The climacteric,osteoporosis and hormone replacement; views of women aged 45–49

We report climacteric symptoms among women aged 45–49, and their attitudes towards HRT and osteoporosis prevention. Semi-structured questionnaires were administered to 481 women attending for bone density screening after random invitation. We recorded social class, menopausal status, history of HRT exposure and climacteric symptoms, awareness of HRT and osteoporosis, and potential willingness to consider HRT before and after bone densitometry. In total, 294 (61%) were from non-manual social classes; 338 (70%) were premenopausal, 68 (14%) postmenopausal and 75 (16%) uncertain; 101 (21%) were current/previous HRT users. Three or more climacteric symptoms were experienced by 189 (56%) of premenopausal women, compared to 64 (94%) of postmenopausal women. Most women had heard of HRT (96%) and osteoporosis (84%), usually from women's magazines or friends. HRT was usually prescribed for climacteric symptoms and, in one case, for osteoporosis prevention. Side effects were reported with most HRT preparations and affected 38% of all users. Of the 380 (79%) women who had never taken HRT, half had concerns about such treatment, and few wanted it at the menopause. However, 364 (96%) said they would consider HRT if their bone scan suggested increased osteoporosis risk. In conclusion, women around the menopause experience considerable climacteric morbidity, but are often anxious about HRT use. Better health education might improve HRT uptake, while long-term compliance might be enhanced by disclosure of fracture risk.     

Use of hormone replacement therapy: women's representations of menopause and beauty care practices

Objectives: Hormone replacement therapy (HRT) during menopause has been shown to have beneficial effects on women’s health, including preventing osteoporosis and probably reducing cardiovascular mortality and morbidity. However, these effects appear only after long use. Knowledge of factors influencing HRT use is a prerequisite for developing and assessing preventive actions. Most studies of user characteristics have focused on medical knowledge and socioeconomic characteristics, although social and cultural models of menopause may also play a role. Therefore, our study of the determinants of HRT use focused on representations of menopause and on beauty care. Methods: Two scores, one concerning the level of beauty care and the other the representations of menopause, were calculated. In our population of 561 postmenopausal women from the GAZEL cohort in France, 409 (72.9%) had been using HRT for more than one year, and 152 (27.1%) had used it for less than three months, if ever. Associations between the study variables and HRT use were then analysed. Results: No association was found between representations of menopause and HRT use. Beauty care and some beliefs about HRT (i.e. that it is useful for osteoporosis prevention, causes resumption of menstruation, and has anti-aging effects) were independently associated with HRT use. Moreover, the proportion of HRT users increased with socioeconomic status, with vasomotor symptoms in early menopause, and among hysterectomised women. Conclusions: The results suggest that the amount of attention women pay to beauty care plays a role, in determining HRT use.     

Perception of future health risks in mid-aged women: estimates with and without behavioural changes and hormone replacement therapy

Cardiovascular disease (CVD) and cancer are major causes of death for women, and osteoporosis negatively impacts upon the health and quality of life of many older women. There is evidence that risk of developing these diseases is partially determined by lifestyle factors, such as physical activity, diet and smoking, as well as being influenced by hormonal changes during the menopause. Participation in preventive strategies will be influenced by women's perceptions of the relative risks of developing these diseases, and beliefs about the effectiveness of the particular strategy. In this study, 103 mid-aged women were asked about their health and health behaviours and to estimate: (1) their future likelihood of developing CVD, osteoporosis and breast cancer; and (2) their future likelihood of developing diseases (a) if they improved their health behaviours, and (b) if they used hormone replacement therapy (HRT) for 5 years. Women believed that improving their health behaviours (diet, physical activity, smoking) would reduce their risks of CVD and osteoporosis, although modest reductions were expected. Breast cancer was not seen as significantly modifiable by lifestyle changes. They believed that taking HRT would significantly reduce their risk of osteoporosis, increase their risk of breast cancer, but not alter their risk of developing CVD. The findings are considered in the context of health psychology models of behaviour change and have implications for health promotion for mid-aged women.     

Recency and duration of postmenopausal hormone therapy: effects on bone mineral density and fracture risk in the National Osteoporosis Risk Assessment (NORA) study

OBJECTIVES: Results from the Women's Health Initiative showed that postmenopausal hormone replacement therapy (HRT) prevents fractures but has an overall unfavorable risk:benefit ratio, leading to the recommendation that HRT be used only for women with troublesome menopause symptoms, and for as short a time as possible. This recommendation has important implications for the timing and duration of HRT and the prevention of osteoporosis. The large number of women participating in the National Osteoporosis Risk Assessment (NORA) program provided the opportunity to evaluate bone mineral density (BMD) and 1-year fracture risk in analyses stratified by duration and recency of HRT. DESIGN: Participants were 170,852 postmenopausal women aged 50 to 104, without known osteoporosis, who were recruited from primary physicians offices across the US. BMD was measured at one of four peripheral sites, and the 1-year risk of osteoporotic fracture was assessed by questionnaire. RESULTS: At baseline, current HRT users had the highest T-scores at every age. Among current hormone users, women who had used HRT longest had the highest BMD levels. Women who had stopped HRT more than 5 years previously, regardless of duration of use, had T-scores similar to never-users. Current but not past hormone use at baseline was associated with a 25% to 29% lower risk of osteoporotic fracture (P < 0.0001) in 1 year, compared with nonusers. These findings were independent of age, ethnicity, body mass index, lifestyle, years postmenopausal, and site of BMD measurement. CONCLUSIONS: We conclude that postmenopausal BMD and fracture are closely associated with current, but not prior, HRT use. Use of HRT for 5 years or less, as proposed for treatment of symptomatic women during menopause transition, is unlikely to preserve bone or significantly reduce fracture risk in later years.     

Australian women's perceptions of hormone replacement therapy over 10 years

The knowledge, beliefs and experience of 60 women with HRT was studied when the women were premenopausal, and 10 years later when they were postmenopausal. Thirty-eight women had taken HRT by 1993. In 1993 women no longer considered clinics and self help groups to be the most useful sources of information about the menopause. They were more likely to think that doctors' knowledge of HRT was not adequate and to favour the use of HRT. Their reservations about all postmenopausal women receiving HRT continued. The women's understanding of long-term use of HRT varied. The women continued to maintain a desire not to experience withdrawal bleeding with HRT. More than 60% of women considered that HRT helped hot flushes, non-specific emotional changes and vaginal dryness. Women in 1993 were more likely to consider that HRT would help the menopausal symptoms of osteoporosis, insomnia and loss of muscle tone while fewer considered anxiety and depression would be relieved by HRT. Only one third believed HRT would reduce the incidence of heart disease. Women were more likely to take or have taken HRT if they were working and had achieved a higher work status (professional), considered reading material as the most useful source of information about menopause, had experienced menopause symptoms as distressing, considered menopause made relationships with husband and children more difficult and supported the universal use of HRT for all women.     

Factors associated with calcium, vitamin D supplements intake and use of hormonal replacement therapy in health workers postmenopausal women

OBJECTIVE: To know the frequency and factors associated with the intake of calcium (Ca), vitamin D supplements and use of hormone replacement therapy (HRT) among postmenopausal (PM) health professionals women. METHODS: During January to June 2004, health workers women of IMSS General Hospitals in Tijuana and Ensenada, Baja California, Mexico, were invited to participate. An interview and measurement of calcaneous bone mineral density (BMD) were performed. The following variables were assessed: sociodemographic, clinic and gynecologic features. We defined preventive osteoporosis (OP) treatment as the use of HRT, intake of Ca supplements (> or =1000 mg/ day) and supplements of vitamin D for a least six months. RESULTS: Among 739 women interviewed, 312 were PM, and 31%, 25% and 31% have been taking Ca supplements, vitamin D, and HRT respectively. Calcium, vitamin D supplements intake and use of HTR was similar during the menopause evolution. The variables significantly associated with the use of preventive OP treatment were older age, low weight, previous ooferectomy and use of corticosteroids. In the multivariate analysis, age and underweight were significantly associated with a low bone mass density, independently of the use of preventive OP treatment CONCLUSIONS: The frequency and length of time of Ca, vitamin D supplements intake and use of HRT was low, and 50% of PM health professional women are not under preventive OP therapy.     

Prevalence of hormone replacement therapy and user''s characteristics: a community survey in Japan

Objectives: It is quite recently that much interest has been paid to the benefits of hormone replacement therapy (HRT) in Japan. We conducted a community survey in Japan in 1992 to examine the prevalence of HRT use and factors related to HRT use. Methods: A total of 8791 female residents aged 45–64 years old in a city of the Gifu Prefecture, Japan, responded to the questionnaire including medical and reproductive histories, lifetime occupational history, diet, exercise, smoking and drinking habits, and use of vitamin supplements or medications. The response rate was 94.2%. Results: Overall, 2.5% of women reported current use of HRT and 6.3% had used HRT previously. The highest prevalence of current use was found among postmenopausal women with surgical menopause (4.8%). Current users were more likely to have participated in cancer screenings, and to have used vitamin supplements or calcium during the past year. Conclusions: HRT use rate was 2.5% among female residents aged 45–64 years old in a Japanese community in 1992. Current users may have more regard for their health status.     

Climacteric symptoms and knowledge about hormone replacement therapy among Hong Kong Chinese women aged 40-60 years

OBJECTIVES: To evaluate the use of hormone replacement therapy (HRT), the prevalence of climacteric symptoms, and the knowledge about HRT. METHODS: A prospective study was conducted by telephone interview among a randomly selected population-based sample of 978 Hong Kong Chinese women aged 40-60 years. RESULTS: Of 414 women with a history of either natural or surgical menopause, 22 (5.3%) and 17 (4.1%), respectively, were either past or current users of HRT. The climacteric symptom scores of premenopausal women were significantly lower than those of perimenopausal women, but were comparable with those of postmenopausal women. The commonest climacteric symptom was 'muscle and joint pains' which was reported in 553 (56.6%) women, while only 228 (23.3%) and 151 (15.4%) women reported hot flushes and night sweating, respectively. Moreover, only 230 (23.5%) women realized that HRT could relieve menopausal symptoms and only 33 (3.4%) women were aware that HRT was protective against osteoporosis. In general, women with more climacteric symptoms, who had ever used HRT, and those with higher education level and higher family income, had better knowledge about HRT. CONCLUSIONS: Postmenopausal Hong Kong Chinese women have a low HRT usage rate and the majority of them are lacking of the knowledge about HRT.     

Hormone replacement therapy and symptom reporting in menopausal women: a population-based study of 35-65-year-old women in mid-Sweden.

OBJECTIVE: To measure the prevalence rate of hormone replacement therapy (HRT) in the general population and to see whether HRT users report less symptoms, better general health and less use of other palliative than non-users and previous users. METHODS: The study was performed in 1995 as a cross-sectional postal questionnaire study in seven counties in mid-Sweden. The questionnaire was sent to a random sample of 4200 35-64-year-old women of whom 2991 responded. The age distribution of responders and non-responders was similar 49.6+/-8.5 and 49.8+/-8.7 years, respectively. The main outcome measures were vasomotor and general symptoms in relation to menstrual status and HRT. RESULTS: Fifteen percent were on HRT and 2.3% had stopped treatment during the past year. Thirteen percent used other palliatives. Twenty-five percent of premenopausal women experienced any vasomotor symptoms, as compared with 51% of menopausal and 40% of postmenopausal women. Those on HRT reported higher frequencies than non-users of all symptoms except for sweating during the daytime. In addition, menopausal women experienced more of other symptoms, usually not associated with the menopause, than premenopausal and postmenopausal women. HRT users reported a significantly worse perceived health and they took other palliatives drugs to a larger extent than HRT non-users. CONCLUSION: HRT seemed to be effective in relieving some vasomotor symptoms but did not affect the prevalence of other symptoms or perceived health, in spite of the fact that women on HRT supplemented their therapy with palliative drugs to a larger extent than other women.     

Hormone replacement therapy and health behavior in postmenopausal polio survivors

Objectives: Little is known about menopause and hormone replacement therapy (HRT) use in women with disabilities. The objectives of this study were to explore the health behaviors, health outcomes, and efficacy of HRT in a group of postmenopausal polio survivors and to compare selected outcomes to nationally representative cohorts. Methods: One hundred and thirty-one postmenopausal polio survivors completed self-report surveys on health behaviors, HRT use, functional status, and psychosocial well-being. During a physical examination, fasting cholesterol and body mass index (BMI) were collected. Independent sample t-tests and Chi-square analysis were used to compare HRT users and non-users on health behaviors and health outcomes; logistic regression was used to predict HRT use. Results: Prevalence of HRT use was 58%. Only BMI predicted HRT use (OR=0.30, CI: 0.11–0.81). HRT users had better high density lipoprotein (HDL), low density lipoprotein, total cholesterol/HDL ratios, lower BMIs, were more confident when communicating with their physicians, more likely to discuss menopause with their physician, and experienced greater overall stress. HRT was not associated with health behavior, health-related quality of life, mood, or life satisfaction. Compared to non-disabled women, more of these women had higher total cholesterol, obesity, more sleeping problems, and were less likely to vigorously exercise or smoke. Conclusions: HRT did not confer substantial benefits in these postmenopausal polio survivors to warrant them using HRT at a higher rate than their non-disabled peers. Comparisons to their non-disabled peers suggested they may be at higher risk for adverse health problems associated with postmenopause.     

Hormone replacement therapy and cognition in an Australian representative sample aged 60-64 years

OBJECTIVE: To investigate the relationship between hormone replacement therapy (HRT) and level of cognitive performance intra-individual variability, and interactions with statin use, progesterone therapy and type of menopause. METHODS: A representative sample of 60-64 year olds was recruited from the Canberra and Queanbeyan regions in Australia. They were administered tests of verbal memory, working memory, speed of information processing, simple and complex reaction time, verbal intelligence and the Mini-Mental State Exam. Intra-individual variation (consistency) on performance on simple and complex reaction time tasks was calculated. Women provided information on HRT use and demographic, health and lifestyle variables. RESULTS: Four hundred and four (35.0%) current postmenopausal HRT users, 316 (27.4%) previous HRT users and 434 (37.6%) women who had never used HRT, were included in this study. There were significant overall differences between HRT current and previous users on age, prevalence of diabetes, alcohol use, body mass index, level of anxiety and lung function. After controlling for potentially confounding health and demographic variables, there were no significant main effects detected between HRT groups on any cognitive measure. Significant interactions were detected between HRT group and statin use on intra-individual variability on simple reaction time, and between HRT group and menopause type on intra-individual variability on choice reaction time. All other interactions were non-significant. CONCLUSIONS: HRT use had no effect on level of cognitive performance. Two interactions were detected between HRT use and statin use, and type of menopause on intra-individual variability. Given the large number of comparisons, little weight can be placed on these significant results.     

Women's responses to a mailed hormone replacement therapy workbook

OBJECTIVE: Effectively communicating information about the complex decisions that face women at midlife, including whether to use hormone replacement therapy (HRT), is an ongoing challenge. Although numerous decision-making tools exist, few have been evaluated. The objective of this study was to examine women's use of a workbook designed to promote informed HRT decision-making. DESIGN: We developed a workbook to prepare women to discuss HRT, osteoporosis, heart disease, and breast cancer with their providers. To evaluate the workbook, women aged 45-65 years were randomly assigned to one of three groups: (1) workbook plus baseline and 6-month surveys, (2) workbook and 6-month survey, or (3) no workbook with both surveys. Results are based on the responses of 580 women in groups 1 and 2 (response rate, 84.2%). RESULTS: At 6 months, 79% of women recalled receiving the workbook, of whom 51% read all or most of it, 35% skimmed or read part of it, and 14% did not read it. The percentages of women completing self-assessments were 55% osteoporosis; 56% heart disease; 58% breast cancer; 57% advantages and disadvantages of HRT; and 52% personal preferences about HRT. As a result of the workbook, 10% made an appointment with their providers, and 12% had a discussion about HRT with their providers. Use of the workbook was not associated with menopause symptoms, attitudes about or use of HRT, hysterectomy, or provider discussions about menopause and HRT. CONCLUSION: This simple approach of using a mailed workbook holds promise as a successful mechanism to prepare women to discuss HRT and other related health issues with their providers.     

Health beliefs and attitudes toward the prevention of osteoporosis in older women

OBJECTIVE: A pilot study to determine health belief factors associated with osteoporosis prevention behaviors in peri-and postmenopausal women. DESIGN: We administered a survey to a convenience sample of 60 women aged 40-95 years old in an urban family practice center and an associated retirement community. The self-reported questionnaire addressed demographics, osteoporosis risk factors, current preventive behaviors for osteoporosis, and health beliefs. RESULTS: The majority of women (89%) believed that osteoporosis is a serious condition, but only 29% perceived a personal susceptibility. Women were less concerned about osteoporosis when compared with cancer, cardiovascular disease, and neurologic disorders. Only 40% of women were taking active measures to prevent osteoporosis. There was no significant relationship between active osteoporosis prevention behaviors and five health belief factors (motivation, barrier, active participant in health care, frustration, and benefit) (p >or= 0.43). However, active behaviors to prevent osteoporosis were found to correlate with the single item "I am worried about developing osteoporosis" (p = 0.03). Most women surveyed would be willing to exercise and take calcium and a multivitamin to prevent osteoporosis. CONCLUSION: Few women are taking active measures to prevent osteoporosis despite their belief that it is a serious condition. Our data suggest that most women do not perceive a personal susceptibility to the disease. Only women who reported actively worrying about developing osteoporosis were more likely to be engaged in significant osteoporosis preventive behaviors.     

Changes in body mass index around menopause: a population study of Chilean woman.

OBJECTIVE: To evaluate the influence of menopause and hormone replacement therapy (HRT) on weight and the effect of weight gain on coronary risk factors. DESIGN: From 1991 to 1992 cardiovascular risk factors were assessed in 271 premenopausal women between the ages of 40 and 53 years. The women were not receiving HRT at that time. Five years later, these women were reevaluated. RESULTS: Weight and body mass index (BMI) increased steadily with age. During the observation period there was an average increase of 4.0 kg +/- 4.6 (p < 0.0001). Women who experienced menopause and those who did not experience menopause had a similar weight increase (3.8 +/- 4.4 kg vs. 4.3 +/- 4.8, p = 0.37). Likewise, weight gain was similar in those who did or did not use HRT (nonusers, 4.3 +/- 4.6 kg; users, 3.5 +/- 3.7 kg; ex-users, 3.4 +/- 5.8 kg). At their first checkups, overweight women and obese women already had significant differences in their risk factors, including higher systolic pressure (p < 0.02), diastolic pressure (p < 0.01), glucose (p < 0.02) and triglycerides (p < 0.0001), and lower high-density lipoprotein cholesterol (p < 0.004) as compared with women of normal weight. Unexpectedly, women of normal weight who became overweight or obese during the monitoring period did not show any deterioration in their risk factors. CONCLUSIONS: During the perimenopausal period there is a weight gain that does not seem to depend on the menopause or HRT. Being overweight or obese during the menopausal transition is not necessarily associated with deterioration in coronary risk factors. This seems to imply the existence of different metabolic populations within this group of women.     

The relative effects of progesterone and progestins in hormone replacement therapy

Hormone replacement therapy (HRT) was initially given to protect women against osteoporosis and alleviate menopausal symptoms, such as hot flashes, depression, sleep disturbances, and vaginal dryness. In view of the understanding of oestrogen deficiency as a major trigger for the acceleration of cardiovascular risk after menopause, HRT may also be proposed as a substantial beneficial cardioprotective agent. Progestins, which may be added to oestrogen in combined HRT to reduce the risk of uterine malignancy, have a number of potential adverse effects on the cardiovascular system which could even attenuate the benefit of unopposed oestrogen replacement therapy in post-menopausal women.     

Hormone replacement therapy in Germany: determinants and possible health-related outcomes. Results of National Health Surveys from 1984 to 1999

OBJECTIVES: To explore the determinants of hormone replacement therapy (HRT) use and possible health-related outcomes in Germany. METHODS: 827 current HRT users (age range 31-78 years, who had taken HRT products in the last 7 days before the medical interview) and 2371 age-matched nonusers were identified from five population-representative National Health Surveys performed from 1984 to 1999 in Germany. Cross-sectional comparisons between HRT users and nonusers were performed for socioeconomic factors and possible health-related outcomes. Regression models were used to obtain odds ratios of HRT use. RESULTS: HRT use increased dramatically from 3% in 1984/1985 to 21% in 1998/1999 among German women aged 40-69. Regression analysis and comparison between HRT users and nonusers suggested that HRT use was closely associated with socioeconomic factors and personal lifestyle that may favor better health. In HRT users, however, we did not observe any health-related benefits in satisfaction with life or health. While HRT users appeared superior to nonusers with respect to the glycemic status, histories of cardiovascular diseases, despite a favorable lipid profile, occurred not less than in the group of nonusers. CONCLUSIONS: In the settings of our cross-sectional studies in Germany HRT did not improve users' health benefits and did not show cardioprotective effects. The better glycemic status should be balanced against the higher risks of cardiovascular diseases and breast cancer.     

Menopause characteristics of women with physical disabilities from poliomyelitis

OBJECTIVE: To describe menopause characteristics of women with physical disabilities from poliomyelitis. METHODS: Nine hundred and nine women with a history of poliomyelitis completed a survey on health, physical functioning, emotional well being and menopause. RESULTS: The majority of the sample was postmenopausal having had a natural menopause around the average age of 50.3 years; 34.7% of the sample had had hysterectomies. Thirty-nine percent were using some form of hormone replacement therapy (HRT). Menopause symptoms were clustered into psychological, somatic-sensory, somatic-sleep and vasomotor factors. Among never and past HRT users, there were significant differences in menopause factor severity by menopause status. Somatic/sleep symptoms were lowest in never users; past users had significantly higher vasomotor symptoms; desire for sexual activity and painful intercourse did not vary by HRT use. Compared to population estimates, post-polio women had similar rates of hysterectomies overall, but among some age cohorts they had significantly lower rates, contrary to expectations. However, they used HRT at significantly higher rates than expected. CONCLUSIONS: This study suggests that basic menopause characteristics of women with polio are generally similar to those of their non-disabled peers. There were few substantial differences in severity of menopause symptoms by HRT use, which is critical in light of the dearth of studies examining its risk-benefit ratio among women with physical disabilities. Until such studies provide some evidence of the specific risks or benefits to women with physical disability, each woman should carefully weigh the known risks and benefits with her physician.     

Assessment of the QoL in Italian menopausal women: comparison between HRT users and non-users

Objectives: The aim of this cross-sectional study was to describe QoL in a large sample of women attending menopause centres and compare untreated postmenopausal women and matched HRT users by employing the Women's Health Questionnaire (WHQ) and two generic instruments, the SF-36 and the EQ-5D. Methods: Overall, 2906 women were recruited by 64 menopause centres throughout Italy, of whom 2160 filled in the questionnaire (1093 on HRT and 1067 not on HRT; response rate: 74%). Results: HRT users tended to be younger, healthier and with shorter menopause duration as opposed to non users, while no major socio-economic differences were present. At multivariate analysis, the presence of chronic diseases, low socio-economic status and living in Southern Italy represented the most important predictors of poor QoL. Furthermore, HRT users showed a lower probability of reporting problems in usual activities and pain/discomfort (EQ-5D), role limitations due to emotional problems (SF-36) and anxiety/fears (WHQ). HRT users also showed highly significant better outcomes in those areas that are more directly attributable to hormonal changes of mid age, namely vasomotor symptoms and sexual problems. Conclusions: Although QoL is mainly influenced by socio-economic and cultural factors, HRT has the potential for improving not only symptoms, but also more general aspects of physical and psychological well-being of symptomatic postmenopausal women.     

Factors associated with intention to use hormone replacement therapy among Thai middle-aged women

OBJECTIVES: To examine the differences among those who express their intentions to use hormone replacement therapy (intenders), those who express their intentions not to use hormone replacement therapy (non-intenders), and those who are undecided, and to examine the factors associated with hormone replacement therapy (HRT) intention among Thai middle-aged women. METHODS: A total of 420 women aged 40-59 years, recruited from one hospital in Bangkok were asked to complete a self-administered questionnaire. RESULTS: Compared to intenders and non-intenders, the undecided were significantly less knowledgeable about menopause and HRT, and perceived the highest level of decisional uncertainty. Being inadequately informed was the most important factor that distinguished the undecided from intenders and non-intenders. When looking at intenders and non-intenders, no significant differences in perceived information inadequacy, level of knowledge, and perceived risks of HRT were found. However, it was found that intenders perceived higher benefit over risk of HRT (OR = 1.05, 95% CI = 1.02, 1.07), held more negative beliefs towards menopause (OR = 1.61, 95% CI = 1.03, 2.53), and were approximately two times more likely to have ever used oral contraceptives (OR = 1.99, 95% CI = 1.13, 3.47) than non-intenders. CONCLUSION: The findings reveal the importance of being informed about menopause and HRT in making decision about HRT use. Changes in knowledge, and beliefs are promising avenues to study to see how these impacts HRT use.