Obstacles to the use of estrogen replacement therapy in women of lower socioeconomic levels.

The value of estrogen replacement in postmenopausal women is well documented. Estrogen prevents or modifies the disease course of osteoporosis, I coronary artery disease,2-4 and atrophic vaginitis, and it often is used to treat urinary incontinence. The role of estrogen replacement in prevention of strokes is more controversial; some studies suggest a positive roleS and others suggest no role.6 Recent studies indicate estrogen might have a positive effect on memory.? Although documented risks exist, for most women the risk-benefit ratio strongly favors estrogen use after menopause. Nevertheless, despite the favorable risk-benefit ratio, studies document rates of estrogen use as low as 30 percent among postmenopausal women who are candidates for estrogen therapy. 8 Even though many studies document predictors of which women are more or less likely to use estrogen, few researchers have asked the women themselves why they chose not to use estrogen, particularly women in lower socioeconomic groups. In 1987 Ravnikar8 documented fear of cancer as the most common reason women discontinued estrogen replacement. In 1988 Ferguson et al9 concluded that fear of a return of menstrual periods was the most unfavorable factor in the decision to use estrogen replacement. In 1996 Handa et apo found the strongest predictor of estrogen use in the Piedmont region of North Carolina to be socioeconomic status, with higher rates of estrogen use associated with higher socioeconomic status. Fear of cancer was not directly addressed in