Characteristics and prevalence of MHT use among women aged 40-65 years with low socioeconomic status: a multi-district study in Shanghai, China

Characteristics and prevalence of MHT use among women aged 40-65 years with low socioeconomic status: a multi-district study in Shanghai, China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Characteristics and prevalence of MHT use among women aged 40-65 years with low socioeconomic status: a multi-district study in Shanghai, China Yang Zhou, Changbin Li, Yixuan Sun, Dongyao Zhang, Zhijie Wang, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5447444/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: China faces a burgeoning demand for menopausal health care. Guidelines recommend Menopausal Hormone Therapy (MHT) as the most effective treatment for menopausal symptoms. However, the prevalence of MHT use and its influencing factors remains largely unknown in China, especially for women with minimal assurance. Objective: This multi-center study aimed to explore the prevalence of MHT use with low socioeconomic status in shanghai and to understand its factors associated with MHT use. Methods and design We conducted a cross-sectional, multi-district, large-scale study of 6068 women aged 40-65 years with minimal living assurance from 10 health facilities in 7 districts of Shanghai supported by the Chinese government's public health benefit program. Data from cross-sectional survey of women between January 2023 and September 2023 were collected from comprehensive and modified questionnaires. Odds ratios (ORs) were calculated using logistic regression for characteristics related to MHT use, adjusting for sociodemographic, reproductive, health and lifestyle factors. Discussion This was the first largest of all similar studies to investigate the prevalence and the specific determinants of MHT use in southeast China. Our study revealed a low rate of MHT prescription among women with minimal assurance in Shanghai and MHT use was independently associated with undergoing a dual energy x-ray absorptiometry (DXA) scan, family history of osteoporosis, hospital-based sample source, regular physical activity, menopause, employment and higher educational level. It raises the need for increased awareness and strategies to help women seek menopausal health care of socioeconomic deprivation. Trial registration: chiCTR-EPC-17011255. Menopausal hormone therapy cross-sectional multi-center DXA regular physical activity Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Menopause is a crucial stage in women's lives that affects both neurological and psychiatric health. According to the most recent China’s seventh national census, it impacts 180 million Chinese women, accounting for nearly 13% of the total population, and is projected to reach 280 million by 2030[1]. This suggests a burgeoning demand for menopausal health care. Current evidence has supported that menopausal hormone therapy (MHT) is the only medical measure that can comprehensively address all the issues arising from estrogen deficiency in menopausal women[2, 3]. However, the evolution of MHT has encountered numerous complexities and controversies, notably the persistent concern regarding cancer risks[4]. During its peak in the late 1990s[5], MHT in the United States (U.S.) rose sharply, fueled by observational studies suggesting a protective effect on bone health and cardiovascular mortality. However, after the Women’s Health Initiative trial in 2002 revealed that the risks of MHT surpassed its benefits, the use of MHT declined significantly [6-8]. Even though subsequent long-term follow-ups have shown that the all-cause mortality rate has not increased [9], the number of people undergoing MHT use has not returned to previous levels in most countries[10, 11]. In China, the management of menopause started later compared to international standards. The Chinese Menopause Society was established in 2001[12], with goals including training specialist doctors and promoting MHT among the public and healthcare providers. Over 200 menopause clinics have been set up in mainland China. Despite over twenty years of efforts, the use of MHT in China remains much lower than in Western countries[13]. So far, there lacks large-scale research on MHT use in China, especially for minimal living assurance. Shanghai, as the most developed municipality in southeast China, has a population of approximately 3,441,200[14], indicating a corresponding increase in health demands for peri-postmenopausal health care. However, the prevalence of MHT use among Shanghai women with low socioeconomic status remains largely unknown. Objective This aim of this study was to 1) explore the prevalence of MHT use in women aged 40-65 years with low socioeconomic status in shanghai, the largest city in China, 2) characterize women aged 40-65 years in terms of socio-demographic, reproductive, health-related and lifestyle characteristics. Methods/design Study design We conducted a large-scale, multi-district and cross-sectional study encompassing 6,068 women aged 40 to 65 years in Shanghai. Supported by the Chinese government's public health benefit program, titled the "Cervical and Breast Cancer Screening Project", we recruited participants from the tertiary hospitals, secondary hospitals, district maternal, child health centers and the community. The participants were from low-income families with minimal living assurance and had resided in Shanghai for at least five years. This cross-sectional study was conducted between January 2023 and September 2023 from 10 health facilities in 7 districts: Xuhui, Putuo, Pudong, Jiading, Fengxian, Jinshan, and Chongming. Participants were deliberately selected to represent both central and suburban areas, considering factors such as population distribution, research capacity, and their willingness to participate. The sample size was calculated based on the rate of MHT utilization in previous study[15], using an appropriate sample size estimation formula. G∗power was used to estimate the minimum sample size, with test efficacy (1 - β) set at 0.80 and Type I error rate (α) at 0.05. Each eligible woman provided her informed consent prior to participation. Subsequently, all consenting participants were invited to complete a self-administered questionnaire, with trained health professionals available to assist with any inquiries. This study protocol was approved by the Ethics Committee of Shanghai Sixth People's Hospital (Approval Number: 2020-R05), and all participants provided their written informed consent after receiving a comprehensive explanation of the study's purpose and procedures. The study was conducted in strict accordance with the approved guidelines and ethical standards. Socio-demographic survey questionnaire A comprehensive and modified questionnaire [16] was utilized by highly trained investigators, consisting of three sections: (1) Sociodemographic information：age, last menstrual period, education level, marital status, employment status, menopausal status, years since menopause, type of MHT (including estradiol+dydrogesterone, estradiol alone, and tibolone)； (2) Reproductive and Health status：history of chronic disease (hypertension, diabetes mellitus, hyperlipidemia, osteoporosis), family history of osteoporosis, history of DXA for bone mineral density (BMD) test screening (based on responses to question, “Have you ever undergone a DXA scan for BMD?”； (3) Lifestyle attributes: body mass index (BMI), smoking, alcohol status, exercise status (exercise intensity, exercise frequency, exercise time, acceptable forms of exercise including (1) Jogging, (2) Racket sports, (3) Yoga, (4) Swimming, (5) Cycling, (6) Dancing, (7) Other forms of exercise (multiple choice). Statistical analysis All variables were tested for normal distribution by Kolmogorov-Smirnov test. Levene’s test of homogeneity of variance were further performed. Categorical data were presented as frequencies and percentages. χ2 test (categorical variables) were carried out to compare the differences among the MHT Users and never-users. The multivariate logistic regression analyses were performed to examine independent determinants for MHT use, stratified by socio-demographic factors, reproductive and health-related as well as lifestyle attributes. A two-sided p＜0.05 was considered to be a significant difference. Statistical analysis and graphing were performed using SPSS 24.0 and GraphPad Prism 9.0 software. Result Baseline information The fundamental information of 6068 subjects based on socio-demographic factors, reproductive and health-related as well as lifestyle attributes was presented in Figure. 1. As presented in Fig.1, 106 were never-MHT users (1.75%), among which 0.48 % had ever used MHT, while current users accounted for (1.27%). The mean age of the participants was 55.56 ± 6.29 years, with non-MHT users being slightly older (55.61 ± 6.30 years) and MHT users younger (53.06±5.60 years). The majority of the women were normal-weight (90.67%), married (97.07%), unemployed (62.71%), non-smokers (99.41%), and non-alcoholic (97.51%). Most participants (62.84%) had a junior or below education degree. Regarding lifestyle characteristics, 46.89% participants reported no physical activity, whereas 42.70% had irregular activity, and only 10.41% engaged in regular activity (among which 0.87% exercising ≥30 minutes per day for ≥ 5 days a week, and 9.54% exercising <30 minutes per day for <5 days a week). In addition, we surveyed the preferred forms of exercises (multiple choice) among women aged 40-65 with low socioeconomic status (supplementary figure1). The results showed that jogging was the most popular choice, with 2,779 participants. This was followed by dancing (1,664), yoga (1,213), walking (1,044), cycling (910), racket sports (810), and swimming (713). Only 12 participants chose brist walking. In terms of health conditions, 23.71% reported hypertension, 7.14% diabetes, 5.01% commodities, 2.49% had a family history of osteoporosis, and 3.72% had undergone a DXA scan. Determinants of MHT use Table 1 comprehensively outlined the association between the MHT users and socio-demographic, reproductive, health-related factors, as well as lifestyle behaviors. In comparison to non-users of MHT, MHT users tend to originate from hospitals (V.S. the community), possess higher educational attainment, be unmarried, employed, abstain from alcohol consumption, engage in regular physical activity, experience surgical menopause, have a family history of osteoporosis, and have previously undergone a DXA scan. Figure 2-4 presented the adjusted associations between the use of MHT and socio-demographic, reproductive and health-related characteristics, as well as lifestyle behaviors, respectively. Table 1. Characteristics of MHT use among women aged 40-65 years with low socioeconomic status Socio-demographic characteristics Lifestyle behaviours Health-related characteristics Variables MHT users Variables MHT users Variables MHT users Age Groups(years) BMI, kg/m 2 History of hypertension < 45 4(1.21%) =28 1(0.22%) History of diabetes ≥ 60 19(0.95%) Smoking status Yes 10(1.78%) Menopausal status Never 104(1.72%) No 95(2.31%) Premenopause 25(1.74%) Current /Past regular smoker 2(5.56%) Missing 1(1.82%) Postmenopause 81(1.75%) Alcohol History of hyperlipidemia Sample source Never 100(1.69%) Yes 4(1.84%) Hospital 69(3.01%)*** Current /Past regular smoker 6(3.97%)* No 101(1.46%) Community 37(0.98%) Physical activity Missing 1(1.82%) Education level Nil activity 32(1.11%) History of osteoporosis Junior or below 38(1.00%)*** Irregular activity 57(2.20%)*** Yes 7(3.33%) Senior or high 68(3.02%) Regular activity 17(2.93%)*** No 98(1.77%) Marital status Missing 1(1.82%) Married 98(1.66%)**** Type of menopause Single/Widowed 8(4.49%) Natural menopause 74(1.67%) Employment status Surgical menopause 7(3.55%)*** Work/reemployment 62(2.74%)*** Family history of osteoporosis Departure/retirement 44(1.16%) Yes 24(10.62%)*** Number of births No 82(1.40%) None 2(3.13%) Undergone DXA or not 1to2 103(1.75%) Yes 24(22.64%) ≥3 1(0.97%) No 82(1.40%)*** MHT : Menopausal hormone therapy, BMI: Body mass index, Ordered categorical variables were computed by Wilcoxon rank sum test, while unordered two–categorical variables were tested by χ2 tests, *** means p ＜0.001,* means p＜0.05 After adjusting for socio-demographic variables, MHT users were more likely to be menopausal (OR: 3.682, 95% CI: 2.039-6.649), employed (OR: 1.990, 95% CI: 1.678-2.769) and from hospitals compared to the community (OR: 2.464, 95% CI: 1.624-3.739) (Fig.2). As regard to the physical activity, it was observed that both irregular and regular activity, when compared to no activity, were significantly associated with increased odds of MHT use, with odds ratios (ORs) of 1.804 (95% CI: 1.141-2.852) and 2.018 (95%CI: 1.067-3.818), respectively. Notably, women who engaged in yoga demonstrated almost double the odds of using MHT (OR: 1.742, 95% CI: 1.012-2.999) (Fig.3). Furthermore, women with a family history of osteoporosis had approximately fourfold increased odds of utilizing MHT (OR: 3.964, 95% CI: 1.812-8.674), while those who had previously undergone a DXA had over six times higher odds of using MHT (OR: 6.231, 95% CI: 3.486-11.138) (Fig.4). All these observed ORs were statistically significant. In summary, after adjusting for various crucial variables, including sociodemographic, reproductive, health-related factors and lifestyle behaviors, as shown in Fig.5., we identified several independent determinants for the utilization of MHT. These included undergoing a DXA scan (OR: 5.193, 95% CI: 3.080-8.756), having a family history of osteoporosis (OR: 3.697, 95% CI: 1.973-6.925), a hospital-based sample source (OR: 2.638, 95% CI: 1.724-4.037), regular physical activity (OR: 2.276, 95% CI: 1.186-2.909), menopause (OR: 2.192, 95% CI: 1.311-3.665), employment (OR: 2.190, 95% CI: 1.401-3.423), and higher educational level (OR: 1.942, 95% CI: 1.255-3.005). Discussion To our knowledge, this was the first largest of all similar studies to investigate the prevalence and the specific determinants of MHT use in southeast China. In our multi-district, large-scale study of women aged 40–65 years with low socioeconomic status, only 1.75% reported as current or ever users in 2023 (0.48% had ever used MHT, while current users accounted for 1.27%). Previous data on MHT use in China is very limited. An Asian menopausal survey in 2006, involving a sample of 300 Chinese individuals, revealed that only 9% of Chinese women have ever used MHT, and 2% were current users [ 17 ]. Another survey [ 15 ] has conducted in Guangdong in southern China reported that ever and current MHT usage was reported in 0.8% and 1.3% of women in 2008, respectively. A 2014 study showed that the utilization rate of MHT among Chinese menopausal obstetrician-gynecologists was only 1.3–1.4%[ 18 ]. Collectively, these data suggested a decline in MHT use over the nearly 20-year period in China, albeit with varying quality of researches. Additionally, MHT use in China was lower compared to other countries. A most recent Spanish research has reported that 2.5% postmenopausal women used MHT[ 19 ], while only 1.6% perimenopausal women used MHT. In contrast, a report from the National Health and Nutrition Examination Survey (NHANES) in U.S. showed that the proportion of women over 40 years using oral MHT was 4.7% in 2009–2010[ 6 ]( decreased from 22% in 1999–2002). Studies conducted in other nations, such as Australia (12–13% in 2013), Germany (6% in 2016), and Korea (6.3% in 2003), have also reported similar declines in the prevalence of MHT use [ 20 – 22 ]. These international comparisons highlighted the relatively low adoption of MHT in China. Several reasons could be addressed to the low prevalence MHT use in China. Firstly, the fear of its short-term and long-term side effects, such as cancers, appears to be the most significant cause of the decline and low prevalence in MHT use[ 13 ]. This perception may be fueled by limited awareness and misunderstanding about MHT's benefits and risks. Secondly, he emergence of the COVID-19 pandemic in China since 2019 has strained medical resources, leading to squeeze on non-emergency medical services. Meantime, the uncertainty and anxiety brought by the pandemic further affected the utilization rate of MHT among menopausal women. Thirdly, as this study was funded by the Chinese government's public health benefit program, the participants were sourced from low-income families with minimal living assurances. These subject sample exhibited relatively low level of education, income, and social status, consequently lacking sufficient understanding of menopause-related issues and MHT options, which was consistent with that women from deprived backgrounds are less likely to be receiving MHT[ 23 ]. As regard to the determinants for MHT use, we found that women who have ever undergone DXA scan and have a family history of osteoporosis were independently associated with MHT use. This aligns with clinical guidelines recommending DXA screening and MHT for most menopausal women to reduce osteoporosis and fracture risk [ 24 ]. Additionally, subjects who originated from hospitals (V.S. the community) positively correlated with MHT use, perhaps due to their higher health awareness and health care-seeking behaviors compared to community populations. Consequently, they may have a higher rate of MHT use. We also found that regular physical activity was associated with the increasing odds of MHT use compared with no physical activity, which was in line with the result of the study [ 25 ], but inconsistent with another that did not subdivide physical activity [ 26 ]. Specifically, women preferring yoga tended to use MHT more, suggesting that those with good health awareness and a pursuit of a high-quality life are more likely to adopt MHT. Our study revealed that higher educational level, employment and menopause status were independently associated with MHT use, which concurred with the data showing that education, occupation, and menopause were associated with current MHT use [ 25 , 27 – 30 ]. In contrast, other independent indicators such as alcohol consumption [ 29 , 31 ], and smoking [ 29 – 31 ] in previous study, however, in our study, were not found to be significantly related to MHT use. These discrepancies may be due to differences in outcome variables, cohort sizes, populations selection and time periods of questioning, and other factors[ 22 ] . As this was a cross-sectional study, recall bias and report bias could not be completely avoided, especially for the approximate onset time of symptoms. However, the bias might occur evenly among the participants and therefore have little impact on the overall results and conclusions drawn from this study. Conclusions This study revealed the low prevalence of MHT use in women with low socioeconomic status in Shanghai, China. Besides, the MHT use was associated with women who have previously undergone DXA scan, have a family history of osteoporosis, originate from hospitals (V.S. the community), engage in regular physical activity, possess higher educational attainment, and are employed. To effectively address this issue, it is imperative to enhance the knowledge of menopausal health among Chinese middle-aged women with low socioeconomic status, as this may lead to a positive change in their health-seeking behaviors. Furthermore, in response to the accelerating aging population, it is urgent to provide professional and accessible perimenopausal health services in Shanghai, particularly for women from low-income families with minimal health coverage. Our findings have contributed significantly to the understanding of menopausal hormone therapy (MHT) use among women with low socioeconomic status, highlighting the necessity for comprehensive strategies that address professional training deficiencies, increase the availability of MHT, and optimize the dissemination of information to patients, thereby overcoming barriers to access and utilization of menopausal health care services. Abbreviations MHT: Menopausal Hormone Therapy, ORs: Odds ratios, DXA: Dual energy x-ray absorptiometry, BMD: bone mineral density, BMI: Body mass index, NHANES: National Health and Nutrition Examination Survey. Declarations Acknowledgements We would like to thank the study participants and many chief directors (ZJ W, MW, Z L, FY, MJS, XXP, RFJ, FYX, XLC, LZ) who helped with the investigation. The research was funded by the Shanghai Municipal Health Commission - Child Health 【2023】NO.12. Ethics approval and consent to participate The Shanghai sixth people’s hospital authorized the corresponding study involving human participants. All participants provided written informed consent prior to study commencement. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Researchers with a specified purpose should send request email to Professor Minfang Tao: [email protected] ,cn Competing interests The authors declare that they have no competing interests. Funding The research was funded by Shanghai Municipal Health Commission - Child Health 【2023】NO.12. Authors’ contributions MFT and YCT contributed to study conception and design; YZ performed the data analysis and interpretation of results, and drafted the manuscript; CBL, YX S,DY Z contributed to data collection; ZJW, MW, ZL, FY, MJS, XXP, RFJ, FYX, XLC, LZ (These authors have equal contributions and are listed in no particular order)were responsible for the investigation of respective health facility. All authors reviewed the results and approved the final version of the manuscript. Acknowledgments We would like to thank the study participants and many chief directors (ZJ W, MW, Z L, FY, MJS, XXP, RFJ, FYX, XLC, LZ) who helped with the investigation. The research was funded by the Shanghai Municipal Health Commission - Child Health 【2023】NO.12. References Yu Q. Population education of menopausal knowledge in China. Climacteric. 2019;22(4):323. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767–94. Crandall CJ, Mehta JM, Manson JE. Management of Menopausal Symptoms: A Review. JAMA. 2023;329(5):405–20. Cagnacci A, Venier M. The Controversial History of Hormone Replacement Therapy. Medicina. 2019;55(9):602. Keating NL, Cleary PD, Rossi AS, Zaslavsky AM, Ayanian JZ. Use of hormone replacement therapy by postmenopausal women in the United States. Ann Intern Med. 1999;130(7):545–53. Sprague BL, Trentham-Dietz A, Cronin KA. A sustained decline in postmenopausal hormone use: results from the National Health and Nutrition Examination Survey, 1999–2010. Obstet Gynecol. 2012;120(3):595–603. Tsai SA, Stefanick ML, Stafford RS. Trends in menopausal hormone therapy use of US office-based physicians, 2000–2009. Menopause. 2011;18(4):385–92. Crawford SL, Crandall CJ, Derby CA, El Khoudary SR, Waetjen LE, Fischer M, Joffe H. Menopausal hormone therapy trends before versus after 2002: impact of the Women's Health Initiative Study Results. Menopause. 2018;26(6):588–97. Chlebowski RT, Anderson GL, Aragaki AK, Manson JE, Stefanick ML, Pan K, Barrington W, Kuller LH, Simon MS, Lane D, et al. Association of Menopausal Hormone Therapy With Breast Cancer Incidence and Mortality During Long-term Follow-up of the Women's Health Initiative Randomized Clinical Trials. JAMA. 2020;324(4):369–80. Cho L, Kaunitz AM, Faubion SS, Hayes SN, Lau ES, Pristera N, Scott N, Shifren JL, Shufelt CL, Stuenkel CA, Lindley KJ. Rethinking Menopausal Hormone Therapy: For Whom, What, When, and How Long? Circulation. 2023;147(7):597–610. Hickey M, LaCroix AZ, Doust J, Mishra GD, Sivakami M, Garlick D, Hunter MS. An empowerment model for managing menopause. Lancet. 2024;403(10430):947–57. Lin L, Feng P, Yu Q. Attitude and knowledge for menopause management among health professionals in mainland China. Climacteric. 2020;23(6):614–21. Wang Y, Wang W, Feng Y, Tan Z, Yang X, Peng D, Zhao Y, Dong H, Zheng Q, Zeng X, et al. What is behind the fear of cancer during menopausal hormone therapy in China? Arch Gynecol Obstet. 2021;304(5):1353–61. Huang C, Zheng Y, Zhu L, Li Y, Du L, Tao M, Xu B. Demands for perimenopausal health care in women aged 40 to 60 years-a hospital-based cross-sectional study in Shanghai, China. Menopause. 2019;26(2):189–96. Yang D, Haines CJ, Pan P, Zhang Q, Sun Y, Hong S, Tian F, Bai B, Peng X, Chen W, et al. Menopausal symptoms in mid-life women in southern China. Climacteric. 2008;11(4):329–36. Zhou Y, Lin J, Li C, Zheng Y, Meng Z, Teng Y, Tao M. A fNIRS investigation of menopausal-related symptoms and brain cortical activity in menopause. J Affect Disord. 2024;353:101–8. Huang KE, Xu L, I NN, Jaisamrarn U. The Asian Menopause Survey: knowledge, perceptions, hormone treatment and sexual function. Maturitas. 2010;65(3):276–83. Wang Y, Yang X, Li X, He X, Zhao Y. Knowledge and personal use of menopausal hormone therapy among Chinese obstetrician-gynecologists: results of a survey. Menopause. 2014;21(11):1190–6. Baquedano L, Coronado P, De la Viuda E, Sánchez S, Otero B, Ramírez I, Llaneza P, Mendoza N. Population-based survey on menopausal symptoms and treatment use. Climacteric. 2023;26(1):47–54. Heinig M, Braitmaier M, Haug U. Prescribing of menopausal hormone therapy in Germany: Current status and changes between 2004 and 2016. Pharmacoepidemiol Drug Saf. 2021;30(4):462–71. Park CY, Lim JY, Kim WH, Kim SY, Park HY. Evaluation of menopausal hormone therapy use in Korea (2002–2013): A nationwide cohort study. Maturitas. 2021;146:57–62. Velentzis LS, Egger S, Banks E, Canfell K. Menopausal hormone therapy: Characterising users in an Australian national cross-sectional study. PLoS ONE. 2021;16(8):e0253725. Hillman S, Shantikumar S, Ridha A, Todkill D, Dale J. Socioeconomic status and HRT prescribing: a study of practice-level data in England. Br J Gen Pract. 2020;70(700):e772–7. Jones AR, Enticott J, Ebeling PR, Mishra GD, Teede HT, Vincent AJ. Bone health in women with premature ovarian insufficiency/early menopause: a 23-year longitudinal analysis. Hum Reprod. 2024;39(5):1013–22. Lucas R, Barros H. Life prevalence and determinants of hormone replacement therapy in women living in Porto, Portugal. Maturitas. 2007;57(3):226–32. Cornuz J, Krieg MA, Sandini L, Ruffieux C, Van Melle G, Burckhardt P, Büche D, Dambacher M, Hartl F, Häuselmann H, et al. Factors associated with the use of hormone replacement therapy among older women. Age Ageing. 2003;32(6):675–8. Parazzini F. Trends of determinants of hormone therapy use in Italian women attending menopause clinics, 1997–2003. Menopause. 2008;15(1):164–70. Manzoli L, Di Giovanni P, Del Duca L, De Aloysio D, Festi D, Capodicasa S, Monastra G, Romano F, Staniscia T. Use of hormone replacement therapy in Italian women aged 50–70 years. Maturitas. 2004;49(3):241–51. Nagel G, Lahmann PH, Schulz M, Boeing H, Linseisen J. Use of hormone replacement therapy (HRT) among women aged 45–64 years in the German EPIC-cohorts. Maturitas. 2007;56(4):436–46. Lambert LJ, Straton JA, Knuiman MW, Bartholomew HC. Health status of users of hormone replacement therapy by hysterectomy status in Western Australia. J Epidemiol Community Health. 2003;57(4):294–300. Costanian C, Edgell H, Ardern CI, Tamim H. Hormone therapy use in the Canadian Longitudinal Study on Aging: a cross-sectional analysis. Menopause. 2018;25(1):46–53. Additional Declarations No competing interests reported. Supplementary Files supplementaryfig1.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5447444","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":387948384,"identity":"c4e4506e-8fa4-4552-9d3e-17e0f5e6c700","order_by":0,"name":"Yang Zhou","email":"","orcid":"","institution":"Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Zhou","suffix":""},{"id":387948386,"identity":"0c9b5dc0-5330-4b1d-9a83-1b7240abecfa","order_by":1,"name":"Changbin Li","email":"","orcid":"","institution":"Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Changbin","middleName":"","lastName":"Li","suffix":""},{"id":387948388,"identity":"3aa7840a-3c76-4512-bf54-c0baab4990d9","order_by":2,"name":"Yixuan Sun","email":"","orcid":"","institution":"Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yixuan","middleName":"","lastName":"Sun","suffix":""},{"id":387948392,"identity":"1db6ff66-884c-466b-9174-523c33868f0c","order_by":3,"name":"Dongyao Zhang","email":"","orcid":"","institution":"Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Dongyao","middleName":"","lastName":"Zhang","suffix":""},{"id":387948393,"identity":"ef8e5178-5fe1-4a98-88ad-00ecc0592085","order_by":4,"name":"Zhijie Wang","email":"","orcid":"","institution":"Shanghai Eighth People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhijie","middleName":"","lastName":"Wang","suffix":""},{"id":387948394,"identity":"0208000f-5e36-460c-89f2-7ed6019dbe2f","order_by":5,"name":"Mei Wang","email":"","orcid":"","institution":"Pudong New Area People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mei","middleName":"","lastName":"Wang","suffix":""},{"id":387948396,"identity":"12918f6b-44f9-411f-a037-531883992712","order_by":6,"name":"Zhou liu","email":"","orcid":"","institution":"Zhoupu Hospital, Shanghai University of Medicine \u0026 Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Zhou","middleName":"","lastName":"liu","suffix":""},{"id":387948397,"identity":"8ce04206-4bbf-46fd-b3ca-dd70546d5b6c","order_by":7,"name":"Yang Fengyun","email":"","orcid":"","institution":"Maternal and Child Healthcare Hospital, Jiading District","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Fengyun","suffix":""},{"id":387948398,"identity":"73dd955b-ade7-49ba-aee5-a7787edb79a3","order_by":8,"name":"Minjun Su","email":"","orcid":"","institution":"Maternal and Child Healthcare Hospital, Songjiang Distric","correspondingAuthor":false,"prefix":"","firstName":"Minjun","middleName":"","lastName":"Su","suffix":""},{"id":387948399,"identity":"69efce30-caf7-4a4c-97a4-201c14d6d5c2","order_by":9,"name":"Xixia Pang","email":"","orcid":"","institution":"Obstetrics and Gynecology Department, Kongjiang Hospital, Yangpu District,","correspondingAuthor":false,"prefix":"","firstName":"Xixia","middleName":"","lastName":"Pang","suffix":""},{"id":387948400,"identity":"39c40c8f-50c8-47b6-9957-39a52a75405a","order_by":10,"name":"Ruifu Jin","email":"","orcid":"","institution":"International Peace Maternity \u0026 Child Health Hospital of the China Welfare Institute, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ruifu","middleName":"","lastName":"Jin","suffix":""},{"id":387948401,"identity":"63647b6c-7da4-442e-b5dd-fd1c63e80e29","order_by":11,"name":"Fengyin Xu","email":"","orcid":"","institution":"Maternal and Child Healthcare Hospital, Jinshan District,","correspondingAuthor":false,"prefix":"","firstName":"Fengyin","middleName":"","lastName":"Xu","suffix":""},{"id":387948402,"identity":"b2c9decb-8112-469e-a4d8-36c5f5140fd1","order_by":12,"name":"Xuelian Chen","email":"","orcid":"","institution":"Maternal and Child Healthcare Hospital, Jinshan District,","correspondingAuthor":false,"prefix":"","firstName":"Xuelian","middleName":"","lastName":"Chen","suffix":""},{"id":387948403,"identity":"1f3985a6-dd35-42c6-bfe4-402e1547782c","order_by":13,"name":"Lin Zhang","email":"","orcid":"","institution":"Maternal and Child Healthcare Hospital, Putuo District","correspondingAuthor":false,"prefix":"","firstName":"Lin","middleName":"","lastName":"Zhang","suffix":""},{"id":387948405,"identity":"fe003e79-22b6-4614-a684-0eca30268c8b","order_by":14,"name":"Yincheng Teng","email":"","orcid":"","institution":"Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yincheng","middleName":"","lastName":"Teng","suffix":""},{"id":387948406,"identity":"4cfacc21-eaf8-405a-ae9a-827b643e1c3a","order_by":15,"name":"Minfang Tao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxElEQVRIiWNgGAWjYLCCigoGZjCDhxjVYEVnzjAw85Cm5WwblEGUFnv2w0c3HJxXx24vkcD44G0bg7w5QVt40tJuHNx2mJlHIoHZcG4bg+HOBoIOyzG7/XHbAZAWNmneNoYEgwOEtPC/MbtxcE4dSAv7b+K0SOQAtTQwg21hJk7LjWdpNw4cA/rlzMNmyTnnJAw3ENLC3p987MaBmrpk9vbkgx/elNnIE7QFBpIZGBgbgLQEkeqBwI54paNgFIyCUTDiAAA2ejxsRdWGlQAAAABJRU5ErkJggg==","orcid":"","institution":"Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Minfang","middleName":"","lastName":"Tao","suffix":""}],"badges":[],"createdAt":"2024-11-13 13:38:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5447444/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5447444/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71747985,"identity":"d23c8c80-8d4d-4ed3-a8e0-4095bc3de5bd","added_by":"auto","created_at":"2024-12-18 09:06:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":35923,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBasic information of 6068 women aged 40-65 years with minimal assurance\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5447444/v1/261c1eeaa51c26811fef7b22.png"},{"id":71747336,"identity":"0ce8b2f1-37cb-4439-8675-0ca27ef24db6","added_by":"auto","created_at":"2024-12-18 08:58:35","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":72402,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAssociations between socio-demographic characteristics and MHT use among women aged 40–65 years old. Adjusted ORs obtained from logistic regression model.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea \u003c/sup\u003eadjusted for age, sample source, employment status, educational level, marital status, menopause status OR, odds ratio; CI, confidential interval\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5447444/v1/7ac910892cd826e6d09b9ece.png"},{"id":71747331,"identity":"68b6c423-b26a-47f6-aa69-14d9c43989bc","added_by":"auto","created_at":"2024-12-18 08:58:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":115878,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAssociations between lifestyle behaviors and MHT use among women aged 40–65 years old. Adjusted ORs obtained from logistic regression model.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea \u003c/sup\u003eadjusted for BMI, smoking status, alcohol drinking status, physical activity, OR, odds ratio; CI, confidential interval\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5447444/v1/2e9998d54ee66b867dc42f2c.png"},{"id":71747332,"identity":"34acc0f3-c522-42b1-8d6b-095971ec4694","added_by":"auto","created_at":"2024-12-18 08:58:35","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":92284,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAssociations between health-related characteristics\u003c/strong\u003e\u0026nbsp;\u003cstrong\u003eand MHT use among women aged 40–65 years old.\u003c/strong\u003e\u003csup\u003e \u003c/sup\u003e\u003cstrong\u003eAdjusted ORs obtained from logistic regression model. \u003c/strong\u003e\u003csup\u003ea \u003c/sup\u003eadjusted for diabetes, hypertension, osteoporosis, hyperlipidemia, type of menopause, parity, family history of osteoporosis, DXA bone density test, OR, odds ratio; CI, confidential interval\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5447444/v1/a6b6112bb36eb87fb2ac94c6.png"},{"id":71747334,"identity":"9992ec3e-1765-4241-bc66-674a5b580f95","added_by":"auto","created_at":"2024-12-18 08:58:35","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":117753,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdjusted odds ratio for MHT use by logistic regression.\u0026nbsp; \u003c/strong\u003e\u003csup\u003ea \u003c/sup\u003eadjusted for all variates including. age, sample source, employment status, educational level, marital status, menopause status, BMI, smoking status, alcohol drinking status, physical activity, diabetes, hypertension, osteoporosis, hyperlipidemia, type of menopause, parity, family history of osteoporosis, DXA bone density test, OR, odds ratio; CI, confidential interval.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-5447444/v1/2b5ac295d8a6597cf156f0c9.png"},{"id":101296534,"identity":"3af16f6a-76b6-4cd7-ba77-f26a99537183","added_by":"auto","created_at":"2026-01-28 09:13:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1379444,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5447444/v1/2ed3ab9d-766f-43dd-8a8b-0930700081d7.pdf"},{"id":71747986,"identity":"af09054f-9fca-40a9-8fd3-ffbb5f8b69af","added_by":"auto","created_at":"2024-12-18 09:06:35","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":94857,"visible":true,"origin":"","legend":"","description":"","filename":"supplementaryfig1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5447444/v1/e12133fcdde8a2c962fb6a06.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Characteristics and prevalence of MHT use among women aged 40-65 years with low socioeconomic status: a multi-district study in Shanghai, China","fulltext":[{"header":"Background","content":"\u003cp\u003eMenopause is a crucial stage in women\u0026apos;s lives that affects both neurological and psychiatric health. According to the most recent China\u0026rsquo;s seventh national census, it impacts 180 million Chinese women, accounting for nearly 13% of the total population, and is projected to reach 280 million by 2030[1]. This suggests a burgeoning demand for menopausal health care. Current evidence has supported that menopausal hormone therapy (MHT) is the only medical measure that can comprehensively address all the issues arising from estrogen deficiency in menopausal women[2, 3].\u003c/p\u003e\n\u003cp\u003eHowever, the evolution of MHT has encountered numerous complexities and controversies, notably the persistent concern regarding cancer risks[4]. During its peak in the late 1990s[5], MHT in the United States (U.S.) rose sharply, fueled by observational studies suggesting a protective effect on bone health and cardiovascular mortality. However, after the Women\u0026rsquo;s Health Initiative trial in 2002 revealed that the risks of MHT surpassed its benefits, the use of MHT declined significantly [6-8]. Even though subsequent long-term follow-ups have shown that the all-cause mortality rate has not increased [9], the number of people undergoing MHT use has not returned to previous levels in most countries[10, 11].\u003c/p\u003e\n\u003cp\u003eIn China, the management of menopause started later compared to international standards. The Chinese Menopause Society was established in 2001[12], with goals including training specialist doctors and promoting MHT among the public and healthcare providers. Over 200 menopause clinics have been set up in mainland China. Despite over twenty years of efforts, the use of MHT in China remains much lower than in Western countries[13]. So far, there lacks large-scale research on MHT use in China, especially for minimal living assurance.\u003c/p\u003e\n\u003cp\u003eShanghai, as the most developed municipality in southeast China, has a population of approximately 3,441,200[14], indicating a corresponding increase in health demands for peri-postmenopausal health care. However, the prevalence of MHT use among Shanghai women with low socioeconomic status remains largely unknown.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis aim of this study was to 1) explore the prevalence of MHT use in women aged 40-65 years with low socioeconomic status in shanghai, the largest city in China, 2) characterize women aged 40-65 years in terms of socio-demographic, reproductive, health-related and lifestyle characteristics.\u003c/p\u003e"},{"header":"Methods/design","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a large-scale, multi-district and cross-sectional study encompassing 6,068 women aged 40 to 65 years in Shanghai. Supported by the Chinese government\u0026apos;s public health benefit program, titled the \u0026quot;Cervical and Breast Cancer Screening Project\u0026quot;, we recruited participants from the tertiary hospitals, secondary hospitals, district maternal, child health centers and the community. The participants were from low-income families with minimal living assurance and had resided in Shanghai for at least five years.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis cross-sectional study was conducted between January 2023 and September 2023 from 10 health facilities in 7 districts: Xuhui, Putuo, Pudong, Jiading, Fengxian, Jinshan, and Chongming. Participants were deliberately selected to represent both central and suburban areas, considering factors such as population distribution, research capacity, and their willingness to participate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe sample size was calculated based on the rate of MHT utilization in previous study[15], using an appropriate sample size estimation formula. G\u0026lowast;power was used to estimate the minimum sample size, with test efficacy (1 -\u0026nbsp;\u0026beta;) set at 0.80 and Type I error rate (\u0026alpha;) at 0.05.\u003c/p\u003e\n\u003cp\u003eEach eligible woman provided her informed consent prior to participation. Subsequently, all consenting participants were invited to complete a self-administered questionnaire, with trained health professionals available to assist with any inquiries. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study protocol was approved by the Ethics Committee of Shanghai Sixth People\u0026apos;s Hospital (Approval Number: 2020-R05), and all participants provided their written informed consent after receiving a comprehensive explanation of the study\u0026apos;s purpose and procedures. The study was conducted in strict accordance with the approved guidelines and ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSocio-demographic survey questionnaire\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA comprehensive and modified questionnaire [16] was utilized by highly trained investigators, consisting of three sections:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(1) Sociodemographic information：age, last menstrual period, education level, marital status, employment status, menopausal status, years since menopause, type of MHT (including estradiol+dydrogesterone, estradiol alone, and tibolone)；\u003c/p\u003e\n\u003cp\u003e(2) Reproductive and Health status：history of chronic disease (hypertension, diabetes mellitus, hyperlipidemia, osteoporosis), family history of osteoporosis, history of DXA for bone\u0026nbsp;mineral density (BMD) test screening (based on responses to question, \u0026ldquo;Have you ever undergone a DXA scan for BMD?\u0026rdquo;；\u003c/p\u003e\n\u003cp\u003e(3) Lifestyle attributes: body mass index (BMI), smoking, alcohol status, exercise status (exercise intensity, exercise frequency, exercise time, acceptable forms of exercise including (1) Jogging, (2) Racket sports, (3) Yoga, (4) Swimming, (5) Cycling, (6) Dancing, (7) Other forms of exercise (multiple choice).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll variables were tested for normal distribution by Kolmogorov-Smirnov test. Levene\u0026rsquo;s test of homogeneity of variance were further performed. Categorical data were presented as frequencies and percentages. \u0026chi;2 test (categorical variables) were carried out to compare the differences among the MHT Users and never-users. The multivariate logistic regression analyses were performed to examine independent determinants for MHT use, stratified by socio-demographic factors, reproductive and health-related as well as lifestyle attributes. A two-sided p＜0.05 was considered to be a significant difference. Statistical analysis and graphing were performed using SPSS 24.0 and GraphPad Prism 9.0 software.\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003e\u003cstrong\u003eBaseline information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe fundamental information of 6068 subjects based on socio-demographic factors, reproductive and health-related as well as lifestyle attributes was presented in Figure. 1. As presented in Fig.1, 106 were never-MHT users (1.75%), among which 0.48 % had ever used MHT, while current users accounted for (1.27%). The mean age of the participants was 55.56 \u0026plusmn; 6.29 years, with non-MHT users being slightly older (55.61 \u0026plusmn; 6.30 years) and MHT users younger (53.06\u0026plusmn;5.60 years). The majority of the women were normal-weight (90.67%), married (97.07%), unemployed (62.71%), non-smokers (99.41%), and non-alcoholic (97.51%). Most participants (62.84%) had a junior or below education degree. Regarding lifestyle characteristics, 46.89% participants reported no physical activity, whereas 42.70% had irregular activity, and only 10.41% engaged in regular activity (among which 0.87% exercising \u0026ge;30 minutes per day for \u0026ge; 5 days a week, and 9.54% exercising \u0026lt;30 minutes per day for \u0026lt;5 days a week). In addition, we surveyed the preferred forms of exercises (multiple choice) among women aged 40-65 with low socioeconomic status (supplementary figure1). The results showed that jogging was the most popular choice, with 2,779 participants. This was followed by dancing (1,664), yoga (1,213), walking (1,044), cycling (910), racket sports (810), and swimming (713). Only 12 participants chose brist walking. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;In terms of health conditions, 23.71% reported hypertension, 7.14% diabetes, 5.01% commodities, 2.49% had a family history of osteoporosis, and 3.72% had undergone a DXA scan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeterminants of MHT use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 comprehensively outlined the association between the MHT users and socio-demographic, reproductive, health-related factors, as well as lifestyle behaviors. In comparison to non-users of MHT, MHT users tend to originate from hospitals (V.S. the community), possess higher educational attainment, be unmarried, employed, abstain from alcohol consumption, engage in regular physical activity, experience surgical menopause, have a family history of osteoporosis, and have previously undergone a DXA scan. Figure 2-4 presented the adjusted associations between the use of MHT and socio-demographic, reproductive and health-related characteristics, as well as lifestyle behaviors, respectively.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"748\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1. Characteristics of MHT use among women aged 40-65 years with low socioeconomic status \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 256px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocio-demographic characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLifestyle behaviours\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 275px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth-related characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMHT users\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMHT users\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMHT users\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 256px;\"\u003e\n \u003cp\u003eAge Groups(years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eBMI, kg/m\u003cstrong\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eHistory of hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026emsp;\u0026lt; 45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e4(1.21%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026lt;18.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e1(0.84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e24(1.88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026emsp;45\u0026ndash;49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e25(3.13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e18.5-23.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e66(1.98%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e81(1.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026emsp;50\u0026ndash;55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e37(2.65%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e24-27.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e38(1.76%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e1(0.94%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026emsp;55\u0026ndash;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e21(1.35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026gt;=28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e1(0.22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eHistory of diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026emsp;\u0026ge;\u0026nbsp;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e19(0.95%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 217px;\"\u003e\n \u003cp\u003eSmoking status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e10(1.78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003eMenopausal status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026emsp;Never\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e104(1.72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e95(2.31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003ePremenopause\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e25(1.74%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026emsp;Current /Past regular smoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e2(5.56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e1(1.82%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003ePostmenopause\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e81(1.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eAlcohol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 275px;\"\u003e\n \u003cp\u003eHistory of hyperlipidemia\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003eSample source\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026emsp;Never\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e100(1.69%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e4(1.84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e69(3.01%)***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026emsp;Current /Past regular smoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e6(3.97%)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e101(1.46%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003eCommunity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e37(0.98%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePhysical activity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e1(1.82%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eNil activity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e32(1.11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eHistory of osteoporosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026nbsp; Junior or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e38(1.00%)***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eIrregular activity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e57(2.20%)***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e7(3.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026nbsp; Senior or high\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e68(3.02%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eRegular activity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e17(2.93%)***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e98(1.77%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003eMarital status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e1(1.82%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026nbsp; Married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e98(1.66%)****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eType of menopause\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026nbsp; Single/Widowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e8(4.49%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eNatural menopause\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e74(1.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003eEmployment status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eSurgical menopause\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e7(3.55%)***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003eWork/reemployment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e62(2.74%)***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 275px;\"\u003e\n \u003cp\u003eFamily history of osteoporosis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026nbsp;Departure/retirement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e44(1.16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e24(10.62%)***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003eNumber of births\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e82(1.40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e2(3.13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eUndergone DXA or not\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e1to2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e103(1.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e24(22.64%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026ge;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e1(0.97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e82(1.40%)***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 748px;\"\u003e\n \u003cp\u003eMHT : Menopausal hormone therapy, BMI: Body mass index, Ordered categorical variables were computed by Wilcoxon rank sum test, while unordered two\u0026ndash;categorical variables were tested by \u0026chi;2 tests, *** means p\u0026nbsp;＜0.001,* means p＜0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAfter adjusting for socio-demographic variables, MHT users were more likely to be menopausal (OR: 3.682, 95% CI: 2.039-6.649), employed (OR: 1.990, 95% CI: 1.678-2.769) and from hospitals compared to the community (OR: 2.464, 95% CI: 1.624-3.739) (Fig.2). As regard to the physical activity, it was observed that both irregular and regular activity, when compared to no activity, were significantly associated with increased odds of MHT use, with odds ratios (ORs) of 1.804 (95% CI: 1.141-2.852) and 2.018 (95%CI: 1.067-3.818), respectively. Notably, women who engaged in yoga demonstrated almost double the odds of using MHT (OR: 1.742, 95% CI: 1.012-2.999) (Fig.3). Furthermore, women with a family history of osteoporosis had approximately fourfold increased odds of utilizing MHT (OR: 3.964, 95% CI: 1.812-8.674), while those who had previously undergone a DXA had over six times higher odds of using MHT (OR: 6.231, 95% CI: 3.486-11.138) (Fig.4). All these observed ORs were statistically significant.\u003c/p\u003e\n\u003cp\u003eIn summary, after adjusting for various crucial variables, including sociodemographic, reproductive, health-related factors and lifestyle behaviors, as shown in Fig.5., we identified several independent determinants for the utilization of MHT. These included undergoing a DXA scan (OR: 5.193, 95% CI: 3.080-8.756), having a family history of osteoporosis (OR: 3.697, 95% CI: 1.973-6.925), a hospital-based sample source (OR: 2.638, 95% CI: 1.724-4.037), regular physical activity (OR: 2.276, 95% CI: 1.186-2.909), menopause (OR: 2.192, 95% CI: 1.311-3.665), employment (OR: 2.190, 95% CI: 1.401-3.423), and higher educational level (OR: 1.942, 95% CI: 1.255-3.005).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this was the first largest of all similar studies to investigate the prevalence and the specific determinants of MHT use in southeast China.\u003c/p\u003e \u003cp\u003eIn our multi-district, large-scale study of women aged 40\u0026ndash;65 years with low socioeconomic status, only 1.75% reported as current or ever users in 2023 (0.48% had ever used MHT, while current users accounted for 1.27%). Previous data on MHT use in China is very limited. An Asian menopausal survey in 2006, involving a sample of 300 Chinese individuals, revealed that only 9% of Chinese women have ever used MHT, and 2% were current users [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Another survey [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] has conducted in Guangdong in southern China reported that ever and current MHT usage was reported in 0.8% and 1.3% of women in 2008, respectively. A 2014 study showed that the utilization rate of MHT among Chinese menopausal obstetrician-gynecologists was only 1.3\u0026ndash;1.4%[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Collectively, these data suggested a decline in MHT use over the nearly 20-year period in China, albeit with varying quality of researches.\u003c/p\u003e \u003cp\u003eAdditionally, MHT use in China was lower compared to other countries. A most recent Spanish research has reported that 2.5% postmenopausal women used MHT[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], while only 1.6% perimenopausal women used MHT. In contrast, a report from the National Health and Nutrition Examination Survey (NHANES) in U.S. showed that the proportion of women over 40 years using oral MHT was 4.7% in 2009\u0026ndash;2010[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]( decreased from 22% in 1999\u0026ndash;2002). Studies conducted in other nations, such as Australia (12\u0026ndash;13% in 2013), Germany (6% in 2016), and Korea (6.3% in 2003), have also reported similar declines in the prevalence of MHT use [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese international comparisons highlighted the relatively low adoption of MHT in China. Several reasons could be addressed to the low prevalence MHT use in China. Firstly, the fear of its short-term and long-term side effects, such as cancers, appears to be the most significant cause of the decline and low prevalence in MHT use[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This perception may be fueled by limited awareness and misunderstanding about MHT's benefits and risks. Secondly, he emergence of the COVID-19 pandemic in China since 2019 has strained medical resources, leading to squeeze on non-emergency medical services. Meantime, the uncertainty and anxiety brought by the pandemic further affected the utilization rate of MHT among menopausal women. Thirdly, as this study was funded by the Chinese government's public health benefit program, the participants were sourced from low-income families with minimal living assurances. These subject sample exhibited relatively low level of education, income, and social status, consequently lacking sufficient understanding of menopause-related issues and MHT options, which was consistent with that women from deprived backgrounds are less likely to be receiving MHT[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs regard to the determinants for MHT use, we found that women who have ever undergone DXA scan and have a family history of osteoporosis were independently associated with MHT use. This aligns with clinical guidelines recommending DXA screening and MHT for most menopausal women to reduce osteoporosis and fracture risk [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Additionally, subjects who originated from hospitals (V.S. the community) positively correlated with MHT use, perhaps due to their higher health awareness and health care-seeking behaviors compared to community populations. Consequently, they may have a higher rate of MHT use.\u003c/p\u003e \u003cp\u003eWe also found that regular physical activity was associated with the increasing odds of MHT use compared with no physical activity, which was in line with the result of the study [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], but inconsistent with another that did not subdivide physical activity [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Specifically, women preferring yoga tended to use MHT more, suggesting that those with good health awareness and a pursuit of a high-quality life are more likely to adopt MHT.\u003c/p\u003e \u003cp\u003eOur study revealed that higher educational level, employment and menopause status were independently associated with MHT use, which concurred with the data showing that education, occupation, and menopause were associated with current MHT use [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28 CR29\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In contrast, other independent indicators such as alcohol consumption [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], and smoking [\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] in previous study, however, in our study, were not found to be significantly related to MHT use. These discrepancies may be due to differences in outcome variables, cohort sizes, populations selection and time periods of questioning, and other factors[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003eAs this was a cross-sectional study, recall bias and report bias could not be completely avoided, especially for the approximate onset time of symptoms. However, the bias might occur evenly among the participants and therefore have little impact on the overall results and conclusions drawn from this study.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study revealed the low prevalence of MHT use in women with low socioeconomic status in Shanghai, China. Besides, the MHT use was associated with women who have previously undergone DXA scan, have a family history of osteoporosis, originate from hospitals (V.S. the community), engage in regular physical activity, possess higher educational attainment, and are employed. To effectively address this issue, it is imperative to enhance the knowledge of menopausal health among Chinese middle-aged women with low socioeconomic status, as this may lead to a positive change in their health-seeking behaviors. Furthermore, in response to the accelerating aging population, it is urgent to provide professional and accessible perimenopausal health services in Shanghai, particularly for women from low-income families with minimal health coverage. Our findings have contributed significantly to the understanding of menopausal hormone therapy (MHT) use among women with low socioeconomic status, highlighting the necessity for comprehensive strategies that address professional training deficiencies, increase the availability of MHT, and optimize the dissemination of information to patients, thereby overcoming barriers to access and utilization of menopausal health care services.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMHT: Menopausal Hormone Therapy, ORs: Odds ratios, DXA: Dual energy x-ray absorptiometry, BMD: bone mineral density, BMI: Body mass index, NHANES: National Health and Nutrition Examination Survey.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the study participants and many chief directors (ZJ W, MW, Z L, FY, MJS, XXP, RFJ, FYX, XLC, LZ) who helped with the investigation. The research was funded by the Shanghai Municipal Health Commission - Child Health 【2023】NO.12.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Shanghai sixth people\u0026rsquo;s hospital authorized the corresponding study involving human participants. All participants provided written informed consent prior to study commencement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Researchers with a specified purpose should send request email to Professor Minfang Tao: [email protected],cn\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research was funded by Shanghai Municipal Health Commission - Child Health\u0026nbsp;【2023】NO.12.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMFT and YCT contributed to study conception and design; YZ performed the data analysis and interpretation of results, and drafted the manuscript; CBL, YX S,DY Z contributed to data collection; ZJW, MW, ZL, FY, MJS, XXP, RFJ, FYX, XLC, LZ (These authors have equal contributions and are listed in no particular order)were responsible for the investigation of respective health facility. All authors reviewed the results and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the study participants and many chief directors (ZJ W, MW, Z L, FY, MJS, XXP, RFJ, FYX, XLC, LZ) who helped with the investigation. The research was funded by the Shanghai Municipal Health Commission - Child Health 【2023】NO.12.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYu Q. Population education of menopausal knowledge in China. Climacteric. 2019;22(4):323.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrandall CJ, Mehta JM, Manson JE. Management of Menopausal Symptoms: A Review. JAMA. 2023;329(5):405\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCagnacci A, Venier M. The Controversial History of Hormone Replacement Therapy. Medicina. 2019;55(9):602.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeating NL, Cleary PD, Rossi AS, Zaslavsky AM, Ayanian JZ. Use of hormone replacement therapy by postmenopausal women in the United States. Ann Intern Med. 1999;130(7):545\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSprague BL, Trentham-Dietz A, Cronin KA. A sustained decline in postmenopausal hormone use: results from the National Health and Nutrition Examination Survey, 1999\u0026ndash;2010. Obstet Gynecol. 2012;120(3):595\u0026ndash;603.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsai SA, Stefanick ML, Stafford RS. Trends in menopausal hormone therapy use of US office-based physicians, 2000\u0026ndash;2009. Menopause. 2011;18(4):385\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrawford SL, Crandall CJ, Derby CA, El Khoudary SR, Waetjen LE, Fischer M, Joffe H. Menopausal hormone therapy trends before versus after 2002: impact of the Women's Health Initiative Study Results. Menopause. 2018;26(6):588\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChlebowski RT, Anderson GL, Aragaki AK, Manson JE, Stefanick ML, Pan K, Barrington W, Kuller LH, Simon MS, Lane D, et al. Association of Menopausal Hormone Therapy With Breast Cancer Incidence and Mortality During Long-term Follow-up of the Women's Health Initiative Randomized Clinical Trials. JAMA. 2020;324(4):369\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCho L, Kaunitz AM, Faubion SS, Hayes SN, Lau ES, Pristera N, Scott N, Shifren JL, Shufelt CL, Stuenkel CA, Lindley KJ. Rethinking Menopausal Hormone Therapy: For Whom, What, When, and How Long? Circulation. 2023;147(7):597\u0026ndash;610.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHickey M, LaCroix AZ, Doust J, Mishra GD, Sivakami M, Garlick D, Hunter MS. An empowerment model for managing menopause. Lancet. 2024;403(10430):947\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin L, Feng P, Yu Q. Attitude and knowledge for menopause management among health professionals in mainland China. Climacteric. 2020;23(6):614\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Y, Wang W, Feng Y, Tan Z, Yang X, Peng D, Zhao Y, Dong H, Zheng Q, Zeng X, et al. What is behind the fear of cancer during menopausal hormone therapy in China? Arch Gynecol Obstet. 2021;304(5):1353\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang C, Zheng Y, Zhu L, Li Y, Du L, Tao M, Xu B. Demands for perimenopausal health care in women aged 40 to 60 years-a hospital-based cross-sectional study in Shanghai, China. Menopause. 2019;26(2):189\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang D, Haines CJ, Pan P, Zhang Q, Sun Y, Hong S, Tian F, Bai B, Peng X, Chen W, et al. Menopausal symptoms in mid-life women in southern China. Climacteric. 2008;11(4):329\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou Y, Lin J, Li C, Zheng Y, Meng Z, Teng Y, Tao M. A fNIRS investigation of menopausal-related symptoms and brain cortical activity in menopause. J Affect Disord. 2024;353:101\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang KE, Xu L, I NN, Jaisamrarn U. The Asian Menopause Survey: knowledge, perceptions, hormone treatment and sexual function. Maturitas. 2010;65(3):276\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Y, Yang X, Li X, He X, Zhao Y. Knowledge and personal use of menopausal hormone therapy among Chinese obstetrician-gynecologists: results of a survey. Menopause. 2014;21(11):1190\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaquedano L, Coronado P, De la Viuda E, S\u0026aacute;nchez S, Otero B, Ram\u0026iacute;rez I, Llaneza P, Mendoza N. Population-based survey on menopausal symptoms and treatment use. Climacteric. 2023;26(1):47\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeinig M, Braitmaier M, Haug U. Prescribing of menopausal hormone therapy in Germany: Current status and changes between 2004 and 2016. Pharmacoepidemiol Drug Saf. 2021;30(4):462\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark CY, Lim JY, Kim WH, Kim SY, Park HY. Evaluation of menopausal hormone therapy use in Korea (2002\u0026ndash;2013): A nationwide cohort study. Maturitas. 2021;146:57\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVelentzis LS, Egger S, Banks E, Canfell K. Menopausal hormone therapy: Characterising users in an Australian national cross-sectional study. PLoS ONE. 2021;16(8):e0253725.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHillman S, Shantikumar S, Ridha A, Todkill D, Dale J. Socioeconomic status and HRT prescribing: a study of practice-level data in England. Br J Gen Pract. 2020;70(700):e772\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones AR, Enticott J, Ebeling PR, Mishra GD, Teede HT, Vincent AJ. Bone health in women with premature ovarian insufficiency/early menopause: a 23-year longitudinal analysis. Hum Reprod. 2024;39(5):1013\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLucas R, Barros H. Life prevalence and determinants of hormone replacement therapy in women living in Porto, Portugal. Maturitas. 2007;57(3):226\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCornuz J, Krieg MA, Sandini L, Ruffieux C, Van Melle G, Burckhardt P, B\u0026uuml;che D, Dambacher M, Hartl F, H\u0026auml;uselmann H, et al. Factors associated with the use of hormone replacement therapy among older women. Age Ageing. 2003;32(6):675\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParazzini F. Trends of determinants of hormone therapy use in Italian women attending menopause clinics, 1997\u0026ndash;2003. Menopause. 2008;15(1):164\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManzoli L, Di Giovanni P, Del Duca L, De Aloysio D, Festi D, Capodicasa S, Monastra G, Romano F, Staniscia T. Use of hormone replacement therapy in Italian women aged 50\u0026ndash;70 years. Maturitas. 2004;49(3):241\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNagel G, Lahmann PH, Schulz M, Boeing H, Linseisen J. Use of hormone replacement therapy (HRT) among women aged 45\u0026ndash;64 years in the German EPIC-cohorts. Maturitas. 2007;56(4):436\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLambert LJ, Straton JA, Knuiman MW, Bartholomew HC. Health status of users of hormone replacement therapy by hysterectomy status in Western Australia. J Epidemiol Community Health. 2003;57(4):294\u0026ndash;300.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCostanian C, Edgell H, Ardern CI, Tamim H. Hormone therapy use in the Canadian Longitudinal Study on Aging: a cross-sectional analysis. Menopause. 2018;25(1):46\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Menopausal hormone therapy, cross-sectional multi-center, DXA, regular physical activity","lastPublishedDoi":"10.21203/rs.3.rs-5447444/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5447444/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChina faces a burgeoning demand for menopausal health care. Guidelines recommend Menopausal Hormone Therapy (MHT) as the most effective treatment for menopausal symptoms. However, the prevalence of MHT use and its influencing factors remains largely unknown in China, especially for women with minimal assurance.\u003c/p\u003e\n\u003cp\u003eObjective: This multi-center study aimed to explore the prevalence of MHT use with low socioeconomic status in shanghai and to understand its factors associated with MHT use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods and design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a cross-sectional, multi-district, large-scale study of 6068 women aged 40-65 years with minimal living assurance from 10 health facilities in 7 districts of Shanghai supported by the Chinese government's public health benefit program. Data from cross-sectional survey of women between January 2023 and September 2023 were collected from comprehensive and modified questionnaires. Odds ratios (ORs) were calculated using logistic regression for characteristics related to MHT use, adjusting for sociodemographic, reproductive, health and lifestyle factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was the first largest of all similar studies to investigate the prevalence and the specific determinants of MHT use in southeast China. Our study revealed a low rate of MHT prescription among women with minimal assurance in Shanghai and MHT use was independently associated with undergoing a dual energy x-ray absorptiometry (DXA) scan, family history of osteoporosis, hospital-based sample source, regular physical activity, menopause, employment and higher educational level. It raises the need for increased awareness and strategies to help women seek menopausal health care of socioeconomic deprivation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003echiCTR-EPC-17011255.\u003c/p\u003e","manuscriptTitle":"Characteristics and prevalence of MHT use among women aged 40-65 years with low socioeconomic status: a multi-district study in Shanghai, China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-18 08:58:30","doi":"10.21203/rs.3.rs-5447444/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1df35356-05b2-4201-8200-7996dc89305b","owner":[],"postedDate":"December 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-27T09:26:10+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-18 08:58:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5447444","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5447444","identity":"rs-5447444","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}