Hormone Agreement form

Nancy Lonsdorf, MD
1100 N 4^th St Suite 211
Fairfield, IA 52556
641-469-3174

Consent for Use of Bioidentical Hormone Replacement Therapy (BHRT)

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.

1. Breast exam: An annual palpation breast exam by a health practitioner
2. Breast imaging: Yearly or bi-annual (at least every other year) Breast Ultrasound or Mammogram exam
3. Breast self-exam: Do monthly breast self-exams on myself.
4. Pelvic exam: I will have an annual or bi-annual pelvic exam by a health practitioner.
5. Pap Smear: I will have pap smear test at least every 3 years, up to age 75.

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.

Reported Benefits of using Bioidentical Hormone Replacement Therapy:

1. Improvement in numerous symptoms of menopause: hot flashes, night sweats, insomnia, slowed thinking, loss of libido (sex drive), vaginal dryness
2. Decreased Osteoporosis
3. Better vaginal and bladder health, decreased risk of urinary tract infections
4. Improved sleep
5. Better skin texture and reduced hair loss
6. May help Depression, Anxiety, Irritability, and other Mood problems
7. Decreased risk of Alzheimer’s disease, dementia, or memory problems
8. Decreased cardiovascular risk, with improved lipids and blood pressure
9. Decreased joint pain

REPORTED RISKS of taking Bioidentical or other Hormone Replacement Therapy:

1. Abnormal uterine bleeding, Fibroid growth and /or Uterine Cancer, especially if estrogen is given without progesterone in women who have a uterus.  (Dr. Lonsdorf does not prescribe estrogen without progesterone in women with a uterus.)
2. Deep Vein Thrombosis or Pulmonary emboli if oral estrogen used (by mouth), this risk has not been shown with transdermal estradiol.
3. Breast Cancer risk may be increased in some women however this has never been demonstrated in a controlled trial. One study with Premarin alone (a horse-derived estrogen mix) showed a decreased risk.
4. Excess testosterone or DHEA in women may be associated with increased facial hair, acne, scalp hair loss, lowered voice, increased sex drive or some other unknown effects. These are usually dose-related side effects.
5. Other potential risks may include: cramps, headaches, migraines, breast tenderness, weight loss or gain, nausea, bloating, irritability, fluid retention or some other unlisted or unknown effects.

Treatment Alternatives:

1. I understand that one alternative is simply NOT to take any hormone replacement/substitution therapy.
2. Other treatment alternatives include: herbs, vitamins, diet, antidepressants, deep breathing, exercise, lifestyle changes, blood pressure medications, other pharmaceuticals, or simply doing nothing.
3. The possible risks of alternative treatment, if any, include: side effects from the herbs, vitamins or medications.
4. The alternative treatment simply may not work.
5. On the other hand, the alternative treatments may be adequate to improve menopausal symptoms and turn around memory and cognitive issues.
6. Taking hormones is one option and is decided on an individual basis by you in collaboration with your doctor. You may decide at any time to stop use of hormones.  In such a case, please inform Dr. Lonsdorf who may suggest a taper schedule to avoid possible sudden increase in symptoms.

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 and on following document, 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.