The survey was conducted from 10 December 2015 to 31 January 2016. The target respondents were menopausal or PMW aged 45 to 60 years, with no previous diagnosis of osteoporosis or breast cancer, who attended private clinics across Hong Kong for annual physical examination. PMW Health Alliance, a Hong Kong-based concern group of physicians from various medical disciplines, organized the survey by assigning interviewers for data collection. Face-to-face interview was performed with respondents from each clinic, in accordance to the prepared questionnaire. All respondents were interviewed in their native language.

All respondents were informed about the purpose of the survey, their right to refuse to participate, and confidentiality of survey data. Verbal consent to participate in this survey was obtained from all respondents.

During the interview, respondents were asked about their education level and anthropometric profile, which included age, height, and weight. From a list of common menopause symptoms and risks, respondents were asked to select three items that concerned them the most. Respondents were also categorized according to the osteoporosis self-assessment tool for Asians (OSTA) score to assess their risk for osteoporosis.9 OSTA score is calculated by subtracting age from weight and multiplying by 0.2.

The questionnaire consisted of 17 questions, comprising separate sections for osteoporosis and breast cancer. In an attempt to minimize response bias due to question design,10 we tried to formulate a questionnaire that contains nonambiguous and simple questions, with the minimum use of medical terms. An interviewer was deemed necessary to reduce the tendency of participants to say yes or no to all questions. The section for osteoporosis was developed in consideration of the 2013 Osteoporosis society of Hong Kong (OSHK) guideline for clinical management of postmenopausal osteoporosis in Hong Kong.11 The section for breast cancer was developed in consideration of the 2015 American Cancer Society (ACS) document on breast cancer prevention and early detection.12 The correct technique for breast self-exam (BSE) was based on the description by the Eastern Mediterranean Regional Office of the World Health Organization (WHO/EMRO).13

Between 10 December 2015 and 31 January 2016, 573 menopausal or PMW were successfully interviewed (mean age 53.9 years, range 42-62 years). The demographic profile of respondents is presented in Table 1. Mean body mass index (BMI) was 23.13 ± 5.17. A total of 123 respondents (21.5%) had BMI greater than 24.9, categorized as overweight according to WHO classification. Around 1 in 5 respondents had bachelor's degree or higher. Based on T-score, 66% of respondents were classified as having normal bone density, 25% with low bone mass, and 9% with osteoporosis. The OSTA score categorization was then matched with the T-score. Sixty percent of respondents in the OSTA moderate-risk group had normal bone density, 27% had low bone mass, and 14% had osteoporosis. As for OSTA low-risk, 71% had normal bone density, 23% had low bone mass, and 6% had osteoporosis. Regarding menopausal issues, the top three concerns were osteoporosis and fracture (72%), breast cancer (44%), and sleep disorder/insomnia/headache (40%).

Fifty-nine percent of respondents did not know about the median age of onset for osteoporosis; 17% thought it is over 66 years old. Among 314 respondents (55%) who tried to prevent osteoporosis, 74% of them began to do it after they were 40 years old. Sixty-eight percent included eating bean products or food therapy as one of their prevention methods. Other prevention methods mentioned by respondents were exercise (72%), sunbathe (54%), drink high-calcium milk (47%), take supplements (42%), or take prescription drugs from doctors (2%). Only 23% thought what they did is sufficient to prevent osteoporosis, the rest said they were not doing enough or they did not know if they were doing enough to prevent osteoporosis. The survey result regarding the personal habit of respondents to prevent osteoporosis is shown in Figure 1.

Fourty-five percent of respondents knew about the rapid bone loss in PMW, whereas 28% said it happens during menopause; the rest of respondents said it happens before menopause. Regarding bone density, the most recent bone density test taken by 35% of respondents who did it was on average 5.4 years ago. The rest of respondents (65%) never had a bone density test; their reasoning can be seen in Figure 2. For those who said “I'm too young, so I don't need to check”, their mean age was 52 years old. In addition, 53% of all respondents agreed to the claim “If we lose bone density, adequate intake of calcium and exercise should be enough to prevent osteoporosis”. Three out of four respondents said they had low chance of osteoporosis, had no chance, or did not know.

Among all respondents, only 63% did regular breast examination; the reasoning from those who did not do it is shown in Figure 3. Ninety percent of respondents mistakenly believed that regular breast examination, regular breast massage, drink soy milk, or vaccine can prevent breast cancer. Among 363 respondents with regular breast examination, 40% did regular BSE every month, 54% were checked by their doctor every year, and 49% had screening mammography every 1 to 2 years. Only 0.7% of 146 respondents who had regular BSE were able to describe the correct technique.

Around 65% of all respondents agreed that they have a low chance for breast cancer if no one from their families has suffered from breast cancer, 58% agreed that regular screening is enough as long as she doesn't have genes associated with high-risk for breast cancer, 30% agreed that the removal of both breasts is the most thorough method to prevent breast cancer, and 37% agreed that breast removal to prevent breast cancer is worse than death.