Original Article Gynecol Obstet Invest 2015;79:40–45 DOI: 10.1159/000365172
Published online: September 25, 2014
Knowledge and Attitude towards Menopause and Hormone Replacement Therapy in Chinese Women Feng Jin a MinFang Tao a YinCheng Teng a HongFang Shao a ChangBing Li a Edward Mills b, c a
Department of Gynecology, Affiliated Sixth People’s Hospital, Shanghai Jiaotong University, Shanghai, China; Faculty of Health Sciences, University of Ottawa, Ottawa, Ont., Canada; c Stanford Prevention Research Center, Stanford University, Stanford, Calif., USA b
Abstract Objective: To explore the knowledge and prevalence of menopausal symptoms as well as the use and attitude toward hormone replacement therapy (HRT) in Chinese women. Methods: A cross-sectional study was conducted between May 2011 and April 2012 in Shanghai, China. The structured questionnaire addressing sociodemographic characteristics, knowledge and prevalence of menopausal symptoms, and knowledge and attitude towards HRT and its use were investigated. Results: 3,619 women aged 40–65 years were included in the analysis. The majority of the women had knowledge of menopause. Symptoms were prevalent in 16.1% of premenopausal women and in 49.3% of peri-, post- and surgical-menopausal women. Back and joint pain, sleeplessness, fatigue and sweating/hot flushes were frequently reported. HRT awareness among women was 3.5% and was related to menopausal, working and marital status; 75 (2.1%) women had used or were using HRT, of which 57.3% used HRT with a doctor’s prescription and 29.3% experienced side effects from the use of HRT. Conclu-
© 2014 S. Karger AG, Basel 0378–7346/14/0791–0040$39.50/0 E-Mail [email protected] www.karger.com/goi
sion: Most Chinese women had knowledge of menopause and thought menopausal symptoms should not be treated. The awareness of HRT was poor and influenced by menopausal, working and marital status. Chinese health care providers have to assume responsibility for educating women about menopause and HRT use. © 2014 S. Karger AG, Basel
Introduction
Menopause is defined as the end of menstruation and fertility, occurring 12 months after the last menstrual period [1, 2]. It typically occurs in women that have reached middle age. Bilateral oophorectomy may induce menopause at a younger age. The gradual or sudden cessation of estrogen and progesterone production by the ovaries impacts many tissues from brain to skin. Women may experience physical, emotional and urogenital symptoms that significantly affect their daily personal, professional and social lives [3, 4]. Hormone replacement therapy (HRT) has been one of the most broadly prescribed medications in recent centuries to relieve menopause symptoms [5], and has demonstrated long-term joint protection as well as slowing of cardiovascular and neurological deterioration [6–9]. MinFang Tao Department of Gynecology, Affiliated Sixth People’s Hospital Shanghai Jiaotong University, No. 600, Yi Shan Road 200233, Shanghai (China) E-Mail taomf @ hotmail.com
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Key Words Chinese women · Hormone replacement therapy · Menopause · Menopausal knowledge · Menopausal symptoms
However, the upward trend regarding HRT prescription changed course after the results of the Heart and Estrogen/Progression Replacement Study (HERS) [10] and the Women’s Health Initiative (WHI) randomized controlled trial [11] were published in 1998 and 2002, respectively. These trials found that HRT can increase the risk of invasive breast cancer, pulmonary embolism, coronary heart disease and stroke [10, 11]. After their publication, the use of HRT has decreased, in spite of new analyses of the WHI data. Recent follow-up and re-analysis of these data have found that in women aged 50–59 years, conjugated equine estrogens alone during the intervention phase were more favorable than placebo in all-cause mortality, myocardial infarction, deaths due to cancer and with regard to the global index [12–16]. In 2011, we conducted a meta-analysis looking at knowledge, perception and information in the field of HRT in women since 2002. Our findings indicate that many women still viewed HRT as favorable for climacteric symptom relief despite the potential hazard of breast cancer normally associated with its long-term use [17]. However, the majority of studies included in this review were conducted in western countries. The only study conducted in Asia had strict inclusion criteria related to education levels and background health. As such, the results of this study cannot be considered to reflect the general Chinese population [18]. This reflects a dearth of evidence on this topic with respect to Asia. Therefore, we conducted a study to explore the knowledge and prevalence of menopausal symptoms, as well as the knowledge and attitude towards HRT use in the general population of Chinese women.
pertinent items from the previously conducted meta-analysis [17]. Finally, part four collected information on previous or current HRT use, reasons for use and side effects of HRT. Two experienced interviewers conducted the survey and responded to any questions raised by the participants. Illiterate participants were offered the survey through face-to-face interviews, whereas literate participants received a self-administered survey. Menopausal status was categorized as premenopausal (defined as reporting regular menstrual cycles in the 12 months before the survey), perimenopausal (defined as climacteric transition with irregular menses), postmenopausal (defined as no menstruation 12 months prior to the survey) and surgical menopause (defined as those who had a hysterectomy with or without removal of the ovaries). Prior to study initiation, two pilot studies were initially conducted in 50 women to identify any potential problems in the question formatting. Projected enrollment was 4,000 women. This was based on the estimated 3 million women aged 40–65 years in Shanghai and the prevalence rate of menopausal symptoms (40%). On average, 10,000 persons come per day to the outpatient clinic for diagnosis, treatment and routine physical examination. A computer randomly selected 1 of every 50 eligible women according to the hospital computer registration system. This ensured the sample was representative. Statistical Analysis Continuous variables are presented as means ± SD. Categorical variables are presented as numbers (%), with statistically significant differences being calculated using the χ2 test. Multinomial logistic regression analysis was used to investigate whether sociodemographic factors affect women’s awareness of HRT. All statistical assessments were two sided and evaluated at the 0.05 level of statistical significance. Statistical analyses were performed using the StatsDirect statistical package (www.statsdirect.com; StatsDirect, Manchester, UK).
Results
This study was conducted in outpatient services of the Affiliated Sixth People’s Hospital, Shanghai Jiao Tong University, China, between May 2011 and April 2012. Women eligible for participation were required to be between 40 and 65 years of age and had normal cognitive function. Exclusion criteria were a history of psychiatric disorders or a medical condition requiring the use of serious treatments (e.g. cancer). The ethics review board of the hospital approved the study and each participant provided written informed consent prior to participation. The structured questionnaire consisted of four parts. Part one collected sociodemographic characteristics of the participant, such as age, height, weight, menarche age, education level, marital status, menopausal status, number of children and disease history. Part two collected information about the knowledge and prevalence of menopausal symptoms according to the items raised by the modified Kupperman menopause index [1]. Part three collected information about the knowledge of HRT designed according
Knowledge and Attitude towards Menopause and HRT in the Chinese
Demographics A total of 3,800 women consented to participate in the study. Of these, 3,619 completed the survey and are included in this analysis. The demographic characteristics of the 3,619 women are presented in table 1. The women ranged between 40 and 65 years of age, with a mean age of 50.5 (SD 7.6). The mean body mass index and age at menarche in the study population was 22.6 (SD 3.3) and 14.8 years (SD 1.7), respectively. Knowledge and Prevalence of Menopausal Symptoms Eleven (0.3%) women had no knowledge of menopausal symptoms; 3,429 (94.8%) and 2,483 (68.6%) women thought sweating/hot flushes and mood swings were related to menopause, respectively. Headache was less frequently thought to be related to menopause (54.5%; Gynecol Obstet Invest 2015;79:40–45 DOI: 10.1159/000365172
41
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Materials and Methods
Table 1. Description of the study participants
Table 2. Knowledge and attitude towards menopause and its prev-
alence Age 40–49 years 50–59 years 60–65 years Education level Illiteracy/primary school Middle/high school University and above Missing Occupation status Employed Unemployed Retired Other or missing Marital status Married (with partner) Single (divorced, widow) Missing Menopausal status Premenopausal Perimenopausal Postmenopausal Surgical-menopausal Missing Number of children 0 1 >1 Missing Disease history Osteoporosis Thrombosis Diabetes Hypertension Tumor
%
1,788 1,269 562
49.40 35.06 15.53
187 1,622 1,804 6
5.17 44.82 49.85 0.17
1,972 195 1,434 18
54.49 5.39 39.62 0.50
3,570 41 8
98.65 1.13 0.22
1,744 263 1,467 123 22
48.19 10.04 40.54 3.40 0.61
680 2,906 618 15
2.21 80.30 17.08 0.41
191 0 201 442 306
5.28 0 5.55 12.21 8.46
table 2). Among them, 1,981 (54.7%) women reported the source of their knowledge on menopause was from friends or colleagues, followed by media (45.4%) and health care providers (2.5%). A total of 1,215 (33.6%) women reported experiencing at least one menopausal symptom. The prevalence of symptoms was 16.1, 55.1, 49.4 and 44.7% in pre-, peri-, post- and surgical-menopausal women, respectively. Back/joint pain, sleeplessness, fatigue and sweating/hot flushes were the most frequently reported menopausal symptoms; 85.4% of symptom sufferers thought the symptoms were tolerable and should not be treated, while few (12.9%) thought the menopausal symptoms should be treated. 42
Gynecol Obstet Invest 2015;79:40–45 DOI: 10.1159/000365172
Menopausal symptoms, n (%) Sweat/hot flushes Sleeplessness Mood swings Fatigue Libido reduction Headache Depression Vaginal dryness Urinary disorder Back/joint pain Information source, n (%) Health care provider Media Friend, colleagues Others Missing Treatment of menopause, n (%) Should not be treated Should be treated Did not understand Missing
Knowledge and attitudes towards menopause (n = 3,619)
Prevalence of menopausal symptoms (n = 1,215)
3,429 (94.75) 2,279 (62.97) 2,483 (68.61) 2,227 (61.54) 2,104 (58.14) 1,972 (54.49) 2,307 (63.75) 2,143 (59.22) 2,068 (57.14) 2,299 (63.53)
614 (50.53) 675 (55.56) 529 (43.54) 609 (50.12) 464 (38.19) 348 (28.64) 257 (21.15) 232 (19.09) 330 (27.16) 697 (57.37)
91 (2.51) 1,644 (45.43) 1,981 (54.74) 47 (1.30) 7 (0.19)
64 (5.27) 614 (50.53) 605 (49.79) 32 (2.63) 6 (0.49)
3,396 (93.84) 168 (4.64) 49 (1.35) 6 (0.17)
1,038 (85.43) 157 (12.92) 18 (1.48) 2 (0.16)
Awareness of HRT HRT awareness (i.e. those who have knowledge) was reported in 126 (3.5%) women. Those who were 50–59 years old, retired, had a peri- and surgical-menopausal status with complaints of menopausal symptoms and singles were more likely to be aware of HRT. Their attitudes towards HRT are listed in figure 1. Fifty-four percent of the women thought the benefits of HRT overweigh its risks. Staying younger was considered the major positive effect of HRT, followed by climacteric symptom relief. Most of the women (73.8%) thought HRT was associated with adverse effects and more than 50% of them though HRT can cause cancer and weight gain. The majority (51.7%) reported that their HRT knowledge was from health providers, followed by media (32.5%) and friends/ colleagues (14.3%). Use of HRT Altogether, 75 (2.1%) women had ever used HRT or were taking HRT currently; 43 (57.3%) women used HRT following doctors’ prescription: 9 (12.0%) received HRT Jin/Tao/Teng/Shao/Li/Mills
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n
Information source
Negative effects of HRT
Positive effects of HRT
Attitudes towards HRT 54.0%
Benefits outweigh risks
74.6%
Keep younger
72.2%
Relieve climacteric symptoms 54.8%
Relieve atrophic vaginitis
52.4%
Prevent osteoporosis
50.8%
HRT with dif. admission route 42.9%
Prevent cardiovascular diseases
73.8%
HRT had side effects 63.5%
May cause breast cancer
57.9%
May cause uterus cancer
51.6%
May cause weight gain 34.9%
Cause vaginal bleeding 21.4%
Can be used >5 years
51.7%
Health providers 32.5%
Media 14.3%
Friends, colleagues Others
1.6% 0%
10%
20%
30%
40%
50%
60%
70%
80%
to relieve climacteric symptoms, 10 (13.3%) to improve quality of life, 7 (9.3%) to prevent osteoporosis and 4 (5.3%) to prevent cardiovascular diseases. Twenty-two (29.3%) women had experienced side effects associated with the use of HRT and 6 (8.0%) preferred to use traditional Chinese medicine instead of HRT.
Our study found that more than 90% of the Chinese women had knowledge of menopause, a majority of which came from the media and friends/colleagues. Of the peri-, post- and surgical-menopausal women, 49.6% had experienced symptoms and 85.4% thought the symptoms were tolerable and should not be treated. Compared with asymptomatic sufferers, more symptomatic suffers thought they should be treated and liked to seek the relevant knowledge from their health care providers. In general, the awareness of HRT was poor in Chinese women (3.5%). Maintaining youth was thought the major advantage of HRT, however, participants acknowledged the ad-
verse effects associated with HRT. Few Chinese women (2.1%) had used or were taking HRT currently, and more than 50% of them used HRT following physicians’ prescription. We found that the majority of the Chinese women had knowledge of menopausal symptoms, but the prevalence of symptoms was different compared with European women [19, 20] and highly educated Asian women [18]. Acknowledging that women in the study varied in ethnicity and this may explain part of the differences in knowledge [21], women that were considered highly educated were likely to acquire knowledge actively and paid more attention to their health. In our study, 85% of symptom suffers thought the symptoms were tolerable and should not be treated, which is a rate comparable to those of other studies conducted in Asian and Arabic populations [22, 23]. The prevalence of HRT awareness is 3.5% in our study population, which is in accordance with the lower range of other Asian countries (i.e. 2.0–23.5%) [21, 24] and was much lower than that in western countries [25–27]. In 126 women with HRT awareness, 74.6% of them thought
Knowledge and Attitude towards Menopause and HRT in the Chinese
Gynecol Obstet Invest 2015;79:40–45 DOI: 10.1159/000365172
Discussion
43
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Fig. 1. Attitudes towards HRT in 126 women with HRT awareness.
HRT promoted youth and climacteric symptom relief. Most Chinese women (51.7%) listed health care providers as their major information source. The reason for this may be limited HRT knowledge that could be obtained from the national public media. Language barriers also prohibited women from obtaining the latest information from international media. Instead, with Chinese social health education in communities since the 1990s, health care providers became the major source of health information as the population’s quality of life increased [28]. Currently, the results of both follow-up WHI trials and systematic reviews have further confirmed the effects of HRT. Its benefits included decreased hip fractures, diabetes and vasomotor symptoms. However, there are many risks irrespective of a woman’s age. Furthermore, primary and secondary prevention of cardiovascular disease or dementia as well as prevention of deteriorating cognitive function have not been validated in later studies [15, 29, 30]. Therefore, the new information concerning HRT education must be promoted among professionals and the general population. The low rate of HRT use found in our study (2.1%) is comparable to those of other Asian countries [14, 23]. Apart from cultural differences, the reasons were considered to be the lower prevalence and less severity of menopausal symptoms in the Asian population [23, 31]. Our prior meta-analysis estimated that 15% of women on HRT followed a physician’s prescription [17]. Our current study, however, reports 57% (95% CI: 41–77%) of Chinese women used HRT following a prescription. Un-
der such circumstances, Chinese health providers are encouraged to inform patients better regarding adverse events as well as provide a more detailed follow-up immediately after HRT is discontinued [32]. Our study was conducted exclusively in Chinese women and evaluated the knowledge and prevalence of menopause symptoms, specifically the knowledge and attitudes towards HRT. We believe our study presents a representative sample due to the method of patient selection, with no background bias related to education, income or any other demographic factors. One limitation of our analysis is the lack of reporting on symptom severity.
Conclusion
Our results indicate that most Chinese women have knowledge of menopause. The prevalence of symptoms was 50% in peri-, post- and surgical-menopausal women. Most women felt that menopausal symptoms should not be treated. Due to the low awareness of HRT and the higher medical compliance, the Chinese health providers have a responsibility to educate women regarding menopause and HRT use.
Acknowledgments We appreciate Mr. Eric Druyts’ contributions to paper editing The study was supported by Shanghai Science and Technology Commission 11411950103.
1 Cao ZY: Chinese Obstetrics and Gynecology. Beijing, People’s Medical Publishing House, 2005. 2 Prendergast A, Bwakura-Dangarembizi M, Cook A, et al: Hospitalisation for severe malnutrition amongst HIV-infected children starting antiretroviral therapy in the ARROW trial. Aids 2011;25:951–956. 3 Oldenhave A, Jaszmann LJ, Haspels AA, Everaerd WT: Impact of climacteric on wellbeing. A survey based on 5213 women 39 to 60 years old. Am J Obstet Gynecol 1993; 168: 772–780. 4 Graziottin A, Leiblum SR: Biological and psychosocial pathophysiology of female sexual dysfunction during the menopausal transition. J Sex Med 2005;2(suppl 3):133–145. 5 Keating NL, Cleary PD, Rossi AS, Zaslavsky AM, Ayanian JZ: Use of hormone replacement therapy by postmenopausal women in
44
6
7
8 9
10
the United States. Ann Intern Med 1999;130: 545–553. Hunt K, Vessey M, McPherson K: Mortality in a cohort of long-term users of hormone replacement therapy: an updated analysis. Br J Obstet Gynaecol 1990;97:1080–1086. Harlap S: The benefits and risks of hormone replacement therapy: an epidemiologic overview. Am J Obstet Gynecol 1992; 166: 1986– 1992. Mendelsohn ME, Karas RH: The protective effects of estrogen on the cardiovascular system. N Engl J Med 1999;340:1801–1811. Seo SK, Yang HI, Lim KJ, et al: Changes in serum levels of cartilage oligomeric matrix protein after estrogen and alendronate therapy in postmenopausal women. Gynecol Obstet Invest 2012;74:143–150. Hulley S, Grady D, Bush T, et al: Randomized trial of estrogen plus progestin for
Gynecol Obstet Invest 2015;79:40–45 DOI: 10.1159/000365172
secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/Progestin Replacement Study (HERS) Research Group. JAMA 1998; 280: 605–613. 11 Rossouw JE, Anderson GL, Prentice RL, et al: Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA 2002;288: 321–333. 12 Majumdar SR, Almasi EA, Stafford RS: Promotion and prescribing of hormone therapy after report of harm by the Women’s Health Initiative. JAMA 2004;292:1983–1988. 13 Kang BM, Kim MR, Park HM, et al: Attitudes of Korean clinicians to postmenopausal hormone therapy after the Women’s Health Initiative study. Menopause 2006; 13: 125–129.
Jin/Tao/Teng/Shao/Li/Mills
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References
Knowledge and Attitude towards Menopause and HRT in the Chinese
20 Buhling KJ, Daniels BV, Studnitz FS, Eulenburg C, Mueck AO: The use of complementary and alternative medicine by women transitioning through menopause in Germany: results of a survey of women aged 45–60 years. Complement Ther Med 2014;22:94–98. 21 Malik HS: Knowledge and attitude towards menopause and hormone replacement therapy (HRT) among postmenopausal women. J Pak Med Assoc 2008;58:164–167. 22 Bener A, Rizk DE, Shaheen H, Micallef R, Osman N, Dunn EV: Measurement-specific quality-of-life satisfaction during the menopause in an Arabian Gulf country. Climacteric 2000;3:43–49. 23 Kaur S, Walia I, Singh A: How menopause affects the lives of women in suburban Chandigarh, India. Climacteric 2004;7:175–180. 24 Lam PM, Leung TN, Haines C, Chung TK: Climacteric symptoms and knowledge about hormone replacement therapy among Hong Kong Chinese women aged 40–60 years. Maturitas 2003;45:99–107. 25 Strothmann A, Schneider HP: Hormone therapy: the European women’s perspective. Climacteric 2003;6:337–346.
26 Lindh-Astrand L, Brynhildsen J, Hoffmann M, Kjellgren KI, Hammar M: Knowledge of reproductive physiology and hormone therapy in 53- to 54-year-old Swedish women: a population-based study. Menopause 2007;14: 1039–1046. 27 Castelo-Branco C, Ferrer J, Palacios S, Cornago S, Peralta S: Spanish post-menopausal women’s viewpoints on hormone therapy. Maturitas 2007;56:420–428. 28 Hu Q, Li C, Tian F: Domestic Research of social health education to patients with diabetes: a systematic review. J Jishou Univ 2009; 30: 118–121. 29 Marjoribanks J, Farquhar C, Roberts H, Lethaby A: Long term hormone therapy for perimenopausal and postmenopausal women. Cochrane Database Syst Rev 2012; 7: CD004143. 30 Rozenberg S, Vandromme J, Antoine C: Postmenopausal hormone therapy: risks and benefits. Nat Rev Endocrinol 2013;9:216–227. 31 Heinemann K, Ruebig A, Potthoff P, et al: The Menopause Rating Scale (MRS) scale: a methodological review. Health Qual Life Outcomes 2004;2:45. 32 Perrone G, Capri O, Galoppi P, et al: Menopausal symptoms after the discontinuation of long-term hormone replacement therapy in women under 60: a 3-year follow-up. Gynecol Obstet Invest 2013;76:38–43.
Gynecol Obstet Invest 2015;79:40–45 DOI: 10.1159/000365172
45
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/15/2015 2:25:29 PM
14 Heinemann K, Rubig A, Strothmann A, Nahum GG, Heinemann LA: Prevalence and opinions of hormone therapy prior to the Women’s Health Initiative: a multinational survey on four continents. J Womens Health (Larchmt) 2008;17:1151–1166. 15 Manson JE, Chlebowski RT, Stefanick ML, et al: Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women’s Health Initiative randomized trials. JAMA 2013;310:1353–1368. 16 Ettinger B, Wang SM, Leslie RS, et al: Evolution of postmenopausal hormone therapy between 2002 and 2009. Menopause 2012; 19: 610–615. 17 Tao M, Teng Y, Shao H, Wu P, Mills EJ: Knowledge, perceptions and information about hormone therapy (HT) among menopausal women: a systematic review and metasynthesis. PLoS One 2011;6:e24661. 18 Huang KE, Xu L, I NN, Jaisamrarn U: The Asian Menopause Survey: knowledge, perceptions, hormone treatment and sexual function. Maturitas 2010;65:276–283. 19 Genazzani AR, Schneider HP, Panay N, Nijland EA: The European Menopause Survey 2005: women’s perceptions on the menopause and postmenopausal hormone therapy. Gynecol Endocrinol 2006;22:369–375.
Published online: September 25, 2014
Knowledge and Attitude towards Menopause and Hormone Replacement Therapy in Chinese Women Feng Jin a MinFang Tao a YinCheng Teng a HongFang Shao a ChangBing Li a Edward Mills b, c a
Department of Gynecology, Affiliated Sixth People’s Hospital, Shanghai Jiaotong University, Shanghai, China; Faculty of Health Sciences, University of Ottawa, Ottawa, Ont., Canada; c Stanford Prevention Research Center, Stanford University, Stanford, Calif., USA b
Abstract Objective: To explore the knowledge and prevalence of menopausal symptoms as well as the use and attitude toward hormone replacement therapy (HRT) in Chinese women. Methods: A cross-sectional study was conducted between May 2011 and April 2012 in Shanghai, China. The structured questionnaire addressing sociodemographic characteristics, knowledge and prevalence of menopausal symptoms, and knowledge and attitude towards HRT and its use were investigated. Results: 3,619 women aged 40–65 years were included in the analysis. The majority of the women had knowledge of menopause. Symptoms were prevalent in 16.1% of premenopausal women and in 49.3% of peri-, post- and surgical-menopausal women. Back and joint pain, sleeplessness, fatigue and sweating/hot flushes were frequently reported. HRT awareness among women was 3.5% and was related to menopausal, working and marital status; 75 (2.1%) women had used or were using HRT, of which 57.3% used HRT with a doctor’s prescription and 29.3% experienced side effects from the use of HRT. Conclu-
© 2014 S. Karger AG, Basel 0378–7346/14/0791–0040$39.50/0 E-Mail [email protected] www.karger.com/goi
sion: Most Chinese women had knowledge of menopause and thought menopausal symptoms should not be treated. The awareness of HRT was poor and influenced by menopausal, working and marital status. Chinese health care providers have to assume responsibility for educating women about menopause and HRT use. © 2014 S. Karger AG, Basel
Introduction
Menopause is defined as the end of menstruation and fertility, occurring 12 months after the last menstrual period [1, 2]. It typically occurs in women that have reached middle age. Bilateral oophorectomy may induce menopause at a younger age. The gradual or sudden cessation of estrogen and progesterone production by the ovaries impacts many tissues from brain to skin. Women may experience physical, emotional and urogenital symptoms that significantly affect their daily personal, professional and social lives [3, 4]. Hormone replacement therapy (HRT) has been one of the most broadly prescribed medications in recent centuries to relieve menopause symptoms [5], and has demonstrated long-term joint protection as well as slowing of cardiovascular and neurological deterioration [6–9]. MinFang Tao Department of Gynecology, Affiliated Sixth People’s Hospital Shanghai Jiaotong University, No. 600, Yi Shan Road 200233, Shanghai (China) E-Mail taomf @ hotmail.com
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Key Words Chinese women · Hormone replacement therapy · Menopause · Menopausal knowledge · Menopausal symptoms
However, the upward trend regarding HRT prescription changed course after the results of the Heart and Estrogen/Progression Replacement Study (HERS) [10] and the Women’s Health Initiative (WHI) randomized controlled trial [11] were published in 1998 and 2002, respectively. These trials found that HRT can increase the risk of invasive breast cancer, pulmonary embolism, coronary heart disease and stroke [10, 11]. After their publication, the use of HRT has decreased, in spite of new analyses of the WHI data. Recent follow-up and re-analysis of these data have found that in women aged 50–59 years, conjugated equine estrogens alone during the intervention phase were more favorable than placebo in all-cause mortality, myocardial infarction, deaths due to cancer and with regard to the global index [12–16]. In 2011, we conducted a meta-analysis looking at knowledge, perception and information in the field of HRT in women since 2002. Our findings indicate that many women still viewed HRT as favorable for climacteric symptom relief despite the potential hazard of breast cancer normally associated with its long-term use [17]. However, the majority of studies included in this review were conducted in western countries. The only study conducted in Asia had strict inclusion criteria related to education levels and background health. As such, the results of this study cannot be considered to reflect the general Chinese population [18]. This reflects a dearth of evidence on this topic with respect to Asia. Therefore, we conducted a study to explore the knowledge and prevalence of menopausal symptoms, as well as the knowledge and attitude towards HRT use in the general population of Chinese women.
pertinent items from the previously conducted meta-analysis [17]. Finally, part four collected information on previous or current HRT use, reasons for use and side effects of HRT. Two experienced interviewers conducted the survey and responded to any questions raised by the participants. Illiterate participants were offered the survey through face-to-face interviews, whereas literate participants received a self-administered survey. Menopausal status was categorized as premenopausal (defined as reporting regular menstrual cycles in the 12 months before the survey), perimenopausal (defined as climacteric transition with irregular menses), postmenopausal (defined as no menstruation 12 months prior to the survey) and surgical menopause (defined as those who had a hysterectomy with or without removal of the ovaries). Prior to study initiation, two pilot studies were initially conducted in 50 women to identify any potential problems in the question formatting. Projected enrollment was 4,000 women. This was based on the estimated 3 million women aged 40–65 years in Shanghai and the prevalence rate of menopausal symptoms (40%). On average, 10,000 persons come per day to the outpatient clinic for diagnosis, treatment and routine physical examination. A computer randomly selected 1 of every 50 eligible women according to the hospital computer registration system. This ensured the sample was representative. Statistical Analysis Continuous variables are presented as means ± SD. Categorical variables are presented as numbers (%), with statistically significant differences being calculated using the χ2 test. Multinomial logistic regression analysis was used to investigate whether sociodemographic factors affect women’s awareness of HRT. All statistical assessments were two sided and evaluated at the 0.05 level of statistical significance. Statistical analyses were performed using the StatsDirect statistical package (www.statsdirect.com; StatsDirect, Manchester, UK).
Results
This study was conducted in outpatient services of the Affiliated Sixth People’s Hospital, Shanghai Jiao Tong University, China, between May 2011 and April 2012. Women eligible for participation were required to be between 40 and 65 years of age and had normal cognitive function. Exclusion criteria were a history of psychiatric disorders or a medical condition requiring the use of serious treatments (e.g. cancer). The ethics review board of the hospital approved the study and each participant provided written informed consent prior to participation. The structured questionnaire consisted of four parts. Part one collected sociodemographic characteristics of the participant, such as age, height, weight, menarche age, education level, marital status, menopausal status, number of children and disease history. Part two collected information about the knowledge and prevalence of menopausal symptoms according to the items raised by the modified Kupperman menopause index [1]. Part three collected information about the knowledge of HRT designed according
Knowledge and Attitude towards Menopause and HRT in the Chinese
Demographics A total of 3,800 women consented to participate in the study. Of these, 3,619 completed the survey and are included in this analysis. The demographic characteristics of the 3,619 women are presented in table 1. The women ranged between 40 and 65 years of age, with a mean age of 50.5 (SD 7.6). The mean body mass index and age at menarche in the study population was 22.6 (SD 3.3) and 14.8 years (SD 1.7), respectively. Knowledge and Prevalence of Menopausal Symptoms Eleven (0.3%) women had no knowledge of menopausal symptoms; 3,429 (94.8%) and 2,483 (68.6%) women thought sweating/hot flushes and mood swings were related to menopause, respectively. Headache was less frequently thought to be related to menopause (54.5%; Gynecol Obstet Invest 2015;79:40–45 DOI: 10.1159/000365172
41
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Materials and Methods
Table 1. Description of the study participants
Table 2. Knowledge and attitude towards menopause and its prev-
alence Age 40–49 years 50–59 years 60–65 years Education level Illiteracy/primary school Middle/high school University and above Missing Occupation status Employed Unemployed Retired Other or missing Marital status Married (with partner) Single (divorced, widow) Missing Menopausal status Premenopausal Perimenopausal Postmenopausal Surgical-menopausal Missing Number of children 0 1 >1 Missing Disease history Osteoporosis Thrombosis Diabetes Hypertension Tumor
%
1,788 1,269 562
49.40 35.06 15.53
187 1,622 1,804 6
5.17 44.82 49.85 0.17
1,972 195 1,434 18
54.49 5.39 39.62 0.50
3,570 41 8
98.65 1.13 0.22
1,744 263 1,467 123 22
48.19 10.04 40.54 3.40 0.61
680 2,906 618 15
2.21 80.30 17.08 0.41
191 0 201 442 306
5.28 0 5.55 12.21 8.46
table 2). Among them, 1,981 (54.7%) women reported the source of their knowledge on menopause was from friends or colleagues, followed by media (45.4%) and health care providers (2.5%). A total of 1,215 (33.6%) women reported experiencing at least one menopausal symptom. The prevalence of symptoms was 16.1, 55.1, 49.4 and 44.7% in pre-, peri-, post- and surgical-menopausal women, respectively. Back/joint pain, sleeplessness, fatigue and sweating/hot flushes were the most frequently reported menopausal symptoms; 85.4% of symptom sufferers thought the symptoms were tolerable and should not be treated, while few (12.9%) thought the menopausal symptoms should be treated. 42
Gynecol Obstet Invest 2015;79:40–45 DOI: 10.1159/000365172
Menopausal symptoms, n (%) Sweat/hot flushes Sleeplessness Mood swings Fatigue Libido reduction Headache Depression Vaginal dryness Urinary disorder Back/joint pain Information source, n (%) Health care provider Media Friend, colleagues Others Missing Treatment of menopause, n (%) Should not be treated Should be treated Did not understand Missing
Knowledge and attitudes towards menopause (n = 3,619)
Prevalence of menopausal symptoms (n = 1,215)
3,429 (94.75) 2,279 (62.97) 2,483 (68.61) 2,227 (61.54) 2,104 (58.14) 1,972 (54.49) 2,307 (63.75) 2,143 (59.22) 2,068 (57.14) 2,299 (63.53)
614 (50.53) 675 (55.56) 529 (43.54) 609 (50.12) 464 (38.19) 348 (28.64) 257 (21.15) 232 (19.09) 330 (27.16) 697 (57.37)
91 (2.51) 1,644 (45.43) 1,981 (54.74) 47 (1.30) 7 (0.19)
64 (5.27) 614 (50.53) 605 (49.79) 32 (2.63) 6 (0.49)
3,396 (93.84) 168 (4.64) 49 (1.35) 6 (0.17)
1,038 (85.43) 157 (12.92) 18 (1.48) 2 (0.16)
Awareness of HRT HRT awareness (i.e. those who have knowledge) was reported in 126 (3.5%) women. Those who were 50–59 years old, retired, had a peri- and surgical-menopausal status with complaints of menopausal symptoms and singles were more likely to be aware of HRT. Their attitudes towards HRT are listed in figure 1. Fifty-four percent of the women thought the benefits of HRT overweigh its risks. Staying younger was considered the major positive effect of HRT, followed by climacteric symptom relief. Most of the women (73.8%) thought HRT was associated with adverse effects and more than 50% of them though HRT can cause cancer and weight gain. The majority (51.7%) reported that their HRT knowledge was from health providers, followed by media (32.5%) and friends/ colleagues (14.3%). Use of HRT Altogether, 75 (2.1%) women had ever used HRT or were taking HRT currently; 43 (57.3%) women used HRT following doctors’ prescription: 9 (12.0%) received HRT Jin/Tao/Teng/Shao/Li/Mills
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n
Information source
Negative effects of HRT
Positive effects of HRT
Attitudes towards HRT 54.0%
Benefits outweigh risks
74.6%
Keep younger
72.2%
Relieve climacteric symptoms 54.8%
Relieve atrophic vaginitis
52.4%
Prevent osteoporosis
50.8%
HRT with dif. admission route 42.9%
Prevent cardiovascular diseases
73.8%
HRT had side effects 63.5%
May cause breast cancer
57.9%
May cause uterus cancer
51.6%
May cause weight gain 34.9%
Cause vaginal bleeding 21.4%
Can be used >5 years
51.7%
Health providers 32.5%
Media 14.3%
Friends, colleagues Others
1.6% 0%
10%
20%
30%
40%
50%
60%
70%
80%
to relieve climacteric symptoms, 10 (13.3%) to improve quality of life, 7 (9.3%) to prevent osteoporosis and 4 (5.3%) to prevent cardiovascular diseases. Twenty-two (29.3%) women had experienced side effects associated with the use of HRT and 6 (8.0%) preferred to use traditional Chinese medicine instead of HRT.
Our study found that more than 90% of the Chinese women had knowledge of menopause, a majority of which came from the media and friends/colleagues. Of the peri-, post- and surgical-menopausal women, 49.6% had experienced symptoms and 85.4% thought the symptoms were tolerable and should not be treated. Compared with asymptomatic sufferers, more symptomatic suffers thought they should be treated and liked to seek the relevant knowledge from their health care providers. In general, the awareness of HRT was poor in Chinese women (3.5%). Maintaining youth was thought the major advantage of HRT, however, participants acknowledged the ad-
verse effects associated with HRT. Few Chinese women (2.1%) had used or were taking HRT currently, and more than 50% of them used HRT following physicians’ prescription. We found that the majority of the Chinese women had knowledge of menopausal symptoms, but the prevalence of symptoms was different compared with European women [19, 20] and highly educated Asian women [18]. Acknowledging that women in the study varied in ethnicity and this may explain part of the differences in knowledge [21], women that were considered highly educated were likely to acquire knowledge actively and paid more attention to their health. In our study, 85% of symptom suffers thought the symptoms were tolerable and should not be treated, which is a rate comparable to those of other studies conducted in Asian and Arabic populations [22, 23]. The prevalence of HRT awareness is 3.5% in our study population, which is in accordance with the lower range of other Asian countries (i.e. 2.0–23.5%) [21, 24] and was much lower than that in western countries [25–27]. In 126 women with HRT awareness, 74.6% of them thought
Knowledge and Attitude towards Menopause and HRT in the Chinese
Gynecol Obstet Invest 2015;79:40–45 DOI: 10.1159/000365172
Discussion
43
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Fig. 1. Attitudes towards HRT in 126 women with HRT awareness.
HRT promoted youth and climacteric symptom relief. Most Chinese women (51.7%) listed health care providers as their major information source. The reason for this may be limited HRT knowledge that could be obtained from the national public media. Language barriers also prohibited women from obtaining the latest information from international media. Instead, with Chinese social health education in communities since the 1990s, health care providers became the major source of health information as the population’s quality of life increased [28]. Currently, the results of both follow-up WHI trials and systematic reviews have further confirmed the effects of HRT. Its benefits included decreased hip fractures, diabetes and vasomotor symptoms. However, there are many risks irrespective of a woman’s age. Furthermore, primary and secondary prevention of cardiovascular disease or dementia as well as prevention of deteriorating cognitive function have not been validated in later studies [15, 29, 30]. Therefore, the new information concerning HRT education must be promoted among professionals and the general population. The low rate of HRT use found in our study (2.1%) is comparable to those of other Asian countries [14, 23]. Apart from cultural differences, the reasons were considered to be the lower prevalence and less severity of menopausal symptoms in the Asian population [23, 31]. Our prior meta-analysis estimated that 15% of women on HRT followed a physician’s prescription [17]. Our current study, however, reports 57% (95% CI: 41–77%) of Chinese women used HRT following a prescription. Un-
der such circumstances, Chinese health providers are encouraged to inform patients better regarding adverse events as well as provide a more detailed follow-up immediately after HRT is discontinued [32]. Our study was conducted exclusively in Chinese women and evaluated the knowledge and prevalence of menopause symptoms, specifically the knowledge and attitudes towards HRT. We believe our study presents a representative sample due to the method of patient selection, with no background bias related to education, income or any other demographic factors. One limitation of our analysis is the lack of reporting on symptom severity.
Conclusion
Our results indicate that most Chinese women have knowledge of menopause. The prevalence of symptoms was 50% in peri-, post- and surgical-menopausal women. Most women felt that menopausal symptoms should not be treated. Due to the low awareness of HRT and the higher medical compliance, the Chinese health providers have a responsibility to educate women regarding menopause and HRT use.
Acknowledgments We appreciate Mr. Eric Druyts’ contributions to paper editing The study was supported by Shanghai Science and Technology Commission 11411950103.
1 Cao ZY: Chinese Obstetrics and Gynecology. Beijing, People’s Medical Publishing House, 2005. 2 Prendergast A, Bwakura-Dangarembizi M, Cook A, et al: Hospitalisation for severe malnutrition amongst HIV-infected children starting antiretroviral therapy in the ARROW trial. Aids 2011;25:951–956. 3 Oldenhave A, Jaszmann LJ, Haspels AA, Everaerd WT: Impact of climacteric on wellbeing. A survey based on 5213 women 39 to 60 years old. Am J Obstet Gynecol 1993; 168: 772–780. 4 Graziottin A, Leiblum SR: Biological and psychosocial pathophysiology of female sexual dysfunction during the menopausal transition. J Sex Med 2005;2(suppl 3):133–145. 5 Keating NL, Cleary PD, Rossi AS, Zaslavsky AM, Ayanian JZ: Use of hormone replacement therapy by postmenopausal women in
44
6
7
8 9
10
the United States. Ann Intern Med 1999;130: 545–553. Hunt K, Vessey M, McPherson K: Mortality in a cohort of long-term users of hormone replacement therapy: an updated analysis. Br J Obstet Gynaecol 1990;97:1080–1086. Harlap S: The benefits and risks of hormone replacement therapy: an epidemiologic overview. Am J Obstet Gynecol 1992; 166: 1986– 1992. Mendelsohn ME, Karas RH: The protective effects of estrogen on the cardiovascular system. N Engl J Med 1999;340:1801–1811. Seo SK, Yang HI, Lim KJ, et al: Changes in serum levels of cartilage oligomeric matrix protein after estrogen and alendronate therapy in postmenopausal women. Gynecol Obstet Invest 2012;74:143–150. Hulley S, Grady D, Bush T, et al: Randomized trial of estrogen plus progestin for
Gynecol Obstet Invest 2015;79:40–45 DOI: 10.1159/000365172
secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/Progestin Replacement Study (HERS) Research Group. JAMA 1998; 280: 605–613. 11 Rossouw JE, Anderson GL, Prentice RL, et al: Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA 2002;288: 321–333. 12 Majumdar SR, Almasi EA, Stafford RS: Promotion and prescribing of hormone therapy after report of harm by the Women’s Health Initiative. JAMA 2004;292:1983–1988. 13 Kang BM, Kim MR, Park HM, et al: Attitudes of Korean clinicians to postmenopausal hormone therapy after the Women’s Health Initiative study. Menopause 2006; 13: 125–129.
Jin/Tao/Teng/Shao/Li/Mills
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/15/2015 2:25:29 PM
References
Knowledge and Attitude towards Menopause and HRT in the Chinese
20 Buhling KJ, Daniels BV, Studnitz FS, Eulenburg C, Mueck AO: The use of complementary and alternative medicine by women transitioning through menopause in Germany: results of a survey of women aged 45–60 years. Complement Ther Med 2014;22:94–98. 21 Malik HS: Knowledge and attitude towards menopause and hormone replacement therapy (HRT) among postmenopausal women. J Pak Med Assoc 2008;58:164–167. 22 Bener A, Rizk DE, Shaheen H, Micallef R, Osman N, Dunn EV: Measurement-specific quality-of-life satisfaction during the menopause in an Arabian Gulf country. Climacteric 2000;3:43–49. 23 Kaur S, Walia I, Singh A: How menopause affects the lives of women in suburban Chandigarh, India. Climacteric 2004;7:175–180. 24 Lam PM, Leung TN, Haines C, Chung TK: Climacteric symptoms and knowledge about hormone replacement therapy among Hong Kong Chinese women aged 40–60 years. Maturitas 2003;45:99–107. 25 Strothmann A, Schneider HP: Hormone therapy: the European women’s perspective. Climacteric 2003;6:337–346.
26 Lindh-Astrand L, Brynhildsen J, Hoffmann M, Kjellgren KI, Hammar M: Knowledge of reproductive physiology and hormone therapy in 53- to 54-year-old Swedish women: a population-based study. Menopause 2007;14: 1039–1046. 27 Castelo-Branco C, Ferrer J, Palacios S, Cornago S, Peralta S: Spanish post-menopausal women’s viewpoints on hormone therapy. Maturitas 2007;56:420–428. 28 Hu Q, Li C, Tian F: Domestic Research of social health education to patients with diabetes: a systematic review. J Jishou Univ 2009; 30: 118–121. 29 Marjoribanks J, Farquhar C, Roberts H, Lethaby A: Long term hormone therapy for perimenopausal and postmenopausal women. Cochrane Database Syst Rev 2012; 7: CD004143. 30 Rozenberg S, Vandromme J, Antoine C: Postmenopausal hormone therapy: risks and benefits. Nat Rev Endocrinol 2013;9:216–227. 31 Heinemann K, Ruebig A, Potthoff P, et al: The Menopause Rating Scale (MRS) scale: a methodological review. Health Qual Life Outcomes 2004;2:45. 32 Perrone G, Capri O, Galoppi P, et al: Menopausal symptoms after the discontinuation of long-term hormone replacement therapy in women under 60: a 3-year follow-up. Gynecol Obstet Invest 2013;76:38–43.
Gynecol Obstet Invest 2015;79:40–45 DOI: 10.1159/000365172
45
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/15/2015 2:25:29 PM
14 Heinemann K, Rubig A, Strothmann A, Nahum GG, Heinemann LA: Prevalence and opinions of hormone therapy prior to the Women’s Health Initiative: a multinational survey on four continents. J Womens Health (Larchmt) 2008;17:1151–1166. 15 Manson JE, Chlebowski RT, Stefanick ML, et al: Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women’s Health Initiative randomized trials. JAMA 2013;310:1353–1368. 16 Ettinger B, Wang SM, Leslie RS, et al: Evolution of postmenopausal hormone therapy between 2002 and 2009. Menopause 2012; 19: 610–615. 17 Tao M, Teng Y, Shao H, Wu P, Mills EJ: Knowledge, perceptions and information about hormone therapy (HT) among menopausal women: a systematic review and metasynthesis. PLoS One 2011;6:e24661. 18 Huang KE, Xu L, I NN, Jaisamrarn U: The Asian Menopause Survey: knowledge, perceptions, hormone treatment and sexual function. Maturitas 2010;65:276–283. 19 Genazzani AR, Schneider HP, Panay N, Nijland EA: The European Menopause Survey 2005: women’s perceptions on the menopause and postmenopausal hormone therapy. Gynecol Endocrinol 2006;22:369–375.
