- Email: [email protected]
CERVICAL SMEARS—WHEN AND HOW OFTEN?
309 should be a searching review. Failure may indicate thwarting of complex subconscious motives and/or diverse interpersonal difficulties. These patients are likely to require a mainly psychotherapeutic approach. Sometimes non-response may reflect limiting constitutional factors. In these cases therapy should focus on the non-sexual facets of the relationship, which often improve dramatically once the nature of the sexual dysfunction is understood. Although perhaps not the original treatment aim, the possibility of such benefits should not be over-
looked. E. Merck Ltd., Four Marks, Alton, Hants GU34 5HG
ALAN
J. COOPER
CERVICAL SMEARS—WHEN AND HOW OFTEN?
SIR,-Your editorial’ refers to the report which we prepared for the British Society for Clinical Cytology.2 May we comment on a few individual points where readers might be misled ? You say that our report suggests that: "it is both wasteful of resources and a cause of needless anxiety to perform a biopsy in those under 25 years who have positive smears." We did not say this. Our point was that the cost-benefit of taking smears in the first place is very low in that age-group. Once a smear has been taken and found to be positive it is certainly important to continue investigating the case, and to do a biopsy if clinically or cytolbgically indicated. Again you state: "the in-situ stage lasts 10-20 years". Although the rationale of cervical smear screening rests on the supposition that these long intervals are the rule, your statement is too sweeping; it also embraces, presumably, the various degrees of dysplasia under the expression "the in-situ
stage". "According to Knox and the Walton report screening should be prolonged at the other end of the age-scale." This is correct for Knox but not for the Walton report which recommends that women over 60 whose previous smears have been normal be "dropped from the cervical cancer screening programme". We have suggested extending this to 70. Your figure of 99% for the screening coverage of women aged 20-60 in Aberdeen is not really credible and has never been claimed by Dr J. E. Macgregor and her colleagues. Even if it could be achieved in a free society, there would need to be a police State to find the figure out for any given point in time.
Finally, you suggest that the new generation should be informed that cervical cancer is a sexually transmitted disease. This we would agree with if information relating to the association of intercourse and cervical cancer is factually and judiciously presented. Indiscriminate, mass propaganda about it, however, might be counterproductive and result in some older women being deterred from having smears done or even reoortins svmotoms. Laboratory of Clinical Cytology, Churchill Hospital, Oxford
Regional Cytology Centre, St. Stephen’s Hospital, London SW10
CORONARY-ARTERY SPASM
SIR,-Maseri et at.reported that, in their series of patients with coronary-artery spasm, ST depression during episodes of pain was seen only in patients with significant double or triple vessel coronary-artery disease. We have reviewed our experience with the intravenous injection of ergonovine maleate during coronary angiography of patients with normal coronary arteries, chest pain, and suspected coronary-artery spasm. One patient who had normal coronary arteries but who developed a complete occlusion of the circumflex coronary artery after ergonovine maleate, showed ST downsloping and greater than 1 mm depression in lead I during a spontaneous attack of pain. A second patient had 1.55 mm ST depression during exercise in the lateral praecordial leads. She, too, had normal coronary arteries, but had chest pain and up to a 30% narrowing of her coronary arteries after ergonovine maleate. The second patient had a prolapse of the mitral valve, but the first patient did not. It therefore seems that, in patients with coronary-artery spasm, ST depression does not necessarily indicate severe two or three vessel coronary-artery disease. S. A. MAGDER Division of Cardiology, Toronto General Hospital, Toronto, Ontario M5G 1L7, Canada
D. E. JOHNSTONE V. F. HUCKELL A. G. ADELMAN
EFFECT OF PROPRANOLOL ON SERUM-MELATONIN
SIR,-Animal studies indicate that melatonin formation is
partly regulated by a beta-adrenergic receptor.2 Little is known about the regulation of the formation of the putative pineal hormone melatonin in man. The beta-adrenergic blocking agent propranolol inhibits melatonin formation in rats.3 While investigating the use of propranolol in schizophrenia we studied serum-melatonin concentrations in one patient. A 27-year-old female patient was examined before and after propranolol treatment. She received 640 mg propranolol daily for 7 days. No other drug was given. Blood-samples were collected whilst the patient was sleeping in the dark. 1. Maseri, A., and others Lancet, 1977, i, 713. 2. Wurtman, R. J., Shein, H. M., Larin, F. J. Neurochem. 1971, 18, 1683. 3. Wetterberg, L., Eriksson, O., Friberg, Y., Vangbo, B. Unpublished.
A. I. SPRIGGS O. A. N. HUSAIN
**0ur figure for screening coverage in Aberdeen should have been 95% of women aged 25-60; and we were indeed wrong to bracket Walton with Knox. Otherwise the differences between what we said and what Dr Spriggs and Dr Husain said are microscopic rather than gross.-ED.L. Nocturnal rise in serum-melatonin. 1.
Lancet, 1977, i, 1297.
2. British Society for Clinical Cytology. Br. med.
before and D after propranolol treatment. Serum-melatonin (in nmot/1) measured by rapid radioimmunoassay.
0
J. 1977, i, 1516.
=
=
looked. E. Merck Ltd., Four Marks, Alton, Hants GU34 5HG
ALAN
J. COOPER
CERVICAL SMEARS—WHEN AND HOW OFTEN?
SIR,-Your editorial’ refers to the report which we prepared for the British Society for Clinical Cytology.2 May we comment on a few individual points where readers might be misled ? You say that our report suggests that: "it is both wasteful of resources and a cause of needless anxiety to perform a biopsy in those under 25 years who have positive smears." We did not say this. Our point was that the cost-benefit of taking smears in the first place is very low in that age-group. Once a smear has been taken and found to be positive it is certainly important to continue investigating the case, and to do a biopsy if clinically or cytolbgically indicated. Again you state: "the in-situ stage lasts 10-20 years". Although the rationale of cervical smear screening rests on the supposition that these long intervals are the rule, your statement is too sweeping; it also embraces, presumably, the various degrees of dysplasia under the expression "the in-situ
stage". "According to Knox and the Walton report screening should be prolonged at the other end of the age-scale." This is correct for Knox but not for the Walton report which recommends that women over 60 whose previous smears have been normal be "dropped from the cervical cancer screening programme". We have suggested extending this to 70. Your figure of 99% for the screening coverage of women aged 20-60 in Aberdeen is not really credible and has never been claimed by Dr J. E. Macgregor and her colleagues. Even if it could be achieved in a free society, there would need to be a police State to find the figure out for any given point in time.
Finally, you suggest that the new generation should be informed that cervical cancer is a sexually transmitted disease. This we would agree with if information relating to the association of intercourse and cervical cancer is factually and judiciously presented. Indiscriminate, mass propaganda about it, however, might be counterproductive and result in some older women being deterred from having smears done or even reoortins svmotoms. Laboratory of Clinical Cytology, Churchill Hospital, Oxford
Regional Cytology Centre, St. Stephen’s Hospital, London SW10
CORONARY-ARTERY SPASM
SIR,-Maseri et at.reported that, in their series of patients with coronary-artery spasm, ST depression during episodes of pain was seen only in patients with significant double or triple vessel coronary-artery disease. We have reviewed our experience with the intravenous injection of ergonovine maleate during coronary angiography of patients with normal coronary arteries, chest pain, and suspected coronary-artery spasm. One patient who had normal coronary arteries but who developed a complete occlusion of the circumflex coronary artery after ergonovine maleate, showed ST downsloping and greater than 1 mm depression in lead I during a spontaneous attack of pain. A second patient had 1.55 mm ST depression during exercise in the lateral praecordial leads. She, too, had normal coronary arteries, but had chest pain and up to a 30% narrowing of her coronary arteries after ergonovine maleate. The second patient had a prolapse of the mitral valve, but the first patient did not. It therefore seems that, in patients with coronary-artery spasm, ST depression does not necessarily indicate severe two or three vessel coronary-artery disease. S. A. MAGDER Division of Cardiology, Toronto General Hospital, Toronto, Ontario M5G 1L7, Canada
D. E. JOHNSTONE V. F. HUCKELL A. G. ADELMAN
EFFECT OF PROPRANOLOL ON SERUM-MELATONIN
SIR,-Animal studies indicate that melatonin formation is
partly regulated by a beta-adrenergic receptor.2 Little is known about the regulation of the formation of the putative pineal hormone melatonin in man. The beta-adrenergic blocking agent propranolol inhibits melatonin formation in rats.3 While investigating the use of propranolol in schizophrenia we studied serum-melatonin concentrations in one patient. A 27-year-old female patient was examined before and after propranolol treatment. She received 640 mg propranolol daily for 7 days. No other drug was given. Blood-samples were collected whilst the patient was sleeping in the dark. 1. Maseri, A., and others Lancet, 1977, i, 713. 2. Wurtman, R. J., Shein, H. M., Larin, F. J. Neurochem. 1971, 18, 1683. 3. Wetterberg, L., Eriksson, O., Friberg, Y., Vangbo, B. Unpublished.
A. I. SPRIGGS O. A. N. HUSAIN
**0ur figure for screening coverage in Aberdeen should have been 95% of women aged 25-60; and we were indeed wrong to bracket Walton with Knox. Otherwise the differences between what we said and what Dr Spriggs and Dr Husain said are microscopic rather than gross.-ED.L. Nocturnal rise in serum-melatonin. 1.
Lancet, 1977, i, 1297.
2. British Society for Clinical Cytology. Br. med.
before and D after propranolol treatment. Serum-melatonin (in nmot/1) measured by rapid radioimmunoassay.
0
J. 1977, i, 1516.
=
=