Editorials
Taking hormone replacement therapy Women and health professionals should make the decision jointly and review it periodically
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n the United Kingdom women at midlife are facing the decision whether to take hormone replacement therapy or not. The backdrop to this includes widespread discussion in the media of hormone replacement therapy, high levels of lay awareness, a medical profession that is mostly pro-hormone replacement therapy (although expressing some concern about long term side effects such as breast cancer), one of the highest rates of breast cancer in Europe,1 and a large but changing clinical evidence base.2 In some regions the decision to use hormone replacement therapy or not may be less prominent in society owing to a different backdrop, such as low levels of breast cancer or less awareness of hormone replacement therapy. Furthermore the experience of the menopause is closely linked with a woman’s physical and social environment.3 4 Interaction between health professionals and women about hormone replacement therapy is one of the ways in which the role and status of hormone replacement therapy are negotiated in society. Thus the development of concordance between a health professional and a woman has implications for the woman, for the health professional involved, and for wider society. Most relevant research published internationally in both clinical and social science disciplines comes from North America, northern Europe, and Australasia. This editorial draws on this body of research to explore what women and health professionals bring to their interaction and how concordance may be reached.2–5 Hormone replacement therapy is used mostly for the relief of menopausal symptoms such as hot flushes, and for the prevention of osteoporosis. Its effectiveness and safety continue to be tested and debated.6 7 Decisions about hormone replacement therapy are considered sensitive to preference, with the best choice for the woman dependent on her preferences and values; “decision aids” have been developed for women.8 The many studies of women’s perspectives on the menopause and hormone replacement therapy indicate considerable diversity of preferences and values. However, the types of influences are similar and include the woman’s role in society and her relationships, her previous experience of health and health care as well as that of her family and friends, and the balance between fear and feeling in control of her body, health, and future. Influences may change over time, and interaction between them is negative and positive. These influences are acting close to individual women but are themselves influenced by wider social trends. For example, women working in leadership roles may find hot flushes problematic and take hormone replacement therapy while in that role. Wider changes in society have enabled more women to take on leadership roles. The perception of hot flushes as a problem at work is reinforced by social norms that keep the menopause invisible. 820
Many women have considered risks and benefits of hormone replacement therapy before they make contact with a health professional, and they continue to reconsider them. Evidence about risk and benefits is filtered through family, social networks, the media, and health professionals. Health professionals in the United Kingdom need to be aware of being generally in favour of hormone replacement therapy, although we tinker with the emphasis about risk and benefit as new evidence is published.2 Being aware of this favourable stance will help to prevent hormone replacement from becoming a hidden assumption, which then becomes difficult to question, both for ourselves as health professionals and for those seeking our advice. Women consider diverse types of risk and benefit by using a variety of evidence. Experiential evidence is powerful—stories of what happened to themselves or women they know or have heard of. Women consider the evidence from clinical research particularly in relation to risk of breast cancer and the use of hormone replacement therapy for prevention. However, they struggle with interpreting it for themselves. They take account of their symptoms, clinical risk factors such as family history of osteoporosis, and what can be termed social risk. For example, a woman concerned about the breakdown of her marriage may take hormone replacement therapy to help with sexual function to reduce risk to her marriage. A woman living alone and valuing independence may take hormone replacement therapy to reduce risk of fracture and related loss of independence in later life. The task of reaching concordance between a woman and her health professional in relation to hormone replacement therapy is therefore not an easy one. Women hope the health professional will listen to their individual experiences and provide information adapted to their situation.9 From this women and health professionals can develop decision making processes that leave women in control of their use of hormone replacement therapy. Women can monitor the effect of therapy on their symptoms and social situations, including changes over time, and feed this back into the decision making process. The decision to take or not to take hormone replacement therapy should be seen as a provisional decision, negotiated for a particular time and place, and then reviewed. This is important for women taking hormone replacement therapy to relieve symptoms and to prevent osteoporosis: individuals change, priorities change, evidence changes, and society changes. Frances Griffiths senior clinical lecturer Warwick Medical School, University of Warwick, Coventry CV4 7AL (
[email protected])
Competing interests: None declared.
BMJ 2003;327:820–1
BMJ VOLUME 327
11 OCTOBER 2003
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Editorials 1
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Report from the Council, the European Parliament, the Economic and Social Committee and the Committee of the Regions, European Communities. The state of women’s health in the European Community. European Commission. Office for Official Publications of the European Communities, Luxembourg. 1997. Innovative Health Technologies. IHTs at women’s midlife: theory and diversity among women and experts. http://www.york.ac.uk/res/iht/ (accessed 2 October 2003). Ballard KD, Kuh DJ, Wadsworth MEJ. The role of the menopause in women’s experiences of the “change of life.” Sociol Health Illness 2001;23:397-424. Locke M. Anomalous ageing: managing the postmenopausal body. Body Soc 1998;4:35-61.
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Green E, Thompson D, Griffiths FE. Narratives of risk: women at midlife, medical “experts” and health technologies. Health Risk Soc 2002;4: 243-86. Grady D, Cummings S. Postmenopausal hormone therapy for prevention of fractures. JAMA 2001;285:2909-10. Stearns V, Ullmer L, Lopez JF, Smith Y, Isaacs C, Hayes DF. Hot flushes. Lancet 2002;360:1851-61. O’Connor AM, Tugwell P, Wells GA, Elmslie T, Jolly E, Hollingworth G, et al. A decision aid for women considering hormone therapy after menopause: decision support framework and evaluation. Patient Educ Counseling 1998;33:267-79. Massé R, Légaré F. The limitations of a negotiation model for perimenopausal women. Sociol Health Illness 2001;23:44-64.
Is concordance the primrose path to health? It might not make much difference
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BMJ 2003;327:821–2
BMJ VOLUME 327
he concept of concordance—consensual prescribing—emerged after an inquiry “into the causes and consequences of non-compliance with medicines.”1 The notion of “doctor’s orders,” where the passive patient is given treatment by the authoritarian and supposedly knowledgeable doctor is replaced by the idea of discussion and agreement between patient and prescriber before treatment. The final aim is “to optimise the potential benefits of medical care.”1 Two thirds of older patients prescribed a statin for coronary artery disease will have given up treatment within two years.2 Concordance implies that these patients are denied real benefits if they do not take treatment as prescribed, and informed discussion should improve matters. Constructive dialogue between patient and prescriber is ethically and professionally desirable, even if the public good sometimes demands an authoritarian approach, as with directly observed treatment for tuberculosis or methadone maintenance. Usually, however, the patient, who has most to gain by success and the most to lose from harm, should decide whether to have treatment, and the prescriber should provide information on the risks and benefits to help make the decision. To make rational therapeutic decisions, we should weigh risk of harm against chance of benefit. Risk is notoriously difficult to calculate, and even where it can be measured accurately, the same absolute risk will be perceived very differently by different people and in different contexts.3 This explains in part why it is hard to establish what risks patients would be prepared to take for a given benefit—for example, a cure for rheumatoid arthritis.4 It is also hard to establish how people perceive the chances of benefit. They spend £4.5bn ($7.5bn; €6.4bn) per year on United Kingdom lottery tickets, even though the probability of winning the jackpot is one in 14 million. This does not prove that treatments offering higher chances of benefit are good. A meta-analysis shows that treatment of 1000 people with hypertension (mean blood pressure 177/90) aged between 60 and 80 reduces the number who die in five years from 129 to 111, that is, by 0.36% per year; and all cardiovascular events are reduced by about 1% per year.5 The authors concluded that treating healthy elders with hypertension is highly efficacious, but 95% of patients who dutifully take their tablets for five years 11 OCTOBER 2003
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will be no better off, and there are benefits, too, in neither taking tablets nor regarding oneself as suffering from a medical condition. It may be possible to discuss the potential benefit and harm from a treatment, and agree with the individual patient what course to take. This will probably be insufficient to influence behaviour. Up to 80% of information given to patients during medical consultations is forgotten at once, and almost half of what remains is incorrect.6 “Decision aids,” such as leaflets explaining the options for treatment of specific conditions, improve patients’ knowledge and increase their satisfaction with treatment, but rarely, if ever, improve measures of physical outcome.7 Many patient information leaflets are unintelligible, anyway.8 Patients can intend to take treatment, but nevertheless find it hard to keep to the prescribed regimen. The consequences may be less severe for some drugs than for others but generally act to reduce the benefits that might be expected from clinical trials.9 10 Patient diaries and tablet counts overestimate the degree of adherence to the prescribed schedule when they are compared with more sophisticated methods of assessment.11 12 We should hardly be surprised that our patients wish to hide their failings from us, and concordance, where the patient and prescriber have discussed in detail the value of adherence, and by implication the price of failure to adhere, may encourage this all too human deceit. The practical difficulties of providing information, allowing the individual patient to make rational decisions, and translating decisions into action, stand beside the realisation that, in altering behaviour, logic counts for little. Doctors are certainly bad at altering their own behaviour in response to logic. They accept that hand washing can reduce the spread of healthcare associated infection, but they still do not wash their hands.13 Such failings do not encourage optimism about concordance. There is another way in which behaviour may inhibit rational drug treatment. “The strategy of desire,”14 which appeals to the emotions rather than the intellect, is the foundation of modern ideas of selling. In the United States and New Zealand it has been deployed in advertising of prescription only medicines directly to consumers (that is, directly to patients). The 821
