Viking Alternative Medicine HRT Disclosure and Consent Form

Potential side effects related to HRT protocols and dosing include but are not limited to the following:

• Acne
• Breast/nipple soreness.
• Decreased sperm count. Caused by exogenous testosterone regardless of HCG/Gonadorelin use.
• Excessive hair growth.
• Gynecomastia. Can be genetic due to higher levels of estrogen conversion.
• Increased blood pressure. Can be due to elevated HCT.
• Possibility of increased prostate specific antigen labs due to stimulation (sexual activity, heavy leg exercise, etc). This will be monitored and will likely be referred to primary care physician or urology for evaluation if still elevated. HRT may be put on hold until medically cleared.
• Increased red blood cell production which leads to elevated hemoglobin and/or hematocrit. Testosterone increases red blood cell production and routine blood donations or therapeutic phlebotomies will be needed at least 3-4 times a year.
• Irritability. Can be related to estradiol imbalance.
• Pain and swelling at injection site. Initial irritation due to improper cleaning techniques or sensitivity to a carrier oil. If not resolved with adjustments, then primary care physician follow up and antibiotics may be required.
• Testicular shrinkage. Common in approximately 20% of patients.
• Water retention/bloating. Can be due to estradiol imbalance.
• Weight gain. Between 2 and 5 pounds is expected due to increased muscle mass.

CAUTION- If you are pregnant, intend to become pregnant, or you are breastfeeding HRT is not recommended and can potentially lead to fetal malformation.

I HAVE READ AND UNDERSTAND THE POTENTIAL SIDE EFFECTS OF HRT AND WOULD LIKE TO PROCEED WITH TREATMENT.