Hysteroscopic evaluation of menopausal women with endometrial thickness of 4 mm or more

STUDY OBJECTIVE: To assess the diagnostic and operative potential of hysteroscopy in postmenopausal patients selected by ultrasound criteria. DESIGN: Cohort study (Canadian Task Force classification II-2). SETTING: Outpatient ultrasound and hysteroscopy department of a university-affiliated hospital. PATIENTS: One hundred fifty-five postmenopausal women with endometrial thickness of 4 mm or more by ultrasound, in menopause for at least 1 year, with or without menopausal complaints. INTERVENTIONS: Transvaginal ultrasound and office hysteroscopy with eye-directed biopsy specimens using a 5-mm, continuous-flow, operative hysteroscope. MEASUREMENTS AND MAIN RESULTS: Of the 155 women, 129 (83%) were asymptomatic (irregular bleeding). Hysteroscopy showed endometrial pathology in 28% of asymptomatic patients (23 polyps, 5 cases of hyperplasia, 8 submucous myomata) and 76% of symptomatic women (13 polyps, 6 hyperplasia, 1 submucous myoma). Hysteroscopic results compared with histologic diagnosis showed a positive predictive value equal to 97. 1% and 95% in asymptomatic and symptomatic women, respectively, and a negative predictive value equal to 100% in both groups. CONCLUSION: Office hysteroscopy with endometrial biopsy samples has a diagnostic and operative role in postmenopausal patients selected based on endometrial thickness on ultrasound, in view of the high prevalence of endometrial pathology in both symptomatic and asymptomatic women.     

The significance of intrauterine lesions detected by ultrasound in asymptomatic postmenopausal patients

A retrospective study on 82 women with an incidental sonographic finding suspected to be intrauterine polyps was undertaken to assess the histopathologic characteristics of such polyps utilising operative hysteroscopy. Endometrial polyps were found in 68 patients, submucousal myomas in 7, atrophic endometrium in 6 and thickened proliferative endometrium was found in 1 patient. Simple hyperplasia was found in one polyp but neither endometrial carcinoma nor complex hyperplasia was found. The total complication rate was 3.6%. It appears that the risk of endometrial carcinoma in postmenopausal women with asymptomatic endometrial polyps is low, although a larger series is required to confirm this finding.     

Discrepancy between ultrasonography and hysteroscopy and histology of endometrium in postmenopausal breast cancer patients using tamoxifen

BACKGROUND: The increased risk of endometrial carcinoma following the use of tamoxifen has stimulated studies on endometrial diagnostic screening methods. In tamoxifen users the endometrial thickening observed with transvaginal ultrasonography (TVU) frequently cannot be confirmed by hysteroscopy or histology. OBJECTIVE: The aim was to investigate the relationship between TVU and hysteroscopic and histologic endometrial findings in postmenopausal patients using tamoxifen. METHODS: Fifty-three asymptomatic postmenopausal tamoxifen-using breast cancer patients underwent a gynecological examination combined with TVU. Patients with an endometrial thickness of >5 mm were offered hysteroscopy and endometrial biopsy. FINDINGS: Thirty-one patients (58%) had an endometrial thickness of >5 mm with enhanced, inhomogeneous echogenicity. Hysteroscopy was performed in 22 patients and 3 underwent hysterectomy. Seven of 22 patients had endometrial polyps, histologically characterized by cystically dilated glands lined with atrophic epithelium and periglandular stromal condensation. Histology of the three hysterectomy specimens showed a similar picture of atrophic luminal epithelium, covering dilated glands lined with atrophic epithelium and surrounded by dense stroma, which resembled the histology of the endometrial polyps. In all three specimens the histologically measured endometrial thickness corresponded with that on TVU. INTERPRETATION: Tamoxifen can induce specific endometrial changes consisting of cystically dilated glands with periglandular stromal condensation while the overlying epithelium remains atrophic. The changes occur either in the endometrium itself or as a protrusion of the endometrium, i.e., as endometrial polyps. These findings explain the discrepancy between ultrasound, hysteroscopy, and histology. Due to the high number of false-positive findings, TVU is not an effective screening instrument in these patients.     

Sonographic, hysteroscopic, and histologic evaluation of the endometrium in postmenopausal women with breast cancer receiving tamoxifen

STUDY OBJECTIVE: To evaluate the estrogenic effects of tamoxifen on the endometrium in postmenopausal women with breast cancer. DESIGN: Consecutive study (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: Thirty-three women. Interventions. All patients underwent transvaginal sonography (TVS) and color flow Doppler of endometrial vessels, hysteroscopy, and, if necessary, endometrial biopsy or other operative hysteroscopic procedures. MEASUREMENTS AND MAIN RESULTS: In four women the endometrium was thin on TVS and atrophic at hysteroscopic assessment. In 29 women with thick endometrium on TVS, hysteroscopy and endometrial biopsy showed atrophy (11 patients), hyperplasia (5), polyps (11), and well-differentiated adenocarcinoma (2). The two endometrial cancers were present in women with uterine bleeding. In women with positive histologic findings, the endometrium was significantly thicker (p = 0.04) and duration of tamoxifen therapy longer than in those with negative findings, although this was not statistically significant (p = 0.067). CONCLUSION: We believe regular assessment of the endometrium by TVS should be performed in postmenopausal patients at the start of the tamoxifen therapy, and hysteroscopy in women with a thick endometrium or postmenopausal bleeding. We believe that patients with thin endometrium on TVS at the beginning of tamoxifen therapy, who have no abnormal uterine bleeding should be screened with these examinations for 2 years.     

Detection of feeding artery improves the ultrasound diagnosis of endometrial polyps in asymptomatic patients

OBJECTIVE: To investigate whether transvaginal power Doppler imaging of the vascularity improves the ultrasound detection rate of endometrial polyps in symptomatic and asymptomatic patients. STUDY DESIGN: Forty-one patients with endometrial polyps confirmed by operative hysteroscopy and histologic examination. They were all examined with grey-scale and subsequent power Doppler enhanced ultrasound preoperatively according to the same protocol. Double layer endometrium and detailed endometrial morphology were described at grey scale scan. With power Doppler imaging pattern of endometrial vascularity. In the presence of a single feeding artery the ultrasound diagnosis of an endometrial polyp was made. RESULTS: With grey-scale imaging 20 polyps (49%) were recognized, while the subsequent application of power Doppler diagnosed the remaining 21 polyps increasing the overall detection rate to 10% (P < 0.01). The grey-scale detection rate for the polyp was 11/30 (0.37) in the asymptomatic patients and 9/11 (82%) in the symptomatic patients. No difference in endometrial thickness was observed. With power Doppler imaging, the detection rate for the feeding arteries was 97% (29/30) in the asymptomatic polyps and a similar 91% (10/11) in the symptomatic polyps. In the 21 polyps, where imaging of the vascularity was the only diagnostic marker, all but two were asymptomatic. CONCLUSION: Power Doppler enhanced ultrasound detection of the feeding vessels can be a simple, non-invasive and highly effective first line test for the diagnosis of endometrial polyps in asymptomatic patients.     

Diagnosis of malignant mesenchymal uterine tumors by hysteroscopic excisional biopsy

STUDY OBJECTIVE: To emphasize the need for histologic evaluation of intrauterine lesions. Six cases of unexpected mesenchymal uterine tumors were diagnosed following pathologic review of specimens obtained during hysteroscopy to evaluate intrauterine lesions. DESIGN: Retrospective chart review (Canadian Task Force classification II-3). SETTING: Large tertiary care medical center. PATIENTS: Four postmenopausal and two perimenopausal women with uterine mesenchymal tumors. INTERVENTION: Hysteroscopy and staging laparotomy. MEASUREMENTS AND MAIN RESULTS: Mean age of the patients was 57.5 +/- 19.5 years (mean +/- 2SD). Four women (67%) were postmenopausal. Three patients had abnormal uterine bleeding, one had a cervical mass, and the other two were asymptomatic and referred for evaluation of thick endometrium detected by routine ultrasound, which had been preformed as part of their annual check-up. In all cases, the initial hysteroscopic diagnosis was endometrial polyp or submucous myoma. Following the pathologic review, all six women underwent complete staging laparotomy. In two women, there was no residual disease in the surgical specimen. None of the patients had extrauterine spread of the disease. At mean follow-up of 21.5 +/- 9.7 months (mean +/- 2SD), all women were asymptomatic. CONCLUSIONS: Intrauterine lesions erroneously considered to be benign endometrial polyps or myomas can turn out to be malignant mesenchymal uterine tumors. Hysteroscopic evaluation and biopsy might offer early diagnosis and treatment to these patients.     

Ultrasound assessment of endometrial thickness and endometrial polyps in women on hormonal replacement therapy

OBJECTIVE: This study was performed to evaluate the thickness and the sonographic features of the endometrium in postmenopausal women on hormone replacement therapy (HRT). STUDY DESIGN: This prospective study was based on 483 vaginal ultrasound examinations performed in 238 consecutive postmenopausal women on HRT. RESULTS: Endometrial polyps were diagnosed by ultrasound in 16.3% of the patients; 43.6% were asymptomatic. In the nonpolyp group, a significant difference in endometrial thickness between sequential and continuous schemes was found. In sequential HRT, a three-layer ultrasound pattern of the endometrium was seen in 47% of the women in the estrogen-alone phase of cycle versus 11% in the estrogen-progestogen phase. CONCLUSION: Patients on HRT need other reference values for endometrial thickness compared with postmenopausal women without HRT. In women on sequential HRT, a transvaginal sonographic evaluation performed in the estrogen-alone phase of cycle may optimize the accuracy for focal lesion detection. The significance of the incidental finding of polyps in an important number of asymptomatic women on HRT remains unsettled.     

Comparison of transvaginal sonography, saline infusion sonography and hysteroscopy in the evaluation of uterine cavity pathologies

AIMS: To determine whether performing transvaginal sonography (TVS) and saline infusion sonography (SIS) before hysteroscopy could reduce the number of diagnostic hysteroscopies performed for the evaluation of uterine cavity abnormalities. METHODS: Two hundred and twenty three women with suspected uterine cavity abnormalities were prospectively evaluated by TVS, SIS and hysteroscopy, and had histological evaluation of the endometrium with hysteroscopic biopsy or dilatation and curettage (D&C). One hundred and sixty five patients (74%) were premenopausal and 58 patients (26%) were postmenopausal. RESULTS: The positive predictive value (PPV) for endometrial polyps was 69% for TVS, 78% for SIS and 81% for hysteroscopy in premenopausal patients. In the postmenopausal group, TVS and SIS could detect only 24% of endometrial polyps, whereas 70% were diagnosed by hysteroscopy. The PPV for submucous fibroids was 47% for TVS, 81% for SIS and 77% for hysteroscopy in the premenopausal group. CONCLUSIONS: In premenopausal patients, SIS and hysteroscopy are equally accurate in the diagnosis of endometrial polyps and submucous fibroids. Hysteroscopy is the most accurate test for polypoid lesions in the postmenopausal group. Performing TVS, SIS and D&C could reduce the number of diagnostic hysteroscopies performed for the evaluation of uterine cavity abnormalities by 71.5% in premenopausal patients. However, this rate decreases to 40% in the postmenopausal group.     

Dilatation and curettage fails to detect most focal lesions in the uterine cavity in women with postmenopausal bleeding

OBJECTIVE: To determine the prevalence of focally growing lesions in the uterine cavity in women with postmenopausal bleeding and endometrium > or = 5 mm and the extent to which such lesions can be correctly diagnosed by D&C. METHODS: In a prospective study, 105 women with postmenopausal bleeding and endometrium > or = 5 mm at transvaginal ultrasound examination underwent diagnostic hysteroscopy, D&C and hysteroscopic resection of any focally growing lesion still left in the uterine cavity after D&C. Twenty-four women also underwent hysterectomy. If the histological diagnosis differed between specimens from the same patient, the most relevant diagnosis was considered the final one. RESULTS: Eighty percent (84/105) of the women had pathology in the uterine cavity, and 98% (82/84) of the pathological lesions manifested a focal growth pattern at hysteroscopy. In 87% of the women with focal lesions in the uterine cavity, the whole or parts of the lesion remained in situ after D&C. D&C missed 58% (25/43) of polyps, 50% (5/10) of hyperplasias, 60% (3/5) of complex atypical hyperplasias, and 11% (2/19) of endometrial cancers. The agreement between the D&C diagnosis and the final diagnosis was excellent (94%) in women without focally growing lesions at hysteroscopy. CONCLUSION: If there are focal lesions in the uterine cavity, hysteroscopy with endometrial resection is superior to D&C for obtaining a representative endometrial sample in women with postmenopausal bleeding and endometrium > or = 5 mm.     

The role of outpatient diagnostic hysteroscopy in identifying anatomic pathology and histopathology in the endometrial cavity

STUDY OBJECTIVE: To evaluate the role of outpatient diagnostic hysteroscopy. DESIGN: Retrospective review (Canadian Task Force classification II-2). SETTING: University teaching hospital-based outpatient clinic. PATIENTS: One thousand six hundred women, 67.3% premenopausal and 32.7% postmenopausal. INTERVENTION: Diagnostic hysteroscopy without premedication or anesthesia; endometrial sampling or hysteroscopy-guided biopsy was performed when appropriate. MEASUREMENTS AND MAIN RESULTS: Outpatient hysteroscopy was successfully performed in 1468 women (91.8%). Eleven women (0. 7%) developed vasovagal response during the procedure, 18 required hospital admission because of pain or hemorrhage, and 2 were suspected of having uterine perforation. All recovered spontaneously without intervention. Intrauterine anatomic pathology was diagnosed in 17.0%; the overall frequency of myomas and endometrial polyps was 12.3% and 7.1%, respectively. The sensitivity and positive predictive value of hysteroscopy without biopsy in diagnosing endometrial carcinoma were only 58.8% and 20.8%, respectively. Of 1112 women with hysteroscopic impression of normal or atrophic endometrium, 10 (0.9%) had endometrial hyperplasia on biopsy. CONCLUSION: Hysteroscopy without biopsy carries low sensitivity and positive predictive value in the diagnosis of endometrial carcinoma and hyperplasia. In our opinion the predictive value of a negative hysteroscopy is inadequate, and endometrial biopsy should be performed during hysteroscopy for accurate diagnosis of endometrial histopathology.     

Postmenopausal bleeding: a diagnostic approach for both private and public sectors

OBJECTIVE: To assess the optimal diagnostic approach to women with postmenopausal bleeding by comparing transvaginal ultrasound and endometrial sampling with office hysteroscopy. METHODS: A prospective collective study was performed on 102 consecutive patients with postmenopausal bleeding who were evaluated by ultrasound measurement of the endometrial thickness (EL), endometrial sampling by Accurette and outpatient hysteroscopy and directed biopsy. RESULTS: Accurette was inadequate for histological diagnosis in 65 of 136 samples and many repeat investigations were required. In all 16 cases of endometrial polyps, ultrasound measurement of the EL was > or =4 mm and hysteroscopy confirmed the findings. Accurette detected only 5 polyps. All 7 cases of endometrial hyperplasia were detected using an EL of > or =4 mm and hysteroscopy confirmed the findings. Accurette failed to detect 5 out of 7 cases of endometrial hyperplasia. Five cases of endometrial cancer were diagnosed: all had an EL > or =4 mm but were inadequately sampled for diagnostic purposes in 3 cases. A definitive diagnosis was made on hysteroscopy in 4 cases (1 patient did not have a hysteroscopy). CONCLUSION: Accurette is not a good sampling device for the diagnosis of postmenopausal bleeding. An ultrasound measurement of the EL > or =4 mm in patients with postmenopausal bleeding warrants further investigation. Outpatient office hysteroscopy is an accurate and sensitive modality to employ as a first line investigation for definitive diagnosis.     

Saline sonohysterography for monitoring asymptomatic postmenopausal breast cancer patients taking tamoxifen.

OBJECTIVES: To evaluate the effectiveness of sonohysterography for monitoring asymptomatic postmenopausal breast cancer patients on long-term tamoxifen therapy. METHODS: Thirty-eight asymptomatic postmenopausal patients receiving tamoxifen for breast cancer were enrolled into the study. The endometrium of study subjects was measured by transvaginal ultrasound. If a distinct echo measured < or = 5 mm, no further procedure was performed. For thickened or inadequately visualized endometrium by transvaginal ultrasound (TVS), sonohysterography was performed. Endometrial biopsies were performed for patients with generalized symmetrical changes on sonohysterography. In cases with focal changes, or inadequate SHG, hysteroscopy/dilatation and curettage (D&C) were performed. RESULTS: Transvaginal ultrasound examination showed 12 (31.6%) patients with thin endometrium < or = 5 mm, 18 (47.4%) cases with thickened endometrium while eight (21%) cases were not adequately visualized by TVS. Sonohysterography was satisfactorily performed in 22 of 26 (84.6%) cases. Of these, three cases showed thin endometrium, 10 patients had endometrial polyps (45.5%) and nine patients showed abnormal endometrial-myometrial junction. Histology revealed hyperplasia in three cases and well differentiated adenocarcinoma associated with one polyp. Endometrial curettage for cases with abnormal endometrial-myometrial junction showed endometrial hyperplasia in two cases. Hysteroscopy and D&C were performed for four (15.4%) patients where SHG was unsuccessful, histopathology revealed inactive endometrium in three cases and one was hyperplastic. CONCLUSIONS: Sonohysterography is superior to unenhanced transvaginal sonography in specifying the abnormal ultrasonographic appearance induced by prolonged tamoxifen therapy, it is easily performed, cost-effective and very well tolerated by the patients with no complications. Sonohysterography is recommended as a minimally invasive diagnostic tool for the assessment of endometrial changes in asymptomatic postmenopausal breast cancer patients on long-term tamoxifen therapy with thickened endometrium or inadequately visualized endometrial echo on transvaginal sonography.     

Endometrial survey during phytoestrogens therapy in postmenopausal women

AIM: The aim of this study was to verify the effects on endometrium of short-term phytoestrogens therapy in postmenopausal women. METHODS: This randomized study compared two groups of 50 patients undergone respectively to phytoestrogens therapy or placebo. An endometrial survey was performed on the study groups by ultrasound and hysteroscopy at baseline and at 6 and 12 months. RESULTS: The ultrasonographic findings and the hysteroscopic biopsies in the 47 women submitted to phytoestrogens therapy that completed the follow-up showed an atrophic and/or inactive endometrial mucosa less than in one patients (2.1%) with endometrial thickness and proliferative endometrium bioptical sample after 12 months of treatment; no cases of endometrial hyperplasia were found. CONCLUSION: In the authors' 12 month experience, phytoestrogens therapy in postmenopausal women was safe for endometrial stimulation because did not cause any significant alteration of the mucosa in a short-term administration.     

Diagnostic value of hysteroscopy and hysterosonography in endometrial abnormalities in asymptomatic postmenopausal women

Objective  To estimate the diagnostic value of hysteroscopy and hysterosonography in endometrial pathologies in asymptomatic postmenopausal women. Materials and methods  In this prospective study, 77 asymptomatic postmenopausal women that had a suspicion of endometrial abnormalities based upon transvaginal ultrasonography were studied. The patients underwent transvaginal ultrasonography and hysterosonography. All patients then had office diagnostic hysteroscopy or operative hysteroscopy. The final diagnosis was made by operative hysteroscopy with resection and excision of the lesions or endometrial biopsy with vacuum curettage. Sensitivity, specificity, positive predictive value and negative predictive value of transvaginal ultrasonography, hysterosonography and diagnostic hysteroscopy were calculated. Results  The patients’ age ranged from 45 to 80. The most common frequent abnormalities were endometrial hyperplasia in transvaginal ultrasonography (62.33%), endometrial polyp in sonohisterography (57.14%), and also endometrial polyp in diagnostic hysteroscopy (51.94%). Transvaginal ultrasonography revealed a sensitivity of 59.7% and a specificity of 35.5%. Sonohysterography revealed a sensitivity of 88.8% and a specificity of 84.4%. Diagnostic hysteroscopy revealed a sensitivity of 91% and a specificity of 82%. Conclusion  Hysterosonography showed very good agreement with hysteroscopy for the diagnosis of endometrial abnormalities in asymptomatic postmenopausal women. In asymptomatic postmenopausal women that had a suspicion of endometrial abnormalities based upon transvaginal ultrasonography should undergo both hysterosonography and hysteroscopy.     

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.     

Transvaginal ultrasound and diagnostic hysteroscopy as a predictor of endometrial polyps: risk factors for premalignancy and malignancy

The aim of this study is to assess accuracy of transvaginal ultrasound (TVUS) and diagnostic hysteroscopy in diagnosing endometrial polyps and to determine premalignancy and malignancy rates in asymptomatic women. The study was designed to retrospectively analyze 438 women who underwent operative hysteroscopy in a day-care unit when endometrial polyp was suspected after TVUS and diagnostic hysteroscopy. Multivariate logistic regression modeling showed effects of age, previous breast cancer with tamoxifen treatment, and menopause with or without bleeding on pathologic results. The results indicate that positive predictive value of TVUS with diagnostic hysteroscopy was 79.9%. Premalignancy or malignancy occurred in 3.2% and was significantly related to menopause with abnormal bleeding (P < 0.001), which carried a 20-fold higher risk of pathology than any other group. Age was also a risk factor. It was concluded that TVUS with diagnostic hysteroscopy reliably evaluates endometrial polyps. The low incidence of endometrial tumors in asymptomatic (especially premenopausal) women suggests that their operative evaluation may not be cost effective. Larger studies are needed to support this tentative conclusion.     

Value of Sonohysterography in Asymptomatic Postmenopausal Tamoxifen-Treated Patients

A prospective study was performed to assess the efficacy of sonohysterography (SHG) in identifying endometrial pathologies among asymptomatic, postmenopausal breast cancer patients treated with tamoxifen. In this study the uterine cavity of 68 such patients with endometrial thickness of ≥8 mm was prospectively evaluated by SHG. Forty-six (67.6%) patients in whom SHG did not identify any findings in the uterine cavity (negative group) were followed by diagnostic hysteroscopy. Another 22 (32.4%) who were identified by SHG to have abnormal endometrial findings, such as an echogenic or polypoid mass (positive group), were followed by operative hysteroscopy and by postoperative SHG. In the positive group the basal transvaginal sonogram revealed an endometrial echogenic mass in only 10 (45.5%). In the remaining 12 (54.5%) patients, the transvaginal sonogram identified only thick endometrium. In these latter 12 patients, histological assessment confirmed endometrial polyps in 8 (66.7%) and fibroid in 1 (8.3%). Four (18.2%) patients in the positive group had no histological endometrial pathology. Two (50%) of them had a uterine septum as diagnosed during hysteroscopy, in one (25%) operative hysteroscopy failed to resect the endometrial polyp, and in another (25%) there was a false-positive SHG diagnosis. Overall, SHG accurately diagnosed endometrial and/or other intrauterine pathology in 95.5% of these patients. In the 46 patients with “negative” basal SHG features, diagnostic hysteroscopy confirmed this diagnosis. Thus, there was no SHG false-negative diagnosis. Comparing the results of the basal SHG with those of operative hysteroscopy and/or the histopathological findings in the positive group, the sensitivity of SHG was 1.0, the specificity 0.0, positive predictive value 95.5%, and negative predictive value 0.0. It is suggested that SHG is a useful diagnostic tool for the assessment of specific endometrial pathologies in asymptomatic postmenopausal breast cancer patients treated with tamoxifen who were diagnosed by transvaginal sonography to have thick endometrium.