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

The effect of 17beta-estradiol plus norethisterone acetate on anthropometric indices: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Little evidence exists on the effect of 17beta-estradiol plus norethisterone acetate on all the anthropometric indices. Hence, this systematic review and meta-analysis of Randomized Controlled Trials was conducted to give an evidence-based report on the effect of 17beta-estradiol plus norethisterone acetate on anthropometric indices.

METHODS

The literature search was executed in databases including PubMed/Medline, Web of Science, Scopus, Embase, and Google Scholar to recognize clinical trials that examined the influence of 17beta-estradiol plus norethisterone acetate on obesity indices from database inception to Jan 2023.

RESULTS

Combined findings were generated from 20 eligible articles. The meta-analysis showed that body weight (Weighted Mean Difference (WMD): -0.47 kg, 95% CI: -1.32, 0.37, p = 0.274), body fat (WMD: 0.16 kg, 95% CI: -1.26, 1.59, p = 0.821), WHR (WMD: 0.001 kg, 95% CI: -0.006, 1.15, p = 0.872), and LBM (WMD: -0.02 kg, 95% CI: -1.19, 1.15, p = 0.970) were not modified in DHEA group compared to the control, but BMI levels were significantly reduced in 17beta-estradiol plus norethisterone acetate group (WMD: -0.15 kg/m2, 95% CI: -0.30, -0.008, p = 0.039). Moreover, based on intervention duration (months), a more significant reduction in BMI was found in trials that were performed on studies with ˃3 months duration (WMD: -0.176 kg/m2) than studies with ≤ 3 months (WMD: 0.05 kg/m2).

CONCLUSION

Administration of 17beta-estradiol plus norethisterone acetate for more than 3 months results in a decrease in BMI, which helps to reduce cardiovascular disease risk.

Hormonal therapy in menopausal transition: implications for improvement of health-related quality of life

The study aim was to assess scores of the Menopause Rating Scale (MRS) among women who use and desire to use hormonal therapy (HT), as well as to evaluate factors contributing to HT use and desire to use HT among women in menopausal transition. A total of 513 mid-aged women participated in the study. Data were collected using socio-demographic questionnaire, MRS and Beck Depression Inventory. The prevalence of current HT use was 9.7%, while 4.5% of women who did not use HT expressed a desire to start using HT. The MRS cutoff score for HT use was 10.5 and 11.5 among those who desire to use HT. Living in the central city districts, having lower body mass index, younger age at menopause, more gynecological illnesses, and worse MRS were associated with HT use. Living in the central city districts, having fewer births, more gynecological and chronic illnesses and having more depressive symptoms were associated with the desire to use HT. Mid-aged women who perceive their quality of life as poor due to climacteric symptoms should be advised to consider HT to improve their health status and everyday functioning.

Ovarian hormones and obesity

BACKGROUND

Obesity is caused by an imbalance between energy intake, i.e. eating and energy expenditure (EE). Severe obesity is more prevalent in women than men worldwide, and obesity pathophysiology and the resultant obesity-related disease risks differ in women and men. The underlying mechanisms are largely unknown. Pre-clinical and clinical research indicate that ovarian hormones may play a major role.

OBJECTIVE AND RATIONALE

We systematically reviewed the clinical and pre-clinical literature on the effects of ovarian hormones on the physiology of adipose tissue (AT) and the regulation of AT mass by energy intake and EE.

SEARCH METHODS

Articles in English indexed in PubMed through January 2016 were searched using keywords related to: (i) reproductive hormones, (ii) weight regulation and (iii) central nervous system. We sought to identify emerging research foci with clinical translational potential rather than to provide a comprehensive review.

OUTCOMES

We find that estrogens play a leading role in the causes and consequences of female obesity. With respect to adiposity, estrogens synergize with AT genes to increase gluteofemoral subcutaneous AT mass and decrease central AT mass in reproductive-age women, which leads to protective cardiometabolic effects. Loss of estrogens after menopause, independent of aging, increases total AT mass and decreases lean body mass, so that there is little net effect on body weight. Menopause also partially reverses women's protective AT distribution. These effects can be counteracted by estrogen treatment. With respect to eating, increasing estrogen levels progressively decrease eating during the follicular and peri-ovulatory phases of the menstrual cycle. Progestin levels are associated with eating during the luteal phase, but there does not appear to be a causal relationship. Progestins may increase binge eating and eating stimulated by negative emotional states during the luteal phase. Pre-clinical research indicates that one mechanism for the pre-ovulatory decrease in eating is a central action of estrogens to increase the satiating potency of the gastrointestinal hormone cholecystokinin. Another mechanism involves a decrease in the preference for sweet foods during the follicular phase. Genetic defects in brain α-melanocycte-stimulating hormone-melanocortin receptor (melanocortin 4 receptor, MC4R) signaling lead to a syndrome of overeating and obesity that is particularly pronounced in women and in female animals. The syndrome appears around puberty in mice with genetic deletions of MC4R, suggesting a role of ovarian hormones. Emerging functional brain-imaging data indicates that fluctuations in ovarian hormones affect eating by influencing striatal dopaminergic processing of flavor hedonics and lateral prefrontal cortex processing of cognitive inhibitory controls of eating. There is a dearth of research on the neuroendocrine control of eating after menopause. There is also comparatively little research on the effects of ovarian hormones on EE, although changes in ovarian hormone levels during the menstrual cycle do affect resting EE.

WIDER IMPLICATIONS

The markedly greater obesity burden in women makes understanding the diverse effects of ovarian hormones on eating, EE and body adiposity urgent research challenges. A variety of research modalities can be used to investigate these effects in women, and most of the mechanisms reviewed are accessible in animal models. Therefore, human and translational research on the roles of ovarian hormones in women's obesity and its causes should be intensified to gain further mechanistic insights that may ultimately be translated into novel anti-obesity therapies and thereby improve women's health.

Predictors of intentions to use hormone replacement therapy in clinical postmenopausal women

OBJECTIVES

To investigate the contribution of components of the Health Beliefs Model (perceived susceptibility, perceived severity, health motivation, perceived risk and benefits of hormone replacement therapy (HRT) use), sociodemographic variables (age, duration of postmenopause, hysterectomy and social class) and psychological stress to intentions to use HRT for the first time.

METHODS

A quasi-experimental design was used to recruit a clinical sample of 180 postmenopausal women, attending a menopause clinic, with a mean age of 50.74 years (standard deviation 4.75 years). Data were collected using self-report questionnaires. A regression analysis was carried out to establish what predicts intentions to use HRT in this sample; sociodemographic variables were entered in the first step of the regression, followed by health motivation and perceived stress in step two, the third step involved the addition of perceived severity measures, and in the final step susceptibility and perceived risks and benefits were added.

RESULTS

The main predictor of intentions to use HRT, after controlling for all other variables, was the belief that the benefits outweigh the risks associated with taking HRT.

CONCLUSIONS

This information should be used to develop interventions and health awareness materials about HRT in clinical postmenopausal women.

Adjuncts or adversaries to shared decision-making? Applying the Integrative Model of behavior to the role and design of decision support interventions in healthcare interactions

Background

A growing body of literature documents the efficacy of decision support interventions (DESI) in helping patients make informed clinical decisions. DESIs are frequently described as an adjunct to shared decision-making between a patient and healthcare provider, however little is known about the effects of DESIs on patients' interactional behaviors-whether or not they promote the involvement of patients in decisions.

Discussion

Shared decision-making requires not only a cognitive understanding of the medical problem and deliberation about the potential options to address it, but also a number of communicative behaviors that the patient and physician need to engage in to reach the goal of making a shared decision. Theoretical models of behavior can guide both the identification of constructs that will predict the performance or non-performance of specific behaviors relevant to shared decision-making, as well as inform the development of interventions to promote these specific behaviors. We describe how Fishbein's Integrative Model (IM) of behavior can be applied to the development and evaluation of DESIs. There are several ways in which the IM could be used in research on the behavioral effects of DESIs. An investigator could measure the effects of an intervention on the central constructs of the IM - attitudes, normative pressure, self-efficacy, and intentions related to communication behaviors relevant to shared decision-making. However, if one were interested in the determinants of these domains, formative qualitative research would be necessary to elicit the salient beliefs underlying each of the central constructs. Formative research can help identify potential targets for a theory-based intervention to maximize the likelihood that it will influence the behavior of interest or to develop a more fine-grained understanding of intervention effects.

Summary

Behavioral theory can guide the development and evaluation of DESIs to increase the likelihood that these will prepare patients to play a more active role in the decision-making process. Self-reported behavioral measures can reduce the measurement burden for investigators and create a standardized method for examining and reporting the determinants of communication behaviors necessary for shared decision-making.

Using decision aids in community-based primary care: a theory-driven evaluation with ethnically diverse patients

OBJECTIVE

To assess the effects of informational brochures and video decision aids about cancer screening on patient intention to engage in shared decision-making and its predictors in a racially diverse sample.

METHODS

Participants were recruited from 13 community-based primary care practices serving racially and ethnically diverse patients in predominately economically disadvantaged neighborhoods. Participants completed theory-based measures assessing attitudes, perceived social norms, self-efficacy and intentions for working with their physician to make a cancer screening decision after reviewing a brochure or video decision aid, but before seeing the physician. A post-questionnaire assessed screening decisions and participant knowledge.

RESULTS

Participants who reviewed a video decision aid had higher knowledge and were more likely to want to be the primary decision-maker. They reported lower perceived social norms, self-efficacy and intentions to work with their physicians than participants who reviewed a brochure. Participants who decided against cancer screening reported lower intentions to work with their physician in making a decision and were less likely to report having spoken with their physician about screening.

CONCLUSION

Participants who opted against cancer screening after reviewing a brochure or decision aid were less likely to discuss their decision with their physician. The tendency toward autonomous decision-making was stronger among participants who reviewed a video decision aid.

La pharmacologisation de la ménopause

La littérature souligne le rôle central que jouent les médicaments dans l’expansion du processus de médicalisation. Les traitements pharmaceutiques modifient également la façon dont les individus perçoivent leur action sur le corps. Cet article, basé sur 26 entretiens semi-directifs réalisés auprès de femmes françaises, s’interroge sur les fonctions qu’elles attribuent à l’hormonothérapie, les comparant à celles rapportées dans les recherches chez les utilisateurs du Viagra. L’analyse met en évidence des usages communs de restauration, de normalisation et d’extension des capacités corporelles. Des différences sont observables concernant l’inscription du médicament dans le corps, qui est interprétée en termes de naturalité ou d’artificialité.

Women's attitudes to hormone replacement therapy in the aftermath of the Women's Health Initiative study

AIM

This paper is a report of a study conducted in 2004 on the determinants of attitudes towards hormone replacement therapy in the aftermath of the report on the findings of the Women's Health Initiative study.

BACKGROUND

The unexpected findings of the Women's Health Initiative study, published in July 2002, showed that the risk of using combined hormones exceeded their benefits. This complicated women's decision-making about hormone use and made it important to study the determinants of their attitudes to hormone therapy, as these are likely to influence their behaviour.

METHODS

A cross-sectional design was conducted with a sample of 561 women drawn from the National Registry of Iceland. A self-administered questionnaire, measuring attitudes towards hormone replacement therapy, attitudes towards menopause, extent and source of menopausal education, symptom experience, health and lifestyle and knowledge about the findings of the Women's Health Initiative, was used. The overall response rate was 56%. Attitudes to hormone replacement therapy were compared using anova, t-tests and correlations.

RESULTS

Participants generally had positive attitudes. Knowledge about the Women's Health Initiative study was not associated with more negative attitudes. However, receiving the information from and discussing it with a doctor were associated with more positive attitudes. Positive attitudes towards hormone therapy were also associated with higher age, time since last menstrual period and current use of hormone replacement therapy. Negative attitudes were associated with use of natural remedies and receiving information from or discussing hormone therapy with family or friends.

CONCLUSION

Research is needed to identify the dynamics of the medical interview, and the nature of input from friends, spouse and other family members. The content of these messages may be different and conflicting, for example, between doctors and family members. The nature of this conflict and conflicts of interests need to be identified in order to inform women's decision-making. In addition, action needs to be taken in order to strengthen the advisory role of nurses.

Women's use of hormone therapy before and after the Women's Health Initiative: a psychosocial model of stability and change

OBJECTIVE

This longitudinal study examined factors underlying hormone therapy (HT) use before and after termination of the landmark Women's Health Initiative (WHI) estrogen plus progestin HT trial in July 2002, after which dramatic reductions in HT use occurred.

METHODS

A community sample of 324 women (aged 40-86) from Arizona was interviewed four times between 1995 and 2003. A model of medical and psychological factors underlying intentions for long-term HT use expressed in 1995/1996 was developed and employed to predict subsequent use and discontinued use pre- and post-WHI.

RESULTS

Philosophy of menopause and perceived susceptibility to breast cancer predicted perceived benefits of and barriers to long-term HT use, beyond age, oophorectomy, and physician recommendation. Age, benefits, and barriers predicted intentions for long-term HT use over and above current use. Intentions predicted use 3 years later, controlling for previous use. HT use in 1995/1996 predicted use until the WHI announcement, but not thereafter. Oophorectomy predicted continued HT use before WHI trial termination; perceived barriers, expressed 8 years earlier, predicted discontinued use after WHI trial termination.

CONCLUSIONS

Medical and psychological factors predicted sustained and discontinued HT use before and after the WHI announcement. The WHI findings apparently activated potential barriers to use expressed almost a decade earlier.

Variation in the psychosocial determinants of the intention to prescribe hormone therapy prior to the release of the Women's Health Initiative trial: a survey of general practitioners and gynaecologists in France and Quebec

BACKGROUND

Theory-based approaches are advocated to improve our understanding of prescription behaviour. This study is an application of the theory of planned behaviour (TPB) with additional variables. It was designed to assess which variables were associated with the intention to prescribe hormone therapy (HT). In addition, variations in the measures across medical specialities (GPs and gynaecologists) and across countries (France and Quebec) were investigated.

METHODS

A survey among 2,000 doctors from France and 1,044 doctors from Quebec was conducted. Data were collected by means of a self-administered questionnaire. A clinical vignette was used to elicit doctors' opinions. The following TPB variables were assessed: attitude, subjective norm, perceived behavioural control, attitudinal beliefs, normative beliefs and power of control beliefs. Additional variables (role belief, moral norm and practice pattern-related factors) were also assessed. A stepwise logistic regression was used to assess which variables were associated with the intention to prescribe HT. GPs and gynaecologists were compared to each other within countries and the two countries were compared within the specialties.

RESULTS

Overall, 1,085 doctors from France returned their questionnaire and 516 doctors from Quebec (response rate = 54% and 49%, respectively). In the overall regression model, power of control beliefs, moral norm and role belief were significantly associated with intention (all at p < 0.0001). The models by specialty and country were: for GPs in Quebec, power of control beliefs (p < 0.0001), moral norm (p < 0.01) and cytology and hormonal dosage (both at p < 0.05); for GPs in France, power of control beliefs and role belief (both at p < 0.0001) and perception of behavioural control (p < 0.05) and cessation of menses (p < 0.01); for gynaecologists in Quebec, moral norm and power of control beliefs (both at p = 0.01); and for gynaecologists in France, power of control beliefs (p < 0.0001), and moral norm, role belief and lipid profile (all at p < 0.05).

CONCLUSION

In both countries, compared with GPs, intention to prescribe HT was higher for gynaecologists. Psychosocial determinants of doctors' intention to prescribe HT varied according to the specialty and the country thus, suggesting an influence of contextual factors on these determinants.

Hormone therapy prescription among physicians in France and Quebec

OBJECTIVE

Our objective was to compare physician characteristics associated with high-frequency hormone therapy (HT) prescription between gynecologists and general practitioners (GPs) within and between France and Quebec, Canada.

DESIGN

A self-administered mail survey was sent to a representative sample of 2,000 physicians in France and 1,000 physicians in Quebec. High-frequency prescribers were those who reported prescribing HT to more than 70% of their postmenopausal patients. The following characteristics were included in the analysis: country, specialty, age, gender, characteristics of the practice (solo or group, private or public, rural or urban, number of patients seen daily, duration of practice, percentage of women 45 years or older), teaching or research activities, participation in education course on HT, and practice patterns relating to menopausal women (having patient education materials available, providing materials to patients, and discussing the possibility of HT).

RESULTS

The analysis covered 974 physicians in France (389 GPs and 585 gynecologists) and 452 physicians in Quebec, Canada (318 GPs and 134 gynecologists). Despite differences in health care, in both countries gynecologists were more likely to be high-frequency prescribers than were GPs, although this difference was smaller in Quebec. Canadian physicians were more likely to prescribe HT. The difference between countries was greatest among GPs. Except for nationality and practice patterns designed to provide women with information, none of the physician characteristics was associated with high-frequency prescription among GPs. Among gynecologists, only the number of patients per day and the provision of information were associated with high-frequency prescription.

CONCLUSIONS

Notwithstanding a common language, differences in the prescription pattern of HT between countries were greatest at the level of primary care than secondary care. In both countries, specialists were more likely to prescribe HT than were GPs. Implementation of clinical practice guidelines to set baseline standards in the field of menopausal health remains a challenge but will need to take into account cultural characteristics as well as level of medical care.

Factors associated with intention to use hormone replacement therapy among Thai middle-aged women

OBJECTIVES

To examine the differences among those who express their intentions to use hormone replacement therapy (intenders), those who express their intentions not to use hormone replacement therapy (non-intenders), and those who are undecided, and to examine the factors associated with hormone replacement therapy (HRT) intention among Thai middle-aged women.

METHODS

A total of 420 women aged 40-59 years, recruited from one hospital in Bangkok were asked to complete a self-administered questionnaire.

RESULTS

Compared to intenders and non-intenders, the undecided were significantly less knowledgeable about menopause and HRT, and perceived the highest level of decisional uncertainty. Being inadequately informed was the most important factor that distinguished the undecided from intenders and non-intenders. When looking at intenders and non-intenders, no significant differences in perceived information inadequacy, level of knowledge, and perceived risks of HRT were found. However, it was found that intenders perceived higher benefit over risk of HRT (OR = 1.05, 95% CI = 1.02, 1.07), held more negative beliefs towards menopause (OR = 1.61, 95% CI = 1.03, 2.53), and were approximately two times more likely to have ever used oral contraceptives (OR = 1.99, 95% CI = 1.13, 3.47) than non-intenders.

CONCLUSION

The findings reveal the importance of being informed about menopause and HRT in making decision about HRT use. Changes in knowledge, and beliefs are promising avenues to study to see how these impacts HRT use.

Associations between attitudes toward hormone therapy and current use of it in middle-aged women

OBJECTIVES

To investigate the association between attitudes toward hormone therapy (HT) and use of it and explanatory factors for the association found.

METHODS

All women in two primary healthcare districts aged 45, 50, 55 or 60 in 2000 or 2001 (n=771) received a questionnaire consisting of quality-of-life instruments and items concerning menopause, health, healthcare, symptoms, sociodemographic factors and attitudes toward HT.

RESULTS

A total of 564 women (74%) responded to the questionnaire. In the women with a positive or a neutral attitude, rather than a negative one, the age- and menopause-adjusted odds ratios for current HT use were 18.55 (95% CI 8.55, 40.11) and 2.61 (1.15, 5.93), respectively. Health-related factors, factors concerning one's own person and psychosocial factors were the groups of factors found to contribute to explaining the association between attitudes and current HT use. Together, the three groups of factors explained 42 and 98%, respectively, of a positive and a neutral attitude's association with current use of HT. Individual factors of importance in these factor groups were a feeling of being appreciated outside the home, satisfaction with one's work, marital status, own climacteric period, visits to a physician and past use of hormonal contraceptives. In contrast, level of education and the occurrence of cold sweats/hot flushes was not found to contribute to the explanation.

CONCLUSIONS

Factors concerned with women's everyday life, contentment with oneself and use of healthcare services were of importance in explaining the associations between attitudes toward HT and current use of it. Consideration at these factors in counselling women about HT is recommended.

Hormone replacement therapy counseling: prevalence and predictors

OBJECTIVES

To evaluate the prevalence of hormone replacement therapy (HRT) counseling and to investigate the relationship between patients' cultural background and healthcare professionals' counseling practices. HRT is the principal preventive intervention for reducing risk of menopause-related pathologic conditions. This study assessed self-reports of HRT counseling among women receiving care in an urban community hospital.

METHODS

A descriptive self-reported survey study of 134 women aged 45-65 was conducted in the medical clinic at an urban community teaching hospital in a multicultural area in New York. Questionnaires asked about age, ethnicity, HRT use, contraindications, health professional counseling, and barriers to HRT counseling. Possible predictors of HRT counseling were analyzed with logistic regression models. Categorical variables were compared with chi-square statistics.

RESULTS

Overall prevalence of HRT counseling was 25%. Prevalence of HRT use was 19%; among those using HRT, only 12.7% reported receiving HRT counseling. Physicians were more likely to discuss HRT than other healthcare professionals. Over 90% of the patients reported a desire for HRT counseling.

CONCLUSIONS

The low rates of HRT counseling suggest physicians have limited daily experience with HRT counseling practices. Public health efforts should focus on increasing physician and general population awareness to promote HRT counseling strategies and ensure public access to HRT information.

A social-cognitive model to predict the use of assistive devices for mobility and self-care in elderly people

PURPOSE

To provide insight into the contribution of psychological variables in understanding use and nonuse of assistive devices (ADs) for self-care and mobility.

DESIGN AND METHODS

A survey on a representative sample of 491 community-dwelling elderly people in Flanders was conducted. A theoretical model of the factors predicting the use of ADs was tested with path analysis.

RESULTS

The possession and use of 32 ADs were found to be bivariately related to intention to use ADs, awareness of ADs, attitude toward AD use, subjective norm regarding AD use, self-efficacy concerning AD use, and socio-demographic characteristics. In regression analyses the intention to use ADs was found to be related to self-efficacy concerning AD use, attitude toward AD use, and subjective norm regarding AD use.

IMPLICATIONS

This study suggests that a social-cognitive model of human behavior can be helpful in explaining the use of ADs. The model can suggest measures to be developed aiming to improve the introduction of ADs.

Obesity and sarcopenia after menopause are reversed by sex hormone replacement therapy

OBJECTIVE

Menopause is linked to an increase in fat mass and a decrease in lean mass exceeding age-related changes, possibly related to reduced output of ovarian steroids. In this study we examined the effect of combined postmenopausal hormone replacement therapy (HRT) on the total and regional distribution of fat and lean body mass.

RESEARCH METHODS AND PROCEDURES

Sixteen healthy postmenopausal women (age: 55 +/- 3 years) were studied in a placebo-controlled, crossover study and were randomized to 17beta estradiol plus cyclic norethisterone acetate (HRT) or placebo in two 12-week periods separated by a 3-month washout. Total and regional body composition was measured by DXA at baseline and in the 10th treatment week in both periods. Changes were compared by a paired Student's t test.

RESULTS

The change in body weight during HRT was equal to the change during placebo (-24.6 g vs. -164 g, p = 0.42), but relative fat mass was significantly reduced (-0.5% vs. +1.24%, p < 0.01). During HRT, compared with during placebo, lean body mass increased (+347 g vs. -996 g, p < 0.01) and total fat mass decreased (-400 g vs. +836 g, p = 0.06). Total bone mineral content increased (+28.9 g vs. -4.4 g, p = 0.04) and abdominal fat decreased (-185 g vs. +253 g, p = 0.04) during HRT compared with placebo.

DISCUSSION

HRT is linked to the reversal of both menopause-related obesity and loss of lean mass, without overall change in body weight. The increase in lean body mass during HRT is likely explained by muscle anabolism, which in turn, prevents disease in the elderly.