Treatment of Menopausal Symptoms in Family Medicine Settings

Treatment of Menopausal Symptoms in FamilyMedicine Settings following the Women’s HealthInitiative FindingsThe Florida Behavioral Health Research Consortium; Mary Ann Burg, LCSW, PhD,Kathryn Fraser, PhD, Serena Gui, PhD, Kathryn Grant, PhD,Shae Graham Kosch, PhD, Barry Nierenberg, ABPP, PhD, Oliver Oyama, PhD,Heidi Pomm, PhD, Kimberly Sibille, LMHC, Timothy Spruill, EdD, andVirginia Swartz, DSW

Purpose: This study explores trends in treatment of menopausal symptoms and use of hormone replace-ment therapy (HRT) in family medicine settings subsequent to the release of the Women’s Health Initia-tive (WHI) findings.

Methods: Anonymous self-administered questionnaires were distributed to family medicine residentsand faculty from 8 participating family medicine residency programs in the state of Florida. The surveyasked physicians how they typically treated common menopausal symptoms in otherwise healthy meno-pausal women, and how their practice patterns had changed since the release of the WHI findings. Weanalyzed survey responses from 62 faculty and 148 residents (66% of eligible respondents).

Results: HRT is still prominent for treating irregular menses, vaginal dryness, vasomotor symptoms,and decreased libido. Faculty physicians were significantly more likely than residents to use HRT formenopausal symptoms. Female physicians were more likely than male physicians to say their treatmentpatterns had changed as a result of the WHI.

Conclusions: After weighing the evidence of potential risks of HRT from the WHI study, family medi-cine physicians altered and broadened their strategies for treating common menopausal symptoms. Al-though HRT remains a prominent treatment approach, there is now more physician-patient discussionof individual risks and benefits than occurred before the WHI’s release of findings. (J Am Board FamMed 2006;19:122–31.)

There are diverse findings regarding the rates andprogression of menopausal symptoms in womenaged 45 years and older. There is evidence that upto 80% of women will experience some level ofphysical and/or psychological symptoms duringperimenopause and menopause including vasomo-tor symptoms, vaginal dryness, sleep disturbances,changes in libido, mood changes, and fatigue.1,2 An

Australian study found that between early and lateperimenopause, hot flushes increased by 27%,night sweats by 17%, vaginal dryness by 17%,whereas sleep disturbance progressed at a moregradual rate of 6%.3

Until 2002, physicians recommended hormonereplacement therapy (HRT) as a first line treatmentof common menopausal symptoms and as a prudentapproach for the primary prevention of coronaryheart disease (CHD) in menopausal women.4–5 Be-tween 1995 and 2002, HRT prescriptions increasedfrom 58 million to 91 million annually. The per-centage of patient visits for HRT increased from5% to 28%, and 90% of physicians reported pre-scribing HRT primarily for treatment of meno-pausal symptoms.6

The Women’s Health Initiative (WHI) was amulti-site randomized clinical trial designed to as-sess the effects of conjugated equine estrogen alone(for women with prior hysterectomy) and estrogen

Submitted 26 April 2005; revised 14 June 2005; accepted20 June 2005.

From the University of Florida, Gainesville, FL (MAB,KG, SGK); Halifax Medical Center, Daytona Beach, FL(KF); Florida Hospital, Orlando (SG, TS); University ofMiami School of Medicine, Miami, FL (BN); Morton PlantMease/University of South Florida, Clearwater, FL (OO);St. Vincent’s Medical Center, Jacksonville (HP); BayfrontMedical Center, St. Petersburg, FL (KS); University ofFlorida—Shands Jacksonville (VS).

Conflict of interest: none declared.Corresponding author: Mary Ann Burg, LCSW, PhD,

Women’s Health Research Center, Box 100171, Universityof Florida, Gainesville, FL 32610-0171 (E-mail: [email protected]).

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plus progestin (for women with intact uteri) onCHD incidence, and to examine the overall risksand benefits of HRT for rates of invasive breastcancer, stroke, pulmonary embolism, endometrialand colorectal cancer, and hip fracture in post-menopausal women 50 to 79 years old.7 Between1993 and 1998, this 40-site randomized trial en-rolled 16,608 women in the study arm comparingcombined estrogen/progestin (Prempro) to pla-cebo. This study arm was halted in May 2002 afterinvestigators found that the associated health risksof the combination hormone therapy outweighedthe benefits. The preliminary data showed a 26%increase in relative breast cancer risk and increasedrelative risk in CHD events.8 Guidelines for the useof HRT were quickly amended: the AmericanHeart Association recommended against initiatingcombined estrogen and progestin for secondaryprevention of CHD, and the US Preventive Ser-vices Task Force recommended against womentaking HRT solely for the purpose of preventingchronic conditions.9–11 The early discontinuationof the WHI estrogen/progestin clinical trial cre-ated an intense media and public reaction to thereports of potential harm from HRT. There was arapid decline in prescriptions for HRT, most spe-cifically Prempro, the HRT used in the WHI.Between the second quarter of 2002 and the lastquarter of 2004, prescriptions for Premprodropped by 80%.6,12 Subsequently in March 2004,the WHI’s estrogen-alone arm of the trial was alsoterminated early, when analyses of the data showedan increased risk of stroke and no overall benefit forCHD.13

Other than the evidence of declining prescribingof HRT in the years following the WHI findings,there is little evidence of how physicians now man-age menopause symptoms subsequent to the WHIfindings. Are physicians now suggesting othertreatment approaches such as lifestyle changes, psy-chotropic medications or complementary therapiesfor symptom management? Are physicians restrict-ing HRT for otherwise healthy women, or arethere some physicians, eg, those who have beenpracticing for many years, still recommendingHRT to most of their symptomatic patients? Weundertook this study to explore trends in treatmentpractices of family medicine physicians in the 2years subsequent to the release of the WHI find-ings.

MethodsStudy Design and PopulationThe University of Florida Institutional ReviewBoard approved this study protocol in 2004. Thedata presented are from a cross-sectional survey ofinterns, residents, and faculty of the 8 participatingfamily medicine residency programs in Florida.The participating programs are those whose behav-ioral medicine/science faculty or staff participatedin the Florida Behavioral Health Research Consor-tium (FBHRC). All the participating programshave family medicine centers where faculty andresidents see patients in a community setting.

Eligible respondents were all Family Medicineinterns, residents, and faculty in these 8 programs.We excluded surveys completed by non-physicianclinicians (eg, physician assistants and nurse prac-titioners) and physicians who were in specialtiesother than family medicine because they were sucha small proportion of the total sample (n � 5 andn � 8, respectively). Overall there were 229 eligibleresidents and 90 eligible program faculty in familymedicine.

Survey AdministrationThe FBHRC members distributed the surveys attheir program sites between the months of June2004 and August 2004. Several methods were usedfor survey distribution, including handing surveysout at residency program meetings, putting them inresident and faculty mail boxes, and giving themdirectly to eligible respondents. To maintain ano-nymity, the FBHRC members were asked to in-struct respondents to complete and return the sur-veys with no identifiers on the survey. The FBHRCmembers then mailed the completed surveys to theresidency program site responsible for final collec-tion and entry of the data.

Survey ContentThe FBHRC met several times over the course ofa year to develop and to refine the survey questions.The survey instrument was also reviewed and pre-tested by the program directors at each of theparticipating residency programs, and their sugges-tions for changes were incorporated into the finalsurvey instrument.

The final instrument was a 2-page self-adminis-tered questionnaire that took approximately 5 min-utes to complete. The survey elicited demographic

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information including gender, specialty, and yearresidency training was/would be completed. Toevaluate the volume of practice respondents hadwith menopausal patients, we also asked respon-dents to estimate the approximate number ofwomen patients aged 45 to 65 they saw in theirpractice in an average week.

For this study, we analyzed responses to 3 sets ofsurvey items. First, we provided a list of 9 commonmenopausal symptoms (vaginal dryness, vasomotorsymptoms, sleep disturbance, decreased libido,emotional lability, anxiety, depression, irregularmenses, and fatigue). Respondents were asked toindicate the approximate proportion of female pa-tients aged 45 to 65 for whom each of these symp-toms was present. Response categories were 0% to25%, 26% to 50%, 51% to 75%, and 76% to100%. Next, we asked them to refer to a list of 9common menopausal symptoms and to indicatewhich modes of treatment (wait and see, hormonetherapy, psychotropic medications, lifestylechanges, alternative therapies, or other) they typi-cally recommended to female patients aged 45 to65 who reported these symptoms but who were inotherwise good overall health. They were in-structed to check as many of the modes of treat-ment that applied. They were also asked to whatextent their practice patterns had changed as aresult of the WHI study results published so far.Response categories were “a great deal,” “some-what,” “not much at all,” and “unsure.” If theirpractice patterns had changed, they were asked tobriefly explain the changes in an open-ended for-mat.

AnalysisBased on responses to the year residency was com-pleted, we created a new variable indicating if therespondent was a resident or a faculty member atthe time of the survey (ie, those who completedresidency in 2003 or earlier were coded as faculty;those who were completing residency in 2004 orlater were coded residents). Responses to the itemthat asked respondents to estimate the approximatenumber of women patients aged 45 to 65 that theysaw in their practice in an average week were re-coded into a categorical variable for the bivariatecomparisons in the analysis (ie, “1 to 10,” “11 to20,” “21 or more”). Responses to the item askingrespondents about the proportion of their femalepatients who presented with any of the 9 listed

menopausal symptoms were recoded into a bivari-ate response variable where 1 � the majority ofpatients and 0 � less than half of patients. Descrip-tive statistics were used to examine the distributionof responses to all the survey items: �2 significancetests were used to examine bivariate associations inthe data; t tests were used to examine significantdifferences in the means of continuous variables inthe data. Responses to the open-ended questionabout how respondent’s practices had changed inresponse to the WHI findings were coded intothematic categories and reported as such in theanalysis.

ResultsRespondent CharacteristicsOut of the 319 eligible respondents, 210 returnedcompleted surveys for an overall response rate of66%. Almost three quarters of the survey respon-dents were family medicine residents and the re-mainder were family medicine residency programfaculty (Table 1). Specific response rates for facultyand residents were 69% (62/90) and 65% (148/229), respectively. The majority of respondentswere women. The mean number of women patientsaged 45 to 65 seen by all respondents in an averageweek in the total sample was 14.9 (SD � 13.6);residents reported a mean of 13.7 (SD � 11.2)female patients aged 45 to 65 per week, and facultyreported a mean of 16.8 (SD � 14.7) each week.The difference between the mean numbers ofwomen seen by residents versus faculty respondentswas not significant.

Table 1. Characteristics of Physician Respondents toSurvey

N Percentage

Residents 148 72.5Faculty 62 27.5Female 120 57.7Male 88 42.3Female Residents 80 54.1Male Residents 68 45.9Female Faculty 35 62.5Male Faculty 21 37.5Average number of women patients

aged 45 to 65 seen each week:1 to 10 108 53.711 to 20 57 28.421 or more 36 17.9



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Frequency of Menopause Symptoms Seen in PatientsRespondents were asked to indicate the frequencywith which they saw each of the 9 listed meno-pausal symptoms in their patients. Approximatelyone third of the physicians saw fatigue, vasomotorsymptoms, irregular menses, and emotional labilityin the majority of female patients aged 45 to 65(Table 2). About one fourth of the physicians saidsleep disturbances, depression, and anxiety werecommon in the majority of female patients. Therewere no significant associations between trainingstatus (ie, residents versus faculty) or respondentgender and responses to any of these items. Therewas a positive relationship between the number offemale patients aged 45 to 65 seen in an averageweek and patient reports of fatigue: 31% of respon-dents who saw only 1 to 10 female patients perweek said that half or more of their patients re-ported fatigue, whereas 54% of respondents whosaw 21 or more female patients per week said thathalf or more of their patients reported fatigue (P �.035).

Respondent Differences in Treatment ModalitiesRecommended for Specific Common MenopausalSymptomsFigures 1 to 9 show the treatment modalities rec-ommended for each of the common menopausalsymptoms. Respondents were instructed to checkall the treatment recommendations they used foreach menopausal symptom in female patients age45 to 65 who were in otherwise good health. Themajority of respondents recommended hormonetherapy for vaginal dryness (69%), and very fewrecommended any other types of therapeutic ap-

proaches for this symptom. Of those recommend-ing hormone therapy for vaginal dryness, 10.3%wrote in topical hormones under “other therapies,”whereas 29.9% of those who did not recommendhormone therapy for vaginal dryness wrote in top-ical hormones. Treatment recommendations forvasomotor symptoms were diverse with half of therespondents recommending hormone therapy,

Figure 1. Percentage of Physicians Using SpecificTreatment Modalities for Vaginal Dryness.

Table 2. Percentage of Physicians Who Say ThatCommon Menopausal Symptoms Are Present inMajority of Women Patients Aged 45 to 65:

Symptoms Reported inMajority of Patients

Percentageof Physicians

Fatigue 40.1Vasomotor symptoms 38.9Irregular menses 36.9Emotional lability 35Sleep disturbance 25.4Depression 24Anxiety 23.7Decreased libido 17.9Vaginal dryness 13.6

Figure 2. Percentage of Physicians Using SpecificTreatment Modalities for Vasomotor Symptoms.



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40% recommending alternative therapies, 28%recommending “wait and see,” 18% recommend-ing psychotropic medications, and 15% recom-mending lifestyle changes. The majority of respon-dents recommended lifestyle changes for sleepdisturbance, approximately one third recom-mended psychotropic medications, and approxi-

mately one fifth recommended “wait and see.” De-creased libido was another symptom that generateddiverse therapeutic responses in this sample, withHRT being the most frequent response. Emotionallability, depression, and anxiety were all treatedprimarily with psychotropic medications and life-style changes. Respondents were almost equally

Figure 3. Percentage of Physicians Using SpecificTreatment Modalities for Sleep Disturbance.

Figure 4. Percentage of Physicians Using SpecificTreatment Modalities for Decreased Libido.

Figure 5. Percentage of Physicians Using SpecificTreatment Modalities for Emotional Lability.

Figure 6. Percentage of Physicians Using SpecificTreatment Modalities for Anxiety.



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likely to recommend “wait and see” and hormonaltreatment for irregular menses. The majority ofrespondents recommended lifestyle changes, onefourth recommended “wait and see,” and one fifthrecommended alternative therapies for fatigue.

Table 3 summarizes the previous 9 charts bydisplaying the relative frequency of treatment rec-

ommendations in a hierarchy table from high tolow frequency for each of the 9 menopausal symp-toms. The table shows that hormone treatment wasthe primary mode of treatment recommended towomen patients who reported irregular menses,vaginal dryness, vasomotor symptoms, and de-creased libido. There were no obvious trends in theuse of other therapeutic modalities for addressingmenopausal symptoms. Complementary and alter-native medicine (CAM) therapies were recom-mended most often for vaginal dryness and vaso-motor symptoms.

Analysis of Hormonal Therapy RecommendationsTable 4 shows data comparing the percentage ofresidents versus faculty who reported recommend-ing hormone treatment for the listed menopausalsymptoms. Faculty respondents were significantlymore likely than residents to report recommendinghormone therapy for the following symptoms: va-somotor symptoms, sleep disturbance, decreasedlibido, emotional lability, anxiety, irregular menses,and fatigue. There were no significant differencesbetween faculty and residents in recommendinghormone therapy for vaginal dryness and depres-sion.

We also looked specifically at faculty respon-dents and examined the associations between timesince completion of residency training and use of

Figure 7. Percentage of Physicians Using SpecificTreatment Modalities for Depression.

Figure 8. Percentage of Physicians Using SpecificTreatment Modalities for Irregular Menses.

Figure 9. Percentage of Physicians Using SpecificTreatment Modalities for Fatigue.



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HRT for menopausal symptoms. There was a trendfor faculty who had completed their residencytraining 10 years or more before the WHI resultswere published (ie, faculty who completed trainingin 1993 or earlier) to report recommending HRTfor most menopausal symptoms (anxiety, depres-sion, irregular menses, fatigue, vaginal dryness, va-somotor symptoms, and decreased libido) com-pared with faculty who completed training morerecently, but none of the associations attained sig-nificance because of small sample sizes.

Change in Treatment Patterns As a Result of WHIOverall, the majority of respondents reported thattheir practice patterns had changed as a result ofthe findings from the WHI study (Table 5). Spe-cifically, 86% of the female faculty and 72% of themale faculty reported changing their practice pat-terns. Reports of changed practice were more fre-quent among respondents with higher volumes offemale patients in an average week. Responses tothe open-ended question to briefly explain changesin practice patterns fell into 8 general categories. In

the order of frequency those categories are: (1)their use of HRT had been reduced; (2) they use itonly for symptom relief and not preventive pur-poses; (3) they prescribe HRT for only brief peri-ods, eg, 2 to 5 years; (4) they don’t recommend it atall or rarely recommend it; (5) they engage in morediscussion with patients about the risks and benefitsof HRT and seek informed consent; (6) they suggestcomplementary and alternative therapy treatment ap-proaches more often; and, (7) they report continuingconfusion about the WHI results and how those find-ings should influence practice (Table 6).

DiscussionUntil the year 2002, HRT was a standard approachin the treatment of common symptoms of meno-pause, and it was believed to provide some protec-tion against heart disease and osteoporosis. Newevidence of the potential risks of HRT from theWHI and several other large clinical trials gener-ated prolific media coverage of the issue and at leasta temporary decline in use of HRT by femalepatients.6,14–16

Table 3. Hierarchy of Treatment Recommendations For Common Menopausal Symptoms (Percentages)

IrregularMenses

VaginalDryness

VasomotorSymptoms

SleepDisturbance

DecreasedLibido

EmotionalLability Fatigue

Higher HRT (50.9) HRT (68.4) HRT (50.9) Lifestylechanges(58.5)

HRT (39.2) Psych meds(68.4)

Lifestylechanges(67.5)

Wait and see(50)

CAM (12.7) CAM (39.6) Psych meds(33)


Lifestylechanges (41)

Wait and see(25.9)

CAM (8) Lifestylechanges(11.3)

Wait and see(27.4)

Wait and see(22.2)

Wait and see(24.1)

HRT (18.4) Psych meds(20.8)

Lifestylechanges (6.1)

Wait and see(8.5)

Psych. Meds(17.5)

CAM (15.6) Psych meds(17.5)

Wait and see(16.5)

CAM (19.8)

Lower Psych.meds(1.9)

Psych.meds(0.5)


HRT (10.4) CAM (15.1) CAM (14.2) HRT (13.2)

HRT, hormone replacement therapy; CAM, complementary and alternative medicine.

Table 4. Percentage Who Recommend Hormone Therapy for Menopausal Symptoms: Comparison of Residents toFaculty

Percentage Who Recommend Hormone Therapy For Specific Symptoms

VaginalDryness

VasomotorSymptoms

SleepDisturbance

DecreasedLibido

EmotionalLability Anxiety Depression

IrregularMenses Fatigue

Residents 68.9 41.2 6.1 35.1 12.8 7.4 6.1 45.9 8.9Faculty 69.6 76.8 23.2 53.6 35.7 17.9 12.5 66.1 23.2P value NS .001 .001 .025 .001 .001 NS .012 .009



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Our survey demonstrated that the WHI hadsignificant impact on physician practice. Femaleresidents and female faculty were more likely toreport having changed their practice as a result ofthe WHI. The majority of family medicine facultystill recommended HRT as a treatment approachfor the most common physical symptoms of meno-pause, but interns and residents were not as likely

to recommend it. HRT was used less for preventivereasons, recommended mostly only for symptomrelief, and was being prescribed only for brief pe-riods, eg, 2 to 5 years, rather than indefinitely.

HRT was still the primary mode of treatmentrecommended to women patients who reportedirregular menses, vaginal dryness, vasomotor symp-toms, and decreased libido, but it was not com-monly recommended for other menopausal symp-toms. In this survey, treatment approaches for theother menopausal symptoms defied categorization.From the comments section of the survey, it seemsthat family medicine physicians are possibly morelikely now to suggest CAM approaches for meno-pausal symptom management than they were be-fore the release of the WHI findings. CAM wasmentioned second only to HRT as a commontreatment recommendation for both vasomotorsymptoms and vaginal dryness. Remifemin (blackcohosh), is an example of an alternative approach tomenopausal symptom management. Remifemin hasbeen shown through randomized clinical trials tobe more effective than placebo in the treatment ofhot flushes (two 20-mg tablets twice daily), and ithas been recommended by the German Commis-sion E Guidelines for the treatment of dysmenor-rhea.17 Foods containing phytoestrogens have alsodemonstrated potential benefits for symptom relief,particularly hot flashes.18 For certain menopausalsymptoms, eg, sleep disturbance, fatigue, decreasedlibido, and emotional lability, physicians generallyadvise patients to consider lifestyle changes forsymptom relief. Although there is some limitedevidence that supports using relaxation therapy toreduce vasomotor symptoms, future studies areneeded to more clearly define the effects of otherbehavioral therapies and lifestyle changes on meno-pausal symptoms.19,20

It is evident from this survey of family medicinephysicians that there is still some uncertainty aboutbest practices to address menopausal symptoms,because of the lack of standardization of practicerecommendations. There is also evidence thatsome ambiguity persists about which patients arecandidates for HRT.21 A limitation of our survey isthat it used as a point of reference for responsesabout HRT “menopausal patients in otherwisegood health.” This point of reference limits us inmaking any specific comments about some of thespecific risks the physician respondents take intoaccount in HRT treatment decisions, such as fam-

Table 5. Percentage of Respondents Who ChangedPractice Patterns after Women’s Health Initiative StudyFindings Were Published: by Gender, Training Status,and Average Number of Women Aged 45 to 65 SeenEach Week

ChangedNot

changedP

Value

Total sampleGender

Female 85.8 14.2 .014**Male 71.6 28.4

Training statusResident 75.2 24.8 .005*Faculty 92.7 7.3

Average number of female patientsaged 45 to 65 seen each week

1 to 10 75.2 24.8 .018**11 to 20 80.7 19.321 or more 97.1 2.9

* P � .05.** P � .001.

Table 6. Common Answers to the Question, ‘How HasYour Prescribing of Hormone Replacement Therapy(HRT) Changed Since Women’s Health Initiative(WHI)?’

“I don’t use HRT as preventive therapy. Still use as treatmentfor acute symptoms after risks/benefits explained. Try toget people off it in 2 years or less. Use as a treatmentrather than prevention or global measure”

“I prescribe HRT and ERT significantly less, taper it morequickly, and seek certain alternatives (specifically topicalestrogen and Effexor) much more.”

“Not confident about prescribing HRT anymore and onlygiven for postmenopausal symptoms refractory to othertreatment modalities. Confused about what emphasis to puton past research.”

“The results were overblown. The absolute risks were not asstaggering as the relative risks reported. For me, it triggersa discussion with the patient.”

“I would like to know more about natural options. I wouldlike to see more of this in residency training.”

“I really don’t like HRT and would not recommend it to anypatients. I think things like soy and really more behavioralpsychology approaches may be more helpful.”



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ily history of coronary artery disease or breast can-cer.

The conclusions of the recent National Insti-tutes of Health consensus panel on “Managementof Menopause-related Symptoms” added almost nospecificity in regards to best practices in this area.22

The panel acknowledged that although HRT wasstill the most effective therapy for menopausalsymptoms, it was important to consider the definedrisks of HRT in deciding whether to recommend itas a therapy for menopausal women. The onlyspecific guideline that emerged from the consensuspanel was the following: “decision making forwomen regarding treatment for menopausal symp-toms requires personal knowledge and balancing ofthese risks.”

A clear and consistent finding of this study wasthat family medicine physicians report spendingmore time discussing the risks and benefits of HRTwith their patients since the WHI findings werereleased. This is a valuable outcome of the WHIregardless of the clinical uncertainty that still sur-rounds the topic. Further studies regarding thenature of these discussions in combination withpatients’ interpretations of the information pre-sented by the WHI may provide data that will beuseful to family medicine physicians in their deci-sion making and treatment of menopausal symp-toms.

We thank the Residency Program Directors at each participat-ing study site for comments on the survey and the manuscript:Bruce Flareau, MD (Morton Plant Mease/University of SouthFlorida); Kristen Gray, MD (Florida Hospital); Karen Hall, MD(University of Florida); David McInnes, MD (St. Vincent’sMedical Center); David Parrish, MS, MD (Bayfront MedicalCenter); Ed Prevatte, MD (Halifax Medical Center); PennyTenzer, MD (University of Miami School of Medicine); andAnna M. Wright, MD (University of Florida, Jacksonville).

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Treatment of Menopausal Symptoms in Family Medicine Settings

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