Board Certified Podiatrist Foot & Ankle Surgeon

Joint pain is typically blamed on arthritis, but if it occurs particularly in your big toe, it’s likely gout, a condition caused by too much uric acid in your body. With nowhere to go, the uric acid forms hard deposits in your joint that causes pain, redness, and swelling. Your big toe isn’t the only joint gout affects, but it is the most common. It can also occur in your other toe joints or in the knuckles on your hands.

When you’re one of the more than 8 million Americans who suffer from gout, you’re going to need a good podiatrist. And if you live in the Salt Lake City area, you have access to two of the leading, board-certified specialists, Dr. Dan Preece and Dr. Darren Groberg, who can evaluate the stage and severity of your gout and develop an individualized treatment plan just for you. 

Because gout tends to cause spontaneous attacks of pain when you’re least expecting it, it can be hard to predict it and plan your activities accordingly. While our team recommends a comprehensive, long-term treatment plan, there are times you simply need help getting through a painful gout flare-up. 

Our experts at Utah Musculoskeletal Specialists put together this list of tips that can ease your acute gout attacks.

Medication

At the first signs of a gout flare-up, many people find that a regular dose of an over-the-counter nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen can be very effective at stopping the pain, or at least decreasing it. 

When you meet with us about your gout, we complete a thorough examination, including your current and past health issues. We can recommend the right type of medication for you to keep on hand in case of sudden attack. 

Ice

The inflammation that comes along with gout is often the main culprit causing your pain. Instead of, or in addition to, the over-the-counter medication, good, old-fashioned ice can do wonders to reduce the swelling and pain.  

Whether you choose some crushed ice in a bag buffered by a thin towel, a frozen bag of peas, or a nice cold pool of water, dropping the temperature is often all it takes. 

Caution: Don’t leave ice on the area for more than 20 minutes, and don’t use this method if you have nerve damage or diabetes.

Rest

When you have a gout attack, especially if it’s in your toe, no one has to tell you to get off your feet; the pain will lead you to do that instinctively. But beyond the initial reaction to stop using the affected joint, whether in your hands or your feet, it’s important to stay off it as long as possible and give it some rest.

If you can, elevate the joint to alleviate some of the inflammation, as well. 

Next-level at-home tips

While ice, rest, and NSAIDs can help you endure a gout flare-up in the moment, there are more things you can do to give your gout a helping hand. 

• Drink an abundance of water
• Avoid alcohol and sweet drinks, especially soda
• Cut out foods with added sugars or yeast
• Avoid organ meats, game meats, and seafood

These steps can help you manage the amount of uric acid in your system.  

Although gout is known to cause an occasional mild fever, if you have an elevated temperature along with chills, it could be the sign of an infection, in which case you should call us immediately. 

If you have gout or think you might, coming to see us for the right treatment is critical. Dr. Preece and Dr. Groberg can prescribe stronger medications, if necessary, and help you decide on the best course of treatment to avoid further complications. Call us today or request an appointment online to get a handle on your gout symptoms. 

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5 Ways to Ease a Gout Attack

Sep 2, 2016

If you have gout, you know what it’s like to suffer from a flare-up. Also known as gouty arthritis, a gout attack begins with a burning or itching feeling in your joints. The next sign is redness, swelling, or severe pain in the joint. This is caused by a buildup of uric acid around the joints, which forms uncomfortable uric crystals. This condition can be so painful that anything touching the joint—even a bedsheet—can cause severe pain.

If you are suffering from a gout attack or flare-up, you don’t need to agonize alone or in silence. There are a few things you can do to ease the pain and prevent future flare-ups.

Over-the-counter treatments.

Several over-the-counter treatments can help relieve the pain caused by a gout attack. These nonsteroidal anti-inflammatory drugs can lower uric acid levels and treat episodes of inflammation. Some good choices include Aleve, Motrin, and Advil, and, when taken in prescription doses, can be very effective.

Contact Carolina Arthritis for guidance and to learn more about this strategy for your gout attacks.

Change your diet.

Many dietary and lifestyle changes can assist in recovery. Foods high in purines can increase the uric acid in your blood and trigger a gout flare-up. Some of these foods include:

• Some seafood
• Organ meats like liver
• Fatty foods

Fructose-sweetened drinks and alcohol, especially beer, can have a similar effect. If you’re suffering from gout, limiting your intake of these foods is a great place to start. You should also make an effort to drink more water. Allowing yourself to become dehydrated can cause your uric acid levels to rise. Drinking more water will help keep things at a normal level.

[We know the foods to avoid, what about the ones that help manage? Click here for more information!]

Ice, elevate, and relax.

As long as the pain isn’t too extreme, a cold compression or ice pack applied gently to the area can help ease the inflammation. For the most effective treatment, ice the joint for 20 to 30 minutes several times a day and keep the affected area elevated. Another trigger for gout is stress.

While a gout flare-up can put you on edge, it’s crucial to keep calm and do your best to relax. Try watching a movie, reading a favorite book, or catching up with a friend to keep your mind off things.

Steroids treatments.

If you can’t take over-the-counter drugs or if they are not effective, you can try the steroid drug prednisone instead. Prednisone is usually given orally for two weeks, with less given each day to ween the patient off. If you’re hospitalized, it can also be given intravenously.

Make an appointment with Carolina Arthritis.

There are several different gout-specific medications, such as Colchicine, Allopurinol, and Probenecid, and it can be tricky to figure out which one is best for you. This is why we recommend making an appointment with Carolina Arthritis.

Carolina Arthritis’s team of specialized doctors can meet with you to discuss your specific situation and create a tailored treatment plan specific to you. Don’t wait for your next gout attack—contact us today and get the relief you need today.

How to cure gout on the legs [effective SWT method]

Gout is the deposition of uric acid salts in various tissues of the body, most often in the joints and cartilage. With gout of the legs, physiotherapy, especially the SWT method, significantly improves well-being.

“Gout <…> gave birth to hell itself,” wrote I.A. Krylov. Of course, the nature of the occurrence of this disease is different, but nevertheless it delivers a lot of “hellish” troubles to its carriers.

The disease is especially common among Caucasians and occurs in 50 men and 10 women out of a thousand. In order for gout not to lead to serious complications, it needs to be diagnosed and treated in time.

1. Causes and symptoms of gout

2.
How to treat gout in the legs

2.1. Prevention of gout on the legs

Causes and symptoms of gout

Gout belongs to the group of arthritis. Arthritis refers to any disease of the joints. The term “gout” is used when talking about the deposition of uric acid salts in various tissues of the body, most often in the joints and cartilage. What is causing this process?

Uric acid is a product of the breakdown of purines, special substances that are produced in our body, and also get to us with food. We get a large amount of purines when we eat fatty meat and fish (herring, sardine, cod), organ meats (sausages, sausages), fast food. And also when we drink alcohol (especially beer and grape wine), unnatural juices, sweet carbonated drinks, coffee. In this case, a huge amount of uric acid is synthesized in the body, and the kidneys cannot cope with its excretion. Another cause of gout is when the body produces a normal amount of this acid, but the kidneys are unable to remove it due to any pathologies.

Salts of uric acid (urates) are deposited in joints, especially small ones, gradually destroying them. Salt deposition is most susceptible to injured joints. The joint of the big toe (popularly called the “big bone on the leg”) becomes the object of the lesion due to the fact that we wear uncomfortable, narrow shoes. Gout can also lead to the formation of kidney stones, which in turn can lead to kidney failure, which in some cases can be fatal.

Symptoms of gout may include:

• acute joint pain (especially after heavy meals or large amounts of alcohol). Sometimes the sensations are so unbearable that it hurts even from the fact that a sheet lies on the arm or leg. The pain begins to torment at night, passes during the day, and then returns again. This may take several days or even months;
• redness and swelling of the joint;
• increased temperature in the joint area up to 39–40°C;
• fever;
• general weakness.

If the attacks are repeated again and again, then, for example, gout of the toe can go to other joints, making them painful and inactive.

Gout is considered a disease of the elderly, but due to the fact that a modern person consumes a lot of fats and alcohol, in particular beer, this leads to a “rejuvenation” of the pathology. The disease is chronic, that is, it cannot be completely cured. But in order to avoid serious consequences, one should resort to therapy that will stop or slow down the process of destruction of the joints.

How to treat gout in the legs

Since the Middle Ages, gout has been called the “disease of kings”, since it was the holiest persons who had the opportunity to indulge themselves in plentiful meals and were prone to gluttony. Therefore, first of all, to control gout, you need to reconsider the diet. You should reduce the consumption of meat and meat offal, refuse fatty foods, beans and fish caviar, beer, wine and, if possible, other alcoholic beverages. Patients with gout are usually prescribed dietary table number 6. It is recommended to drink at least 2 liters of fluid per day. Mineral waters such as Borjomi, Narzan, Essentuki will be useful.

In acute attacks of gout, it is recommended to apply ice to the inflamed area, make compresses with dimexide. The use of painkillers and anti-inflammatory drugs that do not contain steroids is shown.

Please note!

American scientists have established the relationship between calcium and ascorbic acid deficiency in the body and the development of gout. Therefore, as a treatment and prevention of the disease, it is necessary, in agreement with the doctor, to take these substances.

Physiotherapy significantly improves the well-being of the leg with gout. One of the most advanced and high-tech treatments for gout is shock wave therapy. When exposed to the affected tissue by a shock wave of a certain frequency, the following occurs: microcrystals of salts and connective tissue seals are loosened, blood flow increases tenfold, which in turn leads to the absorption of salts and tissue restoration.

In particularly severe cases, surgical methods are used to remove deposits of uric acid in the joints. But, in order to avoid this, it is necessary to carry out the prevention of arthritic diseases, such as gout of the foot.

Prevention of gout on the legs

In order for the joints of your legs to retain mobility and performance until old age, you should pay attention to the following preventive measures:

• lead an active lifestyle, walk more, do exercises in the morning;
• give up bad habits;
• eat more grains, vegetables, fruits, boiled or steamed meats and fish;
• drink more plain water;
• for preventive purposes, take a blood test to determine the content of the most important vitamins and minerals. If necessary, supplement the diet with a mineral-vitamin complex.

If you still experience gout, do not rush to despair. The main thing – do not postpone the solution of the problem “for later”, contact the specialists. A reliable assistant in the fight against the disease will be the method of shock wave therapy (SWT) we have already noted. You will find some of the most affordable prices for procedures at the Health Plus Medical Center. Even the elderly can receive effective and affordable treatment here. Procedures at the Health Plus Medical Center are performed without anesthesia in a course of several sessions of 10-15 minutes each, the number of which depends on the severity and duration of the disease. Qualified specialists will help you maintain a healthy state of the body.

symptoms and causes of the disease

Gout is a disease that is most often associated with men, but it can also occur in women. In this article, we will discuss the symptoms of gout in women to help you detect and treat the disease in a timely manner.

Gout is a disease that causes severe pain in the joints, usually in the big toe. This is a serious form of arthritis that can lead to joint damage and organ complications. In the past, gout was often called the “disease of kings” because it often occurs in people who abuse alcohol and fatty foods.

However, gout can also affect other people, including women. In women, the occurrence of gout may be associated with hormonal changes, a decrease in estrogen levels during menopause, as well as the presence of obesity and kidney disease. The symptoms of gout in women are slightly different than in men, making it more difficult to diagnose and treat.

Knowing the symptoms and risks of gout in women can help prevent complications early and prescribe the right treatment. In this article, we look at gout symptoms, diagnosis, and treatments in women.

Gout: a chronic disease

What is gout?

Gout is a disease that manifests itself in the form of inflammation of the joints and the formation of uric acid in the body. In gout, uric acid crystals accumulate in the joints, causing severe pain and limited movement.

What symptoms do women have?

Gout is less common in women than in men. However, if the disease has developed, then the symptoms may be the same as in men. This is an acute attack of pain in the joints of the feet, fingers and toes, redness and swelling at the site of the lesion, fever. Also, women sometimes have problems with the kidneys and bladder.

How to treat gout?

Treatment of gout depends on its degree and manifestations. Painkillers may be used for acute pain. But most patients require long-term therapy, which is aimed at reducing uric acid and preventing new exacerbations of the disease. For this, special diets, medications and physiotherapy procedures can be used.

How to prevent gout?

Prevention of gout comes down to lowering the level of uric acid in the blood and maintaining a healthy lifestyle. It is recommended to avoid alcohol, fatty and fried foods, take measures to control weight, exercise regularly and follow a diet.

Main symptoms of goutSymptoms Description

901 09 Kidney and bladder problems may develop

Female form of gout

Gout is a chronic disease characterized by excessive accumulation of uric acid crystals in the joints. Gout usually affects men between the ages of 35 and 55, but women can also be affected.

Although women are less likely to suffer from gout, when they become ill, they most often suffer from ingrown uric acid crystals in soft tissues, including ligaments and tendons, and are also susceptible to early complications.

The symptoms of gout in women can range from trivial symptoms such as mild pain or discomfort to painful and severe joint damage causing nervous and psychological disturbances. The female form of gout can also cause an increase in uric acid levels in the blood, which can rupture joints that are prone to gout.

It is important to pay attention to the symptoms of gout in women and to be aware of possible treatments. Women are less likely to get gout, but that doesn’t mean they’re not at risk. Moreover, when gout occurs in women, it can be more dangerous and cause more serious consequences, so it is important not to ignore the symptoms and see a doctor in time.

Main signs of gout in women

Gout is a disease that occurs mainly in men, but can also occur in women. Symptoms of gout in women can vary and include:

• Severe joint pain is the main symptom of gout. It appears suddenly, often at night, and is very intense.
• Swelling and redness of the joints – they may be swollen and hot to the touch. This is due to inflammation, which is caused by the formation of uric acid crystals in the joint fluid.
• Restriction of joint movement – the symptom appears due to pain and inflammation of the joints, which makes movement difficult and reduces flexibility.
• The appearance of subcutaneous nodules (tophi) are formations around the joints or on the ear and other places. They are caused by deposits of uric acid crystals and may be painless or painful.
• Kidney problems – chronic gout may increase the risk of kidney stones and lead to chronic kidney failure.

If you notice these symptoms, you should consult a doctor and undergo an examination in order to obtain an accurate diagnosis and prescribe the correct treatment.

How to diagnose gout in women?

Gout is a disease commonly associated with the male sex. However, it can also occur in women. For the correct diagnosis of gout in women, it is necessary to take into account all the features of its manifestation.

People with gout experience severe joint pain. In women, gout often affects large joints, including the knees and ankles. Also, women who are prone to gout may experience painful swelling and redness of the skin around the joints.

To diagnose gout, a doctor will usually examine the patient and order laboratory tests to check the level of uric acid in the blood. A high level of uric acid may indicate the presence of gout. In addition, educational radiographs and magnetic resonance imaging may be ordered to visualize internal organs and joints.

Even if a woman has symptoms consistent with gout but the test shows low uric acid levels, the doctor may order additional tests to rule out other conditions that may mimic gout.

Conclusion: the diagnosis of gout in women can be difficult due to the peculiarities of the manifestation of the disease in the female body. If symptoms appear, you should immediately consult a doctor who will conduct all the necessary studies and prescribe complex therapy for quick and effective treatment.

Common mistakes in the treatment of gout

Wrong diet

One of the main causes of gout is a violation of purine metabolism. However, some patients try to solve the problem by completely eliminating purines from their diet, thereby increasing the likelihood of vitamin and mineral deficiencies in the body. It is not necessary to completely exclude foods from the diet, but it is necessary to limit their consumption. In the first place is to remove alcohol, fried, spicy and fatty foods.

Lack of respect for doctor’s advice

Gout is a serious disease that can lead to severe complications. At the first symptoms, it is necessary to consult a doctor and get a competent treatment appointment. Often, patients risk their health by trying to cope with the disease on their own. This can lead to worsening of the condition and complication of the course of the disease.

Non-compliance with the diet

In gout, the diet should be strictly limited, but some patients do not follow the written diet, while hoping for improvement. However, this approach can only worsen the situation and cause new bouts of the disease. Before starting treatment, it is necessary to obtain detailed recommendations from the doctor regarding nutrition during the period of illness.

Excessive physical activity

Moderate physical activity is considered by many patients to be the best way to combat gout. However, with an exacerbation of the state of the disease, physical activity can only aggravate the patient’s condition. Before starting exercise, be sure to consult your doctor.

Incorrectly chosen course of treatment

Gout is a serious disease, which is expressed in the difficulty of certain organs and body systems. An incorrectly chosen course of treatment can lead to additional complications and worsening of ill health. Before starting therapy, you should consult with a qualified specialist and carefully study all the recommendations.

Key principles for the treatment of gout in women

1. Diet. In women with gout, it is recommended to avoid foods high in purine bases from the diet. These are meat, fish, marinades, canned food, chocolate, mushrooms, alcohol and other products. Instead, you can eat vegetables, fruits, herbs, dairy products and drink plenty of water.

2. Taking medications. Treatment of gout in women should include medication to relieve pain symptoms, prevent the formation of new uric acid crystals, and destroy existing ones. The appointment of drug therapy should be carried out only by a doctor!

3. Physical activity. Moderate exercise helps improve metabolism, reduce blood acid levels and strengthen joints. For gout in women, swimming and yoga are the most effective.

4. Correct daily routine. Women with gout need to arrange a regular daily routine, including not only work, but also rest, sleep, sports, nutrition and other fidactors. This will help support metabolism and strengthen the immune system.

5. Spa treatment. Many sanatoriums and resorts specialize in the treatment of gout and organize a full course of treatment. When visiting a sanatorium, women can not only receive qualified medical assistance, but also improve their health in a pleasant atmosphere.

Medicines for gout in women

Gout is a disease that can lead to serious complications, so it is important to start treatment immediately. As a rule, doctors prescribe complex therapy, which includes not only drugs, but also diet, daily routine and other measures.

The first thing to consider when choosing medicines is the phase of the disease. During the period of exacerbation against the background of severe pain and inflammation, drugs aimed at eliminating the inflammatory process are a priority. During this period, drugs containing colchicine or steroids may be prescribed. In the remission phase, a longer and more detailed program of drug therapy should be followed.

It is important to note that women with gout should be especially careful, as many medications may be contraindicated during pregnancy or breastfeeding. Therefore, it is recommended to discuss all possible uses of drugs with a doctor and, if necessary, to conduct additional examinations before starting treatment.

• Colchicine is a drug that has been one of the main drugs for the treatment of gout for many years. As an anti-inflammatory drug, colchicine reduces the number of inflammatory cells and prevents the formation of new ones, reducing pain and inflammation.
• NSAIDs (non-steroidal anti-inflammatory drugs) are drugs of choice for pain relief. However, they should only be used if there are no contraindications such as stomach ulcers, kidney failure, allergies, or discontinuation of medication due to side effects.
• Corticosteroids are also used to treat gout, especially when other medications have failed. They are used in the first days of the onset of an exacerbation of the disease in order to quickly reduce pain and eliminate inflammation.

Conclusions about which drug to prescribe in each specific case should be made by the doctor after a complete examination of the patient and clarification of the causes of the disease. Do not self-medicate and use drugs at random, as this can adversely affect health and lead to serious complications. It is important to follow all the doctor’s prescriptions and not skip the medication.

Diet advice for women with gout

Avoid certain foods

Women with gout should not consume foods high in purines, as they may exacerbate symptoms. These foods include: red meat, animal organs, seafood, chicken skin, legumes, spinach, cauliflower, and mushrooms.

Increase your water intake

It is important to increase your water intake to flush the kidneys and remove harmful substances from the body. It is recommended to consume an average amount of water each day, approximately two liters for women with gout.

Increasing consumption of fruits and vegetables

Fruits and vegetables are low in purines and therefore the best choice for women with gout. They also contain many vitamins, minerals, antioxidants and other beneficial substances necessary for the human body.

Limiting foods high in sugar

Consuming large amounts of sugary foods and drinks, such as lemonade and sweet tea, may increase the level of uric acid in the blood, which increases the symptoms of gout. Therefore, you should limit the consumption of foods high in sugar.

Consumption of a low thyroid diet

A low thyroid diet may lead to increased uric acid rush due to decreased levels of uric acid production in the liver. This can help lower blood uric acid levels and reduce the risk of gout flare-ups. Women should consult a doctor to develop an individual diet.

Sample list of foods for women with gout: Allowed foods Restricted foods Prohibited foods

How can women avoid gout attacks?

Gout is a disease that is associated with metabolism and is manifested by painful attacks in various parts of the body, mainly in the joints. This disease can have a negative impact on the quality of life and numb the normal activities of life if it is not controlled. How to avoid gout attacks in women?

1. Maintain normal weight . Gout is associated with obesity and high cholesterol levels. Therefore, it is important to pay attention to your weight and be careful with the consumption of fatty foods.
2. Do not drink alcohol . Alcohol is the main source of purine compounds, which lead to increased levels of uric acid in the blood – it is its excess that causes gout.
3. Avoid certain foods . Some foods are high in purine compounds, which can trigger a gout attack. Such products include tomatoes, anchovies, pink salmon, shrimp and other seafood.
4. Monitor uric acid levels . It is important to monitor the level of uric acid in the blood and if it rises, consult a doctor for advice and treatment.
5. Drink enough water . Drinking enough water can reduce the risk of uric acid crystals forming in the kidneys and joints, which can lead to gout attacks.

Effective physiotherapeutic methods for the treatment of gout

Gout is a disease that manifests itself as an acute inflammatory reaction in the joints. It is caused by a violation of the metabolism of uric acid in the body, which leads to the formation of uric acid in the blood and its deposition in the joints. Physiotherapeutic methods can be used to effectively treat and prevent gout. They help improve blood circulation in the affected areas, relieve swelling and reduce pain.

Ultrasound therapy is a method in which ultrasound is applied to the affected area of ​​the joint at a frequency of 0.8 to 3 MHz. It helps reduce inflammation and improve blood circulation in the affected tissues and joints.

Inductothermy is a method that uses high frequency electromagnetic flux. It improves blood circulation and reduces swelling in the affected area of ​​the joint.

• Magnetotherapy is a method of applying a magnetic field to reduce pain, improve blood circulation and metabolism in the affected area of ​​the joint.
• Electrotherapy is a method that uses an electric field to improve blood circulation, reduce pain and swelling in the affected area of ​​the joint.

Ice application is one of the simplest and most affordable treatments for gout. Ice is applied to the affected area of ​​the joint to reduce inflammation and swelling.

Laser therapy is a method of using laser radiation to improve blood circulation and reduce pain in the affected area of ​​the joint.

Consult your doctor for complete and accurate information on how to use them to treat gout.

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Q&A:

What is gout?

Gout is a disease associated with a violation of the metabolism of purines, which are converted into uric acid. It is characterized by the formation of uric acid crystals in the joints, which leads to severe pain and dysfunction of organs.

What are the symptoms of gout in women?

In women, the symptoms of gout may include pain, swelling and redness around the joints, which may become hot to the touch. Kidney and heart health problems can also occur.

Can gout be cured in women?

Gout is incurable but can be controlled. Treatment is aimed at reducing pain and preventing the recurrence of attacks. Treatment options include medication, diet, and physical therapy.

What is hyperuremia and how is it related to gout?

Hyperuremia is a condition where the level of uric acid in the blood is higher than normal. Hyperuremia is the main cause of gout. In women, this condition can be related to both nutritional and genetic factors.

What is the role of nutrition in the development of gout in women?

Diet plays an important role in the development of gout in women. Fish, seafood, meat, and alcohol can increase blood uric acid levels. Therefore, women suffering from gout are advised to limit their intake of such foods and increase their intake of complex carbohydrates, fruits and vegetables.

What causes gout in women?

Gout in women can be caused by genetic factors, obesity, kidney disease and metabolic disorders. Diet, alcohol consumption, and physical inactivity may also play a role.

How to maintain health with gout in women?

Gout is a chronic disease that usually affects men. However, with age, the likelihood of developing the disease in women increases. Gout occurs due to an increased level of uric acid in the blood, which leads to the formation of crystals in the joints, on the skin and periarticular tissues. Women may differ from men in having additional risk factors.

To maintain your health with gout, you should follow a special diet, limiting the intake of animal proteins, alcohol, sugar and fatty foods. Maintaining a healthy weight is also important, as being overweight can exacerbate gout symptoms. It is recommended to engage in physical exercises that will help strengthen muscles, improve blood circulation and reduce the risk of developing the disease.

Women with gout may also be given special medicines to help relieve pain and inflammation in the joints. It is important to follow the intake of prescribed medications and not to exceed the recommended dose, as this can lead to complications.

We must not forget that gout is a chronic disease and should not be self-medicated. At the first symptoms, you should definitely consult a doctor and start treatment in order to avoid complications.

New life after the diagnosis of gout

Gout is not a death sentence!

The diagnosis of gout can be a real shock, especially if you are a woman. However, do not despair, because modern medicine can cope with this disease and help you reach a new level of life.