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Haemorrhagic ulceration of gut.

Firstly, R. J. Weir, of the Medical Research Council's Blood Pressure Unit in Glasgow, and colleagues in the Glasgow Clinic of the Family Planning Association2 studied levels of blood pressure in 100 women before and during a year's treatment with oral contraceptives and in a control group of 34 women using mechanical forms of contraception. All were normotensive before beginning contraception. Since there is some evidence that oestrogen is the cause of the hypertension, two oral contraceptives with different concentrations of oestrogen were used. Of the 100 women who started 66 were followed up for a year. Reasons for failure to complete the trial included pregnancy (one patient) and adverse publicity about oral contraceptives (7 patients). Twenty-one of the 34 patients (62 I',) using mechanical forms of contraception stayed the course. It was noticeable, and perhaps important, that the women using oral contraceptives were younger than those in the other group, and more were nulliparous. The first reassuring fact which emerged was that in no patient on oral contraceptives did the blood pressure rise above 140/90 mm Hg. An average rise in systolic pressure of 6-6 mm Hg was noted, but there was no significant change in the mean level of the diastolic pressure. Further, there appeared to be no difference between the two contraceptive preparations used in their tendency to produce this rise in systolic pressure. Of particular interest were four women whose systolic blood pressure increased by between 20 and 30 mm Hg in 12 months, and further information on this subgroup would be welcome. In the control group there was no significant change in either systolic or diastolic blood pressure. Dr. Weir and his colleagues are to be congratulated on the lengths they went to in order to prevent bias, which has vitiated so many previous studies of this kind. The second report comes from California and concerns 22 women who were found to be hypertensive while taking oral contraceptives.3 The mean blood pressures before, during, and after treatment were 125/76, 183/110, and 130/82 mm Hg respectively. Several of these patients were hypertensive before oral contraception began. The time recorded for high levels of pressure to become evident varied considerably, but in some cases the delay was due to a failure to document blood pressure over long periods. This illustrates one of the problems which the Glasgow study should be in a position to answer-the time relationship between development of hypertension and start of oral contraception. There was also a variation of between 1 and 12 months after stopping oral contraceptives before normal levels of blood pressure were regained. The third report, from the University of Texas, documents the occurrence of a level of blood pressure above 140/90 mm Hg in 10 of 56 women given an oral contraceptive and followed up for periods up to 30 weeks.4 Of six women with already raised levels of pressure one became normotensive, four remained hypertensive, and in one the hypertension became worse. The authors of this article are, rightly, unwilling to extrapolate their findings to a large group, since there was no proof that in this sample of postpartum woman oral contraceptives were the only possible cause of the hypertension. Secondly, the patients were mainly coloured women, in whom the incidence of essential hypertension is high. What then are the practical consequences to be considered? If a woman wishes to take oral contraceptives, her blood pressure should be measured first. If she is normotensive, the risk of her blood pressure going up would appear to be small, though not immeasurably small, and it would be wise to check it at regular (say six-monthly) intervals. If she is already hypertensive the position may be different, though there is still little published evidence to suggest any risk of an exacerbation of the hypertension. Here it is hardly possible to say more than that the woman's requirements need to be assessed with exceptional care, attention being paid to all her needs and circumstances.