Endometrial patterns and endocrinologic characteristics of asymptomatic menopausal women

The endometrial histology and endocrinologic and demographic characteristics of 556 asymptomatic postmenopausal women ,who attended the menopause outpatient clinic at Ankara Numune Education and Research Hospital were studied before initiating estrogen replacement therapy. Of these women ,486 (87.4%) had atrophic endometrium ,37 (6.65%) had proliferative endometrium ,27 (4.86%) had endometrial hyperplasia without atypia ,three (0.54%) had endometrial hyperplasia with atypia and three (0.54%) had endometrial adenocarcinoma on their biopsy specimens. When demographic characteristics of the patients were considered, we found that the patients with endometrial adenocarcinoma and endometrial hyperplasia with atypia had potential risk factors for endometrial pathology such as chronic anovulation ,diabetes or hypertension. This study confirms that routine endometrial sampling in asymptomatic postmenopausal women is not warranted ,but patients with associated risk factors should be screened for endometrial pathology before starting estrogen replacement therapy.     

The role of hormones in the etiology and prevention of endometrial cancer

Unopposed estrogens, both exogenous and endogenous, increase the risk of endometrial cancer although the magnitude of the association between estrogen replacement therapy and adenocarcinoma has been exaggerated by the epidemiologic case-control studies. Not all postmenopausal women need estrogen replacement therapy since some produce sufficient endogenous estrogens to remain asymptomatic and prevent atrophic vaginitis, osteoporosis and atherosclerosis. However, within this group may be those at risk for endometrial cancer, so they need to be identified and treated with cyclic progestogens. Sequential oral contraceptives did not protect young women from adenocarcinoma of the endometrium because of too little progestogen for too short a duration in view of the relatively high dosage of estrogen. However, combination birth control pills significantly decrease the risk for endometrial carcinoma. Endometrial hyperplasia is a precancerous lesion in some women and can be effectively reversed with 10-13 days of progestogen monthly in at least 98% of patients. The progestogen challenge test has been devised to identify postmenopausal women at greatest risk for adenocarcinoma. It should be administered to all postmenopausal women with an intact uterus. This includes asymptomatic women, patients receiving estrogen replacement therapy and women being evaluated for hormone therapy. If there is a positive response to the progestogen challenge, as manifested by withdrawal bleeding, then the progestogen should be continued for 13 days each month for as long as withdrawal bleeding results. If there is no response then the progestogen challenge test should be repeated at each annual examination. Universal use of the progestogen challenge test should prevent nearly all endometrial cancers.     

TV sonographic assessment in postmenopausal asymptomatic women

The aim of this study was to evaluate retrospectively the usefulness of transvaginal sonography for the detection of endometrial disease in postmenopausal women without symptoms. The study involved 750 postmenopausal women aged 52-65 (mean 58.5). None of them were on hormone replacement therapy and all had had amenorrhea for more than two years. Transvaginal sonography was performed in 750 women. An endometrium of < 5 mm and non-measurable (627 women) was not investigated further. The 627 cases of this group were reassessed one year later. In the remaining 123 postmenopausal women with suspicious endometrium > 5 mm, 19 endometrial polyps (7.13%), one cervical polyp with extension in the cavity (0.8%), 90 endometrial atrophies (73.17%), ten atrophic endometritis (8.13%), two simple hyperplasias (1.62%), and one hyperplasia with atypia (0.8%) were found. Transvaginal sonography is an efficient and acceptable noninvasive method for the early detection of endometrial pathology in postmenopausal asymptomatic women.     

Estrogens, progestogens and endometrial cancer.

At the Wilford Hall U.S. Air Force Base Medical Center, Texas, about 4000 postmenopausal women received estrogen replacement therapy during 1975. Of these, 2700 took estrogens only and 1240 were given a progestogen along with estrogen. Hysterectomy had been done previously on 1700 patients (42%), leaving 2300 with intact uteri and a risk of endometrial cancer. Adenocarcinoma of the endometrium was diagnosed in 7 patients. Of these, 6 had received estrogen therapy. There was 1 endometrial malignancy in a patient also receiving a progestogen. Among 510 untreated postmenopausal women with intact uteri, 1 adenocarcinoma of the endometrium was found. Type and dosage of estrogen were unrelated to endometrial malignancy. In addition to the 7 endometrial cancers from the clinic, 22 cases were diagnosed elsewhere and referred for treatment, 11 of these had received no hormones. 10 were taking estrogens and 1 was receiving Oracon for birth control. The incidence of endometrial malignancy in the U.S. is reported to be 21/100,000 women/year. There is a 3-fold to 9-fold increased risk of endometrial cancer associated with obesity alone. The probability that untreated postmenopausal women with intact uteri will develop carcinoma of the endometrium is 1/1000/year. With estrogen users, it is reported to be increased -7.6/1000 women/year. In the author's clinic during 1975, the incidence among those receiving only estrogen was 4.7/1000. Among those also receiving a progestogen the incidence was .8/1000. Unopposed estrogens apparently have a role in the etiology of endometria hyperplasia and neoplasia through incomplete shedding of the endometrium. Progesterone produces more complete sloughing of the endometrium and also converts all degrees of hyperplasia into secretory endometrium. Nulliparity, infertility, and anovulation are predisoposing factors to endometrial carcinoma. Progestogens are palliative therapy for endometrial cancer.     

Significance of benign endometrial cells in Pap smears from postmenopausal women

OBJECTIVE: To assess the significance of benign exfoliated endometrial epithelial or stromal cells on cervicovaginal Pap smears obtained from postmenopausal women not receiving exogenous hormones. STUDY DESIGN: A computerized search of the cytology database at two institutions was performed for a five-year period, and all cervical cytology cases from postmenopausal patients diagnosed with benign endometrial cells were identified. Those cases with histologic follow-up within 12 months of the original cytologic evaluation were selected for analysis, and their cytology and surgical pathology slides were reviewed. RESULTS: A total of 227 postmenopausal women with benign endometrial cells were identified. Of the 61 patients with histologic follow-up, 25 (41%) had significant endometrial diseases, including hyperplasia without atypia (11), atypical endometrial hyperplasia (5), well-differentiated adenocarcinoma (8) and high grade serous carcinoma (1). Benign diagnoses, including atrophy (15), weakly proliferative endometrium (9) and proliferative endometrium (6), were noted in 30 patients (49%). Endometrial polyp was identified in three patients (5%). There were three cases of nondiagnostic histologic specimens that lacked endometrial tissue (5%). Two of nine women (22%) with proven carcinoma were asymptomatic. CONCLUSION: The diagnosis of endometrial cells, cytologically benign, in a postmenopausal woman not receiving hormone on Pap smears is associated with a significant number of cases of endometrial hyperplasia, atypical hyperplasia and carcinoma.     

Cancer and the use of estrogens

Although unopposed estrogen therapy, as well as persistent or increased endogenous estrogens, increases the risk for endometrial hyperplasia and cancer, added progestogen decreases the risk for adenocarcinoma of the endometrium to less than that observed in untreated women. The progestogen challenge test should be administered to all postmenopausal women with an intact uterus--including estrogen-treated postmenopausal women and those with sufficient endogenous estrogens to remain asymptomatic--and the progestogen continued for 13 days each month for as long as withdrawal bleeding results. Estrogen replacement therapy should not be withheld from postmenopausal women who are estrogen deficient, since there is no evidence that estrogens increase the risk for breast cancer. Progestogen added to estrogen replacement significantly reduces the risk for mammary malignancy; therefore, progestogens should be given, even to women who have had a hysterectomy, for 10 to 13 days each month whenever they are prescribed estrogen therapy.     

Liquid-based endometrial cytology: its possible value in postmenopausal asymptomatic women

The incidence of endometrial adenocarcinoma in asymptomatic women is low. Nevertheless, some of these women might require endometrial surveillance. In this study, we evaluated the accuracy of liquid-based endometrial cytology compared to biopsy in asymptomatic postmenopausal women. Three hundred twenty women scheduled for hysteroscopy were enrolled for this study. After hysteroscopy, patients were submitted to endometrial cytology and to biopsy. Two hundred ninety-three (92%) women had sonographically thickened endometrium (>5 mm), 53 (17%) were on tamoxifen, and 16 (5%) were on hormonal substitutive treatment. The evaluation of the biopsies determined that six (2%) women had adenocarcinoma, one (<1%) had adenomatous atypical hyperplasia, and eight (3%) had simple nonatypical hyperplasia. Endometrial cytology evidenced 5 (2%) neoplastic cases, 2 (<1%) hyperplastic with atypia cases, and 25 (8%) hyperplastic without atypia cases. Two hundred twenty-two biopsies (69%) and 17 (5%) cytologies were inadequate. One adenocarcinoma and one simple nonatypical hyperplasia were underrated by cytology resulting, respectively, as atypical hyperplasia and as negative. Four cases were false positive (simple nonatypical hyperplasias on cytology, negative on biopsy). The sensitivity and specificity were estimated, respectively, at 94% and 95%; the positive and negative predictive value were estimated, respectively, at 80% and 99%. Endometrial cytology provided sufficient material more often than biopsy (P < 0.01). We suggest to introduce liquid-based endometrial cytology in the management of some subpopulations of asymptomatic postmenopausal women. Particularly, the combination of liquid-based endometrial cytology and transvaginal sonography may improve their diagnostic accuracy and reduce unnecessary more invasive and expensive procedures.     

Ultrastructural effects of estrogen replacement on postmenopausal endometrium

Endometrial adenocarcinoma occurs almost exclusively in postmenopausal women, and excessive or unopposed estrogen stimulation is suspect as a causative factor in its pathogenesis. Furthermore, the incidence of endometrial adenocarcinoma has increased in women undergoing estrogen replacement therapy. In the present study, the cellular response of premenopausal and postmenopausal endometrium to estrogenic stimulation was compared with endometrial adenocarcinoma by the electron microscope. Tissues were obtained at hysterectomy, endometrial biopsy, or endometrial curettage and were processed routinely for light and electron microscopy. Ultrastructurally the endometrium from postmenopausal patients undergoing estrogen replacement therapy was similar to normal cyclic endometrium in the late proliferative phase. At least three features of the estrogen-treated postmenopausal tissue resembled those observed in adenocarcinoma of the endometrium: accumulation of lipid droplets, irregular nuclei, and perinuclear whorls of microfibrils.     

Significance of "normal" endometrial cells in cervical cytology from asymptomatic postmenopausal women receiving hormone replacement therapy

OBJECTIVE: The aim of this study is to assess the significance of normal endometrial cells identified in screening Pap smears from asymptomatic postmenopausal women taking hormone replacement therapy (HRT). METHODS: Endometrial histology reported from 93 asymptomatic postmenopausal women receiving HRT noted to have normal endometrial cells on a screening Pap smear was reviewed. Information regarding HRT, endometrial sampling, and interval between the sentinel Pap and sampling was extracted from the record. RESULTS: Endometrial biopsies were obtained an average of 1.7 months after the Pap smears. Eighteen of the ninety-three histology specimens (19%, 95% CI: 12--27%) identified abnormalities, in four cases precancerous or cancerous lesions. These 18 abnormalities included 7 endometrial polyps; 7 cases of simple hyperplasia, 1 with atypia; 3 cases of complex hyperplasia, 1 with atypia; and 1 endometrial adenocarcinoma. CONCLUSION: Normal endometrial cells identified on a screening Pap smear in this population may be an indication of endometrial disease.     

Detection of postmenopausal women at risk for endometrial carcinoma by a progesterone challenge test

Currently, there exists no convenient, inexpensive screening test for the detection of postmenopausal women at risk for developing adenocarcinoma of the endometrium. After the administration of a progesterone challenge test (PCT) to asymptomatic postmenopausal women, the presence or absence of withdrawal bleeding may aid in detecting premalignant lesions of the endometrium. Of 30 such women who had endometrial sampling followed by a PCT, 25 had no withdrawal bleeding and all had nonpathologic histology. Five patients exhibited withdrawal bleeding. Of these five, three had unsuspected adenomatous hyperplasia (p < 0.001). It is concluded that a PCT may be a reliable screening test for detecting those women at greater risk for developing endometrial hyperplasia or adenocarcinoma.     

Transvaginal ultrasonographic measurement of endometrial thickness in postmenopausal women receiving estrogen replacement therapy

OBJECTIVE: This study was undertaken to evaluate endometrial thickness by transvaginal ultrasonography in asymptomatic postmenopausal women receiving estrogen replacement therapy. The endometrial thickness in this study group was compared with endometrial thickness measurements in a group of women who had abnormal postmenopausal bleeding. The recent literature was reviewed.STUDY DESIGN: Asymptomatic postmenopausal women receiving estrogen replacement, seen for routine examination during the 1-year period from Jan. 1, 1994, to Dec. 31, 1995, had the endometrium evaluated by transvaginal ultrasonography. Women with abnormal postmenopausal bleeding were likewise evaluated and their measurements compared with those of the study group.RESULTS: Twenty-seven different estrogen and estrogen-progestin combinations in 327 asymptomatic women were studied. Additionally, 24 women who were bleeding, not receiving estrogen, and 46 women with abnormal bleeding on estrogen therapy underwent ultrasonography of the endometrium. Endometrial thickness ranged from 1 to 15 mm in women on a regimen of combined estrogen-progestin therapy, 1 to 14 mm in women using sequential estrogen-progestin, and 3 to 15 mm for women receiving unopposed estrogen in the study group. For women with abnormal bleeding not using estrogen, the endometrium measured an average of 12.3 mm (range 2 to 29 mm), with unopposed estrogen 8.3 mm (range 4 to 13 mm), and for estrogen with progestin 6.5 mm (range 2 to 15 mm). Significant pathologic features were found in those women who had bleeding and endometrial measurements between 5.0 and 29 mm.CONCLUSION: There was no significant difference between endometrial thickness measurements in women receiving various combinations of estrogen replacement. In general, expected endometrial measurements can range from 1 to 15 mm. In women with postmenopausal bleeding, however, significant pathologic features may exist with an endometrium measuring as little as 5 mm. (Am J Obstet Gynecol 1997;176:1334-9.)     

Implementation of assisted reproductive technologies following conservative management of FIGO grade I endometrial adenocarcinoma and/or complex hyperplasia with atypia

OBJECTIVE: The objective was to report a series of infertility therapy outcomes following conservative management of endometrial adenocarcinoma and/or complex hyperplasia with atypia. METHODS: A retrospective review of the University of Iowa assisted reproductive technology database was performed. All women presenting with International Federation of Obstetrics and Gynecology (FIGO) grade I uterine adenocarcinoma and/or complex hyperplasia with atypia were assessed for type and duration of medical management, initial, interim treatment, and preinfertility treatment endometrial biopsy (BX) findings. Assessment of infertility treatment outcomes and postinfertility endometrial biopsy findings were performed. All of the pathology samples were re-reviewed at the Gynecologic Oncology Tumor Board to confirm the diagnosis by a pathologist with a particular expertise in gynecologic pathology. RESULTS: Four infertile women, three nulligravid and one primigravid, were evaluated with the diagnosis of FIGO grade 1 endometrial adenocarcinoma and/or complex hyperplasia with atypia desiring to preserve fertility. Two women with FIGO grade 1 endometrial adenocarcinoma were successfully treated with high-dose progestational agents resulting in normal proliferative endometrium. In addition, both women with complex hyperplasia with atypia were successfully treated with progestins and/or ovulation induction. Successful pregnancy outcomes were achieved for three of the four women with assisted reproductive technology. A total of five successful pregnancies and eight healthy live-born infants were achieved among three women. One of the four women was unable to conceive despite three cycles of in vitro fertilization. Hysterectomy was performed for recurrent complex hyperplasia with atypia. In our series, we found it can take 3-10 months (mean, 6.25 months; median, 6 months) to obtain benign endometrium preceding infertility therapy. CONCLUSION: This report demonstrates that conservative management of well-differentiated endometrial adenocarcinoma and/or complex hyperplasia with atypia followed by aggressive assisted reproduction is an option to highly motivated and carefully selected women.     

Persistence of endometrial activity after radiation therapy for cervical carcinoma

Radiation therapy is a proved treatment for cervical carcinoma; however, it destroys ovarian function and has been thought to ablate the endometrium. Estrogen replacement therapy is often prescribed for patients with cervical carcinoma after radiation therapy. A review of records of six teaching hospitals revealed 16 patients who had endometrial sampling for uterine bleeding after standard radiation therapy for cervical carcinoma. Fifteen patients underwent dilatation and curettage, and one patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy when a dilatation and curettage was unsuccessful. Six patients had fibrosis and inflammation of the endometrial cavity, seven had proliferative endometrium, one had cystic hyperplasia, one had atypical adenomatous hyperplasia, and one had adenocarcinoma. Although the number of patients who have an active endometrium after radiation therapy for cervical carcinoma is not known, this report demonstrates that proliferative endometrium may persist, and these patients may develop endometrial hyperplasia or adenocarcinoma. Studies have indicated that patients with normal endometrial glands have an increased risk of developing endometrial adenocarcinoma if they are treated with unopposed estrogen. Patients who have had radiation therapy for cervical carcinoma should be treated with estrogen and a progestational agent to avoid endometrial stimulation from unopposed estrogen therapy.     

Endometrial hyperplasia: a review

Endometrial hyperplasia is a precursor to the most common gynecologic cancer diagnosed in women: endometrial cancer of endometrioid histology. It is most often diagnosed in postmenopausal women, but women at any age with unopposed estrogen from any source are at an increased risk for developing endometrial hyperplasia. Hyperplasia with cytologic atypia represents the greatest risk for progression to endometrial carcinoma and the presence of concomitant carcinoma in women with endometrial hyperplasia. Abnormal uterine bleeding is the most common presenting symptom of endometrial hyperplasia. Specific Pap smear findings and endometrial thickness per ultrasound could also suggest the diagnosis. Unopposed estrogen in women taking hormone replacement therapy increases the risk of endometrial hyperplasia. Tamoxifen has demonstrated its efficacy in treating women at risk for breast cancer, but it increases the risk of endometrial hyperplasia. The choice of treatment for endometrial hyperplasia is dependent on patient age, the presence of cytologic atypia, the desire for future childbearing, and surgical risk. Endometrial hyperplasia without atypia responds well to progestins. However, women with atypical hyperplasia should be treated with hysterectomy unless other factors preclude surgery. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to describe the definition and classification of endometrial hyperplasia, to outline the clinical features of a patient with endometrial hyperplasia, to point out the natural history of endometrial hyperplasia, and to summarize the diagnostic options for patients with endometrial hyperplasia.     

Histopathologic correlation of dilatation and currettage and hysterectomy specimens in patients with postmenopausal bleeding

PURPOSE OF INVESTIGATION: To evaluate the consistency of preoperative and postoperative histopathological findings in postmenopausal patients with abnormal bleeding. METHODS: Pathologic diagnoses of 42 postmenopausal women with abnormal bleeding or increased endometrial thickness who underwent both dilatation and curettage (D and C), and hysterectomy for proper indications were retrospectively examined. RESULTS: The most common diagnosis was irregular proliferative endometrium in both the pre- and postoperative groups with 16 patients each (38%). After subgroup analysis, 50% of the patients with a preoperative diagnosis of complex hyperplasia without atypia, had complex atypical hyperplasia, and two-thirds of the patients with a preoperative diagnosis of complex atypical hyperplasia had endometrial cancer as the final diagnoses. CONCLUSION: Preoperative D and C endometrial pathology findings positively correlated with postoperative hysterectomy pathology results. However, as the real pathology gets worse , D and C seems to under-diagnose the real pathology. In cases with complex hyperplasia with or without atypia , a second D and C or hysteroscopic evaluation may be recommended.     

Asymptomatic Thickened Endometrium in Postmenopausal Women: Malignancy Risk

Study ObjectiveTo assess the diagnostic findings and determine the frequency of malignancy in postmenopausal women evaluated by office hysteroscopy for a thickened endometrium without bleeding.DesignRetrospective cohort (Canadian Task Force classification II-B).SettingAcademic medical center in the Midwestern United States.PatientsOver 3600 women underwent an office hysteroscopy between January 1, 2007, and October 20, 2011, for abnormal uterine bleeding or an abnormal ultrasound. Of these, 154 postmenopausal women had a thickened endometrium (>4 mm) and no bleeding.InterventionsFlexible office hysteroscopy using a 3.1-mm scope with saline as the distending media was performed for clinical reasons, and results were captured within a research database.Measurements and Main ResultsFor the 154 women, the range of endometrial measurements was 4.2 to 28 mm (mean = 10.0 mm). Hysteroscopy diagnoses included 93 patients with polyps, 19 with myomas or uterine synechiae, and 34 with benign-appearing endometrium. Nine hysteroscopies were inadequate because of poor visualization (n = 1), cervical stenosis (n = 6), or patient discomfort (n = 2). Endometrial biopsies (EMBs) were performed in 109 patients, and none were found to have cancer or an atypical endometrium. Six had simple hyperplasia without atypia, and their endometrial measurements were within the range of the patients in our study who had a benign endometrium (5–15 mm, mean = 10.3). Of the women with a polyp, 73 (78.4%) subsequently underwent polypectomy. On final pathology, 1 had cancer (endometrial measurement = 24 mm), and 1 had complex hyperplasia with atypia (endometrial measurement = 17 mm). EMBs performed in the office for these 2 patients showed an insufficient endometrium and inactive endometrium, respectively.ConclusionCancer and atypia can occur in asymptomatic women. Endometrial thickness was 17 mm or greater in 2 cases, and EMBs performed in the office were inconsistent with the final diagnosis. Hysteroscopy is important when ultrasound and EMB do not agree. Polypectomy may be indicated even in asymptomatic women, but further studies regarding an endometrial measurement threshold or polyp size are warranted.     

Endometrial findings in asymptomatic postmenopausal women on exogenous estrogens—A preliminary report

Multiple retrospective studies have been done implicating estrogen replacement therapy as a factor in the increasing rise of endometrial cancer. This prospective study consisted of 94 asymptomatic postmenopausal females on exogenous estrogen. Duration of therapy ranged from 1 through 5 and greater than 5 years. All these patients were subjected to endometrial biopsies. We encountered a total of 71 negative biopsies (75.5%) and 23 positive biopsies (24.4%) ranging from cystic hyperplasia, through frank adenocarcinoma. All positive biopsies underwent formal diagnostic curettage. Histologic findings on the dilation and curettage specimens correlated with the original biopsy findings. All histologic slides were reviewed by an independent pathologist without knowledge of history or previous grading. Risk factors in the Positive biopsy group were present in only 17%. Therefore, it is not possible to predict the patient on estrogen who is at a higher risk for developing future hyperplasia, and in order to avoid missing early precursor lesions in endometrial carcinoma all patients must be biopsied. Significant cancer precursor lesions did not appear until after the patients had been on at least 3 years duration of unopposed estrogen replacement therapy. We conclude that postmenopausal patients on estrogen therapy at high risk can not be identified by risk factors alone, and as a minimum their endometrial status should be evaluated at least every 3 years.     

Endometrial morphology in asymptomatic postmenopausal women

Few data are available regarding endometrial histologic features in asymptomatic perimenopausal and postmenopausal women. This study encompasses endometrial biopsy specimens obtained from 801 such women before enrollment in a multicenter study of estrogen-progestin replacement. One endometrial cancer was found (0.13%); four additional biopsy specimens showed atypia (total 0.63%). The endometrium was atrophic in 373 (46.9%), proliferative in 133 (16.7%), secretory in 54 (6.8%), and hyperplastic in 41 (5.2%). Insufficient tissue for diagnosis was obtained in 195 (24.5%). We conclude that the yield for neoplasia is so low that screening endometrial biopsy is not justified in asymptomatic perimenopausal and postmenopausal women.     

Oncogenic potential of tamoxifen on endometria of postmenopausal women with breast cancer--preliminary report

Tamoxifen (TAM), a nonsteroidal antiestrogen, is used for pre- and postmenopausal patients with breast cancer. Recent reports suggest that TAM may cause endometrial neoplasia. This study is designed to evaluate the oncogenic potential of low-dose TAM on the endometrium. Initially, endometrial screening of patients with breast cancer who had received TAM therapy for at least 12 months was conducted. Seventy patients were interviewed and office endometrial biopsies were obtained from thirty-eight patients. Seven (18%) had hyperplastic changes, ranging from simple hyperplasia through complex hyperplasia with atypia. The following prospective study was conducted: after breast surgery and prior to initiation of TAM therapy, an office endometrial sampling was obtained as a control. After initiation of TAM therapy, biopsies were repeated every 4 to 6 months as long as the patients remained asymptomatic. Nineteen patients were interviewed. Twelve patients were biopsied and followed from 3 to 15 months. One patient refused additional biopsies. Eleven patients had repeat biopsies after initiation of TAM. New hyperplastic changes were found in 3/11 (27%) patients. The preliminary results of this study (although with a small number of patients) indicate that TAM may have some neoplastic effect on the endometrium of postmenopausal patients with breast cancer. This study is still in progress. Additional prospective studies are warranted before a significant correlation between TAM and endometrial neoplasia is confirmed.     

Transvaginal sonography of the endometrium in postmenopausal women

The purposes of this study were to compare transvaginal sonographic scanning of the uterus and endometrium with histology obtained by endometrial biopsy or curettage and to determine whether the sonographic technique might be useful in the evaluation of postmenopausal women. Eighty postmenopausal women were studied. Of these, 65 were asymptomatic (38 on no hormone therapy and 27 on hormone replacement). Fifteen women underwent evaluation because of postmenopausal bleeding. In both groups, endometrial thickness of 4 mm or less as depicted by sonography correlated well with endometrial characteristics of decreased estrogen stimulation. However, in women with measured endometrial thickness between 5-8 mm, proliferative endometrium could not be distinguished from hyperplastic endometrium or, in one case, low-grade carcinoma. Large polyps and invasive carcinoma with myometrial extension were easily recognized.