Tamoxifen and endometrial pathologies: a prospective study.

OBJECTIVE:The purpose of this study was to prospectively follow a group of women with breast cancer, on tamoxifen, for the development of endometrial pathologies. MATERIALS AND METHODS: Eighty women with breast cancer, on tamoxifen, were prospectively followed every 6 months with pelvic examination, Pap smear, vaginal ultrasound, and endometrial biopsy. RESULTS: Nine women were lost to follow-up prior to initiation of treatment and 4 refused biopsies, leaving 67 patients for evaluation. Fifty (74.6%) of the 67 patients were already on tamoxifen for a mean duration of 15.8 +/- 16.6 months and had a baseline benign, unremarkable endometrium at the time of entry into the study. The total duration of treatment was 32.5 +/- 19.6 months (median 30 months). The mean age of the patients was 51.7 +/- 9.9 years (median 52 years). Of the patients, 56.7% were postmenopausal. Sixty-three patients had a benign endometrium (mean age 51.8 +/- 10.1 years, mean duration 33.1 +/- 19.6 months). Two patients had simple hyperplasia (mean age 43.5 years, duration 28.5 +/- 33.2 months), 1 patient had complex hyperplasia with atypia (age 57 years, duration 13 months), and another patient developed adenocarcinoma (grade 3) after 22 months. These 4 patients had abnormal vaginal bleeding. Seven patients developed endometrial polyps (mean age 54.0 +/- 8.5 years, duration 36 +/- 24.2 months). The mean endometrial thickness for patients with histologically unremarkable and abnormal endometrium was not significantly different (7.6 +/- 3.9 vs 8.8 +/- 5.0 mm, respectively) (median 7.0 mm for both groups). No endometrial thickness cutoff point reached statistical significance. The patient who developed endometrial cancer had a thickness of only 3 mm. CONCLUSION: All patients who developed an abnormal endometrium had abnormal vaginal bleeding. There was no correlation between endometrial thickness and endometrial pathology; thus the value of routine screening remains controversial.     

Tamoxifen-induced endometrial changes in postmenopausal women with breast carcinoma.

OBJECTIVES: To assess the effects of tamoxifen (TAM) on the endometrium in postmenopausal women. METHODS: A case control study of postmenopausal women with breast carcinoma, who were undergoing treatment in the Department of Radiotherapy and Surgery at the Christian Medical College Hospital, Vellore, India was done. Thirty-five women who were on tamoxifen (20 mg/day) for a period of at least 6 months formed the study group. Thirty-three women who were not receiving tamoxifen, formed the control group. Subjects in both groups had a pelvic examination and transvaginal sonogram followed by endometrial biopsy. RESULTS: There was a statistically significant difference in the mean endometrial thickness between the study group and control group (7.8+/-6.4 mm vs. 4.0+/-2.0 mm, respectively) More women in the tamoxifen group had an endometrial thickness of >5 mm but the number of women with polyps or hyperplasia of the endometrium did not differ significantly between the two groups. There were no women with endometrial carcinoma in either group. CONCLUSION: All patients on tamoxifen need to be evaluated by clinical examination annually. A transvaginal sonogram and endometrial biopsy/hysteroscopy may be performed on patients with abnormal vaginal bleeding, bloody discharge, staining or spotting.     

Ultrasonography of the endometrium and endometrial pathology under tamoxifen treatment

PURPOSE: The estrogenic effects of tamoxifen on the endometrium and the vaginal epithelium are evaluated. METHOD: 211 postmenopausal women were examined (tamoxifen group: 176 estrogen-receptor positive breast cancer patients; control group I: 35 estrogen-receptor negative breast cancer patients; control group II: 50 women without breast cancer taking no hormones). We determined the endometrial thickness and the maturation index (MI). Person's chi-square-test and the t-test for independent samples were used. RESULTS: In the tamoxifen group, the mean endometrial thickness and the MI were significantly higher (p<0.0001) than in the control groups. No evidence of correlation in duration of tamoxifen intake and endometrial thickness was found (Pearson's correlation coefficient: 0.4773; p=0.0001). The maturation index significantly (p<0.0001) increased under tamoxifen therapy. There was no correlation in the maturation index and endometrial thickness (Pearson's correlation coefficient: 0.1649; p=0.169). The histological clarification (N=47; endometrial thickness greater than 8 mm) revealed 3 neoplasms, 9 endometrial polyps, 2 glandular-cystic hyperplasias and in 32 cases atrophic endometrium. CONCLUSION: An apparent increase of endometrial thickness and the maturation of the vaginal epithelium caused by the estrogenic effect of tamoxifen was demonstrated.     

Endometrial ablation versus hysterectomy in women treated with tamoxifen

AIM: The aim of our study is the assessment of the importance of the endometrial ablation versus hysterectomy in patients treated with tamoxifen for previous breast cancer. METHODS: Fifty-eight outpatients in therapy with tamoxifen for 1 year were controlled in the Department of Gynaecology of the University of Naples. We have selected these patients in two groups: group A, with 28 women with abnormal uterine bleeding and endometrial thickness >8 mm and group B, with 30 normal endometrium asymptomatic women. All patient of group A and 18 of group B were treated with endometrial ablation. RESULTS: Next follow-up showed normal hysteroscopy figures in 89% of cases and 5% of cases needed a hysterectomy for new abnormal uterine bleeding and cytology. CONCLUSION: Our results show the utility of endometrial ablation especially in selected cases in therapy with tamoxifen for previous breast cancer.     

Endometrial pathology of 104 postmenopausal breast cancer patients treated with tamoxifen

OBJECTIVE: To investigate the effects of tamoxifen on the endometrium in postmenopausal breast cancer patients. METHODS: Endometrial thickness was measured by transvaginal sonography and endometrial biopsies were done in 104 postmenopausal breast cancer cases who were treated with tamoxifen. Histopathologic findings were discussed. RESULTS: Mean endometrial thickness was 11.7+/-5.9 mm and duration of tamoxifen administration was 35.3 months. Four endometrial cancers, 17 endometrial hyperplasias, 25 proliferative endometrium, 5 endometrial polyps in the endometrial biopsies. We observed atrophic endometrium in 53 of the cases. Only one case with endometrial polyps was observed as a premalignant lesion when the endometrium was less than 5 mm, 51% of the cases had thicker endometrium (more than 10 mm) and 32% of these cases had malignant and premalignant endometrium. We found a significant correlation with the duration of tamoxifen and age (p<0.05). One hundred and two of our cases were asymptomatic; only 2 out of 4 endometrial cancer cases had vaginal spotting. A significant relation was noticed between endometrial thickness and duration of tamoxifen treatment (p=0.025). CONCLUSION: It was concluded that positive endometrial findings and endometrial thickness were due to continuous unopposed tamoxifen treatment and our findings support the hypothesis that tamoxifen increases the risk of endometrial carcinoma and premalignant changes.     

Endometrial thickness in tamoxifen-treated patients: an independent predictor of endometrial disease.

OBJECTIVE: To assess the independent contribution of transvaginal ultrasound in identifying women at risk for endometrial disorders, and determine whether a cutoff value identifies women who need endometrial histologic assessment. METHODS: Postmenopausal women with breast cancer who were receiving tamoxifen, with ultrasonographic endometrial thickness greater than 4 mm or vaginal bleeding, had hysteroscopy with selective endometrial biopsies. Endometrial thickness, duration of tamoxifen therapy, and endometrial histology were studied. Parametric and nonparametric tests and logistic regression and receiver operating characteristic curves were used for statistical analysis. RESULTS: The study population consisted of 163 women, 46 with vaginal bleeding. The proportion of women with abnormal histologic findings was greater among those with endometrial thicknesses exceeding 9 mm compared with those with endometrial thicknesses 9 mm or less (60% versus 6.1%, P < .001) and among women who received tamoxifen for more than 27 months than those who received it for less time (46% versus 16%, P < .005). Logistic regression showed that endometrial thickness greater than 9 mm and vaginal bleeding were independent predictors of abnormal findings at hysteroscopy. CONCLUSION: In women taking tamoxifen, sonographic endometrial thickness exceeding 9 mm and the presence of vaginal bleeding are independent predictors of endometrial disease. If either exists, hysteroscopy and biopsy should be done.     

Rating of transvaginal sonography in the evaluation of postmenopausal bleeding

OBJECTIVE: The purpose of this study was to evaluate transvaginal ultrasonography (TVS) in differential diagnosis of vaginal bleedings in postmenopausal patients. MATERIAL AND METHODS: Between January 1990 and December 1996, 1198 postmenopausal patients with vaginal bleedings were sent to our clinic for a histological evaluation. Eight hundred and seventy-nine patients (73.4%) were preoperatively scanned by transvaginal probe, and endometrial thickness (< 5, 5-7, 8-10, > 10 mm) was measured. RESULTS: Atrophy was found in 46.3%, endometrial polyps in 19.8%, endometrial cancer in 17.5%, and hyperplasia in 6.7%. An endometrial thickness of lower than 5 mm (p < 0.0001) was shown in TVS patients with atrophy in 71%, with endometrial polyps in 10.9%, with endometrial cancer in 3.9% and hyperplasia in 6.8%. In 55.2% of these eases with endometrial cancer the preoperatively estimated thickness was 10 mm or more. The additionally morphologic examination in cases with an endometrium smaller than 5 mm was false positive in 75% (9/12). Thus an endometrial thickness of > 5 mm had a sensitivity of 92.5%, specificity of 71.0%, positive and negative predictive value of 75.6, respectively 90.9% for the detection of endometrial pathology. CONCLUSIONS: TVS allows the detection of an endometrial pathology in the vast majority of patients with postmenopausal bleedings. In cases with a single postmenopausal bleeding and an endometrium smaller than 5 mm we recommend expectative procedures with repeated ultrasound examination of the endometrium.     

Ultrasonographic measurement of endometrial changes following discontinuation of tamoxifen treatment in postmenopausal breast cancer patients

Objective To assess whether there is a decrease in endometrial thickness following discontinuation of tamoxifen treatment as measured by ultrasound.
Design Prospective study.
Setting Department of Obstetrics and Gynaecology, Sapir Medical Centre, Kfar-Saba, Israel.
Population Fifty-eight postmenopausal women with breast cancer who were treated with tamoxifen.
Methods Transvaginal ultrasonographic measurements of endometrial thickness.
Main outcome measures Evaluation of the changes of endometrial thickness and the frequency the endometrium reached a thickness of ≤ 5 mm at different time intervals after stopping tamoxifen treatment.
Results There was a significant decrease in median thickness of the endometrium, within six months after stopping tamoxifen, from 7.75 mm measured at the last ultrasonographic study performed before tamoxifen discontinuation down to 5.2 mm (   P = 0.002  ). There were no further reductions in endometrial thickness, and it remained constantly low in subsequent ultrasonographic studies which were performed at various times up to 30 months following the discontinuation of tamoxifen treatment. While taking tamoxifen, only 25.9% of the women had an endometrial thickness of ≤ 5 mm. This proportion doubled in their first six months after stopping.
Conclusions Median thickness of endometrial thickness significantly reduced within six months following tamoxifen discontinuation, and remained constantly low thereafter. This finding may support use of ultrasonographic imaging for the measurement of tamoxifen's effect on the endometrium of postmenopausal breast cancer patients.     

三苯氧胺对子宫内膜的影响

目的：观察乳腺癌患者服用三苯氧胺（TAM）后对子宫内膜的影响。方法：26例乳腺癌患者服用TAM（TAM组）后出现阴道异常出血或B超检查发现子宫内膜增厚而行宫腔镜检查及子宫内膜病理检查。另外以同时期无TAM服药史的非乳腺癌患者因绝经后阴道出血而行宫腔镜检查的78例作为对照组。结果：TAM组发生子宫内膜息肉和宫颈息肉共13例（50.0%）,而对照组为14例（17.9%),两组比较,差异有显著性（P＜0.05)。TAM组发生子宫内膜增生9例（34.6%),明显高于对照组的12例（15.4%,P＜0.05)。结论：乳腺癌患者长期服用TAM后子宫内膜病变增多,故对这些患者应进行B超监测子宫腔镜检查。     

Evaluation of the endometrium in postmenopausal women by means of vaginal ultrasound]

In the context of a prospective study, the authors carried out vaginal ultrasound examinations at the Gynecology-Obstetrics Clinic of G?ttingen University of two groups of post-menopausal women: 233 women with hemorrhage and 539 who were asymptomatic. A diagnostic curettage was carried out in cases where the endometrium had a depth of at least 4 mm. The authors identified a 6% incidence of cases of adenomatous hyperplasia, 21% of endometrial cancer in women with hemorrhages and a 20% cancer rate in the asymptomatic women. Where the thickness of the endometrium was less than 4 mm, there were no cases of cancer. The infiltration depth examined microscopically was twice as great in the patients with hemorrhages (10 mm vs 4 mm).     

Expression and clinical significance of pepsinogen C in epithelial ovarian carcinomas

OBJECTIVES: To describe the endometrial appearance in postmenopausal breast cancer patients on tamoxifen and to assess a routine surveillance scheme for endometrial lesions. STUDY DESIGN: Three hundred and seventeen postmenopausal breast cancer women already on tamoxifen at the start of the study (group I) and 89 breast cancer women assessed before any tamoxifen intake (group II) underwent an initial and then yearly scans with transvaginal ultrasonography, followed by an hysteroscopy and biopsy for women with an endometrium thickened above 8mm. Endometrial thickness was also measured in 823 women with no breast cancer nor tamoxifen intake (group III). RESULTS: Initial mean endometrial thickness was 8.2mm in group I, 4.4mm in group II and 3.4mm in group III (P<0.001). Eighteen percent endometrial lesions were found in group I and 3.3% in group II. We observed a significant association between endometrial pathology and both cumulated dose and total duration. Polyps were the most frequent and first to appear pathology. Five cancers were detected in group I, and all of them had taken tamoxifen for more than 3 years. CONCLUSION: Our surveillance scheme could be lightened; an acceptable screening scheme might include a baseline assessment before the start of tamoxifen and, if normal, yearly screening after 3 years of tamoxifen therapy, yearly surveillance for women with an abnormal baseline assessment and immediate investigation for symptomatic women.     

Non-assessable endometrium in women with post-menopausal bleeding: to investigate or ignore

Background

In women presenting with post-menopausal bleeding (PMB), the incidence of endometrial cancer is 1–10 %; Trans-vaginal scan (TVS) is offered as the first line of investigation to triage women further and a thick endometrium (>4 mm) merits endometrial tissue sampling for further evaluation. When it is difficult and not possible to assess the endometrium sonographically, decision to investigate further lies with the clinician.

Aim

Study outcomes for women with PMB and endometrium not assessable on TVS.

Methods

We collected data retrospectively between September 2007 and December 2010. We identified our study group from the radiology database. Data collected include ultrasound findings, methods of endometrial sampling, and the result of cytology/histology.

Results

In our study period of 40 months, 671 women with post-menopausal bleeding were referred to the ultrasound department for TVS to assess endometrial thickness. 92 % (614/671) women had the assessment. In 57 women (8 %), endometrial thickness was not assessable and this formed our study group. 3/57 records were not retrievable and excluded from our study. 43/54 (79 %) had some form of endometrial sampling done. Among the 81 % adequate samples (35/43), 7 (20 %) had endometrial cancer; 1 (3 %) had CAH, 1 (3 %) was diagnosed with cervical cancer. In women who had thickened endometrium (>4 mm; n = 448), there were 29 cases of endometrial cancers detected giving an incidence of 6.4 %. In women with PMB and non-assessable endometrial thickness, there is increased incidence of endometrial cancer when compared to the group where endometrial thickness could be measured. (Odds ratio = 3.3 [95 % CI = 1.2–9]). This is a statistically (p = 0.017) and clinically significant finding.

Conclusion

In women with PMB, there will be a subgroup in which ultrasound cannot assess endometrial thickness. When compared to women where endometrial thickness is measurable, this group stands a higher risk of endometrial cancer and hysteroscopy/ hysterosonography with endometrial sampling is recommended in this group.     

Assessment of the reliability of different methods in diagnosing endometrial cancer

OBJECTIVES: Endometrial cancer is the most common gynecologic malignancy. The purpose of the study was to compare the reliability of different methods for diagnosing endometrial cancer. DESIGN: A prospective study from January 1996 to September 1998. MATERIALS AND METHODS: 264 women at risk of endometrial cancer with clinical indications for hysteroscopy with curettage participated in the study. They underwent different diagnostic methods: endometrial cytology (121 cases), endometrial biopsy (150) or ultrasonography (200). The accuracy of these methods was related to the following results obtained from hysteroscopy with curettage. RESULTS: The results of the study suggest higher reliability of endometrial biopsy from cytology. The hysteroscopic diagnosis conforms with the histologic examination showed by the curettage. Endometrial cancer as the cause of post-menopausal bleeding can be excluded in cases with endometrial thickness of < or = 5 mm measured by vaginal ultrasonography. CONCLUSIONS: We concluded that the combination of hysteroscopy and endometrial biopsy may substitute for curettage and become the method of choice for the endometrium.     

Managing women with post-menopausal bleeding

Transvaginal ultrasound examination can reliably distinguish women with post-menopausal bleeding (PMB) who are at low risk of endometrial pathology (endometrial thickness < or =4 mm) from those who are at high risk (endometrium > or =5 mm) and can rule out focally growing lesions in the uterine cavity using saline infusion into the cavity as a negative contrast agent (hydrosonography). The 5 mm cut-off is applicable irrespective of the use of hormone replacement therapy. It is justified to refrain from endometrial sampling in women with PMB and an endometrial thickness of < or =4 mm because the risk of endometrial cancer in these women is low (0.1-1.0%). However, it is not known whether these women need follow-up. About 80% of women with PMB and an endometrium of > or =5 mm have focally growing pathological lesions in the uterine cavity. These should be removed by operative hysteroscopy because dilatation and curettage (D and C) will fail to diagnose and remove a large proportion of these lesions. However, D and C is a reliable diagnostic method for women without focal lesions in the uterine cavity. It is not known whether simple outpatient sampling devices (e.g. Pipelle) are as reliable as D and C in women without focal lesions. A measurement of endometrial thickness is a simple and accurate method for estimating the risk of endometrial cancer. The reliability of ultrasound evaluation of endometrial morphology and/or vascularization for risk estimation of endometrial malignancy remains to be determined.     

Transvaginal endometrial sonography in postmenopausal women taking tamoxifen

OBJECTIVE: To evaluate sonographic measurements of endometrial thickness in postmenopausal women taking adjuvant tamoxifen therapy for breast cancer, and to correlate sonographic and pathologic findings to symptoms and duration of tamoxifen therapy. METHODS: Medical records and sonograms of 80 postmenopausal women treated for breast cancer with adjuvant tamoxifen therapy were reviewed retrospectively. Endometrial thickness was recorded as a single-layer thickness and considered abnormal when greater than 2.5 mm for postmenopausal women. Sonographic endometrial thickness was correlated to histologic findings, symptoms, and duration of tamoxifen therapy. RESULTS: Fifty-seven of 80 postmenopausal women (69%) had single-layer endometrial thicknesses of 2.5 mm or greater, measured by transvaginal sonography, and 55 of 57 had endometrial biopsies or dilatations and curettage. Biopsies detected 24 cases of abnormal endometria, including endometrial carcinoma (two), breast carcinoma metastatic to the endometrium (one), endometrial polyps (13), tubal metaplasia (three), and benign endometrial hyperplasia (five). Using a single-layer endometrial thickness greater than 2.5 mm by transvaginal ultrasound, 21 of 24 (87.5%) women with abnormal endometria were detected. Women with abnormal pathologic findings had a significantly thicker mean single-layer endometrial thickness than those with normal findings, 7 mm versus 4 mm (P < .01). Twelve women had postmenopausal bleeding, all of whom had a single-layer endometrial thickness greater than 2.5 mm on transvaginal sonography. CONCLUSION: With a sensitivity of detecting endometrial abnormalities of 84%, transvaginal sonography was useful for studying postmenopausal tamoxifen-treated women.     

Uterine effects of tamoxifen: a prospective study

The purpose of the study was to evaluate tamoxifen-associated changes in the vagina and uterus in postmenopausal breast cancer patients. Between June 1994 and December 1998, 45 patients enrolled in a prospective study before commencing tamoxifen therapy. Patients with endometrial thickness >5 mm or neoplasia were excluded. Transvaginal ultrasonography, vaginal maturation indexes (VMI), and endometrial biopsy were performed at baseline and repeated at 6 months (n= 42), 1 year (n= 39), 2 years (n= 32), 3 years (n= 26), 4 years (n= 19), and 5 years (n= 15). For the 39 patients followed for 1 year, VMI (% parabasal/intermediate/superficial) was 21/71/8 at baseline compared with 1/90/9 at 1 year (P value = 0.0008/0.001/0.78). At baseline, mean endometrial thickness and uterine volume were 2.6 mm and 64 cm(3), respectively, compared with 5.8 mm and 84 cm(3) at 1 year (P= 0.0002, 0.002). At baseline, 80% of patients had atrophic endometrium and 9% proliferative endometrium compared with 61% and 26% at 1 year, respectively (P= 0.04). No cases of endometrial hyperplasia or adenocarcinoma were detected. Findings observed at 6 months persisted through 5 years of follow-up. Tamoxifen exerts a weak estrogenic effect on the vagina and uterus in highly prescreened postmenopausal women without preexisting endometrial pathology.     

Pretreatment and prospective assessment of endometrium in menopausal women taking tamoxifen for breast cancer

OBJECTIVES: To estimate the pretreatment incidence of endometrial pathology and to prospectively assess the endometrial morbidity emerging during tamoxifen intake for breast cancer. STUDY DESIGN: One-hundred and forty-six menopausal breast cancer patients, candidate to receive tamoxifen underwent endometrial assessment by Transvaginal Ultrasonography (TU) before the start of therapy. A double-layered endometrial stripe measuring more than 4mm indicated hysteroscopy and endometrial biopsy. Endometrial abnormalities detected before the start of tamoxifen were treated by operative hysteroscopy or by hysterectomy; no therapy and yearly hysteroscopic follow-up was scheduled for patients showing non-atypical hyperplasias. All women were asked to undergo TU on a yearly basis; during the follow-up period, indication for hysteroscopy and endometrial biopsy were the following: (i) an endometrial lining measured above 4mm at the first time, (ii) at least a 50% increase of endometrial thickness since the last finding in patients previously assessed by hysteroscopy, (iii) a recorded vaginal bleeding, and (iv) previous findings of endometrial hyperplasia. Histopathologic result from biopsy or hysterectomy was the reference test to establish the baseline prevalence of endometrial pathology and the emerging prevalences of morbidity after 12, 24, 36, 48 and 60 months of tamoxifen therapy. RESULTS: One-hundred and five patients were followed for 60 months, whereas 113, 126, 137 and 141 patients were evaluated up to 48, 36, 24 and 12 months, respectively. In 44 out of 146 patients, pretreatment TU showed an endometrium thicker than 4mm and in 31 (21.2%) of these patients abnormalities consisting of 16 endometrial polyps, seven polyps harboring simple hyperplasia, four simple hyperplasias, three atypical hyperplasias and one adenocarcinoma were found. During tamoxifen intake benign endometrial abnormalities were detected in 36 out of 114 assessable patients showing normal endometrium before the start of tamoxifen therapy (31.5%) and in seven out of 27 patients with baseline endometrial abnormalities (25.9%). Overall, an endometrial pathology emerged in 30.4% of patients during tamoxifen administration and in no patients we found an atypical lesion. CONCLUSIONS: In menopausal breast cancer patients the incidence of endometrial abnormalities before the start of tamoxifen therapy is high and includes 2.7% of atypical pathology. After the diagnosis and treatment of baseline atypical lesions were accomplished, no atypical endometrial lesion emerged after the start of tamoxifen administration. Based on these findings, we believe that pretreatment assessment of endometrium is recommended in all menopausal women candidate to receive tamoxifen therapy.     

Can ultrasound replace dilation and curettage? A longitudinal evaluation of postmenopausal bleeding and transvaginal sonographic measurement of the endometrium as predictors of endometrial cancer

OBJECTIVE: The purpose of this study was to evaluate postmenopausal bleeding and transvaginal sonographic measurement of endometrial thickness as predictors of endometrial cancer and atypical hyperplasia in women whose cases were followed for > or =10 years after referral for postmenopausal bleeding. STUDY DESIGN: Women (n = 394) who had postmenopausal bleeding from November 1987 to October 1990 underwent transvaginal sonographic measurement of endometrial thickness and curettage. It was possible to assess the medical records (regarding recurrence of a postmenopausal bleeding, development of endometrial cancer, and death) in 339 of the 394 women (86%) > or =10 years after referral for postmenopausal bleeding. RESULTS: Thirty-nine of the 339 women (11.5%) had endometrial cancer, and 5 women (1.5%) had atypical hyperplasia. The relative risk of endometrial cancer in women who were referred for postmenopausal bleeding was 63.9 (95% CI, 46.0-88.8); the corresponding relative risk for endometrial cancer and atypical hyperplasia together was 72.1 (95% CI, 52.8-98.5) compared with women of the same age from the general population of the same region of Sweden. No woman with an endometrial thickness of < or =4 mm was diagnosed as having endometrial cancer. The relative risk of the development of endometrial cancer in women with an endometrial thickness of >4 mm was 44.5 (95% CI, 6.5-320.1) compared with women with an endometrial thickness of < or =4 mm. The reliability of endometrial thickness (cutoff value, < or =4 mm) as a diagnostic test for endometrial cancer was assessed: Sensitivity, 100%; specificity, 60%; positive predictive value, 25%; and negative predictive value, 100%. The incidence of endometrial cancer or atypical hyperplasia in women with an intact uterus whose cases had been followed for > or =10 years was 5.8% (15/257 women) compared with 22.7% (15/66 women) in women who had < or =1 episode of recurrent bleeding. No endometrial cancer was diagnosed in women with a recurrent postmenopausal bleeding who had an endometrial thickness of < or =4 mm at the initial scan. CONCLUSION: Postmenopausal bleeding incurs a 64-fold increase risk for endometrial cancer. There was no increased risk of endometrial cancer or atypia in women who did not have recurrent bleeding, whereas women with recurrent bleeding were a high-risk group. No endometrial cancer was missed when endometrial thickness measurement (cutoff value, < or =4 mm) was used, even if the women were followed up for < or =10 years. We conclude that transvaginal sonographic scanning is an excellent tool for the determination of whether further investigation with curettage or some form of endometrial biopsy is necessary     

The use of screening ultrasonography in the evaluation of postmenopausal breast cancer patients on tamoxifen: Is endometrial echo thickness enough?

This study addresses the efficacy of endometrial echo thickness and uterine volume in predicting endometrial histology in postmenopausal breast cancer patients on tamoxifen citrate. Sixty-four post-menopausal women with breast cancer using tamoxifen for at least 6 months were entered in the study. All subjects underwent transabdominal and transvaginal ultrasonography by a board-certified radiologist as well as having an office endometrial biopsy performed by a gynecologist. Twenty of the 64 patients were evaluated on two separate occasions at least 6 months apart. Histologic findings ranged from atrophic or inactive endometrium (N = 29), proliferative endometrium (N = 6), simple hyperplasia without atypia (N = 9), and scant tissue insufficient for diagnosis (N = 20). Endometrial echo averaged 10.6 mm (range: 1.2–25.0 mm), and mean uterine volume was 105 cm³ (range: 12–600 cm³). The correlation between histology and endometrial thickness was not significant (r = 0.12, P = 0.34). However, the correlation between histology and uterine volume was statistically significant (r = 0.31, P = 0.017). Both uterine volume and endometrial thickness were found to increase with duration of therapy but only uterine volume was found to correlate with the length of treatment. This study suggests that tamoxifen has a universal uterotropic effect stimulating myometrial as well as endometrial growth and, in addition, a uterine volume measurement may be more predictive of endometrial histopathology than endometrial thickness in this patient population.