Sonographic evaluation of the uterus in postmenopausal women receiving tamoxifen: characterization of mid-uterine abnormalities

Significance of secondary ultrasonographic endometrial thickening in postmenopausal tamoxifen-treated women

BACKGROUND

Ultrasonography has a limited value in endometrial assessment for identification of endometrial pathologies in postmenopausal tamoxifen-treated patients.

METHODS

We compared the rate of endometrial pathologies and the mean +/- SD of endometrial thickness diagnosed after the first and second transvaginal ultrasonographic studies performed on 55 postmenopausal tamoxifen-treated patients with secondary endometrial thickening (Group I). This rate was also compared with 46 similar patients without secondary thickening (Group II). We also compared the mean +/- SD of endometrial thickness detected in various ultrasonographic studies, as well as various clinical features.

RESULTS

A significantly higher rate of endometrial pathologies, including two cases of endometrial cancer identified in gynecologically asymptomatic patients (3.6%), was diagnosed in Group I after the second study compared with the first study (52.7% and 9.1%, respectively; P = 0.001) and compared with those diagnosed after the second study in Group II (30.4%; P = 0.03). There was a significant increase (74.7 +/- 115%) in endometrial thickness after the second study compared with the first study performed on Group I (10.7 +/- 5.53 mm and 16.59 +/- 5.53 mm, respectively; P = 0.0001) and a significant difference in endometrial thickness demonstrated in the second study performed on Groups I and II (16.59 +/- 5.53 mm and 11.4 +/- 3.91 mm, respectively; P = 0.001). There were no significant differences in the time elapsed since the diagnosis of breast carcinoma and from the beginning of tamoxifen treatment to the performance of the first ultrasonographic study as well as the time elapsed between the first and second studies performed.

CONCLUSIONS

A significant increase (> 50%) in secondary endometrial thickening, measured ultrasonographically, in postmenopausal tamoxifen-treated patients, is associated with a high rate of endometrial pathologies, including endometrial cancer.

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 < or = 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 < or = 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.

Hysteroscopy and transvaginal ultrasonography in postmenopausal women with uterine bleeding

OBJECTIVE

To evaluate the accuracy of hysteroscopy and transvaginal ultrasonography (TU), based on a histopathological report from endometrial specimens, in diagnosing endometrial pathology in menopausal women with uterine bleeding.

METHODS

Four-hundred and nineteen postmenopausal women with uterine bleeding underwent TU, hysteroscopy and endometrial biopsy. Hysteroscopic and sonographic findings have been evaluated on the basis of the final diagnosis established by histologic examination. Sensitivity, specificity and positive predictive value of TU at an endometrial thickness cut-off point of 4 and 8 mm (double layer technique) and of panoramic hysteroscopy have been detected.

RESULTS

Normal and abnormal endometrium was found in 222 and in 197 women, respectively. TU showed sensitivity of 95.1%, specificity of 54.8% and positive predictive value of 63.7% at a cut-off limit of 4 mm. With a cut-off limit of 8 mm the corresponding figures were 83.8%, 81.3% and 79.4%. Hysteroscopy demonstrated a sensitivity of 96.5%, specificity of 93.6% and positive predictive value of 92.6%. The combination of the two diagnostic tools showed a 100% sensitivity, 94.8% specificity and 93.3% positive predictive value.

CONCLUSIONS

With cut-off limit of 4 mm, TU can be considered the first choice modality of endometrial investigation in women with postmenopausal uterine bleeding to select patients at risk to carry endometrial pathology. Hysteroscopy is a more accurate technique than TU because of better specificity and must be indicated for all patients showing an endometrial strip more than 4 mm. When an endometrial thickness below 4 mm is detected by ultrasound, hysteroscopy may be indicated on clinical background because of the possibility to miss infrequent (2.5% in our series), but relevant endometrial pathologies. Endometrial sampling should follow hysteroscopic view in all cases showing abnormal or suspicious lesions as well as in all cases with irregularly shaped endometrial lining and/or suboptimal endoscopic vision.

The role of ultrasound in the detection of endometrial pathologies in asymptomatic postmenopausal breast cancer patients with tamoxifen treatment

Transvaginal ultrasonography is an effective diagnostic procedure, and thus, it can reasonably be used to determine which asymptomatic, postmenopausal breast cancer patient with tamoxifen treatment will require endometrial sampling. Overall, it seems that the contribution of pulsed Doppler flow in the diagnosis of endometrial pathologies in such patients is nonconclusive. It is suggested that sonohysterography is a useful diagnostic tool for the assessment of specific endometrial pathologies, especially of space-occupying lesions in the endometrial cavity, in such patients.

Controversies regarding tamoxifen and uterine carcinoma

An increasing number of cases of endometrial cancer in women receiving tamoxifen have been reported but most are from non-randomized studies and case reports. In the last year, there have been no further results either confirming or disproving an association between tamoxifen and endometrial cancer from randomized controlled studies in breast cancer patients and those participating in chemopreventative trials with tamoxifen. Several papers have examined the possible mechanisms behind tamoxifen's endometrial effects.