Please read this form entirely. It contains information to assist you in making a decision to have a specific therapy. Initial each paragraph if you understand it. If you do not understand it, do not initial it and each paragraph will be discussed with you separately. There are risks and complications that may result from this therapy, they are rare, but do exist and you must be aware of them.
Hormone replacement therapy (HRT) involves prescribing ovarian hormones including estrogens, progesterone and/or testosterone. The expectation of treatment is improvement in symptoms of hormone deficiency and possibly decreased health risks.
_____ I understand that the majority of studies done on HRT have involved synthetic drugs that mimic hormones in the body. The Women’s Health Initiative studied the effects of premarin and provera and found:
- 26% increased risk of invasive breast cancer
- 13% increased risk of non-invasive breast cancer
- 29% increased risk of heart attack or death from heart disease
- 41% increased risk of stroke
- 200% increased risk of blood clot
_____ Possible side effects of HRT include but are not limited to irregular or heavy menstrual bleeding, water retention, breast tenderness, PMS symptoms, weight gain, mood changes, acne or excess body hair.
_____ I understand there is controversy about the risks and benefits of Bioidentical hormone replacement therapy (BHRT) even though they have been studied extensively and most studies show BHRT does not have the same risks that were found in the Women’s Health Initiative study.
_____ The above listed risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization and/or extended outpatient therapy to permit adequate treatment.
_____ I will take full responsibility for obtaining or choosing not to obtain recommended screening exams, including pap smears and mammograms. The providers at AdvantAge Integrative Medicine will not be responsible for monitoring my screening exams.
_____ I will conform and comply with the recommended dosing of HRT. If recommended, I will obtain baseline and periodic lab tests to assure proper monitoring of my HRT.
_____ I understand that medicine is not an exact science and that no guarantees are offered regarding my expected results. I am aware that it is possible that this treatment will not work for me.
I have read the foregoing information, it has been explained, and I understand it. All of my questions have been answered. By executing this form, I am indicating that I have no questions whatsoever and I give my full informed consent to have HRT prescribed.
Patient / Legal Guardian Signature / Date:
Medical Assistant/Nurse/Physician / Date: