Thesis Nurs. c.2 Larson, Meg. 1997 L334h J. Hormone rreplacement ’ therapy : Women ---------- 1' s 1997. Hormone Replacement Therapy; Women s Knowledge and Attitudes Meg J. Larson, BSN, RN Submitted in Partial Fulfillment of the Requirements for the Master of Science in Nursing Degree Approved by. jWpejJel, Phi)., RN Date ^naitperson, Thesis Committee Edinboro University of Pennsylvania Mary Lonelier, Ph.D?, RN Date Committee Member QuM Janice Giltinan, MSN, RN Committee Member /f/i/ Date • C Abstract Hormone Replacement Therapy: Women’s Knowledge and Attitudes The purpose of this study was to describe the knowledge source, knowledge level and attitude of women about to hormone replacement therapy. With this information health care providers can better understand how to assist women to make informed decisions. A literature review was conducted including research on the physiologic effects of hormone replacement therapy, the risks of treatment, and the overall effect of hormone replacement therapy on mortality and life span. Published research related to women’s knowledge and attitude was extremely limited. The sample used in this study was 30 white married women who belong to a marriage support group at a northwestern Pennsylvania church. The survey used in this study was developed by the researcher. Questions were based on the information in a review of literature. Women were asked to identify the effects of Hormone replacement therapy on physiologic systems. Of a possible 8 correct answers the range was 1 to 5 correct answers with a mean score of 3.6. They were to describe their view of Hormone replacement therapy as beneficial or risky. The study found no participant answered all knowledge questions correctly. The women with the highest scores on knowledge about Hormone replacement therapy also had the most positive attitude. Further research should be done to verify these results in more diverse populations. Effective ways of educating health care providers and women about hormone replacement therapy need to be developed. i Acknowledgments The author wishes to express her sincere gratitude and appreciation to her thesis committee chairperson, Janet Geisel and committee members Janice Giltinan and Mary Louise Keller and friend Wendy Parker for their suggestions, time and effort. 1 also want to thank my family for their support and help with this project. Without their generous assistance this project could not have been completed. M.J.L. April, 1997 ii Table of Contents Title Page Abstract. . . i Acknowledgments . ii List of Tables vi Chapter I Introduction 1 Theoretical Framework Statement of Purpose 5 Assumptions and Limitations 5 Definition of Terms 6 Summary 7 Chapter II Review of Literature 8 Cardiovascular Disease 8 Osteoporotic Disease 10 Alzheimer’s Disease and Memory 11 Breast Cancer . 11 Endometrial Cancer 12 Gastrointestinal Effects 13 Vasomotor Effects . 13 Genitourinary Tract. 14 Androgens . .. . 15 Contraindications and Precautions 15 iii Women’s Decisions 15 Summary . 19 Chapter III Methodology 21 Sample and Setting 21 Instrumentation . 21 Data Collection 22 Analysis of Data ,23 Summary 24 Chapter IV Results 25 Description of the Participants 25 Utilization of Health Care 26 Hormonal Medications 26 Medical History 26 Information Source 28 Knowledge about Hormone Replacement Therapy 28 Knowledge and Information Source 30 Knowledge and Attitude . 30 Knowledge and Concerns About Hormone Replacement Therapy 30 Knowledge and Benefits of Hormone Replacement Therapy 31 32 Summary .. Chapter V Discussion and Recommendations 34 34 Discussion . . . iv Recommendations 37 Summary 38 References 39 Appendixes 48 A. Women’s Health Survey .48 B. Cover Letter . 50 C. Total of Responses to Women’s Health Survey v 51 List of Tables Table Page 1. Personal/Family Medical History and Attitude about HRT (Risk vs. Benefit) 27 2. Information Source for HRT and Mean Knowledge Score 28 .29 3. Knowledge of Effect of HRT on Disease 4. Concerns About the Use of HRT 31 5. Greatest Benefit of HRT 32 vi 1 Chapter I Introduction As the United States enters the twenty-first century, millions of baby boomers will be entering or will have arrived at middle life. The women bom during the baby boom, along with an already large and growing number of elderly women, will comprise a tremendous population of peri menopausal, menopausal and post menopausal women. There are now forty-six million Americans at or beyond the age of the menopause, and their numbers are projected to surge to fifty million by the year 2000 (Spencer, 1984). These women have a life expectancy of about eighty years and greater than one third of their lives will be post menopausal (Grady, et al., 1992). Women’s and news magazines feature many articles on successful aging and the menopause and book stores carry entire sections related to women’s health, particularly the menopause. Several of these volumes have become best sellers. These books span personal accounts (Sand, 1993), self help (Sheehy, 1995), medical advice, nontraditional and anti medical viewpoints (Coney, 1994) and often give incomplete and inaccurate as well as inconsistent advice. There may not be any topic related to the menopause with more varied information than hormone replacement therapy. While the lay public and media appear ambivalent, the American Academy of Family Physicians, American College of Obstetricians and Gynecologists, American College of Physicians and U.S. Preventative Services Task Force recommend that: All women should understand the probable risks and benefits of hormone replacement therapy, decide how valuable they consider each of the potential effects 2 of therapy and participate with their physician in deciding whether to take preventive hormone therapy. All women regardless of race should consider preventive hormone therapy (Clinician’s Handbook of Preventative Services, 1994, p. 245). Guidelines released by the American Heart Association in 1995 encouraged the consideration of hormone replacement therapy by all post menopausal women. Because there is such varied information in the popular press, it is difficult for women to make informed rational choices regarding hormone replacement therapy. Logothetis (1991) identified that a recurrent theme emerging from her subjects was their need for more accessible and reliable information about the menopause and hormone replacement therapy. There have been relatively few studies focused on women’s decision making related to hormone replacement therapy. It is not known where women obtain their information regarding the risks and benefits of hormone replacement therapy. Despite endorsement by many major medical groups, fewer than 15% of women use hormone replacement therapy and even fewer remain on it long term (Cauley, Cummings, Black, Mascioli, Seeley, 1995). Studies related to determinants of hormone replacement use showed that parental fracture history has a strong influence on utilization of hormone replacement therapy (Cauley, et al., 1995). Another study identified a positive correlation between women with higher education and socioeconomic levels and the likelihood of utilization of hormone replacement therapy (Salamone, Pressman, Seeley, Cauley, 1996). All women are entitled to hear a balanced view of hormone replacement therapy. 3 To facilitate this, health care providers must understand where women are getting information and what helps them decide about hormone replacement therapy. Several studies on women s attitudes toward hormone replacement therapy show that women are skeptical about long term estrogen use (Salamone, et al., 1996). Questions remain unanswered about whether this skepticism is related to real knowledge about hormone replacement therapy or misinformation. The debate about whether the menopause should be viewed as a natural developmental event (Coney, 1994) or the failure of an endocrine gland, the ovaries, requiring long term treatment with hormones (Utian, 1987) will continue. The menopause may be nothing new in human history, but the ability to treat it by replacing hormones has only existed for about fifty years (Gambrell, 1996), and the large number of women living to the menopause and far beyond has only occurred in this century. Research into the menopause and hormone replacement therapy will continue to add to our knowledge and allow women to make more educated choices about their health. To make these educated choices, information related to the risks and benefits of hormone replacement therapy must be presented in a clear, unbiased manner to all women. Theoretical Framework Orem defines nursing as “a deliberate action with the nurse acting as an agent to provide nursing care” (Orem, 1991, p. 79). The central idea of her theory is that people can benefit from nursing because they are subject to health-derived limitations that render them incapable of continuous self care or dependent care or that result in ineffective or incomplete care. This supports the role of nursing, especially in the role of 4 a nurse practitioner helping women during the climacteric years to meet their self care deficit needs. Dorothea Orem s view of guiding another is valid in situations requiring patients to make a choice (Orem, 1991) such as whether or not they will utilize hormone replacement therapy. This method of helping requires that both the person extending guidance and the person being guided communicate with each other. The guidance must be given appropriately in the form of suggestions, instructions, directions or supervision (Orem, 1991). Guiding another is often used as an adjunct to supporting another. Supporting another can be seen as physical or emotional support. With hormone replacement therapy, support could be to encourage the patient to think about a situation or to make a decision based on factual information. Without correct information about the changes of the menopause and the risk and benefits of hormone replacement therapy, these women are rendered incapable of making a knowledgeable choice about hormone replacement therapy. Providing a developmental environment may be the most important helping method a nurse can provide for women making decisions related to their bodies and hormone replacement therapy. Developmental goals include the forming or changing of attitudes and values, the creative use of abilities and the adjustment of self concept and physical development (Orem, 1991). An environment that is conducive to development, and is favorable to learning and participation, is of great value when used with teaching. Teaching is an important method of helping a person acquire knowledge. Learning cannot take place if the learner is not ready, not interested or is unaware that she does not 5 know. To use teaching as a method of helping requires that the nurse has a thorough knowledge of what the person being helped needs to know. The nurse must consider the patient s background, experience, lifestyle, attitude, prior learning or knowledge and self care requisites. Primary health care providers, such as nurse practitioners, must keep informed of research and development, know their patients, and help them make decisions related to hormone replacement therapy as well as their other self care requisites. Understanding a patient’s attitudes about treatment decisions can help the provider to change or modify treatment and help improve compliance with treatment. Statement of Purpose The purpose of this study is to investigate the attitudes and knowledge of peri menopausal and post menopausal women related to hormone replacement therapy. The results of this study will increase the understanding of factors affecting the attitudes of women and their present knowledge of hormone replacement therapy. This information should assist primary health care providers to ensure that women have accurate information to make informed decisions. Assumptions and Limitations It is assumed that the women participating in this survey answered all questions honestly. The study was limited to a convenience sample of women from a church group in northwestern Pennsylvania. The church is located in a middle to upper middle class socioeconomic area. All participants were Caucasian. The questionnaire used in the study was researcher designed. 6 Definition of Terms The terms used in this study are defined as follows: 1 Menopause. The last menses. When a woman goes for one year without a period it is considered her last menses (Thomas, 1981). The average age of the menopause in the United States is forty-eight to fifty-one (Carr, Greund, Somani, 1995). 2. Peri menopause: Occurring around the time of the menopause (Thomas, 1981). 3. Premenopause: The time before the menopause (Thomas, 1981). 4. Post menopause: Any time after the menopause (Thomas, 1981). 5. Hormone replacement therapy: The replacement or supplementation of previously endogenous hormones. Most commonly estrogen and progesterone for women. 6. Climacteric: The gradual stopping and starting of ovarian function before and after the menopause. Ovarian function begins to drop by age forty in most women (Thomas, 1981). 7. Osteoarthritis: A chronic disease involving the joints, especially those bearing weight. Characterized by destruction of cartilage and impaired function (Thomas, 1981). 8. Osteoporosis: Increased porosity of bone seen most often in the elderly (Thomas, 1981). 9. Vasomotor response: Pertaining to the nerves having a muscular control of blood vessel walls. The circularly arranged fibers of the muscles of the arteries and veins can contract or relax; the affected area can blanch or flush (Thomas, 1991). Relaxation can lead to the flush or “hot flash” associated with the menopause. 7 Summary Health care providers must be prepared to help a growing number of women make decisions related to the menopause if they are to meet their self care needs. As continued research is conducted about the role of hormone replacement therapy in women’s health care its application for disease prevention is more accepted in medicine. To assist women’s decisions about the use of hormone replacement therapy their knowledge level, attitude and source of information related to the subject should be understood. 8 Chapter II Review of Literature The menopause marks the beginning of a period in life when risks for cardiovascular disease, cerebral vascular accidents, cancer, osteoporosis and Alzheimer’s disease increase. Hormone replacement therapy is recommended by many medical associations (Clinicians Handbook of Preventative Services, 1994). Its use has many benefits in combating diseases and prolonging life as well as potential risks. Cardiovascular Disease A fifty year old woman has a 46% lifetime probability of developing and a 31% probability of dying of heart disease (Grady, et al., 1992). In the last decade, researchers have reported that post menopausal women taking estrogen replacement therapy are at decreased risk for cardiovascular disease compared to other women (PEPI Trial Writing Group, 1995). These results are consistent and can be explained. Estrogen has been shown to lower low density lipoprotein and raise high density lipoprotein (Tikkanen, Nikkila, Vartianen, 1978). The most commonly prescribed estrogen, conjugated equine estrogen, has been shown to have a positive impact on the entire lipid profile (Miller, Muesing, LaRosa, Phillips, Stillman, 1991). A randomized, double blind placebo controlled crossover study by Haines, Chung, Chang, Masarei, Tomlison, (1996) reached the conclusion that estrogen replacement therapy is effective in reducing concentrations of lipoproteins in post menopausal women. They also found the most benefit was experienced by those with the highest low density lipoproteins before treatment. As well as its effect on lipid profiles, estrogen was shown to have a direct effect on coronary 9 vessels causing dilation with increased blood flow (Haines, et al., 1996). Estrogens may alter thrombotic mediators leading to decreased platelet adhesiveness (Clarkson, et al., 1990) and lower blood pressure and blood glucose (Barret-Connor, 1990), all risk factors for heart disease. The effects of estrogen replacement have been studied with a variety of end points including fatal coronary event (Talbot, Kuller, Petre, Perpe, 1977), non fatal infarction (Sullivan, et al., 1990) and lipid profiles (PEPI Writing Group, 1995). Cardiac events in post menopausal women on estrogen replacement therapy shows a decrease of 40% in overall mortality (Ettinger, Friedman, Bush, 1996). Some evidence shows that the protective effects are even stronger in women with known heart disease (Grady, et al., 1992). Risk for recurrent disease in one group of women, angiographically diagnosed with coronary heart disease, was reduced by 84% in women on hormone replacement therapy (Grady, et al., 1992). In the early nineties the Post Menopausal Estrogen/Progestin Intervention Trial or PEPI study was begun (PEPI Writing Group, 1995). This National Institute of Health funded three year study compared various hormone replacement regimens. They found, estrogen taken alone or with progesterone cut the risk of heart disease and myocardial infarction by 50%. The addition of progesterone did not negate the benefit of estrogen (PEPI Writing Group, 1995; Greendale, Bodin-Dunn, Ingles, Haile, Barrett-Connor, 1996). The results of nineteen studies reviewed by Paganini-Hill (1995) showed a 20% to 60% decrease in stroke risk for women on hormone replacement. Still, there were many questions and a need for more investigation of estrogen, progesterone and stroke risk. 10 “Prevention of cardiovascular disease, the major killer of post menopausal women, would far exceed the known and theorized adverse events related to estrogen use including cancer.” (Emster, et al., 1988, p. 220) Osteoporotic Disease A fifty year old woman has a 15% probability of hip fracture and a 1.5% probability of dying from complications related to hip fracture (Grady, et al., 1992). She is also at risk for forearm and vertebral compression fractures (Grady, et al., 1992). Approximately twenty-five percent of women over the age of sixty have spinal compression fractures (Gambrell, 1996). The studies reviewed on osteoporosis used the cardiovascular protective doses of estrogen, 0.625 mg (Grady, et al., 1992; Lindsay, et al., 1978; Christiansen, Christiansen, Transbol, 1981). The studies reviewed showed significant benefits from the use of estrogen in treating and preventing osteoporosis. The risk of hip fracture decreased by twenty-five percent with estrogen replacement (Grady, et al., 1992). Studies by Lindsay, et al., (1978) and Christiansen, et al. (1981) concluded that once estrogen is discontinued, bone loss returns to base line within six years, leading to recommendations of long term estrogen replacement (Gambrell, 1996). The addition of progesterone seems to further enhance and stabilize bone mass (Munk-Jensen, Nielsen, Obel, 1988). New studies have made the recommendation that women older than 60 be started on hormone replacement therapy for both protection from osteoporosis and heart disease (Col, et al.,1997). 11 In the Leisure World Cohort study (Paganini-Hill, 1995) on estrogen replacement and oral health, tooth loss was significantly lower among women using estrogen replacement therapy. The differences between groups grew with the duration of estrogen use (Paganini-Hill, 1995). Some of the differences may have been related to improved oral mucosal health as well as protection of bone by estrogen. Alzheimer's Disease and Memory The prevalence of Alzheimer’s disease doubles every five years after the age of sixty-five, and is more common in women (Stein, 1994). In the Leisure World Cohort study (Paganini-Hill, 1995), women with Alzheimer’s disease were less likely to have used estrogen replacement. The Alzheimer’s risk decreased with increasing duration of estrogen replacement therapy and long term users had a 50% reduction in the risk for Alzheimer’s disease. A recent study by Tang, et al. (1996) showed that risk reduction of Alzheimer’s began with one year of estrogen therapy and that overall risk of Alzheimer’s was reduced. When Alzheimer’s did develop, it was at a significantly later age. This study discussed possible effects of estrogen on the brain including; increased cerebral blood flow, promoting growth of dendrites and improving acetylcholine levels that normally decline with aging. Kapen and Sherwin (1994) researched short term memory of women placed on hormone replacement therapy and found significant improvement. Breast Cancer Breast cancer is the most common cancer in women in the United States (American Cancer Society, 1995). Studies by the National Cancer Institute show a 13% risk of developing breast cancer if a woman lives beyond the age of ninety-five. The risk of 12 death from breast cancer is four percent. The potential effect of prolonged exposure to hormones and the risk of breast cancer have been a strong deterrent to women’s use of hormone replacement therapy (Gambrell, 1996). Several of the risk factors for breast cancer such as early menarche, late menopause, nulliparity and obesity (Carr, Greund, Somani, 1995) seem to support a hormone link. Studies related to hormone replacement's effects on the development of breast cancer are inconsistent. One meta-analysis found increased risk of breast cancer in all forms of hormone replacement therapy (estrogen alone, progesterone and estrogen simultaneously or sequentially) even when controlling for increased screening by mammography in these women (Colditz, et al., 1995). Gambrell’s study demonstrated that a woman’s risk of breast cancer was significantly decreased while on hormone replacement therapy (Gambrell, 1996). Meta-analyses by Henrich (1992) and Dupont (1991) did not support an increased risk of breast cancer and the recent post menopausal estrogen/progesterone intervention trial showed no increased risk. It is probable that women on hormone replacement therapy are screened for breast cancer more frequently (Gambrell, 1996). Other variables such as alcohol and tobacco use concurrent with hormone replacement, are also being studied (Gambrell, 1996). Women with a history of personal breast cancer are considered for hormone replacement by many physicians (Cobleigh, et al., 1994). Endometrial Cancer Endometrial cancer is strongly linked to unopposed estrogen use in women with intact uteruses (Shapiro, et al.,1935; Ziel and Finkle, 1975). Now the recommended 13 reg, men of honnone replacement for these women is combined estrogen and progesterone, which prevents the endometrial hyperplasia which leads io endometrial cancer (Gambrell, 1987). It is recommended that women with uteruses have periodic sonograms or endometrial biopsies (American College of Physicians, 1992). Gastrointestinal Effects Evidence shows that at times of low ovarian hormone levels, abdominal distress increases and gastrointestinal transit time increases (Carr, et al., 1995). The climacteric when ovarian hormones begin to decline, is associated with many gastrointestinal symptoms (Sandler, 1990). Slowed gastrointestinal transit time is a recognized risk for colon cancer (Carr, et al., 1995). A large study of women using hormone replacement therapy reported a significant reduction in the risk of colon cancer (Newcomb, Storer, 1995). This single study needs prospective replication of results, but may be noteworthy for women at increased risk for colon cancer. Vasomotor and Sleep Disturbances Women have attributed hot flashes, headache, insomniajoint pain and skin sensitivities to the menopause (Barbach, 1993). Up to 50% of women have symptoms for five years and women seeking relief of these symptoms usually find it with hormone replacement therapy (Carr, et al., 1995). Three other drugs are prescribed frequently for symptom relief. Methyldopa, Clonidine, and Bellergal-S may help some symptoms, but carry their own risks and contraindications (Merz, Goldfinger, 1996). The sleep disturbances and insomnia often suffered during menopause respond to honnone replacement as well (Carr, et al., 1995). 14 Genitourinary Tract Atrophic changes caused by estrogen deficiency occur in the urethra leading to both stress and urge incontinence as well as dysuria (Fantl, Wyman, Anderson, 1988; Hilton, Stanton, 1983). The thinning and shortening of the urethra may contribute to urinary tract infection, noninfectious dysuria and frequency. Hormone replacement helps to decrease these symptoms (Carr, et al., 1995). Estrogen in combination with phenylpropanolamine, a sympathomimetic used for nasal congestion symptoms (Gilman, 1993), showed a 50% cure rate for urge incontinence symptoms (Carr, et al., 1995). Other treatments for incontinence include kegal exercises, pessaries and surgery (Carr, et al., 1995). Although study is scarce in this area, many women may appreciate a medical treatment option. Just as the urethra shortens and thins during decreased estrogen states, so does the vagina. The vaginal walls may thin, vaginal length may decrease by one third and the cervix may develop stenosis (Semmens, Wagner, 1982). Thinning walls and decreased lubrication may cause dyspareunia and, along with falling hormone levels, decreased libido (Barbach, 1993; Carr, et al., 1995; Sheehy, 1995). The increased pH caused by estrogen deficiency also decreases women’s resistance to bacterial vaginosis (Carr, et al., 1995). Vaginal atrophy is responsive to estrogen replacement and when symptoms are persistent, estrogen vaginal creams are recommended (Carr, et al., 1995). Although many products are available for vaginal dryness (Replens. Astrogl.de, KY Jelly), none treat the thinning of vaginal tissue. 15 Androgens Estrogens give relief of most menopausal symptoms. If symptoms persist at doses of 1.25 mg of conjugated estrogen adding a low dose of androgen is recommended (Gambrell, 1995). Up to 50% of androgen production is lost when ovanan Emotion ceases (Greenblatt, 1987). Possible positive effects of androgen include increased libido, decreased hot flashes, lessening of depression and headaches (Greenblatt, 1987). Androgens may aggravate hirsutism, acne and skin oiliness (Gambrell, 1995). Contraindications and Precautions to Hormone Replacement Therapy Present guidelines by the American College of Physicians consider hormone related cancer (such as some breast cancers), active liver disease, active thrombosis and vaginal bleeding of unknown cause the only absolute contraindication to hormone replacement therapy. Relative contraindicators include chronic liver disease, history of endometrial cancer without hysterectomy, hormone induced thrombosis, pulmonary embolism unrelated to trauma, or severe hypertriglyceridemia (significantly worsened by estrogen therapy which can lead to gallbladder disease). These guidelines are frequently revised as more information on the risks and benefits of hormone replacement therapy is gained. Women’s Decisions about Hormone Replacement._Therapy The literature related to determinants of hormone replacement therapy use found that women utilizing it were more educated than those who didn’t (Cauley, et al.,1995). The highest prevalence of use was found in female physicians in the United Kingdom, approximately fifty-five percent of them (Isaac, Britton, McPherson, 1995). One study concluded that women taking hormone replacement therapy were more knowledgeable 16 about the protection offered by hormone replacement therapy against osteoporosis than those not taking hormone replacement therapy (Roberts, 1991). This study found other protective benefits were not well known to women (Roberts, 1991). Salamone, Pressman, Seeley, and Cauley (1996) found that the three major reasons women gave for using hormone replacement therapy were menopausal symptoms (39.3%), physician prescription (38.7%) and prevention of osteoporosis (33.6%). It was concluded from this study that: Older women in the United States remain skeptical about long term estrogen use despite its protection against two major chronic diseases: osteoporosis and cardiovascular disease. Greater understanding about barriers to estrogen replacement therapy and improved knowledge of its risks and benefits may reduce skepticism surrounding estrogen replacement therapy among older women (p. 1293). Studies related to compliance show that approximately thirty percent of women given prescriptions for hormone replacement never fill them because they were not fully convinced of the benefits and safety of therapy (Ravnikai, 1987). Women in several studies expressed a desire for more information related to both menopause and hormone replacement (Ferguson, et al., 1989; Logothetis, 1991; Roberts, 1991). Vaginal bleeding was rated negatively as a decision factor for women that had never taken, and for those currently taking hormone replacement therapy (Ferguson, 1989). The most statistically significant predictors of hormone replacement therapy studied were: perceiving natural approaches to menopause as less preferable, knowing hormone replacement reduced the risk of osteoporosis and viewing menopause as a medical 17 condition (Logothetis, >991). From „hom a wmin important predictor of a woman’s decision to use hormone replacement therapy (Griffiths, 1995; Ravnikai, 1987). Overall use of hormone therapy shows about 13% usage, and this decreases with age (Cauley, et al., 1995). Women who do use it are more likely to participate in sports and recreation and are thinner than other women (Cauley, et al., 1995). Some of the weight differences may be related to the treatment of osteoporosis in thin women, however with the greater cardiac risks of obesity, this may change. Cauley, et al. (1995), Barret-Connor (1990) and Roberts (1991) found that in general, women on hormone replacement were better educated, had a higher income and had increased utilization of health maintenance screening. Perhaps women with less health care coverage would be willing to utilize hormone replacement therapy, but can not afford the mammograms and endometrial work ups as well as the medication itself. No studies were found that evaluated hormone replacement therapy with minority women. Minority women may have less access to health care and are at less risk for osteoporosis than white women (Grisso, Kelsey, Strom, 1994). Their risk of heart disease and stroke are at least the equal of whites (Grady, et al., 1992). Women who had undergone surgical menopause were more likely to use hormone replacement therapy (Cauley, et al., 1995; Griffiths, 1995; Logthetis, 1991). Women’s views of the menopause were also factors. Women who viewed the menopause as a medical condition that should be treated medically were more likely to take hormone replacement therapy (Ferguson. Hoegh, Johnson. 1989; Logothetis, 199!). 18 The seventy and frequency of menopausal symptoms did not seem to affect women’s choices about treatmem (Ferguson, et al, 1989), ,„creaS(i(l su„ell|ance and medlca| screenings were rated positively by both women who did and those who did not take hormone replacement (Ferguson, et al., 1989). The most important source of information about hormone replacement therapy in these studies was the woman’s physician, with the media a close second (Griffiths 1995; Roberts 1991). The type of physician was important, with women going to gynecologists much more likely to receive hormone replacement therapy than those seeing a family practitioner (Ferguson, 1989). In the British studies, women reported more awareness of cosmetic reasons to utilize hormones, and apparently celebrities in that country speak out on their own hormone therapy (Griffiths, 1995; Roberts, 1991). Only 30% of women who begin hormone replacement continue on it, and many women take it intermittently (Ravnikai, 1987). The major reason women ascribed to either stopping or never using hormone replacement was fear of cancer (Ravnikai, 1987). In another study, women stopped or did not start hormone replacement therapy because they felt they didn’t need it (Salamone, et al., 1996). Consensus by the medical community of actual risks and education of women would likely impact compliance with therapy. The inconvenience of daily medication may also be decreased as more women use estrogen patches (progesterone patches are being developed). The new continuous estrogen and progesterone therapy decreases compliance in women with a uterus. vaginal bleeding and so may improve 19 Very few studies measuring women’s knowledge and attitude related to hormone replacement therapy exist. One study focused on the decreased risks of osteoporosis, and did not investigate other benefits of therapy (Roberts, 1991). The women on hormone replacement therapy were much more knowledgeable about osteoporosis (Roberts, 1991). Other questions were generalized, such as “Do risks of estrogen outweigh benefits? (Ferguson, 1989). This does not measure the knowledge base women have on either the risks or benefits of therapy. It is probable that with increased knowledge of the benefits of hormone replacement therapy and factual risks, women’s attitudes towards hormone replacement would be impacted positively and more women would make the decision to use this therapy. Summary The literature reviewed showed an increased life expectancy of one to two years for women on hormone replacement therapy (Grady, et al., 1992). Hormone replacement’s effect on quality of life during the menopause when vasomotor symptoms occur was discussed. Most studies related to its use have focused on predictors of mortality such as coronary heart disease or fractured hips. Hormone replacement therapy appears to decrease the risk of colon cancer and cerebral vascular accident (Grady, et al., 1992). Potential benefits such as prevention of kyphosis, decreased symptoms of osteoarthritis, preservation of urinary and sexual function, slowed skin aging and increased mood and memory have not been as developed. At the same time, taking daily medications, vaginal bleeding and the need for increased medical surveillance with mammograms and endometrial monitoring ma, be seen as decreased qual.t, of life b, some women 20 (Ettinger, et al., 1991). Once the chronic diseases that hormone replacement may prevent occur, medical care along with physical disability may be even more destructive to quality of life. With continued study, more answers will be available to help with women’s decision making. 21 Chapter IH Methodology The review of literature reaffirmed the widespread benefits of hormone replacement therapy in postmenopausal women to prevent disease, prolong life and improve quality of life. The literature also pointed to the under explored area of why women don’t utilize hormone replacement. Perhaps women, as several studies suggested, do not have an adequate knowledge about hormone replacement therapy. With so few women utilizing hormone replacement therapy, the general attitude of women towards it and their source of information also deserves exploration. This study is to help health care providers to understand and assist women making these decisions. Sample and Setting The design of this research was a non experimental, descriptive study. A convenience sample of 30 women was obtained from a large northwestern Pennsylvania church. All the participants were white, married, aged 40-65, and involved in a married life support group. Instrumentation The instrument used for this study was constructed by the researcher after a review of the literature. It was based upon instruments used by Ferguson, et al (1989), Roberts (1991) and Salamone, et al. (1996). Before the actual study was undertaken the questionnaire was piloted on a group of ■ed as teachers in a northwestern Pennsylvania public 11 women aged 40-65, employ* 22 that they were part of a pilot study and that data collected from them would not be included in the final study. They were gwen the assurance of complete anonymity and confidentiality and told that return of a completed survey would signify consent to participate in the pilot study. The women were asked to comment on any problems with clarity in questions or cover letter and to report length of time taken to complete survey. All surveys were returned completed. A few responses were unclear although the women denied difficulty understanding survey questions. Three nursing educators reviewed the survey and also offered suggestions. After this input the survey questions were revised to improve readability and to simplify responding to the survey. The instrument (Appendix A) explores several areas related to women’s health as well as hormone replacement therapy. The initial questions assess the women’s age and utilization of preventive women’s health care. One question also focuses on personal or family history of disease entities impacted by hormone replacement therapy (Cauley, et al., 1995). In the last section of the survey women’s knowledge of what hormone replacement therapy is and its physiologic effects are determined. Finally the attitude of the participants about hormone replacement therapy is evaluated by one multiple choice and two open ended questions. Data Collection This research project was reviewed with a group representative and its purpose described before permission to distribute the survey was given. The su y administered in the group’s regular meeting room before business began. Each 23 participant received a cover letter (Appendix B) briefly describing th, e purpose of the study, the survey form, a pencil and an envelope. The women were verbally assured of the confidential and anonymous nature of all responses. They were instructed that return of a completed survey w<'ould signify consent to be entered in the study. Participants returned the surveys in less than 15 minutes. Analysis of Data Analysis of the data was performed using the SAS computer software package for the analysis of elementary statistics (SAS, 1987). Questions related to the demographics of the group were analyzed to arrive at a group mean for age. Participants were identified by menopausal status and separated according to their candidacy for hormone replacement therapy. These questions were either yes/no or multiple choice with the exception of the question related to age. A question related to whether the participant had a family or personal history of diseases that are impacted by hormone replacement therapy was evaluated to determine how it effected women s attitude about hormone replacement therapy. The women were asked to identify their primary source of information. The knowledge base of the sample about this topic was evaluated by asking what hormones are used in hormone replacement therapy. Questions were asked about hormone replacement therapy’s effect on osteoporosis, heart disease, breast cancer, genitourinary health, sexual taction, and shin aging. The answers were considered correct if they agreed with research results in the review of the literature. Participants mean taow.edge scores were emulated out of a possible 3 correct answers. Next. 24 participants were asked to identify whether they felt hormone replacement therapy has more benefit or risk. The two final questions were open ended and asked participants to name their greatest concern about HRT and what they perceived to be the greatest benefit. The mean knowledge score for physiologic questions was compared based on the participant s source of information and attitude, concerns and perceived benefits. Summary This descriptive study to understand the attitudes and knowledge of women about hormone replacement therapy was done using a researcher designed instrument after a thorough review of the literature. A convenience sample of 30 women age 40-65, married, white and part of a marriage support group was surveyed. The 17 question instrument was used to identify the utilization of preventative women’s health care, their knowledge base about hormone replacement therapy and its physiological effects. General questions about whether hormone replacement was of more benefit or risk and the concerns and greatest benefit women saw from hormone replacement were asked. Several questions related to the knowledge of the group about the hormones in use and their physiologic effect. The participants mean knowledge scores, their source of information and whether they felt that hormone replacement had more benefit, more risk or were unsure were compared. 25 Chapter IV Results As the benefits of hormone replacement thei:rapy continue to be affirmed by research, it becomes more important for women to be offered this option. In order to help women make informed choices about this topic, health care providers must understand the knowledge base of their patients. This descriptive study was undertaken to explore the knowledge and attitude of women and what factors influence their decisions about •l ■■ hormone replacement therapy. Comparisons were made using mean knowledge score about hormone replacement, their view of the benefits versus risks of hormone replacement therapy; and their source of information about hormone replacement therapy. The results of the study are presented in this chapter and tables are used to compare and contrast groups. Description of the Participants A total of 35 women were present in the group to be surveyed and all were given packets. Of the 35 surveys, 32 were returned. Two surveys were discarded because they were incomplete leaving a total of 30 participants in the sample. The sample surveyed were a homogenous group of married white women with a„ age range of 43-65 and a mean age of 52.6. The group was part of a mamage suppori group Northwestern Pennsylvania. When asked their menopause! status, S (26%) reported they were premenopausal, 6 (20%) experiencing the menopause. 15 (50%) postmenopausal and there were no participants who answered unsure. 26 Utilization of Health Care. The participants’ utilization of health care and type of health care provider were explored by questions 1,2, 3, 9 and 10 of the survey (Appendix A). Twenty-five (83.3%) of the women had breast exams yearly. Ninety percent had yearly pelvic exams. Five (16.7%) participants had a hysterectomy. Health care providers were identified as 6 (20%) female and 24 (80%) male. All of the participants described their health care provider as a physician: 1 (3.3%) internist, 11 (36%) family or general practice physician and 18 (60%) gynecologist (Appendix C shows total participant responses). Hormonal Medications. Questions 4 and 8 asked the participants about their use of hormonal medications. When asked “Have you ever used birth control pills?” 19 (63.3%) answered yes. Of the women who had used oral contraceptive pills, the majority (63.2%) felt that hormone replacement therapy was beneficial, 26% were unsure and only 10% felt the risks out weighed the benefits. Oral contraceptive pill users had a mean knowledge score of 3.8, slightly higher than the group mean of 3.6. Present users of hormone replacement therapy comprised 9 (42.8%) of the women in the post menopausal and experiencing menopause group who would be appropriate candidates for hormone replacement therapy. Medical History. Participants were asked to identify personal and family history of major disease groups which are impacted by hormone replacement therapy. Participants were also asked to identify whether hormone replacement therapy would benefit or increase the risk for these diseases. Table 1 presents how participants who identified personal or family history of a disease responded to the risk benefit questions. The 27 Table 1 Personal/Family Medical History and Attitude about HRT (Risk vs. Benefit) Disease Group Incidence of Disease Attitude Towards HRT n Risk Benefit Unsure Heart Disease 22 27.2% 45.4% 27.4% Osteoporosis 10 0.0% 80.0% 20.0% Stroke 7 14.2% 57.1% 28.6% Breast Cancer 6 42.8% 28.5% 28.7% Alzheimer’s Disease 2 0.0% 100.0% 0.0% n number of responses, total could be greater than 30 as participants could choose more than one answer. HRT is Hormone Replacement Therapy. majority, 22 (73%) of the participants, reported histories of heart disease but fewer than half (45%) believed hormone replacement therapy would be beneficial. Eighty percent of the participants who identified histories of osteoporosis believed hormone replacement therapy was beneficial. No one with a history of osteoporosis felt that the risk of hormone replacement therapy exceeded the benefit. Further, although only two women cited histories of Alzheimer’s disease, both felt that hormone replacement therapy was of benefit. Greater than fifty percent of women reporting histories of stroke believed in the benefits of hormone replacement therapy. The women with a history of breast cancer were most likely to see hormone replacement as a risk. 28 Information Source, When participants were asked where they had obtained information about hormone replacement therapy 50% indicated physicians as the source (Table 2). Fewer than 20% obtained information on hormone replacement therapy through friends and relatives. Table 2 Information Source for Hormone Replacement Therapy and Mean Knowledge Score Information Source Physician Friend or relative Books and magazines Television n (%) Mean Knowledge Score 15(50.0%) 3.8 5(16.6%) 4.0 10(33.3%) 4.0 7 (23.3%) 2.0 ni = number of responses, total could be greater than 30 as participants could choose more than one answer. Percentages can also equal greater than 100% because participants could choose more than one answer. Knowledge About Hormone Replacement Therapy To identify the knowledge base of participants about hormone replacement therapy, two questions were asked. The participants were asked to identify the hormones in use and given the choice of any combination of estrogen, progesterone and testosterone. Four (13.3%) participants chose the correct answer by checking all three. Estrogen alone was chosen by seven (23.7%) of the sample. Sixteen (53.3%) chose estrogen and progesterone. Three (10%) individuals left this question unanswered. To explore the participants knowledge of physiological effects of hormone replacement therapy, an eight item question was used. This question gave physiologic states and asked the 29 women if hormone replacement would be beneficial or increase the risk for the condition. Participants could also answer unsure. Answers were considered correct if they agreed with the information reported in the review of literature. The range of correct responses was 1 to 5. The mean score was 3.6 of 8 possible correct responses (the standard deviation was 1.5). Ninety percent of women surveyed knew hormone replacement therapy reduced hot flashes (Table 3). The benefits to bone density were known by over 80% of respondents. An increase in sexual and urinary function resulting from hormone replacement therapy. Of this group, 40% were on hormone replacement therapy and felt replacement therapy was known by 30% and 10% of women, respectively. Table 3 Knowledge of Effect of Hormone Replacement Therapy (HRT)on Disease n Sample Answering Correctly Protect the bones 26 86.6% Slow skin aging 15 50.0% Decrease heart disease 14 46.6% Decrease risk of stroke 2 6.6% Unsure effect on breast cancer 9 31.0% Increase sexual function 10 2 33.3% 27 90.0% Actual Effect of HRT Increase urinary function Decreased hot flashes n = number answering correctly 10.0% 30 Knowledge and InfonnationSource. The mean scores relating to knowledge were similar for all information sources except for television which had a lower score. Participant’s mean knowledge score is correlated with the source of the information in Table 2. (The majority of women, twenty (67%), identified a need for more information about hormone replacement therapy. Despite this perceived lack of information sixteen (53%) of these women felt that hormone replacement therapy is beneficial.) Knowledge and Attitude. The five women who had hysterectomies were all candidates for hormone replacement therapy and felt it was beneficial. The mean knowledge score for these 5 women was 3.4. The nine women (including two women who had hysterectomies) taking hormone replacement also had a mean score of 3.4. Both of these scores are similar to the group mean of 3.6. Knowledge and Concerns Related to Hormone Replacement Therapy. Survey question 15 asked women if they would like more information on hormone replacement therapy. Twenty (66.6%) wanted more information and 10 (33.3%) did not. Women were asked to identify their greatest concern about the use of hormone replacement therapy (Table 4). Cancer was the overwhelming concern (46.6/o). six (20%) described cancer as their biggest worry and eight (26.6%) narrowed this down to breast cancer. The cost and long term medication were also concerns. Four (13.3%) women denied any concern. The women with the highest mean knowledge scores of 4 or greater listed their greatest concerns as taking it forever, long term effects, and didn’t know enough about hormone replacement therapy. Those with the lowest mean knowledge scores said they 31 had no concerns or that it was not natural (Table 4) Table 4 Concerns About the Use of HRT Concern n (%). Mean Knowledge Score Causes breast cancer 8 (26.6%) 3.6 Causes cancer 6 (20.0%) 3.4 Long term effects 4(13.3%) 4.3 None 4(13.3%) 2.8 Taking forever 2 (6.6%) 4.5 Not natural 2 (6.6%) 2.5 Don’t know enough about 2 (6.6%) 4.0 Cost 2 (6.6%) 3.5 n=number of participants Knowledge and Benefits of Hormone Replacement Therapy. The final survey question was “What is the greatest benefit of hormone replacement therapy?” The treatment of menopausal symptoms was chosen by 11 (36.6%) of the sample (Table 5). Protection from osteoporosis was the second most common answer with 8 (26.6%). Five (16.6%) women were unsure. Only two (6.6%) women felt protection from heart disease was the greatest benefit. Those participants who identified heart protection (6.6%), slowed aging (6.6%) and improved memory (3.3%) had higher mean knowledge scores than the group mean of 3.6. Their scores had a range of 4 to 5. However most participants selected 32 Table 5 Greatest_Benefit of Hormone Replacement Therapy Benefit of Hormone Replacement Therapy (Sample) Improve hot flashes n(%) Mean Knowledge Score 11 (36.6%) 3.0 Bone protection 8 (26.6%) 3.1 Unsure 5 (16.6%) 3.0 Heart protection 2 (6.6%) 5.0 Slowed aging 2 (6.6%) 4.0 Improved memory 1 (3.3%) 4.5 Improved mood 1 (3.3%) 3.0 n=number of participants improvement of hot flashes or bone protection and had mean knowledge scores of 3 and 3.1 respectively which was lower than the group mean. The 19 (63%) women who had used oral contraceptive pills, the 10 (39%) who had a personal or family history of osteoporosis, and those 10 (33%) with higher mean knowledge scores had the most positive views of the benefits of hormone replacement therapy. Summary To explore the knowledge and attitude of women about hormone replacement therapy survey questions were asked to establish their age, candidacy for hormone replacement therapy and family history of diseases impacted by hormone replacement therapy. Women were also asked to identify the hormones included in hormone 33 replacement therapy for women. Mean knowledge scores about the physiologic effects of hormone replacement therapy were calculated and compared with source of information attitudes, perceived risks and benefits of hormone replacement therapy. Results suggest that women generally are not well informed about hormone replacement therapy with a mean score of 3.6 out of 8 and no participant answering all 8 questions correctly. Source of information about hormone replacement therapy had little impact on mean knowledge scores although those who obtained their information from television did have lower mean knowledge scores (Table 2). Participants higher mean knowledge scores did generally have a positive view of hormone replacement therapy. Participants with a family history of osteoporosis or Alzheimer’s disease also viewed hormone replacement therapy as beneficial. Participants identified a learning need with 20 (66%) saying they would like more information about hormone replacement therapy. Despite their general lack of knowledge the majority of the group felt that hormone replacement therapy is beneficial. 34 Chapter V Discussion and Recommendations Few references were found in the literature that addressed women’s attitude, knowledge or source of information about hoiirmone replacement therapy. The literature review consisted of material pertaining to the risks and benefits of hormone replacement as presently researched. This study was undertaken to examine the basic knowledge and attitude of women toward hormone replacement therapy. Several questions were used to investigate the sources of information, the type of health care provider, use of preventative services, and knowledge level related to hormone replacement therapy. Women were asked whether they felt hormone replacement therapy was risky or beneficial. The final questions asked women to document their concerns and what they perceived as the greatest benefit of hormone replacement therapy. Discussion The demographic information obtained included age, marital status, race and sex. Information on education and socioeconomic status was not collected. The group as a whole had contact with physicians for preventative health care. They also showed a higher utilization (50%) of hormone replacement therapy than seen in the review of literature (15%) (Cauley, et al., 1995). The women showed a lack of knowledge about hormone replacement therapy. No participants answered all questions measuring knowledge correctly. Of a possible score of 8 the range was 1 to 5, with a mean of 3.6 and a standard deviation of 1.5. Of great concern to primary health care providers was the fact only 14 (46%) of the 35 participants were aware of the protects effects of hormone replacement therapy on cardiac disease though 22 (73.3%) of the group had a personal or family history of heart disease. Improved longevity is most associated with the cardiac protective effects of hormone replacement therapy (Cummings, 1992). Only 2 participants felt cardiac protection was hormone replacement therapy’s greatest benefit. This suggests a learning need for menopausal women about the cardiovascular benefits of hormone replacement therapy and risk of cardiovascular disease for post menopausal women. The women demonstrated the most knowledge about hormone replacement’s therapeutic effects on menopausal symptoms (90%) and bone protection (86.6%). As in the review of the literature (Cauley, et al., 1995), women in the study with personal or family history of osteoporosis were likely to view hormone replacement therapy as beneficial. Greater than half of the sample stated that hormone replacement therapy increased breast cancer, a contention that is not supported in the review of the literature. While several studies have suggested a hormonal link (Carr, Greund, Somani, 1995, Colditz, et al., 1995) others continue to show no relationship between hormone use and breast cancer (Gambrell 1996; PEPI Trial Writing Group 1995). Oral contraceptive pill users viewed hormone replacement therapy more positively than the rest of the group, but they did not have a higher mean knowledge score. Only four participants were aware that hormone replacement therapy for women could include estrogen, progesterone and testosterone, Testosterone is far less prescribed than estrogen or progesterone although women’s levels of testosterone dimmish almost as rapidly with menopause (Gambrell. 1996). Lack of androgens may lead to fatigue and 36 decreased libido. The addition of androgens to hormone replacement therapy may have significant benefit to women (Greenblatt, 1987). Sources of information such as books, friends, and relatives, scored similarly to each other. The 7 participants who received their information from television scored the lowest with a mean knowledge score of 2 compared to the group mean knowledge score of 3.6 (Table 2). Since the majority of these women obtained their information from primary health providers, the lack of knowledge about hormone replacement therapy may represent a lack of knowledge on the part of prescribers. It is also possible that health care providers are unable to adequately disseminate knowledge to their patients. Health care professionals need to be involved in educating women about hormone replacement therapy because the evidence indicates that the mass media does not meet this need. The majority of women who participated in this study identified their need for more information related to hormone replacement therapy. The decision to take hormone replacement therapy is complex. The review of literature shows the result of hormone replacement therapy is to increase life expectancy and decrease the probability of coronary heart disease and hip fracture. It also effects many other quality of life issues such as osteoarthritis, sexual, urinary and mental function. Ideally a woman experiencing menopause should understand her risks for vanous diseases and the effect of hormone replacement therapy on these risks. She should also be aware of the quality of life impact. The common side effects of various hormone replacement therapy regimens. endometrial Weeding patterns and monitoring required for homtone repiaeement therapy 37 must also be explained. The majority of participants, Even without knowledge of all the potential health benefits of hormone replacement therapy, and with a significant number of the sample believing it increased cancer risk, felt hormone replacement therapy had more benefits than risks. Once knowledgeable about hormone replacement therapy, a woman’s decision about it is likely to depend on her personal risk status. For example, a woman with heart disease may place more value on prevention of recurrent heart disease than a woman with increased risk of breast cancer. Each woman should participate in the decision concerning hormone replacement therapy. Health care professionals must provide detailed information to women to facilitate appropriate decision making. Recommendations Further research is needed to investigate the most appropriate, effective way to provide information on hormone replacement therapy. Based on the results of this study, the following recommendations were made: 1. The study should be replicated using a larger sample size with a less homogenous population distribution, to reflect different racial, educational, economic, geographic, and health status variations. 2. The instrument should be further refined related to women’s knowledge and attitude about hormone replacement therapy. Questions should be asked concerning contra indications of hormone replacement therapy and common side effects. 3. Educational programs on hormone replacement therapy should be developed to educate women about the benefits and risks of hormone replacement therapy. 38 4. Health care providers should be studied to assess their knowledge, attitude and how information is provided to women about hormone replacement therapy. Summary This study suggests that women experiencing the menopause have a self care deficit (Orem, 1995) related to knowledge about the risks, benefits, and effects of hormone replacement therapy. By using Orem’s Theoretical Framework for Nursing, the women’s self care needs can be met and the autonomy of the individual protected. Family Nurse Practitioners are in a valuable position to meet these needs. The women in the study that were more knowledgeable about hormone replacement therapy viewed it more positively. Written materials should be developed and provided to women to reinforce teaching. Once the learning needs of the patient are met, they should be guided to a decision about hormone replacement therapy. The decision of the patient should be supported by the health care provider. This study demonstrated that women have a self care deficit related to knowledge of hormone replacement therapy. It is unclear if the knowledge deficit of participants is because of poor dissemination of information by their primary care providers or a lack of knowledge by providers. If women are more educated regarding hormone replacement therapy, they can better meet their self care needs. 39 References American Cancer Society. (1995). QntaJaga^giJi^ Allanta GA American College of Physicians (1992). Guidelines for counseling post menopause! women about preventative hormone therapy. 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Do you have a family or personal history of: (check all that apply) Osteoporosis (thinning of the bones ) Heart disease Alzheimer’s disease Breast Cancer Stroke 8. Are you using hormone replacement therapy ? 9. Is your primary health care provider? Male 10. Yes No Female What type of health care provider do you use for women’s health care? ------------------—----- Internist Family or general practice physician Gynecologist Nurse Practitioner None 49 11. Most of the information I have about hormone replacement therapy comes from (please choose one) Physician Nurse Practitioner Friend or relative Books or magazines Television Other 12. Hormone replacement therapy for women may include ? Mark all that apply. Estrogen Progesterone Testosterone 13. Hormone replacement therapy may ? ( Choose one on each line ) Thin the bones Unsure Protect the bones Increase skin aging Unsure Slow skin aging Increase heart disease Unsure Decrease heart disease Unsure Increase risk of stroke Decrease risk of stroke Unsure Increase breast cancer Decrease breast cancer Unsure Increase sexual function Decrease sexual function Decrease urinary function Unsure Increase urinary function Decrease hot flashes Increase hot flashes Unsure 14. How do you personally feel about hormone replacement therapy ? Has more risk than benefit. Has more benefit than risk. Unsure 15. Would you like more information on hormone replacement therapy ? Yes No 16. What is your greatest concern about hormone replacement therapy ? 17. What do you feel is the greatest benefit of hormone replacement therapy ? Thank you ! 50 Appendix B Meg Larson 242 Waterford Street Edinboro, PA 16412 (814) 734-3088 Dear Participants, The following questionnaire is part of a research study related to women’s health as part of the requirement of Edinboro University’s Master of Science in nursing. The study will help develop a better understanding of women’s health care needs. The questionnaires are completely anonymous. They will take approximately 15 minutes to complete. Your assistance with this project is greatly appreciated. Once my research is complete, I would be happy to provide information and results to your group. Thank you for your time and consideration. Sincerely, Meg Larson 51 Appendix C Total Responses to Women's Health survey 1. Present Age M SD Max Min 52.6 6.9 65 43 2. Do you have a yearly breast exam? Yes n=25 (83%) No n=5 (17%) 3. Do you have a yearly pelvic exam? Yes n=27 (90%) No n=3 (10%) 4. Have you ever used birth control pills? Yes n=19 n; (63%) No n=l 1 (37%) 5. Have you had a hysterectomy ? Yes n=5 (17%) No n=25 (83%) 6 What is your menopausal status ? Premenopausal n=8 (27%) Experiencing menopause n=6 (20%) Post menopausal n=15 (50%) Unknown n=l (3%) 7. Do you have a family or personal history of: Osteoporosis n=10 (33%) Heart disease n=22 (73%) Alzheimer's disease n=l (3%) 52 Breast Cancer n=6 (20%) Stroke n=7 (23%) 8. Are you using hormone replacement therapy ? Yes n=9 (30%) No n=21 (70%) 9. Is your primary health care provider? Male n=24 (80%) Female n=6 (20%) 10. What type of health care provider do you use for women's health care? Internist n=2 (6%) Family Physician n=13 (43%) Gynecologist n=18 (60%) Nurse Practitioner n=0 (0%) None n=0 (0%) 11 Most of the information I have about hormone replacement therapy comes from: n=14 Nurse Practitioner n=l (3%) Friend or relative n=5 (16%) Books or magazines n=10 (33%) Television n=7 (23%) n=0 (0%) Other 12. (46%) Physician Hormone replacement therapy for women may include: n=27 (90%) Progesterone n=20 (66%) Testosterone n=4 (13%) n=3 (10%) Estrogen None 53 13. Hormone replacement therapy may: A. B. C. D. E. Thin the bones Unsure n=0 n=4 Increase skin aging Unsure n=0 n=15 Unsure n=1 n=15 Unsure n=5 n=22 (17%) Increase breast cancer (55%) Increase sexual function (34%) Increase urinary function n=3 H. (3%) Increase risk of stroke n=10 G. (0%) Increase heart disease n=16 F. (0%) (10%) Increase hot flashes n=0 (0%) Protect the bones (13%) (50%) (50%) (76%) n=14 n=2 (31%) n=4 Unsure 15. (66%) n=0 n=20 (67%) No n=10 (33%) (14%) (0%) Decrease urinary function (86%) n=l (4%) Decrease hot flashes (10%) n=27 n=16 (53%) n=8 (27%) Would you like more information on hormone replacement therapy ? Yes (7%) Decrease sexual function 14. How do you personally feel about hormone replacement therapy ? n=6 (20%) Has more risk than benefit. Has more benefit than risk. (47%) Increase breast cancer Unsure n=3 (50%) Decrease risk of stroke Unsure n=25 n=15 Decrease heart disease Unsure n=19 (87%) Slow skin aging Unsure n=9 n=26 (90%)