Family Practice Vol. 20, No. 2, 112-119
© Oxford University Press 2003
Clinical Research |
Women’s knowledge of and attitudes towards hormone replacement therapy
Department of General Practice and Primary Care, University of Aberdeen, Aberdeen, UK.
Correspondence to Kathryn Lewin, c/o Department of General Practice and Primary Care, Foresterhill Health Centre, Westburn Road, Aberdeen AB25 2AY, UK; E-mail: gppc{at}aberdeen.ac.uk
Lewin KJ, Sinclair HK and Bond CM. Women’s knowledge of and attitudes towards hormone replacement therapy. Family Practice 2003; 20: 112–119.
Received 4 February 2002; Revised 2 August 2002; Accepted 4 November 2002.
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Abstract |
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Background. Hormone replacement therapy (HRT) could benefit women who have reached the natural menopause, have had a hysterectomy or have a family history of osteoporosis.
Objective. Our aim was to monitor changes in women’s knowledge of, and attitudes towards, HRT since 1991.
Methods. The study was a repeat of a postal survey conducted in 1991 in the Grampian region in the North East of Scotland. Six hundred women, aged 20–69 years, were selected randomly from the eight Local Health Care Co-operatives in Grampian, Scotland. The main outcome measures were women’s knowledge of HRT, their attitudes towards it and the percentage of users, past users and never users within the sample.
Results. A 79% response rate was achieved. Overall, 17% of post-menopausal women were current takers (increased from 9% in 1991), 22% were previous takers (increased from 7%) and 61% were never takers (decreased from 84%). This increase in ever use of HRT was more pronounced in the less educated women (increase of 24% since 1991) compared with the more educated (increase of 13%). Almost half (48%) of post-menopausal women had considered taking HRT (25% increase). However, of never users, the majority (86%) had never considered HRT and had not discussed it with a doctor. Attitudes towards the menopause remained positive, although knowledge of the effects of HRT and of risk factors for osteoporosis had decreased. Forty-two per cent of never users would be persuaded to take HRT if they knew it would not cause any problems, and 52% would be persuaded to take HRT on the recommendation of a doctor.
Conclusions. Since 1991, HRT use increased overall; this increase was greater in the less educated women. However, the majority of post-menopausal women remain never users, and many were unaware of HRT. Conflicting research evidence since 1991 on the risks and benefits of HRT may account for the decrease in the women’s knowledge of the effects of HRT.
Keywords. Hormone replacement therapy, patient’s attitudes, patient’s knowledge, women’s health.
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Introduction |
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Hormone replacement therapy (HRT) is an effective treatment for menopausal symptoms1 and can protect women from developing osteoporosis, although effectiveness is associated with continued use.2 Research suggests that it decreases the risk of hip fracture in post-menopausal women by 30% and spinal fracture by 50%.3 HRT may also decrease the risk of cardiovascular disease—the main cause of death in post-menopausal women in western societies.4 There is also an association between HRT and the prevention of Alzheimer’s disease5 and enhanced cognitive performance.6
A 1991 survey of 1500 Grampian women (aged 20–69 years),7 based on a study in the USA, 8 showed that 9% of post-menopausal women were currently taking HRT and 7% had taken it in the past.7 In 1998, Hope et al. stated that only 17% of British post-menopausal women were taking HRT.9 Furthermore, the Scottish Health Survey (1998) found that 27% of 45- to 54-year-old women were using HRT and 10% had taken it in the past.10
It has been demonstrated that women’s attitudes towards the menopause and their knowledge of the benefits and risks of HRT have a direct effect on their use of HRT.8,10 Women may be concerned about HRT because of the increased risks of breast cancer,11 endometrial cancer12 and venous thromboembolism.13 The 1991 Grampian study found that 70% of all women not receiving HRT had never considered it and 79% had never discussed it with their GP.7 In addition, ‘more educated’ women were more likely to use HRT than ‘less educated’ women. More recently, Larkin has reported that "a third of menopausal women are undecided about HRT and feel they are not getting enough information from their GP to make an informed choice."14
With recent publications about increased risks,11–13 it seemed to be relevant to explore what effects, if any, this information had on attitudes and HRT use. This paper reports on a repeat survey, carried out in Grampian, which describes women’s attitudes towards the menopause and their knowledge of the risks and benefits of HRT. Ideally this follow-up study should have used the same sampling frame and sampling method to maximize the validity of the comparison. However, data protection legislation now precludes researchers from sampling and approaching patients. We chose to approach patients through GP practices, randomly selecting one practice from each of the eight Local Health Care Co-operatives (LHCCs) in Grampian.
The primary aim was to describe changes in these variables with time since the first study was conducted 9 years previously. A secondary aim was to compare the response rates of a word-processed questionnaire with a computer-readable (Formic) version of the same questionnaire.
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Methods |
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Ethical approval was granted by the Joint Ethical Committee of Grampian Health Board. It was calculated that to detect a 10% increase of either women currently taking HRT or never users who had discussed HRT with a doctor, at 80% power at the 5% significance level, 123 evaluable questionnaires would be required from peri-/post-menopausal women. One general practice was selected randomly (using random number tables) from each of the eight Grampian LHCCs. Each practice provided a list, stratified by age (20–29, 30–39, 40–49, 50–59, 60–69 years) of all women, from which 75 were selected, 15 from each age band and 600 in total. Assuming a conservative response rate of 50%, and an estimated 40% of responders being peri-/post-menopausal, this would provide 124 evaluable questionnaires.
The questionnaire gathered demographic data, information on past medical history, and use of HRT and attitudes towards it, including perceived risks and benefits. It also assessed knowledge of osteoporosis and attitudes towards the menopause. Menopausal status was assessed by asking women if they were still having periods. Those women whose periods had stopped due to ‘natural menopause’, or who had ‘had a hysterectomy’ were considered to be menopausal/post-menopausal.
Two formats of the questionnaire were developed, (a word-processed and a computer-readable version) based on the 1991 questionnaire.7 Three minor alterations were made: (i) the question on the price of HRT was removed; (ii) the question on whether or not the respondent had considered HRT was moved to precede the question regarding HRT status to improve the continuity of the questionnaire; and (iii) question 17 was reworded to ensure that women who were still having periods but taking HRT were directed to complete the questions on HRT.
The revised questionnaire was piloted on 26 women; further minor refinements were made. In December 2000, the questionnaire was mailed to the study sample (a word-processed version to 300, and a computer-readable version to 300). Both versions were identical with respect to question wording and order, but the computer-readable questionnaire contained six pages and the word questionnaire 11 pages. An explanatory covering letter on practice headed paper and signed by the relevant senior partner was enclosed with each questionnaire. A reminder letter and duplicate questionnaire were mailed to non-responders after 2 and 4 weeks.
SPSS 7.0 was used for data storage and analysis. Response rates between questionnaires were compared to identify any preferences. Sample descriptive statistics were carried out, and associations between variables such as age, education and HRT status were made using the chi-square test. The one-sample t-test was used to detect attitudinal changes between 1991 and 2000, and multiple logistic regression to identify confounding factors.
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Results |
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Response rate
Of the 600 questionnaires, 17 were excluded (14 returned by the post office and three by disabled people unable to complete the questionnaire), giving a corrected response rate of 79.1% (461/583); 15.2% (70/461) were aged 20–29 years, 20.8% (96/461) 30–39 years, 21.5% (99/461) 40–49 years, 20.4% (94/461) 50–59 years and 22.1% (102/461) 60–69 years.
Of the respondents, 49.9% (230/461) completed word-processed and 50.1% (231/461) computer-readable questionnaires. No preference for either questionnaire was found among age or educational subgroups.
The response rates to individual questions reported in this paper ranged from 89.8 to 100%. More of the younger women failed to answer the questions relating to attitudes towards the menopause. The knowledge-based items were less likely to have been answered by the women aged 60–69 years.
Characteristics of respondents
Of the respondents, 52.7% (243/461) were pre-menopausal and 47.3% (218/461) menopausal/post-menopausal (referred to hereafter as post-menopausal women). Of the post-menopausal women, 17.4% (38/218) were current users, 22.0% (48/218) were past users and 60.6% (132/218) were never users of HRT. HRT use was significantly associated with age. No women aged 20–29 years, 2.1% of women aged 30–39 years, 8.1% aged 40–49 years, 47.9% aged 50–59 years and 30.4% aged 60–69 years reported ever use of HRT (chi-square = 350.2, df 4, P < 0.001). Since 1991, there was an increase of 7.6% in the number of current users (from 9.3 to 16.9%; chi-square = 7.78, P < 0.01), a 14.9% increase in past users (7.1 to 22.0%; chi-square = 30.79, P < 0.01) and a 22.4% decrease in never users of HRT (83.5 to 61.1%; chi-square = 40.32, P < 0.01).
By defining ‘less educated’ as those not educated beyond secondary school level, and ‘more educated’ as those educated beyond secondary school, 57.2% (262/458) of respondents were less educated and 42.8% (196/458) more educated. Of those aged 20–29 years, 54.3% were less educated, as were 50.0% of those aged 30–39 years, 45.5% of those aged 40–49 years, 63.8% of those aged 50–59 years and 77.2% of those aged 60–69 years.
Although not statistically significant, more of the less educated post-menopausal women [40.4% (62/135)] were ‘ever takers’ of HRT than the more educated women [37.5% (24/64)]. In contrast, in 1991 (when 24.7% of more educated and 16.3% of less educated women were ever users), the more educated women were more likely than the less educated women to have used HRT at some point.7 The increased use of HRT among the less educated women was statistically significant (chi-square = 19.4, P < 0.001). Age did not confound this relationship (P = 0.255). Previous use of the oral contraceptive pill (OCP) was more likely in current 75.6% (30/37) and past users 72.9% (35/48) of HRT, than never users 54.6% (88/162) (chi-square = 61.6, P = 0.025). Compared with 1991,7 prior use of the OCP in all HRT subgroups had increased (current users, 20.1%; past users, 32.9%; and never users, 25.2%).
Symptoms experienced by post-menopausal women
The post-menopausal women were given a list of symptoms and asked if they had experienced any of them for >6 months following their last menstrual period (Table 1
). Two of these symptoms were significantly associated with HRT status of the women; more of the ever takers experienced depression (P = 0.031) and insomnia (P = 0.041) than never users. There was no statistical difference between levels of reported symptoms compared with 1991.
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Attitudes towards the menopause
The women were asked to rate 10 statements about the menopause on a scale from 1 (strongly agree) to 7 (strongly disagree) (Table 2
). The majority of respondents agreed (score 1–3) that if the menopause is brought on by diminished hormone levels it should be viewed as a medical condition and treated as such [76.3% (29/37) of current users, 82.2% (37/45) of past users, 62.0% (75/121) of never users and 74.8% (178/238) of pre-menopausal women]. The majority also agreed that women with distressing symptoms should take HRT. Yet many agreed that natural approaches were better than HRT: 29.7% (11/37) of current users; 48.9% (22/45) of past users; 57.4% (70/122) of never users; and 46.0% (108/235) of pre-menopausal women. Compared with 1991,7 current users agreed less strongly that the ‘menopause should be viewed as a medical condition and treated as such’ [confidence interval (CI) = 1.14–2.3, P = 0.05) and also disagreed more strongly that ‘a woman feels less of a woman after the menopause’ (CI = 3.1–3.7, P = 0.05). Never users agreed less strongly that the risks of taking HRT outweighed the benefits (CI = 4.3–5.7, P = 0.05).
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Factors influencing the use of HRT
The women were asked to rate 10 factors that might influence their use of HRT on a scale of 1, ‘would persuade me to take HRT’, to 5 ‘would persuade me not to take HRT’ (Table 3
). Over 50% (53/103) of never users would be persuaded to take HRT on a doctor’s recommendation. The other factors rated most positively by never users were that ‘a test could determine the risk of osteoporosis’ and that it ‘would not cause problems if taken properly’. Compared with 1991, past users had become less persuaded to take HRT if a friend was taking it without problems (CI = 1.7–2.5, P = 0.05). Pre-menopausal women had become more persuaded not to take HRT if a friend was taking it and having problems (CI = 3.4–3.8, P = 0.004).
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Knowledge of HRT
In order to determine knowledge of HRT, women were asked to assess the validity of four statements relating to oestrogen. The results according to age and educational level are shown in Table 4
. The majority of women did not know that oestrogen alone may decrease the chance of a heart attack, that oestrogen increases the risk of uterine and breast cancer and that oestrogen is safer if a progestogen is taken with it. Less educated women were less knowledgeable than more educated women. Women aged 50–59 years were most knowledgeable.
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Compared with 1991,7 knowledge of HRT had decreased in all groups, but was only significantly decreased among women aged 30–39 years and 40–49 years (Table 4
).
Consideration of HRT
Forty-eight per cent (105/218) of the post-menopausal women had considered taking HRT, and 39.0% (85/218) had gone on to take the treatment (compared with 22.5 and 16.9%, respectively, in 19917). Of the 132 never users, 85.6% (113/132) had never considered it [representing 51.8% (113/218) of all post-menopausal women], 4.5% (6/132) were advised against it by their GP and 9.8% (13/132) had considered it but decided not to take it. The number of never users who had discussed HRT with a doctor had increased since 1991 from 11.9 to 13.6%.
Use among hysterectomized women
Thirteen per cent (58/461) of the respondents had had a hysterectomy (current age range 26–69 years, mean age 53.9 years, SD 8.9). Sixty-four per cent (36/56) of these women had considered HRT. Seven per cent (34/461) of the respondents had had a hysterectomy in the past 16 years. Of these women, 32.4% (11/34) were current HRT users, 20.6% (7/34) were past users and 47.1% (16/34) were never users. Our recent study showed that women with a hysterectomy were more likely to be taking HRT currently or have taken it in the past than those in 19917 (rates not significant).
Osteoporosis
Forty-two per cent (192/461) of the women realized there are no warning signs of osteoporosis (44.2% ever users, 44.1% never users, 41.2% pre-menopausal women). This rate was 10.9% higher than that found in 1991. However, knowledge was not associated with HRT status (P = 0.877).
The majority of women recognized that decreased dietary calcium intake was a risk factor for osteoporosis (50% current users, 62.5% past users, 51.2% never users, 62.7% of pre-menopausal women). However, this knowledge was not associated with HRT status (P = 0.127). There was a lack of awareness of the risks associated with smoking, family history, underweight and inactivity. Significantly more of the post-menopausal women who had ever taken HRT [55.2% (48/87)] recognized that lack of oestrogen is a risk factor than those who had never taken it [32.3% (40/124)] (chi-square = 13.73, P = 0.003). Compared with 1991, current users had an increased knowledge that smoking was a risk factor (chi-square = 7.58, P = 0.006). However, never users had a decreased knowledge of the risks of decreased dietary calcium (chi-square = 32.08, P = 0.001) and family history of osteoporosis (chi-square = 14.39. P < 0.001).
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Discussion |
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This was a repeat of an earlier study which had surveyed an age-stratified, random sample of 1500 women aged 20–69 years, selected by computer from Grampian Health Board lists. However, as discussed previously, this method could not be repeated. The eight practices (one from each LHCC) that we used to obtain the sample may not have been representative of the parent LHCC in each case, or, as a group of practices, may not have been representative of Grampian. In addition, the general practices may not be comparable with the practices used in 1991. The electoral role was considered as a way of obtaining the sample but this is not age stratified and does not specify gender.
Instead of allowing women to decide whether they considered themselves to be menopausal or post-menopausal, we categorized them as menopausal if their periods had stopped due to the natural menopause, they had had a hysterectomy or were taking HRT. This was because women may not have known what is really meant by the menopause and some otherwise may have stated they were menopausal when strictly speaking they were not and would not benefit from HRT.
This study achieved a good response rate, indicating that HRT use is still a relevant subject for women. There was no difference in response rate for either format of the questionnaire despite the questionnaires looking quite different. Since the computer-readable questionnaire greatly decreases data entry time and removes transcription errors, it is likely to be of increasing use in the future. However, irrespective of questionnaire format, we found that the younger women were less likely to respond to the questions relating to attitudes towards the menopause, which may have been because they did not consider them relevant. The older women were less likely to respond to the knowledge-based questions. A possible explanation for this reduced response might be that these items were more complex and the oldest age group, of whom a higher percentage were less educated, were deterred by this.
The level of HRT use found is similar to that in other UK studies,9 but is still dramatically lower than in America, where 4315 to 71%16 of post-menopausal women currently use HRT.
Only 39% of all post-menopausal women had used HRT. As in the previous two studies,7,8 no information was collected on duration of HRT use. This might have been useful as it is a crucial factor in all but the relief of hot flushes. Ever users reported a higher incidence of depression and insomnia (before beginning therapy) than never users. The majority had never used it despite experiencing symptoms. Although depression and insomnia were self-diagnosed by many women, it appears that some GPs may not have fully explored their patient’s agenda during the consultation and so failed to diagnose these conditions, and inappropriately prescribed HRT.
Forty-two per cent of never users claimed that if HRT would stop hot flushes then this would persuade them to take it. It is unclear whether these women are unaware of HRT, are not particularly troubled by their symptoms or have never considered consulting their GP. Half of never users claimed they would be persuaded to take HRT on a doctor’s recommendation, yet only 14% had discussed HRT with their doctor.
Although there was an overall increase in HRT use, this increased use was less pronounced in the more educated women. This may indicate that these women are more aware of the inconclusive evidence regarding the risks and benefits of HRT and therefore less inclined to take HRT. Recent American research evidence from the National Institutes of Health17 has fuelled the debate on the risks and benefits of HRT by highlighting the significantly increased risks of invasive breast cancer, coronary heart disease, stroke and pulmonary embolism associated with combined formulations of HRT.
Although the level of knowledge regarding HRT had decreased since 1991, knowledge was higher than that reported in the literature,18,19 except, however, when compared with an American study which reported that 30% of women were aware of the effects of HRT.20 The apparent decrease in knowledge since 1991 is interesting given that the number of post-menopausal women discussing HRT with their GP had doubled. Reasons for the decrease may include the limited retention of information given in the consultation, or could reflect confusion caused by conflicting evidence regarding the risks and benefits.
Never users were most in favour of using natural methods to control menopausal symptoms and were less likely to have used the OCP than current or past users of HRT—a trend found in other studies.21 It is possible that certain women are more disposed to taking medications, although, conversely, the results found that 30% of current users thought that natural methods were better than HRT for controlling menopausal symptoms.
It appears that the low rate of HRT use in Grampian is unlikely to be due to a problem of attitude. Interestingly, we found that women agreed less strongly in 2000 compared with 1991 that ‘the menopause should be viewed as a medical condition’ and also that they disagreed more strongly that ‘a woman feels less of a woman after the menopause’. This might be explained by anthropological and sociological findings on the menopause and HRT. It was possible that never users may have decided to ‘never use’ based on ‘lay evaluations’. However, our survey tool was not designed to explore these issues in depth. There is a need for high quality qualitative studies to shed light on how women make decisions about HRT, menopause, natural versus medical interventions, and medical and culturally constructed explanations about menopause and HRT.
As found in the 1991 study, the most common reason for not taking HRT was that the women had never considered it. This is more disturbing when hysterectomized women are considered, as 47% of them had never used HRT. Are GPs still disinclined to prescribe drugs which may later be found to be responsible for undesirable side effects? Or is it a cost-cutting exercise? Further exploration of these issues is needed.
The knowledge-based questions in our questionnaire are now out-dated as recent research has shown that previously believed theories about HRT (e.g. cardioprotective properties, risks of breast and endometrial cancers between the various preparations of HRT) are being challenged. The uncertainty of the risks and benefits of HRT, increased by the recent research evidence from the National Institutes of Health,17 appears to be reflected in the apparent confusion in the majority of the women we surveyed. For the same reason, we would also suggest that, while short-term use of HRT can be beneficial for symptomatic control, the long-term use of HRT for unproven benefit is now questionable.
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Acknowledgments |
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This research was undertaken as part of a BSc Medical Science thesis written by KJL at the University of Aberdeen. We are grateful to the eight general practices and the large number of women who made the study possible by responding to our requests for information. We are grateful to Caroline Gault and Mary Bruce, Clinical Audit staff from the Department of Public Health (Grampian Health Board) who aided the design and production of the computer-readable (Formic) questionnaire. We also wish to thank Julie Simpson for her statistical advice.
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References |
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