Hormone Replacement Therapy (HRT)

Pill Bottle
    If you are currently taking HRT, how long have you been using it?
    If you currently aren't using HRT, choose N/A.
    • Utrogestan or another progesterone
    • Contraceptive pill
    • Mirena coil
    Select one or more answers.
    • Breast
    • Womb
    • Ovarian
    • Breast tenderness
    • Swelling
    • Discharge from the nipple
    • New lumps or changes to existing lumps
    • Pain
    • Discolouration
    • Gallstones
    • Diabetes
    • Migraines
    • A blood clot or blood clotting disorder
    • Porphyria
    • Medicines for epilepsy (such as phenobarbital, phenytoin, carbamazepine).
    • Medicines for tuberculosis (such as rifampicin, rifabutin).
    • Medicines for HIV infection (such as nevirapine, efavirenz, ritonavir, telaprevir, nelfinavir).
    • Herbal remedies containing St John's wort (Hypericum perforatum).
    • Yellowing of the skin or whites of your eyes (jaundice).
    • A large rise in your blood pressure (symptoms can include headache, dizziness and tiredness).
    • Migraine-like headaches which can happen for the first time, with or without disturbed vision.
    • Pain in your chest that spread to your arm or your neck.
    • Signs of a blood clot (painful swelling and redness of the legs, sudden chest pain or difficulty breathing).
  • Enter N/A if not applicable.
  • Enter N/A if not applicable.
    • You will read the patient information leaflet (provided with your medication or by following the relevant link).
    • The treatment is solely for your own use.
    • All the information you have provided is accurate. You understand our prescribers can only base decisions on the information provided and that incorrect information can be detrimental to your health.
    • We need to ensure that this medicine is suitable for the person it is intended for. Therefore may be required to contact you by phone/video call, If we are unable to speak to you when required your order may be delayed.
    • If necessary you consent to My Pharmacy contacting your GP Surgery and/or accessing your Summary Care Records in regards to this treatment.
    • I consent to receive treatment from My Pharmacy, and confirm that I have the mental capacity to do so. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always rest with the prescriber and is subject to approval. If treatment is not suitable, you will be signposted to another point of care.
    • You will seek medical advice if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
    • You will inform your GP with regards to this prescription (It is best practice to inform your GP of any private treatment you receive. All treatment is completely confidential).
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