Bioidentical Hormone Replacement Therapy for Menopause

BHRT is a Great Option to Balance Hormones, But it Isn’t Always the Best One

• Hormone Replacement Therapy for Menopause|
• Hormone Replacement: Bioidentical vs Conventional|
• Risks of Bioidentical Hormone Replacement Therapy|
• BHRT Isn’t Forever|
• Should You Go Bioidentical?|
• Natural Ways to Treat Menopausal Symptoms|
• BHRT Isn’t the Only Choice for Menopause Relief|

Many women facing menopause opt for bioidentical hormone replacement therapy (BHRT) to help ease the well-known symptoms that accompany the natural decline in hormones like estrogen. Of the 2 million women who transition through menopause each year, 40% reach for BHRT to cope with menopausal symptoms [1] like hot flashes, night sweats, vaginal dryness, brain fog, bone loss, insomnia, and mood swings [2]. 

Although both BHRT and conventional hormone replacement therapy (HRT) are synthetic, BHRT is derived from plant sources, like soy, and the final product mimics the natural hormones made by the body. While many women benefit from BHRT, it still comes with its fair share of side effects, like weight gain and acne. BHRT may also increase the risk for certain chronic diseases while decreasing the risk of others. 

Opting for more natural treatments like diet, probiotics, exercise, or herbs makes sense for a lot of women who are approaching or already in menopause. A natural approach can be as effective as conventional or bioidentical HRT and can help treat other factors, like an unhealthy gut, that may contribute to your symptoms. But when all else fails, BHRT may be a great option for relieving your symptoms of menopause. 

Hormone Replacement Therapy for Menopause

Hormone replacement therapy (HRT) supplements the body’s natural production of sex hormones with external hormones also called exogenous hormones. Women commonly turn to HRT during peri- and post-menopause to treat symptoms that come with the natural decline in hormones like estrogen, progesterone, and testosterone.

Fluctuations in estrogen levels can lead to both mood-related premenstrual symptoms in premenopause, as well as typical peri- and post-menopausal issues like hot flashes and night sweats. Low levels of estrogen are also associated with increased belly fat, obesity, and metabolic syndrome [3], which push many women to seek conventional or bioidentical HRT. 

Progesterone is another crucial hormone that starts to decline during perimenopause. It plays a role in balancing the nervous system [4], and insufficient levels can manifest as irritability, mood swings, and insomnia [5, 6]. These symptoms often prompt women to consider conventional or bioidentical HRT.

Though androgen hormones like testosterone are generally thought of as male hormones, women also need them in smaller quantities. Testosterone and its precursor, dehydroepiandrosterone (DHEA), contribute significantly to women’s sex drive and motivation [4], both of which often plummet around the time of menopause.

So, what can HRT do for drops in these hormones? A 2021 umbrella meta-analysis (very high quality of evidence) showed that HRT can help [7]:

• Reduce the risk of chronic disease. Hormone replacement can help lessen the risk of diabetes, colorectal cancer, and death from cardiovascular disease in menopausal women.
• Improve symptoms of low estrogen. HRT can reduce vasomotor symptoms (hot flashes and night sweats) and vaginal thinning and dryness.

Some HRT may also help boost sex drive. According to a systematic review of randomized controlled trials [8], testosterone replacement therapy (TRT) has become more well-known for its modest ability to increase sex drive in women. While many women report a short-term benefit from TRT, we don’t know much yet about its long-term effects.

Hormone Replacement: Bioidentical vs Conventional

While conventional HRT has been around for a while to help ease the menopausal transition, they have well-known side effects that have pushed women to look for alternatives. The pitfalls of HRT became very clear when the Women’s Health Initiative trials showed that conventional HRT (with conjugated equine estrogen and progestins) increased the risk for chronic diseases, including stroke, heart disease, gallbladder disease, and breast cancer. Other research found similar results; especially a higher risk of breast cancer [7, 9, 10, 11, 12, 13, 14].  

After the Women’s Health Initiative, the medical community decided the risks of HRT outweighed the benefits (though this was later overturned), and many doctors stopped prescribing it for perimenopause, menopause, and postmenopause [15]. Due to the rising demand for a more “natural” treatment, bioidentical hormone replacement therapy (BHRT) took center stage as another option for relieving the symptoms of menopause. 

The hormone precursors used in BHRT are derived from plants like soy and yam, and then processed to be chemically identical to the hormones naturally produced by the body [9]. Contrary to common belief, bioidentical hormones are synthetic and highly processed, similar to conventional HRT [9]. 

But, because bioidentical hormones start as plants, and the body recognizes them more than some forms of conventional HRT, BHRT is often considered more “natural.” Many think of BHRT as safer and more effective than conventional HRT, but as I’ll explain in the next section, this may not always be the case. 

Common hormones used in BHRT include:

• Estradiol
• Estrone
• Estriol
• Progesterone
• Testosterone
• Dehydroepiandrosterone (DHEA)
• Pregnenolone

Although regular pharmacies carry FDA-approved bioidentical hormones, many bioidentical formulas are not available at standard pharmacies and must be ordered through compounding pharmacies. These specialized pharmacies can customize hormone formulations (dose, strength, delivery system, etc.) for your specific symptoms, lab work, and preferences. They can also combine multiple hormones into the same formula to make using HRT easier.

Some hormones are delivered orally in capsules, but troches/lozenges (which are dissolved under the tongue), gels, creams, patches, pellets under the skin, injectables, and vaginal suppositories are other common delivery methods. The choice often comes down to what you prefer. 

For example, if you choose low-maintenance skin pellets, you only have to get them implanted every 2–3 months, but it does require an invasive, in-office surgical procedure. Transdermal (absorbed through the skin) options like creams and gels are easy to apply and can deliver a more consistent dose of hormones, but you should be careful with these if you regularly interact with children or animals whose skin will absorb the hormones, too. Usually, you’ll be safe if you apply the cream or gel on your inner upper thigh and wash your hands well afterward.  

Ultimately, BHRT is highly personalized and individualized, which has made it a great option for treating the symptoms of menopause.

Risks of Bioidentical Hormone Replacement Therapy

Because of the controversy surrounding the Women’s Health Initiative, many people are wary of using conventional HRT and lean toward its bioidentical cousin. But as I noted above, some of the perceptions about BHRT — like that it’s a more “natural” form of HRT — aren’t accurate. Even though all BHRT mimics natural hormones, it undergoes a lot of processing to get there. 

The media-driven perception that it’s natural also leads many to believe that BHRT is safer than conventional HRT. However, FDA-approved BHRT in standardized doses probably carries the same risks and rewards as conventional HRT [7]. It’s harder to know whether this is true for compounded versions because they don’t come in standardized amounts that are easy to measure and test.

BHRT, whether FDA-approved or compounded, comes with plenty of possible side effects that can vary for each person [9, 10], depending in part on the hormone type and strength. Common side effects of bioidentical hormones include [16]:

• Weight gain
• Blurred vision
• Fatigue
• Acne
• Increased facial hair (hirsutism) 
• Headaches
• Breast tenderness
• Spotting (intermittent and light uterine bleeding)
• Cramping
• Bloating
• Mood swings

Safety varies significantly for each person, depending on individual factors and the specific hormones you use. The research on how HRT affects breast cancer is mixed, and it may be more detrimental in women who have a history or higher risk of hormone-positive breast cancer [11, 17]. In any case, it’s probably best to steer clear of certain HRT regimens (especially those containing estradiol) if you have a higher risk of any reproductive cancer, and to always talk with your provider about your personal health risk before starting any HRT.

Lastly, it is essential that women with an intact uterus who are taking estrogen (bioidentical or conventional) take progesterone or progestin to decrease the risk of endometrial thickening and endometrial cancer [13].

Regulation of Bioidentical Hormones

One concern with custom-compounded hormone preparations is that they aren’t approved by the FDA, which raises questions about their purity, strength, and quality. In contrast, some bioidentical hormones are available in FDA-approved products with standardized amounts that have been tested for safety and effectiveness [9]. 

But just because they aren’t FDA-approved doesn’t mean that compounding pharmacies don’t follow certain standards. They still have to adhere to protocols that ensure they deliver the right product. The FDA is also working on guidelines to regulate compounded products better, which should address concerns about their safety and effectiveness [9].

One of the most harmful myths concerning BHRT is that it is a “miracle cure” for symptoms. While it can be effective, it certainly has its limitations, including possible side effects, regular dosing (often multiple times a day), and cost. It can also take a while to fine-tune the dose of hormones you need to reduce your symptoms. Because of this, BHRT is often best for women who have not benefited from a more natural approach that includes diet, exercise, and other lifestyle interventions [8]. 

BHRT Isn’t Forever

Certainly, there is a big caveat to HRT — you’re relying on medications for symptom relief. When you rely solely on bioidentical or conventional HRT for hormone balancing, your symptoms can recur after you discontinue the hormones because they don’t permanently correct an imbalance.

With menopause, HRT can’t restore your hormones to their prior levels. That means that if you rely on bioidentical or conventional HRT for symptom relief, those symptoms may return after you stop using it. This is where women can run into using HRT for long periods of time, which may pose health risks.

The good news is that many menopausal women will only temporarily need HRT for 2–4 years, and using more natural methods alongside HRT (if you decide to go this route) can help your body adjust to normal changes in hormone levels. 

Certain natural treatments, like an anti-inflammatory diet and probiotics, may help you reduce  the dose or duration of hormones you take for symptom relief and make it easier to discontinue bioidentical or conventional HRT when you and your provider feel you are ready. They may also save you money and reduce side effects in the long run.

Should You Go Bioidentical?

In general, bioidentical hormone replacement therapy can be helpful for some women, and some of its potential risks may have been overblown in certain natural health circles. But, it isn’t right for everyone, and there are safer, more natural options you can try before turning to BHRT.

In some cases, HRT, whether bioidentical or conventional, makes sense right off the bat. For example, if you have severe menstrual bleeding (which can occur during perimenopause) or your symptoms heavily impact your quality of life, it makes sense to give HRT a try. In many cases, the benefits of HRT — especially when started within 10 years of menopause onset and used for no more than 5 years [13, 18] — outweigh the risks. 

If you’re considering bioidentical HRT, it can be challenging to know where to start. It’s important to know that there are two different directions you can go: FDA-approved, standardized BHRT, or compounded BHRT. 

Standardized BHRT: Formulas come at set doses that have been tested and shown to be effective for specific menopausal concerns. The vast majority of standardized BHRT is estradiol-only, with varied doses and delivery systems between products.

• Climara is one of the more popular BHRT formulas that can help reduce the vasomotor symptoms of menopause. 
• Estrace is often prescribed at a higher dose for vaginal application to specifically target dryness and burning. 
• Vivelle-Dot offers a much lower dose of estradiol and is intended to prevent osteoporosis.
• Prometrium is bioidentical progesterone that can be taken alongside any estradiol product.

Note that there is a chance that if you are taking one of these formulas for a specific issue, such as vaginal dryness, it may not help resolve other menopausal symptoms. 

Your primary care physician can prescribe standardized BHRT, and insurance companies often cover these prescriptions, making them a relatively cheap and easy option. They are also FDA-approved, meaning their effectiveness and safety are better understood than compounded BHRT.

Compounded BHRT: The estradiol doses in standardized formulas may be too high for some women, increasing the risk for side effects. Therefore, many women opt for customized compounded formulas, as it is easier to adjust your dose based on your symptoms and labs. If you are interested in including multiple hormones, such as estriol and DHEA, in your regimen, compounded BHRT is likely your best bet. 

However, you will need to find someone who is knowledgeable in compounded BHRT, and these formulas can be expensive (and not covered by insurance). Many women also choose to try a mix of standardized and compounded BHRT. Finding a hormone-savvy provider can help you determine your best course of action when it comes to choosing BHRT.

Now that we’ve covered conventional and bioidentical HRT options, it’s important to say that many menopausal women get symptom relief from more natural methods. Diet, probiotics, stress management, sleep, exercise, and certain herbs can help resolve underlying issues like chronic, low-grade inflammation that can contribute to symptoms. I often see that by making a few lifestyle changes, many women don’t need to jump to HRT, bioidentical or otherwise.

Natural Ways to Treat Menopausal Symptoms

Trying more natural methods first is especially important if you are postmenopausal, you have a medical history (like blood clots or breast cancer) that puts you at a greater risk for side effects, and/or you just don’t want to deal with the cost, time investment, or risks of menopausal hormonal replacement therapy. Other, non-hormonal approaches to managing menopausal symptoms have some research support and can work well for many women.

Diet for Balancing Hormones

A whole-food, anti-inflammatory diet helps ensure digestive health, sufficient vitamin and mineral levels, balanced blood sugar levels, and adequate healthy fat intake. All of these can help support healthy hormone production [19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29]. A nutrient-dense diet, like the Paleo diet, that keeps you from eating common inflammatory triggers can be helpful for reducing menopausal symptoms.  

Sex hormones are synthesized from fats, so getting enough is essential for balancing your hormones. Foods like avocados, seeds, nut butters, plant-based milk substitutes (oat, almond, cashew, hemp), and fatty fish are great ways to get fat into your diet.  

Probiotics

Gut imbalances, such as bacterial dysbiosis or inflammation from eating processed foods, are stressful for your body. When stress is continuous, your body uses materials it needs to make sex hormones, like estrogen and progesterone, to produce stress hormones instead [30, 31]. This can worsen the symptoms of menopause, and it makes gut health a great place to start treating symptoms.

Research indicates that the following can negatively affect the balance of female hormones:

• Poor fat digestion [4, 32]
• The diversity and balance of gut bacteria [33, 34, 35]
• The balance of the female reproductive tract microbiome [36, 37]

Women who experience menopausal hot flashes, night sweats, and other related symptoms may have more dysbiosis — specifically, a decrease in beneficial Bifidobacterium and Lactobacillus species, and an increase in opportunistic species like C. diff  [38].

Probiotics are great for resolving gut dysbiosis. As an example, you can listen to how they helped to reduce the symptoms of menopause for one of my patients who did not have success with HRT. 

Probiotics can promote an overall healthy gut environment that helps ensure healthy estrogen metabolism and overall hormone balance [34, 39, 40, 41]. At the clinic, we suggest implementing our Triple Therapy approach, which combines probiotic strains from three different categories to provide a broader array of benefits. 

A Healthy Lifestyle

Managing stress levels with a regular exercise routine, high-quality sleep, and stress reduction techniques, is important for reducing the symptoms of menopause. Since stress can deplete hormones like progesterone and worsen insomnia and irritability, stress management is essential for women facing symptoms of menopause [30, 31]. 

One simple lifestyle improvement that can help reduce menopausal symptoms is to get regular, moderate exercise, such as walking. And as much as possible, spend time — exercising or not — outdoors, as nature is highly effective for lowering stress levels. 

Another way to reduce the symptoms of menopause is to get 7–8 hours of good sleep every night. Not sure how to improve your sleep quality? A 2022 meta-analysis of 16 randomized controlled trials with over 2,000 perimenopausal and menopausal women found that stress reduction techniques, including mindfulness, relaxation, and low-intensity exercise, were the most effective approaches for improving sleep quality [42].

Herbal Neutraceuticals

If you still have symptoms after making the above changes, you may need additional support. Herbal supplements containing soy isoflavones, black cohosh, chasteberry, and evening primrose oil can reduce menopausal symptoms, including hot flashes, insomnia, depression, and irritability [43]. 

Our online store carries Progest-Harmony and Estro-Harmony, formulas with botanicals shown in studies to balance estrogen and progesterone. These and similar products may be able to relieve symptoms of many hormonal imbalances, including menopause.

BHRT Isn’t the Only Choice for Menopause Relief 

Bioidentical hormone replacement therapy is an alternative to conventional HRT for menopausal women, and provides hormones that are easily recognizable by the body. And while the research supports that HRT can be useful for lessening symptoms like hot flashes, night sweats, insomnia, and low libido, both conventional and bioidentical HRT can still come with side effects and a risk for certain diseases. 

Going with more natural methods like a Paleo diet, probiotics, exercise, and herbs can be equally (if not more) effective, without the risks of HRT. But if you have severe symptoms that affect your quality of life, BHRT can be a viable option to discuss with your healthcare provider.

For more help with balancing your hormones and reducing the symptoms of menopause, reach out to the Ruscio Institute for Functional Health.

The Ruscio Institute has developed a range of high-quality formulations to help our patients and audience. If you’re interested in learning more about these products, please click here. Note that there are many other options available, and we encourage you to research which products may be right for you.