Uterine bleeding at menopause

Uterine bleeding during menopause is a very serious problem, and before starting its treatment, it is necessary to know the etiology of this process. The menopause period is characterized by the development of various pathologies against the background of hormonal imbalance, and it is very important to identify all these disorders and begin treatment in time. The key to successful treatment is timely diagnosis, which is possible only if you know certain symptoms and clinical manifestations of such bleeding.

Causes menopausal uterine bleeding

When talking about the causes of menopause, it is necessary to understand the general hormonal changes in a woman's body during this period. During a normal menstrual cycle, there is a fluctuation of the main female steroid hormones, which change, and according to these fluctuations, changes occur throughout the body, including the uterus.

Menopause is a physiological process of changes in the female reproductive system, during which hormonal imbalances occur in the body and these changes affect many processes in the female body - the menstrual function, the activity of the nervous system, the gastrointestinal tract and the skeletal system, as well as the work of the cardiovascular system. Therefore, the most characteristic manifestations of hormonal imbalance are disruptions in the work of these organs. Normal menstrual function is disrupted, which can have various manifestations, including uterine bleeding. The process of menopause development should have its successive stages. The menopause period is conventionally divided into:

1. premenopause – the period from 45 years to the onset of menopause;
2. menopause – the period of the last menstruation, average age is about fifty years;
3. postmenopause – the period from the last menstruation until the end of a woman’s life.

All these periods are characterized by their own peculiarities, which must be known in order to regulate the state of the body and know exactly when something is wrong. Thus, during the premenopause period, the first clinical symptoms of uterine bleeding may occur, so in this case it is necessary to correctly correct such disorders and find the cause.

Thus, the main etiological factor for the occurrence of uterine bleeding during menopause can be called the onset of menopause itself, which, with insufficient regulation of the hormonal background, can cause menstruation in the form of uterine bleeding. This develops due to the fact that the hypothalamus involution occurs and the sensitivity of the hypothalamus to the influence of estrogens gradually decreases, which disrupts its regulatory function according to the principle of feedback regulation. There is insufficient stimulation of the pituitary gland and the release of follicle-stimulating and luteinizing hormones is disrupted, which leads to an anovulatory cycle without the release of an egg. At the same time, the level of pituitary hormones - follicle-stimulating and luteinizing - decreases, which disrupts their normal concentration and the first changes in menstruation can occur. The most specific changes occur in the ovaries in the form of follicle atresia, destruction of membranes, death of oocytes and preservation of only the stroma, which helps to reduce the amount of secreting estrogen. This in turn disrupts the work of the functional layer of the endometrium, which can cause its premature and simultaneous detachment with the development of uterine bleeding. This may be one of the reasons for such bleeding.

Another very common cause of uterine bleeding during menopause may be uterine myoma, which, depending on its shape and location, may have serious complications in the form of bleeding. Uterine myoma or fibromyoma is a benign disease of the uterus, which is accompanied by high proliferative activity of myometrium cells with the formation of a volumetric structure in the uterine cavity. This disease is hormone-dependent, that is, the stimulus for such active reproduction is female sex hormones. Therefore, the main cause can be considered hormonal imbalance, which occurs with the onset of menopause, so the development of these diseases is more typical for the climacteric period. In pathogenesis, the main role in the development of uterine myoma during menopause belongs to a violation of hormonal levels. During menopause, the level of estrogens drops, their regulatory effect on the first phase of the menstrual cycle decreases, which is accompanied by a decrease in the process of proliferation of endometrial cells. This in turn entails a compensatory increase in the proliferation of myometrial cells, which is accompanied by hyperplasia of these cells with the development of different types of uterine fibroids.

There is another series of reasons associated with the development of fibroids during menopause - this is a group of non-hormonal reasons. The basis of all these reasons is the natural physiological involution of myometrium cells during menopause in women, which is accompanied by changes in the metabolism of myocyte cells, their antigenic changes. In this case, normal processes of cell growth and reproduction with an increased tendency to proliferation can be disrupted, and specific cytokines and vascular growth factors are formed, which additionally stimulate pathological excessive differentiation of these cells. As a result, uncontrolled cell division, their reproduction and an increase in the volume of the myometrium occur, which can be local or diffuse. In the case of the development of submucous forms of uterine fibroids, uterine bleeding develops very often, which requires immediate action. Therefore, if the etiological factor of uterine bleeding is fibroids, the treatment tactics here are different.

Another cause of uterine bleeding may be an endometrioid cyst of the uterine cavity, which, if it ruptures, may manifest itself as significant bleeding. Therefore, it is necessary not to exclude such a cause, which requires special tactics of examination and treatment to prevent infection.

That is why it is important to know about the main causes of uterine bleeding during menopause.

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Symptoms menopausal uterine bleeding

Very often, symptoms of uterine bleeding during menopause develop against the background of certain changes, which are often manifested by emotional-vegetative disorders. A woman is concerned about irritability, mood swings, depression, decreased sexual desire, insomnia, fatigue. Also, vegetative manifestations can often be attacks of sweating, fever, headaches and palpitations.

If we are talking about uterine bleeding, which is caused by the peculiarities of menstruation, then such changes will be characteristic. Menstrual cycle disorders during menopause have the character of irregular menstruation - one month there is, and the next two are absent, and then they disappear altogether. There may also be heavy periods, and the next month they are absent. In this case, such a process from changes in menstruation to their complete disappearance takes about six months, no more. Heavy bleeding during menopause, which often recurs, require urgent intervention, because it affects the woman's condition by developing anemia and disrupting the general condition. In this case, there will be symptoms of dizziness, fainting, and flickering of midges before the eyes. All these manifestations require immediate action.

If the cause of uterine bleeding during menopause is myoma, then this disease is often asymptomatic until the moment complications arise. If uterine myoma begins in the premenopausal period, then symptoms of menstrual irregularities may develop, which is associated with a disruption of the endometrium structure due to the presence of nodes or with initial changes in hormone levels. The first symptoms of uterine myoma during menopause can also be varied - bleeding, pain in the lower abdomen or a feeling of heaviness in the pelvis, sexual dysfunction, decreased libido, disruption of the normal functioning of the bladder or rectum, secondary chronic iron deficiency anemia. These symptoms often appear already with significant volumes of myoma precisely because the course is asymptomatic. There are some features of the clinical picture of uterine myoma during menopause depending on the location and form of the formation.

In the nodular form of uterine myoma, clinical manifestations directly depend on the location of the node. When subserous nodes are formed, menstrual function is not impaired if it is preserved in premenopause. Acute abdomen is often observed, since such nodes are very labile in their position and can shift, forming a torsion or necrosis of the node stalk. Sometimes the pain is not sharp, but dull, aching, constant, if the node irritates the peritoneum or nerve endings, then there may also be heaviness in the abdomen. If the subserous myomatous node is of significant size, it can cause a syndrome of compression of adjacent organs with difficulty in the act of defecation with compression of the rectum, with difficulty in urination or reactivity of the bladder, and compression can also disrupt the outflow of venous blood and lymph with the formation of stagnation in the small pelvis and the development of hemorrhoids. Often, with a subserous location of a fibromatous node in uterine myoma during menopause, local neurological symptoms are observed due to compression of nerve structures with the development of disorders such as paresthesia or osteochondrosis of the lumbar spine. Then it is very important to correctly diagnose the pathology, and not treat these neurological disorders.

With a submucous location of the node, the clinical picture is less pronounced in terms of compression symptoms, but local manifestations are more pronounced. Metrorrhagia may be observed, even if there is no menstruation at all during menopause, then such discharge may appear with uterine myoma during menopause. These discharges are painful, accompanied by aching pain in the lower abdomen. Discharge with uterine myoma during menopause can also be in case of infection of the node, then infectious inflammation develops with yellow-green discharge with an unpleasant odor, which is also accompanied by symptoms of intoxication. But at a certain point, severe bleeding from the node may develop, which may be the first episode and the only symptom of this pathology.

If the cause of bleeding is an endometrioid cyst, it is characterized by minor spotting before and after menstruation, which can be a diagnostic sign of the disease. When the cyst ruptures completely, severe uterine bleeding occurs, which is accompanied by significant abdominal pain of a spasmodic nature.

Therefore, if any changes occur in a woman’s health, it is necessary to pay attention to this and conduct a comprehensive examination for the purpose of early diagnosis and prevention of such complications.

Complications and consequences

The main complications that may arise in case of uterine bleeding are the development of acute posthemorrhagic anemia or hemorrhagic shock, if the bleeding is very pronounced. Other complications that may arise are ascending infection with the development of secondary complications in the form of purulent myometritis or suppuration of the myomatous node. Consequences may arise if the myoma is not diagnosed in a timely manner. Then there are severe abdominal pains and bloody discharge, which is associated with the rejection of the fibromatous node and its exit into the uterine cavity. Such a complication is very dangerous and requires surgical intervention with further complex therapy. Therefore, if the uterine myoma has symptoms of uterine bleeding, then this is an indication for surgical treatment to prevent such complications.

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Diagnostics menopausal uterine bleeding

Timely diagnosis of uterine bleeding and correct differential diagnosis of its cause are very important not only for the treatment of this pathology, but also for preventing episodes of repeated bleeding and preventing complications. Therefore, first of all, it is necessary to find out the anamnestic data. It is necessary to carefully collect anamnesis with details of complaints and an accurate definition of the obstetric anamnesis. It is necessary to find out when the climacteric period began, the characteristics of the menstrual cycle, the presence of an active sex life. It is also necessary to find out whether the bleeding is associated with heavy menstruation as a manifestation of menopause. If the cause of uterine bleeding is a fibroid, then, as a rule, the woman already knows about its presence, less often it happens when bleeding for the first time indicates a disease. Then proceed to examination. It is necessary to examine the woman on the chair, which allows identifying disorders in the form of dryness of the vaginal mucosa, concomitant pathological discharge, the volume of uterine bleeding, which allows us to assume a probable diagnosis. If we are talking about uterine myoma, then during a bimanual examination of a woman a tumor-like formation of various sizes and locations is determined, it is painless, mobile - in the case of nodular uterine myoma. If the myoma is diffuse, then an increase in the entire uterus is observed, which corresponds to a certain period of pregnancy, the uterus is dense, slightly mobile and painless. In this case, it is also possible to palpate the submucous node that caused the bleeding. The tests that are necessary to clarify the diagnosis are general clinical and special. General ones are a blood test, a biochemical blood test with a lipidogram and kidney function indicators, and a urine test. In a general blood test for prolonged uterine bleeding, chronic posthemorrhagic anemia can be determined, which allows us to judge the duration of this disease. As for special tests, it is necessary to determine the level of the main female hormones in the blood. This is necessary not only for further treatment of menopause, but also for analyzing the level of hormonal changes and the duration of the pathology.

Instrumental diagnostics of uterine bleeding during menopause is aimed at identifying the etiology and excluding other organic pathologies. Mandatory and special research methods are carried out. Ultrasound of the pelvic organs allows identifying organic changes in the pelvis, as well as finding out the condition of the ovaries to predict pathology, if uterine bleeding is heavy menstruation, as a manifestation of menopause. If a myoma is suspected, ultrasound will make it possible to determine its size and localization, which is necessary to predict the disease and choose treatment tactics. This method allows you to see an anechoic formation in the case of a myomatous node with an accurate determination of the location of this formation, its size, structure, as well as the degree of enlargement of the uterus in the case of a diffuse form of fibroids.

Hysterography is one of the methods of special diagnostics, which is carried out by filling the uterus with a contrast fluid in the volume of 5-7 milliliters with subsequent registration of changes. In this case, a filling defect may be observed, which corresponds to the location of the node, as well as a decrease in the uterine cavity. Another examination is hysteroscopy. This is a special method of examining the uterine cavity with a special device with a video camera at the end, which allows you to see the uterine cavity, as well as conduct a biopsy with further examination of the puncture for accurate verification of the diagnosis.

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Differential diagnosis

Differential diagnostics of acute uterine bleeding during menopause should be carried out primarily with the complication of submucous uterine myoma in the form of metrorrhagia. In this case, anamnesis and objective examination are important. It is very important, given the woman's advanced age, to carry out differential diagnostics of uterine bleeding with endometrial cancer during menopause, since oncological alertness should always be present. Endometrial cancer is characterized by the appearance of bloody discharge already several years after the onset of menopause. But bleeding in the case of uterine myoma is characterized by periodic bleeding, and the node is clearly defined during examination. In case of doubts about the nature of the formation in the uterus, diagnostic curettage of the uterine cavity is carried out with a histological examination of this material, which allows you to accurately determine the benign or malignant nature of the formation.

Differential diagnostics should also be performed with a ruptured uterine cyst, especially if it is an endometrioid cyst. On ultrasound, the cyst has an anechoic structure, an oval shape, clear edges with a thin capsule and uniform content. A myomatous node is also anechoic, but it is heterogeneous and corresponds to the myometrium in density, often has a stalk and is well supplied with blood, unlike a cyst, which is avascular.

Uterine bleeding during menopause also needs to be differentiated from internal endometriosis, which can also be accompanied by profuse bloody discharge from the uterus. But with endometriosis, there is a characteristic anamnesis in the form of bleeding that corresponds to menstruation. These two diagnoses can be accurately verified using histology, as well as accurate ultrasound diagnostics.

Considering the period of menopause, that is, not a young age of a woman, it is necessary to carefully diagnose uterine bleeding and differential diagnostics, since various malignant processes are possible at this age, which must be diagnosed as early as possible with the beginning of appropriate treatment. It is very important to provide timely assistance, because this is a life-threatening condition.

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Treatment menopausal uterine bleeding

The tactics of therapy of acute uterine bleeding during menopause should be immediate and have a hemostatic character, as well as a preventive character to prevent repeated bleeding and the development of more serious symptoms. There are drug and non-drug treatments. Drug treatments are aimed mainly at the use of hemostatic drugs, as well as at replacement therapy for hormone deficiency during menopause or uterine fibroids. Non-drug treatment is aimed at correcting hormonal imbalance on the one hand and at a preventive effect on the other hand. You can also use herbs and infusions that help restore the body after bleeding. Therefore, the use of folk remedies is a priority only in complex treatment during remission.

The means of stopping such bleeding must be precisely known in order to determine the tactics. This issue should be a priority in the case of acute uterine bleeding and hemostatic drugs are used for this purpose.

1. Tranexam is one of the most widely used hemostatic agents in gynecology. This drug affects the external mechanism of coagulation by inhibiting the formation of plasmin from plasminogen. Due to this effect, its antifibrinolytic property is revealed. The drug is available in the pharmacological form of tablets and a solution in ampoules for injection. In acute uterine bleeding, tranexamic acid is used intravenously by drip. The dosage in this case is about ten to fifteen milligrams per kilogram of body weight with intravenous drip administration at a rate of about one drop per minute. Indications for use of the drug are acute bleeding, mainly in the postoperative period or those that are accompanied by an increased amount of fibrinolysin. The drug also has anti-inflammatory and anti-allergic properties, which relieves the severity of symptoms in uterine fibroids or endometrioid cysts. Contraindications to the use of Tranexam are hypersensitivity to the components of the drug, as well as vascular pathology in the form of thrombosis in the anamnesis, stroke or heart attack. Side effects are possible in the form of allergic reactions, as well as changes in the digestive system - loss of appetite, heartburn, abdominal pain, nausea. Manifestations from the vascular system are possible in the form of hypotension with rapid administration of the drug, as well as increased heart rate, increased thrombotic activity with the risk of thrombosis or thromboembolism.
2. Dicynone is an additional remedy for the treatment of acute uterine bleeding during menopause, since the drug acts mainly on the vascular-platelet link of hemostasis. The drug increases the permeability of the vascular cell, and also increases the rate of thromboplastin formation, which increases the reaction to the formation of a primary thrombus during bleeding. The drug begins to act a few minutes after administration, and the duration of action is about five hours. The drug is available in the pharmacological form of tablets and a solution for intravenous injections. In case of acute uterine bleeding, the drug is administered at a dose of 500 milligrams intramuscularly. Contraindications to the use of the drug are hypersensitivity to the components of the drug, as well as vascular pathology in the form of thrombosis in the anamnesis, stroke or heart attack, overdose of drugs from the anticoagulant group. Side effects are possible in the form of allergic reactions, as well as changes in the gastrointestinal tract - nausea, heartburn, abdominal pain, loss of appetite. Manifestations from the nervous system in the form of dizziness, drowsiness, sleep disturbances, and headaches are possible.

Hormonal therapy for concomitant uterine myoma, if it is the etiological factor of bleeding, is mandatory, as well as for the correction of hormonal imbalance during menopause. In this case, hormone replacement therapy is used.

Hormonal therapy for uterine fibroids may include several groups of drugs:

1. Gonadotropin-releasing factor agonists, of which Diphereline or Triptorelin is a representative, are used from the 3rd day of the menstrual cycle for six months at 3.75 milligrams.

• Goserelin - is used for six months at 3.6 milligrams subcutaneously
• Buserelin - 200 micrograms in the nose twice a day for a six-month course
• Zoladex – from the 1st to the 5th day of the cycle by injection.

1. Gonadotropic hormone antagonists, a representative of which is the drug Danazol, are used at 400-800 milligrams per day, also with a course of treatment for six months.
2. Progesterone series drugs are various drugs that are able to regulate the ovariomenstrual cycle in case of insufficiency of its second luteal phase. The main representatives of this series are:

• Norethisterone acetate – is used from the fifth day of the menstrual cycle, 5-10 milligrams twice a day for six months.
• Medroxyprogesterone acetate is used in the same dose and for the same course.
• The Mirena system is an intrauterine device that is inserted for five years with monitoring of its condition.
• Norcolut and Primolut are drugs that are used from the 16th to the 25th day of the menstrual cycle for three to six months.

It is also possible to use combined oral hormonal drugs, two-phase, with a large amount of progesterone.

1. Triziston is a complex hormone replacement drug. This drug is produced in the pharmacological form of dragees of three colors, which are used according to a special scheme for three weeks, then a break for a week. The course of treatment is at least three to six months. Contraindications for prescribing the drug are malignant tumors of any localization, vascular pathology in the form of thrombosis in the anamnesis, hepatitis. It is necessary to use with caution in diabetes mellitus, since the drug can change glucose tolerance, as well as in arterial hypertension. Side effects may appear in the form of cholestasis, liver dysfunction, embolism, as well as allergic and dyspeptic reactions.
2. Logest is a drug containing estradiol and gestagen, is a high-dose drug, due to which its preventive role is manifested not only in the correction of hormonal levels, but also in the prevention of oncological diseases of the female reproductive system. The drug helps to level out hormonal imbalances and due to this, menopause disorders are less pronounced, especially with regard to heavy bleeding. Logest is available in the pharmacological form of capsules, containing 21 pieces per package. The intake should be started on the first day of the cycle. You can start taking it on the fifth day of the menstrual cycle in case of menopause in a woman. The course of admission is one capsule per day for three weeks, then a break of seven days, then you need to resume taking it. Side effects are possible from the gastrointestinal tract in the form of stool disorders, nausea, a feeling of bitterness in the mouth, vomiting. There may also be asthenovegetative reactions, manifestations of hormonal treatment from the chest in the form of a feeling of heaviness, pain, discharge, and increased vaginal secretion. Contraindications to the use of the drug for treatment are problems with blood clotting and a history of heart attack or stroke, malignant neoplasms, severe liver damage, pancreatic damage, and diabetes.

Surgical treatment of acute uterine bleeding during menopause is performed if the cause of bleeding is a myomatous node. In this case, after simple preoperative preparation, surgical treatment is performed. It is imperative to stop the bleeding, confirm the presence of the node, and only then perform surgical treatment. Surgical treatment can be performed in the volume of organ-preserving intervention and radical intervention. Tactics depend on the type of myoma, its size, location, and the duration of the operation. Organ-preserving operations are myomectomy - removal of the myomatous node itself within healthy tissues - and embolization of the uterine arteries, which disrupts the blood supply to the node and it regresses.

Radical operations include supravaginal amputation of the uterus, subtotal hysterectomy and extirpation of the uterus, which also depends on the size and location of the fibroid and the age of the woman, as well as the ability to quickly stop uterine bleeding.

Traditional treatment of uterine bleeding during menopause

Traditional treatment of uterine bleeding, due to its risk of complications, is carried out during the period of remission. Traditional treatment methods that are used are aimed at correcting hormonal homeostasis and the main ones are:

1. Honey has the ability to increase local immunity and stimulate regeneration. To create a medicine from honey, you need to take the core of an onion and place it in a glass of honey so that it is completely filled with it. Leave this solution overnight and in the morning, soak a tampon in this solution and insert it into the vagina overnight, repeat this for 10 days, after which the fibroid, if it caused bleeding, should decrease.
2. Honey, as a natural source of nutrients and microelements that increase local immunity and stimulate regeneration, is widely used to treat pathologies of the female genital organs, including menopause. To create a medicine from honey, you need to make a solution of three tablespoons of honey, five drops of flaxseed oil and three tablespoons of boiled water and take a teaspoon twice a day, the course is 10 days. This remedy helps to normalize hormonal levels, which is also aimed at preventing disorders of local immunity.
3. Aloe leaves, which have a pronounced anti-inflammatory and regenerating effect, are squeezed into a glass and, after wetting a tampon, inserted into the vagina, repeating the procedure once a day for a whole month.
4. Burdock juice is excellent for relieving irritation, swelling and has an antiproliferative effect, which increases the ability of the endometrioid cyst to resolve. To do this, squeeze the juice out of the pre-washed burdock leaves and take one teaspoon three times a day for five days, and then one teaspoon twice a day for another five days.
5. Barberry leaves, valerian, linden, coriander, motherwort and oregano should be poured with a liter of hot water and after infusion, drink 2 teaspoons in the morning and evening. This solution calms the nervous system and reduces bloody discharge by stabilizing the hemostasis system. This prevents disorders of the nervous system during menopause, which relieves the symptoms of vegetative-emotional manifestations and prevents vascular tone disorders.

Homeopathic remedies can not only correct hormonal imbalances, but they can also be taken to restore the body after bleeding.

1. Klimakthel is a homeopathic remedy that has a composition similar to phytoestrogen drugs and helps to normalize hormonal levels during menopause. The drug also reduces proliferative processes at the cellular level. Klimakthel is used in tablets, one tablet before meals or an hour after three times a day. The duration of treatment with the drug is about two months. No side effects have been identified. Contraindications to taking Klimakthel are hypersensitivity to the components of Klimakthel.
2. Dysmenorm is a homeopathic remedy that regulates hormonal levels and affects benign uterine formations such as cysts or fibroids. Dysmenorm is used for treatment in tablets in a dose of one tablet three times a day one hour after meals.
3. Remens is a homeopathic drug that helps regulate hormonal imbalance during menopause by influencing the hypothalamic-pituitary zone, and also has protective properties on the endometrium. This prevents the development of repeated bleeding and restores the functional layer of the uterus. The drug is available in the form of a solution and tablets. The medicine is used on the first and second day in an increased dose - one tablet or ten drops eight times a day, and then for three months in the same dose, but only three times a day. No side effects have been identified. Contraindications to taking Remens are hypersensitivity to individual contents of the drug.
4. Ginekohel is a combined homeopathic remedy that has an effect on menopause disorders by normalizing the synthesis of estrogen and progesterone, which helps reduce the effects of deficiency of these hormones. The drug is available in drops and is dosed ten drops three times a day, can be dissolved in water or taken as a pure solution. Side effects are rare, but stool disorders, dyspeptic phenomena and allergic reactions may occur. No contraindications have been identified.

Thus, the main thing in the treatment of uterine bleeding during menopause is its immediate cessation, and only then additional research methods are carried out, the diagnosis is clarified and the tactics of further treatment are decided - surgical or conservative. Such a wide range of drugs, not only medicinal, but also folk remedies, as well as homeopathic drugs, allows you to choose the necessary treatment and successfully correct changes in hormonal levels during menopause with the prevention of further disorders, but these methods are possible during the period of remission.

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Prevention

Specific prevention can be carried out in case of the first symptoms of menopause, then you can start taking homeopathic remedies to regulate hormonal levels, which can prevent serious menstrual irregularities in the form of heavy uterine bleeding. Non-specific preventive measures include regular examinations by a gynecologist, examination in case of the first symptoms of menopause. This can detect a uterine fibroid or cyst at an early stage, which makes it possible to use early treatment of the pathology and prevent such a complication as uterine bleeding.

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Forecast

The prognosis for uterine bleeding during menopause for recovery is relatively favorable in case of timely treatment and proper treatment, since this condition has a direct threat to life. The prognosis for life is favorable, since bleeding with proper treatment can be stopped and other complications can be prevented.

Uterine bleeding during menopause is a very serious symptom that can develop as a manifestation of menopause itself, and can also be a symptom of uterine fibroids or endometrioid cysts. Therefore, it is important to conduct differential diagnostics and, after stopping the bleeding, decide on the treatment of the pathology. But the best option in this case is the prevention of such bleeding through timely examinations and monitoring of your health.

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