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Post Reprod Health OnlineFirst, published on May 11, 2015 as doi:10.1177/2053369115586122

Original article

The need to do better – Are we still letting our patients down and at what cost?

Post Reproductive Health 0(0) 1–7 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/2053369115586122 prh.sagepub.com

Grant Philip Cumming1, Heather Currie2, Edward Morris3, Rik Moncur4 and Amanda J. Lee5

Abstract Objective: To survey women’s views on HRT and alternative therapies and make comparisons with 2007 data. Study design: A questionnaire on a UK patient-tailored independent clinician-led website with anonymous responses analysed using descriptive statistics. Main outcome measures: Answers to survey questions in 2007 and 2014. Results: A total of 1476 responses from 33 countries were obtained. Almost 70% of respondents had used/would consider using HRT. Over the last 5 years, 27.7% felt that their views had changed for the better. Most obtained information from health professionals or the Internet. About 51.1% felt that their family doctor did not recognise the importance of the menopause with one-third feeling resistance to being offered HRT. Compared to 2007, significantly more women were aware of the different risks associated with different types of HRT. More women were able to respond positively to the question asking whether or not they felt able to make an informed choice regarding HRT/ alternative therapies. Conclusions: There has been negativity and confusion regarding HRT management since the beginning of the millennium. Our findings suggest that we, as health professionals, continue to let our patients down with poor provision of information, inaccurate or wrong information, or access to the right care. The cost of this is women living with preventable sequelae associated with the menopausal transition with a consequent adverse impact on health and the health economy. The importance of the menopause consultation as part of a life course approach is highlighted as well as the emerging discipline of Health Web Science.

Keywords Menopause, HRT, health web science, alternative therapies, online questionnaires

Introduction In a recent Editorial in this journal, the Title was ‘‘Delayed recognition and management of the menopause – at what cost?’’.1 This article was motivated in response to a health outcomes modelling study2 on the money saved from a reduced use of hormone replacement therapy (HRT) as a consequence of the adverse findings of the combined therapy arm of the Women’s Health Initiative (WHI) trial. The NIH director commenting on the results said ‘‘Americans should be pleased to see that their investment in NIH continues to provide such a strong return to their health and the economy.’’3 The conclusions drawn from this modelling study are arguably flawed4 and that for health professionals not to address the symptoms and health risks of the menopause when there are acceptable means of treatment could be considered negligent. In 2002, the

Women’s International Study of long Duration Oestrogen after Menopause (WISDOM) was prematurely stopped5 after a number of studies6–8 challenged the suggestion from the publications arising from the Nurses’ Health Study that HRT may be useful in preventing and managing chronic disease.9 The closure of the WISDOM trial led two commentators to conclude 1

NHS, Dr Grays Hospital, Elgin, Elgin UK Dumfries and Galloway, Dumfries, UK 3 Norfolk & Norwich University Hospital, Norwich, UK 4 The Internet Design Shop, Dumfries, UK 5 Medical Statistics Team, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK 2

Corresponding author: Grant Philip Cumming, NHS, Dr Grays Hospital, Elgin, Elgin IV301QG, UK. Email: [email protected]

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that ‘the closure of this trial is a sad loss for women and the future health of our daughters. We have let them down.’10 These publications along with papers from the Million Women Study,5,6,7 and the subsequent unbalanced reporting in the press and conflicting messages emanating from various learned bodies, resulted in the medical management of the menopause becoming an area of confusion not only among the public, but also among health professionals.11–16 However, the pendulum may be swinging back with the increasing recognition that these previous studies were flawed and that HRT is an important therapeutic option in the perimenopausal and postmenopausal years.17–19 We have previously expressed concern that a large number of women who obtained information from health professionals and the Internet still felt that they did not have enough information to assist them to make informed decisions regarding the use of HRT. We called on health professionals to provide information on both hormonal and alternative options.20 This paper provides new data and an update to describe the current situation.

Statistical methods Responses to individual questions were summarised as % (n). The chi-squared test was used to compare responses to identical questions from the 2014 and 2007 surveys.

Results The survey went online on 2 June 2014 and offline 19 October 2014 (20 calendar weeks). There were 1476 responses from 33 countries. The majority of respondents (91.9%, n ¼ 1357) were from the UK. Of these, 79.3% (n ¼ 1076) were from England, 15.0% (n ¼ 203) from Scotland, 3.8% (n ¼ 52) from Wales and 1.9% (n ¼ 26) from Northern Ireland. The remaining 119 respondents composed 38 from Europe, 27 from the USA, 8 from Canada, 6 from New Zealand, 5 from Australia and 4 from South Africa. There were single responses from Angola, Argentina, Azerbaijan, Honk Kong, Svalbard and Jan Mayen, Puerto Rico and Venezuela. A total of 24 respondents classified themselves as ‘‘outwith the UK’’ only. The stratification of the cohorts answering each questionnaire by self-perception of menopausal status is shown in Table 1.

Methods An online, convenience survey, devised by independent clinicians with a special interest in the menopause, was run on the patient-tailored menopause website, www.menopausematters.co.uk. No incentives were offered and no prior contact with potential participants had been made. The survey was also announced through social media channels and in the Menopause Matters magazine. The participants were told the purpose of the surveys, allowing them the option not to follow the link to the survey. The methodology is as described in our previous paper.20

HRT Almost 70% (n ¼ 1023) of the 1464 respondents to the 2014 survey had used or would consider using HRT. The group most likely to say they would never use it were the perimenopausal group (40.9%, n ¼ 187/ 457), followed by the premenopausal women (38.1%, n ¼ 8/21), the postmenopausal women (30.9%, n ¼ 180/ 582), those menopause symptomatic (17.7%, n ¼ 32/ 181) and those menopausal with no symptoms (21.1%, n ¼ 4/19). A total of 10.4% (n ¼ 14/134) said that they did not know.

Table 1. Stratification of cohorts answering each questionnaire by self-perceived menopausal status. Premenopausal

Perimenopausal

Postmenopausal

Bilateral oophorectomy

Hysterectomy, no symptoms

Hysterectomy with symptoms

Do not know

Total

Age (years) %

n

%

n

%

n

%

n

%

n

%

n

%

n

%

n

60 – Total 1.4

1 – 13 7 – 21

0.2 2.4 56 41.4 – 31.6

1 11 258 191 – 461

0.3 1.5 18.7 65.1 14.4 40

2 9 109 380 84 584

– 6.7 48.3 41.7 3.3 13

– 4 29 25 2 60

– – 26.3 36.8 36.8 0.6

– – 5 7 7 19

– 5 29.3 50.8 14.9 12.4

– 9 53 92 27 181

2.2 3 35.1 5.1 4.5 9.2

3 4 47 74 6 134

0.5 2.5 35.2 53.2 8.6 1460

7 37 514 776 126

Note: Values are column percentages.

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Over the last 5 years, 27.7% (n ¼ 402/1451) of women felt that their views on the use of HRT had changed for the better, 61.9% (n ¼ 898/1451) said it had stayed the same and 10.4% (n ¼ 151/1451) said that their views were less favourable. Regarding the media, almost half the women (46.1%, n ¼ 670/1454) were undecided whether or not the risks of HRT were exaggerated in the media, while 39.8% (n ¼ 579/1454) felt they were and 14.1% (n ¼ 205/1454) felt they were not. The majority of women felt that they were clear about the risks and benefits of HRT (68.8%, n ¼ 1008/1465); many were aware that different types of HRT were associated with different types of risk (65.3%, n ¼ 950/1455). Over half were aware that the age at which HRT is started affects an individual’s risk (54.1%, n ¼ 790/1459) and over half felt that they knew enough to make an informed choice (53.2%, n ¼ 766/1439). Most women obtained their information from their health professional (50%, n ¼ 738/1476) or the Internet (38.4%, n ¼ 567/1476). The press only accounted for 2.6% of responses (n ¼ 38/1476). The small remainder was from books, family and other sources. In those respondents who answered the question, the family doctor (55.4%, n ¼ 756/1364) was the health professional who was felt to be the most likely to provide the care they needed, followed by the nurse (13%, n ¼ 178/1364) with 31.5% (n ¼ 430/1364) saying they did not know. Just over 50% felt that their family doctor did not recognise the importance of the menopause (51.1%, n ¼ 697/1364) with one-third feeling there was resistance to being offered HRT (33.8%, n ¼ 379/1121). In those 872 women who were started on HRT, 60.1% (n ¼ 524) were on a tablet, 25.7% (n ¼ 224) were on a patch, 4.9% (n ¼ 43) were on gel and 9.3% (n ¼ 81) were on a vaginal preparation. In those 596 women who answered the question and could remember, 50.8% (n ¼ 303) had their weight checked, 61.9% (n ¼ 369) had their smoking habit

discussed and 59.7%, (n ¼ 356) were asked about their alcohol intake. In those 399 women aged over 50 years old, 72.7% (n ¼ 290) had a mammogram performed. Almost 40% (n ¼ 427/1077) of women were not offered a review appointment. A total of 34% (n ¼ 340/999) said a limit on duration of HRT was advised, but 16.3% (n ¼ 55/337) were not given a reason for this limited duration. For those not prescribed HRT, no reasons were given in 53.5% (n ¼ 239/447). Among those who were prescribed HRT, 88.9% (n ¼ 863/971) were advised to stop by their GP without a clear reason being given. Table 2 shows a comparison between results obtained in our previous 2007 survey and those obtained in 2014. Overall, significantly less women were in favour of HRT (69.9% in 2007 versus 74.7%, p ¼ 0.008). However, significantly less women said that their views on HRT had become less favourable in 2014 (10.4% in 2007 versus 22.5%, p < 0.001). There was no significant change in the percentage of women who said that HRT risks were exaggerated by the media between the two surveys (39.2% in 2007 versus 36%, p ¼ 0.102). Compared to the 2007 survey, significantly more women were aware of the different risks associated with different types of HRT (65.3% in 2014 versus 55%, p < 0.001) including age (54.1% in 2014 versus 35.9%, p < 0001). More women were able to respond positively to the question asking whether or not they felt able to make an informed choice (53.2% in 2014 versus 27%, p < 0.001).

Over the counter alternative therapies Overall, of those women who answered the question, 76.7% (n ¼ 1091/1422) had tried or would try alternative therapies before taking HRT for menopausal symptoms. Table 3 shows responses and cumulative totals to those who answered the question, ‘How much you would be prepared to pay per month?’ Compared

Table 2. Comparison of answers to HRT questions between the 2014 and 2007 surveys. 2007 Survey

In favour of HRT View HRT less favourably Media exaggerates risks Different risks with different HRT Age affects risk Able to make informed choice

2014 Survey

Percentage (n) answering yes

N valid responses

Percentage (n) answering yes

N valid responses

P-value

74.7 22.5 36.0 55.0 35.9 27.0

1026 954 956 984 986 982

69.9 10.4 39.2 65.3 54.1 53.2

1464 1451 1474 1455 1459 1439

0.008

The need to do better - Are we still letting our patients down and at what cost?

To survey women's views on HRT and alternative therapies and make comparisons with 2007 data...
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