Prescription Of Hormone Replacement Therapy Research Articles

Drug related negative side-effects is a common reason for poor compliance in hormone replacement therapy

Objectives: The reasons for poor compliance with hormone replacement therapy (HRT) and, in particular drug-related reasons, have not yet been fully elucidated. In this study, a cohort of peri- or postmenopausal women—mainly workers from a small town and surrounding rural area—was studied. The aim of the study was to investigate why some women never start or discontinue HRT, even when great effort has been made to inform and fulfill the demands of the patient. Methods: All women who were given a HRT prescription at a gynecological practice between September 1991 and December 1992 participated in a longitudinal study. A written questionnaire was mailed to these patients in 1996. Data from the questionnaire was supplemented with information from the medical records. Care of patients included initial information, follow-up within 4 months, yearly visits supplemented with contacts on demand. Results: 356 women received the questionnaire, among which 92% replied. A total of 2% never started HRT. Seventy-five percent continued the therapy for more than 3 years. Reasons for discontinuing HRT were negative side-effects (35%), desire to find out if climacteric symptoms had ended (26%), fear of cancer and thrombosis (25%), weariness of bleeding (19%) and a wish to deal with the problems ‘naturally’ (15%). Conclusions: Compliance with HRT can be high if adequate information is given and follow-ups are made. The main reason for poor compliance was negative side-effects, most likely progestin-related. The results of this study suggest that the future challenge will be to minimize negative side-effects of HRT.

Hormone replacement therapy in women treated for gynaecological malignancy

Can we prescribe hormone replacement therapy (HRT) safely for women, with postmenopausal complaints who were treated for a gynaecological malignancy? Only three retrospective studies have investigated this issue in endometrial cancer patients. No recurrences or deaths occurred in these treated groups. However, the physician introduced bias through the selection of favourable groups. At present, combined estrogen and progestogen therapy is probably not contra-indicated in endometrial cancer stage I and probably also not in stage II, although so far there is only circumstantial evidence. Squamous cell cancers of the cervix, vulva, and vagina are unlikely to be influenced by HRT. In the only study available of women with ovarian cancer, ≤50 years, estrogen replacement therapy did not have a negative influence on (disease-free) survival. According to the data currently available, no evidence exists that HRT adversely influences survival and overall survival after treatment for ovarian cancer. In general, adenocarcinomas of the cervix and leiomyosarcomas of the uterus may be managed such as the adenocarcinomas of the uterus. During the last 25 years, HRT has been shown to substantially reduce the risk of cardiovascular diseases, osteoporotic fractures and colon carcinoma. On the other hand there is a significant increase of the risk in breast cancer with prolonged use of >5 years. Re-evaluation of the current view that HRT should no be given to women treated for a gynaecological malignancy is strongly warranted after evaluating the advantages and the disadvantages of HRT use in each individual patient. Long-term HRT in women treated for a gynaecological cancer must be based on the medical history of the individual patient (and her family).

Racial differences in hormone replacement therapy prescriptions

Objective: To examine racial differences in hormone replacement therapy (HRT) use by analyzing the relative risks and rates of HRT prescriptions for black and white women. Methods: Data on visits to hospital outpatient departments and office-based physicians by black and white women aged 45–64 years were obtained from 25,203 visits sampled in the 1993–1995 National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys. The relative effect of race on the provision of an HRT prescription at an ambulatory visit was estimated by controlling confounders using logistic regression. Population-based rates of physician visits and visits with HRT prescriptions were also calculated to address issues involving access to care. Results: Approximately 98,787,000 annual visits were made by black and white women 45–64 years of age, 9.2% of which involved prescriptions for HRT. The percentage of visits by black women in which prescriptions for HRT were reported (4.5%) was roughly half that of white women (9.7%). The association persisted after controlling for type of physician, practice type, geographic region, payment source, and non-HRT prescription(s) (odds ratio 2.1; 95% confidence interval 1.5, 2.9). The rate of ambulatory care among black women (3.82 visits per year per woman) was virtually identical to that of white women (3.94 visits per year), whereas the rate of visits with HRT prescriptions for white women was twice as high as for black women (0.38 and 0.17 visits per year, respectively). Conclusion: Apparent racial differences in HRT use persist after controlling for physician and visit factors not explored in previous studies.

Low use of long-term hormone replacement therapy in Denmark.

To examine individual use of hormone replacement therapy (HRT) in a defined population of Danish women during a 5-year period. HRT may reduce osteoporosis and cardiovascular disease in postmenopausal women, but may also have side-effects. Little is known about the use of HRT in most populations. A Pharmacoepidemiological Prescription Database was used to identify all reimbursed prescriptions for HRT in the county during the period 1991 to 1995. The Danish retail pharmacies' drug subsidy system made it possible to identify prescriptions by individual use. We examined 255797 HRT prescriptions issued during the period in the County of North Jutland. Total sales reached 16.5 million defined daily doses (DDDs), purchased by 31653 women, which corresponds to 26.9% of the female population above the age of 39 years. The annual prevalence proportion of current users rose from 10.4% to 14.8% during the study period, and the therapeutic intensity (DDD/1000 women/day) increased from 20.6 to 32.0. The mean DDD sum of systemic HRT per user was 73.4 in 1991; it and the proportion of users who received less than 90 DDD per year (83.4% in 1991) remained almost constant during the study period. The amount of oestrogen unopposed by progestin was high, 28.1% of all prescriptions. Less than one-fifth of the study population used HRT for more than 3 months per year, and only 32.8% of the women who were new users of HRT in 1992 continued this therapy throughout the study period.

Racial differences in hormone replacement therapy prescriptions

Abstract Objective: To examine racial differences in hormone replacement therapy (HRT) use by analyzing the relative risks and rates of HRT prescriptions for black and white women. Methods: Data on visits to hospital outpatient departments and office-based physicians by black and white women aged 45–64 years were obtained from 25,203 visits sampled in the 1993–1995 National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys. The relative effect of race on the provision of an HRT prescription at an ambulatory visit was estimated by controlling confounders using logistic regression. Population-based rates of physician visits and visits with HRT prescriptions were also calculated to address issues involving access to care. Results: Approximately 98,787,000 annual visits were made by black and white women 45–64 years of age, 9.2% of which involved prescriptions for HRT. The percentage of visits by black women in which prescriptions for HRT were reported (4.5%) was roughly half that of white women (9.7%). The association persisted after controlling for type of physician, practice type, geographic region, payment source, and non-HRT prescription(s) (odds ratio 2.1; 95% confidence interval 1.5, 2.9). The rate of ambulatory care among black women (3.82 visits per year per woman) was virtually identical to that of white women (3.94 visits per year), whereas the rate of visits with HRT prescriptions for white women was twice as high as for black women (0.38 and 0.17 visits per year, respectively). Conclusion: Apparent racial differences in HRT use persist after controlling for physician and visit factors not explored in previous studies.

Prescription of hormone replacement therapy in postmenopausal women with renal failure

Prescription of hormone replacement therapy in postmenopausal women with renal failure

Hormone replacement therapy usage: a 10 year experience of a solo practitioner

The objective of this study was to identify factors affecting hormone replacement therapy (HRT) usage among patients of a single physician. All active patients ( n=330) given a HRT prescription over the past 10 years (1985–1995) by the physician were sent a questionnaire on health knowledge, lifestyle patterns, general medical and reproductive histories, responses to HRT usage and decision-making about HRT use. A total of 214 useful questionnaires were returned giving a response rate of 65%. For this cohort, the length of HRT use for those still taking HRT was 60 months; and for those no longer taking HRT, it was 32 months; and 85% of those ever given an HRT prescription were still using HRT at the time of survey. The educational backgrounds, exercise patterns, health knowledge, medical and reproductive histories of this group were representative of those found among suburban postmenopausal women in central Pennsylvania. Among this cohort, the most important reason for them taking HRT was the physicians’ recommendation.

Do women with diabetes receive hormone replacement therapy?

AbstractThe principal cause of death in post‐menopausal women with diabetes is cardiovascular disease. Women who use hormone replacement therapy (HRT) have been shown to have a 50% reduction in their risk of coronary heart disease (CHD). The aim of this study was to determine if general practitioners prescribed HRT as frequently to women with diabetes as to other women of the same age. A prevalence study of HRT prescribing was carried out using a GP database. There were 188,933 women aged 45–79 years on the database, of whom 17% were prescribed HRT. The overall age‐standardised rate ratio for HRT use in women with diabetes compared with women without diabetes was 0.71 (95% CI 0.64–0.78). Within the diabetic group, insulin‐treated patients compared with those treated with hypoglycaemic agents were more likely to be prescribed HRT, with an age‐standardised rate ratio of 1.31 (95% CI 1.06–1.62). The study shows that general practitioners are less likely to prescribe HRT to women with diabetes despite the potential major benefits of a reduced incidence of CHD.

Comparison of Continuation of Postmenopausal Hormone Replacement Therapy

To determine possible differences in the rate at which hormone replacement therapy (HRT) is continued among postmenopausal women treated initially with transdermal estradiol versus those treated initially with oral conjugated estrogens. A retrospective database search for prescription use. Northern California facilities of Kaiser Permanente, a health maintenance organization. Women aged > or = 45 years who filled index prescriptions for HRT during 1995 for either 0.05 mg transdermal estradiol semiweekly or 0.625 mg oral conjugated estrogen daily. All had filled prescriptions for medroxyprogesterone acetate (MPA) on the same day as the index estrogen prescription. We found statistically significantly greater relative risk (RR) of discontinuation among women whose HRT began with transdermal estradiol compared with women whose HRT began with oral conjugated estrogens [RR = 2.6, 95% confidence interval (CI) = 1.8-3.8]. After multiple adjustments, RR was 2.7 (95% CI = 1.8-3.9). Complete discontinuation of HRT treatment accounted for most of the stopping we observed, but more women switched from transdermal to oral (25% of those discontinuing this route) than switched from oral to transdermal (0.9% of those discontinuing this route). Risk of discontinuation was not associated with whether prescriber was a gynecologist (RR = 1.2, 95% CI = 0.9-1.7). Type of progestin schedule (cyclic vs. continuous combined) also was not a predictor for discontinuation (RR = 0.9, 95% CI = 0.8-1.0). Older age at start of treatment was associated with discontinuation (RR = 1.1, 95% CI = 1.0-1.2) for every additional 5 years of age. Among women starting HRT, those using a semiweekly transdermal estradiol regimen have a lower rate of continuation than do those using oral estrogen daily.

Hormone Replacement Therapy in Women with Previous Breast Cancer

As breast cancer is known to be a tumour sensitive to the effects of endogenous oestrogens, clinicians are reluctant to prescribe hormone replacement therapy (HRT) to women with a history of previous breast cancer for fear of stimulating disease recurrence, and it is currently contraindicated in this group of women. However, an increasing proportion of breast cancer patients are requesting the use of HRT to relieve the symptoms of oestrogen deficiency, which are also a common side-effect of adjuvant therapy for breast cancer. Observational data on the use of HRT in breast cancer survivors has not demonstrated an increase in disease recurrence, but uncertainty will continue in the absence of data from prospective, randomized trials. This review aims to demonstrate why it is ethical and scientifically important to undertake such studies.

The use of hormone replacement therapy in women with acute myocardial infarction: an audit of current practice.

We undertook criterion-based audit of the current practice of prescribing hormone replacement therapy for women with acute myocardial infarction; the audit included 181 consecutive women admitted to one hospital with this diagnosis in one calendar year. The set standard was that, barring any contraindication, all postmenopausal women with acute myocardial infarction should be prescribed hormone replacement therapy before discharge from hospital. The evidence base of this standard derives from more than 30 epidemiological and clinical studies and a large body of biological data. Only 4.7% of the women were current users of hormone replacement therapy and the set standard was met in only 3% of eligible nonusers. Professionals caring for women who have had a myocardial infarction need to consider hormone replacement therapy as a secondary prophylaxis of myocardial infarction. Gynaecologists should liaise with colleagues in other specialties and general practice to ensure that information on the nongynaecological benefits of hormone replacement therapy is widely disseminated.

Initiation of hormone replacement therapy after diagnosis of osteoporosis by bone densitometry

The effect of osteoporosis, as diagnosed by bone densitometry, on general practitioners' decisions to initiate hormone replacement therapy (HRT) was assessed. Data for the study were collected by questionnaire from 147 women (>40 years), previously referred for measurement of bone mineral density (BMD) at the proximal forearm. Among the women, at the time of BMD measurement, current and ever use of HRT was 35% and 50% respectively, and 25.2% were osteoporotic on the basis of their BMD level. HRT was more likely to be initiated by women who were told that their BMD was low (ODR 3.4; 95% CI 1.2–9.7); 35% of all women with osteoporosis were using HRT compared with 78% who were taking calcium supplements. Potential reasons for the low HRT prescription may include the nature of the BMD report, patient aversion to HRT and doctors' concern with the long-term side-effects of HRT.

Factors Influencing the Prescription of Hormone Replacement Therapy

Objective: To assess the effects of age, bone mineral density, risk of cardiovascular disease, and of breast cancer on the prevalence of hormone replacement therapy (HRT) prescriptions.Methods: Seventeen charts of postmenopausal women were summarized. For each chart, we constructed 36 different cases by modifying the age (two levels), the bone mineral density (three levels), the cardiovascular risk (three levels), and the breast cancer risk (two levels). Twelve cases of these 612 files were sent to each Belgian gynecologist (n = 1010).Results: Overall, HRT was prescribed in 67% of the cases. It was prescribed in 54.6% of women who had a normal bone mass, 67.9% of women with a low bone mass, and 79.0% of those with osteoporosis (P < .001). The prescription rate was higher in younger women (mean ± standard deviation 55 ± 4 years) than in their peers who were 10 years older (79.3% versus 55.2%; p < .001). No significant variation was observed in relation to the cardiovascular risk profile or to breast cancer risk.Conclusion: Osteoporosis is associated with an increased rate and older age with a decreased rate of HRT prescription, whereas no difference is observed in association with cardiovascular or breast cancer risk.

Women's beliefs and decisions about hormone replacement therapy.

To examine preventive health practices in older women, we conducted computer-assisted telephone interviews with 1082 women aged 50-80 who were enrollees of Group Health Cooperative of Puget Sound (June-November 1995; 80.3% response rate). We sought to describe the women's reasons for initiating, discontinuing, or not initiating hormone replacement therapy (HRT). HRT use was categorized as current (42.5%), past (20.9%), or never (36.6%) based on the interviews. The reasons most frequently cited by current users for initiating HRT were menopausal symptoms (47.3%), osteoporosis prevention (32.4%), and physician advice (30.3%). The most frequently cited reasons for quitting HRT were side effects (26.6%), physician's advice (22.9%), fear of cancer (15.4%), and not wanting menstrual periods or bleeding (15.2%). Of past users, 53.8% reported stopping HRT on their own, and 46.2% did so at their physician's advice. The reasons most commonly cited by never users for not initiating HRT were that hormones were not needed (49.9%) and that menopause is a natural event (17.9%). Among never users, 33.1% reported considering HRT, only 46.6% discussing it with their provider, and 5.0% being given an HRT prescription they did not fill. Many women made decisions about HRT independent of interactions with health care providers. Better understanding of the beliefs and decisions that influence women's choice to use or not use HRT is needed to develop more effective counseling strategies.

Hormone replacement therapy among Danish women aged 45–65 years: Prevalence, determinants, and compliance

To study the prevalence and determinants of consultation for climacteric complaints and the prescription, commencement, and continuation of hormone replacement therapy (HRT) among women aged 45-65 years. A cross-sectional national survey was conducted in Denmark in November 1994 among 1459 women. A total of 1015 women (response rate 69.6%) agreed to participate and provided questionnaire data. Of the women who had experienced climacteric complaints, 67.4% (95% confidence interval [CI] 63.3, 71.4%) had consulted a physician. More women consulted if their complaints were severe rather than slight-to-moderate (odds ratio [OR] 6.46). Within the total sample, 33.4% of the women had been prescribed HRT at some time, and 94.1% of these women actually had started the treatment. Of the women who started the treatment, 66.3% reported that they still were using HRT at the time of the survey. The current HRT use rate among all respondents was 18.4% (95% CI 16.1, 20.9%). Women with severe or slight-to-moderate climacteric complaints more often reported having had HRT prescribed than women without complaints (OR 23.2 and 5.80, respectively). Furthermore, women who had had a hysterectomy with bilateral oophorectomy more often reported use than women with an intact uterus (OR 10.0). Hormone replacement therapy prescription was associated only weakly with osteoporosis concerns (OR 1.74). Its continuation decreased with age, was higher after hysterectomy and among women who regularly participated in sports or exercised, but was not (P > .05) related to osteoporosis concerns. Age-specific HRT continuation rates decreased among users who reported withdrawal bleeding (P < .05) but not among users who did not experience such bleeding (P > .05). In this survey, HRT had been used by one in three women at menopause, mainly for the alleviation of climacteric complaints and hardly ever because of osteoporosis concerns. Although it might be expected that HRT users who are concerned about developing osteoporosis in later life would be likely to continue the treatment for longer than other users, the study results did not bear this out. Continuation depended mainly on having had a hysterectomy and participation in sports and was higher among users with an intact uterus if they had had no withdrawal bleeding.

Effect of bone density information on decisions about hormone replacement therapy: A randomized trial

Objective: To determine the effect of bone density information on a woman's decision about hormone replacement therapy (HRT). Methods: One hundred forty women were assigned randomly to receive either educational information about osteoporosis and a voucher for a bone mineral density test 12 months later or the same educational information plus an immediate dual-energy x-ray absorptiometry test for bone mineral density. Women in both groups were offered prescriptions for HRT. Results: Of the 93 women who received a bone mineral density test, 63.4% elected HRT and filled their prescription, compared with only 20.0% of the 43 women who did not have a bone mineral density test ( P Conclusions A bone mineral density test, regardless of the result, had a significant effect on women's decisions to accept HRT. Within the group having the test, women with lower bone mineral density were more likely to choose HRT.

Hormone replacement therapy and major risk factors for reproductive cancers, osteoporosis, and cardiovascular diseases: Evidence of confounding by exposure characteristics

Observational studies have yielded reports on long-term effects of hormone replacement therapy (HRT) for cardiovascular, osteoporosis-related, and cancer diseases. There is concern that risk estimates may be confounded by complex mechanisms of selection with regard to important risk determinants. In this study, we tested the hypothesis that baseline characteristics of women vary with exposure characteristics, i.e., the choices of complying with prescriptions, using different compounds and regimens, and continuing intake long-term. We analyzed the prevalence of relevant risk factors and their relationships to characteristics of exposure among 11,231 Swedish women who had received prescriptions for HRT. Associations were studied through logistic regression, with comparisons of women with ever-use versus non-compliance, long-term (73+ months) versus short-term use (1–72 months), intake of conjugated estrogens versus estradiol compounds, and intake of estrogens only versus estrogens combined with progestins, respectively. We found that women denying intake or using HRT short-term had higher parity, earlier age at first birth and a lower prevalence of hysterectomy or oophorectomy than those complying or exposed long-term. A high level of education was associated with compliance and long-term exposure, and heavy physical exercise and high intake of food fibers were associated with compliance. Climacteric symptoms were associated with compliance, long-term intake and use of conjugated estrogens, whereas a history of oral contraceptive intake was associated with use of estrogens alone without progestins. We conclude that selection biases in studies of HRT effects are important and complex in that they may vary with the reported exposure. Our findings are important, as they point to the need for improved methods for measuring, in particular, factors linked to lifestyle and health behavior, in order to account more fully for confounding in the analyses of risk relationships.

Effect of bone density information on decisions about hormone replacement therapy: A randomized trial

To determine the effect of bone density information on a woman's decision about hormone replacement therapy (HRT). One hundred forty women were assigned randomly to receive either educational information about osteoporosis and a voucher for a bone mineral density test 12 months later or the same educational information plus an immediate dual-energy x-ray absorptiometry test for bone mineral density. Women in both groups were offered prescription for HRT. Of the 93 women who received a bone mineral density test, 63.4% elected HRT and filled their prescription, compared with only 20.0% of the 43 women who did not have a bone mineral density test (P < .01). Women who were classified as osteopenic (between -1 and -2.5 standard deviations [SDs] of the young normal bone mineral density) or osteoporotic (more than 2.5 SDs below young normals) were more likely to choose HRT (69.4%) than were women whose bone mineral density was in the normal range (51.6%) (above -1 SD of the young normal bone mineral density value). A bone mineral density test, regardless of the result, had a significant effect on women's decisions to accept HRT. Within the group having the test, women with lower bone mineral density were more likely to choose HRT.

Initiation of hormone replacement therapy after diagnosis of osteoporosis by bone densitometry.

The effect of osteoporosis, as diagnosed by bone densitometry, on general practitioners' decisions to initiate hormone replacement therapy (HRT) was assessed. Data for the study were collected by questionnaire from 147 women (> 40 years), previously referred for measurement of bone mineral density (BMD) at the proximal forearm. Among the women, at the time of BMD measurement, current and ever use of HRT was 35% and 50% respectively, and 25.2% were osteoporotic on the basis of their BMD level. HRT was more likely to be initiated by women who were told that their BMD was low (ODR 3.4; 95% CI 1.2-9.7); 37% of all women with osteoporosis were using HRT compared with 78% who were taking calcium supplements. Potential reasons for the low HRT prescription may include the nature of the BMD report, patient aversion to HRT and doctors' concern with the long-term side-effects of HRT.

Is systematic osteoporosis prevention and detection possible in a district hospital?

Osteoporosis demands systematic management for optimum use of resources. Guidelines from the Primary Care Rheumatology Society (PCRS) aim to improve its diagnosis and treatment. We identified all admissions over three months to a district general hospital of patients with fracture of femur, vertebra, or distal forearm and of women who underwent oophorectomy or hysterectomy. We audited their care using the criteria that the diagnosis and risk of osteoporosis should be recorded; that management should follow PCRS guidelines; and that this information should be communicated to general practitioners. An ideal standard of 100% compliance with these criteria was chosen. Overwhelmingly these audit criteria were not met, the only one that was met being the prescription of hormone replacement therapy after oophorectomy. Potential for prevention of 35% of hip and distal forearm fractures was identified, the commonest risk factor being long‐term corticosteroid therapy. Identification of high risk patients is feasible by simple methods and their management needs improvement. We suggest that a ‘long‐term corticosteroid therapy register’ and a dedicated ‘osteoporosis service’ would facilitate this.