Use of hormone replacement therapy in Italian women aged 50-70 years

OBJECTIVES: The aim of the present cross-sectional analysis was to describe patterns and determinants of use of hormone replacement therapy (HRT) in a large sample of women attending mammographic screening. METHODS: Between 1999 and 2001, 8533 women aged 50-70 years were recruited by 11 screening centres, and structured interviews were made collecting information on socio-demographic characteristics, lifestyle habits, medical and reproductive history (overall response rate 87%). RESULTS: Current HRT use was reported by 6.9% of women (n=585), the average duration of use being 3.5 years; 13.2% were ever HRT users. Binomial and multinomial logistic regression (MLR) analyses showed that younger age, higher educational level, past mammographic examination and history of bilateral oophorectomy were the major predictors of current and ever HRT use. Current use was also more frequently reported by women who were thinner, nulliparae, had had induced menopause, had a later onset of menopause, with history of oral contraceptive use and hysterectomy without bilateral oophorectomy. By contrast, those who were diabetics or had positive history of cardiovascular disease were less likely to be current HRT users. No differences were found in HRT use according to marital status, type of occupation, menopausal status, smoking, history of breast cancer, hypercholesterolemia, hypertension and phlebitis. CONCLUSIONS: Our results support previous findings indicating that HRT use in Italian women is uncommon and of short duration. Current HRT users were less likely than non-users to report several characteristics associated with higher mortality and morbidity, in accordance with the healthy-user phenomenon described in other countries.     

Hysterectomy and oophorectomy are unrelated to bone loss in older women

OBJECTIVE: The relation of hysterectomy and oophorectomy to change in bone mineral density (BMD) was examined in older women using and not using estrogen replacement therapy (ERT). METHODS: Women aged 60-80 years from the Rancho Bernardo Study attended clinic visits in 1988-1991 and 1992-1995 when hysterectomy and oophorectomy were ascertained, ERT use was validated and spine and hip BMD was assessed at both visits with DEXA. Women were either current ERT users or nonusers at both visits. RESULTS: Among these 447 women, average age was 71 (S.D.=9.0); average years postmenopause was 24.7 (S.D.=10.9). Overall, 122 had a hysterectomy with ovarian conservation and 91 had a hysterectomy with bilateral oophorectomy; 41% reported current ERT use for an average duration of 19.1 years (S.D.=10.8). Hysterectomized women were 2.3 times more likely to report ERT use than intact women (P<0.001). Comparisons adjusted for age, obesity, and age at menopause but not for ERT use showed hysterectomized women had less bone loss per year at the hip than intact women (P<0.05). However, this difference was explained by ERT; after adjustment for ERT, mean hip bone loss per year was -0.57% for intact women, -0.42% for hysterectomized women with ovarian conservation and -0.32% for bilaterally oophorectomized women (P's>0.10). There were no differences by hysterectomy or oophorectomy in bone loss at the spine or femoral neck. For all sites, women using ERT had higher BMD at both visits than nonusers (P's<0.001). Stratification by ERT showed that within users and nonusers, there were no differences in BMD or bone loss at any site by hysterectomy or oophorectomy. CONCLUSIONS: There are no long term effects of hysterectomy and bilateral oophorectomy on bone loss. Women who use ERT have better BMD than nonusers.     

Correlates of hormone replacement therapy use in Italian women, 1992-1996

OBJECTIVES: we analyzed the determinants of hormonal replacement therapy (HRT) use in Italy for the period 1992-1996, using data from a framework of case-control studies of colon and rectal neoplasm. METHODS: a total of 1574 women aged 45-74 years were considered. This group comprised women with acute, non neoplastic, non-hormone-related diseases admitted to a network of hospitals in six areas of Italy. RESULTS: a total of 146 women (8.5%) reported ever HRT use. The multivariate odds ratio (OR) of ever use was 1.6 (95% CI 1.0-2.6) for women with 12 years of education or more, compared with those with < 7 years. The frequency of use of HRT tended to decrease with increasing parity: the OR was 0.6 for women with four or more children as compared to nulliparae (chi2 trend 3.5, P = 0.06). Ever HRT users were more frequently smokers. HRT use was more frequent in women reporting surgical menopause (OR = 2.7) than those with natural menopause. Among post menopausal women, HRT use was related with early age at menopause (chi2 trend 4.6, P = 0.03). HRT use was more common among women reporting lower body mass index (BMI) both at interview and at age 30 years and the difference between current BMI and BMI at age 30 years, was not related with HRT use. CONCLUSIONS: women of higher socioeconomic status or education reported more frequent HRT use and nulliparae and smokers were also more likely to use HRT. Further HRT use was directly associated with early age at menopause and surgical menopause and inversely related with measures of body weight.     

Hormone therapy, timing of initiation, and cognition in women aged older than 60 years: the REMEMBER pilot study

OBJECTIVE: The aim of this pilot study was to assess any trends related to the timing of initiation, and duration, of hormone therapy (HT) use on cognitive function to facilitate the design and power calculations for a future large cohort study entitled Research into Memory, Brain function and Estrogen Replacement (REMEMBER). DESIGN: A total of 428 women aged older than 60 years were recruited from a computer-generated random selection of Adelaide households. Demographic and lifestyle characteristics, and HT use history were recorded and confirmed. The Center for Epidemiological Studies-Depression score was used to assess mood. Cognitive tests were administered measuring global cognition (Mini-Mental State Examination), attention and concentration (Trail Making Test Parts A and B), verbal learning and memory (Consortium to Establish a Registry for Alzheimer's Disease [CERAD] word list immediate and delayed recall), and verbal expression (letter fluency [FAS], category fluency [Animals], and the Boston Naming Test [short form]). Analyses were adjusted for age, education, mood, body mass index, smoking, alcohol intake, and history of cerebrovascular disease. HT use was defined as the use of systemic HT for at least 1 year. Early initiation of HT use was defined as commencement of HT before age 56 years for women with a uterus and ovaries, or within 5 years of a hysterectomy and bilateral oophorectomy. Late initiation of HT use was defined as HT commencing after these times. RESULTS: Early initiators of HT performed better than late initiators on the Mini-Mental State Examination (P = 0.04) and were faster than never users on the Trail Making Test Part A (P = 0.02). Women aged 70-79 years who initiated HT early performed better on the FAS test than never users (P = 0.0008). Late initiators performed worse than never users on the Mini-Mental State Examination (P = 0.09), and on the FAS test in the 60-69 year (P = 0.06) and 80 years and older (P = 0.095) age groups. However, late initiators performed better than never users on the FAS test in the 70-79 year age group (P = 0.015). HT users of less than 11 years (P = 0.09), HT users of more than 11 years (P = 0.04), and estrogen-only users (P = 0.024) performed faster than never users on the Trail Making Test Part A. Combined estrogen plus progestin users performed better than never users on the Boston Naming Test short form (P = 0.07). CONCLUSIONS: For some cognitive domains, early initiation of HT from around menopause may be beneficial, and initiation of HT in late menopause may be detrimental. The timing of the initiation of HT seems critical. To fully test these hypotheses and to further examine these trends by route and type of HT regimen in this population, a study size of 2,500 women would be required.     

Life prevalence and determinants of hormone replacement therapy in women living in Porto, Portugal

OBJECTIVE: To survey the life prevalence and determinants of hormone replacement therapy (HRT) in Portugal. METHODS: We evaluated 908 women with mean age (standard deviation) 62.3 (9.6) years, as part of the assembling of a cohort of adults, representative of Porto inhabitants. Extensive data collection was conducted and included socio-demographic, lifestyle and clinical characterisation. The latter comprised gynecologic and obstetric history, as well as lifetime use and duration of HRT. RESULTS: Life prevalence of hormone replacement therapy was 26.8% (95% confidence interval: 23.9-29.8). Prevalence of lifetime HRT was higher in younger (born after 1949: 37.1%) and more educated women (over 12 schooling years: 48.7%), as in white-collar workers (36.8%), and women using private healthcare (39.4%). HRT use was also more frequent among ever smokers (43.1%), and in women reporting regular sports practice (35.6%). Ever users of oral contraceptives underwent HRT more frequently (33.3%) and women who experienced menopause more recently were more likely to use HRT (after 1994: 40.5%). No differences were found in the prevalence of HRT according to whether women had been hysterectomised or oophorectomised. Education, regular sports practice and menopause year were independent determinants of HRT. Median duration of therapy was 2 years. Short-term HRT users were more educated, and had more recent menopause. Long-term HRT users were more educated, engaged in sports more frequently, and were more frequently oophorectomised. CONCLUSIONS: Prevalence of hormone replacement therapy increased until 2001 and was mainly determined by high socioeconomic status, regardless of important therapeutic indications, such as oophorectomy and hysterectomy.     

Knowledge of reproductive physiology and hormone therapy in 53- to 54-year-old Swedish women: a population-based study

OBJECTIVE: To investigate knowledge of hormone therapy (HT), reproductive physiology, and menopause in a population of 53- to 54-year-old women. Further aims were to determine whether the knowledge differed between users and nonusers of HT and between groups with different levels of education. DESIGN: In 2003, all 53- and 54-year-old women (N = 1,733) in Link?ping, Sweden, were sent a questionnaire containing questions about reproductive physiology related to menopause and HT. Answers from 73% of the women were analyzed. RESULTS: Swedish women had limited knowledge of HT, reproductive physiology, and menopause irrespective of HT use or educational level. Most of the women knew that hot flashes are common around menopause and decreasing estrogen production causes the menopause. They knew little about the effects of progestagens and the effects of HT on fertility. Women with low educational level were more likely to answer the questions by stating that they were unsure than did women with high educational level. Ever-users of HT knew more than never-users about risks and benefits of HT in relation to breast cancer and osteoporosis, and ever-users thought that the risks of thrombosis and myocardial infarction were lower than did never-users. CONCLUSIONS: Women need improved knowledge of the risks and benefits of HT as well as education about the reproductive system around menopause. This would probably better support and empower women to manage an important period of their lives.     

Personal use of hormone therapy by postmenopausal women doctors and male doctors' wives in Italy after the publication of WHI trial

OBJECTIVE: To describe the prevalence of hormone replacement therapy (HT) use by postmenopausal women doctors and doctors' wives in Italy and to explore the relationship between their personal characteristics and HT use. DESIGN: A total of 500 women doctors and 500 men doctors answering on behalf of their female partners were interviewed by a specialised company in the first months of 2003. Questions were meant to explore medical, behavioural and professional characteristics, personal use of HT, reasons for or against HT use and side effects of HT. The distribution of doctors' specialisation (general practitioners (GPs), gynaecologists, medical oncologists) in the sample interviewed was the same as that of the Italian medical community. RESULTS: Overall, 37% of women doctors and 39% of doctors' wives had ever used HT after menopause, of which 64 and 58%, respectively, were current users. The median duration of HT in the past users was 2.7 years for women doctors and 3.7 for doctors' wives. There were wide differences of HT use according to the type of specialisation: gynaecologists were more willing to use HT (56-59%) than GPs (30-31%) or medical oncologists (16-30%).Vasomotor symptoms (68-69%), followed by the prevention of osteoporosis (28-39%), were the main reasons for commencing HT. The main reasons not to take or to stop HT were the absence or resolution of menopausal symptoms. Only 8% of women doctors and 4% doctors' wives stopped HT after the publication of the WHI data. CONCLUSIONS: In Italy, women doctors/doctors' wives personally use HT much more than postmenopausal general population.     

Health behaviors and other characteristics of women on hormone therapy: results from the Third National Health and Nutrition Examination Survey, 1988-1994

OBJECTIVE: To examine the prevalence of hormone therapy (HT) use and compare demographic characteristics, health behaviors, and health indicators between current HT users and never-users in a nationally representative sample of postmenopausal women. DESIGN: The Third National Health and Nutrition Examination Survey was a cross-sectional survey conducted between 1988 and 1994, including 3,673 postmenopausal women aged 40 years and older. RESULTS: Overall, 419 (11.4%) of the women reported current HT use, 857 (23.3%) reported past use, and 2,397 (65.3%) were never-users. Non-Hispanic black women and women aged 70 years or older were less likely to be current users. Higher socioeconomic status (education and income) and surgical menopause were associated with increased odds of current hormone use. After adjusting for the above variables, women who reported being inactive during leisure time and obese women (body mass index >or= 30) were less likely to be current users. Women who had 5 to 29 alcoholic drinks per month, perceived their health status as "good," took a multiple vitamin, were aware of having high blood cholesterol, and had a clinic for regular medical care were more likely to be current users. Smoking habits were not significantly different between the groups. CONCLUSIONS: Current HT users have different demographic profiles and may lead healthier lives than never-users. This is important to take into account when studying the effects of HT, and it may partly explain differences in findings regarding the health effects of HT use in observational studies compared with randomized clinical trials.     

Compliance with hormone replacement therapy in Thai women

A retrospective study was performed to determine the compliance of hormone replacement therapy (HRT), the characteristics of women who continue to use HRT and the reasons for discontinuation. This study comprised of 821 postmenopausal women who attended the menopause clinic between January 1993 and December 1997. A total of 613 women (74.67%) were considered to be good compliant users. They had been on HRT for at least 1 year. Two hundred and eight women (25.33%) discontinued the treatment, with an average of 5.1 months duration of use. The younger age group at time of consultation and at menopause and those with previous hysterectomy were factors associated with higher degree of compliance. Its compliance decreased with age and the duration of menopause. The common reasons in the women's decision to discontinue HRT were bleeding episodes (23.08%), undesirable side effects (15.05%) and on physicians' advice (13.46%), respectively. Compliance with HRT appears to be similar to that reported in other specialist centres. Factors affecting compliance were age, age at menopause, duration of menopause, and hysterectomy. Irregular vaginal bleeding was the major reason for discontinuation.     

Postmenopausal status and early menopause as independent risk factors for cardiovascular disease: a meta-analysis

OBJECTIVE: Loss of ovarian function and subsequent deficiency of endogenous estrogens is suggested to enhance cardiovascular disease risk and related death after menopause. The aim was to obtain valid estimates of the cardiovascular disease risk associated with postmenopausal status and early menopause. DESIGN: A literature search of observational studies was performed using PubMed and EMBASE (1966 to May 1, 2004). Eighteen studies on postmenopausal status and age at menopause in relation to cardiovascular disease were selected. Six studies investigated menopausal status, nine studies investigated menopausal age, and three studied both. General variance-based methods were used to pool relative risk estimates and corresponding 95% confidence intervals. Stratification was performed for study design, type of menopause, outcome, and adjustment for age and smoking. RESULTS: The pooled relative risk estimate for postmenopausal versus premenopausal status and cardiovascular disease was 1.36 (95% CI, 1.15-1.60). In the stratified analysis, the pooled effect was 0.96 (95% CI, 0.77-1.21) after controlling for age and smoking. The pooled effect of bilateral oophorectomy on cardiovascular disease was 2.62 (95% CI, 2.05-3.35). For early menopause and cardiovascular disease, with the menopausal age category containing 50 years as a reference, the pooled relative risk estimate was 1.25 (95% CI, 1.15-1.35). In the stratified analysis, the pooled effect was 1.38 (95% CI, 1.21-1.58) after controlling for age and smoking. The pooled effect of bilateral oophorectomy on cardiovascular disease was 4.55 (95% CI, 2.56-8.01). CONCLUSIONS: Overall, there was no convincing relationship between postmenopausal status and cardiovascular disease. However, there was a modest effect of early menopause on cardiovascular disease. The effect was more pronounced for women with an artificial menopause than for women with a natural menopause.     

Women''s use of hormone replacement therapy for relief of menopausal symptoms, for prevention of osteoporosis, and after hysterectomy.

BACKGROUND. Hormone replacement therapy is used for the relief of menopausal symptoms. In the United Kingdom, guidelines have been developed for the use of hormone replacement therapy in the prevention of osteoporosis, and in the United States of America its use has also been recommended for cardiovascular disease prevention. However, compliance has been found to be a problem, and rates of prescribing vary between general practitioners. AIM. This study set out to describe the prescribing of hormone replacement therapy in one general practice, to enable doctors to plan future prescribing and promotion of hormone replacement therapy, taking into account constraints on its use. METHOD. The patient records of users of hormone replacement therapy were examined to collect data on menopausal status, reason for use, length of use, breaks from therapy and reasons for stopping therapy. Women with a history of hysterectomy and with risk factors for osteoporosis were identified from the practice morbidity register. Their use of hormone replacement therapy was recorded. RESULTS. Of women aged 40-59 years on the practice list, 348 were taking hormone replacement therapy (20%). Of 107 women aged under 52 years who had had a hysterectomy and bilateral oophorectomy 76 were taking therapy (71%). Of 158 women under the age of 52 years who had had a hysterectomy with preservation of the ovaries 39 were taking therapy (25%). Among women taking hormone replacement therapy for the relief of menopausal symptoms, the highest rate of use was among those aged 50-54 years where 93 were on therapy (24% of women in that age group in the practice). Twenty out of 47 women with a recorded risk factor for osteoporosis were taking therapy. More than three quarters of women using hormone replacement therapy appeared to be taking it continuously. CONCLUSION. The uptake of hormone replacement therapy was found to be high for women with a surgical menopause, the group most easily identifiable as at risk of osteoporosis. Women who decided to take therapy appeared to take it continuously, and therefore effectively for prevention. Rate of uptake, rather than compliance, is more likely to constrain its use in prevention.     

Hysterectomy prevalence and cardiovascular disease risk factors in American Indian women

OBJECTIVES: We investigated hysterectomy prevalence and associated demographic and reproductive factors among American Indian women. The association between hysterectomy and cardiovascular disease (CVD) risk factors was also examined. METHODS: Data were from 2689 American Indian women who participated in the first examination of the Strong Heart Study from 1989 to 1992. Odds ratios were estimated for factors related to hysterectomy adjusting for other covariates. The association between hysterectomy and CVD risk factors was examined among 1726 eligible women using analysis of covariance. RESULTS: Hysterectomy prevalence ranged from 24% to 34% across differing age groups and the percent with oophorectomy among those with a hysterectomy ranged from 43% to 63%. Geographic area, more prior pregnancy losses, more education, and less speaking of the native language were associated with increased hysterectomy prevalence. After adjustment for age, the women who had a hysterectomy with intact ovaries had higher total cholesterol and low-density lipoprotein cholesterol levels than those with a natural menopause. CONCLUSIONS: American Indian women have comparable hysterectomy prevalence as non-Hispanic white women. Education and native language speaking related to hysterectomy in this population. Hysterectomy alone may relate to unfavorable changes of lipid profile.     

Climacteric symptoms in an unselected sample of Swedish women

A questionnaire on climacteric symptoms was sent to every woman living in the city of Linköping, Sweden (120,000 inhabitants) who was born in 1928 or 1930. Of the 1246 women concerned, 1118 (90%) responded. At the time of the survey, 252 women (23%) were pre-menopausal. In the total sample, 10B had undergone hysterectomy and/or bilateral oophorectomy. The median age at natural menopause was 51 yr.

Climacteric symptoms were reported by 75% of the women, the predominating complaints being sweating attacks and hot flushes. Vaginal dryness and tenderness were experienced by 30% of the post-menopausal women, the discomfort tending to become more common as the duration of the post-menopausal period lengthened.

After the menopause, every third woman experienced periods of depression more often than previously. Depression was positively correlated to the severity of the vasomotor symptoms.

Fifty percent of the women expressed interest in receiving oestrogen treatment, although only 7% were using oestrogens at the time of the survey. This discrepancy is probably due to widespread apprehension in Swedish society - shared by the doctors - in regard to ‘hormonal treatment’.     

Women's views of the climacteric at the time of low menopausal hormone use, Estonia 1998

OBJECTIVES: This study examined women's opinions about the climacteric and hormone therapy (HT) after menopause and compared women's and physicians' opinions in a country of low-HT use. METHODS: In 1998, a postal questionnaire was sent to a random sample of 2000 Estonian 45-64-year-old women; 69% (n=1312) responded. In 1999, a postal questionnaire was sent to a random sample of 500 Estonian gynaecologists and general practitioners; 68% (n=342) responded. RESULTS: Mean age at menopause was 49.8 years (S.D. 4.0), and there was no difference by socioeconomic classes or by age in self-rated health. Ten percent of women reported having used HT, with 3% currently using it. Most women reported some symptoms, with vasomotor symptoms more frequently reported by 50-54 years old; women most often reported tiredness (48%). Half of the women but under a fifth of physicians considered the climacteric a normal phase of life. Women's awareness about HT was low and about half had no opinion on its health effects. Half of the women had visited a gynaecologist, older women less so. Women with contacts with health care were more aware of HT. CONCLUSIONS: Women reported symptoms by age-group as similarly found in high-HT use countries and it verifies that many symptoms experienced were not due to menopause. As in other low-HT use countries, women were unfamiliar with HT and their attitudes were traditional, although physicians' attitudes were more positive. Estonian women seemed to have escaped the period of the preventive use of HT.     

The association between early menopause and risk of ischaemic heart disease: influence of Hormone Therapy

Randomised clinical trials find no protection against development of ischaemic heart disease by use of Hormone Therapy (HT) after the age of 50 years. Observational studies suggest that early menopause is a risk factor for ischaemic heart disease. Yet, a clinical very relevant question is whether HT reduces this risk associated with early menopause. OBJECTIVE: To analyse whether early menopause based on various causes are independent risk factors for ischaemic heart disease, and to investigate whether the risks are modified by use of HT. METHODS: In a prospective cohort study questionnaires were mailed to Danish female nurses above 44 years of age in 1993. Information on menopause, use of HT and lifestyle was obtained. In total 19,898 (86%) nurses fulfilled the questionnaire, among them 10.533 were postmenopausal with definable menopausal age, free of previous ischaemic heart disease, stroke or cancer. Through individual linkage to national register incident cases of ischaemic heart disease were identified until end of 1998. RESULTS: Menopause below both age 40 and 45 was associated with an increased risk of ischaemic heart disease, seeming most pronounced for women who had an early ovariectomy but also among spontaneous menopausal women. Generally HT did not reduce the risk except for the early-ovariectomised women, where no increased risk of ischaemic heart disease for HT users was found. CONCLUSION: We found an increased risk of ischaemic heart disease associated with early removal of the ovaries that might be reduced with HT. The present study need confirmation from other studies but suggests that early ovariectomised women could benefit from HT.     

Use of hormones in the menopausal transition period in the Netherlands between 1993 and 1997

OBJECTIVES: To describe the patterns and to assess the indicators of hormone use during the menopausal transition period in a Dutch population. METHODS: Between 1993 and 1997, 17,357 women aged 49-70 years participated in the Prospect-EPIC (European Prospective Investigation into Cancer and Nutrition) cohort and filled out an extensive questionnaire, which included information about hormone use during menopausal transition and other medical and lifestyle characteristics. Patterns of hormone use were described and various characteristics were evaluated as indicators of current hormone use by logistic regression. RESULTS: Overall, 13% of women were current hormone users, which was highest in the 49-54 age group (19%). Hysterectomized women and older non-hysterectomized women mainly used unopposed estrogen therapy (ET), whereas younger non-hysterectomized women mainly used oral contraceptives or combined estrogen+progestogen therapy. Of all ever users, 61% used hormones for more than 1 year and 28% for more than 5 years. The most important indicators of hormone use for women without a surgical menopause were age, alcohol use, smoking, parity, ever use of oral contraceptives and family history of breast cancer. For women with a surgical menopause age, parity, ever use of oral contraceptives, diastolic blood pressure and the number of removed ovaries were the most relevant indicators. CONCLUSIONS: The frequency of hormone use during menopausal transition in the Netherlands is low compared to other western countries, but the duration of use is quite long. Hormone use seems to be largely determined by factors that are known to affect endogenous estrogen levels.