The Egyptian Journal of Radiology and Nuclear Medicine (2015) 46, 235–243

Egyptian Society of Radiology and Nuclear Medicine

The Egyptian Journal of Radiology andNuclearMedicine

www.elsevier.com/locate/ejrnmwww.sciencedirect.com

ORIGINAL ARTICLE

Role of transvaginal ultrasonography and colour

Doppler in the evaluation of postmenopausal

bleeding

Abbreviations: PMB, postmenopausal bleeding; PI, pulsatility index;

RI, resistive index; S/D ratio, systolic/diastolic ratio; TVUS,

transvaginal ultrasound; TVCD, transvaginal colour Doppler* Corresponding author at: Tanta University Hospital, Tanta,

Gharbeya, Egypt. Tel.: +20 1068643995.

E-mail addresses: hythamharoon@yahoo.com (N.M. AbdelMaboud),

reemnagaty20@rocketmail.com (H.H. Elsaid).1 Address: Tanta University Hospital, Tanta, Gharbeya, Egypt.

Tel.: +20 1223658711.

Peer review under responsibility of Egyptian Society of Radiology and

Nuclear Medicine.

http://dx.doi.org/10.1016/j.ejrnm.2014.11.0140378-603X � 2014 The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier B.V. All rights reserv

Noha Mohamed AbdelMaboud *, Hytham Haroon Elsaid1

Department of Radiology, College of Medicine, Tanta University, Egypt

Received 28 May 2014; accepted 20 November 2014Available online 12 December 2014

KEYWORDS

Transvaginal ultrasound;

Postmenopausal bleeding;

Endometrial carcinoma

Abstract Aim of the work: The aim of this study is to evaluate the role of transvaginal ultrasonog-

raphy and colour Doppler in postmenopausal bleeding.

Patients and methods: In the study fifty female patients with their age ranging between 45 and

80 years were subjected to transvaginal US examination and transvaginal colour and pulsed

Doppler examination.

Results: All the malignant cases and 94.7% of the benign cases had endometrial thickness P5 mm,

however 90% of the control group with the remaining of the benign cases (5.2%) had endometrial

thickness <5 mm. The mean uterine artery RI and PI were lower in cases with PMB than in control

cases and in cases with malignant causes than benign causes. The mean spiral artery RI & PI were

lower in cases with benign than in cases with malignant causes of PMB.

Conclusion: In conclusion, transvaginal colour Doppler as a noninvasive method has a significant

place in the diagnostic procedures for evaluation of PMB. Transvaginal colour Doppler can help in

differentiating benign from malignant endometrial changes.� 2014 The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier

B.V. All rights reserved.

1. Introduction

Abnormal uterine bleeding at any age in women’s life isdisruptive and worrisome, but postmenopausal bleeding is of

special concern because it is the only common clinical indica-tion of the presence of endometrial carcinoma (1). Postmeno-pausal bleeding (PMB) can be defined as uterine bleeding

occurring at least one year after menopause, its incidencecan be as high as 10% (2). The differential diagnosis of post-menopausal bleeding is wide, and includes, endometrial hyper-

plasia, endometrial polyp, endometrial carcinoma, cervicalcancer and uterine leiomyosarcoma (3). It is estimated that

ed.

236 N.M. AbdelMaboud, H.H. Elsaid

10–15% of patients who present with postmenopausal bleed-ing end up having endometrial cancer (4). Several differentapproaches have been proved to be clinically useful screening

methods for early detection of endometrial abnormality inwomen with irregular uterine bleeding. These include dilata-tion and curettage (D&C), hysteroscopy, sonohysterography

and transvaginal sonography (TVS) with the measurement ofendometrial thickness (1). Recently transvaginal colour andpulsed Doppler ultrasound has increased the reliability of ultr-

asonographic diagnosis of women with certain endometrialpathologies. It is able to detect subtle changes in the endome-trium and it has been observed that endometrial thickness<4 mm is usually associated with normal morphology (5).

In patients with thickened endometrium, a secondary test suchas power Doppler could play a role in refining the diagnosis(6). Doppler velocimetric study of the uterine artery offers a

simple, noninvasive and valuable method in screening womenwith postmenopausal bleeding. Transvaginal colour Dopplerimaging allows the assessment of endometrial vascularization

(7). A good correlation has been found between the uterineartery flow velocity waveform and the histopathological diag-nosis in women with PMB (8). It is recommended to take 5 mm

endometrial thickness and 0.85 uterine artery RI as a cut-offvalue to detect endometrial pathology (9). Colour Dopplersonography has a role in assessment of endometrial polypsby detection of pedicle artery reaching the central part of the

endometrium (10).

2. Patients and methods

2.1. Patients

This prospective study was conducted according to the guide-lines of the ethics committee of our university and wasapproved by our institutional review board. All females gave

us a written informed consent.This prospective study was done between December 2013

and April 2014 including 50 females with the age range from

45 to 80 years old, complaining of postmenopausal bleeding,and 10 control females with the same age range.

2.2. Methods

Transvaginal US was carried out using 6 MHz transvaginaltransducer. All women were examined transvaginally in the

Table 1 Comparison between the endometrial thickness cutoff betw

Endometrial thickness Pt. with PMB

Benign Ma

No. % No

P5 mm 36 94.7 12

<5 mm 2 5.3 0

Total 38 100 12

Benign and malignant Benign and control

P value

0.417 0.001

P< 0.05 was considered to be statistically significant.

lithotomy position, with an empty bladder. First, theconventional grey-scale US examination of the uterus wasperformed. Transverse and longitudinal sections of the endo-

metrium were obtained and maximal endometrial thickness inthe sagittal plane was measured (double layer). Malignancywas suspected if there was an irregular endometrial/myome-

trial junction, or an inhomogeneous endometrial texture.After completion of grey-scale US, power Doppler US wascarried out. The endometrial and subendometrial areas were

magnified and blood vessels were observed. Only blood ves-sels that were within 5 mm from the endometrial edge wereincluded. Endometrial thickness of 5 mm and PI < 1 wereused as cutoff points for endometrial thickness and blood

flow respectively. The uterine artery was examined and thePI, and RI were measured. Clinical and ultrasound data werecompared with the final histological diagnosis of the endome-

trium, which was obtained by D&C or hysteroscopicresection or by hysterectomy.

3. Statistical analysis

Statistical analyses were performed using the SPSS softwarepackage version 16.0 (statistical package for social science

TM) and P < 0.05 was considered to be statistically signifi-cant. The sensitivity and specificity for each protocol werecompared in order to evaluate the reliability of each of them

and when they are combined.

4. Results

Comparison between the endometrial thickness cutoff (5 mm)in the control group and the group with postmenopausalbleeding whether benign or malignant is shown in Table 1.

This table shows that all the malignant cases and 94.7% ofthe benign cases had endometrial thickness P5 mm, however90% of the control group with the remaining of the benigncases (5.2%) had endometrial thickness <5 mm.

This table shows that the mean uterine artery RI and PIwere lower in cases with PMB than in control cases and incases with malignant causes than benign causes (Table 2).

This table shows that the mean spiral artery RI and PI werelower in cases with malignant than in cases with malignantcauses of PMB (Table 3).

This table shows that the mean uterine artery RI, PI andspiral artery RI, PI were lower in malignant uterine lesionsthan other benign causes (Table 4).

een both groups of the study.

PM control group

lignant

. % No. %

100 1 10

0 9 90

100 10 100

Malignant and control

0.001

Table 2 Comparison of uterine artery RI and PI between

cases with PMB PM control groups.

Doppler indices Pt. with PMB PM control group

Benign Malignant

RI 0.57–0.82 0.47–0.52 0.85–1

0.73 0.50 0.98

Mean 0.67 0.98

P value 0.001

PI 0.80–1.60 0.80–1.60 1.80–2.33

1.19 1.19 2.16

Mean 0.99 2.16

P value 0.001

Total 38 12 10

Table 3 Comparison of spiral artery RI and PI between cases

with benign and malignant causes of PMB.

Doppler indices Benign causes Malignant causes P value

RI 0.54–0.73 0.42–0.48 0.059

Mean 0.61 0.45

PI 0.77–1.33 0.52–0.56 0.001

Mean 0.96 0.54

Transvaginal ultrasonography and colour Doppler in evaluation of postmenopausal bleeding 237

5. Discussion

The measurement of endometrial thickness by transvaginal USis the most convenient, noninvasive method for the diagnosis

of endometrial pathologies but it is a nonspecific clinical evi-dence for endometrial malignancy (11). Doppler analysis ofuterine and myometrial arteries could be used in differentia-

tion between benign and malignant uterine findings (11). Usingthe transvaginal approach, the accuracy of measurement isincreased because of the small distance between the probe

and the vessels under investigation and better identificationof smaller vessels due to better resolution (12). The presentstudy aimed at making a correlation between results obtainedby TVUS with colour Doppler of uterine and spiral arteries

(myometrial vessels) and endometrial histopathological find-ings in a trial to disclose the helpful role of TVCD for detectingmalignancy as a cause of PMB. This study has been conducted

on 60 females, 50 of them complaining of PMB, the other 10were control (postmenopausal females not complaining of

Table 4 Comparison of uterine artery RI, PI and spiral artery RI,

Doppler indices RI

Causes of PMB Uterine artery Spiral

Endometrial carcinoma 0.47–0.52 (0.50) 0.42–0

P value 0.255

Endometrial hyperplasia 0.61–0.82 (0.77) 0.57–0

P value 0.033

Uterine fibroid 0.57–0.75 (0.66) 0.54–0

P value 0.297

bleeding), 38 cases were diagnosed as benign endometriallesion and 12 were diagnosed as malignant endometrial lesionby histopathology. As regards the results of TVUS in the pres-

ent study, 5 mm is the cutoff point of endometrial thickness fordifferentiating malignant from benign cases. There was a sta-tistically significant difference in endometrial thickness mea-

sured by TVUS between the two groups with a tendencytowards a thicker endometrium in the malignant group.

Develioglu et al. (9) who had studied 97 postmenopausal

women presented by PMB stated that the endometrial thick-ness of 9.6 mm is the cutoff value for diagnosing endometrialcarcinoma. In a study performed by Jacobs et al. (13) to assessthe sensitivity of TVUS screening for endometrial cancer in

postmenopausal women, they found that the endometrialthickness of 5 mm is the cutoff value in endometrial carcinomawith sensitivity of 77.1% and specificity of 85.8%. The studied

groups included in that study were 96 patients with PMB.TVCD imaging is a simple, noninvasive and valuable

method in screening women with PMB. Doppler velocimetric

study of the uterine artery also allows the assessment of endo-metrial vascularization (1). Svetlana et al. (14) stated that thelow value of hemodynamic parameters at the uterine arteries

level (RI < 0.61) has a positive predictive value in the detec-tion of endometrial pathological changes. They also stated thatin majority of patients with endometrial cancer the PI valueswere less than 1.1 in the group of patients with benign endome-

trial changes, and values of this hemodynamic parameters werehigher than 2.0.

In our study, the results obtained by TVCD were through

studying the RI and PI of the uterine arteries. There was a sig-nificant difference in RI of the uterine arteries in benign andmalignant groups, measured by Doppler US between the two

groups, with a tendency towards a lower RI in the malignantgroup, the best cutoff value for RI of uterine artery is 0.50,(0.50 or less predict malignancy). There was also a significant

difference in PI of the uterine arteries in benign and malignantgroups with a tendency towards a lower PI in the malignantgroup; the best cutoff value is 0.64. Colour Doppler studiesof the uterine arteries in the present study showed that the

RI is lower in cases of malignancy compared to those withbenign lesions. The decrease in RI values in cases of malig-nancy is thought to be a reflection of the neovascularization

occurring within and around the tumour tissue distal to thepoint of sampling of the uterine artery. There was a significantcorrelation between left and right uterine artery measurements

so either can be used for screening.Kucur et al. (15) found that there was a significant correla-

tion between spiral artery RI and PI and different endometrial

PI between cases with benign and malignant causes of PMB.

PI

artery Uterine artery Spiral artery

.48 (0.45) 0.55–0.79 (0.67) 0.52–0.56 (0.54)

0.025

.73 (0.63) 0.98–1.60 (1.31) 0.83–1.33 (1.01)

0.016

.70 (0.60) 0.80–0.83 (0.81) 0.60–0.82 (0.77)

0. 571

Fig. 1 (a) Transvaginal ultrasound examination found regular, thick and heterogeneous endometrium, measured about 1.2 cm; (b)

Colour Doppler examination of the endometrium revealed increased endometrial vascularity and pulsed Doppler examination of spiral

arteries showed its blood flow velocity waveform with RI = 0.59, PI = 0.63; (c) Doppler examination of uterine artery showed its blood

flow velocity waveform with RI = 0.61, PI = 0.83. The patient underwent D and C and histopathological study confirming the diagnosis

of endometrial hyperplasia with atypia.

238 N.M. AbdelMaboud, H.H. Elsaid

Fig. 2 (a) Transvaginal ultrasound examination found a well defined, inhomogenous myometrial focal mass lesion measured about

23 · 21 mm with regular, thick endometrium, measured about 7 mm; (b) Colour Doppler examination of the uterus showed vasculature

around the lesion and pulsed Doppler examination of spiral arteries showed blood flow velocity waveform with RI = 0.54, PI = 0.77; (c)

Doppler examination of uterine artery showed its blood flow velocity waveform with RI = 0.57, and PI = 80 patient underwent

hysterectomy and histopathological study of the lesion confirms the diagnosis of uterine fibroid.

Transvaginal ultrasonography and colour Doppler in evaluation of postmenopausal bleeding 239

Fig. 3 (a) Transvaginal ultrasound examination of the uterus showed grossly thickened heterogeneous echogenic endometrium,

measured about 29 mm; (b) Colour Doppler examination of the uterus showed increased vascularity of the lesion and pulsed Doppler

examination of spiral arteries showed its blood flow velocity waveform with high diastolic flow, its RI = 0.42, PI = 0.54; (c) Doppler

examination of uterine artery showed its blood flow velocity waveform with high diastolic flow, RI = 0.52, and PI = 0.60. The patient

underwent hysterectomy and histopathological study of the lesion confirms the diagnosis of endometrial carcinoma.

240 N.M. AbdelMaboud, H.H. Elsaid

histologies, in patients with endometrial cancer spiral artery PIwas found to be lower and significantly lower than other

groups in endometrial cancer, hyperplasia, submucous fibroid,and endometrial polyp. Spiral artery RI was also lower inendometrial polyp, hyperplasia and fibroid groups.

In our study, there was a significant difference in RI of thespiral arteries for both benign (Figs. 1, 2 and 5) and malignantgroups measured by Doppler US with a tendency towards a

lower RI in the malignant group (Figs. 3 and 4); the best cutoffvalue for RI of spiral arteries is 0.45. There was also a signif-icant difference in PI of the spiral arteries for both benign andmalignant and the malignant group with tendency towards a

lower RI in the malignant group, and the best cutoff valuefor PI of spiral arteries is 0.45.

The difference between the results of the present study andthose reported by the different authors previously mentioned,might be attributed to many variables that can influence the

Doppler measurements such as variation in the angle of inson-ation of the Doppler beam which cannot be standardized orprecisely determined, type of Doppler beam used, machine res-

olution, the sample sizing ability, quality of produced image,and the patient cooperation during the examination.

In agreement with our results, colour Doppler is a useful toolfor identifying the presence of uterine cancer, as it determines

Fig. 4 (a) Transvaginal ultrasound examination of the uterus showed grossly thickened heterogeneous endometrium with myometrial

infiltration, and endometrial thickness measured about 35 mm; (b) Doppler examination of the uterus showed increased vascularity of the

lesion and pulsed Doppler examination of spiral arteries showed its blood flow velocity waveform with high diastolic flow, its RI = 0.47.

(c) Doppler examination of uterine artery showed its blood flow velocity waveform with high diastolic flow, RI = 0.50, and PI 0.55. The

patient underwent hysterectomy and histopathological study of the lesion confirms the diagnosis of endometrial carcinoma.

Transvaginal ultrasonography and colour Doppler in evaluation of postmenopausal bleeding 241

the type of angiogenesis. High resistance in the sub-and intra-endometrial vessels measured by resistive and/or pulsatilityindices indicates benign pathology, while low resistance demon-

strates possible malignant pathology (3).

Furthermore, from our study, we conclude that, thecombination of both TVUS and Doppler examination of theendometrium and the uterine arteries can contribute to a

correct pathology of endometrial malignancy in women with

Fig. 5 (a) Transvaginal ultrasound examination of the uterus showed a well defined homogenous polyp like mass occupying the uterine

cavity, and endometrial thickness measured 11 mm. (b) Colour Doppler examination of the uterus showed feeding vessel supplying the

polyp. (c) Doppler examination of uterine artery showed its blood flow velocity waveform with high diastolic flow, RI = 0.73, and

PI = 1.33. The patient underwent hysterectomy and histopathological study of the lesion confirms the diagnosis of endometrial polyp.

242 N.M. AbdelMaboud, H.H. Elsaid

postmenopausal bleeding and endometrium P5 mm. The

greater the colour content of the endometrium, the greaterthe risk of endometrial malignancy.

6. Conclusion

In conclusion, transvaginal colour Doppler as a noninvasivemethod has a significant place in the diagnostic procedures

for evaluation of PMB. Transvaginal colour Doppler can

help in differentiating benign from malignant endometrialchanges.

Conflict of interest

None declared.

Transvaginal ultrasonography and colour Doppler in evaluation of postmenopausal bleeding 243

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