Hormone replacement therapy is implemented to optimize hormone levels in the blood, helping to reduce symptoms associated with low levels of these hormones.
Many individuals have inadequate hormone levels despite technically normal blood tests. Some individuals suffering symptoms related to menopause or andropause or inability to lose weight may also benefit from these therapies. Hormone replacement therapy can be used to augment hormone levels in a number of conditions where diminished hormone levels are evident.
I understand that treatment with estradiol is FDA approved for menopausal symptoms, progesterone is FDA approved for endometrial hyperplasia, and testosterone is FDA approved for hypogonadism.
I acknowledge that estradiol, progesterone and testosterone may be prescribed off label for a variety of other reasons and symptoms.
I acknowledge that there are no guarantees or assurances made with respect to the benefit of the bio-identical hormone supplementation therapy prescribed for me.
I understand that I will be in charge of administering these hormones and supplements prescribed to me.
I will conform and comply with the recommended doses and methods of administration.
I understand that initial blood tests will be performed to establish my baseline hormone levels.
I agree to comply with requests for ongoing testing to assure proper monitoring of my hormone levels.
I agree to report to the medical provider any adverse reaction or problems that might be related to my hormone therapy.
I understand that with hormone supplementation there are possible risks and complications:
Estrogen Therapy: Estrogens are available in various forms including oral capsules, troches, patches, topical creams/gels, or pellets. Adverse reactions may include bloating, breakthrough bleeding, breast swelling and tenderness, fluid retention, weight gain, liver cysts, death (e.g.-from blood clots or cancer) and mood swings. High potency conjugated estrogens (e.g. Premarin), and perhaps even estradiol, have been associated with an increased risk of breast cancer and blood clots (the latter especially in smokers). Estriol may carry a lower risk of breast cancer and may even protect against breast cancer. Nonetheless, the whole area of estrogen replacement is undergoing further evaluation. Do not take estrogen if you have estrogen receptor-positive breast cancer. Alternatives to bioidentical estrogen include but are not limited to nutraceutical supplementation, acupuncture, and non-treatment.
Progesterone Therapy: Progesterone is available in various forms including oral capsules, troches, vaginal or rectal suppositories, and topical creams/gels, or pellets. Progesterone therapy may be sedating, so it is recommended to coordinate dosing with the sleep cycle. Adverse reactions may include bloating, breakthrough bleeding, missed menstrual cycles, breast swelling and tenderness, fluid retention, weight gain, sedation, and depression. Do not take progesterone if you have progesterone receptor positive breast cancer. Alternatives to bioidentical progesterone include but are not limited to nutraceutical supplementation, acupuncture and non-treatment.
Testosterone Therapy: Testosterone therapy is available in various forms including sublingual drops, troches, topical creams/gels, intramuscular injections, or pellets. Side effects may include acne, chronic priapism (persistent, abnormal erection of the penis), change in libido, angina or heart attacks, hirsutism (facial hair growth) and scalp hair loss, clitoral engorgement, voice changes, or water retention. Because it may improve insulin resistance in males, diabetics who use insulin should monitor glucose levels closely, as less insulin may be needed.Check with your physician before adjusting your dose of insulin. If using a formulation of testosterone that is applied to the skin, a local irritation may occur. ln women, excessive testosterone or DHEA doses could increase the risk of diabetes or facial hair. Testosterone therapy is contraindicated if you have a history of testicular or prostate cancer. Alternatives to bioidentical testosterone include but are not limited to nutraceutical supplementation, acupuncture and non-treatment.
After consideration of these risks I consent to treatment with hormones.
I have not been promised or guaranteed any specific benefit from the administration of this therapy.
I understand that the role of the medical provider is for hormone replacement only.
I agree that I am and will be under the care of another physician for all other medical conditions. Revv Health does not accept insurance for hormone therapy services and any associated lab work.
I, therefore, agree to pay for all services including laboratory, membership and/or medication charges myself, with the understanding that I will not be reimbursed by my insurance company. There are no exceptions.
I have read and understand all of the above consent and I fully understand what I am signing and hereby request and consent to treatment using hormone supplementation therapy.