Hormone replacement therapy in general practice: a survey of doctors in the MRC's general practice research framework H C Wilkes, T W Meade
MRC Epidemiology and Medical Care Unit, Northwick Park Hospital, Harrow, Middlesex HAI 3UJ H C Wilkes, MSC, scientific
staff T W Meade, FRCP, director
Correspondence to: Ms Wilkes BMJ 1991;302:1317-20 BMJ
VOLUME 302
postmenopausal women using hormone replacement Abstract Objectives-To survey current prescribing prac- therapy will increase considerably over the next decade tice for hormone replacement therapy among emphasises the importance of establishing the relative general practitioners and to elicit their views on the benefits and hazards of different regimens as conclurole of hormone replacement therapy in the preven- sively as possible. The survey described here sought to tion of osteoporosis and cardiovascular disease; establish current practice in prescribing hormone to determine whether they would participate in replacement therapy among general practitioners randomised controlled trials to evaluate the long in the Medical Research Council's general practice term beneficial and adverse effects of hormone research framework, the factors that might influence their future prescribing patterns, and, in particular, replacement therapy. Design-Postal questionnaires to general practi- their willingness or otherwise to take part in randomised trials. tioners throughout the United Kingdom. Participants- 1268 general practitioners in the Medical Research Council's general practice Methods research framework. Results-1081 (85%) doctors in 220 (95%) pracThe survey was carried out at the request of an MRC tices responded. The doctors were currently ad hoc group considering the use of hormone replaceprescribing hormone replacement therapy to an ment therapy in osteoporosis. Initially, the ad hoc estimated 9% of their female patients aged 40 to group was concerned mainly with the feasibility of 64, and 55% of doctors were prescribing opposed trials to compare opposed and unopposed treatment. hormone replacement therapy (oestrogen plus pro- At a later stage general practitioners' views were also gestogen) to more patients than a year previously. sought on a trial of hormone replacement therapy Over half the doctors would consider prescribing compared with no treatment in those not requiring hormone replacement therapy for prevention of hormone replacement therapy for menopausal osteoporosis (670, 62%) and cardiovascular disease symptoms. (611, 57%) to asymptomatic women. Overall, 79% The Medical Research Council's general practice of the doctors (851) would definitely or probably research framework is a confederation of group general consider entering women who have had a hysterec- practices located throughout the United Kingdom and tomy into a randomised controlied trial comparing linked by an interest in research and collaboration unopposed (oestrogen only) hormone replacement in multicentre studies in a primary care setting. therapy with opposed hormone replacement therapy; The research framework, coordinated by the MRC 49% (524) would enter patients with a uterus into Epidemiology and Medical Care Unit, at present such a trial. Among a subsample, 85% (180/210) comprises 232 practices actively involved in a variety of would consider entering patients without meno- projects. Practices have on average 5-4 partners and list pausal symptoms into a trial comparing hormone sizes average about 11 000. This provides access to replacement therapy with no treatment (unopposed some 2-6 million people, about 4 5% of the British in patients who have had a hysterectomy, opposed in population. There is some underrepresentation of the those with a uterus). metropolitan districts, but all the Office of Population Conclusion-There is considerable uncertainty Censuses and Surveys area aggregates have at least 2% among general practitioners as to the balance of of their populations represented. In each practice one beneficial and harmful effects of hormone replace- partner, the contact doctor, liaises with the coordiment therapy in the long term, particularly relating to nating centre. its use for prevention of osteoporosis and cardioQuestionnaires were posted in November 1989 to all vascular disease. Most of these doctors would be general practitioners in the research framework. Nonprepared to participate in randomised controlled responders were sent up to three reminders. The trials to determine the long term effects of this questionnaire sought personal details and continued increasingly widely used treatment. with questions on current prescribing practice for hormone replacement therapy. There followed a summary of the risks and benefits of the treatment, the Introduction uncertainty of these estimates being emphasised. A The increasing use of hormone replacement therapy table showing estimated changes in mortality from hip for menopausal symptoms in the late 1970s was slowed fracture, endometrial cancer, breast cancer, ischaemic and then reversed with the finding that unopposed heart disease, and stroke due to both opposed and oestrogen may cause endometrial cancer.'2 Usage has unopposed hormone replacement therapy was given.4 once again increased as a result of an increase in the The doctors' views were sought on the use of hormone use of opposed hormone replacement therapy. It is, replacement therapy for prevention and their willinghowever, possible that the addition of progestogen in ness to enter asymptomatic patients into randomised opposed preparations might reduce the protective trials. A second questionnaire was sent only to the effect of unopposed oestrogen against cardiovascular contact doctors in May 1990. disease because the progestogens most widely used in Associations between categorical variables were opposed preparations have potentially adverse effects tested with the X2 distribution. All doctors in the on blood lipids.3 The likelihood that the proportion of research framework were included in the survey. 1 JUNE 1991
1317
TABLE IV-Brands of hormone replacement therapy specified as most frequently prescribed
Results CHARACTERISTICS OF DOCTORS
A total of 1267 doctors in 232 practices received the questionnaire and 1081 (85%) doctors in 220 (95%) practices replied. Table 1 shows that 809 (75%) of the responders and 150 (81%) of the non-responders were male (p= 0 1). Only 15 (7%) of the senior partners and 21 (10%) of the contact doctors were women. Nearly half (47%) of the women worked part time. CURRENT PRESCRIBING PRACTICE
Only two (0-2%, one male, one female) respondents stated that they never prescribe hormone replacement therapy to perimenopausal or postmenopausal women for the relief of menopausal symptoms. Twenty four (9%) female doctors and 117 (15%) male doctors prescribe, if indicated, only at the specific request of the patient; the remainder prescribe with or without the patient's specific request. Also, 616 (76%) male and 228 (84%) female doctors prescribe to prevent osteoporosis. Table II lists other reasons for prescribing hormone replacement therapy: 154 (14%) of doctors gave at least one other reason, notably for preventing cardiovascular disease (37% of reasons) and for women with an early menopause. The 1023 (95%) doctors who could give an estimate were treating an average of 24-6 women each (range 0-150), with female doctors (both full time and part time) treating an average of about five more women than their male colleagues. An estimated 9% of women aged 40-64 registered with these doctors are currently receiving hormone replacement therapy, but these figures remain to be validated by a search for recorded prescriptions in a sample of NHS notes. There is some TABLE I -Characteristics of doctors responding to questionnaire on hormone replacement therapy
No (%) responding No (%) working part time (
MRC Epidemiology and Medical Care Unit, Northwick Park Hospital, Harrow, Middlesex HAI 3UJ H C Wilkes, MSC, scientific
staff T W Meade, FRCP, director
Correspondence to: Ms Wilkes BMJ 1991;302:1317-20 BMJ
VOLUME 302
postmenopausal women using hormone replacement Abstract Objectives-To survey current prescribing prac- therapy will increase considerably over the next decade tice for hormone replacement therapy among emphasises the importance of establishing the relative general practitioners and to elicit their views on the benefits and hazards of different regimens as conclurole of hormone replacement therapy in the preven- sively as possible. The survey described here sought to tion of osteoporosis and cardiovascular disease; establish current practice in prescribing hormone to determine whether they would participate in replacement therapy among general practitioners randomised controlled trials to evaluate the long in the Medical Research Council's general practice term beneficial and adverse effects of hormone research framework, the factors that might influence their future prescribing patterns, and, in particular, replacement therapy. Design-Postal questionnaires to general practi- their willingness or otherwise to take part in randomised trials. tioners throughout the United Kingdom. Participants- 1268 general practitioners in the Medical Research Council's general practice Methods research framework. Results-1081 (85%) doctors in 220 (95%) pracThe survey was carried out at the request of an MRC tices responded. The doctors were currently ad hoc group considering the use of hormone replaceprescribing hormone replacement therapy to an ment therapy in osteoporosis. Initially, the ad hoc estimated 9% of their female patients aged 40 to group was concerned mainly with the feasibility of 64, and 55% of doctors were prescribing opposed trials to compare opposed and unopposed treatment. hormone replacement therapy (oestrogen plus pro- At a later stage general practitioners' views were also gestogen) to more patients than a year previously. sought on a trial of hormone replacement therapy Over half the doctors would consider prescribing compared with no treatment in those not requiring hormone replacement therapy for prevention of hormone replacement therapy for menopausal osteoporosis (670, 62%) and cardiovascular disease symptoms. (611, 57%) to asymptomatic women. Overall, 79% The Medical Research Council's general practice of the doctors (851) would definitely or probably research framework is a confederation of group general consider entering women who have had a hysterec- practices located throughout the United Kingdom and tomy into a randomised controlied trial comparing linked by an interest in research and collaboration unopposed (oestrogen only) hormone replacement in multicentre studies in a primary care setting. therapy with opposed hormone replacement therapy; The research framework, coordinated by the MRC 49% (524) would enter patients with a uterus into Epidemiology and Medical Care Unit, at present such a trial. Among a subsample, 85% (180/210) comprises 232 practices actively involved in a variety of would consider entering patients without meno- projects. Practices have on average 5-4 partners and list pausal symptoms into a trial comparing hormone sizes average about 11 000. This provides access to replacement therapy with no treatment (unopposed some 2-6 million people, about 4 5% of the British in patients who have had a hysterectomy, opposed in population. There is some underrepresentation of the those with a uterus). metropolitan districts, but all the Office of Population Conclusion-There is considerable uncertainty Censuses and Surveys area aggregates have at least 2% among general practitioners as to the balance of of their populations represented. In each practice one beneficial and harmful effects of hormone replace- partner, the contact doctor, liaises with the coordiment therapy in the long term, particularly relating to nating centre. its use for prevention of osteoporosis and cardioQuestionnaires were posted in November 1989 to all vascular disease. Most of these doctors would be general practitioners in the research framework. Nonprepared to participate in randomised controlled responders were sent up to three reminders. The trials to determine the long term effects of this questionnaire sought personal details and continued increasingly widely used treatment. with questions on current prescribing practice for hormone replacement therapy. There followed a summary of the risks and benefits of the treatment, the Introduction uncertainty of these estimates being emphasised. A The increasing use of hormone replacement therapy table showing estimated changes in mortality from hip for menopausal symptoms in the late 1970s was slowed fracture, endometrial cancer, breast cancer, ischaemic and then reversed with the finding that unopposed heart disease, and stroke due to both opposed and oestrogen may cause endometrial cancer.'2 Usage has unopposed hormone replacement therapy was given.4 once again increased as a result of an increase in the The doctors' views were sought on the use of hormone use of opposed hormone replacement therapy. It is, replacement therapy for prevention and their willinghowever, possible that the addition of progestogen in ness to enter asymptomatic patients into randomised opposed preparations might reduce the protective trials. A second questionnaire was sent only to the effect of unopposed oestrogen against cardiovascular contact doctors in May 1990. disease because the progestogens most widely used in Associations between categorical variables were opposed preparations have potentially adverse effects tested with the X2 distribution. All doctors in the on blood lipids.3 The likelihood that the proportion of research framework were included in the survey. 1 JUNE 1991
1317
TABLE IV-Brands of hormone replacement therapy specified as most frequently prescribed
Results CHARACTERISTICS OF DOCTORS
A total of 1267 doctors in 232 practices received the questionnaire and 1081 (85%) doctors in 220 (95%) practices replied. Table 1 shows that 809 (75%) of the responders and 150 (81%) of the non-responders were male (p= 0 1). Only 15 (7%) of the senior partners and 21 (10%) of the contact doctors were women. Nearly half (47%) of the women worked part time. CURRENT PRESCRIBING PRACTICE
Only two (0-2%, one male, one female) respondents stated that they never prescribe hormone replacement therapy to perimenopausal or postmenopausal women for the relief of menopausal symptoms. Twenty four (9%) female doctors and 117 (15%) male doctors prescribe, if indicated, only at the specific request of the patient; the remainder prescribe with or without the patient's specific request. Also, 616 (76%) male and 228 (84%) female doctors prescribe to prevent osteoporosis. Table II lists other reasons for prescribing hormone replacement therapy: 154 (14%) of doctors gave at least one other reason, notably for preventing cardiovascular disease (37% of reasons) and for women with an early menopause. The 1023 (95%) doctors who could give an estimate were treating an average of 24-6 women each (range 0-150), with female doctors (both full time and part time) treating an average of about five more women than their male colleagues. An estimated 9% of women aged 40-64 registered with these doctors are currently receiving hormone replacement therapy, but these figures remain to be validated by a search for recorded prescriptions in a sample of NHS notes. There is some TABLE I -Characteristics of doctors responding to questionnaire on hormone replacement therapy
No (%) responding No (%) working part time (
