FEMALE TESTOSTERONE AND/OR ESTRADIOL CONSENT
Bio-identical hormones are concentrated hormones biologically identical to the hormones you make in your own body. Estrogen, progesterone, and testosterone are derived from the female ovaries (primarily) and adrenal glands (secondarily) prior to menopause.
All testosterone use in women is considered "off-label." The off-label use of testosterone therapy has not been evaluated by the FDA and any claims of benefit are purely educated opinions that come from consideration of various medical research studies. Regarding hormone pellets, the production of the pellet is highly FDA regulated; however, the pellet insertion procedure is not an FDA approved procedure for hormone replacement.
SIDE EFFECTS may include but are not limited to:
- Pellet insertion: bleeding, bruising, swelling, pain, extrusion, infection, scarring
- Estradiol: dysfunctional uterine bleeding, breast tenderness, growth of estrogen dependent tumors
- Testosterone: hyper-sexuality, acne, increased body/facial hair, abnormal menstrual cycles, hair loss, voice changes
If you have a uterus and are on estradiol therapy, oral micronized progesterone (prescription) must be taken daily for protection against uterine cancer.
The safety of hormone therapy during pregnancy cannot be guaranteed. Notify your provider immediately if you are pregnant, suspect pregnancy, or plan to become pregnant.
MAMMOGRAM REQUIREMENT: Mammograms are recommended as a baseline prior to estradiol therapy. Every patient has the right to refuse. If refused, a mammogram waiver must be signed before receiving hormone therapy.
I have read and understand this information. I have been given the opportunity to ask questions. I consent to hormone replacement therapy and, if pertinent to my agreed treatment plan, subcutaneous hormone pellet insertion. This consent is ongoing for all future management of hormone therapies and pellet insertions.
By typing my full name below I am providing my electronic signature and confirm all information on this form is accurate and complete to the best of my knowledge.