Climacterium and the menopause

Quality of information
The world of menopausal care is changing. For many years, the scientific community involved in menopause research has been amassing evidence that the menopause is associated with multiple complaints and chronic diseases, and that postmenopausal hormone therapy has the potential to prevent or treat most of them. Because of the consistency of the scientific evidence there has been a high level of agreement among menopause specialists and their patients as regards the balance between the benefits and risks of postmenopausal hormone therapy. Since 1998, however, new findings from several large, randomised, controlled trials[1–5] have prompted physicians to hesitate before prescribing postmenopausal hormone therapy and have made women doubt its safety. 

“Not all information is of the same quality and therefore ought not to have the same impact.”

The recently published results of the Million Women Study[6] and the rapidly growing number of comments in the medical[7] and lay press have increased the uncertainty among doctors and their patients about who or what to believe. Contrary to what patients would expect, there are not only contrasting results from large and frequently quoted studies, but also doctors and opinion leaders often differ in their interpretations of the same publication[7, 8]. Which study can doctors rely on, and which doctors can patients rely on? Clearly, not all information is of the same quality and therefore ought not to have the same impact.

Quantity of information
Unlike just 10 years ago, women now have easy access to medical information on the Internet and are able to compare their doctor’s view with that of health care providers all over the world. This enables them to enrich their personal knowledge and to prompt their doctor to do so too. Shared information and responsibility in treatment decisions can be the basis for better treatment compliance and patient satisfaction. However, this target may prove to be too idealistic since there is a large heterogeneity in the type and quality of information that is available on the Internet. Anyone can start a health information website. A quick search on the Internet for ‘menopause’ will produce over a million websites. AltaVista presents over 500,000, Yahoo comes up with 1,290,000 and Google with about 200,000 sites. How should doctors and patients deal with this ‘problem’? And if it is hard for doctors to distinguish between information sources, then how can they advise their patients?

Reliable websites
For professionals there is the Doctor’s Guide to the menopause (www.pslgroup.com/menopause.htm). Furthermore, an interesting source of menopause information is MEDLINEplus (www.nlm.nih.gov/medlineplus/menopause.html), a health information website from the US National Library of Medicine and the National Institutes of Health. For specific menopause issues, excellent websites from menopause societies are accessible by both doctors and the general public. In North America the first port of call is the website of the North American Menopause Society (www.menopause.org), whose target audiences are professionals and patients. The European Menopause and Andropause Society launched its website in 2002 (www.emasonline.org), which gives access not only to official opinions from the European Society but also from the national societies. For example, doctors and patients can now find objective opinions on the results of the Million Women Study from both the British (www.the-bms.org/news.htm) and the Dutch Menopause Society (emas.obgyn.net/about.asp?page=millionw_DMS).

Table I: Categories of websites open to the public[9]

Pharmaceutical industry

Private health care providers

Government

Charity-run, public information sites

Personal

Community pharmacy

National health service providers

Educational establishments

Web provider

Table II: Health on the Net Foundation’s code of conduct principles for medical and health websites

Authority

Complementarity

Confidentiality

Attribution

Justifiability

Transparency of authorship

Transparency of sponsorship

Honesty in advertising and editorial policy

OBGYN.net (www.obgyn.net) is one of the biggest in the field of female health care. It has a special section devoted to the menopause (www.obgyn.net/meno/meno.asp) and is also available in different languages, among them a Dutch site (europe.obgyn.net/nederland) with its own menopause section (www.overgang.net). Almost every health care institution and organisation has its own website. In the Netherlands, the website of the ‘Ageing Women’ programme at Amsterdam’s Free University Medical Centre provides an excellent updated translation of the textbook Practical HRT (www.de-ouder-wordendevrouw.nl).

“Websites from the pharmaceutical industry, community pharmacies, governments and charities are among the higher quality sites.”

Other sources of information are listed in Table I and were excellently reviewed recently by Reed and Anderson[9]. These authors concluded that websites from the pharmaceutical industry (e.g. www.climodien.com and www.hrtinfo.co.uk), community pharmacies (e.g. www.boots.co.uk), governments (e.g. www.nih.gov) and charities (e.g. www.hysterectomy-association.org.uk) were among the higher quality sites and that doctors could safely direct women to these sites, although some warning may be given that commercial sites could be biased towards particular products. Website owners found using MedHunt, the search engine of the Health on the Net Foundation (www.hon.ch), must have specific qualifications defined by the Foundation (Table II).

New opportunities in menopausal health care
Besides the great potential of information available for patients as well as professionals, the Internet provides us also with a variety of new opportunities in health care in general, and in menopausal health care in particular. Menopause clinics can implement current telematics knowledge in the development of, for example, online services for booking of appointments and examinations, and for consultations. The Woman Project, supported by a European Commission grant, is actively involved in such a development (www.womanlab.com). This website for European professionals and patients is now available in 10 languages and integrated into 15 European menopause institutions. Online support in obtaining information and completing questionnaires, which subsequently become part of the woman’s electronic patient record, will improve health care efficiency. This kind of one-stop health care is now within reach and will certainly favour as much the individual patient as the general health care system.

References:

Ageing Women Project, Department of Obstetrics and Gynaecology, VU University Medical Center,Amsterdam, The Netherlands (mj.vandermooren@vumc.nl)

References

1. Hulley S, Grady D, Bush T, et al., for the Heart and Estrogen/Progestin Replacement Study (HERS) Research Group. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. J Am Med Assoc 1998; 280: 605–13.

2. Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results from the Women’s Health Initiative randomized controlled trial. J Am Med Assoc 2002; 288: 321–33.

3. Hays J, Ockene, Brunner R, et al. Effects of estrogen plus progestin on health-related quality of life. N Engl J Med 2003; 348:1839–54.

4. Shumaker SA, Legault C, Thal L, et al., for the WHIMS Investigators. Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women. The Women’s Health Initiative Memory Study: a randomized controlled trial. J Am Med Assoc 2003; 289: 2651–62.

5. Wassertheil-Smoller S, Hendrix SL, Limacher M, et al., for the WHI Investigators. Effect of estrogen plus progestin on stroke in postmenopausal women. The Women’s Health Initiative: a randomized trial. J Am Med Assoc 2003; 289: 2673–84.

6. Beral V, Million Women Study Collaborators. Breast cancer and hormone-replacement therapy in the Million Women Study. Lancet 2003; 362: 419–27.

7. Lagro-Janssen T, Rosser WW, van Weel C. Breast cancer and hormone-replacement therapy: up to general practice to pick up the pieces. Lancet 2003;362: 414–5.

8. Speroff L. The Million Women Study and breast cancer. Maturitas 2003; 46: 1–6.

9. Reed M, Anderson C. Evaluation of patient information Internet web sites about menopause and hormone replacement therapy. Maturitas 2002; 43:135–54.