Menopause Live (26 November, 2012) From IMS

A recently published paper by Sprague and colleagues [1] is the second publication after the report from Steinkellner and colleagues [2] within 6 months showing a sharp and still continuing decline of hormone use in the US following the publication of the preliminary data of the Women’s Health Initiative (WHI) in 2002. The new prospective data collection [1] is based on a complex cluster sampling method to create a sample population from which nationally representative estimates for hormone use can be produced. It describes a decrease of the overall prevalence of oral postmenopausal hormone use from 22.4% (95% confidence interval (CI) 19.0–25.8) in 1999–2000 to an overall prevalence of 11.9% (95% CI 9.6–14.2) in 2003–2004. Since then, hormone use has continued to decline through 2009–2010 across all patient demographic groups, with the current overall prevalence at 4.7% (95% CI 3.3–6.1) in 2010. The decline in hormone use after 2002 was observed among all age groups. Before 2002, current use of postmenopausal hormones was highest among non-Hispanic whites, women who attended college, and women with a higher income-to-poverty ratio. After 2002, the decrease of hormone use was more marked in non-Hispanic whites, and the decline in use was delayed for non-Hispanic blacks and Hispanic women. Non-Hispanic whites continued to have a higher prevalence of hormone use, although the absolute magnitude of the difference in use has declined sharply compared to women from other ethnicities. In conclusion, today, the percentage of American women aged 40 years and older reporting that they are currently using postmenopausal hormones has declined to less than 5%. In 1999–2002, one in five women older than age 40 years was a current user of oral postmenopausal hormones, whereas, by 2009–2010, the prevalence was fewer than 1 in 20.

Comment

Sprague and colleagues [1] show a still continuing decline of global hormone use for US women aged 40 years and older, from 22.4% before 2002 to 4.7% 10 years after the first publication of the preliminary WHI data. The velocity and the extent of this decline depended on social class and on ethnicity. The strongest drop occurred in non-Hispanic white women characterized by a better education and a higher income. The authors speculate that this phenomenon might be due to a higher preventive hormone use in better educated white women before 2002, followed by a greater decline in hormone use after the publication of the first WHI data speaking strongly against such a preventive hormone use.

However, the following table, a raw estimation of the decrease in hormone use based on the relative changes in the sales of global systemic hormone preparations in different countries, shows that the dramatic decline of hormone use found by Sprague and colleagues [1] for the US is not shared by all countries. In this comparison, the year 2001 is set arbitrarily as 100%:
2001 2004 2010 2011
US [1] 100% 53% 21% no data
US + Canada (sales) 100% 43% 39% 38%
Europe (sales) 100% 57% 37% 35%
Switzerland (sales) 100% 69% 47% 51%
China (sales) 100% 54% 157% 190%

In my eyes, the authors neglect to discuss the high impact of the media, mainly between 2002 and 2007, promoting breast cancer and cardiovascular mortality fear, although fully unjustified [3,4]. Media campaigns reach preferentially higher educated women in good social conditions, probably explaining the sharp and important decline found in this group. This negative media campaign was much stronger in the US than in most European countries (except in the UK and in Germany), and particularly stronger than in Switzerland. I would speculate that the less important decrease of hormone use in Switzerland and the recovery now starting is due to a different local media climate. On the other hand, China, a very different and rapidly growing market, had not experienced the strong pro-hormone campaign in western countries in the 1990s, and therefore no reason to overreact after 2002. 

Unfortunately, this study concentrates on oral hormone use only and neglects the potential switch of doctors and users to non-oral routes of administration, as has been observed in Europe since 2002. In southern Europe, the percentage of non-oral hormone use reaches today up to 70% of the global systemic hormone market. In Switzerland, on the border between southern Latin and northern non-Latin Europe, the non-oral use is 35%. This European switch to patches and gels might be due in part to cultural reasons, but two large French studies, ESTHER [5] and E3N [6], had an important impact on the selection of the form of administration of estradiol and of the type of the progestogen. Both studies pointed to the importance of these two parameters for the risks and side-effects of hormone use, particularly of the most feared ones such as cardiovascular diseases, stroke, deep venous thrombosis and breast cancer. Finally, it is not astonishing that, in parallel with the drop in the systemic market, the market for local-vaginal estrogens is increasing significantly. 

The conclusion to be drawn from these different behaviors of the hormone markets in different countries is that the impact of the media might have been underestimated by our Scientific Societies after 2002. Our societies have to work in the future proactively and even closer with the media than they do now, and they should renew their efforts to inform and educate postmenopausal women, adapted to the local conditions.

Martin Birkhäuser
University of Berne, Basel, Switzerland

References

1. Sprague BL, Trentham-Dietz A, Cronin KA. A sustained decline in postmenopausal hormone use. Results from the National Health and Nutrition Examination Survey, 1999–2010. Obstet Gynecol 2012;120:595–603.
http://www.ncbi.nlm.nih.gov/pubmed/22914469
2. Steinkellner AR, Denison SE, Eldridge SL, Lenzi LL, Chen W, Bowlin SJ. A decade of postmenopausal hormone therapy prescribing in the United States: long-term effects of the Women’s Health Initiative. Menopause 2012;19:616-21.
http://www.ncbi.nlm.nih.gov/pubmed/22648302
3. LaCroix AZ, Chlebowski RT, Manson JA, et al. Health outcomes after stopping conjugated equine estrogens among postmenopausal women with prior hysterectomy. A randomized controlled trial. JAMA 2011;305:1305-14.
http://www.ncbi.nlm.nih.gov/pubmed/21467283
4. Schierbeck LL, Rejnmark L, Tofteng CL, et al. Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: randomised trial. BMJ 2012 Oct 9;345:e6409. doi: 10.1136/bmj.e6409.
http://www.ncbi.nlm.nih.gov/pubmed/23048011
5. Canonico M, Oger E, Plu-Bureau G, et al. Hormone therapy and venous thromboembolism among postmenopausal women: impact of the route of estrogen administration and progestogens: The ESTHER Study. Circulation 2007;115:820-2.
http://www.ncbi.nlm.nih.gov/pubmed/17309934
6. Fournier A, Berrino F, Clavel-Chapelon F. Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study. Breast Cancer Res Treat 2008;107:103-11.
http://www.ncbi.nlm.nih.gov/pubmed/17333341