Objective To determine the effect on the bone density of the skeleton after changing from oral oestrogen to subcutaneous oestradiol and testosterone replacement.Design Prospective non‐randomized single centre study.Subjects Twenty women who were receiving long‐term oral oestrogen replacement. Ten changed to oestradiol and testosterone implants; the remaining ten continued with oral oestrogens.Main outcome measures Bone density was measured using dual photon absorptiometry at the lumbar spine and neck of femur at the start of the study and after one year.Results The bone density increased significantly by 5.7% at the spine and by 5.2% at the neck of femur in those women who changed to implant therapy but remained unchanged in those women who continued with oral therapy.Conclusion Subcutaneous oestradiol and testosterone implants will result in an increase in bone mass even after many years of oral oestrogen replacement therapy.

Objective To investigate the attitude of consultant gynaecologists and general practitioners to various aspects of hormone replacement therapy and to compare the findings in these two groups.Design Anonymous postal survey of 589 general practitioners and 998 consultant gynaecologists; 373 (63 %) and 655 (66 %) valid replies, respectively, were received. Main outcome measuresViews on universal treatment of eligible women, indications for hormone replacement therapy, prescribing practice, pretreatment investigation, monitoring, and contraindications to treatment. ResultsMore consultants (64 %) than general practitioners (56 %) thought hormone replacement therapy should be offered to all eligible women, with a significant trend against treatment amongst more senior consultants. Most practitioners were prepared to offer treatment before the cessation of menstruation, but only 27 % of consultants and 11 % of general practitioners recommended indefinite treatment. Most limited treatment to less than 10 years. Menopausal symptoms, premature natural and surgical menopause, and a family history of osteoporosis were regarded as indications for treatment, but less than half felt established osteoporosis an indication. Hormone replacement therapy was judged to reduce the risk of ischaemic heart disease and osteoporosis by both groups but there was less consensus on the prevention of cerebrovascular accident. In general, consultants had more faith in hormone replacement therapy as prophylaxis. One-quarter of consultants said that hormone replacement therapy should be initiated by consultants. Only 4 % of general practitioners shared this view. About 30 70 of both groups required mammography, but less than 10 % required sophisticated tests. A range of common cardiovascular conditions were regarded as contraindications, although general practitioners were more likely to regard thrombosis and cerebrovascular accident as contraindications. Breast cancer and a family history of breast cancer were regarded with suspicion by both groups.Conclusions Practitioners were positively inclined to hormone replacement therapy, but many were unconvinced of its chronic use and use in those with cardiovascular conditions. There were differences in views as to who should initiate therapy.38, 398-401. 5 I 9-522. 822-824.

Objective-To estimate the local incidence of ectopic pregnancy and to review the management of ectopic pregnancy with reference to those misdiagnosed at presentation. To establish management guidelines to be applied to all possible ectopic pregnancies. Design-A review of all ectopic pregnancies presenting over a 2-year period, and of emergency gynaecological admissions during 4 months. Setting-A teaching hospital Results-The local rate of ectopic pregnancy was similar to that seen in other UK studies. Nineteen (13%) women with ectopic pregnancies were sent home with an incorrect diagnosis. Eight were recalled but eight required emergency admission and one died at home. Undue confidence in ultrasound reports and failure to follow up inconclusive histology results were a feature in cases where patients were not recalled. A set of simple management guidelines has been drawn up. Amongst general gynaecological admissions 1 in 12 of all first trimester complications was an ectopic pregnancy. Amongst apparently true uterine miscarriages 20% of histological examinations were inconclusive and histology and ultrasound examinations failed to confirm a uterine miscarriage in 14% of apparently true missed miscarriages. Conclusions-Ectopic pregnancy is common amongst first trimester complications. Adherence to simple management guidelines would minimize the number of patients requiring emergency admission, though up to 20% of patients with apparently true uterine miscarriages would also require further investigation.A review of the management of women with an ectopic pregnancy over a 2-year period was undertaken. The aims of the audit were threefold. (i) To establish the rate of ectopic pregnancy in the district population and within the emergency gynaecological intake with a complication of the first trimester. (ii) To establish the proportion of women with a final diagnosis of ectopic pregnancy who were initially discharged with an incorrect diagnosis and to identify factors contributing to the error, thus enabling guidelines to be established for all gynaecologi-

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