ABSTRACT Distinguishing benign and malignant endometrial lesions on the basis of endometrial thickness (ET) may lead to a missed diagnosis of endometrial carcinoma (EC) in women with

postmenopausal bleeding (PMB) or increased invasive examination and pain in women with benign endometrial lesions. Our research aims to establish an ultrasonic prediction model for

differentiating between benign endometrial lesions and EC in women with PMB. PMB women with ET ≥ 5 mm (_n_ = 412) or ET < 5 mm who presented with recurrent vaginal bleeding (_n_ = 57)

were enrolled in this prospective observational study. According to the pathological examination results of the endometrium, women with PMB were divided into endometrial atrophy (EA) (_n_ = 

ultrasonic parameters analyzed by ROC curves was used to establish prediction model. Women with EC had significantly thicker endometrium and higher endometrial volume (EV), vascularization

index (VI), flow index (FI) and vascularization-flow index (VFI) than women with other pathological types of endometrium (_P_ < 0.05). The endometrial VI, FI and VFI of women with EH were

significantly higher compared with those in women with EA and EP (_P_ < 0.05). For patients with ET ≥ 5 mm, the best parameter for distinguishing between benign lesions and EC was the

FI, with an area under the curve (AUC) of 0.86, a sensitivity of 86.7% and a specificity of 81.4%. In addition, for patients with ET < 5 mm, the best parameter for distinguishing between

benign lesions and EC was the VI, with an AUC of 0.92, a sensitivity of 92.1% and a specificity of 72.9%. The ultrasonic prediction model based on the FI and VI had better predictive value

for EC in both patients with ET ≥ 5 mm and patients with ET < 5 mm. The ultrasonic parameters differed among the different pathological types of the endometrium in women with PMB. The

ultrasonic prediction model based on the endometrial FI and VI was clinically useful for differentiating between benign endometrial lesions and EC, especially in postmenopausal patients with

recurrent vaginal bleeding presenting with ET of less than 5 mm. SIMILAR CONTENT BEING VIEWED BY OTHERS A RISK PREDICTION MODEL FOR ENDOMETRIAL HYPERPLASIA/ENDOMETRIAL CARCINOMA IN

PREMENOPAUSAL WOMEN Article Open access 06 January 2025 MACHINE LEARNING NOMOGRAM FOR PREDICTING ENDOMETRIAL LESIONS AFTER TAMOXIFEN THERAPY IN BREAST CANCER PATIENTS Article Open access 06

January 2025 AUTOMATED ENDOMETRIAL IDENTIFICATION AND VOLUME CALCULATION IN NORMAL UTERI USING A NOVEL SMART ERA TECHNIQUE Article Open access 04 September 2024 INTRODUCTION Endometrial

cancer (EC) is the most common gynecologic malignancy in developed countries1, as well as in some developed cities in China2. Postmenopausal bleeding (PMB) is the initial presenting symptom

in 80–90% of women with EC3. Therefore, distinguishing between benign endometrial lesions and EC in women with PMB is very important to provide accurate and timely diagnoses for surgical

treatment4. At present, the diagnosis of EC is mainly based on clinical symptoms, measurement of endometrial thickness (ET) by transvaginal ultrasound scanning (TVS), endometrial sampling

devices, dilatation and curettage (D&C) and hysteroscopy5. Although different types of endometrial sampling devices have been used in the screening and diagnosis of EC in recent years,

TVS has been recommended as an initial tool because it is less invasive compared with other tests, and TVS is not affected by the atrophic cervix due to menopause6. In most women, the

measurement of ET is used to assess the risk of endometrial lesions7. However, studies reported that some patients who subsequently developed EC with ET less than 5 mm were missed or had a

delayed diagnosis. A cohort research showed that approximately 6% of women with PMB and with a confirmed diagnosis of EC had thinner ET(≤ 4 mm)8. In addition, other studies have analyzed the

pathological results of women with PMB whose ET greater 5 mm measured via TVS, approximately 70% of women are diagnosed with endometrial benign lesions9. Therefore, distinguishing benign

and malignant endometrial lesions on the basis of ET may lead to missed diagnoses of EC in women with ET less than 5 mm, or increased invasive examination and pain in women with benign

endometrial lesions. The occurrence of EC involves cancerous changes in endometrial epithelial cells under the action of multiple factors, which are accompanied by abnormal proliferation of

blood vessels. Therefore, the assessment of EC occurrence based solely on ET has certain limitations, and the accuracy is higher if blood flow parameters are combined. Three-dimensional (3D)

power Doppler ultrasound is generally superior to color Doppler imaging for detecting low-velocity flows and visualizing small vessels. Studies have reported that the endometrial volume

(EV), vascularization index (VI), flow index (FI) and vascularization-flow index (VFI) are significantly higher in EC than in endometrial hyperplasia (EH)10. Therefore, 3D power Doppler

parameters are more useful than ET for differentiating between EH and EC, and blood flow in tumors could predict the spread of EC11. Gynecological doctors want to identify women at high risk

for EC when they present with PMB. Therefore, ultrasonic prediction model based on the 3D power Doppler may help to assist doctors in triaging patients for further investigations and reduce

missed diagnoses, especially for women with PMB whose endometria are less than 5 mm. Our research aims to establish the ultrasonic prediction model for EC in patients with PMB. MATERIALS

AND METHODS STUDY DESIGN We conducted a prospective observational study on patients with PMB. All methods were performed in accordance with the relevant guidelines and regulations. This

study was approved by the ethics committee of The First Affiliated Hospital of Xi’an Jiaotong University (XJTU1AF2016LSL-022). All the participants gave written informed consent. This study

has been registered on Clinical Trials.gov (NCT 03289468). The study complied with the STROBE guidelines for observational studies. PARTICIPANTS Figure 1 presents the flow chart of study

participation. Five hundred and ninety-two patients with PMB at the First Affiliated Hospital of Xi’an Jiaotong University from November 2015 to February 2020 were initially enrolled in this

prospective observational study. Patients had a median age of 57.8 years, with an age range of 45–79 years. The inclusion criteria were as follows: ① women with natural menopause, and

menopause was defined as at least 1 year of menstrual cessation after the age of 40, ② definitive endometrial histological diagnosis was obtained in our hospital. The exclusion criteria were

as follows: ① menstruation of women stopped for less than 1 year, ② women who received tamoxifen or menopausal hormone therapy (MHT), ③ women who presented with PMB because of coagulation

related diseases, iatrogenic factors, cervical disease or reproductive tract infection. The recurrent vaginal bleeding (RVB) was defined as two or more separate bleeding events within the

last 12 months12. Data were collected including body mass index (BMI), age at menopause, duration of PMB, and history of disease (diabetes, hypertension). The definition of normal

endometrial thickness after menopause is controversial, and most academic institutions recommend a low risk of EC when the endometrium is less than 5 mm. However, a small number of women

with postmenopausal bleeding are eventually diagnosed with EC when the endometrial thickness is less than 5 mm, especially women with RVB or risk factors for endometrial cancer. The standard

recommended by the Society of Gynecologic Oncology and Society of Obstetricians and Gynecologists of Canada was less than 5 mm13. The American College of Obstetricians and Gynecologists

(ACOG) committee recommends ≤ 4 mm14. Therefore, in order to reduce unnecessary testing and medical costs, patients with ET ≥ 5 mm (_n_ = 412) or ET < 5 mm who presented with RVB (_n_ = 

57) received D&C or hysteroscopy to obtained histopathological diagnosis in this study. The histopathology of the endometrium was assessed standardized by senior attending physicians,

and then reviewed by senior pathologists at our hospital. The patients were divided into four groups according to the pathological examination results of the endometrium: endometrial atrophy

(EA) (_n_ = 231), endometrial polyp (EP) (_n_ = 98), EH (_n_ = 58) and EC (_n_ = 82) groups. OUTCOME MEASURES Ultrasonic examinations were performed using Voluson E8 (GE Medical Systems,

USA) ultrasound system with vaginal probe frequency of 4–9 MHz. All the participants were examined by TVS. The maximum thickness of the endometrium on both sides of the midline was measured

in a longitudinal plane from the echogenic interface at the junction of the endometrium and myometrium. To further detect the EV and index of blood flow, the ultrasound machine was switched

to the 3D mode with power Doppler. The patient was asked to remain as still as possible. All the ultrasonic scans were performed by one operator to avoid interobserver variation. The

ultrasonic parameters were measured three times, and the average value was used for the final statistical analysis. The manual mode of the VOCAL contour editor was used to cover the entire

3D volume of the endometrium with a 15° rotation step. A total of 12 endometrial slices were obtained outlining the endometrium at the myoendometrial junction from the fundus to the internal

os. A histogram automatically showed the vascularization indices. The 3D volume was formed using basic units called voxels. The voxel contains all information about the grey scale and

colour, according to an intensity scale that ranges from 0 to 100. The vascularization indices are as follows: VI refers to the colour voxel-tototal voxel ratio, FI refers to the weighted

colour voxel divided by the total colour voxel ratio and provides an amplitude value for the colour signal, and VFI refers to the weighted colour voxel-to-total voxel ratio. The EV, VI, FI

and VFI were calculated automatically by the VOCAL software (GE Medical Systems, USA). VI manifests the number of vessels in the endometrium. FI estimates the average intensity of flow. VFI

manifests a combination of vascularity and blood flow15. STATISTICAL ANALYSIS Statistical analyses were performed using SPSS 20.0 software (IBM, USA)

(http://www.onlinedown.net/soft/1229603.htm). The Kolmogorov–Smirnov test was used to check the normal distribution prior to statistical tests. The continuous data variables were given as

mean ± standard deviation, and statistical comparison was performed by using the analysis of variance or Student’s t-test. The enumeration data were given as number and percentage (%), which

were compared by chi-square test. The predictive value of different parameters for differentiation between benign endometrial lesions and EC in women with PMB was performed by ROC curves,

and the cut-off value of each parameter was calculated by these curves. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and accuracy of the 3D

power Doppler ultrasound with surgico-pathologic findings as the reference standard. _P_ < 0.05 was considered statistically significant. RESULTS Among the 469 women with PMB,

pathological examination results revealed 231 that (49.3%) women with EA, 98 (20.9%) with EP, 58 (12.4%) with EH, and 82 (17.5%) with EC including 8 women with ET < 5 mm presented RVB.

Table 1 shows the clinical data of patients according to their histopathological diagnosis. There was significant difference in the duration of PMB among the four groups (_P_ = 0.045), women

with EC had the longest duration of PMB, followed by women with EH. However, no significant differences were found when comparing other characteristics among the four groups (_P_ = 

0.126–702). The ET, EV, VI, FI and VFI of women with EC were significantly higher compared with those of women with other pathological types of endometrium (_P =_ 0.006–0.020). The ET and EV

of women with EH were significantly higher than in women with EA (_P =_ 0.032, 0.028). In addition, the endometrial VI, FI and VFI of women with EH were significantly higher than those of

women with EA and EP (_P =_ 0.017–0.033). However, no significant difference was found in the ultrasonic parameters between women with EA and those with EP (_P =_ 0.189–0.560) (Fig. 2). For

patients with ET ≥ 5 mm, the data in our study suggested that the FI was the best predictor for EC, with AUC of 0.86. However, ET had a poorer predictive value for EC compared with other

parameters, with AUC of 0.74 (Table 2) (Fig. 3A). In addition, for patients with ET < 5 mm, the data in our study suggested that the VI was the best predictor for EC, with AUC of 0.92

(Table 2) (Fig. 3B). Because the FI and VI had better predictive values in both patients with ET ≥ 5 mm and those with ET < 5 mm, so they were used to establish ultrasonic prediction

model. Table 3 shows the assignment score of FI and VI according to the cut-off analyzed by ROC curves, which were used to establish prediction model. The risk of EC increased in women with

PMB as the score of the model increased. For patients with ET ≥ 5 mm, the AUC for ultrasonic prediction model was 0.90 (95% CI: 0.81–0.98) (_P_ = 0.006). The cut-off of the ultrasonic

prediction model was 3 points, with sensitivity and specificity were 92.2% and 83.6%, respectively (Fig. 3C). For patients with ET < 5 mm, the AUC for the ultrasonic prediction model was

0.92 (95% CI: 0.84–0.99) (_P_ = 0.005). The cut-off of the ultrasonic prediction model was 3 points, with sensitivity and specificity of 95.2% and 84.7%, respectively (Fig. 3D). DISCUSSION

In our study, 17.5% of women with PMB were diagnosed with EC, similar to previous studies and the meta-analyses by Gupta et al. showed that the prevalence of EC among all PMB patients was

10–24%16,17. However, the incidence of EC in some studies was less than 10%, such as 3.8% reported among 4383 women with PMB in Hong Kong18 and 4.9% reported in the United Kingdom12. This

difference may be explained by differences in the health-care system, use of screening methods, sample size, habits of the participants and place of residence. Most studies have confirmed

that ET can be used to distinguish benign and malignant endometrial lesions19,20. Makled et al. reported that the cut-off value of the ET was 11.5 mm21. Similarly, in this study, we found

that the cut-off of the ET was 9.4 mm. With pathological examination of the endometrium as the gold standard diagnostic tool for detecting EC, the diagnostic performance of ET for EC was as

follows: sensitivity 75.2%, specificity 65.4%, PPV 68.2%, NPV 72.2% and AUC 0.74. There are different ET cut-off values recommended by various professional groups. Although ET has been used

to assess the risk of EC in women with PMB, approximately 4% of EC are still missed, and this parameter has a false-positive rate as high as 50%22. Therefore, there is a limitation in

predicting EC based on ET alone, so prediction models based either on clinical risk factors or a combination of clinical risk factors plus ET have been reported to differentiate between

benign endometrial lesions and EC in women with PMB15,23. Changes from EH to EC are accompanied with angiogenesis and neovascularization, which can be tested through power Doppler

ultrasound. The 3D power Doppler technique has high sensitivity for detecting blood flow with very low velocities24. Therefore, very small vessels and low velocity blood flow can be detected

via power Doppler25. With these features, the blood flow indexes of 3D power Doppler have good predictive value for EC, especially in patients with borderline ET or women presenting with

PMB whose ET is less than 5 mm. Some scholars have been confirmed that 3D power Doppler can be used to predict endometrial lesions, including EP, EH and EC19. The data in this study revealed

that the ET, EV, VI, FI and VFI of women with EC were significantly increased than those of women with other pathological types of endometria. The ET and EV of women with EH were

significantly higher than those of women with EA. In addition, the VI, FI and VFI of women with EH were significantly higher than in women with EA and EP. Therefore, as endometrial lesions

progress, the endometrial thickness and blood flow increase. Many studies have been conducted to evaluate the accuracy of indexes measured by 3D power Doppler in differentiating benign and

malignant lesions of the endometrium in women with PMB. Larger EV and higher Doppler indices were correlated with malignant lesions. Merce et al. reported that ET and EV were significantly

higher in women with EC than in those with EH26. In 2016, indices measured by 3D power Doppler were used to differentiate between EH and EC, which improved the sensitivity and specificity.

The cut-off values for ET in their study were EV (7 cm3), VI (0.7%), FI (0.22) and VFI (25), respectively27, which were similar to the results of our study. However, other researchers have

revealed different cut-off measurements of 3D power Doppler for EC in women with PMB. Epstein et al. demonstrated that the cut-off values of the EV, VI, FI and VFI were 2.7 cm3, 4.3%, 1.15

and 30.1, respectively19. In 2018, Pandey et al. indicated that the variables with good discriminatory potential between benign and malignant statuses were the VI and VFI28. The differences

in results could be explained by differences in the use of screening methods, sample sizes, places of residence and habits of the subjects, EC standards of endometrial pathology results

obtained (≥ 4 mm or ≥ 5 mm), ultrasonic equipment, etc. Vitale et al. demonstrated a prediction model based on the presence and duration of abnormal uterine bleeding, the ultrasound vascular

pattern and echogenicity, and the hysteroscopic appearance of the endometrium. The sensitivity and specificity were 79.17% and 95.19%, respectively, with an area under the ROC curve of

0.96529. Additionally, previous studies reported two prediction models for the development of endometrial cancer in the general population (risk models) and one extension. The risk models

included epidemiological variables related to the reproductive history of women, hormone use, BMI, and smoking history. The diagnostic models also included clinical predictors, such as

endometrial thickness and recurrent bleeding. The data showed that the concordance statistic, which was used to assess discriminative ability, varied from 0.68 to 0.77 in the risk models and

from 0.73 to 0.96 in the diagnostic models30. The data in our study suggested that the FI and VI had better predictive value in patients with both ET ≥ 5 mm and ET < 5 mm. Hence, to

predict EC in women with PMB more conveniently and accurately, especially for women with ET less than 5 mm, the FI and VI were used to establish ultrasonic prediction model. According to the

results of this study, for patients with ET ≥ 5 mm, the AUC for the ultrasonic prediction model was 0.90, and for patients with ET < 5 mm, the AUC for the ultrasonic prediction model was

0.92. Therefore, the ultrasonic prediction model based on 3D power Doppler scanning had better predictive value for EC in both patients with ET ≥ 5 mm and patients with ET < 5 mm. Our

study has several limitations. First, the sample size of this study was not large enough, and it was a single-center study. Second, although the effect of MHT on the endometrium was excluded

in this study, the BMI and metabolic syndrome, which are considered risk factors for EC, were not analyzed in depth. Third, patients with endometrial thickness less than 5 mm and no history

of RVB did not undergo pathological examinations, which may include EC. In addition, specific equipment is required to measure endometrial blood flow parameters, such ultrasound instruments

need to be equipped with 3D ultrasonic probes, and sonographers need to be trained to ensure the accuracy and repeatability of the measurements. Therefore, the validity and reproducibility

of the ultrasonic prediction model in this study remain to be studied in the future. CONCLUSION The ultrasonic parameters differed among the different pathological types of the endometrium

in women with PMB. The ultrasonic prediction model based on the endometrial FI and VI was clinically useful for differentiating between benign endometrial lesions and EC, especially in

postmenopausal patients with recurrent vaginal bleeding presenting with ET of less than 5 mm. DATA AVAILABILITY All datasets generated for this study are included in the article. Further

inquiries can be directed to the corresponding author (Xiaofeng Yang). REFERENCES * Siegel, R. L. et al. Cancer statistics, 2025. _CA Cancer J. Clin._ 5, 10–45.

https://doi.org/10.3322/caac.21871 (2025). Article  Google Scholar  * Jiang, D. Y. et al. Endometrial sampling devices for early diagnosis of endometrial lesions. _J. Cancer Res. Clin.

Oncol._ 142, 2515–2522. https://doi.org/10.1007/s00432-016-2215-3 (2016). Article  Google Scholar  * Clarke, M. A. et al. Association of endometrial cancer risk with postmenopausal bleeding

in women: a systematic review and meta-analysis. _Jama Intern. Med._ 178, 1210–1222. https://doi.org/10.1001/jamainternmed.2018.2820 (2018). Article  PubMed  PubMed Central  Google Scholar 

* Kim, S. et al. Long-term diabetes risk among endometrial cancer survivors in a population-based cohort study. _Gynecol. Oncol._ 156, 185–193. https://doi.org/10.1016/j.ygyno.2019.10.015

(2020). Article  PubMed  Google Scholar  * Van Hanegem, N. et al. The accuracy of endometrial sampling in women with postmenopausal bleeding: a systematic review and meta-analysis. _Eur. J.

Obstet. Gynecol. Reprod. Biol._ 197, 147–155. https://doi.org/10.1016/j.ejogrb.2015.12.008 (2016). Article  PubMed  Google Scholar  * Timmermans, A. et al. Endometrial thickness measurement

for detecting endometrial cancer in women with postmenopausal bleeding: a systematic review and meta-analysis. _Obstet. Gynaecol._ 8, 160–167. https://doi.org/10.1097/AOG.0b013e3181e3e7e8

(2010). Article  Google Scholar  * Verbakel, J. Y. et al. Validation of ultrasound strategies to assess tumor extension and to predict high-risk endometrial cancer in women from the

prospective IETA (International endometrial tumour Analysis) 4 cohort. _Ultrasound Obstet. Gynecol._ 55, 115–124. https://doi.org/10.1002/uog.20374 (2020). Article  CAS  PubMed  Google

Scholar  * Wong, A. S. et al. Reappraisal of endometrial thickness for the detection of endometrial cancer in postmenopausal bleeding: a retrospective cohort study. _BJOG_ 123, 439–446.

https://doi.org/10.1111/1471-0528.13342 (2016). Article  PubMed  Google Scholar  * Turnbull, H. L. et al. Investigating vaginal bleeding in postmenopausal women found to have an endometrial

thickness of equal to or greater than 10 mm on ultrasonography. _Arch. Gynecol. Obstet._ 295, 445–450. https://doi.org/10.1007/s00404-016-4249-9 (2017). Article  PubMed  Google Scholar  *

Merce, L. T. et al. Clinical usefulness of 3-dimensional sonography and power doppler angiography for diagnosis of endometrial carcinoma. _J. Ultrasound Med._ 26, 1279–1287.

https://doi.org/10.7863/jum.2007.26.10.1279 (2007). Article  PubMed  Google Scholar  * Hanafi, S. et al. Value of three dimensional power doppler ultrasound in prediction of endometrial

carcinoma in patients with postmenopausal bleeding. _J. Turk. Ger. Gynecol. Assoc._ 15, 78–81. https://doi.org/10.5152/jtgga.2014.07355 (2014). Article  PubMed  PubMed Central  Google

Scholar  * Burbos, N. et al. Predicting the risk of endometrial cancer in postmenopausal women presenting with vaginal bleeding: the Norwich DEFAB risk assessment tool. _Br. J. Cancer_. 102,

1201–1206. https://doi.org/10.1038/sj.bjc.6605620 (2010). Article  CAS  PubMed  PubMed Central  Google Scholar  * Renaud, M. C., Le, T. & Bentley, J. Epidemiology and investigations for

suspected endometrial cancer. _J. Obstet. Gynaecol. Can._ 35, 380–383. https://doi.org/10.1016/S1701-2163(15)30970-1 (2013). Article  PubMed  Google Scholar  * The American College of

Obstetricians and Gynecologists. Endometrial intraepithelial neoplasia. _Obstet. Gynecol._ 125, 1272–1278. https://doi.org/10.1097/01.AOG.0000465189.50026.20 (2015). Article  CAS  Google

Scholar  * Yuan, T., Zhang, T. & Han, Z. Placental vascularization alterations in hypertensive disorders complicating pregnancy (HDCP) and small for gestational age with HDCP using

three-dimensional power doppler in a prospective case control study. _BMC Pregnancy Childbirth_. 15, 240. https://doi.org/10.1186/s12884-015-0666-1 (2015). Article  PubMed  PubMed Central 

Google Scholar  * Musonda, P. et al. Comparing the performance of two clinical models in estimating the risk of endometrial cancer in symptomatic postmenopausal women. _Eur. J. Obstet.

Gynecol. Reprod. Biol._ 159, 433–438. https://doi.org/10.1016/j.ejogrb.2011.09.005 (2011). Article  PubMed  Google Scholar  * Gupta, J. K. et al. Ultrasonographic endometrial thickness for

diagnosing endometrial pathology in women with postmenopausal bleeding: a meta-analysis. _Acta Obstet. Gynecol. Scand._ 81, 799–816. https://doi.org/10.1034/j.1600-0412.2001.810902.x (2002).

Article  PubMed  Google Scholar  * Wong, A. S. et al. Development and validation of prediction models for endometrial cancer in postmenopausal bleeding. _Eur. J. Obstet. Gynecol. Reprod.

Biol._ 203, 220–224. https://doi.org/10.1016/j.ejogrb.2016.05.004 (2016). Article  PubMed  Google Scholar  * Epstein, E. et al. Ultrasound characteristics of endometrial cancer as defined by

international endometrial tumor analysis (IETA) consensus nomenclature: prospective multicenter study. _Ultrasound Obstet. Gynecol._ 51, 818–828. https://doi.org/10.1002/uog.18909 (2018).

Article  CAS  PubMed  Google Scholar  * Doll, K. M. et al. Endometrial thickness as diagnostic triage for endometrial cancer among black individuals. _JAMA Oncol._ 11, 354.

https://doi.org/10.1001/jamaoncol.2024.1891 (2025). Article  Google Scholar  * Makled, A. K. et al. Three-dimensional power doppler and endometrial volume as predictors of malignancy in

patients with postmenopausal bleeding. _J. Obstet. Gynaecol. Res._ 39, 1045–1051. https://doi.org/10.1111/j.1447-0756.2012.02066.x (2013). Article  PubMed  Google Scholar  * Tabor, A., Watt,

H. C. & Wald, N. J. Endometrial thickness as a test for endometrial cancer in women with postmenopausal vaginal bleeding. _Obstet. Gynecol._ 99, 663–670.

https://doi.org/10.1016/s0029-7844(01)01771-9 (2002). Article  PubMed  Google Scholar  * Burbos, N. et al. Estimating the risk of endometrial cancer in symptomatic postmenopausal women-a

novel clinical prediction model based on patients’ characteristics. _Int. J. Gynecol. Cancer_. 21, 500–506. https://doi.org/10.1097/IGC.0b013e31820c4cd6 (2011). Article  PubMed  Google

Scholar  * Nieuwenhuis, L. L. et al. Fibroid vascularisation assessed with three-dimensional power doppler ultrasound is a predictor for uterine fibroid growth: a prospective cohort study.

_BJOG_ 125, 577–584. https://doi.org/10.1111/1471-0528.14608 (2018). Article  CAS  PubMed  Google Scholar  * Ni, J. et al. Three-dimensional 3D ultrasound combined with power doppler for the

differential diagnosis of endometrial lesions among infertile women. _Int. J. Gynaecol. Obstet._ 145, 212–218. https://doi.org/10.1002/ijgo.12787 (2019). Article  PubMed  Google Scholar  *

Merce, L. T. et al. Endometrial volume and vascularity measurements by transvaginal threedimensional ultrasonography and power doppler angiography in stimulated and tumoral endometria:

intraobserver reproducibility. _Gynecol. Oncol._ 100, 544–550. https://doi.org/10.1016/j.ygyno.2005.09.024 (2006). Article  PubMed  Google Scholar  * Abd Elkhalek, Y. I., Mansour, M. G.

& Farouk, O. Three dimensional transvaginal sonography and power doppler angiography in the differentiation between endometrial hyperplasia and endometrial carcinoma in postmenopausal

women with abnormal uterine bleeding. _Egypt. J. Radiol. Nucl. Med._ 47, 1795–1801. https://doi.org/10.1016/j.ejrnm.2016.08.014 (2016). Article  Google Scholar  * Pandey, H. et al. Utility

of three dimensional(3-D) ultrasound and power doppler in identification of high risk endometrial cancer at a tertiary care hospital in Southern India: a preliminary study. _Taiwan. J.

Obstet. Gynecol._ 57, 522–527. https://doi.org/10.1016/j.tjog.2018.06.007 (2018). Article  PubMed  Google Scholar  * Vitale, S. G. et al. Risk of endometrial malignancy in women treated for

breast cancer: the BLUSH prediction model - evidence from a comprehensive multicentric retrospective cohort study. _Climacteric_ 27 (5), 48248–48248.

https://doi.org/10.1080/13697137.2024.2376189 (2024). Article  Google Scholar  * Alblas, M. et al. Prediction models for endometrial cancer for the general population or symptomatic women: a

systematic review. _Crit. Rev. Oncol. Hematol._ 126, 92–99. https://doi.org/10.1016/j.critrevonc.2018.03.023 (2018). Article  PubMed  Google Scholar  Download references FUNDING This study

was supported by the grant from the Health Research Project of Shaanxi Province (No. 2018D054), the Health Science and Technology Innovation Project of Shaanxi Province (No. 2024PT-11), and

the China Maternal and Child Health Association Maternal and Child Health Research and Innovation Technology Project (No. ZGFYBJXH-KY2104). AUTHOR INFORMATION AUTHORS AND AFFILIATIONS *

Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, Shaanxi, China Li Wang, Shimin Quan & Xiaofeng Yang Authors * Li Wang

View author publications You can also search for this author inPubMed Google Scholar * Shimin Quan View author publications You can also search for this author inPubMed Google Scholar *

Xiaofeng Yang View author publications You can also search for this author inPubMed Google Scholar CONTRIBUTIONS L.W. conceived the study, analyzed the data and wrote the manuscript. S.M.Q

collated the data. X.F.Y. provided participants and revised the manuscript. CORRESPONDING AUTHOR Correspondence to Xiaofeng Yang. ETHICS DECLARATIONS COMPETING INTERESTS The authors declare

no competing interests. ADDITIONAL INFORMATION PUBLISHER’S NOTE Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. RIGHTS

AND PERMISSIONS OPEN ACCESS This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use,

sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons

licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or

other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in

the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the

copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Wang, L., Quan, S.

& Yang, X. Ultrasonic prediction model using three-dimensional power doppler for endometrial cancer detection in women with postmenopausal bleeding. _Sci Rep_ 15, 18302 (2025).

https://doi.org/10.1038/s41598-025-02067-y Download citation * Received: 10 October 2024 * Accepted: 12 May 2025 * Published: 26 May 2025 * DOI: https://doi.org/10.1038/s41598-025-02067-y

SHARE THIS ARTICLE Anyone you share the following link with will be able to read this content: Get shareable link Sorry, a shareable link is not currently available for this article. Copy to

clipboard Provided by the Springer Nature SharedIt content-sharing initiative KEYWORDS * Postmenopausal bleeding * Benign endometrial lesions * Endometrial cancer * Three-dimensional power

doppler ultrasound * Ultrasonic prediction model