Disparity in HT Use Between Women Ob-Gyns and Women Overall
In the pre–Women’s Health Initiative (WHI) years of the early 1990s, a report from a Boston health maintenance organization (HMO) indicated that the prevalence of menopausal hormone therapy (HT) use was 21% overall, with 24% of women aged 50 to 54 years using HT. In Switzerland, Sweden, and Finland, the pre-WHI prevalence of HT use was higher at 46%, 41%, and 38%, respectively.

After the 2002 publication of the initial findings from the WHI estrogen-progestin therapy clinical trial, HT prescriptions in the United States plummeted by some 60%, whereas a report from five HMOs found declines of some 40%, corresponding to an approximately 8% aggregate prevalence of HT use in these HMOs. In Europe, HT prevalence after the WHI 2002 report dropped by 33% (31% prevalence) in Switzerland, by 38% (25% prevalence) in Sweden, and by 29% (27% prevalence) in Finland.

In contrast to HT prevalence among postmenopausal women overall, HT use among female physicians in the United States and Europe is markedly higher. In 1993-1994, the prevalence of HT use among US menopausal physicians aged 50 to 59 years was 49%, with use being substantially higher among female obstetrician gynecologists (ob-gyns). I am not aware of any survey of female US physicians overall conducted since 2002. However, the American College of Obstetricians and Gynecologists commissioned a Gallup survey in 2003, which noted that, among female ob-gyns with symptoms, one half were current HT users. A 2004 report noted that more than two thirds of female physicians and partners of male physicians residing in Northern Italy currently used HT, and it pointed out that HT use among surveyed physicians was “…much higher than in the general population.” In this issue of Menopause, Buhling et al report the findings of their 2010-2011 survey, which observed that 97% of female ob-gyns or the female partners of male German ob-gyns used or would use HT for the management of vasomotor symptoms. This prevalence or prescription of HT among German ob-gyns is substantially higher than that noted in the findings of a 2005 report, which observed that 37% of “informed” West German women 45 to 60 years of age used HT.

Ob-gyns arguably represent a population of individuals who are highly knowledgeable regarding the risks and benefits of HT. The observations I have summarized suggest a striking disparity between the use of HT by ob-gyns and/or their partners and the use of HT by the patients—a disparity that, in the United States, seems to have widened since the initial 2002 WHI report. The differences between HT use among women overall and ob-gyns can be considered a lack of parity between less informed women and more informed women. What factors might account for this disparity?

First, as pointed out by Buhling et al, the time constraints faced by clinicians during hurried well-woman visits may preclude broaching the issue of HT use in symptomatic patients. For example, given women’s fears regarding breast cancer, helping women appreciate that there is only a modestly elevated risk of breast cancer associated with more than 3 to 5 years of estrogen therapy use is a task that clinicians may find difficult to accomplish quickly.

Second, many patients do not have the tools to discriminate between balanced evidence-based guidance, such as information available online from The North American Menopause Society, and other guidance regarding HT, whether encountered in the media, online, or from other sources.

Third, some clinicians may perceive the medicolegal consequences of prescribing HT (eg, HT users diagnosed with breast cancer or pulmonary embolism) to be so daunting that they prefer to leave the issue of HT use unaddressed, unless a patient specifically requests such treatment.

Understanding disparities in the provision of healthcare services can help identify critical opportunities for provider and patient interventions. To paraphrase Dr. JoAnn E. Manson, 2011-2012 president of The North American Menopause Society and principal investigator for the WHI Vanguard Center at Brigham and Women’s Hospital: “Menopausal symptoms impair women’s quality of life and are seriously undertreated. It is important for clinicians to begin to address these issues with the patients by opening up lines of communication—letting women know their treatment options.”

How can clinicians caring for postmenopausal women help close the gap between the high prevalence of HT among well-informed women and the markedly lower use among those less informed? Dr. Manson’s comments point us toward better communication with patients regarding HT. One approach to improving such communication is recognizing that a well-woman visit may not allow sufficient time to help a symptomatic woman make an informed choice regarding HT use. Encouraging symptomatic patients to return for a problem-oriented visit devoted to reviewing symptom treatment provides an opportunity for reviewing the pros and cons of HT in an unhurried manner. An appropriate diagnosis for such a visit might be “menopausal syndrome/hot flashes” (International Classification of Diseases, Ninth Revision, code 627.2). Provided that more than half of the time expended during an office visit involves counseling, problem-oriented office visits can be coded according to the time expended counseling. In addition, steering women to reliable sources of evidence-based information on HT, including The North American Menopause Society’s Web site (menopause.org; click “For Women” on the home page), facilitates patient education without expending additional time in the office. Finally, women who perceive their decision regarding HT use/nonuse to be based on a balanced discussion with a caring clinician will be less likely to sue should an adverse outcome, such as breast cancer, later occur.