Evidence supports the finding that use of hormone therapy (systemic estrogen with or without a progestin) for more than three to five years after the cessation of menses puts women at increased risk for breast, ovarian, and endometrial cancer, coronary heart disease, ischemic stroke, thromboembolism, gallbladder disease, incontinence, and dementia. For this reason, prescription of hormone therapy is not recommended beyond this therapeutic window except in rare circumstances, such as for osteoporosis that cannot be treated with bisphosphonates. Nevertheless, more than a quarter of prescriptions for hormone therapy are written for women over the age of 60, which raises the question of why. Surveys of women approaching menopause have found that hormone therapy decisions are strongly influenced by health care providers, the prescribers. A belief that estrogen has cosmetic, youth-prolonging benefits has been shown to be a predictor of estrogen use among women in their 40s and early 50s. No research on hormone therapy decision making specific to long-term users or women 60 years or older was found in the literature, and these processes may differ from those of younger women. For example, older women may perceive the risks and benefits of hormone therapy differently due to age- or cohort-specific medical or personal histories. It is also not clear whether hormone users or their providers are the primary drivers of hormone use in this population. The proposed study will use a qualitative design to examine hormone therapy decision-making processes of women 60 years and older, women who are at the greatest risk for hormone therapy related diseases. Grounded theory methodology will be used to explore the questions: What factors influence older women to use hormone therapy beyond the menopause transition? and How do older women weigh the risks and benefits of hormone therapy? In-depth interviews will be conducted with women who are long-term users of systemic estrogen therapy. Interviews will explore the participants' knowledge, beliefs, and attitudes about menopause, aging, and hormone therapy. Perceptions of risk, both embodied risk (such as for osteoporosis) and risk related to using hormones will be explored along with perceptions of benefits. The roles of others, including health care providers, in shaping these perceptions will also be explored. Interview transcripts will be analyzed using grounded theory methods. Theory generated from this formative study will be tested in future research and used to guide development of an intervention, such as a decision tool, to facilitate informed decision making about continuation of hormone therapy.
Over 25% of systemic estrogen prescriptions in the US are written for women aged 60 years and older, and the prevalence of use ranges from 13 percent in those aged 61 to 65 to 4 percent in those over age 75 despite prescribing guidelines advising that use beyond 5 years is unsafe and seldom warranted. The proposed research training grant study is a qualitative exploration of the decision-making processes of women 60 years and older who have chosen to continue systemic estrogen therapy despite associated health risks. Subsequent to this training grant study, theory built from the grounded theory analysis will be tested and refined (using quantitative strategies) and used to guide the development of an intervention, such as a decision-tool, to help women make informed decisions about continued use of hormone therapy.
