Table 1.

Emergent Themes from Qualitative Interviews with Physicians at Two Health Care Organizations

No.	Theme	Quotes
1a	WHI was an important groundbreaking study that changed clinical practice	“A good study that really changed the way everybody practiced.”
		“Prior to WHI my colleagues were pressuring me to write more prescriptions for HT. I was always cautious about using HT. So, after WHI, I felt relief to be able to practice closer to what I believe.”
		“I’m eternally grateful to it [the WHI]. I think being a large prospective study that carries statistical weight makes it easier to say, ‘Based upon what we know now, this is the information that you need to use to make your decision. Then you can go ahead and make it.’”
		“It [the WHI] has made my life much simpler and much more straightforward. I have no troubles with it at all.”
		“Publicity [from WHI] helped more than harmed, because I think people became more aware of osteoporosis risks, and just became more aware about the quality-of-life issues surrounding menopause.”
1b	WHI influenced how physicians counsel women about HT	“Women are in control. It is their decision.”
		“I am happy when they [women patients] don’t bring it up. I felt better 10 years ago being ignorant and saying ‘HT will even cure heart disease.’”
		“There’s no longer a treatment for women with menopausal symptoms; there’s calcium and vitamin D for bones, but other than that, there is nothing else.”
		“It’s a woman’s choice. After describing the risk factors, if in 10 years she gets breast cancer, will she look back at her decision to take HT?”
		“Some women want doctors to tell them what to do. I start from where a woman is at. I can’t make the decision for her. There are no right or wrong answers: There are risks of taking and not taking.”
2	WHI is not applicable to the women I see	“WHI does not represent all women, I mean the population in that study was a little bit older, the majority were anywhere from 5 to 10 years remote from menopause.”
		“WHI applies only to older [women], 5–10 years remote from menopause. They do not have severe symptoms, and they may have started it for prevention.”
		“WHI published risks for heart disease are very minimal; there’s maybe an increased risk of cardiovascular disease, but it’s very minimal.”
		“The study applied to a particular group of patients. It doesn’t apply to most of the patients I’m talking to.”
		“The other problem with the study of course is that most of the women I treat are starting their HT early because they’re symptomatic. They’re not starting it from the age of 65 and I don’t know if that’s a different route than the women who are not symptomatic and being started on it for the WHI. So I’m not sure I’m comparing my group of patients to the group that was in the study.”
3	WHI raised concerns about the impact of health information on women	“Too much misinformation leads to confusion.”
		“[WHI] was blown out of perspective; the risks have been vastly overplayed in the public mind even in the mind of medical professionals.”
		“The media has not been helpful... It’s all scare–scare–scare–scare... I’ve never seen a television presentation that talked about the gray areas. They never give the absolute numbers. It’s always, ‘[HT] raises risks.’ They use inflammatory language.”
		“The people who are on it [HT] want to try to go off of it certainly more readily because of everything they’ve read and the fear factor with it.”
		“Women are ill-informed; I think the best way for women to get the information is from a health care provider in both verbal and printed form.”
		“Some women have seen so many studies that they don’t believe anything—and the HT helps them, so they don’t really want to change.”
4	WHI created uncertainty in the scientific evidence	“It raised more questions than it answered.”
		“Everybody is different in what symptoms they might perceive from a sudden loss of estrogen, and how they might respond to various compounds.”
		“Knowing how things have gone in medicine, I don’t want to say it [the WHI] is the final word.”
		“I am not convinced of the data.”
		“One study does not usually erase all prior research.”
		“We need another study that follows women from the perimenopausal transition through after menopause.”
		“There are still a zillion unanswered questions. There are still uncertainties.”
		“Neither of us is satisfied with our current treatment or explanations at this point.”
		“Science changes, and that’s a lesson I try to also talk to my patients about. I say [to my patients], ’Bring this up every time you have a well visit, because there may be new science in two or three years, and I may be telling you something different, and the story does change.’”
		“I’m not at all sure that the net effect of it [WHI] is going to do more good than harm. If you look at all of the ramifications and effects on women’s health that this study has produced [the sum], it could easily be negative.”
5	Physicians lack information and decision aids	“It’s hard to keep up with the literature.”
		“Researchers at the WHI released results before preparing physicians. We were not adequately armed with information. This continues to be a problem as more papers are coming out of the WHI.”
		“Things have changed so much, and there’s really not any current information on what to do.”
		“I am looking for some sort of statement of what to do. I haven’t seen anything in print from any national organization that really tells you what to do.”
		“I’d like to know how to counsel women: how directive to be, whether to recommend [HT] versus let a woman decide versus individualize.”
		“If somebody would think through the decision-making tree in a careful way and work out an algorithm that a clinician could use—or even one that the patient could use based on real evidence—that would be a very useful thing.”
6	Physicians are using various discontinuation strategies	“That’s the art, not the science, of medicine.”
		“If they have a significant risk of heart disease, I tell them to come off. I gave everyone a year to think about it.”
		“Every other day unless on high dose, for two weeks to one month; then take every third day, then two times per week.”
		“I ask them how long they’ve been on HT and if they’re aware of the new information suggesting risk for breast cancer and dementia. I ask, ‘Are you interested in working with me to taper you off?’ and I try to make it, I guess the buzzwords are a shared decision about the benefits and risks of staying on, and then work with trying to taper them off if they’re willing.”
7	The silver lining in WHI is a chance for discussion	“An opportunity to discuss important issues of lifestyle, health habits, and aging in general.”
		“It is a doorway for discussing other issues: lifestyle, quality of life, aging, planning for the next 50 years. It’s more important than the HT [to] plant those seeds regarding lifestyle and aging.”
		“Some women are in denial about being overweight or diabetic. So I use the estrogen discussion to get to the importance of lifestyle. ‘Are you exercising? This [exercise] is good for everything.’ The biggest challenge for women is to learn how to start ‘taking care of me’ [themselves].”
		“Everyone is hemming and hawing over an odds ratio of 1.2; and yet, if they exercised and got their weight appropriate, they could make huge differences in many other things.”
		“The physical part of menopausal symptoms is less of an issue for women than the changes in lifestyle, social, and environmental stresses.”
		“I think that it’s important for physicians to know enough about their patient and have an understanding of their patients’ lifestyle so that they can have that kind of discussion with them.”