Introduction

In recent years, increasing attention has been paid to the influence of sex hormones and hormone therapy on ocular health. A number of ophthalmological disorders demonstrate sex-related differences in prevalence and clinical course, which may be associated with the effects of estrogens, progesterone, and age-related hormonal changes [1]. Women are more frequently affected by dry eye disease, glaucoma, retinal vascular disorders, and several degenerative eye diseases [1].

This issue is particularly relevant during the peri- and postmenopausal period. Dry eye disease occurs more often in women older than 50 years than in men of a similar age [1–4]. Female sex, aging, menopause, thyroid disorders, autoimmune diseases, contact lens use, and hormonal changes are recognized risk factors [3,4]. Garcia-Alfaro et al. reported dry eye symptoms in 79% of peri- and postmenopausal women, with higher prevalence after menopause [5]. Beyond discomfort, dry eye disease may impair quality of life, visual function, work productivity, sleep, and psychological well-being [5,6].

Current evidence suggests that hormonal changes may affect the ocular surface, meibomian glands, and tear-film stability [2,7–9]. Estrogens, progesterone, and androgens influence ocular surface tissues, tear production, and tear-film lipid composition [2,7,8]. Studies of hormone therapy and dry eye have produced inconsistent findings [7,10–13]. Some authors reported improved Schirmer test results or symptoms [10–12], whereas others described possible worsening during prolonged hormone exposure [7,13]. Hormonal contraceptive use has also been associated with dry eye disease in women of reproductive age [14]; however, this evidence should not be directly equated with menopausal HRT.

Possible associations between hormone therapy and ocular vascular disorders have also been discussed. Lee et al. reported an association between HRT and nonarteritic anterior ischemic optic neuropathy, with higher risk estimates at longer exposure durations [15]. Other publications have examined retinal vascular occlusion and thrombotic complications in relation to hormonal medications [16–19]. A large study did not identify a significant association between female hormone prescriptions and retinal vascular occlusion [16], whereas higher-dose combined hormonal contraception was associated with retinal vascular occlusion in a different population [18], and isolated case reports have described retinal vascular events during hormone therapy [19]. These heterogeneous data do not establish a uniform causal risk but support clinical awareness and individualized assessment.

Previous research has evaluated women’s knowledge of HRT, communication with healthcare professionals, and concerns regarding adverse effects [20,21]. In contrast, gynecologists’ awareness specifically regarding potential ophthalmological effects of HRT, related counseling practices, and interaction with ophthalmologists remains insufficiently characterized. The practical relevance of this gap is increased by the common use of HRT and the high background prevalence of ocular symptoms in peri- and postmenopausal women.

The aim of the study was to assess gynecologists’ awareness of potential ophthalmological risks associated with HRT, as well as clinical practice patterns, interdisciplinary interaction, and educational needs in outpatient settings.

Materials and Methods

Study design and setting

An exploratory cross-sectional questionnaire-based study was conducted from April 15 to May 5, 2026, among outpatient obstetricians and gynecologists involved in prescribing or managing HRT. The manuscript was structured with reference to the STROBE recommendations for cross-sectional studies and the CHERRIES recommendations for web-based surveys.

Participants and recruitment

The electronic questionnaire was distributed by email to 120 specialists. Inclusion criteria were informed consent, current work in an outpatient setting, and experience in prescribing or managing HRT. Physicians working exclusively in inpatient departments were excluded. All complete responses meeting the eligibility criteria were included. The final sample comprised 42 physicians: 19 from private medical centers and 23 from public outpatient clinics, corresponding to a response rate of 35.0%. Because participation was voluntary and the response rate was limited, the sample was treated as exploratory and not as nationally representative.

Questionnaire development and pilot testing

Data were collected using an anonymous author-developed questionnaire comprising 23 items on demographic characteristics, HRT prescribing, counseling about complications, awareness of potential ophthalmological risks, referral practices, interdisciplinary interaction, organizational barriers, and educational needs. The questionnaire was developed by an obstetrician–gynecologist and an ophthalmologist. Two independent experts in these specialties reviewed the preliminary version for relevance, completeness, and clarity. Face validity and comprehensibility were evaluated in a pilot focus group of seven practicing gynecologists who were not included in the main sample; minor editorial changes were made after pilot testing.

Most items were closed-ended and permitted either a single response or multiple responses, depending on the question. No composite knowledge or practice score was calculated. Consequently, internal consistency was not estimated; the instrument should be regarded as a content- and face-validated descriptive questionnaire rather than a fully psychometrically validated scale.

Variables and outcomes

The primary descriptive outcomes were self-reported awareness of potential ophthalmological risks of HRT, discussion of ocular risks during patient counseling, assessment of ocular complaints, referral to an ophthalmologist, ophthalmological consultation before HRT, and perceived need for clinical guidance. Secondary variables included age, work experience, frequency of HRT prescribing, workplace type, interdisciplinary interaction, and willingness to participate in educational programs.

Survey administration and potential bias

The questionnaire was administered through Google Forms and distributed electronically. Participation was voluntary, and questionnaires were anonymous. The design may nevertheless be affected by volunteer, nonresponse, recall, and social-desirability bias. No objective test of knowledge or audit of clinical records was performed; therefore, the findings reflect self-reported awareness and practice.

Ethics approval and informed consent

The study protocol was approved by the Local Ethics Committee of Kazakhstan Medical University “Higher School of Public Health”. Electronic informed consent was obtained before participation. No patient-level or directly identifying respondent data were analyzed.

Statistical analysis

Statistical analysis was performed using R software (R Foundation for Statistical Computing, Vienna, Austria). Quantitative variables were summarized as median (Me) and interquartile range (IQR), and categorical variables as counts and percentages. Age was compared using the Mann–Whitney U test. Because of the small sample and sparse contingency tables, categorical variables were compared using two-sided Fisher’s exact test. Exact p-values for categorical comparisons were recalculated from the aggregate counts displayed in Tables 1 and 2. A two-sided p-value <0.05 was considered statistically significant. No adjustment for multiple comparisons was applied; inferential results are therefore interpreted as exploratory.

Results

Participant characteristics and clinical practice

Of 120 invited specialists, 42 complete eligible responses were analyzed (response rate, 35.0%). Participants from private clinics were older than those from public outpatient clinics (Me 45 [IQR 42–49] vs 36 [IQR 33–40] years; p<0.001) and more often had over 10 years of professional experience (78.9% vs 34.8%; p=0.006). Frequency of HRT prescribing, general counseling about HRT complications, assessment of ocular complaints, and referral practices did not differ significantly by workplace (Table 1).

Table 1 - Demographic characteristics and clinical practice patterns by workplace

* Mann–Whitney U test. † Two-sided Fisher’s exact test; p-values recalculated from the displayed aggregate counts.

Awareness, interdisciplinary interaction, and educational needs

Overall, 32/42 respondents (76.2%; 95% CI 61.5–86.5) reported no awareness of the ophthalmological risks listed in the questionnaire. Only 2/42 (4.8%; 95% CI 1.3–15.8) reported discussing ocular risks during counseling. Thirty-one respondents (73.8%) never referred patients to an ophthalmologist, and 39 (92.9%) did not request ophthalmological consultation before HRT. At the same time, 34/42 respondents (81.0%; 95% CI 66.7–90.0) supported the development of clinical guidance, and 32/42 (76.2%) were willing to participate in interdisciplinary educational programs. No statistically significant differences between workplace groups were identified for these outcomes (Table 2).

Table 2 - Awareness, interdisciplinary interaction, and educational needs regarding potential ophthalmological risks of HRT

† Two-sided Fisher’s exact test; p-values recalculated from the displayed aggregate counts. ‡ Not estimable because both groups had identical responses and no variation.

Figure 1 summarizes the main awareness and interdisciplinary-practice indicators. The figure is descriptive; it does not imply statistically significant differences between private and public outpatient settings.

Figure 1 - Awareness and interdisciplinary practice regarding

potential ophthalmological risks of HRT among gynecologists