BMJ  2003;327:845-846 (11 October), doi:10.1136/bmj.327.7419.845

Primary care

Changes in use of hormone replacement therapy after the report from the Women's Health Initiative: cross sectional survey of users

¹ Department of General Practice, Wellington School of Medicine and Health Sciences, PO Box 7343, Wellington South, New Zealand

Introduction

In 2002 the Women's Health Initiative reported the results of a study on the effects of combined oestrogen plus progestogen on healthy postmenopausal women. They found increased rates of breast cancer, coronary heart disease, stroke, and venous thromboembolism and decreased rates of hip fracture and colorectal disease but no "global" benefit. They concluded that combined oestrogen and progestogen is not suitable for the prevention of chronic diseases.¹ The subsequent extensive media coverage came at a time when the prevalence,^{2 3} duration,^{2 4} and use of hormone replacement therapy (HRT) for the prevention of chronic disease had been increasing.^{2 4} After the report, government regulatory authorities issued advice to health professionals and women, and guidelines relating to the postmenopausal use of hormone replacement therapy were updated.⁵ We examined changes in HRT use since the publication of the report.

Participants, methods, and results

Between January 2000 and November 2002, 3500 women were screened from 23 general practices in four New Zealand centres as part of the recruitment process for the women's international study of long duration oestrogen after menopause (WISDOM) and a New Zealand observational study. We surveyed 998 women who were using HRT at the time they were screened but who were ineligible or unwilling to join the international study.

We sent participants an information sheet and questionnaire by post six months after the trial results were published. One reminder questionnaire was sent to non-responders, and 810 surveys (81%) were completed and returned. In total 776 respondents were taking HRT when the trial results were published and were eligible for inclusion. No significant differences were observed between non-responders (n = 188) and responders (n = 776) regarding age (² = 2.89, df = 3, P = 0.41) and education (² = 1.78, df = 3, P = 0.62). Non-responders were more likely than responders to have taken HRT for less than five years (² = 9.71, df = 2, P = 0.008). The table shows the analyses for the 734 respondents for whom we had complete data on HRT use.

We analysed data using SAS Insight and estimated associations between a range of independent variables and the dependent variables (stopping and restarting HRT) from a generalised linear model with a log link and binomial errors. Independent variables included women's age at the time of the survey, type of HRT, years of HRT use, hysterectomy status, education, and reasons for starting HRT.

Of the 734 respondents, 423 (58%) stopped taking HRT. Of the 423 who stopped when the results were published, 132 (18%) had restarted at the time of our survey and 291 (40%) had not. Most respondents (610, 83%) reported that they had discussed HRT with a health professional. Older age, use of combined HRT, and longer duration of HRT were associated with stopping HRT. The association between stopping HRT and increased age was explained by the duration of HRT use (table).

View this table: [in this window] [in a new window]   Factors associated with stopping hormone replacement therapy in six months after oestrogen and progestogen trial report

 

Restarting HRT was associated with taking oestrogen only, use for relief of symptoms, and having a hysterectomy. Of the 132 women who restarted, 100 did so because of the return of symptoms, 16 because they "felt better" on HRT, and 15 for other reasons.

Comments

After the publication of the results from the oestrogen plus progestogen trial there was a substantial change in HRT use among the women we surveyed: 58% initially stopped taking HRT and 18% of them subsequently restarted, leaving 40% stopped at the time of this survey. Data suggest that stopping HRT was consistent with updated international guidelines. Our survey has limitations as we did not use a random sample of HRT users, nor is the background rate of stopping HRT known.

---

We thank Selina Brown and the team of research nurses for their role in the collection of interview data from the cohort, for commenting on drafts of the questionnaire, and for assisting with sending the survey; Katie Abbott for entering questionnaire data on the database; Sonya White, who assisted with the questionnaire design; and the women for participating in this study.

Contributors: All authors developed the idea for the study and participated in the questionnaire design. SR drafted the questionnaire, reviewed the literature, and coordinated the survey. BL and SR wrote the introduction, SR and DM carried out the analysis and interpretation of the data and wrote the participants, method, and results sections. All authors edited and were responsible for the final version of the paper. BL will act as the guarantor.

Funding: The UK Medical Research Council (MRC) funded the recruitment of women into the WISDOM trial.

Competing interests: BL is a member of a New Zealand Guidelines committee focusing on the appropriate prescribing of hormone replacement therapy and has separately received conference and research grants from pharmaceutical companies. BL and AD were the principal investigators and SR a coinvestigator of WISDOM in New Zealand.

Ethical approval: The survey was approved by the Wellington Regional Ethics Committee, accredited by the Health Research Council of New Zealand.

References

1. Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results from the Women's Health Initiative randomised controlled trial. JAMA 2002;288: 321-33.[Abstract/Free Full Text]
2. North F, Sharples K. Changes in the use of hormone replacement therapy in New Zealand from 1991-1997. N Z Med J 2001;114: 250-3.[Medline]
3. Beral V, Banks E, Reeves G. Evidence from randomised trials on the long-term effects of hormone replacement therapy. Lancet 2002;360: 942-4.[CrossRef][ISI][Medline]
4. Ballard K. Women's use of hormone replacement therapy for disease prevention: results of a community survey. Br J Gen Pract 2002;52: 835-7.[ISI][Medline]
5. International Menopause Society. The International Menopause Society develops consensus clinical recommendations regarding HRT and heart disease. www.imsociety.org/pages/news.html (accessed 4 Mar 2002).

(Accepted September 18, 2003)

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Related Articles

Main morbidities recorded in the women's international study of long duration oestrogen after menopause (WISDOM): a randomised controlled trial of hormone replacement therapy in postmenopausal women

Madge R Vickers, Alastair H MacLennan, Beverley Lawton, Deborah Ford, Jeannett Martin, Sarah K Meredith, Bianca L DeStavola, Sally Rose, Anthony Dowell, Helen C Wilkes, Janet H Darbyshire, Tom W Meade WISDOM group
BMJ 2007 335: 239. [Abstract] [Full Text] [PDF]

Trial results have dramatically reduced HRT use
BMJ 2003 327: 0. [Full Text]

This article has been cited by other articles:

• Li, M., Chapman, S., Agho, K., Eastman, C. J. (2008). Can even minimal news coverage influence consumer health-related behaviour? A case study of iodized salt sales, Australia. Health Educ Res 23: 543-548 [Abstract] [Full text]  
• Vickers, M. R, MacLennan, A. H, Lawton, B., Ford, D., Martin, J., Meredith, S. K, DeStavola, B. L, Rose, S., Dowell, A., Wilkes, H. C, Darbyshire, J. H, Meade, T. W, WISDOM group, (2007). Main morbidities recorded in the women's international study of long duration oestrogen after menopause (WISDOM): a randomised controlled trial of hormone replacement therapy in postmenopausal women. BMJ 335: 239-239 [Abstract] [Full text]  
• Clegg Smith, K., Cho, J., Gielen, A., Vernick, J. S (2007). Newspaper coverage of residential fires: an opportunity for prevention communication. Inj. Prev. 13: 110-114 [Abstract] [Full text]  
• Rice, S., Whitehead, S. A (2006). Phytoestrogens and breast cancer -promoters or protectors?. Endocr Relat Cancer 13: 995-1015 [Abstract] [Full text]  
• Mishra, G., Kok, H., Ecob, R., Cooper, R., Hardy, R., Kuh, D. (2006). Cessation of Hormone Replacement Therapy After Reports of Adverse Findings From Randomized Controlled Trials: Evidence From a British Birth Cohort. Am. J. Public Health 96: 1219-1225 [Abstract] [Full text]  
• Whelan, A. M., Jurgens, T. M, Bowles, S. K (2006). Natural Health Products in the Prevention and Treatment of Osteoporosis: Systematic Review of Randomized Controlled Trials. The Annals of Pharmacotherapy 40: 836-849 [Abstract] [Full text]  
• Wei, F., Miglioretti, D. L., Connelly, M. T., Andrade, S. E., Newton, K. M., Hartsfield, C. L., Chan, K. A., Buist, D. S. M. (2005). Changes in Women's Use of Hormones After the Women's Health Initiative Estrogen and Progestin Trial by Race, Education, and Income. J Natl Cancer Inst Monogr 2005: 106-112 [Abstract] [Full text]  
• Ness, J., Aronow, W. S., Newkirk, E., McDanel, D. (2005). Use of Hormone Replacement Therapy by Postmenopausal Women After Publication of the Women's Health Initiative Trial. J. Gerontol. A Biol. Sci. Med. Sci. 60: 460-462 [Abstract] [Full text]  
• Buist, D. S. M., Newton, K. M., Miglioretti, D. L., Beverly, K., Connelly, M. T., Andrade, S., Hartsfield, C. L., Wei, F., Chan, K A., Kessler, L. (2004). Hormone Therapy Prescribing Patterns in the United States. Obstet Gynecol 104: 1042-1050 [Abstract] [Full text]  
• Majumdar, S. R., Almasi, E. A., Stafford, R. S. (2004). Promotion and Prescribing of Hormone Therapy After Report of Harm by the Women's Health Initiative. JAMA 292: 1983-1988 [Abstract] [Full text]  
• Schwartz, L. M., Woloshin, S. (2004). The Media Matter: A Call for Straightforward Medical Reporting. ANN INTERN MED 140: 226-228 [Full text]  

Rapid Responses:

Read all Rapid Responses

reason

Jo Ann Rosenfeld
bmj.com, 13 Oct 2003 [Full text]

Back to the Dark Ages

PeterR Bradley
bmj.com, 16 Oct 2003 [Full text]

Changes in Italy after the WHI study: the fishing out of tibolone

Anna Maria Marata, et al.
bmj.com, 24 Oct 2003 [Full text]

“It’s an overestimate”

Nicholas Collins, et al.
bmj.com, 13 Nov 2003 [Full text]