Knowledge and Awareness Toward Menopausal Hormone Therapy in a Fourth-Tier City of China

Introduction

With the progress of society and the improvement of medical care, the average life expectancy of people is gradually lengthening. By 2050, the number of women aged 50 years and older is projected increase to 1.6 billion worldwide, up from 1 billion in 2020 [1]. Natural menopause occurs at a mean age of 49 years [2]. More and more people are paying attention to the health problems associated with menopause, especially in developed areas. However, in developing countries, especially in small–medium cities and rural areas, even though women have obvious menopausal symptoms, they are still reluctant to choose medical intervention. Menopausal hormone therapy (MHT) is the most effective treatment for managing vasomotor and genitourinary symptoms [3,4]. MHT has had a difficult history, with the 2002 US Women’s Health Initiative study pointing to an overall increased health risk, rather than benefit, of MHT use in healthy postmenopausal women in the United States (US), but the findings were controversial. Through reanalysis of the data and more research, the use of MHT has stabilized after a decade. The UK NICE guidelines state that MHT has a favorable risk–benefit ratio in women initiating treatment between the ages of 50 and 59 years or within 10 years of onset of menopause. It also depends on the dose and type of hormone [5,6]. However, Chinese women’s knowledge of MHT is insufficient, and doctors and nurses also differ in their perceptions of menopausal hormone therapy.

We conducted a survey of local menopausal women. In this study, 186 menopausal women who came to our consulting room were retrospectively analyzed for their menopausal symptoms and treatment. At the same time, relevant investigations were conducted among medical staff in our hospital to understand their cognition of MHT. The aim of our study was to provide a basis for strengthening health education and popularization of MHT for menopausal women.

Material and Methods

STUDY DESIGN AND PARTICIPANTS:

Cases of perimenopausal syndrome from the menopausal outpatient clinic of Qinhuangdao Maternal and Child Health Hospital, from January 2022 to January 2023 were selected for retrospective analysis. Inclusion criteria were: (1) Age less than 60 years, menopause less than 10 years; (2) The patient was diagnosed as having perimenopausal syndrome with menopausal-related symptoms; (3) The length of 2 adjacent menstrual cycles changed by more than 7 days in 10 months; (4) No history of hysterectomy or oophorectomy. Exclusion criteria were: (1) History of malignant tumor or radiotherapy and chemotherapy; (2) Those with MHT contraindication; (3) People with major organ diseases such as heart, liver, kidney, brain or other serious diseases that have not been controlled. We enrolled 186 patients, with an average age of 48.36±5.75 years. The study was approved by the Ethics Committee of Qinhuangdao Maternity and Child Health Hospital in December 2021. Informed consent was obtained by telephone from all participants.

METHODS:

The profile included all variables in the study, including general information about the patients, as well as menopausal symptoms such as hot flashes and insomnia. We collect the case files of patients with perimenopausal syndrome in our menopausal clinic and retrospectively analyzed their basic information, including general demographic characteristics, such as age, marital status, degree of education, and monthly income, and we assessed their menstruation- and menopause-related symptoms. The severity of perimenopausal syndrome was assessed with an international questionnaire, the modified Kupperman scale, which covers 13 symptoms. For each symptom, no symptoms receive 0 points, mild symptoms receive 1 point, moderate symptoms receive 2 points, and severe symptoms receive 3 points. Then, the score is multiplied by the symptom index (4 points for hot flashes, 2 points for abnormal sensation, insomnia, excitability, sexual life, and urinary tract infection, and 1 point for the rest), and then add the values to get the total score. The total score of the scale is ≤6 normal, 7–15 mild perimenopausal syndrome, 16–30 moderate, and ≥31 severe. Any item greater than 2 points is considered to affect life. We also assessed the understanding of patients about MHT. All data were analyzed retrospectively.

The understanding of 100 medical and nursing staff (including obstetrics and gynecology, pediatrics, internal medicine, and surgery department) about menopausal hormone treatment in our hospital was analyzed by questionnaire. Questionnaires were sent to the department, and participants gave informed consent to answer the questions.

STATISTICAL ANALYSIS:

SPSS 16.0 was used for statistical analysis. The measurement data are expressed as mean±standard deviation (x±s), and the independent sample t test was used for comparisons between groups. Count data are expressed as absolute numbers and proportions. Relative numbers and chi-square test were used for comparisons between groups. Differences were considered statistically significant at P<0.05.

Results

BASIC INFORMATION:

We assessed data from 186 patients with perimenopausal syndrome divided into 3 groups according to the use of MHT. The 41 patients in group A had been treated with MHT for more than 1 cycle; the 49 patients in group B had received MHT but had stopped for more than 3 months; and the 96 patients in group C had never received MHT. There were no significant differences in age and marital status among the 3 groups, but there were significant differences in educational level and monthly income. The education level of patients in group A was higher than that of patients in group B and group C, and the proportion of patients whose monthly income was more than 5000 yuan was higher (Table 1).

MENOPAUSE-RELATED SYMPTOMS:

According to the statistics of 186 patients with perimenopausal syndrome, the incidence of menopause-related symptoms was (top 5): hot flashes and sweating (102 cases, 54.8%), insomnia (86 cases, 46.2%), osteoarthralgia (65 cases, 34.9%), excitability (54 cases, 29.0%), and fatigue (43 cases, 23.1%). The incidence of hot flashes and sweating, paresthesia, insomnia, excitability, dizziness, fatigue, osteoarthralgia, headache, palpitation, pain during sexual intercourse, vaginal dryness, and urinary tract infection in the 3 groups were significantly different. There were no significant differences among the 3 groups in terms of depression, suspicion, palpitation, and formication. However, we observed a significant difference between the original group A (MHT in use) and the original group B+C (MHT discontinued, MHT never used) when they were regrouped according to whether they were receiving menopausal hormone therapy (Tables 2, 3).

COMPARISON OF KUPERMANN SCORES:

There were significant differences in modified Kupermann scores before treatment among groups (P<0.05) (Table 4), but the difference disappeared after MHT treatment (P>0.05) (Table 5). Among the patients who discontinued MHT or who had never received MHT (groups B and C), 45 patients (31%) were assessed as having moderate or severe menopausal syndrome.

REASONS FOR NOT USING OR STOPPING MHT IN PATIENTS WITH PERIMENOPAUSAL SYNDROME:

Among the patients in group C who had never used MHT, 32 patients (33%) did not know of or never heard of MHT, 60 (62.5%) worried about the risk of breast cancer/endometrial cancer/thrombosis, 24 (25%) worried about high costs, and 67 (70%) had no obvious symptoms and did not want MHT. Among the patients in group B who had used MHT before and now stopped taking it, 33 patients (67%) felt that their symptoms had been relieved after taking the drug, 28 (57%) worried about the risk of breast cancer/endometrial cancer/thrombosis, 14 (29%) stopped due to high cost; 5 (10.2%) stopped because it was inconvenient to see a doctor, and 3 (6%) had other reasons.

UNDERSTANDING OF MHT BY MEDICAL AND NURSING STAFF:

A questionnaire was used to assess the understanding of 100 medical and nursing staff (gynecology and obstetrics, medical, and surgical) about MHT in our hospital – 35 (35%) said they fully understood menopausal symptoms, 56 (56%) knew some of the symptoms, and 9 (9%) said they did not know anything about them. As for the long-term complications of menopause, 40 (40%) knew about osteoporosis/fracture, 37 people (37%) knew about cardio-cerebrovascular diseases, 43 (43%) knew about repeated urinary infection, and 36 (36%) knew about Alzheimer’s disease. We found that 14 (14%) knew about and were willing to accept MHT, 44 (44%) knew about MHT but were afraid to use it, and 42 (42%) knew nothing about MHT.

Discussion

Menopause is a physiological phenomenon. In China, the average life expectancy has increased to 77 years old, and the average age of menopause is 49 years old. The perimenopausal and postmenopausal periods account for one-third of a woman’s life. Therefore, problems caused by menopause are increasingly prominent, and the number of patients seeking medical treatment due to menopause-related symptoms is gradually increasing. This study analyzed patients who came to the gynecological endocrine clinic of our hospital due to menopausal discomfort, and found that the most common menopausal symptoms were hot flashes and sweating, and insomnia, osteoarthralgia, excitability, and fatigue are also the reasons for menopausal women to see a doctor, suggesting that menopausal symptoms have adverse effects on women’s life, physiology, psychology, and other aspects, which need to be paid attention to. Hot flashes and sweating were the most prominent vasoconstriction symptoms, and 80% of menopausal women have them [7]. Its prevalence in patients receiving MHT is lower than that of those who do not receive it or who discontinued, which is similar to results of SRIPRASERT I [8], which fully demonstrates the effectiveness of MHT in relieving vasoconstriction symptoms [9–11].

The results of this study show that the incidence of most menopausal symptoms and Kupperman scores of current MHT patients were lower than those of patients who did not receive MHT or discontinued it, except for depression, palpitation, and formication, and there were significant differences in these 3 indicators between group A and group B+C. However, when we analyzed these 3 indicators again, there were significant differences between the medication group and non-drug group, whether on or off the drug. This also fully demonstrates the effectiveness of MHT in relieving menopausal symptoms [6,11,12], as all symptoms were different before and after MHT.

MHT is an effective way to treat menopausal syndrome [13]. After nearly 80 years of development, the treatment schedule has matured, new drugs are coming out, and the safety is improving, which is gradually being recognized and accepted by the public. In economically developed countries, the use of MHT among menopausal women has reached 30%, but in Beijing, China only 1.4% received MHT [14]. Our data show that this is related to education level and monthly income.

We found that only 22% of patients who came to the clinic with symptoms continued with MHT, most had little information about MHT and would not consider receiving it, and 26% who started MHT discontinued it. Their main concern was that hormone therapy might increase the risk of breast cancer, despite ample evidence that MHT is relatively safe. In 2016, the International Menopause Society (IMS) stated that there is only a small increase in the risk of breast cancer associated with MHT (<0.1% per year), which is similar to or lower than the increased risks associated with common lifestyle risk factors such as sedentary lifestyle, obesity, and alcohol consumption [15]. Some of our respondents believed it is a natural aging process that does not require intervention. In addition to the insufficient public knowledge and popularization of science, the lack of patient interest in MHT is also related to the lack of awareness of MHT by medical personnel themselves. In our research, only 35% of medical staff fully understood the symptoms of menopause, and only 14% were willing to accept menopausal hormone treatment. Such a low proportion is mainly due to insufficient knowledge and fear of adverse reactions, suggesting the need to improve public health education on menopause.

Osteoporosis is one of the important factors that affect the health and quality of life of postmenopausal women, which in turn affects family stability and social economy. The lack of estrogen is an important cause of osteoporosis, and MHT helps to prevent osteoporosis [16,17]. Unfortunately, according to our survey, nearly 60% of the medical staff still do not know that osteoporosis is related to menopause. Similarly, low levels of estrogen can also cause abnormal metabolism of blood lipids, increase the incidence of cardiovascular diseases, cause atrophy of the genitourinary tract, cause symptoms such as vaginal dryness, difficulty in sexual function, and repeated urinary tract infections, and increase the risk of Alzheimer’s disease, but these are not generally recognized by medical staff, let alone the general population [18–20].

Conclusions

Health problems related to menopause affect women’s quality of life, family harmony, and even social stability. In developing countries, women’s understanding of MHT is inadequate. Medical staff in gynecology and endocrinology should spread knowledge related to menopause, so that the concept of menopause-related symptoms and diseases requiring treatment is deeply rooted in the hearts of the people. We have a long way to go to recognize and accept MHT. Of course, this study is based on the current situation of the hospital, which cannot fully reflect the epidemiological characteristics of the population. Large-scale research is needed and more efforts need to be made in developing countries.