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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
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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
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
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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