Chilet-Rosell et al. BMC Public Health 2010, 10:134 http://www.biomedcentral.com/1471-2458/10/134 Page 5 of 9 Table 1 Compliance with Farmaindustria’s “Code of Good Practice for the Promotion and Use of Medicines” on the web pages of pharmaceutical companies marketing the best-selling HRT drugs in Spain. Web Site Registration Required Registered Company Name and Address Given Summary of Product Characteristics Yes Yes Yes Yes Yes Yes Yes Information about HRT products does not appear Information about Perifem does not appear No (patient information is given) Therapeutic Indications Yes Yes Information about HRT products does not appear Information about Perifem does not appear Yes Bibliographic References No references No references Information about HRT products does not appear Information about Perifem does not appear No references http://www.esteve.es http://www.isdin.es http://www.novartis.es http://www.organon.es http://www. bayerscheringpharma.es (Web pages consulted January 2009) Must register, but professional body membership number not required Must register, but professional body membership number not required Must register, but professional body membership number not required Must register and provide professional body membership number Registration not required (registered in the UK, according to http://www.whois. net) sells worldwide, but accepted no responsibility for compliance with legislation in other countries. Discussion Despite important efforts by the European Union to reg- ulate and control medicines, our study shows that the European Code of Good Practice for the Promotion of Medicines has not had the desired effect on the quality of the information available on the best selling pharma- ceuticals in Spain. The corporate web pages of pharmaceutical companies owning HRT drugs do not comply with all the precepts laid down in this Code. On the other hand, forums and non-corporate web pages are promoting HRT irrespec- tive of EU regulations. These websites contain misleading or erroneous information about the potential therapeutic uses of HRT, the information they provide is rarely based on scientific evidence, and they sometimes publicise online pharmacies. Similarly, the study confirmed a well- known fact that, despite EU prohibitions, it is still possible and easy to buy HRT medications from online pharmacies from anywhere in the world. For women seeking information about the benefits and risks associated with HRT, there is a wealth of informa- tion available, but this is frequently contradictory. Much of this information is found in the media. For example, the first item retrieved by our search on the web page of the Spanish Agency for Medicines was the 2002 warning [15], where the use of HRT in the prevention of osteo- porosis continued to be recommended. However, the 2004 [16] warning, restricting its use, did not appear dur- ing this search, whilst the 2008 warning appeared in sec- ond place, despite being the most current [17]. HRT has for decades been the source of a conflictive debate between pharmaceutical companies, epidemiolo- gists, regulatory agencies and feminist groups. If a woman searches for HRT information online, the infor- mation she will find will be confusing, incomplete and frequently erroneous. In fact, women can even buy HRT online, without a prescription or medical advice and monitoring. This fact is particularly alarming since HRT drugs are powerful pharmacological agents shown to be thrombogenic and carcinogenic in the long term [2-4]. Significant inappropriate HRT indications were observed in the advertising published on the web pages analysed, for example indicating the use of HRT to pre- vent osteoporosis whilst failing to mention the restric- tions imposed on this particular use [7,8]. Of greater concern is the fact that these sites promote other thera- peutic uses for which the medication has not been approved, such as “boosting femininity” or regulating the menstrual cycle. These indications could involve a long-term use, which might constitute a significant health risk to the consumer, according to the evidence currently available [2-4]. Controlling the promotion and sale of medicines through indirect online marketing presents a challenge to European regulatory bodies. Unaffected by any regu- lations in this respect, forums, chat rooms and non-cor- porate web pages all constitute an ideal place to promote medications indirectly, and to broaden the scope of drugs’ therapeutic applications. Thus, faced with the impossibility of generating direct demand for prescription-only drugs in Europe, pharmaceutical mar- keting may exploit these “disease mongering” strategies for menopausal and postmenopausal women [19-21]. Osteoporosis has been classified as a disease only in so