Relation between cigarette smoking and use of hormonal replacement therapy for menopausal symptoms.

The aim of this study was to characterise new users of hormonal replacement therapy (HRT) for the relief of menopausal symptoms and to compare these women with never-users of HRT; 402 new users and 804 never-users were studied. Hot flushes were the most common symptom in both users and non-users and were the most frequent reason for prescribing HRT. The prevalence of menopausal symptoms in non-users of HRT was high although substantially lower than that in users. HRT users were more likely to be current cigarette smokers than were never-users. There was also, within smokers, a significant relation between the number of cigarettes smoked and the likelihood of using HRT. This relation between HRT use and smoking could result from an anti-oestrogen effect of smoking, intensifying menopausal symptoms. Of potential clinical relevance is the suggestion that a proportion of women using HRT may be doing so in order to alleviate smoking-induced symptoms. Users of HRT were also more likely to have used oral contraceptives than were never-users; this relation was probably behavioural.     

Health status of users of hormone replacement therapy by hysterectomy status in Western Australia

STUDY OBJECTIVES: To compare the demographic, behavioural, and biological correlates of use of hormone replacement therapy (HRT) in women with an intact uterus and women who have undergone hysterectomy. DESIGN: Cross sectional analysis of data from the Busselton Health Study and the 1994 Healthway-National Heart Foundation Risk Factor Survey. SETTING: Busselton and Perth, Western Australia, 1994. PARTICIPANTS: 2540 women aged 35-79 years. MAIN OUTCOME MEASURES: Demographic, behavioural, and biological correlates of use of HRT by hysterectomy status. RESULTS: In women with an intact uterus, after adjustment for age and place of residence, current use of HRT was significantly associated with having a professional level of occupation, ever use of alcohol, having a history of smoking, and a lower body mass index. Current users of HRT had significantly lower levels of total cholesterol and higher levels of triglycerides than non-users. In women who had undergone hysterectomy, the only non-biological characteristic associated with use of HRT was having a history of smoking. Current users of HRT had lower levels of systolic blood pressure, lower levels of LDL cholesterol, higher levels of HDL cholesterol, and higher levels of triglycerides. The association between use of HRT and participation in exercise, level of systolic blood pressure, level of HDL cholesterol, and total/HDL cholesterol ratio varied significantly by hysterectomy status. After adjustment for age and place of residence, the mean levels of systolic and diastolic blood pressure, body mass index, waist/hip ratio, LDL cholesterol, and total/HDL cholesterol ratio were highest in women who had undergone hysterectomy and were not using HRT. CONCLUSIONS: Demographic/behavioural and biological correlates of use of HRT varied depending on hysterectomy status. Demographic and behavioural characteristics were more important as selection factors for use of HRT in women with an intact uterus than in women who had undergone hysterectomy. Women who had undergone hysterectomy and were not using HRT had a significantly worse profile for CHD than did women with an intact uterus. These results indicate that any bias in estimates of the protective effect of HRT on risk of CHD in observational studies is likely to depend on the prevalence of hysterectomy within the study population. Hysterectomy status needs to be taken into account in any studies that investigate the effect of HRT on risk of CHD.     

The effect of hormone replacement therapy and route of administration on selected cardiovascular risk factors in post-menopausal women

BACKGROUND: There is increasing use of hormone replacement therapy (HRT) by post-menopausal women. Observational epidemiological studies have shown reductions in cardiovascular risk factors in HRT users in the USA, but no randomized controlled trials of HRT have been carried out in the primary practice setting. Previous studies of cardiovascular risk factors have shown a variety of responses according to type of progestagen and oral or topical administration. None has examined the effect of route using an identical progestagen. OBJECTIVES: Our aim was to establish differences, if any, in alteration in cardiovascular risk factors with HRT in post-menopausal women according to route of administration of HRT, oral, transdermal and implant, using first oestrogen alone then oestrogen plus norethisterone, or testosterone for implant. METHODS: Subjects were recruited by letter of invitation to women aged 50-65 years from lists in general practices local to the Charing Cross Hospital Lipid Clinic in West London. Their menopausal status was confirmed and they were randomized to one of three treatment groups or acted as controls. They attended for three visits; at baseline, HRT was initiated as oestrogen alone, oral or transdermal. At the 3-month visit, HRT with the progestagen, norethisterone, was given cyclically, continuously or transdermally until the final visit at 6 months. A separate group of women from the menopause clinic at Chelsea and Westminster Hospital were studied on oestrogen implant then on implanted oestrogen and testosterone. The outcome measures studied were the separate effects of the four regimes as compared with controls on lipoproteins, glucose, insulin, fibrinogen, factor VII and E-selectin, together with weight, waist:hip ratio and blood pressure. RESULTS: The continuous combined oestrogen-progestagen therapy had similar effects on cardiovascular risk factors as oestrogen with cyclical progestagen. All regimes lowered low-density lipoprotein cholesterol, the oral route being more potent than the parenteral; the effect of transdermal HRT was similar to the implant. Lp(a) was reduced only with the oral route. Reductions in factor VII and E-selectin were observed in both the oral and transdermal routes. There was no increase in body mass index, waist:hip ratio, blood pressure or glucose and insulin levels with any of the HRT regimes used. Systolic blood pressure was reduced with the transdermal route. CONCLUSIONS: This study supports the evidence that oestrogen-progestagen HRT, both oral and transdermal, although attenuating some of the benefit of oestrogen alone on fibrinogen and high-density lipoprotein, significantly reduces cardiovascular risk factors, which should diminish post-menopausal risk of coronary disease.     

The relationships of SHBG with current and previous use of oral contraceptives and oestrogen replacement therapy

Sex hormone binding globulin (SHBG) concentration was measured in serum samples from 2077 premenopausal and 901 naturally postmenopausal women who had no history of disease or of recent drug use likely to affect SHBG. Current users of oral contraceptives (OCs) and of oestrogen replacement therapy had higher mean SHBG values than non-current users. Both premenopausal and postmenopausal women who had previously used OCs had a lower mean SHBG concentration than never users of OCs. Previous use of oestrogen replacement therapy was not related to SHBG.     

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.     

Self-reported data on reproductive variables were reliable among postmenopausal women

OBJECTIVE: We aimed to assess the reliability of self-reported reproductive variables in postmenopausal women. STUDY DESIGN AND SETTING: We evaluated 535 women in two interviews, as part of the recruitment and first follow-up of a cohort of Portuguese adults. Median time between evaluations was 5 years. Women were inquired about sociodemographic characteristics, cognitive status, and reproductive history: gravidity, parity, lifetime use of oral contraceptives, menopausal status, age at menopause, hysterectomy, oophorectomy, and lifetime use of hormone replacement therapy (HRT). RESULTS: Age at menopause was consistent within 1 year for 66% of women and agreement was higher in women reporting surgical menopause. Reliability regarding age at menopause decreased with time since menopause. Gravidity was consistent for 81% of women, whereas parity was consistent for 94%. The proportion of different answers regarding number of pregnancies and number of live births was higher in women with high gravidity and parity, respectively. Agreement was 96% for hysterectomy and 92% for oophorectomy. The proportion of consistent reports was 90% for oral contraceptives and 93% for HRT. Women with higher education reported parity and HRT more reliably. CONCLUSION: Agreement was over 90% for self-reported parity, hysterectomy, oophorectomy, and HRT, which supports their use in analytical studies.     

A study of hysterectomy in a family practice.

This paper reports on a study of women in a family practice who have undergone hysterectomy as compared with a group of matched controls. Significant differences were found in the greater number of major surgical procedures (other than hysterectomy) and the reporting of chronic and recurrent symptoms for the study group. Study group women were also found to have a greater number of identified intrapersonal and family problems. There was no significant difference, however, in the number of identified chronic organic problems. Differences which did not reach statistical significance suggest that women in the study group may be more likely to be living without a male partner, to be using long-term medication, and to be smokers. A most important finding was that the group of women who had undergone hysterectomy had also had 2.6 times the number of major surgical operations than the controls, excluding the hysterectomy. There were no differences between the two groups with respect to a number of other factors studied, eg, education, religion, history of psychiatric admission, obesity.     

Has the impact of hormone replacement therapy on health-related quality of life been undervalued?

Previous economic evaluations of hormone replacement therapy (HRT) have restricted positive effects to alleviation of postmenopausal symptoms and negative effects to drug side effects. We studied the association between HRT use and postmenopausal women's valuation of both health-related quality of life and potential treatment side effects. Postmenopausal women with either a documented first vertebral fracture within the past 5 years or no history of osteoporotic fractures were recruited from Olmsted County, Minnesota, and from Dartmouth-Hitchcock Medical Center in New Hampshire to participate in a study to assess quality of life and women's attitudes toward osteoporosis prevention. Women's valuations of their current health and potential HRT-related side effects were quantified as quality-adjusted life years (QALYs) assessed by an automated utility assessment instrument (U-Titer) and the time tradeoff technique, by a vertical rating scale, and by estimated quality of well-being (QWB) scores. Health status was measured using the Medical Outcomes Study SF-36. Regression methods were used to assess the impact of current HRT use on health-related quality of life and valuation of side effects. There were 106 women with vertebral fracture and 180 with no history of hip, wrist, or vertebral fractures. Altogether, 116 (40.6%) women were currently taking HRT, 64 (22.2%) had taken HRT in the past, and 106 (37.1%) women had never taken HRT. Current HRT users had higher time tradeoff QALYs than never and past HRT users, with gains ranging from 15.0 to 83.7 days per year for current users relative to the others. Benefits were largest for women with a vertebral fracture and limitations in activities. The secondary QALY measures also showed significantly higher values for current HRT users compared with other women, as did SF-36 subscales for general health, physical function, role-emotional function, and vitality. There was substantial variability in women's perceptions of HRT side effects. Overall, the proportion of women willing to trade time to avoid bleeding was largest, at 95.5%, followed by breast tenderness, weight gain, and endometrial biopsy at 90.4%, 87.4%, and 82.7%, respectively. Current HRT users had higher health-related quality of life than past or never users according to all measures studied. Women's perceptions of potential side effects were highly variable and should be considered by physicians when prescribing an HRT regimen. If, as our results suggest, postmenopausal therapy has positive effects beyond the immediate postmenopausal years, previous economic studies may have underestimated the value of HRT.     

Use of hormone replacement therapy by Melbourne women

Abstract: Hormone replacement therapy (HRT) is used for relief of symptoms related to the menopause and for the prevention of postmenopausal osteoporosis and cardiovascular disease. Patterns of use of HRT are thought to be changing rapidly, but little is known about who is using the therapy, for what purpose or for what period of time. Telephone interviews were conducted in May 1991 with a randomly selected sample of 2001 Australian-born women aged 45 to 55 years living in Melbourne, as part of the Melbourne Women's Midlife Health Project. Questions related to use of HRT, health status, use of health services, sexual functioning, attitudes to menopause and aging, and sociodemographic characteristics. Twenty-one per cent of the sample were using HRT. Use was more prevalent among women 50 years and over (28 per cent) than those under 50 (15 per cent). Seventeen per cent of nonhysterectomised women, 31 per cent of hysterectomised women and 49 per cent of women who had undergone hysterectomy and bilateral oophorectomy were current users. Almost 60 per cent had been using the therapy for two years or less, and 34 per cent for one year or less. Just over half reported control of hot flushes as a benefit, and 10 per cent mentioned prevention of bone loss as a benefit Logistic regression analysis identified differences between users and nonusers in experience of hot flushes, health status, use of preventive and treatment services, sexual functioning, wellbeing, attitudes to menopause and aging, and sociodemographic characteristics. These differences may relate to risk of later cardiovascular disease.     

Osteoporosis risk factors: association with use of hormone replacement therapy and with worry about osteoporosis

Among risk factors for osteoporosis, only family history was associated with worry about osteoporosis, while white race was the only factor associated with hormone replacement therapy use.

Abstract

Objectives: To determine whether postmenopausal women with risk factors for osteoporosis are more likely to use hormone replacement therapy (HRT) or to worry about osteoporosis than women without risk factors. Method: Cross-sectional survey of postmenopausal women at the Women Veteran Comprehensive Health Center. Statistical analysis was performed using the chi-square test and logistic regression analysis. Results: Of the 230 postmenopausal women who answered the questionnaire (mean age 55.7 years), 167 (72%) reported ever having used HRT and 113 (49%) worried about osteoporosis. Factors that were significantly associated (P < .05) with ever having used HRT were race, marital status, hysterectomy, worry about osteoporosis, and being aware that HRT reduces the risk of osteoporosis; however, no other risk factors for osteoporosis were associated with HRT use, nor was having the diagnosis of osteoporosis. Women who worried about osteoporosis were significantly more likely to be under age 60; to have a family history of osteoporosis, poor self-rated current health, and osteoporosis as a medical condition; to be aware that HRT reduces the risk of osteoporosis; and to have used HRT (P < .05). Conclusions: Among risk factors for osteoporosis, only family history was associated with worry about osteoporosis, while white race was the only risk factor associated with HRT use in our cohort of postmenopausal woman veterans. This may represent a lack of awareness and knowledge about osteoporosis and its sequelae and about the benefits of HRT. An understanding of patient awareness of risk factors for osteoporosis and their motivations to take HRT can be valuable when counseling women on their decision to use HRT or other medications to prevent osteoporosis.     

Women's knowledge of and attitudes towards hormone replacement therapy

BACKGROUND: Hormone replacement therapy (HRT) could benefit women who have reached the natural menopause, have had a hysterectomy or have a family history of osteoporosis. OBJECTIVE: Our aim was to monitor changes in women's knowledge of, and attitudes towards, HRT since 1991. METHODS: The study was a repeat of a postal survey conducted in 1991 in the Grampian region in the North East of Scotland. Six hundred women, aged 20-69 years, were selected randomly from the eight Local Health Care Co-operatives in Grampian, Scotland. The main outcome measures were women's knowledge of HRT, their attitudes towards it and the percentage of users, past users and never users within the sample. RESULTS: A 79% response rate was achieved. Overall, 17% of post-menopausal women were current takers (increased from 9% in 1991), 22% were previous takers (increased from 7%) and 61% were never takers (decreased from 84%). This increase in ever use of HRT was more pronounced in the less educated women (increase of 24% since 1991) compared with the more educated (increase of 13%). Almost half (48%) of post-menopausal women had considered taking HRT (25% increase). However, of never users, the majority (86%) had never considered HRT and had not discussed it with a doctor. Attitudes towards the menopause remained positive, although knowledge of the effects of HRT and of risk factors for osteoporosis had decreased. Forty-two per cent of never users would be persuaded to take HRT if they knew it would not cause any problems, and 52% would be persuaded to take HRT on the recommendation of a doctor. CONCLUSIONS: Since 1991, HRT use increased overall; this increase was greater in the less educated women. However, the majority of post-menopausal women remain never users, and many were unaware of HRT. Conflicting research evidence since 1991 on the risks and benefits of HRT may account for the decrease in the women's knowledge of the effects of HRT.     

Racial Differences in Physician Recommendation of Hormone Replacement Therapy

PURPOSE: Previous studies have suggested that black women may be less likely than white women to be offered and to take hormone replacement therapy (HRT). Thus, race and other factors associated with physician recommendation of HRT that may influence women's decisions about HRT were examined. METHODS: Data were from a baseline assessment of participants in a randomized controlled trial designed to evaluate the efficacy of a tailored decision-aid on HRT decision-making. We telephone interviewed 581 Durham women ages 45-54. The association of race and other factors with reported physician recommendation of HRT was tested using chi(2) and logistic regression analysis. RESULTS: Overall, 45% of women surveyed reported that their physician recommended HRT; black women were significantly less likely than white women to report being advised about HRT (35% vs. 48%, respectively, P < 0.005). Additional factors associated with being recommended HRT included older age, being postmenopausal, having had a hysterectomy, having thought about the benefits of HRT, and being satisfied with information about HRT. CONCLUSIONS: Black women are less likely than white women to receive physician recommendation of HRT. Racial differences in patient-provider communication about HRT exist and thus require greater diligence on the part of health care providers to minimize such a gap.     

Psychological Meaning of a Woman with a Hysterectomy Among Mexican Physicians and Women

The psychological meaning of women who have had a hysterectomy, and attitudes toward them, were explored in 121 Mexican gynecologists, 155 women who had undergone a hysterectomy, and 115 women who had not had a hysterectomy. The surveys were completed between January and May 2011. Both groups of women defined a woman who had had a hysterectomy using words with positive meanings (healthy, happy, reassured, and complete), as well as words with negative meanings (sad, incomplete, and irritable). However, the participants who had not had a hysterectomy defined a woman who had had a hysterectomy using more negative words and showed more negative attitudes toward such a woman with a hysterectomy than those women who had undergone a hysterectomy. Among participants who had undergone a hysterectomy, those who were premenopausal prior to the surgery and those who had undergone bilateral salpingo-oophorectomy defined a woman who had had a hysterectomy in a more negative manner and showed the most negative attitudes. The gynecologists did not use words with emotional content regarding women who had had a hysterectomy and showed more neutral attitudes toward such a woman than did both groups of women. These findings could be helpful in designing support programs for women facing a hysterectomy.     

Bone mineral density in young women aged 19-24 after 4-5 years of exclusive and mixed use of hormonal contraception

Background

Use of depot-medroxyprogesterone acetate (DMPA), norethisterone enanthate (NET-EN) and low-dose combined oral contraceptives (COCs) has been associated with loss of bone mineral density (BMD) in adolescents. However, the effect of using a combination of these methods over time in this age group is limited. The aim of this cross-sectional study was to investigate BMD in young women (aged 19-24 years) with a history of mixed hormonal contraceptive use.

Study Design

BMD was measured at the spine, hip and femoral neck using dual X-ray absorptiometry. Women were classified into three groups: (1) injectable users (DMPA, NET-EN or both) (n=40), (2) mixed COC and injectable users (n=13) and (3) non-user control (n=41).

Results

Women in the injectables-only user group were found to have lower BMDs compared to the non-user group at all three sites, and there was evidence of a difference in BMD between these two groups at the spine after adjusting for body mass index (p=.042), hip (p=.025) and femoral neck (p=.023). The mixed COC/injectable user group BMD values were lower than those for controls; however, there was no evidence of a significant difference between this group and the non-user group at any of the three sites.

Conclusion

This study suggests that BMD is lower in long-term injectable users but not when women have mixed injectable and COC use.     

Perceptions of hormone replacement therapy among African American women

Hormone replacement therapy (HRT) is commonly prescribed for women to relieve symptoms associated with menopause. The medical community does not uniformly recommend HRT, and ethnic and cultural differences may influence a woman's decision to request and adhere to it. Thirty-eight African American women were enrolled in a qualitative study to investigate beliefs, attitudes, and knowledge about HRT. Data collected from six focus groups were part of Ethnicity, Needs, and Decisions of Women (ENDOW), a multisite project investigating decision making and hysterectomy. Participants, age 30 to 65 years, were recruited from community agencies and public health clinics. The women were aware of the medical indications for HRT and its risks and benefits. Although a majority of participants were past or current users, they expressed reservations about the use of HRT and wanted a better dialogue with health care providers, including information about alternative treatments.     

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.     

Social and health related characteristics of women using oral contraceptives

Users of oral contraceptives tend to differ in some socioeconomic and health related characteristics from nonusers. These differences were documented in a 1968–1969 household survey in the Baltimore Standard Metropolitan Statistical Area. Analysis of responses from 653 women aged 18–44 revealed that oral contraceptive users were more apt to be young, married women with one child and tended not to be in the highest income or education brackets. While smokers were not significantly more likely to be users than nonsmokers, heavy smokers were more likely to be users than light smokers. On the average, three-fifths of women in both study groups were using medicines other than oral contraceptives. The high rates of other medicines used, both prescribed and nonprescribed, raise the question of whether other medicines used concurrently with oral contraceptives may be contributing to side effects attributed to use of oral contraceptives.