Informed consent for hormone therapy for feminizing hormones

The full medical effects and safety of hormone therapy are not known

Potential reversible effects may include, but are not limited to:

• Changes in cholesterol and/or fats (hypertriglyceridemia) in the blood
• Changes in sex drive and sexual function (decreased libido and loss of spontaneous erections)
• Decreased muscle mass and strength
• Decreased number of red blood cells (anemia)
• Hair and skin changes:
  • decreased acne
  • decreased thickness and quantity of facial and body hair
  • hair loss at the temples or scalp may halt or slow
  • softer skin
• Increased migraine headaches
• Patients on androgen blockers may experience increased thirst, more frequent urination, lightheadedness, and elevated potassium in the blood, which can cause abnormal heart rhythms

Potential irreversible effects may include, but are not limited to:

• Breast growth
• Decreased bone density
• Fat redistribution
• Genital changes (smaller testes & penis)
• Decreased sperm production that could cause infertility. Sperm banking prior to starting HRT is recommended if you desire a biological child in the future.

HRT may be associated with an increased risk of the following:

• Blood clots, deep vein thrombosis, pulmonary embolism, and stroke
• Breast tumors/cancer
• Gallstones
• High blood pressure, heart disease
• Liver inflammation (abnormal liver enzymes)
• Pituitary tumors (tumor of a small gland in the brain which makes prolactin)
• Type 2 diabetes

The risks for some of the above adverse events may be INCREASED by:

• Pre-existing medical conditions
• Pre-existing psychiatric conditions 
• Cigarette smoking
• Alcohol use

We know hormone therapy is life-affirming care, but some side effects from hormones are irreversible and could cause death in rare circumstances.

Sexual and reproductive health:

• HRT does not reliably prevent pregnancy.
• HRT provides no protection from sexually transmitted infections including HIV
• Condoms and barrier methods are recommended. 
• A daily pill called PrEP or Truvada can significantly decrease risk of HIV infection. Talk to your provider if you want more information about PrEP.

Mental health:

• Changes in mood or pre-existing mood disorders such as depression, suicidal feelings, anxiety, and psychosis (disorganization and loss of touch with reality) may occur.
• Many patients report significant improvement in overall quality of life.
• Changes in relationships, academic, work, and other support networks can occur during transition.

We offer support and can help you connect with resources in the community.

• UHS Mental Health Services provides individual and group therapy for students who experience symptoms of anxiety or depression, want to explore gender identity, seek support for acts of bias or discrimination, or other concerns.
  • Access appointments can be scheduled online at https://myuhs.uhs.wisc.edu or by calling 608.265.5600 (24/7 crisis support available).
• UW-Madison's Gender and Sexuality Campus Center (https://lgbt.wisc.edu) makes referrals to resources for community support, education, and crisis response.

My signature below constitutes my acknowledgement of the following:

• My medical provider has discussed the nature and purpose of HRT; the benefits and risks, including the risk that HRT may not accomplish the desired objective; the possible or likely consequences of HRT; and all feasible alternative diagnostic or treatment options.
• I have read and I understand the above information about HRT, and accept the risks involved.
• I have had sufficient opportunity to discuss my concerns and treatment with the medical provider. All questions have been answered to my satisfaction.
• I have adequate knowledge to make an informed consent decision about HRT.
• I authorize and give my informed consent to start hormone therapy.
• I understand my eligibility to receive medical care and prescriptions for HRT from UHS ends when my UHS eligibility ends with graduation or transfer from the University of Wisconsin-Madison. Refer to UHS website for eligibility dates and information: https://www.uhs.wisc.edu/about-uhs/.
  • Summer break: Students who aren’t enrolled in summer classes or covered by SHIP insurance can pay the one-time summer fee to receive services. 
  • Graduation/transfer/academic leave: Please schedule an appointment with your UHS provider before your eligibility ends so we can help you transfer medical care and prescriptions to a new provider in the community.

Signature of Patient Date: _______________________ Date: _______________________

Printed Name: _______________________

Signature of Provider: _______________________ Date: _______________________

Printed Name: _______________________

CF226 Final 11/13/18

Informed consent for hormone therapy for feminizing hormones (PDF version)