TESTOSTERONE / ESTRADIOL PELLET INSERTION CONSENT FORM
FEMALE: Bio-identical hormone pellets are hormones, biologically identical to the hormones you make in your own body prior to menopause. Bio- identical hormone pellets are not FDA approved for female hormonal replacement. Patients who are pre-menopausal are advised to continue reliable birth control while participating in pellet hormone replacement therapy. Testosterone is category X (will cause birth defects) and cannot be given to pregnant women.
MALE: Bio-identical hormone pellets are hormones biologically identical to the hormones you make in your own body. During andropause, the risk of not receiving adequate hormone therapy can outweigh the risks of replacing testosterone.
RISKS OF TESTOSTERONE/ESTROGEN PELLETS INCLUDE BUT NOT LIMITED TO
FEMALE: Bleeding, bruising, swelling, infection and pain; reaction to local anesthetic and/or preservatives; extrusion of pellets; hyper sexuality (overactive Libido); lack of effect (from lack of absorption); breast tenderness and swelling especially in the first three weeks (estrogen pellets only); increase in hair growth on the face, similar to pre- menopausal patterns; water retention (estrogen only); increased growth of estrogen dependent tumors (endometrial cancer, breast cancer); birth defects in babies exposed to testosterone during their gestation; growth of liver tumors, if already present; change in voice (which is reversible); clitoral enlargement (which is reversible). The estradiol dosage that I may receive can aggravate fibroids or polyps, if they exist, and can cause bleeding. Testosterone therapy may increase one’s hemoglobin and hematocrit or thicken one’s blood. This problem can be diagnosed with a blood test. Thus, a complete blood count (Hemoglobin & Hematocrit) should be done at least annually. This condition can be reversed simply by donating blood periodically.
MALE: Bleeding, bruising, swelling, infection, and pain; reaction to local anesthetic and/or preservatives; extrusion of pellets; lack of effect (from lack of absorption); thinning hair, male pattern baldness, increased growth of prostate and or prostate tumors, Hyper sexuality (overactive libido), 10-15% shrinkage in testicle size, and significant reduction in sperm count. Testosterone therapy may increase one’s hemoglobin and hematocrit or thicken one’s blood. This problem can be diagnosed with a blood test. Thus, a complete blood count (Hemoglobin & Hematocrit) should be done at least annually. This condition can be reversed simply by donating blood periodically. There is risk of enhancing an existing prostate cancer to grow more rapidly. A PSA test is recommended before starting testosterone replacement therapy. Urinary symptoms can improve, or they may worsen before improving.
HORMONE TRANSITION CHANGES THAT MAY OCCUR
Fluid retention, Hand / Feet Swelling, Uterine spotting/bleeding, Mood swings, irritability, facial breakout, hair loss, body hair growth.
BENEFITS OF TESTOSTERONE/ESTROGEN PELLETS CAN INCLUDE
Increased libido, energy, & sense of well-being; increased muscle mass/strength/stamina; decreased frequency & severity of migraine headaches; decrease in mood swings/anxiety/irritability; decreased weight; decrease in risk or severity of diabetes; decreased risk of heart disease; decreased risk of Alzheimer’s / dementia. Decreased risk of heart disease in men
CONSENT FOR TREATMENT
I consent to the insertion of testosterone and/or estradiol pellets in my hip. I have been informed that I may experience any of the complications to this special procedure as described below. The side effects are like those related to traditional testosterone and/or estrogen replacement. Surgical risks are the same as for any minor medical procedure. I agree that sedation / anesthetics may be given by Betty Laurie Ryba, CFNP as indicated for this ELECTIVE procedure. I understand that surgery/procedures & the use of sedation/anesthesia can lead to serious reactions, injury, or even death. I understand there is no guarantee this treatment will be successful. On rare occasions, other conditions may present themselves prior to, during, or immediately following the above-listed procedure. These conditions may require immediate treatment for my well-being. Should this occur, I consent to such additional treatments/procedures. I have read and understand the above. I have been encouraged and have had the opportunity to ask any questions regarding pellet therapy. All my questions have been answered to my satisfaction. I further acknowledge that there may be risks of testosterone and or estrogen therapy that we do not yet know, at this time, and that the risks and benefits of this treatment have been explained to me and I have been informed that I may experience complications, including one or more of those listed above. I accept these risks and benefits, and I consent to the insertion of hormone pellets under my skin. This consent is ongoing for this and all future pellet insertions unless change is made in writing.
PAYMENT
I understand that payment is due in full at the time of service. I have been advised that most insurance companies do not consider pellet therapy to be a covered benefit and my insurance company may not pay, depending on my coverage. I want to receive these services and I agree to take full financial responsibility for the total cost. I understand that by signing this consent, I agree to the price estimated regardless of insurance coverage determinations (ie.: If insurance denies any part of the procedure.) I understand it is my responsibility to verify the exact amount of the services BEFORE the visit/procedure is performed. CPT/HCPCS Codes: 11980-Insertion, A4550/A4649/99070-Surgical tray/Supplies, J7999/ea Compound Hormone Pellet
I understand that HRT is also available via injections, creams, orally, etc and I am electing to receive HRT via subcutaneous pellet implants.