Informed Consent for Hormone Replacement Therapy

Because of the rapidly changing ideas about the safety and effectiveness of hormone therapy for anything other than birth control, I feel it is important to be sure that you have information about the risks and benefits of hormone therapy before you take the therapy we have discussed.

Hormone replacement therapy (HRT) is often prescribed to women during perimenopause (the time from first symptoms to up to several years beyond the last period) and menopause (starting one year after the last period) for symptoms of hot flashes, vaginal dryness, loss of libido, depression, irritability or PMS-like symptoms, bone loss and osteoporosis or its prevention, and cardiovascular disease. HRT is approved by the FDA only for hot flashes and osteoporosis. Using it for other symptoms or problems is considered “off-label” use, and the burden is on the physician to be sure that there is adequate science to support the use in a given situation. Needless to say, there will be differences of opinion about how much science is necessary.

It is now thought that the combination of estrogen and progestogens increases the risk of breast cancer over estrogen alone.

Estrogen replacement therapy (ERT) is used primarily for women who have had their uterus removed and for whom estrogen alone does not cause negative symptoms. Use of estrogen alone in the doses most often prescribed in America increase the risk of uterine cancer. In very low doses, estrogen alone may be used without progestogen (progesterone or artificial progestins such as Provera) if adrenal function is healthy. In this case, there is a risk of bleeding, endometrial hyperplasia, or cancer, and you should discuss this with your doctor.

When hormone levels are brought back to “normal” for your age, there is much evidence that your overall health benefits. The risk of osteoporosis and fractures decreases. HRT is the most effective treatment for hot flashes. There may be other long-term beneficial effects of treatment. If your (female sex) hormones are already normal, adding additional hormone to address symptoms such as hot flashes may increase your risk of diseases like cancer or problems like blood clotting.

The current medical thinking is always changing, so it is important to discuss HRT with your doctor each year at your annual exam to find out what the latest thinking is.

Please read the following and sign:

I have discussed the reason for taking female sex hormones with my doctor and understand why he/she is prescribing them and the risks associated with taking hormones, including but not limited to the possibility of an increased risk of breast or endometrial cancer, blood clotting, stroke, or heart attack.

I understand that there are different risks if I take progestogens or testosterone, and they may be higher or lower than taking estrogen alone. I have discussed this risk and the reasons for taking them with my doctor.

I understand that my doctor will do everything he/she knows to do to decrease and minimize the risks of HRT but that there are no guarantees that these measures will be effective at preventing the negative side effects mentioned above or others that we do not yet know about.

I accept the risks and unknowns of taking hormone therapy and wish to have my doctor prescribe them for me.

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Patient Name(Required)

Informed Consent for Hormone Replacement Therapy will be submitted to Sayana Medical Spa and Wellness Center