Women's Health Initiative Study Research Articles

Managing menopausal symptoms

Summary Until the mid 1990s, hormone therapy was seen as not only a safe means of relieving troublesome menopausal symptoms but as a way of preserving youth and vitality. Adverse findings from a number of studies in the 1990s cast doubt on some of the earlier claims, but it was the publication of the women's Health Initiative study in 2002 that resulted in a complete reappraisal of the principles of menopause management.

Women's decision making during the menopausal transition

To describe women's experiences during decision making about hormonal and nonhormonal therapies during the menopausal transition. Transcripts from 21 semi-structured audio taped interviews with seven peri- and postmenopausal women who had a recently visited a nurse practitioner (NP) and were making a decision about menopausal management. Decision making was a nonlinear process in which women considered available options, weighed benefits and risks and likely outcomes. Reevaluation of the decision was ongoing. Both internal and external conditions influenced their decisions. Media reports of findings from the Women's Health Initiative study may have influenced some women's perceptions of the risk of using hormones for symptom relief. Women described caring and empowering consultations with the NPs. They appreciated provision of information, adequate time spent at the visit, and decision support. NPs have a critical role to play in providing women with current research findings about hormone therapy and alternatives for symptom relief, and assisting women with understanding risks and benefits of each possible choice. Both individual and group approaches for decision support should be available to women. The approach of a collaborative partnership in decision making is a model that is congruent with nursing practice.

Correlates of spirituality in older women

Introduction: The role of spirituality in the context of mental health and successful aging is not well understood. In a sample of community-dwelling older women enrolled at the San Diego site of the Women's Health Initiative study, we examined the association between spirituality and a range of variables associated with successful cognitive and emotional aging, including optimism, resilience, depression, and health-related quality of life (HRQoL). Methods: A detailed cross-sectional survey questionnaire on successful aging was completed by 1973 older women. It included multiple self-reported measures of positive psychological functioning (e.g., resilience and optimism), as well as depression and HRQoL. Spirituality was measured using a five-item self-report scale constructed using two items from the Brief Multidimensional Measure of Religiosity/Spirituality and three items from Hoge's Intrinsic Religious Motivation Scale. Results: Overall, 40% women reported regular attendance in organized religious practice, and 53% reported engaging in private spiritual practices. Several variables were significantly related to spirituality in bivariate associations; however, using model testing, spirituality was significantly associated only with higher resilience, lower income, lower education, and lower likelihood of being in a marital or committed relationship. Conclusions: Our findings point to a role for spirituality in promoting resilience to stressors, possibly to a greater degree in persons with lower income and education level. Future longitudinal studies are needed to confirm these associations.

Lung cancer among postmenopausal women treated with estrogen alone in the women's health initiative randomized trial.

In the Women's Health Initiative (WHI) randomized controlled trial, use of estrogen plus progestin increased lung cancer mortality. We conducted post hoc analyses in the WHI trial evaluating estrogen alone to determine whether use of conjugated equine estrogen without progestin had a similar adverse influence on lung cancer. The WHI study is a randomized, double-blind, placebo-controlled trial conducted in 40 centers in the United States. A total of 10 739 postmenopausal women aged 50-79 years who had a previous hysterectomy were randomly assigned to receive a once-daily 0.625-mg tablet of conjugated equine estrogen (n = 5310) or matching placebo (n = 5429). Incidence and mortality rates for all lung cancers, small cell lung cancers, and non-small cell lung cancers in the two randomization groups were compared by use of hazard ratios (HRs) and 95% confidence intervals (CIs) that were estimated from Cox proportional hazards regression analyses. Analyses were by intention to treat, and all statistical tests were two-sided. After a mean of 7.9 years (standard deviation = 1.8 years) of follow-up, 61 women in the hormone therapy group were diagnosed with lung cancer compared with 54 in the placebo group (incidence of lung cancer per year = 0.15% vs 0.13%, respectively; HR of incidence = 1.17, 95% CI = 0.81 to 1.69, P = .39). Non-small cell lung cancers were of comparable number, stage, and grade in both groups. Deaths from lung cancer did not differ between the two groups (34 vs 33 deaths in estrogen and placebo groups, respectively; HR of death = 1.07, 95% CI = 0.66 to 1.72, P = .79). Unlike use of estrogen plus progestin, which increased deaths from lung cancer, use of conjugated equine estrogen alone did not increase incidence or death from lung cancer.

A component of Premarin ® enhances multiple cognitive functions and influences nicotinic receptor expression

In women, ovarian hormone loss at menopause has been related to cognitive decline, and some studies suggest that estrogen-containing hormone therapy (HT) can mitigate these effects. Recently, the Women's Health Initiative study found that conjugated equine estrogens, the most commonly prescribed HT, do not benefit cognition. Isolated components of conjugated equine estrogens (tradename Premarin ®) have been evaluated in vitro, with delta 8,9-dehydroestrone (∆ 8E1) and equilin showing the strongest neuroprotective profiles. It has not been evaluated whether ∆ 8E1 or equilin impact cognition or the cholinergic system, which is affected by other estrogens and known to modulate cognition. Here, in middle-aged, ovariectomized rats, we evaluated the effects of ∆ 8E1 and equilin treatments on a cognitive battery and cholinergic nicotinic receptors (nAChR). Specifically, we used 125I-labeled epibatidine binding to assay brain nicotinic receptor containing 4α and 2β subunits (α4β2-nAChR), since this nicotinic receptor subtype has been shown previously to be sensitive to other estrogens. ∆ 8E1 enhanced spatial working, recent and reference memory. ∆ 8E1 also decreased hippocampal and entorhinal cortex α4β2-nAChR expression, which was related to spatial reference memory performance. Equilin treatment did not affect spatial memory or rat α4β2-nAChR expression, and neither estrogen impacted 86Rb + efflux, indicating lack of direct action on human α4β2 nAChR function. Both estrogens influenced vaginal smear profiles, uterine weights, and serum luteinizing hormone levels, analogous to classic estrogens. The findings indicate that specific isolated Premarin ® components differ in their ability to affect cognition and nAChR expression. Taken with the works of others showing ∆ 8E1-induced benefits on several dimensions of health-related concerns associated with menopause, this body of research identifies ∆ 8E1 as a new avenue to be investigated as a potential component of HT that may benefit brain health and function during aging.

Effectiveness of phytoestrogens in climacteric medicine

The increased interest in phytoestrogens in the management of menopausal symptoms followed the publication of the Women's Health Initiative study. A wide-spread perception that these plant-derived compounds are equivalent to estrogen was established. These compounds evolved to fulfill the needs of plant physiological processes and are natural for the plant cells but not natural to the human cell. Epidemiological data suggest a possible protective effect of phytoestrogen if consumed during adolescence, but later on in life this effect is not clear. The utility of phytoestrogen as a "natural and safe" alternative to estrogen in alleviating vasomotor symptoms has failed the test in randomized clinical trials. Because many breast cancer sufferers seek in phytoestrogen a relief of estrogen deficiency symptoms, the possible interaction of such remedies with risk of recurrence of breast cancer or interference with tamoxifen action should not be overlooked.

The impact of menopausal hormone therapy on the incidence of different breast cancer types – Data from the Cancer Registry Hamburg 1991–2006

Background: The publication of the Women's Health Initiative Study [1] in 2002 and the Million Women Study [31] in 2003 on the association of menopausal hormone therapy (HT) and breast cancer were followed by a decrease in the prescription of HT to menopausal women in western countries. In the following years several papers from different countries reported declines in breast cancer incidence and discuss whether this decline is related to the decreased use of menopausal hormone therapy. Methods: We contribute further data by analysing breast cancer incidence rates from the Hamburg Cancer Registry, Germany, for the time period 1991–2006 and HT use data from a large case–control study conducted in the Hamburg region. At first we determined whether there is a decline in breast cancer incidence in 2002/2003. To find supporting evidence for a causal relationship between breast cancer incidence and use of menopausal hormones we addressed the following issues: The decline in incidence should be more pronounced in the age groups, in which HT is used predominantly, i.e. age group 50–69. The decline in incidence should be most pronounced for breast cancer types more strongly associated with HT, i.e. invasive lobular cancer. Results: We observed a statistical significant decline in incidence of all invasive breast cancer in 2002/2003 in Hamburg. The increase in breast cancer incidence as well as the decline was most pronounced in the age group 50–69. Regarding the histological types of tumours in this age group the decline was only pronounced for invasive lobular cancer. The estimated prevalence of HT indicates a decreasing hormone use starting in 2001/2002. We found a strong decrease in prescriptions for menopausal hormone therapy between 2002 and 2005. Conclusion: In summary, our data add to the evidence of a relation between breast cancer incidence and menopausal hormone use.

Long‐Term Effects of Conjugated Equine Estrogen Therapies on Domain‐Specific Cognitive Function: Results from the Women's Health Initiative Study of Cognitive Aging Extension

To determine whether small decrements in global cognitive function that conjugated equine estrogen (CEE) therapies have been shown to produce in older women persist after cessation and extend to specific cognitive domains. Randomized controlled clinical trial. Fourteen clinical centers of the Women's Health Initiative. Two thousand three hundred four women aged 65 to 80 free of probable dementia at enrollment. CEE 0.625 mg/d with or without medroxyprogesterone acetate (MPA, 10 mg/d) and matching placebos. Annual administrations of a battery of cognitive tests during and after the trial. Assignment to CEE-based therapies was associated with small mean relative decrements in global cognitive function and several domain-specific cognitive functions during the trial, which largely persisted through up to 4 years after the trial. The strongest statistical evidence was for global cognitive function (0.07-standard deviation decrements during (P=.007) and after (P=.01) the trial. For domain-specific scores, the mean decrements were slightly smaller, were less significant, and tended to be larger for CEE-alone therapy. CEE-based therapies, when initiated after the age of 65, produce a small broad-based decrement in cognitive function that persists after their use is stopped, but the differences in cognitive function are small and would not be detectable or have clinical significance for an individual woman. Differences in effects between cognitive domains suggest that more than one mechanism may be involved.

Postmenopausal Hormone Therapy: An Endocrine Society Scientific Statement

Our objective was to provide a scholarly review of the published literature on menopausal hormonal therapy (MHT), make scientifically valid assessments of the available data, and grade the level of evidence available for each clinically important endpoint. PARTICIPANTS IN DEVELOPMENT OF SCIENTIFIC STATEMENT: The 12-member Scientific Statement Task Force of The Endocrine Society selected the leader of the statement development group (R.J.S.) and suggested experts with expertise in specific areas. In conjunction with the Task Force, lead authors (n = 25) and peer reviewers (n = 14) for each specific topic were selected. All discussions regarding content and grading of evidence occurred via teleconference or electronic and written correspondence. No funding was provided to any expert or peer reviewer, and all participants volunteered their time to prepare this Scientific Statement. Each expert conducted extensive literature searches of case control, cohort, and randomized controlled trials as well as meta-analyses, Cochrane reviews, and Position Statements from other professional societies in order to compile and evaluate available evidence. No unpublished data were used to draw conclusions from the evidence. A consensus was reached after several iterations. Each topic was considered separately, and a consensus was achieved as to content to be included and conclusions reached between the primary author and the peer reviewer specific to that topic. In a separate iteration, the quality of evidence was judged using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system in common use by The Endocrine Society for preparing clinical guidelines. The final iteration involved responses to four levels of additional review: 1) general comments offered by each of the 25 authors; 2) comments of the individual Task Force members; 3) critiques by the reviewers of the Journal of Clinical Endocrinology & Metabolism; and 4) suggestions offered by the Council and members of The Endocrine Society. The lead author compiled each individual topic into a coherent document and finalized the content for the final Statement. The writing process was analogous to preparation of a multiauthored textbook with input from individual authors and the textbook editors. The major conclusions related to the overall benefits and risks of MHT expressed as the number of women per 1000 taking MHT for 5 yr who would experience benefit or harm. Primary areas of benefit included relief of hot flashes and symptoms of urogenital atrophy and prevention of fractures and diabetes. Risks included venothrombotic episodes, stroke, and cholecystitis. In the subgroup of women starting MHT between ages 50 and 59 or less than 10 yr after onset of menopause, congruent trends suggested additional benefit including reduction of overall mortality and coronary artery disease. In this subgroup, estrogen plus some progestogens increased the risk of breast cancer, whereas estrogen alone did not. Beneficial effects on colorectal and endometrial cancer and harmful effects on ovarian cancer occurred but affected only a small number of women. Data from the various Women's Health Initiative studies, which involved women of average age 63, cannot be appropriately applied to calculate risks and benefits of MHT in women starting shortly after menopause. At the present time, assessments of benefit and risk in these younger women are based on lower levels of evidence.

Long-Term Effect of the Women's Health Initiative Study on Antiosteoporosis Medication Prescribing

To describe long-term prescribing patterns of osteoporosis therapy before and after the Women's Health Initiative (WHI) publication. We conducted a time-series analysis from 1997 to 2005 using nationally representative data based on office-based physician and hospital ambulatory clinic visits. Bivariate and multivariable analyses were conducted using chi-square tests and logistic regression, respectively, and trends in the prevalence of osteoporosis therapies were evaluated per 6-month (semiannual) intervals. Linear regression and graphic techniques were used to determine statistical differences in the prevalence trends between the two periods. Overall prevalence of therapeutic or preventive osteoporosis therapy was similar between the WHI periods. However, a significant decrease in estrogen therapy and increases in bisphosphonates, calcium/vitamin D were observed in the period after the WHI publication (p < 0.05). Multiple logistic regression analysis showed older age and white race were associated with a higher likelihood of antiosteoporosis medication (AOM) prescription, and Medicaid insurance type was associated with a lower likelihood of an AOM prescription. Excluding calcium/vitamin D, nonestrogen therapy was more likely to be prescribed in the after-WHI period (office-based physician clinic: [adjusted OR, aOR] 2.49 [2.04-4.04]; hospital-based clinic: aOR 2.42 [1.67-7.50]) Nonestrogen therapy was more prevalent in visits made by older women, women of white race, women with contraindicated conditions for estrogen therapy, and women from the Northeast region. After the WHI publication, the overall prevalence of osteoporosis therapy did not change; however, a shift from estrogen to nonestrogen therapy was observed after the WHI publication. Black women were less likely to receive nonestrogen antiosteoporosis therapy in hospital-based clinics.

The role of hormone therapy in the treatment of osteoporosis

The concerns raised by the findings of the Women's Health Initiative study resulted in many practitioners no longer considering the use of menopausal hormone therapy for the treatment of osteoporosis. Subsequent re-analyses of this study, recent publications on the use of lower doses and different modes of delivery of hormone therapy, and data suggesting that certain women will receive longer-term fracture prevention even with short-term use have resulted in a reappraisal of the use of oestrogen and oestrogen plus progestin therapy for the prevention and treatment of osteoporosis. These issues are discussed, and based on these more recent analyses it is suggested that menopausal hormone therapy could still be considered a first-line option for osteoporosis prevention and treatment in certain patients.

Preventing breast cancer in postmenopausal women by achievable diet modification: A missed opportunity in public health policy

The Diet Modification trial of the Women's Health Initiative studies was reported to be inconclusive as the overall risk reduction was not statistically significant at the 0.05 level. By our calculation, the trial's demonstrated risk reduction at average adherence to a simple diet modification translates into avoiding 7.3% invasive breast cancers in post-menopausal women in the USA. The trial also demonstrated a clear dose response between diet modification and risk reduction, meaning a higher percentage of breast cancers can be avoided among women whose diet modification was better than average. Yet, the DM trial findings as reported and interpreted in public sent the message to post-menopausal women that reducing the fat intake does not reduce the risk of breast cancer. Clearly, a valuable opportunity to affect public health policy was missed because the contextual significance and policy implications of the findings were ignored.

Subthreshold Depression and Successful Aging in Older Women

Subthreshold depression (StD) is common in older adults and is associated with poor self-rated health. However, the impact of StD on broader indicators of successful aging, such as positive psychological constructs, cognitive functioning, or quality of well-being, has not been assessed. The authors compared persons with scores above and below a predetermined threshold on the Center for Epidemiological Studies Scale for Depression (CES-D) with nondepressed (ND) persons on measures of multiple domains associated with successful aging. Cross-sectional survey-based psychological assessments. A total of 1,979 community-dwelling older women participating in the Women's Health Initiative study. ND was defined as a CES-D score below 8, StD as a score between 8 and 15, and CES-D Depression (CD) as a score of 16 or above. The study questionnaire consisted of multiple self-reported measures of positive psychological functioning (e.g., optimism and resilience), cognitive functioning and complaints, and quality of well-being. The authors also obtained a history of diagnosis, treatment, and hospitalization related to mental health problems. Overall 20.2% of women met CES-D criteria for StD and 7% for CD. Women with StD had worse self-rated successful aging, worse physical and emotional functioning, lower optimism, more negative attitudes toward aging, lower personal mastery and self-efficacy, and greater anxiety and hostility than ND women but scored better on all these measures than women with CD. Subjects with StD also had higher self-reported rates of previous diagnosis, treatment, and hospitalization for mental health problems than the ND group. Subjects with StD with depressed mood and/or anhedonia were largely similar to those without these symptoms. Mild-moderate levels of depressive symptoms that likely fall under a general category of StD were common and were associated with worse functioning on virtually every component of successful aging that the authors examined. StD represents a clinical entity that may affect the longitudinal course of successful aging for large numbers of persons and is a potential target for clinical intervention.

The Women's Health Initiative Study: individualisation of hormone replacement therapy in a defined South African population

Abstract Objective The aim of this study was to investigate the impact of the Women's Health Initiative (WHI) study on the prescribing of hormone replacement therapy (HRT) in a defined South African population and to establish whether patient therapy was appropriately individualised as a result of the WHI study. Setting Claims data from a South African managed healthcare organisation. Method A retrospective drug utilisation review (DUR) was conducted to identify HRT-related prescribing patterns in the defined study groups. This analysis included determining discontinuation and initiation rates for HRT during selected 6-month periods. An investigation into patient demographics and prescribing patterns followed, whereby trends observed among patients either initiating or discontinuing HRT in the 6-month period post-WHI publication were contrasted with patients using HRT prior to publication of the WHI study. The prevalence of concomitant disease states among these subgroups was also assessed. Key findings The discontinuation rate for HRT following publication of the WHI study increased from 3.47% to 7.54%, while the initiation rate decreased from 15.34% to 9.10%. Patients initiating HRT post-WHI publication were generally found to be in the younger menopausal age categories (40 to 49 years). These patients were more likely to have been initiated on HRT types other than those investigated in the WHI study and were at a higher risk for disease states for which HRT use is beneficial, such as osteoporosis. Patients discontinuing HRT post-WHI publication were generally found to be in the older menopausal age categories (60 to 69 years), were more likely to have been combined HRT users (although not necessarily the type investigated in the WHI study), and were at a higher risk for disease states for which HRT use is considered harmful, such as diseases affecting the cardiovascular system. Conclusion It can be concluded that HRT was appropriately individualised according to recommendations based on the results of the WHI study in the defined populations of this study.

Decline in US Breast Cancer Rates After the Women's Health Initiative: Socioeconomic and Racial/Ethnic Differentials

We investigated whether there were socioeconomic and racial/ethnic disparities in recent reported declines in overall US breast cancer incidence rates attributed to post-2002 declines in hormone therapy use following publication of the Women's Health Initiative study. We analyzed 1992-2005 US breast cancer incidence data from the US Surveillance, Epidemiology and End Result (SEER) 13 Registries Database, stratified by race/ethnicity, county income level, age, and estrogen receptor (ER) status. As we hypothesized, between 1992 and 2005, the temporal pattern of rising and then falling US breast cancer incidence rates occurred only among White non-Hispanic women who lived in high-income counties, were aged 50 years and older, and had ER-positive tumors. No such trends were evident--regardless of county income level, ER status, or age--among Black non-Hispanic, Asian/Pacific Islander, Hispanic, or-where numbers were sufficient to conduct meaningful analyses-American Indian/Alaska Native women. The recent decline in US breast cancer incidence was not equally beneficial to all women, but instead mirrored the social patterning of hormone therapy use. Joint information on socioeconomic resources and race/ethnicity is vital for correctly understanding disease distribution, including that of breast cancer.

Building Translation Science With Interdisciplinary Research: Why a Special Issue on the Proceedings of a Research Conference?

In answer to the question posed for this editorial: a Special Issue on the Proceedings of a Research Conference: Building Translation Science with Interdisciplinary Research? The answer is simple. The presentations of the conference held April 15, 2009, were thoughtful and eloquent about two topics critical to nursing and to in today's world. They addressed complex issues and challenges facing health care providers and scientists. The ideas were captured in the articles collected for this special issue so that they might be shared with the nursing community as well as our interdisciplinary colleagues. It is exciting to read these articles and envision ways that nursing can provide leadership in improving the health of the nation. As we began our planning activities for the conference, we had multiple objectives. First, we aimed to highlight the interdisciplinary research and translational supported by the Michigan Center for Nursing Intervention (P30 NR0090000). Our other objectives were to establish an ongoing forum for scientific inquiry among the faculty and students at the School and to disseminate our research among our colleagues within the School and across the University in order to forge lines of inquiry. As the National Institutes of Health roadmap initiatives have unfolded, interdisciplinary and translational have been emphasized as necessary for developing knowledge to solve today's complex health problems. We believed that a focus on strengthening our interdisciplinary collaborations and methods for building translational would be of high interest to the faculty. Many faculty at the School are actively engaged in interdisciplinary research and as nurses, all are committed to developing knowledge for use in practice. We believed, too, that learning about interdisciplinary and translational would benefit our early career investigators and doctoral students as they prepared for future careers in science. Dr. Nancy Fugate Woods, Professor and Dean Emerita of the University of Washington School of Nursing, was identified as the keynote speaker because of her longstanding history of collaborative, interdisciplinary research. Dr. Woods served as an investigator for the Women's Health Initiative Study and as President of interdisciplinary organizations, including the North American Menopause Society and the Society for Menstrual Cycle Research. She has participated in setting research agendas as a member of the National Institutes of Health Women's Health Task Force and Office of Women's Health Research Advisory Council. We invited her to build on this experience and present a paper entitled Translational Research: Why Interdisciplinary Collaboration Is Essential. Dr. Woods has produced an article that acknowledges past contributions of nursing to translational and delineates challenges and opportunities. She describes how scientists of all disciplines are working to learn ways of doing science as well as transitioning to a new social contract for how one does science (Woods, this issue). In explaining transdisciplinarity, Dr. Woods gives the benefits of creating perspectives that can cross the traditional boundaries of disciplines in finding solutions. She lists the skill sets needed for working in this paradigm. Importantly, Dr. Woods gives us compelling reasons why nurses need to lead in interdisciplinary, translational research and examples of how we can lead. We invited two School of Nursing faculty and their interdisciplinary colleagues to present an overview of a research study and describe the necessity of having an interdisciplinary team. Dr. Bernadine Cimprich, Associate Professor of Nursing, and her colleague, Dr. Douglas Noll, Professor and Chairperson of Bioengineering and Co-Director, fMRI Laboratory, presented An Interdisciplinary Focus on Altered Brain Function in Chemotherapy for Breast Cancer. …

The change of hormone therapy in postmenopausal women in Korea before and after women's health initiative study: 2000~2009

목적: 본 연구의 목적은 Women`s Health Initiative Study (WHI) 발표 전후 2000년부터 2009년까지 10년 동안의 폐경 여성에서 호르몬 사용의 변화와 WHI의 결과가 우리나라의 호르몬 요법 사용에 어떠한 영향을 보였는지 알아보고 이를 통해 앞으로의 폐경 후 호르몬 요법의 전망을 알아보고자 한다. 연구 방법: 이 연구는 International Medical Service HEALTH 회사에서 발표된 약제 통계자료에 기초하였다. 우리나라에서 판매된 호르몬 제제들에 대한 통계자료들은 2000년부터의 자료를 이용하였다. 폐경여성들의 호르몬 제제들의 사용은 연간 호르몬 제제들의 판매액으로 표시하였으며 총 호르몬 제제는 에스트로겐, 에스트로겐/프로게스토겐, 티볼론 제제들의 합으로 표시하였다. 호르몬 제제의 사용 변화를 알기 위해 전년 대비 성장률과 2000년을 기준으로 한 축적성장률을 산출하였다. WHI발표 이후의 사용 변화를 알기 해서 2002년부터 2009년까지 2002년을 기준으로 한 변화를 확인하였다. 결과: 2002년 WHI 발표 이후 우리나라의 총 호르몬 요법 사용은 2002년도의 511억에 비해 2006년에 39%의 감소를 보여 314억까지 감소하였다. 이후 조금씩 상승하여 2009년에는 356억이었다. 반면 티볼론의 사용은 WHI 이후 2년간은 감소하여 2002년 134억에 비해 2004년에는 100억으로 25.4% 감소하였으나 이후 지속적으로 상승하여 2007년에는 134억으로 2002년의 사용량보다 증가하였고, 2009년에는 145억으로 2002년 대비 8.2% 증가하였다. 저용량 호르몬 제제 또한 WHI 이후 지속적으로 증가하여 2002년 8억 대비 2009년에는 71억으로 787.5% 증가하였다. 결론: WHI의 발표 후 폐경 여성들의 호르몬 사용은 2002년에 비해 2003년에 23.9% 감소하였고 저용량 호르몬과 티볼론 사용이 확연히 증가하였다. 앞으로 우리나라 폐경 여성에서 호르몬 사용은 저용량의 호르몬과 티볼론이 대세를 이룰 것으로 생각된다. 또한 호르몬 요법을 시작할 때 환자의 병력, 신체검사를 통한 이득과 위험을 판단한 후 각 개인에 맞는 호르몬 요법을 시행하여야 할 것이다.

Attitudes and practices of gynecologists in Jaipur toward management of menopause

Background:In earlier days, hormone replacement therapy (HRT) was recommended for menopause symptoms and also gained much popularity. However, the Women's Health Initiative (WHI) studies suggested an increased risk of cardiovascular and Alzheimer's disease. These findings led to a dramatic decrease in hormone therapy (HT) prescriptions all over the world. However, the WHI conclusions remain debatable especially because of contradictory results from antecedent studies. Inspite of these controversies, post-WHI, most gynecologists refrain from prescribing MHT (menopausal hormone replacement therapy, MHT). Furthermore, many Indian gynecologists prefer to prescribe alternative treatments that would help alleviate symptoms and thus avoid HRT. We decided to carry out a survey and document the current opinions regarding indications of HRT and alternative therapies and prescribing practices of Jaipur-based gynecologists.Objective:This study was designed to find out the current attitudes and practices of gynecologists (Jaipur) towards management of menopause.Materials and Methods:A questionnaire concerning attitudes, management strategies, and use of HT was mailed out to gynecologists, and they are asked to complete the questionnaire. Data were analyzed using the total number of respondents (n = 321). The results were analyzed using a simple percentage method as this was most suitable for this kind of studies.Results:From the results, 69.04% gynecologists were currently prescribing MHT. Hot flashes were the most common indication for MHT prescriptions and 78.57% were familiar with controversies surrounding WHI study. Also, 61.9% would consider using MHT for themselves. Alternative therapy was adopted by 83.48% in their prescribing practice. The reason cited by 71% for preferring alternative therapies was that it was safer and less controversial.Conclusions:The prescribing practices of Jaipur gynecologists in lieu of ongoing controversies surrounding HT have shifted and now also support alternative therapies for menopause management. In this era of phasic prescriptions, for immediate relief of hot flashes and mood swings, MHT was favored. However, for long-term management of women with poor compliance, alternative therapies were considered a safer option.

Reduced Lung Cancer Mortality Risk among Breast Cancer Patients Treated with Anti-Estrogens.

Abstract Background: The Women Health Initiative study recently reported that women on hormone replacement therapy (HRT) were at increased risk of dying from lung cancer. If exposure to estrogens can worsen lung cancer outcome, we hypothesized that anti-estrogens may, on the contrary, improve its prognosis. We compared lung cancer incidence and mortality among breast cancer patients with and without anti-estrogen therapy.Methods: All 6715 patients recorded with a breast cancer in the population-based Geneva Cancer registry in the period 1980-2003 were included in the study. Forty-six percent of these women (3066) received anti-estrogen therapy (tamoxifen in large majority). Age, sex and year-specific population data were used to calculate standardised incidence ratios (SIRs) and standardised mortality ratios (SMRs), to compare the study population to the general female population of Geneva canton. For each woman we computed person-years at risk from the date of diagnosis of breast cancer to the date of diagnosis of invasive lung cancer cancer, date of death, date lost to follow-up, or end of the study period (December 31, 2007).Results: The cohort yielded a total of 57,100 person-years.During the study period we observed a total of 40 cases of metachronous lung cancers (diagnosed at least six months after the breast cancer). Compared with the general population, the risk of developing a lung cancer among women who received anti-estrogens was 0.63 (95% Confidence Intervals [CI]: 0.33-1.10) and among women without anti-estrogens was 1.12 (95% CI: 0.74-1.62). Lung cancer mortality rate was 31.44/100,000. The mortality rate were 9.23/100,000 for women with anti-estrogens and 44.97/100,000 for women without anti-estrogens.Compared to the general population the SMR for lung cancer was 0.13 (95% CI: 0.02-0.47) among women who took anti-estrogens (p&amp;lt;0.001), and 0.76 (95% CI: 0.43-1.23) among women who did not receive anti-estrogens.Discussion: Women who received anti-estrogens as breast cancer treatment have a significantly decreased risk of dying from lung cancer. This result further supports the role of estrogens in lung cancer prognosis and suggests that exposure to anti-estrogens may offer some protection against tumor mortality. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 35.

Antidepressant use and risk of incident cardiovascular morbidity and mortality among postmenopausal women in the Women's Health Initiative study.

Antidepressants are commonly prescribed medications, but their effect on cardiovascular morbidity and mortality remains unclear. Prospective cohort study of 136 293 community-dwelling postmenopausal women in the Women's Health Initiative (WHI). Women taking no antidepressants at study entry and who had at least 1 follow-up visit were included. Cardiovascular morbidity and all-cause mortality for women with new antidepressant use at follow-up (n = 5496) were compared with those characteristics for women taking no antidepressants at follow-up (mean follow-up, 5.9 years). Antidepressant use was not associated with coronary heart disease (CHD). Selective serotonin reuptake inhibitor (SSRI) use was associated with increased stroke risk (hazard ratio [HR],1.45, [95% CI, 1.08-1.97]) and all-cause mortality (HR,1.32 [95% CI, 1.10-1.59]). Annualized rates per 1000 person-years of stroke with no antidepressant use and SSRI use were 2.99 and 4.16, respectively, and death rates were 7.79 and 12.77. Tricyclic antidepressant (TCA) use was associated with increased risk of all-cause mortality (HR,1.67 [95% CI, 1.33-2.09]; annualized rate, 14.14 deaths per 1000 person-years). There were no significant differences between SSRI and TCA use in risk of any outcomes. In analyses by stroke type, SSRI use was associated with incident hemorrhagic stroke (HR, 2.12 [95% CI, 1.10-4.07]) and fatal stroke (HR, 2.10 [95% CI, 1.15-3.81]). In postmenopausal women, there were no significant differences between SSRI and TCA use in risk of CHD, stroke, or mortality. Antidepressants were not associated with risk of CHD. Tricyclic antidepressants and SSRIs may be associated with increased risk of mortality, and SSRIs with increased risk of hemorrhagic and fatal stroke, although absolute event risks are low. These findings must be weighed against quality of life and established risks of cardiovascular disease and mortality associated with untreated depression.