Assessment of knowledge, understanding and awareness of Chinese women clinical staff towards menopause hormone therapy: a survey study

Abstract Menopausal Hormone Therapy (MHT) is recommended for climacteric peri- and postmenopausal symptoms. The rate of use of MHT in China is much lower than the western regions. Therefore, a survey was conducted for the understanding and utilization of MHT among clinical staff in various hospitals of China. A total of 3216 eligible questionnaires were included for the evaluation. According to 19.2% participant opinion, MHT could relieve menopausal symptoms, whereas the majority had no knowledge of the benefits and risks of MHT. The most common concern about MHT was the risk of cancer and about 430 (13.4%) and 176 (5.5%) participants were apprehensive that MHT could increase the risk of breast and endometrial cancer, respectively. This survey demonstrated that the knowledge of clinical staff was not comprehensive and they should be educated more about the use of MHT so that this knowledge can be imbibed into the general population. Impact Statement What is already known on this subject? Menopausal Hormone Therapy (MHT) is recommended for climacteric peri- and postmenopausal symptoms. The rate of use of MHT in China is much lower than the western regions. What do the results of this study add? Only 19.2% of the respondents were of the opinion that MHT could relieve menopausal symptoms. The most common concern about MHT was the risk of cancer and about 430 (13.4%) and 176 (5.5%) participants were apprehensive that MHT could increase the risk of breast and endometrial cancer. What are the implications of these findings for clinical practice and/or further research? The survey demonstrated that Chinese medical professionals had some understanding about MHT, but their knowledge was not comprehensive. Thus, it is necessary to educate these medical professionals which in turn will help them to imbibe this knowledge among the general population.


Introduction
According to worldwide demographic data, about 25 million women experience menopause every year and predicted that number of postmenopausal women will reach 1.2 billion by 2030 (Du et al. 2020).The 2010 census of China predicted that ageing process will be accelerated in the coming years and perimenopausal women accounted for approximately 10% of the total population (China Releases First 2010 Census Results no date).Significant biological and social transformations occur in perimenopausal women as menopause increases vasomotor symptoms, vaginal dryness, dyspareunia and central abdominal fat and decreases breast tenderness, bone mineral density and sexual functioning (World Health Organization and United Nations Population Fund 2007).UK NICE guideline recommended that Menopausal Hormone Therapy (MHT) has a favourable risk-benefit ratio in women initiating treatment between the age of 50 and 59 years or within 10 years of onset of menopause (Lumsden et al. 2016).The utilisation of MHT in western countries increased during 1990 and declined abruptly in the early 2000.This decline was attributed to the principal results obtained from the Women's Health Initiative (WHI) randomised controlled trial suggesting the increase in the overall health risks than benefits from the MHT use among healthy postmenopausal women in the United States (US) (Writing Group for the Women's Health Initiative Investigators 2002).However, findings from this trial were controversial and the use of MHT was stabilised after a decade (Utian 2012).Currently, regulatory bodies in Europe and the US recommend the use of MHT with the smallest effective dosage and for the shortest possible duration while some clinical guidelines give emphasis on liberal use (Collaborative Group on Hormonal Factors in Breast Cancer 2019).Notably, the rate of use of MTH in China is much lower than the western regions (Lin et al. 2020).A telephonic survey conducted in China using the electronic records of the 825 outpatients revealed that about one-third (35.9%) of the patients discontinued MHT.The main reasons reported for withdrawal of therapy included fear of developing breast and uterine cancer, reduced menopausal symptoms and the non-compliance in taking pills or inconvenience in visiting a doctor (Chu et al. 2018).Generally, a physician is an important source of information and thus plays a strong influence in MHT decisionmaking by perimenopausal women (Newton et al. 1998).A cross-sectional study revealed that physician guidance increased MHT use by 5.2-fold compared with patients not consulting a physician (C ¸ilgin 2019).Therefore, it is expected that compared to the general public, clinical staff should have a better understanding and awareness about MHT.Presently in China, only a few studies have investigated clinical staff members' knowledge of MHT.Keeping this in mind, we conducted a survey on the understanding and utilisation of MHT among clinical staff members in various hospitals of China.

Study design and participants
This survey study was conducted on 3500 clinical staff members that included Chinese doctors, nurses, managerial and technical staff.Specific lectures on menopause were conducted in 21 tertiary hospitals from 18 provinces throughout China in 2019.Participants were asked to complete the questionnaire before attending the lecture.The study was approved by the Clinical Research Ethics Committee of Peking University People's Hospital in October 2018.Written informed consent was obtained from all participants.The details about the participants identity were kept confidential and the authors had no access to any information before and after data collection.

Socio-demographic survey questionnaire
The study questionnaires collected the information about socio-demographic characteristics of participants including age, height, weight, profession, menstrual volume along with pregnancy and abortion status.

Assessment of understanding, knowledge and awareness of menopause hormone therapy
In our survey, we defined MHT as oestrogen-progestogen therapy.Knowledge of risks and benefits of MHT was accessed among participants based on profession and medical expertise (Obstetrician-Gynaecologists Compared with Non-obstetrician-Gynaecologists).Menopausal Symptoms among participants age> 40 years were assessed using the modified Kupperman Index.Examinations were conducted after getting consent from participants for menopausal symptoms included sex hormone levels and bone mineral density test, pelvic ultrasound, radiography (mammary glands) and organ function tests (liver and kidney).

Statistical analysis
Statistical analysis of data was performed using R software (R Core Team 2020-European Environment Agency no date) Non-reasonable answers and obvious coding errors were screened and rectified using the original survey.Categorical and continuous data are presented as n (%)and mean (standard deviation [SD]), respectively.Categorical data were compared using v 2 test.Differences among respondents were examined on the basis of their professional position (doctor, nurse, managerial staff, or technician).When these four groups were compared, p < .05 was considered statistically significant.The Bonferroni method was used to adjust for multiple comparisons and p < .008was considered statistically significant.

Results
A total of 3216/3500 (92%) participant's questionnaires were eligible for evaluation.8% of the questionnaires, which have not answered or partially answered questions of MHT, were excluded.Questionnaires found to be missing for >20% of the critical answers were also excluded from the study.

Demographic characteristics
The demographic characteristics of the participants are presented in Table 1.Mean ± SD age, height and weight of the clinical staff was 35.26 ± 9.4 years, 163.46 ± 4.6 cm and 57.85 ± 7.9 kg, respectively.The mean age reported at menarche was 13 ± 1.5 years.More than half of the participants were nurses (55.3%) followed by doctors (29.1%).Among participants, 646/3216 (20.1%) and 379/3216 (11.8%) experienced irregular menstrual cycles and amenorrhoea (absence of menstruation during reproductive age of female) respectively.

Knowledge of risk and benefits of MHT
Table 2 shows that most of the participants were unaware about the risks and benefits of menopausal hormonal therapy.A total of 616 (19.2%) and 444(13.8%)participants agreed that MHT could relieve menopausal symptoms and prevent osteoporosis.On the contrary, 430 (13.4%) patients agreed that MHT may increase the risk of breast cancer.
There were significant (p < .05)differences in the respondents' views regarding risks and benefits of MHT among the four groups of professionals (Table 3).The managerial staff and technicians selected significantly more accurate responses than the doctors' with regard to whether MHT can relieve menopausal symptoms (v 2 ¼ 29.85, p ¼ .000;v 2 ¼ 14.39, p ¼ .000).Moreover, doctors selected more precise responses for risk of venous thrombosis than nurses (v 2 ¼ 10.26, p ¼ .001).With respect to osteoporosis, colon cancer and cerebral infarctions, the group selecting the most correct answer could not be determined.It was found that the managerial staff and technicians' error rate was higher than that of the doctors when asked about whether MHT may increase the risk of breast cancer (BC) (v 2 ¼ 24.857, p ¼ .000;v 2 ¼ 25.116, p ¼ .000)and endometrial cancer (v 2 ¼ 10.63, p ¼ .001).
A total of 3076 questionnaires (140 missing) were obtained when participants were divided into obstetricsgynaecologist (ob-gyn) and non-ob-gyn.The respondents of the ob-gyn group significantly (p < .05) agreed that HT can 'prevent and treat osteoporosis, reduce risks of colon cancer, increase the risk of venous thrombosis, and endometrial cancer' (Supplementary Table 1).

Symptoms of menopause, previous treatments and presumptions for MHT
A Total of 646 of 1210 participants (age > 40 years) experienced changes in their 2 consecutive menstrual cycles with relevant perimenopausal symptoms exceeding 7 days.Among them, a consent for undergoing an accessory examination of sex hormone level, and bone mineral density test was obtained from 220 (34.1%), 94 (14.6%) and 111 (17.2%) participants, respectively.The most common perimenopausal symptoms (Supplementary Among 646 participants, 154 (23.8%) participants received treatments for perimenopausal symptoms which included MHT, health products, psychotherapy, Chinese herbs, exercises and others; 65 (10.1%) and 11 (1.7%) participants had previously tried oral hormonal replacement therapy and transdermal/transvaginal hormones, respectively.The treatment duration varied from 2 weeks to 5 years.
Reasons for not using MHT were, 302 (46.7%) participants believed that these symptoms were part of the natural process of ageing; 171 (26.5%) participants thought that symptoms of menopause were mild which can be managed without treatment; 43 (6.7%) participants were suffering with uterine myoma, ovarian cysts, or endometriosis and non-willing to receive MHT; 43 (6.7%) participants found the treatment complex; 12 (0.9%) participants considered it as

Discussion
To the best of our knowledge, this is an exclusive survey on the understanding and attitudes towards MHT, of clinical staff such as doctors, nurses, managerial staff and technicians in tertiary hospitals of China.In this survey, more than half of participants reported, MHT is necessary and should be initiated at appearance of postmenopausal symptoms.However, majority of them were unaware about the risks and benefits of MHT.Among participants, 430 (13.4%) believed that MHT could increase the risk of breast cancer.According to 302/646 (46.7%) participants (aged >40 years), symptoms of menopause were part of the natural process of ageing and only 154 (23.8%) participants received treatments for perimenopausal symptoms.
This study had some limitations.Firstly, stratified sampling was not employed.The majority of the respondents voluntarily participated in the survey and had greater knowledge of MHT than the other medical professionals.Secondly, most of the respondents were of a younger age and only a few of them were in the perimenopause period, suggesting that the sample might not have accurately represented the actual rate of MHT use among Chinese medical staff.Lastly, structure of the questionnaire was very complex with plenty of questions and thus some attendees failed to complete it.
In present study, 2695 (83.8%) and 354 (11.0%), participants responded that, optimum time for MHT initiation is 'at appearance of postmenopausal symptoms' and 'post-menopause' respectively.Similar findings were reported by a Chinese study in which 66.9% and 22.4% healthcare professionals opined that optimum time for starting MHT is early menopause and within 5 years of menopause respectively (Lin et al. 2020).
The International Menopause Society (IMS) 2016 stated that there is a small possibility of increase in the risk of BC associated with MHT (<0.1% per annum), which is almost similar or lower than the increased risks associated with common lifestyle risk factors such as sedentary lifestyle, obesity and alcohol consumption (Baber et al. 2016).In our study, 430 (13.4%) of patients agreed that MHT may increase the risk of breast cancer.This is in agreement in one of the other Chinese studies where 51.4% healthcare professionals believed breast cancer as one of the MHT contraindications (Lin et al. 2020).A large meta-analysis and randomised clinical trial pointed out that systemic MHT provides symptomatic relief compared with other alternative treatments (Skouby et al. 2005).In a systematic review and meta-analysis of randomised trials showed that (HRT) is the most effective and standard treatment for vasomotor symptoms of menopause (Shams et al. 2014).Where as in our study, when responses of the participants were grouped by profession, it was observed that the lack of knowledge about MHT relieving symptoms was similar among four groups, doctors (83.4%), nurses (82.4%), managerial staff (67.65%) and technicians (73.11%).This suggest the need to strengthen the knowledge of Clinical staff regarding menopause management in China.
Furthermore, in the current study, (848) respondents of the ob-gyn group significantly (p < .05) agreed that MHT can 'prevent and treat osteoporosis, reduce risks of colon cancer, increase the risk of venous thrombosis, and endometrial cancer'.Also, the US survey on MHT showed that 61% (N ¼ 1614) of physicians were aware of MHT's effect on reducing the risk of colon cancer (Sangi-Haghpeykar and Poindexter 2007).The long-term use of oestrogen in perimenopausal women with a uterus might increase the rate of endometrial carcinoma, whereas if progestin is added in combination, the risk is reduced to a much greater extent (Grady et al. 1995, Weiderpass et al. 1999).Therefore, apprehension among clinical staff regarding endometrial cancer seemed to be unjustified and they are required to be educated accordingly.The IMS 2016 stated that the MHT-related risk of serious venous thromboembolic events increases with age and is positively associated with obesity and thrombophilia.MHT may increase the risk of stroke at age >60 years.Thus, it can be concluded that if a patient uses MHT during the optimal window, it will not increase rather it may reduce the incidence of the coronary artery disease (Baber et al. 2016).
Our survey has also indicated that clinical staff's use of MHT was higher than the general population, out of 646 perimenopausal women 154 (23.8%) received treatment in the form of oral MHT and transdermal or transvaginal hormones.The results of an Asian menopause survey showed that a few Chinese women reported previous use of MHT (9%, N ¼ 300), and only 2% reported current MHT use (Huang et al. 2010).
Chinese clinical staff showed non-compliance to MHT as they thought that menopause is a natural process of ageing, and intervention is not required.Previous studies have demonstrated that Chinese immigrant women interpreted menopause as a natural ageing process (Liu and Eden 2007).A total of 209 (32.4%) participants were reluctant to the use of MHT as they were worried about weight gain and medication dependence, which is also a common concern among the general population.A retrospective analysis revealed that there is no evidence that oestrogen or a combination of oestrogen and progestogen increases body weight and body mass index.Approximately 60% of women in menopause will gain weight, due to decreased oestrogen levels, increased food intake and reduced physical activity (Kongnyuy et al. 1999).
Overall, these findings suggested that Chinese clinical staff participants' knowledge was insufficient, and they were unnecessarily concerned and anxious about MHT use.As long as indications, contraindications and personalisation are well controlled, MHT is safe and effective for menopausal women initiating treatment before the age of 60 years (Studd 2010).This knowledge gap needs be bridged by imparting proper education and training to clinical staff, which can be further disseminated to general population.

Conclusion
This survey indicates lack of knowledge and exposure, regarding MHT and menopause management among various professional groups, that in turn might influence the acceptance of MHT among general population.This fact necessitates the need to strengthen the education and training of clinical staff which would be subsequently helpful in disseminating information to general public.This would help in better menopause management and improving quality of life in Chinese society.

Table 1 .
General information regarding the medical staff.

Table 2 .
Knowledge about the benefits and risks of menopausal hormonal therapy.

Table 3 .
Knowledge about the risks and benefits of HT among the different professional groups.