We thank Jeremy Isaacs for assiduous data input and processing. Funding: ... 20 Hammond CB, Jelovsek FR, Lee KL, Creasman WT, Parker RT. Effects of.
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A J Isaacs, A R Britton, Klim McPherson 'Me attitudes of general practitioners may be important determinants of women's choices on whether to use hormone replacement therapy and for TropicalMedicine, how long, particularly as many women consider that London WC1E 7HT the menopause should be viewed as a medical conDesign-Postal questionnaire A J Isaacs, visiting research dition. We investigated the use of hormone replace in the United King- ment Setting-General practices fellow therapy by women doctors as they are a well A R Britton, research assistant dom. informed group in a strong position to influence the Khm McPherson, professor of stratified sample Subjects-Randomised behaviour of other women. women doctors who obtained full registration ofpublic health epidemiology between 1952 and 1976, taken from the current Correspondence to: principal list of the Medical Register. Professor McPherson. Main outcome measures-Prevalence and dura- Methods Sampling-The sampling frame consisted of all tion of use of hormone replacement therapy; menoBM,71995;311:1399-401 women doctors who obtained full registration with the status. pausal Results-43verall, 45.7% (436/954) of women General Medical Council between 1952 and 1976 doctors aged between 45 and 65 years had ever used inclusive and whose names appeared on the principal hormone replacement therapy. When the results list of the Medical Register in 1993. A randomised from women still menstruating regularly were sample of 1550 was taken, stratified by five year bands, obtain an approximately even age distribution across excluded, 55-2% (428) were ever users and 41-2% to the age range 40 to 65 years. Of these, 36 living abroad of The cumulative current users. probability (319) final sample size of 1514. remaining on hormone replacement therapy was were excluded Questionnaire-A postal questionnaire, explanatory 0-707 at five years and 0-576 at 10 years. Conclusions-Women doctors have a higher letter, and reply paid envelope were sent to all doctors prevalence of use of hormone replacement therapy in the sample in June 1993. Initial non-responders than has been reported for other women in the were sent a reminder letter, and finally a further letter United Kingdom, and most users seem to be taking with a second copy of the questionnaire and another hormone replacement therapy for more than five reply paid envelope was sent in July. All responses years. The results may become generalisable to the received by the end of 1993 were coded and the wider population as information on the potential data entered onto a computerised database. Statistical benefits of hormone replacement therapy is dissemi- analyses were carried out with Epi-Info.1 When answers to specific questions were missing these nated. were omitted from the relevant analyses. TABLEi-Response rate to respondents questionnaire on use of hormone The questionnaire covered various demographic and replacement therapy in women behavioural factors which will be reported fully elseIntroduction doctors by registration group current report being restricted to the Long term hormone replacement therapy is where., the and duration of use of hormone replaceprevalence in the instrumental as No in No (%) Year of reducing increasingly accepted registration sample responding risk of osteoporosis and cardiovascular disease in ment therapy. postmenopausal women.' Little is known for certain, 1952-6 301 251 (83-4) however, of the overall uptake of hormone replace- Results 306 252 (82-4) 1957-61 303 247 (81-5) 1962-6 ment therapy in the United Kingdom and the use in the 301 228 (75-5) 1967-71 Response rate-A total of 1211 completed responses longer term which may produce a considerable impact were 299 233 (77-9) 1972-6 received. Four were returned as having failed to on public health. reach the intended recipient. The total valid response rate was therefore 80-2%. Table I shows the numbers TABLF- u-1--revalence of use of hormone replacement therapy by age group in women doctors responding by year of registration. Ever Current use Menopausal status-Periods had ceased completely in 771 women; 45 were perimenopausal; 93 had started % (95% Confidence No of % (95% Confidence No of Total interval) interval) hormone replacement therapy before the menopause; and 302 were still menstruating regularly. A total of All women 1211 39.6 (36.8 to 42-4) 344 28-4 (25-9 to 30-9) 480 All ages 186 women had ceased menstruating as a result of Age group (years): surgery. 140 7-9 (3-4 to 12-4) 6-4 (2-3 to 10-5) 11 9 40-44 231 55 23.8 (18.3 to 29-3) I-Irevalence of hormone replacement therapy use49 21-2 (15-9 to 26-5) 45-49 196 109 55-6 (48-6 to 62-6) 43-3 (36-5 to 50-2) 85 50-54 480 of the 1211 respondents (39-60/6) had ever Overall, 254 61-0 (55-0 to 67-0) 44-9 (38-8 to 51 -0) 155 114 55-59 used hormone replacement therapy, of whom 344 273 117 42-9 (37-0 to 48-8) 71 26-0 (20-8 to 31-2) 60-64 91 30-8 (21-3 to 40-3) 28 14 15-4 (8-0 to 22-8) 65-69 (28-4% of the whole group) were still using it (table II). 26 19-2 (4-1 to 34-3) 5 2 7-7 (0-0 to 17-9) 70Of the 954 women aged between 45 and 65., 436 Excluding premenopausal 909 472 51-9 (48-7 to 55- 1) 344 37-8 (34-6 to 41 -0) All ages (45-7%) had ever used hormone replacement therapy. Age groups (years): of current use was highest in the 50-59 year Prevalence 17 64-7 (42-0 to 87-4) 11 9 52-9 (29-2 to 76-6) 40-44 band 44-2%); this declined after age 60. (199; 90 age 52 57.8 (47-6 to 68-0) 49 54.4 (43-2 to 64-7) 45-49 159 104 65.4 (58.0 to 72-8) 85 53-5 (45-7 to 61-3) 50-54 When we excluded data on women still menstruating 253 61-3 (55-3 to 67-3) 155 45-1 (39-0 to 51-2) 114 55-59 regularly, 472 out of 909 (51-9%) had ever used 42.9 (37-0 to 48-8) 273 117 71 26-0 (20-8 to 31-2) 60-64 91 30-8 (21-3 to 40-3) hormone replacement therapy. Between the ages of 28 14 15-4 (8-0 to 22-8) 65-69 26 19-2 (4-1 to 34-3) 5 22 7-7 (0-0 to 17-9) 7045 and 65 years, 55-2% (428) were ever users and 41-2% (319) current users. The prevalence of ever use *Fourteen respondents who did not state their date of birth were allocated to the most probable group according to was of highest below age 60 (322/519; 62%) and declined year registration.
Abstract
Department ofPublic Health and Policy, London School ofHygiene and
Objectives-To ascertain the prevalence and duration of use of hormone replacement therapy by menopausal women doctors -
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thereafter. Current use was stable up to 55 years (143/266; 53.80/6) and then declined. Use of hormone replacement therapy was higher in women with a surgical menopause, particularly after bilateral oophorectomy. Of 50 women in the latter group, 42 had received hormone replacement therapy at some time and 29 were current users. Duration of hormone replacement therapy-Past users had received hormone replacement therapy for a median (range) period of 0-8 (0-1-20) years, whereas current users had taken hormone replacement therapy for 3-6 (0-1-26-1) years. Life table analysis of the combined group showed that over 70.70/% of ever users were still receiving hormone replacement therapy five years after starting and over 57-60/6 at 10 years (figure). When asked their intentions, 130 (37-8%) current users anticipated taking hormone replacement therapy for between five and 10 years altogether and 166 (48 1%) for more than 10 years.
Key messages * The high rate of personal use of hormone replacement therapy by women doctors in the United Kingdom suggests that such rates are likely to increase considerably in the general female population * Over half of women starting hormone replacement therapy may be expected to continue the treatment for 10 years or more * A considerable number of women will be unlikely to take up hormone replacement therapy in the absence of full evaluation of benefit and risk * Full evaluation will require randomised controlled trials
v
by our results may in part be attributable to the high socioeconomic status of women doctors, a known & determinant of use of hormone replacement therapy in the United Kingdom"4"1 as elsewhere. Women doctors o-!tS V may perhaps be pace setters for the wider female population in this respect, as for smoking,'6 another 0= health related behaviour. The benefits of hormone replacement therapy to the o~5 individual in terms of reduction of risks of fracture and cardiovascular disease are thought to be related to duration of use. Risk-benefit and cost effectiveness models of the impact on public health, taking into Years since starting hormone replacement therapy account potential adverse consequences such as an Probability of continuing to take hormone replacement therapy. increased risk of breast cancer risk'7 as well as Vertical bars represent 95% confidence intervals benefits, often assume compliance with treatment over 10 years.'8 '9 Cross sectional surveys in the United Kingdom have not so far studied the issue of length Discussion of treatment. Studies from the United States have There have been relatively few published surveys reported rather low rates of compliance overall,20 21 and on the use of hormone replacement therapy in the it has been suggested that these could be increased by United Kingdom, and these have differed in respect of education of both patients and physicians about the methodology, target age group, and geographical value of hormone replacement therapy.22 The current location. A survey in Greater London of women aged survey indicated that, although 10% of women doctors 45-65 showed 10% of the whole group (and 18% of stopped hormone replacement therapy within six those no longer having periods) had ever received months, the discontinuation rate subsequently hormone replacement therapy.6 Doctors in the declined, and over 50% of those starting would still be Medical Research Council's general practice research expected to be taking hormone replacement therapy at framework prescribed hormone replacement therapy 10 years. This may be because they rely less on the to an estimated 9% of their female patients aged 40-64 views of their general practitioners than do other in 1989, with female doctors treating an average of women. about five more women than male doctors.7 An Though these data are based on the respondents' international survey indicated current rate of use of unvalidated recollections of their past use of hormone hormone replacement therapy of 7% in women aged replacement therapy, a longitudinal study showed 40-69 in the United Kingdom.8 Another study in reasonable consistency of reporting of perimenopausal Scotland found a prevalence of 9% for current use and use of oestrogen, at least up to 10 years since last use.2' 16% for ever use among postmenopausal women aged Furthermore, the subjects' own predictions of their likely duration of future use gave similar results. It may 33-68.4 The above rates are all considerably lower than those therefore be reasonable to take 50% compliance at 10 found in the present study, in which current use of years as a target for other groups of women and to hormone replacement therapy was 33% in the 45-64 use this figure in cost effectiveness analyses. The age group and ever use was 46%, these figures rising to possibility of increasing rates of use and compliance 41% and 55% if data for premenopausal women were in the general population has been shown by the excluded. The prevalence of use of hormone replace- establishment of a dedicated clinic in primary care.24 ment therapy among women doctors in the United Overall, the results of the survey are consistent with Kingdom is thus closer to the reported rates in the increasing use of hormone replacement therapy by western United States>" than to those among other younger postmenopausal women doctors. This may women in the United Kingdom (though unpublished presage more widespread use in the general population, data suggest that rates in the latter are now rising). particularly as more information becomes available In the United States rates of use of surgical proce- on the preventive effects of hormone replacement dures by doctors have been shown to reflect or only therapy.2' About 40% of those in the most eligible age slightly exceed those in comparable groups of lay group, however, had never tried it, and more general people,'2 whereas there is greater use of obstetric use still may depend on the further elucidation of the interventions by women doctors." The substantial benefit:risk ratio, which is likely to have to await the difference for hormone replacement therapy suggested results of large scale randomised controlled trials.26 a
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The authors take sole responsibility for the views expressed. We thank Jeremy Isaacs for assiduous data input and processing. Funding: Department ofHealth. Conflict of interest: None. 1 Ettinger B, Genant HK, Cann CE. Long-term estrogen replacement therapy prevents bone loss and fractures. Ann Intern Med 1985;102:319-24. 2 Stampfer MJ, Colditz GA. Estrogen replacement therapy and coronary heart disease: a quantitative assessment of the epidemiologic evidence. Prev Med
1991;20:47-63. 3 Ferguson KJ, Hoegh C, Johnson S. Estrogen replacement therapy: a survey of
women's knowledge and attitudes. Arch Intern Med 1989;49:132-6. 4 Sinclair HK, Bond CM, Taylor RJ. Hormone replacement therapy: a study of women's knowledge and attitudes. Bry General Practice 1993;43:365-70. 5 Dean AG, Dean JA, Burton AH, Dicker RC. Epi Info. Version 5. Stone Mountain, GA, USA: 1990. 6 Spector TD. Use of oestrogen replacement therapy in high risk groups in the United Kingdom. BMJ 1989;299:1434-5. 7 Wilkes HC, Meade TW. Hormone replacement therapy in general practice: a survey of doctors in the MRC's general practice framework. BMJ 1991;302: 1317-20. 8 Oddens BJ, Boulet MJ, Lehert P, Visser AP. Has the climacteric been medicalized? A study on the use of medication for climacteric complaints in four countries. Maturitas 1992;15:171-81. 9 Hemminki E, Kennedy DL, Baum C, McKinlay SM. Prescribing of noncontraceptive oestrogens and progestins in the United States, 1974-86. Am J Public Health 1988;78:1478-81. 10 Barrett-Connor E, Wingard DL, Criqui MH. Postmenopausal estrogen use and heart disease risk factors in the 1980s.JAMA 1989;261:2095-100. 11 Harris RB, Laws A, Reddy VM, King A, Haskeil WL. Are women using postmenopausal estrogens? A community survey. Am J Public Health 1990;80:1266-8. 12 Bunker JP, Brown BW. The physician-patient as an informed consumer of surgical services. NEnglJMed 1974;290:1051-5.
13 Dugowson E, Holland SK. Physicians as patients: the use of obstetric technology in physician families. WestjMed 1987;146:494-6. 14 Hunt K, Vessey M, McPherson K, Coleman M. Long-term surveillance of mortality and cancer incidence in women receiving hormone replacement therapy. Brl Obstet Gyanecol 1987;94:620-35. 15 Coope J. Postmenopausal oestrogen and cardioprotection. Lancet 1991;337: 1162. 16 Doll R, Peto R. Mortality in relation to smoking: 22 years' observations on female British doctors. BMJ 1980;i:967-71. 17 Colditz GA, Hankinson SE, Hunter DJ, Willett WC, Manson JE, Stampfer MJ, et al. The use of estrogens and progestins and the risk of breast cancer in postnenopausal women. NEnglJMed 1995;332:1589-93. 18 Ross RK, Pike MC, Henderson BE, Mack TM, Lobo RA. Stroke prevention and oestrogen replacement therapy. Lancet 1989;i:505. 19 Daly E, Roche M, Barlow D, Gray A, McPherson K, Vessey M. HRT: an analysis of benefits, risks and costs. BrMed Bug 1992;48:368-400. 20 Hammond CB, Jelovsek FR, Lee KL, Creasman WT, Parker RT. Effects of long-term estrogen replacement therapy. II. Neoplasia. Am J Obstet Gynecol 1979;133:537-47. 21 Ravnikar VA. Compliance with hormone therapy. Am J Obster Gynecol 1987;156:1332-4. 22 Hahn RG. Compliance considerations with estrogen replacement: withdrawal bleeding and other factors. AmJ Obstet Gynecol 1989;161:1854-8. 23 Jannausch ML, Sowers MR. Consistency of perimenopausal oestrogen use reporting by women in a population-based prospective study. Maturitas 1992;14:161-9. 24 Coope J, Marsh J. Can we improve compliance with long-term HRT? Matunrias 1992;15:151-8. 25 McPherson K. The policy implications of HRT: is there a case for preventive intervention? In: Sharp I, ed. Coronary heart disease: are women special? London: National Forum for Coronary Heart Disease Prevention, 1994: 141-52. 26 Rosenberg L. Hormone replacement therapy: the need for reconsideration. AmJPsdblic Heakh 1993;3:1670-3. (Accepted 28 September 1995)
Waist circumference action levels in the identification of cardiovascular risk factors: prevalence study in a random sample T S Han, E M van Leer, J C Seidell, M E J Lean
Department ofHuman Nutrition, University of Glasgow, Royal Infirmary, Queen Elizabeth Building, Glasgow G31 2ER T S Han, PhD student M E J Lean, Rank professor of human nutrition
Abstract Objective-To determine the frequency of cardiovascular risk factors in people categorised by previously defined "action levels" of waist circumference. Design-Prevalence study in a random population sample. Setting-Netherlands. Suljects-2183 men and 2698 women aged 20-59 years selected at random from the civil registry of Amsterdam and Maastricht. Main outcome measures-Waist circumference, waist to hip ratio, body mass index (weight (kg)/ height (m2)), total plasma cholesterol concentration, high density lipoprotein cholesterol concentration, blood pressure, age, and lifestyle. Results-A waist circumference exceeding 94 cm in men and 80 cm in women correctly identified subjects with body mass index of ,25 and waist to hip ratios 20-95 in men and >0-80 in women with a sensitivity and specificity of 2 96!/o. Men and women with at least one cardiovascular risk factor (total cholesterol 6 5 mmol/l, high density lipoprotein cholesterol 0*9 mmol/l, systolic blood pressure 160 mm Hg, diastolic blood pressure 95 mm Hg) were identified with sensitivities of 57'!. and 67%/ and specificities of 72% and 62% respectively. Compared with those with waist measurements below action levels, age and lifestyle adjusted odds ratios for having at least one risk factor were 2*2 (95% confidence interval 1-8 to 2 8) in men with a waist measurement of 94-102 cm and 16 (1.3 to 2.1) in women with a waist measurement of 80-88 cm. In men and women with larger waist measurements these age and lifestyle adjusted odds ratios were 4*6 (3.5 to 6.0) and 2*6 (2-0 to 3.2) respectively. Conclusions-Larger waist circumference identifies people at increased cardiovascular risks.
