Susan Wilhelm, Ph.D., assistant professor, UNMC College of Nursing West
Nebraska Division, recently received an award for a clinical research poster
and dissertation titled, Exploring the Relationship of Attitudes, Knowledge,
Support and Self-efficacy on Intent to Adhere to Hormonal Replacement Therapy
for Menopause.
She presented the poster at the annual Association of Womens Health,
Obstetric and Neonatal Nurses convention in Boston. The study, which she
concluded last year, has also recently been accepted for publication in
the Journal of Obstetric, Gynecologic, and Neonatal Nursing. Dr. Wilhelm,
also a clinical nurse specialist who has been involved in obstetric nursing
for about 25 years, was as surprised as many to learn in early July, the
National Institutes of Health prematurely halted a hormone replacement
therapy (HRT) study about three years early, citing health risks.
The NIHs National Heart, Lung, and Blood Institute halted its Womens
Health Initiative study after it found an increased risk of invasive breast
cancer, increases in coronary heart disease, stroke, and pulmonary embolism
in study participants on estrogen plus progestin, compared to women taking
placebo pills. HRT is prescribed to treat symptoms of menopause, including
hot flashes, night sweats, sleeplessness, and vaginal dryness, as well
as to prevent some long-term conditions more common in women after menopause.
The NIH study found a 41 percent increase in strokes, 29 percent increase
in heart attacks, doubling of rates of blood clots, 22 percent increase
in total cardiovascular disease, 26 percent increase in breast cancer,
37 percent reduction in cases of colorectal cancer, one-third reduction
in hip fracture rates, and 24 percent reduction in total fractures. Although
benefits included fewer cases of hip fractures and colon cancer, the NIH
said the harm was greater than the benefit
While Dr. Wilhelms award stands on its own merit, the recent news most
likely will affect follow-up in her study. Dr. Wilhelms study looked at
the factors affecting a womans decision of whether to take hormone replacement
therapy. Not surprising, she found one of the biggest determinants was
safety. She also found a majority of women were worried about breast cancer
but not about heart disease.
What is worrisome about the findings of the Womens Health Initiative
is the lack of support for HRT as a primary cardiovascular disease prevention
therapy because for years, we (health professionals) thought HRT prevented
heart disease, Dr. Wilhelm said. The findings seem to reinforce what
women are already afraid of. It also shows we should be more concerned
about heart disease than breast cancer as far as occurrences.
She studied 167 peri-menopausal and menopausal rural women, 39 to 58
years old, who were considering whether to go on HRT. One of the goals
was to assist women in the decision making process. The majority of study
participants were not yet experiencing menopausal symptoms that interfered
with their daily activities and did not have a history of chronic illnesses,
uterine problems, or a history of osteoporosis.
The purpose of Dr. Wilhelms study was to explore the relationship between
attitudes toward menopause, knowledge of menopause, perception of support
from relatives, friends and health providers in taking HRT, and self-efficacy
for HRT.
Women were asked to respond, on a scale from one to seven, with seven
being very likely, whether they would take HRT. Most answered five, that
they were slightly likely to take HRT.
She found one of the most significant factors in whether to take HRT
or not is access to information in order to make an informed decision.
She said women consistently report a lack of access to what they believe
are valid and reliable sources of knowledge concerning the menopause experience.
When Dr. Wilhelm rated the study participants on their knowledge of
menopause issues, they scored 72 percent, with knowledge especially lacking
on the benefits and risks of HRT and physiology (signs and symptoms).
Dr. Wilhelm knows firsthand the struggle of finding the right information.
When I turned 40, I became menopausal, Dr. Wilhelm said. When I tried
to find valid information about menopause, I had a very difficult time.
I thought if I had a difficult time as an ob nurse, I know others would
too. Some of my friends were having menopause symptoms too.
Other studies report that although benefits of HRT are known, the majority
of women do not take it. Dr. Wilhelm said this also may be due to how women
view menopause.
She said women with a more positive attitude towards menopause may not
perceive the need to adopt HRT. She cited one study which found attitude
was related inversely to HRT use.
Women have been leery about taking hormones. For one thing, if we are
going to promote HRT, we need to help women feel more confident in taking
it and provide them with the knowledge and a benefits versus the risk ratio.
Her study also found women are significantly more likely to take HRT
if they feel their relatives, friends and health care providers support
their taking HRT.
Dr. Wilhelm said the makeup of the study participants may have been
a factor in the level of intent to seek HRT.
Rural individuals tend to take medications and seek treatment for health
problems only if they cannot perform their activities of daily living,
she said. There also seems to be a difference in managing menopause between
women who view menopause as a medical condition that needs to be treated
and those women who view menopause as a natural transition.
Whatever the final outcome of the NIH study, Dr. Wilhelm hopes the recent
news will prompt health professionals to more thoroughly educate women
about the risks and benefits of HRT in the future. The issue has a large
impact, she said, considering it is estimated by the year 2015, half of
all women in the United States will be menopausal.
You have to look at your own risk factors and look at the quality of
life issues now and weigh the benefits and risks for you personally, she
said.