Evaluation of a Shared Decision Making Intervention between Patients and Providers to Improve Menopause Health Outcomes: Issue Brief

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1 Evaluatin f a Shared Decisin Making Interventin between Patients and Prviders t Imprve Menpause Health Outcmes: Issue Brief Key Findings Tablet technlgy can be successfully incrprated int primary practices fr patient-reprted data cllectin and patient educatin. Patient-specific infrmatin and educatin can be used t enhance shared decisin making (SDM); hwever, statistically significant differences were nt realized in this study when tls designed specifically fr menpause health were incrprated int tablet technlgy. Ideally, data cllected wuld be aut-ppulated int the Electrnic Health Recrd (EHR). Rates f menpause diagnsis and menpause medicatins (e.g., hrmne therapy) increased fr wmen years when tablet technlgy was incrprated at the pint f care during prvider visits; hwever, these increased rates were nt statistically significantly different between cntrl and interventin grups. Wmen years are very satisfied with their prvider acrss several dmains f the Ambulatry Care Experiences Survey (ACES) including: cmmunicatin, interpersnal treatment, patient trust, whle persn rientatin and health prmtin. Prviders rated themselves lwer than their patients in all dmain areas. A majrity f patients (88-93%) in cntrl and interventin grups indicated cmplete satisfactin with the SDM prcess. Mst wmen years had discussins with their prvider abut menpause (72-77%), breast cancer risk (64-65%), and lifestyle mdificatin (84-88%); hwever, there were n differences between the cntrl and interventin grups. Half f the wmen cmpleting the Menpause Rating Scale survey (127/252; 50.4%) indicated at least ne severe t very severe smatic, psychlgical, and/r urgenital symptm. The mst prevalent symptms with >40% f wmen reprting mderate, severe, r very severe symptms included muscular pain, sleep issues, depressin, exhaustin and sexual symptms. Mderate, severe, r very severe ht flashes/sweating were nted in nly 32.3% f wmen. Mst wmen (84-85%) indicated they enjyed using the tablet, but it did nt change their understanding f menpause symptms and treatment. Ratinale and Design Apprximately half f all wmen years f age experience at least ne menpausal symptm r a cmbinatin f symptms, yet nly ne-third f wmen talk abut treatment ptins with their prvider. Further, 45% f wmen say infrmatin abut managing and treating symptms f menpause is cnfusing. Hrmne therapy (HT) has been prven t be the mst effective treatment fr vasmtr symptms and is an acceptable ptin amng many wmen up t 59 years f age; hwever, lng-term use appears t impse greater risks than benefits. Therefre, it is equally imprtant t ensure that wmen between the ages f years discntinue HT, unless deemed apprpriate by her clinician using a shared decisin apprach. Breast cancer risk increases with age and risk-reductin medicatins are recmmended fr wmen at higher risk; hwever, use f these medicatins remains lw. Other treatments, including nn-prescriptin therapies, may be mre apprpriate fr individual situatins. Wmen cming in and ut f the menpause transitin require individualized evaluatin and management strategies. The brad gal f this study was t prmte SDM thrugh the use f tablet technlgy amng health care prviders and wmen age years regarding menpause, HT use and breast cancer risk. Wmen in the cntrl grup used tablet technlgy t cmplete surveys regarding demgraphics and SDM during the prvider visit. Wmen in the interventin grup used tablet technlgy t cmplete surveys regarding demgraphics, menpause symptms, breast cancer risk, and SDM during the prvider visit. 1

2 Primary utcmes were t: 1) Evaluate changes in dcumented diagnsis f menpause and 2) Evaluate patient and prvider satisfactin with the SDM prcess. Secndary utcmes were t: 1) Evaluate implementatin success f validated health risk appraisal tls fr menpause; 2) Determine rate f all prescriptins used t treat menpausal symptms ver a specific time perid; 3) Determine rate f HT discntinuatin in wmen age years; 4) Determine rate f patients age years that discussed menpause r menpausal symptms with their prvider; 5) Determine rate f cunseling regarding breast cancer risk preventin and lifestyle changes in wmen age years; 6) Determine rate f cunseling regarding lifestyle changes (e.g., diet, exercise, alchl) in wmen age years; and 7) Evaluate prvider knwledge regarding menpause. Please see Appendix A: Summary table f the utcmes, hyptheses, methds and results. Please see Appendix B: Patient demgraphics. Results Nine primary care practices and 14 healthcare prviders cmpleted the study and were included fr analysis. Practices were lcated in Massachusetts, Pennsylvania, Gergia, Ohi, Virginia, Iwa, Cnnecticut, and Califrnia, and in varius gegraphic areas: rural (2), suburban (5), and urban (2). A ttal f 438 unique participants cmpleted 408 full datasets fr evaluatin. Patients were given the ptin t nt answer survey questins which accunts fr sme differences in patient respnses. See Appendix B: Patient Demgraphics Primary Outcme 1: Evaluate changes in dcumented diagnsis f menpause Based n the Electrnic Health Recrd (EHR) data extractin f wmen years amng eligible practices (n=7), the rate f diagnsis a baseline was 8.7/100 wmen and at the end f the study was 10.5/100 wmen. The ttal number f wmen with a diagnsis f menpause was 42.8 per clinician at baseline and 70.5 per clinician at study cmpletin (27.7 mean increase, 95% CI: ( ), p-value=0.44). Fr practice-specific data, see practice utcmes reprt: Chart 1. Primary Outcme 2: Evaluate patient and prvider satisfactin with the SDM prcess A mdified versin f the Ambulatry Care Experiences Survey (ACES) was used as a prxy fr SDM t evaluate patient and prvider experiences acrss the fllwing dmains: cmmunicatin, interpersnal treatment, patient trust, whle persn rientatin and health prmtin. Overall, wmen in the cntrl and interventins grups rated prviders very high acrss all five dmains (range ut f 100). There were n significant differences between wmen in the cntrl and interventin grups. Prviders cmpleted the ACES at three times pints: baseline, six and 12 mnths. Prviders scred themselves lwer acrss time fr each f the dmains f the ACES cmpared with patients. See Figure 1 belw. Fr practice-specific data, see practice utcmes reprt Table A and Chart 2. 2

3 Figure 1: ACES survey results by dmain: Participants and Prviders Nte: *Cntrl/Interventin ppulatin numbers are an average f respndents. Prvider data is the mean f all prviders at baseline and at study cmpletin. Fr patients respnding t specific questins abut satisfactin with the SDM prcess, mst patients in the cntrl and interventin grups were cmpletely satisfied (143/154, 92.9% and 189/214, 88.3% respectively, p=0.15 between grups). All ther patients were smewhat satisfied. N patients were dissatisfied. Secndary Outcme 1: Evaluate implementatin success f validated health risk appraisal tls fr menpause All practices were able t view the menpause health assessment reprt at the pint f care. Practices were able t view the reprt by a practice staff printing the health assessment r dwnlading it frm a secured server and directly n the tablet. Mst wmen indicated they enjyed using the tablet, but it did nt change their understanding f menpause symptms and treatment. The limited number f views f the vides received made it difficult t discern if vides played a majr rle in SDM, but warrant further cnsideratin and research. Overall, results f survey questins related t tablet technlgy are shwn in Table 1 belw. Table 1: Tablet Technlgy Implementatin Outcmes Cntrl (n=156) Interventin (n=213) Participants strngly/smewhat agreed they enjyed using the tablet 133 (85%) 179 (84%)^ Fund the surveys easy t understand and answer 153 (98%) 201 (94%)^ Participants strngly/smewhat agreed they left their appintment 106 (68%) 131 (62%)^ less cnfused abut menpausal symptms and treatment ptins Early Exit Had truble using the tablet Reprted study tk t lng and appintment was ver N lnger wish t participate Feel uncmfrtable with questins Thse presented pprtunity t view at least ne vide Fund the vides helpful (regarding SDM prcess) Cmplete r partial viewing f all vides ffered ^N statistically significant difference between cntrl and interventin grup (p>0.2). 4 1 (25%) 0 (0%) 1 (25%) 2 (50%) N/A N/A N/A 7 2 (25%) 2 (25%) 3 (38%) 0 (0%) 127/253 (50%) 43/83 (52%) 41/221 (19%) 3

4 Secndary Outcme 2: Determine rate f all prescriptins used t treat menpausal symptms ver a specific time perid Many wmen were receiving treatment fr varius menpausal symptms at the time f study enrllment. (See Appendix B: Patient Demgraphics) The rate f prescriptins used t treat menpausal symptms (e.g., HT, SSRI) increased ver time amng eligible practices (n=7): baseline: 6.1/100 wmen cmpared with end f study: 9.2/100 wmen. When lking at the rate per clinician (rather than per 100 wmen), the number f medicatins prescribed fr menpause als increased with baseline at 59.2/clinician and end f study at 94.3/clinician (35.1 mean increase; 95% CI (-5.5, 66.9); p-value=0.085). Medicatin changes fr menpausal symptms were reprted by 11/177 (6.25%) wmen in the cntrl grup and 27/231 (11.25%) wmen in the interventin grup, indicating a trend tward significance (p=0.06) when the Menpause Rating Scale (MRS) data was available at the pint f care. Other medicatin changes such as calcium and vitamin D, and allergy medicatin were nted, but nt cnsidered in the analysis regarding medicatins fr menpause. Fr practice-specific data, see practice utcmes reprt: Chart 1. Secndary Outcme 3: Determine rate f HT discntinuatin in wmen age years Given that all medicatin changes were either substitutins (e.g., discntinue ral cntraceptive and initiate HT) r additins, n discntinuatin f HT ccurred fr wmen age years. Of 93 wmen in this chrt, nly 3 wmen (3.2%) were taking an estrgen cntaining medicatin. Secndary Outcme 4: Determine rate f patients age years that discussed menpause r menpausal symptms with their prvider Wmen age years in the cntrl and interventin grups reprted having frequent discussins abut menpause: Cntrl: 79/106; 74.5%; Interventin: 112/142; 78.9%. There was n statistical difference between grups; p-value=0.42. Amng all enrlled wmen (45-65 years-includes pst-menpausal aged wmen), the majrity als reprted having frequent discussins abut menpause: Cntrl: 105/145; 72.4%; Interventin: 143/187; 76.5%. There was n statistical difference between the grups (p-value=0.40). See Table 2 belw. Fr practice-specific data, see practice utcmes reprt: Chart 3. Fr wmen in the interventin grup, the MRS survey and breast cancer risk assessment were presented prir t the ther surveys s this health assessment reprt wuld be available at the pint f care. Fr this reasn, 252 wmen cmpleted the MRS survey and 127/252 (50.4%) indicated at least ne severe t very severe symptm in ne f three categries: smatic, psychlgical, and/r urgenital. Specifically, 87/252 (34.5%) had at least ne smatic severe t very severe symptm, 65/252 (25.8%) had at least ne severe t very severe psychlgical symptm, and 69/252 (27.4%) had at least ne severe t very severe urgenital symptm. The mst prevalent symptms with >40% f wmen reprting mderate, severe, r very severe included muscular pain, sleep issues, depressin, exhaustin and sexual symptms. See Appendix C: Individual Symptms. Secndary Outcme 5: Determine the rate f cunseling regarding breast cancer risk preventin and lifestyle changes in wmen age years Mst wmen years reprted having frequent discussins with their prviders abut breast cancer: Cntrl: 109/167; 65.3%; Interventin: 146/187; 63.5%. There was n statistical difference between the grups (p-value=0.71). See Table 2 belw. Fr practice-specific data, see practice utcmes reprt: Chart 3. Wmen (n=225) in the interventin grup tk the Natinal Cancer Institute s Breast Cancer Risk Assessment Tl. The mean five-year risk was 1.61% (standard errr 0.07) with a range f 0.47%-8.20%. Wmen with a five-year risk f 1.67% r higher are classified as "high-risk"; this scre is the cut-ff fr the FDA guidelines recmmending a risk-lwering drug (tamxifen r ralxifene) fr patients t reduce breast cancer risk. Secndary Outcme 6: Determine the rate f cunseling regarding lifestyle changes (e.g., diet, exercise, alchl) in wmen age years All wmen (45-65 years) in cntrl and interventin grups had very frequent discussins abut lifestyle, but there was n statistical difference between grups: Cntrl: 151/179 (84.4%); Interventin: 225/255; 88.2%; p- value=0.25. See Table 2 belw. Fr practice-specific data, see practice utcmes reprt: Chart 3. 4

5 Table 2: Discussins between participants and prviders. Tpic Cntrl Interventin P-value Menpause (45-59 years) 79/106 (74.5%) 112/142 (78.9%) 0.42 Menpause (45-65 years) 105/145 (72.4%) 143/187 (76.5%) 0.40 Breast Cancer Risk 109/167 (65.3%) 146/187 (63.5%) 0.71 Lifestyle Mdificatin 151/179 (84.4%) 225/255 (88.2%) 0.25 Secndary Outcme 7: Evaluate prvider knwledge regarding menpause Prviders (n=14) cmpleted a pre- and pst-test assessment f an educatinal webinar designed t increase prvider knwledge and impact clinical practice. There was an insufficient sample size t detect a difference, but the trend indicated imprved knwledge n this assessment f 14 multiple chice questins (mean crrect: pre=66%, pst=74%, mean difference=0.07; 95% CI ; p-value=0.07). Fr prvider-specific data, sl prviders please see practice utcmes reprt: Table B. Fr practices with mre than ne participating prvider, pre-pst test results will be sent via . Discussin and Cnclusins Integratin f tablet technlgy imprves SDM pprtunities t ensure higher quality medical decisins and fcus health care n patients persnal values and preferences. This study evaluated the impact f imprved infrmatin cllectin and SDM amng health care prviders and wmen age years regarding issues f menpause, pstmenpause, hrmne therapy, and breast cancer risk. We aimed t imprve hw we assess menpausal symptms by integrating tablet technlgy t measure menpause health assessment, ambulatry care experiences, and varius aspects f the patient-prvider visit. Questins cncerning menpause, sexual health, geniturinary symptms, and breast cancer risk are cmmnly asked n intake frms fr annual exams; hwever, they are nt standardized r tied t an educatinal interventin r treatment plan. Tablet technlgy is ne tl that was used t facilitate this persn-centered care. Althugh the number f wmen diagnsed with menpause r pstmenpause imprved with the interventin, it still represented a minrity f wmen years and was nt different between cntrl and interventin grups. This is likely because mst prviders did nt include a diagnsis unless wmen had been prescribed a medicatin related t menpause. We wuld assert that having this diagnsis readily apparent in the EHR helps t ensure re-assessment f menpausal symptms and apprpriate medicatin use n a rutine basis. Overall, patients reprted high satisfactin with prvider-patient interactins acrss several dmains; clinician perceptins were lwer. A majrity f patients reprted cmplete satisfactin with the SDM prcess. Prviders discussed lifestyle, menpause, and breast cancer risk mst f the time with their patients. This is imprtant given that half f these wmen had severe r very severe menpause symptms. In this chrt f wmen, the mst prevalent symptms were nt ht flashes, but >40% f wmen experienced mderate, severe, r very severe symptms f muscular pain, sleep issues, depressin, exhaustin, and sexual symptms. Medicatin use fr menpause symptms increased fr patients in the interventin cmpared with the cntrl grup, but the difference was nt statistically significant. This study successfully integrated tablet technlgy int practices t assess menpause health utcmes fr wmen age years. It wuld be ideal fr patient care, mnitring, and fllw-up if the assessment tls within the tablet technlgy culd readily be integrated int the EHR. This study demnstrated that tablet technlgy can prvide effective SDM between prviders and wmen age years t deliver individualized and specific infrmatin regarding issues related t menpause. Future research culd evaluate effective use f tablet technlgy fr SDM prcesses in ther medical cnditins and medicatin use. 5

6 Appendix A: Outcmes, Hyptheses, Methds and Results Primary Outcmes Hypthesis Methd fr Assessment Results 1. Evaluate changes in dcumented diagnsis f menpause r pstmenpause state Dcumented diagnsis f menpause r pstmenpause state will increase after physician educatin interventin and health risk tls discussed with patient. (Baseline: 16%; Pst-interventin: 36%) Pre- and pst-interventin assessment via query f EHR fr diagnsis f menpause r pstmenpause in wmen age years. Rate f diagnsis f menpause increased acrss eligible practices (n=7): Baseline: 8.7/100 wmen; End f study: 10.5/100 wmen Ttal number f wmen with a diagnsis f menpause: Baseline: 42.8/clinician; End f study: 70.5/clinician (27.7 mean increase, 95% CI: ( ), p-value=0.44) 2. Evaluate patient and prvider satisfactin with the shared decisin making (SDM) prcess Wmen and physicians will be very r cmpletely satisfied with the shared decisin making prcess t aid in health care decisins. (Baseline: 40%; Pst-interventin: 70%) Wmen will cmplete a brief experiences survey fllwing the prvider visit. See practice level utcmes reprt: Chart 1. Ambulatry Care Experiences Survey (ACES) Overall, wmen in cntrl and interventin grups rated clinicians very high n cmmunicatin, interpersnal treatment, patient trust, whle-persn rientatin, and health prmtin (range ut f 100) See Figure 1 in Issue Brief. Satisfactin: SDM Cntrl grup: 143/154 (92.9%) reprted cmplete satisfactin with shared decisin making prcess; all thers were smewhat satisfied. Interventin grup: 189/214 (88.3%) reprted cmplete satisfactin with shared decisin making prcess; all thers were smewhat satisfied (p-value=0.15 between grups) Prviders will cmplete a mdified ambulatry care experiences survey baseline, 6 mnths, and 12 mnths. See practice utcmes reprt: Chart 2. See practice utcmes reprt: Table A.

7 Secndary Outcmes Hypthesis Methd fr Assessment Results 1. Evaluate implementatin success f validated health risk appraisal tls fr menpause Validated health risk assessment tls embedded in tablet technlgy will be integrated int a majrity f EHRs fr physician viewing at the pint f care. (Baseline: 0%; Pstinterventin: 80%) Determine number (%) f practices that are able t view health risk appraisal tls at the pint f care (after patient cmpletes them) in EHR. 100% f practices were able t view health assessment reprt in the fllwing ways: printing the health assessment r dwnlading it frm a secured server and directly n the tablet. Mst patients enjyed using the tablets and fund the surveys easy t use. 2. Determine rate f all prescriptins used t treat menpausal symptms ver a specific time perid Dcumented prescriptin use fr HT and nn-hrmnal therapies (e.g., SSRI, SNRI, gabapentin) fr menpausal symptms will increase fr wmen age years. (Baseline: 28%; Pst-interventin: 34%) Pre- and pst-interventin assessment via query f EHR fr prescriptins f HT r nn-hrmnal therapy in wmen age years. See Table 1 in Issue Brief Rate f prescriptin use increased acrss eligible practices (n=7); Baseline: 6.1/100 wmen; End f study: 9.2/100 wmen The number f medicatins prescribed fr menpause; Baseline: 59.2/clinician. End f study: 94.3/clinician (35.1 mean increase; 95% CI (-5.5, 66.9); p-value= Determine the rate f HT discntinuatin in wmen age years 4. Determine rate f patients age years that discuss menpause r symptms with prvider Dcumented prescriptin use fr hrmne therapy fr menpausal symptms will decrease fr wmen age years. (Baseline: 8.6%; Pst-interventin: 4%) Discussins abut menpause r menpausal symptms will increase fr wmen age years after taking the MRS. (Baseline: 38%; Pst-interventin: 50%) Wmen will be asked abut therapy changes after visit with prvider. Pre- and pst-interventin assessment via query f EHR fr prescriptins f HT in wmen age years. Wmen will als be asked abut therapy changes after visit with prvider. Wmen will be asked abut discussins with their prvider abut menpause r menpausal symptms after the visit. See practice level utcmes reprt; Chart 1. Cntrl grup: 11/177 (6.25%) had medicatin changes Interventin grup: 27/231 (11.25%) had medicatin changes; p-value=0.06 N discntinuatin f HT ccurred fr wmen age years. The SDM prcess between prvider and wmen may have deemed this treatment apprpriate. Of 93 wmen in this chrt, nly 3 wmen (3.2%) were taking an estrgen cntaining medicatin. Wmen age years in cntrl and interventin grups had frequent discussins abut menpause, but it was nt statistically different between grups. Cntrl grup: 79/106 (74.5%) had discussins. Interventin grup: 112/142 (78.9%) had discussins (p-value = 0.42) Wmen age years in cntrl and

8 interventin grups had frequent discussins abut menpause, but it was nt statistically different between grups. Cntrl grup: 105/145 (72.4%) had discussins. Interventin grup: 143/187 (76.5%) had discussins (p-value = 0.40) 5. Determine rate f cunseling regarding breast cancer risk preventin in wmen years Cunseling regarding breast cancer risk will increase fr wmen age years after taking breast cancer risk assessment. (Baseline: 20%; Pst-interventin: 50%) Wmen will be asked abut discussins with prvider abut breast cancer risk after the visit. See Table 2 in Issue Brief See practice utcmes reprt: Chart 3 Wmen age years in cntrl and interventin grups had frequent discussins abut breast cancer, but it was nt statistically different between grups. Cntrl grup: 109/167 (65.3.4%) had discussins. Interventin grup: 146/187 (63.5%) had discussins (p-value = 0.71) 6. Determine the rate f cunseling regarding lifestyle changes (e.g., diet, exercise, alchl) in wmen age years Cunseling abut lifestyle mdificatin will increase fr wmen age years after taking the MRS and breast cancer risk assessment. (Baseline: 25%; Pstinterventin: 40%) Wmen will be asked abut discussins with prvider abut lifestyle mdificatins after the visit. See Table 2 in Issue Brief See practice utcmes reprt: Chart 3 Wmen age years in cntrl and interventin grups had very frequent discussins abut lifestyle, but it was nt statistically different between grups Cntrl grup: 151/179 (84.4%) had discussins. Interventin grup: 225/255 (88.2%) had discussins (p-value = 0.25) 7. Prvider knwledge Imprvement in knwledge frm pret pst-test Pre-Psttest Webinar See Table 2 in Issue Brief See practice utcmes reprt: Chart 3 Overall results fr prviders: Mean % Crrect: pre-test=66%; pst-test=74% (Mean difference = 0.07; 95% CI ; p=0.07) Individual pre-pst test results will be sent via t practices with mre than ne prvider. Sl Prviders: See practice utcmes reprt: Table B

9 Appendix B: Participant Demgraphics Descriptr Age Race Ethnicity Menpausal status Breast cancer histry Cncurrent cnditins Medicatins fr menpause Respnse Categry Ttal N=408 n (%) Cntrl N=177 (43.4%) Interventin N=231 (56.6%) p-value years 84 (20.6%) 33 (18.6%) 51 (22.1%) years 116 (28.4%) 53 (30.0%) 63 (27.3%) years 114 (27.9%) 53 (29.9%) 61 (26.4%) years 94 (23.0%) 38 (21.5%) 56 (24.2%) 0.51 AI/AK 1 (0.2%) 0 (0.0%) 1 (0.4%) Asian 5 (1.2%) 3 (1.7%) 2 (0.9%) Black/AA 65 (15.9%) 35 (19.8%) 30 (12.9%) 0.06 Unknwn 7 (1.7%) 5 (2.8%) 2 (0.8%) White 332 (81.0%) 134 (75.7%) 198 (85.0%) 0.01 Hispanic 24 (5.9%) 12 (6.8%) 12 (5.2%) Nn-Hispanic 384 (94.1%) 165 (93.2%) 219 (94.8%) Perimenpausal 60 (14.7%) 27 (15.3%) 33 (14.3%) Menpausal 98 (24.1%) 44 (25.0%) 54 (23.4%) Pstmenpausal 123 (30.2%) 50 (28.4%) 73 (31.6%) 0.73 Surgical Menpause 50 (12.3%) 22 (12.5%) 28 (12.1%) Unknwn 76 (18.7%) 33 (18.8%) 43 (18.6%) Yes 23 (5.7%) 10 (5.6%) 13 (5.6%) N 384 (94.3%) 167 (94.4%) 218 (94.4%) Anxiety 112 (27.5%) 37 (11.2%) 75 (32.0%) 0.02 Back Pain 93 (22.8%) 40 (21.4%) 58 (23.8%) 0.56 Depressin 104 (25.5%) 39 (22.0%) 65 (28.1%) 0.57 High Chlesterl 132 (32.4%) 61 (33.3%) 24 (31.6%) < Hypertensin 149 (36.5%) 75 (41.2%) 76 (32.9%) 0.05 Obesity 94 (23.0%) 37 (20.3%) 59 (25.1%) 0.27 Allergic Rhinitis 58 (14.2%) 24 (13.6%) 34 (14.7%) 0.7 Asthma 50 (12.3%) 21 (11.9%) 29 (12.6%) 0.6 Diabetes 48 (11.8%) 22 (13.6%) 14 (10.4%) 0.03 Hypthyridism 54 (13.1%) 15 (8.5%) 39 (16.5%) 0.01 Nne 69 (16.9%) 30 (16.4%) 40 (17.3%) 0.92 Reflux Esphagitis 71 (17.4%) 37 (20.3%) 35 (15.2%) 0.13 Black chsh 8 (1.9%) 3 (1.6%) 5 (2.1%) Cmbined estrgen and prgesterne (in ne dsage frm) 8 (1.9%) 4 (2.2%) 4 (1.6%) Cmpunded biidentical hrmne 6 (1.4%) 0 (0.0%) 6 (2.5%) therapy Estrgen 25 (5.8%) 9 (4.9%) 16 (6.6%) Gabapentin 7 (1.6%) 4 (2.2%) 3 (1.2%) 0.03 Nne 297 (69.4%) 143 (77.7%) 154 (63.1%) Other 18 (4.2%) 7 (3.8%) 11 (4.5%) Prgesterne 16 (3.7%) 5 (2.7%) 11 (4.5%) SNRI (e.g.,venlafaxine) 11 (2.6%) 2 (1.1%) 9 (3.7%) SSRI (e.g., sertraline, fluxetine, parxetine) 32 (7.5%) 7 (3.8%) 25 (10.3%) Overall p-value

10 Appendix C: Individual Symptms fr Wmen Taking the Menpause Rating Scale Specific Symptm Ht Flushes N=253 Jint and muscular discmfrt N=250 Sleep prblems N=253 Heart discmfrt N=253 Smatic Symptms Psychlgical Symptms Urgenital Symptms Respnse Frequency Specific Respnse Frequency Specific Respnse Categry (%) Symptm Categry (%) Symptm Categry Frequency (%) Nne 75 (29.6%) Nne 83 (32.9%) Nne 103 (41.0%) Mild 96 (37.9%) Mild 83 (32.9%) Dryness f Mild 58 (23.1%) Anxiety Mderate 53 (21.0%) Mderate 62 (24.6%) vagina Mderate 51 (20.3%) N=252 Severe 22 (8.7%) Severe 19 (7.5%) N=251 Severe 26 (10.4%) Very severe 7 (2.8%) Very severe 5 (2.0%) Very severe 13 (5.2%) Nne 57 (22.8%) Nne 74 (29.3%) Nne 95 (37.9%) Mild 87 (34.8%) Depressive Mild 69 (27.3%) Bladder Mild 79 (31.5%) Mderate 64 (25.6%) md Mderate 80 (31.6%) prblems Mderate 50 (19.9%) Severe 37 (14.8%) N=253 Severe 26 (10.3%) N=251 Severe 20 (8.0%) Very severe 5 (2.0%) Very severe 4 (1.6%) Very severe 7 (2.8%) Nne 58 (22.9%) Nne 65 (25.8%) Nne 82 (32.7%) Mild 63 (24.9%) Mild 93 (36.9%) Sexual Mild 56 (22.3%) Irritability Mderate 83 (32.8%) Mderate 66 (26.2%) prblems Mderate 66 (26.3%) N=252 Severe 39 (15.4%) Severe 24 (9.5%) N=251 Severe 32 (12.8%) Very severe 10 (4.0%) Very severe 4 (1.6%) Very severe 15 (6.0%) Nne 148 (58.5%) Nne 47 (18.7%) Physical Mild 71 (28.1%) Mild 89 (35.3%) and mental Mderate 29 (11.5%) Mderate 75 (29.8%) exhaustin Severe 4 (1.6%) Severe 33 (13.1%) N=252 Very severe 1 (0.4%) Very severe 8 (3.2%)