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Women's health after 40: an honest discussion

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A discussion of women's health issues over age 40 including fertility, infertility, family planning, contraception, PMS, menopause, hormones, urinary incontinence, and osteoporosis, and cancer for the Illuminate women's luncheon.

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Women's health after 40: an honest discussion

  1. 1. optimawomenshealthcare.com drjerath.com
  2. 2. General Information
  3. 3. Illuminate | Women’s Luncheon | March 9, 2012 Vandna Jerath, MD, FACOG FACOG - Board-Certified Private practice - 13 years Located at Parker Adventist Hospital Full-scope obstetrics & gynecology Enjoy education and community outreach Disclosure – no affiliations Healthcare social media pioneer & expert locally Educate, engage, and empower women Blog – drjerath.com
  4. 4. Illuminate | Women’s Luncheon | March 9, 2012 Optima Women’s Healthcare Services  Low and high risk obstetrics  Minimally invasive gynecologic surgery  Novasure and Thermachoice Endometrial ablation  Essure sterilization  Family planning and infertility  Menopause and hormone replacement therapy  Bladder retraining and incontinence surgery Women’s health resource/expert Female empowerment Spa-like setting, patient pampering Individualized, personalized, and compassionate care optimawomenshealthcare.com
  5. 5. Basic Overview
  6. 6. Illuminate | Women’s Luncheon | March 9, 2012 The Basics - Screening  Cervical Cancer Screening  Start age 21, regardless of sexual activity  Age 21-29 – every 2 years  Age 30-64 – every 1-3 years  Stop age 65 – if normal for 10 years  Breast Cancer Screening  Self-breast exams monthly  Clinical breast exam annually  Mammograms annually starting at age 40  Or 10 years before relative with breast cancer  Colon Cancer Screening  Fecal occult blood stool cards yearly starting age 50  Colonoscopy start at age 50 – every 10 years, every 5 years with risk factors  Start 10 years before relative with colon cancer and every 5 years  Medical Screening  Labs every 5 years – CBC, Chem 20, Lipid, TSH; glc every 3 years  Heart disease, thyroid disease, Anemia, liver disease, metabolic syndrome  BP, Skin, Eyes, Teeth – annually  Osteoporosis Screening  Bone Density (DEXA) starting age 65 – every 2 years  Or as indicated clinically
  7. 7. Illuminate | Women’s Luncheon | March 9, 2012 The Basics - Immunizations cdc.gov/mmwr/preview/mmwrhtml/mm6104a9.htm?s_cid=mm6104a9_w
  8. 8. Illuminate | Women’s Luncheon | March 9, 2012 The Basics - Immunizations cdc.gov/mmwr/preview/mmwrhtml/mm6104a9.htm?s_cid=mm6104a9_w
  9. 9. Infertility - Fertility
  10. 10. Illuminate | Women’s Luncheon | March 9, 2012 Fertility by Age Rba-online.com
  11. 11. Illuminate | Women’s Luncheon | March 9, 2012 Infertility  Common  Low success rate after 40  Increased risk of congenital anomalies or miscarriage  Healthy lifestyle is important  Male factor vs Female factor  Basic Testing  Day 3 Labs  Estrogen  Follicle Stimulating Hormone (FSH)  Anti-Mullerian Hormone (AMH)  Clomid Challenge Test  Pelvic Ultrasound  Hysterosalpingogram  Check for tubal patency  Semen Analysis  Laparoscopy  Anxiety/Depression  Mental Health Specialist
  12. 12. Illuminate | Women’s Luncheon | March 9, 2012 Reproductive Endocrine Infertility Referral to REI specialist Options Clomid Clomid-Intrauterine Insemination (IUI) In-vitro Fertilization (IVF) Gamete Intrafallopian Tube Transfer (GIFT) Egg Donor Surrogacy Adoption Genetic Testing
  13. 13. Illuminate | Women’s Luncheon | March 9, 2012 Family Planning Unintended pregnancy rates high over age 40 40-50% result in termination Contraception Options How to decide What is best over 40? Political Firestorm Preventative Coverage
  14. 14. Illuminate | Women’s Luncheon | March 9, 2012 Contraception – Short Term Barrier  Condoms  Diaphragm Hormonal  Oral Contraceptives “the pill”  Estrogen/Progesterone combination or Progesterone only  Daily  Patch  Weekly  Vaginal Ring  Monthly  Depo-Provera injection  Progesterone only  Every 3 months
  15. 15. Illuminate | Women’s Luncheon | March 9, 2012 Contraception – Long Term Reversible Implanon – implantable device  Every 3 years Intrauterine Device (IUD)  Paraguard  Non-hormonal  10 years  Benefits – no hormones, use until menopause  Risks – pain, cramping, discharge  Mirena  Progesterone hormone  5 years  Benefits - decrease heavy periods, stabilize fibroids  Risks – breakthrough bleeding, acne, weight gain
  16. 16. Illuminate | Women’s Luncheon | March 9, 2012 Contraception - Permanent Non-reversible Sterilization Traditional surgery  Tubal ligation In-office  ESSURE  Metal coils  In-office Adiana  Silicone plugs  No cutting  No general anesthesia  No hormones  Quick Recovery
  17. 17. Sexual Health
  18. 18. Illuminate | Women’s Luncheon | March 9, 2012 Sexually Transmitted Infections  STI/STD  Women over 40 getting divorced  Infidelity  New partners  Anxiety  Condoms  Regular testing  Treatment  Most common  HPV – Human Papilloma Virus  HSV - Herpes  GC/CT – Gonorrhea/Chlamydia  HPV vaccine  FDA approved  Girls ages 9-26, ideal age 11-12, boys too
  19. 19. Illuminate | Women’s Luncheon | March 9, 2012 Sexual Dysfunction  Marked distress and interpersonal difficulty  Anxiety and fear - difficulty discussing with healthcare provider  Desire Problems  Most common – 8% prevalence; peak women age 40-60  Decreased libido  Arousal Problems – 5%  Orgasmic Problems – 3.4-5.8%  Inability to orgasm  Sexual Pain Disorders  Dyspareunia – 8-22%; recurrent painful sex  Vaginismus – 1-6%; involuntary spasm of lower 1/3 vagina  Vestibulitis  Vulvodynia  Causes  Physiologic - Menopause, atrophic vaginitis, lack of estrogen, chronic disease  Psychological - Dysfunctional interpersonal relationship, depression, traumatic life event, history of abuse  Meds – SSRI, OCPs, steroids, anti-hypertensives, histamine blockers  Treatment  Physiologic – ERT, testosterone, lubricants  Physical – Pelvic floor therapy, masturbation, muscle relaxation, vaginal dilators, clitoral therapy  Therapy - Psychotherapy, couples counseling, communication exercises, decrease stress  Meds – Sildenafil (Viagra), Testosterone, ERT, antidepressants, adjust SSRI, change OCPs, analgesics, xylocaine  Date Night  Validate and reassure patient
  20. 20. Gyn Conditions
  21. 21. Illuminate | Women’s Luncheon | March 9, 2012 Clinical Conditions Premenstrual Syndrome – PMS/PMDD Heavy periods Perimenopause/Menopause Urinary Incontinence Pelvic Organ Prolapse Osteoporosis Cancers
  22. 22. Illuminate | Women’s Luncheon | March 9, 2012 Premenstrual Syndrome
  23. 23. Illuminate | Women’s Luncheon | March 9, 2012 Premenstrual Syndrome Cyclic occurrence of symptoms with physical, emotional, and/or psychological manifestations Occur 5-7 days before menses and subside within 4 days after onset Common age 25-45; may worsen in perimenopause Imbalance of neurotransmitters Premenstrual Syndrome (PMS) 75-85% women have one symptom 20-30% moderate to severe symptoms Premenstrual Dysphoric Disorder (PMDD) 3-5% have debilitating symptoms with impairment of lifestyle
  24. 24. Illuminate | Women’s Luncheon | March 9, 2012 PMS - Symptoms  Emotional/Mood  Crying  Angry outbursts  Mood Swings  Depressed  Irritable  Social Withdrawal  Poor Concentration  Physical  Breast tenderness  Bloating  Constipation  Weight gain  Swelling  Acne  Headache  Fatigue  Sleep disturbances  Appetite changes/food cravings  Keep mood and menstrual diary  Distinguish from medical conditions  Hypothyroidism, IBS, chronic fatigue, fibromyalgia, mood disorders, and migraines
  25. 25. Illuminate | Women’s Luncheon | March 9, 2012 PMS - Treatment  Lifestyle Modifications  Stress reduction  Exercise  Healthy diet  Reducecaffeine, alcohol, tobacco  Alternative/Natural Therapies  Vitamins – Calcium, B6, Magnesium, Vit E  Herbs – Black Cohosh, Gingko, St. John’s Wort, not FDA approved  Acupuncture  Psychotherapy  Light therapy  Medications  NSAIDs – Motrin, Aleve, Ponstel  OCPs – Yaz, Yasmin  Diuretics  Ovarian Suppression – Danacrine, Lupron  Antidepressants – SSRI – Prozac, Sarafem, Zoloft, Celexa, Effexor, Cymbalta
  26. 26. Illuminate | Women’s Luncheon | March 9, 2012 Heavy Periods  Menorrhagia – heavy periods, >80ml blood loss  Excessive, prolonged, heavy bleeding  1 in 5 women affected  In the U.S. 10 million women suffer  Takes physical, social, emotional, and psychological toll  70% of women suffer in silence  Causes  Anatomical  Endometrial Polyp  Fibroids  Hyperplasia  Cancer  Hormonal  Ovulatory  Anovulatory  Polycystic Ovarian Syndrome (PCOS)  Other
  27. 27. Illuminate | Women’s Luncheon | March 9, 2012 Heavy Periods - Treatment  Expectant Management  Oral Contraceptives (OCPs) – birth control pills  Provera withdrawal  Hormones  Dilation and Currettage (D&C)  Hysteroscopy  Endometrial Ablation  Novasure  Thermachoice  Hydrothermablation (HTA)  Her Option cryotherapy  Microwave endometrial ablation  Myomectomy  Uterine Artery Embolization  Hysterectomy  Laparoscopic – LAVH, TLH, DaVinci  Vaginal  Abdominal
  28. 28. Illuminate | Women’s Luncheon | March 9, 2012 Menopause
  29. 29. Illuminate | Women’s Luncheon | March 9, 2012 Menopause  Pre, Peri, and Post- Menopause  No period for 1 year  Average age in U.S. is 51; range age 45-55  Symptoms  Hot flashes – 75%  Vaginal dryness  Mood swings  Decreased libido  Decreased concentration  Insomnia  Hair loss  Weight gain  Metabolic Syndrome  Risk CVD & diabetes  Natural aging vs medical disorder
  30. 30. Illuminate | Women’s Luncheon | March 9, 2012 Menopause - Treatment  Hormone Replacement Therapy  Types  Estrogen  Estrogen/Progestin  Pills, patches, creams, vaginal suppositories,shots, pellets  Bioidentical hormones  Cyclic or daily  Benefits  Reduction and improvement of symptoms  Protect bones  Risks  Side Effects – bleeding, breast tenderness, bloating, abnormal uterine bleeding (AUB)  Anxiety  Stroke  Heart attack  Blood clot  Breast cancer  Women’s Health Initiative (WHI) results  Lowest dose for shortest duration that is effective  Currently fewer than 1 in 3 women take  Antidepressants  SSRI or SNRI  Gabapentin  Quality of life issue  Duration of Treatment
  31. 31. Illuminate | Women’s Luncheon | March 9, 2012 Menopause – Alternative Therapy  Holistic or natural approach – not an assurance of safety or efficacy  Used by more than 30% of women  Significant costs  Bioidentical Hormones  Not FDA approved  Herbal  Not FDA approved  High degree of variation  Hot flashes – soy, black cohosh, evening primrose, dong quai  Mood disturbances – St. John’s wort, valerian root  Sexual dysfunction – chasteberry, ginseng  AUB – wild yam  Soy  Phytoestrogen - isoflavones  Avoid in Breast CA?  Acupuncture  Lifestyle modification  Nutrition  Exercise  Yoga
  32. 32. Illuminate | Women’s Luncheon | March 9, 2012 Menopause – WHI Women’s Health Initiative Launched in 1991, 15+ year study Clinical trials and an observational study, 161,808 generally healthy postmenopausal women Age 50-79 Test the effects of postmenopausal hormone therapy, diet modification, calcium and vitamin D supplements on heart disease, fractures, and breast and colorectal cancer. Some follow-up studies ongoing nhlbi.nih.gov/whi/
  33. 33. Illuminate | Women’s Luncheon | March 9, 2012 Menopause – WHI Data  Compared with the placebo, estrogen plus progestin resulted in:  Increased risk of heart attack  Increased risk of stroke  Increased risk of blood clots  Increased risk of breast cancer  Reduced risk of colorectal cancer  Fewer fractures  Increased risk of dementia (study included only women 65 and older)  Stopped 2002  30/10,000  Compared with the placebo, estrogen alone resulted in:  No difference in risk for heart attack  Increased risk of stroke  Increased risk of blood clots  Uncertain effect for breast cancer  No difference in risk for colorectal cancer  Reduced risk of fracture  Stopped 2004  8-10/10,000
  34. 34. Illuminate | Women’s Luncheon | March 9, 2012 Urinary Incontinence Video Whoopi Goldberg - Poise Http://youtu.be/Ih7lI2IhJao
  35. 35. Illuminate | Women’s Luncheon | March 9, 2012 Urinary Incontinence  Urinary Incontinence  Involuntary leakage / loss of urine  Spontaneously  Response to a stimulus  Dribble  Overflow from full bladder  Urgency  Neurologic  More than 50% of women with symptoms do not discuss it with their doctor or seek help  Can lead to stigma, embarrassment, isolation, sexual dysfunction, depression, and decreased quality of life  Estimated 50 million women  Twice as common in women than men  Affects 10-70% of all women  > 50% of nursing home women  25% premenopausal  40% postmenopausal
  36. 36. Illuminate | Women’s Luncheon | March 9, 2012 Urinary Incontinence - Etiology Pelvic Floor Damage  Pregnancy and childbirth  1 delivery 2 x risk of POP  50% of incontinence  75% of prolapse  Stretching, compression, tearing of nerve, muscle, tissue  Episiotomy  Pudendal nerve damage  Weak evidence to support elective c-section  Can occur in nulliparous women  Diabetes  Back Surgery  Neurologic disease  Menopause
  37. 37. Illuminate | Women’s Luncheon | March 9, 2012 Urinary Incontinence - Types
  38. 38. Illuminate | Women’s Luncheon | March 9, 2012 Pelvic Organ Prolapse (POP) Vaginal support tissue  Weakening  Results in protrusions “Bump” or “Falling out”  Pelvic pressure Uterine Cystocele (bladder) Rectocele (rectum) Enterocele (bowel) Vaginal or paravaginal defect Coexist in 15 to 80 % of women 80% with severe POP have SUI due to urethral obstruction Corrective surgery for POP can result in SUI
  39. 39. Illuminate | Women’s Luncheon | March 9, 2012 Incontinence and POP - Treatment  Incontinence products  Lifestyle Modification  Kegel Exercises  Pelvic Floor Rehab and Physical Therapy  Biofeedback  Ultrasound  Electrical stimulation  Acupuncture  Pessary  Medications  No oral ERT/HRT  Periurethral injections  ISD – intrinsic sphincter (urethral) deficiency  Surgical  Older procedures  MMK, Pyrera, KKP, Raz  Burch Retropubic Urethropexy  Fascial sling  Mid-urethral Sling  TVT – tension free vaginal tape  TOT – trans obturator tape  Mesh – erosion, FDA safety concerns
  40. 40. Illuminate | Women’s Luncheon | March 9, 2012 Osteoporosis
  41. 41. Illuminate | Women’s Luncheon | March 9, 2012 Osteoporosis  Bones become thin and brittle due to more bone loss than bone formation  WHO – disorder characterized by  Deterioration of bone microarchitecture  Skeletal fragility  Increased risk of fracture  Osteopenia – low bone mass, not yet osteoporosis  Affects 200 million worldwide  55% of the population over 50 have a fracture and risk increases 3% for each year of advancing age  Greatest risk for postmenopausal women  2-5% bone loss per year  Underdiagnosed and undertreated  Peak bone mass by age of 30  Two types of bone  Cortical – hard outer shell, 75%  Trabecular – inner spongy structure, 25%, first to lose and first to respond to therapy  Fracturescan cause chronic pain, deformity, disability, depression, inability to walk, deconditioning, debilitation, long-term care, and death
  42. 42. Illuminate | Women’s Luncheon | March 9, 2012 Osteoporotic Brittle Bones
  43. 43. Illuminate | Women’s Luncheon | March 9, 2012 Osteoporosis – Risk Factors  History of prior fracture  Family history of osteoporosis  Caucasian race  Poor nutrition  Smoking  Low BMI  Estrogen deficiency  Long-term low calcium intake  Alcoholism  History of falls or fall hazards  Sedentary lifestyle  Certain diseases – eating disorders, IBS, Cushing’s, AIDS, Diabetes  Certain medication use – anticonvulsants, steroids, heparin, thyroxine, lithium, tamoxifen
  44. 44. Illuminate | Women’s Luncheon | March 9, 2012 Osteoporosis - Fractures
  45. 45. Illuminate | Women’s Luncheon | March 9, 2012 Osteoporosis - Treatment  Lifestyle modification  Decreasing fall risks  Hip protectors  Medication  Calcium – 1200-1500 mg/day  Vit D – 800 IU/day  Combo therapy 12% reduction fractures  HRT –  24-34% reduction fractures  Biphosphonates –  30-50% reduction fractures  Selective Estrogen Receptor Modulators  35-50% decrease in vertebral fractures  Calcitonin  Parathyroid Hormone  Other  Fluoride, Testosterone, Soy  Prolia
  46. 46. Cancer
  47. 47. Illuminate | Women’s Luncheon | March 9, 2012 Cancers - Breast  Breast  Family history – 1st degree (parent, sibling, child)  Lifetime risk 1 in 8  20-30% BRCA 1 & 2  70% no family h/o or known genetic risk  Breast cancer mortality decreasing since 1990  Earlier detection – 50-70% self-detected  Improved treatment  Gail Model – risk assessment tool; cancer.gov/bcrisktool  Detection  Self-breast exam vs awareness  Clinical breast exam  Mammography  MRI – greater than 20% lifetime risk  Thermography – Not Recommended, Not FDA approved
  48. 48. Illuminate | Women’s Luncheon | March 9, 2012 Breast Cancer Screening Guidelines Organization Mammo Clinical Exam SBE SBA ACOG American College of Ob/Gyn Age 40+ annually Age 20-39: 1-3 yrs; age40+: annually Consider for high-risk patients Recommended ACS American Cancer Society Age 40+ annually Age 20-39: 1-3 yrs; age40+: annually Optional for age 20+ Recommended NCCN National Comprehensive Cancer Network Age 40+ annually Age 20-39: 1-3 yrs; age40+: annually Recommended Recommended NCI National Cancer Institute Age 40+ 1-2yrs Recommended Not Recommended N/A USPSTF U.S. Preventative Services Task Force Age 50-74 biennially Insufficient Evidence Not Recommended N/A
  49. 49. Illuminate | Women’s Luncheon | March 9, 2012 Breast Cancer Risk Factors Relative Risk Factor Factor >4.0 Female Age 65+ Genetic mutation Personal h/o Breast CA 2+ 1st degree relatives High breast tissue density Biopsy – Atypical Hyperplasia 2.1-4.0 1 first degree relative High-does radiation High bone density (postmenopausal) 1.1-2.0 1st pregnancy > age 30 Onset of menses < age 12 Late menopause > age 55 No full-term pregnancies No h/o breastfeeding Recent use of oral contraceptives Recent & long-term use of HRT Obesity (postmenopausal) Other H/O uterine or ovarian CA Alcohol Tall height High socioeconomic status Ashkenazi Jewish heritage
  50. 50. Illuminate | Women’s Luncheon | March 9, 2012 Cancers - Colorectal  Facts  Diagnosed in more women than all gyn cancers combined  70,000 women in the U.S. yearly  24,000 women die yearly  3rd leading cause of CA death in women  Screening  Colonoscopy every 10 years starting age 50  Earlier or more frequent with family history  With polypectomy reduces incidence by 76-90%  Miss rate polyp – 6-12% and CA – 5%  Fecal occult blood or fecal immunochemical testing annually starting age 50  Flexible sigmoidoscopy  Double contrast barium enema  Virtual Colonoscopy
  51. 51. Illuminate | Women’s Luncheon | March 9, 2012 Colorectal Cancer Screening Test Interval Key Issues Colonoscopy Every 10 years Complete bowel prep Conscious sedation Need transportation Risks – perforation, bleeding, and death Flexible Sigmoidoscopy Every 5 years Complete or partial bowel prep No sedation, some discomfort Limited view of colon If positive colonoscopy Double Contrast Barium Enema Every 5 years Complete bowel prep If positive colonoscopy Risks – very low Expertise to interpret
  52. 52. Illuminate | Women’s Luncheon | March 9, 2012 Gyn Cancer - Uterine  Uterine  In U.S. – 40,000 cases, 7,310 deaths annually  Most common gyn CA – 8th most common CA death  Precursor – endometrial hyperplasia  Risk Factors  Obesity  Early menses  Late menopause  Nulliparity  Infertility  White race  Tamoxifen use  ERT  Diabetes  Symptoms – abnormal uterine bleeding (AUB)  Diagnosis – Endometrial biopsy or Dilation & Curettage (D&C)  Treatment – surgery, radiation, progestin (hyperplasia)
  53. 53. Illuminate | Women’s Luncheon | March 9, 2012 Gyn Cancer - Ovarian  Ovarian/Fallopian Tube  In U.S. – 22,430 cases, 15,280 deaths annually  Lifetime risk 1 in 70  2nd most common gyn CA  20% diagnosed Stage 1 with 90% 5 year survival rates  70% diagnosed advanced stage with 5 year survival rates 30-55%  Risk factors  Older age  Post-menopausal  Family h/o breast or ovarian cancer  BRCA 1 (60x) & BRCA 2 (30x)  Nonpolyposis colorectal CA or Lynch II (13x)  Nulliparity (never pregnant)  Infertility  Endometriosis  Prophylaxis  Oopherectomy  Combined oral contraceptives (OCPs)  Evaluation/Diagnosis – pelvic exam, ultrasound, doppler, CT scan, CA-125, OVA-1, surgery  Treatment – surgery, chemo
  54. 54. Illuminate | Women’s Luncheon | March 9, 2012 Gyn Cancer - Cervical Gynecological  Cervical  In U.S – 12,900 cases, 4,400 deaths annually  Decreased due to effective screening – 16% of gyn CA  Precursor – cervical dysplasia  Risk Factors  HPV  Early onset of sexually activity  History of STD/STI  Multiple sexual partners  Smoking  Symptoms – watery vaginal discharge, post-coital and intermittent spotting  Diagnosis – pap/colposcopy  Treatment – surgery, radiation, chemo
  55. 55. Resources
  56. 56. Illuminate | Women’s Luncheon | March 9, 2012 Helpful Links  General Women’s Health  Acog.org  Drjerath.com  Contraception  Plannedparenthood.org  Essure.com  Adiana.com  Paraguard.com  Mirena-us.com  Infertility  Resolve.org  Sexually Transmitted Infections/Diseases  cdc.gov/std  Heavy Periods  Novasure.com  Pelvichealthsolutions.com  Menopause  Menopause.org  Knowmenopause.com  nhlbi.nih.gov/whi/  Incontinence  AUGS.com  Mypelvichealth.com  NAFC.org  Osteoporosis  NOF.org  WHO.int/en  Heart Disease  Goredforwomen.org  Cancer  Foundationforwomenscancer.org  Cancer.org
  57. 57. Contact Information
  58. 58. Illuminate | Women’s Luncheon | March 9, 2012 Contact Information Optima Women’s Healthcare Vandna Jerath, MD Sierra Medical Office Building Parker Adventist Hospital Campus 9399 Crown Crest Blvd, Suite 450 Parker, CO 80138 303.805.1807 P | 303.595.5390 F optimawomenshealthcare.com drjerath.com Email - vjerathmd@optimawomenshealthcare.com
  59. 59. Illuminate | Women’s Luncheon | March 9, 2012 Social Media  Facebook  Facebook.com/drjerath  Facebook.com/optimawhc  Twitter  Twitter.com/drjerath  Twitter.com/optimawhc  LinkedIn  Linkedin.com/in/drjerath  Pinterest  Pinterest.com/drjerath  Pinterest.com/optimawhc  Google Plus  profiles.google.com/Vandna Jerath, M.D.  YouTube  Youtube.com/doctorjerath
  60. 60. Illuminate | Women’s Luncheon | March 9, 2012 Thank You Many thanks to Julie Groves for this wonderful Illuminate luncheon series Definitely a wonderful way for women to learn and grow For more info Grovesllc.com/illuminate

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