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NAMS-gallup survey on women's knowledge, information sources, and attitudes to menopause and hormone replacement therapy

Utian, Wulf H.1; Schiff, Isaac2

doi: 10.1097/GME.0000000000001213
Commemorative Papers

The North American Menopause Society (NAMS) sponsored a Gallup Organization survey of 833 women aged 45-60 to determine attitudes and experience with menopause and various forms of hormone replacement therapy (HRT). The results of this survey are presented herein.

1Department of Obstetrics and Gynecology, Case Western Reserve University School of Medicine, Cleveland, Ohio

2Department of Gynecology, Harvard Medical School, Vincent Memorial Gynecology Services, Women's Care Division, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.

Address correspondence to: Dr. Wulf H. Utian, at Department of Obstetrics and Gynecology, Case Western Reserve University School of Medicine, 2074 Abington Rd., Cleveland, OH 44106, U.S.A.

Received 22 November, 1994

Accepted 27 January, 1994

There has been no recent published survey of women's attitudes and experience with menopause and various forms of hormone replacement therapy (HRT). To further its mission of sponsoring research and education into these subjects for both providers and consumers of health care, the North American Menopause Society (NAMS) sponsored such a survey by The Gallup Organization (The Gallup Organization, Inc., Princeton, NJ 08542, U.S.A.). The purpose of this communication is to outline the methods and results, and to comment on the pertinent findings of this survey of women aged 45-60 years. The objectives of the study were to (a) determine women's knowledge about menopause, (b) identify obstacles to effective physician/patient communication, and (c) define issues of concern to women over age 45.

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MATERIALS AND METHODS/DESIGN OF THE SAMPLE

To meet the stated objectives, The Gallup Organization interviewed 833 women between the ages of 45 and 60. The 833 interviews were conducted nationally by telephone during the period May 14-June 8, 1993. The sampling error was ±4 percentage points at the 95% confidence level.

The sample used for this survey was a proportionate stratified random digit telephone sample drawn from telephone exchanges serving the continental United States.

The random digit aspect of the sample was used to avoid “listing” bias. According to the most recent estimates from the Bureau of the Census, there are 93.3 million households in the United States, and approximately 93% of them contain one or more telephones. Telephone directories only list about 69% of such “telephone households,” and numerous studies have shown that households with unlisted telephone numbers are different in several important ways from listed households. Moreover, nearly 15% of listed telephone numbers are “discontinued” due to household mobility and directory publishing lag, and it is reasonable to assume that a roughly equal number are working residential numbers too new to be found in published directories.

In order to avoid these various sources of bias, a random digit procedure designed to provide representation of both listed and unlisted (including not-yet-listed) numbers was used. The design of the sample ensures this representation by random generation of the last two digits of telephone numbers selected on the basis of area code, telephone exchange (the first three digits of a seven digit telephone number), and bank number (the fourth and fifth digits).

The selection procedure produces a sample that is superior to random selection from a frame of listed telephone households, and the superiority is greater to the degree that the assignment of telephone numbers to households is made independently of their publication status in the directory. That is, if unlisted numbers tend to be found in the same telephone banks as listed numbers and if, in general, banks containing relatively few listed numbers also contain relatively few unlisted numbers, then the sample that results from the procedure described below will represent unlisted telephone households fully as well as it represents listed households. Random number selection within banks ensures that all numbers within a particular bank (whether listed or unlisted) have the same likelihood of inclusion in the sample and that the sample so generated will represent listed and unlisted telephone households in the appropriate proportions.

The first eight digits of the sample telephone numbers (area code, telephone exchange, and bank number) were selected so that they would be proportionately stratified by state, county, and telephone exchange within the county. That is, the number of telephone numbers randomly sampled from within a given county is proportional to that county's share of households in the set of counties from which the sample is drawn.

Only working banks of numbers were selected. A working bank was defined as 100 contiguous telephone numbers containing three or more residential telephone listings. By eliminating nonworking banks of numbers from the sample, the likelihood that any sampled telephone number would be associated with a residence increased from only 20% (where all banks of numbers were sampled) to between 60% and 70%.

The sample of telephone numbers produced by this method was thus designed to produce an unbiased random sampling of telephone households in the continental United States.

A total of 833 interviews were completed between the dates of May 14 and June 8, 1993. Interviewers were instructed to make up to five calls to complete an interview with a qualified respondent. Qualified respondents were women aged 45-60. In the event that the interviewer contacted a household containing more than one eligible respondent, a systematic procedure was used to select the respondent.

The survey data were weighted to bring the demographic characteristics of the sample into alignment with estimates of the demographic characteristics of the national population of women aged 45-60. These estimates were obtained from the U.S. Bureau of the Census. This type of weighting is designed to correct various potential sources of random error and bias that can affect the accuracy of conclusions drawn from survey data. This demographic balancing was performed on the variables of education, race, and region.

Thus, the sampling, the data collection, and the weighting procedures were designed to allow projection of survey results to the total population of women aged 45-60 living in telephone households in the continental United States.

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Sampling tolerances

In interpreting survey results, it should be borne in mind that all sample surveys are subject to sampling error, that is, the extent to which the results may differ from what would be obtained if the whole population had been interviewed. The size of such sampling errors depends largely on the number of interviews.

The following tables may be used in estimating the sampling error of any percentage in this report. The computed allowances have taken into account the effect of the sample design upon sampling error. They may be interpreted as indicating the range (plus or minus the figure shown) within which the results of repeated samplings in the same time period could be expected to vary, 95% of the time, assuming the same sampling procedures, the same interviewers, and the same questionnaire.

Table 1 shows how much allowance should be made for the sampling error of a percentage. The table should be read in the following manner: Let us say a reported percentage is 33 for a group which includes 833 respondents. Then we go to the row marked “Percentages near 30” in the table and go across to the column headed “833.” The number at this point is 3, which means that the 33% obtained in the sample is subject to a sampling error of plus or minus 3 points. Another way of saying it is that very probably (95 chances out of 100) the true figure would be somewhere between 30 and 36, with the most likely figure being the 33 obtained.

TABLE 1

TABLE 1

In comparing survey results in two samples, the question arises as to how large a difference there must be between them before one can be reasonably sure that it reflects a real difference. In Tables 2 and 3, the number of points that must be allowed for in such comparisons is indicated.

TABLE 2

TABLE 2

TABLE 3

TABLE 3

Table 2 is for percentages near 20 or 80, Table 3 for percentages near 50. For percentages in between, the error to be allowed for is between those shown in the two tables.

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RESULTS

The demographics of the 833 women ultimately surveyed are listed in Table 4.

TABLE 4

TABLE 4

For purposes of clarity, we present the detailed findings of the survey individually as responses to the main questions posed.

(a) “What type of doctor do you usually see for your gynecological care—a gynecologist, a general practitioner/family physician, or an internist?”

Slightly more than half of the surveyed women aged 45-60 reported seeing an ob/gyn, while one-third used a general practitioner or family physician for their gynecological care. One in twelve said they used an internist for gynecological care. Postmenopausal women were less likely to report using a gynecologist for their gyn care than were women currently going through menopause or premenopausal women.

(b) “Where do you get most of your information about menopause and other women's health issues?”

More than one-third (36%) of the women surveyed reported getting most of their information about menopause and women's health issues from a physician. Magazines or journals accounted for 27% of the mentions. Books, female friends, and television and newspapers were each mentioned by 6% of the women as references for women's health issues and menopause.

Women who reported that they had not gone through menopause were less likely than women who had or were currently going through menopause to cite their doctor as the source of most of their information on these topics.

(c) “How satisfied are you with the information on menopause that your physician has given you— would you say very satisfied, somewhat satisfied, not too satisfied, or not at all satisfied?”

Most women said they were satisfied with the information they had received from their physicians on menopause—44% were very satisfied and one in four reported being somewhat satisfied. Still, 16% said they were not satisfied with the information on menopause that their physicians had given them. Women who were currently using some type of HRT were more likely than women who had never used HRT or women who had used it in the past to say they were very satisfied with the information on menopause their doctors had given them (Table 5).

(d) “Has your physician ever discussed any of the following aspects of menopause with you?

 • Physical symptoms such as hot flashes or night sweats

 • Any changes you might experience in your sexual functioning such as a decreased interest in sex, painful intercourse, or vaginal dryness

 • Emotional symptoms such as irritability, nervousness, or depression

 • Irregular or skipped periods

 • The treatments available that might help with any symptoms of menopause

 • Your mother's menopausal experience

 • Osteoporosis

 • Heart disease”

TABLE 5

TABLE 5

Three in five (61%) women said their doctors had discussed with them the physical symptoms of menopause such as hot flashes and night sweats—73% among women currently going through menopause. More than half reported their doctors had discussed the treatments available that might help them with menopausal symptoms—among women currently going through menopause, two-thirds said their doctors had discussed treatments. Approximately half (49%) said their doctors had discussed their risks for osteoporosis and/or the emotional symptoms such as irritability, nervousness, or depression (47%). Among women currently going through menopause, more than half (57%) said their doctors had discussed the emotional symptoms of menopause with them. At least four in ten said their doctors had discussed their risk for heart disease (42%)—among postmenopausal women, the comparable figure was 44%. More than one-third reported that their physicians had discussed changes they may experience in their sexual functioning. Fewer (21%) reported that their doctors had asked them about their mothers’ menopausal experiences.

(e) “Which of the following do you think women's bodies naturally produce?

 • Estrogen

 • Progesterone

 • Androgens”

Most women (83%) surveyed stated that a woman's body naturally produces estrogen, but fewer (46%) thought women's bodies naturally produce progesterone, and no more than one in five (20%) believed a woman's body produces androgens. College-educated women were more likely than women who had not attended college to say that estrogen and progesterone are hormones that are naturally produced in women's bodies.

(f) (Asked of women who mentioned hormone as naturally produced by women's bodies): “To the best of your knowledge, does the production of (estrogen, progesterone, androgens) increase after menopause, decrease after menopause, or doesn’t this have an effect on production of this hormone?”

Approximately nine in ten (88%) women who said a woman's body naturally produces estrogen believed that the production of estrogen decreases after menopause, but women were more uncertain about the production of progesterone or androgen. Among women who had said that a woman's body naturally produces progesterone, approximately half (49%) thought progesterone decreases after menopause, while 34% had no response. Among women who thought that androgens are naturally produced in a woman's body, one in four believed that the production of androgens decreases after menopause, 18% did not think menopause had any effect on production of androgens, and half could not answer the question.

(g) “I am going to read some physical and emotional effects that may or may not be associated with menopause. From what you have heard or read, which one of the following concerns you most? Which would be second?

 • A risk of osteoporosis or bone loss

 • Increased risk of heart disease

 • Decreased interest in sex or problems related to sex

 • Depression or your mental attitude

 • Some other?”

The risk of osteoporosis, mentioned by one-third (33%), was most frequently mentioned by women as of greatest concern to them. Depression and mental attitude was of greatest concern to 28% of the women surveyed, while as many (27%) said the increased risk for heart disease was of the most concern to them. Of the four physical and emotional effects read to them, a decreased interest in sex was seen as least important, mentioned by only 3% of the women surveyed as their greatest concern.

Women were asked which effect would be their second greatest concern. When women's first and second mentions are combined, heart disease and osteoporosis are mentioned by 57% and 56%, respectively, while approximately half (48%) are concerned with depression and mental attitude. One in twelve were concerned about sexual problems related to menopause.

(h) (Asked of all women who indicated they were postmenopausal, menopausal, surgical menopause): “Were there any symptoms that made you aware you were going through menopause? Did you have any of the following symptoms?

 • Physical symptoms (hot flashes or night sweats)

 • Irregular periods

 • Emotional symptoms (irritability, nervousness, depression)

 • Changes in sexual relationships (lack of interest, painful intercourse, vaginal dryness)”

Eight in ten (80%) said they had symptoms that made them aware they were going through menopause. Among women currently going through menopause, 94% said they had symptoms that made them aware they were going through menopause.

Physical symptoms, such as hot flashes or night sweats, were the most common, mentioned by 72% among this group of women. Irregular periods (50%) or emotional symptoms (49%), such as irritability or nervousness or depression, were each mentioned by approximately half of the women. Slightly more than three in ten (31%) reported having had changes in their sexual relationships, such as decreased interest in sex, painful intercourse, or vaginal dryness (Fig. 1).

(i) (Asked of all who had symptoms): “Did you see your doctor for any of your symptoms? For which symptoms did you see your doctor?”

FIG. 1

FIG. 1

Approximately three in five (62%) said they had seen their doctors, while 37% had not. Among women currently going through menopause, seven in ten (70%) said they had consulted a doctor for their symptoms. Women who experienced problems with their sexual relationships (decreased interest in sex, vaginal dryness, etc.) and women who reported having emotional symptoms of menopause were more likely than women who experienced physical symptoms such as hot flashes to say they had seen their doctors. Yet, when they were asked for which specific symptoms they had seen their doctors, women most frequently mentioned the physical symptoms (hot flashes, night sweats, and/or irregular periods). Slightly more than one-third (35%) reported having seen their doctors for emotional symptoms, and only 16% said they had seen their doctors for changes in their sexual relationships. It may be that some women are reluctant to tell their doctors about any emotional symptoms or sexual problems they may be experiencing. For example, among women who said they experienced physical symptoms (hot flashes, etc.), 65% said they had seen their doctors about these symptoms. Among women who had experienced emotional symptoms, 55% reported having seen their doctors. However, among women who said they experienced sexual problems, no more than 40% said they had seen their doctors about these symptoms (Table 6).

(j) (Asked of those who had not seen a doctor for symptoms): “Why didn’t you see your doctor?”

TABLE 6

TABLE 6

The most frequent response was that the symptoms did not require medical attention. More than one in four did not see a doctor because they felt the symptoms were a natural part of menopause. Ten percent said their symptoms were not severe enough. Fewer (4%) said they had just accepted dealing with their symptoms, while 3% said they were not comfortable talking to their doctors about their symptoms (Table 7).

(k) (Asked of all who had experienced changes in their sexual relationships): “What changes in your sexual relationship did you experience?”

TABLE 7

TABLE 7

Decreased interest in sex (62%) and vaginal dryness (55%) were the two most frequent responses. Depression or feelings of sadness were mentioned by 44%. Anxiety was mentioned by one-third of the women, and a feeling of being unattractive (33%) was another change they had experienced. Painful intercourse was cited by 32%.

(l) (Asked of all who were currently going through menopause or postmenopause and those who had had a hysterectomy): “Has your sexual activity increased, decreased, or stayed the same since menopause?”

More than half (55%) of women 45-60 who had gone through menopause, were currently going through menopause, or who had had a hysterectomy said their sexual activity had remained the same as before menopause. Three in ten reported their sexual activity had decreased, while 7% said their sexual activity had increased since menopause. Among women who said they had experienced changes in their sexual relationships, half (50%) reported their sexual activity had decreased, while 36% said it had remained the same.

(m) (Asked of all who were currently going through menopause or postmenopause and those who had had a hysterectomy): “What methods, if any, have you ever tried to help relieve the symptoms of menopause?”

Hormone treatment was the most common method women said they used to help relieve the symptoms of menopause. Four in ten (41%) menopausal and postmenopausal women said they had used hormones to help relieve the symptoms of menopause. Exercise was mentioned by one in twenty (5%) women. Proper nutrition, vitamins, vaginal creams, relaxation techniques, and mental attitude were other methods mentioned, each by approximately 2%.

(n) (Asked of women who said their doctors discussed treatment): “You mentioned that your doctor discussed treatments for menopause. What types of treatments did your doctor discuss with you?”

The vast majority (84%) reported that their doctors had discussed HRT with them. Exercise, proper nutrition, medications, vitamins, calcium, hysterectomy, relaxation techniques, and vaginal creams were each mentioned by ≤ 2% as treatments their doctors had discussed.

(o) “I am going to name some types of hormone replacement therapies. As I read each, please tell me which, if any, you have heard or read about?”

More than eight in ten women aged 45-60 said they had heard of estrogen. Two-thirds said they were aware of the combination therapy of estrogen and progestin. Sixteen percent said they had heard or read about a combination therapy of estrogen and androgen.

Awareness of a combination estrogen and androgen therapy is not significantly different between women who had had a hysterectomy and women who had not (17% vs. 14%).

(p) “Have you ever or are you currently taking any hormone replacement therapy?”

(Asked of all who had previously taken hormone replacement therapy but were no longer): “Why did you stop taking hormone replacement therapy?”

(Asked of all currently taking or having taken hormone replacement therapy in the past): “Did you ask your doctor for hormone replacement therapy or did your doctor bring it up?”

While approximately three in five (58%) of the women surveyed said they had never taken HRT, 34% were currently taking hormones and one in twelve (8%) reported having taken HRT in the past but not currently. Women who had a hysterectomy were more likely than women who had not to say they were currently taking HRT (53% vs. 21%).

Among women who had taken HRT in the past but were no longer taking it, 34% said they had stopped because of the side effects. Eighteen percent reported they had stopped because of their concerns about their risk of cancer or, more specifically, breast cancer. One in seven (14%) said that the problem had been resolved, and 11% did not think they needed HRT. Six percent cited cost as a reason for discontinuing HRT, and weight gain was another reason mentioned by 6%.

Asked if they had asked their doctors for HRT or whether their doctors had brought it up, most (79%) women who had used HRT reported their doctors had brought it up. However, one in five (19%) said that they had asked their doctors for HRT (Table 8).

(q) (Asked of all who reported they have taken HRT): “Which type of hormone replacement therapy did you or are you currently taking?”

TABLE 8

TABLE 8

The majority (56%) of women who had used HRT said they had taken estrogen only, while 38% reported taking a combination of estrogen and progestin. Few reported taking a combination of estrogen and androgen or progestin only. Women who were currently taking HRT were more likely to say they took estrogen only than those who had taken it in the past but had stopped. A combination therapy of estrogen and progestin was the type 37% of current users said they were taking.

Women who had a hysterectomy were more likely than women who had not (71% vs. 32%) to say they had taken estrogen only, while women who had not had a hysterectomy were more likely to have used a combination of estrogen and progestin (76% vs. 14%).

(r) “Has a doctor ever prescribed hormone replacement therapy and you refused or decided not to take the medication?”

(Asked of all who said “yes”): “Why is it that you decided not to take hormone replacement therapy?”

One in seven (15%) women in this age group reported that they had refused or decided not to take HRT. Past users of HRT were the most likely to say they had refused it (28%). Even among women who were currently taking HRT, 13% had changed their minds, saying that they had refused or decided not to take this medication in the past. Among those who had never taken HRT, 14% reported that they had refused or decided not to take the medication prescribed by their doctors.

When asked why they had decided not to take HRT, women most frequently cited side effects (35%) and/or concerns over cancer (26%) as their reasons for not taking this medication. Seven percent said they did not want to take medication every day, 5% did not think it was necessary, and 5% said it did not help. Not wanting to take drugs, weight gain, symptoms not severe enough, menstruation, or the idea that menopause is natural were other reasons, each mentioned by ≤3%. Only 1% reported bad publicity or “hearing bad things about it” as reasons for refusal.

(s) “What do you think would be the main reason for menopausal and postmenopausal women to take hormone replacement therapy?”

Women were read a number of reasons why women might take HRT and asked which they felt was the main reason for menopausal and postmenopausal women to take it. They were allowed to give up to three responses. Based on their first response, help in resolving the symptoms of menopause, mentioned by 41%, was the most frequent response. When women's total responses are combined, resolving the symptoms of menopause (60%) is still the reason women most frequently chose for a woman to take HRT. To help prevent osteoporosis and/or heart disease was the next most frequent response, mentioned by 38% and 34%, respectively. Nearly as many (30%) believed women take HRT to improve the quality of their lives.

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COMMENTS ON THE GALLUP SURVEY

While many of the responses to this Gallup Survey of 833 women aged 45-60 could have been expected or predicted, there were some unanticipated findings.

On a single response question for a primary source of menopause information, barely one-third of women reported receiving such information from their physicians. Moreover, of those who did receive information, many felt that physicians failed to address their primary concerns. As a result, the majority of women were relying on other outlets including news media (40% encompassing magazines, journals, book, TV, and/or newspapers), friends (9%), or family members (2%). Information of such a nature may well be unreliable or misleading. Clearly then, there is an urgent need for health providers to enhance their educational role.

Treatment options discussed with women also reflected a singularly narrow approach. While variants of HRT were discussed with or offered to four in five women, there was little or no emphasis on nonhormonal options such as smoking cessation, exercise, diet, and stress reduction techniques, none of which was discussed by more than 2% of physicians. Again, there appears to be a need to educate health care providers, or at least to modify attitudes and provision of services.

The survey data suggest that physicians are more comfortable discussing or providing information on physical complaints like hot flashes or potential problems like osteoporosis or heart disease than addressing emotional or sexual issues. However, a surprisingly low number in the sample survey actually listed sex as a serious concern.

Virtually all (94%) women currently going through menopause said they had symptoms that made them aware of the situation. Thirty-seven percent of this group did not feel that symptoms were severe enough to justify medical care.

Less than half of the population seeking medical care expressed a concern or interest in long-term health problems such as osteoporosis, heart disease, or cancer. This would seem to reflect a situation in which the majority of women regard menopause as a short-term event and do not relate menopause to any potential long-term outcomes. Once again, this would reflect an area for increased educational effort if menopause is to be regarded as a potential time in a woman's life for introduction of full-scale primary preventive health care programs to be conducted on a long-term basis.

A finding in this current survey differing from previous reports was the number of women currently on variants of HRT. A previous report on current user rate in white postmenopausal women over 65 years of age showed a figure of 13.7%.1 That report also noted that younger age, higher education levels, and surgical menopause were important determinants of estrogen use. The 34% current user rate in this survey is more than twice that previously reported. However, if one looks at the demographics of the surveyed group, all were below 60 years old and more than half were premenopausal, 86% were white, 75% had household incomes over $20,000, and 37.5% had a hysterectomy. All of those factors indicate that the potential for selection bias should be factored in as one interprets the current estrogen user rate in this survey.

Current user rates do not reflect long-term compliance, which is an important determinant of the risk of osteoporosis and coronary artery disease. It is estimated that 20-30% of women who receive prescriptions do not fill them.2 Of those who do fill their prescriptions 50% are noncompliant for the long term.3

Efforts to improve the long-term compliance are essential and perhaps even more important than improving short-term user and prescription rates. Overall, two-thirds of eligible women surveyed in this study had never taken HRT. This figure is probably higher in the older postmenopausal women most at risk for osteoporosis and coronary artery disease. It is granted that a subgroup of women will never accept estrogen replacement therapy (ERT), regardless of educational efforts, because of rigid views regarding menopause and HRT.4 The question is how to recruit and maintain the other sub-groups of peri- and postmenopausal women in whom ERT/HRT has a clear indication.

We would recommend targets to enhance appropriate use of HRT.

  1. Prescribing rates: Gynecologists tend to have a more aggressive attitude toward ERT and to prescribe it more frequently as compared with internists. This means that women who see internists and receive their gynecological care from them are less likely to receive HRT.5 Internists who provide gynecological care for women may be more forthcoming if they are better informed concerning the benefits versus the risks of HRT. The distinction between estrogens in oral contraceptive pills versus those in HRT vis-a-vis the risks of cancer, thromboembolic disease, and coronary ischemia should be clarified to patients and practitioners. Whereas there are still lingering fears about estrogen side effects and cancer risks, it is hoped that the Women's Health Initiative study6 will clarify those concepts and pave the way for enhanced utilization of estrogens/ progestins. Certainly, in this survey, the fear of cancer or concerns about HRT side effects were the most common reasons for deciding not to take HRT.
  2. Compliance rates: Continued research on regimens of hormone prescriptions with little or no side effects should be encouraged. Follow-up visits or phone calls to ensure compliance and reemphasize benefits may be useful. There is evidence that the absence of withdrawal bleeding greatly enhances the long-term compliance7 and regimens that reduce or prevent withdrawal bleeding while providing adequate endometrial protection should be developed further.

The majority of women have heard about estrogen and progestins, with a minority reflecting knowledge about androgens. This parallels physicians’ current prescribing habits and is not unexpected. These data may reflect lack of physician knowledge or information about androgen and another area for improved provider and consumer education.

This survey is believed to be of value in meeting its objectives of determining women's knowledge, information sources, and attitudes to menopause and HRT. Clearly it is not all-encompassing, but the information provided should serve as an encouragement to health care providers to enhance their efforts in terms of consumer information.

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Acknowledgments

The authors acknowledge the assistance of Stacey Harris. This survey was made possible through an unrestricted educational grant from Solvay Pharmaceuticals, Inc.

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REFERENCES

1. Cauley JA, Cummings SR, Black DM, Mascioli SR, Steeley DG. Prevalence and determinants of estrogen replacement therapy in elderly women. Am J Obstet Gynecol 1990; 163:1438–1444.
2. Rowles TB. Third International Symposium on Osteoporosis and Consensus Development Conference, Copenhagen, 1990. Copenhagen: Osteopress; 1990.
3. Coope J, March J. Can we improve compliance with long-term HRT? Maturitas 1992; 15:151–158.
4. Leiblum SR, Swartzman LC. Women's attitudes toward the menopause: an update. Maturitas 1986; 8:47–56.
5. Ferguson KJ, Hoegh C, Johnson S. Estrogen replacement therapy: a survey of women's knowledge and attitudes. Arch Intern Med 1989; 149:133–136.
6. National Institutes of Health. Largest US clinical trial ever gets under way. JAMA 1993; 270:1521.
7. Williams SR, Frenchek B, Speroff T, Speroff L. A study of combined continuous ethinyl estradiol and norethindrone acetate for postmenopausal hormone replacement. Am J Obstet Gynecol 1990; 162:438–446.
Keywords:

Hormone replacement therapy; Hysterectomy; NAMS-Gallup survey

© 2018 by The North American Menopause Society.