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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ajog.2009.02.006 Byline: Steven R. Goldstein Keywords: Abnormal uterine bleeding; endometrial biopsy; endometrial thickness; postmenopausal bleeding; transvaginal ultrasound Abstract: All postmenopausal women with vaginal bleeding need endometrial assessment. Disposable suction piston biopsy devices have virtually replaced dilatation and curettage despite little scientific validation. In patients with known carcinoma, false-negative rates with such devices range from 2.5-32.4%. Large prospective studies have shown that an endometrial thickness [less than or equal to] 4 mm on transvaginal ultrasound in postmenopausal women with bleeding has a risk of malignancy of 1 in 917. Thus, in postmenopausal patients with bleeding, biopsy is not indicted when endometrial thickness is [less than or equal to] 4 mm. The significance of a thick endometrial echo in nonbleeding postmenopausal women has not been validated and need not require automatic tissue sampling. Author Affiliation: Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY Article History: Received 4 August 2008; Revised 22 January 2009; Accepted 18 February 2009 Article Note: (footnote) Reprints not available from the author.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ajog.2004.05.017 Byline: Steven R. Goldstein Keywords: Transvaginal ultrasound; Sonography; Endometrium; Endometrial echo; Endometrial cancer Abstract: Transvaginal ultrasound has been explored as an inexpensive, noninvasive, convenient way to indirectly visualize the endometrial cavity. For more than a decade numerous studies have indicated that a thin, distinct, well-visualized echo ( Author Affiliation: Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY Article History: Received 13 April 2004; Accepted 7 May 2004

The drug levormeloxifene appears to have serious side effects, according to a study of 2,924 postmenopausal women. This drug is similar to estrogen that was developed for treating osteoporosis. This study had to be stopped after only 10 months because of the large number of women who experienced side effects from the drug. Side effects included uterine prolapse, urinary incontinence, constipation, abdominal pain, leg cramps, and hot flashes.

Color flow Doppler ultrasound imaging does not appear capable of distinguishing benign endometrial polyps from cancerous polyps, according to a study of 61 women. Biopsy and pathological examination are necessary to identify cancerous endometrial polyps.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1067/mob.2000.105941 Byline: Steven R. Goldstein Keywords: SERMs; selective estrogen receptor modulators; tamoxifen; raloxifene; breast cancer Abstract: Tamoxifen was approved for breast cancer prevention in October 1998. Thus, for the first time, we as gynecologists are being asked to prescribe this drug to healthy women. In the past each one of us has cared for women with breast cancer who have been treated with tamoxifen by oncologists or breast surgeons for the malignancy. Effects of tamoxifen on the uterus resulting in carcinomas, hyperplasia, and polyps are well known. Furthermore, tamoxifen has estrogenic properties in the venous system, increasing the incidence of deep vein thrombosis and pulmonary emboli. A new SERM (selective estrogen receptor modulator), raloxifene, has been approved for prevention and treatment of osteoporosis in postmenopausal women. It does not have stimulatory effects on the endometrium; however, it is estrogenic in the venous system. Preclinical data, as well as the breast cancer incidence reported in studies of the skeleton, seem to indicate that its effects in the breast are similar to those of tamoxifen. This article reviews tamoxifen and the new SERM, raloxifene, in an attempt to help gynecologists better understand each compound and what data are currently known, what we hope to learn from future studies, and what currently makes sense for clinical practice. (Am J Obstet Gynecol 2000;182:1121-6.) Author Affiliation: Department of Obstetrics and Gynecology, New York University School of Medicine New York, New York Article Note: (footnote) [star] Reprint requests: Steven R. Goldstein, MD, Department of Obstetrics and Gynecology, New York University School of Medicine, 530 First Ave, Suite 10N, New York, NY 10016.

Selective estrogen receptor modulators (SERMs) may provide postmenopausal women with all the benefits of estrogen but not its risks. Tamoxifen is one of the best-known SERMs, and is used to treat breast cancer because it blocks the activity of estrogen in the breast. This is important because many breast tumors are stimulated by estrogen. Tamoxifen also prevents bone loss just as estrogen does and lowers cholesterol levels. However, it can cause proliferation of endometrial tissue, which could lead to endometrial cancer. A newer SERM called raloxifene does not cause endometrial proliferation.

A systematic scheme for evaluating women with abnormal bleeding at or around the time of menopause appears to be successful. Initial ultrasound screens were performed on 433 women experiencing abnormal perimenopausal bleeding. Based on the lining thickness, 79% were not treated further. The remaining patients with thicker linings were then examined with a contrast medium. Abnormalities revealed at this stage were treated by either removing the growths, scraping the lining, or examining tissue samples microscopically.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/S0002-9378(97)80025-7 Byline: Lisa Barrie Schwartz, Lewis Krey, Rita Demopoulos, Steven R. Goldstein, Lila E. Nachtigall, Khush Mittal Keywords: Tamoxifen; progesterone receptors; estrogen receptors; endometrial polyps; menopause Abstract: OBJECTIVE: Our purpose was to evaluate whether tamoxifen has estrogenic endometrial effects as defined by histologic study or alterations in steroid hormone receptor expression. STUDY DESIGN: Nineteen postmenopausal tamoxifen-treated breast cancer patients who also had endometrial sampling were identified from files in the Department of Obstetrics and Gynecology. To examine the subgroup of 15 polyps, age-matched, non-hormonally treated patients with polyps (n = 8) or atrophic endometria (n = 5) served as comparison groups. Proliferative (n = 3) and secretory (n = 5) endometria served as procedural controls. Immunohistochemical studies for steroid receptors (estrogen, progesterone) were performed. RESULTS: Glandular cell progesterone receptor was significantly increased and stromal cell estrogen receptor was significantly decreased in tamoxifen-treated versus atrophic endometria. Progesterone receptor staining was not significantly different in tamoxifen-treated versus control polyps, although staining was high in both groups. Stromal cell estrogen receptor staining was significantly reduced in tamoxifen-treated versus control polyps, although there were no histologic differences. Reduced stromal cell estrogen receptor and increased glandular cell progesterone receptor staining was found in all tamoxifen-treated endometria regardless of the diagnosis. CONCLUSION: The tamoxifen-associated changes in endometrial steroid receptors support an estrogenic effect that is independent of histologic diagnosis and duration of use. This may contribute to the pathogenesis of tamoxifen-associated polyps and carcinomas. (Am J Obstet Gynecol 1997;176:129-37.) Author Affiliation: New York, New York Article History: Received 21 February 1996; Revised 10 July 1996; Accepted 6 September 1996 Article Note: (footnote) [star] From the Departments of Obstetrics and Gynecologya and the Division of Obstetric and Gynecologic Pathology,b New York University School of Medicine., [star][star] Supported by the 1995-1996 North American Menopause Society/Bristol-Myers Squibb Company Research Fellowship Award (L.B.S.), the Helena Rubenstein Foundation (L.E.N., L.B.S.), and Kaplan Cancer Center National Cancer Institute Core grant No. CA16087 (R.D.)., a Reprint requests: Lisa Barrie Schwartz, MD, Department of Obstetrics and Gynecology, NYU Medical Center, 550 First Ave., New York, NY 10016., aa 6/1/77746

The following guidelines may help gynecologists detect ovarian cancer in postmenopausal women while not subjecting too many healthy women to unnecessary exploratory surgery. Small, one-sided, single-cavitied cysts can be followed with serial ultrasonography provided blood levels of CA 125 remain normal. CA 125 measurement is not sufficiently accurate to be used to screen women not suspected of having cancer. Color flow Doppler holds promise for noninvasive diagnosis but requires more research. Endoscopic examinations should be performed only when the mass can be completely removed if necessary. Suctioning the fluid from the cyst should never be done.

Fluid-enhanced ultrasonography may help identify the cause of uterine bleeding in perimenopausal women. Researchers examined the endometrium, the mucous membrane lining the uterus, in 21 women entering menopause using fluid-enhanced vaginal probe ultrasonography. Of the 21 women, eight had obvious polyps that may have caused uterine bleeding and had surgery to remove the benign lesions. Three patients had benign tumors of the uterine muscle beneath the endometrium. Two of these patients underwent surgery to remove the tumors and one patient remained on observation. Nine patients had no obvious lesions and uniform endometria measuring four millimeters (mm) or less. Biopsy samples from these nine women revealed early proliferation of the endometrium. One patient had an endometrial thickness of 8 mm and a hysterectomy showed evidence of abnormal numbers of normal cells.

Women taking tamoxifen may develop strange-looking endometria. Tamoxifen is a nonsteroidal oral antiestrogen used to treat breast cancer. The endometrium is the mucous membrane lining of the uterus. Ultrasonographic studies in five women revealed bizarre-appearing endometria with areas suggestive of polyp. None of the women had experienced any vaginal bleeding. The first patient had a polyp, but curettage obtained very little tissue and an examination of her uterus revealed a smooth, thin endometrium. Using a fluid enhancement technique, doctors found that the changes were actually beneath the endometrium and located in the muscular layer of the uterus wall. Four additional patients taking tamoxifen had thin endometria. Endometrial sampling by suction showed inactive endometrial tissue in all four women.

Ultrasound, the use of high frequency sound to visualize internal structures, has been used in obstetrics and gynecology for 30 years. A new development in ultrasound technology is the endovaginal ultrasound probe. Despite the high magnifications produced by the higher frequencies used with endovaginal probes, high resolution images of structures not normally visible to the naked eye can be obtained. A full bladder is needed to visualize the reproductive structures when traditional abdominal ultrasound is used. The endovaginal procedure is performed during a routine pelvic examination with an empty bladder and requiring no advanced preparation. It takes one to three minutes to perform a endovaginal ultrasound once the examiner is experienced with the procedure. Endovaginal probes can detect fetal cardiac activity during a routine exam within a few seconds. However, findings not confirmed by traditional ultrasonographic methods may actually be normal, and the danger arises that these findings will be overinterpreted. Issues that need to be addressed include the cost of training practitioners, the cost to the physician and patient, and the safety of the procedure. The significance of unfamiliar findings must be established. It is anticipated that the endovaginal probe will become a routine diagnostic tool similar to the traditional stethoscope. (Consumer Summary produced by Reliance Medical Information, Inc.)

Byline: Steven R. Goldstein Author Affiliation: Department of Obstetrics and Gynecology, New York University Medical Center, 530 First Ave New York, NY 10016