Tamoxifen-associated endometrial changes
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View Jeremy Jones's current disclosures- Endometrial changes associated with tamoxifen
- Endometrial changes associated with tamoxifen use
- Tamoxifen-induced endometrial changes
The oncological agent tamoxifen has pro-oestrogenic changes on the endometrium resulting in abnormal growth with an increased prevalence of:
- endometrial polyps: occurs in ~8-36% of women in treated 8
- endometrial hyperplasia: occurs in ~1-20% of women treated ref
- cystic endometrial atrophy
- endometrial carcinoma
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Epidemiology
Up to one-half of breast cancer patients who are treated with tamoxifen may develop an endometrial lesion within 6-36 months. Therefore, any patient who develops bleeding while taking tamoxifen requires evaluation.
Pathology
Tamoxifen is a non-steroidal selective estrogen receptor modulator (SERM), which acts as an "anti-estrogen". It binds to the estrogen receptor and is used primarily for adjuvant therapy in breast cancer. However, it can also act as a pro-estrogen agonist in a low estradiol environment. The agonist properties can affect the endometrium, and does, in half of treated patients.
Radiographic features
Ultrasound
Tamoxifen may cause the endometrium to appear thickened, irregular, and cystic. Most patients tend to display a multiplicity of findings.
-
normal endometrial thickness despite tamoxifen use, i.e. <5 mm (although ~50% of those receiving tamoxifen have been reported to have a thickness of >8 mm) 2
- it has also been reported that the degree of endometrial thickening corresponds to the duration of tamoxifen therapy
- subendometrial cysts
-
endometrial polyps
- usually larger than in untreated women
- sonohysterography may be useful for their identification
MRI
Endometrial thickening and subendometrial cysts, similar to pelvic ultrasound.
Treatment and prognosis
Ultrasound screening of asymptomatic patients taking tamoxifen has been shown to be problematic due to a high number of false positives. Thus, routine ultrasound is not typically recommended for screening if a patient on tamoxifen is not experiencing bleeding 11,12.
It has been proposed that patients taking tamoxifen who present with vaginal bleeding should go directly to hysteroscopy and endometrial biopsy 7.
Quiz questions
References
- 1. Nalaboff KM, Pellerito JS, Ben-levi E. Imaging the endometrium: disease and normal variants. Radiographics. 21 (6): 1409-24. Radiographics (full text) - Pubmed citation
- 2. Hann LE, Giess CS, Bach AM et-al. Endometrial thickness in tamoxifen-treated patients: correlation with clinical and pathologic findings. AJR Am J Roentgenol. 1997;168 (3): 657-61. AJR Am J Roentgenol (abstract) - Pubmed citation
- 3. Buijs C, Willemse PH, De vries EG et-al. Effect of tamoxifen on the endometrium and the menstrual cycle of premenopausal breast cancer patients. Int. J. Gynecol. Cancer. 2009;19 (4): 677-81. doi:10.1111/IGC.0b013e3181a47cbe - Pubmed citation
- 4. Dallenbach-hellweg G, Schmidt D, Hellberg P et-al. The endometrium in breast cancer patients on tamoxifen. Arch. Gynecol. Obstet. 2000;263 (4): 170-7. Arch. Gynecol. Obstet. (link) - Pubmed citation
- 5. Hann LE, Gretz EM, Bach AM et-al. Sonohysterography for evaluation of the endometrium in women treated with tamoxifen. AJR Am J Roentgenol. 2001;177 (2): 337-42. AJR Am J Roentgenol (full text) - Pubmed citation
- 6. Williams PL, Laifer-narin SL, Ragavendra N. US of abnormal uterine bleeding. Radiographics. 23 (3): 703-18. doi:10.1148/rg.233025150 - Pubmed citation
- 7. Dreisler E, Poulsen LG, Antonsen SL et-al. EMAS clinical guide: assessment of the endometrium in peri and postmenopausal women. Maturitas. 2013;75 (2): 181-90. doi:10.1016/j.maturitas.2013.03.011 - Pubmed citation
- 8. Ascher SM, Imaoka I, Lage JM. Tamoxifen-induced uterine abnormalities: the role of imaging. Radiology. 2000;214 (1): 29-38. doi:10.1148/radiology.214.1.r00ja4429 - Pubmed citation
- 9. Gupta A, Desai A, Bhatt S. Imaging of the Endometrium: Physiologic Changes and Diseases: Women's Imaging. (2017) Radiographics : a review publication of the Radiological Society of North America, Inc. 37 (7): 2206-2207
- 10. Polin SA, Ascher SM. The effect of tamoxifen on the genital tract. (2008) Cancer imaging : the official publication of the International Cancer Imaging Society. 8: 135-45. doi:10.1102/1470-7330.2008.0020 - Pubmed
- 11. Love CD, Muir BB, Scrimgeour JB, Leonard RC, Dillon P, Dixon JM. Investigation of endometrial abnormalities in asymptomatic women treated with tamoxifen and an evaluation of the role of endometrial screening. (1999) Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 17 (7): 2050-4. doi:10.1200/JCO.1999.17.7.2050 - Pubmed
- 12. Fung MF, Reid A, Faught W, Le T, Chenier C, Verma S, Brydon E, Fung KF. Prospective longitudinal study of ultrasound screening for endometrial abnormalities in women with breast cancer receiving tamoxifen. (2003) Gynecologic oncology. 91 (1): 154-9. doi:10.1016/s0090-8258(03)00441-4 - Pubmed
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