BHRT Consent Form

What Is BHRT?

BHRT is a treatment designed to alleviate symptoms caused by hormonal imbalances, such as those related to menopause, andropause, or other conditions affecting hormone levels. BHRT uses hormones that are chemically identical to those produced by the human body.

Common hormones used in BHRT include, but are not limited to:

• Estrogen (estradiol, estriol)

• Progesterone

• Testosterone

• Dehydroepiandrosterone (DHEA)

• Thyroid hormones (T3, T4)

Potential Benefits of BHRT

BHRT is intended to address symptoms that may include:

• Hot flashes, night sweats, and other menopausal symptoms

• Decreased libido or sexual dysfunction

• Fatigue or lack of energy

• Sleep disturbances

• Mood changes, depression, or anxiety

• Weight gain or changes in body composition

• Cognitive difficulties, including memory issues

Potential Risks and Complications of BHRT

While many patients experience relief from symptoms, BHRT may involve risks and potential complications. By signing this form, you acknowledge that you understand these risks, which include, but are not limited to:

• Increased Risk of Cancer: Hormone therapy may increase the risk of certain cancers, including breast, ovarian, and endometrial cancer.

• Cardiovascular Risks: BHRT may increase the risk of heart disease, stroke, blood clots, or high blood pressure.

• Liver Dysfunction: Hormone therapy can affect liver function.

• Gallbladder Disease: BHRT may increase the risk of gallbladder problems.

• Breast Tenderness/Enlargement: Some patients may experience changes in breast tissue.

• Mood Changes: Hormones can sometimes lead to irritability or anxiety.

• Weight Gain or Fluid Retention: BHRT may cause weight changes or swelling due to fluid retention.

• Other Side Effects: Headaches, dizziness, nausea, fatigue, and skin reactions (e.g., rash at application sites) may occur.

Cancer Risk Mitigation

• For Women: Women with a uterus must take progesterone alongside estrogen to reduce the risk of endometrial cancer.

• Screening: Regular screenings, including mammograms, Pap smears, pelvic exams, and other cancer screenings, are required as part of BHRT treatment to monitor for potential risks.

• Alternatives: Options such as non-hormonal therapies and selective estrogen receptor modulators (SERMs) may be considered in certain high-risk individuals.

Duration of Treatment

The duration of BHRT varies based on individual needs and treatment goals. You may require ongoing treatment to maintain hormone balance, and your provider will regularly assess whether to continue or adjust the treatment.

Alternatives to BHRT

You have been informed of alternative treatments to BHRT, including:

• Non-hormonal therapies (e.g., SSRIs, SNRIs, Gabapentin for menopausal symptoms)

• Lifestyle modifications (e.g., diet, exercise, stress management)

• No treatment (allowing symptoms to persist without medical intervention)

Pregnancy and Hormone Therapy

BHRT is contraindicated in pregnant women or those trying to conceive. You confirm that you are not pregnant and do not intend to become pregnant while undergoing BHRT. You agree to notify your healthcare provider immediately if you become pregnant.

Patient Responsibility

• Medical History: I confirm that I have provided a full and accurate medical history, including any history of cancer, cardiovascular disease, liver or gallbladder disease, and other significant medical conditions.

• Lifestyle Modifications: I acknowledge that a healthy lifestyle, including a balanced diet, regular exercise, and stress management, is recommended to optimize BHRT outcomes.

• Regular Follow-ups: I understand the importance of regular follow-up appointments and lab tests to monitor hormone levels and my health during BHRT treatment.

No Guarantees

I understand that while BHRT may alleviate symptoms, there is no guarantee that the treatment will be successful or that I will experience relief from symptoms. The results of BHRT can vary significantly between individuals.

Acknowledgment of Understanding

By signing this consent form, I acknowledge that:

• I have read this document in full or have had it read to me.

• I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction.

• I have been provided with information about the benefits, risks, and alternatives to BHRT.

• I understand that BHRT involves certain risks, including the potential for serious health conditions such as cancer and cardiovascular disease.

• I am aware that no guarantees or assurances have been made as to the results of the therapy.

• I understand that I am free to withdraw from BHRT at any time, but doing so may lead to the recurrence of symptoms.

• I agree to follow my provider’s recommendations, including regular screenings and follow-up appointments.

Release of Liability

By signing this form, I acknowledge that I have been fully informed about the nature of BHRT and its potential risks and benefits. I agree to release my provider, the clinic, and all associated medical staff from any liability arising from the administration of BHRT, except in cases of gross negligence or willful misconduct.