Burckhardt, Peter

Cornuz, Jacques

Krieg, Marc-Antoine

Ruffieux, Christiane

Sandini, Lorenzo

van Melle, Guy

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Research letters675Factors associated with the use of hormone replacement therapy among older women SIR—The long-term use of postmenopausal hormonereplacement therapy (HRT) to prevent diseases has beenrecently questioned by the results of the Women’s HealthInitiative [1]. The discrepancy between data provided byobservational studies and those from randomised con-trolled trials suggests that some apparent positive associ-ation between HRT use and long-term health beneWtsmight be partially attributable to the presence of biases inthe observational studies, such as selection [2] and com-pliance [3] biases. Data obtained in upper-middle classwomen [4, 5], early postmenopausal women [6] andwomen aged on average 65 years [7, 8] suggest that HRTusers are healthier and more health conscious than thenon-users. A recent study suggested a similar proWleamong older women [9], but without adjusting for themenopause status and/or hysterectomy, two determin-ants of HRT use [8]. The only population-based studyassessing the determinants of HRT use in older womenby taking into account the menopausal status was per-formed in the eighties [10]. The aim of our study was to determine the character-istics of HRT use among older women aged 70 or morewho participated in the Swiss Study for the Evaluation ofthe Methods of Measurement of Osteoporotic FractureRisk (SEMOF Study). Popul ation and methods The SEMOF Study is a prospective multi-centre studyassessing the predictive value of bone ultrasound devicesfor hip fractures in a cohort of 7,609 women aged 70 andolder [11, 12]. BrieXy, participants were recruited fromJanuary 1998 to Summer 1999 from the Swiss ofWcialpopulation-based listings in 10 areas across the country.We excluded those with a history of hip fracture, bilateralhip replacement, renal failure, active cancer or dementia. Sociodemographic data included age, education, cur-rent partnership situation, and previous professional sta-tus. Clinical variables included report of previous andcurrent medications, menopausal status, diagnosis ofosteoporosis, personal history of hip fractures, currentalcohol consumption, cigarette smoking, and level ofphysical activity. We measured weight and height to cal-culate the body mass index (BMI). HRT use was identi-Wed as any report of systemic (oral or transdermalmedications) oestrogen, with or without progesterone.Current or past users were deWned as women who reporteduse of HRT either at the time of the interview, or anytimein the past. Women whose only prescribed HRT wastopical oestrogen creams were considered as never users. We assessed the validity of the questionnaire inform-ation by comparing the participant’s answers with theinformation provided by their primary care physician. Werandomly selected 170 participants of one centre andasked them permission to contact their physician, and154 women agreed (91%). One hundred and twenty-fourphysicians answered the questionnaire (81% participationrate). The agreement between the self-reported inform-ation and the data obtained from the physician can bedeemed as either good or excellent, since the kappa stat-istics ranged between 0.76 (diagnosis of osteoporosis)and 0.94 (vertebral fracture) for fracture events and between0.69 (previous calcium supplementation) and 0.94 (currentHRT use or calcium supplementation) for medication. We performed bivariate analyses where current usersof HRT were opposed to the others using the t-test forcontinuous and the Pearson chi-square test for categor-ical variables. The comparisons were also performed onthree categories (current, past and never) using analysisof variance, Pearson chi-square, as well as a Wilcoxon-type test for trend. We conducted a multivariable logisticregression analysis of current users to adjust for potentialconfounding bias. Adjusted odds ratios and 95% con-Wdence interval are reported. Statistical analyses wereperformed using STATA 7.0 statistical package. The ethics committee of the Swiss Academy of Med-ical Sciences approved the study protocol. Results We included 7,609 women whose mean age (±SD) was75.3 (±3.1) years, and mean age at menopause was 49(±5.5) years. The vast majority (75%) reported a naturalmenopause, and 22% a post-surgery menopause (mainlydue to a hysterectomy). Overall, 11% of the womenreported current and 7% past use of HRT, with an aver-age duration of 11.3 and 5.8 years, respectively. Amongcurrent users, the percent of women reporting unop-posed oestrogen therapy was 27%. Current use of HRTdeclined with age and BMI (Figure 1). As compared to never and past users, current usersexperienced signiWcantly more frequently a surgical meno-pause (38.0% versus 21.3%), were younger (mean age 74.0versus 75.4), more likely to have a BMI lower than themedian (58.8% versus 49.1%), to live with a spouse or part-ner (56.0% versus 49.4%), to have a high education (13.2%versus 9.1%) and previous qualiWed professional level(60.6% versus 50.8%), to be supplemented with calcium(29.3% versus 19.3%) and vitamin D (19.6% versus 12.1%),as well as to report occasional alcohol consumption (62.6%versus 58.9%) and a diagnosis of osteoporosis (26.2% versus17.6%). Smoking status, level of physical activity, history ofvertebral or forearm fractures, and age of menopause didnot differ between current HRT users and others. When we compared the distribution of these variablesamong the HRT categories, we found a signiWcant lineartrend for age, BMI, diagnosis of osteoporosis, surgicalmenopause, living with a spouse, professional and educa-tional level, calcium or vitamin D supplementation, andalcohol consumption (Table 1). Multiple logistic regressionanalyses including age and all variables statistically signiWcant with a P-value <0.20 in the bivariate analysisResearch letters676revealed that the major determinants of current use ofHRT were the following (Table 2): surgical menopause;calcium supplementation; diagnosis of osteoporosis; highsocioeconomic status; lower weight; marital status. Discussion The proportion of current and past HRT users amongthese 7,609 older women was 11 and 7%, respectively.To our knowledge, this is the Wrst study performed dur-ing the nineties taking into account the type of meno-pause and reporting the prevalence of HRT use and thehealth proWle of the HRT users in older women. After adjustment for age, the major determinant forthe use of HRT was a post-surgery menopause, whichextends a similar association in younger women [8]. Thecurrent HRT users were different from former and neverusers with regard to disease prevention measures. Aftertaking into account age, the report of post surgery meno-pause and the diagnosis of osteoporosis, current HRTusers appear to be more likely to have a ‘health con-scious’ proWle (i.e., to be thinner and more likely to havecalcium supplementation) and a higher socioeconomicstatus. The signiWcant trends for several determinants innever, former, and current users, suggest that the more awoman is health conscious and has a high socioeconomicstatus, the more likely she is to keep on using HRT. Ourresults are in concordance with data obtained during theeighties [10, 13, 14]. These results extend data obtained inyounger women [6–9, 13] and in older women butFigure 1. Use of hormone replacement therapy among women aged 70 and older by body mass index (kg/m2). The areas ofthe symbols are proportional to the size of the population at that speciWc BMI.Table 1. Analysis of the association between various factors and the use of hormone replacement therapy (n = 7,609) aBMI = body mass index (weight – kg/height2 – cm). bHigh education = having a university or equivalent degree (versus lower education level). cJob requiring any form of training, such as apprenticeship or college (versus unqualiWed job). dAny alcohol consumption = any level of consumption, i.e. occasional or regular (versus no drink at all). eNo sedentary lifestyle = any lifestyle or sports activities (versus no activity at all).  Factors Current (n = 841) Past (n = 533) Never (n = 6235) P-value P for trend. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Age (mean ± SD), year 74.0 ± 2.9 74.4 ± 2.9 75.5 ± 3.0 <0.001 <0.001 BMIa (mean ± SD), kg/m2 24.9 ± 3.8 25.5 ± 4.0 26.1 ± 4.5 <0.001 <0.001 BMIa <25.5 kg/m2, % 58.8 54.4 48.5 <0.001 <0.001 Living with a spouse, % 56.0 54.6 48.9 <0.01 <0.01 High educationb, % 13.2 11.8 8.9 <0.001 <0.001 Previous qualiWed jobc, % 60.6 57.0 50.3 <0.001 <0.001 Post-surgery menopause, % 38.0 29.7 20.4 <0.001 <0.001 Diagnosis of osteoporosis, % 26.2 23.6 17.1 <0.001 <0.001 Ca supplementation, % 29.3 25.0 18.8 <0.001 <0.001 Vitamin D supplementation, % 19.6 17.7 11.6 <0.001 <0.001 Any alcohol consumptiond, % 62.6 67.3 58.1 <0.001 <0.001 No sedentary lifestylee, % 25.3 25.5 27.1 NS – No current smoking, % 91.6 93.4 92.0 NS – Any fracture in the past, % 53.0 54.2 51.0 NS – Research letters677without control for previous hysterectomy [13]. Such a‘health-conscious’ proWle has also been demonstrated inother preventive medicine areas [15]. Why this difference regarding health consciousnessbetween current, past and never older HRT users? A self-selection by the women themselves is possible; thewomen with a health conscious proWle might either haveasked their physicians for or were compliant with HRTmore frequently than other women. Current HRT usershave been recently shown more likely to be worriedabout becoming less attractive, suggesting that they mayhave asked for or were compliant with HRT because oftheir desire to feel and look younger [8]. It is also possiblethat physicians themselves selected among their patientsthe candidates for such therapy according to their life-style, current medications or socioeconomic status. Ourdata support the recommendations to share with thepatient the pros and cons of HRT before prescribing thistherapy to a postmenopausal woman [16]. We compared the distribution of some variables withdata in the age-matched Swiss general population pro-vided by the Swiss Health Survey [17]. The prevalence ofsmoking (8% versus 7%, respectively) and of hysterec-tomy (23% versus 21%) and the median BMI (25.5 versus25.2 kg/m2) were similar. These comparisons indicatethat our study population are not different from thesource population. Furthermore, the age at the meno-pause and the proportion of natural menopause wereconcordant with previous data [18, 19]. Our study has limitations. First, we used self-reporteddata. However, the very good agreement between the reportof the medications (including HRT use) and the history offractures, and the data provided by the participant’s phys-ician give credence to the validity of our data. The validity ofinformation on medications and fractures has also been pre-viously demonstrated [20–25]. Second, a recall bias is poss-ible [26]. However, we did not Wnd any differences betweenHRT users and the other women in their proportion toreport other events, such as previous fractures. We conclude that older women using HRT had moreoften a post-surgery menopause and a diagnosis of oste-oporosis. Besides, they were more likely to have a ‘healthconscious’ proWle, as well as to have a high socioeco-nomic status, than non-users. Acknowledgements The authors thank Dr Emmanuelle Bovard for her helpin getting data and Christine Fehr for her help in prepar-ation of the manuscript. Conflicts of interests None declared. Funding This study was funded by the Swiss Federal OfWce forSocial Security. JACQUES CORNUZ1,2*, MARC-ANTOINE KRIEG1,LORENZO SANDINI1, CHRISTIANE RUFFIEUX2,GUY VAN MELLE2, PETER BURCKHARDT11Department of Medicine, 2Institute of Social and PreventiveMedicine,University Hospital, 1011 Lausanne, SwitzerlandFax: ( 41) 21 314 08 71Email: Jacques.Cornuz@chuv.hospvd.ch*To whom correspondence should be addressedFor the SEMOF research group (alphabetical order):D. Büche (State Hospital, St. Gall); M. Dambacher (BalgristClinic, Zürich);F. Hartl (University Hospital, Basel); H. Häuselmann(University Hospital, Zürich);K. Lippuner (University Outpatient clinic, Bern); M. Neff(Osteoporosis Center, Zürich);P. Pancaldi (Osteoporosis Center, Locarno); R. Rizzoli(University Hospital, Geneva);F. Tanzi (Osteoporosis Center, Lugano); R. Theiler (StateHospital, Aarau);A. Tyndall (University Hospital, Basel); C. Wimpfheimer,(Private practice, Luzern)1. Rossouw JE, Anderson GL, Prentice RL et al. Risks andbeneWts of estrogen plus progestin in healthy postmenopausalwomen: principal results from the Women’s Health Initiativerandomized controlled trial. JAMA 2002; 288: 321–33. 2. Vandenbroucke JP. How much of the cardioprotectiveeffect of postmenopausal estrogens is real? Epidemiology1995; 6: 207–8. 3. Petitti DB. Coronary heart disease and estrogen replace-ment therapy: can compliance bias explain the results of obser-vational studies? Ann Epidemiol 1994; 4: 115–8. 4. Barret-Connor E. Postmenopausal estrogen and preventionbias. Ann Intern Med 1991; 115: 455–6. 5. Barrett-Connor EL, Cohn BA, Wingard DL, Edelstein SL.Why is diabetes mellitus a stronger risk factor for fatal ischemicheart disease in women than in men? The Rancho BernardoStudy. JAMA 1991; 254: 627–31. Table 2. Age-adjusted odds ratio for variables associatedwith current use of HRT aEstimated from a multivariate model which included age, body massindex, type of menopause, diagnosis of osteoporosis, calcium and vitaminD supplementations, high education, previous qualiWed professional level,living with a spouse, and alcohol consumption. Variable Odds ratioa 95% CI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Post surgery menopause 2.12 1.81–2.49Calcium supplementation 1.49 1.23–1.80Diagnosis of osteoporosis 1.48 1.22–1.80High education 1.46 1.16–1.84Body mass index <25.5 kg/m2 1.44 1.23–1.69Previous qualiWed job 1.43 1.23–1.68Living with a spouse 1.20 1.02–1.39Research letters6786. Matthews KA, Kuller LH, Wing RR, Meilahn EN,Plantinga P. Prior to use of estrogen replacement therapy,are users healthier than nonusers? Am J Epidemiol 1996;143: 971–8. 7. Brett KM, Madans JH. 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Factors associated with the use of hormone replacement therapy among older women

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