Scandinavian Journal of Primary Health Care
ISSN: 0281-3432 (Print) 1502-7724 (Online) Journal homepage: http://www.tandfonline.com/loi/ipri20
General Practitioners' Attitudes to Oestrogen Prescription in the Menopause: A National Survey in Norway Bjørn Backe, Steinar Hunskaar & John Arne Skolbekken To cite this article: Bjørn Backe, Steinar Hunskaar & John Arne Skolbekken (1992) General Practitioners' Attitudes to Oestrogen Prescription in the Menopause: A National Survey in Norway, Scandinavian Journal of Primary Health Care, 10:3, 179-184, DOI: 10.3109/02813439209014058 To link to this article: http://dx.doi.org/10.3109/02813439209014058
© 1992 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted Published online: 12 Jul 2009.
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Date: 17 March 2016, At: 19:21
Scand J Prim Health Care 1992; 10: 179-184
General Practitioners’ Attitudes to Oestrogen Prescription in the Menopause: A National Survey in Norway BJBRN BACKE’, STEINAR HUNSKAAR? and J O H N A R N E SKOLBEKKEN’ ‘Norwegian Institute of Hospital Research, Trondheim, Norway, ’Division of Public Health and Primary Health Care, University of Bergen, Norway
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Backe B, Hunskaar S , Skolbekken JA. General practitioners’ attitudes to oestrogen prescription in the menopause. Scand J Prim Health Care 1992; 1 0 179-84. A questionnaire was mailed to a random sample of approximately 10% of Norwegian general practitioners (CPs) in order to investigate attitudes to the prescription of hormone replacement therapy (HRT) in menopausal women. Nine short case histories were presented, and the GPs indicated their attitude to oestrogen prescription in each case on a five-step scale. Each case history contained four items that were systematically varied so that the effect of each could be investigated by comparing the answers from case to case. 251 GPs (74%) responded to the questionnaire. The answers indicated restrained attitudes towards prescription of HRT. Smoking and a family history of cardiovascular disease were regarded as contraindications. Angina pectoris was considered a contraindication for local oestrogen application in elderly women with urogenital complaints. Key words: oestrogens, menopause, prescriptions, general practice. Bjern Backe,
MD, Norwegian Institute of Hospital Research, N-7034Rondheim, Norway.
New application methods and recent acknowledgement of positive effects of hormone replacement therapy (HRT) on osteoporosis and cardiovascular morbidity have led to renewed interest for HRT. As opinions of the female menopause vary from that of a natural life event to its being an endocrinopathy requiring indefinite HRT, attitudes to the need for HRT, and its desirability, vary among doctors and lay people. Life expectancy of 45-year-old women in the Nordic countries is in the range of 36 years ( l ) , so the potential population for H R T is large. As a result of the debate on the use of oestrogens, the Norwegian Medical Research Council and the Norwegian Institute of Hospital Research arranged a consensus conference in 1990 on the use of oestrogens. The present study was undertaken to provide background information for the consensus panel ( 2 ) . The aim of the study was to investigate the attitudes and prescription habits of GPs concerning HRT, as well as local oestrogen therapy in women with urogenital complaints. It has previously been claimed that Norwegian doctors associate H R T with 14’
the same risk factors as hormones for contraceptive use (3). This was also the clinical impression of the investigators. Hence, the GPs were asked specifically whether they considered that smoking and risk for cardiovascular disease were contraindications for H R T , and whether they regarded angina pectoris as a contraindication for local oestrogen application in elderly women with atrophic urogenital symptoms. MATERIAL A N D M E T H O D S A 10% sample of primary care Norwegian doctors was randomly drawn from the database of a company offering address lists for marketing purposes. 4200 doctors were registered in the database. A questionnaire was sent to 420 doctors in August 1990, and a reminder was sent two weeks later. 331 answers were received, including 80 from doctors not working in general practice and who were therefore excluded. 251 answers from GPs remained for the analysis (74%). T h e answers were anonymous. The participating doctors came from all 19 counScand I Prim Heulth Cure 1992; 10
180
B . Backe et al.
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Table I. The 9 case histories (1-7 about hormone replacement therapy, 8 and 9 about local oestrogen therapy). 1.
50-year-old woman, depressed, complaining of sleeping problems and daily flushes. Oligomenorrhoeic.
2.
As 1, but reports many cases of cardiovascular disease in her family (both parents have had stroke and myocardial infarction). Normal bloodpressure.
3.
As 1, but smokes more than 20 cigarettes per day.
4.
50-year-old, depressed, complaining of sleeping problems and daily flushes. Oligomenorrhoeic. Smokes a lot. She reports many cases with osteoporosis in the family, and also many cases with cardiovasculaf disease.
5.
50-year-old healthy woman who asks for oestrogen replacement therapy. Brings with her an article from a woman’s magazine where use of oestrogen is recommended.
6.
50-year-old, depressed, complaining of sleeping problems and daily flushes. Oligomenorrhoeic. Reports many cases with osteoporosis in the family.
7.
50-year-old healthy oligomenorrhoeic woman. Says that her mother and an aunt have osteoporotic compressim fractures in the spine,
8.
58-year-old, complaining of dyspareunia and frequent episodes of cystits.
9.
74-year-old. Angina pectoris. Mixed stress-urge urinary incontinence.
ties. The mean age was 40.4 years (range 26-72), 77% were male, and 37% were approved specialists in general practice. 64% worked in a group practice. The questionnaire An introductory letter explained the purpose of the study. Nine short case histories were presented, 7
about HRT and 2 about local oestrogen therapy. The case histories about HRT contained four items: menopausal complaints, regular smoking, a family history suggesting increased risk for cardiovascular disease, and a family history indicating an accumulation of cases with osteoporosis. It was implied that, unless otherwise stated, the condition was not present. The case histories (Table I) were presented in a random order and were constructed to allow for pairwise comparisons (comparing 2 histories in which only one of the 4 variables was different). The distribution of the items in the HRT-cases is shown in Table 11. The GPs stated their views on prescribing oestrogen on a five-step scale for each case history. The choice of answers was: “Should not be prescribed”, assigned the score one, “In doubt” (score two), “Could be prescribed” (score three), “Ought to be prescribed” (score four), and “Definitly recommended“ (score five). The respondents were also asked to state age, sex, practice type, and the estimated number of patients in their practice receiving oestrogen therapy for indications specified. Statistical analysis Data were analysed with the Statistical Package for Social Sciences (4). The Sign test was applied for comparisons between cases. The Wilcoxon rank sum test was used for comparisons of answers between groups of doctors. p-values < 0.001 were considered as significant.
RESULTS Table 111 shows the GPs’scoring (% s), together with the mean and the median scores, for each case history. The highest mean score (4.1) was for case history 6, which described a woman with climacteric symptoms and a family history of osteoporosis. The
Table 11. The distribution of the 4 items from which the 7 case histories about hormone replacement therapy were built. (+) and (-) indicate whether the case history contained information on the actual item. Case history
Climacteric symptoms
1.
2. 3. 4.
5. 6. 7.
S c a d J Prim Health Care 1992; 10
Smoking
Cardiovascular risk
Family history of osteoporosis
General practitioners’ attitudes to oesrrogen
181
Table 111. The answers given on 9 case histories, in % of responding GPs (n = 251). A 5-step answering scale was used, ranking from negative ( I ) to positive (5) on whether oestrogen should be prescribed. The mean and median scores are shown. Case
history
1.
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2. 3. 4. 5. 6. 7. 8. 9.
Answering score
Mean
1
2
3
4
5
3 19 45 25 36
2 29 31 35 16 4 11 2 15
36 35 16 25 39 13 33 13 33
47 14 7 11 8 43 32 29 21
12
1
5 1
13
lowest mean score (1.8) was for case history 3 , which included climacteric symptoms, smoking, and a family history of cardiovascular diseases. The second lowest mean score (2.2) was for case history 5, where only the patient’s demand for H R T was indicated. As can be seen from Table 11, the effect of climacteric complaints on GPs’ readiness to prescribe H R T can be studied in two pairwise comparisons of the answers given: case one compared with case 5, and case 6 with case 7. In both comparisons the case history containing climacteric complaints (case one and six, respectively) scored significantly higher. The effect of a family history of osteoporosis could be elucidated in two pairwise comparisons: case 5 compared with case 7 and case one with case 6. In both comparisons the answers were significantly in favour of a greater willingness to prescribe oestrogen when a family history of osteoporosis was suggested. Comparison of case histories 1 and 2 reveals the effect of a family history of cardiovascular disease. Case 2 had significantly lower scores, indicating that this information is interpreted as a contraindication for H R T . Comparison of case histories 1 and 3 reflects GPs’ reaction to a history of smoking, when H R T is otherwise indicated. Case 3 scored significantly less than case one, indicating that smoking acts as a contraindication. Comparison of case one with case 4 shows that smoking and cardiovascular disease counterweigh the influence of a family history of osteoporosis, since case 4 scored significantly lower than case one, which only had climacteric symptoms.
Local treatment Two case histories adresstd the question of manifest
3 1 4 2 39 20
55 19
Median
3.6 2.5 1.8 2.3 2.2 4.1 3.5 4.4 3.2
cardiovascular disease as a possible contraindication to local oestrogen therapy. Case 9, presenting with angina pectoris, scored significantly lower than case 8, indicating that angina pectoris is considered a contraindication for local oestrogen therapy.
Doctor characteristics Neither gender nor type of practice (single versus group practice) revealed significant differences in the answers given. 12% of the doctors reported that they had no patient under oestrogen treatment for climacteric complaints. Most doctors estimated that they had one to six patients on H R T treatment for each of the three groups of indications: climacteric complaints, prophylaxis of osteoporosis, and long-term treatment for postmenopausal complaints. Female doctors reported significantly more patients on treatment for menopausal and postmenopausal complaints than male doctors, but there was no difference for the indication prevention of osteoporosis.
DISCUSSION H R T has apparently gained less popularity in Norway than in neighbouring countries. In a recent health survey comprising three Norwegian counties, only 5% of women aged 5C-54 reported use of oestrogens ( 5 ) . This contrasts with reports that oestrogens were used by 19% of Finnish women aged 45-64 (6), by 21% of Danish women aged 50-54 (7), and by 8.6% of Swedish women aged 50-54 (8). This indicates that the therapeutic traditions in Norway Scond J Prim Health Care 1992; 10
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B. Backe et al.
are different from those of the other Nordic countries. No explanation has yet been offered for this. Other authors have successfully applied case-history questionnaires to test doctors’ attitudes to various clinical problems (9-12). Briefly sketching a clinical situation might be more indicative of clinical practice than asking direct questions, because the resemblance to an examination is reduced. Thus, attitudes might be recorded rather than reproductions of textbook knowledge. The non-parametric tests applied generally revealed remarkably small p-values, due to large figures and also substantial differences in the scores between cases. Recent consensus on H R T is that breast cancer and cancer of the endometrium are the main contraindications. Angina pectoris and previous myocardial infarction should not be regarded as contraindications for HRT; neither should a family history of cardiovascular disease influence the decision to prescribe HRT in a negative manner (13). A history of typical menopausal cornplaints led to higher scores. This consistency with the expected response pattern may provide an indication of the validity of the questionnaire. Anamnestic information about relatives with osteoporosis also increased the readiness to prescribe HRT. This is remarkable because there is no evidence that osteoporosis is a hereditary disease (14). The major problem in the prevention of osteoporosis is precisely the inability to identify women who will eventually develop osteoporosis and thus are likely to benefit from prophylactic treatment. Smoking aggravates osteoporosis (15). In one study, the beneficial effect of oestrogen therapy on osteoporosis was greatest in women who smoked (16). Thus, in our opinion, GPs’ association of smoking and postmenopausal oestrogen should rather be a positive than a negative one: if anything, smoking should increase doctors’ readiness to prescribe oestrogens. We have not found published evidence that smoking contraindicates postmenopausal oestrogen use. When the information that the patient smoked was given, doctors were less inclined to prescribe HRT. A family history of cardiovascular disease acted the same way, and together the two items counterweighed the two positive items: history of climacteric complaints and family history of osteoporosis. Thus, the two questions we had in mind when designing the study were both confirmed: a family Scand J Prim Health Care 1992: 10
anamnesis of cardiovascular diseases is regarded as a contraindication for HRT, as well as smoking. In our opinion, this contrasts with present medical knowledge. When local therapy of urogenital oestrogen deficiency in elderly women is considered, there is no reason to refrain from local oestrogen therapy in cases of manifest cardiac disease (13). Also in this regard, our data indicate a more restrictive practice than current medical knowledge calls for. A recent survey of GPs’ prescribing habits in the UK (17) concluded that more than half of the doctors would consider prescribing hormone replacement therapy for the prevention of cardiovascular disease. Also, cardiovascular problems were the most frequent reason given for oestrogen prescription. These observations contrast with our findings, and we feel tempted to share the opinion of others (3) that Norwegian GPs apparently fail to distinguish between oestrogen compounds used for contraception and oestrogens for postmenopausal use, despite different metabolic and biological properties of the compounds used for the various purposes. We are unable to explain how this misconception may have arisen. In the study of Holzman et al. (lo), the possibility that US doctors confuse the two types of oestrogens was discussed. The contrast between our results and the recent UK study (17) is striking, also in the light of medical knowledge that is supposed to be international. A recent telephone opinion poll of 1000 women, representative of the Norwegian population, showed that they too associate oestrogen therapy with increased risk for heart infarction and stroke (18). The low user rates in Norway may reflect that the doctors share the reluctant attitude of the women. In that case, the contraindications they practice may simply reflect their effort to rationalize their scepticism. The present study provides background for improvement of training and information for doctors in primary health care. The pharmaceutical industry provides a major part of the information for doctors on the use of drugs, and it has a special obligation to provide correct information about its products. The scientific evidence for risks and benefits of HRT relies on uncontrolled observational studies and case-control studies. No controlled randomized trial has been reported. With few exceptions (19), all relevant studies have been conducted in the USA and are related to the use of unopposed HRT, i.e. use of oestrogen without added progestogen. The oestrogen compound in the reported studies have
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General practitioners’ attitudes to oestrogen usually been conjugated oestrogen. Conjugated oestrogens have never been on sale in N o w a y , combined oestrogen-progestogen therapy being the rule. Norwegian hysterectomy rates (20) are four-five times lower than the US-rates (21). Thus, interpretation of publications and transfer of knowledge is not straightforward. Uncertainty, reluctancy, and differing opinions among experts and practitioners may result. Most doctors estimated having one to six patients under treatment for each of the three groups of indications offered. Thus, we can calculate a selfassessed average number of patients between 15-20, which is similar to the recent UK study in which an average of 24.6 women per doctor was reported (17). By contrast, a US questionnaire to gynaecologists in Los Angeles revealed that each doctor had a median number of 200 patients on oestrogen therapy ( 2 2 ) . CONCLUSION GPs in Norway have a restrictive view on postmenopausal oestrogen use, more restrictive than recent medical knowledge calls for. Smoking and a family history indicating increased risk for cardiovascular disease are both regarded as contraindications. Manifest cardiac disease is regarded as a contraindication for local therapy. These opinions should be corrected by proper information. ACKNOWLEDGEMENTS We thank the participating GPs. Financial support was given by the Norwegian Research Council for Science and the Humanities. Support was also given by Ciba-Geigy ds, Organon, and Kabi Pharmacia.
REFERENCES I . Health statistics in the Nordic Countries 1988. Copenhagen: Nordic Medico-Statistical Committee, 1990. 7 Hunskaar s. Norske leger og kvinners hold-. ninger ti1 0strogenbehandling (Norwegian doctors’ and Norwegian women’s attitudes to oestrogen treatment), in: Backe B (ed.) Konsensuskonferansen om bruk av estrogen i og etter overgangsalderen (The consensus conference on menopausal use of oestrogens). NIS rapport 5/90, Trondheim: Norwegian of Haspita1 Research, 1990. 3. Iversen OE. Dstrogenbehandling (Oestrogen treatment). Tidsskr Nor Lregeforen 1989; 109: 2531-4. 3 . Norussis MJ, SPSS/PC +, SPSS Inc., Chicago 111.. 1956. 5. Lund-Larsen PG, Stensvold 1. lbstrogenbruk blant
183
kvinner i fylkesunders0kelsene (Use of oestrogen among women in the county health surveys), in: Backe B (ed.) Konsensuskonferansen om bruk av astrogen i og etter overgangsalderen (the consensus conference on menopausal use of oestrogens). NIS rapport 5/90. Trondheim: Norwegian Institute of Hospital Research. 1990. 6. Andrew M, Toverud EL. 0strogenbruk i Norge og Norden (Oestrogen use in Norway and the Nordic countries), in: Backe B (ed.) Konsensuskonferansen om bruk av estrogen i og etter overgangsalderen (The consensus conference on menopausal use of oestrogens). NIS rapport 5/90. Trondheim: Norwegian Institute of Hospital Research, 1990. 7. Pedersen SH, Jeune B. Prevalence of hormone replacement therapy in a sample of middle-aged women. Maturitas 1988; 9: 33940. 8. Persson I, Adami H O , Lindberg BS, Johansson EDB, Manell P. Practice and patterns of oestrogen treatment in climacteric women in a Swedish population. A descriptive epidemiological study. Acta Obstet Gynecol Scand 1983; 62: 289-96. 9. Holmes MM, Rovner DR, Rothert ML, Schmitt N, Given CW, Ialongo NS. Methods of analyzing physician practice patterns in hypertension. Med Care 1989; 27: 59-68. 10. Holzman GB, Ravitch MM, Metheny W, Rothert ML, Holmes M, Hoppe R. Physicians’ judgements about estrogen replacement therapy for menopausal women. Obstet Gynecol 1984; 63: 303-1 1. 11. Sandvik H, Hunskaar S , Eriksen BC. Management of urinary incontinence in women in general practice: Actions taken at the first consultation. Scand J Prim Health Care 1990; 8: 3-8. 12. Eriksen BC, Sandvik H, Hunskaar S . Management of urinary incontinence in gynecological practice in Norway. Acta Obstet Gynecol Scand 1990; 69: 515-9. 13. The consensus statement, in: Backe B (ed.) Konsensuskonferansen om bruk av estrogen i og etter overgangsalderen (The consensus conference on menopausal use of oestrogens). NIS rapport 5/90. Trondheim: Norwegian Institute of Hospital Research, 1990. 13. Consensus conference: Osteoporosis. JAMA 1983; 252: 799-802. 15. Pocock NA, Eisman JA, Kelly PJ, Sambrook PN, Yeates MG. Effects of tobacco use on axial and appendicular bone mineral densitv. Bone 1989: 10: 329-31. 16. Williams AR, Weiss NS, 6 r e CL, Ballard J , Daling JR. Effect of weight, smoking and estrogen use on the risk of hip and forearm fractures in postmenopausal Obstet Gynecol 1982; ‘O: 695-9’ 17. Wilkes HC1 Meade TW. Hormone replacement apY in general practice: a survey Of doctors i n the MRC’s general practice research framework. BMJ 1991; 302: 1317-20. 18. Hunskaar S , Backe B. Attitudes towards and information of menopausal and postmenopausal hormone replacement therapy among Norwegian itas (in press). 19. Bergkvist L, Adami H-O, Persson I , Hoover R, Schairer C. The risk of breast cancer after estrogen and
Scand I Prim Health Care 1992: I0
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estrogen-progestin replacement. N Engl J Med 1989; 321: 293-7. 20. Pedersen PB. Jsrgensen S (eds.) Samdata-sykehus 1990. (Samdata-hospital 1990). NIS-rapport 1/91. Trondheim: Norwegian Institute of Hospital Research, 1991, 21. Coulter A, McPhenon K, Vessey M. Do British women undergo too many or too few hysterectomies? Soc Sci Med 1988; 27: 987-94.
22. Ross RK, Paganini-Hill A, Roy S , Chao A, Henderson BE. Past and present preferred prescribing practices of hormone replacement therapy among Los Angeles gynecologists: Possible implications for public health. AJPH 1988; 78: 5169. Received November 1991
Accepted
1992
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Call for abstracts WONCNSIMG Congress 1993 "Quality of Care in Family MedicindGeneral Practice" June 13-17, 1993 The Hague, The Netherlands
The main topics of this conference, orgainsed by the Dutch College of General Practitioners (NHG) in collaboration with WONCA AND SIMG, are:
1. Procedures and methods in developing standards, guidelines and protocols, contents of standards, guidelines, and protocols. 2. Present quality of care in family medicine/gneral practice; development of valid instruments to measure the present quality of care. 3. Improving the quality of care; improving the functioning of general practice and the general practitioner; improving the health of patients. 4. Imperative conditions for quality of care.
Scund J Prim Heulth Cure 1992; 10
Other topics than mentioned above are also welcome! We would like to ask you to submit your abstract for the paper you would like to present on one of the themes. We would like to receive the abstracts no later than November 1, 1992. Scientific Secretariat NHG (Dutch College)lWONCNSIMG 1993 P.O. Box 3231/Lomanlaan 103 3502 G E Utrecht The Netherlands Tel. () 31 30 881700 Fax. () 31 30 870668
ISSN: 0281-3432 (Print) 1502-7724 (Online) Journal homepage: http://www.tandfonline.com/loi/ipri20
General Practitioners' Attitudes to Oestrogen Prescription in the Menopause: A National Survey in Norway Bjørn Backe, Steinar Hunskaar & John Arne Skolbekken To cite this article: Bjørn Backe, Steinar Hunskaar & John Arne Skolbekken (1992) General Practitioners' Attitudes to Oestrogen Prescription in the Menopause: A National Survey in Norway, Scandinavian Journal of Primary Health Care, 10:3, 179-184, DOI: 10.3109/02813439209014058 To link to this article: http://dx.doi.org/10.3109/02813439209014058
© 1992 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted Published online: 12 Jul 2009.
Submit your article to this journal
Article views: 45
View related articles
Citing articles: 6 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipri20 Download by: [45.79.85.112]
Date: 17 March 2016, At: 19:21
Scand J Prim Health Care 1992; 10: 179-184
General Practitioners’ Attitudes to Oestrogen Prescription in the Menopause: A National Survey in Norway BJBRN BACKE’, STEINAR HUNSKAAR? and J O H N A R N E SKOLBEKKEN’ ‘Norwegian Institute of Hospital Research, Trondheim, Norway, ’Division of Public Health and Primary Health Care, University of Bergen, Norway
Downloaded by [45.79.85.112] at 19:21 17 March 2016
Backe B, Hunskaar S , Skolbekken JA. General practitioners’ attitudes to oestrogen prescription in the menopause. Scand J Prim Health Care 1992; 1 0 179-84. A questionnaire was mailed to a random sample of approximately 10% of Norwegian general practitioners (CPs) in order to investigate attitudes to the prescription of hormone replacement therapy (HRT) in menopausal women. Nine short case histories were presented, and the GPs indicated their attitude to oestrogen prescription in each case on a five-step scale. Each case history contained four items that were systematically varied so that the effect of each could be investigated by comparing the answers from case to case. 251 GPs (74%) responded to the questionnaire. The answers indicated restrained attitudes towards prescription of HRT. Smoking and a family history of cardiovascular disease were regarded as contraindications. Angina pectoris was considered a contraindication for local oestrogen application in elderly women with urogenital complaints. Key words: oestrogens, menopause, prescriptions, general practice. Bjern Backe,
MD, Norwegian Institute of Hospital Research, N-7034Rondheim, Norway.
New application methods and recent acknowledgement of positive effects of hormone replacement therapy (HRT) on osteoporosis and cardiovascular morbidity have led to renewed interest for HRT. As opinions of the female menopause vary from that of a natural life event to its being an endocrinopathy requiring indefinite HRT, attitudes to the need for HRT, and its desirability, vary among doctors and lay people. Life expectancy of 45-year-old women in the Nordic countries is in the range of 36 years ( l ) , so the potential population for H R T is large. As a result of the debate on the use of oestrogens, the Norwegian Medical Research Council and the Norwegian Institute of Hospital Research arranged a consensus conference in 1990 on the use of oestrogens. The present study was undertaken to provide background information for the consensus panel ( 2 ) . The aim of the study was to investigate the attitudes and prescription habits of GPs concerning HRT, as well as local oestrogen therapy in women with urogenital complaints. It has previously been claimed that Norwegian doctors associate H R T with 14’
the same risk factors as hormones for contraceptive use (3). This was also the clinical impression of the investigators. Hence, the GPs were asked specifically whether they considered that smoking and risk for cardiovascular disease were contraindications for H R T , and whether they regarded angina pectoris as a contraindication for local oestrogen application in elderly women with atrophic urogenital symptoms. MATERIAL A N D M E T H O D S A 10% sample of primary care Norwegian doctors was randomly drawn from the database of a company offering address lists for marketing purposes. 4200 doctors were registered in the database. A questionnaire was sent to 420 doctors in August 1990, and a reminder was sent two weeks later. 331 answers were received, including 80 from doctors not working in general practice and who were therefore excluded. 251 answers from GPs remained for the analysis (74%). T h e answers were anonymous. The participating doctors came from all 19 counScand I Prim Heulth Cure 1992; 10
180
B . Backe et al.
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Table I. The 9 case histories (1-7 about hormone replacement therapy, 8 and 9 about local oestrogen therapy). 1.
50-year-old woman, depressed, complaining of sleeping problems and daily flushes. Oligomenorrhoeic.
2.
As 1, but reports many cases of cardiovascular disease in her family (both parents have had stroke and myocardial infarction). Normal bloodpressure.
3.
As 1, but smokes more than 20 cigarettes per day.
4.
50-year-old, depressed, complaining of sleeping problems and daily flushes. Oligomenorrhoeic. Smokes a lot. She reports many cases with osteoporosis in the family, and also many cases with cardiovasculaf disease.
5.
50-year-old healthy woman who asks for oestrogen replacement therapy. Brings with her an article from a woman’s magazine where use of oestrogen is recommended.
6.
50-year-old, depressed, complaining of sleeping problems and daily flushes. Oligomenorrhoeic. Reports many cases with osteoporosis in the family.
7.
50-year-old healthy oligomenorrhoeic woman. Says that her mother and an aunt have osteoporotic compressim fractures in the spine,
8.
58-year-old, complaining of dyspareunia and frequent episodes of cystits.
9.
74-year-old. Angina pectoris. Mixed stress-urge urinary incontinence.
ties. The mean age was 40.4 years (range 26-72), 77% were male, and 37% were approved specialists in general practice. 64% worked in a group practice. The questionnaire An introductory letter explained the purpose of the study. Nine short case histories were presented, 7
about HRT and 2 about local oestrogen therapy. The case histories about HRT contained four items: menopausal complaints, regular smoking, a family history suggesting increased risk for cardiovascular disease, and a family history indicating an accumulation of cases with osteoporosis. It was implied that, unless otherwise stated, the condition was not present. The case histories (Table I) were presented in a random order and were constructed to allow for pairwise comparisons (comparing 2 histories in which only one of the 4 variables was different). The distribution of the items in the HRT-cases is shown in Table 11. The GPs stated their views on prescribing oestrogen on a five-step scale for each case history. The choice of answers was: “Should not be prescribed”, assigned the score one, “In doubt” (score two), “Could be prescribed” (score three), “Ought to be prescribed” (score four), and “Definitly recommended“ (score five). The respondents were also asked to state age, sex, practice type, and the estimated number of patients in their practice receiving oestrogen therapy for indications specified. Statistical analysis Data were analysed with the Statistical Package for Social Sciences (4). The Sign test was applied for comparisons between cases. The Wilcoxon rank sum test was used for comparisons of answers between groups of doctors. p-values < 0.001 were considered as significant.
RESULTS Table 111 shows the GPs’scoring (% s), together with the mean and the median scores, for each case history. The highest mean score (4.1) was for case history 6, which described a woman with climacteric symptoms and a family history of osteoporosis. The
Table 11. The distribution of the 4 items from which the 7 case histories about hormone replacement therapy were built. (+) and (-) indicate whether the case history contained information on the actual item. Case history
Climacteric symptoms
1.
2. 3. 4.
5. 6. 7.
S c a d J Prim Health Care 1992; 10
Smoking
Cardiovascular risk
Family history of osteoporosis
General practitioners’ attitudes to oesrrogen
181
Table 111. The answers given on 9 case histories, in % of responding GPs (n = 251). A 5-step answering scale was used, ranking from negative ( I ) to positive (5) on whether oestrogen should be prescribed. The mean and median scores are shown. Case
history
1.
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2. 3. 4. 5. 6. 7. 8. 9.
Answering score
Mean
1
2
3
4
5
3 19 45 25 36
2 29 31 35 16 4 11 2 15
36 35 16 25 39 13 33 13 33
47 14 7 11 8 43 32 29 21
12
1
5 1
13
lowest mean score (1.8) was for case history 3 , which included climacteric symptoms, smoking, and a family history of cardiovascular diseases. The second lowest mean score (2.2) was for case history 5, where only the patient’s demand for H R T was indicated. As can be seen from Table 11, the effect of climacteric complaints on GPs’ readiness to prescribe H R T can be studied in two pairwise comparisons of the answers given: case one compared with case 5, and case 6 with case 7. In both comparisons the case history containing climacteric complaints (case one and six, respectively) scored significantly higher. The effect of a family history of osteoporosis could be elucidated in two pairwise comparisons: case 5 compared with case 7 and case one with case 6. In both comparisons the answers were significantly in favour of a greater willingness to prescribe oestrogen when a family history of osteoporosis was suggested. Comparison of case histories 1 and 2 reveals the effect of a family history of cardiovascular disease. Case 2 had significantly lower scores, indicating that this information is interpreted as a contraindication for H R T . Comparison of case histories 1 and 3 reflects GPs’ reaction to a history of smoking, when H R T is otherwise indicated. Case 3 scored significantly less than case one, indicating that smoking acts as a contraindication. Comparison of case one with case 4 shows that smoking and cardiovascular disease counterweigh the influence of a family history of osteoporosis, since case 4 scored significantly lower than case one, which only had climacteric symptoms.
Local treatment Two case histories adresstd the question of manifest
3 1 4 2 39 20
55 19
Median
3.6 2.5 1.8 2.3 2.2 4.1 3.5 4.4 3.2
cardiovascular disease as a possible contraindication to local oestrogen therapy. Case 9, presenting with angina pectoris, scored significantly lower than case 8, indicating that angina pectoris is considered a contraindication for local oestrogen therapy.
Doctor characteristics Neither gender nor type of practice (single versus group practice) revealed significant differences in the answers given. 12% of the doctors reported that they had no patient under oestrogen treatment for climacteric complaints. Most doctors estimated that they had one to six patients on H R T treatment for each of the three groups of indications: climacteric complaints, prophylaxis of osteoporosis, and long-term treatment for postmenopausal complaints. Female doctors reported significantly more patients on treatment for menopausal and postmenopausal complaints than male doctors, but there was no difference for the indication prevention of osteoporosis.
DISCUSSION H R T has apparently gained less popularity in Norway than in neighbouring countries. In a recent health survey comprising three Norwegian counties, only 5% of women aged 5C-54 reported use of oestrogens ( 5 ) . This contrasts with reports that oestrogens were used by 19% of Finnish women aged 45-64 (6), by 21% of Danish women aged 50-54 (7), and by 8.6% of Swedish women aged 50-54 (8). This indicates that the therapeutic traditions in Norway Scond J Prim Health Care 1992; 10
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are different from those of the other Nordic countries. No explanation has yet been offered for this. Other authors have successfully applied case-history questionnaires to test doctors’ attitudes to various clinical problems (9-12). Briefly sketching a clinical situation might be more indicative of clinical practice than asking direct questions, because the resemblance to an examination is reduced. Thus, attitudes might be recorded rather than reproductions of textbook knowledge. The non-parametric tests applied generally revealed remarkably small p-values, due to large figures and also substantial differences in the scores between cases. Recent consensus on H R T is that breast cancer and cancer of the endometrium are the main contraindications. Angina pectoris and previous myocardial infarction should not be regarded as contraindications for HRT; neither should a family history of cardiovascular disease influence the decision to prescribe HRT in a negative manner (13). A history of typical menopausal cornplaints led to higher scores. This consistency with the expected response pattern may provide an indication of the validity of the questionnaire. Anamnestic information about relatives with osteoporosis also increased the readiness to prescribe HRT. This is remarkable because there is no evidence that osteoporosis is a hereditary disease (14). The major problem in the prevention of osteoporosis is precisely the inability to identify women who will eventually develop osteoporosis and thus are likely to benefit from prophylactic treatment. Smoking aggravates osteoporosis (15). In one study, the beneficial effect of oestrogen therapy on osteoporosis was greatest in women who smoked (16). Thus, in our opinion, GPs’ association of smoking and postmenopausal oestrogen should rather be a positive than a negative one: if anything, smoking should increase doctors’ readiness to prescribe oestrogens. We have not found published evidence that smoking contraindicates postmenopausal oestrogen use. When the information that the patient smoked was given, doctors were less inclined to prescribe HRT. A family history of cardiovascular disease acted the same way, and together the two items counterweighed the two positive items: history of climacteric complaints and family history of osteoporosis. Thus, the two questions we had in mind when designing the study were both confirmed: a family Scand J Prim Health Care 1992: 10
anamnesis of cardiovascular diseases is regarded as a contraindication for HRT, as well as smoking. In our opinion, this contrasts with present medical knowledge. When local therapy of urogenital oestrogen deficiency in elderly women is considered, there is no reason to refrain from local oestrogen therapy in cases of manifest cardiac disease (13). Also in this regard, our data indicate a more restrictive practice than current medical knowledge calls for. A recent survey of GPs’ prescribing habits in the UK (17) concluded that more than half of the doctors would consider prescribing hormone replacement therapy for the prevention of cardiovascular disease. Also, cardiovascular problems were the most frequent reason given for oestrogen prescription. These observations contrast with our findings, and we feel tempted to share the opinion of others (3) that Norwegian GPs apparently fail to distinguish between oestrogen compounds used for contraception and oestrogens for postmenopausal use, despite different metabolic and biological properties of the compounds used for the various purposes. We are unable to explain how this misconception may have arisen. In the study of Holzman et al. (lo), the possibility that US doctors confuse the two types of oestrogens was discussed. The contrast between our results and the recent UK study (17) is striking, also in the light of medical knowledge that is supposed to be international. A recent telephone opinion poll of 1000 women, representative of the Norwegian population, showed that they too associate oestrogen therapy with increased risk for heart infarction and stroke (18). The low user rates in Norway may reflect that the doctors share the reluctant attitude of the women. In that case, the contraindications they practice may simply reflect their effort to rationalize their scepticism. The present study provides background for improvement of training and information for doctors in primary health care. The pharmaceutical industry provides a major part of the information for doctors on the use of drugs, and it has a special obligation to provide correct information about its products. The scientific evidence for risks and benefits of HRT relies on uncontrolled observational studies and case-control studies. No controlled randomized trial has been reported. With few exceptions (19), all relevant studies have been conducted in the USA and are related to the use of unopposed HRT, i.e. use of oestrogen without added progestogen. The oestrogen compound in the reported studies have
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General practitioners’ attitudes to oestrogen usually been conjugated oestrogen. Conjugated oestrogens have never been on sale in N o w a y , combined oestrogen-progestogen therapy being the rule. Norwegian hysterectomy rates (20) are four-five times lower than the US-rates (21). Thus, interpretation of publications and transfer of knowledge is not straightforward. Uncertainty, reluctancy, and differing opinions among experts and practitioners may result. Most doctors estimated having one to six patients under treatment for each of the three groups of indications offered. Thus, we can calculate a selfassessed average number of patients between 15-20, which is similar to the recent UK study in which an average of 24.6 women per doctor was reported (17). By contrast, a US questionnaire to gynaecologists in Los Angeles revealed that each doctor had a median number of 200 patients on oestrogen therapy ( 2 2 ) . CONCLUSION GPs in Norway have a restrictive view on postmenopausal oestrogen use, more restrictive than recent medical knowledge calls for. Smoking and a family history indicating increased risk for cardiovascular disease are both regarded as contraindications. Manifest cardiac disease is regarded as a contraindication for local therapy. These opinions should be corrected by proper information. ACKNOWLEDGEMENTS We thank the participating GPs. Financial support was given by the Norwegian Research Council for Science and the Humanities. Support was also given by Ciba-Geigy ds, Organon, and Kabi Pharmacia.
REFERENCES I . Health statistics in the Nordic Countries 1988. Copenhagen: Nordic Medico-Statistical Committee, 1990. 7 Hunskaar s. Norske leger og kvinners hold-. ninger ti1 0strogenbehandling (Norwegian doctors’ and Norwegian women’s attitudes to oestrogen treatment), in: Backe B (ed.) Konsensuskonferansen om bruk av estrogen i og etter overgangsalderen (The consensus conference on menopausal use of oestrogens). NIS rapport 5/90, Trondheim: Norwegian of Haspita1 Research, 1990. 3. Iversen OE. Dstrogenbehandling (Oestrogen treatment). Tidsskr Nor Lregeforen 1989; 109: 2531-4. 3 . Norussis MJ, SPSS/PC +, SPSS Inc., Chicago 111.. 1956. 5. Lund-Larsen PG, Stensvold 1. lbstrogenbruk blant
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kvinner i fylkesunders0kelsene (Use of oestrogen among women in the county health surveys), in: Backe B (ed.) Konsensuskonferansen om bruk av astrogen i og etter overgangsalderen (the consensus conference on menopausal use of oestrogens). NIS rapport 5/90. Trondheim: Norwegian Institute of Hospital Research. 1990. 6. Andrew M, Toverud EL. 0strogenbruk i Norge og Norden (Oestrogen use in Norway and the Nordic countries), in: Backe B (ed.) Konsensuskonferansen om bruk av estrogen i og etter overgangsalderen (The consensus conference on menopausal use of oestrogens). NIS rapport 5/90. Trondheim: Norwegian Institute of Hospital Research, 1990. 7. Pedersen SH, Jeune B. Prevalence of hormone replacement therapy in a sample of middle-aged women. Maturitas 1988; 9: 33940. 8. Persson I, Adami H O , Lindberg BS, Johansson EDB, Manell P. Practice and patterns of oestrogen treatment in climacteric women in a Swedish population. A descriptive epidemiological study. Acta Obstet Gynecol Scand 1983; 62: 289-96. 9. Holmes MM, Rovner DR, Rothert ML, Schmitt N, Given CW, Ialongo NS. Methods of analyzing physician practice patterns in hypertension. Med Care 1989; 27: 59-68. 10. Holzman GB, Ravitch MM, Metheny W, Rothert ML, Holmes M, Hoppe R. Physicians’ judgements about estrogen replacement therapy for menopausal women. Obstet Gynecol 1984; 63: 303-1 1. 11. Sandvik H, Hunskaar S , Eriksen BC. Management of urinary incontinence in women in general practice: Actions taken at the first consultation. Scand J Prim Health Care 1990; 8: 3-8. 12. Eriksen BC, Sandvik H, Hunskaar S . Management of urinary incontinence in gynecological practice in Norway. Acta Obstet Gynecol Scand 1990; 69: 515-9. 13. The consensus statement, in: Backe B (ed.) Konsensuskonferansen om bruk av estrogen i og etter overgangsalderen (The consensus conference on menopausal use of oestrogens). NIS rapport 5/90. Trondheim: Norwegian Institute of Hospital Research, 1990. 13. Consensus conference: Osteoporosis. JAMA 1983; 252: 799-802. 15. Pocock NA, Eisman JA, Kelly PJ, Sambrook PN, Yeates MG. Effects of tobacco use on axial and appendicular bone mineral densitv. Bone 1989: 10: 329-31. 16. Williams AR, Weiss NS, 6 r e CL, Ballard J , Daling JR. Effect of weight, smoking and estrogen use on the risk of hip and forearm fractures in postmenopausal Obstet Gynecol 1982; ‘O: 695-9’ 17. Wilkes HC1 Meade TW. Hormone replacement apY in general practice: a survey Of doctors i n the MRC’s general practice research framework. BMJ 1991; 302: 1317-20. 18. Hunskaar S , Backe B. Attitudes towards and information of menopausal and postmenopausal hormone replacement therapy among Norwegian itas (in press). 19. Bergkvist L, Adami H-O, Persson I , Hoover R, Schairer C. The risk of breast cancer after estrogen and
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estrogen-progestin replacement. N Engl J Med 1989; 321: 293-7. 20. Pedersen PB. Jsrgensen S (eds.) Samdata-sykehus 1990. (Samdata-hospital 1990). NIS-rapport 1/91. Trondheim: Norwegian Institute of Hospital Research, 1991, 21. Coulter A, McPhenon K, Vessey M. Do British women undergo too many or too few hysterectomies? Soc Sci Med 1988; 27: 987-94.
22. Ross RK, Paganini-Hill A, Roy S , Chao A, Henderson BE. Past and present preferred prescribing practices of hormone replacement therapy among Los Angeles gynecologists: Possible implications for public health. AJPH 1988; 78: 5169. Received November 1991
Accepted
1992
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Call for abstracts WONCNSIMG Congress 1993 "Quality of Care in Family MedicindGeneral Practice" June 13-17, 1993 The Hague, The Netherlands
The main topics of this conference, orgainsed by the Dutch College of General Practitioners (NHG) in collaboration with WONCA AND SIMG, are:
1. Procedures and methods in developing standards, guidelines and protocols, contents of standards, guidelines, and protocols. 2. Present quality of care in family medicine/gneral practice; development of valid instruments to measure the present quality of care. 3. Improving the quality of care; improving the functioning of general practice and the general practitioner; improving the health of patients. 4. Imperative conditions for quality of care.
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Other topics than mentioned above are also welcome! We would like to ask you to submit your abstract for the paper you would like to present on one of the themes. We would like to receive the abstracts no later than November 1, 1992. Scientific Secretariat NHG (Dutch College)lWONCNSIMG 1993 P.O. Box 3231/Lomanlaan 103 3502 G E Utrecht The Netherlands Tel. () 31 30 881700 Fax. () 31 30 870668
