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Menopausal decisions


Making decisions about whether or not to use hormone replacement therapy (HRT) will never be easy for women. In the immediate post-menopausal period some women may have tremendous problems with flushing and other symptoms, for which oestrogen replacement is efficacious. Yet the main benefits of oestrogens on bone and cardiovascular risks are long term, and have to be balanced against small increased risks of breast cancer associated with oestrogen use. It is all very complicated, and information available for women is variable, so a randomised trial which examined different ways of giving information [ 1 ] is interesting.

Study


This study of 165 women recruited women at least one year past the menopause by referrals, posters and radio and other announcements. They were randomised to getting information about HRT either by the use of an American College of Pathologists educational pamphlet describing the benefits, risks and side-effects of HRT or to a specially-designed decision aid. The decision aid comprised a 32-page illustrated booklet plus a 40 minute audio tape providing information about coronary heart disease, osteoporosis, endometrial and breast cancer in some detail, information about HRT regimens, and steps to assess a woman's own benefits and risk according to her individual risks for these factors. It was designed to take about 40 minutes, and be used by the woman at home. Randomisation was properly done, and included strategies to reduce influences from researchers during interviews. Data analysis was done by individuals blind to assignments.

Outcomes


A whole range of outcomes was used, including scales which measured decisional conflict, general knowledge about HRT benefits and risks, acceptability of the decision aids, and decisions about use of HRT. Realistic expectations were determined by whether the women made a sensible judgement approximating to their present or future risk of heart disease, breast cancer, or hip fracture.

Results


Women using the decision aid had significantly less conflict over making a decision, and more women using the decision aid had responses indicating no conflicts about their decision. The biggest difference was in the proportion of women having realistic expectations about the effects on HRT on their risks for coronary heart disease, risk fracture and breast cancer (Figure).


Despite an overall increase in knowledge about HRT and appreciation of the risk and benefits of HRT, there was no difference in the decisions women made. In both groups, 58% declined HRT, 15% accepted treatment, and 27% remained unsure.

Comment


Women liked the decision aid, and those who used it found it more acceptable and made better judgements about their own personal position. It reduced the number of women who underestimated their baseline risks of heart disease and overestimated their baseline risks of breast cancer and the benefits and risks of HRT. In that respect it was a valuable educational tool.

Perhaps there's the rub. It was an educational tool, and despite better education women may not change their attitudes to HRT. But choosing HRT is not a one-time, all-or-none decision. Women may reflect, or their circumstances may change, or new treatments like selective oestrogen receptor modulators may become available. Women knowledgeable about HRT may make different decisions in the future, and will certainly be more confident if they want to change their minds.

Reference:

  1. A O'Connor, P Tugwell, GA Wells et al. Randomized trial of a portable, self-administered decision aid for postmenopausal women considering long-term preventive hormone therapy. Medical Decision Making 1998 18: 295-303.

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