Informed Consent for Hormone Therapy for Masculinizing Hormones

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

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

• Acne 
• Increased muscle mass and strength
• Increased red blood cells (increased hemoglobin)
• Increased or decreased sex drive, sensation, and sexual function
• Menstrual cycles (periods) and ovulation may stop or become infrequent. Vaginal tissues may thin or become dry

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

• Deepening of voice
• Hair changes:
  • Increased thickness and quantity, darker color, and wider distribution of facial and body hair
  • Hair loss at temples and scalp may begin or worsen
• Fat redistribution
• Genital changes (enlargement of clitoris & labia)
• Increased bone density
• Reduced ovulatory function could cause infertility. Egg harvesting prior to starting HRT is recommended if you desire a biological child

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

• Heart disease and high blood pressure
• Increased cholesterol
• Liver inflammation (abnormal liver enzymes)
• Polycythemia (increased hemoglobin/red blood cells). If untreated, it can cause headache, dizziness, heart attack, confusion, visual disturbances, or stroke.
• Sleep apnea
• Type 2 diabetes
• Weight gain

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. Talk to your provider if you want more information about pregnancy prevention or schedule an ehealth contraception visit at https://myuhs.uhs.wisc.edu.
• 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.
• Testosterone is not a protection from ovarian, uterine, cervical, or breast cancer. Routine screening is recommended based on age and other risk factors.

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 that testosterone is a controlled substance. It is my responsibility to deliver the paper prescription promptly to my pharmacy and to store medication vials safely. My provider is required to monitor my records via the Wisconsin Enhanced Prescription Drug Monitoring program or ePDMP (https://pdmp.wi.gov/) when they prescribe more than a 3 day supply of a controlled substance. It may be difficult to fill your testosterone prescription across state lines so check with your provider prior to breaks/traveling to make a plan and ensure you have an adequate supply
• 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: _______________________

CF225 Final 11/13/18

Informed Consent for Hormone Therapy for Masculinizing Hormones (PDF version)