MoonDragon's ObGyn Information

VAGINAL HERNIAS (Cystocele, Enterocele, Rectocele, Urethrocele)

"For Informational Use Only" For more detailed information contact your health care provider about options that may be available for your specific situation.

BASIC INFORMATION

DESCRIPTION
A vaginal hernia is a weakness in the pelvic supporting structure that allows the pelvic organs to descend into the vagina.

Cystocele - is a descent of a portion of the bladder into the vagina.

Enterocele - is a protrusion of the intestine through the back of the vaginal wall.

Rectocele - is a protrusion of the rectum through the vaginal wall.

Urethrocele - is a sagging of the urethra. When associated with a cystocele, it is called a cystourethrocele.

MoonDragon's ObGyn Information: Uterine Prolapse Helpful information about uterine prolapse, vaginal vault as well as other types of prolapses/hernias discussed here.

FREQUENT SIGNS & SYMPTOMS

Sometimes, no symptoms are apparent. Stress incontinence (urine leakage that occurs with coughing, sneezing or lifting. Incomplete emptying of the bladder. Increased urinary frequency.

 Urinary incontinence. A sensation of vaginal fullness, pressure or "falling out". Pain during sexual intercourse. Increased susceptibility to urinary tract infection (UTI).

Constipation caused by a rectocele that interferes with muscle contraction

in the rectum.

CAUSE Weakness in the tissues of the vaginal wall.

RISK INCREASES WITH

Multiple pregnancies. Congenital malformations. Prolonged labors. Birth of a large baby. Lack of estrogen in menopause. Obesity. Chronic cough, such as in chronic bronchitis. Fenake smokers are at higher risk of developing a vaginal hernia. Constipation. Occupations involving much standing and lifting, such as working in the nursing profession. Large pelvic tumors.

PREVENTIVE MEASURES
Pelvic strengthening exercises (Kegel exercises) during and following pregnancy. Kegels should be done every day to be effective.

Pelvic Floor Exercises (Kegel Exercises)

Pelvic floor exercises help prevent prolapse by strengthening the muscles that support the pelvic organs. The exercises are easy and quick to do, but it is important to do them correctly, and many women benefit from guidance from a physiotherapist. Start by locating the muscles you need to exercise. There are a few different ways to do this: Place one or two fingers in your vagina and squeeze your muscles until you can feel your vagina tighten around your fingers. These are your pelvic muscles. Imagine you are trying to stop the flow of urine midstream. The muscles you tighten (contract) are your pelvic floor muscles.

The other way to identify the correct muscles is to imagine you are trying to stop yourself from passing gas. The muscles you squeeze to do this are your pelvic muscles.

Once you have identified the correct muscles you are ready to begin. The exercises can be done while lying down, sitting or standing, with your knees together or slightly apart. Set 1 - Slowly tighten your pelvic floor muscles and count to four, then let the muscles relax for a count of four. As your muscles get stronger gradually increase the count to 10. Try to repeat this 10 to 15 times. Check that you are not tightening the muscles in your legs, abdomen or buttocks, as it is important to use only your pelvic muscles. Remember to keep breathing. Set 2 - Now tighten and relax your pelvic muscles as quickly as you can, again 10 to 15 times. As a preventive measure, try to do the exercises two or three times a day. If you have a prolapse, you may be advised to increase the number of times you do the exercises, but do not overdo it. Excessive

exercising of the pelvic muscles can cause muscle fatigue and make the exercises less effective. You can do the exercises anywhere, anytime, but studies show that when women do them at home, they are more likely to do them correctly. Some women find it helps to set aside specific times to do the exercises, such as before getting out of bed in the morning and before going to sleep at night. If you think you are doing the exercises incorrectly or need help locating your pelvic floor muscles, a physiotherapist will be able to help you. Ask your health care provider for a referral. Estrogen therapy (hormone replacement therapy) after menopause. Avoidance or correction of obesity, chronic cough, straining and traumatic deliveries (which includes episiotomy, forceps and vacuum extractions). Plenty of daily fiber and fluids to prevent constipation.

EXPECTED OUTCOME
With small or moderate sized hernias, conservative therapy is usually sufficient to relieve symptoms. In more severe cases, surgery is curative.

POSSIBLE COMPLICATIONS
Recurrent urinary tract infections (UTIs). Uterine prolapse. Chronic constipation. Fecal impaction.

TREATMENT GENERAL MEASURES

 Diagnostic tests may include examination of vagina and pelvis, pelvic xray, urinalysis, cystoscopy and urethroscopy (both use a telescopic instrument with fiberoptic light for diagnosis. Treatment measures will depend on the severity of the symptoms, age of the woman and desire for future pregnancies. Treatment steps may include exercises, use of a pessary, medications and surgery. Other treatment steps may be recommended for obese patients, those with chronic cough or chronic constipation. Kegel exercises will help to tighten and strengthen the pelvic floor muscles and relieve symptoms. Use of a pessary (a device placed in the vagina to help support the uterus) may provide adequate temporary support. See Uterine Prolapse for information about pessaries and how they are used. Surgery is recommended for severe symptoms and is usually required for final resolution. There are different methods depending on the type of defect, any associated conditions, desire for future pregnancies, and age and general health of the woman. Rarely, an enterocele may require emergency procedures.

VAGINAL PESSARIES
A vaginal pessary is a small device, similar to a diaphragm or cervical cap, which is inserted into the vagina to hold the prolapsed organ(s) in place. Pessaries are made of latex or silicone and come in many different shapes and sizes. Ring pessaries are the most common, but may not be right for every woman. Pessaries are generally recommended as treatment for women who are waiting for surgery, women who are pregnant or want to have more children in the future, and women who are unable or choose not to have surgery. Pessaries need to be individually fitted and you may need to try a few different shapes and sizes before you find one that feels comfortable and stays in place. Your health care provider should have a variety of pessaries for you to try. During your fitting, your health care provider will insert the pessary and ask you to walk around, sit, squat, cough and strain to test if it's comfortable and remains in place. If you feel uncomfortable doing this in front of your health care provider, ask for a minute or two of privacy while you test the pessary's staying power. Tell the health care provider if it does not feel right, even if it is the second, third or fourth pessary you have tried. Once you have found the best fit, you will be asked to try it for a month or two

before returning for a follow-up appointment. If you have any difficulties or concerns during this period, contact your health care provider for an earlier appointment. If your pessary is not working or is causing problems, you can either try a different pessary or a different treatment option entirely. If the pessary is relieving your symptoms and you are not having difficulties with it, you will be scheduled for follow-up visits every 3 to 6 months. At your follow-ups the health care provider will remove the pessary, check whether it is causing any internal problems and whether your prolapse is getting worse, and will insert a new pessary. Follow-up visits are also a good opportunity for you to talk to your health care provider about any changes you have noticed or concerns you may have. If your pessary becomes less effective at relieving symptoms you may need to be fitted with a different type or size. This is common. If you have any difficulties with the pessary or if you have any unusual discharge, bleeding or pain, contact your health care provider immediately - do not wait for your next appointment. Questions to ask your health care provider about pessaries:

What type of pessary do you recommend and why? Will it interfere with my sex life? Will it relieve all of my symptoms? What are the pros and cons of this type of pessary? How often does it need to be removed? Can I remove it myself in between appointments? How long can I use a pessary for?

Inserting, removing and cleaning your pessary - Recommendations about how often a pessary should be removed range from once a week (for an overnight period) to once every three months or more. In the United States, women are advised to remove, clean and reinsert their own pessaries on a regular basis. In the United Kingdom (UK), standard practice is for pessaries to be inserted and removed by the health care provider every 3 to 6 months. If you would like to have the option of removing and inserting your own pessary between your scheduled follow-up visits, talk to your health care provider about it. She or he should be able to teach you how to insert the pessary yourself. It will probably take a bit of practice to get used to placing it correctly and while some women may be comfortable with this, others may find it too difficult or too much of a nuisance. Double pessaries for severe prolapse - Women with severe prolapse who do not want or are advised against surgery may be able to use two ring pessaries together. The double-ring technique is new but an initial study shows it relieves symptoms of severe prolapse, with the exception of rectocele and enterocele. Things to consider before deciding to use a pessary - Some pessaries may

interfere with sexual intercourse. A ring pessary may be left in place during sex - if it is comfortable for you - but other pessaries may literally get in the way. There is no published information about whether pessaries affect other sexual activity (such as oral sex) or a woman's ability to achieve orgasm. You (and your partner) may want to explore what is comfortable and pleasurable for you both. Some women experience a bad-smelling discharge when they use a pessary. If this happens, contact your health care provider, as the pessary may be causing an infection. If a pessary does not fit right or is left in place for too long it can irritate the vaginal walls and cause raw, open sores (ulcers). If this happens, the pessary should be removed and estrogen cream applied to the vagina until the sores have healed. Some people are allergic to latex or develop allergies after using latex products. Tell your health care provider if you think you have a latex allergy. If you have any difficulties with your pessary, or have any unusual bleeding or pain, contact your health care provider. TYPES OF PESSARIES A pessary is usually a small ring-shaped device that is inserted into the vagina to help maintain the uterus in a normal position) may be prescribed. This approach can have undesirable results, however. It can interfere with sexual intercourse and may also cause irritating discharge with an unpleasant odor and even infection. Here are a selection of pessaries that are available:

Gehrung Pessary (HCPCS Code: A4562): The Gehrung pessary has wires that allow it to be manually shaped for different anatomies. It is used to support both cystoceles and rectoceles as well as second to third degree uterine prolapse. It is available in nine sizes. Because of the shapable wires, the Gehrung pessary must be removed during x-rays, ultrasounds and MRIs. The Gehrung pessary's flexibility and adaptability makes it an excellent choice for support of significant cystocele and rectocele, especially in cases of associated procidentia. Folding Silicone Gehrung Sizes Available: GH50S #0, GH55S #1, GH60S #2, GH65S #3, GH70S #4, GH75S #5, GH80S #6, GH85S #7, GH90S #8

Ring Pessary (HCPCS Code: A4562): The ring pessary, available in nine sizes, both with and without support, is a very common pessary for a first to second degree prolapse. The Ring with Support can also be used on an accompanying cystocele. Insertion is eased with the folding action of the Ring. Not only does the EvaCare Ring pessary support a mild uterine prolapse and a cystocele, but it can also be helpful when used as a diagnostic device during urodynamic testing. The Ring can help to show what effect surgery may have as well as what type of surgery will be most beneficial for the patient. The pessary can act as a surgical facsimile predicting the need for anti-incontinence surgery. Flexible Silicone Rings (w/ support) Sizes Available: R2.00S #1, R2.25S #2, R2.50S #3, R2.75S #4, R3.00S #5, R3.25S #6, R3.50S #7, R3.75S #8, R4.00S #9

Flexible Silicone Rings (w/o support) Sizes Available: R2.00 #1, R2.25 #2, R2.50 #3, R2.75 #4, R3.00 #5, R3.25 #6, R3.50 #7, R3.75 #8, R4.00 #9

Oval Pessary (HCPCS Code: A4562): The oval pessary performs the same function as the Ring pessary but it is designed specifically to fit a narrow vaginal vault. It is available in nine sizes, all with support, and is used for a first to second degree prolapse as well as an accompanying cystocele. The Oval pessary works extremely well in women with a prior history of vaginal surgery, resulting in scarring and in some cases, palpable sutures from anterior repair or bladder suspension procedures. Where a round pessary is too wide, the Oval pessary fits well and is comfortable and effective. Flexible Silicone Oval Sizes Available: OV2.00S #1, OV2.25S #2, OV2.50S #3, OV2.75S #4, OV3.00S #5, OV3.25S #6, OV3.50S #7, OV3.75S #8, OV4.00S #9

Shaatz Pessary (HCPCS Code: A4562): The Shaatz pessary, available in nine sizes, is used for a first to second degree prolapse and an accompanying cystocele. The Shaatz pessary is versatile because it will help alleviate symptoms from uterine prolapse and cystocele. The convexity of its shape provides a snug fit. Additionally the design with the drainage ports allows easier removal by the patient who is dextrous enough to maintain her own pessary. Flexible Silicone Shaatz Sizes Available: SH1.50 #0, SH1.75 #1, SH2.00 #2, SH2.25 #3, SH2.50 #4, SH2.75 #5, SH3.00 #6, SH3.25 #7, SH3.50 #8

Gellhorn Pessary (HCPCS Code: A4562): The Gellhorn Pessary is used for a second to third degree prolapse, or procidentia. It has drainage holes in its base and comes in nine sizes. The knob of the Gellhorn easily folds over for insertion, and once in place rests on the posterior vaginal wall. The Gellhorn pessary is often a health care provider's first choice for women with more advanced pelvic organ prolapse. It is easy to insert and remove, and allows for self-care. This device is also less likely to be expelled. Flexible Silicone Gellhorn Sizes Available: G1.50D #0, G1.75D #1, G2.00D #2, G2.25D #3, G2.50D #4, G2.75D #5, G3.00D #6, G3.25D #7, G3.50D #8

Dish Pessary (HCPCS Code: A4562): The Incontinence Dish is used to relieve stress incontinence and minor degrees of prolapse. The Incontinence Dish comes with and without support. It is available in eight different sizes. The

Incontinence Dish is designed to provide bladder neck support as well as to support a cystocele. It is easy to fit, stays in place and some patients have actually leave the health care provider's office dry. Flexible Silicone Dish (w/ support) Sizes Available: DSH50S #1, DSH55S #2, DSH60S #3, DSH65S #4, DSH70S #5, DSH75S #6, DSH80S #7, DSH85S #8 Flexible Silicone Dish (w/o support) Sizes Available: DSH50 #0, DSH55 #1, DSH60 #2, DSH65 #3, DSH70 #4, DSH75 #5, DSH80 #6, DSH85 #7,

Hodge Pessary (HCPCS Code: A4562): The Hodge pessary has wires that allow it to be manually shaped for different anatomies. It can be used for a first to second degree prolapse, cystocele, stress incontinence and an incompetent cervix or uterine retroversion. It is available in ten sizes both with and without support. Because of the shapable wires, the Hodge pessary must be removed during x-rays, ultrasounds and MRIs. A Hodge pessary is often considered for a young, reproductive age woman with stress incontinence, who prefers conservative therapy. Folding Silicone Hodge (w/ support) Sizes Available: HD65S #0, HD70S #1, HD75S #2, HD80S #3, HD85S #4, HD90S #5, HD95S #6, HD100S #7, HD105S #8, HD110S #9 Folding Silicone Hodge (w/o support) Sizes Available: HD65 #0, HD70 #1, HD75 #2, HD80 #3, HD85 #4, HD90 #5, HD95 #6, HD100 #7, HD105 #8, HD110 #9

Mar-Land Pessary (HCPCS Code: A4562): The Mar-Land is used for stress incontinence and minor prolapse. It is available both with and without support in seven different sizes. The Mar-Land pessary offers excellent support for moderate to extensive cystocele, as well as providing support for the bladder neck in managing stress incontinence. Flexible Silicone Mar-Land (w/ support) Sizes Available: M2.25S #2, M2.50S #3, M2.75S #4, M3.00S #5, M3.25S #6, M3.50S #7, M3.75S #8 Flexible Silicone Mar-Land (w/o support) Sizes Available: M2.25 #2, M2.50 #3, M2.75 #4, M3.00 #5, M3.25 #6, M3.50 #7, M3.75 #8,

Donut Pessary (HCPCS Code: A4562): The donut pessary is designed for third degree prolapse as well as cystocele and rectocele. The soft donut can be compressed for insertion. It is available in seven sizes. Health care providers often use the Donut pessary on their patients with severe prolapse who are not immediately appropriate for surgery. It works well in a vaginal vault with little or no support, the type commonly found in older, post- menopausal women. Flexible Silicone Donut Sizes Available: D2.00 #0, D2.25 #1, D2.50 #2, D2.75 #3, D3.00 #4, D3.25 #5, D3.50 #6

Cube Pessary (HCPCS Code: A4562): The Cube pessary is designed for third

degree prolapse, including procidentia, as well as a cystocele and rectocele. The Cube pessary is available both with and without drainage holes and has a silicone tie to aid in removal. The Cube pessary is available in ten sizes. A Cube pessary may be used in women with either a very small or a large introitus due to its malleability. It is a very versatile pessary, but it should be used cautiously. Flexible Silicone Cube (w/ drain) Sizes Available: CU25D #0, CU29D #1, CU33D #2, CU37D #3, CU41D #4, CU45D #5, CU50D #6, CU56D #7, CU63D #8, CU70D #9, CU75D #10 Flexible Silicone Cube (w/o drain) Sizes Available: CU25 #0, CU29 #1, CU33 #2, CU37 #3, CU41 #4, CU45 #5, CU50 #6, CU56 #7, CU63 #8, CU70 #9, CU75 #10

Fitting Set: The Fitting Set is a set of six different sizes of ring pessaries that can be used to determine the proper size of pessary for each patient. The Set comes with a cross reference chart that translates ring size into the correct size of other EvaCare pessaries. The Fitting Set can be disinfected in three ways: autoclaved, boiled or cold sterilized. EvaCare Pessary Fitting Set CAT # FS 1000 QTY 1

PESSARY USAGE & FITTING GUIDELINES

TIPS ON FITTING A PESSARY Fitting a pessary is more of an art than a science. A little experience and using the following tips will make selecting and fitting the right pessary quite easy. Although each style of pessary is unique, some basic fitting guidelines apply to all styles. Some Guidelines: Cubes and Gehrungs usually are one size smaller than the selected ring. Gellhorns, Rings, Dishes, Donuts, and Shaatz pessaries are the size you measured with the finger technique. Some of the most common pessaries and their uses are:

PRIMARY REASON FOR USING A PESSARY

TYPES OF EVACARE PESSARIES TO CONSIDER Dish

Grade-Two Prolapse With Incontinence

Mar-Land Hodge (with support)

Second- To Third-Degree Prolapse

Shaatz Ring (with support)

Cystocele or Rectocele

Gehrung Hodge (with support)

Primary Uterine Prolapse Fourth-Degree Prolapse Without Any Vaginal Tone

Gellhorn Donut Cube

EvaCare Pessary Guide (800) 328-3863 Prolapse Coitus w/ 1-2nd 2-3rd Stress Retro Incompetent Pessary Degree Degree Cystocele Rectocele Incontinence Displacement Cervix In Ring Oval Shaatz Dish MarLand Gellhorn Donut Cube Gehrung Hodge X X X X X X X X X X X X X X X X X X X X
Distributed by Mentor |

YES YES YES X X X X X X X X X YES YES NO NO NO YES YES

Manufactured by Bioteque America, Inc.

MEDICATION
Antibiotics if infection is present. In postmenopausal women, estrogen or hormone replacement therapy may improve the tone and quality of the pelvic support muscles. Pain medication if required following surgery. Stool-softening laxatives and lubricating rectal suppositories may be necessary for constipation caused by rectocele.

ACTIVITY
Avoid occupations or activities that require heavy lifting or cause intraabdominal pressure.

DIET
If overweight, a weight loss diet is recommended and behavior modification techniques for weight control should be examined. http://www.moondragon.org/obgyn/disorders/vaghernias.html

Eating a high fiber diet and increasing fluid intake help relieve problems of constipation.

NUTRITIONAL RECOMMENDATIONS Nutrients Supplement Suggested Comments

Dosage
Essential Essential minerals needed for muscle tone and metabolism. Calcium, Magnesium & Vitamin D, 100% Natural, Nature's Way, 250 Caps, Just An Ounce Calcium & Magnesium, Almond Flavor Liquid, 16 fl. oz., Calcium Citrate / Malate Complex, Nature's Way, 500 mg, 250 Caps, Calcium Ionic Mineral Supplement, Fully Absorbable, 700 +/- ppm, 16 fl. oz., Liquid Calcium W/ConcenTrace, Orange Vanilla, Trace Minerals, 1000 mg, 32 fl. oz., Cal-Mag Pre-Chelated Calcium & Magnesium, Vital Earth, 240 Gelcaps

Calcium

1,500-2,000 mg daily.

And Magnesium

Important in Calcium uptake. Magnesium Ionic Mineral Supplement, Fully Absorbable, 350 +/- ppm, 16 fl. oz., 750-1,000 mg daily. Just An Ounce Calcium & Magnesium Liquid, Almond Flavor, 16 fl. oz., Calcium & Magnesium Mineral Complex, 100% Natural, Nature's Way, 500 mg / 250 mg, 250 Caps As directed on label. A good source of necessary minerals and other nutrients. Bone Strength, NOW Foods, 240 Caps, Calcium Complex Bone Formula, Nature's Way, 100 Caps, Bone, Flesh & Cartilage,

Bone Defense (From KAL)

Nature's Way, 100 Caps Improves muscle strength in the uterus. L-Carnitine, Stable Tartrate Form, NOW Foods, 500 mg, 60 Caps, L-Carnitine, Stable Tartrate Form, NOW Foods, 500 mg, 30 Caps, Acetyl L-Carnitine Powder, 500 mg twice daily, Vegetarian, NOW Foods, on an empty 635 mg, 3 oz., stomach. L-Carnitine, Liquid Double Strength, NOW Foods, 16 fl. oz., L-Carnitine, Stable Tartrate Form, NOW Foods, 250 mg, 30 Caps, L-Carnitine (Acetyl), NOW Foods, Pharmaceutical Grade, 500 mg, 100 Caps 500 mg twice daily, on an empty stomach. Take with water or juice. Do not take with milk. Take with 50 mg vitamin B-6 and 100 mg vitamin C for better absorption. As directed on label. Retards muscle degeneration. L-Glycine Powder, Free Form, Vegetarian, 1 lb., DMG Supplement, N,N, Dimethyl Glycine, NOW Foods, 125 mg, 100 Caps Promotes healing of muscle tissue. Amino 1000 Complete, NOW Foods, 120 Caps, Amino 1500, Chewable Blend of 20 Amino Acids, Predigested, NOW Foods, 150 Tabs, Spectrum Shake (Amino Acids), Original (Unsweetened vanilla), 1 lb, 4 oz., Spectrum Shake (Amino Acids), Vanilla, 1 lb. 3 oz., Branched Chain Amino Acids, Free Form, 120 Caps,

L-Carnitine

And L-Glycine

Plus Branched-Chain Amino Acid Complex

Branched Chain Amino Acid Powder, NOW Foods, 12 oz. A natural sulfur compound found in foods and present in body tissues. It is used by the body to build healthy new cells. MSM provides the flexible bond between the cells and provides support for tendons, ligaments, and muscles. Use a capsule form for easier absorption. Liquid Glucosamine Chondroitin MSM, Joint Support Supplement, Trace Minerals, 32 fl. oz., MSM With Glucosamine, Pure Lignisul, 500 mg/500 mg, 120 Caps, MSM Supplement, Pure Lignisul With Free 4 oz. Lotion, 1000 mg, 120 Caps, MSM Supplement, Pure Lignisul, 1000 mg, 240 Caps, MSM Liquid, Pure Lignisul, 16 fl. oz., MSM Powder, Pure Lignisul, 4 oz., MSM Supplement, Pure Lignisul, 500 mg, 250 Caps Important for calcium uptake, bone support, all bodily enzyme systems, and immune function. Use zinc gluconate lozenges or OptiZinc for best absorption. Zinc Ionic Mineral Supplement, Fully Absorbable, 100 +/- ppm, 16 fl. oz., Zinc Chelate, 100% Natural, Nature's Way, 30 mg, 100 Caps, Ionic Zinc, Trace Minerals,

Methylsulfonylmethane (MSM)

As directed on label. Do not exceed the recommended dose.

Zinc

50 mg daily. Do not exceed a total of 100 mg daily from all supplements.

50 mg, 2 fl. oz., Zinc Lozenges w/Echinacea & Vitamin C, Nature's Way, 23 mg, 60 Lozenges, Colloidal Silver & Zinc Lozenges, SilvaSolution, 90 Lozenges, Elderberry & Zinc, Vegetarian Formula, Now Foods, 90 Lozenges All nutrients work together for healing and tissue repair. Completia Diabetic MultiVitamin, Iron Free, Nature's Way, 60 Tabs, Damage Control Master Formula, High Potency Multi-Vitamin, 60 Packets, Prenatal Multi-Vitamin & Mineral, 100% Natural & Complete, Nature's Way, 180 Caps, Multi-Vitamin With Minerals, Hi-Tech, 90 Tabs, Super Multi-Vitamin & Mineral Liquid, Pure Vital Earth, 98% Bio-Available For Absorption, 32 fl. oz., Multi-Vitamin & Mineral without Iron, Complete Vitamin Supplement, Nature's Way, 100 Caps, Multi Vitamin & Mineral with Iron, Nature's Way, 100 Caps Needed for proper immune function. Build resistance to infection. Beta Carotene (Natural Dunaliella Salina), Nature's Way, 100% Natural, 25,000 IU, 100 Softgels, Multi-Carotene Antioxidant, Nature's Way, 60 Softgels Important for keeping

Multi-Vitamin & Mineral Complex and vitamin B complex

As directed on label.

Plus Natural Carotenoid Complex Or Natural Beta-Carotene

Carotenoid Complex: As directed on label. Beta Carotene: 15,000 IU daily.

Vitamin C With

3,000-5,000 mg

Bioflavonoids

daily, in divided doses.

bladder infections under control and to enhance immune function. Use an esterified from for best absorption. Vitamin C Liquid w/ Rose Hips & Bioflavonoids, Kosher, Natural Citrus Flavor, Dynamic Health, 1000 mg, 16 fl. oz., Ester C With Bioflavonoids, Nature's Way, 1000 mg, 90 Tabs, Vitamin C 1000 With Bioflavonoids, Nature's Way, 100% Natural, 1000 mg, 250 VCaps, The Right C, Nature's Way, 1000 mg, 120 Tabs, Vitamin C 1000 w/ Rosehips, 100% Natural, 1000 mg, 250 Caps, Electro C Powder, Vitamin C Supplement, Cherry Flavor, 1250 mg, 8 oz.