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
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48
Appendix A
Women’s Health Care Survey

1.

Present age

2.

Do you have a yearly breast exam ?

Yes

No

3.

Do you have a yearly pelvic exam ?

Yes

No

4.

Have you ever used birth control pills ?

Yes

No

5.

Have you had a hysterectomy ?

Yes

No

6.

What is your menopausal status ?

Premenopausal
Experiencing menopause
Post Menopausal
Unknown
7. 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%)