Ultrasound Obstet. Gynecol. 1 (1991) 359-373 Transvaginal color Doppler in gynecology T. H, Bourne The Ovarian Seree Wg. and Gynaecological Scanning Unit, Academic Department of Onstetrics and Gynaecology. King’s College School of Medicine and Dentistry, London, UK Key words: COLOR DOPPLER, TRANSVAGINAL PREGNANCY, ECTOPIC ULTRASONOGRAPHY, ANGI FESIS, SCREENING, CANCER, OVULATION, INTRODUCTION The use of ultrasonography in obstetrics and gynecology has evolved rapidly since the pioneering work of Donald and the publication of his seminal paper in The Lancer during 1958. The introduction of gray-scale techniques enhanced the ability to identify different tissues on the basis of their texture, However, it was the introduction of the linear array real-time scanner in the mid-1970s that changed ultrasonography from being an ‘eccentric art form’ to a readily available and usable technique. In the midst ofthis activity, the parallel development of the transvaginal probe by Kratochwil went almost unnoticed by most gynecologists, However, the application of this, technique has since had a major impact on many areas of gynecological practice, and on the management of infertility in particular. By placing the probe closer to the area of interest, higher frequency ultrasound can be used and higher resolution intages obtained, Transvasi nal ultrasonography has now become routine in the assessment of many gynecological disorders". Since the demonstration of transvaginal follicle aspiration, the use of this route has become standard practice for most invasive ultrasound-guided gynecological procedures! The relatively new technical advance of transvaginal color Doppler also promises to have a great impact. The introduction and use of transvaginal eolor flow imaging has facilitated the study of vascular changes within the pelvis. The follicle and corpus luteum of the ovary and the endometrium of the uterus are the only areas in a normal adult body where angiogenesis (the development of new blood vessels) occurs to any significant extent The same process occurs during the growth of carci- nomas. The ability to recognize these carly vascular changes with color Doppler is facilitating the diagnosis of pelvic cancers as well as the assessment of normal and abnormal ovarian and uterine functions. It seems likely that this new technique will lead to a greater under- standing of haw vessel growth is involved in reproductive pathophysiology. ‘The ability to monitor changes in vascularity may enable the development of methods to inhibit or enhance angiogenic activity in vivo. ‘This review will outline the principles of transvaginal color Doppler and its practical use, and discuss its current and possible future applications. THE TECHNIQUE For some time research efforts have been directed towards developing techniques to observe vascular changes within the human pelvis. This work has eoncen- trated on the use af Doppler ultrasound, and the prin- ciples and physics have been reviewed’. Whilst B-mode imaging has progressed to allow structures to be in spected in ‘real time’. up to now the use of pulsed or spectral Doppler has required considerable length of time to select the point that best represents the vessel oF nea of tissue being investigated. The operator is limited by the fact that flow information is confined to the highly restricted pulsed Doppler range gate. As a result, sam pling errors are not uncommon. These limitations have made the study of small vessels and minor vascular changes very difficult to carry out in a reproducible fashion. Color Doppler may solve many of these prob- lems. The B-mode image is divided into many pixels, and by the use of multiple range gates the Doppler flow parameters for each of the pixels on the screen are demonstrated in “real time’, The Doppler information is color frequency-coded, i.e. a converter assigns color, based on the direction and variance of the detected frequency shifts. Red usually indicates flow towards the transducer, and bluc away. The brightness of the color is proportional to the velocity of flow within the vessel, whilst turbulent flow may appear as various shades of green’. In this way regions of vascularization can be located anatomically as areas of color. A pulsed Doppler range gate is placed over the area of interest to provide How velocity waveforms which may he analyzed in a conventional fashion. This additional information is not achieved without some compromise. The maximum color Doppler sensitivity is achieved at tow frame rates, and is Correspondenss: Dr TH, Bourn, The Ovarian Screening and Gynaccological Scanning Unit, Academic Department of Obsterics and Gynaecology, King’s College School of Medicine and Denustry. London, SES 8X, UK a9 Keceved 29-/-91 Accepted 19-8-91Transvaginal color Doppler in gynecology Bourne Table 1 Range of values for indices of intaovarian blod flow (King's Collage Hospital Ovarian Serening Cine, 1991 Folie (pas-L) Corpora hea Tit irae aparece? ne) rn) we) Variable Mean Range Meo Range Mean Ronee Resstane index (RD ods 036-038 0a) 028-054 ogg 03-078 Pratatty indox (1) oe «ee ONSOatto Oe Val emi get ae? ers eG SS m3 therefore prone to movement artifact. Attempts may be ‘made to inerease the frame rate by raising the minimum displayed Doppler shift frequency threshold, collecting fewer lines, or increasing the pixel size. Filling missing, pixels by interpolation also adds to the amount of color displayed. These ways of processing the image must be remembered when interpreting information displayed on sereen, as the area of color displayed may not he a totally accurate representation of the vascular area being inter- rogated. There is a tendency for manufacturers to try to make the images as attractive and thus commercial as possible, with little regard to how useful this extra color might be clinically. By placing the unit on a vaginal probe, other advan- tages are gained. There is the major practical advantage that a full bladder is not needed for the examination. A full bladder acts to displace the pelvic organs even further from the ultrasound souree. Small blood vessels may also be compressed, leading to alterations in blood flow within them. Using the vaginal romte means that an optimal angle of insonation is achieved for many of the pelvic vessels, especially the uterine arteries. Having the transducer placed closer 10 the tissues being studied permits the use of higher pulsed repetition frequencies. AS a result, there are fewer limitations on the snaximura Doppler shifted frequencies that can be measured without aliasing (the Nyquist limit). Whilst it is an clegant way of displaying Doppler information, at the present time it is not possible to quantify color Doppler. Tt must be remembered that it acts to identify vessels such that a pulsed Doppler range gate can be used to obtain, flow velocity waveforms. We therefore rely on the analy sis of these frequency spectra for the collection of {quantitative data. The conventional indices of resistance index (RI) and the pulsatility index (PI) are both thought 10 reflect changes in impedance to flow distal to the point of sampling”. In many cases these indives fail show any differences when comparing physiological and pathological processes. In a study by Bower and Camp- bell, the presence or abscnce of a notch in the uterine artery waveform was far more predictive of future pregnancy outcome than the use of either the RI or PL Similarly, we have been unable to define cut-off values to separate the RI and PI indices of early ovarian cancers, corpora lutea and preovulatory follicles (able 1). Subtle differences in waveform shape and character are lost in the spectrum analysis. It is probable that this lost information is useful, and so new ways to analyze this Doppler information are needed. 360 Ultrasound in Obstetrics and Gynecology ‘The safety aspects of transvaginal color Doppler must not be forgotten, In gencral the power output of color Doppler units is not a eause for concern, and for most units the spatial peak average intensity (SPTA) is of the order of 30 mWiem?. This is well within the highest limit recommended by the Food and Drug Administration (EDA) foruse in obstetries. There are, however, concerns regarding the use of transvaginal pulsed Doppler units. and @ number of machines currently available have power outputs above the FDA guidelines when used at high power settings. Such power outputs are not required tw obtain good waveforms using uansvaginal Doppler, and the power should be reduced to the lowest level possible. The trend towards the display of power output levels on sereen is 10 be recommended. The use of transvaginal color Doppler should, if anything, lead to safety advantages when compared to the use of trans- vaginal pulsed Doppler alone. By reducing the time required to find and sample 4 vessel, the total exposure of the area of interest to ultrasound should be reduced. COMMON PRACTICAL. DIFFICULTIES It is important to remember that any information ob- tained using transvaginal color Doppler is of litte value if the vessel sampled has been incorrectly identified, There are certainly published data claiming to relate to ovarian artery flow, when the waveforms shown are clearly iliac in origin. All of the major pelvic vessels have characteristic waveform ‘signatures’ (Figure 1); these have been confirmed in a study where a continuous wave Doppler probe was placed on the vessels in question at the time of laparotomy" It is our experience that it is extremely difficult to measure blood flow in the ovarian artery. It is not clear whether this is because the angle of insonation is suboptimal, or because the blood Mow velocity is very low, or a combination of both, In the absence of color Doppler, itis common practice to move the pulsed Doppler range gate from the lateral ovarian surface medially along the infundibulo-pelvic ligament and through the ovarian stroma until flow velocity waveforms are obtained. The results often reflect a mixture of signals from the ovarian artery, the terminal branch of the uterine artery, and blood flow trom within the ovary, Most reliable ovarian blood flow data refer to areas of intraovarian vascularity rather than the ovarian artery itself. When interrogating these vessels, the brightest point of color must be sampled to obtain the highest velocity flows. The probe can then be angledTransvaginal color Doppler in gynecology very slightly to maximize the amplitude of the waveform. The first measurable waveform should not be accepted as being representative of blood flow within the tissue being studied, It is worth spending a little time to ensure that the vascular region with the highest velocity and Jowest impedance has been sampled. In this way, highly reproducible measurements of hoth the RI, PI and velocity can be made. Often the identification of small subtle vascular areas within the ovary is made difficult by movement artefact. The proximity of the ovaries to the pulsatile iliac vessels makes this inevitable. With experience, itis possible to discriminate between artefact, and areas of ‘true’ color that represent blood flow. The vaginal approach provides an optimal angle of insona- tion for the uterine arteries. The main branch can be reliably identified lateral to the supravaginal portion of the cervix, where itis best seen in the longitudinal plane. Careful examination will usually demonstrate their tortu- ous path. Distally the radial arteries can be visualized, as can the openings of the spiral arteries in pregnancy. In this way all points of the uterine circulation can be identified and sampled. POTENTIAL USES The interrelated effects of vascularization are illustrated in Figure 2. Itis clear that the growth of new vessels and the development of existing ones form a common thread throughout many areas of reproductive patho- physiology. In recent years, there has been an enormous increase in our knowledge of the factors that regulate this angiogenic activity", It has been shown in @ number of studies that ovarian tissue is capable of inducing angiogenesis"; the same effects on assays of angiogenesis can be observed in response to tissues from malignant tumors”. It is of particular interest that prostaglandins have also been shown (o stimulate angiogenesis, and that the production of these substances by the ovary is increased by luteinizing hormone (LH)'*'*, Normal follicular and corpus lutcum function depends on the development of a satisfactory blood supply. Malignant tumors exhibit the same reliance on new vessel forma- tion. The detection of these vascular areas may be used as a criterion on which to judge the benign or malignant nature of an ovarian tumor. Furthermore, by altering these vascular responses, it may be conceivable to inhibit or enhance potential fertility, and the prospects of successful treatment for some types of carcinoma may be improved. Transvaginal color Doppler can be used (0 identify areas of angiogenesis. There is therefore poten tial for the use of transvaginal color Doppler as a way of identifying both pathological and physiological processes involving changes in tissue vascularity, as well as monitoring the effects of intervention. Transvaginal color Doppler also facilitates the study ‘of major vessels. Arteries can be reliably identified and reproducible measurements made, The current major areas of use are in the fields of gynecological oncology and infertility. Some of these potential applications are outlined below. Bourne ‘The normal pelvis and infertility The ovary and ovulation Normal ovarian morphology and function The current status regarding the use of transvaginal color Doppler in infertility has heen discussed'®. At the present time, there are no useful morphological markers of impending ovu- lation, although ultrasound has been used to monitor follicular growth and rupture as well as to observe the formation of the early corpus luteum’”. Whilst the ability to detect follicular rupture is being used to develop practical selftests for potential fertility, there is still a need for a technique that can predict (and possibly detect) the release or possible retention of a viable oocyte at the time of follicular rupture. Transvaginal color Doppler has been used to monitor sequential changes in intrafollicular blood flow in the periovulatory period, and the data obtained related to defined biochemical indices, It is hoped that it will he possible to use information about ovarian blood flow both to predict ovulation, and to investigate ovulatory dysfunction. Previous studies have shown that it is possible to assess ovarian blood flow during the normal menstrual cycle". This study, using tansabdominal pulsed Doppler, showed significant changes in ovarian blood flow in the ovarian cycle. In particular, there was a marked drop in blood flow impedance within the ovary during the late follicular and luteal phases. Although the authors inter- pret their data as being from the ovarian artery, it is more likely that serial measurements of intraovarian flow have bbeen recorded. Transvaginal pulsed Doppler has been used subsequently ta record blood flow in the corpus, luteum in in vitro fertilization (IVF) patients following. embryo transfer”, In the absence of color Doppler. the authors had to move the sample volume gate (of 3.5 mm) over the ovarian stroma unlil suitable waveforms were obtained. These waveforms are more likely to reflect intraovarian rather than ovarian artery blood flow. Impedance to blood flow was measured on days 3 and 10 following cmbryo transfer, and significantly higher impedance to flow was observed in the corpora lutea of ‘women who failed to become pregnant, Using transvag nal color Doppler, areas of vascularity can be clearly visualized on the follicular rim, or within or around the corpus Inteum. Transvaginal color Doppler has since been used to monitor intensively vascular events in the periovulatory follicle”. Color Doppler facilitates the detection of small vascular areas in the ovarian stroma and follicular rim tat are easy (o aniss when applying a pulsed Doppler range gate ‘blind’. In this study, the aim was to assess each patient every 3-4 h from the time of the serum LH surge up to the formation of the corpus luteum. Blood flow velocity waveforms from the folic: ular rim were first seen at the time of the LH surge (or estradiol peak). Figure 3 shows the sequential increase in vascularity in the follicular rim from the time of the LH rise, at its peak, and finally just prior to follicular rupture and the formation of the corpus luteum. These observations represent the first report of the changes in intrafollicular vascularity over the periovulatory period Ultrasound in Obstetrics and Gynecology 361Transvaginal color Doppler in gynecology Figure 1 Flow velocity waveforms from (a) the internal iiae artery: (b) the uterine artery: and (c) from within a corpus luteum in the human female. These data are supported by studies of ovarian blood flow and volume in laboratory a mals”, and the fact that red blood cells have been seen in the granulosa cell layer between the time of the LIL peak and presumed ovulation. A report of the vascular changes at the time of a presumed ovulation shows increased vascularity on the innermost rim ofthe follicle, and a coincident surge in blood flow velocity just prior to follicular rupture. This may represent the dilatation of new vessels that have developed between the relatively vascular theca cell layer and the normally hypoxic granulosa cell layer of the follicle. Disruption of these 362 Ultrasound in Obstetrics and Gynecology Bourne LHICG, eytokines, hypoxia | Neowangiogenesis Ovulation Implantation and and corpus luteum ——_placentation inetastasis formation | Embryogenesis and neovascularization Figure 2. The related effects of angiogenesis in reproductive pathophysiology vascular changes would have profound effects on the oxygen concentration across the follicular epithelium Figure 4 shows how the area of vascularization seen on the follicle just before ovulation appears to coincide with, the theca cell/granulosa cell interface when the ultra- sound image is compared to the cross-section of the follicle shown, Ovulatory dysfunction We have observed one case of drug-associated luteinized unruptured folhicle (LUE) there was a reduction in vascularization and a failure of the blood flow velocity to peak in the immediate preovu- latory period”. This is consistent with the view that the changes in oxygen tension within the follicle brought about by angiogenesis are necessary for normal ovulation to occur. Transvaginal color Doppler may be used to monitor hormonal and other methods of increasing or doercasing intrafollicular blood flow. Steroids that in- hibit angiogenesis in the presence of heparin have already If the process of ovulation could be inhibited independently of the main pathways of steroidogenesis, novel methods of contraception might he envisaged. Initial evidence suggests that transvaginal color Doppler may be used to monitor progress towards, these objectives. It is further hoped that this technique will facilitate the study of other aspects of ovarian function such as follicular recruitment and corpus luteum development and failure. The uterus The normal menstrual eycle Transvaginal color Dop- pler can be used reproducibly to obtain flow velocity waveforms from the uterine arteries at any time during the menstrual’ cycle”. It is apparent that there are ‘complex relationships between the concentration of ovar- ian hormones in peripheral venous plasma and uterineTransvaginal color Doppler in gynecology Figure 3 Bourne (a) The leading Follicle (left pane!) and the first blood flow velocity waveforms (right panel) at about the time of the LH rise in peripheral plasma. Note position of gate or recording waveforms from the inner edge of follile:(b) the ding follicle (eft panel) and the first visual sign of blood vessels (right pane!) (probably at the theca/granulosa interface) at the time of the LH peak and progesterone isc in peripheral plasma. Note position of gate o us and ooeyte (35 h afler the LH rise). The red area is artefactual (due to ‘movement of the probe oF patient); the blue area shows that blood vessels have penetrated the leading follicle with a clear view of the cumulus ooph follicle (es Collins eal. U99LY by permission of Oxford University Press) the left panel for sampling flow velocity waveforms, (¢) the ulosa laver; (d) the collapsed iy corpus, luteum) 40 h after the LH rise. Note echogenic areas and fuzzy low veloeity waveforms. (Reproduced from Figure 4 (a) A ring of angiogenesis around a follicle during the moment of presumed ovulation compared to a scetion (b) through a rat follicle. Note the close relationship af the ares af angingenesis to the theca artery blood flow parameters. Steer and colleagues** used transuaginal color Doppler to sindy ulerine artery blood flow in 23 healthy women. Figure 5 shows the daily mean changes in pulsatility index within the uterine arteries relative to the mean concentration of plasma estradiol elV/granuosa cell interface and progesterone. The overall trend suggests an increase im perfusion of the uterus during the course of the cycle. It is particularly interesting that the lowest blood flow impedance occurs during the time of peak luteal function, during when implantation is most, menstrual Ultrasound in Obstetrics and Gynecology 363Transvaginal color Doppler in gynecology 100 80 o 10 g E E & Bourne os —o— Estradiot Progesterone Daye from LH peak Figure 5 Changes in the mean uterine artery pulsatility index during the ovarian cycle related t0 the mean concentrations of plasma estradiol and progesterone. Reproduced from Steer et al. (1990), by permission of Oxford University Press likely to occur. Using transvaginal color Doppler, it has therefore been possible to define normal uterine blood Mow in the menstrual eycle, Possible relevance to infertility Goswamy and his col leagues (using transvaginal pulsed Doppler) have pre sented preliminary evidence that decreased uterine perfusion may be associated with infertility”. It has been suggested that one of the major reasons for the relatively Tow success rates for assisted reproctuction techniques 18 the failure of embryos to implant. This has led to the transfer of up to four embryos in order to achieve a reasonable singleton pregnancy rate. However. the mul tiple pregnancy rate associated with such actions has ‘major social and medical implications. A nowinvasive assay of uterine receptivity would enable a clinician to cryopreserve embryos if uterine conditions were adverse, and to reduce the number of transferred embryos when conditions were optimal. Steer and colleagues have suggested that studies of uterine artery blood flow may be used to predict a hostile uterine environment prior to embryo transfer”. Women who failed to achieve a pregnancy in this study had significantly raised imped ance to blood flow in their uterine arteries. There was a zero implantation rate associated with a mean uterine artery PI of greater then 3.0, According to these data, if this figure was used as the upper limit for the transfer of embryos, the sensitivity of the test for predicting an unreceptive uterus and thus failed implantation would bbe 35.2%4, the specificity 100%, and the positive predictive value of a high-impedance blood flow result also 100%. 364. Ultrasound in Obstetrics and Gynecology If substantiated, these data may have important clinical implications. Those women with poor uterine perfusion could be advised that a presutancy is unlikely in their current treatment cycle, and be advised to have their embryos cryopreserved for transfor at a later date, Color Doppler may also be used to monitor ways of manipu. lating the uterine environment. Transvaginal color Dop- pler measurements of uterine artery blood flow have the potential for use as a biological assay of uterine recep- tivity, and may theoretically substantially improve the pregnancy rate per treatment cycle. Prospective control led clinical trials hased on these preliminary data are awaited with interest It is clear that changes in tissue vascularity are fundamental to many aspects of normal uterine and ovarian functions. The preliminary data with transvagi- nal color Doppler suggest that it provides a relatively non-invasive tool for their detailed study. Prospective data are now needed to assess whether ways can be found to alter these vaseular processes either to enhance or reduce the chance of a couple achieving a pregnancy. Pregnancy It is unclear as yet what role transvaginal color Doppler will play in the study of pregnancy. The fact that it enables the operator reliably to identify the different branches of the utetoplavental circulation should eu- hance our ability to study the profound vascular changes that occur in the carly stages of gestation.Transvaginal color Doppler in gynecology Predicting pregnancy outcome The assessment of uteroplacental blood flow has been suggested as an early screening test for the identification of pregnancies at increased risk of developing pregnancy- induced hypertension and growth retardation”. Using transabdominal color Doppler. the main branch of the uterine artery cant be reliably identified at its junction with the intemal iliac artery. Analysis of waveforms from this point at 24/40 gestation has been shown to have a 75% sensitivity for the detection of pregnancies that are going to suffer from proteinuric pregnancy-induced hy- pertension (PIH)*, Interestingly, it was found that the presence or absence of a ‘notch’ in the waveform was ‘more predictive of poor pregnancy outcome than any of the indices of impedance to blood flow currently used. More recently, Jaunianx and colleagues" have demon- strated how the different branches of the uteroplacental circulation can be identified using transabdominal color Doppler and characteristic flow velocity waveforms ob- tained. Sampling of these more distal points in the uterine circulation may prove to be a more useful predictor of potential fetal compromise than studies of the .nain branch of the uterine artery. It has been shown previously that vaginal pulsed Doppler can be used to assess impedance to flow in the uterine arteries throughout pregnancy". The use of transvaginal color Doppler facilitates the identification of all branches of the maternal uterine circulation in eurly pregnancy". In this way the point of sampling is more reproducible and the examination time required to obtain good quality flow velocity waveforms shortened. It is hoped that this will enable blood flow studies to be performed reliably earlier on in pregnaney around the time of trophoblast invasion. If poor uterine perfusion ‘were recognized at an earlier stage, drug therapy such as aspirin might be used to try to improve placentation However, a recent paper in this journal by Arduini and colleagues” was pessimistic about the use of measure- ‘ments of uterine artery blood flow using Doppler ultra- sonography to predict poor fetal outcome. Transvaginal color Doppler was used to identify the arcuate and trophoblast vessels, the main uterine and the umbilical arteries in 282. pregnancies defined as normal and 48 pregnancies that were thought by the authors to be complicated either by gestational hypertension or growth retardation. Of the pregnancies thought to be abnormal, only four fell outside the normal ranges for any of the vessels assessed. The authors conclude that this informa- tion is unlikely to be of value in the identification of the ‘at risk’ pregnaney. However, this study has several limitations. First of all, tho number of complicated pregnancies for each gestation is too small to make definite conclusions. In addition, the end-points of the study are unclear. How many of the hypertensive women were proteinuric? Moreover, a birth weight on the 10th centile does indicate a small haby but does not prove growth retardation, Once again, this study turns our attention to the question of flow velocity waveform analysis. Te has been suggested that the presence or Bourne absence ofa diastolic notch in the flow velocity waveform is more predictive than indices of impedance alone. By using the systolicidiastolic ratio, information available from the flow velocity waveforms may have been lost, Further data are therefore required to assess the full role of transvaginal color Doppler in assessing the fetomater- nal circulation to identify pregnancies in need of close monitoring. The fetat circulation Transvaginal color Doppler is being used to make preliminary studies of the fetal circulation in the first trimester of pregnancy. Whilst much of the information derived from this work will not have any immediate clinical relevance, our knowledge of fetal physiology will be further advanced. Any transvaginal ultrasound study in early pregnancy 18 limited by fetal movement and positioning. Whilst recordings from fetal vessels can he made using pulsed Doppler. the use of color Doppler reduces the examination time, This makes the study of Fetal vessels at this yestation more practical, and acts (0 reduce the fetal exposure to ultrasound. Recently, Wladi- miroff and colicagues* have reported blood flow veloci- ties from the atrioventricular valve and outflow tract in 30 pregnancies between II and 13 weeks’ gestation. In a number of eases it was not possible to obtain acceptable flow velocity waveforms from the area of interest. Al though they have yet to publish their data, the same {group are also examining blood flow in the fetal internal carotid and middle cerebral arteries in the first trimester. There are anecdotal reports of other workers using ‘transvaginal color Doppler to confirm absent renal artery ow in pregnancies complicated by oligohydramnios”. Color Doppler may help to facilitate such studies Ectopic pregnancy The advent of relatively non-invasive approaches to the management of ectopic pregnancy™ has led to the intro duction of screening programs for this disorder®. The need for sensitive and specific tests to diagnose 1 condition is therefore greater than ever, and the availa bility of a technique other than serum human chorionic gonadotropin (hCG) estimation to monitor trophoblast activity would be of benefit. It is probable that transvagi- nal ultrasonography has facilitated the earlier and more accurate diagnosis of ectopic pregnancy. Whether trans vaginal color flow imaging is of any lelp ia this context is not yet certain, Our experience is that, whilst it can be «useful adjunct, itis unlikely to change dramatically the diagnostic performance of ultrasound for this condition, Zalud and Kurjak# observed a significantly lower im. pedance to flow within the corpus luteum of women with ectopic pregnancies compared to intrauterine pregnan- ies of the same gestation. The mean RI for luteal blood flow in normotopic pregnancies was 0153 compared to 0.48 for ectopic pregnancies. Although the difference in RI between the groups reached statistical significance, Ultrasound in Obstetrics and Gynecology 368Transvaginal color Doppler in gynecology Figure 6 An ectopic pregnancy showing an arca of presumed angiogenesis in a peripheral segment of the trophoblast ring the practical application of using measurements of luteal blood flow to discriminate between intra- and extra- uterine pregnancies seems limited. Given a probable coefficient of variation in the assessment of RL of around S-10%, the differences between the groups is easily obscured. Excluding what can be a lethal condition on the basis of an RI difference of 0.05 is unlikely ever to be considered a safe practice. In contrast, Jurkovie and colleagues" concluded that there were no significant hemodynamic differences either in the corpus luteum, uterine arteries or trophoblast when comparing intra- uterine to ectopie pregnancies. The only significant difference was a reduction in blood flow velocity in the uterine arteries of women with ectopic pregnancies, pethaps suggesting an overall reduction in uterine blood supply. Whilst this difference was statistically significant and of academic interest, it has little if any clinical relevance. Although these data may suggest a limited diagnostic role for color Doppler, this is not necessarily the case, Our impression is that the most clinically helpful role of color Doppler in this context is in reliably identifying the side of the corpus luteum (on the same side as the ectopic pregnancy in over 85% of cases in out series) such that it can be used as a guide to direct the search for the cetopie gestational sae. Color Doppler can also be used to delineate subtle vascular changes in the tube suggestive of the presence of trophoblast. Unfor- tunately, the low impedance blood flow pattern that can be observed in and around the corpus luteum is similar to that of the blood supply to the ectopic sac and can cause confusion. However, with care the vascular branches to both the corpus luteum and ectopic sac can be identified separately. It is this capability that can be particularly helpful in trying to make a definitive diag nosis in the presence of an adnexal urass. Vessels are often seen at the periphery of the ectopic sac and are usually confined to one segment of the trophoblast ring, (Figure 6). Reports showing the presence of low- impedance flow on the side of most ectopics are not surprising given the ipsilateral presence of the corpus luteum in most cases. The blood supply to the ectopic sac must be demonstrated as separate from that to the ‘ovary for its recognition to he diagnostically useful 366 Ultrasound an Obstetries and Ciynecology Bourne Those of us familiar with the technique of transvaginal color Doppler find that it enhances our ability to make a definitive diagnosis of ectopic pregnancy. However, at this time there are limited data from well designed trials, to demonstrate a significant benefit from the use of color Doppler for the diagnosis of this condition. Good com- parative data are needed to establish the precise role of color Doppler in this context, There is alsa the possibility that the technique may he used to monitor treatment. It has yet to be established whether an apparent decrease in the vascular supply to an ectopic sac is an indication of poor viability, and hence whether it can be used 10 form the basis of criteria to select patients for observation alone, or local non-invasive treatment. Ovarian malignancy Background ‘Ovarian cancer remains the most common cause of death from gynecological malignancy. About SOK) women in England and Wales and 22 000 in the United States of America develop the disease each year. In the early stages of the disease there are few characteristic symp- toms or signs, and as a resull the majority of women with his disease present at stage TIT or IV when palliation is often the only realistic management strategy. The overall 5-year survival rate of 30% isa reflection of the limited impact that new approaches to treatment have had on mortality from this disease. Conversely, the S-year survival rate for women with stage T ovarian cancer may be over 90%". In view of the depressing results relating to the treatment of late-stage disease, attempts are heing made to develop effective screening, procedures for early cancers in asymptomatic women. Once a test with suitable sensitivity and specificity for early-stage disease has been identified, a randomized trial will need to be carried out to determine whether earlier diagnosis and treatment will improve the prognosis for substantially more women. The problems associated with ovarian cancer screening have been reviewed" Cancer sereening ‘The use of ultrasonography to screen for ovarian cancer ‘was first proposed by Campbell and colleagues in 1982" Subsequently, in a large prospective trial, transabdomi- nal ultrasound was used to sereen over 5000 women for the presence or absence of ovarian pathology”. This, study suggests that, whilst conventional transabdominal ultrasound is a sensitive (echmigue fur the detection of sunalleystic lesions suggestive of cancer, itis difficult to discriminate between malignant and benign cystic esions on the basis of B-mode imaging alone. There are now preliminary reports on the use of higher resolution trans vaginal ultrasound to screen asymptomatic women for ovarian cancer both in low! and high-risk populations™. The consensus view is that transvaginal ultrasonography is a sensitive first.stage screening test that will detect nearly all cystic ovarian lesions suggestive of carcinoma.Transvaginal color Doppler in gynecology Figure 7 Presumed angiogenesis throughout a stage I primary igure 8 A low-impedance low velocity waveform typical of ‘What is needed is a second-stage test that will discrimi- nate between benign and malignant cysts. Color Doppler ‘may fulfil this role, being used after an ovarian morpho- logical abnormality has first been detected using B-mode imaging, Changes in tissue vascularity, mediated by angiogenic factors, are associated with the early stages of ovarian oncogenesis. Recent studies with transgenic ‘mice have shown that, for at least one type of cancer, angiogenesis occurs during the transition from hyper plasia to neoplasia". An inhibitor of angiogenesis has also been found that is produced by cells when they are capable of expressing an active cancer suppressing gene” This evidence suggests that angiogenesis may well be an obligate event in the earliest stages of ovarian carcinoma. In animal models, Doppler techniques have been used to identity areas of altered vascularization within tumors as, small as 30 mg, In this study, vascular morphology was Further evaluated by digital angiography. This technique demonstrated coincidence between the site of high-veloc ity low-impedance signals and the prescnec of arterio- venous anastomoses®. Initial experience with the use of color Doppler was limited to tumors other than the ovary®, Preliminary data suggest that it may be possible to detect the vascular changes associated with early avannan Bourne cancers using color Doppler (Figure 7). In malignant, lesions, blood flow can be demonstrated throughout diastole, probably reflecting a decrease in impedance 10 flow distal to the point of sampling (Figure 8). A possible ation for this is that the new vessels associated with carcinoma have limited vascular tone due to the absence of the tunica media, and as a result the} Tow-impedance shunts, Its hoped that it will he possible to characterize henign and malignant lesions on the basis, of their vascularity, and in so doing reduce the false positive rate of an ultrasound-based screening program. ‘We have used transvaginal color Doppler to examine 30 women with no apparent pelvic pathology and 18 wonen with ovaian tumors”, All cases of invasive cancer showed evidence of neovascularization with low-imped- ance blood flow. One serous cystadenoma of borderline nancy did not demonstrate an abnormal blood flow pattern, and there was one false-positive test result (a benign teratoma). Two of the invasive cancers were at stage Ta, suggesting that this technique can detect ovarian, cancer when it 1s shill confined within the capsule of the ‘ovary, These results were supported by the work of Kurjak and co-workers, who studied infertile women ‘with normal pelvie morphology and patients with known, pelvic masses. Low-impedance intratumoral flow was seen int four cases of unstaged primary ovarian cancer the resistance index was used as an index of impedance to low and was below 0.40 in all cases. There was one false-positive result (a granulosa cell tumor) amongst the 15 benign cystic lesions that were studied, Hata and colleagu ss of ovarian cancer, and the studied eight ca mean RI value of the tumors was 0.503 + 0.216". Itis of interest that this group was unable to discriminate between the blood flow of a corpus luteum cyst, an endometrioid ovarian cyst and carcinoma, The same authors point out that in one case flow velocity waveforms from the internal iliac artery were mistaken for those from within the ovary. a common and impor- tant source of error. More recently, Kusjak and col- ues have presented data on the color Doppler findings in 624 benign and $6 malignant ovarian masses Presumed ncovascularization was demonstrated in six out of seven stage I primary ovarian cancers, and in 48 (of 49 of the other malignant lesions in the study, In all of the cases where neovascularization was seen, the RL value was again less than 0.40, The authors regard an RL value of 0 Al) 2s-a significant cut-off, values below this heing thought to have a high predictive value for carci noma, However. the data of Hata and colleagues” suggest that we have yet to determine the values that define normal and abnormal blood flow within the ovary Data fiom our own clinic are supportive of this view (Table 1) and demonstrate a clear overlap between the blood flow within normal physiological ovarian eystic lesions and carcinoma*'. The use of an arbitrary cut-off value of 0.40 seems likely to result in a number of both false-positive and -negative results. In our series of seven cases of stage I ovarian carcinomas, neovascularization in all cases of invasive carcinoma. The details of each ease as well as their RI values are shown in Ultrasound in Obstetrics and Gynecology 367Transvaginal color Doppler in gynecology Bourne ‘Table 2 The detection of early ovarian cancer by transvaginal ultrasonography with color flow imaging and blood flow analysis (King’s College Hospital Ovarian Screening Unit, 1991) Case ‘Menopausal HIGO Test umber Age (years) status Histological classification stage result RI 8 an ‘horderline serous eystadenocarcinoma Ia negatives 0.96 2 s4 pre endometrioid eystadenocarcinoma la positive 0.68 3 46 pre borderline endometuivid eystadenovarvinoma Ta positive 034 4 32 post serous eystadenocarcinoma la positive 037 5 2 post serous eystadenocarcinoma Ib positive 0.38 6 3 ost endomeinoid cystadenocarcinoma Ie poxitive os 2 pre__ serous cystadenocarcinoma Ie positive 033 = Woman had one «an only; Taiifically postmenopausal following hysterectomy Table 2". Clearly, more data are needed to define ways of discriminating between malignant conditions and some benign processes on the basis of flow velocity waveform analysis, Potential limitations Whilst it is not unreasonable to be optimistic, we must remember that there are potential limitations. For women in whom ovarian activity has ceased, there are 1no physiological events occurring within the ovary that may lead to altered vascularity. In our ovarian cancer screening program, there have been no false-positive results from postmenopausal women. In premenopausal ‘women this is not the case, Similar processes of angio- xenesis, und hus very similar indices of impedance to blood flow are seen from within the developing corpus luteum and the preovulatory follicle as ate seea i eatly cancer. The appearance of altered vasculature within the follicle has been directly related to defined biochemical indices such as the LH surge and peak”. The identifica tion of the B core fragment of hCG as a tumor marker in the urine of women with ovarian cancer may reflect a ‘iegree of angiogenic activity from these related hor- mones®, Cireat care must, therelore, be taken to ex- clude vascular changes that are secondary to normal physiological events. Vascular information derived from the ovary must be viewed critically and related to the patient's ovasias eyele, and any abnormal findings sub- jected to a repeat scan. Theie is probably quite a narrow window within any ovarian cycle during which these will bbe a complete absence of angiogenic activity. Accord ingly, for the purposes of ovarian canecr screening, we currently examine premenopausal patients between days 3.and 11 of their eyele. If such a policy is adhered to, the majority of physiological lesions will be identified and false-positive test results avoided. The uncritical enthusi- asm of some authors for transvaginal color Doppler is to be deprecated and is unhelpful to those of us who believe that this technique will improve our ability to diagnose carly ovarian carcinoma. A recent unsigned Lancet editorial states that transvaginal color Doppler can be used to detect ovarian cancer belore itis otherwise 368 Ultrasound in Obstetrics and Gynecology discernible, and that it should be utilized to characterize the nature of cystic ovarian lesions in pregnancy®, ‘There are little data to support the former statement and none 10 support the latter. These problems have been dis- cussed. Future prospects Despite these possible pitfalls, transvaginal color Dop- pler has already been shown to reduce the false-positive rate of an ultrasound-based screening program. When applied to eystie ovarian masses detected in a screening program for women with a family history of ovarian cancer, the odds of finding a cancer amongst women roferred for surgery were rediiced from about 1° 15 to. 1:5, Knowledge of the lesions likely to cause false- positive results with color Doppler suggests that similar figures will be obtained when screening the general population, It has often beet said that, for a screening test for ovarian cancer to be credible, it would have to achieve a positive predictive value of better than 10% (an ‘odds ratio of about 1 : 10). A combination of transvagi- nal ultrasonography and color flow imaging satisfies this criterion. Any worries about color Doppler findings in physiological lesions must be seen in the context of the technique being used as a second-stage test, its use being limited to persistent ovarian masses. Hence any mass found at screening would be subjected to a repeat scan at an interval, at which time color Doppler would be performed. In this way most physiological lesions will have regressed. The fact, that all cases of invasive stage Tovarian cancer examined with transvaginal color Dop- pler in our series showed evidence of neovascularization, gives cause for optimism about the sensitivity of the test for early-stage disease. That color Doppler can detect, vascular changes in the ovary around the time of ovula tion suggests that, if the development of new vessels is an obligate event in the earliest stages of ovarian cancer, color Doppler will be able to demonstrate them. How- ever, even in a high-risk population, the prevalence of the disease means that about 300 women need to he screened in order to detect one case of early ovarian cancer. To examine the sensitivity and specificity of colorTransvaginal color Doppler in gynecology Doppler as a second-stage test in an ovarian cancer serecning program will require large-scale screcning trials in order to have enough clinical material with which to work. A prospective randomized trial is now required to satisfy this requirement, as well as to answer the larger question of whether sereening and hence early treatment will reduce the currently high mortality rate from this, disease Benign and malignant disorders of the uterus Endometrial cancer About 33.000 new cases of endometrial cancer are reported in the United States cach year. Uterine bleeding, js the most frequent initial sign of this disease, and at present demands invasive investigation (ie. endometrial biopsy). However, less than 10% of women with post- menopausal bleeding have endometrial cancer. A less invasive technique than diagnostic biopsy that also has f high detection rate and low false-positive rate would be of value. If this test could detect cancers at an early stage in asymptomatic women, then the number of ‘women cured by surgery alone might be increased, and. the morbidity and mortality from the disease reduced This would be particularly relevant for women at in- creased risk of developing endometrial abnormalities, such as those taking unopposed estrogens or tamoxifen therapy“, It has been proposed that tamoxifen be given to apparently healthy women at increased risk of breast cancer". It may be necessary to monitor the endo- rmetrium of such patients at regular intervals. There are now good data to suggest that the measurements of endometrial thickness made using transvaginal ultra- sonography can have hoth high positive and negative predictive values for malignancy. An endometrium that ‘measures greater than 8.0mm from one myometrial endometrial interface to another is highly likely to be associated with significant endometrial pathology" ‘There is, however, a significant false-positive rate. The characteristic flow velocity waveforms that can be ob- tained from the uterine artery have been described!” Recent reports have suggested that transvaginal color Doppler ean be used reproducibly to measure impedance to blood flow in the uterine arteries", The uterine arteries can be identified in the longitudinal plane slightly lateral to the supravaginal portion at the cervix (Figure 9). Color Doppler enables the main branch of the vessels to be reliably identified and then sampled using pulsed Doppler. This should be carried out once the probe has been angled (o oblain the maximum color intensity front the vessel in question. Using the pulsatility index, a one-way analysis of variance of replicate data from 20 women gave @ cocflicicnt of variation of about 10% for both uterine arteries”. We recently reported the impedance to blood flow in the uterine arteries and the endometrial thickness in women with postmenopausal bleeding both with and without cancer, as well as women taking hormone replacement therapy and those thought to have a normal uterus taking no drug therapy”, Data Bourne from this study suggest that, in the presence of malignant tissue, the impedance to blood flow within the uterine artery is reduced significantly when compared to control groups. Figure 10 shows how measurements of im- pedance to flow (as Pl) in the uterine arteries can discriminate between those women with and without uterine malignancy. The impedince ta blood flow in the hterine arteries increases with years from the menopause, and so these results cannot be explained by differences in patient age. These data can be compared to measure ments of endometrial thickness from the same groups of women (Figure 11), By using eolor Doppler whilst rraintaining, sensitivity, the false-positive rate of the ultrasound-based testis reduced. If color Doppler is used to interrogate the endometrium in such cases, angiogene- sis can be demonstrated as areas of color superimposed on the B-mode gray-scale image and the sensitivity of the technique enhanced (Figure 12). An interesting observa jon in this study was that there was a marked reduction in blood flow impedance within the uterine arteries of women taking hormone replacement therapy (Figure 10) Other workers have also reported vascular changes in the presence of uterine cancer using color Doppler. In one report, two cases of endometrial cancer were examined: RI values from the periphery of the endometrial ecto were 0.26 and 0.31, respectively, Hata and colleagues” examined ten women with endometrial cancer and found arcas of low-impedance blood flow in all cases (PI 0.535, +0.158); in patients with uterine myomata the intra tumoral blood flow impedance was 0.679 + 0.131. Our experience of uterine fibroids is that they are charac- terized by low-impedance but high-velocity blood flow. Attempts have been made to characterize uterine ttimors using transvaginal color Doppler Intratmaral blood flow was looked for in 291 benign and 17 malignant uterine tumors. The RI value was 0.58 0.12 SD for cases of uterine myomata, and 0.34 0.03 in cases of endometrial carcinoma. The authors conclude Gat trats- vaginal color Dopplet can be used to help discriminate between benign and malignant uterine tumors, and that an intratumoral RI value of less than 0.40 should be regarded as malignant and between 0.40 and 0.50 as suspicious. In general, the ultrasound appearances of myomata und endometrial carcinoma are distinct and quite different. To what extent color Doppler will ever bbe necessary to discriminate between the two is uncertain The observation in the same report that a uterine sarcoma (RI 0.31) had significantly lower-impedance blood flow than benign myomata may have more prac- tical clinical implications Management of fibroids Impedance to blood flow within the uterine arteries has, been assessed in women taking a gonadotropin releasing, hormone agonist for the treatment of uterine myomata” Transvaginal color Doppler permits the accurate measurement of blood flow within myomata rather than just the uterine arteries (Figure 13). ‘There is, therefore, the potential (0 monitor the response of myomata to a Ultrasound in Obstetrics and Gynecology 369Transvaginal color Doppler in gynecology Figure 9 The uterine artery at the supravaginal portion of the cervix identified using eolor Doppler en p=85 na3s Palsy ices Cancer Non cancer (no HRT) Non-canosr (with HRT) Figure 10. Impedance to blood flow in the uterine arteries of women with endometrial eancer, with no apparent endometrial Pathology. and those taking hormone seplacement therapy (Reproduced fiom Bowne er ui. (1991)”, by permission of ‘Academie Press) ial of medical therapy and in some cases optimize the foaming of surgery Hormone replacement therapy Following the observation that there was a decreased PI in the uterine arteries of women taking hormone replace- ment therapy, attempts have been made to quantify this effect. In w subsequent study, estrogen was shown to reduce impedance to blood flow in the uterine artery by 50%". If extrapolated to the general vasculature, this ‘would have important implications with regard to the cardioprotective effect of estrogen replacement therapy. The changes in nlerine artery impedance occurred rapidly. A protein related to the estradiol receptor has, been identified in the intima of major vessels”, and itis possible that estrogens affect arterial status through a conventional sex hormone receptor mechanism, ‘The addition of progestogens appeats partially to reverse this 370 Ultrasound in Obstetrics and Gynecology Bourne naa nn35 so cancer Non-cancer (no HRT) Non-cancer (ith HRT) Figure 11 Endometrial thickness in thesame groups of wgynen, asin Figure 10. (Reproduced from Bourne et al. (1991)"” by permission of Academic Press) Figure 12 (a) Presumed angiogenesis within the endometrial cavity. The patient had an endometiial carcinoma, and had ‘been taking tamoxifen therapy for 5 years; (b) demonstrates a low-impedance flow velocity waveform suggestive of carci- drop in impedance, although not to pretreatment levels” This takes effect within 36h of starting progestogen therapy, suggesting that the mechanism is also receptor- mediated (M. S. Marsh and T. H. Bourne, unpublishedTransvaginal color Doppler in gynecology Figure 13 The vascular supply around the periphery of a fibroid data). A particularly interesting observation in this study ‘was that the response to exogenous estrogens was pro- portional to the number of years since the menopause. II this 1s contirmed, there may he cardiovascular benefit from estrogen administration even in very elderly women, as they may still show a significant vascular response to therapy. Selecting progestogens that have the least effect on the vasodilatation brought about. by estrogen therapy may be of great importance if the beneficial effects of hormone replacement therapy are to be maximized. Such a choice may be investigated with the use of transvaginal color Doppler. These data were later supported by that of de Ziegler”, In six women with cither idiopathic premature 0% failure secondary to chemotherapy, uterine artery blood flow was assessed before and during estrogen therapy The PI belare treatment was 57-4014 (mean + SEM), dropping to 1.3 + 0.3 when taking exogenous estrogens. Studies of other vessels have shown similar changes in response to estrogen therapy”. Doppler echography of the aorta has demonstrated (hat estrogens increase both stroke volume anid Mow acceleration, These are thought to reflect a combination of inotropism and vasodilata- tion. Changes in uterine artery response to exogenous estrogens sccm to act as a model for what is happening, in the general vasculature, Transvaginal color Doppler can, therefore, be used to assess the effect of drugs on the circulation, and on the uterine arteries in particular. rian failure or ovarian URE DEVELOPMENTS New approaches to the assessment of blood flow are being investigated, The use of volume flow measurements, is one possibility, but obtsining (his information from, suuall pulsating vessels seems rather optimistic. Volume flow is the product of mean velocity and vessel arca, thus any errors in the measurements of vessel diameter will be multiplied, Attempts to quantily the information, generated by color Doppler have been disappointing, but, it may be possible to estimate the number of pixels that are excited using the digitized memory of the scanner. The new color velocity imaging scanners may have a role to play. Color velocity imaging uses the data contained Bourne in the gray-scale B-mode image scan lines to determine the velocity of blood flow”. The potential advantages of color velocity imaging include both quantitation of flow and tissue motion assessment, both at lower power ‘outputs. The relative importance of this new technology awaits evaluation in clinical trials CONCLUSIONS: Transvaginal color Doppler promises to play a major role in obstetrics and gynecology over the next decade. ‘The development of the follicle and corpus luteun as well as cancers depends on the parallel development of adequate blood supplies. The ability to study these processes and the factors that may enhance or inhibit them, using a non-invasive technique, offers a new opportunity to researchers. The practical clinical role of color Doppler is not yet clear. However, it seems certain to improve our ability to diagnose and thus treat ayneco- logical malignancies, early pregnancy complications and infertility secondary to ovarian and uterine dystunction Transvaginal color Doppler has great potential, but we must be certain of its precise clinical role before it is, allowed to move from being an exciting research tool, into routine clinical practice. ACKNOWLEDGEMENTS Financial support for the ovarian screening clinic at King’s College Hospital is provided by the Cancer Research Campaign (CRC) and the Imperial Cancer Research Fund (ICRF). I am grateful to Keymed Ltd (Southend, LIK) and to the ALOKA Co. Ltd (Tokyo, Japan) for the use of their ultrasound equipment REFERENCES 1. Timor-Tritsch, I. E., Yeh, M. N., Peisner, D. B., Lesser, K. B, and Slavik, T. A’ (198), The use af transvaginal sono- raphy in the diagnosis of ectopic pregnancy. Am. J. Obstet. Gynecol, W61, 157 Granberg, 8.) Fberg, LG. and Norstrum, A. 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