European Journal of Obstetrics & Gynecology and Reproductive Biology, 45 (1992) 193-200 0 1992 Elsevier Science Publishers B.V. All rights reserved 0028-2243/92/$05.00
EUROBS
193
0136X
Determinants of hormonal replacement therapy in recently postmenopausal women Virginie Ringa ‘, Bernard Ledbert
‘, Rem5 Gueguen b, Franqoise Schiele ’
and Gerard
Breart
a
’ INSERM U 149, VillejuiJ France and ’ Centre de Midecine Prkentice Vandoeuwe-l&-Nancy, France Accepted
for publication
3 March
1992
Summary
Although the efficacy of hormonal replacement therapy (H’RT) on the consequences of the menopause is not questioned, it appears that in Europe and in the USA only a small proportion of women are users of HRT. In this study, we examined the prevalence and the determinants of HRT among 1986 French menopausal women, aged 45 to 55 years, presenting to a preventive medicine centre. Overall, 8.1% of women reported current use of HRT. The estrogen preparation most commonly reported was transcutaneous 17p-oestradiol. The first determinant of current HRT was birth-place. Women born in France were nearly four times more likely to be on treatment than foreign-born women. A surgical menopause multiplied the probability of current HRT by 2, as did a high level of education. An age at first pregnancy of more than 20 and less than 4 children were also positively linked with HRT use. Even in this population of recently menopausal women, volunteering to undergo health evaluation, the prevalence of HRT was low. The reservations towards HRT may be partly due to the women themselves, and partly due to the physicians. It seems very important to inform the medical profession about the risks and benefits of HRT, and to understand more precisely the reasons why so few women use HRT. Hormonal
replacement
therapy;
Menopause
Introduction
The efficacy of hormonal replacement therapy (HRT) on the consequences of the menopause, and especially for the prevention of osteoporotic bone loss, has been demonstrated in randomised controlled trials [1,21. This treatment is recommended to postmenopausal women to suppress climacteric symptoms such as hot flushes or vagi-
Correspondence to: Virginie Ringa, INSERM enue Paul Vaillant Couturier, 94807, Villejuif,
U 149, 16, avCLdex, France.
nal dryness [3,41. In order to prevent osteoporotic fractures, treatment should be started as soon after menopause as possible and the appropriate duration of HRT is at least 5 years. However, HRT which is not recommended to all menopausal women, is especialiy indicated for patients with a high risk of osteoporotic fractures [51. From the rare studies concerning the prevalence of hormonal therapy among postmenopausal women in Europe or in the USA, it appears that a small proportion of women are users of HRT [6-81.
194 In this study we examined, in a group of French recently postmenopausal women, the prevalence and the determinants of hormonal replacement therapy, including social, demographic and health characteristics, and especially factors reflecting a general attitude towards health.
Population and Methods Data were collected among 5266 women aged 45 to 55 years who came to the Centre for Preventive Medicine of Vandoeuvre-les-Nancy or to one of its subcentres, between January 1986 and May 1987.
The Preventive Medicine Centre of Vandoeuvre-les-Nancy is a private company in agreement with the French Social Security organisms, offering free health screening investigations. It is also a research centre, where clinical and laboratory data are recorded prospectively for each subject. People come to the centre because they have been sent an invitation for themselves and their family. This invitation is systematically sent to every member of French Social Security. The whole family initially comes for functional and biological examination and return on another day for the clinical examination and the final conclusions. At the first visit, two self-administered
TABLE I Variables used in the analysis of determinants Social-demographic
characteristics
Birth-place Number of years living in France Marital status Number of sisters and brothers Highest diploma Work status Social class Principal activity at work Principal leisure activity Dwelling residence Cigarette smoking Number of cigarettes per day Alcohol consumption Meals at regular hours Eating between meals Diet Sleeping duration
urinary and genital tracts
Perception of health concerning digestion
Appetite Recent loss of weight Slimming diet Overall perception concerning digestive system
history
Age at first pregnancy Number of full term pregnancies Number of children born alive Number of miscarriages Number of voluntary abortions Type of menopause Years since menopause of health concerning
of health concerning
Breast cyst Nipple discharge Self breast examinatlbn Satisfaction concerning sex life Overall perception concerning urinary and genital health
Lifestyle
Perception
Perception
Difficulties to urinate Nocturia Burning micturition Loss of bladder control Haematuria Treated for urinary or renal problem Treated for genital problem Regular gynaecological follow up
Age
Gynaecological
of HRT use
Perception
of health
concerning heart and circulation Treated for hypertension Treated for cardiac or circulation problem Overall perception concerning heart and circulation back and joints
Back pain Joint pain Treated for back or joints Overall perception concerning back and joints
Medications used Medical follow-up Sensation of getting older (physical/ intellectual/sexual activity) Number of days in hospital over previous year Overall perception of current health status (score from 0 to 10)
195
questionnaires, one called ‘Your life conditions’, and the other named ‘Your health conditions’ are proposed to each subject. Data used in this analysis are derived from these two questionnaires. Hormonal status was determined from the questionnaire ‘Your health conditions’. We considered to be surgically menopausal those women who no longer had menstrual periods and who answered that this was because of an operation. Naturally menopausal women were those who no longer had menstrual periods, who had not had an operation and who answered yes to the question ‘Are-you menopausal?‘. 488 women did not answer the question ‘Do-you still have your periods?‘, and 468 no longer had periods without being menopausal and without having had an operation. The hormonal status could therefore be determined for 4310 women. 1986 (46%) of these women were menopausal and were included in the analysis. During the first visit, data concerning treatments, including use of HRT, were collected by nurses from the prescriptions brought by the women. Menopausal women who were current users of HRT at the time of the questionnaire were compared with menopausal women who did not use HRT at the same period. Variables considered in the analysis are listed in Table I. They include age, social characteristics (birth-place, time spent in France if foreign-born, marital status, years of education, occupation), 1ifestyIe (residence, type of leisure activities, alcohol and tobacco use), gynaecological events (age at first pregnancy, number of miscarriages, number of full-term pregnancies), prior and current health status, and family history. In the first part of the anaIysis, we studied relationships between these individual variables and current use of HRT. We used Pearson’s Chi2 test, Fisher’s exact test, Mantel-Haenzel’s test and covariance analysis. In the second part of the analysis, variables associated with the use of HRT were simultaneously studied in a logistic model. The dependent variable was current use of HRT. All independent variables were qualitative. Ascending stepwise logistic regression was performed. The P
TABLE
II
Characteristics population
of the postmenopausal
women in the Centre’s
(n = 1986)
(%‘J
II
-
Age (years) 136 220 341 45x 532 20’)
45-46 47-48 49-50 51-52 53-54 55
Mean age (years i 1 SD)
6.X 11.1 11.2 23.1 26.X 15.1
.1.4&2.X 176X
French origin
80.1
Number of years in France (if foreign-born)
(years k
I
25.7 + 10.4
SD)
Marital status 1637
x3.7
1x55
93.4
Y83 3
49.6 0.2 0.9 1.3 Y.6 26.6
workers
16 24 176 4YO 211
retired
31
1.7
798
43.4
90
4.9
currently
married
Years of education less than bachelor degree Work farmers craftsmen,
tradesmen,
company directors executives, professionals middle executives employees
other unemployed unemployed worked
people
11.5
who have previously
Residence big town
341
17.2
country
739
37.3
suburbs
323
16.3
little town
579
2Y.2
value to enter was 0.10. Parameters were estimated by the maximum likelihood method. We used the SAS and the BMDP statistical packages. Results Among the 1986 postmenopausal women, 1112 had had a natural menopause, and 874 were surgically menopausal women. The characteristics of these 1986 women are described in Table II. Their mean age was 51.4 years, most of them were born in France and
196 TABLE III Hormonal therapy use status according to the characteristics of the women Current u*rs
OR
95% confidence interval
n
%
1289 697
7.0 10.3
1 1.5
l.l-
217 1768
3.2 8.8
1 2.9
1.3- 6.2
1840 131
7.5 16.0
1 2.3
1.4- 3.8
999 983
6.9 9.4
1 1.4
l.O- 1.9
452 1358
5.1 8.8
1 1.8
l.l-
516 1345
5.0 9.2
1 1.9
1.2- 2.9
1112 874
5.8 11.1
2.0
1895 59
8.0 15.3
2.1
l.O- 4.3
Treated for a genital problem No Yes
1596 104
7.6 17.3
1 2.5
l.5- 4.3
Regular gynaecological No Yes
739 1165
2.7 11.8
1 4.8
2.8- 7.7
Breast self-examination No Yes
734 1187
5.4 10.0
1 1.9
1.3- 2.8
Treated for hypertension Yes No
282 1649
4.6 8.7
1 2.0
l.l-
138 697 604
2.2 7.6 10.3
1 3.7 5.2
1.1-12.0 1.6-16.7
424
9.0
4.4
1.3-14.6
Ape > 50 years G 50 years
2.1
Born in France No Yes Years of education
Less than high school diploma High school diploma and higher Employed No Yes Age at first pregnancy d 20 years > 20 years
2.8
Number of children born alive
>4 l-3 Type of menopause
Natural Surgical Micturation No Yes
1
1.5- 2.8
diffkulties 1
follow-up
3.6
Frequency of medical follow-up
Never 1 or 2 times/a year 1 time/trimester 1 time/month Regularly
were currently married or living with someone. Half of them were employed at the time of the interview. Overall, 161 (8.1%) women reported current use of hormonal therapy. 51 (32%) of the current users used unopposed estrogens; 61 (38%) used estrogens combined with progestogen, and 49 (30%) used progestogen only. The estrogen preparation most commonly reported among estrogen users was transcutaneous oestradiol 17 beta (OestrogelR), used by 39 (24%) of the treated women, while 20 (12%) reported the use of oral conjugated oestrogen (PremarinR). The most frequent progestogen (15% of treated women) was dyhydrogesterone (DuphastonR), a retroprogestogen. Current users were younger and were more often born in France than non users (Table III). The proportion of current users was higher among employed women and among those with higher education. None of the characteristics concerning lifestyle was associated with use of HRT. With regard to gynaecological and obstetric history, treatment was more frequent among women who were older than 20 at their first pregnancy, and among those who had less than 4 children. Treatment was associated with the type of menopause, and was more frequent in surgically menopausal women (11% vs. 5.8%). Treatment was more frequent among women with disturbances of micturation. Use of HRT was also more frequent among women regularly followed for gynaecological problems and among those who regularly practiced self-examination of the breasts. All variables associated to HRT, except those which could be considered to be consequences of HRT (treatment for a genital problem, regular gynaecological follow-up, frequency of medical follow-up) were simultaneously tested in a logistic model. These variables were age, birth-place, years of education, work status, age at first pregnancy, number of children born alive, type of menopause. The strongest determinant of current hormonal therapy use was birth-place; women born in France were more likely to be on current treatment (Table IV) compared with women who were foreign-born (OR = 3.9; 95% confidence interval: 1.4-10.6). After birth-place, the two
TABLE
IV
Significant
determinants
of hormonal
therapy
use: multiple
logistic analysis (n = 1775, cases = 138) Determinants
Current
use versus no use
Odds ratio
9% confidence interval
French origin No
1
Yes
3.0
1.3.-10.6
Type of menopause Natural
I
Surgical
2.2
Education Less than high school diploma
I
High school diploma and higher
2. I
Age at first pregnancy < 20 years > 20 years
I
Number of children born alive 24 63
I.6
15
3.1
I.?-
3.7
l.O-
2.6
O.Y-
2.4
I 1.5
strongest determinants were type of menopause and education; current users were more often women who had undergone surgical menopause (OR = 2.2; 95% confidence interval: 1.5-3.1) and who had a higher level of education (OR = 2.1; 95% confidence interval: 1.2-3.7) compared with non users. Age at first pregnancy and number of children born alive were also determinants of current use of hormonal therapy. Discussion
The overall prevalence of hormonal replacement therapy was low (8.1%), despite the fact that the women in our sample were volunteers who are probably more health conscious than women who do not accept the invitation to have a health examination. There may be several explanations for the low prevalence in our sample. Data concerning the use of HRT were collected from the prescriptions brought by the women who were told in advance to bring their
198
prescriptions to the Centre, or to write down their current treatments. It is possible that some of the women may have forgotten to bring their prescriptions, but among these volunteers wishing to have a complete physical examination, we can expect a good level of data collection. The low prevalence of HRT use may also be explained by the characteristics of the population. We used data from the 1982 census to compare the characteristics of our sample to the ones of the general population of the Centre’s catchment areas and to the overah French population. In comparison with the population of the catchment areas, among women aged 45 to 54 years, there was an over-representation of executives, middle executives and employees, and an under-representation of workers and unemployed women in our sample. In comparison with the overall French population, there was a slight over-representation of middle executives, employees and unemployed workers, and an under-representation of executives in the Centre’s population. Overall, there was an under-representation of the active population and an over-representation of the inactive one. These comparisons did not include farmers, craftsmen and tradespeople, who depend on another insurance system than Social Security. Considering that current use of HRT is associated with being at work, the low prevalence of HRT use may be partly explained by these differences, but even among working women, the prevalence of HRT remained low (9.4%). In any case, although the type of population studied can influence the prevalence of HRT use, it cannot influence the relationships we found between the characteristics of the women and use of HRT. Another point to consider is that the prevalence of hormonal therapy should be higher among women between 45 and 55 years of age than among older women, because the most frequent reason for the introduction of hormonal replacement therapy is hot flushes [9], which often occur among peri-menopausal women, and because women take the treatment for short periods. Given that our estimate may be an under estimate of the true prevalence of HRT among
recently postmenopausal women, the overall prevalence among all postmenopausal women may be close to 8%. Although the prevalence of HRT in our population was low, our results are consistent with those of Barlow et al. [6] who found a 7% prevalence of current users of HRT in Glasgow among women between 40 and 60 years of age. Similarly Spector in Greater London reported that 10% of menopausal women with a mean age of 52 years had received hormonal replacement therapy [lo]. However higher prevalences have been reported in Denmark: 18.3% among women between 45 and 54 years of age [7], 20.2% among 51-year-old menopausal women [9]. The highest prevalence reported is 31% in Californian women between 50 and 54 years of age [81. In France, the estimation of the overall prevalence of estrogen therapy use among postmenopausal women under 65 years of age based on the sales of estrogen medications was 12% in 1990 Ill]. It is difficult to estimate from sales the proportion of women treated by progestogens as treatment of menopause is not the only indication for progestogens. In our population the prevalence of hormonal replacement therapy was higher among women with surgical menopause, which is consistent with previous reports among English, Danish, and American women [6,7,12]. However, this prevalence was low (11%) compared with the prevalences reported in these studies: 37% and 41% among Danish women [7,9], 10.7% in the hysterectomy group and 27.3% in the oophorectomy group among Glasgow women [6], 25% and 27.5% in the same groups among the population studied by Spector [lo]. We considered to be surgically menopausal those women who reported that they no longer had periods and who answered positively to the question: “Is this because of an operation?” Data obtained from the questionnaires cannot give information about the type of operation, hysterectomy with preservation of the ovaries or hysterectomy with bilateral oophorectomy. In France, the tendancy is not to systematically perform oophorectomy. If women who reported surgery still had their ovaries, this could partly explain the small proportion of current
1’)‘)
users of hormonal therapy in the group of women with surgical menopause. The relationship between hormonal replacement therapy use and years of education has been reported in previous studies [8,12]. On the other hand, we did not find any difference in marital status between current users and nonusers as reported by Cauley et al. [12]. Cigarette smoking was not associated with use of treatment, which is consistent with the American studies [8,12]. Use of HRT can be compared with other health behaviours such as use of the contraceptive pill or use of antenatal care, because, in the same way as during the climacteric period, women who use these medical services do not suffer from a real disease but are going through a specifically feminine phase of life. In a survey conducted on a representative sample of French women, contraceptive pill use was higher among women with more years of education, and antenatal care was significantly better among women of higher social class, except when they were under the age of 20 113,141. A review of the literature concerning participation in breast cancer screening reported similar results, with level of education positively associated with mammography completion [15]. In our population, HRT was more frequent among women practicing self-examinations of the breasts, among those regularly consulting for gynaecological problems, and among those regularly consulting in general. This may reflect the fact that treated women are a special type of women with an active attitude towards health care in general. Similar results were found for mammography completion and other self reported health behaviours: completion of breast screening was positively associated with regular dental checkups, use of seat belts, previous breast, cervical or faecal occult blood test screening, or chest X-rays [151. No information about prior use of contraceptive pill was available in our study, but Ferguson et al. did not find any relationship between prior use of contraceptive pill and use of HRT [161. On the other hand we cannot exclude the possibility that women consult more often be-
cause they are treated, as part of the monitoring of treatment. This could have a positive value even without considering the direct benefits of HRT, because regular follow-up leads to a better screening of genital cancer in particular. However the prevalence of HRT was low (11.8%) even among women regularly consulting for gynaecological problems. This may be related to the reservation of physicians towards the use of HRT. As a matter of fact, the low prevalence of HRT could be explained by distrust on the part of the women themselves and on the part of the physicians. Although surveys in the US have shown that fear of cancer and return of bleeding were the major reservations expressed by women [17,18], similar surveys have not been conducted in France. Physicians play a very important role as, among the factors which influence postmenopausal women in their decision to use HRT, recommendation by their physician would appear to be the most important factor [16]. A British study about doctors’ attitudes reported that among 310 general practitioners interviewed about their practices, only 7% declared that they routinely discussed the possibility of HRT with menopausal patients [19]. The risk of endometrial cancer and intensity of hot flushes were the two major determinants in the decision to prescribe HRT among American physicians [20]. Conclusion
From the study of this population of women volunteering to undergo health evaluations, it appears that most recently postmenopausal women do not use HRT. Even among those women presenting characteristics positively associated with HRT use, such as type of menopause or regular gynaecological follow-up, the prevalence of treatment was low. It seems particularly important to find out the reasons for this phenomenon, and to understand the reservations expressed by patients and by their doctors. The medical profession should be better informed about the risks and benefits of HRT, in order to discuss them with their patients.
200
Acknowledgement
This work was supported in part by La Fondation Pierre Louis WR). References 1 Jensen J, Christiansen C. Dose-response and withdrawal effects on climacteric symptoms after hormonal replacement therapy: a placebo-controlled therapeutic trial. Maturitas 1983;5:125-133. 2 Sporrong T, Hellgren M, Samsioe G, Mattsson LA. Comparison of four continuously administered progestogen plus oestradiol combinations for climacteric complaints. Br J Obstet Gynaecol 1988;95:1042-1048. 3 Judd HL, Cleary RE, Creasman WT, Figge DC, Kase N, Rosenwaks Z, Tagatz GE. Estrogen replacement therapy. Obstet Gynecol 1981;58:267-275. 4 Ettinger B. Overview of the efficacy of hormonal replacement therapy. Am J Obstet Gynecol 1987;156:1298-1303. 5 Consensus Development Conference: prophylaxis and treatment of osteoporosis. Br Med J 1987;295:914-915. 6 Barlow DH, Grosset KA, Hart H, Hart DM. A study of the experience of Glasgow women in the climacteric years. Br J Obstet Gynaecol 1989;96:1192-1197. 7 Pedersen SH, Jeune B. Prevalence of hormone replacement therapy in a sample of middle-aged women. Maturitas 7988;9:339-34.5. 8 Barret-Connor E, Wingarg DL, Criqui MH. Postmenopausal estrogen use and heart disease risks factors in the 1980s. JAMA 1989;261:2095-2100. 9 Koster A. Hormone replacement therapy: use patterns among 51-year-old Danish women. Maturitas 1990;345356.
10 Spector TD. Use of oestrogen replacement therapy in high risks groups in the United Kingdom. Br Med J 1989;299:1434-1435. 11 Jamin C. Evolution du traitement hormonal de la menopause en France, en Europe. La menopause au quotidien. Lyon 1992. 12 Cauley JA, Cummings SR, Black DM, Mascioli SR, Seeley. DG. Prevalence and determinants of estrogen replacement therapy in elderly women. Am J Obstet Gynecol 1990;163:1438-1444. 13 Breart G, Crost-Deniel M, Rumeau-Rouquette C. Contraception et surveillance de la grossesse. J Gynecol Obstet Biol Reprod 1978;7:377-385. 14 Blonde1 8, Kaminski M, Brtart G. Antenatal care and maternal demographic and social characteristics. Evolution in France between 1972 and 1976. J Epidemiol Community Health 1980;34:157-163. 15 Vernon SW, Laville EA, Jackson GL. Participation in breast screening programs: a review. Sot Sci Med 1990;30:1107-1118. 16 Ferguson KJ, Hoegh C, Johnson S. Estrogen replacement therapy: a survey of women’s knowledge and attitudes. Arch Intern Med 1989;149:133-136. 17 Wren BG, Brown L. Compliance with hormonal replacement therapy. Maturitas 1991;13:17-21. 18 Hahn RG, Nachtigall RD, Davies TC. Compliance difficulties with progestin-supplemented estrogen replacement therapy. J Fam Pratt 1984;18:411-414. 19 Bryce FC, Lilford RJ. General practitioners use of hormone-replacement therapy in Yorkshire. Eur J Obstet Gynecol 1990;37:55-61. 20 Grisso JA, Baum CR, Turner B. What do physicians in practice do to prevent osteoporosis? J Bone Min Res 1990;5:213-219.
EUROBS
193
0136X
Determinants of hormonal replacement therapy in recently postmenopausal women Virginie Ringa ‘, Bernard Ledbert
‘, Rem5 Gueguen b, Franqoise Schiele ’
and Gerard
Breart
a
’ INSERM U 149, VillejuiJ France and ’ Centre de Midecine Prkentice Vandoeuwe-l&-Nancy, France Accepted
for publication
3 March
1992
Summary
Although the efficacy of hormonal replacement therapy (H’RT) on the consequences of the menopause is not questioned, it appears that in Europe and in the USA only a small proportion of women are users of HRT. In this study, we examined the prevalence and the determinants of HRT among 1986 French menopausal women, aged 45 to 55 years, presenting to a preventive medicine centre. Overall, 8.1% of women reported current use of HRT. The estrogen preparation most commonly reported was transcutaneous 17p-oestradiol. The first determinant of current HRT was birth-place. Women born in France were nearly four times more likely to be on treatment than foreign-born women. A surgical menopause multiplied the probability of current HRT by 2, as did a high level of education. An age at first pregnancy of more than 20 and less than 4 children were also positively linked with HRT use. Even in this population of recently menopausal women, volunteering to undergo health evaluation, the prevalence of HRT was low. The reservations towards HRT may be partly due to the women themselves, and partly due to the physicians. It seems very important to inform the medical profession about the risks and benefits of HRT, and to understand more precisely the reasons why so few women use HRT. Hormonal
replacement
therapy;
Menopause
Introduction
The efficacy of hormonal replacement therapy (HRT) on the consequences of the menopause, and especially for the prevention of osteoporotic bone loss, has been demonstrated in randomised controlled trials [1,21. This treatment is recommended to postmenopausal women to suppress climacteric symptoms such as hot flushes or vagi-
Correspondence to: Virginie Ringa, INSERM enue Paul Vaillant Couturier, 94807, Villejuif,
U 149, 16, avCLdex, France.
nal dryness [3,41. In order to prevent osteoporotic fractures, treatment should be started as soon after menopause as possible and the appropriate duration of HRT is at least 5 years. However, HRT which is not recommended to all menopausal women, is especialiy indicated for patients with a high risk of osteoporotic fractures [51. From the rare studies concerning the prevalence of hormonal therapy among postmenopausal women in Europe or in the USA, it appears that a small proportion of women are users of HRT [6-81.
194 In this study we examined, in a group of French recently postmenopausal women, the prevalence and the determinants of hormonal replacement therapy, including social, demographic and health characteristics, and especially factors reflecting a general attitude towards health.
Population and Methods Data were collected among 5266 women aged 45 to 55 years who came to the Centre for Preventive Medicine of Vandoeuvre-les-Nancy or to one of its subcentres, between January 1986 and May 1987.
The Preventive Medicine Centre of Vandoeuvre-les-Nancy is a private company in agreement with the French Social Security organisms, offering free health screening investigations. It is also a research centre, where clinical and laboratory data are recorded prospectively for each subject. People come to the centre because they have been sent an invitation for themselves and their family. This invitation is systematically sent to every member of French Social Security. The whole family initially comes for functional and biological examination and return on another day for the clinical examination and the final conclusions. At the first visit, two self-administered
TABLE I Variables used in the analysis of determinants Social-demographic
characteristics
Birth-place Number of years living in France Marital status Number of sisters and brothers Highest diploma Work status Social class Principal activity at work Principal leisure activity Dwelling residence Cigarette smoking Number of cigarettes per day Alcohol consumption Meals at regular hours Eating between meals Diet Sleeping duration
urinary and genital tracts
Perception of health concerning digestion
Appetite Recent loss of weight Slimming diet Overall perception concerning digestive system
history
Age at first pregnancy Number of full term pregnancies Number of children born alive Number of miscarriages Number of voluntary abortions Type of menopause Years since menopause of health concerning
of health concerning
Breast cyst Nipple discharge Self breast examinatlbn Satisfaction concerning sex life Overall perception concerning urinary and genital health
Lifestyle
Perception
Perception
Difficulties to urinate Nocturia Burning micturition Loss of bladder control Haematuria Treated for urinary or renal problem Treated for genital problem Regular gynaecological follow up
Age
Gynaecological
of HRT use
Perception
of health
concerning heart and circulation Treated for hypertension Treated for cardiac or circulation problem Overall perception concerning heart and circulation back and joints
Back pain Joint pain Treated for back or joints Overall perception concerning back and joints
Medications used Medical follow-up Sensation of getting older (physical/ intellectual/sexual activity) Number of days in hospital over previous year Overall perception of current health status (score from 0 to 10)
195
questionnaires, one called ‘Your life conditions’, and the other named ‘Your health conditions’ are proposed to each subject. Data used in this analysis are derived from these two questionnaires. Hormonal status was determined from the questionnaire ‘Your health conditions’. We considered to be surgically menopausal those women who no longer had menstrual periods and who answered that this was because of an operation. Naturally menopausal women were those who no longer had menstrual periods, who had not had an operation and who answered yes to the question ‘Are-you menopausal?‘. 488 women did not answer the question ‘Do-you still have your periods?‘, and 468 no longer had periods without being menopausal and without having had an operation. The hormonal status could therefore be determined for 4310 women. 1986 (46%) of these women were menopausal and were included in the analysis. During the first visit, data concerning treatments, including use of HRT, were collected by nurses from the prescriptions brought by the women. Menopausal women who were current users of HRT at the time of the questionnaire were compared with menopausal women who did not use HRT at the same period. Variables considered in the analysis are listed in Table I. They include age, social characteristics (birth-place, time spent in France if foreign-born, marital status, years of education, occupation), 1ifestyIe (residence, type of leisure activities, alcohol and tobacco use), gynaecological events (age at first pregnancy, number of miscarriages, number of full-term pregnancies), prior and current health status, and family history. In the first part of the anaIysis, we studied relationships between these individual variables and current use of HRT. We used Pearson’s Chi2 test, Fisher’s exact test, Mantel-Haenzel’s test and covariance analysis. In the second part of the analysis, variables associated with the use of HRT were simultaneously studied in a logistic model. The dependent variable was current use of HRT. All independent variables were qualitative. Ascending stepwise logistic regression was performed. The P
TABLE
II
Characteristics population
of the postmenopausal
women in the Centre’s
(n = 1986)
(%‘J
II
-
Age (years) 136 220 341 45x 532 20’)
45-46 47-48 49-50 51-52 53-54 55
Mean age (years i 1 SD)
6.X 11.1 11.2 23.1 26.X 15.1
.1.4&2.X 176X
French origin
80.1
Number of years in France (if foreign-born)
(years k
I
25.7 + 10.4
SD)
Marital status 1637
x3.7
1x55
93.4
Y83 3
49.6 0.2 0.9 1.3 Y.6 26.6
workers
16 24 176 4YO 211
retired
31
1.7
798
43.4
90
4.9
currently
married
Years of education less than bachelor degree Work farmers craftsmen,
tradesmen,
company directors executives, professionals middle executives employees
other unemployed unemployed worked
people
11.5
who have previously
Residence big town
341
17.2
country
739
37.3
suburbs
323
16.3
little town
579
2Y.2
value to enter was 0.10. Parameters were estimated by the maximum likelihood method. We used the SAS and the BMDP statistical packages. Results Among the 1986 postmenopausal women, 1112 had had a natural menopause, and 874 were surgically menopausal women. The characteristics of these 1986 women are described in Table II. Their mean age was 51.4 years, most of them were born in France and
196 TABLE III Hormonal therapy use status according to the characteristics of the women Current u*rs
OR
95% confidence interval
n
%
1289 697
7.0 10.3
1 1.5
l.l-
217 1768
3.2 8.8
1 2.9
1.3- 6.2
1840 131
7.5 16.0
1 2.3
1.4- 3.8
999 983
6.9 9.4
1 1.4
l.O- 1.9
452 1358
5.1 8.8
1 1.8
l.l-
516 1345
5.0 9.2
1 1.9
1.2- 2.9
1112 874
5.8 11.1
2.0
1895 59
8.0 15.3
2.1
l.O- 4.3
Treated for a genital problem No Yes
1596 104
7.6 17.3
1 2.5
l.5- 4.3
Regular gynaecological No Yes
739 1165
2.7 11.8
1 4.8
2.8- 7.7
Breast self-examination No Yes
734 1187
5.4 10.0
1 1.9
1.3- 2.8
Treated for hypertension Yes No
282 1649
4.6 8.7
1 2.0
l.l-
138 697 604
2.2 7.6 10.3
1 3.7 5.2
1.1-12.0 1.6-16.7
424
9.0
4.4
1.3-14.6
Ape > 50 years G 50 years
2.1
Born in France No Yes Years of education
Less than high school diploma High school diploma and higher Employed No Yes Age at first pregnancy d 20 years > 20 years
2.8
Number of children born alive
>4 l-3 Type of menopause
Natural Surgical Micturation No Yes
1
1.5- 2.8
diffkulties 1
follow-up
3.6
Frequency of medical follow-up
Never 1 or 2 times/a year 1 time/trimester 1 time/month Regularly
were currently married or living with someone. Half of them were employed at the time of the interview. Overall, 161 (8.1%) women reported current use of hormonal therapy. 51 (32%) of the current users used unopposed estrogens; 61 (38%) used estrogens combined with progestogen, and 49 (30%) used progestogen only. The estrogen preparation most commonly reported among estrogen users was transcutaneous oestradiol 17 beta (OestrogelR), used by 39 (24%) of the treated women, while 20 (12%) reported the use of oral conjugated oestrogen (PremarinR). The most frequent progestogen (15% of treated women) was dyhydrogesterone (DuphastonR), a retroprogestogen. Current users were younger and were more often born in France than non users (Table III). The proportion of current users was higher among employed women and among those with higher education. None of the characteristics concerning lifestyle was associated with use of HRT. With regard to gynaecological and obstetric history, treatment was more frequent among women who were older than 20 at their first pregnancy, and among those who had less than 4 children. Treatment was associated with the type of menopause, and was more frequent in surgically menopausal women (11% vs. 5.8%). Treatment was more frequent among women with disturbances of micturation. Use of HRT was also more frequent among women regularly followed for gynaecological problems and among those who regularly practiced self-examination of the breasts. All variables associated to HRT, except those which could be considered to be consequences of HRT (treatment for a genital problem, regular gynaecological follow-up, frequency of medical follow-up) were simultaneously tested in a logistic model. These variables were age, birth-place, years of education, work status, age at first pregnancy, number of children born alive, type of menopause. The strongest determinant of current hormonal therapy use was birth-place; women born in France were more likely to be on current treatment (Table IV) compared with women who were foreign-born (OR = 3.9; 95% confidence interval: 1.4-10.6). After birth-place, the two
TABLE
IV
Significant
determinants
of hormonal
therapy
use: multiple
logistic analysis (n = 1775, cases = 138) Determinants
Current
use versus no use
Odds ratio
9% confidence interval
French origin No
1
Yes
3.0
1.3.-10.6
Type of menopause Natural
I
Surgical
2.2
Education Less than high school diploma
I
High school diploma and higher
2. I
Age at first pregnancy < 20 years > 20 years
I
Number of children born alive 24 63
I.6
15
3.1
I.?-
3.7
l.O-
2.6
O.Y-
2.4
I 1.5
strongest determinants were type of menopause and education; current users were more often women who had undergone surgical menopause (OR = 2.2; 95% confidence interval: 1.5-3.1) and who had a higher level of education (OR = 2.1; 95% confidence interval: 1.2-3.7) compared with non users. Age at first pregnancy and number of children born alive were also determinants of current use of hormonal therapy. Discussion
The overall prevalence of hormonal replacement therapy was low (8.1%), despite the fact that the women in our sample were volunteers who are probably more health conscious than women who do not accept the invitation to have a health examination. There may be several explanations for the low prevalence in our sample. Data concerning the use of HRT were collected from the prescriptions brought by the women who were told in advance to bring their
198
prescriptions to the Centre, or to write down their current treatments. It is possible that some of the women may have forgotten to bring their prescriptions, but among these volunteers wishing to have a complete physical examination, we can expect a good level of data collection. The low prevalence of HRT use may also be explained by the characteristics of the population. We used data from the 1982 census to compare the characteristics of our sample to the ones of the general population of the Centre’s catchment areas and to the overah French population. In comparison with the population of the catchment areas, among women aged 45 to 54 years, there was an over-representation of executives, middle executives and employees, and an under-representation of workers and unemployed women in our sample. In comparison with the overall French population, there was a slight over-representation of middle executives, employees and unemployed workers, and an under-representation of executives in the Centre’s population. Overall, there was an under-representation of the active population and an over-representation of the inactive one. These comparisons did not include farmers, craftsmen and tradespeople, who depend on another insurance system than Social Security. Considering that current use of HRT is associated with being at work, the low prevalence of HRT use may be partly explained by these differences, but even among working women, the prevalence of HRT remained low (9.4%). In any case, although the type of population studied can influence the prevalence of HRT use, it cannot influence the relationships we found between the characteristics of the women and use of HRT. Another point to consider is that the prevalence of hormonal therapy should be higher among women between 45 and 55 years of age than among older women, because the most frequent reason for the introduction of hormonal replacement therapy is hot flushes [9], which often occur among peri-menopausal women, and because women take the treatment for short periods. Given that our estimate may be an under estimate of the true prevalence of HRT among
recently postmenopausal women, the overall prevalence among all postmenopausal women may be close to 8%. Although the prevalence of HRT in our population was low, our results are consistent with those of Barlow et al. [6] who found a 7% prevalence of current users of HRT in Glasgow among women between 40 and 60 years of age. Similarly Spector in Greater London reported that 10% of menopausal women with a mean age of 52 years had received hormonal replacement therapy [lo]. However higher prevalences have been reported in Denmark: 18.3% among women between 45 and 54 years of age [7], 20.2% among 51-year-old menopausal women [9]. The highest prevalence reported is 31% in Californian women between 50 and 54 years of age [81. In France, the estimation of the overall prevalence of estrogen therapy use among postmenopausal women under 65 years of age based on the sales of estrogen medications was 12% in 1990 Ill]. It is difficult to estimate from sales the proportion of women treated by progestogens as treatment of menopause is not the only indication for progestogens. In our population the prevalence of hormonal replacement therapy was higher among women with surgical menopause, which is consistent with previous reports among English, Danish, and American women [6,7,12]. However, this prevalence was low (11%) compared with the prevalences reported in these studies: 37% and 41% among Danish women [7,9], 10.7% in the hysterectomy group and 27.3% in the oophorectomy group among Glasgow women [6], 25% and 27.5% in the same groups among the population studied by Spector [lo]. We considered to be surgically menopausal those women who reported that they no longer had periods and who answered positively to the question: “Is this because of an operation?” Data obtained from the questionnaires cannot give information about the type of operation, hysterectomy with preservation of the ovaries or hysterectomy with bilateral oophorectomy. In France, the tendancy is not to systematically perform oophorectomy. If women who reported surgery still had their ovaries, this could partly explain the small proportion of current
1’)‘)
users of hormonal therapy in the group of women with surgical menopause. The relationship between hormonal replacement therapy use and years of education has been reported in previous studies [8,12]. On the other hand, we did not find any difference in marital status between current users and nonusers as reported by Cauley et al. [12]. Cigarette smoking was not associated with use of treatment, which is consistent with the American studies [8,12]. Use of HRT can be compared with other health behaviours such as use of the contraceptive pill or use of antenatal care, because, in the same way as during the climacteric period, women who use these medical services do not suffer from a real disease but are going through a specifically feminine phase of life. In a survey conducted on a representative sample of French women, contraceptive pill use was higher among women with more years of education, and antenatal care was significantly better among women of higher social class, except when they were under the age of 20 113,141. A review of the literature concerning participation in breast cancer screening reported similar results, with level of education positively associated with mammography completion [15]. In our population, HRT was more frequent among women practicing self-examinations of the breasts, among those regularly consulting for gynaecological problems, and among those regularly consulting in general. This may reflect the fact that treated women are a special type of women with an active attitude towards health care in general. Similar results were found for mammography completion and other self reported health behaviours: completion of breast screening was positively associated with regular dental checkups, use of seat belts, previous breast, cervical or faecal occult blood test screening, or chest X-rays [151. No information about prior use of contraceptive pill was available in our study, but Ferguson et al. did not find any relationship between prior use of contraceptive pill and use of HRT [161. On the other hand we cannot exclude the possibility that women consult more often be-
cause they are treated, as part of the monitoring of treatment. This could have a positive value even without considering the direct benefits of HRT, because regular follow-up leads to a better screening of genital cancer in particular. However the prevalence of HRT was low (11.8%) even among women regularly consulting for gynaecological problems. This may be related to the reservation of physicians towards the use of HRT. As a matter of fact, the low prevalence of HRT could be explained by distrust on the part of the women themselves and on the part of the physicians. Although surveys in the US have shown that fear of cancer and return of bleeding were the major reservations expressed by women [17,18], similar surveys have not been conducted in France. Physicians play a very important role as, among the factors which influence postmenopausal women in their decision to use HRT, recommendation by their physician would appear to be the most important factor [16]. A British study about doctors’ attitudes reported that among 310 general practitioners interviewed about their practices, only 7% declared that they routinely discussed the possibility of HRT with menopausal patients [19]. The risk of endometrial cancer and intensity of hot flushes were the two major determinants in the decision to prescribe HRT among American physicians [20]. Conclusion
From the study of this population of women volunteering to undergo health evaluations, it appears that most recently postmenopausal women do not use HRT. Even among those women presenting characteristics positively associated with HRT use, such as type of menopause or regular gynaecological follow-up, the prevalence of treatment was low. It seems particularly important to find out the reasons for this phenomenon, and to understand the reservations expressed by patients and by their doctors. The medical profession should be better informed about the risks and benefits of HRT, in order to discuss them with their patients.
200
Acknowledgement
This work was supported in part by La Fondation Pierre Louis WR). References 1 Jensen J, Christiansen C. Dose-response and withdrawal effects on climacteric symptoms after hormonal replacement therapy: a placebo-controlled therapeutic trial. Maturitas 1983;5:125-133. 2 Sporrong T, Hellgren M, Samsioe G, Mattsson LA. Comparison of four continuously administered progestogen plus oestradiol combinations for climacteric complaints. Br J Obstet Gynaecol 1988;95:1042-1048. 3 Judd HL, Cleary RE, Creasman WT, Figge DC, Kase N, Rosenwaks Z, Tagatz GE. Estrogen replacement therapy. Obstet Gynecol 1981;58:267-275. 4 Ettinger B. Overview of the efficacy of hormonal replacement therapy. Am J Obstet Gynecol 1987;156:1298-1303. 5 Consensus Development Conference: prophylaxis and treatment of osteoporosis. Br Med J 1987;295:914-915. 6 Barlow DH, Grosset KA, Hart H, Hart DM. A study of the experience of Glasgow women in the climacteric years. Br J Obstet Gynaecol 1989;96:1192-1197. 7 Pedersen SH, Jeune B. Prevalence of hormone replacement therapy in a sample of middle-aged women. Maturitas 7988;9:339-34.5. 8 Barret-Connor E, Wingarg DL, Criqui MH. Postmenopausal estrogen use and heart disease risks factors in the 1980s. JAMA 1989;261:2095-2100. 9 Koster A. Hormone replacement therapy: use patterns among 51-year-old Danish women. Maturitas 1990;345356.
10 Spector TD. Use of oestrogen replacement therapy in high risks groups in the United Kingdom. Br Med J 1989;299:1434-1435. 11 Jamin C. Evolution du traitement hormonal de la menopause en France, en Europe. La menopause au quotidien. Lyon 1992. 12 Cauley JA, Cummings SR, Black DM, Mascioli SR, Seeley. DG. Prevalence and determinants of estrogen replacement therapy in elderly women. Am J Obstet Gynecol 1990;163:1438-1444. 13 Breart G, Crost-Deniel M, Rumeau-Rouquette C. Contraception et surveillance de la grossesse. J Gynecol Obstet Biol Reprod 1978;7:377-385. 14 Blonde1 8, Kaminski M, Brtart G. Antenatal care and maternal demographic and social characteristics. Evolution in France between 1972 and 1976. J Epidemiol Community Health 1980;34:157-163. 15 Vernon SW, Laville EA, Jackson GL. Participation in breast screening programs: a review. Sot Sci Med 1990;30:1107-1118. 16 Ferguson KJ, Hoegh C, Johnson S. Estrogen replacement therapy: a survey of women’s knowledge and attitudes. Arch Intern Med 1989;149:133-136. 17 Wren BG, Brown L. Compliance with hormonal replacement therapy. Maturitas 1991;13:17-21. 18 Hahn RG, Nachtigall RD, Davies TC. Compliance difficulties with progestin-supplemented estrogen replacement therapy. J Fam Pratt 1984;18:411-414. 19 Bryce FC, Lilford RJ. General practitioners use of hormone-replacement therapy in Yorkshire. Eur J Obstet Gynecol 1990;37:55-61. 20 Grisso JA, Baum CR, Turner B. What do physicians in practice do to prevent osteoporosis? J Bone Min Res 1990;5:213-219.
