December 1999 · Vol. 48, No. 12

• CLINICAL QUESTION: What are the concerns of women considering hormone replacement therapy (HRT)?

• BACKGROUND: Counseling women about HRT is common in family practice, but available research has focused on risks and benefits from the perspective of providers. This qualitative study explores the perspective of patients.

• POPULATION STUDIED: Twenty-six women who received new HRT prescriptions at a staff-model health maintenance organization were interviewed. Originally, 176 were identified as potential participants; reasons for exclusion included premenopausal state, previous use of estrogens, and use of topical estrogens. Thirty-four women refused to participate, 20 were never contacted, and 34 consented but were never interviewed because study data were sufficient. The median age was 53, 85% were white, and median annual income was $46,000. Fifty-four percent stated they had initiated discussion of HRT with their provider, and 81% had filled the HRT prescription at the time of interview.

• STUDY DESIGN AND VALIDITY: This was a qualitative study. Each woman was interviewed for 1 hour, and the audiotape was transcribed and analyzed. Three judges used a consensus process to identify the variety of domains (specific concerns) the women mentioned. Another investigator assigned patient comments to specific domains. Interviewing new subjects stopped when no new information was being added.

  The methodologic strength of the study was fair. The qualitative design was appropriate, and strengths included attention to transcript accuracy, use of independent reviewers to define domains, and the decision to interview the women individually rather than as members of a focus group. Compared with other qualitative studies, weaknesses included lack of details about the training of the interviewer or conduct of the interviews and limited use of triangulation (ie, the use of additional informants, the group of patients themselves, or other observers to review the domains for completeness).

  The findings may not apply to all women beginning HRT. The sample of interviewees was selected from patients already given a prescription, and the opinions of women initially refusing HRT may not be represented. The sample reflects primarily white upper-middle-class women whose attitudes and behaviors regarding preventive care in general and HRT in particular may be very different from other populations. Finally, more information about the severity of specific symptoms and the risk for breast cancer and other diseases would be valuable in helping place patients’ concerns in context.

• OUTCOMES MEASURED: This qualitative study identified womens’ concerns about HRT. By design, a qualitative study can neither quantify the prevalence or strength of particular concerns nor address clinical outcomes.

• RESULTS: Influences on the decision to begin HRT were broad and included provider opinion (96% of interviewees reported), media reports (81%), experiences and opinions of friends (77%), and experiences and opinions of family (65%). Specific clinical concerns cited included risk for breast cancer, having to take medication, prevention of osteoporosis, hot flashes, prevention of heart disease, insomnia, living with medical uncertainty, menstrual-type bleeding, and genitourinary symptoms.

  The authors compared patients’ concerns with published guidelines from the American College of Obstetricians and Gynecologists, the United States Preventive Services Task Force (USPSTF), and the American College of Physicians. Only USPSTF acknowledges the impact of provider opinion on decision making, and none of the guidelines seem to address patients’ concerns or address decision making in the setting of limited and evolving evidence.

RECOMMENDATIONS FOR CLINICAL PRACTICE

This study provides good evidence that women who have received a prescription for HRT use many sources of information—in addition to the opinion of their physicians—to make their decision about whether to begin the therapy. These women have concerns about HRT that are substantially broader than those identified in the medical literature. Physicians should take into account the impact of their recommendations and the influence of the patients’ family, friends, and the media and should seek to identify the specific concerns of individual patients.