The prevalence of hormone therapy (HT) use among active duty service women ages 45 to 65 is lower than HT use among the US veteran population age 45 and older but higher than among the United States general population age 45 and older.
Key Words: Active duty service women, Hormone therapy, Menopausal hormone therapy, Menopause, Military health system, Military medicine, Reproductive health, Women's health
Abstract
Objective
Menopausal hormone therapy (HT) has been shown to be effective in alleviating symptoms of menopause. While previous literature has described the frequency of HT use for the relief of menopausal symptoms in both the general and veteran female populations, there is currently no literature describing this frequency within the female active duty population. This study aims to address this gap in knowledge by conducting a retrospective cross-sectional study of HT receipt in active duty service women (ADSW) ages 45 to 64 during fiscal years (FYs) 2018 to 2022.
Methods
We used the Military Health System (MHS) Data Repository (MDR) to conduct a retrospective study of ADSW ages 45 to 64 in the US Army, Air Force, Navy, and Marine Corps during FY 2018 to 2022. Study analyses included descriptive statistics on participant demographics and HT type. Logistic regressions were performed to assess for significant associations between participant demographics and receipt of HT.
Results
We identified a total of 13,629 women aged 45 to 64 on active duty service in the US Army, Air Force, Navy, and Marine Corps during FY 2018 to 2022, of whom 1,290 (9.5%) received HT. Significantly lower odds for receipt of HT was observed among ADSW ages 45 to 49, 60 to 64, of Asian/Pacific Islander race, and all ranks below Senior Officer. No significant associations were observed by Service branch.
Conclusions
The prevalence of HT use among ADSW ages 45 to 65 is lower than HT use among the US veteran population age 45 and older but higher than among the US general population age 45 and older.
The mean age of menopause, defined as cessation of menses for 12 months, is 51.4 years, occurring in 90% of women between the ages of 45 and 56.1 However, the menopause transition, the interval of time characterized by waning estrogen levels and changes in menstrual cycles, can start an average of 4 years prior to the last menstrual period.2 Approximately 80% of women experience vasomotor symptoms (VMS), including hot flashes and night sweats, during the menopause transition, with a median duration of 7 years.3 Black women are reported to experience higher rates of hot flashes compared to White women.3 VMS are often poorly tolerated and may be associated with poor sleep quality, irritability, difficulty concentrating, and decreased quality of life.4 Menopausal hormone therapy (HT) is the most effective treatment for reducing VMS and is Food and Drug Administration (FDA)-approved as first-line therapy for alleviating moderate to severe VMS.1 HT typically consists of an estrogen alone (ET) (in people without a uterus) or an estrogen in combination with a progestogen (EPT) (in people with a uterus).4 ET can be prescribed as oral, transdermal, or transvaginal formulations, and EPT can be prescribed as oral or as a combination transdermal patch.4 In addition to the treatment of VMS, HT is also FDA-approved for the prevention of bone loss, premature hypoestrogenism, and genitourinary syndrome of menopause (GSM).4
The use of HT in the form of oral conjugated equine estrogen (CEE, marketed as Premarin) was FDA-approved in 1942 for the treatment of menopausal symptoms.5 Progestogens were added to the HT regimen in the 1970s to mitigate the risk of endometrial cancer from unopposed estrogen use in women with a uterus, with HT use gradually increasing during the 1980s and 1990s.5 Its use dramatically declined in 2002 after results from the Women's Health Initiative (WHI) indicated that participants who received combination HT of estrogen (CEE) and medroxyprogesterone acetate (MPA) had increased risk of coronary heart disease, stroke, venous thromboembolism, and invasive breast cancer.6 However, the women included in the WHI study were older, with an average age of 63, than most women presenting with menopausal symptoms, which led to the statistically significant results observed.7 Subsequent stratified analyses by age led experts to conclude HT is relatively safe for those under age 60 or within 10 years of the final menstrual period.6 While the risk of breast cancer was increased to a similar degree with use of CEE and MPA for all age groups by 21%-24%, it was decreased with CEE alone to a similar extent in all age groups.4 With the exception of breast cancer risk with EPT, the use of HT in women under age 60 or within 10 years of the final menstrual period demonstrates an overall favorable benefit-risk ratio for the treatment of VMS, GSM, and bone loss prevention.4,7
The number of active duty service women (ADSW) in the military has grown steadily. In 2021, women made up 17.3% (231,741 members) of the active duty component, an increase of 15.6% compared to 2005 (200,470 members).8 This growing demographic has specific health needs related to their military service that require consideration.9 This is especially true for older service women, who comprise an even smaller demographic.8,9 As the female active duty population continues to expand and its members advance in age, it is vital that the Military Health System (MHS) takes action to ensure that the health needs of these service members are not neglected.
While previous literature has described the frequency of HT use for the relief of menopausal symptoms in both the general and female veteran populations, there is currently no literature describing the frequency of HT use for the relief of menopausal symptoms within the female active duty population.10,11 This study aims to address this gap in knowledge by conducting a retrospective cross-sectional study of HT receipt in ADSW ages 45 to 64 during fiscal years (FYs) 2018 to 2022.
METHODS
We used the MHS Data Repository (MDR) to conduct a cross-sectional study of ADSW in the US Army, Air Force, Navy, and Marine Corps during FY 2018 to 2022. The MDR houses administrative and healthcare claims for MHS beneficiaries, including active duty service members, retirees, and their dependents. The MHS is a bifurcated system that provides its beneficiaries access to care in two systems: military treatment facilities, also known as direct care, and civilian fee-for-service facilities through their Department of Defense TRICARE benefit, also known as private sector care.12-14 TRICARE covers 9.6 million beneficiaries and does not include care delivered in theater (during deployment or war time operations) or through the Veteran's Health Administration.12,13
Utilizing the Defense Enrollment Eligibility Reporting System (DEERS) in the MDR, we identified all ADSW ages 45 to 64 from FY 2018 to 2022. This age range was chosen as this is the cohort most likely to present with menopause-related symptoms and be a candidate for HT therapy.1-4 Service women in the Coast Guard, Public Health Service, National Guard, and Reserves were excluded because of their inconsistent access to the MHS. Additionally, transgender women were identified using the International Classification of Diseases, 10th revision, diagnostic codes (Z87.890, F64.0, F64.2, F64.8-64.9) and were excluded from the analysis. Using the American Hospital Formulary Service therapeutic class code 681604, we queried the Pharmacy Detail Transaction Service data in the MDR for all women in the study population who received a systemic HT prescription in either direct or private sector care during the study period. Because the aim of our study was to address the frequency of systemic HT use, our query focused on identifying ADSW who were prescribed any formulation of systemic HT: ET (for those without a uterus) or a combination of EPT (for those with a uterus). Systemic HT prescriptions were categorized in this study as estrogen pill, estrogen/progestogen combination pill, and transdermal therapy (estrogen vaginal ring, estrogen gel, estrogen patch, and estrogen/progestogen combination patch). Specific prescriptions by HT category can be found in supplementary materials (see Table, Supplemental Digital Content 1, http://links.lww.com/MENO/B332). Individuals taking nonsystemic vaginal ET and individuals taking hormone contraceptives were not included in this analysis. Demographic characteristics for those who did or did not receive systemic HT were obtained and used in analysis. For those who received a systemic HT prescription, the initial prescription during the study period was identified as well as the date that the prescription was filled. Demographic data at the time the prescription was filled were identified: age (categorized as 45 to 49, 50 to 54, 55 to 59, 60 to 64), race (captured in the MDR as White, Black, Asian/Pacific Islander, American Indian/Alaskan Native, other), rank (categorized as Junior Enlisted, Senior Enlisted, Junior Officer, Senior Officer, Warrant Officer, Other), and service (captured in the MDR as Army, Air Force, Navy, Marine Corps) at the time of receipt was included in the analysis. ‘Other’ race is self-selected by patients and includes all races and ethnicities that do not match to the available race categories. For women without systemic HT, their earliest DEERS record during the study period was obtained and included all associated demographic characteristics. Because of the high rate of missing data, ethnicity was not retained for analysis.
Study analyses included descriptive statistics on participant demographics and HT type. Chi-square tests were performed to assess for significant differences in participant demographics between those who received HT and those who did not and were used to determine which variables to include in regression modeling. Unadjusted and adjusted logistic regressions with 95% confidence intervals were performed to assess for significant associations between receipt of HT and age, race, rank, and branch of service. The regression model was a complete case and fully saturated model; meaning all demographics were used as predictors in the model and each variable was adjusted by all other variables present in the model and any observations with missing values were automatically removed in the regression analysis. Statistical significance was determined using P < 0.05, and all analyses were performed using SAS, 9.4. This study was reviewed and considered exempt by the institutional review board of the Uniformed Services University of the Health Sciences.
RESULTS
We identified a total of 13,629 women on active duty service in the US Army, Air Force, Navy, and Marine Corps during FY 2018 to 2022, of whom 1,289 (9.5%) received systemic HT. Table 1 details the demographics of the ADSW study population stratified by receipt of systemic HT. Of those who received systemic HT during the study period, the majority were 45 to 49 years old, White, in a Senior Officer rank, and in the Army. Compared to the overall prevalence of HT, greater within-group prevalence was observed in women 50 years or older, of Black race, officer rank, and in the Air Force.
Table 1.
Demographics of active duty service women, fiscal years 2018-2022
| No HT Received | HT Received | Total Study Population | |
|---|---|---|---|
| N (% of total) | N | N | |
| Total | 12,340 (100) | 1,289 (100) | 13,629 (100) |
| Age group | |||
| 45-49 | 10,420 (84.44) | 762 (59.12) | 11,182 (82.05) |
| 50-54 | 1,415 (11.47) | 411 (31.89) | 1826 (13.40) |
| 55-59 | 410 (3.32) | 103 (7.99) | 513 (3.76) |
| 60-64 | 95 (0.77) | 13 (1.01) | 108 (0.79) |
| Race | |||
| American Indian/Alaskan Native | 102 (0.83) | 10 (0.78) | 112 (0.82) |
| Asian/Pacific Islander | 1,280 (10.37) | 89 (6.90) | 1,369 (10.04) |
| Black | 3,804 (30.83) | 368 (28.55) | 4,172 (30.61) |
| Other | 625 (5.06) | 64 (4.97) | 689 (5.06) |
| White | 6,285 (50.93) | 749 (58.11) | 7,034 (51.61) |
| Unknown/missing | <11 | <11 | 253 (1.86) |
| Rank | |||
| Junior Enlisted | <11 | <11 | 152 (1.12) |
| Senior Enlisted | 4,921 (39.88) | 389 (30.18) | 5,310 (38.96) |
| Junior Officer | 2,879 (23.33) | 278 (21.57) | 3,157 (23.16) |
| Senior Officer | 3,933 (31.87) | 574 (44.53) | 4,507 (33.07) |
| Warrant Officer | 449 (3.64) | 46 (3.57) | 495 (3.63) |
| Other/missing | <11 | <11 | <11 |
| Service | |||
| Army | 5,719 (46.35) | 561 (43.52) | 6,280 (46.08) |
| Air Force | 3,547 (28.74) | 394 (30.57) | 3,941 (28.92) |
| Marine Corps | 237 (1.92) | 27 (2.09) | 264 (1.94) |
| Navy | 2,837 (22.99) | 307 (23.82) | 3,144 (23.07) |
| Hysterectomy | |||
| Yes | 1,091 (8.84) | 294 (22.81) | 1,385 (10.16) |
| No | 11,249 (91.16) | 995 (77.19) | 12,244 (89.84) |
Exclusions included transgender women and women in the Coast Guard, National Guard, or Reserves. Other race is self-selected by the patient and includes any race or ethnicity that does not match to the available race categories. Small cell sizes and any additional stratifications that could aid in back calculation were censored and noted using <11.
HT, hormone therapy.
Table 2 details the distribution of HT type first received during the study period. Oral therapy was the most commonly prescribed form (65%), with the majority being estrogen pills, followed by transdermal methods (35%).
Table 2.
Distribution of hormone therapy type, fiscal years 2018-2022
| Hormone Therapy Type | N (% of total) |
|---|---|
| Total hormone therapy | 1,289 (100) |
| Estrogen pill (ET) | 597 (46.31) |
| Estrogen/progesterone combination pill (EPT) | 243 (18.85) |
| Transdermal therapy | 449 (34.83) |
Those who received estrogen vaginal ring therapy were combined with transdermal therapy for censorship purposes due to cell counts of 10 or fewer. Estrogen pill indicates a prescription for estrogen only, however, it does not indicate women were on oral estrogen only therapy and they could additionally be receiving progesterone therapy.
Table 3 details the unadjusted and adjusted logistic regression results for the odds of receiving systemic HT during the study period. After adjustment for all other variables in the multivariable model, significantly lower odds for receipt of systemic HT were observed in women ages 45 to 49 (0.25 OR, 0.23-0.30 95% CI) and 60 to 64 (0.48 OR, 0.26-0.87 95% CI), of Asian/Pacific Islander race (0.67 OR, 0.53-0.85 95% CI), in all ranks below Senior Officer, compared to their respective referent groups. Compared to each referent group, there was no significant association between receipt of HT and branch of service, age for women aged 55 to 59, or race for ADSW of Black, American Indian/Alaskan Native, or “other” race.
Table 3.
Unadjusted and adjusted odds ratios for receipt of systemic hormone therapy, fiscal years 2018-2022
| Effect | Unadjusted Odds Ratio (95% CI) | Adjusted Odds Ratio (95% CI) |
|---|---|---|
| Age group (years) | ||
| 45 to 49 | 0.25 (0.22-0.29)a | 0.26 (0.23-0.30)a |
| 50 to 54 (ref) | 1 | 1 |
| 55 to 59 | 0.87 (0.69-1.11) | 0.83 (0.65-1.06) |
| 60 to 64 | 0.47 (0.26-0.85)a | 0.48 (0.26-0.87)a |
| Race | ||
| White (ref) | 1 | 1 |
| Black | 0.81 (0.71-0.92)a | 0.93 (0.80-1.07) |
| Asian/Pacific Islander | 0.58 (0.46-0.73)a | 0.67 (0.53-0.85)a |
| American Indian/Alaskan Native | 0.82 (0.43-1.58) | 0.97 (0.50-1.90) |
| Other | 0.86 (0.66-1.12) | 1.04 (0.79-1.36) |
| Rank | ||
| Junior Enlisted | 0.09 (0.02-0.37)a | 0.12 (0.03-0.48)a |
| Senior Enlisted | 0.54 (0.47-0.62)a | 0.73 (0.63-0.85)a |
| Junior Officer | 0.66 (0.57-0.77)a | 0.82 (0.70-0.96)a |
| Senior Officer (ref) | 1 | 1 |
| Warrant Officer | 0.70 (0.51-0.96)a | 0.88 (0.63-1.22) |
| Service | ||
| Army (ref) | 1 | 1 |
| Air Force | 1.13 (0.99-1.30) | 1.09 (0.94-1.25) |
| Navy | 1.10 (0.95-1.28) | 1.06 (0.91-1.24) |
| Marine Corps | 1.16 (0.77-1.76) | 1.33 (0.88-2.02) |
Other race is self-selected by the patient and includes any race or ethnicity that does not match to the available race categories.
Each variable in the table was adjusted by all other variables in the table.
Ref, reference group.
aStatistically significant, P < 0.05.
DISCUSSION
A total of 13,629 ADSW aged 45 to 64 were identified, of whom 1,289 (9.5%) received HT during FY 2018 to 2022. This prevalence is lower than rates reported in the veteran population (10.3%),10 but higher than rates reported in the general US population of women aged 40 and older (4.7%).11 To put these prevalences in context, it is important to consider the frequency of HT use prior to the WHI study, which was 22.4% from 1999 to 2000 among the general population.11 This discrepancy in use indicates a significant gap in current HT use compared to HT use before the WHI study. Furthermore, as nearly 80% of women experience VMS, a prescription prevalence of nearly 10% suggests undertreatment. Even considering that not everyone is a candidate for HT or may choose to use HT, there is likely still a gap. A study on the prevalence of select HT contraindications using a database of abstracted medical records of a randomly selected sample of adult female members (age range 40-55 yr) of a large health maintenance organization (HMO) found that 9% of participants had an absolute contraindication and 44% of women had either an absolute or relative contraindication to HT.15 This suggests that more than 35% of participants are appropriate candidates for HT. This discrepancy in HT use may stem from a gap in both participants' and providers' attitudes and knowledge regarding the benefits of HT use for VMS.3
There is currently a lack of data explicitly examining provider practice patterns and patient attitudes and perceptions regarding menopause care of ADSW. However, it is likely that the historical context surrounding HT use following the results of the WHI study had some impact, as we have seen in the general population.11,16 This may have led to biases on behalf of both patients and providers that deterred patients from receiving HT.6,17,18 A 2007 study of physicians' attitudes toward HT indicated that as a result of the WHI study, many were reluctant to prescribe HT for relief of menopausal symptoms and were more likely to suggest discontinuation.16 Additionally, physicians who are knowledgeable about specific results of large trials regarding HT are more likely to prescribe HT, while physicians with less understanding may underutilize HT.19 Furthermore, there may be gaps in resident education and knowledge about menopause, which may continue into practice after graduation. In a needs assessment study about menopause education, more than 60% of American obstetrics and gynecology residents reported they had limited knowledge and needed to learn more about menopause medicine.20 In a cross-sectional study of family medicine, internal medicine, and obstetrics and gynecology residents in US training programs, nearly 35% of participants failed to offer HT to a newly menopausal, severely symptomatic patient without any contraindications to treatment.21 Many military treatment facilities have residency training programs. After graduation, these military residents are assigned to practice at military training facilities to fulfill their service obligations. Lack of menopause care knowledge and education during residency may perpetuate and influence physician practice after trainee graduation. Moreover, the number of ADSW over age 41 constitutes an overall small percentage of patients at military treatment facilities, thus limiting clinician exposure to this population.8
From a patient perspective, a recent review by Pershad et al assessed factors regarding women's attitudes toward HT. They found that concern for adverse effects and negative perceptions about HT from family and friends influenced participants' views negatively toward HT, indicating that biases against HT persist among the general population.18 Furthermore, in online surveys, over 60% of participants reported a lack of education and limited knowledge about menopause.22,23 Many women (68%) sought information once their symptoms started, and over 60% turned to the Internet and friends for information, while only 46% used a health professional for advice.22
Specific to our study population of ADSW, we found significantly lower odds for receipt of systemic HT by women ages 45 to 49 and 60 to 64, of Asian/Pacific Islander race, and in all ranks below Senior Officer. Given that the average age of menopause is 51.4 and that the benefit-risk ratio for treatment of VMS is most favorable for women within 10 years of menopause or less than age 60, it is not surprising that women between the ages of 50 to 59 are most likely to receive treatment.3 Lower odds of receiving HT in women ages 45 to 49 could be explained by not including those individuals taking hormone contraceptives to manage menopausal symptoms. Our findings of lower receipt of HT by Asian/Pacific Islander race may be due to a lower reported prevalence of VMS in Asian/Pacific Islander women compared to women of Black and White race.24,25 However, in the study by El Khoudary et al, though lower prevalence of VMS was reported among Chinese and Japanese women, Pacific Islander women were not included, and in the study by Reed et al, the women surveyed were premenopausal, so additional research is needed to confirm these findings.24,25 The grouping of Asian women with Pacific Islander women in our analyses likely obscured our ability to understand odds of HT use among Pacific Islander women. Additionally, our study did not demonstrate lower HT prescription receipt in participants of Black compared to White race. This is in contrast to the study by Gerber et al of the veteran population, where they found that Black veterans were 26% less likely to receive HT compared to White veterans.10 This aligns with findings from Koehlmoos et al that indicate many, but not all, racial disparities are mitigated within the Military Health System.26 Lastly, a study evaluating women's healthcare in deployed settings found that senior officers were more likely to receive obstetrics and gynecology (OBGYN) services during deployment.27 It is possible ADSW in lower ranks experience greater difficulties when seeking care for their concerns due to barriers in navigating the healthcare system or not feeling empowered to advocate for treatment of menopause symptoms.
An advantage of the MHS compared to the general population is universal health coverage with no-cost or low-cost prescription medication. This may contribute to the higher prevalence of HT use in ADSW compared to the general population, as HT may not be affordable for some women in the general population.
Additionally, the study by Gerber et al found that women veterans with a mental health disorder were more likely to use HT and may be less likely to discontinue HT due to estrogen's mood regulating effects. The study further suggests that the higher prevalence of HT use in veteran women may be due to higher rates of mental health disorders in this population. Furthermore, a study by Travis et al found that military sexual trauma (defined as sexual assault or harassment occurring during military service) was common among Veteran women and associated with vasomotor and mental health symptoms.28
Although our study did not examine an association between mental health disorders and HT use in ADSW, a study by Adams et al demonstrated that Army women with reports of combat exposure had increased odds of posttraumatic stress disorder, depression, or at-risk drinking.29 This finding and potential military sexual trauma exposure may contribute to increased HT use among ADSW compared to the general population. Further investigation is necessary to investigate this gap in the literature.
This study has some limitations. This study is cross-sectional and cannot be used to infer causality. The menopause status of participants is unknown. Additionally, we strictly queried for systemic HT prescriptions; therefore, people using hormone contraceptives or nonsystemic vaginal estrogen therapy for menopausal symptoms would not be captured. Our analysis was also unable to account for changes in rank, branch of service, or a participant getting a hysterectomy during the study period. Claims data, used in our study, has the potential for errors in coding and inadequate specificity for a condition. Further, there is a lack of clinical information associated with the claims data used in this study; therefore, we are unable to determine the indications for receipt of HT. In addition, this study does not capture healthcare received outside of TRICARE, though ADSW are generally not authorized to receive healthcare outside of the direct care system. Furthermore, care received outside of the direct care system is often undocumented, and seeking documentation at a later date is often unsuccessful, which can result in incomplete records. Additionally, the timeframe of this study spanned several years during the COVID-19 pandemic when participants faced decreased access to healthcare. However, menopause care can often be completed through telephone or video visits with high patient satisfaction rates.30 Finally, additional research is needed to determine if there are any differences in menopause care practices between direct and private care practitioners.
CONCLUSIONS
The prevalence of HT use among ADSW ages 45 to 64 (9.5%) is lower than HT use reported among the US veteran population age 45 and over (10.3%) but higher than that reported in the general US population age 45 and older. Despite higher rates of HT use among ADSW compared to the general population, a significant gap exists between the number of ADSW currently receiving HT and the number of ADSW that may benefit from receiving HT. Therefore, it is important that patients and providers understand the risk-benefit ratio of HT use for treating VMS. Yet, a gap in the literature exists regarding attitudes and knowledge of HT use among ADSW and military healthcare providers.
Footnotes
Funding/support: This work was conducted with the Center for Health Services Research and funded by the Department of Defense, Defense Health Agency, grant no. HU0001-11-1-0023. The funding agency played no role in the design, analysis, or interpretation of findings.
Financial disclosure/conflicts of interest: Jill Brown receives ongoing funding from McGraw Hill and receives current institutional funding from Military Women's Health Research Program. Katerina Shvartsman receives ongoing funding from NBME to serve on an OBGYN question committee and ongoing funding from McGraw-Hill as the author of a gynecology chapter in Current Medical Diagnosis and treatment. She also serves as editor for Aquifer Women's Health Course. The other authors have nothing to disclose.
Disclaimer: The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, assertions, opinions or policies of the Uniformed Services University of the Health Sciences (USUHS), the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF), the Department of Defense (DoD), or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government. The authors declare no conflict of interest.
This manuscript was presented at The Menopause Society 2024 Annual meeting in Chicago, IL September 11-14, 2024.
Miranda L. Janvrin ORCID 0000-0002-3083-5581
Amanda Banaag ORCID: 0000-0001-6660-1229
Tracey Koehlmoos ORCID: 0000-0003-1377-8615
Supplemental digital content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s Website (www.menopause.org).
Contributor Information
Amanda Banaag, Email: amanda.banaag.ctr@usuhs.edu.
Jill Brown, Email: jill.brown@usuhs.edu.
Katerina Shvartsman, Email: katerina.shvartsman@usuhs.edu.
Tracey P. Koehlmoos, Email: tracey.koehlmoos@usuhs.edu.
REFERENCES
- 1.Crandall CJ, Mehta JM, Manson JE. Management of menopausal symptoms: a review. JAMA 2023;329:405–420. doi: 10.1001/jama.2022.24140 [DOI] [PubMed] [Google Scholar]
- 2.Santoro N, Roeca C, Peters BA, Neal-Perry G. The menopause transition: signs, symptoms, and management options. J Clin Endocrinol Metab 2021;106:1–15. doi: 10.1210/clinem/dgaa764 [DOI] [PubMed] [Google Scholar]
- 3.Avis NE, Crawford SL, Green R. Vasomotor symptoms across the menopause transition: differences among women. Obstet Gynecol Clin North Am 2018;45:629–640. doi: 10.1016/j.ogc.2018.07.005 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.The 2022 hormone therapy position statement of The North American Menopause Society. Menopause 2022;29:767–794. doi: 10.1097/gme.0000000000002028 [DOI] [PubMed] [Google Scholar]
- 5.Stefanick ML. Estrogens and progestins: background and history, trends in use, and guidelines and regimens approved by the US Food and Drug Administration. Am J Med 2005;118:64–73. doi: 10.1016/j.amjmed.2005.09.059 [DOI] [PubMed] [Google Scholar]
- 6.Manson JE, Bassuk SS, Kaunitz AM, Pinkerton JV. The Women's Health Initiative trials of menopausal hormone therapy: lessons learned. Menopause 2020;27:918–928. doi: 10.1097/gme.0000000000001553 [DOI] [PubMed] [Google Scholar]
- 7.Bolton JL. Menopausal hormone therapy, age, and chronic diseases: perspectives on statistical trends. Chem Res Toxicol 2016;29:1583–1590. doi: 10.1021/acs.chemrestox.6b00272 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Office of the Deputy Assistant Secretary of Defense for Military Community and Family Policy . 2021 demographics: profile of the military community. Department of Defense 2022:232. December 14, 2022. Available at: https://download.militaryonesource.mil/12038/MOS/Reports/2021-demographics-report.pdf. Accessed June 14, 2023 [Google Scholar]
- 9.Defense Health Board . Active duty women's health care services. Department of Defense 2020:190. November 5, 2020. Available at: https://www.health.mil/Reference-Center/Reports/2020/11/05/Active-Duty-Womens-Health-Care-Services. Accessed June 14, 2023 [Google Scholar]
- 10.Gerber MR King MW Pineles SL, et al. Hormone therapy use in women veterans accessing veterans health administration care: a national cross-sectional study. J Gen Intern Med 2015;30:169–175. doi: 10.1007/s11606-014-3073-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Sprague BL, Trentham-Dietz A, Cronin KA. A sustained decline in postmenopausal hormone use: results from the National Health and Nutrition Examination Survey, 1999-2010. Obstet Gynecol 2012;120:595–603. doi: 10.1097/AOG.0b013e318265df42 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Koehlmoos TP, Madsen CK, Banaag A, Haider AH, Schoenfeld AJ, Weissman JS. Assessing low-value health care services in the military health system. Health Aff (Millwood) 2019;38:1351–1357. doi: 10.1377/hlthaff.2019.00252 [DOI] [PubMed] [Google Scholar]
- 13.TRICARE . TRICARE: facts and figures. defense health agency. Updated January 12, 2022. Available at: https://www.tricare.mil/About/Facts. Accessed June 14, 2023.
- 14.Korona-Bailey J, Banaag A, Nguyen DR, Pasieka H, Koehlmoos TP. Free the bun: prevalence of alopecia among active duty service women, fiscal years 2010-2019. Mil Med 2023;188(3-4):e492–e496. doi: 10.1093/milmed/usab274 [DOI] [PubMed] [Google Scholar]
- 15.Whitlock EP, Valanis B, Ernst D, Smith L. Prevalence of contraindications to hormone replacement therapy in middle-aged women in a managed care setting. J Womens Health 1995;4:293–302. doi: 10.1089/jwh.1995.4.293 [DOI] [Google Scholar]
- 16.Bush TM Bonomi AE Nekhlyudov L, et al. How the Women's Health Initiative (WHI) influenced physicians' practice and attitudes. J Gen Intern Med 2007;22:1311–1316. doi: 10.1007/s11606-007-0296-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Temkin SM, Mallen A, Bellavance E, Rubinsak L, Wenham RM. The role of menopausal hormone therapy in women with or at risk of ovarian and breast cancers: Misconceptions and current directions. Cancer 2019;125:499–514. doi: 10.1002/cncr.31911 [DOI] [PubMed] [Google Scholar]
- 18.Pershad A, Morris JM, Shearer K, Pace D, Khanna P. Influencing factors on women's attitudes toward hormone therapy acceptance for menopause treatment: a systematic review. Menopause 2023;30:1061–1069. doi: 10.1097/GME.0000000000002243 [DOI] [PubMed] [Google Scholar]
- 19.Taylor HS, Kagan R, Altomare CJ, Cort S, Bushmakin AG, Abraham L. Knowledge of clinical trials regarding hormone therapy and likelihood of prescribing hormone therapy. Menopause 2017;24:27–34. doi: 10.1097/gme.0000000000000711 [DOI] [PubMed] [Google Scholar]
- 20.Christianson MS, Ducie JA, Altman K, Khafagy AM, Shen W. Menopause education: needs assessment of American obstetrics and gynecology residents. Menopause 2013;20:1120–1125. doi: 10.1097/GME.0b013e31828ced7f [DOI] [PubMed] [Google Scholar]
- 21.Kling JM MacLaughlin KL Schnatz PF, et al. Menopause management knowledge in postgraduate family medicine, internal medicine, and obstetrics and gynecology residents: a cross-sectional survey. Mayo Clin Proc 2019;94:242–253. doi: 10.1016/j.mayocp.2018.08.033 [DOI] [PubMed] [Google Scholar]
- 22.Harper JC Phillips S Biswakarma R, et al. An online survey of perimenopausal women to determine their attitudes and knowledge of the menopause. Womens Health (Lond) 2022;18:17455057221106890. doi: 10.1177/17455057221106890 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Aljumah R, Phillips S, Harper JC. An online survey of postmenopausal women to determine their attitudes and knowledge of the menopause. Post Reprod Health 2023;29:67–84. doi: 10.1177/20533691231166543 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Reed SD Lampe JW Qu C, et al. Premenopausal vasomotor symptoms in an ethnically diverse population. Menopause 2014;21:153–158. doi: 10.1097/GME.0b013e3182952228 [DOI] [PubMed] [Google Scholar]
- 25.El Khoudary SR Greendale G Crawford SL, et al. The menopause transition and women's health at midlife: a progress report from the Study of Women's Health Across the Nation (SWAN). Menopause 2019;26:1213–1227. doi: 10.1097/gme.0000000000001424 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Koehlmoos TP, Korona-Bailey J, Janvrin ML, Madsen C. Racial disparities in the military health system: a framework synthesis. Mil Med 2021;187(9-10):e1114–e1121. doi: 10.1093/milmed/usab506 [DOI] [PubMed] [Google Scholar]
- 27.Hamlin L, Banaag A. Women's health care in the deployed setting 2013-2020: a health services research approach. Mil Med 2022:usac025. doi: 10.1093/milmed/usac025 [DOI] [PubMed] [Google Scholar]
- 28.Travis KJ Huang AJ Maguen S, et al. Military sexual trauma and menopause symptoms among midlife women veterans. J Gen Intern Med 2024;39:411–417. doi: 10.1007/s11606-023-08493-w [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Adams RS, Nikitin RV, Wooten NR, Williams TV, Larson MJ. The association of combat exposure with postdeployment behavioral health problems among U.S. army enlisted women returning from Afghanistan or Iraq. J Trauma Stress 2016;29:356–364. doi: 10.1002/jts.22121 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Wright E, Shaltout O, Zokvic MA, Shirreff L. Delivery of menopause care during a pandemic: an evaluation of patient satisfaction with telephone visits. Menopause 2021;29:184–188. doi: 10.1097/gme.0000000000001906 [DOI] [PMC free article] [PubMed] [Google Scholar]