as in the case ofhepatitis B. NIGEL O'FARRELL. King Edward VIII Hospital,. Congella, Durban,. South Africa. 1 Simonsen JN, Cameron DW, Gakinya MN, et al.
this complaint. So far as I could tell they had merely a foreskin incompletely retractable owing to persisting preputial adhesions and, apart from four boys with ballooning of the prepuce during micturition (a quite harmless and transient phenomenon), seem to have been without symptoms. As Mr MacKinlay relates, preputial adhesions are developmental not pathological, and they lyse spontaneously during childhood so that by the mid-teens the foreskin is fully and easily retractable in all boys,' apart from in only a tiny proportion (not above 1%) who develop pathological phimosis2 as a secondary phenomenon. So why interfere at all in such cases? Was it to satisfy the parents or the family doctor that "something was being done"? Or was it simply Mr MacKinlay's enthusiasm for his new technique? It would not suffice to answer that these boys were at least fortunate enough to have avoided a surgeon bent upon circumcision as there must be thousands more entirely escaping the medical profession's attentions in this respect, and it may be doubted whether they are or ever will be any the worse off for that. Even for those boys with balanitis separation of preputial adhesions could be a less beneficial procedure than logic might predict. In my practice 53% of patients presented with a single attack and very few of them returned with further episodes despite lack of any positive action.3 Also 25% of patients had a fully and easily retractable foreskin and several of them continued to suffer recurrent attacks of balanitis despite seemingly satisfactory preputial hygiene. Until such time as a prospective comparative trial proves that separation of preputial adhesions materially reduces the risk of recurrent balanitis I shall continue to leave alone those boys who have had one or two attacks and to circumcise the minority with multiple recurrences. A M K RICKWOOD
Royal Liverpool Children's Hospital, Liverpool L12 2AP 1 Oster J. The further fate of the foreskin. Arch Dis Child
circumcisions recently other than for valid medical or religious indications. I am very sorry to hear that Mr Rickwood finds it necessary to circumcise those boys with multiple recurrences of balanitis. In my experience these do not occur once adhesions have been completely separated or in boys with a fully retractable foreskin provided that appropriate advice about preputial hygiene is given. Perhaps Edinburgh boys and their parents are more receptive to instruction on hygiene than those in Liverpool. Mr Rickwood can be assured that 'I did quote his 1980 article in the first draft of my paper but the related paragraph was deleted by judicious editing. G A MacKINLAY Royal Hospital for Sick Children, Edinburgh EH9 1LF 1 Spence on circumcision. Lancet 1964;ii:902.
Mr G A MacKinlay (3 September, p 590) describes an excellent method of saving the prepuce in the 2-12 age group, but I am unable to share his enthusiasm for avoiding circumcision in the case of African males, in whom the uncircumcised state may enhance the transmission of the human immunodeficiency virus (HIV).' Circumcision is uncommon in the Zulu population for tribal reasons, and the consequent standard of subpreputial hygiene seen in attenders at sexually transmitted disease clinics at this hospital may be described only as very low. Genital ulceration is commoner in uncircumcised males,' but many patients are in addition seen without evidence of sexually transmitted diseases in whom areas of exposed mucosa are present. Friable scars and areas of deep pitting from old ulceration, particularly along the coronal sulcus, and balanitis with secondary infection may provide possible portals of entry and exit for HIV. Circumcision, if acceptable, may provide a more viable alternative in preventing the spread of HIV in this population than a vaccine likely to be priced out of the market, as in the case of hepatitis B.
1968;43:200-4. 2 Rickwood AMK, Hemalatha V, Batcup G, Spitz L. Phimosis in
boys. BrJ Urol 1980;52:147-50. 3 Escala JM, Rickwood AMK. Balanitis. BrJ Urol (in press).
AUTHOR'S REPLY,-General practitioners refer boys to hospital with a view to possible circumcision for various reasons. My simple table of "reasons for referral" was intended to illustrate these. The primary recorded indication was not the sole factor. Only 13 out of 39 boys are listed as having balanitis. In fact six of the 10 boys with phimosis also had recurrent balanitis, as did three of the six "for circumcision." Several of the others reported recurrent pain on micturition. Cultures of urine showed no growth, and the discomfort may well have been secondary to inflammation. The history obtained from many mothers supported this. These reasons for referral are, however, taken by many surgeons as indications for circumcision. There are three principal indications for circumcision. Firstly, medical reasons such as true fibrous phimosis; secondly, as a religious ritual; and, thirdly, for suitable remuneration. I can assure Mr Rickwood that the technique was used in these cases with the purpose of alleviating valid symptoms. It was not to satisfy the parents or the family doctor and certainly not my enthusiasm for this technique. To suggest the latter is similar to my implying that Mr Rickwood wrote his letter merely as an opportunity to quote his own papers on the subject. Most boys referred to me for possible circumcision are left well alone and my usual letter to the referring doctor quotes from "Spence on circumcision."' I have now used this technique without complication and with excellent results on a large number of boys. I have performed very few
BMJ
VOLUME
297
29
OCTOBER
1988
Mean (SD) blood pressure (mm Hg) before and during hormone replacement in normotensive postmenopausal women
Before replacement* 0-2 weeks
(n= I11) Systolic Diastolic
125 (11-9) 76 (7 3)
During replacement 6 weeks (n= I11)
1 Simonsen JN, Cameron DW, Gakinya MN, et al. Human immunodeficiency virus infection among men with sexually transmitted diseases. N EnglJ Med 1988;319:274-8.
Oestrogens and cardiovascular disease The likely protective effect of postmenopausal oestrogen treatment on cardiovascular and cerebrovascular disease described in the editorial by R Beaglehole (3 September, p 571) raises questions on the effect of such treatment on blood pressure. As hypertension is a risk factor for myocardial infarction and the dominant risk factor for stroke hormone replacement treatment (beneficial effects on serum lipids notwithstanding) is unlikely to affect blood pressure adversely. We cannot extrapolate from the experience with fairly high dose oestrogen, as in the oral contraceptive given to oestrogen replete women in whom a consistent rise in blood pressure has been observed.' Reports on the subject (reviewed by Bush and Barrett-Connor') are contradictory. No clear picture of postmenopausal hypertension induced by oestrogen emerges. Indeed, the balance of evidence tilts in favour of either no effect or a beneficial effect on blood pressure. The only population based case-control study to show a clear association between postmenopausal oestrogen treatment and blood pressure is difficult to interpret as it was not known whether hypertension preceded oestrogen treatment in some cases.3 We have examined in a pilot study the effect of
12 weeks
(n=9)
(n=8)
123 (12 4) 120 (14-1) 118 (141) 70(13-1) 71 (9 0) 67 (9-7)
*Mean of two visits, two weeks apart.
hormone replacement in a few normotensive postmenopausal women. Data on 11 women (table) are available so far. Their mean age was 50 (SD 6 5) and mean body mass index 27 (3 8) kg/m2; seven were non-smokers. Five women had a family history of hypertension. All blood pressures were measured in the morning, with the woman seated and after five minutes' rest, by one observer with a random zero sphygmomanometer, and the mean of two readings was recorded. We found a tendency for blood pressure to fall with repeated observation (simple regression towards the mean), which was consistent with no effect on blood pressure in this small open study. Blood pressure rose in one woman, from 128/82 mm Hg to 139/90 mm Hg at eight weeks, but she subsequently defaulted from follow up. Two additional women, whose blood pressure had tended to fall, were also lost to follow up. One hypertensive woman not included in the analysis showed a rise in blood pressure over 10 weeks of observation, so hypertensive drugs were prescribed. Though blood pressure may rise (perhaps idiosyncratically) in a minority of women receiving hormone replacement we think that adverse effects on blood pressure are unlikely in most women, and probably blood pressure may fall, leading to a reduced risk of stroke. A long term prospective controlled study is planned to elucidate this matter. IVAN PERRY M BEEVERS G BEEVERS DAVID LEUSLEY
NIGEL O'FARRELL
King Edward VIII Hospital, Congella, Durban, South Africa
8 weeks
Departments of Medicine and Obstetrics, Dudley Road Hospital, Birmingham B18 7QH 1 Weir RJ, Briggs E, Mack A, Naismith L, Taylor L, Wilson E. Blood pressure in women taking oral contraceptives. Br MedJ3
1974;i:533-5. 2 Bush TL, Barrett-Connor E. Non-contraceptive oestrogen use and cardiovascular disease. Epidemiol Rev 1985;7:80-104. 3 Pfeffer RI. Oestrogen use, hypertension and stroke in postmenopausal women.J Chronic Dis 1978;31:389-98.
Like Professor Robert Beaglehole (3 September, p 571), we too found low mortality from all circulatory disease in comparison with that expected on the basis of national rates (relative risk 0-51; 95% confidence interval 0-36 to 0 69) and significantly decreased mortality from ischaemic heart disease (relative risk 0-48; 95% confidence interval 0-29 to 0 74) in our recent prospective study of 4544 British users of hormone replacement treatment.' Our data are perhaps particularly interesting as they derive from a cohort of users of hormone replacement treatment who have used substantially more opposed treatment than that used in other studies that have been reported to date. We examined opposed and unopposed use among the 20 women who had died from ischaemic heart disease. Nine had had a hysterectomy and had used almost exclusively unopposed treatment. In the remaining 11 the mean duration of opposed use was 29-8 months and that of unopposed use 19 6 months. The corresponding figures for the cohort as a whole (again among women who had not had a hysterectomy) were 39-2 months and 21-3 months, respectively. Although these data 1127
