Menopause: The Journal of The North American Menopause Society Vol. 21, No. 11, pp. 1190/1196 DOI: 10.1097/gme.0000000000000233 * 2014 by The North American Menopause Society
Knowledge and personal use of menopausal hormone therapy among Chinese obstetrician-gynecologists: results of a survey Yanjie Wang, MD,1 Xin Yang, MD,1 Xiaodong Li, MD,2 Xiaojing He, MD,2 and Yang Zhao, MD1 Abstract Objective: Obstetrician-gynecologists’ (ob-gyns) knowledge of the benefits and risks ofVand attitude towardVmenopausal hormone therapy (HT) have evolved since the publication of the Heart and Estrogen/progestin Replacement Study and the Women’s Health Initiative. The survey investigated Chinese ob-gyns’ perception and personal use ofVand attitude towardVHT. Methods: A total of 2,000 self-administered questionnaires were sent to female ob-gyns who attended gynecological endocrinology workshops in 15 provinces and cities in China from February to May 2013. Results: A total of 904 eligible questionnaires were collected (response rate, 45.2%). Most of the respondents knew that HT could relieve menopausal symptoms (97.7%) and prevent osteoporosis (93.5%). Most (69.4%) of the respondents thought that HT would increase the risk of breast cancer, and 52.9% thought that HT would increase the risk of endometrial cancer. The most common concern regarding adverse effects of HT was risk of breast cancer, followed by risk of endometrial cancer, risk of venous thrombosis, and weight gain. One hundred twenty-three of 324 symptomatic respondents (38.0%) reported HT use, and a further 28 respondents (8.6%) had tried transdermal and vaginal estrogen creams. Conclusions: These findings show better knowledge of HT among Chinese ob-gyns compared with the general Chinese population. However, HT use is relatively low, and ob-gyns seem to be overconcerned with the risks of HT. HT education must be promoted among Chinese ob-gyns to enhance the proper use of HT in the general population. Key Words: Hormone therapy Y Knowledge and attitude Y Obstetricians and gynecologists Y Personal use.
M
enopausal hormone therapy (HT) is the most effective treatment of menopausal symptoms and is beneficial for the prevention of long-term complications.1 HT use in the Chinese population remains low, especially since the release of the Heart and Estrogen/progestin Replacement Study and Women’s Health Initiative (WHI) findings.2,3 A study published in 2008 showed that ever and current HT use in Guangdong province was 0.8% and 1.3%, respectively4; another study published in 2008 showed that the current rate of HT use among perimenopausal women in Beijing was 1.4%.5 A study (conducted in 2006 and published in 2012) of HT knowledge and use in Asian countries showed that the hot flash rate among postmenopausal women in China was 57.0%; the previous rate of HT use in Chinese postmenopausal women was only 9%, and the current rate of HT use is Received December 1, 2013; revised and accepted February 12, 2014. From the 1Department of Obstetrics and Gynecology, Peking University People’s Hospital, Beijing, China; and 2Department of Obstetrics and Gynecology, The Second Hospital of Hebei Medical University, Hebei Province, China. Funding/support: This study was supported by the China Key Project BNational twelfth 5-year plan for science and technology support: evaluation of reproductive health and menopausal health condition[ (project no. 2012 BAI32B00). Financial disclosure/conflicts of interest: None reported. Address correspondence to: Xin Yang, MD, Department of Obstetrics and Gynecology, Peking University People’s Hospital, Xicheng District, Beijing, China. E-mail: [email protected]
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2%.6 Many other studies were conducted to investigate the general Chinese population’s perception and use of HT, but very few studies have assessed knowledge, attitude, and menopausal health needs from the perspective of Chinese female obstetrician-gynecologists (ob-gyns). Ten years have passed since the publication of the Heart and Estrogen/progestin Replacement Study and the WHI, and ob-gyns’ views have evolved with ongoing debates regarding the interpretation of the results. How ob-gyns assess the merits and risks of HT and how they advise women about HT use are important public issues. Therefore, we conducted a survey on knowledge and personal use of HT among Chinese ob-gyns to provide current insights into their perception of and attitude toward HT. METHODS The survey was approved by the Clinical Research Ethics Committee of the Peking University People’s Hospital (Beijing, China). The Endocrinology Committee of the Chinese Medical Doctor Association held gynecological endocrinology workshops from February to May 2013 in 15 provinces and cities in China. Before the workshops began, female ob-gyns attending the workshops were invited to voluntarily complete questionnaires that were distributed on the spot. The questionnaire included questions on general information (eg, age, marital status, cities or areas of origination, hospital grade, and clinical specialty), health condition (eg,
Menopause, Vol. 21, No. 11, 2014
Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
MENOPAUSAL HORMONE THERAPY IN CHINESE OB-GYNS
parity, menstruation status, contraception choices, and history of clinical confirmed diseases), and knowledge of and attitude toward HT (eg, necessity, appropriate time for HT use, and risks and benefits of combined estrogen-progestin therapy). The modified Kupperman Menopausal Index was used to evaluate the severity of menopausal symptoms in ob-gyns who presented with menstruation changes and climacteric symptoms. Supplemental questions (primarily multiplechoice questions) regarding the most bothersome symptoms, examinations and treatments sought, concerns regarding the adverse effects of combined estrogen-progestin therapy, and reasons for nonuse (or cessation) of HT were added to further assess ob-gyns’ personal HT use and their attitude toward HT. Statistics Data were entered and analyzed using SPSS Statistics version 19.0. Implausible answers and obvious coding errors were screened and corrected by reviewing the original survey. Questionnaires with more than 20% of the critical answers missing were considered invalid and were excluded from the study. Categorical data are presented as n (%), and continuous data are presented as mean (SD). W2 test was used to compare categorical data; continuity correction was used when categorical variables had expected numbers between 1 and 5; and Fisher exact test was used when expected numbers were less than 1. Differences between respondents were examined based on specialty (ie, gynecological endocrinology and nongynecological endocrinology). P G 0.05 was considered statistically significant, and P G 0.01 was considered highly statistically significant. RESULTS A total of 2,000 questionnaires were distributed, and 904 of the 1,027 returned questionnaires were eligible (response rate, 45.2%). Table 1 summarizes participants’ general information and health condition. Participants’ age varied from 22 to 76 years, with a mean (SD) age of 40.0 (9.2) years. Most participants were married/cohabiting (98.8%) and parous (83.6%). As for the current choice of contraception (including contraception used before menopause), 311 (34.4%) reported intrauterine devices, and 7 (0.7%) used the levonorgestrel intrauterine system. Thirty (3.3%) participants were taking oral contraceptives, 57 (6.3%) used condoms all the time, 191 (21.1%) used condoms plus the rhythm method, and 33 (3.7%) used condoms plus external contraceptives. Three (0.3%) participants had undergone sterilization: 2 (0.2%) underwent tubal sterilization and 1 (0.1%) had vasectomy. A total of 145 participants did not use contraception because of absence of menstruation due to breast-feeding, hysterectomy, and menopause. Most participants were generally healthy, but 58 (6.4%) reported hyperlipidemia, 32 (3.5%) reported cardiovascular diseases, 14 (1.5%) reported diabetes mellitus, 25 (2.8%) reported low bone density or osteoporosis, and 5 (0.6%) reported thyroid dysfunction. Among all of the ob-gyns, 48 (5.3%) were from grade 1 hospitals (ie, primary hospitals providing basic health care in
TABLE 1. General characteristics of respondents (N = 904) Characteristics
n (%)
Age 22-29 y 30-39 y 40-49 y 50-59 y Q60 y Missing Marital status Married/cohabiting Single Missing Parity Parous Nulliparous Missing Current choice of contraception Intrauterine device Levonorgestrel intrauterine system Oral contraceptives Condom alone Condom + rhythm method Condom + external contraceptives External contraceptives Withdrawal (coitus interruptus) Tubal sterilization Vasectomy Unmarried and no sexual activities No menstruation (including breast-feeding, hysterectomy, and menopause) Without contraception Missing History of clinical confirmed diseasesa Hyperlipidemia Cardiovascular diseases Diabetes mellitus Low bone density/osteoporosis Hyperthyroidism/hypothyroidism Hospital grade 1 2 3 Missing Clinical specialty Gynecological endocrinology Nongynecological endocrinology Gynecology Obstetrics Obstetrics-gynecology Missing a Multiple-choice questions.
108 (11.9) 310 (34.3) 324 (35.8) 122 (13.5) 19 (2.1) 21 (2.3) 893 (98.8) 11 (1.2) 0 (0) 756 (83.6) 148 (16.4) 0 (0) 311 (34.4) 7 (0.7) 30 (3.3) 57 (6.3) 191 (21.1) 33 (3.7) 42 (4.6) 45 (5.0) 2 (0.2) 1 (0.1) 11 (1.2) 145 (16.0) 27 (3.0) 2 (0.2) 58 (6.4) 32 (3.5) 14 (1.5) 25 (2.8) 5 (0.6) 48 (5.3) 335 (37.0) 413 (45.7) 108 (12.0) 63 (7.0) 358 (39.6) 62 (6.9) 332 (36.7) 89 (9.8)
communities), 335 (37.0%) were from grade 2 hospitals (ie, secondary hospitals affiliated with a medium-size city or district), and 413 (45.7%) were from grade 3 hospitals (ie, comprehensive or general hospitals providing specialist health services, medical education, and scientific studies). A total of 63 (7.0%) ob-gyns specialized in gynecological endocrinology. Among nongynecological endocrinologists, 358 (39.6%) specialized in gynecology, 62 (6.9%) specialized in obstetrics, and 332 (36.7%) specialized in obstetrics-gynecology. A total of 89 (9.8%) ob-gyns gave no answer to specialty. Among the 904 participants, 363 (40.2%) thought that HT was Bvery necessary,[ 506 (56.0%) thought that HT was Bnecessary,[ and only 34 (3.8%) thought that it was Bunnecessary.[ One obgyn did not answer. Most ob-gyns (879; 97.2%) thought that HT should start when menopausal symptoms emerge. Menopause, Vol. 21, No. 11, 2014
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WANG ET AL TABLE 2. Perceived benefits and risks of combined estrogen-progestin therapy stratified by menopause status and specialty Specialty
Benefits of hormone therapy Relief of menopausal symptoms Prevention of osteoporosis Reduction of colon cancer risk Potential risks of hormone therapy Venous thrombosis Cerebral infarctions Breast cancer Endometrial cancer Data are presented as n (%).
Total (N = 904)
Gynecological endocrinology (n = 63)
Nongynecological endocrinology (n = 752)
Unknown (n = 89)
W2
P
883 (97.7) 845 (93.5) 238 (26.3)
61 (98.8) 59 (93.7) 27 (42.9)
734 (97.6) 702 (93.4) 193 (25.7)
88 (98.7) 84 (94.4) 18 (20.2)
0.722 0.000 8.718
0.395 1.000 0.003
494 (54.6) 280 (31.0) 627 (69.4) 478 (52.9)
36 (57.1) 20 (31.7) 42 (66.7) 25 (39.7)
411 (54.7) 229 (30.5) 522 (69.4) 406 (54.0)
47 (52.8) 31 (34.8) 63 (70.8) 47 (52.8)
0.145 0.046 0.206 4.775
0.703 0.830 0.650 0.029
A series of true-false questions was designed to study obgyns’ perception of the pros and cons of HT. Table 2 summarizes the answers. Most respondents reported that HT had positive effects on menopausal symptoms (883; 97.7%) and osteoporosis (845; 93.5%). However, only 26.3% of all respondents were certain of the protective role of HT against colon cancer. Gynecological endocrinologists had significantly better knowledge of this issue than did nongynecological endocrinologists (42.9% vs 25.7%, P = 0.003). More than half of the participants were alert to potentially increased risks of cancer attributable to HT. A total of 69.4% thought that combined estrogen-progestin therapy would increase the risk of breast cancer, and 52.9% thought that HT would increase the risk of endometrial cancer. The difference between gynecological endocrinologists and nongynecological endocrinologists was significant (39.7% vs 54.0%, P = 0.029). Approximately half (54.6%) of the respondents were aware of the increased risk of venous thrombosis, and 31.0% confirmed negative effects of HT on cerebral infarction. Among the 904 respondents, 446 were aged 40 to 59 years. In this group, 324 (35.8% of all respondents) reported more than two consecutive menstrual cycle length changes greater
TABLE 3. Prevalence of menopausal symptoms as measured by the modified Kupperman index Variables
n (%)
Mood swings Insomnia Fatigue Muscle/joint pain Sexual problems Hot flashes Palpitations Melancholia Vertigo Headache Urinary problems Paresthesia Formication
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184 (56.8) 171 (52.8) 170 (52.5) 136 (42.0) 135 (41.7) 128 (39.5) 119 (36.7) 113 (34.9) 110 (34.0) 106 (32.7) 74 (22.8) 68 (21.0) 50 (15.4)
than 7 days and presented with climacteric symptoms. Their climacteric symptoms, evaluated by the modified Kupperman Menopausal Index, are presented in Table 3. Memory loss was the most bothersome aspect of perimenopause in 54.0% of the participants. The second most frequently reported complaint was hot flashes (31.2%). Other disturbances included menstrual disorders (14.8%), cardiovascular symptoms (10.2%), and urogenital discomfort (9.3%). A total of 215 (66.4%) participants had undergone some type of examination. Serum hormone levels were examined in 108 (33.3%) participants, and bone density was tested in 70 (21.6%) participants. Other tests included pelvic ultrasound, mammography, and hepatic and renal function tests. When asked about treatments of menopausal symptoms, 123 (38.0%) of the 324 symptomatic respondents reported HT use, and the mean (SD) age of this group was 50.4 (5.5) years. A further 28 (8.6%) respondents had tried transdermal and vaginal estrogen creams. The duration of HT use varied from 2 weeks to 5 years, and 90 participants had follow-ups at regular intervals. Alternative treatments, such as traditional Chinese medicine, healthcare products (eg, isoflavone products), and psychological treatments, were used by 83 (25.6%), 44 (13.6%), and 54 (16.7%) of the participants, respectively. These details are presented in Table 4. When asked about the reason for not using or stopping HT, 108 (33.3%) participants answered that they experienced mild tolerable symptoms; 95 (29.3%) considered menopause to be a natural course of aging; 60 (18.5%) attributed their nonuse of HT to worry about adverse effects; 28 (8.6%) reported having uterine fibroids, ovarian cysts, or endometriosis; 22 (6.8%) feared the complexity of examinations and treatments; and 12 (3.7%) declined or stopped HT use because of cost. These details are presented in Table 5. Increased risk of cancer was the most frequently reported adverse effect concern. A total of 175 (54.0%) participants feared the risk of breast cancer, and another 143 (44.1%) feared endometrial cancer. Venous thrombosis was mentioned by 124 (38.3%) participants. Other apprehensions included weight gain (100; 30.9%), irregular uterine bleeding (74; 22.8%), and * 2014 The North American Menopause Society
Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
MENOPAUSAL HORMONE THERAPY IN CHINESE OB-GYNS TABLE 4. Treatment of menopausal symptoms Specialty
Oral hormone therapy Transdermal and vaginal estrogen Traditional Chinese medicine Healthcare products Psychological treatments Data are presented as n (%).
Total (N = 324)
Gynecological endocrinology (n = 23)
Nongynecological endocrinology (n = 270)
Unknown (n = 31)
W2
P
123 (38.0) 28 (8.6) 83 (25.6) 44 (13.6) 54 (16.7)
11 (47.8) 6 (26.1) 10 (43.5) 5 (21.7) 3 (13.0)
101 (37.4) 19 (7.0) 67 (24.8) 36 (13.3) 46 (17.0)
11 (35.5) 3 (9.7) 6 (19.4) 3 (9.7) 5 (16.1)
0.974 7.566 3.811 0.644 0.041
0.324 0.006 0.051 0.422 0.840
hormone drug dependence (56; 17.3%). These details are presented in Table 6. DISCUSSION With an aging population, more women are exposed to potentially long-term consequences of menopause. Many surveys have provided facts on HT use in the general population in different countries. Only a few of those studies have explored gynecologists’ personal use of and attitude toward HT. Our survey is the first investigation of Chinese ob-gyns’ opinions, knowledge, and personal use of HT. Our results provide insights into what HT Bshould be[ and what it Bactually is[ in this country. Most of the respondents of this survey were middle-aged women in generally good health. Most of the respondents showed good knowledge of the two main benefits of HT, with 97.7% assuring relief of menopausal symptoms and with 93.5% noting osteoporosis prevention. These results are comparable with previous results in white populations.7 However, only slightly more than a quarter of the respondents were sure about reduction in colorectal cancer, which is an established nonmenopausal benefit of HT. In a prior survey of ob-gyns, family doctors, and internists in the United States, overall awareness of HT’s colon cancer benefit was 84%.7 As for the hazards of HT, 69.4% of the clinicians stated that combined estrogen-progestin therapy could potentially increase the risk of breast cancer. No difference between gynecological endocrinologists and nongynecological endocrinologists was observed. The risk of cancer, especially breast cancer, seemed to be the major concern with HT use in various
studies, whether among general populations or clinicians/ob-gyns. Our study was no exception; fear of breast cancer and endometrial cancer was the most concrete reason of symptomatic respondents for ceasing or avoiding HT use. The incidence of breast cancer in the Chinese population is lower than that in western countries, but a slight increase has been observed in the past several years,8 which has caused fear among doctors and the general population. A modestly elevated rate of breast cancer has been associated with more than 3 to 5 years of estrogen-progesterone therapy use.9,10 Observational studies showed that the increased risk is more probably attributable to the continuous use of progestogen.1 In the WHI estrogen therapy arm, estrogen therapy, however, demonstrated no increase in breast cancer risk after an average of 7.1 years of use.11 International Menopause Society recommendations on HT state that women should be reassured that the potentially increased risk of breast cancer associated with HT is small and less than the increased risks associated with lifestyle factors such as obesity and alcohol consumption.12 The awareness of this risk in our study was higher than that in the general Chinese population (reported as 10%).6 This result may reflect Chinese ob-gyns’ possible overconcern with the association between breast cancer and HT. About 39.7% and 54.0% of gynecological endocrinologists and nongynecological endocrinologists, respectively, cited combined estrogen-progestin therapy as a risk factor for endometrial cancer, and this difference was significantly different. Unopposed systemic estrogen therapy in women with an intact uterus is associated with increased endometrial cancer risk, and adequate concomitant progestogen is recommended
TABLE 5. Reasons for nonuse or cessation of hormone therapy Specialty
Experienced mild tolerable symptoms Menopause is a natural course of aging Worried about adverse effects Developed uterine fibroid, ovarian cyst, or endometriosis Feared the complexity of examinations and treatments Cost Data are presented as n (%).
Total (N = 324)
Gynecological endocrinology (n = 23)
Nongynecological endocrinology (n = 270)
Unknown (n = 31)
W2
P
108 (33.3) 95 (29.3) 60 (18.5) 28 (8.6)
10 (43.5) 5 (21.7) 3 (13.0) 3 (13.0)
87 (32.2) 82 (30.4) 49 (18.1) 20 (7.4)
11 (35.5) 8 (25.8) 8 (25.8) 5 (16.1)
1.213 0.756 0.109 0.315
0.271 0.384 0.741 0.575
22 (6.8)
3 (13.0)
14 (5.2)
5 (16.1)
1.173
0.279
12 (3.7)
0 (0.0)
7 (2.6)
5 (16.1)
6.066
0.014
Menopause, Vol. 21, No. 11, 2014
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Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
WANG ET AL TABLE 6. Concerns regarding the adverse effects of hormone therapy Specialty
Risk of breast cancer Risk of endometrial cancer Risk of venous thrombosis Weight gain Irregular uterine bleeding Hormone drug dependence Data are presented as n (%).
Total (N = 324)
Gynecological endocrinology (n = 23)
Nongynecological endocrinology (n = 270)
Unknown (n = 31)
W2
P
175 (54.0) 143 (44.1) 124 (38.3) 100 (30.9) 74 (22.8) 56 (17.3)
14 (60.9) 10 (43.5) 8 (34.8) 8 (34.8) 3 (13.0) 5 (21.7)
143 (53.0) 118 (43.7) 101 (37.4) 79 (29.3) 61 (22.6) 45 (16.7)
18 (58.1) 15 (48.4) 15 (19.4) 13 (42.0) 10 (32.3) 6 (19.4)
0.533 0.000 0.063 0.310 1.132 0.110
0.465 0.983 0.803 0.578 0.287 0.740
for negation.1 The Postmenopausal Estrogen/Progestin Interventions Trial and other studies showed that endometrial cancer risk in women taking combined estrogen-progestin therapy was the same as that observed in non-HT populations.13 In this study, nearly 40% of gynecological endocrinologists and 54% of nongynecological endocrinologists had a misunderstanding of the risk of endometrial cancer attributable to combined HT. The effect of HT on cardiovascular diseases is another issue that might need further clarification in Chinese ob-gyns. The HT-associated risks of venous thrombosis and cerebral infarction were not fully understood by the ob-gyns. The 2013 global consensus statement on menopausal HT states that standard-dose estrogen-alone menopausal HT may decrease coronary heart disease and all-cause mortality in women younger than 60 years and within 10 years of menopause and that the risks of venous thromboembolism and ischemic stroke increase with oral menopausal HT but that absolute risk is rare below 60 years of age.14 In the Nurses’ Health Study, women initiating menopausal HT, especially estrogen therapy, at or near menopause were observed to experience significant coronary heart disease protection.15 Subgroup analyses of WHI data showed that estrogen-progestin trial, especially estrogen trial, resulted in trends toward protection against coronary heart diseases among women aged 50 to 59 years and within 10 years of menopause.16,17 Recently, cardiovascular outcomes from the Danish Osteoporosis Prevention Study also supported the cardioprotective effects of HT early after menopause in women younger than 60 years.18 In China, menopausal HT guidelines published in 2013 confirmed for the first time the positive effect of estrogen therapy on coronary heart disease early after menopause.19 Data from observational studies and randomized controlled trials consistently verified an increased risk of venous thrombosis with oral HT, especially those with progestogens.20
Knowledge and personal use of menopausal hormone therapy among Chinese obstetrician-gynecologists: results of a survey Yanjie Wang, MD,1 Xin Yang, MD,1 Xiaodong Li, MD,2 Xiaojing He, MD,2 and Yang Zhao, MD1 Abstract Objective: Obstetrician-gynecologists’ (ob-gyns) knowledge of the benefits and risks ofVand attitude towardVmenopausal hormone therapy (HT) have evolved since the publication of the Heart and Estrogen/progestin Replacement Study and the Women’s Health Initiative. The survey investigated Chinese ob-gyns’ perception and personal use ofVand attitude towardVHT. Methods: A total of 2,000 self-administered questionnaires were sent to female ob-gyns who attended gynecological endocrinology workshops in 15 provinces and cities in China from February to May 2013. Results: A total of 904 eligible questionnaires were collected (response rate, 45.2%). Most of the respondents knew that HT could relieve menopausal symptoms (97.7%) and prevent osteoporosis (93.5%). Most (69.4%) of the respondents thought that HT would increase the risk of breast cancer, and 52.9% thought that HT would increase the risk of endometrial cancer. The most common concern regarding adverse effects of HT was risk of breast cancer, followed by risk of endometrial cancer, risk of venous thrombosis, and weight gain. One hundred twenty-three of 324 symptomatic respondents (38.0%) reported HT use, and a further 28 respondents (8.6%) had tried transdermal and vaginal estrogen creams. Conclusions: These findings show better knowledge of HT among Chinese ob-gyns compared with the general Chinese population. However, HT use is relatively low, and ob-gyns seem to be overconcerned with the risks of HT. HT education must be promoted among Chinese ob-gyns to enhance the proper use of HT in the general population. Key Words: Hormone therapy Y Knowledge and attitude Y Obstetricians and gynecologists Y Personal use.
M
enopausal hormone therapy (HT) is the most effective treatment of menopausal symptoms and is beneficial for the prevention of long-term complications.1 HT use in the Chinese population remains low, especially since the release of the Heart and Estrogen/progestin Replacement Study and Women’s Health Initiative (WHI) findings.2,3 A study published in 2008 showed that ever and current HT use in Guangdong province was 0.8% and 1.3%, respectively4; another study published in 2008 showed that the current rate of HT use among perimenopausal women in Beijing was 1.4%.5 A study (conducted in 2006 and published in 2012) of HT knowledge and use in Asian countries showed that the hot flash rate among postmenopausal women in China was 57.0%; the previous rate of HT use in Chinese postmenopausal women was only 9%, and the current rate of HT use is Received December 1, 2013; revised and accepted February 12, 2014. From the 1Department of Obstetrics and Gynecology, Peking University People’s Hospital, Beijing, China; and 2Department of Obstetrics and Gynecology, The Second Hospital of Hebei Medical University, Hebei Province, China. Funding/support: This study was supported by the China Key Project BNational twelfth 5-year plan for science and technology support: evaluation of reproductive health and menopausal health condition[ (project no. 2012 BAI32B00). Financial disclosure/conflicts of interest: None reported. Address correspondence to: Xin Yang, MD, Department of Obstetrics and Gynecology, Peking University People’s Hospital, Xicheng District, Beijing, China. E-mail: [email protected]
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2%.6 Many other studies were conducted to investigate the general Chinese population’s perception and use of HT, but very few studies have assessed knowledge, attitude, and menopausal health needs from the perspective of Chinese female obstetrician-gynecologists (ob-gyns). Ten years have passed since the publication of the Heart and Estrogen/progestin Replacement Study and the WHI, and ob-gyns’ views have evolved with ongoing debates regarding the interpretation of the results. How ob-gyns assess the merits and risks of HT and how they advise women about HT use are important public issues. Therefore, we conducted a survey on knowledge and personal use of HT among Chinese ob-gyns to provide current insights into their perception of and attitude toward HT. METHODS The survey was approved by the Clinical Research Ethics Committee of the Peking University People’s Hospital (Beijing, China). The Endocrinology Committee of the Chinese Medical Doctor Association held gynecological endocrinology workshops from February to May 2013 in 15 provinces and cities in China. Before the workshops began, female ob-gyns attending the workshops were invited to voluntarily complete questionnaires that were distributed on the spot. The questionnaire included questions on general information (eg, age, marital status, cities or areas of origination, hospital grade, and clinical specialty), health condition (eg,
Menopause, Vol. 21, No. 11, 2014
Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
MENOPAUSAL HORMONE THERAPY IN CHINESE OB-GYNS
parity, menstruation status, contraception choices, and history of clinical confirmed diseases), and knowledge of and attitude toward HT (eg, necessity, appropriate time for HT use, and risks and benefits of combined estrogen-progestin therapy). The modified Kupperman Menopausal Index was used to evaluate the severity of menopausal symptoms in ob-gyns who presented with menstruation changes and climacteric symptoms. Supplemental questions (primarily multiplechoice questions) regarding the most bothersome symptoms, examinations and treatments sought, concerns regarding the adverse effects of combined estrogen-progestin therapy, and reasons for nonuse (or cessation) of HT were added to further assess ob-gyns’ personal HT use and their attitude toward HT. Statistics Data were entered and analyzed using SPSS Statistics version 19.0. Implausible answers and obvious coding errors were screened and corrected by reviewing the original survey. Questionnaires with more than 20% of the critical answers missing were considered invalid and were excluded from the study. Categorical data are presented as n (%), and continuous data are presented as mean (SD). W2 test was used to compare categorical data; continuity correction was used when categorical variables had expected numbers between 1 and 5; and Fisher exact test was used when expected numbers were less than 1. Differences between respondents were examined based on specialty (ie, gynecological endocrinology and nongynecological endocrinology). P G 0.05 was considered statistically significant, and P G 0.01 was considered highly statistically significant. RESULTS A total of 2,000 questionnaires were distributed, and 904 of the 1,027 returned questionnaires were eligible (response rate, 45.2%). Table 1 summarizes participants’ general information and health condition. Participants’ age varied from 22 to 76 years, with a mean (SD) age of 40.0 (9.2) years. Most participants were married/cohabiting (98.8%) and parous (83.6%). As for the current choice of contraception (including contraception used before menopause), 311 (34.4%) reported intrauterine devices, and 7 (0.7%) used the levonorgestrel intrauterine system. Thirty (3.3%) participants were taking oral contraceptives, 57 (6.3%) used condoms all the time, 191 (21.1%) used condoms plus the rhythm method, and 33 (3.7%) used condoms plus external contraceptives. Three (0.3%) participants had undergone sterilization: 2 (0.2%) underwent tubal sterilization and 1 (0.1%) had vasectomy. A total of 145 participants did not use contraception because of absence of menstruation due to breast-feeding, hysterectomy, and menopause. Most participants were generally healthy, but 58 (6.4%) reported hyperlipidemia, 32 (3.5%) reported cardiovascular diseases, 14 (1.5%) reported diabetes mellitus, 25 (2.8%) reported low bone density or osteoporosis, and 5 (0.6%) reported thyroid dysfunction. Among all of the ob-gyns, 48 (5.3%) were from grade 1 hospitals (ie, primary hospitals providing basic health care in
TABLE 1. General characteristics of respondents (N = 904) Characteristics
n (%)
Age 22-29 y 30-39 y 40-49 y 50-59 y Q60 y Missing Marital status Married/cohabiting Single Missing Parity Parous Nulliparous Missing Current choice of contraception Intrauterine device Levonorgestrel intrauterine system Oral contraceptives Condom alone Condom + rhythm method Condom + external contraceptives External contraceptives Withdrawal (coitus interruptus) Tubal sterilization Vasectomy Unmarried and no sexual activities No menstruation (including breast-feeding, hysterectomy, and menopause) Without contraception Missing History of clinical confirmed diseasesa Hyperlipidemia Cardiovascular diseases Diabetes mellitus Low bone density/osteoporosis Hyperthyroidism/hypothyroidism Hospital grade 1 2 3 Missing Clinical specialty Gynecological endocrinology Nongynecological endocrinology Gynecology Obstetrics Obstetrics-gynecology Missing a Multiple-choice questions.
108 (11.9) 310 (34.3) 324 (35.8) 122 (13.5) 19 (2.1) 21 (2.3) 893 (98.8) 11 (1.2) 0 (0) 756 (83.6) 148 (16.4) 0 (0) 311 (34.4) 7 (0.7) 30 (3.3) 57 (6.3) 191 (21.1) 33 (3.7) 42 (4.6) 45 (5.0) 2 (0.2) 1 (0.1) 11 (1.2) 145 (16.0) 27 (3.0) 2 (0.2) 58 (6.4) 32 (3.5) 14 (1.5) 25 (2.8) 5 (0.6) 48 (5.3) 335 (37.0) 413 (45.7) 108 (12.0) 63 (7.0) 358 (39.6) 62 (6.9) 332 (36.7) 89 (9.8)
communities), 335 (37.0%) were from grade 2 hospitals (ie, secondary hospitals affiliated with a medium-size city or district), and 413 (45.7%) were from grade 3 hospitals (ie, comprehensive or general hospitals providing specialist health services, medical education, and scientific studies). A total of 63 (7.0%) ob-gyns specialized in gynecological endocrinology. Among nongynecological endocrinologists, 358 (39.6%) specialized in gynecology, 62 (6.9%) specialized in obstetrics, and 332 (36.7%) specialized in obstetrics-gynecology. A total of 89 (9.8%) ob-gyns gave no answer to specialty. Among the 904 participants, 363 (40.2%) thought that HT was Bvery necessary,[ 506 (56.0%) thought that HT was Bnecessary,[ and only 34 (3.8%) thought that it was Bunnecessary.[ One obgyn did not answer. Most ob-gyns (879; 97.2%) thought that HT should start when menopausal symptoms emerge. Menopause, Vol. 21, No. 11, 2014
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WANG ET AL TABLE 2. Perceived benefits and risks of combined estrogen-progestin therapy stratified by menopause status and specialty Specialty
Benefits of hormone therapy Relief of menopausal symptoms Prevention of osteoporosis Reduction of colon cancer risk Potential risks of hormone therapy Venous thrombosis Cerebral infarctions Breast cancer Endometrial cancer Data are presented as n (%).
Total (N = 904)
Gynecological endocrinology (n = 63)
Nongynecological endocrinology (n = 752)
Unknown (n = 89)
W2
P
883 (97.7) 845 (93.5) 238 (26.3)
61 (98.8) 59 (93.7) 27 (42.9)
734 (97.6) 702 (93.4) 193 (25.7)
88 (98.7) 84 (94.4) 18 (20.2)
0.722 0.000 8.718
0.395 1.000 0.003
494 (54.6) 280 (31.0) 627 (69.4) 478 (52.9)
36 (57.1) 20 (31.7) 42 (66.7) 25 (39.7)
411 (54.7) 229 (30.5) 522 (69.4) 406 (54.0)
47 (52.8) 31 (34.8) 63 (70.8) 47 (52.8)
0.145 0.046 0.206 4.775
0.703 0.830 0.650 0.029
A series of true-false questions was designed to study obgyns’ perception of the pros and cons of HT. Table 2 summarizes the answers. Most respondents reported that HT had positive effects on menopausal symptoms (883; 97.7%) and osteoporosis (845; 93.5%). However, only 26.3% of all respondents were certain of the protective role of HT against colon cancer. Gynecological endocrinologists had significantly better knowledge of this issue than did nongynecological endocrinologists (42.9% vs 25.7%, P = 0.003). More than half of the participants were alert to potentially increased risks of cancer attributable to HT. A total of 69.4% thought that combined estrogen-progestin therapy would increase the risk of breast cancer, and 52.9% thought that HT would increase the risk of endometrial cancer. The difference between gynecological endocrinologists and nongynecological endocrinologists was significant (39.7% vs 54.0%, P = 0.029). Approximately half (54.6%) of the respondents were aware of the increased risk of venous thrombosis, and 31.0% confirmed negative effects of HT on cerebral infarction. Among the 904 respondents, 446 were aged 40 to 59 years. In this group, 324 (35.8% of all respondents) reported more than two consecutive menstrual cycle length changes greater
TABLE 3. Prevalence of menopausal symptoms as measured by the modified Kupperman index Variables
n (%)
Mood swings Insomnia Fatigue Muscle/joint pain Sexual problems Hot flashes Palpitations Melancholia Vertigo Headache Urinary problems Paresthesia Formication
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184 (56.8) 171 (52.8) 170 (52.5) 136 (42.0) 135 (41.7) 128 (39.5) 119 (36.7) 113 (34.9) 110 (34.0) 106 (32.7) 74 (22.8) 68 (21.0) 50 (15.4)
than 7 days and presented with climacteric symptoms. Their climacteric symptoms, evaluated by the modified Kupperman Menopausal Index, are presented in Table 3. Memory loss was the most bothersome aspect of perimenopause in 54.0% of the participants. The second most frequently reported complaint was hot flashes (31.2%). Other disturbances included menstrual disorders (14.8%), cardiovascular symptoms (10.2%), and urogenital discomfort (9.3%). A total of 215 (66.4%) participants had undergone some type of examination. Serum hormone levels were examined in 108 (33.3%) participants, and bone density was tested in 70 (21.6%) participants. Other tests included pelvic ultrasound, mammography, and hepatic and renal function tests. When asked about treatments of menopausal symptoms, 123 (38.0%) of the 324 symptomatic respondents reported HT use, and the mean (SD) age of this group was 50.4 (5.5) years. A further 28 (8.6%) respondents had tried transdermal and vaginal estrogen creams. The duration of HT use varied from 2 weeks to 5 years, and 90 participants had follow-ups at regular intervals. Alternative treatments, such as traditional Chinese medicine, healthcare products (eg, isoflavone products), and psychological treatments, were used by 83 (25.6%), 44 (13.6%), and 54 (16.7%) of the participants, respectively. These details are presented in Table 4. When asked about the reason for not using or stopping HT, 108 (33.3%) participants answered that they experienced mild tolerable symptoms; 95 (29.3%) considered menopause to be a natural course of aging; 60 (18.5%) attributed their nonuse of HT to worry about adverse effects; 28 (8.6%) reported having uterine fibroids, ovarian cysts, or endometriosis; 22 (6.8%) feared the complexity of examinations and treatments; and 12 (3.7%) declined or stopped HT use because of cost. These details are presented in Table 5. Increased risk of cancer was the most frequently reported adverse effect concern. A total of 175 (54.0%) participants feared the risk of breast cancer, and another 143 (44.1%) feared endometrial cancer. Venous thrombosis was mentioned by 124 (38.3%) participants. Other apprehensions included weight gain (100; 30.9%), irregular uterine bleeding (74; 22.8%), and * 2014 The North American Menopause Society
Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
MENOPAUSAL HORMONE THERAPY IN CHINESE OB-GYNS TABLE 4. Treatment of menopausal symptoms Specialty
Oral hormone therapy Transdermal and vaginal estrogen Traditional Chinese medicine Healthcare products Psychological treatments Data are presented as n (%).
Total (N = 324)
Gynecological endocrinology (n = 23)
Nongynecological endocrinology (n = 270)
Unknown (n = 31)
W2
P
123 (38.0) 28 (8.6) 83 (25.6) 44 (13.6) 54 (16.7)
11 (47.8) 6 (26.1) 10 (43.5) 5 (21.7) 3 (13.0)
101 (37.4) 19 (7.0) 67 (24.8) 36 (13.3) 46 (17.0)
11 (35.5) 3 (9.7) 6 (19.4) 3 (9.7) 5 (16.1)
0.974 7.566 3.811 0.644 0.041
0.324 0.006 0.051 0.422 0.840
hormone drug dependence (56; 17.3%). These details are presented in Table 6. DISCUSSION With an aging population, more women are exposed to potentially long-term consequences of menopause. Many surveys have provided facts on HT use in the general population in different countries. Only a few of those studies have explored gynecologists’ personal use of and attitude toward HT. Our survey is the first investigation of Chinese ob-gyns’ opinions, knowledge, and personal use of HT. Our results provide insights into what HT Bshould be[ and what it Bactually is[ in this country. Most of the respondents of this survey were middle-aged women in generally good health. Most of the respondents showed good knowledge of the two main benefits of HT, with 97.7% assuring relief of menopausal symptoms and with 93.5% noting osteoporosis prevention. These results are comparable with previous results in white populations.7 However, only slightly more than a quarter of the respondents were sure about reduction in colorectal cancer, which is an established nonmenopausal benefit of HT. In a prior survey of ob-gyns, family doctors, and internists in the United States, overall awareness of HT’s colon cancer benefit was 84%.7 As for the hazards of HT, 69.4% of the clinicians stated that combined estrogen-progestin therapy could potentially increase the risk of breast cancer. No difference between gynecological endocrinologists and nongynecological endocrinologists was observed. The risk of cancer, especially breast cancer, seemed to be the major concern with HT use in various
studies, whether among general populations or clinicians/ob-gyns. Our study was no exception; fear of breast cancer and endometrial cancer was the most concrete reason of symptomatic respondents for ceasing or avoiding HT use. The incidence of breast cancer in the Chinese population is lower than that in western countries, but a slight increase has been observed in the past several years,8 which has caused fear among doctors and the general population. A modestly elevated rate of breast cancer has been associated with more than 3 to 5 years of estrogen-progesterone therapy use.9,10 Observational studies showed that the increased risk is more probably attributable to the continuous use of progestogen.1 In the WHI estrogen therapy arm, estrogen therapy, however, demonstrated no increase in breast cancer risk after an average of 7.1 years of use.11 International Menopause Society recommendations on HT state that women should be reassured that the potentially increased risk of breast cancer associated with HT is small and less than the increased risks associated with lifestyle factors such as obesity and alcohol consumption.12 The awareness of this risk in our study was higher than that in the general Chinese population (reported as 10%).6 This result may reflect Chinese ob-gyns’ possible overconcern with the association between breast cancer and HT. About 39.7% and 54.0% of gynecological endocrinologists and nongynecological endocrinologists, respectively, cited combined estrogen-progestin therapy as a risk factor for endometrial cancer, and this difference was significantly different. Unopposed systemic estrogen therapy in women with an intact uterus is associated with increased endometrial cancer risk, and adequate concomitant progestogen is recommended
TABLE 5. Reasons for nonuse or cessation of hormone therapy Specialty
Experienced mild tolerable symptoms Menopause is a natural course of aging Worried about adverse effects Developed uterine fibroid, ovarian cyst, or endometriosis Feared the complexity of examinations and treatments Cost Data are presented as n (%).
Total (N = 324)
Gynecological endocrinology (n = 23)
Nongynecological endocrinology (n = 270)
Unknown (n = 31)
W2
P
108 (33.3) 95 (29.3) 60 (18.5) 28 (8.6)
10 (43.5) 5 (21.7) 3 (13.0) 3 (13.0)
87 (32.2) 82 (30.4) 49 (18.1) 20 (7.4)
11 (35.5) 8 (25.8) 8 (25.8) 5 (16.1)
1.213 0.756 0.109 0.315
0.271 0.384 0.741 0.575
22 (6.8)
3 (13.0)
14 (5.2)
5 (16.1)
1.173
0.279
12 (3.7)
0 (0.0)
7 (2.6)
5 (16.1)
6.066
0.014
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WANG ET AL TABLE 6. Concerns regarding the adverse effects of hormone therapy Specialty
Risk of breast cancer Risk of endometrial cancer Risk of venous thrombosis Weight gain Irregular uterine bleeding Hormone drug dependence Data are presented as n (%).
Total (N = 324)
Gynecological endocrinology (n = 23)
Nongynecological endocrinology (n = 270)
Unknown (n = 31)
W2
P
175 (54.0) 143 (44.1) 124 (38.3) 100 (30.9) 74 (22.8) 56 (17.3)
14 (60.9) 10 (43.5) 8 (34.8) 8 (34.8) 3 (13.0) 5 (21.7)
143 (53.0) 118 (43.7) 101 (37.4) 79 (29.3) 61 (22.6) 45 (16.7)
18 (58.1) 15 (48.4) 15 (19.4) 13 (42.0) 10 (32.3) 6 (19.4)
0.533 0.000 0.063 0.310 1.132 0.110
0.465 0.983 0.803 0.578 0.287 0.740
for negation.1 The Postmenopausal Estrogen/Progestin Interventions Trial and other studies showed that endometrial cancer risk in women taking combined estrogen-progestin therapy was the same as that observed in non-HT populations.13 In this study, nearly 40% of gynecological endocrinologists and 54% of nongynecological endocrinologists had a misunderstanding of the risk of endometrial cancer attributable to combined HT. The effect of HT on cardiovascular diseases is another issue that might need further clarification in Chinese ob-gyns. The HT-associated risks of venous thrombosis and cerebral infarction were not fully understood by the ob-gyns. The 2013 global consensus statement on menopausal HT states that standard-dose estrogen-alone menopausal HT may decrease coronary heart disease and all-cause mortality in women younger than 60 years and within 10 years of menopause and that the risks of venous thromboembolism and ischemic stroke increase with oral menopausal HT but that absolute risk is rare below 60 years of age.14 In the Nurses’ Health Study, women initiating menopausal HT, especially estrogen therapy, at or near menopause were observed to experience significant coronary heart disease protection.15 Subgroup analyses of WHI data showed that estrogen-progestin trial, especially estrogen trial, resulted in trends toward protection against coronary heart diseases among women aged 50 to 59 years and within 10 years of menopause.16,17 Recently, cardiovascular outcomes from the Danish Osteoporosis Prevention Study also supported the cardioprotective effects of HT early after menopause in women younger than 60 years.18 In China, menopausal HT guidelines published in 2013 confirmed for the first time the positive effect of estrogen therapy on coronary heart disease early after menopause.19 Data from observational studies and randomized controlled trials consistently verified an increased risk of venous thrombosis with oral HT, especially those with progestogens.20
