Correlates of postmenopausal estrogen use and trends through the 1980s in two southeastern New England communities

Characteristics of HRT users in Japan: Evidence from the Japan Nurses' Health Study

OBJECTIVES

Little is known about what type of women use hormone replacement therapy (HRT) in Japan. Based on the Japan Nurses' Health Study (JNHS), a large population cohort study, we determined the characteristics of HRT users by comparing the characteristics of new HRT users and the characteristics of women who did not use HRT during a 10-year follow-up period.

STUDY DESIGN

Of the 15,019 JNHS participants, 4886 women reported an experience of menopausal transition during the 10-year follow-up period.

MAIN OUTCOME MEASUREMENT

Characteristics of new HRT users.

RESULTS

The proportion of HRT users during the 10-year period was 8.5 %. Advanced age at menopause was significantly associated with a low rate of use of HRT. Past use of oral contraceptives, dysmenorrhea with disturbance in daily life and vasomotor symptoms were significantly associated with a high rate of use of HRT. The occupations of public health nurse and midwife and a history of bilateral oophorectomy were also significantly associated with a high rate of use of HRT.

CONCLUSIONS

We determined the characteristics of new HRT users among middle-aged women during a 10-year follow-up period. Women who had sufficient knowledge about endocrinological hormones and women who had less reluctance to visit doctors for gynecological problems were likely to use HRT.

Use of Hormone Replacement Therapy and Risk of Dementia: A Nationwide Cohort Study

BACKGROUND AND OBJECTIVES

Estrogen has the potential to influence brain physiology implicated in dementia pathogenesis. Hormone replacement therapy (HRT) might be expected to influence the risk of dementia. Observational data indicated that HRT was associated with reductions in dementia risk, but experimental evidence demonstrates that HRT increases the incidence of dementia. To determine the effect of HRT on the risk of dementia, a retrospective cohort study was performed using a nationwide claims dataset in Taiwan.

METHODS

A population-based longitudinal study was performed using data from the Longitudinal Health Insurance Database in Taiwan. A total of 35,024 women with HRT were enrolled as the exposed cohort and 70,048 women without HRT were selected on the basis of propensity matching as the comparison cohort. All participants were followed up until the diagnosis of dementia, death, or at the end of December 31, 2013, whichever occurred first. Overall, the average duration of follow-up (±SD) in the HRT and comparison cohorts was 12.3 (±2.3) and 12.2 (±2.4), respectively. The Cox proportional hazards regression models were conducted to produce hazard ratios (HRs) with 95% CIs to evaluate the association of HRT with the risk of dementia.

RESULTS

In the follow-up period, the cumulative incidence of dementia for the HRT cohort (20.04 per 1,000) was significantly higher than the corresponding cumulative incidence for the comparison cohort (15.79 per 1,000), resulting in an adjusted HR of 1.35 (95% CI 1.13-2.62). There was an increased risk of dementia with a higher cumulative dose of HRT prescription (p for trend <0.0001).

DISCUSSION

This cohort study documented that HRT was associated with an increased risk of dementia. The clinical implications of this study merit further investigations.

Reproductive factors and hormone use and risk of adult gliomas

Previous research suggests there may be a hormonal influence on glioma risk as evidenced by lower rates in females, change in incidence rates around ages at menarche and menopause, and presence of hormone receptors in glial tumors. Using the large San Francisco Bay Area Adult Glioma Study, we investigated whether reported reproductive factors and hormone use were associated with gliomas overall or with histologic subtypes among female cases (n = 619) and controls (n = 650). We found that reproductive factors were generally not associated with gliomas. Weak to moderately elevated odds ratios were observed for self-reported later age at menarche (14+ vs. 12-13 years old: adjusted odds ratio (AOR) = 1.39, 95% confidence interval (CI): 1.02-1.89), particularly for non-glioblastoma histologies (AOR = 1.64, 95% CI: 1.11-2.43). Inverse associations were observed for ever self-reported use of exogenous hormones (oral contraceptive use: AOR = 0.72, 95% CI: 0.53-0.99; postmenopausal hormone use: AOR = 0.56, CI: 0.37-0.84). However, cumulative hormone exposure defined multiple ways demonstrated no clear pattern of association. The results of this study suggest that any protective effect of hormones on gliomas may be limited to exogenous hormones, but a more detailed history of exogenous hormone use is needed to confirm findings.

Agreement of self-reported estrogen use with prescription data: an analysis of women from the Kuopio Osteoporosis Risk Factor and Prevention Study

OBJECTIVE

Self-reported data are usually used for the evaluation of the effects of hormone therapy in population studies. We examined the agreement between self-reported hormone therapy use and nationwide prescription data from the Social Insurance Institution of Finland to evaluate the accuracy of self-reports.

DESIGN

The 10-year questionnaire of the population-based Kuopio Osteoporosis Study was sent in 1999 to 12,562 women aged 57 to 67 years; 11,377 women who completed questionnaires were eligible for analysis. We asked women whether they had been taking estrogen hormone therapy as a gel, plaster, or tablet for the treatment of climacteric symptoms or osteoporosis and if the answer was yes, to specify the brand and duration of treatment for each year from 1994 to 1999.

RESULTS

Among the 11,377 women, 3,105 (27.3%) reported the use of an estrogen-based preparation in 1996 to 1999, and 97.6% were confirmed by Social Insurance Institution of Finland to have been prescribed hormone therapy during that time. In these women the median duration of use was 32 months (range, 1-41), according to Social Insurance Institution of Finland data. An additional 1,738 women had been prescribed hormone therapy for short periods, but those women did not report it. The duration of self-reported hormone therapy use was compared to the duration of prescriptions. A difference of 3 months or less per year was observed in 63.4% to 77.0% of women during the years 1996-1998.

CONCLUSIONS

A postal inquiry is a reliable method of recording long-term hormone therapy use.

Prospective association of vascular endothelial growth factor-A (VEGF-A) with coronary heart disease mortality in southeastern New England

BACKGROUND

Autopsy data suggest that plaque neovascularization may be associated with coronary heart disease (CHD) death. Since vascular endothelial growth factor-A (VEGF-A) is upregulated in angiogenesis and therefore neovascularization, we hypothesized that individuals with elevated levels of VEGF-A at baseline would be a greater risk of dying of CHD compared to those with lower levels over time.

METHODS

We measured VEGF-A levels in 46 CHD death cases and a 14% random sample of 2321 community participants who were free of self-reported CHD at baseline. Traditional CHD risk factors such as age, gender, family history of CHD, cigarette smoking, hypertension, total cholesterol/HDL ratio, diabetes mellitus, were also evaluated at baseline. Mortality follow-up was determined through linkage of baseline data with the National Death Index.

RESULTS

During a median of 13 years of follow-up, 46 subjects died of coronary heart disease. Mean VEGF-A levels were significantly higher in the CHD death cases than among the random population sample (400 pg/ml vs. 303 pg/ml, p=0.0004). In proportional hazards models adjusting for traditional risk factors, the hazard ratios (95%CI) for CHD death associated with increasing tertiles of VEGF-A were 1.0 (referent), 2.12 (0.74, 6.10), and 3.85 (1.37, 10.78), respectively (P(test for trend)=0.008).

CONCLUSION

In this population-based prospective, case-cohort study, baseline levels of VEGF-A showed a significant independent association with the risk of CHD death.

Persistence with oral and transdermal hormone replacement therapy and hospitalisation for cardiovascular outcomes

BACKGROUND

The effect of persistence with transdermal and oral administrations of hormone replacement therapy (HRT) on the risk of hospitalisation for cardiovascular disease, and the role of income as potential confounder, were explored in a large population-based cohort study.

METHODS

Seventy-eight thousand eight hundred and seventy-five women resident in the Italian Lombardy Region aged 45-65 years who received at least one HRT prescription during 1998-2000 were followed until December 2003. The 828 cohort members who experienced at least one hospitalisation for a circulatory system disease were identified from the Regional hospital discharge database. The Regional prescription drug database was used to assess cumulative persistence with hormone treatment during follow-up. Data on individual taxable income was also obtained for women resident in the city of Milan. A proportional hazards model was fitted to estimate the association between cumulative time-dependent persistence with HRT and cardiovascular risk.

RESULTS

Compared with women who took HRT for less than 6 months, those exposed for more than 3 years to HRT as a whole, and to transdermal and oral HRT, respectively, showed hazard ratios of 0.65 (95% confidence interval: 0.45, 0.92), 0.53 (0.34, 0.82), and 1.15 (0.47, 2.79). CVD reducing potential of HRT disappeared when estimates were adjusted for income being hazard ratio associated with long-term use 0.94 (0.52, 1.71).

CONCLUSIONS

Evidence that CVD risk associated with long-term hormone treatment varies according to the route of HRT administration, and that economic position confounds the effect of HRT on the risk of cardiovascular hospitalisation, is provided by the current study.

The neurology of menopause

BACKGROUND

Menopause is a normal milestone experienced annually by 2 million American women each year, and many women are concerned about the relation between menopause and health. Associated hormonal changes have the potential to influence neurologic disease, as do hormonal therapies prescribed for menopausal symptoms or other conditions. The objective of this article is to increase neurologists' awareness of the relation between menopause and neurologic illness.

REVIEW SUMMARY

This was a focused review of 4 common neurologic disorders potentially influenced by menopause or by estrogen-containing hormone therapy: stroke, epilepsy, Parkinson disease, and Alzheimer disease. Hormonal effects are germane to each illness, although clinical implications are clearer for stroke and Alzheimer disease than for epilepsy and Parkinson disease. For women with epilepsy, few clinical data directly address the role of menopause or estrogen-containing hormone therapy on seizure frequency. Relevant clinical research findings on Parkinson disease are inconsistent and provide an inadequate basis for practice guidelines. There is clinical trial evidence that hormone therapy does not reduce stroke incidence and may increase risk of ischemic stroke; hormone therapy cannot be recommended for stroke prevention. The natural menopausal transition is not characterized by objective memory loss. There is clinical trial evidence that hormone therapy should not be used for the postmenopausal woman age 65 years or older for the preservation of cognitive skills, prevention of dementia, or treatment of dementia due to Alzheimer disease. Long-term cognitive consequences of short-term hormone therapy used by younger women for menopausal symptoms remains an important area of uncertainty.

CONCLUSIONS

Increased awareness of hormonal influences on neurologic illness is important for the practicing neurologist.

Estrogen-containing hormone therapy and Alzheimer’s disease risk: Understanding discrepant inferences from observational and experimental research

Estrogen has the potential to influence brain processes implicated in Alzheimer's disease pathogenesis. With the loss of ovarian estrogen production after menopause, estrogen-containing hormone therapy might be expected to influence the risk of Alzheimer's disease. Observational data link use of hormone therapy to reductions in Alzheimer risk, but experimental evidence from the Women's Health Initiative Memory Study trial demonstrates that oral estrogen, with or without a progestin, increases the incidence of dementia for postmenopausal women age 65 years or older. Mechanisms of harm in this setting are unknown. Bias and unrecognized confounding in observational research are leading candidates for discrepant results between observational studies and the Women's Health Initiative Memory Study trial. Studies are also distinguished by differences in outcome measures, hormone therapy formulations, prevalence of menopausal symptoms among study participants, and participant age. Finally, Women's Health Initiative Memory Study findings may not generalize to estrogen use by relatively young women during the menopausal transition or early postmenopause, a class of women who were ineligible for the Women's Health Initiative Memory Study trial. In observational studies, hormone therapy exposure often included use by younger women for menopausal vasomotor symptoms. Although there is no clinical trial evidence that hormone therapy at any age protects against Alzheimer's disease, it remains to be determined whether the age at which hormone exposure occurs or the timing of hormone therapy initiation in relation to the menopause (the critical window hypothesis) modifies treatment outcomes on dementia risk.

The woman patient after WHI

An epidemic of fear and distrust has infected women (and physicians) after publication of the Women's Health Initiative (WHI). The overinflated negative data emerging from the oestroprogestinic arm of WHI have frightened women and gave rise to the most difficult emotions to cope with. Keywords such as cancer, death and hormones combined together, have potentiated an avoidant attitude towards hormonal therapy (HT) driven more emotionally than rationally. This negative aura has not been dissipated by the positive data from the oestrogen-only arm of WHI. This paper will discuss: women's different emotional reactions to and coping strategies for HT-related fear after WHI; the communication skills physicians should use in focusing on positive messages emerging from WHI; predictors of current HT use; the meaning of the higher use of HT in postmenopausal highly-educated women and women gynaecologists; the importance of increasing healthy life-styles as a taking of responsibility towards aging by every woman; shifting from passivity to active sharing of the decision making process with the caring physician; and the use of an individually tailored HT, when appropriate, as part of an active strategy in the pursuit of a longer health expectancy.

Use of hormone replacement therapy in Italian women aged 50-70 years

OBJECTIVES

The aim of the present cross-sectional analysis was to describe patterns and determinants of use of hormone replacement therapy (HRT) in a large sample of women attending mammographic screening.

METHODS

Between 1999 and 2001, 8533 women aged 50-70 years were recruited by 11 screening centres, and structured interviews were made collecting information on socio-demographic characteristics, lifestyle habits, medical and reproductive history (overall response rate 87%).

RESULTS

Current HRT use was reported by 6.9% of women (n=585), the average duration of use being 3.5 years; 13.2% were ever HRT users. Binomial and multinomial logistic regression (MLR) analyses showed that younger age, higher educational level, past mammographic examination and history of bilateral oophorectomy were the major predictors of current and ever HRT use. Current use was also more frequently reported by women who were thinner, nulliparae, had had induced menopause, had a later onset of menopause, with history of oral contraceptive use and hysterectomy without bilateral oophorectomy. By contrast, those who were diabetics or had positive history of cardiovascular disease were less likely to be current HRT users. No differences were found in HRT use according to marital status, type of occupation, menopausal status, smoking, history of breast cancer, hypercholesterolemia, hypertension and phlebitis.

CONCLUSIONS

Our results support previous findings indicating that HRT use in Italian women is uncommon and of short duration. Current HRT users were less likely than non-users to report several characteristics associated with higher mortality and morbidity, in accordance with the healthy-user phenomenon described in other countries.

Health behaviors and other characteristics of women on hormone therapy: results from the Third National Health and Nutrition Examination Survey, 1988-1994

OBJECTIVE

To examine the prevalence of hormone therapy (HT) use and compare demographic characteristics, health behaviors, and health indicators between current HT users and never-users in a nationally representative sample of postmenopausal women.

DESIGN

The Third National Health and Nutrition Examination Survey was a cross-sectional survey conducted between 1988 and 1994, including 3,673 postmenopausal women aged 40 years and older.

RESULTS

Overall, 419 (11.4%) of the women reported current HT use, 857 (23.3%) reported past use, and 2,397 (65.3%) were never-users. Non-Hispanic black women and women aged 70 years or older were less likely to be current users. Higher socioeconomic status (education and income) and surgical menopause were associated with increased odds of current hormone use. After adjusting for the above variables, women who reported being inactive during leisure time and obese women (body mass index >or= 30) were less likely to be current users. Women who had 5 to 29 alcoholic drinks per month, perceived their health status as "good," took a multiple vitamin, were aware of having high blood cholesterol, and had a clinic for regular medical care were more likely to be current users. Smoking habits were not significantly different between the groups.

CONCLUSIONS

Current HT users have different demographic profiles and may lead healthier lives than never-users. This is important to take into account when studying the effects of HT, and it may partly explain differences in findings regarding the health effects of HT use in observational studies compared with randomized clinical trials.

Use of oral contraceptives and hormone replacement therapy in the WHO MONICA project

AIMS

To compare menopausal age and the use of oral contraceptives (OC) and hormonal replacement therapy (HRT) between the 32 populations of the WHO MONICA Project, representing 20 different countries.

METHODS

Using a uniform protocol, age at menopause and the use of OC and HRT was recorded in a random sample of 25-64 year-old women attending the final MONICA population cardiovascular risk factor survey between 1989 and 1997. A total of 39,120 women were included.

RESULTS

There were wide variations between the populations in the use of OC and HRT. The use of OC varied between 0 and 52% in pre-menopausal women aged 35-44 years, Central and East Europe and North America having the lowest and West Europe and Australasia the highest prevalence rates. Among post-menopausal women between 45 and 64 years, the prevalence of HRT use varied from 0 to 42%. In general, the use of HRT was high in Western and Northern Europe, North America and Australasia and low in Central, Eastern and Southern Europe and China. With the exception of Canada (45 years), the mean age at menopause differed only little (ranging from 48 to 50 years) between the populations.

CONCLUSION

The use of OC and HRT varies markedly between populations, in general following a regional pattern. Whereas, the prevalence rates are mostly similar within a country, there are remarkable differences even between neighbouring countries, reflecting nation-specific medical practice and public attitudes that are not necessarily based on scientific evidence.

Therapeutic decisions for menopause: results of the DAMES project in central Massachusetts

OBJECTIVE

To investigate the factors that influence therapeutic decisions at menopause, particularly those related to the burden of menopause symptoms, in a population of women living in Massachusetts, as part of the multisite DAMES (Decisions At Menopause Study).

DESIGN

A survey using face-to-face interviews with a randomly selected sample of 293 women aged 45 to 55 who are members of the Fallon Community Health Plan in Central Massachusetts. The instrument combined closed- and open-ended questions and elicited information about a number of health topics, including the symptoms experienced by respondents over the preceding month and the decisions they made regarding therapies.

RESULTS

Symptom reporting was found to be relatively high, with more than half of the sample reporting hot flashes, sleep disturbances, joint pains, and headaches in the month preceding the survey; one third to one half of the women reported palpitations, night sweats, fatigue, and numbness. The highest frequency of symptoms occurred during perimenopause. Nearly four fifths of the women consulted a healthcare provider, and one fifth used hormone therapy. More than half of the respondents said menopause is a difficult phase, and about half found decisionmaking about it to be difficult.

CONCLUSIONS

This study documents a relatively heavy burden of symptoms in a relatively healthy population and provides an update on earlier studies in Massachusetts.

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.

Physician counseling on hormone replacement therapy and bone loss: do socioeconomic and racial characteristics of women influence counseling?

BACKGROUND

Although women consider multiple issues when deciding to take hormone replacement therapy (HRT), both women's use and physician counseling about HRT are strongly associated with sociodemographic factors. As prevention of bone loss is the best established long-term benefit of HRT, we sought to determine (1) if counseling about bone loss is included in discussions of HRT and (2) if sociodemographic factors affect the preventive content of HRT counseling.

METHODS

We evaluated reports of counseling on estrogen and bone loss from 1404 women aged 40-60 who reported any counseling on HRT in the 1994 National Health Interview Survey (NHIS). We also examined the association between these reports and sociodemographic factors, adjusting for clinical history, physician specialty, and physician visits.

RESULTS

We found that 80% of the women reported counseling on the effects of estrogen on bone loss. After adjustment, high school graduates (adjusted odds ratio [AOR] 1.68, confidence interval [CI] 1.02, 2.77) and college graduates (AOR 2.45, CI 1.33, 4.52) were much more likely to be counseled than women without a high school diploma. Black women were less likely to be counseled about bone loss (AOR 0.55, CI 0.33, 0.93). Although general health and menopausal symptoms were strongly associated with counseling on HRT and bone loss, neither of the osteoporosis risk factors of low body mass index (BMI) and smoking influenced counseling.

CONCLUSIONS

Most patients who discussed HRT with their providers discussed the effects of HRT on bone loss. For those who did not, several sociodemographic factors associated with any counseling on HRT are also associated with the content of HRT counseling. Understanding and addressing counseling inequities could reduce the effect of such factors on osteoporosis assessment and treatment.

Hormone replacement therapy dissociates fat mass and bone mass, and tends to reduce weight gain in early postmenopausal women: a randomized controlled 5-year clinical trial of the Danish Osteoporosis Prevention Study

The aim of this study was to study the influence of hormone replacement therapy (HRT) on weight changes, body composition, and bone mass in early postmenopausal women in a partly randomized comprehensive cohort study design. A total of 2016 women ages 45-58 years from 3 months to 2 years past last menstrual bleeding were included. One thousand were randomly assigned to HRT or no HRT in an open trial, whereas the others were allocated according to their preferences. All were followed for 5 years for body weight, bone mass, and body composition measurements. Body weight increased less over the 5 years in women randomized to HRT (1.94 +/- 4.86 kg) than in women randomized to no HRT (2.57 +/- 4.63, p = 0.046). A similar pattern was seen in the group receiving HRT or not by their own choice. The smaller weight gain in women on HRT was almost entirely caused by a lesser gain in fat. The main determinant of the weight gain was a decline in physical fitness. Women opting for HRT had a significantly lower body weight at inclusion than the other participants, but the results in the self-selected part of the study followed the pattern found in the randomized part. The change in fat mass was the strongest predictor of bone changes in untreated women, whereas the change in lean body mass was the strongest predictor when HRT was given. Body weight increases after the menopause. The gain in weight is related to a decrease in working capacity. HRT is associated with a smaller increase in fat mass after menopause. Fat gain protects against bone loss in untreated women but not in HRT-treated women. The data suggest that women's attitudes to HRT are more positive if they have low body weight, but there is no evidence that the conclusions in this study are skewed by selection bias.

Leisure-Time Activity among Older U.S. Women in Relation to Hormone-Replacement-Therapy Initiation

Hormone-replacement therapy (HRT) and physical activity are both related to aging and health. U.S. minorities are more likely to be inactive and less likely to initiate HRT than are non-Hispanic White women. The purpose of this investigation was to examine the relationship of race and HRT use with physical inactivity among older women (60+ years). The authors used data from 3,479 women who had participated in the Third National Health and Nutrition Examination Survey (NHANES III), conducted in 1988-1994. NHANES III included an in-person interview and a medical examination. The prevalence of physical inactivity among women who reported ever having used HRT was 28.5% (CI 22.9–34.1%), compared with 40.0% (CI 35.9–44.1%) among those who had never used HRT. Mexican American and non-Hispanic Black women reported higher levels of inactivity than did non-Hispanic White women across HRT-use categories. To promote successful aging, physicians should educate postmenopausal women on the possible health benefits of HRT combined with an active lifestyle.

The relationship of race/ethnicity and social class to hormone replacement therapy: results from the Third National Health and Nutrition Examination Survey 1988-1994

OBJECTIVE

To use a nationally representative sample to examine the prevalence of hormone replacement therapy (HRT) use and its relationship to different markers of social class in American women 60 years of age and older.

DESIGN

Nationally representative cross-sectional survey with an in-person interview and medical examination. Between 1988 and 1994, 3,479 women aged 60 to 90+ years were examined as part of the National Health and Nutrition Examination Survey III. Mexican Americans, non-Hispanic blacks and much older women were oversampled to produce reliable estimates for these groups.

RESULTS

Overall, the number of women who reported ever having used HRT was 37% [confidence interval (CI), 33%-40%] of all women older than 60 years of age; 40% (CI, 37%-41%) of older, non-Hispanic white women; 20% (CI, 14%-25%) of non-Hispanic black women; and 24% (CI, 20%-29%) of Mexican American women. HRT was used by 43% (CI, 38%-47%) of women 60 to 70 years old, 37% (CI, 32%-41%) of those 71 to 80 years old, and 20% (CI, 13%-26%) of women older than 80. HRT use was lowest among women who did not complete high school or among those in the lowest family income categories. Among women more than 60 years old who reported having a hysterectomy, 51% (CI, 47%-55%) reported using HRT, whereas only 20% (CI, 17%-23%) of those who had a natural menopause reported using HRT.

CONCLUSIONS

Although many women can benefit from HRT, the number of American women who report they have ever used it remains low. More research is needed to examine the implications of racial differences in compliance, patient and physician attitudes toward HRT, and possible environmental barriers that may prevent use.

Soy isoflavones' osteoprotective role in postmenopausal women: mechanism of action

Ovarian hormone deficiency is a major risk factor for osteoporosis. Current therapies emphasize the use of antiresorptive agents, such as estrogen, calcitonin, and bisphosphonates. These therapies are associated with certain risks and side effects making compliance a major obstacle. Recent findings suggest that a class of synthetic and naturally occurring compounds, selective estrogen receptor modulators, e.g. raloxifene and soy isoflavones can offer attractive alternatives. Evidence for bone-sparing effects of isoflavones relies mainly on animal findings supported by a limited number of human studies. These observations suggest that isoflavones exert their effects on bone by stimulating bone formation and at the same time suppressing bone resorption. However, the precise osteoprotective mechanism of isoflavones remains uncertain and awaiting further clarification. From a clinical point of view, larger and longer duration studies are warranted to enable us to draw clear conclusions in regards to the role of isoflavones on bone.

Systemic lupus erythematosus and the risk of malignancy

The objective of this study was to determine the relative risks of malignancy and of site-specific malignancies in patients with systemic lupus erythematosus (SLE). A cohort of 297 patients (91% Caucasian) with SLE were seen between 1975 and 1994 and followed for a mean of 12 years at the University of Saskatchewan Rheumatic Disease Unit. Expected cancer incidence rates were determined based on Province of Saskatchewan population statistics matched to each study patient for age, sex and calendar year of follow-up. Standardized incidence ratios (SIRs) of observed to expected cancers and 95% confidence intervals (95% CI) were calculated. A total of 27 cases of cancer were observed, whereas only 16.9 were expected (SIR 1.59 (95% CI 1.05-2.32)). For site-specific malignancies, an excess of cancer of the cervix (SIR 8.15 (95% CI 1.63-23.81)) as well as hemopoietic malignancy (SIR 4.9 (95% CI 1.57-11.43)) was found. The hemopoietic cancers were predominantly non-Hodgkin's lymphoma (SIR 7.01 (95% CI 1.88-17.96)). We did not find an association of malignancy with known risk factors, including use of cytotoxic agents. Increased risk of malignancy, notably non-Hodgkin's lymphoma and perhaps cervical cancer, should be regarded as a complication of SLE.

Gender- and age-related prescription drug use patterns

OBJECTIVE

To report the top 15 prescription drug categories used by males and females of all ages and to compare this information with national prevalence data.

METHODS

Data used were pharmacy claim and eligibility information over the period January 1, 1999, through December 31, 1999, for 1,294,295 members of a large pharmacy benefit manager. Participant ages ranged from 1 to more than 100 years. Each participant was assigned to 1 of 9 age categories. Use of a drug category was defined as filling at least 1 prescription for a medication in that category during the study year. The percentage of males and females that used each drug group was established, and the 15 drug groups used most frequently were reported for each age category.

RESULTS

Most gender differences in medication use appear after or around the puberty years. Women are more likely to use several classes of medications, including antidepressants and antianxiety and pain medications. Except for diuretics, men use cardiovascular medications at an earlier age than do women. The use of medications for chronic conditions increases with older age categories for both genders. The use of female hormones represents only a small proportion of the difference in medication use between genders.

CONCLUSIONS

Analysis of data from the epidemiologic literature suggests that the gender differences in medication use shown in this study generally are to be expected.

Hormone replacement therapy in Norwegian women, 1996-1997

OBJECTIVES

To assess the prevalence of hormone replacement therapy (HRT) among Norwegian women and examine factors related to use.

MATERIALS AND METHODS

A random sample of 18,199 Norwegian women aged 45-64 years responded to a postal questionnaire in 1996-1997. The questionnaire included questions about menstruation status and fertility, oral contraceptives (OC) and HRT use, lifestyle, health and socio-economic status. The response rate was 60%.

RESULTS

Overall prevalence of ever using systemic or local HRT was 43.9%. Current use was reported by 31.9% of the women. The highest prevalence was in the age group of 55-59 years where 57.4% reported ever use, and 43.1% current use. Mean duration of use among current users was 4.6 years. More than 60% of the women were classified as postmenopausal, two-thirds of them naturally postmenopausal. The prevalence of ever using HRT was 51.8%. Prevalence of use was higher among earlier OC users, smokers, lean women and in households with high income. Among older women, users had a higher educational level than non-users, while this difference disappeared among the youngest of the women. Fixed combinations of estradiol and noretisteroneacetate either cyclic or continuous, are used by six out of ten users.

CONCLUSIONS

Our results confirm the increasing trend in sales of estrogens in Norway and suggest that user patterns are changing. More than four out of ten women aged 45-64 years reported ever use of HRT, and one out of three reported current use. Socio-economic differences between users and non-users seem to disappear among women under 55 years of age, but persist in the older age groups. Short time use still dominates.

Use of multiple providers for regular care and women's receipt of hormone replacement therapy counseling

BACKGROUND

Prior research has explored women's lifetime receipt of HRT counseling and correlates of counseling, but has not explored receipt of counseling by current health care provider(s). The number and type(s) of provider(s) that women see for their regular care may be an important enabling factor in women's receipt of HRT counseling.

OBJECTIVES

Whether there is an association between the number and specialties of physicians that women use for regular care and their receipt of HRT counseling by a current regular physician is explored.

RESEARCH DESIGN

A self-administered mail survey was sent to 1,500 female members (ages 40-69) of a Connecticut IPA-model health plan.

RESULTS

One thousand seven completed questionnaires were received (response rate = 69%). Twenty-eight percent of women reported seeing only a family practitioner or internist (no OB/GYN) for their regular care; 11% saw an OB/GYN only; and 59% saw both a family practitioner/internist and an OB/GYN. After adjustment for women's other predisposing and enabling characteristics, women who used both a family practitioner/internist and an OB/GYN were 3.1 times as likely (95% CI, 2.02, 4.66) as those seeing only a family practitioner/internist to have been counseled about HRT by a current provider, and those using only an OB/GYN were 2.5 times as likely (95% CI, 1.34, 4.61).

CONCLUSIONS

The number and specialty of physician(s) that women use for their regular care is an important enabling factor in women's receipt of HRT counseling. Changes in the organization and delivery of women's primary care may help increase the receipt of female-specific clinical preventive services, particularly among women less likely to use an OB/GYN for regular care, such as low-income and older women.

Clinical correlates of estrogen replacement therapy use and duration of use among medicaid recipients

Estrogen replacement therapy (ERT) is used not only for the short-term control of menopausal symptoms but long-term for disease prevention. This study examined the influence of selected clinical conditions on the use of ERT and the duration of ERT use among women enrolled in a state Medicaid program. We identified 60,531 women, aged >/=45 years, who were enrolled in Maryland Medicaid continuously for at least 2 of 3 years. ERT use was determined through prescription claims submitted for reimbursement. The presence or risk of selected clinical conditions (e.g., osteoporosis, heart disease, estrogen-sensitive cancers) was determined by screening Medicaid claims files for related diagnoses, procedures, or prescription claims. Multiple logistic regression was used to model ERT use, and proportional hazards regression was used to model duration of use. Fourteen percent of these women filled an ERT prescription, with use varying by age, race, and place of residence. Oral dosage forms were the most popular (80.8%), followed by vaginal cream or ring (22.2%), and transdermal patch (7.3%). In adjusted models, osteoporosis, heart disease, hypertension, hyperlipidemia, diabetes, ovarian cancer, and thromboembolic disease were positively associated and dementia and breast cancer were negatively associated with ERT use. None of these medical conditions predicted the duration of estrogen therapy. Use of ERT was very low among these women despite coverage of prescription medications, and the presence of clinical indications had no influence on the length of therapy among these women despite known benefits for long-term preventive therapy.

Postmenopausal hormone replacement therapy use by older Mexican-American women

OBJECTIVES

To determine the prevalence of current hormone replacement therapy (HRT) use and describe its correlates among community-dwelling, Mexican-American women aged 67 and older.

DESIGN

A population-based survey of older Mexican-Americans conducted in 1995/1996.

SETTING

Five Southwestern states: Texas, New Mexico, California, Arizona, and Colorado.

PARTICIPANTS

An area probability sample of 1,424 noninstitutionalized Mexican-American women aged 67 and older (mean age = 75.1) completed the survey instrument via a 90-minute in-home interview, which included examination and recording of all medications taken.

MEASUREMENTS

Current use of HRT.

RESULTS

In this sample of older Mexican-American women, 4.7% were current users of HRT. Controlling for sociodemographic characteristics (age, marital status, living arrangements, years of education, income, language of interview), current HRT use is significantly related to years of education (per each year) (odds ratio (OR) = 1.13; 95% confidence interval (CI) = 1.05-1.20), having had a hysterectomy (OR = 4.37; 95% CI 2.50-7.64), a diagnosis of osteoporosis (OR = 3.40, 95% CI = 1.58-7.33), age at menopause (per each year) (OR = 1.07; 95% CI = 1.03-1.12), ever having a mammogram (OR = 3.72; 95% CI = 1.66-8.37), ever having a Pap test/pelvic examination (OR = 2.11; 95% CI = 1.08-4.12), having spoken with a pharmacist within the past year regarding health conditions (OR = 1.96; 95% CI = 1.06-3.65), and having Medicare plus private insurance (OR = 2.13; 95% CI = 1.14-3.97).

CONCLUSION

The prevalence of HRT use is lower than that reported in the older non-Hispanic white female population. In general, these findings indicate that access to and utilization of the traditional U.S. health care system are indicators of HRT use.

Characteristics associated with recent recreational exercise among women 20 to 44 years of age

Data on 1,501 control women from a multi-center, population-based, case-control study of breast cancer were used to examine characteristics associated with recreational exercise during the year prior to the interview among women 20 to 44 years of age. In a univariate analysis, higher levels of recreational exercise were associated with: higher education; higher family income; white race; previous participation in recreational exercise above the median level at ages 12 to 13 and at age 20; being nulliparous; ever lactating; being a never or past smoker; having a low current Quetelet's index (QI: weight in kilograms divided by height in meters squared); and living in Atlanta or Seattle (compared to New Jersey). In a multiple linear regression model, independent predictors of higher levels of recreational exercise were: participation in higher levels of exercise at 20 years of age; having a low current QI; and never having smoked. Though all women should be encouraged to participate in exercise, these findings identity subgroups of women that may need targeting when developing exercise intervention programs.

Midlife women making hormone therapy decisions

This study focuses on midlife women aged 40-65 years who were in transition to menopause, were menopausal or had a hysterectomy, to examine and better understand hormone therapy (HT) choices women make. Among the nationally representative sample of women in the Commonwealth Fund 1998 Survey of Women's Health (n = 884), 39% of the menopausal women reported current HT use. The two primary reasons for initiating HT are following a doctor's recommendation and seeking relief of menopausal symptoms. Age, education, race, hysterectomy status, having health insurance, use of calcium supplements and comfort in communicating with a doctor are important factors associated with HT use. This study underscores the importance of physicians and other health professionals providing accurate HT information to assist women in making HT decisions.

Postmenopausal endogenous oestrogens and risk of endometrial cancer: results of a prospective study

We assessed the association of postmenopausal serum levels of oestrogens and sex hormone-binding globulin (SHBG) with endometrial cancer risk in a case-control study nested within the NYU Women's Health Study cohort. Among 7054 women postmenopausal at enrolment, 57 cases of endometrial cancer were diagnosed a median of 5.5 years after blood donation. Each case was compared to 4 controls matched on age, menopausal status at enrolment, and serum storage duration. Endometrial cancer risk increased with higher levels of oestradiol (odds ratio = 2.4 in highest vs lowest tertile, P for trend = 0.02), percent free oestradiol (OR = 3.5, P< 0.001), and oestrone (OR = 3.9, P< 0.001). Risk decreased with higher levels of percent SHBG-bound oestradiol (OR = 0.43, P = 0.03) and SHBG (OR = 0.39, P = 0.01). Trends remained in the same directions after adjusting for height and body mass index. A positive association of body mass index with risk was substantially reduced after adjusting for oestrone level. Our results indicate that risk of endometrial cancer increases with increasing postmenopausal oestrogen levels but do not provide strong support for a role of body mass index independent of its effect on oestrogen levels.

Reasons for use of hormone replacement therapy in women undergoing coronary angiography

The recommendation has been made that all women be counseled about the risks and benefits of hormone replacement therapy (HRT). Use of HRT among women undergoing coronary angiography was explored to assess whether patterns of use were similar to data drawn from community samples. Using a descriptive design, a convenience sample of 414 postmenopausal women was interviewed. Fifty-eight percent had never used HRT, 18.3% were past users, and 23.7% were currently using HRT. The primary reason given for ever using HRT was for symptoms of menopause. Less than 14% of women cited coronary heart disease (CHD) or osteoporosis as their primary reason for using HRT. The most common reasons for stopping HRT were side effects and fear of cancer. The most common reasons given for never having used HRT were that their healthcare provider had never talked about it and that they had never thought about it. Use of HRT among women undergoing coronary angiography is similar to that found in community samples. The challenge is to promote patient-provider interactions that include information about HRT based on the scientific model as well as attention to women's individual concerns.

Sociodemographic and clinical factors associated with HRT use in women attending menopause clinics in Italy

OBJECTIVE

The aim of this analysis is to find any association between the use of hormone replacement therapy (HRT) and sociodemographic and clinical factors among women attending 54 menopause clinics in Italy.

METHODS

The analysis includes data relating to 17,851 women who attended one of 54 menopause clinics in Italy for general gynecological evaluations and counselling between 1995 and 1997. The characteristics of women reporting ever HRT use were compared with those of never users. The odds ratios (ORs) of HRT use were computed in relation to selected reference categories, together with their 95% confidence intervals (CIs).

RESULTS

Of the 17,851 women interviewed, 8539 reported ever HRT use. The mean age of the never and ever HRT users was 52.8 years and 53.7 years, respectively. Higher education was associated with an increased frequency of HRT use: in comparison with women reporting no or primary-/middle-school education, the OR of HRT use of women reporting a high-school diploma or university degree was 1.3 (95% CI 1.1-1.6). HRT use tended to be less frequently reported with increasing body mass index (BMI): in comparison with women whose BMI was < 23.4 kg/m2, the OR of HRT use in those with a BMI of 23.4-26.1 kg/m2 and > or = 26.2 kg/m2 was 0.8 (95% CI 0.8-0.9) and 0.6 (95% CI 0.5-0.7), respectively. Among the postmenopausal women, those who had undergone surgical menopause had an OR of HRT use of 1.3 (95% CI 1.2-1.4). A history of breast cancer was associated with a lower frequency of HRT use (OR 0.3, 95% CI 0.2-0.4). Likewise, a history of thromboembolic disease (OR 0.5, 95% CI 0.4-0.7) or myocardial infarction (OR 0.7, 95% CI 0.6-0.9) was associated with a lower frequency of HRT use.

CONCLUSIONS

In our study population, the variable most closely related to HRT use was education/social class, thus underlining the impact of information campaigns on HRT and women's health. Among the medical determinants, our analysis indicates that a history of myocardial infarction, thromboembolic disease or breast cancer is associated with less frequent use of HRT.

Smoking, body mass index, socioeconomic status and the menopausal transition in a British national cohort

BACKGROUND

This study investigates whether cigarette smoking, body mass index (BMI) and socioeconomic status are independently associated with age at menopausal transition.

METHODS

Menopausal status and risk factor information were collected prospectively from 1572 British women followed up since their birth in 1946, so far until 50 years. Cox's regression models were used to investigate the relationships of interest.

RESULTS

Cigarette smokers started the perimenopause and reached the menopause earlier than ex-smokers and non-smokers. The relative risk for smokers compared with non-smokers was 1.31 (95% CI : 1.09-1.56) for perimenopause and 1.63 (95% CI : 1.17-2.27) for menopause. Body mass index was associated with the age at inception of the perimenopause only among smokers and ex-smokers, with underweight women having the earliest perimenopause. No association was observed between BMI and age at menopause. Smokers and underweight women were more likely than others to start hormone replacement therapy (HRT) before becoming postmenopausal. There was no effect of education or social class on age at inception of the perimenopause or age at menopause. Single women had an earlier perimenopause but the effect was confounded by parity.

CONCLUSIONS

Smoking was independently related to an earlier menopausal transition, although the effect on inception of the perimenopause was particularly observed among underweight women. There was no independent effect of socioeconomic status. The popularity of HRT use in this cohort may have had an impact on the findings.

Prevalence and duration of postmenopausal hormone replacement therapy use in a managed care organization, 1990-1995

OBJECTIVE

To determine the prevalence and duration of postmenopausal hormone replacement therapy (HRT) use and identify correlates of adherence to therapy.

DESIGN

Population-based cohort study.

SETTING

Staff-model health maintenance organization.

PARTICIPANTS

Female members, 40 years and older.

MEASUREMENTS AND MAIN RESULTS

Prevalence and duration of use were measured between 1990 and 1995. Duration was assessed by Kaplan-Meier and proportional hazards methods. Hormone replacement therapy use increased from 10.3% in 1990 to 20.7% in 1995. Greatest use (24%) occurred among menopausal women age 50 to 54 years. Less than 5% of women 75 and older used HRT. Among 1,680 first-time recipients of HRT, two thirds of initial prescriptions were written by internists. Thirty-eight percent discontinued HRT within 1 year. For the subset whose indication for therapy was ascertained, prevention of chronic disease was associated with a 33% 1-year discontinuation rate. Factors associated with longer duration of therapy included white race (relative risk [RR], 1.63; 95% confidence interval [95% CI], 1.32 to 2.02), younger age (RR, 1.02 per year; 95% CI 1.01 to 1.03), and changing the preparation or dose of estrogen (RR, 5.62; 95% CI, 4.33 to 7.25). The formulation (esterified estrogens 0.625 mg versus conjugated estrogens 0.625 mg) was also associated with greater duration of use; all other estrogens were, as a group, associated with shorter duration of use. Those who received their initial HRT prescription from an internist were more likely to continue therapy than those who received it from a gynecologist.

CONCLUSIONS

Despite increased use of HRT, only a minority of women in this population used HRT, and many of those discontinued therapy within 1 year.

The effects of delayed hormone replacement therapy on estrogen receptors of the cynomolgus monkey bladder and vagina

The aim of this study was to determine cytosolic estrogen receptor content of the cynomolgus monkey bladder and vagina after hormone replacement therapy. Animals maintained without hormone therapy for 2 years after surgical menopause were randomized to receive either no hormones (OVX), conjugated equine estrogens (CEE), or estrogen/medroxyprogesterone acetate (CEE + MPA) treatment for 30 months. Estrogen receptor content of bladder and vagina cytosolic extracts was determined using a commercial enzyme-linked immunosorbent assay. Estrogen receptors were uniformly present, although the vaginal concentration was 100-fold greater than in the bladder. Estrogen and combination therapy significantly decreased cytosolic receptor content in both sites compared with controls. The cynomolgus urogenital tract remains estrogen sensitive 2 years after surgical menopause. Prolonged exposure to estrogens decreases cytosolic estrogen receptor content in a manner similar to that described for short-term estrogen therapy. These results suggest that the effects of hormone replacement on the urinary tract can be identified even if initiated years after menopause.

Mammography in New Hampshire: characteristics of the women and the exams they receive

New Hampshire (NH) is one of two states that has developed a population-based mammography registry. The purpose of this paper is to describe what we have learned about mammography use in New Hampshire. After collecting data for 20 months, the database contains almost 110,000 mammographic encounters representing 101,679 NH women, who range in age from 18 to 97 with a mean of 56.7 years (SD=10.91). Education levels are high with 92% having a high school education and 59% with some college. Forty-six percent report their primary insurance is private, 29% report HMO/PPO coverage, and 25% receive federal health care assistance. Risk factors represented in the database include (categories not mutually exclusive) advancing age (60% over age 50), hormone replacement therapy use by menopausal women (40.6%), and a family history of breast cancer (29%). Penetration of mammography relative to the NH population is higher for younger age groups (40-48% for those aged 44-64) than older age groups (34-39% for those aged 65-84). The majority of mammographic encounters are routine screening exams (86%), often interpreted as negative or normal with benign findings (88%). Use of comparison films to interpret either diagnostic or screening mammography occurred in 86% of encounters. We have matched 3,877 breast pathology records to these mammographic encounters. The distribution of pathology outcomes for diagnostic exams was very similar to that for screening exams (approximately 65% benign, 17% invasive breast cancer, and 6% noninvasive breast cancer). Overall, we have designed a system that is well accepted by the NH community. Challenges include careful monitoring of data for coding errors, and a limitation of linking variables in mammography and pathology data. Data represented in this registry are a critical resource for research in mammographic screening and breast cancer early detection.

Social and behavioural influences on the uptake of hormone replacement therapy among younger women

OBJECTIVE

To describe the social and behavioural influences on the uptake of hormone replacement therapy before the age of 50.

DESIGN

Nationally representative birth cohort study with detailed hormone replacement therapy histories and prospective data on health, social and behavioural factors collected throughout life.

SETTING

England, Scotland and Wales.

POPULATION

General population sample of 1,572 women followed to the age of 50 years.

MAIN OUTCOME MEASURE

Age at first hormone replacement therapy use

RESULTS

By the age of 50 years, 45% of women had tried hormone replacement therapy and one third were current users. Over two-fifths of users had tried more than one preparation and over one quarter had episodic use. For the vast majority, prescribing conformed to current guidelines. More educated women took hormone replacement therapy for long term prevention compared with their less educated peers. Hysterectomy increased the chances of taking hormone replacement therapy, particularly where an oophorectomy had also been performed, and was associated with longer and more continuous use. Results of a Cox's proportional hazards model showed that the age at which first hormone replacement therapy is used by women who have not had a hysterectomy was influenced by previous contact with health services for menstrual disorders, previous use of oral contraception and cigarettes, past reporting of health problems and low social class. The relation between smoking and low social class with early use of hormone replacement therapy may be due to their association with early menopause.

CONCLUSIONS

The trend over the last two decades towards greater use of hormone replacement therapy has continued unabated for younger women. So far, hormone replacement therapy users in this generation have had less healthy lifestyles and social advantages than nonusers, in contrast to many older mainly American studies based on earlier generations. This may have long term implications for health and health care as the postwar baby boom generation ages.

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.

Consumption of soy protein reduces cholesterol absorption compared to casein protein alone or supplemented with an isoflavone extract or conjugated equine estrogen in ovariectomized cynomolgus monkeys

Dietary intake of soy protein is associated with reductions in plasma cholesterol. Isoflavones are thought to be active components of soy and responsible for the beneficial effects because of their structural similarities to estrogen. The purposes of this study were to determine if i) soy protein or a semipurified soy extract, rich in isoflavones, is responsible for improving the lipid profile and ii) altered intestinal cholesterol metabolism is one mechanism for hypocholesterolemic effects. Ovariectomized adult female cynomolgus monkeys (40) were assigned to groups fed diets containing i) casein-lactalbumin (CAS) ii) intact soy protein (SOY), iii) CAS plus an isoflavone-rich semipurified soy extract similar in isoflavone content as SOY (ISO) or iv) CAS plus conjugated equine estrogen (CEE) for 20 wk. Cholesterol absorption was determined using the fecal isotope ratio method. Bile acid excretion was measured using the 3alpha-hydroxysteroid dehydrogenase assay. The SOY group had significantly lower total- and VLDL + LDL-cholesterol compared to the other three groups and significantly higher HDL-cholesterol compared to the CAS and CEE groups. Cholesterol absorption was significantly lower in the SOY group compared to the other groups, but bile acid excretion was not significantly affected. The hypocholesterolemic effect of soy protein appears to be mediated in part by decreased cholesterol absorption. The semipurified soy extract, rich in isoflavones, added to casein protein did not have lipid-lowering effects. Other components of soy such as saponins, phytic acid or the amino acid composition may be involved in the hypocholesterolemic effects seen in this study.

Cross-sectional study of determinants of menopausal age and hormone replacement therapy use in Italian women

OBJECTIVE

The aim of the study was to analyze determinants of age at menopause and hormone replacement therapy (HRT) use. Women included were identified in a large cross-sectional study into epidemiology of the menopause among a sample of women visiting their general practitioners, conducted in Italy.

METHODS

Eligible women were identified among consecutive patients, aged 44-66 years, who visited their general practitioner for a general health check-up during the period May-November 1997. A total of 16,916 postmenopausal women were identified by 1123 general practitioners.

RESULTS

Overall, the mean age at menopause was 50.2 (SD 3.8) years. Ever-married women reported a slightly higher age at spontaneous menopause than that of never-married women. The finding was significant, but the difference was small. Smoking women reported a younger age at menopause. No clear association emerged between age at menopause, physical activity and body mass index (BMI). A total of 3515 women (20.8%) reported HRT ever-use; the mean duration of use was 3.6 years. HRT use was more frequent among women of higher socioeconomic status, those with a lower BMI and smokers. In particular, in comparison with women reporting a BMI of < 25 kg/m2, the odds ratio (OR) of HRT use was 0.7 (95% confidence interval (CI) 0.7-0.8) and 0.5 (95% CI 0.4-0.6), respectively, in women with a BMI of 25-28 kg/m2 and > or = 29 kg/m2. No association emerged between alcohol consumption, level of physical activity and HRT use. Diabetic women reported HRT use less frequently than non-diabetic women. Likewise, hypertensive women, and those with a history of cardiovascular disease, were less likely to be HRT users than those not reporting these conditions. Women with a diagnosis of osteoporosis/osteopenia reported HRT use more frequently.

CONCLUSION

This study, using a large dataset from an Italian population, has confirmed that smoking is related to age at menopause. It has also demonstrated that HRT is more frequently used by women of higher socioeconomic status, those with low BMI and smokers. Diabetes is associated with less frequent use of HRT; conversely, osteoporosis/osteopenia is associated with more frequent HRT use.

Has the impact of hormone replacement therapy on health-related quality of life been undervalued?

Previous economic evaluations of hormone replacement therapy (HRT) have restricted positive effects to alleviation of postmenopausal symptoms and negative effects to drug side effects. We studied the association between HRT use and postmenopausal women's valuation of both health-related quality of life and potential treatment side effects. Postmenopausal women with either a documented first vertebral fracture within the past 5 years or no history of osteoporotic fractures were recruited from Olmsted County, Minnesota, and from Dartmouth-Hitchcock Medical Center in New Hampshire to participate in a study to assess quality of life and women's attitudes toward osteoporosis prevention. Women's valuations of their current health and potential HRT-related side effects were quantified as quality-adjusted life years (QALYs) assessed by an automated utility assessment instrument (U-Titer) and the time tradeoff technique, by a vertical rating scale, and by estimated quality of well-being (QWB) scores. Health status was measured using the Medical Outcomes Study SF-36. Regression methods were used to assess the impact of current HRT use on health-related quality of life and valuation of side effects. There were 106 women with vertebral fracture and 180 with no history of hip, wrist, or vertebral fractures. Altogether, 116 (40.6%) women were currently taking HRT, 64 (22.2%) had taken HRT in the past, and 106 (37.1%) women had never taken HRT. Current HRT users had higher time tradeoff QALYs than never and past HRT users, with gains ranging from 15.0 to 83.7 days per year for current users relative to the others. Benefits were largest for women with a vertebral fracture and limitations in activities. The secondary QALY measures also showed significantly higher values for current HRT users compared with other women, as did SF-36 subscales for general health, physical function, role-emotional function, and vitality. There was substantial variability in women's perceptions of HRT side effects. Overall, the proportion of women willing to trade time to avoid bleeding was largest, at 95.5%, followed by breast tenderness, weight gain, and endometrial biopsy at 90.4%, 87.4%, and 82.7%, respectively. Current HRT users had higher health-related quality of life than past or never users according to all measures studied. Women's perceptions of potential side effects were highly variable and should be considered by physicians when prescribing an HRT regimen. If, as our results suggest, postmenopausal therapy has positive effects beyond the immediate postmenopausal years, previous economic studies may have underestimated the value of HRT.

Knowledge of menopause and hormone replacement therapy use in low-income urban women

Hormone replacement therapy (HRT) can have significant long-term health benefits in postmenopausal women, yet rates of HRT use are low, especially in low-income urban women. Previous research has revealed that knowledge of menopause is a key predictor of HRT use in this population. A descriptive cross-sectional survey of 215 perimenopausal and postmenopausal low-income urban women was carried out to characterize knowledge of menopause and HRT and factors associated with knowledge level. Sociodemographic characteristics, patterns of HRT use, and knowledge about menopause and HRT were collected through a structured interview. Results revealed a general lack of knowledge about menopause and HRT, particularly relative to heart disease and the role of HRT in prevention. Major independent predictors of increased knowledge (R2 = 0.31) were having talked with a healthcare provider about HRT, having at least a high school education, and being less than 60 years of age. These findings emphasize the key role of providers in educating this vulnerable population about menopause and HRT and the potential subsequent impact on HRT use.

Correlates of hormone replacement therapy use in Italian women, 1992-1996

OBJECTIVES

we analyzed the determinants of hormonal replacement therapy (HRT) use in Italy for the period 1992-1996, using data from a framework of case-control studies of colon and rectal neoplasm.

METHODS

a total of 1574 women aged 45-74 years were considered. This group comprised women with acute, non neoplastic, non-hormone-related diseases admitted to a network of hospitals in six areas of Italy.

RESULTS

a total of 146 women (8.5%) reported ever HRT use. The multivariate odds ratio (OR) of ever use was 1.6 (95% CI 1.0-2.6) for women with 12 years of education or more, compared with those with < 7 years. The frequency of use of HRT tended to decrease with increasing parity: the OR was 0.6 for women with four or more children as compared to nulliparae (chi2 trend 3.5, P = 0.06). Ever HRT users were more frequently smokers. HRT use was more frequent in women reporting surgical menopause (OR = 2.7) than those with natural menopause. Among post menopausal women, HRT use was related with early age at menopause (chi2 trend 4.6, P = 0.03). HRT use was more common among women reporting lower body mass index (BMI) both at interview and at age 30 years and the difference between current BMI and BMI at age 30 years, was not related with HRT use.

CONCLUSIONS

women of higher socioeconomic status or education reported more frequent HRT use and nulliparae and smokers were also more likely to use HRT. Further HRT use was directly associated with early age at menopause and surgical menopause and inversely related with measures of body weight.

Hormone therapy use in Australian-born women: a longitudinal study

OBJECTIVES

To describe the pattern of use of hormone therapy (HT) among Australian women, and its side-effects and benefits, and to compare baseline characteristics of HT users with never users.

DESIGN

Longitudinal community-based study with annual interviews.

SETTING

Melbourne, May 1991-October 1997.

PARTICIPANTS

357 Australian-born women aged 45-55 years who were pre- or perimenopausal and not using HT at baseline.

MAIN OUTCOME MEASURES

Rates of HT use; baseline characteristics of users and non-users; side effects and benefits of HT use.

RESULTS

151 women (42%) used HT over the six years and 93 (26%) were current users at six-year follow-up. HT users did not differ significantly from non-users in lifestyle, sociodemographic and cardiovascular risk factors or in most health status factors at baseline. However, HT users were significantly more likely to have had a breast examination by a health professional (odds ratio [OR], 2.60; 95% CI, 1.62-4.17), to have had a tubal ligation (OR, 1.73; 95% CI, 1.09-2.74), to report a history of premenstrual complaints (OR, 1.72; 95% CI, 1.08-2.74), to agree that women "regret when their period stops for the last time" (OR, 1.69; 95% CI, 1.04-2.74), and to report that they took non-prescription medications (OR, 1.62; 95% CI, 1.02-2.59). Most (84%) HT users described benefits (most commonly relief of hot flushes and improved wellbeing), while 53% complained of side effects (most commonly weight gain and breast tenderness).

CONCLUSIONS

HT users did not differ significantly from non-users at baseline in most characteristics. Long-term follow-up of this cohort is now required to assess any difference in cardiovascular events or other health outcomes between HT users and non-users.