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pressed to a small extent but never to values found in pre-menopausal women;8 the fact that after therapy was discon-tinued the gonadotrophins returned to pre-treatment levels isnot therefore surprising as no-one has shown that the concen-trations of circulating equilin we found will inhibit gonadotro-phin release. But in any case their effect upon gonadotrophinsecretion probably does not reflect biopotency of equilin interms of human endometrial response. Indeed it was the poten-tial of equilin for long-term action as an endometrial stimu-lator that prompted our comment that it would seem prudentto discontinue ’Premarin’ after 12 months. Furthermore, thistherapy time-span has the total support of Ayerst Labora-tories, the manufacturers of premarin, as indicated in theirrecent advertisements.9 If our findings are confirmed by otherworkers using immunoassay methods it might be’necessary tosuggest that, in view of the other preparations available, pre-marin should not be prescribed at all.

M.R.C. Human Reproduction Group,Princess Mary Maternity Hospital,Newcastle upon Tyne NE2 3BD

P. G. WHITTAKERT. LIND

Department of Physiology,University of Manchester M. R. A. MORGAN

Department of Biochemistry,University of Liverpool P. D. G. DEAN

LIVER TUMOURS AND ORAL CONTRACEPTIVES

SiR,-In their description of ten cases of oral-contraceptive-associated liver tumour Dr Neuberger and colleagues (Feb. 9,p. 273) state that for two patients they could not ascertain thename of the contraceptive that had been used for at least 5years. Did these patients have no pharmacists or general prac-titioners ? Neuberger et al. state that "Eight of our patients hadbeen using the pill for 5 years or longer". The table shows thatone woman had been on the pill for 2 years and that two othershad used it for 4 years. Continuous use of the pill for 5 yearsis said to increase the risk of liver tumour "5-fold", while "Therisk of a woman on oral contraceptives developing livertumour is very low". Neuberger et al. shun absolute figures:how low? They give no indication at all of how important thisrisk is when set against, for instance, the risk of lung cancerin smokers or of fatal accidents in motorists. This paper couldhave been more informative.

Rijksinstituut voor de Volksgezondheid,3720 BA Bilthoven, Netherlends J. BORST

SIR,-Dr Neuberger and his colleagues describe 10 cases ofhepatic tumour in women on oral contraceptives collected overa period of 10 years at King’s College Hospital from a pro-bable population of at least 10 million people. I take exceptionto their recommendation that "routine six month screeningshould include examination of the abdomen for hepatomegalyas well as estimation of ESR and liver function tests". Thismay be clinically sound in the context of a specialist liver unitbut seems financially naive for the N.H.S. as a whole.

Neuberger et al. cite two papers in their discussion of the in-cidence of pill-associated liver tumours. M. P. Vessey and hiscolleagues described hepatic tumours in association with thepill as "extremely rare" and found only 1 case in a study whichinvolved seven years of morbidity in the 5 million populationof Scotland and 299 000 women-years of pill use in theR.C.G.P. study and the Oxford record linkage study, suggest-

8. Lind T, Cameron E, Hunter WM, et al. A prospective, controlled trial of sixforms of hormone replacement therapy given to post-menopausal women.Br J Obstet Gynœcol 1979; 86: suppl 3.

9. Ayerst Laboratories. Summary of prescribing information. Am J ObstetGynecol 1979: 135: xxiv.

ing an annual incidence of 1 or 2 cases in the whole of theU.K. H. A. Edmondson and others identified 42 patientsthrough the University of California department of pathologyover a twenty year period. Out of 34 patients traced, 17 hadbeen on the pill for more than five years and 17 for less thanfive years. From these figures an inspired guess would lead meto suggest that the incidence of pill-associated liver tumours inBritain would be of the order of 5-10 cases per year or 1-2cases per year for every million women on the pill.

If the K.C.H. workers’ recommendation were to be

accepted, then each of the 5.94 million women on the pillwould have her abdomen palpated and ESR and liver functiontests done every 6 months. Even if this check-up costs only jl(a ludicrously low estimate) for all of nearly 12 million exam-inations, the early diagnosis of 1 pill-related hepatic tumourwould cost about /1 million. I can suggest many more worth-while destinations for N.H.S. funds.A more reasonable conclusion to the paper would have been

to advise liver function tests and ESRs in any woman on the

pill who complains of upper abdominal or lower chest pain.

Buchan Lodge,7 Pedwell Way,Norham, Berwick upon Tweed G. A. C. BINNIE

ELECTROPHYSIOLOGY AND AVOIDANCE OFINVASIVE NEURORADIOLOGY IN MULTIPLE

SCLEROSIS

SIR,-I agree with Professor Mastaglia and his colleagues(Jan. 19, p. 144) that visual evoked responses (VEP) and otherelectrophysiological techniques are valuable in the investiga-tion of patients with multiple sclerosis (MS) but a note of cau-tion is needed, as a recent patient illustrates.A 58-year-old man was admitted with a 12-month history of

clumsiness of both hands, particularly the right, causing diffi-culty in fastening buttons and tying shoelaces. He had alsonoted he was dragging his right leg. There was no history ofprevious neurological episodes and in particular no visual

symptoms. The cranial nerves were normal and visual acuitywas not impaired. Proprioception was impaired in both handsand the arm reflexes were symmetrically increased. There wasmild weakness of the right leg and the right plantar responsewas extensor. All the reflexes were increased but more so onthe right with knee and ankle clonus. Sensation in the legs wasnormal.

His symptoms and signs could, on clinical grounds, be

explained by a cervical cord lesion and, despite the late age ofonset, demyelination had to be considered. The VEP was 120ms in the right eye (normal 106-$±7-5 5 ms) and normal in theleft eye. Auditory evoked responses were also normal. PlainX-rays of the cervical spine showed marked narrowing at C3/4and C4/5 disc spaces. A metrizamide myelogram demonstratedsevere cervical cord compression from cervical spondylosisboth anteriorly and posteriorly at C3/4, C4/5 and C5/6. Thecerebrospinal fluid protein content, including the IgG com-ponent, was normal and the cell count was not increased. Acervical laminectomy was recommended and at operation themyelogram findings were confirmed.MS and cervical spondylosis with myelopathy may coexist,

particularly in the older patient. MS is untreatable but cervicalspondylosis may be improved or its progression checked by sur-gery. Reliance on the VEP might have deprived this patient ofpotential benefit. As with any other investigation, the VEPmust be interpreted in the clinical context. Invasive neuro-radiology must not be too readily abandoned in the older pa-tient who, on clinical grounds, has a solitary spinal cord lesion.

Department of Neurology,Salford Royal Hospital,Salford M60 9EP A. C. YOUNG