A survey of obstetrician-gynecologists concerning practice patterns and attitudes toward hormone therapy

OBJECTIVE: To examine the knowledge and prescribing practices of obstetrician-gynecologists regarding hormone therapy in light of the published evidence from the Women's Health Initiative study on combined estrogen + progestin. DESIGN: A survey questionnaire was sent to 2,500 randomly selected Fellows of the American College of Obstetricians and Gynecologists in November of 2003; 705 surveys were returned. Of those, 644 reported their specialty as obstetrics and/or gynecology and those responses are reported. RESULTS: A majority of physicians that completed their residency before 1995, both men and women, were not convinced by the WHI research results and disagreed with the decision to end the trial. Physicians that rated themselves very confident about their ability to interpret the scientific literature were more likely to be unconvinced by the results and to disagree with the decision to end the trial. In general, physicians that completed their residency more recently rated the benefits of hormone therapy lower and the risks higher. A majority of respondents (53.3%) reported that their prescribing practices were unlikely to change; however, 29.6% reported that they would be somewhat less likely and 9.5% dramatically less likely to prescribe hormone therapy. Physicians reported that their patients were less likely to request hormone therapy (91.8%) and were more likely to discontinue use (93.0%). CONCLUSION: Physicians that have been in practice longer were more positive about the risks and benefits of HT, and were more skeptical about the recent research. The published data seem to have affected patient preferences and to have had some effect on physician prescribing practices.     

The Women’s Health Initiative Conundrum

Summary The WHI has been designed to evaluate the metabolic risks and benefits of Estrogen/Progestagen Therapy (HT) or Estrogen Therapy (ET) in women in their later postmenopause. It has not been designed to study the effect of HT or ET on symptomatic peri- and early postmenopausal women. Furthermore, the selection criteria used in the WHI are not congruent with the profiles of women treated in daily medicine by HT/ET: women starting HT/ET in clinical routine are younger, less obese and healthier than the WHI population. Therefore, the results and the risk-benefit-conclusions of the WHI cannot be applied to normal symptomatic peri- and immediately postmenopausal women, and even less to women with early (40–50 years) or premature (40yrs.) menopause.     

Changing use of hormone therapy among minority women since the Women's Health Initiative

OBJECTIVE: There has been a significant shift in the use of hormone therapy (HT) among nonminority women since the publication of results of the Women's Health Initiative (WHI). Little is known about how the WHI results affected minority populations. This survey measured patterns of HT use among inner city women after publication of the WHI results, identified factors involved in the decision to continue or discontinue HT, and characterized the symptom burden and the experience of women who attempted to discontinue HT. DESIGN: We conducted a cross-sectional survey of 101 English- and Spanish-speaking women in an inner city general internal medicine clinic from August 2003 to April 2004. All women had been taking HT at the time of the publication of the WHI results. The survey included questions on patient-reported experience with HT, symptoms of menopause, and use of alternative treatments. RESULTS: Overall, 101 of 142 (71%) eligible women agreed to participate. The mean age of participants was 60 years; 43% were African American and 46% were Hispanic. The mean duration of HT use was 9.6 years. Three quarters (74%) had heard about the WHI findings, and 87% had attempted to stop taking HT after their publication. The most common reason for attempting to stop HT was concern about an increased risk of cancer or a general increase in risk to health. Of those who stopped HT, the vast majority (85%) reported vasomotor symptoms, and 26% restarted HT, mostly to treat those symptoms. CONCLUSIONS: Nearly all minority women in this small sample attempted to stop HT use after the results of the WHI were published. Restarting HT for treatment of symptoms was common.     

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.     

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.     

Women's midlife health across cultures: DAMES comparative analysis

OBJECTIVE: The Decisions At Menopause Study (DAMES) investigates the experience of menopause in four countries. This article explores self-reported health. DESIGN: Women aged 45 to 55 years were interviewed in Lebanon (n=298), Morocco (n=299), Spain (n=300), and the United States (n=293). The survey instrument included closed- and open-ended questions. Statistical analyses were used to assess the determinants of reporting poor health, and textual analyses were used to highlight themes related to perceptions of health. RESULTS: In Lebanon and Morocco, 22% and 28%, respectively, of the women sampled indicated that their health was not good. In Spain and the United States, 15% and 11% of the women sampled reported their health as fair or poor. We explored significant predictors of poorer reported health across sites. Responses to the open-ended questions "How is your health?" and "How do you compare your health to other women your own age?" revealed common concerns of aches and pains, tiredness, work/responsibilities, and family across all four sites. Unique themes included the war in Lebanon, poverty in Morocco, and social activity in Spain. Menopausal symptoms may in many cases be overshadowed by other health concerns of middle-aged women. Nonspecific symptoms such as tiredness and aches and pains serve to link bodily health with social circumstances. Family and work responsibilities are common concerns of middle-aged women. CONCLUSIONS: Research on midlife health and menopause needs to be systematic enough to enable cross-cultural comparisons. At the same time, it must be flexible enough to identify population-specific symptoms, social context, and lifestyle concerns.     

WHI risks: Any relevance to menopause management?

Two randomised controlled trials of hormone therapy (HT) were conducted within the US Women's Health Initiative. Both were chronic disease prevention trials, undertaken to determine whether HT reduced cardiovascular risk and increased breast cancer risk. Because the majority of subjects in both trials were asymptomatic and many years postmenopausal, and because substantial numbers had received HT prior to recruitment to the trials, care must be taken in drawing conclusions that the observed risks are applicable to women for whom HT is conventionally prescribed. Each of the reported risks must be examined critically to determine its likely applicability to symptomatic women treated for two to three years to relieve symptoms, but sometimes for substantially longer periods. Further, the risks reported in each of the two trials must be considered separately. Concerning cardiovascular disease, many subjects in the trials were at increased baseline risk because of their age, body mass index, smoking status, blood pressure and years since menopause, in contrast to the usual situation for symptomatic perimenopausal women. Therefore the reported overall cardiovascular risks in WHI, in both treatment arms, should be regarded as irrelevant to menopause management. In contrast, breast cancer risk is relevant, providing that proper note is taken of the fact that there was no increased risk after five years of combined hormone therapy in non-prior HT users and there was a tendency to a decreased risk in oestrogen only treated individuals. Other risks are analysed similarly.     

Age at natural menopause in Beirut,Lebanon: the role of reproductive and lifestyle factors

Summary. Primary objective: To determine the median age of natural menopause and factors associated with the timing of menopause in Beirut, Lebanon. Research design: A population-based sample of 298 women were interviewed using a semistructured questionnaire. Methods and procedures: Logit analysis and logistic regression were used to estimate the median age and identify correlates of menopausal status. Main outcomes and results: The median age of natural menopause in Beirut, Lebanon is estimated to be 49.3 years. Not being currently married (odds ratio (OR)=4.19, 95% CI: 1.53, 11.51) and smoking (OR=1.02 for each year of smoking, 95% CI: 1.00, 1.05) are significantly associated with an earlier age at menopause. Women with menstrual bleeding longer than 5 days have later ages at menopause (OR=0.50, 95% CI: 0.26, 0.97). Age at menarche, parity, education and socio-economic status are not statistically associated with the age at menopause. Conclusions: The age at natural menopause in Lebanon is comparable to median ages reported for women in industrialized countries (49.3-51.4). Our results emphasize the role of smoking in determining an earlier age at menopause and indicate that reproductive characteristics affect the timing of menopause.     

An evaluation of the contents and quality of menopause information on the World Wide Web

OBJECTIVE: To evaluate the content and quality of currently available World Wide Web based information about menopause. DESIGN: A sample of the 100 top sites obtained with the search engine Google for the key word "menopause" was evaluated according to predefined general and specific criteria, content type, language, and quality. The Internet popularity was established by the number of links to each website. Using a systematic scoring tool each site was assessed on factual information provided and quality of site. RESULTS: The websites studied were heterogeneous in content and quality. The most frequent type of website has commercial content with low quality, biased or useless information. Few sites provided comprehensive medical information about menopause. The scientific societies not always provided complete information about the possible adverse events related with hormone replacement therapy. The results of the Women's Health Initiative (WHI) and the Million Women (MW) studies are discussed by very few websites. Internet popularity did not correlate with measures of quality such as display of authorship, attribution or references, currency of information, and disclosure. CONCLUSION: The content and quality of the websites concerning menopause are widely varied and sometimes biased to commercial goals. The dominant medical information is of low quality and do not comply with general quality scores although the most informative sites have comprehensive content about the menopause including the recent results of the WHI and MW studies.     

Age at natural menopause in Beirut, Lebanon: the role of reproductive and lifestyle factors

PRIMARY OBJECTIVE: To determine the median age of natural menopause and factors associated with the timing of menopause in Beirut, Lebanon. RESEARCH DESGIN: A population-based sample of 298 women were interviewed using a semi-structured questionnaire. METHODS AND PROCEDURES: Logit analysis and logistic regression were used to estimate the median age and identify correlates of menopausal status. MAIN OUTCOMES AND RESULTS: The median age of natural menopause in Beirut, Lebanon is estimated to be 49.3 years. Not being currently married (odds ratio (OR)=4.19, 95% CI: 1.53, 11.51) and smoking (OR = 1.02 for each year of smoking, 95% CI: 1.00, 1.05) are significantly associated with an earlier age at menopause. Women with menstrual bleeding longer than 5 days have later ages at menopause (OR = 0.50, 95% CI: 0.26, 0.97). Age at menarche, parity, education and socio-economic status are not statistically associated with the age at menopause. CONCLUSIONS: The age at natural menopause in Lebanon is comparable to median ages reported for women in industrialized countries (49.3-51.4). Our results emphasize the role of smoking in determining an earlier age at menopause and indicate that reproductive characteristics affect the timing of menopause.     

Correlates of the age at natural menopause in Morocco

PRIMARY OBJECTIVE: To determine the median age of natural menopause and factors associated with the timing of menopause in Morocco. RESEARCH DESIGN: A population-based sample of 299 women from Rabat, Morocco were interviewed using a semi-structured questionnaire. METHODS AND PROCEDURES: Logit analysis and logistic regression were used to estimate the median age and identify factors associated with the age at menopause. MAIN OUTCOMES AND RESULTS: The median age of natural menopause in Morocco is estimated to be 48.4 years (95% CI: 36.9, 70.3). Women who reported the onset of menstruation at age 11 or younger (OR = 2.84, 95% CI: 1.00, 8.10) had an earlier age at menopause than women who started menstruating at age 12 or older. Women who had ever used oral contraceptives were more likely to have a later age at menopause (OR = 0.55, 95% CI: 0.30, 1.00). The length of time a woman used oral contraceptives influenced the timing of the menopause in unadjusted models but after adjusting for the age at menarche the effect was no longer statistically significant. Marital status, parity, education level, and social class were not statistically associated with the age at menopause. CONCLUSIONS: The estimated age at natural menopause in Morocco is 1-3 years earlier than the median ages reported in industrialized countries and some developing countries. Factors that alter the frequency of ovulation or rate of follicular atresia appear to be important in determining the age at menopause.     

Body mass index trajectories and age at menopause in a British birth cohort

OBJECTIVE: This study investigates the influence of body mass index (BMI) at ages 15, 20, 26, 36, and 43, and of BMI trajectories from 20 to 36 years on the timing of menopause and hormone therapy (HT) use until age 57 years. METHODS: A nationally representative British cohort of 1583 women born in March 1946 with prospective data across the life course. RESULTS: By age 57, a total of 695 women had experienced natural menopause while 431 women had started HT prior to menopause. Cox regression models indicated no significant associations between BMI at any age, or BMI trajectory, and timing of natural menopause. At every age BMI was strongly (p< or =0.01) and linearly associated with age at HT use and BMI from 26 years onwards was associated with age at first event (menopause or HT use). Decreasing BMI was associated with earlier HT use at all ages. These associations were not accounted for by parity, cigarette smoking or childhood and adult social class. CONCLUSION: BMI across the reproductive lifespan did not influence age at menopause to an extent that would be clinically relevant for postmenopausal health. Lower BMI at all ages and underweight trajectory were related to an earlier start of HT. Further studies are required to understand whether such relationships are due to underweight women experiencing menopause earlier (and because of menopausal symptoms starting HT earlier) than heavier women, or having behavioural characteristics related to earlier HT use, independent of menopause.     

Correlates of the age at natural menopause in Morocco

Primary objective : To determine the median age of natural menopause and factors associated with the timing of menopause in Morocco. Research design : A population-based sample of 299 women from Rabat, Morocco were interviewed using a semi-structured questionnaire. Methods and procedures : Logit analysis and logistic regression were used to estimate the median age and identify factors associated with the age at menopause. Main outcomes and results : The median age of natural menopause in Morocco is estimated to be 48.4 years (95% CI: 36.9, 70.3). Women who reported the onset of menstruation at age 11 or younger (OR = 2.84, 95% CI: 1.00, 8.10) had an earlier age at menopause than women who started menstruating at age 12 or older. Women who had ever used oral contraceptives were more likely to have a later age at menopause (OR = 0.55, 95% CI: 0.30, 1.00). The length of time a woman used oral contraceptives influenced the timing of the menopause in unadjusted models but after adjusting for the age at menarche the effect was no longer statistically significant. Marital status, parity, education level, and social class were not statistically associated with the age at menopause. Conclusions : The estimated age at natural menopause in Morocco is 1-3 years earlier than the median ages reported in industrialized countries and some developing countries. Factors that alter the frequency of ovulation or rate of follicular atresia appear to be important in determining the age at menopause.