Gynaecological health care utilization and use of sex hormones–the study of Health in Pomerania

S. Schwarz1, H. Völzke2, D. Alte2, W. Hoffmann3, U. John2 and M. Dören1,4

1 Charité–Universitätsmedizin Berlin, Campus Benjamin Franklin, Clinical Research Center of Women’s Health, Hindenburgdamm 30, D-12200 Berlin, 2 Ernst-Moritz-Arndt-University of Greifswald, Institute of Epidemiology and Social Medicine, Walther-Rathenau-Str. 48, D-17487 Greifswald and 3 Ernst-Moritz-Arndt-University of Greifswald, Institute of Community Medicine, Section Epidemiology of Health Care and Community Health, Ellerholzstr. 1–2, D-17487 Greifswald, Germany

4 To whom correspondence should be addressed. E-mail: martina.doeren{at}charite.de


    Abstract
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
BACKGROUND: In Germany, there is a lack of population-based data related to the use of gynaecological health care services. The objectives of our analyses utilizing a population-based cross-sectional survey conducted in one geographically defined area [Study of Health in Pomerania (SHIP)] are to assess the prevalences of: (i) attendance of gynaecological outpatient facilities and of (cervical) cancer screening; (ii) gynaecological and breast surgery; (iii) use of oral contraceptives (OC) and menopausal hormone therapy (MHT). METHODS: We analysed socio-demographic factors, reproductive history, gynaecological service utilization, and use of sex hormones in 2186 women aged 20–79 years. We used standard statistics and sex- and age group-specific weighting factors to reflect characteristics of the population of Western Pomerania. RESULTS: Approximately 43% of women reported surgical procedures. Participation in cancer screening at least once was reported by 78% of women (lifetime prevalence). Two-thirds of women stated ever use of OC, 28% (aged >40 years) ever use of MHT. CONCLUSIONS: Women in Western Pomerania reported a high life-time use of both OC and MHT. The use of cervical cancer screening exceeded the national average. Women had an almost 50% risk of undergoing gynaecological, breast or obstetric surgery. The high use of MHT and surgical procedures calls for efforts regarding continuing medical education and health care policy actions.

Key words: cervical cancer screening/gynaecological surgery/HRT/menopausal hormone therapy/oral contraception


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
In Germany, there is a lack of population-based information providing insights into women’s health care (BMFSFJ, 2001Go). In particular, there are shortcomings regarding information on the use of gynaecological/reproductive health care services including cancer screening and the use of oral contraceptives (OC) and menopausal hormone therapy (MHT), all of which contribute to public health. At present, available information is largely based on cross-sectional data of one National Health Survey addressing the use of OC (Knopf and Melchert, 1999Go), and on independent regional surveys addressing use of MHT within the framework of the multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) project (Müller et al., 2002Go). However, MONICA was primarily designed to study cardiovascular health in largely male populations. Preliminary information about use of MHT is derived from a European cohort study which was primarily designed to assess the relationship between nutrition and cancer (Banks et al., 2002Go).

The Study of Health in Pomerania (SHIP) is a cross-sectional, population-based survey of one distinct geographical region, covering a broad range of diseases, risk factors and resources for health, many of which contribute to women’s health. The objective of our analyses utilizing this population-based study is to delineate major characteristics of reproductive health care service utilization: (i) the prevalence of attendance of gynaecological outpatient facilities and of (cervical) cancer screening; (ii) of gynaecological and breast surgery; and (iii) of use of OC and MHT, utilizing the baseline data of all participating women aged ≥20 years (n = 2193).


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Design
The study of health in Pomerania is a population-based, cross-sectional study with a broad range of examinations assessing a multitude of risk factors and determinants of health and diseases in the adult population in Western Pomerania (n = 212157 inhabitants), the northeastern region of Germany. Objectives and design have been published elsewhere (John et al., 2001Go). Briefly, a random sample of study participants aged 20–79 years (n = 7008; 292 survey participants of each sex in each of twelve 5 year age strata) was taken, utilizing the regional residents’ registration offices data. The net sample (without migrated or deceased persons) comprised 6267 eligible subjects. The final sample comprised 4310 participants (68.8% of eligible subjects). Data were collected between October 1997 and May 2001. All participants gave informed written consent to all study procedures (standardized interviews and medical examinations). The study was approved by the Ethics Committee of the University of Greifswald.

Study population and survey instruments
Computer-aided face-to-face interviews included questions about socio-demographic status, reproductive health status, and reproductive health care utilization, the answers to which were the subject of this analysis. A total of 2193 women (49.3 ± 16.2 years) participated in the survey. Data from seven women who declined to be interviewed were excluded from this analysis, thus a total of 2186 were eligible for analysis.

Socio-demographic characteristics included marital status, number of living children, duration of school education, professional status and monthly household income. The number of children refers to all living children including adopted and foster children. According to duration of school attendance, we defined three groups [low (<10 years), medium (10 years), high (>10 years)] based on the Eastern German three level school system. Regarding professional status, women were classified as employed (full time or part time), unemployed (also including students or retirees), being on vocational training, or on maternity leave respectively.

We defined attendance at gynaecology outpatient facilities during the last 12 months preceding the survey and participation in any cancer screening as main indicators of reproductive health care service utilization. We obtained information about the frequency of attendances and recent participation in cancer screening. The survey did not provide information on antenatal services or obstetric care.

Information about gynaecological surgery including breast surgery was ascertained by unstructured self-reports. Full text information was structured by means of a post hoc categorization, according to anatomical regions involved. The category ‘uterine surgery’ refers to any surgery or procedure involving the uterus and the cervix such as curettage, removal of myoma, surgical removals of intrauterine devices except hysterectomy. The category ‘hysterectomy’ comprises two groups, one with hysterectomy only, the other with involvement of one or more additional organs (ovary and/or tube; uni- and/or bilateral). Surgical procedures involving the ovaries and/or tubes (uni-/bilateral) mainly include procedures such as oophorectomy and or salpingectomy. The category ‘pregnancy-associated surgery’ was subdivided according to outcome of pregnancy. One group includes terminations of pregnancy (including spontaneous/induced abortion and procedures following extrauterine pregnancies), the other group includes obstetric procedures (i.e. Caesarean section, assisted vaginal deliveries). ‘Surgery of the breast’ was classified according to character of the disease (surgery for benign disease including mastitis; surgery because of breast cancer; and surgical procedures without specified reasons). ‘Vaginal surgery’ includes ablational procedures (i.e. cysts or polyps). The category ‘unspecified surgical procedures involving unspecified organs’ includes unknown procedures in conjunction with, for example, laparoscopy or abdominal surgery.

We analysed information about menstrual periods and menopause, ever use and duration of use of OC and MHT respectively. The analyses of duration of use of MHT were restricted to women aged ≥40 years irrespective of self-reported menopausal status. We used World Health Organization (1996)Go definitions to define the women with natural menopause, which is recognized to have occurred after 12 consecutive months of amenorrhoea and which is not due to causes and procedures such as hysterectomy that would be associated with cessation of menses. The subgroup ‘induced menopause’ consists of women who reported cessation of menstruation after either surgical removal of both ovaries, iatrogenic ablation of ovarian function (i.e. chemotherapy). All sex hormone medications were recorded together with any other medications in the last 7 days preceding the interview and categorized in a standard fashion using the GoAnatomical Therapeutic Chemical (ATC, 2000)Go classification index. All hormonal drugs licensed for climacteric complaints were listed as MHT. Essentially, this group consists of estrogens and estrogen-progestin combinations (all routes of administration).

Statistical analysis
Univariate frequencies and summary statistics were calculated to describe the study population. Data on qualitative characteristics are expressed as percentage values or absolute numbers as indicated. Data on quantitative characteristics are expressed as median and range. Adjusted prevalences were calculated by using sex- and age group-specific weighting factors reflecting the sex and age distribution of the total population of Western Pomerania (Statistisches Landesamt Mecklenburg-Vorpommern, 1999Go). All statistical analyses were performed with SPSS software, version 12.0 (SPSS GmbH Software, Munich, Germany).


    Results
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Socio-demographic characteristics
The basic socio-demographic characteristics of women in SHIP across different age groups are shown in Table I. Except for the age groups 20–29 years and ≥70 years respectively, ≥65% of women were married. Among the group of unmarried women, 28.8% lived with a partner. Most women had two children. Only a minority (30.4%) of the women aged <30 years had children, in contrast to the other age groups. The majority of women attended school for 10 years. There was an inverse relation between level of education and age. The highest level of education (>10 years) was most frequent in the youngest age group. The employment rate of the participants was 50.9% (any of various types of employment). Most of the women in the youngest age classified as ‘unemployed’ were students (49.5%). Almost all women aged ≥60 years received a pension. The majority of women reported a monthly household income of between 765 and 2040). The prevalence rate of women with a reported household income of ≥2040 was highest among the women aged 30–39 years.


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Table I. Basic socio-demographic characteristics of women participating in SHIP (X/1997 – V/2001), n = 2.186

 

Use of gynaecological outpatient facilities and adherence to cancer screening
Most women (69.8% of the total sample) attended at least once the outpatient facilities of a gynaecologist during the year preceding the interview. For all participants the median reported number of visits within 1 year was one. Prevalences of attendance and the median number of visits decreased with age (Figure 1). On average, among those women who attended a gynaecological outpatient facility, the median number of visits per year was 2. The lifetime prevalence of any past cancer screening including cervical cancer screening was 77.7% in the total sample. Among women who ever participated in any cancer screening programme, 72% did so within the 12 months preceding the interview. The participation in any cancer screening was less frequent in young (20–29 years) as well as older women (aged ≥70 years; Figure 2).



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Figure 1. Attendance of gynaecology outpatient facilities.

 


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Figure 2. Prevalence rates of cancer screening attendance.

 

Gynaecological and breast surgery
The prevalence of at least one surgical procedure was 42.8% (Table II). Uterine surgery was the most common type of surgery performed. The lowest prevalence was found in the youngest age group (0.7%) and the highest among women aged 50–59 years (19.3%). Hysterectomies were not reported by women between 20 and 29 years. Approximately 10% of the women in all age groups ≥50 years reported a hysterectomy in conjunction with additional procedures involving at least one other pelvic organ, i.e. ovary and or salpinx. Women aged 50–59 years stated the highest prevalence of hysterectomy without procedures involving ovary and/or salpinx (10.3%). Within the group of women aged ≥70 years, 5.1% reported breast cancer surgery. Sterilization was most prevalent in women aged 40–49 years (15.6%) compared with women <30 years (0.7%) and >60 years (0.5%).


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Table II. Prevalence rates of self-reported gynaecological surgical procedures (including breast surgery)

 

Oral contraceptives
Ever use of OC was reported by 67.7% of the total sample. The prevalence of use was higher among women aged <49 years compared with older women (Figure 3). Among ever users of OC, the median duration of use was 9 years (range 1–34). The median duration of ever use of OC of all women was 5 years. Women aged 30–39 years and 40–49 years respectively reported the longest duration of use of OC (10 years in both groups).



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Figure 3. Prevalence rates and median duration of oral contraceptive use among woman of different age groups.

 

Menopause and menopausal hormone therapy
Of the total sample, 44.6% of women stated that they were menopausal. The type of menopausal status was related to age (Figure 4). The median age of women with natural menopause was 50 years. Details of ever use of any systemic oral, transdermal or intramuscular MHT in women aged ≥40 years are provided in Table III. The highest prevalence of use was reported by women aged 50–59 years. Among women aged >40 years who used MHT, the median duration of use was 5 years (range 1–26). Women aged 50–59 years reported the longest use of MHT. Use of MHT for 6–10 years was reported by 28.3% of women aged 60–69 years; use for >10 years by 9.9% in this age group. In women aged ≥70 years, 13.9% used MHT for 6–10 years, and 8.3% for >10 years. In women with ever use of both OC and MHT, the median duration of use was 9 years (range 1–40).



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Figure 4. Prevalence rates of natural and induced menopause in women of all age groups.

 

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Table III. Ever use of any systemic menopausal hormone therapy (MHT) and duration of use of MHT by women aged ≥40 years (n = 1435)

 


    Discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Considerable use of gynaecological services and hormone therapies, OC and MHT alike, is one characteristic of this population-based sample of women aged 20–79 years. Approximately 43% of women reported gynaecological or obstetric procedures, 78% participation in (cervical) cancer screening at least once, two-thirds of women reported ever use of OC, and 28% of women aged >40 years ever use of MHT.

One major finding of our study is the degree of considerable utilization of gynaecological services (antenatal care not included) across a wide age range in this region. In Germany, the main care providers for both cervical cancer screening and therapy with both OC and MHT are gynaecologists; the same service system applies to antenatal care as shown in a comparative study investigating this part of women’s health care in 13 European countries including Germany (Hemminki and Blondel, 2001Go). Although we found that prevalence of cervical cancer screening decreased with age; the prevalence of use of this service (>70%) appears to be higher in our study population compared to attendance rates of 47% for East Germany and 50% for West Germany (Schenk and von Karsa, 2001Go). This is interesting as the German statutory early detection programme for cervical cancer is an opportunistic screening programme which is not population-based. However, screening was consistently encouraged and occupational health services in the former German Democratic Republic, including Pomerania, frequently provided facilities for employed women. This may at least partially explain our finding.

We are not aware of any other published population-based data of the prevalence of specified gynaecological procedures including hysterectomy in Germany. The prevalence of hysterectomy (irrespective of type and extent potentially involving adjacent organs) is quite similar to figures reported in a population-based sample of women in Copenhagen followed between 1982 and 1990 (Settnes et al., 1997Go). As the survey did not include a record-linking procedure (surgical and pathological reports), we do not know how many procedures, in particular how many hysterectomies and ovariectomies, were performed for benign and non-benign reasons.

A second major finding, in the context of health care utilization, is the wide use of OC by women in the present study. Available data from the MONICA project (data collection 1993–1994) demonstrate that prevalences of use among women in the former German Democratic Republic were 63% in the age group 25–34 years, and 52% in the age group 35–44 years (Lundberg et al., 2004Go). These figures are the highest in both age groups within this study of 32 populations in 20 countries. Data from the National Health Survey 1998 demonstrate that OC are by far the most frequent medication in women, in particular in the former German Democratic Republic (Knopf and Melchert, 1999Go). In a representative sample of women aged 18–24 years conducted in 1996/1997 in the metropolitan area of Dresden, East Germany, this finding was confirmed (Hach et al., 2004Go). Our data appear to be in line with these studies. As the indications for OC use were not recorded, we cannot delineate the reasons why women had a strong preference for OC use given the availability of a large variety of pharmacological and non-pharmacological choices.

The third major finding is the extensive use of MHT by women. Prevalence of use of estrogen–progestin preparations, which constitute two-thirds of all MHT prescriptions in Germany (Schwabe and Rabe, 2004Go), was 9.5, 25.4, 34.4, 32.3 and 20.9%, in women aged 45–49, 50–54, 55–59, 60–64 and 65–69 years respectively in a population-based survey in the city of Bremen, West Germany (Greiser et al., 2002Go). Our figures exceed those prevalence data (we included all menopausal hormone preparations, in particular also estrogen-only preparations). In one urban MONICA study area in Southern Germany (identical age groups as in the Bremen study) the prevalence of use of estrogen–progestin preparations was 12.4, 17.8, 17.7, 7.8 and 1.4% respectively (Müller et al., 2002Go). Thus, the prevalence of use was lower in this region compared with the Bremen survey. In a third data source, the prevalence of ever use of MHT was ~53% in women aged 45–64 years in a pooled analysis of the two German centres of the EPIC study (Banks et al., 2002Go). Looking at EPIC figures, it is evident that both ever and current use was highest in the German centres compared with centers in six European countries. Our figures are comparable to the German study centres of EPIC and other large population-based studies in the UK, Sweden, and Norway (Li et al., 2000Go; Million Women Study Collaborators, 2002Go; Bakken et al., 2004Go) as well as to estimates from prescription databases in the USA suggesting that 33% of American women aged 50–74 years are ever users of MHT (Hersh et al., 2004Go).

Finally, duration of use of MHT is remarkable as a substantial number of women aged >60 years use MHT. In our study, median duration of use was 5 years, in women with previous OC exposure of 9 years. The increased likelihood of MHT use in women with prior OC use is a common finding in surveys analysing determinants of MHT use (Million Women Study Collaborators, 2002Go; Müller et al.; 2002; Bromley et al., 2004Go). These figures are similar to data from the Bremen survey with average durations of use of ~5–6 years in women aged 45–54 years, and of the UK and Norwegian studies (Million Women Study Collaborators, 2002Go; Bakken et al., 2004Go). A further German study assessing the use of MHT in the same area as previously mentioned (Müller et al., 2002Go), demonstrated that 32.6% of current users used MHT for 5–9 years, and 42.9% for ≥10 years (Löwel et al., 2003Go). However, duration of MHT was lower in the Swedish study (Li et al., 2000Go), but difficult to compare with the Women’s Health Initiative Observational Study, where two-thirds of women used MHT for >4 years, which does not allow for a distinction of women with long-term use (Pradhan et al., 2002Go).

In the absence of population-based studies in various regions of Germany to provide data about the incidence of symptoms and complaints of midlife women often attribute to the climacteric period, it is merely speculation whether only prevalence and severity of climacteric symptoms are responsible for the pattern of use we observed in our study. It is possible that use of MHT was widely recommended for prevention of diseases including, but not restricted to, osteoporosis or as an anti-ageing strategy. This hypothesis is supported by rising numbers of prescriptions after 1985 (Schwabe and Rabe, 2004Go) and declining numbers since regulatory actions (i.e. changes of indications, information upon risks of MHT) were taken in Germany after the publication of results of the Women’s Health Initiative and other recent studies. It is also possible that attendance at gynaecological facilities had an impact on the likelihood of using OC and MHT. The importance of risk communication by physicians related to use of MHT may be just one factor contributing to the pattern of use of MHT in Germany (Heitmann et al., 2005Go).

In conclusion, women in Western Pomerania aged 20–79 years reported a high lifetime use of both OC and MHT, compared with other (European) countries. The use of cervical cancer screening appeared to exceed the national average according to available data in Germany. Women had an almost 50% chance of undergoing gynaecological surgical procedures, including breast and obstetric surgery.

All major findings call for recommendations regarding further research into the determinants of usage of hormonal medications, OC and MHT alike, and gynaecological surgery. Furthermore, apart from health care policy recommendations highlighting the importance of applying state-of-the-art care by professional bodies, continuing medical education appears to be crucial to assure that indications for use of sex hormones and surgical treatments respectively meet the criteria of evidence-based medicine. We believe that the lifetime risk of reported surgical procedures raises concerns whether non-medical approaches to manage diseases and symptoms were used exhaustively prior to decisions to perform surgery. This could be due to lack of availability of certain procedures, lack of knowledge about choices, or physicians’ and patients’ preferences for surgical treatment options such a hysterectomy (Schaffer and Word, 2002Go). Unfortunately we cannot comment on the indications and the information provided to women about treatment options prior to any surgery as this specific information was not available. However, best available evidence from non-representative data as listed in the report about women’s health care in Germany (BMFSFJ, 2001Go) hints at the strong possibility that the vast majority of surgeries was performed for benign reasons not all of which called for surgical treatment. Thus, resources are needed to allow for a thorough analysis of the present standard of care regarding common gynaecological procedures allowing for a re-adjustment of health care services.

Whether the impaired economic situation in this region is a contributing factor for the extent of OC use is highly speculative. It is well known that family planning is influenced by socio-economic factors. Available demographic data demonstrate that after the reunification of the former West and the former East Germany, pregnancy rates substantially and constantly declined. Thus, this ‘economic’ argument could be an explanatory factor for the extent of OC use. However, it was beyond the scope of the questionnaires used to analyse indications of OC use or any other method of family planning, and moreover allow for analyses of any potential links between family planning and socio-economic status.

Both extent and length of MHT use raise public health concerns. For the same methodological limitations mentioned above, we do not know why substantial numbers of women, in particular long after the immediate peri-menopausal period around the age of 50 years, use MHT. We have to acknowledge the complete absence of population-based studies in Germany providing details about the prevalence of health-related symptoms in middle-aged women including vasomotor, urogenital, and other symptoms thought to be linked to the menopause (Agency for Healthcare Research and Quality, 2005Go). Thus, we do not know how many women in which age groups have vasomotor and other symptoms potentially eligible for MHT, how symptoms affect their quality of life, how symptoms resolve and quality of life develops in women deciding to use or not to use MHT. We assume that the extent of use is not only symptom-oriented, but also due to the concept of prevention, beyond osteoporosis, in the sense of ‘healthy ageing’. Limited data from one metropolitan area in Germany suggest that MHT at least until 2002 was not only prescribed for vasomotor symptoms and prevention of osteoporosis by gynaecologists, but also to treat urinary incontinence, prevent cognitive decline and improve sexuality (Jantke et al., 2003Go). We believe that our results call for an extension study to ascertain knowledge about womens’ contraceptive expectations and choices, about the prevalence and scope of health-related symptoms in ageing women, particularly their effects on quality of life in users and non-users of (long-term) MHT, and about physicians’ preferences regarding indications for sex hormone prescriptions and surgical treatments respectively. Finally, we suggest that future health care policy provides an educational framework to promote efforts to raise standards in women’s heath care, including efforts to demedicalize the menopause. This policy should appeal to professionals, women and the general public alike.


    Acknowledgements
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
The work is funded by the Clinical Research Center of Women’s Health (Charité-Universitätsmedizin Berlin). It is part of the Community Medicine Research net (CMR) of the University of Greifswald, Germany, which is funded by the Federal Ministry of Education and Research (grant no. ZZ9603), the Ministry of Cultural Affairs as well as the Social Ministry of the Federal State of Mecklenburg–West Pomerania.


    References
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
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Submitted on January 31, 2005; resubmitted on May 23, 2005; accepted on May 27, 2005.





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