Bioidentical hormones — a guide to your options and alternatives
By Marcy Holmes, NP
Topics covered in this article:
We're now a decade past the Women’s Health Initiative and the fear of health implications
with Hormone Replacement Therapy (HRT), and there’s new information, new research,
and more attention on Bioidentical hormones. Bioidentical hormones are
formulated in a lab with the same molecular structure as the hormones we make in
our own bodies. They’ve gained popularity in the past few years, but many women
still have questions.
We hear from women who are frustrated and confused about the process of getting
bioidentical hormone therapy (bHRT). Some have no access to specialty providers,
and think their provider will only offer up Premarin or Prempro — which raises concerns
about the health risks of synthetic hormones. Others began using bioidentical hormones,
but their provider retired or relocated, or they just plain can’t afford it anymore.
These women feel stuck, thinking they can’t afford the time, effort, or expense
of compounded bHRT. Yet they continue to suffer with perimenopause symptoms. And
that’s just not necessary, since there are so many wonderful options and alternatives
Why is there so much confusion about bHRT?
Looking for hormone-free relief?
If you’re on HRT and would like to get off or if you’d like an effective herbal
solution to menopause symptoms, Herbal Equilibrium can help.
Using the latest research, we formulated Herbal Equilibrium to address the ten most
common symptoms of menopause. Our product includes herbs like Red Clover, Passionflower,
Ashwagandha and more to help you balance estrogen, progesterone, and testosterone.
We have programs designed for women to get off HRT safely as well as programs for
women interested in natural menopause relief.
Learn more about our Health Packages.
There’s a lot of misinformation out there about the availability of different bioidentical
hormone options. Many ad campaigns imply the only “real” choice for severe menopause
symptoms is between synthetic HRT and antidepressants. There are blogs and websites
stating bHRT is illegal or banned by the FDA (which aren’t true). There are also
concerns about consistency and quality in the products made. No wonder women are
First of all, bioHRT is not banned or illegal. So far the FDA has just wanted compounding
pharmacies to refrain from making false claims about bHRT that have not yet been
proven in studies. The FDA has approved many bHRT-based products from pharmaceutical
companies, such as estradiol products and Prometrium (progesterone).
Second of all, the best way to ensure quality is by finding a trustworthy provider.
You can locate a trustworthy compounding pharmacy that’s accredited through the
Pharmacy Compounding Accreditation
Board. The Pharmacy Compounding Accreditation Board (PCAB) is a nonprofit
organization created by eight pharmacy organizations to set standards for compounding
pharmacies in the United States.
What about avoiding HRT or getting off of HRT?
There is a wealth of natural alternatives to HRT, including a huge variety of herbs,
flax seed, soy, exercise, stress reduction, and optimal nutrition that can make
a huge impact when weaning off or trying to avoid HRT. In fact, we’ve created our
our Health Package specifically for women who want to get off of HRT safely using
these natural alternatives. Our herbal product along with diet and lifestyle changes,
can help you wean off of HRT with minimal symptoms.
Natural measures work synergistically to help relieve symptoms and balance your
hormones yet pose a mere fraction of the potential HRT risk. And when used alongside
HRT, they allow for faster, better, and more sustainable results, often using lower
If bioidentical hormones are the next step
We want you to know that if you and your healthcare provider determine you need
hormone replacement therapy, there is a bioidentical option that will work well
for you. It may take a few tries, but you are worth the effort. Understanding some
basics will help you know what to ask for.
If you’re looking for bioidentical hormone replacement therapy but don’t want or
cannot access compounded bioidentical hormones, there are some simple ways to cue
your practitioner toward alternative forms of hormonal support rather than synthetics.
- you don’t want to take estrogen in conventional pill or capsule (oral) form.
- you don’t want Premarin or Prempro — conjugated equine estrogens or synthetic progesterone/progestin
products — in any form.
- you’d prefer to stick with estradiol, a natural human estrogen, and Prometrium,
which is bioidentical progesterone, at least to start with. (Both are available
from ordinary pharmacies, and there are several popular brands of estradiol to choose
from. If you have your uterus, you will need to “oppose” the estrogen with the progesterone.
If you’ve had a hysterectomy, you likely won’t need Prometrium.
Often it is usually best to schedule a special appointment for discussing hormone
therapy with your practitioner, so they allot enough time to answer all your questions
— rather than try to squeeze the topic in during a physical.
There are many forms of “natural” or bioidentical HRT available. See our
table of natural hormone options for bHRT for more information. All of the
non-compounded, brand-name hormone preparations listed in our table are FDA-approved,
legal, and available by prescription.
Getting natural estrogen
Due to the fact that Premarin is made from horse urine and has been implicated in
the increased health risks seen in studies such as the WHI, there are many women
looking for alternatives. This is making it easier to get bioidentical estrogen.
Estradiol is bioidentical estrogen that is now readily available in many forms (see
table). Estradiol is the primary biologically active estrogen that changes in menopause,
and it’s the one that usually matters most for estrogen replacement.
We do suggest you avoid estradiol in the pill forms that must be swallowed. We now
know that any form of estrogen taken orally, even bioidentical estrogen, can induce
the liver to make more blood-clotting factors and can increase the risk of stroke.
It also drives up a protein that binds up hormones over time, and can disrupt blood
sugar and triglycerides as well. That means that taking oral estrogen pills of any
kind can, over time, affect your body in ways that are problematic. This does not
include the sublingual (under the tongue) troches (tro’-keez) or “melt” products,
which pass directly into the blood stream through the thin membranes of the mouth,
bypassing the GI system and liver.
The latest evidence suggests that low-dose estrogen delivered by transdermal
(through the skin) methods, such as patches, creams, or sprays, is superior and
lacks the negative effects associated with oral formulas. Transdermal delivery should
be the first-line approach when using estrogen these days, but some conventional
practitioners may not be aware of these options. Often it’s worth bringing the subject
up yourself. (One important note: birth control patches such as the one sold under
the name Evra are not the same as transdermal estradiol.)
The FDA has approved many brands of estradiol patches for many years, and they are
a wonderful option that is usually well covered by insurance (see table). Patches
are not for everyone, as skin sensitivities or hot humid climates can result in
irritation, but there are also gels, lotions, and even a topical spray for estradiol
(see table). These forms do tend to be more costly as they’re newer, but they all
deliver bioidentical estradiol through the skin.
There are also estradiol products that target the genital tissues directly, such
as the vaginal or urethral tissues where they are applied or worn, without exposing
the rest of your body to the hormones in the products (the exception is the brand-name
vaginal ring called Femring, which does deliver a systemic dose of estradiol).
Getting bioidentical progesterone
For most women — though not all — bioidentical progesterone has a calming, mood-stabilizing
effect. Synthetic progestins, on the other hand, such as medroxyprogesterone acetate
(MPA) and norethindrone acetate, tend to be associated with a set of net unpleasant
effects. We rarely prescribe synthetic progestins, but there are particular circumstances
when certain women can benefit from them.
When progesterone therapy is called for, we favor the use of bioidentical forms,
whether in low-dose over-the-counter creams, compounded prescription-strength preparations,
such as creams, “melts” and troches, or in the sole brand-name, FDA-approved prescription-strength
called Prometrium. If you have a uterus, and you go on estradiol estrogen
replacement, a prescription-strength dose of oral progesterone (as in Prometrium)
is needed to protect your uterus.
If you have had a hysterectomy, you may find that a low-dose, over-the-counter progesterone
cream is right for you. Other women who are post hysterectomy choose to complement
their estrogen replacement therapy with botanical support, such as chasteberry,
wild yam, and other herbs that mimic or complement natural progesterone, using it
instead of, or in addition to, bioidentical progesterone. (Chasteberry and wild
yam are two of the phytotherapeutic ingredients in our
Oral progesterone doesn’t have the same risk profile as oral estrogen; it has an
entirely different set of molecular actions in the body. The progesterone in Prometrium
is derived in a laboratory setting from yams or soybeans, then micronized in (peanut)
oil, to allow for better absorption. (If you’re allergic to peanuts, you should
avoid Prometrium.) Because of its calming effects, it’s best taken at night, and
taking it with a bit of food also enhances absorption.
Troubleshooting and making adjustments
As explained above, you can obtain a prescription for bioidentical hormones by requesting
any one of the standard-dose, FDA-approved bHRT products. If you find that one brand
of bHRT doesn’t work well for you, you can always ask to try a different one, or
even a different combination.
At our clinic, we sometimes find a woman does best with a brand-name form of bHRT
used in combination with a compounded bioidentical cream, lotion, gel, or lozenge.
For example, she might use a trademark estradiol patch each week, together with
a compounded prescription-strength progesterone cream during the second half of
her cycle, mixed with a small amount of testosterone. She’s unique, and so are you.
But there are situations where a bioidentical version from a compounding pharmacy
is more desirable. Among these are the following situations:
What to avoid:
- Combination patches like Climara Pro or the CombiPatch (because it includes synthetic
- Combination pills like Prempro, Premphase, Estratest, Activella, FemHRT, and Angelia
(because of risks associated with oral estrogens and synthetic hormones).
*Please note: If Prometrium is unavailable or you are allergic to it, then
a combination patch is a reasonable alternative and a better choice than a combination
- Prometrium can be costly if not covered by insurance, and a bioidentical progesterone
from a compounding pharmacy can be a less expensive option. Even those practitioners
who don’t normally prescribe compounded hormones may be willing to do so when cost
is an issue, so be up-front with your provider if expense is a concern.
- If you are allergic or sensitive to peanuts, avoid Prometrium. A compounded peanut-free
version is the only other prescription-strength option for bioidentical progesterone.
(Many compounding pharmacies suspend the progesterone in olive oil instead of peanut
- For a small amount of women, Prometrium taken orally is too sedating or has depressive
side effects. Cutting the dose, or adjusting the time you take it, can often help.
It’s also possible to insert the capsule into the vagina to be more directly absorbed,
which can help eliminate these side effects (but talk to your practitioner about
that alternative). Or your provider can prescribe a similarly-dosed capsule, troche,
melt, or topically-applied cream.
These are all prime examples of why the service that compounding pharmacies provide
is essential to our well-being.
Related to this article:
References & further reading for
bioHRT options & alternatives
Last Modified Date: 08/01/2012
Principal Author: Marcy Holmes, NP, Certified Menopause Clinician