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December 2001, Volume 51, Issue 12

Student's Corner

Hormone Replacement Therapy menopause with a Better Future - A survey of views on Hormone Replacement Therapy (HRT)

S. Shafi  ( Department of Community Health Sciences, The Aga Khan University Hospital. Karachi. )
Z. Samad  ( Department of Community Health Sciences, The Aga Khan University Hospital. Karachi. )
S. Syed  ( Department of Community Health Sciences, The Aga Khan University Hospital. Karachi. )
A. Sharif  ( Department of Community Health Sciences, The Aga Khan University Hospital. Karachi. )
M. A. U. Khan  ( Department of Community Health Sciences, The Aga Khan University Hospital. Karachi. )
U. S. Nehal  ( Department of Community Health Sciences, The Aga Khan University Hospital. Karachi. )
A. R. Siddiqui  ( Department of Community Health Sciences, The Aga Khan University Hospital. Karachi. )

Abstract

Objective: To assess the views and prescribing practices of doctors regarding hormone replacement therapy (HRT).
Methods:  In April 1999,103 doctors from a teaching hospital participated in a survey. Using a self-administered questionnaire, subjects were contacted at the departments of Internal Medicine, Family Medicine, Obstetrics and Gynaecology, and Orthopaedics.
Results: Seventy-two percent were below 40 years of age and 67% of the respondents were male. Most doctors believed that HRT decreases the risk of subsequent osteoporosis (97%), ischaemic heart disease (77%) and depression associated with menopause (64%). Doctors generally considered menopausal symptoms (90%), premature menopause (87%), surgical menopause (85%) and osteoporotic fracture (77%) as clear indications for hormone replacement therapy. Absolute contraindications to the therapy were stated as recent breast cancer (82%) and recent endometrial cancer (84%). Among the specialties covered, there were differing views on proposed duration of HRT. It was generally believed that a pelvic examination, cervical smear and mammography were pre-requisites when initiating and monitoring HRT. Majority (69%) felt that HRT should be offered to all menopausal women, assuming no contraindications and most (73%) did discuss HRT with their patients. However, less than 10% of the menopausal patients under their care were using HRT. Those doctors not in favor of universal offering of HRT (31%) considered unreliable patient folio w up to be the main reason. Females were two times more likely to discuss HRT with their patients (p= .08). Doctors who discussed HRT with their patients were four times more likely to consider HRT for themselves or their spouses (p= .13). Gynecologists were eight times more likely to prescribe HRT than non-gynecologists (p= .001).
Conclusion: Doctors are positively disposed to the universal offering, and use of HRT. Further studies are needed to understand a possible gap between perceived and actual prescribing practice (JPMA 51:450,2001).

Introduction

Hormone Replacement Therapy (HRT) consists of treatment with estrogen or a combination of estrogen plus progestin. There is extensive data suggesting that HRT is effective in alleviating the effects of the menopause and in protecting against the chronic cardiovascular and cerebrovascular consequences of estrogen deficiency1-4. The consensus amongst specialists is that contraindications to HRT are few and less than those associated with oral contraceptives5. The American College of Physicians recommends that all women, regardless of race, should consider HRT6. Despite this fact, the current use of HRT is still low. An international survey indicated current rate of use of HRT in women aged 40-69 to be 7% in UK7 and 9% in Scotland8, 30% in USA, 21% in Sweden and 25% in France9.
According to Ringa10 the difference between the prevalence of climacteric complaints and HRT use rates may be attributed to unwillingness on the part of women to use HRT, or the part of physicians to prescribe it. HRT use is strongly related to interactions with the physicians; women are likely to use written materials as a source of information in making decisions about HRT, and most women feel that the amount of information received about HRT is inadequate”. A recommendation by a doctor is one of the major factors determining compliance with subsequent prescription for HRT. About 75% of non-users of HRT would consider HRT if so recommended by their doctor. The doctor’s attitude was found to be a factor in encouraging compliance12.
Bryce and Lilford13 found that the approach of general practitioners (GP) to prescribing HRT was guarded with regard to both frequency and duration. The study carried out by Wilkes and Meade14 showed that there was considerable doubt among GPs as to the balance between the beneficial and harmful effects of HRT in the long term. However, other studies found that the GPs surveyed were generally able to recognize the menopause by its complaints and that they had a positive attitude towards treatment , but many were skeptical of its chronic use and use in women with cardiovascular conditions15,16 Doctors differed in opinion as to who should initiate therapy, gynecologists or GPs.
However, the studies concerned were conducted in developed countries and the situation could be different in Pakistan. This study reports the views of doctors about prescribing HRT in a tertiary care hospital.

Methods

This cross-sectional survey, was conducted in April 1999 at The Aga Khan University Hospital (AKUH), Karachi. As a convenient sample, we chose the doctors working at AKUH in the departments of internal medicine, gynecology, orthopedics, and family medicine, A self-administered questionnaire was distributed amongst 125 doctors (consultants, residents, and medical officers), who were present in their departments. units or wards .The questionnaire was pre-tested on 15 doctors.
EPI-INFO 6 was used to calculate sample size. With a confidence interval of 95%, a power of 80 and a positive attitude of at least 40% towards HRT, we estimated the sample size to be 96.
Data was coded before entry and it was analyzed using EPI INFO 6 statistical program software. Odds ratio was used as a measure of association. Levels of significance used were confidence interval of 95%.

Results

Of the 125 questionnaires, 103 were returned completed, making a response rate of 82%.

Figure shows The majority of responders (72%) were below 40 years of age and 67% responders were male. Most doctors believed that HRT decreases the risk of osteoporosis (97%), ischemic heart disease (77%) and depression (64%) subsequent to menopause. 62% felt that the use of HRT does not decrease the risk of hypertension. Regarding prevention of cerebrovascular accident (CVA), 32% felt that HRT decreased the risk, 44% disagreed, and 18% did not know.
Doctors generally considered menopausal symptoms. premature menopause, surgical menopause, and osteoporotic fracture as clear indications for hormone replacement therapy. (Table 1).


Regarding contraindications to HRT, the majority considered recent breast cancer (82%) and recent endometrial cancer (84%) as absolute contraindications. More than half of the respondents (54%) considered a family history of breast cancer to be a relative contraindication. Fifty nine percent respondents felt that HRT should be given for more than 10 years. Almost half of the gynecologists (54%) felt that HRT should be prescribed indefinitely. In orthopedics, a shorter duration was preferred, that is. 55% believed in URT for less than five years.


Table 2 shows the investigations that doctors considered necessary before starting HRT. It was generally believed that a pelvic examination, cervical smear and mammography were specifically indicated when initiating and monitoring HRT. Breast examination and measurement of blood pressure were also considered necessary for monitoring HRT. Thirty-five percent of the respondents felt comfortable prescribing HRT themselves whereas the rest (61 .2%) referred to gynecologists. Gynecologists were found to be 8 times more likely to prescribe HRT then non-gynecologists (Odds ratio (OR) 8.5; 95% Cl: 1.93 - 43.98). The majority of family medicine practitioners felt at ease while prescribing HRT (67%). Among other specialties, the general trend was to refer.
Among non-Gynecologists, doctors in family medicine were 15 times more likely to prescribe HRT, as compared to cardiologists, orthopedic surgeons, and internists. (OR=15; 95%Cl: 4.41 - 55.9).
Only 32% of doctors had patients on HR’T, however, these patients comprised less than 10% of the menopausal patients under their care. 14% of doctors did not respond, 25% did not know and 18% of doctors had no patients on HRT.
The majority of the doctors (69%) favored universal offering of HRT assuming no contraindications and most doctors (73%) did discuss HRT with their patients.
Majority of gynaecologists (100%) and family practitioners (90%) discussed HRT with their patients, whereas only 54% of internists did so.
Those doctors who were not in favor of universal offering of HRT (31%), considered the following to be their main reasons: unreliable patient follow up, risks of HRT outweigh it’s benefits, unwilling patients and the need for further research on the subject. Lack of availability of HRT, a time consuming screening process, that HRT interfered with a natural phenomenon and that it is not a priority for a developing country were not considered to be important reasons.
Female doctors were two times more likely to discuss HRT with their patients, as compared to male doctors. People who discussed HRT with their patients were 4 times more likely to consider HRT for themselves or their spouses. Current medical literature was the primary source for 71% of the doctors.

Discussion

This study indicated that the doctors at this hospital are fairly aware and positively disposed towards HRT. There was possibly a disproportionate response from young doctors, who might be more positively inclined to HRT than their older colleagues.
The doctors are positively disposed to HRT, regarding its role in ischemic heart disease, osteoporosis, depression and treatment of menopausal symptoms, premature menopause and surgical menopause. Reservations exist over the role of HRT in the prophylaxis of cerebrovascular accident and Hypertension. While estrogen therapy has little control on blood pressure there is data that it can reduce significantly mortality of ischemic heart disease2. Data indicating a relative risk of 0.53 of death from stroke following estrogen therapy3 differ with more recent data17, which show no reduction (or increase) in risk of stroke. The bulk of evidence now suggests that in contrast to the combined oral contraceptive, HRT does not cause or aggravate essential hypertension18,19. However, 23% of the doctors in our study, considered even treated hypertension to be an absolute or relative contraindication to HRT.
An over guarded approach, or investigations and monitoring that are too invasive and expensive may daunt women from opting for HRT. There is no evidence to link cervical abnormality to HRT16 but the majority of the doctors’ required cervical smears before HRT. Regarding duration of therapy, the maximum benefits of therapy in reducing risk for coronary heart disease and osteoporotic fractures are more likely to be achieved with long-term therapy (10 to 20 years or more). 40% of the respondents in this study felt that HRT should be given for less then 10 years. Family practitioners and gynecologists were comfortable with prescribing HRT, while in other specialties the trend was to refer.
Most of the doctors favored universal offering of HRT and almost all of them thought that every women should be educated about HRT. Unreliable patient follow up, unwillingness on the part of the patients and likely risks versus benefits were cited as important reasons for not offering HRT. Financial cost, cost in time for supervision and monitoring and concern about the pharmacological approach to what is seen as a natural process in humans were not considered important reasons for not offering HRT as opposed to other studies13.
On the basis of the results of this study, one might get the notion that there was no major reluctance on the part of the doctors to use HRT. However, less than 10% of the menopausal patients under their care were using HRT. A possible justification is that the unwillingness to use HRT may come primarily from the women in our setting. Whether or not women really are hesitant to use HRT would require further investigation.
We recommend that guidelines in keeping with the most recent literature should be formulated and made available to all doctors. Furthermore, seminars and workshops should be held to highlight the preventive role of HRT during and after the climacteric phase of life.

Acknowledgements

We would like to thank Dr. Nadeem Zuberi, Mr. Raheem Makani and the Departments of Community Health Sciences, Family Medicine, Medicine, Obstetrics and Gynaecology and Orthopaedics for their support and cooperation.

References

1.Grady D, Rubin SM. Petitti DB Hormone therapy to prevent disease and prolong life in postinenopausal women, Ann. Intern. Med., 1992. 117:1016­, 37.
2.Henderson BE, Paganini -Hill, Ross RK. Estrogen replacement therapy and protection from myocardial infarction. Am. J. Obstet. Gynecol., 1986: 159; 3 12-17.
3.Paganini-Hilt. Ross RK, Henderson B. Postmenopausal oestrogen treatment and stroke; a prospective study Br. Med. J., 1988: 297:519-22.
4.Falkeborn M, Persson 1, Adami HO. et al The risk of acute myocardial infarction after oestrogen-progestogen replacement. Br. J Obstet Gynecol., 1992; 99821.28.
5.Studd JWW. Complications of hormone replacement therapy tn postmenopausal women, J. Roy. Soc. Med., 1992: 85:376-78.
6,American College of Physicians. Guidelines for counseling postmenopausal women about preventive hormone therapy. Ann. Inter. Med., 1992. 117:1038­,41.
7.Odenns BJ, Boulet Mi, Lehert P, et al. Has the climacteric been medicalized? A study on the use of medications for climactenc complaints on four countries. Maturitas.. 1992; 15:171-81.
8.Sinclain HK, Bond CM, ‘raylor RJ. HRT: A study of women’s knowledge and attitudes. Br J Gene Prac., 1993; 43365-70.
9.Lars-Ake, Stadberg E, Milson, L.. Management of hormone replacement therapy; the Swedish experience. Eur. J. Obstet. Gynecol Reprod. Biol., 1996: 64 (Sttppl 1) :S3-S5.
10.Ringa V, Ledesert B, Gueguen R, et al. Determinants of hormonal replacement therapy in recently postmenopausal women. Eur. J. Obstet. Gynecol. Reprod Biol., 1990: 37:55-61.
11Newton KM. Lacroix AZ, et al. The physician’s role in women’s decision Making about hormone replacement therapy. Obstet. Gynecol., 1998: 92:580-84.
12.Ferguson Ki, Hoegh C, Johnson A. Estrogen replacement therapy: A survey of women’s knowledge and attitudes, Arch. Int, Med., 1989: 149; 133-36.
13.Bryce FC, Lilford RJ. General practitioners views of hormone-replacement therapy in Yorkshire. Eur. J. Obstet. Gynecol. Reprod. Biol., 1990: 37: 55-61.
14.Wilkes HC, Meade TW. Hormone replacement therapy in general practice: a survey of doctors in the MRC’s general practice research framework. Br. Med. J., 1991;302: 1317-20.
15,Stouthamer N, Visser AP,, Oddens BJ,et al. Dutch general practitioners’ attitudes towards the climacteric and its treatment, Eur. J. Obstet, Gynecol Reprod. Biol.,1993; 50: 147-52.
16.Norman SG. Studd JWW. A survey of views on hormone replacement therapy. Br. J. Obstet. Gynecol.,1994;101: 879-87.
1 7,Stampfer Mi, Colditz GA, Willett WC. et al. Postmenopausal estrogen therapy and cardiovascular disease. N. EngI J. Med.,1991, 325:756-62.
18,Laragh JH., Scaly JE., Ledingham JG, et al. Oral contraceptives: renin, aldosterone and high blood pressure. J. Am. Med. Assoc., 1967; 201; 918-22.
19Eggersscn R. Influence on blood pressure of oestrogen substitution therapy in the menopause. Sand. J. Prim. Health. Care., 1987; 5: 51-53.

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