Comparison of endometrial changes among symptomatic tamoxifen-treated and nontreated premenopausal and postmenopausal breast cancer patients

Guideline No. 451: Asymptomatic Endometrial Thickening in Postmenopausal Women

OBJECTIVE

To formulate strategies for clinical assessments for endometrial thickening on ultrasound in a postmenopausal woman without bleeding.

TARGET POPULATION

Postmenopausal women of any age.

OUTCOMES

To reduce unnecessary invasive interventions and investigations in women with asymptomatic endometrial thickening while selectively investigating women at risk for endometrial cancer.

BENEFITS, HARMS, AND COSTS

It is anticipated that the adoption of these recommendations would save postmenopausal women unnecessary anxiety, pain, and risk of procedural complications. It is also expected to decrease the cost to the health care system by eliminating unnecessary interventions.

EVIDENCE

English language articles from Medline, Cochrane, and PubMed databases for relevant peer-reviewed articles dating from 1995 to 2022 (e.g., asymptomatic endometrial thickness, endometrial cancer, postmenopausal bleeding, transvaginal ultrasound, endometrial biopsy, cervical stenosis, hormone therapies and the endometrium, tamoxifen, tibolone, aromatase inhibitors). Results were restricted to systematic reviews and meta-analyses, randomized controlled trials/controlled clinical trials, and observational studies.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

Physicians, including gynaecologists, obstetricians, family physicians, radiologists, pathologists, and internists; nurse practitioners and nurses; medical trainees, including medical students, residents, and fellows; and other providers of health care of the postmenopausal population.

SOCIAL MEDIA ABSTRACT

Postmenopausal women often have a thickening of the lining of the uterus found during ultrasound. Without bleeding, an endometrium <11 mm is rarely a serious problem but should be evaluated by a health care provider.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with early breast cancer

The European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with early breast cancer were updated and published online in 2023, and adapted, according to previously established standard methodology, to produce the Pan-Asian adapted (PAGA) ESMO consensus guidelines for the management of Asian patients with early breast cancer. The adapted guidelines presented in this manuscript represent the consensus opinions reached by a panel of Asian experts in the treatment of patients with breast cancer representing the oncological societies of China (CSCO), Indonesia (ISHMO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), the Philippines (PSMO), Singapore (SSO), Taiwan (TOS) and Thailand (TSCO), co-ordinated by ESMO and KSMO. The voting was based on scientific evidence and was independent of the current treatment practices, drug access restrictions and reimbursement decisions in the different Asian regions represented by the 10 oncological societies. The latter are discussed separately in the manuscript. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with early breast cancer across the different regions of Asia, drawing on the evidence provided by both Western and Asian trials, whilst respecting the differences in screening practices, molecular profiling, as well as the age and stage at presentation. Attention is drawn to the disparity in the drug approvals and reimbursement strategies, between the different regions of Asia.

Progestogen Hypersensitivity

Progestogen hypersensitivity (PH) is a heterogeneous disease characterized by diverse cutaneous manifestations, bronchospasm, and/or anaphylaxis. Possible triggers include ovarian progesterone and exogenous progestogens. The timing of symptoms is critical to diagnose PH: during the luteal phase of the menstrual cycle for the endogenous form and after exposure to progestins for exogenous PH. Diagnostic modalities such as progesterone skin testing have low sensitivity and specificity for PH. When exogenous PH is suspected, the allergist should consider a progestogen challenge. Treatment strategies should be tailored for each patient, including symptom-directed therapies, ovulation suppression, and progesterone desensitization. Future studies should explore the mechanisms of PH, validation of diagnostic criteria, and standardization of treatment strategies.

Female reproductive health in pediatric, adolescent, and young adult cancer survivors

An estimated 500,000 cancer survivors of reproductive age in the United States will live to experience the long-term consequences of cancer treatment. Therefore, a focused aspect of cancer care has appropriately shifted to include quality of life in survivorship. Infertility is a late effect of therapy that affects 12% of female survivors of childhood cancer receiving any cancer treatment in large cohort studies and results in a 40% decreased likelihood of pregnancy in young adults of ages 18-39 years. Nonfertility gynecologic late effects such as hypoestrogenism, radiation-induced uterine and vaginal injury, genital graft-versus-host disease after hematopoietic stem cell transplant, and sexual dysfunction also significantly affect quality of life in survivorship but are underdiagnosed and require consideration. Several articles in the special edition "Reproductive Health in Adolescent and Young Adult Cancer Survivorship" address infertility, genital graft-versus-host disease, and psychosexual functioning in survivorship. This review article focuses on other adverse gynecologic outcomes of cancer therapies including hypogonadism and hormone replacement therapy, radiation-induced uterovaginal injury, vaccination and contraception, breast and cervical cancer screening, and pregnancy considerations in survivorship.

The relationship of endometrial pathologies with endometrial thickness and inflammatory markers in breast cancers using tamoxifen

PURPOSE

Some proliferative and neoplastic changes can be seen in the endometrium of breast cancers using tamoxifen adjuvant therapy (TMX-BC). Identifying risk groups is crucial, but methods and frequency of endometrial follow-up are still controversial. This study aimed to investigate the clinical, ultrasonographic, and inflammatory factors to differentiate pathological endometrium in TMX-BC.

METHODS

This study retrospectively analyzed endometrial biopsy results of TMX-BC (n 361). Normal endometrium (Group I, n 237) and pathological endometrium (Group II, n 124) were compared for clinical, ultrasonographic, and inflammatory features. Neutrophil and platelet to lymphocyte ratio (NLR; PLR), mean platelet volume (MPV), platelet distribution width (PDW), red blood cell distribution width (RDW), and lymphocyte-monocyte ratio (LMR) were the inflammatory markers.

RESULTS

The majority of TMX-BC with endometrial biopsy were asymptomatic (72.6%) and had normal endometrium (65.7%). Pathologic endometrium included endometrial polyp (31.9%), endometrial hyperplasia (1.7%), and endometrial cancer (0.8%). The duration of tamoxifen, cancer stage, vaginal bleeding, and menopause was similar in Group I and Group II (p > 0.05). Group II had increased endometrial thickness (11.22 ± 5.44 mm) compared to Group I (8.51 ± 3.43 mm). Group II had higher RDW and PDW than Group I (p < 0.05). Endometrial thickness ≥ 10 mm had significant diagnostic potential in postmenopausal women (AUC 0.676, p 0.000, CI 0.5-0.7), but not in premenopause.

CONCLUSION

PDW and RDW may be promising markers for pathological endometrium differentiation, but these preliminary findings should be validated by clinical studies. Measurement of endometrial thickness in asymptomatic patients may predict high-risk women with pathological endometrium in postmenopausal women. Further studies are needed in premenopausal women and those using tamoxifen for more than 5 years.

Effect of Vaginoscopy versus Conventional Hysteroscopy on Pain, Complications, and Patient Satisfaction in Patients with Endometrial Polyps

Background

Hysteroscopy is considered the gold standard for diagnosing intrauterine pathology. Traditional hysteroscopy requires the placement of a vaginal speculum and cervical forceps, which are large in diameter, causing discomfort and pain to the patient and even causing vagal reflexes.

Aims

To investigate the impact and clinical value of vaginoscopy versus conventional hysteroscopy on pain, complications, and patient satisfaction in patients with endometrial polyps and to analyse the advantages of clinical application of vaginoscopy examination.

Materials and Methods

One hundred and twenty-five patients with endometrial polyps treated in our hospital from May 2021 to December 2021 were selected for this study and divided into 52 cases in the hysteroscopy group and 73 cases in the vaginoscopy group according to the random remainder grouping method. Conventional hysteroscopy was used, and in the vaginoscopy group, vaginoscopy was performed. The impact of pain, complications, patient satisfaction, and clinical value of the two groups was observed and compared.

Results

The time taken for the examination varied between the different hysteroscopic methods, with the hysteroscopy group taking the longest time compared to the vaginoscopy group (P < 0.01). The VAS scores immediately after the examination and 30 minutes after the examination were both significantly higher in the hysteroscopy group than in the vaginoscopy group (P < 0.01). The difference in NPY, PGE2, and 5-HT after the pain-causing mediator intervention was significantly better in the vaginoscopy group than in the hysteroscopy group. The difference in the incidence of complications such as abortion syndrome, cervical laceration, uterine perforation, and haemorrhage after treatment was significantly lower in the vaginoscopy group than in the hysteroscopy group. In the vaginoscopy group, the satisfaction rate was 91% significantly higher than that of the hysteroscopy group (P < 0.05).

Conclusion

The vaginoscopy technique shortens the examination and treatment time, reduces patient pain, improves patient compliance, reduces the use of preintervention drugs and anaesthetics, and reduces complications.

New Light on Endometrial Thickness as a Risk Factor of Cancer: What Do Clinicians Need to Know?

Transvaginal ultrasound (TVUS) represents an accurate and noninvasive technique to investigate endometrial thickness (ET) in the early diagnosis of endometrial cancer (EC). In the literature, for maximum ET there is no consensus on the cutoff value for normal ET in postmenopause for either symptomatic or asymptomatic women. Most patients with EC present with postmenopausal bleeding (PMB) and in these patients is necessary to perform TVUS to evaluate ET as an indicator for endometrial biopsy. On the contrary, if ET is incidentally detected in postmenopausal patients without bleeding, endometrial sampling for a postmenopausal woman without bleeding should not be routinely performed, although it is estimated that up to 15% of EC occurs in women without vaginal bleeding. The aim of our review was to give clinicians necessary and useful knowledge on the role of TVUS and ET for early detection of EC in their daily routine practice. Based on the most important studies in the literature, we summarized that in premenopausal woman with abnormal uterine bleeding, an optimal cutoff for ET has not yet been established. For postmenopausal women with PMB, at low risk, and ET <4 mm, a follow-up scan could be offered, and for women with ET ≥4 mm, office hysteroscopy-guided endometrial sampling is recommended independently of ET results. On the other hand, in postmenopausal women with PMB and at high risk of EC, office hysteroscopy-guided endometrial sampling is necessary. In postmenopausal women without PMB and ET ≥4 mm, arbitrary endometrial sampling is not recommended, but evaluated case by case based on risk factors. In conclusion, there is broad consensus on the importance of TVUS and the need for further investigation based on risk factors of EC.

Endometrial hyperplasia as a risk factor of endometrial cancer

Endometrial hyperplasia (EH) is the precursor lesion for endometrioid adenocarcinoma of the endometrium (EC), which represents the most common malignancy of the female reproductive tract in industrialized countries. The most important risk factor for the development of EH is chronic exposure to unopposed estrogen. Histopathologically, EH can be classified into EH without atypia (benign EH) and atypical EH/endometrial intraepithelial neoplasia (EIN). Clinical management ranges from surveillance or progestin therapy through to hysterectomy, depending on the risk of progression to or concomitant EC and the patient´s desire to preserve fertility. Multiple studies support the efficacy of progestins in treating both benign and atypical EH. This review summarizes the evidence base regarding risk factors and management of EH. Additionally, we performed a systematic literature search of the databases PubMed and Cochrane Controlled Trials register for studies analyzing the efficacy of progestin treatment in women with EH.

Risk Factors Associated with Endometrial Pathology in Premenopausal Breast Cancer Patients Treated with Tamoxifen

PURPOSE

To evaluate factors associated with endometrial pathology during tamoxifen use in premenopausal breast cancer (BC) patients.

MATERIALS AND METHODS

We reviewed the medical records of premenopausal BC patients treated with tamoxifen who underwent endometrial biopsy with or without hysteroscopy. Clinical characteristics were compared between women with endometrial pathology (endometrial hyperplasia or cancer) and those with normal histology or endometrial polyps.

RESULTS

Among 284 endometrial biopsies, endometrial hyperplasia was diagnosed in 7 patients (2.5%), endometrial cancer was diagnosed in 5 patients (1.8%), normal histology was noted in 146 patients (51.4%), and endometrial polyp was present in 114 patients (40.1%). When comparing women with endometrial cancer (n=5) to women with normal histology, abnormal uterine bleeding was more common (p=0.007), and endometrial thickness was greater (p=0.007) in women with endometrial cancer. Chemotherapy for BC was also more common in patients with endometrial cancer (p=0.037). When comparing women with endometrial polyps and those with endometrial hyperplasia or cancer, the presence of abnormal uterine bleeding was more common in patients with endometrial hyperplasia or cancer (p<0.001); however, tamoxifen duration and endometrial thickness did not differ significantly between the two groups.

CONCLUSION

In premenopausal BC patients treated with tamoxifen, abnormal uterine bleeding, increased endometrial thickness, and chemotherapy for BC were associated with the occurrence of endometrial cancer. These findings may provide useful information for gynecologic surveillance and counseling during tamoxifen treatment in premenopausal BC patients.

Benign and Premalignant Lesions of the Endometrium

In this review, we highlight the benign and premalignant lesions of the endometrium that the pathologist may encounter in daily practice. We begin by detailing our current understanding of excess estrogen in the progression of endometrial neoplasia. We outline the currently accepted terminology to be used when evaluating proliferative endometrial lesions, while highlighting their key features. Attention is then turned to the molecular underpinnings of neoplastic progression and how this can be exploited with immunohistochemical stains when appropriate. Finally, we discuss types of metaplasia and their associations, including so-called papillary proliferations of the endometrium.

Comparative Study on Hysteroscopic and Histologic Examinations of the Endometrium in Postmenopausal Women Taking Tamoxifen

Objectives

To evaluate the histologic effects of tamoxifen on the endometrium using hysteroscopy in postmenopausal women with breast cancer.

Methods

The study included 46 postmenopausal patients who were referred from another clinic due to thickening or bleeding of the endometrium after taking tamoxifen for breast cancer. All patients underwent transvaginal sonography (TVS) and hysteroscopic endometrial biopsy with a 5-mm, continuous-flow, operating hysteroscope.

Results

The incidence of malignancy was high (20%) in cases of abnormal uterine bleeding (AUB) after taking tamoxifen. However, in the non-AUB group with thick endometrium after taking tamoxifen, the incidence of adenocarcinoma was 3.2%.

Conclusions

Our findings confirm the estrogen-like effect of tamoxifen on the endometrium. Endometrial evaluation with TVS suggests further diagnostic procedures; moreover, histologic examination is necessary under hysteroscopy, especially in cases of endometrial bleeding after taking tamoxifen.

The effect of tamoxifen therapy on the endometrium and ovarian cyst formation in patients with breast cancer

Objective

To evaluate the effect of tamoxifen on female reproductive organs in women with breast cancer.

Methods

We retrospectively reviewed the medical records of 309 women with breast cancer who were currently receiving tamoxifen and undergoing regular gynecological examination.

Results

We evaluated 92 pre- and 217 postmenopausal women. The prevalence of endometrial thickening was 12% in the pre- and 10.6% in the postmenopausal group. An endometrial biopsy was performed in 43 women and confirmed endometrial cancer in 1, endometrial polyps in 14, and endometrial hyperplasia in 4 women. Transvaginal ultrasonography showed 25 cases of newly developed ovarian cysts. Most ovarian cysts had disappeared during follow-up.

Conclusion

Tamoxifen use in women with breast cancer causes few complications and is considered safe for female reproductive organs in case of regular gynecological examination.

Post-menopausal bleeding - Is transvaginal ultrasound a useful first-line investigation in tamoxifen users?

Objective To evaluate the role of transvaginal ultrasound triage in women with a history of tamoxifen treatment who present with post-menopausal bleeding. Study design A retrospective review was undertaken of patients who presented with symptoms of post-menopausal bleeding and underwent ultrasound triage. Endometrial thickness and ultrasonographic features were then correlated with hysteroscopic and histopathological outcome data. The findings and outcomes for women with a history of tamoxifen use (tamoxifen group) were compared to those who had not taken tamoxifen (non-tamoxifen group). Results A total of 614 women with post-menopausal bleeding underwent transvaginal ultrasound triage, of whom 53 had a history of current or previous tamoxifen treatment. An endometrial thickness of ≥5 mm or the presence of other abnormal features was used to triage women to further investigation by hysteroscopy and biopsy. Endometrial thickness was significantly greater in the tamoxifen group (11 mm vs. 6 mm). Nearly all of the tamoxifen group were triaged to further investigation (98.1%), compared with significantly fewer in the non-tamoxifen group (68.3%) Overall, the incidence of endometrial pathology was also significantly higher in tamoxifen patients (43.4% vs. 31.7%). Conclusion For women presenting with post-menopausal bleeding, the use of transvaginal ultrasound as a triage tool is rarely helpful in evaluating women who have a history as tamoxifen use, as most will require further investigation with hysteroscopy and biopsy. A post-menopausal bleeding protocol that omits transvaginal ultrasound for women with a history of tamoxifen use may be an appropriate and effective pathway for managing these patients.

Endometrial polyp surveillance in premenopausal breast cancer patients using tamoxifen

Objective

To describe the endometrial pathologic lesions in premenopausal breast cancer patients with a history of tamoxifen (TMX) use.

Methods

We retrospectively reviewed the medical records of 120 premenopausal breast cancer patients with a history of TMX use that had undergone a gynecological examination.

Results

Among 120 patients, 44.2% (n=53) were asymptomatic with an endometrial thickness ≥5 mm, as assessed by transvaginal ultrasonography. Of the patients that reported abnormal uterine bleeding, 5% (n=6) had an endometrial thickness <5 mm and 20% (n=24) had an endometrial thickness ≥5 mm by transvaginal ultrasonography. The final group of patients were asymptomatic, but showed an abnormal endometrial lesion, such as an endometrial polyp, by transvaginal ultrasonography (30.8%, n=37). Of the 56 benign lesions that were histologically reviewed, 50 (41.7%) were endometrial polyps, 3 (2.5%) were submucosal myomas, 2 (1.7%) were endometrial hyperplasias, and 1 (0.8%) was chronic endometritis. There were 64 (53.3%) other non-pathologic conditions, including secreting, proliferative, and atrophic endometrium, or in some cases, there was insufficient material for diagnosis. In our data, only one case was reported as a complex hyperplasia without atypia arising from an endometrial polyp, and one patient was diagnosed with endometrioid adenocarcinoma.

Conclusion

For premenopausal breast cancer patients with a history of TMX use, the majority of the patients were asymptomatic, and endometrial polyps were the most common endometrial pathology observed. Therefore, we believe that endometrial assessment before starting TMX treatment, and regular endometrial screening throughout TMX treatment, are reasonable suggestions for premenopausal breast cancer patients.

Endometrial cancer risk in postmenopausal breast cancer patients treated with tamoxifen or aromatase inhibitors

INTRODUCTION

The gynaecological toxicity profile of tamoxifen presents a significant burden to the patients and oncologist as tamoxifen-related side effects result in additional investigations, procedures and referrals. Aromatase inhibitor have been shown to result in significant reduction in gynaecological problems, possibly including endometrial cancer. Areas covered: We reviewed the main breast cancer trials, observation or cohort studies investigating tamoxifen or an aromatase inhibitor to report on endometrial adverse events and cancer. Expert commentary: Evidence for an increase in endometrial cancers with tamoxifen in breast cancer treated patients is now very clear. Aromatase inhibitors have shown to have a beneficial effect on the endometrium. There is an important need for further studies to clearly determine the influence of aromatase inhibitors on the endometrial in tamoxifen-naïve women. The effect of aromatase inhibitors on gynaecological problems may have potentially a very important impact in clinical practice.

Randomized trial of medroxyprogesterone acetate for the prevention of endometrial pathology from adjuvant tamoxifen for breast cancer: SWOG S9630

The proliferative effect of adjuvant tamoxifen on the endometrium can potentially result in endometrial abnormalities, including cancer in postmenopausal women. We conducted a randomized, controlled trial to assess endometrial pathological diagnoses in postmenopausal women with early stage, ER-positive breast cancer without endometrial pathology at baseline. They were assigned to tamoxifen alone versus tamoxifen plus cyclical medroxyprogesterone acetate (MPA 10 mg for 14 days every 3 months) for 5 years. Endovaginal sonograms (EVS) +/− endometrial biopsies (EMB) were required at baseline, 2 and 5 years. Of 313 patients registered, 296 were eligible and 169 (57%; 89, tamoxifen; 80, tamoxifen+MPA) were evaluable (completed year-2 EVS, with an EMB if stripe width was ⩾5 mm). Sixty (67%) of these in the tamoxifen arm had an endometrial stripe width ⩾5 mm (and underwent subsequent EMB) compared with 48 (60%) in the tamoxifen+MPA arm (P=0.40). There were four cases of proliferative endometrium and one simple hyperplasia on the tamoxifen arm (6% (95% confidence interval (CI): 2–13%) among evaluable patients and one proliferative endometrium on the tamoxifen+MPA arm (P=0.11). The overall fraction with benign endometrial abnormalities at year 2 was 3.6% (6/169; 95% CI: 1.3–7.6%), with only 1 (of 102) new benign proliferative event at year 5. The event rate in both arms was much lower than projected, making treatment arm comparisons less informative. A normal endometrium prior to tamoxifen may provide reassurance regarding future endometrial events. However, validation in a larger trial is needed before changing practice in asymptomatic, postmenopausal women.

Clinical factors and malignancy in endometrial polyps. Analysis of 1027 cases

STUDY OBJECTIVE

To assess the prevalence of polyps carrying a malignancy and match association between clinical factors and oncologic progression.

STUDY DESIGN

A retrospective study (Canadian Task Force classification II-3) at a university hospital in Rome, Italy. We retrospectively analyzed data from 1027 women consecutively treated for endometrial polyps at our center in the period 2002-2011. The association of malignancy with hormonal status, tamoxifen, hypertension, symptoms, diabetes mellitus, obesity, and hormonal replacement therapy in pre- and post-menopausal women was assessed.

RESULTS

Mean age was 45.8±10.8 years. Benign polyps accounted for 95.8% of the total, pre-malignant for 2.67%, malignant for 1.54%. Our data showed that post-menopausal and older women (>60y) with endometrial polyps have a higher risk of developing a related endometrial cancer (OR: 3.05, 95% CI [1.54, 6.19], p<0.001 and OR: 2.8, 95% CI [1.38, 5.56], p≤0.003. Also we observed that women with AUB in the post-menopausal period displayed a risk of malignancy (OR: 31.1, 95% CI [10.3,111], p value <0.001).

CONCLUSION

Special attention should be drawn to symptomatic post-menopausal patients that appear to be at higher risk of malignancy. Symptomatic pre-menopausal women and asymptomatic post-menopausal women with polyps may be a group with intermediate-risk. These patients should undergo an individualized management plan, balancing both risks and benefits of surgical intervention after discussion with the patient.

Factors influencing endometrial thickness in postmenopausal women

Background:

Cut-off values for endometrial thickness (ET) in asymptomatic postmenopausal woman have been standardized. However, there are no comprehensive studies to document how various factors can influence the ET after the age of menopause.

Aim:

To study the various factors influencing the ET in postmenopausal women.

Subjects and Methods:

This was a prospective observational study. A total of 110 postmenopausal women underwent detailed history taking, clinical examination, and transvaginal scan for uterine volume and ovarian volume. The volumes were calculated by using ellipsoid formula: Width × thickness × height × 0.523. The variation in ET with respect to the influencing factors such as age, duration of menopause, parity, body mass index (BMI), medical illness like diabetes/hypertension, drugs like tamoxifen, presence of myoma, uterine volume, ovarian volume, and serum estradiol (in selected patients) were measured. Descriptive analysis was performed using SPSS software (version 16, Chicago II, USA) to obtain mean, standard deviation (SD), 95% confidence intervals (CIs) and inter quartile ranges. Comparison of means was carried out using analysis of variance.

Results:

The mean (SD) age of the patients was 55.4 (6.91) years (95% CI, 54.1, 56.7). The mean (SD) age at menopause was 47.95 (3.90) years (95% CI, 47.2, 48.7) and the mean (SD) duration of menopause was 7.27 (6.65) years (95% CI, 6.01, 8.53). The mean (SD) ET was 3.8 (2.3) mm (95% CI, 3.36, 4.23). Medical illness like diabetes and hypertension did not alter the ET. ET increased as BMI increased and it was statistically significant. The presence of myoma increased uterine volume significantly and was associated with thick endometrial stripe. Similarly, whenever the ovaries were visualized and as the ovarian volume increased, there was an increase in ET. When ET was > 4 mm (n = 37), they were offered endocel, of which 16 agreed to undergo the procedure. None were found to have endometrial cancer.

Conclusion:

This study suggests that parity, BMI, presence of myoma, tamoxifen usage, uterine volume, ovarian volume and serum estradiol influence the ET in postmenopausal women.

Uptake of tamoxifen in consecutive premenopausal women under surveillance in a high-risk breast cancer clinic

BACKGROUND

Randomised trials of tamoxifen versus placebo indicate that tamoxifen reduces breast cancer risk by approximately 33%, yet uptake is low. Approximately 10% of women in our clinic entered the IBIS-I prevention trial. We assess the uptake of tamoxifen in a consecutive series of premenopausal women not in a trial and explore the reasons for uptake through interviews.

METHODS

All eligible women between 33 and 46 years at ≥17% lifetime risk of breast cancer and undergoing annual mammography in our service were invited to take a 5-year course of tamoxifen. Reasons for accepting (n=15) or declining (n=15) were explored using semi-structured interviews.

RESULTS

Of 1279 eligible women, 136 (10.6%) decided to take tamoxifen. Women >40 years (74 out of 553 (13.4%)) and those at higher non-BRCA-associated risk were more likely to accept tamoxifen (129 out of 1109 (11.6%)). Interviews highlighted four themes surrounding decision making: perceived impact of side effects, the impact of others' experience on beliefs about tamoxifen, tamoxifen as a 'cancer drug', and daily reminder of cancer risk.

CONCLUSIONS

Tamoxifen uptake was similar to previously ascertained uptake in a randomised controlled trial (IBIS-I). Concerns were similar in women who did or did not accept tamoxifen. Decision making appeared to be embedded in the experience of significant others.

Special considerations in early-stage breast cancer patients and survivors

Long-term outcomes for early-stage breast cancer have continued to improve, and more patients are becoming long-term survivors. In addition to patients' concern about risk of developing recurrent disease, they are also concerned about potential toxicities of treatment. Current guidelines for long-term follow-up are reviewed. Potential toxicities of tamoxifen and aromatase inhibitors are reviewed. Management of menopausal symptoms, cancer-related fatigue, and cognitive function is discussed.

Endometrial surveillance in tamoxifen users: role, timing and accuracy of hysteroscopic investigation: observational longitudinal cohort study

To determine the role, timing and indications for endometrial hysteroscopic investigation in relation to the clinical, ultrasound and histological features of the endometrium during tamoxifen (TAM) use. We performed an observational longitudinal cohort study (years 2007-2012) that investigated the endometria of 151 TAM users with hysteroscopy and histology. For all patients, gynaecological history, years of adjuvant treatment, ultrasound endometrial thickness measurement and indications for hysteroscopy were recorded. Hysteroscopic findings showed that 100% of patients referred for simple follow-up had no evidence of endometrial disease. We found a strong correlation between previous history of abnormal uterine bleeding (with or without endometrial thickening) and hysteroscopic suspicion of endometrial atypia that was confirmed by histology. Hysteroscopy had 83.3% sensitivity, 99% specificity, 83.3% positive predictive value (PPV) and 99% negative predictive value (NPV) in detecting endometrial atypia. No significant correlation was found between endometrial thickening to >5 mm without bleeding and histological atypia. Similarly, the duration of treatment was not related to endometrial thickening and histological atypia. Endometrial stromal hyperplasia was detected by histology in 70.5% of patients with endometrial thickness measurements ranging from 5 to 10 mm. In contrast, no atypia was detected when endometrial thickness was <5 mm. Ultrasound performed using a 5-mm cut-off threshold for endometrial thickness resulted in 100% sensitivity, 15% specificity, 4% PPV and 100% NPV in detecting endometrial atypia, while a 10-mm cut-off threshold resulted in 84% sensitivity, 69% specificity, 10% PPV and 99% NPV. Low-risk TAM users do not require different endometrial surveillance than the general population. Hysteroscopy could play a fundamental role in determining the endometrial status of patients before the initiation of TAM treatment and in assessing the endometrial status of patients when bleeding occurs.

Challenges in the gynecologic care of premenopausal women with breast cancer

Premenopausal women with a new diagnosis of breast cancer are faced with many challenges. Providing health care for issues such as gynecologic comorbidities, reproductive health concerns, and vasomotor symptom control can be complicated because of the risks of hormone treatments and the adverse effects of adjuvant therapies. It is paramount that health care professionals understand and be knowledgeable about hormonal and nonhormonal treatments and their pharmacological parameters so they can offer appropriate care to women who have breast cancer, with the goal of improving quality of life. Articles for this review were identified by searching the PubMed database with no date limitations. The following search terms were used: abnormal uterine bleeding, physiologic sex steroids, endometrial ablation, hysteroscopic sterilization, fertility preservation in endometrial cancer, tranexamic acid and breast cancer, menorrhagia treatment and breast cancer, abnormal uterine bleeding and premenopausal breast cancer, levonorgestrel IUD and breast cancer, tamoxifen and gynecologic abnormalities, tamoxifen metabolism, hormones and breast cancer risk, contraception and breast cancer, pregnancy and breast cancer, and breast cancer and infertility treatment.

Role of GPR30 in endometrial pathology after tamoxifen for breast cancer

OBJECTIVE

This study was undertaken to evaluate the potential role of G-protein-coupled estrogen receptor in endometrial pathology associated with tamoxifen treatment of breast cancer patients.

STUDY DESIGN

We investigated whether G-protein-coupled estrogen receptor plays a role in mediating proliferating effect of tamoxifen in endometrial carcinoma cells. These results were compared with the G-protein-coupled estrogen receptor expression pattern in endometrial tissue from a cohort of 95 breast cancer patients, who received tamoxifen or another adjuvant therapy.

RESULTS

In vitro tamoxifen significantly stimulated the mitogen-activated protein kinase phosphorylation and cell proliferation of endometrial cell lines via G-protein-coupled estrogen receptor. In vivo, there was a significant correlation between G-protein-coupled estrogen receptor expression and the tamoxifen-induced endometrial pathology (P = .006). Moreover, G-protein-coupled estrogen receptor positivity was predictive of an earlier development of symptoms, such as bleeding or suspect endometrial thickness, induced by tamoxifen therapy (P = .019).

CONCLUSION

G-protein-coupled estrogen receptor plays an important role in tamoxifen-induced endometrial abnormalities.

Uterine changes during tamoxifen, toremifene, and other therapy for breast cancer: evaluation with magnetic resonance imaging

PURPOSE

We have performed pelvic magnetic resonance imaging (MRI) in patients undergoing breast cancer surgery before and after adjuvant drug therapy. Our purpose was to detect any radiographic uterine changes induced by various types of adjuvant therapy on pre- and postmenopausal patients by evaluating prospectively performed MRI.

MATERIALS AND METHODS

Between September 2004 and December 2007, a total of 41 women with breast cancer (11 premenopausal, 30 postmenopausal) were enrolled. All underwent MRI of the pelvis before and after drug therapy, and uterine changes were evaluated. Postoperative drugs used were selective estrogen receptor modulators (SERMs) including tamoxifen and toremifene (n = 18), aromatase inhibitors (n = 13), and anticancer drugs (n = 10).

RESULTS

Only the postmenopausal patients receiving SERMs showed a significant increase in endometrial thickness: from 2.4 +/- 0.4 mm before therapy to 4.5 +/- 2.6 mm after therapy (P = 0.0485). No statistically significant endometrial change was evident in postmenopausal patients treated with aromatase inhibitors (P = 0.573) or anticancer drugs (P = 0.754). Also, in premenopausal patients treated with SERMs or anticancer drugs, the change in endometrial thickness was not statistically significant (P = 0.958, 0.370).

CONCLUSION

This prospective study using MRI has demonstrated that uterine changes associated with adjuvant drugs for breast cancer occur exclusively in postmenopausal patients receiving SERMs.

Malignancy in endometrial polyps: a 12-year experience

OBJECTIVE

Endometrial polyps (EPs) are common pathological lesions in all women. The objective of this study was to evaluate the risk of malignancy of EPs and to investigate whether clinical parameters may predict the histopathologic features of these lesions.

STUDY DESIGN

A retrospective study was conducted from January 1995 to December 2006 and all consecutive 1242 cases with clinical EPs were included. The charts of all these women were reviewed and clinical data were related to histopathologic results.

RESULTS

Histologically, polyps were distinguished as benign, premalignant, and malignant. Overall, 95.2% benign polyps, 1.3% premalignant, and 3.5% malignant lesions were detected. When clinical variables were considered, patient age, menopause, presence of abnormal uterine bleeding, and hypertension were statistically significant characteristics related to premalignant and malignant features.

CONCLUSION

Older menopausal bleeding patients with hypertension are at high risk for premalignant and malignant polyps. Therefore, besides abnormal bleeding symptoms, this kind of patient needs to have the polyps removed.

Tamoxifen use and endometrial lesions: hysteroscopic, histological, and immunohistochemical findings in postmenopausal women with breast cancer

OBJECTIVE

To evaluate immunohistochemical, hysteroscopic, and histological findings in postmenopausal women taking tamoxifen for breast cancer.

METHODS

Forty postmenopausal women taking 20 mg/day tamoxifen for breast cancer underwent hysteroscopy and endometrial biopsy from January 2000 to December 2003. Medical records and paraffin blocks were analyzed retrospectively, and Ki-67, estrogen receptors (ERs), and progesterone receptors were measured using an immunohistochemical technique.

RESULTS

The mean +/- SD age of the women was 59 +/- 14 years at hysteroscopy (95% CI, 54.2-63.7) and 45.1 +/- 7 years at menopause (95% CI, 42.6-47.6). Mean +/- SD duration of tamoxifen therapy was 27.3 +/- 16.5 months (95% CI, 22.0-32.5). Hysteroscopies were performed because of abnormal sonographic findings in 60% of the women and postmenopausal bleeding in 40%. The most common hysteroscopic and histological findings were endometrial polyps (32.5%) and atrophic endometria (22.5%). Immunohistochemistry showed that 85% of the women were progesterone receptor positive, 75% were ER positive, and 50% were Ki-67 positive. Endometrial polyps and polyps associated with atrophic endometrium were ER positive (P = 0.019). Results that were ER negative were more frequent in atrophic endometria (P = 0.01). The longer the time since menopause, the lower the Ki-67 expression in the endometrium was (P = 0.03). Ki-67 expression was greater in the endometrium of younger postmenopausal women (P = 0.01).

CONCLUSIONS

The expression of steroid receptors in the endometrium was high in our series. All cases of endometrial polyps were ER positive. Estrogen receptors may play a major role in the development of endometrial polyps in postmenopausal women taking tamoxifen. Although most histological findings were benign, 22.5% were atrophic.

Women's health, breast health: a review of the gynecologic effects of breast cancer

Breast cancer is very common and seen in both premenopausal and postmenopausal women. Research into prevention, better screening, and more effective treatments is occurring continually, and changes are translated into clinical practice relatively quickly. It is important for women's health care providers to have an understanding of breast cancer treatments and the gynecologic side effects. For premenopausal women interested in fertility, options should be discussed prior to chemotherapy. Issues pertaining to pregnancy after breast cancer should be discussed in a multidisciplinary fashion, involving the obstetrician/gynecologist, breast surgeon, and oncologist. Ovarian suppression is often used as part of breast cancer treatment in premenopausal women with hormone positive disease, and menopausal symptoms may be severe. Hormonal therapies including tamoxifen and the aromatase inhibitors are used in the treatment of hormone positive breast cancers. Each of these drugs has a variety of gynecologic implications. Understanding the options for treatment for menopausal complaints in breast cancer patients is important for women's health providers. Although most breast cancers are sporadic, a small percentage will be due to mutations in the BRCA genes. It is important for women's health providers to take an appropriate family history and refer to genetic counselors for possible testing when hereditary cancer is suspected. This review focuses on the various women's health issues pertaining to breast cancer and treatment.

Effect of tamoxifen on the endometrium and the menstrual cycle of premenopausal breast cancer patients

OBJECTIVE

Tamoxifen, a nonsteroidal antiestrogen, is the agent of choice in the treatment of premenopausal receptor-positive breast cancer. This study aimed to investigate the influence of tamoxifen on the menstrual cycle and serum hormone levels and the subsequent endometrial response in premenopausal breast cancer patients.

METHODS

In tamoxifen-using breast cancer patients aged 55 years or younger, the last menstrual period was registered, serum hormone levels measured, and the endometrial response visualized by transvaginal ultrasonography every 6 months. Premenopausal status was defined as serum levels of estradiol (E2) 0.10 nmol/L or more and follicle-stimulating hormone 30 IU/L or less. Premenopausal patients with an endometrial response of greater than 12 mm were offered a hysteroscopy and curettage.

RESULTS

In 121 patients, a total of 241 measurements were performed. Amenorrhea predicted menopausal status incorrectly in 85 (35%) of the 241 measurements in 47 patients. In 8 of 47 endocrinologic premenopausal patients, transvaginal ultrasonography showed an endometrial response of greater than 12 mm (range,15-29 mm). Histopathology in women with an endometrial thickness of greater than 12 mm showed no malignancy. No relation between E2 levels and endometrial thickness was found.

CONCLUSIONS

Tamoxifen leads to a disconnection between clinical and endocrinologic menopause in breast cancer patients aged 55 years or less. In premenopausal patients, tamoxifen has a predominantly antiestrogenic effect on the endometrium without a correlation between E2 levels and endometrial response.

The effect of adjuvant hormonal therapy on the endometrium and ovary of breast cancer patients

OBJECTIVE

To investigate the effect of adjuvant hormonal therapy on the endometrium and ovary of breast cancer patients.

METHODS

A retrospective review was performed on the 207 patients who had taken tamoxifen or anastrozole, as adjuvant hormonal therapy after breast cancer surgery between January 2003 and December 2006. Gynecologic surveillance constituted of ultrasonographic exam of the endometrial thickness and ovarian cyst formation. The patients were classified into three groups and analyzed; premenopausal/postmenopausal women receiving tamoxifen and women receiving anastrozole.

RESULTS

Mean duration of follow up was 20.6+/-6.6 months. There was no difference of mean endometrial thickness before hormonal therapy among the three groups (p=0.327). In women receiving tamoxifen, the endometrium was continuously thickened in proportion to the duration of the therapy irrespective of menopausal status while it remained unchanged in women receiving anastrozole (p<0.05). Endometrial biopsies were performed in 28 patients receiving tamoxifen. The most common histologic finding was proliferative endometrium in premenopausal women (7/21) and atrophic endometrium in postmenopausal women (6/7). There was no case of endometrial cancer in both groups. Ovarian cyst was found in 32 women and the most were developed in premenopausal women receiving tamoxifen (30/32). All of them showed benign nature on transvaginal ultrasonographic findings.

CONCLUSION

Women undergoing adjuvant hormonal therapy after breast cancer surgery exhibited changes in the endometrium and ovary. However most changes were not a serious problem in this study and frequent gynecologic surveillance in these patients needs further investigation.

Effects of tamoxifen and raloxifene on normal human endometrial cells in an organotypic in vitro model

The selective estrogen receptor modulator tamoxifen is widely used in breast cancer therapy though its use is associated with an elevated risk of endometrial carcinoma. An organotypic culture model was employed here to examine the effects of tamoxifen and raloxifene, a related compound with no known adverse uterine effects, on epithelial cells of the premenopausal human endometrium. Changes in the expression levels of the proliferation marker Ki67, and estrogen and progesterone receptors were evaluated. No change in the Ki67 index compared to untreated controls was detected in cultures exposed to tamoxifen or tamoxifen+estradiol. In response to tamoxifen, the level of progesterone receptor-expressing organoids was shown to vary markedly between individual samples, whereas no change in estrogen receptor expression could be demonstrated. A significant decrease in Ki67 expression was observed in raloxifene-exposed cultures. Raloxifene or raloxifene+estradiol had no effect on progesterone receptor expression. The expression of estrogen receptor was markedly inhibited in response to raloxifene or raloxifene+estradiol in all but two samples displaying an intense estrogen receptor labelling. The present observations add to current clinical data on the respective estrogen receptor agonist and antagonist activities of tamoxifen and raloxifene on the human uterus by providing novel insights into the interindividual variation in cellular responses. Our organotypic model may have uses as an alternative to animal experimentation in preclinical screening of the endometrial effects of selective estrogen receptor modulators and may serve as a tool in personalized medicine by identifying patients with an increased risk of developing endometrial pathologies.

The effect of tamoxifen on the genital tract

Tamoxifen is a selective estrogen receptor modulator (SERM) that is widely used in the treatment of patients with breast cancer and for chemoprophylaxis in high risk women. Tamoxifen results in a spectrum of abnormalities involving the genital tract, the most significant being an increased incidence of endometrial cancer and uterine sarcoma. This article reviews the effects of tamoxifen on the genital tract and the strengths and weaknesses of various imaging modalities for evaluating the endometrium.

Selective estrogen receptor modulators: an update on recent clinical findings

Recent clinical data on selective estrogen receptor modulators (SERMs) have provided the basis for reassessment of the SERM concept. The molecular basis of SERM activity involves binding of the ligand SERM to the estrogen receptor (ER), causing conformational changes which facilitate interactions with coactivator or corepressor proteins, and subsequently initiate or suppress transcription of target genes. SERM activity is intrinsic to each ER ligand, which accomplishes its unique profile by specific interactions in the target cell, leading to tissue selective actions. We discuss the estrogenic and anti-estrogenic effects of early SERMs, such as clomiphene citrate, used for treatment of ovulation induction, and the triphenylethylene, tamoxifen, which has ER antagonist activity in the breast, and is used for prevention and treatment of ER-positive breast cancer. Since the development of tamoxifen, other triphenylethylene SERMs have been studied for breast cancer prevention, including droloxifene, idoxifene, toremifene, and ospemifene. Other SERMs have entered clinical development more recently, including benzothiophenes (raloxifene and arzoxifene), benzopyrans (ormeloxifene, levormeloxifene, and EM-800), lasofoxifene, pipendoxifene, bazedoxifene, HMR-3339, and fulvestrant, an anti-estrogen which is approved for breast cancer treatment. SERMs have effects on tissues containing ER, such as the breast, bone, uterine and genitourinary tissues, and brain, and on markers of cardiovascular risk. Current evidence indicates that each SERM has a unique array of clinical activities. Differences in the patterns of action of SERMs suggest that each clinical end point must be evaluated individually, and conclusions about any particular SERM can only be established through appropriate clinical trials.

Signaling by estrogens and tamoxifen in the human endometrium

Tamoxifen is used as adjuvant treatment for postmenopausal breast cancer patients. The mechanism of action of tamoxifen in breast cancer patients is that tamoxifen inhibits growth of cancer cells by competitive antagonism for estrogens at the estrogen receptor (ER). In the endometrium, tamoxifen has an effect that varies with the ambient concentration of estrogen: in premenopausal women (high estrogen levels), tamoxifen displays an estrogen-antagonistic effect, while in postmenopausal women (low estrogen levels), tamoxifen displays an estrogen-agonistic mode of action. Here, using microarray technology we have compared estrogen signaling with tamoxifen signaling in the human endometrium. It was observed that on the one hand tamoxifen-treatment results in modulation of expression of specific genes (370 genes) and on the other hand tamoxifen-treatment results in modulation of a set of genes which are also regulated by estrogen treatment (142 genes). Upon focusing on regulation of proliferation, we found that tamoxifen-induced endometrial proliferation is largely accomplished by using the same set of genes as are regulated by estradiol. So, as far as regulation of proliferation goes, tamoxifen seems to act as estrogen agonist. Furthermore, tamoxifen-specific gene regulation may explain why tamoxifen-induced endometrial tumors behave more aggressively than sporadic endometrial tumors.

Tumorigenic effects of tamoxifen on the female genital tract

Tamoxifen is widely used for endocrine treatment and breast cancer prevention. It acts as both an estrogen antagonist in breast tissue and an estrogen agonist in the female lower genital tract. Tamoxifen causes severe gynecologic side effects, such as endometrial cancer. This review focuses on the effects of prolonged tamoxifen treatment on the human female genital tract and considers its tumorigenicity in the gynecologic organs through clinical data analysis. Tamoxifen is associated with an increased incidence of benign endometrial lesions such as polyps and hyperplasia and a two- to four-fold increased risk of endometrial cancer in postmenopausal patients. Moreover, the incidence of functional ovarian cysts is significantly high in premenopausal tamoxifen users. To prevent tamoxifen from having severe side effects in gynecologic organs, frequent gynecological examination should be performed for both premenopausal and postmenopausal patients with breast cancer who are treated with this drug.

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.

Résultats à long terme de la résection des polypes endométriaux chez 367 patientes. Place de l'endométrectomie associée

OBJECTIVE

To assess the results of hysteroscopic resection of endometrial polyps and the eventual role of associated endometrial resection.

PATIENTS AND METHODS

Retrospective study. Between 1998 and 2001, 367 patients had hysteroscopic resection of endometrial polyps, which were initially confirmed by diagnostic hysteroscopy. Fifty-four percent of these had associated endometrial resection.

RESULTS

Five intraoperative complications and/or incidents were noted, but there was no major complication. 83% of patients were followed up and the median follow-up period was 40 months (range 17-66 months). The success rate in this study was 96.4%. This is higher in the group of patients that had associated endometrial resection: 98.3 vs 93.7%.

DISCUSSION AND CONCLUSION

Hysteroscopic resection is the optimal method for treatment of benign endometrial polyps. Associated endometrial resection in older patients or in patients not desiring to conserve their fertility potential improves the success rate and decreases the rate of recurrences.

Endometrial pathologies associated with postmenopausal tamoxifen treatment

OBJECTIVE

To evaluate various endometrial pathologies described in association with postmenopausal tamoxifen treatment, as well as the clinical aspects of these endometrial pathologies.

METHODS

A search was made in PUB MED for all studies published in English, up to the end of 2003, reporting on endometrial pathologies in association with postmenopausal tamoxifen treatment. Overall 106 studies were available, and all are included in this review. The types of studies included were mostly randomized clinical trials, non-randomized cohort studies, prospective and retrospective case controlled studies.

RESULTS

Endometrial polyps represent the most common endometrial pathology associated with postmenopausal tamoxifen exposure. A high rate of malignancy was reported in these polyps. Endometrial hyperplasia, endometrial polyps, endometrial cancer and malignant mixed mesodermal tumors and sarcoma are more commonly diagnosed in postmenopausal breast cancer tamoxifen-treated patients as compared to non-treated patients. Long-term tamoxifen users are more likely to succumb to endometrial cancer and endometrial sarcomas than non-users, due to the unfavorable histology of the endometrial malignancy, and an advanced stage of diagnosis.

CONCLUSIONS

The clinician should be alerted to these pathologies, which, in some cases, may potentially increase the mortality of these patients. Consequently, it is suggested that their supervision is of importance, especially if the patients experience any gynecological symptoms, including pelvic pain or pressure.

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.

Surveillance de l’endomètre des femmes sous tamoxifène

Tamoxifen estrogenic action in the uterus induces several uterine diseases, benign and/or malignant ones. The risk of endometrial adenocarcinoma is multiplied by two to three in post-menopausal women. It is mainly linked with the doses and the length of the treatment. However, the global benefit of that drug is not questioned anymore. What matters now though is to find the best way to follow patients on tamoxifen. As a matter of fact, there is no such thing as a consensus that would include specific tests, nor a surveillance protocol in women on tamoxifen. Most teams do not propose any special follow-up. Some patients already show uterine anomalies prior to the beginning of tamoxifen treatment. A yearly gynecologic examination, together with a cervico-vaginal smear, is enough when there are no specific endometrial adenocarcinoma risk factors, nor anomalies detected during the pre-therapeutical evaluation, nor clinical symptomatology. In case of risk factors, or cervical stenosis, or again initial abnormalities though, a yearly transvaginal sonography may be proposed. There is no need for other exploratory examinations if the results are satisfying. In case of symptoms, anomalies in the cervico-vaginal smears, intra-uterine liquid retention with a stenosed cervix, or suspicious endometrial thickness, then an endometrial sampling must be carried out. MRI could be of interest in asymptomatic patients with unclear ultrasonography images. Follow-up must be continued after interruption of tamoxifen. It is important to inform patients about the additional risks of developing an endometrial cancer because of tamoxifen, while still being reassuring. Besides, it is absolutely necessary to recommend them to take quickly medical advice in case of gynecologic symptoms.

The early response of the postmenopausal endometrium to tamoxifen: expression of estrogen receptors, progesterone receptors, and Ki-67 antigen

OBJECTIVE

To enlighten the early response of endometrium to tamoxifen by assessing the expression of estrogen receptors, progesterone receptors, Ki-67, and the histological response in endometria from normal postmenopausal women treated for 21 days with tamoxifen.

DESIGN

A total of 40 women, scheduled to undergo vaginal hysterectomy because of uterine prolapse, were randomly assigned to the tamoxifen group (20 mg/day; 20 women) or the control group (20 women). Samples were obtained from the upper and the lower thirds of the uterine cavity. Standard immunohistochemical staining of estrogen and progesterone receptors and of Ki-67 was performed on frozen sections. Staining was assessed using semiquantitative immunoreactivity scores.

RESULTS

Simple endometrial hyperplasia was diagnosed in 18 of the 20 samples exposed to tamoxifen compared with only 2 of the 20 controls ( P< 0.0005). Staining was increased in both the epithelium and stroma in the tamoxifen samples, a difference that was significant for estrogen receptors in glandular epithelium (180 +/- 80 v 110 +/- 110; P< 0.05). Also, Ki-67 antigen was expressed more frequently in both glandular epithelium ( P< 0.05) and stroma ( P< 0.05) in the tamoxifen samples.

CONCLUSIONS

Tamoxifen rapidly up-regulated the cell proliferation markers, an effect that was associated with enhanced growth as confirmed by increased expression of estrogen receptors and Ki-67, in addition to a high incidence of glandular hyperplasia.