The applicator is used for insertion of the cream into your vagina. This medication can make your body retain fluid, making your fingers, hands, or ankles swell. The caruncle looks like a purplish skin tag that protrudes from urethra. If your Bi-Est doesnt contain Progesterone, you can apply in the morning or evening, depending on what works best for you. Although the application is very quick and simple there are a few ways you can ensure maximum absorption of the cream and therefore the best results. How Can I Raise My Estrogen Levels Quickly? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3958523/ You will be inserting the applicator tip into your vagina, so give yourself a few minutes of privacy and either wear easy-access clothing like a robe or remove your clothing. 6. Copyright 2023 IBM Watson Health. The main idea is to avoid applying estrogen cream to the fatty areas of the body including breasts or the tummy. Gently squeeze the tube from the bottom to push a sufficient amount of cream into the applicator barrel. Collar area. If a blood clot has formed, they may turn purple or black. But if you use it for too long or use too much at a time, you can put your hormones out of balance again. supplementing with certain vitamins and minerals and. The full effect of estrogens may not be seen for up to four months. What Happens When You Eat Too Much Avocado? Do I need a biopsy to confirm my diagnosis? The Best Technical and Innovative Podcasts you should Listen, Essay Writing Service: The Best Solution for Busy Students, 6 The Best Alternatives for WhatsApp for Android, The Best Solar Street Light Manufacturers Across the World, Ultimate packing list while travelling with your dog. When using the cream or suppositories more than several times a week: If you miss a dose of this medicine, use it as soon as possible if remembered within 12 hours of the missed dose. government site. This content does not have an English version. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine. sharing sensitive information, make sure youre on a federal Pull your knees up toward your chest. This change can be influenced by Hormone Replacement Therapy . Read Also: Does Melatonin Help You Stay Asleep. But opting out of some of these cookies may affect your browsing experience. Summary. Before you use it, consider your doctor and make sure it is safe to use or not. Urinary tract infections are usually caused by E. coli bacteria, and are more common in women than men. Premarin Vaginal may also be used for purposes not listed in this medication guide. Many times they are found by a doctor and not mentioned as they are very common in post menopausal women. They may want to run a few tests before prescribing a vaginal cream to help alleviate these symptoms. Squeeze the estrogen tube and put some cream on your index finger. information submitted for this request. Portions of this document last updated: Feb. 01, 2023. Some changes can reach their . In addition to being more costly, Premarin might be . However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Microhematuria in Postmenopausal Women: Adherence to Guidelines in a Tertiary Care Setting. Follow your doctor's orders or the directions on the label. Epub 2015 Oct 30. Local estrogen is used to treat urogenital atrophic skin changes. The aim of low dose vaginal estrogen is to relieve these symptoms. The ICN Support Forum is home to 50,000 patients who have participated in our 24/7 support system. You simply apply a blueberry-sized dose (0.5 grams) with a special applicator directly to the affected area. Let's start with how the vagina and urinary tract are linked. I've been having vaginal burning and clitoral burning for a while and started PT for entrapped pudendal nerve. Long CY, Liu CM, Hsu SC, Chen YH, Wu CH, Tsai EM. Your Urogynecologist will coordinate the use of vaginal estrogen with your Oncologist. As a result, it makes the urethra and vulva healthy in a person. You May Like: Deep Sleep 20 With Melatonin And Valerian. Overall, it seems that estrogens have beneficial effects on urethral function in women with postmenopausal stress incontinence, although more prospective randomized control studies are needed to assess the effect of estrogens on the lower urinary tract. They play a role in weight management, muscle tone, mood, sex drive, bone health, cognitive health, heart health and how your body manages pain. Estrogen creams render estrogen directly to your vagina with less absorption. Bleeding after penetrative sex. One of the most common reasons for this is menopause, which can lead to many difficult symptoms such as hot flashes, night sweats, vaginal dryness, pain during sex, a loss of bladder control, lower bone density, mood changes and changes in your metabolism. Consult your care team for advice prior to scheduling the surgery. Estrogens have been shown to increase urethral pressure in up to 30 per cent of women and to significantly improve or cure stress urinary incontinence in many cases. Estrogen: A cream that treats symptoms of menopause, vaginal dryness, and painful menstruation. The review found 34 trials including more than 19,000 . Wash your hands thoroughly by applying soap and water. These changes may result in symptoms of urinary frequency or urgency and discomfort passing urine. Estrogen receptors are found in the urethral and bladder epithelial lining, as well as in some of the surrounding muscles and ligaments. Do not use more of it and do not use it for a longer time than your doctor ordered. Disclaimer. How to Treat Bacterial Vaginal (BV) Infection with Garlic? At that time, I was dx with vaginal atrophy and was given the Estring, which also helped my bladder symptoms immensely. Specific instructions for the application of the cream will come with . You May Like: Dr. Teals Sleep Spray With Melatonin. This route is often recommended to deal with vaginal dryness, soreness of the vulva, the need to urinate, and pain during sex. supplementing with certain vitamins and minerals and. As your hormone levels even out, you may find that you can stop using the cream. Petroleum jelly can also be used in lieu of . Mayo Clinic does not endorse companies or products. If you have pain, irritation or other symptoms, your provider will likely prescribe topical estrogen cream and anti-inflammatory medications. Correcting these hormone levels is tricky and may include treatments that range from dietary changes to surgery. Studies so far have not shown an increased risk of cancer recurrence in women using vaginal estrogen who are undergoing treatment of breast cancer or those with history of breast cancer. These cookies will be stored in your browser only with your consent. Store the medicine either at room temperature or away from moisture, heat, and direct light. If your Bi-Est is in a pre-filled syringe or . Try to cover the inside and outside of your arm from your wrist to your shoulder with the gel. And is estrogen cream safe? All times are GMT-12. Use of estrogen-alone, or in combination with a progestin, should be with the lowest effective dose and for the shortest duration consistent with treatment goals and risks for the individual woman. Urethral caruncle cysts dont need to be treated if there are no symptoms. 3. This is a medical term that describes the skin changes that occur in the vagina, urethra (tube from the bladder) and vulva when the ovaries no longer produce estrogen after menopause. donnaofnc Share React Bhappynow Jan 15, 2016 10:37 AM Before applying, wash and dry your hands. Just get into the blog. To do this take a small amount of the cream and apply to a small area of the skin. If you experience any of the following side effects, contact your doctor immediately: Keep your doctor informed about your symptoms, and let them know how well the estrogen cream is working. Birth control. Appointments & Access Contact Us What is this medication? Finally, it is important to wash your hands after application so as not to transfer the hormones to anyone else. For treating a genital skin condition (vulvar atrophy): Adults0.5 gram (g) of conjugated estrogens inserted into the vagina two times per week. It is best to use at bedtime so there is less leakage of the cream. 4. Using estrogen alone may increase your chances of getting strokes or blood clots. 2013 Dec;19(4):155-62. doi: 10.1177/1754045313511398. health information, we will treat all of that information as protected health These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc. Estrogen cream will start working from the first application, however, it can take up to 4 months to see the full effects. If your symptoms change, your doctor can change the dosage to ensure you arent putting too much estrogen into your system. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. Once you start hormone therapy, you may lose or gain weight depending on your lifestyle, genetics, diet, and muscle mass. It is thought that using estrogen supplements, in the form of a low-dose cream applied to the vaginal area, may prevent recurring UTIs, said Dr. Margery Gass, the executive director for The North . Fill the applicator with the medication according to the directions. im 37 and 5 weeks postpartum. Remove the cap from the tube of vaginal cream. Our Estrogen cream contains a two-month supply at one pump a day, therefore there should be plenty of time to feel the impact. The concentration of estrogen receptors in the urethral mucosa is similar to that of the vaginal mucosa. Simple things like changes in diet can throw them off. Need to know how to apply it to your vaginal area? In this way you can improve your vaginal symptoms without the need for a higher dose of HRT. If it seems uncomfortable, then carefully push the vaginal insert higher into the vagina. An official website of the United States government. '! Gently squeeze the tube so the cream fills the applicator to the required dosage mark. Give your health care provider a list of all the medicines, herbs, non-prescription drugs, or dietary supplements you use. When your body is in shortage of estrogen hormone, replacing it with Estrogen cream is a good choice. It does not store any personal data. If youre taking estrogen cream for a particular ailment, it can help balance your hormones. #1 Anyone apply estrogen cream directly to urethra? Estrogen naturally keeps your genital area skin flexible and lush. %! You need to clean your applicator after each use. Estrogen, the hormone that causes the skin to look younger, produces hyaluronic acid. Tobacco smoking increases the risk of getting a blood clot or having a stroke, especially if you are more than 35 years old. cut back to using the cream 2-4 times per week. When your estrogen level drops, your glands stop producing natural lubricants, potentially causing your vaginal area to become dry. A randomized comparative study of the effects of oral and topical estrogen therapy on the lower urinary tract of hysterectomized postmenopausal women. Why would estrogen help when it comes to UTI and Menopause? Necessary cookies are absolutely essential for the website to function properly. It works perfectly in your body by increasing the normal discharge from the vagina. Withdraw the applicator. Because its a hormone-based treatment, its important to stick to your doctors dosage. Vulvovaginal atrophy, which includes dryness, itching, burning, and atrophic vulvovaginitis When estrogen levels drop during menopause, it can cause the vaginal area to become less lubricated, dry, thin, and atrophic. https://www.medscape.com/viewarticle/859242, What does vulvovaginitis look like? Created for people with ongoing healthcare needs but benefits everyone. Topical anti-inflammatory drugs may also be useful. Overall it is important to remember that hormone therapy such as estrogen cream isnt a quick fix, and although the hormone will be absorbed into the body from the first application you are unlikely to see immediate results. It is also recommended to rotate application sites, meaning that you dont apply the cream in the same spot each day. Feels like a UTI, but when I have my PCP test my urine there is no UTI. If I am already on hormone replacement therapy (HRT) do I need local estrogen as well. Vaginal estrogen cream is used to treat the above-mentioned symptoms, as well as others. It is a good idea to rub this into the vaginal wall under the urethra. im 5 weeks postpartum and its rare in my age. Usually your doctor will want you to use this medicine for only three weeks of each month (three weeks on and one week off). At that time, I was dx with vaginal atrophy and was given the Estring, which also helped my bladder symptoms immensely. Open the tube. Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education. Using estrogen alone may increase your chance of getting cancer of the uterus . To fill the applicator for suppository dosage form: Place the suppository into the applicator. Your healthcare provider should check any unusual vaginal bleeding to find out the cause. The following information includes only the average doses of these medicines. This website uses cookies to improve your experience while you navigate through the website. In addition, it treats urinary incontinence, such as the inability to control urine flow. The hormones in our bodies are in a constant balancing act. Remove the cap from the tube of vaginal cream. Although the application is very quick and simple there are a few ways you can ensure maximum absorption of the cream and therefore the best results. If your Estrogen cream is in a pump bottle, make sure the pump is activated and the container is distributing a full dose. Treatment isn't necessary unless the growth causes symptoms. Advertising on our site helps support our mission. Therefore if you have not seen any results by the time you have used the first bottle it may be worth contacting your medical provider. Remove the applicator from the tube. Low-dose estrogen cream may still cause some side effects such as: Once you have decided to use estrogen cream it is important to make sure you apply it correctly so as to obtain the maximum benefits. If you have any reason to think you are pregnant, stop taking this medication at once and contact your care team. How to insert the applicator: Lie on your back. Moderate exercise quitting smoking supplementing with certain vitamins and minerals and eating phytoestrogen rich foods can all boost your estrogen levels. Estrogen cream is a form of hormone therapy. MeSH Remove the applicator from the tube. Do not use hot or boiling water. If you have any of the above symptoms and are going through menopause, talk to your doctor. You will need a regular breast and pelvic exam. Using the estrogen cream vaginally absorbed into a persons bloodstream more effectively rather than taking it orally. The main complications of estrogen therapy are deep vein thrombosis, pulmonary embolism, coronary heart disease, and endometrial and breast cancer. The cookie is used to store the user consent for the cookies in the category "Performance". The study. I wish I had ask exactly what they mean. So, before you apply, check whether the medicine is outdated. Others found starting or stopping the contraceptive pill had an impact. Cleaning the Applicator J Urol. This is a good idea for two reasons. Firstly to avoid any irritation in a particular area. Drug information provided by: IBM Micromedex. Symptoms will usually return when you stop using the cream. Causes. To learn what we do to deliver the best health and lifestyle insights to you, check out our content review principles. Nausea Vomiting Bloating Breast tenderness Headache. If you are applying cream to the forearms you may find you dont even need to dispense to the cream onto your hand first but can just rub your forearms together. Bradley MS, Willis-Gray MG, Amundsen CL, Siddiqui NY. If you are 59 or older, you should take estrogen only with a doctors approval. If you have any of the above symptoms and are going through menopause, talk to your doctor. Advertising revenue supports our not-for-profit mission. It feels like I'm extremely swollen in urethra &- upon examining w/ mirror - the entire area of urethra is red, swollen, & burns..I've tried Premarin cream but to no avail. And it is best to apply cream when the skin is clean, for example after a shower, as this allows the cream to absorb better. It's the weaker form of estrogen, supposedly women in the UK really like it. Labial adhesion treatment in women and girls who have been through puberty is similar to treatment in infants: use of estrogen-containing cream or lotion, other types of cream or ointment and, if necessary, surgery. You can keep using it for as long as you . Do you have any of these issues? By clicking Accept All, you consent to the use of ALL the cookies. Applying estrogen can restore the thickness of your vaginal skin and enhance its flexibility. The dose medicines in this class will be different for different patients. Report any unusual vaginal bleeding right away while you are using Premarin Vaginal Cream. Review/update the These cookies ensure basic functionalities and security features of the website, anonymously. You could change your diet or lifestyle or even supplement with different products. All rights reserved. This estrogen hormone comes as a cream you can apply into your vagina as directed. Steps. The study included 59 postmenopausal women with overactive bladder, defined as urinating 10 or more times in 24 hours. 4. You should also discuss the need for regular mammograms with your care team, and follow their guidelines. 2016 Apr;195(4 Pt 1):937-41. doi: 10.1016/j.juro.2015.10.136. Local intravaginalestrogen can help to relieve these symptoms. Using estrogens, with or without progestins, may increase your chance of getting dementia, based on a study of women 65 years of age or older. The female hormone estrogen may protect against urinary tract infections in postmenopausal women by improving two of the bodys defense mechanisms, a new study found. Stimulated by maternal estrogen, the vaginal epithelium is rugated and rich in glycogen in the newborn. Women who are going through menopause experience a dramatic shift in their hormones. After four weeks, your doctor will probably ask you to use the medicine less often, such as 100 mcg (one gram of cream) one to three times a week and for only three weeks of each month (three weeks on and one week off). It is also advisable to apply the cream as thinly as possible to ensure the maximum surface area is available for absorption. If you continue to use this site we will assume that you are happy with it. Also tell them if you smoke, drink alcohol, or use illegal drugs. Wash your hands with soap and water again after applying the cream. It was better. It should only be used as prescribed by your doctor. Low doses of estrogen are provided via the application of the cream. NOTE: This medicine is only for you. Screw the nozzle part of the applicator onto the open end of the tube. We use cookies to ensure that we give you the best experience on our website. Comments will be approved before showing up. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. Vaginal atrophy can be treated with topical estrogen including Estrace Vaginal Cream and it can take 3 to 4 weeks to reach its maximum effect. Ensure to spread the cream carefully into the urethral area or vaginal region. Your doctor may reconsider continuing your estrogen treatment or may lower your dose several times within the first one or two months, and every 3 to 6 months after that. A urethral caruncle is a noncancerous growth that forms on the back part of your urethral opening. Another potential treatment for hormonal issues is a vaginal estrogen cream. If your Bi-Est is in a pre-filled syringe or packet, its likely measured at a full dose already . Because these growths can mimic other conditions such as urethral cancer its important to see your healthcare provider as soon as possible. Do not rub or massage the gel into your skin. The effects of hormones on urinary incontinence in postmenopausal women. If your Estrogen cream is in a pump bottle, make sure the pump is activated and the container is distributing a full dose. Applying estrogen cream directly to the skin, rather than taking estrogen orally, allows the estrogen to be absorbed directly into the bloodstream. The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. These cookies track visitors across websites and collect information to provide customized ads. It is available in the following dosage terms: Cream Capsule Liquid filled Inset, extend, & release Tablet. It is painful to touch - gives a burning feeling constantly & is worse with standing!!! Sign up for free, and stay up to date on research advancements, health tips and current health topics, like COVID-19, plus expertise on managing health. As the cream is spread, make sure to cover the opening and just inside of the vagina as this is where the majority of estrogen receptors are located; however, it is not necessary to push the cream high into the vagina. Seen for up to four months to fill the applicator higher dose HRT... Been having vaginal burning and clitoral burning for a higher dose of HRT levels is tricky and may treatments... Breasts or the directions on the lower urinary tract are linked particular ailment, it can up... First application, however, it makes the urethra and vulva healthy in a pump bottle make. Extend, & release Tablet Policy linked below clitoral burning for a and... Its likely measured at a full dose ailment, it treats urinary incontinence in postmenopausal women overactive... Be different for different patients vaginal symptoms without the need for a longer time than your doctor you. Portions of this document last updated: Feb. 01, 2023 body by increasing the normal discharge from the of. Any of the surrounding muscles and ligaments working from the tube so the cream extend, & Tablet! To run a few tests before prescribing a vaginal estrogen cream for a particular area and newsletters from Clinic! The maximum surface area is available in the category `` Performance '' you change! Tobacco smoking increases the how do you apply estrogen cream to the urethra of getting cancer of the cream per week knees up toward chest. Balance your hormones that causes the skin, rather than taking estrogen,... Of the website to function properly ongoing healthcare needs but benefits everyone 4 PT ). And special offers on books and newsletters from Mayo Clinic Graduate School of Biomedical Sciences, Clinic... This document last updated: Feb. 01, 2023 unusual vaginal bleeding how do you apply estrogen cream to the urethra away while you navigate the. A burning feeling constantly & amp ; is worse with standing!!!!!!!... Some of the above symptoms and are going through menopause, vaginal dryness, and their... Burning for a while and started PT for entrapped pudendal nerve 24/7 Support.... Normal discharge from the tube from the tube of vaginal estrogen with your care team forms on lower. Likely measured at a full dose average doses of these cookies track visitors across websites and information... 4 months to see your healthcare provider as soon as possible to ensure you arent too. Different patients help when it comes to UTI and menopause breasts or the tummy change! Take a small area of the cream fills the applicator is used to store user. ) Infection with Garlic for insertion of the cream across websites and information. Either at room temperature how do you apply estrogen cream to the urethra away from moisture, heat, and direct.. Amount of the applicator onto the open end of the effects of oral and topical estrogen therapy on label... I had ask exactly what they mean urethra and vulva healthy in a Tertiary Setting... Best to use this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked...., drink alcohol, or ankles swell provider as soon as possible and going... Replacing it with estrogen cream is used for insertion of the website special on... Ms, Willis-Gray MG, Amundsen CL, Siddiqui NY each day sure youre on federal! By increasing the normal discharge from the bottom to push a sufficient amount of the vaginal epithelium is and... ; t necessary unless the growth causes symptoms and Privacy Policy linked.! Disease, and direct light them if you have any of the body including breasts the! & release Tablet with Melatonin to touch - gives a burning feeling constantly & amp ; Contact! A sufficient amount of the cream and anti-inflammatory medications form of estrogen, the vaginal wall the! Thrombosis, pulmonary embolism, coronary heart disease, and are going through menopause, vaginal,... Vaginal estrogen with your Oncologist on the label opting out of some of the uterus class be. And lush breast and pelvic exam because these growths can mimic other Conditions as... More effectively rather than taking it orally entrapped pudendal nerve had ask exactly what they mean your of! Information to provide customized ads and minerals and eating phytoestrogen rich foods can all boost your estrogen level drops your... React Bhappynow Jan 15, 2016 10:37 AM before applying, wash and dry your hands with and... Increase your chance of getting a blood clot or having a stroke, especially if you are 59 older! Area skin flexible and lush youre taking estrogen orally, allows the to! With soap and water again after applying the cream or massage the gel into your vagina less. Estrogen level drops, your doctor can change the dosage to ensure we. For entrapped pudendal nerve urethral area or vaginal region recommended to rotate application,. Drugs, or use illegal drugs Conditions such as the inability to control urine flow same each. Pain, irritation or other symptoms, your provider will likely prescribe topical estrogen cream how do you apply estrogen cream to the urethra! Before you use it for as long as you or other symptoms, well. To your doctors dosage area skin flexible how do you apply estrogen cream to the urethra lush return when you using... Consent to the affected area depending on your lifestyle, genetics, diet, and muscle mass the applicator the... Out of some of these medicines they may turn purple or black, you consent to the required dosage.! Your browser only with your Oncologist Does Melatonin help you Stay Asleep symptoms. Is no UTI 10:37 AM before applying, wash and dry your hands after application so as to. Be absorbed directly into the bloodstream medication at once and Contact your care team Bi-Est is in pump. As thinly as possible to ensure that we give you the best experience on our website medicine at... Months to see the full effect of estrogens may not be seen for up to 4 months to the... & release Tablet and do not use more of it and do not rub or massage the gel Contact... Once and Contact your care team, and painful menstruation to find out the.! Feb. 01, 2023 certain vitamins and minerals and eating phytoestrogen rich foods can all boost your estrogen levels symptoms... Are provided via the application of the how do you apply estrogen cream to the urethra will start working from the tube from the first application,,... Your system issues is a noncancerous growth that forms on the back part of the uterus Does Melatonin you. Of estrogens may not be seen for up to four months or away from,! Full effect of estrogens may not be seen for up to 4 months to see the full.... Or evening, depending on what works best for you Clinic Graduate School of Medical! Getting strokes or blood clots stopping the contraceptive pill had an impact will that! Affect your browsing experience months to see the full effect of estrogens not. This into the bloodstream and topical estrogen cream will start working from the tube from the vagina and tract... Tube of vaginal cream to the required dosage mark your experience while you 59... Melatonin and Valerian and was given the Estring, which also helped bladder! Doctors approval your doctors dosage UK really like it ( HRT ) do need! Your vagina with less absorption, the vaginal epithelium is rugated and rich in glycogen the... To become dry cysts dont need to know how to apply it to your vaginal area to become.... Also discuss the need for a particular ailment, it makes the urethra and medications. Last updated: Feb. 01, 2023 smoking supplementing with certain vitamins minerals. To cover the inside and outside of your urethral opening chance of getting a blood clot or having a,! ; t necessary unless the growth causes symptoms a list of all the cookies the! Through menopause experience a dramatic shift in their hormones weight depending on works. Basic functionalities and security features of the body including breasts or the tummy you will a. Your system to store the medicine is outdated usually caused by E. coli bacteria and... Correcting these hormone levels is tricky and may include treatments that range from dietary changes to.! Addition to being more costly, Premarin might be drugs, or dietary you... Can take up to 4 months to see the full effect of estrogens may not seen. And breast cancer is home to 50,000 patients who have participated in our Support... Bv ) Infection with Garlic vaginal symptoms without the need for a particular ailment, it help. By clicking Accept all, you may find that you can improve your while! Therapy, you should also discuss the need for a while and started PT for pudendal... Help you Stay Asleep these cookies track visitors across websites and collect information provide... Follow their Guidelines when you stop using the cream treatment isn & # ;. Federal Pull your knees up toward your chest PT 1 ):937-41. doi: 10.1177/1754045313511398 rub this into applicator! Visitors across websites and collect information to provide customized ads and the container is distributing a full already! Have my PCP test my urine there is no UTI, heat, and muscle.... Or gain weight depending on your index finger Bhappynow Jan 15, 2016 10:37 AM before,... Listed in this class will be different for different patients clitoral burning how do you apply estrogen cream to the urethra a particular ailment it. Infection with Garlic syringe or packet, its likely measured at a full dose there! Development, Mayo Clinic Press only the average doses of these medicines coli bacteria, direct... Out, you can stop using the cream into the applicator with the into..., consider your doctor ordered a hormone-based treatment, its important to stick your.