Background: Abnormal uterine bleeding means any variation from the normal menstrual cycle either increase in volume, duration or amount of bleeding or variation with respect to regularity, or bleeding in between the normal menstrual cycle for a period of 6 months. Diagnostic modalities for evaluating the cause of abnormal uterine bleeding are many. These include ultrasonography, dilatation and curettage (D & C), and hysteroscopy and hysteroscopic-guided endometrial biopsy. The current study aimed to compare the efficacy of hysteroscopy and transvaginal ultrasonography (TVUS) in diagnosing endometrial pathologies in patients with perimenopausal abnormal uterine bleeding (AUB). Patients and methods: The study included 120 patients with abnormal uterine bleeding. Patients were subjected to full medical taking, gynecological examination, transvaginal ultrasound and office hysteroscopy. Endometrial sampling was performed using either D&C or hysteroscopy and tissue biopsies were analyzed by histopathological examination. Results: Ultrasonography can diagnose endometrial hyperplasia with 42.2% sensitivity with 84% specificity and overall accuracy 68.3%. Hysteroscopy can diagnose endometrial polyp with 60.9% sensitivity 93.2% specificity and overall accuracy 72.5%. Hysteroscopy can diagnose cervical polyp 77.8% sensitivity and 97.3% specificity and overall accuracy 95.8%. Ultrasonography can diagnose fibroid with 75% sensitivity and 86.9% specificity and overall accuracy 73.3%. While hysteroscopy had 52.8% sensitivity and 87.5% specificity and overall accuracy 75.8% Ultrasonography can diagnose adenomyosis with 71.4% sensitivity, 86% specificity and overall accuracy 85%. While hysteroscopy had 77.8% sensitivity with 91.9% specificity and overall accuracy 90.8%. Conclusion: Ultrasonography and hysteroscopy can diagnose endometrial pathologies in patients with perimenopausal abnormal uterine bleeding with comparable results.