Hormone Replacement Therapy (HRT) involves the administration of hormones to address deficiencies or imbalances that may contribute to various symptoms and health concerns. This treatment aims to restore hormonal balance and improve overall well-being. Before beginning therapy, it is essential that you fully understand the potential benefits, risks, and alternatives to HRT. The goal of HRT is to restore optimal hormone levels, which may help improve symptoms such as fatigue, weight gain, hot flashes, night sweats, mood disturbances, vaginal dryness, cognitive decline, and osteoporosis. Estrogen, progesterone, and, in some cases, testosterone and thyroid replacement therapy are commonly used in females with clinically low hormone levels.
I acknowledge that estradiol, progesterone, testosterone, thyroid and other hormones may be prescribed off label to treat a variety of signs and symptoms.
I acknowledge that there are no guarantees or assurances made with respect to the benefit of the hormone 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:
The use of estrogen and progesterone therapy can regulate or suppress menstrual cycles, affecting ovulation. Women who are considering pregnancy or wish to maintain fertility should discuss alternative options with their healthcare provider. Additionally, long-term use of HRT may impact ovarian function, and discontinuation of therapy may result in hormonal fluctuations requiring careful monitoring.
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). Estradiol 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 sometimes used in women to help improve libido, energy levels, muscle mass, and cognitive function. However, it must be carefully monitored, as excessive testosterone levels can lead to side effects, including: Increased facial and body hair growth (hirsutism), Acne and oily skin, Deepening of the voice, Enlargement of the clitoris, Mood changes, including increased aggression or irritability, Potential disruptions in menstrual cycles, Increased risk of cardiovascular issues if improperly managed.
Thyroid hormone replacement therapy is often used to treat hypothyroidism, a condition in which the thyroid gland does not produce enough hormones. While these hormones play a crucial role in metabolism, energy production, and overall cellular function, improper dosing can lead to symptoms such as rapid heartbeat, anxiety, unintended weight loss, osteoporosis, and muscle weakness. Patients with pre-existing heart conditions should exercise caution, as excessive thyroid hormone levels can increase the risk of arrhythmias and cardiovascular complications. Regular monitoring of thyroid function (TSH, Free T3, Free T4) is necessary to ensure proper dosing and minimize risks.
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.
