Consent to Hormone Therapy for Perimenopause / Menopause (If Part of Treatment Plan)

Many women experience hot flashes, vaginal dryness, and other physical changes with menopause. Some women may benefit from hormone therapy (HT) containing estrogen or other hormones to address these symptoms. In consultation with your healthcare provider, and as part of your perimenopause or menopause care, you may decide to proceed with HT based on your symptoms, your personal and family health history, and your own beliefs and preferences about menopause treatments. In the event that you choose to receive HT, you understand that there are associated risks and benefits, which are detailed below.

Risks and Benefits of HT for Perimenopause/Menopause

I, the undersigned, acknowledge that I have reviewed the following information regarding the potential risks and benefits of HT. I understand that I may be offered HT as part of my treatment plan if deemed appropriate by my healthcare provider. If HT is recommended, I will have an opportunity to discuss the treatment with my healthcare provider and ask any questions I have about the risks and benefits of HT, including those below, before deciding whether to proceed with such treatment.

1. I understand that there are risks to any medical procedure, treatment or therapy, and that it is not possible to guarantee or give assurance of a successful result. I understand that, like any other medication, HT has risks and benefits. Healthy women who are younger than 60 years or within 10 years of menopause and who have significant symptoms are typically best positioned to benefit.
2. I understand that the main benefit of HT is the mitigation of menopausal symptoms. HT may help minimize hot flashes, night sweats, vaginal symptoms, and other symptoms of menopause.
3. I understand that HT may increase the risk of stroke or blood clots in the legs or lungs (especially in pill form). For women older than 60, HT may increase the risk of heart disease. For women older than 65, HT may increase the risk of dementia. HT with combined estrogen and progestogen may increase the risk of breast cancer after more than 5 years of usage.
4. I understand that if I have a uterus and am taking estrogen, I will also take progesterone medication to help ensure there is no increased risk of uterine cancer.
5. I understand it is possible that HT can have adverse side effects, including breast tenderness, gastrointestinal symptoms, skin rashes, headaches, and irregular bleeding or spotting.
6. If testosterone is part of my treatment plan, I understand that testosterone dosage will be based on lab results and my symptoms. Except for hypoactive sexual desire disorder (for which testosterone replacement is considered medically necessary) all other usages of testosterone replacement in women is considered off-label and is there to treat signs and symptoms of low testosterone. Potential adverse side effects of testosterone include, but are not limited to, acne, hair loss, hair gain, irritability, edema, erythrocytosis (increased production of red blood cells), transference (cream only), clitoromegaly, and deepened voice.
7. I understand that I should individually assess the benefits and risks of HT, and I am free to ask my healthcare provider any questions that I may have about HT and associated risks and benefits.
8. As with all medications, I understand that I should take the lowest dosage to relieve symptoms and minimize associated risks. I will work with my healthcare provider to decide what is best for me.

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I acknowledge that I understand and agree to the following:

I understand that I have the right to refuse any medical treatment recommended at any time prior to its performance by notifying my healthcare provider.

If any unforeseen condition arises during treatment, I further request and authorize my healthcare provider to do whatever they deem advisable on my behalf, including coordinating further care on my behalf.

I agree to inform my healthcare provider of any new symptoms or medical conditions that develop before or while I am undergoing HT treatment.

I acknowledge that no guarantees have been made to me concerning the results of HT.

I acknowledge that I have read (or have had read to me) and fully understand the above information. Furthermore, I certify that I will address concerns with my individual provider before proceeding with HT, including any questions on risks and benefits. In the event that I choose to proceed with HT based on my treatment plan and in consultation with my healthcare provider, then I consent to the administration of HT.