CLINICAL QUESTION: What are the concerns of women considering hormone replacement therapy (HRT)?
BACKGROUND: Counseling women about HRT is common in family practice, but available research has focused on risks and benefits from the perspective of providers. This qualitative study explores the perspective of patients.
POPULATION STUDIED: Twenty-six women who received new HRT prescriptions at a staff-model health maintenance organization were interviewed. Originally, 176 were identified as potential participants; reasons for exclusion included premenopausal state, previous use of estrogens, and use of topical estrogens. Thirty-four women refused to participate, 20 were never contacted, and 34 consented but were never interviewed because study data were sufficient. The median age was 53, 85% were white, and median annual income was $46,000. Fifty-four percent stated they had initiated discussion of HRT with their provider, and 81% had filled the HRT prescription at the time of interview.
STUDY DESIGN AND VALIDITY: This was a qualitative study. Each woman was interviewed for 1 hour, and the audiotape was transcribed and analyzed. Three judges used a consensus process to identify the variety of domains (specific concerns) the women mentioned. Another investigator assigned patient comments to specific domains. Interviewing new subjects stopped when no new information was being added.
OUTCOMES MEASURED: This qualitative study identified womens’ concerns about HRT. By design, a qualitative study can neither quantify the prevalence or strength of particular concerns nor address clinical outcomes.
RESULTS: Influences on the decision to begin HRT were broad and included provider opinion (96% of interviewees reported), media reports (81%), experiences and opinions of friends (77%), and experiences and opinions of family (65%). Specific clinical concerns cited included risk for breast cancer, having to take medication, prevention of osteoporosis, hot flashes, prevention of heart disease, insomnia, living with medical uncertainty, menstrual-type bleeding, and genitourinary symptoms.
This study provides good evidence that women who have received a prescription for HRT use many sources of information—in addition to the opinion of their physicians—to make their decision about whether to begin the therapy. These women have concerns about HRT that are substantially broader than those identified in the medical literature. Physicians should take into account the impact of their recommendations and the influence of the patients’ family, friends, and the media and should seek to identify the specific concerns of individual patients.