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Ask The Expert

Are these symptoms of Menopause?
Are these symptoms of Menopause? 2
What about life after "the change?


Doctor, Are these symptoms of Menopause?

Q: Irregular Periods
I am 50 years old and experienced irregular periods right up to my 40s. Then they came like clockwork. Almost exactly the time I turned 50, they became irregular again. One cycle lasting up to 37 days and next 26-28 days. Is this a sign of the onset of menopause? I have no other symptoms associated with menopause. Thank you for your response.

A: Maybe your problem in the past was PCOS: Polycystic Ovary Syndrome. That syndrome with irregular periods is usually cured by time with diminishing cohorts of follicles in the ovaries. So periods become regular. And now it is the time for the change. However, you cannot diagnose that with only one prolonged cycle. Wait and you will see what is happening.

(Please visit the PCOS Pavilion for more information on PCOS)

Q: Does early menarche mean early menopause?
I am 47 years of age and started my monthly at the age of 8. Does this give me reason to start menopause early? I was given provera to see if I had anything left for bleeding but to no avail. I have the night sweats really bad and the attitude change is scary. Or is this all in the mind?

A: An early menarche is not related to early menopause. The remainder of your question cannot be answered due to a lack of data.

Q: Should I have my estrogen levels checked?
I have been having intermittent hot flashes for several months now yet I have not missed a period. My OB/GYN told me a year ago that unless I start missing periods or experience an irregular cycle I could not be in menopause. I am 45 years old and due to see my doctor soon. Should I request a blood test to measure estrogen levels? I also have frequent headaches, lower mid and right side abdominal pain, fatigue, and irritability at times other than the onset of my period.

A: Blood tests are usually not helpful. Be aware for psychological problems. Anxiety, and panic, can mimic perimenopausal symptoms.

Q: Am I too young for Perimenopause?
I am a 42 year old woman with symptoms of Missing periods, seldom night sweats, moodiness (which I was on Celexa for a short time) felt better though and sleeplessness. My periods may come every two months, every three months, sometimes they actually fall month after month. A great deal of cramping that I have never had even as a teenager and Adult. I was told by a gyn that I am too young for all of these symptoms. Could you tell me if I really am too young, or maybe I have to look at another answer. My last Pap test done just a few months ago came out negative. My FSH levels are at 28.

A: No one is too young for perimenopause. And your symptoms with the FSH levels and your age make the diagnosis perimenopause rather likely.

Q: Change in sleep patterns, irregular periods, are these symptoms of perimenopause?I am a 43 year old. Last spring, I skipped 3 periods. There were no other symptoms. This year, I started skipping periods again, one month it would be very light, the next month, very heavy. I now do not know what to expect. The last couple of weeks, it has taken me longer to fall asleep and I'm up a little earlier now. Are these symptoms of perimenopause? I thought I was a little too young to be starting menopause. I don't have any hot flashes or dizziness, but I can walk into another room and forget what I was going to do. Although this only happened to me once or twice. Please let me know if there are any natural remedies for perimenopausal symptoms and if I am truly experiencing them, what can I expect from now on?

A: Only time can tell you what will happen in the forthcoming years. But without any complaint, why worry about remedies? 43 is not too young to start with perimenopause. This period will stay for 4 years (mean) and sometimes much longer.

Q: Missed period
I am 43, apparently in good health, and am usually very regular with my periods. This month, however, I felt all the build-up to a normal period, then 4 days before it was due I had some very slight blood spotting. Then nothing! Should I be worried? Could this be a symptom of perimenopause?

A: There is no reason to be worried by 1 unusual period. Wait to see what happens next month.

Q: What happens to fat women during menopause?

A: Basically the same as with thin women. However, women who are overweight have an large amount of adipose tissue, or fat tissue, on their bodies. This tissue can produces estrogens all by itself, so women who have a lot of adipose tissue will have extra estrogens in their bodies because of the extra estrogens made in this tissue. They consequently do not have as fast or as large a decline in the estrogen at menopause because of this extra production, and rarely become as hypo-estrogenic as someone who has less adipose tissue.

After menopause the basal metabolic rate slows down so women need less intake than before just to stay at he same weight. So many women will grow somewhat if they continue with the same diet and intake. Be careful. It is important to diminish your nutritional intake after menopause if you are overweight.

Q: No periods for two months and I'm not pregnant
I am a 36 year old women with normal cycles till about two months ago. I still get the symptoms of a monthly coming on the lower back ache, the bloating, break out on my face, the high energy and the low energy but no menstrual flow. Sometimes when I make love to my husband during the time I will have some blood flow. but nothing like a normal flow. Is there a reason for why I do not have the monthly flow and only the symptoms of the cycle. I am not pregnant.

A: There is a need for proper evaluation of spontaneous amenorroea at your age. Go to see a gynecologic endocrinologist

Q: Spotting between periods
I'm 42, for the last 3 months I have bleeding between periods. Sometimes it is a pink discharge, other times it is actual blood. For about two days during my period I bleed heavily, this has been going on for over a year. My primary care physician did a pap smear and an endometrial biopsy, both were negative. She says its hormonal fluctuations. Is there a need for me to follow this up with a gynecologist?

A: Intermenstrual bleeding needs further investigation. Maybe it is a submucosal myoma, but other causes are also possible. Bleeding between regular periods are usually not caused by hormonal dysbalance.

Q: Does irregular bleeding signal menopause?
Over the last few months I have been passing a lot of blood clots with my menses. It usually happens on the 2nd & 3rd day, the worst being on the 2nd day. It is uncomfortable and I spend a lot of the day in the restroom changing pads. My menses still occur on a regular monthly cycle, and I bleed approximately six days. I am 41 yrs. old. I have been told that my uterus is enlarged, although I am not sure how much, and no further testing was discussed. Do I assume this is normal for my age?

A: Your problem is hypermenorroe. With regular menstruations it is usually a problem with your uterus. When bleeding is causing anemia, further investigations are necessary. With age the mean amount of blood loss with a period increase from 30 ml to 60 ml. So you can decide for yourself if further testing is necessary.

Q: Do long cycles mean menopause?
I am a thirty year old female with 2 children aged 6 and 12. I've had abnormal paps twice, had LEEP about a 18 months ago, and cryotherapy about 2 years before that. Paps since my LEEP have been normal. Since discontinuing the Depo-Provera shot about a year ago, my cycles for the last several months have been every 38 days whereas they were always 28 days before. Could set your clock by them. I called my family practitioner's office and they asked when my last pap was. I scheduled an appt to go in a few weeks. Should I be concerned about this? There is no history of ovarian, cervical or breast cancer in my family..... but since they asked about my last Pap...... I'm worried. Should I be? What are they thinking? Seems rather early for Menopause.... or is it?

A: A cycle of 38 days is not abnormal. It fits in a completely normal hormonal milieu. And it has nothing to do with cancer. Early menopause is extremely unlikely.

Q: Heart Palpitations and Perimenopause
I am 44 years old and am in the perimenopause stage. Every so often, I'll experience a month where I have a lot of heart palpitations, sometimes lasting several days straight where my heart is not beating regularly. Years ago this happened and I had an echocardiogram, stress test, halter monitor for a day, and an EKG, and everything seemed to be normal except for a slight MVP and a heart murmur, which I've had all my life. Then the symptoms disappeared for a while, or would only happen occasionally.

Now, at the age of 44, I find the palpitations are happening more often. There is no chest pain or shortness of breath involved, although occasionally I do feel a "fullness" in my nose, if that makes any sense! Is this a normal or common occurrence in women of perimenopausal age? Naturally, when I go to the doctor, the palpitations disappear. Just like when you bring your car in for repairs and it doesn't make that strange noise anymore!

A: Palpations is a matter of unrest. You can get them as you work too hard, and in many other circumstances. Especially when you take a rest after a busy day. Seldom there is a relation with heart disease. Perimenopausal palpitations have to do with flushes and vascular instability. Without flushes, no relation with perimenopause is to be expected.

Q: Perpetual PMS or Perimenopause?
For about the last 2 years My periods have been very hard with gushing upon standing for the first 3 days then it slows down but continues for about 10 days. There is a bloody discharge for a few more days after that. Lately it has been coming every 22 days. It feels like I am always in the PMS state with my stomach bloated and my breasts tender. What is going on? Is this how menopause starts or does it sound like a problem? I had my last check-up in October of 99. Should I call for an appointment. I was told unless you soak a pad an hour not to worry about it. I sure would like to know if this is common.

A:  This pattern of bleeding is called menorrhagia. Menorrhagia can exist with regular periods or with cycle problems. With regular periods one has to search for uterine problems like myomas. With irregular cycle ovarian function is likely to be involved. And with your PMS like complaints this is likely your problem now. And with a treatment of the cycle problem (with oral contraceptives?) usually the bleeding problem will stop also. Consult your gynecologist for an advice.

Q: Enlarged Uterus
My uterine lining measured 8mm on a transvaginal sonogram. I am 54 years old and have been without a period for 4 months. Is this a concern for hyperplasia that should be treated immediately with a progestin? (I have never had heavy bleeding. My doctor ordered the sonogram because my periods were light but long and he suspected that I am not ovulating.) I am not pregnant, as was confirmed by the sonogram, but feel that I am. If this feeling suggests that I am producing unopposed estrogen, what are the chances that this condition would correct itself and that I would eventually shed my uterine lining without taking a progestin? What risks are associated with a 14 day course of Prometrium, 200mg/day? What are the risks of doing nothing?

A: A uterine lining of 8 mm after 4 months of amenorrea is suggestive for some proliferation of the endometrium due to estrogenic stimulation. It is completely normal in this period of life. The thickness of the endometrial lining has only meaning in detection of hyperplasia and carcinoma at least 1 year after menopause. Before that time no one has done adequate research and the sign of endometrial thickness is atypical. With a course of Prometrium 200 mg for 14 days, most probably a withdrawal will occur. Normally one has not this information and waits if a next bleeding will occur. perhaps yes, perhaps no. Again, this is completely normal in perimenopause

Doctor, Are these symptoms of Menopause?

Q: Is there a relationship between perimenopause and blood pressure fluctuations?
I am 48 years old and experiencing some irregularities in my menstrual period, night sweats on occasion, hot flashes once in a while. My blood pressure seems to vary a lot also. It can be right on in the a.m., high in pm (such as 140/90) and then low in the evening. Can hot flashes be related to elevated blood pressure? In my research I've read that clonidine (a drug used to treat high blood pressure) can help hot flashes? I do not want to medicate this if it's a normal part of perimenopause.

A: Yes, hot flushes and instability of blood pressure are related. With clonidine moderate hot flushes can disappear. Also estrogens (in the postmenopause) can stabilize blood pressure. But without flushes I do not believe there is a relationship between instability of blood pressure and perimenopause

Q: Irregular bleeding
I am a 39 year old female that is having trouble with irregular bleeding. It usually occurs on the day ovulation ends and continues until my period starts. Each year for the past two years my OBGYN has not felt any abnormalities. I also experience headaches PMS symptoms. I have two children. I want to try natural supplements and I can not tolerate oral contraceptives. Do you have any suggestions?

A: No, I have not. This is particular a problem to discuss with your gynecologist.

Q: Early signs of perimenopause?
I am 52 years old and have always been regular, every 26-28 days, average menses 3-4 days--heavy bleeding on the second day only. I had 4 normal live births--all natural, no pain, no medication necessary. I have never experienced cramps or PMS symptoms. I had a tubal ligation 20 years ago. I am not subject to mood swings or any psychological changes during my cycle. The only signal I get that my menses is due (aside from the calendar) is that I get at least one pimple a week before my menses comes on.

This past month I experienced spotting (for 2 days) one week after my normal (3-4 day) menses and then again one week later (again for 2 days). Is this the beginning of perimenopause? I have not seen an ob-gyn since I had my tubal, but I do have an internal with PAP smear and mammogram yearly by my primary physician.

A: This is intermenstrual blood loss and that is a reason for further investigation. Go to see a gynecologist. Intermenstrual blood loss is not a sign of (peri)menopause

Q: Does tubal ligation cause ovarian failure?
Part 1: I am 33 and had a tubal ligation almost 2 years ago. After the tubal my periods got lighter and lighter. Now I have started mid-cycle spotting then heavy menstruation which lasts 3 days then abruptly stops. Followed 2 days later by what seems like ovulation. I am concerned because I am often feel extremely fatigued & very moody. I have recently heard of something called Post tubal ligation syndrome. Are my ovaries failing because of the tubal? Can that happen 2 years later? My ob/gyn has run thyroid tests which are normal, and all my other blood work looks fine too. I have not had an FSH test done yet. I am concerned because I have always been very regular. Am I now perimenopausal?

Part 2: Since I had a tubal ligation 6 months ago I have been experiencing hot flashes, itching rashes, flushing of the skin, worsening PMS symptoms. I am 42. These symptoms are new to me. I work for an allergist and the itchy rash and flushing of the skin are not a dermatological condition. My symptoms increase with stress which since I am perimenopausal seems to be more intolerable. Is there a connection with these symptoms since tubal and can perimenopause cause flushing and heat in my hands and feet as well as my face and neck?

A: There is no scientific evidence that tubal ligation will interfere with ovarian function. You cannot blame the tubal ligation for your complaints.

Q: Early perimenopause after chemotherapy?
I had chemotherapy at 37 while pregnant. I started my menses again and got pregnant two years later. I had a miscarriage at 14 weeks and got pregnant a month later miscarrying at 9 weeks this time. During the performance of the D&C, the doctor accidentally punctured my uterus and I bled for eight weeks. Right after that I was told that I was perimenopausal. Do you think this had anything to do with the chemo treatments? I have heard that chemo can cause a person to go into early menopause but hadn't read anything about perimenopause. What about the fact my uterus was punctured, could this have been a cause or is it purely coincidental?

A: This is a very specific personal question. It depends on the kind of chemotherapy, the dose and so on. It is not unusual that ovarian function restores after chemotherapy. Puncture or perforation of the uterus has nothing to do with perimenopause.

Q: Does my blood test mean I'm in menopause?
I had a blood test to determine if I was in perimenopause or menopause that gave me a result of 204. My doctor mailed me a copy of the test results but didn't explain them. There is a list of phases on the page containing follicular and min-cycle ranges and I fall into two of these ranges. Help, I am no closer to knowing now than before I paid for this expensive test.

A: An interpretation of a test is a part of the consultation and a part of the fee. Ask your doctor. I do not know which test is done and what the normal values are.

Q: Could this be perimenopause?
I am 36 years old and my past 3 or 4 menstrual cycles have been between 32-35 days (I am usually 28 days on the dot) and my period lasts only 2 days where it used to last 4 or 5. Could this be the beginning of menopause?

A: Nobody can answer questions like this. Perhaps yes, probably no.

Q: Screening for Menopause
Is there a blood test to indicate how close one is to menopause?

A: No, there is no reliable test for menopause. Sometimes one is testing FSH level. But FSH can fluctuate enormously during the early perimenopause. Age, regularity of periods, flushes and FSH have to be considered all together. After that one can make a rather reliable guess.

Q: Vaginal itching
I am 47 and perimenopausal - missed periods, headaches, hot flashes and a host of other symptoms. I used the Combi-patch hrt for 2 1/2 months, but discontinued it as I spotted for 6 weeks straight and had severe breast soreness. I have a problem with itching in the vaginal area (though I do not have any problem with vaginal dryness or intercourse). It seems to be external and can range from the clitoral area to the rectal area. It can be extremely intense but comes and goes for days at a time. My internist prescribed Premarin cream to be used externally once or twice a week, but I am concerned about using it as I often need something more frequently than that. Do you have any suggestions? Should I be taking a soy product such as Genestein or using a progesterone cream or both. I am not certain I want to use hrt again.

A: Vaginal itching can be caused by local atrophy and in that case local estrogen are a good solution. But (peri)vulvar itching can also be caused by dermatological diseases or by VIN (vulvar intraepithelial neoplasia) or by lichen sclerosus. In those situations local estrogens will not be helpful and other creams are much better like corticosteroids or androgens. But first a diagnosis is needed.

Q: Many symptoms
I wonder if you can give me some insight into what is going on? I am obese, my menstrual cycles are very irregular, usually three or four months apart, but sometimes 6 months apart. I have been infertile since the birth of my son who just turned six. I take Levothyroxine 50mcg daily. My GYN just says to lose weight. I agree that losing weight would do me a a lot of good, but I also wonder if something else is going on. He tested me i to see if I was menopausal. He said that I was not, I believe he said that there was enough estrogen. I always hesitate to go to the doctor because it seems as if by the time I get to have my appointment, my symptoms have subsided for the time being, and any tests run would turn out to be negative.

For about four years now. I would wake up with a headache in my right temple. I call it a hormone headache because that's what I think causes it. At first it was so severe that I had to sleep all day to get rid of it. I would liken it to a hangover. Now I can usually get rid of it in about two hours of sleep. 

I was experiencing extreme insomnia over the summer, not falling asleep until 2:00 or 3:00. I was also experiencing severe hot flashes with palpitations. Then I discovered a product called Healthy Woman Soy Menopause. I haven't had a sleepless night since, the hot flashes are rare and intensity reduced, and no more palpitations. However, for about the past four weeks I have been experiencing severe fatigue. 

I have had before but this is the longest this has lasted. I get this severe, I'm going to call it, acidy vaginal discharge. For the first day or two of this, I get a blue, yes, you read it correctly, a blue discharge. But after this, it's just plain old acidy. I don't believe this is yeast as it goes away on it's own, this discharge is eventually followed by menstruation. This particular time has been lasting about two weeks, the longest yet, and directly followed the fatigue cycle. Any help you could give me would be greatly appreciated.

A: This is not the place to discuss particular health problems. Anyhow, there are no clues in your history for (peri)menopause. A very irregular menstrual cycle deserves the attention of a gynecological endocrinologist. Sometimes obesity will come from ovarian disorder like PCO

There is a lot of attention by lay people on Soy products, but there is no scientific evidence that soy products are helpful for menopause symptoms complaints. But when you are a believer and it is helpful to you, please go with the soy further, but remember that there are also no studies on the safety of the products.

(Please visit the PCOS Pavilion for more information on PCOS)

Doctor, What about life after "the change?"  

Q: Post Menopausal Bleeding
My sister is 55, and has been through menopause for about 3 years, now she is starting to spot, is this a normal sign? Or is this something we should be worried about.

A: This is postmenopausal bleeding and there is a need for further investigation. There are several columns on covering postmenopausal blood loss. Have a look at this article Menopause FAQ - Menopause, Perimenopause & Postmenopause: Definitions, Terms & Concepts by Peter Kenemans, MD, PhD

Q: Does Menopause cause digestive problems?
Can menopause create or be responsible for digestive problems, i.e. stomach cramps, diarrhea etc?

A: No.

Q: Could my itching be caused by menopause?
I have recently heard in a health report that itchy skin may be a system to perimenopause. I have been suffering from extreme itchy skin for the last 4-5 month and can't seem to figure out why. No rashes, no dry skin, just itching. What can be done about this?

A: This question cannot be answered at a distance. Diabetes can cause itching too as well as other systemic diseases, consult your doctor.

Q: If you don't use it, do you lose it?
Doctors, I think that I have this perimenopausal thing pretty much under control. I was having horrific hot flashes that would drench my clothes, and frightening mood swings, sleepless nights, memory lapses, etc. My GYN put me on Levlite and it finally kicked in after a few months. My question is sexual in nature. I have not been in a relationship for over four years, I am 47, and I am afraid of the vaginal dryness. All that I read is to continue having intercourse and it will help to keep you lubricated and your muscles toned. I am concerned about the future, if and when I have a relationship again. Anything that I can do? Or do I just sit around and shrivel up?

A: It is useless to be afraid for problems that will never come. First of all problems with intercourse occur only by 20% of postmenopausal women. So you have 80% change of no problems at all. And when problems arise, there is an easy cure.

Doctor, What should I expect from HRT?

Q: Frequent periods while on Prempro, is this "normal"?
I began taking Prempro in July of 1999. As of this writing, I am currently experiencing a period every one to two weeks. The Prempro has eliminated the heart palpitations, hot flashes, and irregular sleep patterns that I had been experiencing. I had an endometrial biopsy done in April of 1999 and was found to be fine (this was done because I had experienced some heavy bleeding for one month, 3/99). After the biopsy I did not have a period until two weeks after I began the Prempro (July 1999). My doctor had a blood test done to determine the FSH level and found it to be extremely high and thus recommended that I start on the Prempro. I have read and understand that the HRT can cause irregular bleeding for the first several months as the body adjusts. I would like to know if after 7 months of continuous therapy that the periods every one to two weeks is considered "normal". I have taken the Prempro at the same time every day and have never missed. I understand that you can't give specific info but I would appreciate your guidance.

A: I think, The problem is that you have still some ovarian activity. And then bleeding comes more often with Prempro. When you are not postmenopausal, Premphase with every month a withdrawal bleed is much better. Continuous combined therapies are not so good in perimenopause. Sequential combined therapies are preferred.

Q: Is there a link between estrogen and insomnia?
I recently had my estrogen increased to treat severe night sweats. I am 44 years old. I feel much better but I immediately noticed an increase in vaginal secretions to the point of having to use tissue. I have started taking the estrogen at night. Is there any link between estrogen and insomnia?

A: An increase in oestrogens can be accompanied with heavier transudation. It has nothing to do with infectious discharge. There is certainly a link between oestrogens and sleep behaviour.

Q: Antithrombin III Deficiency/Ovary removal?
I am 38 yr. female, uterus removed already, looking at possible ovary removal. Have AT-III deficiency Family history of CAD mother deceased age 50. No clinical Thrombosis evident x38 yrs. Hematology conferred no HRT'S for me. Pain unbearable in Abdomen. Lupron Depot used 3 mo. pain relieved. But controversy involving Lupron. A decision needs to be made, Progestrin mentioned, searched HERS Study, also Homosiestine Abnormality and adhesions. If no HRT than what is % risk for Cardiovascular disease, etc. vs. pain management if any other than Lupron Depot . Any research available to help with Education to make best decision? Where to go? Choice's all seem to be high risk.

A: I cannot give medical advice for such a personal history. In complicated decisions like this, you have to discuss all relevant data and to set them in proper perspective.

Q: A question regarding side effects of Estroven
I took Healthy Woman soy for a period and I took Estroven for a few days. They say there are no side effects, but I have trouble sleeping when I take them. It seems like I am running all night and my legs ache. Is there a study about this? I also took Prempro for awhile and it made me sick to my stomach and very gassy. It seems that I must go through this menopause thing without help. One doctor prescribed birth control pills, but I couldn't even take them when I was younger. I will be 50 in October. Do you have any advice?

A: I have no further advice. Estroven is unknown to me. And Healthy Women Soy has not studied. No one can give any advice on plant estrogens for climacteric complaints, because there are no placebo controlled studies

Q: Plant derived estrogen?
My doctor recently prescribed Prempro for me but I asked her to give me something that was not derived from horses and she is going to prescribe estrase and progesterone for me next month. Is estrase plant-based?

A: The source of estrogens is usually on the leaflet in the package. And there is no difference at all between estrogens from plant sources or the same estrogens from industrial plants. The structure of the compound is the only important point, regardless the source.

Q: Will natural estrogen control bleeding without side effects?
I am 46 years old and have been dealing with perimenopause for about 2 1/2 years. Heavy bleeding for long periods and placed on the bcp - Lo-Estrin. I don't like taking the bcp for obvious concerns . My question is will a "natural" estrogen supplement, i.e., Estroven control bleeding and regulate a cycle as effectively as the bcp, without side effects? Thank you for any information or direction that you may provide in advance.

A: I do not know what Estroven is. What kind of estrogen? All estrogens can have side effects. I am not aware of any medicament natural or not without any side effect.

Q: Is breast calcification common?
I was diagnosed with breast calcification that is probably benign. There is no need for further testing now, but I need to return for another mammogram is 6 months. I am 48 yrs old, no history of breast cancer myself or in family. My gyn says this is very common. What do you think?

A: Only microcalcifications are a sign of early breast cancer. Other calcifications have no meaning and I cannot guess what reason exists for another mammogram in 6 months.

Q: HRT Medicine causing dark patches?
I have been taking Premarin 0.625 Day 1-25 then I add Provera 5 Mg. from day 14 to 25. I have been doing this for 21 months now. My question is that I am experiencing darkening on my face that seems to be getting worse. Is this due to the hormones and if I stop using them will it go away?

A: I know this problem with oral contraceptives and in pregnancy. It is called chloasma. And although I am not aware of chloasma with HRT, I think that here is also a kind of chloasma. If this is true, it will disappear slowly over several months after stopping HRT. By the way, chloasma worsens with sunlight. When you avoid the sunshine, no problem exists. Also sun blocking creams are helpful.


Opinions expressed here are for educational purposes only and, as such, do not constitute and should not be interpreted as initiation of a physician-patient relationship. This information is not intended to supplant the need for you to consult with your physician prior to choosing therapeutic options and/or interventions.

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