Declining socioeconomic differences in the use of menopausal and postmenopausal hormone therapy in Finland.

OBJECTIVE: Sales figures for the use of menopausal and postmenopausal hormone therapy in Finland show a rapid increase during the 1980s continued into the first half of the 1990s. Hormone therapy use became very common in Finland compared to many other Western countries. The aim of our study was to investigate the sociodemographic distribution of hormone therapy among Finnish women aged 45-64 years. METHODS: The study is based on population-based surveys conducted in 1989 and 1996 (response rates 87% and 78%). RESULTS: Between 1989 and 1996 the current use of hormone therapy increased from 22% to 27%; in 1989 it was most common in the age group 50-54 years, but in 1996 among 55-59-year-olds. In 1989 it was significantly more common among women with longer education than other women in every age group, but in 1996 this difference was significant only in those 55 years and older. In 1989 the use was more common in the capital area than elsewhere and this difference decreased but remained significant in 1996. CONCLUSION: Our results suggest that hormone therapy has become a routine treatment during the menopause in all educational groups and throughout the country. The lack of socioeconomic differences indicates that among women under 55 year of age the saturation point in short-term hormone use was reached in 1996. However, the persistence of socioeconomic differences among older women suggests that the use of long-term postmenopausal hormone therapy will continue to increase for some time.

Climacteric hormone therapy in medical and lay texts in Finland from 1955 to 1992.

The "social shaping of technologies" approach holds that a technology is both socially embedded and that it shapes the social environment. The aim of this study was to investigate how hormone therapy use during the climacterium and subsequently was socially shaped in texts published in the main Finnish medical journals and lay magazines during 1955-1992. In these two arenas physicians, especially gynecologists, played the major role in the debate and their professional knowledge on hormone therapy was mixed with their views on women's status and roles, the quality of life and fears about aging when they were promoting hormone use, especially in the lay magazines. This type of argument for the promotion of hormone use persisted in the most recent texts, despite the availability of substantial evidence both for the against of hormone therapy. Overall, the texts clearly favored the benefits of the therapy. Three periods of differing orientation can be discerned. Attitudes towards hormone therapy tended to be cautious from 1955 through the 1970s, more enthusiastic in the 1980s, and mixed at the start of the 1990s. In the most recent texts critical comments came from individual women who had used the therapy or decided not to, including female physicians and other professionals. The results suggest that hormone therapy is socially embedded, but may also shape perceptions and the understanding of women's aging. The social shaping of the technology approach may improve our understanding of the development of health policy towards women at and after the age of the climacterium.

Prescribing of hormone therapy in menopause and postmenopause.

This article describes the use and prescribing of menopausal and postmenopausal hormone therapy (HT) in one example country, Finland, and the trends and levels of HT use in other western countries for comparison. Previously published studies were reviewed and reanalyzed, and some additional unpublished data from Finnish surveys were compiled. The use of HT increased in Finland up to 1994. In Finland the initiative for HT use came more often from physicians than women themselves, physicians valued HT more than women, women's period of use of HT was shorter than physicians' recommendations, women's reasons for using HT were usually to treat symptoms, but physicians considered HT also useful in the prevention of later diseases. Gynecologists were more favorable toward HT than other physicians. HT has become common in very different times in different countries, but with the exception of the US experience in the 1970s, the trend has been towards increasing use. One motivation to do surveys on physicians' prescribing or women's use of HT has been to facilitate HT use. The large variation in HT use may reflect the uncertainty concerning its true value. The reasons for the large-scale prevention with HT have not been systematically studied, but it is likely due to various social and commercial forces.

Alternative drug use for the climacteric in Finland.

OBJECTIVES: To investigate the use of alternative drugs for the climacteric in Finland, which products are used, and who are the women using them. METHODS: The study was based on a population-based survey conducted in 1989 among 2000 Finnish women aged 45-64 (response rate 86%). RESULTS: 11% of the women reported the use of alternative drugs for the climacteric. Food supplements and bee products were the most common types of alternative drugs used. Some of them may have allergic or other side effects. Users differ little from other women judging by health habits and the utilization of health care services. The best predictors for alternative drug use were urban residence, more than 9 years of general education, and among 50 54-year olds, the use of prescription or OTC drugs for menopause. Over half of the users of alternative drugs had also used hormone therapy. CONCLUSIONS: Women using alternative drugs during and after the climacteric represent a large group. More information is needed about the clinical effects of alternative drugs, and the characteristics of alternative drug users.

Physicians' gender and clinical opinions of reproductive health matters.

The purpose of this study was to investigate the effect of physicians' gender when sex-specific conditions are being treated in a country where almost half of the physicians are women. Five Finnish surveys originally conducted for other purposes were reanalyzed. Two surveys examined physicians' and medical students' views about hormone therapy during and after menopause, one survey examined medical students' attitudes about medicines, one survey examined physicians' obstetric practices, and one examined contraceptive counselling. All the surveys showed more similarities than differences in the clinical decision-making of women and men physicians. In opinions about menopause the physician's medical specialty was more important than gender. Physicians' obstetrical practices were also similar in five cases out of six, but in one situation where medical factors were not a deciding issue, women physicians acted differently. These results suggest that socialization into the medical profession makes physicians' practices more alike and diminishes gender differences.

PIP: To determine the effect of gender on the type of reproductive health treatment offered to women in a setting where half of the physicians are female, this study reanalyzed data collected from five surveys in Finland. The surveys were originally conducted to investigate the views of physicians (74% of 500 responding) and medical students (74% of 125 responding) about menopausal hormone replacement therapy, the attitudes of medical students about prescribing hormones, obstetric practices (83% of 90 responding), and contraceptive counseling (74% of 480 responding). It was found that the number of menopausal patients was highest for female gynecologists, followed by male gynecologists, female physicians, and male physicians. Female and male gynecologists offered similar recommendations for hormone replacement therapy, but female physicians were more likely to prescribe hormones for prevention only. Results for medical students were not influenced by gender. The only significant difference in obstetric practice was that female obstetricians were three times more likely than males to induce labor for convenience. While equal numbers of female and male physicians prescribed oral contraceptives and IUDs, females were more likely to prescribe condoms, implants, and diaphragms. It is concluded that professional identification among these physicians was stronger than gender influences.

Trends in the use of climacteric and postclimacteric hormones in Nordic countries.

The extent of menopausal and postmenopausal hormone use in Denmark, Finland, Norway, and Sweden during 1981-1992 was studied by means of drug sales figures and associations between hormone use, education, employment and occupational status, by questionnaire surveys in each of the respective countries in the 1980s-90s. According to sales figures, hormone use has been different in each of the countries studied. In 1981 use was three times more common in Denmark than in Norway. In 1992 use had increased in all the other countries except Denmark, and was highest in Finland and Sweden. Based on 1981 data for Norway, on 1987 data for Denmark and on 1989 data for Finland, use of hormone therapy was related to education, employment or occupational status in Finland but not in Denmark or Norway. Differences in the phases of innovation diffusion between these countries may offer a partial explanation for these results.

Experience and opinions of climacterium by Finnish women.

OBJECTIVE: Literature on women's experiences with climacterium is mostly based on patients or on North American women. In this study, the experiences and opinions of Finnish women were investigated. STUDY DESIGN: In 1989, a questionnaire was sent to a representative sample of 45-64-year-old Finnish women (n = 2000); 1713 (86%) responded, of which 1308 were postmenopausal. RESULTS: Most women (87%) reported their health to be good or rather good. Symptoms were commonly experienced, but each symptom usually by a minority of women. Most subjective health problems were not related to climacterium as such, but were problems also encountered otherwise or related to aging. Some symptoms decreased with increased age, others increased or stayed the same. Comparing the symptoms reported in the past two weeks and women's own judgements suggests that hot flashes and irritability were specific to climacterium. Most women had a neutral or positive opinion of climacterium in general. CONCLUSION: Our study challenges the view that climacterium is a time of big subjective health problems.

Is menopause withering away?

Menopause (cessation of menstruation) and the period surrounding it (climacterium) are often defined retrospectively by asking a woman the date of her last menstrual period (LMP). Based on a survey of 2000 women aged 45-64 in 1989 in Finland, this study examines (1) the relation between these definitions and women's own definition of their climacteric status and of the cessation of menstruation and (2) the effect of menopausal and postmenopausal hormone therapy and hysterectomy on the definition of menopause and climacterium. Agreement of the woman's own definition of her climacteric status and interval since LMP was 25% among current hormone users, 41% among hysterectomised women and 64% among those who were neither currently using hormones nor had been hysterectomised. Current hormone users defined the climacteric phase as longer than their LMP suggested. Current hormone use and hysterectomy had little effect on reported final cessation of menstrual periods. It is concluded that hysterectomy and hormone therapy shape women's thinking about the end of reproductive life, blur the concepts of menopause and postmenopause and confuse the measurement of age at menopause.

Feedback for participants in a health survey: feasible and useful.

The use of quantitative methods has often limited the communication between researchers and research participants to being one-sided. Use of feedback in survey-oriented research is one possibility for creating a more communicative relationship. After doing a postal survey of 2000 Finnish 45 to 64-year-old women about their climacterium we produced a feedback leaflet about the main results of the study and about climacterium in general and sent it to all respondents (n = 1713). Later a postal questionnaire concerning the feedback leaflet was sent to a consecutive sample of every eighth (n = 200) woman, of whom 153 (76%) responded. Most of the women gave neutral or positive responses to the content of the leaflet. There was more interest in the feedback among the younger and pre-menopausal groups than among the older or postmenopausal women. Some women wanted more information about climacterium-related issues than was possible to give in the space of eight pages. According to this experiment, feedback offers fresh view-points and valuable critique for researchers as a result of being more in contact with respondents.

Physicians' views on hormone therapy around and after menopause.

Estrogens and progestins are commonly and increasingly used during and after menopause. We studied Finnish physicians' views of this hormone therapy based on their specialty. A questionnaire was sent to a stratified random sample of gynecologists, internists, general practitioners and nonspecialists (n = 500; response rate 74%). Reported prescription habits and opinions concerning benefits and harms of hormones were asked and compared to current literature. Combined therapy was much more popular than was estrogen alone. One fourth of the physicians said hormones should be preventively given to all or to all those at risk for osteoporosis. Long therapies were accepted by many and for our patient cases hormones were recommended much more commonly than were other medical therapies. Most considered prevention of osteoporosis to be a benefit of combined therapy, but opinions of other benefits and harms varied. Gynecologists had the most favourable opinions and most of them considered hormone therapy very useful; the other physicians' opinions were characterized by uncertainties about hormone therapy and its long term effects.

Selection to postmenopausal therapy by women's characteristics.

Many surveys have shown that women using postmenopausal hormone therapy have a lower incidence of cardiovascular diseases and lower overall mortality. The purpose of this study was to compare past and non-users with current users of hormone therapy in regard to characteristics known to, or assumed to, predict poor subsequent health (indicators). The main data source was a survey in 1989 of a random sample (n = 2000, 86% response rate) of 45-64 year-old Finnish women. Among women with their uterus, after adjusting for age and urbanism, of the 21 indicators studied, 10 suggested a poorer and none a better health prognosis for the non-users than for current users. Many differences were greater among older women, suggesting a cohort effect or long-term users being an especially selected group. Among hysterectomized women, differences between users and non-users were similar or smaller than among women with uteri. The past users were more similar to non-users than current users. Our study suggests that women with a better health prognosis are selected or select themselves for hormone therapy, and that may impede interpretation of observational studies on hormone therapy and health.

Hysterectomy among Finnish women: prevalence and women's own opinions.

This article describes the prevalence of hysterectomy, women's own opinions of it, and socioeconomic characteristics of hysterectomized women compared to non-hysterectomized ones. The questionnaire was sent in spring 1989 to 2000 45 to 64-year-old Finnish women picked randomly from the Population Census. After two reminders, 1713 (86%) had responded. One fifth of the women had had a hysterectomy and 5% had also had both ovaries removed. Among the highest educated there were less hysterectomized women than among the less educated. The largest differences in the prevalence of hysterectomy were between counties, not between socioeconomic groups. Fourty-one percent of the hysterectomized women had themselves wished hysterectomy, 25% did not have any specific opinion about the operation. Results raise further questions about clinical decision making and regional variation of hysterectomy.

Use of hormone replacement therapy in 1976-89 by 45-64 year old Finnish women.

STUDY OBJECTIVE: The aim was to describe changes in the use of hormone replacement therapy (HRT) in Finland during the period 1976-1989. DESIGN: The study involved four separate cross sectional population surveys in the years 1976, 1978-1980, 1987, and 1989. Three of them involved interviews and one a questionnaire. Sales figures of hormones in 1981-1989 were used. PARTICIPANTS: Participants were national samples of non-institutionalized Finnish women 45-64 years of age. Participation rates ranged from 85% to 96%. MEASUREMENTS AND MAIN RESULTS: Current reported hormone use in the surveys of 1976, 1978-1980, and 1987 was assessed, together with reported hormone use in the last month in the 1989 survey. During the study period the proportion of HRT users increased fivefold. In 1989, 20% of women reported current use of HRT, and the highest rate of use was found among 50-54 year old women in the Helsinki area. In 1976, users were mainly women around the age of menopause, those living in the capital area, and those having a rather high level of education. By 1989 use had spread to postmenopausal women, those in rural areas, and those with less education. CONCLUSIONS: Use of HRT has increased in Finland. It is difficult to evaluate whether the level of current use is too high, optimal, or too low, because recommendations are contradictory and the long term effects of HRT are unkown.