Consent for Use of Bioidentical Hormone Replacement Therapy (BHRT)
Nancy Lonsdorf, MD1100 N 4th St Suite 211Fairfield, IA 52556641-469-3174
Estradiol, Estriol, Progesterone, Dehydroepiandrosterone (DHEA), and Testosterone are hormones which may be given in any variety of combinations, delivery routes, and dosages depending on my own individual requirements.
Bioidentical hormones are those that are identical to those produced by human ovaries, adrenals or other tissues. They are not synthetic (i.e. made in a lab and chemically different from human hormones,) or altered human hormones or derived from animals. Dr. Lonsdorf only prescribes bioidentical hormones, ones that precisely match the body’s own hormones.
I have consulted with Dr. Nancy Lonsdorf about the potential risks and benefits of using hormone replacement therapy (HRT), which are summarized below. I have reviewed the results of the Women’s Health Initiative Studies and understand that the hormones used in those studies were not bioidentical and not the same as those Dr. Lonsdorf prescribes, which are bioidentical, as described above.
I understand that taking any Drug, Hormone or other Medication carries some risk, no matter how natural to the body, including bioidentical hormones.
Therefore, I agree to maintain the recommended regular schedule of well woman care, and will obtain the following:
I will provide Dr. Lonsdorf with a copy of these reports annually or biannually, in order to begin or continue Bioidentical Hormone Treatment. (BHRT)
An annual follow-up visit is required with Dr. Lonsdorf each year for renewal of BHRT, and testing of hormone levels is required at least once a year to assure that hormonal balance is achieved, and that levels are both safe and effective.
I understand that spotting or bleeding can be normal in the first 3 to 6 months on the hormones.
I agree to report any vaginal bleeding after 6 months of starting BHRT to the doctor, as bleeding that occurs after a woman has completed menopause is one of the warning signs of possible uterine cancer. It will need further in-person examination and evaluation by an OB/GYN doctor.
Reported Benefits of using Bioidentical Hormone Replacement Therapy:
REPORTED RISKS of taking Bioidentical or other Hormone Replacement Therapy:
I have read and understand the risks above.
I have read and understand the alternatives to BHRT as listed above.
I understand the risks to me as an individual vary greatly, and can be greater or less than those found in studies. Medical science is always learning new information; this could include the discovery of other significant risks to me besides the ones listed above.
In signing below, I agree that I have read and understand the above discussion, had my questions answered, am aware of the potential risks and benefits, and agree to follow the recommendations given above. I wish to proceed with the Bioidentical Hormone Replacement Therapy.
Physician Declaration: To the best of my knowledge, I believe the patient has been adequately informed and has consented to the use of Bioidentical hormones.
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Signed by Nancy K. Lonsdorf
Signed On: December 22, 2020
If you have questions about the contents of this document, you can email the document owner.
Document Name: Consent for Use of Bioidentical Hormone Replacement Therapy (BHRT)
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