BMJ NO 7023 Volume 312 Saturday 13 January 1996

Editorials

News

73 Doctors' hunger strike in Bombay * Australia confidentiality row * Pharmacy staff criticised * German health insurance deficit * Personality and genetics * Older women and breast screening * India and prescribing * Dutch euthanasia prosecutions * Britain puts asylum children at risk * French cancer charity investigated * German heart valve scandal * NHS reforms need reform * Doctors as Delilahs

Papers

General Practice

Education & Debate

Obituaries

C M Fletcher, T C Chalmers, A S Anderson, H Climie, E A F Dickie, C J Frederick, G B Hollings, D F McLauchlan,M L Soni

Letters

Medicopolitical Digest

Summative assessment * Juniors' contracts * Waiting lists * Violence against doctors * Assessing mental capacity * Transplanting animal organs to humans * Changes to PLAB test

Soundings

Quangoholics anonymous James Owen Drife; Evidence based politics Tony Smith

Personal View

Gifts Huw Morgan; Time to audit audit David Sellu

Medicine and the Media

Trying experts Philip Joseph

Medicine and Books

Minerva

BMJ

Editor's Choice

Third generation contraceptive pills: the continuing saga

This week we add yet another twist to the story of the risks associated with third generation contraceptive pills, and maybe it's time for the sociologists to begin work on analysing the episode.

The story began last October when the British Committee on Safety of Medicines (CSM) announced on the basis of unpublished data that the risk of thromboembolism in women using third generation pills was about twice that in women using longer established pills. Doctors were upset that they first heard about the risks through the mass media. Manufacturers thought that the CSM had acted prematurely. Some observers muttered about the government wanting to reduce costs by discouraging people from using the more expensive pills; others speculated that British politicians were anxious to prove their independence from European authorities; while a few were gratified that the drug companies that had promoted their new drugs on dubious grounds had got their comeuppance. Meanwhile, older women - brought up on pill scares - generally seemed to react sensibly, but some younger women may have stopped taking any pill.

The next development came just before Christmas, when the Lancet published data from three studies confirming the risk. By now the media were beginning to tire of the story, and the relatively small coverage was devoted to ideas on better ways to let doctors and others know about such risks. Surely a way could be found to publish peer reviewed results and make a public announcement at the same time.

Today we publish one of the studies used by the CSM, and it confirms the higher risk of thromboembolic disease (p 83). But a second paper from the same study suggests that the risk of myocardial infarction might be lower in women taking the third generation pills than in those taking longer established pills (p 88). These data will remain forever preliminary because the studies were interrupted by the "scare," and editorialist Klim McPherson thinks that such data "cannot provide a reliable basis for policy decisions on safe contraception" (p 68). Both Professor McPherson and the Faculty of Family Planning and Reproductive Health Care (p 121) provide straightforward advice on prescribing the pill.

Our obituary columns include accounts of two remarkable men - Charles Fletcher and Tom Chalmers - who would no doubt have been fascinated by the messy saga of the pill. Fletcher is perhaps best known as the secretary to the Royal College of Physicians working party that produced the college's first report on smoking and as the first British doctor to excel on television (p 117). He believed that doctors failed to explain things adequately to patients, and he was much criticised - including by the BMJ - for his work on television. Now doctors and hospitals are fighting to get on television. Chalmers, an American epidemiologist, was another who challenged conventional thinking, and he produced the commandment "randomise the first patient" (p 118). He extended his commandment to saving money by blinded wine tasting.