Hormone replacement therapy (HRT) may be recommended to address symptoms related to hormonal imbalance or deficiency, including but not limited to menopause, perimenopause, or other medical conditions. HRT may include testosterone, estrogen, and/or progesterone, and may be administered as creams, injections, oral formulations, or other routes as determined appropriate.
Potential benefits of HRT may include improvement in hot flashes, night sweats, mood, sleep, energy, libido, vaginal dryness, and bone density. Some patients may also experience improved cognitive function, muscle mass, and overall sense of well-being.
Potential risks and side effects of HRT may include, but are not limited to, breast tenderness, bloating, nausea, headache, mood changes, acne or oily skin, increased facial or body hair (with testosterone), changes in voice (with testosterone), irregular vaginal bleeding, fluid retention, increased risk of blood clots, stroke, heart attack, gallbladder disease, and, with long-term use, a possible increased risk of certain cancers such as breast or endometrial cancer (primarily with unopposed estrogen). Testosterone therapy may also cause changes in cholesterol levels, liver function, and may decrease fertility. There is a risk of local skin reactions with topical forms and injection site reactions with injectable forms.
Regular follow-up visits and laboratory monitoring (including hormone levels, blood counts, liver function, and other relevant tests) are required to ensure safety and effectiveness of therapy. The decision to initiate, continue, or adjust HRT will be based on ongoing assessment of risks and benefits.
Alternatives to HRT include lifestyle modifications, non-hormonal medications, or no treatment. I understand that I may choose to stop therapy at any time.
I have read and understand the information above regarding hormone replacement therapy. I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction. I understand the potential risks, benefits, and alternatives to therapy. I consent to begin hormone replacement therapy as discussed and agreed upon with my provider.
I understand that payment is due in full at the time of service. I have been advised that most insurance companies do not cover HRT therapy. I acknowledge that my provider has no contracts with any insurance company and is not contractually obligated to pre-certify treatment with my insurance company or answer letters of appeal.