{"paper_id":"9a4cc63c-261d-477f-98be-d2cf9c8ba431","body_text":"GENERAL GYNECOLOGY\nThe diagnostic value of evaluating the maximum velocity of blood\nflow in the uterine arteries of women with postmenopausal\nbleeding\nDariusz Samulak • Maciej Wilczak •\nMonika Englert-Golon • Magdalena Monika Michalska\nReceived: 9 August 2010 / Accepted: 16 December 2010 / Published online: 1 January 2011\n/C211The Author(s) 2010. This article is published with open access at Springerlink.com\nAbstract\nPurpose The aim was to evaluate the utility of ultraso-\nnographic examinations, such as the Doppler technique, in\ndiagnosing women with postmenopausal bleeding.\nMethods Specifically, maximum end-diastolic velocity of\nblood flow (MEDV), time-averaged maximum velocity of\nblood flow (TAMXV) and peak systolic velocity of blood\nflow (PSV) were evaluated. Data were obtained and ana-\nlyzed from a group of 100 female patients diagnosed and\ntreated because of abnormal bleeding from the genitals in\nthe Gynecological-Obstetrics Clinical Hospital of Poznan\nUniversity of Medical Sciences. The following packages\nwere used for statistic analyses: STATISTICA v 7.1\n(StatSoft, Inc. 2005), StatXACT v.5.0.3, CYTEL SOFT-\nWARE CORPORATION and Analyse-it Software v.1.68.\nResults The parameters evaluated were highest in the\ncarcinoma group, lower when proliferation was diagnosed\nand the lowest in the control group.\nConclusions Transvaginal ultrasonography diagnostics\nusing the Doppler technique was found to play an impor-\ntant role in the diagnostic process of pathologies within the\nendometrium.\nKeywords Endometrial carcinoma /C1MEDV /C1\nProliferation of the endometrium /C1PSV /C1TAMXV\nIntroduction\nThe introduction of ultrasonography to gynecological\ndiagnostics has improved the precision with which the\nendometrium can be evaluated in physiological and path-\nological states. Although carcinoma of the endometrium\ndoes not show typical ultrasonographic features, ultraso-\nnographic examination with a transvaginal probe is typi-\ncally used to detect these neoplasms. This examination is\nalso very useful in evaluating the degree of infiltration\nbefore an operation. Ultrasonography is non-invasive and\nis currently one of the most frequently used diagnostic\ntechniques for evaluating the endometrium. Thus, ultraso-\nnography has become an important supplement to a routine\ngynecological examination, and clinical procedures are\noften based on the results of this examination. However,\nusing this technique to measure the thickness of the\nendometrium itself is not sufficient [ 1–4].\nImaging using ultrasonography with the color Doppler\ntechnique created the potential to distinguish malignant\nchanges from non-malignant changes. This is one of the\nmost advanced diagnostic methods used in the diagnostic\nprocess of female genitals. Analyses of blood flow-\nvelocity in artery vessels based on maximum blood flow-\nvelocities makes it possible to create objective Doppler\nmeasurements, which allows for comparisons using any\nD. Samulak ( &) /C1M. M. Michalska\nDepartment of Obstetrics and Gynecology,\nRegional Hospital in Kalisz, ul. Torun´ska 7,\n62-800 Kalisz, Poland\ne-mail: samulakd@wp.pl\nD. Samulak\nClinic of Mother’s and Child’s Health,\nPoznan University of Medical Sciences, Poznan, Poland\nD. Samulak /C1M. Englert-Golon\nClinic of Gynecological Surgery,\nPoznan University of Medical Sciences, Poznan, Poland\nM. Wilczak\nDepartment of Medical Education,\nPoznan University of Medical Sciences, Poznan, Poland\n123\nArch Gynecol Obstet (2011) 284:1175–1178\nDOI 10.1007/s00404-010-1824-3\n\napparatus. However, due to existing controversies related\nto the measurement of particular Doppler parameters, the\naim of this paper was to analyze the perfusion in uterine\narteries in women hospitalized due to abnormal bleeding\nfrom the uterus using vaginal ultrasonography with color\nDoppler.\nMaterials and methods\nA group of 100 female patients diagnosed with and treated\nfor abnormal bleeding from the uterus in the Clinic of\nGynecological Surgery of the Gynecological-Obstetrics\nClinical Hospital of Poznan University of Medical Sci-\nences between December 2005 and January 2007, were\nstudied. The median age of endometrial cancer patients\nwas 62 years, of patients with endometrial hyperplasia was\n59 years and 46 years for the women without endometrial\npathology.\nGynecological examination and ultrasounds were\nalways done by the same doctor. During ultrasound\nexamination with empty bladder of patients we used vag-\ninal probe 5.0–6.5 Hz of Aloka model 5500. After analysis\nin the gray scale we always performed Doppler examina-\ntion analysis.\nBased on the analysis of blood velocity wave form in\nartery vessels, the following parameters were evaluated:\ntime-averaged maximum velocity of blood flow (TAM-\nXV), maximum end-diastolic velocity of blood flow\n(MEDV) and peak systolic velocity of blood flow (PSV).\nThese values were calculated automatically using ultraso-\nnographic software. Average values of three measurements\nof consecutive blood velocity waves were assumed to be\nrepresentative for the examination conducted. Results of\nthis ultrasonography examination were compared with a\nhistopathological examination of the endometrium. To\nevaluate the endometrium, the diagnostic curettage was\ndone and in some cases the endometrium was collected\nafter hysterectomy. Patients were divided into following\ngroups: 43 patients in whom endometrial carcinoma was\ndiagnosed during further diagnostics; 11 women in whom\nhyperplastic changes of endometrium were detected during\nfurther diagnostics and 46 patients in whom no changes\nwere diagnosed in the endometrium, as a control group.\nHistopathological examination was performed in histopa-\nthological laboratory in our hospital.\nCurettage was always performed in general anesthesia,\nafter dilatation of cervical canal. We collected material\nfrom the cervix and from the uterine cavity in different\nglasses and after the procedure the material was sent\nimmediately to the histopathological laboratory. Hyster-\nectomies were always performed transabdominaly in the\ngeneral anesthesia.\nThe results obtained were submitted to a statistical\nanalysis. TAMXV, MEDV and PSV values, measured on\nan interval scale due to the diagonal distribution of the\nparameters analyzed, were characterized with the aid of\nmedian values. The distributions of the above-mentioned\nparameters were assessed to determine their normality\nusing a Shapiro–Wilk test. An analysis of variance\nANOVA with a Newman–Keuls post-hoc test and a non-\nparametric Kruskal–Wallis test with Dunn’s multiple\ncomparisons test were used in order to make comparisons\nbetween the three groups. A level of 0.05 was assumed for\nthe risk of erroneous conclusions and for the significance\nlevel in this paper.\nCalculations were performed using the STATISTICA v\n7.1 (StatSoft, Inc. 2005) statistical package, as well as\nStatXACT v.5.0.3 by CYTEL SOFTWARE CORPORA-\nTION and Analyse-it Software v.1.68.\nThe studies have been approved by The Ethics Com-\nmittee in the University of Medical Sciences in Poznan on\n8 December 2005 and the project number is 1681/05.\nResults\nAfter histopathological examination we observed three\ngroups of patients: 43 patients with endometrial carcinoma,\n11 women with hyperplastic changes of the endometrium\nand 46 patients with no pathological changes in the endo-\nmetrium, as a control group.\nAfter statistical analysis it was shown that endometrial\nhyperplasia and carcinoma are found most frequently in\nurban women aged 51–60 years old. Among patients living\nin the country these lesions were observed much less fre-\nquently. Before the age of 40 endometrial carcinoma was\nfound occasionally. It turned out that among factors coin-\nciding with these endometrial pathologies the biggest\nimportance was found for obesity, arterial hypertension and\ndiabetes. Endometrial hyperplasia was most frequently\naccompanied by cholecystolithiasis, while the risk of\nendometrial carcinomas was much less affected by this\ndisease. Menopause after the age of 51 years increased the\nrisk of development of carcinoma or hyperplasia. However,\nearly menarche was not recorded in these groups. Increased\nparity was not a protective factor against the disease.\nRelationships occurring between the three groups of\npatients and the TAMXV are shown in Table 1.\nThe highest median value of TAMXV, 18.50 cm/s, was\nobserved in the group with carcinoma of the endometrium.\nThe median value of TAMXV was lower in the group of\nproliferations (TAMXV = 17.00 cm/s) and the lowest in\nthe control group (16.40 cm/s).\nWhen comparing average values of TAMXV in the\ndifferent groups, higher values were observed in patients\n1176 Arch Gynecol Obstet (2011) 284:1175–1178\n123\n\nwith carcinoma (TAMXV = 20.19 cm/s) and with prolif-\neration of the endometrium (TAMXV = 18.49 cm/s) than\nin women with no pathology within the endometrium\n(TAMXV = 17.20 cm/s). However, these differences were\nnot statistically significant. MEDV values based on mea-\nsurements in uterine arteries are shown in Table 2.\nThe median value of MEDV was 10.00 cm/s in patients\nwith carcinoma, 8.90 cm/s in patients with proliferation\nand 7.95 cm/s in the control group. Average MEDV values\nwere lowest in the group with carcinoma of the endome-\ntrium, amounting to 10.60 cm/s. Similar results were\nobtained in the group of proliferations (MEDV= 8.58 cm/s)\nand in the control group (MEDV = 8.99 cm/s). However,\nno significant differences of MEDV were found in the\nstatistical analyses performed.\nIn the carcinoma and proliferation groups, similar\nmedian values of PSV, 34.10 and 34.20 cm/s, were\nobtained. A lower median value, 29.55 cm/s, was obtained\nin the control group. Comparisons of average values of\nmaximum systolic velocity of blood flow did not show any\nstatistically significant differences between the three\ngroups, despite the fact that the PSV values obtained were\nhighest in women with carcinoma, lower in patients with\nproliferation and much lower in the control group\n(Table 3).\nTo summarize the results of the analysis, the highest\nvalues of TAMXV, MEDV and PSV were observed in the\ncarcinoma group, while values of these parameters were\nlower in the proliferation group and lowest in the control\ngroup. However, it is important to highlight that no\nparameter measured was significantly higher in the group\nof patients with carcinoma or proliferation in comparison\nwith the control group.\nDiscussion\nIn recent years, many studies have focused on the use of\nthe Doppler technique in evaluating blood flow in artery\nvessels. Many authors have reported that these examina-\ntions are important in enabling non-malignant and malig-\nnant changes to be distinguished. In the results of the\npresent study, no statistically significant increase of max-\nimum blood flow velocity in uterine arteries was observed\nin patients with carcinoma or proliferation in comparison to\nthe group showing no pathology within the endometrium.\nOur results are compatible with the results obtained by\nSladkevicius et al. [ 5]. This study found no statistically\nsignificant differences between TAMXV values in groups\nof women studied in an analysis of blood perfusion in\nuterine arteries.\nThe same authors, Sladkevicius et al. [ 6] in another\nstudy say that the measurement of endometrial thickness\nwith transvaginal ultrasonography is a better method for\ndiscriminating pathologies within endometrium than that\nDoppler velocimetry of the uterine arteries. Szpurek et al.\n[7] presented a different opinion. While evaluating TAM-\nXV values in uterine arteries in 58 patients with endome-\ntrial carcinoma, they showed significantly higher values of\nthis parameter in comparison with TAMXV values in 75\nwomen with no changes detected in the histopathological\nanalysis of the endometrium.\nTable 1 Comparison of TAMXV (cm/s) values in the cancer and proliferation groups and in the control group\nNumber\nof patients\nAverage Minimum Maximum Median 25 percentile 75 percentile\nCarcinoma 43 20.19070 10.20000 36.90000 18.50000 14.70000 24.60000\nProliferation 11 18.49091 12.60000 28.50000 17.00000 15.30000 22.40000\nControl group 46 17.20000 9.60000 28.60000 16.40000 13.70000 21.10000\nTotal 100 18.62800 9.60000 36.90000 17.20000 14.20000 22.40000\nP value [0.05 [0.05 [0.05 [0.05 [0.05 [0.05\nTable 2 Comparison of MEDV (cm/s) values in the cancer and proliferation groups and in the control group\nNumber\nof patients\nAverage Minimum Maximum Median 25 percentile 75 percentile\nCarcinoma 43 10.60930 2.800000 23.500000 10.00000 7.600000 12.10000\nProliferation 11 8.58182 4.800000 11.300000 8.900000 7.600000 9.00000\nControl group 46 8.99783 2.400000 21.100000 7.950000 6.500000 11.40000\nTotal 100 9.64500 2.400000 23.500000 8.900000 6.900000 11.80000\nP value [0.05 [0.05 [0.05 [0.05 [0.05 [0.05\nArch Gynecol Obstet (2011) 284:1175–1178 1177\n123\n\nIn data published in 2005, Englert-Golon et al. [ 8] also\ndemonstrated the utility of TAMXV in evaluating uterine\narteries in women with abnormal postmenopausal bleeding.\nAfter analyzing the results of 256 patients, these authors\nobtained significantly higher values of this parameter in the\ngroup of endometrial carcinoma in comparison with the\ngroup of proliferations of the endometrium.\nIn the databases available online, there are few infor-\nmation related to the evaluation of the maximum velocity\nof blood flow in the uterine arteries. However, after anal-\nysis of available data, it can be noted that the authors have\nreported an increase in the value of these parameters in\npatients with pathology in the endometrium but such dif-\nferences were not always statistically significant.\nConclusions\n1. Transvaginal ultrasonography diagnostics using the\nDoppler technique is a useful method for diagnosing\npathologies within the endometrium.\n2. Evaluating blood flow velocity in uterine arteries in\nwomen with abnormal bleeding from the genitals does\nnot allow groups with a higher risk of proliferation or\ncarcinoma of the endometrium to be distinguished.\nConflict of interest The authors declare that they have no conflict\nof interest.\nOpen Access This article is distributed under the terms of the\nCreative Commons Attribution Noncommercial License which per-\nmits any noncommercial use, distribution, and reproduction in any\nmedium, provided the original author(s) and source are credited.\nReferences\n1. Epstein E, Skoog L, Isberg PE et al (2002) An algorithm including\nresults of gray-scale and power Doppler ultrasound examination to\npredict endometrial malignancy in women with postmenopausal\nbleeding. Ultrasound Obstet Gynecol 4(20):370–376\n2. Lynch PM (1999) Clinical challenges in management of familial\nadenomatous polyposis and hereditary non polyposis colorectal\ncancer. Cancer 86(11):25–33\n3. Stachowicz N, Czekierdowski A, Daniłos´ J, Kotarski J (2002) Use\nof three-dimensional ultrasonography in the evaluation of the\nvolume of the endometrium in women experiencing bleeding from\nthe uterine cavity. Ginekol Pol 11(73):970–975\n4. Warming L, Ran P, Skouby S, Christiansen C (2002) Measurement\nprecision and normal range of endometrial thickness in a\npostmenopausal population by transvaginal ultrasounds. Ultra-\nsound Obstet Gynecol 5(20):492–495\n5. Sladkevicius P, Valentin L, Marsal K (1995) Transvaginal gray-\nscale and Doppler ultrasound examinations of the uterus and\novaries in healthy postmenopausal women. Ultrasound Obstet\nGynecol 6(2):81–90\n6. Sladkevicius P, Valentin L, Marsal K (1994) Endometrial thick-\nness and Doppler velocimetry of the uterine arteries as discrim-\ninators of endometrial status in women with postmenopausal\nbleeding: a comparative study. Am J Obstet Gynecol 171(3):722–\n728\n7. Szpurek D, Moszyn´ski R, Sajdak S, Roszak A (2000) Evaluation\nof blood flow in the arteries of the uterus in patients with\nendometrial carcinoma by means of vaginal ultrasonography using\nthe color Doppler technique. Nowotwory 50(1):35–38\n8. Englert-Golon M, Szpurek D, Moszyn ´ski R, Pawlak M, Sajdak S\n(2005) Diagnostic value of evaluating blood flow by means of the\n‘‘power’’ angio Doppler technique in uterine arteries and in\nendometrium vessels in women with postmenopausal bleeding.\nGinek Pol 76(Suppl 2):134\nTable 3 Comparison of PSV (cm/s) values in the cancer and proliferation groups and in the control group\nNumber\nof patients\nAverage Minimum Maximum Median 25 percentile 75 percentile\nCarcinoma 43 34.11860 16.60000 55.30000 34.10000 26.30000 39.80000\nProliferation 11 33.61818 21.30000 48.90000 34.200000 28.10000 36.40000\nControl group 46 31.48696 13.10000 56.70000 29.55000 23.20000 39.80000\nTotal 100 32.85300 13.10000 56.70000 33.20000 25.25000 38.40000\nP value [0.05 [0.05 [0.05 [0.05 [0.05 [0.05\n1178 Arch Gynecol Obstet (2011) 284:1175–1178\n123","source_license":"CC0","license_restricted":false}