Department of Obstetrics and Gynecology, St Peter University Hospital, Free University of Brussels, Brussels, Belgium
1 To whom correspondence should be addressed at: Department Obstetrics and Gynecology, St Peter University Hospital, Free University of Brussels, Rue Haute, 322, 1000 Brussels, Belgium. e-mail: serge.rozenberg@skynet.be
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Abstract |
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Key words: breast cancer/HRT/questionnaire/WHI study
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Introduction |
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Moreover, whilst gynaecological journals underlined the uncertainty related to the study (McDonough, 2002; Schneider, 2002
; Skouby, 2002
; Sturdee and MacLennan, 2002
; Barlow, 2003
), certain medical journals discussed more the changes in attitude that should occur (Laine, 2002
; Nelson, 2002
; Caren and Dluhy, 2003
; Kirschstein, 2003
; Rymer et al., 2003
).
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Do physicians adapt their HRT prescription after WHI? |
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Briefly, the charts were summarized of one post-menopausal 55-year-old patient with no particular medical history who used to complain of climacteric symptoms but no longer does. From this chart, eight clinical case-types were constructed by modifying three variables: (i) the type of HRT she was using [two possibilities of either conjugated estrogens (CEE) 0.625 mg + medroxyprogesterone acetate (MPA) or tibolone 2.5 mg]; (ii) the duration of HRT use (either 2 years or 11 years); and (iii) the bone density result [a T-score of +0.5; that is, a normal bone mass or one of 1.5 (osteopenia) according to definitions given by the World Health Organization] (Report of a World Health Organization Study Group, 1994).
Every practising Belgian gynaecologist (n = 1374) received, by mail, during February 2003, one of these cases (selected at random from the eight case-types). The gynaecologists were asked: (i) whether they would pursue the same HRT regimen (closed answer, no/yes); (ii) whether they would prescribe another HRT regimen (closed answer, no/yes) and, if so, which ones (open answer); and (iii) whether the HRT would be stopped (closed answer no/yes) and, if so, whether treatments other than HRT would be prescribed (open answers). The gynaecologists were assured that their participation would remain anonymous and that the survey was not commercially motivated.
A questionnaire about demographic data was included. Statistical analysis was performed using SPSS software. Descriptive and chi-square tests were used, and a P-value < 0.05 was considered statistically significant.
Do gynaecologists consider the results of the WHI study to be applicable to a particular product or to all types of HRT?
A total of 577 returns was obtained (42% response rate) after a single mailing, and the mailing was closed after 1 month. There was no difference in response rates in relation to the eight cases. Neither was there any difference in the proportion of women to men physicians (40 versus 60%), between the responders and non-responders (mean age 47.1 ± 11.8 years), nor any difference in the distribution of the number of years of practice.
Globally, 19.8% of the physicians said they would stop prescribing the CEE+MPA regimen, 19.5% would continue the same regimen, and 60.7% would prescribe another HRT type, while respectively 15.9% would stop prescribing tibolone, 76.1% would continue it, and 8% would prescribe another regimen (Table I).
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Finally, some gynaecologists have psychological difficulties in discontinuing medication that they have prescribed often for many years, especially to patients who are not asking to stop their regimen and may feel well while using it. These hypotheses may also explain why HRT discontinuation remained very low after 2 years of HRT use (<15%) and even after 11 years of HRT use (<25%). The result of the bone density investigations had no significant effect on the (dis)continuation rates, which suggested that the physicians main reason for maintaining patients under treatment was not osteoporosis prevention. Nonetheless, it should be noted that those practitioners who would stop HRT also more frequently prescribed calcium associated with vitamin D (7078% of cases; data not shown). It is also possible that some physicians believe that HRT improves the quality of life and should therefore be maintained for long periods.
Some limitations of the present study must be considered. The response rate obtained was low, and it was not clear whether these results could be extrapolated to physicians other than those who answered the questionnaire. Despite this, the results observed were also in concordance with the decrease in sales by almost 40% of conjugated estrogens 0.625 mg + medroxyprogesterone acetate that has been noted in Belgium during the year following the first WHI results, whilst on the other hand there was an increase of more than 10% in tibolone use. It should also be noted that, since the study was conducted, additional reports have appeared in the fields of breast cancer, stroke, cognitive function, dementia and quality of life, all from the team of the WHI study, that reinforce the negative opinion concerning long-duration combined HRT (Chlebowski et al., 2003; Hays et al., 2003
; Rapp et al., 2003
; Shumaker et al., 2003
; Wassertheil-Smoller et al., 2003
). The attitude of Belgian physicians has not been reassessed since publication of these data, however.
In summary, this survey reveals that Belgian gynaecologists who are confronted with patients who became asymptomatic while using HRT, will generally continue to prescribe HRT, despite the negative findings of the WHI study. When patients are using CEE+MPA, physicians tend to prescribe another HRT regimen, but when patients use another regimen such as tibolone, physicians generally tend to maintain the same regimen. The real clinical setting of a patient informed (frightened!) by the lay press or by another health provider may however result in a different scenario. If gynaecologists intend to maintain their patients on HRT, then incomprehension and possibly distrust may arise. Gynaecologists should be aware of this situation, in addition to the potential dangers of HRT.
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References |
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Submitted on June 3, 2003; accepted on July 21, 2003.