Godalming, Surrey GU8 4BD. I Bolt D, Robertson RF, Williams DI, Walton J, Yellowices H. P'rofile of the GMIC. BrMedJ 1989;298:1641. (17 June.) GMC election.
CORRESPONDENCE * All letters must be typed with double spacing and signed by all authors. * No letter should be more than 400 words.
* For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BM7. * We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.
Hormone replacement treatment SIR,-Dr Paul Belchetz reviewed the advantages and risks of oestrogen replacement therapy and pointed to the advantages of percutaneous or subcutaneous routes of delivery. Even so, a casual reader could be forgiven for concluding that oral therapy with so called "natural oestrogens" is safe, but is it? These oestrogenic preparations are natural to horses rather than humans, and, furthermore, they undergo substantial change in the gut and liver before entering the systemic circulation. Can we really be reassured that oral oestrogens reduce the risk of cardiovascular morbidity? Unfortunately, in the published case-control and cohort studies comparison is not between like and like. Study groups invariably contain more health conscious women, at low risk from death from all causes other than suicide.2 There are fewer smokers or obese or hypertensive women and their exercise and dietary habits are likely to be more favourable than those of the controls. Even so, the Framingham study showed an increase in cardiovascular morbidity.3 This long running study included more older patients and should not be ignored. Why should oral oestrogens, given together with 12 days of progestogen, not carry similar risks to oral contraceptive steroids? Given the available alternatives, should we not be circumspect, especially for women judged to be at high risk? Nor should we underrate the potential for inducing breast cancer. Too few studies continued long enough to give meaningful results. The Louisville study, however, suggests an increasing risk when oestrogens are taken for more than 12 years and that the risk increases with duration of use.4 This accords with what we know of the natural biology of the disease. All patients, especially those with a first degree family history, should know of this possible risk and cooperate with careful follow up examinations, including mammography. Anyone who is now more confused may find more help by reading Hunt et al.2 ANTHONY D NOBLE
Department of Gynaecology, Royal Hampshire County Hospital, Winchester S022 5DG 1 Belchetz P. Hormone replacement treatment. Br Med J 1989; 298:1467-8. (3 June.) 2 Hunt K, Vessey M, McPherson K, Coleman M. Long term surveillance of mortality and cancer incidence in women receiving hormone replacement therapy. Brj Obstet Gvnaecol 1987;94:620-35. 3 Wilson PWF, Garrison RJ, Castelli WP. Postmenopausal estrogen use, cigarette smoking and cardiovascular morbidity in women over 50. The Framingham study. N Engl J Med 1985;313: 1038-43. 4 Hoover R, Gray LA, Cole P, MacMahon B. Menopausal estrogens and breast cancer. N Englj Med 1976;295:401-5.
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AUTHOR'S REPLY,-To identify oestrogens commonly used in hormone replacement treatment as "natural" is not necessarily to equate them with better but simply to differentiate from the components of oral contraceptives. The proof of the pudding is in the eating and the studies cited do seem to indicate long term cardiovascular protection. The fact that equilin is natural for the horse rather than women does not in itself disqualify its use. There are certainly theoretical reasons to prefer preparations which deliver oestradiol into the systemic circulation, as was clearly emphasised. The important work by Hunt and her colleagues was referred to explicitly and is a source of many important data. The topic is bound to remain contentious, but when an accumulation of evidence produces a general consensus on matters as important as cardiovascular morbidity and mortality and prevention of osteoporosis, not to mention physical and psychological wellbeing, I believe it is responsible to come off the fence. The advice must necessarily be qualified by a realisation that absolute knowledge is unattainable and it is imprudent and unethical not to highlight areas of special concern. PAUL BELCHETZ General Infirmary, Leeds LS I 3EX
We urgently need a progestogen only pill or other systemic treatment releasing one of the new progestogens with less relative binding affinity for the androgen receptor-that is, 3-keto-desogestrel or gestodene. These would permit the oestrogen to have its potentially beneficial effects on lipids and sex hormone binding globulin. Possibly the best option of all, however, would be the use of a progestogen releasing intrauterine device simultaneously with systemic oestrogen.4 This would virtually eliminate the systemic dangers of progestogens, the "premenstrual" symptoms, and (normally) all uterine bleeding. It is a tenable hypothesis that the uterus would be protected against endometrial cancer, and, when relevant, the contraceptive effect would be particularly high in this age group. But the important point is that this intrauterine "contraceptive" would be valuable even when contraception itself was not required. May I reinforce pressure on the relevant manufacturers: we urgently need them to produce these 3-keto-desogestrel-gestodene only treatments and progestogen releasing intrauterine devices. The latter are needed not only to replace the Progestasert but also the levonorgestrel releasing devices whose future development has been blocked. JOHN GUILLERAUD
SIR,-Dr Paul Belchetz rightly argues that this treatment with oestrogen deserves wider use.' And as women have falls more often after the age of 452 the antiosteoporosis benefits could be considerable, even if the treatment began before the menopause. But there are concerns about the progestogen, which is given to protect the intact uterus from endometrial carcinoma. As Dr Belchetz says, "Current wisdom dictates that it (progestogen) is given for 10 to 12 days each month." Current wisdom may be wrong, or at least half right. The type of progestogen used and its route of administration require more attention. Most of the studies that show a benefit in circulatory disease have used unopposed oestrogen. There are metabolic grounds for believing that the progestogens (chiefly norethisterone and levonorgesterel) currently used in hormone replacement preparations could undo the good work of oestrogen by their adverse effects on lipids (particularly high density lipoprotein cholesterol).3 In the younger age group a contraceptive effect cannot be promised and in women past the menopause the withdrawal bleeds are not always acceptable. Moreover, women frequently report loss of the benefits, or even the development of a "premenstrual syndrome," just during the time the progestogen is being given. Professor Malcolm Pike hypothesises (personal communication, 1989) that its effect in suppressing the oestrogen induced rise in sex hormone binding globulin might nullify a potential reduction in risk of breast cancer.
Margaret Pyke Centre, London WIV 5TW 1 Belchetz P. Hormone replacement treatment. Br Med 7 1989; 298:1467-8. (3 June.) 2 Winners J, Morgan CA, Evans JG. Perimenopausal risk of falling and incidence of distal forearm fracture. Br Med J 1989;298: 1486-8. 3 Larosa JC. Effect of estrogen replacement therapy on lipids: implications for cardio-vascular disease risk. J Reprod Med 1985;30(suppl 10):811-3. 4 Bowen-Simpkins P. Contraception for older women. BrJ Obstet
Gynaecol 1984;91:513-5.
SIR, -Dr Paul Belchetz contended that in the face of the relatively low level of prescribing in Britain and the "flood of material in the media . . promoting the treatment" we need to "look hard at the risks and benefits of hormone replacement therapy."' A focus of his brief review was the potential benefits of oestrogen treatment in relation to cardiovascular disease. It is true that there is now a substantial body of evidence suggesting a strong protective effect.2 There was, however, no reference to the fact that these data are derived almost exclusively from studies of women taking unopposed oestrogens. As most women with intact uteri are now prescribed oestrogens.opposed by a progestogen it is important to acknowvledge that we do not yet know whether the use of opposed oestrogens in the perimenopausal and postmenopausal period will have a similar protective
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effect. It could be as misleading to extrapolate from the experience of women using unopposed oestrogens as it would be to do so from that of younger women taking oral contraceptives. If we are to look hard at the balance of benefits and risks of hormone replacement treatment it is important to bear this distinction in mind when assessing the available evidence. KATE HUNT
MIRC Medical Sociology Unit, Glasgow (G12 8QQ
MARTIN VESSEY Departmenit of Community Medicine and (;eneral Practice, Oxford OX2 6HE I Belchetz P. Hormone replacement treatment. Br Med .7 1989;298: 1467-8. (3 June.) 2 Vessey MP, Hunt K. The menopause, hormone replacement therapy and cardiovascular disease: epidemiological aspects. In: Studd JWW, Whitehead Mll, eds. The menopause. Oxford: Blackwell Scientific, 1988.
SIR,-Dr Paul Belchetz's editorial' presents an oversimplistic and overoptimistic assessment of the risks, benefits, and acceptability of currently offered hormone replacement treatment. I agree that there is evidence that oestrogen treatment protects against cardiovascular and cerebrovascular disease in postmenopausal women, but I am not so confident that the evidence is abundant and leaves no room for doubt. I also agree that doctors remain suspicious about climactic oestrogen treatment because they "wrongly extrapolate from the experience of younger women who take oral contraceptives." Unfortunately, Dr Belchetz does not explain why the extrapolation is wrong. It is because oral contraceptives contain progestogens. The protective effect of oestrogens against vascular disease has been measured almost exclusively in women who have not taken progestogens. The benefits may well be substantial. Henderson et al estimated that women aged between 50 and 75 who had taken a moderate dose of oestrogen (equivalent to 0 625 mg of conjugated oestrogens daily) would show a reduction in 25 year mortality from ischaemic heart disease alone of 5250 per 100000 women whereas the comparable increased mortality from endometrial cancer would be only 63 per 100 000.2 Progestogens generally cause changes in lipid and carbohydrate metabolism that are associated with increased risks of atheroma. Among others we have shown that the risks of arterial disease in users of oral contraceptives are associated with the progestogen component in combined oral contraceptives.3 What happens then if progestogen is added to the oestrogen treatment in climacteric women? The simple and honest answer is that we don't know. There may be no adverse effects, but we have no scientific justification for this assumption. If an adverse response was no greater than to neutralise the benefits of unopposed oestrogen in arterial disease it would still be the wrong treatment. At worst, if the addition of progestogens was to increase the occurrence of ischaemic heart disease and stroke in postmenopausal women above that in untreated women the outcome might be disastrous. In. 1977 this unit conducted a pilot study of the clinical course in women receiving hormone replacement treatment with a design similar to that of our oral contraception study, which has been in progress since 1968. The methods used in the pilot study were entirely successful, but prescribing of hormone replacement treatment by general practitioners at that time was impracticably low. Now that the rate of prescribing has doubled updated proposals for a study are being prepared; unfortunately, its chance of funding is much lower than it would have been 10 years ago. The objective of the study is to measure the balance of risk between potential beneficial and
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adverse effects of treatment on many different diseases-cancers, vascular disease, osteoporosis, and perhaps other unsuspected outcomes. These can be appropriately assessed only in the course of a cohort study in which the incidences of these diseases are measured directly. The issues are so important that reliance on a single study would be foolish, and at least two independent investigations should be started soon. Manchester Research Unit, Royal College of General Practitioners, Manchester M20 OTR
CLIFFORD R KAY
easy task, as many members of the council will acknowledge -and for his fair minded presentation of arguments that have gone on in and around the council for more years than I care to remember. MICHAEL O DONNELL
Godalming, Surrey GU8 4BD I Bolt D, Robertson RF, Williams DI, Walton J, Yellowices H. P'rofile of the GMIC. BrMedJ 1989;298:1641. (17 June.)
GMC election
1 Belchetz P. Hormone replacement treatment. Br Med J 1989;298:1467-8. (3 June.) 2 Henderson BE, Ross RK, Paganini-Hill A, Mack TM. Estrogen use and cardiovascular disease. AmJ Obstet Gynecol 1986;154: 1181-6. 3 Kay CR. Progestogens and arterial disease-evidence from the Royal College of General Practitioners' study. Am J Obstet Gvnecol 1982;142:762-6.
SIR,-Dr Paul Belchetz stated, "Many doctors remain suspicious that thrombotic disorders are promoted by oestrogens."' In surgical practice, particularly in recent years, it has become routine to ask patients taking any form of hormone replacement treatment, be it for postmenopausal causes or for contraceptive purposes, to stop taking their tablets anything up to six weeks before elective surgery. This advice is contained within the British National Formulary and has been reinforced by various of the medical defence unions.
With the increasing use of hormone replacement treatment further large numbers of women will come into this category and have their surgery postponed and their hormone treatment interrupted ifthis advice is correct. Are we to understand from Dr Belchetz that such precautions against deep venous thrombosis are unnecessary in hormone replacement therapy? I have yet to find a definitive statement in any of the literature on this particular aspect. P A SLATER
Stracathro Hospital, Brechin, Angus DD9 7AQ I Belchetz P. Hormone replacement treatment. Br Med J 1989;298:1467-8. (3 June.)
Profile of the GMC SIR,-Doctors are acknowledged masters of the delicate expression of uncertainty and I have, till now, illustrated their mastery with a footnote from the Lancet: "Since this paper was written, one of us has died." I can now replace that aging gem with a quotation from your leading letter of 17 June, in which five doctors of irrefutable distinction write: "We fully acknowledge that Dr Richard Smith's articles about the General Medical Council have been written after wide consultation with members and staff of the council, other interested persons, and at least one of us."' (The italics, of course, are mine.) That "at least" is dangerous fuel for an irreverent imagination. Is it the pressure of busy lives or, perish the thought, failing powers of memory that make it difficult for them to recall whether the good doctor consulted more than one? Or are they indulging in an extreme form of professional anonymity, pour encourager .? Or could it be that "one of us" is being used as the generic phrase so favoured by the Prime Minister? Or is the whole thing just a sophisticated guessing game with discreet off course bets being laid in the corridors of power? I suppose we should be grateful that, in these days of excessive fragmentation, no less than one was consulted. Meanwhile Dr Richard Smith deserves congratulations for a series of articles which give a clear account of the way the GMC operates-no
SIR,-With so much time, energy, and space in the medical press rightly devoted to discussing the issues raised by the new contract for general practitioners and the white paper on the NHS I fear that the recent General Medical Council elections will yet again have passed unnoticed by most doctors. Are we, as a profession, satisfied with the status quo? Are we so apathetic that we cannot be bothered to exercise our recently won democratic rights, or do we feel that the GMC is completely out of touch with the ordinary working doctor? I believe the latter is the case, and for this reason I am standing as a candidate in this year's elections. A strong and healthy GMC, acting effectively to promote and uphold high standards and ideals, is in the best interests of the profession as a whole, but the recent proposals by the GMC to extend disciplinary procedures to cover professional competence serve only to emphasise their dissociation from the main body of the profession and general practice in particular. Imagine the dilemma at 3 am: Do I fling a duffel coat over my pyjamas and risk prosecution for "scruffiness" or do I take an extra half hour to shave and brush my pinstripe suit, only to be charged with "tardiness in visiting"? Surely the examples of "minor incompetence" cannot have been drawn up by a working general practitioner. Such matters are best dealt with by allowing patients the freedom to choose a general practitioner whose personality and style of dress they can relate to. Self regulation is vitally important if we are not to have regulation imposed on us by the government. But the present situation, with doctors being judged by individuals who have little knowledge of the working environment of the practitioner concerned, is grossly unfair. I hope that the same system is not applied to the recent proposals. Re-education of practitioners who are not clinically competent seems a sensible idea, but I believe that this could best be undertaken by the postgraduate dean, in association with the regional adviser, making use of an experienced and competent trainer. Medical education as a whole needs to be centred closer to the community, rather than becoming increasingly remote. With so many far reaching issues facing the profession it is vitally important that the GMC's composition reflects more closely the structure of the profession as a whole. If the GMC is not to remain stuffed with academics and professional committee men each and every general practitioner must make it his or her personal responsibility to make sure that his or her voice is heard and vote counted. A NAWROCKI
Croydon CRO 5JP
Ethnic differences in incidence of severe burns and scalds SIR, -Dr V Vipulendran and colleagues suggested that burns and scalds are more common in Asian than non-Asian children in Birmingham,' but their analysis ignores several possible confounding factors that might explain this statistical finding. Although recognising that most of the children
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