POSTMENOPAUSAL BLEEDING
CHIDAMBARAM HOSPITAL
How Is Postmenopausal Bleeding Treated?
Hysterectomy: Bleeding that cannot be treated in less invasive ways may
require a hysterectomy. During a hysterectomy, your doctor will remove the
patient’s uterus. The procedure may be done laparoscopically or through
conventional abdominal surgery.
POSTMENOPAUSAL BLEEDING
What is normal vaginal bleeding?
Normal vaginal bleeding is the periodic blood that flows as a
discharge from the woman's uterus. Normal vaginal bleeding is also
called menorrhea. The process by which menorrhea occurs is called
menstruation.
Normal vaginal bleeding occurs as a result of cyclic hormonal changes. The ovaries are the main source of female hormones, which control the development of female body characteristics such as the breasts, body shape, and body hair. The hormones also regulate the menstrual cycle. The ovary, or female gonad, is one of a pair of reproductive glands in women. They are located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of an almond. The ovaries produce eggs (ova) and female hormones. During each monthly menstrual cycle, an egg is released from one ovary. The egg travels from the ovary through a Fallopian tube to the uterus.
Unless pregnancy occurs, the cycle ends with the shedding of part of the inner lining of uterus, which results in menstruation. Although it is actually the end of the physical cycle, the first day of menstrual bleeding is designated as "day 1" of the menstrual cycle in medical jargon.
The time of the cycle during which menstruation occurs is referred to as menses. The menses occurs at approximately four week intervals, representing the menstrual cycle.
Menarche is the time in a girl's life when menstruation first begins. Menopause is the time in a woman's life when the function of the ovaries ceases and menstrual periods stop. Menopause is defined as the absence of menstrual periods for 12 consecutive months. The average age of menopause is 51 years old.
What is abnormal vaginal bleeding?
Abnormal vaginal bleeding is a flow of blood from the vagina that
occurs either at the wrong time during the month or in inappropriate
amounts. In order to determine whether bleeding is abnormal, and its
cause, the doctor must consider three questions:
1. Is the woman having abnormal vaginal bleeding during pregnancy?
Much of the abnormal vaginal bleeding during pregnancy occurs so
early in the pregnancy that the woman doesn't realize she is pregnant.
Therefore, irregular bleeding that is new may be a sign of very early
pregnancy, even before a woman is aware of her condition. Vaginal
bleeding during pregnancy can also be associated with complications of
pregnancy, such as miscarriage or ectopic pregnancy.
The duration, interval, and amount of vaginal bleeding may suggest what type of abnormality is responsible for the bleeding.
An abnormal duration of menstrual bleeding can be either bleeding for too long of a period (hypermenorrhea), or too short of a period (hypomenorrhea).
The interval of the bleeding can be abnormal in several ways. A woman's menstrual periods can occur too frequently (polymenorrhea) or too seldom (oligomenorrhea). Additionally, the duration can vary excessively from cycle to cycle (metrorrhagia).
The amount (volume) of bleeding can also be abnormal. A woman can either have too much bleeding (menorrhagia) or too little volume (hypomenorrhea). The combination of excessive bleeding combined with bleeding outside of the expected time of menstruation is referred to as menometrorrhagia.
Usually, the ovary releases an egg every month in a process called
ovulation. Normal ovulation is necessary for regular menstrual periods.
There are certain clues that a woman is ovulating normally including
regular menstrual intervals, vaginal mucus discharge halfway between
menstrual cycles, and monthly symptoms including breast tenderness,
fluid retention, menstrual cramps, back pain, and mood changes. If necessary, doctors will order hormone blood tests (progesterone level), daily home body temperature testing, or rarely, a sampling of the lining of the uterus (endometrial
biopsy) to determine whether or not a woman is ovulating normally.
On the other hand, signs that a woman is not ovulating regularly include prolonged bleeding at irregular intervals after not having a menstrual period for several months, excessively low blood progesterone levels in the second half of the menstrual cycle, and lack of the normal body temperature fluctuation during the time of expected ovulation. Sometimes, a doctor determines that a woman is not ovulating by using endometrial sampling with biopsy.
What conditions cause abnormal vaginal bleeding in women who are ovulating regularly?
Abnormal vaginal bleeding in women who are ovulating regularly, most
commonly involve excessive, frequent, irregular, or decreased bleeding.
Some of the common conditions that produce each of these symptoms are
discussed below.
Excessively heavy menstrual bleeding, called menorrhagia, is
menstrual bleeding of greater than about eight tablespoons per month
(normal menstrual bleeding produces between two and eight tablespoons
per cycle). The most common pattern of menorrhagia is excessive bleeding
that occurs in regular menstrual cycles and with normal ovulation.
There are several important reasons that menorrhagia should be evaluated by a doctor. First, menorrhagia can cause a woman substantial emotional distress and physical symptoms, such as severe cramping. Second, the blood loss can be so severe that it causes a dangerously lowered blood count (anemia), which can lead to medical complications and symptoms such as dizziness and fainting. Third, there can be dangerous causes of menorrhagia that require more urgent treatment.
Benign (noncancerous) causes of menorrhagia include:
Although there are many causes of menorrhagia, in most women, the specific cause of menorrhagia is not found even after a full medical evaluation. These women are said to have dysfunctional uterine bleeding. Although no specific cause of the abnormal vaginal bleeding is found in women with dysfunctional uterine bleeding, there are treatments available to reduce the severity of the condition.
Menstrual periods that are abnormally frequent (polymenorrhea) can be caused by certain sexually transmitted diseases (STDs) (such as Chlamydia or gonorrhea) that cause inflammation in the uterus. This condition is called pelvic inflammatory disease. Endometriosis
is a condition of unknown cause that results in the presence of uterine
lining tissue in other locations outside of the uterus. This can lead
to pelvic pain
and polymenorrhea. Sometimes, the cause of polymenorrhea is unclear, in
which case the woman is said to have dysfunctional uterine bleeding.
Irregular menstrual periods (metrorrhagia) can be due to benign
growths in the cervix, such as cervical polyps. The cause of these
growths is usually not known. Metrorrhagia can also be caused by
infections of the uterus (endometritis) and use of birth control pills (oral contraceptives).
Sometimes after an evaluation, a woman's doctor might determine that
her metrorrhagia does not have an identifiable cause and that further
evaluation is not necessary at that time.
Perimenopause is the time period approaching the menopausal transition. It is often characterized by irregular menstrual cycles, including menstrual periods at irregular intervals and variations in the amount of blood flow. Menstrual irregularities may precede the onset of true menopause (defined as the absence of periods for one year) by several years.
An overactive thyroid function (hyperthyroidism) or certain kidney diseases can both cause hypomenorrhea. Oral contraceptive
pills can also cause hypomenorrhea. It is important for women to know
that lighter, shorter, or even absent menstrual periods as a result of
taking oral contraceptive pills does not indicate that the contraceptive
effect of the oral contraceptive pills is inadequate. In fact, many
women appreciate this "side effect" of oral contraceptives.
Women who are ovulating normally can experience light bleeding
(sometimes referred to as "spotting") between menstrual periods.
Hormonal birth control methods (oral contraceptive pills or patches) as well as IUD use for contraception may sometimes lead to light bleeding between periods. Psychological stress, certain medications such as anticoagulant drugs,
and fluctuations in hormone levels may all be causes of light bleeding
between periods. Other conditions that cause abnormal menstrual
bleeding, or bleeding in women who are not ovulating regularly (see
below) can also be the cause of intermenstrual bleeding.
Many conditions can interfere with the proper function of female
hormones that are necessary for ovulation. For example, many conditions
or circumstances may cause oligomenorrhea (reduction in the number of
menstrual periods and/or amount of flow than usual) such as:
Women who are postmenopausal (those who have not had a menstrual period for 12 consecutive months or more) should not experience vaginal bleeding. Any vaginal bleeding is considered abnormal in postmenopausal women. Women who are taking combined estrogen and progesterone hormone therapy (HRT or HT) may experience some light, irregular vaginal bleeding during the first six months of treatment. Likewise, postmenopausal women who are taking a cyclic hormone regimen (oral estrogen and a progestin for 10-12 days per month) may experience some vaginal bleeding that is similar to a menstrual period for a few days each month.
Postmenopausal women who experience heavy or prolonged vaginal bleeding while on hormone therapy should always see a doctor to rule out more serious causes of vaginal bleeding. Less frequent but serious causes of vaginal bleeding in postmenopausal women include endometrial cancer or hyperplasia (overgrowth of the lining tissues of the uterus, which can be precancerous in some cases).
Vaginal bleeding may occur during or after sexual intercourse for a number of reasons including:
CHIDAMBARAM HOSPITAL
चिदंबरम अस्पताल,
ചിദംബരം ഹോസ്പിറ്റൽ
சிதம்பரம் மருத்துவமனை,
திசையன்விளை.627657
Hysterectomy: Bleeding that cannot be treated in less invasive ways may
require a hysterectomy. During a hysterectomy, your doctor will remove the
patient’s uterus. The procedure may be done laparoscopically or through
conventional abdominal surgery.
POSTMENOPAUSAL BLEEDING
- Normal vaginal bleeding is the periodic blood flow from the uterus.
- Normal vaginal bleeding is also called menorrhea. The process by which menorrhea occurs is called menstruation.
- In order to determine whether bleeding is abnormal, and its cause, the doctor must answer 3 questions: Is the woman pregnant? What is the pattern of the bleeding? Is she ovulating?
- Abnormal vaginal bleeding in women who are ovulating regularly most commonly involves excessive, frequent, irregular, or decreased bleeding.
- There are many causes of abnormal vaginal bleeding that are associated with irregular ovulation.
- A woman who has irregular menstrual periods requires a physical examination with a special emphasis on the thyroid, breast, and pelvic organs.
- Treatment for irregular vaginal bleeding depends on the underlying cause. After the cause is determined, the doctor decides if treatment is actually necessary.
What is normal vaginal bleeding?
Normal vaginal bleeding occurs as a result of cyclic hormonal changes. The ovaries are the main source of female hormones, which control the development of female body characteristics such as the breasts, body shape, and body hair. The hormones also regulate the menstrual cycle. The ovary, or female gonad, is one of a pair of reproductive glands in women. They are located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of an almond. The ovaries produce eggs (ova) and female hormones. During each monthly menstrual cycle, an egg is released from one ovary. The egg travels from the ovary through a Fallopian tube to the uterus.
Unless pregnancy occurs, the cycle ends with the shedding of part of the inner lining of uterus, which results in menstruation. Although it is actually the end of the physical cycle, the first day of menstrual bleeding is designated as "day 1" of the menstrual cycle in medical jargon.
The time of the cycle during which menstruation occurs is referred to as menses. The menses occurs at approximately four week intervals, representing the menstrual cycle.
Menarche is the time in a girl's life when menstruation first begins. Menopause is the time in a woman's life when the function of the ovaries ceases and menstrual periods stop. Menopause is defined as the absence of menstrual periods for 12 consecutive months. The average age of menopause is 51 years old.
What is abnormal vaginal bleeding?
- Is the woman pregnant?
- What is the pattern of the bleeding?
- Is she ovulating?
1. Is the woman having abnormal vaginal bleeding during pregnancy?
2. What is the pattern of the abnormal vaginal bleeding?
An abnormal duration of menstrual bleeding can be either bleeding for too long of a period (hypermenorrhea), or too short of a period (hypomenorrhea).
The interval of the bleeding can be abnormal in several ways. A woman's menstrual periods can occur too frequently (polymenorrhea) or too seldom (oligomenorrhea). Additionally, the duration can vary excessively from cycle to cycle (metrorrhagia).
The amount (volume) of bleeding can also be abnormal. A woman can either have too much bleeding (menorrhagia) or too little volume (hypomenorrhea). The combination of excessive bleeding combined with bleeding outside of the expected time of menstruation is referred to as menometrorrhagia.
3. Is the woman ovulating?
On the other hand, signs that a woman is not ovulating regularly include prolonged bleeding at irregular intervals after not having a menstrual period for several months, excessively low blood progesterone levels in the second half of the menstrual cycle, and lack of the normal body temperature fluctuation during the time of expected ovulation. Sometimes, a doctor determines that a woman is not ovulating by using endometrial sampling with biopsy.
What conditions cause abnormal vaginal bleeding in women who are ovulating regularly?
Abnormal vaginal bleeding in women who are ovulating regularly, most
commonly involve excessive, frequent, irregular, or decreased bleeding.
Some of the common conditions that produce each of these symptoms are
discussed below.
Excessively heavy menstrual bleeding (menorrhagia)
There are several important reasons that menorrhagia should be evaluated by a doctor. First, menorrhagia can cause a woman substantial emotional distress and physical symptoms, such as severe cramping. Second, the blood loss can be so severe that it causes a dangerously lowered blood count (anemia), which can lead to medical complications and symptoms such as dizziness and fainting. Third, there can be dangerous causes of menorrhagia that require more urgent treatment.
Benign (noncancerous) causes of menorrhagia include:
- uterine fibroids (benign tumors of smooth muscle tissue),
- endometrial polyps (tiny benign growths that protrude into the womb),
- adenomyosis (the presence of uterine lining tissue within the muscular wall of the uterus),
- intrauterine devices (IUD's),
- underactive thyroid function (hypothyroidism),
- an autoimmune disorder systemic lupus erythematosus,
- blood clotting disorders such as inherited bleeding disorders, and
- certain medications, especially those that interfere with blood clotting.
Although there are many causes of menorrhagia, in most women, the specific cause of menorrhagia is not found even after a full medical evaluation. These women are said to have dysfunctional uterine bleeding. Although no specific cause of the abnormal vaginal bleeding is found in women with dysfunctional uterine bleeding, there are treatments available to reduce the severity of the condition.
Irregular vaginal bleeding; menstrual periods that are too frequent (polymenorrhea)
Menstrual periods at irregular intervals (metrorrhagia)
Perimenopause is the time period approaching the menopausal transition. It is often characterized by irregular menstrual cycles, including menstrual periods at irregular intervals and variations in the amount of blood flow. Menstrual irregularities may precede the onset of true menopause (defined as the absence of periods for one year) by several years.
Decreased amount or duration of menstrual flow (hypomenorrhea)
Bleeding between menstrual periods (intermenstrual bleeding)
What conditions cause vaginal bleeding after menopause or abnormal vaginal bleeding in women who are not ovulating regularly?
- If a woman has chronic medical illnesses or is under significant medical or emotional stress, she can begin to have a loss of her menstrual periods.
- Malfunction of a particular part of the brain, called the hypothalamus, can cause oligomenorrhea.
- Anorexia nervosa is an eating disorder associated with excessive thinness that causes many serious medical consequences as well as oligomenorrhea or amenorrhea (the absence of menstrual periods).
- Polycystic ovarian syndrome (PCO or POS) is a hormonal problem that causes women to have a variety of symptoms that include irregular or no menstrual periods, acne, obesity, infertility, and excessive hair growth; that are detectable with blood tests.
Women who are postmenopausal (those who have not had a menstrual period for 12 consecutive months or more) should not experience vaginal bleeding. Any vaginal bleeding is considered abnormal in postmenopausal women. Women who are taking combined estrogen and progesterone hormone therapy (HRT or HT) may experience some light, irregular vaginal bleeding during the first six months of treatment. Likewise, postmenopausal women who are taking a cyclic hormone regimen (oral estrogen and a progestin for 10-12 days per month) may experience some vaginal bleeding that is similar to a menstrual period for a few days each month.
Postmenopausal women who experience heavy or prolonged vaginal bleeding while on hormone therapy should always see a doctor to rule out more serious causes of vaginal bleeding. Less frequent but serious causes of vaginal bleeding in postmenopausal women include endometrial cancer or hyperplasia (overgrowth of the lining tissues of the uterus, which can be precancerous in some cases).
What causes vaginal bleeding during or after sexual intercourse?
- Injuries to the vaginal wall or introitus (opening to the vagina) during intercourse
- Infections (for example, gonorrhea, Chlamydia, yeast infections) can be a cause of vaginal bleeding after intercourse.
- Lowered estrogen levels in peri-menopausal or postmenopausal women may cause the lining of the vagina to become thinned and easily inflamed or infected, and these changes can be associated with vaginal bleeding after intercourse.
- Anatomical lesions, such as tumors or polyps on the cervix or vaginal wall may lead to vaginal bleeding during or after intercourse.
How Is Postmenopausal Bleeding Diagnosed?
The first steps in diagnosing the
cause of postmenopausal bleeding are a physical exam and a medical history
analysis. A doctor may conduct a Pap smear as part of a pelvic exam. This can
also screen for cervical cancer.
Doctors may use other procedures to view the inside of the vagina and the uterus.
One option is a transvaginal ultrasound. This procedure allows doctors to view the ovaries, uterus, and cervix. In this procedure, a technician inserts a probe into the vagina, or asks the patient to insert it herself. The probe emits sound waves that bounce off of inner structures. A computer then creates pictures of the inner structures.
Another diagnostic procedure is a hysteroscopy. This procedure shows endometrial tissue. In this procedure, a doctor inserts a fiber optic scope into the vagina and cervix. The doctor then pumps carbon dioxide gas through the scope. This helps to expand the uterus and makes the uterus easier to see. During this procedure, a doctor may also remove polyps or take a biopsy of endometrial tissue in order to rule out cancer.
Doctors may use other procedures to view the inside of the vagina and the uterus.
One option is a transvaginal ultrasound. This procedure allows doctors to view the ovaries, uterus, and cervix. In this procedure, a technician inserts a probe into the vagina, or asks the patient to insert it herself. The probe emits sound waves that bounce off of inner structures. A computer then creates pictures of the inner structures.
Another diagnostic procedure is a hysteroscopy. This procedure shows endometrial tissue. In this procedure, a doctor inserts a fiber optic scope into the vagina and cervix. The doctor then pumps carbon dioxide gas through the scope. This helps to expand the uterus and makes the uterus easier to see. During this procedure, a doctor may also remove polyps or take a biopsy of endometrial tissue in order to rule out cancer.
How Is Postmenopausal Bleeding Treated?
Treatment depends on the cause of the
bleeding, on whether bleeding is heavy, or if additional symptoms are present. In
some cases, bleeding may require no treatment. In other situations, where
cancer has been ruled out, treatment may include the following:
CHIDAMBARAM HOSPITAL
चिदंबरम अस्पताल,
ചിദംബരം ഹോസ്പിറ്റൽ
சிதம்பரம் மருத்துவமனை,
திசையன்விளை.627657
- தீவிர சிகிச்சை மருத்தவம்
- பொது மருத்துவரம்
- பொது அறுவை சிகிச்சை
- குழந்தை அறுவை சிகிச்சை
- குழந்தை லேப்ராஸ்கோப்பி அறுவை சிகிச்சை
- Cesarean section
- Dilation and Curettage
- Vulvectomy
- Tubal Ligation
- Trachelectomy
- Selective Salpingography
- Myomectomy
- Hysterosalpingography
-Endometrial or Uterine Biopsy
- Colporrhaphy
-Vaginal hystectomy
- Appendicitis
- Lymphangioma
- Cleft lip and palate
- Esophageal atresia and tracheoesophageal fistula
- Hypertrophic pyloric stenosis
- Intestinal atresia
- Necrotizing enterocolitis
- Imperforate anus
- Undescended testes
- Omphalocele
- Gastroschisis
- Hernias
- Teratomas
- Amputation
- Appendectomy
- Cholecystectomy
- Colectomy
- Cystoscopy
- Hemorrhoidectomy
- Hysterectomy
- Hysteroscopy
- Inguinal Hernia
- Laparoscopy
- Mastectomy
- Thyroidectomy
- Tracheostomy
- Tonsillectomy and Adenoidectomy
- Umbilical Hernia
- லேப்ராஸ்கோப்பி அறுவை சிகிச்சை
- மகப்பேறு மருத்துவம்
- தாய்மை மருத்துவம்
- மகளிர் நோய் இயல்
- சர்க்கரை வியாதி மருத்தவம்
- X - ரே (X-Ray)
- ஈசிஜி (ECG)
- இரத்த ஆய்வு (Blood Investigation LAB)
- அல்ட்ராசவுண்ட் ஸ்கேன்
(ULTRASOUNDSCAN)
- பிசியோதெரபி பயிற்சி (PHYSIOTHERAPY)
- முக வாதம் தூண்டுதல் பயிற்சி (BELLS PALSY STIMULATION)
- துரக்கம்-முதுகு வலி நிவாரணத் பயிற்சி(TRACTION)
- மெழுகு ஓத்தLம் (WAX BATH)
- அகச்சிவப்பு கதிர் வலி நிவாரணத் ஓத்தLம்(INFRA RED Hot Fermentation)
Dr.M.I. கிறிஸ்டோபர் சாமுவேல் MBBS,MS.,FIAGES.,லேப்ராஸ்கோப்பி அறுவை சிகிச்சை நிபுணர்.,
DR.அலெக்ஸ் J கிறிஸ்டோபர் MBBS,MS,MCH.,(PAEDIATRIC SURGEON),லேப்ராஸ்கோப்பி அறுவை சிகிச்சை நிபுணர்.,
DR.அருண் G கிறிஸ்டோபர் MBBS,MD(Anaesthesia)மயக்க மருந்து நிபுணர்,Pain Management., Dip.Diab., சர்க்கரை வியாதி மருத்துவர்.,
PT.அந்தோணி றீகன் B.P.T
(பிசியோதெரபி நிபுணர்)MCSE,COPA,D.Pharm.,
- Estrogen creams: Your doctor may prescribe estrogen cream if your bleeding is due to thinning and atrophy of your vaginal tissues.
- Polyp removal: Polyp removal is a surgical procedure.
- Progestin: Progestin is a hormone replacement therapy. Your doctor may recommend it if your endometrial tissue is overgrown. Progestin can decrease the overgrowth of tissue and reduce bleeding.
- Hysterectomy: Bleeding that cannot be treated in less invasive ways may require a hysterectomy. During a hysterectomy, your doctor will remove the patient’s uterus. The procedure may be done laparoscopically or through conventional abdominal surgery.
चिदंबरम अस्पताल,
ചിദംബരം ഹോസ്പിറ്റൽ
சிதம்பரம் மருத்துவமனை,
திசையன்விளை.627657
- தீவிர சிகிச்சை மருத்தவம்
- பொது மருத்துவரம்
- பொது அறுவை சிகிச்சை
- குழந்தை அறுவை சிகிச்சை
- குழந்தை லேப்ராஸ்கோப்பி அறுவை சிகிச்சை
- Cesarean section
- Dilation and Curettage
- Vulvectomy
- Tubal Ligation
- Trachelectomy
- Selective Salpingography
- Myomectomy
- Hysterosalpingography
-Endometrial or Uterine Biopsy
- Colporrhaphy
-Vaginal hystectomy
- Appendicitis
- Lymphangioma
- Cleft lip and palate
- Esophageal atresia and tracheoesophageal fistula
- Hypertrophic pyloric stenosis
- Intestinal atresia
- Necrotizing enterocolitis
- Imperforate anus
- Undescended testes
- Omphalocele
- Gastroschisis
- Hernias
- Teratomas
- Amputation
- Appendectomy
- Cholecystectomy
- Colectomy
- Cystoscopy
- Hemorrhoidectomy
- Hysterectomy
- Hysteroscopy
- Inguinal Hernia
- Laparoscopy
- Mastectomy
- Thyroidectomy
- Tracheostomy
- Tonsillectomy and Adenoidectomy
- Umbilical Hernia
- லேப்ராஸ்கோப்பி அறுவை சிகிச்சை
- மகப்பேறு மருத்துவம்
- தாய்மை மருத்துவம்
- மகளிர் நோய் இயல்
- சர்க்கரை வியாதி மருத்தவம்
- X - ரே (X-Ray)
- ஈசிஜி (ECG)
- இரத்த ஆய்வு (Blood Investigation LAB)
- அல்ட்ராசவுண்ட் ஸ்கேன்
(ULTRASOUNDSCAN)
- பிசியோதெரபி பயிற்சி (PHYSIOTHERAPY)
- முக வாதம் தூண்டுதல் பயிற்சி (BELLS PALSY STIMULATION)
- துரக்கம்-முதுகு வலி நிவாரணத் பயிற்சி(TRACTION)
- மெழுகு ஓத்தLம் (WAX BATH)
- அகச்சிவப்பு கதிர் வலி நிவாரணத் ஓத்தLம்(INFRA RED Hot Fermentation)
Dr.M.I. கிறிஸ்டோபர் சாமுவேல் MBBS,MS.,FIAGES.,லேப்ராஸ்கோப்பி அறுவை சிகிச்சை நிபுணர்.,
DR.அலெக்ஸ் J கிறிஸ்டோபர் MBBS,MS,MCH.,(PAEDIATRIC SURGEON),லேப்ராஸ்கோப்பி அறுவை சிகிச்சை நிபுணர்.,
DR.அருண் G கிறிஸ்டோபர் MBBS,MD(Anaesthesia)மயக்க மருந்து நிபுணர்,Pain Management., Dip.Diab., சர்க்கரை வியாதி மருத்துவர்.,
PT.அந்தோணி றீகன் B.P.T
(பிசியோதெரபி நிபுணர்)MCSE,COPA,D.Pharm.,
