Take-home message

Schiff: We started off by saying that if the health-care provider and the patient together come to the conclusion that hormones are indicated, we want to help her to get the full benefits of that decision. So in closing this discussion, I’m going to ask each of you for some bullet points—things that you stress to your patients—to encourage continuance.

Berga: My bullet point is “trial and error.” You have to tell the patient up front that if she doesn’t feel better with what you’re giving her, you’re going to try something else. I say that what will disappoint me most is not hearing back from her about how she’s doing. I explain that I have no stake in any one product and that I get no benefit from her using one rather than another. I stress that her well being is my only concern.

What I’ve found in my community is that there are a lot of physicians who are very well intentioned about HRT but don’t know what to try when there are problems with the formulation they’re used to prescribing. So part of what we need to do is increase awareness of the different products that are available so that women have a real choice—not just from specialists, but from the people they consult in the wider community of health-care providers.

It’s also true that not all physicians are open to HRT. In fact, some internists and generalists are dead set against it, so patients are sometimes caught in the middle. I tell patients I’d be happy to talk to their internist if that’s the case. I think it’s a relief for them to know that I’m willing to do that for them.

Schiff: Dr. Nachtigall, what point would you like to stress?

Nachtigall: I would stress being accessible. I’ve had phone hours for 25 years, and I now have phone hours for 6 hours every Tuesday. Sometimes I get 70 phone calls on that Tuesday. Probably 60% aren’t necessary, but patients know there’s a time they can reach me. If a woman doesn’t think her doctor is receptive to hearing about her problems, she’s very likely to drift away, because she feels foolish saying her breasts hurt or she’s feeling bloated. So I do the phone hours, and when I’m busy I have a trained nurse in my office who does it very well.

Schiff: Dr. Sarrel, do you have a bullet point?

Sarrel: I have several. First, I want to emphasize how important the first visit is in establishing a good working relationship—what in psychiatry is called a “therapeutic alliance.” We teach our psychiatric residents that the first visit is the single most important contact between the therapist and the patient. You either connect and establish trust, mutual understanding, and professional credibility, or you don’t connect. If you don’t, it’s very difficult to recoup after that.

Second, to make that connection, the most important thing is to listen. You need to understand what the woman is experiencing and what she wants you to do for her. Time is important, too. When the first visit lasts less than 15 minutes—and that’s not unusual across the country—the 1-year continuance rate for HRT is 40%.⁴³ However, if the first visit lasts between 15 and 30 minutes, the 1-year continuance rate is 85%. Just that extra 10 or 15 minutes to answer questions, provide information, and establish the professional relationship can make a world of difference.

I also suggest to all of my patients that they keep a daily diary of their response to treatment. In that way, I engage them in an interactive process in keeping track of themselves.

Let me make one other point: we need to distinguish between “continuance” and “compliance.” What we’re seeking is continuance to achieve major beneficial effects and compliance in how the medication is taken. I tell patients, “We have a medication that can help you, but there’s the right way to take it and it’s very important that you take it in the right way.” In that sense, compliance isn’t pejorative or dictatorial. I think most patients understand that.

Nachtigall: That’s a very important point. As you noted earlier, Dr. Sarrel, missing 3 days of a medication can have a serious impact on outcome. We haven’t addressed that enough. Continuing therapy won’t do much good if the patient is taking the medication sporadically or incorrectly.

Schiff: It could even be that we’re putting too much stress on long-term continuance and not enough on current use. It’s wrong to give patients the idea that once they start HRT, they’re committed to it for the next 20 or 30 years. As Dr. Berga said, it’s trial and error at first. You start, and you see how you feel. If you feel better, you continue. If you feel worse, you’re going to discontinue.