TRUST WOMEN Patient Registration Form PLEASE PRINT ...

Trust Women 1240 SW 44th St Oklahoma City, OK 73109 405.429.7940

TRUST WOMEN Patient Registration Form

PLEASE PRINT

Legal First Name ____M.I. _

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Date of Birth: _____/______/________ Age:_____________

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Please answer this question even if you plan to pay cash today. This helps us help you with contraception options and lab tests. Please give card to reception.

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CONTACT INFORMATION: We need accurate contact information to notify you of any abnormal medical findings. You must give us some way to contact you. If your phone does not accept blocked numbers, we may not be able to guarantee confidentiality. If this may cause a problem please discuss this with a staff member. Non-identifying information may be used for program evaluation and research. In case of an emergency or life threatening medical condition, confidentiality may be broken.

I verify that I have answered these questions to the best of my ability. I am financially responsible for any balance due.

PATIENT NAME: ________________________SIGNATURE__________________________________ DATE: ___/___/____ TIME ____: ____

Reviewed and discussed by staff: __________________________________________________ DATE: _______/_______/_________

Physician Name: _______________________Signature: ___________________________________ DATE: ___/___/____ TIME ____: ____

TRUST WOMEN

1240 SW 44th StOklahoma City, OK 73109

Phone: (405) 429-7940

Health Information Portability and Accountability Act

(HIPAA)

This notice describes how medical information about you may be used and disclosed and how you can get access to this

information. Please review the HIPAA privacy notice carefully. Passage of HIPAA occurred to improve the efficiency and effectiveness of the health care system by standardizing the

transmission of certain transactions and protecting the privacy and security of the patient’s personal health

information. Privacy Rule essentially controls the use and disclosure of protected health information (PHI). The Security Rule protects

and safeguards confidentiality of medical information and information that could identify an individual. Trust Women understands that your medical information is private and confidential. All Physicians and staff must

adhere to these policies.

As required by law, the HIPAA privacy notice provides you with information about your rights and our legal duties and

privacy practices with respect to the privacy of protected health information. You can request a written copy of our

most current privacy notice. If you have any questions or would like furthering information about this notice, please contact Trust Women.

I, , acknowledge that I have been offered a copy of Trust Women's Privacy Notice and I have read that information that is posted in the lobby.

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Trust Women's Privacy Policy I have read Trust Women's privacy policies and patient bill of rights and have been offered a copy.

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Trust Women's Advance Directive Policy

I have read Trust Women's Advance Directive Policy and have been offered a copy.

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Patient Consent for Text and Voice Appointment Reminders and Messaging

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I ____ Do OR ____ Do NOT give my express consent to receive automated text and voice messaging to the number listed above.

Patient/ Guardian Name _____________________________________________ Patient/ Guardian Signature __________________________________________

Trust Women 1240 SW 44th Oklahoma City, OK 73109 405.429.7940

TRUST WOMENHealth History

Please print your full name here: _____________________________________________Date of birth: _____/______/______ Do you have any allergies to medications, metals, latex, rubber gloves, tape, shellfish, or antiseptic solutions (iodine/Hibiclens)?

NO YES If yes, list allergy and reaction: ___________________________________________________________________ Have you ever had a bad reaction to anesthesia or sedation? NO YES explain: ____________________________________ Current medications: _________________________________________________________________________________________

SOCIAL HISTORY

No Yes

Do you smoke or chew tobacco? If yes, how many/much a day? _____________

Do you drink alcohol? If yes, how often and how much? ____________________________________________________

Have you ever used street or IV drugs? ____________________________________________________

CONTRACEPTIVE HISTORY Are you interested in getting birth control today? no yes If yes, what: ____________________________________________ What birth control method are you currently using?__________________________________________________________________ What methods have you used in the past? _________________________________________________________________________ Any problems with your previous methods? no yes If yes, explain: ______________________________________________

PREGNANCY HISTORY (Please include current pregnancy) When was the first day of your last menstrual period?_____/_____/_______ Are you breastfeeding now? no yes Number of: Pregnancies _____ Vaginal deliveries _____ C-sections _____ Miscarriages ____ Abortions ____ Ectopic(tubal) ____ When did your last pregnancy end? _____/_____/_______ Any complications? ________

PAST MEDICAL HISTORY Have you EVER had any of the following: No Yes No Yes

Heart disease or serious heart valve problem Uterine abnormalities/fibroids

Pulmonary Embolism (PE), heart attack, or stroke Seizure or epilepsy Bleeding problems or anemia Asthma, breathing problems, other lung

disease Serious medical problems, hospitalizations, surgeries: _______________________________________

Migraine

REVIEW OF SYSTEMS: Do you NOW have any of the following: No Yes No Yes

Cardiovascular: Severe chest pain Respiratory: Difficulty breathing Neurological: Migraine OR severe headache Genitourinary: Severe/persistent pelvic pain Endocrine: Excessive thirst or night sweats Genitourinary: Abnormal discharge or itching Lymph: Painful or swollen glands in your groin Genitourinary: Severe pain with periods Gastrointestinal: nausea or severe abdominal pain Mouth: Bumps or sores in the mouth Chest/Breast: lump, constant pain, or nipple discharge

Patient signature: ______________________________________________________________ Date: ______/______/________

Trust Women 1240 SW 44th St Oklahoma City, OK 73109 (405) 429-7940

TRUST WOMEN

Authorization for Release of Information to Family Members/Friends

Patient Name: ______________________________ Date of Birth: ____________________________ (PRINT)

Many of our patients allow family members such as their spouse, parents or others to call and request medical or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical or billing information released to friends/family members, you must sign this form. Only individuals listed on this form will be authorized to obtain/inquire about medical and billing information for the patient.

I authorize Trust Women to release and discuss my medical and/or billing information to the following individual(s):

1.____________________________________ Relation to Patient:___________________________

2.____________________________________ Relation to Patient:___________________________

3.____________________________________ Relation to Patient:___________________________

______ I do not authorize any individuals to inquire/request medical information regarding my treatment at Trust Women.

SIGNATURE:__________________________________________________ DATE:__________________

PATIENT INFORMATION I understand I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed.

I understand that information disclosed to any above recipient is no longer protected by federal or state law and may be subject to redisclosure by the above recipient.

I have the right to revoke this consent in writing at any time.

Trust Women 1240 SW 44th St Oklahoma City, OK 73109 (405) 429-7940

AUTHORIZATION FOR THE RELEASE OF MEDICAL RECORDS AND CANCELLATION OF FUTURE APPOINTMENTS

Patient’s Name: _____________________________ Date of Birth: _______________

Address: ___________________________________ Home Phone: _______________

__________________________________ Other Phone: _____________

Email: ____________________________________

REQUESTING RECORDS FROM: ________________________________ ________________________________ ________________________________

MAIL OR FAX RECORDS TO: Trust Women 1240 SW 44th St OKC, OK 73109Phone: (405) 429-7940 Fax: (316) 425-3451

Please release medical records pertaining to the following:

_____________________________________________________________________________________

Reason for requesting records:

_____________________________________________________________________________________

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I authorize the release of the above requested records, including those, which may contain confidential HIV/AIDS related information, confidential communicable disease related information, confidential information related to mental health, drug and/or alcohol use, or sexual history, and that the records be forwarded to the above name and address. I further authorize that these medical records may be faxed if necessary. I understand that I may revoke this authorization at any time, except to the extent that action based upon this authorization has already been taken. I have given my consent freely, voluntarily, and without coercion.

_______________________________ _____________________ ____________ Patient Signature Relationship to Patient Date (or parent/legal guardian if minor)

Authorization to Bill Insurance

I decline to have my insurance billed for the services received today.

Patients Printed Name:_____________________________ Date of appointment: ____________________

Patients Signature: ________________________________

If you agree to have your insurance billed for the services received, please continue to fill out the information below.

SECTION 1: Patient Information

Last Name: ________________ First Name_________________________ Middle Initial: _____

DOB:_________ SS#: ________________ Daytime Phone: (_________)_______________

SECTION 2: Guarantor Information

This section must be completed if someone other than the patient is financially responsible for the patient’s account.

Last Name: _____________________ First Name: _______________ Middle Initial: _________

Address: ____________________ City: _______________ State: _______ Zip: ___________ Phone:

(_______)____________

I hereby acknowledge that I am financially responsible for payment of all services rendered to the above-

named patient and that I am subject to all financial terms listed below.

____________________________________________ _____________________

Guarantor’s Signature Date

I understand that all co-pays are due at the time of service and that I am financially responsible for all charges whether

or not they are paid by my insurance. I understand that finance charges will begin accruing on accounts that are 60

days past due for payment at a rate of 1.5% per month. I further understand that excessively overdue accounts will be

forwarded to an outside collection agency and I will be responsible for any fees generated as a result of collection

efforts. I understand that some third-party payers may require that my medical information, including copies of

treatment notes, be submitted along with requests for payment. I hereby authorize Trust Women to release all medical

information necessary to secure payment of benefits from the third-party payers specified above, and I authorize the

use of this signature on all related submissions. I understand that this information may include medical information

related to drug and alcohol abuse, sexually transmitted diseases, HIV/AIDS and mental health. I understand that this

authorization shall remain valid without expiration unless expressly revoked by me in writing.

X ____________________________________ ______________________

Patient’s Signature Date

X______________________________________ ______________________

Guardian/Representative’s Signature Date

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Relationship to Patient/Representative Authority

Client Information for Informed Consent

FEMINIZING MEDICATIONS FOR TRANSGENDER CLIENTS Minors and Parents/Guardians

What are the different medications that can feminize my appearance?

Part of transition for many transgender people involves taking hormones. For hormone treatment to be most effective, transgender girls and women take not only estrogens (female hormones), but also medicines to block their body from producing or utilizing testosterone (male hormones).

Different forms of the hormone estrogen are used to feminize appearance in transgender females. Estrogen can be given as an injection, weekly or every other week, as a pill, daily or twice a day, or as a patch, which is changed every three or four days.

Medications that block the production or effects of testosterone are called androgen blockers. Androgen is another term for male sex hormones. Spironolactone is the androgen blocker that is most commonly used in the United States. Other medicines are sometimes used, but because spironolactone is relatively safe, inexpensive, and effective to block testosterone, it is the primary androgen blocker used for transgender women.

Every medication has risks, benefits, and side effects that are important to understand before starting. The effects and side effects of medicines used for transition need to be monitored with laboratory studies and regular visits to your provider to make sure that there are no negative effects on your body.

Both the medicines that you take, as well as the process of transitioning can affect your mood. While trans women are relieved and happy with the changes that occur, it is important that you are under the care of a gender-qualified therapist while undergoing transition. The therapist can work with you, your family and friends and your school staff.

Before using medications to transition and feminize, you and your parents or guardians need to know the possible advantages, disadvantages and risks of these medications. We have listed them here for you. It's important that you understand all of this information before you begin taking these medications.

Please read the following with your parent or guardian. Once your questions or concerns are addressed, and you have decided to proceed with the medication(s), both you and your parent or guardian will need to sign this information and consent form.

We are happy to answer any questions you have.

Estrogen can cause blood clots. We must be careful that you are not at risk to develop a blood clot. 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)

Estrogen should be used with caution and only after a full 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 uncontrolled diabetes• has heart disease• has chronic hepatitis or other liver disease• has uncontrolled high cholesterol• has migraines or seizures• is obese• smokes cigarettes

Both you and your parent or guardian should initial each statement on this form to show that you and your parent or guardian understand the benefits, risks, and changes that may occur from taking these medications.

Feminizing

_____ _____ I know that estrogen or anti-androgens – 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 clinician because it could be caused by the estrogen or by something else.• I know that while we do not know the exact risk the 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 stopcompletely, even if I take the medicines for years.

• I know I will probably have less fat on my abdomen and more on my buttocks, hips, and thighs.It will be redistributed to a more female shape — changing from “apple shape” to “pear shape.

• I know that if I have the predisposition to have male pattern baldness it may start later than itwould 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.

_____ _____ 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 apregnancy. I also know that there is a small risk that I might never produce mature sperm again.But I know that it’s also possible that my sperm could still mature even while I am takinghormones. So, I know that I might get someone pregnant if we have vaginal intercourse and wedon’t use birth control.

• I know that my testicles may shrink down to half their size. Even so, I know that they are part ofmy body and that I need to take care of them unless I have surgery to remove them. This meansthat 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 mustache 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 agree to continue therapy with a qualified therapist.

_____ _____ I know if I have any concerns about these issues, you can make referrals for me to help me explore other treatment options.

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 clinician 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 clinician 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 clinician 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 clinician if I get severe or long-lasting pain in my abdomen.

_____ _____ I know that estrogen can cause nausea and vomiting. I know I should talk with my clinician 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 clinician 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 prolactinoma. These are non-cancerous tumors of the pituitary gland. 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 Antagonists

_____ _____ I know that spironolactone affects 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 antagonists 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.

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 certain conditions to take these medicines. I agree to be evaluated if my clinician 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.

_____ _____ I know that I should stop taking estrogen two weeks before any 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 it again a week after I’m back to normal or when my clinician says it’s 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 clinician. This will help me make sure there are no negative reactions. I also know my clinician may suggest that I cut the does 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.

Our signatures below confirm that • My clinician has talked with me and my parents or guardian about the benefits and risks of taking feminizing medication the possible or likely consequences of hormone therapy 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 clinician.• 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.

Based on all this information

I want to begin taking estrogen.

I want to begin taking androgen antagonists (e.g., spironolactone).

I do not wish to begin taking feminizing medication at this time.

_________________________________________ ___________________

Patient Signature Date

_________________________________________ ___________________

Signature of Parent or Guardian Date

_________________________________________ ___________________

Prescribing clinician signature Date

Your health is important to us. If you have any questions or concerns please contact us. We are happy to help you.

You are considering taking feminizing hormones, so you should learn about some of the risks, expectations, long term considerations, and medications associated with medical transition.

It is very important to remember that everyone is different, and the extent of, and rate at which your changes take place depend on many factors. These factors include your genetics, the age at which you start taking hormones, and your overall state of health.

It is also important to remember that because everyone is different, your medicines or dosages may vary widely from other transitions, or what you may have read in books or online. Many are eager for changes to take place rapidly: Please remember that you are going through puberty, and puberty normally takes several years for the full effects to occur. Taking higher doses of hormones will not necessarily make things move more quickly; it may, however, endanger your health.

There are four areas where you can expect changes to occur as your hormone therapy progresses.

I) Physical

The first changes you will probably notice are that your skin will become a bit drier and thinner. Your pores will become smaller, and there will be less oil production. You may become more prone to bruising or cuts. You may notice that you experience pain or temperature differently, or that things just "feel different" when you touch them. You will probably notice skin changes within a few weeks. In these first few weeks you will notice that the odors of your sweat and urine will change, and that you may sweat less overall.

You will also notice small "buds" developing beneath your nipples within a few weeks of starting your treatment. These may be slightly painful (especially to the touch) and uneven between the right and left side. This is normal, and is the normal course of breast development. The pain will diminish somewhat over the course of several months. Breast development is quite variable from person to person. Not everyone develops at the same rate, and more transgender women can expect to develop an "A" cup or perhaps a small "B" cup, sometimes only after many ears of hormone therapy. Like non-transgender women, the breasts of transgender women vary in shape and size, and are sometimes different sizes or shapes between the right and the left.

Weight will begin to redistribute around your body. Fat will begin to collect around your hips and thighs, and the fat under your skin throughout your body will become a bit thicker, giving your arms and legs less muscle definition and a smoother appearance. Hormones will not have a significant effect on the fat in your abdomen. Your muscle mass will decrease significantly, as will your strength. Continue to exercise to maintain your muscle tone as well as your general health. Depending on your diet, lifestyle, genetics, starting weight and muscle mass; you may gain or lose weight once you begin HRT.

The fat under the skin in your face will increase and shift around to give your eyes and face in general a more feminine appearance. Please note that your bone structure (including your hips, arms, hands, legs, and feet) will not change. The facial changes can take up to 2 years or more to see the final result. It is usually a good idea to wait at least 2 years after beginning HRT before considering facial feminization procedures.

The hair on your body, such as your chest, back and arms will decrease in thickness and will grow at a slower rate. It may not all go away, however, and some may need electrolysis or laser to help reduce unwanted body hair. Your beard may thin a bit and grow a bit slower; however, it will rarely go away completely without electrolysis or laser treatments. If you have had any scalp balding, this should slow or stop, though the amount that will grow back is variable.

Some people may notice minor changes in shoe size or height. This is not due to bone changes, but due to changes in the ligaments and muscles of your feet.

2) Emotional

Your overall emotional state may or may not change, this varies from person to person. Puberty is a roller coaster of emotions, and the second puberty that you will experience during your transition is no exception. You may find that you have access to a wider range of emotions or feelings, or have different interests, tastes or pastimes, or behave differently in relationship with other people. While psychotherapy is not for everyone, most people would benefit from a course of supportive psychotherapy while in transition to help you explore these new thoughts and feelings, and get to know you new self.

3) Sexual

Soon after beginning hormone treatment, you will notice a decrease in the number of erections that you have. When you do have an erection, it will be less firm, and will not last as long. You may lose the ability to penetrate. You will still have erotic sensation, and will still be able to orgasm. However, when you do orgasm, it may be "dry." You may find that there are different sex acts or different parts of your body that bring you erotic pleasure. Your orgasms will feel different, with more of a "whole body" experience, less peak intensity, and longer duration. It is recommended that you explore and experiment with our new sexuality through masturbation, using sex toys such as dildos or vibrators, and involve your sexual partner(s).

Your testicles will shrink to less than half their original size, or less. In nearly all cases, this does not affect the amount of scrotal skin available for future genital surgery.

4) Reproductive

You must assume that within a few months of beginning hormone therapy, you will become permanently and irreversibly sterile. While some people may be able to maintain a sperm count on hormone therapy, or have their sperm count return after stopping hormone therapy, you must

assume that this will not be the case for you. If you think that there might be any chance that you may, in the future, want to parent a child using you own sperm, you should speak to the doctor about preserving your sperm in a sperm bank. This process generally takes 2-4 weeks and costs between roughly $2000-$3000. If you want to, you should store your sperm before beginning any hormone therapy.

Also, if you are on hormones but remaining sexually active with someone who is able to become pregnant, you should always continue to use a birth control method to prevent unwanted pregnancy.

Many of the effects of hormone therapy are reversible, if you stop taking them. The degree to which they can be reversed depend on how long you have been taking them. Breast growth, and possibly sterility are not reversible. If you have an orchiectomy (which is removal of the testicles) or genital reassignment surgery, you will be able to take a lower dose of hormones. However, it is important to remain on at least a low dose of hormones post-op until at least age 50 years old, to prevent a weakening of the bones, otherwise known as osteoporosis.

Cross-gender hormone therapy for transwomen may include three different kinds of medicines: estrogen, testosterone blockers, and progesterones.

1) Estrogen

Estrogen is the hormone responsible for most female characteristics. It causes the physical changes of transition, as well as many of the emotional changes. Estrogen may be given as a pill, by injection, or by a number of preparations applied to the skin, such as a cream, a gel, a spray or a patch.

Pills are convenient, cheap and effective, but they are harder on your liver and are less safe after age 35 or if you smoke. Patches can be very effective and safe, they may cost a little more than pills, and they require that you wear them at all times. Sometimes, they may irritate your skin. Creams, sprays, and gels are very effective and safe, and absorb quickly into your skin. These do tend to be a bit more expensive, and may not work as well for people who still have testicles.

Risks associated with estrogen include high blood pressure, blood clots, liver problems, stroke, and perhaps diabetes. Also, there are potential unknown risks because research is limited on the use of estrogen in transwomen. Contrary to what many may believe, a very small amount of estrogen is needed to deliver the maximum effect. Taking very high doses of estrogen does not necessarily make changes happen more quickly, but it can be dangerous and harmful to your health.

Regarding the risks of cancer in transwomen, there is a lack of scientific evidence.

Your risk of prostate cancer may decrease, but you will still need to be screened when appropriate. Your risk of breast cancer may increase slightly, though it will still be less than

A non-transgender female. Breast cancer screening with mammograms is recommended to begin between ages 40 and 50, for people who have been on hormones for more than 2-3 years.

Many transwomen are interested in taking estrogen injections. Estrogen injections may be appropriate for some people in some cases. When you take estrogen injections, you will have the same amount of estrogen as a pregnant woman. This can make you nauseous, tired, or cause you to gain weight or have mood swings. In people who smoke, or people over 35-40 years old, this high level of estrogen can be dangerous and increase you risk of stroke, blood clots, diabetes, or other disorders. If the doctor does start you on estrogen injections, you should expect to stop them after 1-2 years, since the body is not designed to be constantly exposed to such high levels of estrogen. When you stop the injections and switch to another form of estrogen, you may feel sick for a while, with mood swings, anxiety, and other symptoms as your body re-adjusts to the lower and healthier levels of estrogen.

After you have had genital surgery or orchiectomy (removal of testicles), your estrogen dose will be lowered, and estrogen injections will be stopped. Once you have your testicles removed, you need very little estrogen to maintain your feminine characteristics.

Estrogen can make your liver work too hard, causing damage. Your doctor will periodically check your liver functions, cholesterol, and perform a diabetes screening test to monitor your health while on testosterone therapy.

2) Testosterone blockers

There are a number of medicines which can be used to block testosterone. Some of these drugs block the action of testosterone in your body, and some of them also prevent the production of testosterone. Most of the testosterone blockers are very safe. The one most commonly used, spironolactone, does have some side effects. If can make you urinate excessively, especially when you first start taking it. This can make you feel dizzy or lightheaded. It is important to drink plenty of fluids when taking this medicine. Also, spironolactone can interact with some blood pressure medicines and can be dangerous in people with kidney problems. It is important to share your full medical history and medication list with the doctor so that they can be sure there will be no interactions. People taking spironolactone may have their potassium levels checks periodically, as it can rarely get dangerously high, which can cause your heart to stop.

3) Progesterone

Progesterone is a source of constant debate among both transwomen and providers. Progesterone has a number of reported benefits, such as improved mood, energy or libido, better breast development, or better body fat redistribution and "curves." There is very little scientific evidence to support these claims. However, some transwomen do prefer to take progesterone and have seen some of these benefits. When you take a natural form of progesterone, your risk of

things like blood clots, stroke, or cancer are minimized, but still may be increase. There simply is not enough research in this area to make an accurate prediction of your risk.

Progesterone may be given by a pill or by a cream. The pill is easy and relatively safe, the cream is also quite easy and safe. Both are about the same price.

I understand the foregoing information about feminizing hormone usage, and I hereby consent to the prescription use of feminizing hormones.

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