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HEALTH POLICY Use of Hormone Replacement Therapy Not Determined by Clinical Factors Nancy Keating, John Ayanian, and colleagues have shown that a woman's use of hormone replacement therapy has more to do with her sociodemographic characteristics than with factors like having diabetes and a high risk of cardiovascular disease. For a woman, the decision to use hormone replacement therapy (HRT) is not a simple one. It generally involves discussion between the patient and her physician, in an effort to weigh the individual risks and benefits of the therapy, which are not fully defined. Reflecting this uncertainty, a study published in the April 6 Annals of Internal Medicine shows that a woman's sociodemographic characteristics are more strongly associated with the use of HRT than are clinical characteristics.     "Certain clinical factors that one might think would have an influence were not at all associated with use of HRT," says Nancy Keating, instructor in health care policy and medicine at HMS, and first author of the study.     The risk of conditions such as osteoporosis and heart disease increases considerably after menopause. Studies show that HRT prevents osteoporosis and may significantly reduce the risk for coronary artery disease, but they also indicate that HRT may increase a woman's risk for breast cancer. The result, says Keating, is "a lot of uncertainty among women and physicians as to who should be using this therapy."     To get a better sense of how HRT is used across the country, Keating and her colleagues used data from a national survey to analyze the patterns of HRT use in 495 postmenopausal women during 1995. Paul Cleary, Alan Zaslavsky, and John Ayanian, also in the Department of Health Care Policy at HMS, and Alice Rossi from the University of Massachusetts, joined Keating in this investigation of the relationship between HRT use and certain sociodemographic, clinical, and psychological factors.     They report that the region of the U.S. where a woman lives and her level of education are more strongly associated with HRT use than are clinical characteristics like risk of cardiovascular disease. "In fact, having diabetes, which is a cardiac disease risk factor, was significantly associated with less use of HRT,"     Keating says. This has major clinical implications, she adds, since the potential benefit from HRT might be greatest among women at high risk for coronary heart disease.     According to the study, nearly 38 percent of postmenopausal women in the U.S. between the ages of 50 and 74 are users of HRT. Having undergone a hysterectomy was the factor most strongly correlated with the use of HRT among these women. Location Matters When it came to HRT variation by geographic region, women in the South and West were more likely to use the therapy than those in the Northeast. Regional variations in health care have been documented for other procedures with unclear risks and benefits, says Keating. "The large geographic differences in our results likely reflect the uncertainty among women and their physicians about how HRT can best be used," Keating says.     Women who graduated from college were also more likely to use HRT. According to the authors, well-educated women may read more articles about the therapy and have better discussions with their physicians. Interestingly, among women who underwent a hysterectomy, those who worried about becoming less attractive with aging were more likely to use HRT. Other psychological characteristics like depression or assertiveness were not correlated with use of HRT.     According to Keating, a better understanding of the sociodemographic variations reported in the study may help physicians address HRT use with those women who would benefit most from the therapy. "As physicians, we need to make sure we consider who will be most likely to benefit from HRT based on clinical characteristics," she says. —Sylvia Pagán Westphal Back to Top