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Hormone replacement therapy:
Maturitas 35 (2000) 201 – 214 www.elsevier.com/locate/maturitas
Hormone replacement therapy: Knowledge, attitudes, self-reported use — and sales figures in Nordic women Anne Johanne Søgaard a,*, Anne Tollan b, Gro K.R. Berntsen c, Vinjar Fønnebø c, Jeanette H. Magnus c b
a Ulle6a˚l Uni6ersity Hospital, Oslo, Norway Department of Gynaecology and Obstetrics, Central Hospital of Hedmark, Hamar, Norway c Institute of Community Medicine, Uni6ersity of Tromsø, Tromsø, Norway
Received 22 September 1999; accepted 25 February 2000
Abstract Objecti6es: To evaluate knowledge about, attitudes towards and use of hormone replacement therapy (HRT) in Norwegian women — and to compare self-reported use with sales statistics of HRT in the Nordic countries during recent years. Material and methods: Random samples of Norwegian women age 16 – 79 were interviewed by the Central Bureau of Statistics in 1994 (n= 737), in 1996 (n = 665) and in 1998 (n =680). Statistics on the sale of estrogen were provided by the Norwegian Medical Depot and Nordic Council on Medicines. Results: One in three women had received information about HRT during the last 2 years (1994), mainly through weekly magazines and physicians. The proportion answering in accordance with the prevailing view of HRT’s effects (‘correct knowledge’) varied from 36.4 to 47.2%. Those informed by a physician possessed correct knowledge, had positive attitudes towards HRT and were willing to use HRT more often than women informed through other channels. Women with a high level of education had received information and had correct knowledge more often than others, but they were still less willing to use HRT and did not use HRT more often than the less educated. In the age group 45 – 69 years the use of HRT was 16.3% in 1994, 19.1% in 1996 and 19.1% in 1998 (P = 0.421, trend). In addition to received information, attitudes towards and knowledge about estrogen were the most important factors predicting use of HRT after adjusting for other variables. According to sales figures, the use of systemic estrogen in Norway has increased more than 360% since 1990. Although no other Nordic country has experienced a corresponding increase, Iceland had the highest sales figures in 1997. Conclusions: Based on the limited proportion of women receiving information on HRT and the ambivalence found in groups of educated women, we suggest that more and better information should be given middle-aged women to make them better able to make informed choices regarding use of HRT. © 2000 Elsevier Science Ireland Ltd. All rights reserved.
* Corresponding author. Present address: Department of Epidemiology, Institute of General Practice and Community Medicine, University of Oslo, PO Box 1130, Blindern, 0318 Oslo, Norway. Tel.: +47-22-850649; fax: +47-22-850620. E-mail address: [email protected] (A.J. Søgaard). 0378-5122/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 7 8 - 5 1 2 2 ( 0 0 ) 0 0 1 1 3 - 4
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Keywords: Hormone replacement therapy; Estrogen; Knowledge of health; Opinions; Attitude; Information
1. Introduction Long-term use of hormone replacement therapy (HRT) is still a dilemma for the peri- and postmenopausal women — as well as for their physicians. Due to observational studies over the past years about reduced mortality and morbidity in HRT users [1–4], physicians have prescribed HRT not only to reduce menopausal complaints, but also to prevent chronic diseases like osteoporosis and coronary heart disease. However, women often stop using HRT after a short period or use the medication irregularly [5 – 10]. Furthermore, the physician’s prescription habits and the women’s use vary between the countries in the industrialized world. Comparable estimates (1991/ 1992) for the use of HRT in women aged 45 – 70 years showed that the Scandinavian countries and England reported a median level of use (13%), while USA was alone on the top (20%) and the southern Europe was lowest (Spain and Italy below 1%) [11]. The reasons for this may be many, cultural differences in the understanding of perimenopause [10,12–14], different traditions concerning use of hormones — as the contraceptive pill [15–17], different practice concerning who is prescribing the medication [16,18,19], practical differences concerning ways of administration [13], and knowledge about the use of HRT — both among women and physicians [7,16,19 – 26]. Finally, previous studies have shown that less than half of the perimenopausal women in industrial countries have received information about HRT [16,20] and about half of European women (range across countries, 38 – 61%) have not discussed menopause or its symptoms with their doctors [27]. A great uncertainty concerning advantages and disadvantages regarding use of estrogen have been demonstrated [9,20,23,27,28]. Therefore, we want to chart self-reported use of HRT in Norway, how the use had developed from 1994 to 1998, how the use differed in parts of the population, and which factors that matter the most for the use of HRT. In addition, we wished to compare self-reported use with sales figures in
Norway 1990–1998, and describe the development in the sale of HRT in all the Nordic countries from 1981 to 1997. Finally, we wanted to find the proportion of women who reported to have received information about estrogen, the source for this information, their knowledge of and their attitudes towards HRT, and their willingness to use HRT if recommended by their physician.
2. Materials and methods The data were collected by means of Omnibussurveys carried out in March 1994, March 1996 and March 1998 by the Central Bureau of Statistics. Statistics on the sale of estrogen (both HRT and low potent estrogen) in Norway were provided by the Norwegian Medical Depot for the period 1990–1998 [29,30]. The corresponding figures for the Nordic countries came from the Nordic Council on Medicines for the period 1981–1997.
2.1. Material Three different random samples of the Norwegian population 16–79 years of age were at all three occasions selected in the same way and interviewed by trained interviewers. In 1994, 76.2% (n= 1514) were willing to be interviewed, while the corresponding numbers in 1996 and 1998 were 66.5% (n=1316) and 67.4% (n = 1342), respectively. The age group 67–79 years was under-represented in the net sample in all three surveys [31], however, not more than 2.5%. Therefore, the Central Bureau of Statistics found no reason to weight the data (T. Dale, Central Bureau of Statistics, personal message). More details about the procedure of selection, the skewness in the samples and the way the interviews were carried out have been described previously [31,32]. In this paper, we only report the questions asked to the women.
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Information about the respondents’ knowledge about, attitude towards, and willingness to use HRT was collected only in 1994 (n =737). The analyses of the data about the use of HRT from the three points in time have been limited to women aged 30–79 years (1994, n = 565; 1996, n= 460; 1998, n=489). Analyses of the use of estriol for urogenital disorders were limited to women 40–79 years old (1994, question not asked, 1996, n=305; 1998, n =334).
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2.2. Variables In addition to socioeconomic background information, the respondents were, in 1994, asked questions about received information and knowledge about estrogen, attitudes towards and willingness to use estrogen and whether they used estrogen. The questions are rendered in Table 1. The questions about the respondent’s knowledge about HRT were constructed based on what was
Table 1 Questions with response alternatives addressed to representative selections of Norwegian women aged 16–79 years in 1994, 1996 and 1998 Omnibus 1994 1 Have you, during the latest couple of years, received information about estrogen treatment? (Yes/no/I do not know) 2 If yes, from which of the following sources have you received this kind of information? (Weekly magazines, newspapers, radio, TV, physician, friend, relative, other sources, I do not know) 3 On the card, you see some assertions about estrogen treatment. As I read the assertions I ask you to answer yes if you believe the assertion is correct, and no if you believe it is incorrect. Estrogen reduces the risk of getting: (a) Myocardial infarction (yes/no/I do not know) (b) Breast cancer (yes/no/I do not know) (c) Osteoporosis (yes/no/I do not know) 4 I will now read some usual understandings of estrogen treatment. States if you totally agree, agree, disagree or totally disagree with each of the understandings. We are here interested in your personal opinion (a) Estrogen has many side effects (b) Estrogen treatment of women after menopause increases quality of life (c) One knows too little, science often changes its opinion concerning whether estrogen treatment is dangerous or not. (Totally agree/agree/disagree/totally disagree/I do not know) 5 Imagine that you have climacteric complaints connected to the menopause, e.g. hot flashes, mood changes or irregular menstrual periods, and get to know that these complaints can be treated effectively with estrogen. Will you be positive or negative to this kind of treatment? (Positive/negative/I do not know) 6 Recent research indicates that long time estrogen treatment can prevent some sufferings. Imagine that you are well, but that your doctor after a thorough examination of your situation recommends you to use HRT to avoid future illness. Will you be positive or negative to estrogen treatment to prevent (a) Osteoporosis (Positive/negative/I do not know) (b) Myocardial infarction? (Positive/negative/I do not know) 7 Do you use any kind of estrogen treatment today?a (Yes/no/I do not know) Omnibus 1996 and 1998 1 Here follows some questions about medicine containing estrogenb Do you use (a) Contraceptive pills (yes/no) (b) Vaginal cream/suppository containing estrogen (yes/no) (c) Transdermal estrogen (yes/no) (d) Ovesterine-pills or Estriol-pills (yes/no) (e) Other kinds of pills containing estrogen (yes/no) a The respondents were informed that estrogen treatment in this context meant hormone substitution treatment (estrogen/gestagen-pills or patches) — not contraceptive pills or local estrogen treatment in the vagina — i.e. estriol. b Those who answered in the affirmative to (c) and (e) were considered HRT users. Those who answered yes to (b) and (d) were considered users of low-dose estrogen for urogenital disorders.
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consistent with evidence from observational studies at that time — i.e. that HRT reduced the risk of coronary heart disease and osteoporosis and increased the risk of breast cancer. Results from the HERS study [33] has later questioned this, without giving the ultimate answers. Some other questions from the 1994-study have been reported and analyzed earlier [32].
2.3. Statistics The statistical analyses have been made as crosstables with simple x 2-tests, covariance analysis and logistic regression in SPSS. Possible interactions were tested by ANOVA. Because of interactions between level of education, knowledge, attitude and use/willingness to use, we performed stratum-specific analyses with all these variables. Because information, from doctors in particular, was so strongly correlated to the use of estrogen, and probably also measures information received because of the use of HRT, we decided to study, by means of logistic regression, which of the other variables could explain the use of estrogen. The level of significance is 5%. The numbers of subjects included in each analysis varies because of lacking answers from some respondents.
2.4. Sales figures We received written statistics concerning the sale of medicine containing estrogen in ATCgroup G03C and G03F, i.e. oral/transdermal hormone replacement and oral/vaginal treatment for urogenital disorders. The sales figures are in this paper, stated as defined daily doses per day (DDDs per day) or as DDDs/1000 inhabitants per day. A DDD is defined as the assumed average maintenance dose per day for a drug used on its main indication in adults [30]. DDDs per day divided by the numbers of women in the current age groups give a maximum estimate for the proportion of users.
3. Results
3.1. Who ha6e been informed about estrogen and from what sources? More than 30% of the women said that they had been given information about estrogen-treatment during the last 2 years — equally divided by about 10% from each of the three sources weekly magazines, physicians and friends/relatives/others (Table 2). The proportion that had received information was above 50% in the age group 45–59 years and in women with 13 years of education or more.
3.2. What do women know concerning the effects of estrogen? More than 35% of the women believed that HRT reduces the risk of getting a myocardial infarction, while 47.2% thought estrogen reduces the risk of acquiring osteoporosis (Table 3). One in three answered that estrogen reduces the risk of breast cancer. About one in three claimed they were ignorant to all the HRT effect questions. Age 45–59 years, being informed by a physician, high level of education and current use of HRT was associated with a belief of the effect of HRT that are consistent with the findings in observational studies.
3.3. What attitudes do women ha6e concerning estrogen? Almost 70% of the women believed that there is too little scientific knowledge about estrogen and more than 50% agreed totally or partly that estrogen has several side effects (Table 4). However, almost 65% of the women thought that estrogen treatment increases quality of life. Women aged 30–59 years, the ones with the highest educational level, women who used HRT, and the ones who had received information from their doctors had the highest proportion answering in the affirmative to this last statement. Information from media was associated with a larger degree of skepticism (Table 4).
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Table 2 The proportion of women (16–79 years) who said they had received information about estrogen treatment from different sources according to age and education Have received information from
Age (years) 16–29 30–44 45–59 60+ P Education (years) B10 10–12 13+ P Total
Have not received information
Media
Physician
Friends/relatives/others
n=78
n =67
n= 95
n =497
n 172 220 168 177
% 11.6 13.6 10.7 5.6
% 0.6 4.1 25 8.5
% 14 11.8 17.3 9
% 73.8 70.5 47 76.8 B0.001
236 367 134
8.5 9.5 17.2
11.4 7.1 10.4
7.6 12.5 23.1
737
10.6
9.1
12.9
72.5 70.8 49.3 B0.001 67.4
3.4. Are women willing to use estrogen for perimenopausal complaints and in pre6ention of illnesses? Almost 75% of the women were willing to use HRT for climacteric complaints (Table 5), and the percentage was highest among the youngest. Further, the percentage was highest in women who both had short/medium education level, correct knowledge and positive attitude (87%), while the percentage was lowest (43%) if long education was combined with correct knowledge and a negative attitude. Regarding willingness to use longterm estrogen in the prevention of osteoporosis and myocardial infarction, 65.0 and 68.1% of the women, respectively, answered on the affirmative. The combination of medium education, correct knowledge and positive attitude gave the highest willingness (76%), while high level of education, incorrect knowledge and negative attitude was associated with the lowest willingness (23%). Logistic regression showed that information from doctors, short/medium education and a positive attitude were the most important predictors for the willingness of preventive use. Young age and a positive attitude were the most important factors associated with willingness to use HRT against climacteric complaints.
3.5. Self-reported use of estrogen In 1994, 9.9% of Norwegian women (30–79 years) reported that they used estrogen, while the numbers for 1996 and 1998 were 8.1 and 8.9%, respectively (Table 6). In the same period, the use of HRT in the most relevant age group (45–69) was 16.3% in 1994, 19.1% in 1996 and 19.1% in 1998 (P=0.421, trend). In 1996 and 1998, 2.5 and 4.1%, respectively, in the same age group stated that they used transdermal estrogen. There was no statistically significant difference in the use of HRT in relation to the woman’s level of education. The proportion of HRT-use was higher in the more urban parts of Norway in 1996 and 1998. In all 23.8% (10 out of 42) of the HRT-users and 90.7% (195 of 215) of the non-users aged 45–69 years stated in 1994 that they had not received any information about estrogen from a doctor during the last 2 years. After age, a positive attitude towards and knowledge about estrogen were the factors that mattered the most for use of HRT (received information was not in the model). Education, area of residence and willingness to use HRT were not statistically significant. Table 7 shows that there was an interaction between attitude, knowledge
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and length of education concerning the use of estrogen. Short education, correct knowledge and a positive attitude towards estrogen gave the highest percentage of users. We found no association between the use of HRT and marital status, own income, area of residence, whether they were unemployed or not, or if the woman was in a leading position. The prevalence of low potent estrogen for urogenitial disorders was 8.5% in 1996 and 9.3% in 1998 in women older than 40 years of age (Table 8).
3.6. Sale of estrogen Fig. 1 shows the sales figures for different types of systemic estrogen (ATC gr G03C and G03F) Table 3 The proportion of women (16–79 years) who answered in the affirmative (correctlya) to questions about knowledge of the effect of HRT (n = 737) Estrogen reduces the risk of getting
Age (years) 16–29 30–44 45–59 60+ P Education (years) B10 10–12 13+ P
Myocardial infarction (%)
Osteoporosis (%)
23.8 36.4 53.6 32.2 B0.001
32.0 47.3 65.5 44.6 B0.001
36.4 33.8 43.3 0.148
37.7 45.8 67.9 B0.001
Recei6ed information from Media 44.9 Physician 68.7 Friends/relatives/o 46.3 thers Not received 28.9 information P B0.001 Total 36.4 a
59.7 79.1 68.4 37.2 B0.001 47.2
Correctly is what was consistent with evidence from observational studies at that time — i.e. that HRT reduced the risk of coronary heart disease and osteoporosis.
and the total use of systemic estrogen for the period 1990–1998. Purchased daily doses of systemic estrogen increased from 1990 to 1994 with about 30% annually, leveling off the last years. Norethisteron and estradiol in continuous combination (Kliogest) and as sequential medication (Trisekvens, Trisekvens forte, Estracomb) increased most in the period. Estradiol (transdermal or orally) have also increased, while the sale of other preparations has been stable between 1990 and 1998. Totally, 143 971 daily doses (DDDs per day) of estrogen for systemic use were sold in 1998, which corresponds to an estimated prevalence of 25%, calculated from the number of women in the age group 45–69 years pr. 1.1.1998 (n= 576 563), which is the most relevant group of users. In spite of an increase of 362.5% in purchased systemic estrogen (DDDs per day) in Norway in the period 1990–1998, women in Iceland purchased more HRT than Norwegian women in 1997 (Fig. 2). In the period 1990–1998, the sale of low potent medication for urogenital disorders in Norway has been two-fold, and the sale in 1998 was 57 869 DDDs per day, which corresponds to about 9.4% presumptive users (n = 618 046 aged 50–79 years). Because of intermittent use of vaginal cream and suppositories, and some variation in daily oral dose, it is difficult to compare sales figures and self-reported use.
4. Discussion The women aged 45–59 years, those with the highest level of education, and those who used HRT had to the highest degree received information about estrogen. Compared to other women, they also had the best knowledge about the effects and they thought that estrogen-treatment increases the quality of life. On the other hand, these groups were just as uncertain as the other groups when they evaluated the statement ‘‘one knows too little, science often changes its opinion concerning whether HRT treatment is dangerous or not’’. When the women then were asked about
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Table 4 The proportion of women (16–79 years) who totally or partly agree in some common statements about HRT (n = 737) Estrogen has many side effects (%)
Estrogen-treatment increases quality of life (%)
59.9 52.7 51.8 50.3 0.283
62.8 73.2 75.6 45.8 B0.001
68 69.5 72 67.8 0.823
Education (years) B9 53.8 9–12 54.2 13+ 51.5 P 0.860
54.7 66.5 77.6 B0.001
64.4 70.8 73.9 0.111a
Age (years) 16–29 30–44 45–59 60+ P
Recei6ed information from Media 59.0 Physician 44.8 Friends/relatives/o 58.9 thers Not received 52.9 information P 0.242 Total 53.6 a
One knows too little about estrogen (%)
69.2 89.6 76.8
88.5 65.6 75.8
58.4
65.6
B0.001 64.7
B0.001 69.3
PB 0.05 for trend.
Table 5 The proportion of women (16–79 years) who were willing to use HRT for climacteric complaints and who were positive towards long term treatment to prevent myocardial infarction and osteoporosis (n= 737) Climacteric complaints (%) Age (years) 16–29 30–44 45–59 60+ P Education (years) B10 10–12 13+ P Total
Myocardial infarction (%)
84.3 73.2 77.4 62.7 B0.001
69.2 64.5 73.2 66.7 0.313
72.9 76.3 70.9 0.403 74.2
73.7 70.3 52.2 B0.001 68.1
willingness to use estrogen, the ones with the highest educational level were the least willing. Finally, we found no difference in self-reported use of HRT between the educational groups after adjustment for age.
Osteoporosis (%)
61.6 63.6 70.2 65.0 0.382 64.8 68.9 54.5 B0.01 65.0
There was a small insignificant increase in selfreported use of HRT in the age group 45–59 years from 1994 to 1998. Except for age, a positive attitude towards HRT was the most important predictor for self-reported use, followed by-
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Table 6 Self-reported use of HRT in Norwegian women 30–79 years of age according to age and level of education
Age (years) 30–44 45–59 60–79 P Education (years) B9 10–12 13+ P P (adjusted for age) Total
1994a (n= 565) (%)
1996 (n = 460) (%)
1998 (n =489) (%)
3.2 20.8 7.9 B0.001
1.3 21.8 7.3 B0.001
0.9 22.8 6.3 B0.001
11.1 10.1 7.4 0.588 0.868 9.9a
9.2 8.1 6.9 0.804 0.886 8.1
9.2 9.3 7.8 0.884 0.885 8.9
a The question about use of estrogen was asked differently in 1994. The total proportion probably contains some younger women using the contraceptive pill and some older women using low potent estrogen for urogenital disorders.
knowledge consistent with results from observational studies. We suppose that the samples we analyzed are representative of the female Norwegian population between 16 and 79 years, since there were only minor differences between the samples frame and actual sample with regard to age, gender, and area of residence [31]. Besides, the sample frame in 1994 was very similar to the total population with regard to age and gender [34].
4.1. Information and source of information is important Only one third of the women had received information about estrogen during the last 2 years, which shows that the proportion of Norwegian women who have received information on this topic has not increased considerably between 1990 and 1994 [20]. Several studies show that women would prefer more information about estrogen from doctors and others [20,21,27,35 – 39], and that women receive too little information and lack sufficient knowledge to make well-founded choices concerning use of hormonal substitution [21,23,27,35,40 – 43].
Table 7 The proportion of women (30–79 years) who use estrogen, according to education, knowledge about and attitude towards estrogen (n = 565) Education
Knowledge
Attitude (n)
Use estrogen (%)
Long (13+years)
Correcta
Positiveb(56)
12.5
Incorrect
Negative (28) Positive (9) Negative (15)
3.6 – –
Correcta
Positive (98)
19.4
Incorrect
Negative (67) Positive (38) Negative (74)
9.0 5.3 1.4
Correcta
Positive (61)
24.6
Incorrect
Negative (40) 2.5 Positive (9) 11.1 Negative (70) 4.3
Medium (10–12 years)
Short (B10 years)
a
Correct knowledge: think that estrogen reduces the risk of getting osteoporosis and/or reduces the risk of getting myocardial infarction. b Positive attitude: totally or partly agree that estrogen increases quality of life and/or totally or partly disagree that estrogen has several side effects and/or totally or partly disagree that one knows too little about estrogen.
A.J. Søgaard et al. / Maturitas 35 (2000) 201–214 Table 8 Self-reported use of low potent estrogen (estriol) for urogenital disorders in Norwegian women 40–79 years of age according to age and level of education
Age (years) 40–49 50–59 60–69 70–79 P Education (years) B9 10–12 13+ P P (adjusted for age) Total
1996 (n =305) (%)
1998 (n=334) (%)
0.8 15.9 13.6 13.7 B0.001
3.3 8.5 18.8 12.3 B0.005
10.4 7.6 7.4 0.698 0.760 8.5
9.7 10.3 6.6 0.664 0.235 9.3
Weekly magazines were the most important source of information for Norwegian women in 1990 [20], a finding that corresponds well with similar results in other countries [16,23,28,41,44]. Our study shows that the doctors were almost equally important as source of information in those who said they had received information. The proportions are, however, difficult to com-
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pare, since the questions were asked differently in 1990 and 1994. The women, who had received their information from a physician more often than other women had correct knowledge, an open attitude towards HRT and were more willing to use estrogen to prevent chronic diseases. Women who had received information through media often had less correct knowledge, a more skeptical attitude and less willingness to use HRT. Perhaps the public health service should use the different media more actively to improve the quality of information given about estrogen, and thereby make the women better prepared to take informed choices.
4.2. The women still lack knowledge Women’s knowledge about the long-term effects of HRT on different illnesses was to some extent consistent with results from observational studies, but about one in three claimed that they did not know. The proportion of women answering that estrogen reduces the risk of myocardial infarction increased from 3% in 1990 [20] to 36.4% in 1994 (but the questions were not totally identical in the two surveys). More than half of the perimenopausal women believed HRT prevented myocardial infarction (MI). The survey
Fig. 1. Sale of HRT (ATC gr G03C and G03F) for systemic use in DDD per day for the period 1990 – 1998 in Norway (Norwegian Medical Depot [29,30]).
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Fig. 2. Sale of HRT (ATC gr G03C and G03F) in DDD per 1000 inhabitants per day for the period 1981 – 1997 in the Nordic countries (Nordic Council on Medicines). Statistics from Finland in 1985 and from Denmark in 1993 are missing, and are extrapolated. Denmark changed registration-procedure in the mid 1990s — i.e. sale from hospitals are not included.
was performed during a period with increasing focus in media on these aspects, due to the optimistic results on the prevention of MI in many observational studies. That more than 65% of these respondents believed that HRT could prevent osteoporosis is not so surprising, since the lack of estrogen has been associated with osteoporosis for decades [4]. The importance of knowledge may be illustrated by studies which show that far more female doctors and doctors’ wives, compared to the general female population, were using HRT [19,45].
4.3. Ambi6alent attitudes towards long-term estrogen treatment Both with regard to willingness to use estrogen, and actual use of HRT, a positive attitude was the most important predictor, assuming the same level of knowledge. The results in Table 4 indicate that Norwegian women are ambivalent towards estrogen. The duplicity is most obvious in women with the highest level of education. These women had received most information, they had the best knowledge on estrogen’s preventive effect, but had a somewhat ambivalent attitude towards estrogen. They had the highest proportion with the opinion that estrogen increases quality of life, but
at the same time they claimed more than others that scientists know too little. They were less willing to use estrogen to prevent chronic disease than those with less education were, and they did not report more frequent use than other educational groups. We do not know the background for this ambivalence; it could perhaps have ideological and historical reasons. May be the objections and oppositions created in the mid 1970s by books like e.g. ‘Always Woman: Is the Menopause a Deficiency Disease?’ [46], still affects the view of this cohort of well-educated women, whom today are in the actual age for starting HRT? But, why is this resistance more pronounced in Norway than in other countries? With a few exceptions [47,48], most international studies show that the proportion of users is highest among women with long or medium education [8,15–17,21,49,50].
4.4. Increased willingness to HRT use The willingness to use estrogen against menopausal complaints and for prevention of different diseases is surprisingly high, considering the large amount of skepticism that is revealed. The willingness to use estrogen has increased considerably in the 1990s. In 1990, 45% were positive to
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use estrogen for menopausal complaints in general, while 60% were positive to use HRT in the prevention of osteoporosis [20]. The corresponding numbers from our study were 74.2 and 65.0%. The fact that the youngest women were the most positive towards the use of estrogen for menopausal complaints, may suggest that they perhaps are less preoccupied with this issue than those engaged in the ideological debate in the mid 1970s. There is, in our study, little accordance between the proportion of users of estrogen and the percentage who are positive to this kind of use to prevent myocardial infarction (68.1%) and osteoporosis (65.0%) after recommendation from their physician. Several authors have recently focused on the need for physicians to engage in a dialogue with their patients, which allows individual evaluation and application of current knowledge about HRT [27,35,40].
4.5. Sale and use of HRT The sale of HRT in Norway has increased significantly in the 1990s, a development already observed at the end of the 1980s [51]. No other Nordic country had a larger increase in the sale of HRT in the ATC-group G03C and G03F in the period 1990–1997 (Fig. 2). All the Nordic countries, except Denmark, have had a large increase in the sale of HRT the last 15 years (Fig. 2). Denmark, which in the beginning of the 1980s was clearly highest in the North concerning sale of HRT in the two mentioned ACT-groups, are now definitively the lowest (Fig. 2). However, the statistics from Denmark is uncertain, since they had a change in their registration-procedures in the mid 1990s. They do not any more include sale from hospitals in their statistics. The sales statistics may, therefore, underestimate the real Danish HRT-use (personal message M.-L. Lunn, Lægemiddelstyrelsen, Copenhagen). Self-reported use of HRT among Danish women 45– 65 years was in 1994 18.4% [52], which is the same as the corresponding age group reported in our study in 1994 (18.8%). That the percentage reporting use of HRT between 30 and 79 years, according to our studies,
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decreased from 1994 to 1996, in spite of a clear increase in the sale, could have two possible explanations. Firstly, the prevalence of HRT-use in 1994 was probably overestimated as users of contraceptive pills and users of low-potent estrogen may erroneously have been included. If we look at the age group 45–59 years, there has been a slight increase. Secondly, compliance problems may account for part of the difference. Several authors [10,13,15,16,21,22,36,47,53 –55] have reported lack of compliance concerning use of estrogen. The numbers from our three studies and the sales statistics from the corresponding years indicate that the sale is 1–6% points above the proportion that reports to use estrogen based on the age group 45–69 years. But if we include the margins of error to the Omnibus study, the sales figures are inside the confidence intervals for the users in this age group. We would also underline the risk of error which is inherent in calculating the percentage HRT-users based on sales statistics and an unknown denominator which is the number of potential users.
4.6. What influences the use of estrogen? The women’s attitudes were the most important predictor for use of estrogen in our study, which verifies findings from earlier studies [6,9,10,13,53]. In addition to this factor, information and knowledge were important concerning the use of HRT, which is also found by others [21,22,35,43,56]. The doctor was an important source of information concerning HRT. But it was obvious that several women in the actual age had not received information about estrogen from their physician. Several authors have pointed out that the doctors attitude and prescription-practice may be the most important factor to determine women’s use of estrogen [10,18,19,24,26,40,48,53,57], and that there is an obvious need for more information from doctors concerning HRT [9,21,27,35,37,40,54 –56,58,59]. If we compare percentage of use of HRT in Norway and Finland from the late 1980s, it may seem like there is a positive connection between the sale of estrogen and the doctors attitudes towards hormone substitution [21]. Several au-
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thors have mentioned not just a restrictive attitude in the doctors [26,60,61], but also lack of knowledge [25,26,61]. A Norwegian study from 1990 [26] indicates great uncertainty among GP’s concerning the effect of hormone substitution. At that time, a considerable proportion of the physicians considered coronary heart disease in the family and smoking to be contraindications for HRT [26]. Some of them were also restrictive to prescribe local estrogen (low dose) to women with angina pectoris. It is interesting to see that women more often get HRT prescribed if they visit female doctors [62], that female doctors are more positive to HRT than men [24,63], and that they have less problems than their male colleagues concerning the settling/adjusting of a HRT treatment program [25]. After the Consensus Conference on the use of estrogen in Norway in 1990, female doctors changed their prescription-practice more than men did [64]. Only 4.1% of the women in the most actual age group used transdermal estrogen in 1998, a kind of administration that may have some advantages compared to oral estrogen [65]. In addition, some studies show better compliance by the use of estrogen patches compared to pills [65,66]. The choice of pills versus patches is obviously an economical question for several women, but probably also a question of being informed of the possible alternatives.
5. Conclusion The relatively large willingness, especially in those with middle and short education, to use HRT to prevent osteoporosis and myocardial infarction after a doctor’s recommendation, places a lot of responsibility with the physicians and nurses. These women seem to count on the experts’ advise, because they have a lesser degree than those with a high level of education, have correct knowledge and in general, receive less information from other sources than the doctor. Here is obviously a great challenge and a large potential for matter-of-fact/objective information about hormone substitution. The goal must be to
make the women better prepared to make informed choices based on evidence-based knowledge of positive and negative effects.
Acknowledgements We would like to thank Tine-Norske Meierier, Sandoz, Novo Nordisk and Eli Lilly, Norge A.S. for supporting the collection of the data.
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Hormone replacement therapy: Knowledge, attitudes, self-reported use — and sales figures in Nordic women Anne Johanne Søgaard a,*, Anne Tollan b, Gro K.R. Berntsen c, Vinjar Fønnebø c, Jeanette H. Magnus c b
a Ulle6a˚l Uni6ersity Hospital, Oslo, Norway Department of Gynaecology and Obstetrics, Central Hospital of Hedmark, Hamar, Norway c Institute of Community Medicine, Uni6ersity of Tromsø, Tromsø, Norway
Received 22 September 1999; accepted 25 February 2000
Abstract Objecti6es: To evaluate knowledge about, attitudes towards and use of hormone replacement therapy (HRT) in Norwegian women — and to compare self-reported use with sales statistics of HRT in the Nordic countries during recent years. Material and methods: Random samples of Norwegian women age 16 – 79 were interviewed by the Central Bureau of Statistics in 1994 (n= 737), in 1996 (n = 665) and in 1998 (n =680). Statistics on the sale of estrogen were provided by the Norwegian Medical Depot and Nordic Council on Medicines. Results: One in three women had received information about HRT during the last 2 years (1994), mainly through weekly magazines and physicians. The proportion answering in accordance with the prevailing view of HRT’s effects (‘correct knowledge’) varied from 36.4 to 47.2%. Those informed by a physician possessed correct knowledge, had positive attitudes towards HRT and were willing to use HRT more often than women informed through other channels. Women with a high level of education had received information and had correct knowledge more often than others, but they were still less willing to use HRT and did not use HRT more often than the less educated. In the age group 45 – 69 years the use of HRT was 16.3% in 1994, 19.1% in 1996 and 19.1% in 1998 (P = 0.421, trend). In addition to received information, attitudes towards and knowledge about estrogen were the most important factors predicting use of HRT after adjusting for other variables. According to sales figures, the use of systemic estrogen in Norway has increased more than 360% since 1990. Although no other Nordic country has experienced a corresponding increase, Iceland had the highest sales figures in 1997. Conclusions: Based on the limited proportion of women receiving information on HRT and the ambivalence found in groups of educated women, we suggest that more and better information should be given middle-aged women to make them better able to make informed choices regarding use of HRT. © 2000 Elsevier Science Ireland Ltd. All rights reserved.
* Corresponding author. Present address: Department of Epidemiology, Institute of General Practice and Community Medicine, University of Oslo, PO Box 1130, Blindern, 0318 Oslo, Norway. Tel.: +47-22-850649; fax: +47-22-850620. E-mail address: [email protected] (A.J. Søgaard). 0378-5122/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 7 8 - 5 1 2 2 ( 0 0 ) 0 0 1 1 3 - 4
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Keywords: Hormone replacement therapy; Estrogen; Knowledge of health; Opinions; Attitude; Information
1. Introduction Long-term use of hormone replacement therapy (HRT) is still a dilemma for the peri- and postmenopausal women — as well as for their physicians. Due to observational studies over the past years about reduced mortality and morbidity in HRT users [1–4], physicians have prescribed HRT not only to reduce menopausal complaints, but also to prevent chronic diseases like osteoporosis and coronary heart disease. However, women often stop using HRT after a short period or use the medication irregularly [5 – 10]. Furthermore, the physician’s prescription habits and the women’s use vary between the countries in the industrialized world. Comparable estimates (1991/ 1992) for the use of HRT in women aged 45 – 70 years showed that the Scandinavian countries and England reported a median level of use (13%), while USA was alone on the top (20%) and the southern Europe was lowest (Spain and Italy below 1%) [11]. The reasons for this may be many, cultural differences in the understanding of perimenopause [10,12–14], different traditions concerning use of hormones — as the contraceptive pill [15–17], different practice concerning who is prescribing the medication [16,18,19], practical differences concerning ways of administration [13], and knowledge about the use of HRT — both among women and physicians [7,16,19 – 26]. Finally, previous studies have shown that less than half of the perimenopausal women in industrial countries have received information about HRT [16,20] and about half of European women (range across countries, 38 – 61%) have not discussed menopause or its symptoms with their doctors [27]. A great uncertainty concerning advantages and disadvantages regarding use of estrogen have been demonstrated [9,20,23,27,28]. Therefore, we want to chart self-reported use of HRT in Norway, how the use had developed from 1994 to 1998, how the use differed in parts of the population, and which factors that matter the most for the use of HRT. In addition, we wished to compare self-reported use with sales figures in
Norway 1990–1998, and describe the development in the sale of HRT in all the Nordic countries from 1981 to 1997. Finally, we wanted to find the proportion of women who reported to have received information about estrogen, the source for this information, their knowledge of and their attitudes towards HRT, and their willingness to use HRT if recommended by their physician.
2. Materials and methods The data were collected by means of Omnibussurveys carried out in March 1994, March 1996 and March 1998 by the Central Bureau of Statistics. Statistics on the sale of estrogen (both HRT and low potent estrogen) in Norway were provided by the Norwegian Medical Depot for the period 1990–1998 [29,30]. The corresponding figures for the Nordic countries came from the Nordic Council on Medicines for the period 1981–1997.
2.1. Material Three different random samples of the Norwegian population 16–79 years of age were at all three occasions selected in the same way and interviewed by trained interviewers. In 1994, 76.2% (n= 1514) were willing to be interviewed, while the corresponding numbers in 1996 and 1998 were 66.5% (n=1316) and 67.4% (n = 1342), respectively. The age group 67–79 years was under-represented in the net sample in all three surveys [31], however, not more than 2.5%. Therefore, the Central Bureau of Statistics found no reason to weight the data (T. Dale, Central Bureau of Statistics, personal message). More details about the procedure of selection, the skewness in the samples and the way the interviews were carried out have been described previously [31,32]. In this paper, we only report the questions asked to the women.
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Information about the respondents’ knowledge about, attitude towards, and willingness to use HRT was collected only in 1994 (n =737). The analyses of the data about the use of HRT from the three points in time have been limited to women aged 30–79 years (1994, n = 565; 1996, n= 460; 1998, n=489). Analyses of the use of estriol for urogenital disorders were limited to women 40–79 years old (1994, question not asked, 1996, n=305; 1998, n =334).
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2.2. Variables In addition to socioeconomic background information, the respondents were, in 1994, asked questions about received information and knowledge about estrogen, attitudes towards and willingness to use estrogen and whether they used estrogen. The questions are rendered in Table 1. The questions about the respondent’s knowledge about HRT were constructed based on what was
Table 1 Questions with response alternatives addressed to representative selections of Norwegian women aged 16–79 years in 1994, 1996 and 1998 Omnibus 1994 1 Have you, during the latest couple of years, received information about estrogen treatment? (Yes/no/I do not know) 2 If yes, from which of the following sources have you received this kind of information? (Weekly magazines, newspapers, radio, TV, physician, friend, relative, other sources, I do not know) 3 On the card, you see some assertions about estrogen treatment. As I read the assertions I ask you to answer yes if you believe the assertion is correct, and no if you believe it is incorrect. Estrogen reduces the risk of getting: (a) Myocardial infarction (yes/no/I do not know) (b) Breast cancer (yes/no/I do not know) (c) Osteoporosis (yes/no/I do not know) 4 I will now read some usual understandings of estrogen treatment. States if you totally agree, agree, disagree or totally disagree with each of the understandings. We are here interested in your personal opinion (a) Estrogen has many side effects (b) Estrogen treatment of women after menopause increases quality of life (c) One knows too little, science often changes its opinion concerning whether estrogen treatment is dangerous or not. (Totally agree/agree/disagree/totally disagree/I do not know) 5 Imagine that you have climacteric complaints connected to the menopause, e.g. hot flashes, mood changes or irregular menstrual periods, and get to know that these complaints can be treated effectively with estrogen. Will you be positive or negative to this kind of treatment? (Positive/negative/I do not know) 6 Recent research indicates that long time estrogen treatment can prevent some sufferings. Imagine that you are well, but that your doctor after a thorough examination of your situation recommends you to use HRT to avoid future illness. Will you be positive or negative to estrogen treatment to prevent (a) Osteoporosis (Positive/negative/I do not know) (b) Myocardial infarction? (Positive/negative/I do not know) 7 Do you use any kind of estrogen treatment today?a (Yes/no/I do not know) Omnibus 1996 and 1998 1 Here follows some questions about medicine containing estrogenb Do you use (a) Contraceptive pills (yes/no) (b) Vaginal cream/suppository containing estrogen (yes/no) (c) Transdermal estrogen (yes/no) (d) Ovesterine-pills or Estriol-pills (yes/no) (e) Other kinds of pills containing estrogen (yes/no) a The respondents were informed that estrogen treatment in this context meant hormone substitution treatment (estrogen/gestagen-pills or patches) — not contraceptive pills or local estrogen treatment in the vagina — i.e. estriol. b Those who answered in the affirmative to (c) and (e) were considered HRT users. Those who answered yes to (b) and (d) were considered users of low-dose estrogen for urogenital disorders.
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consistent with evidence from observational studies at that time — i.e. that HRT reduced the risk of coronary heart disease and osteoporosis and increased the risk of breast cancer. Results from the HERS study [33] has later questioned this, without giving the ultimate answers. Some other questions from the 1994-study have been reported and analyzed earlier [32].
2.3. Statistics The statistical analyses have been made as crosstables with simple x 2-tests, covariance analysis and logistic regression in SPSS. Possible interactions were tested by ANOVA. Because of interactions between level of education, knowledge, attitude and use/willingness to use, we performed stratum-specific analyses with all these variables. Because information, from doctors in particular, was so strongly correlated to the use of estrogen, and probably also measures information received because of the use of HRT, we decided to study, by means of logistic regression, which of the other variables could explain the use of estrogen. The level of significance is 5%. The numbers of subjects included in each analysis varies because of lacking answers from some respondents.
2.4. Sales figures We received written statistics concerning the sale of medicine containing estrogen in ATCgroup G03C and G03F, i.e. oral/transdermal hormone replacement and oral/vaginal treatment for urogenital disorders. The sales figures are in this paper, stated as defined daily doses per day (DDDs per day) or as DDDs/1000 inhabitants per day. A DDD is defined as the assumed average maintenance dose per day for a drug used on its main indication in adults [30]. DDDs per day divided by the numbers of women in the current age groups give a maximum estimate for the proportion of users.
3. Results
3.1. Who ha6e been informed about estrogen and from what sources? More than 30% of the women said that they had been given information about estrogen-treatment during the last 2 years — equally divided by about 10% from each of the three sources weekly magazines, physicians and friends/relatives/others (Table 2). The proportion that had received information was above 50% in the age group 45–59 years and in women with 13 years of education or more.
3.2. What do women know concerning the effects of estrogen? More than 35% of the women believed that HRT reduces the risk of getting a myocardial infarction, while 47.2% thought estrogen reduces the risk of acquiring osteoporosis (Table 3). One in three answered that estrogen reduces the risk of breast cancer. About one in three claimed they were ignorant to all the HRT effect questions. Age 45–59 years, being informed by a physician, high level of education and current use of HRT was associated with a belief of the effect of HRT that are consistent with the findings in observational studies.
3.3. What attitudes do women ha6e concerning estrogen? Almost 70% of the women believed that there is too little scientific knowledge about estrogen and more than 50% agreed totally or partly that estrogen has several side effects (Table 4). However, almost 65% of the women thought that estrogen treatment increases quality of life. Women aged 30–59 years, the ones with the highest educational level, women who used HRT, and the ones who had received information from their doctors had the highest proportion answering in the affirmative to this last statement. Information from media was associated with a larger degree of skepticism (Table 4).
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Table 2 The proportion of women (16–79 years) who said they had received information about estrogen treatment from different sources according to age and education Have received information from
Age (years) 16–29 30–44 45–59 60+ P Education (years) B10 10–12 13+ P Total
Have not received information
Media
Physician
Friends/relatives/others
n=78
n =67
n= 95
n =497
n 172 220 168 177
% 11.6 13.6 10.7 5.6
% 0.6 4.1 25 8.5
% 14 11.8 17.3 9
% 73.8 70.5 47 76.8 B0.001
236 367 134
8.5 9.5 17.2
11.4 7.1 10.4
7.6 12.5 23.1
737
10.6
9.1
12.9
72.5 70.8 49.3 B0.001 67.4
3.4. Are women willing to use estrogen for perimenopausal complaints and in pre6ention of illnesses? Almost 75% of the women were willing to use HRT for climacteric complaints (Table 5), and the percentage was highest among the youngest. Further, the percentage was highest in women who both had short/medium education level, correct knowledge and positive attitude (87%), while the percentage was lowest (43%) if long education was combined with correct knowledge and a negative attitude. Regarding willingness to use longterm estrogen in the prevention of osteoporosis and myocardial infarction, 65.0 and 68.1% of the women, respectively, answered on the affirmative. The combination of medium education, correct knowledge and positive attitude gave the highest willingness (76%), while high level of education, incorrect knowledge and negative attitude was associated with the lowest willingness (23%). Logistic regression showed that information from doctors, short/medium education and a positive attitude were the most important predictors for the willingness of preventive use. Young age and a positive attitude were the most important factors associated with willingness to use HRT against climacteric complaints.
3.5. Self-reported use of estrogen In 1994, 9.9% of Norwegian women (30–79 years) reported that they used estrogen, while the numbers for 1996 and 1998 were 8.1 and 8.9%, respectively (Table 6). In the same period, the use of HRT in the most relevant age group (45–69) was 16.3% in 1994, 19.1% in 1996 and 19.1% in 1998 (P=0.421, trend). In 1996 and 1998, 2.5 and 4.1%, respectively, in the same age group stated that they used transdermal estrogen. There was no statistically significant difference in the use of HRT in relation to the woman’s level of education. The proportion of HRT-use was higher in the more urban parts of Norway in 1996 and 1998. In all 23.8% (10 out of 42) of the HRT-users and 90.7% (195 of 215) of the non-users aged 45–69 years stated in 1994 that they had not received any information about estrogen from a doctor during the last 2 years. After age, a positive attitude towards and knowledge about estrogen were the factors that mattered the most for use of HRT (received information was not in the model). Education, area of residence and willingness to use HRT were not statistically significant. Table 7 shows that there was an interaction between attitude, knowledge
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and length of education concerning the use of estrogen. Short education, correct knowledge and a positive attitude towards estrogen gave the highest percentage of users. We found no association between the use of HRT and marital status, own income, area of residence, whether they were unemployed or not, or if the woman was in a leading position. The prevalence of low potent estrogen for urogenitial disorders was 8.5% in 1996 and 9.3% in 1998 in women older than 40 years of age (Table 8).
3.6. Sale of estrogen Fig. 1 shows the sales figures for different types of systemic estrogen (ATC gr G03C and G03F) Table 3 The proportion of women (16–79 years) who answered in the affirmative (correctlya) to questions about knowledge of the effect of HRT (n = 737) Estrogen reduces the risk of getting
Age (years) 16–29 30–44 45–59 60+ P Education (years) B10 10–12 13+ P
Myocardial infarction (%)
Osteoporosis (%)
23.8 36.4 53.6 32.2 B0.001
32.0 47.3 65.5 44.6 B0.001
36.4 33.8 43.3 0.148
37.7 45.8 67.9 B0.001
Recei6ed information from Media 44.9 Physician 68.7 Friends/relatives/o 46.3 thers Not received 28.9 information P B0.001 Total 36.4 a
59.7 79.1 68.4 37.2 B0.001 47.2
Correctly is what was consistent with evidence from observational studies at that time — i.e. that HRT reduced the risk of coronary heart disease and osteoporosis.
and the total use of systemic estrogen for the period 1990–1998. Purchased daily doses of systemic estrogen increased from 1990 to 1994 with about 30% annually, leveling off the last years. Norethisteron and estradiol in continuous combination (Kliogest) and as sequential medication (Trisekvens, Trisekvens forte, Estracomb) increased most in the period. Estradiol (transdermal or orally) have also increased, while the sale of other preparations has been stable between 1990 and 1998. Totally, 143 971 daily doses (DDDs per day) of estrogen for systemic use were sold in 1998, which corresponds to an estimated prevalence of 25%, calculated from the number of women in the age group 45–69 years pr. 1.1.1998 (n= 576 563), which is the most relevant group of users. In spite of an increase of 362.5% in purchased systemic estrogen (DDDs per day) in Norway in the period 1990–1998, women in Iceland purchased more HRT than Norwegian women in 1997 (Fig. 2). In the period 1990–1998, the sale of low potent medication for urogenital disorders in Norway has been two-fold, and the sale in 1998 was 57 869 DDDs per day, which corresponds to about 9.4% presumptive users (n = 618 046 aged 50–79 years). Because of intermittent use of vaginal cream and suppositories, and some variation in daily oral dose, it is difficult to compare sales figures and self-reported use.
4. Discussion The women aged 45–59 years, those with the highest level of education, and those who used HRT had to the highest degree received information about estrogen. Compared to other women, they also had the best knowledge about the effects and they thought that estrogen-treatment increases the quality of life. On the other hand, these groups were just as uncertain as the other groups when they evaluated the statement ‘‘one knows too little, science often changes its opinion concerning whether HRT treatment is dangerous or not’’. When the women then were asked about
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Table 4 The proportion of women (16–79 years) who totally or partly agree in some common statements about HRT (n = 737) Estrogen has many side effects (%)
Estrogen-treatment increases quality of life (%)
59.9 52.7 51.8 50.3 0.283
62.8 73.2 75.6 45.8 B0.001
68 69.5 72 67.8 0.823
Education (years) B9 53.8 9–12 54.2 13+ 51.5 P 0.860
54.7 66.5 77.6 B0.001
64.4 70.8 73.9 0.111a
Age (years) 16–29 30–44 45–59 60+ P
Recei6ed information from Media 59.0 Physician 44.8 Friends/relatives/o 58.9 thers Not received 52.9 information P 0.242 Total 53.6 a
One knows too little about estrogen (%)
69.2 89.6 76.8
88.5 65.6 75.8
58.4
65.6
B0.001 64.7
B0.001 69.3
PB 0.05 for trend.
Table 5 The proportion of women (16–79 years) who were willing to use HRT for climacteric complaints and who were positive towards long term treatment to prevent myocardial infarction and osteoporosis (n= 737) Climacteric complaints (%) Age (years) 16–29 30–44 45–59 60+ P Education (years) B10 10–12 13+ P Total
Myocardial infarction (%)
84.3 73.2 77.4 62.7 B0.001
69.2 64.5 73.2 66.7 0.313
72.9 76.3 70.9 0.403 74.2
73.7 70.3 52.2 B0.001 68.1
willingness to use estrogen, the ones with the highest educational level were the least willing. Finally, we found no difference in self-reported use of HRT between the educational groups after adjustment for age.
Osteoporosis (%)
61.6 63.6 70.2 65.0 0.382 64.8 68.9 54.5 B0.01 65.0
There was a small insignificant increase in selfreported use of HRT in the age group 45–59 years from 1994 to 1998. Except for age, a positive attitude towards HRT was the most important predictor for self-reported use, followed by-
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Table 6 Self-reported use of HRT in Norwegian women 30–79 years of age according to age and level of education
Age (years) 30–44 45–59 60–79 P Education (years) B9 10–12 13+ P P (adjusted for age) Total
1994a (n= 565) (%)
1996 (n = 460) (%)
1998 (n =489) (%)
3.2 20.8 7.9 B0.001
1.3 21.8 7.3 B0.001
0.9 22.8 6.3 B0.001
11.1 10.1 7.4 0.588 0.868 9.9a
9.2 8.1 6.9 0.804 0.886 8.1
9.2 9.3 7.8 0.884 0.885 8.9
a The question about use of estrogen was asked differently in 1994. The total proportion probably contains some younger women using the contraceptive pill and some older women using low potent estrogen for urogenital disorders.
knowledge consistent with results from observational studies. We suppose that the samples we analyzed are representative of the female Norwegian population between 16 and 79 years, since there were only minor differences between the samples frame and actual sample with regard to age, gender, and area of residence [31]. Besides, the sample frame in 1994 was very similar to the total population with regard to age and gender [34].
4.1. Information and source of information is important Only one third of the women had received information about estrogen during the last 2 years, which shows that the proportion of Norwegian women who have received information on this topic has not increased considerably between 1990 and 1994 [20]. Several studies show that women would prefer more information about estrogen from doctors and others [20,21,27,35 – 39], and that women receive too little information and lack sufficient knowledge to make well-founded choices concerning use of hormonal substitution [21,23,27,35,40 – 43].
Table 7 The proportion of women (30–79 years) who use estrogen, according to education, knowledge about and attitude towards estrogen (n = 565) Education
Knowledge
Attitude (n)
Use estrogen (%)
Long (13+years)
Correcta
Positiveb(56)
12.5
Incorrect
Negative (28) Positive (9) Negative (15)
3.6 – –
Correcta
Positive (98)
19.4
Incorrect
Negative (67) Positive (38) Negative (74)
9.0 5.3 1.4
Correcta
Positive (61)
24.6
Incorrect
Negative (40) 2.5 Positive (9) 11.1 Negative (70) 4.3
Medium (10–12 years)
Short (B10 years)
a
Correct knowledge: think that estrogen reduces the risk of getting osteoporosis and/or reduces the risk of getting myocardial infarction. b Positive attitude: totally or partly agree that estrogen increases quality of life and/or totally or partly disagree that estrogen has several side effects and/or totally or partly disagree that one knows too little about estrogen.
A.J. Søgaard et al. / Maturitas 35 (2000) 201–214 Table 8 Self-reported use of low potent estrogen (estriol) for urogenital disorders in Norwegian women 40–79 years of age according to age and level of education
Age (years) 40–49 50–59 60–69 70–79 P Education (years) B9 10–12 13+ P P (adjusted for age) Total
1996 (n =305) (%)
1998 (n=334) (%)
0.8 15.9 13.6 13.7 B0.001
3.3 8.5 18.8 12.3 B0.005
10.4 7.6 7.4 0.698 0.760 8.5
9.7 10.3 6.6 0.664 0.235 9.3
Weekly magazines were the most important source of information for Norwegian women in 1990 [20], a finding that corresponds well with similar results in other countries [16,23,28,41,44]. Our study shows that the doctors were almost equally important as source of information in those who said they had received information. The proportions are, however, difficult to com-
209
pare, since the questions were asked differently in 1990 and 1994. The women, who had received their information from a physician more often than other women had correct knowledge, an open attitude towards HRT and were more willing to use estrogen to prevent chronic diseases. Women who had received information through media often had less correct knowledge, a more skeptical attitude and less willingness to use HRT. Perhaps the public health service should use the different media more actively to improve the quality of information given about estrogen, and thereby make the women better prepared to take informed choices.
4.2. The women still lack knowledge Women’s knowledge about the long-term effects of HRT on different illnesses was to some extent consistent with results from observational studies, but about one in three claimed that they did not know. The proportion of women answering that estrogen reduces the risk of myocardial infarction increased from 3% in 1990 [20] to 36.4% in 1994 (but the questions were not totally identical in the two surveys). More than half of the perimenopausal women believed HRT prevented myocardial infarction (MI). The survey
Fig. 1. Sale of HRT (ATC gr G03C and G03F) for systemic use in DDD per day for the period 1990 – 1998 in Norway (Norwegian Medical Depot [29,30]).
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Fig. 2. Sale of HRT (ATC gr G03C and G03F) in DDD per 1000 inhabitants per day for the period 1981 – 1997 in the Nordic countries (Nordic Council on Medicines). Statistics from Finland in 1985 and from Denmark in 1993 are missing, and are extrapolated. Denmark changed registration-procedure in the mid 1990s — i.e. sale from hospitals are not included.
was performed during a period with increasing focus in media on these aspects, due to the optimistic results on the prevention of MI in many observational studies. That more than 65% of these respondents believed that HRT could prevent osteoporosis is not so surprising, since the lack of estrogen has been associated with osteoporosis for decades [4]. The importance of knowledge may be illustrated by studies which show that far more female doctors and doctors’ wives, compared to the general female population, were using HRT [19,45].
4.3. Ambi6alent attitudes towards long-term estrogen treatment Both with regard to willingness to use estrogen, and actual use of HRT, a positive attitude was the most important predictor, assuming the same level of knowledge. The results in Table 4 indicate that Norwegian women are ambivalent towards estrogen. The duplicity is most obvious in women with the highest level of education. These women had received most information, they had the best knowledge on estrogen’s preventive effect, but had a somewhat ambivalent attitude towards estrogen. They had the highest proportion with the opinion that estrogen increases quality of life, but
at the same time they claimed more than others that scientists know too little. They were less willing to use estrogen to prevent chronic disease than those with less education were, and they did not report more frequent use than other educational groups. We do not know the background for this ambivalence; it could perhaps have ideological and historical reasons. May be the objections and oppositions created in the mid 1970s by books like e.g. ‘Always Woman: Is the Menopause a Deficiency Disease?’ [46], still affects the view of this cohort of well-educated women, whom today are in the actual age for starting HRT? But, why is this resistance more pronounced in Norway than in other countries? With a few exceptions [47,48], most international studies show that the proportion of users is highest among women with long or medium education [8,15–17,21,49,50].
4.4. Increased willingness to HRT use The willingness to use estrogen against menopausal complaints and for prevention of different diseases is surprisingly high, considering the large amount of skepticism that is revealed. The willingness to use estrogen has increased considerably in the 1990s. In 1990, 45% were positive to
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use estrogen for menopausal complaints in general, while 60% were positive to use HRT in the prevention of osteoporosis [20]. The corresponding numbers from our study were 74.2 and 65.0%. The fact that the youngest women were the most positive towards the use of estrogen for menopausal complaints, may suggest that they perhaps are less preoccupied with this issue than those engaged in the ideological debate in the mid 1970s. There is, in our study, little accordance between the proportion of users of estrogen and the percentage who are positive to this kind of use to prevent myocardial infarction (68.1%) and osteoporosis (65.0%) after recommendation from their physician. Several authors have recently focused on the need for physicians to engage in a dialogue with their patients, which allows individual evaluation and application of current knowledge about HRT [27,35,40].
4.5. Sale and use of HRT The sale of HRT in Norway has increased significantly in the 1990s, a development already observed at the end of the 1980s [51]. No other Nordic country had a larger increase in the sale of HRT in the ATC-group G03C and G03F in the period 1990–1997 (Fig. 2). All the Nordic countries, except Denmark, have had a large increase in the sale of HRT the last 15 years (Fig. 2). Denmark, which in the beginning of the 1980s was clearly highest in the North concerning sale of HRT in the two mentioned ACT-groups, are now definitively the lowest (Fig. 2). However, the statistics from Denmark is uncertain, since they had a change in their registration-procedures in the mid 1990s. They do not any more include sale from hospitals in their statistics. The sales statistics may, therefore, underestimate the real Danish HRT-use (personal message M.-L. Lunn, Lægemiddelstyrelsen, Copenhagen). Self-reported use of HRT among Danish women 45– 65 years was in 1994 18.4% [52], which is the same as the corresponding age group reported in our study in 1994 (18.8%). That the percentage reporting use of HRT between 30 and 79 years, according to our studies,
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decreased from 1994 to 1996, in spite of a clear increase in the sale, could have two possible explanations. Firstly, the prevalence of HRT-use in 1994 was probably overestimated as users of contraceptive pills and users of low-potent estrogen may erroneously have been included. If we look at the age group 45–59 years, there has been a slight increase. Secondly, compliance problems may account for part of the difference. Several authors [10,13,15,16,21,22,36,47,53 –55] have reported lack of compliance concerning use of estrogen. The numbers from our three studies and the sales statistics from the corresponding years indicate that the sale is 1–6% points above the proportion that reports to use estrogen based on the age group 45–69 years. But if we include the margins of error to the Omnibus study, the sales figures are inside the confidence intervals for the users in this age group. We would also underline the risk of error which is inherent in calculating the percentage HRT-users based on sales statistics and an unknown denominator which is the number of potential users.
4.6. What influences the use of estrogen? The women’s attitudes were the most important predictor for use of estrogen in our study, which verifies findings from earlier studies [6,9,10,13,53]. In addition to this factor, information and knowledge were important concerning the use of HRT, which is also found by others [21,22,35,43,56]. The doctor was an important source of information concerning HRT. But it was obvious that several women in the actual age had not received information about estrogen from their physician. Several authors have pointed out that the doctors attitude and prescription-practice may be the most important factor to determine women’s use of estrogen [10,18,19,24,26,40,48,53,57], and that there is an obvious need for more information from doctors concerning HRT [9,21,27,35,37,40,54 –56,58,59]. If we compare percentage of use of HRT in Norway and Finland from the late 1980s, it may seem like there is a positive connection between the sale of estrogen and the doctors attitudes towards hormone substitution [21]. Several au-
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thors have mentioned not just a restrictive attitude in the doctors [26,60,61], but also lack of knowledge [25,26,61]. A Norwegian study from 1990 [26] indicates great uncertainty among GP’s concerning the effect of hormone substitution. At that time, a considerable proportion of the physicians considered coronary heart disease in the family and smoking to be contraindications for HRT [26]. Some of them were also restrictive to prescribe local estrogen (low dose) to women with angina pectoris. It is interesting to see that women more often get HRT prescribed if they visit female doctors [62], that female doctors are more positive to HRT than men [24,63], and that they have less problems than their male colleagues concerning the settling/adjusting of a HRT treatment program [25]. After the Consensus Conference on the use of estrogen in Norway in 1990, female doctors changed their prescription-practice more than men did [64]. Only 4.1% of the women in the most actual age group used transdermal estrogen in 1998, a kind of administration that may have some advantages compared to oral estrogen [65]. In addition, some studies show better compliance by the use of estrogen patches compared to pills [65,66]. The choice of pills versus patches is obviously an economical question for several women, but probably also a question of being informed of the possible alternatives.
5. Conclusion The relatively large willingness, especially in those with middle and short education, to use HRT to prevent osteoporosis and myocardial infarction after a doctor’s recommendation, places a lot of responsibility with the physicians and nurses. These women seem to count on the experts’ advise, because they have a lesser degree than those with a high level of education, have correct knowledge and in general, receive less information from other sources than the doctor. Here is obviously a great challenge and a large potential for matter-of-fact/objective information about hormone substitution. The goal must be to
make the women better prepared to make informed choices based on evidence-based knowledge of positive and negative effects.
Acknowledgements We would like to thank Tine-Norske Meierier, Sandoz, Novo Nordisk and Eli Lilly, Norge A.S. for supporting the collection of the data.
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