gms | German Medical Science

In Germany, there is a lack of population-based information providing insights into women’s health care [Ref. 1]. In particular, there are shortcomings regarding information upon use of gynaecological/reproductive health care services, and the use of oral contraceptives (OC) and menopausal hormone therapy (MHT), all of which are important for public health. The study of Health in Pomerania (SHIP) is a cross-sectional, population-based survey of one distinct geographical region, covering a broad range of diseases, risk factors, and resources of health, many of which contribute to women’s health. The objectives of our analyses are to delineate major characteristics of reproductive health care utilization: (1) the prevalence of attendance of gynaecological outpatient facilities and of (cervical) cancer screening, (2) of gynaecological and breast surgery, and (3) of use of OC and MHT.

Objectives and design of SHIP have been published elsewhere [Ref. 2]. 2,193 women (49.3±16.2 years) participated in the survey. Socio-demographic characteristics, reproductive history, gynaecological service utilization and use of sex hormones were assessed by computer-aided personal interviews. We used standard descriptive statistics to characterize this sample, and used sex- and age group specific weighted factors to reflect characteristics of the population of Western Pomerania.

Most women (69.8% of the total sample) attended at least once outpatient facilities of a gynaecologist during the year preceding the interview. Participation in cancer screening was reported by 77.7% of women (life time prevalence). Approximately 43% of women reported gynaecological or obstetrical procedures. Uterine surgery was the most common type of surgery performed. Approximately 6% of women reported a hysterectomy with additional procedures involving at least one other pelvic organ, i.e. ovary and or salpinx and 4.3% women stated a hysterectomy without procedures involving ovary and/or salpinx. The highest prevalence for hysterectomy was found in women above ≥50 years. Surgery of the breast due to cancer was reported by 0.9% and sterilisation by 5.6% of participants. Two thirds of women stated ever use of OC. The prevalence of use was higher among women <50 years compared to older women. Among ever-user of OC, the median duration of use was 9 years. Of the total sample, 44.6% of women reported to be menopausal. The median age of natural menopause was 50 years. Ever use of MHT was reported by 28.2% of woman above 40 years.

Considerable use of gynaecological services and hormone therapy, OC and MHT alike, is one of the characteristics of this population-based sample of women aged 20-79 years. One major finding of the study is the degree of considerable utilization of gynaecological services (antenatal care not included) across a wide range in this region. In Germany, the main care providers for both cervical cancer screening and therapy with both OC and MHT are gynaecologists [Ref. 3]. Although we found that acceptance of cervical cancer screening decreased with age; the prevalence of this service (>70%) appeared to exceed the national average [Ref. 4]. Women had an almost risk of 50% to undergo gynaecological surgical procedures, including breast and obstetrical surgery. We are not aware of any other published population-based data of the prevalence of specified gynaecological procedures including hysterectomy in Germany. A second major finding is the wide use of OC by women in the present study. Data from a National Health Survey 1998 demonstrate that OC are by far the most frequent medication in women, in particular in the former German Democratic Republic [Ref. 5]. Available data from the MONICA project demonstrate that prevalences of use of OC in the former German Democratic Republic are the highest within this study in 20 countries [Ref. 6]. Our data appear to be in line with these studies. The third major finding is the extensive use of MHT by women. Our figures are comparable to the German study centres of EPIC [Ref. 7] and other large population-based studies in the UK, Sweden or Norway [Ref. 8], [Ref. 9], [Ref. 10] as well as to estimates from prescription databases in the US suggesting that 33% of American women aged 50-74 years are ever users of MHT [Ref. 11]. Duration of use of MHT is remarkable as a substantial number of women above the age of 60 years use MHT. In our study, median duration of use was 5 years, in women with previous OC exposure 9 years. These figures are similar to data of a representative survey conducted in Bremen [Ref. 12].

It is possible that use of MHT was widely recommended for prevention of diseases including but not restricted to solely osteoporosis and as anti-aging strategy, a hypothesis supported by rising prescription figures since 1985 [Ref. 13] and declining figures since regulatory actions were taken after the publication of results of the Women’s Health Initiative and other recent studies. It is also possible that attendance of gynaecological facilities had an impact on the likelihood to use OC and MHT.

The work is funded by the Clinical Research Center of Women’s Health (Charité- Universitätsmedizin Berlin). It is part of the Community Medicine Research net (CMR) of the University in Greifswald, Germany, which is funded by the Federal Ministry of Education and Research (grant no. ZZ9693), the Ministry of Cultural Affairs as well as the Social Ministry of the Federal State of Mecklenburg-West Pomerania.