台灣家醫科醫師及婦產科醫師對於荷爾蒙補充療法知識、態度、及處方的探討

An empirical survey on knowledge, attitude and practice between family physicians and gynecologists toward hormone replacement therapy in Taiwan

程劭儀(Shao-Yi Cheng)

指導教授 ： 林瑞雄

共同指導教授 ： 謝長堯

國立臺灣大學/公共衛生學院/預防醫學研究所/碩士(2004年)

https://doi.org/10.6342/NTU.2004.00120

摘要

背景: 近來大型的隨機，雙盲，對照臨床試驗紛紛否定了荷爾蒙補充療法於更年期婦女心臟血管疾病的預防功效，且認為荷爾蒙補充療法與乳癌的關係密切。

目的: 我們欲探討美國’婦女健康促進研究’(Women’s Health Initiative)發表後，不同科別，執業場所，性別，年齡，畢業學校，住院醫師訓練，及執業年限的醫師對於荷爾蒙補充療法知識，態度及實行的情形。

方法: 我們於2004年4到6 月間進行一項橫斷式研究， 依據台灣婦產科醫師學會及台灣家醫科學會的名冊，抽樣寄出1000份問卷，回收率為18.3%。 除了郵寄問卷，並藉由電子郵件的方式寄出100份問卷，回收率為88%。 271份中共有256份有效問卷。 知識， 態度，行為等變相的頻率百分比以five-Likert scale 表示。 因子分析(factor analysis)方法則用來探討知識，態度，行為等因子間的關係。 除此之外亦採用多變項迴歸模式亦用來探討新因子與實行的關係。

結果； ‘科別’是影響開立荷爾蒙補充療法處方(OR27.06)，同時亦是利用荷爾蒙補充療法來以改善更年期症狀(OR3.2)及骨質疏鬆(OR2.6)的重要因子。 ‘女醫師’及’醫院醫師’對於有乳癌家族史的更年期婦女較不傾向以荷爾蒙補充療法改善停經症候群及骨質疏鬆。 與開業醫師相較，醫院醫師處方較少鈣片。 在’醫學中心接受住院醫師訓練的醫師’過去一年內處方較多荷爾蒙(OR 13.89)。 ‘荷爾蒙補充療法預防慢性病’的觀念影響了採用荷爾蒙補充療法以治療骨質疏鬆(OR4.06)，以及開立植物性荷爾蒙(OR4.24)及SERM(OR5.44)的處方。 ‘荷爾蒙處方前的評估’影響荷爾蒙處方以改善更年期症狀及患有心血管疾病的更年期婦女。 ‘荷爾蒙補充療法的好處’影響荷爾蒙補充療法以改善更年期症狀，及SERM 的處方。 ‘荷爾蒙補充療法的使用狀況’亦與荷爾蒙補充療法以改善更年期症狀及骨質疏鬆有關。 ‘荷爾蒙補充療法的促銷’深刻影響醫師過去一年內處方荷爾蒙(OR28.93)來減緩更年期不適。 ‘荷爾蒙補充療法帶來的傷害’影響對具有乳癌家族史患者的處方。 Structural equation model 顯示家庭醫師在開立荷爾蒙補充療法之前，較會考慮慢性病預防及可能帶來的傷害等因素，而婦產科醫師則較著重荷爾蒙補充療法的益處。

結論； 儘管台灣家醫科及婦產科醫師對於荷爾蒙補充療法的處方情形截然不同，但台灣醫師對於荷爾蒙補充療法知識，態度及實行狀況與國外醫師相似。 針對更年期婦女停經症候群的治療及慢性病的防治，期待往後家醫科及婦產科醫師間能達到共識。

關鍵字

態度 ； 知識 ； 處方 ； 荷爾蒙補充療法 ； 實行

並列摘要

Background: Recent large- scaled randomized double-blind placebo- controlled trials have elucidated the lack of benefits of hormone replacement therapy to menopausal women for prevention of cardiovascular disease and increased speculation on the carcinogenesis of hormone replacement therapy in breast cancer.

Purpose: We want to compare and investigate the current knowledge, attitude and practices toward HRT after the impact of WHI among physicians in Taiwan regarding to specialty, site of practice, gender, age school, residency training and years of practice.

Method: A cross-sectional survey was conducted from April to June in 2004. A total of 1,000 copies of questionnaires were mailed according to the selective active name lists of Taiwan Association of Obstetrics and Gynecology and Taiwan Association of Family Medicine. 183 copies of questionnaires were returned, with a response rate equivalent to 18.3%. In addition to mailed questionnaire, another 88 copies of questionnaires out of 100 were obtained through E-mail (response rate 88%). A total of 256 copies of valid questionnaire were available. The frequencies of variables on knowledge, attitude and practice were expressed by percentage according to five-Likert scale. Factor analysis was used to assess relationship among the correlated factor of attitude, knowledge, and practice. The effects of new factor on practice were also assessed by using multiple logistic regression models.

Results: ‘Specialty’ was an important factor affecting HRT prescription in the past one year (OR 27.06), HRT prescription for menopausal symptoms (OR 3.2) and osteoporosis (OR2.6). To those menopausal women with family history of breast cancer, ‘female physicians’ were reluctant to prescribe HRT for vasomotor symptoms and osteoporosis treatment. ‘Physicians in hospitals’ tended not to prescribe HRT to those with family history of breast cancer and prescribe less calcium than private practitioners. Those who’ received residency training at medical centers’ tended to prescribe more HRT in the past one year (OR 13.89). The knowledge and attitude of ‘chronic disease prevention of HRT ‘affected HRT prescription for osteoporosis (OR 4.06), prescription of phytoestrogen (OR 4.24) and SERM (OR 5.44). ‘Assessments before the prescription of HRT’ were associated with HRT prescription for menopausal symptoms and those with CVD. The prescription of HRT to menopausal symptoms and prescription of SERM for osteoporosis were related with ‘benefits of HRT’. The prescription of HRT for menopausal symptoms and osteoprosis were related with ‘use of HRT’. ‘Propaganda of HRT by pharmaceutical industry’ strongly influenced HRT prescription of physicians (OR 28.93) in the past one year and relief of menopausal symptoms. The knowledge and attitude that’ HRT would bring harms’ such as breast cancer and thromboembolism affected the prescription of HRT to those with family history of breast cancers. Structural equation model revealed that family physicians tend to consider the chronic disease prevention benefits and evaluate the harms before prescribing HRT whereas gynecologists emphasize the beneficial effects of HRT only.

Conclusion: Although the prescription of HRT is different between family physicians and gynecologists in Taiwan, the knowledge, attitude and practice of physicians toward HRT in Taiwan are concurrent with those of the west. However, a consensus between family physicians and gynecologists is urgent in order to establish a guideline for the treatment of menopausal symptoms and chronic disease prevention in Taiwan.

並列關鍵字

hormone replacement therapy ； prescription ； practice ； knowledge ； attitude

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