Endometrial cancer is cancer that starts in the endometrium — the inner lining of the uterus that thickens each month under estrogen, then sheds as a period if pregnancy does not happen. When the cells of this lining grow out of control, the result is endometrial cancer. It is different from cervical cancer (which starts at the mouth of the uterus) and ovarian cancer (which starts in the ovaries), even though all three are often discussed together as gynaecological cancers.

In developed countries, endometrial cancer is the most common gynaecological cancer. In India it currently ranks fourth or fifth among cancers in women, but its incidence is rising faster than almost any other female cancer because the risk factors that drive it — obesity, type 2 diabetes, PCOS, delayed childbearing, and unopposed estrogen exposure — are all rising in urban India at the same time.

There are two broad types. Type I (endometrioid) is the common form, driven largely by long-term exposure of the endometrium to estrogen without enough progesterone to balance it. Type I generally has a better prognosis when caught early. Type II (serous, clear cell, and a few rarer subtypes) is estrogen-independent, more aggressive, and tends to be diagnosed at a later stage. The treatment principles overlap but Type II usually needs more intensive multi-modal therapy.

The single most important fact about endometrial cancer is the one that saves lives: it almost always bleeds before it spreads. A cancer that loudly announces itself with abnormal bleeding is a cancer we can catch early — but only if the bleeding is taken seriously the first time it happens.

India sees roughly 15,000 to 20,000 new endometrial cancer cases every year and around 10,000 deaths. The numbers from the National Cancer Registry have crept upward year on year for the last two decades, especially in metro cities and tier-1 urban centres.

Three forces are driving the rise. First, obesity. Body fat is its own estrogen factory — fat tissue converts circulating androgens into estrogen, which keeps stimulating the endometrium long after a woman's ovaries have stopped producing progesterone. A woman with a BMI above 30 carries roughly three times the risk of endometrial cancer compared with a woman in the healthy BMI range.

Second, type 2 diabetes and metabolic syndrome. Insulin resistance and high circulating insulin levels both encourage endometrial cell growth, independent of obesity. Diabetes adds roughly a two-fold risk on its own. PCOS, which combines insulin resistance with chronic anovulation and unopposed estrogen, raises lifetime risk further.

Third, delayed childbearing and smaller family size. Pregnancy and breastfeeding both protect the endometrium by giving it long stretches without estrogen stimulation. Women who have no children, or who have their first child later in life, lose that protection. Add late menopause (after 55), early menarche (before 12), and the increasing use of perimenopausal hormone therapy — sometimes prescribed without the protective progestin in women who still have a uterus — and you have the full picture of why this cancer is climbing in India.

The good news is that almost every one of these risk factors is modifiable, treatable, or at minimum monitorable. The bad news is that very few Indian women aged 40 to 65 are currently aware that they are in the risk window.

• Obesity. A BMI above 30 carries roughly three times the risk of endometrial cancer. Central (abdominal) obesity is especially relevant for Indian women because of the higher tendency to deposit fat around the waist even at lower overall body weights.
• Type 2 diabetes. Independent of weight, diabetes roughly doubles the risk. Poorly controlled diabetes raises it further.
• PCOS (polycystic ovary syndrome). Chronic anovulation means the endometrium is exposed to estrogen month after month without the progesterone that would normally trigger a withdrawal bleed. Over years, this raises endometrial cancer risk significantly. PCOS is increasingly common and increasingly under-diagnosed in India.
• Nulliparity. Never having had a child removes the long stretches of progesterone exposure that pregnancy and breastfeeding provide. Women without children have a higher lifetime risk.
• Late menopause (after 55) and early menarche (before 12). Both extend the years of estrogen exposure across a lifetime.
• Tamoxifen. The drug used to prevent breast cancer recurrence acts as an estrogen on the endometrium even while blocking estrogen in the breast. Women on long-term tamoxifen need annual gynaecology review and any bleeding investigated promptly.
• Estrogen-only hormone replacement therapy. Estrogen-only HRT in a woman who still has a uterus is a major and well-established risk factor. If HRT is needed, it should be combined estrogen plus progestin (or a Mirena IUS for the progestin part) — never estrogen alone unless the uterus has been removed.
• Lynch syndrome. An inherited condition that raises risk of endometrial, colon, ovarian, and a few other cancers. Genetic testing is worth discussing if endometrial cancer is diagnosed under age 50 or if there is a strong family history of multiple cancers.
• Family history of endometrial, colon, or ovarian cancer. Even without confirmed Lynch syndrome, a family history of these cancers raises personal risk.
• High-calorie, low-activity lifestyle. Diets high in refined carbohydrates and saturated fats, combined with sedentary work patterns, drive obesity and insulin resistance and so contribute indirectly.

Menopause is defined as 12 consecutive months without a period. Any vaginal bleeding after that point — even a single spot, even brown discharge, even one episode that never repeats — is abnormal and is endometrial cancer until proven otherwise.

About one in ten women with postmenopausal bleeding turns out to have endometrial cancer. Most of the other nine have benign causes — endometrial atrophy, polyps, hormone therapy effects, or thinning of the vaginal walls. But the only way to tell which group a particular woman falls into is to investigate. Waiting and watching is never the right answer for postmenopausal bleeding.

The Indian cultural pattern most likely to cost lives is the assumption that postmenopausal bleeding is just hormones returning, or a delayed period, or a normal part of getting older. None of these is true. Hormones do not return after menopause is complete. Periods do not restart on their own. Bleeding after menopause is always a symptom worth checking.

What to do: book a gynaecology appointment within the same week, not the same month. The first visit will usually involve a focused history, a speculum exam to rule out cervical or vaginal sources, and a transvaginal ultrasound to measure the thickness of the endometrium. If the lining is thicker than expected, an endometrial biopsy follows. The whole process is straightforward and the great majority of women walk out with a benign diagnosis — but the few who do have cancer get it caught at the most treatable stage.

• Heavy or irregular bleeding during perimenopause. As periods become unpredictable in the years before menopause, it is easy to dismiss a new pattern of very heavy or unusually frequent bleeding as 'just perimenopause'. It often is. But if the bleeding is consistently heavy, lasts longer than seven days, comes more often than every 21 days, or is accompanied by clotting or anaemia, it needs gynaecology review with an endometrial assessment. See What Is Perimenopause? Navigating the Transition with Confidence for context on what is and is not normal in this transition.
• Inter-menstrual bleeding. Bleeding between periods, in a woman who is still cycling, should be investigated. The cause is most often benign (polyps, hormonal fluctuation, contraceptive effect) but endometrial pathology is on the list and needs to be ruled out.
• Bleeding after sex (postcoital bleeding). More often a cervical or vaginal sign than an endometrial one, but in a woman over 40 or after menopause it should still trigger a full work-up.
• Persistent pelvic pain. Endometrial cancer is not typically painful in early stages. New, persistent, or worsening pelvic pain in a woman in the at-risk age range deserves a gynaecology evaluation, especially when combined with any abnormal bleeding.
• A pelvic mass felt by the woman herself or noticed on routine examination. Usually benign (fibroids are common), but worth investigating, especially in postmenopausal women in whom new growths are less likely to be benign.
• Unexplained weight loss in the at-risk age range. A late and non-specific sign, but in combination with abnormal bleeding it raises concern for advanced disease.
• Abnormal Pap smear findings. The Pap smear is designed to screen for cervical cancer, not endometrial cancer, but it occasionally picks up endometrial cells outside their expected window. Any such finding should prompt an endometrial assessment.

The diagnostic pathway starts in the gynaecology outpatient clinic. The first test in nearly every case is a transvaginal ultrasound (TVS), which uses a small probe placed inside the vagina to image the uterus and ovaries at high resolution. The most important measurement is endometrial thickness. In a postmenopausal woman, an endometrial thickness of 4 mm or less makes endometrial cancer very unlikely. A thickness above 4 mm needs further evaluation. A TVS costs roughly 500 to 2,500 rupees at private radiology centres and is free at most government hospitals.

If the ultrasound suggests further work-up is needed, the next step is an endometrial biopsy. This is the definitive test — only a biopsy can confirm or rule out cancer. A simple office endometrial biopsy uses a thin flexible tube (a Pipelle catheter) passed through the cervix to suction a small sample of the endometrial lining. It takes a few minutes, can be done without anaesthesia in most women, and costs roughly 2,000 to 8,000 rupees privately.

If the lining is unusually thick, if the office biopsy is inconclusive, or if the clinician suspects a focal lesion like a polyp, a hysteroscopy with directed biopsy is performed instead. A thin camera is passed into the uterine cavity (usually under short general or regional anaesthesia) so the gynaecologist can see the lining directly and biopsy or remove any suspicious area. This is a day-care procedure costing roughly 15,000 to 50,000 rupees in private centres and free or heavily subsidised at government hospitals.

If the biopsy confirms cancer, staging investigations follow. A CT or MRI of the pelvis and abdomen looks at lymph nodes, the extent of local spread, and any distant disease. CT or MRI costs roughly 3,000 to 15,000 rupees depending on the protocol and centre. Blood tests and sometimes a chest X-ray complete the staging.

From the first ultrasound to a confirmed diagnosis and stage, the process usually takes two to four weeks at a well-organised centre. That is a manageable timeline — but only if the woman comes in promptly when the bleeding first happens, not months later.

• Stage I. The cancer is confined to the body of the uterus. This is by far the most common stage at diagnosis when postmenopausal bleeding is acted on promptly. Five-year survival is around 95 percent for the earliest sub-stages.
• Stage II. The cancer has spread from the body of the uterus to the cervix but is still contained within the uterus as a whole. Five-year survival is around 70 to 80 percent.
• Stage III. The cancer has spread locally — to the outer surface of the uterus, the fallopian tubes, the ovaries, the vagina, or the pelvic lymph nodes. Five-year survival is roughly 40 to 60 percent depending on the exact pattern of spread.
• Stage IV. The cancer has spread to the bladder or bowel, or to distant organs like the lungs, liver, or distant lymph nodes. Five-year survival drops to around 15 to 20 percent.
• The single most powerful predictor of outcome is stage at diagnosis. Every conversation that gets a woman in for a same-week appointment after her first episode of postmenopausal bleeding shifts the odds dramatically in her favour.

Stage I and early Stage II are treated primarily with surgery — total hysterectomy plus bilateral salpingo-oophorectomy (removal of the uterus, cervix, both fallopian tubes, and both ovaries), most often performed laparoscopically as a total laparoscopic hysterectomy (TLH BSO). Pelvic and para-aortic lymph nodes may be sampled depending on the tumour grade and depth of invasion. After surgery, depending on the final pathology and stage, adjuvant radiation (external beam, vaginal brachytherapy, or both) or chemotherapy may be added. For favourable Stage IA Type I tumours, surgery alone is often sufficient.

Stage II proper, where the cancer has clearly spread to the cervix, is treated with the same hysterectomy and lymph node dissection followed by adjuvant radiation and often chemotherapy, depending on the tumour features.

Stage III is usually treated with surgery where it is technically possible, followed by combination chemotherapy and radiation. The standard chemotherapy regimen in India typically uses paclitaxel plus carboplatin for several cycles, sometimes with cisplatin-based radiation sensitisation.

Stage IV often combines surgical debulking (where feasible) with chemotherapy and radiation, individualised to the spread pattern. Hormonal therapy with progestins is an option in selected hormone-receptor-positive tumours and is used both in advanced disease and in occasional fertility-sparing protocols for very early disease in young women — under specialist oncology supervision only.

Recurrent and advanced disease is increasingly treated with targeted therapies and immunotherapy. The molecular subtyping of endometrial cancer (POLE, MSI-H, copy-number-low, copy-number-high) now guides which patients benefit most from immune checkpoint inhibitors like pembrolizumab. These options are available at the major Indian cancer centres and through PMJAY-empanelled tertiary oncology units.

Treatment for endometrial cancer should always happen at a comprehensive cancer centre with a dedicated gynaecologic oncology team. The combination of surgery, radiation, chemotherapy, and increasingly targeted therapy means the team matters as much as any individual treatment.

• Tata Memorial Hospital, Mumbai — the country's flagship cancer institution with a dedicated gynaecologic oncology department, full multi-modal treatment, and significant subsidised and free care alongside paying services. Tata Memorial Centre Varanasi extends the same model to eastern India.
• All India Institute of Medical Sciences (AIIMS), New Delhi — comprehensive gynaecologic oncology services with heavily subsidised care, plus several other AIIMS centres across the country (Bhopal, Bhubaneswar, Jodhpur, Patna, Raipur, Rishikesh) developing similar capacity.
• Christian Medical College, Vellore — one of India's strongest tertiary oncology centres with full gynaecologic oncology services and a long tradition of careful, well-organised cancer care.
• Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry — a central government institution offering comprehensive oncology including gynaecologic cancers at heavily subsidised cost.
• Regional Cancer Centres (RCCs) across the country — including Kidwai (Bengaluru), Cancer Institute WIA (Chennai), RCC Thiruvananthapuram, Chittaranjan National Cancer Institute (Kolkata), and Mahavir Cancer Sansthan (Patna) — all offer full gynaecologic oncology services.
• RGCB-empanelled and government-empanelled centres across all states accept PMJAY referrals for endometrial cancer diagnosis and treatment. Your district cancer programme office or your state health insurance scheme office can direct you to the nearest one.
• Private oncology centres including Apollo, HCG, Manipal, Fortis, and Max have dedicated gynaecologic oncology units in most major cities, many of which accept PMJAY and corporate insurance.

Out of pocket, endometrial cancer treatment in India ranges widely depending on the centre, the stage at diagnosis, and the specific protocol. As a rough guide: surgery (TLH BSO with lymph node sampling) typically costs 50,000 to 2,00,000 rupees at private centres. Adjuvant chemotherapy costs roughly 20,000 to 3,00,000 rupees per cycle, with 6 to 8 cycles usually required depending on the regimen. Adjuvant radiation costs roughly 50,000 to 3,00,000 rupees for a full course, depending on the modality (external beam alone, brachytherapy alone, or both). These costs are dramatically lower at government cancer centres, where treatment is often free or heavily subsidised regardless of income.

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) covers the entire endometrial cancer pathway — diagnosis, surgery, chemotherapy, and radiation — for eligible families at empanelled hospitals, with a ceiling of 5 lakh rupees per family per year. The empanelled list includes most major government cancer centres, many private cancer hospitals, and a growing number of tertiary hospitals across all states. Most patients with valid PMJAY cards walk through treatment cashless.

Many state health insurance schemes (such as Mahatma Jyotiba Phule Jan Arogya Yojana in Maharashtra, Chief Minister's Comprehensive Health Insurance Scheme in Tamil Nadu, Aarogyasri in Andhra Pradesh and Telangana, and Yeshasvini in Karnataka) cover endometrial cancer treatment in addition to or instead of PMJAY, often with similar or higher ceilings.

Corporate and private health insurance policies generally cover endometrial cancer treatment as a standard inpatient procedure, subject to the sum insured. It is worth checking your policy's specific exclusions and waiting periods early in the treatment journey so the hospital billing team can plan accordingly.

Financial assistance schemes — including the Prime Minister's National Relief Fund, Chief Minister's Relief Funds in most states, the Health Minister's Cancer Patient Fund, and Tata Memorial's own subsidy mechanisms — can fill gaps for patients without PMJAY or insurance cover.

Hormone replacement therapy (HRT) for menopausal symptoms can be a genuine quality-of-life intervention for the right woman. But it carries one strict rule that gets broken too often in India: a woman who still has her uterus must never be prescribed estrogen alone. Estrogen-only HRT in a woman with an intact uterus is a major and well-established cause of endometrial cancer — by some estimates raising the risk five to eight fold over years of use.

The fix is simple. Any woman who needs HRT and still has her uterus must take combined HRT — estrogen plus a progestin — or use a Mirena intrauterine system (IUS) to deliver the progestin locally to the endometrium while taking estrogen by mouth, patch, or gel for the systemic effect. The progestin protects the endometrium by triggering regular shedding (or by keeping the lining thin) and largely cancels the estrogen-driven cancer risk.

Estrogen-only HRT remains appropriate for women who have had a hysterectomy and no longer have a uterus to protect. It is also the formulation accidentally prescribed most often when a clinician forgets to ask whether the woman has had a hysterectomy. If you have been prescribed estrogen-only HRT and still have your uterus, see a gynaecologist within the week to add or switch in the progestin component.

For the broader picture on HRT decision-making in the Indian context — who benefits, who should avoid it, how long to take it, and how to monitor — see Hormone Therapy – Facts in Indian Context. Endometrial protection is one of the most important pieces of that conversation.

• Myth: bleeding after menopause is just hormones returning. Fact: menopause is permanent. Once a woman has gone 12 months without a period, her ovaries are no longer producing the hormones that cause periods. Any bleeding after that point comes from somewhere — most often a benign cause, but in about one in ten cases from endometrial cancer. It always needs investigation.
• Myth: a normal Pap smear means the uterus has been checked too. Fact: the Pap smear screens for cervical cancer only. It does not screen the endometrium and cannot rule out endometrial cancer. A normal Pap is not a reason to ignore postmenopausal bleeding. For Pap smear context see cervical-cancer-india-screening.
• Myth: endometrial cancer only affects very old women. Fact: while the peak is between 50 and 70, the incidence in younger women is rising in India because obesity, diabetes, and PCOS are starting earlier. Endometrial cancer under 50 is no longer rare and deserves the same prompt work-up.
• Myth: a hysterectomy is always recommended because the doctor suspects cancer. Fact: hysterectomy is one of the most common gynaecological surgeries in India and is performed for many entirely non-cancerous reasons, including fibroids, heavy bleeding, prolapse, adenomyosis, and severe pelvic pain. Recommending hysterectomy does not imply cancer. Always ask your gynaecologist clearly why it is being recommended and what the alternatives are.
• Myth: tamoxifen is completely safe. Fact: tamoxifen is a life-saving drug for many women with hormone-receptor-positive breast cancer, and the breast cancer benefit clearly outweighs the risks for most women who need it. But tamoxifen does carry a small increased risk of endometrial cancer because of its estrogen-like effect on the uterine lining. Any abnormal bleeding while on tamoxifen needs prompt gynaecology review, and women on long-term tamoxifen need an annual gynaecology check-in.
• Myth: postmenopausal bleeding can wait until the next routine check-up. Fact: it cannot. Any bleeding after menopause needs a same-week gynaecology appointment, not a same-month one. The earlier endometrial cancer is caught, the better the outcome — and the difference between Stage I and Stage III is often a difference of weeks to months in how long the bleeding was ignored.
• Myth: cervical cancer screening also screens the uterus. Fact: it does not. Cervical screening is for the cervix only. There is currently no routine population screening for endometrial cancer; the strategy relies on women and clinicians responding promptly to abnormal bleeding.