Insights into Singaporean Physicians’ Knowledge and Attitudes on Menopause Hormone Therapy

Abstract

Objectives

To evaluate physicians’ knowledge and attitudes in Singapore regarding menopause hormonal therapy (MHT).

Methods

We conducted a cross-sectional survey of 186 physicians practicing in Singapore, including 113 in Family Medicine and 73 in Obstetrics and Gynaecology (O&G). Knowledge was assessed using 21 questions: five questions each on indications, contraindications and risks, and six clinical scenario questions. Attitudes were assessed using five questions: confidence in prescribing, beliefs about the necessity of MHT, whether they would recommend it for patients or family, and concerns about its safety profile. Data were analyzed using descriptive statistics. Comparisons of knowledge and attitudes across demographic variables and specialties were performed using t tests for continuous variables and chi-squared tests for categorical variables.

Results

Forty point three percent of physicians were unaware that MHT is used to prevent postmenopausal osteoporosis. Sixty-six point one percent and 30.6% of physicians, respectively, were unaware that patients on MHT are at a higher risk of gallbladder disease and stroke. Fifty-two point two percent would have chosen non-hormonal treatments for patients with premature ovarian insufficiency. Most physicians expressed a lack of confidence in prescribing MHT (74.2%), with a significant difference (P < 0.001) between the specialties (58.9% of O&G physicians vs. 84.1% of Family Medicine physicians). More than half (61.3%) of physicians expressed safety concerns about MHT.

Conclusions

Information about MHT continues to evolve, emphasizing the importance of keeping physicians updated. Knowledge gaps vary among specialties. Improving physicians’ knowledge by targeted educational interventions should help bolster confidence.

INTRODUCTION

Menopause is a universal life transition for women, with symptoms often severe enough to impair quality of life. Growing social media discussions about menopause [1] are increasing awareness among women, creating a greater demand for physicians to remain current on the cornerstone for menopause management – menopause hormone therapy (MHT).

MHT is a very effective but underutilized treatment for menopausal symptoms. Its benefits in relieving vasomotor, genitourinary symptoms and preventing bone loss are widely documented, with ongoing controversies on cardiovascular and dementia risk reduction [2,3]. MHT use declined drastically following safety concerns from the 2002 Women’s Health Initiative (WHI) study [4,5,6]. Despite subsequent data and updated guidelines from The International Menopause Society (IMS) [7] and The Menopause Society [8] recommending safe use of MHT, acceptance and use amongst physicians remains low.

MHT utilisation rates in Asia (1.9%–13.8%) are substantially lower than that of Western populations (12.0%–48.7%) [9,10,11]. A local study reported an utilisation rate of 8.8%, with Chinese women showing higher rates than Indian or Malay women [12]. These disparities likely reflect cultural, religious, and personal beliefs, accessibility to treatment, and health literacy – with many women favouring non-hormonal therapies in this transition [13,14]. Senior clinicians across Asia Pacific report that patients perceive MHT as being “unnatural” and fear side effects, particularly cancer risk, with many expressing preferences for non-hormonal options [15].

Physicians are well-placed to give accurate and updated patient education, potentially shifting patients’ negative attitudes to a more objective assessment of MHT, allowing patients to make a more informed decision on their own health and quality of life. However, patient perspectives may not solely explain low MHT utilisation. Physicians may represent a large barrier to accessibility of MHT, especially if they lack knowledge on safe prescribing of MHT, or are not kept up to date with evolving guidelines. Like patients, physicians may hold cultural, religious, or personal beliefs that could influence their own perspectives and attitudes towards MHT. With increasing access to information, emphasis on women’s health and conversations on menopause, patients may have more queries related to MHT use, providing an opportunity for physicians to provide accurate patient education.

Currently, limited data exists regarding physician’s knowledge adequacy and prescribing comfort levels. This study assessed knowledge and attitudes of local physicians towards MHT in Singapore, where menopause management is shared by family medicine physicians, gynaecologists, and endocrinologists. We aimed to evaluate physicians MHT knowledge accuracy, identify gaps and understand their attitudes. This information can guide educational initiatives to ensure physicians remain current with literature, enabling them to better advise and guide their patients with informed decision making and potentially reshaping negative attitudes with accurate, objective and more positive perspectives.

MATERIALS AND METHODS

This study was approved by the Singhealth Central Institutional Review Board (No. CIRB 2023/2186).

Study design and subjects

This is a cross-sectional study intended to assess knowledge and attitudes of physicians towards MHT. An anonymous questionnaire created by a secure government website (form.gov.sg/) was disseminated to physicians in the practice of seeing patients with menopause or prescribing MHT in Singapore via email circulation within their respective practice centers and societies. We collected information on age, gender, specialty, years of experience, and whether they prescribe MHT as part of their practice. Twenty-one questions assessed knowledge, and five questions were used to assess physician attitudes to MHT.

Questionnaire

The knowledge questionnaire was crafted to assess specific detailed questions on the use of MHT in patients. The 21 knowledge questions included: five questions on indications of MHT, five questions on contraindications to MHT and five questions on risks of MHT (fact recall). The remaining six questions were clinical scenarios crafted by the authors to test certain principles related to the use of MHT in the form of a multiple-choice question, with five options for each question. The clinical premise for these questions were - the requirement for treatment of premature ovarian insufficiency (POI) patients with hormones, safety of using MHT for severe menopausal symptoms in patients with a history of cervical squamous cell carcinoma, treatment options and considerations in breast cancer patients with severe vasomotor symptoms, preferred regimen of MHT in women as they age, and treatment of vaginal atrophy. All the above questions had an additional option of “unsure” or “beyond my expertise” as an option.

The correct answers for indications, contraindications and risks of MHT were based on what has been conventionally taught, verified with the 2016 IMS recommendations on women’s midlife health and MHT [7], The Menopause Society guidelines on MHT published in 2022 [8], and in line with Health Sciences Authority of Singapore’s recommendations. The correct answers for the clinical scenarios were determined by experts in the field of menopausal management, with each testing a specific principle.

The five attitude questions were yes/no questions derived from other published studies dealing with the same topic [16,17,18,19]. They assessed confidence in prescribing MHT, whether physicians would recommend their patients or family members to take MHT for troublesome menopausal symptoms, whether they believe it is an essential therapy to offer patients in the treatment of menopausal symptoms and whether the safety profile of MHT is concerning, regardless of the patient’s medical history.

The knowledge and attitudes questions asked are available in Appendix 1.

The questions received content validation from experts in the field. A small pilot group of physicians tested the questionnaire for clarity, relevance and ease of understanding. Feedback was obtained and the questionnaire was modified accordingly.

Statistical analysis

Data from the questionnaire was summarized using descriptive statistics. Means and standard deviations were computed for continuous variables, and frequency (count) and appropriate percentages were computed for categorical variables. Participants’ knowledge was assessed through four domains separately: indications, contraindications, risks, and clinical scenario questions. The total score of correct answers were computed for each domain, and for the entire instrument. Attitudes were assessed using five questions, and these were not scored.

Comparison of knowledge and attitudes across demographic variables, and across speciality (Family Medicine and Obstetrics & Gynaecology [O&G]) were conducted using t tests for continuous variables, and chi-squared tests for categorical variables. Where necessary, categories were collapsed to ease with the interpretation for larger cross-tabulations. Multivariable analyses were not conducted as our research study was a cross-sectional survey of a convenience sample. The a-priori primary interests were the associations between the demographic and work-related variables to the outcome variables.

Data was analysed using IBM SPSS Statistics Version 29 (IBM Co.) and P values less than 0.05 were considered as statistically significant.

RESULTS

One hundred ninety-eight responses were obtained, of which 186 were used in analysis (Fig. 1). Further details on the respondents’ profiles are detailed in Table 1. Responses from physicians not in the practice of menopause management (e.g., emergency medicine, ophthalmology) were removed from analysis. The participants’ characteristics are presented in Table 2. All respondents practice medicine in Singapore. One hundred seventeen (62.9%) were female and 69 (37.1%) were male. One hundred thirteen (60.8%) of physicians were trained or undergoing training in Family Medicine and 73 (39.2%) were from Obstetrics and Gynaecology. One hundred twenty-one (65.1%) of the physicians, worked in the public sector of healthcare while 55 (29.6%) worked in the private sector. Seventy-one (38.2%) participants had less than 10 years of clinical experience, 61 (32.8%) had between 10 and 20 years, and 54 (29.0%) had more than 20 years of clinical experience.

Fig. 1. Flowchart detailing participant responses. A&E: Accident and Emergency.

Table 1. Participant demographic, practice, and qualification characteristics.

		No. of participant (n = 186)
Age (y)
	20–30	27 (14.5)
	31–40	76 (40.9)
	41–50	37 (19.9)
	> 50	46 (24.7)
Gender
	Female	117 (62.9)
	Male	69 (37.1)
Specialty/subspecialty
	Family Medicine	113 (60.8)
	Obstetrics and Gynaecology	73 (39.2)
Highest qualification achieved
	Fellowship/advanced specialty training	57 (30.6)
	Masters and equivalents (e.g., MRCP, MRCGP)	59 (31.7)
	Graduate diploma	30 (16.1)
	MBBS/MD	40 (21.5)
Setting of work
	Public sector	121 (65.1)
	Private sector	55 (29.6)
	Both	10 (5.4)
Number of years in clinical practice (y)
	< 10	71 (38.2)
	10–20	61 (32.8)
	> 20	54 (29.0)
Actively prescribe MHT?
	Yes	50 (26.9)
	No	136 (73.1)
Frequency of prescription of MHT to new patients (n = 50)
	Less than once a year	3 (6.0)
	A few times a year	21 (42.0)
	Once a month	11 (22.0)
	Once a week	12 (24.0)
	Daily	3 (6.0)

Data are presented as number (%).

MRCP: member of the Royal College of Physicians, MRCGP: member of the Royal College of General Practitioners, MBBS: bachelor of medicine, bachelor of surgery, MD: doctor of medicine, MHT: menopause hormone therapy.

Table 2. Knowledge questions.

		Answer	Correct	Wrong or unsure
Indications
	Prevention of cardiovascular disease	No	65.1	34.9
	Vasomotor symptoms	Yes	93.5	6.5
	POI	Yes	92.5	7.5
	Prevention of post-menopausal osteoporosis	Yes	59.7	40.3
	Pre-menstrual syndrome	No	61.3	38.7
Contraindications
	Breast cancer	Yes	94.6	5.4
	Unexplained vaginal bleeding	Yes	96.8	3.2
	History of endometriosis	No	69.4	30.6
	Fatty liver without transaminitis	No	72.6	27.4
	History of provoked deep vein thrombosis	Yes	79.0	21.0
Risks
	Endometrial cancer	No	25.3	74.7
	Pulmonary embolism	Yes	88.7	11.3
	Gallbladder disease	Yes	33.9	66.1
	Breast cancer	Yes	90.3	9.7
	Stroke	Yes	69.4	30.6
Clinical scenario questions (6 options, including “beyond my expertise”) Premise for questions include
	Best MHT regime for a woman who has been amenorrhoeic < 1 year	-	37.1	62.9
	Treatment of POI with MHT	-	47.8	52.2
	Treating menopausal symptoms in patients with cervical cancer	-	55.4	44.6
	Treating menopausal symptoms in patients with breast cancer	-	21.0	79.0
	Recommended individualized MHT regime if there are safety concerns	-	26.9	73.1
	Treatment of vaginal atrophy	-	81.7	18.3

Data are presented as %.

POI: premature ovarian insufficiency, MHT: menopause hormone therapy, -: not available, refer to Appendix 1.

Of all the physicians, 136 (73.1%) described themselves as not actively prescribing MHT and 50 (26.9%) described themselves as actively prescribing MHT. Of the 136 who were not in the practice of prescribing MHT, six physicians previously did but stopped due to reasons of safety concerns or change in scope of their practice, with two respondents citing specifically their concern about WHI data.

Assessment of knowledge

Scores for the knowledge questions were analysed within their respective categories of indications, contraindications, risks and clinical scenario (or application) questions and are available in Table 2.

For indications, 40.3% of physicians were unaware that MHT is used in the prevention of post-menopausal osteoporosis, and 34.9% wrongly perceived that it was indicated for use in the prevention of cardiovascular disease. Thirty-eight point seven percent thought incorrectly that it was indicated for use in pre-menstrual syndrome. No significant difference was found across age, gender, qualifications, work setting, or years of clinical practice for this domain.

For contraindications, up to 30.6% of physicians mistakenly thought that fatty liver without transaminitis and endometriosis were contraindications to using MHT. Seventy-nine percent were aware that a history of deep vein thrombosis (DVT) was an absolute contraindication. The correct answer for this was based on conventional teachings that patients with a thrombotic history should not be prescribed MHT. More recently though, the 2024 IMS paper on controversies in MHT use that mentions patients with a history of DVT can still cautiously be prescribed MHT [3], speaking to the evolving nature of data on MHT use. Ironically, we found that there was a statistically significant association between years of clinical practice and the total score for contraindications (P = 0.006), with more experienced clinicians (> 20 years) scoring lower for contraindications than younger counterparts.

Despite MHT being relatively safe in the right populations at the right time, there are risks involved. Sixty-six point one percent of physicians were unaware that patients on MHT are at a higher risk of gallbladder disease, and 30.6% were unaware that the risk of stroke increases for patients on MHT. Seventy-four point seven percent of physicians wrongly thought the MHT increases the risk of endometrial cancer.

The clinical scenario multiple-choice questions were understandably answered poorly as they relied on deeper understanding of the use of MHT and individualization of therapy. Most physicians were unaware of how to individualize MHT regimes, were cautious about MHT use in patients with cervical cancer and were unaware of potential drug interactions between tamoxifen and certain selective serotonin reuptake inhibitors when used to treat specific menopausal symptoms. Generally, O&G physicians did better in this category for all questions than Family Medicine physicians, with the exception of the question on treatment of atrophic vaginitis. Most concerning is that 52.2% would have chosen non-hormonal treatments to treat patients with POI, even without contraindications to MHT. Physicians who actively prescribe MHT did significantly better in the clinical scenarios component, with 58% (n = 29) scoring at least four correct out of the six questions compared to 20.3% in the non-prescribing group, but there was no significant difference in knowledge scores for the domains of indications, contraindications, and risks.

Assessment of attitudes

The overall results are summarised in Figure 2.

Fig. 2. Attitudes towards MHT. MHT: menopause hormone therapy.

One hundred thirty-eight (74.2%) physicians were not confident in prescribing MHT for their patients. A significant difference (P < 0.001) was noted between the specialties, where only 58.9% of O&G physicians expressed a lack of confidence compared to 84.1% of Family Medicine physicians. Physicians in the private sector also tended to be more confident prescribing MHT, with 38.1% expressing confidence compared to 20.6% in public sector (P = 0.044). Confidence also increased progressively with qualifications (P < 0.001), from 10.0% for those with a basic medical degree (MBBS/MD) to 52.6% of those with a fellowship or equivalent qualification and with years of clinical experience. Interestingly, of those who actively prescribe MHT, only 60% expressed confidence in doing so. Beyond knowledge deficits, prescriber uncertainty may be related to confusion regarding formulation choices and administration routes, limited specialist support particularly for complex case discussions, time constraints preventing comprehensive assessment, and medicolegal concerns stemming from historical controversies. These doctors may also lack confidence in individualising treatment approaches and managing the nuanced adjustments required for optimal hormone therapy outcomes. These barriers can collectively impede effective menopause care delivery despite clinical need. Physicians who expressed confidence in prescribing MHT did better overall in the scores for risks and the six clinical questions, and were more likely to recommend MHT for themselves or a family member.

Although a large proportion were not confident to prescribe the drugs to their patients, 130 (69.9%) would still recommend that their patients take MHT for early menopause or troublesome menopausal symptoms, with 156 (83.9%) believing that it is an essential option to offer for treatment of perimenopausal symptoms. Physicians that recommend their patients, family members or self to take MHT for early menopause or troublesome menopausal symptoms were more likely to have overall better knowledge scores than those that did not, and they scored better particularly in the clinical scenario questions.

Overall, 114 (61.3%) physicians expressed concern about the safety profile of MHT regardless of the patient’s medical history. These 114 physicians scored significantly worse in the clinical scenario questions with 20.0% getting a score of at least 4/6 compared to 46.5% for physicians that did not have safety concerns. Ironically, the physicians with more than 20 years of clinical experience were more concerned about the safety profile than those with less experience. This could be due to more cautious practices, prior negative experiences or a niche practice resulting in a lack of expertise in menopausal management.

Those who believed MHT was an essential option to offer for the treatment of perimenopausal symptoms were more likely to recommend it to a patient or family member and were less concerned about the safety aspects of the drug.

DISCUSSION

In this study, we examined physicians’ knowledge and attitudes towards MHT, shedding light on their understanding and clinical practices. Our findings indicate that while many physicians have a foundational knowledge of MHT, significant gaps and misconceptions remain. Although most do not actively prescribe MHT, having adequate and updated knowledge is crucial for assessing patient suitability before the opportunity for effective intervention is lost. The relationship between knowledge and prescribing behaviour is vital [14]; physicians who feel uninformed are less likely to advocate for treatments that could significantly benefit their patients.

Knowledge

Our results revealed that while the majority of physicians did have some basic knowledge about MHT, there were some knowledge gaps that would be crucial to rectify. These include MHT being indicated for use in the prevention of osteoporosis, endometriosis and fatty liver not being contraindications, risks of MHT include gallbladder disease and stroke but not endometrial cancer, and that POI patients should be treated with MHT until the natural age of menopause.

The discrepancies in the knowledge amongst Family Medicine physicians and O&G physicians in their knowledge about MHT was expected – with Family Medicine physicians being more aware about fatty liver not being a contraindication as well as the gallbladder and stroke risk associated with MHT, and O&G physicians being more aware about endometriosis not being a contraindication and endometrial cancer not being a risk. Overall, O&G physicians did slightly better in the clinical scenario questions, implying better knowledge about the practical application of MHT use – possibly because a larger proportion of 70% of O&G physicians actively prescribe MHT, while only 28% of Family Medicine physicians do.

Responses regarding contraindications indicate that physicians tend to adopt a cautious approach toward MHT. Many believed that conditions such as fatty liver without transaminitis and endometriosis were contraindications. There was also significant caution expressed in clinical scenario question where hormones were preferentially avoided in cases of cervical cancer, even when medically indicated [20,21,22]. This caution aligns with our finding that more than half of the physicians have safety concerns about MHT. This risk aversion implies that patient safety is prioritised, but it may come at the cost of effective symptom management, leading to under-treatment of menopausal symptoms and, consequently, a diminished quality of life.

The prevalent misconception that MHT increases the risk of endometrial cancer is a finding echoed in other studies [23]. While unopposed estrogen does elevate the risk of endometrial cancer, when used appropriately with adequate progesterone in women with an intact uterus, MHT does not pose this risk. The fear of cancer associated with MHT is a significant barrier for patients considering this therapy, making it crucial for physicians to provide accurate information about cancer risks [13,14]. A physician’s apprehension can influence patient decisions, emphasising the need for a balanced view on the true risk-benefit ratio of MHT.

Of particular concern is that more than half the physicians would not have treated a patient with POI with MHT. Global studies have estimated the pooled prevalence of POI to be 3.5%–3.7% [24]. This implies that a large proportion of POI patients may not receive the cardiovascular and bone-protective effects of MHT, augmenting their risk of cardiovascular disease and osteoporosis at a younger age, and the morbidity associated with these conditions [25,26,27]. In an ageing society, it is important that we view a woman’s health longitudinally, with the aim to delay the onset of disease and maximise quality of life. Physicians need to be aware that in the setting of POI and early menopause, MHT use should be considered for its cardioprotective and bone-decelerating effects, before the window of opportunity is missed [28,29].

Attitudes

In line with a low utilization rate locally of 8.8% [12], our finding is that many physicians (74.5%) expressed a lack of confidence in prescribing MHT. This may be one of the significant barriers in the use of MHT – and can be contributed by lack of knowledge or existing misconceptions. In our study, confidence correlated with better scores on the clinical application questions on knowledge (which reflect real-life case scenarios) – proving that better knowledge is associated with more confidence in using MHT. A review article echoed that a significant barrier to health care professionals prescribing MHT was the deficient knowledge of the true evidence-based information, with inadequate training regarding the efficacy and safety of personalized MHT and the real risk-benefit ratio in the treatment of symptomatic women [14]. This is an easy barrier to overcome, with appropriate training and education directed towards physicians that will encounter these women in their practice, and access to the latest evidence-based medicine around menopause.

The safety profile of MHT has been challenged across the years, from the time the initial WHI study was published in 2002 to today – where cardiovascular concerns have been diminished but cancer concerns still exist [30]. The data around MHT is constantly evolving but the perspectives of physicians may have yet to catch up. Sixty-one point three percent of physicians are still concerned about the safety profile of MHT – and even more so amongst the more senior clinicians. This could be due to the need for safe practice in a highly litigious environment but may reflect overly cautious behaviours. Fortunately, about 84% of physicians believe it is an essential treatment to offer – and although most may not be the ones prescribing MHT, the hope is that they can identify the patients that would benefit from its use safely and refer these patients on.

We also identified a gap between knowledge and prescribing behaviour. Eighty-four percent of respondents recognized MHT as an essential treatment option for women experiencing troublesome menopausal symptoms, yet only 70%–73% would offer it to patients, family members, or use it themselves. Ninety-two point five percent of respondents indicated that MHT is indicated for POI; however, fewer than half of the respondents (48.4%) indicated they would treat patients with POI using hormones. It appears that knowledge did not always translate into prescribing behaviour. This discrepancy suggests that barriers to recommending and hence prescribing MHT extend beyond knowledge; factors such as lack of confidence, safety concerns, and personal or cultural preferences, or biases may also play significant roles.

Strengths and limitations

This study is the first of its kind locally to assess knowledge and attitudes towards MHT. We were able to identify common misconceptions about MHT and whether physicians are comfortable with using MHT. The information gathered can help shape educational initiatives and guide curriculum for physicians to keep abreast of the latest evidence and clinical guidelines – this would hopefully not just enlighten but also change negative attitudes towards MHT that exist. Eventually, the aim is to improve accessibility of MHT to the eligible population and improve patient outcomes.

There are some limitations of our study. Results may not be generalizable to the entire physician population, or even of those in the various specialties. Endocrinologists, some of whom see menopausal patients were omitted from this study due to very small numbers. Physicians more familiar with or interested in menopause were more likely to participate in this study. As respondents were allowed to use their own phones and not monitored during answering of the questions, they may have sought help or used search engines to obtain the answers required. Our questionnaires were not fully validated for use in our population (and none currently exist in the literature), though self-crafting enabled us to focus on specific information that we wanted to assess. Self-reported knowledge surveys do not accurately predict performance in a clinical setting and should not be used in isolation to reflect clinical competence. However, our questions may not have captured all aspects of an attitude assessment or reasons behind certain beliefs, limiting the depth of insight.

CONCLUSION

The results of this study highlight the need for targeted educational interventions and guidelines to improve physicians’ knowledge and confidence regarding MHT. Although many physicians possess a foundational understanding of MHT, significant gaps and misconceptions remain, with discrepancies between knowledge and prescribing practices. While a cautious approach, rooted in valid safety concern, is commendable, it may inadvertently prevent eligible women from accessing effective treatment for menopausal symptoms and increase the risk of osteoporosis in at-risk populations, such as those with POI.

Information related to the use of MHT in clinical guidelines is constantly evolving as new data gets published – what was previously recognised as fact-recall may soon fall into grey areas as new evidence emerges. Clinicians in the practice of menopausal management should keep abreast on the latest information on MHT use, as new recommendations may surface. Furthermore, with the rise of social media and other platforms, patients are better informed and will want to discuss treatment to improve their quality of life. By equipping physicians with accurate, up-to-date information, we can bolster their confidence and reshape their attitude towards MHT. Positive physician attitudes can shape patient perspectives, promoting a balanced view of MHT, empowering patients to make informed decisions about their health.

Appendix 1

Questionnaire details

MHT: menopause hormone therapy, FSH: follicle stimulating hormone, BMI: body mass index.