Background: Abnormal uterine bleeding is a common gynecological presentation in outpatient clinic, but is often complex and difficult to diagnose. Abnormal uterine bleeding (AUB) is the main reason in women to refer to gynecologists and accounts for two thirds of all hysterectomies. Objectives: The aim of this study was to compare the diagnostic accuracy of two dimensional transvaginal ultrasound and hysteroscopy referring to histopathology in evaluation of uterine cavity lesions in perimenopausal women with abnormal uterine bleeding. Subjects and methods: This was a prospective cohort study. The study was carriedout at Al Agouza Police Hospital, on fifty women in peri-menopausal period, The study was conducted the period from April 2019 till December 2019. All participants received comprehensive information regarding objective and the expected benefit of the study. All ethical considerations were taken throughout the whole work. Results: The results of the study revealed that sensitivity 2D TVS in detection of endometrial hyperplasia was 100%, specificity was 88.7%, PPV was 73.30%, NPV was 100%, and accuracy was 94% with area under ROC curve 0.99, and sensitivity of hystroscope in detection of endometrial polyp was 36.3%, specificity was 100%, PPV was 100%, NPV was 84.7%, accuracy was 86% with area under ROC curve 0.45. Conclusion: Transvaginal sonography has a moderate diagnostic accuracy in detecting endometrial hyperplasia and other intrauterine pathology. It is safe, acceptable and easily available in most secondary and tertiary care setting and is noninvasive. It should be continued as 1st line diagnostic tool in patients with abnormal uterine bleeding in perimenopausal women.