Hormone Replacement Therapy Forms for Women

FORM #1 - INFORMED CONSENT FOR HORMONE REPLACEMENT THERAPY

There are three forms to complete for HRT.  Please review and complete each form.

Purpose of Treatment

The purpose of Hormone Replacement Therapy (HRT) is to restore hormone levels that naturally decline with age or as a result of certain medical conditions. This therapy uses hormones that are chemically identical to those produced by the human body. The goal is to improve quality of life, alleviate symptoms related to hormone imbalance, and support long-term health and well-being. BHRT is intended to bring hormone levels into optimal balance rather than merely within the “normal” laboratory range.

Nature of the Treatment

HRT involves the use of hormones such as estrogen, progesterone, testosterone, DHEA, thyroid hormones, pregnenolone, and melatonin. These hormones may be administered in various forms including creams, gels, oral capsules, troches, injections, or pellets. Each treatment plan is individualized based on your medical history, physical examination, symptoms, and laboratory testing. Doses are adjusted over time in response to your clinical progress and repeat laboratory results. Because every person’s hormonal needs are unique, ongoing adjustments
are an expected part of treatment.

Potential Benefits

The potential benefits of HRT may include increased energy, improved mood, enhanced cognitive function, restored libido and sexual function, better sleep quality, improved muscle tone and bone density, and more effective weight management.  Many patients also experience relief from hot flashes, night sweats, and other symtoms associated with menopause or andropause.  Results vary between individuals, and it may take several month for hormone levels to stabilize and for full beneits to be realized.

Potential Risks and Side Effects

Although hormones are designed to mimic natural human hormones, all hormone therapies carry some degree of risk.  Possible side effects may include breast tenderness, bloating, fluid retention, headaches, mood changes, irritability, acne, hair changes, alterations in libido, and irregular bleeding or spotting.  In men, testosterone therapy may contribute to enlargement of prostate tissue.  There is also the potential for increased risk of blood clots, stroke, cardiovascular events, or hormone-sensitive cancers.  It is important that you immediately report any unusual symptoms or adverse affects to your provider so thay appropriate adjustments can be made.

Contraindications

HRT may not be appropriate for everyone. Individuals with a history of hormone-sensitive cancers such as breast, ovarian, or prostate cancer, active liver disease, unexplained vaginal bleeding, a history of blood clots or stroke, or uncontrolled cardiovascular disease may not be suitable candidates for hormone replacement therapy. Your medical history and laboratory results will be reviewed in detail prior to beginning treatment to determine if HRT is appropriate for you.

Monitoring and Follow-Up

Careful monitoring is essential to ensure the safety abd effectiveness of HRT.  You agree to complete all baseline and follow-up laboratory testing as recommended by your provider. Follow-up appointments are generally scheduled every eight to twelve weeks during the initial adjustment period and then every three to six months once hormone levels are stabilized. You agree to inform your provider promptly of any new medical diagnoses, medications, or changes in symptoms. Failure to comply with recommended follow-up visits and lab testing may result in discontinuation of therapy for your safety.

Alternative Treatments

Alternative to HRT include conventional hormone replacement therapy using synthetic hormones, non-hormonal prescriptions, and lifestyle-based interventions such as dietary modification, exercise, stress management, and nutritional supplimentation.  You may also choose to decline any form of hormone therapy.  Your provider can discuss the risks and benefits of each alternative to help you make an informed decision about your care.

No Guarentee of Results

While many patients report significant improvement in their symptoms and overall well-being, HRT outcomes cannot be guarenteed.  Every individual responds differently to hormone therapy, and results depend on numerous factors including adherence to the treatment plan, underlying health conditions, and lifestyle habits.  The goal of therapy is optimization of your hormonal balance, not perfection or the elimination of all symptoms.

Pharmacy Disclosure

Some hormone formulations are compounded by licensed compounding pharmacies that meet all state and federal quality standards.  These compounded preparations are custom-tailored to your individual prescription and may not be FDA-approved as final products, although the active ingredients used are FDA-regulated for safety and purity.  You may discuss pharmacy options and preferences with your provider at any time.

Patient Acknowledgement and Consent

By signing below, I confirm that I have read and fully understand the information provided in this consent form.  I have had a the opportunity to ask questions and HRT, its risks, benefits, and alternatives, as all of my questions have been answered to my satisfaction.  I understand that HRT is an elective treatment and that no guarentees have been made regarding its outcome.  I consent to begin or continue Hormone Replacement Therapy under the care and supervision of my provider.  I agree to comply with all recommended laboratory testing, follow-up visits, and communication requirements as partof my ongoing care.

FORM #2 - Hormone Replacement Therapy Questionnaire

Health and Background Information

FORM #3 - ADAM Questionnaire About Symptoms Of Estrogen Deficiency

Less than 6 points - it is not likely that you have androgen deficiency

7-16 points - mild androgen deficiency

17-26 points - moderate androgen deficiency

Above 27 points - severe androgen deficiency