Patient Name: ______________________________________________ Date of Birth: _____________
Physician/Practitioner: ________________________________________
Patients who are not sterilized and not menopausal are advised to continue reliable birth control while participating in pellet hormonal replacement therapy. Testosterone is category X (will cause birth defects) and cannot be given to pregnant women. YOU MUST BE POSTMENOPAUSAL, STERILIZED, OR USE HIGHLY EFFECTIVE BIRTH CONTROL IN ORDER TO RECEIVE HORMONE PELLETS!
My birth control method is: (please circle)
Abstinence Birth control pill NuvaRing Hysterectomy Depo Provera IUD
Menopause Tubal ligation Nexplanon Vasectomy Other
What are bioidentical hormone pellets?
Bioidentical hormone pellets are concentrated hormones, slightly larger than a grain of rice, that are placed under the skin and slowly release into the bloodstream. They are designed to last for 3 to 6 months giving patients a steady level of natural estrogen and/or testosterone to help alleviate symptoms related to hormone deficiency or imbalance. Because hormone pellets are made by compounding pharmacists, they are not FDA approved.
Initial______
How long have hormone pellets been in use?
Hormone pellets have been used since the 1930’s. Pellets were more widely used up until the 1970’s when hormone pills became available. Today, hormone pellets are more widely used in Europe and Australia than in the United States.
Initial______
What are some of the risks of estrogen and testosterone hormone pellet insertion?
- Bleeding, infection, pain, and allergic reaction at the insertion site
- Uterine bleeding
- Breast tenderness and swelling
- Increased facial hair growth, loss of hair on scalp, acne, deepening of voice, clitoral enlargement
- Fluid retention/swelling, mood swings and irritability
- Growth of preexisting estrogen dependent tumors (e.g. breast cancer, endometrial cancer)
- Birth defects if an unborn baby is exposed to testosterone
- Blood clots
- Growth of preexisting liver tumors
Initial______
What are some of the benefits that I might experience from estrogen and testosterone pellets?
- Decreased hot flashes and night sweats
- Decreased hormone related mood swings, anxiety, and irritability
- Improved sleep and energy
- Decreased hormone related headaches
- Improved sex drive, vaginal lubrication and sensation
- Improved sense of well-being
- Increased muscle mass and bone strength
Initial______
What are other means of hormone replacement?
Other available hormone delivery systems include pills, injections, creams, patches and vaginal inserts. Each has its advantages and disadvantages. Pellets offer the convenience of dosing every 3 to 6 months and consistent hormone levels. It is often reasonable for a patient to use no type of hormone replacement therapy.
Initial______
How long does it take before my symptoms will improve?
Most patients notice some improvement of symptoms within the first few days after hormone pellet insertion. Some patient will notice continued improvement of symptoms up to several months after the insertion.
Initial______
What should I do if I experience any problems or have any side-effects?
You should call your doctor or practitioner with any related problems or questions that arise after hormone pellet insertion. Many questions might be answered by reviewing the written information that has been provided to you.
Initial______
If I still have my uterus can I still use hormone pellets?
Yes, but if you are receiving estrogen pellets you must take some form of progesterone to protect your uterine lining.
Initial______
I understand and agree to follow the nationally recommended guidelines regarding regular breast examinations, pelvic examinations, mammograms, and pap smears. I will also continue to see a primary care provider for routine recommended screening and monitoring of chronic medical conditions.
Initial______
My signature below signifies that I have reviewed the above information and have been informed of the risks, benefits, and alternatives to hormone pellet therapy. I understand the risks and benefits of not treating my symptoms. I have been given ample opportunity to ask my doctor/practitioner questions that have been answered to my satisfaction. I hereby consent to the hormone pellet insertion procedure.
_____________________________________ ________________________________
Patient Signature Witness Signature
_____________________________________
Physician/Practitioner Signature