Use of hormone replacement therapy in the Hong Kong public health sector after the Women's Health Initiative trial.

OBJECTIVES: To determine the impact of Women Health Initiative (WHI) trial on the use of hormone replacement therapy (HRT) in the Hong Kong public health sector. METHODS: The central prescription database of the Hospital Authority was used to describe the half-yearly trend in the use of HRT between July 2000 and December 2003. The data of hysterectomy was retrieved from another clinical database. RESULTS: Before the publication of the WHI trial in July 2002, conjugated equine estrogens (CEE) and its related products dominated HRT prescribing. Relative to the first half of 2002, there was an immediate and substantial decline by 43.5% in the prescriptions of combined CEE/progestogen products and a modest decline by 22.4% in the prescriptions of CEE-alone therapy in the second half of 2002. In the first half of 2003, a decline in the prescriptions of all HRT preparations except raloxifene was observed. However, in the second half of 2003, there were no more declines in overall HRT users. Relative to the first half of 2002, the decline in the overall HRT users in the first half of 2003 was more than 46% in women aged 50-69. The decline was greater in women with a history of hysterectomy (60.3%) than women without (38.6%), but was similar between gynaecology specialty (41.7%) and non-gynaecology specialty (43.9%). CONCLUSIONS: Similar to the U.S., an immediate and substantial decline in the use of CEE and its related products was observed in Hong Kong after the publication of the WHI trial.

Lymphocyte subsets in patients with oestrogen deficiency.

We have previously shown that in patients with idiopathic premature ovarian failure there were significant changes in lymphocyte subsets. To test our hypothesis that these changes were due to oestrogen deficiency we studied lymphocyte subsets in patients with oestrogen deficiency due to other causes. Blood was taken for serum oestradiol, lymphocyte counts and lymphocyte subset counts (CD2+, CD4+, CD8+ and B cells) before oestrogen replacement in 19 patients with gonadal dysgenesis, 22 patients with hypothalamic-pituitary failure and 24 healthy female control subjects. The CD4:CD8 ratio in both groups of patients was significantly lower than that in the normal control subjects while the percentages and counts of lymphocytes and CD8+ cells were significantly higher. There was a significant positive correlation between the serum oestradiol level and the CD4:CD8 ratio. These findings support the hypothesis that the changes in lymphocyte subsets are due to oestrogen deficiency.

Reactions to emergency hysterectomy.

The recovery from emergency hysterectomy of 18 Chinese patients is described. During the recovery period, patients experienced fear, depression, anger, doubt, selfreproach, and multiple somatic complaints without physical origins. Sexual activity was reduced. The recovery course was particularly difficult for those patients who were nonsymptomatic before operation, those who still wanted to bear more children, and those who lacked family support. These women needed continuous reassurance and ample opportunities to ventilate their feelings. None of the patients had psychiatric sequelae requiring expert consultation after the operation. It is emphasized that the reactions and needs of these patients deserve recognition, attention, and follow-up.

Immunologic studies in patients with premature ovarian failure.

Tests for a range of autoantibodies, and counts of lymphocytes, B cells, T cells, and T cell subsets were performed in 45 Chinese patients with premature ovarian failure and 45 age-matched normal control subjects. Eight patients (18%) were positive for at least one autoantibody. Only one patient was positive for antiovarian antibody. Patients with autoantibodies had a significantly higher percentage of circulating B cells. The lymphocyte, T cell, CD4+, and CD8+ counts in patients with premature ovarian failure were significantly higher than those in the control group, but the CD4:CD8 ratio was significantly lower in women with premature ovarian failure. There was a significant negative correlation between plasma estradiol levels and CD8+ counts, and a significant positive correlation between plasma estradiol levels and CD4:CD8 ratios. The changes in lymphocytes and lymphocyte subpopulations in premature ovarian failure may be due to estrogen deficiency.

Diagnosis of early pregnancy by enzyme immunoassay of Schwangerschafts-protein 1.

Serum Schwangerschafts-protein 1 (SP1) and beta subunit of human chorionic gonadotropin (beta-hCG) were measured by enzyme immunoassay and radioimmunoassay, respectively, in the follicular phase and luteal phase of 50 human menopausal gonadotropin treatment cycles. SP1 could be detected in 63% of blood samples taken in the follicular phase up to the level of 1.56 micrograms/l. Using a cutoff level of 2 micrograms/l, SP1 could be used to diagnose pregnancy 16 to 25 days after the ovulating dose of hCG. The serum SP1 level is not affected by hCG injections and it can be used for diagnosis of pregnancy even when hCG has been given recently. SP1 also may be used as a prognostic indicator of the outcome of the pregnancy.

The relationship between the human sperm hypoosmotic swelling test, routine semen analysis, and the human sperm zona-free hamster ovum penetration assay.

The functional integrity of sperm membranes of 270 semen samples collected from fertile men and the male partners in couples with infertile marriages was assessed by the hypoosmotic swelling test and the results correlated with routine semen analysis and the human sperm zona-free hamster ovum penetration assay. Semen samples with abnormal semen parameters had lower values of percentage of swollen sperm after hypoosmotic treatment in comparison with those with normal semen parameters. A weak positive correlation was observed between sperm swelling and sperm morphologic features (r = 0.32, P less than 0.05) and between sperm swelling and sperm motility (r = 0.22, P less than 0.05). Insignificant correlation was observed between sperm swelling and in vitro sperm fertilizing capacity, as assessed by the zona-free hamster ovum penetration assay. The results indicate that the sperm swelling test and the zona-free hamster ovum penetration assay are evaluating different functional qualities of sperm that are apparently not associated with each other.

The climacteric of Chinese factory workers.

Chinese factory workers (427) mainly of Fujian origin were found to have few climacteric symptoms. Of these, 65% and 50% reported having no circulatory and nervosity symptoms, respectively. Only 18% of women experienced hot flushes. The climacteric symptoms were more pronounced at the perimenopausal period (P < 0.001) when these women experienced more irregular menstruation. Low socio-economic status and educational level did not have adverse effects on the symptom reporting. High parity and employment may be positive factors in this period of change of life. A majority of women (74%) felt that the climacteric and menopause is a natural process which caused them no concern. Of those who were still menstruating 80% did not anticipate that they would have problems with the climacteric and menopause. These women's different climacteric pattern could be related to their introspective abilities to cope adequately or in an impersonal manner.

Continuation rate of hormone replacement therapy in Hong Kong public health sector.

OBJECTIVES: To assess the 1-year continuation rate of HRT prescribed in Hong Kong public health sector and to identify factors affecting this continuation rate. METHODS: All women who received at least one dispensed prescription of estrogens between January 1998 and December 2000 from 36 specialist outpatient clinics of the Hospital Authority were selected, and observed for at least 2 years and at most 3 years. The duration of use and variables including age, types of hormones, routes of delivery, dose of estrogen, and prescribing specialty were retrieved from the central prescription database of the Hospital Authority. RESULTS: Of 12,711 incident users of HRT, more than half were aged 50-59. Most (78.5%) of the users took conjugated equine estrogens (CEE) 0.625 mg or related products. Only a small proportion (3.0%) of women used CEE 0.3 mg. Initial estrogen prescriptions were written by gynaecologists in 86.7%. The overall 1-year continuation rate was 68.3%. The highest and lowest continuation rates were observed in women aged 40-49 and the two extreme age groups (35-39 and 70-79), respectively. Better continuation rate was observed in women taking estrogen-only therapy such as CEE or estradiol (overall 76.3%) than in women using continuous combined therapy (58.6%), sequential combined therapy (64.8%), or transdermal estrogen (60.6%). In the age group 60-69, the use of CEE 0.3 mg was associated with better continuation rate than CEE 0.625 mg. CONCLUSIONS: Better continuation rate at 1 year was associated with age younger than 60, oral route of HRT and hysterectomy.

A pilot study of acceptability of RU486 and ONO 802 in a Chinese population.

RU486 and ONO 802 in combination have been shown to be effective in early termination of pregnancy. Anecdotal information suggests that Chinese women have been using herbs to induce abortion, believing that such medication and means of abortion is less harmful to the body than surgery. Hence, a medical means of abortion using RU486 and ONO 802 may be the method of choice for some Chinese women. A pilot study involving 42 Chinese women in Hong Kong was conducted to explore the reasons for acceptance or refusal of RU486 and ONO 802 as abortifacient agents. It was found that more single women chose the medical method for abortion, the main reasons being fear of trauma to the body due to surgery and the feeling of having undergone menstrual regulation rather than having had an abortion with the medical method. Those who refused the treatment were worried about the efficacy and side effects of the new drugs and the long induction-abortion interval. There were 3 failures in the medical group of 23 women. All these 23 women were gland they had chosen the medical abortion method. Twenty-one out of the 23 women said they would choose the same abortion method again. The practice of the use of Chinese herbs was not more common in this group of women as compared to women who did not choose this method of abortion.

PIP: RU486 and ONO 802 in combination have been shown to be effective in early termination of pregnancy. Anecdotal information suggests that Chinese women have been using herbs to induce abortion, believing that such medication and means of abortion is less harmful to the body than surgery. Thus, a medical means of abortion using both may be the method of choice for some Chinese women. A pilot study involving 42 Chinese women in Hong Kong was conducted to explore the reasons for acceptance or refusal of RU486 and ONO 802 as abortifacient agents. It was found that more suitable women chose the medical method for abortion, the main reasons being fear of trauma to the body during surgery and the feeling of having undergone menstrual regulation rather than having had an abortion with the medical method. Those who refused the treatment were worried about the efficiency and side effects of the new drugs and the long induction-abortion interval. There were 3 failures in the medical group of 23 women. All 23 were glad they has chosen the medical abortion method. 21 of 23 women said they would choose the same abortion method again. The practice of the use of Chinese herbs was not more common in this group of women when compared to women who did not choose this method of abortion.

Non-surgical sterilization using phenol-mucilage: acceptability versus efficacy.

Sterilization has become a popular means of birth control and many methods have been developed to meet the needs of different groups of women. In a pilot study, non-surgical sterilization using phenol-mucilage was found to be extremely acceptable to a group of Chinese women despite its failure rate. The method is simple, safe and inexpensive. It is suggested that this method would be suitable for women who are afraid of surgical sterilization.

PIP: A pilot study conducted among 34 Chinese women recruited through the Family Planning Association of Hong Kong indicates that nonsurgical sterilization with phenol-mucilage is a highly acceptable, although less effective, approach. The volunteers were 30 years or older and had 2 or more children. After cannulation of the tubal ostium, 0.25 ml of phenol-mucilage was injected on each side and the presence of the chemical in the Fallopian tubes was confirmed by pelvic x-ray. Time required for the procedure averaged 20 minutes. Bilateral cannulation failed in 7 cases, generally because of large uterine size or uterine irregularities, yielding a success rate of 79.4%. The average length of tube containing phenol-mucilage was 5 cm. Acceptors remained in the hospital for 24 hours and returned for follow-up visits at 1 week, 6 weeks, 3 months, 12 months, and 24 months. Post-procedure complications were minor (fever, lower abdominal pain, and spotting) and of short duration. Hysterosalpingography was used at the 3-month visit to confirm tubal occlusion. Women's primary reasons for selecting nonsurgical sterilization were its lack of adverse health affects (34%), fear of a surgical wound (24%), and the reduced need for convalescence (9%). During the 2 years of follow-up, no woman expressed regret about sterilization. Two pregnancies occurred after 1 year, for a failure rate of 7.4%. The noninvasiveness of the procedure was considered by acceptors to be more important than its relatively low effectiveness. Moreover, the high failure rate in the present study may be an artifact of storage-induced changes in the chemical nature of the corrosive.

Levonorgestrel intrauterine device in the treatment of menorrhagia in Chinese women: efficacy versus acceptability.

Ten Chinese women who had menorrhagia without organic cause and suffered from anaemia were treated with levonorgestrel intrauterine device for a total of 129 woman-months. There was a 54%, 87% and 95% reduction in menstrual blood loss at the first, third and sixth month of treatment when compared with the pretreatment cycle. These percentages of reduction were statistically significant, with p values of 0.004, 0.03 and 0.008, respectively. There was a median increase in menstrual cycle length of 12 days in nine months. Fifteen percent of the menstrual cycles were longer than 60 days. The total bleeding days increased by 4 days at the third menstrual cycles, but reduced to a median of 6 days at 6 months. Seventy-six percent of the menstrual bleeding was in the form of spotting. These Chinese women accepted such menstrual alterations. There was no hormonal side effects. All women preferred the device to hysterectomy. Levonorgestrel intrauterine device appeared to be an effective and acceptable treatment for menorrhagia in perimenopausal Chinese women.

PIP: Clinicians followed 10 married multiparous women aged 38-50 admitted to Queen Mary Hospital in Hong Kong for menorrhagia for 12 months to confirm the efficacy of the levonorgestrel IUD (LNG-IUD) in treating menorrhagia, to examine menstrual changes, and to determine the acceptability of LNG-IUD as a treatment for menorrhagia in Chinese women. The women served as their own controls. They had hemoglobin levels less than 11.7 gm%. Menstrual blood loss (MBL) declined significantly after LNG-IUD treatment (183 ml vs. 85.5 ml at 1 month, 24 ml at 3 months, and 10 ml at 6 months). The percent reductions were 54.35%, 86.89%, and 95%, respectively (p = 0.004, 0.031, and 0.008, respectively). The post-treatment median hemoglobin levels were higher than pretreatment levels (12.5 gm% at 6 months vs. 10.1 gm%). The median menstrual cycle length increased by 12 days in 9 months. 15% of menstrual cycles lasted longer than 60 days. Between pretreatment and the third menstrual cycle, the total median bleeding days increased by 4 days (8-12 days). At 6 months, however, they were reduced to a median of 6 days. Spotting was the predominant form of menstrual bleeding (76%). The changes in the menstrual pattern did not affect continuation. The women's chief concern was a reduction in MBL, so changes in the menstrual pattern were acceptable. No one complained of hormonal side effects (e.g., acne, weight gain, and mood changes). The women preferred the LNG-IUD to remembering when to take oral contraceptives or to undergoing hysterectomy. These findings show that perimenopausal Chinese women find the LNG-IUD to be an effective and acceptable treatment for menorrhagia.

Further acceptability evaluation of RU486 and ONO 802 as abortifacient agents in a Chinese population.

Of 144 consecutive women who requested early induced abortion, 99 (68.7%) and 45 (31.3%) women chose RU486 combined with ONO 802 (medical method) and suction evacuation (surgical method), respectively. Logistic regression analysis of covariates showed that age and marital status were significantly correlated with the acceptability and hence the choice of the medical method. There were also more working women in this medical group. Previous experience of induced abortion had no influence on the current choice of the abortion method. This group of women appeared to have a tendency of treating their disease with medication rather than with surgery if the condition would allow. They expressed fear about surgery. The long induction-abortion interval of three days will have to be tolerated, but the duration of bleeding should be minimised in order to improve the acceptability of the drug. RU486 is an alternative abortion method which should be made widely available.

PIP: Of 144 consecutive women who requested 1st trimester induced abortion at the Family Planning Association of Hong Kong, 99 (68.7%) chose a medical method consisting of RU-486 (mifepristone) combined with ONO 802 (gemeprost) and 45 (31.3%) chose the surgical method of suction evacuation. The study intended to define the profile of women who would accept the RU-486 tablets on day 1, and then on day 3, ONO 802 pessaries were inserted during 6 hours of hospitalization. Follow-up days were 15 and 43 from the day RU-486 was taken. The median age of the medical group was 29 years vs. 33 years for the surgical group. 91% of women in the surgical group were married compared with 67% in the medical group. Significantly more nulliparous women (40%) and single women below the age of 30 years preferred the medical method. The condom was used more often in the medical group (61%), while oral contraceptive pills were used by 55% of women in the surgical group. Significantly more women in the medical group preferred medication to surgery. On day 3, 88 women reported headache, tenderness of breasts, sleep disturbance, palpitation, and weakness, however, only 5 women had intolerable symptoms, and 1 woman was hospitalized because of severe abdominal pain. On day 3, 67 (68%) of women said they were not worried because their abortion had not yet occurred, while 32 women (32%) were worried because they were skeptical about the efficacy of the drug. Comments on days 8, 15, and 43 indicated that 80 women would choose medical abortion again including 4 women who had to undergo suction evacuation because of failed medical abortion. 12 women required subsequent suction evacuation because of incomplete or missed abortion. Single, young, nulliparous Chinese working women are likely to accept RU-486 and ONO 802.

Pre-operative cervical dilatation in termination of first trimester pregnancies using 16, 16-dimethyl-trans-delta 2 PGE1 methyl ester vaginal pessaries.

The effect of a prostaglandin E1 analogue on the cervix prior to termination of first trimester pregnancy was studied in a double-blind placebo-controlled trial with 70 primigravid and 125 multigravid patients in the Hong Kong University Gynaecological Unit. One mg of 16, 16-dimethyl-trans-delta 2-prostaglandin E1 methyl ester (ONO 802) in the form of vaginal pessary was inserted 3 hours before vacuum aspiration. The cervical dilatation in patients receiving ONO 802 pessaries was significantly greater than that in patients who received no treatment or placebo pessaries but the difference in dilatation between patients who received no treatment or placebo was not significant. The blood loss during operation in patients receiving ONO 802 pessaries was also significantly less than that in patients receiving placebo pessaries. The side effects due to ONO 802 pessaries were mild and infrequent.

Effects of androgens on fertilizing capacity of human spermatozoa.

The potential functions of testosterone and 5 alpha-dihydrotestosterone, the androgens normally present in human seminal plasma, on human spermatozoal physiology were evaluated by studying the effects of these two steroid hormones on the in vitro fertilizing capacity of human spermatozoa. Spermatozoa collected from presumably fertile men were washed in BWW medium and incubated with different concentrations (0, 100, 250, 500, 1000 pg/ml) of testosterone or 5 alpha-dihydrotestosterone for 5 hr before insemination of the zona-free hamster ova. Penetration of the zona-free hamster ova was scored 6 hr later and the results were analyzed statistically. Both testosterone and 5 alpha-dihydrotestosterone, at the concentrations tested, significantly decreased the in vitro penetration of the denuded hamster ova in comparison to the controls (p less than 0.05). A dose-dependent response was also observed for the 5 alpha-dihydrotestosterone tested. These findings indicate that exogenous testosterone and 5 alpha-dihydrotestosterone can inhibit the fertilizing capacity of human spermatozoa in vitro, and suggest that the androgens normally present in human seminal plasma may serve, in part, to prevent premature spermatozoal capacitation before the spermatozoa reach the site of fertilization in vivo.

Psychosocial study on Hong Kong Chinese with gynecological cancer.

Psychosocial support and adjustment to cancer in 115 Chinese patients with gynecological malignancies were studied by interviews using semi-structured and structured questionnaires before commencement of treatment. Ninety per cent of patients had emotional support with 72% coming from family members, while 77% of the patients said that they were clearly informed of their diagnosis. The majority of our patients (63%) did not wish to see a counsellor. Psychological outcome of the patients was good, with less than 21% having expression of anxiety or depression. Social adjustment was less favorable; 42% of women had a reduction in leisure activity. The majority of married couples maintained a good marital relationship even though 78% had reduction or cessation of their sexual activity. Good emotional support was associated with fewer neurotic symptoms. Though there was no statistical significance demonstrated, the good psychosocial support and the favorable psychological outcome in this group of patients indicated the likelihood of a positive relationship between the two.

Psychosocial aspects of gestational trophoblastic disease in Chinese residents of Hong Kong.

Gestational trophoblastic disease has several special aspects as compared with others tumors of the female genital tract. It occurs in young women who want to start a family and expect to have a normal pregnancy. It can be very effectively treated with chemotherapeutic agents, and the subsequent reproductive potential of these young women is not affected. In a survey of 105 Chinese residents of Hong Kong who had had the disease, it was found that their emotional reactions to the disease and treatment, the effects of such on their self-esteem, martial and sexual life, and their attitudes towards their physicians and future pregnancy were different from those of their Western counterparts.

Continuing professional development--a surrogate for recertification?

Medical practitioners are certified as competent when they graduate from medical schools. They are certified as competent specialists after they have completed the various specialist training programmes. To maintain specialist status, the commonest requirement is mandatory continuing professional development (CPD), and in some places, continuing medical education (CME), which has been perceived by some as inadequate because it is passive, and skills and professionalism are excluded. In order to sustain the standard of medical practice and to assure quality of care, some registration organisations require that recertification be conducted not only through CPD, but written and oral examinations as well. In this manner, the criteria for quality medical care, which are evidence of professional standing, lifelong learning and self-assessment, cognitive functioning and evaluation of performance in practice, are fulfilled. CPD should involve educational activities of the medical practitioner's choice and be capable of enhancing his or her practice at any particular period of time. Well-structured, well-designed and validated CPD can be considered as a surrogate for recertification.

The use of the Minimum Data Set. Home Care in a case management project in Hong Kong.

130 hospital-discharged elderly patients received our comprehensive assessment by using a Chinese Minimum Data Set-Home Care (MDS-HC). Our case manager developed and implemented care plans with reference to the computer-generated Clients Assessment Protocols. Results showed that the MDS-HC was sensitive to identify elderly persons' holistic needs, and helpful in formulating all-inclusive care plans.