Factors affecting shared decision-making concerning menopausal hormone therapy

Abstract

Menopausal hormone therapy (MHT) is an effective treatment for menopause-related symptoms. Menopause management guidelines recommend a personalized approach to menopause care, including MHT use. Decision-making around menopause care is a complex, iterative process influenced by multiple factors framed by perspectives from both women and healthcare providers (HCPs). This narrative review aims to summarize evidence around factors affecting decision-making regarding menopause-related care. For HCPs, the provision of individualized risk estimates is challenging in practice given the number of potential benefits and risks to consider, and the complexity of the data available, especially within time-limited consultations. Women seeking menopause care have the difficult task of making sense of the benefit versus risk profiles to make choices in line with their decisional needs influenced by sociocultural/economic, educational, demographic, and personal characteristics. The press, social media, and influential celebrities also impact the perception of menopause and decision-making around it. Understanding these factors can lead to improved participation in shared decision-making, satisfaction with the decision and decision-making process, adherence to treatment, reduced decisional regret, efficient use of resources, and ultimately long-term satisfaction with care.

INTRODUCTION

Menopause is the permanent cessation of menstrual cycles and ovarian function. In the UK, menopause occurs at a median age of 51 years, typically between 45 and 55 years.¹ The onset of menopause-related symptoms is highly variable in the years leading up to menopause (termed the “perimenopause”), and symptoms can begin well before menstrual periods stop.² It is estimated that currently there are ∼13 million women who are perimenopausal or postmenopausal in the UK. By the year 2030, it is projected that ∼1.2 billion women will be affected worldwide by symptoms related to menopause.³

The hormonal changes associated with menopause, including reductions in estrogen, progesterone, and androgens, can impact physical, emotional, mental, and social well-being. Around 80% of women experience some symptoms related to menopause,¹ and a quarter describe their symptoms as severe.⁴ The average duration of symptoms is 7 years,⁵ but for one third of women symptoms last longer, with one in 10 experiencing symptoms for 12 years.¹ Symptoms may include, but are not limited to, hot flashes, night sweats, genitourinary symptoms, mood changes, insomnia, and memory changes.

Menopausal hormone therapy (MHT), also known as hormone replacement therapy (HRT), is a pharmacological preparation containing estrogen, with or without a progestogen, and occasionally testosterone, for the relief of menopause-related symptoms. MHT is effective and is the most commonly prescribed treatment for the management of symptoms related to menopause. The benefit versus risk profile of MHT is complex and contingent on each individual woman's personal demographic characteristics, symptomology, and medical background. National and international menopause management guidelines, including the National Institute for Health and Care Excellence,¹ the British Menopause Society,⁶ the International Menopause Society,⁷ the European Menopause and Andropause Society,⁸ and the North American Menopause Society,⁹ all recommend a comprehensive, personalized approach to menopause management.

The number of potential benefits and risks to consider, together with the uncertainty of the available evidence, makes holistic and individualized management of menopause challenging in frequently time-constrained clinical consultations. For example, general practice appointments in the UK only last 9.2 min on average.¹⁰ This narrative review offers a greater understanding of factors that influence how decisions are made regarding menopause care and awareness of women's counseling needs to provide context to the challenges faced by women and their healthcare providers (HCPs) in shared decision-making concerning MHT.

MATERIALS AND METHODS

This narrative review aims to summarize evidence around factors affecting decision-making regarding MHT use. To provide the reader with context underlying the complexity around this topic, seminal studies that have influenced risk perceptions around MHT and the importance of shared decision-making in menopause care are first described. Subsequently, factors affecting decision-making regarding MHT use are explored.

Findings from these sections are derived from publications identified using a Medline search for publications from January 1, 2000 to November 1, 2022 using the terms “menopause” AND “decision-making” AND “MHT” OR “menopause hormonal therapy” OR “HRT” OR “hormone replacement therapy” conducted on November 16, 2022. The abstracts returned in the search were reviewed and articles most relevant to decision-making in menopause were selected and reviewed by K.K. and S.N. Only articles published in English and with full text available were included. Guidelines and position statements from national and international menopause management during the 2000–2022 time period on menopause management were also reviewed.

RESULTS

Landmark studies that influenced risk perceptions concerning MHT

Since becoming available in the UK in 1965, the use of MHT rose steadily over the following three decades before declining precipitously following the publication and premature termination of the Women's Health Initiative (WHI) trial in 2002,¹¹ as well as the Million Women Study (MWS) in 2003.¹²

WHI trial

The WHI trial was the largest randomized controlled trial conducted in the United States between 1993 and 2004 that aimed to evaluate the effect of MHT on the most common causes of death and disability in postmenopausal women, such as cardiovascular disease (CVD), cancer, and osteoporosis.¹¹ In the combined estrogen and progestogen arm (n = 16,608), the incidence of breast cancer, coronary heart disease, stroke, and pulmonary embolism were deemed to outweigh the benefits of decreased risk of hip fractures and colorectal cancer, leading to premature termination after a mean of 5.2 years follow-up.¹¹ Similarly, in the estrogen-only arm (n = 10,739), concerns regarding an increased risk of ischemic stroke led to early termination after a mean of nearly 7 years follow-up.¹³ Following the release of these data, an urgent safety restriction of MHT was released by the UK regulatory authorities recommending that the lowest effective dose should be prescribed for relief of menopause-related symptoms.

Million Women Study

The MWS was an unprecedentedly large-scale observational study in the UK that aimed to investigate the effects of specific types of MHT on breast cancer incidence and mortality. Over one million women (n = 1,084,110) were recruited through 66 National Health Service (NHS) breast screening centers in England and Scotland between 1996 and 2001.¹² The first published findings in 2003 concluded that the current use of MHT was associated with an increased incidence of breast cancer and mortality, particularly when estrogen and progestogen were used in combination. Following the publication of the MWS findings, the UK Committee on Safety of Medicines reacted by issuing MHT prescribing advice to HCPs recommending that the lowest effective dose of MHT should be used for the shortest duration and that MHT should not be a first-line therapy for preventing osteoporosis in women older than 50 years.¹⁴

Impact of the landmark studies on risk perceptions concerning MHT

The widely publicized results from both the WHI trial and the MWS had profound effects on the uptake of MHT and in turn the lives of millions of women affected by menopause. Findings from the WHI trial were widely discussed in the popular press, with more than 200 stories published in major newspapers and magazines within a month following publication.¹⁵ Media portrayals of the WHI trial and the MWS affected women's use of MHT,¹⁵ such that in the UK, the proportion of new MHT prescriptions halved from 17,349 in 1996 to 9536 in 2005.¹⁶

Critiques of the limitations of the WHI trial have since emerged. These include the inclusion of women of older ages (up to 79 years) who may not have the same risks as younger women likely to present with menopause-related symptoms and benefit from MHT. Similarly, recruitment from breast cancer screening facilities in the MWS may have led to detection bias and recall bias as participants self-report current MHT use at the time of screening mammography. Despite this, in most countries, MHT uptake has never returned to the levels prior to publications of these landmark studies; indeed between 2002 and 2020, MHT prescriptions dropped by 84% in the United States without recovery.¹⁷

Complexities around the risk and benefits of MHT after the WHI trial and the MWS

Two decades from the publication of the WHI trial and the MWS, subsequent analyses and follow-up data have provided further insights into the risks and benefits of MHT. For example, with regard to breast cancer, long-term cumulative follow-up of the WHI trial found that prior estrogen-only MHT use was associated with a significant reduction in breast cancer incidence and mortality, while combined MHT use was associated with an increased incidence of breast cancer,¹⁸ although this was not associated with a significant increased risk of mortality.¹⁹ In contrast, a recent meta-analysis of observational studies (weighted heavily by the MWS) demonstrated an increased risk of breast cancer with both estrogen-only and combined MHT in a duration-dependent manner.²⁰ The French E3N cohort highlighted that the type of progesterone influences the risk of breast cancer,²¹ while the Finnish Cancer Registry suggested that only combined therapy was associated with an increased risk of breast cancer.²²

More recent studies provided data on the impact of modern MHT formulations and are thus more reflective of current practices. The mode of delivery has been demonstrated to impact the risks of MHT. Nested case-control studies²³ and a meta-analysis of observational studies²⁴ report that transdermal MHT appears to offer a favorable venous thromboembolism (VTE) risk profile compared to oral MHT and that the type of both estrogen and progestogen also impacted VTE risk. The timing of initiation and duration of MHT use also appears to affect risks associated with MHT use. Long-term, follow-up data from the WHI trial suggested that these risks may be influenced by women's age and time since menopause.²⁵ A Cochrane analysis²⁶ suggests that MHT started before the age of 60 or within 10 years of menopause is associated with reduced progression of atherosclerosis, coronary heart disease, deaths from CVD causes, and all-cause mortality.^{6, 9}

The diversity of findings described above highlights that the risks of MHT are nuanced and depend on specific formulation and patient-dependent factors. For logistical reasons and given the volume of evidence already available, it is unlikely that another large randomized controlled trial on MHT will be conducted. The absence of consistent outcomes on important clinical questions relating to menopause management has necessitated triangulation of evidence from observational studies and data from smaller randomized controlled trials and meta-analyses. The heterogeneous study designs and conflicting results between different studies make the interpretation of these findings a challenge. No single trial's findings can be extrapolated to all women as the restricted populations included in clinical trials may not fully represent the complex comorbidities seen in real world clinical practice.

Importance of shared decision-making in menopause care

Decision-making around the use of MHT should be taken in the context of its overall benefits in terms of symptom management and improving quality of life, as well as improving bone and cardiovascular health (in some women).^{8, 9} The benefits and risks should also be considered in comparison with lifestyle factors such as alcohol intake and obesity.²⁷ Recommendations for the use of the appropriate dose, route of administration, regimen, and duration need to be individualized to manage a woman's symptoms and to meet treatment goals with a periodic re-evaluation to determine an individual's benefit–risk profile. It is, therefore, imperative that these benefits and risks are conveyed clearly and accurately so that a woman can make an informed decision about what is important for her in the context of her values and circumstances.

When faced with multiple treatment options and their own benefit and risk profiles, shared decision-making is advocated. This refers to a collaborative process to support individuals to make decisions that are right for them.²⁸ In shared decision-making, clinicians and individuals aim to work together to understand available treatment options, their benefits and risks, and subsequently reach a decision using evidence-based, high-quality information, while taking into account the individual's personal preferences and values.

For shared decision-making to be successful in menopause care, it relies on the HCPs’ expert knowledge of the effectiveness, probable benefits, and potential harms of treatment options, including MHT, for each individual. HCPs must then be able to translate and communicate the probabilistic nature of the evidence in a manner that is understandable. Women receiving menopause-related care must also understand their own values, preferences, and attitudes toward risk in order to use the information provided to make informed decisions.

Shared decision-making is recognized by menopause-related guidelines as an effective consultation model. Women appreciate the provision of information, decision support, and adequate, dedicated consultation time.²⁹ Adopting a shared decision-making approach, putting the risks of MHT into perspective, explaining the statistics about published benefits and risks, and personalizing them for each individual can lead to high satisfaction and empowering consultations. Indeed, women value being treated as partners in the healthcare process.²⁹

Factors influencing decision-making regarding MHT use

Decision-making regarding menopause-related symptom management is complex. Women's decision-making on how to manage menopausal symptoms has been described as a nonlinear process consisting of iterative cycles in which women consider available options; evaluate benefit–risk profiles and the likely outcome of their decision; re-evaluate their decision; and instigate changes as required.³⁰ A study by Theroux and Taylor found that changes in personal and environmental situations are important to the evolving decision-making process. The duration spent at each stage varied from one woman to another. Some women progressed rapidly through the process, while others took a protracted period of time to do so and cycled back and forth among the phases; however, interestingly, this difference did not appear to be associated with a woman's final choice.³⁰

A systematic review of factors related to decision-making in menopause care classify factors into internal and external factors, each comprising two broad categories³¹ (Figure 1):

FIGURE 1

Factors affecting women's and healthcare providers’ perception of risk and shared decision-making. Abbreviations: MHT, menopausal hormone therapy; VTE, venous thromboembolism.

Internal factors:

1. Individual characteristics, which include demographics, menopause experience, and menopause-related symptoms experienced.

2. Values, attitudes, beliefs, and preferences, which include preferred treatment modalities, tolerance for risks and side-effects of treatment, and importance of quality of life as a threshold for treatment.

External factors:

• 3 Information about menopause and symptom-management, which include the amount, type, source, credibility, and availability of information regarding menopause and management options.
• 4 Healthcare context, which includes relationship, trust, perception of knowledge of HCPs, availability, and time.

The Ottawa Decision Support Framework

The Ottawa Decision Support Framework (ODSF) is a theoretical framework for decisions by women considering MHT.³² The ODSF aims to guide the assessment of patients’ decisional needs, provision of decision-support interventions, and evaluation of their effects on the quality of their decision, decision-making process, and impact of their decisions.³³

The factors identified from the aforementioned systematic review, when interpreted according to this framework, form part of the decisional needs, which are deficits that can adversely affect the quality of a decision.³³ Decisional needs encompass nonmodifiable factors including decision type/timing; personal and clinical needs; and modifiable factors including an unreceptive decisional stage, decisional conflict, inadequate knowledge, unrealistic expectations, unclear values, inadequate support, and lack of resources to make/implement the decision.³³ Decisional needs provide a structured framework when considering factors affecting decision-making in menopause-related care. Figure 2 summarizes women's and HCP's decisional needs identified in this narrative review using the ODSF and illustrates how decision-support tools fit into the process of shared decision-making to reach decisional outcomes.

FIGURE 2

Women's and healthcare providers’ decisional needs, and the role of a decision-support tool in shared decision-making. Abbreviations: HCP, healthcare provider; MHT, menopausal hormone therapy.

Women's personal and clinical needs

Cultural expectations are important for women's perception of menopause. For example, women from ethnic minority groups are less likely than White women to use MHT.³⁴ Asian women associate menstruation with a cleansing effect; cessation of menstruation is, therefore, associated with poor health and illness—a belief not commonly shared among Caucasian women.³⁵ Markers of affluence, including place of residence,^{36, 37} education,³⁷ and employment status,³⁸ have been shown to influence decisions to seek menopause-related treatments. MHT use was more frequently reported among women with high levels of education and who were residents in urban areas in Spain.³⁷ Similarly, more than twice as many women were prescribed MHT in the least deprived areas compared to the most deprived areas in the UK. A strong link has previously been demonstrated between health literacy score and knowledge about MHT.³⁹ The uptake of MHT prescription increased by 47% between 2022 and 2023 compared to 2021–2022 in England.⁴⁰ This coincided with the launch of the MHT prescription prepayment certificate in April 2023 which reduces prescription charges for women on repeat MHT prescription, thus illustrating the impact of costs on the uptake of MHT.⁴⁰

Experiences of menopause transition vary considerably. For some, symptoms can be troublesome with a negative impact on personal, interpersonal, and working lives,⁴¹ while others express pleasure toward the prospect of menstrual cessation, and in some cases, women are hopeful that menopause may bring about symptom improvements for conditions such as endometriosis and fibroids.⁴¹ Management decisions around menopause can provoke feelings of confusion, worry, anger, and grief likely due to the uncertainty about present needs and long-term outcomes of MHT use.^{30, 42} Powerful emotions affecting information processing have been linked to reduced openness to receive information about management options, which contribute to the unreceptive decisional stage.

HCPs’ personal and clinical needs

Physicians rely on personal experience and also are subject to a wide range of influences during the clinical decision-making process.⁴³ Physicians’ demographics and personal characteristics affect consultation and decision-making; for example, female physicians spend more time with their patients.^{44, 45} Physicians are found to be more likely to adopt new drugs earlier if they are involved and interact with their professional community; for example, having regular contact with colleagues in secondary or tertiary care settings.⁴⁶

Specific to menopause care, MHT prescription practices vary depending on a practitioner's gender,⁴⁷ ethnic background,⁴⁸ length of medical training,⁴⁷ specialty,⁴⁹ and geographical locations.⁵⁰ Newton et al. compared MHT prescriptions in Washington state between family practice physicians, gynecologists, and women's healthcare specialists (e.g., nurse practitioners and physician assistants), and nurse midwives. The study demonstrated that MHT is less frequently prescribed by younger providers and prescribing frequency was higher among midwives and women's healthcare specialists compared to gynecologists, family practice, and general internal medicine providers.⁵¹

The media and social media

The influence of the media and social media on decision-making around menopause care merits attention, though published evidence around this topic is scarce. Increased media and government representation on menopause resulted in rising demand for MHT-related consultations in primary care.⁵² Prescriptions of MHT in the UK nearly doubled⁵³ after the May 2021 airing of the documentary “Davina McCall: Sex, Myths and the Menopause”. Analysis of 440 menopause-related posts on Instagram, a leading photo/video-sharing platform, with the hashtag #menopause demonstrated that the top three categories of menopause-related posts are advertisement (48% included advertisements for nonpharmacological treatments, menopause-related services by HCPs, and personal fitness coaches), self-care (47.2%), and physical health (43.9%).⁵⁴ The pervasiveness of advertising, which targets individuals based on gender, age group, and interests, is concerning as it may be difficult to discern the differences between advertisement and evidence-based medical advice. Additionally, the majority of content in Instagram posts (such as weight loss and fitness) were infrequently listed in biomedical literature related to menopause.⁵⁴ Bioidentical hormone therapy has gained popularity among internet communities.⁵⁵ Numerous claims state that these therapies are less risky compared to US Food and Drug Administration (FDA)-approved MHT, often with limited scientific evidence, information on purity, bioavailability, and safety data.⁵⁶ Altogether, these suggest that there may be discrepancies between what is perceived to be important by women with menopause-related symptoms and HCPs. It is important to understand these discrepancies as these may be overlooked during clinical encounters. Social media is an avenue in which people can discuss sensitive issues and connect with others with common interests for peer support. While resources on the internet and social media may be well-intended, unfortunately plenty of misinformation and uncertainties remain; for example, there is conflicting information on the role of MHT in the prevention of dementia.⁵⁷

Factors limiting the adoption of shared decision-making in menopause care

Inadequate support and resources to make and implement decisions

Data on treatment decisions related to menopause demonstrated that MHT was prescribed the most following the initiative of a doctor and least at the suggestion of the patient.⁵⁸ Analysis of menopause-related consultations from Sweden demonstrated that MHT was prescribed even though the woman was indecisive or reluctant to use MHT, with the intention that the woman should derive her own conclusion after the consultation.⁵⁹ A nationwide survey from the Republic of Korea showed that many postmenopausal women played a limited role in decision-making on the use of MHT: 56.8% of primary care physicians reported that they explained the benefits and risks of MHT and then left the decision to the woman, while others either recommended (27.6%) or discouraged MHT use (15.2%).⁶⁰ This is reflective of the inconsistent adoption of shared decision-making in the field of menopause care; the challenges faced are ubiquitous and not unique to a single cultural or healthcare provision setting.

Discrepancies between physicians’ perception of risk, the information conveyed, and women's understanding of the risk conveyed was demonstrated by An et al.⁶¹ HCPs perceived that their consultations included discussions about vasomotor symptom control (99.6%), risk of breast cancer (92.8%), and optimal duration of treatment (84.8%); however, a significantly lower proportion of postmenopausal women acknowledged being informed by physicians on these aspects of MHT (78.2%, 65.3%, and 36.7%, respectively).⁶¹ Physicians have been shown to have a tendency to overestimate the extent to which risks of prescribed medications are discussed.⁶¹ Reasons for disparities between physician-to-postmenopausal woman transfer of information on the benefits/risks of MHT may include lack of consultation time, lack of visual aids, and inadequate communication.

Inadequate knowledge

Physicians’ knowledge gaps related to menopause may also contribute to the discrepancies between perceived and actual communication concerning the management of menopause.⁶⁰ A recent online survey and interview of general practitioners (GPs) in the UK indicated that 52% felt not enough support was offered to enable the provision of effective menopause-related treatment, and 77.5% felt that there is a need to improve training provided on menopause in medical school and GP training.⁶² This is likely to be compounded by the complex and constantly changing range of MHT formulations available to GPs due to the absence of a national formulary and supply shortages as well as the lack of benefit/risk data. Likewise, over 60% of perimenopausal women did not feel at all informed about menopause, with more than 90% of women having never been taught about menopause at school.⁴¹

Perception of risk and risk communication

Dissemination of precise and accessible evidence-based information is key for accurate risk assessment. Effective risk communication relies on the premise that the meaning and interpretation of the language of risk is shared between HCPs and the patient.⁶³

Decisional conflict

A qualitative study in primary care demonstrated that active risk assessment processes involve a complex interplay between knowledge of risk, core beliefs, and personal experiences.⁶³ Most of these factors are, therefore, unique to each woman; however, HCPs can impact risk presentation and thereby influence women's knowledge and perception of risk. Numerical values such as odds or probabilities are usually used by HCPs to communicate risk. Numerical risks are frequently accompanied by words and most women needed the context of risk information to conceptualize risk and assign it a personal meaning. Numbers were described by some to be abstract, scientific, or data; some people felt numbers were truthful, while others felt that statistics can be manipulated.⁶³ Words were felt to be an opinion, which gave personal meaning and context. Generalized risk information is often perceived as impersonal, and greater satisfaction can be achieved by providing a more tailored, personalized approach.⁶³

Decision-making was shown in some women to be affected more by the short-term risks associated with MHT than the long-term benefits.⁶⁴ Women perceived risks as threats, and in particular, the risks of breast cancer, blood clots, heart attacks, and stroke were considered to be life-threatening,⁶³ while the benefits of MHT such as osteoporosis were considered life-changing.⁶⁴ The causal link to specific conditions, such as breast cancer, were considered more important than the numerical changes in risks or benefits as the actual numbers were considered too small to affect decision-making.

Detailed analyses of 20 menopause-related consultations demonstrated that risk discussion could be identified in 18 of the 20 consultations, while in the remaining two, the decision for MHT was made without any discussion about benefits and risks. The discussion of risks was frequently initiated by the physician in 83% of consultations.⁶⁵ Interestingly, the point at which the decision to prescribe MHT is made can sometimes occur before risk discussions are completed (28%) or prior to risk discussion (17%), and 33% of women continued the risk discussion after MHT had been prescribed.⁶⁵ Risk discussions were thus skewed toward the needs of physicians in structuring the encounter, controlling the flow, as well as overall contribution to the consultation.⁶⁵ Discussion of risks comprise predominantly of information provided by the physician interspersed with patients’ questions. Approximately 21% of each consultation's content was spent on risk discussion, of which 80% is occupied by the physician providing risk information.⁶⁵

Decision-support tools

The ODSF advocates that decision support should be tailored to the patients’ decisional needs and aims to achieve decisions that are informed and based on patients’ values.³³ Decision support includes clinical counseling, coaching, and tools such as decision aids.³³ By providing the most up-to-date, evidence-based information about the associated benefits and risks of treatment, decision support helps individuals to consider what matters most to them in relation to the possible outcomes in preparation for decision-making. Decision-support tools can be implemented before, during, or after a clinical consultation and serve to enhance shared decision-making.

A quality framework such as The International Patient Decision Aid Standards (IPDAS)⁶⁶ provides an evidence-based framework with established criteria to improve the content, development, implementation, and evaluation of decision aids. A Cochrane review demonstrated that people exposed to decision aids when compared to usual care felt better informed and had a clearer understanding of their values and risk perceptions, and they were probably more active in decision-making.⁶⁷ Importantly, no adverse effects on health outcomes or satisfaction were observed with the use of decision aids.⁶⁷

To date, there is a paucity of tools to provide decision support for the management of menopause; however, a number of patient decision aids have been developed. A systematic review of available decision aids in menopause by Carpenter et al. demonstrated a lack of uniform improvements in decisional conflict scores, confidence, satisfaction, and knowledge in those using decision aids.³¹ More recently, a meta-analysis by Ghehi et al. similarly indicated limited effects of the use of decision aid–based intervention on decisional conflict, satisfaction, and knowledge in menopause care.⁷⁰ However, both authors did note the high heterogeneity among the studies included in the systematic review and meta-analysis, with some decision aids not meeting the Ottawa and the IPDAS standards. This may thus account for the difficulties in demonstrating a definite effect of decision aids in menopause care.

As highlighted in Figure 2, based on the ODSF, decision-support interventions need to first establish rapport in order to facilitate effective communication and patient involvement. The ODSF proposes that decision-support interventions, by providing tailored support and addressing patients’ decisional needs, can result in good quality decision-making processes and ultimately decisional outcomes. Such decision-support intervention for menopause care is much needed. Indeed, England's NHS Menopause Pathway Improvement Programme highlighted the need for decision-support tools to help women to record their symptoms, understand their treatment options such as self-care and MHT, and aid conversations with HCPs.⁶⁸

DISCUSSION

Decision-making around menopause care and the use of MHT is a complex, iterative process influenced by a multitude of factors framed by perspectives both from women and HCPs. Women's decisional needs are affected by sociocultural, economic, educational, demographic, and personal characteristics. HCPs’ decisional needs specific to menopause are less well-defined; however, personal experiences, demographic characteristics, and interactions with the professional community appear to influence their decision-making. The media has potent effects in relation to perception and decision-making around menopause as reflected in the exponential rise in MHT demand following increased media portrayal. The discordance between social media content related to menopause and the scientific literature, as well as the pervasiveness of advertisements, highlights the need for HCPs to have an appreciation for the effect that social media may have on women seeking menopause-related care.⁵⁴

Shared decision-making, a consultation model that has been shown to lead to empowering consultations advocated by menopause-related guidelines, can be hindered by inadequate resources, limited consultation times, and the dynamics between HCPs and women in menopause-related consultations. The challenges have been demonstrated by studies from various settings and countries illustrating that this is not unique to a single cultural or healthcare setting. Knowledge and understanding of menopause-related management and women's perception of their HCPs’ knowledge also influences decision-making regarding menopause care. The manner in which benefits and risks are communicated also affects how women conceptualize risk, with greater satisfaction being achieved by providing a tailored, personalized approach.

Strengths of this review include extensive exploration of the factors influencing perceptions of benefits and risks related to menopause management, including less published areas such as the effect of social media. This review does not include decisions on taking estrogen for gender affirmation or premature ovarian insufficiency. Although important factors affecting women's decisions have been described, the complexity of women's decision-making is difficult to fully capture. Most studies describing decision-making around menopause-related symptom management are cross-sectional studies, thus limiting evaluation of the evolving decision-making process. An improved and more thorough understanding of factors affecting women's decision-making and its iterative nature is needed. This will be beneficial to guide the development of interventions to promote informed decision-making about menopause-related symptom management.

Decision-support tools in menopause care are recognized as important and the need for their development are highlighted by the NHS Menopause Pathway Improvement Programme. Decision-support tools have been shown to improve knowledge, understanding, and risk perceptions compared to standard care. The COVID-19 pandemic has resulted in rapid expansion and adoption of technology in the NHS. In particular, primary care has seen huge increases in remote consultations and patient uptake of remote health services including the NHS app and e-prescription services. Data from the Office for National Statistics indicate that internet usage among women aged 45–54 years has increased consistently to over 98.4% in 2020.⁶⁹ Therefore, digital platforms (e.g., digital decision aids) offer huge potential for health promotion for women to access information in a private and self-paced manner.

CONCLUSION

Decisions around menopause management are complex. For HCPs, keeping abreast of the different types of MHT formulations and the constantly developing literature to provide relevant benefit/risk estimates individualized to each woman is challenging in time-constrained clinical consultations. Women seeking menopause care have the difficult task of making sense of the conveyed benefit and risk profiles to reach management decisions in line with their own values and preferences, often with influences from friends, family, and a wider social context including social media and opinion leaders (e.g., celebrities). Challenges faced by both parties include time-constrained clinical encounters, limited evidence-based resources, and inadequate understanding and training in menopause. Improved understanding of decisional needs and appropriate design of decision-support interventions can help achieve informed, values-based decisions and ultimately satisfaction of menopause care. It is important for women, HCPs, and commissioners to have a good understanding and appreciation of the barriers, challenges, and factors affecting decision-making related to menopause care. Understanding and addressing these important factors appropriately can lead to improved participation in shared decision-making, satisfaction with the decision and decision-making process, adherence to treatment, reduced decisional regret, efficient use of resources, and ultimately long-term satisfaction with care.

AUTHOR CONTRIBUTIONS

K.K., S.N., and A.A. drafted the original manuscript. A.M., H.P., Y.V., J.B., H.D., A.N.C., V.T., J.V.B., and W.S.D. contributed to the revision and editing of the manuscript. W.S.D. and A.A. are co-corresponding and senior authors. All authors contributed to the article and approved the submitted version.

ACKNOWLEDGMENTS

This work was supported by grants from the National Institute of Health Research (NIHR), the NIHR/Wellcome Trust Imperial Clinical Research Facility, and the NIHR Imperial Biomedical Research Centre (BRC). The Section of Endocrinology and Investigative Medicine was funded by grants from the Medical Research Council (MRC), Biotechnology and Biological Sciences Research Council (BBSRC), NIHR and was supported by the NIHR Biomedical Research Centre Funding Scheme. The views expressed are those of the authors and not necessarily those of the MRC, the NHS, the NIHR, or the Department of Health. K.K. was supported by the NIHR Academic Clinical Fellowship Award (ACF-2021-21-001). A.C. was supported by the NHS. W.S.D. was supported by an NIHR Research Professorship NIHR-RP-2014-05-001 and the NIHR Senior Investigator Award. A.A. was supported by NIHR Clinician Scientist Award (CS-2018-18-ST2-002).

COMPETING INTERESTS

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Open Research

PEER REVIEW

The peer review history for this article is available at: https://publons.com/publon/10.1111/nyas.15185