Hormone Therapy Varies by Location

Women deciding whether to use hormone replacement therapy to ease the transition through menopause may be swayed by factors other than the medical risks and benefits, a new study indicates.

For example, college graduates were more likely to use hormone replacement therapy than women with less education, and women in the South and West were more likely to be users than women in the Northeast, according to the study in the Annals of Internal Medicine.

The influence of factors such as education and region rather than clinical considerations such as heart disease risk shows a need for greater efforts to define which women are most likely to benefit from the therapy, the study concluded.

“In an ideal world, we would think it would be a person’s risks and benefits that would be driving this decision,” Dr. Nancy L. Keating, researcher at Brigham and Women’s Hospital in Boston, said.

The study, based on a 1995 survey of 495 women aged 50 to 74, showed that 38% had used hormones after menopause.

The largest factor was a medical consideration: 59% of the women who had undergone hysterectomies used hormone replacement therapy, compared with 20% of those who had not. In 1992 guidelines, the American College of Physicians said post-menopausal women who had had hysterectomies were likely to benefit from the therapy.

But there also were wide variations in hormone replacement therapy use that coincided with nonmedical factors.

The study said 54% of the college graduates surveyed used hormone replacement therapy, compared with 37% of those with high school diplomas and 30% of those without diplomas.

Geographically, the therapy was used by 45% of the women in the South, 42% in the West, 32% in the Midwest and 22% in the Northeast.

Keating said the results showed a lack of uniformity in weighing the risks and benefits of hormone replacement therapy.

“There clearly is a lot of uncertainty about who really is the ideal candidate--who is going to benefit and who is not,” she said. “Both physicians and their patients are not entirely clear.”

The therapy has been shown to decrease symptoms of menopause and help women get through their menopausal years, but there is uncertainty about its long-term use to prevent disease and prolong life, she said.

Hormone replacement therapy has been shown to improve cholesterol levels and bone density. Some observations, unproven by clinical trials, indicate it may lower the risk of heart disease and broken bones but may also increase the risk of breast cancer, Keating said.

While awaiting further studies, she said, patients and physicians “must try to do what they can with available data.”

Illustrating the uncertainty, Dr. Jennifer Daley of Beth Israel Deaconess Medical Center in Boston wrote in an editorial in the journal that she was having trouble making up her own mind whether to use hormone replacement therapy and that more study is needed.

“Current recommendations suggest committing generations of women to decades of a preventive treatment that offers potentially dramatic positive effects on their health and longevity, unpleasant side effects for some and unclear risks for breast cancer,” Daley wrote.

“Can we think of another example of a medical intervention, requiring millions of patients to take daily medication for many years, in which we have an incomplete understanding of the medical science and know even less about the motivations, attitudes, perceptions and decision-making styles of the women we want to help?” she wrote.