to: (a) outline the clinical scenario underlying the increased interest on phytoestrogens, by overviewing the evolution of the evidence on HRT and its main therapeutic goals (e.g., menopausal symptoms relief, chemoprevention, osteoporosis prevention); (b) address the chemical and pharmacological features (e.g. chemical structure, botanical sources, mechanism of action) of the main compounds (e.g., isoflavones, lignans, coumestans); (c) describe the clinical evidence on potential therapeutic applications; (d) put available evidence on their riskbenefit profile in a regulatory perspective, in light of the recent regulation on health claims of food supplements.

Knowledge of reproductive physiology and hormone therapy in 40-60 year old women: a population-based study in Yazd, Iran

Background : Evidences shows that menopause affects women's health, but women's knowledge of proper care and maintenance is insufficient.

OBJECTIVE

To determine knowledge of hormone therapy (HT), reproductive physiology, and menopause in a population of 40-60 year old women.

MATERIALS AND METHODS

This cross-sectional study was conducted through a cluster sampling among 330 women in Yazd, Islamic Republic of Iran, in 2010. Data was collected using a questionnaire containing questions about reproductive physiology related to menopause and HT by interviewing. Inferential and descriptive statistics via SPSS.15 software were used for data analysis.

RESULTS

Overall, 2.1% of women were current takers of HT, 13.4% had taken it in the past but had stopped and 84.5% had never taken hormone replacement therapy. Iranian women had low knowledge of HT, reproductive physiology, and menopause. Most of the women (85.5%) knew that hot flashes are common around menopause and only 77.2% knew decreasing estrogen production causes the menopause. They knew little about the effects of progestagens and the effects of HT on fertility. Logistic regression determined that age, educational level and BMI were the most important factors predicting use of HT after adjusting for other variables.

CONCLUSION

Iranian women have a low HT usage rate and the majority of them are lacking of the knowledge about HT and menopause. Women need improved knowledge of the risks and benefits of HT as well as education about the reproductive system around menopause.

Long-term effect of the Women's Health Initiative study on antiosteoporosis medication prescribing

AIM

To describe long-term prescribing patterns of osteoporosis therapy before and after the Women's Health Initiative (WHI) publication.

METHODS

We conducted a time-series analysis from 1997 to 2005 using nationally representative data based on office-based physician and hospital ambulatory clinic visits. Bivariate and multivariable analyses were conducted using chi-square tests and logistic regression, respectively, and trends in the prevalence of osteoporosis therapies were evaluated per 6-month (semiannual) intervals. Linear regression and graphic techniques were used to determine statistical differences in the prevalence trends between the two periods.

RESULTS

Overall prevalence of therapeutic or preventive osteoporosis therapy was similar between the WHI periods. However, a significant decrease in estrogen therapy and increases in bisphosphonates, calcium/vitamin D were observed in the period after the WHI publication (p < 0.05). Multiple logistic regression analysis showed older age and white race were associated with a higher likelihood of antiosteoporosis medication (AOM) prescription, and Medicaid insurance type was associated with a lower likelihood of an AOM prescription. Excluding calcium/vitamin D, nonestrogen therapy was more likely to be prescribed in the after-WHI period (office-based physician clinic: [adjusted OR, aOR] 2.49 [2.04-4.04]; hospital-based clinic: aOR 2.42 [1.67-7.50]) Nonestrogen therapy was more prevalent in visits made by older women, women of white race, women with contraindicated conditions for estrogen therapy, and women from the Northeast region.

CONCLUSIONS

After the WHI publication, the overall prevalence of osteoporosis therapy did not change; however, a shift from estrogen to nonestrogen therapy was observed after the WHI publication. Black women were less likely to receive nonestrogen antiosteoporosis therapy in hospital-based clinics.

Disparities between rural and urban areas for osteoporosis management in the province of Quebec following the Canadian 2002 guidelines publication

RATIONALE, AIMS AND OBJECTIVES

Clinical guidelines have been seen as a tool for improving management of osteoporosis in order to prevent fragility fractures. However, the impact of guidelines on clinical management of osteoporosis has not been measured. We examined medical investigation and treatment before and after the 2002 Canadian guidelines publication and examined if practice changes were different between rural and urban areas.

METHODS

We conducted a retrospective population-based observational study using secondary data analysis. Two studied populations were selected; one before, the other after the publication of Canadian practice guidelines. The studied populations consisted of all individuals 65 years or older from Quebec (Canada) for whom a physician claimed a consultation or have been hospitalized for fragility fracture between the two predefined periods.

RESULTS

There was no significant difference in the rate of bone mineral density testing for women before and after guidelines publication. For men a statistically significant increase was observed but remained very low. A significant increase in bisphosphonates prescribing, but no increased in the reporting of a diagnosis of osteoporosis were observed. A significant reduction of hormonal replacement therapy was seen during the year following guidelines publication. The strongest significant increases were mostly seen in urban regions compared to rural areas.

CONCLUSIONS

Very small changes were observed for diagnostic recognition by physicians, diagnostic testing and some recommended drugs prescribing following guidelines publication. This suggests low guidelines impact on medical practice for osteoporosis in patients suffering fragility fractures.

Documentation of self-care actions taken for somatic complaints by postmenopausal Malay women living in Kelantan Malaysia

OBJECTIVE

The aim of this study was to document some of the self-care actions taken by women in Kelantan to manage their somatic symptoms associated with menopause.

METHOD

A verified semi-structured questionnaire in the Malay language was administered to 326 naturally menopaused healthy women (mean age of 57.01+/-6.58 (S.D.) years) residing in Kelantan to determine the prevalence and types of self-care actions taken for their somatic complaints.

RESULTS

Mean age at menopause was 49.4+/-3.4 (S.D.) years and 75% of these women were within the first 10 years of menopause. Of the four somatic symptoms, tiredness was the most prevalent followed by reduced level of mental concentration, musculoskeletal aches and pains, and backache. The prevalence of self-care actions was highest for backache (91%) and the lowest for reduced level of concentration (47.7%), and both prevalence and type of self-care action appear to depend upon the area of residence, and the educational level of the subject. Of those who took self-care actions, majority were from urban areas and with a higher educational level. Although HRT was used for all the four complaints, the use of pain relief tablets and traditional body massage was more commonly used for musculoskeletal aches and pains and backache than HRT. There was also a small fraction of women who had used the traditional herbs like 'akar kayu' and 'jamu' for these two complaints.

CONCLUSION

It appears that the self-care actions used by postmenopausal women in Kelantan for their somatic complaints ranged from HRT to a combination of conventional, traditional, and alternative remedies. The fraction of women taking self-care action varied from symptom to symptom and the choice of self-care action also depended upon the education level, socio-economic status and place where the respondents were domiciled. There was a tendency for the more affluent and educated women to use more of the modern practices and slightly less of the traditional remedies whereas the rural women did the opposite. This is the first study of its kind in Kelantan documenting the self-care practices of menopausal women for their somatic complaints. Clearly more studies are needed to document these practices and the effectiveness of these self-care remedies.

Hormone therapy use and prescription durations of menopausal women in Taiwan: a 5 years' National Cohort study

OBJECTIVES

To describe the prevalence and associated factors of hormone replacement therapy (HRT)-related utilization in a national representative fixed cohort in Taiwan.

METHOD

The study population are women aged 40 years and over in Taiwan. Our data, provided by National Health Research Institutes, are the sampled registry information of 37,315 beneficiaries of National Health Insurance from 2000 to 2004. The dependent variables were HRT-related utilizations, including physician contact, HRT utilization rate/duration/patterns (new, prevalent and discontinue users). The independent variables were age, time, prior co-morbidities and prior utilization pattern. We used generalized estimating equation (GEE) model for repeated measurement analysis.

RESULTS

The outpatient contact rates for menopause syndrome were low, though the HRT prescription rate among those who have contact were high. GEE shows that age, time, prior co-morbidities/HRT utilization patterns were significantly associated with all types of HRT-related utilizations, which all declined significantly following the publications of Women's Health Initiative (WHI) in 2002. The magnitudes of reduction, though similar in 2003-2004, were greater for physician contact and HRT durations than that of HRT prescription rate for those have contacts in 2002. Besides, the percentages of new (discontinue) users have already declined (increased) since 2001 although it had not declined until 2003 for the continued users.

CONCLUSIONS

WHI publications have great impact on HRT-related utilizations. However, the response of the women was quicker and much drastic than that of the physicians in 2002. Besides, the efforts of the various women's associations before WHI might have some contribution to the declined (increased) of new (discontinued) users.