IN THE MATERNITY WARD

931 DANAZOL AND CHOLESTEROL METABOLISM

SIR,- The novel steroid, danazol, is treatment of endometriosis, and

now

being

to a

lesser

used

widely

in the of other conditions.1,2 Most receive no patients management more than six months of continuous therapy, but occasionally patients are given much more prolonged treatment. We have found metabolic changes in a group of patients treated for endometriosis with doses of danazol varying from 400 to 800 mg daily. Our results may be of concern in relation to patients receiving prolonged treatment. Nineteen women were studied over a 6-month period. Plasma-total-cholesterol in fasting patients rose progressively from (mean±S.E.M.) 5.24±0.30 mmol/1, pre-treatment through 6-39+0-40 mmol/1. at 2 months and 7.07±040 mmol/1 at 4 months to 7-15+0.38 mmol/l at 6 months. The difference between the pre-treatment and 6 month-value was highly significant (paired t test; for the

extent

p<0.001). small group of eight patients studied subsequently, we dramatic fall in high-density lipoprotein cholesterol (H.D.L.-C.) measured before danazol and 2 months after starting treatment. Since H.D.L.-C. correlates negatively with risk of coronary heart-disease,3.4 this decrease in H.D.L.-c. indicates that patients taking danazol may be at risk. Initially, six of the eight patients studied had H.D.L.-C. values within the normal range for the Sydney population (0.9-2 .1mmol/l, for women). One of the two remaining women was grossly obese and the other, before starting the danazol, had recently undergone surgery for endometriosis. For these eight patients, aged 25-39, the pre-treatment H.D.L.-C. was (mean+s.E.M.): 1.14+0.12 mmol/1, and after danazol for 2 months, H.D.L.-C. was 0.53±0.04 mmol/l. A pairedt test shows this drop to be significant (P<001). Combined with an increasing total cholesterol, this decrease in H.D.L.-C. could be of some concern. These changes are being investigated more thoroughly. Patients are being studied throughout the course of treatment and their return to normal is being followed also. We report this preliminary finding as a warning against very long use of danazol, at least in high-risk patients, until the additional risk due to danazol is clarified. We hope that our findings also stimulate other groups to review their data. In

a

found

a

of Obstetric

Department and Gynæcology,

J.

K. ALLEN

IN THE MATERNITY WARD

Mary (April 14, p. 818) filled me of déjà vu. In the 1950s when I was a pupil midwife, mothers and doctors and midwives were at each other’s throats in that self-same "abrasive triangle" Martha described. In the early 1960s, when I was having my own babies, the same dismal arguments were going on. Then mothers complained bitterly about being forced to stay at home to have their babies (Britain had hospital accommodation for only about 60‘% of deliveries, if I recall the figures correctly) and not being given enough help in labour. Now they are complaining that they are not being allowed to stay at-home, and about too much help (active management techniques) in labour. Plus SIR,-Martha’s letter

dreary

I believe that an honest account of what childbirth is really like would allow more women actually to enjoy aspects of it. My own three experiences, like the curate’s egg, were good in parts. Incidentally, few people come out of hospital after surgery complaining so bitterly of how badly they were treated. And midwives and obstetricians and hospital nurses and surgeons are not really members of different species. Could the difference be because, preoperatively, patients expect surgery to be less than fun and so develop a certain amount of stoicism?

Holly Wood House, Roxborough Avenue,

I. S. FRASER

Royal Prince Alfred Hospital, Camperdown, N.S.W.

a

not).

CLAIRE RAYNER

Harrow-on-the-Hill HA1 3BU

University of Sydney, Sydney, New South Wales 2006, Australia Department of Biochemistry,

with such

Martha wonders how we are to "restore the anticipatory excitement to childbirth" and I suspect that she may here have put her finger firmly on what is the real problem. Surely women are made to expect too much of the experience of giving birth? We are force-fed all our reproductive lives with images of loving perfect motherhood, ushered in by meaningful emotional experiences. In fact motherhood is often an exhausting, boring, self abnegating way of life that goes on for rather too long, ushered in by a messy, often painful, and largely disagreeable experience that also goes on for too long. I know and receive letters from far too many women who still nurse bitter fury at what happened when they had their babies; at the way they were "cheated" of their marvellous "painless" experience; at the "wicked" midwives and doctors who ruined it instead of espousing the latest form of "romantic childbirth". And there are midwives who share this point of view-who actually advise their patients to refuse to go into hospital, and to stay at home until it is too late for "interventionist" obstetrics. I am now convinced that we could protect patients from a lot of misery and risk and doctors and midwives from a lot of criticism if we-and I include many of my fellow writers in this area-stopped being quite so sentimental about this particular physiological event. It is no more glamorous or romantic or meaningful than eating or vomiting or defæcating-except that you end up with an infant to show for your pains. Which is great or not, according to your personality, your financial situation, and the sort of partner you have (or have

to

sense

cachange ...

CHOLESTEROL AND COLON CANCER

SIR The hypothesis that dietary cholesterol might act as co-carcinogen for colorectal cancer, set out by Dr Cruse and his colleagues (April 7, p. 752) is timely because some people working on atherosclerosis are concerned that agents which lower raised serum-cholesterol concentrations by promoting the excretion of cholesterol through the biliary and intestinal systems might have a similar effect. Thus the W.H.O. trial’ of clofibrate in the primary prevention of ischxmic heart-disease reported a significant excess of deaths from diseases of the liver, biliary system, small intestines, colon, and rectum; the

a

incidence of colorectal cancer was not in itself in excess but the number of cases were too few to permit any definitive conclusion. A nearly significant excess of commonly occurring visceral cancers was reported from the Los Angeles Veterans Administration trial2 where a polyunsaturated fat diet was used to lower raised cholesterol concentrations, but the sites were not predominantly colorectal, and a subsequent appraisal,3 including four other cholesterol-lowering dietary trials, was reas-

suring. Both the 1.

primary prevention trials 1,4,5and the clofibrate sec-

Report of the

Committee of

Principal Investigators

Br.

Heart J. 1978, 40,

1069.

Pearce, M. L., Dayton, S. Lancet, 1971, i, 464. 3. Ederer, F., Leren, P, Turpeinen, O., Frantz, I. D., Jr. ibid. 1971, ii, 203. 4. Dayton, S., Pearce, M. L., Hashimoto, S., Dixon, W J., Tomiyasu, U. Circulation, 1969, 39/40, suppl. II,p 1. 5. Sturdevant, R. A. L., Pearce, M. L., Dayton, S. New Engl. J. Med. 1973, 288, 24. 2.

1. Young, M D, Blackmore, W. P. J. int. med. 2. Fraser,I S. Scot. med.J. (in the press).

Res.

1977, 5, suppl. 3, p. 86.

3 Miller, G. J., Miller, N. E. Lancet, 1975, i, 16. Gordon, T., Castelli, W. P., Hjortland, M. C., Kannel, T R. Am. J. Med. 1977, 62, 707.

W.

B., Dawber,