Form ### Transgender Hormone Therapy - Estrogen Informed Consent SAMPLE
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- Buddy Lyons
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1 What are the different medications that can help to feminize me? Estrogen - Different types of the hormone estrogen can help you appear more feminine. Estrogen is the female sex hormone. Androgen blocker (Spironolactone) - This medication can help you to appear less masculine. Androgen blockers are also called androgen antagonists or antiandrogens. Androgen is the male sex hormone. How is estrogen taken? Estrogen can be taken as a: skin patch or skin cream pill an injection (rarely) How is an androgen blocker taken? An androgen blocker is usually a pill Warning --- Who should not take estrogen? Estrogen should not be used by anyone who has a history of: an estrogen-dependent cancer a disorder that makes them more likely to get blood clots that could travel to the lungs (unless they are also taking blood thinners and are followed by a specialist) Warning --- Who should not take an androgen blocker? Spironolactone should not be taken by anyone who has a history of: Acute kidney failure or significant kidney impairment Chronic high potassium levels (hyperkalemia) Use with Caution Estrogen is used with caution and only after a discussion of risks by anyone who: has a strong family history of breast cancer or other cancers that grow quicker when estrogens are present has a family history of blood clots has diabetes has eye problems such as retinopathy has heart disease, heart valve problems, or a tendency to have easily clotted blood has hepatitis or other serious liver problems has high cholesterol, high lipids has kidney or liver disease has migraines or seizures is obese is a smoker Page 1 of 9
2 Feminizing Effects of Estrogen and Androgen Blockers I know that estrogen or androgen blockers or both may be prescribed to feminize my appearance. I know it can take several months or longer for the effects to become noticeable. I know that no one can predict how fast or how much change will happen. I know that if I am taking estrogen I will develop breasts. I know it takes several years for breasts to get to their full size. I know the breasts will remain, even if I stop taking estrogen. I know I might have a milky discharge from my nipples galactorrhea. If I do, I know I should check it out with my health care provider because it could be caused by the estrogen or by something else. I know that while we do not know the exact risk, my risk of breast cancer may be increased to as high as if I had been born female I know that I should take care of my breasts like every other woman. This includes annual breast exams from my health provider, and when I am older, regular mammograms. I know that the following changes are usually not permanent they are likely to go away if I stop taking the medicines. I know my body hair will become less noticeable and will grow more slowly. But it won t stop completely, even if I take the medicines for years. I know I will probably have less fat on my abdomen. Taking hormones will redistribute the fat to my buttocks, hips, and thighs. I know that if I have the predisposition to have male pattern baldness, it may start later than it would have, but may not stop completely. If I stop taking hormones I may lose my hair faster than if I hadn t taken hormones. I know I may lose muscle and strength in my upper body. I know that my skin may become softer. Page 2 of 9
3 I know that my body will make less testosterone. This may affect my sex life in different ways and future ability to cause a pregnancy: I know my sperm may no longer get to mature. This could make me less able to cause a pregnancy. I know that I might still get someone pregnant if we have vaginal intercourse and we don t use birth control. I know there may be options for banking my sperm and I know I can get more information about this by asking my health care provider. I know that my testicles may shrink down to half their size. Even so, I know that they are part of my body and that I need to take care of them unless I have surgery to remove them. This means that I will need regular checkups for them. I know that I won t have as much cum when I ejaculate. I know it is likely that I won t be hard in the morning as often as before. And it is likely that I will have fewer spontaneous erections. I know I may not be able to get hard enough for penetrative sex. I know that I may want to masturbate or have sex less and may find it harder to cum when I do. I know this treatment may (but is not assured to) make me permanently unable to make a woman pregnant. I know that some parts of my body will not change much by using these medicines. I know the hair of my beard and moustache may grow more slowly than before. It may become less noticeable, but it will not go away unless I have treatments like electrolysis. I know the pitch of my voice will not rise, and my speech patterns will not become more like a woman s. I know my Adam s apple will not shrink. Although these medicines can t make these changes happen, there are other treatments that may be helpful. I know that there may be mood changes with these medicines. I know if I have any concerns about these issues, you can make referrals for me to help me explore other treatment options. Page 3 of 9
4 Risks of Feminizing Medications I know that the side effects and safety of these medicines are not completely known. There may be long-term risks that are not yet known. I know not to take more medicine than I am prescribed. I know it increases health risks. I know that taking more than I am prescribed won t make changes happen more quickly or more significantly. I know these medicines may damage the liver and may lead to lead to liver disease. I know I should be checked for possible liver damage as long as I take them. I know these medicines cause changes that other people will notice. Some transgender people have experienced discrimination because of this. I know my health care provider can help me find advocacy and support resources. Risks of Estrogen I know that taking estrogen increases the risk of blood clots or problems with blood vessels that can result in chronic problems with veins in the legs heart attack pulmonary embolism blood clot to the lungs which may cause permanent lung damage or death stroke, which may cause permanent brain damage or death I know that the risk of blood clots is much worse if I smoke cigarettes. I know the danger is so high that I should stop smoking completely if I start taking estrogen. I know that I can ask my health care provider for advice about how to stop smoking. I know taking estrogen can increase the deposits of fat around my internal organs. This can increase my risk for diabetes and heart disease. I know taking estrogen can raise my blood pressure. I know that if it goes up, my health care provider can work with me to try to control it with diet, lifestyle changes, and/or medication. I know that taking estrogen increases my risk of getting gallstones. I know I should talk with my health care provider if I get severe or long-lasting pain in my abdomen. Page 4 of 9
5 I know that estrogen can cause nausea and vomiting. I know I should talk with my health care provider if I have long-lasting nausea or vomiting. I know that estrogen can cause migraines or make them worse if I already have them. I know I should talk with my health care provider if I have headaches or migraines often or if the pain is unusually severe. I know that it is not yet known if taking estrogen increases the risk of non-cancerous tumors of the pituitary gland (prolactinomas). I know they are not usually life threatening, but they can damage vision and cause headaches if they are not treated properly. I know that changes in vision, headaches that are worse when I wake up in the morning and milky discharge from my nipples can be signs of a prolactinoma, and I should talk to my health care provider if I develop these symptoms. There is a blood test that can check for this. I know that I am more likely to have dangerous side effects if I smoke I am overweight I have a personal or family history of blood clots I have a personal or family history of heart disease and stroke my family has a history of breast cancer Risks of Androgen Blockers I know that an androgen blocker can affect the balance of water and salts in the kidneys. This may increase the amount of urine I produce, making it necessary to urinate more frequently. increase thirst. rarely, cause high levels of potassium in the blood, which can cause changes in heart rhythms that may be life threatening. reduce blood pressure. I know some androgen blockers make it more difficult to evaluate test results for cancer of the prostate. This can make it more difficult to check up on prostate problems. I know that if I am over 50, I should discuss appropriate prostate cancer screening with my care provider. I know that even if I have genital sex reassignment surgery the prostate is not usually removed. Page 5 of 9
6 Prevention of Medical Complications I agree to take feminizing medications as prescribed. And I agree to tell my care provider if I have any problems or am unhappy with the treatment. I know that the dose and type of medication that s prescribed for me may not be the same as someone else s. I know I need periodic physical exams and blood tests to check for any side effects. I know that in addition to periodic checks from my provider, I must also treat my body with respect. This means that paying attention and talking to my provider if I develop any symptoms that might be side effects from medicines. This also means keeping my partners and myself safe, when and if I choose to have sex with others, by using condoms or methods to keep me safe from sexually transmitted infections (STIs). I know that feminization medications can interact with other drugs and prescribed and over the counter medicines. These include alcohol, diet supplements, herbs, other hormones, and street drugs. This kind of interaction can cause dangerous complications. I know that I need to prevent complications because they can be life threatening. That s why I need to be honest with my provider about whatever else I take. I also know that I will continue to get medical care here no matter what I share about what I take. I know that it can be risky for anyone with the following conditions to take these medicines. I agree to be evaluated if my health care provider if he or she thinks I may have one of them. Then we will decide if it s a good idea for me to start or continue using them: strong family history of breast cancer or other cancers that grow quicker when estrogens are present family history of blood clots diabetes eye problems such as retinopathy heart disease, heart valve problems, or a tendency to have easily clotted blood hepatitis or other serious liver problems high cholesterol, high lipids kidney or liver disease migraines or seizures obese smoker Page 6 of 9
7 I know that I may be asked to stop taking estrogen before any major surgery or when I may be immobile for a long time (for example, if I break my leg and am in a cast). This will lower the risk of getting blood clots. I know I can start taking estrogen again after I recover or when my health care provider says it is okay. I know that even if I have to stop my estrogens, I may still be able to take the testosterone blockers that I am on, to help prevent the effects of my testicles producing testosterone again. I know that using these medicines to feminize is an off-label use. I know this means it is not approved by the Food and Drug Administration (FDA). I know that the medicine and dose that is recommended for me is based on the judgment and experience of my health care provider and the best information that is currently available in the medical literature. I know that I can choose to stop taking these medicines at any time. I know that if I decide to do that, I should do it with the help of my health care provider. This will help me make sure there are no negative reactions. I also know my health care provider may suggest that I cut the dose or stop taking it at all if certain conditions develop. This may happen if the side effects are severe or there are health risks that can t be controlled. Alternatives There are alternatives to using feminizing medicines to help people appear more feminine. Some transgender people choose to not take hormones or have surgery and may only socially transition. If you are interested in alternatives, talk with your health care provider about your options. Page 7 of 9
8 My signature below confirms that My health care provider has talked with me about the benefits and risks of taking feminizing medication, the possible or likely consequences of hormone therapy and potential alternative treatments I understand the risks that may be involved. I know that the information in this form includes the known effects and risks. I also know that there may be unknown long-term effects of risks. I have had enough opportunity to discuss treatment options with my health care provider. All of my questions have been answered to my satisfaction. I believe I know enough to give informed consent to take, refuse, or postpone therapy with feminizing medications. Legal Name (printed) Preferred Name (if different, printed) Legal Signature Date and Time Prescribing health care provider signature Date and Time Page 8 of 9
9 This client does not speak English, interpretive services were provided by Hospital # Interpreter name and type of Interpretive Date service (on site, telephonic etc.) Page 9 of 9
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