Determinants of hormone replacement therapy among postmenopausal women enrolled in the French GAZEL cohort

Hormone therapy use in the Canadian Longitudinal Study on Aging: a cross-sectional analysis

OBJECTIVE

The aim of the study was to assess the prevalence and factors associated with hormone therapy (HT) use among Canadian women.

METHODS

Baseline data from the Tracking cohort of the Canadian Longitudinal Study on Aging (CLSA) was used for this analysis. The main outcome was HT use among women aged 45-85 years, defined as current, past, and never users. Multinomial logistic regression models were used to examine the differences between current, past, and never HT users in terms of sociodemographic, health behavior, and health-related variables.

RESULTS

Overall, 9.5% of the sample reported current use of HT, whereas 21.9% reported past use. The main factors associated with a lower likelihood of current HT use were older age (>80 y), nonwhite ethnic background, current employment, regular smoking, obesity, and breast cancer. By contrast, alcohol consumption, and the presence of allergies or mood disorders were positively associated with current HT use.

CONCLUSIONS

These findings provide a recent national picture of HT use in Canada that may be used to inform opportunities for improved physician-patient communication regarding menopause management.

Incidence and remission of urinary incontinence at midlife: a cohort study

OBJECTIVE

Urinary incontinence (UI) is often considered to be an age-related disease that develops gradually as women grow older. Much remains to be learnt about factors that promote its incidence or its remission. Our objective was to assess its incidence and risk factors.

DESIGN

Longitudinal cohort study.

SETTING

French GAZEL cohort.

POPULATION

A cohort of 4127 middle-aged women (aged 47-52 years at baseline) over an 18-year period (1990-2008).

METHODS

UI was defined as 'difficulty retaining urine'. The question was asked at baseline and repeated every 3 years over an 18-year period. Two groups (UI incidence and remission) were analysed according to status at baseline (continent or incontinent). A multivariable analysis (Cox model) was used to estimate the risk factors for UI incidence and remission.

MAIN OUTCOME MEASURES

Annual incidence and remission rates and risk factors for UI incidence and remission.

RESULTS

The annual incidence and remission rates for UI were 3.3% and 6.2%, respectively. High educational level (hazard ratio [HR] = 1.28; 95% confidence interval [95% CI] = 1.05-1.55), parity, i.e. at least one baby versus no baby (HR = 1.64; 95% CI = 1.19-2.27), menopause (HR = 5.44; 95% CI = 4.47-6.63), weight gain, i.e. for each kilogram change in weight (HR = 1.00; 95% CI = 1.00-1.02), onset of depressive symptoms (HR = 1.31; 95% CI = 1.09-1.57) and impairment in health-related quality of life incidence (social isolation dimension [HR = 1.29; 95% CI = 1.04-1.60] and energy dimension [HR = 1.41; 95% CI = 1.17-1.70]) were associated with an increased probability of UI. The factors associated with persistent UI were age (HR = 0.58; 95% CI = 0.55-0.61), weight gain (HR = 0.99; 95% CI = 0.98-0.99) and transition to menopausal status (HR = 1.54; 95% CI = 1.19-1.99).

CONCLUSIONS

Our study suggests that, in our population of middle-aged women, age, menopause, weight gain, onset of depression and impaired health-related quality of life may promote UI.

Symptomatic pelvic organ prolapse at midlife, quality of life, and risk factors

OBJECTIVE

To estimate quality of life, prevalence, and risk factors associated with symptomatic pelvic organ prolapse (POP) among middle-aged women.

METHODS

This was a cross-sectional study. A questionnaire was mailed to 3,114 women aged 50-61 years in the GAZEL cohort; 2,640 (85%) returned it. Symptomatic POP was defined by feeling a bulge from the vagina (sometimes, often, or all the time compared with never or rarely). Quality of life was determined with the Nottingham Health Profile questionnaire. Multiple linear regression was used to examine the association between frequency of POP symptoms and the quality-of-life score. Logistic regression was used to estimate the effect of risk factors on past or present symptomatic POP (current symptoms or previous surgery for POP).

RESULTS

The prevalence of symptomatic POP was 3.6% (96 of 2,640) and that of surgery for POP was 2.7% (70 of 2,640). Pelvic organ prolapse symptoms were associated with difficulty defecating, lower abdominal pain, and difficulty voiding. The frequency of POP symptoms was associated with a poorer quality-of-life score in each Nottingham Health Profile domain (physical mobility, pain, emotional reaction, social isolation, energy, and sleep). Even when we took general characteristics, medical history, and lifestyle associated with quality of life into account, the global Nottingham Health Profile score was significantly impaired by POP symptoms. Factors significantly associated with past or present symptomatic POP were high body mass index and the number of vaginal deliveries.

CONCLUSION

In our population of women in their 50s, POP symptoms are associated with impaired quality of life, and the number of vaginal deliveries is a risk factor for past or present symptomatic POP.

Trends of determinants of hormone therapy use in Italian women attending menopause clinics, 1997-2003

OBJECTIVE

Analysis of patterns of hormone therapy (HT) use among postmenopausal Italian women, before and after publication of results from the Heart and Estrogen/progestin Replacement Study and the Women's Health Initiative.

DESIGN

This was a cross-sectional study conducted between 1997 and 2003 on the characteristics of women around the age of menopause. The study population consisted of 106,784 women (mean age 53 y) attending menopause clinics in Italy. Postmenopausal women were defined as women with surgical menopause (ie, bilateral oophorectomy with or without hysterectomy), women older than 55 years who underwent hysterectomy without bilateral oophorectomy, and women whose menstrual cycles had stopped more than 1 year before their interview.

RESULTS

A total of 15,657 women (14.7%) reported ever using HT. The prevalence of HT prescription was 17.6% among women observed in 1997-1998, 14.9% in 1999, 12.2% in 2000, 12.1% in 2001, and 11.4% in 2002-2003. HT use was related to age at menopause and level of education in all the periods considered and was more frequent in women reporting surgical menopause. The odds ratio of HT prescription tended to decrease in women with surgical menopause, with slight fluctuations in the intermediate years. Ever users of oral contraceptives and nulliparae were more frequently HT users.

CONCLUSIONS

In our population the percentage of current HT users dropped from 17.6% in 1997-1998 to 11.4% in 2002-2003. However, the determinants of use were largely unchanged during the study period: women with higher education, nulliparae, and smokers reported more frequent HT use.

Mode of delivery and fecal incontinence at midlife: a study of 2,640 women in the Gazel cohort

OBJECTIVE

To estimate obstetric risk factors of fecal incontinence among middle-aged women.

METHODS

We conducted a mail survey of the Gazel cohort of volunteers for epidemiologic research. In 2000, a questionnaire on anal incontinence was mailed to 3,114 women who were then between the ages of 50 and 61 years; 2,640 (85%) women returned the completed questionnaire. Fecal incontinence was defined by involuntary loss of stool. Logistic regression was used to estimate the effect of obstetric and general risk factors.

RESULTS

Prevalence of fecal incontinence in the past 12 months was 9.5% (250). Significant risk factors for fecal incontinence were completion of high school (adjusted odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1-2.0), self-reported depression (OR 2.1, 95% CI 1.6-2.7), overweight or obesity measured by body mass index (BMI) (OR 1.5 for BMI of 25-30, 95% CI 1.1-2.0; OR 1.6 for BMI more than 30, 95% CI 1.1-2.5), surgery for urinary incontinence (OR 3.5, 95% CI 2.0-6.1), and anal surgery (OR 1.7, 95% CI 1.1-2.9). No obstetric variable (parity, mode of delivery, birth weight, episiotomy, or third-degree perineal tear) was significant. Prevalence of fecal incontinence was similar for nulliparous, primiparous, secundiparous, and multiparous women (11.3%, 9.0%, 9.0%, and 10.4%, respectively), and among parous women, it was similar for women with spontaneous vaginal, instrumental (at least one), or only cesarean deliveries (9.3%, 10.0%, and 6.6%, respectively).

CONCLUSION

In our population of women in their 50s, fecal incontinence was not associated with either parity or mode of delivery.

Health problems were the strongest predictors of attrition during follow-up of the GAZEL cohort

BACKGROUND AND OBJECTIVES

This study examined socioeconomic, lifestyle, and health factors associated with response to annual mail questionnaires in a longitudinal study from 1990 through 2000 within the French GAZEL cohort.

METHODS

Twenty thousand six hundred twenty-four participants volunteered in 1989, and received each year a questionnaire. As responding one given year was not independent of responding in other years, mixed models were used to analyze the variables associated with response.

RESULTS

Higher response rates were associated with gender (male), age (older), managerial status, and retirement. Smoking and alcohol drinking at baseline were associated with lower participation. Subjects who had at least three sick leaves were less likely to respond, especially for absence for psychiatric and alcohol-related diseases among men. Those who had rated their health as bad at baseline were less prone to respond during the follow-up. Attrition in subsequent response to questionnaires was associated with cancer diagnosis and with episodes of coronary heart disease for men.

CONCLUSION

Most of the variables that predicted initial participation were also associated with continued participation during follow-up. Health problems strongly predicted attrition, whereas socioeconomic factors played a weaker role. Withdrawing is a reversible state and considering only one episode of nonparticipation could be misleading.

Negative impact of urinary incontinence on quality of life, a cross-sectional study among women aged 49-61 years enrolled in the GAZEL cohort

AIMS

The aim of the study was to analyze the relations between severity of urinary incontinence (UI), defined as involuntary loss of urine considered to be a hygienic or social problem, and quality of life (QoL) among middle-aged French working women enrolled in a cohort study, while taking into account characteristics that may affect this relation.

METHODS

Data came from self-administered mail questionnaires completed by 2,640 women aged 49-61 years in the GAZEL cohort of utility company employees. The analysis considered social and demographic characteristics, lifestyle, hormone status, and body mass index. We used bivariate and multivariate analysis to study the associations between UI severity (measured by SANDVIK's index) and QoL scales (Contilife, specific for UI, and the generic Nottingham Health Profile).

RESULTS

The sample included 556 women (21%) with UI. QoL alterations associated with UI severity were observed for all six Contilife dimensions (daily and effort activities, self-image, emotional impact, sexuality, and well-being) and two dimensions of the NHP (pain and physical mobility). These results remain after adjustment for age, BMI, and living arrangements.

CONCLUSIONS

UI affects QoL even among women from a nonclinical population, and the more severe the UI, the more harmful the effect. These results raise the question of whether UI in its severe forms should be considered a disability because of its negative effects on mobility in daily life.

Mode of delivery and severe stress incontinence. a cross-sectional study among 2,625 perimenopausal women

OBJECTIVE

To estimate the prevalence of severe stress urinary incontinence (SUI) among perimenopausal women and to examine potential obstetric risk factors.

DESIGN

Mail survey of female volunteers for epidemiological research.

SETTING

Postal questionnaire on SUI.

POPULATION

Three thousand one hundred and fourteen women aged 49-61 years who comprised the GAZEL cohort.

METHODS

Logistic regression using data from the entire cohort to estimate the impact of risk factors. A second logistic regression using data from women who had given birth included obstetric history.

MAIN OUTCOME MEASURE

Prevalence of severe SUI defined by the response 'often' or 'all the time' to the question 'Does urine leak when you are physically active, cough or sneeze?'

RESULTS

Two thousand six hundred and twenty-five women (85%) completed and returned the questionnaire The frequency of SUI reported in the preceding four weeks was as follows: 'never' 32%, 'occasionally' 28%, 'sometimes' 26%, 'often' 10% and 'all the time' 5%. Prevalence of severe SUI was lowest among nulliparous women (7%), but it was similar among parous women regardless of birth number (14-17%). The prevalence of severe SUI was not associated with mode of delivery (14% for women delivered by caesarean only vs 16% for vaginal births). Significant risk factors for severe SUI were high body mass index (BMI >30), diabetes mellitus, previous incontinence surgery, parity and first delivery under the age of 22 years.

CONCLUSION

Previous pregnancy itself is a risk factor for severe SUI among women who reach the age of 50. In this age group the impact of the mode of delivery (spontaneous, forceps or caesarean) on severe SUI is slight.

Estimated numbers of postmenopausal women treated by hormone therapy in France

OBJECTIVES

To estimate the number of women aged 50-69 years treated by hormone therapy (HT) in France before Women's Health Initiative's (WHI) results and to evaluate the potential decrease of HT prescriptions since the publication of WHI clinical trial.

METHODS

We used data from eight computerized databases of French cohort studies providing information on HT and constituted by women aged over 50 years living in metropolitan France. From these, we used direct standardization on the French population to estimate the prevalence of HT users across 5 years age groups. Data from the National Health Insurance Agency on two time-periods November 2002-January 2003 and November 2003-January 2004 were used to evaluate the evolution of HT prescriptions since WHI's publication among women aged 50-69 years living in the Rhône-Alpes region.

RESULTS

The crude prevalence of HT users among women aged 50-69 years was 52.3% (51.8-52.8) and corresponds to a standardized prevalence of 35.7% (35.1-36.4), that is about 2.56 (2.51-2.59) million women. Standardized prevalence was the highest in 50-54 years age group then it decreased significantly across the older age groups (p<10(-6)). HT reimbursements decreased significantly between the two studied time-periods in the Rhône-Alpes region (p<10(-6)) from -14 to -45%, depending on the considered age groups (65-69 or 50-54 years).

CONCLUSIONS

Although WHI results have been criticized by French professional societies based on the fact that treatments used were different in France--mainly transdermal estrogens--and that French postmenopausal women were at lower vascular risk than those of the WHI, the release of this study had effect on the prescription before the French regulatory agency (AFSSAPS) edited limiting recommendations for HT prescription. Further efforts have to be made to collect systematically information on preventive treatments used at menopause followed by evaluation studies.

Estimated number of women likely to benefit from bone mineral density measurement in France

OBJECTIVES

To determine the number of women in France at least 50 years of age with risk factors for osteoporosis likely to lead to bone mineral density measurement, an investigation reimbursed by the French national health insurance system in patients at risk for osteoporosis. The study was commissioned by the French health authorities.

MATERIALS AND METHODS

Risk factors for osteoporosis were defined as recommended by the French Agency for Accreditation and Evaluation in Health (ANAES) in 2001. The study data were from nine cohort studies done in France and from the National Health Insurance Agency for the Rhone-Alpes region of France. Risk factor prevalences in France were standardized by extrapolation according to the age distribution in France.

RESULTS

Overall, data were collected in 123,986 women aged 50 years or older. From these data, risk factor estimates were as follows: menopause before 40 years of age, 1.5 million women; body mass index (BMI) lower than 19 kg/m(2), nearly 700,000; history of fracture, more than 2 million; history of femoral neck fracture in the mother, more than 1 million; history of health problems potentially responsible for osteoporosis, 400,000; and history of long-term glucocorticoid therapy, 612,000. In all, 3,186,318 (30%) women were estimated to have at least one risk factor and 785,512 (7.5%) at least two risk factors.

CONCLUSIONS

Although our study sample was not representative of the population residing in France, the large sample size and diversity of data sources support the validity of our estimate of the prevalence of risk factors for osteoporosis in postmenopausal women living in France.

[Compliance with hormone replacement therapy in menopausal women: results of a two-year prospective French study comparing transdermal treatment with fixed oral combination therapy]

OBJECTIVES

To evaluate rates of continuation with hormone replacement therapy (HRT) at 2 years in 2 cohorts of female patients, one of which was treated with a set combination of oral oestradiol valerate and medroxyprogesterone acetate and the other with percutaneous 17 beta-oestradiol gel combined with an oral progestogen selected by the prescribing doctor.

PATIENTS AND METHODS

A prospective, randomised, open study, including 885 patients followed for 2 years whose 477 were in the oral HRT cohort and 408 were in the dermal cohort. Randomisation was done by group with prescription of the selected HRT for the cohort. The 2 treatment groups were compared using chi(2) tests and Fisher's exact test for qualitative variables, Student's t test or Wilcoxon's test for qualitative variables and Kaplan-Meier survival curves for continuation of HRT, with comparisons using the log-rank test. The prognostic value of baseline parameters on subsequent continuation of HRT was studied using the Cox model (Wald test, odds ratio). RESULTS; Among the 885 treated patients, 711 received the HRT assigned to their cohort (382 in the oral HRT cohort, 329 in the dermal HRT cohort). After 2 years, 77.9% of the patients in the oral HRT cohort and 73.4% of the patients in the dermal HRT cohort were continuing to take their prescribed HRT (P = 0. 076): 37.9% of patients in the oral HRT cohort and 20.2% of patients in the dermal HRT cohort (P < 0.001) continued taking their treatment without any modification.

CONCLUSION

Although there was no significant difference in the level of compliance in the 2 groups, it is nonetheless worth noting that the HRT compliance with a sequential fixed estroprogestogen combination was, in this trial, at least equal to that with the free combination of a transdermal estrogen and a progestogen whose nature, dosage and sequence duration are selected by the prescriber. On the other hand, treatment modifications occurred more frequently in the cutaneous HRT group, which is logical as free combination affords to adapt the treatment to each patient.

Prevalence and determinants of hormone replacement therapy in German women 1984-1995

OBJECTIVES

To describe trends in prevalence and determinants of hormone replacement therapy (HRT) in German women.

METHODS

Three representative samples of women in Augsburg, Germany were examined in the MONICA surveys in 1984/85 (45-64 years; N=1013), 1989/90 and 1994/95 (both 45-74 years; N=1496 and 1475) by interview and anthropometry, and all drugs taken during the previous week were documented. The prevalence of HRT use was calculated by survey, age group and HRT type, and various characteristics were evaluated as determinants for any systemic HRT use by logistic regression.

RESULTS

The prevalence of HRT use in women aged 45-64 years in 1984/85, 1989/90 and 1994/95 was 3, 9% (age 45-74, 6%) and 23% (17%), respectively. In 1994/1995, positive determinants of HRT use were daily consumption of salad and vegetables, having quit smoking (vs. current smoking), regular exercise, ever having taken oral contraceptives, body mass index <25 kg/m(2) and age, and negative determinants were not drinking alcohol and education for <9 years (all P-value <0.10 in multivariate model). After multiple adjustment, HRT users were five times more likely to have participated in cancer screening and to have visited a gynaecologist >or=5 times during the previous year, and were less likely not to have seen a general practitioner or gynaecologist (all P-values <0.001).

CONCLUSION

HRT use increased substantially in Germany between 1984 and 1995. Women with characteristics associated with lower morbidity and mortality were more likely to use HRT, which agrees with the healthy-user phenomenon described in other countries.

Attitudes towards hormone replacement therapy among middle-aged women and men

OBJECTIVES

To survey the attitudes of middle-aged women and men towards HRT and associated issues. Men were included because of the possible influence of their attitudes on womens decisions to use HRT.

METHODS

Two-hundred women and 311 men, (not wife and husbands), between 45 and 55 years of age, from a general population sample, were queried about their attitudes towards menopause and HRT and on their knowledge about side effects of HRT.

RESULTS

The men had a more negative attitude towards HRT than the women. Two-thirds of the subjects, mostly women, considered menopause to be a medical issue and not a developmental stage in the life cycle. The most mentioned benefits of HRT were the prevention of osteoporosis and cardiopathy, and the disadvantages were "cancer" and "side effects". The concept of menopause as a medical entity was significantly correlated with a positive attitude towards HRT and whether the responder currently used HRT.

CONCLUSIONS

The attitudes of most women and men towards menopause and its psycho-social meaning play a vital role in the decision of whether women should start HRT. Education on HRT should be extended to include men who seem to have a more negative attitude towards HRT and are less informed about its benefits. Our results indicate that a positive attitude to HRT is associated with factual knowledge about its benefits and disadvantages, while a negative attitude is based more on emotional arguments.

Postmenopausal hormone use following a 3-year randomized clinical trial

Postmenopausal women often discontinue estrogen therapy within the first year. No studies have examined reasons why women continue or discontinue hormone replacement therapy (HRT) after several years of use, when hormone side effects have subsided. We wanted to identify determinants of estrogen use after participation in a 3-year randomized placebo-controlled trial. The Postmenopausal Estrogen/Progestin Intervention (PEPI) study compared the effects of estrogen alone or in combination with one of three progestogens with placebo. Post-PEPI use of hormone therapy was ascertained 1-4 years after the trial in 775 (90%) of the originally enrolled women. Potential correlates of treatment decisions were identified from sociodemographic characteristics, medical histories, and clinical measures ascertained at baseline and during and after the trial. Among women who had been assigned to placebo during PEPI, post-PEPI hormone use was significantly less common in women who were adherent to placebo during PEPI, older, or of non-Caucasian ethnicity. Hormone use was positively associated with hysterectomy. Among women assigned to an active regimen during PEPI, post-PEPI hormone use was significantly more common in women who used hormones before PEPI and in women who were adherent to hormones during PEPI. Older age, less education, and being non-Caucasian predicted less hormone use. Post-PEPI hormone use was highest in San Diego and lowest in Iowa City. Women on placebo who lost more bone mineral density (BMD) were more likely to begin hormones than women with less bone loss. Lipids, blood pressure, and other cardiovascular risk factors had relatively little influence on hormone use. The main predictors of post-PEPI hormone use were those associated with use in the general population (education, ethnicity, geographical region, hysterectomy, and prior use/adherence).

Use of hormone replacement therapy: women's representations of menopause and beauty care practices

OBJECTIVES

Hormone replacement therapy (HRT) during menopause has been shown to have beneficial effects on women's health, including preventing osteoporosis and probably reducing cardiovascular mortality and morbidity. However, these effects appear only after long use. Knowledge of factors influencing HRT use is a prerequisite for developing and assessing preventive actions. Most studies of user characteristics have focused on medical knowledge and socioeconomic characteristics, although social and cultural models of menopause may also play a role. Therefore, our study of the determinants of HRT use focused on representations of menopause and on beauty care.

METHODS

Two scores, one concerning the level of beauty care and the other the representations of menopause, were calculated. In our population of 561 postmenopausal women from the GAZEL cohort in France, 409 (72.9%) had been using HRT for more than one year, and 152 (27.1%) had used it for less than three months, if ever. Associations between the study variables and HRT use were then analysed.

RESULTS

No association was found between representations of menopause and HRT use. Beauty care and some beliefs about HRT (i. e. that it is useful for osteoporosis prevention, causes resumption of menstruation, and has anti-aging effects) were independently associated with HRT use. Moreover, the proportion of HRT users increased with socioeconomic status, with vasomotor symptoms in early menopause, and among hysterectomised women.

CONCLUSIONS

The results suggest that the amount of attention women pay to beauty care plays a role, in determining HRT use.

Factors determining the use of hormone replacement therapy in recent naturally postmenopausal women participating in the French SU.VI.MAX cohort

The determinants of hormone replacement therapy (HRT) were studied in a cohort of recently postmenopausal women participating, in France, in a nutritional study (SU.VI.MAX Study). Analysis was performed-analysis on 592 women aged 45 years or more, who had undergone natural menopause which appeared in the 2 previous years. No differences were observed in education level, socio-professional categories, marital status, geographic residence, smoking habits, physical activity, or past contraceptive practice. Past regular gynecologic follow-up appeared to be the strongest determinant of HRT use (odds ratio [OR]: 3.18). Women who reported having had at least one of the studied pathologies (past history of breast cancer, phlebitis, anger, uterine fibroma, hypertension, diabetes or hypercholesterolemia), past abundant menstrual blood losses, and with body mass index (BMI) > or = 25 were less likely to be taking HRT than women free of pathology, with no history of past abundant menstrual blood losses and with low BMI (OR respectively of 0.40, 0.64, 0.62). Women over 51.3 years of age were less likely to use HRT than younger women (OR: 0.92). Finally, in our population, while socio-economic level was not a major determinant of HRT use, the regularity of gynecological follow-up before menopause, overweight, and the existence of a definite or possible contra-indication were strong determinants of HRT use.

Determinants of the intention to adopt hormone replacement therapy among premenopausal women

OBJECTIVE

To identify the psychosocial factors that influence the intention to adopt hormone replacement therapy (HRT) at menopause.

METHODS

Random Digit Dialing was used to recruit 644 premenopausal non-hysterectomized women aged 45-54. Data were collected using a telephone questionnaire previously developed according to the theory of planned behaviour. Variables measured were: intention to adopt HRT (INT); attitude towards HRT (Aact); perceived social norm (SN); perceived behavioural control (PBC); and personal normative belief (PNB). Socio-demographic data were also obtained.

RESULTS

Stepwise multiple regression of INT on the theoretical variables yielded an R(2) of 0.70. The determinants were Aact (beta=0.39, P<0.001), PNB (beta=0.25, P<0.001), PBC (beta=0.23, P<0.001) and SN (beta=0.12, P<0.001). Women with a strong intention to adopt HRT represented 25% of the sample. These women were more likely to believe that adopting HRT would have the following positive consequences: an improvement in general well-being, the prevention of health problems, an improvement in interpersonal relationships, an increase in productivity, the regulation of mood swings and a reduction of hot flashes. They were also more likely to believe in the following negative consequences: side-effects, an increased risk of cancer, the likelihood of weight gain, and interference in the natural course of menopause (all at P<0.001).

CONCLUSION

Actions that target behaviourial beliefs regarding HRT and perceived barriers to its adoption are most likely to influence adoption of HRT.

Evaluation of hormone replacement therapy use by the sales figures

Despite the efficiency of hormone replacement therapy (HRT) to prevent climacteric manifestations and possibly the long-term deleterious influences of menopause, the prevalence of HRT is relatively low, and quite variable, depending on the population studied. Presently, there is no information regarding HRT in Switzerland and in the region of Geneva, which have particularly aged populations, with a life expectancy among the longest in the Western world. In this study, the number of women treated per year in 1993 and 1996, as well as the prevalence of HRT were estimated, based on the total amount of hormone preparations sold for HRT. In Switzerland, for a female population older than 45 years of about 1.45 million, the number of women on HRT was approximately 166,000 in 1993 and 202,000 in 1996. For Geneva, the female population was more than 86,000, and the number of treated women was about 14,000 and 21,000 in 1993 and 1996, respectively. Depending on the age class considered as susceptible of receiving HRT, the prevalence of this therapy may vary between 15 and 20% for Switzerland, and between 21 and 27% for Geneva in 1993. It was estimated between 17 and 24%, and 31 and 41% in 1996. These values are quite comparable to those reported for other countries with a similar socioeconomic level and obtained using different methods of evaluation.

Psychosocial factors at work and sickness absence in the Gazel cohort: a prospective study

OBJECTIVE

To test whether psychosocial factors at work are predictors of rates of sickness absence.

METHODS

The study population consisted of middle aged men and women employed by the French national electricity and gas company (EDF-GDF) in various occupations and followed up since 1989 by annual self administered questionnaires and independent data obtained from the medical and personnel departments of EDF-GDF. The 1995 questionnaire provided information about three psychosocial work factors: psychological demands, decision latitude, and social support at work. Sick-ness absence data were provided by the company's social security department. The occurrence of spells and days of absence in the 12 months after completion of the 1995 questionnaire was studied. Potential confounding variables were age, smoking, alcohol, and marital status, assessed in the 1995 questionnaire, and educational level and occupation, assessed from data provided by the personnel department. This study was restricted to the 12,555 subjects of the initial cohort who were still working and answered the self administered questionnaire in 1995.

RESULTS

Low levels of decision latitude were associated with more frequent and longer sickness absences among men and women. Low levels of social support at work increased the numbers of spells and days of absence among men only. These associations weakened after adjustment for potential confounding factors, but remained significant.

CONCLUSION

The study indicates that psychosocial factors at work, especially decision latitude, are predictive of sickness absence.

Compliance with hormone replacement therapy in Chinese women in Hong Kong

Compliance with hormone replacement therapy (HRT) has been extensively studied in western countries. However, there is little data concerning women in Asian countries. A retrospective study was performed to determine compliance in a group of Hong Kong Chinese women who commenced HRT over a 2 year period. Two years after the commencement of HRT, 68.3% were still taking HRT, although not always in the original formulation. The highest drop out rate occurred during the first 6 months. Factors which were associated with a higher degree of compliance were young age at menopause and at the time of initial consultation and the use of unopposed HRT. A number of significant medical problems were identified during the 2 years of follow up which may have remained otherwise undetected. Compliance with HRT appears to be comparable to that reported in other western specialist centres. Nearly 9% of women who stopped HRT did so because other doctors told them that they did need the treatment and another 6.5% because of the fear of breast cancer.

Improving compliance with hormonal replacement therapy in primary osteoporosis prevention

OBJECTIVES

To evaluate whether introduction of treatment alternatives would improve compliance with hormonal replacement therapy (HRT) as primary osteoporosis prevention in women not tolerating the first line osteoporosis prevention schedule.

MATERIAL AND METHODS

Follow-up in four hospitals participating in the Danish Osteoporosis Prevention Study. A total of 706 peri- and postmenopausal women aged 45-57 years between 3 and 24 months from last menstrual bleeding took part, 489 women were randomised to HRT and 217 received HRT by personal choice. A total of 135 (19%) women were hysterectomised. HRT was given as oral or transdermal oestradiol supplemented with progestogen. If the initial treatment allocation was not acceptable several alternatives were available in a pragmatic approach.

RESULTS

Compliance with first treatment schedule was lower in women with intact uterus (at 5 years: 48.3 +/- 2.4% compliance) than in hysterectomised (64.7 +/- 5.8%, P < 0.001 in a Cox analysis) but did not differ after the introduction of HRT alternatives (67.0 +/- 2.9 vs 77.8 +/- 5.9, P = 0.12). Compliance decreased with increasing age at treatment start (RR = 1.11, P < 0.001) in women with intact uterus but not in hysterectomised women (P = 0.96). Headache/migraine was more frequent among women with intact uterus on oral sequential oestrogen plus progestogen than among hysterectomised women receiving oral continuous oestrogen (RR = 11.3, P < 0.01).

CONCLUSIONS

It seems possible to maintain a high HRT compliance by a pragmatic approach including offering alternative HRT formulations to women not tolerating the primary HRT. Further research into long-term compliance with HRT and cost-benefit is warranted.

Time-trend of sleep disorder in relation to night work: a study of sequential 1-year prevalences within the GAZEL cohort

We examined two longitudinal hypotheses: the 1-year prevalence for night workers is consistently higher than for others; the time trend is steeper for night workers than for others. Subjects were 12,779 men (age 40-50) working at Electricité de France-Gaz de France, and recruited in the GAZEL cohort. Five questionnaires were sent to all subjects on 1989 through 1993. Self-reported occurrence of sleep disorder in the previous year was regressed on night work status in 1989 and covariates to estimate prevalence rate differences (PRDs). The estimated PRD for regular night workers versus others was 6.1% (95% CI, 1.1-11.1%). There was a common time trend of 1.4% per year (1.0-1.9%), and evidence of excess trend for regular night workers: 1.1% (-0.7-2.9%). Findings indicate that the effect of night work on sleep complaints manifests itself during the first year of night work and is permanent.

What do Norwegian women and men know about osteoporosis?

A survey of a random sample of 1514 Norwegian women and men aged 16-79 years was undertaken to investigate knowledge of osteoporosis and attitudes towards methods for preventing this disease. The interviews were carried out by Central Bureau of Statistics of Norway as part of their monthly national poll using a structured questionnaire. Women knew more about osteoporosis than did men (p < 0.001). In both men and women increased knowledge of osteoporosis was correlated to a high level of education. Furthermore it was clearly demonstrated that knowing someone with osteoporosis or suffering from it oneself increased the knowledge of osteoporosis significantly in both women and men. Multiple regression analysis confirmed the univariate analyses, and education was the strongest predictive factor for knowledge. To a hypothetical question as many as two-thirds of the women answered that they would use long-term hormone replacement therapy (HRT) to prevent osteoporosis on the recommendation of their general practitioner. Their attitudes towards the use of estrogen therapy did not show any significant relation to age, but their reluctance towards HRT increased with education (p < 0.001). When asked a question about their preferences regarding the use of physical activity as a means to prevent osteoporosis, older women preferred walking (p < 0.001), whereas younger women wanted more organized athletic activity (p < 0.001). The data demonstrated that there was a high degree of general knowledge of osteoporosis and its consequences in the general population.

Menopause and perceived health status among the women of the French GAZEL cohort

The aim of this study was to evaluate the effect of menopause on women's quality of life. Women (1171) aged from 45-52 years who work for the French national gas and electricity company volunteered for this study (response rate 75%). They completed a self-administered questionnaire pertaining to general health. Quality of life was measured by the Nottingham Health Profile (NHP). Within this group 289 women were postmenopausal. After controlling for age, those women were more likely to show a lower quality of life than women still menstruating for 4 of the 6 sections of the NHP: social isolation (odds ratio 1.4; 95% confidence interval 1.1-1.9), pain, sleep and energy (odds ratios 1.5; 95% confidence intervals 1.1-2.0). Those alterations of quality of life are explained by the climacteric complaints the women report. Those findings suggest that the treatment of menopausal symptoms with medication of proven efficacy may prevent lowering of quality of life due to menopause.

Bone mass measurements around menopause and prevention of osteoporotic fractures

The objective of this work is to try to answer the question: is it useful to recommend bone densitometry at the time of the menopause as a screening test for women at high risk of osteoporotic fractures? This analysis is based on a review of the literature for the period 1981-1993, considering published articles in English or French. Prospective studies demonstrate that low bone mass (BM) in women who have been menopausal for more than 10 years is actually a risk factor for fracture, with a fracture risk multiplied by about two for a decrease in BM of one standard deviation. At present no studies have shown this association when BM determinations have been realised at the age of 50 years. The use of BM measurements remains difficult in practice because there is no international consensus concerning the definition and the value of a threshold for a high fracture risk. Concerning the efficacy of preventive interventions applied following the identification of a low BM, i.e. hormonal replacement therapy (HRT), data are lacking concerning the magnitude of its efficacy on fracture prevention and in the presence of an already decreased BM. Moreover osteoporosis is not the only indication for HRT, which may be prescribed for other consequences of the menopause. There is not enough evidence for the screening, by BM measurements, of high risk fracture at the time of the menopause. These measurements may help women who hesitate to take HRT, but they do not seem to improve compliance with the treatment to a large extent. Knowledge concerning osteoporosis and its prevention remains a major determinant in the use of preventive measures.