The lining of the uterus changes throughout the menstrual cycle in response to the hormones (oestrogen and progesterone) that is produced by the ovaries. Oestrogen is made before the egg ovulates and progesterone is made after the egg ruptures. Oestrogen enables the lining to grow and progesterone enables the lining to store glycogen. As and when the fertilized egg comes along, the lining can nourish it and enable it to attach itself to the uterus and thus grow. If fertilization has not happened, then the hormone levels decrease and the lining is eventually shed as a period.

There are times when a woman may not ovulate, oestrogen is produced, progesterone is not produced (as in patients with PCOS, perimenopause women, long term use of drugs like tamoxifen and commonly after menopause). In this case the lining continues to grow in response to oestrogen but it is not shed as there is no progesterone. It is not shed appropriately and the woman may have irregular bleeding and spotting.

The lining can then become very thick. It is then called hyperplasia. This is not cancer but the same lining can become cancerous in the long run.

The commonest presenting symptom for endometrial hyperplasia is abnormal bleeding. This may be in form of heavier cycles, longer duration of flow, short cycles, erratic bleeding and bleeding after menopause.

One must report to the gynaecologist in case one as any abnormal bleeding. The doctor will do a complete gynaecological examination and then suggest tests. These may be blood tests and pelvic sonography.

The sonography is useful in diagnosing a thick lining. But this is not enough to diagnose hyperplasia. A definitive diagnosis is obtained only after the doctor takes a small fragment of the lining and it is examined under the microscope to see changes of hyperplasia.


Menopause is said to have occurred if you do not have period for 1 year. The average age of menopause is 51 years, but it can happen anytime from 45 to 55 years. Bleeding after menopause is not normal and you should see a gynecologist for a checkup. The bleeding can be due to various causes as follow:

1. Polyps
These are small finger like growths from the lining of the uterus. They grow from the lining into the cavity of the uterus and sometimes into the cervical canal. They may also protrude out of the external opening of the cervix and may be seen with a naked eye on a speculum examination of the vagina. They are usually noncancerous. They can cause heavy irregular bleeding and sometimes bleeding after sex.

2. Endometrial Hyperplasia
In this situation the lining of the uterus becomes thick. This happens when there is estrogen production but no progesterone available after menopause. Sometimes the cells of the lining can become abnormal and eventually turn into cancer. Women usually complain of heavy frequent and abnormal vaginal bleeding.

3. Withdrawal Bleeding
This is bleeding that occurs sometimes when a menopausal women is on hormonal therapy and then discontinues with it.

4. Endometrial Cancer
This occurs in the menopausal women, is usually slow growing, and does not spread fast. Women complain of blood stained discharge or frank bleeding after menopause. If you have bleeding after menopause then you will need a complete examination and certain tests:
a. A pelvic sonography is the commonest test
b. You may also need diagnostic hysteroscopy (i.e. look into the cavity of the uterus with a camera)
c. Dilatation and curettage i.e. the lining of the uterus is scraped and sent for examination under a microscope. The report of the lining will decide the further course of action.
Polyps can be removed at the same time. Hyperplasia can be treated with medication but in some cases with complex hyperplasia, it may be prudent to remove the uterus. In case of cancer, surgery is usually step one and further treatment may be required depending on the stage.

Uterine Fibroids

What are uterine fibroids?
Uterine fibroids are benign (not cancer) growths that develop from the muscle tissue of the uterus. They also are called leiomyomas or myomas. The size, shape and location of fibroids can vary greatly. They may be present inside the uterus, on its outer surface or within its wall, or attached to it by a stem-like structure. A woman may have only one fibroid or many of varying sizes. A fibroid may remain very small for a long time and suddenly grow rapidly, or grow slowly over a number of years. What are uterine fibroids?
      • Changes in menstuation

    – Longer, more frequent or heavy menstrual periods

    • – Menstrual pain (cramps)
    • – Vaginal bleeding at times other than menstrual
    • – Anemia (from blood loss)
      • Pain

    -In the abdomen or lower back (often dull, heavy and aching, but may be sharp)

    • – During Sex
    • Pressure

– Difficulty urinating or frequent urination – Constipation, rectal pain or diffcult bowel movements – Abdominal cramps

  • Enlarged uterus and abdomen
  • Miscarriage
  • Infertility

Fibriod also may cause no symptoms at all. Fibroids may be found during routine pelvic exam or during tests for other problems.

How are fibroid diagnosed?

The first sign of fibroids may be detected during routine pelvic exam. A number of tests may show more information about fibroids: • Ultrasonography uses sound waves to create a picture of the uterus and other pelvis organs. • Hysteroscopy uses a slender device (the hysteroscope) to see the inside of the uterus. It is inserted through the vagina and cervix (opening of the uterus). This permits the doctor to see fibroid inside the uterine cavity. • Hysterosalpingography is a special X-ray test. It may detect abnormal changes in the size and shape of the uterus and fallopian tubes. • Sonohysterography is a test in which fluid is put into the uterus through the cervix. Ultrasonography is then used to show the inside of the uterus. The fluid provides a clear picture of the uterine lining. • Laparoscopy uses a slender device (the laproscope) to help the doctor see the inside of the abdomen. It is inserted through a small cut just below or through the navel. The doctor can see fibroids on the outside of the uterus with the laparoscope. Imaging test, such as magnetic resonance imaging and computed tomography scans, may be used but are rarely needed. Some of these tests may be used to track the growth of fibroids over time.

When is treatment necessary for fibroids?

Fibroids that do not cause symtoms, are small, or occur in a woman who is nearing menopause oftem do not require treatment. Certain signs and symptoms may signal the need for treatment.
  • Heavy or painful menstrual periods that cause anemia or that disrupt a woman’s normal activities.
  • Bleeding between periods
  • Uncertainty whether the growth is a fibroid or another tyoe of tumor such as ovarian tumor.
  • Rapid increase in growth of the fibroid
  • Infertility
  • Pelvic Pain

Ovarian Cysts

What is an ovarian cyst?
An ovarian cyst is a sac or pouch filled with fluid or other tissue that forms in or on an ovary. Ovarian cysts are very common. They can occur during the childbearing years or after menopause. Most ovarian cysts are benign (not cancer) and go away on their own without treatment. Rarely, a cyst may be malignant (cancer).

What are different types of cysts?
Types of cysts include the following:

Functional cyst – This is the most common type of ovarian cyst. It usually causes no symptoms. Functional cysts often go away without treatment within 6-8 weeks.
Teratoma – This type of cyst contains different kinds of tissues that make up the body, such as skin and hair. This cysts may be present from birth but can grow during a woman’s reproductive years. In very rare cases, some teratomas can become cancer.
Cystadenoma – These cysts form on the outer surface of the ovary. They can grow very large but usually are begign.
Endometrioma – This cyst forms as a result of endometriosis.

What are the symptoms of ovarian cysts?
In most cases, cysts do not cause symptoms. Many are found during a routine pelvic exam or imaging test done for another reason. Some cysts may cause may cause a dull or sharp ache in the abdomen and pain certain activities. Larger cysts may cause twisting of the ovary. This twisting usually causes pain on one side that comes and goes or can start suddenly. Cysts that bleed or burts also may cause sudden or severe pain.

How are ovarian cysts diagnosed?
If your obstetrician-gynecologist (ob-gyn) or other health care professional thinks that you may have cyst, the following tests may be recommended to find our more information:
• Ultrasound exam – This test uses sound waves to create pictures of the internal organs. An instrument called a transducer is placed in the vagina or on the abdomen. The views created by the sound waves show the shape, size and location of the cyst. The views also show whether the cyst is solid or filled with fluid.
• Blood tests – You may have blood test that measures the level of a substance called CA 125. An increased level of CA 125, along with certain findings from ultrasound and physical exams, may arise concern for ovarian cancer, especially in a women who is past menopause. Several other blood tests also can be used to help identify whether a mass of the ovary is concerning for ovarian cancer.

How are ovarian cysts treated?
There are several treatment options for cysts. Choosing an option depends on the type of cyst and other factors. Treatment options include watchful waiting and, if the cyst is large or causing symptoms, surgery.


What is endometriosis?
Endometriosis is a condition in which the type of tissue that forms the lining of the uterus (the endometrium) is found outside the uterus.

What are symptoms of endometriosis?
The most common symptom of endometriosis is chronic (long-term) pelvic pain, especially just before and during the menstrual period. Pain also may occur during sex. If endometrosis is present on the bowel, pain during bowel movements can occur. If it affects the bladder, pain may be felt during urination. Heavy menstrual bleeding is another symptom of endometriosis. Many women with endometriosis have no symptoms.

How is endometriosis diagnosed?
A health care provider first may do physical exam, including a pelvic exam. However the only way to tell for sure that you have endometriosis is through a surgical procedure called laparoscopy. Sometimes a small amount of tissue is removed during the procedure. This is called a biopsy.

How is endometriosis treated?
Treatment for endometriosis depends on the extent of the disease, your symptoms, and whether you want to have children. Endometriosis may be treatmetn with medication, surgery or both. When pain is the primary problem, medication usually is tried first.

Vaginal Infection

Vaginal inflammation and infection can happen to women of all ages but it is most common in women of reproductive years. The vagina normally has certain bacteria and yeast that live in the vagina and are in harmony with the body.
They do not cause any problems. Sometimes the environment of the vagina may change and the balance of the yeast and the bacteria may be disturbed. Under the circumstances the vagina may get inflamed and/or infected.
Various factors predispose to vaginal infection. They are use of antibiotics, pregnancy, breast feeding, menopause, douching, use of spermicides, and sexual intercourse per se. Antibiotics, douching and use of spermicides change the pH of the body and can cause change in the normal flora. During pregnancy, breast feeding and menopause there is alteration in the hormone levels and therefore the flora may change.
Three types of infection commonly occur in the vagina.

Yeast {fungal} infection is the commonest type of vaginal infection. Most common symptoms are itching and burning in the vulval region. The vulva may be swollen and red. The discharge is typically thick white curd like odorless and sticks to the skin of the vulva.

Bacterial vaginosis
This is caused by overgrowth of bacteria that are normally present in the vagina. Women complain of foul smelling thin watery vaginal discharge with a characteristic fishy odor.

It is caused by an organism called trichomonas vaginalis. It is sexually transmitted. Women complain of greenish yellow discharge, local burning, irritation, redness and swelling.

The diagnosis can be done by examining the discharge under the microscope. The fungus / the trichomonas may be seen in the discharge.

All these infections are treated with local medication and oral tablets. In case of trichomoniasis, the sexual partner should also be treated.

Human Papillomavirus (HPV) Vaccines

What is human papillomavirus (HPV) ?
Human papillomavirus (HPV) is a virus that can be passed from person to person through skin-to-skin contact. More than 100 types of HPV have been found. About 30 of these types infect the genital areas of men and women.

How is HPV spread?
HPV is primarily spread through vaginal, anal or oral sex but sex intercourse is not required for infection to occur. HPV is spread by skin-to-skin contact. Sexual contact with an infected partner, regardless of the sex of the partner, is the most common way the virus is spread.

What disease does HPV Cause?
Approximately 12 types of HPV cause genital warts. Two types, type 6 and type 11, cause most cases of genital warts. Genital warts are growths that may appear on the outside or inside vagina or on the penis and can spread to nearby skin. They also can grow around the anus, on the vulva, or on the cervix. They can be treated with medication that is applied to the area or by surgical removal. The type of treatment depends on where the warts are located. About 15 types of HPV cause cancer of the cervix. They also cause cancer of the vulva, vagina, anus, penis, and the head and neck. Most cases of cervical cancer are caused by just two types of HPV-Type 16 and type 18.

How does HPV cause cancer of the cervix?
The cervix is covered by a thin layer of tissue made up of cells. If one of the cancer-causing types of HPV is present, it may enter these cells. Infected cells may become abnormal or damaged and begin to grow differently. It usually takes several years for cervical cancer to develop. Cervical cancer screening can detect early signs of abnormal changes of the cervix and allows early treatment so that they do not become cancer.

How effective are the vaccines in preventing HPV infection?
The four type vaccine is almost 100% effective in preventing cervical precancer and genital warts caused by four types of HPV. The two type vaccine is almost 100% effective in preventing cervical precancer caused by two types of HPV. The vaccines are most effective if they are given before a women is sexually active and exposed to HPV. If a women is already infected with one type of HPV, the vaccines will not protech against disease caused by that type. However the vaccines can protect against the other types of HPV included in the vaccines.

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