BHRT vs traditional HRT: which should I ask for and where?

Short answer

• Start by asking your clinician for evidence-based, FDA‑approved hormone options first (eg, transdermal 17β‑estradiol patch or oral estradiol + micronized progesterone if you have a uterus). Those have known dosing, safety data, and are usually covered by insurance.
• Be cautious about compounded “BHRT” (custom bioidentical hormones) — they’re marketed as “natural” but are less regulated, have variable dosing and limited safety data. If you still want BHRT, only use a reputable compounding pharmacy with appropriate accreditation and a prescriber experienced in menopause care.

Why this choice

• “Traditional” HRT (many of which are actually bioidentical molecules like 17β‑estradiol and micronized progesterone) is FDA‑approved, standardized, and has the best evidence for benefits/risks.
• Compounded BHRT can be useful in rare situations (allergies to excipients, need for a specific dose/vehicle not commercially available), but it lacks large trials, consistent quality control, and often uses unreliable testing (eg, saliva levels) to guide dosing.

Practical recommendations — what to ask for

• If you have menopausal symptoms, ask for:
  • A full assessment first (symptoms, medical/family history, breast cancer risk, clotting history, smoking, BMI, blood pressure).
  • Consider transdermal estradiol (patch or gel) if you’re worried about clotting risk — transdermal has a lower venous thromboembolism (VTE) risk than oral estrogen.
  • If you have a uterus, ask for endometrial protection: micronized progesterone (Prometrium) is often preferred over medroxyprogesterone acetate (Provera) by some clinicians because it may have a more favorable safety/tolerability profile.
  • For purely genitourinary symptoms, ask about local vaginal estrogen (Vagifem tablets, Estring ring, Estrace cream) which gives low systemic exposure.
  • Ask about nonhormonal options if you have contraindications (eg, certain cancer histories, active clotting disorders).

If you’re considering BHRT (compounded)

• Don’t use saliva testing for dosing — it’s not reliable for guiding systemic HRT.
• If you still want compounded BHRT, ask your prescriber why it’s needed, what evidence supports the chosen formulation, and insist on a compounding pharmacy with accreditation (PCAB or USP standards). Avoid pellets unless you understand the risks and monitoring plan — pellets give long, fixed dosing that can be hard to manage.

Where to get care

• Start with your primary care doctor or OB‑GYN for initial evaluation. If you want more specialized care:
  • Look for a menopause specialist — use North American Menopause Society (NAMS) “Find a Provider” or search for board‑certified OB‑GYNs or endocrinologists with menopause training.
  • Women’s health/menopause clinics (eg, academic medical centers) or menopause-focused telemedicine services (Elektra Health is one example that focuses on menopause care) can be helpful.
• If you must use a compounding pharmacy, choose one with PCAB accreditation or that follows USP standards and can provide certificates of analysis.

Specific product names (for discussing with a clinician)

• Transdermal estrogen patches: Vivelle‑Dot, Climara, Alora
• Oral estradiol: Estrace
• Conjugated equine estrogens: Premarin (different profile; discuss with clinician)
• Micronized progesterone: Prometrium (oral)
• Medroxyprogesterone acetate: Provera (a synthetic progestin)
• Local vaginal options: Vagifem (estradiol tablet), Estring (vaginal ring), Estrace cream

Questions to ask your clinician

• Why are you recommending this specific hormone, dose, and route?
• What are the benefits and the short‑ and long‑term risks for me (breast cancer, VTE, stroke, heart disease)?
• How will you monitor me (what tests, how often)?
• If suggesting compounded BHRT: why is compounded necessary, and what pharmacy will you use?
• Alternatives if I have contraindications or prefer nonhormonal therapy.

Red flags

• Any provider who insists on saliva testing to dose systemic hormones.
• Pushy marketing that “bioidentical” = safer without data.
• Compounded pellet therapy offered without clear discussion of risks and reversibility.

Final note Discuss your personal risk factors (age, smoking, clotting history, breast cancer history, family history) and symptom goals with a clinician. If you want, tell me your age, symptoms, and any medical history/concerns and I can give more tailored questions to bring to your appointment.