Cost-effectiveness analysis of single-dose or 2-dose of bivalent, quadrivalent, or nonavalent HPV vaccine in a low/middle-income country setting.

OBJECTIVE: To compare the health impact and economic benefits among individuals who did not receive the human papillomavirus (HPV) vaccine to those who received a single dose, or 2 doses. The comparison was stratified by 4 types of vaccine in conjunction with primary HPV screening in a low/middle-income country setting. METHODS: A Markov model was employed to simulate HPV infection and cervical cancer in a cohort of 100,000 12-year-old girls free of HPV. The study scrutinized 9 strategies: 1 dose and 2 doses of 2vHPV (Cervarix®), 2vHPV (Cecolin®), 4vHPV (Gardasil®), 9vHPV vaccine (Gardasil9®), and no vaccination. The primary outcome measure was the quality-adjusted life year (QALY) of each strategy. Incremental cost-effectiveness ratios were estimated over a lifetime horizon, accompanied by sensitivity analyses conducted. RESULTS: All vaccination programs yielded 41,298-71,057 QALYs gained accompanied by cost savings of 14,914,186-19,821,655 USD compared to no vaccination. Administering 2 doses of 9vHPV vaccine emerged as the most cost-effective strategy, boasting 406 USD/QALY, within a lower willingness to pay threshold. Sensitivity analysis demonstrated an 80% probability of the cost-effectiveness of the 2 doses of 9vHPV vaccine regimen. Furthermore, uncertainty around the costs of vaccination and vaccine efficacy exerted the most substantial influence on the cost-effectiveness findings. CONCLUSION: Oping for 2 doses of 9vHPV vaccine in conjunction with a primary HPV screening represents the most cost-effective option for implementing a school-based HPV vaccination program targeting 12-year-old girls in Thailand. Such findings provide valuable insights for policymakers in the realm of cervical cancer prevention.

The epidemiologic and economic impact of a quadrivalent human papillomavirus vaccine in Thailand.

BACKGROUND: The human papillomavirus (HPV) vaccine was introduced into Thailand's national immunization program in 2017 for 11-12 year old school girls. The objectives of this study were to examine the epidemiological consequences and cost-effectiveness of a routine quadrivalent HPV (4vHPV) vaccination and the routine 4vHPV vaccination plus 5-year catch-up vaccination by comparing with cervical cancer screening only (no vaccination) in Thailand. METHOD: A transmission dynamic model was used to assess the cost-effectiveness of the routine 4vHPV vaccination and the routine 4vHPV vaccination plus catch-up vaccination, compared with no vaccination (screening only) in Thai population. The vaccination coverage rate assumptions were 95% in 11-12-year-old girls for the routine vaccination and 70% in 13-24 year-old females for the 5-year catch-up vaccination. Vaccination costs, direct medical costs of HPV-related diseases, and the number of quality of life years (QALYs) gained were calculated for over a 100-year time horizon with discount rate of 3%. RESULT: The model indicated that the routine 4vHPV vaccination and the routine plus catch-up 4vHPV vaccination strategies could prevent approximately 434,130 and 472,502 cumulative cases of cervical cancer, 182,234 and 199,068 cumulative deaths from cervical cancer and 12,708,349 and 13,641,398 cumulative cases of HPV 6/11 related genital warts, respectively, when compared with no vaccination over 100 years. The estimated cost per QALY gained (ICER) when compared to no vaccination in Thailand was 8,370 THB/QALY for the routine vaccination and 9,650 THB/QALY for the routine with catch-up vaccination strategy. CONCLUSION: Considering the recommended threshold of 160,000 THB/QALY for Thailand, the implementation of the routine 4vHPV vaccination either alone or plus the catch-up vaccination was cost-effective as compared to the cervical cancer screening only.

Cost-Effectiveness of Primary HPV Screening Strategies and Triage With Cytology or Dual Stain for Cervical Cancer.

To identify the optimal cost-effective strategy for cervical cancer screening program in Thailand by comparing the different algorithms which based on the use of primary human papilloma virus (HPV) assay. We use a Microsoft Excel-based spreadsheet to calculate the accumulated cases of preinvasive and invasive cervical cancer and the budget impact of each screening program. The model was developed to determine the cost-effectiveness of 3 screening strategies: pooled HPV test with reflex liquid-based cytology triage, HPV genotyping with reflex p16/ki67 dual stain cytology, and pooled HPV test with dual stain. The main outcomes were the total cost, incremental quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs). Strategy entailing primary HPV genotyping and reflex dual stain cytology is the least costly strategy (total cost US$37 893 407) and provides the similar QALY gained compared to pooled high-risk HPV testing with reflex dual stain (Average QALY 24.03). Pooled HPV test with reflex dual staining is more costly compared to strategy without reflex dual staining. The ICER was US$353.40 per QALY gained. One-way sensitivity analysis showed that the model is sensitive to the cost of dual stain and the cost of cancer treatment. Decreasing the incidence of cervical cancer case and increasing the QALYs can be successful by using dual stain cytology as the triage test for pooled HPV test or HPV genotyping. The result of our analysis favors the use of HPV genotyping with the reflex dual stain as it offers the most QALY at the lowest cost.

Cost effectiveness analysis of HPV primary screening and dual stain cytology triage compared with cervical cytology.

OBJECTIVES: To assess the clinical and cost-effectiveness of human papillomavirus (HPV) primary screening triage with p16/Ki-67 dual stain cytology compared to cytology. METHODS: We conducted an Excel®-based budget impact model to estimate the preinvasive and invasive cervical cancer cases identified, mortality rate, direct medical costs, quality-adjusted life years (QALYs) and the incremental cost-effectiveness analysis of two strategies from the healthcare payer perspective. The study population is a cohort of women 30-65 years of age presenting for cervical screening. RESULTS: HPV primary screening triage with p16/Ki-67 dual stain showed higher sensitivity without losing specificity compared to conventional Pap smear. The improving the screening performance leads to decrease the prevalence of precancerous lesion, annual incidence and mortality of cervical cancer. The incidence of cervical cancer case detected by new algorithm compared with conventional method were 31,607 and 38,927, respectively. In addition, the new algorithm was more effective and more costly (average QALY 24.03, annual cost $13,262,693) than conventional cytology (average QALY 23.98, annual cost $7,713,251). The incremental cost-effective ratio (ICER) per QALY gained was $1,395. The sensitivity analysis showed if the cost of cytology and HPV test increased three times, the ICER would fall to $303/QALY gained and increased to $4,970/QALY gained, respectively. CONCLUSION: Our model results suggest that screening by use of HPV genotyping test as a primary screening test combined with dual stain cytology as the triage of HPV positive women in Thai population 30-65 years old is expected to be more cost-effective than conventional Pap cytology.

Cost-effectiveness analysis study of HPV testing as a primary cervical cancer screening in Thailand.

OBJECTIVES: The aim of this study is to compare the cost and benefit of four different cervical cancer screening strategies involving primary HPV 16/18 genotyping, hrHPV testing alone and cytology for detecting CIN2 +. METHODS: Economical analysis using Markov modeling approach to combine the epidemiological data from current population-based study of The National Cancer Institute of Thailand. A cohort of 100,000 hypothetical female population age 30-65 years was simulated in each strategy. The compared strategies are HPV 16/18 genotyping with reflexed cytology, hrHPV testing alone followed by colposcopy, Papanicolaou standard cytology and liquid based cytology followed by colposcopy. The interval of screening was 5 years' interval. The main outcomes were defined as a number of CIN2 + cases and cost per 100,000 women screening over 35 years. RESULTS: Model predictions indicated that, the most cost-effectiveness strategy is hrHPV testing alone by reducing cost and also increase CIN2 + detection rate. It identify an additional 130 cases and decrease cost by 46,950,840 THB (1,394,441 USD) per 100,000 women screened when compared to HPV 16/18 genotyping. Compared with cytology, hrHPV testing decrease cost by 51,279,781 THB (1,523,011 USD) and detected more 506 cases of CIN2 +. From sensitivity analysis, the cost of HPV testing, cost of colposcopy, incidence of HPV infection and sensitivity of cytology may affect the results. (1 USD = 33.67 Baht). CONCLUSION: The results of this cost-effectiveness analysis support the full scale implementation of HPV testing as a primary cervical cancer screening in Thailand.

A Model Approach for Assessing the Benefits of HPV Testing against Cytology in Screening for Cervical Cancer Precursors in Thailand

Objective: The aim of this study was to compare the efficacy of HPV 16/18 genotyping test, high risk HPV DNA testing, alone and in conjunction with the liquid-based cytology method in screening for cervical cancer precursors. Methods: A Markov model was used to describe the course of the cases of CIN2+ that had been detected over a 35 year period. Screening programs started at age 30 and were performed at an interval of once every five years. The model compared three strategies of HPV 16/18 genotyping with reflex cytology triage, high-risk HPV testing alone with referral to colposcopy and cytology-based screening with referral to colposcopy. We assumed the rate of patients lost to follow-up for those referred to colposcopy would be 0%. The clinical parameters were estimated using the data from a study conducted by the Thailand National Cancer Institute. Result: Of the three screening strategies evaluated, the high risk HPV DNA testing alone was the most effective for detecting CIN2+ over the 35 year study period. It detected 143 and 510 cases per 100,000 women more than the HPV 16/18 genotyping test and cytology-based strategy, respectively. The HPV genotyping test detected 368 cases per 100,000 women more than the cytology-based approach. In addition, when viewed with five year intervals, there were missed cases totaling approximately half of the detected cases screened by the cytology strategy and 10% of cases detected with screening by the HPV genotyping test. Conclusion: This study strongly indicates that HPV/DNA testing is preferable to cytology-based screening for cervical cancer precursors. However, the balance between the benefits, burdens and cost of each screening program should be considered.

Cost Effectiveness Analysis of Different Management Strategies between Best Supportive Care and Second-line Chemotherapy for Platinum-resistant or Refractory Ovarian Cancer.

BACKGROUND: There is no standard treatment for patients with platinum-resistant or refractory epithelial ovarian cancer. Single agent chemotherapies have evidence of more efficacy and less toxicity than combination therapy. Most are very expensive, with appreciable toxicity and minimal survival. Since it is difficult to make comparison between outcomes, economic analysis of single-agent chemotherapy regimens and best supportive care may help to make decisions about an appropriate management for the affected patients. OBJECTIVE: To evaluate the cost effectiveness of second-line chemotherapy compared with best supportive care for patients with platinum-resistant or refractory epithelial ovarian cancer. MATERIALS AND METHODS: A Markov model was used to estimate the effectiveness and total costs associated with treatments. The hypothetical patient population comprised women aged 55 with platinum-resistant or refractory epithelial ovarian cancer. Four types of alternative treatment options were evaluated: 1) gemcitabine followed by BSC; 2) pegylated liposomal doxorubicin (PLD) followed by BSC; 3) gemcitabine followed by topotecan; and 4) PLD followed by topotecan. Baseline comparator of alternative treatments was BSC. Time horizon of the analysis was 2 years. Health care provider perspective and 3% discount rate were used to determine the costs of medical treatment in this study. Quality-adjusted life-years (QALY) were used to measure the treatment effectiveness. Treatment effectiveness data were derived from the literature. Costs were calculated from unit cost treatment of epithelial ovarian cancer patients at various stages of disease in King Chulalongkorn Memorial Hospital (KCMH) in the year 2011. Parameter uncertainty was tested in probabilistic sensitivity analysis by using Monte Carlo simulation. One-way sensitivity analysis was used to explore each variable's impact on the uncertainty of the results. RESULTS: Approximated life expectancy of best supportive care was 0.182 years and its total cost was 26,862 Baht. All four alternative treatments increased life expectancy. Life expectancy of gemcitabine followed by BSC, PLD followed by BSC, gemcitabine followed by topotecan and PLD followed by topotecan was 0.510, 0.513, 0.566, and 0.570 years, respectively. The total cost of gemcitabine followed by BSC, PLD followed by BSC, gemcitabine followed by topotecan and PLD followed by topotecan was 113,000, 124,302, 139,788 and 151,135 Baht, respectively. PLD followed by topotecan had the highest expected quality-adjusted life-years but was the most expensive of all the above strategies. The incremental cost-effectiveness ratios (ICER) of gemcitabine followed by BSC, PLD followed by BSC, gemcitabine followed by topotecan and PLD followed by topotecan was 344,643, 385,322, 385,856, and 420,299 Baht, respectively. CONCLUSIONS: All of the second-line chemotherapy strategies showed certain benefits due to an increased life- year gained compared with best supportive care. Moreover, gemcitabine as second-line chemotherapy followed by best supportive care in progressive disease case was likely to be more effective strategy with less cost from health care provider perspective. Gemcitabine was the most cost-effective treatment among all four alternative treatments. ICER is only an economic factor. Treatment decisions should be based on the patient benefit.

Cost-Effectiveness Analysis of Different Management Strategies for Detection CIN2+ of Women with Atypical Squamous Cells of Undetermined Significance (ASC-US) Pap Smear in Thailand.

BACKGROUND: To identify the optimal cost effective strategy for the management of women having ASC-US who attended at King Chulalongkorn Memorial Hospital (KMCH). DESIGN: An Economical Analysis based on a retrospective study. SUBJECT: The women who were referred to the gynecological department due to screening result of ASC-US at King Chulalongkorn Memorial Hospital, a general and tertiary referral center in Bangkok Thailand, from Jan 2008 - Dec 2012. MATERIALS AND METHODS: A decision tree-based was constructed to evaluate the cost effectiveness of three follow up strategies in the management of ASC-US results: repeat cytology, triage with HPV testing and immediate colposcopy. Each ASC-US woman made the decision of each strategy after receiving all details about this algorithm, advantages and disadvantages of each strategy from a doctor. The model compared the incremental costs per case of high-grade cervical intraepithelial neoplasia (CIN2+) detected as measured by incremental cost-effectiveness ratio (ICER). RESULTS: From the provider's perspective, immediate colposcopy is the least costly strategy and also the most effective option among the three follow up strategies. Compared with HPV triage, repeat cytology triage is less costly than HPV triage, whereas the latter provides a more effective option at an incremental cost-effectiveness ratio (ICER) of 56,048 Baht per additional case of CIN 2+ detected. From the patient's perspective, the least costly and least effective is repeat cytology triage. Repeat colposcopy has an incremental cost-effectiveness (ICER) of 2,500 Baht per additional case of CIN2+ detected when compared to colposcopy. From the sensitivity analysis, immediate colposcopy triage is no longer cost effective when the cost exceeds 2,250 Baht or the cost of cytology is less than 50 Baht (1USD = 31.58 THB). CONCLUSIONS: In women with ASC-US cytology, colposcopy is more cost-effective than repeat cytology or triage with HPV testing for both provider and patient perspectives.

Should we use the shorter Thai-version quality of life and symptoms questionnaires in women with overactive bladder?

AIM: The aim of this study was to test: (i) the validation and reliability of the Thai versions of overactive bladder (OAB) questionnaires (the 8-item and 3-item Overactive Bladder Symptoms Score questionnaires [OAB-v8 and OAB-v3, respectively] and the Overactive Bladder Questionnaire [OAB-q]); and (ii) the correlation of the OAB-v8, OAB-v3, and the single-question Quality of Life Questionnaire (1-QoL) to the OAB-q in Thai women with OAB. MATERIAL AND METHODS: During January to March 2011, 36 Thai women with OAB attending a urogynecology clinic at Chulalongkorn Hospital, Bangkok, Thailand were recruited. All questionnaires were given as a psychometric test twice, 2 weeks apart. RESULTS: Cronbach's alpha of the OAB-v8 was higher (and above 0.7) than OAB-v3 at both week 0 and week 2. The intraclass correlations (ricc ) were 0.64, 0.85, and 0.97 for the OABV8, OAB-v3, and OAB-q, respectively. The correlation coefficient (r) of OAB-v3 and OAB-q at weeks 0 and 2 (0.40 and 0.49) were lower than those for OAB-v8 and OAB-q at weeks 0 and 2 (0.62 and 0.62). All questions on the OAB-v3 had a lower weighted kappa than OAB-v8. There was no statistically significant difference in the OAB-q score in each level of 1-QoL score at week 0 (P = 0.12) and at week 2 (P = 0.29). CONCLUSION: The reliability of the OAB-v3 is poorer than that of the OAB-v8. The OAB-v3 is poorer correlated to the OAB-q than to the OAB-v8. A short questionnaire, such as the OAB-v3 and the 1-QoL, has poor reliability and is poorly correlated to the OAB-q and is not recommended as a replacement for the standard questionnaires, such as the OAB-q and the OAB-v8. The OAB-v3 should only be used in large screening populations where there are time limits.

Cost and effectiveness evaluation of prophylactic HPV vaccine in developing countries.

BACKGROUND: Approximately 80% of cervical cancer cases occur in developing countries. In Thailand, cervical cancer has been the leading cancer in females, with an incidence of 24.7 cases per 100,000 individuals per year. OBJECTIVES: We constructed a decision model to simulate the lifetime economic impact for women in the context of human papillomavirus (HPV) infection prevention. HPV-related diseases were of interest: cervical cancer, cervical intraepithelial neoplasia, and genital warts. The two strategies used were 1) current practice and 2) prophylactic quadrivalent vaccine against HPV types 6, 11, 16, and 18. METHODS: We developed a Markov simulation model to evaluate the incremental cost-effectiveness ratio of prophylactic HPV vaccine. Women transition through a model either healthy or developing HPV or its related diseases, or die from cervical cancer or from other causes according to transitional probabilities under the Thai health-care context. Costs from a provider perspective were obtained from King Chulalongkorn Memorial Hospital. Costs and benefits were discounted at 3% annually. RESULTS: Compared with no prophylactic HPV vaccine, the incremental cost-effectiveness ratio was 160,649.50 baht per quality-adjusted life-year. The mortality rate was reduced by 54.8%. The incidence of cervical cancer, cervical intraepithelial neoplasia grade 1, cervical intraepithelial neoplasia grade 2/3, and genital warts was reduced by up to 55.1%. CONCLUSION: Compared with commonly accepted standard thresholds recommended by the World Health Organization Commission on Macroeconomics and Health, the nationwide coverage of HPV vaccination in girls is likely to be cost-effective in Thailand.

Quality of life among Thai women diagnosed with cervical cancer and cervical intraepithelial neoplasia at King Chulalongkorn Memorial Hospital.

OBJECTIVE: To determine health related quality of life (QoL) of patients diagnosed with cervical intraepithelial neoplasia (CIN) and cervical cancer compared QoL among stages of cancer and to study the association between QoL and patients' characteristics. MATERIAL AND METHOD: The questionnaire elicited information and QoL using Functional Assessment of Cancer Therapy General (FACT-G) questionnaire. The study population was patients with a diagnosis of one of the four FIGO stages of cervical cancer RESULTS: One hundred seventy two patients completed the present study. The adjusted mean scores QoL was 78.76. There were no significant differences between FIGO stages on the global QoL and subscale. The authors found negative association between age and physical wellbeing scores (p = 0.049) and a positive association between age and emotional wellbeing scores (p = 0.004). Lower educational attainment was associated with higher emotional wellbeing scores (p = 0.004). CONCLUSION: For many patients, family, religion, or psycho-social support may be considered a necessity. The younger and better-educated groups may require more information and psycho-emotional support.

Participatory ergonomics intervention for improving work-related musculoskeletal disorders in the 'One Tambon One Product' industry in Thailand.

This paper relates to the first phase one of a three-phase study. Phase 1 investigated and identified risk factors for work-related musculoskeletal disorders (WMSDs) in 26 'One Tambon One Product' (OTOP) groups working in the informal sector. Data was collected from 93 participants in Khangkoi District, Saraburi Province, Thailand during 2009-2010. Results of inspections and direct observations of work places and interviews of managers and workers showed risk factors related to posture, repetition, force and duration in the workers' operations and the application of a checklist revealed that the OTOP groups had simple work processes. A knowledge-attitude-practice survey of managers and workers indicated that there was a moderate to high awareness regarding ergonomics and occupational safety and health principles and approximately 15% of workers reported WMSDs at a moderate level, mainly associated with lower back and shoulder pains, due to protracted periods of sitting. Specific recommendations in response to OTOP conditions and needs were made. The second phase of the study involves a participatory ergonomics worksite intervention by a number of stakeholders and the final phase deals with an evaluation of the intervention and an establishment of guidelines for ergonomics programs for OTOP groups.

WITHDRAWN: Argon plasma coagulation therapy for acute non-variceal upper gastrointestinal bleeding.

BACKGROUND: Endoscopic treatment is recommended for initial hemostasis in non-variceal upper gastrointestinal bleeding. Many endoscopic hemostatic devices are used. Argon Plasma Coagulation (APC) is an alternative. OBJECTIVES: This study reviews all available literature to access the efficacy of APC compared to other endoscopic therapies in the control of acute non-variceal upper GI hemorrhage. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4 2003), MEDLINE 1966 to December 2003, EMBASE 1980 to December 2003, Web of Science for SCISEARCH (1980 to December 2003), BIOSIS (1985 to December 2003), and the National Research Register Issue 4 2003. We also handsearched abstracts from conference proceedings of the United European Gastroenterology Week and Digestive Disease Week. SELECTION CRITERIA: Randomized, controlled trials of APC compared with other endoscopic hemostasis interventions in the treatment of non-variceal upper gastrointestinal bleeding. DATA COLLECTION AND ANALYSIS: Two reviewers assessed trial quality and independently extracted data. MAIN RESULTS: Two trials involving 121 people were included. There was no common intervention to pool. One trial compared APC to heat probe, another trial compared APC to injection sclerotherapy. There was no significant difference between groups in either of these trials. AUTHORS' CONCLUSIONS: On the basis of the two randomised controlled trials identified in this review, there is no evidence to suggest that APC is superior to other endoscopic therapies. Further randomised controlled trials are needed.

Initial signs and symptoms as prognostic indicators of severe gastrointestinal tract injury due to corrosive ingestion.

Corrosive ingestion can produce severe upper gastrointestinal tract injury with long-lasting suffering and even death. Early assessment of the extent of damage is important, not only for treatment, but also for hospitalization. We did a prospective study to determine the prognostic value of initial signs and symptoms as indicators of the degree of gastrointestinal injury. We found that drooling saliva, buccal mucosa burn, and white blood cell count were significant independent predictors. The simple chart, "Med-TU chart," has been developed. We consider it to be a useful tool for emergency physicians who evaluate patients with corrosive ingestions.

Cost comparison of rabies pre-exposure vaccination with post-exposure treatment in Thai children.

Thailand is a canine rabies endemic country with an annual prevalence above 1,000 reported animals diagnosed rabid . Over 345,000 humans are treated for possible rabies exposures annually . Lack of perception of the disease burden, social, cultural and traditional beliefs play an important role in the failure of canine rabies control. It is unfortunate that health care budgets are increasingly allocated to human post-exposure treatment rather than to the eradication of rabies in the canine animal vector. Children under the age of 15 years represent up to one-half of dog bite victims and of human rabies deaths, but accurate data of dog bite prevalence are not available . Large scale pre-exposure immunization of children has been advocated but financial and logistic barriers have hindered implementation. This study analyzes direct medical costs of pre-exposure vaccination (PREP) as a human rabies preventive strategy, against the cost of post-exposure prophylaxis (PEP) in Thai children. Three pre- and post-exposure vaccine regimens are in use and this impacts on cost calculations. It was found that costs of both strategies, PREP of children or PEP of exposed, become equal when the dog bite incidence is 2-30%; depending on which post-exposure treatment regimens (PEP) are used.

Hormone replacement therapy: attitude and acceptance of Bangkokian women.

OBJECTIVE: To conduct a hospital-based survey to assess women's attitude and acceptance towards menopause and hormone replacement therapy (HRT). METHOD: The authors conducted a survey in women who visited the menopause clinic in 5 university and public hospitals in Bangkok. A group of 615 women who lived in those catchment areas and voluntarily cooperated in responding to a set of standardized questionnaires was randomly selected. RESULTS: Of the total respondents, 97.0 per cent were in the age range between 40-70 years, 51.7 per cent were in the peri- and postmenopausal period, 65.7 per cent believed that menopause is a natural change but some may need medical treatment, 53.9 per cent were current users of which the average duration of HRT use was 4.70 +/- 3.36 years. The most common reasons for HRT initiation were osteoporosis, hot flashes, and vaginal dryness. The most common side effects found in the current users were breast pain, headache, and vaginal bleeding. Of all the current users, 43.2 per cent wanted to switch from HRT. Most of the respondents (95.4%) based their decision on the choices of treatment on medical advice. Of the total respondents, 62.0-74.7 per cent reported not having enough clear information on menopause and HRT. CONCLUSION: According to the present study, most of the women regarded menopause as a natural change of life although some need treatment. The most common indications for HRT were osteoporosis, hot flashes and vaginal dryness. Nearly half of the current users wanted to switch from HRT. Most of the respondents based their treatment decision on medical advice.