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ORIGINAL RESEARCH |
From the Division of Epidemiology, National Center for Health Statistics/Centers for Disease Control and Prevention, Hyattsville, Maryland.
Address reprint requests to: Kate M. Brett, PhD, NCHS, Division of Epidemiology, 3311 Toledo Road, MS 6226, Hyattsville, MD 20782; E-mail: KBrett{at}cdc.gov.
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ABSTRACT |
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METHODS: We analyzed data from female respondents 40 years of age and older (n = 9400) who were interviewed in the 1999 National Health Interview Survey. Hormone therapy use was categorized into four types: current estrogen–progestin therapy use, current estrogen-only therapy use, former hormone therapy use, and never use. We calculated the prevalence of hormone therapy by different levels of previously identified covariates of hormone therapy, as well as overall prevalence of hormone therapy use by length of use.
RESULTS: Approximately 24% of women aged 40 years or older were current hormone users. Of these, 30% were taking estrogen–progestin therapy, and 70% were taking estrogen-only therapy. The prevalence of hormone use differed dramatically by hysterectomy status and age, and less so by many demographic, health-risk behavior, medical access, and medical history variables. Among women with no hysterectomy, the associations with many of the covariates were stronger for estrogen–progestin therapy use than for estrogen-only therapy use. Only 3% of women were estimated to be current estrogen–progestin therapy users for 5 or more years, whereas 10% were current estrogen-only therapy users for 5 or more years.
CONCLUSION: Although many women at midlife and older were current hormone users, very few were long-term users of estrogen–progestin therapy.
Use of menopausal hormone therapy has fluctuated over the past 50 years owing to changes in its perceived risks and benefits. Unopposed estrogen therapy was widely used in the 1960s to relieve menopausal symptoms.1 Use declined in the 1970s after reports of an association between estrogen use and uterine carcinoma were published.2,3 With the introduction of the combination estrogen–progestin therapy in the 1980s, hormone therapy’s popularity soared.4 This popularity was partially due to observational studies that showed that women who used hormone therapy were less likely to develop heart disease,5–7 osteoporosis,8 and possibly Alzheimer’s disease.9 The benefits of hormone therapy were offset by evidence of an increased risk of breast cancer, especially among long-term estrogen–progestin therapy users.10,11 Recently, two randomized trials published findings of increased risk for coronary heart disease, stroke, pulmonary embolism, dementia, and breast cancer associated with estrogen–progestin therapy use.12–16 One of these studies has also found no increase in cognitive functioning or quality of life among estrogen–progestin therapy users.17,18 Estrogen-only therapy has not been studied fully in randomized, clinical trials, and so its risk–benefit profile is less well developed. Thus, recent reviews have suggested that short-term use to relieve menopausal symptoms is the only established indication for hormone therapy.19–22
Although there have been well-recognized risks associated with hormone therapy use for several decades, these drugs are prescribed for, and used by, a large proportion of US women.23 Approximately 40% of postmenopausal US women were using hormone therapy in 1995.24 However, most of the studies of hormone therapy use in the United States as a whole are outdated.24,25 Furthermore, no separate national estimates of the use prevalence of estrogen–progestin therapy and estrogen-only therapy have been published.
We conducted this exploratory study using data from a nationally representative survey to obtain estimates of current hormone therapy use in 1999 by type of therapy and to estimate the effect of numerous sociodemographic, medical, access-to-care, and behavioral factors on each type of hormone therapy use. We calculated national estimates for women who have never taken any hormone therapy, former hormone therapy users, women who were taking estrogen-only therapy in 1999, and women who were taking estrogen–progestin therapy in 1999. The prevalence of each hormone therapy use category was then estimated by numerous covariates that have been identified in previously published analyses of hormone therapy prevalence in the United States. Additionally, we calculated the prevalence of hormone therapy use by type and length of use. The purpose of these analyses was to present a more recent description of hormone therapy use in the United States by broad classifications of hormone therapy type (estrogen-only therapy and estrogen–progestin therapy).
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MATERIALS AND METHODS |
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The interviewed sample for 1999 consisted of 37,573 households, which yielded 97,059 persons in 38,171 families. The Sample Adult Questionnaire, in which the hormone therapy questions were included, was answered by approximately 31,000 adults 18 years of age and older; the response rate was 70%,26 which is a combination of the household response rate of 88% and the sample adult response rate of 81%.
The 1999 questionnaire included a special section of questions pertaining to menopause and hormone therapy. Female respondents were asked the following question: "Estrogen is a female hormone that may be taken after a hysterectomy or during or after menopause. Have you ever taken medication containing estrogen like Premarin, for any reason? Do not include birth control pills." Women who responded that they had taken estrogen were then asked when they first started using estrogen, if they were currently using estrogen, and for how long they had taken estrogen, not including breaks in use of more than 30 days. They were then asked the following question: "Progestin is a female hormone that may be taken in addition to estrogen therapy. Have you ever taken medication containing progestin, like Provera, for any reason? Do not include birth control pills." Women who responded that they had taken progestin were asked the same timing and length-of-use questions as followed the estrogen question.
We obtained information regarding most of the expected correlates of hormone therapy use from the core section of the National Health Interview Survey questionnaire. All the covariates we analyzed have been found in at least one previous study to predict overall hormone therapy use.24,25,27–34 Demographic variables include age at time of the interview, location of residence (Northeast, Midwest, South, West), race or ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, other), education (less than 12 years, 12 years–some college, baccalaureate degree or higher), and marital status (never married, ever married). Medical risk factors considered were self-reported health as an indicator of overall health, history of hysterectomy and bilateral oophorectomy, and having current menopausal symptoms (eg, hot flashes). Behavioral risk factors included were cigarette smoking, exercise, and alcohol consumption, to measure risky behavior. Finally, the medical access factors included were health insurance coverage, physician visits in the previous 12 months, and obstetrician or gynecologist visits in the previous 12 months, as indicators of the level of health care received during the time before the interview.
Hormone therapy use was categorized as follows. Women who answered that they had never used estrogen other than in birth control pills were identified as "never users." Women who were currently using estrogen and progestin when interviewed in 1999 were defined as "current estrogen–progestin therapy users." Women who were currently using estrogen when interviewed and not currently using progestin, regardless of possible use of progestin in the past, were defined as "current estrogen-only therapy users." Finally, women who had taken estrogen-only therapy or estrogen–progestin therapy in the past but were not currently using hormone therapy at the time of the interview, were defined as "former users."
In the 1999 National Health Interview Survey, the hormone therapy questions were asked only of selected women 18–39 years of age and of all of women 40 years of age and older. Therefore, the analysis was limited to women 40 years of age and older. Of the 10,526 female respondents 40 years of age and older, we excluded 293 women because they did not answer the questions regarding ever having used estrogen, and an additional nine women were excluded who did not provide enough information to define current use of hormone therapy. Eight hundred twenty-four (824) women were dropped from the analysis because information on one or more of the other covariates of interest was missing. Thus, the final analytic sample comprised 9400 women.
We constructed contingency tables crossing overall hormone therapy use by the demographic and health factors that were identified before analysis as potentially associated with hormone therapy use. Separate analyses were conducted by hysterectomy status, because hormone therapy use is so strongly associated with history of hysterectomy. We conducted a second analysis to examine the overall proportion of women who were current users of hormone therapy at the time of interview by type, as well as the proportion of women who were users of hormone therapy for at least 5 years by type. These estimates were crossed by hysterectomy and age only, owing to sample size constraints, and presented as age-adjusted estimates.
The National Health Interview Survey sample is designed to be representative of the US population and therefore has a complex sampling design. Estimates presented are weighted to account for sampling and response factors. SUDAAN software (Research Triangle Institute, Research Triangle Park, NC) was used to produce estimates of standard errors and 
2 test statistics in accordance with the sampling design.35 The test statistics were used to identify variables in which differences for hormone replacement therapy use were found.
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RESULTS |
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. These demographic estimates are similar to estimates obtained with all female 1999 National Health Interview Survey respondents 40 years of age and older (data not shown), which suggests that inferences from this study are likely applicable to the general population. The unadjusted prevalence of hormone therapy use by type is also presented in Table 1.
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. Only 3% of these women were current estrogen–progestin therapy users, and therefore the sample size was too small to fully investigate differences by covariates. Approximately 75% of women who were 50–59 years of age had used hormone therapy at some time (ever users), and almost 60% of women in this age group were current estrogen-only therapy users. Among women in younger, and older, age categories, the percentage of hormone therapy ever-use was lower, although in all but the very oldest and youngest age categories the proportion was greater than 50%. Current drinkers were more likely to use estrogen-only therapy, although in analyses not presented, we found no difference in hormone therapy use by magnitude of current alcohol consumption. We found no difference in use by health care coverage and smoking status. All other variables investigated were significantly associated with hormone therapy use among hysterectomized women.
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presents the same information for women who had not had a hysterectomy. The overall prevalence of current hormone therapy use, as well as prevalence of specific type of hormone therapy, was very different from women who had undergone a hysterectomy (Table 2
). Prevalence of current estrogen–progestin therapy use in this group was 9.2%, whereas the prevalence of current estrogen-only therapy use was 5.3%. All of the variables being investigated were significantly associated with hormone therapy use. There were fairly large differences in estrogen–progestin therapy prevalence by race and education level but smaller differences in estrogen-only therapy use by these variables. Former hormone therapy users were older than the current users, but otherwise the associations between former hormone therapy and the other covariates were similar to those of current hormone therapy users.
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). However, only 3% were current users of estrogen–progestin therapy for at least the past 5 years, and 10% were current users of estrogen-only therapy for at least the past 5 years. Based on census estimates of the 1999 resident population, this translates into approximately 2.0 million women having been using estrogen–progestin therapy for at least 5 years and 6.5 million women having been using estrogen-only therapy for at least 5 years.36 The highest level of current hormone therapy use for 5 or more years, 31%, was found among women with a history of hysterectomy who were using estrogen-only therapy.
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DISCUSSION |
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Consistent with prior studies, we found hormone therapy to be associated with many demographic and health characteristics. Most of the covariates of any hormone therapy use that were present in this study have been previously identified. Age is directly related to probability of being menopausal,37–39 and given the temporal trends in hormone therapy use,1 it was expected that the relationship between current hormone therapy use and age would be highest among women closest to age of menopause.
History of hysterectomy and bilateral oophorectomy are medical conditions that might result in physician recommendations for hormone therapy use. Women who have had a hysterectomy have no need for progestin.21 Thus, a strong negative association with estrogen–progestin therapy use was expected. The finding that having a history of bilateral oophorectomy, after controlling for hysterectomy status, was associated with an increased probability of combination therapy use has not been documented previously. Sensitivity analyses (not presented in this report) confirmed this association, even when the analysis was limited to women who had a history of hysterectomy, and therefore the uterine protection of estrogen–progestin therapy was unnecessary. Further study of this issue is warranted.
Race,27,31,33 education,24,25,28–31,34 and marital status28,40 are all demographic characteristics that have been consistently associated with hormone therapy use. Education and race were more strongly associated with current estrogen–progestin therapy use than they were to estrogen-only therapy use. Cigarette smoking, alcohol consumption, and lack of exercise were considered covariates of hormone therapy because they are indicators of risky lifestyles. We hypothesized that women who engaged in risky behavior would be less likely to use hormone therapy for preventive purposes, and therefore, in general, have lower prevalence of use. Our analysis indicated that the only difference by smoking was in the group of women who had never had hysterectomies, and in this group, former smokers were more likely to use hormone therapy than either current or never smokers. This does not validate our risky behavior hypothesis. Some previous studies have found no association between smoking and hormone therapy use,24,25,31,34 although both higher hormone therapy use28 and lower hormone therapy use30 among smokers have been reported previously. The association between exercise and hormone therapy use was in the hypothesized direction. Women who did not engage in leisure time exercise were slightly less likely to use hormone therapy overall and, among women who had not had a hysterectomy, were somewhat less likely to use estrogen–progestin therapy than estrogen-only therapy.
The associations between lifetime abstinence from alcohol and hormone therapy were unexpected. Among the nonhysterectomized women, lifetime abstaining women were less likely to either currently use estrogen–progestin therapy or be former hormone therapy users. Among the hysterectomized women, lifetime abstainers were more likely to be currently using estrogen-only therapy. This group constitutes almost 30% of the US population of women 40 years of age and older. Other published analyses have found abstainers to have a lower probability of hormone therapy use,25,28,40 although most of the prior work addressed current abstainers, not only lifetime abstainers. More information on lifetime abstainers is needed to understand why they might use hormone therapy differently than do other women.
These results indicate that a fairly small proportion of US women are at increased risk of disease due to hormone therapy use, assuming the Women’s Health Initiative results are accurate and the increased disease risks only apply to current long-term estrogen–progestin therapy users.12 We estimate that 3% of women 40 years of age and older were current estrogen–progestin therapy users who had continued use for 5 or more years. In some subpopulations, such as women with a 4-year college degree or more, the proportion was higher but did not exceed 8%. Another 10% of the population were current long-term users of estrogen-only therapy. The Women’s Health Initiative is continuing the trial arm investigating the effects of estrogen-only therapy among hysterectomized women. Our findings would indicate that results of this continuing portion of the Women’s Health Initiative will have implication for many more women than the section of the study investigating estrogen–progestin therapy use that was terminated.
Several limitations of this study need to be mentioned. Hormone therapy data were collected by self-report in the National Health Interview Survey. Although this has been found to adequately estimate ever-use and duration of use,41,42 the reliability of reported data diminishes over time.42 Validation of self-report by pharmacy record searches would be ideal but impractical with national survey data of this type. Preliminary analysis of these data identified problem records with inconsistent or contradictory responses, and these records were corrected if possible or eliminated. We believe that the vast majority of data are correct, and the data problems that exist in the National Health Interview Survey probably make the relationships observed slightly weaker, but we know of no method to validate this assumption.
Secondly, because the National Health Interview Survey is a general health survey, detailed information on specific topics cannot be completely covered. Examples of potential covariates regarding hormone therapy that were not included in the 1999 National Health Interview Survey are whether the respondent had ever talked with a health care professional about hormone therapy and information on her beliefs regarding menopause and hormone therapy.
On the other hand, the National Health Interview Survey sample is very large and is designed to represent the civilian, noninstitutionalized population of the United States. Due to these design attributes, the National Health Interview Survey data provide fairly precise estimates of hormone therapy use in the United States. Given the wide breadth of the National Health Interview Survey, there were quite a large number of potential covariates to be explored. Finally, the menopause and hormone therapy questions that were included in the 1999 menopause supplement had been used in prior surveys (eg, National Health and Nutrition Examination Survey, NHANES I Epidemiologic Followup Study) and therefore, it will be possible to compare these results with estimates previously reported.
Previous work on national prevalence estimates of hormone therapy are outdated and have not provided separate estimates by type of hormone used. In these data, we found high levels of hormone therapy use among women 40 years of age and older. However, far fewer women reported estrogen–progestin therapy use than estrogen-only therapy use, even though the prevalence of women who did not have a history of hysterectomy was higher than the prevalence of women with a history of hysterectomy. The use patterns documented in this analysis of 1999 data might have changed since the publication of the first Women’s Health Initiative results12; it has already been noted that the sales of some hormone therapy products have dropped.43,44 Although the factors associated with hormone therapy use have remained very similar over time, we do not know how a change in overall prevalence will affect the patterns of association. Therefore, continued research into the changes in hormone therapy use is warranted. Furthermore, more in-depth study of current users would help uncover the characteristics of these women and the reasons they continue to use hormone therapy beyond the initial perimenopausal period.
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Footnotes |
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Received June 5, 2003. Received in revised form August 28, 2003. Accepted September 11, 2003.
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REFERENCES |
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