Tamoxifen is the standard treatment for hormonal receptor-positive premenopausal women to receive either alone or following chemotherapy. It plays a role also in the metastatic situation and as a primary preventive agent. It has, however, a number of potential side effects of which the most serious are venous thrombosis and endometrial cancer. Over 5 years (the standard treatment duration for adjuvant tamoxifen) the risk of endometrial cancer is between 2 and 3 times the population risk. Most of these extra cases involve women over age 50, and are found at an early stage. Vaginal bleeding is the most common presentation. Increased mortality from this hasn’t been demonstrated. There’s some suggestion of an increased incidence of a more serious (although rarer) uterine sarcoma. It’s standard practice to warn patients about this when they begin prolonged tamoxifen for primary prevention.

In terms of screening for this problem we lack good evidence that transvaginal ultrasound or endometrial biopsy is helpful. Ultrasound has about a 25% false positive rate and has led to significant iatrogenic complications. There’s no consensus on what constitutes an abnormal endometrial thickness or relative change in thickness, and obviously more studies need to be done. Endometrial biopsy studies have led to no change in detection but an increased rate of D&C’s (14 D&C’s and 3 hysterectomies in 111 patients).

The recommendations are that premenopausal women require no additional monitoring beyond routine gynecologic care, while postmenopausal women need annual gynecological examination, education and investigation of abnormal vaginal symptoms.

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