BHRT Patient Education

You will then be scheduled with one of our providers for a hormone consultation where they will provide an in-depth educational review of the risks and benefits associated with BHRT as well as the different forms and routes of replacement. At that time, we suggest that you come fasting, meaning nothing to eat and drink (except for water) for the past 12 hours so that labs can be drawn after your appointment.

Once your labs are drawn and resulted, your provider will complete your plan of care depending on your lab results and the discussions regarding your initial consultation. Your provider will discuss these results and plan with you once completed; this can be done in the office or via telehealth platform.

If you are a pellet candidate, then you will come back to the clinic to have your pellets placed. 

After initiation of any hormone replacement therapy, you will receive a follow up symptomatology intake form to be completed; this should be filled out based on your CURRENT symptoms as this is usually when your hormones are starting to peak. You may or may not also have labs to be repeated. Typically Labs will happen on an initial consultation (more comprehensive), 6-8 weeks after (less comprehensive panel) and then annually thereafter, unless your provider feels it is necessary to obtain again for either a dose change or symptom management reason.

Pellet Patients will be re-pelleted at at the following intervals:

Women: 3-4 months

Men: 4-6 months

All other routes of replacement will need follow-up appointments every 4 months for prescription renewals and plan review/symptom check ins. 

Pros: Convenient and easy to take.Familiar method for most patients.May be more cost-effective compared to other routes.

Cons: Hormone metabolism in the liver can result in variable hormone levels, increased risk of liver-related side effects, limited dosing flexibility as the liver can affect hormone potency (this is why we do not offer certain hormones this route such as testosterone because it can cause liver damage). 

Pros: Absorbed directly through the skin, bypassing the liver and reducing liver-related side effects.Steady and controlled hormone delivery over a specific duration (if applied correctly and consistently). Dosage can often be adjusted easily to suit individual needs.

Cons: Application can be messy or inconvenient. Skin sensitivity or allergic reactions to the delivery system may occur.Absorption rates can vary between individuals, affecting hormone levels. There have been some reports of transferring the medication/hormone to small children, would recommend caution in those who are rubbing up against others in where this can become problematic. In effort of avoiding iatrogenic transfer to others,  we recommend avoiding contact with others by allowing 4 hours before contact or exposure once applying. Applying at 7AM and 7PM is best. Wash hands to avoid transference to others and cover application site.

Pros: Hormones are absorbed directly into the bloodstream through the mucous membranes under the tongue.Bypasses the liver, reducing the risk of liver-related side effects.Allows for more rapid absorption and potentially quicker symptom relief.

Cons: Taste or texture of sublingual medications may be unpleasant for some individuals.May require frequent dosing due to faster absorption rates.Hormone levels can still fluctuate significantly if labs are not drawn accurately or if the compliance has been inconsistent. 

Pros: Provides a long-lasting and steady release of hormones over several months.Reduces the need for frequent dosing or application.Mimics the body’s natural hormone secretion patterns more closely.

Cons: Requires a minor surgical procedure for implantation.Potential for infection or other complications associated with the insertion site.Difficult to adjust dosages once the pellets are implanted.

Pros: Consistent/reliable dosing if compliance and labs are done correctly 

Cons: Can be painful, usually needs twice a week injections to avoid roller-coaster effects, testosterone injections can adversely affect HDL/cholesterol 

It’s important to note that the pros and cons of BHRT routes of administration may vary depending on individual circumstances and preferences. Our providers who specialize in hormone therapy can help determine the most suitable route for your specific needs, taking into account factors such as hormone levels, medical history, lifestyle, and personal preferences.

Potential Benefits include increased libido and clitoral sensitivity, energy strength and endurance,  decreased hot flashes, increase in muscle mass which maintains metabolism and decrease in visceral fat, improved insulin sensitivity, improved lipid panel which can lead to a decrease in cardiovascular disease, decreased risk of dementia, decreased bone loss, decrease in wrinkles, fat deposition, and cellulite, increases collagen and skin thickness, leading to improved skin texture, improved cognition and memory, breast cancer protection

We use the lab tests to demonstrate improvement above baseline and for no other reason (optimals are different than standard lab values). Most studies demonstrate very supraphysiologic levels to be therapeutic, and there is no standard or guide on how high one should go which makes testing nebulous. Some women may require high doses to see benefits, while others need lower doses.  

Risks of testosterone replacement may include, but are not limited to: an increase in red blood cells (erythrocytosis/secondary polycythemia; which we will typically send for therapeutic phlebotomy if a hematocrit increases above 54%/or at customized provider threshold) reduced insulin requirements in insulin-dependent diabetics, increased estradiol levels, edema (fluid retention) and feeding hormone responsive cancers.

There is a risk of infertility/sterility in males as it can cause a decrease in sperm production and a decrease in testicle size. While there are ways to mitigate this risk, we do not recommend any man who wants to preserve his fertility to initiate hormone optimization. With any testosterone treatment, men will produce less endogenous testosterone from  testicles and if they stop replacement, they may experience a temporary decrease in natural testosterone production. Compliance with additional pharmaceuticals as prescribed is imperative to ensure best success for to eventually begin reproduction but understand that this will likely fall back to pre-treatment levels and the symptoms  endured pre-treatment will likely return. It is imperative to comply with provider ordered labs, we recommend you have at least one annual PSA to help screen for prostate cancer (1 in 7 men will get prostate cancer regardless of testosterone therapy but testosterone therapy can feed/grow hormone responsive cancers.)

Premenopausal females MUST use birth control.Testosterone is a known teratogenic and should not be used in pregnant females or those planning to become pregnant as it can also cause virilization of a fetus (masculinize a female fetus)

Side effects may include, but are not limited to: enlarged clitoris, hormonal acne or back acne, temporary water retention, acne, irritability, hirsutism (facial hair)  These are mostly dose related and usually resolve with reduction in dose or addition of spironolactone; however, it can take up to 6 months for hirsutism and acne to resolve. Insulin resistance/ PCOS can also cause acne/hirsutism  as they often cause low SHBG which can cause or worsen hirsutism. If this is the case, we aim at treating the insulin resistance to raise SHBG will also help improve these symptoms. It can also cause “PMS” type symptoms such as mastalgia (nipple tenderness) which can be improved with medications such as an aromatase inhibitor (anastrozole) or nutraceuticals to decrease estrogen levels such as DIM or by decreasing the dose. Natural testosterone does not equal synthetic testosterone. Synthetics raise cholesterol and lowers HDL, as opposed to natural testosterone which lowers cholesterol and raises HDL (opposite of synthetics). We will monitor lipid levels annually/as seen appropriate by the provider to ensure that if synthetic testosterone is utilized, this is being monitored and treated accordingly. Of note, a recent study published by the New England Journal of Medicine states that there is NOT an increased cardiovascular risk with synthetic testosterone! Some patients may be on additional medications to help improvement in other hormone related issues such as hair loss or benign prostate hypertrophy; medications that are commonly used to treat these conditions such as finasteride or dutasteride can affect important lab results. If I am on any additional medications, I will ensure that these are fully disclosed to ensure best and safest care. 

Active prostate cancer; men who do not want to risk their fertility should not use testosterone. Men who want to preserve their fertility should consider banking sperm prior to treatment or consider HCG or Clomid which does not affect fertility; these should also be used in conjunction with testosterone to help endogenous production not be affected by the negative feedback system.

History of breast cancer; if history of blood clots, should use transdermal route.

Side effects may include, but are not limited to: increased body fat, bloating, breast swelling/tenderness, fluid retention and uterine bleeding. These side effects can typically be resolved with dose adjustments/balancing of the three main hormones. Progesterone will help decrease high estradiol levels. It is not uncommon for postmenopausal women to have a period after starting BHRT, however, if persistent bleeding or spotting may warrant additional work up; including labs, a vaginal ultrasound, and possibly an OB-GYN referral if any of the results come back abnormal or if the bleeding persists despite hormone balancing. 

Side effects can include; drowsiness with oral form due to first pass effect (ODT form does not cause drowsiness),; therefore, only take oral at bedtime, one hour before sleep. Breast or nipple tenderness with oral form, switching to a sublingual form will resolve. Do not recommend a transdermal approach as monitoring is too unreliable and benefits will likely never be obtained due this way as it is not very effective. 

DHEA is classified as a dietary supplement given orally or by transdermal cream. DHEA is a hormone secreted by the adrenal glands. This hormone is a precursor to other sex hormones. In addition to having its own hormone effect, it results in a shift to an anabolic or protein building state.

It reduces cardiovascular risk by increasing lipolysis or breakdown of fat. It also may improve adrenal fatigue/exhaustion, restores sexual vitality to improve erectile dysfunction, improves mood, decreases cholesterol and body fat which may help decrease cardiovascular risks. Recent studies point to DHEA as an anti-stress hormone, reversing the effects of stress on the immune system by acting on T cells.

Contraindications : avoid in patients with a history of hormone responsive cancers.

Side effects of DHEA replacement are generally dose related and may include but are not limited to: acne or oily skin, hair growth on the face, arms or legs, acne in women, prostate enlargement in men, male pattern baldness, decreased HDL cholesterol, fatigue, mood changes,  weight gain and insomnia. If there are any side effects there is no push to continue for patients under age 40. 

(Off-Label): Acne vulgaris, females, moderate to severe; Hair loss, female pattern; Heart failure with preserved ejection fraction; Hirsutism, females; Hormone therapy for transgender females (assigned male at birth); Post myocardial infarction, complicated by reduced ejection fraction

Spironolactone has some unique properties that make it useful for specific conditions.

One of the main reasons doctors prescribe spironolactone is to help regulate the balance of fluids and electrolytes in your body. It works by reducing the amount of water and salt reabsorbed by the kidneys, which can help you get rid of excess fluid and prevent your body from retaining too much water. Spironolactone is commonly used to treat conditions such as high blood pressure, edema (swelling caused by excess fluid buildup), and certain hormonal imbalances. In particular, it is known for its ability to block the effects of a hormone called aldosterone, which can cause your body to retain too much salt and water. For women, spironolactone can also be prescribed to help manage conditions such as polycystic ovary syndrome (PCOS), hirsutism (facial hair) and acne. In these cases, the medication can help reduce the production of androgens, which are hormones that can contribute to acne breakouts and other symptoms of PCOS.

It’s important to note that spironolactone may take some time to show its full effects (up to 6 months at times for androgen improvement) ! Your doctor will typically start you on a low dose and adjust it as needed to find the right balance for your condition. It’s crucial to follow your doctor’s instructions carefully and take the medication as prescribed.

Potential side effects and risks are increased urination, dizziness, stomach upset, and changes in electrolyte levels if dehydrated. It is essential to let your doctor know about any other medications or supplements you are taking, as spironolactone can interact with certain drugs, including some blood pressure medications and potassium supplements. It is also essential that you stop taking this medication if you feel dehydrated and notify your provider if this occurs for further instruction.

Drugs with thyroid hormone activity, alone or together with other therapeutic agents have been used for the treatment of obesity. In euthyroid patients, doses within the range of daily hormonal requirements are ineffective for weight reduction. Larger doses may produce serious or even life-threatening manifestations of toxicity, particularly when given in association with sympathomimetic amines such as those used for their anorectic effects.

• Do not use NP THYROID® if you have hyperthyroidism, overactive thyroid, uncorrected adrenal problems, or are allergic to any of its ingredients.
• Tell your doctor about any other medical conditions you may have, especially heart disease, diabetes, blood clotting problems, and adrenal or pituitary gland problems. The dose of other drugs you may be taking to control these conditions may have to be changed while you are taking NP THYROID®.
• Tell your doctor immediately if you experience chest pain; increased pulse rate; rapid, strong, irregular heartbeat; excessive sweating; or any other unusual event.
• If you have diabetes, check your blood sugar levels and/or the glucose in your urine, as ordered by your doctor and immediately tell your doctor if there are any changes.
• If you are taking oral anticoagulants, blood clotting status should be checked often by your doctor.
• Partial loss of hair may be experienced by children in the first few months of thyroid therapy, but this will usually go away on its own.
• Tell your doctor if you are allergic to any foods or drugs, are pregnant or plan to become pregnant, are breastfeeding or are taking any other drugs, as well as prescription and over-the counter products.
• Use NP THYROID® only as ordered by your doctor. Do not stop or change the amount you take, or how often you take it, unless told to do so by your doctor.

If you deviate  from your provider’s medication orders since your last appointment or had labs drawn but were not following exactly what was prescribed by your provider for 6-8 weeks prior to drawing your labs, your lab results can be inaccurate. Please ensure you inform us of any compliance issues with what we prescribe/plan so we can adjust labs and treatment plan accordingly.

Take your regular medications as prescribed; I.E. If you are having hormones tested, it is imperative that you are on your dose consistently for at least 6-8 weeks; if you are on injections, you are having your labs drawn mid week injection schedule; etc..).If you deviate  from your provider’s medication orders since your last appointment or had labs drawn but were not following exactly what was prescribed by your provider for 6-8 weeks prior to drawing your labs, your lab results can be inaccurate. Please ensure you inform us of any compliance issues with what we prescribe/plan so we can adjust labs and treatment plan accordingly

Recommended Lab collection timing for best results:6-8 weeks post initiation or dose changes and :

• Creams- 12-24 hrs post dosing
• Oral-12-24 hrs post dosing
• Patches- 1 -2 days post dosing
• Pellets-no specific timing
• Injections: Midpoint between injections (i.e. If on IM Testosterone every 7 days, specimen should be collected on day 3-4

Some medications can affect lab results.  It is imperative that you refrain from the following: 

• No biotin for 48 hours (if greater than 5000 mg/day)
• High Dose Vitamin C (anything greater than 15g; hold for 1 wk)
• Any vitamin testing should be done after being off of supplements for at least 3 days, preferably  1 week

*If receiving a prostate lab; it should be drawn prior to receiving a digital rectal exam.

Your provider will discuss the results of your labs once they receive them and have the chance to review them in combination with the symptomatology form that you will fill out to give you appropriate guidance and recommendations based on these findings.

Note: It is crucial to follow the instructions provided by your healthcare provider or the laboratory staff accurately. Deviations from the instructions may affect the reliability and accuracy of the test results. If you have any questions or concerns, please contact our laboratory or consult your healthcare provider for clarification.

Many individuals have inadequate hormone levels despite technically “normal blood tests”. There are limitations to “measuring” hormone levels as it reflects what is in the serum or saliva only rather than inside the cell. Some individuals suffering symptoms related to fluctuations in their hormones such as perimenopause, menopause, and declining testosterone levels may benefit from these therapies. Bio-identical hormone replacement therapy can be used to augment hormone levels in a number of conditions where diminished hormone levels are evident or clinically suggestive based on symptoms. The providers at Nervana Medical may prescribe these hormones at dosages designed to achieve a pharmacologic effect to reduce the symptoms of hormonal decline. The diagnosis and treatment will involve many components including your symptoms, confounding medical issues or medications, blood levels, physical exam, response to therapy, possible side effects, individual reaction/response to therapy, and other information. Your blood levels may fall into “normal” lab reference ranges, which may not in our opinion, reflect your deficiency. We also feel it is important that you know there are significant medical differences of opinion/controversies regarding the best method to diagnose and treat low hormone levels, whether or not blood tests are needed at all, the best methods of treatment, and the most appropriate way to monitor dosage and therapy. This is especially true when “standard” blood tests are “normal”, meaning that the result is within the normal laboratory reference range for the test. The diagnosis and treatment used may be considered non-conventional, complementary or alternative. Other physicians may disagree with the need for treatment at all, the method of treatment, dosing and/or the methods of monitoring. Thus, you may consult another doctor who does not agree with our diagnosis or therapy.

Control of symptoms associated with declining hormone levels.

May help prevent, reduce or control physical diseases and dysfunction associated with declining hormone levels.

Include, but are not limited to: Leaving the hormone levels as they are and doing nothing. Risks may include, but are  not limited to: experiencing symptoms of hormone deficiency, and increased risk for aging-related diseases or dysfunction resulting from declining hormone levels. This alternative may result in the need to treat diseases or dysfunctions associated with declining hormone levels. Treating the symptoms of declining hormone levels as they develop with non-hormonal therapies such as SSRI’s (antidepressants), sleeping pills, and herbal therapies, essential oils, lifestyle modifications such as weight loss, stress reduction, yoga, etc. Many of these hormones are used “off-label”, which means they are not FDA approved. Many of these hormones are made by a compounding pharmacy. Off-label refers to use of, relating to or being an approved drug legally prescribed for a purpose for which it has not been specifically approved. Seeing another provider who believes in using non-bioidentical synthetic hormones such as Premarin and Prempro or other therapies FDA approved therapies for menopause (synthetic hormones have extensive research suggesting numerous risks of therapy, remember, bioidentical hormones and synthetic hormones are DIFFERENT).

Hormone Responsive Cancers: Patient has been educated regarding BHRT and its potential to “feed” potential “undiagnosed hormone responsive cancers” as well as alternative therapies to BHRT. Patient understands and accepts the risk. * Patient was educated of the importance of staying up to date on preventative exams as recommended by CDC/WHO for age. Reproduction Risks have been outlined and explained in detail to patient; more details can be seen under Medication education.

Pellet extrusion is uncommon and occurs in <5% of procedures. If the wound becomes sore again after it has healed, begins to ooze or bleed or has a blister-type appearance, please contact the office. Warm compresses may help soothe discomfort.

Itching or redness in the area of the incision and pellet placement is common. If you have a reaction to the tape, please apply hydrocortisone 2-3 times per day to the rash. If redness becomes firm or starts to spread after the first few days, you will need to contact the office.

Testosterone stimulates the muscle to grow and retain water which may result in a weight change of two to five pounds. This is only temporary. This happens frequently with the first insertion, and especially during hot, humid weather conditions.

This is common in hot and humid weather. It may be treated by drinking lots of water, reducing your salt intake, or by taking a mild diuretic, which the office can prescribe.

This usually occurs most commonly in the first round of pellets but does not usually continue thereafter. DIM 1 capsule daily is helpful in preventing this, but the dose may be increased to 2-3 daily, if needed. Evening primrose oil (available in our office) is helpful as is Iodine+ if this occurs.

These may occur if you were quite deficient in hormones. These symptoms usually improve as hormone levels improve. 5HTP can be helpful for this temporary symptom and can be purchased at many health food stores.

(most common in men): Testosterone may stimulate growth in the bone marrow of the red blood cells. This condition is called erythrocytosis. Erythrocytosis may also occur in some patients independent of any treatments or medications. If your blood count goes too high, you may be asked to see a blood specialist called a hematologist to make sure there is nothing worrisome found. If there is no cause, the testosterone dose may have to be decreased.

Is rarely due to pellets but can occur in some patients who convert testosterone to DHT. Dosage adjustment generally reduces or eliminates the problem. Prescription medications may be necessary in rare cases. Workup for other causes may also be needed.

Some pimples may arise if the testosterone levels are either too low or rise rapidly. This lasts a short period of time and can be handled with a good face cleansing routine, astringents and toner. If these solutions do not help, please call the office for suggestions and possibly prescriptions.

This may occur in the first few months after an insertion, especially if you have been prescribed progesterone and are not taking properly: i.e. missing doses, or not taking a high enough dose. Please notify the office if this occurs. Bleeding is not necessarily an indication of a significant uterine problem.

Testosterone may stimulate some growth of hair on your chin, chest, nipples and/or lower abdomen. This tends to be hereditary. Fine vellus hairs or “peach fuzz” often occurs but is not thick nor coarse. You may also have to shave your legs and arms more often. Dosage adjustment generally reduces or eliminates the problem

Pellet extrusion is uncommon and occurs in <5% of procedures. If the wound becomes sore again after it has healed, begins to ooze or bleed or has a blister-type appearance, please contact the office. Warm compresses may help soothe discomfort.

Itching or redness in the area of the incision and pellet placement is common. If you have a reaction to the tape, please apply hydrocortisone 2-3 times per day to the rash. If redness becomes firm or starts to spread after the first few days, you will need to contact the office.

Testosterone stimulates the muscle to grow and retain water which may result in a weight change of two to five pounds. This is only temporary. This happens frequently with the first insertion, and especially during hot, humid weather conditions.

This is common in hot and humid weather. It may be treated by drinking lots of water, reducing your salt intake, or by taking a mild diuretic, which the office can prescribe.

This usually occurs most commonly in the first round of pellets but does not usually continue thereafter. DIM 1 capsule daily is helpful in preventing this, but the dose may be increased to 2-3 daily, if needed. Evening primrose oil (available in our office) is helpful as is Iodine+ if this occurs.

These may occur if you were quite deficient in hormones. These symptoms usually improve as hormone levels improve. 5HTP can be helpful for this temporary symptom and can be purchased at many health food stores.

(Most common in men): Testosterone may stimulate growth in the bone marrow of the red blood cells. This condition is called erythrocytosis. Erythrocytosis may also occur in some patients independent of any treatments or medications. If your blood count goes too high, you may be asked to see a blood specialist called a hematologist to make sure there is nothing worrisome found. If there is no cause, the testosterone dose may have to be decreased.

Is rarely due to pellets but can occur in some patients who convert testosterone to DHT. Dosage adjustment generally reduces or eliminates the problem. Prescription medications may be necessary in rare cases. Workup for other causes may also be needed.

Some pimples may arise if the testosterone levels are either too low or rise rapidly. This lasts a short period of time and can be handled with a good face cleansing routine, astringents and toner. If these solutions do not help, please call the office for suggestions and possibly prescriptions.

Some men will form higher-than-expected levels of estrogen from the testosterone. Using DIM 2 capsules daily as directed may prevent this. Symptoms such as nipple tenderness or feeling emotional may be observed. These will usually resolve by taking DIM, but a prescription may be needed.

The majority of times, we administer the hormone dosage that is best for each patient, however, every patient breaks down and uses hormones differently. Most patients will have the correct dosage the first insertion, but some patients may require dosage changes and blood testing. If your blood levels are low, results are not optimal and it is not too far from the original insertion, we may suggest you return so we can administer additional pellets or a “boost” (at no charge). This would require blood work to confirm. On the other hand, if your levels are high, we can treat the symptoms (if you are having any) by supplements and/or prescription medications. The dosage will be adjusted at your next insertion.

Testicular shrinkage is expected with any type of testosterone treatment.

Any testosterone replacement will cause significant decrease in sperm count during use. Pellet therapy may affect sperm count up to one year. If you are planning to start or expand your family, please talk to your provider about other options.

• Your insertion site has been covered with two layers of bandages.

• Remove the outer pressure bandage any time after 24 hours. It must be removed as soon as it gets wet. The inner layer (usually a steri strip) should be removed in 7 days. 

• Do not take tub baths or get into a hot tub or swimming pool for 7 days.

• You may shower, but do not remove the bandage or steri-strips for 7 days. 

• No heavy lifting or major exercises for the incision area for the next 7 days, which includes running, elliptical, squats, lunges, etc. You can do moderate upper body work and normal walking on a flat surface.

• The sodium bicarbonate in the anesthetic may cause the site to swell for 1-3 days. 

• The insertion site may be uncomfortable for up to 2 to 3 weeks. If there is itching or redness you may take Benadryl for relief (25 to 50 mg orally every 6 hours). Caution: this can cause drowsiness!

• You may experience bruising, swelling, and/or redness of the insertion site which may last from a few days up to 2 to 3 weeks. If the redness worsens after the first 2-3 days, please contact the office. 

• You may notice some pinkish or bloody discoloration of the outer bandage. This is normal. 

• If you experience bleeding from the incision, apply firm pressure for 5 minutes. 

• Please call if you have any bleeding not relieved with pressure (not oozing), as this is NOT normal. 

• Please call if you have any pus coming out of the insertion site, as this is NOT normal. 

• We recommend putting an ice pack on the area where the pellets are located a couple of times for about 20 minutes each time over the next 4 to 5 hours. You can continue this for swelling, if needed. Be sure to place something between the ice pack and your bandages/skin. Do not place ice packs directly on bare skin.

• Remember to have your post-insertion blood work done 6 weeks after your FIRST insertion. If you are not feeling any better by 4 weeks, however, please call the office to have your labs drawn early.

• Most women will need re-insertion of their pellets 3-4 months and men 4-6 months after their initial insertion. If you experience symptoms prior to this, please call the office.

• Please call as soon as symptoms that were relieved from the pellets start to return to make an appointment for your next insertion.