Traditional Hormone Replacement Therapy (HRT) vs. Bioidentical Hormone Replacement Therapy (BHRT)

As a compounding pharmacist, I am often asked what is the difference between bioidentical hormone replacement (BHRT) and conventional hormone replacement (HRT).  BHRT, as described in my earlier post, is an approach to hormone replacement that has three key attributes:

  1. All hormones used are chemically identical to human hormones
  2. The dosage is individualized to a patient’s specific hormonal needs
  3. The goal is to achieve a balance of activities of the hormones to improve quality of life

(See my post entitled “Key Principles of Bioidentical Hormone Replacement Therpay (BHRT)” for a more detailed description)

Conventional HRT is best exemplified by the commercial drug Prempro.  Prempro is a combination drug that has both estrogens and a progestin.  The estrogens are derived from the urine from pregnant mares and the progestin is medroxyprogesterone, a synthetic hormone not found in nature.  Prempro comes in approx. 4 different dosages and is taken orally once daily.  It can be found at any pharmacy.

So let’s go down the list and talk about the differences between conventional hormone replacement (HRT) and bioidentical hormone replacement (BHRT):

  • Hormones are identical to human hormones – HRT=no; BHRT=yes
  • Dosage customized for individual patient – HRT=no; BHRT=yes
  • Hormone balance goal of therapy – HRT=no; BHRT=yes
  • Primary goal is improved quality of life – HRT=possibly; BHRT=yes
  • Primary goal is to prevent disease – HRT=yes; BHRT=no

– There are some who claim that BHRT can prevent all types of diseases from osteoporosis to certain types of cancer, and although there is some scientific evidence supporting these statements, there is not enough good, solid research out there to back-up any definitive claim that BHRT prevents disease.

– Be very skeptical of anyone who claims that BHRT is going to prevent any type of disease.  With that said, there is lots of good evidence to support that BHRT is safe.

– Furthermore, there is lots of good evidence that conventional HRT actually causes disease!

  • close monitoring is regular part of treatment – HRT=no; BHRT=yes
  • only available from a compounding pharmacist – HRT=no; BHRT=yes and no

– Here’s another area where people get confused.  BHRT does not necessarily have to be made by a compounding pharmacist.  Now, I don’t want to put myself out of a job and there are lots of reasons why a compounded product is superior to an off-the-shelf medication, but there are a handful of mass produced prescription drugs that are bioidentical.

– There are various estradiol containing patches and an oral form of progesterone called Prometrium available.  Dosages and routes of administration (topical vs. oral) are limited, but these products are biologically identical to human hormones and therefore meet at least the first criteria of BHRT.

  • The estrogen “estriol” is available – HRT=no; BHRT=yes

– I will discuss the specific hormones that are bioidentical in future posts

  • Hormones can be given topically – HRT=sometimes (estradiol patches); BHRT=yes (any hormone)
  • Drug manufactured with FDA oversight – HRT=yes; BHRT=no

– Here’s one of the areas that critics of BHRT pounce on.  Compounded bioidentical hormones are not regulated by the FDA.  This is true.  Compounding pharmacies are regulated by the individual state agencies that regulate retail pharmacies and for that reason the quality and potency of compounded medications can vary greatly.  With that said, a compounding pharmacy that is using the top of the line equipment and has the proper quality assurance procedures  in place will consistently exceed any standards the FDA might have for a mass produced medication.

– It is important, however, to make sure you choose a compounding pharmacy that is using this equipment and has good quality assurance.  I will discuss specific questions to ask when evaluating a compounding pharmacy in my next post.

  • Drugs covered by most insurance plans – HRT=usually; BHRT=sometimes

– In my experience practicing in Californa, about 25-30% if insurance plans will pay for compounded medications

  • Clinical evidence to support its use – HRT=no; BHRT=yes

– This is where the critics get it wrong.  Many nay-sayers say that there is little scientific evidence to support the use of bioidentical hormones, when this couldn’t be further from the truth.  For example, the hormone progesterone has been available for almost 80 years now and there are reams of clinical trials that have looked at its efficacy and safety in a number of ways.  Also, estradiol, progesterone, and testosterone are available as mass produced pharmaceuticals and have passed the current FDA safety and efficacy standards.

– Furthermore, there are good clinical trials that have studied HRT and they all show that it is dangerous, so the scientific evidence clearly does not support its use.

– In future posts, I will make my case for bioidentical hormones as well as talk more about topical vs. oral hormones and saliva vs. blood testing.  In the mean time, if you have any questions or comments, please post them.

Thank you and live well!


24 Responses to “Traditional Hormone Replacement Therapy (HRT) vs. Bioidentical Hormone Replacement Therapy (BHRT)”

  1. 1 Krista March 6, 2009 at 10:09 pm

    You mention in this comparison of traditional hormone replacement and bioidentical hormone replacement that the goal of the traditional approach was to prevent disease, and with the bioidentical approach, that is not the goal. Why is that? What research previously suggested that traditional hormone replacement could prevent disease, especially considering the study in 2002 that proved that the opposite was actually the case, that it actually often increased the risk of different diseases? Why does bioientical hormone replacement not strive to prevent disease?

  2. 2 thecompounder March 7, 2009 at 2:01 pm

    That is a great, great question. I want to give a thorough answer so I am going to answer in my next blog post ( Stay tuned!

  3. 3 L. Hamann November 15, 2009 at 6:01 pm

    Can you discuss testerone/progesterone RT for women and its benefits?

    • 4 thecompounder November 16, 2009 at 4:06 pm

      This question is pretty general. I would always recommend starting with a saliva test (or blood test for those who have not had any hormone replacement) to see where the baseline estradiol, progesterone and testosterone levels are. The goal of therapy is always balancing the activity of the hormones so everyone’s regimen will be different since everyone’s hormone levels are different. I will say that it is has been rare in my experience when a peri- or post-menopausal women does not need at least some amount of progesterone supplementation. Testosterone can vary, since it is primarily produced by the adrenal glands and not the ovaries, so it’s levels do not have the precipitous decline we often see with estrogens and progesterone. Some may benefit from testosterone, some may not. Testosterone supplementation will definitely depend on hormone levels AND the sympoms presented. See my website for links to symptom checklists for men and women.

      I hope that helps.

  4. 5 bio-identical hormone replacement June 18, 2010 at 9:55 pm

    It is important, however, to make sure you choose a compounding pharmacy that is using this equipment and has good quality assurance. I will discuss specific questions to ask when evaluating a compounding pharmacy in my next post.

  5. 7 Diane July 4, 2011 at 2:22 pm

    I just started bio hormones 12 days ago 50-50- BIest feel terrible very agitated and a host of problems. I dropped down half the dose and all my hair is falling out. I have no overies I am 67 yrs old and don’t no what to do Can anyone help…. Thanks Diane,

    • 8 thecompounder July 5, 2011 at 5:56 pm

      I would recommend discussing possible dose adjustments with your prescriber, making sure all your hormones are balanced (including estrogens, progesterone, testosterone, thyroid and cortisol). BHRT should make you feel good (at least not bad).

  6. 9 Sanadana July 8, 2011 at 7:58 am

    I have been using bioidentical hormones now for 2 years. I was forced to seek out a reputable doctor that could administer bioidentical hormones as my HMO catered only to the one size fits all HRT which initially made me feel good for 1 month and then a quick downcline in health as my weight shot up and I felt like I was going to have a heart attack. After this I had chosen not to use any HRT but my eyes would no longer produce tears and I was extremely dry everywhere. This was not quality of life for me. After bioidentical hormone treatment my eyes don’t feel glued shut in the morning and my skin is moist again. I no longer feel like I am walking with corregated cardboard up my private parts. It is soooooo worth it to feel good again.

  7. 10 nettie pope August 9, 2011 at 4:53 pm

    My concern is my sister had breast cancer due to hormones. I found a compounding pharmacy and went to the dr. to have blood work done to check my hormone levels. My pharmacist said the hormone that he compounds is safe for me even though my sister had breast cancer due to hormones. Is this true. I have never taken prempro or premarin. I have only used the compounded hormones.

  8. 11 quality assurance October 30, 2011 at 2:16 pm

    Hi there, simply became aware of your weblog through Google, and found that it’s really informative. I am gonna watch out for brussels. I’ll appreciate in case you continue this in future. A lot of people might be benefited out of your writing. Cheers!

  9. 12 Sherryanne February 11, 2012 at 9:44 am

    As of January 2012, my insurance company has stopped covering my compounded hormone , Bi-Est, because Estriol is the primary ingredient in Bi-Est (Estriol is 80% & Estradiol is 20%). My understanding is that previous to January 2012, compounding pharmacies would submit a list of ingredients for each compounded prescription of B-Est in any order and as such, the pharmacy could then show Estradiol as the first ingredient, making Bi-Est accepted through insurance. Apparently (as of 2012) pharmacies must now submit each prescription with the primary ingredient listed first. Is there any way to get around this so that Bi-Est can again be covered through insurance?

  10. 13 Jacqui Goss May 23, 2012 at 8:48 pm

    Given that doctors have had a rethink re the safety of HRT and consider it safe – indeed preventing osteoporosis, dementia, heart attack etc, what is your stance regarding HRT and BHRT now. Article in Australian newspaper ‘The Age’ Wed 23 May 2012.

  11. 15 Vera July 17, 2012 at 9:35 pm

    UGH….please help! I am 38yrs old and confirmed to be in menopause! Yes….38 and in menopause, started around 36yrs. I am extremely overwhelmed and have no idea which direction to head in. Research speaks to women 15-25 yrs older then me. My doctor/nurse practitioner have not been helpful, they seem to be more amazed at my age then they are to properly educate me. I’m doing my research, but I end up more confused. I feel as though I should schedule an appointment with a Therapist, since emotionally/mentally I am a mess! Today I was perscribed Elestrin gel and progesterone capsules. Based on what I read, side effects to the progesterone scare me. And I don’t know what the heck I’m really taking. Help me please….anyone!

  12. 16 leslie marlar September 21, 2012 at 2:59 pm

    Where and how does one get bhrt? Is it suitable for someone who has has stage 1 endometrial cancer and who has had a complete hysterectomy?

  13. 17 Jane February 25, 2013 at 4:58 pm

    I am currently taking HRT called the combi-patch which has .05 mg estrogen and .14 mg progesterone. The great news is the hot flash and night sweat symptoms have subsided but I’ve gained 7 lbs in a very short time period (two months). I talked with my current OB-GYN about BHRT and of course, she had nothing good to say about it and did say that it was a big marketing ploy. Despite her negative comments, I am still considering pursuing a BHRT Dr. and have found one in my area on the internet associated with BodyLogic. Can I really expect to see this weight issue resolved by changing to a customized BHRT program? It’s expensive (not covered by my insurance – BCBS) but worth the money to me if I can resolve the weight issue. I am a fitness finatic and eat healthy so I know the weight gain is due to the HRT. It sounds like a compound BH might be the right answer for me but still a little hesitant.

  14. 18 Charlene August 9, 2013 at 9:16 am

    Please tell me what is the down side if any to BHRT?

  15. 19 Bhrtfan October 18, 2015 at 7:54 am

    What di i say to a friend who has been diagnosed with cancer, claims she was taking bhrt and blanes the hrt fir her cancer. Im tired of the nay saying. I dont know that she was on bhrt or just hrt. But i have full faith in my Dr. And i beleive that what I am doing is safe and doesnt cause breast cancer. Your input?

  16. 20 Arlene Sizemore July 31, 2016 at 7:34 pm

    Are there some women who just can’t take BHRT?
    I’ve been on BHRT for 3 years. I feel terrible in my body. I have felt great all my life up until menopause and harmone replacement.
    I don’t know what to do…..sometimes I feel so bad in my body im afraid something detrimental is going to happen… a stroke or seizure…..very hard to describe…..but
    certainly an unwell feeling inside my body.
    I thought about coming off BHRT and trying traditional harmones…. but after reading this article I don’t know what to do. I just want to feel strong and a wellness once again. Any advice would be appreciated. Thank you so much.

    • 21 thecompounder August 2, 2016 at 1:08 pm

      Thank you for writing in with your question. Your experience is really important to talk with both your doctor and pharmacist about. If you need a resource for a high quality compounding pharmacy in your area, we recommend the website of the Pharmacy Compounding Accreditation Board, which allows you to search for compounding pharmacies by state that have high quality standards: The general question that you have raised of whether some women can’t take BHRT or don’t respond well to it is important as well, and I will include it in the next blog post with frequently asked questions about hormone replacement and answers from Peter. All my best, Krista Shaffer, Outreach Director at Koshland Pharm

  17. 24 donna lazorchak January 28, 2017 at 11:01 am


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