The Asian Menopause Survey

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Maturitas

j o u r n a l h o m e p a g e :w w w . e l s e v i e r . c o m / l o c a t e / m a t u r i t a s

The Asian Menopause Survey: Knowledge, perceptions, hormone treatment and sexual function

Ko-En Huang

^a,∗

, Ling Xu

^b

, Nik Nasri I

^c

, Unnop Jaisamrarn

^d

aCenter for Menopause and Reproductive Medicine Research and Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung 83305, Taiwan

bDepartment of Obstetrics and Gynecology, Peking Union College Hospital, Chinese Academy Medical Sciences, Beijing, China

cDepartment of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Universiti Sains Islam Malaysia, Menara B, Persiaran MPAJ, Jalan Pandan Utama, Kuala Lumpur, Malaysia

dDepartment of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

a r t i c l e i n f o

Article history:

Received 3 September 2009 Received in revised form 16 November 2009 Accepted 17 November 2009

Keywords:

Menopause Breast cancer Survey Compliance Sexual function

Hormone replacement therapy

a b s t r a c t

Objective:To provide current insights into the opinions, attitudes, and knowledge of menopausal women in Asia regarding menopause and hormone replacement therapy (HRT).

Study design:Cross-sectional.

Main outcome measures:Between January 2006 and February 2006, 1000 postmenopausal women from China, Malaysia, Taiwan, Thailand and Hong Kong were interviewed to determine postmenopausal symptoms, HRT use and knowledge, breast discomfort and knowledge of breast cancer risks, and sexual function.

Results:Almost all women reported experiencing postmenopausal symptoms. Sleeplessness (42%) was reported as the main reason for seeking treatment. On average, 54% of women were aware of HRT, despite the fact that most (38%) were unable to mention any associated beneﬁts. Most women had used natural or herbal treatments (37%) for the alleviation of menopausal symptoms. Only 19% had received HRT. 27% of respondents reported having breast discomfort, while 70% reported performing self-breast examinations. 53% of women had never received a mammogram, despite breast cancer concern (50%).

24% of women described HRT as being a risk factor for breast cancer. Most women and their partners reported no reductions in sexual function (66 and 51%, respectively), while 90% of respondents did not seek treatment for reduced sexual function. In the event of sexual dysfunction, 33% of women replied that they would be willing to seek treatment.

Conclusions:Many Asian women experience postmenopausal symptoms that are often left untreated (due to the acceptance of menopause as a natural process) or treated with herbal/natural remedies. There was a general lack of knowledge among these women regarding treatment options, HRT, and possible risks associated with HRT. A more concerted effort should be made to better disseminate information regarding the pathogenesis and risk factors associated with breast cancer, menopause, and menopausal symptoms to Asian women.

1. Introduction

Postmenopausal hormone replacement therapy (HRT) with estrogen or estrogen plus progestogen is widely considered to be the therapeutic standard for treatment of vasomotor symptoms and protection from chronic diseases[1]. Yet with the publication of ﬁndings from studies such as the Heart and Estrogen/Progestin Replacement Study[2], the Women’s Health Initiative (WHI)[3],

∗ Corresponding author. Tel.: +886 7 733 6676; fax: +886 7 733 5099.

E-mail address:[email protected](K.-E. Huang).

and the Million Women Study[4], the assumptions underlying the putative effects of HRT (in particular, estrogen plus progestin therapy) have undergone a stringent paradigm shift, with radical public perception changes reﬂected in altered prescribing practices[5].

A study of HRT and menopause in Europe has revealed that while women appear to be well-informed regarding the issues (83%), 40–50% reported having negative feelings towards HRT, despite the high prevalence of postmenopausal symptoms[6]. Whereas some women opted for natural remedies, the majority did not opt for HRT because of the risks (breast cancer and side effects). Of the few post- WHI studies conducted in Asia, two recent retrospective studies evaluating changes in prescription use of HRT in Taiwan reported a pronounced decline in use[7], with college-educated women less 0378-5122/$ – see front matter© 2009 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.maturitas.2009.11.015

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likely to be prescribed HRT compared to lesser educated women [8]. Similar studies in Thailand revealed that 67% of Thai women knew about HRT, and that only 4% of these women were aware of the WHI, even though one-half of all previous users of HRT discontinued therapy following publication of the WHI results[9]. Several studies conducted in Hong Kong (following publication of the WHI) revealed that only 24% of women were familiar with HRT[10], while 76% had never used any form of therapy nor ever thought of using HRT prior to being interviewed[11]. Caution should be taken, however, in extrapolating from these results for the following reasons:

(1) the studies reported by Huang’s group[7,8]relied on a retrospective review of the National Health Insurance database records;

(2) the studies reported by Chaikittisilpa’s group[9]employed an non-validated self-completed questionnaire; and (3) the participants of Ngai’s study[11]were not randomized, and therefore not representative of a postmenopausal population sample. Finally, as of writing, there exists no large, post-WHI study of the perceptions of menopause or HRT in women from other regions in Asia, such as China and Malaysia.

The objective of this Asian Menopause Survey was to provide current insight into the opinions, attitudes, and knowledge of Asian (China, Hong Kong, Malaysia, Taiwan, and Thailand) menopausal women regarding menopause and HRT, with a focus on perceptions pertaining to breast cancer, breast cancer risks, and sexual function.

Such information is clearly needed to facilitate the implementation of public health policies in these countries that focus on improving women’s knowledge regarding the beneﬁts and risks of HRT and the potential impact (both positive and negative) of this therapy on quality of life.

2. Materials and methods 2.1. Participants

This cross-sectional survey was conducted between January 2006 and February 2006 in ﬁve Asian countries (China, Hong Kong, Malaysia, Taiwan, and Thailand). A total of 1000 women took part in the study (China,n= 300; Hong Kong,n= 100; Malaysia,n= 300;

Taiwan,n= 150; Thailand,n= 150). Participants were interviewed face-to-face following street interception or door-to-door visits.

Interviews were conducted by Synovate Healthcare (Kuala Lumpur, Malaysia), a specialist healthcare division of the Synovate Group and leading international market research ﬁrm. Eligible women were 45–60 years of age and met the following inclusion: (1) had completed secondary education or higher; (2) had spent an average amount of money (or more) on healthcare; (3) had consulted with a general practitioner, internal medicine physician, or obstetrician and gynecologist at least once within the preceding two years; and (4) were postmenopausal, but not >5 years beyond menopause.

Given the inclusion criteria, street interceptions and door-to-door visits were focused in middle class communities, rather than poorer urban settings.

Sample size was determined by examining eligible women in each country and ensuring that sampling error for a proposed sample was <10%. The selection process was based on quota sampling for age ranges (30%, 50%, and 20% for ages 45–49, 50–55, and 56–60, respectively) to ensure that the sample was representative of the overall population of menopausal women from the ﬁve different countries. The survey was continued until the quota was met for each country.

2.2. Interview

Two pilot studies were initially performed to identify potential problems regarding the ﬂow of questions and length of the inter-

view. In these pilot studies quality control (QC) assessments were performed by the Synovate Healthcare QC department for at least 20% of the sample.

Women were interviewed in their native language by trained female interviewers. Native translations of the questionnaire were prepared by translators experienced in cross-cultural adaptations of health questionnaires and were validated by means of pilot testing on two separate occasions using a select group of women from each of the ﬁve participating countries. Discrepancies and uncertainties were reviewed and reconciled by consensus. The questionnaire also underwent internal validation by a panel con- sisting of researchers from all ﬁve countries. Ethical approval was obtained from local institutes and ethical committees.

The average interview duration was approximately 20 min. The structured questionnaire consisted of multiple-choice questions that were divided into the following categories:

(1) Demographics.

(2) Breast discomfort (prevalence and impact) and perceptions, knowledge of breast cancer risks, as well as treatment options (e.g. HRT, herbal treatments).

(3) Postmenopausal symptoms (prevalence and impact); sources of menopause information.

(4) HRT (usage, knowledge, experience, and women’s attitudes and opinions).

(5) Sexual function (prevalence and impact of reduced sexual functioning and current intercourse frequency) and attitudes regarding treatment options on 10-point scales. These scales are similar to the visual analog pain score scale. For example, subjects were asked questions such as “How would you rate your level of sexual desire and interest in the past three months on a scale of 1 to 10?”

2.3. Statistical analysis

Continuous variables (sexual desire scores) were compared by analysis of variance, while categorical variables were compared by Chi-square test; the Fisher exact test was used when >20% of categorical variables had expected numbers <5 for responses. Cate- gorical data are represented by number (%) and continuous data are presented as the mean±standard deviation. All statistical assessments were two-sided and evaluated at the 0.05 level of statistical signiﬁcance. Statistical analyses were performed using SPSS statistical software (SPSS Inc., Chicago, IL).

3. Results 3.1. Demographics

Table 1summarizes the demographic characteristics of the participating women. Statistical signiﬁcance was observed between the ﬁve different countries with respect to education, marital status, number of children, medical history (osteoporosis, diabetes mellitus, hypertension) and sexual desire (P< 0.05 for all).

3.2. Breast discomfort and knowledge of breast cancer risk

Women generally replied negatively to having a history of breast discomfort (Table 1), with women from Hong Kong reporting the highest incidence of breast discomfort. Most women reported performing self-breast examinations, but having never received a mammogram, despite worries about breast cancer. Of the women who reported having a history of breast discomfort, 56% had complained of sore breasts, 24% breast ten- derness, 11% suspicious tissues or lumps upon palpation, 10%

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Table 1

Demographics of participants stratiﬁed with respect to country.

Total (n= 1000) China (n= 300) Hong Kong (n= 100) Malaysia (n= 300) Taiwan (n= 150) Thailand (n= 150) P-value Age (years)

45–49 317 (31.7%) 90 (30.0%) 29 (29.0%) 105 (35.0%) 47 (31.3%) 46 (30.7%)

0.955

50–55 481 (48.1%) 150 (50.0%) 51 (51.0%) 135 (45.0%) 72 (48.0%) 73 (48.7%)

56–60 202 (20.2%) 60 (20.0%) 20 (20.0%) 60 (20.0%) 31 (20.7%) 31 (20.7%)

Education

Secondary 701 (70.1%) 211 (70.3%) 96 (96.0%) 287 (95.7%) 42 (28.0%) 65 (43.3%)

<0.001^*

College 215 (21.5%) 80 (26.7%) 0 (0.0%) 9 (3.0%) 98 (65.3%) 28 (18.7%)

University/postgraduate 84 (8.4%) 9 (3.0%) 4 (4.0%) 4 (1.3%) 10 (6.7%) 57 (38.0%)

Marital status

Married/living with a partner 891 (89.1%) 299 (99.7%) 90 (90.0%) 265 (88.3%) 133 (88.7%) 104 (69.3%)

<0.001^*

Single 109 (10.9%) 1 (0.3%) 10 (10.0%) 35 (11.7%) 17 (11.3%) 46 (30.7%)

Number of children

0 37 (3.7%) 0 (0.0%) 5 (5.0%) 5 (1.7%) 7 (4.7%) 20 (13.3%)

<0.001^*

1 321 (32.1%) 241 (80.3%) 22 (22.0%) 18 (6.0%) 17 (11.3%) 23 (15.3%)

2 281 (28.1%) 46 (15.3%) 46 (46.0%) 58 (19.3%) 73 (48.7%) 58 (38.7%)

>3 361 (36.1%) 13 (4.3%) 24 (24.0%) 219 (70.3%) 53 (35.3%) 49 (32.7%)

Medical history

Osteoporosis 151 (15.1%) 66 (22.0%) 22 (22.0%) 19 (6.3%) 39 (26.0%) 18 (12.0%) <0.001^*

Thrombosis 14 (1.4%) 5 (1.7%) 0 (0.0%) 3 (1.0%) 3 (2.0%) 3 (2.0%) 0.639

Renal problems 15 (1.5%) 4 (1.3%) 0 (0.0%) 2 (0.7%) 6 (4.0%) 3 (2.0%) 0.057

Diabetes mellitus 58 (5.8%) 12 (4.0%) 1 (1.0%) 35 (11.7%) 6 (4.0%) 14 (9.0%) <0.001^*

Hypertension 100 (10.0%) 18 (6.0%) 3 (3.0%) 42 (14.0%) 6 (4.0%) 31 (20.7%) <0.001^*

History of breast discomfort

Yes 271 (27.2%) 89 (30.0%) 42 (42.0%) 50 (16.7%) 56 (37.3%) 56 (27.2%)

<0.001^*

No 725 (72.8%) 208 (70.0%) 58 (58.0%) 249 (83.3%) 116 (77.3%) 94 (62.7%)

Self-breast examinations

Yes 700 (70.0%) 209 (69.7%) 86 (86.0%) 215 (71.7%) 98 (65.3%) 92 (61.3%)

0.001^*

No 300 (30.0%) 91 (30.3%) 14 (14.0%) 85 (28.3%) 52 (34.7%) 58 (38.7%)

History of mammogram

Yes 472 (47.4%) 173 (57.9%) 57 (57.0%) 94 (31.6%) 85 (56.7%) 63 (42.0%)

<0.001^*

No 524 (52.6%) 126 (42.1%) 43 (43.0%) 203 (68.4%) 65 (43.3%) 87(58.0%)

Worried about breast cancer

Yes 498 (50.1%) 113 (37.8%) 64 (64.0%) 173 (58.4%) 90 (60.0%) 58 (38.7%)

<0.001^*

No 497 (49.9%) 186 (62.2%) 36 (36.0%) 123 (41.6%) 60 (40.0%) 92 (61.3%)

Sexual desire (n= 897) 3.9±1.77 3.99±1.42 4.20±1.49 4.08±1.96 3.89±1.78 3.19±2.05 <0.001^*

*Indicates statistical signiﬁcance (P< 0.05)

breast swelling, and 8% increased breast density. When ques- tioned about their knowledge of known risk factors for breast cancer development (Table 2), women reported most knowledge (by order of extent) regarding hereditary factors, HRT, natural hormone levels, and increased breast density. Signiﬁ- cant differences among different countries were observed for the following risk factors: increased breast density, natural hormone levels, oophorectomy, HRT, hereditary factors, and “don’t know”.

3.3. Postmenopausal symptoms

The prevalence of postmenopausal symptoms is summarized in Table 3. Overall, Malaysian women reported the lowest incidence of postmenopausal symptoms, while women from Thailand reported the highest incidence of symptoms. Women from Hong Kong reported the highest incidence of irritability, headaches/migraines, reduced sex drive and vaginal dryness. The prevalence of all postmenopausal symptoms, except headaches/migraines, was

Table 2

Knowledge of risk factors for breast cancer development stratiﬁed with respect to country (n= 1000).

Total (n= 1000) China (n= 300) Hong Kong (n= 100) Malaysia (n= 300) Taiwan (n= 150) Thailand (n= 150) P-value

Increased breast density 206 (20.6%) 57 (19.0%) 43 (43.0%) 73 (24.3%) 10 (6.7%) 23 (15.3%) <0.001^*

Natural hormone levels 243 (24.3%) 81 (27.0%) 22 (22.0%) 70 (23.3%) 13 (8.7%) 57 (38.0%) <0.001^*

Birth of ﬁrst child at an older age 148 (14.8%) 47 (15.7%) 17 (17.0%) 53 (17.7%) 11 (7.3%) 20 (13.3%) 0.052

Premenopausal weight gain 156 (15.6%) 37 (12.3%) 24 (24.0%) 44 (14.7%) 24 (16.0%) 27 (18.0%) 0.070

Late menopause 133 (13.3%) 47 (15.7%) 15 (15.0%) 40 (13.3%) 9 (6.0%) 22 (14.7%) 0.064

Waist to hip ratio 27 (2.7%) 2 (0.7%) 6 (6.0%) 13 (4.3%) 1 (0.7%) 5 (3.3%) 0.006^*

Menarche before 12 years age 69 (6.9%) 18 (6.0%) 5 (5.0) 21 (7.0%) 15 (10.0%) 10 (6.7%) 0.525

Oophorectomy 135 (13.5%) 24 (8.0%) 11 (11.0%) 45 (15.0%) 18 (12.0%) 37 (24.7%) <0.001^*

HRT 244 (24.4%) 14 (4.7%) 51 (51.0%) 40 (13.3%) 59 (39.3%) 80 (53.3%) <0.001^*

Hereditary factors 495 (49.5%) 133 (44.3%) 61 (61.0%) 157 (52.3%) 99 (66.0%) 45 (30.0%) <0.001^*

Don’t want to say/Don’t know 146 (14.6%) 53 (17.7%) 0 (0.0) 65 (21.7%) 21 (14.0%) 7 (4.7%) <0.001^*

HRT: hormone replacement therapy.

*Indicates statistical signiﬁcance (P< 0.05).

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Table 3

Prevalence of postmenopausal symptoms stratiﬁed with respect to country (n= 1000).

Hot ﬂashes 496 (49.9%) 170 (57.0%) 58 (58.0%) 89 (30.1%) 74 (49.3%) 105 (70.0%) <0.001^*

Depression 377 (37.9%) 105 (35.2%) 59 (59.0%) 57 (19.1%) 67 (44.7%) 89 (59.3%) <0.001^*

Sleeplessness 615 (61.7%) 196 (65.8%) 60 (60.0%) 160 (53.7%) 80 (53.3%) 119 (79.3%) <0.001^*

Irritability 598 (60.0%) 196 (65.3%) 75 (75.0%) 152 (51.2%) 68 (45.3%) 107 (71.3%) <0.001^*

Mood swings 557 (55.8%) 178 (59.3%) 67 (67.0%) 131 (44.0%) 64 (42.7%) 117 (78.0%) <0.001^*

Headaches/migraines 560 (56.2%) 170 (56.9%) 63 (63.0%) 163 (54.7%) 78 (52.0%) 86 (57.3%) 0.500

Reduced sexual drive 537 (55.9%) 163 (55.4%) 73 (73.0%) 137 (50.0%) 68 (47.2%) 96 (64.4%) <0.001^*

Vaginal dryness 361 (37.4%) 92 (31.0%) 51 (51.0%) 81 (29.6%) 70 (47.9%) 67 (45.0%) <0.001^*

Urinary incontinence 222 (22.4%) 44 (14.7%) 33 (33.0%) 51 (17.5%) 35 (23.3%) 59 (39.3%) <0.001^*

Any symptom 921 (92.3%) 289 (93.7%) 98 (98.0%) 259 (86.9%) 135 (90.0%) 148 (98.7%) <0.001^*

statistically signiﬁcant between all countries (all P< 0.001). As shown in Fig. 1, sleeplessness was the symptom which most prompted women to seek treatment, followed by hot ﬂashes, headaches/migraine, and mood swings.

3.4. Hormone replacement therapy

On average, 54% of women had heard, seen, or read about HRT. The awareness was generally higher in Taiwan (90%) and Thailand (95%) compared with in other countries. Greater than 90% of Thai women had knowledge of natural or herbal treatments for menopause symptoms. Fifty-three percent of Chinese women reported having no knowledge of any type of treatment for menopausal symptoms.

Fig. 2summarizes the ﬁndings with regards to knowledge pertaining to risk factors associated with HRT. The most fre- quently mentioned risk factor associated with HRT was breast cancer development (29%, range: 10–55% [China to Thailand]).

Most women had received information regarding the risk fac-

tors of HRT from friends (21%), physicians (13%), or print and electronic media. Approximately 50% of participants had learned about the risk factors of HRT within the preceding 3 years.

When asked about their general perceptions of HRT, 41% of women reported as having somewhat positive feelings, while 35%

reported having somewhat negative feelings. Thai women had more positive perspectives with respect to HRT (58% were somewhat positive and 11% very positive). Women in China had more negative perspectives with respect to HRT (38% were somewhat negative and 23% very negative).

The ﬁndings pertaining to perceived health beneﬁts of HRT are summarized inTable 4

. Of note, over one-third of women were unable to mention any benefits of HRT. Statistical significance was observed between all countries for all types of perceived benefits of HRT (P< 0.001).

Taiwanese and Thai women tended to mention alleviation of menopausal symptoms as a beneﬁt of HRT, while Thai women also mentioned the prevention of osteoporosis (brittle bones) as a ben-

Fig. 1.Summary of primary postmenopausal symptoms which led study participants to seek treatment. Based on answers obtained from respondents who sought treatment (n= 390).

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Fig. 2.Summary of participant perceived main risk factors associated with hormone replacement therapy. Based on answers obtained from all respondents (n= 1000).

eﬁt. Most Chinese women were unable to mention any beneﬁts of HRT.

Overall, 45% of women had never taken any treatments, and 59%

were not currently taking any treatments for menopause symptoms. The percentage of the total study group ever having used HRT was 19%, whereas only 7% of women were taking HRT at the time of being interviewed. Very few Chinese women reported previous use of HRT (9%), and even fewer (2%) current HRT use. Taiwanese and Thai women reported the highest previous (33% and 25%, respectively) and current use of HRT (10% and 12%, respectively). Overall, 37% of women had used natural or herbal treatments for the alleviation of menopausal symptoms, while 32% of women reported current use of natural or herbal treatments. Most Thai women (84%) reported previous use of natural remedies, with 85% reporting current use.

Among the women currently using HRT who stopped previously and the women who had taken HRT in the past but were no longer using, the reasons for discontinuing HRT were diverse. These are summarized inFig. 3. Concerns regarding breast cancer were most common reason for discontinuation.

3.5. Sexual function

Hong Kong women scored the highest sexual desire score, followed by Malaysian women, and Chinese women, with Thai women scoring the lowest (Table 1). The difference between these countries was significant (P< 0.001).Table 5summarizes the intercourse frequency for the women studied. Most women reported sexual activity 2 or 3 times a month. There was a significant difference in the frequency of current intercourse between the five countries (P< 0.001).

Most women felt reductions in sexual function somewhat negatively impacted the relationship with their partner (61.5%), as well as feelings of femininity (69%) and quality of life (69%). Most women and their partners claimed that they did not experience a period of reduced sexual function (66% and 51%, respectively).

Table 6 summarizes the ﬁndings regarding the willingness of participants to improve sexual function in the event of dysfunction. On average, only one-third of women were willing to seek treatment to improve sexual function. There was a signiﬁcant difference in the willingness to seek all forms of treat-

Table 4

Perceived beneﬁts of hormonal therapy stratiﬁed with respect to country (n= 1000).

Total (n= 1000) China (n= 300) Hong Kong (n= 100) Malaysia (n= 300) Taiwan (n= 150) Thailand (n= 150) P-value Alleviation of menopausal symptoms 360 (36.0%) 56 (18.7%) 42 (42.0%) 86 (28.7%) 90 (60.0%) 86 (57.3%) <0.001^* Prevention of osteoporosis/brittle bones 115 (11.5%) 8 (2.7%) 4 (4.0%) 20 (6.7%) 15 (10.0%) 68 (45.3%) <0.001^*

Prevention of heart disease 46 (4.6%) 4 (1.3%) 0 (0.0%) 16 (5.3%) 4 (2.7%) 22 (14.7%) <0.001^*

Improvement of general health 192 (19.2%) 17 (5.7%) 9 (9.0%) 73 (24.3%) 20 (13.3%) 73 (48.7%) <0.001^*

Improved of sex drive 90 (9.0%) 14 (4.7%) 9 (9.0%) 34 (11.3%) 9 (6.0%) 24 (16.0%) 0.001^*

General well-being; quality of life 162 (16.2%) 24 (8.0%) 0 (0.0%) 67 (22.3%) 10 (6.7%) 61 (40.7%) <0.001^*

Others 109 (10.9%) 15 (5.0%) 57 (57.0%) 8 (2.7%) 21 (14.0%) 8 (5.3%) <0.001^*

Don’t know 384 (38.4%) 200 (66.7%) 19 (19.0%) 116 (38.7%) 35 (23.3%) 14 (9.3%) <0.001^*

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Fig. 3.Summary of participant reasons for discontinuing hormone replacement therapy. Based on answers from respondents who had previously used or were using hormone replacement therapy but had stopped treatment in the past (n= 64).

Table 5

Frequency of sexual activity for participants from each country (n= 1000).

Not at all 170 (17.0%) 31 (10.3%) 10 (10.0%) 43 (14.3%) 27 (18.0) 59 (39.3%)

<0.001^*

Once every few months 166 (16.6%) 64 (21.3%) 19 (19.0%) 49 (16.3%) 26 (17.3%) 8 (5.3%)

Once a month 184 (18.4%) 75 (25.0%) 22 (22.0%) 37 (12.3%) 23 (15.3%) 27 (18.0%)

2 or 3 times a month 225 (22.5%) 85 (28.3%) 32 (32.0%) 44 (14.7%) 38 (25.3%) 26 (17.3%)

Once a week 103 (10.3%) 28 (9.3%) 14 (14.0%) 28 (9.3%) 19 (12.7%) 14 (9.3%)

2 or 3 times a week 45 (4.5%) 4 (1.3%) 3 (3.0%) 28 (9.3%) 4 (2.7%) 6 (4.0%)

More than once a day 4 (0.4%) 0 (0.0%) 0 (0.0%) 3 (1.0%) 1 (0.7%) 0 (0.0%)

Don’t want to share 103 (10.3%) 13 (4.3%) 0 (0.0%) 68 (22.7%) 12 (8.0%) 10 (6.7%)

Table 6

Willingness to improve sexual function in the event of dysfunction (n= 1000).

Seek treatment 307 (32.7%) 51 (17.6%) 67 (67.0%) 123 (45.9%) 38 (27.1%) 28 (20.0%) <0.001^*

Take medication/drugs 244 (26.3%) 47 (16.3%) 39 (39.4%) 114 (43.7%) 28 (20.0%) 16 (11.4%) <0.001^*

Take hormone replacement therapy 194 (21.4%) 26 (9.2%) 37 (37.4%) 71 (28.9%) 30 (21.7%) 30 (21.4%) <0.001^*

ment between women from the different countries (P< 0.001).

Chinese women were the least willing to seek treatment to improve sexual function, whereas women from Hong Kong and Malaysia were the most willing to seek treatment in the form of medications, or for women from Hong Kong, in the form of HRT.

4. Discussion

Parallel to the European Menopause Survey 2005[6], the Asian Menopause Survey is the ﬁrst large Asian study to investigate the opinions, attitudes, and knowledge of postmenopausal women regarding menopause and HRT, with a focus on perceptions of

breast cancer, breast cancer risks, and sexual function in line with WHI[3]and the Million Women Study[4].

Findings from a previously published study indicated that almost all European women experience postmenopausal symptoms and are affected by the symptoms[6]. In the present study, we also found that a very high percentage of women (>90%) experienced some form of postmenopausal symptom. Several previous studies have assessed postmenopausal symptoms in Asian pop- ulations[12,13]. Shea reported markedly lower prevalence rates for hot ﬂashes, sleeplessness, depression, headache, irritability and vaginal dryness in a population of Chinese women aged between 40 and 60 than those reported herein[12]. However, it must be noted that the study population included peri-, pre- and post-

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menopausal women, perhaps accounting for the lower prevalence rates. In another study of menopausal symptomatic women from 11 different Asian countries (including those in the present study), Haines et al. reported similar or slightly higher prevalence rates of irritability, sleeplessness, mood swings, hot ﬂashes, reduced sex drive and vaginal dryness [13]. The higher prevalence rates are presumably due to the fact that only symptomatic women were included in the study, in contrast to our study where this was not an inclusion criterion.

In terms of treatment, we found that 59% of women were not currently receiving treatment for postmenopausal symptoms. This is virtually identical to the percentage reported in the European Menopause Survey[6]. For women from countries in which the incidence of symptoms were comparatively high (i.e. Thailand and Hong Kong), respondents were more likely to be more informed of the treatment options available, and more likely to start HRT. Wider use of HRT, which also entailed a greater degree of acceptance or knowledge of its risks and beneﬁts, was consistent with attitudes previously reported for European women[6]. In the current study, women from Thailand were found to have more positive feelings about HRT, while women from Hong Kong generally reported more negative feelings towards HRT.

Awareness of HRT as a treatment option for menopausal symptoms was low, with over 30% of women being unable to mention any beneﬁts of HRT. This is comparable to the relatively low level of awareness reported in Spanish women[6]. The low awareness of HRT may be due to the lower prevalence of women having ever used HRT in countries such as China and Malaysia. In China, the low prevalence of using HRT can be attributable to a general lack of knowledge regarding treatment; while in Malaysia, the low prevalence of HRT use may be explained by the general low incidence of symptoms. Over one-third of women who reported taking HRT were doing so for current symptom relief, but only slightly over 10% of women reported knowing that HRT could prevent postmenopausal osteoporosis. Thai women reported the highest familiarity with HRT (95%) and positivity towards this treatment (69%).

In terms of reasons for HRT discontinuation, the results of this study are in disagreement with several previous published results, where HRT use was discontinued primarily following the resolu- tion of menopausal symptoms[4,14]. In this study, discontinuation of HRT was primarily due to concerns pertaining to breast cancer risk and the actual risk of breast, such as 38% of Taiwanese women reported discontinuing HRT on the basis of actual risk of breast cancer development. Interestingly, a high percentage of Chinese women (40%) reported weight gain being the most inﬂuential reason for stopping HRT. This ﬁnding is comparable to the results of a European study[6], in which weight gain was a concern in 29% of French women on HRT.

The ﬁndings of this survey suggest that Asian women (exclud- ing those from Thailand) were generally uninformed not only in their knowledge of HRT, but also breast cancer risks, when compared to European women[6]. European women were well-aware of heredity factors (83%) and HRT (59%) as risk factors for breast cancer. However, only 50% of women in our study were aware of heredity risk factors, and only 24% of women were aware of HRT as a risk factor (mostly women from Thailand, Hong Kong and Taiwan).

Women in this study also generally reported a negative history of breast discomfort, and regular self-breast examinations, perhaps due to the fact that one-half of the respondents were worried about breast cancer, and would be “alarmed” if receiving a recall for a mammogram. Despite this, over 75% of women had never seen, heard, or read anything about breast density. Breast density may decrease mammographic accuracy[15], and like heredity factors, age at ﬁrst birth, early menarche and late menopause have been correlated with breast cancer risk. These results reveal

the necessity of continuing education on breast cancer risks in Asia.

Even though a majority of women in the current study reported a negative impact on the quality of life from reduced libido, only slightly less than one-third of women were willing to seek treatment. This is not to say that women were entirely accepting of decreased sexual function as a natural course of aging since 48%

of all respondents agreed that sex was an important aspect of marital life, and 75% reported a willingness to discuss the subject if their physician took the initiative. Notably, nearly 80% of women did not search or had never sought information regarding reduced sexual function, and more than half believed that no solutions existed to resolve sexual dysfunction. These results may reﬂect cultural perceptions of sexual dysfunction, and the lack of education on this subject. This leads us to suggest that physicians be encouraged to routinely ask menopausal patients about their sexual problems to better facilitate diagnosis and treatment.

This study has a number of limitations that warrant mention. Firstly, due to the inclusion criteria (leading to the exclusion of women from lower socioeconomic backgrounds), the study ﬁndings cannot be considered representative of the different pop- ulations as a whole. Along these lines, the differences described herein may in reality be more extreme, given the inherent overall variability in the level and quality of education between the Asian countries included. Future studies should incorporate broader socioeconomic population samples. A further limitation is that fact that chronic disease conditions were self-reported. Finally, it must be noted that this study has many dimensions, and that the differences among sites are difﬁcult to follow beyond each individual area. Thus, further studies examining the local and cultural differences are warranted.

5. Conclusions

The Asian Menopause Study revealed that many women experience postmenopausal symptoms that are often left untreated due to acceptance of menopause as a natural process of life or are treated with herbal/natural remedies due to a lack of knowledge of the treatment options available. The largest hurdle for these women preventing them from potentially taking HRT for postmenopausal symptoms was fear of increased breast cancer risk.

It is essential that detailed information regarding the pathogenesis and risk factors associated with breast cancer, menopause, and menopausal symptoms (including sexual dysfunction) be available to allow women living in Asia to make informed decisions regarding potential treatment for postmenopausal symptoms.

Contributors

We declare that all the listed authors participated in supervising and serving as consultant of the interview, and also collecting and reviewing the data and that we have seen and approved the ﬁnal version. In addition to the above, Dr. Ko-En Huang conducted in the writing and editing of the manuscript.

Competing interest None.

Ethical approval

Ethical approval was obtained from local institutes and ethical committees.

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Acknowledgement

This study was supported by a research grant from Organon, Schering Plough Co.

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