Menopause Live (18 October, 2010) from IMS

A recent prospective, randomized, controlled follow-up study from Slovenia was started on February 15, 2003 and terminated on February 28, 2005 [1]. The participants answered one questionnaire before starting hormone therapy (HT) and another during follow-up visits after the 3rd, 6th, 12th, and 24th months. The study group (n = 64) attended oral presentations on menopause and HT, whereas those in the control group (n = 63) did not. The educational presentations aimed at helping the women to make their own informed decision about whether to start HT and then to continue HT, and about whether to change aspects of their way of life (e.g. improve their diet and/or exercise more frequently and/or use alternative therapies such as acupuncture and natural healing). At 3 months, 31% of the women in the control group had already discontinued therapy, but only 14% in the study group had done so. Fear of breast cancer was among the major reasons for stopping therapy so soon. After 24 months, 47% of the participants in the study group and 32% in the control group were still using HT. The duration of hormone use was found to correlate with the following items at 12 and 24 months: (1) never used or had only occasionally used an oral contraceptive (odds ratio (OR) 3.7, 95% confidence interval (CI) 1.74–7.85; OR 2.2, 95% CI 1.30–3.91, respectively); (2) not attended the educational presentations (OR 2, 95% CI 1.14–3.53; OR 1.8, 95% CI 1.13–2.97, respectively); (3) a friend’s advice (OR 1.7, 95% CI 0.93–3.17; OR 1.8, 95% CI 1.07–3.15, respectively); (4) starting HT to relieve climacteric symptoms (OR 2.1, 95% CI 0.98–4.51; OR 2, 95% CI 1.05–3.72, respectively); (5) realizing that HT improved their quality of life (OR 0.46, 95% CI 0.21–1.05; OR 0.5, 95% CI 0.26–1.03, respectively).

Comment
This study was initiated after the first release of data from the Women’s Health Initiative (WHI) trial, and thus women were probably already exposed to the problematic atmosphere that surrounded the whole issue of postmenopausal HT at that time. Rate of hormone use, compliance and adherence to therapy were affected by the WHI data throughout the whole world, mainly because of flawed interpretation leading to misperceptions in regard to the attributed risks of HT [2]. Although Franić’s study [1] interviewed a relatively small number of women, it clearly demonstrated the impact of proper counseling in the set-up of postmenopausal HT. Women who were well-informed about HT were more adherent to therapy, yet, despite this educational intervention, half discontinued therapy within 2 years. Interestingly, women who started HT because of vasomotor symptoms tended to stop treatment earlier than those who received it for other reasons, which is probably the result of the transient nature of hot flushes in many women, on the one hand, and the popular recommendation to use hormones for the shortest duration, on the other hand. Nevertheless, the study also showed that women who felt that their quality of life improved because of HT were more adherent. Several surveys pointed at the sources of information on HT for postmenopausal women. While a discussion with the health-care provider should be the most appropriate, in real life the media and internet rank first. This is also reflected in Franić’s study, where one of the significant reasons for stopping HT was advice from a friend.

The position of the International Menopause Society in this respect was summarized in its 2007 statement as follows [3]: ‘Counselling should convey the benefits and risks of HT in simple terms… This allows a woman and her physician to make a well-informed decision about HT… Whether or not to continue therapy should be decided at the discretion of the well-informed hormone user and her health professional, dependent upon the specific goals and objective estimation of individual benefits and risks.’ Counseling is the heart of the matter concerning HT. It is time-consuming, but the benefits of such an approach are substantial. In parallel, education should be provided also for the primary physicians, who are exposed to the same drawbacks of the media and the internet resources, these being on many occasions incorrect, partial or even biased.

Amos Pines
Department of Medicine ‘T’, Ichilov Hospital, Tel-Aviv, Israel

References
1. Franić D, Verdenik I, Meden-Vrtovec H. Effect of counseling on adherence to perimenopausal hormone therapy in Slovenia. Int J Gynaecol Obstet 2010 Sep 24. Epub ahead of print.
http://www.ncbi.nlm.nih.gov/pubmed/20870230
2. Silverman BG, Kokia ES. Use of hormone replacement therapy, 1998–2007: sustained impact of the Women’s Health Initiative findings. Ann Pharmacother 2009;43:251-8.
http://www.ncbi.nlm.nih.gov/pubmed/19193581
3. Pines A, Sturdee DW, Birkhäuser M, et al. IMS updated recommendations on postmenopausal hormone therapy. Climacteric 2007;10:181-194.
http://www.ncbi.nlm.nih.gov/pubmed/17487645