|Year : 2019 | Volume
| Issue : 4 | Page : 1388-1392
Uterine artery Doppler indices may predict significant causes of perimenopausal bleeding
Ayman Shabana1, Mohamed Rezk1, Dalia Ibrahim1, Shaimaa Abd-Elhamid2, Mohammed Salah1
1 Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Radiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||03-Nov-2018|
|Date of Decision||13-Dec-2018|
|Date of Acceptance||15-Dec-2018|
|Date of Web Publication||31-Dec-2019|
Department of Obstetrics and Gynecology, Menoufia University, Sirs Ellyan, Menoufia
Source of Support: None, Conflict of Interest: None
The aim was to assess whether uterine artery Doppler indices can predict significant causes of uterine bleeding in patients with perimenopausal bleeding or not.
Treatment of abnormal uterine bleeding needs easy diagnostic procedure, for determining the etiological factor of disease. The abnormal uterine bleeding is more common in the perimenopausal than in the postmenopausal women, and it is a sign of endometrial proliferative or hyperplastic changes.
Patients and methods
This prospective observational study was conducted on 106 women with perimenopausal bleeding [who were subdivided into two groups, one with nonsignificant causes (52 patients) and the other with significant causes (54 patients)] and 50 healthy controls, with transvaginal ultrasonic color Doppler study performed before endometrial sampling with pipelle in those with perimenopausal bleeding. Test characteristics of uterine artery pulsatility index and resistance index for prediction of significant causes of bleeding were the main outcome measures.
Uterine artery pulsatility index at cutoff value of 1.82 with area under the curve of 0.834, sensitivity of 70.8%, specificity of 92%, positive predictive value of 94.9%, negative predictive value of 69.9%, and accuracy of 78%, whereas uterine artery resistance index at cutoff value of 0.575 with area under the curve of. 998, sensitivity of 96.2%, specificity of 100%, positive predictive value of 100%, negative predictive value of 92.6%, and accuracy of 97% were predictive of significant causes of perimenopausal bleeding.
Uterine artery Doppler is a simple, readily available and noninvasive tool that could be beneficial in conjunction with endometrial sampling to detect significant causes of perimenopausal bleeding.
Keywords: endometrial thickness, hysteroscopy, perimenopausal bleeding, transvaginal ultrasonography, uterine artery Doppler
|How to cite this article:|
Shabana A, Rezk M, Ibrahim D, Abd-Elhamid S, Salah M. Uterine artery Doppler indices may predict significant causes of perimenopausal bleeding. Menoufia Med J 2019;32:1388-92
|How to cite this URL:|
Shabana A, Rezk M, Ibrahim D, Abd-Elhamid S, Salah M. Uterine artery Doppler indices may predict significant causes of perimenopausal bleeding. Menoufia Med J [serial online] 2019 [cited 2020 Jun 6];32:1388-92. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1388/274260
| Introduction|| |
Menstrual cycle irregularity marks the menopausal transition in most women and starts around mid-40s till the last menstrual period . Abnormal uterine bleeding (AUB) may be defined as a bleeding pattern that differs in frequency, duration, and amount from a pattern observed during a normal menstrual cycle or after menopause . Ultrasonography is noninvasive and is currently the most frequently used diagnostic modality for evaluating the endometrium in patients with AUB ,,. Transvaginal color Doppler sonography with a possibility of analyzing vascular changes in the uterine arteries presents an important diagnostic dimension in the evaluation of AUB, particularly in women older than 40 years . More than 10 years have elapsed since the use of uterine artery Doppler indices [chiefly, resistance index (RI) and pulsatility index (PI)] for evaluating patients with AUB. The aim of this study was to determine whether uterine artery Doppler indices can predict significant causes of uterine bleeding in patients with perimenopausal bleeding or not.
| Patients and Methods|| |
This was a prospective observational study that included perimenopausal women presenting with AUB from November 2017 to June 2018 at the Department of Obstetrics and Gynecology in collaboration with the Radiology Department at Menoufia University hospital, Menoufia Governorate, Egypt. Ethical approval of the study protocol was obtained from Menoufia faculty of Medicine (Ethical clearance letter number 218 G/2017) in accordance with the revised Helsinki declaration. All participants signed the informed consent form before commencing the study. The study included 106 perimenopausal consecutive women with AUB with inclusion of 50 healthy women without bleeding as controls [Figure 1]. Calculation of the sample size was based on the results of a previous observational study conducted on 71 patients  to test the value of Doppler study of uterine arteries in women with AUB. Eligibility criteria included women above the age of 40 years with intact uterus and no prior endometrial sampling, and with isolated endometrial causes of AUB following clinical examination, transvaginal ultrasound, and endometrial sampling by Pipelle. Women with organic lesions such as uterine fibroids and adnexal masses, cervical or vaginal pathology, bleeding tendency, medical disorders (as hypertension and diabetes mellitus), hormonal contraception in the past 3 months as well as postmenopausal women were excluded from the study. Menopausal status was defined as absence of menstruation for a minimum of 12 months. Patients with medical disorders or receiving hormonal therapy particularly progesterone were excluded to alleviate the effect of drug therapy or the disorder on uterine artery Doppler indices . Uterine artery Doppler study was performed at the Radiology Department, using a Hitachi EUB-7000 ultrasound machine (Hitachi, TOKYO, Japan) by 7-MHz transvaginal probe. Examinations were done by a single sonographer with previous experience in Doppler ultrasound to avoid interobserver variability with intraobserver variability of 0.003. Pulsed wave Doppler was applied at a sampling gate of 2 mm with the angle of insonation at less than 30°. PI and RI were determined automatically following three similar waveforms in both right and left uterine arteries with recording of the average readings. Women were instructed to avoid the intake of nonsteroidal anti-inflammatory drugs 24 h before the examination. All the ultrasound Doppler studies were measured between 8: 00 and 11: 00 a.m. to eliminate diurnal variation in the early follicular phase between days 4 and 7 after menstruation. Included women underwent outpatient endometrial sampling by the Pipelle the next day following ultrasound examination, with the use of cervical tenaculum in difficult cases. All endometrial biopsies were classified according to The International Federation of Gynecology and Obstetrics classification system , PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified). All endometrial samples were examined by two different pathologists with interobserver variability of 0.004. Gynecologists performed endometrial sampling as well as pathologists were blinded to the results of Doppler studies. Patients with perimenopausal bleeding were divided into two groups based on the results of endometrial sampling. Group A included 52 patients with nonsignificant causes of AUB such as disordered endometrium, secretory endometrium, and atrophic endometrium. Group B included 54 patients with significant causes of AUB such as endometrial hyperplasia (all subtypes) and endometrial carcinoma. The data were tabulated and analyzed by SPSS (statistical package for the social sciences) version 22 on IBM compatible computer (SPSS Inc., Chicago, Illinois, USA). Descriptive statistics were presented as number, percentage, mean, and SD. Analytic statistics included Kruskal–Wallis test, which was used when data are not normally distributed. χ2-test was also used. P value of less than 0.05 was considered statistically significant. Receiver operator characteristic (ROC) curve was done to determine cutoff value, sensitivity, and specificity of PI and RI for prediction of significant causes of AUB.
|Figure 1: Flow diagram of recruitment and retention of participants in the study.|
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| Results|| |
There was no significant difference between patients and controls regarding age and prior contraception [Table 1]. Features of AUB included duration of bleeding, patterns of bleeding, number of bleeding days in the last month, number of the used vulval pads over the last month as well as hemoglobin concentration and pathological spectrum according to International Federation of Gynecology and Obstetrics classification in patients with AUB groups [Table 2]. Ultrasound features among cases in comparison with controls show highly significant difference regarding endometrial thickness, uterine artery PI, and uterine artery RI [Table 3]. Uterine artery PI and ROC curve of uterine artery RI [Figure 2] showed that Uterine artery PI at cutoff value of 1.82 with area under the curve of 0.834, sensitivity of 70.8%, specificity of 92%, positive predictive value (PPV) of 94.9%, negative predictive value (NPV) of 69.9%, and accuracy of 78%, whereas uterine artery RI at cutoff value of 0.575 with area under the curve of. 998, sensitivity of 96.2%, specificity of 100%, PPV of 100%, NPV of 92.6%, and accuracy of 97% were predictive of significant causes of AUB [Table 4].
|Table 2: Features and pathological spectrum of abnormal uterine bleeding (n=106)|
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|Figure 2: Receiver operator characteristic curve of uterine artery pulsatility index and resistance index.|
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|Table 4: Test characteristics of uterine artery Doppler indices for prediction of significant causes of abnormal uterine bleeding (in group B)|
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| Discussion|| |
Perimenopausal bleeding is related to abnormalities along the hypothalamic–pituitary–ovarian axis resulting in changes in the hormonal milieu in this age group . In approximately half of the patients in the current study, the cause of AUB was endometrial hyperplasia. Previous studies reported variable incidence as low as 5–10% in some studies , and as high as 60–62% in others ,. Uterine artery PI and RI at cutoff value, sensitivity, specificity, PPV, NPV, and accuracy of 1.82, 70.8%, 92%, 94.9%, 69.9%, and 78% for PI and 0.575, 96.2%, 100%, 100%, 92.6%, and 97% for RI, respectively, were predictive of significant causes of AUB, including endometrial hyperplasia and endometrial carcinoma in the current study. A previous comparative study between endometrial thickness and uterine artery Doppler study (PI and time-averaged maximum velocity) in 138 patients with postmenopausal bleeding revealed the superiority of endometrial thickness for the discrimination between benign and malignant endometrial lesions  High BMI raises the chance of atypical hyperplasia diagnosis in endometrial biopsy . A total of 71 patients with AUB older than 40 years, of which 10 were in postmenopause phase, have been tested by transvaginal color Doppler before endometrial curettage. Significantly lower uterine artery PI values were obtained in the group of patients with pathologically altered endometrium . In another previous study conducted on 81 patients with AUB, the final pathology analysis revealed that 55/81 (67.9%) had normal endometrial tissue and 26/81 (32.1%) had an abnormality (endometrial hyperplasia, polyp, or cancer). Univariate analysis found that PI less than 2 and RI less than 0.9 were correlated with abnormal endometrium . Transvaginal color Doppler sonography as sensitive, specific, and noninvasive method has significant place in the diagnostic procedure for evaluation of AUB to detect significant causes of bleeding such as endometrial hyperplasia and carcinoma ,. The strength of this study resides in the inclusion of control group to compare the ultrasonic features (endometrial thickness and uterine artery Doppler indices) with those having perimenopausal bleeding. Inability to extend the period of follow-up to record the clinical outcome of patients with significant causes of AUB as well as the low number of patients with malignant lesions constitute unintended limitations of the current study. Uterine artery Doppler study is simple and noninvasive and could be a valuable tool to assess women with perimenopausal bleeding before endometrial sampling to guide further management.
| Conclusion|| |
Uterine artery Doppler is a simple, readily available, and noninvasive tool that could be beneficial in conjunction with endometrial sampling to detect significant causes of perimenopausal bleeding. Larger studies are warranted to confirm or refute these findings.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Taff e JR, Dennerstein L. Menstrual patterns leading to the final menstrual period. Menopause 2002; 9
Ely JW, Kennedy CM, Clark EC, Bowdler NC. Abnormal uterine bleeding: a management algorithm. J Am Board Fam Med 2006; 19
Gull B, Carlsson S, Karlsson B, Ylostalo P, Milsom I, Granberg S. Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding: is it always necessary to perform an endometrial biopsy? Am J Obstet Gynecol 2002; 182
Bedner R, Rzepka-Gorska I. Transvaginal ultrasonography in the diagnosis of endometrial and uterine cavity changes in perimenopausal women. Ginekol Pol 2002; 73
Kotdawala P, Kotdawala S, Nagar N. Evaluation of endometrium in peri-menopausal abnormal uterine bleeding. J Midlife Health 2013; 4
Badawy AM, Abu-Elata M. Can colour Doppler ultrasonography predict the prognosis of endometrial hyperplasia ? J Obstet Gynaecol 2003; 23
Dragojević S, Mitrović A, Dikić S, Canović F. The role of transvaginal colour Doppler sonography in evaluation of abnormal uterine bleeding. Arch Gynecol Obstet 2005; 271
Rezk M, Al-Halaby A, Emarh M, Shawky M. Correlation between uterine artery Doppler indices and menstrual irregularities among levonorgestrel releasing intrauterine system and depot medroxyprogesterone acetate users: a prospective observational study. Eur J Contracept Reprod Health Care 2017; 22
Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011; 113
Jairajpuri ZS, Rana S, Jetley S. Atypical uterine bleeding – histopathological audit of endometrium – a study of 638 cases. Al Ameen J Med Sci 2013; 6
Abdullah LS, Bondagji NS. Histopathological pattern of endometrial sampling performed for abnormal uterine bleeding. Bahrain Med Bull 2011; 33
Anwer M, Imdad SK, Jamal Q, Naqvi SQH. Histopathological correlation of endometrial curettage with abnormal uterine bleeding pattern. J Surg Pak 2004; 9
Vaidya S, Lakhey M, Vaidya S, Sharma PK, Hirachand S, Lama S, KC S. Histopathological pattern of abnormal uterine bleeding in endometrial biopsies. Nepal Med Coll J 2013; 15
Sladkevicius P, Valentin L, Marsál K. Endometrial thickness and Doppler velocimetry of the uterine arteries as discriminators of endometrial status in women with postmenopausal bleeding: a comparative study. Am J Obstet Gynecol 1994; 171
Gawron I, Loboda M, Babczyk D, Ludwin I, Basta P, Pityński K, Ludwin A. Endometrial cancer and hyperplasia rate in women before menopause with abnormal uterine bleeding undergoing endometrial sampling. Przegl Lek 2017; 74
Wilailak S, Jirapinyo M, Theppisai U. Transvaginal Doppler sonography: is there a role for this modality in the evaluation of women with postmenopausal bleeding? Maturitas 2005; 50
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]