Lichen sclerosus is a benign inflammatory condition of the skin of the vulva. It can occur in women of any age, but is most common in postmenopausal women. Symptoms include itching and burning with associated pain during intercourse. The surface of the vulvar skin is often extremely thin and may have a paper-like appearance. Because of this, the skin may tear during intercourse and cause pain or bleeding.

Standard initial treatment of lichen sclerosus is application of creams containing high-potency steroids to the affected area. The most common steroid cream is known as clobetasol or Temovate. This cream should be applied to the area twice a day for approximately 2 to 3 weeks, then tapered to once a day, and finally down to occasional use. Most women notice an improvement in symptoms within 1 month of use of the steroid cream. This treatment may be continued on a long-term basis.

Fibrocystic changes of the breasts are very common, especially from the ages of 20 to 50, and are thought to be directly related to estrogen. Fibrocystic breast masses usually occur on a cyclic basis in relation to the menstrual cycle. They can be quite painful and often appear rapidly with the onset of menses, and then disappear afterward.

The most important characteristic of a fibrocystic lesion of the breast is that it resolves on its own. If your masses/cysts do not resolve, especially after a menstrual cycle, you need to see your physician so that the mass can be further evaluated to assure that it is not a cancerous lesion. This evaluation may necessitate cyst aspiration or biopsy of the mass.

Often people with fibrocystic changes of the breasts notice associated breast tenderness. This pain may be alleviated by wearing a tight bra for support. Although there is no good evidence to support its use, many physicians advocate use of vitamin E and reduction of caffeine to alleviate some of the symptoms.

If you have cysts under the skin, rather than in your breast tissue, you may need other treatments. You should see your physician to exclude this possibility.

It is thought that 45% to 75% of women experience yeast infections (also known as vulvovaginal candidiasis) in their lifetime. It is thought that 45% to 75% of women experience yeast infections (also known as vulvovaginal candidiasis) in their lifetime. In over 80% of cases, infection is caused by an orgainism known as Candida albicans. This is a fungus that resides in the vagina of a significant number of women. Several situations allow overgrowth of Candida albicans including recent antibiotic use, pregnancy, and diabetes.

The signs and symptoms of a vaginal yeast infection often include itching, a thick white vaginal discharge often described as being similar to cottage-cheese, and redness of the vulvar and vaginal areas.

Treatment of a yeast infection is variable. The most common treatment involves using a topical antifungal cream in the vaginal area (such as Gyne-Lotrimin or Monistat). An applicator full of cream is placed in the vagina at bedtime from 1 to 7 days. The medication can be obtained over-the-counter, but should only be used by someone who has been diagnosed by a physician or has had similar symptoms in the past where a diagnosis was made. An oral treatment is now available by prescription.

If you have chronic yeast infections, your physician may start you on a monthly regimen of treatment, usually for a total of 6 months.

Blood in the urine is called hematuria and should never be ignored. It is important to determine exactly where the blood is coming from. In women, the blood may appear to be in the urine when it is actually coming from the vagina or rectum. Discoloration from drugs or foods can mimic hematuria. A catheterized urine sample is an important diagnostic test to make sure that the discoloration is really blood and that the bleeding is coming from the bladder. Also, there is a condition called microscopic hematuria, in which the urine has microscopic amounts of blood that cannot be seen with the naked eye. In the majority of cases tests will be negative and no treatment is necessary. However, before you can make this diagnosis, other more serious causes must be eliminated.

Blood in the urine should never be ignored. It is important to see your physician and have the problem isolated and treated.

Dysplasia is considered a precancerous cell type. However, if the dysplasia is classified as low-grade squamous dysplasia, then about 30% of the time, the abnormal cells will disappear without treatment.

Endometriosis is a condition in which tissue that normally lines the inside of the uterus (the endometrium) spreads and implants in areas outside of the uterus. Often the site of the implantation is somewhere in the abdominal cavity. In patients with endometriosis, these implants of endometrium grow on a cyclic basis just as the normal endometrium does. When the normal endometrium sheds during your menstrual cycle causing your period, so do these endometrial implants. They can cause a small amount of bleeding within your abdominal cavity which results in pain.

Symptoms of endometriosis are often described as menstrual cramping and pain that begins before the onset of menstrual bleeding, and continues through the menstrual cycle. The severity of endometriosis often does not correlate with the degree of pain experienced with endometriosis. Often women with a small amount of endometriosis will have significant cyclic pain, and often women with a large amount of endometriosis will have minimal pain. Endometriosis is often seen in women who previously had pain-free menstrual cycles, and have gradually noticed a worsening in their pain.

The definitive diagnosis of endometriosis can only be made through surgery where the endometriotic lesions can be seen and sometimes biopsied to make the diagnosis.

Bladder infections or urinary tract infections are also known as cystitis. Women often notice an abrupt onset of symptoms, which include burning with urination, urinating more frequently than usual, and abdominal pain. If a urinary tract infection has spread to the kidneys (also known as pyelonephritis) a woman may experience fever and back pain.

Urinary tract infections are caused by spread of bacteria that normally reside in the rectum into the urethra and bladder. Several situations increase your risk of getting a urinary tract infection, among them, recent intercourse, delayed emptying of your bladder after intercourse, and use of a diaphragm.

Many women with one urinary tract infection will have multiple urinary tract infections. Your physician will grow out your urine before and after treatment to be sure treatment is completely irradicating the bacteria. Additionally, it may be helpful to empty your bladder completely after each episode of intercourse. The ultimate treatment for recurrent urinary tract infections will be up to your doctor. She may recommend staying on a medicine that suppresses bacteria consistently, taking medication after intercourse, or taking medication as soon as you notice symptoms.

Some antibiotics and certain other medications have the potential to reduce the effectiveness of birth control pills. Some antibiotics slightly reduce the amount of hormones absorbed by the system.

Among the suspect antibiotics are those in the penicillin family, including penicillin, amoxicillin, and ampicillin; tetracycline, and related drugs such as doxycycline and erythromycin. Some epilepsy drugs, tranquilizers, barbiturates, anti-inflammatories, and laxatives may also reduce the effectiveness of oral contraceptives. The same effect may also occur if you have an intestinal illness that causes diarrhea or vomiting.

The difference between oral hormones and transdermal hormones involves the route of absorption. Oral hormones are absorbed in the gastrointestinal tract and metabolized in the liver. Transdermal hormones, however, are directly absorbed into the blood stream. Therefore the difference between the two routes may account for some difference in gastrointestinal symptoms. Additionally, for people with elevated triglyceride levels, transdermal hormones have been found to be beneficial.

To date, hormone replacement therapy has not been linked to weight loss or weight gain. There is also no evidence to suggest hair loss or acne are related to the low levels of hormones supplied by hormone replacement therapy. The progesterone component of hormone replacement therapy has been associated with bloating. However, it is not safe to take estrogen without progesterone unless you have had a hysterectomy. Sometimes changing the type of progesterone used can be of benefit.

It is unlikely that changing from oral to transdermal hormone replacement therapy will improve all of your symptoms.

In a normal menstrual cycle there is regular hormone production and thickening of the lining of the uterus. This cycle primes the endometrium (uterine lining) for implantation of a developing embryo. If no implantation occurs, the lining sheds, resulting in a menstrual period. There are two phases in the menstrual cycle: the follicular phase and the luteal phase. The follicular phase occurs prior to ovulation and involves thickening of the lining of the uterus. This phase usually lasts 10 to 14 days. The luteal phase is the period of time from ovulation to the onset of menses when the lining of the uterus undergoes stabilization prior to menses. This phase usually lasts 14 days.

During the first 2 years after the onset of menstruation, cycles are often irregular. These early cycles are often anovulatory-there is no ovulation during the menstrual cycle and therefore the luteal phase does not occur properly. Because of this a woman will experience irregular bleeding. As long as the menstrual cycles are no longer than 35 days, no shorter than 21 days, and the duration of bleeding is no longer than 7 days, this is considered normal in a woman who has recently started menstruating.

If irregular bleeding lasts longer than 2 years or the blood flow is excessive, your physician may suggest further evaluation.

Despite all the advertising by manufacturers of feminine hygiene products, there are no practical reasons for women to douche on a regular basis.

Premenstrual Syndrome (PMS) is a disorder experienced by many women. This syndrome has many associated symptoms. One of these symptoms is bloating. This often begins approximately 1 to 2 weeks prior to menses and is characterized by bloating and weight gain. Often women notice a significant reduction in their weight immediately after menses.

Initial treatment for PMS is lifestyle changes such as exercise and changing your diet to decrease salt, caffeine, and chocolate intake. If you have a significant amount of bloating prior to your menses and it is affecting your daily life. You may consult your physician. Although no good studies support their use, many women report improvement in symptoms with the use of birth control pills.

What you are describing is a normal pattern of menstruation and a normal menstrual period. A normal menstrual period last about 5 to 7 days, the bleeding is heaviest during the first couple of days and then slows for the remaining 3 or 4 days. As your bleeding slows, the blood clots. This could be what you are seeing. Another possibility is that you are seeing a portion of the uterine lining (endometrium) which is the tissue that is shed during menstruation. In short, you should be reassured that your period is normal.

Females should have their first gynecological exam by the age of 25, or when they become sexually active. At this point they should begin having yearly pap smears and pelvic exams. Many pediatricians are comfortable taking care of their patients' gynecological problems. If this is the case, your pediatrician may continue to see you for your gynecological exams. If you or your pediatrician feel that it would be more comfortable for you to see a gynecologist, you may be given a referral to one. Should your gynecological issues become more difficult, seeing a gynecologist may be to your benefit.

Periods are also known as menstrual cycles. The onset of menstrual cycles (menarche) occurs during the teenage years. Menstruation continues until a women is in her 50s and reaches menopause. The average age of menarche in the United States is 9 to 17 years of age, with a median age of 13.

Primary amenorrhea is a condition where a woman fails to start her menstrual cycles. If you have other signs of puberty, such as breast development or pubic hair, but fail to start your menses by the age of 16, you should see a physician. If you have no signs of puberty by age 14, you should see a physician.

Over the last twenty years the number of women waiting until their 40s to conceive has nearly doubled. One of the main determinates of having a healthy pregnancy is being healthy as you enter pregnancy. However, no matter how healthy you are, there are still risks beyond your control. Medical conditions such as high blood pressure and diabetes are more common when a woman reaches her 40s. Also, the number of chromosomal disorders, such as Down syndrome, increases as your age increases. For example, the risk of Down syndrome at age 25 is one in 250.

At age 35 is the risk is about one in 300. At age 45 the risk is one in 30, and at age 49 the risk is one in 11. Your total risk for chromosome abnormalities is a bit higher too. At age 35 it is one in 200, while at age 45 the risk increases to one in 21, and to 1 in 8 at age 49. Women in their 30s and 40s have an increased risk of miscarriage. This is most likely due to the increase in chromosomal disorders. In addition, it appears that older women also have an increased risk of requiring a cesarean section.

In order to diagnose PCOS, the doctor will need a detailed medical and Gynaecological history. In addition, the doctor may perform a physical examination, which will include blood testing and in some cases an ultrasound. The current criteria for the diagnosis of PCOS include:

• Signs of excess androgens or male hormones in the form of excess hair growth or blood tests that show elevated levels of androgen.
• Polycystic Ovaries.
• Besides the above conditions, problems with the pituitary, thyroid, or adrenal glands may also be considereds.

Through the history, physical exam, and blood testing your physician will have enough information to diagnose PCOS or determine any other cause for your symptoms.

Unfortunately, at this time there is no cure for PCOS. However, with proper treatment many of the symptoms can be controlled and possibly be even eliminated. With appropriate treatment hirsutism, acne, irregular periods, weight gain, and infertility can be treated. Although there is no cure, all women with PCOS should seek the care of a physician to optimize their health and prevent the progression of the symptoms.

Women with PCOS generally have irregular, infrequent, or even absent ovulation. Without ovulation there is no egg or ovum that is available for fertilization. Due to the abnormal hormonal levels, the endometrium, or the inside lining of the uterus, does not develop normally in women with PCOS. Therefore, even if a rare ovulation was to occur and the egg was fertilized, the endometrium may not be properly developed to allow for the attachment and growth of the embryo. This may explain the increased risk of miscarriage in women with PCOS.

There is no specific title that guarantees that a doctor is knowledgeable in the diagnosis and treatment of hirsutism and PCOS. Many board-certified reproductive endocrinologists are familiar with these disorders, and these physicians may serve as your first line of consultation.

The removal of ovarian cysts is not an effective way to treat PCOS. Cysts on the ovaries are the result of hormonal imbalance that begins with the production of excess insulin. This over abundance of insulin causes an increase in male hormones, which eventually create the cysts. As a result, removing the cyst does not remove the problem but just a symptom.

Studies have shown that there is no risk of abnormality in IVF conceived babies compared to those conceived naturally.

The procedure demands absolutely no special precautions, but you are supposed to avoid any kind of strenuous activity. You need to be mentally and physically relaxed as much as possible. You can return to work if you wish, but it is better to rest for few days.

You can go through the IVF procedure as many times as you wish, but we advise up to five cycles at the most.

IVF has highest success rate and is also the most expensive. But, it is not the "end of the road". Many women have conceived naturally or with intrauterine insemination, even after IVF. However, for those with blocked tubes and very poor sperm counts, it is only option.

IVF is not as expensive as perceived in general. Generally, the cost of IVF cycle depends upon the dose of drugs that would be needed for ovarian stimulation. It is only as expensive as perhaps a gall bladder stone removal or removal of uterus.

A patient undergoing IVF does not require admission. However, one should visit the centre 3-5 times during the monitoring cycle. On the day of egg collection, the patient would need to fast for 6 hours and come to clinic and the procedure takes about half an hour. Patients can go home after the effect of anaesthesia weans off which takes about 2-3 hours. The next scheduled visit is after 2-3 days for the embryo transfer. This takes about half an hour and the patients are free to go home after resting for one hour.

Standard medical textbooks define infertility as the "failure to conceive following one year of unprotected sexual intercourse." For young and healthy heterosexual couples having frequent intercourse, about 85 per cent will be pregnant after one year of trying and about 93 per cent will be pregnant after two years of trying to conceive. While this is the "classic" definition of infertility, you may label yourself as infertile if there is "failure to conceive following one year of unprotected intercourse if under 35 years of age or six months if over 35."

You should approach a fertility unit for help if the female partner is.

• Under 35 years of age and trying for more than 1 year.
• Between 35 and 39 years and trying to conceive with adequately timed intercourse for a period of 6 months or more.
• 40 years or more and attempting a pregnancy for 3 months or more.

We do this because we recognize that female age is one of the most important predictors of subsequent conception.

When female age is a factor, moving more aggressively towards completing the evaluation and initiating treatment can help to maximize the chances of pregnancy.

At the beginning of the menstrual cycle, an egg begins to develop in the ovary. After approximately two weeks of growth, the egg is released or "ovulated". Following ovulation, the ovary produces the hormone progesterone to prepare the lining of the uterus for implantation of the embryo (baby).

After ovulation, the egg survives for approximately 24 hours. Which means that a woman can get pregnant only once in the month. Therefore, it is extremely important to ascertain the time of ovulation.

There are various methods for detection of ovulation. The following are a few:

• Basal body temperature charts are an inexpensive means of ovulation detection but are inaccurate.
• Ovulation can now be predicted by at-home kits that measure luteinizing hormone (LH) in the urine.
• Midluteal phase (a week before menses) measurement of serum (blood) progesterone concentrations remains the simplest and most accurate method of detecting ovulation.
• Serial pelvic ultrasounds (follicle study) are currently the most accurate noninvasive method of ovulation detection. But even ultrasound is not the perfect test due to the variable ultrasonic appearance of the ovary after ovulation and documentation of retained oocytes in follicles that have collapsed on ultrasound.

In the beginning of the menstrual cycle (cycle days 1-5), the pituitary gland in the brain secretes Follicle Stimulating Hormone (FSH) to stimulate to ovaries to select and grow an egg for the cycle. Measuring the levels of FSH and Estradiol (estrogen) on cycle day 2 or 3 (first day of FLOW is cycle day 1) provide us with an assessment of the quality of the eggs. Newer tests like Inhibin B may be suggested for a few patients.

In case you are not ovulating, there are various tablets and injections, which can help to make your eggs grow. However, you have to be monitored with the help of follicle studies to assess the growth of the eggs and detect the day of ovulation.

The following are a few ways to evaluate the status of the Fallopian tubes:

• A hysterosalpingogram (HSG) is an X-ray test that determines whether there is a blockage in the fallopian tubes, which would prevent the union of a sperm and egg. It may also be used to detect irregularity or scarring of the lining of the uterus. The HSG is performed between the 8th and 10th day of the period to make sure that you are not pregnant during the procedure.
• The test involves lying on an X-ray table, in the same manner as for a routine pelvic examination. A small catheter is placed snugly in the cervix. The catheter is connected to a syringe that contains the HSG " dye". It is this dye that shows up on the X-ray.
• An HSG takes 5-10 minutes to perform and may have some cramping associated with it, but it is not necessary to miss work. You may take an analgesic an hour or two before the procedure if desired.
• A sonosalpingography is similar to the HSG, but is done with the help of saline (instead of dye) and sonography (instead of X-ray).
• Laparoscopy is the direct visualisation of the pelvis (inside of lower abdomen), with the help of a scope and camera. This procedure is routinely done as a day care procedure at our centre. (Insert image) A number of fertility related procedures can be done with the help of Laparoscopy, including treatment of cysts, endometriosis, opening of tubes etc.

Certain kind of blocked tubes can be corrected with the help of a surgery, which may be performed laparoscopically. In other conditions, we have to consider by passing the tubes with the help of IVF.

Sperms are evaluated by a simple semen analysis which is the measurement of 4 different properties of a single ejaculate:

• Volume is the amount of the ejaculate measured in cc's.
• Count is the concentration of sperm, measured in million of sperm/cc.
• Motility is the percentage of sperm that are moving, i.e. living.
• Morphology is the percentage of sperm that are normal in shape.

The "normal" values for these parameters are greater than 2cc in volume, 20 million/cc in concentration, 50% motility, and 50% normal morphology. The presence of white blood cells in the semen may indicate an infection of the prostate or urethra, even if no symptoms are present.

At our centre, we insist on abstinence of 2 to 5 days in order to evaluate the semen accurately. The collection can be done by masturbation and the sample should be collected in the container provided by the centre. For the comfort of our male patients, we provide a comfortable collection room, offering complete privacy. In case you wish to collect the semen at home, it must reach the centre within half an hour.

If the semen analysis is persistently abnormal, a urological exam, more specific sperm testing and hormonal testing are recommended. The urological examination by our andrologist, will check for the presence of anatomical abnormalities (varicocele, congenital absence of the vas deferens). More specific sperm testing might include more stringent morphology testing (Kruger morphology), or testing for the presence of white blood cells or antibodies. Hormonal testing includes measurement of Prolactin, FSH and Testosterone.

Depending on the quality of the sperm you may be offered an IUI (intra uterine insemination) or ICSI (Intra cytoplasmic Sperm Injection).

A uterine fibroid is the most common benign (not cancerous) tumour of a woman’s uterus (womb). Fibroids are tumours of the smooth muscle that is normally found in the wall of the uterus.They can develop within the uterine wall itself or attached to it. They may grow as a single tumour or in clusters. They can grow:-

• Into the uterine cavity (sub mucosal)
• Into the thickness of the uterine wall (intramuscular)
• Or on the surface of the uterus (subserosal)
• Or may occur as pedunculated masses. (fibroids growing on a stalk on the uterus)

The term FIBROIDS is misleading because they consist of muscle tissue, not fibrous tissue. The medical term for a fibroid is leiomyoma

The prevalence rate worldwide for fibroids among women is 10-20% (Natural women’s health info centre NICD.NIH). Fibroids are number one reason for hysterectomy in USA (CDC). They result in 150,000-175,000 hysterectomies in the US. The prevalence of fibroids identified by USG imaging ranges from:

• 4 per cent in women between ages 20 and 30
• 11-18 per cent in women between ages 30 and 40
• 33 per cent in women 40-60 yrs of age

Most fibroids even large ones produce no symptoms. These masses are often found during a regular pelvic examination. The most common symptoms that a woman with fibroids may experience:-

• Excessive menstrual bleeding known as menorrhagia.
• Sometimes with blood clots
• Irregular vaginal bleeding
• Pelvic pain
• Pressure on the bladder, which may cause frequent urination, and a sense of urgency to urinate and rarely, inability to urinate.
• Pressure on the rectum, resulting in constipation
• Pelvic pressure, "feeling full" in the lower abdomen
• Increase in size around the waist and change in abdominal contour
• Infertility, which is defined as an inability to become pregnant after 1 year of attempting to get pregnant.
• A pelvic mass discovered by a doctor during a physical examination

Often a Gynaecologist can feel an irregularly shaped uterus when fibroids are present. The doctor normally prescribes the following tests to help decide if the patient has fibroids and to exclude other and potentially more serious causes of ongoing symptoms.

• An abdominal, transvaginal or pelvic ultrasound can help identify the site, shape, no. of most fibroids.
• An endometrial biopsy is performed by taking a tissue sample from the uterus.
• A hysteroscopy can be done to rule out submucosal fibroid, by passing a small fibreoptic camera through the opening of the cervix.
• Hysterosalpingography can be done, which involves injection of dye into the uterus and fallopian tubes, which is then X-rayed, to identify the anatomy of these structures.
• Laparoscopy is a surgical procedure. The surgeon inserts a small fibreoptic camera into the abdomen through a small insertion to look directly at the uterus, fallopian tubes and ovaries.

Treatment for fibroids depends on the following symptoms:

• Size and location of the fibroids
• Age (how close the person is to menopause
• The patients desire to have children.
• The patients' general health

In most cases, treatment is not necessary. This is true in the following scenarios:

• Size and location of the fibroids
• If a woman has no symptoms
• If the size of fibroids is small
• If woman is menopausal

These patients may require a check up maybe every 6 months to a year, to check on changes with the fibroid.

Patient may be given oral medications to control the pain and excessive bleeding.

• Size and location of the fibroids
• NSAID’s – Non steroidal anti- inflammatory agents are good for pelvic pain relief
• OCP’s – Oral Contraceptive pills help by decreasing the menstrual blood flow along with some amount of pelvic pain relief.
• Gonadotrophin releasing hormone (GnRH) agonists are medications that act on the pituitary gland to decrease the estrogen produced by the body. A decrease in estrogen causes fibroids to decrease in size. This is often used prior to surgery to shrink the fibroid, to decrease the amount of blood loss during surgery, or to improve pre-operative haemoglobin count.
• The drug Danazol, has been used to reduce bleeding in women, but it does not shrink the size of fibroids.
• The anti-hormonal drug RU-486 has been shown to reduce fibroid size by half. This drug has also been shown to reduce pelvic pain, bladder pressure and lower back pain.
• Newer drug which is a progesterone receptor modulator has been found to shrink fibroids and reduce bleeding associated with fibroids. It is awaiting US FDA approval.
• Patients who are unresponsive to oral medications or in whom oral hormonal medicines are contra-indicated due to some reason can opt for a surgical procedure.

The various types of procedure which are best suited as per individual case are:-

• Myomectomy – is the surgical removal of fibroids only. This can be accomplished by hysteroscopy, laparoscopy or an open procedure (an incision on lower abdomen)
• Hysterectomy- is the surgical removal of the uterus with fibroids.
• Hysterectomy with removal of the fallopian tubes and ovaries (called salpingo - oophorectomy) may be indicated if there is a suspicion of cancer or if ovarian masses are present.
• Uterine artery embolization: - involves clotting of the arterial blood supply to the fibroid, is an innovative approach that has shown promising results.
• This method may prove to be a good option for woman if other methods have not worked, patient is not willing for surgery, or may not be a good candidate for surgery.