Prevalence of and factors associated with hormone replacement therapy counseling: results from the 1994 National Health Interview Survey

Access and Attitudinal Factors Related to Breast and Cervical Cancer Rescreening: Why are Latinas Still Underscreened?

To identify access, attitudes, and health practices of Latina women undergoing regular mammography and Pap smear screening, 977 Latinas aged 40 to 74, residing in four California cities, answered a telephone interview. Forty-one percent of women had regular mammography, and 73% had regular Pap smear screening. Cancer screening maintenance was associated with having health insurance, a regular place of care, and fewer fatalistic attitudes about cancer. Regular mammography and Pap smear screening were also associated with ever being married, attending church, and having taken hormone replacement therapy. Being older than 50, residing in the United States a long time, and having had a hysterectomy predicted mammography maintenance. Pap smear screening maintenance was negatively associated with poverty, old age, and negative attitudes toward physicians. There are structural and attitudinal barriers to regular cancer screening among Latinas. Interventions that increase access to care and address women's attitudes about cancer are needed.

Physician counseling on hormone replacement therapy and bone loss: do socioeconomic and racial characteristics of women influence counseling?

BACKGROUND

Although women consider multiple issues when deciding to take hormone replacement therapy (HRT), both women's use and physician counseling about HRT are strongly associated with sociodemographic factors. As prevention of bone loss is the best established long-term benefit of HRT, we sought to determine (1) if counseling about bone loss is included in discussions of HRT and (2) if sociodemographic factors affect the preventive content of HRT counseling.

METHODS

We evaluated reports of counseling on estrogen and bone loss from 1404 women aged 40-60 who reported any counseling on HRT in the 1994 National Health Interview Survey (NHIS). We also examined the association between these reports and sociodemographic factors, adjusting for clinical history, physician specialty, and physician visits.

RESULTS

We found that 80% of the women reported counseling on the effects of estrogen on bone loss. After adjustment, high school graduates (adjusted odds ratio [AOR] 1.68, confidence interval [CI] 1.02, 2.77) and college graduates (AOR 2.45, CI 1.33, 4.52) were much more likely to be counseled than women without a high school diploma. Black women were less likely to be counseled about bone loss (AOR 0.55, CI 0.33, 0.93). Although general health and menopausal symptoms were strongly associated with counseling on HRT and bone loss, neither of the osteoporosis risk factors of low body mass index (BMI) and smoking influenced counseling.

CONCLUSIONS

Most patients who discussed HRT with their providers discussed the effects of HRT on bone loss. For those who did not, several sociodemographic factors associated with any counseling on HRT are also associated with the content of HRT counseling. Understanding and addressing counseling inequities could reduce the effect of such factors on osteoporosis assessment and treatment.

The role of treatment intentions and concerns about side effects in women's decision to discontinue postmenopausal hormone therapy

OBJECTIVES

To investigate the factors that influence women's decisions about hormone therapy use and the duration of use, in particular the effect of women's reasons for initiating hormone therapy, the source of information about hormones, women's symptom experience, and their concerns about side effects from hormone therapy.

METHODS

Eight hundred and sixteen women aged 45-59 who began hormone therapy between July 1993 and June 1995 in a Massachusetts health maintenance organization were followed for two years from the day they received a prescription for estrogen. This cohort has been previously studied for health, treatment and demographic determinants of hormone therapy discontinuation. In March 1999, these women were mailed a questionnaire containing closed and open-ended questions. 449 women (55%) completed the survey. Discrete-time hazards models were used to identify determinants of discontinuation, controlling for medical predictors of survey nonresponse.

RESULTS

Women's assessment of the difficulty of their decision to use hormone therapy (RR=1.25 for each point on a 7-point scale, 95% CI: 1.16, 1.35) was associated with discontinuation. Women who described their decision as extremely difficult had the greatest likelihood of discontinuing. The importance placed on preventing osteoporosis (RR=0.93 for each point on a 7-point scale, 95% CI: 0.86, 0.99) and cardiovascular disease (RR=0.94 for each point on a 7-point scale, 95% CI: 0.88, 0.99) were also statistically significant predictors of discontinuation. Women for whom the prevention of osteoporosis and cardiovascular disease were extremely important in deciding to use hormone therapy were the most likely to continue using hormones. Concerns about the return of monthly bleeding (RR=3.00, 95% CI: 1.45, 6.17) and weight gain (RR=2.06, 95% CI: 1.16, 3.67) at the time hormone therapy was initiated, but not the actual experience of these side effects while using hormones, were associated with a higher rate of discontinuation. Symptoms around the time of initiating hormone therapy, including the perceived severity of the symptom, were not statistically associated with discontinuation.

CONCLUSIONS

Discontinuation of hormone therapy is the result of a complex process of decision-making that is influenced by the value placed on the prevention of osteoporosis and cardiovascular disease at the time of initiation and women's perceptions and interpretations of side effects. Concerns about the potential side effects of hormone therapy, in particular weight gain and monthly bleeding, lead women to discontinue hormone therapy.

Hormone replacement therapy counseling: prevalence and predictors

OBJECTIVES

To evaluate the prevalence of hormone replacement therapy (HRT) counseling and to investigate the relationship between patients' cultural background and healthcare professionals' counseling practices. HRT is the principal preventive intervention for reducing risk of menopause-related pathologic conditions. This study assessed self-reports of HRT counseling among women receiving care in an urban community hospital.

METHODS

A descriptive self-reported survey study of 134 women aged 45-65 was conducted in the medical clinic at an urban community teaching hospital in a multicultural area in New York. Questionnaires asked about age, ethnicity, HRT use, contraindications, health professional counseling, and barriers to HRT counseling. Possible predictors of HRT counseling were analyzed with logistic regression models. Categorical variables were compared with chi-square statistics.

RESULTS

Overall prevalence of HRT counseling was 25%. Prevalence of HRT use was 19%; among those using HRT, only 12.7% reported receiving HRT counseling. Physicians were more likely to discuss HRT than other healthcare professionals. Over 90% of the patients reported a desire for HRT counseling.

CONCLUSIONS

The low rates of HRT counseling suggest physicians have limited daily experience with HRT counseling practices. Public health efforts should focus on increasing physician and general population awareness to promote HRT counseling strategies and ensure public access to HRT information.

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

BACKGROUND

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

OBJECTIVES

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

RESEARCH DESIGN

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

RESULTS

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

CONCLUSIONS

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

Discontinuation of postmenopausal hormone therapy in a Massachusetts HMO

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