BARRIERS TO HORMONAL REPLACEMENT THERAPY Barri ers to hormonaI replacement therapy / by Janice Dean. Thesis Nurs. 1999 D281b Janice Dean BSN, R.N. Submitted in partial Fulfillment of the Requirements for the Master of Science in Nursing Degree Edinboro University of Pennsylvania Approved by: 7 Mary Lx fu Killer, Ph.D., CRNP Chairperson, Thesis Committee A&las J Jai tjS^isel, Ph.D., RN Date ‘ ' / 'mittee Member Jolynn Agostini MSbi^ R& Committee Member Date <7^5 Abstract Barriers to Hormonal Replacement Therapy The American College of Obstetricians recommends that all postmenopausal women consider Hormonal Replacement Therapy (American College of Obstetricians and Gynecologists, 1992). Although HRT has clearly been shown to have life-prolonging benefits, women remain skeptical (Salamone, Pressma, Seeley & Cauley, 1996) and treatment remains widely underutilized by the menopausal population (Rabin, 1998). The purpose of this study was to identify the barriers that may influence a woman’s decision regarding HRT. By studying these barriers the nurse practitioner will have a better understanding of a women’s existing concerns, and can better assist her in making an informed decision. A non-experimental descriptive study was conducted utilizing a questionaire consisting of 19 questions. A convenience sample of 78 menopausal women were recruited from the northwestern region of Pennsylvania. Analysis consisted of compilation of total percentages from all respondents and comparison was made between HRT users versus nonusers in regard to demographic factors, health practices, knowledge, and attitudes. Several underlying themes were identified. Sixty-seven (86%) of the participants reported that they knew what HRT was. Current users appear convinced of the potential role of HRT in the prevention of menopausal symptoms (70%), osteoporosis (67%), and i cardiovascular disease (57%). Nonusers represented the largest group in this study and showed similar awareness of the role of HRT in menopausal symptoms ((65%) and osteoporosis (54%). Nonusers appear to be skeptical and unconvinced of the potential role of HRT. The uncertainity expressed by the nonusers in this study about fear of cancer (31%), questionable safety (29%), and just not wanting to take HRT (35%) points to a need for balanced information and the opportunity for discussion of these complex issues. All PCP’s who care for women should fully discuss the positive and negative effects of HRT and identify and address the concerns, beliefs, and attidudes that may influence a woman’s decision regarding HRT. Acknowledgements The author wishes to express her sincere gratitude and appreciation to her thesis committee chairperson, Mary Lou Keller and committe members Janet Geisel and Jolynn Agostini. I would not have been able to accomplish this project without the vigilant support and encouragement from my family and friends. Thank you all ! We did it Marcy! J.B.D. December, 1999 ii Table of Contents Title Page Abstract i Acknowledgments ii List of Tables vi Chapter I 1 Introduction Background of the Problem 2 Statement of the Problem 4 Theoretical Framework 4 Statement of the Purpose. 6 Definition of Terms. 6 Assumptions 7 Limitations 7 Summary 7 Chapter II Review of Literature. 9 Current Benefits and Risks of HRT. 9 Positive Effects of HRT 9 Negative Effects of HRT 14 18 Barriers to HRT Demographic Factors 18 Lack of Knowledge 19 Women’s Concerns. 21 Provider-Patient Communication 22 Incongruent Agenda 23 iii Type of PCP. 24 Summary 25 Chapter III Research Methodology 27 Purpose................................... 27 Operational Definition 27 Research Design 28 Sample 29 Informed Consent 29 Instrumentation 29 Pilot Study 30 Data Analysis 31 Summary 31 Chapter IV Results 32 Description of Participant 32 Demographic Barriers, 33 Knowledge Barriers 34 Women’s Concerns as Barriers 37 Communication Barriers 39 Incongruent Agenda as a Barrier. 40 Type of PCP as a Barrier. 40 Summary 43 Chapter V Discussion and Recommendations Discussion 45 45 iv Conclusions 51 Recommendations 52 References 54 Appendixes 63 A. Menopausal Health Questionaire. B. Cover Letter 63 67 v 1 Chapter I Introduction Menopause signals a transition from the reproductive stage to the nonreproductive stage in a woman's life. More than 30 million United States women are now at or beyond menopause and at least another 6 million women will reach this stage of life during the next decade (Scharbo-Dehaan, 1996). As these women reach menopause the problems associated with the postmenopausal years will increase the likelihood that hormonal replacement therapy will be considered (Scharbo-Dehaan, 1996). Hormonal replacement therapy (HRT) has been used successfully for more than 40 years as a short-term therapy for perimenopausal symptoms (Ferguson, Hoegh & Johnson, 1989; Rabin, 1998), and more recent evidence suggests that HRT may prevent major chronic diseases of aging (Schneider, Barrett-Connor & Morton, 1997; Grodstein et al., 1997; Kawas et al., 1997). Although HRT has clearly been shown to have life-prolonging benefits, women remain skeptical (Salamone, Pressma, Seeley & Cauley, 1996), and treatment remains widely underutilized by the menopausal population (Rabin, 1998). According to Ferguson et al. (1989) even though the health benefit-to-risk ratio may favor prophylactic treatment for some women, many remain reluctant to take estrogen even when the primary care provider carefully explains the benefits. Despite its numerous proven benefits and relative safety, as many as 50% of eligible women 2 are not taking HRT (Brett & Madans, 1997), and the proportion of postmenopausal women under treatment remains low and compliance poor (Gass, Rebar, Liu & Cedars, 1997). The Health Belief Model was developed to provide a means for understanding health related behavior. It identified that women’s decision making is largely based on a therapy’s benefits weighed against its barriers (Logothetis, 1991). The primary care provider (PCP) must attempt to recognize and address underlying variables that act as barriers. For it is these obstacles or barriers that may influence a woman’s attittude and decision regarding HRT use. According to Salamone et al. (1996) greater understanding of the barriers women face when considering HRT and improved knowledge of its risks and benefits may reduce the skepticism surrounding HRT. The purpose of this study is to identify variables that act as barriers to HRT use in menopausal and postmenopausal women. The background of the problem, theoretical framework, assumptions, limitations, and definitions of terms are defined in this chapter. Background of the Problem The American College of Obstetricians and Gynecologists recommends that all women should understand the probable risks and benefits of HRT, and in conjunction with her PCP consider each of the potential effects in deciding whether to take preventative hormone therapy (American College of Obstetricians and Gynecologists [ACOG], 1992). HRT has been an available treatment for over 50 years (Rabin, 3 1998). In the 1970’s estrogen received strong negative publicity because it was found that unopposed estrogen placed women with a uterus at substantial risk for endometrial hyperplasia and cancer (Hammond, 1997).) In the 1980’s the addition of progestin to the regimen increased acceptance of HRT and as a result there has been a steady increase in its usage (Salamone et al., 1996). Recent studies suggest that long term use of HRT provides not only relief of early symptoms of estrogen deficiency (Stafford, Saglum, Causino & Blumenthal, 1997), but prevention of osteoporosis (Schneider et al., 1997), cardiovascular disease (Stampfer et al., 1991; Grodstein et al., 1997), Alzheimer’s disease (Kawas, Resnick & Morrison, 1997), and improvement in quality of life (Ettinger, Friedman, Bush & Quesenberry, 1996). Informing the millions of women due to experience menopause in the coming decades of the possible long-term benefits and risks of HRT presents a major challenge to the PCP. According to Hunskaar & Backe (1992) and Roberts (1991), most women desire further information on HRT and expressed an interest in taking HRT. Contrary to this, in a more recent study by Gass et al., (1997), it was found that many of the participants were not interested in using HRT, or stopped using it once they started. Despite endorsement by many major medical groups fewer than 20% of postmenopausal women in the United States have been prescribed HRT and even fewer remain on it long term (Gass et al., 1997). Adherence to the treatment is a common dilemma (Gass et al., 1997). Of those receiving HRT, more than 70% fail to 4 adhere to the recommended treatment program (Hammond, 1997) and fewer than 49% of those on the treatment continue longer than a year (Hammond, 1997). There is a need to understand the beliefs and decisions that influence a woman’s choice to use HRT (Goldani von Muhlen, Kritz-Silverstein & BarrettConnor, 1995). To date only a handful of population-based studies have examined this issue. The decision to take HRT is and will remain a difficult choice for all postmenopausal women because the factors that govern patient acceptance remain complex and are further complicated by the fact that there are still no definitive answers (Hampson & Hibbard, 1996). Whether the identification of potential barriers to HRT use can improve the compliance to estrogen therapy among menopausal women remains an important question. Statement of the Problem Although research clearly shows that the benefits of HRT far outweigh the risks, as many as 50% of eligible women are not using HRT (Brett & Madans, 1997) and of those taking the treatment fewer than 49% continure for longer than a year (Hammond, 1997). Theoretical Framework The theoretical framework of this study is based on the Health Belief Model (Becker, 1978). The model was originally developed in the 1950’s to explain why people failed to use prevention and screening programs (Logothetis, 1991). It is 5 particularly popular in the nursing forum because it focuses on patient compliance and preventive health care practices (Polit & Hungler, 1995). The major components of the Health Belief Model include four constructs, perceived susceptibility, severity, benefits and barriers (Becker, 1978). The combined perception of these four components determine an individual's health-related behavior. Health-seeking behavior is influenced by a person's perception of a threat of illness and the value associated with actions aimed at reducing the threat (Becker, 1978). Therefore the menopausal woman must perceive that declining estrogen production is relevant, warranting action. Even when one recognizes personal susceptibility, action will not occur unless the individual perceives the severity to be high, enough to have serious organic or social implications (Polit & Hungler, 1995). The women who reach menopause symptom-free and do not perceive a threat to their well being, consequently see no reason to initiate HRT. Likewise, the women who experience hot flashes, vaginal dryness, and or insomnia may perceive this as impacting their health and agree to treatment with HRT as a perceived benefit. Logothetis (1991) found that the most important factor in the women’s decision regarding HRT use was the perception of HRT’s benefits and how they weighed against its barriers. By studying the barriers that affect HRT usage, the health care provider will gain insight into a woman’s concerns. Knowing and understanding a woman’s concerns about HRT will enable the PCP, in partnership with the patient, to 6 provide specific evidence-based information about the benefits and risks of HRT so that an informed decision can be reached. Statement of Purpose The purpose of this study is to indentify variables that act as barriers to HRT use among menopausal and postmenopausal women. Definition of Terms The terms used in the study are defined and are listed below. 1. Barriers are obstacles that obstruct or influence a woman’s decision regarding HRT use. 2. Climacteric is 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). 3. Hormonal replacement therapy is the replacement or supplementation of previously endogenous hormones. For menopausal woman, HRT involves the replacement of estrogen and progesterone (Thomas, 1981). 4. Hot flash is the transient sensation of warmth experienced by some women during or after menopause. Hot flashes result from autonomic vasomotor disturbances that accompany changes in the neurohormonal activity of the ovaries. hypothalamus, and the pituitary gland (Glance, 1990). 5. Menopause is the cessation of menses, but commonly used to refer to the period of the female climacteric (Glance, 1990). 7 6. Osteoporosis is a disorder characterized by abnormal rarefaction of bone, occurring most frequently in postmenopausal women. Estrogen therapy is often used for the prevention and management of postmenopausal osteoporosis (Glance, 1990). 7. Postmenopausal is any time after the menopause (Thomas, 1981). 8. Vasomotor response pertains to the nerves and muscles that control the caliber of the lumen of the blood vessels. Circularly arranged fibers of the muscles of arteries can contract, causing vasoconstriction, or they can relax, causing vasodilatation (Glance, 1990). Assumptions It is assumed that all women participating in this survey will answer the questions honestly. The assumption has been made that all women want to be informed and have the right to health prevention measures. It is also assumed that HRT is a standard approach for all eligible menopausal women. Limitations The study was limited to a convenience sample of women in the North West Pennsylvania area. The results of the study will be limited to menopausal and post­ menopausal women surveyed and can not be generalized to other populations. Summary Of great concern to the PCP is the finding that the majority of eligible menopausal women are not choosing to use HRT and of those that do, few continue for more than a year (Brett & Madans, 1997; Hammond, 1997). According to the 8 Health Belief Model a women’s decision regarding HRT is based on her perception of it’s benefits weighed against its barriers (Becker, 1978). It is imperative that the PCP identify the variables or concerns that act as barriers. Knowing and understanding a women’s concerns about HRT and providing up to date evidence-based information will enable the PCP in partnership with the patient to reach an informed decision. This chapter reviewed the background of the problem, theoretical framework, assumptions, limitations, and definitions of terms. 9 Chapter II Review of the Literature The review of literature presents the current researched data regarding the benefits and risks of HRT. In addition the barriers that influence women’s decisions to use or not use HRT documented in previous research is discussed. Current Benefits and Risks of HRT HRT has many researched benefits in combating disease and prolonging life as well as potential risks. Studies that have evaluated and explored the positive and negative effects of HRT are discussed. Positive Effects For more than 40 years estrogen has been used as an effective short-term therapy for improving vasomotor symptoms, insomnia, and genitourinary symptoms (Hammond, 1997). The hot flash and nightsweats experienced by up to seventy-five percent of perimenopausal women, are the major clinical symptoms that cause women to seek medical attention (Hammond, 1997). Newton et al., (1997) examined health practices in 1082 women aged 50-80 and found that menopause-related symptoms (47.3%) were the most frequently cited reason by current users for initiating HRT. One of the primary problems caused by hot flashes is the disruption of sleep. Estrogen therapy given orally or transdermally, has been shown to provide relief of these symptoms (Lichtman, 1994 ; Hammond, 1997). 10 Within four to five years after the cessation of menstruation, many women not using HRT experience atrophy of the vagina, urethra, vulva and trigone of the bladder (Hammond, 1997). These urogenital symptoms, which are characterized by decreased lubrication, dyspareunia, irritation, puritis and repeated vaginal infections, affect approximately 20% to 40% of women (Lichtman, 1994; Hammond, 1997). Both systemic and local estrogen has been shown to be an effective treatment (Scharbo- Dehaan, 1996). Urgency, nocturia, urinary tract infections, stress incontinence, and urge incontinence are all associated with menopause (Scharbo-Dehaan, 1996). Literature on the effects of estrogen on these symptoms is inconclusive due to the lack of understanding of how aging influences the urinary tract but both Lichtman (1994) and Davila (1996) found that urge incontinence responded well to local estrogen use, and stress incontinence responded better to systemic estrogen. As women age, they experience an increasing incidence of two major health problems, osteoporosis and cardiovascular disease (Scharbo-Dehan, 1996). Many studies have shown that HRT may prevent these major chronic diseases (Postmenopausal Estrogen/Progestin Intervention (PEPI) Trial, 1995; Schneider et al., 1997; Colet al., 1997). The studies reviewed showed significant benefits from the use of estrogen as a protective agent and treatment against osteoporosis. Newton et al., (1997) reports that osteoporosis prevention was cited as the second most frequent reason for 11 initiating HRT. HRT has been proven to help older women avoid the devastating effects of osteoporosis by increasing bone mineral density (Schneider et al., 1997; PEPI Trial, 1995; Col et al., 1997). A fifty year old woman has a 15% lifetime probability of suffering a hip fracture and a 1.5% probability of dying of a hip fracture (Grady et al., 1992). According to Grady et al. (1992), HRT reduces the risk for hip fracture in postmenopausal women by about 25%. Schneider et al., (1997) found that HRT initiated in the menopausal period and continued into late life is associated with the highest bone density. Even when begun after age sixty similar bone-conserving benefits are noted. Orwoll, Bauer & Vogt (1996) found that the beneficial effects of estrogen are not permanent, and that use of estrogen for a few years around menopause does very little to prevent osteoporotic fractures in women when they reach 75 to 80 years of age. Estrogen has been shown to reduce key cardiovascular risk factors in women (PEPI Trial, 1995). Cardiovascular disease, especially coronary artery disease (CAD), is the most important cause of mortality in postmenopausal women (Langer & Barrett-Conner, 1994). One out of every two women will develop heart disease (Grady et al., 1992) and 233,000 women will die annually from coronary heart disease (U.S. Dept, of Health and Human Services, 1991). Numerous studies conclude that post menopausal women taking HRT are at decreased risk for cardiovascular disease compared to other women as a result of the cardioprotective effects of estrogen on CAD (Langer & Barrett-Conner, 1990; Stampfer et al., 1991; Grady et al., 1992). 12 Oral estrogen with or without progesterone has been shown to reduce low-density lipoprotein cholesterol and raise high-density lipoprotein cholesterol, lower fibrinogen levels (Pike, Henderson, Mack, Lobo & Ross, 1989; PEPI Trial, 1995), lower blood pressure and decrease blood glucose (Langer et al., 1990; PEPI Trial, 1995), all known cardiac risk factors. Estrogen has been shown to have a direct effect on the myocardium and coronary artery wall by altering prostaglandin and prostacyclin, enhancing coronary artery vasodilation (Wild, 1996). In a prospective study of 48,470 women, it was observed that when current postmenopausal estrogen users were compared with women who had never used estrogen, they had about half the risk of major coronary disease (Stampfer et al., 1991). Paganini-Hill (1995) reviewed the results of nineteen studies and found current estrogen users had one third the risk of fatal stroke (Paganini-Hill, 1995). However, it is important to note that nearly all these studies tested the effect of oral conjugated equine estrogens without progestin. It was thought that the use of progestins may reduce the beneficial effects of estrogen on cardiovascular risk factors (Langer et al., 1990), but the Post Menopausal Estrogen/Progestin Intervention Trial or PEPI (1995) showed this to be invalid. The PEPI trial which was conducted over a three year period compared various hormone replacement regimens, and found estrogen taken alone or with progesterone cut the risk of heart disease and myocardial infarction by 50%. Triglyceride levels increased significantly with the administration of oral 13 estrogen replacement (PEPI Trial, 1995), but this effect is somewhat mitigated by a progestin (Thomeycroft, 1995; PEPI Trial, 1995). Grady et al., (1992) proposes that HRT should be recommended to all women with CAD and may be especially protective in women with traditional cardiovascular risk factors, such as smoking, hypertension, previous stroke or MI, and age. According to the Lipid Research Clinics study, cigarette smokers had a lower risk of fatal CAD when they also used estrogen, although nonsmoking women who used estrogen had the lowest risk (Langer & Barrett-Conner, 1994). Grady et al. (1992) concurs that women who have CAD, or two or more heart disease risk factors could expect to extend their life on the average of 2.1 years if treated with estrogen. Alzheimer’s disease claims about 14,000 women each year (Kawas et al., 1997). New prospective studies show that HRT was associated with more than a 50% reduction in the risk of developing Alzheimer’s disease (Kawas et al., 1997), and retards the likelihood and severity of the disease (Paganini-Hill & Henderson, 1994). Tang et al., (1996) found that the age at onset of Alzheimer’s disease was significantly later in women who had begun taking estrogen at menopause, than in those who did not, and the relative risk of the disease was significantly reduced. Attempts to link depression to menopause has been inconclusive and unsuccessful. Sherwin (1996) found that administration of estrogen and androgen may be beneficial in the treatment of depression that occurs around the time of menopause. Sherwin (1996) and Paganini-Hill & Henderson (1994) found significant 14 improvement in short term memory in postmenopausal women treated appropriately with estrogen. A more recent study by Hogervorst, Boshuisen, Riedel, Willeken & Jolies (1999) showed no positive effects of HRT use on subjective feelings of well being (sleep, physical and psychological complaints), or memory. Sherwin (1996) found that some women who have undergone bilateral oophorectomy may benefit in their sense of well-being and libido by the regular addition of androgen to estrogen therapy. Further studies are needed regarding estrogen and cognitive function. Several studies have examined the relationship between tooth loss and HRT. According to Norderyd, Grossi & Machtei (1993), Grodstein & Stampfer (1994), and Paganini-Hill (1995) who reviewed the Leisure World Cohort Study, the use of HRT significantly lowered the rate of edentia and tooth loss, and the need for dentures. Studies by Calle (1995), and Newcomb & Storer ( 1995) analysed the relationship between fatal colon cancer and use of HRT among women and concluded that long-term users and current users had a substantially decreased risk of fatal colon cancer. Given the limited number of studies further investigation is merited. Negative effects of HRT. As with most therapies, HRT is not without risks. HRT preparations can produce adverse effects such as nausea, GI upset, breast tenderness, headache, weight gain, fluid retention, exacerbation of both fibroids and existing endometriosis, premenopause-like symptoms, and hypertension (ScharboDehaan, 1996). The use of a progestin in combination with estrogen therapy is associated with unpleasant adverse effects such as bloating, weight gam, anxiety, 15 irritability, and depression, and a PMS-like syndrome (Scharbo-Dehaan, 1996). According to Hammond (1997) a common reason for women to decline HRT is reluctance to experience reactivation of uterine bleeding which results with cyclic use of progestins. Newer regimens of administrration of estrogen and progestin continuously, as opposed to cyclically, or on a 3-month sequential regimen eliminates the monthly withdrawal bleeding, however most women experience irregular spotting for the first six months (Scharbo-Dehaan, 1996). The risk of breast cancer has been studied intensively and despite numerous observational studies the association is not clear (Stanford et al., 1995; Colditz et al., 1995). Estrogens role as a tumor promotor in reproductive cancers and some breast cancers has suggested that a personal history or even family history containing breast cancer contraindicates estrogen use (Scharbo-Dehaan, 1996). The addition of progestin to estrogen therapy has been increasing among women in the United States during the past decade, but data on the effects of combination therapy is limited, and controversial (Stanford et al., 1995). An initial report by Gambrell, Maier, & Sanders (1983) suggests that combination therapy has a protective effect against breast cancer. Similar findings by Palmer, Rosenberg, Clarke, Miller & Shapiro (1991) who analyzed data obtained from the Toronto Breast Cancer Study, found no increased risk in association with combined therapy. A population­ based case-control study by Stanford et al., (1995) analysed 492 middle-aged women without a history of breast cancer, and 537 patients with primary breast cancer and 16 found similar results that there was no overall association between breast cancer risk and the use of either estrogen alone or estrogen with progestin hormone replacement regimens. A more recent study by DiSaia et al., (1996) compared 41 breast cancer survivors receiving HRT after completing breast cancer treatment to 82 breast cancer survivors not receiving HRT and found that women who survived breast cancer may not have an increased risk of reocurrence with subsequent HRT. According to Kaufman, Palmer, & de Mouzon (1991), and Yang et al., (1992) the use of combined therapy increased the risk of breast cancer. Similar findings were reported by Colditz et al., (1995) based on the Nurses’ Health Study which followed 121,700 registered nurses from 1976 to 1992. Colditz et al., (1995) found an elevated risk of invasive breast cancer among postmenopausal women who were currently taking estrogen alone (relative risk 1.32) or both estrogen and progestin (relative risk 1.41). The increase in risk was most pronounced among women over the age of fifty - five and was largely limited to the women who had used HRT for five or more years. Studies related to hormone replacement’s effects on the development of breast cancer are inconsistent. According to Stanford et al. (1995) future investigations must assess whether breast cancer incidence is altered many years after estrogen-progestin HRT has been initiated, particularly among long-term users. According to Colditz et al., (1995) women over fifty-five years of age should carefully consider the risks and benefits of HRT, especially if they have used estrogen for five or more years. 17 Prolonged estrogen therapy unopposed by progestin causes hyperplasia of the endometrium in women with intact uteruses and is associated with a fourfold to sixfold increase in endometrial cancer (Gambrell, 1986). The risk of endometrial cancer is substantially mitigated, though not wholly abolished, by addition of progestins (Beresford, Weiss, Voigt & McKnight, 1997). According to Fraenkel et al., (1998) HRT with estrogen alone may increase a woman’s risk of Raynaud syndrome. Four hundred ninety- seven postmenopausal women participating in the Framingham Offspring Study who used estrogen alone were 2.5 times more likely to experience symptoms of Raynaud syndrome compared to women who were not using hormone therapy. Women who took estrogen and progesterone had the same risk as non-users. Osteoarthritis of the knee has been associated with the use of hormone therapy according to Sandmark, Hogstedt, Lewold, & Vingard (1999). According to Sandmark et al., (1999) women taking HRT after age fifty have twice the risk of knee joint disease. Several studies report evidence for an association between postmenopausal hormone therapy and venous thromboembolic events (Grady, Hulley & Furberg, 1997; Daly et al., 1996; Grodstein, Stampfer & Goldhaber, 1996). The Heart and Estrogen-Progestin Replacement Study (HERS) was designed to test the effect of HRT on the rate of new coronary heart disease events in 2763 postmenopausal women younger than eighty years who had preexisting CAD and an intact uterus. 18 With more than three quarters of follow-up completed, findings are showing an mcreased relative risk of venous thromboembolic event among HERS participants taking HRT compared with those taking placebo (Grady et al., 1997). This is consistent with the findings of several other studies that found that the risk of venous thromboembolic events among current users of hormone replacement therapy was 2 to 3.6 times higher than the risk among non-users (Daly et al., 1996 ; Grodstein et al., 1996). Barriers to HRT A barrier as defined by this researcher is an obstacle that obstructs or influences a woman’s decision regarding HRT use. Whether the identification of potential barriers to estrogen use can improve usage and compliance to estrogen therapy among women remains an important question. Several studies have researched and identified variables that act as barriers and these will be discussed. Demographic Factors Several studies support the hypothesis that HRT use is associated with sociodemographic factors (Stafford et al., 1997; Brett & Madans, 1997; Keating, Cleary, Rossi, Zaslavsky & Ayanian, 1999). Stafford et al. (1997) surveyed 6,341 women older than 40 years of age and found that HRT was more common among women who were white, had menopausal features, were 50 to 59 years old, had increased utilization of health maintenance screening, history of high cholesterol or osteoporosis, and lived in the western United States. Brett & Madans, (1997) examined trends in HRT use and obtained similar data from the 19 Epidemiologic Follow-up Study, a nationally representative cohort followed from the mid- 1970s until 1992. He concluded that a higher probability of HRT use was found among women who were white, who were more highly educated, and who lived in the West, or who had experienced a surgical menopause. According to Cauley, Cummings, Black, Basioli & Seeley (1995) a woman with a personal or family history of osteoporosis were likely to view HRT as beneficial. Lack of Knowledge Lack of knowledge about menopause and the lack of an informed decision-making process are factors that lead to the limited use of HRT (Rabin, 1998). According to Hunskaar & Backe (1992) and Roberts (1991) women desire information on estrogen therapy but much of the information they receive is conflicting; coming from media sources, books, magazines, and other women. Many women still recall the strong negative publicity estrogen received in the 1970’s (Rabin, 1998) and question the treatments value (Barrett-Connor, 1995; Hunter, O’Dea & Britten, 1997). Lydakis, Kerr, Hutchings & Lip (1998) surveyed 180 women to investigate knowledge of HRT and found that of the 152 women that responded seventy-one (47%) of the women had heard of HRT. Awareness of HRT was found to be higher in the 50-59 year age group. The women ranked their overall understanding of HRT as low; seventy-eight percent felt they did not know enough about the subject. The most important source of information about HRT was the woman’s physician with friends and relatives a close second (Griffith, 1995; Lydakis et al., 1998). 20 Utian & Schiff (1994) report that 56% of women aged 45 to 60 years were dissatisfied with the information they received from their physicians. Less than one in three of the women surveyed according to Andrews (1995) was satisfied with the information provided by her physician. According to Utian et al. (1994) physicians are more likely to discuss the short-term effects of hormone therapy, such as reduced hot flushes, than to give information regarding long-term health risks. Karokoc & Erenus (1998) evaluated 437 Turkish women who were postmenopausal and found that the women who were educated about the long-term benefits of HRT had a higher incidence of beginning HRT. According to a Harris survey of working women of menopausal age, only one half were able to name any long-term health concerns associated with the postmenopausal years (Utian et al., 1994). Of those who could, twenty seven percent named osteoporosis and only six percent mentioned heart disease. Similar data supporting this is reported by Salamone et al. (1996). A total of 7667 women who participated in the Multicenter Study of Osteoporotic Fractures was asked to complete a detailed estrogen therapy questionnaire. Of the 1335 subjects who were current users only 33.6% reported prevention and treatment of osteoporosis as a primary reason for initiating therapy and only 1.5% of the current users reported the prevention of heart disease as a principal reason for initiating HRT. Similar findings regarding cardiovascular disease prevention was cited by Newton et al. (1997). Only 15% of the 460 women who were current users cited cardiovascular disease prevention as a reason for taking HRT. 21 Similar data was published by Andrews (1995) in which a slim majority of the women questioned knew about osteoporosis, and only one in forty knew about an increased risk of heart disease. Women’s Concerns. Women’s attidudes and concerns can be potential barriers to HRT use and may lead to the common dilemma of lack of compliance (Gass et al., 1997). Many studies have sought to describe women’s reasons for discontinuing, and or refusing HRT (Logothetis, 1991; Ryan , Harrison, Blake & Fogelman, 1992; Griffith, 1995; Gass et al., 1997; Hunter et al., 1997; Newton et al., 1997 & Rabin, 1998). Ryan et al. (1992) evaluated HRT compliance using 352 postmenopausal women aged 40-69 years. Those who rejected advice to take HRT had concern regarding side effects or the effectiveness or safety of treatment. Of the women who started HRT 28% subsequently stopped, the principal reasons being withdrawal bleeding and weight gain. Of the women recommended to take HRT, 39% were not taking treatment by eight months after referral, either because they ignored advice given (22%), or because of side effects (17%). Similar findings were documented by Groeneveld et al. (1998) who reported of the 103 Dutch women prescribed HRT, the mean duration of use was seven months, and only 8% of the women remained on HRT for more than two years. According to Gass et al. (1997) and Hunter et al. (1997) the reasons cited most often for not taking or discontinuing HRT were concerns about safety, unacceptable side effects (bloating and weight gam), problems with bleeding and breast symptoms. 22 Rabin (1998) sought to answer the question of why women are reluctant to take HRT. Of the 105 menopausal women that completed the questionnaire, sixteen were currently taking HRT. The 89 menopausal women who were not taking HRT responded to a checklist of potential reasons for not taking HRT (Rabin, 1998). Fear was the reason most commonly noted for not taking HRT, cited by 43% of respondents. Thirty -eight percent of the women reported that they no longer experienced menopausal symptoms and 32% said they had never experienced them. Thirty-eight percent of the women said HRT was never offered to them by their physician. Provider-Patient Communication. According to Kaufert & Gilbert (1986) women desire information about menopause and HRT but are reluctant to discuss these issues with their PCP. A study by Schnebly, Hibbard, Hampson, & Harvey (1993) studied women’s experiences and attitudes concerning menopause and found that one-third of the well-educated white participants who were experiencing significant discomfort from menopausal symptoms never discussed them with their PCP. Ziegler (1992) reports that as few as 10-15% of women are seriously affected by the menopausal transition, so many may not see the need to discuss menopause management and possible HRT use with their providers. According to Ferguson et al. (1989) the most important person involved in a women’s decision regarding HRT use was her PCP. Of the 125 women who had never taken HRT, 64% had never discussed HRT with their physician. When asked if 23 a physician s recommendation would have a positive effect regarding HRT use 75% agreed. According to Hampson et al. (1996), there is evidence that women are dissatisfied with the care they receive for menopause. They report receiving inadequate information and feel that their providers do not listen to them (Kaufert et al., 1986). Communication skills in older women has been identified as a barrier to HRT use (Hampson et al., 1996). According to Hibbard & Weeks (1987), older women are less skillful at successfully negotiating the medical encounter than are younger patients. Rost & Frankel (1993) focused on older patients in a general clinic and reported that 27% of patient problems were never discussed during the medical visits. Over half of all patients had at least one important medical problem that was never raised. Ferguson et al. (1989) concluded that simple communication between a woman and her PCP could significantly alter HRT use. Incongruent Agendas. PCP’s generally view menopause as a hormone deficiency disease requiring treatment by HRT (Prior, 1994). Many women on the other hand see menopause as a natural aging process (Prior, 1994). Hunter et al. (1997) surveyed 45 year old women regarding future intentions about possible HRT use, and reported the main reasons given for not intending to take HRT were a general preference not to take medication, and a belief that treatment of the menopause is unnatural or not necessary. Newton et al. (1997) reports similar findings. Three hundred ninety six women aged 50-80 who reported never taking HRT were 24 surveyed. The most frequently cited reasons for never using HRT were that hormones were not needed (49.9%), and that menopause was viewed as a natural event for which medications were unnecessary (17.9%). According to Hibbard & Hampson (1993) women and doctors may have different agendas in consultations about HRT and menopause. Women are primarily concerned with short-term symptoms whereas providers are primarily concerned with long-term health risks and mitigating the risks of life-threatening diseases such as osteoporosis and cardiovascular disease (Robert, 1991). The fact that as few as 10-15% of women are estimated to be seriously affected by menopausal symptoms, and a few have no symptoms at all (Ziegler, 1992) is consistent with contributing to incongruent agendas. According to Logothetis (1991) the majority of these women may never seek medical care because they do not perceive a threat to their health, and consequently many may avoid discussing menopause managment and possible HRT use with their providers. These women are less likely to use HRT than those who seek out medical help for menopausal symptoms. Type of PCP. Hall, Irish, Roter, Ehrlich & Miller (1994) identifies that barriers to communication exist between male physicians and their patients. An analysis of audiotaped medical encounters indicated that male physicians engaged in less partnership-building, positive talk, and question- asking compared to female physicians. Although these encounters were not menopause related, their findings 25 according to Hall et al. (1994) reflect women’s complaints about medical encounters regarding menopause management. Roter, Lipkin & Korsgaard (1991) found that male physicians also provide less information to their HRTpatients. The study found that women physicians are more attentive and nondirective, giving more subjective and objective information to patients (Meeuwesen, Schaap & Van der Staak, 1991). According to Ferguson et al. (1989) women who received care from gynecologists were much more likely to be on a HRT regimen than those who received care from other practitioners. He found that of the women from his study who were currently taking HRT, 24% usually saw a family practitioner, 19% saw an internist, and 57% saw a gynecologist. Those not taking HRT were more likely to see a family practitioner. Similar findings were reported by Stafford et al. (1997). According to an analysis of a nationally representative sample of 6,341 women over 40 years old who visited physicians’ offices, only 6.5% of the women under the care of an internist took HRT, compared to 23.1% of women who saw a gynecologist. This suggests that educational efforts need to be directed at other specialists to encourage use of HRT, and to educate their patients about its benefits. Summary The literature review presented a detailed synopsis of the positive and negative effects of HRT currently found in the literature. The decision to use or not use HRT remains a complex issue which may be complicated further if the woman s decision is influenced by variables that act as barriers. The review of literature 26 identified the barriers as demographic factors, lack of knowledge, women’s concerns, communication, incongruent agendas, and type of PCP. Each variable was discussed according to findings in previous literature. 27 Chapter ITT Research Methodology This chapter describes the methodology utilized to identify the variables that act as barriers to HRT use. Included in this chapter are the operational definitions, research design, sample and setting, informed consent procedure, instrumentation utilized to gather the data, and the data analysis. Purpose The purpose of this study is to identify the variables that act as barriers to HRT use among menopausal and postmenopausal women. Operational Definition Barriers are obstacles that obstruct or influence a woman’s decision regarding HRT use. The barriers as defined annd measured within this study were: 1. Demographic factors which included age, ethnicity, education level, personal/family history of major diseases that are impacted by HRT, and a history of a hysterectomy. 2. Knowledge level was measured according to how each participant answered questions eleven, and fourteen on the questionaire. If a participant identified a reason for HRT use in question 14 she was considered knowlegeable about that component. General knowledge was further assessed by comparing the responses of current users versus nonusers. 28 3. Women’s concerns were identified by selection and self reporting of concerns listed in question nineteen of the questionaire. The participant was said to have the specific concern if it was selected. 4. Patient-provider communication was measured according to how each participant answered question 12 which asks where participants receive their information about HRT. 5. Incongruent agenda is a term used in this study to describe the physician’s viewpoint of menopause as a medical condition requiring medication, as compared to the woman’s view of menopause as a natural physiologic process. The agenda of the participant disagreed with the physician’s agenda if the participant selected the component in question 19 that confirmed that she viewed menopause as a natural process. 6. Type of PCP was defined as male or female, internist, family or general practice physician, gynecologist, or nurse practitioner. Research Design This study utilized a nonexperimental descriptive research design. Data was collected by administering a questionaire (Appendix A) consisting of nineteen multiple choice questions. The goal of this study was to gather information regarding menopausal women’s knowledge and attidudes regarding HRT and their health practices, and to identify variables that may act as barriers to HRT use. 29 Sample The targeted convenience sample consisted of seventy-eight menopausal and postmenopausal women from the northwestern region of Pennsylvania. The researcher-designed questionaire was administered to residents of a senior citizen retirement facility, and to members of a garden club both located in Erie, Pennsylvania. Informed Consent A written introduction (Appendix B) accompanied the survey to enhance the subjects’ understanding of the study and to convey anonymity and confidentiality. It asked that no names be placed on the survey. Participation was voluntary and consent was assumed with the return of the completed survey. The written introduction provided details on how to request the results of the study. Instrumentation A questionaire (Appendix A) consisting of nineteen multiple choice questions was utilized to evaluate women’s health practices and knowledge and attitudes regarding HRT use. The research tool was constructed by the researcher after a review of the literature, and was developed from instruments used by Ferguson et al. (1989), Logothetis (1991), Gass et al. (1997), Newton et al. (1997) and Rabin (1998). The first question was designed to ascertain that participants met the criteria for inclusion in the study. Basic demographic information including ethnicity and level of education was obtained along with menopausal status, surgical versus natural 30 menopause, present health care practices, and family or personal health history. Questions 11 through 17 assessed the subjects knowledge of HRT and current status regarding HRT use. Question 18 asked those subjects that were currently using HRT to indicate their reasons for taking HRT. Choices included hot flashes, vaginal dryness, inability to sleep, depression, anxiety and/or emotional distress, hysterectomy history, doctor advised, as well as protection from osteoporosis and cardiovascular disease. Space to wnte in other reasons was provided. No limitation was placed on the number of choices an individual might select. Question 19 asked the participants not currently on HRT the reasons for their choice. The subjects could select as many reasons as they thought applied and were given space to write in additional reasons. Pilot Study A pilot study was conducted on a group of five women employed in an urban public school setting who ranged in age from 54 to 62. The participants were informed that they would not be a part of the actual study, and the data collected would not be used in the study. The participants, upon completion of the survey, were asked to provide the researcher with suggestions regarding readability, clarity, and length of time to complete. All participants in the pilot study completed the questionnaire in less than 5 minutes, and there were no recommendations for clarification of the items. 31 Data Analysis Analysis of the data was performed using the Statistical Products and Service Solutions Incorporated (SPSS, 1996). The data was analysed using descriptive statistics and compilation of total percentages. Percentage of responses by user versus nonuser was determined for each question. Summary The purpose of the chapter was to describe the methodology used in this nonexperimental research design. Operationalized definitions were provided for barriers, demographics, knowledge, women’s concerns, communication, incongruent agenda, and type of provider. A convenience sample of 78 menopausal and postmenopausal women were surveyed utilizing a questionaire consisting of 19 multiple choice questions. A pilot study of five women tested the clarity of the questions on the tool. Data analysis consisted of comparing current users of HRT to nonusers according to the percentage of each group that responded to each question on the tool. 32 Chapter IV Results Research has affirmed that the benefits of HRT outweigh the risks, yet one half of all eligible menopausal women are not using HRT (Brett & Madans, 1997). In order to help women make informed choices about HRT, health care providers must understand not only the knowledge base of their patients, but identify the barriers to its use. This descriptive study was undertaken to identify and explore the variables that influence HRT use. The variables identified are demographic factors, knowledge level, women’s concerns, communication between patient and provider, incongruent agendas, and type of PCP. The results of the study are presented in this chapter and tables are used to compare users of HRT to nonusers of HRT. Description of the Participant A convenience sample was recruited from two distinct groups. A total of 30 women were present at a garden club meeting and all were given packets. Of the 30 questionnaires, all were returned. A total of 60 questionnaires were given to the director of recreation and activities at a senior citizen residential center. The director distributed the packets to residents participating in a knitting and sewing group. Of the 60 questionnaires, 51 were collected and returned. Three surveys were discarded because they were incomplete leaving a total of 78 participants in the sample. Ninety-four percent of the participants sampled were white, 5% black, and 1% other. Six (8%) of the participants had less than a high school education, 27 33 (35%) achieved a high school education, 16 (21%) some college 14 (18%) coUege degree, and 15 (19%) masters level of education. Menopausal status was assessed and reported as 5 (6%) premenopausal, 21 (27%) experiencing menopause, 49 (63%) postmenopausal, and 4 (5%) unsure Forty-six (59%) of the women surveyed reported that HRT had been prescribed for them. Only 30 (38%) reported currently taking HRT. Twenty-one (66%) of the current users have been on the treatment for more than two years. Forty-eight (61%) of the participants were classified as nonusers. Hysterectomy was not associated with current use. Participants were asked to identify personal or family history of major diseases that are impacted by HRT (Table 1). Of note is that 60% of women with a personal or family history of heart disease and 56% of those with a personal or family history of osteoporosis are nonusers. Demographics Barriers Demographic characteristics of the participants by estrogen use status are shown in Table 2. In general, current HRT users were found to be between the age of 50-59, white, and highly educated. Sixty-seven percent of the current users had at least some college or more, while only 51% of nonusers did. Prevalence of HRT use declined with age. Due to the fact that there was an inadequate minority sample population, the statistics are skewed to the white population. It is interesting to note that 20 (42%) of the nonusers had a history of hysterectomy. 34 Table 1 Personal/Family Medical History and Use of HRT HRT Status Disease Group User Nonuser n=30 (38%) n=48(61%) High Cholesterol (n = 31) 11(35%) 20 (65%) Heart Disease (n = 42) 17 (40%) 25 (60%) Osteoporosis (n =18) 8 (44%) 10 (56%) Diabetes (n = 26) 9 (35%) 17 (65%) Obesity (n = 13) 5 (38%) 8 (62%) Smoke (n =16) 8 (50%) 8 (50%) Knowledge Barrier Participants were asked if they knew what HRT was. Sixty-seven (86%) answered yes, and 11 (14%) were not sure or did not know. HRT awareness was found to be highest in the 40-49 year age group. The least knowledgeable group was women 80 years or older. Fifty-six (72%) of the participants reported obtaining HRT information from a physician, 33 (42%) books/magazines, 16 (21%) television, 11 (14%) friend/ relative, and 5 (6%) other. Two of the respondents marked other. One subject responded that coworkers were her source of information, and the other was aware because she was a nurse. 35 Table 2 Demographic Characteristics By Self Reported Use Of HRT HRT Status Characteristic User Nonuser n = 30 (38%) n = 48(61%) Ages (years) (%) 40-49 2(7%) 5 (10%) 50-59 20 (67%) 15 (31%) 60-69 5 (17%) 15(31%) 70-79 1 (3%) 9 (19%) 80 or older 2(7%) 4 (8%) White race (%) 29 (40%) 44 (60%) Black race (%) 1 (25%) 4 (75%) Less than high school 0(0%) 6 (13%) High school graduate 10 (33%) 17 (35%) Some college 5 (17%) 11 (22%) College graduate 6 (20%) 8 (17%) Masters level 9 (30%) 6 (12%) 10 (33%) 20(42%) Education (%) Hysterectomy 36 General knowledge was further assessed by comparing current users versus nonusers to their responses to the question “ What are the reasons for using HRT?” (Table 3). Each responder was instructed to check all that apply. Ten nonusers did Table 3 Percentage Who Answered the Question; What Are The Reasons For Using HRT? HRT Status User Nonuser Reasons for Using HRT n =30 (36%) n=48(61%) Hot Flashes 21 (70%) 31 (65%) Vaginal dryness 18 (60%) 25 (52%) Inability to sleep 13 (43%) 14 (29%) Depression, anxiety, emotional distress 10 (33%) 19 (40%) Osteoporosis prevention 20 (67%) 26 (54%) Cardiovascular disease prevention 17 (57%) 18 (38%) After a hysterectomy 17 (57%) 28 (58%) 6 (20%) 5 (10%) 23 (77%) 19 (40%) Prevent or alter alzheimers progression Doctor advised note: Total number of responses could be greater than 78 as participants could c more than one answer. not indicate a response to any of these reasons. The assumption can be made. 37 therefore, that these ten nonusers had a lack of knowledge regarding the reasons for HRT use. Doctor advised (77%), hot flashes (70%) and osteoporosis prevention were cited by current users as the primary reasons for using HRT. Nonusers cited hot flashes (65%), after a hysterectomy (58%) and osteoporosis prevention as the primary reasons. Fifty -seven percent of current users identified cardiovascular prevention as a reason for HRT compared to 39% of nonusers. Both groups demonstrated a knowledge deficit regarding prevention of alzheimers. Current users and nonusers were knowledgeable regarding HRT use in prevention of early symptoms of estrogen deficiency and osteporosis. The majority of current HRT users were also aware of cardiovascular disease prevention as a reason for HRT. Women’s Concerns as a Barrier The concerns a woman may have regarding HRT can be potential barriers to its use and can lead to the common dilemma of lack of compliance. The study identified 48 (61%) participants who were characterized as nonusers. The participants were asked why they were not taking HRT (Table 4). The most frequently cited reasons for not using HRT were “did not want to” (35%), “fear of cancer” (31%), “unsure of safety” (29%), and “were not menopausal” (25%). The researcher questioned the high percentage of women that responded that they they were not menopausal. Upon further analysis it was found that 8 out of the 12 women 38 Table 4 Womens Concerns as a Primary Barrier. Nonuser 48 (61%) Response n(%) I am not menopausal 12 (25%) I no longer have menopausal symptoms 10(21%) I did not like having a period again 5 (10%) I did not like the bloating and weight gain 5 (10%) I am concerned about its safety 14(29%) Fear of cancer 15(31%) I never had menopausal symptoms 3 (6%) My doctor never discussed HRT with me 6(13%) I do not understand the benefits of HRT 2 (4%) I am afraid to use HRT 5 (10%) I do not want to take HRT 17 (35%) I have a medical problem. My physician says I can’t take it 6(13%) Other 6(13%) Note: Total number of responses could be greater than 48 as participants could choose more than one answer. HRT is Hormone Replacement Therapy. 39 were sixty or older possibly representing a knowledge deficit regarding menopause and its meaning. Seventeen (35%) women who responded that they did not want to take HRT cited these reasons for their decision: family history of cancer, no need for it, not interested, hot flashes aren’t bad, mother and siblings did not take it, preferred natural methods, and don’t like to take medication. Compliance with HRT was not measured in this study but it is of interest that of the 46 (59%) women who reported that HRT had been prescribed for them, only 30 (38%) reported currently taking HRT. Sixteen women chose not to follow doctor recommendations. The most frequently cited reasons for not wanting to take HRT by this group were “fear of cancer” (50%), “did not want to take HRT” (44%), and “concern about safety” (38%). Communication Barrier Seventy two percent of the women in this study reported obtaining HRT information from a physician. Seventy percent of current users responded that their doctor advised them to take HRT. Of the 48 women who had never taken HRT, only 6 (13%) reported that their PCP never discussed HRT and 2 (4%) reported that they did not understand the benefits of HRT. Fifty-six percent of the total participants reported they were dissatisfied with the information provided by their PCP. 40 Incongruent Agendas as a Barrier Women and PCP’s do not always agree about the management of menopause because of a difference in how they view menopause. This study demonstrated that 5 (10%) of the nonusers viewed menopause as a natural aging process for which prescription medication was not necessary. Two of these women reported taking natural supplements. Type of PCP as a Barrier The majority of women in this study viewed preventative health care as important. Eighty-two percent of the participants had a yearly breast exam, and 76% had a yearly pelvic exam. Thirty six (46%) of the women received care from a female PCP and 42 (53%) from a male PCP. The majority of participants recieved women’s health care from physicians: 2 (3%) from an internist, 22 (28%) from a family or general practice physician, 51 (65%) from a gynecologist, and 3 (4%) from a nurse practitioner. Table 5 presents the type of PCP and their prescribing practice. There were no women under the care of an internist taking HRT. Four (13%) of the current users were under the care of a family physician and 24 (80%) current users were receiving health care from a gynecologist. Of the women receiving care from a nurse practitioner, 2 (66%) out of the 3 were receiving HRT. Women who receive care from a nurse practitioner were more likely to be on an HRT regimen than those who 41 received care from other practitioners, and the majority of women who were currently taking HRT were seeing a gynecologist. Fifty-six (72%) of women in this study report obtaining information Table 5 Prescribing Practice of Physicians HRT Status User Nonuser n = 30 (38%) n = 48 (61%) Family practice 4(13%) 18(38%) Internist 0 (0%) 2 (4%) 24 (80%) 27 (56%) 2(7%) 1 (2%) Type of Physician Gynecologist Nurse Practitioner regarding HRT from a physician. A comparison was made to determine if there was a significant difference in the amount and content of knowlege received from a female PCP versus a male PCP (Table 6). According to the results, the information provided by male and female physicians regarding reasons for HRT use is similar in all categories except prevention of alzheimers. Prevention of alzheimers was identified as a considerable knowledge deficit that is apparently not being addressed by either male or female physicians. The data shows that of the 30 users, sixteen (53%) follow with a male 42 physician and 14 (47%) with a female physician. Seventy-nine percent of the participants with a female physician reported that a doctor advising use is a significant reason to take HRT, compared to 39% of those with male physicians. Table 6 Women’s Knowledge and Physician Gender Type of Physician Female Male Reasons for Using HRT n = 29(37%) Hot Flushes 21(72%) 31(80%) Vaginal Dryness 19(66%) 24(62%) Inability to Sleep 13(45%) 14(36%) Depression, anxiety 15(52%) 14(36%) Osteoporosis prevention 18(62%) 28(72%) Cardiovascular disease prevention 15(52%) 20(51%) After a Hysterectomy 20(69%) 25(64%) Prevent Alzheimers Progression 6(21%) 5(13%) Doctor Advised 23(79%) 19(49%) n = 39 (50%) n - number of women receiving care from a male or female physician who responded to the question asking reasons for using HRT. 43 Summary According to Logothetis (1991) barriers may influence a woman’s attitude and decision regarding HRT use. This study attempted to identify the barriers that affect women’s decision regarding use. The barriers discussed were demographic factors, knowledge level, women’s concerns, communication, agenda, and type of PCP. The women in this study were generally well educated and valued yearly health maintenance screening, yet over half (61%) of these women were nonusers. A personal history of hysterectomy or personal/family history for which HRT is beneficial was not associated with HRT use. Prevalence of HRT use declined with Knowledge level for the majority of participants was found to be similar. Physicians are discussing the short-term and long-term effects of HRT, although prevention of alzheimers disease was identified as a considerable knowledge deficit. Women’s concerns were identified. The primary reasons for not wanting to take HRT were fear of cancer, lack of desire, safety concerns, and no longer menopausal. Communication between the PCP and participant was measured by how each woman answered the question “from where did you receive HRT information’. The majority of women in the study reported obtaining HRT information from a physician, yet about half the respondents reported being dissatisfied with the information received. 44 The majority of current users reported seeing a gynecologist. According to the findings there was no significant difference in the amount and content of knowledge received from a female PCP versus a male PCP and neither male nor female physicians are discussing the benefit of prevention of Alzheimers disease. 45 Chapter V Discussion and Recommendations This study was undertaken to identify the barriers that may influence a woman’s decision to use HRT. Barriers according to the Health Belief Model are an instrumental component in the decison-making process and have the potential to inadvertently influence a woman’s choice regarding HRT. The PCP has the opportunity and obligation to provide the latest researched findings regarding the benefits and risks of HRT, and must take the time to identify and address the issues that may interfere or prevent a woman from considering HRT. Only when these variables are thoroughly examined and discussed will the woman be capable of an educated informed decision. Discussion The results of this study will be disussed and compared to the findings in the literature. The authors conclusions and recommendation are presented. Demographics Forty (52%) of the eligible women in this study are not taking HRT, a finding similar to the literature reported by Brett & Madans et al. (1997). The participants were generally well educated. Fifty-eight percent had recieived an education beyond high school. Because a small sample size was used the respondents may have been better educated than the general population. Therefore the results may indicate a higher level of knowledge than would be expected in the general population. 46 Current HRT users were white, between the age of 50-59, educated with at least some college or more, had menopausal features, and valued regular health maintenance screening. This supports the literature findings of Stafford, et al., (1997). Nonusers of HRT on the other hand were white, as equally educated, between the age of 50-69, with the majority receiving yearly health maintenance screening. According to these findings a woman’s level of education and having yearly health maintenance screenings does not appear to be a predictor of usage. A personal history of hysterectomy, or personal/family medical history for which HRT is beneficial was not associated with taking HRT. This opposed the literature review findings which reported a higher probability of HRT use with both hysterectomy and personal/family medical history. Knowledge Base According to this study women’s decisions about HRT appear to be influenced primarily by concurrent or relatively short-term issues, and by physician recommendation. The majority (72%) of the women in this study reported the PCP as her primary source of information regarding HRT which may be inherent in the high level of knowledge the participants displayed. Only 13% of nonusers reported that the PCP never discussed HRT with them. Eighty-five percent of the participants were aware of HRT. This number was significantly higher than the 47% reported by Lydakis (1998). HRT knowledge was found to be higher in the 40-49 year age group followed by women aged 50-59 which is consistent with the literature findings. The least knowledgeable group was women 80 years or older. In 47 general participants appeared to be well informed regarding benefits of HRT as illustrated by the fact that a majority of current users and nonusers cited hot flushes and osteoporosis prevention as primary reasons for using HRT. Current users and nonusers responded remarkably similar to the reasons for taking HRT in all areas except cardiovascular disease prevention, prevention of alzheimers and doctor advised. Both groups demonstrated a significant knowledge deficit in the area of prevention of alzheimers. Current users appear aware and convinced of the potential role of HRT in cardiovascular disease prevention. According to these findings physicians are discussing the short-term and long­ term effects of HRT contrary to the literature review findings. Karokoc et al. (1998) found that women who were educated about the long term benefits of HRT were more likely to be a user. This finding was validated in this study. Women’s Concerns Women’s concerns regarding HRT may impact and influence her decision regarding HRT use. The largest group represented in this study was nonusers (61%). The most frequently cited reasons for not wanting to take HRTin this study were similar to those documented by Rabin (1998) and Gass et al. (1997) and included just not wanting to take HRT, fear of cancer, safety concerns and not menopausal. Several women expressed they were not interested and just did not feel they needed it. Even though the majority of women in this study received HRT information from a physician, and have been shown to be knowledgeable regarding HRT benefits, they appear to be skeptical and unconvinced of the potential role of 48 HRT. The uncertainity expressed by the women in this study about fear of cancer, questionable safety, and just not wanting to take HRT points to a need for balanced information and the opportunity for discussion of these complex issues. All PCP’s who care for women should fully discuss the benefits and risks of HRT and address womens concerns. Provider-Patient Communication Communication is a key component in any medical encounter. Barriers may exist when communication is not effective. According to Kaufert and Gilbert (1986) women want information about menopause and HRT but are reluctant to discuss these issues with their PCP. This was not found in this study. Seventy-two percent of the women in this study reported obtainng HRT information from a physician. This indicates that the PCP plays an important role in a woman’s decision, and is discussing menopausal issues with current users. How thorough the information is being covered was not measured but it is worth noting that of the current users 67% identified osteoporosis and 57% cardiovascular prevention as reasons for using HRT. Of the 48 (61%) women who had never taken HRT, only 6 (13%) reported that they did not understand the benefits of HRT. According to this data 87% of nonusers have discussed HRT with their PCP and 85% understood the benefits. This is further supported by the above average knowledge base nonusers were found to have about HRT. 49 The literature review identified communication skills in older women as a barrier to HRT. According to Hibbard et al. (1987) older women were found to be less skillful at negotiating than younger women, which led to concerns and problems never being discussed. Special attention must be made to incorporate the older women in the HRT discussion as this was the group that was found to be least knowledgeable in this study and substantiates the finding by Hibbard et al. (1987) that communication barriers may exist in this group. The PCP must especially concentrate educational efforts on the older population of menopausal women. Provider-Patient Communication Evidence exists that when women and their PCP are not communicating adequately dissatisfaction results. Data was not collected that would enable the researcher to examine negotiating skills and patient- doctor interaction, but information was collected regarding women’s satisfation with their PCP. More than one-half of the participants reported they were dissatisfied with the information provided by their PCP. Similar findings were reported by Hampson et al. (1996) and verifies the importance of effective communication between the PCP and the patient. Improving provider-patient interactions concerning menopause management will likely increase patient satisfaction. Of great concern to the PCP is the large number of nonusers 22 (46%) who reported not using HRT because they were not menopausal or no longer had menopausal symptoms. Becker (1986) reports that women do not seek health care unless their well being is threatened. It is apparent that the women in this study value 50 preventative health care and are seeking care since the majority are receiving yearly breast and pelvic examinations. Evidence suggests that these women are either not initiating discussion regarding HRT or their physicians are not communicating adequate information. Incongruent Agendas A woman’s view of menopause and how it is managed may not agree with her PCP’s. According to Prior (1991) physicians view menopause as a condition requiring medication while women may see menopause as a natural process where treatment is unnatural or not necessary. Only 5 (10%) of the nonusers in this study viewed menopause as a natural aging process. The nonusers are congruent with the PCP’s view of menopause. The PCP and current users in this study appear to have congruent agendas. According to Hibbard et al. (1993) women are mainly concerned with alleviating short term symptoms while PCP’s value treatment for the long term duration to prevent disease. Current users and nonusers in this study cited hot flushes as one of the main reasons for using HRT which correlates with the view of treating short-term symptoms. Of interest are the findings that more than 50% of current users reported taking HRT for osteoporosis and cardiovascular prevention, and 21 (70%) have been on the treatment for more than two years, which indicates that these women value the importance of long-term use of HRT. Type of PCP The data does not support the notion that physician gender has an impact on a woman’s decision to use HRT. Analysis showed that women who 51 receive women’s health care from a gynecologist are more likely to be on HRT. This correlates with the finding by Stafford, et al. (1997) and Roter et al. (1991). Conversely, women who utilize an internist or family practice physician were less likely to be a user. This suggests that educational efforts need to be directed at other specialists to encourage them to use HRT and to educate their patients about its benefits. Of interest was the finding that women who receive care from a nurse practitioner were more likely to be on an HRT regimen then those who received care from other PCP’s. Conclusions Several demographic factors did not appear to influence HRT use. According to the findings in this study a woman’s level of education, having yearly health maintenance screenings, and a personal history of hysterectomy, or personal/family medical histoiy was not associated nor a predictor of HRT use. Physicians are discussing the short-term and long-term benefits of HRT except in the area of Alzheimers disease. Being knowledgeable and well informed about the benefits of HRT did not appear to predict HRT usage. Women’s concerns regarding HRT appear to act as barriers and influence its use. The nonusers in this study appear to be skeptical and unconvinced of the potential role of HRT even though the majority were shown to be knowledgeable about the benefits. 52 Women in this study report obtaining HRT information from a physician which indicates that physicians are communicating to their patients. Communication barriers were found to exist in woman 80 years old and older. The PCP must especially concentrate educational efforts on the older population of menopausal women as this group was found to be the least knowledgeable, and least likely to be on HRT. Of great concern to the PCP is the large number of women who were not taking HRT because they no longer had menopausal symptoms. According to the Health Belief Model health-seeking behavior is influenced by a person’s perception of a threat of illness. Women who transitioned through menopause without symptoms did not seek medical attention. The PCP as the primary care provider must engage these and all women during their yearly health maintenance exams and provide on- going education regarding menopause and its management. Recommendations The PCP has an obligation to his/her patient to thoroughly educate her regarding the benefits and risks of HRT. Existing concerns a woman might have that may act as barriers to HRT use must be identified and discussed. Only after these issues are thoroughly discussed can an informed decision be reached. 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 races. 53 2. Question # 14 on the instrument should have as one of its answers the response, “I don’t know.” 3. Question #3 on the instrument should designate type of hysterotomy. 4. Develope a tool to assess the degree to which providers and patients discuss the menopause. 5. Facilitate mechanisms that will cue physicians to initiate discussions about menopause management. This could be accomplished through automatic prompts in the records of women who reach a certain age. 6. Provide both individual and group educational programs in the primary care setting aimed at increasing women’s knowledge, efficacy in provider-patient partnership, and decision-making skills. 54 References American College of Obstetricians and Gynecologists. Hormone replacement therapy. Washington: The College: 1992. Technical Bulletin No. 166. Andrews, W. (1995) The transitional years and beyond. Obstetric Gynecology, 85, 1-5. Barrett-Conner, E. (1995). Prevalence, initiation, and continuation of hormone replacement therapy. Journal of Womens Health, 4, 143. Becker, M. (1978). The Health Belief Model and sick role behavior. Nursing Digest, 6, 35-40. Beresford, S., Weiss, N., Voigt, L., McKnight, B. (1997). Risk of endometnal cancer in relation to use of oestrogen combined with cyclic progestagen therapy in postnebopausal women. Lancet, 349, 458-61. Brett. K., Madans, J. (1997). Use of postmenopausal hormone replacement therapy: estimates from a nationally representative cohort study. American Journal of Epidemiology, 145, 536-545. Calle, E. (1995). Estrogen replacement therapy and risk of cancer in postmenopausal women. Journal of the National Cancer Institute, 87, 517-523. Cauley, J., Cummings, S., Black, D., Basioli, S., Seeley, D. (1995). Prevalence and determinants of estrogen replacement therapy in elderly women. American Journal of Obstetric Gynecology, 163, 1438. Col, N., Eckman, M., Karas, R.Pauker,S., Godberg, R., Ross, M., Orr, R., Wong, J. (1997). Patient-specific decisions about hormone feplacement therapy in postmenopausal women. Journal of the American Medical Association, 277, 11401147. Colditz, G., Hankinson, S., Hunter, D., Willett, W., Manson, J., Stampfer, M., Hennekens,C., Rosner, B., Speizer, F. (1995). The use of estrogens and 55 progestins and the risk of breast cancer in postmenopausal women. The New England Journal of Medicine, 332, 1589-1593. Daly, E., Vessey, M., Hawkins, M., Carson, J., Gough, P., Marsh, S. (1996). Risk of venous thromboembolism in users of hormone replacement therapy. Lancet, 348, 977-980. Davila, G. (1996). Managing stress incontinence without surgery. Menopause Management, 5, 15-24. DiSaia, P., Grosen, E., Kurosake, T., Gildea, M., Cowan, B., Anton-Culver, H. (1996). Hormone replacement therapy in breast concer survivors- a cohort study. American Journal of Obstetrics and Gynecology, 174, 1494-99. Ettinger, B., Friedman, G., Bush, T., Quesenberry, C. (1996). Reduced mortality associated with long-term postmenopausal estrogen therapy. Obstetric Gynecology, 87, 6-12. Ferguson, D., Hoegh, C., Johnson, S. (1989). Estrogen replacement therapy. Archives of Internal Medicine, 149, 133-136. Fraenkel, L., Zhang, Y., Chaisson, C., Evans, S., Wilson, P., Felson, D. (1998). The association of estrogen replacement therapy and the Raynaud phenomenon in postmenopausal women. Annals of Internal Medicine, 129, 208-212. Gambrell, R. (1986). Prevention of endometrial cancer with progestagens. Maturitas, 8, 159-68. Gambrell, R., Maier, R., Sanders, B. (1983). Decreased incidence of breast cancer in postmenopausal estrogen-progestogen users. Obstetrics and Gynecology, 62, 435-43. Gass, M., Rebar, R., Liu, J., Cedars, M. (1997). Characteristics of women who continue using hormone replacement therapy. Menopause, 4, 19-23. 56 Glance, W. (3rd Ed.). (1990). Mosby’s Dictionary. St. Louis, MO: The C.V. Mosby Company. Goldani von Muhlen, D., Kritz-Silverstein, D., Barrett-Connor, E. (1995). A community-based study of menopause symptoms and estrogen replacement in older women. Maturitas, 22, 71. Grady, D., Rubin, S., Petiti, D., Fox, C., Black, D., Ettinger, B., Emster, V., Cummings, S. (1992). Hormone therapy to prolong life in post menopausal women. Annals of Internal Medicine, 17, 1016-1037. Grady, D., Hulley, S., Furberg, C. (1997). Venous thromboembolic events associated with hormone replacement therapy. The Journal of the American Medical Association, 6, 477. Griffiths, F. (1995). Women’s health concerns. Is the promotion of hormone replacement therapy for prevention important to women? Family Practice, 12, 54. Grodstein, F., Stampfer, M. (1994). A prospective study of tooth loss and postmenopausal hormone use. American Journal of Epidemiology, 139, S3. Grodstein, F., Stampfer, M., Colditz, G., Willett, W., Manson, J., Joffe, M., Rosner, B., Fuchs, C., Hankinson, S., Hunter, D., Hennekens, C., Speizer, F. (1997). Postmenopausal hormone therapy and mortality. The New England Journal of Medicine, 336, 1769-1775. Grodstein, F., Stampfer, M., Goldhaber S. (1996). Prospective study of exogenous hormones and risk of pulmonary embolism in women. Lancet, 348,983- 987. Groeneveld, F., Bareman, F., Barentsen, R., Dokter, H., Drogendijk, A., Hoes, A. (1998). Duration of hormonal replacement therapy in general practice; a follow-up study. Maturitas, 29, 125-131. 57 Hall, J., Irish, J., Roter, D., Ehrlich, C., Miller, L. ( 1994). Gender in medical encounters; an analysis of physician and patient communication in a primary care setting. Health Psychology, 13, 384-392. Hammond, C. (1997). Management of Menopause. American Family Physician, 55, 1667-1677. Hampson, S., Hibbard, J. (1996). Cross-talk about the menopause: enhancing provider-patient interactions about the menopause and hormone therapy. Patient Education Counsel, 27, 177-184. Hibbard, J., Hampson, S. (1993). Evaluating women’s partnership with health providers in hormonal replacement therapy: research and practice directions. Journal of Women’s Health, 5, 17-29. Hibbard, J., Weeks, E., (1987). Consumerism in health care: Prevalence and predictors. Medical Care, 25, 1019-1032. Hogervorst, E., Boshuisen, M., Riedel, W., Willeken, C., Jolies, J.(1999). !998 Curt P. Richter Award. The effect of hormone replacement therapy on cognitive function in elderly women. Psychoneuroendocrinology, 24, 43-68. Hunskaar, S., Backe, B. (1992). Attitudes towards and level of information on perimenopausal and postmenopausal hormone replacement therapy among Norwegian women. Maturitas. 15, 183. Hunter, M., O’Dea, I., Britten, N. (1997). Decision-making and hormone replacement therapy: a qualitative analysis. Social Science Medicine, 45, 1541-1548. Kaufman, D., Palmer, J., de Mouzon, J. (1991). Estrogen replacement therapy and the risk of breast cancer; results from the case-control surveillance study. American Journal Epidemiology, 134. 1375-85. Karakoc, B., Erenus, M. (1998). Compliance considerations with hormone replacement therapy. Menopause, 5, 102-106. 38 Kaufert, P., Gilbert, P. (1986). Women, menopause, and medicalization. Cultural Medicine Psychiatry, 10, 7-21. Kawas, C., Resnick, S., Morrison, A. (1997). A prospective study of estrogen replacement therapy and the risk of developing Alzheimer’s disease: The Baltimore Longitudinal Study of Aging. Neurology.6, 1517-1521. Keating, N., Cleary, P., Rossi, A., Zaslavsky, A., Azanian, J. (1999). Use of hormonal replacement therapy by post menopausal women in the U. S. Annal of Internal Medicine, 130, 545-46. Langer, R., Barrett-Connor, E. (1990). Menopausal estrogens and cardiovascular disease. Obstetric/Gynecology,2, 255-65. Langer, R., Barrett-Connor, E. (1994). Extended hormone replacement: Who should get it, and for how long? Geriatrics, 49, 20-29. Lichtman, R. (1994) Perimenopausal and postmenopausal hormone replacement therapy. Nurse Practitioner, 19, 1-8. Logothetis, M. (1991). Women’s decisions about estrogen replacement therapy. Western Journal of Nursing Research, 13, 458-473. Lydakis, C., Kerr, H., Hutchings, K., Lip, G. (1998). Women’s awareness of, and attitudes towards hormonal replacement therapy: ethnic differences and effects of age and education. International Journal of Clinical Practice, 52, 7-12. Newcomb, P., Storer, B. (1995). Postmenopausal hormone use and risk of large bowel cancer. Journal of the National Cancer Institute. 87. 1067-1070. Newton, K., LaCroix, A., Leveille, S., Rutter, C., Keenan, N., Anderson, L. (1997). Women’s beliefs and decisions about hormone replacement therapy. Journal of Womens Health, 6, 459-465. 59 Norderyd, O., Grossi, S., Machtei, E. (1993). Periodontal status of women taking postmenopausal estrogen supplementation. Journal of Periodontology, 64, 957962. Orwoll, E., Bauer, D., Vogt, T. (1996). Axial bone mass in older women. Annual of Internal Medicine, 124, 187-196. Paganinni-Hill, A. (1995). Estrogen replacement therapy and stroke. Progress in Cardiovascular Disease. 38, 223-242. Paganinne-Hill, A. (1995). The benefits of estrogen replacement therapy on oral health: the Leisure World Cohort. Archives of Internal Medicine. 155, 2325-2329. Paganini-Hill, A., Henderson, V., (1994). Estrogen deficiency and the risk of Alzheimer’s disease in women. American Journal of Epidemiology. 140, 256-261. Palmer, J., Rosenberg, L., Clarke, E., Miller, D., Shapiro, S. (1991). Breast cancer risk after estrogen replacement therapy; results from the Toronto Breast Cancer Study. American Journal of Epidemiology, 134, 1386-95. PEPI Trial Writing Group (1995). Effects of estrogen or estrogen/progestin regimens on heart disease risk factors in postmenopausal women. The postmenopausal estrogen/progestin intervention (PEPI) trial. Journal of the American Medical Association. 273, 199-207. Pike, M., Henderson, B., Mack, T., Lobo, R., Ross, R. (1989). Stroke prevention and oestrogen replacement. The Lancet, 2, 1034-35. Polit, D., Hungler, B. (1995). Nursing Research (5thed.) Philadelphia, PA: J.B. Lippincott Company Prior, J. (1994). One voice on menopause. Journal of American Medicine Women’s Association. 49, 27-29. Rabin, D. (1998). Understanding why women won’t take HRT. Contemporary OB/GYN, 133-141. 60 Roberts, P. (1991). The menopause and hormone replacement therapy: Views of women in gemeral practice receiving hormone replacement therapy. British Journal of General Practice. 41, 421-424. Rost, K., Frankel, R. (1993). The introduction of the older patients problems in the medical visit. Journal of Health Aging, 5, 387-401. Roter, D., Lipkin, M., Korsgaard, A. (1991). Sex differences in patients and physicians communication during primary care medical visits. Medical Care. 29, 1083- 93. Ryan, P., Hamson, R., Blake, G., Fogelman, I. (1992). Compliance with hormone replacement therapy (HRT) after screening for post menopausal osteoporosis. British Journal of Obstetrics and Gynecology, 99, 325-328. Salamone, L., Pressma, A., Seeley, D., Cauley, J. (1996). Estrogen replacement therapy: a survey of older women’s attitudes. Archives of Internal Medicine. 126, 1293-1298. Sandmark H., Hogstedt, C., Lewold, S., Vingard, E. (1999). Osteoarthrosis of the knee in men and women in association with overweight, smoking, and hormone therapy. Annuals of the Rheumatic Diseases, 58, 151-56. Scharbo-Dehaan, M. (1996). Hormonal replacement therapy. Nurse Practitioner, 21, 1-13. Schnebly, M., Hibbard, J., Hampson, S., Harvery, S. (1993). Presented at the Annual Meeting of the American Public Health Association, Sanfrancisco, CA. Schneider, D., Barrett-Connor, E., Morton, D. (1997). Timing of postmenopausal estrogen for optimal bone mineral density: the Rancho Bernardo study. JAMA, 277. 543-548 Sherwin, B. (1996). Hormones mood, and cognitive functioning in, postmenopausal women. Obstetric Gynecology, 87A 20-26. 61 Stanford, J., Weiss, N., Voigt, L., Daling, J., Haabel, L., Rossing, M. (1995). Combined estrogen and progestin hormone replacement therapy in relation to risk of breast cancer in middle-aged women. JAMA, 274, Stafford, R., Saglam, D., Causino, N., Blumenthal, D. (1997). Low rates of hormone replacement in visits to United States primary care physicians. American Journal of Obstetrics and Gynecology. 177, 381-387. Stampfer, M., Colditz, G., Willett, W., Manson,J., Rosner, B., Speizer, F., Hennekens, C. (1991). Postmenopausal estrogen therapy and cardiovascular disease. The New England Journal of Medicine. 325, 756-62. Tang, M., Jacobs, D., Stem, Y., Marder, K., Schofield, P., Gurland, B., Andrews, H., Mayeux, R. (1996). Effect of oestrogen during menopause on risk and age at onset of Alzheimer’s disease. The Lancet, 348, 429-32. Thomas, C., (Ed). (1981). Taber’s encyclopedic medical dictionary. Philadelphia, PA: F.A. Davis. Thomeycroft, I. (1995). Practical aspects of hormone replacement therapy. Progress Cardiavascular Dis, 38, 243-55. U. S. Department of Health and Human Services. (1991). National Center for Healthe Statistics. Washington, DC: Health U.S., table 76. Utian, W. (1987). Overview on menopause. American Journal of Obsttetrics and Gynecology, 156, 1280-1283. Wild, R. (1996). Estrogen: effects on the cardiovascular tree. Obstetrics Gynecology, 87, 275-355. Yang, C., Daling, J., Band, P., Gallagher, R., White, E., Weiss, N. (1992). Noncontraceptive hormone use and risk of breast cancer. Cancer Causes Control, 3, 475-9. 62 Ziegler, J. (1992). After menopause begins: the dilemma of estrogen replacement. American Health, 11, 68-71. 63 Apppendix A Menopausal Health Questionnaire 1. What is your age? 40-49 50-59 60-69 70-80 _ 80 or older 2. What is your menopausal status? Premenopausal Experiencing menopause Post Menopausal Unknown 3. Have you had a hysterectomy? Yes No 4. What is your ethnic background? Asian Black American Indian White Other 5. What is your level of education? Less than high school High school graduate Some College College graduate Masters level of education Doctorate 6. What type of provider do you use for women’s health care? Family or general practice physician Nurse Practitioner Internist None Gynecologist Other 64 7. Is the above health care provider? -— Male Female 8. Do you have a yearly breast exam? Yes No 9. Do you have a yearly pelvic exam? Yes No 10. Do you or a family member have a history of any of the following? Check all that apply. High cholesterol Heart disease Osteoporosis Diabetes Obesity Smoking 11. Do you know what hormone replacement therapy is, such as estrogen and/or progesterone treatment? Yes Uncertain No 12. If you answered Yes to # 11, from where did this information come? Books/Magazines Television Physician Nurse Practitioner Friend/Relative Other 13 Are you satisfied with the information you have received from your doctor regarding hormone replacement therapy? Yes No 14. Which of the following are reasons for using hormonal replacement therapy? Check all that apply. Hot Flushes Cardiovascular disease prevention After a hysterectomy Vaginal dryness Osteoporosis prevention Inability to sleep Doctor advised Depression, anxiety, emotional distress Prevent or alter progression of alzheiners disease 65 15. as hormone replacement therapy ever been prescribed for you? ---- Yes Uncertain No 16. Are you currently taking hormone replacement therapy, such as estrogen and/or progesterone treatments? If you answered No proceed to #18. ---- Yes Uncertain No 17. How long have you been on the treatment? Less than 6 months 6-24 months More than 2 years 18. Why are you taking hormone replacement therapy? Please check all that apply. Hot flushes Vaginal dryness Inability to sleep Depression, anxiety, emotional distress Osteoporosis prevention Cardivascular disease prevention I had a hysterectomy Doctor advised me to take it Other 19. If you are not currently taking hormone replacement therapy, why not? Please check all that apply. I am not menopausal I no longer have menopausal symptoms (hot flashes, flushing, night sweats, difficulty sleeping, repeated urine or bladder problems, loss of sexual desire, or pain with sexual relations). I did not like having a period again I did not like the bloating and weight gain I am concerned about its safety Fear of cancer I never had menopausal symptoms. My doctor or care provider never discussed hormone replacement therapy with me. I do not understand the benefits of hormone replacement therapy. I am afraid to use hormone replacement therapy. Explain below. I do not want to take hormone replacement therapy. Explain below. 66 __ Menopause is a natural process. Hormones are not needed. __ I have a medical problem. My physician says I cannot take it. Explai lain below. __ Other, Please explain. 67 Appendix B Janice Dean 5210 Abington Way Erie, PA 16502 (814) 835-8336 Dear Participants, I am a graduate student in the Family Nurse Practitioner program at Edinboro University. The following questionnaire has been developed as part of a research study with the purpose of obtaining information related to women’s knowledge and decision making regarding hormonal replacement therapy. Please take a few minutes to complete the questionaire, and return it in the self-addressed envelope provided. To maintain confidentiality please do not provide your name. Your assistance with this project is greatly appreciated. Upon completion of my research, the results will be available upon request from the Nursing Department of Edinboro University. Sincerely, Janice Dean R.N., BSN